Feb 26 2010

Homeopaths On The Run

It’s been a bad year for homeopathy, and it’s still February. The 10^23 campaign has been making a proper mockery of the magical medicine that is homeopathy, capped off with their mass homeopathic “overdose.” In Australia skeptics have been taking homeopathic websites to task for making unsupported health claims. And in the UK there has been increasing pressure to question NHS support for homeopathy – most recently the House of Commons Science and Technology Committee concluded that homeopathy is nothing more than an elaborate placebo and the NHS should completely defund and remove any support for homeopathy. This could be a death blow to homeopathy in the UK, and provide support for similar efforts elsewhere.

Last year was no better. Most memorable was this comedy sketch by Mitchell and Webb, who nicely skewered homeopaths and other cranks. When comedians are not ridiculing them, homeopaths were doing a fine job of lampooning themselves – the best is this video where Dr. Werner tries to explain how homeopathy works – pure comedy gold. Of course the best real explanation for how homeopathy works is here.

Even before the House Committee presented its final report, the embarrassing moments were being immortalized on YouTube, for example the head of a major UK pharmaceutical chain admitting that they market homeopathic products with full knowledge that they don’t work.

All of this has homeopaths a bit desperate, it would seem. They now realize that skeptics and scientists are starting to get traction with their criticism. This is good, because as I have argued before the more we get homeopaths and other pseudoscientists trying to defend themselves, the more they will do our work for us.

Thanks to commenter tl;dr for pointing out this video by homeopath, John Benneth. This is the best incoherent rant yet by a crank against skeptics. If I did not already know Benneth from his other videos, where he puts forward rambling technobabble trying to make homeopathy seem scientific, I could easily have believed this was satire. Benneth looks disheveled, distracted, and gets childishly sarcastic at one point. But that aside, the content of his rant is priceless.

Benneth decides to take on skeptics directly, and by name. He mentions Randi, Edzard Ernst, Simon Singh, Harriet Hall, Michael Shermer, and your humble servant (thanks for including me in such excellent company). He then proceeds straight to the logical fallacy aisle and fills his cart.

He does everything he can to smear our reputations – the video is mostly a giant ad hominem logical fallacy. He says of us:

Whose purpose is to destroy legal medical practice. They’ve made an industry out of libeling others and they’re getting sued for it.

He equates being sued for libel with lying, and mentions Singh and Randi specifically. Yes – being a public critic opens oneself up for being sued for libel as an intimidation and silencing tactic. In fact, this has gotten so out of control, especially in England, that the scientific community (such as this editorial in the British Medical Journal) have called for keeping libel laws out of science. Let us have open debate in the public interest – and not abuse the courts to silence critics.

Benneth misses the fact (or I suspect just does not care) that Simon Singh’s case is still ongoing, and that his criticism of the British Chiropractic Association was completely legitimate – in my opinion and that of many others. Also, while Randi was sued (for example, by Uri Geller) he won those cases. So Benneth seems to be following the strategy – sue someone for libel, then claim they are not legitimate because they were sued for libel – no matter what the status of the case. The accusation of lying is equivalent to lying, for the individual and all of their associates – for reference, see “witch hunt.”

But it gets much worse. Benneth says:

Their action’s like a bunch of terrorists spreading lies and trying to discourage anyone who wants to get legal medical treatment.

I see your ad hominem and raise you a straw man. Wow – the terrorist card. Nice. Of course, our criticism has nothing to do with discouraging people from getting legal medical treatment. Rather, we are trying to educate the public about the scientific basis for treatments that are available, and also to lobby for rational and science-based regulation. Benneth, it seems, is taking the “restraint of trade” tactic that worked for American chiropractors against the AMA. In fact, he characterizes what we are doing as “not legal,” – he is accusing us of actually breaking the law by criticizing his nonsense.

He then returns for some more ad hominem, saying:

None of these people I’ve named, Randi, Ernst, Novella, Singh, are medical practitioners.

Harriet Hall’s not a medical practitioner. Oh, she might have been a flight surgeon at one time, but she’s not now. They’re always retired people, or they’ve been disbarred or defrocked or something, you know they have had some problems in the past. They can’t make it as real doctors or real scientists so they make their livings now by criticizing the works of real practitioners and real scientists, and then they try to run of their business is support. That’s called interference with trade. It’s a crime.

Edzard Ernst is a Professor of Complementary and Alternative Medicine. He is widely published in the peer reviewed literature, including many reviews of homeopathy. He has, by all accounts, a successful and internationally regarded academic career.

Harriet Hall is retired, after a full career as a primary care doctor. She was never “disbarred” or “defrocked” (probably because she was never a lawyer or a priest) – she simply retired. She decided to remain productive in her retirement, and so spends some of her golden years educating the public about science and medicine.

I work with many physicians who have decided to spend time defending the standard of science in medicine and educating our fellow professionals and the public about the relationship between science and the practice of medicine. Most are either actively practicing doctors and nurses or retired professionals. Some, like me, are academics. We also work at times with scientists and educators in other disciplines – such cross-fertilization in science can be very fruitful. We come together over a shared commitment to logic and reason.

Benneth, while ironically accusing us all of actual libel, has decided to slander us by making the demonstrably false accusation that we are all “failed doctors and scientists.” And I wonder what “problems” he is referring to.  I suppose Benneth is used to just making up his facts to suit his needs. After all – he is a homeopath.

Benneth apparently did not do his homework before switching on the video camera, and had to add this caveat in the middle of his video.

I have been informed that Stephen Novella [sic], a notorious self proclaimed “skeptic,” homeopathy basher and professor of neurology at Yale, does indeed qualify as a practitioner. However, I question whether or not he is really a practitioner of medicine, or is simply listed as such for political reasons; why is he thrusting himself into the limelight to pass judgment and argue on another medical doctrine which he denies? His involvement in strange activities have little to do with his profession. A good practicing physician would not take such an extensive, rancorous and defamatory political position against another modality that has support in the material sciences, debating the heads of departments from other universities, such as Professor Ruston Roy of Penn State, Professor William Tiller of Stanford and Professor Iris Bell, MD of the University of Arizona, calling their conclusions “nonsense.” so I question whether he can take on the heavy responsibility of being a competent practicing clinical neurologist while racing around the country to appear on TV shows, pursuing such comparatively frivolous and defamatory activities as organized “skepticism,” (not Pyrrhic skepticism, which demands withholding judgment in lieu of man’s inherent agnosticism.) The man is bizarre. President and co-founder of the New England Skeptical Society (NESS), he hosts their podcast, “The Skeptics’ guide to the Universe,” writes a monthly column called “Weird Science” for the New Haven Advocate, writes a blog and contributes to others. He has also appeared on several television programs, including an [sic] crude cable TV program hosted by abusive magicians. So where he gets time to be a good practicing neurologist is questionable.

Cranks really do not like to be criticized, especially by an academic with some credentials. It really irritates them. Recently on this very blog, naturopath Christopher Maloney, responding to criticism of the lack of science behind his claims and practices, took a similar approach in the comments to this blog. He went as far as to accuse me of neglect for spending my time in skeptical activities.

Maloney and Benneth appear to be blissfully unaware of the academic lifestyle. I have many colleagues who spend more of their non-clinical time than I doing things like maintaining websites, writing textbooks, doing research, or engaging in other academic activities. It’s pretty much expected. I do teaching, writing, and some research as well. But I have decided to spend much of my spare time pursuing public science education and advocating for high standards of science in medicine. All of this is in addition to a full time clinical schedule. Such are the realities of an academic medical career.

Benneth and Maloney are only interested in making a cheap (and naive) ad homimen attack – which basically amounts to saying “shut up.” They cannot deal with the substance of the scientific criticism aimed against them and their beliefs, so they try to make it seem like the entire endeavor of criticizing pseudoscience in medicine is not legitimate. It’s all quite childish.

I also like how Benneth says that my “involvement in strange activities have little to do with his profession.”  “That,” as Yoda once said, “is why you fail.” Skepticism is essential to being a good clinician. A clinician must understand how to read and apply the scientific literature, and how to be wary of the mental pitfalls that tend to lead us astray. Being a good clinician is partly being a good investigator, a Sherlock Holmes of medicine – which has everything to do with skeptical philosophy. Benneth rejects skepticism and practices homeopathy – it is easy to see how these two things are related.

Sprinkled throughout the video is also Benneth’s claim, implied or direct, that homeopathy works. He makes the astonishing claim:

Nobody would practice homeopathy unless there was clear evidence, clear evidence that it worked.

This is naive in the extreme, and by extension would mean that every medical practice must work, or else why would people use it. I guess this means that the bloodletting that was practiced in the West for two thousand years must have also worked. Throughout the video he also presents text from published studies which presume to show that homeopathy works. But as usual he is cherry picking and misrepresenting the evidence.

A thorough review of the homeopathic literature shows a clear pattern of no effect greater than placebo. In a systematic review of systematic reviews, Edzard Ernst concluded:

In particular, there was no condition which responds convincingly better to homeopathic treatment than to placebo or other control interventions. Similarly, there was no homeopathic remedy that was demonstrated to yield clinical effects that are convincingly different from placebo. It is concluded that the best clinical evidence for homeopathy available to date does not warrant positive recommendations for its use in clinical practice.

