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January 7, 2010
10:39 AM
838 views

Circumcision: A Response to Amy Tuteur

by Martin Robbins in The Lay Scientist

This is a response to a controversial piece in Science Based Medicine by Amy Tuteur, M.D. on circumcision: "The case for neonatal circumcision," which cites a recent journal paper of the same title [1]. Beyond calling for the American medical establishment to put pressure on parents to circumcise their infant children, the article implicitly compares those who don't circumcise or who are opposed to circumcising infants to anti-vaccination activists.

read more... Read more »

Tobian, A., Gray, R., & Quinn, T. (2010) Male Circumcision for the Prevention of Acquisition and Transmission of Sexually Transmitted Infections: The Case for Neonatal Circumcision. Archives of Pediatrics and Adolescent Medicine, 164(1), 78-84. DOI: 10.1001/archpediatrics.2009.232

Kim, D., & Pang, M. (2007) The effect of male circumcision on sexuality. BJU International, 99(3), 619-622. DOI: 10.1111/j.1464-410X.2006.06646.x

Krieger, J., Mehta, S., Bailey, R., Agot, K., Ndinya-Achola, J., Parker, C., & Moses, S. (2008) Adult Male Circumcision: Effects on Sexual Function and Sexual Satisfaction in Kisumu, Kenya. Journal of Sexual Medicine, 5(11), 2610-2622. DOI: 10.1111/j.1743-6109.2008.00979.x

November 25, 2009
04:13 AM
910 views

Is the Belgian Coma Patient's 'Voice' a Hoax?

by Martin Robbins in The Lay Scientist

Recently, claims have surfaced surrounding a Belgian coma victim - Rom Houben - who spent 23 years 'locked in', conscious but paralysed. It was only recently discovered that he had been conscious, and efforts were made to enable him to communicate using a controversial technique called 'Facilitated Communication'. As The Times report; "Mr Houben is now seemingly able to express himself in remarkably lucid messages while [his 'facilitator'] Mrs [Linda] Wouters guides his hand over a computer screen." This sounds all very good, until you watch the following video, and in particular the section around 1m 17s:

Watch CBS News Videos Online

The facilitator is moving the finger at an incredible rate of knots, but Houben is not even looking at the screen, or the keypad - his eyes are firmly shut. Now, yes, I can touch-type, but try touch-typing with your eyes closed, and directing somebody else's finger. It's a bloody big ask.

It sounds even more unlikely when you look at the scientific evidence for facilitated communication - or rather, the lack of evidence, since - as James Randi has pointed out in a gloriously annoyed blog - the technique has about as much support as Nick Griffin at an ACLU meeting. Wikipedia note that:

The majority of peer reviewed scientific studies conclude that the typed language output attributed to the clients is directed or systematically determined by the therapists who provide facilitated assistance.

In other words, as Randi points out, FC is most likely a case of the "Clever Hans Effect", a psychological quirk in which "a person's or an animal's behaviour can be influenced by subtle and unintentional cueing on the part of a questioner," notorious for its destructive influence on poorly controlled trials of this kind. The facilitator may not be doing it consciously, but it seems far more likely that the words are coming from her mind.

The Times, one of the few papers to question the findings, notes:

The novel method of communication has not convinced all medical experts, however. "It’s Ouija board stuff. It’s been discredited time and again when people look at it. It’s usually the person who is doing the pointing who is doing the messages," Arthur Caplan, Professor of Bioethics at the University of Pennsylvania, said after watching a video of the pair.

In a comment to Wired, Caplan has drawn attention to the unlikely language being expressed by Houben via his facilitator:

"You’re going to lie for 23 years in a hospital bed with almost no stimuli, and then sound completely coherent and cogent?" he said. "Something is wrong with that picture. The messages are almost poetic. It sounds too lucid, like someone prepared these things to say. I’m not saying it’s all a fraud, but I want to hear a lot more."

Caplan's disdain for Facilitated Communication (FC) is well justified. Mark Mostert published a systematic review of the literature in 2001 [1] [pdf], painting a bleak picture for proponents. Of 29 studies reviewed, 19 had one or more control procedures and refuted FC claims, 6 had one or more control procedures and supported FC claims but were often riddled with methodological problems, while 4 had no controls and supported FC claims.

Mostert concluded with a statement that should sound all too familiar to anyone who has ever read meta-studies of treatments like homeopathy or chiropractic:

The results of the review support and confirm the conclusions reached by previous reviewers of the empirical FC literature. The divide between the results of studies incorporating control procedures find very little to no support for the efficacy of FC, studies employing fewer control procedures produce mixed results, and studies ignoring control procedures almost universally find FC to be effective. In the cases of the few, tentative positive results emerging from studies reporting some form of control procedures, as in the cases of Cardinal et al. [2] and Weiss et al. [3], these results are much more likely the artifact of methodological problems than an accurate representation of persuasive evidence.

Professor Laureys, the patient's neurologist claims to have performed a simple test to establish the truth, as The Times report:

The spectacle is so incredible that even Steven Laureys, the neurologist who discovered Mr Houben’s potential, had doubts about its authenticity. He decided to put it to the test.

"I showed him objects when I was alone with him in the room and then, later, with his aide, he was able to give the right answers," Professor Laureys said. "It is true."

The problem is that these claims are extraordinary, and therefore require extraordinary evidence to back up. Laureys cannot be considered an unbiased observer, given his emotional investment in the case. That isn't an accusation of fraud or wrong-doing - it is incredibly easy to deceive yourself in such situations.

Given what we know then, Professor Laureys and other medical staff working with Houben need to back up their extraordinary claims with much more solid evidence than the anecdata presented so far. After all, if it turns out that in fact the results produced by FC aren't real, they could be causing their patient even more stress than he has experienced so far.

And there's a further reward on offer. The James Randi Foundation have offered a one million dollar prize to anyone who can provide a valid demonstration of facilitated communication, and Randi has told Wired that the offer "is still there."

The gauntlet has been thrown. Will Professor Laureys be willing to put his claims to the test?

[1] Mostert, M. (2001). Facilitated Communication Since 1995: A Review of Published Studies Journal of Autism and Developmental Disorders, 31 (3), 287-313 DOI: 10.1023/A:1010795219886

[2] Cardinal DN, Hanson D, & Wakeham J (1996). Investigation of authorship in facilitated communication. Mental retardation, 34 (4), 231-42 PMID: 8828342

[3]... Read more »

Mostert MP. (2001) Facilitated communication since 1995: a review of published studies. Journal of autism and developmental disorders, 31(3), 287-313. PMID: 11518483

Cardinal DN, Hanson D, & Wakeham J. (1996) Investigation of authorship in facilitated communication. Mental retardation, 34(4), 231-42. PMID: 8828342

Weiss MJ, Wagner SH, & Bauman ML. (1996) A validated case study of facilitated communication. Mental retardation, 34(4), 220-30. PMID: 8828341

November 24, 2009
08:10 AM
816 views

Studying Anti-Vaccination Activists on the World Wide Web

by Martin Robbins in The Lay Scientist

The paper I'm about to present was written in 2002, and in the fast-paced world of the internet may seem out of date - after all, Youtube hadn't even been invented then, and Wikipedia and Google were shiny new businesses. But in fact, Davies et al's study of anti-vaccination websites is as relevant today as it was then - perhaps even more so [1].
"The internet has provided antivaccinationists with unprecedented opportunities for exposure. In the USA, 55% of adults with internet access use it to seek health related information. For all its benefits, the internet has great potential to
disseminate health information that is incorrect and potentially dangerous."
The scale of the internet in 2009 is of course orders of magnitude larger than it was seven years ago, reaching more of the population in a greater part of the world. Additionally, new ways of putting information across have been developed: in 2002, Youtube and the age of viral videos were still three years in the future, podcasts were a rarity, and mainstream blogging was still in its infancy. The scale of the problem is doubtless larger today, but what's remarkable is how quickly anti-vaccination activists came to dominate this scene in the early days of the web.
The researchers look at a hundred anti-vaccination websites, including the tone of their content, and also looked at search results from the leading search engines of the day (back then, you could still use the plural of 'search engine'). The table below shows the number of anti-vaccination pages in the top ten search results for 'vaccination' for each search engine:

