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

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by Osteopathie Praxis im Klinikum Karlsruhe - Thursday 19 July 2018 09:35
SISTER SURVIVORS AWARDED FOR COURAGE This tragedy was happening in the name of Visceral Osteopathy (former Thure Brandt Massage) which is an open door for such a misuse and for which there is no evidence neither for reliability of diagnosis nor for clinical efficacy ... http://www.espn.com/video/clip?id=24134625

by Alan Henness - Thursday 19 July 2018 01:31
Asparagus juice you say? Like this?

by Rich Wiltshir - Wednesday 18 July 2018 16:30
My wife's niece emailed saying asparagus juice (as recommended by a doctor who has no footprint in reality) would be helpful against her breast / liver cancer. Similarly, this is a person who I've no intention of meeting again. Characteristic of such buffoons is the "I want to remember him / her how (s)he was" excuse for not visiting in their final months. BS tarnishes grief, too. Sorry to hear of your sadness, Frank.

by Frank Collins - Tuesday 17 July 2018 02:09
A dear friend of mine was suffering from terminal cancer (and died just over 12 months ago) and when I mentioned it to an acquantaince, she suggested lymphatic drainage as a possible cure because her sister 'does it'. I don't recall speaking to that person again, voluntarily. In some people's minds, LD is far more capable than the scant information suggests. Then again, the feeble-minded will believe in anything without evidence.

by Osteopathie Praxis im Klinikum Karlsruhe - Monday 16 July 2018 14:55
I achieved my certificate from http://www.lymphologicum.de/das-lymphologicum/netzwerkfibel/die-autoren/oliver-gueltig.html at Kneipp School for Physical Therapists https://www.kneippschule.de And we were told to follow a standard including (in Germany called:) ML / KPE (komplexe physikalische Entstauungstherapie means lymphatic or phlebologic compression bandage and other special supply articles ) I don't know wether this is a standard known outside of German speaking countries at all. MLD alone doesn't make sense.

by Edzard - Monday 16 July 2018 12:47
yes, there is need for more research, as there is only scant evidence for it as a treatment of lymphoedema.

by Dr Julian Money-Kyrle - Monday 16 July 2018 11:47
I'm not really sure why manual lymphatic drainage is being discussed in an alternative medicine Web site. It is a standard treatment for established upper-limb lymphoedema after treatment for breast cancer, which is a very difficult problem to manage, and it is used in addition to compression sleeves (which are very uncomfortable). The main problem is that the services available to NHS patients are in high demand and the waiting lists are long, and when I was working MLD was provided locally by the palliative care system. I haven't come across it as prophylaxis against lymphoedema, though from reading this paper it doesn't appear to be any better than exercise, which is much cheaper and easier to implement. The authors freely discuss the limitations of their study, including the very important fact that it was not randomised. Probably the most interesting piece of information in the paper is that the pre-operative drainage of the limb, as measured by scintolymphography, appears to be predictive of the risk of subsequent lymphoedema. This is worth further investigation, as if it is true it may inform oncological treatment decisions (such as radiotherapy technique and dose). The two main risk factors for lymphoedema after breast surgery are well established. These are irradiation of the lymph nodes, and level of lymph node dissection. The current standard of care is sentinel node biopsy, which involves identifying the lymphatic drainage of the tumour using a radioactive marker, then biopsying the first few nodes, examining them immediately (using a "frozen section" to prepare the specimen quickly) and only extending the dissection if the "sentinel node" is involved. One thing that struck me about this paper was the sub-optimal oncological treatment that the subjects had received. Thankfully none had had a Halstead mastectomy - this mutilating operation, involving removal of the underlying ribs as well as the breast, was dropped in the UK before I qualified as a doctor in 1986, and I am rather worried that it was even mentioned in the trial. Neither are modified radical mastectomies performed very much these days, many tumours being amenable to wide local excision of the lump followed by radiotherapy to the breast. I was also surprised at the number of patients who had their supraclavicular fossae irradiated as this is something else that we try to avoid (due to the risk of overlapping field boundaries at the brachial plexus, which can lead to brachial plexopathy, a much more serious problem than lymphoedema). Coming back to manual lymphatic drainage as treatment for lymphoedema, as opposed to prevention, although it is widely used I don't know to what extent it has been subjected to good trials. In my experience patients seem to find it helpful, but the improvements certainly aren't dramatic. I think there is a need for more data here.

