quackery
Due to the common adverse effects of motion sickness pharmaceuticals (e.g., drowsiness), medication options to treat the condition are limited. Thus many non-pharmacological therapies are being advocated for it. One of them is osteopathy.
The purpose of this study was to explore the potential utility of a nonpharmaceutical method for motion sickness prevention, specifically an osteopathic manipulative technique (OMT). A novel OMT protocol for the reduction of motion sickness symptoms and severity was evaluated using a sham-controlled, counterbalanced, between-subjects study design. The independent variable was OMT treatment administered prior to the motion sickness-inducing procedure (rotating chair). The primary dependent measures were total and subscale scores from the Motion Sickness Assessment Questionnaire.
The OMT treatment group experienced significantly fewer gastrointestinal (mean scores postprocedure, treatment M = 20.42, sham M = 41.67) and sopite-related (mean scores postprocedure, treatment M = 12.81, sham M = 20.68) symptoms than the sham group while controlling for motion sickness susceptibility. There were no differences between groups with respect to peripheral and central symptoms.
The authors concluded that the results suggest that the treatment may prevent gastrointestinal (nausea) and sopite-related symptoms (sleepiness). These preliminary findings support further exploration of OMT for the prevention of motion sickness. A more precise evaluation of the mechanism of action is needed. Additionally, the duration of the effects needs to be investigated to determine the usefulness of this technique in training and operational settings.
Motion sickness is one of those conditions for which many forms of so-called alternative medicine (SCAM) have been tried and found in dodgy studies to be promissing, e.g.:
And now even OMT!
But before we rush into doing further research on this topic, we should perhaps ask whether the trial really does show OMT to be effective. Unfortunately, the article is behind a paywall, and I can therefore only speculate and ask whether the sham procedure was credible. Was the success of patient-blinding tested? I suspect it wasn’t. If that is so, it could mean that the OMT itself was not the reason for the results but that patient expectation caused the reported outcomes.
In any case, if nothing else, this paper shows yet again that the notion of OMT being an option purely for spinal problems is fantasy. Its advocates try everything to get it accepted as a cure all.
In Germany, two doctors, Dr. Christian Denné (from Vechta), Dr. Hans-Werner Bertelsen (from Bremen), and myself have initiated a petition. Here is my translation of its full text:
We, the undersigned, demand that the “homeopathy” training certificates be revoked. After the deletion from the further training regulations of the vast majority of state medical associations (13 out of 17), as well as the deletion from the model further training regulations (MWBO), it is no longer acceptable that medical fees are paid from the solidarity community pot for a sham therapy. The clear vote of the German Medical Association must be followed by consequences for doctors in private practice in order to avoid continuing to support the organised self-deception of a minority that clings to outdated and thus dangerous forms of medical practice.
1. Dubious cash flows – parallel shadow financing
In addition to the payments made to doctors via the associations of statutory health insurance physicians, there is a second method of cash flow that enables the doctors who bill to generate funds for “homeopathy”, bypassing any control functions of the associations of statutory health insurance physicians (plausibility checks, time profiles). The selective contracts concluded for this purpose with the participating health insurance funds, which were concluded directly by many statutory health insurance funds with the “German Central Association of Homeopathic Doctors” (DZVhÄ), above all Barmer GEK, Techniker Krankenkasse and DAK, are not suitable for building trust, but rather enable medical billing fraud due to the lack of any independent control functions on the part of the health insurance KV.
Enabling parallel billing channels while bypassing the KV’s control function means that the important instrument of billing control is boycotted because neither plausibility checks nor time profiles can be created. The Barmer GEK and Techniker Krankenkasse were informed of the criticism of the implementation of this dubious and non-transparent shadow financing. The management boards of both health insurance funds firmly rejected any interest in changing this situation, for example by cancelling the contracts concluded with the DZVhÄ.
2. Dubious therapies instead of talking medicine
It is no longer acceptable that “homeopathy” will still be used in 2023 to pay for sham therapies in a medical context with annual amounts of up to €530 per patient, while talking medicine remains remunerated with single-digit amounts. Talking medicine must no longer be associated with esotericism in order to generate medical fees. The organised self-deception of inclined sections of the medical profession must be stopped for ethical reasons.
