A paper in Addiction this month looked at drinking in young Danes partying at a Bulgarian holiday resort. They used the Acute Hangover Scale (AHS) to measure how people felt the morning after.

The Acute Hangover Scale is a nine-item scale and the question areas are: experience of hangover, thirst, tiredness, headache, dizziness or faintness, nausea, stomach-ache, heart racing and loss of appetite. You score 0, 1, 4, or 7 for each item depending on whether you rate it as: none, mild, moderate or incapacitating. So maximum score is 63 and it was first tested in Swedish mariners and students. You have to admire the strong-stomached researchers that braved hungover sailors and students to get this scale validated.

Personally, I think the scale could be developed further – an Enhanced Acute Hangover Scale if you will. Suitable items worthy of inclusion might include: craving for fatty food; drunken dialling activities; sensation of gorilla having defaecated in mouth; severity of Miscellanous Drinking Injuries (MDI); and level of regret/guilt over sexual activity.

Overall, the incidence of hangover was 68% after drinking more than 12 standard units. Who are these people that can drink 6 pints and have no hangover? Nearly a third of the sample apparently. However, this is slightly deceptive as many reported milder symptoms but didn’t qualify as having an Official Hangover. The mean AHS score was around 16 for those drinking 12 standard units but they used a cut-off with those above the 90th centile in light drinkers (<7 units) then deemed to have an Official Hangover for the purposes of the research.

There were two main associations with hangover. No one will be surprised to learn that hangover worsened the more the young Danes drank and you can be forgiven for suspecting this paper could lapse into an exercise in Stating the Bleeding Obvious. More interestingly, the severity of hangover increased significantly during a week of heavy drinking. Hangovers clearly got worse over the course of the week for the same drinking the night before. There was also no association with prior drinking habits.

There is a serious side to the paper. The reason that the hangover merits some serious research hinges around the exploration of the development of alcohol dependence. Consider this – do hangovers worsen with repeated exposure to alcohol? If they did, one theory suggests that hangovers are an ‘early and mild form of the alcohol withdrawal syndrome’. One that could later develop into a full blown withdrawal syndrome and this paper offers support to that theory. There may not yet be a clear clinical lesson here but it could have implications in the future when it comes to identifying drinkers at high risk of dependence.

Hesse, M., & Tutenges, S. (2010). Predictors of hangover during a week of heavy drinking on holiday Addiction, 105 (3), 476-483 DOI: 10.1111/j.1360-0443.2009.02816.x

Coffee table

I have to confess that a few years ago I was advising patients to go and get glucosamine for their dodgy knees. There can’t be many GPs that haven’t dropped it into the discussion with a patient with intractable osteoarthritic pain. The therapeutic options for worsening osteoarthritis seem to dwindle rapidly. Unfortunately, the evidence for any effect from glucosamine has been eroded nearly as quickly as the joints involved.

My fondness for glucosamine had been partly motivated by the fact Mrs ND is a vet and she advised me of the potential benefits of glucosamine for arthritis. She was adamant that a glucosamine-chondroitin supplement was good for dogs with arthritis and she gave testimony to having witnessed some near miraculous effects. Apparently this combo could perform wonders for portly labradors, or ‘coffee tables’ as vets occasionally refer to them, with knackered knees.

The GAIT trial was reported a year ago by NCCAM and Dr*T blogged about glucosamine way back last October. I know that NCCAM is not hugely popular amongst anti-quackers in the USA but there are some helpful Q&A here on their $12.5 million GAIT trial.

What were the key results of the study?

Researchers found that:

Participants taking the positive control, celecoxib, experienced statistically significant pain relief versus placebo-about 70 percent of those taking celecoxib had a 20 percent or greater reduction in pain versus about 60 percent for placebo.

Overall, there were no significant differences between the other treatments tested and placebo.

For a subset of participants with moderate-to-severe pain, glucosamine combined with chondroitin sulfate provided statistically significant pain relief compared with placebo-about 79 percent had a 20 percent or greater reduction in pain versus about 54 percent for placebo. According to the researchers, because of the small size of this subgroup these findings should be considered preliminary and need to be confirmed in further studies.