by Edzard - Wednesday 18 July 2018 17:38
I looked it up: 14 November [you can see all my lecture dates by clicking on the bar 'lectures and talks' on the top of the homepage of this blog]

by Rich Wiltshir - Wednesday 18 July 2018 16:21
Sounds like reason for a day trip. Please shout out when the date's confirmed.

by Edzard - Wednesday 18 July 2018 12:11
agree, I am scheduled to give a talk at Café Scientifique in Cambridge later this year, I think November.

by Rich - Wednesday 18 July 2018 12:06
Somehow, I suspect your thoughts are rarely random. It's great to see a competent thinker address a topic that's new to their scrutiny. There are lots of subjects where my ignorance prevents the formation of an opinion (free will, for example), so I focus my enthusiasm on enquiry and testing ideas to destruction - some fail quite quickly, fuelling even more curiosity about how folk fall for them. Sceptics in the pub is an excellent forum. Café Scientifique is worth a visit. In Shrewsbury, there's Hmmm Squad with a vibrant and eclectic range of topics hitting the gang each month. They're all always well-attended.

by Rich Wiltshir - Wednesday 18 July 2018 16:32
Sometimes, I muse how I'd react to a SCAM-merchant visiting my deathbed: it'd probably give me a vibrancy not seen for years as my reaction wouldn't be healthy for either of us.

by Udo Endruscheit - Monday 16 July 2018 09:52
A refuge of anthroposophical philanthropy - and one of the opponents of vaccination...

by Volker H. Richter - Monday 16 July 2018 08:32
....Editor >> "Univ.-Prof. Dr. med. Arndt Büssing, Witten/Herdecke" et. al..... No wonder! The university of Witten/Herdecke is the headquarter of alternative medicine with profound anthroposophical background.

