Acupuncture and Allergic Rhinitis: Another Opportunity for Intellectual Sterility

You need to keep an open mind.

A common suggestion offered to naysayers of nonsense.

The usual retort concerns not letting one’s brain fall out.

Evaluating SCAM’s is less about having an open mind and more about having standards, a conceptual framework that is used to interpret and analyze new information. One of the benefits of writing and reading topics covered by science-based medicine (SBM) is it has clarified and sharpened the ideas by which I understand the world. Those concepts were nicely summed up by Steve Novella at Neurologica, and I reproduce them here, slightly modified. They should be on stone tablets, not quite commandants, but strong suggestions. The 8 strong suggestions somehow doesn’t cut it however.

  1. Respect for knowledge and truth – SBM values reality and what is true. We therefore endeavor to be as reality-based as possible in our beliefs and opinions. This means subjecting all claims to a valid process of evaluation.
  2. Methodological Naturalism – SBM believes that the world is knowable because it follows certain rules, or laws of nature. The only legitimate methods for knowing anything empirical about the universe follows this naturalistic assumption. In other words – within the realm of the empirical, you don’t get to invoke magic or the supernatural.
  3. Promotion of Science – Science is the only set of methods for investigating and understanding the natural world. Science is therefore a powerful tool, and one of the best developments of human civilization. We therefore endeavor to promote the role of science in our society, public understanding of the findings and methods of science, and high quality science education. This includes protecting the integrity of science and education from ideological intrusion or anti-scientific attacks. This also includes promoting high quality science, which requires examining the process, culture, and institutions of science for flaws, biases, weaknesses, and fraud.
  4. Promotion of Reason and Critical Thinking – Science works hand-in-hand with logic and philosophy, and therefore SBM also promotes understanding of these fields and the promotion of critical thinking skills.
  5. Science vs. Pseudoscience – SBM seeks to identify and elucidate the borders between legitimate science and pseudoscience, to expose pseudoscience for what it is, and to promote knowledge of how to tell the difference.
  6. Ideological Freedom/Free Inquiry – Science and reason can only flourish in a secular society in which no ideology (religious or otherwise) is imposed upon individuals or the process of science or free inquiry.
  7. Neuropsychological Humility – Being a functional SBM proponent requires knowledge of all the various ways in which we deceive ourselves, the limits and flaws in human perception and memory, the inherent biases and fallacies in cognition, and the methods that can help mitigate all these flaws and biases.
  8. Consumer Protection – SBM endeavors to protect themselves and others from fraud and deception by exposing fraud and educating the public and policy-makers to recognize deceptive or misleading claims or practices.

An excellent list of the mindset I strive to achieve, with variable success. I have always been reasonably well versed in methodological naturalism. Science in general (physics, chemistry, etc.), and the basic sciences of medicine (physiology, anatomy, biochemistry, etc.) have always been the starting point of my understanding of the world and the practice of medicine. The breadth and depth of understanding of the natural world these disciplines provide is amazing.

My time in science-based medicine has reinforced the validity of methodological naturalism, already strong, but added components that had never been addressed in my formal education. One is the importance of prior probability. In the teaching program at my hospital prior probability is usually invoked in the context of determining if a test result is likely to a true positive. In the real world of medical practice prior plausibility for therapeutic interventions is rarely a consideration. In my 30 years I have seen a lot medical interventions come and go, but none have been attempted or abandoned because of a priori implausibility.  Mine has not been a practice where magic is attempted.  Good ideas for therapy, based on interfering with known pathophysiology, sometimes are not effective.

With an understanding of how the natural world functions, a consideration of prior plausibility, combined with knowledge of the multitudinous ways in which we can fool ourselves and others, allows for near-instant pattern recognition that a medical intervention is nonsense, that it cannot be effective. Like treating a stuffy nose.

One of my favorite goofy therapies is the wet sock treatment, beloved by naturopaths and, along with homeopathy, evidence that naturopathic practice is divorced from any reality I know:

    1. Take a pair of cotton socks and soak them completely with cold/ice water. Be sure to wring the socks out thoroughly so they do not drip. (May place the wet, wrung out thin socks in the freezer as well. Hang them on a freezer shelf so they are easy to remove).
    2. Warm your feet first. This is very important as the treatment will not be as effective and could be harmful if your feet are not warmed first. Place and soak your lower legs into the bucket of hot water which you have prepared (be sure the water is quite hot (an indicator for the proper temperature is one may slowly place their lower legs into the bucket as they tolerate the heat).
    3. Soak your lower legs in the bucket for approximately 3 to 5 minutes or taking a warm bath beforehand can accomplish warming.
    4. Dry off feet with a dry towel.
    5. Remove socks from the ice water bucket. Wring out well. – OR have someone remove your socks from the freezer and bring them to you.
    6. Place cold wet socks on feet.
    7. Cover with thick wool socks.
    8. Go directly to bed, lay down and watch a movie, or read a book. Avoid getting chilled.
    9. Keep the socks on overnight. Place the second set of pajamas next to the bed.
    10. During the night, you may wake up with your whole body wet from sweat. If so, change into the dry pajamas, but leave on the socks. You will find that the wet cotton socks will be dry in the morning.
    11. Do nightly if your symptoms have not yet improved
    12. Stop the Wet Sock Treatment if your symptoms have abated or gone altogether

How does wet sock treatment work?

This treatment acts to reflexively increase the circulation and decrease congestion in the upper respiratory passages, head, and throat. It has a sedating action and many patients report that they sleep much better during the treatment. This treatment is also effective for pain relief and increases the healing response during acute infections.

While nonsense, practitioners swear by it. Readers of this blog are well aware of the multitudinous potential biases with assigning efficacy to wet sock treatment. At a fundamental level there is no difference between wet sock therapy, homeopathy, acupuncture or any other SCAM for the treatment of a stuffy nose. When contrasted with known reality they can’t work, and when neuropsychological humility is factored in, it is highly likely that any effects that are noted can be accounted for by unrecognized bias on the part of patient and practitioner.

