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That’s so Chiropractic

Old Bad Studies: Fantastical Autopsy Results

I found the following quote at Chiropractic care can treat more than just bad backs (FYI. Chiropractic can’t):

Luse references a study published in The Medical Times authored by Dr. Henry Windsor (sic), M.D. that showcases the correlation of spinal health to overall wellness. Windsor dissected 75 human cadavers to investigate their causes of death. The study showed that 138 of the 139 diseases of the internal organs that were present were in connection to the misalignments of the vertebrae.

But I was intrigued. So I went to the video tape. Well, the PDF.

It is an interesting read by a physician who was looking for an association between curvature of the spine and visceral pathology.

He had 50 corpses, age unknown, that he dissected, looked at the spine for curvature and then looked for pathology in organs in the same distribution of sympathetic nervous system as the level of the spine curvature.

It would be important to know the age and co-morbidities of the patients, since curvature of the spine is a natural result of aging and can be found in normal people and those with nutritional and other metabolic problems.

More importantly, there is no description of the definition of what constitutes a curvature of the spine beyond the obscenity definition: He knows it when he sees it. In fact he finds curvatures where

such a curve would have been considered normal by many.

He found the curves then found internal pathology then lined up the diseases with the curvature and found associations. 50 cadavers, 105 curvatures of which 100 were ‘minor’ and of these 105 curvatures, 96

showed evidence of disorders in some of the structures supplied by that portion of the sympathetic system coming from the vertebral segments of the curvature.

Why only some?  What was minor? Why are not all the organs in the sympathetic distribution diseased? Um. Because it is an imaginary association?

Or reversing the process of thought, 221 structures other than the spine were found diseased. Of these, 212 were observed to belong to the same sympathetic segment as the vertebrae in curvature

And when there wasn’t an association, it was due to the levels one vertebrae up or down; close enough, right?

Without knowing how abnormal curvature is defined and how the spines were examined, as far as I can tell this is a massive example of confirmation bias.  He saw what he wanted to see.

There were a hodgepodge of problems discovered: infections, tumors and cirrhosis, that,  as the philosophically notes, are

the ordinary diseases of adult life

It is  curious that diseases with radically different pathophysiologies were thought to be perhaps due to spine curvature and involvement of the sympathetic nervous system.  I can think of no reality based physiology that would result in cancer and infection from interference of the sympathetic nervous system, and we have no way of knowing if the sympathetic nervous system was even impaired in these cadavers.  It is a hypothesis, not a conclusion, from his studies, and an awful one at that.

Some of the processes do not seem to be diseases at all: 1 small bladder, 1 unduly large bladder, 8 large and small 7 red kidneys, 1 degenerated pancreas, whatever that is, one groin wound, 4 dilated stomachs, 7 large and 5 atrophic spleens. So many subjective findings. It seemed as if there was no pathology he found some anyway.

This is as curious an example of presuming causation from association as I have ever seen.

It is fun to read old studies (this study was 1921), in part due to the style of speech used and in part to see the complete lack of rigor in how information was measured and reported. By modern standards  a truly awful study. This report would be a nice example for students on how not to do a study for if a mistake could be made, it was.

He concludes that children and dogs like to curl up to sleep

relaxing the sympathetic nervous system, induces contraction of the great vessels (and) emptying the cerebral vessels.

A unique explanation of sleep: depriving the brain of blood by curling up.  The report was from the 1920′s so I suppose we can cut the author a little slack for his unique hypothesis of sleep physiology.

And how this fanciful study applies to the equally fanciful adjustments of subluxations of the spine performed by chiropractors is uncertain as

All curvatures and deformities of the spine were ridged, apparently of long duration: irreducible by ordinary manual force: extension, counter-extension, rotation, even strong lateral movement failed to remove them or even cause them to change their relative positions.

Noting there a chiropractor could alter, unless they used a hammer. Or perhaps a spring loaded rod.

Modern Bad Studies: Frightening autistic children

Hope for Autism reads the title. From a chiropractor. I thought, I’m skeptical. I can’t see how the manipulation of the spine to correct fanciful subluxations could do anything for autism . So I went looking for the original paper, which is in a journal so obscure, J. Vertebral Subluxation Res., it is not on PubMed. But the original, Clinical Efficacy of Upper Cervical Versus Full Spine Chiropractic Care on Children with Autism: A Randomized Clinical Trial, is available for download.

Their introduction is humorous, although I suspect not deliberately:

Since the primary problem in autistic children is neurological, it is prudent to research the efficacy of chiropractic care in these children.

