Friday, June 29, 2007

Andrew Wakefield, Chronology and "Bad Science"

Timeline graphic on a wall

Mr Matanoski, a lawyer for the US Govt. Health and Human Services Dept., recently made this remarkable comment in his concluding statements for the first part of the Autism Omnibus hearings (pdf) in the US. The MMR-autism case has no plausible or verifiable science to support it.
It's at best speculation, idle speculation. Now, at worst--at worst--it's a contrivance. It's a contrivance that's been developed and articulated and promoted by its chief proponent, and that's Andrew Wakefield. He promoted it for financial gain. Either way it's not science.
pgs 28-9: Day 12 Transcript of Cedillo v. Secretary of Health and Human Services (pdf)
As part of his closing, he presented this unsettling chronology of events. (For a more detailed summary of events, see Brian Deer and the MMR-autism scare.)
I've mentioned several times in the course of these proceedings Andrew Wakefield and his theory, and there's a reason for that. That's because all the strands through these cases come back to him. He presented bad science.

I'm going to run through the chronology again because it's important, the chronology of how this arose and how it was promoted. In 1996, Alexander Harris, a firm of solicitors in Great Britain, approached Andrew Wakefield and asked him to consult with them in cases involving MMR, allegations of MMR causing autism. Andrew Wakefield was paid 55,000 pounds for his efforts at that point.

Andrew Wakefield in 1997 took out a patent for a monovalent measles vaccine. In 1998, he published the paper that caused the stir that we've now seen reinterpreted, rearticulated a number of times until more than 10 years later we have it in our courtroom today.

He did not reveal at the time that he published that paper that he had this financial interest. He did not reveal that several of his patients in that paper were in fact litigants in the MMR litigation.

In 1998, Andrew Wakefield approached John O'Leary and consulted with him. John O'Leary went on to set up Unigenetics, a company of which he was the director and shareholder. Unigenetics' purpose was to test samples for the U.K. MMR litigation.

Now, you've heard testimony about the reliability of that testing. You've seen the papers that have come out of that lab. In fact, the Uhlmann paper that was discussed here at length and relied on so heavily by the Petitioners, the patients, some of the patients at least, some of the patients in that case study were MMR litigants. There's a direct connection between that litigation and our litigation here. That litigation folded. Unigenetics went away, but we have it back here now in this case. It folded in 2004 after the whistle was blown on Andrew Wakefield and it was revealed his substantial financial connection with ongoing litigation.
pgs 30-2: Day 12 Transcript of Cedillo v. Secretary of Health and Human Services (pdf)
According to Brian Deer, the £55,000 was a payment for clinical and scientific tests on the children of clients: Wakefield had been retained by a solicitor involved in anti-MMR action since Feb. 1996. Brian Deer put in a Freedom of Information Act request to the Legal Services Commission and in December 2006 they provided a spreadsheet of fees to paid witnesses in the MMR lawsuit. According to that payment schedule, Wakefield had been paid £435,643 [about $780,000], plus expenses, for his expert participation in the legal case against MMR. Brian Deer reports that these sums do not include the fees for work on individual children's records.

A substantial number of the signatories to the Nigel Thomas petition believe the claim that:
The threat that faces Dr Andrew Wakefield, Professor John Walker Smith and Professor Simon Murch is that they may be struck-off the medical register for daring to investigate why these children are so ill, which no-one else has been prepared to do.
On just one page of signatories, people write of Wakefield as a hero, as a prisoner (who is awaiting crucifixion and will be retrospectively vindicated) and in terms of Pasteur and Galileo. There is no final word on the charges but the GMC is not convening a hearing because these researchers investigated these children, nor, as Patrick Holford would have us believe, for "challenging the status quo".

Related posts
Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 1
Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 2
Kevin Leitch on Andrew Wakefield and the death of the MMR debacle and Justice for Katie
Mike Stanton on Patrick Holford and his unusual views on vaccination, MMR and autism
Patrick Holford Claims Remarkable Benefits for Homeopathic Vaccinations
Holford Watch: Holford believes Secretin is "Worth considering" as an autism treatment; however, there is no evidence that this treatment is effective and
Holford is sceptical about off-label prescribing, but thinks that secretin for autism is "Worth considering"
Patrick Holford alias Doctor Knock aka Holt Senior

Image detail on Flickr

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Thursday, June 28, 2007

Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 2

Question mark and reminders
Patrick Holford is a staunch supporter of Dr Andrew Wakefield and recently set out his case as to why we should likewise support him. Patrick Holford claims to have remarkable insight into the causation of autism and how to "bring them back" when children are on the autistic spectrum. He suggests that there is hard evidence that links MMR and autism.

Wakefield's claims about the inflamed and diseased guts of the children in his original Lancet study have been shown to be unfounded.

But what about those measles antibodies in the cerebro-spinal fluid and the gut tissue of the children Wakefield examined? Whatever significant problems there may be with the rest of his work, surely this is the crux of the matter.

Yes, the findings concerning the measles antibodies are significant, albeit, not in a way that most people would admire. And here we pass to one of the most alarming and distressing aspects of this whole affair; something that has been known for some time but about which Patrick Holford is silent. Those antibodies were never there.

The account of those (now) infamous PCR samples that 'proved' the existence and persistence of the measles antibodies in the children's samples, along with the issues discussed below and in part 1 is why a lawyer for the US Govt. Health and Human Services Dept. recently made this remarkable comment in his concluding statements for the first part of the Autism Omnibus hearings in the US. The MMR-autism case has no plausible or verifiable science to support it.
It's at best speculation, idle speculation. Now, at worst--at worst--it's a contrivance. It's a contrivance that's been developed and articulated and promoted by its chief proponent, and that's Andrew Wakefield. He promoted it for financial gain. Either way it's not science.
pgs 28-9: Day 12 Transcript of Cedillo v. Secretary of Health and Human Services (pdf)
What about those samples, the ones with the measles RNA?

Orac has written an excellent account of the difference between real scientists and crank scientists. By liberal referral to the leading PCR authority, Dr Bustin, we learn precisely why we can have no confidence at all in the Unigenetics lab that reported many of these findings.
Now, here's where Dr. Bustin was so devastating to the claim that MMR causes autism. Andrew Wakefield and Arthur Krigsman, who claimed to have replicated Wakefield's work and found measles virus RNA in the guts of autistic children, both used Professor John O'Leary's Unigenetics Laboratory in Ireland, and it was the Unigenetics lab whose results led to a paper by Uhlman et al and an as yet unpublished poster presentation by Walker et al, both claiming to find measles virus in the guts of autistic children.
The irregularities were extraordinary and the whole of Dr. Bustin's testimony (pdf) is worth reading as a primer into how PCR can go horribly wrong.

I don't know why Patrick Holford still finds this an area of controversy and debate rather than acknowledging that there has been some bad science that has been roundly and repeatedly exposed. He mentions none of this in the theory of autism aetiology that he promotes in his books or websites. He promotes the existence of the measles antibodies in the gut and CSF as fact despite the overwhelming evidence to the contrary. The theoretical underpinning for his heavily promoted treatment programme relies upon the existence and persistence of these measles antibodies.

So, the Unigenetics lab returned suspect results and can not be relied upon but surely the original PCR results from the Royal Free Hospital are above reproach? No.

