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

patient choice

1 2 3 15

An epidemiological study from the US just published in the BMJ concluded that “the mortality gap in Republican voting counties compared with Democratic voting counties has grown over time, especially for white populations, and that gap began to widen after 2008.”

In a BMJ editorial, Steven Woolf comments on the study and provides further evidence on how politics influence health in the US. Here are his concluding two paragraphs:

Political influence on US mortality rates became overt during the covid-19 pandemic, when public health policies, controlled by states, were heavily influenced by party affiliation. Republican politicians, often seeking to appeal to President Trump and his supporters, challenged scientific evidence and opposed enforcement of vaccinations and safety measures such as masking. A macabre natural experiment occurred in 2021, a year marked by the convergence of vaccine availability and contagious variants that threatened unvaccinated populations: states led by governors who promoted vaccination and mandated pandemic control measures experienced much lower death rates than the “control” group, consisting of conservative states with lax policies and large unvaccinated populations. This behavior could explain why US mortality rates associated with covid-19 were so catastrophic, vastly exceeding losses in other high income countries.

Observers of health trends in the US should keep their eye on state governments, where tectonic shifts in policy are occurring. While gridlock in Washington, DC incapacitates the federal government, Republican leaders in dozens of state capitols are passing laws to undermine health and safety regulations, ban abortion, limit LGBT+ rights, and implement more conservative policies on voting, school curriculums, and climate policy. To understand the implications for population health, researchers must break with custom; although scientific literature has traditionally avoided discussing politics, the growing influence of partisan affiliation on policies affecting health makes this covariate an increasingly important subject of study.

_____________________

What has this to do with so-called alternative medicine (SCAM)?

Not a lot.

Except, of course, that Trump has been quite sympathetic to both quackery and quacks (see, for instance, here and here). Moreover, the embarrassing Dr. Oz, America’s charlatan-in-chief, is now a Republican candidate for the US senate. And the creation of the NHI office for alternative medicine, currently called NCCIH, was the idea of the Republican senator, Tom Harkin.

I think we get the drift: on the US political level, SCAM seems to be a right-wing thing.

Am I claiming that SCAM is the cause of the higher mortality in Republican counties?

No.

Do I feel that both are related to irresponsible attitudes towards healthcare issues?

Yes.

Almost 10 years ago, I posted this:

When I decided to become a doctor I, like most medical students, did so mainly to help suffering individuals. When I became a researcher, I felt more removed from this original ideal. Yet I told myself that, by conducting research, I might eventually contribute to a better health care of tomorrow. Helping suffering patients was still firmly on the agenda. But then I realised that my articles in peer-reviewed medical journals somehow missed an important target: in alternative medicine, one ought to speak not just to health care professionals but also to consumers and patients; after all, it is they who often make the therapeutic decisions in this area.

Once I had realised this, I started addressing the general public by writing for The Guardian and other newspapers, giving public lectures and publishing books for a lay audience, like TRICK OR TREATMENT…The more I did this sort of thing, the more I noticed how important this activity was. And when a friend offered to help me set up a blog, I did not hesitate for long.

So, the reason for my enthusiasm for this blog turns out to be the same as the one that enticed me to go into medicine in the first place. I do believe that it is helpful for consumers to know the truth about alternative medicine. Considering the thousands of sources of daily misinformation in this area, there is an urgent need for well-informed, critical information. By providing it, I am sure I can assist people to make better therapeutic decisions. In a way, I am back where I started all those years ago: hoping to help suffering patients in the most direct way my expertise allows.

Helping vulnerable patients often means warning them from dangerous charlatans, and this is precisely what I frequently try to do with this blog. But how successful are my endeavors?

More often than not, I have no idea and can only hope for the best. Sometimes I do get some feedback that is encouraging and motivates me to carry on. Rarely, however, do I witness immediate, tangible success. And this is why the recent story is so remarkable:

  • On 6 June, an Australian acquaintance from the FRIENDS OF SCIENCE IN MEDICINE sent me some material about a planned lecture in the UK by someone promoting dangerous quackery.
  • I looked into it and published a blog post about it a few hours later.
  • A reader then suggested in the comments section of this post alerting the UK press to it.
  • Another reader contacted THE TIMES, and I wrote to several other journalists.
  • THE TIMES turned out to be interested in the story.
  • They did some research and interviewed Michael Marshall from the GOOD THINKING SOCIETY (and myself).
  • Today, THE TIMES published an article about the planned event.
  • Finally, a kind person made the article available to those who don’t want to pay for it.

