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

evidence

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I have been sent a press release dated 26/5/2022 that might interest some of my readers. As it is in German, I took the liberty of translating it:

The 126th German Medical Congress today in Bremen deleted the additional designation of homeopathy from the further education regulations for doctors (MWBO). The request brought by Bremen delegates was decided by the physician parliament with a large majority.

The Bremen delegates justified their request with the fact that 13 of 17 state medical associations have already deleted the additional designation of homeopathy from their further education regulations. The further education regulation is to create uniform rules for the post-graduate training of doctors. However, there is no longer any question of uniformity if 13 state medical associations do not follow the MWBO.

In the debate, Dr. Johannes Grundmann once again pointed out that it is not a matter of prohibiting people from using homeopathic remedies. “However, it is the task of the medical associations to define and check verifiable learning objectives,” Grundmann said to great applause.

In September 2020, the Bremen Medical Association had become the first such chamber in Germany to remove homeopathy from its education regulations. The complaint of a Bremen physician against it had subsequently been rejected in two instances. Most recently, the Bremen health insurance was the first to terminate three selective contracts for the remuneration of homeopathic services.

____________________________

I feel that this is a nice victory of reason over unreason. I might even go as far as assuming that our petition of 2021 might have helped a little to bring it about:

Dear President Dr Reinhardt,

Dear Ms Lundershausen,

Mrs Held,

Dear Ms Johna,

We, the undersigned doctors, would like to draw your attention to the insistence of individual state medical associations on preserving “homeopathy” as a component of continuing medical education. We hope that you, by virtue of your office, will ensure a nationwide regulation so that this form of sham treatment [1], as has already happened in other European countries, can no longer call itself part of medicine.

We justify our request by the following facts:

    1. After the landmark vote in Bremen in September 2019 to remove “homeopathy” from the medical training regulations, 10 other state medical associations have so far followed Bremen’s example. For reasons of credibility and transparency, it would be desirable if the main features of the training content taught were not coordinated locally in the future, but centrally and uniformly across the country so that there is no “training tourism”. Because changes to a state’s own regulations of postgraduate training are only binding for the examination committee of the respective state, this does not affect national regulations but is reduced to only a symbolic character without sufficient effects on the portfolio of medical education nationwide.
    2. Medicine always works through the combination of a specifically effective part and non-specific placebo effects. By insisting on a pseudo-medical methodology – as is “homeopathy” represents in our opinion – patients are deprived of the specific effective part and often unnecessarily deprived of therapy appropriate to the indication. Tragically, it happens again and again that the “therapeutic window of opportunity” for an appropriate therapy is missed, tumors can grow to inoperable size, etc.
    3. Due to the insistence of individual state medical associations on the “homeopathic doctrine of healing” as part of the medical profession, we are increasingly exposed to the blanket accusation that, by tolerating this doctrine, we are supporting and promoting ways of thinking and world views that are detached from science. This is a dangerous situation, which in times of a pandemic manifests itself in misguided aggression reflected not just in vaccination skepticism and vaccination refusal, but also in unacceptable personal attacks and assaults on vaccinating colleagues in private practice.

[1] Homöopathie – die Fakten [unverdünnt] eBook : Ernst, Edzard, Bretthauer, Jutta: Amazon.de: Kindle-Shop

Responsible:

Dr. med. Dent. Hans-Werner Bertelsen

Prof. Dr. med. Edzard Ernst

George A. Rausche

_______________________________________

The first reported reactions from politicians are positive, while those of homeopaths are predictably the opposite:

German Health Minister Karl Lauterbach (SPD) expressly welcomed the delegates’ decision, writing via Twitter. “Good medicine stands on the ground of science. For homeopathy, there is no place there. In such a question, one must show one’s colors.”

Paula Piechotta, a Green Party member of parliament, was equally pleased. “… it is good when in times of Fake Facts and right-wing conspiracy theories clarity is provided where clarity is needed. Thank you Ärztetag,” she tweeted.

Michaela Geiger, chairwoman of the German Central Association of Homeopathic Physicians, noted the decision “with astonishment.” Homeopathy has a high acceptance among the population, she claimed.

 

During their cancer treatment path, cancer patients use numerous drugs,e.g.:

  • anticancer medications,
  • supportive drugs,
  • other prescribed medications,
  • herbal remedies,
  • other OTC products.

This puts them at risk of significant drug interactions (DIs).

