Archive for the ‘ Alternative medicine ’ Category

Daily Deals and Altmed Pseudoscience


I’ve been noticing the occasional product on the daily deal site I frequent that is, how to put this delicately, BS.

Today I saw one that I just had to have some fun with and hopefully give people some idea of what the product is really about at the same time.

In this case the product was an “Energy Calcium Activation Cup”. I hadn’t heard of these before but the altmed buzzword combo of “energy” and “activation” got my attention.

The forum moderators tend to be quick to remove questions about products that are overtly critical so I had to play a bit dumb and make sure I didn’t get too much to the point. The outcome was quite amusing:

Grabone Magic Cup

You can see the discussion at:
http://www.grabonestore.co.nz/energy-calcium-activation-cup/discuss (or archived at  http://www.webcitation.org/6GTWgpSot just in case the entire thing gets deleted after this post goes live)

I would like to thank the company liaison Sabina Chadliwa who here was very forthcoming and quite speedy in comparison with other companies I have interacted with in this way. No offense is meant to her – but BS is BS.

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TCM and You: Cupping


I have noticed that Chinese massage seems to be becoming popular, and seemingly with it Traditional Chinese Medicine (TCM1). At least browsing through two of the larger shopping centres in Hamilton (bring on the hick jokes) I saw massage centres offering these services. In particular cupping was advertised. But what exactly is cupping2?

As with many modalities in TCM Cupping appears to be based on pre-scientific notions of blood stagnation and energy blockages3. Applying cups with a slight vacuum to the skin is meant to draw out the “toxins” which then results in improved health, somehow.

The active part of cupping essentially boils down to a pressure difference. The pressure is lower on the inside of the cup and greater on the outside, this difference causes the skin to be forced up into the cup4. This process in turn causes blood to gather in the region and may cause minor damage to the area resulting in bruising.

Presumably the fact that the skin appears to be drawn up into the cup gives the impression that there is a general pulling action at work here and that toxins and other “bad stuff” are pulled out of the body in this fashion.

The trouble with this is that pressure difference is a fairly crude physical process and with regard to this biological system lacks what we in the science biz call “Specificity”5. What this means is that there is no way for the cup to restrict the “pulling action” to only harmful chemicals (the “toxins”, say) and allow everything else to be unaffected, i.e. it is not “specific” to toxins. Everything will be drawn up in the same way.

In which case you get a lovely bruise and feel like you’ve done something but that’s about it.

Ok, that’s fine for just thinking about it. What about evidence, we’re always going on about evidence here.

I attempted to find a Cochrane review on cupping but while one was listed for pain relief there did not seem to be a completed review for perusal. I did come across this review that found equivocal results for the effectiveness of cupping for pain.

The review comments on the putative mechanism of cupping:

“Assuming that cupping was beneficial for the management of pain conditions, its mechanisms of action may be of interest. The postulated modes of actions include the interruption of blood circulation and congestion as well as stopping the inflammatory extravasations (escaping of bodily fluids such as blood) from the tissues. Others have postulated that cupping could affect the autonomic nervous system and help to reduce pain . None of these theories are, however, currently established in a scientific sense.” [Emphasis added, citations removed]

The discussion of the reviews limitations is especially worth noting:

“Our review has a number of important limitations. Although strong efforts were made to retrieve all RCTs on the subject, we cannot be absolutely certain that we succeeded. Moreover, selective publishing and reporting are other major causes for bias, which have to be considered. It is conceivable that several negative RCTs remained unpublished and thus distorted the overall picture. Most of the included RCTs that reported positive results come from China, a country which has been shown to produce no negative results. Further limitations include the paucity and the often suboptimal methodological quality of the primary data. One should note, however, that design features such as placebo or blinding are difficult to incorporate in studies of cupping and that research funds are scarce. These are factors that influence both the quality and the quantity of research. In total, these factors limit the conclusiveness of this systematic review.

In conclusion, the results of our systematic review provide some suggestive evidence for the effectiveness of cupping in the management of pain conditions. However, the total number of RCTs included in the analysis and the methodological quality were too low to draw firm conclusions. Future RCTs seem warranted but must overcome the methodological shortcomings of the existing evidence.”

In conclusion then, you may see a placebo effect from this treatment – though I suspect this is over rated as a therapeutic outcome6. You may also find yourself covered in bruises (though I hear they are painless – think of them as CAM hickies). So… Dubious premise with dubious benefit, same thing – different day.

Here are a couple of images for you to keep in mind…

Mmmmm, cupping goodness.

[UPDATE 30/5/12: Islam appears to support cupping, check out this completely unbiased arabic wikipedia article]

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Footnotes:

1. Can’t get away from TLAs

2. So many jokes spring to mind, I mean come on – “cupping”?

3. See this link for some scary science illiteracy around cupping. And here’s good old Wikipedia. And “blood stagnation” really? isn’t that gangrene or septicaemia or something?

4. Keeping in mind that a vacuum does not suck, high pressure pushes.  If I may geek out a bit here; hence one of my favourite exchanges from ST:TNG:

You were right. Somebody blew out the hatch. They were all sucked out into space.
Correction, sir, that’s blown out.
Thank you, Data.
A common mistake, sir.

- Riker and Data get precise about the physics of rapid decompression into the vacuum of space

5. Yeah, I know, it sounds made up.

6. See here, here and here.

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Amber Teething Beads: A Follow-Up


Over the week or so I expect the page views for my amber teething necklace post to top 20,000 over the two blogs. Interest in the article has just kept increasing over the last year or so of it being up, as opposed to the majority of my posts which slip into internet obscurity within days. In anticipation of the occasion I thought I’d cover some of the comments that this post has gathered over the last few months.

Many of the comments are along the lines of “It worked for me” and “Try it yourself”.

To the first, I don’t really have much to say. I can’t peer inside the inner workings of your child and determine what is going on. But at the same time a bunch of individuals making claims of efficacy without adequate control for bias, natural history and various other contingencies is not a compelling argument to me. Plenty of others swear by practices that have no hope of working*, why should this one get more credibility based on personal experience?

As to the second, three words for you: Anecdote and Confirmation bias. I know enough to realise that I am not immune to the wiles of confirmation bias, which would make my trial just another anecdote – something I don’t accept from others so what would make my own experience any more valid? I also realise that for most people this sort of reasoning is at best foreign and at worst incomprehensible. The general thinking appears to go something like “If I try something and it seems to work, then it works – QED”.

No.

Related to this point are appeals to the “Placebo Effect”, the idea being that simply trying something helps, somehow. This may be true. But I’ll expand on the faulty reasoning behind this assertion.

The placebo effect as this seems now to be the “go-to” explanation for all things unexplained so it might be a good idea to dwell on this concept on it’s own for a bit. First off with regard to talking about the placebo effect, it depends on what you mean. The placebo effect started off being simply the improvement seen in the control group for clinical studies. It was the group that was given everything except the active treatment. Therefore by definition the placebo response is what happens when people aren’t treated. It was the catch all for everything that could affect the outcome that wasn’t due to the treatment itself: poor method design, confirmation bias, reporting bias, observer effect on the patients, regression to the mean, natural history of the disease, etc, etc.

Recently there has been some work done to see if there is a real change in people that is due to thinking they are getting an active treatment, the so called “Placebo response/effect”, this has been mixed. It is true that people will report less pain and their brain will show less activation in pain related areas. But people are susceptible to what they are told, it turns out if you tell people a cheap wine is expensive they will enjoy it more. Is there a placebo wine effect? possibly, but the wine didn’t change and neither did any underlying physiology in relation to placebo medical treatments.

In fact recent studies in asthma showed that while people reported feeling better while taking placebo their ability to perform on objective measures remained the same, while those on active medications improved. If you feel better while still having a life threatening condition are you better? I don’t think so.

So in appealing to the placebo effect you have to concede that 1. the beads don’t have any active ingredient, and 2. don’t make any difference to the underlying condition.
i.e. They do nothing.
Now notice in my original piece this is not what I say, I merely point out there is no good reason to think they are doing anything, not that they definitely aren’t. A subtle distinction I admit.

In essence the argument becomes: “If you think it works then it does”, well I would counter with why don’t you use something that we know does work and then you can capitalise on both effects: You will think it works and it will actually work too. Double goodness.

One poster asserted that amber necklaces were registered with the Therapeutic Goods Administration in Australia as a Medical Device. Arguing that this must mean they have therapeutic properties.

This one was my favourite as it was almost laughably easy to dismantle. After only a few minutes I found that this was completely untrue (you can search the TGA resister here). Not only that but there were suppliers admitting** that they couldn’t claim therapeutic benefits because they were not on the register:

“Amber Teething Necklace Information – TGA Australia

Due to regulations of the Therapeutic Goods ACT, policed by the Therapeutic Goods Administration (TGA), whose register does not recognise the claimed healing and theraputic[sic] properties of Amber we are unable to offer any detailed information on Amber Teething necklaces or Amber in general in a theraputic[sic] advisory capacity.

Therapeutic goods are defined in the Act to include goods that are represented in any way to be for therapeutic use. Therapeutic use is defined to include use in or in connection with influencing, inhibiting, or modifying a physiological process in persons.

