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

Edzard

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I remember being a student in Munich – that was about half a century ago! – protesting against some new regulations that my University (LMU) was trying to implement. We were in the street and some placards read: “TRAUE NIEMAND UEBER 30!” (DON’T TRUST ANYONE BEYOND THE AGE OF 30!).

And now I am 75!

Do I still trust myself?

Not with everything, of course.

For instance, I would not trust myself to ski down neck-breaking slopes; nor would I trust myself to pass the medical exams again; nor to drum 3 times per week in jazz clubs.

But, generally speaking, I do manage not that badly. In particular, I think I am capable of providing (hopefully constructive) criticism and reliable information on so-called alternative medicine (SCAM), the subject that became my hobby horse in the late 1970s and subsequently my job in the early 1990s.

At my age, people often ask me about regrets.

Do I have regrets?

I used to answer this question with a straight NO.

Lately, I am realizing that this is not entirely true.

I have quite a few regrets – mostly, they are relatively trivial. But some go deeper.

Those who know my CV well often wonder “Do you not regret having left your position in Vienna?” It’s a legitimate question: in Vienna, I had a position for life, a large and well-funded department of high reputation. In Exeter, I initially had as good as nothing followed by 20 years of fighting for ever more scarce funding.

Despite all this, the positives of the last 30 years more than outweighed the negatives, in my view: I was soon able to build up a productive team of researchers; together we managed to publish some exciting and important research; and eventually, we even managed to get a reputation – depending on who you ask, a good or a bad one.

But more important for me was just being in England. I loved it! No, not the food, not the weather, but the British openness, tolerance, understatement, politeness, integrity, gentleness, and decency. Sadly, since the Brexit vote, much of this has started to slowly disappear.

So, regrets?

Yes, several!

Would I do it all again?

Yes!

I am an incorrigible optimist convinced that the UK is presently going through a bit of a rough patch that soon will end. It’s just that, at the age of 75, I feel they better hurry up.

PS

The birthday cake just came from Natalie Grams – thanks Natalie

If you think that scanning through dozens of new scientific articles every week is a dry and often somewhat tedious exercise, you are probably correct. But every now and then, this task is turned into prime entertainment by some pseudoscientists trying to pretend to be scientists. Take, for instance, the latest homeopathy study by Indian researchers with no less than 9 seemingly impressive affiliations:

  • 1Department of Organon of Medicine and Homoeopathic Philosophy, National Institute of Homoeopathy, Ministry of AYUSH, Govt. of India, Salt Lake, Kolkata, West Bengal, India.
  • 2Department of Organon of Medicine and Homoeopathic Philosophy, National Institute of Homoeopathy, Ministry of AYUSH, Govt. of India, Block GE, Sector III, Salt Lake, Kolkata, West Bengal, India.
  • 3Department of Homoeopathy, State Homoeopathic Dispensary, Karaila, Pratapgarh, Uttar Pradesh, India.
  • 4Department of Homoeopathy, State Homoeopathic Dispensary, Tulsipur, Shrawasti, Uttar Pradesh, India.
  • 5Department of Materia Medica, National Institute of Homoeopathy, Ministry of AYUSH, Govt. of India, Salt Lake, Kolkata, West Bengal, India.
  • 6State Homoeopathic Dispensary, Mangalbari Rural Hospital, Matiali Block, Jalpaiguri, West Bengal, under Department of Health & Family Welfare, Govt. of West Bengal, India.
  • 7Department of Repertory, The Calcutta Homoeopathic Medical College and Hospital, Govt. of West Bengal, Kolkata, West Bengal, India.
  • 8Department of Homoeopathy, East Bishnupur State Homoeopathic Dispensary, Chandi Daulatabad Block Primary Health Centre, Village and Post Office: Gouripur (South), Police Station Bishnupur, West Bengal, under Department of Health & Family Welfare, Govt. of West Bengal, India.
  • 9Department of Repertory, D. N. De Homoeopathic Medical College and Hospital, Govt. of West Bengal, Tangra, Kolkata, West Bengal, India.

