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IOM Recommends Replacing CFS with SEID

Exertion intolerance

Exertion intolerance

Chronic fatigue syndrome (CFS) is a controversial diagnosis that has also been called myalgic encephalomyelitis (ME or ME/CFS), post-viral fatigue syndrome (PVS), chronic fatigue immune dysfunction syndrome (CFIDS), Iceland disease, “yuppie flu,” and many other names. A new report from the Institute of Medicine (IOM) says that none of those names really fit the disease and recommends it be re-named systemic exertion intolerance disease or SEID.

ME/CFS is thought to affect as many as 2.5 million Americans. The cause remains unknown, but in many cases it appears to have been “triggered by an infection or other prodromal event, such as immunization, anesthetics, physical trauma, exposure to environmental pollutants, chemicals and heavy meals, and rarely blood transfusions.” Some doctors question its very existence and interpret the symptoms as imaginary or psychological.

The IOM examines the evidence base

At the request of several government agencies including the NIH and the FDA, the IOM convened a committee of 15 experts to examine the evidence base for ME/CFS. They reviewed over 9,000 published studies and heard testimony from patients and advocates. Before publication, an additional 15 experts were asked to provide peer review. The full text of the report is available free online. (more…)

Posted in: Science and Medicine

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Placebo, Are You There?

By Jean Brissonnet, translation by Harriet Hall

Note: This was originally published as “Placebo, es-tu là?” in Science et pseudo-sciences 294, p. 38-48. January 2011. It came to my attention in the course of an e-mail correspondence with the editors of that magazine, where one of my own articles was published in French translation in January 2015. I thought this was the best explanation of placebo that I had ever read. It covers the same points my colleagues and I have addressed and more. It describes the pertinent research and uses particularly effective graphs to illustrate the principles (a picture is worth a thousand words). The author, Jean Brissonnet, kindly gave his permission for me to translate it and share it with our readers.

In fact, you don’t need to give a placebo to get a placebo effect and therefore we can now think about how we can maximize the placebo component of routine care.

~ Damien Finniss, 2010

The scene takes place in a surgical suite where they are preparing to do a cataract operation. The patient is lying on the operating table. A few minutes earlier the anesthetic gel was applied to the cornea to permit an operation under simple local anesthesia. The surgeon arrives in the company of the anesthetist. They are engaged in a spirited discussion and don’t seem to be agreeing.

“It has been proven,” says the surgeon, “that 30% of the action of a medical treatment is due to the placebo effect.”

“I doubt that,” retorts his interlocutor, “I think that placebo story is one of those medical myths on a par with the idea that we only use 10% of our brain, that nails and hair grow after death, or that cellphones create interference in hospitals.”[1]

“No,” insists the surgeon with a superior tone, “the fact is established and has been proven by numerous studies.”

The anesthetist shakes his head with a slight smile, but he doesn’t reply. As for the patient, who might have much to say on the subject, he keeps quiet, because it would not be prudent to argue with someone who is about to suck the lens out of your eye.

This true anecdote would not be of interest if it didn’t concern two members of the medical profession. Why such uncertainty? Why such lack of knowledge about such a fundamental subject? This faith in an all-powerful, magical, and mysterious placebo is common among the general public and it serves as justification for resorting to unconventional medicines that have never been able to show solid proof of efficacy; but we see that it still persists among the medical profession.

To know whether the placebo effect is real or should be relegated to the same category as poltergeists, it will help to go back in history.



Posted in: Clinical Trials, Science and Medicine

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Glucosamine Update

 Stick-and-ball model of the glucosamine molecule (from the Wikimedia Commons, image by Benjah-bmm27)

Stick-and-ball model of the glucosamine molecule (from the Wikimedia Commons, image by Benjah-bmm27)

Osteoarthritis, the “wear-and-tear” type of arthritis, affects a great many of us as we grow older. Knee pain is a common symptom. The diet supplements glucosamine and chondroitin have been proposed as a more “natural” treatment than pharmaceuticals, and they are components of a number of proprietary “joint health” formulations like Osteo Bi-Flex. The GAIT study (Glucosamine/Chondroitin Arthritis Intervention Trial), compared glucosamine, chondroitin, a combination of the two, and a pharmaceutical (celecoxib) to a placebo in patients with knee pain from osteoarthritis. The only one that worked better than placebo was celecoxib. I wrote about the GAIT trial in 2008. The study was reported in the media as both negative and positive. The positive reports emphasized the subgroup analysis: in one of ten subgroups, patients with moderate to severe pain, the combination of glucosamine and chondroitin outperformed placebo. But in the subgroup of patients with mild to moderate pain, it did not. The authors themselves commented that their study was not powered to draw any conclusions from subgroups and that further studies would be required. (The “power” of a study is a measure of its ability to show an association or relationship between two variables if such a relationship exists.) Now a further study with sufficient power claims to have confirmed the subgroup findings. This may encourage some people to try glucosamine/chondroitin, but I remain skeptical.