In all amber related cases that we have seen, the TGA Panel note “that the advertisement appeared likely to breach section 42DL(1)(g) of the Act, which prohibits the publication of advertisements for therapeutic goods that are not included in the Register“” [Emphasis added]

A complaint was made against a supplier for making claims for the product and this was upheld in part because the necklaces are not on the register.

“The Panel noted, without making any formal finding, that the advertisement appeared likely to breach section 42DL(1)(g) of the Act, which  prohibits the publication of advertisements for therapeutic goods that are not included in the Register.

The website involved changed their wording to get around the regulations, spot the difference:

OLD: “natural pain relief provided by Amber works by placing the necklace on your body, this allows your skin to warm the amber beads, releasing healing oils which are then absorbed into the blood stream.

NEW: “Amber is believed to soothe naturally, when Amber is worn next to the skin it is warm and it is reputed to release natural oils that can care for the skin.”

What a difference a few words make.

At the time the comment was made alleging the necklaces were on the register I suspected that intended therapeutic benefits would be enough to fulfil the therapeutic benefits category.

This is supported both in the declaration of the supplier above and from the wording from the complaint, just prior to the excerpt above it states:

Therapeutic goods are defined in the Act to include goods that are represented in any way to be for therapeutic use. Therapeutic use is defined to include use in or in connection with influencing, inhibiting, or modifying a physiological process in persons.

In representing the advertised products to have an “active ingredient”, to release “healing oils which are then absorbed into the blood stream”, and to relieve teething in infants, the advertisement clearly constituted an advertisement for therapeutic goods.” [Emphasis added]

Lets say though that the product had been registered with the TGA or will sometime in the near future, I would note that unless the administration was in possession of studies that are not published elsewhere there is no way that they could be sure that an actual benefit is occurring. Bringing us right back where we are now.

As an extra note on the activities of the Australian government on this topic I found it amusing to see that the Australian Competition and Consumer Commission issued a safety warning about Amber teething beads end of September last year (see here and here and here).

I say amusing because, while it’s not impossible, I do find it unlikely that one branch of the government is condoning their use while another warns against them. Luckily this is not actually the case.

Finally, this post is not intended to address every conceivable objection to my arguments, merely a survey of what has been proffered so far. I am not really convinced by anything I have yet seen but I remain open to changing my mind so long as the evidence is of good quality. It doesn’t have to be much, a good start would be something that suggests succinic acid has the analgesic properties attributed to it. Then we could address whether succinic acid is released from the beads at ambient/skin temperature. Finally we would need to tackle whether the succinic acid is absorbed topically in any significant dose (decent dose response curves could be obtained at stage one of this theoretical research programme).

All three of these items would need to be looked at in order to state that amber beads have good plausibility for what they are marketed for.

[Update 29/4/13: Apparently there is a chain email circulating blaming amber beads for a case of SIDS. This seemed implausible to me and a very brief check seems to back up my gut feeling. There is no reason to think that amber beads contribute to SIDS at all. For a more thorough break-down go here: http://www.hoax-slayer.com/amber-teething-necklace-sids.shtml . I am not one who feels we need to latch onto any reason to vilify our intellectual opponents and spreading misinformation (especially easily debunked misinformation) is a big no-no in my book.]

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*Not that I think this product has “no hope” of working, it could as far as I know. We just can’t make that determination on the basis of anecdote and there are no trials that I’m aware of.

** Argh, this site seems to have removed any trace of of this page. Should have archived it. It has essentially been replaced with this (archive):

In keeping with Australian Fair Trading guidelines no therapeutic claims are made and no medical advice is offered. The material provided on allaboutamber.com.au is for information and educational purposes only and is not a substitute for medical treatment or diagnosis. We assume no responsibility for treatment or cure of any illness or disease. If you have a health problem we recommend seeking medical advice from your qualified natural/health professional. This information is strictly a source of general information and is not intended for use as a tool for self-diagnosis. All About Amber provides this information for you to make your own decisions, if you want to use them on your own family, we believe they work for us and please read the reviews to gather many other peoples opinions.

Which seems to me to be saying “We can’t claim the beads have any healing powers directly, but they really do.”

They haven’t yet learned this lesson for Hazelwood jewellery (archive)though:

How does hazelwood jewellery work?

Hazelwood products are believed to help to create an alkaline environment in your body, which may help, precent[sic] and appease many of the symptoms caused by being to acidic. Hazelwood, being an alkaline wood, has the natural property of absorbing and neutralizing the body’s acidity through contact with the skin. By doing so, the necklaces can also help with digestion, constipation, eczema, migraines, acid reflux, heart burn, nausea, arthritis, skin problems, etc. If you suffer from one of these issues, it is highly probable that you are suffering from an acidity imbalance, and hazelwood may be able to help you alleviate these symptoms in a natural way.  Most people who suffer from an unbalanced pH are unbalanced towards the acidic. This condition forces the body to borrow minerals—including calcium, sodium, potassium and magnesium—from vital organs and bones to buffer (neutralize) the acid and safely remove it from the body.

Hhhhm, perhaps another post is in order. And a complaint.

As a brief aside, as it seems there are quite a few parents out there hungry for this information if you know of a good parenting or early childhood publication that would be willing to print the original article (probably in an altered form) then let me know.

And I’ll stop there before the footnotes become longer than the post.

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Why Do People Use Alternative Medicine?


ResearchBlogging.orgI often read that the reason people are turning to complementary/alternative/integrative(take your pick) medicine is because they are dissatisfied with the care received from mainstream/conventional/”western”* medicine. This may be true for a small segment of the population, those with a chronic illness or with terminal cancer spring to mind. But is this generally true of altmed users? Those who pick up a bottle of homeopathic remedy from the pharmacy or occasionally visit a naturopath?

I don’t think it’s quite as simple as that. A study “Why Patients Use Alternative Medicine” published in 1998 in the JAMA looked at this question using a survey sent to randomly selected participants. 1500 participants were sent the survey and 1035 completed it. Not too bad for a survey response rate.

The survey was geared to look at the use of altmed based on three paradigms:

“1. Dissatisfaction: Patients are dissatisfied with conventional treatment because it has been ineffective,5-6 has produced adverse effects, or is seen as impersonal, too technologically oriented, and/or too costly.

2. Need for personal control: Patients seek alternative therapies because they see them as less authoritarian16 and more empowering and as offering them more personal autonomy and control over their health care decisions.

3. Philosophical congruence: Alternative therapies are attractive because they are seen as more compatible with patients’ values, worldview, spiritual/religious philosophy, or beliefs regarding the nature and meaning of health and illness.”

According to the survey results satisfaction, or lack thereof,  with conventional medicine did not correlate well with altmed use. 54% of respondents reported being “highly satisfied” with conventional medicine providers, of these 39% use alternative therapies. Of those who were highly dissatisfied (40%) only 9% were users of altmed.

It seemed as if those who were fans of medicine overall were more likely to participate in both camps. A sort of “the more the merrier” approach to health care.

What was predictive of alternative medicine use was personal philosophy. Those who considered there to be a strong mind/body/spirit connection as well as those who had had a “transformational experience” were more likely to use alt med than those who did not.

Education and health status also correlated with altmed use. Those with higher educations were more likely to use it, as were those who described themselves as having a lower health status.

The situation was slightly different for those who shunned conventional medicine altogether in order to embrace altmed. These folks tended to be distrustful of and dissatisfied with conventional practitioners, as well they desired a high degree of control over their health and believed in the importance and value of “inner experiences”.

This proportion of the population was quite small however – only 4.4% of the survey respondents fell into this group. Even so somehow the reasons for this group’s embrace of altmed has been generalised to the wider population.

The observation that users of altmed tend to be greater consumers of health services overall is also supported by the paper “Association Between Use of Unconventional Therapies and Conventional Medical Services“. This survey had a base of 16,068 individuals from which to pull data representing a 77% response rate from the 24,676 pool that was originally sampled.

According to this survey only 6.5% of the population use both altmed and conventional medicine** (and 1.8% using only altmed), with this group making more visits to their physician than those who used conventional medicine only. One possible reason for this is the so-called “worried well”, a portion of the population that focuses on their health to a degree higher than would be expected given their health status. Support for this is given within the paper:

“Compared with those with only conventional visits, those who used both types of care had significantly more outpatient physician visits (7.9 vs 5.4; P<.001), and used more of all types of preventive services except mammography. These groups did not differ significantly in inpatient care, prescription drug use, or number of emergency department visits.”

This on it’s own does not show a “worried well” connection but in the comments section of the paper it was noted:

“…there was no difference in any of the 4 self-reported health measures between respondents who had physician visits only, and those who had those visits in conjunction with unconventional therapy. Poor health status appeared to drive use of health services in general, that is, those using no services reported better health than those using either conventional medical services or unconventional therapies. However, poor health was not associated with increased use of unconventional therapies over and above conventional medical care.” [emphasis added]

So it would seem, at least in this sample, that dissatisfaction with conventional care cannot be the driving force for the majority of altmed users. More plausible is that altmed users seek to make the most of every perceived avenue for health.

Another survey published in 2001 also supported the general conclusion that dissatisfaction with conventional medicine does not lead to altmed use for most consumers. “Perceptions about Complementary Therapies Relative to Conventional Therapies among Adults Who Use Both: Results from a National Survey” surveyed 831 respondents who used both regular and alternative medicine.

