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

case-control study

We have previously seen that SCAM-use is associated with shorter survival of cancer patients. A new article now confirms this notion.

The investigators wanted to find out what patient characteristics are associated with use of SCAM for cancer and what is the association of SCAM with treatment adherence and survival. They thus  compared the overall survival between patients with cancer receiving conventional treatments with or without SCAM and the adherence to treatment and characteristics of patients in both groups.

Their retrospective observational study used data from the National Cancer Database on 1 901 815 patients from 1500 Commission on Cancer–accredited centers across the United States who were diagnosed with nonmetastatic breast, prostate, lung, or colorectal cancer between January 1, 2004, and December 31, 2013. Patients were matched on age, clinical group stage, Charlson-Deyo comorbidity score, insurance type, race/ethnicity, year of diagnosis, and cancer type.  Overall survival, adherence to treatment, and patient characteristics were the study endpoints.

The cohort comprised 1 901 815 patients with cancer (258 patients in the SCAM group and 1 901 557 patients in the control group). In the main analyses following matching, 258 patients were in the SCAM group, and 1032 patients were in the control group. Patients who chose SCAM did not have a longer delay to initiation of conventional therapies, but had higher refusal rates of surgery, radiotherapy, and hormone therapy. Use of SCAM was associated with poorer 5-year overall survival compared with no SCAM (82.2% [95% CI, 76.0%-87.0%] vs 86.6% [95% CI, 84.0%-88.9%]; P = .001) and was independently associated with greater risk of death (hazard ratio, 2.08; 95% CI, 1.50-2.90) in a multivariate model that did not include treatment delay or refusal. However, there was no significant association between SCAM and survival once treatment delay or refusal was included in the model.

The authors concluded that patients who received CM were more likely to refuse additional CCT, and had a higher risk of death. The results suggest that mortality risk associated with CM was mediated by the refusal of CCT.

This new evidence confirms previous papers: SCAM-use is associated with shorter survival of cancer patients. As it is based on a large sample size, its results are more compelling. They indicate that it is not SCAM per se, but the attitude of SCAM-users to conventional therapies that is the cause of the effect. As I have said and written hundreds of times: the most serious risk of SCAM is not a direct but an indirect one: the risk of neglecting effective therapies. Essentially, this means that better information targeted at vulnerable patients must be the way forward (one of the main ambitions of this blog, I hasten to add).

Remember when an international delegation of homeopaths travelled to Liberia to cure Ebola?

Virologists and other experts thought at the time that this was pure madness. But, from the perspective of dedicated homeopaths who have gone through ‘proper’ homeopathic ‘education’ and have the misfortune to believe all the nonsense they have been told, this is not madness. In fact, the early boom of homeopathy, about 200 years ago, was based not least on the seemingly resounding success homeopaths had during various epidemics.

I fully understand that homeopath adore this type of evidence – it is good for their ego! And therefore, they tend to dwell on it and re-hash it time and again. The most recent evidence for this is a brand-new article entitled ‘Homeopathic Prevention and Management of Epidemic Diseases’. It is such a beauty that I present you the original abstract without change:

START OF QUOTE

___________________________________________________________________________

Homeopathy has been used to treat epidemic diseases since the time of Hahnemann, who used Belladonna to treat scarlet fever. Since then, several approaches using homeopathy for epidemic diseases have been proposed, including individualization, combination remedies, genus epidemicus, and isopathy.

METHODS:

The homeopathic research literature was searched to find examples of each of these approaches and to evaluate which were effective.

RESULTS:

There is good experimental evidence for each of these approaches. While individualization is the gold standard, it is impractical to use on a widespread basis. Combination remedies can be effective but must be based on the symptoms of a given epidemic in a specific location. Treatment with genus epidemicus can also be successful if based on data from many practitioners. Finally, isopathy shows promise and might be more readily accepted by mainstream medicine due to its similarity to vaccination.

