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The Observable Pseudo-verse.

Selections from Society for Science-Based Medicine’s Points of Interest, a daily compendium of links of interest with comments.

There is not enough time to write a complete blog post on the thousand points of pseudo-medicine that show up in my feeds. But some stars need to be noticed and commented upon. Duty Calls.

NECSS will be June 29-July 2, 2017 in New York City with an entire day, June 30th, devoted to science-based medicine. Preliminary schedule (subject to change):

  • Britt Hermes: The naturopaths are coming! The naturopaths are coming!
  • Harriet Hall: Denialism in Medicine: Statin Denialists and Others
  • Clay Jones: Cultural inertia and various commonly promoted medical beliefs that are wrong
  • David Gorski: TBA
  • Steve Novella: TBA
  • Two Panels: Science-Based Medicine. How are we doing? Q&A

Other appearances of SBM principals

Dr. Gorski was interviewed for the Trolling With Logic podcast. This time around, he discusses VAXXED.

What’s the harm?

Acupuncturists probably only have a vague idea what lies under the skin. There are all sorts of important structures that can be hit by a needle, puncturing which can result in everything from a popped lung to a bleed. As an example, “Acute Spinal Epidural Hematoma after Acupuncture: Personal Case and Literature Review” joins 6 similar cases:

64-year-old man who presented a left hemiparesis associated with paraesthesias. This appeared several hours after acupuncture treatment for left lumbosciatic pain. The Cervico-thoracic Spine MRI scan showed a cervico-thoracic spinal epidural hematoma from C2 to T12.

Needles in the neck for low back pain. Yeah, that shows understanding of neuroanatomy. They jammed the needle “most of the needle length”, around 2 to 3 inches, into the neck until an electric shock feeling let the patient know the spinal cord had been hit. Then came the gusher.

The acupoint used is:

On the nape, in the depression on the lateral border of m. trapezius, within the posterior hairline

And comes with the warning:

Do not insert the needle deeply medially upwards to avoid injuring the medulla oblongata.

Ya think? Because the medulla oblongata is somewhat important.

In subsequent letters to the editor, it is suggested that the points used were safe if the needle penetrated < 34.8 mm at the Fuchi point. That is 1.37 inches. That’s deep. And I like the 0.8. As if there is a practitioner who can tell 0.8 mm.

And of course, true to the inability of pseudo-medical providers everywhere who ignorantly muck about where they do not belong causing injury, they suggest that the epidural hematoma was spontaneous rather than due to a needle jammed to its hilt into the spine.

First chiropractors, and now acupuncturists, are trying their best to damage the cervical spinal cord. And denying it.

Vaccination

Here on Science-Based Medicine I have pontificated at great length about the benefits of influenza vaccination. It is not a perfect vaccine, but it decreases the odds of acquiring flu and, if you get influenza, it decreases the chance that you will die. Not dying is good. In “Influenza Vaccine Effectiveness Against Pediatric Deaths: 2010–2014” they found:

Best estimates based on NHIS survey data suggested that vaccination reduced the risk of influenza-associated death by half among children with high-risk conditions and by nearly two-thirds among children without high-risk conditions.

In 2013 111 children died of flu. In 2014 148. In 2016 89. This year 61. Many of those deaths may have been preventable with the vaccine.

Low vaccination rates are often found in affluent communities and are in part due to anti-vaccination fears. But poverty can also play a large role. In Richmond Virginia: “Lacking Tdap vaccine, 44% of Richmond sixth-graders missed class this school year.” Some of the lack of vaccination is due to vaccination fears and exemptions, but with 40% of the city’s children living in poverty:

Having so few Richmond Public School students submit religious or medical exemptions suggests that other reasons — such as cost, transportation or a lack of education — may be getting in the way of students receiving their vaccinations on time, Holmes noted.

So the poor of Richmond are primed for an outbreak, just like the affluent children of Silicon Valley. The nice thing about infections is they don’t care if you are rich or poor, just that you are susceptible.

Anti-vaccination fears have found new ways to kill and injure children, as it spills over into other medical interventions. As the misleading headline demonstrates: “Five-week-old baby boy fighting for life in hospital after parents’ refused a vital anti-vax shot .”