Of these 70% would visit a conventional medicine practitioner as their first port of call. Only 15% went to a altmed provider first. There was also no significant difference in the level of confidence in altmed providers and regular medical professionals.

To quote the conclusion:

“National survey data do not support the view that use of CAM therapy in the United States primarily reflects dissatisfaction with conventional care.”

From a paper presented at the Proceedings of the 1997 Conference of
the Australian Association for Social Research and published in the Journal of Sociology; “Postmodern values, dissatisfaction with conventional medicine and popularity of alternative therapies“[PDF File download]:

“Those individuals who value natural remedies, are against chemical drugs, do not favour technological progress, and welcome variety in choice of therapy are more likely to have a positive attitude towards alternative medicine.”

These attitudes were enveloped under the “postmodern” rubric and were found to be a better predictor of altmed use than satisfaction levels with regard the conventional medicine.

To elaborate on that point, a further finding was that dissatisfaction with interactions with physicians rather than health outcomes was associated altmed use. This is a subtle point and worth dwelling on as it seems to be a valid criticism of the way in which conventional medicine is practised. It was not that altmed users were unhappy with the actual results of the care received via conventional medicines but the way in which they feel they are treated by doctors.

It seems that those turning to altmed may feel that conventional doctors do not give enough respect, time, don’t listen and are too authoritative. I don’t want to put too much emphasis on this perspective as it isn’t entirely consistent with the picture built up so far and the sample size of this survey was relatively small compared with the ones above (only 209 respondents), but it is worth considering.

In conclusion, while it might be true that some dissatisfaction does lead to an increase in the use of alternative medicine it seems unlikely to me that this is the main reason. I’m not sure why it has become the go-to reason trotted out by participants on both sides of the debate, ease I suppose. I could of course be wrong, perhaps there is a mountain of research out there that I’ve missed pointing in the complete opposite direction. I’m willing to grant that possibility, in the absence of such though I’ll have to go with personal philosophy being the largest contributing reason people use altmed.

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*I hate with a passion the label “Western Medicine”, what? – people from other cultures can’t use science? Nonsense.

** I suspect that the wildly differing definitions of what constitutes “Alternative” medicine are to be blamed for the fluctuating figures around the proportion of users.
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Astin, J. (1998). Why Patients Use Alternative Medicine: Results of a National Study JAMA: The Journal of the American Medical Association, 279 (19), 1548-1553 DOI: 10.1001/jama.279.19.1548

Eisenberg DM, Kessler RC, Van Rompay MI, Kaptchuk TJ, Wilkey SA, Appel S, & Davis RB (2001). Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey. Annals of internal medicine, 135 (5), 344-51 PMID: 11529698

Druss, B. (1999). Association Between Use of Unconventional Therapies and Conventional Medical Services JAMA: The Journal of the American Medical Association, 282 (7), 651-656 DOI: 10.1001/jama.282.7.651

Siahpush, M. (1998). Postmodern values, dissatisfaction with conventional medicine and popularity of alternative therapies Journal of Sociology, 34 (1), 58-70 DOI: 10.1177/144078339803400106

Aditional reading:

Joy, J.M. (2004). Complementary and Alternative Medicine (CAM): Do Barriers to and Dissatisfaction with Traditional Care Affect CAM Utilization Patterns, Masters Thesis, Texas Tech University Health Sciences Center

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First, Do No Harm


Primum non nocere

A while ago I was accused of advocating that doctors should break the Hippocratic oath. That the cardinal rule of “First, do no harm” should be ignored. Setting aside that this phrase does not appear in the Hippocratic oath, what do we mean by harm in the context of medicine?

I was reminded of this by a post on Science Based Medicine by David Gorski in which he muses over the measure of patient satisfaction as a proxy for how well hospitals meet their obligations with regard to patient care. To kick it off the good doctor notes that many interventions used by modern medicine cause harm, often direct harm.

Does this mean that doctors are throwing out their obligation not to harm patients? No, because we recognise that the concept of harm in this case includes those harms that would occur were we to withhold treatment as well as recognising that the total harm is reliant on the amount of benefit obtained by the patient.

The accusation against me was in the context of my arguing against the claims of anti-vaccinationists that vaccines do more harm than good. I don’t want to rehash that argument here but I do want to dwell a bit on our concept of harm and how it applies in the medical arena.

One of the themes that return to over and over again on this blog is that of risk vs benefit. The amount of harm or risk can only be appropriately assessed in light of the benefit accrued. As pointed out by doctor Gorski there are many procedures that hurt, they hurt a lot. Should a doctor refuse to perform them then? Even if they could save a patient’s life?

Of course not.

It is plainly ridiculous to assert that short term harm out weighs long term benefit, it might but that calculation has to be made in each case. In many cases the benefit will be clear, in others less so. If a patient undergoes a painful procedure that is relatively short lived and then makes a full recovery then the choice is fairly simple. If the recovery is likely to be only partial and the patient’s quality of life is ever after severely reduced then we may weigh up the benefits of that treatment differently.

What then of treatments that are good for most but may harm a few? These are the tricky cases and it depends on a few variables. One is can we identify the persons that will be harmed,  second, how much harm are they likely to suffer and what percentage of the treatment population do they make up? Finally what total benefit will accrue to the population if treatment is green lit?

I listed these variables in the order of importance I estimate they have. If we can identify prospectively harmed persons then they may be removed from the treatment group, harm avoided. If this information is unavailable then we may move to the next criterion: how much harm will they suffer? If this is likely to be relatively mild then all to the good. If the harm is considerably more serious then we may stop the treatment altogether in order to avoid these instances. The last two variables may switch in order depending on the situation or individual values.

Should a vital treatment be withheld from the general population if a very small percentage with be greatly harmed by it? Frankly I don’t know. Help – is there a Medical Ethicist in the house?

Often I’ll find that the people who oppose modern medicine will emphasise the risks of medicine while over-hyping the benefits of alternative medicine. The claims that iatrogenic (caused by medical treatment) harms are enormous abound. This point of view seems completely ignore the benefits received by individuals and society by medicine in it’s current form*.

This seems perverse to me, the idea appears to be that any risk is unacceptable – a completely untenable position to my mind – every action carries risk. I take my life in my hands every time I drive to work, but the risks a relatively low and the benefits are more important to me – and the majority of other drivers I suspect. To argue that we should abstain from automotive transport until it is completely safe misses the point entirely. As does decrying the risks of the majority of medical science in the face of the undoubted benefit received.

To conclude this ramble, harm or risk is part of the human condition. Arguably the complete removal of risk is not only impossible but not even desirable**. We have to live with risk and harm, the key is to ensure we balance these against the good that comes from acting in the world to oppose even greater harms.

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*This is quite an extreme view and I would hasten to add that I don’t think the majority of alternative medicine users (however you may break that group down) would subscribe to it, but it exists.

** Depending on how this might be achieved. Possibly we could make ourselves impervious to harm rather than removing everything that might harm us.

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The Freedom of Ignorance: Health Freedom, What is it and Do We Want it?


When policy around how herbal remedies, alternative medicines, supplements and all sorts of other practices outside the mainstream of medical practice is discussed the concept of “Health Freedom” inevitably comes up. It’s not always couched in that term but the idea is that people should be free to choose whatever method of healthcare that they wish.

Sounds good right? Who wants to impinge in someone’s freedom to make their own decisions? Isn’t that what living in a free country is all about? Personal autonomy, the right to take action unfettered by how someone else thinks I should run my life. That’s how I want to live, why should I want to take that away from others?

Well, I don’t. But the notion of freedom has always come with a caveat (several actually), that is – it is inherently restricted by ignorance. Is someone who is uninformed about the actual state of affairs truly free?

That’s what those who speak out about alternative medicine are actually trying to achieve. We aren’t attempting to “defend our turf” or “squelch the competition” we are attempting to inform the public about the true underpinnings of these therapies and point out they they are either unsupported by science or have in fact been disproved.

As has been noted before, a majority of New Zealanders are unaware that Homeopathic medicines do not contain any active ingredient and yet many people think they are scientifically proven.

Education was also the intent of the co-ordinated Sciblogs rebuttal to the poorly conceived and executed series on alternative therapies printed by the Herald earlier this year. (see here, here, here and here)

Policies that are aimed at restricting access to herbal or alternative medicine usually are doing so from the aspect of quality control. Does the remedy or practice have good evidence of efficacy, is it safe? These are the questions that we should be asking about every medical practice, not just those in the “alternative” (or complementary, or integrative, pick your marketing phrase of choice) camp.

Unfortunately is is not in the interests of those pushing alternative modalities to undergo strict evidence based testing so the issue is re-packaged from a quality control issue to a “freedom” issue.

Similar tactics are seen in arenas outside the medical realm. In biology the evolution vs creationism/intelligent design “debate” is framed as “Academic Freedom” as is the debate around climate change. This is not a coincidence. Whether or not these decisions are made consciously or not there has been convergence on the “Freedom” aspect of these cases for a reason, people respond to it. We are jealous of our freedom, and rightly so, freedom forms the basis of our society.

But as I alluded above, freedom is not an absolute and unalloyed good under all circumstances. It comes up against restrictions in all sorts of ways, some epistemological (as in the case of whether a choice is really free if the person is not aware of all the factors affecting that choice) and some are practical (as in should we allow freedom to include the freedom to sell harmful products?).