The big difference is that acupuncture is a form of magic that is likely to get published in formerly reliable journals complete with positive spin: Acupuncture in Patients With Seasonal Allergic Rhinitis. A Randomized Trial. 

Allow me to evaluate the study with

…ad hominem remarks, anonymous criticism, phony expertise and the use of opinion to contradict data, (as a) self-proclaimed sceptic.

with a

… a near complete absence of substantive scientific critique, (A) lack of any reasoned debate… and intellectual sterility.

There multiple flaws, evidently ignored or missed by the editors of the Annals, that render the optimistic conclusions of the paper untenable.

The first is the basic protocol. I have read it multiple times and upon each reading it appears more ludicrous than the time before.

The study takes place during allergy season, springtime for needling and Germany, Deutschland is happy and gay!

Patients were randomized to get real (I will avoid putting real in quotes, like ‘fresh’ fish) or sham acupuncture, 12 treatments over 8 weeks. Their symptoms were followed by three surveys:

Rhinitis Quality of Life Questionnaire (RQLQ), which has 28 questions in 7 domains (activity limitation, sleep problems, nose symptoms, eye symptoms, other symptoms, practical problems, and emotional function) ranked from 0 (no impairment) to 6 (severe impairment) (12). Medication need was measured using an RM score (RMS), comprising the weekly sum of daily assessments (cetirizine, 10 mg/d, or equivalent [1 point]; cetirizine, 20 mg/d, or equivalent [2 points]; and any form of systemic steroids for SAR [3 points]) (daily range, 0 to 3; weekly range, 0 to 21) (13). Secondary outcomes included proportion of responders, defined as patients with a decrease in RQLQ score (mean scores at weeks 7 and 8) of at least 0.5 point compared with baseline; change in symptoms, assessed using a VAS (0 to 100 mm) for overall SAR symptom severity and for nasal, eye, pharyngeal, and common symptoms; and health-related quality of life, assessed with a German version of the Short Form-36 Health Survey (SF-36).

Two weeks ago I have the pleasure of listening to Dr. Ben Goldacre discuss his new book and during the talk he covered the utility of using multiple questionnaires in assessing antidepressant efficacy. He listed a dozen questionnaires in a frenetic manner that should win the title for worlds fastest talker, then he pointed out that if you ask enough questions, some of them will show significant positive effects.

They evaluated the effect of the acupuncture at baseline, at weeks 7 and 8 of the first year, at weeks 15 and 16 (two months after the acupuncture) of the first year, and at weeks 7 and 8 of the second year. A year later.  That is where ludicrous wanders into the study.

The results, from the abstract:

Compared with sham acupuncture and with RM, acupuncture was associated with improvement in RQLQ score (sham vs. acupuncture mean difference, 0.5 point [97.5% CI, 0.2 to 0.8 point; P < 0.001]; RM vs. acupuncture mean difference, 0.7 point [97.5% CI, 0.4 to 1.0 point; P < 0.001]) and RMS (sham vs. acupuncture mean difference, 1.1 points [97.5% CI, 0.4 to 1.9 points; P < 0.001]; RM vs. acupuncture mean difference, 1.5 points [97.5% CI, 0.8 to 2.2 points; P < 0.001]). There were no differences after 16 weeks in the first year. After the 8-week follow-up phase in the second year, small improvements favoring real acupuncture over the sham procedure were noted (RQLQ mean difference, 0.3 point [95% CI, 0.03 to 0.6 point; P < 0.032]; RMS mean difference, 1.0 point [95% CI, 0.2 to 1.9 points; P < 0.018]).

As they note:

After the 8-week follow-up phase in the second year, small improvements favoring real acupuncture over the sham procedure were noted.

suggesting efficacy of the intervention up to a year later. That is one powerful intervention if it can have an effect on outcomes up to a year later.

From my research the RQLQ has to change by more than 0.5 to be considered minimally significant.  So the response as measured by the RQLG is just at the level of normal variation in the score. Hardly impressive.

The hypothetical mechanism by which acupuncture is alleged to work?

… studies have shown a potential effect of acupuncture on atopic diseases via different mechanisms, including changes of the endogenous opioid peptides in the central nervous system; reduction of prostaglandin E2 levels in the brain and serum; suppression of IgE production and modulation of Th1/Th2 cell response; central influence of acupuncture stimulation with specific activation of brain regions, including the influence of neu- ronal structures containing encephalin or beta-endorphin; and reduction of allergen-induced basophil activation.

Outside of vaccines and some biologics such as Rituxan, I cannot think of any medical intervention whose affect upon disease physiology persists longer than a few days after cessation. To continue to alter physiology a year later would make acupuncture one of the most powerful and longest-lasting medical interventions ever discovered.  Especially if applied to the usually transient effects noted above.

Or, as is more likely, the differences are all noise and bias.

And is there the potential for noise and bias? As my in-laws would say, oh yeah, you betcha.

First, they

…developed the trial interventions in a consensus process using a Delphi approach with experienced acupuncture experts.

Which means? It means there is no standard treatment for allergic rhinitis with acupuncture. Everyone did it a different way and the Delphi approach is a method of achieving a consensus when there is no standard. And even then there was variability in how many needles each patient received and where they were placed.

I went looking on the Googles for information concerning the validity of the acupuncture points used in the trial and I will admit to defeat. Most of what I found concerned acupressure points, which were mostly around the nose.  If they used well defined points for allergic rhinitis, I cannot find them.  Which is not surprising as traditional Chinese medicine is not concerned with the underlying pathophysiology of a disease like allergic rhinitis.  TCM practitioners look at the tongue and feel the pulse, among other techniques, to determine a therapeutic intervention.  If acupuncture actually did something to underlying pathophysiology, and there is no reason to suspect it would, it would be like choosing an antibiotic based on the reading of goat entrails.  And I sometimes suspect that is how antibiotics are chosen.

