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The Many Interacting Worlds Hypothesis

Neurologica Blog - 3 hours 52 min ago

Howard Wiseman, a theoretical quantum physicist at Griffith University in Brisbane, Australia, and his colleagues have come up with an entirely new theory to explain the weird behavior of particles at the quantum level. The idea is that quantum effects result from classical universes interacting with each other.

Classical physics is essentially the physics of Newton and describes the macroscopic world. In classical physics particles have a definitive location and momentum. At the scale of fundamental particles, however, the world behaves very differently.

At this so-called quantum level, particles move in waves but then interact as particles. They have only a probabilistic location and cannot be nailed down specifically. There is a minimum amount of uncertainty when trying to measure any linked properties, such as location and momentum. Even more bizarre is quantum entanglement in which particles have linked properties, even when separated across the universe.

The bottom line is that we do not really know why the quantum world behaves as it does. We have experimental data, such as the double-slit experiments, that show consistent results. When a light beam shines through two close narrow slits they interfere with each other as if they are moving like waves, even when the beam is so faint that only one photon will be passing through the silts at a time. One photon can apparently cause a wave interference with itself. But when those same photons strike a film plate or detector, they behave like a particle.

The experimental results are fairly clear. What is not clear is how to interpret those results. Quantum mechanics defies all of our evolved intuitions. It seems to reflect an aspect of reality that is completely foreign to us. Our experiments, while important, are not directly accessing the deepest level of reality. We are just probing in ways that we know how to probe and then trying to infer from the results something about reality that goes beyond our current concepts.

Perhaps the most popular interpretation of quantum experiments is the Copenhagen interpreation. This hypothesis states that fundamental particles exist as waves of probability, but when they are forced to interact with their environment the probability waves collapse into a specific value, more like a classic particle. This is a consistent interpretation, but it’s just that – an interpretation.

We cannot conclude that this is likely to be the correct interpretation because we don’t know what all the alternatives are. We don’t know enough about the fundamental nature of reality to have any confidence that we have a complete set of hypotheses.

This new “many interating worlds” hypothesis is a good example of the fact that physicists can still come up with entirely new interpretations of quantum observations that are no more bizarre than the Copenhagen interpretation. In this hypothesis there are many universes that coexist along with our own, but they are (at least as far as we can say) completely isolated and inaccessible from our own universe. This “many worlds hypothesis” is not new to quantum physics, and has been offered as an interpretation alternative to Copenhagen. In the many worlds view, each collapse of a probability wave actually splits off a separate universe – there is a separate universe in which each quantum possibility becomes reality.

This new twist assumes that universes are classical all the way down. However, these classical universes can bump into each other and interact with each other. They speculate that this interaction might be able to explain some of the quantum experimental observations. For example, two universes bumping into each other might cause one to surge forward while the other bounces back. This behavior could explain the observation of quantum tunneling, where quantum particle will tunnel through a barrier.

It’s actually a little generous to call this a hypothesis. It’s more of a wild speculation, but you have to start somewhere. The next challenge will be to work uot some of the math and physics, and to see if this notion could explain other quantum phenomena, like entanglement. Then the real challenge comes – designing an experiment that could distinguish the many interacting worlds hypothesis from the Copenhagen interpretation. It’s possible that the two interpretations will make slightly different predictions about experimental measurements.

Conclusion

It is very uncertain if the many interacting worlds interpretation will turn out to be of any use to theoretical physics and it’s unlikely to transform our understanding of quantum mechanics. It might, but it’s a long shot.

The bigger lesson here, in my opinion, is that it is premature, to say the least, to use any specific interpretation of quantum mechanics as a justifcation for otherwise fantastical claims.  I find it interesting that most people doing so, for example justifying claims of ESP or astrology, generally don’t really understand quantum theory or the current interpretations, none of which allow for superluminal remote information transfer.

My sense is that we are still a long way away from a meaningful undersanding of what our observations of quantum phenomena actually mean in terms of the fundamental nature of reality. There still room for theoretical physicists to say, “hey, what if this completely different interpretation is true.’

Categories: Medicine

The “It’s All Good!” Fallacy of Complementary and Alternative Medicine…..

Science Based Medicine - 6 hours 43 min ago

“Trust me, have I got a deal for you!”

 

As a young mother comforts her feverish and uncomfortable infant, a doctor enters the dimly lit exam room. The child’s mother and the bedside nurse look at him expectantly.

“I’ve got the results. There is an infection in your son’s spinal fluid, which was one of the things we discussed as a possible cause of his high fever and irritablity,” the physician explains to the now crying mother. “We need to start treatment right away and admit him to the hospital.”

After answering the distraught mother’s questions and discussing her child’s treatment plan, the doctor leaves the room and begins to write orders in the patient’s chart. The nurse, eager to begin appropriate therapy looks over his shoulder with a confused look on his face.

“Excuse me doc, but you’ve got to be a little more clear on that order don’t you think?”

Written in barely legible doctor scribble, next to the date and time of the encounter and above his signature and hospital number, is the lone word “antibiotics”.

“What do you mean? This child is sick and he needs antibiotics stat!”

“Sure doc, but which one, how much and how often? Where did you go to medical school again?”

“Clearly you aren’t current on the literature. Antibiotics have been around for decades and have been proven time and time again to treat infections. Millions of people take them every day and are pleased with the results. Now you are wasting precious time that could be spent caring for this sick child!”

The nurse, unhappy with the response, storms off to find assistance from his supervisor. The doctor, confident that he is providing competent medical are for his patient, expresses dismay at how closed-minded some of his colleagues are.

Naturally, the above situation is absurd, and the nurse is completely correct in questioning the physician on his order for “antibiotics”. What antibiotic, or antibiotics, are appropriate and at what dose? Through what route, oral or parenteral (e.g. intravenously or intramuscularly), should the antibiotic be administered? How often should it be given and for what duration? Five days? Two weeks? To condense the large number of antibiotics available in a hospital pharmacy into one all-encompassing term makes no sense.

Antibiotics are drugs, often consisting of completely different chemical structures with significantly different side effect profiles. There are varying degrees of safety and effectiveness with each individual antibiotic depending on the bacteria/virus/fungus being treated, the location of the infection, the age of the patient, and the presence of co-morbid conditions such as renal or liver disease. Calling for “antibiotics” in this fashion would never happen outside of a poorly written (is there any other kind?) medical drama on Lifetime.

As new antibiotics have been developed over the years, they are studied scientifically on an individual basis. Sure there are classes of antibiotics that work via similar mechanisms, such as breaking down a bacterial cell wall, or that might be effective in killing or delaying the growth of the same types of bacteria, but nobody would make a blanket statement, let alone write an order, like the one written by our fictional physician. Unfortunately, this kind of thinking is rampant in the world of so-called complementary and alternative medicine.

The “It’s All Good!” fallacy is employed by individual practitioners, lobbying organizations and even government agencies sympathetic to alternative medicine as a means of deceptively gaining a foothold for their favorite implausible and unproven therapies. Their targets are the hearts and minds of consumers as well as a growing number of practicing medical professionals. Buoyed by media-fueled public awareness that lacks appropriate context, the growing popularity of a variety of bogus therapies, funding from the National Center for Complementary and Alternative Medicine (NCCAM) and clever marketing, the most ridiculous of ideas are now masquerading as medicine in even our most hallowed academic institutions.

A common saying among advocates of science-based medicine and skeptics who choose to tackle the unfortunate and undeserved incursion of quackery into healthcare is that there is really no such thing as alternative medicine. I agree with this completely and would add that there is no such thing as complementary or integrative medicine either, regardless of what NCCAM puts on its website. These are marketing terms meant to distract from the reality that these therapies have either not been subjected to proper scientific study or that they have failed that study and are held aloft only by a foundation of tenacious anecdote fueled belief, cultural momentum and supporters with deep pockets.

When proponents of alternative medicine, far too many of which being influential lawmakers with little to no knowledge of science or medicine, call for financial support in the form of taxpayer money, they tend to use a similar tactic. They hold up a small group of therapies that have been shown to be effective, typically entities involving stress reduction, positive lifestyle changes like increased exercise and smoking cessation, improved nutrition, or various herbal remedies, as symbols of how wonderful alternative medicine is. This ignores two important facts.

These proposed symbols of the success of alternative medicine have been co-opted from the science-based medicine which discovered them and established their benefit. More importantly, these alt med proponents are ignoring the fact that the overwhelming majority of what is considered CAM is absolute quackery. In other words, just because a good massage helps your migraines or decreases your fatigue it does not mean that non-existent molecules of homeopathic poison ivy will cure your itchy rash. The use by proponents of terminology like alternative medicine is just as preposterous as the above emergency room physician writing an order for antibiotics. Which alternative therapy? Acupuncture? Homeopathy? Quantum Reiki? And for what indication? And what is it an alternative to? A proven therapy? Each individual treatment must be investigated for efficacy and safety with the tools of science, not the machinations of politicians and ideologues.

In the not too distant past, implausible treatments supported only by sloppy anecdotal evidence or poorly designed studies had an accepted name. Rational minded folk were unapologetic when describing a bogus cancer cure or an implausible and disproven treatment for depression as quackery. But over the past couple of decades the quack has become the alternative medicine provider and the bogus treatment has morphed into alternative medicine, CAM, or integrative medicine. This was no accident. The change in terminology has served proponents of quackery quite well by successfully leading the public to think that these therapies are just another way of achieving health, another narrative in the marketplace of ideas. But only science can determine what works and what doesn’t. In the meantime, no therapy should be allowed to circumvent appropriate investigation because of semantics and double standards.

I wrote this post originally in January of 2009 and unfortunately things have only gotten worse. The NCCAM still wastes millions of taxpayer dollars. More respected medical institutions have succumbed to the siren song of quackademic medicine. More medical schools have incorporated alternative medicine courses into their curriculum without appropriate context and skepticism. And the public continues to be victimized by misinformation with the imprimatur of institutions such as Mayo Clinic, Yale and many, many more.

A study published this month in Medical Acupuncture serves as an excellent example of this trend towards obfuscation and seemingly blind acceptance of nonsense. The paper, titled “Acupuncture Helps Reduce Need for Sedative Medications in Neonates and Infants Undergoing Treatment in the Intensive Care Unit: A prospective Case Series”  demonstrates that even critically ill children are not protected from quackery at the hands of bamboozled believers and the more prevalent shruggie. It boggles the mind that this uncontrolled and nonblinded train wreck of a study was approved by an IRB at Stanford’s children’s hospital. At least they probably wore gloves.

 

 

Categories: Medicine, Skepticism

Lessons from the dubious rise and inevitable fall of green coffee beans

Science Based Medicine - Thu, 10/23/2014 - 09:00

News this week that a randomized controlled trial of green coffee bean (GCB) has been officially retracted from the medical literature signals what is hopefully the end to one of the most questionable diet products to appear on the market in years. Plucked from obscurity and then subjected to bogus research, it’s now clear that the only people that actually benefited from GCB were those that profited from its sale. GCB had some powerful boosters, too. Once it became one of Dr. Oz’s “miracle” weight loss cures, sales exploded following two hype-filled episodes. Oz even did a made-for TV clinical trial with GCB, ignoring the requirements for researchers to obtain ethical approvals before conducting human subject research. Oz’s promotion of GCB was so breathless and detached from the actual evidence that his actions were subsequently eviscerated by Senator Clair McCaskill during televised hearings on weight loss scams. It’s a long, sordid, ugly and yet entirely predictable story.

Green coffee bean wasn’t the first miracle weight loss treatment, and I’m certain it won’t be the last. As long as there is an obesity problem, there will those that promote quick fixes and snake oil to treat it. These treatments exist because reality is hard to accept: permanent weight loss is difficult. We all know obesity is a Bad Thing, yet its prevalence continues to grow. As obesity rates rise, so do cases of diabetes, heart disease, and even cancer. Short of quitting smoking, there are few things you can do for your health with as much benefit as maintaining a healthy weight. Given how widespread obesity is, and how difficult it is to fix permanently, it’s not surprising that weight loss cures are fodder to those that want to sell magical cures. And when it comes to promoting quick fixes, there is no platform better than one you can get from being profiled on The Dr. Oz Show.

The story of GCB can’t be told without describing the pivotal role played by Dr. Mehmet Oz. If you’re trying to sell a product, yet you don’t have actual scientific evidence to back up your claims, The Dr. Oz Show is the best platform on television. There is no other show that can top The Dr. Oz Show for the sheer magnitude of bad health advice it consistently offers, all while giving everything a veneer of credibility. That’s because Dr. Oz is a real physician – he just doesn’t play one on television. That might surprise you given his show’s content. He’s promoted homeopathy and faith healing. He’s hosted supplement marketer Joe Mercola to promote unproven supplements, and the notorious “Health Ranger”, antivaccinationist and conspiracy theorist Mike Adams. Oz has promoted ridiculous diet plans, and he gives bad advice to diabetics. Then add the long list of “miracle” foods like red palm oil, or manufactured public health scares like cell phones causing breast cancer. “The Dr. Oz Effect” was coined to describe how Oz drives product sales, but it more accurately describes how Oz’s advice wastes the time and finances of consumers that actually follow the advice he offers.

The dubious trial that convinced Dr. Oz

Dr. Oz’s first episode on GCB looked at the Vinson trial. Even taking the paper at face value (before there was any evidence of fraud), the results were questionable, as I noted when I actually read the study:

  • The study was published in an obscure journal that accepted the paper after 12 days, a period which apparently included peer review
  • The trial was never registered at clinicaltrials.gov, which is an expectation for credible clinical trials
  • The authors had no particular history of research in this area. The lead author was a chemist in Pennsylvania
  • The trial was funded by a supplement manufacturer
  • The trial was made up of just 16 patients and lasted 12 weeks only
  • There was no detail in the paper on how patients were recruited, or if inclusion and exclusion criteria were applied
  • How body mass index (BMI) was measured wasn’t disclosed
  • There was no evidence of research ethics board (institutional review board) approval of the trial
  • The randomization process wasn’t described
  • How the doses were calculated wasn’t described
  • While the trial was called “blinded”, it actually wasn’t, as the design made it easy for patients to figure out if they were receiving GCB or placebo
  • Some patients lost as much weight while taking placebo as they did taking GCB. There was no clear GCB effect
  • There was no tabulation or reporting of side effects

All we could conclude from the Vinson trial was that it was poorly conducted, sloppily written and provided unimpressive and clinically-useless results. There was no convincing evidence to suggest that GCB offered any meaningful benefit. As I noted in my conclusion at the time, GCB had all the features of a bogus weight loss product. It was implausible, and backed by flimsy evidence with some serious methodological issues. Even before we knew it was fraudulent, it was clear this trial should not be used to guide treatment decisions. None of this was an obstacle to Oz, who declared it to be the newest panacea for weight loss, using words like “magic”, “staggering”, “unprecedented”, “cure” and “miracle pill”. He concluded his episode with an absurd “trial” in two audience members who took the supplement for five days. One reported a two pound loss, the other, a six pound loss. In doing so he illustrated one of the worst ways to evaluate a weight loss supplement: short duration of use and informed by anecdotes. It served as nothing more than an extended advertisement for the product.

Part 2: Dr. Oz doubles down on green coffee bean with his own bogus trial

In a hamfisted attempt to address the criticism of Oz’s first episode on GCB, Dr. Oz revisited the topic in a follow-up episode, which he called The Green Coffee Bean Project (Oz has scrubbed the episode’s notes from his website now, but the internet never forgets.) It’s not surprising. Based on the Vinson study, Oz designed and conducted a clinical trial of green coffee bean on his studio audience. He gave what appeared to be about 100 women either GCB or placebo for two weeks. Oz noted that the group taking the green coffee bean extract group lost 81.5 pounds collectively, while the placebo group lost 42 pounds. Assuming 50 participants per group, that’s 1.6lbs in the green coffee bean group, and 0.84 pounds in the placebo group. You can review the whole list of problems with this trial in my prior post, but what’s more concerning to me was that Oz didn’t obtain ethical approval to conduct the trial. (Oz subsequently admitted this in later Senate testimony.) How this could be acceptable to Columbia University, where he still practices as a surgeon, is incredible, yet perhaps reflects another aspect of The Dr. Oz Effect: Daytime TV trumps research ethics.

If Oz’s first episode was a mockery of looking at the evidence, the second episode was a mockery of how we generate evidence. Oz is a published research scientist. He knows how to do proper research. This wasn’t even close. His made-for-TV trial delivered only one thing: more accolades and praise from Oz about a product that still lacked any convincing evidence of benefit.

Dr. Oz and the Terrible, Horrible, No Good, Very Bad Day

When Dr. Oz arrived to speak at Senate hearing into weight loss scams in hearings led by Senator Clair McCaskill, he probably wasn’t expecting to be verbally disemboweled on television. McCaskill called him out for his breathless hyperbole, drawing attention (among all of Oz’s “miracles”) to green coffee bean:

Dr. Oz: Well, if I could disagree about whether they work or not, and I’ll move on to the issue of the words that I used. And just with regards to whether they work or not, take green coffee bean extract as an example. Uh, I’m not gonna argue that it would pass FDA muster if it was a pharmaceutical drug seeking approval, but among the natural products that are out there, this is a product that has several clinical trials. There was one large one, a very good quality one, that was done the year that we talked about this, in 2012. Listen, I’ve…

Sen. McCaskill: wh..wha..I wanna know about that clinical trial. Because the only one I know was sixteen people in India that was paid for by the company that, that was in fact, at the point in time when you initially talked about this being a miracle, the only study that was out there was the one with sixteen people in India that was written up by somebody that was being paid by the company that was producing it.

McCaskill got the evidence exactly right. There was still only a single trial (Vinson) with sixteen people studied. Yet the Oz Effect had driven a massive demand for GCB. And yet Oz was hardly apologetic, and described himself as a victim, rather than the cause of the problem. What was clear from his testimony is that when it comes to facts versus infotainment, television wins, every time:

Dr. Oz: I actually do personally believe in the items I talk about in the show. I passionately study them. I recognize that often times they don’t have the scientific muster to present as fact, but nevertheless, I would give my audience the advice I give my family all the time, and I have given my family these products.

Emphasis added. If you haven’t watched the hearings yet, the best and smartest summary on Oz and supplements in general came from John Oliver.

The Federal Trade Commission gets involved

In May of this year, the FTC announced it was suing a Florida-based company (Applied Food Sciences) for its promotion of green coffee bean. The vendor established web sites that made unsubstantiated claims about green coffee bean, while linking to clips and images of The Dr. Oz Show. In September, the FTC announced it had a deal and settlement from Applied Food Sciences (AFS) and it was a bombshell. Not only was the advertising misleading, but the trial itself was fraudulent:

The FTC charges that the study’s lead investigator repeatedly altered the weights and other key measurements of the subjects, changed the length of the trial, and misstated which subjects were taking the placebo or GCA during the trial. When the lead investigator was unable to get the study published, the FTC says that AFS hired researchers Joe Vinson and Bryan Burnham at the University of Scranton to rewrite it. Despite receiving conflicting data, Vinson, Burnham, and AFS never verified the authenticity of the information used in the study, according to the complaint.

Despite the study’s flaws, AFS used it to falsely claim that GCA caused consumers to lose 17.7 pounds, 10.5 percent of body weight, and 16 percent of body fat with or without diet and exercise, in 22 weeks, the complaint alleges.

Although AFS played no part in featuring its study on The Dr. Oz Show, it took advantage of the publicity afterwards by issuing a press release highlighting the show. The release claimed that study subjects lost weight “without diet or exercise,” even though subjects in the study were instructed to restrict their diet and increase their exercise, the FTC contends.

The FTC complaint really needs to be read to be believed. During the “revisions” to the manuscript, the following appears to have been changed:

  • The trial went from being described as open label to double-blind, placebo controlled
  • The duration of the study grew from 20 weeks, to 24 weeks, and then to 28 weeks
  • Six of the sixteen final weights were restated

Vinson and Burnham, the two authors hired by AFS to be the “authors” of the paper, never actually reviewed the raw data for the trial. Despite the repeated restatements of data, they subsequently finalized and signed off on a manuscript and found a journal willing to publish the results. Add the Dr. Oz effect, and AFS subsequently sold 500,000 bottles, apparently at $50 each. And that’s how a chemist and psychologist in Pennsylvania came to be the authors of a bogus clinical trial of green coffee bean, driving millions of dollars in sales for AFS.

The retraction

In light of the FTC’s findings, it was just a matter of time before there would be pressure to retract the study. And it happened this week. In a terse one-sentence retraction highlighted by Retraction Watch, Vinson and Burnham have now retracted the paper:

The sponsors of the study cannot assure the validity of the data so we, Joe Vinson and Bryan Burnham, are retracting the paper.

In an amazing display of handwaving and fingerpointing, the two hired “authors” are now blaming the sponsor for the validity of the data. No apologies for the serious ethical lapse of pasting their names on research they didn’t even conduct. And yet they blame the sponsor, who was the manufacturer, who should be last group with any involvement in the data collection and analysis.

What have we learned

The retraction of the Vinson trial has been cited by some as damaging Oz’s credibility. I frankly don’t think Oz had any credibility to lose. Even at face value, the evidence was never there and should never have been promoted by Oz as a treatment. Yes, admittedly that’s the case for almost everything Oz seems to promote on his show. Yes, the green coffee bean paper was fraudulent – but the fraud was so incompetent, they couldn’t even make the fake results look impressive, or make the study look credible. Even the fake data wasn’t impressive enough to justify the hype and hyperbole. Yet there seems to be no stopping Dr. Oz. The miracles continue, even after his Senate smackdown. I’m heartened by medical students like Benjamin Mazer, who is determined to go after Dr. Oz by asking his medical regulator to take action against him. Is the Dr. Oz strong enough to deflect a regulator? Time will tell.

Avoiding the next green coffee bean

One of the most frustrating aspects of the green coffee bean is the underlying fact that there simply are no magical pills or panaceas for weight loss. None. So how does one avoid the next miracle cure? It’s what Dr. Oz actually admitted to under Senate questioning: There are no miracle pills that replace a proper diet that includes calorie restriction. The facts of weight loss aren’t catchy, but they are based in reality, not hype. I covered many of them in my review of Yoni Freedhoff’s The Diet Fix:

The laws of thermodynamics hold. To lose weight you must expend more calories than you consume. For practical purposes, you must focus on the consumption side because…

You can’t outrun a bad diet. Calories are simply too easy to come by, and food is too calorie dense, to not restrict your diet. The most effective way to do so is to…

Track your calories consumed. Calorie tracking and journaling is highly correlated with more successful, permanent weight loss. This strategy works because…

The best diet is one you can sustain permanently. You don’t need to demonize any food groups. Temporary changes give temporary results. Permanent weight loss must be accompanied by permanent change. Quick fixes in the form of pills and potions are unnecessary, because…

Supplements, by and large, are useless. Even the most effective weight loss products (that are prescription drugs) provide only modest incremental benefit. In most cases, the benefit from supplements (or prescription drugs) is questionable.

Conclusion

Green coffee bean would probably be a fringe supplement if it wasn’t for a supplement company that decided to buy its own “evidence”. Once the Vinson trial was published, the Dr. Oz Effect pushed green coffee bean from nothing into a supplement blockbuster. Yet the entire trajectory was entirely predictable. Green coffee bean wasn’t the first useless weight loss supplement, and it definitely won’t be the last. While you won’t hear it from Dr. Oz (unless he’s speaking in the Senate) there simply are no quick fixes and no weight loss “miracles”. Let’s hope everyone’s a little more skeptical when the next “miracle” appears.

 

 

Categories: Medicine, Skepticism

A Brain-Training Update

Neurologica Blog - Thu, 10/23/2014 - 08:19

Can playing video games or specifically designed computer games improve your cognitive function? There are many companies who claim that they can and who would like to sell you such games that they claim are “scientifically designed.”

So-called brain-training is a burgeoning business, with perhaps the best known product being Lumosity. Lumosity promises:

“Scientifically designed games: Lumosity scientists study many common neuropsychological tasks, design some new ones, and transform these tasks into fun, challenging games.”

They claim to be a “leader in the science of brain training,” and include a list of 13 studies that allegedly show Lumosity is effective. Many of the studies do not even test efficacy, and strangely the list does not include this recent study from August 2014 showing that Lumosity is not effective.

This new study involved 77 subjects randomly assigned to play 8 hours of Lumosity or Portal 2 (a popular video game). They found that the Portal 2 players outperformed the Lumosity players on all three cognitive evaluations: problem solving, spatial skills, and persistence. The only pre-test to post-test significant improvement was the Portal 2 group for spatial skills.

This is a relatively small and short term test, so by itself it is not definitive. The results, however, are devastating to the claims of Lumosity if they hold up – Lumosity is not as effective as regular video games, and does not appear to be effective at all.

For those who are not familiar with Portal 2, you should be. It is an incredible game, which essentially involves solving interesting three-dimensional physics puzzles. This was a good game to test, and it’s not surprising that it would show an improvement specifically in spatial skills.

But we don’t have to rely on one study to determine if brain-training games work. There is a fairly large body of research exploring the many aspects of this question. I have been writing about this topic for a while. Here are my bottom line thoughts and recommendations:

  • Brain-training is effective, whether designed as classic cognitive tasks, combined tasks, or video games.
  • Effects are mostly restricted to the specific tasks being trained and do not significantly generalize to other tasks or cognitive functions. Effects tend to be short lived, although evidence here is very mixed.
  • Computer-based brain-training does not appear to be significantly different in outcome from traditional pencil and paper-based training, but is less labor intensive.
  • I could find no published evidence to support any claims for individualized programs.
  • Engaging in various types of cognitively demanding tasks is probably a good thing.
  • Try to engage in novel and various different types of tasks. These do not have to be computer-based.
  • Find games that you genuinely find fun – don’t make it a chore, and don’t overdo it.
  • Don’t spend lots of money on fancy brain-training programs with dramatic claims.
  • Don’t believe the hype.

Essentially, engaging in any cognitive task will make you better at that cognitive task and perhaps closely related tasks. The benefits are modest and probably short lived. There is no reason to think from the evidence that any specific brain-training game can improve general cognitive abilities, or that there is a permanent or even long term benefit to brain function. The claims of companies selling such games, therefore, are overhyped and misleading.

