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

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All healthcare professionals have an ethical obligation to be truthful and act in the best interest of the patient by adhering to the best available evidence. Providing false or misleading information to patients or consumers is thus a breach of medical ethics. In Canada, the authorities have started taking action against nurses that violate these ethical principles.

Now it has been reported that a former registered nurse in West Kelowna has been suspended for four weeks after giving a vulnerable client anti-vaccine information and recommending “alternative pseudoscience” treatments.

According to the terms of a consent agreement posted on the B.C. College of Nurses and Midwives site, Carole Garfield was under investigation for actions that happened in September 2021. The college claims that Garfield contacted the client when she was off duty, using her personal mobile phone and email to give information against the COVID-19 vaccine and recommending so-called alternative medicine (SCAM). The exact nature of the “pseudoscience modalities” Garfield recommended to the client was not listed in the college’s notice.

Garfield’s nursing licence was cancelled back in April, according to the college’s registry. It’s unclear how exactly the four-week suspension will be applied. In addition to her month-long suspension and a public reprimand, Garfield is not allowed to be the sole nurse on duty for six months. She will also be given education about ethics, boundaries, and client confidentiality, as well as the province’s professional nursing standards. “The inquiry committee is satisfied that the terms will protect the public,” read a statement from the college.

In my view, it is high time for professional bodies to act against healthcare professionals who issue misleading information to their patients. In the realm of so-called alternative medicine (SCAM), issuing false or misleading information is extremely common and causes untold harm. Such harm would be largely preventable if the professional bodies in charge would start acting responsibly in the best interest of patients. It is high time that they follow the Canadian example!

It is not often that I publish a paper with a philosopher in a leading journal of philosophy. In fact, it is the first time, and I am rather proud of it – so much so that I must show my readers (the article is freely available via the link below and I encourage everyone to read the full text) the abstract of our article entitled WHY HOMOEOPATHY IS PSEUDOSCIENCE (Synthese (2022) 200:394):

Homoeopathy is commonly recognised as pseudoscience. However, there is, to date, no systematic discussion that seeks to establish this view. In this paper, we try to fill this gap. We explain the nature of homoeopathy, discuss the notion of pseudoscience, and provide illustrative examples from the literature indicating why homoeopathy fits the
bill. Our argument contains a conceptual and an empirical part.

In the conceptual part, we introduce the premise that a doctrine qualifies as a pseudoscience if, firstly, its proponents claim scientific standing for it and, secondly, if they produce bullshit to defend it, such that, unlike science, it cannot be viewed as the most reliable knowledge on its topic. In the empirical part, we provide evidence that homoeopathy fulfils both criteria. The first is quickly established since homoeopaths often explicitly claim scientificity.

To establish the second, we dive into the pseudo-academic literature on homoeopathy to provide evidence of bullshit in the arguments of homoeopaths. Specifically, we show that they make bizarre ontological claims incompatible with natural science, illegitimately shift the burden of proof to sceptics, and mischaracterise, cherry-pick, and misreport the evidence. Furthermore, we demonstrate that they reject essential parts of established scientific methodology and use epistemically unfair strategies to immunise their doctrine against recalcitrant evidence.

And here is our conclusion:

At the beginning of the paper, we noted that homoeopathy is commonly named one of the prototypical pseudosciences. However, there has been, to date, no comprehensive discussion as to what makes it a pseudoscience. Moreover, the problem is not trivial since the most well-known and influential demarcation criteria, such as Popper’s falsifiability criterion and Kuhn’s problem-solving criterion, cannot account for it, as we have shown. We have tried to fill this research gap using a novel bullshitology-based approach to the demarcation problem. Following this approach, we have argued that homoeopathy should be regarded as pseudoscience because its proponents claim scientific standing for it and produce argumentative bullshit to defend it, thus violating important epistemic standards central to science.

As numerous of my posts have demonstrated, chiropractic manipulations can cause severe adverse effects, including deaths. Several hundred have been documented in the medical literature. When discussing this fact with chiropractors, we either see denial or we hear the argument that such events are but extreme rarities. To the latter, I usually respond that, in the absence of a monitoring system, nobody can tell how often serious adverse events happen. The resply often is this:

You are mistaken because the Royal College of Chiropractors’ UK-based Chiropractic Patient Incident Reporting and Learning System (CPiRLS) monitors such events adequately. 