Posted in: Clinical Trials, Herbs & Supplements

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Facing Decline and Death

Gawande book

Note: Atul Gawande and his book will be featured on a Frontline episode airing on PBS tonight.

We’re all going to die. (There’s nothing like starting on a positive note! :-) ) We’re all going to die, and if we are fortunate enough to survive long enough to become old, we’re all going to experience a decline of one sort or another before we die: reduced hearing and vision, less strength, poorer memory, etc. As a society, and as a medical profession, we have been reluctant to confront those issues head on. Dr. Atul Gawande faces them unflinchingly in his thought-provoking new book Being Mortal: Medicine and What Matters in the End.

In a simpler time, there were fewer old people; they were respected for their knowledge and were cared for by their families who supplied their increasing needs as age made them more dependent on others; they died at home surrounded by supportive loved ones. Today we warehouse our elders in nursing homes, where they are denied the independence of even making simple everyday choices like when to get up and when to eat. We consign them to a regimented, less enjoyable, less meaningful life; and they frequently die alone in hospitals, connected to tubes and machines.

Doctors are not always good at making it clear to terminally ill patients that they are going to die soon. They are not always good at discussing end-of-life issues and securing advance directives. They often treat end-of-life diseases so aggressively that they end up causing more suffering or even shortening lives. (more…)

Posted in: Book & movie reviews, Cancer, Medical Ethics

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A Scientist in Wonderland

Edzard Ernst is one of those rare people who dare to question their own beliefs, look at the evidence without bias, and change their minds. He went from practicing alternative medicine to questioning it, to researching it, to becoming its most prolific critic. I have long admired his work, and I finally met him in person when we were invited to speak at the same conferences. He shattered my stereotype of the stern, formal, self-important German “Herr Professor Doktor.” He was affable, unassuming, and funny; he was even a jazz musician. I wished I knew more about his history, and my wishes have been granted in the form of his new autobiographical book, A Scientist in Wonderland: A Memoir of Searching for Truth and Finding Trouble.

This is a well-written, entertaining book that anyone would enjoy reading and that advocates of alternative medicine should read: they might learn a thing or two about science, critical thinking, honesty, and the importance of truth.

This is a well-written, entertaining book that anyone would enjoy reading and that advocates of alternative medicine should read: they might learn a thing or two about science, critical thinking, honesty, and the importance of truth.

Edzard Ernst, the early years

Dr. Ernst was born in post-war Germany; his family had suffered greatly during the war and his uncle had been a general in the Waffen SS. He felt slightly ashamed to be German, and as a result he researched and wrote about Nazi health beliefs and medical atrocities so the history of their misdeeds would not be forgotten.

His father was a doctor, his mother an enthusiastic devotee of alternative medicine who subjected him to homeopathy, ice cold baths, and barefoot walks at dawn through wet grass. Early in life, Ernst began to manifest a tendency towards doubt and irreverence, along with an irrepressible sense of curiosity.

Music was his first love. He earned good money when he and his friends spent their summer vacation busking on the beach at St. Tropez, and he had been seriously considering a musical career until his mother persuaded him to study medicine. He earned an MD in Germany, in an environment where alternative medicine was unquestioningly integrated with mainstream medicine. He received hands-on training in acupuncture, autogenic training, herbalism, homeopathy, cupping, massage therapy, spinal manipulation, even leeches. His first job was in a homeopathic hospital where a colleague chose remedies by dowsing with a pendulum. (more…)

Posted in: Book & movie reviews, Clinical Trials, Critical Thinking

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Another Misguided Cancer Testimonial

An economic analyst, Mike “Mish” Shedlock, wrote a blog post to describe how he beat prostate cancer. When laymen and patients write about cancer, they are likely to get some things wrong. Mish’s story is full of typical misunderstandings and misinterpretations.

He interpreted his experience in his own way and did his own research into the medical literature, something he was not qualified to do. Prostate cancer is a very complex subject, and understanding the implications of published studies for treating patients can be difficult even for experts. In typical Dunning-Kruger fashion, he rejected the advice of his doctors, thinking he could do better.

Posted in: Cancer, Herbs & Supplements

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Shedding Light on Unreasonable Decisions


One of the biggest frustrations for a doctor is when a patient refuses to take science-based medical advice. We would like to believe that giving a patient accurate information will lead him to make good decisions that will improve his health or save his life. But that’s not how it works. Patients reject life-saving surgery and chemotherapy, patients on essential medications are non-compliant, parents reject vaccines for their children…what are these people thinking? Why would anyone in their right mind knowingly reject a treatment that has been proven to increase their chances for survival and health? What could their reasons possibly be?

