case-control study
Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in numerous case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). This study‘s hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period.
A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts:
- (1) LBP patients receiving CSM,
- (2) LBP patients receiving PT evaluation without spinal manipulation.
Propensity score matching controlled for confounding variables associated with CES.
67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05–0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09–0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42–0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up.
The authors concluded that the present study involving over 130,000 propensity-matched patients found that CSM is not a risk factor for CES. The incidence of CES in both CSM and PT evaluation cohorts aligns with previous estimates of CES incidence among patients with LBP, indicating a heightened risk of CES compared to asymptomatic individuals regardless of intervention. Moreover, these findings underscore the increased CES incidence within the first two weeks after either CSM or PT evaluation, emphasizing the need for clinicians’ vigilance in identifying and emergently referring patients with CES for surgical evaluation. Further real-world evidence is needed to corroborate these findings using alternative case-control and case-crossover designs, and different clinician comparators.
This is an interesting and well-reported investigation. Its particular strength is the huge sample size. Its weakness, on the other hand, is the fact that, despite the researchers best efforts, the two groups might not have been entirely comparable and that there could be a host of relevant factors that the propensity matching was unable to control for.
It is, I think, to the credit of the authors that they abstain from overrating their results and correctly emphasize in their conclusions that: Further real-world evidence is needed to corroborate these findings using alternative case-control and case-crossover designs, and different clinician comparators.
Acute encephalitis syndrome is a health burden to a populous country like India. It is characterized by a sudden onset of fever, altered sensorium with or without seizures, irritability, abnormal behaviour, or unconsciousness. This study aims to augment further evidence on the effects of add-on homeopathic treatment in reducing mortality and morbidity in children.
This comparative retrospective study included children hospitalized with acute encephalitis syndrome between July 2016 to December 2016. The researchers compared the parameters of children for whom decisions on Glasgow Outcome scale and Liverpool outcome score aided by add-on homeopathy against those of children from the same year when the add-on homeopathy was not used. All the children were on conventional supportive care and treatment tailored to each child. We also counted the days until the resumption of oral feeding and the length of hospital stay.
Ordinal regression analysis on analyses on 622 children (IH +CSC=329; IMP only=293) was done. Odds of a shift towards increased recovery were superior in the homeopathy-added group than in the IMP group without adjustment (crude OR 2·30, 95% CI 1·66 to 3·20; p=0·0001) and with adjustment (adjusted OR 3.38, 95% CI 2·38 to 4.81; p=0·0001). There was 14.8% less mortality and 17.4% more recovery in the add-on homeopathy group compared to CSC alone. Individualized homeopathic remedies commonly used were: Belladonna (n =238), Stramonium (n =17), Opium (n = 14), Sulphur (n=11) and Hyoscyamus niger (n = 7).
The authors concluded that this retrospective cohort study advocates for add-on homoeopathy in children suffering acute encephalitis which can produce notable improvements in terms of mortality and morbidity. Further studies in different settings are warranted.
If responsible physicians come across such an unexpected and implausible finding, instead of publishing it unchecked, they must properly test the hypothesis in a rigorous trial. As it stands, the results are meaningless and might even do untold harm, if some doctors drew the conclusion that homeopathy saves lives in acute encephalitis.
The most likely explanation for the reported outcomes is that there was considerable selection bias in recruiting patients to this study. The less severely ill patients might thus have ended up in the homeopathy group. The plausibility for the outcomes being due to the homeopathic treatment is virtually zero.