The sham acupuncture patients

 …were needled in at least 5 of 7 predefined non acupuncture points bilaterally, with only superficial insertion of needles (maximum 20 mm in length). Needle type and diameter were not defined (10). De qi and manual stimulation of the needles were avoided.

So in essence what they did was come with a quasi-arbitrary quasi-random form of needling and compared it to sham acupuncture, a different quasi-arbitrary quasi-random form of needling.

We all know it is skull, ear and oral acupuncture that is best for ENT problems. No wait, it’s laser acupuncture.  That’s the ticket. Lasers for allergic sinusitis. And of course we all know that acupuncture works better for rhinitis if done during the dog-days.  Such is the state of published acupuncture for rhinitis.  No consistency.

Given the thousands of acupuncture points, the lack of precision of defining these points and the various acupuncture schools (Chinese, German, Japanese, etc) how do they know they were not in another school’s acupuncture point? The only part of the human body that is routinely free of acupuncture points in the genitalia. I doubt they were needling there. Maybe the sham acupuncture was in active sites that were inadvertently altering Japanese or ear qi to make the rhinitis worse.

The sham group was not the same in that they had fewer needles on average: 10 needles (range 4 − 14) compared to the real acupuncture’s 16,  (range 9 to 25).  The sham group also had no manipulation, the needles were shallow and they were not irritated to generate de qi.

The variation in the number of needles also suggests acupuncture is a therapy practitioners just make up as they go along.  In the SCAM world that is referred as individualization. Since bigger placebo and more placebo will have increased effect compared to smaller and lesser placebo, one would suspect a better effect from the real acupuncture.

The sham acupuncture was less of an intervention: fewer needles, less penetration and no manipulation. It was an inferior substitute for real acupuncture, not a valid placebo, which they admit in the study protocol.

Patients were told:

In this study different types of acupuncture will be compared. One type is similar to the acupuncture treatment used in China. The other type does not follow these principles, but as also been associated with positive outcomes in clinical trials.

I suspect that a quick search of the interwebs by patients could suggest if they were getting needled in valid acupuncture points, although not if they were the right valid points.

There is probably sufficient qualitative differences in the two intervention  to account for any differences in comparative efficacy and it is likely that unblinding occurred. Did they check for unblinding?

They did ask the patients:

How confident do you feel that acupuncture can alleviate your complaint? How confident would you be in recommending acupuncture to a friend suffering from similar complaints? How logical does this treatment seem to you? How successful do you think this treatment will be in alleviating other complaints?

The acupuncture groups scored higher in the “How confident do you feel that acupuncture can alleviate your complaint?” question and they note:

Although some degree of unblinding might have influenced the overall result (33), a major bias seems unlikely because we informed patients that 2 types of acupuncture treatment were being compared without mentioning such terms as “placebo” or “sham,” because similar strategies of informed consent have been used in most previous acupuncture trials (34–38), and because post hoc analyses suggested that differences in study outcomes could not be explained by patient beliefs about treatment or other baseline differences.

So they assessed belief in acupuncture but in an impressive manifestation of don’t ask, don’t tell, they did not inquire of the patients what they thought they had received. A key question that was artfully avoided.

And given the differences in number of needles and the techniques used, although practitioners “were instructed to deliver both in the same context and with the same behaviors.” I am skeptical they were successful. Plenty of opportunity for the Clever Hans effect where the patient would note unconscious behaviors of the acupuncturist that suggests they are, or are not, receiving the real deal.

So there is ample opportunity for noise and bias to be the reason the acupuncture group was barely better than the sham group.  And the differences were trivial at best.

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When you look at the overlapping error bars you would conclude that acupuncture = sham acupuncture = doesn’t work. If the graphs were for angina treated with mammary artery ligation verus sham surgery, you would not advise the surgery for the patient nor suggest, as they do in accompanying editorial for acupuncture, that mammary artery ligation is effective.

This article is why I have long given up in the Annals. The editors seem to have turned off the part of the brain that allows for critical thinking.

In the summary they say:

Acupuncture led to statistically significant improvements in disease-specific quality of life and antihistamine use measures after 8 weeks of treatment compared with sham acupuncture and with RM alone, but the improvements may not be clinically significant.

May? The study is flawed in a way to suggest any effect is bias and that acupuncture has yet to find a clinical indication with clear cut efficacy. Which one would expect since it is based on nonsense. The editorial? They say:

With this study lending compelling support to the effectiveness of real world acupuncture for SAR…

Can you say cognitive disconnect? While the patient summary says:

Acupuncture seemed to improve symptoms for people with seasonal allergic rhinitis, but the effects were modest and did not last much beyond treatment. The improvement might have been caused in part by the volunteers’ preexisting beliefs about the treatment.

I do not mind bad studies. Well, I do. But I realize that what appears to be a good idea for a protocol at the beginning may turn out to have issues when carried out. Or the researchers cannot see the flaws of their design and outcomes because they are too enamored of the intervention.

But that is why there are editors of journals and peers to review the paper. Are the editors paying any attention to their content? The patient summary contradicts the editorial contradicts the paper. A careful and critical reading of the paper gives compelling evidence that acupuncture does nothing, in line with all the other well-designed acupuncture studies. The cognitive disconnect between the editorial and conclusion and the data presented in the paper is a wonder to behold. And most people will read only the spin in the abstract and the editorial, not noticing the fatal flaws, and erroneously conclude that acupuncture has efficacy.

Yet another reason why I am glad I let my Annals subscription lapse years ago. The editors of the Annals really need to keep a copy of the 8 strong suggestions on the wall.

I also wonder if this is an example of editorial Dunning-Kruger. Most of us spend our time in biomedical medicine. Pathophysiology leads to disease and we try to alter the disease by altering the pathophysiology. We implicitly evaluate papers with that approach in mind. The assumption is the therapy is doing something.