Since at its heart chiropractic has nothing to do with neurology, or reality.

They decide to answer the question as to

which is the recommended chiropractic technique in these cases of autism?

I would wager none.

It is every bit as methodologically horrible as you could predict: 14 patients, no randomization or blinding, no control, short follow-up and outcomes based on parents observations and the Autism Treatment Evaluation Checklist. Any results, given the zero prior plausibility of chiropractic, are going to be due to bias. The study, and its results, are best described as garbage.

If the study was approved by an IRB it is not mentioned in the methods nor is there any mention of informed consent. The study mentions how stressful it was for these autistic children, and all for no valid reason.

A few of the children displayed aggressive behavior such as pushing, falling, flaying arms in the air, and kicking. These actions were usually momentary. Chiropractic care was resumed when he child was able to continue… X-ray examination proved to be the most difficult procedure for autistic children…Light from the collimator bulb either scared or fascinated the children.

They used the percussion adjustment instrument of the Atlas Orthogonal technique   on these poor children.

The patient is placed on his side with head support at four inches below the mastoid. A metal stylus is placed between the mastoid and the ramus of the mandible. An adjustment, an impulse imparted to the stylus by a plunger that excites a compressional wave in the stylus, is then delivered to the patient. At the patient-stylus interface, a portion of the wave energy is transmitted to the patient and a portion is reflected back to the plunger. The former portion of energy is enough to direct the atlas vertebra to move to its normal orthogonal position.

No wonder they thrashed about in terror, being held down so a  rod could thump them behind the ear like a mob execution. There is zero literature on the PubMeds to support the use of Atlas Orthogonal technique and the patter  used to justify its use sounds science-y, but, as one chiropractor recognizes,

is an outdated, unproven, unsubstantiated technique system.

The kids  also received an unhealthy dose of useless radiation:

To attain this, the technique recommends four pre-adjustment cervical x-rays and two post-adjustment x-rays be taken immediately after the first adjustment in the cervical area.

X-rays are not a benign diagnostic modality (although the data is from CT scans, ionizing radiation should not be given as part of tooth fairy science without IRB approval and informed consent):

Risk estimates are derived for paediatric head computed tomographies (CTs) as well as for brain tumours in adults. On the basis of estimates for Germany about the number of head scans, the annual rate of radiation-induced diseases is calculated. About 1000 annual paediatric CT investigations of the skull will lead to about three excess neoplasms in the head region, i.e. the probability of an induced late effect must be suspected in the range of some thousands.

The scant literature on the topic is also horrible

Our systematic review of the literature revealed a total of five articles consisting of three case reports, one cohort study and one randomized comparison trial. The literature is lacking on documenting the chiropractic care of children with ASD…However, given the ineffectiveness of pharmaceutical agents, a trial of chiropractic care for sufferers of autism is prudent and warranted.

The ‘since airplane design has flaws,  flying carpets should be used’ argument.

A worthless study that only served to scare and irradiate autistic children and proved nothing about the efficacy of chiropractic for autism. If it had been approved by an IRB, they ought to be ashamed for allowing autistic children to be frightened and irradiated without good reason.

Chiropractors, Primary Care and Vaccines

Some chiropractors want to become primary care providers. Jann Bellamy and Harriet Hall have written about this fantasy. There are several issues with having chiropractors function as if there were knowledgeable and competent physicians.

The first is that their education in school is woefully inadequate to diagnose and treat common medical problems.

The second is that their practical training is even less adequate. I have yet to meet a new medical school graduate who is even barely competent to take care of patients. It is why they have a residency. Most of the real meat of medical training occurs during the 3 to 7 years after medical school. Chiropractors do not have any meaningful post graduate training.

And third, they do not want to participate in the key concepts that make up primary care. Part of primary care is to diagnosis and treat acute and chronic medical problems and they have no training for this. But another part is health maintenance: doing the testing and treatments for the prevention of diseases such as colonoscopy, mammograms and vaccines.

Vaccines are a key part of health maintenance and arguably the most important intervention to improve human health. Maybe fresh water and flush toilets were more important.   Part of health maintenance is making sure your patients are up to date in their vaccines.

And Chiropractors are often loudly and proudly against vaccines: Immunizations by Colorado DCs: Really?

Are You Prepared to Vaccinate?

Did no one in Colorado get the memo? Based on the feedback I’ve received from previous columns, not many doctors of chiropractic support prescriptive injectables2 and precious few would be willing to give immunizations to infants.