CONCLUSION:

Several different homeopathic methods can be used to treat epidemic diseases. The challenge for the future is to refine these approaches and to build on the knowledge base with additional rigorous trials. If and when conventional medicine runs out of options for treating epidemic diseases, homeopathy could be seen as an attractive alternative, but only if there is viable experimental evidence of its success.

END OF QUOTE

____________________________________________________________________________________

I don’t need to stress, I think, that such articles are highly irresponsible and frightfully dangerous: if anyone ever took the message that homeopathy has the answer to epidemic seriously, millions might die.

The reasons why epidemiological evidence of this nature is wrong has been discussed before on this blog; I therefore only need to repeat them:

In the typical epidemiological case/control study, one large group of patients [A] is retrospectively compared to another group [B]. In our case, group A has been treated homeopathically, while group B received the treatments available at the time. It is true that several of such reports seemed to suggest that homeopathy works. But this does by no means prove anything; the result might have been due to a range of circumstances, for instance:

  • group A might have been less ill than group B,
  • group A might have been richer and therefore better nourished,
  • group A might have benefitted from better hygiene in the homeopathic hospital,
  • group A might have received better care, e. g. hydration,
  • group B might have received treatments that made the situation not better but worse.

Because these are RETROSPECTIVE studies, there is no way to account for these and many other factors that might have influenced the outcome. This means that epidemiological studies of this nature can generate interesting results which, in turn, need testing in properly controlled studies where these confounding factors are adequately controlled for. Without such tests, they are next to worthless for recommendations regarding clinical practice.

In essence, this means that epidemiological evidence of this type can be valuable for generating hypotheses which, in turn, need testing in rigorous clinical trials. Without these tests, the evidence can be dangerously misleading.

But, of course, Jennifer Jacobs, the author of the new article, knows all this – after all, she has been employed for many years by the Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle, Washington, United States!

In this case, why does she re-hash the old myth of homeopathy being the answer to epidemics?

I do not know the answer to this question, but I do know that she is a convinced homeopath with plenty of papers on the subject.

And what sort of journal would publish such dangerous, deeply unethical rubbish?

It is a journal we have discussed several before; its called HOMEOPATHY.

This journal is, I think, remarkable: not even homeopaths would deny that homeopathy is a most controversial subject. One would therefore expect that the editorial board of the leading journal of homeopathy (Impact Factor = 1.16) has a few members who are critical of homeopathy and its assumptions. Yet, I fail to spot a single such person of the board of HOMEOPATHY. Please have a look yourself and tell me, if you can identify such an individual:

Editor

Peter Fisher
FRCP, FFHom, London, UK

Senior Deputy Editor

Robert T. Mathie
BSc (Hons), PhD, London, UK

Deputy Editors

Leoni Bonamin
Paulista University, São Paulo, Brazil

Menachem Oberbaum
Shaare Zedek Medical Center, Jerusalem, Israel

Ethics Adviser

Kate Chatfield
University of Central Lancashire, Preston, UK

Editorial Advisory Board

Cees Baas
Centre for Integrative Psychiatry, Groningen, The Netherlands

Stephan Baumgartner
University of Witten-Herdecke, Germany

Iris R. Bell
University of Arizona, USA

Jayesh Bellare
Indian Institute of Technology, Mumbai, India

Philippe Belon
Centre de Recherche et de Documentation Thérapeutique, France

Brian Berman
University of Maryland, School of Medicine, USA

Martien Brands
Centre for Integrative Care, Amsterdam, The Netherlands

Michael Carlston
University of California, Santa Rosa, USA

Kusum S. Chand
Pushpanjali Crosslay Hospital, Ghaziabad, India

Martin Chaplin
London South Bank University, UK

Flávio Dantas
University of Uberlândia, Brazil

Peter Darby
Faculty of Homeopathy, UK

Jonathan Davidson
Duke University, USA

Jean-Louis Demangeat
Haguenau Hospital, France

Christian Endler
Interuniversity College Graz/Castle of Seggau, Austria

Madeleine Ennis
Queen’s University Belfast, UK

Edoardo Felisi
Milan, Italy

Peter Gregory
Veterinary Dean, Faculty of Homeopathy, UK

German Guajardo-Bernal
University of Baja California, Mexico

Carla Holandino Quaresma
Universidade Federal do Rio de Janeiro, Brazil

Jennifer Jacobs
University of Washington, USA

Wayne Jonas
Samueli Institute, Alexandria, USA

Lee Kayne
Faculty of Homeopathy, UK

Steven Kayne
Glasgow Homoeopathic Hospital, UK

David Lilley
Pretoria, South Africa

Klaus Linde
Technical University, Munich, Germany

Russell Malcolm
Faculty of Homeopathy, UK

Raj K. Manchanda
Central Council for Research in Homoeopathy, New Delhi, India

David Peters
University of Westminster, London, UK

Bernard Poitevin
Association Française pour la Recherche en Homéopathie, France

David Reilly
Glasgow Homoeopathic Hospital, UK

David Riley
Integrative Medicine Institute, Portland, USA

ALB Rutten
Breda, The Netherlands

Jürgen Schulte
University of Technology, Sydney, Australia

Trevor Thompson
University of Bristol, UK

André Thurneysen
Centre de médecines intégrées, Switzerland

Alexander Tournier
Homeopathy Research Institute, UK

Francis Treuherz
London, UK

Robbert van Haselen
International Institute for Integrated Medicine, Kingston, UK

Michel Van Wassenhoven
Unio Homeopathica Belgica, Belgium

Harald Walach
University of Witten-Herdecke, Germany

Fred Wiegant
University of Utrecht, The Netherlands

___________________________________________________________________________

I rest my case.

 

Have you ever wondered whether doctors who practice homeopathy are different from those who don’t.

Silly question, of course they are! But how do they differ?

Having practised homeopathy myself during my very early days as a physician, I have often thought about this issue. My personal (and not very flattering) impressions were noted in my memoir where I describe my experience working in a German homeopathic hospital:

some of my colleagues used homeopathy and other alternative approaches because they could not quite cope with the often exceedingly high demands of conventional medicine. It is almost understandable that, if a physician was having trouble comprehending the multifactorial causes and mechanisms of disease and illness, or for one reason or another could not master the equally complex process of reaching a diagnosis or finding an effective therapy, it might be tempting instead to employ notions such as dowsing, homeopathy or acupuncture, whose theoretical basis, unsullied by the inconvenient absolutes of science, was immeasurably more easy to grasp. 

Some of my colleagues in the homeopathic hospital were clearly not cut out to be “real” doctors. Even a very junior doctor like me could not help noticing this somewhat embarrassing fact… 

But this is anecdote and not evidence!

So, where is the evidence?

It was published last week and made headlines in many UK daily papers.

Our study was aimed at finding out whether English GP practices that prescribe any homeopathic preparations might differ in their prescribing of other drugs. We identified practices that made any homeopathy prescriptions over six months of data. We measured associations with four prescribing and two practice quality indicators using multivariable logistic regression.

Only 8.5% of practices (644) prescribed homeopathy between December 2016 and May 2017. Practices in the worst-scoring quartile for a composite measure of prescribing quality were 2.1 times more likely to prescribe homeopathy than those in the best category. Aggregate savings from the subset of these measures where a cost saving could be calculated were also strongly associated. Of practices spending the most on medicines identified as ‘low value’ by NHS England, 12.8% prescribed homeopathy, compared to 3.9% for lowest spenders. Of practices in the worst category for aggregated price-per-unit cost savings, 12.7% prescribed homeopathy, compared to 3.5% in the best category. Practice quality outcomes framework scores and patient recommendation rates were not associated with prescribing homeopathy.

We concluded that even infrequent homeopathy prescribing is strongly associated with poor performance on a range of prescribing quality measures, but not with overall patient recommendation or quality outcomes framework score. The association is unlikely to be a direct causal relationship, but may reflect underlying practice features, such as the extent of respect for evidence-based practice, or poorer stewardship of the prescribing budget.

Since our study was reported in almost all of the UK newspapers, it comes as no surprise that, in the interest of ‘journalistic balance’, homeopaths were invited to give their ‘expert’ opinions on our work.

