MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Monthly Archives: May 2021

Research can be defined as the process of discovering new knowledge. There are three somewhat overlapping types of research:

  1. Exploratory research is research around a problem that has not yet been clearly defined. It aims to gain a better understanding of the nature of the issues involved with a view of conducting more in-depth research at a later stage.
  2. Descriptive research creates knowledge by describing the issues according to their characteristics and population. It focuses on the ‘how’ and ‘what’, but not on the ‘why’.
  3. Explanatory research is aimed at determining how variables interact and at identifying cause-and-effect relationships. It deals with the ‘why’ of research questions and is therefore often based on experiments.

The motivation behind doing research in medicine does, of course, vary but essentially it should be to help advance our knowledge and thus create progress.

I have been a researcher in several areas of medicine: physical medicine and rehabilitation, blood rheology, so-called alternative medicine (SCAM). My kind of research was mostly the explanatory type, i.e. formulating a research question and trying to answer it. Looking back at my ~40 years as an active researcher, I find remarkable differences between doing research in SCAM and the other subjects.

The process of discovering new knowledge is rarely contentious. New knowledge may be useful or useless but it should not generate contention. Of course, there can be debates about the reliability of the findings; this is entirely legitimate, helpful, and necessary. We always need to make sure that results are valid, reproducible, and true. And of course, the debates about the quality of the data can generate a certain amount of tension. Such tensions are stimulating and must be welcomed. I have been lucky to have experienced them in all areas of the research I ever touched.

The tension I experienced while doing SCAM research, however, was of an entirely different nature – so much so that I would not even call it ‘tension’; it was outright hostility. While doing non-SCAM research, it had never been in doubt that my research was honestly aimed at creating progress, this issue became the focal point after I had started SCAM research.

  • When my research showed that homeopathy might not be effective, I got PERSONALLY attacked by homeopaths.
  • When my research showed that homeopathy might not be safe, I got PERSONALLY attacked by homeopaths.
  • When my research showed that chiropractic might not be effective, I got PERSONALLY attacked by chiropractors.
  • When my research showed that chiropractic might not be safe, I got PERSONALLY attacked by chiropractors.
  • When my research showed that acupuncture might not be effective, I got PERSONALLY attacked by acupuncturists.
  • When my research showed that acupuncture might not be safe, I got PERSONALLY attacked by acupuncturists.
  • When my research showed that herbalism might not be effective, I got PERSONALLY attacked by herbalists.
  • When my research showed that herbalism might not be safe, I got PERSONALLY attacked by herbalists.
  • Etc., etc.

Essentially, doing SCAM research felt like doing research not FOR but AGAINST the will of those who should have had the most interest in it.

But why?

As I said, one way to describe research is as a process of discovering new knowledge and creating progress. The main difference between doing research in SCAM and non-SCAM areas is perhaps this: in medicine, almost everyone is interested in discovering new knowledge and creating progress, while in SCAM hardly anyone shares this interest. In SCAM, I now tend to feel, research is not understood as a tool for finding the truth, but one for generating more business. To put it even more bluntly: medicine, in general, is open to research and its consequences hoping to make progress; SCAM is mostly anti-science and not interested in progress.

But why?

To me, the answer seems obvious: the truth or progress would be bad for the business of SCAM.

Prince Charles has claimed that people struggling to return to full health after having the coronavirus should practice yoga. This is what the GUARDIAN reported about it on Friday:

In a video statement on Friday to the virtual yoga and healthcare symposium Wellness After Covid, the heir apparent said doctors should work together with “complementary healthcare specialists” to “build a roadmap to hope and healing” after Covid. “This pandemic has emphasised the importance of preparedness, resilience and the need for an approach which addresses the health and welfare of the whole person as part of society, and which does not merely focus on the symptoms alone,” Charles said. “As part of that approach, therapeutic, evidenced-informed yoga can contribute to health and healing. By its very nature, yoga is an accessible practice which provides practitioners with ways to manage stress, build resilience and promote healing…”

… Charles, who has previously espoused the benefits of yoga, is not the only fan in the royal family. His wife, the Duchess of Cornwall, has said “it makes you less stiff” and “more supple”, while Prince William has also been pictured doing yogic poses. In 2019, the Prince of Wales said yoga had “proven beneficial effects on both body and mind”, and delivered “tremendous social benefits” that help build “discipline, self-reliance and self-care”.

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END OF QUOTE

Yoga is a complex subject because it entails a host of different techniques, attitudes, and life-styles. There have been numerous clinical trials of various yoga techniques. They tend to suffer from poor study design as well as incomplete reporting and are thus no always reliable. Several systematic reviews have summarised the findings of these studies. A 2010 overview included 21 systematic reviews relating to a wide range of conditions. Nine systematic reviews arrived at positive conclusions, but many were associated with a high risk of bias. Unanimously positive evidence emerged only for depression and cardiovascular risk reduction.[1] There is no evidence that yoga speeds the recovery after COVID-19 or any other severe infectious disease, as Charles suggested.

Yoga is generally considered to be safe. However, a large-scale survey found that approximately 30% of yoga class attendees had experienced some type of adverse event. Although the majority had mild symptoms, the survey results indicated that patients with chronic diseases were more likely to experience adverse events.[2]  It, therefore, seems unlikely that yoga is suited for many patients recovering from a COVID-19 infection.

The warning by the Vatican’s chief exorcist that yoga leads to ‘demonic possession’[3] might not be taken seriously by rational thinkers. Yet, experts have long warned that many yoga teachers try to recruit their clients into the more cult-like aspects of yoga.[4]

Perhaps the most remarkable expression in Charles’ quotes is the term ‘EVIDENCE-INFORMED‘. It crops up regularly when Charles (or his advisor Dr. Michael Dixon) speaks or writes about so-called alternative medicine (SCAM). It is a clever term that sounds almost like ‘evidence-based’ but means something entirely different. If a SCAM is not evidence-based, it can still be legitimately put under the umbrella of ‘evidence-informed’: we know the evidence is not positive, we were well-informed of this fact, we nevertheless conclude that yoga (or any other SCAM) might be a good idea!

