Posts Tagged ‘ Medicine ’

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.

——————————————————————–

*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.
————————————————————————-

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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2012
03/26
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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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2012
01/13
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Alternative medicine
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The Webwhisperer: A Medical Resource


I generally look with interest to see how people are getting to my blog. Often the referrer is Mr Google, the next culprit is usually Facebook, then there are pages where someone has posted a link to an article I written for others to check out. These are the most satisfying.

Sometimes it’s someone pointing out how stupid I am, many times I’m being used as a resource on some forum discussing AltMed. Today I found I was being linked to by a site called the Webwhisperer.

The Webwhisperer is a blog run by a UK doctor who is attempting to create a resource of reliable medical information, mainly for the doctor’s own family to access it seems but I think it has wider appeal and application.

Since the beginning of the year the Webwhisperer has been running a series on infant teething, the fifth and latest post is a link to my own article on Amber Teething Beads with a favourable intro. Ok, so I’m referred to as a mother but I’ll let that go (mainly because comments are disallowed and I can’t see any other way to contact the author. But also because I’m secure in my masculinity. Mostly).

Teething is something that can be quite distressing for new parents and is a topic that that every family member has an opinion on the best way to handle. A medical resource that gives factual information can be invaluable. So check it out.

There are many, many other topics covered on the site from allergies and alopecia to breast implants and pregnancy. I plan to browse it regularly. You should too.

2012
01/12
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“I was a Skeptic, but…”


I wish people wouldn’t say this, it’s usually followed by some lame reason why we should trust their anecdotal experience over empirical data. Sure the word skeptic (or sceptic if you prefer) has a certain colloquial definition and to a large extent words are defined by the way they are used, I mean no-one uses the word “gay” to refer to being happy anymore.

Even so this usage is getting on my nerves. When I use the word “skeptic” to refer to myself I mean someone who evaluates the available evidence and comes to a reasonable conclusion. Implicit in my definition is also  an understanding of human foibles with regard to cognitive biases and a deep seated inability to view our own experiences impartially. Refer to my previous post for more in this vein.

On a whim I thought I’d look up what on-line dictionaries had to say about the word, I found some variation of the following to be popular:

“1. One who instinctively or habitually doubts, questions, or disagrees with assertions or generally accepted conclusions.”

That doesn’t seem any better to me. So, what’s my problem?

Well for a start those alluded to in the title of this post are not applying skepticism they are merely doubtful. And when evaluating claims they are not using the methods of science they are using the unreliable guide that is personal experience. Thus, while their protestations of skepticism and subsequent conversion sound impressive, they are (to my ears) merely the hollow echo of true inquiry.

Harsh enough for you? well perhaps. I don’t expect all who use the word skeptic to apply to it the same definition that I do, but it still chafes.

The dictionary definition given above is also lacking in nuance, it appears more suited to define a contrarian than skeptic. What my favourite skeptical interviewer DJ Grothe refers to as “knee-jerk skepticism”. A skeptic isn’t someone who just says “no”, a skeptic is someone who asks “how do we know?”.

The reason my hypothetical skeptical convert gets on my wick so much is when answering the “how do we know?” question they assume that they can draw general conclusions from their informal experiment where n=1. This ties into the “don’t knock it ’til you’ve tried it” line of argument. NO. Trying it myself is not the way to determine the validity of a claim. This falls under the category of anecdote, and anecdotes are not good quality evidence. At best they should be the start of investigation – not the end.

When evaluating a claim we should look at two things in particular, yes we should determine the direct evidence for the claim i.e. is there evidence to show that it acts as claimed? but we should also attempt to see how the specific claim fits into the wider scientific ecosystem – the prior probability if you will.

Often in day to day claims this is of little practical importance and so it becomes overlooked when it is relevant. A new gadget or medication is often based on previous iterations of the same technology or medical practice and represents an incremental improvement or merely an additional option in the sphere or possibilities. However some claims are sufficiently far from mainstream understanding that we should take a step back and consider the likelihood that the claim is possible, irrespective of the evidence presented for the claim itself.