So, why did the authors of this paper publish such utterly unreliable findings and did not even include a hint of critical thinking? I think their affiliations might go some way in answering this question:
- Ramesh Prasad, Clinical Trial Unit Homoeopathy,BRD Medical College and Hospital, GorakhpurAlok Upadhyay, Clinical Trial Unit Homoeopathy (Viral encephalitis) BRD Medical College and Hospital, Gorakhpur
- Vinod Kumar Maurya, Clinical Trial Unit Homoeopathy (Viral encephalitis) BRD Medical College and Hospital, Gorakhpur
- Preeti Verma, Clinical Trial Unit Homoeopathy (Viral encephalitis) Medical College and Hospital, Gorakhpur
- Shashi Arya, Clinical Trial Unit Homoeopathy (Viral encephalitis) Medical College and Hospital, Gorakhpur
- Supriya Singh, Central Council for Research in Homoeopathy
- Purnima Shukla, Clinical Trial Unit Homoeopathy (Viral encephalitis) BRD Medical College and Hospital, Gorakhpur
- AK Gupta, Clinical Trial Unit Homoeopathy (Viral encephalitis) BRD Medical College and Hospital, Gorakhpur
- Arvind Kumar, Central Council for Research in Homoeopathy
- Praveen Oberai, Central Council for Research in Homoeopathy
- Raj K Manchanda, Central Council for Research in Homoeopathy, New Delhi
And why did they take all of 8 years to publish this nonsense?
Search me!
Recent studies have demonstrated that sociopolitical attitudes partially explain variance in (SARS-CoV-2) vaccine hesitancy and uptake. Other attitudes, such as those towards esoteric beliefs, so-called alternative medicine (SCAM), and religion, have also been proposed. However, pertinent studies provide limited direction for public health efforts, as the impact of such attitudes has been tested in isolation or on different outcomes. Moreover, related associations between SARS-CoV-2 immunization drivers as well as views towards other modes of immunization (e.g., routine pediatric immunization), remain unclear.
Based on a sample of ~7400 survey participants (Germany), where esoteric belief systems and SCAM (Waldorf, homeopathy) are rather prevalent, and controlling for other sociological factors, this study found that:
- individuals with positive attitudes towards Waldorf education and homeopathy are significantly less likely to have received a (further) dose of SARS-CoV-2 vaccine compared to those with positive views of mainstream medicine;
- for the former, immunization decisions are primarily driven by external pressures, and for the latter overwhelmingly by voluntary considerations;
- attitudes influencing adult SARS-CoV-2 vaccine uptake similarly influence views towards routine pediatric immunization.
The authors concluded that their findings provide significant evidence informing a more nuanced design of public health and communication campaigns, and pertinent policies.
As the authors of this study point out, the attitudes towards mainstream medicine remained the single most influential factor for vaccine uptake. Individuals who viewed mainstream medicine highly favorably, received on average an estimated 1.48 (p < 0.001) more doses of SARS-CoV-2 vaccine than those who held very negative views. In contrast, those who viewed homeopathy highly positively received on average 0.51 (p < 0.001) fewer doses than those who viewed homeopathy highly negatively.
Regarding religious denominations, individuals self-classifying as Roman-Catholic or Protestant received on average 0.17 (p < 0.001) and 0.15 (p < 0.001) more vaccine doses than those self-classifying as non-denominational. The associations between other denominations and vaccine doses were statistically insignificant.
While these associations have been observed before or at least seem logical to me (and we discusses them frequently on this blog), one finding is, I think new (albeit not surprising, in my view): Supporters of the right-wing populist AfD received 1.37 (p < 0.001) fewer vaccine doses than the reference category Christian democrats.
So, does that in essence mean that the typical (German) vaccination hesitant person votes extereme right and loves SCAM?
Proponents of so-called alternative medicine tend to be critical of COVID-19 vaccines and often claim that they do more harm than good. Therefore, I have in the past repeatedly discussed studies that alleviate their concerns and will continue to do so in future. A new study will provide a valuable contribution to this ongoing discussion.
It has been shown that the first dose of COVID-19 vaccines leads to an overall reduction in cardiovascular events, and in rare cases, cardiovascular complications. There is less information about the effect of second and booster doses on cardiovascular diseases. Using longitudinal health records from 45.7 million adults in England between December 2020 and January 2022, this study compared the incidence of thrombotic and cardiovascular complications up to 26 weeks after first, second and booster doses of brands and combinations of COVID-19 vaccines used during the UK vaccination program with the incidence before or without the corresponding vaccination.
The findings reveaal that:
- The incidence of common arterial thrombotic events (mainly acute myocardial infarction and ischaemic stroke) was generally lower after each vaccine dose, brand and combination.
- The incidence of common venous thrombotic events, (mainly pulmonary embolism and lower limb deep venous thrombosis) was lower after vaccination.