by Matthew Bauer - Wednesday 18 July 2018 04:36
Dear Dr. Ernst - You asked me to answer the questions you had asked that I had not yet responded to. As near as I could tell reviewing those questions you asked that I did not answer, I found 4: #1.On 7/2 you asked: do you know what evidence is? My answer – yes. #2. On 7/14 I had stated “Of course, there are many studies including systematic reviews showing acupuncture to outperform sham but people like Dr. Ernst reject all of those as being unreliable studies that have a risk of false positives.” You said: “not true!” Then asked: “which such review did I ‘reject’?” My answer: It is my understanding that you have rejected the findings of at least these reviews. I add quotes from those reviews’ findings. If, in fact, you accept any of those findings please advise which ones and I will stand corrected. Acupuncture Evidence Project- “Key results: Of the 122 conditions identified, strong evidence supported the effectiveness of acupuncture for 8 conditions, moderate evidence supported the use of acupuncture for a further 38 conditions, weak positive/unclear evidence supported the use of acupuncture for 71 conditions, and little or no evidence was found for the effectiveness of acupuncture for five conditions (meaning that further research is needed to clarify the effectiveness of acupuncture in these last two categories). https://www.acupuncture.org.au/wp-content/uploads/2017/11/28-NOV-The-Acupuncture-Evidence-Project_Mcdonald-and-Janz_-REISSUED_28_Nov.pdf Acupuncture Trialists’ Collaboration - Acupuncture for Chronic Pain Individual Patient Data Meta-analysis: “Results : In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition” https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1357513 Cochrane Review - Acupuncture for preventing episodic migraines “Bottom Line: The available evidence suggests that a course of acupuncture consisting of at least six treatment sessions can be a valuable option for people with migraine.” https://www.cochrane.org/CD001218/SYMPT_acupuncture-preventing-migraine-attacks #3. On 7/14 I had posted: “the evidence is clear that for many common pain conditions, acupuncture has been shown to have a better benefit to harm ratio than most pain meds.” Then you asked: “WOULD YOU PLEASE LINK SOME EVIDENCE?” Again, the Cochrane review on preventing migraines found: “ In five trials, acupuncture was compared to a drug proven to reduce the frequency of migraine attacks, but only three trials provided useful information. At three months, headache frequency halved in 57 of 100 people receiving acupuncture, compared with 46 of 100 people taking the drug. After six months, headache frequency halved in 59 of 100 people receiving acupuncture, compared with 54 of 100 people taking the drug. People receiving acupuncture reported side effects less often than people receiving drugs, and were less likely to drop out of the trial.” A 2015 network meta-analysis comparing treatments in addition to exercise for shoulder impingement syndrome found that acupuncture was the most effective adjunctive treatment out of 17 interventions, outperforming all other adjuncts such as steroid injection, NSAIDs, and ultrasound therapy. (Dong W, Goost H, Lin X-B, et al. Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis. Medicine (Baltimore) 2015;94:e510. doi:10.1097/MD.0000000000000510) A 2016 comparison of 20 treatments for sciatica ranked acupuncture as 2nd most effective after the use of biological agents, outperforming manipulation, epidurals, disc surgery, opioids, exercise, and an invasive procedure called radiofrequency denervation, which came in last. (Lewis R, FLCOM NHWPF, PhD AJS, et al. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal 2015;15:1461–77. doi:10.1016/j.spinee.2013.08.049) In 2018, a network-meta-analysis found that acupuncture was more effective than drugs for treating chronic constipation and with the fewest side-effects. (Zhu L, Ma Y, Deng X. Comparison of acupuncture and other drugs for chronic constipation: A network meta-analysis. PLoS ONE 2018;13:e0196128. doi:10.1371/journal.pone.0196128) (I know constipation is not a “common pain condition” but medications for common pain conditions often causes constipation.) #4. On 7/13 you asked: “are you claiming that, in China, there is a uniform treatment schedule? I think this is fantasy! “ My answer: “Not exactly a “uniform treatment schedule” but certainly a uniform treatment schedule approach. The exact number and timing of the treatments will depend on the patient’s progress. The basic ratio is that in the beginning stage for chronic conditions is you see the patient more frequently (in China that will be daily or every other day) then, when the patient has made enough progress, you start to stretch the treatments out to about ½ the initial frequency until they reach the maximum benefit. And that is another BIG problem with acupuncture RCTs in the West – the acupuncturists aren’t allowed to change the treatment frequency based on patient response like we do in practice. I would like to correct how some here seem to have misunderstood about my statement about Western acupuncture trials not being done in such a manner as to allow the real acupuncture to reach its maximum benefit. I have been saying that this happens either because those involved in the trials don’t know how to preform acupuncture to its full clinical potential OR the trials were never designed to allow acupuncture to achieve its full potential. Both have happened. There are trials where the “acupuncturists” involved in the design and/or doing the needling were woefully undertrained and unable to achieve the maximum benefit. In many of the trials where there are better trained acupuncturists involved, the acupuncture proponents you called them, it seems clear they did not think it necessary to allow acupuncture to reach its maximum clinical potential. So the precondition of a legitimate multi-arm sham controlled trail to offer evidence about if verum acupuncture can outperform sham was not built into those trails design. I can give examples of this if you are interested. I hesitate to go through the trouble to give those examples if you don’t care to see the evidence. It seems strange to me though that someone who has a record of picking apart the methodology of trials that find in favor of acupuncture and claiming they are giving false positives would not care to see evidence of methodological problems in acupuncture trials causing false negatives.

