The General Chiropractic Council (GCC) is the statutory body regulating all chiropractors in the UK. Their foremost aim, they claim, is to ensure the safety of patients undergoing chiropractic treatment. They also allege to be independent and say they want to protect the health and safety of the public by ensuring high standards of practice in the chiropractic profession.
That sounds good and (almost) convincing.
But is the GCC truly fit for purpose?
In a previous post, I found good reason to doubt it.
In a recent article, the GCC claimed that they started thinking about a new five-year strategy and began to shape four key strategic aims. So, let’s have a look. Here is the crucial passage:
A clear strategy is vital but, of course, implementation and getting things changed are where the real work lie. With that in mind, we have a specific business plan for 2019 – the first year of the new strategic plan. You can read it here. This means you’ll see some really important changes and benefits including:
- Promote standards: review and improvements to CPD processes, supporting emerging new degree providers, a campaign to promote the public choosing a registered chiropractor
- Develop the profession: supporting and enabling work with the professional bodies
- Investigate and act: a full review of, and changes to, our Fitness to Practice processes to enable a more ‘right touch’ approach within our current legal framework, sharing more learning from the complaints we receive
- Deliver value: a focus on communication and engagement, further work on our culture, a new website, an upgraded registration database for an improved user experience.
The changes being introduced, backed by the GCC’s Council, will have a positive effect. I know Nick, the new Chief Executive and Registrar and the staff team will make this a success. You as chiropractors also have an important role to play – keep engaging with us and take your own action to develop the profession, share your ideas and views as we transform the organisation, and work with us to ensure we maintain public confidence in the profession of chiropractic.
END OF QUOTE
Am I the only one who finds this more than a little naïve and unprofessional? More importantly, this statement hints at a strategy mainly aimed at promoting chiropractors regardless of whether they are doing more good than harm. This, it seems, is not in line with the GCC’s stated aims.
- How can they already claim that the changes being introduced will have a positive effect?
- Where in this strategy is the GCC’s alleged foremost aim, the protection of the public?
- Where is any attempt to get chiropractic in line with the principles of EBM?
- Where is an appeal to chiropractors to adopt the standards of medical ethics?
- Where is an independent and continuous assessment of the effectiveness of chiropractic?
- Where is a critical evaluation of its safety?
- Where is an attempt to protect the public from the plethora of bogus claims made by UK chiropractors?
I feel that, given the recent history of UK chiropractic, these (and many other) points should be essential elements in any long-term strategy. I also feel that this new and potentially far-reaching statement provides little hope that the GCC is on the way towards getting fit for purpose.
Spinal epidural haematoma (SEH) is an uncommon but serious emergency condition. A team of emergency physicians reported the case of a SEH associated with traditional massage initially presenting with delayed lower paraplegia.
A 20-year-old man was seen with bilateral lower extremity weakness and numbness, symptoms that had started three hours prior to presentation. He had received a Thai massage by a friend three days before. Magnetic resonance imaging revealed a spinal epidural lesion suspicious for haematoma extending from C6 to T2 levels. Emergent surgical intervention for cord decompression was performed. An epidural haematoma with cord compression at C6-T2 levels was identified intra-operatively. No evidence of abnormal vascular flow or AV malformations was identified. The authors concluded that, similar to chiropractic manipulation, massage may be associated with spinal trauma. Emergency physicians must maintain a high index of suspicion for spinal epidural haematomas in patients with a history of massage or chiropractic manipulation with neurologic complaints, because delays in diagnosis may worsen clinical outcome.
Thai massage therapists typically use no lubricants. The patient remains clothed during a treatment. There is constant body contact between the therapist – who, in the above case, was a lay person – and the patient.
The authors of this case report rightly stress that such adverse events are rare – but they are by no means unknown. In 2003, I reviewed the risks and found 16 reports of adverse effects as well as 4 case series on the subject (like for all other manual therapies, there is no reporting system of adverse effects). The majority of adverse effects were – like the above case – associated with exotic types of manual massage or massage delivered by laymen. Professionally trained massage therapists were rarely implicated. The reported adverse events include cerebrovascular accidents, displacement of a ureteral stent, embolization of a kidney, haematoma, leg ulcers, nerve damage, posterior interosseous syndrome, pseudoaneurism, pulmonary embolism, ruptured uterus, strangulation of neck, thyrotoxicosis and various pain syndromes. In the majority of these instances, there was little doubt about a cause-effect relationship. Serious adverse effects were associated mostly with massage techniques other than ‘Swedish’ massage.
