A recent editorial entitled “CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don’t” published in Headache: The Journal of Head and Face Pain by Robert Cowan, a headache specialist, addresses the use of complementary and alternative medicine (CAM) in the treatment of headaches. Unfortunately he propagates many common misconceptions about CAM in the article.
I do agree with one point – physicians need to be more aware of CAM treatments and their patients’ use of them. We should be directly asking our patients about such use, in a non-judgmental way, and we should be familiar enough with common CAM treatments so that we can provide knowledgeable guidance to our patients.
Cowan begins by, in my opinion, grossly exaggerating the current popularity of CAM. He writes:
As much as 82% of headache sufferers use complementary and alternative approaches.
The reference he cites, however, states:
Adults with migraines/severe headaches used CAM more frequently than those without (49.5% vs 33.9%, P < .0001); differences persisted after adjustment (adjusted odds ratio = 1.29, 95% confidence interval [1.15, 1.45]). Mind–body therapies (eg, deep breathing exercises, meditation, yoga) were used most commonly.
Only 4.5% of adults with migraines/severe headaches reported using CAM to specifically treat their migraines/severe headaches.
It’s an excellent business model. The only real infrastructure you need is a website, and you can have a custom site made for $5-10 thousand. Then you just have the monthly bandwidth charges. The rest is just e-marketing, which can be done for free, or the cost of some e-mails lists. After that, the money just comes rolling in.
The best part is that other people do all the actual work. All you have to do is charge them for publishing on your open-access online journal.
What you are selling is essentially scientific/academic fraud.
Unfortunately, this is a good business model, even though it is a terrible scientific model, and so it has proliferated. We may be living in the heyday of dubious open-access scientific journals.
The open-access format itself is not a bad one, and there are some very successful and respected open-access journals, such as the PLOS journals. The idea is that, instead of charging a subscription in order to gain access to published articles (in print or online), the articles are open-access, but authors pay a fee to have their work published.
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…)
The American Heart Association and the American Stroke Association recently published in the journal Stroke a thorough analysis of the evidence for an association between cervical manipulative therapy (CMT) and both vertebral artery dissection (VAD) and internal carotid artery dissection (ICAD). The full article is online: “Cervical Arterial Dissections and Association With Cervical Manipulative Therapy: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association.” For background, an arterial dissection is essentially a tear in the inner lining of the artery. This tear disrupts the normal flow of blood, and also causes platelets to gather at the site of injury. This can result in a blood clot at the site of the dissection. This blood clot can block flow through the artery, or it can break off and lodge downstream, blocking flow at that point. Dissections, therefore, can result in a stroke (a lack of blood flow to a portion of the brain causing damage). There are four arteries in the neck that bring blood from the heart to the brain, two carotid arteries in the front, and two vertebral arteries in the back. A dissection in one or more of these arteries is associated with 2% of all strokes, but with 8-25% of strokes in patients <45 years old. This is mostly because strokes associated with processes like atherosclerosis are much less common in the younger population. Arterial dissections are classified as either spontaneous or traumatic. Trauma can be either severe, such as whiplash injury from a car accident, or subtle, such as from yoga or simply turning one’s neck to look past the shoulder. (more…)
Years of analyzing popular but dubious claims leads to the impression that just about all knowledge that filters down to the popular consciousness is essentially wrong, at least as a first approximation. This may sound cynical, but think about any area in which you have specialized knowledge and compare that to what the average person believes about that area. Now extrapolate that to every other area of specialized knowledge.
I may be skeptical, but I am not a nihilist. I do think the situation can be and is being improved by popularizing science and other areas of knowledge. Experts need to be directly involved in teaching the public about their area, and when they are, popular beliefs can be corrected.
One example is the myth that we only use 10% of our brain. This is still fairly popular, and was recently a central plot element to the blockbuster movie, Lucy. However, Google “10% brain” and you will find nothing but links to sites debunking this myth, at least in the first few pages.
In May, prompted by an uncritical article in the Daily Mail, the internet was buzzing about a company that was offering drinkable sunscreen. This is one of those game-changer health products that immediately garners a great deal of attention.
At first the claim seems extraordinary, but it is not impossible. It is theoretically possible to drink a substance that becomes deposited in the skin and absorbs or reflects UV radiation providing protection. However, upon reading the details it becomes immediately apparent that the product in question is pure snake oil.
The product is Harmonized Water by Osmosis Skin Care. In fact, UV protection is just one claim among many for the harmonized water line of products. The website claims:
- Remarkable technology that imprints frequencies (as standing waves) onto water molecules.
- Advances in the ability to “stack” thousands of frequencies onto one molecule.
- Revolutionary formula allows us to reverse engineer the frequencies of substances found in nature and/or the human body.
- Newly identified frequencies that have beneficial effects on the body.