Conclusion

The natural/alternative remedies debate is not, at it’s heart, about freedom at all. Rather it is about education and quality control. We should subject all medical practices to the same rigorous examination regarding safety and efficacy. Long term “after market” monitoring should also factor into this equation to catch those practices that looked good in the necessarily limited testing that they are subjected to prior to being rolled out to the general public but may still have safety problems.

In this way we should be able to serve the public’s health interests and avoid false choices about freedom.

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Chiropractic for the 21st Century


Every week I get a number of email alerts about various online medical journals. Each email represents the opportunity for blogging material though many are deathly dull.

Several of the journals I receive alerts from are in the AltMed domain and I sometimes wonder why I bother looking through them at all. The mix is usually some proportion of “Survey of x population using y alternative modality” often merely chronicling the depressing rise of AltMed/CAM in general use (either actual or claimed depending on your definition of CAM).

The rest are often boringly conventional in their attempt to be scientific having titles like “Effects of vitamin E suplementation on renal non-enzymatic antioxidants in young rats submitted to exhaustive exercise stress“. These I don’t bother with. I just don’t have the expertise to parse them with any reliability.

Then there are the odd gems, either for comedic value or because they offer an alternative perspective on alternative medicine.

Recently one of the later came down the intertubes and into my in-box. Published in BioMed Central’s journal “Chiropractic & Manual Therapies”, the article is entitled “The Five Eras of Chiropractic & the future of chiropractic as seen through the eyes of a participant observer”.

The paper starts with a potted history of Chiropractic and the environment that it was founded and grew up in to the present. The early days could be seen as Chiropractic’s first opportunity to start down the science based path. In 1910 the “Flexner Report” on medical education was published and with it’s acceptance by the medical educational community came legitimation to those who abided by it’s recommendations. As well as:

…generous funding via the Rockefeller Foundation while schools that did not assent, simply ceased operation due to lack of funding. The result was that, by 1930, only 76 of the 168 medical schools remained.

The impact on Chiropractic is characterised thusly:

In part because of the rejection of science by a significant element within the chiropractic profession, and in part because the Flexner Report dismissed the chiropractors as “unconscionable quacks who should be dealt with by the public prosecutor and the grand jury”, the chiropractic profession bypassed the era of educational reform.

The early twentieth century therefore saw a great deal of animosity towards the nascent Chiropractic practice and the emerging scientific medicine of the time. Indeed the author argues that this conflict essentially shaped Chiropractic as we know it today. In order to defend Chiropractic from the legal attacks being made on it it was necessary to develop a definition of Chiropractic that would insulate it from charges of practising medicine without a licence, charges that were common against Chiropractors of the time.

This is related as involving four simple concepts:

1. Chiropractic is not medicine; chiropractic has a “separate and distinct philosophy and practice”.
2. Chiropractors do not diagnose, but analyze the spine for the  cause of dis-ease.
3. Chiropractors do not “treat,” but adjust the spine for the cause of dis-ease.
4. The Chiropractic profession has been built upon success in cases where medical doctors failed.

Putting aside the obvious sophistry in these concepts (how might we define the difference between diagnosis and “analyz[ing] … for the  cause of dis-ease” or between treatment and “adjust[ing] the spine for the cause of dis-ease“?) it is argued then that the very fact of opposition by the medical establishment helped to solidify the tenets and practice of Chiropractic:

During this journey, the chiropractic community developed and embraced a distinct lexicon and rationale toward health and its maintenance in order to emphasise the difference between medicine and chiropractic. Thus the “philosophy of chiropractic” became “an unyielding dogma”.

With this legal history at it’s back Chiropractic moved into the next period of it’s history where it was the focus of a co-ordinated and sustained attack by the medical establishment in the form of the AMA.

Carrying out the opposition to Chiropractic was the “Committee on Quackery”:

The Committee on Quackery was well funded, and operated a highly successful campaign that was centred on three main strategies:
1. An ethics based boycott, which deemed it unethical for AMA members to have professional dealings with chiropractors;
2. Convincing other organizations to adopt or adapt the AMA’s anti-chiropractic policy; and
3. Instituting a comprehensive political campaign to thwart chiropractic progress on several fronts, including but not limited to education, research and insurance funding.

This campaign was put to an end in 1987 thanks to a permanent injunction ordered against the AMA, after a lawsuit was levelled against it by a number of Chiropractors. At this point it’s difficult not to see the Chiropractic as a beleaguered philosophy deserving of empathy on behalf of it’s persecuted adherents.

Emerging from this legal victory Chiropractic has been slowly edging it’s way into mainstream acceptance with the development of Chiropractic based courses in universities and a surge in chiropractic research. Unfortunately the steadfast refusal of many Chiropractors to relinquish the unscientific concepts of old has meant that as a profession they are still looked upon with disdain:

Chiropractic’s problem is that subluxation based chiropractors are not only deluding themselves, they are indoctrinating patients into believing in a purportedly dangerous mythical entity, and that without regular adjustments, patients will not only fail to reach their full potential, they will likely suffer serious health problems.

Some authors have suggested that this may be a threat to public health . And this, at a time when the profession has just entered The Era of Chiropractic Opportunity.”

The opportunity discussed is that of the ever growing need for specialists in musculoskeletal care. As the worlds population ages the demand for providers who are proficient in the treatment of pack pain/musculoskeletal disorders will only increase.

It is into this world that the Chiropractic profession must be re-born as the evidence based providers of musculoskeletal care that are needed. The problem is that if Chiropractic insists on holding onto the non-scientific notions of DD Palmer then it voluntarily relegates itself to the back waters of medical practice.

This then is the proper focus of the article: where Chiropractic will go from here.

Least attractive to the author is the prospect that the practice will stay on it’s current trajectory, keeping the outdated concepts that it was founded upon and denying the very science that would confer upon them the legitimacy they crave.

Two options are given as alternatives to this “Status Quo” approach: one is to definitively split the profession into those that follow the traditional method of chiropractic practice, so-called “Straight Chiropractic”, and those who are willing to discard tradition and step into the light of science and evidence based practice.

The second and preferred option is to move forward with a united front, ditching along the way those parts of Chiropractic that are unsound and unproven. This is also recognised as the most difficult route for the profession, requiring near superhuman commitment from the individuals and organisations that make up the world’s Chiropractic profession:

Escaping from the dogma house will require extraordinary cooperation amongst all aspects of the profession. Organizations such as the World Federation of Chiropractic and all major chiropractic associations will need to agree upon and adopt a position statement identifying the chiropractic subluxation as an historical construct that remains a hypothesis, which cannot form the basis for patient care until and unless there is a body of scientific evidence to support it.

If the profession is to gain the trust of the consuming public it must, of necessity, become truly self-policing.

Only in this way will chiropractic generate the cultural authority required for recognition as a group worthy of the title “Profession”.

No longer can we cast a blind eye. By our silence we are giving consent.

Should Chiropractic refuse to move properly into the 21st Century then the consequences for it as a whole may be dire, leaving it’s future as a force in medical practice in doubt.

The chiropractic profession can choose to be illiterate, but it will do so at its peril. It is realized that thinking is hard and that those who are unaccustomed to thinking may even find it unpleasant. On the other hand, thinkers have always found it rather fun and there are no confirmed reports of anyone dying or being seriously injured by thinking. Thinking may necessitate changing our minds – which may not be a bad thing. At the very least the profession owes it to its patients.

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Thai Yoga Massage: Herald, Wherefore Art Thou Sense?


So here I am, again latching onto the brilliance of others and writing my own counterpoint to the nonsense that is currently being run in the NZ Herald under the “Alternative Therapies” summer fluff.

Previously Alison kicked us off by looking at the use of medicinal leeches, as did  Siouxsie, and Michael took on Ayurvedic Medicine.

The latest round concerns something called Thai Yoga Massage or Nuad (Nuat) Boran. Essentially the practice consists of the massaged party adopting a series of yoga positions while the massager applies pressure to the body’s “Sen” lines. Those familiar with acupuncture’s “Meridians” can replace Miridian with Sen and get the general idea.

From an article describing the practice:

“The theoretical basis for traditional Thai healing is rooted in the belief  that all forms of life are sustained by a vital force (lom) that is carried  along invisible energy pathways (sen) running through our bodies.  This energy force is extracted from air, water, and food, and it is  believed that disease and dysfunction come about when energy  becomes blocked along these pathways. Accordingly, Thai massage’s  intent is to free this trapped energy, stimulate the natural flow of life  force, and maintain a general balance of wellness.”

Thus Nuad Boran is a system of energy medicine based on pre-scientific notions of “Vital Force” or “Life Energy”, blockages in which are the cause of disease (though exactly what disease seems to be harder to pin down). It is also claimed to be based partly on Ayurvedic medicine.

So what exactly does this “Alternative Therapy” treat? From the same article quoted above:

“The result of a full-body Thai session is often an exciting and powerful mind/body experience, bringing both the recipient and the practitioner to greater states of physical and mental well-being.”

But that’s kind of vague, what else?

Like many alternative treatments and especially the ones covered by the Herald this week the actual claims for Thai Massage seem to centre around improved blood flow. At least that’s the impression I got from looking at the listed clinical research on this page.