Fortunately, you don’t have to take my word for it. Recently the Stanford Center on Longevity and the Berlin Max Planck Institute for Human Development published a consensus statement on brain training games. They assembled relevant experts from around the world and then put together a consensus statement. Essentially, they agree with me, which is reassuring. Here is the summary:

In summary: We object to the claim that brain games offer consumers a scientifically grounded avenue to reduce or reverse cognitive decline when there is no compelling scientific evidence to date that they do. The promise of a magic bullet detracts from the best evidence to date, which is that cognitive health in old age reflects the long-term effects of healthy, engaged lifestyles. In the judgment of the signatories, exaggerated and misleading claims exploit the anxiety of older adults about impending cognitive decline. We encourage continued careful research and validation in this field.

I also pulled out some interesting details to add to what I have written on the topic previously. The experts specifically make the point that improvement in performance on cognitive tasks may not represent improvement in brain function, but rather learning new strategies for completing the tasks. In other words, playing games may teach subjects how to use their brain smarter rather than improving brain function itself.

While playing Portal 2, for example, you build your repertoire of the kinds of tactics you can use to solve the spatial problems you are presented with.

This does not mean there is no utility to engaging in cognitive games and puzzles. Engaging in mental activity is better than not engaging in mental activity. It’s also better to engage in a variety of activities, and specifically seek our novel challenges. This will be more interesting, if nothing else. The same goes for physical activity. It’s better to be physically active than not, but there is no magic exercise or machine. Just do something, do lots of things, and keep it fun and convenient. The experts also point out, as I have, that the evidence shows physical activity has a positive, but modest, benefit to brain health also.

Conclusion

Do stuff. Do mental and physical stuff. Do stuff that you find fun and engaging, and try new things. But there is no magical or special stuff, so don’t believe the hype, don’t spend lots of money you don’t have to, or feel you have to do stuff that is inconvenient or unpleasant.

And play Portal 2. It really is a fantastic game.

Categories: Medicine

A TCM Challenge

Science Based Medicine - Wed, 10/22/2014 - 08:09

In the tradition of James Randi, a Chinese doctor who is an outspoken critic of Traditional Chinese Medicine (TCM) has issued a challenge to its proponents. He has put up 50,000 yuan (about $8,000), which has been matched by donors for a total of over 100,000 yuan, to any TCM practitioner who can use pulse diagnosis to determine with accuracy whether females subjects are pregnant.

Ah Bao is the blogging pseudonym of a burn-care doctor at Beijing Jishuitan hospital. He is trained in scientific medicine and has criticized his country for clinging to pre-scientific philosophy-based health care. He calls TCM “fake science” and now wants to demonstrate that the claims of TCM practitioners are without factual basis.

His challenge is a good one because it focuses on a clear criterion. Subjects will either be pregnant or not pregnant, and the TCM practitioner, using only pulse analysis and blinded to the patient themselves, must determine with an 80% accuracy which subjects are pregnant. A TCM practitioner, Zhen Yang, has taken him up on the challenge and they are now working out the details.

Pulse analysis

Scientifically-trained doctors do palpate peripheral pulses as part of the medical exam. We look for the strength, rhythm, and rate of the pulse, compare right-left symmetry and look for the presence of specific pulses. The purpose of examining the pulse is to help evaluate the cardiovascular system. An irregularly irregular pulse would indicate atrial fibrillation. A weak pulse could indicate dehydration, heart failure, or hemorrhage (essentially low blood pressure).

TCM pulse analysis, however, is different. It’s possible that some of the basic physiological phenomena above were recognized even by pre-scientific practitioners. It’s not a stretch to realize that a weak pulse indicates the patient is not healthy. But they had no real understanding of cardiovascular physiology, autonomic function, or cardiac electrical activity. Instead they developed an elaborate scheme relating various properties of the pulse to concepts within TCM.

Here is a description of the 29 pulses of TCM, with a notation about their cause and in places relating to a biological etiology. For example a “hesitant” pulse indicates, “Blood and essence failing to nourish the meridians. Blood is not flowing smoothly.” Whereas a “wiry” pulse indicates: “Tense vascular Qi due to the liver not gently performing its function, can also be due to the retention of a pathogen in the liver. If wiry, Thready [sic] and forceful-like feeling the edge of a knife is indicative of Stomach Qi exhaustion.” Most of the descriptions relate to the Yin and Yang of Chi.

None of this has any basis in our modern understanding of biology or medicine. It is clearly the attempt of a pre-scientific culture to impose an elaborate system onto a complex and mysterious phenomenon.

Disconnected from reality

Pulse diagnosis and other similar aspects of TCM are, in my opinion, an excellent example of what happens when “knowledge” is disconnected from reality. The scientific method is primarily about creating a feedback loop in which our ideas are tested in some objective and systematic way against reality. Without this feedback loop, our ideas are free to drift into any direction. Historically the lack of scientific testing has resulted in elaborate and fanciful systems of pretend knowledge. Humans are creative and inventive, and so we have no difficulty imagining and embellishing such systems. Confirmation bias then convinces us that our systems are real.

There are countless examples of this phenomenon. The many forms of astrology, for example, represent pretend knowledge. Galenic medicine, based on the notion of the four humors, was the Western version of fake medical knowledge. In fact, bloodletting and the balance of the humors in the West was culturally connected to acupuncture and cupping (which actually were forms of bloodletting) and the balance of Chi in the East. These were actually different versions of the same basic ideas.

Another elaborate diagnostic system disconnected from reality was diagnosis by urine color. Medieval doctors would carefully examine their patient’s urine for color, odor, and even taste and had a complex system of diagnosis. As with pulse diagnosis, there are legitimate clues to health that can be gleaned from the urine, but only in specific situations.

Medieval doctors, however, without the knowledge or technology to truly understand what was going on with their patients, grasped onto whatever was available. They developed elaborate charts, like the one here, relating the subtle variations in urine color to specific (but also largely fictitious) conditions. This is a perfect analogy to pulse diagnosis.

Pretend knowledge is very dangerous because it can create the powerful illusion of genuine knowledge. Confirmation bias is a persistent and subtle bias in the way we perceive, filter, and evaluate information that systematically supports what we already believe or wish to be true. It largely occurs without our conscious awareness. We also tend to be unaware of the vast amounts of data we are sifting, and so when we find bits of data that seem to support our beliefs we find it unlikely that there is an alternate explanation.

In medicine there are other factors that also conspire to create the powerful illusion that even entirely fake beliefs are legitimate. Chief among these factors are placebo effects – effects that make it seem as if a treatment is having a benefit even when it is doing nothing. Placebo effects are largely illusory, such as regression to the mean (symptoms getting better as a matter of course).

There are other factors as well, such as the tendency to only test our own hypothesis rather than competing hypotheses. This is often referred to as the toupee fallacy. It is easy to have the illusion that you always recognize when someone has a toupee, because you don’t test the hypothesis when you don’t recognize a toupee. Likewise, when taking a medical history you might preferentially ask the patient questions which are designed to confirm your diagnosis, rather than questions that will challenge the diagnosis.

For example, if you think that a “soggy” pulse is associated with breathing problems, and you feel as if you detect a soggy pulse, you might ask the patient about breathing problems and will take the fact that many patients respond positively as confirming the reality of the “soggy” pulse and its association with breathing problems. But what if you asked all your patients if they had breathing problem, regardless of their pulse? Would the percentage who answers in the positive be any different? That is the difference between science and confirmation bias.

Unsurprisingly, the reality of pulse diagnosis has not been established by scientific evidence, any more than medieval urine analysis or the four humors. There are a few studies looking at pulse diagnosis but they amount to what Harriet cleverly termed “tooth fairy science.” They study aspects of pulse diagnosis without ever doing the kind of test that would establish whether or not it is valid. For example, there is a study attempting to standardize the position of the fingers when sensing the pulse.

Another study correlated how TCM practitioners describe the pulse to the presence or absence of hypertension. This study is problematic in a number of ways. First, hypertension might actually affect the pulse and therefore its description, and so is a problematic model for TCM pulse diagnosis in general. Further, it committed, essentially, the toupee fallacy of only testing the desired hypothesis but not testing this against controls that could disprove the hypothesis.

“Tooth fairy science” takes a fake belief system and transforms it into a pseudoscience by going through the motions of scientific analysis, but only as a more elaborate form of confirmation bias. This makes the fake belief system more dangerous because it gives it the patina of science and therefore false respect and legitimacy.

Conclusion

I agree with Ah Bao that there is no scientific legitimacy to TCM generally and pulse diagnosis specifically. It is, as he says, “fake science.” It is just one more example of what happens when beliefs are disconnected from reality – elaborate and detailed, but entirely fictitious, belief systems emerge.

I look forward to following the development of the pulse diagnosis challenge. Hopefully Ah Bao is experienced enough to design and execute a study that precludes any form of “cheating” or inadvertent information leakage.

It’s not physiologically impossible that the radial pulse is systematically different in pregnant vs non-pregnant women. The pulse, as I mentioned above, is a real physiological phenomenon. I doubt, though, that any such signal will be consistently detected among the noise of all the other factors that affect pulse. I would expect, therefore, that the test, if properly controlled and sufficiently powered, would be negative. Either way the results will be interesting.

Usually more interesting than the outcome of such challenges are the responses of believers to the outcome.
 
 

Categories: Medicine, Skepticism

Graphene Neuro-electrode

Neurologica Blog - Tue, 10/21/2014 - 08:20

This news item combines two technologies that I have been eagerly following, graphene and brain-machine interface. Researchers have developed a 1-molecule thick graphene electrode that is transparent and can be used for high-resolution electrophysiological recordings of brain cell activity.

Before I explain why this is such a cool advance, I will quickly review these technologies. Graphene is an allotrope of carbon – it is made of a single atom thick layer of carbon atoms arranged in a hexagonal sheet like chickenwire. This arrangement is very stable with strong bonds, making for a strong material. It is also flexible and has useful electrical properties. It can be manufactured as a sheet or rolled up into carbon nanotubes.

Graphene is an incredibly promising material that is likely to be the cornerstone of future electronics, promising small, efficient, and flexible components. It conducts both heat and electricity very efficiently and it is a semiconductor. “Doping” the graphene with other elements also has the potential to tweak its physical properties, expanding the number of applications.

The limiting factor is the technology for manufacturing graphene in large enough sheets to be useful. This is an area of steady advance, but right now it is still expensive to make graphene of sufficient quality. Once someone figures out how to mass produce graphene is large amounts and high quality, I think it will really take off as the next revolutionary material.

For this reason I am always excited when I hear about actual applications of graphene. In this case we are talking about specially manufactured very tiny electrodes (so not mass production), but still it’s good to see graphene put to use.

I have also been following the various research programs exploring the circuitry of the brain and ways to interface between computers and that circuitry. One limiting factor is (as you probably guessed by now) the electrodes. Electrodes can be irritating to the brain, they can be brittle or fragile, they can be opaque and not MRI friendly and therefore can interfere with imaging, and they can be noisy limiting the resolution of electrophysiological imaging. It has been very difficult, therefore, to obtain high resolution imaging and electrophysiological recordings of the same part of the brain for research.

Small thin graphene electrodes essentially solve all of these problems. The new study demonstrates an array of graphene electrodes that are thin, small, transparent, strong, flexible (so they can conform to the brain tissue), with great electrical properties (little noise). They are also less caustic than previous electrodes.

This allows for researchers to obtain high resolution mapping of the electrical activity of a part of the brain that they can also image, so that they can better correlate the anatomical structures with their electrical activity.

The present application is to study the hippocampus of rat brains. However, there are many possible applications, both research and clinical. Such electrodes could be used for better detection and characterization of seizures for possible surgical treatment, for example.

Graphene electrodes also are likely to have a much longer lifespan when transplanted into a living brain, because they are strong, small, and not caustic. They also dissipate heat very efficiently. A graphene-based computer chip would use much less energy and and produce much less heat then silicon chips.

In short graphene electrodes, computer chips, and even batteries make transplantable brain-computer interfaces much more feasible.

Conclusion

Both graphene and the brain-machine interface are two technologies that have the potential to transform the 21st century. It is always difficult to predict future technology. It’s possible, for example, that mass production of graphene will never become economical, or that some other material will leap frog over graphene. It’s also possible that practical applications of the brain-machine interface may be more of a technology for the 22nd century than the 21st.

Right now, however, the indicators are very good that these two technologies are going to be increasingly important in the not-too-distant future.

Categories: Medicine

An Overly Pessimistic View of Medicine

Science Based Medicine - Tue, 10/21/2014 - 03:00

Sandeep Jauhar wrote Doctored: The Disillusionment of an American Physician to express his frustration with the modern system of medical care in America. I found the book profoundly disturbing. If his experience is representative, I can understand why so many people have been criticizing doctors for only caring about money.  His experience was so different from mine that I wondered if I had led a sheltered life as a military physician and was oblivious to what was going on in the civilian world.  After further reflection, I think Jauhar is unduly pessimistic. Whatever the opposite of rose-colored glasses is, he’s wearing them.

His Personal Experience of Medicine

Dr. Jauhar is a cardiologist who works in a large teaching hospital, where he had been hired to develop a program for patients with heart failure that would implement the most up-to-date medical knowledge and provide the best possible medical care. After long, grueling years of school, residency, and fellowship, he is elated to have finally finished his training and started a job where he can accomplish something good. But he soon sinks into despair. He is appalled by the realities of life as an attending physician, the many ways in which the “system” interferes with his efforts to provide the best care to patients, the unethical behavior of other doctors, and his inability to support his family.

His family, which soon includes two children, is living in a one-bedroom apartment; and even so, he can’t make the rent payments without large cash infusions from his wealthy father-in-law. To supplement his income, he moonlights by working for doctors in private practice; but he is abusively treated by unethical, money-grubbing employers who are gaming the system to make money by doing unwarranted tests and procedures. He envies his brother, an interventional cardiologist in private practice who is making big bucks doing procedures; but he is unwilling and unsuited to engage in the kind of politics that his brother is constantly obliged to use to keep up the flow of referrals (schmoozing with other doctors and fawning on them). By the end of the book, Jauhar has moved to suburbia and his wife has returned to work, so there is finally a prospect of making ends meet.

I just couldn’t relate to this. I have never encountered a doctor who didn’t make a living wage, although I have heard of a few who unwisely tried to live beyond their means. As an Air Force physician I earned considerably less than my colleagues in private practice, but I always had more income than I needed to maintain a comfortable lifestyle. He doesn’t say what his salary is. According to a 2011 survey,   the average salary of a hospital-employed cardiologist was $254,000. I find it hard to wrap my mind around the idea that a large teaching hospital would pay a subspecialist so little that he would be unable to pay the rent on a 1-bedroom apartment. He seems to be protesting that doctors in general are making too much money while protesting that he doesn’t make enough. Something just doesn’t add up.

Unwarranted Pessimism

In a book review in The Wall Street Journal, Dr. Thomas Stossel says:

Dr. Jauhar also invokes what I term “the great American medical guilt trip”: the fact that we spend far more on health care for allegedly worse health outcomes, including higher mortality, compared to other countries. This self-flagellation is an apples-to-oranges comparison of vastly different geographies, social structures and cultures. After subtracting homicides and automobile fatalities, the mortality discrepancies largely disappear.

He also points out that Dr. Jauhar’s view of the past is too rosy. Jauhar compares today’s doctors to a mythical, highly respected, noncommercial medical “knighthood.” Dr. Stossel says he was there and can attest that no such nobility existed. And he points out that in Jauhar’s specialty, death from heart disease is 60% lower today than in the 1950s. He also points out that despite the statistics Jauhar offers on physician discontent, medical school applications rose by 38% between 2003 and 2013. There is a lot wrong with modern medicine, but there is a lot right, too.

The Problems He Cites Are Not Hopeless

Rather than just complaining, why didn’t Jauhar offer constructive criticism from his privileged point of view as an insider? A lot of the problems that frustrate him are far from insoluble; they have been identified and efforts are already underway to correct them. Here are some of them:

Patients are transferred without records, so doctors don’t have all the information and have to repeat tests that have already been done. (This is a minor glitch that should be trivially easy to fix in this age of information and Internet communications.)

Patients see a number of specialists who don’t communicate with each other. They don’t have a primary doctor who knows them and cares about them as a person. (That’s the reason I specialized in family medicine; it is feasible for a primary care provider to take responsibility for all the patient’s medical care, coordinate referrals, put the specialists’ recommendations into context with the patient’s over-all needs and personal preferences, and translate medicalese for the patient and family.)

Insurance companies overwhelm doctors with paperwork and long telephone battles to get necessary tests and treatments authorized. (This kind of problem is typical of any bureaucracy and there are several conceivable remedies: a single payer national health insurance, competition between insurance companies with survival of the less obstructionist ones, better utilization of ancillary personnel to take the burden off doctors, etc.)

Medical residents are required to go home after a certain number of hours, and continuity of care is lost. (The previous longer hours had the drawback of sleep-deprived doctors endangering patients. The best balance to achieve both training goals and patient welfare goals is still being worked out and impassioned debates are ongoing in medical journals.)

Procedures are reimbursed, but time spent talking to patients is not. (It could be. Reimbursement scales are constantly being revised, and they could be revised to support the goal of doctors spending more time with patients, which both doctors and patients want.)

Terminal patients in hopeless situations are kept alive when it would be kinder to let them go. (It’s often the patient’s family who insists on “doing everything possible.”  It would help to have more discussions with healthy patients and their families about advance directives, and time spent on these discussions could be reimbursable.)

A lot of unnecessary tests and treatments are ordered.  (The medical profession is self-critical about this issue, and is constantly trying to improve the situation with initiatives like Choosing Wisely, consensus recommendations, policy statements from professional organizations, etc.)

Unethical doctors are gaming the system to make more money in disregard of patient welfare. (We have medical boards that ought to be dealing with such abuses. In practice, they are not doing a very good job. They tend to mostly target cases of drug abuse or sexual misconduct and tend to give substandard care a mere slap on the wrist — just think of the Texas medical board’s ineffective response to Burzynski’s obvious misconduct — but surely there are things we could do to make boards more effective. Isn’t it the responsibility of every doctor to notice when other doctors are using substandard and unethical practices, to confront them directly, to report them, to speak out, to stop referring patients to them? Peer pressure might accomplish a lot.)

Conclusion

The book is an affecting, well-written human-interest story of one man’s experience, but the picture it paints is darker than it needs to be. He admits he suffers from depression and has been getting counseling; I suspect his depression has clouded his perceptions. Some of what he describes represents a typical human trajectory in any lifetime and any job. We grow up. The ideals of youth run into the obstacles of adult reality. We have to earn a living now as best we can, and we don’t have the option of holding out for some ideal job that may not even exist. Aspirations of the perfect succumb to compromises with the possible. “I would never do that!” is replaced by “I had to do it!” Campaign promises are shipwrecked on the political realities of office. Black and white becomes gray and nuanced. A father’s absolute intolerance of abortion changes to reluctant approval of at least one case when his own teenage daughter is raped. We learn that the world doesn’t work the way we wish it would. We adapt. We learn to live with the things we can’t change while we try to change the things we can.

Whatever its faults — and I don’t deny that it has a great many — the medicine of today is better than the medicine of the past and far better than any alternative. Bets of all, we are not sitting on our laurels: medicine is self-critical and constantly working towards even better medicine. We could adopt Jauhar’s pessimism and wring our hands in despair or we could be cautiously optimistic and get to work. He has identified a number of problems. That’s only the first step. Now it’s up to all of us to take the next step and look for solutions.

 

 

Categories: Medicine, Skepticism

Defending Sick Children

Neurologica Blog - Mon, 10/20/2014 - 08:32

One of the most difficult issues that skeptical physicians face is dealing with children sick with cancer whose parents refuse standard therapy. These cases are always highly charged, because the stakes are extremely high. Obviously the stakes are highest for the child as their life is literally on the line. The stakes are also high for society, however, because they force a specific decision regarding the relative rights of parents vs the responsible of the state to care for minors.

Two recent cases once again raise these issues. One comes from Western Australia where 10-year-old Tamara Stitt was diagnosed with liver cancer. Her oncologist recommended chemotherapy. Her parents were (understandably) concerned about the side effects of chemotherapy.

He said he and his wife decided against chemotherapy for their daughter because of its horrific side effects and because he felt threatened by doctors.

Mrs Stitt testified that she believed her daughter had a 100 per cent chance of being cured with natural therapies, and she had initially responded well to such treatment.

Her parents decided against chemotherapy and instead chose “alternative” therapies including clay wraps, herbal teas and a healthy diet. Tamara’s cancer predictably progressed until her parent finally relented. Tamara received chemotherapy in El Salvador, but it was too late, and unfortunately she died of her cancer.

The second story comes from Canada, involving an 11-year-old girl with leukemia. She is a member of the Six Nations, Canada’s largest aboriginal community. Her parents also are refusing chemotherapy because of its side effects and are opting for native and alternative treatments. Recently a judge ruled that we should not impose our modern medicine on a member of this culture:

But Justice Gethin Edward of the Ontario Court of Justice suggested physicians essentially want to “impose our world view on First Nation culture.” The idea of a cancer treatment being judged on the basis of statistics that quantify patients’ five-year survival rate is “completely foreign” to aboriginal ways, he said.

“Even if we say there is not one child who has been cured of acute lymphoblastic leukemia by traditional methods, is that a reason to invoke child protection?” asked Justice Edward, noting that the girl’s mother believes she is doing what is best for her daughter.

“Are we to second guess her and say ‘You know what, we don’t care?’ … Maybe First Nations culture doesn’t require every child to be treated with chemotherapy and to survive for that culture to have value.”

First let me say that the point of this article is not to blame parents. They are in a horrific situation and are sincerely doing what they feel is right. The point of this article is to discuss whether or not desperate parents, regardless of their educational or cultural background, should have absolute authority over the treatment of their very sick children, or does the state have some authority and responsibility to defend the welfare of every sick child?

You can probably guess my position. Children deserve basic medical care and an opportunity to grow up to be adults who can then make their own decisions about their beliefs and the healthcare they choose. Parents should not have the right to condemn their own children to an early and unnecessary death simply because it suits their worldview.

In the case of the Six Nations girls, she has a 90% survival rate with chemotherapy, but she will almost certainly die a painful death if she is treated only with non-science-based treatment.

To establish some basic principles as a starting point, I think we can say there is broad consensus that parents do not have the right to murder their own children, for any reason. The rights of parents are not absolute. They do not own their children as property, and the state has a duty to provide minimal care and protection for children.

Parents also do not have the right to allow their children to die due to neglect. They cannot allow their children to starve, for example. Although this still varies by state and individual cases, I think most people would agree that parents do not have the right to allow their children to die through medical neglect. The only time this becomes an issue is in states that have laws defending parents’ religious freedoms, specifically the freedom to allow their children to come to harm through medical neglect if their faith tells them that is what they should do.

That is a fringe belief, however, and overall the courts have supported the duty of parents to provide basic medical care and the right of the state to intervene if parents are neglecting to do so.

What is most interesting is how differently the states and the courts respond depending on the reasons given for the parental neglect. If the parents have only their medical opinions as justification (meaning that they simply disagree with their child’s doctors), the state is often swift and decisive is taking care of neglected children. They will take children away from their parents, make them wards of the state, and give them the care their doctors say they need.

But then there is a spectrum of complicating factors that seems to sap the courts of their will to protect children. The first is a philosophical position, or essentially choosing alternative treatment to science-based treatment. Then there is religious objections, and finally cultural difference. The latter is especially sensitive when dealing with an historically oppressed people.

However, even in these cases I do not think there is a valid ethical argument that children do not deserve basic rights of their own simply because they were born to parents with particular religious beliefs or who are members of a certain group or culture. (I am not going to get into any issues of legal authority here, just ethics.)

For example, I don’t think the state would allow human sacrifice. Imagine if a native culture still practiced occasional infant sacrifice. Could you imagine a judge defending this practice by saying: “Are we to second guess her and say ‘You know what, we don’t care?’ … Maybe First Nations culture doesn’t require every child to survive infancy without being sacrificed for that culture to have value.”

In essence, the 11-year-old girl with leukemia is going to be sacrificed at the altar of Six Nations culture.  I don’t think it will matter much to her if her throat is slit or if she is allowed to die from a curable cancer, she will still be deprived of reaching adulthood.

I understand there is an emotional difference between being the active agent of someone’s death and allowing someone to die through inaction, but the ethical difference is much more subtle. As the trolley experiments reveal, we are bothered more by active rather than passive killing, even when there is no ethical distinction.

I also think this situation has been complicated by alternative medicine culture. In fact, I place a significant portion of the blame for the unnecessary death of children from treatable diseases at the feet of every guru promoting alternative medicine. They have contributed to a culture in which science and doctors are not trusted, and where everyone feels empowered to be their own expert and do whatever feels right. They have promoted “health care freedom” and “right to try” laws that sacrifice standards of care and ethical practice so that the gurus can make any claims they wish and practice any nonsense that suits them.

Alternative medicine practitioners tell an alluring narrative of “natural” treatments free of side effects, which is like a siren song to desperate parents with sick children. They also infamously overstate and hype their claims. As a result you have the mother of Tamara Stitt who was convinced there was a “100 percent chance” that her daughter would be cured by herbs and diet.

The article on the Six Nations girls quotes fellow member Laurie Hill:

“There’s a fear of [aboriginal remedies] or denial of it. If things can’t be quantified or qualified, to them it’s irrelevant,” said Ms. Hill, as she shopped at Ancestral Voices Healing Centre Thursday. “Who are they [doctors] to say she will make it with their treatments. Just because they have a degree, that makes them more knowledgeable?”

Actually, a degree is a certificate that is earned by demonstrating specific knowledge – so, yes, it does make them more knowledgeable. (That doesn’t mean they are always right, but it does literally mean they are more knowledgeable.) In the quote above you can also see standard alternative medicine propaganda. We are seeing a mixture of this new age culture with more traditional culture and also religious beliefs. They are all blurring into one, with the same justifications for abandoning standards and scientific evidence.

Who are the doctors to say that the girl will “make it with their treatments?” There is a large body of published evidence supporting the safety and efficacy of chemotherapy for leukemia, demonstrating a 90% survival rate. Who are you, Ms Hill, to dismiss this large body of scientific evidence?

Conclusion

To me these cases are crystal clear. Adults can treat themselves anyway they wish. However, parents do not have the right to harm or neglect their children for any reason. One of the primary duties of the state is to protect the vulnerable, those who cannot protect themselves. There is a broad consensus that children are a vulnerable population and need at least a basic level of protection.