For participants in the mild pain subset, glucosamine and chondroitin sulfate together or alone did not provide statistically significant pain relief.

Essentially this huge and very expensive study involving around 1800 patients showed no benefits of glucosamine other than a small effect in a sub-group. If you go raking through all the subgroups in a large trial it is an inevitability of the way statistics are analysed that eventually you will turn up a significant result. Torture the data and it will tell you anything.

The possibility remains that perhaps glucosamine and chondroitin supplements are an effective treatment to reduce pain in arthritis in dogs. This could be an effect which is confined to canines and can’t be replicated in humans.

Or maybe there is a subtle placebo effect at work manifesting itself through the owners. It’s an intriguing thought. However, the most likely explanation is that the advice that vets give the owners when clients consult about a dog with dodgy knees is having the effect. Vets will give advice on lifestyle changes for the animal and are likely to give non-steroidal analgesia. It is this that makes all the difference – not the glucosamine and chondroitin supplements.

I’ve had a dig around in the vet literature and I found one systematic review of treatments for osteoarthritis in dogs in the Journal of the American Veterinary Medical Association. Incidentally, in the abstract when they talk about ‘comfort’ they are referring to the reliability of the evidence – not how little pain the animals were in. This isn’t clear until one reads the paper. The trial with glucosamine and chondroitin showed no effect above placebo. They commented:

Presently, the strongest evidence available for the medical treatment of clinical signs associated with osteoarthritis in dogs is mostly limited to nonsteroidal anti-inflammatory drugs. Additional controlled studies in all groups of medical treatments are needed.

There is possibly an argument that dogs will present later than their human counterparts. Dogs won’t turn up at the surgery whining at the first twinges in their knees. Perhaps vets are more likely to be treating severe osteoarthritis in dogs and this might fit with the GAIT trial showing an effect in their subset. Perhaps. But I’m grasping at straws.

However, there was another strand to GAIT which showed that there was no change in structural changes on X-ray. They went on to cast doubt on these findings as the overall changes in joint narrowing were smaller than expected. This week the American College of Rheumatology Annual Scientific Meeting presented an abstract at their conference. This was the Joints on Glucosamine (JOG) Study: A Randomized, Double-Blind Placebo-Controlled Trial to Assess the Structural Benefit of Glucosamine in Knee Osteoarthritis based on 3T MRI study. After 6 months of treatment they found no structural changes using MRI or any evidence of new cartilage formation when measuring a urinary biomarker of cartilage synthesis. It seems likely to be an important trial with negative findings confirming the GAIT findings.

Glucosamine limps on in high street stores but it seems to be running out of steam. One of the GP practices in which I locum has taken the decision to stop prescribing glucosamine. I’ve not been involved in the discussions but I suspect they have taken the view that it is a fundamentally an unremarkable food supplement with a miserable evidence base.

It would have been great to have identified a cheap, well-tolerated remedy to reduce the pain of osteoarthritis. Sadly, wishful thinking isn’t enough and for those with knackered knees it remains a dog’s life.

This post is also published at The Lay Scientist.

Image: Pete Chapman under Creative Commons Attribution ShareAlike 3.0 License

There is almost a sad inevitability about the discussion in the media around the issue of giving heroin to heroin users. When it come to heroin-assisted treatment (HAT) it is inevitable that any reasonable discussion will be drowned out by the clamouring commentariat.

The UK has been using heroin as part of the treatment of users in one form or another since 1926. More recently, there have been studies of HAT in Switzerland, Germany, the Netherlands and Canada which have shown benefits in health, psycho-social adjustment and illicit drug use to socially excluded heroin dependent patients resistant to other treatments.

However, it’s inevitable that ill-informed parallels will be drawn with alcohol, smoking and the funding of almost anything else in the NHS deemed more worthy. It’s even possible to drag in ‘our boys’ fighting the drugs (spot of mission creep here) war in Afghanistan if one wants to work up a proper lather. The RIOTT study (I am assuming the obligatory acronym is an ironic nod to the impact this study will have on Daily Mail readers) isn’t even published yet and already the hysteria begins…

Is it even worth discussing the science amongst this hubbub? It might be better to crawl back under the duvet, let the dust settle and have a more rational discussion when we actually have the results of the UK study.