This study describes potential DIs in cancer patients and their prevalence and predictors.

A cross-sectional study was carried out in two centers in the northern West Bank, Palestine. The Lexicomp® Drug Interactions tool (Lexi-Comp, Hudson OH, USA) was applied to check the potential DIs. In addition, the Statistical Package for the Social Sciences (SPSS) was used to show the results and find the associations.

The final analysis included 327 patients. Most of the participants were older than 50 years (61.2%), female (68.5%), and had a solid tumor (74.6%). The total number of potential DIs was 1753, including 1510 drug-drug interactions (DDIs), 24 drug-herb interactions, and 219 drug-food interactions. Importantly, the prevalence of DDIs was 88.1%. In multivariate analysis, the number of potential DDIs significantly decreased with the duration of treatment (p = 0.007), while it increased with the number of comorbidities (p < 0.001) and the number of drugs used (p < 0.001).

The authors concluded that they found a high prevalence of DIs among cancer patients. This required health care providers to develop a comprehensive protocol to monitor and evaluate DIs by improving doctor-pharmacist communication and supporting the role of clinical pharmacists.

What the investigators did not study was the possibility of herb-herb and herb-non-herbal supplement interactions. The reason for this is probably simple: we know too little about these areas to make reasonable judgments. But even in the absence of such considerations, the prevalence of DDIs among cancer patients was high (88.1%). This means that the vast majority of cancer patients had at least one potential DDI. Over half of them were classified as moderately severe or worse.

The lessons seem to be to:

  • use only truly necessary drugs and omit all remedies that are of doubtful value,
  • educate the public about the risks of interactions,
  • be skeptical about the messages of integrative medicine,
  • consult a healthcare professional who is competent to make such judgments,
  • conduct more rigorous research to increase our knowledge in this complex area.

Practitioners of so-called alternative medicine (SCAM) often argue against treating back problems with drugs. They also frequently defend their own therapy by claiming it is backed by published guidelines. So, what should we think about guidelines for the management of back pain?

This systematic review was aimed at:

  1. systematically evaluating the literature for clinical practice guidelines (CPGs) that included the pharmaceutical management of non-specific LBP;
  2. appraising the methodological quality of the CPGs;
  3. qualitatively synthesizing the recommendations with the intent to inform non-prescribing providers who manage LBP.

The authors searched PubMed, Cochrane Database of Systematic Review, Index to Chiropractic Literature, AMED, CINAHL, and PEDro to identify CPGs that described the management of mechanical LBP in the prior five years. Two investigators independently screened titles and abstracts and potentially relevant full text were considered for eligibility. Four investigators independently applied the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument for critical appraisal. Data were extracted for pharmaceutical intervention, the strength of recommendation, and appropriateness for the duration of LBP.

Only nine guidelines with global representation met the eligibility criteria. These CPGs addressed pharmacological treatments with or without non-pharmacological treatments. All CPGs focused on the management of acute, chronic, or unspecified duration of LBP. The mean overall AGREE II score was 89.3% (SD 3.5%). The lowest domain mean score was for applicability, 80.4% (SD 5.2%), and the highest was Scope and Purpose, 94.0% (SD 2.4%). There were ten classifications of medications described in the included CPGs: acetaminophen, antibiotics, anticonvulsants, antidepressants, benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, oral corticosteroids, skeletal muscle relaxants (SMRs), and atypical opioids.

The authors concluded that nine CPGs, included ten medication classes for the management of LBP. NSAIDs were the most frequently recommended medication for the treatment of both acute and chronic LBP as a first line pharmacological therapy. Acetaminophen and SMRs were inconsistently recommended for acute LBP. Meanwhile, with less consensus among CPGs, acetaminophen and antidepressants were proposed as second-choice therapies for chronic LBP. There was significant heterogeneity of recommendations within many medication classes, although oral corticosteroids, benzodiazepines, anticonvulsants, and antibiotics were not recommended by any CPGs for acute or chronic LBP.

Oddly, this review was published by chiros in a chiro journal. The authors mention that nearly all guidelines the included CPGs recommended non-pharmacological treatments for non-specific LBP, however it was not always delineated as to precede or be used in conjunction with pharmacological intervention.

I find the review interesting because I think it suggests that:

  1. CPGs are not the most reliable form of evidence. Their guidance depends on how up-to-date they are and on the identity and purpose of the authors.
  2. Guidelines are therefore often contradictory.
  3. Back pain is a symptom for which currently no optimal treatment exists.
  4. The most reliable evidence will rarely come from CPGs but from rigorous, up-to-date, independent systematic reviews such as those from the Cochrane Collaboration.