I have heard this so often that it is time, I feel, to have a look at CPiRLS. Here is what it says on the website:

CPiRLS is a secure website which allows chiropractors to view, submit and comment on patient safety incidents.

Access to CPiRLS

CPiRLS is currently open to all UK-based chiropractors, all ECU members and members of the Chiropractic and Osteopathic College of Australasia. To access the secure area of the CPiRLS website, please click the icon below and insert the relevant CPiRLS username and password when prompted.

In the UK, these can normally be found on your Royal College of Chiropractors’ membership card unless the details are changed mid-year. Alternatively, email admin@rcc-uk.org from your usual email address and we will forward the details.

Alternatively, in the UK and overseas, secure access details can be obtained from your professional association.

National associations and organisations wishing to use CPiRLS, or obtain trial access to the full site for evaluation purposes, should contact The Royal College of Chiropractors at chiefexec@rcc-uk.org

Please click the icon below to visit the CPiRLS site.

Yes, you understood correctly. The public cannot access CPiRLS! When I click on the icon, I get this:

Welcome to CPiRLS

CPiRLS, The Chiropractic Patient Incident Reporting and Learning System – is an online reporting and learning forum that enables chiropractors to share and comment on patient safety incidents.

The essential details of submitted reports are published on this website for all chiropractors to view and add comments. A CPiRLS team identifies trends among submitted reports in order to provide feedback for the profession. Sharing information in this way helps to ensure the whole profession learns from the collective experience in the interests of patients.

All chiropractors are encouraged to adopt incident reporting as part of a blame-free culture of safety, and a routine risk management tool.

CPiRLS is secure and anonymous. There is no known way that anyone reporting can be identified, nor do those running the system seek to identify you. For this security to be effective, you require a password to participate.

Please note that reporting to CPiRLS is NOT a substitute for the reporting of patient safety incidents to your professional association and/or indemnity insurers.

So, how useful is CPiRLS?

Can we get any information from CPiRLS about the incidence of adverse effects?

No!

Do we know how many strokes or deaths have been reported?

No!

Can chiropractors get reliable information from CPiRLS about the incidence of adverse effects?

No, because reporting is not mandatory and the number of reports cannot relate to incidence.

Are chiropractors likely to report adverse effects?

No, because they have no incentive and might even feel that it would give their profession a bad name.

Is CPiRLS transparent?

No!

Is CPiRLS akin to postmarketing surveillance as it exists in conventional medicine?

No!

How useful is CPiRLS?

I think I let my readers answer this question.

 

This study aimed to evaluate the efficacy of Persian barley water in controlling the clinical outcomes of hospitalized COVID-19 patients. It was designed as a single-blind, add-on therapy, randomized controlled clinical trial and conducted in Shiraz, Iran, from January to March 2021. One hundred hospitalized COVID-19 patients with moderate disease severity were randomly allocated to receive routine treatment (per local protocols) with or without 250 ml of Persian barley water (PBW) daily for two weeks. Clinical outcomes and blood tests were recorded before and after the study period. Multivariable modeling was applied using Stata software for data analysis.

The length of hospital stay (LHS) was 4.5 days shorter in the intervention group than the control group regardless of history of cigarette smoking (95% confidence interval: -7.22, -1.79 days). Also, body temperature, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and creatinine significantly dropped in the intervention group compared to the control group. No adverse events related to PBW occurred.

The authors from the Department of Traditional Medicine, Shiraz University of Medical Sciences, Shiraz, Iran, concluded that this clinical trial demonstrated the efficacy of PBW in minimizing the LHS, fever, and levels of ESR, CRP, and creatinine among hospitalized COVID-19 patients with moderate disease severity. More robust trials can help find safe and effective herbal formulations as treatments for COVID-19.

I must admit, I did not know about PBW. The authors explain that PBW is manufactured from Hordeum vulgare via a specific procedure. According to recent studies, barley is rich in constituents such as selenium, tocotrienols, phytic acid, catechin, lutein, vitamin E, and vitamin C; these compounds are responsible for their antioxidant and anti-inflammatory properties. Barley grains also have immune-stimulating effects, antioxidant properties, protective effects on the liver and digestive systems, anti-cancer effects, and act to reduce uric acid levels.