So while AltaVista, Yahoo and Netscape produce a couple of dodgy sites each, Google's 'superior' technology failed spectacularly, with all of the top ten search results for 'vaccination' leading to anti-vaccination sites. The situation now is improved, but even today, a search on Google.co.uk brings up whale.to and naturalnews.com in the top ten results (Wikipedia, naturally, is first).
This for me raises interesting ethical questions about the role of search engines. If a parent was five times more likely to see an anti-vaccination result on Google than searching with AltaVista, what responsibility - if any - do Google (motto: "Do No Evil") have for the public health consequences of their abysmal rankings in 2002?
Moving on to the types of sites around, a distinct set of patterns emerged from their results that still sounds familiar today.
"Antivaccination groups sought to present themselves as legitimate authorities with scientific credibility: about one in four websites implied official status at national or international level."
There's an odd Cargo Cult mentality that exists in the alternative medicine and anti-science communities, in that they reject the institutions and research of modern medicine and science, yet seek to appropriate their titles, language and superficial aspects of their methodology, setting up 'clinics', calling each other 'doctor', and attempting to cite references from the literature...
"A majority of sites propounded the scientific validity of their claims by referencing from extensive literature dominated by self published works and the alternative medicine press. Allegedly damning research was often quoted, but without citation of its source. Referencing was frequently incomplete and often indiscriminate, including letters to editors of newspapers and television interviews. Research published in indexed medical journals was also quoted; however, the conclusions drawn were often inconsistent with those of the authors. Overall this produced a spectre of the existence of masses of data on the dangers of vaccination."
This of course is the same sort of behaviour we saw with the British Chiropractic Association's pitiful attempts to produce a 'plethora of evidence' for the use of chiropractic in treating childhood illnesses. But the psychology of this is complex and confusing - if you despise modern medicine, if you want to work against it, why are you so obsessed with imitating your enemy? It almost suggests a sort of authority-envy.
Over half of all sites cited rank breaking doctors speaking out against vaccination. Implied division within the medical community reinforced the notion of a debate among authorities. One third of sites promoted themselves as sources of non-partisan information on both sides of the immunisation 'debate'. Despite these claims a mere 15% contained any information supportive of vaccination. Only a third of sites had links to such sites.
This of course is the classic 'teach the controversy' approach. It follows the time-honoured Tobacco company trick that if you can't directly refute the science, you can wage a war of obfuscation that leaves the public with the impression of a scientific debate where in fact none still exists, something we've seen with tobacco harm, climate change, vaccination, and a dozen other areas.
The problem with all of the above is that it seems to result in a sort of cognitive dissonance. If you believe that the research is inconclusive, and that the 'real' picture of climate change, vaccination, smoking or whatever is not getting out to the public, then the only way to rationalize this is by inventing some sort of conspiracy. In fact, virtually all denialist beliefs seem to eventually come down to a conspiracy theory. Even when this isn't explicitly stated, it is often implied.
"Nearly all sites referred to the antivaccination struggle as a search for truth against a background of cover up and denial. Antivaccinationists portrayed themselves as crusaders excavating hidden truths. The vaccination hoax was a vehicle for the generation of limitless profit and which would produce epidemics of chronic illness, requiring billions of dollars worth of drugs and medical care. To many groups, compulsory vaccination represented the beginning of the slippery slope towards totalitarianism."
That 'nearly all' sites resorted to conspiracy theory is unsurprising then - it's a necessary leap to make since you can't believe that doctors are knowingly giving people dangerous vaccines without some element of conspiracy present. What's perhaps more interesting though is the depersonalization or dehumanization of 'the enemy'.
"Almost all sites featured the adversarial notion of 'us versus them' whereby parents and antivaccinationists stood against the depersonalised 'them' of doctors, health bodies, governments, and pharmaceutical companies. Doctors were presented as either willing conspirators cashing in on the vaccine 'fraud', or pawns manipulated by the shadowy vaccine combine; parents' love and compassion whose intuition about vaccination harms was considered a stronger force than cold, analytical science.
I couldn't have but read that and be reminded of the classic radio clash between Richard Littlejohn and Will Self, in which Self referred to Littlejohn's characterization of John Prescott as a 'chimp' with the observation:
"Well he doesn't say he's a human being, does he? He uses the classic form of demonisation which is to say he's a chimp, in other words he's bestial. So he's actually dehumanised the subject of his abuse before he even moves on to piling on the pejoratives, and I think that's very psychologically interesting, of course we're all familiar with the kind of people who demonise other human beings by turning them into bestiary..."
Which, while a bit strong, is interesting. Again, anti-vaccine propaganda requires that people believe doctors are behaving in an inhuman way, so this would seem to be the logical consequence of rationalizing that. The results of this dehumanization are deeply disturbing since, like the people Self alludes to, it allows people to resort to rabid abuse and attacks on those disagreeing with their ideological view. Paul Offit of course has been a target of concerted hate campaigns, and recently journalist Amy Wallace was subjected to extraordinary attacks, some involving vile misogynistic abuse, for an article she wrote in Wired.
This also seems to touch on people's fears of doctors and science in general, and it's unsurprising to see what follows:
"The answer to disease prevention was not the 'artificial' process of vaccination but the pursuit of natural lifestyle. Many sites asserted that infectious disease was a consequence of lifestyle, not microorganisms."
[...]
"Being unnatural, vaccinations deranged the function of the immune system. The natural immunity provided by infection was considered superior. Many sites urged parents to intentionally expose their children to infectious diseases alleging health benefits."
Yes the natural fallacy, the misguided notion that something 'natural' is healthier for you than something 'artificial.' The terrifying result of this sort of broken thinking is that parents may intentionally expose their children to infectious diseases. It begs the question, how many have fallen seriously ill or died as a result o... Read more »

Davies, P. (2002) Antivaccination activists on the world wide web. Archives of Disease in Childhood, 87(1), 22-25. DOI: 10.1136/adc.87.1.22

November 23, 2009
08:23 AM
931 views

Using Chocolate to Exterminate Coyotes

by Martin Robbins in The Lay Scientist

Chocolate, like many of the things we eat regularly, is a potentially fatal poison, and so it should come as no surprise that a study by the unimaginatively-named John Johnston (at the USDA National Wildlife Research Center) shows that our favourite sweet could prove to be an effective pesticide, for use against coyotes [1].
Chocolate, or rather the theobromine and caffiene it contains, is potentially fatal to many creatures, but of course "the poison is the dose." Humans are particularly efficient metabolizers of theobromine, but the same isn't true for dogs or cats. Whereas it would take dozens of pounds of chocolate to kill a human (probably more than you could physically eat), just 20 mg per kg of theobromine is enough to cause symptoms, while more than 60mg per kg can induce seizures (see the Merck Veterinary Manual).
To put those figures into perspective, milk chocolate contains around 60mg of theobromine per ounce, so if you have a dog weighing 20kg (44lbs), about a pound and a quarter (or half a kilo) of milk chocolate could bring on seizures.
The full set of symptoms for chocolate toxicosis are described in the manual thus:
Clinical signs of chocolate toxicosis usually occur within 6-12 hr of ingestion. Initial signs may include polydipsia, vomiting, diarrhea, abdominal distention, and restlessness. Signs may progress to hyperactivity, polyuria, ataxia, tremors, and seizures. Tachycardia, premature ventricular contractions, tachypnea, cyanosis, hypertension, hyperthermia, bradycardia, hypotension, or coma may occur. Hypokalemia may occur late in the course of the toxicosis, contributing to cardiac dysfunction. Death is generally due to cardiac arrhythmias, hyperthermia, or respiratory failure. The high fat content of chocolate products may trigger pancreatitis in susceptible animals.
Cats are actually somewhat more sensitive than dogs, but they have a useful defense - cats don't find chocolate tasty. Dogs on the other hand love it, which is bad for dogs, but handy if you're a farmer with a major coyote problem that you'd like to deal with without introducing too many nasty chemicals into the environment. And that brings us to the device below - a CLOD, or as only Americans would call it, a Coyote Lure Operative Device.

