Posts Tagged ‘ health ’

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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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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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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Vaccines and Autism – Media Report Card


Just got sent this link by the irrepressible Aimee, a “Not great” article about the Vaccines vs Autism “Debate”.

Here’s my Media Score Card for this article:

Much rubbish, a few good points. I give her a C-.

‘vaccinate at any cost’ = Strawman
Court decisions =/= Science
Incomplete knowledge = No knowledge = Fail
Anecdote =/= Good Evidence
“acceptable risk” argument simplifies risk/benefit assessment = Fail
“Teh Toxins” = Fail
Injection = Unnatural = Fail
“canaries in the coalmine” = Fail.   Can someone say “Mommy instinct”?

Respectful discussion = Win
Pro-information = Win
Complex topic = Win.

All-in-all a reasonable person sucked into the Vaccine -> Autism perspective.

Pity.

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Are You Ready for the Faux-Zombie Apocalypse?


ResearchBlogging.orgThe title of this post is a somewhat obscure reference to an episode of the Nineties Sci-Fi show “Sliders“.  The premise of the show was based on the Multiverse theory in physics, a favourite trope in science fiction.

In “Sliders” a small group of individuals are accidentally set adrift in the multiverse, travelling from Earth to Earth in the hopes of getting home again. The show gave a unique opportunity to explore interesting historical counter factual situations, you know, of the “What if Hitler won the war” variety.

This was handled a little unevenly throughout the 5 season run of the show and some episodes were definitely more plausible than others. One of the less plausible ones sprang to mind when I read this press release a couple of months ago*.

In this episode the intrepid inter-dimensional explorers find themselves on a world where a fat-loss pill turns it’s users into mindless fat craving monsters – coincidentally resembling movie zombies. Cool huh?

Okay, so that isn’t likely to happen. But in a world where approximately a fifth of the population is overweight and a majority of the world populace has more to fear from over rather than under-eating the focus on obesity and methods to combat it is only going to grow. The solutions to obesity likely will need to be multi-pronged, each facet adding an incremental advantage. With this in mind medical solutions have their place alongside education, social and legislative approaches.

One of the medically based avenues open to us is to regulate the activity and/or amount of brown fat in our bodies.

Brief biology lesson: Humans (and other animals) have two main types of fat cell; brown and white. White fat is the regular old fat that we think of, know, and loath. It contributes to unsightly cellulite, increases our risk of various diseases that kill us and is generally something that you want to only have in moderation.

Brown fat on the other hand is a slightly different beast. Like white fat it is a repository of energy, but unlike white fat it is not simply a passive receptacle for these lipids1. Brown fat gets it’s colour (and hence name) from the high density of mitochondria in the cells. The presence of such high numbers of mitochondria allows the cells to channel the force, oh wait that’s a different organelle, sorry. They mean that the cells can burn energy and contribute to thermal regulation, what’s known as Non-shivering thermogenesis.

This type of heat regulation is most important to infants and it was thought that as we grew and matured the brown fat disappeared. This is now known not to be the case, further, manipulation of brown fat in adults may give us a means to burn extra calories and hence reduce our white fat.

Another paper released last year attempts to give a detailed background of the possibility of manipulating brown fat for the purpose of weight regulation. It also notes the potential benefits and drawbacks of this approach and is a very interesting read. Essentially though the idea with utilising brown fat is to increase the body’s basal metabolic rate (the amount of energy you consume while at rest), by doing this we can increase the total number of calories used by the body and effectively burn up the excess calories consumed.

The press released that sparked this post is related to a paper presented at The Endocrine Society’s 93rd Annual Meeting in Boston. It details an investigation into the location of brown fat in the adult body and the mechanisms involved in the creation of brown fat from undifferentiated progenitor fibroblast cells. The fat tends to be deep within the adipose tissue of the neck and chest as well as mixed in with white fat, hence the thinking that we lost it as we age – it’s not easy to find. This incremental step in understanding gives us another tool that may be used to increase our proportion of brown fat cells and thus increase our metabolic capability.

Previous work by the same lead author has correlated amount of brown fat with BMI, finding an inverse relationship. The implication here is that a larger amount of brown fat does contribute to a higher metabolic rate and there for allows some individuals to avoid long term accumulation of fat, confirming that this is a potentially viable approach to weightloss. The numbers of this study were pretty low though and I’m not sure how clinically relevant this finding is.

The authors caution however that benefits may be modest, the lead author is quoted:

“As powerful as brown fat could be at burning calories, we can easily out-eat the benefit.”

So don’t be looking at this as a panacea for obesity, as noted above we will likely have to tackle this problem from multiple sides. Those who view our increasing dependence on drugs and medical interventions with suspicion may not be happy with treating obesity in this fashion2, but it is such a growing problem we should use every tactic at our disposal to reduce the risks associated with this threat to our health.

