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

quackery

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Reports of serious complications of chiropractic manipulation keep on coming. Take this one, for instance:

My daughter went for a routine chiropractor appointment. Now she’s paralysed – 1:20 000 chiropractic neck manipulations result in stroke from vertebral artery dissection.

Or take a recent article by US neurosurgeons:

Cranio-cervical artery dissection (CeAD) is a common cause of cerebrovascular events in young subjects with no clear treatment strategy established. This study evaluated the incidence of major adverse cardiovascular events (MACE) in CeAD patients treated with and without stent placement. COMParative effectiveness of treatment options in cervical Artery diSSection (COMPASS) is a single high-volume center observational, retrospective longitudinal registry that enrolled consecutive CeAD patients over a 2-year period. Patients were ≥ 18 years of age with confirmed extra- or intracranial CeAD on imaging. Enrolled participants were followed for 1 year evaluating MACE as the primary endpoint.

One-hundred ten patients were enrolled (age 53 ± 15.9, 56% Caucasian, and 50% male, BMI 28.9 ± 9.2). Grade I, II, III, and IV blunt vascular injury was noted in 16%, 33%, 19%, and 32%, respectively. Predisposing factors were noted in the majority (78%), including

  • sneezing,
  • carrying a heavy load,
  • chiropractic manipulation.

Stent was placed in 10 (10%) subjects (extracranial carotid n = 9; intracranial carotid n = 1; extracranial vertebral n = 1) at the physician’s discretion along with medical management. Reasons for stent placement were early development of high-grade stenosis or expanding pseudoaneurysm. Stented patients experienced no procedural or in-hospital complications and no MACE between discharge and 1 year follow up. CeAD patients treated with medical management only had 14% MACE at 1 year.

The authors concluded that in this single high-volume center cohort of CeAD patients, stenting was found to be beneficial, particularly with development of high-grade stenosis or expanding pseudoaneurysm. These results warrant confirmation by a randomized clinical trial.

Yes, I know: this study was not meant to investigate the link between chiropractic manipulations and CeAD. The finding that chiropractic manipulation is a predisposing factor for CeAD is entirely incidental. But it is an important finding nevertheless.

Chiropractors will laugh about the notion that manipulation is a risk factor akin to sneezing and thus try to trivialize the danger of their treatments. I would then point out that sneezing is unavoidable and fulfills a purpose. Chiropractic manipulations do neither.

It has been reported by several sources that the NHS is advertising for a Reiki healer.

The NHS stated that “the responsibilities of a reiki healer include treating clients using energy principles … and activating the healing process.” The post is paid for by the Sam Buxton Sunflower Healing Trust (SBSHT) which states on its website:

The SBSHT healing therapists, who work within the NHS and other health areas, are proud to be part of a multi-disciplinary team of professionals to provide vital support cancer patients, their relatives and staff. Since 2006, the SBSHT has funded healers to work in NHS, and other health related areas to support cancer patients and their families. A key role of the SBSHT is to increase awareness within the UK of the importance of providing healing support to cancer patients and families. Another vital role is to generate the crucial funds needed to place more healers in NHS, and other health related areas, throughout the country. Complementary therapy (CT) is increasingly demanded and expected by patients undergoing cancer treatments. An increasing amount of research clearly demonstrates that CT is important to support patients through their conventional treatments. SBSHT is committed to providing funds to NHS hospitals and cancer centers to engage the services of a Reiki practitioner or Healer for cancer patients and their families

As a charity we are or have funded healer posts within the centres below.

  • University College Hospital, London
  • Addenbrookes Hospital, Cambridge
  • Princess Alexandra Hospital, Epping
  • Queen Elizabeth Hospital, Welwyn Garden City
  • Derriford Hospital, Plymouth
  • Wigan NHS Trust, Wigan
  • St Josephs Hospice, London
  • Eden Valley Hospice and Jigsaw Children’s Hospice, Carlisle
  • St Mary’s Hospice, Ulverston and Barrow in Furness NHS Trust
  • St Johns Hospice, Lancaster
  • Kent and Canterbury Hospital, Canterbury
  • Bristol Haematology and Oncology Centre, Bristol
  • Rowcroft Hospice, Torquay
  • The Lister Hospital, Stevenage
  • Barnstaple NHS Trust
  • Treliske Hospital, Cornwall
  • Poole NHS Trust
  • St Michaels Hospice, Herefordshire

The SBSHT was co-founded by Angie Buxton-King in memory of her son Sam, who died of Acute Myeloid Leukaemia in 1998 aged 10. She is a member of the ‘College of Psychic Studies’ which is “committed to serving the evolution of consciousness”. The College website states this:

We were founded in 1884 to support and encourage empirical research into the esoteric. Our programme has since broadened and diversified to meet rising demand and increasingly global interests.

