Wednesday, January 31, 2007

Faith Healing as an Alternative to NHS Waiting Lists: Poll Manipulation?

Polling with a poll on what came first, chicken or the eggPoll takers are remarkably successful at media manipulation that meets their agenda: whether this is raising awareness for a single issue or publicising a launch. So, when Luna the Cat commented about a poll which seemed to highlight that a distressing proportion of the Great British Public has had their brains scrambled, I was miserable. After the first few depressing minutes, I considered the source and started wondering just what questions had been put to those who were polled.

Yahoo headlined their report of this poll as 'Faith healers' an option for many. The headline results were:
More than half of people would turn to therapists such as faith healers rather than endure long NHS waiting lists, according to a new poll.

And more than two thirds (67%) believe in the psychic powers of mediums and clairvoyants, 54% in ghosts, and 41% in an intelligent life on another planet, the poll found.

Seven out of 10 people questioned could name a paranormal expert, compared with one in 10 who could name a nationally acclaimed doctor.

Regionally, 72% of those in Scotland said they would turn to an alternative therapist to get better, followed by 66% of those in Wales and 45% of Londoners.
Now, although these results have a little in common with the recent findings on homeopathy and herbal prescriptions on the NHS, I was a little startled by these differences, particularly in the home of David Hume.

Then I looked at the people who had commissioned the poll. I have never seen ITV 2's Haunted House but I would guess that it is slanted towards an audience that believes in the paranormal or has a strong interest in it. Despite the headline used to promote the piece, it is not clear what it was that poll participants had been asked. However, it is plain that they were not asked how many of them had already used faith healers. Nor is there any indication that people were asked specifically about faith healers or if they were asked about alternative health therapists from which the pollsters chose to isolate and highlight faith healers. E.g., I have been on a long waiting-list for physiotherapy for a knee that was subluxing if I turned over in bed or got up from a sitting-position: I looked around for a Pilates teacher who had a reputation for rehabilitation. That would probably count as a willingness to entertain CAM as an alternative to a long waiting-list but would a pollster feel empowered to claim that I would be willing to consult a faith healer?

I am desperately trying to defend the rationality of the british public here but I do wonder just how much this poll has been manipulated. In the same way that scientists are being asked to be willing to disclose their raw data for scrutiny, I'm beginning to think that pollsters should web-publish their questions and the demographics and other criteria for their participants. Were the participants self-selected (e.g., answering a poll that was only offered on Haunted House's website) or was this a random street poll or a telephone poll of carefully-selected subjects, chosen to be representative of the UK population?

icWales reports this poll as Waiting patients put faith in healers and quotes the following:
Professor Cary Cooper, a behavioural expert from Lancaster University, agreed that a lot of less serious illnesses are psychosomatic.

Professor Cooper said, "People on waiting lists can think, 'well I might as well try something else while I'm waiting, what can I lose'?"
I'm not at all sure that the news organisation was entitled to use that headline. I'm entertained that the news organisation took a comment about the authenticity or gravity of illness from Prof. Cooper without feeling the need for any supportive statistics. Again, I have to wonder what Prof. Cooper was asked, or if he just spoke without regard to the harm that can be done by CAM. E.g., the interaction of herbal and prescription medications or injuries caused by manipulative therapy. Is Prof. Cooper aware that inappropriate allergy advice by unqualified personnel could lead to unhelpfully restrictive diets or even wrongful advice about carrying out home challenges with suspected allergens?

According to the news reports, Mia Dolan, a psychic on Haunted Homes, said:
People are no longer embarrassed to see psychics or healers.

These ancient arts are returning to the forefront of society and, combined with the constant press on the state of the NHS and an increase in the belief of these arts, it's no wonder people are looking elsewhere for healing.
I hope that Mia Dolan is completely wrong. However, I do wonder if people are driven to CAM by the degree of rationing in the NHS. I am annoyed that this poll has had so much uncritical coverage in the mainstream media. For people who do not differentiate well between the value of polls and scientific studies, there is a wider harm that is done by publicising these polls so uncritically. It is time that pollsters had to divulge their questions and poll population: it is well beyond time for lazy journalists to start asking some critical questions. Cynical poll commissioners can abuse polls because it works.

Sunday, January 28, 2007

BritMeds 2007 (4) Is Up!

BritMeds 2007 logo with a Union Jack backdropOver on NHS Blog Doc, Dr. Crippen has been trawling British Blogs for posts on a medical topic for BritMeds.

It is a rich blend of posts that covers politics, medical ethics, economics and general weirdness. Mix all of these with an insight into public health development and political machinations, and we have a thoroughly entertaining compilation.

Paediatric Grand Rounds 1:21 Is Up!

Emerald CityThe excellent Clark Bartram of Unintelligent Design has put together a fantastical and enchanting version of Paediatric Grand Rounds. This PGR is whimsical, entertaining and educational; who could ask for more for suitable Sunday reading?

To quote Sandy of Junk Food Science:
The collection of pediatric articles looks at the scientific reality and debunks popular beliefs about children in this make-believe world, such as food intolerance explanations for general symptoms that lack medical diagnosis, the epidemic of food allergies, the association between ear infections and later developmental problems, heavy metals as causing autism, “poor excretors,” benefits of dietary manipulations in preventing or treating autism, and the labeling obesity and overweight in children. And there’s something about a talking twinky in a cowboy hat....
You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

Saturday, January 27, 2007

Traffic Pollution Damages Children's Lungs

Please sing these lyrics to the tune of Favourite things from The Sound of Music.
Carbon from traffic decreases lung function;
Fossil fuels smudge up the air with corruption.
FEV, FVC, spirometry
Are showing diminished capacity.

Dark coloured sputum and black macrophages
Clutter the airways but act as good gauges
Of exhaust pipes spewing opacity
Causing diminished lung capacity

Breathing in air that is full of pollution
Leads to kids' general health dissolution
Wheezing their way to co-morbidity
Showing diminished lung capacity

When the car fumes
When the plane flies
When the ozone's bad---
Kids simply breathe with lungs harmed by these things
And their future health's so bad!

Mosaic images of pollution, gas mask and child with nebuliserLast year, research confirmed that traffic pollution harms the lungs of healthy children. In a editorial that accompanied that report, Dr. Gauderman observed that the factors that disrupt lung function in childhood are significant because of the lifetime implications of the impairment.
[R]educed lung function later in life has been described as second only to the exposure to tobacco smoke as a risk factor for death.
So, I'm a little surprised that the Guardian quotes unnamed environmental campaigners who describe the findings of a newly-published study into the adverse effects of traffic pollution as a "bombshell". Yes, this study is rather more assertive about the findings that children who live within 500 metres of a motorway grow up with significantly reduced lung capacity but it is only a "bombshell" to those who have sealed their ears with wax and taken up a hermit's existence in a cave on a remote island. This year, Gauderman writes that:
[i]n view of the magnitude of the reported effects and the importance of lung function as a determinant of adult morbidity and mortality, reduction of exposure to traffic-related air pollutants could lead to substantial public-health benefits.
The Times has the grace to notice that this study is not the first to link pollution and lung defects, but says that "the study is more convincing than some earlier ones".

The researchers followed 3,677 children in 12 southern Californian communities for 8 years, and measured their lung function every year. They accounted for other variables that might affect lung function and reported that, when compared with children who lived more than 1,500m away, those who lived within 500m achieved only 97% of their predicted lung volume, and only 93.4% of their maximum air flow when breathing out.

I'm a little unhappy about the status of predicted lung volume and maximum air flow as surrogate markers for future disease. It is possible that longitudinal studies suggest that, for example, the VC and the FEV1 of a contemporary 20 year-old is greater than that of a 20 year-old 40 years ago before clean air legislation was enacted in many countries.

Although the researchers used pulmonary function tests that are comparatively easy to administer, they do not directly indicate the efficiency of gas exchange in children's lungs. In young children, increases in lung volume and capacity are primarily attributable to developing the number of alveoli from around 17 million to around 300 million. In older children, such as the ones in this study, the period of alveoli multiplication is followed by a period of consolidation in which the alveoli increase in size.