Coyotes are to American agriculture what Professor Nutt is to the Daily Mail or Katie Price is to people who want to read a newspaper without being confronted by giant fake breasts every two minutes. As well as being responsible for around three-quarters of all livestock losses due to animal predators (costing some US$44m in losses), other damage caused by coyotes apparently includes:
"...collisions with aircraft, attacks on pets and children, damage to fruit and vegetable crops, predation on game species such as elk and deer, and predation on poultry. In addition to directly damaging fruit and vegetable crops, coyotes also contribute to crop losses via damage to hose irrigation systems. Coyotes have also been implicated in the transmission and spread of epizootic rabies in the United States."
In short, coyotes are responsible for pretty much everything from the global recession to 9/11. If you're living in America and you can't find a pen, the chances are that a coyote has nicked it. Clearly it's time for some mass extermination. We're talking US$40m here. That's, like, Arnie's fuel budget for a month.
Leaving skepticism about the need for this aside, chocolate - or rather the engineered chocolate-mimic used in the trial has a number of advantages as a pesticide. It's safe for humans and many other animals while fatal to coyotes, who love it. Better yet, by carefully adjusting the ratio of theobromine to caffeine in their chocolate mimic (to 5:1), the USDA researchers were able to pretty much remove pre-mortality symptons - the coyotes ate the chocolate, and then later they died. As the researchers point out:
"The results from this research clearly demonstrate that theobromine/caffeine mixtures have potential as a pest coyote toxicant that is effective, selective, and potentially more socially acceptable than fluoroacetate or sodium cyanide."
Of course, numerous coyotes were killed in the course of establishing the 5:1 ratio as the best proportion of theobromine to caffeine to use. " Coyotes dosed with the 1:1 and 1:2 mixtures exhibited undesirable symptoms of toxicosis and were euthanized. " The search for safer pesticides is always a noble one, but personally I'd like to see evidence of a larger problem than a measly US$44m of damage caused before we start breaking out the toxic Mars Bars.
[1] Johnston, J. (2005). Evaluation of Cocoa- and Coffee-Derived Methylxanthines as Toxicants for the Control of Pest Coyotes Journal of Agricultural and Food Chemistry, 53 (10), 4069-4075 DOI: 10.1021/jf050166p
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Johnston, J. (2005) Evaluation of Cocoa- and Coffee-Derived Methylxanthines as Toxicants for the Control of Pest Coyotes. Journal of Agricultural and Food Chemistry, 53(10), 4069-4075. DOI: 10.1021/jf050166p

November 20, 2009
08:26 AM
894 views

The Drink Spiking Myth Part 2

by Martin Robbins in The Lay Scientist

As promised, here's the second part of my look at the myth of drink spiking. Last time, we saw that the idea that drink-spiking is a widespread problem is a myth, with the evidence showing that in fact in the vast majority of cases where people believe their drinks have been spiked, this simply isn't the case - the symptoms they experience have been down to alcohol poisoning. In this post, we'll look at the reasons why this myth has become so widespread, as discussed in Burgess et al's "Embodying Uncertainty?: Understanding Heightened Risk Perception of Drink 'Spiking'" [1].
Their study found that those students showing a high degree of concern about drink spiking were almost exclusively female. To explain this, they propose a two-pronged explanation based on the hundreds of in-depth interviews they conducted:
"A need to explain feelings of vulnerability associated with ‘big nights’ may well impel young female students to assimilate the discourse of drink-spiking awareness, whilst the desire to find a way of framing the masculine practice of binge-drinking in feminine terms may well make the same discourse particularly appealing."
Their questioning of female university students revealed a great deal of anxiety about the drinking culture in universities, in particular the problem of being drunk while exposed to the 'false intimacy' of events like Fresher parties, or 'Flirt nights'.
In the UK interviews, female first-year students commonly saw nights out as risky affairs,
and often implied — although rarely conceded — that alcohol introduced an element of uncertainty into an already difficult social situation.
'Rarely conceded' is the key point, and in fact the interviews conducted showed what can only be described as denialism over drinking, as the following fascinating discussion describes:
Interviewee: I’m always quite precautionary, ’ cos when you’re drunk you’ve got to be, you can’t ... you’ve always got to be aware of things. But I think there is always [the threat of drink-spiking] in the back of your mind now. And I don’t necessarily think that’s a bad thing, it just means you’re more cautious ... it’s a slight paranoia. I mean, I wouldn’t get paranoid to the extent that it ruins a night, but it’s a concern. Especially because I don’t really drink bottled drinks ... I mean, you don’t always want to carry [your drink] around everywhere but, really, that’s inevitable .... Like, before, in the Venue you could leave your drinks and go for a dance. But not so much now. I only leave [my drink] with friends, but even then … [hesitates].
Interviewer: You wouldn’t leave it with a friend?
Interviewee: No, I do trust my friends, I don’t know why I said that...
What is interesting about this conversation, beyond the student’s marked level of distrust, is that concern about alcohol is quickly elided by concern about drink-spiking. Alcohol makes it necessary to be cautious, this young woman suggests, but it is the more specific threat of DFSA — of a drink being spiked rather than the drink itself — that becomes the focus of attention.
Whilst a few students give up drinking altogether, most continue to drink and increasing numbers drink heavily, and, for those in the last two categories — the drinking majority — alcohol is deemed to be less of a problem than drink-spiking. In fact, often, in US respondents’ accounts of suspected drink-spiking incidents, rhere was a distinctly defensive view negating the role of alcohol in producing the events or symptoms. This was accomplished either by identifying symptoms with a specific drink (n = 21) rather than ‘drinking’ or by including information about how little alcohol the victim had consumed (n = 12).
Interestingly, respondents apparently felt the need to address the contribution of alcohol in their stories, but this was often to deny its role. As the authors remark: "There appears to be widespread disbelief, or active denial, that excess alcohol could cause the same incoherence, physical distress and incapacity associated with ‘date rape’ drugs."
Why the denialism? Because of the immense pressure students feel to drink. Indeed, respondents suggested that it was "almost impossible' not to drink, and described "unrelenting pressure", as one response highlights:
"Before every night out there’s a drinking circle at the bar .... And last night I couldn’t go ... and this morning I had loads of text messages saying ‘where were you? It’s terrible, you’re a Fresher, you should be out’. Now I don’t drink that much, but it’s definitely seen as a bonding thing, like the Freshers should get to know the Seniors by going out and drinking .... There are a few people who don’t really drink in the club, and after a while they’ve been forced into doing it. Like I’ve been offered a drink, and when I said ‘No’ I’ve been given very funny looks... "
In other words, there is a deep conflict here. On the one hand, female students in particular describe feelings of vulnerability associated with nights out that involve heavy drinking; but on the other intense peer pressure prevents them from addressing the real cause of the problem. The authors suggest that "'Drink-spiking awareness' ... might perform just such a role."
Before I conclude, it's important to make clear that the mugging, assault or rape of an intoxicated individual is the responsibility of the mugger, attacker or rapist, and the state of their victim in no way absolves them of guilt. In fact in my opinion it makes the crime that much more cynical. Being drunk does not mean you should take the blame when somebody takes advantage of your state to commit a crime against you.
However, we have to confront a culture in which young women and men are abusing alcohol to the extent that they are losing all control over their actions and their situation. Town centres on a Saturday night are like war zones, and it's only thanks to heavy policing at a huge cost to taxpayers that the results of this aren't even worse than they already are in terms of violence, medical problems, and sexual assault.
Alcohol abuse in Britain and elsewhere is at epidemic proportions, and it's something that we seem to be in deep denial about. When something goes wrong on a night out we'll blame spiking, our mood, our friends, anything but the drink itself. The myth of the date rape drug is in many ways a construct of our cultural denial of the harm that alcohol is causing. In many ways, the same denial contributed to Professor Nutt's sacking as he dared to question the idea that alcohol and tobacco are somehow more acceptable than drugs like cannabis or ecstacy.
Don't tell us we're drinking to much; we don't want to hear it.
[1] Burgess, A., Donovan, P., & Moore, S. (2009). Embodying Uncertainty?: Understanding Heightened Risk Perception of Drink 'Spiking' British Journal of Criminology, 49 (6), 848-862 DOI: 10.1093/bjc/azp049
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Burgess, A., Donovan, P., & Moore, S. (2009) Embodying Uncertainty?: Understanding Heightened Risk Perception of Drink 'Spiking'. British Journal of Criminology, 49(6), 848-862. DOI: 10.1093/bjc/azp049

