viernes, 31 de octubre de 2014
A little shameless self-promotion and a plea
Here’s a little shameless self-promotion, which we editors at Science-Based Medicine indulge in from time to time. This time around, I’d just like to mention that I’m the guest on the latest episode of the Skeptics’ Guide to the Universe, where I was permitted to pontificate about children with cancer whose parents deny them chemotherapy. Check it out.
Second, in less than four weeks, I will be giving a talk at Skepticon. The great thing about Skepticon is that it’s free, but that requires donations. So, as a speaker, I’m going to ask you all once again to give until it hurts.
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Ebola: If Nigeria can do it, so can we
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Ebola! But don’t forget about the flu.
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jueves, 30 de octubre de 2014
Do EMRs improve patient safety? A debate.
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Cosmetic Dermatology Training for Nurses and Medspas – Dr. Melvin Elson
Cosmetic Dermatology Training for Nurses and Medspa – http://ift.tt/1p8dVNR – (615) 441-5227
Doctor Melvin Elson has been training doctors and nurses in Cosmetic Medical procedures since 1982 primarily in evaluation of the aging face, Botulinum Toxin and dermal filling materials.
He has trained in 51 countries and in most of the United States. He has instructed independently as well as for companies such as Collagen Corporation, Inamed, Beaufor-Ipsen, Allergan, Prollenium, Merz Aesthetics, and the American Academy of Aesthetic Medicine.
Why Choose Me to Train You In YOUR Office?
1. You don’t have to travel
2. No hotel for you!
3. You do not miss days out of the office
4. You can still see patients in your office while I am training you on your patients
5. You don’t waste time on expensive weekend conferences that may not teach what you really need and want
6. No more questioning whether the Faculty in conferences are well-trained or even qualified to train
7. You choose the day and time
8. Your patients appreciate the effort you are putting forth for them
9. You will have someone experienced seeing your practice in action and can help you learn how to improve your practice
10. My expenses are far less than you would spend to go to one of the courses offered at various conferences
11. No more confusion over whether a course offered leads to recognized board certification. I am honest with you. No course can offer you that no matter what they claim.
About Dr. Elson:
Melvin L. Elson, MD is known world-wide as an expert in treating the appearance of aging. A graduate of Duke University School of Medicine, he also trained at Vanderbilt University Medical Center and Duke Hospital. He has taught physicians and medical personnel in more than 50 countries and most of the US. He has published over 300 scientific articles, has written 2 books, has appeared on national and international television and has developed a number of skin care lines.
As a board-certified dermatologist, he has practiced in Nashville for more than 30 years, specializing in cosmetic dermatology and attracting patients from all over the world. SkinScam details the causes of the appearance of aging as well as informing the consumer what is and what is not effective and what the pitfalls are when one begins to seek help in reversing the signs of aging.
He lives outside Nashville with Betty, his wife of 47 years. They have 2 daughters and 2 grandsons.
More here: http://ift.tt/12jwwCF
Contact Us!
Address: 4081 Highway 96. Burns, TN 37029
Phone : +1 (615) 441-5227
Email : info@drmelvinelson.com
Website: http://ift.tt/1p8dVNR
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The Ebola quarantine: Is 21 days enough?
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Instead of being hysterical about Ebola, respect it
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Pharma needs physician digital key opinion leaders. Here’s why.
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A civil war in psychiatry: Is there common ground?
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Patient satisfaction: Should that be the real mission of health care?
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Customer service in health care: It’s coming. Are you ready?
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Health reform: Great for patients, but this doctor lost his job
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5 ways to increase your EMR efficiency
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A physician undergoes hip surgery: 10 observations from bedside
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Ebola: We suffer from unrealistic expectations
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A little shameless self-promotion and a plea
Here’s a little shameless self-promotion, which we editors at Science-Based Medicine indulge in from time to time. This time around, I’d just like to mention that I’m the guest on the latest episode of the Skeptics’ Guide to the Universe, where I was permitted to pontificate about children with cancer whose parents deny them chemotherapy. Check it out.
Second, in less than four weeks, I will be giving a talk at Skepticon. The great thing about Skepticon is that it’s free, but that requires donations. So, as a speaker, I’m going to ask you all once again to give until it hurts.
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jueves, 16 de octubre de 2014
As Ebola spreads, what can we do to help?
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Reading about health care online: Is it really that bad?
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A musician’s guide to medical training
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To be or not to be: An artist in medicine
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Why the Apple Watch won’t disrupt health care. Yet.
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miércoles, 15 de octubre de 2014
What do you know about breast reconstruction?
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8 tips for spiritual assessment in the hospital
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An ER missed Ebola. Here’s how it could happen to you.
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Almost a convert: Donating one’s body to science
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Open Payments: Detailing the media’s witch hunt
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Research and Reviews in the Fastlane 052
Welcome to the 52nd edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.
This edition contains 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors
This Edition’s R&R Hall of Famer
Infectious Diseases, Epidemiology, Critical Care
WHO Ebola Response Team. Ebola Virus Disease in West Africa — The First 9 Months of the Epidemic and Forward Projections. NEJM 2014 PMID: 25244186
- Since the onset of the Ebola Virus Disease epidemic 7 months ago a total of 4507 confirmed and probable cases, as well as 2296 deaths from the virus had been reported from five countries in West Africa — Guinea, Liberia, Nigeria, Senegal, and Sierra Leone. The disease is rapidly spreading with a case diagnosed in the United States this week. This is an excellent report on the clinical and epidemiologic characteristics of the epidemic and the analyses in this paper can be used to inform recommendations regarding control measures. Unfortunately the current epidemiologic outlook is bleak especially in Guinea, Liberia, and Sierra Leone. Control measures which include improvements in contact tracing, adequate case isolation, increased capacity for clinical management, safe burials, greater community engagement, and support from international partners need to improve quickly otherwise these countries will be reporting thousands of deaths each week. Experimental therapeutics and Vaccines are not available at present and certainly not in the quantities that are required. We must also face the prospect that Ebola Virus Disease may become Endemic to the human population in West Africa.
- Recommended by: Nudrat Rashid
The Best of the Rest
Emergency Medicine
Hwang V et al. Are pediatric concussion patients compliant with discharge instructions? J Trauma Acute Care Surg 2014. PMID: 24977765
- The short and long term morbidity associated with pediatric concussions is becoming better recognized. This study looked at compliance with discharge instructions. Surprisingly (or maybe not so), 39% of pediatric patients returned to play (RTP) on the day of the injury. RTP is widely recognized as a risk for recurrent and more severe concussions as well as significant morbidity. It is the duty of the Emergency Physician to stress the importance of discharge instructions as well as the importance of appropriate follow up.
- Recommended by: Anand Swaminathan
Pediatrics Singleton T et al. Emergency department care for patients with hemophilia and von Willebrand disease. J Emerg Med. 2010; 39(2): 158-65. PMID: 18757163
- Bleeding always catches our attention in the ED… especially when it won’t stop. Von Willebrand disease is often encountered in the Peds ED. Make sure that the patient and their family don’t know more about it than you do.