by Matthew Bauer - Monday 16 July 2018 19:54
Frank - I tried to bring to everyone's attention the sub analysis in the Cochrane review on preventing episodic migraines that showed acupuncture did do better than the sham control and that when higher treatment numbers were used the effectiveness rates went up considerably. Did you see that post? Those higher treatment numbers in that sub analysis are much closer to the numbers I would use myself so that is some evidence from a respected source supporting the manner in which I treat. It also supports the main point I have been trying to make about optimal vs sub-optimal treatment dosages in acupuncture trials and reviews; dosage matters.

by Matthew Bauer - Monday 16 July 2018 19:31
I did answer several of your questions directly but I will review and look for those I did not get to and offer my answers although I believe most of those answers will be found in the following two sources: https://www.evidencebasedacupuncture.org/present-research/acupuncture-scientific-evidence/ https://acunow.org/wp-content/uploads/2017/10/Acupunctures-Role-in-Solving-the-Opioid-Epidemic-_Final_September_20_2017.pdf

by Jashak - Monday 16 July 2018 16:18
@ Mr. Bauer, Quote (from Saturday 14 July 2018 at 17:22) "You said “You have extensively documented your personal successes with acupuncture treatments.” I barley mentioned my personal experience until Jashak asked me to relate them. I know my personal experience is not important in a discussion about evidence." So many times we went back and forth on this. I have even tried different styles to make you understand, but still you do not get the point, it seems. This makes me think that it is not a language barrier, but a “brain barrier”. I WAS NEVER ASKING YOU FOR PERSONAL EXPERIENCE OR ANECDOTES! Quite the opposite, PLEASE STOP trying to use your personal anecdotes as prove! I was asking for EVIDENCE that you method works! Maybe you get it if I illustrate it with an example (as a new style, I will try pre-school writing style): *Ten persons with lower back pain visit your colleague, Mr. White. *He uses HIS acupuncture protocol on them (let´s say, several acupoints, 2 times per week for 6 weeks. *In his satisfaction/experience survey, five persons report back positively (i.e. 50%) . ______ *Ten other persons with lower back pain visit YOU. *You use YOUR acupuncture method/protocol (let´s say, several acupoints, 4 times per week for 18 weeks). *In YOUR satisfaction/experience survey, nine persons report back positively (i.e. 90%). ______ You now claim that this is proof that YOUR way to do acupuncture is correct, resulting in maximum benefit and that Mr. White does it incorrectly. Guys like him would have screwed up all the RCTs that have not shown benefit of acupuncture beyond placebo. I say that your claim is a fallacy, because without proper controls (placebo, no-treatment), MANY OTHER REASONS could explain that you get a better feedback than Mr. White does. (Maybe I should have called him Mr. Impatient or Mr. Body-Odor, instead of Mr. White…). My point is that YOUR METHOD must be evaluated independently via RCTs (which must include all necessary controls and far greater patient numbers for statistical analysis) before you can make ANY claim of efficacy beyond placebo. I hope that you now finally get the intention of my question. If not, I might well try baby-speech next time.

by Bjorn Geir - Monday 16 July 2018 15:39
@Matthew. I was going to respond to you but I see that Frank has addressed practically all the points I was going to make and in a much better way than I could have. I am not giving this blog much attention these days, seeing as the weather has finally improved. This summer we had rain twice, first for 45 days, then for 35 days. Between these periods there was one (1!) day with some sun. 😀