I suppose it was inevitable. In fact, I’m a bit surprised it took this long. SGU Productions, the Society for Science-based medicine, and I are being sued for an article that I wrote in May of 2013 on Science-Based Medicine. My SBM piece, which was inspired by an article in the LA Times, gave this summary:
The story revolves around Dr. Edward Tobinick and his practice of perispinal etanercept (Enbrel) for a long and apparently growing list of conditions. Enbrel is an FDA-approved drug for the treatment of severe rheumatoid arthritis. It works by inhibiting tumor necrosis factor (TNF), which is a group of cytokines that are part of the immune system and cause cell death. Enbrel, therefore, can be a powerful anti-inflammatory drug. Tobinick is using Enbrel for many off-label indications, one of which is Alzheimer’s disease (the focus of the LA Times story).
The claims and practice of Dr. Tobinick have many of the red flags of a dubious medical practice, of the sort that we discuss regularly on SBM. It seems that Dr. Tobinick does not appreciate public criticism of his claims and practice, and he wants me to remove the post from SBM. In my opinion he is using legal thuggery in an attempt to intimidate me and silence my free speech because he finds its content inconvenient.
Of course, we have no intention of removing the post as we feel it is critical to the public’s interest. This is what we do at SBM – provide an objective analysis of questionable or controversial medical claims so that consumers can make more informed decisions, and to advance the state of science in medicine.
We also feel it is critical not to cave to this type of intimidation. If we do, we might as well close up shop (which I suspect the Tobinicks of the world would find agreeable). Defending against even a frivolous lawsuit can be quite expensive, but we feel it is necessary for us to fight as hard as we can to defend our rights and the work that we do here at SBM.
A newly published meta-analysis of studies looking at acupuncture for symptoms resulting from natural menopause (not drug or surgically induced) by Chiu et. al. is entirely negative. That is not what the authors or the press release conclude, however.
This disconnect between the study results and the interpretation of those results is a persistent problem in medicine generally to some degree, but is endemic and profound within the CAM (complementary and alternative medicine) culture. Acupuncture in particular is promoted almost entirely based on this type of misinterpretations – the kind that can magically turn negative studies into positive studies.
In the abstract the authors conclude:
This meta-analysis confirms that acupuncture improves hot flash frequency and severity, menopause-related symptoms, and quality of life (in the vasomotor domain) in women experiencing natural menopause.
Let’s take a close look at the results, however. Indeed, when comparing acupuncture to no treatment controls there was a significant decrease in subjective symptoms in the pooled data. Outcomes were hot flash frequency, hot flash severity, other menopausal symptoms, and quality of life. Some of the included studies were large controlled trials, which the authors used to argue that their results are valid. They also point out that their results showed heterogeneity and lack of publication bias.
Part of the mission of SBM is to continually prod discussion and examination of the relationship between science and medicine, with special attention on those beliefs and movements within medicine that we feel run counter to science and good medical practice. Chief among them is so-called complementary and alternative medicine (CAM) – although proponents are constantly tweaking the branding, for convenience I will simply refer to it as CAM.
Within academia I have found that CAM is promoted largely below the radar, with the deliberate absence of public debate and discussion. I have been told this directly, and that the reason is to avoid controversy. This stance assumes that CAM is a good thing and that any controversy would be unjustified, perhaps the result of bigotry rather than reason. It’s sad to see how successful this campaign has been, even among my fellow academics and scientists who should know better.
The reality is that CAM is fatally flawed in both philosophy and practice, and the claims of CAM proponents wither under direct light. I take some small solace in the observation that CAM is starting to be the victim of its own success – growing awareness of CAM is shedding some inevitable light on what it actually is. Further, because CAM proponents are constantly trying to bend and even break the rules of science, this forces a close examination of what those rules should actually be, how they work, and their strengths and weaknesses.
A new Cornell University study examines the origins of food fears, and possible remedies. It’s a survey of 1,008 mothers asking about foods they avoid and why.
Food fears are a common topic on SBM, likely for several reasons. Humans have an inherent emotion of disgust, which is likely an adaptation to help avoid contaminated or spoiled food. In our modern society this reflex can be tricky, because we do not always have control over the chain of events that leads to food on our plates. Other people grow the food, transport it, process it, and perhaps even cook it.
Modern food technology can also involve many scary sounding substances and unusual processes. As the saying goes, you may not want to know how the sausage is made, as long as the end result is wholesome.
This leads to a second reason for modern food fears – we are living in an age of increasing transparency, partly brought about by the dramatic increase in access to information on the internet. I think ultimately this is a good thing – people are seeing how the sausage is made, which makes it more difficult to hide shady practices. This introduces a new problem, however. If you’re going to inspect the process of making sausage, then you need to know something about sausage-making. (more…)