In my opinion, providing risky immunizations to Colorado babies for the purpose of accomplishing a pro-drug agenda is much like a betrayal of those infants for “30 pieces of silver.”

Chiropractors do not subscribe to the reality that vaccines have been and are one of the key tools in the prevention of infections.

A greater than 92% decline in cases and a 99% or greater decline in deaths due to diseases prevented by vaccines recommended before 1980 were shown for diphtheria, mumps, pertussis, and tetanus. Endemic transmission of poliovirus and measles and rubella viruses has been eliminated in the United States; smallpox has been eradicated worldwide. Declines were 80% or greater for cases and deaths of most vaccine-preventable diseases targeted since 1980 including hepatitis A, acute hepatitis B, Hib, and varicella. Declines in cases and deaths of invasive S pneumoniae were 34% and 25%, respectively.

Chiropractors ‘heck no’ antagonism is further evidence against their being responsible for primary care.

Are you willing to administer all of those vaccinations to your infant, adolescent and adult patients so you can meet the accepted standard of a primary care physician? I suspect the majority of you will not just say, “No,” but will say, “Heck no!” So, if we are not willing to do that, then maybe it’s time for us to stop trying to be something we don’t want to be and trying to obtain authority to do things we don’t want to do…However, I do not think the majority of the chiropractic profession believes that primary care – when it includes the medical “Holy Grail” of vaccinations – is the right course to follow.

It is not a isolated opinion but part of the chiropractic world view.

Anti-vaccination attitudes till abound within the chiropractic profession. Despite a growing body of evidence about the safety and efficacy of vaccination, many chiropractors do not believe in vaccination, will not recommend it to their patients, and place emphasis on risk rather than benefit… But this puts the chiropractic profession outside the greater healthcare community and may contribute to its continued marginalization and small market impact.

and disqualifies them as primary care providers. One would think that to practice primary care people would need to understand the concepts behind primary care and this chiropractor has the correct conclusion for his field.  They have no business being in primary care.

Chiropractic, stroke and patient safety

I learned early in my career that even simple interactions can lead to harm. I had a patient as an intern who had an out of hospital cardiac arrest. In the field they placed an IV for resuscitation. The IV site became infected, she became bacteremic, the infection went to her aortic valve, which blew out acutely and she died.

It is why I roll my eyes when people say the first rule of medicine is do no harm. Everything you do in medicine has the potential for harm, including doing nothing. All actions and all inactions can have bad consequences.

The real rule of medicine is that the odds of providing benefit should be greater than the odds of doing harm. There is also a fudge factor for the disease being treated. I once took care of a patient who died of acute liver failure due to medication she was taking for toenail fungus. I always mention this to patients when they ask for terbinafine. There is a low likelihood of death to treat a trivial problem but most people find the risk/benefit unacceptable when I mention my case. And there are other, less toxic, therapies for nail fungus.

If the disease, like leukemia, offers certain death, patients are more likely to accept the risk of serious complications from chemotherapy or a bone marrow transplant since the potential payoff, life, is worth the risks for the treatment. Risks and benefits are variable and deciding what to do is complex calculus filtered through patients expectations and values that is not done justice by the simplistic phrase ‘Do no harm.’

The issue with most of the pseudo-medicines is they do nothing, they alter no physiologic process,  and so any side effect is not acceptable.  If the benefit is zero, the risk should also be zero.

Cervical Manipulative Therapy has little real proven indication, especially if being used to fix mythical subluxations. Chiropractors are remarkably adamant that their adjustments are safe and do not cause stroke  from vertebral artery dissection (VBD). They love to point to Risk of Vertebrobasilar Stroke and Chiropractic Care Results of a Population-Based Case-Control and Case-Crossover Study, as evidence that chiropractic is safe and suggest patients are seeking chiropractic care for their prior VBD. In point of fact the study confirms the risk of stoke following CMA.

I noted at SBM

A passive hanging (no drop) gives about 686 Newton’s of force around the neck for a 70 kg human. In chiropractic, “the mean force of all manual applications (is) 264 Newton’s and the mean force duration (is) 145 milliseconds”.  So a chiropractic neck manipulation, for a short period of time, can provide 38% the force of a hanging. And a bad hanging at that.

Neck injuries are not that frequent because the muscles of the neck prevent injury by preventing sudden, disastrous, movement. If you want to increase the chance of injury from relatively minor trauma, have the person relax. If the muscles are relaxed because the person is not expecting the trauma, the chance of injury goes up. It is why whiplash can occur after minor injuries. Chiropractors often have their patients relax just before the coup de grâce, I mean manipulation, helping to maximize the chance of injury despite having less force applied to the neck than a noose and gravity.

