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Is Acupuncture Worth a Punctured Lung? or Does the Risk Out Weigh the Benefit? Darcy Cowan Aug 16

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Friday’s issue of The New Zealand Medical Journal includes a case report of pneumothrorax in a recipient of acupuncture. For the interested layperson out there a pneumothorax in the collection of air in the space between the lung and chest wall leading in extreme cases to cardiac arrest. Acupuncture can result in pneumothorax when the needle is inserted into the lung tissue while the patient is breathing leading to the laceration of the lung and air being forced out of the lung and into the pleural cavity1. Mmm-mmm, gimmie some of that lung collapsing goodness.

Now lest I give the impression that complications from acupuncture use are common I will hasten to add that they are not. One paper estimates the rate of serious adverse events at approximately 1 per 20,ooo patients2. Though if we look at the rates of acupuncture use in the United States as an example, as of about 2007 approximately 1% of the population reported using acupuncture in the previous 12 months3. This translates to about 155 serious adverse effects per year. Another study found over 2% of patients reported adverse reactions that required treatment4, commonly for bleeding or pain. Multiply these figures by the likely worldwide numbers of people receiving acupuncture.

Lets compare this with the conventional medical field, the drug Terfenadine marketed under the trade name Seldane (Teldane here in NZ) was removed from the market in the US due to increased risk of cardiac arrhythmia when used in conjunction with certain other drugs. This expressed itself as a risk of 0.04 – 0.08 per million “defined daily doses”5. Once a replacement drug came on the market Terfenadine was taken off.

Pneumothorax as a complication from acupuncture is  rare even in this subgroup. More common is infection. As I’ve noted before6, the underlying theory of acupuncture is the manipulation of life energies (Qi or Chi), blockages or imbalances in which are the cause of disease. If such is the case then why should the treating physician7 bother with proper antiseptic technique? I suspect that most modern practitioners are however not so far down the rabbit-hole that they have thrown away germ theory completely, at least the outward practical side involved in cleaning and sterilising implements. Which is why even infections are still relatively infrequent.

I would like to point out however that given the implausibility of the treatment basis, coupled with the fact that most large well designed studies find no benefit beyond placebo does make the existence of any complications ethically troubling. If your treament is no more than an elaborate placebo, are you willing to suffer adverse effects because of it? As reported by Dr Novella of Science Based Medicine8, a recent review of acupuncture admitted that sham (placebo) acupuncture was as good a “real” acupuncture.

Lets delve into the definition of “sham” acupuncture a little more to give the proper context to this revelation. Whereas “real” acupuncture depends on the proper insertion of the needles in specific meridian points on the body sham acupuncture can be considered to be either the placement of needles into non-meridian points, or the use of implements that feel like needles to the patients but do not pierce the skin like toothpicks9. This indicates that it doesn’t matter where you stick the needles and it doesn’t even matter if you stick the needles. How then can we conclude that acupuncture works if you don’t need to perform the two defining characteristics of acupuncture?

Given this background I find it difficult to imagine why acupuncture continues to be recommended despite convincing evidence of efficacy and indisputable evidence of harm. All medical interventions carry some element of risk, this is then weighed against the potential for benefit. However when there is no benefit any amount of risk must make that equation lopsided with regard to harm. With that in mind, if you are attracted to acupuncture as a therapy let me recommend sham acupuncture as the way to go. All the placebo-y goodness of real acupuncture without the potential for the nasty drawbacks of infection, bleeding, pain or even pneumothorax.

Further reading:

Type “Acupuncture” and “Infection” or “Pneumothorax” into Pubmed as key words and you will find a variety of papers, a selection of which are below:

Acupuncture induced pneumothorax:a case report (not the report mentioned in the post)

Editorial:Acupuncture transmitted infections

Cutaneous Mycobacterium haemophilum infection in a kidney transplant recipient after acupuncture treatment.

Acupuncture needle-associated prosthetic knee infection after total knee arthroplasty

Footnotes:

1. Clinical analysis on 38 cases of pneumothorax induced by acupuncture or acupoint injection

2. A cumulative review of the range and incidence of significant adverse events associated with acupuncture

3. http://nccam.nih.gov/health/acupuncture/introduction.htm

4. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form.

5. Detection and reporting of drug-induced proarrhythmias: room for improvement

6. Scepticon: Acupuncture

7. And here I use the term loosely.

8.Acupuncture Pseudoscience in the New England Journal of Medicine

9. I kid you not, here are a couple of the studies:
Description and Validation of a Noninvasive Placebo Acupuncture Procedure
A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain

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Filed under: Alternative medicine, Medicine, Questionable Techniques, Sciblogs, skepticism Tagged: Acupuncture, Acupuncture and Chinese Medicine, alternative, Alternative medicine, altmed, collapsed lung, complementary and alternative medicine, health, Health and Medicine, Medicine, New England Journal of Medicine, pneumothorax, Science

Delayed Gratification = Success? Darcy Cowan Aug 10

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Today we are going to step into the time machine and go back 21 years to 1989. It was in this year that the study to become known as the “Marshmallow experiment” was published. Performed by Walter Mischel at Stanford University this experiment showed an amazing thing, that testing a child’s self-control at 4yrs could predict academic success later in life.