But of course, Benneth thinks Ernst is not an authority, even though he has more than 70 peer reviewed published articles on homeopathy.

After reviewing the evidence and testimony on both sides, the Science and Technology Committee also agreed that there is no plausibility to homeopathy and the clinical evidence shows it is no better than placebo. This accords with my own reading of the literature. And let us not forget that there is, for all practical purposes, zero plausibility to homeopathy. You don’t have to be a clinician to understand this – homeopathy violates basic principles of physics, chemistry, and thermodynamics. Homeopathic preparations are often diluted beyond the point where there is any active ingredient left, and this fact cannot be rescued by any hand-waving arguments about nanobubbles and radio waves.

Conclusion

The cat is clearly out of the bag. Homeopathy is a 200 year old pre-scientific system of pure pseudoscience. Modern attempts to explain how it might work have failed, and the clinical evidence shows (no surprise) that it does not work.

The public has been largely unaware of these facts, thinking that “homeopathic” was equivalent to “natural” and that they were getting herbs or some plant-based treatment. Like any cult, information is the enemy of homeopathy. The more the public, and regulators, understand about homeopathy the more ridiculous it seems.

Homeopaths are now in the desperate situation of shouting “ignore that man behind the curtain.” They have decided to attack the messengers – skeptics. But in so doing they are just making the situation worse for themselves, as their attempts to explain homeopathy and discredit their critics are indistinguishable from drunken rants.

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61 responses so far

61 Responses to “Homeopaths On The Run”

  1. jugaon 26 Feb 2010 at 9:42 am

    The National Health Service in the UK pays for homeopathic treatments. It would be interesting to know if it would pay more or less if all those patients received conventional medicine. I don’t think the answer is obvious. If the answer is more, is it not legitimate to ask why taxes should go up to pay for people to receive more expensive treatments that they would prefer not to have?

    Much of what is spent on health by the government is wasted in any case on people who should exercise more, stop worrying about their health, wait for a problem to get better, change an unhealthy lifestyle etc. Why is it worse if some of this waste comes from treating these people with ineffective homeopathic remedies as opposed to conventional remedies which do not address the underlying issues?

  2. canadiaon 26 Feb 2010 at 9:43 am

    WOOT! Go Steven!

    Seriously though, good work. It’s incredibly heartening and inspiring to see people taking these quacks on. It’s high time society cracked down on their nonsense.

  3. Steven Novellaon 26 Feb 2010 at 10:27 am

    juga – how, exactly, would you implement what you suggest?

    “I’m sorry, you do not a right to health care because you should have exercised and lost weight to address your problem.”

    It is unethical to refuse to treat someone because you think (even if you are right) that their medical problem was self-inflicted, or could have been handled by preventive or life-style interventions.

    Further – if it costs more to get treatments that are evidenced based, it is reasonable to assume that patients are getting better health for their money. Treatments that do not work are always a waste of money, and may increase costs down the line by delaying timely or preventive measures.

    We should absolutely continue efforts to address obesity, smoking, lack of exercise, etc. But you cannot conclude it’s a “waste” to treat people with health problems resulting from bad lifestyles.

    That would also mean not treating any alcoholics, don’t treat smokers who get lung cancer, don’t treat people who choose not to take aspirin to reduce their heart attack risks, or who simply forget to take their medication, etc.

    Really – it’s an untenable position, and a non-sequitur.

  4. HHCon 26 Feb 2010 at 11:35 am

    juga is pointing to the folly of Britain’s national healthcare. Let’s hope that the U.S. healthcare proposals can avoid this pitfall?! Enjoyed SN’s non-sequitur, well taken point. By this logic, no one should insure or doctor any Olympic athlete who injures themselves while trying to complete their routines for the “Gold.” Bad lifestyles, eh?

  5. Merseyskepticon 26 Feb 2010 at 12:17 pm

    The NHS shouldn’t be using my tax to fund homeopathy.

    I recently had my car serviced. I told them two things I wanted them to look at specifically.

    When I picked it up I got an unconvincing explanation and when I got in the car it became clear they hadn’t bothered to fix or look at those specific problems.

    The bill was the standard service. They didn’t charge me extra for whatever they did. But I still have the problems.

    Perhaps they have saved me some money by not doing anything but is it good value?

    Andy
    10:23

  6. stargazer9915on 26 Feb 2010 at 12:20 pm

    “The more they talked about their honor, the faster we counted the silver.” Paraphrased quote by Mark Twain.

    I think the same could be said for those who abuse the honor of other people. You haved cornered the dog and now it’s trying to bite. This can only mean that you, Steve, and others are doing your jobs in the skeptical community very well.

    I hope this means that the countdown clock for the end of homeopathy is ticking down. Time to strike harder and more often. My hat’s off to you sir.

  7. rmgwon 26 Feb 2010 at 12:21 pm

    “He then proceeds straight to the logical fallacy isle and fills his cart.”

    I like that very much. Is it patented?

  8. skeptologicon 26 Feb 2010 at 12:48 pm

    I just love listening to Dr. Novella take on these cranks. I recently wrote my own response to some of Mike Adams’ (naturalnews) craziness on my blog and mentioned that anyone who wants to criticize skeptics had better have valid arguments because Dr. N will take them to task just like he did here. Dr. Novella, if you’d like to hear some kind words about you, here is the link: http://tinyurl.com/ykkpsnx

  9. ThorGoLuckyon 26 Feb 2010 at 1:36 pm

    Just yesterday I was talking with an advocate of homeopathy. I explained that it had no active ingredients and he replied that it worked for him. He eventually admitted that “ritual” (placebo) was a factor in his “healing” (feeling better).

  10. daijiyobuon 26 Feb 2010 at 2:29 pm

    Regarding that video by Benneth, which is HIGHLY entertaining to me, I am reminded of this physiological possibility:

    when you wake up in the morning [hypothetically], and you are on meds for perhaps mental things [hypothetically], you should wait probably until early afternoon before you video post.

    Something to do with your meds kicking in by then [hypothetically].

    This is not an ad hominem [being hypothetical and all].

    -r.c.

  11. gfishon 26 Feb 2010 at 4:38 pm

    Wait, are we talking about the same John Benneth who made the following mockery of physics while trying to defend homeopathy?

    http://worldofweirdthings.com/2009/11/28/homeopathic-physics-abuse-take-two/

    I mean according to him, homeopathy basically turns water into hazmat which beams radiation in all directions and should be treated with the same care as uranium pellets. And while he’s tripping over his tongue trying to justify how he pays his mortgage with offers of false hope and placebos to the sick, he also thinks he has a legitimate argument against real doctors who practice real medicine and science writers who were able to actually pass their physics classes?

    Truly, the arrogance of ignorance knows no bounds and it’s a good thing there are skeptics like you, Dr. Novella, who have the patience to dismantle these rants claim by claim.

  12. tl;dron 26 Feb 2010 at 5:16 pm

    “Thanks to commenter tl;dr for pointing out this video by homeopath, John Benneth. This is the best incoherent rant yet by a crank against skeptics. ”

    I had a hunch you would get a kick out of that sped.

    Well done sir.

  13. Science Momon 26 Feb 2010 at 9:15 pm

    Benneth screeds, “Have the Randis of the world ever conducted one scientific test of anything like the placebo theory and published in a peer review journal? Of course not.

    Ahem Mr. Benneth, please see http://www.ncbi.nlm.nih.gov/sites/entrez/2455869 Mr. Randi did an exquisite job of debunking the homeopathic work of Dr. Benveniste et al.

    SM

  14. Nitpickingon 26 Feb 2010 at 10:45 pm

    In all fairness, Randi did lose one of the Geller lawsuits. In Japan, he was found to have been “impolite” and assessed minimal damages.

  15. pmacgowan@gmail.comon 27 Feb 2010 at 7:11 am

    Sickem Steve … Its time this bullshit was shown up for what it is … “magic”

  16. Quackaliciouson 27 Feb 2010 at 8:40 am

    Dear Dr. Novella,
    How strange that on my own thread I no longer see any comments, but on this new thread you have grouped me in with the cranks? I believe that I have apologized for my incivility, I have made several very good points, and I made an offer that you have not accepted? As I pointed out in my multiple postings, no one questions your credentials in neurology. I rightly questioned your capacity for fair and unbiased reporting.

    I find it strange that Dr. Atwood has taken over from you in terms of discussing issues with me. Is he concerned you might admit some merit to my claims?

    As to your assertion that this has been a bad year for homeopathy, I don’t believe you’ve reported fairly. The homeopathic community has been celebrating the publication of a landmark study on the effects of homeopathic medicines on cancer apoptosis. http://www.cancerdecisions.com/content/view/414/2/lang,english/ gives a nice summary, and the study can be found here: Int J Oncol. 2010 Feb;36(2):395-403.
    Cytotoxic effects of ultra-diluted remedies on breast cancer cells.Frenkel M, Mishra BM, Sen S, Yang P, Pawlus A, Vence L, Leblanc A, Cohen L, Banerji P, Banerji P.Integrative Medicine Program-Unit 145, Department of Molecular Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030-4009, USA.