Now that I have whetted your appetite, here is their study:

Lumbar spondylosis (LS) is a degenerative disorder of the lumbar spine. Despite substantial research efforts, no gold-standard treatment for LS has been identified. The efficacy of individualized homeopathic medicines (IHMs) in lumbar spondylosis (LS) is unknown. In this double-blind, randomized, placebo-controlled trial, the efficacy of IHMs was compared with identical-looking placebos in the treatment of low back pain associated with LS. It was conducted at the National Institute of Homoeopathy, West Bengal, India.

Patients were randomized to receive IHMs or placebos; standardized concomitant care was administered in both groups. The Oswestry low back pain and disability questionnaire (ODQ) was used as the primary outcome measure; the Roland-Morris questionnaire (RMQ) and the short form of the McGill pain questionnaire (SF-MPQ) served as secondary outcome measures. They were measured at baseline and every month for 3 months. Intention-to-treat analyses (ITT) were used to detect any inter-group differences using two-way repeated measures analysis of variance models overall and by unpaired t-tests at different time points.

Enrolment was stopped prematurely because of time restrictions; 55 patients had been randomized (verum: 28; control: 27); 49 could be analyzed by ITT (verum: 26; control: 23).

The results are as follows:

  • Inter-group differences in ODQ (F 1, 47 = 0.001, p = 0.977), RMQ (F 1, 47 = 0.190, p = 0.665) and SF-MPQ total score (F 1, 47 = 3.183, p = 0.081) at 3 months were not statistically significant.
  • SF-MPQ total score after 2 months (p = 0.030) revealed an inter-group statistical significance, favoring IHMs against placebos.
  • Some of the SF-MPQ sub-scales at different time points were also statistically significant: e.g., the SF-MPQ average pain score after 2 months (p = 0.002) and 3 months (p = 0.007).
  • Rhus Toxicodendron, Sulphur, and Pulsatilla nigricans were the most frequently indicated medicines.

The authors concluded that owing to failure in detecting a statistically significant effect for the primary outcome and in recruiting a sufficient number of participants, our trial remained inconclusive.

Now that I (and hopefully you too) have recovered from laughing out loud, let me point out why this paper had me in stitches:

  • The trial was aborted not because of a “time limit” but because of slow recruitment, I presume. The question is why were not more patients volunteering? Low back pain with LS is extremely common. Could it be that patients know only too well that homeopathy does not help with low back pain?
  • If a trial gets aborted because of very low patient numbers, it is probably best not to publish it or at least not to evaluate its results at all.
  • If the researchers insist on publishing it, their paper should focus on the reason why it did not succeed so that others can learn from their experience by avoiding their mistakes.
  • However, once the researchers do run statistical tests, they should be honest and conclude clearly that, because the primary outcome measure showed no inter-group difference, the study failed to demonstrate that the treatment is effective.
  • The trial did not “remain inconclusive”; it was squarely negative.
  • The editor of the journal HOMEOPATHY should know better than to publish such nonsense.

A final thought: is it perhaps the ultimate proof of homeopathy’s ‘like cures like’ assumption to use sound science (i.e. an RCT), submit it to the homeopathic process of endless dilutions and succussions, and – BINGO – generate utter nonsense?

This prospective study aimed to identify an optimal lifestyle profile to protect against memory loss in older individuals from areas representative of the north, south, and west of China. Individuals aged 60 years or older who had normal cognition and underwent apolipoprotein E (APOE) genotyping at baseline in 2009 were included. Participants were followed up until death, discontinuation, or 26 December 2019.

Six lifestyle factors were assessed:

  • a healthy diet (adherence to the recommended intake of at least 7 of 12 eligible food items),
  • regular physical exercise (≥150 min of moderate intensity or ≥75 min of vigorous intensity, per week),
  • active social contact (≥twice per week),
  • active cognitive activity (≥twice per week),
  • never or previously smoked,
  • never drinking alcohol.