For patients, this means that massage is still amongst the safest form of manual therapy (best to employ qualified therapists and avoid the exotic versions of massage because they are not supported by evidence and carry the highest risks). For doctors, it means to be vigilant, if patients present with neurological problems after having enjoyed a massage.
Chiropractors believe that their spinal manipulations bring about a reduction in pain perception, and they often call this ‘manipulation-induced hypoalgesia’ (MIH). It is unknown, however, whether MIH following high-velocity low-amplitude spinal manipulative therapy is a specific and clinically relevant treatment effect.
This systematic review was an effort in finding out.
The authors investigated changes in quantitative sensory testing measures following high-velocity low-amplitude spinal manipulative therapy in musculoskeletal pain populations, in randomised controlled trials. Their objectives were to compare changes in quantitative sensory testing outcomes after spinal manipulative therapy vs. sham, control and active interventions, to estimate the magnitude of change over time, and to determine whether changes are systemic or not.
Fifteen studies were included. Thirteen measured pressure pain threshold, and 4 of these were sham-controlled. Change in pressure pain threshold after spinal manipulative therapy compared to sham revealed no significant difference. Pressure pain threshold increased significantly over time after spinal manipulative therapy (0.32 kg/cm2, CI 0.22–0.42), which occurred systemically. There were too few studies comparing to other interventions or for other types of quantitative sensory testing to make robust conclusions about these.
The authors concluded that they found that systemic MIH (for pressure pain threshold) does occur in musculoskeletal pain populations, though there was low quality evidence of no significant difference compared to sham manipulation. Future research should focus on the clinical relevance of MIH, and different types of quantitative sensory tests.
An odd conclusion, if there ever was one!
A more straight forward conclusion might be this:
MIH is yet another myth to add to the long list of bogus claims made by chiropractors.
Oscillococcinum is by now well-known to readers of this blog, I am sure (see for instance here, here and here). It seems an important topic, not least because the infamous duck-placebo is the world’s best-selling homeopathic remedy. Just how popular it is was recently shown in a survey by the formidable ‘Office for Science and Society’ of the McGill University in Canada.
The researchers surveyed the five biggest pharmacy chains in Quebec: Jean-Coutu, Familiprix, Uniprix, Proxim, and Pharmaprix. For each chain, a sample of 30 pharmacies was chosen by a random number generator.
The calls started with the following script: “I would like to know if you carry a certain homeopathic remedy. It’s called Oscillococcinum, it’s a homeopathic remedy against the flu made by Boiron.” If they did not have it, the investigator asked if this was something they normally carried. He spoke to either a floor clerk or a member of the pharmacy staff behind the counter, depending on who knew the answer.
Out of the 150 pharmacies on the island of Montreal that were called for this investigation, 66% of them reported carrying Oscillococcinum (30% did not, while 4% could not be reached, often because the listed pharmacy had closed). Some chains were more likely to sell the product, with Jean-Coutu and Pharmaprix being the most likely (80% of their stores had it) and Proxim being the least likely (50% of their stores carried it).
The McGill researcher stated that the fact that two-thirds of Montreal-based pharmacies will sell us a pseudo-treatment for the flu that targets adults, children and infants alike is hard to square with the Quebec Order of Pharmacists’ mission statement. They describe said mission as “ensuring the protection of the public”, but how is the public protected when pharmacies are selling them placebo pills? The harm is partly financial: 30 doses of these worthless globules retail for CAD 36. It is also in the false sense of security parents will gain and the delay in proper treatment if needed. And, ultimately, it is in the legitimization of a pseudoscience the founding principle of which is that the more you add water to something (like alcohol), the more powerful it becomes.
I can only full-heartedly agree. One might even add a few more things, for instance that there are other dangers as well:
- If pharmacists put commercial gain before medical ethics, we might find it hard to trust this profession.
- If people take Oscillococcinum and their condition subsequently disappears (because of the self-limiting nature of the disease), they might believe that homeopathy is effective and consequently use it for much more serious conditions – with grave consequences, I hasten to add.
- If consumers thus start trusting homeopaths, they might also fall for some of their abominable health advice, e. g. that about not vaccinating their children.