- There was a higher incidence of previously reported rare harms after vaccination: vaccine-induced thrombotic thrombocytopenia after first ChAdOx1 vaccination, and myocarditis and pericarditis after first, second and transiently after booster mRNA vaccination (BNT-162b2 and mRNA-1273).
The authors concluded that these findings support the wide uptake of future COVID-19 vaccination programs.
This England-wide study offers reassurance regarding the cardiovascular safety of COVID-19 vaccines, with lower incidence of common cardiovascular events outweighing the higher incidence of their known rare cardiovascular complications. No novel cardiovascular complications or new associations with subsequent doses were found. The findings thus support the wide uptake of future COVID-19 vaccination programs.
Vaccine hesitancy has been defined as a continuum of attitudes, ranging from accepting vaccines with doubts to rejecting them. For good reasons, the topic has featured regularly on this blog, e.g.:
- Anthroposophic medicine and vaccine hesitancy: are there links?
- Endorsement of so-called alternative medicine (SCAM) and vaccine hesitancy among physicians
- So-called alternative medicine (SCAM) and vaccine hesitancy among physicians: findings from Germany, Finland, Portugal, and France
- Echo chambers of vaccine hesitancy and so-called alternative medicine (SCAM)
- Vaccine hesitancy and so-called alternative medicine (SCAM)
- How to reduce vaccination hesitancy?
- Reasons for parental hesitancy or refusal of childhood vaccination
- Intelligence, Religiosity, SCAM, Vaccination Hesitancy – are there links?
- The American Medical Association take a stand against chiropractors, naturopaths, or homeopaths granting medical exemptions to vaccines
- Attitudes of Vaccination-Hesitant Parents Towards So-Called Alternative Medicine (SCAM)
- Do views about so-called alternative medicine (SCAM), nature and god influence people’s vaccination intentions?
This new study aimed to explore the heterogeneity of a childhood-vaccine-hesitant group by using a person-oriented approach, i.e. latent profile analysis.
A non-representative cross-sectional sample of vaccine-hesitant Slovenians (N = 421, Mage = 35.21, 82.9% women) was used to identify differences based on their
- reliance on personal research (“self” researching instead of relying on science),
- over-confidence in knowledge,
- endorsement of conspiracy theories,
- complementary and alternative medicine,
- trust in the healthcare system.
The analysis revealed three profiles of vaccine-hesitant individuals. The most hesitant profile—vaccine rejecting—expressed the greatest reliance on personal research, expressed the highest endorsement of conspiracy theories and complementary and alternative medicine, showed moderate overconfidence in their knowledge, and expressed the highest levels of distrust in the healthcare system. Furthermore, the researchers found differences in sociodemographic structure and noted that the identified profiles differed in their attitudes regarding MMR, HPV, and Seasonal Influenza vaccinations.
The authors concluded as follows: our findings not only further confirm the heterogeneous nature of vaccine-hesitant groups but also offer critical insights for public health interventions. By acknowledging the existence of distinct profiles within the vaccine-hesitant population, strategies can be tailored to address the nuanced beliefs and attitudes of these subgroups more effectively.
- Skeptics who already express a certain level of trust in healthcare, may be most receptive to messages from medical professionals. Given that skeptics are typically older, higher-educated men, interventions could focus on leveraging their existing trust in healthcare professionals and providing detailed, evidence-based information to address their specific concerns.
- Self-directed researchers, who are characterized by high endorsement of CAM and conspiracy theories and moderate over-confidence, could benefit from interventions involving trusted community figures or CAM medicine experts who can bridge the gap between traditional and CAM perspectives. In addition, reaching out to younger women in this group through online platforms and providing credible information that counteracts misinformation could be effective.
- Conventionalists, who have the highest trust in the healthcare system and tend to include more educated individuals with a left-leaning political orientation, may respond well to public health messages that emphasize the collective benefits of vaccination. Campaigns could focus on reinforcing their positive views on the efficacy, safety, and importance of vaccines while leveraging their trust in physicians and public health institutions.
The effectiveness of targeted interventions for each specific subgroup could then also be examined, employing insights from the present study. For instance, tailored communication strategies could be tested to determine which messages and messengers are the most effective in regard to changing attitudes and behaviors within each profile.