This can be done while remaining sensitive to parental feelings and rights. I don’t think draconian measures should be imposed on a hair trigger. But there is a certain threshold that should not be violated. Parents, in my opinion, should not be allowed to refuse life-saving medical treatment for their terminally ill children.

Despite the fact that there is a general consensus that the state has the right and duty to protect children, even from their parents, I feel that specific authorities lose their will to defend children when sticky religious or cultural issues are involved. This is cowardice, in my opinion. Justice Gethin Edward is allowing a young girl to die unnecessarily, failing to perform one of the state’s most basic duties, because it is politically touchy.

Further it is important to recognize that such deaths are part of the harm that is imposed by a culture of anti-science and conspiracy mongering that is represented by the alternative medicine movement. Even the more benign-seeming aspects of alternative medicine contribute to this harm.

Categories: Medicine

What naturopaths say to each other when they think no one’s listening

Science Based Medicine - Mon, 10/20/2014 - 03:35

The true test of a man’s character is what he does when no one is watching.

— John Wooden

Regular readers might have gathered from reading this blog that we are not particularly fond of naturopaths. Actually, naturopaths themselves might be perfectly nice people; rather it’s naturopathy we don’t like, mainly because it is a cornucopia of quackery based on prescientific vitalism mixed with a Chinese restaurant menu “one from column A, two from column B” approach to picking quackery and pseudoscience to apply to patients. Indeed, Scott Gavura features as a excellent recurring series “Naturopathy vs. Science,” which has included editions such as the Facts Edition, Prenatal Vitamins, Vaccination Edition, Allergy Edition, and, of course, the Infertility Edition. Of course, as I’ve pointed out, any “discipline” that counts homeopathy as an integral part of it, as naturopathy does to the point of requiring many hours of homeopathy instruction in naturopathy school and including it as part of its licensing examination, cannot ever be considered to be science-based, and this blog is, after all, Science-based Medicine. Not surprisingly, we oppose any licensing or expansion of the scope of practice of naturopaths, because, as we’ve explained time and time again, naturopathy is pseudoscience and quackery.

A couple of weeks ago, over at my not-so-super-secret other blog, I was “celebrating” (if you will) Naturopathy Week. During that week, one of my readers brought to my attention something that, more than anything else, shows the truth of the quote with which I started this post and another similar quote by J.C. Watts that goes, “Character is doing the right thing when nobody’s looking.” I’m referring to the contents of subreddit posted by a user going by the ‘nym “Naturowhat,” Read what naturopaths say to one another. Conclusion: manipulative, poorly trained, and a threat to public health. Now, I’m not a big fan of Reddit, largely because I can’t figure out how to find things easily, and I hate the sheer ugly and user hostile format of it. However, beggars can’t be choosers; so Reddit it was to examine what naturopaths say to each other when they think no one is looking. I hadn’t planned to comment on this again, but Jann Bellamy thought that our readers would be interested, and who am I to question Jann’s judgment, particularly on a weekend when I was deep into grant writing?

Into the belly of the beast (at least, as much as I can go)

This particular subreddit makes its interesting tidbits available in various ways. Originally, when it was posted two months ago, there were links to a .zip file with a bunch of .txt files representing a private Yahoo! Group named Naturopathic Chat (a.k.a. NatChat). It’s a discussion group in which naturopaths basically let their hair down and discuss…well, everything. In particular, they discuss patients, treatments, and naturopathy. The file is in dBase3 format and, according to the person who tried to upload it, zipped to 62 MB. Ultimately, an anonymous reader pointed me to a copy of the database online containing the entire archive for the NatChat Yahoo! Group. Unfortunately, I have not been able to figure out how to access the actual messages easily using a Macintosh app or, more importantly, to search the database efficiently. So, for the most part, I will be discussing what I found in the subreddit, although I’ve supplemented what some of you might have seen before elsewhere with a couple of examples from the database that are not, as far as I know, online anywhere other than in the database. It’s instructive indeed to peruse them, particularly if you’re sympathetic to claims of naturopaths.

Naturopaths, as regular readers know and as we’ve discussed since the very beginning of this blog, like to claim that they are well-trained to be primary care health providers, a delusion that leads them to try to get states to change their laws to given them that privilege, along with prescribing rights. Across the river from where I live, Ontario made the mistake of granting naturopaths prescribing rights, with an unintended consequence, namely that they can’t find enough pharmacists to test their knowledge of drugs and prescribing. Meanwhile, they lobby states for increased scope of practice and Medicare for reimbursement for their services. Never mind that they regularly demonstrate themselves to be grossly unprepared for the role of primary care practitioner, which is not surprising given their lack of training and how steeped they are in pseudoscience. So little of what’s on that subreddit will likely be a surprise to regular readers here.

It’s actually rather revealing to see what naturopaths themselves have to say about these expansions of their scope of practice. I was simultaneously surprised and not-so-surprised by the reaction of naturopaths to the issues that arise in states where they are both licensed and permitted to prescribe actual pharmaceutical drugs. For instance, see this post by Jared Zeff:

My concern is several-fold, but mostly that WE continue to define ourselves and our standard of practice. I have heard some doctors, particularly younger doctors, tell me that since we now have the prerogative to prescribe antibiotics, for example, we are required to prescribe them exactly like MD’s, as the primary treatment for infections such as cystitis. This means that when confronted with an infection, such as a cystitis, or a Strep pharyngitis, our first treatment must be antibiotic therapy. We may certainly give herbal medicine or whatever in addition, but the standard of care for MD’s is antibiotics, and since we have the same prescribing privilege, we have the same standard of care. I could not disagree in stronger terms. NO, NO, NO!!! I am a naturopath, and I have a separate license, a separate licensure board, and a different standard of care, determined by naturopaths, not by MD’s. Because I may prescribe antibiotics does not meant that I am required to prescribe them, and because I may prescribe pharmaceuticals does not mean that I am required to prescribe them, either. I am a naturopath!

As a naturopathic physician, I am trained and licensed to diagnose and treat the sick, with naturopathic methods, according to naturopathic philosophy. I did this for 30 years without a reliance upon pharmaceuticals, just like Jacob and James. And now, practicing in a state that has given me the privilege of such prescribing, after nearly 100 years of “denying” me such a privilege, does not meant that my practice fundamentally changes. To me, the double-edged sword is that someone may think that because I have this new privilege, I have a new requirement, and am now, suddenly, governed by the same standards as an MD/DO in the treatment of, say, infection, and am somehow suddenly required to use an antibiotic, where 5 years ago I was forbidden from using an antibiotic. This expansion of my prescribing privilege does not fundamentally change my standard of care. My standard of care is determined in part by the therapeutic order concept. Within the therapeutic order, antibiotics are a higher level intervention, after establishing the basis for cure. I may integrate them into my treatment according to my clinical judgement, but by no means am I, or does it make any sense for me to be, required to use them.

Yep. Be careful what you wish for. You might actually get it. Naturopaths in a handful of states and provinces in Canada, have won from the legislature prescribing rights, not because they actually have any clue how to prescribe actual pharmaceuticals to treat real diseases. As was so wisely stated in Spider-Man comics, with great power must also come great responsibility. We physicians know that. Indeed, as a surgeon, I feel this responsibility every time I enter the operating room, because I know that nothing can cure like surgery but nothing can mess a patient up quite like surgery, either. It is a serious responsibility to be permitted to take sharp instruments to the human body to cure disease, and I never forget that.

On the one hand, I have to give Zeff credit for realizing the inherent conflict between medicine and naturopathy that makes laws giving naturopaths prescribing privileges highly problematic—to put it mildly!—but on the other hand, their professional societies (such as they are) are fighting for this. It’s hard not to feel a bit of schadenfreude over the discomfiture of Zeff and other naturopaths like him, but then the fact that it will be actual patients who will be the victims of incompetent, non-evidence-based prescribing of real pharmaceuticals by naturopaths. On the other hand, as we will see, Zeff does not exactly score well on the science-based front overall; so perhaps he just has more self-awareness than most naturopaths when he realizes that he shouldn’t be allowed anywhere near prescribing pharmaceuticals.

Quackery, quackery, quackery

Even in the relatively small sampling available on the subreddit, there are plenty of examples of just why naturopaths should never be allowed to be primary care practitioners—hell, why they shouldn’t be allowed to be health care practitioners of any kind. Perusing them, I was naturally drawn first to this one on IV peroxide:

Hi there,

Looking for experiences that anyone has had with results from IV hydrogen peroxide therapy.

A patient who is ultrasensitive is considering this but hesitant since she reacts so severely even to the minutest amount of homeopathic drainage. I am concerned as well.

Just that she she has severe dysbiosis and many methods we have tried she reacts to.

Any thoughts?

Thank You
Anna Bunda ND
Ottawa, Ontario

Intravenous hydrogen peroxide, of course, is not indicated for, well, anything. Of course, what I’m wondering is what homeopathic drainage has to do with intravenous peroxide therapy or why sensitivity to “homeopathic drainage” would predict problems with intravenous peroxide? But what is homeopathic drainage, anyway? Don’t ask. OK, I’ll tell you. It’s a form of homeopathic “detoxification,” as described here and here. Here’s what Homeopathy Today says about it:

Homeopathic drainage therapy is one of the best ways to promote body`s natural process of detoxification. Clinical experience in homeopathy has shown that some homeopathic medicines are able to improve blood circulation and help the body gently release the accumulated toxins and wastes from all cells and tissues. Homeopathic drugs have a drainage action when prescribed in low potencies (3X,6X, 3C, 5C).

Homeopathic drainage therapy is very useful and effective in every detox program. Complex preparations containing mixtures of such drainage medicines are available and widely used for maintaining health and well-being. The length of treatment may last from 3-10 weeks and usually depends on the person`s state of health. Homeopathic drainage therapy is natural, safe and compatible with other therapeutic modalities. It also minimizes detox side effects.

I do so love how “low potency” in homeopathy-speak means stronger concentrations of homeopathic remedies, you know, not the super ultra-dilutions like 30C. A 30C dilution, as you recall, consists of 30 serial 100-fold dilutions, or a 10-60 dilution, which is, of course, nearly 37 orders of magnitude more than Avogadro’s number, meaning that a 30C homeopathic dilution is incredibly unlikely to contain a single molecule of the starting substance, other than what might have been carried over as a contaminant on the glassware used to do the dilutions. In other words, the “strongest” homeopathic remedies are water. In contrast, 3C and even 5C (albeit to a lesser extent) could have enough compound left to be pharmacologically active, while 3X and 6X could definitely have pharmacologically active compound. (One also can’t help but note that 6X is the same as 3C.) In other words, “low potency” homeopathic compounds are actually the only ones that might do anything, although, given that most of these herbal remedies that form the basis of homeopathic remedies, are not by themselves generally known to do much of anything. I suppose aloe might actually be useful for “detoxification of the rectum,” if by that you mean “soothing,” as aloe soothed a particularly bad sunburn I acquired on my chest and back during my honeymoon on a certain tropical island over 20 years ago.

As for the rest, there’s the ever popular Strychnos nux vomica, which is derived from a tree that produces strychnine. If I were to apply Food Babe reasoning, I’d cringe in horror because it’s active ingredient is still used in pest control products, in gopher bait, and in some rat poisons, but in reality it’s never been shown to have therapeutic value for any condition.

But I digress. Another naturopath is only too happy to help out and tells exactly how he likes to administer IV peroxide:

Anna,

I do a lot of IV H2O2 mostly for acute viral infections, it works very well if this is your goal for treatment.

Mix in 250cc D5W 2.5cc of 3% H2O2, add 5 Manganese sulfate (0.1mg/ml) to prevent phlebitis and irritation on the veins from the peroxide, also add 1cc of Mag sulfate 500mg to help dilate vessels. Drip time is approx 2 hrs.

You may want to half the above formula in the same volume of carrier solution and infuse over 3 hrs for the sensitive person as an initial treatment and then go to full strength if tolerating. Be ready with Benedryl if a reaction occurs.

Jeff Hanson ND
The Nevada Center

See the bizarre mixture of quackery (remember, IV peroxide is not a treatment for infection, viral or otherwise) and seemingly conventional medicine, with manganese sulfate and magnesium sulfate being given, as well as a good old standby of conventional medicine, Benadryl, being available in case of hypersensitivity reaction. And, of course, given that chronic Lyme disease is a favorite bogus diagnosis of quacks everywhere, an undefined disease characterized quite properly as the latest in a series of many labels that have attempted to attribute medically unexplained symptoms to infections, and that antibiotic treatment is not warranted and for which there are many unvalidated tests sold in the clinics of naturopaths and other dubious practitioners.

For instance, a naturopath named Renee Lang of Biologic Integrative Healthcare asks whether IV peroxide is good for “stubborn Lyme infection,” and is told by Stacey Rafferty:

I have used H2O2 a fair amount in the vast protocols needed to treat lyme. I believe it addresses the co-infections the best. Almost all lyme patients have EBV, mycoplasma, yeast et…. I am not convinced H2O2 helps with borrelia. If one is using HCl along with H2O2, the immune stimulation that occurs with HCl might be the therapeutic value.

HCl is hydrochloric acid, for those without a background in chemistry. So, here we have a naturopath injecting not just peroxide but hydrochloric acid, into patients. I’m guessing that’s mighty rough on veins, as rough on veins as some chemotherapeutics, although the 3% peroxide is diluted 1:100, which is relatively dilute and we don’t know what concentration of HCl was used along with H2O2. One wonders if Rafferty puts a Portacath in to administer this rather toxic concoction. It’s probably not nasty enough to do really serious damage to veins unless she’s giving it every week, but I’d be worried about extravasation, just as I would be for chemotherapy. Whatever the case, one wonders where these naturopaths get their H2O2 and HCl. Both are “natural,” but isolating them involves a lot of that evil chemistry that naturopaths so dislike.

Consistent with the love naturopaths bear for the nonexistent entity that is chronic Lyme disease, there’s a letter from a naturopath about her child upon whom a tick was found. The tick was removed by a physician, and the discussion turns to all sorts of concerns about—you guessed it—chronic lyme disease. Naturally, this naturopath is waiting for homeopathic nosodes, which homeopaths think protect agains infection. There’s the usual recommendation for nosodes and “naturopathic care,” but one naturopath named Kathleen Riley helpfully suggests:

Are you able to see the site of the tick bite? If you can , I recommend using a drawing salve until the site is no longer visible. Research presented at a past ILADS conference demonstrated live spirochetes at the bite site when it remains inflamed, even if the bite was a year before. To prevent a possible reservoir of Lyme, I have all my patients use a drawing salve on the bite site until it is no longer visible. This is in addition to using homeopathics and antimicrobials for a minimum of 3 weeks and monitoring for symptoms for 3 months after the bite. Earth Botanical Harvest’s Herbal Compound Ointment has been useful for extracting remnant mouth parts. Patients have also successfully use old fashioned black salve for this purpose.

Black salve? That’s downright delusional. It’s basically acid that burns away skin lesions. It’s not for nothing that I once referred to it as “cutting, poisoning, and burning naturally.”

Speaking of black salve, one of the few discussions I could find in the actual database involved the application of black salve on tumors. In a discussion from 2006 under the subject header of “Black Salve for a Huge Protruding Tumor – Q” we find this question:

I had a patient this morning with multiple large fruit sized tumors erupting from her left axilla and chest. The left arm is completley immobilized and edematous. She is terrified that the tumor will eat into her aorta or jugular vein and she’ll bleed to death. She had DCIS in 1999 which was excised with a lumpectomy, clean margins, 2 lymph nodes of 18 were positive. Clear for 2 years after multiple rounds of chemo; now she’s maxed out on radiation too. Considered inoperable. The armpit looks like a gaping mouth filled with yellow custard. On top of this she has a bad case of shingles under the left breast. I treated her with a B12/ADP shingles IM protocol and helped her devise a smoothie using Thorne Supportive Care nutrients, Hoxsey formula, berries, yogurt. Taught her how to make whey fermented veggies. She came to me for a black salve remedy because she knew I did escharotic Tx for cervical dysplasia. I recommended debridement of the oozing, crusty, erupting tissue with saline and bromelain, twice daily, air dry, then for bed placing an occlusive dressing with a “yellow” salve including calendula. Also hp silica. Any ideas where to get a good black salve, or any other thoughts on helping draw this tumor cluster out of her body? Clearly, she is trying to push this goopy mass out and there are 2 discrete “tops” to what literally looks like a volcanic field on her left chest. I’m concerned that if the tumors don’t come out they will spread laterally and cause further compression and intractable pain. She already takes Oxycodone and has a Dilaudid pump.

Thanks,

Emily Kane
Juneau AK

These sorts of cases are the ones that I as a breast surgeon dread. Fortunately, for the most part, they are almost completely preventable if the tumor is treated when it’s diagnosed. We might not be able to save the life of the patient, but at least we can usually prevent this outcome. In this case, however, it appears, at least as far as I can tell from the question, that everything was done more or less properly at the beginning, although I would point out that it must have been cancer, not ductal carcinoma in situ (DCIS) because otherwise the surgeon would not have performed an axillary dissection (removal of all the lymph nodes under the arm). I would also point out that, whatever this naturopath thought to be shingles, was far more likely to be skin involvement by the tumor. In any case, this is what we call carcinoma en cuirasse. It’s something I’ve described before in the context of the quackery that is New German Medicine, alternative medicine use in breast cancer, as well as another post. It’s a horrible condition, and once surgery, chemotherapy, and radiation have failed, there’s very little left that can be done other than palliation. In any case, Kane seems to misunderstand the significance of these masses in that she thinks that if they don’t “come out” they will spread laterally. Generally, when disease gets to this stage such masses are spreading both ways.

To be honest, I feel a little sorry for Kane, who is utterly out of her depth, although I feel much more sorry for the patient. So what sorts of answers did naturopaths come up with? Well, there’s this one:

She is so lucky to have found you. Last year I did a seminar in Canada and saw pictures a woman took of her breast cancer as it moved out of her body using the Black Salve. It took her 40 days for the tumor to come to the surface and move out. I spoke to a woman in Canada who will go to someone’s house and apply the salve for them. The website I have is http://www.cancersalves.com/. The only notes I have are as follows: Apply Goldenseal paste first and then add Bloodroot on top. Change the bandage every other day. This is very painful. The more cancer, the more painful. Please let me know how this goes for you and if she is successful.

Deanna Hope Berman, ND, CM
Naturopathic Doctor, Certified Midwife

Another naturopath from Portland, OR named Virginia Osborne recommended yampavalleybotanical.com. One naturopath from Seattle named Eric Yarnell was actually skeptical and mostly reasonable, pointing out that black salve fries healthy tissue as well as cancerous tissue and is extremely painful and gruesome. He described melanoma patients who died horrible deaths, although it wasn’t clear if it was due to metastastic melanoma or injury from the black salve. Berman would have none of this:

I have seen people who use naturopathic medicine as they do allopathic medicine for cancer care. What I mean is they come in, do a treatment – black salve or other – and then return to their previous life. I am wondering if the people who did the black salve and later died from metastatic disease were like this. Did they continue to use naturopathic therapies and continually work at healing? If not, I am not surprised by the outcome. If someone “treats” cancer naturopathically, I don’t think there is any turning back. I think they need to change their life and work every day towards health.

In other words, you have to believe, and if naturopathy doesn’t cure your cancer you weren’t dedicated enough to the naturopathic cure (or your naturopath didn’t have enough faith to give up anything resembling conventional medicine and use only naturopathy). You didn’t “change your life and work every tday towards health.” I’m sorry, but once you have a bona fide invasive cancer, working towards health involves using the best science-based treatment there is. If the cancer is incurable, nothing a naturopath can do will make a difference, other than, in the case of using black salve, interfering with good palliative care.

Moving away from cancer, as a surgeon, I was interested in a discussion “Ulcerative colitis – abscess on j-pouch.” Basically, not infrequently, the variety of inflammatory bowel disease known as ulcerative colitis requires a total proctocolectomy (removal of colon and rectum). However, thanks to the wonder of modern surgery, it is possible for such patients not to have to have a permanent ileostomy stoma through the construction of an ileo-anal reservoir more commonly referred to as a “J-pouch.” Basically, the operation involves taking a piece of terminal ileum (the end near where the small intestine dumps into the colon) and bending it back on itself to form a reservoir, which is then sutured to just above the anal sphincter. It forms a reservoir that partially replaces the reservoir function of the rectum and allows a patient to live without a permanent stoma, although the price is several loose bowel movements a day because the water reabsorption function of the colon is missing. Still, most UC patients consider not having a permanent ileostomy to be worth that price. Here was the problem:

I have a 40 year old female with an abscess on her j-pouch. She has ulcerative colitis and had a complete colectomy 4 years ago and had a J-Pouch created. Her chief concern right now is that she has an abscess on her J-Pouch and the antibiotics aren’t helping. She’s had it drained but it just came back. The MDs suspect it is bacterial but haven’t been able to culture anything She’s coming to me acutely to help with the abscess or else she will have to have surgery to have a stoma created. Any ideas on how to treat the abscess?

Also, once that is treated, she wants overall help with digestion, frequent and spasming BMs, fatigue, pain, energy, etc. She had a colectomy but I’m assuming I still treat the ulcerative colitis since it is an autoimmune condition and the underlying process hasn’t been addressed. From another ND, she’s on VSL#3, lots of omega 3, glutamine, Absolute Veggie protein powder, DIDA tablets, Oregano Oil, Marshmallow tea, Chaga tea, Vit C, Genestra Herbal GI, Thorne Ferrasorb, Thorne Muti-B6, Vit D, New Chapter Bone Strength. She’s currently on a liquid diet – protein shakes with fresh veggie/fruit juices. Anything striking that is missing here? I was thinking of trying a low-sulfur elimination diet and am hoping to get her eating again. She’s losing lots of weight and I find that concerning.

What this patient probably has is pouchitis, a common late complication of J-pouches involving chronic inflammation of the pouch that occurs in 15-50% of patients. It’s a difficult and poorly understood complication whose etiology is thought to be multifactorial and involve genetic, immune, microbial, and toxic mediators, with possible causes including fecal stasis, increased anaerobe/aerobe bacterial ratio, ischemia, and underlying disease. Also 1 to 2 cm of anal canal mucosa is usually retained and can develop recurrent UC. The usual treatment consists of antibiotics and antidiarrheal agents. More concerning is the recurrent abscess, which could mean fistula formation. When fistula formation occurs late, a concern should be raised that the patient actually has a different kind of inflammatory bowel disease, Crohn’s disease. In any case, the treatment for recurrent abscesses and fistulae, such as what this patient sounds as though she has, are treated surgically, with a diverting ileostomy that is usually temporary to divert the fecal flow and allow healing.

In jumped Emily Kane again to suggest ozone. She doesn’t seem to realize that the abscess is intra-abdominal, as she suggests that “bagging the wound and applying ozone would be fabulous.” (No, not so much.) Another naturopath, Jennifer Shalit from Toronto, does actually ask the right question, namely “How does that work when the wound is internal?? Answer: It doesn’t. Or maybe ozone enemas will be proposed.

There were a bunch of other discussions, few of which involved anything other than purest quackery, such as this discussion where—of course—chelation therapy is highly recommended for a patient with cardiovascular disease on Plavix (an antiplatelet drug that slows coagulation) and aspirin because he’s had cardiac stents. Jeff Hanson helpfully suggests:

Are you able to do IV Na-EDTA chelation with this patient? Refer to the Alt Med Review from June 2007 regarding chelation, dual anti-platelet tx, and stents. In this review article, “studies demonstrate EDTA inhibits platelet aggregation…… via three mechanisms while it maintains a safety factor my not inhibiting collagen-induced aggregation…whereas, Clopidogrel inhibits by only one”. I have seen a number of patients outlive the expected life of their stents and not requiring re-stenting. Chelation is one of those treatments you can hang-your-hat-on for stable angina sx and cardioprotection post stenting. Chelation is not proven to remove arterial plaque but I have seen clinically in 2 pts receiving this tx that did a before and after Carotid Intima Media Thickness scan, they saw a 50% reduction in the amount of carotid plague and artery thickness. I would recommend 20-30 IV’s 2x/week then 1 tx monthly as maintenance. Don’t include vitamin C in formula because it can promote inflammation (see “alt med review” original study from March 2009 on EDTA and Vit-C). In addition, ozone tx with Major Autohemotherapy before chelation can promote RBC oxygen utilization and add a boost to the chelation tx.

At least he goes on to say that he wouldn’t use chelation in place of Plavix for 6-12 months. Good to know, given that the recommendation was to use Plavix and aspirin for six months but apparently now is to use it for a year after stent placement to prevent clotting. (The things I learn talking to cardiologists about my patients when asking if I can take them off of Plavix for a few days to do some breast surgery operation! I can operate pretty safely when a patient is on aspirin. Plavix, not so easy. It’s not unlike operating on a patient on coumadin.) Of course, as we know, chelation therapy for cardiovascular disease is also quackery, the recent clinical trial known as TACT notwithstanding.

Naturopaths versus vaccination

I could go on and on (indeed, once I figure out how to efficiently search the database it could provide endless blogging material), but instead I’ll close with—of course!—what naturopaths think about vaccination. Let’s just say they aren’t very enthusiastic about vaccines, pulling out old tropes about vaccinations during the baby’s first year, and they like Dr. Sears, although, surprisingly, one naturopath actually mentioned the CHOP website. Of course, that brought out another naturopath pulling the “pharma shill gambit” on the CHOP website. In fact, this naturopath, Doug Cutler, is in my neck of the woods and states plainly at various points:

Agreed. But the sad reality, is that the “study” is being performed today with our children as the guinea pigs. Absolutely shameful that the biggest medical fraud (perpetuated by Big Pharma) continues to indoctrinate the public (“milk does a body good”) that vaccines are safe and effective. As you stated, we still don’t know the longterm vaccine safety so hoping that they are safe and effective for the “greater good” is unacceptable and completely immoral until we fully know.

You are right though, we need to question our personal “dogma/bias”. I fully believed in vaccines until my intimate association with hundreds of mothers that had vaccine injured children, changed that entire belief set completely around. The same amazing mothers that knew more about vaccines than any doctor or scientist out there, hands down. Then with my training and knowledge of environmental toxins, just analyzing the actual ingredients of each vaccine, one by one – I could never in good conscience justify those known toxic ingredients to have a free pass directly (no detox roadblocks) to a baby’s brain.