So, bring on the human experimentation and lets hope the reducing of people to vacant fat-starved cannibals is kept to a minimum.

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Cypess, A., Lehman, S., Williams, G., Tal, I., Rodman, D., Goldfine, A., Kuo, F., Palmer, E., Tseng, Y., Doria, A., Kolodny, G., & Kahn, C. (2009). Identification and Importance of Brown Adipose Tissue in Adult Humans New England Journal of Medicine, 360 (15), 1509-1517 DOI: 10.1056/NEJMoa0810780

Tseng, Y., Cypess, A., & Kahn, C. (2010). Cellular bioenergetics as a target for obesity therapy Nature Reviews Drug Discovery, 9 (6), 465-482 DOI: 10.1038/nrd3138

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* Yes, I really am that lazy.

1. Yes again, I know that’s a gross over simplification. White fat does stuff too.

2. I have no evidence of this but I’m sure they’re out there.

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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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How Narcissistic are You?


Haven’t posted anything for a while, I’m wrapped up in the warm embrace of procrastination. Thought this was interesting though and an easy post. Take the online Narcissism test.

Despite all evidence to the contrary I only scored a 4. If you score greater than 20 you probably have a mirror in your pocket right now.

Some quiz answering music for you….

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“Mantrol” and the Psychology of Destructive Behaviour


Recently the NZ Transport Authority and the Police introduced a new campaign for reducing driver speeding. The “Mantrol” concept attempts to link the safe driving with “manliness” and in this way induce those who might speed out of machismo to take a second look at what constitutes that ever mercurial definition of “real man”.

Looking at a few of the comments on the Stuff version of this story there is a lot of negativity regarding this campaign. I think many of the comments miss the point. I agree many of the comments (in aggregate) that auto fatalities are a multi-factorial problem, not only speed but driver competency, road condition, alcohol, culture, road laws etc are all contributing to the current situation. To expect one ad campaign to address all of these disparate causes is obviously unrealistic. It is even unrealistic to expect one campaign to address and counter every reason that a person might speed. We have had the graphic advertisements showing the consequences of out of control speeding, these will work on one sub-set of the population. Now we have an approach that may have an effect on a different sub-set.

I wrote in January about a study comparing types of cigarette warnings, the study found that warnings emphasising mortality were less effective on individuals who based their self esteem, at least in part, on their smoking behaviour. As a result those individuals would rate themselves as more inclined to continue smoking. On the other hand, warnings that directly attack the source of self esteem are more effective. Individuals who consider smoking to make them more attractive (the “coolness” factor) will be more influenced by warnings that state the opposite.

One of the conclusions of the study was that warnings may need to be tailored to the population you are trying to influence.The depending factor is how much the behaviour is related to a person’s self esteem and self image.

In attempting to tie safe driving to manliness there is a move towards reaching people at a place in their psyche that relates to their self esteem and how that manifests in their behaviour. In other words if speeding is an expression of one of a person’s core beliefs about themselves ie that they are macho man, then pointing out that in the eyes of others their behaviour is inconsistent with that label may lead to a behavioural change.

Now I do think that the current set of ads don’t quite hit that mark but I do think that they are a step in the right direction. The implicit humour of the ads are also a mark in their favour but they are perhaps a little too close in flavour to a number of other ads currently in the market (multitude of beer ads, even McDonalds ads) trying to tie their product to what real manly men do.

In any event, it is too early to tell whether or if the current crop of anti-speeding ads will have an effect on behaviour. I do think that the use of multiple approaches is valuable in itself as a one-size-fits-all attempt is certainly doomed to failure.

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Anti-Vaccination In NZ


As promised here’s my first entry for “Vaccine Awareness Week”, I thought I would take a little look at Anti-vaccination in New Zealand. In particular the  Immunisation Awareness Society. This organisation has set itself up as pro-choice on the subject of vaccination but this is essentially a thin smokescreen for their anti-vaccination views. Here, rather than pick apart a certain piece of writing from their website (of which there is much to choose from) I’ll focus on the points they have put forward as their basic philosophies and see how they stand up. Without further ado, once more into the breach…

1. That natural immunity is far superior to artificial immunity.

This is true, but only for a given value of “Better”. If you are concerned with antibody production and response to infection over your life time then yes, often immunity acquired via infection by a pathogen can last longer than that stimulated by vaccination.  One reason for this is that if you live in an area where vaccine uptake is relatively low (because, you know, they are so harmful) then you will be periodically re-exposed to the pathogen which naturally boosts your immune response. Vaccine induced immunity does tend to wane over the years and if your only contact with antigens (those parts of the pathogen that promote antibody production) is via the Vaccine then the only way to combat this is a booster shot.