However, our core values remain the same. We continue to shine a light on key themes including consciousness, intuition, self-development and meditation. Our courses, workshops, talks and special events provide a safe and inclusive space in which to explore the full spectrum of human potential under the careful guidance of our expert tutors.

The College offers all sorts of courses; I was particularly fascinated by this one: “Alchemise Your Energy Through Dowsing“.

__________________

Now, one could easily claim that there is nothing wrong with reiki healers invading the NHS; after all, they are funded by a charitable trust at no cost to the taxpayer.

Yet, I disagree!

Reiki healing is implausible and ineffective nonsense. As such it is by no means harmless. Employing such healers in the NHS sends out a strong signal that undermines the principles of rational thinking and evidence-based medicine. If the NHS truly does not value these principles, I suggest they also fill the chronic gaps in ambulance services by flying carpets.

DIARALIA is a homeopathic remedy for the symptomatic treatment of acute transient diarrhea. It is produced by Boiron, the world’s largest manufacturer of homeopathic remedies. This is how it is currently advertised:

Instructions DIARALIA

Dosage DIARALIA

Adults and children from 6 years

Lozenge 1, 4 to 6 times a day, for a maximum of three days of treatment.
Discontinue treatment as soon as symptoms disappear.

Method and route of administration DIARALIA
Sublingual (tablet to dissolve under the tongue)
In children 18 months to 6 years: dissolve the tablet in a little water before use, because of the risk of aspiration. As soon as the permitted age, dissolve the tablets under the tongue.

Duration of treatment DIARALIA
The duration of treatment should not exceed one week.

In case of overdose DIARALIA

If you have taken more DIARALIA orodispersible tablets that you don” should have:

Consult your doctor or pharmacist immediately.
In case of failure of one or more doses of DIARALIA

If you miss a dose of DIARALIA orodispersible tablets:

Do not take a double dose to make up for the dose that you forgot to take

Pregnancy and lactation with DIARALIA
Ask your doctor or pharmacist before taking any medicine.

In the absence of experimental and clinical data, and as a precautionary measure, the use of this drug should be avoided during pregnancy and lactation.

Composition DIARALIA

Excipients with known effect: This medicinal product contains lactose,
Active substances:
For a 300 mg tablet
Arsenicum album 9CH 1mg
China rubra 5CH 1mg
Podophyllum peltatum 9 CH 1mg
Excipients: sucrose, lactose monohydrate, magnesium stearate

Cons-indication DIARALIA

N” Never use DIARALIA orodispersible tablets:
· In children under 18 months.
· If you are allergic (hypersensitive) to the active substances or to any of the ingredients in CORYZALIA orodispersible tablets.

Possible interactions with DIARALIA

If you are taking or have recently taken any other medicines, including medicines obtained without a prescription, talk to your doctor or pharmacist.

This medication is to be taken between meals.

Adverse DIARALIA

Like all medicines, DIARALIA orodispersible tablets may cause side effects, although not everybody will not matter.
If you notice any side effects not listed in this leaflet, or if the side effects gets serious, please tell your doctor or pharmacist.

Storage conditions DIARALIA

Store at a temperature not exceeding 30 ° C

Precautions and warnings DIARALIA

This medication should not be used in case of vomiting, high fever, blood in the stool.
Any significant diarrhea exposed to the risk of dehydration requiring appropriate rehydration.
If diarrhea persists beyond 3 days, a medical consultation is necessary.
If your doctor has told you have an intolerance to some sugars, contact your doctor before taking this medicine
Use of this medicine is not recommended in patients with galactose intolerance, a Lapp lactase deficiency or malabsorption syndrome glucose or galactose (rare hereditary diseases).

But is there any evidence that DIARALIA works?

I’m glad you asked!

I looked far and wide but found none (if a reader knows of a clinical trial, please let me know).