- If a sufficiently large percentage of people believe in the magic of shaken water, our rationality will be undermined and we will encounter phenomena like Brexit or fascists as presidents (sorry, I has to get that off my chest).
Chronic back pain is often a difficult condition to treat. Which option is best suited?
A review by the US ‘Agency for Healthcare Research and Quality’ (AHRQ) focused on non-invasive nonpharmacological treatments for chronic pain. The following therapies were considered:
- mind-body practices,
- psychological therapies,
- multidisciplinary rehabilitation,
- mindfulness practices,
- manual therapies,
- physical modalities,
Here, I want to share with you the essence of the assessment of spinal manipulation:
- Spinal manipulation was associated with slightly greater effects than sham manipulation, usual care, an attention control, or a placebo intervention in short-term function (3 trials, pooled SMD -0.34, 95% CI -0.63 to -0.05, I2=61%) and intermediate-term function (3 trials, pooled SMD -0.40, 95% CI -0.69 to -0.11, I2=76%) (strength of evidence was low)
- There was no evidence of differences between spinal manipulation versus sham manipulation, usual care, an attention control or a placebo intervention in short-term pain (3 trials, pooled difference -0.20 on a 0 to 10 scale, 95% CI -0.66 to 0.26, I2=58%), but manipulation was associated with slightly greater effects than controls on intermediate-term pain (3 trials, pooled difference -0.64, 95% CI -0.92 to -0.36, I2=0%) (strength of evidence was low for short term, moderate for intermediate term).
This seems to confirm what I have been saying for a long time: the benefit of spinal manipulation for chronic back pain is close to zero. This means that the hallmark therapy of chiropractors for the one condition they treat more often than any other is next to useless.
But which other treatments should patients suffering from this frequent and often agonising problem employ? Perhaps the most interesting point of the AHRQ review is that none of the assessed nonpharmacological treatments are supported by much better evidence for efficacy than spinal manipulation. The only two therapies that seem to be even worse are traction and ultrasound (both are often used by chiropractors). It follows, I think, that for chronic low back pain, we simply do not have a truly effective nonpharmacological therapy and consulting a chiropractor for it does make little sense.
What else can we conclude from these depressing data? I believe, the most rational, ethical and progressive conclusion is to go for those treatments that are associated with the least risks and the lowest costs. This would make exercise the prime contender. But it would definitely exclude spinal manipulation, I am afraid.
And this beautifully concurs with the advice I recently derived from the recent Lancet papers: walk (slowly and cautiously) to the office of your preferred therapist, have a little rest there (say hello to the staff perhaps) and then walk straight back home.
The notion that ‘chiropractic adds years to your life’ is often touted, particularly of course by chiropractors (in case you doubt it, please do a quick google search). It is logical to assume that chiropractors themselves are the best informed about what they perceive as the health benefits of chiropractic care. Chiropractors would therefore be most likely to receive some level of this ‘life-prolonging’ chiropractic care on a long-term basis. If that is so, then chiropractors themselves should demonstrate longer life spans than the general population.
Perhaps, but is the theory supported by evidence?
Back in 2004, a chiropractor, Lon Morgan, courageously tried to test the theory and published an interesting paper about it.
He used two separate data sources to examine the mortality rates of chiropractors. One source used obituary notices from past issues of Dynamic Chiropractic from 1990 to mid-2003. The second source used biographies from Who Was Who in Chiropractic – A Necrology covering a ten year period from 1969-1979. The two sources yielded a mean age at death for chiropractors of 73.4 and 74.2 years respectively. The mean ages at death of chiropractors is below the national average of 76.9 years; it also is below the average age at death of their medical doctor counterparts which, at the time, was 81.5.
So, one might be tempted to conclude that ‘chiropractic substracts years from your life’. I know, this would be not very scientific – but it would probably be more evidence-based than the marketing gimmick of so many chiropractors trying to promote their trade by saying: ‘chiropractic adds years to your life’!
In any case, Morgan, the author of the paper, concluded that this paper assumes chiropractors should, more than any other group, be able to demonstrate the health and longevity benefits of chiropractic care. The chiropractic mortality data presented in this study, while limited, do not support the notion that chiropractic care “Adds Years to Life …”, and it fact shows male chiropractors have shorter life spans than their medical doctor counterparts and even the general male population. Further study is recommended to discover what factors might contribute to lowered chiropractic longevity.