So, the next time chiropractors osteopaths, acupuncturists, etc. tell you “BUT MY THERAPY IS RECOMMENDED IN THE GUIDELINES”, please take it with a pinch of salt.

I was alerted to the following conference announcement:

The MEP Interest Group on Integrative Medicine and Health is delighted to invite you to the event ‘Integrative Medicine and Health in prevention and management of COVID-19 and long COVID’ on Thursday 2 June 16.0018.00 CEST.

This event will give you in-depth information about:

Expert speakers will share their knowledge and insights about how:

• Complementary and Integrative Medicine and Health interventions can improve resilience to COVID-19 infection.

• Promoting resilience and health restoration can reduce the risk of severe COVID-19 or development of Long COVID.

• These interventions can improve the recovery from Long COVID.

Key speakers and topics:

Therapeutic strategies of complementary medicines in the COVID 19 pandemic and Long COVID in addition to conventional medicine

Dr Joanna Dietzel, MD Neurologist, Acupuncturist. Department for integrative & complementary medicine, Institute of social medicine, epidemiology and health economics, Charité – Universitätsmedizin Berlin, Germany.

Chinese herbal medicine treatment in cases of infections with SARS-CoV-2 – therapeutic strategies for COVID-19 and Long COVID

Dr Christian Thede, MD, General practitioner, specialised in Acupuncture and Chinese Medicine. Former lecturer in Chinese medicine, University of Witten-Herdecke, Germany

Instructor for Acupuncture and Chinese Medicine at International Society of Chinese Medicine (SMS).

Traditional and Complementary Medicine contributions to health system resilience during COVID-19 – the WHO perspective

Dr Geetha Kopalakrishna, MD, Bachelor of Ayurvedic Medicine & Surgery

Technical Officer at Traditional, Complementary & Integrative Medicine, Department of Service Delivery and Safety, World Health Organization, Geneva, Switzerland

Key member of the AYUSH-based COVID-19 response Task Force for the Government of India.

Research programme into integrative medicine’s contribution to improving resilience to COVID-19 infection and reducing the risk of severe COVID-19 or development of Long COVID

Dr Helene M. Langevin, Director at National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, Maryland (MD), USA. Previously, Director of the Harvard Osher Center for Integrative Medicine and professor of medicine at Harvard Medical School, Boston (MA) and professor of neurological sciences at the Larner College of Medicine at the University of Vermont (VT).

Q&A sessions after the presentations.

Resilience to infections: a solution for COVID-19 and other infectious illnesses

Studies show that certain common medical conditions put people at higher risk for severe illness and death from COVID-19. Nearly two-thirds of COVID-19 hospitalizations could be attributed to obesity, diabetes, hypertension, and heart failure. There is increasing awareness that a health system that focuses on improving health could prevent all these conditions to a large extent.

Long COVID

More than 40% of people who have or had COVID-19 get long COVID, and among people who needed hospitalization, the statistics go up to 57%. The recovery from such post viral syndromes will be greatly helped by offering patients access to complementary and integrative medicine interventions that aim at restoring their health balance.

MEP Interest Group on Integrative Medicine and Health

The event is hosted by the members of the MEP Interest Group on Integrative Medicine & Health:

Michèle Rivasi, Greens/EFA, France

Sirpa Pietikäinen, EPP, Finland

Tilly Metz, Greens/EFA, Luxembourg

Margrete Auken, Greens/EFA, Denmark

Romana Jerković, S&D, Croatia

Manuela Ripa, Greens/EFA, Germany

I had not been aware of the ‘MEP Interest Group on Integrative Medicine & Health‘. Therefore, I looked it up and found this:

The newly established Interest Group on Integrative Medicine & Health continues the work of the former MEP Interest Group on CAM. This group brings together MEPs who work collectively to promote the inclusion of CAM as part of Integrative Medicine & Health in all possible European Parliament public health policy.

Why an Interest Group in the European Parliament?

One in two EU citizens uses complementary medicine either alongside or as an alternative to conventional biomedical care. This high demand is not yet reflected in EU or national health policy or provision. In addition, there is diversity in complementary medicine regulation across the EU. There are differences in who can practice complementary medicine, what qualifications are required and how services are offered and financed. These discrepancies mean that citizens experience practical and attitudinal barriers that limit their access to and use of TCIM.