In my view, the regular use of the term ‘evidence-informed’ in the realm of SCAM discloses a lack of clarity that suits all snake-oil salesmen very well.

 

[1] Ernst E, Lee MS: Focus on Alternative and Complementary Therapies Volume 15(4) December 2010 274–27

[2] Matsushita T, Oka T. A large-scale survey of adverse events experienced in yoga classes. Biopsychosoc Med. 2015 Mar 18;9:9. doi: 10.1186/s13030-015-0037-1. PMID: 25844090; PMCID: PMC4384376.

[3] https://www.social-consciousness.com/2017/06/vaticans-chief-exorcist-warns-that-yoga-causes-demonic-possession.html

[4] https://www.theguardian.com/lifeandstyle/2020/jun/26/experience-my-yoga-class-turned-out-to-be-a-cult

 

The Indian AYUSH ministry has a track record of doing irresponsible stuff. Now they have published guidelines for treating Mucormycosis (black fungus) with homeopathy. Allow me to show you the crucial passages of their announcement:

… With the increasing cases of special variety of fungal infection, Mucormycosis (black fungus) the present information have been prepared with experience of senior clinicians in treating specific fungal infections and researchers of the system, for efficient treatment of suspected and diagnosed cases of Mucormycosis with Homoeopathy. This condition requires hospital based treatment under supervision and Homoeopathic medicines can be prescribed in an integrated manner. Since mostly immune compromised patients get this infection, strict monitoring of blood sugar and other vitals is required…

As a system with holistic approach, homoeopathy medicines may be selected based on the presenting signs and symptoms of each patient(4). Fungal infections are amenable to homoeopathic treatment. Various research studies undertaken on various fungi in-vitro model showed that homoeopathy medicine could prevent the growth of the fungus(5-8). Clinical studies have shown encouraging results on fungal infections (9-10). The medicines given here are suggestive based on their clinical use.

Symptomatic Homoeopathy management of Suspected and Diagnosed cases of Mucormycosis-

 

 

 

Note: -Apart from these lists of medicines any other medicine and any other potency may be
prescribed based on the symptom similarity in each case.

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END OF QUOTE

Mucormycosis (black fungus) is a disease of immunocompromised patients. Five types can be differentiated:

  1. rhinocerebral (most common),
  2. pulmonary,
  3. cutaneous,
  4. disseminated,
  5. gastrointestinal (rare).

Rhinocerebral mucormycosis commonly causes headaches, visual changes, sinusitis, and proptosis. Pulmonary mucormycosis commonly presents as a cough. Late diagnosis may result in dissemination, leading to high mortality. Treatment consists of amphotericin B, surgery, and immune restoration.

It is believed that the current surge of mucormycosis in India has an overall mortality rate of 50% and is triggered by the use of steroids which are often life-saving for critically ill Covid-19 patients. It almost goes without saying that homeopathy has not been shown to be effective against this (or any other) condition. As to the AYUSH ministry, the less they interfere with public health in India, the better for the survival of patients, I fear.

Post-traumatic stress disorder (PTSD), previously known as battle fatigue syndrome or shell shock, is a condition that can be triggered by the experience of some frightening event. PTSD can be debilitating leading to the production of feelings of helplessness, intense fear, and horror. Numerous treatments of PTSD exist but few have been shown to be truly effective. A team of Canadian researchers explored the effects of cannabis on PTSD symptoms, quality of life (QOL), and return to work (RTW). Their systematic review also investigated harms such as adverse effects and dropouts due to adverse effects, inefficacy, and all-cause dropout rates.

Their electronic searches located one RCT and 10 observational studies (n = 4672). Risk of bias (RoB) was assessed with the Cochrane risk of bias tool and ROBINS-I. Evidence from the included studies was mainly based on studies with no comparators. Results from unpooled, high RoB studies suggested that cannabis was associated with a reduction in overall PTSD symptoms and improved QOL. Dry mouth, headaches, and psychoactive effects such as agitation and euphoria were the most commonly reported adverse effects. In most studies, cannabis was well tolerated. A small proportion of patients experienced a worsening of PTSD symptoms.

The authors concluded that the evidence in the current study primarily stems from low quality and high RoB observational studies. Further RCTs investigating cannabis effects on PTSD treatment should be conducted with larger sample sizes and explore a broader range of patient-important outcomes.

Various drugs are currently used for the treatment of PTSD including selective serotonin reuptake inhibitors; tricyclic antidepressants (amitriptyline and isocarboxazid); mood stabilizers (Divalproex and lamotrigine); atypical antipsychotics (aripiprazole and quetiapine) but their effectiveness has not been proven. A recent systematic review included 30 RCTs of a range of heterogeneous non-psychological and non-pharmacological interventions. There was emerging evidence for 6 different approaches:

  • acupuncture,
  • neurofeedback,
  • saikokeishikankyoto (a herbal preparation),
  • somatic experiencing,
  • transcranial magnetic stimulation,
  • yoga.

This list makes me wonder: are these treatments, including cannabis, truly promising, or is PTSD one of those conditions for which nearly every treatment works a little because of its placebo effect?

Google Scholar is quite a fantastic tool; I recently (20/5/2021) glanced at my own profile and decided to have a closer look at the 100 of my papers that have been cited most frequently. The list below shows these ‘top 100’; in the 1st column is the reference (title of the article, authors, journal). In the MIDDLE column are the numbers of times each paper has been cited (if you click on it, you see the articles that cited the paper in question), and the far-right column tells you the year of publication.

