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Archive for March, 2011

The benefits and risks of folic acid supplementation

Could a vitamin with proven benefits in one group cause harm to another? That’s the growing concern with folic acid, the vitamin that dramatically reduces the risk of neural tube birth defects such a spina bifida. Studies designed to explore the possible benefits of folic acid for heart disease, stroke and cancer are giving out some worrying signs: At best, folic acid is ineffective, and at worst it may be increasing the risks of some cancers. So what does this say about routine supplementation for the typical healthy individual, and its overall risk and benefit?

Folate (vitamin B9) is an essential nutrient found green, leafy vegetables, broccoli, peas, corn, oranges, grains, cereals, and meats. Folate has important roles in the synthesis of DNA, and consequently cell division. Significant folate deficiency can lead to macrocytic anemia. Folic acid, a synthetic form of folate, is used in multivitamins supplements because it is better absorbed.

Folic acid’s benefits in pregnancy are well documented. Supplementation before conception, and in the first few weeks of pregnancy, significantly and substantially lower the risk of several different birth defects, including neural tube defects (NTDs). The neural tube is the embryonic precursor to the brain and spinal column. NTDs include very serious defects like spinal bifida and anencephaly, birth without part of the brain.

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Posted in: Clinical Trials, Epidemiology

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EMDR and Acupuncture – Selling Non-specific Effects

The scientific approach to understanding the world includes the process of carefully separating out variables and effects. Experiments, in fact, are designed specifically to control for variables. This can be especially challenging in medicine, since the body is a complex and variable system and there are always numerous factors at play. We often characterize the many variables that can influence the outcome in a clinical study as “placebo effects” or “non-specific effect” – things other than a specific response to the treatment in question.

A common error to make when interpreting clinical studies is to confuse non-specific effects – those that result from the therapeutic interaction or the process of observation – with a specific effect from the treatment being studied. While this is broadly understood within the scientific medical community, it seems that within certain fields proponents are going out of their way to sell non-specific effects as if they were specific effects of the favored treatment.

This is perhaps most true for acupuncture. As has been discussed numerous times on SBM, the consensus of the best clinical studies on acupuncture show that there is no specific effect of sticking needles into acupuncture points. Choosing random points works just as well, as does poking the skin with toothpicks rather than penetrating the skin with a needle to elicit the alleged “de qi”.

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Posted in: Acupuncture, Clinical Trials, Neuroscience/Mental Health

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Acupuncture Revisited

Believers in acupuncture claim it is supported by plenty of published scientific evidence. Critics disagree. Thousands of acupuncture studies have been done over the last several decades, with conflicting results. Even systematic reviews have disagreed with each other. The time had come to re-visit the entire body of acupuncture research and try to make sense out of it all. The indefatigable CAM researcher Edzard Ernst stepped up to the plate. He and his colleagues in Korea and Exeter did an exhaustive study that was published in the April 2011 issue of the medical journal Pain:   “Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews.” It is accompanied by an editorial commentary written by yours truly: “Acupuncture’s claims punctured: Not proven effective for pain, not harmless.” (The editorial is reproduced in full below.)

Ernst et al. systematically reviewed all the systematic reviews of acupuncture published in the last 10 years: 57 systematic reviews met the criteria they set for inclusion in their analysis. They found a mix of negative, positive, and inconclusive results. There were only four conditions for which more than one systematic review reached the same conclusions, and only one of the four was positive (neck pain). They explain how inconsistencies, biases, conflicting conclusions, and recent high quality studies throw doubt on even the most positive reviews.

They also demolished the “acupuncture is harmless” myth by reporting 95 published cases of serious adverse effects including infection, pneumothorax, and 5 deaths. Some but not all of these might have been avoided by better training in anatomy and infection control. (more…)

Posted in: Acupuncture

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The Image of Chiropractic: Consensus Based on Belief

EDITOR’S NOTE Today is a big grant deadline for me; at 5 PM EDT, the grant is due. As a consequence of working on my grant application into the wee hours of the morning last night, I didn’t have a chance to write my usual bit of logorrhea of the sort that I’ve laid down each and practically every Monday for the last three-plus years. Fortunately, retired chiropractor turned skeptic of chiropractic Sam Homola was ready to fill in admirably just for this week. Although I might throw up a post later this week, worst case scenario, I’ll be back here, same time, same day, same Bat Channel. In the meantime, take it away, Sam!