Another beautiful theory killed by an ugly fact!
The German Association of Medical Homeopaths (Deutscher Zentralverein homöopathischer Ärzte (DZVhÄ)) have recently published an article where, amongst other things, they lecture us about evidence-based medicine (EBM). If you feel that this might be a bit like an elephant teaching Fred Astaire how to step-dance, you could have a point. Here is their relevant paragraph:
… das Konzept der modernen Evidenzbasierte Medizin nach Sackett [stützt sich] auf drei Säulen: auf die klinischen Erfahrung der Ärzte, auf die Werte und Wünsche des Patienten und auf den aktuellen Stand der klinischen Forschung. Homöopathische Ärzte wehren sich gegen einen verengten Evidenzbegriff der Kritiker, der Evidenz allein auf die Säule der klinischen Forschung bzw. ausschließlich auf RCT verengen möchte und die anderen beiden Säulen ausblendet. Experten schätzen, dass bei einer solchen Auffassung von EbM rund 70 Prozent aller Leistungen der GKV nicht evidenzbasiert sei. Nötiger als eine Homöopathie-Debatte hat die deutsche Ärzteschaft aus unserer Sicht eine klare Verständigung darüber, welcher Evidenzbegriff nun gilt.
For those who cannot understand the full splendour of their argument because of the language problem, I translate as literally as I can:
… the concept of the modern EBM according to Sackett is based on three pillars: on the clinical experience of the doctors, on the values and wishes of the patient and on the current state of the clinical research. Homeopaths defend themselves against the narrowed understanding of ‘evidence’ of the critics which aims at narrowing evidence solely to the pillar of the clinical research or exclusively to RCT, while eliminating the other two pillars. Experts estimate that, with such an view of EBM, about 70% of all treatments reimbursed by our health insurances would not be evidence-based. We feel that we more urgently need a clear understanding which evidence definition applies than a debate about homeopathy.
END OF MY TRANSLATION
So, where is the hilarity in this?
I don’t know about you, but I find the following things worth a giggle:
- ‘narrowed understanding of evidence’ – this is a classical strawman; non-homeopaths tend to apply Sackett’s definition which states that ‘evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical experience with the best available external clinical evidence from systematic research‘;
- as we see, Sackett’s definition is quite different from the one cited by the homeopaths;
- the three pillars cited by the homeopaths are those subsequently developed for Evidence Based Practice (EBP) and include: A) patient values, B) clinical expertise and C) external best evidence;
- as we see, these three pillars are also not quite the same as those suggested by the homeopaths;
- non-homeopaths do certainly not aim at eliminating the ‘other two pillars’;
- current best evidence clearly includes much more than just RCTs – to mention RCTs in this context therefore suggests that the ones guilty of narrowing anything might, in fact, be the homeopaths;
- even if it were true that 70% of reimbursable treatments are not evidence-based, this would hardly be a good reason to employ homeopathic remedies of which 100% are not even remotely evidence-based;
- unbeknown to the German homeopaths, the discussion about a valid definition of EBM has been intense, is as old as EBM itself, and would by now probably fill a mid-size library;
- this discussion does, however, in no way abolish the need to bring the debate about homeopathy to the only evidence-based conclusion possible, namely the discontinuation of reimbursement of this and all other bogus therapies.
In conclusion, I do thank the German homeopaths for being such regular contributors to fun and hilarity. I shall miss them, once they have fully understood EBM and are thus compelled to stop prescribing placebos.
The 2018 World Federation of Chiropractic ACC Education Conference was held on 24-27 October in London. It resulted in several consensus statements developed by the attendees. I happen to know this from a short report that has just been published; it can be found here.
Of the 10 points made in this consensus, I find only the following noteworthy:
“Chiropractic education programs have an ethical obligation to support an evidence-based teaching and learning environment.”
Perhaps it is me – English is not my first language – but I find the phraseology used in this sentence strangely complicated and confusing. I have been a teacher of medical students for most of my life, but I am not sure what an ‘evidence-based teaching and learning environment’ is. I know what ‘evidence-based’ means, of course. However, what exactly is:
- a teaching environment?
- a learning environment?
- and how does ‘evidence-based’ apply to either of the two?
Is there evidence that some environments are better suited than others for teaching?