But there is some science to look at and consider. It is only last month that the New England Journal of Medicine published the results of NAOMI, the North American Opiate Medication Initiative (another tortured acronym) which looked at exactly this issue and it’s probable that RIOTT will have similar results. NAOMI compared oral methadone versus injectable diamorphine. It was open-label and there was no attempt to blind users to their treatment. They had better retention in the diamorphine arm at 88% versus the methadone arm at 54%. The reduction in rates of illicit drugs were 67% in the heroin group and 48% in the methadone group. Overall, the diamorphine arm tended to do better.

There were clear benefits but it wasn’t without issues and there were serious adverse events. There were 18 events in the methadone group (n=111) but none of them were felt to be related to the treatment. In the diamorphine arm (n=115) there were a total of 51 serious adverse events. However, it was reckoned that 27 of these were directly related to the diamorphine and included overdoses and seizures. This has to be put in context: a total of 89,924 doses of diamorphine were self-administered during the course of the study so that’s 0.03% of injections causing an event.

There are some issues around the methodology. Users know what kind of trial they are entering and many will drop-out when they get randomised to methadone rather than injectable. Indeed, this was the case in this study and it raises some issues around bias. The methodology of RIOTT was published in the Harm Reduction Journal in 2006 and is available for free.

The final conclusion of the NEJM paper is a reasonable one:

In this trial, both diacetylmorphine treatment and optimized methadone maintenance treatment resulted in high retention and response rates. Methadone, provided according to best-practice guidelines, should remain the treatment of choice for the majority of patients. However, there will continue to be a subgroup of patients who will not benefit even from optimized methadone maintenance. Prescribed, supervised use of diacetylmor-phine appears to be a safe and effective adjunctive treatment for this severely affected population of patients who would otherwise remain outside the health care system.

It will certainly need to be given in a specialised environment so it is likely to remain a very limited intervention. The headlines have tended to highlight that crime rates fall. How can this be surprising? UK studies have shown reductions in criminal activity across all treatment modalities for years. Part of the reason for this emphasis is presumably to make it as palatable to the public as possible. It’s not enough for it to be a useful option to improve health in a limited group of treatment resistant users. There has to be a fringe benefit to society as well.

There is an excellent paper by the authors of NAOMI commenting on some of the controversies around HAT. Again, it is freely available at the Harm Reduction Journal and will give you as good a background knowledge of the issues around HAT as anything. The authors commented on the media:

Treating heroin addiction with heroin tends to evoke a knee-jerk reaction. Lack of understanding, restrictions on time and resources, and the need for a catchy headline often lead to sensationalism by the media. As previously mentioned, opposition both within Canada and the US also contributed to misleading reports from local, national, and international media. The resulting focus has been on a seeming shift in Canadian drug policy in direct contradiction to the US war on drugs, rather than on the scientific or medical merits of the NAOMI study.

Much hand-wringing will be provoked by these studies for the simple reason that some will perceive that the logical development of this whole debate is that the next step will be de-criminalisation of drugs. It is entirely possible that we are waging a phoney ‘war on drugs’ but that’s really not what these studies are all about.

Oviedo-Joekes E, Brissette S, Marsh DC, Lauzon P, Guh D, Anis A, & Schechter MT (2009). Diacetylmorphine versus methadone for the treatment of opioid addiction. The New England journal of medicine, 361 (8), 777-86 PMID: 19692689

Probiotics irritate the hell out of me. Whenever I walk sourly down the yoghurt aisle of the supermarket I can feel the nebulous manafacturer claims wafting past. Of course, there is some evidence for probiotics but for a useful probiotic primer for the more skeptically-minded I would recommend (again) Mark Crislip’s Quackcast on the subject. I understand that the evidence of benefit doesn’t extend a huge amount beyond the confines of antibiotic-associated diarrhoea. I particularly like the Crislip interpretation of the ‘immune modulating’ effects of probiotics. He suggests that they are basically inducing chronic inflammation – not too surprising when one considers the constant stream of bacteria being dumped in the system. He also highlights the link between the known effects of chronic inflammation in the mouth and an associated increase in cardiovascular risk.