Participants were categorised into the favourable group if they had 4-6 healthy lifestyle factors, into the average group for two to three factors, and into the unfavourable group for zero to one factor.

Memory function was assessed using the World Health Organization/University of California-Los Angeles Auditory Verbal Learning Test, and global cognition was assessed via the Mini-Mental State Examination. Linear mixed models were used to explore the impact of lifestyle factors on memory in the study sample.

A total of 29 072 participants were included (mean age of 72.23 years; 48.54% (n=14 113) were women; and 20.43% (n=5939) were APOE ε4 carriers). Over the 10-year follow-up period (2009-19), participants in the favourable group had slower memory decline than those in the unfavourable group (by 0.028 points/year, 95% confidence interval 0.023 to 0.032, P<0.001). APOE ε4 carriers with favourable (0.027, 95% confidence interval 0.023 to 0.031) and average (0.014, 0.010 to 0.019) lifestyles exhibited a slower memory decline than those with unfavourable lifestyles. Among people who were not carriers of APOE ε4, similar results were observed among participants in the favourable (0.029 points/year, 95% confidence interval 0.019 to 0.039) and average (0.019, 0.011 to 0.027) groups compared with those in the unfavourable group. APOE ε4 status and lifestyle profiles did not show a significant interaction effect on memory decline (P=0.52).

The authors concluded that a healthy lifestyle is associated with slower memory decline, even in the presence of the APOE ε4 allele. This study might offer important information to protect older adults against memory decline.

This is an important and meticulously reported study. It is the first large-scale investigation that assesses the effects of different lifestyle profiles, APOE ε4 status, and their interactions on longitudinal memory trajectories over a 10-year follow-up period. The results show that lifestyle is associated with the rate of memory decline in cognitively normal older individuals, including in people who are genetically susceptible to memory decline. The authors are rightly careful to avoid causal inferences between lifestyle and memory decline. To demonstrate causality beyond doubt, we would need different study designs.

The authors also discuss several weaknesses of the study:

  • Firstly, the assessments of lifestyle factors were based on self-reports and are, therefore, prone to measurement errors.
  • Secondly, several participants were excluded due to missing data or not returning for follow-up evaluations, which might have led to selection bias.
  • Thirdly, the proportion of individuals with an unhealthy lifestyle might have been underestimated in the study because people with poor health were less likely to have participated in the study.
  • Fourthly, given the nature of the study design, it could not assess whether maintaining a healthy lifestyle had already started influencing memory by the time of enrolment in the study.
  • Fifthly, the evaluation of memory using a single neuropsychological test that does not comprehensively reflect overall memory function. However, the Auditory Verbal Learning Test is an effective instrument for memory assessment, and a composite score was used based on four Auditory Verbal Learning Test subscales to represent memory conditions to the greatest extent possible.
  • Sixthly, as participants might become familiar with repeated cognitive testing, a learning effect could have influenced the results.
  • Finally, memory decline was studied solely among older adults; however, memory problems commonly affect young individuals as well.

The authors, therefore, state that further studies should be conducted to facilitate a more extensive investigation into the effects of a healthy lifestyle on memory decline across the lifespan. This approach would help to elucidate the crucial age window during which a healthy lifestyle can exert the most favourable effect.

The UK mainstream media have so far failed to report on this new and highly worrying development: in a rare show of unity, the UK practitioners of so-called alternative medicine (SCAM) have formed the ‘SCAM Union’ (SCAMU) – pronounced ‘scam you’ – and decided to go on strike. Their demands are straightforward:

  1. increase pay in line with inflation;
  2. full recognition of their profession;
  3. right to regular 15 min tai chi breaks.

Already last week, they staged a two-day nationwide walkout.