3 Dubious social consequences and dangers
It is no longer acceptable that doctors allow themselves to be conditioned into self-deception by participating in expensive, so-called “advanced training courses” and ignore elementary scientific laws in order to fulfil the need for causality of their patient clientele. Numerous – sometimes fatal – consequences, such as missing an indicated therapeutic time window, have been documented. In addition to serious individual medical consequences, social effects such as denial of science, refusal to vaccinate, etc. are increasingly becoming a problem with far-reaching, unforeseeable consequences.
You can go to the petition here.
Carola Javid-Kistel is a German medical homeopath who states on her website that “homeopathy is a very powerful yet gentle medicine with no side effects, which accompanies me as a doctor for the rest of my life. Thanks to homeopathy, I was completely cured of my ailments…” (my translation).
She is famous in Germany – not so much for her devotion to homeopathy but for repeatedly breaking the law and evading justice.
Now, finally, the doctor from Duderstadt has been arrested. The Göttingen public prosecutor’s office confirmed that she was handed over to the German authorities by the Swiss judiciary in Constance. She has been charged with issuing false medical certificates for exemption from the obligation to wear a mask.
Carola Javid-Kistel has since been released from custody. As a condition, she had to pay 30,000 Euros bail and surrender her passport and identity card. She also had to report regularly to the Duderstadt police station.
According to the Göttingen public prosecutor’s office, the 57-year-old physician was arrested on arrival at Zurich airport. Javid-Kistel had fled to Mexico last year to avoid a criminal trial that had already been scheduled at the Duderstadt district court. She was due to stand trial there for issuing false certificates, among other things.
Further charges from the Göttingen public prosecutor’s office could include:
- Incitement to hatred, defamation and insult.
- At a rally in Herzberg, Javid-Kistel had claimed that the coronavirus measures were “worse than the Holocaust”.
- She also accused a fellow doctor in a video of “vaccinating patients sick and to death”.
- Furthermore, she is alleged to have said to police officers and officials during a search of her practice: “This is fascism, you’re all crazy.”
The date for her new trial has not yet been announced.
Sources:
Dr. med. Carola Javid-Kistel (naturheilpraxis-duderstadt.de)
Ärztin aus Duderstadt in der Schweiz festgenommen (aerzteblatt.de)
I just found this on ‘X’ (formerly Twitter):
We’re delighted to announce the launch of the #BeyondPills All Parliamentary Group in Westminster. Chaired by Danny Kruger MP and co-chaired by Lord Crisp, this new body aims to tackle #overreliance on pills, reducing the number of unnecessary and inappropriate prescriptions.
It turns out that I did not study the website of College of Quackery and Integrated Health as regualarly as I should have. Because there, the launch had been announced some time ago under the title ‘Beyond Pills All Party Parliamentary Group (APPG) launches to stop over-prescribing‘:
Now, in December 2023, we have an exciting development to report: the launch of the Beyond Pills All Party Parliamentary Group (APPG), in which the Beyond Pills Campaign joins forces with the former APPG for Prescribed Drug Dependence. We’re delighted to announce that the APPG’s former Chair, Danny Kruger MP, joins the new Beyond Pills APPG as Chair.
Danny Kruger said of the launch: ‘There is a natural synergy with our objectives and the APPG for Prescribed Drug Dependence is a great supporter of social prescribing, which we feel can make a valuable contribution to addressing this public and personal health crisis, both in terms of helping to prevent overprescribing and also to treating people who are suffering from the debilitating symptoms of dependence.’
The Beyond Pills Campaign now becomes a founder member of the Beyond Pills Alliance (BPA), alongside the Council for Evidence-based Psychiatry (CEP-UK). Setting up the BPA will, in the near future, give us the opportunity to invite other organisations with a similar goal of reducing overreliance on pills to join the Alliance.
The Beyond Pills APPG has the following Mission and Objectives:
MISSION: To move UK healthcare beyond an over-reliance on pills by combining social prescribing, lifestyle medicine, psychosocial interventions and safe deprescribing. As well as reducing unnecessary and inappropriate prescribing, this integrated approach will improve outcomes and reduce health inequalities.
Elsewhere, Dr. Michael Dixon, who seems to be in charge of the ‘beyond pills’ activities, explained: ‘The Beyond Pills All Party Parliamentary Group heralds a sea change in public perception and medical practice from “a pill for every ill” to recognising that there is so much that we can do for ourselves which will not only help us to heal but also stop us getting ill in the first place.’