The health sector in the EU Member States is facing considerable challenges, such as antimicrobial resistance (AMR), increasing prevalence of Non-Communicable Diseases (NCDs) and soaring costs. Complementary medicine can offer a significant contribution to meet these challenges. These modalities are “integrative”, offering patient-centered healthcare, based on evidence-informed integration of conventional biomedicine and complementary medicine. Integrative Medicine and Health focuses on the whole person and considers the individual in its physical, psychological, spiritual, social and environmental context. It is inclusive of all professions and practices that use this approach and meets the demand of EU citizens for a more holistic, patient-centered approach in medicine. At the same time, TCIM is at the center of political and scientific debate. In this context, a forum for discussion on Integrative and Complementary Medicine’s contribution to EU health systems will bring clarity and rationality to this debate.

Aims and objectives of the Interest Group on Integrative Medicine & Health

  • Establish and maintain a forum for discussion and action with all stakeholders regarding Integrative Medicine and Health.
  • Raise awareness of Integrative Medicine and its contribution to more sustainable healthcare systems in the EU and a more holistic approach to health.
  • Focus on the integration of complementary modalities into the health systems of the EU Member States.
  • Protect and promote citizens’ right to choose their own healthcare while providing access to Integrative Medicine and Health information.
  • Advocate for EU involvement in setting unified standards to regulation of Integrative Medicine and Health.

__________________________________

Unified standards? But what about high or perhaps just scientific standards? What about first doing the research and then making claims about CAM or TCIM or however you decide to call it? Has common sense gone out of fashion?

Yes, you guessed it: I am seriously underwhelmed by all this. To show you why, let me list just a few claims from the above two statements that are based purely on wishful thinking:

  • Complementary and Integrative Medicine and Health interventions can improve resilience to COVID-19 infection.
  • These interventions can improve the recovery from Long COVID.
  • Studies show that certain common medical conditions put people at higher risk for severe illness and death from COVID-19.
  • The recovery from such post viral syndromes will be greatly helped by offering patients access to complementary and integrative medicine interventions that aim at restoring their health balance.
  • One in two EU citizens uses complementary medicine either alongside or as an alternative to conventional biomedical care.
  • The health sector in the EU Member States is facing considerable challenges, such as antimicrobial resistance (AMR), increasing prevalence of Non-Communicable Diseases (NCDs) and soaring costs. Complementary medicine can offer a significant contribution to meet these challenges.
  • These modalities are “integrative”, offering patient-centered healthcare, based on evidence-informed integration of conventional biomedicine and complementary medicine.
  • Integrative medicine … meets the demand of EU citizens for a more holistic, patient-centered approach in medicine.

I find all this confusing and concerning in equal measure. I also seriously doubt that the forum for discussion on Integrative and Complementary Medicine will bring clarity and rationality to this debate. If they really wanted a debate, they would need to include a few critical thinkers; can anyone recognize one on the list of speakers? I cannot!

I fear the aim of the group and their meeting is to mislead us all into thinking that CAM, TCIM, etc. generate more good than harm without ever delivering the evidence for that assumption. Therefore, I suggest they rename both the conference as well as their group:

Wishful thinking in prevention and management of COVID-19 and long COVID

and

MEP Interest Group on Wishful Thinking and Promotion of Quackery

 

 

PS

As an antidote to wishful thinking, I recommend reading some proper science papers on the subject. Here are the conclusions of an up-to-date and wishful-thinking-free review on the subject of post-acute infection syndrome:

Unexplained post-acute infection syndromes (PAISs) appear to be an under-recognized feature of a spectrum of infectious diseases in a minority of patients. At present, our understanding of the underlying pathophysiologic mechanisms and etiologic factors is poor and there are no known objective markers or effective therapeutic options. More basic biomedical research is needed. The overlap of symptoms, signs, and general features of the individual PAISs suggests the involvement of shared pathological pathways and the possibility that common diagnostic markers, or even a unified etiological model, might be established.

However, some symptoms or clinical characteristics seem to be trigger-specific or more prevalent in one PAIS than in others, emphasizing the need for cohorts with a well-documented infectious trigger. The overall clinical picture of many PAISs often overlaps with the presentation of post-infectious ME/CFS or fibromyalgia, or resembles other fatiguing, neurological, or rheumatic disorders. Exploiting existing knowledge of these conditions might help guide future scientific discovery and progress in clinical care.