November 18, 2009
05:26 PM
962 views

Tobacco harm reduction - no smoke without fire

by Martin Robbins in The Lay Scientist

Smoking kills millions of people every year and yet the medical community seems pathologically opposed to any measure to tackle the issue other than through the promotion of total abstinence. Carl Phillips suggests in his paper in the Harm Reduction Journal this month that smoking for just one month is more dangerous than switching to a smokeless nicotine product for a lifetime.
<!--break--
Take a moment to take a deep drag on a few breathtaking statistics.
Across the world approximately 1.3 billion people use tobacco products and by 2030 it is estimated that 10 million people will die annually from smoking-related diseases and 70% of these deaths will be in developing countries. We’ve known about the harmful effects of smoking for over 50 years and yet over that same period 6 million Britons have died of tobacco-related disease.
It’s no secret that it’s hard to stop smoking. Bandolier published an interesting little analysis of trials which included smokers and heroin addicts. They asked: which is the most addictive? In a rather elegant twist they looked at the cessation rates in the placebo arms of all the relevant trials. Cessation rates for smokers were around 8-9% yet for opiates users were around 43%. No surprises there - smoking is extraordinarily difficult to stop. Even in those that are highly motivated 12 month cessation rates are often no better than 10%. Opposing a harm reduction approach might be doing a grave disservice to those that just find it too tough to stop.
I am intrigued by the concept of tobacco harm reduction - not least because it requires a considerable effort of will to put aside a pathological distrust of Big Tobacco. Some of this post is taken from one I posted over at doc2doc a few months ago. The very first comment on the blogpost at doc2doc sums up the gut reaction of many doctors:
I think we should dismiss this out of hand! This argument is like low tar cigarettes are healthier..so you can smoke more of them. There is no such things as a safe(r) cigarette. The safer cigarette makes no sense given my understanding of how nicotine receptors work, not to say addiction. Do not trust Big Tobacco who have a vested interest in not losing their customers.
End of. Decision made. One suspects that the notion of smokeless nicotine products is simply not endorsable by the scientific orthodoxy in any shape or form. Phillips addresses all the arguments and using a back of a fag packet (though he prefers an envelope) calculation suggests that:
Whatever the explanation for it, the present analysis shows that anti-THR [tobacco harm reduction] activism is deadly. Hiding THR from smokers, waiting for them to decide to quite entirely or waiting for a new anti-smoking magic bullet, causes the deaths of more smokers every month than a lifetime using low-risk nicotine products ever could.
If you are inclined to read the paper then flick to the back first and read the competing interests statement. Not for our Carl a bland 'nothing to declare' and instead it reads like a heartfelt plea that we pause, ignore the gut reaction and consider the evidence. It also speaks volumes for the ignominious role of mavericks in the scientific world; they may occasionally be lauded as heroes but more often they will be squeezed out of funding, shunned at the peer-review review stage and ostracised by their own community.
Within the wider medical community tobacco harm reduction remains an exercise in thinking the unthinkable. Doctors recommending it may be vilified and it opens up a researcher to accusations of acting as an industry patsy; labelled as a dull-eyed lackey in the pay of malignant giants. Yet it could save millions of lives and it certainly merits wider debate.
Phillips, C. (2009). Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments Harm Reduction Journal, 6 (1) DOI: 10.1186/1477-7517-6-29
... Read more »

Phillips, C. (2009) Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments. Harm Reduction Journal, 6(1), 29. DOI: 10.1186/1477-7517-6-29

November 17, 2009
07:26 AM
866 views

The Drink Spiking Myth Part 1

by Martin Robbins in The Lay Scientist

Searching the archives of the BBC, Daily Mail or Guardian returns hundreds of results for date rape drugs, such as Rohypnol. Figures from Google Trends show that search volume for 'date rape drugs' or more specific terms like 'Rohypnol' has decreased since 2004, but remains high. Up and down the country, many people are convinced they have been a victim of date rape drugs, their fears fuelled by media scare stories and alarming reports from the usually sensible ACMD.
<!--break--

So it's all the more surprising to hear the Chief Executive of the Suzy Lamplugh Trust - a charity aimed at reducing crime - quoted in a research paper [1] making the following complaint:
"As far as I am aware, there has never been a case of Rohypnol in this country found ever. We ask women when they are out to look after themselves and they say ‘I always put my finger over the bottle so it can’t be spiked’ . I want to tear my hair out because what is in the bottle is what’s lethal!"
To suggest that there have been no cases is perhaps an exaggeration, but the various studies we have on this tell a very different story from that reported in the press until recently.
Michael Scott-Ham of the UK's Forensic Science Service led a study that "analysed samples taken from 1014 victims in the UK soon after the alleged assault between January 2000 and December 2002." They found sedatives in only 2% of samples (the presence of which could of course have several explanations. An Australian study at two hospitals in Perth found that none of the 97 young men and women who claimed to have had their drinks spiked had been drugged.
So if date rate drugs didn't cause these people to lose control of the situation, what was it? The UK Forensic Science Service study provides a big clue. Of the 391 victims who had given samples with 12 hours of the alleged assault, around a third had consumed enough alcohol to result in unconsciousness or memory loss. Similar results have come from Northern Ireland.
To put it another way, scientific studies show that the #1 date rape drug, by far, is alcohol.
A recent study in the British Journal of Criminology - Understanding Heightened Risk Perception of Drink ‘Spiking’ by Adam Burgess, Pamela Donovan and Sarah Moore, takes an interesting look at risk perceptions and psychology surrounding date rape drugs, conducting various surveys of students in Britain and the United States [1].
Their results highlighted the disproportionate level of risk attached to spiking:
"To better establish the strength of concern about DFSA, the UK respondents were asked to rate their sense of risk and sense of worry for the following four crimes: being a victim of drink-driving, being mugged, having a home or room burgled, and being a victim of DFSA (see Table 1 ). UK respondents were more likely to express acute worry about DFSA than any of the other crimes they were asked about."
"Having a drink spiked with drugs was the most commonly cited risk factor for sexual assault, with 150 (75 per cent) of participants identifying this as an important risk factor — a more signi? cant risk factor than drinking alcohol or taking drugs (see Table 2 ). Furthermore, it is noteworthy that [spiking] elicited a more acute sense of worry amongst female students than mugging."
So in spite of the vanishingly small probability of drink spiking ever happening, students were more concerned about it than mugging, or drink driving. What is the explanation for this skewed perception of risk?
The elephant in the bedsit here is alcohol, a drug which culturally we seem to be in a state of denial over. Part of the explanation may be that the myth of drink-spiking provides a useful narrative through which we can rationalize away our own guilt: "I was in control of my drinking, but then somebody spiked my drink."
Is that true, or is it all a bit more complicated than that? How does this relate to the ongoing saga over drug policy? And how does this relate to the alternative medicine meme that 'natural is best'? We'll take a look in Part II of this post, which I'll be putting up this evening.
[1] Burgess, A., Donovan, P., & Moore, S. (2009). Embodying Uncertainty?: Understanding Heightened Risk Perception of Drink 'Spiking' British Journal of Criminology, 49 (6), 848-862 DOI: 10.1093/bjc/azp049
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Burgess, A., Donovan, P., & Moore, S. (2009) Embodying Uncertainty?: Understanding Heightened Risk Perception of Drink 'Spiking'. British Journal of Criminology, 49(6), 848-862. DOI: 10.1093/bjc/azp049