Sea change?
Really?
This made me think – and eventually, I respond by writing this short ‘open letter’ to the group:
Dear ‘BEYOND PILLS All Parliamentary Group‘
please let me begin by stating that I am all in favour of reducing over-prescribing. Who isn’t? The clue is in the name ‘over– prescribing’! Yet, at the same time, I would like to alert you to the fact that your group’s name ‘beyond pills‘ is of questionable merit.
It implies that conventional medicine consits only or predominantly of prescribing pills. My own career as a clinician – long ago now – was in physical medicine and rehabilitation, a discipline that certainly does not rely on pills. Many other areas of healthcare also do not exclusively rely on pills; take surgery or psychosomatic medicine, for instance. As for the rest of the physicians, they will, no doubt, have learnt in medical school that over-prescribing is wrong, dangerous, and not evidence-based.
By putting ‘beyond pills’ on your banner, you either disclose your ignorance of the facts, or you deliberately undermine trust in conventional medicine. Some less benevolent than I might even get the impression that you employ the ‘strawman fallacy‘ in order to push a hidden agenda.
I hope these lines might motivate you to reconsider and alter the irresponsible name of your initiative – how about ‘evidence-based medicine’?
Sincerely
Edzard Ernst
PS
In case anyone wants to use my ‘open letter’ on other sites or publication, I herewith grant permission to reproduce it.
In May this year, I reported that my ex-friend Michael Dixon had been appointed as HEAD OF THE ROYAL MEDICAL HOUSEHOLD. The story was picked up by Gabriel Pogrund, one of the top investigative journalists of THE SUNDAY TIMES, who published a long article about Dixon yesterday which I encourage you to read in full.
In it he revealed many things about Dixon including, for instance, that some of the academic titles he often carries might not be what they seem. On ‘X’. Pogrund commented that “He [Dixon] faces Qs after three unis could not confirm his academic roles”. The article prompted many other newspapers to report on the matter.
The Guardian, for instance, contacted The Good Thinking Society, which promotes scientific scepticism. Michael Marshall, project director at the society, said: “It [promoting homeopathy] isn’t appropriate. I think the role of the monarchy, if it has one in current society, isn’t to be advocating for their own personal projects and their own personal beliefs or using the power and influence they have to further causes that run directly counter to the evidence that we have. “It’s absolutely unequivocal that homeopathic remedies do not work and just because you happen to be in a position of extreme power and privilege, that doesn’t change that.” Marshall said the appointment was also worrying because it suggested the king might still be supporting complementary medicine behind the scenes. He added: “Before Charles became king, he was the patron of homeopathic organisations, he was an outspoken advocate in favour of homeopathy and pushing back the bounds of science towards pseudoscience. And the argument was that he would stop doing that once he became king. This appears to be a sign that he isn’t going to do that, that he isn’t going to stop. What’s worrying is, as we’ve seen from the black spider memos, Charles is someone who also wields his power and influence quietly behind the scenes as well as publicly, so if this is the kind of step he’s willing to make in public, it raises questions about whether he’s willing to make even more steps in private.”
The Guardian also asked me three questions and I provided my answers in writing:
Within hours, the story became an international isse. For example a short article in DER SPIEGEL informed Germany as follows (my translation):
He works with Christian healers and prescribes goat weed for impotence: Dr Michael Dixon looks after the health of the British royal family. Scientists are appalled.
King Charles has appointed a homeopathy advocate as head of the royal medical household and has been heavily criticised by scientists. They call the decision worrying and inappropriate, as reported by the Guardian, among others. Dr Michael Dixon, who promotes faith healing and herbalism in his work as a general practitioner, has quietly held the senior position for a year, writes the Sunday Times. Although 71-year-old Dixon is head of the royal medical household, this is the first time that this role has not been combined with that of a doctor to the monarch. His duties include taking overall responsibility for the health of the King and the entire royal family – and also representing them in discussions with the government. He once invited a Christian healer into his practice to treat chronically ill patients. He also experimented with prescribing devil’s claw for shoulder pain and goat’s weed for impotence, reports the Sunday Times.
Will all this have consequences? Will the King reflect and reconsider his affiliations with those who promote quackery? Will Dixon change?
Personally, I will not hold my breath.