The whole thing amounts to superb teamwork, in my view. It shows how like-minded people who do not even all know each other can manage to achieve a respectable result with little more than goodwill and dedication.

A respectable result?

Of course, the optimal result would be to stop Barbara O’Neill’s UK lectures. Let’s hope this is what eventually will happen – and please let me know if you know more.

I did not know what a ‘body modification provider’ is. My first guess was that it is a car mechanic who specializes in making my vehicle look ok again after I had a minor accident. But I was wrong! In fact, it is a new healthcare profession – one that we are well-advised to avoid, as it turns out. A Media Release from the Health Care Complaints Commission of Australia dated 27 May, 2022 informed us that:

The NSW Health Care Complaints Commission (Commission) investigated the conduct of Mr Brendan Russell, a body modification provider.

In his capacity as a body modification provider, conducting invasive surgical procedures and administering sedation, Mr Russell is a non-registered health practitioner and subject to the Code of Conduct for non-registered health practitioners (Code of Conduct) set out in schedule 3 of the Public Health Regulation 2012.

Mr Russell was charged with criminal offences relating to services provided to three clients. One related to the removal of part of a client’s labia. Another related to the death of a client following a subdermal implant of a silicone object into the client’s right hand. Mr Russell also performed abdominal surgery on another client making incisions into her abdominal tissue to remove fat.

Following convictions in November 2021 for Intentionally Causing Grievous Bodily Harm, Aid/Abet/Counsel or Procure Female Genital Mutilation and Manslaughter, Mr Russell has breached numerous clauses of the Code of Conduct, and it has been determined that he poses a risk to the health and safety of members of the public.

An Interim Prohibition order has been in place to protect the public during the criminal proceedings.  The Commission has now imposed a Permanent Prohibition Order under section 41A(2)(a) of the Health Care Complaints Act 1993 (Act):

Mr Brendan Russell, a body modification provider, is permanently prohibited from providing any health services, either in paid employment or voluntarily, to any member of the public.

___________________________________

What is all this about? Has this man gone doolally? In particular, what is the removal of a woman’s labia supposed to be for? Here is what Wikipedia says about it:

Labiaplasty (also known as labioplastylabia minora reduction, and labial reduction) is a plastic surgery procedure for altering the labia minora (inner labia) and the labia majora (outer labia), the folds of skin surrounding the human vulva. There are two main categories of women seeking cosmetic genital surgery: those with congenital conditions such as intersex, and those with no underlying condition who experience physical discomfort or wish to alter the appearance of their genitals because they believe they do not fall within a normal range.[1]

The size, colour, and shape of labia vary significantly, and may change as a result of childbirth, aging, and other events.[1] Conditions addressed by labiaplasty include congenital defects and abnormalities such as vaginal atresia (absent vaginal passage), Müllerian agenesis (malformed uterus and fallopian tubes), intersex conditions (male and female sexual characteristics in a person); and tearing and stretching of the labia minora caused by childbirth, accident, and age. In a male-to-female sexual reassignment vaginoplasty for the creation of a neovagina, labiaplasty creates labia where once there were none.

A 2008 study reported that 32 percent of women who underwent the procedure did so to correct a functional impairment; 31 percent to correct a functional impairment and for aesthetic reasons; and 37 percent for aesthetic reasons alone.[2] According to a 2011 review, overall patient satisfaction is in the 90–95 percent range.[3] Risks include permanent scarring, infections, bleeding, irritation, and nerve damage leading to increased or decreased sensitivity. A change in requirements of publicly funded Australian plastic surgery requiring women to be told about natural variation in labias led to a 28% reduction in the number of surgeries performed.[4] Unlike public hospitals, cosmetic surgeons in private practice are not required to follow these rules, and critics say that “unscrupulous” providers are charging to perform the procedure on women who would not want it if they had more information.[4]

______________________________

So, now we know. The procedure belongs in the hands of plastic surgeons, not some ‘body modification provider’. S0-called alternative medicine (SCAM) really is a scam where anything goes. Homeopaths claim to cure cancer, chiropractors believe they can treat anything from deafness and heart disease, acupuncturists feel they can reduce body weight, and now ‘body modification providers’ think they are plastic surgeons. What is more, the amazing thing is: there are always some people gullible enough to believe them.