June 18, 2009
08:24 AM
1,202 views

A Review of The BCA's Evidence for Chiropractic

by Martin Robbins in The Lay Scientist

Well over a year after Simon Singh's 'libelous' article on Chiropractic was published; with Singh preparing to launch an appeal against Eady's ruling in the preliminary hearing of the result trial; and with the chiropractic profession under siege from a PR nightmare; the British Chiropractic Association have finally decided to release the evidence that they claim backs up their promotion of Chiropractic treatments.

In doing so, they appear to have been deliberately dishonest in their presentation of the evidence for the effectiveness of chiropractic in treating bed-wetting.

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"In the spirit of wider scientific debate, and having taken appropriate professional advice, the BCA has decided that free speech would be best facilitated by releasing details of research that exists to support the claims which Dr. Singh stated were bogus"

So states the BCA press release. The research consists of 29 references. I have access to most of them, so I'll cover them here. Other bloggers will be covering various papers themselves in more detail, and I'll provide links to them all in this article - if you're a blogger and you've written about this, please let me know so I can link to you.

To avoid any accusations of shifting goalposts, here is the evidence that I want the BCA to present - a comprehensive selection of randomised, placebo-controlled, double-blind clinical trials producing significant results in favour of chiropractic being producing a clinical effect beyond that of a placebo.

I've discussed the conflict between alternative medicine and scientific research before, and when alt-med types cite a list research papers, they tend to fall into the same sort of pattern: papers will be cherry picked; even so a number of papers won't in fact be relevant; some papers will not actually support the position the quack thinks they do; and others will be of poor quality that the quack is unable to distinguish due to a lack of understanding about e.g. clinical trials. I highlighted a good case study regarding acupuncture recently.

The same pattern is evident in the BCA's list. Of the 29 references, 1 is just the GCC's code of practice; 6 is an irrelevent paper about medical ethics; 8, 9, 10 and 17 are about osteopathy; 26 is a description of evidence-based medicine; 27, 28 and 29 are about NSAIDs. That's 10 down straight away, but what's interesting about these is that 6 of them are just attacks on conventional medicine. In other words, this is not a particularly comprehensive or focused review of the literature. It is far from the 'plethora' of evidence promised.

A further three papers, (12, 13 and 14) cover the safety of chiropractic, which has come under considerable criticism. Curiously, this brief selection ignores the numerous studies showing an increased risk from chiropractic. 14 isn't a study at all, 12 is considerably less bullish than the BCA suggest it is pointing to a significant number of side-effects "with a possible neurologic involvement", and 13 provided stronger support ("We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care."), but should be taken in the context of the wider range of studies finding the opposite.

That brings us down to just sixteen papers remaining to deal with the efficacy of chiropractic. Even before we look at them, it's worth noting that it's a miserably small number. Of those 16 papers, 9 cover infantile colic, 1 looks at asthma, 2 study ear infections, 3 look at bed-wetting and 1 at a variety of conditions.

Professor David Colquhoun has reviewed the 9 infantile colic papers on his own blog, and the results are, well, poor. 2 had no control group, with the authors simply following 300 babies and finding that most eventually got better (as you would expect even without treatment), ditto 3 and 25. 4 compares chiropractic with the use of dimethicone. Apparently, this is an ingredient in some over the counter remedies for colic, which are themselves unproven, so hardly the greatest control to compare with. Meanwhile, 5 brilliantly states that:

"The observed improvements are unlikely as a result of the specific effects of chiropractic spinal manipulation alone."

18 and 20 are both reports on two case studies, and therefore simply anecdote rather than evidence. 19 simply compares one chiropractic treatment against another, and as Professor Colquhuon puts it, "shows that both are equally effective, or equally plausibly, both are equally ineffective." 24 isn't actually a study at all. In summary then, as Colquhuon says:

"The nine papers they cite for colic are truly pathetic. Not a single one of them amounts to anything that would be recognised as evidence in the real world."

So that leaves us with just seven papers remaining for the BCA to show that they can present some sort of coherent, clinical evidence: 1 on asthma, 2 on ear infections, 3 on bed-wetting and 1 on 'various'. 7, the asthma paper, is simply a letter to the editor and contains no actual evidence, so we're down to six.

Of the ear infection papers, 15 is an uncontrolled study that simply reports that children with ear infections tend to eventually get better but can't say if that's down to chiropractic. Unfortunately I can't get hold of 23 at the moment - if anyone else can I'd be grateful, but from the BCA description it looks rather like the same sort of thing again.

So on to bed-wetting then, and at last the BCA are able to cite a proper study! 22 is a study of one person (an anecdote), and 21 is another uncontrolled "they eventually got better" study, but 16 is a meta-study by the Cochrane Collaboration no less, the gold-standard in medical research. The BCA quote this study as saying: "There was weak evidence to support the use of [chiropractic]." Could this be the evidence we're looking for?

No. Here's the quote in full, unedited by the BCA - I've underlined the bits the BCA quote-mined:

"There was weak evidence to support the use of hypnosis, psychotherapy, acupuncture and chiropractic but it was provided in each case by single small trials, some of dubious methodological rigour."

So the BCA appear to have been deliberately dishonest in their quote-mining of the Cochrane review. The review clearly states that, "each of these findings came from small single trials, and need to be verified in further trials," suggesting that the results are inconclusive, yet the BCA falsely suggest the trial supports their position. I make the accusation of dishonesty because I simply cannot see how you can extract the quote the BCA took from that without being aware that you were seriously misrepresenting the research, cutting off the qualifying clause of the sentence. If this was a genuine mistake, I expect the BCA to correct it.

In short then, the 'plethora' of evidence provided by the BCA is pathetically inadequate. How much of this is due to ignorance, delusion or dishonesty is hard to say; my experiences dealing with other alternative medicine practitioners in the past suggests that they often genuinely believe that evidence supports their case even when it clearly doesn't, and that there's a element of misunderstanding about that. I've no doubt that in their presentation of this 'evidence' the BCA are the same. However, when they quote a Cochrane review in such a way that they remove the part of a sentence that qualifies the claim they present, for me that is strongly suggests dishonesty. I just don't see how they could make such a convenient error by accident.