  • Homeopaths stopped seeing patients and some had to start taking remedies at the C 2000 potency to keep calm but NOBODY NOTICED AND THE EFFECT ON THE NATIONS HEALTH WAS NOT NOTICABLE.
  • Chiropractors did not adjust a single subluxation and started cracking jokes instead but NOBODY NOTICED AND THE EFFECT ON THE NATIONS HEALTH WAS NOT NOTICABLE.
  • Naturopaths failed to detox a single patient but NOBODY NOTICED AND THE EFFECT ON THE NATIONS HEALTH WAS NOT NOTICABLE.
  • Crystal healers kept their crystals under wraps but NOBODY NOTICED AND THE EFFECT ON THE NATIONS HEALTH WAS NOT NOTICABLE.
  • Osteopath mobilized not a single joint but NOBODY NOTICED AND THE EFFECT ON THE NATIONS HEALTH WAS NOT NOTICABLE.
  • Acupuncturists failed to insert a single needle but NOBODY NOTICED AND THE EFFECT ON THE NATIONS HEALTH WAS NOT NOTICABLE.
  • Vaginal steamers only steamed the odd dim sum for lunch but NOBODY NOTICED AND THE EFFECT ON THE NATIONS HEALTH WAS NOT NOTICABLE.
  • Ear candlers did not light a single candle and instead aligned them in a visual picket line but NOBODY NOTICED AND THE EFFECT ON THE NATIONS HEALTH WAS NOT NOTICABLE.
  • Aromatherapists refused to open any bottles with essential oil but NOBODY NOTICED AND THE EFFECT ON THE NATIONS HEALTH WAS NOT NOTICABLE.
  • Herbalists simply said ‘Thyme will tell’ but NOBODY NOTICED AND THE EFFECT ON THE NATIONS HEALTH WAS NOT NOTICABLE.
  • Bach flower therapists had to consume their own Rescue Remedies in large quantities but NOBODY NOTICED AND THE EFFECT ON THE NATIONS HEALTH WAS NOT NOTICABLE.
  • Holistic practitioners claimed to be wholly distraught but NOBODY NOTICED AND THE EFFECT ON THE NATIONS HEALTH WAS NOT NOTICABLE.

Perhaps the most outrageous thing about these events is that the UK press studiously ignored the all-out strike (one broadsheet editor commented: “if it’s not about Megan, we are not interested). Merely King Charles seemed alarmed and was overheard privately mumbling to Camilla: “What next?”

 

 

PS

I have been told that some of my readers have difficulties knowing when I am pulling their legs. So, let me confirm: every word here is uninvented – or was that uninventive?

About 3 years ago, I reported that the Bavarian government had decided to fund research into the question of whether the use of homeopathy would reduce the use of antibiotics (an idea that also King Charles fancies). With the help of some friends, I found further details of the project. Here are some of them:

The study on individualized homeopathic treatment to reduce the need for antibiotics in patients with recurrent urinary tract infections is a randomized, placebo-controlled, multicenter, double-blind trial. Frequent urinary tract infections (more than two infections within six months or more than three infections within twelve months) occur in up to three percent of all women during their lifetime and represent a high risk for increased antibiotic use in this population.
The current guidelines therefore also provide for therapeutic approaches without antibiotic administration under close monitoring. The approach to be investigated in the study is the administration of a homeopathic medicine individually selected for the patient for prophylaxis. The number of urinary tract infections and the need for antibiotics will be recorded and evaluated at the end of the trial period, around mid to late 2023.
The aim of the study is to find out whether patients taking homeopathics need antibiotics for the treatment of urinary tract infections less often compared to the placebo group. This could lead to a reduction in the use of antibiotics for recurrent urinary tract infections.

Project participants: Technical University of Munich, Klinikum Rechts der Isar

Project funding: 709,480.75 Euros

Project duration: January 1, 2021 to December 31, 2023

____________________

This sketch is of course not enough for providing a full evaluation of the study concept (if someone has more details, I’d be interested to learn more). From the little information given above, I feel that:

  • the design of the trial might be quite rigorous,
  • a fairly large sample will be required to have enough power,
  • the closing date of 31/12/2023 seems optimistic (but this obviously depends on the number of centers cooperating),
  • I, therefore, predict that we will have to wait a long time for the results (the pandemic and other obstacles will have delayed recruitment),
  • the costs of the trial are already substantial and might increase due to delays etc.