The trial’s lead author, Marko Kerac, was on the Lancet’s podcast this week (though it stops working just after 8 minutes). He seems an entirely sensible fellow though he gives an unnervingly positive summary of probiotics that I would be chary of accepting. I should point out that if you are tempted to listen to this podcast the author has an horrendous dose of high rising intonation. In addition, the podcast is abruptly truncated at just over 8 minutes.

He also demonstrates the human qualities of us all. In its perfect manifestation the randomised clinical trial can take out the unreliable subjective element of human behaviour. However, humans still have to interpret the results. In the podcast the author initially expresses disappointment at the lack of positive results and I wouldn’t criticise him for wanting to save the lives of thousands of children.

The abstract finishes with:

Subgroup analyses showed possible trends towards reduced outpatient mortality in the Synbiotic group (p=0.06).

Interpretation

In Malawi, Synbiotic2000 Forte did not improve severe acute malnutrition outcomes. The observation of reduced outpatient mortality might be caused by bias, confounding, or chance, but is biologically plausible, has potential for public health impact, and should be explored in future studies.

After reading the paper I am less convinced about this final conclusion. I get the impression from the paper (though it’s difficult to be certain) that the outpatient phase analysis was entirely post-hoc. The authors have honestly highlighted the potential for any post-hoc findings to be a product of pure chance. I suspect the deep disappointment in the overall negative result has trickled down into the interpretation. The final hook about outpatient mortality adds a tantalising edge to this paper. Getting a paper in the Lancet is tough – would an unrelentingly negative paper with no emphasis on this statistical wrinkle have still been published?

After all, it wasn’t the only significant difference that was found. The Synbiotic group had significantly more severe diarrhoea as an inpatient(at p=0.01 this was the strongest statistical finding in the study), more vomiting as an inpatient (p=0.05) and more cough as an inpatient (p=0.05). These don’t get a mention in the abstract. Given the caution needed when giving probiotics to an immuno-compromised population it would be entirely legitimate to have a quite different emphasis in this report.

At randomisation, groups seem to be well balanced. Minor differences at point of entry to outpatient care (lower HIV and less malnourished according to weight-for-height Z score in the Synbiotic group) raise the possibility of confounding or bias at this point.

In the Synbiotic group 42.6% were HIV positive and in the control group there were 48.5% HIV positive. The p-value for this difference between HIV rates in the two groups is P =0.08. This is not a statistically significant difference but in a total population of 795 children there is only a 4 child swing between significance and non-significance. It is feasible that the outpatient mortality differences could be simply related to this sampling bias and chance. I would not infer any deliberate deception here at all – just the simple desire to do so some good. I’m sure the research will now be repeated in an outpatient population but I’m not convinced the evidence from this trial justified it. On the other hand, maybe their dogged optimism and persistence will triumph and many lives will be saved.

In the podcast the lead author tells the tale of how the senior author, while working for UNICEF in Korea back in ’98, had made the observation that children fed at the local yoghurt factory apparently had better outcomes. He formulated the hypothesis that all those friendly bacteria were having an additive beneficial effect. It would have made a charming modern medical parable – chance favouring the prepared mind and the elegant RCT demonstrating benefit leading to millions of lives saved. No such luck this time.

Kerac, M., Bunn, J., Seal, A., Thindwa, M., Tomkins, A., Sadler, K., Bahwere, P., & Collins, S. (2009). Probiotics and prebiotics for severe acute malnutrition (PRONUT study): a double-blind efficacy randomised controlled trial in Malawi The Lancet, 374 (9684), 136-144 DOI: 10.1016/S0140-6736(09)60884-9

I am sure there is little or no editorial control over the advertising in a journal but I couldn’t help but notice that this month their advert is plastered directly opposite Prof Ernst’s article: ‘Ethics of complementary medicine: practical issues.’¹ I will leave the GCC to muse where on the spectrum between conspiracy and cock-up this sits. Perhaps the BJGP editorial board has similar feelings to Nature and the Daily Mail on the recent Simon Singh vs chiropractic legal battle?