Margaret Wyllie, head of the British Homeopathic Association, was quoted commenting: “This is another example of how real patient experience and health outcomes are so often discounted, when in actuality they should be the primary driver for research to improve our NHS services. This study provides no useful evidence about homeopathy, or about prescribing, and gives absolutely no data that can improve the health of people in the UK.”

The Faculty of Homeopathy was equally unhappy about our study and stated: “The study did not include any measures of patient outcomes, so it doesn’t tell us how the use of homeopathy in English general practice correlates with patients doing well or badly, nor with how many drugs they use.”

Cristal Summer from the Society of Homeopathy said that our research was just a rubbish bit of a study.

Peter Fisher, the Queen’s homeopath and the president of the Faculty of Homeopathy, stated: “We don’t know if these measures correlate with what matters to patients – whether they get better and have side-effects.”

A study aimed at determining whether GP practices that prescribe homeopathic preparations differ in their prescribing habits from those that do not prescribe homeopathics can hardly address these questions, Peter. A test of washing machines can hardly tell us much about the punctuality of trains. And an investigation into the risks of bungee jumping will not inform us about the benefits of regular exercise. Call me biased, but to me these comments indicate mainly one thing: HOMEOPATHS SEEM TO HAVE GREAT DIFFICULTIES UNDERSTANDING SCIENTIFIC PAPERS.

I much prefer the witty remarks of Catherine Bennett in yesterday’s Observer: Homeopath-GPs, naturally, have mustered in response and challenge Goldacre’s findings, with a concern for methodology that could easily give the impression that there is some evidential basis for their parallel system, beyond the fact that the Prince of Wales likes it. In fairness to Charles, his upbringing is to blame. But what is the doctors’ excuse?

Amongst all the implausible treatments to be found under the umbrella of ‘alternative medicine’, Reiki might be one of the worst, i. e. least plausible and outright bizarre (see for instance here, here and here). But this has never stopped enthusiasts from playing scientists and conducting some more pseudo-science.

This new study examined the immediate symptom relief from a single reiki or massage session in a hospitalized population at a rural academic medical centre. It was designed as a retrospective analysis of prospectively collected data on demographic, clinical, process, and quality of life for hospitalized patients receiving massage therapy or reiki. Hospitalized patients requesting or referred to the healing arts team received either a massage or reiki session and completed pre- and post-therapy symptom questionnaires. Differences between pre- and post-sessions in pain, nausea, fatigue, anxiety, depression, and overall well-being were recorded using an 11-point Likert scale.

Patients reported symptom relief with both reiki and massage therapy. Reiki improved fatigue and anxiety  more than massage. Pain, nausea, depression, and well being changes were not different between reiki and massage encounters. Immediate symptom relief was similar for cancer and non-cancer patients for both reiki and massage therapy and did not vary based on age, gender, length of session, and baseline symptoms.

The authors concluded that reiki and massage clinically provide similar improvements in pain, nausea, fatigue, anxiety, depression, and overall well-being while reiki improved fatigue and anxiety more than massage therapy in a heterogeneous hospitalized patient population. Controlled trials should be considered to validate the data.

Don’t I just adore this little addendum to the conclusions, “controlled trials should be considered to validate the data” ?

The thing is, there is nothing to validate here!

The outcomes are not due to the specific effects of Reiki or massage; they are almost certainly caused by:

  • the extra attention,
  • the expectation of patients,
  • the verbal or non-verbal suggestions of the therapists,
  • the regression towards the mean,
  • the natural history of the condition,
  • the concomitant therapies administered in parallel,
  • the placebo effect,
  • social desirability.

Such pseudo-research only can only serve one purpose: to mislead (some of) us into thinking that treatments such as Reiki might work.

What journal would be so utterly devoid of critical analysis to publish such unethical nonsense?

Ahh … it’s our old friend the Journal of Alternative and Complementary Medicine

Say no more!

Do chiropractors even know the difference between promotion and research?

Probably a rhetorical question.