The numerous experiments actually entailed in this study started with the same basic premise. Children were told that they could obtain a small reward immediately or could hold out for a more valuable reward later. The rewards were carefully calibrated to produce conflict in the child over whether to go for the immediate reward or wait for the larger reward (eg one marshmallow vs two, hence the name of the experiment). The experimenter would then leave the child alone and return a short (although not for the child) time later, typically about 15 minutes. The child could ring a bell at any time to recall the experimenter and receive their lesser reward.

Over a series of experiments the researchers examined what strategies were most effective at helping the child to delay their own gratification the longest. In some situations the rewards were fully visible, allowing the children to see only the immediate reward, only the delayed reward or both. In others the rewards were present in the room but hidden. We might find it obvious but those children who could see the rewards could not wait as long as those that had the rewards hidden.

It’s important to remember here that while some of the conclusions of the study seem obvious in hindsight (and possibly to anyone with young children) previous theories of the ability to delay gratification have considered the ability to conceptualise rewards instrumental to being able to to inhibit impulsivity. To explore this hypothesis then the researchers primed the children with various thoughts prior to the experiments, either by encouraging the children to think about the rewards or by giving them other fun things to think about.

The findings showed that how the child thought about the rewards significantly impacted how long they waited, whether or not the rewards was sitting in full display in front of them. Those children that were distracted by the fun thoughts could hold out longer than those who ere primed to think about the rewards.

To examine this further children where then primed to think about the rewards in different ways. Those who were told to think about what were termed “arousing” properties of the rewards, for example the texture and taste of a food reward, had much more difficulty delaying than those who were directed to think about the abstract qualities of the reward. Indeed, those children who were told to imagine real rewards were only pictures of the objects did much better than children who were told to imagine that pictures of the rewards were real.

One of the best strategies found by the study was for the child to imagine the arousing properties of a different food to the one they would get as a reward, eg thinking about the taste of pretzels while waiting for marshmallows.

So far so good, here’s where the real surprising aspect comes, in a follow-up to these experiments children from the original studies were then looked at more than ten years later to see if the ability to delay self gratification had effects later in life. They authors predicted that differences in the ability of children to delay when they had been given no strategies to help them (eg hiding the rewards) would perform better later in life than those who had the rewards removed from sight. This prediction turned out to be upheld, those students who could had been able to delay their own satisfaction without external help had higher test scores and were described by their parents as, to quote the study:

“more verbally fluent and able to express ideas; they used and responded to reason, were attentive and able to concentrate, to plan, and to think ahead, and were competent and skillful. Likewise they were perceived as able to cope and deal with stress more maturely and seemed more self assured.”

The results of this study seem to imply that those individuals who are able to spontaneously generate strategies to aid them in planing for and achieving future rewards are better equipped to deal with life. Hhmm, when I put it that way it seems obvious, I have to point out though that it is only through experiments and observations such as this that these conclusions become obvious. Without the ability to identify the ability of children to employ coping strategies themselves there would have been no basis upon which to predict this outcome.

Congratulations, you’ve made it to the end of this post, here’s a reward. An amusing video featuring a re-creation of the original experiment showing children in the sweet agony of indecision.

Youtube – Marshmallow Experiment

–
Mischel, W., Shoda, Y., & Rodriguez, M. (1989). Delay of gratification in children Science, 244 (4907), 933-938 DOI: 10.1126/science.2658056

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Filed under: Psychological, Sciblogs, Science Tagged: Child, Educational Resources, Experiment, health, psychology, Science, Science and Society, Social Sciences, Stanford University, Walter Mischel

Pharmacy Customers Perception of Complementary and Alternative Medicine in Pharmacies Darcy Cowan Aug 05

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Going through the papers cluttering my inbox I found this survey of Australian pharmacy customers relating to their use of CAM and their impressions of how pharmacists should approach the subject.

Regular readers of Sciblogs may remember a kerfuffle earlier in the year regarding the sale of homeopathic remedies in pharmacies, I and others were uncomfortable with these items being sold in pharmacies to begin with. Fortunately, when surveyed homeopathy didn’t make it into the top ten modalities used in the last 12 months, though 3% noted that they had seen a homeopath.

This survey was published in BioMed Central‘s journal of Complementary and Alternative Medicine. I might point out that I disagree with the authors views of Complementary Medicine (CM) but I agree with many of the conclusions of the survey, though I suspect for different reasons.

The survey included data from 1,221 respondents from 54 pharmacies that cover both rural and urban areas. Beyond that the methods aren’t particularly interesting, people filled out forms.

Findings of the survey showed that a significant number of pharmacy customers think that it is important for pharmacists to be knowledgeable about CM and to know about their customer’s CM use. I would agree with this, pharmacists should be aware of how CM is marketed and of the claims made on order to give customers appropriate advice on effectiveness. Another result of the survey that helps with this point is that almost 70% of respondents agreed that they trust their pharmacist’s advice regarding CM. This reveals an excellent opportunity for education of the public regarding these modalities.

In addition many of the respondent felt comfortable telling pharmacist about their CM use whereas previous research has shown this not to be the case for patients of other medical practitioners. Again this is an opportunity for pharmacists to assess the safety of CM modalities their patients are using, especial in conjunction with other treatments (this was also a conclusion of the survey).

That said, the survey also revealed that many customers rely on family and friends as information sources. This accords with with existing research on the importance of personal anecdote in making decisions. Next most popular were medical doctors (not bad) and in third place (disturbingly) was the media. Pharmacists were in 6th place after naturopaths and pharmacy assistants. While far down on the list pharmacists still rank and one of the important sources of information and should not be under estimated.