But apparently in the medical literature Thai Massage is mainly focused on pain relief, though there is this one hopeful study trying to use it as a treatment for Autism (the current trendy target for alternative therapies where nothing is too insane to try including chemical castration). Though a brief look at the abstract implies to me that they took one implausible treatment added a second implausible treatment and decided that Implausible2 = Success.

Pain is a good candidate for effective use of Thai Massage; the end point is subjective and massage involves close contact which humans generally find inherently soothing. Hopefully any successes in the pain arena will not be parlayed into evidence that the treatment “works” for any other condition.

The main issue I have with all the literature I’ve been able to dig up so far is that only Thai Massage was included in the studys. The specific reason for using Thai Massage (at least traditionally) is the claims regarding redirecting and unblocking life energy. Remove that unscientific aspect and why wouldn’t any massage work just as well?

I’m perfectly sanguine about the possibility that Thai Massage may be beneficial for perception of pain and reliving stress for the reasons given above. Should we be saddled with the extra hypothesis about life force, with the implication that there is something mystical and magical going on; giving the added justification that the therapy could be of use beyond pain and stress (and whatever else massage is good for)?

I don’t think so.

As Michael pointed out in his post, even the Herald reporters aren’t approaching these “therapies” as medical treatments but more as a relaxing massage/spa  session (except for the leeches, but perhaps there are those out there who would consider this relaxing).

Frankly, after the above it should be “’nuff said”. But how does the Herald approach this wellspring of traditional medical wisdom?

Well, possibly this article is the most honest so far, explicitly calling the technique a “relaxation therapy”. The life force concept is only briefly and obliquely referenced and the main emphasis is that this is simply a massage.

Even so, there are vague hints that the procedure is beneficial to your health is way that go beyond simple massage.

Passages like:

“…the yoga-like stretches help to stimulate and move air through the body.

Every vital part of the human body, from the heart to the lungs, needs good air flow to function well, and Thai massage is aimed at stimulating these air vessels in the body,” said Nucharee Weerawan”

Do subtly imply that the massage will not only relax you but will help your body to “function well” whatever that might mean in this context. Which in turn may lead people to be more open to the idea that the massage could be used to treat more serious ailments. Or maybe the population will actually think things through for themselves and see through more extravagant claims.

I’m hoping for the later.

Though reading further into the description of the massage given, it doesn’t sound especially pleasant. Despite the attempt at a positive spin in the last line.

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Breaking News!: Have Constipation? Moxibustion Won’t Help!


ResearchBlogging.orgWhat’s Moxibustion, And why would you want to use it for constipation? The first I can answer, the second…not so much.

Moxibustion is the practice of burning ground up mugwort and applying the smouldering plant indirectly or directly to the skin to alleviate illness. In the indirect method acupuncture needles are inserted and the burning mugwort is used to heat either the skin or the needle. Direct methods are exactly what it sounds like, the mugwort is burned while sitting on the skin and your skin burns too. The amount of skin burning can vary – from minor to burns that will leave scars. On purpose.

Why would you want to subject yourself to this? Beats me.

But people do, and others study what it might be good for and publish papers about it. One of these turned up in my in-box this morning courtesy of BioMed Central Complementary and Alternative Medicine. With a title like “The effectiveness of moxibustion for the treatment of functional constipation: a randomized, sham-controlled, patient blinded, pilot clinical trial” how could I ignore it?

Reading the study I was transported to a place where the underlying physical process of disease matters not a whit and where the sweat, facial features, , body energy, duration of disease, and pulse type are methods of determining treatment. To be fair other measures were also used, including stomach pain, stuffiness and duration of disease.

No indication was given of how “body energy” was measured. Stuffiness was not defined – I’m sure these are standard things that every doctor knows about.

Frankly, if you are using a magical treatment to unblock your magical life energy then this is the type of thing you should expect to be important.

The study itself was quite small, as the title suggests, only 25 participants. 12 in the treatment arm and 13 in the sham moxibustion arm. Now, how do you do sham moxibustion? Apparently, as it is the heat from burning the mugwart that is important, you just introduce an insulator to stop that heat reaching the patient.

Luckily the procedure used was the indirect acupuncture type, so those in the sham group didn’t wonder why no third degree burns where in evidence.

This approach leaves all the burny, smokey goodness of the mugwort though. Given the negative outcome of the study I suspected this would come up in the discussion. I was not disappointed.

We’ll get to that in a bit. First I want to cover how the patients were divided into “deficiency syndromes” and “excess syndromes”. Constipation in traditional Chinese and Korean medicine is apparently due to either a deficiency or excess of qi (chi), you know, the life energy. This is where checking out people’s faces and sweating etc comes in.

I’ll quote directly from the paper at this point:

“A patient with a deficiency syndrome has sunken, weak pulse, whereas a patient with an excess syndrome has superficial and broad pulse. The patients having symptoms such as a pale face, heavy sweat, and depression were considered to have a deficiency syndrome; the patients having symptoms such as a swollen face, little sweat, and chest pressure were considered to have an excess syndrome. Syndrome pattern differentiation was conducted by an OMD before randomization.”

Further on:

“Five participants were diagnosed with an excess syndrome, and twenty-one participants were diagnosed with a deficiency syndrome. In this study, the most prevalent symptoms for an excess syndrome were a strong body energy and superficial pulse; for a deficiency syndrome the symptoms were a long duration of disease and weak body energy.”

Given that “body energy” plays such a part in dividing the patients I was hoping at this point it would be defined and a method to assess it given. Alas, I was out of luck. Obviously it’s too basic to explain here.

To the results!

I already gave the game away: moxibustion was no different than sham moxibustion when it comes to improving symptoms of constipation. To their credit the authors admitted this could be because moxibustion is, in fact, ineffective. But then, maybe they chose the wrong acupuncture points (never mind that large well designed studies show that where you stick the needles has no effect on outcomes). Or perhaps the sample size was too small – I’ll give them this one, though if there was a significant effect then even a small sample should have shown it.

Then the inevitable, perhaps the sham moxibustion was effective after all. Because, you know, the smoke and stuff. And, oh yeah, the patients actually had “excess-cold” syndromes when normally you’d expect excesses to be warm – so maybe that has something to do with it…

Can you say “rationalising”?

The authors also note that while a number of adverse events have been reported for moxibustion, the patients in this group only experienced redness. Another quote:

“Previously reported adverse events related to moxibustion treatment include burns [no kidding, I thought that was a feature - not a bug], an itching sensation, infection, allergy and xerophthalmia [dry eyeballs]“

Dry eyeballs…. hmmm, better than a punctured lung.

The paper concludes with the obligatory call for larger more rigorous studies, despite the fact that this is an implausible treatment based on magical thinking. Oh well, such is the way of things nowadays.
———————————————-
Park JE, Sul JU, Kang K, Shin BC, Hong KE, & Choi SM (2011). The effectiveness of moxibustion for the treatment of functional constipation: a randomized, sham-controlled, patient blinded, pilot clinical trial. BMC complementary and alternative medicine, 11 (1) PMID: 22132755

Defending The Term “Anti-Vaccine”


I have spent some time recently labelling the IAS as anti-vaccine. They themselves categorically state that they are not anti-vaccine. Who am I to say that I’m right and they are wrong?

Well, nobody really. I can’t read their minds, although if I could would that change anything? All anyone can do is examine their output, and that of others, and try to make a determination as to whether it is more consistent with an impartial, or simply safety concious, approach to vaccines and vaccination or an anti-vaccine stance.

I hope that my previous posts have demonstrated that the IAS in particular produces anti-vaccine rather than balanced vaccine safety material.  The mission of the IAS is to cast doubt on the safety and efficacy of vaccines not to educate responsibly about the real concerns and limitations of vaccine use. If this was their aim they could do a much better job. Look at the articles produced on their website and you will see many that promote the “dangers” of vaccinations, try to discredit health campaigns and generally aim to undermine public confidence in vaccines.

An organisation concerned about vaccine safety and promoting responsible use of vaccines might write about reducing wide-scale vaccination in favour of targeted vaccination of at risk populations. Perhaps They would also try to work with health authorities to examine ways in which vaccine production can be improved (better production techniques might avoid allergy issues mentioned below), or ways in which the distribution of vaccines can be made more effective and thereby reducing the need to preservatives that are thought by them to be harmful.

It is important to note that someone can be concerned about the safety of vaccines while not being anti-vaccine at the same time. I alluded to this above, but there are legitimate safety issues surrounding vaccine use and vaccines should indeed be closely scrutinised prior to mass roll-out via safety and efficacy trials and post roll-out via surveillance systems and doctors reports. It is a valid complaint that procedures are not always carried out effectively.

Sometimes though they are carried out quite effectively and in a follow-up post I will look at a couple of examples of this. The trouble is that often when a “danger” of vaccines is reported more coverage is given to the sensationalistic claims than the eventual explanation. Also (perhaps because of this) these claims have a tendency to hang around and affect public sentiment long after the coast is clear from a safety standpoint.

As I mentioned there are real risks associated with vaccine use, there are known side effects that can have implications for the health of a small number of vaccine recipients. One of the more obvious being allergic reactions to the vaccine ingredients. Those with egg allergies are urged to use vaccines cultured via chicken embryos with caution and may be unable to receive the vaccine at all. There can be other serious and not so serious or transitory side effects for specific vaccines and effects that are general to vaccines (such as redness, soreness, syncope etc).