- Recommended by: Sean Fox
- Read More: Von Willebrand Disease (PED EM MORSELS)
Emergency Medicine
Gorchynski J et al. The “Syringe” Technique: A Hands-Free Approach for the Reduction of Acute Nontraumatic Temporomandibular Dislocations in the Emergency Department. J Emer Med 2014. PMID: 25278137
- Reduction of temporomandibular joint (TMJ) dislocations is difficult, time consuming and often requires procedural sedation. This article describes a novel method for reduction of atraumatic TMJ dislocations in the ED. The “syringe” technique successfully reduced 97% (30/31) of dislocations. 77% (24/31) reductions were completed in less than 1 min. While this is not proof of superiority to other techniques, the time to reduction here is stunning and it’s always nice to have another arrow in the quiver
- Recommended by: Anand Swaminathan
Pediatrics Halm BM. Reducing the time in making the diagnosis and improving workflow with point-of-care ultrasound. Pediatr Emerg Care. 2013; 29(2): 218-21. PMID: 23546429
- Ok, so this isn’t hard core research, but I wanted to use it to highlight the fact that intussusception does not commonly present in the “classic” fashion and that by using point of care ultrasound, you can augment your physical exam to help diagnosis the condition in the child who presents with “altered mental status.”
- Recommended by: Sean Fox
- Read More: Intussusception & Altered Mental Status (PED EM MORSELS)
Resuscitation Heidlebaugh M et al. Full Neurologic Recovery and Return of Spontaneous Circulation Following Prolonged Cardiac Arrest Facilitated by Percutaneous Left Ventricular Assist Device. Ther Hypothermia Temp Manag. 2014. PMID: 25184627
- Case report of a novel solution to a patient who sustained intra-cardiac catheterization cardiac arrest. An Impella device (an intraventricular LVAD) was placed into the left ventricle to provide adequate forward flow. Case report only but may offer an alternative to ECLS.
- Recommended by: Cliff Reid
- Read More: Left Ventricular Assist Device for Cardiac Arrest? (RESUS.ME)
Emergency Medicine, Obstetrics Kline JA et al. Systematic Review and Meta-analysis of Pregnant Patients Investigated for Suspected Pulmonary Embolism in the Emergency Department. Acad Emerg Med. 2014; 21(9): 949-959. PMID: 25269575
- This systematic review and meta analysis looked at the literature (and gray lit) for pregnant patients undergoing work-up for pulmonary embolism, a cohort historically classified as high risk. The shocking take-home: we probably over-investigate PE in pregnant patients. The VTE rate in pregnant patients was 4.1%, compared with a rate of 12.4% in non-pregnant patients. The pooled RR of pregnancy VTE was 0.60 (95% CI 0.41-0.87) and patients of childbearing age (≤45 years) had RR 0.56 (95% CI 0.34-0.93). Of note, this study highlights the miniscule number of pregnant patients included in PE studies (n=506) and the tiny number of these who actually had VTE (n=29).
- Recommended by: Lauren Westafer
Education
Cheston CC et al. Social media use in medical education: a systematic review. Acad Med. 2013; 88(6): 893-901. PMID: 23619071
- Systematic review of social media in medical education. They found 12 studies, mostly small, a lot of reflective work. Good to see a growing evidence base for integrating FOAM into formal curricula.
- Recommended by: Seth Trueger
Resuscitation, Critical Care Gu WJ et al. Single-Dose Etomidate Does Not Increase Mortality in Patients with Sepsis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies. Chest 2014. PMID: 25255427
- Etomidate, once the only available induction agent for RSI in US Emergency Departments, has long been maligned for its transient adrenal suppression in spite of the absence of any detrimental patient oriented outcomes. This systematic review and meta-analysis including 18 studies (only 2 RCTs) and > 5,500 patients demonstrated no difference in mortality in septic patients. For now, at least, etomidate is a viable option as an induction agent in patients with sepsis.
- Recommended by: Anand Swaminathan
Emergency Medicine, Opthalmology Moradi P et al. Sudden pseudoproptosis. Emerg Med J 2013; 31(8): 624. PMID: 24136120
- Who knew there was such as thing as “Floppy eyelid syndrome”! Described in overweight middle-aged men. Interesting case with pictures described here. A disorder of unknown origin manifested by an easily everted, floppy upper eyelid and upper palpebral conjunctivitis. The upper eyelid everts during sleep, resulting in irritation, conjunctivitis and conjunctival keratinisation.
- Recommended by: Jeremy Fried
The R&R iconoclastic sneak peek icon key
| The list of contributors | The R&R ARCHIVE | ||
| R&R Hall of famer You simply MUST READ this! | R&R Hot stuff! Everyone’s going to be talking about this | ||
| R&R Landmark paper A paper that made a difference | R&R Game Changer? Might change your clinical practice | ||
| R&R Eureka! Revolutionary idea or concept | R&R Mona Lisa Brilliant writing or explanation | ||
| R&R Boffintastic High quality research | R |
The post Research and Reviews in the Fastlane 052 appeared first on LITFL.
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domingo, 12 de octubre de 2014
Why do doctors still use pagers?
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Why health insurance is the best business to be in
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A physician’s EMR wish list
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sábado, 11 de octubre de 2014
Breast cancer myths: No, antiperspirants do not cause breast cancer
Four weeks ago, I wrote a post in which I explained why wearing a bra does not cause breast cancer. After I had finished the post, it occurred to me that I should have saved that post for now, given that October is Breast Cancer Awareness Month. The reason is that, like clockwork, pretty much every year around this time articles touting various myths about breast cancer will go viral, circulating on social media like Facebook, Twitter, Pinterest, and Tumblr like so many giant spider-microbes on the moon on Saturday. Sometimes, they’re new articles. Sometimes they’re old articles that, like the killer at the end of a slasher film, seem to have died but always come back for another attack, if not immediately, then when the next movie comes out.
So I thought that this October I should take at least a couple of them on, although I can’t guarantee that I’ll stick to the topic of breast cancer myths for the whole month. After all, our “atavistic oncology” crank (you remember him, don’t you?) is agitating in the comments and e-mailing his latest “challenge” to my dean, other universities, and me. It was almost enough for me to put this post on hold for a week and respond to our insistent little friend’s latest “evidence,” but for now I’ll just tell Dr. Frank Arguello, “Be very careful what you ask for. You might just get it.” Maybe next week. Or maybe on my not-so-super-secret other blog. Or maybe never. Because Dr. Arguello has officially begun to bore me.
In the meantime, I’m going to stick with the original plan, at least for now.
So, first up this week is a myth that I can’t believe that I haven’t covered in depth sometime during the nearly seven years of this blog’s existence, other than in passing a couple of times, even though it’s a topic that deserves its own post. I’m referring to the claim that antiperspirants cause breast cancer. I bet you’ve seen articles like this oldie but not so goodie from über-quack Joe Mercola entitled Are Aluminum-Containing Antiperspirants Contributing To Breast Cancer In Women? or this older and even moldier article from seven years ago entitled Why women should avoid using anti-perspirants that could cause breast cancer or this one from last year entitled Attention Deodorant Users: New Studies Link Aluminum To Breast Cancer. Surprisingly, I haven’t found that many from this year yet. (Maybe the Ebola scare is distracting the usual suspects and diverting their efforts.) The same ones, however, keep reappearing every year, and they’re all based on the same sorts of claims and the same studies. So let’s dig in, shall we?