Personally, I have seen them doing so much pseudo-research that I doubt they recognise the real thing, even if they fell over it.

Here is a recent example that stands for many, many more such ‘research’ projects (some of which have been discussed on this blog).

But first a few sentences on the background of this new ‘study’.

The UD chiropractic profession is currently on the ‘opioid over-use bandwagon’ hoping that this move might promote their trade. Most chiropractors have always been against using (any type of) pharmaceutical treatment and advise their patients accordingly. D D Palmer, the founder of chiropractic, was adamant that drugs are to be avoided; he stated for instance that Drugs are delusive; they do not adjust anything. And “as the Founder intended, chiropractic has existed as a drug-free healthcare profession for better than 120 years.” To this day, chiropractors are educated and trained to argue against non-drug treatments and regularly claim that chiropractic is a drug-free alternative to traditional medicine.

Considering this background, this new piece of (pseudo) research is baffling, in my view.

The objective of this investigation was to evaluate the association between utilization of chiropractic services and the use of prescription opioid medications. The authors used a retrospective cohort design to analyse health insurance claims data. The data source was the all payer claims database administered by the State of New Hampshire. The authors chose New Hampshire because health claims data were readily available for research, and in 2015, New Hampshire had the second-highest age-adjusted rate of drug overdose deaths in the United States.

The study population comprised New Hampshire residents aged 18-99 years, enrolled in a health plan, and with at least two clinical office visits within 90 days for a primary diagnosis of low-back pain. The authors excluded subjects with a diagnosis of cancer. They measured likelihood of opioid prescription fill among recipients of services delivered by chiropractors compared with a control group of patients not consulting a chiropractor. They also compared the cohorts with regard to rates of prescription fills for opioids and associated charges.

The adjusted likelihood of filling a prescription for an opioid analgesic was 55% lower among chiropractic compared to non-chiropractic patients. Average charges per person for opioid prescriptions were also significantly lower among the former group.

The authors concluded that among New Hampshire adults with office visits for noncancer low-back pain, the likelihood of filling a prescription for an opioid analgesic was significantly lower for recipients of services delivered by doctors of chiropractic compared with nonrecipients. The underlying cause of this correlation remains unknown, indicating the need for further investigation.

The underlying cause remains unknown???

Really?

Let me speculate, or even better, let me extrapolate by drawing an analogy:

Employees by a large Hamburger chain set out to study the association between utilization of Hamburger restaurant services and vegetarianism. The authors used a retrospective cohort design. The study population comprised New Hampshire residents aged 18-99 years, who had entered the premises of a Hamburger restaurant within 90 days for a primary purpose of eating. The authors excluded subjects with a diagnosis of cancer. They measured the likelihood of  vegetarianism among recipients of services delivered by Hamburger restaurants compared with a control group of individuals not using meat-dispensing facilities. They also compared the cohorts with regard to the money spent in Hamburger restaurants.

The adjusted likelihood of being a vegetarian was 55% lower among the experimental group compared to controls. The average money spent per person in Hamburger restaurants were also significantly lower among the Hamburger group.

The authors concluded that among New Hampshire adults visiting Hamburger restaurants, the likelihood of vegetarianism was significantly lower for consumers frequenting Hamburger restaurants compared with those who failed to frequent such places. The underlying cause of this correlation remains unknown, indicating the need for further investigation.

Daaaahhhhhhh!

 

The claims that are being made for the health benefits of Chinese herbal medicine are impressive. I am not sure that there is even a single human disease that is not alleged to be curable with the use of some Chinese herbal mixture. I find this worrying because some patients might actually believe such outrageous nonsense, particularly since Chinese researchers seem to bend over backwards to support them with science… or should I say pseudoscience?

This study was aimed at evaluating the association between mortality rate and early use of Chinese herbal products (CHPs) among patients with lung cancer. The researchers conducted a retrospective cohort study based on the National Health Insurance Research Database, Taiwan Cancer Registry, and Cause of Death Data. Patients with newly diagnosed lung cancer between 2002 and 2010 were classified as either the CHP (n = 422) or the non-CHP group (n = 2828) based on whether they used CHP within 3 months after first diagnosis of lung cancer. A Cox regression model was used to examine the hazard ratio (HR) of death for propensity score (PS) matching samples.