Brave new world!

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.

This study used a US nationally representative 11-year sample of office-based visits to physicians from the National Ambulatory Medical Care Survey (NAMCS), to examine a comprehensive list of factors believed to be associated with visits where complementary health approaches were recommended or provided.

NAMCS is a national health care survey designed to collect data on the provision and use of ambulatory medical care services provided by office-based physicians in the United States. Patient medical records were abstracted from a random sample of office-based physician visits. The investigators examined several visit characteristics, including patient demographics, physician specialty, documented health conditions, and reasons for a health visit. They ran chi-square analyses to test bivariate associations between visit factors and whether complementary health approaches were recommended or provided to guide the development of logistic regression models.

Of the 550,114 office visits abstracted, 4.43% contained a report that complementary health approaches were ordered, supplied, administered, or continued. Among complementary health visits, 87% of patient charts mentioned nonvitamin nonmineral dietary supplements. The prevalence of complementary health visits significantly increased from 2% in 2005 to almost 8% in 2015. Returning patient status, survey year, physician specialty and degree, menopause, cardiovascular, and musculoskeletal diagnoses were significantly associated with complementary health visits, as was seeking preventative care or care for a chronic problem.

The authors concluded that these data confirm the growing popularity of complementary health approaches in the United States, provide a baseline for further studies, and inform subsequent investigations of integrative health care.

The authors used the same dataset for a 2nd paper which examined the reasons why office-based physicians do or do not recommend four selected complementary health approaches to their patients in the context of the Andersen Behavioral Model. Descriptive estimates were employed of physician-level data from the 2012 National Ambulatory Medical Care Survey (NAMCS) Physician Induction Interview, a nationally representative survey of office-based physicians (N = 5622, weighted response rate = 59.7%). The endpoints were the reasons for the recommendation or lack thereof to patients for:

  • herbs,
  • other non-vitamin supplements,
  • chiropractic/osteopathic manipulation,
  • acupuncture,
  • mind-body therapies (including meditation, guided imagery, and progressive relaxation).

Differences by physician sex and medical specialty were described.

For each of the four complementary health approaches, more than half of the physicians who made recommendations indicated that they were influenced by scientific evidence in peer-reviewed journals (ranging from 52.0% for chiropractic/osteopathic manipulation [95% confidence interval, CI = 47.6-56.3] to 71.3% for herbs and other non-vitamin supplements [95% CI = 66.9-75.4]). More than 60% of all physicians recommended each of the four complementary health approaches because of patient requests. A higher percentage of female physicians reported evidence in peer-reviewed journals as a rationale for recommending herbs and non-vitamin supplements or chiropractic/osteopathic manipulation when compared with male physicians (herbs and non-vitamin supplements: 78.8% [95% CI = 72.4-84.3] vs. 66.6% [95% CI = 60.8-72.2]; chiropractic/osteopathic manipulation: 62.3% [95% CI = 54.7-69.4] vs. 47.5% [95% CI = 42.3-52.7]).

For each of the four complementary health approaches, a lack of perceived benefit was the most frequently reported reason by both sexes for not recommending. Lack of information sources was reported more often by female versus male physicians as a reason to not recommend herbs and non-vitamin supplements (31.4% [95% CI = 26.8-36.3] vs. 23.4% [95% CI = 21.0-25.9]).

The authors concluded that there are limited nationally representative data on the reasons as to why office-based physicians decide to recommend complementary health approaches to patients. Developing a more nuanced understanding of influencing factors in physicians’ decision making regarding complementary health approaches may better inform researchers and educators, and aid physicians in making evidence-based recommendations for patients.

I am not sure what these papers really offer in terms of information that is not obvious or that makes a meaningful contribution to progress. It almost seems that, because the data of such surveys are available, such analyses get done and published. The far better reason for doing research is, of course, the desire to answer a burning and relevant research question.

