The current issue of the BMJ informs us that over 7000 academics have signed an online petition to say they will no longer edit or referee papers for Elsevier journals or have their own papers published in them. This bocott is in response to Elsevier's support for new legislation to end guarantees of free access to publicly funded medical research. As a result, Elevier has withdrawn its support for this legislation.
I'm delighted by this news. Elsevier has long had a restrictive attitude to its publications and has limited free access as much as it could. Its subscription charges are much too high. I accept that publishers have to make a living but their cupidity is often excessive. There is a widespread feeling, which I share, that publishers 'take advantage of the academic community's pursuit of knowledge and commitment to sharing what they discover broadly and free of charge.'
You can sign the petition at http://thecostofknowledge.com/.
The current issue of Nature
has an opinion piece on the dangers of sugar. Robert H, Lustig and colleagues say that sugar should be taxed and restricted in the same way as alcohol. Lustig runs a children's obesity clinic in San Francisco. See Sugar: The Bitter Truth
by Lustig onYouTube,
This view endorses the central claim of Gary Taubes's book The Diet Delusion
. In his lecture Lustig doesn't mention Taubes, but his message is the same as that of Taubes. In outline, this is that reducing calories and exercising more to lose weight doesn't work. The widely promulgated advice to cut down on dietary fat is wrong, because it isn't fat that makes us fat, it's carbohydrate (and especially fructose, which Lustig regards as a major culprit and as dangerous as alcohpl). Lustig even repeats the slogan that Taubes uses: " a calorie isn't a calorie; not all calories are equal."
Like Taubes, Lustig blames much of the mistake on the late Ancel Keys, whose research, he finds, was flawed. Lustig is important because, unlike Taubes, he is a clinician and an academic - Professor of Clinical Pediatrics at the University of California, San Francisco.
This week's BMJ summarises the results of a trial reported in JAMA which had a surprising outcome. The trial was started in 2001 to see whether supplements of selenium and vitamin E would protect men against prostate cancer in more that 35,000 healthy middle-aged men.
What happened was just the opposite: far from reducing the incidence of prostate cancer, the supplements increased the risk of cancer. Men who took the supplements were 17% more likely to develop the disease than those who took placebo. This corresponds to 1.6 extra cases for every 1000 men treated. The incidence of other types of cancer was not affected.
About half of all middle-aged and older men in the USA take supplements containing vitamin E.
The current issue of the BMJ reports the recommendations of the US Preventive Services Task Force, an independent body of 16 experts. They say that the PSA test should not be used to screen men for prostate cancer because it is unlikely to save lives and can cause harm.
The widespread US practice of annual PSA-based screening for prostate cancer in men aged 50 years and older is not supported by results from randomized controlled trials. PSA-based screening may modestly reduce prostate cancer mortality; this absolute benefit is small relative to other causes of death in this age group and is associated with substantial harms.
The potential harms from unnecessary investigations and treament include erectile xysfunction, urinary incontinence, bowel dysfunction, and death.
What is particularly interesting about this report is the delay that attended its publication. The group had made its recommendations in 2009 and 2010, but not until an article appeared in the New York Times
were they made public, nearly two years after they were made. I wonder why.
This week's BMJ (10 Sept 2011) has a nice article by Nigel Hawkes expressing doubt about the validity of much of the dietary advice we are so often regaled with.
The lesson we should have learnt by now is that laying down dietary guidelines that are based on the evidence of the day is a task to be undertaken with humility, Almost every nutritional 'fact' is in reality an opinion, often based on poor quality evidence.
Hawkes is making the same point as Gary Taubes in The Diet Delusion
. Both repay reading by anyone of a sceptical turn of mind.
This book seems to have begun life as a PhD dissertation and that is what it reads like. In other words, there is a huge amount of information and the writing style is somewhat dry and academic. But Barnes makes plentiful use of passages from contemporary writers and these do lighten the tone somewhat.
