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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

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.

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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

BioFuel Cell Batteries May Power Future Implanted Devices Darcy Cowan May 27

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ResearchBlogging.orgWhen I think about the future I sometimes indulge in fantasies that include “bionic” type implants. Not so much artificial muscles that will enhance strength (check this out) but devices that will expand our mental capabilities. Implants that give us greater memory, faster thought processes, the ability to download skills and knowledge directly into our brains.
Perhaps I read too much science fiction.

The trouble with this utopian view of the future is a practical one, where will these devices receive their power from? If I start forgetting things because I haven’t plugged in a new 9volt, I won’t be happy. The ideal solution would be some sort of battery that can be inserted into the body and generate energy from the food I eat, just like the rest of my organs.

Enter: The BioFuel cell. Fuel cells have been around for a few decades and while most people have no dealings with them their essential mechanism is easily understood. Basically a chemical reaction is allowed to proceed under very controlled conditions to generate a flow of electrons (ie an electric current). The usual example given is reacting Hydrogen (the fuel) with Oxygen to generate water and electricity, but really almost any electron donor/acceptor pair will do.

Biofuel cells replace the electron donor (eg Hydrogen as above) with a biological molecule, glucose. These Glucose BioFuel Cells (GBFCs) could then in theory utilise glucose dissolved the blood as a fuel to generate electricity and power implanted devices. The fanciful science fiction devices I dream about above may not arrive on the scene any time soon but there are medical devices and synthetic organs that would benefit from such a power source now.

The device that immediately springs to mind is a pacemaker but the possibilities are much wider, ranging from the artificial urinary sphincter that recipients of Radical Prostatectomy surgery depend on to artificial kidneys which to be portable must currently be wearable because of (among many other reasons) the inability to effectively supply it with power inside the body.

Existing GBFCs have a draw back that the electrodes are inhibited (work less efficiently) by chloride or urate ions, both of which are present in your blood, or require low (acidic) pH to work whereas your body likes to be around neutral pH. This makes them ineffective in a real biological environment. Luckily a recent paper in Plos ONE, “A Glucose BioFuel Cell Implanted in Rats“, details an alternative type of fuel cell that overcomes these limitations and demonstrates it by implanting it inside a rat.

The GBFC produced a specific power of 24.4 µW mL−1 which, to put that in perspective, could power two pacemakers (just in case The Doctor gets into trouble). The mL−1 part refers to the volume of the fuel cell, this really means that the power output is related to the size of the fuel cell, just like regular batteries. The volume of this cell appears to be little more than a quarter of a millilitre (0.266mL, two electrodes of 0.133mL each), think about how much volume a normal 6 sided die takes up, imagine one quarter of that and you’ll be in the right ball park.

Inside the fuel cell electrodes are enzymes that react the glucose with dissolved oxygen also in the blood to produce an electric current. The glucose and oxygen required for the reaction diffuse through a membrane surrounding the electrodes while the waste products diffuse back out into the bloodstream to be taken care of by the body. In this way the fuel is constantly being replenished and so long as the enzymes retain their activity the fuel cell will continue to function and continuously produce energy. The time scales measured in this study were only a few months but experiments by others suggests that the enzymes will stay active in a device such as this for at least a year and possibly more.

The authors of the study consider that a scaled up version of the device would be able to power medical implants with much greater power requirements than a pacemaker, such as the artificial sphincter mentioned above that they calculate would need almost 10 times the amount of power of a pacemaker. Seems like the limit at the moment is how much room you have to spare inside your body to house the fuel cell. Early pacemaker batteries took up about 90mLs worth of volume, that’s roughly a quarter the size of a drink can. It is mentioned that an animal such as a pig could accommodate a fuel cell 133mL in size but it is not made clear if this is an experiment that will actually occur. RoboPig.

All this is pretty exciting and with that sort of potential in a first generation fuel cell, I’m betting I can get my memory expansion before I start going senile. Now I just have to figure out what to do in the mean time.

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Cinquin P, Gondran C, Giroud F, Mazabrard S, Pellissier A, Boucher F, Alcaraz JP, Gorgy K, Lenouvel F, Mathé S, Porcu P, & Cosnier S (2010). A glucose biofuel cell implanted in rats. PloS one, 5 (5) PMID: 20454563

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Filed under: Medicine, Sciblogs, Science Tagged: Add new tag, Artificial pacemaker, Batteries, Biofuel cells, Devices, energy, Fuel cell, Health and Medicine, implantable devices, Medicine, pacemakers, Science

Intelligent Design Flaws: The Evidence for Natural Selection in Our DNA Darcy Cowan May 17

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Here in New Zealand the debate between religion and evolution is a muted affair, while news on the topic regularly makes headlines in the US, here it goes almost beneath notice. That is not to say the clash does not exist here, merely that it tends not to intrude into the public sphere. Over time the form of the argument has changed but at its heart the source of the conflict has remained the same, discoveries in science have unseated the traditional view of a divinely created world in which Humans are the pinnacle of creation.