A problem then arises when researchers, who perceive the use of so-called alternative medicine (SCAM) as a fundamentally good thing, write a paper that smells more of SCAM promotion than meaningful science. Having said that, I find it encouraging to read in the two papers that

  • the prevalence of SCAM remains quite low,
  • more than 60% of all physicians recommended SCAM not because they were convinced of its value but because of patient requests,
  • the lack of perceived benefit was the most frequently reported reason for not recommending it.

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.

There are many patients in general practice with health complaints that cannot be medically explained. Some of these patients attribute their problems to dental amalgam.

This study examined the cost-effectiveness of the removal of amalgam fillings in patients with medically unexplained physical symptoms (MUPS) attributed to amalgam compared to usual care, based on a prospective cohort study in Norway.

Costs were determined using a micro-costing approach at the individual level. Health outcomes were documented at baseline and approximately two years later for both the intervention and the usual care using EQ-5D-5L. Quality-adjusted life year (QALY) was used as the main outcome measure. A decision analytical model was developed to estimate the incremental cost-effectiveness of the intervention. Both probabilistic and one-way sensitivity analyses were conducted to assess the impact of uncertainty on costs and effectiveness.

In patients who attributed health complaints to dental amalgam and fulfilled the inclusion and exclusion criteria, amalgam removal was associated with a modest increase in costs at the societal level as well as improved health outcomes. In the base-case analysis, the mean incremental cost per patient in the amalgam group was NOK 19 416 compared to the MUPS group, while the mean incremental QALY was 0.119 with a time horizon of two years. Thus, the incremental costs per QALY of the intervention were NOK 162 680, which is usually considered to be cost-effective in Norway. The estimated incremental cost per QALY decreased with increasing time horizons, and amalgam removal was found to be cost-saving over both 5 and 10 years.

The authors concluded that this study provides insight into the costs and health outcomes associated with the removal of amalgam restorations in patients who attribute health complaints to dental amalgam fillings, which are appropriate instruments to inform health care priorities.

The group sizes were 32 and 28 respectively. This study was thus almost laughably small and therefore cannot lead to firm conclusions of any type. In this contest, a recent systematic review might be relevant; it concluded as follows:

On the basis of the available RCTs, amalgam restorations, if compared with resin-based fillings, do not show an increased risk for systemic diseases. There is still insufficient evidence to exclude or demonstrate any direct influence on general health. The removal of old amalgam restorations and their substitution with more modern adhesive restorations should be performed only when clinically necessary and not just for material concerns. In order to better evaluate the safety of dental amalgam compared to other more modern restorative materials, further RCTs that consider important parameters such as long and uniform follow up periods, number of restorations per patient, and sample populations representative of chronic or degenerative diseases are needed.

Similarly, a review of the evidence might be informative:

Since more than 100 years amalgam is successfully used for the functional restoration of decayed teeth. During the early 1990s the use of amalgam has been discredited by a not very objective discussion about small amounts of quicksilver that can evaporate from the material. Recent studies and reviews, however, found little to no correlation between systemic or local diseases and amalgam restorations in man. Allergic reactions are extremely rare. Most quicksilver evaporates during placement and removal of amalgam restorations. Hence it is not recommended to make extensive rehabilitations with amalgam in pregnant or nursing women. To date, there is no dental material, which can fully substitute amalgam as a restorative material. According to present scientific evidence the use of amalgam is not a health hazard.

Furthermore, there is evidence that the removal of amalgam fillings is not such a good idea. One study, for instance, showed that the mercury released by the physical action of the drill, the replacement material and especially the final destination of the amalgam waste can increase contamination levels that can be a risk for human and environment health.

As dental amalgam removal does not seem risk-free, it is perhaps unwise to remove these fillings at all. Patients who are convinced that their amalgam fillings make them ill might simply benefit from assurance. After all, we also do not re-lay electric cables because some people feel they are the cause of their ill-health.

This study describes the use of so-called alternative medicine (SCAM) among older adults who report being hampered in daily activities due to musculoskeletal pain. The characteristics of older adults with debilitating musculoskeletal pain who report SCAM use is also examined. For this purpose, the cross-sectional European Social Survey Round 7 from 21 countries was employed. It examined participants aged 55 years and older, who reported musculoskeletal pain that hampered daily activities in the past 12 months.