It is not an anti-vax shot, but a vitamin K shot. Newborns can be deficient in vitamin K (needed to make clotting factors) and, if not boosted after birth, babies can bleed into their brain, as occurred with this child. The shot has nothing to do with vaccination, but is another way for the anti-vaccine rhetoric to kill and maim:

The preventative vitamin K shot has been regarded as new fighting points of anti-vaccine activists, who tactically scare new parents into dismissing the shot – a safe injection which has saved hundreds of newborns from fatal haemorrhagic disease

There has never been a cerebral bleed in a child who has received a vitamin K injection, a few in those who have opted for oral vitamin K, and hundreds in the old days before supplementation. As noted by ForbesThe Anti-Vaccine Movement Has Found A New, Alarming Way To Threaten Public Health.”

Acupuncture

More poorly done acupuncture studies. Of course, that’s being redundant. We have “The effects of acupuncture versus sham acupuncture in the treatment of fibromyalgia: a randomized controlled clinical trial.”

They compared SHAM and real acupuncture in 50 fibromyalgia patients (25 in each group) and evaluated 16 different parameters, of which 8 were ‘statically significant’. They did not show error bars, but every ‘significant’ parameter had huge overlap. They did not evaluate to see if blinding was successful in patients, important since it is belief in receiving acupuncture that results in a positive response.

At least two reasons the results are likely false:

Corollary 1: The smaller the studies conducted in a scientific field, the less likely the research findings are to be true.

Corollary 3: The greater the number and the lesser the selection of tested relationships in a scientific field, the less likely the research findings are to be true.

Plus there was a key and fatal flaw

Baseline demographic findings, pain intensity during activity, rest and at night, quantified with a 10 cm visual analog scale (VAS), FIQ, Medical Outcomes Survey Short Form-36 (SF-36), Beck Depression Inventory (BDI) and Fatigue Severity Scale (FSS) were obtained. Patients were evaluated by the same physician (not blinded)for these parameters before treatment, 1 month and 2 months after the first session treatment

So when they say:

Additionally, a potential bias would have ensued due to the fact that the physician who performed the assessments was not blinded. Nevertheless, our results are noteworthy.

Potential bias? Really? That’s like saying the Grand Wizard of the KKK has potential bias. I would say, yeah, noteworthy for yet another worthless acupuncture study.

Department of Guaranteed False Positives

Clinical trials that compare an intervention to standard care are often useless.

As Dr. Ernst points out, it is:

A trial design that generates only ”positive” results.

We conclude that the ‘A B versus B’ design is prone to false positive results

Where A is an intervention (acupuncture, chiropractic, reiki, homeopathy) and B is standard care.

It’s 2017. They have been doing acupuncture research for over 50 years. One would think researchers would know better. Yet that is the methodology beloved by traditional Chinese pseudo-medicine and other pseudo-medical researchers. Probably because it tells them what they want to hear. Here are this week’s likely false positive studies, a waste of time and resources:

There is “Effects of Auricular Acupressure on Obesity in Women with Abdominal Obesity.” Treatment with:

auricular acupressure using vaccaria seeds was administered to the experimental group

And compared to a control. And they purport causality.

auricular acupressure using vaccaria seeds was effective in decreasing body weight, abdominal circumference, body mass index, and triglyceride levels in adult women with abdominal obesity.

I just want to know why ‘battlefield acupuncture’ doesn’t use vaccaria seeds instead of needles. One of these acupunctures is wrong.

And there is “Electroacupuncture and splinting versus splinting alone to treat carpal tunnel syndrome: a randomized controlled trial.”

181 patients were randomly assigned to electroacupuncture combined with splinting or splinting alone.

Given the methodology that will always lead to a positive result, it is not surprise that:

For patients with primary carpal tunnel syndrome, chronic mild to moderate symptoms and no indication for surgery, electroacupuncture produces small changes in symptoms, disability, function, dexterity and pinch strength when added to nocturnal splinting.

But what were the small changes? Of 18 endpoints, one had a p <0.01. There was almost NO added benefit to adding electroacupuncture. Pseudo-medical researchers are the Fonz and just can’t say the study is negative. Only in the world of pseudo-medicine would such a negative study be spun as positive and the intervention recommended for patients.

Same as it ever was.