My main criticism of the study is that:

  • I see no rationale for doing such a trial,
  • there is no evidence to suggest that homeopathy might prevent recurrent urinary tract infections,
  • there is compelling evidence that homeopathic remedies are placebos,
  • the study thus compares one placebo with another placebo (in fact, it is a classic example of what my late friend Harriet Hall would have called TOOTH FAIRY SCIENCE),
  • therefore, its results will show no difference between the 2 groups (provided the trial was conducted without bias),
  • if that is true, enthusiastic homeopaths will claim that the homeopathic verum was inadequate (e.g. because the homeopaths prescribing the verum did not or could not do their job properly),
  • when that happens, they will therefore not stop claiming that homeopathy can reduce the over-prescribing of antibiotics;
  • that means we will be exactly where we were before the trial.

In other words, the study will turn out to be a waste of 709,480.75 Euros. To express it as I did in my previous post: the Bavarian government has gone barmy!

 

 

This study examined the incidence and severity of adverse events (AEs) of patients receiving chiropractic spinal manipulative therapy (SMT), with the hypothesis that < 1 per 100,000 SMT sessions results in a grade ≥ 3 (severe) AE. A secondary objective was to examine independent predictors of grade ≥ 3 AEs.

The researchers retrospectively identified patients with SMT-related AEs from January 2017 through August 2022 across 30 chiropractic clinics in Hong Kong. AE data were extracted from a complaint log, including solicited patient surveys, complaints, and clinician reports, and corroborated by medical records. AEs were independently graded 1–5 based on severity (1-mild, 2-moderate, 3-severe, 4-life-threatening, 5-death).

Among 960,140 SMT sessions for 54,846 patients, 39 AEs were identified, two were grade 3, both of which were rib fractures occurring in women age > 60 with osteoporosis, while none were grade ≥ 4, yielding an incidence of grade ≥ 3 AEs of 0.21 per 100,000 SMT sessions (95% CI 0.00, 0.56 per 100,000). There were no AEs related to stroke or cauda equina syndrome. The sample size was insufficient to identify predictors of grade ≥ 3 AEs using multiple logistic regression.

The authors concluded that, in this study, severe SMT-related AEs were reassuringly very rare.

This is good news for all patients who consult chiropractors. However, there seem to be several problems with this study:

  • Data originated from 30 affiliated chiropractic clinics with 38 chiropractors (New York Chiropractic & Physiotherapy Center, EC Healthcare, Hong Kong). These clinics are integrated into a larger healthcare organization, including several medical specialties and imaging and laboratory testing centers that utilize a shared medical records system. The 38 chiropractors represent only a little more than 10% of all chiropractors working in Hanh Kong and are thus not representative of all chiropractors in that region. Is it possible that the participating chiropractors were better trained, more gentle, or more careful than the rest?
  • Data regarding AEs was obtained from a detailed complaint log that was routinely aggregated from several sources by a customer service department. One source of AEs in this log was a custom survey administered to patients after their 1st, 2nd, and 16th visits. Additional AEs derived from follow-up phone calls by a personal health manager. This means that not all AE might have been noted. Some patients might not have complained, others might have been too ill to do so. And, of course, dead patients cannot complain. The authors state that “the response to the SMS questionnaire was low. It is possible that severe AEs occurred but were not reported or recorded through these or other methods of ascertainment”.
  • The 39 AEs potentially related to chiropractic SMT included increased symptoms related to the patient’s chief complaint (n = 28), chest pain without a fracture on imaging (n = 4), jaw pain (n = 3), rib fracture confirmed by imaging (n = 2), headache and dizziness without evidence of stroke (n = 1), and new radicular symptoms (n = 1). Of the 39 AEs, grade 2 were most common (n = 32, 82%), followed by grade 1 (n = 5, 13%), and grade 3 (n = 2, 5%). There were no cases of stroke, transient ischemic attack (TIA), vertebral or carotid artery dissection, cauda equina syndrome, or spinal fracture. Yet, headache and dizziness could be signs of a TIA.
  • Calculating the rate of AEs per SMT session might be misleading and of questionable value. Are incidence rates of AEs not usually expressed as AE/patient? In this case, the % rate would be almost 20 times higher.