With numerous bloggers gearing up to provide their own, detailed analyses of the research presented, it will be interesting to see how the BCA respond.

------------------------------------------------------

Further Reading from Others:

Jack of Kent - General commentary and legal background.

Prof. Colquhuon - Detailed look at the nine colic papers.

Ministry of Truth - General review focusing on three of the colic papers.

Cochrane Refere... Read more »

Cathryn MA Glazener, Jonathan HC Evans, & Daniel KL Cheuk. (2009) Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews.

May 19, 2009
07:27 PM
1,224 views

Dismantling the chiropractic claims of the BCA, GCC and others

by Martin Robbins in The Lay Scientist

[bpsdb] Guest blogger "Blue Wode" has produced a definitive review of the science and evidence (or lack of) behind claims made by the BCA, GCC and other chiropractic advocates. [Written by Blue Wode, edited by Martin Robbins]

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It has become apparent that the Achilles’ heel of chiropractic - promoted as an effective, cost-effective, and safe alternative to drugs and surgery for a range of health conditions - is negative publicity. One wonders whether this insecurity is behind the chiropractic industry’s frequent failure to cite the more robust, but unfavourable, scientific research on its interventions.

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For example, not only do the British Chiropractic Association (BCA), and the College of Chiropractors (currently seeking a Royal Charter) omit some of the better scientific evidence from their websites; the UK statutory regulatory body, the General Chiropractic Council (GCC) (created to protect patients and set standards of chiropractic education, conduct and practise), does also. It presently claims that:

"The main treatments of chiropractic have been shown consistently in reviews to be more effective than the treatments to which they have been compared."

...and that chiropractic intervention, including manipulation, is:

"Safe, effective and cost-effective in reducing referral to secondary care."

However, that appears to be a misrepresentation of the facts. As Professor David Colquhoun wrote in a letter to The Times last August, recent research has shown chiropractic to be less safe and no more effective than conventional treatments that are much cheaper [1,2].

It is important at this point to understand that spinal manipulative therapy is not chiropractic, but rather a technique that chiropractors have adopted. Real chiropractic involves the detection of imaginary ‘subluxations’ which chiropractors supposedly correct by administering ‘specific spinal adjustments’ which they allege will enhance a person’s health. Often chiropractors resort to confusing the two approaches in order to give all their practices an air of legitimacy, but many others will admit outright that traditional chiropractic beliefs are central to their interventions.

The GCC, and others, continue to stand by their claims for the evidence for chiropractic despite controversy surrounding the studies they promote, such as the 2004 UK BEAM Trial, and the 1990 Meade report and its follow-up [3,4,5]. The GCC also promotes the European guidelines for the management of low back pain which, although the GCC implies that they recommend chiropractic, only briefly mention spinal manipulation. On top of that, the Royal College of General Practitioners withdrew chiropractic spinal manipulation from its guidelines in 2005, although some chiropractic websites continue to mention them.

Perhaps most disturbing of all, is that the GCC is adamant that chiropractic neck manipulation is safe. Oddly, it claims this even though, by virtue of its statutory empowerment, it doesn’t seem to have a duty to care for patients by regulating the safety of chiropractic treatments (nor, for that matter, does it seem to have a legal obligation to define the scope of practice for its registrants).

So just how safe is chiropractic neck manipulation? A responsible risk/benefit assessment suggests, very strongly, that it is an unacceptable technique when there are equally effective, but safer, options available such as exercise or massage. Other assessments have reached similar conclusions [6]. Indeed, Fig. 2 in this paper (reproduced below) serves to demonstrate why it would probably be wise to avoid neck manipulation by chiropractors [7].

Practitioners providing manipulation of the cervical spine that resulted in injury.

Interestingly, these criticisms also suggest that chiropractors may not be able to provide a risk/benefit ratio for manipulative treatment of the cervical spine. As a consequence, patients would not be able to be fully informed of the risks and benefits of their proposed treatment despite chiropractors being required to do so by section B2.7 of their Code of Practice.

In spite of the above concerns, last year, following the publication of a dubious multi-centre research study in Canada, the GCC decided to declare publicly that the there was no evidence that manipulation of the neck (by any health professional) caused stroke, and went on to say that it could extrapolate from that study that:

"Some people suffering the symptoms of the onset of a stroke consult primary healthcare practitioners – not that the health practitioners cause the stroke."

Those claims are disturbing for a number of reasons:

1. They appear to negate chiropractors’ legal burden of disclosure of risk (at least for neck manipulation).

2. Chiropractors should know from their training that neck manipulation is contraindicated if a patient has, or is suspected to have, a stroke in progress.

3. The impact of the GCC’s views could easily see UK chiropractors becoming even more disinclined to use the Chiropractic Reporting and Learning System' (CRLS) which the BCA attempted to implement nationally in 2005, and which, since then, according to a study published in July 2008 [8], has been very much under-utilised. This finding in itself indicates that the GCC’s recommendations on patient safety, which were made clear in Item 7 of the minutes of its 2nd March 2006 meeting, are not being fully met.

4. The GCC’s views on the study will undoubtedly be seen by many chiropractors as confirming the results of a prospective national survey into the safety of chiropractic manipulation of the cervical spine which were published in Spine in October 2007, and which found that the risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low.

Regarding point 4, last year Professor Edzard Ernst questioned the integrity of the methodology used in that survey, and highlighted the very real problem of

"Having to rely on the honesty of participating therapists [chiropractors] who could have a very strong interest in generating a reassuring yet unreliable picture about the safety of their intervention."

Interestingly, in their response, two of the survey’s authors, JE Bolton and HW Thiel, claimed that, in the UK alone, there were an estimated four million manipulations of the neck carried out by chiropractors each year. Yet, six months earlier, in October 2007, in a letter to the Journal of the Royal Society of Medicine, they claimed that the figure was "estimated to be well over two million cervical spine manipulations". How that estimate could double in under 6 months is anyone’s guess, bu... Read more »

Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, & Shekelle PG. (2004) Spinal manipulative therapy for low-back pain. Cochrane Database of Systematic Reviews. DOI: 10.1002/14651858.CD000447.pub2

Canter, P., Coon, J., & Ernst, E. (2006) Cost-Effectiveness of Complementary Therapies in the United Kingdom--A Systematic Review . Evidence-based Complementary and Alternative Medicine, 3(4), 425-432. DOI: 10.1093/ecam/nel044

, . (2004) United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ, 329(7479), 1377. DOI: 10.1136/bmj.38282.669225.AE

Assendelft WJ, Bouter LM, & Kessels AG. (1991) Effectiveness of chiropractic and physiotherapy in the treatment of low back pain: a critical discussion of the British Randomized Clinical Trial. J Manipulative Physiol Ther, 14(5), 281-286.

Meade TW, Dyer S, Browne W, & Frank AO. (1995) Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up . BMJ, 349-351.

Ernst, E. (2006) A systematic review of systematic reviews of spinal manipulation. Journal of the Royal Society of Medicine, 99(4), 192-196. DOI: 10.1258/jrsm.99.4.192

Di Fabio RP. (1999) Manipulation of the cervical spine: risks and benefits. . Phys Ther, 50-65.