Spaced…1999
It all began, at least as far as it is possible to figure out the precise origin of any recurring myth about health, with an e-mail dating back to 1999, as described on Snopes.com:
BREAST CANCER PREVENTION
Not just for women — men don’t forget to tell mom, cousins, etc. Deodorants (non-antiperspirants) are very hard to find but there are a few out there.
I just got information from a health seminar that I would like to share.
The leading cause of breast cancer is the use of anti-perspirant.
What? Yes ANTI-PERSPIRANT. Most of the products out there are an anti-perspirant/deodorant combination so go home and check your labels.
Deodorant is fine, anti-perspirant is not. Here’s why:
The human body has a few areas that it uses to purge toxins; behind the knees, behind the ears, groin area, and armpits. The toxins are purged in the form of perspiration.
Anti-perspirant, as the name clearly indicates, prevents you from perspiring, thereby inhibiting the body from purging toxins from below the armpits. These toxins do not just magically disappear. Instead, the body deposits them in the lymph nodes below the arms since it cannot sweat them out. This causes a high concentration of toxins and leads to cell mutations: a.k.a. CANCER. Nearly all breast cancer tumors occur in the upper outside quadrant of the breast area. This is precisely where the lymph nodes are located.
Additionally, men are less likely (but not completely exempt) to develop breast cancer prompted by anti-perspirant usage because most of the anti-perspirant product is caught in their hair and is not directly applied to the skin. Women who apply anti-perspirant right after shaving increase the risk further because shaving causes almost imperceptible nicks in the skin which give the chemicals entrance into the body from the armpit area.
PLEASE pass this along to anyone you care about. Breast Cancer is becoming frighteningly common. This awareness may save lives. If you are skeptical about these findings, I urge you to do some research for yourself. You will arrive at the same conclusions, I assure you.
The origin of this myth is rooted in a typical misunderstanding of biology that regular readers probably recognized immediately, namely the issue of “toxins.” It is simply not true that apocrine sweat glands (the variety of sweat gland that are found predominately under the arm and in the groin area that can produce substances that the bacteria on the skin feast upon to make the characteristic stinky aroma) are a major source of “detoxification,” nor is there any compelling evidence that blocking these sweat glands, which is how aluminum-containing antiperspirants tend to work, results in the accumulation of “toxins” under the arm. There’s also another misunderstanding here. If, as is described, nicks from shaving the armpit allow the evil chemicals from the antiperspirant to get in, what would be far more likely to happen than what this e-mail assumes is either that (1) the chemicals would get into the bloodstream and disperse throughout the body, highly diluted, or (2) the chemicals would remain in the dermis (the layer of the skin immediately below the epidermis, which is usually all that is nicked by shaving). In the case of #2, let’s just put it this way: If the skin was cut all the way through the dermis that would be one hell of a cut. Also, with the use of modern safety razors, a cut that goes more than just a little bit into the dermis is highly unlikely. So, if #2 were true, we’d expect an elevated risk of skin cancer in the area, not breast cancer, because there is no plausible mechanism by which the evil chemicals from the antiperspirant to get much beyond the dermis, much less to accumulate in the breast tissue. Given that the apocrine sweat glands are located in the subcutis or at most the superficial subcutaneous fat, the same would be true even if antiperspirants caused toxins that would otherwise escape through sweat to be bottled up in the sweat gland.
So, right off the bat, we see a plausibility problem to this hypothesis. Of course, we’re not talking homeopathy-level implausibility here, but it’s hard to imagine a logical, science-based mechanism whereby antiperspirants could lead to a highly elevated risk of breast cancer in just one quadrant, the upper outer quadrant, of the breast.
But what about the claim that “nearly all” cancers occur in the upper outer quadrant of the breast and the observation that that is “precisely where the lymph nodes are located.” Well, yes and no. First off, this observation seems to be confusing sweat glands and lymph nodes, as though blocking off sweat glands would cause backups of those mysterious, never identified “toxins” in the lymph nodes. They’re two different things, and lymph nodes are not connected to the sweat glands, as this e-mail (and many articles claiming that antiperspirants cause breast cancer) seem to assume.
Also, it is not true that “nearly all” breast cancers are in the upper outer quadrant (the quadrant closest to the armpit), although it is true that there is a propensity for breast cancer to appear there first. Why is this? The reason you will frequently see cited is that most breast cancers occur in the upper outer quadrant of the breast. Because that quadrant of the breast is closest to the underarm, which is where antiperspirants are used, it must be the antiperspirants! And global warming is most definitely due to the decreasing number of pirates over the last three centuries. In fact, it is true that a little more than half of all breast cancers develop first in the upper outer quadrant of the breast, but it’s not because of antiperspirant use. It’s just because of a very simple fact of anatomy. Contrary to what people intuitively think when they hear the word “quadrant,” the distribution of breast tissue is not equal among the quadrants. In other words, each quadrant does not contain one-quarter of the breast tissue making up that breast. Rather, there is much more breast tissue in the upper outer quadrant than there is in other quadrants of the breast, because of a part of the breast known as the “axillary tail” or the “tail of Spence,” which consists of breast tissue extending toward the underarm. It turns out that the number of breast cancers diagnosed in the upper outer quadrant is proportional to the amount of breast tissue located there. There is no preponderance for upper outer quadrant cancers when the distribution of breast tissue in the different quadrants is taken into account.
The best evidence for a link is not so good
To me, the poor quality of evidence cited to support such a link between antiperspirants tends to be epitomized by an article that was being touted a few years back by Sharyl Attkisson. (You remember Sharyl Attkisson, don’t you?) At the time, she was touting an article by Dr. Kris McGrath in Medical Hypotheses, whose speculative nature and lack of peer review has been discussed elsewhere. I’ll start with this evidence and then work my way up to the best evidence cited by proponents of an antiperspirant-breast cancer link.
The evidence first cited is a study by McGrath in which he investigated a group of women with breast cancer and reported that the sooner they began using antiperspirants in their youth, the more frequently they used them, and the more frequently they shaved under their arms, the earlier they were diagnosed with breast cancer. Unfortunately this study was not very convincing. Besides being a retrospective study prone to recall bias, it had an enormous flaw in it, a flaw so obvious that I’m surprised this article got published. There was no control group. It’s a single-arm study that only looked at women who got breast cancer, and it didn’t control for a variety of confounders. For instance, women who started using antiperspirants or shaving earlier probably went through puberty earlier and, as a consequence, had their first menstrual period earlier. Starting menses early is a risk factor for breast cancer that has been known for a very long time. Ditto women who started shaving their underarms earlier. Worse, another, much better designed study that did look at women both with and wtihout cancer (and twice as many of each) had been published the year before and found no correlation between the the use of antiperspirants and the risk of breast cancer.