In the case of say, homeopathy or power balance bands our current understanding of the science should make us extremely wary of efficacy even before the specific claims are considered. To be clear here though, plausibility should be used as only part of the process, there are many things that work without us knowing how they work but the further outside of current knowledge something is the stronger the evidence we should require before we accept it. Certainly for many “alternative” therapies that strong evidence simply does not exist, as I presented for Amber teething beads there is no reason to think they should work from a physical or medical point of view so our standard of evidence should be higher than the earnest assurances of people in mothering forums, or even our own experience – as noted above.

But this is exactly the sort of pseudo-evidence that we are wired to find most convincing. Throughout most of our history the ability to evaluate randomised trials, statistics and p-values would not have aided our survival one whit. Therefore it’s not surprising that most of us are bad at it.*

Yes, it’s hard. Yes, it requires work, and yes you will probably get it wrong most of the time.** But it’s worth it. So give it a try – be skeptical, like you mean it.

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* Arguably all of us, it requires practice and even the “experts” can get it wrong.

* I certainly do.

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2011
04/24
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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?*****.

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*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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2010
10/14
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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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2010
10/04
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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.

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*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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2010
09/28
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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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2010
08/16
CATEGORY
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Pharmacy Customers Perception of Complementary and Alternative Medicine in Pharmacies


Going through the papers cluttering my inbox I found this survey of Australian pharmacy customers relating to their use of CAM and their impressions of how pharmacists should approach the subject.

Regular readers of Sciblogs may remember a kerfuffle earlier in the year regarding the sale of homeopathic remedies in pharmacies, I and others were uncomfortable with these items being sold in pharmacies to begin with. Fortunately, when surveyed homeopathy didn’t make it into the top ten modalities used in the last 12 months, though 3% noted that they had seen a homeopath.

This survey was published in BioMed Central‘s journal of Complementary and Alternative Medicine. I might point out that I disagree with the authors views of Complementary Medicine (CM) but I agree with many of the conclusions of the survey, though I suspect for different reasons.

The survey included data from 1,221 respondents from 54 pharmacies that cover both rural and urban areas. Beyond that the methods aren’t particularly interesting, people filled out forms.

Findings of the survey showed that a significant number of pharmacy customers think that it is important for pharmacists to be knowledgeable about CM and to know about their customer’s CM use. I would agree with this, pharmacists should be aware of how CM is marketed and of the claims made on order to give customers appropriate advice on effectiveness. Another result of the survey that helps with this point is that almost 70% of respondents agreed that they trust their pharmacist’s advice regarding CM. This reveals an excellent opportunity for education of the public regarding these modalities.

In addition many of the respondent felt comfortable telling pharmacist about their CM use whereas previous research has shown this not to be the case for patients of other medical practitioners. Again this is an opportunity for pharmacists to assess the safety of CM modalities their patients are using, especial in conjunction with other treatments (this was also a conclusion of the survey).

That said, the survey also revealed that many customers rely on family and friends as information sources. This accords with with existing research on the importance of personal anecdote in making decisions. Next most popular were medical doctors (not bad) and in third place (disturbingly) was the media. Pharmacists were in 6th place after naturopaths and pharmacy assistants. While far down on the list pharmacists still rank and one of the important sources of information and should not be under estimated.

One of the questions that I disagree with the majority of respondents on is regarding the inclusion of natural medicine practitioners in pharmacy practices. To me this is inviting abuse of the pharmacist’s position of authority, it might even undermine some customers trust of the institution (I’d certainly think twice about any pharmacy that did this). At the very least it may allow pharmacists to divest themselves of the responsibility to actually learn about the alternative products they may be selling.

In conclusion, I consider the results of this survey important to keep in mind when considering the role of pharmacists in the field of CM. Pharmacists are in a somewhat unique position to educate the public regarding CM as a consequence of the level of trust afforded to them by customers. It also reveals that pharmacies are vulnerable to particular abuse for exactly the same reason, products sold in pharmacies are lent an aura of respectability by association.