As a chiropractor, I am often asked why the image of chiropractic is so bad. “Why is chiropractic so often ignored by the media and ridiculed by physicians?” Journalists and health professionals tend to judge chiropractic by the worst of what they see, and what they see is often bad. This March 15, 2011, post from a chiropractic group asking for money to provide chiropractic services for earthquake and tsunami victims in Japan is a good example of why chiropractic has a bad image:

Please consider donating whatever you can to the SOTO-I/PAAC [Sacro Occipital Teaching Organization International-Pacific Asian Association of Chiropractic] Japan Relief Fund. 100% of your donation will go directly to helping the needy Japanese people through SOT Chiropractic treatments and services.

Please consider this avenue of donation rather than the Red Cross etc. While they are worthy organizations, we have ZERO overhead to administration and the funds will provide CHIROPRACTIC services to the needy. Please recommend this avenue of aid to your patients and friends also. Any and everything will help!

Practitioners of Sacro Occipital Technic (SOT) and SOT Craniopathy claim to restore innate healing capacity by removing neurological interference and improving the flow of cerebrospinal fluid (“craniosacral respiration”). Vertebral subluxations affecting certain organs are found by palpating tendon insertions at the base of the skull. Craniosacral respiration is improved by adjusting the bones of the skull and the sacroiliac joint.

There are dozens of such nonsensical chiropractic treatment methods foisted on the public through “press releases” and junk-science journals. NUCCA (upper cervical technique), which identifies slight misalignment of the atlas as a major cause of human ailments, is a commonly-promoted technique based on chiropractic vertebral subluxation theory.

This press release further illustrates the reason for chiropractic’s bad image:

A revolutionary neuro relief technique is being used by chiropractors across the United States and Canada to treat a wide-array of Symptoms and Chronic Disorders they were never before able to handle. This technique, when applied correctly performs absolute miracles for patients who have been suffering for an extensive period in their lives. Thus patients are happier and chiropractors are increasing their visibility and incomes!
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Posted in: Chiropractic

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How popular is acupuncture?

Everybody’s Doing It

One argument that often comes up when skeptics and proponents of so-called complementary and alternative medicine (CAM) debate is the question of the popularity of various CAM practices. Advocates of CAM often claim these practices are widely used and growing rapidly in popularity. Obviously, CAM proponents have an interest in characterizing their practices as widely accepted and utilized. Even though the popularity of an idea is not a reliable indication of whether or not it is true, most people are inclined to accept that if a lot of people believe in something there must be at least some truth to it. The evidence against this idea is overwhelming, but it is a deeply intuitive, intransigent notion that can only rarely be dislodged.

It might therefore be useful to get some idea of whether or not the claims of great popularity for CAM treatments are true. If they are not, fruitless debates about the probative value of such popularity could potentially be avoided, and it might be possible to diminish the allure associated with the belief that “everybody’s doing it.” 
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Posted in: Acupuncture

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Asian Bear Bile Remedies: Traditional Medicine or Barbarism?

Imagine living 20 years spending 24 hours a day in a cage that tightly fits your body, not giving you room to stand up, stretch out, turn around, or move at all.

Imagine that twice a day during these years you would have a metal catheter inserted into a hole which has been cut into your abdomen, allowing the catheter to easily puncture your gall bladder, or maybe a long syringe inserted into your gall bladder, piercing through your skin again and again, by people who are not doctors.

Imagine becoming infected and cancerous because of this twice-daily physical invasion, and becoming neurotic due to your claustrophobic imprisonment.

Imagine having one or both of your hands cut off so someone can sell them for a lot of money.

Imagine you begin to chew at your hands, if you are lucky enough to have one or both left, due to your developing neuroticism, and to distract yourself from the pain you experience twice a day, every day, for your entire life.

This is reality for an estimated minimum of 12,000 bears across Asia.

– Sara Pegarella, JD

Currently, animal activists across China are up in arms because Gui Zhen Tang Pharmaceutical Corporation, a Fujian-based company that sells bear bile for use in Traditional Chinese Medicine (TCM), has tried to increase production through an initial public offering (IPO). The company is being accused of cruelty towards animals in the process of extracting their bile at an industrial scale. Bear bile, or Xiong Dan (熊胆), is an important ingredient in TCM.

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Posted in: Medical Ethics, Politics and Regulation, Science and Medicine

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CAM and Evidenced-Based Medicine

Mark Tonelli, MD has problems with evidence-based medicine (EBM). He has published a few articles detailing his issues, and he makes some legitimate points. We at science-based medicine (SBM) have a few issues with the execution of EBM as well, so I am sympathetic to constructive criticism.