    Isn’t it puzzling how something that “shouldn’t” have any benefit keeps showing up with clinically significant outcomes? How bizarre that whole hospitals in India use homeopathy to treat disease? If this were a drug, it might be part of standard practice: minimal side-effects, high patient compliance, wide ranging application, ease of application, minimal risk of interactions, the list goes on and on. How many experimental neurological drugs have as good a clinical picture?

  17. Steven Novellaon 27 Feb 2010 at 9:45 am

    Seriously – you don’t expect me to keep track of every thread on every blog post I write, no matter how old. I’m too busy treating patients, remember.

    I often leave some threads to my readers, and they do a fine job. I have continued to monitor that thread – you have made no legit points, and your claims have all been dealt with rather deftly. Kimball is a colleague with a particular focus on naturopaths, so he took an interest in the thread.

    Keep cherry picking – no one here is impressed. Systematic reviews show no clinical effect from homeopathy. No alleged test tube effects stand up to replication – the research, in other words, is as good as ESP research.

    All you have demonstrated is your inability to read the medical literature.

    And yet you dismiss my criticisms as not being fair and unbiased – that is all too typical, and you are rightly joined to the likes of Benneth.

  18. Archangl508on 27 Feb 2010 at 11:35 am

    “The homeopathic community has been celebrating the publication of a landmark study on the effects of homeopathic medicines on cancer apoptosis.”

    For those who haven’t read the study, it’s here:

    http://scepticsbook.com/wp-content/uploads/Cytotoxic-effects-of-homeopathic-remedies-on-breast-cancer-cells-2010.pdf

    It is not at all a good quality paper. Here’s a good general critique of the paper:

    http://scepticsbook.com/2010/02/14/a-giant-leap-in-logic-from-a-piece-of-bad-science/

    Some quick points: Worst flow cytometry data I’ve ever seen published. No quantitated fluorescence microscopy. No statistics on the main viability assay and given that the solvent alone has a strong effect on viability, the statistics are definitely needed. No statistics, or even error bars, on cell cycle analysis and it’s unclear whether or not solvent alone was used for these analyses (again given that solvent alone appears to have a pretty significant effect).

    Basically, the poorness of the data doesn’t allow for any conclusions, certainly not that these compounds are affecting cell viability or cell cycle.

  19. Science Momon 27 Feb 2010 at 12:14 pm

    Isn’t it puzzling how something that “shouldn’t” have any benefit keeps showing up with clinically significant outcomes?

    What clinically significant outcomes? Do you understand what the word ‘significant’ implies? There are no data to demonstrate the efficacy of homeopathy beyond that of placebo; it really is that simple.

    How bizarre that whole hospitals in India use homeopathy to treat disease?

    Appeal to popularity or ignorance is hardly an argument. Of course those that use and peddle homeopathy are going to defend it, but evidence of effectiveness is quite another matter.

  20. RickKon 27 Feb 2010 at 1:53 pm

    How bizarre that whole hospitals in India use homeopathy to treat disease?

    You mean the same India where millions of people are absolutely certain that statues of certain gods suddenly start drinking milk, then just as suddenly stop as soon as the skeptics arrive?

    http://en.wikipedia.org/wiki/Hindu_milk_miracle

    Quack, your critical thinking skills are truly abysmal. How many reports do we see of people being either healed or harmed by witchcraft all over the world? How many people believe beyond a shadow of a doubt that the location of the planets in some obsolete picture map of the sky actually affects their lives?

    Science-based medicine is better than that. And that’s why we live longer today – not because of homeopathy, witchcraft or astrology, but because of science and critical thinking.

    But of course you’d argue against critical thinking. After all, your livelihood is entirely dependent upon the credulity of your clients.

  21. MollyNYCon 27 Feb 2010 at 4:15 pm

    “Flaming Hypocrites” would be a great name for a band.

  22. Joeon 27 Feb 2010 at 4:24 pm

    @Quackalicious on 27 Feb 2010 at 8:40 am

    First, you cited a small, poorly-controlled, un-blinded test of naturopathy. Now, you cite an in vitro test of (possibly) homeopathy (do you know what in vitro means?). You exemplify the ignorance of naturopaths with each of your posts.

  23. therlingon 27 Feb 2010 at 9:06 pm

    I wonder what Mr. Benneth would have to say if any of those that he has libeled in this video would sue him? After all, what he’s said in his video has met the three conditions for libel: identification, defamation and publication.

  24. Steven Novellaon 28 Feb 2010 at 7:41 am

    Technically it’s slander because it was spoken – libel is written. But I agree – he specifically targeted our professional reputations with the obvious purpose of causing harm. He acted with reckless disregard for the truth and malice.

    Which of course, makes him a flaming hypocrite.

  25. Doctor Evidenceon 28 Feb 2010 at 1:24 pm

    Fascinating. It seems that Mr. Benneth does not employ a highly-diluted method for criticizing skeptics. After listening to that rant, I need a drop of beer-

  26. therlingon 28 Feb 2010 at 4:32 pm

    With regards to libel law, Benneth’s rant is “publication,” given that the electronic media are considered, in terms of such things (e.g., the First Amendment), equivalent to printed media. The matter of “publication” is that it is disseminated to a large audience.

    See http://en.wikipedia.org/wiki/Libel_%28disambiguation%29

    Slander is defamation that is heard by people directly from the speaker.

    I’d say that Benneth calling people “terrorists” or “frauds” is defamation. As far as malice is concerned that’s generally a factor when the person defamed is a public official or a public figure. Based on the words and how they are spoken on the video, I’d say a reasonable person would consider them as said with malicious intent.

  27. halincohon 28 Feb 2010 at 5:54 pm

    Steven, it’s times like these that makes me glad that I’ve decided to take a more active stand against nonsense. In the past, as long as my patients followed my course of action, a course of action based on standard of care and evidence, I’ve closed my eyes and plugged my ears when patient initiated alternative medicine co-mingled with real therapy. But as I’ve become more involved with skepticism, especially science based medicine, I’ve actively educated my patients on the fallacies, foibles, and calamaties of alternative medicine when appropriate. Thank you for calling me to attention. And thank you for giving me the details in which to fight this fight as best as I possibly can.

  28. DeeTeeon 01 Mar 2010 at 5:35 am

    I just had to share…..

    When I followed the link to the Youtube video of John Benneth, I looked at the side bar on the right where it displays “Related videos”. First on the list?
    “Tortoise chasing a tomato”

  29. SteveAon 01 Mar 2010 at 7:41 am

    Therling is right to say that a defamatory YouTube statement would be regarded as libel rather than slander (though I’m not sure if this distinction would necessarily affect any judgment of the issue).

    Libel relates to any ‘publication’ whether in printed or electronic media, or other (for example a statement recorded on an acrylic record or cassette tape).

    Interestingly ‘slander’ can also apply to ‘gestures’ as well as speech. Which raises the question: If Benneth made ‘slanderous’ gestures on his YouTube video, would that count as slander, or be another form of libel?

  30. Steven Novellaon 01 Mar 2010 at 9:25 am

    Thanks for the clarification of slander vs libel. I thought it was spoken vs written. You are saying it is in person vs published. Interesting.

    Regardless – his statements were certainly defamatory and malicious, not to mention false.

  31. topstepon 01 Mar 2010 at 11:22 am

    Steven! Please, please, please organize a debate between the Rogues and whatever A-team the homeopaths can put together! Get it up on YouTube.

    There are many televised debates between atheists and religious believers, and invariably the believers end up looking very foolish indeed. I think the same thing needs to start happening in the CAM community. They need to start being taken to task on the nonsense the spout, the studies they cherry pick and the logical fallacies they rely on – all in front of a live audience who can decide for themselves who is being more intellectually rigorous.

    Will any of them be brave enough to go head to head with you guys?

  32. dwayneon 01 Mar 2010 at 12:33 pm

    I *love* that logic:

    “Dr. Novella, you have devoted too much time crafting your criticism of my statement; therefore, your criticism is false.”

  33. ChrisHon 01 Mar 2010 at 2:23 pm

    topstep:

    Steven! Please, please, please organize a debate between the Rogues and whatever A-team the homeopaths can put together! Get it up on YouTube.

    I have not checked, but I believe this debate is still online:
    My Day with the Homeopaths – Part I
    and
    My Day with the Homeopaths – Part II

  34. Quackaliciouson 01 Mar 2010 at 6:52 pm

    Dear Dr. Novella,
    It troubles me greatly that you have turned over a portion of your own blog to a person like Dr. Atwood, who has already published his prejudices.

    In examining your own career online, I note that the only medline publications that you have done personally are very small studies (6 and 13 patients respectively), but you found them of sufficient merit to publish. If a small study is unworthy of notice, then why publish it? I would not make such a claim, because small studies are the best route to larger studies and may provide other clinicians with valuable insight. But you and your readers constantly downplay small studies as irrelevant.

    In response to the “deft” replies to my comments on the previous thread, Dr. Atwood defends newspaper articles and random websites as clinical studies. I cannot even make the argument of a double standard, because there is no standard. It is your blog, and you have found sufficient time to comment extensively to other writers on the same thread.

    The bottom line for any medical treatment is its effect in clinical practice. I have a large scale study (1062 patients) done in Germany using Naturopathic methods and showing clinically significant results.

    Please take the time to think about my offer of support, as your patients may benefit.

    Forsch Komplementarmed Klass Naturheilkd. 2002 Oct;9(5):269-76.