One of the questions that I disagree with the majority of respondents on is regarding the inclusion of natural medicine practitioners in pharmacy practices. To me this is inviting abuse of the pharmacist’s position of authority, it might even undermine some customers trust of the institution (I’d certainly think twice about any pharmacy that did this). At the very least it may allow pharmacists to divest themselves of the responsibility to actually learn about the alternative products they may be selling.

In conclusion, I consider the results of this survey important to keep in mind when considering the role of pharmacists in the field of CM. Pharmacists are in a somewhat unique position to educate the public regarding CM as a consequence of the level of trust afforded to them by customers. It also reveals that pharmacies are vulnerable to particular abuse for exactly the same reason, products sold in pharmacies are lent an aura of respectability by association.

It behoves pharmacists to take seriously the responsibility to be current on the debate around the safety and efficacy of CM modalities and be able to confidently relay this information to customers. No longer should pharmacists sit on the sidelines while irrationality invades their practice, hiding behind public demand as an excuse for not taking a stand for science based therapies.

–
Braun, L., Tiralongo, E., Wilkinson, J., Spitzer, O., Bailey, M., Poole, S., & Dooley, M. (2010). Perceptions, use and attitudes of pharmacy customers on complementary medicines and pharmacy practice BMC Complementary and Alternative Medicine, 10 (1) DOI: 10.1186/1472-6882-10-38

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Filed under: Alternative medicine, Medicine, Psychological, Sciblogs, skepticism Tagged: Alternative medicine, BioMed Central, health, Health and Medicine, Homeopathy, Medicine, naturopathy, Pharmacy, Physician

Is there a Biochemical Marker for Suicide? Darcy Cowan Jul 26

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Suicide is a sensitive subject, by it’s very nature it seems we are obliged to treat it with kid gloves. In public it is virtually taboo to even mention suicide, in news media euphemisms are employed in order to avoid explicit use of the “S” word. Attitudes are beginning to change, with more vocal discussion about mental illness and euthanasia in both this country and abroad.

One of the key issues is whether a person is capable of deciding to end their own life or if such a decision automatically excludes them from the definition of mentally competent. I found myself pondering these things as I attempted to come up with a way to introduce the research that is ostensibly the focus of this post.

Regardless of your moral position on the subject of suicide I think we can mostly agree that identifying persons at risk of suicidal tendencies would be helpful in alleviating the pain that accompanies this choice (if indeed it can be described as such). This is where a paper published recently in PLoSONE comes in. The study authors point out in the introduction that previous work has been able to correlate increased blood brain barrier permeability with suicide in patients with prior mental disorder.

Perhaps at this point I should take a step back and provide a little more information on what we are discussing here. The blood brain barrier (BBB) is a system of control that restricts what can and cannot pass between the normal circulatory system and the cerebrospinal fluid (CSF) or the bath that your brain sits in.

In practical terms this means tight connections between the cells of your capillaries to prevent leaks and transport systems to get nutrients back and forth across the barrier. Imagine a dam made of tightly packed stones with channels for the controlled movement of water and you have the basic idea.

Anyway, if the BBB becomes more permeable then it is reasonable to suppose that proteins found in the CSF would be found in higher concentrations in the blood than would normally be expected. If the permeability of the BBB is also correlated with suicidal behaviour then the presence of these proteins become an indirect test for suicidal tendencies.

This is the hypothesis that the research then tested, ie. does the presence of proteins in the blood normally found in the CFS correlate with suicidal tendencies? This study looked specifically at a protein known as S100B, primarily associated with certain cells in the brain and spinal cord. Included in the study were 64 adolescents (average age ~14.5 yrs) diagnosed with either psychosis or mood disorders and 20 healthy control subjects.

The subjects were evaluated and their suicidality was ranked from 1-7*, Blood tests then determined the levels of S100B. The findings showed that levels of S100B significantly correlated with suicidality in the subjects. Looking at the data accompanying the study it seems there is a wide margin of uncertainty on these readings. With a relatively small number of subjects I’m not particularly surprised by this but I would be looking to see more investigation into this approach to determine it’s reliability.

Obviously this technique will not replace psychiatric evaluation, it may prove useful though in helping identify those that are most at risk of suicidal behaviour. If I may return to the broader issues I raised at the start of this post, I would also find it interesting if this test (once extensively validated) could separate those who wish to end their lives due to illness into groups consisting of those with suicidal thoughts because of mood disorders and those who are otherwise of sound mind.

Something to think about.
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* 1-no suicidality is present, 2-very mild (thoughts when angry), 3-mild (occasional thoughts), 4-moderate (thoughts present in the last week), 5-moderately-severe (recurrent thoughts present almost daily), 6-severe (current suicidal plan), 7-extremely severe (patient attempted suicide within the last week)

–

Falcone T, Fazio V, Lee C, Simon B, Franco K, Marchi N, & Janigro D (2010). Serum S100B: a potential biomarker for suicidality in adolescents? PloS one, 5 (6) PMID: 20559426

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Filed under: Medicine, Psychological, Sciblogs, Science Tagged: Death, Disorders, End-of-Life, Euthanasia, health, Health and Medicine, Mental disorder, Mental health, Research, Science, Science and Society, Suicide

Is there Something Fishy about Psychosis? Darcy Cowan Jul 02

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ResearchBlogging.org

Psychosis is a scary word, conjuring images of people who have so lost touch with reality that they are unable to integrate with society. As with most everything else this condition exists on a continuum, mild symptoms may pose no problem for the sufferer1 nor be outwardly visible. Previous studies have seen correlations between the intake of polyunsaturated fatty acids (with the cute acronym PUFA2) and increased severity of psychotic symptoms, with this in mind a study was performed in Sweden looking at the dietary intake of fish and the incidence of psychosis symptoms in the general population.