It behoves pharmacists to take seriously the responsibility to be current on the debate around the safety and efficacy of CM modalities and be able to confidently relay this information to customers. No longer should pharmacists sit on the sidelines while irrationality invades their practice, hiding behind public demand as an excuse for not taking a stand for science based therapies.

–
Braun, L., Tiralongo, E., Wilkinson, J., Spitzer, O., Bailey, M., Poole, S., & Dooley, M. (2010). Perceptions, use and attitudes of pharmacy customers on complementary medicines and pharmacy practice BMC Complementary and Alternative Medicine, 10 (1) DOI: 10.1186/1472-6882-10-38

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2010
08/05
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BioFuel Cell Batteries May Power Future Implanted Devices


ResearchBlogging.orgWhen I think about the future I sometimes indulge in fantasies that include “bionic” type implants. Not so much artificial muscles that will enhance strength (check this out) but devices that will expand our mental capabilities. Implants that give us greater memory, faster thought processes, the ability to download skills and knowledge directly into our brains.
Perhaps I read too much science fiction.

The trouble with this utopian view of the future is a practical one, where will these devices receive their power from? If I start forgetting things because I haven’t plugged in a new 9volt, I won’t be happy. The ideal solution would be some sort of battery that can be inserted into the body and generate energy from the food I eat, just like the rest of my organs.

Enter: The BioFuel cell. Fuel cells have been around for a few decades and while most people have no dealings with them their essential mechanism is easily understood. Basically a chemical reaction is allowed to proceed under very controlled conditions to generate a flow of electrons (ie an electric current). The usual example given is reacting Hydrogen (the fuel) with Oxygen to generate water and electricity, but really almost any electron donor/acceptor pair will do.

Biofuel cells replace the electron donor (eg Hydrogen as above) with a biological molecule, glucose. These Glucose BioFuel Cells (GBFCs) could then in theory utilise glucose dissolved the blood as a fuel to generate electricity and power implanted devices. The fanciful science fiction devices I dream about above may not arrive on the scene any time soon but there are medical devices and synthetic organs that would benefit from such a power source now.

The device that immediately springs to mind is a pacemaker but the possibilities are much wider, ranging from the artificial urinary sphincter that recipients of Radical Prostatectomy surgery depend on to artificial kidneys which to be portable must currently be wearable because of (among many other reasons) the inability to effectively supply it with power inside the body.

Existing GBFCs have a draw back that the electrodes are inhibited (work less efficiently) by chloride or urate ions, both of which are present in your blood, or require low (acidic) pH to work whereas your body likes to be around neutral pH. This makes them ineffective in a real biological environment. Luckily a recent paper in Plos ONE, “A Glucose BioFuel Cell Implanted in Rats“, details an alternative type of fuel cell that overcomes these limitations and demonstrates it by implanting it inside a rat.

The GBFC produced a specific power of 24.4 µW mL−1 which, to put that in perspective, could power two pacemakers (just in case The Doctor gets into trouble). The mL−1 part refers to the volume of the fuel cell, this really means that the power output is related to the size of the fuel cell, just like regular batteries. The volume of this cell appears to be little more than a quarter of a millilitre (0.266mL, two electrodes of 0.133mL each), think about how much volume a normal 6 sided die takes up, imagine one quarter of that and you’ll be in the right ball park.

Inside the fuel cell electrodes are enzymes that react the glucose with dissolved oxygen also in the blood to produce an electric current. The glucose and oxygen required for the reaction diffuse through a membrane surrounding the electrodes while the waste products diffuse back out into the bloodstream to be taken care of by the body. In this way the fuel is constantly being replenished and so long as the enzymes retain their activity the fuel cell will continue to function and continuously produce energy. The time scales measured in this study were only a few months but experiments by others suggests that the enzymes will stay active in a device such as this for at least a year and possibly more.