According to McGrath, underarm antiperspirants clog the pores of apocrine sweat glands and cause the absorption of sex steroids into the blood. It’s a hypothesis that sounds very much like the one in the e-mail in which clogging the pores results in unnamed “toxins” backing up, just substituting sex steroids for “toxins.” It’s a pretty implausible hypothesis at best. The reason is that the amount of sex hormones made by the skin is dwarfed by what is made by the ovaries. Indeed, one of the main enzymes responsible for the production of estrogen in the peripheral tissues is aromatase. In the treatment of breast cancer, aromatase inhibitors don’t work in premenopausal women. The reason is that the ovaries of premonopausal women are still cranking out estrogens, which far outweigh the amount of estrogen produced in peripheral tissues. That’s why aromatase inhibitors are only used in postmenopausal women, where the ovaries have in essence shut down, leaving the aromatase in peripheral tissues as the only source of estrogen, which aromatase inhibitors shut down quite nicely. From a biological standpoint, it’s highly implausible that blocking the apocrine sweat glands can lead to a backup of sex hormones and their absorption into the breast tissue at concentrations sufficiently high compared to the normal levels made by the ovaries in women and the testicles in men.
Of course, “implausible” doesn’t mean “impossible,” and McGrath’s concept, although quite implausible biologically, is not as implausible as, say, homeopathy or reiki. However, because of its implausibility, it would take some pretty compelling evidence to make us as scientists reconsider our understanding of the biology. So does McGrath have compelling evidence or even highly suggestive evidence? Let this graph from the his Medical Hypotheses paper speak for itself:
It’s very similar to this figure from the previous paper:
These are plots of antiperspirant sales in the U.S. versus the incidence of selected cancers, including prostate, breast, and a couple of others. Doe this remind you of anything? Oh, this, maybe? It’s a beautiful example of the fallacy of confusing correlation with causation. It’s also amazingly sloppy in that the incidences of breast and prostate cancer were clearly increasing for at least two decades before the sales of antiperpirant started to take off, and antiperspirant sales have been increasing far faster than the cancer incidence rates shown. I also wonder if there was any attempt to control for common confounders, like age of menarche and number of live births per woman. Early age at menarch, increasing age of first childbirth, and decreasing numbers of children and up to nulliparity, all correlate with a higher risk of breast cancer. Regarding these factors, what have three major trends been over the last century? Earlier age of menarch, fewer children per woman, and an older age at first childbirth. Add to that the use of hormone replacement therapy during the 1980s and 1990s, and there are multiple huge confounders far more likely to explain the increasing incidence of breast cancer not even addressed in McGrath’s hypothesis.
OK, what else do we have?
Well, Joe Mercola referenced a couple of studies in his little bit of viral breast cancer fear mongering. Specifically, if you believe Mercola, it’s supposed to be the aluminum:
Research, including one study published this year in the Journal of Applied Toxicology, has shown that the aluminum is not only absorbed by your body, but is deposited in your breast tissue and even can be found in nipple aspirate fluid a fluid present in the breast duct tree that mirrors the microenvironment in your breast. Researchers determined that the mean level of aluminum in nipple aspirate fluid was significantly higher in breast cancer-affected women compared to healthy women, which may suggest a role for raised levels of aluminum as a biomarker for identification of women at higher risk of developing breast cancer.
The report discussed was a small pilot study of 35 patients, 16 with breast cancer and 19 with no cancer. While the results are somewhat provocative, it is important to remember that (1) the study was small and (2) the significance of the results remain unknown. More importantly, there were a lot of confounding factors not controlled for. For example, presumably both women with breast cancer and those without in the study there was no serious attempt to control for confounding factors or to quantify the use of aluminum antiperspirants. Indeed, there are significant differences between the two groups. For example, the median age of the cancer group was 56, while it was 40 for the no cancer group. Perhaps something as simple as age could account for the difference. Does something happen after menopause leading to increased accumulation of aluminum from the natural exposure that we all have? Who knows? No analysis was done. Another possibility is that breast cancer might somehow accumulate aluminum more than normal tissue.
In other words, the study tells us absolutely nothing about whether or not aluminum-containing antiperspirants contribute to breast cancer risk.
Mercola’s next red herring is this:
In a 2007 study published in the Journal of Inorganic Biochemistry, researchers tested breast samples from 17 breast-cancer patients who had undergone mastectomies. The women who used antiperspirants had deposits of aluminum in their outer breast tissue. Concentrations of aluminum were higher in the tissue closest to the underarm than in the central breast.
Why is this a glaring red flag?
Aluminum is not normally found in the human body, so this study was a pretty clear sign that the metal was being absorbed from antiperspirant sprays and roll-ons. Please note that aluminum is typically only found in antiperspirants. If you are using a deodorant-only product it is unlikely to contain aluminum but might contain other chemicals that could be a concern.
Aluminum is not normally found in the human body? Did Mercola even read any of the articles he cited? The first article in and of itself demonstrated that aluminum is found in measurable quantities in normal human breast tissue nipple aspirates. Its finding was simply that it was found at higher levels in breasts with cancer. Then, the second article that there were detectable levels of aluminum in normal breast tissue, too! Again, what it purported to find was that there was more aluminum in areas of the breast closer to the underarm.
Here’s the study. Basically, in the study Exley et al measured aluminum content in mastectomy specimens taken from 17 women with breast cancer. Four biopsies were taken, one from each quadrant, and measured the aluminum content. Suffice to say, there were huge variations between the concentration of aluminum in the fat and the breast tissue between individuals, so much so that, looking at the evidence, I can’t see a clear difference. The authors claim they found a “statistically higher concentration of aluminium in the outer as compared with the inner region of the breast” even though their statistics showed that there was not. Meanwhile, a followup study by the same group from 2013 found “no statistically significant regionally specific differences in the content of aluminium” and found that the concentrations of aluminum in patients with breast cancer were “comparable with those reported in non-diseased human tissues from other areas of the body.”
In a recent review article, Exley, try as he might, just can’t seem to develop a compelling case for the involvement of aluminum from antiperspirants (or anywhere else, for that matter) in increasing breast cancer risk. In another recent review article, Pineau et al emphasize in vitro results but downplay the negative epidemiological and pathological evidence. Yes, aluminum might increase proliferation in MCF10A cells, which, contrary to what is claimed are not exactly “normal” (I’m well familiar with this cell line) and MCF-7 breast cancer cells, but there’s no compelling evidence that this has any relevance to the real world, given that there is no compelling evidence from epidemiology, pathology, and toxicology studies linking aluminum-containing antiperspirants with breast cancer. Moreover, there is good evidence that there is no correlation between the use of antiperspirants and breast cancer, and a comprehensive literature review failed to find convincing evidence of a link, concluding, “After analysis of the available literature on the subject, no scientific evidence to support the hypothesis was identified and no validated hypothesis appears likely to open the way to interesting avenues of research.”
In other words, although it’s possible that there is a link between antiperspirants and cancer, current existing evidence doesn’t support one and doesn’t even suggest potentially fruitful avenues of research.
But what about parabens?