In total 33,623 women completed the study which covered the period between 1991/92 to 2002/03 (with questionnaires at the beginning and end of this period). This group was then classified based on their answers to the questionnaires into 3 groups: Low, middle and high frequency of symptoms, where the low group included women with no symptoms. This gave a split of 18,411, 14,395 and 817 women in the groups respectively. The first question I had reading this study is how do you classify someone with psychotic symptoms? The women in the study completed two questionnaires to provide the information for this part.

The first was the Community Assessment of Psychic Experiences (CAPE, another cool acronym), this contained questions ranging from those looking at emotional states such as “Do you ever feel sad?”, to those that address personal perception like “Do you ever feel pessimistic about everything?”. Also included are the questions that we would more easily recognise as relating to psychosis such as “Do you ever feel as if a double has taken the place of a family member, friend or acquaintance?” or “Do you ever see objects, people or animals that other people cannot see?”.

There are also questions that might seem to generate positive answers from a wide range of the population that we would not consider psychotic such as “Do you ever think that people can communicate telepathically?”, a belief that if I can take what I see in the media seriously is becoming more widespread. And “Do you believe in the power of witchcraft, voodoo or the occult?” which thinking back to the furore that arose around the Harry Potter books is a view that is held by a disturbing number of people3.

Quite obviously simply answering affirmatively to these questions does not place you in the psychotic camp, it is the aggregate of these answers that matter as well as further variables that relate to these answers such as how these thoughts and experiences make you feel. The experience of seeing or hearing a loved one that has died is quite widespread but I don’t think general conclusions about the sanity of the general population can be reached using this information.

The second questionnaire was a variation on the Peters et al. Delusions Inventory (PDI, and the good acronyms come to an end). There is significant overlap between the questions asked in the PDI and the CAPE questionnaires, the main difference seems to be how each question is followed up. The CAPE approach simply asks how distressed the respondent feels if they answered affirmatively to a question (with a 4 point scale, Not distressed to Very distressed) while the PDI covers this aspect as well as asking how much the respondent thinks about it and how much they believe it is true.

Now how do the categories that I mentioned above (low, middle and high) relate to the results of the questionnaires? Rather than attempt to paraphrase the study I’ll just quote that bit:

“The “low level symptoms group” included women with no or few experiences of psychotic-like symptoms (≤3 “sometimes” and no “almost always” and “often” answers to any of the questions). The “high level symptoms group” included women with frequent experiences of psychotic-like symptoms (≥3 “almost always” or “often” answers). The “middle level symptoms group” was defined as participants not included in the low level or high level groups.”

Fairly simple, not as nuanced as I expect an in-depth psychological evaluation might be but that’s the limitation of performing a large scale study.

Finally, what were the results of the study regarding fish consumption and symptoms of psychosis? Interestingly the authors did not see a simple relationship between the two variables, there was no clear protective effect with increasing intake of fatty fish (those with high levels of PUFAs). Instead there was an optimal intake that was correlated with low (or no) symptoms, higher intake actually correlated with increased symptoms. The authors are unsure what could account for this effect stating:

“This puzzling finding may be due to unknown or known unhealthy constituents of fatty fish. For instance, environmental pollutants such as polychlorinated biphenyls (PCB) and dioxins are known to accumulate in fatty fish. Another possible explanation may be that the frequent intake of fish and PUFA may be advantageous in lower doses but disadvantageous in higher doses.”

The authors also caution that the study was not geared to determine a causal relationship between the variables merely how these were correlated4. Another interesting finding was that high levels of psychotic symptoms are also correlated with women who are both overweight and are smokers (and also for some reason migration to Sweden5).

Bottom line? Hard to say really, the results of this study are indicative but not definitive. The take home message in my book looks to be that it is a balanced diet which is most beneficial, including fish in your meals between 1 and 3 times a week or so. For those of us who aren’t keen on fish, supplements might be the answer but that’s really another question.

OpenLab2010 Submit To Open Laboratory 2010(What’s This?)

1. Indeed they may not even consider themselves to be suffering from anything untoward.

2. You might recognize Omega-3 as representative of this group.

3. For me that number is 5.

4. Remembering the adage: Correlation does not equal Causation.

5. So should the tourism board adopt the slogan “Sweden: You don’t have to be crazy to move here, but it helps”? Too insensitive?

–
Hedelin M, Lof M, Olsson M, Lewander T, Nilsson B, Hultman CM, & Weiderpass E (2010). Dietary intake of fish, omega-3, omega-6 polyunsaturated fatty acids and vitamin D and the prevalence of psychotic-like symptoms in a cohort of 33 000 women from the general population. BMC psychiatry, 10 (1) PMID: 20504323

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Filed under: Psychological, Sciblogs, Science, skepticism Tagged: Causality, Conditions and Diseases, Harry Potter, health, Health and Medicine, Mental health, Nutrition and Metabolism Disorders, Pollution, Psychosis, Religion and Spirituality, Schizophrenia, Science, Science and Society, Women’s Health

Alcohol: Effects on Teenage Brains and Correlations Between Availability and Violence Darcy Cowan Jun 04

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ResearchBlogging.org

I’ve written previously about the effects of alcohol on decision making. Today I’ll be looking at two further aspects of alcohol consumption and how it affects society. First up is a study that examines the cognitive effects of moderate to heavy drinking during adolescence, with different effects on males versus females. Secondly I’d like to cover an interesting paper that relates the amount of violence in a community to the number alcohol outlets in the community.