In line with earlier studies, the researchers argue that fine carbon particles from diesel fumes are the most likely cause of the lung damage. In an accompanying commentary in the Lancet, Thomas Sandström and Bert Brunekreef suggest that these particles cause inflammation of the bronchial walls with long-term consequences.

Professor Stephen Holgate, a respiratory disease specialist from the University of Southampton, said, to the Times:
This study once again draws attention to the toxic effects of traffic pollution on children’s health. This is probably through their powerful oxidant effect on lung development in the first five to eight years of life. The implication of this study is that reduced lung function in childhood is a known risk factor for the development and worsening of asthma in children and the development of chronic obstructive pulmonary disease later in life, as well as reducing exercise tolerance and increasing the risk of serious lung infections in childhood.
There is a push towards encouraging car manufacturers to produce environmental impact labels in their advertising and the running-costs associated with them. This raises the question, "What is a price?". To everyone but economists, it is nothing more that the amount we pay for a given item or service. One example is the amount of money we hand over for our food shopping at the supermarket. But, to an economist, the price is a more sophisticated package. The time that we spend waiting to enter the car-park, at the fish counter, the delicatessen and at the check-out is all part of the price. The food miles accumulated by our purchases are part of the price. According to the economist Kevin Murphy, the nutritional downside of our food choices may be part of the cost: he calculates that a cheeseburger effectively costs $2.50 more than a salad in long-term implications.

What would the true costs be if advertisers had to include health impacts and quality of life for pedestrians, other road users and city inhabitants in their costings? What is the cost/benefit analysis of alternative fuels that reduce the impact on the environment and on children's health? What is the cost/benefit analysis of national and local government policies that allow increased housing density near major roadways?

What would happen if advertisers had to give the true, loaded cost of using their vehicles: moving beyond even the new fuel economy label to include associated health costs as well as the cost to the environment? Similarly, if we had the costings of various policy decisions.

The standard advice for families who live in a high-pollution area and have respiratory symptoms is that they should minimise children's outdoors exposure on high-ozone or high-pollution days. Which all sounds rather bland and ineffectual given the nature of these findings and the lifetime implications for children's well-being. Where is the dream-team of a really smart economist, an epidemiologist and a respiratory specialist when you need one?

Friday, January 26, 2007

Some Sticky Numbers and Comparisons for Food Allergy and Intolerance?

Mosaic of images reads A is for Avoidance
In response to some of the Allergy UK figures cited in a recent post about food allergy and intolerance in the UK, Dr. K remarked:
I find it very difficult to believe that almost half the population are 'severely affected' by a food allergy or intolerance. I wonder if a proportion of these people are simply saying they are affected when it is either mild or non-existent?

I have a colleague with a nut allergy - 2 admissions to hospital with anaphylaxis. Not surprisingly he is very careful to avoid nuts at all costs. I have 2 friends who decided to get tested for food allergies via the internet. They were told they were allergic to wheat, dairy, chocolate and coffee. They both still eat all of these so whatever effects these alleged allergies/intolerances have I would imagine they are not 'severe'.
The comment raises so many issues. Did the people who responded to Allergy UK's survey benchmark their response relative to anaphylaxis, a life-threatening reaction to food, or according to some notion of consequence-free eating, digestion or stress? I've thrown stress into the mix because, thanks to the fascinating work of William Beaumont (the father of gastric physiology), we know that stress and negative emotions have a striking impact on digestion. (Beaumont had treated Alexis St. Martin for a musket wound to his upper-left abdomen that did not heal over. Beaumont used the fistula (hole) to conduct a number of experiments into digestive processes: he observed, among other findings, that anger and distress intefered with digestion.)

I've been discussing allergies and intolerances quite frequently this week and some of the discussions have been surprising. One maths-savvy scientist claimed that if half of the population have a problem then it is so common that no-one can have a problem. I was a little startled by this and asked if this is true of contagious diseases or food-poisoning because enquiring minds need to know. He then modified his claim to "if half of the population claims food sensitivities, then they are no longer unusual or sensitive reactions". I'm still not convinced by this because it very much depends upon the people and the foodstuffs: I have no difficulty in believing that, e.g., people who have been brought up without dairy food and have lost their ability to produce lactase enzyme would be lactose intolerant in large numbers.

Nonetheless, it does feel wrong that half of the population could report 'severe' effects and it does return to the issue of how people are benchmarking the level.

The send-away tests that Dr. K referred to emphasises concerns about the accuracy or utility of those tests. How is it possible to eat these 'suspect' foods without incurring consequences that must be aversive or why would you have paid out so much money to have them confirmed? However, the issue here may be a variation on risk v. danger, where researchers have said that what matters is an individual's feeling for control. E.g., for Diabetes II most people understand the importance of diet and exercise. The question is not whether people can be bothered to control it but whether or not they feel that they can. People with anaphylaxis do not have the choice, but do people with less severe reactions continue to eat 'contentious' foodstuffs because they have the feeling that they could control their diet if they wished?

Is it possible that, in general, the severity of reaction is over-reported and that the cause of the symptoms is mis-attributed? Some commenters argue that modern attitudes to food allergies and intolerances resemble replacements for spiritual concerns or discontent with modern life.

One obvious solution to the question of confirming food allergies and intolerances would be better access to validated clinical tests and clinical allergists who can make an appropriate determination by combining the patient history with the tests. However, there are two concerns. One would be the practicalities of referring half of the population for a clinical assessment. My other concern is centered about whether or not the outcomes of the testing would be accepted: there is a well-accepted clinical test for hypothyroidism and there is an sizable cottage-industry around the diagnosis and treatment of sub-clinical hypothyroidism. Is it possible that more dubious allergy testing and restrictive diet recommendations would continue because these results are more in line with what some people would need to hear?

For more information about the images used in the illustration, click on it or visit the detail on Flickr.

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Thursday, January 25, 2007

Asthma, Food Allergies, Fashion or the New Source of Spiritual Re-Awakening?

Modern life damages childhood
Dr. Crippen has written up his recent experience with a young child who was sent to hospital with
a severe asthma attack. Well, that was my diagnosis. Mum was not keen on it. “We don’t have asthma in our family, doctor.” They do not have broken legs in their family either, but who knows what is round the corner. The hospital kept her in for three days and treated her with nebulisers, steroids and antibiotics (just in case). She is much better now. Back to normal. Mum is delightful, really, but said to me, slightly triumphantly, “and the specialist said it wasn’t asthma”. I looked at the discharge summary. “Bronchial hyper-reactivity, mucus plugging and post-viral wheeze.”
The willingness to diagnose asthma in the under-6s varies in different countries. Doctors are anxious not to miss or under-treat asthma because undiagnosed asthma can have a significant impact on children's development and quality of life. Some doctors will only confirm a diagnosis of asthma with spirometry.

I've met some doctors who defer confirming a diagnosis of asthma for as long as possible because it used to restrict the career options; e.g., police or fire services or the Armed Forces. Nonetheless, they prescribe asthma medications for a child's symptoms which they treat with a high index-of-suspicion for asthma.

Dr. Crippen writes about parents who are unwilling to entertain a diagnosis of asthma. Antipodean Doc had commented on this reluctance:
Semi-seriously though, why is asthma such a dreaded diagnosis when you consider that parents are almost tripping over themselves to diagnose fashionable food allergies in their children? Obviously I exclude nut anaphylaxis etc from that. Sucking on inhalers every so often is far preferable to only being allowed to eat wheat/dairy/colour/taste-free food under the light of a full moon?
I was taken by Antipodean Doc's remark because I recently read a review of Barry Glassner's The Gospel of Food which explores the newly acquired fear of food. Glassner's books opens with a powerful and familiar image:
I was at this birthday party for a child, and I took a bite of the birthday cake and my tongue stuck to the roof of my mouth. The parents were so proud that they had provided this "healthy" birthday cake, because it didn't have anything in it that would make you want to eat a cake. It didn't have eggs, or milk, or wheat, or butter, of course, and it didn't have any sugar because, of course, that could kill you immediately. I started thinking, "It is bizarre that this is what we've come to," and that was kind of the turning point.
I haven't seen Glassner's book so I can't comment on it but he does provide a good summary of some common threads in fashinable attitudes to food.
I think that one way that the food industry is brilliant is in picking up on the bipolar approach to food that we have in [the USA] where we think that certain foods are good or bad, or sacred or profane. The food industry will sell us foods that make us feel like we've been good and righteous and then they'll say, often in so many words, "Now that you have been good you can be bad and buy this other product." And they win both ways.