As such there are a variety of non-histrionic ways that vaccine safety can be discussed, without impugning the general safety of vaccines. Likewise reasonable conversations may be had regarding relative efficacy of vaccine preparations against the myriad of infectious agents that we are exposed to as well as discussions about cost effectiveness of mass vaccination for low incidence infections.

Serotype replacement (or replacement disease) is another issue that can be raised. As infectious strains are targeted by vaccines there is the possibility that other strains that were less important in the pathology of disease become more prominent once the “Top Dog” has been removed.

Encouraging the production and research into more effective vaccines that give better or more long lasting protection could also be a fruitful line of approach. Perhaps we could focus on immunogenicity, better adjuvants would give a vaccine the ability to provoke a stronger immune response, possibly with fewer antigens – as has already been achieved with modern vaccines. If vaccines are improved in this way then there will likely be more local reactions with the inclusion better adjuvants. This again is a reasonable discussion to have.

The lack of large RCTs on all vaccines and the challenges of working around this (for example ethics prohibit withdrawing a measles vaccines then trying a new one against a placebo). The types of studies required or currently used to give us the appropriate information to act upon is something that we can all try to resolve together.

All these things are such that reasonable people may disagree and we should be able to marshal evidence based (rather than emotive) arguments to discover the optimal us of vaccines in society. To my reading of the IAS, their output appears limited to vitriolic and divisive attacks on health authorities and other informational agencies, vilification of pharmaceutical companies, fearmongering over the alleged dangers of vaccination and downplaying the risks of infectious diseases.

Where we start treading into anti-vaccination territory is when we start to become entrenched in a view that sees vaccination as an evil unto itself, perpetrated in the name of profits by immoral pharmaceutical companies and carried out by unethical doctors who are either ignorant dups or willing accomplices. Those who take this stance may make all of the reasonable arguments that I outline above but also be resistant to evidence that contradicts their views and committed to a general non-vaccine outlook.

In discussing this it is very difficult to convey the range of views that may be represented. Obviously we all exist on a spectrum – from fully pro-vaccine to recalcitrant anti-vaccine. It can also be very difficult to determine the views of people in conversation. I prefer to err on the side of caution and assume people are generally well intentioned and open to evidence until proven otherwise.

One of the defining characteristics of the anti-vaccination crowd, it seems to me, is the hyping of dangers far beyond what the evidence supports. As can be seen in some of the attacks on vaccine ingredients, lists of ingredients are given and scary information accompanies them with the toxicological effects of these compounds on living organisms. In these cases  though the dose is often ignored. Dose response is one of the corner stones of medicine and the dose makes the poison. Drink large quantities of formaldehyde and you’re in trouble, but in the tiny doses found in vaccines your body can easily handle it. as noted in a previous post our bodies actually make formaldehyde as part of normal metabolism and the amount found in vaccines is far smaller than that made by the normal process of living.

When it comes down to the bottom line – Vaccines work, and they actually perform that holy grail of CAM, “boosting” the immune system and allowing the body to heal itself. Not in some vague, feel good alternative medicine way but in real objectively measurable and observable ways. Your immune system is primed to react to infectious agents in such a way as to reduce the amount of time that it takes for an effective immune response to be mounted against the pathogen.

With this priming your body can fight off infections much more efficiently and this translates into keeping us healthy, or reducing the severity of diseases. While we can debate the finer points of vaccine safety and efficacy in the end we have a system that works and has saved many lives. I see that as a win.

[for more on this topic see this post from David Gorski of Science-Based Medicine published last year]

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Lemon: The New Miracle Cure!


[EDIT: I'm still getting emails asking how best to consume lemons for their anti-cancer effect here's a disclaimer: Lemons Are NOT A Therapeutic Agent For Cancer Treatment. It Is A Hoax. This Post Is NOT Medical Advice. If you Have Medical Questions Please See A Doctor. Also Please Read the FULL Post Which Continues Past The Green Text]

The surprising benefits of lemon!

Institute of Health Sciences, 819 N. L.L.C. Charles Street Baltimore , MD 1201.
This is the latest in medicine, effective for cancer!

Read carefully & you be the judge.
Lemon(Citrus) is a miraculous product to kill cancer cells. It is 10,000 times stronger than chemotherapy.
Why do we not know about that? Because there are laboratories interested in making a synthetic version that will bring them huge profits. You can now help a friend in need by letting him/her know that lemon juice is beneficial in preventing the disease. Its taste is pleasant and it does not produce the horrific effects of chemotherapy. How many people will die while this closely guarded secret is kept, so as not to jeopardize the beneficial multimillionaires large corporations? As you know, the lemon tree is known for its varieties of lemons and limes. You can eat the fruit in different ways: you can eat the pulp, juice press, prepare drinks, sorbets, pastries, etc… It is credited with many virtues, but the most interesting is the effect it produces on cysts and tumors. This plant is a proven remedy against cancers of all types. Some say it is very useful in all variants of cancer. It is considered also as an anti microbial spectrum against bacterial infections and fungi, effective against internal parasites and worms, it regulates blood pressure which is too high and an antidepressant, combats stress and nervous disorders.
The source of this information is fascinating: it comes from one of the largest drug manufacturers in the world, says that after more than 20 laboratory tests since 1970, the extracts revealed that:
It destroys the malignant cells in 12 cancers, including colon, breast, prostate, lung and pancreas … The compounds of this tree showed 10,000 times better than the product Adriamycin, a drug normally used chemotherapeutic in the world, slowing the growth of cancer cells. And what is even more astonishing: this type of therapy with lemon extract only destroys malignant cancer cells and it does not affect healthy cells.
Institute of Health Sciences, 819 N. L.L.C. Cause Street, Baltimore, MD1201
SEND TO EVERYONE … ! ! ! ! !

—————————————————————————————–

No, I haven’t turned to the dark side, yet. The above was sent to me by a workmate and I have reproduced it here, complete with eye catching colours. Searching the intertubes reveals that many people have perfected the art of the uncritical copy and paste[1]. Not everyone has “drunk the kool-aid” though[2].

Lets deconstruct shall we? This is going to be fun.

Initial reading of this “article” throws up numerous red flags that the claim is either wholly made up or exaggerated. First is the allusion to conspiracy, while drug companies can certainly act in nefarious ways[3] this article implies that scientists in general would close ranks and perpetuate the conspiracy. Otherwise why haven’t government funded scientists or otherwise drug company independent scientists picked this up?
Another is the fact that several authoritative sounding statements are made but there is no detail to back them up

1. lemons kill cancer: Well what part of the lemon? where is it most concentrated? what variety is best? how should it be prepared for maximum benefit? what dose?
2. A laboratory has tested it: Well who? Where? what papers were published? what was the experimental set up? was it in vitro or in vivo? what were the results exactly?
3. Lemons are 10,000 times better than chemotherapy. Really? not 8,000 or 12,000 but exactly 10,000? In all situations?

Many fruits and vegetables have potentially therapeutically beneficial compounds, there are promising anticancer compounds in broccoli[4]. But the levels found in the foods are often too low and too variable to be of therapeutic use. But that’s negative thinking, what matters is that the compounds are there and it’s all natural, practicalities are a downer.

This lack of interest in dose response permeates the altmed/pseudoscientific crowd, both in the positive and negative sense. There is no safe dose of toxic compounds[5] and no lower threshold of benefit for “good” compounds[6]. So questions such as “how many lemons would you have to eat to cure your cancer?” become in this context almost nonsensical. While we in the evidence based camp might ask whether it should be 10 or 100 or 1000 lemons, and is that per day? And for how long? Further, how does the concentration of the anticancer component vary with the nutrition of the plant from year to year, or even within a season? How about between plants? Is the component present in the flesh or the skin? Those in the vague, feel good altmed camp are content with the message “Eat Lemons”.

In a laboratory and medical setting active ingredients aren’t extracted from plants and purified or synthesised solely to generate profits for drug companies (though that’s a motivation don’t get me wrong) but to make it easier to work with and quantify the correct therapeutic doses and optimal delivery methods.

Additionally, labs have to get consent for testing drugs on humans so it’s likely that the tests alluded to, if they occurred at all, were on cell cultures. This method can indicate interesting directions for research but does not guarantee that it will turn into a useful therapy. The body is very complex and things that work in a petri dish do not necessarily work in the body. It could break down too fast, or not reach the right tissues effectively, or be modified by metabolic processes or excreted too efficiently or any number of other things. Basic science research is good at generating these sorts of leads but the journey from bench top to consumer is one fraught with pitfalls.  Few drugs that appear promising at the outset make it to market[7].

Another red flag is the number of other conditions it treats. Each of the ailments listed have different causes and treatments, it is highly unlikely that the same thing will combat both high blood pressure and parasites when these have absolutely nothing in common[8].
Also, much of the text is similar to an article about another “miraculous” fruit, Guyabano, fruit of the Graviola tree[9].

Points of similarity:
1. We don’t know about it because the drug companies are trying to make a synthetic version to patent.
2. You can help a friend by telling him to drink the juice, the taste is not bad and has no side effects.
3. A large drug company has conducted 20 tests on it since the 1970s.
3. Kills 12 types of cancer.
4. “The tree compounds proved to be up to 10,000 times stronger in slowing the growth of cancer cells than Adriamycin, a commonly used chemotherapeutic drug!”
5. Only kills cancer cells.