Therefore, to benefit from this longer lasting immunity you must actually contract the disease. You must then also suffer through the consequences and complications of that disease. Then you must be periodically re-exposed to the disease to keep antibody production high. Those that survive will have superior immunity to those who don’t, I believe it’s called “thinning the herd”.

I also notice some weaselling in the reference to artificial immunity.  It is not the immunity that is artificial but the method of inducing immunity. This may seem like splitting hairs but how we use words affects how those words are understood, by implying that the immunity gained by vaccines is itself artificial this group is subtly undermining how vaccines are perceived. Then again the rest of the website is as subtle as a sledgehammer to the face so…

2. That breast milk is the best immune stimulator for the baby during the first year of life and that a great deal of immunological protection is provided to the child for as long as breastfeeding continues.

That’s fine, I agree that breast feeding has undeniable benefits, but unless you intend to breast feed your child for life, making for the creepiest business lunch ever*, your child will eventually need to acquire immunity in some other fashion. In this instance, see above.

3. That good health, which starts with a balanced diet that includes important vitamins and minerals, is safer, and more effective at preventing many diseases than artificial immunity.

I can’t argue that a balanced diet isn’t good for you, there is good evidence that ensuring your body has the vitamins it needs does improve your immune response to infection. Beyond this diet is not a replacement for acquired immunity, once again vaccination is the best method of acquiring immunity without actually having to contract and suffer the disease itself.

4. That appropriate allopathic (conventional) and homoeopathic/naturopathic treatment in the event of illness is safer and more effective than trying to prevent illness through artificial immunity.

Homeopathy is not a treatment for anything besides thirst. Apart from that , treating the disease is safer than not contracting the disease in the first place? Are you kidding me? So not only do you have to contract the disease and chance any side effect of the disease itself but also any complications from treating the disease. Seems to me it’s better to just sidestep the whole issue and not get sick.

5. That most diseases contracted by a healthy child, at an appropriate age in childhood, provide important challenges to the immune system enabling it to mature and strengthen, and almost always provide lifelong immunity to the disease.

I’m so glad that the potentially life threatening  diseases contracted by children are actually good for you. Whatever doesn’t kill you makes you stronger right? How about Measles, that’s one of the dreaded vaccinations our children now receive, what does the WHO have to say about it’s safety?:

Complications: Up to 75% children may develop complications which include diarrhoea, otitis media,
pneumonia, laryngo-tracheal bronchitis (croup) and encephalitis. Measles also depletes Vitamin A status that
results in severe eye complications and blindness. Measles can lead to longer term brain damage and deafness.

Death: Case–fatality ratios for children under one in emergency settings: 3–30%. The three major causes of
high case–fatality rates are pneumonia, diarrhoea and croup. Children may also die from measles infection or
its sequelae including encephalitis and malnutrition. Measles infection often leads to a prolonged suppression
of the immune system, increasing susceptibility to secondary bacterial and viral infections.

But at least we get life long immunity. Surely the purpose of immunity is to prevent us from getting the disease, in that case a wide vaccination policy will do the same thing and also gives us a chance to wipe out the disease altogether.

Then there is the “important challenges” bit, the number of antigens children are exposed to as part of the vaccine schedule is minuscule compared to the number that they are exposed to every day just interacting with their environment. Our normal body flora, those bacteria that call our skin and gut home, outnumber the cells that we would normally think of as “us” by a factor of 10 or more.

This represents hundreds of different species of organisms, add to that the numbers of bacteria we might come into contact with due to food, dirt, household and public surfaces etc. and the number of antigens represented by the organisms prevented by the vaccine schedule can be seen in their proper context – insignificant. Not just insignificant but not even worth mentioning.

6. That the vast majority of childhood infections are benign and self limiting in a healthy, well-nourished, well cared for child with a healthy immune system.

This must mean that the organisation supports vaccination for those diseases that are life threatening (I couldn’t find any evidence on the website that this is the case though). Say pertussis, or Whooping cough as it is more commonly known (from Wikipedea):

Pertussis is fatal in an estimated one in 100 infants under 6 months, and fatal in one in 200 infants aged 2 to 12 months. Infants under one are also more likely to develop complications (eg pneumonia (20%), encephalopathy, seizures (1%), failure to thrive, and death (0.2%)). Pertussis can cause severe paroxysm-induced cerebral hypoxia and apnea.

Well it’s only 0.5-1% of children who die. Tell that to the parents. The best way to prevent this disease is vaccination, not just of the individual child but of all who come into contact with her. Herd immunity is the barrier between potentially fatal diseases and those who are too young to have received the vaccine and those whose immune system is compromised and the vaccine is not as effective.