  35. ChrisHon 01 Mar 2010 at 8:24 pm

    What are going on about? Dr. Atwood occasionally blogs on ScienceBasedMedicine, I see no post from him here (perhaps comments, but not full posts).

  36. ChrisHon 01 Mar 2010 at 8:29 pm

    Christopher Maloney:

    It troubles me greatly that you have turned over a portion of your own blog to a person like Dr. Atwood, who has already published his prejudices.

    Dr. Atwood made two comments (one was answer a question from you) on the other thread, and you call that turning over a portion?

    If it is, to you it must be very powerful in homeopathic terms!

  37. zvonkoon 01 Mar 2010 at 9:22 pm

    Dr.Novella, please read the book: “the field” from Lynne McTaggart, and you will see how homeopathy works!!

    I understand dr Novella! if he admits homeopathy works, he will have less patients :) )

  38. Science Momon 02 Mar 2010 at 7:51 am

    I understand dr Novella! if he admits homeopathy works, he will have less patients :) )</blockquote

    @zvonko, why should anyone admit to something that doesn't work? Furthermore, if homeopathy was used routinely and as a first course of 'action', I fear that physicians would be dealing with illnesses that have progressed beyond effective treatment.

    SM

  39. modoc451on 02 Mar 2010 at 8:41 am

    @zvonko:
    If Dr. Novella admits that homeopathy works, then he will be breaking his Hippocratic Oath. You know, the part about respecting the hard-won scientific gains of those physicians in whose steps he walks.

  40. modoc451on 02 Mar 2010 at 8:44 am

    @Quackalicious:

    Obviously, you’re not reading what anyone is writing. Nobody is saying that small studies are useless. What everyone is saying is that once naturopathic treatments are subjected to larger, more well designed studies, they fail to show medical benefit better than placebo. They fail every time.

  41. Watcheron 02 Mar 2010 at 10:32 am

    From the abstract of the above citation from Christopher. Emphasis mine.

    METHODS: A prospective observation study with 4 defined times of measurement (hospitalization, discharge, 3 and 6 months after the end of the inhospital stay) and an analysis of the subgroups of patients with rheumatic diseases. The data of 1026 patients of the department of naturopathy were considered, who have been treated because of rheumatic diseases, metabolic diseases, chronic-bronchial diseases and allergic discomforts from July 1, 1999 to December 13, 2000. The mean value of age was 57.3 years, the median 58.5 years. 69.4% of the patients were capable of gainful employment (17-65 years). The patients were treated with classical naturopathic methods (hydrotherapy, phytotherapy), individually adapted to the patient’s situation. Outcome parameters were quality of life (measured with the HLQ and the SF-36), mood (measured with the Bf-S), physical complaints (measured with the GBB24) and pain perception (measured with the SES) of the patient.

    I don’t have access to the full text through my institution so I can’t make a proper judgement, but, what exactly were you testing if individual care was adapted towards each patient?

  42. Science Momon 02 Mar 2010 at 11:05 am

    @Watcher, not to mention the subjectiveness of the measurements.

  43. Enzoon 02 Mar 2010 at 1:30 pm

    @Watcher.

    Article is in German, at any rate.

    I can’t tell only by reading the abstract if the naturopathic therapy was administered in addition to medical treatment. Was standard hospital therapy alone and naturopathic+standard compared? Doubtful. Seems as if they were only looking for a response to treatment. If so, there is no control group for this study. Again, I cannot tell what the entire situation is. Potential for placebo bias due to added attention given to the patient; I’m not sure if this was controlled for. Not even sure if the study was blinded. Again, can’t tell without reading the article. I’m doubtful.

    Therapy adapted toward each patient presumably means different therapies for the different subsets of conditions they were monitored…Which sounds quite broad. “Metabolic diseases” alone is an enormous field. And allergic discomforts doesn’t exactly sound like they are committing to much (6 month follow up for sniffly nose?).

    The measurement tools attempt to standardize what they presume to measure as much as possible, but I agree that they tend to give subjective results that are usually not very consistent. Still, they have their uses.

    If anyone can read German, I can share that article for additional nit picking.

  44. Watcheron 02 Mar 2010 at 3:24 pm

    Yeah, I’m hoping Christopher can maybe explain the methods a bit better. As it stands right now, I’ve shared all of these sentiments regarding it.

  45. Rupovksyon 02 Mar 2010 at 5:59 pm

    I like how he has a one star rating, and that his comments have to be approved by him. Just shows homeopaths, and ultimately quacks, have to sensor criticism. Pathetic really. Oh yeah, Benneth’s video was COMICAL! xD!

  46. zvonkoon 02 Mar 2010 at 10:17 pm

    #
    # modoc451on 02 Mar 2010 at 8:41 am

    @zvonko:
    If Dr. Novella admits that homeopathy works, then he will be breaking his Hippocratic Oath. You know, the part about respecting the hard-won scientific gains of those physicians in whose steps he walks.

    so, better to not admit something(even if it works) just to keep his hipocratic oath?? uauuu!!!!!

    try to think a little wider. don`t be like brainwashed american :) ))

  47. Quackaliciouson 03 Mar 2010 at 7:47 am

    Dear Enzo,

    I believe the comment you were trying to make was: “I can’t read German, could you please provide a translation?”

    By attacking a study you were unable to read you provide a wonderful example of the closed mind, the antithesis of scientific inquiry. At this point I feel it necessary to ask who you are, and what credentials give you the ability to dissect studies without being able to read them?

    Let us be clear, I only blog here because I wish to exonerate myself from the false charges made by Dr. Novella. He has failed the basic test of printing the truth (alterations in the text do not make it to the search engines, Dr. Novella. You continue to accuse me of something I did not do across the web.)

    In my wish to also help others, I have offered Dr. Novella a much more useful test than some laboratory experiment: provide me with ten incurable, untreatable neurologic diseases and see if I can provide some insight and treatment options from the world of alternative medicine. Dr. Novella has refused to come up with a list. I cannot but see this as a reversal of the standards of medicine: rather than seeking first to heal his patients, Dr. Novella is seeking to maintain his reputation as a skeptic.

    On this particular thread, Dr. Novella failed to mention either the study or the thousands of homeopathic supporters that met with parliament. Giving fellow skeptics biased reporting is hardly helpful to the “cause.”

    If the community of skeptics is to gain wider purchase, they need to dialogue with their opponents rather than simply deriding them whenever they turn up. As an M.D. wrote me recently, the skeptic societies have moved from the center of medical thought to take up their place on the fringe specifically because of their inability to assimilate new ideas.

  48. Watcheron 03 Mar 2010 at 8:44 am

    @ Quack

    Would you mind providing the methods section in a language we can all dissect? A few of us have brought up valid concerns of your proof of concept that seem to be present even in the abstract methods.

  49. Enzoon 03 Mar 2010 at 12:26 pm

    @Quack

    First off, my post was addressed to Watcher, and I said that the article was in German assuming he/she could not read German (because Watcher could only access the abstract).

    Second, I went out of my way to make it clear that I did not have all the facts of the article. I did what I could based on the abstract. Given the abstract, I do not think my conclusions are wrong. The concerns I expressed would usually be addressed in the abstract if they were present in the study (control groups, etc.).

    Translations of scientific literature are expensive to produce and time consuming. I didn’t expect anyone to have it handy.

    Do you read German? If so, you could address my concerns instead of questioning my qualifications (straw man). If you don’t, then you are even more guilty of what you just accused me of.

    Regardless of your reasons for starting to blog here, you have also taken stances on issues we are contentious about…So we are not going to ignore those because you are only trying to exonerate yourself.

  50. Watcheron 05 Mar 2010 at 10:24 am

    Admittedly my german is a bit rusty :)

    And were still waiting …

  51. DeeTeeon 05 Mar 2010 at 1:29 pm

    @Quack – the number of patients in the study was 1026, not 1062.
    (Irrelevant difference, but it reveals your inattention to detail).

    An abstract is a concise summary of all the key points regarding an article, and can be taken as representative of it. Sometimes abstracts are poorly written by authors, and do not accurately reflect the article, but there seems to be little room for misinterpretation here.

    This is an uncontrolled observational study and as such it totally lacks scientific rigor. Reported improvements could be influenced by several factors, most notably the placebo effect, the Hawthorne effect, and regression to the mean/natural stabalisation of chronic disease.

  52. Steven Novellaon 05 Mar 2010 at 3:00 pm

    Wow – reference a foreign language article and then criticize people for interpreting the abstract, which is all they can access in English.

    Your criticisms are not even substantive – is the abstract wrong, or is this an uncontrolled study?

    This study is clearly a pragmatic study – the purpose of which is to look at the application of proven therapies in practice – it is not to provide evidence of efficacy. So you linked to a non-efficacy study as if it were evidence of efficacy. And you wonder why we are not impressed.

    Your other comments were just incoherent. Is it really your claim that I need you to tell me what effective treatments there are for the conditions I treat? Such hubris.

    But if you want to play – let’s focus on ALS. Tell me what magical new treatments you have for ALS that I have somehow missed.

  53. Quackaliciouson 05 Mar 2010 at 10:36 pm

    Right. ALS.
    Nerve degeneration may be genetic (1/5 of cases) but predominantly unknown. Autoimmune, but I tend to keep looking because I don’t think autoimmune happens in a vacuum.