When you listen to a lot of people talk about their meals, they use words like, "I've been bad," if they order a creamy dessert at a meal. Or, "I've been good," if they stay on their diet. The key motivator there is guilt and the avoidance of guilt. And it applies not only to ourselves, but to other people. So many Americans take as a literal truth the old maxim that you are what you eat. We believe that we can tell a lot about a person by what he or she eats when really what we're expressing are prejudices.
Glassner does locate some of this in religious traditions that proscribe some foods and recommend practices such as fasting. He identifies that some of the people who 'eat for health' are adherents of a 'doctrine of naught' where a meal is more prized for being free of trans fats, additives, red meat, calories, salt etc. that for what it contains.

Glassner also highlights the evangelical fervour of the followers of a particular way of eating, whether it is veganism or Atkins:
What I'm uncomfortable with are the exaggerated claims that they make, that a meatless regimen can prevent most every serious malady from heart disease to world hunger, or that following an Atkins diet is a magical potion for longevity and weight loss.
I hear a lot of remarks about pure, cleansing and de-toxing foods that 'reduce the burden on children's overloaded systems'. There does seem to be a lot of implicit fear about 'modern toxic environments' in those descriptions that borders into territory more commonly associated with religion and may express some of the parents' fears about modern life.

I have heard parents express alarm about the behaviour of their children when 'intoxicated' by additives and sugar that borders on an analogy to demonic possession. For these parents, one solution seems to be a restricted diet that in comparative modern terms can resemble the asceticism practised by Anchorites. I've met parents who exclude several foodstuffs from a child's diet, administer lots of supplements and are then disappointed when the child does not manifest a 15 point IQ bump within a few weeks. I am concerned that some children are learning that their bodies are battlegrounds that are under assault by the environment and something as ubiquitous as food. They learn that some foods promote health and energy and others strip them of both and should be shunned.

Yet, it is unquestionable that when children have allergies, it is psychologically gruelling. In the US, several hospitals are devising support programmes for affected families.
In a study of 17 families with children with anaphylaxis, the authors describe the profound psychosocial impact on parents of knowing an illness can cause death. "I was completely shocked and surprisingly emotional," says Stefanie Jones, who burst into tears when daughter Darby was diagnosed four months ago with egg, milk, wheat, and peanut allergies. "I realized I'm going to have that weird kid at the party with the dairy-free, prune juice cookies."

Children, of course, bear the brunt. "The emotional toll is huge," says Muñoz-Furlong. "It tends to wear them down, particularly after they have a reaction." Some children lose the ability to trust people. They may want to stay home all the time within a controlled environment. If they have a reaction at home, they may become afraid that even their parents can't control the allergy. Others are fearful of food or develop eating disorders. They might become hypochondriac, phobic, or suffer from panic attacks or post-traumatic stress disorder symptoms.
Parents can be exhausted by the effort involved in proving a milk-free playdate for their children. Paradoxically, because so many parents claim 'fashionable' allergies for their children, it may undermine a full understanding of how deadly serious allergies are for other children.

For more information about the image used in the illustration, click on it or visit the detail on Flickr.

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Monday, January 22, 2007

Food Allergy and Intolerance Week in the UK

Sign text reads: Peanuts and peanut dust everywhereIt's Food Allergy and Intolerance Week in the UK. Allergy UK has been very successful in promoting the news story about this because it seems as if the british public enjoys few scientific stories more than something that involves more dire warnings about the hidden disease and death that lurks in everyday foodstuffs.
2% of the population suffer from life threatening allergy but when coupled with the larger number of people (estimated to be in the region of 45%) who suffer from food intolerance, which whilst not life threatening impacts severely on all aspects of their life, means that almost half of the population are adversely affected by the food they are eating.
Allergy is wretched and it can kill. Intolerance can be miserable but I'd like a little more evidence behind the "impacts severely" and "adversely affected"; failing that, I would open to some examples that have more behind them than self-report.

The NHS has scant to negligible provision for allergy testing. Because of this, the field is open for people to obtain their testing from more dubious sources or sources that do not use validated methods. Allergy testing is useful but it must always be secondary to a good, thorough history that is interpreted by a skilled clinician. Many people are relying upon the results of unvalidated technology to make decisions about their diet, even when this can lead to extraordinary restrictions because they do not have ready access to appropriately qualified allergists.

There is a lot of scepticism about the reported high prevalence of food intolerance as an explanation for feelings of tiredness, malaise and other symptoms that lack a medical diagnosis. An interesting contrast in covering this same issue can be seen in the The Times, which offers us It's Udder Confusion, and The Independent, which has Pasta and milk are root cause of ill health for millions. The latter reports a particularly stark state of affairs for people who report food problems:
more than a third suffer from more than one symptom - the most common being bloating, diarrhoea and vomiting. One in 10 falls victim to lethargy and anxiety. More than half become so sick that they have to take time off work and two-thirds have problems sleeping. Although 76 per cent regularly go to their GP for help, most said their doctor did not understand their problems.

But a survey of 250 GPs by North Union Healthcare last year showed that while 63 per cent reported an increase in patients reporting a food intolerance, 73 per cent claimed such reports were all in the mind.
There is obviously a considerable disjunct in opinion between the people who believe that they have a disorder which "impacts severely" and has "adversely affected" their lives and the GPs who are the gatekeepers for NHS referrals.

However, there are few allergists who work for the NHS. It seems that some GPs may have reservations about the available testing. Some commentators see claims of dietary intolerance as a modern manifestation of regarding nature as good or bad or an underlying fear that modern life is toxic. It is undeniable that if dietary and specialist allergy advice were more high-regarded and available in the UK then patients might feel that GPs are able to "understand their problems" and GPs might have clearer information on which to found recommendations rather than reassurance which may not help or the claim that "it is all in your mind".

Allergy has the potential to kill and allergies must be treated with respect. Allergies must have clinical assessment and management.

The picture is less clear for intolerances. It may be very unwise to restrict your own or a child's diet on the basis of scientifically-dubious tests and in the absence of a clinical assessment. There is some speculation that restriction might even contribute to later sensitivities for a child if there are no appropriately low-level challenges to the immune system. There seems to be little value in test results that are not grounded in science and may imply the need for dietary-restrictions or allergen-avoidance that may have such a significant impact on your well-being or that of a child.

Haloscan comments do not show up in Blogger.

Follow-ups: Asthma and Food Allergies: Fashion or the New Form of Spiritual Re-Awakening?
Some Sticky Numbers and Comparisons for Food Allergy and Intolerance

For more information about the image used in the illustration, click on it or visit the detail on Flickr.

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BritMeds 2007 (3) Is Up!

BritMeds 2007 logo with a Union Jack backdropOver on NHS Blog Doc, Dr. Crippen has been trawling British Blogs for posts on a medical topic for BritMeds.

It is a rich blend of posts that covers politics, medical ethics, economics and general weirdness. Mix all of these with an insight into public health development and political machinations, and we have a thoroughly entertaining compilation.

Paediatric Grand Rounds Wants Your Post, Please

Mock-up cover for Standing Baby magazineYes, it is out with the begging bowl, as I shamelessly rattle the post collection bag and ask you for your contributions to Paediatric Grand Rounds. As you can see from the magazine cover, we are open to conventional and more off-beat topics.

Clark Bartram of Unintelligent Design is hosting the PGR this week and would like to receive the posts by Saturday afternoon.

CB's address is clarkbar2019 AT yahoo DOT com

Friday, January 19, 2007

The Loss of Innocence: Is Ghost-Writing Betraying Trust in Scientific Findings?