There is an interesting contrast between the two papers, one focusing on the effects of alcohol on the individual and possible long term effects and the other on the wider community. Like tobacco the use of alcohol is coming under increased scrutiny in our society and this is a good thing. The difficult part in both processes is to ensure our actions are guided by evidence rather than knee jerk emotion. Smokers complain that they are unfairly victimised when alcohol causes so much harm, this may be true but it is irrelevant to the discussion of the harms of tobacco use. The same is true from the alcohol side of the debate.

Each substance must be approached and dealt with on it’s own merits and derailing the discussion to decry the abuse of one or the other is unhelpful. I am not an expert on public policy and do not advocate any particular solution to either of these issues, I don’t know what the best solution is but it is tiresome to see the same diversionary tactics arise time and again in these sorts of debates. With that, lets move on to the science.

The first paper, “Initiating moderate to heavy alcohol use predicts changes in neuropsychological functioning for adolescent girls and boys“, follows a cohort of 76 adolescents starting at ages 12-14 years. The participants of the study were chosen to limit the amount of exposure at baseline to addictive/mind altering substances. These individuals were then followed over approximately 3 years and given a battery of tests and questionnaires to determine their drinking habits and cognitive abilities.

As we might expect heavier drinking patterns in the adolescents predicted poorer test results. The interesting result is the differences in the effects of the alcohol in male versus female subjects.

Take the test Here

Female subjects that consumed higher amounts of alcohol in the preceding 12 months performed worse on tests of visuospatial functioning than the control group. One of the ways this was measured was using something called the Rey-Osterrieth Complex Figure test (see pic), this entails the subject copying the figure, and then drawing it again some interval of time later (in this case 30 mins) from memory.

The number of drinks required to see this effect appeared to be 12 or more a month (in the previous 3 months), with the larger doses leading to a more pronounced detriment. Of course this was a trend effect in a population, on average heavier drinking females did worse in these tests but any one female was not guaranteed to see a reduction in performance.

Males on the other hand tended to do worse in the attention tests. Going by this measure I’m sure wives the world over would swear their husbands had been habitual binge drinkers throughout adolescence. The test of sustained attention in this case was done by the Digit Vigilance Test, this simple test consists of rows of single digit numbers printed in either red or blue (single colour per page). Subjects must find either 6s or 9s on each page.

By timing the task and counting the errors committed a measure of sustained attention can be determined and compared to the control group.

A drawback of this work is that the number of subject was limited, the entire study had a total of 76 adolescents, of those 29 were female (leaving 47 males). These groups then had to be further bisected to give the drinking and control groups. This study was quite small but is consistent with previous research showing negative effect on the brain for developing individuals. The bottom line of research like this is not difficult to get to, there are detrimental effects to be had by allowing young people to indulging moderate to heavy alcohol consumption. What we do with this information is up to us.

The second paper was presented by William Pridemore and Tony Grubesic at the annual meeting of the American Association for the Advancement of Science in San Diego earlier this year. With the engaging title of “Alcohol outlets and community levels of interpersonal violence: Spatial density, type of outlet, and seriousness of assault” the paper examines the correlation between the number of places where alcohol is available in a community and the amount of violence the community experiences.

I think we can all guess the outcome but it’s nice to have actual data to back up our intuitions. The study was quite detailed in it’s approach with the violence broken down by simple assault and aggravated assault and the type of alcohol outlets subdivided into bars, restaurants and so-called “off-premise” outlets where alcohol is sold but not consumed on site, such as supermarkets and liquor stores.

It comes as no real surprise that a higher density of alcohol outlets was correlated with a higher level of violence in the area. A result that I did not expect though was the significant effect the “off=premise” alcohol outlets appear to have on the levels of violence in the area. The study estimated such sites contribute between 25%-30% of the violence (depending on the category)  of an area. This compares to approximately 10% each for bars and restaurants.

The reason for this difference is suggested to be that these areas can act as impromptu gathering places where it is perceived that the normal rules of society do not apply, especially if the area is unkempt in appearance. In such areas individuals may have an altered perception of the moral expectations and this coupled with the disinhibiting effects of alcohol could lead to the greater propensity for violence.

Once again the information may merely inform our decisions not make them for us. Is the best approach simply to limit the number of alcohol outlets, or ban then from some areas altogether (or completely?). Or should we use this information to put measures into place to reduce violence while retaining access to alcohol, perhaps by creating environments around outlets that are less conducive to violent confrontations. Maybe some nice waterfalls and soothing music would help, I’m sure I have an Enya CD around here somewhere I could donate to the cause (or possibly The Corrs).