SCAM papers are not biomedical papers. Acupuncture does nothing as delivered that would be expected to alter the course of rhinitis or any other disease.

Acupuncture is a participatory passion play whose function is not to alter physiology but is a method of psychological manipulation to alter perception.  It is a ritual based on fantasy.  That is not to say rituals do not have powerful and long lasting effects.  The ritual of marriage objectively adds a ring to a finger, but there are many changes in perception of ones position in society after the ritual.

The researchers and editors behave as if the study is representative of an actual physical intervention, when all the good studies of acupuncture strongly suggest that all the benefits are subjective and dependent solely on the belief that acupuncture will work, as in this case.

Somehow I suspect the editors and reviewers at the Annals had the same approach to the paper that they would for an antibiotic being used to treat cellulitis, as if a real physiologic process is being modified. You cannot read a SCAM paper that way.

Properly evaluating a SCAM paper is a learned skill and it has taken a long time for me to recognize that when evaluating results whose efficacy is unlikely and whose success is subjective, you need to look carefully for differences in treatment groups where potential bias, often subtle, could account for treatment differences that are often just above random noise.  Because nothing is actually be altered in the patient, as occurs in this study.

Or just revert to the ad hominem, point at the paper and say neener neener, you’re ugly.  Works for me.

An ideal acupuncture study would have 4 groups: one that receives real acupuncture and is told they are receiving either real or sham and a group that receives sham acupuncture and is told they are receiving real or sham. There would be a subjective endpoint and an objective endpoint and I predict in advance the results:

The group that is told they are receiving real acupuncture will have more subjective benefit regardless of whether they receive real or sham when compared to those who are told they are receiving sham regardless of whether they are receiving real or sham. No group will have improvement in the objective endpoint.

That sums up the effects of acupuncture.  It is like all SCAM: the beer goggles of medicine;  it changes nothing but the symptoms appear better for a short period of time.

And acupuncture for allergic rhinitis?  There are enough flaws in this study to make any effect unlikely to be due to anything but noise and bias.  Coors Light at that.


Posted in: Acupuncture, Clinical Trials, Science and Medicine

Leave a Comment (67) ↓

67 thoughts on “Acupuncture and Allergic Rhinitis: Another Opportunity for Intellectual Sterility

  1. BillyJoe says:

    “An ideal acupuncture study would have 4 groups: one that receives real acupuncture and is told they are receiving either real or sham and a group that receives sham acupuncture and is told they are receiving real or sham”

    For a moment, I thought you were going to say real/sham/usual_treatment/waiting_list. The last two groups add nothing, of course, and serve only to reduce the numbers in the two groups that can actually tell us something about acupuncture. The four groups in the quote are effectively two groups cut two ways, so nothing is lost and something is actually gained. It should become the standard for trials of acupuncture, though I think it is high time trials of acupuncture were abandoned as a waste of time, money, and manpower.

  2. Eugenie Mielczarek says:

    Mark, thank you for this excellent post . My concerns with publications in some medical journals date back to the claims for positive outcomes published by physicians treating patients with magnets. The experiments weren’t even double blind– impossible to restrict paperclips from any participant. Nevertheless respected science journalists , even from the NY TIMES seized on the claim and wrote heart warming articles about their success. It took years to pull the claims from press releases and a law suit by the National Council Against Health Fraud to pull them from the shelves of Drug Stores. Now thanks to the German Study’s publication and its possible press release the unwary will be urged to seek acupuncture for running noses.
    Eugenie Mielczarek

  3. Janet says:

    Will this be sent to every “integrative” clinic in The Land–especially the ones at formerly prestigious medical centers?

    As I sit here with my ever-present runny nose (since I stopped the allergy shots), I can only hope so. I won’t be getting needled, but I might try the plastic bottle version of the netti-pot the allergist gave me, for some temporary relief.

    I think the netti-pot concept (in whatever form you use it) is possibly an example of a “woo that works” and is therefore no longer woo. I suppose the ritual of the real netti pot is better for believers than my plastic bottle which simply helps me get saline water through my nose to rinse out some of the snot so I won’t have snot-streaked sleeves ay noon.

    Or I could take an antihistamine.

  4. dani681 says:

    “Outside of vaccines and some biologics such as Rituxan, I cannot think of any medical intervention whose affect upon disease physiology persists longer than a few days after cessation. ”

    Immunotherapy, a legitimate treatment for allergies, can achieve this lasting effect. I received this for four years, and it’s been five years since I stopped. In the last five years my allergies have slowly begun to return, but they are still nowhere near the levels they were at before I began the shots. It wasn’t until a year ago that I had to return to daily antihistamines. Before I got the shots, I suffered greatly during ragweed season, even with the pills and nasal sprays.

  5. Calli Arcale says:

    Dr Crislip:

    Outside of vaccines and some biologics such as Rituxan, I cannot think of any medical intervention whose affect upon disease physiology persists longer than a few days after cessation.

    I beg to differ. I had a medical intervention performed upon my foot following an injury. It did involve the insertion of needles. Seventh months later, its beneficial effect persists! Of course, the needles were for the injection of sedatives and anasthetic so they could repair my joint. :-P My good friend had her severe GERD cured surgically, I know several who were cured surgically of cancer, and I know three people who no longer have such bad problems with their sinuses during allergy season because they had surgery to widen them. (Or something. I’m not entirely clear on what exactly was done, but I know they’re all breathing much better now. One of them has practically undergone a personality shift, since he’s able to get a decent night’s sleep now.)

    I have learned one thing from reading articles and watching documentaries about how acupuncture is performed, the philosophies behind it, and the efficacy of it. It has utterly convinced me of one thing: that acupuncturists have no idea what they are doing, but believe they do. If they do help anyone, it is by accident, and they won’t actually know which patients they’ve really helped. Just which ones stopped complaining.