Pirate Mosaic with traditional images and treasure

My father was a hobby-scientist who delighted in collapsing tea-kettles for our entertainment (creating a vacuum), much to the annoyance of my mother who once had to replace three kettles in a week. The only time my mother put her foot down was when my father had myself and my two young sisters in the back-garden, whirling buckets of water around to demonstrate the forces that kept the water in the bucket. The problem was that although I was tall enough to whirl the bucket, the little ones weren't and both of them sustained nasty blows to the head with a heavy, zinc bucket. We burned brazil nuts and marvelled at their fat content.

I've always enjoyed reading about the history of scientific discovery. The popularity of Dava Sobel's Longitude highlights that may people are fascinated by the painstaking work of scientists who were working with the most rudimentary facilities to explore remarkable scientific issues.

I'm completely fascinated by the history of discovery in respiratory and cardiac physiology. Scientists worked under the threat of physical and spiritual death to expand knowledge and to explore the world about them even if it challenged the prevailing religious viewpoints.

Thousands of years ago, both the Chinese and Egyptians recognised that most life depended upon an uninterrupted supply of 'good air'. Hundreds of years ago, there as avid speculation about respiration that could not be confirmed until comparatively recently. Scientists had speculated about the need for 'porosities' and their role in transferring oxygen to the blood and around the body, long before the existence of capillaries was confirmed by microscope in the 17th century.

Devoting endless energy to tedious detail and meticulous data recordings, and using simple tools, people like Stephen Hales calculated how much blood is pumped per minute by the heart and he made an extraordinarily accurate estimate of the size and number of alveoli in the lungs. I've long admired accounts of scientists who experimented upon themselves. For some reason, I've always remembered an account from 1920 of Joseph Barcroft who wanted to research altitude physiology and arterial blood gases. Barcroft needed to tie a large needle into his radial artery to enable him to measure his arterial oxygen levels at the same time as he collected an alveolar air sample. This technique, he noted, meant that the radial artery, "of course had to be sacrificed". There are many accounts of the Haldanes (father and son) and their self-experimentation.

Science, discovery and exploration have many enthralling figures with a magnificent obsession. Science was frequently lampooned; e.g., Swift's Laputa in Gulliver's Travels. Yet, in Pope's bleak vision in the Dunciad, the Goddess of Dulnesse destroys order and science so that she can develop rigid control of the kingdom. She gives directions to her agents to prevent thought and to distract people to engage in foolish and trifling pursuits. As Dulnesse's plan is implemented, Night and Chaos spread throughout the land and the epic closes. European history emphasises the importance of scientific thinking and development in making human, political and social advances.

I've always had a starry-eyed view of science and research. Even my own experience as a researcher did little to crush that: I lost some of my faith in researchers but kept my belief in the essential integrity of research and the peer-review process of publication. However, I've recently been compiling a literature review and I've had a difficult time trying to understand why some particular outcomes were used to measure success and why the data were interpreted with particular statistical tests.

Friends and colleagues have been sending me articles about ghost-writing and the manipulation of research and publication. I've been ridiculously miserable about this: I've been moping about in a way that makes the first Jane Eyre-John Rochester wedding day look like a model of decorum and maturity. I just couldn't write about it. Thankfully, Sandy has written, Behind the Mask: Who Really Wrote That?. She explores the issues involved and discusses their importance:
It is important that the author who has played a substantial role in the research or writing of the article to be disclosed, they said, because authorship “establishes accountability, responsibility and credit for scientific articles.” To not do so can mislead readers and make the potential for manipulated analyses and conclusions much greater, they said.
She highlights the problem that we don't know about negative findings because they are not published. Ghost-writing and data suppression are both strongly linked to commercial interests rather than scientific interest.

Dr. Aubrey Blumson blogs about Scientific Misconduct; he says that, "If you're not outraged, you're not paying attention". Harlan Krumholz and his colleagues discuss the impact of the Vioxx case in the current issue of the BMJ. Controversy was exacerbated when it became public that Merck had obscured data about the drug's toxicity and had used ghost writers to author papers on Vioxx that were published in several academic journals.

The authors argue that the Vioxx case has lead to widespread distrust and is “bad news for industry, academics, journals and the public”. They propose that academic medicine, industry, medical journals and government agencies should define a set of principles governing drug development. They call for greater transparency and round out their desiderata with the piety that:
collaborations between academics, practicing physicians, industry and journals are essential in advancing knowledge and improving the care of patients. Trust is a necessary element of this partnership, but the recent events have made it necessary to institute proper systems that protect the interests of patients.
Of course scientific rivalries and abuses have always existed but there is something especially despicable about suborning the scientific process when lives and wellbeing are at stake. I also think that it is going to be difficult to restore the general trust in research. This is especially relevant when we rely upon the integrity of research to support evidence-based medicine and clinical decisions.

Wednesday, January 17, 2007

Diet Supplements, Safety and Children: Some Concerns

Images of children's vitamin preparationsWe're used to media pieces that warn us of the nutritional inadequacies of our diet or suggestions that intensive farming strips our food of nutritional value to the point where we would all be well-advised to take supplements. Lots of lifestyle media advise us to be wary of pharmaceutical preparations and to consider 'safer, natural' alternatives. The New York Times has published an interesting essay: Diet Supplements and Safety: Some Disquieting Data (use Bug Me Not if it asks for a log-in and read the correction) that is taken from Dan Hurley's Natural Causes: Death, Lies and Politics in America’s Vitamin and Herbal Supplement Industry. I haven't seen the book but it has attracted some adverse comments from interested parties on amazon.com (which is why I've given the US rather than UK link). I'll return to these comments.

Senator Orrin G. Hatch famously defended herbal remedies, saying that they
have been on the market for centuries. In fact, most of these have been on the market for 4,000 years, and the real issue is risk. And there is not much risk in any of these products.
I'm flabbergasted by the notion that there was much competition for herbal remedies on the market over those 4000 years or that the consumers implied by this market had much alternative at all or the luxury to be concerned about relative safety, but I digress. It seems as if Senator Hatch was mistaken. Apparently, there is some risk and children are particularly vulnerable. The American Association for Poison Control Centers has been logging reports of poisoning, including those that involve vitamins, minerals, essential oils and homeopathic remedies. Unsurprisingly, the supplements linked to the most reactions were ordinary vitamins (more than half of all the reports in 2005). Minerals were linked to about half as many total reports but were linked to more deaths.
Injuries to children under 6 account for nearly three-quarters of all the reports of adverse reactions to dietary supplements, according to the poison centers. In 2005, the most recent year for which figures are available, 48,604 children suffered reactions to vitamins alone, the ninth-largest category of substances associated with reactions in that age group.
The standard advice from medical authorities and government agencies is that healthy children do not need vitamin or mineral supplements. However, possibly responding to the the media scare stories that Sandy discusses over at Junk Food Science, Hurley reports a study that found that 54% of parents of preschool children gave them a vitamin or mineral supplement at least three days a week.

It is particularly interesting to note that when there are adverse reactions to prescription drugs, somewhere between 3-4% occur at the recommended dose levels. Adverse reactions to vitamins, minerals and essential oils occurred at comparably low levels when people took the recommended amounts. However,
adverse reactions linked to the recommended levels of herbs, homeopathic products and other dietary supplements accounted for 10.3 percent of all reactions to those products reported to the poison centers — about three times the level seen for most drugs.
Reading this, it occurred to me that I have no idea how the manufacturers of these products establish their recommended doses but I assume that there are no well-validated therapeutic trials. I was interested enough to scamper into a local self-styled health food shop as well as my local pharmacy that stocks some of these products. I didn't find any patient information inserts to alert me to the signs of overdosing or to inform me of the range of side-effects and the likelihood of experiencing them. I looked about on the internet and the following FAQ answer (half-way down) is quite typical:
Homeopathy can be safely taken with over-the-counter drugs or prescription medications. People using other therapies can also use homeopathy. Conventional medicines when combined with other medicines cause side effects and serious to life threatening results. Homeopathy works in a different way and does not interfer [sic] with other therapies, drugs, herbs, vitamins or supplements. Homeopathy is safe to use in conjunction with other medications or with other homeopathic remedies. Homeopathy is without side effects. [My emphasis.]
At a time when the MHRA in the UK is allowing homeopathic remedies to indicate the conditions for which they can be used and when GPs are allowed to prescribe these remedies on the NHS it is cheering to note that the US Congress has approved a measure to require the manufacturers of dietary supplements and over-the-counter drugs to report serious adverse events to the FDA. However, I do wonder how many consumers will report such adverse events when they are repeatedly told that "homeopathy is without side effects" and the like.