Dr Nick Chadwick started to work as a graduate student in Dr Wakefield's lab in the Royal Free Hospital in 1994. The lab started to focus on testing samples and tissue from autistic patients in 1996. Chadwick was responsible for processing the materials and looking for measles RNA. He reported that there were never any confirmed findings of measles RNA. The only positives that were obtained were rapidly shown to be false positives and he reported this. Chadwick's account has been known for some time; more than enough time for Patrick Holford to have addressed this issue. At the very least he should have referred to it when purporting to give his email list an overview of Wakefield's work and why we might consider signing that petition.

Chadwick's testimony to the Autism Omnibus hearings (pdf) was devastating.
pg 10
Q [Y]ou personally tested while you were in Dr. Wakefield's lab gut biopsy material, CFS, PBMCs?

A Yes, that's right.

Q And all the results were either negative, or if they were positive it always turned out that they were false positives?

A Yes, that's correct.

Q Did you inform Dr. Wakefield of the negative results?

A Yes. Yes.
Chadwick further reported that Wakefield had decided that it would be useful to send samples to Dr Kawashima's lab because he was also working on the detection of measles virus using another methodology. Chadwick discovered that there were serious and significant reporting errors from Kawashima's lab and that, yet again, the only positive results were subsequently shown to be false positives. He had concerns about contamination. He informed Wakefield of the problem with the Kawashima results. Chadwick's results also returned negative results, with every positive being subsequently shown to be a false positive.
pg 12
Q [D]uring your time on your Ph.D. research in Dr. Wakefield's lab you only obtained nine positive PCR results for measles. Every time you did that you sequenced them.

A That's correct, yes. We sent it off to a sequencing lab to be sequenced, and the data that came back showed that they were all false positive results.

Q Every positive result you got was a false positive?

A Yes...

[pg 12 cont. to pg 14]
Q [Y]ou state that you had reservations about the immunohistochemistry done to detect measles virus, specifically the use of an antibody from Porton Down?

A Yes, that's right. The antibody seemed to cross-react.
Experiments we did in the lab seemed to show that the antibody cross-reacted with bacterial proteins, which I think is an artifact of how the antibody was made, and that led us or led me to think that it may have been cross-reacting with bacteria in the gut of patients rather than measles virus.

Q Now, that would lead to contamination?

A Well, it would lead to a false positive result. Say for instance if the antibody was binding to something in the guts of these patients, it may well have been a bacteria rather than the measles virus.

Q Okay. Producing the false positives in those?

A Yes, that's correct.

Q You also state in your affidavit that you believe Dr Wakefield was aware of all your negative results when he submitted his paper "Ileal Lymphonodular Hyperplasia, Nonspecific Colitis and Pervasive Developmental Disorder," which was published in 1998 to the Lancet.

A Yes, that's correct.

Q You were working at the lab at that time, and you had actually published some articles with Dr. Wakefield on other subjects, hadn't you?

A Yes. Yes.

Q Why isn't your name on the paper I just referenced?

A Well, my name isn't on that because none of my data went into that paper.
There was a manuscript which did use some PCR data I think from Dr. Kawashima's lab, and I asked for my name to be taken off anything that was related to PCR data because I wasn't comfortable with the quality of the data.
It is a remarkably serious step to request that your name is taken off a paper and should not be used in reference to data. The significance of this would be apparent to any researcher or scientist. Except, of course, to Patrick Holford, who does not mention any of this when instructing his readers in the role of MMR in the development of autism. Nor does he mention it when discussing the scientific rationale for his treatment programme for children on the autistic spectrum.

Patrick Holford has not included any of this material when updating his publications or websites nor when writing his recent books. If he were to, perhaps he would have to acknowledge that there is no scientific foundation to his treatment programme which relies upon the findings of Wakefield.

Patrick Holford recently asked: Was Dr. Andrew Wakefield Right About the Link Between Autism, the Gut, Allergy and the MMR Vaccine?. He purported to give an overview:
If you are not sure, then please read on to find out what we know about autism, the gut, vaccinations and what food has to do with it.
We do not know any of that: the science has been well and truly exposed. At best, Patrick Holford is outdated in his knowledge and it is past time that he updated it. Something he had ample opportunity to do before repeating these beliefs in recently published books.

Patrick Holford depends upon Wakefield's work to justify some of his entrepreneurial and charitable endeavours. He owes it to the people who rely upon him to revise his acceptance of Wakefield's science and findings. And people are guided by Patrick Holford when it comes to MMR. Petition signatory 4797 credits Patrick Holford with her daughter's decision not to vaccinate her children (she was previously no. 4805, there have been some alterations to the petition):
Thank God my daughter used her judgement and did not have the MMR for her children. She based her decision on extensive research, most particularly 'What Doctors Don't Tell You' and Patrick Holford.
Patrick Holford owes it to that woman to put together a better overview of the research that purports to find a link between MMR and autism: he may even owe it to her that he should strongly reconsider his position on a number of important matters.

Related posts
Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 1
Kevin Leitch on Andrew Wakefield and the death of the MMR debacle and Justice for Katie
Mike Stanton on Patrick Holford and his unusual views on vaccination, MMR and autism
Patrick Holford Claims Remarkable Benefits for Homeopathic Vaccinations
Dr Crippen on the remarkable cost-savings that Patrick Holford could offer the NHS: Pay £6.99 to say "no" to cancer
Holford Watch: Holford believes Secretin is "Worth considering" as an autism treatment; however, there is no evidence that this treatment is effective and
Holford is sceptical about off-label prescribing, but thinks that secretin for autism is "Worth considering"
Patrick Holford alias Doctor Knock aka Holt Senior
Flickr credits for the images. 1. question, 2. Questions?

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Wednesday, June 27, 2007

Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 1

Immunisation images, advertising and commemoration
Patrick Holford sent round an email last week in which he asked people to sign a petition in support of Dr Andrew Wakefield for his upcoming hearing before the General Medical Council in the UK. Patrick Holford hadn't signed the petition the last time that I looked (yesterday evening), nor is the petition solely about Wakefield. Nonetheless, Patrick Holford seized this opportunity to reproduce swathes of text from his own books where his claims and recommendations stand and fall with the reliability and accuracy of Wakefield's work: Was Dr. Andrew Wakefield Right About the Link Between Autism, the Gut, Allergy and the MMR Vaccine?. [Update Jan 2008: Patrick Holford's Concerns About the MMR Vaccine] He undertakes the task of providing a salient overview:
If you are not sure, then please read on to find out what we know about autism, the gut, vaccinations and what food has to do with it.
You will notice that Patrick Holford emphasises food allergies because he routinely recommends food allergy and intolerance tests, tests for nutritional deficiencies, hair mineral analysis, restrictive diets and mega-supplementation. However, he does rely upon Wakefield for the scientific underpinning of many of these entrepreneurial opportunities.
Dr Andrew Wakefield, in a now controversial study, published in the Lancet in February 1998, of 60 autistic children with gastrointestinal symptoms, found much greater incidences of intestinal lesions than in non-autistic children with similar digestive problems. Over 90 per cent of autistic children showed clinical evidence of chronic inflammation of the small and large intestine as a result of infection, at levels greater than six times that found in non-autistic children with inflammatory bowel disease [5].

Despite a concerted effort to discredit Wakefield's research, recent studies are confirming the link between autism, digestive problems, immune system abnormalities and the MMR vaccine. Wakefield's own research has shown that, in a group of 15 autistic children versus healthy children, there is clear evidence of immune dysfunction [6]. Three studies have shown measles antibodies in the central nervous system, with the potential to damage both brain and gut. [7;8;9]
Now, I know that there are times when Patrick Holford relies upon news reports rather than troubling to read the scientific papers so I recommend Brian Deer for a very readable summary of The MMR-autism scare and Wakefield's role in it.