The Prof Ernst article shines a harsh ethical light on some of the claims of the GCC. The banner headline in their advert is:

Why refer patients to Chiropractors? Because Chiropractors manage back pain effectively and use methods recommended in current evidence reviews.

Holding up my paper copy of the BJGP I move my eyes two inches to the right to read Prof Ernst’s comment:

A survey of promotional leaflets distributed by US and Canadian professional chiropractic organisations showed that all of those sampled claim chiropractic services that ‘have not been scientifically validated’. The authors concluded that this ‘reinforces an image of the chiropractic profession as functioning outside the boundaries of scientific behaviour’.

The article goes on to lay out some of the practical ethical issues that are not being addressed across the field of complementary medicine.

Informed consent is taken as a sine qua non of ethical medical practice. We teach students that it is an indispensable ingredient of modern medicine. The ethical issue is at its starkest when considering GPs that practice complementary medicine and in particular homeopathy. The overwhelming weight of evidence suggests that the actual homeopathic remedies are ineffective. I do not doubt that many people who visit a homeopath feel better. This is unsurprising as having an extended consultation with almost any practitioner prepared to sit and listen is clearly a massive intervention in itself. I am struggling to believe that any homeopath tells a patient that the pill itself is an inert blank and they are practising, in Dr Aust’s words, ‘stealth psychotherapy’.

The BJGP provides (presumably for ‘balance’) a commentary² by Brian Buckley, a Cochrane fellow and researcher in primary care in Ireland, with no obvious affiliation to complementary medicine. He offers a limp, half-hearted refutation of Prof Ernst’s article. He makes some effort to set up a straw man argument when he suggests that genuine informed consent is not obtained in the practice of conventional medicine. This bears a striking resemblance to the wholly discredited tack that conventional medicine has but a handful of evidence based options.

The example of prostate specific antigen is cited as an example of the dubious ethical nature of consent. Personally, I am careful to counsel patients on the notoriously limited value of this test. Not for nothing is it commonly considered by GPs that PSA stands for Promotes Stress and Anxiety. He suggests that:

Given pressures of time and other factors, it seems unlikely that all patients give genuinely informed consent… to give genuinely informed consent would require a considerable amount of time and preferable some knowledge of epidemiological principles to discuss it with their doctor.

While I am not suggesting I wouldn’t like more time this is exactly what being a GP is all about. Of course, it all depends where you set the bar for ‘genuinely informed consent’ but practising patient-centred medicine means that GPs spend all day trying to give people enough information to allow them to be genuinely empowered. I’m not suggesting it’s perfect but I am sure most GPs are trying damn hard to achieve it.

There are many areas that could be suggested for a discussion about the ethics of complementary medicine. One argument might highlight patient autonomy and this means that people are free to choose complementary medicine. That’s a powerful argument but it is undone by the premise of informed consent. No one can make an informed choice until they are in full possession of the facts.

Complementary medicine, when practised by GPs, skirts very close to the edge of ethical acceptability. Full informed consent is needed and surely that should involve informing patients of the absence of effect and the risks of treatment?

1.  Ernst, E. (2009). Ethics of complementary medicine: practical issues British Journal of General Practice, 59 (564), 517-519 DOI: 10.3399/bjgp09x453404

2.  Buckley, B. (2009). Commentary: Conventional medicine is less than perfect British Journal of General Practice, 59 (564), 519-519 DOI: 10.3399/bjgp09x453558

A few years ago I thought there might be something in acupuncture and I was keen to exploit its potential to help my patients. Unfortunately, my personal experience of a medical acupuncture course left me feeling like I had been sold a timeshare or indoctrinated into a cult. The evidence was brushed aside and selectively quoted by GPs in a feverish atmosphere of enthusiastic and misguided holism. I was not impressed and I became sceptical.

Let’s put aside the traditional acupuncture mumbo-jumbo of chi and meridians to consider, as pragmatic GPs, the simple question: does it work?