Of course, unlike the case among antivaccinationists, where aluminum fears supplanted mercury fears, in terms of breast cancer aluminum fear mongering is old school. New school is parabens. Parabens are hip. They’re now. They’re happening. In fairness, on the surface, there appears to be more of a reason to suspect them as potentially contributing to breast cancer than there is to suspect aluminum-containing antiperspirants. That’s not saying that there’s a compelling reason to suspect them, only that there is a modicum of plausibility. Parabens is a term used to describe a series of parahydroxybenzoates or esters of parahydroxybenzoic acid (also known as 4-hydroxybenzoic acid), chemicals most commonly used as preservatives by the cosmetic and pharmaceutical industries because of their bactericidal and fungicidal properties. They’re found in a variety of products including shampoos, commercial moisturizers, shaving gels, personal lubricants, topical/parenteral pharmaceuticals, spray tanning solution, makeup, and toothpaste. Most major brands of antiperspirant are paraben-free these days, but that doesn’t stop them from being examined as a cause of breast cancer. Typical of such articles is one by—you guessed it!—Joe Mercola entitled Parabens: 99% of Breast Cancer Tissue Contained This Everyday Chemical (NOT Aluminum):
The featured study by Barr et.al. discovered one or more paraben esters in 99 percent of the 160 tissue samples collected from 40 mastectomiesiii. In 60 percent of the samples, all five paraben esters were present. There were no correlations between paraben concentrations and age, length of breast feeding, tumor location, or tumor estrogen receptor content. The median values in nanograms per tissue for the five chemicals were:
- n-propylparaben 16.8
- methylparaben 16.6
- n-butylparaben 5.8
- ethylparaben 3.4
- isobutylparaben 2.1
While antiperspirants are a common source of parabens, the authors note that the source of the parabens cannot be established, and that 7 of the 40 patients reportedly never used deodorants or antiperspirants in their lifetime. What this tells us is that parabens, regardless of the source, can bioaccumulate in breast tissue.
The study to which Mercola refers is this one by Philippa Darbre at the University of Reading. It’s one of multiple followup studies to a study by Darbre from 2004 that is thought to have started the concern about parabens. Basically, it measured the concentration of parabens in samples of 20 human breast tumours using high-pressure liquid chromatography followed by tandem mass spectrometry and found measurable parabens concentrations in all of them, with a mean of approximately 20 ng/g tissue. As noted by Joe Schwarcz, at the time the study received extensive press coverage, with few stories mentioning that there was no control group, making the significance of this observation unclear. That didn’t stop Darbre from promoting the idea that parabens cause breast cancer by pointing out that these chemicals have estrogen-like activity and that such activity has been linked to breast cancer. Since 2004, Darbre has built her career on doing studies trying to demonstrate that parabens and endocrine disrupters cause breast cancer, as a perusal of her PubMed publication list will easily demonstrate. She’s also co-authored articles examining aluminum-containing antiperspirants and breast cancer.
So, it would seem, we have a chemical that is widely used as well as a seemingly plausible mechanism (estrogenic activity) to cause breast cancer. There’s a problem, though. As Schwarcz, who is a chemist, also pointed out:
What she failed to mention was that the estrogenic activity of the various parabens is thousands of times less than that of estrogenic substances found in foods such as soybeans, flax, alfalfa and chickpeas, or indeed of the estrogen produced naturally in the body.
The study cited by Mercola was just the latest of her studies at the time. It suffers from the same sorts of problems as her 2004 study, although these problems are better hidden because more breast specimens were used and there was an attempt to correlate the parabens levels with location in the breast. One notes that, consistent with the 2004 study, Darbre found that every single breast specimen had detectable levels of parabens, even patients who didn’t use antiperspirants. I also note that “no direct, formal adjustment to the significance levels of the multiple Friedman ANOVA analyses has been made,” which makes me wonder about the actual statistical significance of the differences reported, particularly since the differences were so small and Darbre reports ANOVAs for each paraben, resulting in five different comparisons of four breast regions, one for each of the five parabens examined. For example:
Notice how small the differences are in general and how only one of the five parabens shows a statistically significant difference. The whole paper is like that, with multiple comparisons galore for the five parabens. Even though Darbre used an ANOVA, which is designed for multiple comparisons, for each paraben, she didn’t correct for the multiple ANOVA comparisons she did for each experiment. My guess is that, if she did, her statistically significant findings would disappear. Then there’s her observation that parabens levels did not correlate with tumor location, which rather argues against a correlation between parabens and breast cancer development. Most recently, Darbre has published an in vitro study of the effect of long term exposure (20 weeks) to parabens on the migration of breast cancer. It’s not clear to me how relevant these findings are to much of anything, given the lack of clinical evidence to demonstrate the relevance. None of this stops her from handwaving away all the problems with her studies and doing what, for example, antivaccinationists do when confronted with negative results: Invoke “individual susceptibility” without evidence for it.
Conclusion
Given how difficult it is in science ever to prove a negative beyond a doubt, it’s not impossible that something in antiperspirants, be it aluminum or parabens, might contribute to breast cancer development. However, given the existing state of the scientific evidence, it seems incredibly unlikely that there is a causal relationship here, given that no one has yet been able to convincingly demonstrate even a correlation. It’s certainly not for lack of trying. Indeed, scientists convinced of this hypothesis sometimes go to ridiculous extremes to show a “correlation,” as McGrath did in the graphs above.
Unfortunately, by far the most powerful predictors of breast cancer risk are not environmental. They are related to genetics (family history) and biology (age at menarche, age at menopause, number of live births, age at first live birth, breastfeeding, etc.). Lifestyle and environmental factors play a much less significant role, with protective effects due to exercise (for instance) or increased risk due to alcohol consumption (also for instance) producing much smaller effects than the previously mentioned risk factors and protective factors. None of this means that we shouldn’t study environmental risk factors for breast cancer, but it does mean that we should be cautious about spending too much time studying factors lacking strong biological plausibility when the studies aren’t yielding strong evidence of a correlation with breast cancer despite considerable effort to show a link.
It’s a matter of prioritization. Existing evidence is sufficient to conclude that there is no strong link between antiperspirant use and breast cancer and that there is very likely not even a weak link. Given such findings, it is appropriate to move on to other, more promising, avenues of research regarding environmental and lifestyle risk factors for breast cancer. This one’s been investigated and not found to be important.
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viernes, 10 de octubre de 2014
Treating Ebola patients in Uganda: The dilemma of a doctor’s touch
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Why are so many people opposed to epidurals?
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Proton beam therapy: We need more than informed hope on social media
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It’s time to talk trade-offs in health care
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jueves, 9 de octubre de 2014
Media deprivation for children: Are parents doing the right thing?
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A national referendum on single-payer: What if it happened?
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Two-tiered generic drugs will lower quality of care
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miércoles, 8 de octubre de 2014
Acne Scars: Treaments and Causes – By Dr. Melvin Elson
As previously mentioned, acne is the most common cause of scars in the world. Basically, regardless of cause there are 2 types of acne scars. Distensible scars are those that if you pull on the skin on either side, they smooth out. Ice-pick scars are not distensible and do not move. The edges of these are very hard.
Although, there are topical agents that claim to decrease acne scars and shrink pores, there is no such thing. Those products that claim to shrink pores actually merely clean out some of the plug in the oil glands and the glands appear smaller. Basically all the treatment s for acne scars are surgical in nature.
Acne Scars Explained
If the scars are distensible, filling materials such as Restylane, Juvederm or Belotero can be used to smooth them out. If the scar is one of the ice pick type it is necessary to either cut the collagen underneath the scar and let the scar fill in or to cut it out and replace with a piece of skin from behind the ear. Obviously, the number of scars determines whether or not any or some of these types of procedures can be used.