I haven't seen Hurley's book so I can't comment on it. According to the commenters on Amazon he has made some irritating mistakes. At the time of writing, the book has 2.5 stars which is a little surprising when the book received positive reviews in the trade press. One editorial review mentions that
Hurley wraps up with a refreshingly tough-love conclusion: the bamboozled have to accept some of the blame themselves for wanting a quick-fix promise of good health without having to do the work of a salubrious lifestyle.
Some comments accuse Hurley of being selective in choosing his studies (he mentions some well-received meta-analyses in the NYT piece) and ignoring others: there is some speculation that he is "somehow receiving financial or material support from Big Pharma". One commenter does have the grace to conclude his negative review with the information that he is an "attorney specializing in food in drug law. Many of my clients are in the dietary supplement/natural products industry".

Other commenters are 'outed' for their own special interests in the comments on their comments. One 'outed' commenter is Suzanne Shelton who wrote:
Anyone without an agenda who has done a little research knows there are a number of supplements that are very safe and extremely beneficial. Alas, none of those studies are in the book. There are even Lewin Group studies on the cost savings of disease prevention through supplement use, but they aren't in this book either. Dont be mislead, this is not an objective examination of the supplements world, it is the work of someone with a set agenda.
In the spirit of fairness, I consulted the Lewin Group website to see if I could identify these studies. Perhaps I didn't look hard enough because I could only find this one about Multivitamins and Public Health: Exploring the Evidence. At the risk of being pedantic, the report predicts that there would be potential healthcare savings associated with daily use of a multivitamin by the elderly; it would have been premature to have included this study in the book as its predictive model runs until 2008.

I'm also not entirely sure how many of the studies in the literature review on which they grounded the model were speculative or observational rather than large-scale prospective studies. In the fact sheet summary of the study (pdf), the authors single out an article by Drs. Fletcher and Fairfield who they summarise as saying that "suboptimal intake of some vitamins (above levels causing classic vitamin deficiency) is a risk factor for chronic diseases and common in the general population, especially the elderly. Fletcher and Fairfield call multivitamin dosages "safe and inexpensive," and directly "recommend that all adults take one multivitamin daily."

Now, it is true that those recommendations can be culled from the Fletcher and Fairfield Clinical Applications paper (abstract if you don't have access). However, the Fletcher and Fairfield Scientific Review (Entrez PubMed abstract if you don't have access) paper in the same issue is more nuanced and less emphatic about the mulitivitamin message. The concluding paragraph was:
Although the clinical syndromes of vitamin deficiencies are unusual in Western societies, suboptimal vitamin status is not. Because suboptimal vitamin status is associated with many chronic diseases, including cardiovascular disease, cancer, and osteoporosis, it is important for physicians to identify patients with poor nutrition or other reasons for increased vitamin needs. The science of vitamin supplementation for chronic disease prevention is not well developed, and much of the evidence comes from observational studies.
Far from being "common in the general population", the authors highlight that it is particular groups such as
elderly people, vegans, alcohol-dependent individuals, and patients with malabsorption [who] are at higher risk of inadequate intake or absorption of several vitamins.
Throughout the paper, the authors advise testing for various conditions where appropriate, they do not only propose supplementation. Fairfield and Fletcher are scrupulous about qualifying some of their recommendations:
Since the existing evidence is entirely from observational research, it should be viewed with caution until randomized trial results become available.
In their discussion of the benefits of a higher folate intake to reduce breast cancer risks, the authors specify that current evidence only shows a benefit for women who have "low folate levels and consume alcohol".

Even in the Clinical Applications paper, the authors acknowlege that:
Foods contain thousands of compounds that may be biologically active, including hundreds of natural antioxidants, carotenoids, and flavonoids. For these reasons, vitamin supplementation is not an adequate substitute for a good diet.
Suzanne Shelton accuses Hurley of using "selective studies" and having a "set agenda". It is (presumably) this Lewin Group study (or similar) that she castigates Hurley for omitting and it seems as if they, too, may have been selective.

Diet supplements, homeopathic and herbal preparations may have small reported risks but they do have risks (we may not have a clear idea of any risks because it has been widely promulgated that they don't have side-effects and the manufacturers are not obliged to discuss them in information inserts): it seems as if children are especially vulnerable. The general advice is that healthy children do not need such supplements: if parents choose to administer them to their children, they would be well-advised to discuss them with the children's doctors. But, before you buy these supplements, read Junk Food Science and consider the quality of the evidence that is suggesting that your children need them.

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Monday, January 15, 2007

What Are Some of the Improvements in Infant and Childhood Mortality?

Young girl on playround equipment with an ear to ear grin: she is an example of happiness through explorationThe Daily Mail asks Penicillin to the Pill, what is the greatest medical miracle?: it links to the BMJ competition to identify the most significant medical breakthrough from a shortlist. One of the shortlist is oral rehydration therapy. One of the Daily Mail commenters wrote:
I had to laugh at ORAL REHYDRATION THERAPY to replace body fluids lost through diahorrea. I call it HAVING A DRINK. [The emphases are those of the commenter.]
Well, no, it isn't. But from this comparatively privileged standpoint of history, and in the absence of knowing the state-of-play in other countries where many children are still dying for lack of oral rehydration therapy (an estimated 1.8 million deaths per year), why would the commenter know this? But, if you don't know this, can you have an adequate appreciation of the achievements of medicine and the significance of social and public health advances?

There has been quite some discussion on the issue of whether we have an epidemic of diagnoses that is creating over-anxious parents. Over on Dr. Flea's discussion, Brooklyn Girl commented:
I'm not sure it's fair to ask me, the nervous parent, to decide what real sickness is.
Thankfully, in some ways, in western countries, many people have no experience of "real sickness". It's no help with a differential diagnosis, and it's no help when you have a hot, sick child late at night but there's a reason that so few people have seen "real sickness" in children.

Is there some way in which not knowing what we don't know or haven't experienced skews the perception of risk v. danger?

Paediatric outcomes in the UK have changed beyond recognition, thanks to public health measures, adequate nutrition and immunisation, amongst other contributory factors. The London Bills of Mortality up to 1830 had documented a significant improvement in death-rates for the under-fives: from 1730-79 66.2 percent of the children died; from 1780-1829 there was a substantial drop to 37.8 percent. Sanitation and public health measures began to improve the outcome for children. According to a report into Twentieth Century Mortality Trends In England and Wales (pdf) by the Office of National Statistics (ONS), in 1901, approximately 25% of all mortality was from infants who died before their first birthday: deaths in children up until the age of 14 accounted for more than 40% of all deaths. By 2000, these combined mortalities were less than 1%.

Pointing up the need for oral rehydration therapy, the ONS reports:
[t]he peaks of infant mortality in the earlier part of the century coincided with hot summers when diarrhoeal disease played a part in many deaths.
It is worth noting that infant mortality declined steeply in the later years of World War II. It is thought that this may reflect the introduction of a national food policy that guaranteed the nutritional needs of pregnant women, infants and children. The influence of the policy continued after the war ended because of the persistence of food rationing in the UK until the mid-to-late 1950s and because of the Welfare Food Scheme. The Welfare Food Scheme used to be universal but has more recently been restricted to families in receipt of some Social Security benefits. Both school milk and vitamin supplements for children such as cod-liver oil were available for children until comparatively recently.

The introduction of immunisations against preventable child illnesses is also associated with a steep and steady decline in infant and child mortality. According to the ONS, their analysis shows
the dramatic decline in infectious disease mortality that took place in the Twentieth Century. Poliomyelitis, diphtheria, tetanus, whooping cough, measles, mumps and rubella were all virtually eliminated during the second half of the century, following the introduction of childhood immunisation.
The report summarises the statistics on infant and childhood mortality and highlights the dramatic fall during the last 100 years. Infant mortality rates at the beginning of the nineteenth century were nearly thirty times higher than those at the end of the century. Similarly, the childhood mortality rates were nearly fifty times higher in males and sixty-five times higher in females.