In many parts of the world, vaccination rates have been declining in recent years.
Why?
This study aimed to determine the rates and reasons for parental hesitancy or refusal of vaccination for their children in Türkiye. A total of 1100 participants selected from 26 regions of Türkiye were involved in this cross-sectional study conducted between July 2020 and April 2021. Using a questionnaire, the researchers collected data on:
- the sociodemographic characteristics of parents,
- the status of vaccine hesitancy or refusal for their children,
- the reasons for the hesitancy or refusal.
Using Excel and SPSS version 22.0, they analysed the data with chi-square test, Fisher’s exact test and binomial logistic regression.
Only 9.4% of the participants were male and 29.5% were aged 33-37 years. Just over 11% said they were worried about childhood vaccination, mainly because of the chemicals used in manufacturing the vaccines. The level of concern was greater among those who:
- got information about vaccines from the internet, family members, friends, TV, radio, and newspapers,
- used so-called alternative medicine (SCAM).
The authors concluded that parents in Türkiye have several reasons for hesitating or refusing to vaccinate their children, key among which are concerns about the chemical composition of the vaccines and their ability to trigger negative health conditions such as autism. This study used a large sample size across Türkiye, although there were differences by region, the findings would be useful in designing interventions to counter vaccine hesitancy or refusal in the country.
The fact that SCAM users are more likely to be against vaccinations has been reported often and on this blog we have discussed such findings regularly, e.g.:
- Intelligence, Religiosity, SCAM, Vaccination Hesitancy – are there links?
- Andrew Wakefield, Donald Trump, SCAM, and the anti-vaccination cult
- Endorsement of so-called alternative medicine (SCAM) and vaccine hesitancy among physicians
- So-called alternative medicine (SCAM) and vaccine hesitancy among physicians: findings from Germany, Finland, Portugal, and France
- Interest in so-called alternative medicine is linked to vaccination coverage
- Misinformation and conspiratorial thinking are at the heart of so-called alternative medicine(SCAM)
The questinon I ask myself is, what is the cause and what the effect? Does vaccination hesitancy cause people to use SCAM, or does SCAM use cause vaccination hesitancy? I think that most likely both is true. In addition the two are linked via a common trait, namely that of falling for conspiracy theories. We know that someone believeing in one such theory is likely to believe in other such notions as well. In my view, both vaccination heaitancy and SCAM can qualify to be called a conspiracy theory.
Every now and then, I come across a paper that is so remarkable that I feel like copying it for you in its full and untouched beauty. The recent article entitled “Revisiting the therapeutic potential of homeopathic medicine Rhus Tox for herpes simplex virus and inflammatory conditions” falls in this category. Let me present to you its unchanged abstract as recently published in the ‘J Ayurveda Integr Med’:
Background: Herpes simplex virus type-1 and type-2 cause a viral disease named Herpes. Genital herpes is mainly caused by HSV-2 with symptoms of painful and itchy blisters on the vagina, cervix, buttocks, anus, penis, or inner thighs with blisters that rupture and convert into sores. The homeopathic remedy Rhus Tox has been widely used to treat herpes and has shown invitro anti-inflammatory effects in previous studies.
Purpose: The presented review focuses on relapses and harmful effects caused by acyclovir in modern medicine and the probable antiherpetic activity of Rhus Tox on HSV infection based on its pathophysiology, preclinical findings, on primary cultured mouse chondrocytes, mouse cell line MC3T3e1 and a comparative study of Natrum Mur with Rhus Tox on HSV infection.
Study design: The design of the study focuses mainly on the descriptive data available in various literature articles.
Method: Databases such as PubMed, Google Scholar, Medline and ScienceDirect were used to search the articles. Articles are selected from 1994 to 2022 focusing solely on the competence of Rhus Tox against herpes. Keywords used for the study are antiviral, Herpes, Rhus Tox, in vitro and homeopathy.
Results: The review includes fifteen articles, including 4 full-text articles on HSV, 6 in vitro studies of homeopathic compounds performed on the herpes virus, and 5 articles based on the pathophysiology and effects of Rhus tox. The review article proposes the anti-inflammatory and antiviral action of the homeopathic remedy Rhus Tox which can be used in crisis conditions when the physician doubts the simillimum, as it prevents further outbreaks of HSV infection.