To make the skin appear a little smoother a chemical peel can be done with salicylic acid, which gets into the oil gland and removes some of the plugs and makes the surface of the skin appear smoother. Microdermabrasion does not help with acne scars, despite some of the marketing being done.
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A health care story that you normally don’t see in the media
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The problem with primary care residency programs
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Acne Treatments and Causes – By Dr. Melvin Elson
Although there are many types of acne, the one we will consider is the most prevalent in the world and that is acne vulgaris. It occurs in approximately 90% teenagers, both male and female and is the most common cause of scars in the world. Most patients are either self-treated and the problem remits spontaneously or see the family physician or pediatrician. Only a small amount actually end up seeing dermatologists.
The cause of the problem is the formation of a plug in the pilosebaceous unit or oil gland hair follicle complex. These are located on the face, chest, neck and back and that is why there is no acne of the leg etc. The first thing that occurs is a plug in this complex that cuts off the oxygen supply to the area and there is an organism that lives there called p. acnes, that begins to overgrow in this environment and starts the process to the swelling and the pus and eventually can lead to scarring.
What produces Acne?
The primary cause of this thick plug occurring is male hormone—both in girls and boys and a few things play minor roles. Emotions make it worse by having more blood to flow to the face. There is some newer evidence that high carbohydrates may play a role, but chocolate does not. Acne is also not because you are dirty and washing the face many times a day may aggravate it by irritation. Manipulation with the fingers will only make it worse.
Once acne occurs there are a few important items to be taken care of: destruction of p acnes, unplugging the oil gland and treating any scars that may have formed. There are many good methods to treat acne without having to see a physician. One of the best products on the market is ProActive. It does work in most of the cases of acne that it is tried. It contains many of the ingredients you would get from a doctor’s office. One thing you should be careful about is that it contains benzoyl peroxide and may stain cloth—so be careful not to spill.
And how I can cure it?
Dermatologists often use antibiotics either on the skin or by mouth to kill the bacteria in addition to the cleansers and other topicals. One of the most effective procedures in the office is the salicylic acid peel. This particular peel has more ability to get into the oil gland and loosen the plug than any other. the only contraindication is that you cannot have one if you are allergic to aspirin. Another common procedure performed in the office is removal of blackheads and whiteheads (often performed by an aesthetician).
These methods almost always respond to therapy, clear the acne and keep it from scarring. But there are much more complicated therapies from using light and lasers to oral contraceptives to other medications by mouth. One medicine you should be cautioned about is Accutane, which actually has been removed from the market by the FDA because of side-effects. Unfortunately, some doctors get the drug from out of the country and still use it. If you have a doctor that is doing this be certain that he gets blood work every 2 weeks, makes sure you are on birth control pills and follows you closely in terms of depression or diarrhea or other symptoms.
With these modern method to treat acne acne almost always clears, but that does not preclude the fact that patients can develop some significant scars from this disease. In the next communcation I will discuss with you what type of acne scars occur and how they can be treated.
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How pay for performance leads to overdiagnosis and overtreatment
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The Miracle Cure for Everything
One common feature of pseudoscience is that proponents of a specific belief tend to exaggerate its scope and implications over time. In the world of physics this can eventually lead to a so-called “theory of everything” – one unifying theory that explains wide-ranging phenomena and displaces may established theories.
In medicine this tendency to exaggerate leads in the direction of the panacea, the miracle cure for everything. Why does this happen?
There are numerous examples. Here is a video of Bruce McBurney trying to sell his Precious Metals Nano Water to investors in the Dragon’s Den. The product is nothing but distilled water with a tiny amount of silver. McBurney claims that this magic water will essentially cure everything, all bacterial and viral infections, and even cancer.
The panacea is also not the sole domain of the lone crank. Straight chiropractors essentially believe that adjusting the spine can cure everything from bed wetting to asthma, and yes, even cancer.
What factors predispose to the panacea claim?
Theory of Everything
The cure for everything is partly related to the theory of everything. If all disease is caused by blockages in the flow of life energy through the spine, then all disease can be cured by adjusting the spine. In the case of Hulda Clark, all disease was allegedly caused by the liver fluke, and so treating that nasty scourge on humanity could therefore cure all disease.
In the era before science, when medical treatments were based on philosophy rather than an empirical understanding of the world, this approach was unavoidable. Galenic medicine believed that health and illness was a matter of the balance among the four humors, and so all conditions could be treated by bloodletting or purging. The Eastern version of this used acupuncture and cupping for bloodletting, which in the early 20th century was reworked as using needles to balance the life force.
Chiropractic and acupuncture have a similar history in that they began as healthcare theories of everything, but in the era of science are desperately clinging to legitimacy by claiming they improve subjective symptoms, those most amenable to placebo effects. Still, they retain their true believers, such as medical acupuncturists who will treat anything with acupuncture.
The scientific approach to health and disease has moved in the opposite direction from the theory of everything. The more we learn about the complexities of the human body, the more we discover all the many different ways that health can be affected. Every aspect of the biological machine can break down or not work optimally, causing illness. Causes may include genetic, traumatic, neoplastic, nutritional, degenerative, infectious, autoimmune, toxic, metabolic, environmental, biochemical, or physiological.
Modern medical theories of everything are maintained in two basic ways. The first is simply to deny modern science and everything that has been discovered about health and disease. This requires a profound level of scientific illiteracy, but this is unfortunately not uncommon.
The second method is to argue that, even though there may be many causes of disease, the body has an unlimited ability to heal itself. One thing keeps the body from perfectly healing itself, and so if you treat that one thing, self-healing will be restored – no matter what the problem. This is, for example, the subluxation theory of chiropractic. Subluxations block the flow of innate that, unhindered, would heal whatever ails you. This is precisely why alternative practitioners frequently tout that their treatments promote or enhance self healing.
Lack of Scientific Process
Even without the alternative philosophical underpinnings, there is a tendency for dubious treatments to undergo indication creep over time. A treatment that starts out being used for one specific indication has a growing list of conditions it can treat or cure, even conditions with very different real underlying causes.
This happens because the process that is being used to determine if the treatment works is flawed in the first place. Typically unscientific treatments are based upon anecdotal evidence, which is susceptible to placebo effects. Proponents are not being skeptical, nor are they conducting the kinds of studies that are capable of showing that the treatment does not work.
In fact the process they use is designed to show that the treatment does work. Therefore, no matter what they try it for, it will seem to work. They may naively come to believe that it works for everything. In some cases they may then backfill an explanation for why it works for everything, leading again to the theory of everything.
Essentially, if your beliefs and claims are disconnected from reality by the absence of a skeptical scientific process of investigation, then those beliefs will tend to drift off further and further into fantasy land.
Marketing
The final major factor is the simplest – marketing. If you have a product to sell, you want that product to have as wide a market as possible. In medicine this means as many indications for your treatment as possible. In fact, why limit your market at all. If your treatment works for every indication in every population, then you have maximized your potential customer base.
This does not necessarily mean that those selling panaceas are always knowingly lying, although in some cases that certainly seems to be true. Rather, there is a spectrum. There is a powerful motivation to believe that your treatment has wide ranging implications. If you discover a treatment that is effective for some cases of athletes foot, that is an achievement and might even be highly profitable. But if you discover the treatment for all infections, or all cancers, or all human disease, then you should become world famous and fabulously wealthy. This is a powerful motivation to believe.