The SARS-CoV-2 pandemic uncovered a significant gap in knowledge about post-acute sequelae of infectious diseases and identified the need for better diagnostic care and clinical infrastructure for patients experiencing these long-term effects. In addition to basic biomedical research, more needs to be done to refine diagnostic criteria and obtain more reliable estimates of the prevalence and societal burden of these disorders to help shape health-policy decisions. Moreover, we call for unified nomenclature and better conceptualization of post-acute infection symptoms.

There is much to be done, but the unprecedented amount of attention and resources that have recently been allocated to the study of COVID-19-related pathology brings a promise of much-needed progress in the wider field of unexplained infection-associated chronic disability.

This meta-analysis was conducted by researchers affiliated to the Evangelical Clinics Essen-Mitte, Department of Internal and Integrative Medicine, Faculty of Medicine, University of Duisburg-Essen, Germany. (one of its authors is an early member of my ALTERNATIVE MEDICINE HALL OF FAME). The paper assessed the safety of acupuncture in oncological patients.

The PubMed, Cochrane Central Register of Controlled Trials, and Scopus databases were searched from their inception to August 7, 2020. Randomized controlled trials in oncological patients comparing invasive acupuncture with sham acupuncture, treatment as usual (TAU), or any other active control were eligible. Two reviewers independently extracted data on study characteristics and adverse events (AEs). Risk of bias was assessed using the Cochrane Risk of Bias Tool.

Of 4590 screened articles, 65 were included in the analyses. The authors observed that acupuncture was not associated with an increased risk of intervention-related AEs, nonserious AEs, serious AEs, or dropout because of AEs compared with sham acupuncture and active control. Compared with TAU, acupuncture was not associated with an increased risk of intervention-related AEs, serious AEs, or dropout because of AEs but was associated with an increased risk for nonserious AEs (odds ratio, 3.94; 95% confidence interval, 1.16-13.35; P = .03). However, the increased risk of nonserious AEs compared with TAU was not robust against selection bias. The meta-analyses may have been biased because of the insufficient reporting of AEs in the original randomized controlled trials.

The authors concluded that the current review indicates that acupuncture is as safe as sham acupuncture and active controls in oncological patients. The authors recommend researchers heed the CONSORT (Consolidated Standards of Reporting Trials) safety and harm extension for reporting to capture the side effects and better investigate the risk profile of acupuncture in oncology.

You might think this article is not too bad. So, why do I feel that this paper is so bad?

One reason is that the authors included evidence up to August 2020. Since then, there must have been hundreds of further papers on acupuncture. The article was therefore out of date before it was published.

But that is by no means my main reason. We know from numerous investigations that acupuncture studies often fail to report AEs (and thus violate publication ethics). This means that this new analysis is merely an amplification of the under-reporting. It is, in other words, a means of perpetuating a wrong message.

Yes, you might say, but the authors acknowledge this; they even state in the abstract that “The meta-analyses may have been biased because of the insufficient reporting of AEs in the original randomized controlled trials.” True, but this fact does not erase the mistake, it merely concedes it. At the very minimum, the authors should have phrased their conclusion differently, e.g.: the current review confirms that AEs of acupuncture are under-reported in RCTs. Therefore, a meta-analysis of RCTs is unable to verify whether acupuncture is safe. From other types of research, we know that it can cause serious AEs.

An even better solution would have been to abandon or modify the research project when they first came across the mountain of evidence showing that RCTs often fail to mention AEs.

As it stands, the conclusion that acupuncture is as safe as sham acupuncture is simply not true. Since the article probably looks sound to naive readers, I feel that is a particularly good candidate for the WORST PAPER OF 2022 COMPETITION.

 

PS

For those who are interested, here are 4 of my own peer-reviewed articles on the safety of acupuncture (much more can, of course, be found on this blog):

  1. Patient safety incidents from acupuncture treatments: a review of reports to the National Patient Safety Agency – PubMed (nih.gov)
  2. Acupuncture–a critical analysis – PubMed (nih.gov)
  3. Prospective studies of the safety of acupuncture: a systematic review – PubMed (nih.gov)
  4. The risks of acupuncture – PubMed (nih.gov)

Anyone who has followed this blog for a while will know that advocates of so-called alternative medicine (SCAM) are either in complete denial about the risks of SCAM or they do anything to trivialize them. Here is a dialogue between a SCAM proponent (P) and a scientist (S) that is aimed at depicting this situation. The conversation is fictitious, of course, but it is nevertheless based on years of experience in discussing these issues with practitioners of various types of SCAM. As we shall see, the arguments turn out to be perfectly circular.