Ok, that’s just one disease vaccinated against, the rest must be very safe. the vaccination schedule can help us here. The list of diseases vaccinated against and the complications for each is:

DiphtheriaThe bacterial toxin can lead to nerve paralysis and heart failure. Between 2–10 infected people in 100 die.
TetanusThe bacteria produce toxins which cause painful muscle    spasms and lockjaw. Hospital intensive care treatment is needed. About one in 10 patients dies. The risk is greatest for the very young or old.
Whooping CoughCovered above.
PolioAbout one in 20 hospitalised patients dies and 0.1–2 in 100 patients who survive is permanently paralysed. The overall risk of paralysis is about one in 100. This increases with age, ie, one in 75 adults. There are 2–10 fatalities in 100 cases from paralytic poliomyelitis. Post-polio syndrome may occur 30–40 years after poliomyelitis (ie, muscle pain and worsening of existing muscle weakness).
Hepatitis BThe virus causes liver infection and acute illness. Severe illness is rare in children. Fatalities are rare and are more likely in adults. Some people become carriers of the virus, especially children (six in 100). Liver cirrhosis occurs in one in 20 carriers (half of these will die). Liver cancer occurs in one in 10 male carriers and one in 20 female carriers and usually leads to death.
Haemophilus influenzae type bAbout one in 20 patients with meningitis dies and one in three survivors has permanent brain or nerve damage.About one in 100 patients with epiglottitis dies
PneumococcalAbout one in 10 children with pneumococcal meningitis die and one in six survivors will have permanent brain damage. About one in three children will be left with a hearing impairment after pneumococcal meningitis. Pneumonia and septicaemia (blood poisoning) leads to hospitalisation. Less severe illness, such as ear infections, may lead to deafness. Children with medical conditions such as congenital heart disease, some chronic lung diseases, kidney diseases, HIV infection, and children whose immune system is lowered through chemotherapy, radiation therapy, or organ transplant are at higher risk of pneumococcal disease. Children with spinal fluid shunts and with cochlear implants are also at higher risk of pneumococcal disease.
MeaslesCovered above.
MumpsIn about one in ten people it causes meningitis, but it is usually relatively mild. It causes encephalitis (inflammation of the brain) in about one in 6000 people, of whom one in 100 will die, and nerve deafness in one in 15,000 people. If infected after puberty, one in 5 males gets testicle inflammation and one in 20 females gets ovary inflammation. In rare cases this leads to infertility.
RubellaFor women in early pregnancy, 85% of babies infected during the first eight weeks after conception will have a major congenital abnormality such as deafness, blindness, brain damage, or a heart defect. This declines to about 10–20% by 16 weeks of the pregnancy. About one in 3000 patients gets thrombocytopaenia (low platelets causing bruising or bleeding). One in 6000 develops encephalitis (inflammation of the brain). This usually occurs in young adults. This may result in death.

Well, they all sound like a barrel of laughs, and perfectly safe. Seriously, the complications from these diseases are serious while the vaccines are relatively safe**.

That’s it for the IAS “philosophies”, while there are good recommendations mixed in (healthy diet, breast feeding) mostly it’s a collection of misinformation, misunderstanding and distortions. I am of two minds about this organisation as a whole, on the one hand I’m a proponent of free speech and that includes topics that I don’t agree with. On the other hand organisations like these have the potential to do great harm, both to individuals and greater society. Balancing these two things can be tricky and where to draw the line between them is not always clear.

On a related note, the Australian based anti-vaccination group the Australian Vaccination Network – has had it’s charitable status revoked. Part of this decision was based on the group’s failure to place a disclaimer on their website stating that it’s purpose was anti-vaccination and that it’s information should not be considered medical advice.

IAS also has charitable status. Under New Zealand law Charities must serve a charitable purpose, as specified by the Charities Act 2005:

Section 5(1) of the Charities Act 2005:
“In this Act, unless the context otherwise requires, charitable purpose includes every charitable purpose, whether it relates to the relief of poverty, the advancement of education or religion, or any other matter beneficial to the community.”

Given that the information distributed is often incorrect or presented in such a way as to misrepresent the facts I consider this organisation to fail both the “educational” and “beneficial” aspects of this definition. As such I would question the validity of it’s charitable status, but that’s for the law to decide not an irritable blogger***.

Finally, for accurate information on vaccines you should head on over to the Immunisation Advisory Centre, which also has a handy list of websites for both Parents and Health professionals.

Footnotes:

*Although This can’t be far behind.

**No active intervention is 100% safe, no-one is claiming that.

***Similar to irritable bowel only more annoying.

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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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Gamblers Rewarded by Near Misses


ResearchBlogging.orgEarlier this year a study published in the Journal of Neuroscience looked at the brains of compulsive gamblers and concluded that when the the gamblers suffered “near-miss” losses their brains reacted as if they had won. Another study published slightly later in the Journal of the Experimental Analysis of Behaviour also looked at the brains of gamblers but included a control groups of non-gamblers as well. The results were interesting.