Here we go:

Interactions between herbal medicines and prescribed drugs. AA Izzo, E Ernst: Drugs 61 (15), 2163-2175 1608* 2001
Influence of context effects on health outcomes: a systematic review. Z Di Blasi, E Harkness, E Ernst, A Georgiou, J Kleijnen: Lancet 357 (9258), 757-762 1564 2001
Fibrinogen as a cardiovascular risk factor: a meta-analysis and review of the literature. E Ernst, KL Resch: Annals of internal medicine 118 (12), 956-963 1544 1993
The prevalence of complementary/alternative medicine in cancer: a systematic review. E Ernst, B Cassileth: Cancer: Interdisciplinary International Journal of the American Cancer 1173 1998
The desktop guide to complementary and alternative medicine: an evidence-based approach. E Ernst, MH Pittler, C Stevinson, A White 854 2001
Harmless herbs? A review of the recent literature. E Ernst: The American journal of medicine 104 (2), 170-178 852 1998
The desktop guide to complementary and alternative medicine: an evidence-based approach. E Ernst, MH Pittler, C Stevinson, A White 837 2001
Aloe vera: a systematic review of its clinical effectiveness. BK Vogler, E Ernst: British journal of general practice 49 (447), 823-828 767 1999
Leukocytes and the risk of ischemic diseases. E Ernst, DE Hammerschmidt, U Bagge, A Matrai, JA Dormandy: Jama 257 (17), 2318-2324 754 1987
The Risk–Benefit Profile of Commonly Used Herbal Therapies: Ginkgo, St. John’s Wort, Ginseng, Echinacea, Saw Palmetto, and Kava. E Ernst: Annals of internal medicine 136 (1), 42-53 726 2002
Prevalence of use of complementary/alternative medicine: a systematic review. E Ernst: Bulletin of the world health organization 78, 258-266 725 2000
The BBC survey of complementary medicine use in the UK. E Ernst, A White: Complementary therapies in medicine 8 (1), 32-36 646 2000
The efficacy of “distant healing”: a systematic review of randomized trials. JA Astin, E Harkness, E Ernst: Parapsychology, 433-440 633 2017
Toxic heavy metals and undeclared drugs in Asian herbal medicines. E Ernst: Trends in pharmacological sciences 23 (3), 136-139 630 2002
Efficacy of ginger for nausea and vomiting: a systematic review of randomized clinical trials. E Ernst, MH Pittler: British journal of anaesthesia 84 (3), 367-371 623 2000
Meta-analysis: acupuncture for low back pain. E Manheimer, A White, B Berman, K Forys, E Ernst: Annals of internal medicine 142 (8), 651-663 600 2005
Garlic for treating hypercholesterolemia: a meta-analysis of randomized clinical trials