Given the above, to claim that the VBA occurred before the patient had chiropractic neck manipulation is like saying the hanging victim had a broken neck, but it occurred on the steps up to the scaffold.

There is now a position paper Cervical Arterial Dissections and Association With Cervical Manipulative Therapy from the American Heart Association/American Stroke Association and discussed by Dr. Novella

They review the literature and anatomy/physiology of stroke and CMA. The money quote:

Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

In epidemiology, Hills Criteria provides a framework for considering whether association is causation and is helpful when there are no definitive studies.  We will never have a prospective trial of cervical manipulation to see if it can induce a stroke and given the rarity of the event will have to rely on less definitive data.  Hills Criteria are

  • Strength: A small association does not mean that there is not a causal effect, though the larger the association, the more likely that it is causal.
  • Consistency: Consistent findings observed by different persons in different places with different samples strengthens the likelihood of an effect.
  • Specificity: Causation is likely if a very specific population at a specific site and disease with no other likely explanation. The more specific an association between a factor and an effect is, the bigger the probability of a causal relationship.
  • Temporality: The effect has to occur after the cause (and if there is an expected delay between the cause and expected effect, then the effect must occur after that delay).
  • Biological gradient: Greater exposure should generally lead to greater incidence of the effect. However, in some cases, the mere presence of the factor can trigger the effect. In other cases, an inverse proportion is observed: greater exposure leads to lower incidence.
  • Plausibility: A plausible mechanism between cause and effect is helpful (but Hill noted that knowledge of the mechanism is limited by current knowledge).
  • Coherence: Coherence between epidemiological and laboratory findings increases the likelihood of an effect. However, Hill noted that “… lack of such [laboratory] evidence cannot nullify the epidemiological effect on associations”.
  • Experiment: “Occasionally it is possible to appeal to experimental evidence”.
  • Analogy: The effect of similar factors may be considered.

Hill’s Criteria has been applied to the concept of Chiropractic subluxation and the reality of subluxation was found wanting.

There is a significant lack of evidence to fulfill the basic criteria of causation. This lack of crucial supportive epidemiologic evidence prohibits the accurate promulgation of the chiropractic subluxation.

For stroke causation, Hills criteria are modestly met. The preponderance of information points to CMT as a  risk for dissection and stroke and there is certainly plausibility for what is fortunately a rare event.  The case reports of stoke immediately after CMT give one pause; they may reach the level of parachute evidence.

I have spent a significant part of my career in infection control and quality, where we strive apply the literature to maximize patient safety and to good effect.

To date the only pseudo-medical quality initiative that led to an increase in patient safety of which I am aware is the use of sterile disposable acupuncture needles, an intervention they work hard to subvert by ignoring all other infection control interventions like gloves. A hallmark of pseudo-medicines is they do no change because of data.

In real medicine we recognize the potential for harm and strive to reduce it. In my institutions we try to always put patient safety first. The question is the response by the chiropractic community to the position paper. I predict denial rather than changes in practice to increase the safety of their clients.

Well what do you know? From the American Chiropractic Association

“The largest and most credible study, Cassidy et al., found that a patient is as likely to have seen a primary care medical doctor as a doctor of chiropractic prior to experiencing a cervical arterial dissection (CD).

“Neck manipulation is a safe, conservative treatment option for neck pain and headache. The evidence presented in the AHA paper fails to show that neck manipulation is a significant risk factor in CD. In addition, the paper fails to put into context risks associated with other neck pain treatments such as neck surgery, steroid injections and prescription drugs.

And Leading scientist Christine Goertz DC

In an Aug. 8 speech, Christine Goertz, DC, PhD, vice chancellor for research and health policy at Palmer College of Chiropractic, explained that medical doctors and doctors of chiropractic need to be vigilant in assessing patients who may be in the early stages of vertebral arterial dissection (VAD). It’s also extremely important that the data regarding the risk of VAD is presented to patients in an accurate manner.

“The facts are that VADs are very, very rare events, and there’s absolutely no research that shows a cause-and-effect relationship between chiropractic care and stroke,” Goertz said.

We have very rare events in real medicine as well. We used to use the antibiotic trovafloxacin at the rate of 300,000 prescriptions a month, but there were 6 deaths and handful of severe liver failures from the medication.

And now? We no longer use it because we have safer therapies with equal efficacies  And unlike cervical manipulation for neck pain, an intervention that has no benefit, trovafloxacin was an effective antibiotic.