    One further observation: they found that there was a statistically if not clinically significant improvement in quality of life after 8 weeks. Given that seasonal allergic rhinitis is, y’know, *seasonal*, I would expect it to vary over the course of 8 weeks no matter what the hell you did. Maybe the maple bloom ended. I don’t see any indication they considered that.

  6. Earthman says:

    How about ‘the 8 guiding principles’ ?

  7. WilliamLawrenceUtridge says:

    Being a staunch pastafarian, I would suggest “the eight ‘I really rather you dids'”.

  8. Mark Crislip says:

    I slipped into doctor speak and did not know it. In the world of internal medicine, there are medical therapies and surgical therapies.

    Oh man. Of course. Treat a disease at the start of the season and it will be better at the end of the season when all the pollen is gone. Wish I had thought of that; it makes the study even more ridiculous if they did not include, at a minimum, pollen counts, and they note that pollen exposure varies from site to site but that “everything should have balanced out”

    Although classic TCM would not even consider the pollen as a factor in the look of the tongue and the nature of the pulse, since dx and treatment is classically based on pure bogosity.

  9. mousethatroared says:

    I guess I’ll be a nuisance and add another medical intervention that lasts longer than a few days post treatment.

    Let’s not forget my favorite needle based medical intervention – cortisone injections – the last one I had for bursitis lasted years.

    also I like WLU’s – I’d really rather you dids. Although I don’t know what a pastafarian is – someone who likes pasta, someone who paturizes?

  10. JJ Borgman says:

    mtr…google…just google.

  11. ksadrieh says:

    Fascinating read. Made so much better by Neil Young’s “needle and damage done” coming on the classic rock station as I read…

  12. mousethatroared says:

    JJ Borgman – No – I’d just like to contemplate all the things it could be…like in the old days, before the internet and google, when phones had cords, cars had distributors caps and you could get really terrified over a good urban legend without having snopes ruin it for you.

  13. mousethatroared says:

    …used to be – when you wanted to start your own religion you had to do it through word of mouth and poorly xeroxed flyers using 50’s clip art.

  14. JJ Borgman says:

    So. You can’t be troubled to google “pastafarian”? You don’t seem to be the lazy sort. A google on that phrase would give you everything you need to know about it.

    (down a peg)

  15. JJ Borgman says:

    mtr, I certainly empathize with your sentiment to the “good old days”. That sentiment has robbed me of numerous employment opportunities. Keep up or get out is the norm, it seems. Even a well-informed use of modern apps won’t get you far if you fail to meet other criteria.

    Anyway, googling seems to help one keep abreast of modern terminology.

  16. WilliamLawrenceUtridge says:


    Yes, do google. You will be richly rewarded, His Noodly Appendage will grace you with blessings. Ramen.

  17. Quill says:

    Thank you for this article & for this excellent list of strong suggestions. I am particularly taken with the first one:

    Respect for knowledge and truth – SBM values reality and what is true. We therefore endeavor to be as reality-based as possible in our beliefs and opinions.

    This reminds me of the Declaration of Independence and holding certain things to be self-evident. I find reality to be self-evident and think it a great place to start searching for the truth. As noted, this stands in contrast to the first principles or assumptions of many “alternative modalities” whose first premises reside somewhere in ancient history, implausible physics or chemistry, or simply go with the “we don’t really know but keep and open mind” sort of thing. I think starting with reality and methodical search for truth to be a much stronger foundation than anything in the alt-world.

  18. mousethatroared says:

    jjborgman – it’s not that I can’t be bothered, it’s that I would rather wander in the desert until I reach a transcendental epiphany…

  19. Calli Arcale says:

    MTR — that seems remarkable apt for pastafarianism, actually. :-D Pastafarianism is a joke religion used to parody religious establishments. It’s the church of the Flying Spaghetti Monster. You can even get symbols to put on your car which resemble Jesus fish, only with meatballs and tentacles. Pastafarians say “Ramen” instead of “Amen”, and refer to their deity’s “noodly appendages”. Even as a Christian, I can appreciate the joke. It’s developed into a fairly extensive meme.

  20. Chris says:

    Oh, rats. Spring is coming. I noticed I sneezed several times as I was reading a book. I think I will reach for an antihistamine instead getting needled. Stupid alder trees (the allergen which traveled up my arm during the allergy prick test on my arm).

  21. Narad says:

    Treat a disease at the start of the season and it will be better at the end of the season when all the pollen is gone.

    Try telling that to the cats. I did allergy desensitization for about seven years, gave up in my teens out of sheer cussedness, and then gave up on antihistamines in college because of the sedative effect. I now just fill my back pockets with paper towels and have violent sneezing attacks every few days.

  22. mousethatroared says:

    JJ Borgman, WLU and Calli Arcale – but does this “spaghetti monster” offer Eternal Salvation — Or TRIPLE your money back!?

  23. BillyJoe says:

    CA: ” Pastafarianism is a joke religion”

    Pastafarianism, joke, religion?
    I think the idea is that these words are interchangeable.

  24. JJ Borgman says:

    mtr…according to Wikipedia:

    “The Pastafarian conception of Heaven includes a beer volcano and a stripper factory. The Pastafarian Hell is similar, except that the beer is stale and the strippers have sexually transmitted diseases.”

    I’m fairly certain the financial policy is All Sales Final ~:^)

    By the way, He is properly addressed as Flying Spaghetti Monster or FSM rather than ‘this”spaghetti monster”‘.

  25. mousethatroared says:

    JJ Borgman “The Pastafarian conception of Heaven includes a beer volcano and a stripper factory.”

    Oh I think “Bob” would approve then.

  26. mousethatroared says:


  27. Quill says:

    Most of this discussion reminds me of my favorite bit of found public restroom graffiti:

    End the Salad Hegemony! Long Live the Pasta Republic!