But even if these effects would constitute a plausible mechanism for explaining the observed effects (which I do not think they do), the study itself is more than flimsy.

I do not understand why researchers investigating an important issue do not make sure that their study is as rigorous as possible.

  • Why not use an adequately large sample size?
  • Why not employ a placebo?
  • Why not double-blind?
  • Why not report the most important outcome, i.e. mortality?

As it stands, nobody will take this study seriously. Perhaps this is a good thing – but perhaps PBW does have positive effects (I know it’s a long shot) and, in this case, a poor-quality study would only prevent an effective therapy come to light.

There is a broad, growing, international consensus that homeopathy is a placebo therapy. Even the Germans who have been notoriously fond of their homeopathic remedies are now slowly beginning to accept this fact. But now, a dispute has started to smolder in Germany’s southwest about further training for doctors in homeopathy. In July, the representative assembly of the Baden-Württemberg Medical Association decided to remove the additional title of homeopathy from the further training regulations of doctors. However, the local health ministry has legal control over the medical association and must therefore review the decision, and the minister (Manne Lucha), a member of the Green Party, has stated that he considers the deletion to be wrong.

In a further deepening of the conflict, it has been reported that the chairwoman of the Green Party, Lena Schwelling, considers the ongoing controversy over homeopathy to be exaggerated and wants to preserve people’s freedom of choice. She said she agrees with Health Minister Manne Lucha that naturopathy and homeopathy are important issues for many people. “There is freedom of choice of doctor and therapy in this country. And if people want to choose it, I think they should be allowed to do so.” She also said continuing education for homeopathy for physicians should remain.

Schwelling spoke out against omitting homeopathy from the benefits catalog of the statutory health insurance funds, as demanded by the German Liberal Party, for example: “We are talking about about 0.003 percent of the total costs of the statutory health insurance funds, which flow into homeopathic medicines and treatments. If you saw that as a homeopathic medicine, that would also be at the detection limit, that’s how little money it is. It’s so diluted and so little in this overall budget that it’s not worth arguing about. That’s why I’m very surprised at the crusade some are waging against the issue of homeopathy.”

Recently, a dispute has been smoldering in the southwest about continuing education for homeopathy. The representative assembly of the Baden-Württemberg Medical Association decided in July to remove the additional title of homeopathy from the continuing education regulations. The local health minister, Lucha, has legal oversight of the medical association and must review the amendment statute. However, the minister has already stated that he believes the deletion is wrong.

In response, Schwelling stated it is a “normal process” for the ministry to review what the medical association has proposed. He added that it was perfectly clear that “further training in homeopathy is additional training and does not replace medical studies. Of course, homeopathic doctors also prescribe antibiotics when indicated. An important point why homeopathy should remain in the canon is that you then have the established control mechanisms, for example, in further education.”

In a previous post, I explained that anthroposophic education was founded by Steiner in 1919 to serve the children of employees of the Waldorf-Astoria cigarette factory in Stuttgart, Germany. Pupils of Waldorf or Steiner schools, as they are also frequently called, are encouraged to develop independent thinking and creativity, social responsibility, respect, and compassion.

Waldorf schools implicitly infuse spiritual and mystic concepts into their curriculum. Like some other alternative healthcare practitioners – for instance, doctors promoting integrative medicine, chiropractors, homeopaths, and naturopaths – doctors of anthroposophic medicine tend to advise against childhood immunizations. For this and other reasons, Waldorf schools have long attracted criticism.

Now it has been reported that the district government of Münster has withdrawn the school permit of a Waldorf school in Rheine, Germany, because of “serious deficiencies in the teaching operation”. For the 71 children, school operation ends with the start of the fall vacations at the beginning of October, as the district government announced on Tuesday. Already since the end of 2020 there had been numerous complaints. The school board had not succeeded in eliminating the deficiencies, a proper operation is currently and prospectively not guaranteed.