Naturopathy

California NPR asks the question “Should naturopaths be allowed to perform sports physicals?”

Well, no. But the article contains the standard alternative fact:

Naturopaths are trained in four-year “post graduate naturopathic medical schools that are comparable to that of an MD or [Doctor of Osteopathy,]” says Bahr. “This training includes the same diagnostic skills and tools as medical doctors, including physical exams.”

So not true and provided with no contrary information.

NDs and DCs are slowly but surely convincing the world they can perform the same function as real doctors.

In the literature

Some papers of note.

Exercise is valuable for a variety of processes and is not ‘alternative’. But exercise can get a pseudo-scientific patina, as in Does Tai Chi relieve fatigue? A systematic review and meta-analysis of randomized controlled trials.

The results suggest that Tai Chi could be an effective alternative and /or complementary approach to existing therapies for people with fatigue. However, the quality of the evidence was only moderate and may have the potential for bias.

Such a result from exercise does not surprise me, but part of the underlying rationale is bogus.

In the theory of Chinese medicine (CM), Tai Chi can maintain the harmony between qi and the blood, keep yin and yang in balance and also enhance immunity. These properties are both important in relieving fatigue and maintaining energy. Qi, the energy which promotes the body’s movement, can circulate around the entire body freely if yin and yang are kept in balance.

And, as is always the case, there were at least 6 different styles of Tai Chi in the analysis. Like many evaluations of traditional Chinese pseudo-medicine, Tai Chi is treated as if it were a monolithic entity instead of the hodgepodge of styles it is with no commonality beyond movement.

Homeopathy

I have long been suspicious that people care more about pets than we do for each other. The UK is home to homeopathy hospitals for humans paid for by the National Health Service. But don’t mess with cats: “Woman’s animal ban after she used homeopathy on ill cat instead of taking it to the vet“:

“The vet was shocked to see the condition he was in and said there was an atrocious smell that was caused by the poor cat’s rotting flesh that had been left untreated for several weeks.”

Ringblom claimed that the abscess had only begun to get progressively worse over the course of a week and said she specifically wanted her pet to be treated with homeopathy.

As well as being banned from keeping any animals for life, Ringblom was ordered to pay £100 costs and a £85 victim surcharge. She was ordered to do 50 hours of unpaid community work which must be carried out within the next 12 months.

Next up: Prince Charles loses his farm? I don’t think so.

Legal and legislative

The current Trojan rabbit of the pseudo-medical world has been opiate addiction and chronic pain. “As opioid crisis flares, naturopaths and chiropractors lobby for bigger roles in treating pain.” And it is working. Unfortunately, the world is opting for magic carpets.

Acupuncturists are not fans of dry needling and try to stop it at every turn: “Acupuncturists sue Colorado’s physical therapy board over the very definition of their craft.” Their objection?

In the suit, the groups say they pushed to have Rule 211 — adopted five years ago — abolished because it allows physical therapists to practice dry-needling with only 46 hours of training for the very same procedures acupuncturists must attend 1,905 hours of classes to be licensed — more than 40 times the amount.

Doctors can get by with 200 hours of training.

The problem is, of course, that 46 hours or 1,900 hours of training in pseudo-medicine does not make its application any safer or effective.

And the Wyoming legislature has given its imprimatur of approval to acupuncture: “State acupuncturists celebrate new regulations“:

The bill, House Bill 165, was passed by the Legislature and signed last month by Gov. Matt Mead. It creates a board of acupuncture with five governor-appointed members and a mandate to approve license applications and create standards for licensed practitioners.

One reason for the bill was:

To help treat people in pain, which hopefully will reduce opiate use.

Drip, drip, drip. The slow advance of pseudo-medicine.

Remember to go to Summary Pending Legislation 2017 to keep abreast of the pseudo-scientific legislative shenanigans in your state.

Department of Goofiness

The goofiest statement this week was in “Cooling kidney and spleen heat through acupuncture.”

In traditional Chinese medicine, obesity can be distinguished in terms of emptiness, fullness, and full heat. Primary obesity is due to a weakness in the middle burner of spleen and stomach.

And here I thought it was eating too much and exercising too little. I am going to turn down the gas on that middle burner.

And that’s it. See you next week.

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.