To use massive understatement, the pharmaceutical industry has not always been forthcoming about the risks of their products. But when they are discovered by physicians, we respond in a way to maximize patient safety.  The President of the Infectious Disease Society of America doesn’t give a speech release saying

“The facts are that liver failure are very, very rare events, and there’s absolutely no research that shows a cause-and-effect relationship between trovafloxacin and liver failure”


“trovafloxacin is a safe, conservative treatment option for infection. The evidence presented in the  fails to show that trovafloxacin is a significant risk factor in liver failure.”

In medicine we balance the risk and the benefit of an intervention and try to do what is in the best interest of the patient by changing practice.  When in doubt we try and maximize patient safety

Chiropractic is more interested in keeping their business model active than changing to decrease patient risk. But that is the case for all pseudo-medicines.

Lets Increase the Chance of More Strokes

A while back I mentioned a study that wasn’t a study by the British Chiropractor Association that suggested that texting could kill you.

Their completely unsubstantiated theory is that texting, by causing the head to lean forward, would lead to hyper-kyphosis, restrictive lung disease and death. This idea has no basis in the medical literature I can find.

However, the English need some entrepreneurial sprint because it took

Dr. Dean Fishman, a chiropractor (to) create and trademark the phrase “text neck.”

Hereby referred to as TN.

He has an Android app ($2.99 and free version) to let you know if you are using your phone at a dangerous angle. Why might you do this? Because TN, according to the Text-Neck Institute,

… IS A GLOBAL EPIDEMIC! ‘Text Neck’ is a world-wide health concern, affecting millions of all ages and from all walks of life. Widespread overuse of handheld mobile technology is resulting in a harmful and dangerous physical condition on the human body, which is known as Text Neck.

that will lead to

Flattening of the Spinal Curve, Onset of Early Arthritis, Spinal Degeneration, Spinal Misalignment, Disc Herniation, Disc Compression, Muscle Damage, Nerve Damage, Loss of Lung Volume Capacity, (and) Gastrointestinal Problems.

TN is based on almost no data and/or wild extrapolation as the search term “text neck” has no hits on PubMed.

I do not doubt a stiff neck and tension headache may occur from prolonged use of a mobile device in an awkward position. I certainly get a sore neck at the computer, espcially as the screen is not at bifocal level.

But disc herniation? Loss of lung volume? Gastrointestinal problems? Color me skeptical.

He quotes “Roentgenographic findings of the cervical spine in asymptomatic people” as

FHP has been shown to flatten the normal neck curve, resulting in disc compression, damage, and early arthritis.

The abstract from 1986, long before cell phones and texting, concerns normal changes in the neck with aging:

The purpose of this study was to determine the incidence and severity of degenerative changes seen on lateral roentgenograms in 200 asymptomatic men and women in five age groups with an age range of 20-65 years and to determine the normal values of cervical lordosis and spinal canal sagittal diameters and their relationship to degenerative changes. It was found that by age 60-65, 95% of the men and 70% of the women had at least one degenerative change on their roentgenograms. A small sagittal diameter correlated with the presence of degenerative changes at the same disc level, and the strongest correlation was with the size of the posterior osteophytes at C5-6 (r = 0.52). Cervical lordosis measurements did not relate to degenerative changes except for subjects over age 50 with moderate or severe intervertebral narrowing. It is important to realize that although roentgenographic abnormalities represent structural changes in the spine, they do not necessarily cause symptoms.

He conveniently ignores The association between cervical spine curvature and neck pain which suggests

In conclusion, we suggest that when so-called “abnormalities” of the sagittal profile are observed in the older patient with neck pain they must be considered coincidental, i.e. not necessarily indicative of the cause of pain. This should be given due consideration in the differential diagnosis of patients with non-specific neck pain.

The  Cephalalgia article, used as a reference,

the study demonstrated a strong association between an increased forward head posture and decreased respiratory muscle strength in neck patients.”

Was in a whopping 24 patients.

Not the most robust of literature to support the concept of TN.

But the biggest concern with making TN a worry to people is the ‘solution’ to the problem. Somehow I suspect the treatment will be chiropractic manipulation of the neck.

And that could lead to an increase in strokes. Great.