The authors of the study consider that a scaled up version of the device would be able to power medical implants with much greater power requirements than a pacemaker, such as the artificial sphincter mentioned above that they calculate would need almost 10 times the amount of power of a pacemaker. Seems like the limit at the moment is how much room you have to spare inside your body to house the fuel cell. Early pacemaker batteries took up about 90mLs worth of volume, that’s roughly a quarter the size of a drink can. It is mentioned that an animal such as a pig could accommodate a fuel cell 133mL in size but it is not made clear if this is an experiment that will actually occur. RoboPig.

All this is pretty exciting and with that sort of potential in a first generation fuel cell, I’m betting I can get my memory expansion before I start going senile. Now I just have to figure out what to do in the mean time.

-

Cinquin P, Gondran C, Giroud F, Mazabrard S, Pellissier A, Boucher F, Alcaraz JP, Gorgy K, Lenouvel F, Mathé S, Porcu P, & Cosnier S (2010). A glucose biofuel cell implanted in rats. PloS one, 5 (5) PMID: 20454563

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2010
05/27
CATEGORY
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New Zealand Pharmacy Ethics in Relation to Homeopathy in the Wake of Homeopathy Report


Earlier this year I wrote a post (along with fellow Sciblogger Grant) concerning the sale of homeopathic remedies in pharmacies. Monday night saw the release of England’s Science and Technology Committee’s “Evidence Check 2″ report on Homeopathy (also ably covered by Grant). One of the issues covered by the report is that of pharmacy responsibilities regarding sale of these remedies. Essentially the report recommended that sales continue but with adequate disclaimers stating that there is no scientific evidence that homeopathic products work beyond the placebo effect.

I see this as a compromise between commercial freedom to sell safe, though not necessarily effective, products and patient informed consent. It’s reasonable even if I disagree that it is ideal. Regardless, I thought it was a good excuse to look once again at our own pharmacies and see how the selling of scientifically unsupported remedies aligns with their professional responsibilities.

Enquiring into this area I was directed to the Pharmacy Council Code of Ethics for pharmacists. The Pharmacy Council seems to fill the function of professional association and regulatory body for pharmacists their functions including:

prescribe the qualifications required for scopes of practice within the profession, and, for that purpose, to accredit and monitor educational institutions and degrees, courses of studies, or programmes

and

consider the cases of health practitioners who may be unable to perform the functions required for the practice of the profession

Perusing the Code of Ethics (which may be found Here) I found a number of sections that I feel should preclude pharmacists from selling homeopathic remedies in good conscience. In order to try and represent the spirit of the code as accurately as possible I have included here both the relevant over-arching Principles that pharmacists should strive for as well as the Specific Obligations that I feel make my point (any emphases are mine).

The first principle is one of patient autonomy:

Principle 1: Autonomy
The pharmacist shall promote patient
self-determination, respecting the
patient’s right to understandable
information, privacy, and confidentiality

1.4 Professional services
Where the patient is seeking or receiving, from the
pharmacist or from other personnel for whom he or
she has responsibility, any professional service or
intervention, the pharmacist must ensure that the
patient is provided with credible, understandable
information about reasonably expected results,
outcomes or effects of the service or intervention, any
risks of receiving the service or intervention, and any
insufficiency of evidence about the efficacy of the
service or intervention, to allow the patient to make
an informed choice.

This to my reading implies that should pharmacists sell homeopathic remedies they are obligated to inform the patient of the lack of scientific underpinnings for the use of the remedy. One of the objections I have run into regarding the sale of these remedies in pharmacies is that they are commercial enterprises and are within their rights to sell products regardless of their medicinal value. This is partially true but these remedies are specifically sold to treat symptoms, not as entertainment, confection or cosmetic. The Code has several entries covering this aspect the first of which is:

1.5 Independent information
The pharmacist must ensure that their advice is
independent of personal commercial considerations.

Does this not imply that the sale of unscientific medicines should not be undertaken simply because it make financial sense? We will return to this point later.

The next Principle covers patient needs:

Principle 2: Beneficence
The pharmacist shall optimise medicines
related health outcomes for the patient
according to their concerns, needs,
cultural values and beliefs

2.2 Quality use of medicines
The pharmacist must provide scientifically-based,
unbiased medicines information to healthcare
providers, patients and the community in order to
optimise medicines related health outcomes.