The period covered extends from the first contacts with Chinese ideas in the thirteenth century to the middle of the nineteenth. This is divided into five sections: from first beginnings to 1491; 1492 to 1659; 1660 to 1736; 1737 to 1804; and 1805 to 1848. As the title indicates, Barnes is concerned both with Chinese medicine (herbalism and acupuncture) and, to some extent, with Chinese ideas of 'religion', although, as she points out, the concept of religion was unfamiliar to the Chinese before the arrival of Western missionaries. But Daoism, Buddhism, and Confucianism are not discussed in any detail, and are described only in so far as their ideas influenced medical thinking. [More
The strength of wine has increased progressively over the years. At one time in France we used to buy local cheap wine, which was either 9%. 10%, or 11%, depending on price. Now it is quite difficult to find a bottle of wine that is less than 13% and we are being told that even this is an underestimate, with the true strength being more like 13.6%. And there is a rising incidence of alcoholic liver disease.
In classical times it was customary to dilute wine with water and if you didn't you were regarded as a drunkard. We don't know what the strength of wine was at that time but it is unlikely to have been more than it is now. So Is it perhaps time to go back to the practice of watering our wine?
Luc Montagnier is a virologist who was a joint winner of the Nobel Prize in 2008 for his work on HIV as the cause of AIDS. He has now created a considerable stir by publishing research which appears to support some of the claims of homeopathy.
In outline, Montaignier says that the DNA of certain pathogenic bacteria emits an electromagnetic signal. If you dilute that DNA homeopathically so that no DNA is actually present, the water continues to emit the same signal. And if you put two vials of this homeopathically diluted substance together. the signal can move from one to the other. Only bacteria and viruses pathogenic to humans produce this signal; ordinary E. coli does not.
These claims are reminiscent of those made by the late Jacques Benveniste. He carried out research which, he believed, confirmed the reality of the homeopathic potency effect, and he later went on to say that information produced in this way could be transmitted electronically via a telephone wire.
The paper was published in the Journal of Interdisciplinary Sciences: Computational Life Sciences.
It took only two days for publication after receipt of the paper - an astonishingly quick turnaround for a scientific journal, but explicable since the journal in question was set up by Montagnier and he is the chairman of the editorial board.
Of course,.this stuff would not have attracted the attention that it did if it had not been produced by a Nobel laureate. It therefore seems appropiate to remember the words of another member of that illustrious club, Richard Feynman.
Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation ... Learn from science that you must doubt the experts. As a matter of fact, I can also define science another way: Science is the belief in the ignorance of experts.
This is effectively a digest of Taubes's exhaustive study of the causes of obesity, The Diet Delusion
(published as Good Calories, Bad Calories
in the USA). That book was long (600 pages) and included a lot of detailed physiology; this one is intended to be a practical resource for people who are thinking of putting the ideas into practice for themselves. Taubes is sure that they will benefit from doing this but he encourages his readers to think about the ideas he discusses to see if they seem sensible. He also warns them that anyone who adopts his ideas will be going counter to the received wisdom about what constitutes a healthy diet. Taubes hopes that patients will give it to their doctors with the aim of altering their opinion; I'm not sure how likely that is to happen. [more]
The National Archiives have digitised naval surgeons' records from the late eighteenth and nineteenth centuries; they are available here
. This material consists of journals and diaries compiled by Royal Navy Surgeons and Assistant Surgeons who served on HM ships, hospitals, naval brigades, shore parties, and on emigrant and convict ships in the period 1793 to 1880.
Blood-letting was a standard treatment at the time and it was sometimes taken to extremes. One unfortunate seaman suffering from pneumonia had 3.5 pints of blood removed in 3 hours; the case "proceeded rapidly to a fatal termination". An experimental treatment tried for fever was tepid bathing in salt water. Everyone who had the treatment got worse and all died, but the surgeon remarked that the treatment had salutary effects.
Venereal disease was common, of course. This prompted one surgeon to conduct an experiment to investigate transmission. A young woman aboard had venereal disease, and her "keeper" and an officer had "connexion" with her to see how gonorrhoea and syphilis are spread. Impressive self-sacrifice in the cause of science?
There is plenty of interesting and dramatic stuff here. Well worth a look, especially if you enjoy Patrick O'Brian's historical fiction about the navy in the Napoleonic era.
My old hospital, the Royal London Homeopathic Hospital, has renamed itself the Royal London Hospital for Integrated Medicine. I think this is a good development. It reflects the fact that the hospital offers a wider range of CAM than just homeopathy. In fact, the change in name is really a catching-up measure. In the 1980s those of us who were working at the hospital decided to broaden its scope to include a number of different treatments. I was practising medical acupuncture, another of the consultants was interested in dietary approaches, and so on. So the change in name is a logical culmination of this trend. Although homeopathy will still be practised at the hospital it is no longer the explicit focus but just one among a range of unconventional treatments on offer.