First off, what exactly is a near-miss loss? The experiments were performed with slot machine type visual stimuli so in this case lines that contained two out of three matching symbols were considered near-misses. Now from a practical stand point, as the out put is meant to be random a line like this is no closer to winning than one with three different symbols and does not predict any greater likelihood of winning in the future. Although people might realise this from an intellectual stand point it’s still hard not to think “Almost got it that time”.  Hence “near-miss”.

The second study did indeed find that gamblers reacted to the near misses more like they were wins, they also found that non-gamblers reacted to the near misses more as if they were true losses. The thing I found interesting though was that the reactions of gamblers to winning while consistent within the gambling group had nothing in common with the reaction in the non-gambling group.

A further interesting finding was that although the non-gambler group had neural responses more similar to losses when confronted with near-misses, they gave similar answers as the gamblers when asked how close they were to a win. In other words they also rated a near-miss as closer to winning than a more random looking output.

By comparing the neural activation of gamblers and non-gamblers the researchers were able to see that non-gamblers had stronger reactions to losing outcomes than did the gamblers. This makes sense in several ways, humans are generally quite loss averse. We will tend to think of a loss as more negative than a similar gain is positive ie a win of a certain amount versus a loss of the same amount do not cancel out, there is a larger negative emotional balance. In contrast, problem gamblers would be expected to view losses as less damaging over all otherwise continuing losses would result in ceasing gambling activities.

In addition the study authors linked this work with a previous study, suggesting that problem gamblers are activating regions  of their brains associated with impulsive behaviour when wins are experienced while non-gamblers activate regions associated with reflective behaviour when experiencing losses. This part of the study discussion is very interesting and worth a read in itself.

The current study is insufficient to establish the causal direction in the relationship between compulsive gambling behaviour and the network of neural activation that accompanies gambling wins. Even so it is tempting to view the brain response as predisposing a person to becoming a compulsive gambler.  If the “high” for a win is greater in certain individuals because of this difference in brain response then this might lead them to gambling abuse behaviour. I hardly think though that there will ever be wide-scale screening programmes to identify potential gamblers.

The more we learn about the functioning of the brain in these sort of situations though the better equipped we will be to effectively help those who are affected by problem gambling.

 

OpenLab2010 Submit To Open Laboratory 2010(What’s This?)


Chase, H., & Clark, L. (2010). Gambling Severity Predicts Midbrain Response to Near-Miss Outcomes Journal of Neuroscience, 30 (18), 6180-6187 DOI: 10.1523/JNEUROSCI.5758-09.2010

Habib, R. & Dixon, M.R. (2010). Neurobehavioral evidence for the “near-miss” effect in pathological gamblers JOURNAL OF THE EXPERIMENTAL ANALYSIS OF BEHAVIOR, 93 (3), 313-328 : 10.1901/jeab.2010.93-313

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Complexity and Health – A Rant


To shamelessly butcher a great H2G2 quote:

Biology is complicated. Really complicated. You just won’t believe how vastly hugely mindbogglingly complicated it is. I mean you may think it’s complicated to do the morning crossword, but that’s just peanuts to biology.

This may seem trivially obvious, I mean we don’t compare things to brain surgery because brains are simple. But it always seems to me that the attraction of pseudo-science and altmed modalities occurs because of our yearning for easy answers. While proponents of alternative medicine affect superiority while berating conventional medicine for only treating symptoms not underlying problems it is their own philosophy that is childlike in it’s simplicity. In addition those in the altmed camp are sometimes embarrassingly binary in their approach to medicine, either vaccines work or they don’t, they are 100% safe or toxic, science is completely trustworthy or completely corrupt.

Take homeopathy*,while conventional science based medicine determines physiology, observes interactions, makes hypotheses and tests interventions and performs statistical analyses homeopathy stagnates. One of the fundamental precepts of homeopathy, the notion of “like cures like” is the most simplistic of magical thinking. Take a substance that causes a symptom in large doses and give it to a person suffering that symptom (from what ever cause, so much for treating underlying issues) in small doses and it is supposed to cure that symptom. Sympathetic magic as it has been called.

Speaking of magic, the Natural Health Expo is once again in town this month. browsing through the exhibitor list is like stepping through the looking glass. At the other end of those links are places were the rules** of the normal world do not apply, the laws of physics are suspended and anything is possible.

The breadth of inanity is so great that it’s hard to know where to start, so I just clicked on the first exhibitor and saw where it took me. African Gems and Minerals, seems solid, what could be on a firmer foundation than rocks from the earth?

Well, until you get to the page on crystals. Now I have to admit a certain fondness for crystals, the interesting variety of shapes and sizes, the symmetry and range of colours is captivating. What bugs me is the mystical properties attributed to them and the bizzare claims made for their properties, don’t trust me here’s a selection taken directly from the website:

“Kunzite Healing Stones Removes obstacles from one‘s path. It dissolves negativity automatically raising the vibrations of the area surrounding  it. Removes physical and spiritual blockages. Powerful sinus cleanser.  Use on the third eye for spiritual shift.”