Posted in: Chiropractic, Clinical Trials, Energy Medicine, Science and Medicine

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Tens of millions for CAM research — and it’s all on your dime


The Federal Funding Accountability and Transparency Act (FFATA) was signed on September 26, 2006. The intent is to empower every American with the ability to hold the government accountable for each spending decision. The end result is to reduce wasteful spending in the government. The FFATA legislation requires information on federal awards (federal financial assistance and expenditures) be made available to the public via a single, searchable website, which is

And what subject is more deserving of being held accountable by the American people than complementary/alternative/integrative medicine? After all, in what other area of government spending does scientific implausibility – indeed, even scientific impossibility – offer no impediment to spending millions of taxpayer dollars in research funds? We’ve complained about the NCCAM’s wasteful spending on pseudomedicine here on SBM several times: here, here, here and here, among others. As you shall see, the problem doesn’t stop at that particular $2.5 billion. (more…)

Posted in: Acupuncture, Chiropractic, Clinical Trials, Energy Medicine, Homeopathy, Medical Academia, Naturopathy, Politics and Regulation

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Clinical trials of integrative medicine: testing whether magic works?


I just thought that I’d take the editor’s (and, speaking for Steve, the founder’s) prerogative to promote our own efforts. Regular readers of SBM are familiar with our message with respect to randomized clinical trials of highly implausible “complementary and alternative medicine” treatments, such as homeopathy or reiki. Well, believe it or not, Steve and I managed to get a commentary published in a very good journal in which we present the SBM viewpoint with respect to these trials. Even better, at least for now, you can read it too, because it doesn’t appear to be behind a paywall. (I’m at home as I write this, and I can read the whole thing on my wifi, no VPN needed.)

The article is entitled “Clinical trials of integrative medicine: testing whether magic works?” There’s also been a fair amount of news coverage on the article, and I’ve been frantically doing interviews over the last couple of days, including:

There are likely to be at least a couple more, given the interviews I’ve done; that is, unless editors reject the ideas.

In any case, Steve and I are interested in your comments. Trends in Molecular Medicine is good in that it published our article and it’s a pretty high impact review journal, but it doesn’t have a section for comments. So consider this your section for comments on our article.

Posted in: Basic Science, Clinical Trials, Homeopathy

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Vitamin K Refusal – The New Anti-Vax

vitamin K molecules

Variations of the vitamin K molecule.

A small but increasing number of parents are refusing vitamin K injections for their newborns, an intervention recommended since 1961. This is yet another example of the difference between a science-based and philosophy-based approach to medicine. Science has given us the tool of knowledge, and in medicine that knowledge can have very practical applications.

The term “vitamin” was coined in 1912 by the Polish biochemist Kazimierz Funk. A vitamin is an organic nutrient that an organism requires in small amounts but cannot synthesize in adequate amounts and therefore must obtain from the diet. Knowledge of specific vitamins, their food source, and their biochemical activity in the body, has allowed medical scientists to cure many serious nutritional diseases, such as scurvy, rickets, and blindness.

The Vitamin K family are derivatives of 2-methyl-1,4-naphthoquinone, a fat-soluble molecule. It is a cofactor necessary for the formation of factors that function in blood clotting and in bone formation. The primary effect of vitamin K deficiency is therefore bleeding. Infants are at risk for vitamin K deficiency because this molecule does not cross the placenta well. Infants are therefore born relatively deficient in vitamin K. Further, breast milk contains little vitamin K (regardless of the mother’s diet) so infants are at risk for vitamin K deficiency until they start eating solid food at around 6 months (see Clay Jones’ post on the topic here). (more…)

Posted in: Science and Medicine

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Pass the Salt (But Not That Pink Himalayan Stuff)


Humans, like many other animals, crave the taste of salt. Animals frequent salt licks, humans have traded salt for equal weights of gold, and the word “salary” comes from the Roman soldier’s allowance for purchasing salt. Salt appears in our language in idioms like “worth its salt” and “salt of the earth.” Shakespeare’s play King Lear is a variant of a folktale where a daughter tells her father she loves him as much as meat loves salt. In a murder mystery I read years ago, a character listed the four food groups as sweet, salty, sticky, and chocolate.

It’s no fair: everything that tastes good turns out to be bad for us. We love the taste of salt, but dietary guidelines tell us we should all limit our sodium intake to less than 2.3 grams (2300 mg) a day to avoid high blood pressure and death from cardiovascular disease. And those who are over 51, African American, or who have high blood pressure, chronic kidney disease or diabetes should limit their intake even further, to 1500mg a day or less. (Note: the salt molecule consists of an atom of sodium and an atom of chloride; 40% of the weight is sodium, so 1500 mg of sodium equals 3750 mg of salt, roughly ¾ of a teaspoon. Over 75% of our salt is already in the food, not added from the salt shaker.) In 2010, the American Heart Association lowered its recommendations to 1500 mg a day for everyone. We thought that was good advice, but new evidence has muddied the waters. (more…)

Posted in: Nutrition, Public Health

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“Atavistic oncology” revisited: Dr. Frank Arguello responds


EDITOR’s NOTE: There are three Addendums after this post, containing the complete text of e-mails.