The steep decline in mortality levels is also associated with a decline in childhood morbidity: children are not developing the illnesses that used to occur as epidemics. Children are less-frequently injured by preventable or treatable diseases that sometimes left them with significant chronic illnesses.

I think of these figures whenever I hear somebody argue that modern life is toxic and that it leaves people teetering on the edge of a physical breakdown. I think about them whenever I hear discussion that current generations are less healthy than our ancestors. I thought of them when the New York Times published, So Big and Healthy Grandpa Wouldn't Even Know You. The analyses in that article are fascinating.
New research from around the world has begun to reveal a picture of humans today that is so different from what it was in the past that scientists say they are startled. Over the past 100 years, says one researcher, Robert W. Fogel of the University of Chicago, humans in the industrialized world have undergone “a form of evolution that is unique not only to humankind, but unique among the 7,000 or so generations of humans who have ever inhabited the earth.”

The difference does not involve changes in genes, as far as is known, but changes in the human form. It shows up in several ways, from those that are well known and almost taken for granted, like greater heights and longer lives, to ones that are emerging only from comparisons of health records.

The biggest surprise emerging from the new studies is that many chronic ailments like heart disease, lung disease and arthritis are occurring an average of 10 to 25 years later than they used to. There is also less disability among older people today, according to a federal study that directly measures it. And that is not just because medical treatments like cataract surgery keep people functioning. Human bodies are simply not breaking down the way they did before...

[Researchers] also found that diseases early in life left people predisposed to chronic illnesses when they grew older.

“Suppose you were a survivor of typhoid or tuberculosis,” Dr. Fogel said. “What would that do to aging?” It turned out, he said, that the number of chronic illnesses at age 50 was much higher in that group. “Something is being undermined,” he said. “Even the cancer rates were higher. Ye gods. We never would have suspected that.”

Men who had respiratory infections or measles tended to develop chronic lung disease decades later. Malaria often led to arthritis. Men who survived rheumatic fever later developed diseased heart valves.
It's a privilege that there is such little exposure to "real sickness" that some parents find it difficult to know how to judge the significance or severity of their child's symptoms. We should not be complacent but it is important that we should appreciate the advances in paediatric wellbeing and their implications for adult health. These advances did not come about through serendipity.

Edited: A study in The Lancet confirms that the Measles Initiative has succeeded in increasing the number of children who are immunised against measles. Quoted in the BBC report, UNICEF Executive Director, Ann Veneman, said: "Immunising children is clearly saving lives. Reducing measles deaths by 60% in just six years is an incredible achievement." That 60% means that in:
1999: 875,000 Measles Deaths
2005: 345,000 Measles Deaths

Healthbolt does a good job of conceptualising these numbers. 530,000 people were saved from measles last year: each day, 1450 children are alive because they were immunised against measles.

Haloscan comments because they don't show up in Blogger at present.

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Sunday, January 14, 2007

BritMeds 2007 (2) Is Up

BritMeds 2007 logo with a Union Jack backdropOver on NHS Blog Doc, Dr. Crippen has been trawling British Blogs for posts on a medical topic for BritMeds.

It is a rich blend of posts that covers politics, medical ethics, economics and the disgruntlement of healthcare staff and patients. There is a fabulous spoof newsletter that offers a wonderful take on current issues (it's a pdf). And, I must also thank Dr. Crippen for introducing me to the Little Blog of Phlegm that has some fascinating discussion about mucous and how to clear it (I really must get out more).

Mix all of the above with an insight into public health development and notable Britons, and we have a thoroughly entertaining compilation. Somewhere along the way with BritMeds, I also came across Getting a grip on sanitation and germs which reminds us of just how much we owe to the development of public health in Britain.

Paediatric Grand Rounds 1:20 Is Up!

Baby with monitor leadsBryan Vartabedian is the host of this week's Paediatric Grand Rounds 1:20 and it is an good and varied read.

As ever, there are thoughtful and thought-provoking posts. Neonatal Doc contrasts the costs of providing malaria medication for children throughout the world with the costs of supporting his premature patients. Sandy Szwarc questions the appropriateness of the bad news flow (verging on hysteria) about the healthcare costs for obese children.

Purple Puzzle gives us a useful overview of why allergy diagnosis and testing is far from a satisfactory.

All those of us who work with children will understand that sometimes, children who have been very ill, might present with somatizing or factitious disorders. Signout describes how one Magic Doctor dealt with behaviour that persists.

It's an interesting compilation of posts. Our next host for Jan 28 is Clark Bartram of Unintelligent Design. Email him your contributions by 27 January
clarkbar2019 AT yahoo dot com

Wednesday, January 10, 2007

Homeopathy and Herbalism on the NHS: Who Receives It and Why?

Skit on Prince Charles support for CAM as anti-elitistAn interesting paper in the British Journal of Clinical Pharmacology reports that 60% of the 323 of the surveyed doctors' surgeries in Scotland prescribe homeopathic or herbal remedies. Researchers examined the prescribing data for 1.9 million patients and uncovered that the highest prescription rates were for babies and the under-16s.
  • 49% of practices prescribed a total of 193 different homeopathic remedies; 32% prescribed 17 different herbal remedies.
  • 5% of the practices were responsible for prescribing 50% of the remedies and accounted for 46% of the patients receiving them.
  • 4160 patients (2.2 per 1000 registered patients) were prescribed at least one homeopathic remedy during the study period. 73% were female and the average age of patients was 47.
  • Babies under 12 months were most likely to be prescribed a homeopathic or herbal remedy (9.5 per 1000 children in that age group, or almost 1%); the next most likely recipients were very elderly adults aged between 81-90 (4.5 per 1000). 16% of homeopathic prescriptions were for children under 16.
  • Fewer patients received a prescription for herbal remedies (361). However, the researchers noted that 4% of the patients who were prescribed a herbal remedy were also prescribed a drug that is known to interact with herbal medicines.
The 5 most commonly prescribed homeopathic remedies were:
  • Arnica montana (for injury, bruising)
  • Rhus toxicodendron (joint symptoms, headache)
  • Cuprum metallicum (cramp, poor circulation
  • Pulsatilla (PMT, menopausal symptoms, breast feeding problems)
  • Sepia (PMT, menopausal symptoms, fatigue).
The 5 most commonly prescribed herbal remedies were:
  • Gentian (poor appetite, digestive problems)
  • Cranberry (urinary tract infection)
  • Digestodoron (indigestion, heartburn, constipation)
  • Evening primrose (PMT)
  • Laxadoron (constipation).
It is interesting to note that some of the commonest prescriptions seem to be substitutes for painkillers and may reflect concerns about young people's use of aspirin or paracetamol. Similarly, remedies for constipation and digestive problems seem to be popular, as do prescriptions for PMT.

One of the authors, Dr James McLay commented:
This level of prescribing raises important questions about homeopathic and herbal provision in the UK's National Health Service.

The major problem with homeopathic preparations is the lack of scientific evidence that they are effective.

Given the rise of evidence-based medicine and the trend toward prescribing guidance in the UK, should therapies with no convincing positive clinical trial evidence be prescribed and funded by the health service...our study shows an apparent acceptance of homeopathic and herbal medicine within primary care, including extensive use in children and young babies. We believe that these findings underline the need for a critical review of this prescribing trend.
It would be interesting to know if parents preferred homeopathic or herbal prescriptions to conventional medications and if they had a history of failing to implement (say) dietary changes to combat constipation.

Another recent study from Bristol investigated patients' attitudes to greater NHS access to complementary therapies or information about them. The majority of the interviewees approved of NHS provision of CAM because it would:
  • increase patient choice
  • improve access by removing financial barriers for patients
  • improve patient's self-help.
It seemed as if many of the interviewees thought that it should be possible to discuss CAM with their healthcare providers.
As a minimum, the majority of participants wanted NHS health professionals to be more 'open' towards and know more about complementary therapies than their patients - perceived as not currently usual...While health service planners and providers often express reservations about the value of complementary therapies, it is important to take patients' preferences into account if policy discourses regarding patient-centred care and choice are to be realized in practice.
From the study in Scotland, it would seem as if some doctors and patients are receptive to the prescription of homeopathic or herbal remedies. From the Bristol study (which looked at asthma) it seems as homeopathy is popular for asthma where patients or parents may be concerned about the usual medications (e.g., corticosteroids).