  28. mousethatroared says:

    @BillyJoe – Oh I thought it was the words “joke” and “life” that were interchangeable…probably just my life though.

  29. BillyJoe says:

    Oh, Michelle, no…

    “There are many here among us who feel that life is but a joke.
    But you and I, we’ve been through that, and this is not our fate.
    So let us not talk falsely now, the hour is getting late…”

    (Bob Dylan “All Along The Watchtower”)

  30. “The only part of the human body that is routinely free of acupuncture points in the genitalia. I doubt they were needling there.” Really?! Did you check rule 34?

    @Narad, I am not a doctor, but it occurs to me that there might be a way to mitigate the cat dander in your environment.

  31. Narad says:

    @Narad, I am not a doctor, but it occurs to me that there might be a way to mitigate the cat dander in your environment.

    They generally require sedation for shaving. I’m also an allogrooming target, so there are certain proteins that I’m stuck with. They’re my rescues; I deal.

  32. Chris says:

    I am also allergic to cats. But obviously not enough to not have them in my home.

    For a certain birthday in my 20s I knew dear spouse was getting me a pet. I actually asked for a dog, but the family gears were already in motion for a cat. So I ended up with a cat. Despite me wanting a Siamese, spouse chose an orange tabby. Despite wanting to give it a weird scientific/math name (Pythagoras), dear spouse made sure it was named after a character he liked in a TV program, “Louie.”

    On the bright side: I got to take care of Louie, the partial orange tabby, for almost nineteen years. He was was a very good cat. He never shredded the furniture, and he never peed where he was not supposed to. Plus he was a good mouser.

    I dealt with my allergy by washing my hands every time I touched him, by vacuuming, and by getting an electronic filter on the furnace. And by the fact he did go outside, and until the last year of his life he was not much of a lap cat.

    Unfortunately, after he had lived a good long life as a cat, he was in a great deal of arthritic pain and had kitty dementia. It is no fun being awakened in the middle of the night by his mournful meows because he could not find a water dish a few inches from where he was sitting. Le sigh.

    But the real problem is that then we had kids. They thought they could have their own cats after Louie was gone. So now we have two. AAARGH! I cannot believe how many messes we have to clean up for “normal” cats. I really miss Louie. What is worse is that one child has moved out of the house and left us with the most stupid psycho cat in the world.

    I still wash my hands after touching them. Also I make sure that electronic furnace filter is kept clean!

    Plus I have a freaking kitty pheromone emitter to make sure they are happy and don’t pee (or spray in the case of rescued Tomcat) all over the place (it actually works! I did not replace it, and then the idiot cat peed all over the bathroom… put it back and that stops… I am sticking with that anecdote). Both of the cats hate each other. While the ex-Tomcat as had the important parts removed, he still leaves a pungent reminder when he is upset. And it doesn’t help the other cat is just psycho.

    So much angst would have been avoided if Dear Hubby had gotten me a little dog for that twenty-something birthday.

  33. mousethatroared says:

    BillyJoe – Bob Dylan takes life very seriously…I suppose somebody’s gotta do it.

  34. mousethatroared says:

    My good friend’s husband is allergic to cats. Until recently they had a sphynx cat* a hairless cat that is often quite hypoallergenic with no problems with his allergies. Although the cat looked like the arch villain in a Marvel comic book, he was an incredibly sweet, playful and affectionate cat.

    Of course if you already have cats, that’s not helpful. But if you’re allergic and married to a cat lover….


  35. BillyJoe says:

    Michelle, I think we are equivocating, no?
    “My life is a joke” is not the same as “my life is filled with humour”.
    I do hope you meant the latter though. (:

  36. Janet says:

    I can’t believe I am reading about “hypoallergenic” cats on a science blog! Hairless, shmareless–it doesn’t matter. The protein that allergic people react to is in the dander, saliva, and urine (some people react to one, some to all). It’s in skin flakes that are shed regardless of the presence of hair in the case of dander. It may seem to make a difference for the mildly allergic, but no help to me and my ilk at the allergy clinic who can’t even sit next to a person who has been in the same room with a cat.

    The reason I stopped allergy shots is that the cat component was causing me reactions that required epi pens every other time I got a shot. This was after extra-slow progression over a three-year period. I had to have an ice pack for half a day after a shot and that was with use of antihistamines before the shot. I was wheezing five minutes after the shot toward the end. I was using inhalers all the time and even a nebulizer. Now I just sniffle and have returned to strict avoidance.

    Cat dander is much smaller than other animal danders, it is sticky, and it remains active for up to two years even if the cat isn’t there, so all the precautions (I tried them all–ripped out all the carpet, bathed (!) the cat weekly, air cleaners, hand washing, nasal spray, inhalers, etc) in the world make it difficult to avoid it and for the very sensitive, you will end up with horrible, chronic asthma and other lung problems if you try to keep a cat. The shots have made it possible for me to be in a house with cats for about 15 minutes (that would be 15 minutes longer than before the shots), but that’s about it.

    Allergic reaction to dander has nothing to do with breed, color, hair, etc. There are likely individual animals that an allergic person can tolerate, which may lead to anecdotes about certain colors or breeds being “hypoallergenic”, but I have yet to find one. I am able to tolerate my weenie dog with elaborate precautions, but she is probably the source of my previously mentioned runny nose.

    Everyone’s length of response to immunotherapy is different–some people are good for life, but most need maintenance or a redo after a few years. It’s helped my pollen allergies a lot, but not so much with the cat thing.

    Sorry for the rant, but this subject has occupied a big chunk of my life and I have found it rife with misinformation and scams.

  37. mousethatroared says:

    Ah, you caught me there Janet, sorry about the misinformation. Possibly my friend’s allergy was not a true cat allergy, not sure.