    For other readers, I’m attaching the current status of treatments for ALS to get a sense of what you deal with and other options. But I think I may have something helpful.

    Turns out your colleagues in Seattle already came across the same idea, but I don’t think you’re using it yet. It involves Clostridium difficile causing a portion of the ALS cases. I came across this idea when I was researching possible ALS support and I found a small study on stool analysis of ALS patients. About 1/3 had significant Clostridium overgrowth, but I can’t find the study on medline listed under Clostridium. I assume the Seattle neurologists must have found the same study.

    So here’s the thought: if a portion of ALS patients (peripheral onset?) are genetically susceptible to the relatively mild Clostridium difficile toxins then a stool analysis would give a possible treatment option: systemic antibiotics and the addition of Sacchromyces boulardii. Previous trials with antibiotics and ALS haven’t focused on the possibility of an antibiotic resistant organism causing the problem. I think the addition of S. boulardii is essential to provide competition to C. difficile regrowth.

    So, trash away. But maybe have a discussion with Seattle about why they have the same crazy, quacky idea I do. If you don’t want to put ALS patients through the systemic antibiotics, what about a simple trial of S. boulardii for patients? Keep patients on oral feeding and add S. boulardii with every meal. It has a good safety profile.

    I’ve got some other ideas, but I want to get this one out to you quickly. Please at least talk to Seattle about it.

    Med Hypotheses. 2005;64(6):1153-6.

    Hypothesis: a motor neuron toxin produced by a clostridial species residing in gut causes ALS.
    Longstreth WT Jr, Meschke JS, Davidson SK, Smoot LM, Smoot JC, Koepsell TD.

    Department of Neurology, School of Medicine, University of Washington, Seattle, Washington, USA. wl@u.washington.edu

    Comment in:

    Med Hypotheses. 2006;66(2):438-9.

    We hypothesize that a yet-to-be-identified motor neuron toxin produced by a clostridial species causes sporadic amyotrophic lateral sclerosis (ALS) in susceptible individuals. This clostridial species would reside undetected in the gut and chronically produce a toxin that targets the motor system, like the tetanus and botulinum toxins. After gaining access to the lower motor neuron, the toxin would be transported back to the cell body, as occurs with the tetanus toxin, and destroy the lower motor neuron – the essential feature of ALS. Again like the tetanus toxin, some of the toxin would cross to neighboring cells and to the upper motor neuron and similarly destroy these motor neurons. Weakness would relentlessly progress until not enough motor neurons remained to sustain life. If this hypothesis were correct, treatment with appropriate antibiotics or antitoxins might slow or halt progression of disease, and immunization might prevent disease.

    PMID: 15823706

    Ann Neurol. 2009 Jan;65 Suppl 1:S3-9.

    Current hypotheses for the underlying biology of amyotrophic lateral sclerosis.
    Rothstein JD.

    Department of Neurology and Neuroscience, Brain Science Institute, Johns Hopkins University, Baltimore, MD 21287, USA. jrothstein@jhmi.edu

    The mechanisms involved in selective motor neuron degeneration in amyotrophic lateral sclerosis remain unknown more than 135 years after the disease was first described. Although most cases have no known cause, mutations in the gene encoding Cu/Zn superoxide dismutase (SOD1) have been implicated in a fraction of familial cases of the disease. Transgenic mouse models with mutations in the SOD1 gene and other ALS genes develop pathology reminiscent of the disorder, including progressive death of motor neurons, and have provided insight into the pathogenesis of the disease but have consistently failed to predict therapeutic efficacy in humans. However, emerging research has demonstrated that mutations and pathology associated with the TDP-43 gene and protein may be more common than SOD1 mutations in familial and sporadic ALS. Putative mechanisms of toxicity targeting motor neurons include oxidative damage, accumulation of intracellular aggregates, mitochondrial dysfunction, defects in axonal transport, growth factor deficiency, aberrant RNA metabolism, glial cell pathology, and glutamate excitotoxicity. Convergence of these pathways is likely to mediate disease onset and progression.

    PMID: 19191304

    Neuropsychiatr Dis Treat. 2009;5:577-95. Epub 2009 Nov 16.

    Current and emerging treatments for amyotrophic lateral sclerosis.
    Zoccolella S, Santamato A, Lamberti P.

    Azienda Ospedaliero-Universitaria Ospedali Riuniti, Department of Medical and Neurological Sciences, Clinic of Nervous System Diseases, University of Foggia, Italy;

    BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a relatively rare neurodegenerative disorder of both upper and lower motoneurons. Currently, the management of ALS is essentially symptoms-based, and riluzole, an antiglutamatergic agent, is the only drug for the treatment of ALS approved by the food and drug administration. OBJECTIVE: We reviewed current literature concerning emerging treatments for amyotrophic lateral sclerosis. METHODS: A Medline literature search was performed to identify all studies on ALS treatment published from January 1st, 1986 through August 31st, 2009. We selected papers concerning only disease-modifying therapy. RESULTS: Forty-eight compounds were identified and reviewed in this study. CONCLUSIONS: Riluzole is the only compound that demonstrated a beneficial effect on ALS patients, but with only modest increase in survival. Although several drugs showed effective results in the animal models for ALS, none of them significantly prolonged survival or improved quality of life of ALS patients. Several factors have been implicated in explaining the predominantly negative results of numerous randomized clinical trials in ALS, including methodological problems in the use of animal-drug screening, the lack of assessment of pharmacokinetic profile of the drugs, and methodological pitfalls of clinical trials in ALS patients.

    PMID: 19966906

    Cochrane Database Syst Rev. 2007 Jan 24;(1):CD001447.

    Riluzole for amyotrophic lateral sclerosis (ALS)/motor neuron disease (MND).
    Miller RG, Mitchell JD, Lyon M, Moore DH.

    California Pacific Medical Center, Department of Neurosciences, 2324 Sacramento Street, Suite 150, San Francisco, California 94115, USA. millerrx@sutterhealth.org

    Update of:

    Cochrane Database Syst Rev. 2002;(2):CD001447.

    BACKGROUND: Riluzole has been approved for treatment of patients with amyotrophic lateral sclerosis in most countries. Questions persist about its clinical utility because of high cost and modest efficacy. OBJECTIVES: To examine the efficacy of riluzole in prolonging survival, and in delaying the use of surrogates (tracheostomy and mechanical ventilation) to sustain survival. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Register for randomized trials in December 2004 and made enquiries of authors of trials, Aventis (manufacturer of riluzole) and other experts in the field. We searched MEDLINE (January 1966 to August 25 2006) and EMBASE (January 1980 to September 30th 2006). SELECTION CRITERIA: Types of studies: randomized trials. Types of participants: adults with a diagnosis of amyotrophic lateral sclerosis. Types of interventions: treatment with riluzole or placebo. Types of outcome measures: Primary: pooled hazard ratio of tracheostomy-free survival over all time points with riluzole 100 mg. Secondary: per cent mortality with riluzole 50, 100 and 200 mg; neurologic function, muscle strength and adverse events. DATA COLLECTION AND ANALYSIS: We identified four eligible randomized trials. MAIN RESULTS: The four trials examining tracheostomy-free survival included a total of 974 riluzole treated patients and 503 placebo treated patients. The methodological quality was acceptable and three trials were easily comparable, although one trial included older patients in more advanced stages of amyotrophic lateral sclerosis and one had multiple primary endpoints. Riluzole 100 mg per day provided a benefit for the homogeneous group of patients in the first two trials (P value = 0.042, hazard ratio 0.80, 95% confidence interval 0.64 to 0.99) and there was no evidence of heterogeneity (P value = 0.33). When the third trial (which included older and more seriously affected patients) was added, there was evidence of heterogeneity (P value < 0.0001) and the random effects model, which takes this into account, resulted in the overall treatment effect estimate falling just short of significance (P value = 0.056, hazard ratio 0.84, 95% confidence interval 0.70 to 1.01). This represented a 9% gain in the probability of surviving one year (57% in the placebo and 66% in the riluzole group). There was a small beneficial effect on both bulbar and limb function, but not on muscle strength. A threefold increase in serum alanine transferase was more frequent in riluzole treated patients than controls (weighted mean difference 2.62, 95% confidence interval 1.59 to 4.31). AUTHORS' CONCLUSIONS: Riluzole 100 mg daily is reasonably safe and probably prolongs median survival by about two to three months in patients with amyotrophic lateral sclerosis.

    PMID: 17253460

    Clin Infect Dis. 2000 Oct;31(4):1012-7. Epub 2000 Oct 25.

    The search for a better treatment for recurrent Clostridium difficile disease: use of high-dose vancomycin combined with Saccharomyces boulardii.
    Surawicz CM, McFarland LV, Greenberg RN, Rubin M, Fekety R, Mulligan ME, Garcia RJ, Brandmarker S, Bowen K, Borjal D, Elmer GW.