EDITOR’s NOTE #2 (8/19/14 4:51 PM): There is one more Addendum, as Dr. Arguello has sent me another e-mail.

EDITOR’s NOTE #3 (8/20/14 7:18 PM): There is yet another Addendum, as Dr. Arguello is now complaining to my place of work.

EDITOR’s NOTE #4 (8/21/14 5:30 PM): And the beat goes on. See Dr. Arguello’s next e-mail.

The following post will be of a type that I like to refer to as “taking care of business.” That’s not to say that it won’t be, as my posts usually are, informative and entertaining, but it does say that I’m doing it instead of what I had originally had in mind because something came up. That something is a rather unhappy e-mail from the doctor about whom I wrote three weeks ago. It’s just an indication that, although it’s a great thing that this blog is becoming more and more prominent, it’s also a two-edged sword. People actually notice it when I (or other SBM bloggers) criticize them for dubious medicine. We see this in how Dr. Edward Tobinick has launched what I (and many others) consider to be a frivolous lawsuit against SBM founder Steve Novella over a post from 2013 clearly designed to silence criticism. It’s legal thuggery, pure and simple. That’s the bad end of the spectrum. I’ve been at the receiving end of similar retaliation that could have just as bad an impact on me personally as far as my career goes when antivaccine activists tried to get me fired from my job four years ago.

The more common (and far less agita-inducing) end of the spectrum consists of e-mails or letters of complaint. Sometimes they come from eminent radiologists who don’t like my criticism of their attacks on mammography studies. (Actually, truth be told, it is rarely eminent radiologists—or eminent physicians and scholars—who complain.) More commonly, it’s practitioners who object to how their treatments have been described. This time around, it’s a man named Dr. Frank Arguello, whose “atavistic chemotherapy” I criticized in one of my typical long posts that also explained why. Last week, I received this e-mail from Dr. Arguello:

Posted in: Cancer, Clinical Trials, Evolution

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The false dichotomies of CAM and “integrative medicine”


A lot of medical specialties have throwaway newspapers/magazines that are supported by advertising and somehow mysteriously managed to show up for free in the mailboxes of practitioners. In my case, I’ve found myself on the subscription list for such papers about oncology, but also general surgery (I’m Board-certified as a general surgeon). When I have to recertify in about three years, it will be as a general surgeon, which was really fun to try to do last time after having specialized as a breast cancer surgeon, and will likely be even more fun next time, when I will be 10 years further out from my general surgery and surgical oncology training. In any case, that must be why, no matter where I end up working, sooner or later I end up receiving General Surgery News (GSN).

As throwaway professional newspapers go, GSN is not bad. However, occasionally it publishes op-ed articles that make me scratch my head or even tick me off with their obtuseness. Lately, apparently, it’s started some blogs. The one in particular that is the center of attention for this post is by Victoria Stern, is called “The Scope” and is billed as “exploring the lesser known sides of surgery.” Of course, it’s a bit odd that some of the first posts on this blog are about work hour restrictions and whether they leave new surgeons unprepared to practice surgery, the debate over breast screening, and what it takes to train expert surgeons, none of which are exactly “lesser known sides of surgery.” Work hour restrictions, in particular, have been discussed in surgery journals, at conferences, and among surgeons ad nauseam, particularly whether we are training a generation of surgeons unable to deal with the rigors of practicing surgery in the real world.

Posted in: Critical Thinking, Medical Ethics

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A balanced look at gluten sensitivity

Even though it doesn’t appear on any calendar, May 2014 will go down in history as “gluten sensitivity month.” After RealClearScience picked up on a 2013 paper that brought into question the existence of non-celiac gluten sensitivity (NCGS), news sites were obliged to post their own analysis of the article, and the blogosphere was alight with pro- and anti-gluten posts. One of the authors of the paper in question, Dr. Peter Gibson of Monash University, was even mentioned on the People magazine website, which gives him the distinction of being the only researcher to be published alongside the Kardashians.

Photo by flickr user surlygirl used under a CC licence.

Photo by flickr user surlygirl used under a CC licence.