At this point I would like to make it clear that the findings of science are not incompatible with such a view.  Even so, to accommodate the conclusions of scientific enquiries into nature certain tenets that were previously held to be literal truths (such as 7 day creation) must be reinterpreted symbolically. As in any human endeavour there exists a spectrum of approaches to the religious significance of science’s discoveries. To some, science represents the deepest truth we can know about the world, provisional as it may be, and as such must also inform the religious outlook. For others revealed scripture is the ultimate authority and where this disagrees with science, well, so much the worse for science. Most people fall somewhere between these two extremes.

I seldom wade directly into this debate but recently came across a paper that outlines some of the peculiarities to be found in our genome (in particular but multicellular life in general) which was framed in the context of refuting design. The paper is “Footprints of Nonsentient Design Inside the Human Genome” written by John C. Avise and published in Proceedings of the National Academy of Sciences. Before getting to the crux of his argument Avise spends some time to give a brief history of three concepts that have a bearing on the discussion of design in nature. Touching on Socrates, Reverend William Paley’s famous work “Natural Theology” and Darwin’s own thoughts on the topic Avise gives a primer on how the natural world was considered in pre-Darwin times. From here we move onto the rise of modern Creationism and Intelligent Design, charting it’s progression from the early 1980s to the more recent strategy of proposing the concept of “Irreducible Complexity“.

Finally there is a similarly brief sketch of Theodicy, or the attempt to reconcile the existence suffering in the world with the traditional view of an all-powerful and all-loving deity (if you are playing charades I recommend doing “sounds like” and then try acting out Odysseus’ journey following the fall of Troy). This last seems somewhat out of place in a paper such as this but the relevance becomes clear once the author begins to expound on the multitude of human ailments that are the result of imperfections in the architecture and the replicating processes of our genome.

The numbers involved and breadth of disease in this section are truly staggering, to quote from the paper itself:

Various mutations are known to debilitate the nervous system, liver, pancreas, bones, eyes, ears, skin, urinary and reproductive tracts, endocrine system, blood and other features of the circulatory system, muscles, joints, dentition, immune system, digestive tract, limbs, lungs, and almost any other body part you can name.

In covering the various methods we use to keep track of genetic diseases, one of which being the reference text “Mendelian Inheritance in Man” Avise notes that “the current version of which describes thousands of human genes, of which more than 75% are documented to carry mutational defects associated with a disease condition.” and concerning another effort at documentation the “Human Genome Mutation Database” states “recent versions of which describe more than 75,000 different disease-causing mutations identified to date“.

After all of this preamble we finally get to the design flaws we have been promised, the first being “Split Genes”. Here is where things get technical. A quick “Genetics 101″, while we may think of genes as being discrete entities in our cells that code for the proteins making up our bodies, one gene to one protein, things are actually a lot more complicated. What actually occurs for many genes is a long stretch of DNA, some of which is needed for the gene and some of which isn’t. These parts are called Exons (needed bits) and Introns (extra bits), imagine reading Harry Potter and finding someone had randomly glued in pages from the dictionary. This means each time our cells want to make a new copy of a protein the extra bits need to be chopped out and the needed bits stitched back together first.

This process is both wasteful (unnecessary copying and fixing of the gene coding regions) and harmful, to quote once again:

“An astonishing discovery is that a large fraction (perhaps one-third) of all known human genetic disorders is attributable in at least some clinical cases to mutational blunders in how premRNA molecules are processed”

Next up is is a section discussing gene regulation and surveillance of errors. I have to say, this part is too complicated for me to parse ant this late hour. So I’ll leave that one for the adventuresome. Suffice it to say that the regulation (turning genes on and off) and copying of our genes is a complicated and error prone business, too much so if we are to consider it the perfect solution to the problem of creating human life.

The next stop on our curious ride is the mitochondria, or more specifically mitochondrial DNA. You may recall the oft repeated refrain that the mitochondria is the “powerhouse of the cell”, not to be confused with midichlorians which mediate the power of the Force. The mitochondria contain the reactions that allow us to extract energy from our food, without them you would die in very short order. It is one of the more intriguing facts about our cells that the mitochondria are equipped with their own DNA, and yet this DNA does not contain all of the information required to carry out the life giving energy reactions, it is supplemented by the DNA contained in the nucleus of the cell, your genomic DNA. Not only this but the interior of the mitochondria is a poor place to keep DNA, it is after all where energetic reactions are being carried out and toxic waste products are produced. Would you keep a valuable library in a working furnace?