In an article titled: Integrating evidence into clinical practice: an alternative to evidence-based approaches. The abstract states:

Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM approaches recognizes that five distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient.

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Posted in: Science and Medicine

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Herbal Remedies, Street Drugs, and Pharmacology

David Kroll’s recent article on thunder god vine is a great example of what can be learned by using science to study plants identified by herbalists as therapeutic. The herbalists’ arsenal can be a rich source of potential knowledge. But Kroll’s article is also a reminder that blindly trusting herbalists’ recommendations for treatment can be risky.

Herbal medicine has always fascinated me. How did early humans determine which plants worked? They had no record-keeping, no scientific methods, only trial and error and word of mouth. How many intrepid investigators poisoned themselves and died in the quest? Imagine yourself in the jungle: which plants would you be willing to try? How would you decide whether to use the leaf or the root? How would you decide whether to chew the raw leaf or brew an infusion? It is truly remarkable that our forbears were able to identify useful natural medicines and pass the knowledge down to us.

It is equally remarkable that modern humans with all the advantages of science are willing to put useless and potentially dangerous plant products into their bodies based on nothing better than prescientific hearsay. (more…)

Posted in: Herbs & Supplements

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Join Trine Tsouderos for a web chat with Dr. Paul Offit

Here’s something for you all to check out. Trine Tsouderos, the journalist from The Chicago Tribune who’s distinguished herself as being one of the few reporters who “gets it” when it comes to quackery and the anti-vaccine movement (just put her name in the search box of this blog for some examples) will be hosting a web chat about vaccines featuring none other than Dr. Paul Offit, one of the gutsiest (if not the gutsiest) defender of vaccine science out there. The chat will occur here at noon CDT today. Questions can be submitted in advance to Tsouderos at ttsouderos@tribune.com.

Head on over, everyone. The anti-vaccine movement is clearly out in force in the comments. Although the usual intrepid defenders of science are there, reinforcements are always welcome.

Posted in: Announcements, Vaccines

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Ann Coulter says: Radiation is good for you!

Here at Science-Based Medicine, we try to be relatively apolitical. We might not always succeed, but in general our main concern is not so much with right-wing or left-wing politics, but rather with how prevailing government policies and regulation impact the delivery of medical care, in particular whether they tend to prevent, do nothing about, or promote the proliferation of non-science-based medical care. Consequently, when Kimball or I call for the disbanding of the National Center for Complementary and Alternative Medicine (NCCAM), it does not matter one whit to us who is President or which party controls Congress. All that matters is that we see NCCAM as a government entity that, through credulously studying many “alternative medicine” modalities, ends up inadvertently promoting them and providing them with the imprimatur of government approval. The same concept applies to state medical licensing boards licensing pseudoscientific modalities, such as naturopathy, acupuncture, and homeopathy. By regulating these “disciplines,” states also provide them with an unmerited mantle of respectability through their imprimatur of regulating them as professions, just like medicine and nursing.

As far as political views, although all of us have them and they occasionally even come to the fore in disagreements (remember when Wally Sampson occasionally clashed with others with differing political viewpoints?), we generally subsume them for purposes of the SBM blog experience into our advocacy for basing medicine on the best science available. Sometimes, however, when a pundit or politician makes claims that are either contrary to or distort science for ideological or political advantage, I feel the need to discuss those claims, sometimes even sarcastically. Such was the case last week, when Ann Coulter wrote a blisteringly ignorant column, entitled A Glowing Report on Radiation. She wrote this article in the wake of the fears arising in Japan and around the world of nuclear catastrophe due to the damage to the Fukushima nuclear power plant caused by the earthquake and tsunami that hit northern Japan on March 11. Coulter was subsequently interviewed by Fox News pundit Bill O’Reilly on The O’Reilly Factor on Thursday evening:

Yes, according to Coulter, radiation is good for you, just like toxic sludge! Even more amazing, in this video Bill O’Reilly actually comes across as the voice of reason, at least in comparison to Ann Coulter. He’s very skeptical of Coulter’s claims and even challenges her by saying, “So by your account we should all be heading towards the nuclear reactor.”

So, fellow SBM aficionados, is Coulter right? Are all those scientists warning about the dangers of even low-level radiation all wrong? Should we start hanging out in radioactive mine shafts, as Coulter mentions in her column (seriously) in order to boost our health and decrease our risk of cancer?

Not so fast, there, Ann. Here’s a hint: If Bill O’Reilly can lecture you on science and look more reasonable than you, you’re off the rails.
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Posted in: Cancer, Science and the Media

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