This retrospective cohort study investigated the effect of reflexology on immunological parameters of people living with HIV (PLWH). All patients who received at least one reflexology treatment were included and compared with the group of PLWH who were not treated with reflexology. Measured parameters included CD4 count, CD4%, CD8 count, CD8%, CD4/CD8 ratio, and HIV viral load (VL). Changes in these parameters before and after the treatment were compared with changes in two consecutive measurements in the control group.
In total, 74 patients who received reflexology treatments were matched by age and sex to 144 controls. There was a male predominance of 86% in both groups. Patients in the control group were slightly older, with a median age of 45 versus 43 in the treatment group (p = 0.022). The median baseline CD4 count (730 vs. 795, p = 0.187) and CD8 count (890 vs. 832, p = 0.32) did not differ between the groups. Baseline CD4% tended to be lower in the treatment group (34% vs. 36%, p = 0.058), CD8% was higher in the treatment group (40% vs. 38%, p = 0.03), and the
CD4/CD8 ratio was lower in the treatment group (0.8 vs. 1, p = 0.002).
After therapy, there was a significantly higher increase in CD4, CD4%, and CD4/CD8 in the treatment group (p = 0.006, 0.0004, <0.001, respectively), whereas CD8% decreased significantly and CD8 tended to decrease in the treatment group (p < 0.001, 0.054, respectively).
The authors concluded that reflexology showed a positive impact on the immunological parameters of PLWH.
Who on earth conceives such a study?
Who funds such offensive rubbish?
Who publishes it?
We may well ask these questions, because the paper is pure nonsense!
The authors are very clear about their conviction that the observed differences were caused by the reflexology treatment. They don’t even discuss other options. Yet, there are several plausible explanations that have nothing to do with reflexology.
The patients in the control group originate from the hospital’s register from the time before reflexology had been introduced in the standard care package. Thus these patients differ in numerous ways from those of the experimental group. To name just one possibility, these patients were treated at a time when the treatment of PLWH was less sophicticated and thus had worse outcomes.
The two patient groups are clearly not comparable! This is also shown by the data published in the paper. So why compare them?
The only sensible conclusion of this paper is in my view:
In an effort to prove that their SCAM works, enthusiasts without research expertise often go to great lengths. As a result they mislead us all and do a great disservice to science and medicine.
Astrology is a subject that regularly crops up in the realm of so-called alternative medicine (SCAM). Thus we have dealt with it on several occasions, e.g.:
- Astrology determines mortality … torture the data until they confess!
- Astro-homeopathy: “a beautiful blend of Astrology and Homoeopathy”
Many SCAM proponents evidently believe that astrology works.
The question is, does astrology have any value at all in healthcare?
Several recent papers go some way in answering it.
The first paper evaluated the existing research base on correlates of belief in astrology and fortune-telling. the researchers conducted a scoping review to synthesize the available literature base on belief in astrology and to review the evidence for “fortune-telling addiction” using Arksey and O’Malley’s methodological framework. Databases of PubMed, ProQuest, EBSCO, and SCOPUS were searched for relevant studies published in peer-reviewed journals.
The search findings revealed the association of belief in astrology with cognitive, personality, and psychological factors such as thinking style, self-concept verification, and stress. Case studies on “fortune-telling addiction” have conceptualized it as a possible behavioral addiction and have reported symptoms such as distress, cravings, and salience.
The second study examined the relationship between Western zodiac signs and subjective well-being in a nationally representative American sample from the General Social Survey (N = 12,791). Well-being was measured across eight components:
- general unhappiness,
- depressive symptoms,
- psychological distress,
- work dissatisfaction,
- financial dissatisfaction,
- perceived dullness of one’s life,
- self-rated health,
- unhappiness with marriage.
Parametric and nonparametric analyses consistently revealed no robust associations between zodiac signs and any of the well-being variables, regardless of whether demographic factors were controlled for. The effect sizes were negligible, accounting for 0.3% or less of the variance in well-being, demonstrating that zodiac signs lack predictive power for well-being outcomes. An additional analysis revealed that astrological signs were no more predictive of than random numbers. Thus, a randomly generated number between 1 and 12 is statistically as predictive of one’s well-being as one’s zodiac sign.