Of the 4950 older adult participants, the majority (63.5%) were from the West of Europe, reported secondary education or less (78.2%), and reported at least one other health-related problem (74.6%). In total, 1657 (33.5%) reported using at least one SCAM treatment in the previous year.

The most commonly used SCAMs were:

  • manual body-based therapies (MBBTs) including massage therapy (17.9%),
  • osteopathy (7.0%),
  • homeopathy (6.5%)
  • herbal treatments (5.3%).

SCAM use was positively associated with:

  • younger age,
  • physiotherapy use,
  • female gender,
  • higher levels of education,
  • being in employment,
  • living in West Europe,
  • multiple health problems.

(Many years ago, I have summarized the most consistent determinants of SCAM use with the acronym ‘FAME‘ [female, affluent, middle-aged, educated])

The authors concluded that a third of older Europeans with musculoskeletal pain report SCAM use in the previous 12 months. Certain subgroups with higher rates of SCAM use could be identified. Clinicians should comprehensively and routinely assess SCAM use among older adults with musculoskeletal pain.

I often mutter about the plethora of SCAM surveys that report nothing meaningful. This one is better than most. Yet, much of what it shows has been demonstrated before.

I think what this survey confirms foremost is the fact that the popularity of a particular SCAM and the evidence that it is effective are two factors that are largely unrelated. In my view, this means that more, much more, needs to be done to inform the public responsibly. This would entail making it much clearer:

  • which forms of SCAM are effective for which condition or symptom,
  • which are not effective,
  • which are dangerous,
  • and which treatment (SCAM or conventional) has the best risk/benefit balance.

Such information could help prevent unnecessary suffering (the use of ineffective SCAMs must inevitably lead to fewer symptoms being optimally treated) as well as reduce the evidently huge waste of money spent on useless SCAMs.

A multi-disciplinary research team assessed the effectiveness of interventions for acute and subacute non-specific low back pain (NS-LBP) based on pain and disability outcomes. For this purpose, they conducted a systematic review of the literature with network meta-analysis.

They included all 46 randomized clinical trials (RCTs) involving adults with NS-LBP who experienced pain for less than 6 weeks (acute) or between 6 and 12 weeks (subacute). Non-pharmacological treatments (eg, manual therapy) including acupuncture and dry needling or pharmacological treatments for improving pain and/or reducing disability considering any delivery parameters were included. The comparator had to be an inert treatment encompassing sham/placebo treatment or no treatment. The risk of bias was

  • low in 9 trials (19.6%),
  • unclear in 20 (43.5%),
  • high in 17 (36.9%).

At immediate-term follow-up, for pain decrease, the most efficacious treatments against an inert therapy were:

  • exercise (standardised mean difference (SMD) -1.40; 95% confidence interval (CI) -2.41 to -0.40),
  • heat wrap (SMD -1.38; 95% CI -2.60 to -0.17),
  • opioids (SMD -0.86; 95% CI -1.62 to -0.10),
  • manual therapy (SMD -0.72; 95% CI -1.40 to -0.04).
  • non-steroidal anti-inflammatory drugs (NSAIDs) (SMD -0.53; 95% CI -0.97 to -0.09).

Similar findings were confirmed for disability reduction in non-pharmacological and pharmacological networks, including muscle relaxants (SMD -0.24; 95% CI -0.43 to -0.04). Mild or moderate adverse events were reported in the opioids (65.7%), NSAIDs (54.3%), and steroids (46.9%) trial arms.

 

The authors concluded that NS-LBP should be managed with non-pharmacological treatments which seem to mitigate pain and disability at immediate-term. Among pharmacological interventions, NSAIDs and muscle relaxants appear to offer the best harm-benefit balance.

The authors point out that previous published systematic reviews on spinal manipulation, exercise, and heat wrap did overlap with theirs: exercise (eg, motor control exercise, McKenzie exercise), heat wrap, and manual therapy (eg, spinal manipulation, mobilization, trigger points or any other technique) were found to reduce pain intensity and disability in adults with acute and subacute phases of NS-LBP.