P: My therapy is virtually free of risks.

S: How can you be so sure?

P: I am practicing it for decades and have never seen a single problem.

S: That could have several reasons; perhaps the patients who experience problems did simply not come back.

P: I find this unlikely.

S: I don’t, and I know of reports where patients had serious complications after the type of SCAM you practice.

P: These are isolated case reports. They do not amount to evidence.

S: How do you know they are isolated?

P: They must be isolated because, in the many clinical trials of my therapy available to date, you will not find any evidence of serious adverse effects.

S: That is true, but it has been repeatedly shown that these trials regularly fail to mention side effects altogether.

P: That’s because there aren’t any.

S: Not quite, clinical trials should always mention adverse effects, and if there were none, they should mention this too.

P: So, you admit that you have no evidence that my therapy causes adverse effects.

S: The thing is, I don’t need such evidence. It is you, the practitioners of this therapy, who should provide evidence that your treatments are safe.

P: We did! The complete absence of reports of side effects constitutes that evidence.

S: Except, there is some evidence. I already told you that there are several case reports of serious problems.

P: But case reports are anecdotes; they are no evidence.

S: Look, here is a systematic review of all the case reports. You cannot possibly deny that this is a concern.

P: It’s still merely a bunch of anecdotes, nothing more.

S: Only because your profession does nothing about it.

P: What do you think we need to do about it?

S: Like other professions, you need to systematically record adverse effects.

P: How would that help?

S: It would give us a rough indication of the size and severity of the problem.

P: This sounds expensive and complicated to organize.

S: Perhaps, but it is necessary if you want to be sure that your therapy is safe.

P: But we are sure already!

S: No, you believe it, but you don’t know it.

P: You are getting on my nerves with your obsession. Don’t you know that the true danger in healthcare is the adverse effects of pharmaceutical drugs?

S: But these drugs are also effective.

P: Are you saying my therapy isn’t?

S: What I am saying is that the drugs you claim to be dangerous do more good than harm, while this is not at all clear with your SCAM.

P: To me, that is very clear. My therapy helps many and harms nobody!

S: How do you know that it harms nobody?

 

 

… At this point, we have gone full circle and we can re-start this conversation from its beginning.

 

 

A recent article in LE PARISIEN entitled “L’homéopathie vétérinaire, c’est sans effet… mais pas sans risque” – Veterinary homeopathy is without effect … but not without risk, tells it like it is. Here are a few excerpts that I translated for you.

More than 77% of French people have tried homeopathy in their lifetime. But have you ever given it to your pet? Harmless in most cases, its use can be dangerous when it replaces a treatment whose effectiveness is scientifically proven … from a safety point of view, the tiny granules are indeed irreproachable: their use does not induce any drug interaction or undesirable side effects, nor does it run the risk of overdosing or addiction … homeopathic preparations owe their harmlessness to their lack of proper effects. “Neither in human medicine nor in veterinary medicine, at the current stage, clinical studies of all levels do not provide sufficient scientific evidence to support the therapeutic efficacy of homeopathic preparations”, stated the French Veterinary Academy in May 2021. These conclusions are in line with those of the French Academies of Medicine and Pharmacy, the British Royal College of Veterinary Surgeons, and all the international scientific bodies that have given their opinion on the subject.

Therefore, when homeopathy delays diagnosis or is used in place of proven effective treatments, its use represents a “loss of opportunity” for your pet. The greatest danger of homeopathy is not that the remedies are ineffective, but that some homeopaths believe that their therapies can be used as a substitute for genuine medical treatment,” summarizes a petition to the UK veterinary regulatory body signed by more than 1,000 British veterinarians. At best, this claim is misleading and, at worst, it can lead to unnecessary suffering and death.”

But how can we explain the number of testimonies from pet owners who say that “it works”? “I am very satisfied with the Kalium Bichromicum granules for my cat with an eye ulcer, which is healing very well”… These improvements, real or supposed, can be explained by “contextual effects”, among which the famous placebo effect (which is not specific to humans), your subjective interpretation of his symptoms, or the natural history of the disease.