Altogether, this is a laudable effort to generate evidence for the risks of SMT. The findings seem reassuring but sadly they are not fully convincing.

 

The McTimoney College of Chiropractic just announced that it has established a new four-year program in veterinary chiropractic for college students:

It means that those without a prior degree can undertake the training and education necessary to enter this coveted career. To date, animal chiropractors were required to have a prior qualification in human chiropractic or a degree in the relevant sciences.

Applications for the new program are being accepted from September 2023. Students will attend Abingdon-based University, Oxford, and a variety of practical locations, enabling the development of academic knowledge and the application of practical skills together . Modules include anatomy and physiology, veterinary science, practice and professionalism, and clinical skills, with a research dissertation running over the four-year course.

University director Christina Cunliffe said the new program was an exciting step in the development of chiropractic care for animals.

“Building on our decades of experience graduating confident, competent, and highly-skilled animal chiropractors, now is the time to open up this exciting career opportunity to college students.”

For the past 50 years, McTimoney College of Chiropractic has been training and educating human chiropractors to the highest regulatory standards. Over the past 20 years, animal chiropractic has developed to meet the requirements for this gentle, holistic treatment in the veterinary world.

Prospective students are invited to a Open House at McTimoney College of Chiropractic in Abingdon on February 16.

McTimoney Chiropractic for Animals identifies areas of stiffness, asymmetry, and poor range of motion within the skeletal system, particularly the spine and pelvis. This affects the muscles that surround these structures, as well as the nerve impulses that pass from the central nervous system to the periphery of the body. The adjustments are very light and fast, stimulating an instant response in the affected soft tissues and joints, promoting relaxation of muscle spasms, improving nerve function, and helping the skeletal structure regain better symmetry and movement again.

In many cases, animals suffer from underlying conditions such as arthritic changes or degenerative diseases that force them to compensate in their posture and movement in an attempt to remain comfortable. However, these offsets become increasingly entrenched and can be painful or uncomfortable, requiring chiropractic care to provide some relief. In other cases, the animals are working hard or competing and as such accumulate tension and asymmetries due to the demands of their work. Once again, chiropractic care helps relieve pain and promote performance, whether it’s faster speeds over hurdles for racehorses and events, better jumping style in showjumpers, or more extravagant movements for dressage stars.

Two recent graduates of the school’s Master of Animal Handling (Chiropractic) program did not hesitate to recommend the university. Natalie McQuiggan said that she had wanted to do McTimoney Chiropractic from a very young age, “but the process of doing it always seemed really daunting.

“But from the start, the staff and teachers were lovely and welcoming, and queries were answered promptly. I have really enjoyed my two years in the Master of Animal Handling (Chiropractic) program and would recommend anyone thinking of doing it to just do it.”

Pollyanna Fitzgerald said the university offered a supportive and welcoming learning environment, allowing her to grow and develop as a student and future professional. “There is always someone to talk to and offer encouragement when needed. As a student I have learned a lot and have been encouraged to believe in myself and it has been a wonderful place to learn.”

A free webinar, McTimoney’s Animal Chiropractic as a Careeron January 24 at 7:30 p.m. (GMT), is open to those who wish to learn more about the McTimoney technique and its application, and the training paths available to those interested in becoming a McTimoney Animal Chiropractor.