After PS matching, average survival time of the CHP group was significantly longer than that of the non-CHP group. The adjusted HR (0.82; 95% CI: 0.73-0.92) in the CHP group was lower than the non-CHP group. Stratified by clinical cancer stages, CHP group had longer survival time in the stage 3 subgroup. When the exposure period of CHP use was changed from 3 to 6 months, results remained similar.

The authors concluded that results indicated that patients with lung cancer who used CHP within 3 months after first diagnosis had a lower hazard of death than non-CHP users, especially for stage 3 lung cancer. Further experimental studies are needed to examine the causal relationship.

I would argue the direct opposite: further studies along these lines would be a waste of time!

I can name numerous reasons for this, for example:

  • Investigating CHP as though it is one entity is nonsense. There are thousands of different CHPs; some are placebos; some are toxic; and a few might even have some health effects.
  • The observed effect is almost certainly an artefact; the matching of the groups might have been sub-optimal; the CHP group differed systematically from the control group, for instance, by adhering to a healthier life-style; etc, etc.

All of this should be so obvious that it hardly deserves a mention. Why then do the authors not point it out prominently and clearly? Why did they ever embark on such a fatally flawed project? I cannot be sure, of course, … but perhaps one possible answer might be that the lead author is affiliated to a Department of Chinese Medicine?

 

The purpose of the study was to compare utilization of conventional psychotropic drugs among patients seeking care for anxiety and depression disorders (ADDs) from general practitioners (GPs) who

  • strictly prescribe conventional medicines (GP-CM),
  • regularly prescribe homeopathy in a mixed practice (GP-Mx),
  • or are certified homeopathic GPs (GP-Ho).

The investigation was an epidemiological cohort study of general practice in France, which included GPs and their patients consulting for ADDs (scoring 9 or more in the Hospital Anxiety and Depression Scale, HADS). Information on all medication utilization was obtained by a standardised telephone interview at inclusion, 1, 3 and 12 months.

Of 1562 eligible patients consulting for ADDs, 710 (45.5 %) agreed to participate. Adjusted multivariate analyses showed that GP-Ho and GP-Mx patients were less likely to use psychotropic drugs over 12 months, compared to GP-CM patients. The rate of clinical improvement (HADS <9) was marginally superior for the GP-Ho group as compared to the GP-CM group, but not for the GP-Mx group.

The authors concluded that patients with ADD, who chose to consult GPs prescribing homeopathy reported less use of psychotropic drugs, and were marginally more likely to experience clinical improvement, than patients managed with conventional care. Results may reflect differences in physicians’ management and patients’ preferences as well as statistical regression to the mean.

Aren’t we glad they added the last sentence to their conclusion!!!

Without it, one might have thought that the observed differences were due to the homeopathic remedies. In fact, the finding amounts to a self-fulfilling prophecy: Homeopaths tend to be against prescribing conventional drugs. This means that patients consulting homeopaths are bound to use less drugs than patients who consult conventional doctors. In that sense, the study was like monitoring whether consumers who go to the butchers buy more meat than those shopping in a shop for vegetarians.

The only result that requires a more serious consideration is that homeopathically treated patients experienced more clinical improvement than those treated conventionally. But even this difference is not hard to explain: firstly, the difference was merely marginal; secondly, patients with ADD are bound to respond particularly well to the empathetic and long therapeutic encounter most homeopaths offer. In other words, the difference had nothing to do with the alleged effectiveness of the homeopathic remedies.

A sizeable proportion of the general population is convinced that certain moon phases and moon signs may impact their health as well as the onset and clinical course of diseases. Those who believe in alternative medicine tend, I guess, to belong to this group. Here is a quote from one of the many websites making such claims: Understanding moon cycles and how they affect the body can be a key to better health. To understand how the moon influences your health the first step is to realize that your human body is made up of over 60% water, and the moon affects all water on the Earth.  The moon controls the ebb and flow of the oceanic tides and it controls your human body in the same way.