–

Squeglia, L., Spadoni, A., Infante, M., Myers, M., & Tapert, S. (2009). Initiating moderate to heavy alcohol use predicts changes in neuropsychological functioning for adolescent girls and boys. Psychology of Addictive Behaviors, 23 (4), 715-722 DOI: 10.1037/a0016516

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Filed under: Psychological, Sciblogs, Science Tagged: Add new tag, adolescence, alcohol, alcohol consumption, Alcoholic beverage, American Association for the Advancement of Science: Caribbean Studies a Symposium, Binge drinking, health, Health and Medicine, neurological, psychology, Rey-Osterrieth Complex Figure, Science, Science and Society, violence

World Homeopathy Awareness Darcy Cowan Apr 09

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Just when I thought I wouldn’t have to worry about Homeopathy again any-time soon I discover that next week (April 10-16) is World Homeopathy Awareness Week. In theory I am right behind an initiative such as this as homeopaths do a surprisingly poor job of educating the public about what homeopathy actually is.

I suspect though that highlighting the fact that there is no active ingredient in most homeopathic preparations and that huge swathes of established science would have to be wrong for it to work will not feature prominently in the promotional materials.

For those not in the know homeopathy is based on two principles not found anywhere in science, like cures like, known as the “Law of Similars” and less is more or the “Law of Infinitesimals”. In a nutshell these two “Laws” state that a substance that causes similar symptoms to a disease will cure it and the more you dilute the substance the more powerful it becomes. In practice this means that homeopathic preparations can have some unusual starting ingredients (like duck liver) and are diluted to the point that no active ingredient is left in the final product.

A common dilution for preparations is 30C, or 30 consecutive 100 fold dilutions. At this level not only are the no molecules of active ingredient left there aren’t even any molecules of water left from the last dilution that contained any active ingredient.

Due to this fact homeopaths have been reduced to very fanciful explanations of how it might work, most involves invoking some sort of water “memory” effect. This isn’t impossible but neglects to mentions that if it is the case, then the water also remembers every poison it has come into contact with as well. How does it know which effect it should have? Should it kill or cure?

A study performed in 2008 and published in the New Zealand Medical Journal showed that while 85% of respondents believed they knew what homeopathy was less than 5% knew that there is no active ingredient in most preparations. I don’t expect this statistic to change due to any efforts on the part of homeopaths or those that sell generic remedies.

Here’s a pithy website dedicated to How Homeopathy Works.

For those with a high tolerance to brain melting gibberish here’s a video with one of the more confusing explanations of homeopathy:
Youtube Page direct

[UPDATE: Thanks to commenter Lizditz on Dr Steven Novella's blog about this I have been alerted to this great philosophy paper on Homeopathy; "Evidence and simplicity: Why we should reject homeopathy", go read it now.]

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Filed under: Alternative medicine, Medicine, Sciblogs, Science Tagged: alternative, Alternative medicine, altmed, health, Health and Medicine, Homeopathy, pseudoscience

New Zealand Pharmacy Ethics in Relation to Homeopathy in the Wake of Homeopathy Report Darcy Cowan Feb 24

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Earlier this year I wrote a post (along with fellow Sciblogger Grant) concerning the sale of homeopathic remedies in pharmacies. Monday night saw the release of England’s Science and Technology Committee’s “Evidence Check 2″ report on Homeopathy (also ably covered by Grant). One of the issues covered by the report is that of pharmacy responsibilities regarding sale of these remedies. Essentially the report recommended that sales continue but with adequate disclaimers stating that there is no scientific evidence that homeopathic products work beyond the placebo effect.

I see this as a compromise between commercial freedom to sell safe, though not necessarily effective, products and patient informed consent. It’s reasonable even if I disagree that it is ideal. Regardless, I thought it was a good excuse to look once again at our own pharmacies and see how the selling of scientifically unsupported remedies aligns with their professional responsibilities.

Enquiring into this area I was directed to the Pharmacy Council Code of Ethics for pharmacists. The Pharmacy Council seems to fill the function of professional association and regulatory body for pharmacists their functions including:

prescribe the qualifications required for scopes of practice within the profession, and, for that purpose, to accredit and monitor educational institutions and degrees, courses of studies, or programmes

and

consider the cases of health practitioners who may be unable to perform the functions required for the practice of the profession

Perusing the Code of Ethics (which may be found Here) I found a number of sections that I feel should preclude pharmacists from selling homeopathic remedies in good conscience. In order to try and represent the spirit of the code as accurately as possible I have included here both the relevant over-arching Principles that pharmacists should strive for as well as the Specific Obligations that I feel make my point (any emphases are mine).

The first principle is one of patient autonomy:

Principle 1: Autonomy
The pharmacist shall promote patient
self-determination, respecting the
patient’s right to understandable
information, privacy, and confidentiality

1.4 Professional services
Where the patient is seeking or receiving, from the
pharmacist or from other personnel for whom he or
she has responsibility, any professional service or
intervention, the pharmacist must ensure that the
patient is provided with credible, understandable
information about reasonably expected results,
outcomes or effects of the service or intervention, any
risks of receiving the service or intervention, and any
insufficiency of evidence about the efficacy of the
service or intervention, to allow the patient to make
an informed choice.

This to my reading implies that should pharmacists sell homeopathic remedies they are obligated to inform the patient of the lack of scientific underpinnings for the use of the remedy. One of the objections I have run into regarding the sale of these remedies in pharmacies is that they are commercial enterprises and are within their rights to sell products regardless of their medicinal value. This is partially true but these remedies are specifically sold to treat symptoms, not as entertainment, confection or cosmetic. The Code has several entries covering this aspect the first of which is:

1.5 Independent information
The pharmacist must ensure that their advice is
independent of personal commercial considerations.

Does this not imply that the sale of unscientific medicines should not be undertaken simply because it make financial sense? We will return to this point later.

