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Requests for reprints of articles

I just received a request for a reprint of one of ny articles. I get these from time to time; strictly speaking I shouldn't send such reprints since they infringe the copyright of the journal, but I used to do it because the requests usually came from third-world countries where people presumably couldn't easily afford the payment.

But not once did any of these correspondents bother to thank me or even acknowledge receipt, which I take ill; it's a lot less trouble for them to reply than it is for me to find the article in question and attach it to my email. So now I no longer reply to such requests, especially when, as in today's case, the requester is a professor at a university hospital in Paris, who could no doubt easily afford the fee to the journal (which probably wouldn't come out of his own pocket anyway).

Homeopathy - a celebrity's endorsement or not?

The Faculty of Homeopathy is drawing the attention of supporters to "an excellent article" in The Mail Online.

This link takes you to a page where the actress Michelle Collins, who has appeared in East Enders and Coronation Street, describes how she gave up conventional medicine and moved to homeopathy to help her anxiety and depression. This was successful and she now feels much better.

But what is odd about this recommendation by the Faculty is that the article has an inset with a "Expert View" by Dr Ellie Cannon, who says that she does not reommend homeopathy to her patients because more than 150 trials have failed to show that it works.

Homeopathy’s dilution theory – that water ‘remembers’ the active ingredients it comes into contact with – is implausible. If it were true, water would also remember other substances – bacteria, animal waste or the test-tube the remedy was made in.

So how do I explain the positive effects some people experience? Michelle had crucial time and input from a therapist who listened to her worries. It helped her develop a positive mental attitude about coping with her anxiety. I believe it is this that has led to the improvement in her condition.

The placebo effect is real and powerful. So even though the pills are inert, treatment will ease the symptoms of stress. That is why taking a remedy before a show helps to control the panic. But the pill itself could just as well be a sugar lump.

Given the traumatic times Michelle has had, it is so important that she has found something that works for her. But as a general solution for others it would not work.

I think that Dr Collins gets it exactly right here. Homeopathy is best regarded as a form of psychotherapy. Please see my book Homeopathy in Perspective.

Psychotherapy today uses many different theories but it originated with Freud and psychoanalysis. The psychiatrist Anthony Storr was sceptical about much psychoanalytic theory but nevertheless thought that psychoanalysis could have beneficial effects on patients.
. . .
Much or all of homeopathic theory may be mistaken, and the remedies themselves may have little objective efficacy or even none at all, but patients often get better nevertheless. To say that this is due to the placebo effect is to beg the question, because we have only hazy notions about how placebos work anyway. For many patients, especially those whose symptoms really arise from their life situation, merely stating their problems verbally is sometimes enough to put them in a new light and to suggest the direction to look for a solution. In such cases the therapist is merely a sounding board; indeed, even a computer will do as a listener for some people. Many others do need a human individual to interact with, however.

So is the therapist no more than a sympathetic friend? No; this is where the theory comes in. It often doesn’t matter much what a therapist’s theoretical beliefs are (provided they are not actually dangerous, of course); their function in many cases is not to be “right” but to provide a framework to keep the discussion in focus.

Michelle's endorsement illustrates this extremely well.

Prediabetic state in Britain - media storm

There was a lot of excitement in the media this week about a report in the BMJ which, we were told, said that there had been a huge increase in the incidence of prediabetes (blood sugar raised although not to the level of actual diabetes) in the British population since 2003. Now a third of us is in this state and before long the NHS will be swamped by a tsuname of patients with diabetes. So when my copy of the journal arrived I looked to find this item given a prominent place, probably with an editorial comment.

It turns out that the paper is published in the online journal BMJ Online. Its findings are summarised in the current print journal, which also cites a quite extensive comment by John Yudkin, emeritus professor medicine at University College, London. He questions the validity of the "prediabetes" diagnosis, calling it an example of "overdiagnosis". Most people with this "condition" will never develop diabetes The term is rejected both by NICE and the WHO. It "brings with it the the burden of disease labelling and risks of largely unproven interventions."

The media, of course, didn't mention any of this.

Fever as a cancer cure

My online article 'Miraculous' Cures? discusses various mechanisms that may explain spontaneous cures of cancer that are sometimes attributed to divine intervention. One of these is modification of the immune response by means of fever. This is an old idea that is now attracting renewed attention.