Keen-eyed readers will have noticed that Patrick Holford refers to 60 children in the Feb. 1998 Lancet paper when there were 12 but he repeatedly has problems with reporting numbers accurately (and here) so we should overlook that. What we should not overlook is that this paper has been so discredited that it should be left to moulder in a quiet grave and referred to in hushed tones as an example of what can go horribly wrong in research and publication.

The Patients and Methods section of the Lancet paper claims:
12 children, consecutively referred to the department of paediatric gastroenterology with a history of a pervasive developmental disorder with loss of acquired skills and intestinal symptoms (diarrhoea, abdominal pain, bloating and food intolerance), were investigated.
However, most of these children were (through their parents) potential parties in a law-suit against vaccine manufacturers (by the publication of the paper 10 had Legal Aid to sue which meant that public funds were meeting their legal costs). Nor had Wakefield disclosed his conflict of interest arising from the substantial fees he would collect as an expert witness in the litigation that would rely upon his research findings (around £500,000); further, he did not disclose that he had patents for potentially competitive products.

Partly because of Wakefield and this paper, the rules of disclosure are very different now, in most journals. The money and the law-suit may seem murky, but what about the science?

Brian Deer's summary is an excellent guide to the goal-post shifting. Wakefield had claimed that 8 out of 12 [66.6%] of the children had received MMR within 14 days of symptoms and that the onset of symptoms was rapid and dramatic. However, expert witnesses who were recruited to confirm the MMR-autism link reported that the median time to the onset of symptoms among the children in the law-suit was 1.1 years, while Wakefield had claimed a median time of only 6.3 days.

So, the argument had to change. The emergence of autistic disorders after MMR wasn't rapid and dramatic, but delayed and insidious.

What about that scary-sounding ileal-lymphoid-nodular hyperplasia that so impresses Patrick Holford? Wasn't this a new, terrifying, malign finding that must mean something? Well, no. It turns out that the swelling of the glands, near the end of the small intestine and close to the appendix is a generally benign finding in children that has been known about for some time. It has nothing to do with inflammatory bowel disease.

But what about the autistic enterocolitis? Patrick Holford is concerned about the chronic inflammation that scourged the large and small intestines of the children in Wakefield's studies. He still refers to autistic enterocolitis in his books and articles; especially those promoting the need for a restrictive diet that should be supervised by one of his nutritional therapists who will also recommend a gut-healing programme and extensive supplementation. He also emphasises that the children have inflammation arising from infection because he is a staunch advocate of anti-fungal medications for children with these compromised guts.

Patrick Holford cleaves to his belief in this chronic inflammation despite the fact that Wakefield's colleagues have withdrawn their support for his research and retracted the publication on which Patrick Holford relies. Patrick Holford still promotes this idea although one of Wakefield's collaborators and co-authors, Walker-Smith, has admitted that most of the children did not show signs of inflammation and that there were no unusual findings in the children's colons.

So Patrick Holford still relies upon Wakefield's work although it has been known for some time that he was wrong about the rapid emergence of behavioural symptoms after MMR; wrong about the significance of ileal-nymphoid-nodular hyperplasia; and wrong about the autistic enterocolitis. Of course, many of Patrick Holford's recommendations for the treatment of autistic children and his remarkable claims that he can "bring them back" like so many latter-day Lazarus depends upon the validity of Wakefield's research.

But what about those measles antibodies in the cerebro-spinal fluid and the gut tissue of the children Wakefield examined? Whatever significant problems there may be with the rest of his work, surely this is the crux of the matter. That is Part 2.

But, for now, it may be worth pondering the idea of just what would make Patrick Holford give up his belief in the 'science' that underpins so much of his own treatment recommendations. What would make him update his many books and websites to at least acknowledge that this has gone far beyond "he says, she says" and it is now acknowledged that this science is discredited? So discredited that a lawyer for the US Govt. Health and Human Services Dept. recently made this remarkable comment in his concluding statements for the first part of the Autism Omnibus hearings in the US. The MMR-autism case has no plausible or verifiable science to support it.
It's at best speculation, idle speculation. Now, at worst--at worst--it's a contrivance. It's a contrivance that's been developed and articulated and promoted by its chief proponent, and that's Andrew Wakefield. He promoted it for financial gain. Either way it's not science.
pgs 28-9: Day 12 Transcript of Cedillo v. Secretary of Health and Human Services (pdf)
Mike Stanton of Action for Autism has some remarkably robust view on Patrick Holford and his opinions on vaccination, MMR, autism and treatments.

Related posts
Patrick Holford and Dr Andrew Wakefield's Discredited Findings: Part 2
Kevin Leitch on Andrew Wakefield and the death of the MMR debacle and Justice for Katie
Mike Stanton on Patrick Holford and his unusual views on vaccination, MMR and autism
Patrick Holford Claims Remarkable Benefits for Homeopathic Vaccinations
Dr Crippen on the remarkable cost-savings that Patrick Holford could offer the NHS: Pay £6.99 to say "no" to cancer
Holford Watch: Holford believes Secretin is "Worth considering" as an autism treatment; however, there is no evidence that this treatment is effective and
Holford is sceptical about off-label prescribing, but thinks that secretin for autism is "Worth considering"
Patrick Holford alias Doctor Knock aka Holt Senior

Image information: 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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Tuesday, June 26, 2007

Eczema, Asthma, Allergy Links and News

Gotham thugs and a forgotten benefit of vaccination Similar historical oddities may be found in speech as well as comics. I have elderly relatives who still say, "Harder to get rid of than the measles" or "It follows you around like the measles". P.G. Wodehouse has several quotations about measles:
Boyhood, like measles, is one of those complaints which a man should catch young and have done with, for when it comes in middle life it is apt to be serious.
Interactions between breast-feeding, parental atopy, and sex on development of asthma and atopy An intriguing paper that I havered about mentioning but the results are too thought-provoking to ignore. There is an extensive observation and research history which reports both that breast-feeding protects against allergy and asthma and that it increases the risk. This study looked at 1037 children from a 1972–1973 New Zealand birth cohort: the authors report that whether breast-feeding carries an increased risk for atopy and asthma for a child depends on their gender and the family history of the disease.

Breast-fed boys had a 63% increased risk of atopy by age 13 years, and those with atopic mothers had a 95% increased risk but neither of these reached a recognised significance value.

Breast-fed boys with atopic fathers had a significantly increased risk for atopy of 639% when compared with those who were not breast-fed. However, breast-feeding did not increase the risk for atopy among boys with atopic mothers.

For girls, the risk of atopy at age 13 years was not affected by breastfeeding, maternal atopy, or paternal atopy alone. However, breast-fed girls with atopic mothers had a 213% increased risk when compared with those who were not breast-fed. Breast-feeding did not have a reportable effect in girls with atopic fathers.

The authors report that the findings need to be replicated in larger cohorts. They comment that the findings have implications for how other researchers design and report trials of asthma and atopy epidemiology. the findings may also indicate some useful questions for clinicians although it is difficult to assess their practical significance at present.
For clinicians, it may be important to inquire about the history of breast-feeding in the context of assessing risk factors for the development of asthma and allergy.

However… breast-feeding is to be encouraged for its numerous other benefits.
The authors suggest that it is possible that the mechanism of action is the level of oestrogen in the mother's milk; however, like their other findings, this awaits further work and confirmation by others.