Vicks has nothing on this rock, soothes the soul and clears the nose. And it sounds vaguely naughty – a must have.

“Serpentine Healing Stones. Light green is known as infinite stone… Enables one to enjoy each moment and to awaken to the inner knowledge which is so patiently  awaiting access. Excellent for easing pain. “

Opens the mind, and lets your brain fall right out. Good for aches and pains too.

“Peridot Healing Stones – Traditionally known as a stone that wards off evil. Regulates cycles of life: Physical Mental Emotional Intellectual as well as life cycles. Excellent healing stone and acts as a tonic to strengthen and regenerate the body. Birthstone for August. We have small rough stones and jewellery”

Strengthens and regenerates, well that’s vague. Will it help regenerate my dad’s hair?

“Rutile Quartz Healing Stones – Also called Angel Hair. Smokey with Rutile is a superior grounding stone that eliminates negativity promotes upliftment and joy and lifts depression. Banishes bad dreams. Strengthens the energy field. Counters electro-magnetic smog and radiation for example from computers. Rutile acts as an accelerator and speeds up the process while anchoring light into the physical being.”

Electromagnetic Smog, that sounds serious***. I’m curious exactly how this works, as electromagnetic fields are a three dimensional phenomenon how exactly does a lump of rock on your desk help you? I’m obviously over thinking it, that’s dangerous in these circles. Still “anchoring light into the physical being” sound handy, does that mean I won’t need a torch at night?

“Moldavite Healing Stones – Green Tektite found in the Molda Valley Russia. Supreme transformation stone. Activator of the third eye and heart chakra. Decodes the light body causing vibrational shift. This is sometimes experienced as the ”Moldavite Rush”. Best used in the guidance of a practitioner. A complete book was written about this stone “‘Moldavite – Star born stone of transformation‘”

Ah, the stone for professionals. Is this the one rock to rule them all perhaps?

In case you thing I looked around to the wackiest thing I could find to put up here, I assure you I didn’t. I had a clue what I was in for when the exhibitor description mentioned crystals but there was no other outward appearance of kookiness. This site displays no more and certainly less insanity than probably 80% of the other exhibitors listed****. Some further examples: Healing with cards(and reiki, and crystals), oh look a homeopath, Power Animal cards (and oddly, reiki again), not entirely sure what the heck this is.

For any of these things to work large swathes of known science would have to be wrong. I just don’t see the massive amount of evidence that would be required to show that this is true. On the other hand some of the claims are just so nonsensical  it’s difficult to even know what is being asserted let alone how one might go about confirming or refuting it. Still, good for a laugh eh?*****.

—-

*Actually don’t.

**Especially rules of evidence.

*** Probably worth a post of it’s own.

****The craziness is confined to one portion of their website whereas the rest are devoted to it.

***** Just to be clear, it is the claims of the proponents that are amusing and worthy of ridicule, not the unfortunate people who are drawn into these claims. That is most definitely NOT funny.

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Breast Cancer Awareness Month Plug


October is Beast Cancer Awareness Month, or as The New Zealand Breast Cancer Foundation is re-branding it “Action Month“.

Because of this my post last week regarding the screening technology Thermography has been picked up and included in a blogging carnival. If you are not yet aware of blogging carnivals they are collections of blog posts from across the web highlighting single issues or interests, usually they are hosted on a regular schedule and pass from blog to blog.

Pick a topic you’re interested in and there’s likely a carnival out there dedicated to it. Anyway, Highlight Health is hosting this month’s edition of the Cancer Research Blog Carnival (#38). Go over and check it out, there looks to be a large selection of high quality writing gathered in one place and I’m honoured to have been selected to be included with the likes of Science-Based Medicine and The Scientist.

So get over there and educate yourself, learn about breast cancer screening effectiveness, possible new treatments, scams perpetrated on breast cancer sufferers, underlying causes and other fascinating topics.

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Breast Cancer Thermography – Good, Bad or In-between?


Breast cancer screening is in the news once again. Late last year controversy flared around new recommendations in the frequency of screening. (A review of this change can be found Here.) Now it seems that even the type of screening available is generating controversy.

Current breast screening technology in the form of mammograms is a mature approach, the advantages and drawbacks have been extensively studied and are now quite well understood (though more is still being discovered, see the related article at the bottom of this post). As such we can use the mass of accumulated data to create guidelines that attempt to optimise how screening should be done. A balance must be struck between the benefits gained by accurate detection of cancer and the costs, both psychological and financial, of false positives generated by the screening process.