The next Principle covers patient needs:

Principle 2: Beneficence
The pharmacist shall optimise medicines
related health outcomes for the patient
according to their concerns, needs,
cultural values and beliefs

2.2 Quality use of medicines
The pharmacist must provide scientifically-based,
unbiased medicines information to healthcare
providers, patients and the community in order to
optimise medicines related health outcomes.

My reading of this point leads me to understand that any information provided regarding pharmacy products must have scientific backing and moreover must not be biased by the pharmacist’s own views. Any such information regarding homeopathy must therefore be negative.

But, what if the pharmacist is not asked for this information? After all, I do not usually go in asking for a lecture if I already think I know what I need. I think the next obligation covers this instance:

2.8 Involvement in sale of medicines and other
therapies
The pharmacist must be involved and intervene in the
sale of any medicine, complementary therapy, herbal
remedy or other healthcare product whenever this is
necessary to ensure a reasonable standard of
pharmaceutical care.

Scientifically speaking homeopathy should not be considered to encompass a “reasonable standard of pharmaceutical care”.

The next Principle of relevance concerns fairness:

Principle 4: Justice
The pharmacist shall practise fairly and
justly and promote family, whanau and
community health

4.4 Commercial interests not to override good
practice
The pharmacist must ensure that commercial interests
are not permitted either to override the independent
exercise of their own professional judgement on
behalf of a patient or to compromise the standard of
care provided by them or to affect their cooperation
with other healthcare providers.

Once again the issue of financial gain over patient care is addressed with commercial interests coming off second best when the standard of care is concerned.

The next Principle is one I feel is of especial importance when the reputation of pharmacists in the wider community is considered and their self representation in the media is a factor (remember, they’re the health professional you see most often). This is trustworthiness, pharmacists are seen as, and promote themselves as, first and foremost medical professionals not business interests. The sale of homeopathic medicines is antithetical to this position and undermines their credibility in this regard, in direct contraction to the Code of Ethics as follows:

Principle 7: Trustworthiness
The pharmacist shall act in a manner
that promotes public trust in the
knowledge and ability of pharmacists
and enhances the reputation of the
profession

7.7 Non-medical goods and services
The pharmacist must not purchase or sell from a
pharmacy any product or service which may be
detrimental to the good standing of the profession or bring the profession into disrepute.

If the sale of scientifically worthless remedies such as homeopthy does not do this I don’t know what would, perhaps offering Therapeutic Touch?

Finally the Principle of dignity undermines the pharmacist’s sale of unsupported medicines:

Principle 8: Dignity
The pharmacist shall provide
information about professional services,
medicines and healthcare products in a
dignified manner without making
exaggerated or unsubstantiated claims

8.4 Medicines not ordinary articles of
commerce
A pharmacist must only participate in promotional
methods that do not encourage the public to equate
medicines with ordinary articles of commerce.

If the previous examples of why remedies should not be sold with the sole purpose of earning money for the pharmacist this should put that argument to rest. The sale of medicines (which many people consider homeopathy to be) should not be equated with ordinary articles of commerce. This puts the lie to arguing that these remedies are simply another commodity to be bought and sold like chewing gum regardless of therapeutic value.

8.8 Evidence of efficacy
The pharmacist must only promote to a potential
purchaser that any medicine, complementary therapy,
herbal remedy or other healthcare product associated
with the maintenance of health is efficacious when
there is credible evidence of efficacy.

This last obligation explicitly refers to promotion of a therapy to a patient by the pharmacist which I don’t think any reputable pharmacist would do for homeopathy but arguably the presence of the product in the store constitutes an implicit promotion of it to potential customers. This point goes back to the principle of trustworthiness, the public trusts the pharmacist to stock efficacious products. To include unscientific therapies among their wares undermines and betrays this trust. Perhaps I am naive to think so but I think the Pharmacy Council’s own Code of Ethics backs me up when I say that we should hold pharmacists to a higher standard than your average shop owner.

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Filed under: Alternative medicine, Medicine, Sciblogs, Science, skepticism Tagged: health, Health and Medicine, Health care, Herbalism, Homeopathy, homoeopathy, Medicine, Pharmaceutical drug, Pharmacy, Placebo, Science and Society

What is the Harm of Alternative Medicine? Darcy Cowan Jan 26

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Yesterday fellow Sciblogger Grant posted about homeopathic medications in pharmacies and questioned the legitimacy of reputable organisations selling such patent snake oil. The comments to this entry reveal one of the most frustrating aspects of speaking out against unscientific medicine and can be summarised thusly: “I’m far too sophisticated to be taken in by this stuff myself but other people seem to like it and if it doesn’t work then what’s the harm?”.

This attitude is ever present and comes from a reasonable starting point i.e. everyone is entitled to their own opinion and it’s not my job to save them from themselves. I can totally get behind that, usually. When it comes to ineffective medications of the alternative variety however this impulse though understandable is misguided and I’d like to put down a few reasons why I think so, some are speculative but I think the possibility of harm is great enough that they deserve to be considered.

For a start there may well be direct harm caused by using alternative remedies. As there is little to no regulation of these medications then no proof of safety or efficacy is required for sale. Witness the Zicam debacle last year regarding a “homeopathic” cold medication.

Further more the possibility for indirect harm (as multiply alluded to by Grant) may be significant. In case your imagination is not up to the task I will outline a few ways this may be the case. For instance the underlying principles of something like homeopathy are no only unscientific they are in direct contradiction of the last 200 years of scientific understanding. If they are used as the basis of reasoning about health then the results can be more dire than someone getting a bad nights sleep (in the case of the homeopathic sleep aid Grant used as an example).