Eczema gene may predict asthma medication needs in children and young adults Asthma frequently co-exists with dermatitis or eczema. Previous research has suggested that it is possible that filaggrin (FLG) mutations can impair the formation of skin barriers and strongly predispose to childhood skin complaints such as eczema and atopic dermatitis. Mukhopoadhyay and fellow researchers report that this FLG status might identify asthma patients with severe disease who frequently need to use reliever medication.
Filaggrin (FLG) status influences controller and reliever medication requirements in children and young adults with asthma...

If skin barriers play a key role in preventing sensitization in asthma, a greater entry of allergens through a poorly formed epidermal barrier may speed up or intensify the activation of the immunologic changes of asthma.
The team evaluated the role of two FLG null alleles in asthma by assaying 874 patients in Scotland. They discovered that more of the patients with these markers were treated in accordance with the BTS recommendations for greater asthma severity (steps 3 and 4). 40% of those with the FLG null carriers were receiving treatment that implies greater asthma severity as compared with 23% of those who had wild-type FLG status.

The authors conclude:
An understanding of the possible relationships between filaggrin gene defects, a TH2-dominant cytokine response, and asthma could begin to test the exciting hypothesis that primary prevention strategies for asthma and allergy may be more cost-effective for genotype-stratified populations.
It would be interesting to know how much more development is needed before this becomes a recognised and affordable test at (say) secondary care levels. Nonetheless, it is interesting research and is further weight towards the argument that it is past time to abandon the idea of asthma as a single disease concept.

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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.

The next edition of the PGR will be hosted right here at Breath Spa. Please send along your contributions (a little note as to why it appealed to you would be helpful):

breathDOTspaATgooglemailDOTcom

And please do this by Saturday June 30, allowing for the fact that I am in a much earlier timezone than people in the US.

Clark Bartram is looking for hosts for future PGRs. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

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

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Monday, June 25, 2007

Echinacea and Selenium Lack Efficacy for Colds and Asthma

Echinacea promoted as cold preventer and treatment. Stories about the new Lancet review of echinacea are abundant in the general media; e.g., the Daily Mail trumpets that Scientists confirm echinacea halves the risk of catching winter sniffles. It is a little dispiriting that the Daily Mail coverage is more informative than the BBC's; the former is explicit that this isn't a new study but a review of previous studies.
A review shows that taking supplements of the plant, also known as purple coneflower, can cut the chances of catching a cold by more than half.

When used as a treatment it reduces the length of a cold by one and a-half days on average...

The review, which combines the results of 14 previous studies, should finally give the seal of approval to the remedy.
I have to say that I thought the recent negative studies and reviews of echinacea guaranteed it a quiet grave but it is now the echinacea zombie. There is a Cochrane Systematic Review of echinacea for preventing and treating the common cold.
Echinacea preparations tested in clinical trials differ greatly. There is some evidence that preparations based on the aerial parts of Echinacea purpurea might be effective for the early treatment of colds in adults but results are not fully consistent. Beneficial effects of other Echinacea preparations, and for preventative purposes might exist but have not been shown in independently replicated, rigorous randomized trials.
The Lancet provides an analysis of 1,600 patients pooled from 14 previously published studies but the criteria for their inclusion differ from those used by the Cochrane review: as ever, if there are questions about the methodologies of those studies then it can invalidate the meaningfulness of the pooled results.

The authors acknowledge that the analysis indicates that echinacea is less effective against rhinovirus than other cold viruses which would limits its usefulness because rhinovirus is the most common cold virus. They further acknowledge that there is no standardisation of the echinacea used in the studies that they include; beyond that, the studies included people who were taking Vitamin C, rosemary, thyme and other combinations.

It is difficult to understand why this new review is promoted as if it has completely reversed the Cochrane conclusions and those of previous reviews but it has afforded an opportunity for several asinine remarks on breakfast television and possibly makes some of the faithful feel smug that they stood by their nostrum even when science said that it was useless but now science has vindicated it. I don't have a strong feeling on the matter; I just wish that if the story has to be covered, it is presented with an appropriate amount of detail. E.g., there are some theoretical concerns about the safey of echinacea pollen for people with pollen and ragwort allergies and the use of echinacea (unspecified type) with paracetamol. Just because preparations are available over the counter or in a healthfood shop doesn't mean that they don't have known contraindications.

Selenium supplements are not helpful in asthma: however, there is no coverage so far in british media which seems to prefer a good news flow about supplements. People with asthma are reported to have lower-than-normal blood and dietary levels of a number of minerals, including selenium. The authors conducted a randomised, double blind, placebo-controlled trial of selenium supplementation; the participants were 197 adults with asthma, the majority of whom (75%) reported inhaled steroid use at baseline. The study ran for 24 weeks. There was a 48% increase in plasma selenium between baseline and end of trial for those people in the active treatment group but no change in the placebo group. However, there were no clinical effects associated with selenium supplementation for this group. The take-away message is that selenium supplementation is not likely to be a useful public health strategy for mitigating mild-to-moderate asthma in adults.

Plasma selenium levels in pregnant women and neonates relates to wheeze but not asthma in young children. Reduced dietary selenium intake has been linked to the development of asthma. In another UK study involving selenium:
[t]he selenium status of mothers during early pregnancy, and neonates is associated with early childhood wheezing but not asthma or atopic sensitization, furthermore, this association is absent by the age of 5 years.
There may be many contributory factors involved in the development of asthma; however it doesn't seem as if low levels of plasma/dietary selenium, independent of other factors, is a significant one.

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Thursday, June 21, 2007

Asthma, Misunderstood and Misdiagnosed: Interesting Initial Study Results

Mosaic of letters reads AsthmaAn estimated 1 in 6 New Zealanders has a diagnosis of asthma. For some time there have been concerns that asthma is misdiagnosed and over-diagnosed: Asthma: A Multi-Headed Hydra or Misunderstood Genus. So, in research terms, it seemed sensible to use hospitals in New Zealand as a testing-ground for a study to evaluate new tests that promise a more accurate assessment of the patient than was previously practical.

Investigators needed to explore how well patients tolerate the tests and whether or not the tests were both specific and sensitive enough to provide reliable information that would guide a clinician as to whether a diagnosis of asthma was appropriate or not; and whether they were under-treating or over-treating the patient. Initial results on the first 50 patients have been reported at a professional meeting and suggest that misdiagnosis for another condition that mimics asthma is common (the study has yet to be completed, written-up and submitted for peer-review).

A Lancet editorial forms the bulk of the hydra discussion.
[P]erhaps, asthma as a symptom is really only the clinical manifestation of several distinct diseases. As Martinez explains, until the 19th century fever was regarded as a disease and maybe in 20, 30, or 50 years' time we will look back at asthma in the same way.
Other researchers speculate that the simplest explanation for the different phenotypes of asthma is that they are different time points in the progression of a single pathology, that of airway inflammation. People's progress along the timeline reflects their genetic predisposition and vulnerability to various triggers.

Leading asthma researchers, Professors Robin Taylor (University of Otago, New Zealand), Peter Gibson (John Hunter Hospital, Australia) and Ian Pavord (University of Leicester, England) have designed and validated this series of new tests that may provide useful data for considering those issues. They are running several tests:they check for allergies; run a sputum analysis; measure exhaled Nitric Oxide (a measure of inflammation); and perform a lung and airways scan. In the March Thorax australasian meeting, they reported preliminary findings that 50% of the adults to date have a condition that mimics asthma, rather than asthma.

TV New Zealand covers the story and offers a short, interesting video of one woman's experience with the tests.
Lynette Kingsbury has used inhalers for 10 years. She says she has had a lot of similar symptoms to asthma, such as wheezing and shortness of breath.