________________________

I think this announcement is puzzling on several levels:

  1. I was unable to find an ‘Abingdon-based University, Oxford’; could it be this institution that is a college and not a university?
  2. Christina Cunliffe seems to be (or has been?) affiliated with the McTimoney College of Chiropractic which is a bit odd, in my opinion.
  3. The college does not have ‘decades of experience’; it was founded only in 2001.
  4. Most importantly, I am unable to find a jot of good evidence that veterinary chiropractic is effective for any condition (see also here, here, and here). In case anyone is aware of any, please let me know. I’d be delighted to revise my judgment.

If I am right, the new course could be a fine example of quackademia where students are ripped off and taught to later rip off the owners of animals after the academically trained quacks have mistreated them.

Migraines are common headache disorders and risk factors for subsequent strokes. Acupuncture has been widely used in the treatment of migraines; however, few studies have examined whether its use reduces the risk of strokes in migraineurs. This study explored the long-term effects of acupuncture treatment on stroke risk in migraineurs using national real-world data.

A team of Taiwanese researchers collected new migraine patients from the Taiwan National Health Insurance Research Database (NHIRD) from 1 January 2000 to 31 December 2017. Using 1:1 propensity-score matching, they assigned patients to either an acupuncture or non-acupuncture cohort and followed up until the end of 2018. The incidence of stroke in the two cohorts was compared using the Cox proportional hazards regression analysis. Each cohort was composed of 1354 newly diagnosed migraineurs with similar baseline characteristics. Compared with the non-acupuncture cohort, the acupuncture cohort had a significantly reduced risk of stroke (adjusted hazard ratio, 0.4; 95% confidence interval, 0.35–0.46). The Kaplan–Meier model showed a significantly lower cumulative incidence of stroke in migraine patients who received acupuncture during the 19-year follow-up (log-rank test, p < 0.001).

The authors concluded that acupuncture confers protective benefits on migraineurs by reducing the risk of stroke. Our results provide new insights for clinicians and public health experts.

After merely 10 minutes of critical analysis, ‘real-world data’ turn out to be real-bias data, I am afraid.

The first question to ask is, were the groups at all comparable? The answer is, NO; the acupuncture group had

  • more young individuals;
  • fewer laborers;
  • fewer wealthy people;
  • fewer people with coronary heart disease;
  • fewer individuals with chronic kidney disease;
  • fewer people with mental disorders;
  • more individuals taking multiple medications.

And that are just the variables that were known to the researcher! There will be dozens that are unknown but might nevertheless impact on a stroke prognosis.

But let’s not be petty and let’s forget (for a minute) about all these inequalities that render the two groups difficult to compare. The potentially more important flaw in this study lies elsewhere.

Imagine a group of people who receive some extra medical attention – such as acupuncture – over a long period of time, administered by a kind and caring therapist; imagine you were one of them. Don’t you think that it is likely that, compared to other people who do not receive this attention, you might feel encouraged to look better after your health? Consequently, you might do more exercise, eat more healthily, smoke less, etc., etc. As a result of such behavioral changes, you would be less likely to suffer a stroke, never mind the acupuncture.

SIMPLE!

I am not saying that such studies are totally useless. What often renders them worthless or even dangerous is the fact that the authors are not more self-critical and don’t draw more cautious conclusions. In the present case, already the title of the article says it all:

Acupuncture Is Effective at Reducing the Risk of Stroke in Patients with Migraines: A Real-World, Large-Scale Cohort Study with 19-Years of Follow-Up

My advice to researchers of so-called alternative medicine (SCAM) and journal editors publishing their papers is this: get your act together, learn about the pitfalls of flawed science (most of my books might assist you in this process), and stop misleading the public. Do it sooner rather than later!

Chronic kidney disease is common, often progressive, and difficult to treat or prevent. Effective interventions would therefore be more than welcome. This paper explored the relation of habitual fish oil use with the risk of chronic kidney diseases (CKD).