Conclusion: The homeopathic medicine Rhus Tox has no cytotoxicity observed under in vitro conditions and can be used to treat herpes infection. Further studies are needed to confirm the results under in vitro and in vivo conditions as well as in clinical trials.
Considering that the paper was based on ‘descriptive data available in various literature articles’, the conclusion that “Rhus Tox … can be used to treat herpes infection” is surprising, to say the least.
In the paper itself we find many more baffling statements, e.g.:
- Modern medicines target only specific organs at a time, but there is a risk of widespread infection which influence complications such as meningitis or HSV-2 radiculopathy which are not observed after the use of homeopathy as the disease progression does not involve vital organs and the disease level stays on the skin layer itself.
- Homeopathy treats patients holistically taking into consideration all the physical, mental and characteristic ailments of the patient. Rhus tox can effectively relieve all the symptoms of herpes infection, including pain, blisters, redness, restlessness, etc. Rhus Tox can effectively penetrate the capsid structure of the infected cells and cure the patient. Rhus tox in different potencies is currently being used to treat inflammatory and viral diseases
- In homeopathy, many treatments have been clinically proven to have some impact, and in individual cases a solution for herpes viruses. Homeopathy can prevent further outbreaks of herpes simplex infection.
- Homeopathy strengthens immunity to fight infections and contributes to mental, physical, and social well-being, hence complementary therapies should be used along with the traditional antiviral drugs to give maximum comfort to the patient.
I am sure that some readers of the paper are impressed. These statments leave little doubt about the notion that homeopathy is the best thing since sliced bread. What a pity though that, for none of them, the authors (who incedently are affiliated with prestigeous sounding institutions: Homeopathic Materia Medica Department, Bharti Vidyapeeth, Homoeopathic Medical College and Hospital, Dept. of Postgraduate & Research Centre, Pune-Satara Road, Dhankawadi, Pune, 411043, India, ICMR-National AIDS Research Institute, 73 G MIDC Bhosari, Pune, India, ICMR-National AIDS Research Institute, 73 G MIDC Bhosari, Pune, India) provide any evidence whatsoever.
Homeopathy, it seems to me, is a cult characterised not just by a total lack of active ingredients but also by an equally total void of proper evidence supporting the delusions of its proponents.
So-called alternative medicine (SCAM) interventions are often being discussed as possible treatments for long COVID symptoms. However, comprehensive analysis of current evidence in this setting is still lacking. This review aims to review existing published studies on the use of SCAM interventions for patients experiencing long COVID through a systematic review.
A comprehensive electronic literature search was performed in multiple databases and clinical trial registries from September 2019 to January 2023. RCTs evaluating efficacy and safety of SCAM for long COVID were included. Methodological quality of each included trial was appraised with the Cochrane ‘risk of bias’ tool. A qualitative analysis was conducted due to heterogeneity of included studies.
A total of 14 RCTs with 1195 participants were included in this review. Study findings demonstrated that SCAM interventions could benefit patients with long COVID, especially those suffering from neuropsychiatric disorders, olfactory dysfunction, cognitive impairment, fatigue, breathlessness, and mild-to-moderate lung fibrosis. The main interventions reported were self-administered transcutaneous auricular vagus nerve stimulation, neuro-meditation, dietary supplements, olfactory training, aromatherapy, inspiratory muscle training, concurrent training, and an online breathing and well-being program.
The authors concluded that SCAM interventions may be effective, safe, and acceptable to patients with symptoms of long COVID. However, the findings from this systematic review should be interpreted with caution due to various methodological limitations. More rigorous trials focused on SCAM for long COVID are warranted in the future.
The review’s aim is, in my view, nonsense. SCAM is a diverse field which means that the review must capture a wide range of therapies each represented by just one or two primary studies. In turn, this means that general conclusions across all SCAM will be highly questionable, if not misleading.
Furthermore, I find these conclusions odd and irresponsibly misleading. My main reason for this is the poor methodological quality of the primary studies:
- Four trials were considered to have unknown bias risk for generating the random sequence due to insufficient information about the specific method of randomization used.
- Only 5 of the trials provided appropriate random allocation concealment.
- Only 5 trials were blinded to both participants and personnel.
- Three trials were rated as unknown risk of bias since insufficient information was provided.1
- Four trials failed to performed outcome assessment blinding.