In the past, it’s been difficult to do trials with realistic placebos and this is undoubtedly part of the reason for the persistence of the belief that acupuncture is a useful medical intervention. The challenge is to separate the real effects of acupuncture from placebo. It’s important to remember that patients inevitably receive more attention, including lifestyle advice and support, when spending time with any therapist. This all tends to get lumped in as the ‘placebo effect’ and helps explain why even sham acupuncture can show benefit over standard care.

A recent large trial compared acupuncture versus toothpicks touched against the skin in patients with chronic low back pain. There was no difference between the acupuncture and toothpick groups. All these groups, even the toothpicks, did better than standard care, and most right-minded folk would confidently call this a placebo effect.

Acupuncturists claim, with no apparent trace of embarrassment, that this represents a trial in acupuncture’s favour and that needling site and even penetration may be less important than thought. In effect they are suggesting that toothpicks are some kind of acupuncture-lite. I would suggest that toothpicks are patently not acupuncture and that this is strong evidence that acupuncture itself is ineffective.

Another recent trial of acupuncture for hot flushes in menopausal women claimed an impressive effect. But there was no attempt at any placebo control and the outrageous bias in the sample practically guaranteed a positive result. Even with these loaded dice the differences found may have been statistically significant but were clinically minimal. The press releases, duly reported by time-pressured news desks, trumpeted the success of acupuncture for alleviating hot flushes.

A casual and selective approach to evidence, allied to vigorous self-promotion, is a hallmark of the acupuncture lobby’s approach to the literature.

Acupuncture relies on the faith-based collusion of expectation between acupuncturist and patient. Its promotion also feeds into a choice culture capable of overriding common sense in many areas of general practice and that rides roughshod over the medical evidence. Some GPs may shrug and suggest there is no harm in it but I feel uncomfortable sitting back as acupuncturists spend an estimated £32 million of precious NHS funds.

Acupuncturists have an emotional investment in this therapy. They are fervent, enthusiastic advocates who almost certainly have nothing but good intentions. But they are performing contortions when describing these trials and to justify the continued use of acupuncture in the face of mounting evidence that it is nothing more that a dramatic placebo.

Acupuncture has been touted as a panacea for 4,000 years and it may have been used by countless millions around the globe but no one, in that whole time, has proved beyond any reasonable doubt that there is a clinically significant effect that can be distinguished from bias. We would have flushed away any drug with such poor results. It’s time that acupuncture was consigned to the sharps bin.

Bonjourrrr, ya antibiotic eating surrender monkeys!

No doctor likes to think that they are the one who is giving out all these antibiotics to viral illnesses. There is always someone else at fault. Partners blame locums. Locums blame nurses. Everyone blames the patients. Me? I blame the French. They have shamelessly flung antibiotics around for years with Gallic abandon. According to a PLOS paper more than 70 prescriptions per 100 inhabitants were issued for antibiotics in 15 regions in France in the winter of 2000. Sacre bleu.

However, it seems that the French have been making a big effort with a nationwide campaign over the period 2002-07. ‘Les Antibiotiques c’est pas automatique’ was a massive push to educate the public and to support doctors to say ‘non’.  The researchers report that the use of all major antibiotic classes, except quinolones, decreased in all 22 regions of France by around 27% (95% CI 20 to 34%) over the same period. Of course, as we all know, association is not causation and there could be other reasons that have contributed to the reduction.

The BMJ also reported this week on European variations in prescribing for acute cough. There were some huge variations in antibiotic prescribing with the worst culprits being the Slovakians who prescribed on 90% of occasions. The Spanish were the lowest at 20% but given that antibiotics are available OTC this may not be a wholly reliable indicator. The Welsh and English were high prescribers with rates of 70% and 63% respectively. The crucial news from this prospective study is: there was no difference in outcome between the lowest rates of prescribing and the highest. This screams out to almost everyone that we are over-prescribing antibiotics across Europe. The French were not one of the 13 countries involved but it looks a bit like GPs in glasshouses shouldn’t throw stones.