And:

And lastly, I would like to see a part of the topic to properly train docs (who vaccinate) on how they should prepare their patients for the above toxic ingredients by first addressing genetic polymorphisms, nutritional deficiencies, food allergies/sensitivities and parent’s toxic burden before conception. That way, I won’t have to continue to see vaccine injured patients who are very difficult in recovering and supposedly don’t exist in our society.

And:

My disclosure, I am opposed to all sources of toxins therefore I am against vaccines whose one size approach fails to account nutritional statuses, toxic burden of mom/child and genetic polymorphisms that are at epidemic levels. 10 vaccines from birth to 6 years in 1983 and 36-38 vaccines from birth to 6 years in 2010. Insane.

No, being as antivaccine as Cutler is is not in the least bit science-based. He goes on and on against vaccines in the course of several longer-than-average entries in the discussion thread. You know, I might have to explore his website further. It is, as we say in the biz, a “target-rich” environment, and I always wonder about someone who is this antivaccine. In any case, “naturally,” other naturopaths throw out links to the National Vaccine Information Center and its highly deceptive Vaccine Ingredient Calculator. To be fair, there were a couple there, one in particular, criticizing the conspiracy mongering and antivaccine misinformation being spread there, even going so far as to state that “placating anti-vaccination isn’t responsible for our community and does nothing to further the profession,” but I actually think that one naturopath summed up the true case thusly:

Asking naturopaths to accept vaccinations is comparable in my mind to asking dentists to give up amalgams. It touches on some very deep beliefs in the professional group

Those beliefs are, of course, overwhelmingly antivaccine and baked into the very DNA of naturopaths, beginning in naturopathy school.

What to do, what to do?

Naturowhat (NW) is apparently still part of the NatChat Yahoo! Group, because he/she/it is still releasing occasional update documenting the reaction of the group to the release of its contents two months ago, one of which states that NW had published some of it on Facebook, although I haven’t been able to find it. From what I’ve been able to gather (which, unfortunately, isn’t much), NW infiltrated the Yahoo! Group. However, it’s a closed group that requires proof that a person looking to join it is actually a naturopath or a student in a naturopathy school, which would imply either that (1) NW is a naturopath or (2) NW is good at spoofing evidence of having graduated from a naturopathy school and passed the naturopathic board exam. I tend to favor the first possibility, a naturopath who has become disillusioned with the pseudoscience, but I really have no evidence one way or the other.

Understandably and not unreasonably, additional tidbits posted by NW demonstrate that the members of the group are unhappy. One naturopath, Anne Hill of Portland, for instance, suggested getting out of Yahoo! Groups and getting a private group together. I’ll give her credit, too, for seeing opportunity in disaster, financial opportunity:

Hi Mona-maybe this is a good time to reconsider getting out of the yahoo format and getting a private group together. A lot of this information that we share is really cutting edge and many of the protocols that our incredibly savvy naturopaths have come up with could be considered proprietary information. We also do sometimes share some very personal information on here about patient health historys and business practices.

I can’t help but think this breech is more about data mining then caring about what we are doing with our medicine. I mean really-who cares what we do? I haven’t seen a pitchfork or a ring of garlic in ages. Data miners tend to be looking for what they can sell, resell and make money off of themselves. I would worry that continued access might lead to something more damaging on a business level for one or more of our practitioners rather then it being a belief system thing……

I think we had all shared a while back how much we really appreciate this form and utilize it on a regular basis for researching protocols and new ideas for treatment as well as for posting ourselves. And I believe that many shared that they didn’t mind if there was an extra charge involved. Perhaps there can be a front website where advertising can be sold as well. If there was recently reported that we have 3,000 plus members here then that should be a supplement advertisers dream come true:)

Yep. The reason that whoever leaked the information on NatChat was not because he or she was appalled at the quackery exchanged therein or the belief system demonstrated in these conversations among naturopaths. Oh, no. It had to be because of all the “cutting edge” protocols and “proprietary information” that they wanted to make money off of. Indeed. I predict that this Yahoo! Group will soon go away, to be replaced by an advertising-supported web-based forum format. Three thousand naturopaths to advertise to surely would be a goldmine to supplement manufacturers. Meanwhile, the search for the “traitor” goes on, with Mona Morstein, the naturopath who started the Naturopath Chat Yahoo! Group telling members:

Well, the saga continues a bit. I guess the fellow put some stuff on FB. I appreciate everyone understanding this is not the end of the world. I am calling the AANP tomorrow to chat with them for some ideas. I also feel we should not be ashamed AT ALL at who we are, what we believe, what we write. There are always cowardly jerks out there in Internet Land who feel compelled to hate behind the safety of their computer screens. I strongly suggest we all stand firm and proud and not cower from him.

She also goes on to explain that she’s trying to get Reddit to take what’s there down (good luck with that) and hits up her members to help pay for an IT specialist who “who feels quite certain he can track down the problem and get this situation under control”—at a cost of a $300 retainer and $100 an hour. The problem, of course, is that if there is someone on the “inside” leaking information then no amount of “tracking down” in the world will help unless they can identify the person leaking the information. I have no idea who it is (although I’d love to know so that I could buy him or her a beer), and neither does anyone else. Certainly, I hope they don’t figure out who leaked the contents.

In the meantime, if there’s one thing this dump of tens of thousands of messages shows, on just a cursory examination (to truly delve its contents will require a lot of time and work and to do it right is probably beyond my skill set), it’s this. Contrary to the whitewash campaign of “Naturopathic Medicine Week 2014” promulgated a couple of weeks ago by credulous legislators, naturopathy has been, is, and always will be quackery.

Categories: Medicine, Skepticism

Questions and Answers about Chiropractic: The Bottom Line

Science Based Medicine - Sun, 10/19/2014 - 03:00

I am often asked, “What do chiropractors do?” That’s not an easy question to answer. The answer is usually expected to be, “They treat back trouble.” But as alternative medicine practitioners, chiropractors do a lot of things, and they treat a variety of ailments, based largely on a scientifically invalid vertebral subluxation theory which proposes that nerve interference resulting from a misaligned vertebra or a dysfunctional spinal segment can affect general health.

As a co-host of the Chirobase web site, I frequently answer questions about chiropractic, some of which are published in a section titled “Consumer Strategy/Consumer Protection.” In this post, I’ll focus on these:

  • Are Subluxations Causing My Health Problems?
  • Is a Misaligned Atlas Causing My Back Pain?
  • What is that “Thumper” My Chiropractor Uses on My Back?
  • How Does a Chiropractor Locate Subluxations?
  • Should I Let a Chiropractor Adjust My Baby?
  • Why Is Every Chiropractor’s Treatment Different?
  • Can Neck Manipulation Cause a Stroke?
  • Should I Go to a Chiropractic College?
  • Are There Any Good Chiropractors?
  • Is It Possible to Reform the Chiropractic Profession?

By far, most of the questions I receive express concern about questionable methods and advice offered in the offices of chiropractors. Many questions are generated by the suspicions of patients who initially visited a chiropractor for treatment of back pain and who were then offered spinal adjustments as a treatment for health problems unrelated to the spine. Patients are often concerned about the expense involved in such care, usually extended over a long period of time, followed by “maintenance care” to correct or prevent “vertebral subluxations” after symptoms have resolved. I generally advise patients to refuse chiropractic care for anything other than a musculoskeletal problem, to seek treatment only when symptoms are present, never pay for treatment in advance, and to discontinue treatment and see an orthopedic specialist if symptoms worsen after a few days or have not subsided after a week or so.

Are Subluxations Causing My Health Problems?

No. Unfortunately, the chiropractic vertebral subluxation theory sounds plausible to medically untrained persons. When a chiropractor explains the subluxation theory, holding up a real spine and then pointing to a nerve chart showing spinal nerves connecting with all the body’s organs, along with a list of diseases caused by “nerve interference,” few lay persons are knowledgeable enough to question the theory. The truth is that spinal nerves supply musculoskeletal structures. The body’s organs are supplied by ganglia (some of which receive preganglionic fibers from the thoracolumbar portion of the spine) and plexuses in a separate autonomic nervous system located outside the spinal column and by the all-important vagus (cranial) nerves which pass down from openings in the base of the skull to supply thoracic and abdominal organs. Hearing, sight, and other functions involving structures in the head are supplied by cranial nerves which pass through openings in the skull. Autonomic fibers supplying pelvic viscera pass through solid bony openings in the sacrum at the bottom of the spine. Obviously, the well-protected autonomic nervous system, so essential to life, is not threatened by a vertebral subluxation.

A spinal nerve is rarely compressed by a misaligned vertebra. When a spinal nerve is compressed, usually by disc herniation or osteophyte formation, symptoms occur in the musculoskeletal structures supplied by the affected nerve but the body’s organs are not affected. Severance of the spinal cord at or above the 4th cervical vertebra, shutting off brain impulses to spinal nerves, can cause paralysis of muscles from the neck down while the body’s organs continue to function.

Although the original theory of chiropractic defines a subluxation as a vertebral misalignment that places pressure on a spinal nerve, more recent theories define a subluxation as a “vertebral subluxation complex” that affects nerve, blood vessel, and connective tissue structures in a spinal segment, causing nerve interference without misalignment of a vertebra. Both types of subluxations are alleged to affect general health; neither has been proven to exist. Nevertheless, it is common practice among chiropractors to treat a health problem by adjusting the spine to “realign the vertebrae” or to “remove nerve interference.”

Click to embiggen.

This is a portion of an old Meric System chart that assigns certain vertebrae to certain organs and diseases; it ignores the cranial nerves which pass through openings in the skull. Some subluxation-based chiropractors still use this chart to determine which vertebrae to adjust when treating an organic problem. “Up-to-date” chiropractic upper cervical specialists, however, claim that simply adjusting the atlas to remove pressure on the brain stem will “restore perfect health” (www.nucca.org).

Is a Misaligned Atlas Causing My Back Pain?

One of the most common and exasperating questions I receive comes from chiropractic patients who have been told that misalignment of the atlas, the uppermost neck vertebra, is the cause of a great variety of ailments from the neck down, including low-back pain. Frightened by scare tactics that predict dire consequences from atlas misalignment that allegedly presses on the brain stem, patients are often reluctant to discontinue treatment they have been led to believe will prevent the development illness.

When the atlas is not locked or fixated by injury or disease and is freely movable, its resting place is dictated by the anatomical configuration of joint surfaces and cannot be changed. When the atlas is moved by manipulation, it always returns to its normal resting place. Atlas “subluxations” found in the necks of persons who are not having a neck problem are usually the result of measuring structural asymmetry and are not significant.

Patients are always relieved to hear that their atlas is not out of place and that they do not need atlas adjustments to restore or maintain their health. An atlas misalignment is certainly not a cause of low-back pain.

What Is that “Thumper” My Chiropractor Uses on My Back?

An adjusting instrument using a spring-loaded stylus.

Once a patient has been convinced that his or her spine harbors vertebral subluxations that can cause disease or affect general health, any one of dozens of chiropractic adjustive techniques might be used to correct and prevent recurrence of such subluxations. One of the most bizarre methods of adjusting the spine uses a handheld instrument with a spring-loaded or electrically powered mallet or stylus to tap on selected vertebrae. A dubious leg-length check might be used to determine if correct alignment has been restored, a procedure so implausible that it is the subject of many of the letters I have received from chiropractic patients.

Some computerized adjusting instruments use a piezoelectric sensor that will allegedly locate and correct a vertebral subluxation by analyzing the echo of an oscillating force applied to a vertebra. Such an instrument has proved to be an effective way to sell chiropractic care and is often advertised as “advanced chiropractic technology.” While some chiropractors genuinely believe that the vertebral subluxation theory is valid, subluxation-based “chiropractic technologies” have more to do with marketing than with health care.

How Does a Chiropractor Locate Subluxations?

Chiropractors generally locate subluxations by measuring x-ray images of vertebral misalignment caused by degenerative changes or structural abnormality, such as disc degeneration or spinal curvature. Such “subluxations” are usually asymptomatic and not significant. Subluxation-based chiropractors might use such “advanced technology” as computerized surface electromyography (not the same as needle electromyography used by neurologists) that prints out brightly colored charts measuring electrical activity in muscles, alleged to indicate the presence of vertebral subluxations. Some use thermography that measures an elevation in skin temperature believed to be associated with vertebral subluxations. Applied kinesiology (not the same as the science of kinesiology) is a nonsensical way of locating subluxations by testing arm strength before and after a spinal adjustment; it is also used to detect the presence of disease and vitamin deficiency. Many chiropractors claim to be able to find vertebral subluxations by palpating the spine, that is, by using fingertips to feel vertebrae.

All such subluxation-detection devices and procedures are as dubious as the subluxation theory that prompts their use.

Remember that a real orthopedic subluxation, a partial dislocation, causes musculoskeletal symptoms and is not the same as an asymptomatic chiropractic vertebral misalignment (subluxation) or an undetectable “vertebral subluxation complex” alleged to be a cause of bad health.

Should I Let a Chiropractor Adjust My Baby?

No! When I see a chiropractor palpate the spine of an infant or a neonate in a search for subluxations, I suspect either fraud or woeful ignorance. There is no way that a chiropractor can find a subluxation by palpating the fat-padded cartilaginous spine of a newborn baby. Following up such an examination with an attempt to correct vertebral alignment by manipulating the baby’s spine is unnecessary and dangerous.

There has been some speculation that manipulating the immature spine of an infant or a small child might damage the soft, cartilaginous growth centers in the vertebrae, resulting in the development of pre-adolescent spinal deformity, such as scoliosis or Scheuermann’s kyphosis (O’Neal 2003) — a speculation worth considering since there is no reason to believe that manipulating the spine of a small child is ever helpful or indicated.

Why Is Every Chiropractor’s Treatment Different?

The techniques of manual generic spinal manipulation performed by science-based practitioners are pretty much the same, no matter who does the manipulation, whether done by a chiropractor, a physical therapist, an osteopath, or a physiatrist. Spinal manipulation, called a “spinal adjustment,” performed by subluxation-based chiropractors, however, may involve dozens of different techniques, each one different from the other, some of which do not require manual manipulation of the spine, none of which are compatible with conventional manual therapy.

Chiropractic: An Illustrated History, published in 1995 by Mosby-Year Book, listed 97 different chiropractic techniques, ranging from Activator Technique to Zindler Reflex Technique. When a patient goes from one chiropractor to another, each using a different technique that is claimed to be superior to the other, an apparent lack of standards would suggest that it might be best to bypass the chiropractor and seek manipulative care from a physical therapist or an orthopedic manual therapist.

Can Neck Manipulation Cause a Stroke?

Questions often arise about the safety of neck manipulation and the possibility of such treatment causing a stroke. With an increasing number of case reports associating neck manipulation with stroke caused by injury to vertebral and internal carotid arteries, there is good reason to question the use of neck manipulation, no matter who does it. When the neck is forcefully rotated in passive manipulation, the greatest amount of rotation takes place in the atlantoaxial joints in the upper cervical portion of the spine. There is reason to believe that extreme rotation of these joints during thrust manipulation can overstretch or injure the vertebral arteries and cause stroke, affecting the posterior portion of the brain.

Since there is little or no evidence that benefit outweighs risk when manipulating upper cervical structures, it is generally best to avoid such treatment. Unfortunately, many chiropractors, especially “upper cervical specialists,” manipulate the neck of every patient they treat in a misguided effort to correct alleged vertebral subluxations.

Should I Go to a Chiropractic College?

I occasionally receive letters from undergraduate students who are considering enrolling in a chiropractic college, asking which college is best. I also receive letters from chiropractic students who are beginning to doubt what they are being taught in chiropractic class rooms. There are a number of reasons why I generally advise against attending a chiropractic college, the first and foremost of which is the scientifically indefensible chiropractic subluxation theory that isolates the chiropractic profession from mainstream health care, keeping it marginal and controversial. Rejection by healthcare professionals in the scientific community, combined with the aggressive competition of subluxation-based chiropractors, makes it difficult to succeed in practice as an ethical, properly-limited chiropractor. Failure in private practice leads to unpaid student loans and very little opportunity for employment outside of private practice.

In January of 2012, the Health Resources and Services Administration (HRSA) reported that chiropractic schools had a much higher default rate on student loans than other health professional schools. More than half of the individuals on HRSA’s default list attended chiropractic school. Societal suspicion, refusal of accredited academic institutions to recognize chiropractic, the competition of physical therapists who now use manipulative therapy, and uniform criticism by the scientific community has had an adverse affect on chiropractic colleges and the income of chiropractors in private practice (who treat less than 10 percent of the population annually). A November 2012 Gallop Poll reported that only 38% of respondents rated the honesty and ethical standards of chiropractors as high, with a 70% rating for medical doctors.

According to the U.S. Department of Commerce, the average gross income per chiropractic office between January1992 and December 2007 rose at less than half the rate of inflation. This loss of purchasing power makes it difficult to justify the high cost of opening an office today if such an operation does not yield adequate income.

Enrollment in chiropractic colleges in the United States dropped precipitously─35 percent─between 1995 and 2002 and has since flat lined. As a result of a decline in the enrollment of students in chiropractic schools and a reduced demand for chiropractic services, a few chiropractic schools have labeled their institutions as a “University of Health Sciences,” including programs offering degrees or certificates in such subjects as acupuncture, Ayurvedic medicine, naturopathic medicine, oriental medicine, and massage, all of which, with the exception of massage, are questionable practices sheltered under the umbrella of alternative medicine.

My heart goes out to those ethical and well meaning chiropractors who discover too late that they must suffer embarrassment and financial strain in years of struggle that may or may not lead to a successful practice. If I could have advised them beforehand, I would have suggested that they pursue a doctor of physical therapy degree, which would provide opportunity to use manipulative therapy along with other physical treatment methods, without dogma, societal suspicion, or rejection by the scientific community.

Are There Any Good Chiropractors?

I am often asked why I am always badmouthing chiropractors and if I think that there are any good chiropractors. I always respond by saying, “Yes, but they are hard to find.” A chiropractor who limits care to musculoskeletal problems, with emphasis on the care of mechanical-type neck and back pain and related problems, can offer a service of value if he or she does not subscribe to chiropractic vertebral subluxation theory.

Believing that chiropractors are back specialists, patients sometimes request referral to a chiropractor. It has been my observation that physicians are often receptive to referral of a back-pain patient to a properly-limited chiropractor who offers appropriate manipulative therapy that is not readily available in local physical therapy establishments. The availability of a good chiropractor can provide physicians with a way to steer their patients away from the nonsensical, pseudoscientific services of subluxation-based chiropractors.

A physician can sometimes identify a competent chiropractor by personal correspondence that includes an exchange of office notes. Unfortunately, it seems that few chiropractors will publicly renounce the anti-medical subluxation theory that places chiropractors in competition with physicians, making it necessary to generally advise against chiropractic care.

Strip used with permission granted by Bill Janocha c/o Mort Walker. Click to embiggen.

Is It Possible to Reform the Chiropractic Profession?

I gave up trying to reform the chiropractic profession many years ago. My primary concern has long been to separate appropriate use of generic spinal manipulation from subluxation-based chiropractic. It will continue to be necessary for good chiropractors to publicly identify themselves as opponents of chiropractic subluxation theory if they are to receive any support from the scientific community. If chiropractic is ever to be developed as a properly limited musculoskeletal specialty, it must discard subluxation theory and alternative medicine practices that embrace a broad scope of ailments and then make the changes needed to specialize in conservative care for mechanical-type neck and back problems, offering a physical treatment armamentarium that includes use of spinal manipulative therapy as a treatment option.

At the present time, with state laws defining chiropractic as a method of correcting vertebral subluxations to restore and maintain health, change for the better does not seem likely anytime soon. Chiropractors who back away from subluxation theory might use alternative medicine procedures along with spinal adjustments in order to expand their scope of practice. According to National University of Health Sciences, a leading chiropractic college, “National University is a leader in the growing field of integrative medicine. We set the standard in training for careers in health care and prepare students to become first-contact, primary care physicians who are fully qualified to diagnose, treat and manage a wide range of conditions.”

It appears that chiropractors generally prefer to use spinal adjustments or a combination of spinal adjustments and alternative healing methods to treat non-musculoskeletal conditions as well as musculoskeletal problems as primary care providers rather than specialize in the care for back pain and related musculoskeletal problems, despite the fact that back pain and musculoskeletal problems are the No. 1 and No. 2 causes of disability worldwide (Vos et al. 2012).

The Bottom Line

When the National Board of Chiropractic Examiners published its updated version of Practice Analysis of Chiropractic in 2010, a pre-publication bulletin stated that “…the 2009 survey questionnaire did not ask about the use of applied kinesiology or any of the subluxation-based ‘adjustive procedures’ that place chiropractic in an unfavorable light.” The updated report, describing chiropractic as “the nation’s third largest primary health care profession,” stated, however, that “The specific focus of chiropractic practice is known as the chiropractic subluxation or joint dysfunction. A subluxation is a health concern that manifests in the skeletal joints, and, through complex anatomical and physiological relationships, affects the nervous system and may lead to reduced function, disability, or illness.”

Chiropractic continues to be based primarily on subluxation theory, with increasing use of a variety of alternative healing methods. The question “What do chiropractors do?” continues to be difficult to answer. Persons who are not familiar with the controversial aspects of chiropractic care might simply assume that chiropractors are back specialists since they work on the back. A visit to a chiropractic office for back-pain treatment, however, where spinal adjustments or some other alternative medicine procedure might be offered as a treatment for “a wide range of problems” would suggest that chiropractic is certainly not properly limited and is not a specialty or subspecialty in the care of back pain.

Sam Homola is a retired chiropractor who has been expressing his views about the benefits of appropriate use of spinal manipulation (as opposed to use of such treatment based on chiropractic subluxation theory) since publication of his book Bonesetting, Chiropractic, and Cultism in 1963. He retired from private practice in 1998. His many posts for ScienceBasedMedicine.org are archived here.

Categories: Medicine, Skepticism

Ebola conspiracy theories: Same as it ever was

Science Based Medicine - Sat, 10/18/2014 - 12:00

Does anyone remember the H1N1 influenza pandemic? As hard as it is to believe, that was five years ago. One thing I remember about the whole thing is just how crazy both the antivaccine movement and conspiracy theorists (but I repeat myself) went attacking reasonable public health campaigns to vaccinate people against H1N1. It was truly an eye-opener, surpassing even what I expected based on my then five year experience dealing with the antivaccine movement and quacks. Besides the usual antivaccine paranoia that misrepresented and demonized the vaccine as, alternately, ineffective, full of “toxins,” a mass depopulation plot, and many other equally ridiculous fever dream nonsense, there was the quackery. One I remember quite well was the one where it was claimed that baking soda would cure H1N1. Then there was one of the usual suspects, colloidal silver, being sold as a treatment for H1N1. Then who could forget the story of Desiree Jennings, the young woman who claimed to have developed dystonia from the H1N1 vaccine but was a fraud? Truly, pandemics bring out the crazy, particularly the conspiracy theories, such as the one claiming that the H1N1 pandemic was a socialist plot by President Obama to poison Wall Street executives, which was truly weapons-grade conspiracy mongering stupidity. Oh, wait. That last one was a joke. It’s so hard to tell sometimes with these things.

Yes, pandemics and epidemics do bring out the worst in people in many ways, but particularly in terms of losing critical thinking abilities. This time around, five years later, it’s Ebola virus disease. To the average person, Ebola is way more scary than H1N1, even though H1N1, given its mode of transmission, had the potential to potentially kill far more people. Now that cases of Ebola virus disease have been reported in the US, the panic has been cranked up to 10 in certain quarters, even though the risk of an outbreak in the US comparable to what is happening in West Africa is minimal. We’ve seen quackery, too, such as homeopaths seriously claiming that they can treat and quacks advocating high dose vitamin C to “cure” Ebola. The über-quack Mike Adams is selling a “natural biopreparedness” kit to combat Ebola and pandemics, while the FDA is hard-pressed to track down all the quacks, such as hawkers of “essential oils,” who—of course!—also think that their wares can cure Ebola.

Now, given how afraid everyone is of Ebola, not entirely without some justification (it is a horrible disease, after all, and it is spread by contact with blood and bodily fluids; taking reasonable precautions is prudent), you’d think that everyone could and would get behind the fast track development of vaccines against the disease. Given that Ebola is a virus and a successful antiviral treatment tends to be considerably more difficult to develop than a successful antibiotic, a vaccine likely represents the best hope for rapidly bringing the current epidemic under control with as little loss of life as possible. Certainly if such a vaccine were to be developed, as it likely will be relatively soon (at least in terms of drug or vaccine development time), given the urgency now that wasn’t there before), you’d think that a vaccine would be welcomed with open arms. And when it comes to most people, at least not antivaccine activists, you’d be right. However…take a look at this video by Barbara Loe Fisher, Grande Dame of the antivaccine movement and founder of the Orwellian-named National Vaccine Information Center (NVIC):

First, we have a highly cherry-picked timeline designed to make the US and CDC look as incompetent as possible, as Fisher asks a series of “Why?” questions, some semi-reasonable, some pure fear mongering. Then comes the kicker. Near the end of the video, Fisher asks (at the 9:00 mark or so):

And why are experimental Ebola vaccines being fast tracked into human trials and promoted as the final solution rather than ramping up testing and production of the experimental ZPap drug that has already saved the lives of several Ebola-infected Americans?

I wonder what this “ZPapp” drug is. I’ve never heard of it before. I’m guessing that Fisher means ZMapp. Barbara, Barbara, Barbara. How are we supposed take you the least bit seriously if you can’t even get the name of the main experimental drug currently being tested against Ebola right? Then there’s Fisher’s choice of words to describe experimental vaccines: Final solution. Freudian slip much, Barbara? One wonders if she could be more obvious in her biases against vaccines. In any case, contrary to what Fisher claims it isn’t clear whether ZMapp actually did save the lives of those Americans who survived Ebola. It might have. It might not have. It might have been that those patients would have recovered anyway with supportive care alone. Indeed, at least one patient that I’ve read about received the drug but died anyway. That’s why we need more data and a clinical trial to tell if ZMapp is as effective as we all hope it is, based on preclinical studies in primates. As for “ramping up production,” it’s not as though ramping up production of an experimental drug is as easy as just turning a switch, as I discussed in the context of discussing misguided “right to try” laws. This drug is a humanized monoclonal antibody (like Avastin and Herceptin, for instance). Making such drugs is difficult, expensive, and can’t easily just be “ramped up” instantly.