Jenifer Jacobs (JJ) published a review of 3 studies – all her own! – and concluded that the results from these studies confirm that individualized homeopathic treatment decreases the duration of acute childhood diarrhea and suggest that larger sample sizes be used in future homeopathic research to ensure adequate statistical power. Homeopathy should be considered for use as an adjunct to oral rehydration for this illness. So, some homeopathy fans might claim there is good evidence. But I dispute that.

We all know, of course, that diarrhea can be a symptom of a range of serious conditions. Thus, one should not joke about it. On the contrary, one should diagnose the reason for the symptom and treat it adequately.  And one should certainly not advertise unproven treatments for it; one could even go one step further and claim that anyone who does that is fraudulently endangering the health of the often all too gullible consumer.

Trevor Zierke is a D.C. who published several videos that have gone viral after saying that “literally 99% of my profession” is a scam. “When I say almost all the usual lines chiropractors tell you are lies, I mean almost all of them,” he stated. Zierke then went on to give examples of issues chiropractors allegedly make up, including someone’s spine being “misaligned,” tension on nerves causing health problems, and someone having back pain because their hips are off-center. “Almost all of these aren’t true,” he concluded.

In a follow-up video, he claimed that the reasons most people are told they need to go to a chiropractor are “overblown or just flat out lies proven wrong by research.” He also noted that, while there are many scams, that “doesn’t mean you can’t get help from a chiropractor.”

In a third TikTok video, Zierke offered some valid reasons to see a chiropractor. He said that one can seek help from a chiropractor if one has musculoskeletal pain that has been ongoing for more than one to two days, and that’s about it. He stated that issues that a chiropractor couldn’t really fix include “GI pain, hormonal issues, nutrition,” among others.

In comments, users were largely supportive of Zierke’s message.

One said: “As a physiotherapist, I’ve been trying to tell this but I don’t want to like offend any chiropractor in doing so,” a commenter shared.

“Working in a chiropractic office, this is fair,” a further user wrote. “I have issues that I know an adjustment will help & other pain that would be better stretched/released.”

In an email, Zierke reiterated the intention of his videos: “I would just like to clarify that chiropractors, in general, are not a scam or are inherently scammers (I myself am a practicing chiropractor), but rather a lot of very popular sales tactics, phrases, and wording used to imply patients need treatment, and methods of treatment, have never been proven to be true,” he explained. “When chiropractors say & use these methods stating things that are not factually true—I believe it’s scammy behavior and practices. There are still a lot of very good, honest, and integral chiropractors out there,” he concluded. “They can provide a lot of help and relief to patients. But that’s unfortunately not the majority, and I’ve heard too many stories of people falling victim to some of these scam-like tactics from bad apple chiropractors.”

None of what DC Zierke said can surprise those who have been following my blog. On the contrary, I could add a few recent posts to his criticism of chiropractic, for example:

I rest my case.

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.

 

 

It has been reported that a recent inspection from the Care Quality Commission (CQC) found that the diagnostic imaging service at AECC University College in Parkwood Road, Bournemouth, requires improvement in three out of four areas – including patient safety. This is surprising not least because the AECC prides itself on being “a leading higher education institution in healthcare disciplines, nationally and internationally recognised for quality and excellence.”

The unannounced inspection in May this year resulted in several demands for the service to improve upon. For example, the CQC report said staff “did not receive all of the training they needed to keep patients safe” and that patient chaperones “did not receive chaperone training”. Moreover, managers were reported as not always ensuring staff were competent to operate certain equipment. In fact, there was no record of staff competencies which meant inspectors “could not tell if staff had been trained to use equipment”. General cleanliness was also found lacking in relation to certain procedures, namely no sink in any of the site’s nine ultrasound rooms (including those for transvaginal scans) – meaning staff carrying out ultrasound scanning did not have access to a clinical handwashing facility.

The CQC states on its website that it “is the independent regulator of health and adult social care in England. We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve. We monitor, inspect and regulate services. Then we publish what we find, including performance ratings, to help people choose care. Where we find poor care, we will use our powers to take action.”

No doubt, these are laudable aims. What I find, however, disappointing is that the CQC’s inspection of the AECC did not question the nature of some of the courses taught by the AECC. Earlier this year, I reported in a blog post that the AECC has announced a new MSc ‘Musculoskeletal Paediatric Health‘. This motivated me to look into the evidence for such a course. This is what I found with several Medline searches (date of the review on chiropractic for any pediatric conditions, followed by its conclusion + link [so that the reader can look up the evidence]):

2008

I am unable to find convincing evidence for any of the above-named conditions. 