I would add (as I have done so many times before) that the best approach must be the one that has the most favorable risk/benefit balance. Since spinal manipulation is burdened with considerable harm (as discussed so many times before), exercise and heat wraps seem to be preferable. Or, to put it bluntly:

if you suffer from NS-LBP, see a physio and not osteos or chiros!

The associations between so-called alternative medicine (SCAM) and negative attitudes to vaccinations are, as discussed repeatedly on this blog, strong and undeniable. A new paper sheds more light on these issues.

By far the most common strategy used in the attempt to modify negative attitudes toward vaccination is to appeal to evidence-based reasoning. However, focusing on science comprehension is inconsistent with one of the key facts of cognitive psychology: Humans are biased information processors and often engage in motivated reasoning. On this basis, it is hypothesized that negative attitudes can be explained primarily by factors unrelated to the empirical evidence for vaccination; including some shared attitudes that also attract people to SCAM.

This study tested psychosocial factors associated with SCAM endorsement in past research; including aspects of spirituality, intuitive (vs analytic) thinking styles, and the personality trait of openness to experience. These relationships were tested in a cross-sectional, stratified CATI survey (N = 1256, 624 Females).

Questions regarding SCAM were derived from a previously validated instrument, designed to standardize the measurement of SCAM utilization, and distinguish between those that use a particular SCAM from those that do not. Each SCAM item provided an indication of whether the respondent had utilized each of the following therapeutic or self-treatment activities within the last 12 months:

  • herbal and homeopathic remedies,
  • energy-based and body therapies (including therapeutic massage),
  • vitamins, yoga, meditation, prayer, body therapies, hypnosis, spiritual healing,
  • and chiropractic or osteopathic treatments.

The results show that educational level and thinking style did not predict vaccination rejection. Psychosocial factors such as

  • preferring SCAM to conventional medicine (OR .49, 95% CI .36-.66),
  • endorsement of spirituality as a source of knowledge (OR .83, 95% CI .71-.96),
  • openness (OR .86, 95% CI .74-.99),

all predicted negative attitudes to vaccination. Furthermore, for 9 of the 12 SCAMs surveyed, utilisation in the last 12 months was associated with lower levels of vaccination endorsement. Additionally, the rank-order correlation between the number of different alternative therapies used in the last 12 months and vaccination attitude score was significant. Finally, analytical thinking style was negatively related to all forms of CAM, with this relationship significant in three cases:

  • herbal remedies ρ = −.08, p = .0014,
  • homeopathy, ρ = −.06, p = .0236,
  • prayer for the purpose of healing, ρ = −.15, p < .0001.

The authors concluded that vaccination scepticism appears to be the outcome of a particular cultural and psychological orientation leading to unwillingness to engage with the scientific evidence. Vaccination compliance might be increased either by building general confidence and understanding of evidence-based medicine, or by appealing to features usually associated with SCAM, e.g. ‘strengthening your natural resistance to disease’.

In the discussion section of their paper, the authors argue that these results describe a vaccine sceptic as viewing themselves as anti-authoritarian and unconventional, with a preference for unorthodox treatments with spiritual or ‘life-affirming’ features. The significant effect for personality, but not for cognitive style, is congruent with the notion that it is a reluctance to engage with the evidence, rather than a lack of capacity to appropriately process the evidence, that predicts vaccination scepticism…

SCAM endorsement and vaccination scepticism are components of a common attitudinal stance, with some shared psychosocial determinants. The results of the present study indicate that vaccination rejection is related to psychosocial factors: a general preference for complementary over conventional medicines, valuing diverse and unconventional alternatives, and a spiritual orientation to attitude formation. The null findings with regard to cognitive style and educational level suggest that factors unrelated to the actual empirical evidence for vaccination – i.e. a particular personality and attitudinal mindset are most instrumental in determining vaccination attitudes. Efforts to counter vaccination concerns should be mindful that negative vaccination views appear to form part of a broader attitudinal system that does not necessarily trust empirical or positivist evidence from authoritative sources. Vaccination promotion efforts may benefit from targeting groups associated with SCAM and building general confidence in scientific medicine, rather than targeting specific misunderstandings regarding vaccination.

1 2 3 15
Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted but you must tick the box: “Save my name, email, and website in this browser for the next time I comment.”

The most recent comments from all posts can be seen here.

Archives
Categories