These are the points that must be kept in mind when evaluating new approaches for appropriateness in the consumer screening market. Recently the media has highlighted a minor battle between private medical industry, in the form of breast screening clinic Clinical Thermography, and professional medical organisations and cancer research and advocacy groups. Yesterday the NZ Herald ran a story about the clash, and you can see TV3 coverage Here*.

At issue is the offering of a breast cancer screening service using thermal imaging to detect incipient or established tumours in the breast. The operating principle behind this technique is the requirement of tumours to generate access to their own blood supply early in the process of formation in order to secure the nutrients required for the unrestrained cell growth that is typically associated with cancer.

This process is called angiogenesis and entails the formation of new blood vessels in and around the tumour. This brings a larger amount of blood to the area than would be seen normally and this blood would bring extra body heat with it. Given this information it is not unreasonable to attempt to use this physiological change to attempt to detect cancer. By using high resolution thermal imaging the surface temperature of the breast can be measured and used to infer the presence of “hot spots” that may indicate tumours.

Thermography is not a new technology, developed in the 1960s it was largely abandoned in the early 1980s after an influential trial found the false positive rate and sensitivity unsatisfactory. As such, while the approach is not novel there is a distinct lack of large scale trials from which we can determine the appropriate sensitivity and specificity to apply to the technique and thereby judge it’s efficacy in the screening market, especially using current technology. In particular the technique has been emphasised in the existing literature to have the most impact when used in conjunction with more understood approaches such as mammography.

The current halabaloo seems to centre around concerns by the medical community that the appropriate caveats will not be adequately conveyed to the public and thereby may lead to either unwarranted panic in individuals receiving false positive results or complacency in those that may receive false negative tests. In particular position paper put out by the Cancer Society et al. attempts to raise awareness that the thermography screening process does not have the data to allow the decisions regarding balance between benefit and harm mention above to be made effectively (a position echoed by the UK organisation CancerHelp UK).

In investigating this issue I visited the Clinical thermography website to see what they had to say about the relative effectiveness of Thermography and mommography. I found it revealing that on the FAQ page there were two questions addressing accuracy for Thermography and mammograms. The Thermography entry was essentially an apologetic giving reasons why thermography may give a false negative result, no numbers regarding sensitivity or specificity were included in this.Conversely the mammography entry was a condemnatory piece giving percentages of false negative for the two age groups of particular interest, without any further explanation.

The ommision of hard data in the Thermography portion of the FAQ may reflect the dearth of adequate information as decried by the position statement above or may simply be standard marketing tactics. Either way Clinical Thermography aren’t doing themselves any favours with this evasive approach. Now this is not to say that Clinical Thermography is wholly against mammography, they accurately state earlier in the FAQ that Thermography is not a replacement for mammograms and that the technique should be used in conjunction with other screening methods.

Interestingly an American site for Breast Thermography is careful to include a disclaimer on the front page of the website stating:

“Breast thermography offers women information that no other procedure can provide. However, breast thermography is not a replacement for or alternative to mammography or any other form of breast imaging. Breast thermography is meant to be used in addition to mammography and other tests or procedures. Breast thermography and mammography are complementary procedures, one test does not replace the other….”

This is a straight forward upfront statement that Clinical Thermography would do well to emulate on the front page of it’s own site.

Finally, I’d like to point out that the position I have taken in this post is not contested even by those who would be proponents of this screening method. A commentary piece, published in Minnesota Medicine last December, entitled “Emerging Controversies in Breast Imaging: Is There a Place for Thermography?” was essentially pro-thermography at least in terms of investigating the technique further in order to address the questions raised regarding it’s efficacy.

Quoting from the text of this article:

“The biggest question concerns the efficacy of thermography to detect breast cancer. Despite various studies that suggest positive results for thermography, there has never been a major randomized controlled trial to determine baseline measurements of sensitivity and specificity. It is hard to imagine thermography being accepted by the conventional medical establishment without such data or evidence of cost-effectiveness.”

and:

“In lieu of any industry or professional standards for thermography, a variety of practices and protocols have emerged among practitioners and equipment manufacturers. As one practitioner described it, the industry is in its “Wild West” days.”

In addition, a study linked to on a pro-thermography website concluded:

“we currently limit the role of infrared imaging to that of a closely
controlled compliment to clinical exam and high quailty mammography. Our initial data should not be extrapolated to either formal screening or noncontrolled diagnostic environments without appropriate evaluation, preferably in prospective controlled multicenter trials.”

In summary, Thermography is at this stage a screening method of unproven efficacy. This is not to say that it could not become a valuable adjunctive tool in screening for breast cancer but that caution should be exercised by both promoters and customers of the technology not to oversell or over rely on the results obtained using this technique. Further research should be undertaken to determine the answers the the questions raised about the technique, namely accurate estimates of the sensitivity and specificity of the technique and what role in the screening process it is best suited for.