Use of these therapies for minor ailments by the “worried and wonky well” may increase the possibility they they will be used for more serious health issues where the results could be deadly.

Look no further than the position statement of the WHO regarding the use of homeopathy in the treatment of Malaria and AIDs (among other things). The consequences of such thinking could be incalculable in terms of human suffering and spread of disease. But what’s the harm, right?

Additionally it is one thing for adults to make an informed choice for themselves based on available evidence filter through their particular world view but what about when this choice id forced on their children? The recent case of parents being found guilty of manslaughter over giving homeopathic remedies to their sick daughter is a terrible reminder that sometimes it is innocent children that pay the price for people’s gullibility. But, you know, what’s the harm?

When ostensibly professional medical providers such as pharmacists sell demonstrably irrational treatments they lend credibility to them that the average person uses to base decisions on. I mean the wouldn’t sell it if it didn’t work, right?

So while I understand the commitment to individual autonomy and freedom of choice that leads to the “What’s the Harm?” question, I fail to see how this means that fraudulent therapies must be let off the hook simply because there is a demand for them.

This has been a more vitriolic post than I normally write but what’s the point of a blog if you can’t vent once in a while?

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Posted in Alternative medicine, Medicine, Questionable Techniques, Sciblogs, Science, skepticism Tagged: alternative, health, Health and Medicine, Homeopathy, Medicine, Practitioners and Clinics, Science and Society, Scientific method

Smoking Bans and the Effect of Health Warnings Darcy Cowan Jan 21

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In the world today there is an increasing focus on the negative aspects of smoking and a concerted attempt to reduce the presence of smoking in society. Given the harmful effects of this addiction on not only the active smoker but those around them this seems like a prudent move. Two of the approaches with the goal of minimising public exposure to cigarette smoke are the banning of smoking in businesses and public places and the addition of more strenuous warning labels on the cigarettes themselves.

Both of these tactics have been used in New Zealand with varying levels of acceptance (and success). Smoking bans draw the criticism that individual freedoms are being curtailed. This may be a legitimate point but conceptually it is no different than government enforcement of wearing seatbelts while driving on public roads. The aim is to reduce the risk of harm to the public. The real question in each case is whether the intervention is effective in it’s goals.

Addressing this question two studies last year looked at each of these methods, the first I will look at is a meta-analysis (with the concomitant problems those have, that’s another story) of the effect of smoking bans on the hospital admissions of acute myocardial infarction (that’s a heart attack to you and me). The analysis found that smoking bans were associated with an average reduction of heart attacks by 17%.

For each year a ban was in place it was accompanied by a reduction of the incidence rate ratio (the number of new cases per unit of population eg 10 cases per 100,000 people) of 26%. This indicates that the longer a ban is in force the fewer people who will be affected by heart attacks. Looks like an effective strategy to me, 17% is nothing to be sneezed at when it is individual lives you are considering. Depending on individual risk factors the chance of death in the 30 days after a heart attack can be up to 16%.

An editorial discussing these findings in more depth (in the Journal of the American College of Cardiology, the journal this study was published in) can be found Here and is a good read.

The second study focused on the how well explicit (i.e. emphasising death) cigarette pack warnings encouraged smokers to quit. Specifically it looked at smokers for whom the act of smoking formed part of the basis for their self-esteem. Subjects undertook a questionnaire that evaluated whether smoking was tied to their self esteem using statements like ‘‘Smoking allows me to feel valued by others,” and ‘‘Smoking allows me to feel worthy.” (as well as negative versions). The subjects rated how much they agreed with the statements and this was used to determine the smoking-based self esteem for each subject.

Participants were then shown pictures of cigarette packs that either had mortality related warnings (e.g. ‘‘Smoking leads to deadly lung cancer.”) or more moral or self esteem related warnings (e.g. ‘‘Smoking brings you and the people around you severe damage” and ‘‘Smoking makes you unattractive”). After a delay to allow the warnings to be filtered out of conscious awareness the subjects were asked a further series of questions to assess the effect of the warnings (e.g. ‘‘Do you intend to smoke more or less in the future?” ‘‘Do you intend to quit smoking in the future?”).

Subjects for whom smoking formed part of the basis for their self esteem actually increased their likelihood of smoking in response to warnings emphasising mortality. For these people it was the self image warnings that were most effective. Unfortunately is seems that the opposite is true for individuals that do not consider smoking to be an important factor of their self esteem so a one size fits all approach would probably not be effective. The study authors suggest that specific populations could have warnings tailored to be most effective depending on the relevance smoking has to the group identity (e.g. “young smokers who want to impress their peers.”).

This result may be applicable to other areas where minimising harm is the goal, such as drink driving campaigns.

In summary, despite any reservations regarding the form that inducements to stop smoking take it seems that the benefits are indeed worth the attempt. Also, as I often point out, the real world is more nuanced and complicated than we would generally like it to be, more effort may be required to identify sub-groups that respond most to different strategies but this also looks to be worth trying.

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Posted in Medicine, Psychological, Sciblogs, Science Tagged: American College of Cardiology, Cigarette, health, Health and Medicine, Lung cancer, Myocardial infarction, New Zealand, Review, Science, Science and Society, smoking, Smoking ban, Tobacco smoking

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