GUNN, S., THIEL, H., & BOLTON, J. (2008) British Chiropractic Association members’ attitudes towards the Chiropractic Reporting and Learning System: A qualitative study. Clinical Chiropractic, 11(2), 63-69. DOI: 10.1016/j.clch.2008.04.003

Hughes, S. (2002) Is chiropractic an effective treatment in infantile colic?. Archives of Disease in Childhood, 86(5), 382-384. DOI: 10.1136/adc.86.5.382

Vohra, S., Johnston, B., Cramer, K., & Humphreys, K. (2007) Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic Review. PEDIATRICS, 119(1). DOI: 10.1542/peds.2006-1392

Wien Klin Wochenschr. 2005, Canter PH, & Ernst E. (2005) Sources of bias in reviews of spinal manipulation for back pain. Wien Klin Wochenschr., 333-341.

May 17, 2009
05:13 PM
1,052 views

Treating the Morgellons Meme

by Martin Robbins in The Lay Scientist

[bpsdb] Looking at the culture-bound syndrome Grisi Siknis recently, I was reminded of Morgellons - a subject I've been meaning to look at for many months. Sufferers report strange organic and artificial fibers erupting from lesions, sensations of bugs crawling under the skin, and tentacled "starfish" crawling inside flesh. The problem is that while sufferers insist they are suffering from some new and exotic disease, both the medical establishment and the weight of evidence so far suggest that the the condition is largely psychosomatic in nature.

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In other words, while the condition is undoubtedly "real" in the sense that people are suffering from genuine discomfort; no physical trace or cause of the disease can be established, leaving most doctors to conclude that it is a result of the patient's mind - Morgellons sufferers are commonly diagnosed as having delusional parasitosis. Indeed, to dermatologists the signs are unmistakable, as Dr. Koblenzer describes [1]:

"The patients are virtual carbon copies, one of the other. The clinical picture is unmistakable. The patient is intensely anxious, is obsessively focused on his or her symptoms, brings ‘‘specimens’’ of the offending agent, or agents, and is unshakable in his or her belief as to the cause. Usually there will be a logical explanation of exactly howthe infection or infestation was contracted, and the patient will have resorted to the most extreme measures both to eradicate it and to prevent contagion."

[...]

"...the patient is not open to the idea of pathology in the

mind, the nervous system, or the brain. It is also

important for us to distinguish delusional beliefs from

phobic concerns or obsessional worries, a distinction

that caused some confusion in the past13 and that is

important, because both the psychopathology and

the treatment are different between the three."

Unfortunately, delusional parasitosis is understandably not a very popular diagnosis, and seems to have triggered something of a backlash among sufferers. At the extreme end of that, Morgellons has unfortunately attracted a "lunatic fringe" on the internet of conspiracy theorists positing everything from contrail poisoning to secret government tests to infection with aliens. These people with their ridiculous Youtube videos and assertions of nanotechnology are doing more than anyone to stop it being taken seriously.

Fortunately, there are more sensible support groups, but even here the attitude is strongly biased against the idea of a diagnosis of delusional parasitosis. The main reason for this seems to be a fear that somehow a diagnosis of DP means that doctors are saying that their condition is imaginary or not real - a perspective that probably has a lot to do with general public attitudes to mental illness. A good example of this appears in an excellent commentary by a Morgellons sufferer, published recently:

"Now, you can go up there and post all kinds of nasty comments and scream from the top of your lungs that this is real, but why bother."

Simon and Garfunkel once sang that "a man hears what he wants hear and disregards the rest", and this seems to be very much the case with these online communities - they have no rational reason or evidence to reject or refute the diagnosis of delusional parasitosis, but they continue to insist that it cannot be so, fearing that doctors are suggesting that their illness isn't "real". Sufferers take a diagnosis of delusional parasitosis as an offensive insult. And that's understandable - I woudn't particularly want to be called delusional either. As ever, PalMD at White Coat Underground puts it better than I can:

"...this false dichotomy of mind vs body is troubling, and the stigma of brain illnesses is very problematic."

The CDC have allocated some funds to study the disease at an epidemiological level - essentially collating the available reports to see if any pattern emergences. Some Morgellons groups have pinned hope on this study, but my gut feeling is that this can't provide them with an answer, for the simple reason that if the CDC produce the "wrong" result, it will be dismissed as conspiracy or incompetence.

So what can the medical establishment do about this? In my recent post on Grisi Siknis I noted that there were three basic possibilities: either the doctor genuinely shares the belief system of the patient; the doctor educates the patient to come around to his or her way of thinking; or the doctor pretends to believe the patient and plays along ("as it happens, anti-psychotics are very good for tackling skin parasites!"). The latter approach is seen as pretty unethical as it involves potentially deceiving patients, but some dermatologists are coming around to the idea. Murase et al present a particularly compelling account of this sort of thinking in a dermatology journal in 2006 [2]:

"[B]ecause the term 'Morgellons disease' does not have the word 'delusions' embedded in the term, it is a useful way to communicate with patients regarding their disease. As a case in point, I have established a close relationship with the patient described above by referring to her delusions of parasitosis as Morgellons disease. After taking cultures and a biopsy, I reassured her that there were no bacterial, fungal, or parasitic infections. I emphasized that I did not doubt the authenticity of the sensations she was experiencing, and I empathized with how disconcerting it must be to feel bugs crawling and stinging her skin. I explained that sometimes medications that psychiatrists use to calm nerve signals help patients with Morgellons disease. She is currently on the anti-psychotic risperidone, followed by both dermatology and psychiatry."

It's a very seductive approach, but it isn't without hazards and consequences as Accordino et al point out [3]:

"One wonders if using the term “Morgellons

disease” in clinical practice may bring about a

slippery slope of using patient-created diagnostic

terms to describe conditions with no empiric support

of their existence in the medical literature."

There are numerous dangers if this were to happen - for example, it's a very short step from patient-created diagnostic terms to patient-created cures, and the spread of terms like "Morgellons" could well lead to patients rejecting appropriate courses treatment. This is aside from the obvious objection that unless the doctor involved is very careful, they are essentially lying to their patients. What would be the ethical and legal implications of this?

The truth is that Morgellons probably isn't a new or novel disease, but simply delusional parasitosis mixed with an internet meme. That isn't to say that it's not a real condition - it absolutely is - but the unfortunate medical label clashes with the cultural beliefs and expectations of the patients. The question of how best to deal with this is unanswered, but with any luck perhaps the CDC study will stimulate the sharing of ideas between doctors, and help to establish a framework of understanding that benefits both doctor and patient.

- - - - - - - - - - - - - - - - - - -

Find me on Twitter! @mjrobbins

[1] KOBLENZER, C. (2006). The challenge of Morgellons disease Journal of the American Academy of Dermatology, 55 (5), 920-922 DOI: 10.1016/j.jaad.2006.04.043

[2]MURASE, J., WU, J., & KOO, J. (2006). Morgellons disease: A rapport-enhancing term for delusions of parasitosis Journal of the American Academy of Dermatology, 55 (5), 913-914 DOI:... Read more »

KOBLENZER, C. (2006) The challenge of Morgellons disease. Journal of the American Academy of Dermatology, 55(5), 920-922. DOI: 10.1016/j.jaad.2006.04.043

MURASE, J., WU, J., & KOO, J. (2006) Morgellons disease: A rapport-enhancing term for delusions of parasitosis. Journal of the American Academy of Dermatology, 55(5), 913-914. DOI: 10.1016/j.jaad.2006.04.042

Accordino, R., Engler, D., Ginsburg, I., & Koo, J. (2008) Morgellons disease?. Dermatologic Therapy, 21(1), 8-12. DOI: 10.1111/j.1529-8019.2008.00164.x