However the tests have cleared up years of doubt.

Kingsbury's tests showed she had been suffering from allergies and her inhalers had been a waste of time.
Damage to the lower airways during childhood or adolescence when they are more vulnerable to damage may lead to symptoms which may mimic asthma. It seems possible that a significant proportion of people are who being treated for asthma because of a chronic cough, wheeze or chest tightness, may have other inflammatory conditions which respond better to more appropriate medications. In some people, it seems as if they have long-standing, chronic infections that are the cause of their symptoms but these are amenable to the appropriate antibiotics rather than asthma medications that have a very different mechanism of action.

It looks as if well-targeted, specific tests such as expired nitric oxide measurement, sputum analysis and CT scans can differentiate between asthma, chronic infections and damaged airways. A more accurate diagnosis allows for better treatment with more appropriate medication and contribute to a better quality of life.

Dr Jeff Garrett, the local branch president of the Thoracic Society, has been quoted in a number of interviews about the study.
Half of the patients who've been labelled as asthmatic who've come along to the clinic and have been enrolled in the study to date, have had other conditions which have mimicked asthma.

Based on these findings it may well be that as many as half the people who've been labelled as having asthma may well have another sort of inflammatory airways disorder.

The challenge for the Thoracic Society will be to evaluate ways of transferring the results of tests undertaken in the laboratory into the clinical work place. The results of the studies currently being conducted in our leading hospitals in New Zealand will hopefully give us more direction.
It is fascinating research that promises to have a substantial impact on the diagnosis and management of asthma and chronic airways disease: it is important that this is written-up as quickly as practical. The financial considerations are significant for the health systems of many countries. There are potentially significant improvements for the quality of life of many children and adults. Most of all, it promises to add some important data for considering the question of whether asthma is misunderstood, misdiagnosed and sometimes mis-treated.

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

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Wednesday, June 20, 2007

Patrick Holford Claims Remarkable Benefits for Homeopathic Vaccinations

Images of children's vitamin preparations
Bowel-whisperer Patrick Holford has some disturbing ideas about vaccination. If you pay a subscription to him, you can consult his special online reports on a number of topics. One of these reports is about vaccination. I'm accustomed to anti-vax denialism and general crankery but reading this report was like allowing my eyes to turn into two fists and pummel my brain.

I was slightly worried by Holford's introduction:
The orthodox view is that vaccinations are essential, save lives, have few down-sides and are responsible for the decrease in deaths from many infectious diseases.

These views are, however, highly questionable. One of the best reviews of the facts about immunisation is by Lynne McTaggart in the book, What Doctors Don't Tell You in which she explodes the myths surrounding vaccinations...
The content did nothing to alleviate my concerns and I have addressed a number of them previously, when discussing improvements in childhood mortality and morbidity because of vaccinations. Ignoring those issues for now, the concluding section was the one that disturbed me most.

Alternatives to vaccination

The alternatives to vaccination are to ensure that you or your child has a fighting fit immune system. There is no better way to confer immunity to an infant than breast feeding and, once weaned, ensuring an optimal intake of immune-boosting nutrients. Vitamin A, for example, offers protection against measles and probably polio.

In underdeveloped countries deaths from measles are virtually eliminated by ensuring an adequate intake of vitamin A. It is highly likely, although not yet proven, that a good all-round intake of immune-boosting vitamins, minerals, amino acids and essential fats can turn a potentially life-threatening virus into a mild and temporary illness...

Although less well researched, you may wish to investigate homoeopathic immunisations. In one study 18,000 children were successfully protected against meningitis with a homoeopathic remedy, without a single side-effect.
I've previously blogged about the issue of vaccination v. faith in vitamins as a prophylactic for preventable childhood illnesses. You will notice that there is no reference for the "highly likely although not yet proven" thought about the benefit of supplementation in the "underdeveloped countries" and that this assertion has not been tempered even in the light of the successful Measles Initiative vaccination programme in some of those same "underdeveloped countries".

Even in the UK, with comparatively adequate nutrition and abundant medical services, the BBC cited some alarming statistics from the medical newspaper Pulse related to measles:
lowering levels of immunity meant as many as 12% of children and 20% of adults could be hospitalised if infected by measles.
Does a hospitalisation rate of 12% of children and 20% of adults sound like a "mild and temporary illness"?

Holford is a firm believer (without supporting evidence) in the value of an immune boosting diet as a prophylactic or staunch defence against childhood illnesses. A hat-tip to Orac for giving me a polite response for the next time somebody tells me that a product/diet 'supports the immune system'. Orac scrutinises the advertising claims for a herbal remedy that used to claim that it prevented colds until advertising regulations downgraded that claim to 'helps to support the immune system'. Orac hazards a guess that the people who make these products:
don't know an antibody from a T-lymphocyte, but now they're pushing a "boost the immune system" claim. What specific aspect of the immune system are they boosting? Cell-mediated immunity? What cell type? Neutrophils, T-lymphocytes, B-lymphocytes, natural killer cells?
Despite charging for access to this report, Holford does not detail the aspects of the immune system that he believes to be 'boosted' by supplements and diet or why they would be adequate.

As for Holford's claim about homeopathic vaccinations, I have searched everywhere for that study but I can't find it. It would even have helped if he had been more specific about the specific meningitis organism. If you can identify this study, I would be very grateful. Although Holford is not a homeopath, he might be interested to learn that leading homeopath, Dr Peter Fisher, recently argued that homeopaths approve of childhood vaccinations. Fisher even said that Hahnemann would have approved of the vaccination programme (albeit in a very convoluted fashion).

Other issues aside, that subscription is looking like even worse value than I thought. Holford recites the tired anti-vax rhetoric that does not become any more true for the number of times it is cited. You would need very good evidence to argue otherwise, as Holford attempts, but that evidence isn't there. Please discuss vaccination with your paediatrican, Health Visitor, GP and other trusted sources. As a bowel-whisperer Holford may have a touching faith in the "highly likely although not yet proven" and "less well researched" value of an 'immune-boosting' supplementation programme and homeopathic vaccines but the consensus of medical and scientific evidence is in favour of the vaccination programme for children for whom they are not contra-indicated.

Click on the image to read the details on Flickr.

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Eczema and Allergy Links and News

When I attended the Allergy Show last week I picked up an information leaflet about allergies in small children that is starting to be distributed in pharmacies and similar places. The slogans that aroused an Amen Corner response were:
Allergy care starts with early diagnosis

Early testing prevent allergy symptoms becoming severe
The irritating thing was that there is no follow-up relevant website. The leaflet was supported by an educational grant from Pharmacia Diagnostics. It is not surprising that the leaflet contained the summary advice:
Find out to what your child is allergic!

Only a doctor can confirm the diagnosis of allergies, using skin testing or appropriate blood tests.

Go and visit your doctor for an allergy test!

Your child will be tested to identify the substances (allergens) causing the allergy.

The appropriate treatment (eviction, immunotherapy, medication...) can begin to help your child feel much better!
I have no idea what eviction is in this context. I would also say that the leaflet places too much reliance on the value of tests: there is no substitute for a good clinical history taken by an appropriately qualified and experienced clinician. Tests are valuable for confirming a diagnosis, they are rarely sufficient by themselves. So, early diagnosis and appropriate management are good things but parents should be wary of the over-stated clinical significance of some tests. If you're concerned about your child, you might contact one of the allergy charities to ask for details of your best NHS referral that you can discuss with your GP.