2009

Previous research has shown that professional chiropractic organisations ‘make claims for the clinical art of chiropractic that are not currently available scientific evidence…’. The claim to effectively treat otitis seems to
be one of them. It is time now, I think, that chiropractors either produce the evidence or abandon the claim.

2009

The … evidence is neither complete nor, in my view, “substantial.”

2010

Although the major reason for pediatric patients to attend a chiropractor is spinal pain, no adequate studies have been performed in this area. It is time for the chiropractic profession to take responsibility and systematically investigate the efficiency of joint manipulation of problems relating to the developing musculoskeletal system.

2018

Some small benefits were found, but whether these are meaningful to parents remains unclear as does the mechanisms of action. Manual therapy appears relatively safe.

What seems to emerge is rather disappointing:

  1. There are no really new reviews.
  2. Most of the existing reviews are not on musculoskeletal conditions.
  3. All of the reviews cast considerable doubt on the notion that chiropractors should go anywhere near children.

But perhaps I was too ambitious. Perhaps there are some new rigorous clinical trials of chiropractic for musculoskeletal conditions. A few further searches found this (again year and conclusion):

2019

We found that children with long duration of spinal pain or co-occurring musculoskeletal pain prior to inclusion as well as low quality of life at baseline tended to benefit from manipulative therapy over non-manipulative therapy, whereas the opposite was seen for children reporting high intensity of pain. However, most results were statistically insignificant.

2018

Adding manipulative therapy to other conservative care in school children with spinal pain did not result in fewer recurrent episodes. The choice of treatment-if any-for spinal pain in children therefore relies on personal preferences, and could include conservative care with and without manipulative therapy. Participants in this trial may differ from a normal care-seeking population.

I might have missed one or two trials because I only conducted rather ‘rough and ready’ searches, but even if I did: would this amount to convincing evidence? Would it be good science?

No! and No!

So, why does the AECC offer a Master of Science in ‘Musculoskeletal Paediatric Health’?

____________________

Isn’t that a question the CQC should have asked?

Should Acupuncture-Related Therapies be Considered in Prediabetes Control?

No!

If you are pre-diabetic, consult a doctor and follow his/her advice. Do NOT do what acupuncturists or other self-appointed experts tell you. Do NOT become a victim of quackery.

But the authors of a new paper disagree with my view.

So, let’s have a look at the evidence.

Their systematic review was aimed at evaluating the effects and safety of acupuncture-related therapy (AT) interventions on glycemic control for prediabetes. The Chinese researchers searched 14 databases and 5 clinical registry platforms from inception to December 2020. Randomized controlled trials involving AT interventions for managing prediabetes were included.

Of the 855 identified trials, 34 articles were included for qualitative synthesis, 31 of which were included in the final meta-analysis. Compared with usual care, sham intervention, or conventional medicine, AT treatments yielded greater reductions in the primary outcomes, including fasting plasma glucose (FPG) (standard mean difference [SMD] = -0.83; 95% confidence interval [CI], -1.06, -0.61; P < .00001), 2-hour plasma glucose (2hPG) (SMD = -0.88; 95% CI, -1.20, -0.57; P < .00001), and glycated hemoglobin (HbA1c) levels (SMD = -0.91; 95% CI, -1.31, -0.51; P < .00001), as well as a greater decline in the secondary outcome, which is the incidence of prediabetes (RR = 1.43; 95% CI, 1.26, 1.63; P < .00001).

The authors concluded that AT is a potential strategy that can contribute to better glycemic control in the management of prediabetes. Because of the substantial clinical heterogeneity, the effect estimates should be interpreted with caution. More research is required for different ethnic groups and long-term effectiveness.

But this is clearly a positive result!

Why do I not believe it?

There are several reasons:

  • There is no conceivable mechanism by which AT prevents diabetes.
  • The findings heavily rely on Chinese RCTs which are known to be of poor quality and often even fabricated. To trust such research would be a dangerous mistake.
  • Many of the primary studies were designed such that they failed to control for non-specific effects of AT. This means that a causal link between AT and the outcome is doubtful.
  • The review was published in a 3rd class journal of no impact. Its peer-review system evidently failed.

So, let’s just forget about this rubbish paper?