C Stevinson, MH Pittler, E Ernst: Annals of internal medicine 133 (6), 420-429

550 2000
Bringing medicinal plants into cultivation: opportunities and challenges for biotechnology. PH Canter, H Thomas, E Ernst: TRENDS in Biotechnology 23 (4), 180-185 524 2005
St John’s wort: Prozac from the plant kingdom. G Di Carlo, F Borrelli, E Ernst, AA Izzo: Trends in Pharmacological Sciences 22 (6), 292-297 500* 2001
Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. A White, S Hayhoe, A Hart, E Ernst: Bmj 323 (7311), 485-486 498 2001
Concept of true and perceived placebo effects. E Ernst, KL Resch: Bmj 311 (7004), 551-553 495 1995
A systematic review of systematic reviews of homeopathy. E Ernst: British journal of clinical pharmacology 54 (6), 577-582 482 2002
Aromatherapy: a systematic review. B Cooke, E Ernst: British journal of general practice 50 (455), 493-496 476 2000
The efficacy of ginseng. A systematic review of randomised clinical trials. BK Vogler, MH Pittler, E Ernst: European journal of clinical pharmacology 55 (8), 567-575 476 1999
Second thoughts about safety of St John’s wort. E Ernst: Lancet 354 (9195), 2014-2016 475 1999
Dietary supplements for body-weight reduction: a systematic review. MH Pittler, E Ernst: The American journal of clinical nutrition 79 (4), 529-536 473 2004
Herb–drug interactions: review and assessment of report reliability. A Fugh‐Berman, E Ernst: British journal of clinical pharmacology 52 (5), 587-595 468 2001
Acupuncture for back pain: a meta-analysis of randomized controlled trials. E Ernst, AR White: Archives of internal medicine 158 (20), 2235-2241 421 1998
Prospective studies of the safety of acupuncture: a systematic review. E Ernst, AR White: The American journal of medicine 110 (6), 481-485 411 2001
Panax ginseng, JT Coon, E Ernst: Drug safety 25 (5), 323-344 408 2002
The role of complementary and alternative medicine. E Ernst: Bmj 321 (7269), 1133 404 2000
Review of randomised controlled trials of traditional Chinese medicine. JL Tang, SY Zhan, E Ernst: Bmj 319 (7203), 160-161 388 1999
Peppermint oil for irritable bowel syndrome: a critical review and metaanalysis. MH Pittler, E Ernst: The American journal of gastroenterology 93 (7), 1131-1135 384 1998
Yohimbine for erectile dysfunction: a systematic review and meta-analysis of randomized clinical trials. E Ernst, MH Pittler: The Journal of urology 159 (2), 433-436 380 1998
Trick or treatment: The undeniable facts about alternative medicine. S Singh, E Ernst: WW Norton & Company 379* 2008
Prospective investigation of adverse effects of acupuncture in 97 733 patients. D Melchart, W Weidenhammer, A Streng, S Reitmayr, A Hoppe, E Ernst: Archives of internal medicine 164 (1), 104-105 375 2004
Adulteration of Chinese herbal medicines with synthetic drugs: a systematic review. E Ernst: Journal of internal medicine 252 (2), 107-113 374 2002
Mindfulness-based cognitive therapy: evaluating current evidence and informing future research. HF Coelho, PH Canter, E Ernst. Educational Publishing Foundation 1 (S), 97 362 2013
Acupuncture–a critical analysis. E Ernst: J. Intern Med 259 (2), 125-137 357 2006
Acupuncture for treating acute ankle sprains in adults. TH Kim, MS Lee, KH Kim, JW Kang, TY Choi, E Ernst: Cochrane database of systematic reviews 353* 2014
Kava extract versus placebo for treating anxiety. MH Pittler, E Ernst:Cochrane Database of Systematic Reviews 352 2003
Methods for causality assessment of adverse drug reactions. TB Agbabiaka, J Savović, E Ernst: Drug safety 31 (1), 21-37 348 2008
Efficacy of kava extract for treating anxiety: systematic review and meta-analysis. MH Pittler, E Ernst: Journal of clinical psychopharmacology 20 (1), 84-89 345 2000
Horse chestnut seed extract for chronic venous insufficiency. MH Pittler, E Ernst: Cochrane database of systematic reviews 341 2012
A systematic review of randomized controlled trials of acupuncture for neck pain. AR White, E Ernst: Rheumatology (Oxford, England) 38 (2), 143-147 334 1999
Cardiovascular pharmacotherapy and herbal medicines: the risk of drug interaction. AA Izzo, G Di Carlo, F Borrelli, E Ernst: International journal of cardiology 98 (1), 1-14 333 2005
Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy. E Ernst, V Fialka: Journal of pain and symptom management 9 (1), 56-59 332 1994
Complementary medicine—a definition. E Ernst, KL Resch, S Mills, R Hill, A Mitchell, M Willoughby, A White: The British Journal of General Practice 45 (398), 506 331 1995
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. D Moher, A Liberati, J Tetzlaff, DG Altman, D Altman, G Antes, D Atkins, … Journal of Chinese Integrative Medicine 7 (9), 889-896 327 2009
Validating a new non-penetrating sham acupuncture device: two randomised controlled trials. J Park, A White, C Stevinson, E Ernst, M James: Acupuncture in Medicine 20 (4), 168-174 324 2002
Herbal medicinal products during pregnancy: are they safe? E Ernst: BJOG: An International Journal of Obstetrics & Gynaecology 109 (3), 227-235 322 2002
Adverse effects of herbal drugs in dermatology. E Ernst: British Journal of Dermatology 143 (5), 923-929 319 2000
Plasma fibrinogen—an independent cardiovascular risk factor. E Ernst: Journal of internal medicine 227 (6), 365-372 317 1990
Green tea (Camellia sinensis) for the prevention of cancer: K Boehm, F Borrelli, E Ernst, G Habacher, SK Hung, S Milazzo, … Cochrane Database of Systematic Reviews 312 2009
Andrographis paniculata in the treatment of upper respiratory tract infections: a systematic review of safety and efficacy. JT Coon, E Ernst: Planta medica 70 (04), 293-298 310 2004
Different standards for reporting ADRs to herbal remedies and conventional OTC medicines: face‐to‐face interviews with 515 users of herbal remedies: J Barnes, SY Mills, NC Abbot, M Willoughby, E Ernst: British journal of clinical pharmacology 45 (5), 496-500 308 1998
Complementary and alternative medicine use in England: results from a national survey. KJ Hunt, HF Coelho, B Wider, R Perry, SK Hung, R Terry, E Ernst: International journal of clinical practice 64 (11), 1496-1502 305 2010
