A new study published in The Lancet provides the most definitive evidence to date that chronic cerebrospinal venous insufficiency (CCSVI), a hypothetical syndrome of narrowed veins draining the brain that some believe is the true cause of multiple sclerosis (MS), is not associated with MS.
In a science-based world, this study would be yet one more nail in the coffin of this failed hypothesis. But that’s not the world we live in.
CCSVI was first proposed in 2009 by Italian vascular surgeon, Dr. Paolo Zamboni – that multiple sclerosis (MS) is caused by chronic blockage of the veins that drain the brain. The current scientific consensus is that MS is a chronic autoimmune disease, and the pathology is caused by primary inflammation. Dr. Zamboni believes that the venous anomalies he has discovered are the primary cause and the inflammation is secondary. (more…)
It is unfortunately that individual dramatic cases are often required to garner public and regulatory attention toward a clear problem. The Australian press is reporting:
Melbourne paediatrician Chris Pappas cared for a four-month-old baby last year after one of her vertebrae was fractured during a chiropractic treatment for torticollis – an abnormal neck position that is usually harmless. He said the infant was lucky to make a full recovery.
Medicine is a game of risk vs benefit – everything we do, or don’t do, should be evaluated on the potential benefit vs the potential risk, using the best available evidence and scientific rationale. This case is important, not because it is a case of harm, which can happen with any intervention, but because it highlights the risk vs benefit question. Are there any indications for chiropractic care of children, for neck manipulation at any age, and what are the risks?
For an overview of chiropractic see my prior summaries here and here. Overall the evidence suggests some benefit for manipulative therapy for acute uncomplicated lower back strain, but probably no better than physical therapy or even minimal intervention. The risks of chiropractic are not sufficiently studied, and other indications have not been established by adequate evidence. (more…)
Savvy consumers have learned over the years that the primary goal of marketing is to create demand for a product or service. This has risen to the point of inventing problems that do not really exist just to sell a product that addresses the fake problem. Who knew that my social status could be destroyed by spotty glassware.
Better yet, if you can make people worry about a nonexistent problem, something that they were not previously aware of and don’t understand, they might buy your solution just to relieve their worry.
This type of “artificial demand” marketing can be very insidious when it occurs with medical products and services. The pharmaceutical industry has been accused of generating artificial demand for some of their drugs. For example, osteopenia is a relative decrease in bone density, but not enough to qualify for osteoporosis. Osteopenia is not really a disease, or even necessarily a mild version of osteoporosis, although it is a risk factor. Merck, however, was happy to broaden the market for its drug for osteoporosis and argue that patients with osteopenia should be treated also, even though the evidence really did not support this.
Sometimes the accusations are flat-out wrong. GSK has been accused of inventing restless leg syndrome (RLS) to sell a failed Parkinson’s drug. In fact the drugs used for RLS are successful Parkinson’s drugs. Further, I found references to RLS in neurology texts going back over 50 years, and there were even older references although not using the same name.
As the resident neurologist on SBM, my ears always prick up when I come across a new neurology-based scam, and my colleagues often send such items my way. In addition the word “quantum” has become a standard marketing term of alt. med quackery. So how could I resist taking a bite out of “quantum neurology”?
One might think (if one were a completely naïve rube) that those claiming to practice quantum neurology have, through diligent research, discovered how certain quantum principles apply to nervous system function and disease, leading to new treatment modalities. On the other hand, a more savvy consumer of such health claims (such as regular readers of SBM) would likely suspect that quantum neurology will turn out to be the same-old mix of nonsense and snake oil in a shiny new package.
Let’s have a look.
It’s likely you know someone who has bought into the notion that nutrition is everything, the source of all health and the cause of all illness. Nutrition is very important, to be sure, but it is only one of many possible causes of disease, and if you live in a Western industrialized nation you probably have adequate nutrition. The notion, however, that food can heal is powerfully alluring, and it makes great headlines. The result is that people who read the headlines for the latest food to avoid, or the latest ingredient that will make them live longer or stave off disease, seem to have an association for everything. Eating around them is to be constantly told that food X is good for you and will prevent Y, or that some other food should be avoided because it causes Z.
Red peppers will help prevent cancer and help you lose weight. Garlic will help prevent heart disease and aids in iron metabolism. Cayenne pepper prevents strokes. Peaches prevent heart disease and cancer. In fact- think of any food at random and type “random food health benefits” into Google and chances are you will be rewarded with a list of the amazing health benefits of whatever food you wish.