*This link seems to be down currently, but a note with regard to Breast Self-Examination (BSE) as mentioned in the TV3 story. This has also come under scrutiny as a practice that does not lead to improved outcomes. See the review of the new breast cancer screening guidelines linked to above.

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Is Acupuncture Worth a Punctured Lung? or Does the Risk Out Weigh the Benefit?


Friday’s issue of The New Zealand Medical Journal includes a case report of pneumothrorax in a recipient of acupuncture. For the interested layperson out there a pneumothorax in the collection of air in the space between the lung and chest wall leading in extreme cases to cardiac arrest. Acupuncture can result in pneumothorax when the needle is inserted into the lung tissue while the patient is breathing leading to the laceration of the lung and air being forced out of the lung and into the pleural cavity1. Mmm-mmm, gimmie some of that lung collapsing goodness.

Now lest I give the impression that complications from acupuncture use are common I will hasten to add that they are not. One paper estimates the rate of serious adverse events at approximately 1 per 20,ooo patients2. Though if we look at the rates of acupuncture use in the United States as an example, as of about 2007 approximately 1% of the population reported using acupuncture in the previous 12 months3. This translates to about 155 serious adverse effects per year. Another study found over 2% of patients reported adverse reactions that required treatment4, commonly for bleeding or pain. Multiply these figures by the likely worldwide numbers of people receiving acupuncture.

Lets compare this with the conventional medical field, the drug Terfenadine marketed under the trade name Seldane (Teldane here in NZ) was removed from the market in the US due to increased risk of cardiac arrhythmia when used in conjunction with certain other drugs. This expressed itself as a risk of 0.04 – 0.08 per million “defined daily doses”5. Once a replacement drug came on the market Terfenadine was taken off.

Pneumothorax as a complication from acupuncture is  rare even in this subgroup. More common is infection. As I’ve noted before6, the underlying theory of acupuncture is the manipulation of life energies (Qi or Chi), blockages or imbalances in which are the cause of disease. If such is the case then why should the treating physician7 bother with proper antiseptic technique? I suspect that most modern practitioners are however not so far down the rabbit-hole that they have thrown away germ theory completely, at least the outward practical side involved in cleaning and sterilising implements. Which is why even infections are still relatively infrequent.

I would like to point out however that given the implausibility of the treatment basis, coupled with the fact that most large well designed studies find no benefit beyond placebo does make the existence of any complications ethically troubling. If your treament is no more than an elaborate placebo, are you willing to suffer adverse effects because of it? As reported by Dr Novella of Science Based Medicine8, a recent review of acupuncture admitted that sham (placebo) acupuncture was as good a “real” acupuncture.

Lets delve into the definition of “sham” acupuncture a little more to give the proper context to this revelation. Whereas “real” acupuncture depends on the proper insertion of the needles in specific meridian points on the body sham acupuncture can be considered to be either the placement of needles into non-meridian points, or the use of implements that feel like needles to the patients but do not pierce the skin like toothpicks9. This indicates that it doesn’t matter where you stick the needles and it doesn’t even matter if you stick the needles. How then can we conclude that acupuncture works if you don’t need to perform the two defining characteristics of acupuncture?

Given this background I find it difficult to imagine why acupuncture continues to be recommended despite convincing evidence of efficacy and indisputable evidence of harm. All medical interventions carry some element of risk, this is then weighed against the potential for benefit. However when there is no benefit any amount of risk must make that equation lopsided with regard to harm. With that in mind, if you are attracted to acupuncture as a therapy let me recommend sham acupuncture as the way to go. All the placebo-y goodness of real acupuncture without the potential for the nasty drawbacks of infection, bleeding, pain or even pneumothorax.

Further reading:

Type “Acupuncture” and “Infection” or “Pneumothorax” into Pubmed as key words and you will find a variety of papers, a selection of which are below:

Acupuncture induced pneumothorax:a case report (not the report mentioned in the post)

Editorial:Acupuncture transmitted infections

Cutaneous Mycobacterium haemophilum infection in a kidney transplant recipient after acupuncture treatment.

Acupuncture needle-associated prosthetic knee infection after total knee arthroplasty

Footnotes:

1. Clinical analysis on 38 cases of pneumothorax induced by acupuncture or acupoint injection

2. A cumulative review of the range and incidence of significant adverse events associated with acupuncture

3. http://nccam.nih.gov/health/acupuncture/introduction.htm

4. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form.

5. Detection and reporting of drug-induced proarrhythmias: room for improvement

6. Scepticon: Acupuncture

7. And here I use the term loosely.

8.Acupuncture Pseudoscience in the New England Journal of Medicine

9. I kid you not, here are a couple of the studies:
Description and Validation of a Noninvasive Placebo Acupuncture Procedure
A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain

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