Acupuncture for smoking cessation. AR White, H Rampes, E Ernst: Cochrane Database of Systematic Reviews 304* 2002
A review of stroke rehabilitation and physiotherapy. E Ernst: Stroke 21 (7), 1081-1085 298 1990
Ginkgo biloba extract for the treatment of intermittent claudication: a meta-analysis of randomized trials. MH Pittler, E Ernst: The American journal of medicine 108 (4), 276-281 295 2000
Adverse effects of spinal manipulation: a systematic review. E Ernst: Journal of the royal society of medicine 100 (7), 330-338 290 2007
The safety of massage therapy. E Ernst: Rheumatology 42 (9), 1101-1106 282 2003
Life-threatening adverse reactions after acupuncture? A systematic review. E Ernst, A White: Pain 71 (2), 123-126 282 1997
Herbal medicines for treatment of bacterial infections: a review of controlled clinical trials. KW Martin, E Ernst: Journal of Antimicrobial Chemotherapy 51 (2), 241-246 280 2003
Alternative and complementary therapies for the menopause. Borrelli, E Ernst: Maturitas 66 (4), 333-343 278 2010
Valerian for insomnia: a systematic review of randomized clinical trials. C Stevinson, E Ernst: Sleep medicine 1 (2), 91-99 271 2000
Adverse effects profile of the herbal antidepressant St. John’s wort (Hypericum perforatum L.). E Ernst, JI Rand, J Barnes, C Stevinson: European journal of clinical pharmacology 54 (8), 589-594 271 1998
The possible role of hemorheology in atherothrombogenesis. W Koenig, E Ernst: Atherosclerosis 94 (2-3), 93-107 269 1992
Red ginseng for treating erectile dysfunction: a systematic review. DJ Jang, MS Lee, BC Shin, YC Lee, E Ernst: British journal of clinical pharmacology 66 (4), 444-450 263 2008
Complementary therapies for depression: an overview. E Ernst, JI Rand, C Stevinson: Archives of general psychiatry 55 (11), 1026-1032 260 1998
Quality of herbal medicines: challenges and solutions. J Zhang, B Wider, H Shang, X Li, E Ernst: Complementary therapies in medicine 20 (1-2), 100-106 257 2012
Heavy metals in traditional Indian remedies. E Ernst: European journal of clinical pharmacology 57 (12), 891-896 253 2002
Heavy metals in traditional Chinese medicines: a systematic review. E Ernst, JT Coon: Clinical Pharmacology & Therapeutics 70 (6), 497-504 251 2001
Vitex agnus castus. C Daniele, JT Coon, MH Pittler, E Ernst: Drug safety 28 (4), 319-332 245 2005
Acupuncture for peripheral joint osteoarthritis: a systematic review and meta-analysis. YD Kwon, MH Pittler, E Ernst: Rheumatology 45 (11), 1331-1337 242 2006
The efficacy of herbal medicine–an overview. E Ernst: Fundamental & clinical pharmacology 19 (4), 405-409 242 2005
Herb–drug interactions: an overview of systematic reviews. P Posadzki, L Watson, E Ernst. British journal of clinical pharmacology 75 (3), 603-618 241 2013
Adverse events of herbal food supplements for body weight reduction: systematic review. MH Pittler, K Schmidt, E Ernst: obesity reviews 6 (2), 93-111 240 2005
Randomized, double-blind trial of chitosan for body weight reduction. MH Pittler, NC Abbot, EF Harkness, E Ernst: European Journal of Clinical Nutrition 53 (5), 379-381 237 1999
Massage therapy for low back pain: a systematic review. E Ernst: Journal of pain and symptom management 17 (1), 65-69 236 1999
Feverfew for preventing migraine. MH Pittler, E Ernst: Cochrane database of systematic reviews 235 2004
Intermittent claudication, exercise, and blood rheology. EE Ernst, A Matrai: Circulation 76 (5), 1110-1114 235 1987
Adverse effects of herbal medicines: an overview of systematic reviews. P Posadzki, LK Watson, E Ernst: Clinical medicine 13 (1), 7 233 2013
Horse-chestnut seed extract for chronic venous insufficiency: a criteria-based systematic review. MH Pittler, E Ernst: Archives of Dermatology 134 (11), 1356-1360 232 1998
The effectiveness of acupuncture in treating acute dental pain: a systematic review. E Ernst, MH Pittler: British dental journal 184 (9), 443-447 231 1998
 Complementary therapies for asthma: what patients use. E Ernst: Journal of Asthma 35 (8), 667-671 230 1998
87.   Acupuncture: does it alleviate pain and are there serious risks? A review of reviews. E Ernst, MS Lee, TY Choi: PAIN 152 (4), 755-764 229 2011
The effectiveness of spinal manipulation for the treatment of headache disorders: a systematic review of randomized clinical trials. JA Astin, E Ernst: Cephalalgia 22 (8), 617-623 228 2002
Hawthorn extract for treating chronic heart failure: meta-analysis of randomized trials. MH Pittler, K Schmidt, E Ernst: The American journal of medicine 114 (8), 665-674 227 2003
Complementary medicine: what physicians think of it: a meta-analysis. E Ernst, KL Resch, AR White: Archives of internal medicine 155 (22), 2405-2408 226 1995
A brief history of acupuncture. A White, E Ernst: Rheumatology 43 (5), 662-663 225 2004
Hawthorn extract for treating chronic heart failure. R Guo, MH Pittler, E Ernst: Cochrane Database of Systematic Reviews 221 2008
Prevalence of use of complementary and alternative medicine (CAM) by patients/consumers in the UK: systematic review of surveys. P Posadzki, LK Watson, A Alotaibi, E Ernst: Clinical medicine 13 (2), 126 220 2013
Herbal medicines for asthma: a systematic review. A Huntley, E Ernst: Thorax 55 (11), 925-929 218 2000
 Plasma viscosity and the risk of coronary heart disease: results from the MONICA-Augsburg Cohort Study, 1984 to 1992. W Koenig, M Sund, B Filipiak, A Doring, H Lowel, E Ernst: Arteriosclerosis, thrombosis, and vascular biology 18 (5), 768-772 215 1998
Alternative therapy bias. E Ernst, MH Pittler: Nature 385 (6616), 480-480 214 1997
 Systematic review: hepatotoxic events associated with herbal medicinal products. MH Pittler, E Ernst: Aliment Pharmacol & Therapeutics 18 (5), 451-471 212 2003
Anthocyanosides of Vaccinium myrtillus (bilberry) for night vision—a systematic review of placebo-controlled trials. PH Canter, E Ernst: Survey of ophthalmology 49 (1), 38-50 210 2004
Prevalence of complementary/alternative medicine for children: a systematic review. E Ernst: European journal of pediatrics 158 (1), 7-11 210 1999
Homeopathy for postoperative ileus?: a meta-analysis. J Barnes, KL Resch, E Ernst: Journal of Clinical Gastroenterology 25 (4), 628-633