The list of problems described by the district government is long: there were repeated violations in the health protection of children. A spokesman for the district government said that there had been massive and repeated violations of Corona’s protective measures. In addition, there was a risk of accidents in the playground. The school board had also been unable to stop the misconduct of individual teachers, the district government criticized. “In addition, there is an insufficient supply of teachers, school organizational deficits and a massively disturbed school peace,” it said.

In the end, the basis of trust required for continued operation of the school was no longer given, so the school permit had to be revoked for the sake of the children. “This is an absolutely exceptional case,” the spokesman said. It is presumably the first case under the jurisdiction of the Münster district government, he added.

 

 

Le Figaro reported that France’s medical appointment booking service ‘Doctolib’ is being accused of promoting so-called alternative medicine (SCAM) on its platform. “Measures will be taken soon. Several options are on the table, we do not exclude anything,” announced Doctolib after declaring during the day on its Twitter account the immediate suspension of some profiles.

Health professionals and patients have been criticizing the platform for allowing its users to make appointments with practitioners claiming to be naturopaths and some offering dangerous quackery. Naturopathy is not recognized in France and is sometimes considered to be linked to charlatanism.

A member of the office for the control of conspiracies, Tristan Mendès France, had found a practitioner promoting urine therapy via Doctolib. “The presence of these individuals on a service that puts patients and health professionals in touch with each other gives them totally unjustified credit and endorsement,” stated a Twitter account aimed at informing “about the dangers of certain pseudo-alternatives in terms of health and nutrition”.

Amongst the questioned profiles were the naturopaths Thierry Casasnovas and Irène Grosjean, two influential personalities in the naturopathic world who are discredited in the health world. “We would like to point out that it is impossible for a patient to make an [appointment] on Doctolib in a practitioner not referenced by the Ministry of Health, without having expressly sought to do so,” Doctolib defended its position stating that it would proceed to checks on practitioners “whose actions would be dangerous or condemnable by law” and who would have been the subject of complaints on social media.

97%” of practitioners signed up with Doctolib are registered with the Ministry of Health,” the company claimed. According to Doctolib, only 3% of its practitioners are therefore from the realm of SCAM: sophrologists, hypnotherapists, naturopaths. In France, these practitioners are not regulated and do not have the status of health professional, but they are nevertheless legal. The appointments made on Doctolib with such practitioners represent “0.3% of the totality” of the volume recorded on the platform.

The CEO of Doctolib, Stanislas Niox-Chateau, said that he was responding to a request from patients and refused to position his site as a simple directory of the Ministry of Health: “The demand is there. It is not up to us to say whether these activities are effective or useful. They are legal, so we have no reason to prevent practitioners from being listed on our site.”

As so often in the realm of SCAM, the dispute seems to be one between ethical/moral responsibilities and commercial interests of the parties involved.

 

In Austria, even some of the most blatant quackery continues to be supported by the country’s medical association. This has been notorious for a very long time, and many rational doctors have opposed this nonsense. Now my friends and colleagues have courageously sent an open letter to the President of the Austrian Medical Association. In order to support their efforts, I have taken the liberty of translating it:

Dr. Johannes Steinhart
President of the Austrian Medical Association
Weihburggasse 10-12
1010 Vienna

 

Dear President Steinhart,

 

In 2014 we founded the “Initiative for Scientific Medicine” with the aim of counteracting the support of pseudo-medicine by medical associations and the Ministry of Health.

We (www.initiative-wissenschaftliche-medizin.at) have been demanding for years that the Austrian Medical Association distance itself from irrational, predominantly esoteric pseudo-medicine and refrain from awarding diplomas in them. We also made these demands on behalf of the supporters of the initiative (currently 1142 supporters, of which 495 are female doctors and 230 natural scientists) during a discussion with the former president Wechselberger in 2015 (unfortunately unsuccessful at the time).

We would like to draw your attention to a resolution of the German Medical Congress 2022 on homeopathy and a court ruling in the first instance in Germany on the subject of bioresonance, which show that our neighbours have obviously begun to treat pseudomedicine for what it is, namely sham medicine.

The 126th German Medical Congress 2022 in Bremen has, among other things, passed a long overdue resolution. The additional title “homeopathy” was deleted from the (model) further training regulations. Prior to this decision, 12 of 17 state medical associations had already taken this decision themselves.