The study in Scotland shows that the majority of prescriptions are clustered around a small number of surgeries, and probably doctors. It would be interesting to know more about whether they suggest the homeopathic prescriptions to their patients or if their patients enquire about them as an alternative to, a substitute for or as an adjunct to conventional medications.

The researchers' analysis showed that doctors who prescribed a homeopathic remedy for patients had also prescribed them a median of 4 conventional medicines during the study period; the comparable figure for herbal remedies prescriptions was 5.
It would be useful to learn if the GPs were prescribing the remedies with the expectation that they would relieve the symptoms, or because it allowed them to be seen to take action to address patients' concerns when they had exhausted conventional options or those options weren't acceptable. However, Dr. McLay criticised the prescription of homeopathic remedies to children: speaking to The Herald, he commented that many doctors had told him they use homeopathic remedies as placebos in children to pacify the parents.

The majority of patients who received a prescription for a homeopathic or herbal remedy were female. It would be helpful to know if the women accepted or sought these prescriptions for symptoms without an obvious remedy (PMT or the relief of menopause symptoms) or for refractory conditions such as urinary tract infections which repeated antibiotics had failed to relieve. Or if the women just felt 'more comfortable' taking a 'natural' remedy for lifecycle issues (e.g., PMT or the menopause).

Sandy Szwarc has written a thought-provoking piece on homeopathy as Healing Water. Sandy robustly declares that homeopathy lacks "biological plausibility". Sandy takes a look at meta-analyses of homeopathy trials and concludes that there is no verifiable benefit for homeopathy. Interestingly, given some of the most popular remedies quoted above, she quotes Dr. Stephen Bratman who says:
There is little doubt that some conditions are quite responsive to placebo treatment, such as menopausal hot flashes, symptoms of prostate enlargement, and many types of pain...While it’s often reported that only 30% of people respond to placebo, this number has no foundation, and, in fact the response rate seen in some of the conditions I just listed reaches as high as 70%.
Sandy asks some hard questions:
as medical professionals, is it ethical to endorse and put credentials behind modalities that lack reproducible, clinical and scientific evidence — or even plausible, rational explanations in proven biophysical science — simply because patients may want them...Or would that be taking advantage of people and betraying their trust?
From the study in Scotland, it would seem as if some doctors feel conflicted about prescribing homeopathic or herbal remedies but do it in order to preserve a therapeutic relationship with a patient or, where relevant, the parents. Are the GPs making pragmatic decisions that such prescriptions are the best way to achieve this for the minimum amount of harm and at relatively low cost because education and a longer consultation time carry greater associated costs? Although the prescriptions may be offered for the best of motives, should they be dropped from the NHS inventory of prescription medicines because they are only prophylactic against awkward conversations?

Flickr artist Tom Morris offers a skit of Prince Charles talking about complementary and alternative medicine.

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Monday, January 08, 2007

Homeopathy, Vaccination, Misinformation and Infants

Immunisation images, advertising and commemoration
Dr. Ben Goldacre of Bad Science recently participated in a public debate about homeopathy. The audience was heavily pro-homeopathy and their point of view was well-represented by Dr. Peter Fisher who is a rheumatologist and homeopath. Dr. Fisher is very much the respectable face of homeopathy in the UK.

Listening to this long piece has been likened to having your brain put through a liquidiser. It is interesting for many of the incidentals rather than the quality of the debate; e.g., the rhetorical skills of Dr. Fisher and his use of techniques that resemble NLP and Eriksonian Hypnosis. Dr. Fisher's obfuscations concerning trial size and blood tests were disappointing, as was his reluctance to engage with the issue of water memory.

I was particularly intrigued by Dr. Fisher's tap-dancing around the issue of vaccination. I have transcribed Fisher’s answer to the question of whether or not Homeopaths are anti-vax and opposed to immunisation. The following is from around about 1:21 on the video: the punctuation is mine and any transcription errors are mine.
If I could just put the record straight on the vexed question of vaccination.

It is true, regrettably, highly regrettably in my view, that many homeopaths recommend against MMR and this is quite clearly not part of the homeopathic tradition, it is absolutely clear. Homeopathy, actually, was invented in the same year as vaccination, 1796, and Hahnemann, the founder of homeopathy, is on record, absolutely clearly, unequivocally, he wrote a lot, so if you really want to find him contradicting himself you can, but on one thing he never contradicted himself on vaccination, he was 110% in favour. So let’s not, you know, get, you know, be quite clear. Homeopathy is not anti-vaccination. It has become associated with anti-vaccinationionism but this is not part of the authentic homeopathic position.
Oddly enough, the answer sounded far worse even than it reads. There has been some discussion as to whether or not the lexical ambiguity and the circumlocutions were intentional as they would allow different listeners to hear whatever agrees with their own point of view. If the ambiguity wasn't intentional, was it beyond all realm of possibility, than in support of clear communication, Dr. Fisher might have remembered that so many of his audience had English as a Second Language. It is not that unusual a question for a leading homeopath to hear. Could Dr. Fisher not have said:
Hahnemann wholeheartedly endorsed vaccination. Authentic homeopathy supports vaccination. We can not accept responsibility for the anti-vaccination beliefs of those who call themselves homeopaths but who are not accredited by us.
Unless the answer isn't as clear as that. Unless, possibly, there would be little support from other homeopaths for a denial of an anti-vax stance?

Some of the anti-vaccination rhetoric is grounded in accusations of financial interest and Big Pharma selective marketing that callously ignores the wellbeing of children. Interestingly, Orac has posted a piece about Brian Deer's article in the Sunday Times that discloses that a researcher who was prominently involved in the discrediting of MMR, Dr. Wakefield received far more funding from various lawyers than he acknowledged.

In response to Orac, there is a remarkable comment from a parent in the UK:
...deciding to go with MMR, and taking my son to be vaccinated was still one of the most terrifying things I have ever done. I think there is little that is more horrifying to a parent than the idea that your own actions could directly and irreperably harm your child. I am a rational individual, and a strong proponent of the scientific method, and all that I had read on this subject could still not completely eradicate that fear.
How did we get to the point where the preponderance of coverage of vaccination issues has resulted in parents feeling that a routine medical procedure is "terrifying". As Dr. Crippen and Medgadget's follow-up on Google rankings says, this imbalance in information needs to be corrected.

The significance of this was brought home with great force by an email that Dr. Flea received from a mother who thanked him for quieting her anxiety about the risks of immunisation that she had developed from her awareness of media sources and her excursions into parts of the internet.Read Dr. Flea's posts. Arthur Allen has written a well-reviewed book about vaccination and describes the improvements that have made immunisation safer. Allen also discusses why social media such as the internet have a role in distorting our understanding of risk. v. danger.
The government’s growing openness and vigilance about vaccine injuries coincided with the appearance of a new technology-- the Internet. Suddenly, people could get all the information they wanted about disease at the touch of a mouse. But the Internet did something weird to the instinctual math that we use for risk perception. Assume, for the sake of argument, that autism rates really haven’t changed in the past 20 years–assume that, then as now, roughly 1 in 200 people, or 1.5 million Americans, have autistic syndromes. Now if you had an autistic son born in 1986, you probably wouldn’t meet too many other autistics--how easy, pre-Internet, was it to meet 200 other people? Now, overnight, almost everyone was wired, and almost everyone with autistic children looked for answers on the Internet. Suddenly, the parent of an autistic child could instantly find tens of thousands of people in similar circumstances. Many people noticed their child’s problem shortly after a vaccination--at 9 months, or 12 months, or 18 months or whatever. Autism research has found that about a quarter of all autistic children’s symptoms follow this pattern–and have since long before thimerosal was an issue. But tell that to someone with an autistic child. Their doctor can’t explain what went wrong. And there are ten thousand other people on the Internet, in their family room, and they all agree that it was the vaccines. The Internet has created a huge, bitter echo chamber for people who desperately need explanations.
The Internet can also be used to promote another view. Many of us have lost touch with the devastation that is caused by vaccine-preventable childhood illnesses. However, for the sake of children and the public health, we do need to ask for better information about risks v. dangers.