What my analysis of these data suggests is the following:

  1. Only relatively few articles (n=8) are in the ‘top 100’ that I published before I took up the Exeter post starting full-time research into so-called alternative medicine (SCAM).
  2. Despite the fact that in any such analysis older papers are at a significant advantage over newer articles, the vast majority of these 100 papers are relatively recent.
  3. Very few of our clinical trials are in the ‘top 100’, even though I did publish well over 50 during my career.
  4. Systematic reviews dominate by far and amount to 49 of the ‘top 100’.
  5. Even some of my ‘letters to the editor’ did make it into the ‘top 100’.
  6. Six of the 100 papers are surveys.
  7. As to the SCAM topics, most articles are on herbal medicine (n=39), followed by acupuncture (13), manual therapies (4), and homeopathy (2).
  8. A total of 21 of the papers have their main focus on safety issues.
  9. The vast majority of the papers are co-authored by more than one member of my team.
  10. A total of 22 articles were produced in collaboration with researchers who were not members of my team.
  11. Seventeen papers were single-author papers by myself.
  12. Even though I certainly did publish a lot in journals specialized in so-called alternative medicine (SCAM), only very few of these articles made it into this list.

There are many things that I find interesting in all this. Perhaps just a few points:

  • The two SCAM areas in which I have published many articles and do get a lot of flack for what I have written are homeopathy and chiropractic. Surprisingly, not many of these papers are in the ‘top 100’. I am not sure whether this is meaningful and if so how I should interpret this.
  • The fact that hardly any papers published in SCAM journals made the ‘top 100’ is interesting but not surprising. It means that researchers who want to see their work cited – and who doesn’t? – should avoid such journals (there are, of course, other reasons as well for avoiding such journals).
  • The fact that even ‘letters to the editors’ can get cited so frequently seems unexpected but I find it encouraging.
  • Collaboration with researchers who are not from one’s own team can be, in my experience, cumbersome but it is worth it and often fruitful.
  • If you asked me, is there a correlation between the quality of a paper and the frequency with which it is cited, I’d have to say NO.
  • If you asked me, is there a correlation between the importance of a paper and the frequency with which it is cited, I’d have to say NO again.

Due to polypharmacy and the rising popularity of so-called alternative medicines (SCAM), oncology patients are particularly at risk of drug-drug interactions (DDI) or herb-drug interactions (HDI). The aims of this study were to assess DDI and HDI in outpatients taking oral anticancer drugs.

All prescribed and non-prescribed medications, including SCAMs, were prospectively collected by hospital pharmacists during a structured interview with the patient. DDI and HDI were analyzed using four interaction software programs: Thériaque®, Drugs.com®, Hédrine, and Memorial Sloan Kettering Cancer Center (MSKCC) database. All detected interactions were characterized by severity, risk, and action mechanism. The need for pharmaceutical intervention to modify drug use was determined on a case-by-case basis.

A total of 294 patients were included, with a mean age of 67 years [55-79]. The median number of chronic drugs per patient was 8 [1-29] and 55% of patients used at least one SCAM. At least 1 interaction was found for 267 patients (90.8%): 263 (89.4%) with DDI, 68 (23.1%) with HDI, and 64 (21.7%) with both DDI and HDI. Only 13% of the DDI were found in Thériaque® and Drugs.com® databases, and 125 (2.5%) were reported with a similar level of risk on both databases. 104 HDI were identified with only 9.5% of the interactions found in both databases. 103 pharmaceutical interventions were performed, involving 61 patients (20.7%).

The authors concluded that potentially clinically relevant drug interactions were frequently identified in this study, showing that several databases and structured screening are required to detect more interactions and optimize medication safety.

These data imply that DDIs are more frequent than HDIs. This does, however, not tell us which are more important. One crucial difference between DDIs and HDIs is that the former are usually known to the oncology team who should thus be able to prevent them or deal with them appropriately; in contrast, HDIs are often not known to the oncology team because many patients fail to disclose the fact that they take herbal remedies. Some forget, some do not think of herbals as medicine, others may be worried about their physician’s reaction.

It follows that firstly, conventional healthcare practitioners should always ask about the usage of herbal remedies, and secondly, they need to be informed about which herbal remedy might interact with which drug. The first can easily be implemented into routine history-taking; the second is more problematic, not least because our knowledge about HDIs is still woefully incomplete. In view of this, it might often be wise to tell patients to stop taking herbal remedies while they are on prescription drugs.

By guest blogger João Júlio Cerqueira

A word of caution to all the skeptics out there defending Reason, Science, and the Truth. This is a summary of a long story and only about one of many battles. It is not a very beautiful story but it is what it is. I’m a medical doctor, influenced by some of the great minds of our time, all of them familiar to you, Edzard Ernst, Steven Novella, David Gorski, Harriet Hall, Kimball Atwood and so much more (thank you all, for everything that you do).

I started reading skeptic blogs in 2013 and was amazed by the lack of critical thinking about science production and the lack of knowledge about pseudoscience in the medical community. And if this was bad in the medical community, in the general population it should be close to apocalyptic…

In 2017, I was confronted by a medical doctor that imported the great pitches of international charlatans. From alkaline diet, bioidentical hormones, colonic cleansings all through the “health benefits” of drinking diluted saltwater…yes, this is a real thing. He was transformed into a television celebrity, wrote one of the bestselling books in my country, and only a few people were horrified by what was happening. How? How can someone that says that kind of stuff could have this kind of reach in the media? He even sold foot detox!

So, frustrated by the lack of action of the regulatory institutions and the lack of critical approach by the media, I decided to create a blog that I called SCIMED. Using what I had learned through the years with “the masters of skepticism”, I tried to teach and convince people why pseudoscience is useless and dangerous. Why those selling pseudoscience are a danger to society and are only after the wallet of scientifically illiterate people.

Thanks to hard work and a lot of luck, the blog started to have a decent public projection. Started to get invitations to interviews in the media, invited to speak at conferences, started to write in the opinion section of mainstream journals, appearing on television, invited to do a TEDx talk, was invited to be one of the subscribers to the first world manifesto against pseudoscience and even had the pleasure to be a speaker in a conference side by side with Edzard Ernst, one of my heroes!

It was like something was changing. Well, it was not.

With public projection, came the problems…people calling my employers to get me fired, physical and death threats, constant harassment by email or in social media, doxing, and false accusations about my personal and professional life. You name it. And I endured…I considered it the dark side of defending Science and Truth.