A cell biologist, Uwe Hobohm, believes it is time to revive the idea. Fever therapy was used successfully to treat cancer in the nineteenth century. Hobohm discusses the immunological basis for the treatment in New Scientist ('Hot, toxic and healing': 4 January 2014). Hobohm and his colleagues are currently testing the hypothesis in mice at two research centres in Germany. This is fascinating, although, as he says, we are a long way away from having this treatment approved for human patients.

Westerners' misconceptions about Chinese Medicine

When alien ideas are imported into a culture they are pretty well inevitably misunderstood. This happens in religion - how many Christians think of Christianity as a Near-Eastern religion? (There is the probably apocryphal remark by an American congressman: "If English was good enough for Jesus it's good enough for me.")

The same is true of medicine. The current enthusiasm for Chinese medicine is based on a pretty distorted view of what Chinese medicine actually is. One good source for correcting this misconception is Shigehisa Kurihama's book The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine.

Another that I've recently come across is Nigel Wiseman's Westerners' Alternative Health-Care Values Eclipsing a Wealth of Knowledge. available here.

This is a long scholarly discussion of the subject. The topics include:

- Western motives for adopting Chinese medicine
- Influences of spiritual, physical, and philosophical traditions of the Orient
- Inaccurate characterisations eclipsing a body of knowledgge
- Intuition
- The root problem and the solution

The 'solution' proposed is, in outline, more and better translation of the Chinese texts.

From Wiseman's conclusion:

Too often, Chinese medicine is prized for certain qualities judged to be lacking in Western medicine. There is a tendency to assume that any desirable qualities that Western medicine lacks must be present in Chinese medicine, and to project those qualities onto Chinese medicine. In the process of projecting ideas onto Chinese medicine, other features have been obscured. I have argued against the false assumption that clinical experience and intuition are exclusively features of Chinese medicine, while theory and book-learning are characteristics of Western medicine that are of little import to the traditional Chinese physician.

This is an important article for anyone who is seriously interested in Chinese medicine.

Evidence-based medicine

"What if we tried to practise medicine according to the best evidence, only to find that half of it was mssing?" asks Minerva, in today's BMJ. In fact, as she goes on to say, that is exactly our position. She lllustrates this by citing a Cochrane review of a treatment for venous leg ulcers using flavonoid supplements. A previous review had found some support for this although the trials were mostly not good quality. Now a better trial has come to light; it was conducted by the manufacturers and did not find evidence of better healing. it was left unpublished.

Advocates of unorthodox treatments are often criticised for not providing convincing evidence of efficacy, and this criticism is often justified. But what is usually glossed over is the fact that orthodox treatments are usually in not much better shape.

The previous week Minerva reported a Canadian randomised trial of naturopathy that was published in the Canadian Medical Journal. The "more orthodox facets" of this treatment were compared with usual care to reduce cardiovascular risk factors and body mass index. Naturopathy proved more effective, and the methodolocical failings were no greater than those that are found in many similar trials of orthodox treatments.

It's not that we don't need evience of effectiveness in medicine - we do - but it's a lot harder to come by than we often think.

Medical error in 'Endeavour'

In ITV-1's 'Endeavour', the youthful Morse, still a detective constable at this early stage of his career, found a girl who had died with digoxin in her stomach. "Is that dangerous?" he asked a GP who was involved in the case peripherally (the partner of another doctor who was murdered).

"It certainly is. The clue is in the name of the plant it comes from, deadly nightshade," the GP replied.

But deadly nightshade doesn't give us digitalis or digoxin, it gives us belladonna. Digitalis, from which digoxin is derived, comes from the leaf of the foxglove. I thought that perhaps this wasn't really a medical howler and we were being given an artfully planted clue; the GP was going to turn out to be an imposter. But no, it wasn't the doctor who was ignorant, it was his creator.

Misleading remark on BBC about antibiotic resistance

This morning, James Naughtie was commenting on the Chief Medical Officer's warning about increasing antibiotic resistance. He said "our bodies are becoming resistant ." It's not our bodies, of course, it's the bacteria, providing a classic example of Darwinian natural selection in action.

More diet 'wisdom' questioned.