Is there evidence that some environments are better suited than others for learning?
I suppose the answer must be YES!
The environment, i. e. the space and conditions in which teaching and learning happen should, for instance, be/include:
- not cramped,
- not too cold,
- not too hot,
- equipped with ergometric chairs and desks,
- there should be visual aids,
- access to computers,
- a library,
- good mentoring and support,
So, the consensus of the education conference wanted to optimise the environmental conditions of teaching and learning for chiropractic lecturers and students? Most laudable, I must say!
But still, it seems like a missed opportunity for an ‘Education Conference’ not to have stated something about the content of teaching and learning. Personally, I find it a pity that they did not state: Chiropractic education programs have an ethical obligation to be evidence-based.
Or is that what they really wanted to say?
Naaahh … come to think of it … they cannot possibly make such a demand.
Because, in this case, they would have to teach students not to become chiropractors.
Slowly, I seem to be turning into a masochist! Yes, I sometimes read publications like ‘HOMEOPATHY 360’. It carries articles that are enragingly ill-informed. But in my defence, I might say that some are truly funny. Here is the abstract of one that I found outstanding in that category:
The article explains about Gangrene and its associated amputations which is a clinically challenging condition, but Homeopathy offers therapy options. The case presented herein, details about how the Homeopathic treatment helped in the prevention of amputation of a body part. Homeopathy stimulates the body’s ability to heal through its immune mechanisms; consequently, it achieves wound healing and establishes circulation to the gangrenous part. Instead of focusing on the local phenomena of gangrene pathology, treatment focuses on the general indications of the immune system, stressing the important role of the immune system as a whole. The aim was to show, through case reports, that Homeopathic therapy can treat gangrene thus preventing amputation of the gangrenous part, and hence has a strong substitution for consideration in treating gangrene.
The paper itself offers no less than 13 different homeopathic treatments for gangrene:
- Arsenicum album– Medicine for senile gangrene;gangrene accompanied by foetid diarrhoea; ulcers extremely painful with elevated edges, better by warmth and aggravation from cold; great weakness and emaciation.
- Bromium – Hospital gangrene; cancerous ulcers on face; stony hard swelling of glands of lower jaw and throat.
- Carbo vegetabilis – Senile and humid gangrene in the persons who are cachectic in appearance; great exhaustion of vital powers; marked prostration; foul smell of secretions; indolent ulcers, burning pain; tendency to gangrene of the margins; varicose ulcers.
- Bothrops– Gangrene; swollen, livid, cold with hemorrhagic infiltration; malignant erysipelas.
- Echinacea– Enlarged lymphatics; old tibial ulcers; gangrene; recurrent boils; carbuncles.
- Lachesis– Gangrenous ulcers; gangrene after injury; bluish or black looking blisters; vesicles appearing here and there, violent itching and burning; swelling and inflammation of the parts; itching pain and painful spots appearing after rubbing.
- Crotalus Horridus– Gangrene, skin separated from muscles by a foetid fluid; traumatic gangrene; old scars open again.
- Secale cornatum– Pustules on the arms and legs, with tendency to gangrene; in cachectic, scrawny females with rough skin; skin shriveled, numb; mottled dusky-blue tinge; blue color of skin; dry gangrene, developing slowly; varicose ulcers; boils, small, painful with green contents; skin feels too cold to touch yet covering is not tolerated. Great aversion to heat;formication under skin.
- Anthracinum– Gangrene; cellular tissues swollen and oedematous; gangrenous parotitis; septicemia; ulceration, and sloughing and intolerable burning.
- Cantharis – Tendency to gangrene; vesicular eruptions; burns, scalds, with burning and itching; erysipelas, vesicular type, with marked restlessness.
- Mercurius– Gangrene of the lips, cheeks and gums; inflammation and swelling of the glands of neck; pains aggravated by hot or cold applications.
- Sulphuric acid– Traumatic gangrene; haemorrhages from wounds; dark pustules; blue spots like suggillations; bedsores.
- Phosphoric acid– Medicine for senile gangrene. Gunpowder, calendula are also best medicines.
But the best of all must be the article’s conclusion: “Homeopathy is the best medicine for gangrene.”