Of course, to Fisher, this emphasis by public health officials on fast tracking an Ebola vaccine can’t be because it would be a powerful tool in our arsenal to halt the spread of Ebola. Oh, no. it can only mean one thing:

A logical conclusion is that some people in industry, the government, and the World Health Organization did not want the Ebola outbreak to be confined to several nations in Africa because that would fail to create a lucrative global market for mandated use of fast tracked Ebola vaccines by every one of the seven billion human beings living on this planet. Will there be an Ebola outbreak in America? Ask the CDC, WHO, DOD, NIH, and Congress. Learn more about Ebola and Ebola vaccines at NVIC.org. It’s your health, your family, your choice.

Notice how it never occurs to Fisher that the best way to stop an outbreak of an infectious disease is through prevention (i.e., a vaccine, in addition to other public health measures designed to slow the spread of the disease). This is particularly true when the disease in question is a viral disease for which an effective drug is difficult to make. In any case, this is a common theme through the latest crop of Ebola conspiracy theories coming from antivaccine loons like Fisher: The claim, implication, or insinuation that the government either created or at least sustained (and took advantage of) the current Ebola outbreak in order to create a market for vaccines for its pharma overlords, although some variants, as we will see, postulate that the reason for starting and sustaining the epidemic is to create a lucrative market for ZMapp, whose early development was—of course!—funded in part by the U.S. Department of Defense.

Fisher is not alone in promoting paranoid conspiracy theories. All over Twitter and other social media, there are exchanges like this:

@KaiHolloway I cant see any other agenda for the Ebola Feargasm on M$M…fuck I hope im wrong..

— Paul Schmidt (@psc96180_pablo) October 15, 2014

The replies were equally unhinged:

@psc96180_pablo me too brother, but we have seen it coming… as a human being we are entitled to defend our selves. this is fkn bollox!

— no one special (@KaiHolloway) October 15, 2014

That’s right. According to antivaccinationists, the real reason for the Ebola “feargasm” is to promote a toxic mass vaccination program because…well, just because apparently the government wants to poison us in order to…well, I must confess that I really can’t follow the “logic” of this particular conspiracy theory, such as it is. Such is the nature of the conspiracy theories springing up among antivaccinationists about the latest Ebola outbreak. Why would the government want to kill thousands, possibly hundreds of thousands if the epidemic gets out of control in Africa. They honestly seem to think that the epidemic is a pretext for mass vaccination, rather than proposals for vaccines flowing from the understandable desire of public health officials in the US, Africa, and the rest of the world to stop mass suffering and death. Not surprisingly, the paranoia and conspiracy theories are eerily similar to the ones that sprang up five years ago in response to the H1N1 pandemic and the mass vaccination programs instituted by the US and other nations to try to forestall its worst effects.

In fact, the conspiracy theories get even loonier than that. For one thing, there are idiots like Larry Klayman claiming that President Obama actually wants Ebola to become established in the US because he wants to infect white people and make the US more like his “home” in Africa. I kid you not.

However, it is the antivaccine movement that’s really jumped into the Ebola conspiracy theory pond feet first. Remember the whole “CDC whistleblower” conspiracy theory? It broke on a waiting online world like a massive fart only less than two months ago, back in August. It began when biochemical engineer turned “vaccine expert,” epidemiologist, and, of course, mercury militia member published a truly awful “re-analysis” of a decade-old study (DeStefano et al) that failed to find a correlation between age at MMR vaccination and risk of autism in a case control study. Basically, his “re-analysis” proved Andrew Wakefield wrong in that it found no increased risk of autism attributable to MMR vaccination in all but a very small subgroup in the study, African-American boys, and the numbers for that group were so suspect that virtually everyone with any knowledge of statistics, epidemiology, or experimental design highly doubted they were anything other than an anomaly. Unfortunately, it did spark a ridiculous campaign on the part of the antivaccine fringe, who saw this as “smoking gun proof” of their central conspiracy theory that the CDC covered up The Truth that vaccines cause autism, because, it turns out, a CDC psychologist named William Thompson, who was a co-author on DeStefano et al, had been feeding Brian Hooker information out of some sort of misguided “guilt” over a decade-old scientific disagreement over how to analyze the data that he lost. Naturally, there was no evidence presented that the CDC did anything wrong other than the cherry-picked and highly edited quotes and snippets of text from Thompson provided by Andrew Wakefield and Brian Hooker, the latter of whom had recorded Thompson without his knowledge for months, but that didn’t stop the antivaccine movement from going full mental jacket over this affair.

So, now that they’ve failed to get any traction on the “CDC whistleblower” issue in the mainstream press other than a smackdown by MSNBC’s Ronan Farrow, who made one of the “thinking moms” named Lisa Goes look even more ignorant than usual, angering the “media editor” of the antivaccine crank blog Age of Autism. How do antivaccinationists explain their failure to get any significant attention in the mainstream media, despite a whole lot of trying? My explanation is that most reporters know cranks as cranky as this when they see them and, probably more importantly, that Andrew Wakefield is so disgraced and so toxic that his involvement in the story basically killed any opportunity antivaccinationists might have had to get even a bottom feeding “mainstream media” outlet interested in the story. One antivaccinationists’ explanation is that, obviously, Ebola’s the result of a plot to keep the mainstream media from reporting on the “CDC whistleblower” affair:

How is it we suddenly have an Ebola “outbreak” and it is coming to the USA too?
The Ebola outbreak is quite a coincidence – senior CDC scientist Dr Thompson has been talking with Dr Hooker for 10 months about the CDC knowing the MMR vaccine causes autism. The Ebola “problem” was introduced gently to the US public earlier in the year.

Now we have an Ebola “outbreak” in the west just when Hooker’s paper has been published and the admissions about the CDC knowing the MMR vaccine causes Autism issue are breaking news which the mainstream media refuse to report.

And today’s news of a “vaccine” will of course be certain to ensure editors will publish nothing about MMR vaccine causing autism.

Of course to test a new vaccine and a new drug one needs a clinical trial. But people tend not to get Ebola – it has been pretty quiet for a very long time – until now.

And suddenly they ship the sick people off to the USA with all the attendant risks of spreading the disease instead of treating them where they got sick.
Seems a gift for WHO and the CDC but who wrapped it and how long ago?

Because, obviously, the CDC and US government are so nefarious and clever that they foresaw many months ago that in August the whole “CDC whistleblower” thing would blow up, which is why they got an Ebola epidemic in Africa going with enough lead time so that the number of fatalities would be percolating along at the same time, timing it even more ingeniously so that the fear of the disease would be reaching a fever pitch right around the same time those poor, intrepid antivaccinationists were trying to get the attention of the media. Damn, I wish our government functioned so efficiently and with such purpose! Obviously, it doesn’t. But it’s still a hell of a conspiracy theory. Well, not really.

That doesn’t stop the “Vaccine Information Network” from asking Ebola: yet another fake pandemic set up to poison us with drugs and vaccines? The cranks at the VIN do realize that usually when the title of an article is in the form of a question, the answer to that question is, “No,” don’t they? Apparently not, because clearly Jon Rappaport (remember him?) believes that it is. And guess what? He even likens it to H1N1 in this interview:

Q: What is the major psychological factor at work here?
A: Above all else, it is people making an automatic connection between their own frightening image of Ebola and the statement, “So-and-so is sick.”

Q: “Sick” doesn’t automatically = Ebola?
A: That’s right, even when an authority says some person is sick and in the hospital and has Ebola.

Q: Is the Ebola epidemic a fraud, in the same way that Swine Flu was a fraud?
A: In the summer of 2009, the CDC stopped counting cases of Swine Flu in the US.

Q: Why?
A: Because lab tests on samples taken from likely and diagnosed Swine Flu cases showed no presence of the Swine Flu virus or any other kind of flu virus.

Q: So the CDC was caught with its pants down.
A: Around its ankles. It was claiming tens of thousands of Americans had Swine Flu, when that wasn’t the case at all. So why should we believe them now, when they say, “The patient was tested and he has Ebola.” The CDC is Fraud Central.

Q: Where is the fraud now, when it comes to counting Ebola cases and labeling people with the Ebola diagnosis?
A: The diagnostic tests being run on patients—the antibody and PCR tests are most frequently used—are utterly unreliable and useless.

Q: Therefore, many, many people could be labeled “Ebola,” when that is not the case at all?
A: Correct.

Q: But people are sick and dying.
A: People are always sick and dying. You can find them anywhere you look. That doesn’t mean they’re Ebola cases.

Q: In other words, medical authorities can place a kind of theoretical grid over sick and dying people and reinterpret them as “Ebola.”
A: Exactly. The map can be drawn in any number of ways.

Got that? Back in 2009, apparently (if you believe Rappaport), it wasn’t H1N1 that was sickening people, and now in 2014 it’s not Ebola that is killing people in West Africa and has infected a handful of people in the US. What is the cause? According to Rappaport, it’s not the virus. Basically, it’s protein-calorie malnutrition, hunger, starvation, extreme poverty, contaminated water supplies, overall lack of basic sanitation, a decade of horrific war, toxic medical drugs, prior toxic vaccine campaigns, and the like that cause destruction of immune systems, leading to:

Then, any germ that sweeps through the population, a germ that would ordinarily be defeated, instead kills many people. Why? Because the immune system is too weak to respond. With healthy and strong immune systems, the germs would have no significant effect.

This is, of course, utter BS. Rappaport, as usual, argues by assertion and doesn’t know what he’s talking about. It’s amazing how constant the forms of infectious disease denialism are. Just like HIV/AIDS denialism blamed “lifestyle” and immune compromise due to drugs, anal sex, and “lifestyle,” claiming that AIDS is not caused by HIV, Ebola virus denialism claim that what is being diagnosed as Ebola is in fact not due to Ebola but to “toxins,” malnutrition, and, of course, vaccines. Notice the striking similarity to HIV/AIDS denialism claims. One wonders why, if these conspiracy theorists truly believe that a normal healthy immune system in a person living a healthy lifestyle and eating the “right” foods can ward off Ebola, they don’t immediately head over to West Africa to help out in the relief efforts! (Actually, I ask the same question about Homeopaths Without Borders. Why don’t they head over to Africa and help out?)

Delusions upon delusions, to Rappaport, the whole thing is a plot to drive demand for products made by big pharma, such as vaccines. Naturally, as with all good disease conspiracies, Rappaport drives it with claims that the case numbers are being “manipulated,” labeling the Ebola outbreak as a “hoax,” claims that the tests are “unreliable” (they’re not; while it’s true that early in the course of symptomatic Ebola infection the disease resembles a lot of other viral diseases, there are a number of sensitive and accurate diagnostic tests, including PCR, ELISA, and, ultimately, virus isolation); and claims from the inventor of PCR, Kary Mullis, from whom Rappaport cites a 1996 quote claiming that “quantitative PCR is an oxymoron.” It’s not; I’ve been doing highly accurate quantitative real time PCR in my lab for 14 years now, and it’s a routine technique in molecular biology labs. In 1996, reliable quantitative PCR hadn’t been perfected yet, but today it’s a routine, every day test.

Of course, it’s not just the CDC, at least not according to Yoichi Shimatsu, but it’s apparently the UN, too. According to the Shimatsu, Ebola outbreaks coincided with vaccination campaigns by World Health Organization (WHO) and the UN children’s agency UNICEF. To others, however, the Ebola outbreak is not so much a plot to enrich big pharma but rather US-sponsored bioterror. At least, so sayeth someone calling himself Prof. Jason Kissner. Kissner, it turns out, is a criminologist and a birther, but with a twist. While he accepts that President Obama was born in Hawaii, but claims that he holds dual citizenship as an Indonesian. In fact, Kissner is all over the conspiracy sites, and his arguments about Ebola are no more coherent than his arguments about the President’s birth certificate. He also thinks that the “the racial “dialogue we’ve been hectored about for several decades is in reality no ‘dialogue’ at all; it is a monologue imposed by the powerful in order to decimate the values and individuality of the powerless.” After worrying about whether the virus responsible for the current outbreak might have gone airborne, he goes on to invent a conspiracy theory in which the current outbreak is due to a bioengineered variant of Ebola that’s more contagious than previous strains. He bases this almost entirely on an article in the New England Journal of Medicine from April about the emergence of the Zaire strain of Ebola in Guinea, which notes that the Guinea strain in West Africa is distinct:

According to the initial epidemiologic investigation, the suspected first case of the outbreak was a 2-year-old child who died in Meliandou in Guéckédou prefecture on December 6, 2013 (Figure 2). A second investigation confirmed the origin of the outbreak in Meliandou but revealed a somewhat different timing of the early events (including the death of Patient S1 at the end of December and the deaths of Patients S2, S3, and S4 in January). Patient S14, a health care worker from Guéckédou with suspected disease, seems to have triggered the spread of the virus to Macenta, Nzérékoré, and Kissidougou in February 2014. As the virus spread, 13 of the confirmed cases could be linked to four clusters: the Baladou district of Guéckédou, the Farako district of Guéckédou, Macenta, and Kissidougou. Eventually, all clusters were linked with several deaths in the villages of Meliandou and Dawa between December 2013 and March 2014.

In a nutshell, both The Shimatsu conspiracy theory and Kissner’s conspiracy theory rely on an appeal to incredulity. Just because Kissner and Shiamatsu can’t believe that Ebola could remain dormant for years and then reemerge to cause this outbreak, to them something else must be going on. For instance, Shimatsu writes:

The mystery at the heart of the ebola outbreak is how the 1995 Zaire (ZEBOV) strain, which originated in Central Africa some 4,000 km to the east in Congolese (Zairean) provinces of Central Africa, managed to suddenly resurface now a decade later in Guinea, West Africa.

Kissner’s contribution to this argument from incredulity is that he can’t believe that the distinct strain of Ebola could have arisen naturally and then found its way from Zaire all the way to West Africa without human intervention. I bet you can guess what that intervention is:

And, we seem to have a single introduction of the Guinea (West African) Ebola variant into the human population. Thus, we seem not to have, for example, something along the lines of multiple bites of humans by supposedly Guinea variant Ebola infected fruit bats.

Finally, the Western Africa Ebola outbreak does not appear to be traceable to Central Africa or anywhere else, and so we still do not know how Ebola got to West Africa.

To Kissner, this of course means that it must have been US bioterrorism that introduced this “new” Ebola strain into the human population in Guinea in order to…what? Why? To Kissner, it’s all about the experimental Ebola drug ZMapp, which was only identified as a potential Ebola drug candidate in January 2014:

Does “ZMapp was first identified as a drug candidate in January 2014” mean that ZMappwas designed from the ground up, pretty much when the outbreak began, with the specific purpose of treating the Guinea Ebola variant (see above for timing of the outbreak)? Or, does it mean that ZMapp was repurposed in some way to grapple with the Guinea variant? Or does it perhaps mean something else entirely?

That “something else entirely” to Kissner is that the makers of ZMapp knew about the new Guinea variant and designed ZMapp to combat it. Apparently Kissner has never heard of crossreactivity of antibodies. Or perhaps he has but just doesn’t believe it:

Perhaps Mapp had been in the process of designing ZMapp so that it could successfully attack already extant Ebola variants, and whatever properties made it effective against those already extant variants also transferred to the novel Guinea variant?

Maybe.

But if that is so, ZMapp should prove successful against variants of Ebola other than the Guinea variant. Will it?

If it doesn’t prove successful against variants of Ebola other than the Guinea variant, I do not see how one can logically avoid the conclusion that the West African rooted, Guinea variant of Ebola amounts to U.S. government linked bioterror.

Unless, of course, one is willing to invoke what amounts to a miraculous stroke of luck consisting in the design of a solution that successfully attacks something that’s never been seen before and was not anticipated—even though the solution fails against related versions of the same problem.

In closing, please note that the U.S. act of bioterror explanation economically accounts for all three U.S. lies discussed in the article. It explains why the U.S. government is lying about the airborne status of Ebola, why the U.S. government/MSM hybrid is in no hurry to disclose the geographical and virological novelties of the Guinea variant, and, finally, why the U.S. government, out of one side of its mouth, wants to act like its “miracle experimental drug” had to be pried out of its greedy and comprehensive regulatory hands.

“Economically accounts for”? You keep using that phrase, Mr. Kissner. I do not think you it means what you think it means.

That’s one hell of a plot, isn’t it? Of course, ZMapp has been under development at least since 2012 and the antibody cocktail against Ebola virus used went through at least three distinct iterations, its latest composition having been arrived at in early 2014 based on testing in rhesus macaque primates. I suppose that means that those nefarious Department of Defense funders who helped fund the drug and Leaf Biopharmaceutical Inc., the company currently developing ZMapp, must have planned even further ahead than even Kissner could know. Or maybe there’s just good crossreactivity of this antibody cocktail to multiple strains of Ebola.

Shimatsu disagrees. Although his logical fallacy is also an appeal to personal incredulity, unlike Kissner, he thinks it’s all due to the UN vaccine programs:

The reason for suspecting a vaccine campaign rather than an individual carrier is due to the fact that the ebola contagion did not start at a single geographic center and then spread outward along the roads. Instead. simultaneous outbreaks of multiple cases occurred in widely separated parts of rural Guinea, indicating a highly organized effort to infect residents in different locations in the same time-frame.

But how and why? Shimatsu has a ready answer:

Repeated dosages of potent toxins on populations with poor health, which no public-health agency in the Western world dares attempt inside its own borders, can have harmful side effects, especially on children. The casualties of vaccination have gone unreported by the media and buried under official cover-ups. Even worse, vaccine programs could well have been used to conceal human testing of antibodies that originated in biological warfare labs for the purpose of mass murder of entire nations.

Yes, according to Shimatsu, the MSF, UNICEF, WHO, CDC, NIH, USAMRIID and, as Shimatsu puts it, the “rest of the alphabet soup of the hypocritical oafs of pharmaco-witchcraft” are all just that evil.

Throughout history, infectious disease has brought out the best and worst in humanity. The best, like Doctors Without Borders, go selflessly straight into the hearts of epidemics in order to treat the ill, try to prevent further spread of the disease, and alleviate suffering wherever they can. The worst, like antivaccinationists and conspiracy theorists like Kissner and Shimatsu, try to deny the cause of the disease in favor of conspiracy theories that demonize the very organizations trying to help its victims and companies trying to make vaccines to prevent it and drugs to treat it.

What’s really depressing is that, at the heart of these conspiracy theories is a belief that public health officials, doctors, governments, the UN and WHO, and pharmaceutical companies are so irredeemably evil that they would willingly start an outbreak of a deadly disease like Ebola in impoverished African nations, but, realizing that no one cares about Africans that much, make sure it spreads to the US to cause a panic, and then let the disease kill many thousands, all in order to create a market for drugs and vaccines. Oh, and those drugs and vaccines are toxic. Truly, the delusional nature of such conspiracy theories is depressing to behold.

Categories: Medicine, Skepticism

Brain Activity in Vegetative Patients

Neurologica Blog - Fri, 10/17/2014 - 08:31

A vegetative state is a particular kind of coma in which patients appear to be awake but give no signs (by definition) of any awareness. They do not respond to their environment in any way or do anything purposeful. Some patients display a flicker of awareness, and they are categorized as minimally conscious.

Neuroscientists have been using the latest technology to look at brain function in vegetative subjects and comparing that function to healthy controls. In this way they hope to gain insight into the neurological correlates of consciousness – what brain activity is necessary for and responsible for conscious awareness. A new study, published in PLOS Computational Biology, replicates this research with interesting findings.

As with previous studies, the researchers found that the majority of vegetative patients had profound abnormalities of brain function compare to healthy controls. They found:

Here, we apply graph theory to compare key signatures of such networks in high-density electroencephalographic data from 32 patients with chronic disorders of consciousness, against normative data from healthy controls. Based on connectivity within canonical frequency bands, we found that patient networks had reduced local and global efficiency, and fewer hubs in the alpha band.

This means they measure the electrical activity of the brain and found that patients in a vegetative or minimally conscious state had decreased brain activity. A healthy brain has massive local and global networks of neurons exchanging information across the brain. The brains of patients with impaired consciousness had markedly reduced activity and fewer hubs of activity.

This makes sense. Conscious awareness seems to be a distributed function of the brain, and the brain has to have a certain threshold of activity in order to maintain wakefulness and awareness. If that activity is reduced the result is unconsciousness. If that activity is reduced by damage to the brain, the result is long term or permanent unconsciousness, or coma. The study failed to show a tight correlation between the amount of activity and the relative degree of behavioral function in the subjects, but this could be due to the small sample size and the small differences among subjects.

However, this study (also in line with previous studies) found that in a minority of subjects, four of those studied, the network activity in the brain was similar to healthy controls (although not normal). They had much more robust activity than the other subjects with impaired consciousness.

Further, the authors performed another test that has been published before. They imaged brain activity with fMRI scanning and asked subjects to imagine themselves playing tennis. In conscious patients this results in a pattern of activity reflecting motor planning. The four comatose patients with robust brain activity showed motor planning activity when given the tennis test.

To summarize these results – four subjects who appear to be in a vegetative state by neurological exam, showed fairly robust brain activity on EEG and responded to the tennis test as measure by fMRI activity. The big question is, what is going on in the brain’s of these four subjects? The authors write:

Overall, our research highlights distinctive network signatures of pathological unconsciousness, which could improve clinical assessment and help identify patients who are aware despite being uncommunicative.

In other words, these four patients, and patients like them identified in other studies, may have some conscious awareness but we simply cannot detect that awareness because of more focal deficits, such as paralysis. This would make them more in line with locked in patients rather than vegetative patients.

I think, however, we are not yet able to draw that conclusion from the data we have (to be fair, the authors do not draw that conclusion, but they do imply it, and that is the one point the press is focusing on). It is very possible that conscious awareness requires robust local and global brain communication, but also requires some specific activity in the brain. There may be some critical networks without which awareness is impaired. In a subset of patients, overall brain activity may be preserved, but the critical networks are damaged and so awareness is impaired.

Although not part of the current study, previous studies compared patients who were vegetative from diffuse processes such as anoxia (lack of oxygen) and those whose brains were damage by trauma. The trauma patients may have some parts of the brain that are damaged and others that are undamaged. These trauma patients are the ones who are more likely to have the more robust brain activity despite being vegetative or minimally conscious, whereas the diffuse anoxia patients rarely if ever fall into this category. The question remains – are the focal areas of damage inhibiting awareness or just inhibiting motor and sensory function?

At this point the bottom line is that we just don’t know. Both of these possibilities may also be true for different patients. Every permutation likely exists, and researchers are simply sorting out which permutations are possible.

I am not yet convinced that it is possible patients who appear to be vegetative are actually aware and therefore really locked in. These would have to be very special cases, with just the right assortment of deficits to keep them from displaying any signs of their consciousness. I think it is more likely that the subset of patients with relatively preserved brain activity while being in a coma simply have focal damage that is impairing circuits critical to conscious awareness.

We will see. This is a fascinating area of research, and we are making steady progress. Researchers are making better and better use of existing technology, and that technology itself is progressing.

 

 

 

Categories: Medicine

Placebo Speculations

Science Based Medicine - Fri, 10/17/2014 - 03:05

I have a new term to add to the English language, ebolasmacked, a derivative of the the British term gobsmacked. Ebolasmacked defines my life the last few weeks since Ebola, or at last preparations for Ebola, have taken a huge bite out of my time with many interesting twists and turns.  I think think this is maybe the 9th outbreak (HIV, MERS, SARS, Legionella, H1N1, Avian flu, West Nile, MRSA) of my career and has certainly generated more hysteria relative to the risk than any to date.  Many of my usual past times, like SBM (as this essay will no doubt demonstrate),  have had to take a back seat to preparing for what should be a very unlikely, but very disruptive, event. We do not want to get caught with our hazmats down should a case of Ebola come through the door.

What makes life interesting, among other things, is the constant realization that the more you know the more there is to know. I like Richard Dawkins metaphor in Climbing Mount Improbable where he pictures scientific progress as a series of false summits extending into infinity. It sure seems that way.  Every time I think I understand a topic, I find there is still more to learn.

My Dad told me when I graduated from medical school that half of everything I had just learned was probably not true, the only problem is that you didn’t know which half. It was partially true. There have been ideas that have been abandoned since I was an intern, the most famous being that ulcers were due to stress and diet. But a new paradigm has been the exception not the rule.

The last thirty years have been more about refining knowledge about the complexity of disease and its treatment and, perhaps equally importantly, having a better understanding of the all slings and arrows of outrageous fortune that can make the results of a clinical trial suspect.

There are a series of false summits in medicine, but each is only a foot above the preceding summit, more a series of very long, never ending steps of ever more refined and sophisticated understanding of disease. Recently, as an example, my gaster was flabbered to discover there are now 36 interleukins. Where did all those come from?   There were like six last time I looked. As the national ID meetings last  week  demonstrated, yet again there are a never ending  fine points for processes about which I thought I had a good understanding.

It is one of the characteristics of pseudo-medicine of which I am jealous. Each practitioner sits at the summit of a perfect mountain, albeit one make of made of fog, delusion, and unicorn tears, with a perfect and never changing concept of disease and it’s treatment.

I think I have a good understanding of the placebo effect, although perhaps I should say I have my understanding of the placebo effect. The comments will no doubt suggest mine is not a universal interpretation, but given the enormity of my ego, I think it is the correct one in clinical medicine.

I have multiple posts on the topic, so rather than repeat myself, although I do love to quote me, the one liner is: there is no placebo effect. Placebo (I know, I have gone beyond one line) are beer goggles, improving subjective end points with no change in objective endpoints. My archetype is from Penn and Teller’s BS episode where a lady reports her pain is better after treatment with a giant magnet that is actually a painted gutter downspout.

But why are some people prone to having a placebo effect, a subjective improvement, to a worthless intervention like homeopathy or acupuncture? Or a ‘real’ placebo as is used in a clinical trial?

Genes and Placebo

I recently came across “Outsmarting the Placebo Effect” in Science, a short review of the genetic underpinnings of the placebo response. It is interesting, although early work.