My reading of this point leads me to understand that any information provided regarding pharmacy products must have scientific backing and moreover must not be biased by the pharmacist’s own views. Any such information regarding homeopathy must therefore be negative.

But, what if the pharmacist is not asked for this information? After all, I do not usually go in asking for a lecture if I already think I know what I need. I think the next obligation covers this instance:

2.8 Involvement in sale of medicines and other
therapies
The pharmacist must be involved and intervene in the
sale of any medicine, complementary therapy, herbal
remedy or other healthcare product whenever this is
necessary to ensure a reasonable standard of
pharmaceutical care.

Scientifically speaking homeopathy should not be considered to encompass a “reasonable standard of pharmaceutical care”.

The next Principle of relevance concerns fairness:

Principle 4: Justice
The pharmacist shall practise fairly and
justly and promote family, whanau and
community health

4.4 Commercial interests not to override good
practice
The pharmacist must ensure that commercial interests
are not permitted either to override the independent
exercise of their own professional judgement on
behalf of a patient or to compromise the standard of
care provided by them or to affect their cooperation
with other healthcare providers.

Once again the issue of financial gain over patient care is addressed with commercial interests coming off second best when the standard of care is concerned.

The next Principle is one I feel is of especial importance when the reputation of pharmacists in the wider community is considered and their self representation in the media is a factor (remember, they’re the health professional you see most often). This is trustworthiness, pharmacists are seen as, and promote themselves as, first and foremost medical professionals not business interests. The sale of homeopathic medicines is antithetical to this position and undermines their credibility in this regard, in direct contraction to the Code of Ethics as follows:

Principle 7: Trustworthiness
The pharmacist shall act in a manner
that promotes public trust in the
knowledge and ability of pharmacists
and enhances the reputation of the
profession

7.7 Non-medical goods and services
The pharmacist must not purchase or sell from a
pharmacy any product or service which may be
detrimental to the good standing of the profession or bring the profession into disrepute.

If the sale of scientifically worthless remedies such as homeopthy does not do this I don’t know what would, perhaps offering Therapeutic Touch?

Finally the Principle of dignity undermines the pharmacist’s sale of unsupported medicines:

Principle 8: Dignity
The pharmacist shall provide
information about professional services,
medicines and healthcare products in a
dignified manner without making
exaggerated or unsubstantiated claims

8.4 Medicines not ordinary articles of
commerce
A pharmacist must only participate in promotional
methods that do not encourage the public to equate
medicines with ordinary articles of commerce.

If the previous examples of why remedies should not be sold with the sole purpose of earning money for the pharmacist this should put that argument to rest. The sale of medicines (which many people consider homeopathy to be) should not be equated with ordinary articles of commerce. This puts the lie to arguing that these remedies are simply another commodity to be bought and sold like chewing gum regardless of therapeutic value.

8.8 Evidence of efficacy
The pharmacist must only promote to a potential
purchaser that any medicine, complementary therapy,
herbal remedy or other healthcare product associated
with the maintenance of health is efficacious when
there is credible evidence of efficacy.

This last obligation explicitly refers to promotion of a therapy to a patient by the pharmacist which I don’t think any reputable pharmacist would do for homeopathy but arguably the presence of the product in the store constitutes an implicit promotion of it to potential customers. This point goes back to the principle of trustworthiness, the public trusts the pharmacist to stock efficacious products. To include unscientific therapies among their wares undermines and betrays this trust. Perhaps I am naive to think so but I think the Pharmacy Council’s own Code of Ethics backs me up when I say that we should hold pharmacists to a higher standard than your average shop owner.

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2010
02/24
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What is the Harm of Alternative Medicine?


Yesterday fellow Sciblogger Grant posted about homeopathic medications in pharmacies and questioned the legitimacy of reputable organisations selling such patent snake oil. The comments to this entry reveal one of the most frustrating aspects of speaking out against unscientific medicine and can be summarised thusly: “I’m far too sophisticated to be taken in by this stuff myself but other people seem to like it and if it doesn’t work then what’s the harm?”.