When these contextual effects are ignored or misunderstood, the spontaneous resolution or reduction of the disease can be wrongly attributed to homeopathy, and thus maintain the illusion of its effectiveness. This confusion is all the more likely because homeopathy owes much of its popularity to its use to treat “everyday ailments”: nausea, allergies, fatigue, bruises, nervousness, etc., which tend to get better on their own with time, or which have a fluctuating expression…

In April 2019, the association published an open letter addressed to the National Council of the Order of Veterinarians, calling on it to take a position on the compatibility of homeopathy with the “ethical and scientific requirements” of the profession. The organization, whose official function is to guarantee the quality of the service rendered to the public by the 20,000 veterinarians practicing in France, issued its conclusions last October. It invited veterinary training centers to remove homeopathy from their curricula, under penalty of having their accreditation withdrawn, and thus their ability to deliver training credits.

In my view, this is a remarkably good and informative text. How often do homeopathy fans claim IT WORKS FOR ANIMALS AND THUS CANNOT BE A PLACEBO! The truth is that, as we have so often discussed on this blog, homeopathy does not work beyond placebo for animals. This renders veterinary homeopathy:

  • a waste of money,
  • potentially dangerous,
  • in the worst cases a form of animal abuse.

My advice is that, as soon as a vet recommends homeopathy, you look for the exit.

I know, transcutaneous electrical nerve stimulation (TENS) is not really a so-called alternative medicine (SCAM) but it is used by many SCAM practitioners and pain patients. It is, therefore, worth knowing whether it works.

This systematic review investigated the efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for the relief of pain in adults. All randomized clinical trials (RCTs) were considered which compared strong non-painful TENS at or close to the site of pain versus placebo or other treatments in adults with pain, irrespective of diagnosis.

Reviewers independently screened, extracted data, and assessed the risk of bias (RoB, Cochrane tool) and certainty of evidence (Grading and Recommendations, Assessment, Development, and Evaluation). The outcome measures were the mean pain intensity and the proportions of participants achieving reductions of pain intensity (≥30% or >50%) during or immediately after TENS. Random effect models were used to calculate standardized mean differences (SMD) and risk ratios. Subgroup analyses were related to trial methodology and characteristics of pain.

The review included 381 RCTs (24 532 participants). Pain intensity was lower during or immediately after TENS compared with placebo (91 RCTs, 92 samples, n=4841, SMD=-0·96 (95% CI -1·14 to -0·78), moderate-certainty evidence). Methodological (eg, RoB, sample size) and pain characteristics (eg, acute vs chronic, diagnosis) did not modify the effect. Pain intensity was lower during or immediately after TENS compared with pharmacological and non-pharmacological treatments used as part of standard of care (61 RCTs, 61 samples, n=3155, SMD = -0·72 (95% CI -0·95 to -0·50], low-certainty evidence). Levels of evidence were downgraded because of small-sized trials contributing to imprecision in magnitude estimates. Data were limited for other outcomes including adverse events which were poorly reported, generally mild, and not different from comparators.

The authors concluded that there was moderate-certainty evidence that pain intensity is lower during or immediately after TENS compared with placebo and without serious adverse events.

This is an impressive review, not least because of its rigorous methodology and the large number of included trials. Its results are clear and convincing. In the words of the authors: “TENS should be considered in a similar manner to rubbing, cooling or warming the skin to provide symptomatic relief of pain via neuromodulation. One advantage of TENS is that users can adjust electrical characteristics to produce a wide variety of TENS sensations such as pulsate and paraesthesiae to combat the dynamic nature of pain. Consequently, patients need to learn how to use a systematic process of trial and error to select electrode positions and electrical characteristics to optimise benefits and minimise problems on a moment to moment basis.”

During the last two years, I have written more often than I care to remember about the numerous links between so-called alternative medicine (SCAM) and COVID-19 vaccination hesitancy. For instance:

Whenever I publish a post on these subjects, some enthusiasts of SCAM argue that, despite all this evidence, they are not really against COVID vaccinations. But who is correct? What proportions of SCAM practitioners are pro or contra? One way to find out is to check how they themselves behave. Do they get vaccinated or not?

Here are some recent data from Canada that seem to provide an answer.

A breakdown of vaccination rates among Canadian healthcare professions has been released, based on data gathered from 17 of B.C.’s 18 regulated colleges. The findings are most revealing:

  • dieticians, physicians, and surgeons lead the way, with vaccination rates of 98%,
  • occupational therapists were at 97%,
  • Chinese medicine practitioners and acupuncturists were at 79%,
  • chiropractors at 78%
  • naturopaths at 69%.