The point of the article was to review the attempts to identify people who were prone to the placebo effect. There are compelling economic reasons to do this.  If you are designing a clinical trial you want to know if your therapy is better than placebo. The greater the placebo effect in an intervention, the larger the number of patients need to be enrolled to demonstrate efficacy and the bigger the trial the more it will cost. If you can minimize the placebo response, you can to smaller, less expensive and faster trials to show a new therapy is effective.

Dr. Kathryn Hall has found a relationship between the enzyme catechol-O-methyltrasferase (COMT) and a placebo response. The COMT   enzyme breaks down catecholamines which are neurotransmitters.

The COMT gene comes in two polymorphisms, with either a valine (val) or a methionine (met) amino acid at position 158. Since genes come in pairs, people can be val/val, val-met, or met/met. The met/met form of the enzyme has less activity, leads to more dopamine and the met/met

“has been correlated with variations in memory function, cognition, attentional processing, affect , confirmation bias , pain processing and sensitivity. Met/met individuals have higher levels of performance in cognitive tests, which measure executive function as well as increased sensitivity to experimental and chronic pain relative to val/met and val/val individuals.

Which combination of the genes is present is associated with perception of pain as met/met sense pain more acutely than those with the val/val form of the gene. But even more curious for this blog, met/met carriers also respond more to placebo.

They had patients from a previous study of irritable bowel symptom who were treated with waitli st, sham acupuncture offered in a no frills business like way (a limited placebo) and

“limited placebo arm augmented with a supportive warm provider who expressed confidence in the effectiveness of the treatment (‘‘augmented placebo’’).

In the original study, the more placebo offered, the better the response in the IBS-SSS score:

IBS-SSS includes abdominal pain severity, abdominal pain frequency, abdominal distention severity, dissatisfaction with bowel habits, and disruption of quality of life.

So they went back and genotyped everyone and looked at response and their genotype.  It was a nice, linear relationship: met/met with the most response on the IBS-SSS, the val/val had the least and the val-met right in the middle.

And there is more:

Significantly more drug-specific as well as general side effects were reported from homozygous carriers of the Val158 variant during medication as well as placebo treatment compared to the other genotype groups. Val158/Val158 carriers also had significantly higher scores in the somatosensory amplification scale (SSAS) and the BMQ (beliefs about medicine questionnaire). Together these data demonstrate potential genetic and psychological variables predicting nocebo responses after drug and placebo intake, which might be utilized to minimize nocebo effects in clinical trials and medical practice.

and  met carriers are impaired on emotional processing tasks compared with val carriers with met-hetero- and homozygotes experience larger subjective stress responses than Val-homozygotes.

I recognize that genes are not destiny and that the final understanding will far more complicated, especially in an organ as complex as the brain. Well, some brains. The ID literature is growing with reports of various polymophisms in Toll like receptors and other proteins and the resultant increase or decrease in the risk of infections. My personal favorite is

Gene polymorphism resulting in the substitution of glutamine with lysine at residue 223 in the carbohydrate recognition domain of SP-A2 increases susceptibility to meningococcal disease, as well as the risk of death.

Translation: have the wrong snot, increase your risk of meningitis and death. And this is but one among hundreds of subtle variations in genes that alter our risk for disease.  As Willie said “The fault lies not in the stars, but in ourselves”

This leads to an alternative, and a testable, partial explanation for the continued popularity and loyalty to what should be worthless pseudo-medical interventions. It is not the innumerable flaws of the modern medicine or the wonderful bedside manner of pseudo-medical providers. It could be that there is a subset of the population that is predisposed to the perceived benefit of a pseudo-medicine and are receiving continued positive reinforcement every time they get, say,  an acupuncture treatment.  It could also explains why so many different forms of acupuncture all have the same effects. It is not the beloved endorphins in the spinal fluid but they are all stimulating the placebo centers in the predisposed. It would be interesting to know the COMT composition of regulars in a chiropractic or acupuncture clinic. Perhaps there is a preponderance of met/met polymorphisms in these practices.

And it would be interesting to know how the val/val patients respond to standard therapy as well since

Despite their best efforts, many a warm and caring physician has had patients that seemed to derive minimum benefit from their empathic attentions. Our findings that val/val patients are less influenced by the placebo treatment, regardless of whether it is delivered in an augmented or limited context, potentially shed some light on this clinical challenge.

What is the distribution in somatosizers? Chronic pain patients? Or the distribution in TAM attendees or the commenters to this blog. I would love to know my own genotype, as well as how much Neanderthal DNA I have and where my genes come from. When asked my ethnic background, a popular question in Minnesota (Crislip.  Where’s that name from?) I like to say my ancestors came from Hadar.

As I think I have mentioned in the past I am sometimes skeptical of free will and consciousness, suspicious that both are an illusion. So I am biased in favor of studies like this that point to variations in the meat machine that could alter its function. It is interesting to think about, and great grist for beer fueled late night discussions

Of Mice and Pain

The May 2nd Science had an article called Male Scent May Compromise Biomedical Studies and reviews how mice respond to pain.

Dr. Jeffrey Mogil studies pain in mice. Mice exhibit less pain response if there is someone in the room, even if that someone is a cut out of Paris Hilton. But even more curious, animals demonstrate less pain response if there is a male in the room. Then they refined that response even more. It is the smell of the male that the mice were responding to:

So he told the people in his lab to place their worn T-shirts near injected animals and then leave the room. Even when the humans weren’t present, the results were the same. Rats and mice showed about a 36% lower score on the grimace scale when exposed to male versus female T-shirts, the team reported online this week in Nature Methods. (Female mice were slightly more sensitive to the effect). Placing a woman’s T-shirt next to a man’s T-shirt negated the impact. Bedding material from unfamiliar male mice and guinea pigs, as well as pet beds slept in by unsterilized male cats and dogs, produced the same response: Male odors seemed to act like painkillers.

He hypothesized that it is an evolved response to being potentially hunted. To show pain is to show weakness and make it more likely you will be attacked.

Does this apply to humans? Interesting question. Humans are not mice although it is estimated we can detect a trillion (not a typo) smells and those of you with teenaged boys know that is not an underestimate.

I think back to acupuncture pain studies and wonder what the gender of the acupuncturists was and if the gender of the therapist could have made a difference in pain. It is an interesting potential confounding variable, and would make for an interesting review of the acupuncture literature. Does the published literature demonstrate better results from male vrs female acupuncturists?

I remember one pain study, and I can’t locate it on the web or my drive (so many references to find that particular needle in the pdf stack), where several acupuncturists were used in a trial and only one had a consistent positive improvement on patient pain scores. I wish I could find the study as I wonder about the gender of the acupuncturists and perhaps the one with the better results was a more manly man, a user, perhaps, of Old Spice.

Acupuncture could be an excellent modality to tease out any effects on pain due to the gender of the provider. A researcher would not have worry about any real physiologic effects. It is reasonably clear that the features most associated with responding to acupuncture are knowing you are receiving acupuncture and believing or being told that acupuncture works.

Have male and female acupuncturists apply real and sham acupuncture (as if there is a difference) in a neutral manner and double blind methodology. If there is a gender difference due the provider and patients pain it would be very interesting.

Another step up.

Now back to Ebola preparations.

 

Categories: Medicine, Skepticism

Lockheed Martin’s Fusion Reactor

Neurologica Blog - Thu, 10/16/2014 - 08:30

Since I recently covered the new claims being made for the E-cat cold fusion device (which, in my opinion, is almost certainly bogus), I found it interested that Lockheed Martin recently produced details for their research into a hot fusion reactor. Their research team, called the Skunk Works, have been working on a new design for a fusion reactor. It has two distinct advantages over the E-cat – it does not require the assumption of new physics, and it is not being promoted by a convicted con-artist.

Fusion is a type of nuclear reaction that involves combining lighter elements into heavier elements. The resulting reaction releases a significant amount of energy, and that energy can be used to generate electricity. Fusion, in fact, is the power source for stars. The immense temperature and pressure in the core of stars fuse hydrogen into helium, and then helium into heavier elements, depending on how massive the star is. The heaviest element that can be made in this fashion is iron. Elements heavier than iron require energy to fuse, and therefore you cannot get any energy out of iron from fusion or fission. Heavier elements are therefore made in the powerful explosion of supernova.

If we could engineer a device that could produce sufficient temperature and pressure we could theoretically creation nuclear fusion on earth. In fact we have already done so, in the form of hydrogen bombs. Of course, creating a massive explosion isn’t exactly useful as an energy source. The trick is creating a controlled nuclear fusion without the huge explosion.

One method being worked on is using heavy hydrogen (deuterium and tritium, a proton with one and two neutrons respectively) heated to a plasma (stripped of its electrons). Plasma therefore has an electric charge, and so will respond to a magnetic field. Fusion projects like the ITER (a multi-billion dollar fusion project in France) use a configuration of magnets known as the tokamak, which is basically a torus or doughnut shape, in order to confine the hydrogen plasma. If you confine the plasma enough, the hydrogen ions will be pushed together with enough force to overcome their mutual repulsion (because the protons have a positive charge) and they can fuse together forming helium 4.

This reaction will in turn free neutrons, which don’t have a charge and therefore can escape the magnetic confinement. They will impact the containment wall, heating it up. This heat can then be used to drive a conventional turbine, generating electricity.

Lockheed Martin is now claiming they have a design for a similar fusion reactor that has an innovative arrangement of the magnetic confinement – in a spiral shape rather than a torus. Their design, they claim, has the property of creating a positive feedback loop in which, the more the plasma pushes out against the magnetic field, the stronger the field becomes, generating much greater pressure in a smaller design. Their reactor design is 1/10 the size of typical tokamak designs, such as the ITER.

They argue this will have many advantages. It will enable them, due to reduced costs, to iterate their design once a year. They claim that within five years they will achieve a working prototype. It will then take another 5 years, for a total of 10 years, to build an actual working fusion power plant. Such plants, again because of their small size, will be much cheaper to build than the ITER design, and therefore will be much more economically feasible.

They claim their fusion reactor could fit onto a large truck, and a reactor of that size could power 80,000 homes, using 50 pounds of fuel for a full year’s operation. The process does create some radioactive waste, but the half-life of this waste is only a century, compared to the thousands of years for fission waste.

Such reactors are small enough that they can be used as portable power generators for ships and even large jets.

OK – that all sounds good. I am seeing no red flags of pseudoscience. No laws of physics are being broken. No mysterious “fusion without radiation” is being claimed. They are simply claiming an innovation in the design of the magnetic containment field that allows the overall reactor size to be significantly smaller.

There are, however, two things about which I am a bit skeptical. First, the timeline they are giving is almost certainly overly optimistic. Apparently they still have some technical hurdles to overcome, and companies tend to assume (or at least pretend to their would-be investors)  that such hurdles will be mastered in due course. Sometimes, however, such hurdles prove to be stumbling blocks.

Remember the hydrogen economy? It all looked great on paper. All engineers had to do was work out some kinks and we would all be driving hydrogen cars and using them to power our homes. However, it turned out not to be so easy to design a way to store large amounts of hydrogen without too much weight in a manner that can rapidly release the hydrogen as needed and yet not explode in a car crash. They’re still working on it. We’re still waiting. We may yet see hydrogen fuel cells, but this little hurdle turned out to be a fatal flaw, at least for now.

So, how can the researchers at Lockheed Martin know for sure that five iterations will result in a working prototype? They can’t. I don’t have enough details to know what the biggest hurdles are they have to overcome, but since no one has achieved controlled fusion so far, they are likely non-trivial. The “5-10 years” may become 10-20, or 20-50. The running joke is that controlled fusion is 10 years away, and always will be. The “5-10 years” has become a running joke on the SGU because that always seems to be the claim, and yet rarely is the reality.

The other little niggle I have is that Lockheed Martin is apparently releasing details because they want to partner with other investors. Some have speculated that this is a negative commentary on their confidence in the project. If they really thought it was going to work, why would they want to spread out the risk and return?

Conclusion

The Lockheed Martin fusion reactor (unlike the E-cat) should be taken seriously. There is nothing impossible or pseudoscientific in their claims. However – they don’t have a working prototype, just the hope that they will have one in 5 years or so. I certainly hope that their claims pan out. A fusion reactor would be a huge boon to our civilization. This would be a game-changer – cheap, abundant, non-carbon emitting energy.

But I always take claims of “5-10 years” with a massive grain of salt. The problem always is – we don’t know what we don’t know. Until you try to do something, you can’t anticipate all the possible hurdles. Also, until you try to solve a hurdle, you don’t really know how difficult it’s going to be. From what is being released, I don’t yet know what the specific technical hurdles are here, so we’ll see.

I guess we’ll just have to check back in in five years.

Categories: Medicine

Connecticut “modernizes” naturopathic scope of practice

Science Based Medicine - Thu, 10/16/2014 - 01:00

Legislative Alchemy

Naturopathy has been legal in Connecticut for almost 90 years, but with a scope of practice limited to counseling and a few treatments like physiotherapy, colonic hydrotherapy and “natural substances.”  There was no specific authority to diagnose and treat.  All that changed on October 1, 2014, courtesy of the Connecticut legislature, which, in the words of the American Association of Naturopathic Physicians (AANP), “modernized” the naturopathic scope of practice.

Actually, the legislature did nothing of the sort.   Naturopathy is based on the prescientific concept of vitalism, and we find it right there in the very first paragraph of the new law. Naturopathy is defined as

diagnosis, prevention and treatment of disease and health optimization by stimulation and support of the body’s natural healing processes, as approved by the State Board of Natureopathic [sic] Examiners, with the consent of the Commissioner of Public Health. . .

Also included in the expanded scope of practice are

ordering diagnostic tests and other diagnostic procedures, . . . ordering medical devices, including continuous glucose monitors, glucose meters, glucose test strips, barrier contraceptives and durable medical equipment; and . . . removing ear wax, removing foreign bodies from the ear, nose and skin, shaving corns and calluses, spirometry, tuberculosis testing, vaccine administration, venipuncture for blood testing and minor wound repair, including suturing.

So, they will be measuring lung function with spirometry (and presumably treating lung diseases) and diagnosing and treating diabetes, as well as removing ear wax and shaving corns and callouses. What an odd hodgepodge!  “Vaccine administration” obviously includes advice on whether to vaccinate, a disturbing thought given naturopaths’ anti-vaccination ideology.  And I do have to wonder exactly how much suturing naturopaths have had the opportunity to do in their residency-free education and training.

The Connecticut Naturopathic Physicians Association (CNPA) appears to be unaware of their legislative success.  (Yes, they will be able to call themselves “physicians.”) As of October 15, 2014,  their website is still asking for support for practice expansion.

Naturopaths wanted, but were not given, the authority to “prescribe, dispense and administer legend and non-legend drugs in all routes of administration.”  They vow to come back next year to ask again in accordance with the AANP’s strategy of naturopaths having full primary care physician scope of practice in all states.

In promoting this legislation, the naturopaths made the same arguments they always make. First, they that their education and training prepares them for full primary care scope of practice, which will help ease the primary care physicians shortage. This is what we call a “conclusory allegation” in the legal trade.  There are no facts to back it up. It’s like saying “the defendant was negligent” in a personal injury case without presenting any facts to support that conclusion. You can’t get away with it in court and they shouldn’t get away with it before the state legislatures, but they do.

On the other hand, there is quite a bit of evidence that their education and training is wanting. As we know, the naturopathic educational system is virtually self-contained.  Their schools are stand-alone, not part of any public or private university system. No objective evaluation of these schools by third parties has ever taken place and there are no studies to support this imagined equivalency.

Or you could just look at their practices: whether treatment of allergies or infertility, vaccination, pre-natal vitamins, women’s health, or the many other ways SBM posts have demonstrated that naturopathic practice is not science-based, or evidence-based or even reality-based.  Or the fact that what little data there is shows that seeing a naturopath is associated with worse care. And if that doesn’t convince you, Orac’s posts last week (here and here), revealing some recently-discovered discussions among naturopathic practitioners, should leave no doubt.

Naturopaths contend they can safely prescribe drugs because there have been few malpractice and disciplinary claims made against them arising from prescribing medications.  Of course, for those figures to be relevant, one would have to first show that there is a connection between provider negligence and malpractice claims. In fact, no such relationship has been established. (Also here.)

One good argument against their having prescription privileges is right there on the CNPA website.  After the recent contaminated compounded drug debacle, Congress wanted to clean up the industry.  The FDA is enacting new rules governing compounding pharmacies, and the naturopaths are terrified that their in-office compounding privileges might be taken away.  The AANP is making a pitch on the CNPA’s website for everyone to rally to the cause. They want to pump their patients’ bodies with questionable treatments such as injectable vitamins and IV solutions and herbal suppositories, from which patients, according to the AANP, “derive tremendous benefit” and they want to do it in the privacy of their own offices.

The naturopaths also touted the enhanced ability to collaborate with other health care professionals.  That hasn’t worked out so well elsewhere.  One MD, the “Physician Lead for Integrative Medicine at Kaiser Permanente Northwest,” (KPNW) who is quite sympathetic to CAM, reported on the difficulties of managing patients with naturopaths.

At KPNW, medical physicians will refer patients “who have failed usual care” to naturopaths for a limited number of conditions based on an “evidence grid” developed by KPNW. (The grid is necessary due to the lack of adequate evidence for naturopathic treatments.  If you don’t have much in the way of actual studies and such, you have to work something out, and they came up with a grid.) The article gives us a rare glimpse into the world of actual naturopathic practice and what we see is disturbing, although entirely consistent with what we might expect. (I’ve omitted citations in the interest of brevity.)

These problems included patients asking MDs to order tests recommended by naturopaths which “are either unrecognizable or seem inappropriate.”

The most frequent example relates to evaluation and management of thyroid disorders. Naturopathic physicians will commonly recommend multiple hormone studies, including T3 and T4 levels, in settings where, from a primary care internal medicine perspective, the sensitive thyroid stimulating hormone (TSH) test is the only appropriate test. The patient is understandably confused, having received contradictory advice from the naturopath on the one side and internist, or endocrinologist, on the other. Whom to believe? Many patients do not discriminate that endocrinolo­gists, who are residency and fellowship trained, have five more years of train­ing than the naturopathic physician in this area.

That five years hardly begins to describe the differences between a naturopath and an endocrinologist. Of course, you’d think the naturopath would defer to the endocrinologist, as an MD or DO PCP would do, but apparently not.

Patient management is an issue as well.

Naturo­paths will typically advise patients to supplement with combination T3-T4 preparations, such as desiccated thyroid. This contradicts conventional endocrine guidelines for Levothroid T4 supplemen­tation in the setting of hypothyroidism. Desiccated thyroid preparations may provide inconsistent levels of thyroid hormone from one batch to the next. T3-containing preparations may also provide for more fluctuation, and less steady state, of thyroid hormone levels because of the rapid gastrointestinal absorption and the relatively short half-life of T3. In addition, blinded RCT data have shown no benefit of combination T3-T4 preparations over T4 in terms of patients’ symptoms and quality of life. The naturopathic community’s failure to clearly articulate responses to these points severely aggravates nega­tive perceptions of naturopathy within mainstream medicine. Some naturopaths will recommend thyroid supplementation for patients who are biochemically eu­thryoid (normal TSH). A subset of these patients will later present to the primary care internist or endocrinologist on in­appropriate doses of thyroid hormone, with a suppressed TSH. In the worst-case scenario, the patient rejects the internist’s advice to change and reduce thyroid supplementation, and assumes a hostile stance to the internist’s refusal to order T4 and T3 levels. Yet such inappropriate thyroid supplementation will increase the patient’s risk for atrial fibrillation, osteoporosis, and other complications of hyperthyroidism.

Yes, I suppose a physician’s “negative perceptions of naturopathy” would be “severely aggravated” if some naturopath were endangering his patients’ health.  Just imagine being a fellowship-trained endocrinologist and dealing with this folderol from folks who’ve never even done a residency and spent a good bit of time learning the finer points of homeopathy in “medical” school.

Beyond management of thyroid patients “there are numerous other sources of contention.”  Such as:

Many patients with fatigue and other nonspecific complaints will be given the diagnosis of “systemic candidiasis” by their naturopathic physi­cian. This naturopathic diagnosis pre­sumably suggests some imbalance or irregularity of the indigenous microbial flora. These patients sometimes present to their internists for further evaluation and management of this condition. However, as the patients generally have no clinical or laboratory evidence of candidemia, the baffled internist cannot locate or reinforce the diagnosis, leaving all parties frustrated.

And then there are the dietary issues:

Although most allopathic primary care physicians welcome additional attention and counseling for the patient toward proper and healthy dietary habits, many in the naturopathic community seem to promote eating patterns that may appear faddish to the internist. For example, patients who visit naturopaths are al­most universally advised to discontinue consumption of wheat and dairy products.

Also:

Similarly, prescribing a strict gluten-free diet in the absence of objective biopsy or serologic evidence of celiac disease imposes extremely severe restrictions on the patient’s cuisine which may be largely unnecessary.

Patients and medical physicians aren’t the only ones who are disadvantaged by these practices. The author reports that, of the funds spent on referrals to CAM practitioners over the first 8 months of 2012, 72% was paid to acupuncturists, 23% to chiropractors, but only 4% to naturopaths.  They cause too many problems and medical doctors simply don’t want to refer to them.

Look out, Connecticut

Connecticut naturopaths have already established a beachhead in quackademic medical centers at Yale and the University of Connecticut.  According to the CNPA, naturopaths

are trained to serve as primary care general practitioners who are experts in the prevention, diagnosis, management, and treatment of both acute and chronic health conditions.

What sort of “primary care” might Connecticut’s citizens expect from the state’s 228 licensed “naturopathic physicians” now that their scope of practice has been “modernized?” (By way of comparison, there are 17,294 physicians and surgeons and 9 homeopaths.)

Let’s visit the Connecticut Center for Health, a 5-member practice with offices in Middleton and West Hartford.One of their practitioners is a founding member of the AANP and another is the acting president of CNPA. All are graduates of naturopathic schools accredited by the Council on Naturopathic Medical Education. Some are hold positions at these schools. Certainly, we would not expect such leaders to deviate from the naturopathic standard of care. In fact, they seem to be regarded as exemplars of naturopathic practice by their peers.

Remember those problems Kaiser Permanente medical doctors were having with naturopaths? Apparently, Connecticut MDs and DOs will be confronting the same issues.

Thyroid disorders:

We thoroughly evaluate thyroid function by looking at T3 and T4 and determine if they are optimum and not just normal.

“Systemic candidiasis:”

Antibiotics, high sugar diet, steroids, and a low fiber diet may cause an imbalance in either the bacteria or fungi (yeast) in your intestines. Once an imbalance takes hold, it can cause significant problems with the intestines directly causing irritable bowel, gas, bloating, colitis, and a depressed immune function leading to chronic infections and/or allergies, asthma, hives, and fatigue. (For more information on this you can read The Yeast Connection by William Crook).

Three different lab tests help identify these underlying problems. Candida antibody blood panel, dysbiosis markers in urine, and stool culture.

Faddish diets (in this case for autism):

  • Diet of foods that are unrefined, free of additives, varied, fresh, little or no sugar. Focus on minimizing carbohydrate and make sure there is an adequate intake of protein and essential fatty acids (EFAs).
  • A gluten (no wheat, oats, rye, barley) and casein-free (no dairy) diet, avoiding both for at least 12 weeks.
  • A yeast- and mold-free diet for a minimum of 6 weeks.
  • A diagnostic trial of avoidance of all common allergenic foods for a minimum of 4 weeks, including: dairy products, wheat, baker’s yeast, brewer’s yeast, sugar, eggs, corn, peanuts, orange, lemon, lime, soy foods, shellfish, and tomato.
  • A trial removing the foods your child is allergic to, as identified through food allergy testing.

In their discussion of autism’s causes, they posit that

immunizations, particularly measles, mumps, and rubella (MMR) vaccine, may precipitate autism. This is a very heated debate and research is still ongoing–no one knows for sure.

Well, I suppose if you are the vaccine-autism fraud perpetrator Andrew Wakefield there is a “heated debate.” Actually, we do know that the MMR vaccine never had any connection with autism and it doesn’t now. Remember, these folks can now administer immunizations. Wonder what they’ll tell parents about the MMR vaccine?

Unfortunately, their autism “treatments” are not limited to diet. They also recommend dietary supplements, non-fluoridated water and toothpaste, injections of secretin and IV gamma globulin, anti-fungal medication if intestinal “imbalances” are found, a trial of DMSA to chelate mercury if the child’s levels were high on testing (presumably the unvalidated and possibly harmful provoked urine test). As they don’t have the authority to prescribe, I am not sure how they are giving the injections and IV treatments. If the autistic child has “never been well” since being vaccinated, they say they can address this with homeopathy.

Autistic children are not the only victims of their pediatric quackery.  They also claim they are “quite experienced in how to treat osteogenesis imperfecta.”  Osteogenesis imperfecta is a rare genetic bone disorder characterized by fragile bones that break easily.  It is also known as “brittle bone disease.” Specially trained medical professionals, such as pediatric orthopedists, supervise the management of a patient with OI. Notably, the OI Foundation does not count naturopaths among those professionals. But that doesn’t stop the naturopaths at Connecticut Center for Health, who promote herbal medicine, avoiding dairy, and (I kid you not) homeopathy for OI.

If you will permit me one more example from this target-rich website, just because naturopaths seem so enamored of the bowels:

The amount of stool that you eliminate each day has a tremendous impact on health and wellbeing. Stool volume eliminated in a 24-hour period should total 18 inches or more. If stool stays in the bowel longer than it should, the bowel reabsorbs a variety of potentially toxic chemicals into the blood. These chemicals cause the liver to overwork and may disorder the immune and nervous systems. . .  Making sure you have daily adequate stool elimination is probably one of the most important things you can do to restore and maintain health.

Get our your rulers Connecticut! If you’re not producing 18 inches a day, you’re toast.

Categories: Medicine, Skepticism

Neuro-Acupuncture and Stroke

Science Based Medicine - Wed, 10/15/2014 - 08:11

On the home page of Zhu’s Neuro-Acupuncture Center there is a video relaying a testimonial of how scalp acupuncture helped a patient recover from acute stroke. The use of testimonials is very common in the promotion of dubious health treatments. A personal story and endorsement is psychologically more compelling than dry data. Testimonials are completely unreliable, however, and in fact I would argue that they are ethically questionable. I would even go as far as saying that the presence of testimonials is almost a sure sign that the treatment being promoted is not legitimate.

What I could not find on Zhu’s website were links to published scientific researcher establishing the safety and efficacy of his treatments. You would think if they existed, he would display them prominently.