by Frank Odds - Monday 16 July 2018 11:22
@Matthew Bauer "Might it be possible the Chinese do get higher success rates because they have more expertise and do a lot more treatments on average that are done in the West?" I very much doubt that. Since it reopened to the West in the 1970s, China has had a particular difficulty. While its economy has blossomed amazingly over the past 40 years, it numbers only a few internationally elite scientists among its citizens. Its government has therefore taken steps to rectify the situation, but the attitudes and cultures of the Chinese population (in common with most populations) are slow to move. They remain steeped in traditional beliefs, which are particularly notable in medicine, and the catch-up is a tedious process. You should first read this article so you can appreciate I am not exaggerating the problem. Like the article explains, a focus on short-term positive results from scientific experiments is unhealthy: it is likely to tempt some investigators into publishing data they know won't be reproducible. (The same thing happens all over the world when scientists are pressured to publish, but a government reward scheme has to be an exceptional pressure.) Now look here, here and here. (That last link is a news report describing the previous link in easy-to-read language.) Lest you think the cheating described is a recent problem, you should take at look at this and this. As an academic, retired after a career of 45 years, I can assure you that most of my colleagues involved in biomedical research are aware of a 'China problem'. While the best of young scientists from China who spend time doing research in the West are often first-class, even superb, there seem to be some to whom falsifying research results is almost second nature. I have personally refereed papers in my own field (broadly, medical microbiology/infectious disease) submitted by Chinese groups that contained blatant examples of crudely fiddled data, but all this is mere personal anecdote and you can disregard the comments if you wish. Lest you should think I have some kind of cultural/racist bias against the Chinese (I definitely don't!), this paper puts the relative contributions of nationalities for scientific paper retraction into perspective; the USA leads the field for research fraud, with China a poor fourth. But those are figures for all types of research, and they're based only on publication retractions: most fraudulent or otherwise dodgy papers never get retracted. For clinical research publications, China has a more serious problem. This article is one of many reporting the 2016 Chinese government revelation on data fabrication in 80% of new drug trials. You may say this is not evidence for a similar problem with acupuncture trials and other types of Chinese altmeds, but, against the background I set out above, I'd suggest such a view is over-optimistic. Up to this point I hope you notice I have not referred so far to any material on the Ernst blog, which always seems to aggravate you, but I'm now going to link to this post from 2014. Please re-read it carefully. It contains what I would characterize as unassailable logic; but I'm sure you will have a different perspective. In science (and, dare I say, particularly in medical science?) I consider it is essential to maintain a sceptical eye about everything you read, particularly when one's 'personal experience' may be an influence. Experience is a valuable asset, but history shows us it can lead us down many wrong paths. Perhaps the discovery that peptic ulcer is an infectious disease might serve as a recent example of the triumph of science over collective medical experience.

by jm - Monday 16 July 2018 07:31
"at it again? ““Prof. Ernst has pointed out, repeatedly, that it is the totality of evidence that needs to be considered.” That was actually Frank putting words in your mouth.

by Edzard - Monday 16 July 2018 06:53
"And who gets to decide what evidence is “reliable”? " I am surprised by this question from someone who pretends to understand research! there are accepted and validated instruments for estimating the quality of clinical trials. if you want to see how unacceptably poor most Chinese studies are, there are many posts on this blog and elsewhere about the issue. here is one of many papers: https://www.ncbi.nlm.nih.gov/pubmed/?term=ernst+e%2C+tang+bmj now Sir, tell me something: when will you answer the questions I put to you [feels a bit one-sided to answer yours and not get answers of mine]?

by Matthew Bauer - Sunday 15 July 2018 21:50
And who gets to decide what evidence is "reliable"? Sounds ripe for subjective opinion rather than data driven. Being that I have been responding to several posters, I can find it difficult to keep up. Please remind me of any specific questions you have for me and I will respond. Sometimes, what you see as me putting words in your mouth is my repeating what others here have said you have said. As for insults, I am pretty sure I only responded in kind and then apologized when I realized I went too far. However, two wrongs don't make a right so I will refrain from those in kind responses.

by Edzard - Sunday 15 July 2018 20:25
at it again? "“Prof. Ernst has pointed out, repeatedly, that it is the totality of evidence that needs to be considered." what I do say often [because it is true] is that one has to consider the totality of the RELIABLE evidence. by and large the Chinese trials do NOT fall into this category [a statement which is based on the totality of the reliable evidence].