If only it were so easy!

Journalists always have a keen interest in exotic treatments that contradict established wisdom. Predictably, they have been reporting about the new review thus confusing or misleading the public. One journalist, for instance, stated:

Acupuncture has been used for thousands of years to treat a variety of illnesses — and now it could also help fight one of the 21st century’s biggest health challenges.

New research from Edith Cowan University has found acupuncture therapy may be a useful tool in avoiding type 2 diabetes.

The team of scientists investigated dozens of studies covering the effects of acupuncture on more than 3600 people with prediabetes. This is a condition marked by higher-than-normal blood glucose levels without being high enough to be diagnosed as diabetes.

According to the findings, acupuncture therapy significantly improved key markers, such as fasting plasma glucose, two-hour plasma glucose, and glycated hemoglobin. Additionally, acupuncture therapy resulted in a greater decline in the incidence of prediabetes.

The review can thus serve as a prime example for demonstrating how irresponsible research has the power to mislead millions. This is why I have often said that poor research is a danger to public health.

And what can be done about this more and more prevalent problem?

The answer is easy: people need to behave more responsibly; this includes:

  • trialists,
  • review authors,
  • editors,
  • peer-reviewers,
  • journalists.

Yes, the answer is easy in theory – but the practice is far from it!

I have often called out unreliable or fraudulent research in the realm of Traditional Chinese Medicine (TCM). I think it is important to do so because the abundance of scientific misconduct is such that it has become a danger to public health. Today, I present yet another example:

This recent review claimed to summarize the evidence on TCM in treating MI, the clinical evaluations of TCM in treating male infertility (MI), and the molecular mechanisms of TCM effects. I was alerted to the fact that the authors cite a paper on acupuncture that I had co-authored. Here is the section in question from the review:

Acupuncture is one of the therapeutic techniques that are part of TCM. Acupuncture is a non-invasive technique and is regarded as free of risk if performed by trained personnel [35]. One of the advantages of acupuncture was that the incidence of adverse effects was substantially lower than that of many drugs or other accepted [35]. Acupuncture has been used in the treatment of male and female infertility and in assisted reproductive technology treatments for many years. A total of 100 patients with MI who met the diagnostic criteria were randomly divided into two groups [7]. Half of the patients received acupuncture treatment, and the other half received placebo acupuncture. After 10 weeks treatment, acupuncture successfully improved the indicators of the semen, including the spermatozoa survival rate, b-level activity rate, sperm density, sperm activity rate. A total of 28 infertile patients with severe oligoasthenozoospermia received acupuncture according to the principles of acupuncture and 29 infertile patients received placebo acupuncture. A significantly higher percentage of motile sperm (World Health Organization categories A-C), but no effect on sperm concentration, was found after acupuncture compared with placebo acupuncture [36]. Of the 279 cases of male sterility treated by the combination of acupuncture, pilose antler essence injection to acupoints and oral administration of Chinese materia medica, 142 cases (47.8%) were cured, 81 cases (27.3%) markedly effective, 53 cases (17.8%) effective and 21 cases (7.1%) ineffective [37]. The therapeutic effect of the combination of these three treatments was satisfactory.

Ref 7

Emerging evidence has shown that cell-cell interactions between testicular cells, in particular at the Sertoli cell-cell and Sertoli-germ cell interface, are crucial to support spermatogenesis. The unique ultrastructures that support cell-cell interactions in the testis are the basal ES (ectoplasmic specialization) and the apical ES. The basal ES is found between adjacent Sertoli cells near the basement membrane that also constitute the blood-testis barrier (BTB). The apical ES is restrictively expressed at the Sertoli-spermatid contact site in the apical (adluminal) compartment of the seminiferous epithelium. These ultrastructures are present in both rodent and human testes, but the majority of studies found in the literature were done in rodent testes. As such, our discussion herein, unless otherwise specified, is focused on studies in testes of adult rats. Studies have shown that the testicular cell-cell interactions crucial to support spermatogenesis are mediated through distinctive signaling proteins and pathways, most notably involving FAK, Akt1/2 and Cdc42 GTPase. Thus, manipulation of some of these signaling proteins, such as FAK, through the use of phosphomimetic mutants for overexpression in Sertoli cell epithelium in vitro or in the testis in vivo, making FAK either constitutively active or inactive, we can modify the outcome of spermatogenesis. For instance, using the toxicant-induced Sertoli cell or testis injury in rats as study models, we can either block or rescue toxicant-induced infertility through overexpression of p-FAK-Y397 or p-FAK-Y407 (and their mutants), including the use of specific activator(s) of the involved signaling proteins against pAkt1/2. These findings thus illustrate that a potential therapeutic approach can be developed to manage toxicant-induced male reproductive dysfunction. In this review, we critically evaluate these recent findings, highlighting the direction for future investigations by bringing the laboratory-based research through a translation path to clinical investigations.