Action Against Allergy Parent Workshops These workshops are for the parents of allergic children: the venue is St Thomas' Hospital in central London. The workshops will be led by consultants, dietitians and nurses from the deservedly-renowned Children's Allergy Service at the Evelina Children's Hospital based at St Thomas'. The sessions are scheduled for 2 hours and will take place in the afternoon or evening. The anticipated cost is £10 per participant. The first 3 workshops are planned for autumn 2007: they focus on eczema, asthma and food allergy. Register at their website to be kept up-to-date with developments. These sound very promising; I hope that they fulfil their potential and meet the needs of parents.

Do lifestyle choices such as frequent washing, harsh soap and biological washing powders contribute to eczema and allergies? Specialists from Great Ormond St Hospital argue that too much washing with strong soaps, the use of exfoliants and other such skin care products, and even biological washing powders (as promoted for low-temperature, energy-saving laundry) may be stripping away the skin's outer protective layer, resulting in allergic responses to allergens in susceptible individuals. There was a nicely specialist argument in the original paper about the role of Langerhans cells that raises some interesting questions about the widely-accepted hygiene-hypothesis. However, the take-home message for parents is that you might be well advised to avoid using harsh soaps or exfoliating products with your children and switch to less abrasive emollients. I would also add that you may have to give up low-temperature laundry and use gentler washing-aids. Take advice from suitable sources such as the National Eczema Society and GP.

Apply corticosteroid creams only once daily for atopic eczema Atopic eczema affects many adults and up to 20% of children; the health costs are comparable to diabetes and asthma. Corticosteroid creams are a mainstay of treament: usually applied twice or more a day, recent studies indicate that once a day is adequate.

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Tuesday, June 19, 2007

Children's Health, Asthma, Eczema and Allergy Links and News

Blossom - Stop Allergies Spoiling Childhood A campaign to reduce the social exclusion of children with allergies. The members promise reliable and regularly updated information, advice resources and support. The site is a little light on content at present but it will be interesting to see how this site and campaign mature.

Food allergies reported to have increased 12-fold in australian children since 1995 It's a gallimaufrey of numbers and it is hard to avoid the speculation that some of the increase reflects increasing awareness of the symptoms of allergies and a greater readiness by parents to request allergy testing for their children. Nonetheless, it is worth looking at the paediatric trends in food allergy in a community-based allergy practice.

Omegas 3 and 6 exposure from early life do not influence asthma, eczema or atopy levels at age 5 Last year, there was some surprise when the Childhood Asthma Prevention Study failed to show any protective benefits for omega-3 fatty acid supplementation and restriction of dietary omega-6 fatty acids in children. The interventions did not prevent asthma, eczema, or atopy at age 5 years. This related observational analysis of the cohort, adds further weight to the negative findings of the randomised controlled trial. Both the study and trial report that modifying or supplementing dietary polyunsaturated fatty acids in early childhood does not protect against atopy and asthma in children.

Wales has one allergy specialist to deal with an estimated one million people with allergies This is an interesting story made ridiculous by the implication that the excellent Dr Paul William, a clinical immunologist at Cardiff University, is solely responsible for the secondary/tertiary care of these people and yet he has only an 8 month waiting-list. The rest of the article is pretty run-of-the-mill except for some gratuitous and inappropriate advice at the end about garlic, lavender, chamomile, eucalyptus, royal jelly and honey.

Backlash against bipolar diagnoses in children After recent enthusiasm for this diagnosis, it was inevitable that it would fall into disfavour once people considered the wisdom/experienced the reality of prescribing antipsychotic medication to very young children. The article offers a recent overview of the issues and mentions that Biederman's insight was correct as it is now acknowledged that bipolar disorder can strike before puberty. However, the 2001 guidelines also state the difficulties in validating a diagnosis in children is challenging because normal children are prone to be irritable, aggressive, or giddy. It does contain some details of the death of a child who may have been over-medicated by her parents in an attempt to wrest control of her behaviour.

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Sunday, June 17, 2007

Paediatric Grand Rounds 2:5 Is Up!

Star - text is Paediatric Grand RoundsPaediatric Grand Rounds 2:5 is up, courtesy of Christian Bachmann of Med Journal Watch. Bachmann has 30 years of experience as a science and medical writer and editor and it shows in the elegant way that he has put the PGR together, assembling the posts into appropriate sections and commenting on them thoughtfully.

PGR is back into the usual swing of controversial ethical issues and childhood concerns like handing out icecream. Neonatal Doc considers the ethics of resuscitation for the very premature and for babies with Downs Syndrome. New to me, the Black Breastfeeding Blog reports that there are racial/ethnic disparities in the breastfeeding advice given to african-american and white women.

One of the unexpected consequences of sucessful treatment for previously fatal childhood illnesses is that they age out of the paediatric domain where they have got best care, but sometimes there isn't the transitioning care available for them in adult healthcare.

Sandy is always an educational read. For this PGR she offers a post how public health messages may be pushing young girls towards anorexia.

The Autism Omnibus hearings have extensive coverage in several blogs. We also hear about recent awareness and fund-raising campaigns for primary immunodeficiency and neurofibromatosis.

All this and more for some of the odd and interesting about paediatric healthcare. I commend PGR to you.

Dr. Clark Bartram is looking for hosts for future PGRs. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

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Thursday, June 14, 2007

Laughter, Children, Babies and Eczema

Young girl on playround equipment with an ear to ear grin: she is an example of happiness through explorationWhen a young child had eczema the sleepless nights can disturb the whole family (and neighbours in several directions if the child is particularly vocal about distress). Every so often, I come across a researcher who publishes in some quirky areas and I'm intrigued. I wonder about their research group, who funds their research, how easy they find it to attract research fellows, stuff like that. Sometimes, I think ?!? but most of the time, I wonder about what they are doing with their findings and how they might hope to investigate the biological mechanisms involved or to apply their findings to a wider population.

Kimata has published several papers on laughter and eczema; this is the sort of area that piques my interest. When an abstract blips on my quirk-meter, I don't always consult the full paper because I don't want to be disillusioned and learn that underneath the charming eccentricity lies something that is terribly staid. I'm about to mention a couple of Kimata's papers that I haven't seen in their full form, so please be aware of that.

Eve Van Cauter has reported studies that show short sleep duration in young, healthy men is associated with decreased leptin levels, increased ghrelin levels, and increased hunger and appetite, and cortisol disturbances that influence the ability to cope with stress and also promote the laying down of a personal duvet of body fat.

Kimata measured ghrelin levels in a comparison group of healthy children and those with atopic eczema and night-time wakenings. Kimata discovered that the children with eczema had higher ghrelin levels at 02:00 when compared with healthy children.
Neither viewing control non-humorous film nor viewing humorous film had any effect on healthy children. In contrast, viewing humorous film improved night-time wakening and reduced elevation of salivary ghrelin levels in patients with atopic dermatitis, while viewing control film failed to do so.
There are so many possible mechanisms of action here that it nudges across into being a substantial part of PNI (aka, psychoneuroimmunology, psychoendoneuroimmunology, PENI). Are parents desperate enough to add humorous films into their usual night-time routine (whatever that involves)?

Babies seem to laugh a lot; probably at the notion that parents have plans that involve sticking to meticulous timetables that disintegrate with the first unscheduled nappy-change. Babies have eczema but, sophisticated as children's marketing is, I doubt that there is a readily accessible range of humour for the neonate and infant. So, what do you do if your baby has eczema?