    Division of Gastroenterology, Department of Medicine, University of Washoington, Seattle, WA USA. surawicz@u.washington.edu

    Recurrent Clostridium difficile disease (CDD) is a difficult clinical problem because antibiotic therapy often does not prevent further recurrences. In a previous study, the biotherapeutic agent Saccharomyces boulardii was used in combination with standard antibiotics and was found to be effective in reducing subsequent recurrences of CDD. In an effort to further refine a standard regimen, we tested patients receiving a regimen of a standard antibiotic for 10 days and then added either S. boulardii (1 g/day for 28 days) or placebo. A significant decrease in recurrences was observed only in patients treated with high-dose vancomycin (2 g/day) and S. boulardii (16.7%), compared with those who received high-dose vancomycin and placebo (50%; P=.05). No serious adverse reactions were observed in these patients. Comparison of data from this trial with data from previous studies indicates that recurrent CDD may respond to a short course of high-dose vancomycin or to longer courses of low-dose vancomycin when either is combined with S. boulardii.

    PMID: 11049785

    Can J Gastroenterol. 2009 Dec;23(12):817-21.

    Prevention of Clostridium difficile infection with Saccharomyces boulardii: a systematic review.
    Tung JM, Dolovich LR, Lee CH.

    Department of Pharmacy, St. Joseph's Healthcare, Hamilton, Ontario.

    BACKGROUND: Clostridium difficile is a major cause of antibiotic-associated diarrhea within the hospital setting. The yeast Saccharomyces boulardii has been found to have some effect in reducing the risk of C difficile infection (CDI); however, its role in preventive therapy has yet to be firmly established. OBJECTIVE: To review the effectiveness of S boulardii in the prevention of primary and recurrent CDI. Benefit was defined as a reduction of diarrhea associated with C difficile. Risk was defined as any adverse effects of S boulardii. METHODS: A literature search in MEDLINE, EMBASE, CINAHL and the Cochrane Library was performed. Included studies were English language, randomized, double-blind placebo controlled trials evaluating S boulardii in CDI prevention. RESULTS: Four studies were reviewed. Two studies investigated the prevention of recurrence in populations that were experiencing CDI at baseline. One trial showed a reduction of relapses in patients experiencing recurrent CDI (RR=0.53; P<0.05). The other demonstrated a trend toward reduction of CDI relapse in the recurrent treatment group of patients receiving high-dose vancomycin (RR=0.33; P=0.05). Two other studies examined primary prevention of CDI in populations that had been recently prescribed antibiotics. These studies lacked the power to detect statistically significant differences. Patients on treatment experienced increased risk for thirst and constipation. CONCLUSION: S boulardii seems to be well tolerated and may be effective for secondary prevention in some specific patient populations with particular concurrent antibiotic treatment. Its role in primary prevention is poorly defined and more research is required before changes in practice are recommended.

    PMID: 20011734

    Neurology. 2009 Oct 13;73(15):1218-26.

    Practice parameter update: The care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.
    Miller RG, Jackson CE, Kasarskis EJ, England JD, Forshew D, Johnston W, Kalra S, Katz JS, Mitsumoto H, Rosenfeld J, Shoesmith C, Strong MJ, Woolley SC; Quality Standards Subcommittee of the American Academy of Neurology.

    Department of Neurology, California Pacific Medical Center, San Francisco, California, USA.

    Erratum in:

    Neurology. 2009 Dec 15;73(24):2134.
    Neurology. 2010 Mar 2;74(9):781.

    OBJECTIVE: To systematically review evidence bearing on the management of patients with amyotrophic lateral sclerosis (ALS). METHODS: The authors analyzed studies from 1998 to 2007 to update the 1999 practice parameter. Topics covered in this section include slowing disease progression, nutrition, and respiratory management for patients with ALS. RESULTS: The authors identified 8 Class I studies, 5 Class II studies, and 43 Class III studies in ALS. Important treatments are available for patients with ALS that are underutilized. Noninvasive ventilation (NIV), percutaneous endoscopic gastrostomy (PEG), and riluzole are particularly important and have the best evidence. More studies are needed to examine the best tests of respiratory function in ALS, as well as the optimal time for starting PEG, the impact of PEG on quality of life and survival, and the effect of vitamins and supplements on ALS. Recommendations: Riluzole should be offered to slow disease progression (Level A). PEG should be considered to stabilize weight and to prolong survival in patients with ALS (Level B). NIV should be considered to treat respiratory insufficiency in order to lengthen survival (Level B) and to slow the decline of forced vital capacity (Level B). NIV may be considered to improve quality of life (Level C) [corrected].Early initiation of NIV may increase compliance (Level C), and insufflation/exsufflation may be considered to help clear secretions (Level C).

    PMID: 19822872

  54. Steven Novellaon 08 Mar 2010 at 8:53 am

    Christopher – I am involved with the ALS research community, so this is an area where I am particularly up to date. The information you provide is not new or useful.

    There are many speculations about possible causes of ALS, and perhaps several will turn out to be correct as ALS is a syndrome made up of several, perhaps many, diseases. Many options are being explored, and generally those of us who treat ALS use the one proven therapy (riluzole) while adding 2-3 experimental treatments either as part of a clinical trial (preferable) or as compassionate use. We use treatments with some rationale and positive evidence and at least evidence of safety, and with full informed consent. But we also study them, and if they fail in clinical trials we stop using them.

    The clostridium paper was published 5 years ago (and not in a reputable journal) with no follow up research that I can find. This is very problematic, and may reflect the fact that it is a dead end. In any case – this is a naked hypothesis with nothing close to the data we would need to use as a compassionate treatment. Maybe someone is working on a clinical trial somewhere, but if so I have not heard (there is no buzz), but I will ask at the next meeting.

    Antibiotic and anti-inflammatory approaches to ALS have already been tried and failed in the past. The only antibiotic recently studied for ALS is minocycline, but that was due to its pharmacological non-antibiotic properties. In any case – patients did worse on minocycline than placebo – it had a net negative effect. Which is another cautionary tale against prematurely using experimental treatments – they can do harm, even when the animal and preliminary data looks positive (the same thing happened with topiramate).

    The bottom line is that you have nothing new to add or any useful treatments beyond what is already being used by neurologists or being studied. Naturopathy has nothing unique to offer.

  55. Quackaliciouson 11 Mar 2010 at 9:37 pm

    Dear Dr. Novella,
    How can you conclude a negative? First you “moderate” my response, then you ignore my plea that you contact the Seattle neurology department (which I am attempting to do on your behalf to see if they have unpublished data), and finally you conclude that I have nothing to offer when I’m only starting.

    Please unmoderate my responses unless you have decided to moderate all blog responses. It made me very concerned that you had simply blocked my response and had no intention of engaging in a dialogue. After days of delay, I had given up on you. I just checked back for the first time today.

    Before you read further, do you know that over half your patients are likely to be using alternative medicine? How open are you about that discussion?

    Do you really expect me to produce high quality studies that you would even consider from the Naturopathic journals? The information we both can use is readily available on medline. But the question is whether or not ALS patients are currently receiving the following:

    Megadoses of vitamin E- good safety profile and short term benefits, no long term benefits or long term side effect picture.

    Antibody screening for celiac disease- several reports of celiac mimicking ALS

    Any of the following supportive therapies: creatine, folic acid, alpha lipoic acid, lyophilized red wine, coenzyme Q10, epigallocatechin gallate, Ginkgo biloba, or melatonin?

    If you’re doing all of the above, great, but if not, please tell me which ones aren’t in current use. I have attached the creatine information. Surely you are supplying patients already?