The provincial health officer Dr. Bonnie Henry said the province is still working with the colleges on how to notify patients about their practitioner’s vaccination status. “We are working with each college on how to build it into professional standards. The overriding principle is patient status,” she told a news conference. “It may be things like when you call to book, you are asked whether you would prefer to see a vaccinated or unvaccinated professional. We are trying to protect privacy and provide agency to make the decision.”

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As far as I am aware, these are unique data. It would be interesting to see additional evidence. If anyone knows about vaccination rates in other countries of acupuncturists, herbalists, homeopaths, osteopaths, Heilpraktiker, etc. I would love to learn more.

The cardiothoracic surgeon and famous US woo merchant, Dr. Mehmet Oz, is probably known to most readers. I have previously mentioned him several times, for instance, here and here. His institution, Columbia University in New York City, has had many (I’d say too many) years of patience with his relentless promotion of outright and often dangerous quackery. Now it has been reported that the university has finally cut ties with Dr. Oz:

“It took Columbia far too long to remove Oz from its otherwise distinguished medical faculty,” Henry Miller, MD, of the Pacific Research Institute in California, told MedPage Today via email. Miller stressed that “the ‘Oz controversy’ was never about free speech. It was about an unethical grifter whose claims and pronouncements were not supported by science and were injurious to consumers — in the interest of financial benefit to Oz himself. That constitutes professional misconduct.”

The university’s Irving Medical Center quietly ended its relationship with Oz at the end of April, according to The Daily Beast. He had been removed from several pages of the medical center’s website in mid-January. In 2018, Oz’s title had been changed to professor emeritus and special lecturer, according to reports. A spokesperson for Columbia University confirmed the 2018 change in an email to MedPage Today.

In 2015, Miller and colleagues sent a letter to Lee Goldman, MD, MPH, dean of the Faculties of Health Sciences and Medicine at the university, calling for Oz’s expulsion. Oz had “repeatedly shown disdain for science and for evidence-based medicine” and “manifested an egregious lack of integrity by promoting quack treatments and cures in the interest of personal financial gain,” according to Miller’s group…

In 2014, Oz was called to testify before the Senate Subcommittee on Consumer Protection, Product Safety, and Insurance during a hearing on false advertising in the diet and weight-loss industry. Senators grilled Oz regarding statements he made on “The Dr. Oz Show” that promoted green coffee bean extract as a “miracle pill” for weight loss.

But long before that hearing, tensions had built between Oz and the medical community because of his penchant for spouting dubious medical claims on his TV show and in the media. For example, in a 2011 segmentABC News‘ chief health and medical editor Richard Besser, MD, called out a purported “study” of arsenic in apple juice that Oz conducted for an episode of his show.

Besser charged that Oz’s science was shoddy because he reported total arsenic rather than the breakdown between organic and inorganic arsenic — only the latter of which is known to be toxic. Even the FDA sent the show a letter before the segment aired saying it would be “irresponsible and misleading” to report the results.

Oz again broke with medical science during the pandemic when he touted hydroxychloroquine as a cure for COVID-19, even as evidence mounted that it had no effect on disease course.

Oz is currently running for a U.S. Senate seat in Pennsylvania as a Republican candidate. Former President Trump endorsed Oz, touting Oz’s medical and academic credentials in a statement, according to NPR: “He even said that I was in extraordinary health, which made me like him even more (although he also said I should lose a couple of pounds!).”

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I have to admit that I find these reports somewhat puzzling. Don’t get me wrong: it’s not that I don’t think Oz deserves to be dismissed. In fact, he had already richly deserved it many years ago. What I find, however, odd is that giving someone the title ’emeritus professor’ can hardly be called ‘cutting ties’ with him. In some ways, it is even the opposite (I should know because I currently have this status).

When I looked up Oz, Columbia listed him as:

Oz, Mehmet C. (MD)
Special Lecturer in the Department of Surgery
Phone: 212.305.4434 · Fax: 212.342.3520
Location: MHB, Rm. 435-62

Similarly, the website of the Irving Medical Center is full of entries about Oz. Confusion is therefore more than justified, I think.

What is needed, I feel, is a clear statement from Columbia University about its relationship with Dr. Oz. Are they still proud of his considerable fame/notoriety, or did they in fact have the integrity to cut ties with one of the most self-aggrandizing woo merchants of all times?

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