These facts are all but inexplicable (and a great many more are mentioned in the paper) by appeal to a perfect designer but they are relatively easily dealt with via the paradigm that mitochondria are the remnants of a symbiotic bacteria. One which long ago insinuated itself into our cells and over the millennia has shed much of it’s own genome while housed in it’s comfortable new habitat. An analogy might be the loss of certain mathematical abilities in modern students who rely on electronic devices to to the hard work of calculation for them.

The paper goes on to deal with repeating sections of DNA, the existence of duplicated genes and pseudogenes and roving DNA that copies itself around the genome. But you can read about those for yourself, this post is already more than typically verbose. I would just like to sum up with the final hopeful run-on sentence (cousins of which plague my own writing) of the author:

“The evolutionary-genetic sciences thus can help religions to escape from the profound conundrums of ID, and thereby return religion to its rightful realm—not as the secular interpreter of the biological minutiae of our physical existence but, rather, as a respectable philosophical counselor on grander matters, including ethics and morality, the soul, spiritualness, sacredness, and other such matters that have always been of ultimate concern to humanity.”

Not exactly an uncontroversial sentiment itself.

Avise, J. (2010). Colloquium Paper: Footprints of nonsentient design inside the human genome Proceedings of the National Academy of Sciences, 107 (Supplement_2), 8969-8976 DOI: 10.1073/pnas.0914609107

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Filed under: Medicine, Religion, Sciblogs, Science Tagged: Atheism, atheist, Biology, disease, DNA, Eukaryotic, evolution, gene, genetics, Human, Human Genome, Mitochondrial DNA, Religion, Science, Science and Society, theodicy

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

Persistent Vegetative States and the Problem with Facilitated Communication Darcy Cowan Nov 25

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If you read the print version of the NZ Herald today you would have seen featured on the front page a miraculous case of a man [Rom Houben] recovering from a persistent vegetative state and communicating with the world through a touch screen with the help of a carer. The topic of persistent vegetative state (PVS) is an interesting one and has received increasing attention in recent years. It would seem that this man was incorrectly diagnosed after an accident as being in a PVS while at the time of the accident it is more likely that he was in a minimally conscious state (MCS). A fine distinction sometimes and an excellent summary of the differences between the two diagnoses and the difficultly of accurately deciding between them can be found at the Science Based Medicine site.

Essentially a PVS is defined as the patient exhibiting no signs of consciousness, as with everything, whether you find something is dependent on how hard you look, simply opening a couple of drawers and glancing in the cupboard may not turn it up. In determining a case of PVS a more thorough search will reveal fewer legitimate cases as you may find extremely subtle signs of intermittent consciousness that will then flip the designation to a MCS. This process is also dependent on the sensitivity of the equipment used to perform the examination, the sophisticated scanning technology we have today simply did not exist 20 years ago. This equipment is the equivalent of rummaging around in the back of the couch and looking behind the fridge.

That this man was unfortunately diagnosed incorrectly is not in dispute, we have made significant advances in brain imaging technology that allows us to determine activity quite well. The issue here is the man’s ability to communicate so coherently and poetically. After so long without mental stimulation it seems bordering on the fantastic that this could be the case. When watching the video of the touch screen being used to bring this man’s thoughts to the world it seems very close to a practice known as Facilitated Communication, (this is actually confirmed in the TimesOnline article) this consists of a facilitator supporting the arm or hand of a subject ostensibly to allow them to then choose letters and words themselves which otherwise they would not have the strength or the focus to do.

The difficulty here is that this technique is very susceptible to the unconscious influence of the facilitator. In this way it can seem as though it is the patient communicating when in reality it is the thoughts of the facilitator that we are hearing. It is difficult to say for sure in this case, the video is ambiguous as to how much control the patient has over his movements so it is possible that we are indeed being exposed the inner world of a man with a very unique perspective but from the evidence shown it is equally plausible that the facilitator is the true originator of these words.

I would be interested in if any simple tests to determine the true origin of this material have been carried out, some of the suggestions I have seen elsewhere include swapping the facilitator for someone who does not speak the patient’s language, asking the patient questions that presumably only he would know, or asking the facilitator to leave the room while the patient is shown an object or told specific information and then seeing if this can be reliably produced after the facilitator returns. Any of these would help determine whether this man is truely communicating.

The print version of the Herald is mostly credulous in it’s coverage of this story but it appears that enough scepticism has filtered through the journalistic world that the online version has incorporated some of it. Better late than never.

[EDIT: The incomparable Dr Novella of the SGU and SBM has posted his take on this news item, as I hoped he would. Get the thoughts of a neurologist. Also had to add a link to this video from Dr.N's site that shows the patient typing with his eyes closed, simply not possible. Added Patient's name]

Posted in Psychological, Sciblogs, Science, skepticism Tagged: consciousness, Facilitated communication, Health and Medicine, MCS, Medicine, minimally conscious state, persistent vegetative state, PVS, Rom Houben, Science and Society

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