Even legitimate scientists fall prey to the allure of believing their discovery is bigger than it actually was. They have the rest of the scientific community to give them a reality check.
Companies also are highly motivated to exaggerate the indications and effectiveness of their products, and they need effective regulations that require scientific evidence to keep that trend in check.
In the world of alternative medicine and supplements, there is no reality check. The tendency to exaggerate claims is therefore unimpeded.
Conclusion
We have warned often on Science-Based Medicine to beware the “one cure for all disease.” The greater the claims for any treatment, the more improbable those claims become, and the greater should be the level of skepticism.
Biology is complex, and diseases have many causes. It is highly improbable that any one treatment will address a significant portion of human illness. Skepticism should also be high for any intervention that is claimed to address diseases or disorders that seem to have very different causes.
The “self healing” gambit, while appealing, is also not realistic. Our bodies do have some ability to heal themselves. This ability to fight off infection, heal wounds, and compensate for illness can keep us going for many decades. The various systems of the body, however, break down in many ways, may be overwhelmed by an infection, can suffer trauma, or may have been suboptimal in the first place (such as with a genetic mutation). Entropy always wins out in the end.
We do not have an infinite ability to keep ourselves forever in perfect health. This is a religious belief that runs contrary to overwhelming scientific evidence. It’s a seductive belief, however.
The reality check of science may be disappointing to our emotional desires, but at the same time it has given us the actual ability to prolong life and improve quality of life significantly. I personally would never trade the hard-won knowledge of science for the comforting fictions of the cure-all.
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martes, 7 de octubre de 2014
Narrow networks on the health care exchanges: Can they survive?
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I will build a practice, but I will also build a life
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The public perception of oncologists: Is it really true?
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Do we really need soda companies to cut calories for us?
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Chaperones Needed
I receive a monthly newsletter from my medical board. Among other issues discussed are the results of disciplinary actions for physicians. Occasionally a physician who has boundary issues is required to have a chaperone present when doing exams.
I was thinking that the concept of a chaperone could be more widely applicable. Consider “You Docs: Amazing acupuncture,” the latest from Drs Oz and Roizen. Both are Professors at their respective institutions. Professors. To judge from the ability to read and interpret the medical literature, both should not be allowed near a journal without a chaperone to remind them about cognitive biases, logical fallacies and what constitutes a good clinical study. Looking at their recent review of acupuncture suggests they lack an understanding of all three.
They start with the argument from antiquity, which is not only wrong as a logical fallacy, it is wrong historically when they say:
acupuncture has been a go-to therapy for 5,000 years.
Off by a factor of about 500. They are unaware that acupuncture as currently practiced is relatively new, having been a form of bloodletting until recently when the modern version with steel needlesbecame popular under Mao.
However, in the early 1930s a Chinese pediatrician by the name of Cheng Dan’an (承淡安, 1899-1957) proposed that needling therapy should be resurrected because its actions could potentially be explained by neurology. He therefore repositioned the points towards nerve pathways and away from blood vessels-where they were previously used for bloodletting.
They explain the mechanism of action as stimulating
points in the body that affect chi or qi, the life energy.
without noting that chi or qi is a fantasy. No life energy has ever been measured and virtually every point on the body is an acupoint in one of the multiplicity of styles that are acupunctures. Except, as mentioned in the past, the genitals.
And they are unaware of the fact that the concept of qi and meridians has more to do with the inventions of Soulié de Morant, a Frenchman of the 1930s, who popularized acupuncture in Europe and that de Morant’s
claims about acupuncture, and the lore of energy meridians and qi, are founded on sloppy translations, misconceptions, or even pure forgery.
They proceed to the appeal to popularity noting that singer Alicia Keys and bike racer Vincenzo Nibali use acupuncture and
North Americans being needled jumped from 2 million in 2002 to more than 14 million in 2007.
I have found that entertainers are not a good source of information for my health care. Rob Schneider and Jenny McCarthy have not been optimal for vaccine advice or TV physicians for dietary supplement advice. The popularity of vaccine refusal has only been good for the spread of whooping cough, measles and mumps. So perhaps the wisdom of the celebrities and the crowd may not be the most reliable source for other health information.
But, they note, the WHO recommends acupuncture for a wide variety of illnesses:
The World Health Organization says acupuncture may help ease digestive problems like constipation and diarrhea; chronic sinus and lung infections; all sorts of pain, from headaches and migraines to neck pain, back pain and osteoarthritis; infertility; and even urinary and menstrual problems.
That weasel word: may. Come to me with pneumococcal pneumonia and there’s no ‘may’ about it. I’ll cure you. Perhaps using acupuncture for lung infections explains why it is the third and fourth most common cause of death in the world.
Here is a problem with newspaper articles: no references. So I have to guess what references the You Docs are using. I suspect they are referring to the 1996 WHO report, described as a
highly flawed pro-acupuncture piece of propaganda, not a scientific review of evidence. It was worthless in 1996, and now it has the added burden of being outdated.
It is a truly appalling work, ignoring prior plausibility, minimizing risks, and also suggesting acupuncture for convulsions in infants, colour blindness (?!?), closed head injury, and progressive bulbar and pseudobulbar paralysis among other diseases. I am sure Dr. Oz will have the courage of his convictions and use acupuncture in lieu of bypass surgery, should he ever need it. The WHO recommends it after all.
They mention that Dr Mike, the Chief Wellness Officer at the Cleveland Clinic (with concerning difficulties counting as “there are more than 10 certified acupuncture practitioners in the Wellness Institute’s Center for Integrative Medicine”. That would be a number greater than 11 and less than infinity and that represents a lot of acupuncture being done at the Cleveland Clinic) has found
good evidence that it works to ease gastroesophageal reflux, nerve pain and post-surgery pain.
Now if good evidence is small, unblinded, non-placebo controlled trials, then yeah, there is good evidence for gastroesophageal reflux, and nerve pain
Despite the number of trials of manual acupuncture for DPN and their uniformly positive results, no clinically relevant conclusions can be drawn from this review due to the trials’ high risks of bias and the possibility of publication bias.
8 relevant papers were identified. One was an experimental study which showed that electroacupuncture suppressed CIPN pain in rats. In addition, there were 7 very heterogeneous clinical studies, 1 controlled randomised study using auricular acupuncture, 2 randomized controlled studies using somatic acupuncture, and 3 case series/case reports which suggested a positive effect of acupuncture in CIPN. Conclusions. Only one controlled randomised study demonstrated that acupuncture may be beneficial for CIPN. All the clinical studies reviewed had important methodological limitations.
The meta-analysis showed positive results for acupuncture treatment of pain after surgery in terms of the visual analogue scale (VAS) for pain intensity 24 hours after surgery, when compared to sham acupuncture (standard mean difference -0.67 (-1.04 to -0.31), P = 0.0003), whereas the other meta-analysis did not show a positive effect of acupuncture on 24-hour opiate demands when compared to sham acupuncture (standard mean difference -0.23 (-0.58 to 0.13), P = 0.21).