The authors concluded that these findings challenge popular astrological claims about the influence of zodiac signs on well-being and quality of life.
The third paper reports a retrospective, single-center cohort study of 2545 adult patients with confirmed COVID-19 infection presenting to the emergency room over a 14-month period (September 2020 to November 2021). COVID-19 infectivity was determined based on polymerase chain reaction (PCR) testing. Western and Chinese Zodiac signs were designated using date of birth. Both Zodiac signs were evaluated for risk of infection and death.
Mortality rates across the zodiac and astrology signs showed no statistical difference using the 12-sample test for equality of proportions. Coincidentally, the mean age for the deceased was 74.5 years, and it was 53.9 years for those alive, resulting in a difference of 20.6 years. A two-sample t-test confirms that the observed difference of 20.6 years of age between the two groups is statistically significant with a p-value <0.05. The coefficient of the predictor age is statistically significant. The odds ratio estimate of age is 1.06, with the corresponding 95% confidence interval (CI) being (1.048, 1.073). This means that the odds of dying increase by 6% for every additional year.
The authors concluded that there was no statistical significance between Western and Chinese Zodiac signs and mortality or infections.
So, does astrology have any value in healthcare?
The answer is as simple as it is unsurprising:
No!
This prospective cohort study examined the effects of fish oil supplements on the clinical course of cardiovascular disease, from a healthy state to atrial fibrillation, major adverse cardiovascular events, and subsequently death.
The analysis is based on the UK Biobank study (1 January 2006 to 31 December 2010, with follow-up to 31 March 2021 (median follow-up 11.9 years)) including 415 737 participants, aged 40-69 years. Incident cases of atrial fibrillation, major adverse cardiovascular events, and death, identified by linkage to hospital inpatient records and death registries. Role of fish oil supplements in different progressive stages of cardiovascular diseases, from healthy status (primary stage), to atrial fibrillation (secondary stage), major adverse cardiovascular events (tertiary stage), and death (end stage).
Among 415 737 participants free of cardiovascular diseases, 18 367 patients with incident atrial fibrillation, 22 636 with major adverse cardiovascular events, and 22 140 deaths during follow-up were identified. Regular use of fish oil supplements had different roles in the transitions from healthy status to atrial fibrillation, to major adverse cardiovascular events, and then to death:
- For people without cardiovascular disease, hazard ratios were 1.13 (95% confidence interval 1.10 to 1.17) for the transition from healthy status to atrial fibrillation and 1.05 (1.00 to 1.11) from healthy status to stroke.
- For participants with a diagnosis of a known cardiovascular disease, regular use of fish oil supplements was beneficial for transitions from atrial fibrillation to major adverse cardiovascular events (hazard ratio 0.92, 0.87 to 0.98), atrial fibrillation to myocardial infarction (0.85, 0.76 to 0.96), and heart failure to death (0.91, 0.84 to 0.99).
The authors concluded that regular use of fish oil supplements might be a risk factor for atrial fibrillation and stroke among the general population but could be beneficial for progression of cardiovascular disease from atrial fibrillation to major adverse cardiovascular events, and from atrial fibrillation to death. Further studies are needed to determine the precise mechanisms for the development and prognosis of cardiovascular disease events with regular use of fish oil supplements.
I must admit that I am slightly puzzled by this study and its findings. The authors clearly speak of the ‘role’ regular use of fish oil supplements has. This language implies a casual impact. Yet, what we have here are associations, and every 1st year medical student knows that
correlation is not causation.
Other things to note are that:
- the associations are only very weak;
- they go in opposite directions depending on the subpopulation that is examined,
- there is no plausible mechanism of action to explain all this.
Collectively, these facts suggest to me that we are indeed more likely dealing here with a non-causal association and not a causal link. All the more surprising then that the (UK) press took up this paper in a major and occasionally alarmist fashion (the headline in THE TELEGRAPH was Revealed: How cod liver oil could be bad for your health). I learned of it by listening to the BBC headline news.
Conspiracy theories, as often discussed here, plague the realm of so-called alternative medicine (SCAM), e.g.:
- Conspiracy beliefs prompt consumers to use so-called alternative medicine
- How can we reduce the belief in conspiracy theories?