In May 2022 in Reutlingen, two managing directors of a company producing and selling bioresonance devices were sentenced to 2 and 3 years in prison and a fine of 2.5 million euros, and the former sales director to 90 days’ imprisonment for commercial fraud and violation of the Therapeutic Products Advertising Act. The verdict is not yet legally binding. Unfortunately, many Austrian doctors also practice this pseudo-medicine method.

The fact that many colleagues offer esoteric, pseudo-medical “therapies” without proven benefits to their patients and can refer to diplomas and accredited further training courses of the Medical Association/Academy of Physicians is difficult for us to understand, especially in view of the fact that the majority of the accredited further training courses are of high scientific quality. A medical association that argues that such pseudo-medical practices “should better remain in the hands of doctors (as “healers”)” contradicts the principles of evidence-based medicine to which the medical association always refers. The corona pandemic has shown us all the damage potential of science denial.

We believe that the time has also come for the Austrian Medical Association to come clean. We call on the Austrian Medical Association to unreservedly declare its support for scientific medicine, to clearly distance itself from pseudo-medicine, to suspend the awarding of diplomas in pseudo-medicine methods that are far removed from science, and to end the accreditation of pseudo-medicine training courses by the Medical Academy.

We are publishing this open letter on our website and will also publish your reply if you so wish.

 

With collegial greetings

Dr. Theodor Much, Specialist in Dermatology and Venereology, Baden near Vienna
DDr. Viktor Weisshäupl, retired specialist in anaesthesiology and intensive care medicine, Vienna

About a year ago, I reported last on the situation of homeopathy in France. Now it might be time for another update. The end of the reimbursement of homeopathy was, of course, a heavy blow for the laboratories concerned, especially Boiron and Weleda.

Are these firms now going bust?

Is the French public missing homeopathy?

The cessation of reimbursement took place in two steps: in 2020, the reimbursement rate was reduced to 15 % and expired completely in 2021. The new director of Weleda France, Ludovic Rassat, explains that, in 2020, when the reimbursement was reduced to 15 %, the impact on sales was just 20 %. The decrease was limited because of the supplementary health insurance which 80 % of French people have still supplemented the reimbursement up to 100 %. In 2021, this generosity stopped and the reimbursement fell from 100 to 0 %. This led to a 60 % drop in sales and to losses of 13 million Euros for Weleda France.

According to an Ipsos survey commissioned by Boiron Laboratories in October 2018, 70 % of all French used homeopathy to relieve their first symptoms, 74 % thought homeopathic remedies were effective and 71 % thought homeopathy was a good complement to conventional treatments. One might, therefore, have assumed that French consumers would continue using their beloved remedies despite the cessation of reimbursement. However, this was not the case. The most obvious explanation for this phenomenon, I think, is that the above-mentioned survey had generated false-positive results and that people correctly judged homeopathic remedies to be superfluous.

Faced with unsustainable losses, the French manufacturers of homeopathic products are now forced to react. A press release by Weleda France from 4 July 2022 stated that “This project would result in the discontinuation of pharmaceutical production and medical information in France and the closure of the Weleda division. This would result in the cessation of production activities at the Huningue site and an adjustment of the organisation of activities at headquarters. In total, 127 jobs could be cut at Weleda France.” If this step is taken as planned, Weleda France will have to earn its money purely on its cosmetic and anthroposophical products, according to the director.

In 2019, Laboratoires Boiron owned 4 production laboratories and 28 distribution facilities in France. In March 2020, the company announced that it had decided to cut 646 jobs in France and close 13 of its 31 sites, due to the poor economic results that followed the cessation of reimbursement of its products by the social security system. Following the decision by the Minister of Health, Agnès Buzyn, to stop the reimbursement of homeopathic preparations by the social security system, Boiron announced that the Montrichard site in the Loir-et-Cher region had not managed to find a buyer. As a result, the site, which employed around 80 people, closed on 31 December 2021.

And the French consumers?

Are they missing homeopathy?

Are they suffering from homeopathy withdrawal?

Are they more frequently ill without homeopathy?

Are they switching to more expensive conventional drugs?

I currently spend much of my time in France and cannot say that I have noticed any of this. On the contrary, most people I talk to are delighted that homeopathy is no longer reimbursed. But this is no evidence, of course. I am unable to find any reliable data to answer the above questions.