This paper does not relate to the statement it is meant to support by the review authors.

Ref 35

The review by Qin et al (1) includes 5 trials none of which should have been included in a quality metaanalysis as the methodology was unconvincing: In the trial by Alraek et al., patients were randomised to receive either acupuncture or no treatment. This means that no attempt was made to control for the effects of placebo or extra attention. Therefore, this study does not demonstrate an effect of acupuncture as the outcome could be due to non-specific effects unrelated with this therapy. By contrast, the trial by Aune et al. did attempt to control for placebo effects by using a sham control group. Sham acupuncture was given using six needles superficially inserted in the calves, thighs or abdomen outside known acupuncture points or meridians. Needles were not manipulated in the sham group. Sham or placebo controls have the purpose of rendering patients unaware of whether they receive the real or the sham treatment. The method used here cannot achieve this aim; patients would be easily able to tell which intervention they received. In other words, this study also did not adequately control for placebo effects. The remaining three trials are all not Medline-listed, authored by Chinese investigators and published in inaccessible journals. This should disqualify them from inclusion as they were unverifiable by the peer review process. According to the published table, they were equivalence trials of acupuncture versus antibiotics with a sample size around 30. This means they are grossly underpowered and thus unable to generate reliable results. Unless BJOG peer reviewers could see the primary articles, or be provided with translations from Chinese, the systematic review should not have been accepted. The “many eyes of science” requires transparency, testing, challenge and verification. Although in the past, inconclusive results of acupuncture have not been thought to be due to Chinese influence (2), it has been noted that virtually all recent published acupuncture trials are “positive” (3), raising questions of publication and other biases. Our colleagues are under tremendous pressure to publish, but we do them no favours by effectively lowering the standard of scientific peer review. Elite journals too have an obligation to train and reiterate about publication ethics and sound scientific writing (4). As none of the primary studies convincingly demonstrated that acupuncture is an effective therapy for recurrent urinary tract infections, no positive conclusion was warranted. Although Qin et al. did state that the risk of bias of the included trials was generally high or unclear (1), the BJOG nevertheless allowed them to turn massive uncertainty into relatively firm, positive conclusions in the abstract (“Acupuncture appeared to be beneficial for treatment and prophylaxis of rUTIs”) and tweetable abstract (“This review found that acupuncture may improve treatment and prevent recurrence of urinary tract infection in women”), thus leading to excited media headlines that inevitably mislead the public. ‘May’ is a weasel word which should be avoided as it is unfalsifiable (for example, pigs do not fly but they ‘may’ fly in the future). The definite, straightforward conclusion must be “There is no good evidence to support the use of acupuncture for the treatment and prophylaxis of recurrent UTIs”. It is not acceptable to give international credibility to an implausible modality that no objective, independent high-quality review has found effective beyond placebo (5). The dampening accompanying mini-commentary (6) does not undo the damage.
The review should be withdrawn while the primary papers are translated for peer reviewers to examine, the above limitations discussed in the text, and the positive ‘spin’ in conclusions corrected. These improvements would consolidate the researchers’ probity and justify the accolade of BJOG publication.

Our letter to the editor does not bear any relation to the statement it is meant to support by the review authors.

Ref 36

In this first prospective, randomized, single-blind, placebo-controlled study, 28 infertile patients with severe oligoasthenozoospermia received acupuncture according to the principles of traditional Chinese medicine (TCM) and 29 infertile patients received placebo acupuncture. A significantly higher percentage of motile sperm (World Health Organization categories A–C), but no effect on sperm concentration, was found after acupuncture compared with placebo acupuncture.