    But wikipedia confirms “Although Sphynx cats are sometimes thought to be hypoallergenic due to their lack of coat, this is not the case for cat-specific allergies. Allergies to cats are triggered by a protein called Fel d1, not cat hair itself. Fel d1 is a tiny and sticky protein primarily found in cat saliva and sebaceous glands. “

  38. mousethatroared says:

    eh…messed up my wikiquote…it goes on to say that Sphinx still have the protein, etc.

  39. mousethatroared says:

    BillyJoe – Life is a joke, clearly.

  40. BillyJoe says:

    Who’s playing it then?

  41. kathy says:

    @Janet “bathed (!) the cat weekly”.

    Crikey Mikey, Janet, you were truly desperate! I used to have a show cat that got a bran bath before going to the shows … no water involved! … stuck her (head out) into a pillowcase 1/4 full of warm bran and rubbed it in. The look in her eyes resembled the furious glare of a bowler (in cricket, for those of you that don’t know about civilised sport) staring at a basman that has just hit him for six, and thinking, “I’m gonna get you, I’m gonna get you …”

  42. kathy says:


  43. elburto says:

    @Calli – The interventions you mentioned are all surgical, cutting bits up/out tends to work long-term because we can’t regenerate most parts of ourselves!

    Having said that, I’ve scared myself because I’ve imagined a surgical form of acupuncture, where organs are exposed and then directly needled. FSM save me from my insomnia-fuelled imagination.

  44. BillyJoe says:


    You are English then?

    My brother is a vet. He sometimes has to attend a cat that looks like something the…um…cat dragged in. His strategy is to give the cat a false sense of security, stroking it gently and talking sweet nothings into its ear. He then slowly curls one hand around the front paws and the other around the back paws and, before it knows what hit it, rapidly submerge it in a tub of water, shake as fast and furiously as he can for a few seconds, and then let it go, giving the cat a wide birth as he does so.

  45. kathy says:

    BillyJoe, your brother is a hero. You’d be astonished (but your brother can no doubt tell you!) how strong a 5-pound cat can be when she is angry enough, and how she can turn into a whirling dervish armed with about 500 claws and the fangs of 40 vipers, when dunked into a basin of water … besides being slippery.

    [Not English, no, South African, or as we say here, Sarth Efrican. Also a Protea cricket team supporter, and (I know it’s waaaay off forum, so abject advance ‘pologies) rejoicing in my beloved cricket team FINALLY getting the success they deserve. Being a Protea supporter has, for the past twenty or so years, been a triumph of hope over common sense and logic, and all things held dear in this forum. GO PROTEAS!!]

  46. mousethatroared says:

    @BillyJoe – Bill Gates or maybe Stephen Kowalski, I’m not 100% sure which.

  47. DevoutCatalyst says:

    Protea maybe is a good thing for the genteel of SA, but must remind that you are describing love of game to BillyJoe who lives in the nation that birthed the finest team sport ever devised by Homo sapiens — Footy. To my mind the only dandered cats severely in need of a bath are in Geelong. GO THE MAGPIES !

  48. Calli Arcale says:

    elburto — I know, I was intending to be cheeky by mentioning surgery. :-P (Though it occurs to me my mom took a *drug* therapy that had long-term effects. Radioactive iodine to treat her Grave’s Disease. Also sort of cheeky to mention in this context since although it isn’t technically surgery, it does completely kill the thyroid which would obviously have a permanent effect.)

    Janet — the difference with hairless cats is only that they’re easier to bathe. I am allergic to both cats and dogs (more violently to cats) and so I have a poodle. Her coat doesn’t shed, which helps control the allergens, but I am still careful to wash my hands every time I pet her, lest I get dog dander on my face. That said, there are researchers attempting to genetically engineer a truly hypoallergenic cat. This strikes me as a little silly, but hey, if they can get someone to pay the big bucks for such a cat, I guess it’s fair. Just seems like a waste of resources.

    Narad — “”Treat a disease at the start of the season and it will be better at the end of the season when all the pollen is gone.” Try telling that to the cats.” Well, strictly speaking, cat allergy isn’t seasonal allergic rhinitis, since it is *not* seasonal. ;-) So that experience wouldn’t apply to this study, although if you just get a bunch of people with allergic rhinitis and treat ‘em all with whatever hokum strikes your fancy, enough probably will have seasonal allergies to make a statistical difference. And if you’ve taken pains to find out what they’re all allergic to, you’ll notice that only the seasonal ones had an improvement, and then you’ll trumpet your study as proving that the hokum is good for seasonal allergic rhinitis. Voila! :-D

  49. kathy says:

    LOL! OK, OK … DevoutCat, I’ll tell the rough-edged lot of boytjies that blog on the horseracing forum I often go to, that they are the “genteel of SA” next time they say nasty things about the Proteas’ latest (non)performance in 20-20 cricket. Since they are thinking in betting terms they may not agree with me … eek! … just saying.

    Good luck to the Magpies next time out. Me, I prefer the SA-NZ version to Oz Futbal, but that’s upbringing for you. It’s not as if I ever played either.

  50. @elburto: “Having said that, I’ve scared myself because I’ve imagined a surgical form of acupuncture, where organs are exposed and then directly needled. FSM save me from my insomnia-fuelled imagination.”

    Fueling your nightmares, I recently had my cervix needled multiple times!!!!11!!

    But for an awesome, actual medical reason! (To inject some sort of numbing agent so that it could be pried open to facilitate placing fallopian tube inserts intended to prevent any more little anthropologists from occupying my uterus.)

    @everyone else: The solution to cat allergies is to have a dog instead. *ducks…*

  51. DevoutCatalyst says:

    Or one of Belyaev’s adorable foxes. *quacks…*

  52. mousethatroared says:

    Okay – Now Anthropologist Underground just gave me nightmares….Please tell me that you weren’t conscious for that, cause it sounds awful.