Although there are many postoperative acupuncture pain studies with variable results, the preponderance of literature and high quality studies suggests no efficacy. But the Cleveland Clinic is not a bastion of Science-Based Medicine.
If I am trying to decide on a restaurant or a new pair of shoes I pick ones I tried and enjoyed in the past or have good reviews. When it comes to health care I am a bit more selective in my criteria. I want what is effective in the best clinical trials. For the You Doctors the criteria is
if you’re one of the folks who like the idea (of acupuncture), and the treatments work for you
try it and offer the following as support.
It’s a pain soother: In a new University of California San Diego study, after 31 kids (ages 2 to 17) had tonsillectomies, acupuncture muted their throat aches within minutes.
Retrospective, not blinded, no sham acupuncture, conducted by a clinician who is a believer.
The reported benefits of L14 stimulation is reinforced by the author’s own personal clinical acupuncture experience.
No opportunity for researcher bias here, is there?
A hot-flash cooler: A new review of 12 studies involving 869 menopausal women concludes that acupuncture reduces the number and intensity of this annoying menopause symptom.
Take Effects of acupuncture on menopause-related symptoms and quality of life in women on natural menopause: a meta-analysis of randomized controlled trials. There is no reason what-so-ever to suspect that acupuncture would do anything for hot flashes, certainly not by classical Chinese Medicine theory of nonexistent chi and meridians. An article suggests
…that acupuncture caused a reduction in the concentration of β-endorphin in the hypothalamus, resulting from low concentrations of estrogen. These lower levels could trigger the release of CGRP, which affects thermoregulation.
Acupuncture aficionados love to point to endorphin release secondary to sticking someone with a sharp piece of metal for many of the alleged effects of acupuncture. It is much to do about nothing, and would not explain how the ever so laughable laser acupuncture and acupressure would have the same effects. They included many types of acupuncture, some mutually exclusive, in the study:
traditional Chinese medicine acupuncture (TCMA), acupressure, electroacupuncture, laser acupuncture and ear acupuncture.
The mappings in the ear for ear acupuncture are not the same as traditional Chinese acupuncture. But there is no acupuncture, but rather acupunctures plural, as many as there are practitioners, since there is zero standardization of diagnosis and practice of the many forms of this pseudo-medicine.
If you are a Bayesian kind of gal, you would understand that if an intervention has no prior plausibility, then any likely positive results are likely false positives and due to bias.
And the study suggests that any and all positive effects are due to poor methodology and bias. As a rule, effects of pseudo-medical interventions such as acupuncture only have effects for subjective, not objective, endpoints, and the number and intensity of hot flashes is a subjective endpoint.
Key to any clinical trial: if an intervention is no different from placebo, IT DOESN’T WORK. Sorry I shouted. The effect on hot flash frequency or severity appeared to be linked to the number of treatment doses, number of sessions or duration of treatment.
However, they also demonstrated that sham acupuncture could induce a treatment effect comparable with that of true acupuncture for the reduction of hot flash frequency.
The dose and the frequency of the drug made no difference in the outcome and it was no better than placebo. Therefore it works. And so we get misleading headlines suggesting efficacy of acupunctures.
- Small sample size? Check.
- High drop out rate? Check.
- Bad statistics? Check.
- Inadequate blinding? Check.
- Small effect size? Check.
- Underlying prejudice/bias in favor of an intervention? Check.
- Totally improbable intervention? Check.
Ioannidis identified many features that render a clinical trial suspect. It sometime appears that pseudo-medicine researchers try to hit as many of them as possible. Certainly this is the case where ear acupuncture was used as an adjunct to weight loss and found to be effective. Almost every error that could be applied to a study, was. Patients received 5 point ear acupuncture, 1 point ear acupuncture or sham acupuncture for 8 weeks:
Those who received five-point acupuncture had needles placed 2 millimeters deep in one outer ear taped in place and kept there for a week. Then the same treatment was applied to the other ear… Other patients received similar treatment with one needle or with sham acupuncture where the needles were removed immediately after insertion.
I suspect that there was such a high drop out in the sham treatment as because they knew they were not getting acupuncture. A lousy placebo renders an already silly and poorly done trial completely meaningless, like most of the acupuncture trials.
But the real reason this trial is not valid is that Korean ear acupuncture is not real acupuncture. Real acupuncture is traditional Chinese. Or Japanese. Not wait, hand acupuncture. Or foot acupuncture. No, wait, tongue acupuncture. That’s the ticket. Or perhaps it’s the Micro Acupuncture Point System.
An energizer for cancer patients: In two recent University of Pennsylvania studies, women receiving chemotherapy for early-stage breast cancer reported reductions in tiredness, anxiety, depression and joint pain after receiving acupuncture.
Which was discussed by Dr. Novella:
They were treated for 8 weeks with either RA (real) or SA (sum). Outcomes included several scales that essentially involve reporting subjective symptoms. The study found that both groups reported improvement in symptoms with treatment, but there was no statistically significant difference between the two. In the real world we refer to this as a negative study.
So acupuncture includes Chinese, Korean ear and electroacupuncture. Any and all acupunctures are equally useless. Except when the You Doctors read the literature.
The You Docs finish by admitting it is all placebo anyway:
We know that in some studies, sham acupuncture produces results almost as good (or as good) as the real thing. Perhaps the sham technique (pricking acupuncture points) works as well as inserting needles … or, in some cases, acupuncture works because people want it to. Future research will help sort that out.
It has already been sorted out by past research. Acupuncture only has subjective effects when the patient believes it is effective. The You Docs need to read the past literature.
They also suggest making sure that
your practitioner is certified and state-licensed.
As if that makes a difference in quality. There is a letter to Acupuncture in Medicine entitled Pneumothorax complication of deep dry needling demonstration . Pneumothorax is a rare but well described complication of acupuncture. I almost feel sorry for the practitioner as in the accompanying video he keeps emphasizing the care that must be done in order to avoid just that complication. Then you see the needle abruptly goes really deep. Pop.
Procedures, even useless procedures, have complications. It happens. But watch the video for the most god-awful adherence to infection control you could ever want to see.
- No gloves.
- No cleaning of the site where the needle is going to go (at least on film).
- His ungloved hands wander all over the patients back.
- He uses the tube in which the sterile needle sits as a pointer, touching his finger with it
- As he manipulates the needle up and down in the skin it bows, evidently bouncing against his other hand.
- And the coup de grace: after taking out the needle he covers bloody spot with his bare finger.
Aarrrrrggggghhhhhhhhhhhhh.
And this from a practitioner of 45 years experience teaching others how to do dry needling. I cannot tell from the video if hands were washed before the procedure; supposedly they were. It sure gives me the Infection Control willies. It is difficult to infect people, even if you are trying. But not impossible, given the 506 hits searching PubMed for “acupuncture and infection.” The British acupuncturists are not enthusiastic for either gloves or cleaning the skin. Perhaps that number of hits would have been a little smaller if they were more fastidious about infection control.
But I have long noted an unwillingness of pseudo-medical providers to improve practice for the patients’ benefit.
The You Doctors: they do not understand how to read the literature, recognize acupuncture is a placebo yet go ahead suggest ways to
get the most out of this healing therapy.
Come to think of it, I do not think a chaperone when reading the medical literature will work.
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