This small study is far from convincing and does not lend itself to far-reaching conclusions

Ref 37

Of the 279 cases of male sterility treated by the combination of acupuncture, pilose antler
essence injection to acupoints and oral administration of Chinese materia medica, 142
cases (47.8%) were cured, 81 cases (27.3%) markedly effective, 53 cases (17.8%) effective
and 21 cases (7.1%) ineffective. The therapeutic effect of the combination of these three
treatments was satisfactory.

This study had no control group and used two different therapies. Therefore, it does not allow any conclusion about the effectiveness of acupuncture.

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Perhaps you feel that these errors are trivial. But I would disagree. The review authors’ praise of acupuncture for MI is misplaced and will mislead the public. There are plenty of reviews on the subject, and those that are not overtly biased arrive at conclusions like these:

So, how did this sloppy review come about?

Its authors are affiliated to the TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072, China, and the Tea Research Institute, Sichuan Academy of Agricultural Sciences, Chengdu 610066, China. A footnote tells us that their review was supported by the National Natural Science Foundation of China [No. 81973647] and the Xinglin scholar discipline promotion talent program of Chengdu University of traditional Chinese medicine [No. BSH2021018]. This sounds respectable enough.

The journal that published the review is ‘Pharmacological Research – Modern Chinese Medicine‘. Its stated aims are as follows: The journal publishes articles reporting on advances in our comprehension of mechanism and safety in experimental pharmacology and clinical efficacy and safety of pharmacologically active substances, including compound prescriptions, utilized in Traditional Chinese Medicine applying modern scientific research methods. Studies reporting also on the mechanisms of actions of the active substance(s) investigated are encouraged.

The editors in chief of the journal are Guan-Hua Du, PhD, China Academy of Chinese Medical Sciences Institute of Chinese Materia Medica, Beijing, China and Emilio Clementi, M.Mus, MD, PhD, University of Milan, Milan, Italy. No doubt, these are respectable scientists. And because they are, they should make sure that what they publish is correct – a criterion this recent review clearly does not meet.

I had totally forgotten this amusing little episode: According to THE GUARDIAN, Jacob Rees-Mogg (JRM) once tweeted that I should be locked up in the Tower of London!

If you are not from the UK, you may not know this Member of Parliament. So, let me explain.

JRM is the MP for North East Somerset and currently the ‘Minister for Brexit Opportunities and Government Efficiency’. His personal net worth is estimated to be well over £100 million. I probably don’t need to add much more about JRM; there is plenty about him on the Internet and on social media, for instance, this little gem:

Some of JRM’s medically relevant voting records are revealing:

  • He voted against raising welfare benefits five times in 2013.
  • He voted against higher benefits over long periods for those unable to work as a result of an illness or disability: 14 votes over 5 years.
  • Between 2012-2016, he voted 52 times to reduce the spending on welfare benefits.
  • He voted to exempt pubs and clubs where food is not served from the smoking ban in October 2010.
  • He voted against a law to make private vehicles smoke-free if a child is present.
  • He voted against allowing terminally ill people to be given assistance in ending their lives.

Wikipedia mentions that Rees-Mogg is against abortion in all circumstances, stating: “life begins at the point of conception. With same-sex marriage, that is something that people are doing for themselves. With abortion, that is what people are doing to the unborn child.” In September 2017, he expressed “a great sadness” on hearing about how online retailers had reduced pricing of emergency contraception. 

In October 2017, it was reported that Somerset Capital Management, of which Rees-Mogg was a partner, had invested £5m in Kalbe Farma, a company that produces and markets misoprostol pills designed to treat stomach ulcers but widely used in illegal abortions in Indonesia. Rees-Mogg defended the investment by arguing that the company in question “obeys Indonesian law so it’s a legitimate investment and there’s no hypocrisy. The law in Indonesia would satisfy the Vatican”. Several days later, it was reported that the same company also held shares in FDC, a company that sold drugs used as part of legal abortions in India. Somerset Capital Management subsequently sold the shares it had held in FDC. Rees-Mogg said: “I am glad to say it’s a stock that we no longer hold. I would not try to defend investing in companies that did things I believe are morally wrong”.

In a nutshell, JRM seems to stand for pretty much everything that I am against. But that is no reason to send me to the Tower of London. So, what exactly was JRM referring to when he wanted me locked up?