    J Neurol Sci. 2001 Oct 15;191(1-2):151-4.
    The use of alternative medicine by patients with amyotrophic lateral sclerosis.
    Wasner M, Klier H, Borasio GD.
    Department of Neurology and Interdisciplinary Palliative Care Unit, Ludwig Maximilians University, University Hospital, Grosshadern, D-81366, Munich, Germany.
    The use of complementary and alternative medicine (CAM) is increasing in all industrialised countries, especially in patients with chronic and incurable diseases. However, no data are available on the use of CAM by patients with amyotrophic lateral sclerosis (ALS). The German Association for Neuromuscular Diseases (DGM) mailed out a questionnaire on CAM to 350 ALS patients, 171 of whom completed and returned the survey (response rate 49%). The use of CAM was reported by 92 patients (54%). There were no significant demographic differences between users and nonusers. The patients used 73 different methods or substances; some tried up to 11 different treatments. The most widely used methods were: acupuncture (47%), homeopathy (40%), naturopathy (24%) and esoteric treatments (20%). The lower the patients’ expectations from CAM, the better was the subjectively perceived effect. In most cases (60%), alternative treatments were performed by a physician. Patients spent on average 4000 (approximately US$4500) on CAM, generally without reimbursement. CAM is most often used in addition to conventional treatments and may be part of the patients’ coping strategy. Open communication between patients and physicians is essential to warn the patients of medically or financially hazardous treatments. Future research should look at the possible palliative effects of CAM on symptom control and quality of life of patients and families.
    PMID: 11677007
    J Herb Pharmacother. 2005;5(3):23-31.
    The use of herbal supplements and alternative therapies by patients with amyotrophic lateral sclerosis (ALS).
    Vardeny O, Bromberg MB.
    University of Winconsin-Madison School of Pharmacy, Madison, WI, USA.
    OBJECTIVES: Alternative medicine is widely used in all industrialized Western countries. However, there are no published data regarding the use of botanical or herbal supplements in Ayotrophic Lateral Sclerosis (ALS). Our goal was to survey patients with ALS in our clinic regarding their use of herbal supplements, vitamins, and other therapies or compounds. METHODS: Study subjects participated in the University of Utah Motor Neuron Disease Clinic. An anonymous questionnaire was mailed and designed to assess the following: disease duration and onset site, use of riluzole, alternative therapies (i.e., homeopathy, acupuncture), vitamins, herbal supplements, and other compounds, sources of information about herbal supplements or vitamins, estimated monthly expenditure on vitamins, herbal supplements, and other compounds, and expectations from herbal supplements/vitamins. RESULTS: Fifty-three subjects participated; mean age 60 years old (range 39-83 years), 15 females, 38 males. Symptom duration averaged 1-5 years (45 limb onset, 8 bulbar onset). Thirty-two percent took riluzole and 42% used herbal supplements, 70% took vitamins, and 21% used other compounds (prescription medications used for ALS, but not indicated for ALS). Fifteen percent used alternative therapies. Information about herbal medicines was obtained mostly via friends and relatives (n = 17), a physician (n = 20), and the Internet (n = 9). Our patients selected improvement of general well being and slowing of disease progression most often as reasons for using these therapies. CONCLUSIONS: Our study demonstrated that almost half of patients surveyed utilized herbals supplements, and two thirds of ALS study subjects took vitamins. Twenty-one percent used unproven prescription drugs, and 15% used other alternative therapies.
    PMID: 16520295
    Amyotroph Lateral Scler Other Motor Neuron Disord. 2001 Mar;2(1):9-18.
    A double-blind, placebo-controlled randomized clinical trial of alpha-tocopherol (vitamin E) in the treatment of amyotrophic lateral sclerosis. ALS riluzole-tocopherol Study Group.
    Desnuelle C, Dib M, Garrel C, Favier A.
    Service Médecine Physique et de Réadaptation, Maladies Neuromusculaires, CHU de Nice Hĵpital, France. desnuelle.c@chu-nice.fr
    INTRODUCTION: Increasing evidence suggests that oxidative stress may be involved in the pathogenesis of amyotrophic lateral sclerosis (ALS). The antioxidant vitamin E (alpha-tocopherol) has been shown to slow down the onset and progression of paralysis in transgenic mice expressing a mutation in superoxide dismutase found in certain forms of familial ALS. The current study was designed to determine whether alpha-tocopherol (500 mg b.i.d.) may be efficacious in the treatment of ALS. METHODS: Two hundred and eighty-nine patients with ALS of less than 5 years duration, treated with riluzole, were enrolled in this study, and were randomly assigned to receive either alpha-tocopherol or placebo daily for one year. The primary outcome measure was the rate of deterioration of function assessed by the modified Norris limb scale. Patients were assessed at entry, and every 3 months thereafter during the study period. Survival was also recorded. Biochemical markers of oxidative stress were measured in a subset of patients on entry and after 3 months of treatment. RESULTS: After 12 months of treatment, alpha-tocopherol had no effect on the primary outcome measure. Survival was not influenced by treatment. Among secondary outcome measures, patients given alpha-tocopherol were less likely to progress from the milder state A to the more severe state B (P=0.046) of the ALS Health State scale. After 3 months treatment, analysis of oxidative stress markers showed an increase in glutathione peroxidase activity in plasma (P = 0.0389) and a decrease in plasma levels of thiobarbituric acid reactive species (P = 0.0055) in the group of patients given alpha-tocopherol in combination with riluzole. CONCLUSION: Although alpha-tocopherol did not appear to affect the survival and motor function in ALS, patients receiving riluzole plus alpha-tocopherol remained longer in the milder states of the ALS Health State scale and showed, after 3 months, changes in biochemical markers of oxidative stress. Further studies are required to confirm the greater sensitivity of the ALS Health State scale over other clinical endpoints.
    PMID: 11465936
    J Neural Transm. 2005 May;112(5):649-60. Epub 2004 Oct 27.
    High dose vitamin E therapy in amyotrophic lateral sclerosis as add-on therapy to riluzole: results of a placebo-controlled double-blind study.
    Graf M, Ecker D, Horowski R, Kramer B, Riederer P, Gerlach M, Hager C, Ludolph AC, Becker G, Osterhage J, Jost WH, Schrank B, Stein C, Kostopulos P, Lubik S, Wekwerth K, Dengler R, Troeger M, Wuerz A, Hoge A, Schrader C, Schimke N, Krampfl K, Petri S, Zierz S, Eger K, Neudecker S, Traufeller K, Sievert M, Neundörfer B, Hecht M; German vitamin E/ALS Study Group.
    michael.graf@psl.ap-hop-paris.fr
    Increasing evidence has suggested that oxidative stress may be involved in the pathogenesis of amyotrophic lateral sclerosis (ALS). The antioxidant vitamin E (alpha-tocopherol) has been shown to slow down the onset and progression of the paralysis in transgenic mice expressing a mutation in the superoxide dismutase gene found in certain forms of familial ALS. The current study, a double blind, placebo-controlled, randomised, stratified, parallel-group clinical trial, was designed to determine whether vitamin E (5000 mg per day) may be efficacious in slowing down disease progression when added to riluzole. METHODS: 160 patients in 6 German centres with either probable or definite ALS (according to the El Escorial Criteria) and a disease duration of less than 5 years, treated with riluzole, were included in this study and were randomly assigned to receive either alpha-tocopherol (5000 mg per day) or placebo for 18 months. The Primary outcome measure was survival, calculating time to death, tracheostomy or permanent assisted ventilation, according to the WFN-Criteria of clinical trials. Secondary outcome measures were the rate of deterioration of function assessed by the modified Norris limb and bulbar scales, manual muscle testing (BMRC), spasticity scale, ventilatory function and the Sickness Impact Profile (SIP ALS/19). Patients were assessed at entry and every 4 months thereafter during the study period until month 16 and at a final visit at month 18. Vitamin E samples were taken for compliance check and Quality Control of the trial. For Safety, a physical examination was performed at baseline and then every visit until the treatment discontinuation at month 18. Height and weight were recorded at baseline and weight alone at the follow-up visits. A neurological examination as well as vital signs (heart rate and blood pressure), an ECG and VEP’s were recorded at each visit. Furthermore, spontaneously reported adverse experiences and serious adverse events were documented and standard laboratory tests including liver function tests performed. For Statistical Analysis, the population to be considered for the primary outcome measure was an “intent-to-treat” (ITT) population which included all randomised patients who had received at least one treatment dose (n = 160 patients). For the secondary outcome measures, a two way analysis of variance was performed on a patient population that included all randomised patients who had at least one assessment after inclusion. RESULTS: Concerning the primary endpoint, no significant difference between placebo and treatment group could be detected either with the stratified Logrank or the Wilcoxon test. The functional assessments showed a marginal trend in favour of vitamin E, without reaching significance. CONCLUSION: Neither the primary nor the secondary outcome measures could determine whether a megadose of vitamin E is efficacious in slowing disease progression in ALS as an add-on therapy to riluzol. Larger or longer studies might be needed. However, administration of this megadose does not seem to have any significant side effects in this patient population.
    PMID: 15517433
    AJNR Am J Neuroradiol. 2009 Nov 12. [Epub ahead of print]
    White Matter Lesions Suggestive of Amyotrophic Lateral Sclerosis Attributed to Celiac Disease.
    Brown KJ, Jewells V, Herfarth H, Castillo M.
    Department of Radiology and Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina.
    SUMMARY: CD is an autoimmune-mediated disorder of the gastrointestinal tract. Initial symptom presentation is variable and can include neurologic manifestations that may comprise ataxia, neuropathy, dizziness, epilepsy, and cortical calcifications rather than gastrointestinal-hindering diagnosis and management. We present a case of a young man with progressive neurologic symptoms and brain MR imaging findings worrisome for ALS. During the diagnostic work-up, endomysium antibodies were discovered, and CD was confirmed by upper gastrointestinal endoscopy with duodenal biopsies. MR imaging findings suggestive of ALS improved after gluten-free diet institution.
    PMID: 19910450
    Nat Clin Pract Neurol. 2007 Oct;3(10):581-4.
    A case of celiac disease mimicking amyotrophic lateral sclerosis.
    Turner MR, Chohan G, Quaghebeur G, Greenhall RC, Hadjivassiliou M, Talbot K.
    Department of Neurology, John Radcliffe Hospital, Oxford, UK.
    BACKGROUND: A 44-year-old male presented to a general neurology clinic with a 6-month history of progressive right-sided spastic hemiparesis without sensory symptoms or signs. The thigh muscle in the affected leg showed signs of wasting. The patient had a remote family history of celiac disease. INVESTIGATIONS: Neurological examination, neurophysiological studies, brain MRI scan, routine blood tests, duodenal biopsy, cerebrospinal fluid analysis including polymerase chain reaction test for JC virus DNA, serological testing for HIV and for the presence of serum antibodies to endomysium, gliadin and tissue transglutaminase. DIAGNOSIS: Celiac disease with neurological involvement, mimicking amyotrophic lateral sclerosis. MANAGEMENT: Strict gluten-free diet.
    PMID: 17914346
    Clin Nutr. 2009 Dec;28(6):604-17. Epub 2009 Sep 25.