In April of 2019, I was invited to represent my country´s Medical College in a debate about pseudoscience on television, prime time. I was very excited and emotion clouded my reason. I didn´t think about the consequences. And well, it was a shitshow.

The audience was dominated by alternative health practitioners. The moderator was sympathetic with alternative health practices. And of course, the people representing the alternative health practitioners didn’t play by the same rules. They used deception, lying, testimonials, and all the logical fallacies you can think of.

But what really took me over the hedge was a Traditional Chinese Medicine Practitioner with connections to the Chinese Government, a constant presence in the mainstream media, that started to sell “acupuncture anesthesia” as something valid. Talking about how he, more than 20 years ago, used this practice to help perform surgical procedures. For me, that was a disrespect for all the people that suffered at the hands of Mao´s Chinese dictatorship. All the people that suffered excruciating pain, being operated on without general anesthesia only to sell East Snake Oil to the West. The “miracle” of acupuncture and Eastern medicine. The propaganda.

We exchanged words in the debate and that continued into social media. In the days after, I was called everything you can imagine by the defenders of alternative therapies. And this man took the opportunity to write that I was “short, ugly and bald” and that I have an “inferiority complex” because of that. That I´m a lousy doctor that cannot compete with his clinics. That only a masochist woman would want something with me.

But I endured. I could not stop feeling disgusted by the lack of shame of these people. I could not let go. Like Gaad Sad, I feel physical pain when someone is bullshitting. It makes me physically sick that people can say outrageous things with a serious face.

So, I wrote a blog post to explain the myth and the horror of acupuncture anesthesia and to dismantle other claims said by that man, like “all babies born with fire in the

liver…if you treat that problem, you can prevent infertility and cancer metastasis in the future!”. Preventing metastasis of a non-existing cancer… And I used a lot of adjectives: dumb, ignorant, charlatan, and snake oil salesman.

In November of 2019, this man goes to a wannabe Joe Rogan show and tells all sort of outrageous things like “Chinese people are so many because Traditional Chinese Medicine was very advanced for those days” or “until recently Traditional Chinese Medicine was more effective treating cancer than Conventional Medicine” or “Homeopathy works but they don´t want you to know…see this Documentary”. Again, I used sarcasm, irony, and a lot of adjectives.

And then, legal problems…

Soon after I wrote this last blog post, I received a letter from the court saying that I was being sued by this man. I hired a lawyer and made a lengthy response to all the accusations, more than 100 pages. Nevertheless, I have been charged with seventeen defamation crimes, awaiting trial, for defending the truth. For defending the people that Institutions refused to defend.

My country, Portugal, legally recognizes “Non-Conventional Therapies” like Homeopathy, Acupuncture, Traditional Chinese Medicine, Osteopathy, Chiropractic, and Naturopathy. My country, instead of defending the consumer, took the option to give these people the legal right of robbing people. I thought that the COVID-19 pandemic would change that a little bit since pseudoscience contributed zero for solving the problem, alternative practitioners embraced negationism about COVID-19, and Traditional Chinese Medicine was put in the corner. It was Science that came to the rescue with vaccines.

But now, when the pandemic is finally getting managed in my country, the snakes are starting to come out of hibernation to sell snake oil. And the media are giving them credit, again, like nothing has happened…nothing has changed, except for me.

Right now, I face four legal battles, for defamation. Besides this man, I have another lawsuit from a Nurse that promotes Reiki and Traditional Chinese Medicine, other from a Naturopath/Quantum Doctor and, lastly, from a Medical Doctor that was the head of the “Doctors For the Truth”, an organization part of an international network of Health Professionals that still denies the science about COVID-19.

So, this is my prize for all the hours battling liars and charlatans. The regulatory institutions don´t care. The mainstream media and Social Media don´t care. They are like brokers. They always win no matter if the stock market goes up or down. They will use you just to fuel the battle between science and pseudoscience and make money out of it. Why do you think the “Disinformation Dozen” still exists, besides some gestures of goodwill by the Social Media giants?

What I learned and you should learn…

I learned that it is pointless trying to convince people to change their minds on social media… People don´t follow reason, follow emotion, and something closer to religious belief. People want to be right, don´t want to learn what is right. Facts don´t change the minds of believers.

I learned that “True Skeptics” are unicorns. Everyone is a rational, skeptical person that values truth, reason, and science until you hit some nerve, some irrational belief that they hold dear. And then the “skepticism” goes down the drain. The more topics you talk about, the lonely you will be. And then you became a unicorn or, in the words of Malcolm Gladwell in the book “Talking to Strangers”, a Holy Fool: the truth-teller that is an outcast.

The COVID-19 pandemic just made things a lot worse…People started to getting hit by the pandemic in their quality of life and you start seeing hardcore skeptics doubting the most basic science and common sense. You even see some of your personal heroes like John Ioannidis going down the rabbit hole. Making the same basic mistakes that he spent his life point out about science production!

You start to see the animal inside us taking ground, what William James argued: if something improves your chances of survival, is not that the “truth”? The pragmatic, utilitarian truth? We saw irrationality in all its splendor, people negating reality, trying to conserve their way of life, making sense of events they don´t control. Fighting for control. Reason went to sleep and a lot of skeptics ceased to be…

So, I came to ask for your help… After two years of enduring the Sword of Damocles over my head, the energy to continue is running out. The SLAPP (Strategic lawsuit against public participation) they call it, is making a dent in my will to continue to fight against irrationality and charlatans.

So, I came to ask for your help, the International Skeptic community, for covering the legal expenses. I already asked for the support of my country’s skeptical community but it was not enough…only after two years of this marathon probably will take another two, I took this decision. I´m not proud of this, I´m angry that these people, besides robbing the sick and fragile giving them false hope are now making those who fight them spend money and probably pay “compensation” for not be silent about charlatanism. You can support me through Paypal or Patreon. Thank you in advance and I will keep you up-to-date.