The Guardian article explains: At a press conference to mark his retirement [Ernst] agreed with a Daily Mail reporter’s suggestion that the Prince of Wales is a “snake-oil salesman”. In the living room of his house in Suffolk he unpacks the label with the precision on which he prides himself. “He’s a man, he owns a firm that sells this stuff, and I have no qualms at all defending the notion that a tincture of dandelion and artichoke [Duchy Herbals detox remedy] doesn’t do anything to detoxify your body and therefore it is a snake oil.” Far from regretting the choice of words and the controversy it has generated, he appears to relish it.

Looking back at all this bizarre story, I am surprised that JRM did not advocate chopping my head off in the Tower of London. He must have been in a benevolent mood that day!

The interest in the medicinal properties of honey is lively. A recent review, for instance, concluded that honey is a safe natural substance, effective in the inhibition of bacterial growth and the treatment of a broad range of wound types, including burns, scratches, diabetic boils (Skin abscesses associated with diabetic), malignancies, leprosy, fistulas, leg ulcers, traumatic boils, cervical and varicose ulcers, amputation, burst abdominal wounds, septic and surgical wounds, cracked nipples, and wounds in the abdominal wall. Honey comprises a wide variety of active compounds, including flavonoids, phenolic acid, organic acids, enzymes, and vitamins, that may act to improve the wound healing process. Tissue-engineered scaffolds have recently attracted a great deal of attention, and various scaffold fabrication techniques are being researched.

But there is also reason to be cautious. The U.S. Food and Drug Administration (FDA) posted warning letters to four companies for illegally selling honey-based products that may pose a significant health risk to consumers. The FDA’s laboratory testing found that product samples contained active drug ingredients not listed on the product labels, including the active drug ingredients found in Cialis (tadalafil) and Viagra (sildenafil), which are FDA approved drugs used to treat men with erectile dysfunction. Sildenafil and tadalafil are restricted to use under the supervision of a licensed health care professional. These undeclared ingredients may interact with nitrates found in some prescription drugs, such as nitroglycerin, and may lower blood pressure to dangerous levels. People with diabetes, high blood pressure, high cholesterol, or heart disease often take nitrates.

“Tainted honey-based products like these are dangerous because consumers are likely unaware of the risks associated with the hidden prescription drug ingredients in these products and how they may interact with other drugs and supplements they may take,” said FDA Associate Commissioner for Regulatory Affairs Judy McMeekin, Pharm.D., “Products marketed with unidentified ingredients may be dangerous and, in some cases, deadly to consumers. We encourage consumers to remain vigilant when shopping online or in stores to avoid purchasing products that put their health at risk, and instead seek effective, FDA-approved treatments.”

Today’s warning letters outline how companies violated federal law by selling active drug ingredients in products marketed as foods, like honey, and by making unauthorized claims that their products treat disease or improve health. These products are promoted and sold for sexual enhancement on various websites and online marketplaces, and possibly in some retail stores.

The warning letters were issued to:

Companies marketing food products containing tadalafil and/or sildenafil violate federal law. Some of the products cited in the warning letters are also unapproved new drugs because they are intended for use in the cure, mitigation, treatment, or prevention of disease and they lack FDA approval. In some cases, product claims reference diseases that can only be diagnosed or treated under medical supervision. Additionally, some products cited in the warning letters are represented as dietary supplements even though tadalafil and sildenafil products are excluded from the dietary supplement definition.
The FDA has requested responses from the companies within 15 working days stating how they will address these issues or providing their reasoning and supporting information as to why they think the products are not in violation of the law. Failure to promptly address the violations may result in legal action, including product seizure and/or injunction.

Consumers using or considering using any over-the-counter product marketed for sexual enhancement should talk to a health care professional first, as some ingredients may interact with medications or dietary supplements. The FDA’s health fraud products database can help consumers identify nearly 1,000 of these potentially dangerous products.

The FDA previously warned consumers about more than 10 honey-based products containing hidden drug ingredients. The FDA’s laboratory testing found that product samples contained undeclared active ingredients, including sildenafil and tadalafil. The agency also previously warned consumers to avoid products with hidden drug ingredients sold through Amazon, eBay, Walmart and other retailers. The FDA is committed to protecting consumers by identifying and removing these potentially dangerous products from the market and urges stores, websites, and online marketplaces to stop selling these products.

If a consumer thinks that a product might have caused a reaction or an illness, they should immediately stop using the product and contact their health care provider. The FDA also encourages health care providers and consumers to report adverse reactions associated with FDA-regulated products to the agency using MedWatch or the Safety Reporting Portal.

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