I know, there are many people who will not be able to find this funny, particularly patients who suffer from gangrene and are offered homeopathy as a cure. This could easily kill the person – not just kill, but kill very painfully. Gangrene is the death of tissue in part of the body, says the naïve little caption. What it does not say is that it is in all likelihood also the death of the patient who is treated purely with homeopathy.
And what about the notion that homeopathy stimulates the body’s ability to heal through its immune mechanisms?
Or the assumption that it might establish circulation to the gangrenous part?
Or the claim that through case reports one can show the effectiveness of an intervention?
Or the notion that any of the 13 homeopathic remedies have a place in the treatment of gangrene?
ALL OF THIS IS TOTALLY BONKERS!
Not only that, it is highly dangerous!
Since many years, I am trying my best to warn people of charlatans who promise bogus cures. Sadly it does not seem to stop the charlatans. This makes me feel rather helpless at times. And it is in those moments that I decide to look at from a different angle. That’s when I try to see the funny side of quacks who defy everything we know about healthcare and just keep on lying to themselves and their victims.
My last post was rather depressive, and I certainly do not want my readers to be under the weather when they go into 2019. For this last post of 2018, I have therefore selected 20 events which gave me hope that perhaps we – those who prefer rationality to nonsense – are making progress.
- It has been reported that New Brunswick judge ruled this week that Canadian naturopaths — pseudoscience purveyors who promote a variety of “alternative medicines” like homeopathy, herbs, detoxes, and acupuncture — cannot legally call themselves “medically trained.”
- The Spanish Ministries of Health and Sciences announced their ‘Health Protection Plan against Pseudotherapies’.
- The medical school of Vienna axed their courses in homeopathy.
- A most comprehensive review of homeopathy concluded that the effects of homeopathy do not differ from those of placebo.
- The UK Pharmaceutical Society has stated that it does not endorse homeopathy and that pharmacists must advise patients considering a homeopathic product about their lack of efficacy beyond that of a placebo.
- A top medical journal has retracted a dodgy meta-analysis of acupuncture.
- A prominent BMJ columnist wrote : Many people seek to make money from those who don’t understand science. Doctors should call out bollocksology when they see it.
- Pharmacare and Bioglan received a ‘Stonky’ for its over-the-counter Melatonin Homeopathic Sleep Formula.
- The Governing Body of Bristol, North Somerset and South Gloucestershire (BNSSG) Clinical Commissioning Group (CCG) approved changes that mean NHS funded homeopathy will only be available in exceptional circumstances in the area.
- Health ministers of all German counties have decided that they will start reforming the profession of the Heilpraktiker, the German non-medically trained alternative practitioners.
- The NHS chief, Simon Stevens was quoted saying: There is no robust evidence to support homeopathy which is at best a placebo and a misuse of scarce NHS funds.
- A systematic review concluded that there is no evidence in the literature of an effect of chiropractic treatment in the scope of primary prevention or early secondary prevention for disease in general. Chiropractors have to assume their role as evidence-based clinicians and the leaders of the profession must accept that it is harmful to the profession to imply a public health importance in relation to the prevention of such diseases through manipulative therapy/chiropractic treatment.
- A Cochrane review did not show any benefit of homeopathic medicinal products compared to placebo on recurrence of acute respiratory tract infections or cure rates in children.
- The French minister of health stated that ‘the French are very attached [to homeopathy]; it’s probably a placebo effect. If it can prevent the use of toxic medicine, I think that we all win. I does not hurt.
- The Australian Acupuncture and Chinese Medicine Association retracted false accusation against me about their assumption that I had undeclared conflicts of interest.
- The ‘Daily Telegraph‘ published the following statement after misquoting me: Emeritus Professor Edzard Ernst, Britain’s first professor of complementary medicine at Exeter University said that doctors should make it clear to patients that they could not be taking herbal remedies alongside drugs. Prof Ernst said there was no good evidence that they work and that doctors were ‘contributing to disinformation’ by turning a blind eye to the practice.
- A comprehensive overview of the therapeutic options for chronic low back pain showed that chiropractic is not any better than over-the-counter painkillers or exercise, and that patients need to take precautions when seeking out a chiropractor.
Hold on, you promised 20, but these are just 17!!!, I hear my attentive readers mutter.
Yet, this should not depress us. On the contrary, let’s see it as a challenge to get on with out work of fighting for good evidence, ethical standards, rationality and critical thinking.In this spirit, I wish you all a very good, healthy and productive year 2019.