My father, who died peacefully in his late eighties, ignored recommendations to avoid eating saturated fat, saying that he had eaten butter all his life and it had never done him any harm. It seems he may have been right.

This week's BMJ has a research paper and accompanying editorial questioning the American Heart Association's advice on diet to prevent heart disease. The Association recently repeated its advice to maintain and even increase your intake of linoleic acid, which is found in high concentration in vegetable oils such as corn, sunflower, safflower, and soybean oils. We are supposed to use these oils in preference to saturated fat.

There is little objective evidence to show that exchanging linoleic acid for saturated fat does any good. Most trials of this hypothesis have involved other dietary changes and/or other interventions. And the new research suggests that increasing linoleic acid may actually be bad for you.

The researchers, Ramsden and colleages, looked at the original data from the Sydney Diet Heart Study, a randomised controlled trial conducted between 1966 and 1977 and involving 458 men aged 30 to 59 who had had a recent coronary event. Total serum cholesterol was lowered in those taking an increased amount of linoleic acid but deaths from heart disease were not reported in the original paper.

The new research is based on a re-examination of the original data (a technically difficult task). They found that mortality due to heart disease was higher in the group taking increased linoleic acid. Notice that this happend even though the serum cholesterol level in these men was reduced.

These findings contradict the view that replacing saturated fat with linoleic acid is a good idea. They do agree with what Gary Taubes contends in The Diet Delusion, in which he claims that saturated fat is not harmful.

What strikes me particularly about this is that the original researchers assumed unquestioningly that reducing serum cholesterol would automatically lead to a reduction in deaths from coronary heart disease. It didn't, and in fact their intervention actually increased the death rate from this cause.

Telomeres - the latest "scientific"(?) way to tell your fortune

Today's Independent has a piece about having your telomeres measured. These sequences at the ends of chromosomes are alleged to give an indication of how far your biological age differs from your chonological age. The longer they are, the longer you are likely to live. The test is now available commercially; it's still expensive but is forecast to become increasingly cheaper in coming years, to the point where everyone will be able to afford it.

The one prediction I'm prepared to make is that it will be a money-spinner for the Spanish company that markets it. Professor Carol Greider, who won a Nobel Prize for her work on telomeres in 2009, is sceptical about the value of the test but that won't prevent many thousand or millions of people from taking it. Another egregious example of useless screening. Plenty more about this in my blog - search for "screening" with the search button on the right for links.

Scepticism, homeopathy, and the Swiss Government report

For some reason the fact that the Swiss Government had produced a favourable report on homeopathy had escaped my notice until today, but when I learnt of it I looked it up on the net. This brought me to the Quackometer site, which has a discussion of the report called The Swizz report on homeopathy.

Well, of course, you'd expect the Quackometer to be critical of a report that supports homeopathy, but fortunately their piece contains some quotations from the Swiss article which help us to make up our own minds..

The current thinking and research of mainstream medicine are influenced mainly by Newton’s mechanistic and strictly causal-analytical physics (classical reductionist biomedical model), which ignores the more complex phenomena of nature, the organism’s systemic correlations, its life processes and overall regulation, and life as a whole, as well as qualitative experiences and the phenomena of spiritual science.

This passage is a complete give-away, particularly the reference to spiritual science. This will no doubt puzzle many readers, but anyone who knows anything about Anthroposophy, the so-called "Spiritual Science" founded by the philosopher and mystic Rudolf Steiner in the first half of the twentieth century, will recognise the term at once. It seems certain that Anthroposophical influences helped to shape the authors' conclusions.

So Newton is outmoded and a waste of time but science is not a total washout, it seems. Further on, predictably, we are told that homeopathy is supported by quantum physics.

Modern physics with its theory of relativity and quantum physics has long overtaken Newtonian mechanics and is paving the way for an understanding of the homeopathic mechanism of action.

Since few of us who are not trained physicists have any deep understanding of quantum mechanics or relativity we mostly have to rely on non-mathematical descriptions of these things written for readers like us. Some of these are very good, but physicists assure us that verbal accounts cannot give an in-depth understanding of the matter. Quantum mechanics is often invoked to explain the action of highly dilute homeopathic medicines. Often, I think, this amounts to little more than asserting that quantum mechanics and homeopathy are both mysterious, so they ought work in the same way. Moreover, if science can tolerate the paradoxes of quantum mechanics, why baulk at homeopathy?