If you are Kimata, you recruit currently breastfed babies with atopic eczema and allergies to latex and house dust mite (HDM) in the 5-6 months of age demographic (my first typo of that was demongraphic which seems quite apposite). You arrange matters so that half of mothers have atopic eczema and half are free of it.

You show the mothers an 87 minute video of either Charlie Chaplin or non-humorous weather reporting. After that, you collect and analyse samples of the breastmilk at 2 hourly intervals and measure the amount of melatonin in it. You also study skin wheal responses to HDM an latex in the infants.
Laughter increased the levels of breast-milk melatonin in both mothers with AE and healthy mothers, and feeding infants with increased levels of melatonin-containing milk reduced allergic responses in infants.
I don't want to know any more about this study. I'm entertained just by knowing that Charlie Chaplin is still so popular in Japan. I'm intrigued by the reported results.

Yes, the boring, tedious, obvious response to this paper would be to experiment with ways of delivering melatonin to babies with eczema to dampen their allergic response and enable them to get a good night's sleep. But I like the notion of mother and baby chuckle clubs.

I've written frequently about the inadequacy of allergy services in the NHS. Prof. Hourihane was recently giving evidence to the House of Lords committee that is looking into allergy and allergic diseases. He commented:
The NHS is the laughing stock of Europe for its absence of immunotherapy for allergic diseases.
Several other experts made similar comments about other aspects of the provision of allergy services in the UK. Despite this awareness of the need for proper, clinical diagnosis and management of allergies, sadly, one eczema related document is likely to elicit snorts of derision rather than laughter: the National Institute for Health and Clinical Excellence Guideline for the Management of atopic eczema in children from birth up to the age of 12 years. There is no recommendation that children with atopic eczema should be referred to an allergy specialist; not even when a child has hit the trifecta of eczema, allergic rhinitis and asthma that needs especially careful management, particularly if the child has unstable asthma.

I don't know why the members who drew up this guideline decided not to recommend allergy assessment: given the paucity of paediatric allergists in the UK, it was perhaps inevitable that there was only one in this group. In light of this, it is particularly disappointing that the group will consider:
What is the place of complementary therapies in the treatment of atopic eczema? This will include consideration of homeopathy, and Chinese and Western herbal medicine.
Too many desperate parents feel that they have no option but to consult CAM practitioners precisely because they can not obtain timely access to allergy services on the NHS.

Click on the image or visit Flickr for further information about the image.

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Sunday, June 10, 2007

We Do Not Have Adequate Provision of Allergy Services in the UK

Art illusions, anaphora etc.
There are so few clinical allergists in the UK and such a surge in need for them that it is hardly surprising that Jo Revill has a dramatic headline for her story: NHS Swamped by an Epidemic of Allergies. There are the equivalent of 26 fulltime posts in clinical allergy in the UK. I don't fully agree with her overview of the situation but you can understand the scale of the mismatched resources when Revill claims that:
One in three people in Britain can expect to suffer from some form of allergy during their lifetime - including 2 million people in the UK thought to have some allergy to food - but there has been barely any increase in NHS services to cope with this. Experts will warn this week that demand for care is outstripping the NHS's ability to cope, and many patients go to private clinics or dietitians that may offer unconventional diets.
I'm sure that Registered Dietitian, Catherine Collins, might argue that most of these 'dietitians' who are advising "unconventional diets" are nutritionists rather than registered dietitians (the latter is a protected term, the former isn't - anyone can declare themselves to be a nutritionist). However, the larger point holds; the NHS provision for allergy services is completely inadequate with 12 million people thought to be in need of appropriate diagnosis and management advice.
Britain has one of the highest rates of allergy in the world, along with America, Australia and New Zealand. For reasons not understood, in the last 20 years the rate of eczema and asthma has at least doubled, and there has been at least a threefold increase in nut allergies. Before the mid-Nineties nut allergies were rare, but one in 50 schoolchildren now has one. In the last four years the number of adults with food allergies has also shot up, partly as a result of more awareness, with thousands suffering reactions to shellfish, vegetables, seeds, nuts, kiwis and plums.
Food intolerance or sensitivity is frequently described as hidden or delayed food allergy by many writers. There are claims that there are clinically validated tests for it but most of these have yet to be fully substantiated (e.g., IgG food intolerance tests). Because there is a perception that normal physiological responses to food or sensititivies have become medicalised into an illness, Dr. Jonathan Brostoff acknowledges that:
there [is] still enormous scepticism within the health service about whether patients 'truly' [have] an allergy or [are] just imagining it.
Allergy provision with the NHS is scarce. Clinical allergists frequently express their concern that it is this lack of provision that is driving some desperate people towards inappropriately qualified advisers who may lack a full understanding of allergy, anaphylaxis, intolerance and their appropriate diagnosis and management. It is long past time for the provision of adequate allergy services on the NHS.

Edited to include Claire's comment (doesn't show in Haloscan):
"It is long past time for the provision of adequate allergy services on the NHS."

Hear, hear. The patient charities Allergy UK and The Anaphylaxis Campaign and many doctors and patients have made this point until they're blue in the face (no pun intended). Donna Covey of Asthma UK stated recently that an astonishing proportion of people contacting them don't know know if they have a diagnosis of allergic or non-allergic asthma. But very little seems to change and I recall HoC health comittee report warned that the situation might even deteriorate, as some of the small number of clinical allergists near retirement. Appeals for central funding and direction to boost provision to the levels recommended in the 2003 RCP report ('Allergy: the unment need") continue to fall on deaf ears, as evidenced most recently in the BBC Radio 4 'Allergic Reactions' broadcast, where Minister Andy Burnham simply passed the buck back to the PCTs, even though Dr Ewan had explained why this is not working and why allergy could be considered as a special case (historic cinderella status in NHS, now faced with rising numbers of affected patients, increasing incidence of severe and/or complex disease).

Clutching at straws, I fear, but, given that there is now an overall surplus in NHS funds, perhaps Gordon Brown could mark his accession to power by earmarking some of this to kick start the process of building up NHS allergy provision? I know lots of people who would respond to such a move with undying gratitude.

I've described my concerns about CAM and allergy on your other blog (HW), particularly my theory that the overstated and inaccurate claimes made by some of these practitioners is actually reinforcing the scepticism people can encounter when they raise concerns about allergies with their doctors. On a more personal note, one of the burdens a parent of an allergic child has to bear is the constant torrent of unsolicited advice about CAM 'cures' from friends and family, mostly based on something they have come across in the media. Often, this is accompanied by uninformed opinions about the dangers of conventional medications. I realise this is well meant but it drives me mad: parents doing their best to work with their doctors to deal with these difficult conditions don't need to be undermined by suggestions that they are harming their children. I have taken to telling people who offer me unsolicited advice on ear candling, homeopathy, kinesiology, fad diets etc that what would really help me would be easier access to a clinical allergy service, and if they really want to help, please would they kindly write to their MPs about this.
Click on the image or visit Flickr for further information about the images. 1. IMG_2441, 2. IMG_2446

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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.

The next edition of the PGR will be hosted by Mousetrapper at Med Journal Watch. Mousetrapper says:
Come on, post it and mail me the link, best along with a blurb that tells me what is your key message, why you find your post important and the like. The better you help me in the presentation, the better a presentation you are likely to get. PGR 2:5 is now open for your submissions. I am looking forward to get your mails.

Send your submission as follows: Type info. Type this little at-sign. Type gesundheit. Type a dot. Type ch (beware of typo, this is a Swiss domain). Please enter Pediatric Grand Rounds in the subject line, this will help me to filter your message out of the stream.
And please do this by Friday June 15.