There is, of course, no plausible reason for such claims and convictions, but this rarely stops the gullible. And anyway, it could be true – or couldn’t it?

This study investigated the perioperative and long-term outcome of living donor kidney transplantation (LDKT) dependent on moon phases and zodiac signs. Patient data were prospectively collected in a continuously updated kidney transplant database. Two hundred and seventy-eight consecutive patients who underwent LDKT between 1994 and December 2009 were selected for the study and retrospectively assigned to the four moon phases (new-moon, waxing-moon, full-moon, and waning-moon) and the corresponding zodiac sign (moon sign Libra), based on the date of transplantation. Pre-existing comorbidities, perioperative mortality, surgical outcome, and long-term survival data were analysed.

Of all LDKT procedures, 11.9; 39.9; 11.5; and 36.5% were performed during the new, waxing, full, and waning moon, respectively, and 6.2% during the moon sign Libra, which is believed to interfere with renal surgery. Survival rates at 1, 5, and 10 years after transplantation were 98.9, 92, and 88.7% (patient survival) and 97.4, 91.6, and 80.6% (graft survival) without any differences between all groups of lunar phases and moon signs. Overall perioperative complications and early graft loss occurred in 21.2 and 1.4%, without statistical difference (p > 0.05) between groups.

The authors concluded that moon phases and the moon sign Libra had no impact on early and long-term outcome measures following LDKT in our study. Thus, concerns of patients awaiting LDKT regarding the ideal time of surgery can be allayed, and surgery may be scheduled independently of the lunar phases.

The authors also concede that their study has some limitations. First, it is a retrospective analysis of a single transplant centre and the number of patients is not huge. In addition, due to the retrospective design of the study, no randomization of the patients was possible. However, a randomization of the patients would systematically ignore the patients preferences. Realization of such a randomized trial would therefore be challenging. As a consequence, we do not know in how many cases the transplant was scheduled according to the lunar phases on the explicit request of the patient. It would be interesting to know whether a strong desire of the patient and a corresponding fulfilment has any influence on the short- and long-term success of the surgery.

Nonsense, I hear the loonies shout: there are numerous studies confirming that the moon has a definite effect on our health!

How do you explain that?

I think there are at least two possible explanations:

  1. these studies were methodologically flawed and lack independent replications;
  2. it cannot be excluded that patients’ fear of the wrong moon-phase might exert a negative influence on their health, irrespective of any influence of the moon. In this case, the moon-phase itself would be irrelevant, but the fear would mimic a real phenomenon.

We have repeatedly discussed the fact that alternative medicine (AM) is by no means free of risks. I find it helpful to divide them into two broad categories:

  1. direct risks of the intervention (such as stroke due to neck manipulation, or cardiac tamponade caused by acupuncture, or liver damage due to a herbal remedy) and
  2. indirect risks usually due to the advice given by AM practitioners.

The latter category is often more important than the former. It includes delay of effective treatment due to treatment with an ineffective or less effective form of AM. It is clear that this will cause patients to suffer unnecessarily.

Several investigations have recently highlighted this important problem, including this study from Singapore which assessed the predictors of AM-use in patients with early inflammatory arthritis (EIA), and its impact on delay to initiation of disease-modifying anti-rheumatic drugs (DMARD). Data were collected prospectively from EIA patients aged ≥ 21 years. Current or prior AM-use was ascertained by face-to-face interviews. Predictors of AM-use and its effect on time to DMARD initiation were determined by multivariate logistic regression and Cox proportional hazards, respectively.

One hundred and eighty patients were included: 83.9% had rheumatoid arthritis, 57% were seropositive. Median (IQR). Chinese race, being non-English speaking,  smoking and high DAS28 were independent predictors of AM-use. AM-users initiated DMARD later (median [IQR] 21.5 [13.1-30.4] vs. 15.6 [9.4-22.7] weeks in non-users, P = 0.005). AM-use and higher DAS28 were associated with a longer delay to DMARD initiation. Race, education level, being non-English speaking, smoking and sero-positivity were not associated.