1. Mass Vaccination Ouch!, 2. Double ouch, double vaccination, 3. Polio outbreak campaign, 4. 065 Norwich Historic Plaque (Green)

Created with fd's Flickr Toys Mosaic.

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Sunday, January 07, 2007

Paediatric Grand Rounds Wants Your Contribution, Please!

Mock-up cover for Standing Baby magazineYes, it is out with the begging bowl, as I shamelessly rattle the post collection bag and ask you for your contributions to Paediatric Grand Rounds. As you can see from the magazine cover, we are open to conventional and more off-beat topics.

Bryan Vartabedian is hosting the PGR on January 13. He would like us to aim for a deadline of 1700ish central time, that's 2300ish GMT on January 12th.

Please get your post to in good time to stave off PGR-deadline indigestion: the address for our editor is

fox42 AT mac dot com

You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

BritMeds 2007 (1) Is Up

BritMeds 2007 logo with a Union Jack backdropOver on NHS Blog Doc, Dr. Crippen has been trawling British Blogs for posts on a medical topic for BritMeds.

A recurrent thread throughout the posts is the poor level of research that is supporting some contempary funding emphases such as Herceptin and nicotine replacement for smoking cessation. Another miserably common thread is the poor management of the NHS and the destruction of morale that accompanies it: I feel that I am watching a particularly drawn out version of They Shoot Horses, Don't They.

Saturday, January 06, 2007

Epidemic of Diagnoses: Is It Creating Over-Anxious Parents?

Illustration of Huxley lecture on enslavement through terrorism, suggestibility and pharmacologyBoth Dr. Flea and Dr. Bryan Vartabedian of Parenting Solved have commented on the New York Times' essay, What's Making Us Sick Is An Epidemic of Diagnoses (use Bug Me Not if it requests a log in).

The essay authors claim that it is an epidemic of diagnoses rather than disease that poses the greatest health threat to Americans. However, the authors make some particularly interesting observations about the medicalisation of childhood.
Perhaps most worrisome is the medicalization of childhood. If children cough after exercising, they have asthma; if they have trouble reading, they are dyslexic; if they are unhappy, they are depressed; and if they alternate between unhappiness and liveliness, they have bipolar disorder. While these diagnoses may benefit the few with severe symptoms, one has to wonder about the effect on the many whose symptoms are mild, intermittent or transient... Exactly what are we doing to our children when 40 percent of summer campers are on one or more chronic prescription medications?
Is there a clear dividing line between the vigilant, health-conscious parent and the hyper-vigilant who see potential death and disaster in every sore throat and cough? Dr. Crippen has just written up a spell as a Duty Doctor in which he took 18 calls about hot children (scroll down to the final entry). He mentions that one parent asked specifically and somewhat threateningly about meningitis. On average, children have between 5-12 colds per year. Leaving aside the issue of 'being the doctor who missed the diagnosis', it must be frightening and tiring to be a parent on the look-out for something more malignant on each of those occasions. However, the official advice on meningitis symptoms to look for does not suggest that it is possible to make a distinctive diagnosis. Of necessity, the advice does emphasise the subtle or ambiguous nature of the symptoms and both the swiftness or more delayed nature of disease onset.

In the UK, we have about 2000 cases of meningitis and septicaemia every year. However, it is difficult to disentangle this information from the official guidance because the information is presented in unwieldy language and unhelpful graphs. The odds are different for children, but in general, if there are 400 million cases of viruses or infections a year that might have symptoms that overlap with some of those for meningitis, only 2000 are meningitis or septicaemia. Whoever commissioned this website can not have checked it for its clarity of communication or usefulness. Meningitis.org certainly does not understand the level of health literacy, risk assessment or number-handling skills in the UK.

We have had many years of food labelling schemes. In the UK, there is controversy about the relative merits of food labelling schemes: one is supported by the food manufacturers and supermarkets, and the other by the Food Standards Agency (FSA). The former claim that the FSA traffic-light labelling scheme is so simple that it is misleading and is difficult to use to make sensible food choices. The FSA argues that the traffic-light system is more useful because more than half of all adults in the UK can not make the necessary calculations to make use of the information that highlights the percentage of GDA contained in a food portion.

Almost a year ago, the NYT published a piece on the issue of Of Not Wanting To Know What Hurts You. The basic argument was that people worry more about comparatively esoteric risks (like MRSA) than familiar dangers such as diabetes: we feel more outrage about MRSA than diabetes.

According to Peter Sandman (a risk communications wonk) the chance of being affected by a disease is not the major factor that influences whether we experience outrage. It is factors like control and familiarity (or the lack of both) and whether the disease provokes dread or disgust that are much stronger influences.

MRSA can kill gruesomely and quickly and it tends to occur in hospitals where you have (usually voluntarily) handed over some responsibility for your health to the medical, nursing and other staff.

On the other hand, diabetes is all around us, in the home, school, workplace. It is also a chronic illness that has some well known management techniques and offers people some sense of being in control.

Dr. Sandman says that for Diabetes II most people understand the importance of diet and exercise. The question is not whether people can be bothered to control it but whether or not they feel that they can. Car accidents can be as horrific as some illnesses in their consequences but we travel by car so frequently that we don't experience dread about motor transport.

Prof. Howard Leventhal lectures in Health Psychology. According to the NYT, he says that when we contemplate unfamiliar diseases, we cast about for measures to help us evaluate the risk. Unfortunately, we may ground our evaluation in alarmist media reports, our own experience and hearsay. For example, we may have recourse to prevalence to judge the risk. Rare events are more frightening than common events.

It seems that we use simple population polling to assess risk. If we know that lots of people have a disease but few of them have publicly distressing symptoms, and they don't need to be hospitalised and few of them die, then it must be relatively benign. If, however, a condition is rare, and the first few times that we hear about it, it publicises distressing symptoms, medical emergencies and death, then we fear that condition, no matter whether it is very unlikely that we would develop it (e.g., anthrax, bird flu and MRSA).

Meningitis matches some of the outrage criteria of MRSA. It is stealthy and unpredictable, it is dramatic in its impact. When so much uncertainty attends it, it is probably unsurprising that the prospect of it alarms parents, particularly when it is difficult to form a realistic assessment of the likelihood of developing it.

What would be the financial and personal cost of treating every cold or sore throat in the under-5s (the most vulnerable group) with a high index of suspicion for meningitis or other rare diseases? How much harm would it cause the parents to be alarmed about a cold 5-12 times a year? The authors of the Epidemic of Diagnoses piece highlight the harm that illness hyper-vigilance causes for children in raising their anxiety and sense of vulnerability.

Is it possible to assuage parental concerns? Is it plausible, practical, affordable or desirable that every sore throat/hot child should have a full meningitis work-up, just in case? I would be interested in the statistics that estimate the amount of harm done to children if there were such widespread testing v. the present system.

At a time when there are significant gains in paediatric health because of wider social changes and immunization against common preventable diseases, are we moving towards a healthcare system that will need to assess everyday symptoms to exclude rare illnesses? Whom would this benefit? Or does it presuppose the development of non-invasive testing methods? Barsky has suggested the theory of somatic amplification to account for hypochondriasis. If we medicalise everyday illnesses and symptoms, then is there a risk that we are encouraging an entire generation towards somatic amplication:
somatic amplification refers to a tendency in hypochondriacal patients to scrutinize their bodies for somatosensory input and then to amplify and misinterpret the sensation as representing a pathological process.
In default of striking medical advances, it is implausible that such widescale testing would be affordable or implementable. Could any medical care system cope with an entire generation of people with iatrogenic or socially-induced hypochondriasis? If we have an epidemic of diagnoses, have we created an epidemic of parental anxiety?

The Flickr artist Russell Higgs is illustrating a transcript of Aldous Huxley's 1962 lecture, The Ultimate Revolution, in which he discusses using terrorism, suggestibility and pharmacology to create willing slaves out of the population.

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