Acupuncture for stroke is a common claim, contradicting the notion that acupuncture is primarily used for the symptomatic treatment of subjective symptoms. That, in my experience, is part of the promotional strategy for many CAM treatments. They are presented as benign treatments for symptomatic treatment only, so what’s the possible harm. In reality, proponents will claim they can actually treat diseases whenever given the chance.

Treating Stroke

A stroke results from an acute lack of blood supply to a portion of the brain, usually caused by a blockage in a cerebral artery, but can also be caused by overall lack of blood flow to the brain. Brain cells are metabolically very hungry, and can only go a few minutes without a steady blood supply before they start to die.

When the blockage of blood flow occurs brain cells will immediately stop functioning. Depending on how completely the blood flow is blocked, the amount of collateral flow from other arteries, and the duration of blockage, brain cells might be temporarily stunned, damaged but capable of recovery, severely damaged and likely to die, or they may be already dead. Clinically (based on patient symptoms and neurological exam) it is not possible to tell the difference, because stunned and dead brain cells look the same. They don’t function.

In fact some patient who present with a stroke actually have a transient ischemic attack (TIA), which is essentially a stroke that leaves behind no permanent damage and completely resolves within 24 hours.

Some patient with acute stroke are candidates for a drug called TPA that can break up a clot and restore flow. In the best cases, treatment with TPA can rapidly reverse the clinical signs of stroke, and so apparently restored flow before permanent damage occurred.

Therefore, when a patient presents with, for example, paralysis of one side of the body due to stroke, it is possible that they may recover very quickly, or they may recover over days as stunned brain cells recover, or over weeks as damaged but viable brain cells recover. Or, the patient may have permanent deficits due to dead brain tissue from the stroke. Modern imagine such as MRI scanning can help us predict to some extent how bad the damage is, but not completely. So in practice we mostly have to wait and see how the patient recovers.

What all this means is that, in order to study the effects of any treatment in the recovery from acute stroke, you need to perform careful double-blind placebo controlled trials. Cherry picking for testimonials can produce seemingly amazing stories of recovery no matter what treatment you are looking at, and therefore testimonials for stroke recovery are completely useless.

The testimonial promoted on Zhu’s homepage is just such a case. The story appears to be that of a patient with an acute stroke who recovered most of his function over several days, and then had rehab to complete his recovery. This is a very common outcome and therefore says nothing about the effects of the scalp acupuncture he received. It is therefore also deceptive (and unethical) to use this testimonial to promote a treatment that has not been scientifically validated.

Recovery long after stroke is another claim made for acupuncture, and other questionable treatments. Here the issues are a little different, because we are dealing with patients with chronic symptoms, sometimes for years. They are unlikely to make a rapid genuine neurological recovery, therefore.

However, when evaluating chronic stroke patients we need to consider both neurological recovery and functional recovery. Neurological recovery means making new connections between neurons, recruiting neural stem cells to lay down new circuits, and engaging the plasticity of the brain to have healthy areas take over for damaged areas.

Functional recovery means having improved function with stable neurological deficits. This type of recovery is often neglected by inexperienced stroke researchers (such as when non-neurologists study dubious treatments). For example, you can take someone who is weak from a stroke they had 10 years earlier and they can improve their function even without any further neurological recovery. They may be deconditioned and not fully rehabbed. Getting them exercise, mobilizing their joints, and training them to function better with their weakness can make a significant functional improvement. There is also what stroke researchers call the
“cheerleader effect.” Simply encouraging someone to try harder can have a measurable effect.

So again we see that unless a treatment is properly controlled for, it can be easy to present non-specific functional recovery as if it were a specific neurological effect of a treatment.

The Literature

Are there any well-designed trials of acupuncture for stroke? Not many. There are many preliminary or poor quality studies and some moderate quality. There is no single definitive study, however.

The most recent Cochrane systematic review of acupuncture for acute stroke is from 2005, and concludes:

Acupuncture appeared to be safe but without clear evidence of benefit. The number of patients is too small to be certain whether acupuncture is effective for treatment of acute ischaemic or haemorrhagic stroke. Larger, methodologically-sound trials are required.

The most recent Cochrane systematic review of acupuncture for chronic stroke rehab is from 2006, and concludes:

Currently there is no clear evidence on the effects of acupuncture on subacute or chronicstroke. Large, methodologically-sound trials are required.

A 2009 systematic review of acupuncture for post stroke spasticity concluded:

A reliable conclusion can not be drawn from the present data because of the defects in methodological quality and insufficient numbers of trials, especially lack the long-term terminal outcomes, although it appears a tedency that acupuncture can improve the conditions of post-stroke spastic paralysis.

A 2012 systematic review concluded:

The evidence for the effectiveness of acupuncture for stroke was inconclusive, mainly due to poor methodological quality and small samples.

And a 2014 systematic review concluded:

The available evidence suggests that acupuncture may be effective for treating poststroke neurological impairment and dysfunction such as dysphagia, although these reported benefits should be verified in large, well-controlled studies. On the other hand, the available evidence does not clearly indicate that acupuncture can help prevent poststroke death or disability, or ameliorate other aspects of stroke recovery, such as poststroke motor dysfunction.

There is a clear consensus, agreeing with my own take on the literature, that the current evidence does not establish that acupuncture is effective for stroke, post-stroke rehab, or post-stroke symptoms such as spasticity. Most of the studies are poorly controlled, and therefore non-significant trends are of no value.

Conclusion

Acupuncture is a highly implausible treatment for stroke in any phase. While it is possible to make hand-waviug speculations about possible mechanisms by which inserting a needle into the skin might reduce pain (even though a benefit has never been reliably demonstrated), there is nothing approaching a plausible mechanism for stroke recovery.

Needling the scalp or any part of the body will not restore blood flow to the brain, dissolve clots, or help neurons recover. Some acupuncturists will resort to claims based on Chi or life energy, but this is a pre-scientific belief without a shred of support from our modern scientific understanding of biology.

I do disagree with the reviewers above in that I do not think that larger well-controlled trials are necessary to conclude that acupuncture is not an effective treatment for stroke. Acupuncture is a highly implausible treatment, it has not been shown to work for any indication, and preliminary data for stroke is unimpressive. This is sufficient evidence to abandon a treatment as likely useless.

The expense and trouble of a large rigorous trial is only justified if a treatment is likely to be safe and effective based on a reasonable combination of prior plausibility and encouraging preliminary data. In this case we have neither.

One might argue that because acupuncture is already culturally embedded, definitive trials will be useful to convince proponents and the public that it does not work, if nothing else. However, history has shown this to not be the case. We already have large definitive trials showing acupuncture does not work for several indications, and this has not altered the enthusiasm for which proponents continue to support and use acupuncture. They simply ignore the negative evidence, or spin the results as somehow being positive – because placebo acupuncture works too. The entire exercise is therefore fruitless.

It should simply be acknowledged by the scientific and medical community that acupuncture is a failed hypothesis and the position of any self-respecting science-based organization should be the complete abandonment of this anachronistic treatment.

Categories: Medicine, Skepticism

Ebola and Human Error

Neurologica Blog - Tue, 10/14/2014 - 08:28

It has been fascinating, and a little scary, to watch the first ever Ebola epidemic from the comfort of my Connecticut environs – about as far from the epidemic as you can get. Two thoughts keep coming back to me. The first, as this epidemic progresses and the CDC and WHO keep advancing their predictions about how bad it’s going to get, is this question: are we witnessing the unfolding of a major epidemic or even pandemic? Are we going to look back at the second half of 2014 and wonder how no one recognized how serious this is going to get?

Of course, I do not want to overstate the situation, stoke unnecessary fears, or come off as sensationalist. So I, like the CDC, will point out that the probability of a pandemic is extremely small. Unlike West Africa, most industrialized nations have a robust healthcare infrastructure and we’ll be able to deal with an outbreak before it gets out of control.

But this leads me to my second thought – how did it get so bad in the first place? The story is essentially a story of human error. The current epidemic represents a failure at many levels. This is not about finger pointing, but recognizing human limitations and frailty.

By all accounts the current Ebola epidemic is overwhelming the governments and the infrastructure in West Africa where it is still spreading, and in fact increasing geometrically. The world is reacting, some have charged, too late to this crisis. In fact, an Ebola rapid response infrastructure should have been in place, ready to squash any outbreak in its infancy.

I guess we were made complacent by past experience. Ebola has always caused small local outbreaks. When I first heard of a new Ebola outbreak, months ago, I assumed (probably like everyone else) that this would be yet another typical small outbreak, and it hardly caught my attention at all.

Now we’re launching a massive effort, but the disease may be growing faster than our efforts to stem it. The fire is already spreading out of control, it’s too late to install sprinklers.

The culture in West Africa is partly responsible. There is widespread superstition, distrust of government and outsiders (with good reason), and paranoia. In Guinea, for example, 8 health care workers, trying to treat the Ebola epidemic, were killed with clubs and machete’s by villagers who believed they were spreading Ebola.

There are also reports that people who are sick often do not show up to treatment centers, for fear that they will simply be quarantined and left to die.

Victims are often not buried properly because of local burial customs. Funerals are therefore a very dangerous place to be.

There are also reports of profound individual failures. I wrote previously about an herbalist who may have been solely responsible for the spread of the epidemic to Sierra Leone by promising an herbal cure for Ebola. All she succeeded in doing was luring infected people across the border, spreading the infection, resulting in her own death from Ebola.

There is now also the case of the Liberian man, Thomas Duncan, who did not disclose his contact with Ebola victims, entered the US, and then was diagnosed with Ebola in Texas (and has subsequently died). A nurse caring for Duncan has now also contracted Ebola. The CDC reports that this must be due to some breach in protocol.

The assumption was that US hospitals have the training and equipment to deal with a virus like Ebola, but then the very first case diagnosed in an American hospital (so not counting health care workers who contracted Ebola in Africa and were brought home for treatment) resulted in a failure to prevent spread.

Ebola screening has now begun at JFK airport, and is likely to begin at other international airports.

Here are some updated Ebola statistics from the CDC.

Total Cases: 8400
Laboratory-Confirmed Cases: 4656
Total Deaths: 4033

And some good news:

Nigeria and Senegal have not reported any new cases since September 5, 2014, and August 29, 2014, respectively. All contacts in both countries have now completed their 21-day follow up, with no further cases of Ebola reported.

So it is possible to contain the virus’s spread in West Africa.

Conclusion

Whenever events like this unfold I always sense conflicting imperatives from officials responsible for dealing with the crisis. One the one hand they do not want to stoke fears and panic. So they reassure the public that we are dealing with the crisis and everything will be fine.

On the other hand, they have to convey the seriousness of the crisis so that proper resources will be allocated to dealing with it, and the public will take it seriously and do their part. This is serious, but don’t panic.

Further, it is essentially the job of those responsible for the crisis to prepare for it being much worse than it probably will be. Better to overprepare then to underprepare by even a little. We saw this with the H1N1 epidemic a few years ago. It was not as bad as projections predicted, and then the public criticized the CDC for being Cassandras. But that is their job.

Trying to write about the Ebola epidemic in a balanced way, I understand how difficult this can be. I don’t want to overstate the situation, but I don’t want to minimize it either. The fact is, the probability of a pandemic is very small. Outside of West Africa, you are probably safe and have nothing to worry about.

On the other hand, the epidemic is still in a phase where it is exceeding our prior projections, and we are still escalating our response in order to contain it. How draconian will containment measures have to get before the epidemic is over?

Thrown into this is the factor of human error. This is a variable that is difficult to predict, and we have already seen irresponsible decisions on the part of individuals foil our best efforts at preventing spread. In the end I suspect this will be a story of human error more than anything else.

Categories: Medicine

Does the Movie Fed Up Make Sense?

Science Based Medicine - Tue, 10/14/2014 - 03:00

The 2014 film Fed Up is an advocacy documentary. Its message:

  • There is a worldwide epidemic of obesity.
  • It is endangering our children.
  • Increased sugar consumption is responsible.
  • The food industry is responsible for our increased sugar consumption because it puts hidden sugar in processed foods, bombards us with advertising, favors profits over health, and lobbies against regulation.
  • The government is responsible because it has failed to control the food industry.

The film has received mostly positive reviews and has been called the Inconvenient Truth of the health movement. It was written and directed by Stephanie Soechtig, whose earlier films attacked GMO foods and the bottled water industry, and narrated by Katie Couric, who “gave anti-vaccine ideas a shot” on her talk show in late 2013.

The film shows families struggling with childhood obesity and “experts” expressing their opinions. Their selection of “experts” is heavy on politicians and journalists and light on nutrition scientists.

Is Sugar Really the Cause of the Obesity Epidemic?

Between 1971 and 2000, the prevalence of obesity in the United States doubled. During that time, fat consumption decreased, carbohydrate consumption rose, and average calorie intake rose (from 2450 to 2618 for men, and from 1542 to 1877 for women); the film blames sugar, but one could argue that total calorie intake was to blame.

Correlation is not causation, even when there is a strong correlation like the one between the rise in autism diagnoses and the rise in the sales of organic food. There is no such strong correlation between sugar consumption and obesity, much less any convincing evidence of causation.

Sugar consumption has actually decreased around the world even as the rate of obesity has continued to climb. Between 1999 and 2008, American consumption of added sugars decreased from 100 g/d to 76 g/d, mainly due to a reduction in soda consumption.

This webpage lists per capita sugar consumption by country, and it clearly does not correlate with rates of obesity in those countries. Countries with higher per capita sugar consumption than the US include Argentina, Australia, Austria, Belarus, Belgium, Brazil, Chile, Denmark, Estonia, France, Georgia, Germany, Iceland, Malaysia, Malta, Mexico, Morocco, Netherlands, New Zealand, Norway, Poland, Slovakia, Sweden, Switzerland, Ukraine, UK, and Venezuela. According to this source there are 17 countries with higher rates of obesity than the US. Not a single one of those countries has a higher per capita sugar consumption than the US.

There are other sources with different numbers, and these statistics don’t tell us much, because there are so many possible confounders such as lifestyle, total calorie intake, fiber, the type of sugar, hidden sugar in prepared foods, consumption of an otherwise nutritious diet, etc. The point is that it’s premature to make the kind of definitive pronouncements that the film makes about the role of sugar.

Gary Taubes makes a strong case for low-carb diets both for weight loss and health, but he admits that his hypothesis has not yet been properly tested. Chris Voight did an informal test of its exact opposite, a carbs-only diet: he ate nothing but potatoes for 60 days. According to Taubes’ low-carb theories he should have gained weight and raised his blood sugar, but instead he lost 21 pounds and lowered his blood sugar. His cholesterol and triglyceride levels dropped; he felt well and had plenty of energy.

The sugar/obesity hypothesis has not been properly tested either. There are plenty of examples of people who eat a lot of sugar and processed foods and don’t gain weight. In fact, one obese boy in the film complains that his brother eats the same way he does but doesn’t gain weight. There are plenty of examples of people who have lost weight and kept it off by reducing calorie intake and increasing exercise. We know some of the factors involved in successful weight loss, and eliminating sugar is not on the list.

Restaurants contribute to obesity by providing high-calorie food choices, large servings, and super-sized drinks. Fast food restaurants get a lot of blame, but John Cisna lost 56 pounds in 6 months while eating all his meals at McDonald’s. He counted calories and stuck to a 2000 calorie a day limit.

We don’t know that eliminating sugar from the diet is an effective strategy by itself. A family in the film eliminated sugar from their diet (they said they were “detoxing”!) and lost weight, but that could have been because they ate fewer total calories, and we don’t know that they would have lost any less weight if those fewer calories had included some calories from sugar. And the teenage boy lost weight but then gained it right back. What went wrong?

Colin Campbell of the Center for Nutritional Studies points out that the evidence showing sugar to be a major factor in obesity is relatively weak and is confounded by total calorie intake and other factors. He says:

I know of no evidence that were we to eliminate all sugar from our diets, presumably leaving the rest of the diet the same, we could rid ourselves of disease and restore our health.

The Film Gets a Lot of Things Wrong

I was going to do some further fact checking, but Google saved me the trouble. I discovered that two writers at Food Insight had already analyzed the claims in Fed Up and shown that the filmmakers got many of their facts wrong. They give these examples:

  • “This year for the first time in the history of the world, more people will die from the effects of obesity than from starvation.” Not true: three times as many die of starvation.
  • “For the first time in 200 years, the current generation of children are expected to live shorter lives than their parents.” Expected by whom? According to the CDC and the Census Bureau, life expectancies are on an uninterrupted upward trajectory that is expected to continue rising until at least 2020.
  • While fitness club memberships more than doubled, the obesity rate also doubled. A meaningless comparison that is intended to suggest that we are helpless to do anything about our weight.
  • It rejects the concept of energy balance, but the scientific evidence clearly shows that it is possible to lose weight by decreasing calorie intake and increasing calorie expenditure.
  • Dr. Robert Lustig gets a lot of screen time. He says that there is “really good data” that “a calorie is not a calorie,” in that the “toxicity” of sugars is an inherent and unique contributor to obesogenicity. “When your liver gets that big sugar rush… it has no choice but to turn it into fat immediately.” His language is inflammatory, demonizing sugar as toxic and addictive. Lustig’s views are inconsistent with mainstream scientific opinions based on all the available evidence. Dr. David Katz of the Yale Prevention Research Center characterizes Lustig’s theories as “humbug” and explains why.
  • “Between 1977 and 2000, Americans have doubled their daily intake of sugar.” Not true: Americans are eating more total calories but have not doubled the calories from sugar.
  • “Over 95 percent of all Americans will be overweight or obese in two decades.” No, obesity prevalence has leveled off since 2003 and the forecasted trend-line is virtually flat.
  • It claims that consuming a single soda per day increases one’s risk of diabetes by 22 percent. Sugar doesn’t cause diabetes; the film presents a simplistic caricature of the relationship between sugar and diabetes.
  • The film says the pledge of food companies to remove 1.5 trillion calories from the marketplace amounts to “nothing,” a mere 14 calories a day per person. Actually, they have already removed 6.4 trillion calories, ahead of schedule and more than 400 percent of the original goal. The resulting reduction of 78 calories a day per person is probably more than enough to meet the Healthy People 2020 target for obesity reduction.

This review concludes by saying the central claims of the film are shadings of the truth, sins of omission, and outright fabrication. It says the film’s “obsessive focus on a single nutrient actually could cause more harm than good, in that overconsumption of any macronutrient can lead to overweight and obesity.” It offers credible evidence and provides links to additional resources.

At Reason.com, Baylen Linnekin points out that the film overwhelmingly features supporters of increased food regulation, and non-supporters are treated unfairly. David Allison is asked for his opinion on the contribution of sugar sweetened beverages to obesity, and when he asks for a moment to collect his thoughts, the editing cuts him off and makes him look foolish.

In the film, Senator Tom Harkin asks how the food industry executives can sleep at night. I find that ironic. He supported farm bills that pay billions of dollars in subsidies to farmers in his home state Iowa, which leads the nation in high fructose corn syrup production. Harkin is a major advocate of alternative medicine who has been instrumental in legislation such as creating the NCCAM, a travesty and a waste of taxpayer dollars. He is so ignorant of how science works that he complained that the NCCAM has been disproving things rather than doing its intended job of “seeking out and approving.” He has been characterized on this blog as “waging a war on science.” I wonder how Harkin can sleep at night.

What Can Be Done to Improve the American Diet?

I think we can all agree that the typical American diet is not healthy. It provides too much processed food, convenience food, sodas, red meat, salt, sugars, and calories; and it is deficient in fruits, vegetables, and fiber. Sugar is only one part of the obesity problem, a part that may be due to its contribution to total calorie intake rather than anything inherently bad about sugar. No one would argue that we shouldn’t try to reduce sugar consumption; the question is how to accomplish that.

The film’s comparison to tobacco is interesting. For a long time, the tobacco industry misled the pubic about the dangers of smoking. Tobacco advertising dropped when equal time was required for anti-smoking information. Societal attitudes changed rapidly for tobacco thanks to public information campaigns. Legislation has contributed to a decrease in smoking, but I would argue that legislation would not have been possible without a change in public perceptions.

I think the general public is well aware of the need to control weight, and instead of trying to control their eating habits by passing laws to control the food industry, we might do better to educate them about how to eat a healthier diet. There is so much they don’t understand. The film shows tearful families unable to lose weight and trying so hard — but their efforts include things like switching from regular Hot Pockets to a low-fat version. There are many flavors of Lean Pockets, but the very first one I looked up contained the equivalent of 3-4 tsp of sugar and a whopping 655 calories. Obese teenagers are shown lamenting their inability to lose weight while gorging on cereal, finishing large bags of potato chips to “savor the flavor,” and choosing hamburgers and fries for lunch at school. One is shown making what he thinks is a “healthy lunch” to take to school: a peanut butter and jelly sandwich! These people desperately want to adopt healthier eating habits, but they have no idea how to go about it. How can we best help them?

People complain that they weren’t able to lose weight by reducing calories, but some of them don’t realize that they never actually reduced calories enough to get results. I once had an overweight 13-year-old boy as a patient. I asked what he usually ate for lunch, and we calculated that his daily cheeseburger, fries, and milkshake added up to over 1000 calories. I asked if he would consider bringing a lower calorie sack lunch from home, and he enthusiastically agreed. He had never even thought of that option. I had an adult patient who couldn’t understand why she hadn’t lost weight when she was eating mostly yogurt. She thought yogurt was “diet food” so she could eat as much of it as she wanted. When I asked her to read the label, she was astounded to learn that each container of yogurt had 240 calories.

Efforts are already underway to improve school lunches and remove junk food vending machines from schools. That’s a step in the right direction. Agatha Raisin, a character in a delicious series of mystery novels by M. C. Beaton, brags that she loves to cook, but her idea of cooking is sticking a TV dinner in the microwave. A lot of our young people grow up with similar ideas about what it means to cook. Why not require Home Ec classes in our schools? They could teach nutrition, menu planning, and meal preparation from scratch with fresh ingredients. Students might learn to think of healthier options when it comes to planning what to do for dinner.

To my mind, it’s not just a matter of educating children, but of educating the parents who buy and serve the food their children eat at home, educating the parents who think you can lose weight by switching from Hot Pockets to Lean Pockets. Just as information campaigns educated the public about smoking, they could educate the public about healthy food choices, hidden sugars, and calorie content of various foods. Even without legislation, a public outcry and grass roots movements would be enough to change food manufacturing. The food industry exists to please its customers and has provided us with easy, timesaving, attractive options that are hard to resist. What if the general public learned to buy less processed food, to read labels, to avoid hidden sugars, to be aware of how many calories they are ingesting, and to enjoy cooking at home. If they did that, market forces would make the food industry adapt. If companies wanted to keep profits up, they would have to be creative about providing healthier products. Just think how quickly they responded to public enthusiasms like gluten-free and low-carb.

People naturally tend to eat the way their parents ate, the way their culture eats. It can be hard for them to even imagine other ways of eating. My parents grew up on farms and ate the way their own parents and grandparents had always eaten. I grew up thinking the ideal meal was meat, potatoes, a green vegetable, a yellow vegetable, bread and butter, a sugary dessert, and milk for a beverage. Last night I cooked dinner from scratch, using several ingredients that never crossed the threshold of my mother’s kitchen, including red quinoa, chickpeas, collard greens, olive oil, yogurt, and limes. I used to see items like those in the grocery store and pass them by; it never would have occurred to me to cook with them because I had no experience with them and wouldn’t have known what to do with them. We can’t expect people to think outside the box of the traditional American family dinner table and the fast food restaurant without some help. My horizons have been hugely expanded by subscribing to the Blue Apron program, which has me cooking from scratch with a variety of ingredients like heirloom vegetables and exotic foods from other cultures (many of which I had never even heard of) and trying out new cooking techniques. Blue Apron is expensive and is not something that could be recommended for everyone, but I can see how school programs and media campaigns might be able to accomplish something similar.

I favor education over regulation. I’m not against regulating the food industry, but I would like to see proposals tested before they are widely implemented. Providing nutrition information on menus seemed like a great idea, but it has had minimal impact on food choices in real-world settings. Many thousands of young people were put through abstinence-only sex education programs before we realized they were ineffective and might even be doing more harm than good. We can’t just assume that any proposed remedy for the obesity epidemic will work. No matter how slam-dunk it sounds, it must be tested using scientific methods.

Conclusion

The film’s thesis, that sugar has caused the obesity epidemic, is not well supported by evidence. It is a partial truth that the filmmakers have dogmatically represented as the whole truth, with nary a hint of nuance. And it’s not fair to demonize the food industry. It has done a lot of good by providing a greater variety of safer food to more people for lower prices. We must share the responsibility for their shortcomings, because their less healthy offerings were created in response to public demand, and large numbers of people have chosen to buy those products because they don’t know any better.

The film will undoubtedly do some good by helping raise public awareness of childhood obesity and of hidden sugars in processed foods. I only wish it could have done so without misrepresenting the facts and without the bias and hype in support of the filmmakers’ political agenda of increasing food regulation. I try to eat a healthy diet, but I enjoy an occasional sugary treat and fast food meal, and I appreciate the convenience of packaged, processed foods when I don’t have a lot of time to shop and cook. I see no compelling reason to think it is impossible for people to lose weight on a diet that is overall nutritious and calorie controlled but that allows small amounts of even the “worst” foods.

 

 

Categories: Medicine, Skepticism

Anomaly Hunting and the Umbrella Man

Neurologica Blog - Mon, 10/13/2014 - 08:24

This is not a new story, but it is worth repeating. At the moment that bullets were being fired into JFK’s motorcade, a man can be seen standing on the side of the road near the car holding an open black umbrella. It was a sunny day (although it had rained the night before) and no one else in Dallas was holding an umbrella.

This is exactly the kind of detail that sets a fire under conspiracy theorists. It is a genuine anomaly – something that sticks out like a sore thumb.

The event also defies our intuition about probability. Even if one could accept that somewhere on the streets of Dallas that morning one man decided to hold an open umbrella for some strange reason, what are the odds that this one man would be essentially standing right next to the president’s car when the bullets began to fly?

Our evolved tendency for pattern recognition and looking for significance in events screams that this anomaly must have a compelling explanation, and since it is associated with the assassination of a president, it must be a sinister one.