    Nutritional and exercise-based interventions in the treatment of amyotrophic lateral sclerosis.
    Patel BP, Hamadeh MJ.
    School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada M3J 1P3.
    BACKGROUND & AIMS: Disease pathogenesis in amyotrophic lateral sclerosis (ALS) involves a number of interconnected mechanisms all resulting in the rapid deterioration of motor neurons. The main mechanisms include enhanced free radical production, protein misfolding, aberrant protein aggregation, excitotoxicity, mitochondrial dysfunction, neuroinflammation and apoptosis. The aim of this review is to assess the efficacy of using nutrition- and exercise-related interventions to improve disease outcomes in ALS. METHODS: Studies involving nutrition or exercise in human and animal models of ALS were reviewed. RESULTS: Treatments conducted in animal models of ALS have not consistently translated into beneficial results in clinical trials due to poor design, lack of power and short study duration, as well as differences in the genetic backgrounds, treatment dosages and disease pathology between animals and humans. However, vitamin E, folic acid, alpha lipoic acid, lyophilized red wine, coenzyme Q10, epigallocatechin gallate, Ginkgo biloba, melatonin, Cu chelators, and regular low and moderate intensity exercise, as well as treatments with catalase and l-carnitine, hold promise to mitigating the effects of ALS, whereas caloric restriction, malnutrition and high-intensity exercise are contraindicated in this disease model. CONCLUSIONS: Improved nutritional status is of utmost importance in mitigating the detrimental effects of ALS.
    PMID: 19782443
    CNS Drugs. 2004;18(14):967-80.
    The role of creatine in the management of amyotrophic lateral sclerosis and other neurodegenerative disorders.
    Ellis AC, Rosenfeld J.
    Carolinas Neuromuscular/ALS Center, Charlotte, North Carolina 28203, USA. amy.ellis@carolinahealthcare.org
    Creatine is consumed in the diet and endogenously synthesised in the body. Over the past decade, the ergogenic benefits of synthetic creatine monohydrate have made it a popular dietary supplement, particularly among athletes. The anabolic properties of creatine also offer hope for the treatment of diseases characterised by weakness and muscle atrophy. Moreover, because of its cellular mechanisms of action, creatine offers potential benefits for diseases involving mitochondrial dysfunction. Recent data also support the hypothesis that creatine may have a neuroprotective effect. Amyotrophic lateral sclerosis (ALS) is characterised by progressive degeneration of motor neurons, resulting in weakening and atrophy of skeletal muscles. In patients with this condition, creatine offers potential benefits in terms of facilitating residual muscle contractility as well as improving neuronal function. It may also help stabilise mitochondrial dysfunction, which plays a key role in the pathogenesis of ALS. Indeed, the likely multifactorial aetiology of ALS means the combined pharmacodynamic properties of creatine offer promise for the treatment of this condition. Evidence from available animal models of ALS supports the utility of treatment with creatine in this setting. Limited data available in other neuromuscular and neurodegenerative diseases further support the potential benefit of creatine monohydrate in ALS. However, few randomised, controlled trials have been conducted. To date, two clinical trials of creatine monohydrate in ALS have been completed without demonstration of significant improvements in overall survival or a composite measure of muscle strength. These trials have also posed unanswered questions about the optimal dosage of creatine and its beneficial effects on muscle fatigue, a measure distinct from muscle strength. A large, multicentre, clinical trial is currently underway to further investigate the efficacy of creatine monohydrate in ALS and address these unresolved issues. Evidence to date shows that creatine supplementation has a good safety profile and is well tolerated by ALS patients. The purpose of this article is to provide a short, balanced review of the literature concerning creatine monohydrate in the treatment of ALS and related neurodegenerative diseases. The pharmacokinetics and rationale for the use of creatine are described along with available evidence from animal models and clinical trials for ALS and related neurodegenerative or neuromuscular diseases.
    PMID: 15584767
    Amyotroph Lateral Scler. 2008 Oct;9(5):266-72.
    Creatine monohydrate in ALS: effects on strength, fatigue, respiratory status and ALSFRS.
    Rosenfeld J, King RM, Jackson CE, Bedlack RS, Barohn RJ, Dick A, Phillips LH, Chapin J, Gelinas DF, Lou JS.
    The Carolinas Neuromuscular/ALS Center, Charlotte North Carolina, Carolinas Medical Center, USA.
    Our objective was to determine the effect of creatine monohydrate on disease progression in patients with amyotrophic lateral sclerosis (ALS). One hundred and seven patients with the diagnosis of probable or definite ALS, of less than five years duration from symptom onset, were randomized to either treatment with daily creatine monohydrate (5 g/d) or placebo. In this multicenter, double-blinded study we followed changes in disease progression: using quantitative measures of strength via maximal isometric voluntary contraction, forced vital capacity, ALSFRS, quality of life, fatigue and survival. Patients were followed for nine months. The results showed that creatine monohydrate did not significantly improve motor, respiratory or functional capacity in this patient population. The drug was well tolerated and the study groups well balanced, especially considering the absence of forced vital capacity criteria for entrance into the study. There was a trend toward improved survival in patients taking daily creatine monohydrate and this was identical to the trend seen in another recently published report of creatine in ALS patients 1. In conclusion, creatine monohydrate (5 g/d) did not have an obvious benefit on the multiple markers of disease progression measured over nine months. We measured fatigue during isometric contraction and found no significant improvement despite anecdotal patient reports prior to and during the study. The trend toward improved survival was also found in another recently completed blinded trial using creatine monohydrate. Further investigation on the possible survival benefit of creatine in this patient population is ongoing.
    PMID: 18608103

  56. RickKon 11 Mar 2010 at 10:36 pm

    Christopher – pick a treatment and stick with it, please. You really are not advancing medical thinking by posting studies that conclude: “Improved nutritional status is of utmost importance in mitigating the detrimental effects of ALS.”

    And, your collection of studies show another trend – the bigger and better the study, the weaker the effect. That’s a classic characteristic of useless treatments.

    So which are you advocating for ALS? Which do you use for your ALS patients?
    Creatine monohydrate?
    Vitamin E?
    Folic acid?
    Alpha lipoic acid?
    Lyophilized red wine?
    Coenzyme Q10?
    Epigallocatechin gallate?
    Ginkgo biloba?
    Melatonin?
    Cu chelators?

    Or are you just advocating ANY substance that didn’t come from a pharmacist?

  57. Quackaliciouson 13 Mar 2010 at 12:18 pm

    Dear RickK,

    I tried to interest Dr. Novella in pursuing a possible cause, but he denies any possibility of effect without taking any investigatory steps. I contacted the Seattle neurologists, but no one has followed up on their hypothesis. Dr. Novella is ideally suited to pursue studies in this area. His credentials as a skeptic make any possibility of bias on his part a non-issue, and he has both the staff and the expertise to do some real good here.

    Given Dr. Novella’s dismissal of any possible bacterial link, I’ve moved on nutritional supplements as support for ALS patients. Given the short term data on Vitamin E and the study on creatine, I would think a short three month trial combining the two would be useful. If it is negative, it would refute the short term outcomes of the German study, and might convince patients not to experiment personally with vitamin megadoses.

    As I point out, over half of Dr. Novella’s ALS patients are likely to be using some form of alternative medicine so engaging in this sort of study would only involve organizing those who are already experimenting on their own.

    My point in bringing up the range of nutritional supplements is that a number of things considered “alternative” have some data to support their use in ALS. We are talking about a disease process with a miserable outcome and a minimally effective drug protocol. I am truly interested if Dr. Novella is using any of the supplements in clinical practice, but I suspect that he is dismissive of any supplementation.

    If Dr. Novella is consistently discouraging patients to try alternatives, and those patients are still using those alternatives without his knowledge, then the situation is not optimal. A much more functional doctor/patient relationship would be for Dr. Novella to engage in trials, so that he can say: “we tried that, but it doesn’t help.” As a skeptic, Dr. Novella can combine his hatred for quackery with his love of neurology and serve all of us by providing definitive data.

  58. Biteyon 13 Mar 2010 at 1:21 pm

    Chris, do you really operate this site-

    http://www.maloneymedical.com/

    For a second I thought it was TimeCube related (http://timecube.com/), due to the haphazard HTML, the copypasta wall-of-texts and bizarre linguistic constructions.

    And then as looked closer at it, I noticed the smoothing sunsets, emotional appeals and existentialist questions. Are you a medical doctor or attempting to start a new-age eastern religion?

  59. Quackaliciouson 18 Mar 2010 at 9:59 pm

    Dear Bitey,

    How marvelously clever of you to attack the construction of my website when you cannot think of anything to add to the discussion at hand. I suggest that you take a moment to read the thread and perhaps add something constructive.

    But if you’d like, you can be the first “Maloneyite” and make up your own religion around my website. Have fun, and be sure to wear a funny hat.

  60. studio34on 19 Mar 2010 at 5:54 pm

    You’ve all clearly missed the point. Homeopathy just works. See for yourselves how well it is applied in the ER:

    http://www.youtube.com/watch?v=HMGIbOGu8q0&amp;

    S

  61. [...] here. (Steve’s deconstruction of Benneth’s nonsense brought responses calling him a hypocrite, a Nazi or a “slave [...]

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