My usual response when offered such advice is – you know, food is healthy for you. I recommend you eat food every day. Food is full of nutrition, essential vitamins and minerals, and will give you energy. If you don’t eat food, your health with dramatically suffer. But don’t eat too much food – that’s not healthful.
One of the tactics of snake-oil salesmen is to fearmonger about mainstream medical practices so as to scare potential customers into their clutches. A common target of such fearmongering is vaccines. Vaccine are an easy target – they are generally required by the government to some degree, and involve sticking small children with needles and injecting them with a cocktail that parents often don’t understand in detail.
While vaccines are of clear benefit, no one argues that they are risk free. There are rare serious complications. For this reason the US established the NVIC – National Vaccine Injury Compensation program. This is funded by a small tax on each vaccine, and is designed to compensate families of children who have a possible reaction to vaccines, bypassing the slow and costly regular court system. The NVIC works well.
The goal of the NVIC is not to determine scientifically if there is a link between a particular vaccine and a particular side effect. That is determined by the scientific community. Rather, the NVIC’s charge is to determine if “compensation is appropriate” in specific cases. They also give the benefit of the doubt to the families.
Science-based medicine is partly an exercise in detailed navel gazing – we are examining the use of science in the practice of medicine. As we use scientific evidence to determine which treatments work, we also have to examine the relationship between science and practice, and the strengths and weaknesses of the current methods for funding, conducting, reviewing, publishing, and implementing scientific research – a meta-scientific examination.
There have been several recent publications that do just that – look at the clinical literature to see how it is working and how it relates to practice.
Dr. Vinay Prasad led a team of researchers through the pages of the New England Journal of Medicine hunting for medical reversals – studies that show that current medical practice is ineffective. Their results were published recently in the Mayo Clinic Proceedings:
Dr. Prasad’s major conclusion concerns the 363 articles that test current medical practice — things doctors are doing today. His group determined that 146 (40.2%) found these practices to be ineffective, or medical reversals. Another 138 (38%) reaffirmed the value of current practice, and 79 (21.8%) were inconclusive — unable to render a firm verdict regarding the practice.
Prasad also found that 27% of published studies looked at existing treatments while 73% studied new treatments.
I did not coordinate my topic for today with Harriet’s excellent review yesterday of Satel and Lilienfeld’s excellent book; the timing is just fortuitous. Harriet discussed popular abuses of neuroscience, which often amount to an oversimplification and hyperreductionism of a complex area of study. I was recently asked to comment on a claim that I feel falls squarely into this realm – so-called conscious discipline.
From the conscious discipline website:
It surpasses behavioral approaches that teach specific behaviors, and offers a neurodevelopmental model of the brain…
The Conscious Discipline Brain State Model becomes a frame for us to understand the internal brain-body states that are most likely to produce certain behaviors in children and in ourselves. With this awareness, we learn to consciously manage our own thoughts and emotions so we can help children learn to do the same.
They even offer a helpful picture of the brain to illustrate their model (above).
A recently published epidemiological study in JAMA Pediatrics looked at the association between induction and enhancement of labor and the risk of autism. The researchers found a positive association, especially with males. The study has been variously reported in the popular press with causal interpretations not justified by the data.
The study itself is very robust – the authors looked at 625,042 live births, including 5,500 children with a diagnosis of autism. They found:
Compared with children born to mothers who received neither labor induction nor augmentation, children born to mothers who were induced and augmented, induced only, or augmented only experienced increased odds of autism after controlling for potential confounders related to socioeconomic status, maternal health, pregnancy-related events and conditions, and birth year. The observed associations between labor induction/augmentation were particularly pronounced in male children.
Although this is a large study, it is one study, and so the correlation needs to be independently confirmed. But if we assume the correlation is accurate, the next question is – what is the arrow of causation? Observational studies can only indicate an association. By themselves they cannot prove causation, although multiple observational studies may be able to triangulate to the most likely causal interpretation. (more…)
Those who cannot remember the past are condemned to repeat it.
– George Santayana
Science-based medicine is more than a set of methods or certain philosophy of medicine – it is an entire approach to what should be the core questions for any interventionist profession: is it real and does it work?
These are often deceptively difficult questions to answer. Fortunately we have at least a century of experience applying systematic methods to answering these questions within the context of medicine. This is a wealth of history from which to learn, full of cautionary tales and enlightening examples.
However, as Winston Churchill lamented, we tend to forget the lessons of the past leading to, “…the most thoughtless of ages. Every day headlines and short views.”
Part of the mission of science-based medicine (and skepticism in general) is to remember the lessons of the past as they relate to science and pseudoscience, and to constantly remind the public and our colleagues of these lessons.