- Conspiracy Beliefs Predict Health Behavior and Well-being during the Pandemic
- Coronavirus conspiracy beliefs, mistrust, and compliance with government guidelines
- Conspiracy theories and dangerous recommendations via YouTube videos
In fact, I did recently suggest that so-called alternative medicine is a conspiracy theory in disguise. Previous research has found that individuals who struggle with emotion regulation are more prone to believing in conspiracy theories. Emotional granularity – the ability to differentiate between nuanced emotional states – is a key component of effective emotion regulation, yet its relationship with conspiracy beliefs has not been explored thoroughly.
Psychologists from the Uni Graz in Austria conducted an experience-sampling study (165 participants, mean age = 26.3 years) including measures of emotion regulation and differentiation. The study started with an online survey that assessed participants’ sociodemographic (age, sex, and education) and trait measures. Following this, participants were asked to install an in-house developed app on their smartphones to obtain the emotional granularity specificity index. The app displayed two notifications each day for over a week (14 max.). Notifications were randomly displayed between 08:00 am and 10:00 pm with a minimum of at least 5 h between two notifications. Participants, on average, answered 57% of the notifications.
The findings revealed that individuals who endorse conspiracy theories engage in repetitive thinking about the causes and consequences of events and exhibit a reduced ability to distinguish between negative emotions. This effect, however, was observed only in the performance-based measure of emotion differentiation, not in the self-report measures.
The authors conclused that this suggests that enhancing emotional granularity may help individuals in regulating their emotions more effectively, thereby reducing their vulnerability to adopt conspiracy beliefs.
To reduce belief in conspiracy theories, one might, according to the authors, consider a training program to enhance emotion regulation and differentiation. A combination of cognitive control training on emotion regulation, which has been shown to reduce overthinking, as well as reflecting on and diversifying emotional experiences, could provide simple tools for assessing and regulating emotional experiences. This, in turn, may lead to decreased endorsement of conspiracy theories in the long run.
Perhaps we should recommend this to the chaps who recularly comment on this blog bursting with conspiracy theories?
In the realm of so-called alternative medicine (SCAM), dental amalgam is a big topic. Therefore, we have discussed it several times before, e.g.:
- The EU will phase out the use of dental amalgam
- Long awaited: EU prohibits the use of dental amalgam
- Is removal of dental amalgam a good idea?
- Dental Amalgam
- Three Trends In “Alternative Dentistry” Part 3: Amalgam Removal and Avoidance
This study evaluated the changes of health complaints after removal of amalgam restorations in patients with health complaints attributed to dental amalgam fillings.
Patients with medically unexplained physical symptoms (MUPS) attributed to dental amalgam (Amalgam cohort) had all their amalgam fillings removed. The participants indicated an intensity of 11 local and 12 general health complaints on numeric rating scales before the treatment and at follow-up after 1 and 5 years.
The comparison groups comprising
- a group of healthy individuals
- a group of patients with MUPS without symptom attribution to dental amalgam
did not have their amalgam restorations removed.
In the Amalgam cohort, mean symptom intensity was lower for all 23 health complaints at follow-up at 1 year compared to baseline. Statistically significant changes were observed for specific health complaints with effect sizes between 0.36 and 0.68. At the 5-year follow-up, the intensity of symptoms remained consistently lower compared to before the amalgam removal. In the comparison groups, no significant changes of intensity of symptoms of health complaints were observed.
The authors concluded that, after removal of all amalgam restorations, both local and general health complaints were reduced. Since blinding of the treatment was not possible, specific and non-specific treatment effects cannot be separated.
This is an interesting study with a particularly long follow-up. Unfortunately, due to the study’s design, its results tell us very little about causality. The results are perfectly consistent with two entirely different explanations:
- Amalgam was the cause of MUPS and therefore removal of amalgam cured the problem permanently.
- Amalgam was not the cause of MUPS but the knowledge that the evil substance had finally been removed sufficed for MUPS to disappear.
It is to the credit of the authors that they consider both options.
A word of caution: amalgam removal can lead to a spike in Hg levels in the body!