Public health is a slowburn. There aren’t many that go into medical school with the fiery passion of John Snow for epidemiology burning in their breast. For more of them it is the chest-cracking and heart thumping that fires them up. Preserving antibiotics will almost certainly save lives in the future but you won’t get any credit for it now. There is a significant problem with multi-resistance pneumococcal pneumonia but someone getting pneumonia that responds to penicillin will quietly go home. Where’s the drama in that? We are oblivious to the fine line that separates us from the horrors of the pre-antibiotic age.  As has been said: public health isn’t seen when it’s done right.

It’s a slow job. A million tiny incremental steps working toward a global reduction in antibiotic use that could have real significance for all our health. We can all keep chipping away but the results of the French campaign, while encouraging, were not spectacular. Is it enough? Perhaps we should look to a future where public health policy becomes more draconian to curtail our continued profligacy with antibiotics. 

Sabuncu, E., David, J., Bernède-Bauduin, C., Pépin, S., Leroy, M., Boëlle, P., Watier, L., & Guillemot, D. (2009). Significant Reduction of Antibiotic Use in the Community after a Nationwide Campaign in France, 2002–2007 PLoS Medicine, 6 (6) DOI: 10.1371/journal.pmed.1000084

Butler, C., Hood, K., Verheij, T., Little, P., Melbye, H., Nuttall, J., Kelly, M., Molstad, S., Godycki-Cwirko, M., Almirall, J., Torres, A., Gillespie, D., Rautakorpi, U., Coenen, S., & Goossens, H. (2009). Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries BMJ, 338 (jun23 2) DOI: 10.1136/bmj.b2242

I’ve been on my hols in beautiful Galloway but Pulse chose this week to print my contribution to the acupuncture debate.

A few years ago I thought there might be something in acupuncture and I was keen to exploit its potential to help my patients. Unfortunately, my personal experience of a medical acupuncture course left me feeling like I had been sold a timeshare or indoctrinated into a cult. The evidence was brushed aside and selectively quoted by GPs in a feverish atmosphere of enthusiastic and misguided holism. I was not impressed and I became sceptical.

You can read the rest of my contribution to the debate at Pulse.

I had to chuckle at the comment by Mike Cummings. It turns out the other GP, Dr Andrew Hamilton, who wrote the pro-acupuncture piece attended the same BMAS course as me in 2003. I think I can safely say that our views have since diverged…

Why refer patients to Chiropractors?

Because Chiropractors manage back pain effectively and use methods recommended in current evidence reviews

The problem that chiropractic now has is one of credibility. And let’s make no mistake about it the chiropractic profession wants, indeed craves, the credibility.

One article in Chiropractic & Osteopathy in August 2008 asks this very question: How can chiropractic become a mainstream respected profession? The example of podiatry.

Objective: To present a perspective on the current state of the chiropractic profession and to make recommendations as to how the profession can look to the podiatric medical profession as a model for how a non-allopathic healthcare profession can establish mainstream integration and cultural authority.

Well, my first piece of advice would be not to refer to us mainstream practitioners with the pejorative term ‘allopathic’. That aside, I have always felt that there are plenty of chiropractors out there who try to practise evidence-based interventions and who look askance at evidence for chiropractic in a variety of medical conditions. And this is the point the authors make in this paper when considering the original chiropractic concept of ‘innate intelligence’:

These concepts are lacking in a scientific foundation and should not be permitted to be taught at our chiropractic institutions as part of the standard curriculum. Much of what is passed off as “chiropractic philosophy” is simply dogma, or untested (and, in some cases, untestable) theories which have no place in an institution of higher learning, except perhaps in an historical context.

Fundamentally, there exists a gap between this approach and the reality. This is presumably why the GCC are directly targeting general practitioners and advertising in the BJGP. The debacle with Simon Singh is only serving to widen the gap and it is has the potential to set chiropractors’ professional position back years. This paper suggests that chiropractic drops any pretence to treat any other condition and sets out their stall as the market leaders in spine care. Nothing else; pretty much just bad backs. Very sensible and I could envisage the future for chiropractic they set out:

But, most importantly, it means becoming experts in patient management, i.e., helping patients overcome spinal pain, whether that means providing adjustments, exercise, short-term medication use and/or education regarding the issues related to LBP provided in a cognitive-behavioral context. Currently, there is no profession that adequately fills that role, although as we noted earlier, the physical therapy profession is moving quickly in this direction. The opportunity is there for us to correct our mistakes, but we must act now. The only question is whether the chiropractic profession has the integrity, vision and self reflection required to make the necessary changes. Time will tell.