Curiously similar given it is a completely different plant being talked about.

Searching the “Health Sciences Institute” (not the Institute of Health Sciences) I couldn’t find anything about Lemon and cancer but a Graviola and cancer search turned up a similar looking article (requires a subscription[10] to read but I suspect it may well be the source of the information for the one at the address above)

So it looks like this is actually a mash up of at least two different claims. I think we are witnessing the birth of a new altmed mythology, right here.

None of this means that Lemons cannot be used as a basis for anti-cancer drugs, in fact I did actually find that there are at least a couple of citrus derived compounds being investigated for anticancer activity[11&12]. Even so, the likelihood that simply eating lemons will cure you of cancer seems quite low, for all the reasons given above.

Multiple lines of evidence appear to be converging on this being if not a scam then at least a confabulation. Well meaning people will forward items like this to friends and relatives without much thought. I consider this to be irresponsible behaviour. As I have pointed out before in the context of chain emails, if we truly want to help our loved ones it behoves us to investigate these claims before passing them on. Whom do we help by perpetuating falsehoods?


Footnotes:

1. Here, here, here, here, here, here, here, here, here, here, here- and about a thousand others. I’m so depressed right now.

2. While searching out instances of this rot I found a breast cancer forum that had posted it, as a joke to be ridiculed. Read it now, it shows how these ridiculous items are actually insulting to those affected by cancer.

3. Like ghost-writing research and review articles in their favour. Yes they are profit driven entities, and yes they can go too far to ensure those profits but they do crucial research and development and we need them.

4. Yanyan Li et al (2010), Sulforaphane, a Dietary Component of Broccoli/Broccoli Sprouts, Inhibits Breast Cancer Stem Cells
Clinical Cancer Research May 1, 2010 16; 2580

http://clincancerres.aacrjournals.org/content/16/9/2580.abstract

5. For example in the anti-vax movement.

6. Like homeopathy, even ZERO isn’t a small enough amount for there to be no benefit.

7. Shoot, I’ve been archiving wecite versions of pages I link to to make sure the don’t vanish without a trace but was too late for this one. http://brneurosci.org/drug-failures.html
8. Not withstanding that everything in the altmed world is linked, it’s all toxins or vibrations or pH or quantum or something.

9. http://guyabano.com/   [webcite]  – with another version containing even closer wording here: http://mybongabon.com/samut-sari/the-sour-sop-miraculous-natural-cancer-cell-killer-by-arlyn-roa/ [webcite].

10. 1-year risk-free membership, Brand-New Encyclopedia of HSI’s 100 Greatest Cures and FREE bonus reports :No More Sick Days: The Immune Discovery of the Decade” and “How to Survive the FDA’s 10 Deadliest Hush-ups” for just US$67. [webcite]. You can’t get more credible than that. [article webcite]

11. Chidambara Murthy K.N., et al(2011), Citrus Limonin and Its Glucoside Inhibit Colon Adenocarcinoma Cell Proliferation through Apoptosis.
Journal of Agricultural and Food Chemistry

http://www.ncbi.nlm.nih.gov/pubmed/21338095

12. Cazal, C.M., et al(2010), Evaluation of effect of triterpenes and limonoids on cell growth, cell cycle and apoptosis in human tumor cell line.
Anti-Cancer Agents in Medicinal Chemistry, 10(10):769-76.

http://www.ncbi.nlm.nih.gov/pubmed/21269253

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Amber Teething Beads: A Few Points to Consider


Being a new parent and a sceptic I have been on guard regarding dubious advice and practices. Parents, especially new parents like myself, are a vulnerable group. We tend to be full of anxiety that we are doing the “right thing” by our children. Where-ever you find a vulnerable group like this you also tend to find those who prey on such fears. I have actually been pleasantly surprised, despite my vigilance I have not yet been subjected to any dubious advice (that I’ve noticed). But early last week I was confronted by a practice from a fellow new parent that I found a little disturbing. I’m taking about using necklaces of amber beads to reduce the pain of teething for babies.

Teething can be an especially stressful time for parents and children, the child may be experiencing pain as the new teeth break through the gums. This means an irritable child and frazzled parents. Anything that promises to relieve or prevent this harrowing time is gratefully embraced.

On to the amber beads. This practice disturbs me for several reasons. First is safety, the necklace if left on the baby for long periods may pose a strangling hazard of it becomes caught on something. Most advertise that they are made to break easily to prevent this and that the beads are individually knotted onto the necklace to prevent scattering on breakage. However this still seems to leave a broken string of beads in reach of a baby, as as most people know – anything a baby can get it’s hands on goes straight into the mouth. So choking is also a concern[1&17].

Now, I’m not one to be a worry wart over every little potential hazard, used correctly under parental supervision I suspect that the likelihood of a tragedy of this kind is low. But not zero[15&16]. This coupled with the low possibility that the necklace actually does anything is what worries me. The second disturbing thing is that parents are accepting this via word of mouth and apparently not consulting their doctors before subjecting their child to an intervention of unknown safety and efficacy.

I have three main points I want to cover with regard to these amber beads that parents should consider before trying these beads (in addition to the physical safety above). The first relates to basic plausibility.

Before we get to that though it depends on which mechanism of action for the beads you subscribe to. There are several explanations regarding how the beads are supposed to work floating around the intertubes, many are of the tinfoil hat brigade variety, these will be ignored (but look here and here for a bit of a chuckle). Only one explanation I have found makes biological sense so that’s the one I’ll be focusing on.

That explanation is Succinic acid, baltic amber is known to contain between 3-8% succinic acid. According to proponents this is released from the beads and into your baby. The succinic acid then allegedly has an analgesic effect and so reduces the pain of teething. Here is where my first point regarding plausibility comes in:

Amber is tough, really tough. This is a material that has persisted for thousands and in some cases millions of years unchanged. Suffering through heating and cooling of innumerable climatic changes through the years. Yet this same tough unchanging material with happily give up it’s chemical components upon the gentle heating it receives on being placed next to your baby’s skin? Colour me unconvinced[1&2]. Related to this point amber has a hardness on the Mohs scale of between 1 and 3 [3], baltic amber which is usually touted as the therapeutic variety (because of the high succinic acid content) is at the high end of this scale 2 – 2.5. To put this in perspective, Tin has a hardness of about 1.5 and Gold is 2.5-3 [4]. But forget about this point, I don’t need it. Lets say for argument sake that clinically relevant amounts of succinic acid are released by the amber and absorbed by your baby’s skin.

My second point then, relates directly to the claims made for succinic acid. Succinic acid is made in the body (and in plants) as part of the citric acid cycle (aka krebs cylce)[5]. It is also use in the food and beverage industry as a food acid (additive #363 to be precise)[6]. Interestingly in this capacity there are recommendations from some quarters to avoid the substance[7]. Even so, apart from it’s early use as a topical treatment for rheumatic pain[8] there is no evidence that I could find (searching Pubmed at least, where I would expect a decent study to be referenced) that it is effective as either an anti-inflammatory or general analgesic. Let me be clear on that, I don’t mean low quality evidence, I don’t mean small poorly designed trials with equivocal effects, I mean nothing. Zip. Nada. In fact if anyone knows of any let me know because I find this complete lack quite surprising, I’m open to the idea that I was looking in the wrong place or was using incorrect search terms. So, unless there is late breaking news, it fails on that count as well. Meh, what do we care about evidence of efficacy anyway? Throw this point out too. Lets move on to my final argument, uh, I mean point to consider.

Lets say that a. the beads do indeed release succinic acid into your baby and b. this succinic acid has an analgesic effect once it enters your baby’s body. Doesn’t the very fact that an unknown amount of a drug[9] is being put into your baby’s body bother you? What is that I hear? It’s natural? Oh, well, that’s ok then. No wait, no it’s not. I don’t care what the origin of a compound is, the question is what are it’s effects on the body and do the benefits out weigh the risks. Ok, lets replace succinic acid with some other naturally occurring substance, salicylic acid. This is a compound with known anti-inflammatory properties[10]. Would you be happy with a product that introduced unknown levels of this compound into your baby? What if I said that overdoses with this compound could lead to a 1% chance of death?[11] It’s natural, it’s also the precursor to acetylsalicylic acid, otherwise known as Aspirin[12].

Now, lest I be accused of unnecessary fear mongering and drawing false comparisons I would like to admit that at present there is no evidence to suggest that succinic acid is hazardous, nor even that it is potentially hazardous[5]. This does not detract from my main point however, the point isn’t whether this particular compound is safe or not but that the reasoning[13] around it’s use is faulty and cannot be used as a substitute for evidence.

Based on the complete lack of plausibility on any level of efficacy any potential for harm, however small, must tip the balance of this equation away from the use of this product. Don’t trust me though, talk to your doctor, I suspect though that given the complete lack of reliable information on this topic they will be left to rely on their own philosophy of harm vs benefit. In the final analysis, there are not always clear answers[14], but developing good critical thinking skills will at least provide you with a small light in the darkness.