This attitude is ever present and comes from a reasonable starting point i.e. everyone is entitled to their own opinion and it’s not my job to save them from themselves. I can totally get behind that, usually. When it comes to ineffective medications of the alternative variety however this impulse though understandable is misguided and I’d like to put down a few reasons why I think so, some are speculative but I think the possibility of harm is great enough that they deserve to be considered.

For a start there may well be direct harm caused by using alternative remedies. As there is little to no regulation of these medications then no proof of safety or efficacy is required for sale. Witness the Zicam debacle last year regarding a “homeopathic” cold medication.

Further more the possibility for indirect harm (as multiply alluded to by Grant) may be significant. In case your imagination is not up to the task I will outline a few ways this may be the case. For instance the underlying principles of something like homeopathy are no only unscientific they are in direct contradiction of the last 200 years of scientific understanding. If they are used as the basis of reasoning about health then the results can be more dire than someone getting a bad nights sleep (in the case of the homeopathic sleep aid Grant used as an example).

Use of these therapies for minor ailments by the “worried and wonky well” may increase the possibility they they will be used for more serious health issues where the results could be deadly.

Look no further than the position statement of the WHO regarding the use of homeopathy in the treatment of Malaria and AIDs (among other things). The consequences of such thinking could be incalculable in terms of human suffering and spread of disease. But what’s the harm, right?

Additionally it is one thing for adults to make an informed choice for themselves based on available evidence filter through their particular world view but what about when this choice id forced on their children? The recent case of parents being found guilty of manslaughter over giving homeopathic remedies to their sick daughter is a terrible reminder that sometimes it is innocent children that pay the price for people’s gullibility. But, you know, what’s the harm?

When ostensibly professional medical providers such as pharmacists sell demonstrably irrational treatments they lend credibility to them that the average person uses to base decisions on. I mean the wouldn’t sell it if it didn’t work, right?

So while I understand the commitment to individual autonomy and freedom of choice that leads to the “What’s the Harm?” question, I fail to see how this means that fraudulent therapies must be let off the hook simply because there is a demand for them.

This has been a more vitriolic post than I normally write but what’s the point of a blog if you can’t vent once in a while?

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2010
01/26
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Persistent Vegetative States and the Problem with Facilitated Communication


If you read the print version of the NZ Herald today you would have seen featured on the front page a miraculous case of a man [Rom Houben] recovering from a persistent vegetative state and communicating with the world through a touch screen with the help of a carer. The topic of persistent vegetative state (PVS) is an interesting one and has received increasing attention in recent years. It would seem that this man was incorrectly diagnosed after an accident as being in a PVS while at the time of the accident it is more likely that he was in a minimally conscious state (MCS). A fine distinction sometimes and an excellent summary of the differences between the two diagnoses and the difficultly of accurately deciding between them can be found at the Science Based Medicine site.

Essentially a PVS is defined as the patient exhibiting no signs of consciousness, as with everything, whether you find something is dependent on how hard you look, simply opening a couple of drawers and glancing in the cupboard may not turn it up. In determining a case of PVS a more thorough search will reveal fewer legitimate cases as you may find extremely subtle signs of intermittent consciousness that will then flip the designation to a MCS. This process is also dependent on the sensitivity of the equipment used to perform the examination, the sophisticated scanning technology we have today simply did not exist 20 years ago. This equipment is the equivalent of rummaging around in the back of the couch and looking behind the fridge.

That this man was unfortunately diagnosed incorrectly is not in dispute, we have made significant advances in brain imaging technology that allows us to determine activity quite well. The issue here is the man’s ability to communicate so coherently and poetically. After so long without mental stimulation it seems bordering on the fantastic that this could be the case. When watching the video of the touch screen being used to bring this man’s thoughts to the world it seems very close to a practice known as Facilitated Communication, (this is actually confirmed in the TimesOnline article) this consists of a facilitator supporting the arm or hand of a subject ostensibly to allow them to then choose letters and words themselves which otherwise they would not have the strength or the focus to do.