- One trial did not report detailed information about drop-out cases and was defined as high risk of bias.
- Three study protocols were unavailable and had relevant outcomes that were not reported in the pre-specified way.
Moreover, safety cannot possibly be reliably estimated on the basis of the data. And finally, the statement that SCAM interventions may be effective, as the authors put it, is in my view not a valid conclusion but a silly platitude.
I therefore suggest to re-formulate the conclusion of this review as follows:
At present there is no sound evidence to assume that any SCAM intervention is effective in the management of long COVID.
I was alerted to the updated and strengthened guidance to ensure safer practice by chiropractors who treat children under the age of 12 years that has recently been published by the Chiropractic Board of Australia after considering the recommendations made by the Safer Care Victoria independent review. The Board also considered community needs and expectations, and specifically the strong support for consumer choice voiced in the public consultation of the independent review.
The Board examined how common themes in the independent review’s recommendations align with its existing regulatory guidance, and used these insights to inform a risk-based approach to updating its Statement on paediatric care. This includes updated advice reinforcing the need to ensure that parents or guardians fully understand their rights and the evidence before treatment is provided to children. ‘Public safety is our priority, and especially so when we consider the care of children’, Board Chair Dr Wayne Minter said.
According to the statement, the Board expects chiropractors to various things, including the following [the numbers in the following passage were added by me and refer to my brief comments below]:
- inform the patient and their parent/guardian about the quality of the acceptable evidence and explain the basis for the proposed treatment [1]
- provide the patient and their parent/guardian with information about the risks and benefits of the proposed treatment and the risks of receiving no treatment [2]
- appropriately document consent, including considering the need for written consent for high-risk procedures [3]
- refer patients when they have conditions or symptoms outside a chiropractor’s area of competence, for example ‘red flags’ such as the presence of possible serious pathology that requires urgent medical referral to the care of other registered health practitioners [4]
______________________________
- I know what is meant by the ‘quality of the evidence’ but am not sure what to make of the ‘quality of the acceptable evidence]. Acceptable by whom? In any case, who checks whether this information is being provided?
- Imagine the scenatio following this guidance: Chiro informs that there is a serious risk and no proven benefit – which parent would then procede with the treatment? In any case, the informed consent is incomplete because it also requires information as to which conventional treatment is effective for the condition at had [information that chiros are not competent to provide].
- Who checks whether this is done properly?
- Arguably, all pediatric conditions or symptoms are outside a chiropractor’s area of competence!
In view of these points, I fear that the updated guidance is a transparent attempt of window dressing, yet unfit for purpose. Most certainly, it does not ensure safer practice by chiropractors who treat children under the age of 12 years.
A case report of a U-type sacral fracture, or spinopelvic dissociation, resulting from chiropractic manipulation has recently been published. It presents the case of a 74-year-old male patient who sustained a U-type sacral fracture after drop-table chiropractic manipulation.
The drop table chiropractic technique is claimed by chiropractors to involve lesser brute force for spinal manipulation than traditional chiropractic care. It involves low-velocity movement and less spinal manoeuvring on the specific area of injury. It is said to be particularly beneficial for adjusting the pelvis or sacroiliac joints. Furthermore, this is, according to chiros, one of the only methods that can adjust spondylolisthesis. In fact, the evidence that it is effective for anything other that boosting the chiros’ income is more than thin, while there is at least one tragic report that it can be lethal.
The recent case of a spinopelvic dissociation demonstrates that chiropractic manipulative therapy involving the commonly used drop-table can cause severe injury. The patient’s course was complicated by a delay in diagnosis and a prolonged hospital stay. Orthopaedic surgeons should have a high degree of suspicion for spinopelvic dissociation in the setting of bilateral sacral fractures. One year after injury, with conservative management, the patient returned to baseline function with mild residual neuropathy.
Spinopelvic dissociation is a rare injury associated with 2% to 3% of transverse sacral fractures and 3% of sacral fractures associated with pelvic ring injuries. When spinopelvic dissociation is expediently identified and treated appropriately, patient outcomes can be maximized, highlighting the importance of early diagnosis and treatment. Because of its rarity and complexity, there remains a paucity of high-level evidence-based guidance on treating this complex issue. Most cases are caused by a fall from heights, followed by road accidents. Many patients show neurologic impairment at initial presentation, which often improves after surgery, the treatment of choice.