When you delve into the details of any complex historical event, however, anomalies such as this are certain to surface. People are quirky individual beings with rich and complex histories and motivations. People do strange things for strange reasons. There is no way to account for all possible thought processes firing around in the brains of every person involved in an event.

Often the actions of others seem unfathomable to us. Our instinct is to try to explain the behavior of others as resulting from mostly internal forces. We tend to underestimate the influence of external factors. This is called the fundamental attribution error.

We also tend to assume that the actions of others are deliberate and planned, rather than random or accidental.

The common assumption underlying all of these various instincts is that there is a specific purpose to events, and especially the actions of others. We further instinctively fear that this purpose is sinister, or may be working against our own interests in some way. In this way, we all have a little conspiracy theorist inside us.

I also find it interesting that these tendencies are often not inhibited by the many counter-examples that we encounter on a regular basis. The vast majority of the time, when I find the actions of another person puzzling, if I am able to simply ask them to account for their behavior, there is usually a non-sinister explanation. There were factors of which I was unaware. They knew (or at least believed) something I did not know, or were reacting to an external stimuli, or had a previous experience informing their current action. Sometimes they were just doing something whimsical for fun or to stave off boredom, or perhaps they were satisfying some minor curiosity.

In response to such experiences we should question our basic underlying assumptions of purpose and deliberateness. Instead, we tend to dismiss this data as quirky exceptions, and carry on with our assumptions intact.

Conspiracy theorists have essentially formalized the tendency to assume agency, deliberateness, and sinister motivations in the quirky details of events. Conspiracy theories are often an exercise in anomaly hunting. When anomalies, like the Umbrella Man, are inevitably found it is assumed that they are evidence for a conspiracy.

The assumption that anomalies must be significant rather than random is an error in the understanding of statistics, a form of innumeracy. It is also partly the lottery fallacy – which involves asking the wrong question. The name of the fallacy is based on the most common illustrative example. If John Smith wins the lottery our natural tendency is to consider what the odds are that John Smith won (usually hundreds of millions to one). However, the correct question is – what are the odds that anyone would have won, in which case the odds are close to one to one (at least over a few weeks).

The fallacy is in confusing a priori probability with posterior probability – once you know the outcome, asking for the odds of that particular outcome. This is perhaps more obvious when we consider the odds of someone winning the lottery twice. This occurs regularly, and when it does the press often reports the odds as being astronomical. They are usually also falsely considering the odds of one person winning on two successive individual lottery tickets. Further, they calculate the odds of John Smith winning twice, rather than the odds of anyone anywhere winning twice (the odds are actually quite good and match the observed rate).

So – conspiracy theorists tend to ask, what are the odds of a man standing with an open umbrella right next to the president when he was shot? Rather they should be asking – what are the odds of anything unusual occurring in any way associated with the JFK assassination?

There is another aspect to anomaly hunting and that is the use of open-ended criteria. What constitutes an anomaly? Well, anything you want to count as an anomaly. There are no specific criteria. In practice the criterion is – it seems weird to me. This then opens the door to confirmation bias. Seek and ye shall find.

What, then, is the explanation for the seemingly bizarre actions of the Umbrella Man? A nice documentary, recirculating on social media, has the answer. The man (Louie Steven Witt) was asked to come forward and explain his actions, and he did, before congress. The umbrella was a protest of Joseph Kennedy’s appeasement polices when he was Ambassador to the Court of St. James in 1938-39, with the umbrella being a reference to the umbrella often carried by Neville Chamberlain.

This is actually not as random as it may seem (and this is the one hole in the documentary’s treatment of the topic). An open umbrella was a common protest of appeasement policies. According to the historical society:

Umbrella protests first began in England after Chamberlain arrived home from the conference carrying his trademark accessory. Wherever Chamberlain traveled, the opposition party in Britain protested his appeasement at Munich by displaying umbrellas. Throughout the 1950s and 1960s, Americans on the far Right employed umbrellas to criticize leaders supposedly appeasing the enemies of the United States. Some politicians even refused to use them for that reason. Vice President Richard Nixon banned his own aides from carrying umbrellas when picking him up at the airport for fear of being photographed and charged as an appeaser.

That puts the umbrella protest into more context. In the early 1960′s I can see there still being people around who were angry at any attempts to appease Hitler and the Nazis prior to the start of WWII. I also wonder if Witt was protesting JFK in some way, but did not want to say so after he was assassinated and so blamed the protest on his father. Either way, the umbrella is not such a random detail after all.

Conclusion

The various aspects of anomaly hunting are critical to understand in order to avoid falling into this seductive mental trap. Poor intuition for statistics, logical fallacies, confirmation bias, and the use of open-ended criteria combine with the fundamental attribution error and the tendency to see patterns and significance everywhere to create the powerful impression that something (usually sinister) must be going on.

Our penchant for narrative then takes over. We love a good story, and the notion that some tiny clue in the form of an anomaly can reveal a vast unseen conspiracy is more compelling story telling than just random noise in the background of history. Unless, of course, your telling the story of how we fool ourselves. That, of course, is a story I like telling.

Categories: Medicine

Andrew Wakefield, the MMR, and a “mother warrior’s” fabricated vaccine injury story

Science Based Medicine - Mon, 10/13/2014 - 03:00

As the time came to do my usual weekly post for this blog, I was torn over what to write about. Regular readers might have noticed that a certain dubious cancer doctor about whom I’ve written twice before has been agitating in the comments for me to pay attention to him, after having sent more e-mails to me and various deans at my medical school “challenging” me to publish a link to his results and threatening to go to the local press to see if he can drum up interest in this “battle.” I’ve been assiduously ignoring him, but over time the irritation factor made me want to tell him, “Be very careful what you ask for. You might just get it.” Then I’d make this week’s post about him, even though I wasn’t thrilled with the idea of giving in to his harassment and giving him what he wants.

That’s I have to thank the ever-intrepid investigative reporter Brian Deer for providing me an alternative topic that is way more important than some self-important little quack and a compelling topic to blog about in its own right. Brian Deer, as you might recall, remains the one journalist who was able to crack the facade of seeming scientific legitimacy built up by antivaccine guru Andrew Wakefield and demonstrate that (1) Wakefield’s work concluding that the MMR vaccine was associated with “autistic enterocolitis” was bought and paid for by a solicitor named Richard Barr, who represented British parents looking to sue vaccine manufacturers, to the tune of over £400,000; (2) Wakefield expected to make over £72 million a year selling a test patent Wakefield had filed in March 1995 claiming that “Crohn’s disease or ulcerative colitis may be diagnosed by detecting measles virus in bowel tissue, bowel products or body fluids”; and Wakefield’s case series published in The Lancet in 1998 was fraudulent, the equivalent of what Deer correctly characterized as “Piltdown medicine.” Ultimately, these revelations led to Wakefield’s being completely discredited to the point where The Lancet retracted his paper and even Thoughtful House, the autism quackery clinic in Austin, TX where Wakefield had a cushy, well-paid position as scientific director, had to give him the boot. Yes, Wakefield is a fraud, and it’s only a shame that it took over a decade for it to be demonstrated.

As much as I hate how it took discrediting Wakefield the man as a fraud rather than just discrediting his bogus science to really begin to turn the tide against the annoying propensity of journalists to look to Wakefield or his acolytes for “equal time” and “balance” whenever stories about autism and vaccines reared their ugly heads, I can’t argue with the results. Wakefield is well and truly discredited now, so much so that, as I noted, his prominent involvement probably ruined any chance promoters of the “CDC whistleblower” scam ever had to get any traction from the mainstream press.

What is sometimes forgotten is the effect Wakefield’s message has had on parents. These are the sorts of parents who tend to congregate into groups designed to promote the idea that vaccines are dangerous and cause autism, such as the bloggers at the antivaccine crank blog Age of Autism, the equally cranky blog The Thinking Moms’ Revolution, or groups like The Canary Party. It is Wakefield’s message and the “autism biomed” quackery that it spawned that have led to unknown numbers of autistic children being subjected to the rankest form of quackery in order to “recover” them, up to and including dubious stem cell therapies and bleach enemas.

This is the sort of parent that is the topic of Brian Deer’s story in the The Sunday Times yesterday entitled A warrior mother lost to MMR lies. (Mother warriors, remember, was the title of a book by Jenny McCarthy promoting the idea that vaccines cause autism and the biomedical quackery parents of such children use to treat autistic children.”) It is the story of a mother who became an acolyte of Andrew Wakefield and how she completely made up the link between vaccination and her child’s autism. Because of what is characterized by Deer as a “pathological conflict with his carers,” an unnamed local brought legal action against E and A to allow M to get the care he required.

Unfortunately, the article is behind a paywall. Fortunately, there is a version of his article, Wakefield ‘MMR mother’
fabricated injury story
, on Brian Deer’s own website, along with a 45,000 word judgment by High Court judge Mr Justice Baker that entered the public domain last week from the Court of Protection. A link to the complete text of that judgment is also available on Deer’s website. In order to protect the child’s anonymity, the parents are not named, the mother being referred to as “E,” the father as “A,” and the child as “M.” To continue that protection, given that I know many of our readers are quite knowledgeable about l’affaire Wakefield, some even considerably more so than I, I must insist that there be no speculation about the identities of E, M, or A, and no naming of them. In any case, E is what Deer has dubbed a “Wakefield mother,” Wakefield mothers being forgotten victims of the MMR scare engineered by Andrew Wakefield. The story of E is harrowing reading, and Deer is not unsympathetic:

By any reckoning, “E” is a formidable crusader. She is intelligent, articulate and outwardly confident. She has worked as a health service manager. She is a former school governor and a trained mediator. And, most of all, she is a loving parent. She champions her son “M” – who is autistic and learning-disabled – and for his first 18 years looked after him at home, generally “very well” by all accounts.

In America, she likely would be called a “mother warrior”, a name coined by Jenny McCarthy, an actress. These are women who have concluded that their child’s disorders were caused by vaccines, and will stop at almost nothing to prove “the truth”. In recent years, Britain’s “MMR scare” has been exported to the United States, and such mothers have rallied to networks of websites and conferences, even as infectious diseases have returned.

But “E” is British, a leading disciple of Andrew Wakefield, the former “MMR doctor”, who was struck off the medical register in 2010. He is the man who terrified a generation of young parents, claiming that the triple shot against measles, mumps and rubella causes autism and a novel bowel disease. As my lengthy investigations revealed, while he secretly worked for lawyers and tried to launch his own personal business ventures, he caused vaccination rates to plummet, and triggered outbreaks of measles. The British Medical Journal dubbed his research “an elaborate fraud”.

“E”, I believe, is one of the scare’s forgotten victims. I call them the “Wakefield mothers”. Here is a woman, now in her fifties, who I have met but am forbidden to name. She has appeared at public rallies and in media, with her son. She has protested to government ministers. She has denounced judges, doctors and journalists (including me). She sued a drug company that makes MMR.

It also turns out that what E relates to the authorities (and everyone else) about her child’s development of autism does not jibe with available records and evidence, to the point that the judgment finds it hard not to conclude that “E has fabricated, or at least grossly exaggerated, her account.” The entire judgment is incredibly damning, documenting numerous cases of E recounting health issues that are not supported by available documentary evidence. How did this happen? Was E lying, or is this just another example of how malleable memory is and how a mother, finding what she thinks to be a potential cure, can find her memories unconsciously altered to fit her beliefs, so that she really believes her false accounts are true? Or is it a combination? Let’s look at her story, as related by Deer, and the judgment.

The archetype versus reality

Brian Deer carefully points out how E’s story is an “archetype,” the same sort of story that he’s heard “hundreds of times” since he started investigating Wakefield and that I’ve heard too many, many times since I first took an interest a decade ago in the antivaccine movement, Andrew Wakefield, and the pseudoscientific myth that the MMR vaccine causes autism. As Deer put it, “It was the template media and lawsuit “Mothers’ Story” that would be recited so many times, by so many mothers over the years, that a reasonable person might assume it was true.” Indeed, the most famous “mother warrior” in the US, Jenny McCarthy, tells a story that fits the archetype. When told by these “mother warriors,” the core story is always the same, although the details can vary considerably. The core story is that the child was perfectly healthy, with no indication whatsoever of neurodevelopmental issues (or, usually, anything at all wrong) until sometime after MMR vaccination. In the case of Jenny McCarthy, she claimed that soon after the shot, “boom—the soul’s gone from his eyes.” McCarthy’s story has mutated and morphed through the years and with other retellings, so much so that it is difficult to tell what really happened. Unfortunately, E’s story about M has also morphed through the years.

I’ve read the entire judgment, and one thing that leaps out is a passage at the beginning. After noting that M was born in July 1989, the chronology used by the judge indicates that “on four dates between September 1989 (when he was aged six weeks) and March 1990 (aged eight months) M received the normal range of inoculations, with no recorded reactions,” and that “6. Between July and December 1990 there were eight further visits to the GP noted in M’s medical records in which he was reported as suffering from a variety of infections. There is no record of any developmental delay in these notes.” Then:

On 12th January 1991, aged just under 18 months, M was given the measles, mumps and rubella (“MMR”) vaccination. There is no record in his GP notes of any adverse reaction. In fact, there is no report of any adverse reaction to the MMR in any record relating to M for the next nine years. From 2000 onwards, however, M’s parents, and in particular his mother, have given increasingly vivid accounts of an extreme reaction to the injection experienced by M. There are descriptions of M screaming after having the injection, followed by six hours of convulsions, screaming and projectile vomiting. It is the parents’ case that the mother told their GP that he had had a bad reaction to the MMR but was told by him that she was an over-anxious mother and must be imagining it. When E called the GP a second time and said she was calling the emergency services, she was told not to do this, but went ahead because M was going in and out of consciousness. The paramedics and the GP had arrived at the same time, at which point M’s temperature was 104. The GP had told the paramedics to leave. Before going, they had told her that this was a case of meningeal encephalitis. The GP had been verbally abusive to E. The above account, given to Dr. Beck, a psychologist instructed as an expert witness in these proceedings, is similar to that given by the mother to a variety of professionals. She also gave a detailed description of M’s reaction to the MMR in the course of her oral evidence. One note in an “auditory processing assessment report” dated 31st October 2002 records E alleging that, following the MMR, M had remained in, “A persistent vegetative state for six months.”

The judgment (Deer as well) notes multiple inconsistencies in E’s accounts of M’s health problems, which she never linked to the MMR until at least 2000, after news of Wakefield’s case series and claims about the MMR, autism, and “autistic enterocolitis” had begun well and truly circulating in the British press. Ironically, as Deer and the judgment relate, E claimed repeatedly that her son had autistic enterocolitis, even after M had been evaluated by Wakefield’s group. Why is this unusual? The reason is simple, despite the tendency of Wakefield’s group at the time to promote autistic enterocolitis as a real entity and blame it on the MMR, even his group at the Royal Free Hospital didn’t diagnose M with the condition. It’s noted that E and A “have stated that M displayed signs of a severe gut disorder from the time of the MMR vaccine for 10 years until he was assessed and diagnosed at the Royal Free gastroenterology department” even though “there is no record in the GP notes or any other contemporaneous complaint that M had suffered a gut disorder during this 10 year period.” In fact, what M had been diagnosed with was constipation. The hospital notes from 2002, for instance, list E’s diagnosis as “progressive [regressive] autism – constipation.” As High Court judge Mr. Justice Baker’s judgment states:

Throughout the hearing, E insisted that M had been given the diagnosis of autistic enterocolitis or leaky gut syndrome and alleged that some of the Royal Free medical records must be missing. I reject that assertion. I find that not even the Royal Free team, who at that time were leading the way and postulating the link between autism and a form of colitis, found any evidence in 2001 of significant gut disorder in M. In his case no diagnosis of autistic enterocolitis or leaky gut syndrome was ever made.

If even Wakefield’s group at the Royal Free Hospital didn’t diagnose M with autistic enterocolitis, that really ought to tell you something! In any case, as Deer and this judgment recount is that the mother, having discovered Wakefield’s hypothesis, changed her story. Indeed, E filed for compensation in the “class action” lawsuit three months after she obtained an appointment at the Royal Free. Before she learned of Wakefield’s MMR scare, E blamed M’s condition on this:

The first relevant concern was in May 1990, when “M” was aged 10 months. In an account taken later, his parents said that on one night they felt that he had three times “nearly stopped breathing”, turned blue, and from then had difficulties swallowing.

“A clear indication of the trauma his body experienced from this illness was from that time onwards he could not bear his head to be anything other than upright,” said an education service report of the parents’ words, filed in evidence. “If it was moved lower than his shoulders his whole body would go completely rigid. For a time he lacked control over his tongue, until we managed to teach him how to keep it in his mouth.”

This was almost eight months before “M” received MMR, which was given to him in January 1991. And there were no reports of any reactions, or anything related to the shot, in his notes for the next nine years. Meanwhile, “E”, and her husband, “A”, who worked for the fire service, cared for their son, with devotion and love, as paediatricians struggled with the boy’s emerging autism and his significant intellectual delay.

Once E had discovered the dark path of vaccine injury and autism biomed, however, she jumped in, head first, taking her son to a variety of alternative medicine practitioners, garnering a huge number of diagnoses at various times, and treating him with virtually every form of quackery you can think of to which autistic children are subjected. The sorts of health issues reported by E included loss of sensation in M’s hands and feet, seizures, meningitis, leaky gut syndrome, tumors in his gums, “chronic blood poisoning,” bilateral deafness, uncontrollable temperatures, heavy metal poisoning (of course!), a “black shadow sitting on his left sinuses,” stabbing pains in his groin, uncontrollable sneezing, adverse effects of “electromagnetic energies” (against which E wrapped “electronic items in his [M’s] bedroom in tin foil to protect him”), “black grunge oozing from every orifice,” and Lyme disease (also of course). Other diagnoses included, rheumatoid arthritis; heavy metal poisoning (based on an isolated test result when such a diagnosis turns on repeated elevated levels); and a defective blood brain barrier. It gets even worse, though.

When M reached his teenage years and started to demonstrate more difficult behaviors, E blamed his personality change on “an unavoidable personality change” brought about because he was “dominated by testosterone and mercury.” This, as you might recall, is a truly quacky idea promulgated by a father-son team of autism quacks, Mark and David Geier, whose concept was that testosterone somehow “bound” mercury (from vaccines, of course) so that it couldn’t be properly chelated out of the brain. Never mind that the study they relied on for claiming that testosterone could bind mercury reported such binding in hot benzene, whose relevance to the aqueous solution that is human blood and serum is highly dubious, at best. The Geiers’ suggested solution was chelation therapy plus Lupron, the latter of which shuts down sex hormone production quite markedly and is a drug sometimes used for chemical castration.

As repeated several times in the judgment and by Deer, nowhere is there evidence to support any of these diagnoses from reputable medical practitioners, nor does the medical record support a temporal link between MMR vaccination and onset of autistic symptoms (or other symptoms), for that matter. E’s explanation? Those records are missing, doctors didn’t record the stories and incidents that she related to them, and that doctors or someone has removed relevant pages of the medical record. However, the court, after considerable investigation, concluded:

For some time E has alleged that part of M’s medical record is missing. The inference that she invited the court to draw was that pages had been deliberately removed to conceal contemporaneous records of his reaction to the MMR. It is now clear that no part of the records have been removed. One page of the records was missing and copies produced by E and A, but the original record was intact. I am not going to speculate on the reason why the copies produced by E and A are incomplete.

This sort of claim is repeated time after time after time by E, as described in the judgment. Conveniently, all the verifiable medical records that would back up her assertions have gone missing somehow. The implication, of course, is that it’s a conspiracy to discredit her, an implication the judge rejected:

If M had an experienced an extreme reaction to the vaccine, as now alleged, it is inconceivable that E and A would not have sought medical advice and thereafter told all doctors and other medical practitioners about what had happened. As I put it to E in the course of the hearing, there are only three possible explanations for what has happened. The first is that E did give the account to Dr Baird and all the other practitioners at every appointment, but each of them has negligently failed to record it. The second is that she gave an account but all the practitioners have chosen not to include it in their records. That is what E maintains has happened, alleging that the whole of the medical profession is deliberately concealing the truth about the MMR vaccine. The third is that E has fabricated, or at least grossly exaggerated, her account.

Which is more likely? That M’s doctors over the course of nearly a decade failed to document such an important part of his medical history, or that the story about M’s vaccine reaction is not accurate? If the court were to believe the mother, it would have to have concluded that there was “an MMR conspiracy, through which thousands of doctors and scientists (and, more recently, journalists) concealed horrific alleged injuries to children,” a “legal conspiracy, through which judges denied fairness,” and a “local government conspiracy, by which hard-pressed social workers wanted to remove autistic children from their parents.” These are exactly the sort of conspiracy theories I’ve seen time after time since becoming interested in the antivaccine movement. I could write about them every day if I wished.

Of course, once the fake diagnoses are made, can the quack treatments be far behind? In this case, they weren’t. M was subjected to a veritable cornucopia of quackery by E and A. Besides the aforementioned wrapping of electrical equipment in M’s room with tin foil, there was quackery that involved everything from cranial osteopathy, reflexology, oxygen chamber sessions for six hours at a time (it’s not clear if it was hyperbaric oxygen or not), and, of course, lots and lots of supplements and homeopathic remedies. According to the judgment, “the range of biomedical interventions being supplied to M included a probiotic, six vitamin supplements, four mineral supplements, five trace elements, fatty acids, amino acids, enzymes and a range of homeopathic remedies.” One description of a treatment administered on November 11, 2012 states:

M had a cranial osteopathic appointment that focused on the contorted membrane between the two frontal lobes, apparently where both optical and auditory brain stems sit. The twist in his central membrane was significant for most of the treatment to be spent on it and it would appear to have come from M’s head overheating, obviously trying to release body heat.

Then there was reflexology:

He is also benefiting from reflexology twice a week at the moment, as his hands and feet are so pale, freezing cold, rigid and painful. We are giving sips of water in between mouthfuls to help it go down and we are ensuring his bite size is far smaller, but he does seem to be suffering with trapped wind.

All of this doesn’t even include the rigid diets imposed on M to try to cure his apparently nonexistent gut problems. Overall, in the story of M, we see a story I’ve seen all too often, that of parents latching on to vaccines as a cause of their child’s autism and trying to “recover” their child through a wide variety of quackery. These stories appear frequently at blogs like Age of Autism and The Thinking Moms’ Revolution.

Into darkness

The scenario described above would be bad enough if it were completely innocent, but there is more than just well-meaning parents who latched on to the myth that vaccines cause autism as an explanation why their child isn’t normal and embraced quackery in order to try to “recover” their “real” child. Deer states at one point that he had “merely thought that her son’s autism plus Wakefield had so stripped her of trust in almost anyone but charlatans that she had been driven off the rails and round the bend” and, elsewhere, that he had “wondered if the mother was mad” (an offensive way to wonder if the mother had a mental illness that made me really wish he had chosen a different way to say what he meant). He also noted that E’s picture could fit that of “thousands of parents” who are taken in by Wakefield, who, Deer notes, regularly appears at “conferences dominated by quack remedy merchants and crowded with mother warriors who – wrongly blaming themselves for having their children vaccinated – are uniquely vulnerable prey.” This latter observation is, of course, absolutely true. That is how Wakefield operates. He blames autism on vaccines, which leads these parents to feel guilty over their decision to vaccinate and, in their minds, cause their children’s autism. Then he offers them a way to assuage that guilt through “recovering” their “real” child via biomedical quackery.

However, as bad as that is, in some cases, it gets even darker than that. Some parents, apparently E among them, use vaccine injury as a means of control, and that is what the court found:

Although not a criminal case, a litany of misbehaviour runs from page to page in the judgment. “E” subjected her son to unnecessary tests and interventions “and/or lied” about purported illnesses. She behaved in a “devious and destructive” way towards professionals. She denied her son the chance to develop more independence. She allowed the pain and suffering of a dental abscess to go untreated for a year, then planned to send the lost teeth to Wakefield. She made false allegations against social workers, and vexatiously complained to regulators.

In the end, Baker ruled that, not only did she have factious disorder, but a bunch of other disorders as well: “narcissistic personality disorder”, “histrionic personality disorder” and elements of “emotionally unstable personality disorder”. Her legal deputyship status was revoked. “M” would receive a vaccine if a GP advised it. And the mother was told to demonstrate a “fundamental change of attitude”, or face “permanent steps” to restrict her involvement in the future of her much-loved son.

It’s as sad a story as one can imagine, particularly for M. In E’s case, where did the normal malleability and suggestibility of human memory, such that later information and influences can alter our memories such that we “remember” things that that didn’t happen or our memories of incidents are not what really happened, end and E’s factitious disorder begin? Who knows? Who can tell for sure when she was lying, when she really believed her son had various disorders, and what they were? In the end, when trying to safeguard M’s welfare, it really doesn’t much matter. What we do know is that Wakefield’s antivaccine message, coupled with the quackery that it spawned (it’s not for nothing that I like to describe Wakefield’s Lancet paper as the “paper that launched a thousand quacks”) gave E the tools, and she used them. She subjected M to unnecessary tests and quack treatments; she prevented him from becoming more independent; and she even sued a pharmaceutical company. Most bizarrely, she allowed M to suffer for a year with an untreated tooth abscess, planning to deliver the tooth to Wakefield.

None of this helped her son, and the judge concluded:

It is inevitable that, were M to return home, he will be subjected to the same regime as before in which his mother sought to reimpose control over all aspects of his life. Furthermore, it is likely that she would continue to misrepresent his state of health and expose him to unnecessary examinations and treatments. It is inconceivable that M could return home unless E demonstrates a fundamental change of attitude.

And:

This court acknowledges the enormous demands placed on anyone who has to care for a disabled child. Even though such carers are motivated by love – and I accept that both E and A love M and are deeply devoted to him – the burdens and strains on them are very great. Every reasonable allowance must be made for the fact that they love their vulnerable son and want the absolute best for him. Every reasonable allowance must be made for the impact of these burdens and strains when assessing allegations about the parents’ behaviour. However, having made every reasonable allowance for those factors, I find the behaviour exhibited on many occasions, by E in particular, was wholly unreasonable.

The saddest part is at the end, where the judge concludes that unless E and A can demonstrate a “fundamental change of attitude,” the court will have to move to take permanent steps to restrict their involvement in his life.

This whole family, but most of all M, is the sort of victim of Andrew Wakefield who don’t get enough attention.

Categories: Medicine, Skepticism
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