Clark Bartram is looking for hosts for future PGRs. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

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

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Monday, June 04, 2007

Paul Offit on How We Could Lose the Modern Medical Marvel of Vaccines

Immunisation images, advertising and commemoration
Dr. Paul Offit has written an admirably clear account of why a legal case could mean the end of the modern medical marvel of vaccines (try BugMeNot if you need a log-in for the full article).
No single medical advance has had a greater impact on human health than vaccines. Before vaccines, Americans could expect that every year measles would infect four million children and kill 3,000; diphtheria would kill 15,000 people, mostly teenagers; rubella (German measles) would cause 20,000 babies to be born blind, deaf, or mentally retarded; pertussis would kill 8,000 children, most of whom were less than one year old; and polio would paralyze 15,000 children and kill 1,000.

Because of vaccines all of these diseases have been completely or virtually eliminated from the United States. Smallpox -- a disease estimated to have killed 500 million people -- was eradicated from the face of the earth by vaccines. And we're not finished; vaccines stand as our only chance to prevent pandemic influenza, AIDS, and bioterror, and our best chance to prevent certain cancers.

Now, massive litigation could force companies to leave the vaccine business, threatening the future of one of medicine's greatest achievements. On June 11, in an unprecedented action before a federal claims court, lawyers for 4,800 autistic children will argue that vaccines caused autism. If successful, these claims could exhaust the pool of money currently set aside to compensate children who have been hurt by vaccines. Further, lawyers will likely take their claims that vaccines cause autism to civil court, where awards could be enormous.
Offit provides an overview of the consequences of a scare about pertussis vaccines in the UK in the 1970s.
The British media hailed Wilson's report as fact and the percentage of children immunized dropped from 80 to 30. During the next few years, 300,000 children in England were hospitalized and 70 killed by pertussis.

By the late 1970s fears of pertussis vaccine had spread to the United States. Before jurors persuaded more by emotional appeals than by science, lawyers successfully claimed that the pertussis vaccine caused sudden infant death syndrome (later found to be associated with sleep position), Reye's syndrome (later found to be associated with aspirin), unexplained coma, paralysis, mental retardation, and epilepsy.

Seven companies stopped making the vaccine; within a few years only one, Lederle Laboratories, remained. Lederle was punished for its persistence. In 1986 a jury awarded $1.13 million to parents claiming that Lederle's pertussis vaccine had paralyzed their son -- an award that was more than half of the annual sales of the vaccine. Subsequent studies of hundreds of thousands of children showed that the risk of permanent brain damage was the same in children who had not received the vaccine as in those who had. [My emphases.]
The disincentives for remaining in the business of vaccine production were so strong that the US Government introduced the National Childhood Vaccine Injury Act in 1986. The Act was intended to deal with and compensate cases where children had been injured by vaccines, and to disallow those speculative claims for harm for which there was no epidemiological support (e.g., the purported connection between the vaccine for hepatitis B and Multiple Sclerosis). Despite the provisions of this Act, the potential profits did not justify the risk exposure. At the start of the 1980s, 18 companies made vaccines; by the close of the 1980s, only 4 were still producing vaccines.

Since that time, both in the UK and the US, there have been periodic shortages of vaccines: these have had consequences for the young, the elderly and those with compromised immune systems.

In the US, the companies that produce vaccines are about to find themselves in the dock, again.
Lawyers will argue that either the measles-mumps-rubella (MMR) vaccine or a mercury-containing preservative (thimerosal) in vaccines or the combination of the two can cause autism. This theory has been advanced on television shows such as 60 Minutes, in popular magazines like Time and Newsweek, and on national radio programs such as Imus in the Morning...

Certainly there is plenty of evidence to refute the notion that vaccines cause autism. Fourteen epidemiological studies have shown that the risk of autism is the same whether children received the MMR vaccine or not, and five have shown that thimerosal-containing vaccines also do not cause autism. Further, although large quantities of mercury are clearly toxic to the brain, autism isn't a consequence of mercury poisoning; large, single-source mercury exposures in Minamata Bay and Iraq have caused seizures, mental retardation, and speech delay, but not autism.

Finally, vaccine makers removed thimerosal from vaccines routinely given to young infants about six years ago; if thimerosal were a cause, the incidence of autism should have declined. Instead, the numbers have continued to increase. All of this evidence should have caused a quick dismissal of these cases. But it didn't, and now the court has turned into a circus. The federal and civil litigation will likely take years to sort out.

Autism can be a heartbreaking disorder, often draining parents emotionally and financially...

It would be nice if there were someone or something to blame. We could blame the government and use the federal vaccine compensation program to pay for care. Or we could blame vaccine makers, and get them to pay in civil court. But if vaccine makers -- faced with large awards for a problem that wasn't their fault -- make the same decisions they did in the early 1980s, all American children will suffer, including those with autism. Then, we'll have only ourselves to blame.
I hope that Offit's jeremiad doesn't come true. If it were to come true, then truly we might be facing the prospect of the first generation of children to die before their parents.

Dr. Paul A. Offit, MD, is the chief of infectious diseases at the Children's Hospital of Philadelphia; he is the co-inventor of the rotavirus vaccine currently licensed in the United States, and the author of Vaccinated: One Man's Quest to Defeat the World's Deadliest Diseases: I have no direct or indirect, personal, financial, or professional connection to him. Likewise, I do not have a conflict of interest, personal, financial, professional, upstream or downstream connection to any pharmeceutical company.

Image information: 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, June 03, 2007

Paediatric Grand Rounds 2:4 Is Up!

Star - text is Paediatric Grand RoundsPaediatric Grand Rounds 2:4 is up, courtesy of Awesome Mom of Awesome Mom. I often recall one of my favourite posts by Awesome in which she discusses her thankfulness that her son Evan is no longer a chronically ill heart patient but transitioning to a normal child.

Awesome addresses the cold wind that has been blowing through the paediatric and wider medical blogging world and provides a dignified account of the recent, very public, travails of Dr. Flea. She discusses what Dr. Flea's blog had meant to her:
He wrote out many evidence based posts on things that were being widely discussed about children's health. His series of posts on vaccinations are treasures that may never be replaced. His looks at alternative therapies and possible causes for Autism were also reoccurring themes in his blog. I especially loved how tried to empower parents by teaching them to take care of simple illnesses at home, keeping sick kids out of the doctor's office. I will never look at Neosporin the same way again.
So, on with the motley for the remainder of PGR which covers why you need to plan carefully for any time your child is near water: Swimming: Fun Exercise or Dangerous Diversion? You decide! Picking up some of the slack from Dr. Flea, Dr. Scott knows that the treatment decisions for an earache or cold should be simple, but will the parents accept them?

The mercury malicia has attacked Arthur Allen for his cogent piece on the upcoming Autism Omnibus hearings: Dad of Cameron unleashes a robust response: You Got Nothing.

On the topic of Bad Science and whipping up hysteria over dramatic interpretations of science, rumour and popular concerns, we learn that WiFi wants to kill your children. Wellington Grey presents an excellent diagram to help us understand this nexus of dubious science, the precautionary principle and the megaphone of television.

Sandy is always an educational and entertaining read. For this PGR she offers several posts on the joy (and science) of sweets - do go and read them.

All this and more for some of the odd and interesting about paediatric healthcare.

Dr. Clark Bartram is looking for hosts for future PGRs. You can consult both the hosting schedule and earlier editions in the Paediatric Grand Rounds archive.

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