This ties into a subject we have debated over and over: why do people choose alternative medicine? Many reasons have been suggested: cost and accessibility, the need for control, dissatisfaction with mainstream medicine, the peer pressure of a popular fad, “belonging” to a group of like-minded people, a need for answers, autonomy, health freedom, ideology, rebellion against authority, a need for hope even if it is false hope, giving more importance to stories than to studies, the post hoc ergo propter hoc fallacy, scientific illiteracy, misinformation, superstition, magical thinking…the list goes on. Studies have been done, but we can’t be sure the reasons people give to researchers are the real reasons. There is a problem with the search for reasons: these decisions are not made on the basis of reason. Physician Lisa Rosenbaum has written a beautiful essay in The New England Journal of Medicine entitled “Beyond Belief — How People Feel about Taking Medications for Heart Disease“, that sheds a penetrating light on what is really going on. It made me think of the subject in a whole new way. (more…)

Posted in: Critical Thinking

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Smoking Cessation and the Affordable Care Act

A young child and a chicken — neither of whom should smoke.

A young child and a chicken — neither of whom should smoke.

Smoking is the leading preventable cause of death. Each year it kills more than 5 million people around the world, 480,000 in the US alone. And for every person who dies, about 30 more have serious illnesses caused by smoking. On average, smokers die 10 years earlier than nonsmokers. Anyone who is concerned about preventive medicine must consider smoking cessation a priority. Fortunately, the Affordable Care Act (ACA) has taken a step in the right direction.

The ACA’s provisions

The Affordable Care Act requires health plans and health insurance to cover tobacco-use counseling and interventions without cost sharing or prior authorization. It requires screening of all patients for tobacco use and covering at least two attempts to quit each year. For each quit attempt, it authorizes four tobacco-cessation counseling sessions, each at least ten minutes long (including telephone, group, and individual counseling) and any FDA-approved tobacco-cessation medications (whether prescription or over-the-counter) for a 90-day treatment regimen when prescribed by a health care provider. In a separate provision, it requires that states not exclude FDA-approved cessation medications from existing Medicaid programs. These provisions should encourage providers and patients to increase their smoking cessation efforts. (more…)

Posted in: Politics and Regulation, Public Health

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Is the Ebola Crisis a Reason to Skip RCTs?

Ebola virus


In a recent “Perspective” article in The New England Journal of Medicine, three physicians (Drs. Cox, Borio, and Temple) make a strong case for not letting the rush to save Ebola patients tempt us to deviate from good science and skip the randomized controlled trial (RCT). Their arguments cut to the essence of the scientific approach to medicine, and they deserve careful consideration.

Ebola is uniquely scary

Ebola is the kind of threat that really gets our attention. The virus was first identified in 1976, and prior to 2013 there were several small outbreaks in Africa with death rates as high as 90%. This time the death rates are lower, but the numbers are much greater. It has spread to several African countries, and a few cases have even reached the US and Europe due to infected travelers and health care workers. We face a risk that Ebola may become endemic, smoldering along as a constant presence in Africa.

There is no known effective treatment. Fear of Ebola has sparked bizarre conspiracy theories and claims of “natural” cures and prevention kits from homeopaths, alternative medicine advocates like Mercola, and purveyors of remedies like colloidal silver and essential oils. These have been covered on SBM here, here, and here. (more…)

Posted in: Clinical Trials, Science and Medicine

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The Health Benefits of Moderate Drinking

A Book of Verses underneath the Bough,
A Jug of Wine, a Loaf of Bread–and Thou
Beside me singing in the Wilderness–
Oh, Wilderness were Paradise enow!”

– The Rubaiyat of Omar Khayyam


Alcoholic beverages have always inspired strong opinions pro and con. Omar Khayyam included wine in his vision of Paradise; Carrie Nation took a hatchet to saloons. Humans have been drinking alcoholic beverages for at least 12,000 years. In earlier eras beer and wine were dietary staples that provided essential calories and were safer to drink than water. Early cultures worshipped wine deities; today, some religions ban all forms of alcohol while others embrace red wine as an essential part of a holy sacrament. Alcoholic beverages are widely used as an accompaniment to meals and as a social lubricant (as Ogden Nash put it, “Candy is dandy, but liquor is quicker”). Prohibition didn’t work.

It’s always good when opinions can be backed up by scientific evidence. Those who drink, especially wine lovers, can bolster their personal preference with the evidence from recent studies showing that moderate alcohol consumption prolongs life and improves health in various ways. Those who prefer not to drink are being told they can get the same benefits from resveratrol, a component of red wine. Just how good is the evidence, and what does it really tell us? (more…)

Posted in: Nutrition

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