May 4, 2009
12:00 AM
1,084 views

Burma - How an Early Warning from Science was Ignored

by Martin Robbins in The Lay Scientist

It was the most disasterous cyclone-hit in recent times. Over 140,000 people have been confirmed dead with tens of thousands more missing and millions rendered homeless, mostly in the low lying Irrawaddy delta region on the Burmese coast, where even one year on, survivors are facing deficits of foot, water, shelter and sanitation, and the UN have only recently been granted significant access. The damage was done not by the winds of "Cyclone Nargis" however, but by a tidal surge more than ten feet high that swept across the land. It's tempting to attribute such disasters to bad luck, but in fact this was at least partly preventable, and scientists explained exactly why in 2005 in the research that I'll show you now for my first regular post at worldismycountry.org - Dahdouhguebas et al's "How effective were mangroves as a defence against the recent tsunami?" ... Read more »

DAHDOUHGUEBAS, F., JAYATISSA, L., DINITTO, D., BOSIRE, J., LOSEEN, D., & KOEDAM, N. (2005) How effective were mangroves as a defence against the recent tsunami?. Current Biology, 15(12). DOI: 10.1016/j.cub.2005.06.008

December 18, 2008
08:51 AM
1,403 views

Catching Snowflakes: The Media and Public Perceptions of Disease

by Martin Robbins in The Lay Scientist

It's repeated so often that it has long been regarded as a cliche, but we live in an increasing information-intensive world, bombarded by facts and figures from an endless queue of media outlets, websites, television shows and Windsor-based science bloggers. This abundance of information often comes with a cost. If my grandfather wanted to learn something about his health - and of course like many men of his generation he didn't - he would have seen a doctor or read a reputable book.

read more... Read more »

Meredith E. Young, Geoffrey R. Norman, & Karin R. Humphreys. (2008) Medicine in the Popular Press: The Influence of the Media on Perceptions of Disease. PLoS ONE, 3(10). DOI: 10.1371/journal.pone.0003552

Ahern J, Galea S, Resnick H, Kilpatrick D, Bucuvalas M, et al. (2002) Television images and psychological symptoms after the September 11 terrorist attacks. Psychiatry, 289-300.

November 26, 2008
08:12 AM
1,499 views

NHS Takes Aim at Daily Mail over Baby Buggy Bollocks

by Martin Robbins in The Lay Scientist

November 26, 2008
08:12 AM
1,342 views

NHS Takes Aim at Daily Mail over Baby Buggy Bollocks

by Martin Robbins in The Lay Scientist

[BPSDB] It started off as a simple observational study [1] that showed that babies facing forwards in their buggies have slightly higher heart rates, a phenomenon that could be attributable to stress, or perhaps simply to the increased amount of stimuli the babies received. Then the papers got a hold of it.

read more... Read more »

Dr. M. Suzanne Zeedyk. (2008) What's life in a baby buggy like? The impact of buggy orientation on parent-infant interaction and infant stress . University of Dundee Research Report. DOI: http://www.literacytrust.org.uk/talktoyourbaby/Buggy_research.pdf

Health

September 19, 2008
10:16 AM
1,735 views

WARNING: Ejaculation as a Treatment for Nasal Congestion is Inconvenient, Unreliable and Potentially Hazardous!

by Martin Robbins in The Lay Scientist

Awesome fellow blogger Scicurious delved into the Journal of Medical Hypotheses today and showed us the recently published hypothesis of one doctor who believes that the answer to nasal congestion could be... masturbation. Go and read her brilliant blog post on this moment of medical genius, but then come back here, because the journal has now published a letter by Mohammad Fakhree angrily rejecting the claims, in the prelude to what could be the biggest medical controversy since MMR.

read more... Read more »

M FAKHREE. (2008) Ejaculation as a treatment for nasal congestion in men is inconvenient, unreliable and potentially hazardous. Medical Hypotheses. DOI: 10.1016/j.mehy.2008.07.022

Biology

September 19, 2008
08:43 AM
1,933 views

The Great Global Cooling Swindle

by Martin Robbins in The Lay Scientist

You've heard it before, at dinner parties, from taxi drivers, from commenters on the intertubes: "Global warming? Pah! I remember they were talking about global cooling when I was a lad." As Peterson, Connolley, and Fleckthe, the authors of "The Myth of the 1970s Global Cooling Scientific Consensus" [1] explain: "the following pervasive myth arose: there was a consensus among climate scientists of the 1970s that either global cooling or a full-fledged ice age was imminent." But was it true? No.

read more... Read more »

Thomas C. Peterson, William M. Connolley, & John Fleck. (2008) The Myth of the 1970s Global Cooling Scientific Consensus. Bulletin of the American Meteorological Society, preprint(2008), 1. DOI: 10.1175/2008BAMS2370.1

D SAREWITZ. (2004) How science makes environmental controversies worse. Environmental Science , 7(5), 385-403. DOI: 10.1016/j.envsci.2004.06.001

August 15, 2008
06:14 AM
1,601 views

The Birth of Maggot Therapy

by Martin Robbins in The Lay Scientist

In 1917, at the height of the Great War, William Baer made a chance, startling discovery. The result was his exploration of a novel form of treatment, one that - while somewhat grim to contemplate, is still used today. His experiences and early experiments are described in this paper, "The Treatment of Chronic Osteomyelitis with the Maggot (Larva of the Blow Fly)" [1].

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William Baer. (1931) The Treatment of Chronic Osteomyelitis with the Maggot (Larva of the Blow Fly). Journal of Bone and Joint Surgery, 438-475. http://www.ejbjs.org/cgi/content/abstract/13/3/438

July 24, 2008
10:06 PM
1,371 views

MMR: The Roles of Education and the Media in Vaccine Uptake

by Martin Robbins in The Lay Scientist

The controversy over MMR that Andrew Wakefield managed to trigger in the U.K. with his botched Lancet study, has given researchers the opportunity to study the dynamics of a public health scare. Their report, "Anatomy of a Health Scare: Education, Income and the MMR Controversy in the UK" studies the relationship between the media, certain family attributes, and uptake of the MMR vaccine. Their findings call into question conventional wisdom regarding the positive role of parent education in vaccine uptake.
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Dan Anderberg, Arnaud Chevalier, & Jonathon Wadsworth. (2008) Anatomy of a Health Scare: Education, Income and the MMR Controversy in the UK. IZA Discussion Paper Series, n/a(3590), 1-58. http://ftp.iza.org/dp3590.pdf

C Gellin, E Maibach, & E Marcuse. (2000) Do Parents Understand Immunization? A National Telephone Survey. Pediatrics, 1097-1102.

M Pareek, & H Pattison. (2000) The Two-Dose Measles, Mumps and Rubella (MMR) Immunization Schedule: Factors Affecting Maternal Intention to Vaccinate . British Journal of General Practice, 969-971.

K Viscusi, & . (19977) Alarmist Decisions with Divergent Risk Information. Economic Journal, 1657-1670.

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July 10, 2008
07:07 AM
1,179 views

The Eerie Symphony of the Icebergs

by Martin Robbins in The Lay Scientist

This is pretty special and interesting, especially as I work in an Antarctic research group (or will until my funding is killed soon, pah). A paper by Doug MacAyeal (reported in New Scientist today) has been published that suggests an explanation for mysterious "songs" coming from icebergs, and picked up by hydrophones in the world's oceans [1].
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D MacAyeal, E A Okal, R C Aster, & J N Bassi. (2008) Seismic and Hydro-Acoustic Tremor Generated by Colliding Icebergs JOURNAL OF GEOPHYSICAL RESEARCH, VOL. ???, XXXX, DOI:10.1029/, Seismic and Hydro-Acoustic Tremor Generated by Colliding Icebergs D. R. MacAyeal,1 E. A. Okal,2 R. C. Aster,3 and J. N. . Journal of Geophysical Research, ??(XX). http://www.agu.org/journals/pip/jf/2008JF001005-pip.pdf

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