The difficulty here is that this technique is very susceptible to the unconscious influence of the facilitator. In this way it can seem as though it is the patient communicating when in reality it is the thoughts of the facilitator that we are hearing. It is difficult to say for sure in this case, the video is ambiguous as to how much control the patient has over his movements so it is possible that we are indeed being exposed the inner world of a man with a very unique perspective but from the evidence shown it is equally plausible that the facilitator is the true originator of these words.

I would be interested in if any simple tests to determine the true origin of this material have been carried out, some of the suggestions I have seen elsewhere include swapping the facilitator for someone who does not speak the patient’s language, asking the patient questions that presumably only he would know, or asking the facilitator to leave the room while the patient is shown an object or told specific information and then seeing if this can be reliably produced after the facilitator returns. Any of these would help determine whether this man is truely communicating.

The print version of the Herald is mostly credulous in it’s coverage of this story but it appears that enough scepticism has filtered through the journalistic world that the online version has incorporated some of it. Better late than never.

[EDIT: The incomparable Dr Novella of the SGU and SBM has posted his take on this news item, as I hoped he would. Get the thoughts of a neurologist. Also had to add a link to this video from Dr.N's site that shows the patient typing with his eyes closed, simply not possible. Added Patient's name]

2009
11/25
CATEGORY
Psychological
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Natural Health Expo(sed)?


Driving around Hamilton the past few weeks I couldn’t help but notice the signs sprinkled around the city for the “Natural Health Expo” which is to take place here this week end. As I perused the website for this event yesterday I was disturbed by the large number of anti-scientific “treatments” that will be showcased. Like my co-blogger Grant who has already posted on this, I was troubled by the amount of misinformation that will be leveled directly at consumers.

As I was pondering how to answer the bewildering array of AltMed that will be promoted I checked my email and found a great little article just published in Chiropractic & Osteopathy (made available through the open access publisher BioMed Central).

The paper, “Why do ineffective treatments seem helpful? A brief review” written by Steve E Hartman, looks at how practitioners and patients can fool themselves into thinking that ineffective medical interventions actually work. An excellent example of Evidence Based Medicine 101, Steve covers the cognitive biases that hinder our ability to draw logical conclusions in the medical sphere such as the Post Hoc, Ergo Propter Hoc logical fallacy, confirmation bias and cognitive dissonance. Also covered are explanations of how it can seem that a treatment has been directly responsible for improvement in a patient’s condition when it may not  have been.

The paper touches on disease natural history, which simply refers to how a particular malady might be expected to progress without treatment. Self limiting diseases such as colds, headaches and fatigue can be expected to get better on their own . If a patient is taking a treatment at the time, the treatment (rather than their own immune system) might erroneously be given the credit.

This combined with the overlapping arenas of the placebo effect and regression to the mean can be a powerful confounding factor when treatments are not being considered in light of scientifically controlled settings. The placebo effect is referred to frequently in common culture but regression to the mean is a less well known entity for the layman. Steven does a good job of explaining the concept, essentially people experience a variety of different intensities in their symptoms. Also they will tend to seek medical help when the symptoms become severe, knowing that the severity of the symptoms will tend to cluster about a mean value it is likely that whether treatment is sought or not the patient’s condition will tend to get better.

Thus the patient will feel relief and attribute that relief to what ever modality they are using at the time. Practitioners are not immune to these effects either and will in their practice see time and again that patients are getting better after their pet therapy is applied. In which case they will feel justified in proclaiming it works in the absence of confirming studies (or even in the face of disconfirming evidence).

The one aspect that I felt was missing from the paper, although it may have been obliquely implied, is the role of prior plausibility in evaluating treatments. Many modalities that will be on offer at the Natural Health expo are not only unusual they fly in the face of currently understood science. Scientific plausibility is our compass, without it we can become lost in the wilderness of fanciful ideas without any method of discerning the way forward. This concept is what separates Science Based Medicine from simply Evidence Based Medicine. The former takes the plausibility of a treatment into account when deciding the threshold of evidence needed before it can be considered effective. The later only measures outcomes and so is less able to distinguish true effects from chance outcomes.