My own view has long been that those forms of CAM that work should be incorporated into conventional medicine. This has already happened to a large extent in the case of hypnosis and medical acupuncture is going the same way. I hope that the new name for the hospital will help this progression.
The Science and Technology Committee of the House of Commons concluded in February that homeopathy is a placebo treatment that should no longer be provided by the NHS, mainly because it entailed deception of patients which could do damage to the doctor-patient relationship. In its official response, published on 26 July, the government said: "... we do not believe that this risk amounts to a risk to patient trust, nor do we believe that the risk is sufficient enough for the Department to take the unusual step of removing PCTs' flexibility to make their own decisions."
Whatever one may think about the government's view (which seems to me to be a first-class example of buck-passing), "sufficient enough" is an absurd pleonasm.
The current issue of the BMJ has a long article by Klim MacPherson, visiting professor of public health epidemiology at Oxford, on mammography. The article finds that the present situation of screening is unsartisfactory and there is inadequate evidence to reach firm recommendations. "The misplaced propaganda battle seems now to rest on the ratio of the risks of saving a life compared with the risks of diagnosis."
For the individual woman, deciding whether or not to go for screening is difficult. "Arguments that polarise are unhelpful and render women, many with strong preferences, more helpless. For too long they have been misled and confused by too much agenda driven analyses of these data." The article, which is quite long and complex, deserves to be read in its entirety.
If women are likely to be confused by the propanda, men face a possibly even more contentious issue when thinking about screening for prostate cancer. The same issue of the BMJ summarises a paper in Arch Intern Med 2020;170:1256-61 which finds that in the USA most men with low-risk prostate cancer opt for invasive treatments that are likely to do more harm than good. This is largely due to widespread use of screening for prostate specific antigen (PSA). PSA is a poor test for cancer; indeed, as I reported in an earlier post, the discoverer of the antigen says that it should never have been used as a test.
A new paper in Nature Neuroscience
has contributed to our understanding of how acupuncture relieves pain (Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture: http://www.nature.com/neuro/journal/vaop/ncurrent/full/nn.2562.html).
We found that adenosine, a neuromodulator with anti-nociceptive properties, was released during acupuncture in mice and that its anti-nociceptive actions required adenosine A1 receptor expression. Direct injection of an adenosine A1 receptor agonist replicated the analgesic effect of acupuncture. Inhibition of enzymes involved in adenosine degradation potentiated the acupuncture-elicited increase in adenosine, as well as its anti-nociceptive effect. These observations indicate that adenosine mediates the effects of acupuncture and that interfering with adenosine metabolism may prolong the clinical benefit of acupuncture.
This work was done in mice so its relevance to human acupuncture remains to be shown. But probably the authors' research does explain part of the analgesic effect of acupuncture. In their discussion they make a couple of interesting points. One, with which I agree, is that the mechanism of action of other kinds of physical treatment, such as chiropractic and osteopathy, may be similar to that of acupuncture. Another is that non-penetrating pressure on the skin, used in some attempts to find a placebo for acupuncture trials, may also cause transient increases in adenosine. Adenosine has anti-inflammatory effects as well as relieving pain, which may explain how acupuncture works for acute injuries such as sprains and tenosynovitis.
Manual stimulation (twisting) of the needles was necessary to produce the effect.
The authors appear to discount the central effects of acupuncture (effects on the spinal cord and brain). But there is a lot of research to support a central mechanism and I think it likely that the adenosine mechanism is part but not all of the explanation for how acupuncture works.
The writers of the BBC TV hospital soaps like Holby City and Casualty try to get their medical facts right with the help of advisers, even if the plot lines sometimes strain credulity well beyond breaking point. The commonest errors to get through are mispronunciations of medical terms, which happens surprisingly often, but yesterday's Holby came up with an old chestnut which surprised me. Connie, the cardiothoracic surgeon, has carried out an unethical procedure which has resulted in severe brain damage to a patient who is also an old friend, and the patient's husband is becoming suspicious. Talking to her registrar, who is also involved, Connie said that she didn't think the husband would complain to the BMA. It is, of course, the GMC who would be involved, not the BMA, which Connie would obviously have known perfectly well.