‘Integrity, vision and self-reflection’ eh? The authors must be hanging their head in despair at the current situation. Their claims for efficacy in conditions such as asthma, colic, chronic ear infections etc are being subject to the closest scrutiny and concerns regarding safety are being highlighted.

Prof Edzard Ernst has come to this conclusion.

But I strongly feel that whatever the judge decides, chiropractic (as a profession) can only lose.

Even if he rules in the BCA’s favour, the British public will have learnt a lot of embarrassing things about chiropractic which will severely undermine the reputation of this profession. This damage could well prove to be irreparable.

If I was minded to follow the new NICE guidance on low back pain I can’t see how I can recommend chiropractic to my patients. If anyone is going to do spinal manipulation then I’ll send them to the local physioterrorist who is perfectly capable of all the interventions that chiropractors offer. Many GPs will be even more reticent about referring to chiropractors. The credibility gap is simply too great.

Murphy, D., Schneider, M., Seaman, D., Perle, S., & Nelson, C. (2008). How can chiropractic become a respected mainstream profession? The example of podiatry Chiropractic & Osteopathy, 16 (1) DOI: 10.1186/1746-1340-16-10

This study in Spain was a retrospective cross-sectional survey in Catalonia. They called up the parents of 630 children to ask them about vaccine coverage and to assess their knowledge about vaccines.

It showed that higher vaccination rates were associated with maternal age >30 and better knowledge scores about the vaccination. This seems fairly reasonable but it doesn’t entirely tally with my practical experience. I used to have far more trouble with the educated mothers and have experienced some terrifyingly irrational consultations. At its peak it didn’t matter how much the facts about vaccination were emphasised mothers just couldn’t get past the media screaming the unfounded risks at them.

The highest percentage of unvaccinated children corresponded to the MMR vaccine (1.58%). Non vaccination with the MMR vaccination was observed in 57% of children aged 18 months in the United Kingdom. In Switzerland, 21.34% of children were not vaccinated against rubella in 1998, and 77.52% in Italy in 1997. In Edmonton (Canada), 7% of children had received no dose of the MMR vaccine in 2002. The proliferation of negative publicity about vaccines in the mass media, especially the Internet, questioning the benefits of vaccination and leading to increased belief in natural or alternative therapies may explain these higher proportions of unvaccinated children.

Can you imagine a situation in the UK where the lowest rate of MMR vaccination is 1.58%? Yes, the decimal point is in the right place. It is a quite staggering difference and Spain does not seem to have been gripped by the autism-MMR hoax. DeeTee has posted over at Lay Science on the current situation in Wales and the single vaccine vultures are hovering.

To recap: As of Tuesday, 207 cases of measles had been reported in Wales, with 26 children being admitted to hospital and several ending up in intensive care with life-threatening complications. There have fortunately been no deaths yet, but that is probably a testament to the good care these kids have had in ITU. I just hope none have had measles encephalitis or any other complication that will cause long-term damage.

Has the recent MMR catch up campaign made any difference? We continue to teeter on the brink of an epidemic and the NHS Immunisation Information site reports that:

The data suggests that nationally there has been about 3.5 percentage point increase in the number of children aged 5 – 18 years who have received two doses of MMR from end of September 2008 to the end of April 2009. Over the same period of time, a decrease of about 1.3 percentage points was seen in children aged 5-18 who had received no doses of MMR.

They recommend caution with the data as it does not represent absolute rates but it seems to represent a trend toward improved uptake. 

How else can we help? Well, I would re-iterate Margaret McCartney’s point that I don’t know a single doctor who hasn’t vaccinated their kids. This paper suggests we need older and better educated mothers. I don’t think we can wait for the current crop to age so I guess we will all keep doing our bit to inform whenever and wherever possible.