A total of 408,023 participants (54.2% female) without prior CKD and with completed information regarding their consumption of major food groups and fish oil in the UK Biobank were enrolled. Fish oil use and dietary intakes were assessed by touch screen questionnaire and food frequency questionnaire, respectively. Incident CKD was recorded from hospital inpatient records.

At baseline, 128,843 (31.6%) participants reported taking fish oil supplements. During a median follow-up period of 12.0 years, a total of 10,782 (2.6%) participants developed CKD. With adjustments for important confounders, habitual fish oil use was associated with a significantly lower hazard of incident CKD (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.87-0.95), compared with non-use. Consistently, participants reporting ≥2 servings/week of oily fish (HR, 0.86; 95% CI, 0.79-0.94) and nonoily fish (HR, 0.86; 95% CI, 0.77-0.97) consumption had a lower hazard of incident CKD compared to those reporting no consumption ever. Additionally, among the 97,914 participants with data on plasma fatty acid, there were significant inverse relationships of plasma omega-3 polyunsaturated fatty acid (PUFA) (per SD increment, HR, 0.89, 95% CI, 0.84-0.94) and eicosatetraenoic acid (per SD increment, HR, 0.91, 95% CI, 0.87-0.96) with incident CKD.

The authors concluded that habitual fish oil use was associated with a lower hazard of CKD, which was further confirmed by the consistent inverse relations between fish consumption and circulating omega-3 PUFA concentration with incident CKD.

I like this paper! It shows in an exemplary fashion how to interpret an association between two variables: fish oil consumption does not necessarily CAUSE the lower risk, it is merely associated with it and there might be a number of non-causal explanations for the link. Whether there is a true cause-effect relationship needs to be investigated in further, differently designed studies. The present paper does not overstate its conclusions but it is nevertheless important, as it hopefully will prompt others to clarify the crucial issue of causality.

Wouldn’t it be nice, if researchers of so-called alternative medicine (SCAM) finally learned this simple lesson?

On 20/1/2023, I conducted multiple Medline searches aimed at generating a rough idea about which areas of so-called alternative medicine (SCAM) are currently more research active than others. I searched for:

  1. the topic in question
  2. clinical trial
  3. publication in 2023

Here are my findings (subject area and the number of hits):

  • TCM 56
  • dietary supplements 47
  • acupuncture 34
  • integrative medicine 27
  • mindfulness 26
  • herbal medicine 23
  • massage 10
  • aromatherapy 2
  • hypnotherapy 2
  • osteopathy 2
  • tai chi 2
  • chiropractic 1
  • homeopathy 0
  • iridology 0
  • naturopathy 0
  • Reiki 0

Several caveats must be considered, of course: The searches do not include all SCAMs. The results are not precise and most of the retrieved articles are not really clinical trials (in fact, only a minority are). The numbers are low because I deliberately did this exercise early in the year.

Yet, the findings do, I think, give an indication as to the current state of SCAM research and indicate which areas are more research active than others. To put the numbers in perspective, here are a few conventional therapies for which I searched on the same day and in the same manner:

  • pharmacology 539
  • physiotherapy 162
  • psychiatry 239
  • surgery 879

I think this makes one point fairly clear: SCAM is not an impressively research-active area. Another point stems from looking at the individual articles. TCM and acupuncture articles are almost exclusively authored by Chinese researchers. While this might not be surprising, the fact that herbal medicine is similar did amaze me; about half of the papers in this category are by Chinese authors. Essentially, this suggests that more than half of the SCAM articles currently originate from China. Considering the concerns one must have about Chinese SCAM research (see for instance here and here), do you think this finding might be worrying?

The far greater worry, I feel, is the attitude of the SCAM researchers publishing their work. Glancing at these papers I did not get the impression that many approached their subject critically, In fact, most of the papers looked to me overtly promotional and of poor quality. For instance, I did not see a single paper assessing the risks of SCAM which arguably is the most important issue in SCAM research. I admit that these concerns cannot be addressed by the above simple head count; they are best dealt with by critically analyzing individual studies – a task I regularly try to tackle on this blog

 

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