  53. @mtr: Only the first two needle sticks really hurt. After that, I got to watch on a monitor! Biology is so cool! And the inside of my uterus is gorgeous…;)

    @devoutcatalyst: yes! So cute!

  54. physicsmum says:

    Cats really do rule the interwebs!!

    This thread is already totally derailed, so may I suggest anyone interested in either cats or cancer check out Tuxedo Stanley? Before him, I thought euthanasia was the only option for cats with cancer, but to my great surprise this poor lovely cat is getting chemotherapy for an aggressive lymphoma of the kidneys.

    Another really big surprise to me (how out of touch can one get??), from the comments I gather that some people think marijuana can cure cancer?? Trying to imagine a cat smoking a joint……..

    Do check him out – Tuxedo Stan is much nicer than “Count Stan”!

    The facebook page has more info, and thousands more comments (!!) than the website.

  55. Narad says:

    Before him, I thought euthanasia was the only option for cats with cancer, but to my great surprise this poor lovely cat is getting chemotherapy for an aggressive lymphoma of the kidneys.

    Believe or not, there are a few places in the U.S. where one can obtain feline hemodialysis. My understanding is that this is generally part of a plan for transplant. (And you have to adopt the donor cat.)

  56. pmoran says:

    Mark, did they perform pill counts so as to have an objective measure of rescue medication use? If so, how do you explain the apparently quite substantial medication-sparing effect of real acupuncture at 7-8 weeks in the second graph? How does biased reporting account for that?

    We can, of course, choose to regard that as some other kind of study glitch, but there are other studies, along with those suggesting considerable placebo responsiveness of allergic rhinitis, that make this a plausible finding.

    I agree that the superiority of “real” acupuncture over sham is more likely to be a response to perceptions regarding treatment effectiveness, its invasiveness, and its distracting abilities, than any mysterious physiological activity of acupuncture.

  57. Scott says:

    @ pmoran:

    Statistical variation. Picking out that one point as important is a classic case of failing to correct for multiple comparisons. The error bars would have to be MUCH smaller to say there’s any effect there at all.

  58. pmoran says:

    Yet symptom scores followed the same pattern, also with P values of <.001 at this end-point, and similar confidence intervals, Scott. Makes a purely chance finding very unlikely.

    If placebo responses are as capable as some think (without going to the overly-imaginative extremes of a few) then it is likely that CAM modalities will regularly produce results like this. Can we defend the position that patient biases at certain end points could retrospectively influence the number of tablets used for symptom relief?

  59. Scott says:

    Hardly that unlikely when you consider how many possibilities there were for such coincidences to arise. You HAVE to do the proper correction for multiple comparisons before you can make the slightest claim that there’s anything there.

  60. pmoran says:

    Well, even Mark seems to agree that there is “something there”, since he has gone to some lengths with his preferred explanation, that of biased patient reporting.

    That is one possible explanation, but is it the most likely reason for people taking less medication for symptoms?

  61. physicsmum says:

    Narad, that is quite remarkable! For serious cat lovers with plenty of moolah only, I expect…..

    I was somewhat taken aback to find myself paying $400 for a feline ultrasound (heart murmur) a few years ago. I cannot imagine how much a transplant would set one back.

  62. nukenorth says:

    The feline fans, feline allergy sufferers, and feline “phobiasts” took over the comments to this fine post.

    Perhaps this has something to do with toxiplasmosis?

    That’s really scary. Have the SCAM folks got a fix for that too?

  63. Bentham says:

    To continue the nitpicking…

    “Outside of vaccines and some biologics such as Rituxan, I cannot think of any medical intervention whose affect upon disease physiology persists longer than a few days after cessation.”

    I might be misunderstanding your meaning here.

    Ketamine for depression or for treatment of complex regional pain syndrome seems to be capable of lasting long after serum level of drug are gone. (ECT has a lasting effect as well on depression as well.)

    Radionuclides for metastatic bone pain?

    Bisphosphonates have long lasting effects on bone density as well as on hypercalcemia or perhaps bony metastatic pain.

    Chemical or electrical cardioversions?


    None of this should suggest in any way that I don’t generally agree with and appreciate your post. Or that I think that acupuncture has any medical indications.

  64. Narad says:


    I was somewhat taken aback to find myself paying $400 for a feline ultrasound (heart murmur) a few years ago.

    I don’t remember the price, but perhaps seven years ago I was referred to a specialty vet clinic way out in the suburbs for a liver ultrasound. Two things stand out: (1) That it was way nicer than the local university medical center. (2) The somewhat shaken look on the doctor’s face when she came out to ask whether they could administer a sedative, even though I had warned them in advance that he was, shall we say, rather a tough cat.

  65. pmoran says:

    It is remarkable how these tips can be applied to SCAM-related articles and the articles are found wanting. For example, the acupuncture article I reviewed last week: barely significant p-values, large confidence intervals and misleading multiple tests; the sine qua non of positive SCAM studies.

    This is a bit loose, Mark. P<.001 is now "barely significant"? Two measurements (which correlated very plausibly between the three groups) are now "multiple tests"? Were those confidence intervals unusually large for medical studies involving subjective complaints with "placebo responsive" conditions (I don't know, — I am no statistician either, but I seriously doubt it)?

    If you really believed the findings were this easy to dismiss on statistical grounds, then there was no real need for your extensive explanation of how the differences observed were probably due to reporting biases. I asked you to support that view further at the time, but you either missed several comments or chose not to answer.

    Note also that most of the findings in that study are replicated by numerous other studies on acupuncture using sham and "untreated" controls, including the differences (typically much smaller, of course) between sham and real acupuncture.

    The only difference here was this unusually poor performance from sham acupuncture. That fits your case that there was a very inadequate placebo for any comparison of "real" and "sham", but it does not exclusively support any particular explanation for the apparent "effects" observed here, and also in many other studies.

  66. Mark Crislip says:

    Just very busy, a slow typist, and you are partly correct.

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