[Edit - I recently posted a follow-up article to this addressing some of the points raised in the comments below. It may be found Here]

[Update 20/07/12:  Commenter Heidi Pogner-Schultz has provided a thoughtful and researched perspective in support of amber beads (here), I disagree for reasons outlined in my reply to her (here). But this is exactly the type of reasoned evidence I was looking for so I thank her for the contribution.]

[Update 29/4/13: Apparently there is a chain email circulating blaming amber beads for a case of SIDS, a visitor mentioned this in the polling comments. This seemed implausible to me and a very brief check seems to back up my gut feeling. There is no reason to think that amber beads contribute to SIDS at all. For a more thorough break-down go here: http://www.hoax-slayer.com/amber-teething-necklace-sids.shtml . I am not one who feels we need to latch onto any reason to vilify our intellectual opponents and spreading misinformation (especially easily debunked misinformation) is a big no-no in my book.]

Informal Poll:

After reading the preceding post I wonder if you’d like to help me measure what sort of effect this research is having. Please indicate on the poll below your attitude to using Amber beads -

[Edit: Preliminary results from the poll - most consider their opinion unchanged, what a shock. Also the "Other" section is not for insults, if you wish to call me an idiot please do so in the comments of the post where you may be held up for ridicule.]

Footnotes:

1. http://www.3news.co.nz/Teething-necklaces-dangerous—sceptics/tabid/423/articleID/160820/Default.aspx

2. I found this paper that analysed the volatile out gassing of amber, succinic acid was not mentioned as an identified component. http://www.springerlink.com/content/865ku15055np3x78/

3. http://www.emporia.edu/earthsci/amber/physic.htm

4. http://en.wikipedia.org/wiki/Mohs_scale_of_mineral_hardness

5. http://www.accessdata.fda.gov/scripts/fcn/fcnDetailNavigation.cfm?rpt=scogsListing&id=339

6. http://en.wikipedia.org/wiki/List_of_food_additives,_Codex_Alimentarius

7. http://www.foodreactions.org/allergy/additives/300.html

8. http://en.wikipedia.org/wiki/Succinic_acid#History

9. If it has biologic activity that can be used in a therapeutic fashion, it’s a drug, no quibbling on that point please.

10. http://en.wikipedia.org/wiki/Salicylic_acid#Medicinal_and_cosmetic_uses

11. http://en.wikipedia.org/wiki/Salicylic_acid#Safety

12. http://en.wikipedia.org/wiki/Aspirin

13. ie “It’s got to be good, it’s natural.”. Don’t make me barf.

14. Who am I kidding, there are almost never clear answers. Who wants certainty anyway?

15. http://safekidspiercecounty.health.officelive.com/Documents/Choking%20and%20Suffocation%20Fact%20Sheet.pdf This is an american document but I don’t think necklaces become safer just because we’re in NZ.

16. http://www.nzchildren.co.nz/infant_mortality.php NZ infant mortality statistics.

17. http://www.bpac.org.nz/magazine/2010/april/docs/bpj_27_oral_pages_30-41.pdf See page 33.

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Vaccination Awareness Week Round-Up


There’s still officially one more day of Anti-Vaccine Awareness Week (two really, as it’s an American idea) but here’s a round up of the posts anyway. While I know there are lots of great in-depth posts around the blogosphere on this the following list has been restricted to NZ posts to keep the local flavour. The posts are in roughly chronological order.

The University of Auckland Library at Tamaki Library blog Misinformation spread about HPV vaccine

Me Anti-Vaccination in NZ

Scott at Imperatorfish They Can’t Vaccinate Against Tin-Foil Hat Syndrome

Michelle at Skeptics In The Pub Vaccines: The actual facts (well, the links to some anyway…)

Alison Campbell at Bioblog on polio

Michelle at Skeptics In The Pub More facts about vaccines….

Me A Side Benefit of the ‘Flu Vaccine – Reduction in Heart Attacks

Michael Edmondsat Sciblogs Guest Work “I’m not a Scientist but …”; Dissection of an antivaxxer’s argument

Alison Campbell at Bioblog chelation quackery around vaccination

Grant Jacobs at Code for Life Immunisation, then and now

Alison Campbell at Bioblog homeopathic vaccinations – fail

The next couple are not specifically about vaccination but I think are worth a mention:

Grant Jacobs at Code for Life If presenting a claim on a popular issue

Megan Leask at Southern Genes This Week in Science History: 1-11-10

If anyone knows of a post I’ve missed then please feel free to add it in the comments.

[Edit] One more – Alison @ Bioblog vaccination & smallpox

For those of you interested in the international posts, blogger Liz Ditz has done an awesome job collating all of the posts here:

The Big List of Reality-Based Vaccine & Infectious Disease Blogging

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A Side Benefit of the ‘Flu Vaccine – Reduction in Heart Attacks


ResearchBlogging.orgIt’s a bold claim, that being vaccinated for Influenza will protect you against having a heart attack or Myocardial Infarction (MI). Well according to a study published last month in the Canadian Medical Association Journal that could well be the case.

The study, “Influenza vaccination, pneumococcal vaccination and risk
of acute myocardial infarction: matched case–control study
“, included 78,706 individuals over the age of 40 in an attempt to determine whether and how much of an effect the vaccine had on MI. The results showed that the vaccine was associated with an almost 20% reduction in risk of MI compared to the unvaccinated population.

My first thought when I read this was that those individuals who get vaccinated might engage in other activities that would lend themselves to reducing risk of MI, healthy eating habits, regular exercise etc. The so called “healthy user” effect. This study attempted to control for this sort of confounding factor by using matched controls with similar risk factors. In particular they performed two further analyses that I think comfortably undermine this interpretation of the results.

First they compared the timing of the receipt of the vaccine, ie early or late in the ‘flu season. Second they looked at subjects who had been vaccinated with the pneumococcal vaccine as a comparison. In the first case there was a greater reduction in risk for those who had received the vaccine early in the season, 21% compared to only 12%. In the second case they found no protective effect for those who had received the pneumococcal vaccine. It seems unlikely that the subjects of the study would vary their healthy habits in precisely the ways they would have to in order to see these results as being independent of the vaccine itself.

An interesting aspect of this kind of epidemiology though is that simply looking at the raw numbers there is a greater incidence of MI in the vaccinated group compared to the unvaccinated group. This is an artefact of how the vaccines are administered clinically. Those patients who have greater cardiovascular risk are also the patients who are more likely to be recommended for vaccination. It’s like noticing that people who buy antiperspirant tend to have sweatier armpits than those who don’t*. Those who are prone to sweaty armpits will likely tend to be those who will buy and use antiperspirant, to accurately gauge effectiveness you would have to control for this factor.

Tying this into the anti-vax focus of this week, one of the claims I’ve seen is that the flu vaccine is useless as it is based on strains that were around the previous season (Here via IAS). This is distressingly simplistic thinking. This paper shows that the vaccine is far from useless, in fact the most benefit was found within ‘flu seasons. If there was no effect of the vaccine on the current ‘flu season strains then the study would not have shown the protective effect that it did. Once again the anti-vax crowd (and by extension the altmed crowd as there tends to be overlap) has shown their inability to grasp the nuance of the situation.

There is a gradation of effect when a vaccine does not exactly match the wild strain, the interaction of antigens and antibodies is more complicated than you might suppose. Changes in the antigen (mutation of the virus over the ‘flu season) mean that antibodies may bind less tightly and therefore have a reduced effect but that is not the same as no effect.

To sum up, health is a complicated thing. Many factors are inter-related and in order to get the whole picture we sometimes have look at things from an unusual perspective. Vaccinating for the ‘flu can reduce your risk of heart attack, who knew? But, we should also be wary that we are keeping things within the realm of plausibility. Infection does cause inflammation which can plausibly effect heart function**. This does not mean it’s valid to blame the Wi-fi at your local school for your vague aches and pains.***

Footnotes:

*To make up an example.

** See http://www.sciencebasedmedicine.org/?p=6926

*** http://theness.com/neurologicablog/?p=2215

—-

Siriwardena AN, Gwini SM, & Coupland CA (2010). Influenza vaccination, pneumococcal vaccination and risk of acute myocardial infarction: matched case-control study. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 182 (15), 1617-23 PMID: 20855479

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Vaccine Awareness Week


Thanks to the incomparable Orac over at Respectful Insolence we here at Sciblogs have been made aware of an effort by Anti-Vax proponents to have their own consciousness raising week. The haven of anti science that is Mercola.com is promoting November 1st-6th as “Vaccine Awareness Week”.

Like the “World Homeopathy Awareness Week” earlier this year I think this is a great idea, we can use the opportunity to raise awareness of anti-vax misinformation. Like Homeopaths Anti-vaxxers are generally less than forthcoming about the cherry-picking and distortions that underpin the “information” they spout. To be fair, I have no doubt that most are sincere and want nothing more than to help people. I would venture that most don’t really realise that they are perpetuating myths (like vaccines containing anti-freeze, they don’t).

Still, you know what they say about good intentions – they give you excitations, or it that vibrations I forget. Anyway, I’m working on a couple of posts to publish during this time, those of a similar mindset may wish to do the same. I intend to give the week a NZ flavour but I’m aware there are readers of Mercola in our midst so I might throw in a bit of that stuff too if I have time. The more the merrier. It’s at this point I wish I had a flock of monkeybirds at my disposal, fly my pretties and spread the word.

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