by has - Tuesday 17 July 2018 22:24
Bless you, sir, for your concern. Though as it happens, I could not find my baseball bat—do you think a chainsaw would do…?

by ChristianB - Tuesday 17 July 2018 06:42
I agree that this statement was somewhat bold and I acknowledge the progress in psychiatry. Nevertheless it is somewhat disappointing when you see that systematic collecting lab data such as analysis of metabolites did not happen, albeit it has been proposed by scientists more than 25 years ago. The discussion on homoeopathy not only in psychiatry reveals in my opinion also the cultural differences between medicine and science in the narrow sense of the word. I couldn't imagine how deep this differences are before a became part of a big interdisciplinary project - as a computer technician (with a life science background) not as a scientist. I think these mostly obfuscated differences hinder the scientists to present there results in a way that makes it easier for medical person to accept them emotionally not only rationally. And it makes it possible that ideas which are hilarious for scientists, such as homoeopathy, are still seriously discussed in some medical circles.

by RichardR - Monday 16 July 2018 09:09
I could imagine the use of these new set of technologies to do the bare minimum: classifying symptoms into diseases with a common root cause I think your view of psychiatry is somewhat outdated. Efforts are under way to give psychiatry more solid, science-based and evidence-based foundations, even though technology still only plays a minor role compared to the rest of medicine. Just look at the development in the DSM: over the years, diagnostic criteria have been critically assessed and adjusted, being far more consistent now than even 25 years ago. And the fact that a lot of separate, specific diagnoses have been abandoned and brought under an ever widening spectrum of a smaller number of disorders is a good sign of this scientific approach: it removes false categorizations and fictitious boundaries between 'normal' and 'abnormal', and acknowledges that mental conditions can be just as varied and vague as physical conditions. Then again, psychiatry is indeed still not a 'hard' science in most respects. It is still largely an observational science, with little powers of prediction and deduction. I see the efforts I mentioned mostly as a good first step: admit that the whole field is still largely based on case descriptions, and not so much on solid theories. However, the point here is that homeopaths apparently try to hitch a free ride. They try to insert their proven ineffective pseudoscience into the regular system for treating mental disorders, in the hopes that they can get their hands on a piece of this pie, without anyone noticing that what they are contributing is literally nothing (it is homeopathy, after all). The main weakness of psychiatry, i.e. that it is still lacking good theoretical foundations, makes it an attractive target. This is in other words a classic example of parasitic behaviour.

by Jashak - Tuesday 17 July 2018 12:21
Matt Dillahunty, host of an atheist call-in webcast, sometimes asks his callers the simple question: “Are you interested in the truth?” I quite like this question, despite its confronting nature. For obvious reasons, it applies well to CAM believers as well. If you ask this question, you will no doubt always get the answer “yes, I am”. But as soon as the debates start on the definition of “truth”, how to set up falsifiable hypotheses for testing, collecting reproducible evidence and objectively interpreting the results, it turns out that pretty much all believers are NOT interested in the truth, but indeed want to reinforce the specific belief that makes them feel good instead, even if it becomes increasingly apparent that their position contradicts simple logical reasoning and basic natural laws.

by Les Rose - Tuesday 17 July 2018 10:35
I don't know if Richard Smith realises the irony of publishing such a paper. If there is so much poor research published, why do editors accept it, and reviewers approve it? It reminds me of his lecture to HealthWatch several years ago, when he stated that medical journals are a branch of pharmaceutical marketing. If they are, then he made a very good living out of it. The answer of course is that scientific publishing is big business and you have to follow the money. As you say, alt med research is much worse. Peer reviewers for a quack journal are yet more quacks. It would be very interesting to see a study of homeopathy that used Bayesian statistics. How would they derive the prior probability?

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