PS

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Vertebral artery dissections (VAD) are a rare but important cause of ischemic stroke, especially in younger patients. Many etiologies have been identified, including motor vehicle accidents, cervical fractures, falls, physical exercise, and, as I have often discussed on this blog, cervical chiropractic manipulation. The goal of this study was to investigate the subgroup of patients who suffered a chiropractor-associated injury and determine how their prognosis compared to other-cause VAD.

The researchers, neurosurgeons from Chicago, conducted a retrospective chart review of 310 patients with vertebral artery dissections who presented at their institution between January 2004 and December 2018. Variables included demographic data, event characteristics, treatment, radiographic outcomes, and clinical outcomes measured using the modified Rankin Scale.

Overall, 34 out of our 310 patients suffered a chiropractor-associated injury. These patients tended to be younger (p = 0.01), female (p = 0.003), and have fewer comorbidities (p = 0.005) compared to patients with other-cause VADs. The characteristics of the injuries were similar, but chiropractor-associated injuries appeared to be milder at discharge and at follow-up. A higher proportion of the chiropractor-associated group had injuries in the 0-2 mRS range at discharge and at 3 months (p = 0.05, p = 0.04) and no patients suffered severe long-term neurologic consequences or death (0% vs. 9.8%, p = 0.05). However, when a multivariate binomial regression was performed, these effects dissipated and the only independent predictor of a worse injury at discharge was the presence of a cervical spine fracture (p < 0.001).

The authors concluded that chiropractor-associated injuries are similar to VADs of other causes, and apparent differences in the severity of the injury are likely due to demographic differences between the two populations.

The authors of the present paper are clear: “chiropractic manipulations are a risk factor for vertebral artery dissections.” This fact is further supported by a host of other investigations. For instance, the Canadian Stroke Consortium found that 28% of strokes following cervical artery dissection were preceded by chiropractic neck manipulation. Dziewas et al. obtained a similar rate in patients with vertebral artery dissections. Many chiropractors are in denial; however, this is merely due to their overt conflicts of interest.

My conclusions from the accumulated evidence are this:

Spinal manipulations of the upper spine should not be routinely used for any condition. Patients who nevertheless insist on having them must be made aware of the risks and give informed consent.

By guest blogger Michael Scholz

For several years, the “flower essences” invented by Dr. Edward Bach had a difficult time in the European Union and especially Germany. The manufacturers were regularly taken to court for violating the EU Health Claim Regulation. This now culminates in the fact that the manufacturer, Nelsons, who sells the “Original Bach Flowers” in Germany, was forced to rename its popular “Rescue” remedies.

What happened?

The “Rescue” remedies were promoted with statements such as “calm and strong through the day” and “recommended use in emotionally exciting situations, e.g. at work” or to “face emotional challenges”. The competitor, Annoyax Nutripharm, regarded this as a health-related statement that is prohibited according to the EU Health Claim Regulation. Since the “Bach Flower Remedies” are not considered to be medicinal products in Germany, they are treated as food supplements, according to a ruling by the Oberlandesgericht (Higher Regional Court) Hamburg in 2007.

As it is strictly forbidden to advertise food supplements with health-related claims that are unproven, Annoyax Nutripharm filed a lawsuit against Nelsons that all the way to the Bundesgerichtshof (Federal High Court of Justice) in Karlsruhe. Since the case concerned European law, the judges in Karlsruhe referred it to the European Court of Justice in Luxemburg.

The judges wanted two questions clarified: 1. Are the “Rescue” remedies to be regarded simply as Brandy due to their alcohol content of 27%? (in which case, health-related claims would be strictly forbidden). 2. Does the product’s name “Rescue” itself constitute a violation of the Health Claims Regulation?

The Luxemburg judges ruled “No” and “Yes”. “No”, it is not Brandy, although the „essences“ consist of a considerable quantity of alcohol, the recommended dose is too small to be intoxicating. But “Yes”, the term “Rescue” does indeed violate the Health Claim Regulation. So the plaintiff won – and what is the result?

When the Health Claims Regulation was enacted in 2005, a transition period until 2022 was established. This applied to all products that were sold using the same brand name and composition before 2005. This now gave the defendant – Nelsons – the opportunity to use Edward Bach’s 135th anniversary for launching an advertising campaign that praises the court-ordered renaming as „modernization“ for the 21st century. And as you see, the new name is a paragon of creativity, innovation & modernism, indeed (//irony:off): “Rescue” becomes – drum roll – “Rescura”. Yes, I looked just like that too…

This pyrrhic victory for the plaintiffs shows how important it is to protect the European citizens against misleading advertising. And – far more important – it is now established through a ruling of the Federal High Court of Justice that “Bach Flowers” are an esoterical concept devoid of medical evidence.

This amazing announcement reached me via Twitter. It seems that the people in the AYUSH ministry are highly delusional. According to Wikipedia, the Ministry of AyurvedaYogaNaturopathyUnaniSiddha, Sowa-Rigpa and Homoeopathy (abbreviated as AYUSH) is purposed with developing education, research and propagation of indigenous alternative medicine systems in India. As per a recent notification published in the Gazette of India on 13 April 2021, the  Ministry of AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy), will now be known as the Ministry of Ayush.

India is suffering from a very severe health crisis, and the ministry should stop its propaganda for useless solutions.

  • Ayurveda,
  • Homeopathy (considered to be indigenous in India),
  • Yoga,
  • Naturopathy,
  • Unani,
  • Sidda,
  • Sowa-Rigpa (the traditional medicine of Tibet)

have in common that they can offer very little help to patients infected by COVID-19. In view of this fact, the announcement is ununderstandable and irresponsible, in my view.

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