The Monash paper,1 which was previously discussed on SBM, suggested that it might be the fructans in wheat and not gluten that is responsible for symptoms in IBS sufferers who feel better on a gluten-free diet. Fructans belong to a group of short-chain carbohydrates known as FODMAPs that are readily fermented by bacteria in the intestine. If fructans were really to blame for wheat-induced gastrointestinal symptoms, this would be good news for IBS sufferers currently on a gluten-free diet — for some, a diet low in FODMAPs would be less restrictive than one without gluten, making it less prone to nutritional deficiencies.

As it stands, the existence of NCGS has neither been proven nor disproven by anyone. But gluten sensitivity sits at the intersection of several dilemmas in medicine today and, unlike how it’s betrayed in the media, is hardly an all-or-nothing affair. Proving it wrong will not instantly heal the people who have prescribed themselves a gluten-free diet. Proving it wrong will not produce a cure for IBS, a shorter time to a celiac diagnosis, or the correct way to handle potential celiac disease. Neither will proving it right. In the eyes of one gluten avoider, “Modern medicine is really good at crisis intervention…[but] they don’t do well with chronic issues”.2

With these issues in mind, it’s time to move past the media debates and fad dieters and take a balanced look at NCGS. This overview will use four recent articles by the Monash group1, 3, 4, 5 as a framework to uncover some of the factors contributing to the gluten sensitivity phenomenon. Even though it has been gone over many times, a discussion of the FODMAPs study is still in order — in fact, essential — to appreciate the central importance of the elimination diet in diagnosing a food sensitivity. Along the way, we’ll get an idea of who the gluten sensitive might be, how successful gluten-free diets really are, and how challenging it is to pursue a celiac diagnosis. (more…)

Posted in: Nutrition

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Separating Fact from Fiction in Pediatric Medicine: Nocturnal Enuresis


There is no role of chiropractic in treating childhood bedwetting

In pediatrics, very few things are completely black and white. This is an aspect of conventional medicine in general that tends to separate the approach of science-based practitioners from that of proponents of the many forms of irregular medicine commonly discussed on SBM. They appear to experience no shame in claiming absolute certainty while doling out all manner of implausible remedies for ailments ranging from the well-established to the fictional.

While we do face questions from patients and their caregivers regarding largely invented diagnoses in pediatrics, with chronic Lyme disease and non-celiac gluten sensitivity being just two of many increasingly encountered concerns, my experience has been that alternative medical providers tend to focus their efforts on the same real problems that pediatricians and family practitioners deal with on a daily basis. And I don’t believe that it is mere coincidence that these conditions are largely self-limited in nature, a fact often not shared. Parental and patient buy-in is often more easily obtained with certainty rather than nuance.

Chiropractors, for example, seem to pride themselves on their ability to cure ear infections. Of course in greater than 80% of children with acute ear infections, symptoms will resolve without any intervention whatsoever. This is why the AAP has been trying for years to decrease the rates of antibiotic prescriptions for ear infections, unfortunately with little in the way of success thus far. And when the infections don’t resolve on their own, there is no good evidence that anything a chiropractor has to offer can help. The same can be said for their claims regarding colic and gastroesophageal reflux, which I’ve written about before.

Another condition frequently mentioned by chiropractors as being particularly in their wheelhouse is nighttime bedwetting, the medical term for this being nocturnal enuresis. Rarely have I seen a chiropractic website with a section on the benefits for children that does not mention their success in curing bedwetting. Fred Clary, DC, even claims on his website to be able to cure bedwetting in the newborn baby. And to think I’ve just been ignoring the problem as a newborn hospitalist. Is it because the thought of a newborn infant gaining continence is absurd, or am I just a shill for Big Pampers?

Posted in: Science and Medicine

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Naturopathy vs. Science: Prenatal Vitamins


This is another post in the naturopathy versus science series, where a naturopath’s medical advice is assessed against the scientific evidence. Today’s topic is brought to you by Toronto naturopath Shawna Darou, who recently published her evaluation of prenatal vitamins.

Vitamin supplementation is unnecessary for the vast majority of people. You wouldn’t know this walking through a drug store, where you’ll usually find an entire aisle packed with supplements. Alternative health providers like naturopaths tend to be strong supporters of supplementation, but this advice seems to be based mainly on the belief that “vitamins are magic” rather than good science. The best research hasn’t established a strong evidence base for taking  supplements. We definitely need vitamins in our diet to live. But that’s where we should be getting those vitamins – from our food, instead of from pills. If you eat a reasonable and balanced diet, and have no medical conditions that require special consideration, vitamin supplementation won’t offer meaningful health benefits. In the absence of any deficiency, vitamin supplements seem to be useless at best and harmful at worst. (more…)

Posted in: Science and Medicine

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