Consider the following scenario: I claim to be able to influence the outcomes of coin tosses by virtue of what I had for breakfast on a particular day. If I have eggs then tails with predominate, lettuce produces more heads. Now without considering the plausibility of the setup we could run a trial, perform statistical analysis and find that my predictions are correct. But given that there is no good reason to suspect that my diet can influence a coin toss the positive is more likely to be because of chance than because of a real effect. In this case then a higher standard of evidence would need to be achieved than if I had said I could alter the probabilities be sticking a piece of gum to one side.

All-in-all though this a very nice paper and my complaint is a small one, given the probable readership of the journal the inclusion of plausibility may even have alienated those that might otherwise have been receptive to the other points presented. I recommend reading it for yourself, it is a very easy and informative read.

2009
10/15
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Gardasil Post-licensure Study


Last month the Post-licensure safety study for Gardasil (the HPV vaccine) was released. The study focused on the reports of adverse events as reported to the VAERS database by the manufacturer, doctors and patients or caregivers. Much has been made by detractors of the vaccine about the serious alleged side effects that have struck young women given the course of injections. These allegations have been supported by referring to the VAERS database itself so if they are valid they should be upheld by this study.

Of the 12,424 reports that VAERS received in the 2.5 year period following implementation of the vaccine, 772 (6.2%) were classified as “serious”, the total number of vaccine doses distributed in this period was 23 million. The category of “serious” was defined according to the FDA regulatory definition of an adverse event that “is life threatening; results in death, permanent disability, congenital anomaly, hospitalization, or prolonged hospitalization; or necessitates medical or surgical intervention to preclude one of these outcomes”.

It must be noted at this point that the VAERS database cannot determine causality, the events reported merely have to occur after vaccination takes place. Therefore anything that happens to a patient in this time frame that someone thinks might be related to the vaccine may be entered. I point this out only to remind that while we may be looking at vaccine safety life does go on, accidents happen and co-incidences occur. The point of a study such as this is to determine if these events are occuring at a frequency higher than what we would expect in the normal population. In other words, is there really a correlation between these events and the vaccine or is is simply a statistical fluke.

The study looked into each type of adverse report in detail and attempted to answer the above question, does the rate of reporting exceed that which would be expected in the general population? In almost all cases the answer appears to be “No”, the exceptions to this were reports of syncope (fainting) and venous thromboembolic events (blood clots), this finding will certainly be followed up in future studies. Curiously one of he more prominent adverse effects that has been concerning many on both sides of the debate, Guillain-Barre´ Syndrome was not found to occur more than expected.

Guillain-Barre´ Syndrome is an auto-immune condition that can be brought on by vaccines but also by normal infections. The syndrome is caused when the immune system is stimulated by an antigen but then starts to target the body’s own nervous system, it usually exhibits as an ascending paralysis noted by weakness in the legs that spreads to the upper limbs and the face along with complete loss of deep tendon reflexes. As vaccines are made to induce an immune reaction the link between vaccines and the syndrome is biologically plausible and not controversial in the medical community.

The study concludes favourably but cautiously, as scientific studies are wont to do:

Vaccination with qHPV has the potential to decrease the global morbidity and
mortality of HPV-associated diseases, including cervical cancer. After hepatitis B vaccine, which can prevent liver cancer, qHPV is only the second vaccine licensed with an indication to prevent cancer. The postlicensure safety profile presented here is broadly consistent with safety data from prelicensure trials. Because VAERS data must be interpreted cautiously and cannot generally be used to infer causal associations between vaccines and AEFIs, postlicensure monitoring will continue, and identified signals may be
evaluated using epidemiologic observational studies.

The full study can be found here, a summary of the study here and a comprehensive discussion of the study here.

2009
09/27
CATEGORY
Medicine
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