When the French health minister decided against homeopathy two years ago, she said: “It’s possible to leave the doctor’s office without a prescription! Let’s take advantage of this debate on homeopathy to reflect more broadly on our use of medicine. The ultimate goal is to consume less.” She was correct, it seems.

 

 

Zinc has been in the limelight recently. The reason is that it has been recommended as a preventative and/or treatment of COVID infections. The basis for such recommendations has been some trial evidence suggesting it is effective for viral respiratory tract infections (RTIs). But the evidence has been full of contradictions which means, we need a systematic review that critically evaluated the totality of the available data.

This systematic review was aimed at evaluating the benefits and risks of zinc formulations compared with controls for the prevention or treatment of acute RTIs in adults.

Seventeen English and Chinese databases were searched in April/May 2020 for randomized clinical trials (RCTs), and from April/May 2020 to August 2020 for SARS-CoV-2 RCTs. Cochrane rapid review methods were applied. Quality appraisals used the Risk of Bias 2.0 and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

Twenty-eight RCTs with 5446 participants were identified. None were specific to SARS-CoV-2. Compared with placebo, oral or intranasal zinc prevented 5 RTIs per 100 person-months (95% CI 1 to 8, numbers needed to treat (NNT)=20, moderate-certainty/quality). Sublingual zinc did not prevent clinical colds following human rhinovirus inoculations (relative risk, RR 0.96, 95% CI 0.77 to 1.21, moderate-certainty/quality). On average, symptoms resolved 2 days earlier with sublingual or intranasal zinc compared with placebo (95% CI 0.61 to 3.50, very low-certainty/quality) and 19 more adults per 100 were likely to remain symptomatic on day 7 without zinc (95% CI 2 to 38, NNT=5, low-certainty/quality). There were clinically significant reductions in day 3 symptom severity scores (mean difference, MD -1.20 points, 95% CI -0.66 to -1.74, low-certainty/quality), but not average daily symptom severity scores (standardised MD -0.15, 95% CI -0.43 to 0.13, low-certainty/quality). Non-serious adverse events (AEs) (eg, nausea, mouth/nasal irritation) were higher (RR 1.41, 95% CI 1.17 to 1.69, NNHarm=7, moderate-certainty/quality). Compared with active controls, there were no differences in illness duration or AEs (low-certainty/quality). No serious AEs were reported in the 25 RCTs that monitored them (low-certainty/quality).

The authors concluded that in adult populations unlikely to be zinc deficient, there was some evidence suggesting zinc might prevent RTIs symptoms and shorten duration. Non-serious AEs may limit tolerability for some. The comparative efficacy/effectiveness of different zinc formulations and doses were unclear. The GRADE-certainty/quality of the evidence was limited by a high risk of bias, small sample sizes and/or heterogeneity. Further research, including SARS-CoV-2 clinical trials is warranted.

The authors provide a short comment on the assumed mode of action of zinc. The rationale for topical intranasal and sublingual zinc is based on the in vitro effects of zinc ions that can inhibit viral replication, stabilize cell membranes and reduce mucosal inflammation. Other conceivable mechanisms include the activation of T lymphocytes, monocytes, and granulocytes.

The authors also remind us to be cautious: clinicians and consumers need to be aware that considerable uncertainty remains regarding the clinical efficacy of different zinc formulations, doses, and administration routes, and the extent to which efficacy might be influenced by the ever changing epidemiology of the viruses that cause RTIs. The largest body of evidence comes from sublingual lozenges and zinc gluconate and acetate salts, suggesting these are suitable choices. Yet, this does not mean that other administration routes and zinc salts are less effective. The new evidence on the prophylactic effects of low-dose nasal sprays adds weight to the otherwise inconclusive findings from the handful of RCTs evaluating zinc nasal sprays or gels for acute treatment. A minimum therapeutic dose for zinc is also yet to be determined. An earlier review suggested the minimum dose for sublingual lozenges is 75 mg. However, the present analysis does not support this conclusion. Furthermore, a daily oral dose of 15 mg has been shown to upregulate lymphocytes within days, so it is plausible that much lower doses might also be effective.

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