Just to round off, I should point out that we even get the long-discredited idea of the vital force.

The vital force, just as vitality in general, cannot be measured and quantified by science, but it exists as a phenomenon.

I admit I haven't read the whole of this (long) report and perhaps some parts of it are better. But at least it seems clear that its authors are hostile to the values of the Enlightenment, which is enough to move it a long way down my reading list.

Values of health checks, breast screening, flu vaccine questioned

The BMJ of 24 November 2012 has a Cochrane systematic review and metanalysis that questions the value of routine health checks. Not only do they fail to prevent death or illness, they may also cause harm through unnecessary investigations or treatment.

We did find that health checks led to more diagnoses and more medical treatment for hypertension, as expected, but, as these did not improve mortality or morbidity, they may be considered harms rather than benefits.

The same issue of the BMJ also has a piece about screening for breast cancer. It reports an article in The New England Journal of Medicine which finds that screening has led to the overdiagnosis of breast cancer in 1.5 million women in the USA in the last 39 years. Mammography only marginally reduced the rate at which women presented with advanced cancer. Although death from breast cancer has reduced considerably over this period, the reduction is mainly due to better treatment, not screening.

Here are a couple of quotes from the article in the NEJM.

Our study raises serious questions about the value of screening mammography. It clarifies that the benefit of mortality reduction is probably smaller. and the harm of overdiagnosis probably larger, than has been previously recognized.

Although no one can say with any certainty which women have cancers that are overdiagnosed, there is certainty about what happens to them: they undergo surgery, radiation therapy, hormonal therapy for 5 years or more, chemotherapy, or (usually) a combination of these treatments for abnormalities that otherwise would not have caused illness.

Finally, there is an article citing a report from the University of Minnesota which says that the effectiveness of 'flu vaccination has been greatly overestimated, at least for the over-65s for whom it is mainly recommended. There is no harm in having the vaccine, but it should certainly not be made compulsory fo health workers, as is increasingly happening.

NICE and headaches due to analgesic over-use

I was interested to hear today that NICE has now told doctors and patients that taking too many analgesics can cause headaches. This has been known for over 20 years; I was first made aware of it when I attended a symoposium on headache at the National Hospital for Nervous Diseases some time in the 1990s. Since then I have seen a number of patients whose life was transformed by telling them to stop taking the tablets, 'Cold turkey' seems to work best; I warned them they would have six weeks of hell, after which their headaches would largely disappear. I have always mentioned it while teaching acupuncture to health professionals.

It seems odd that it has taken so long for NICE to come out with this 'discovery'.

Poor-quality paper on low-carbohydrate high-protein diets in BMJ

The current issue of the BMJ (7 July 2012) has a research paper by Pagona Lagiou and others on the incidence of cardiovascular disease in over 43,000 Swedish women who were following low-carbohydrate high-protein diets. They found a dose-related association, with those following the diet most strictly being at biggest risk.

An accompanying editorial points out that most studies of diets of this kind have been short-term. They have found improvements in risk factors for heart disease and this has encouraged the idea that these diets are safe. But their long-term safety is questionable, the editorial suggests, and low-carb high-protein diets should therefore not be advised to patients at present.

This contradicts what Gary Taubes famously advocates in The Diet Delusion. But if you have been persuaded by him to follow a low-carb diet and are finding it suits you (as I am), don't immediately rush off and start stuffing yourself with carbohydrates. Instead, go to the BMJ site ( and read the rapid responses to the article. So far there are 12 all unfavourable or downright dismissive.

The correspondents give numerous reasons for these unfavourable opinions. I'll cite just one: the average duration of the diet period was 15 years yet the nature of the women's diet was established simply by a single questionnaire given at the outset. Yes, that's right: no folllow-up assessment!. Can you honestly say you've eaten the same diet for the last 15 years? Could we believe you if you did? I could scarcely believe that this was what the paper is based on when I first read it, but it is.

Several commentators say that the article should not have been published, let alone endorsed by an editorial. One, a (Swedish) paediatrician, describes it simply as a total disaster.

If you are following a low-carb diet there is no need to panic just yet.