The authors concluded that healthcare professionals should be aware of the unique challenges in treating patients with EIA in Asia. Healthcare beliefs regarding AM may need to be addressed to reduce treatment delay.

These findings are not dissimilar to results previously discussed, for instance:

The only solution to the problem I can think of would be to educate AM practitioners and the public such that they are aware of the issue and do everything possible to prevent such problems. But this is, of course, easier said than done, and it seems more than just optimistic to hope that such endeavours might be successful. The public is currently  bombarded with misleading information and outright lies about AM (many of my previous post have addressed this problem). And practitioners would have to operate against their own financial interest to prevent these problems from occurring.

This means that treatment delays caused by AM-use and advice from AM practitioners are inevitable…

unless you have a better idea.

If so, please let me know.

 

The fact that some alternative medicine (the authors use the abbreviation ‘CAM’) practitioners recommend against vaccination is well-known and often-documented. Specifically implicated are:

As a result, children consulting homeopaths, naturopaths or chiropractors are less likely to receive vaccines and more likely to get vaccine-preventable diseases. These effects have been noted for several childhood infections but little is known about how child CAM-usage affects influenza vaccination.

A new nationally representative study fills this gap; it analysed ∼9000 children from the Child Complementary and Alternative Medicine File of the 2012 National Health Interview Survey. Adjusting for health services use factors, it examined influenza vaccination odds by ever using major CAM domains: (1) alternative medical systems (AMS; eg, acupuncture); (2) biologically-based therapies, excluding multivitamins/multi-minerals (eg, herbal supplements); (3) multi-vitamins/multi-minerals; (4) manipulative and body-based therapies (MBBT; eg, chiropractic manipulation); and (5) mind-body therapies (eg, yoga).

Influenza vaccination uptake was lower among children ever (versus never) using AMS (33% vs 43%; P = .008) or MBBT (35% vs 43%; P = .002) but higher by using multivitamins/multiminerals (45% vs 39%; P < .001). In multivariate analyses, multivitamin/multimineral use lost significance, but children ever (versus never) using any AMS or MBBT had lower uptake (respective odds ratios: 0.61 [95% confidence interval: 0.44-0.85]; and 0.74 [0.58-0.94]).

The authors concluded that children who have ever used certain CAM domains that may require contact with vaccine-hesitant CAM practitioners are vulnerable to lower annual uptake of influenza vaccination. Opportunity exists for US public health, policy, and medical professionals to improve child health by better engaging parents of children using particular domains of CAM and CAM practitioners advising them.

There is hardly any need to point out that CAM-use is associated with low vaccination-uptake. We have discussed this on my blog ad nauseam – see for instance here, here, here and here. Too many CAM practitioners have an irrational view of vaccinations and advise against their patients against them. Anyone who needs more information might find it right here by searching this blog. Anyone claiming that this is all my exaggeration might look at these papers, for instance, which have nothing to do with me (there are plenty more for those who are willing to conduct a Medline search):

  • Lehrke P, Nuebling M, Hofmann F, Stoessel U. Attitudes of homeopathic physicians towards vaccination. Vaccine. 2001;19:4859–4864. doi: 10.1016/S0264-410X(01)00180-3. [PubMed]
  • Halper J, Berger LR. Naturopaths and childhood immunizations: Heterodoxy among the unorthodox. Pediatrics. 1981;68:407–410. [PubMed]
  • Colley F, Haas M. Attitudes on immunization: A survey of American chiropractors. Journal of Manipulative and Physiological Therapeutics. 1994;17:584–590. [PubMed]

One could, of course, argue about the value of influenza vaccination for kids, but the more important point is that CAM practitioners tend to be against ANY immunisation. And the even bigger point is that many of them issue advice that is against conventional treatments of proven efficacy.

In a previous post I asked the question ‘Alternative medicine for kids: when is it child-abuse?’ I think that evidence like the one reported here renders this question all the more acute.

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