The Cleveland Clinic Foundation: Mixing cow pie with apple pie in pediatrics

oracknows — Wed, 27 Feb 2013 08:30:16 +0000

Thanks to a winter storm that dumped a heapin' helpin' of heavy wet snow on us last night, we lost power before this post even got going. However, I did have a bit of time this morning to finish it up as a quickie (by my standards) before my laptop battery indicator started expressing its displeasure. Since it's a topic that doesn't really necessitate a long post anyway, it's a perfect fit for today, and I'll just put off what I was going to write about today until tomorrow. Or the day after if nothing else comes up between now and then that interests me more. You see, the power company is currently giving an estimate of late tonight for getting our power back on, and I can't blog at work. If that happens and we remain without power tonight, I'm afraid there will likely be a rerun tomorrow. True, it won't be the end of the world, but it will be annoying, as I think I've been on a roll lately. Sadly, though, nature (and our power company) do not respect such things. Stay tuned. In the meantime, let's take a brief look at something a reader sent me that is emblematic of what's wrong with academic medicine.

Regular readers know that I did my surgery residency at University Hospitals of Cleveland (i.e., Case Western Reserve University), and if you didn't know you do now. Of course, unfortunately, of late I've been very embarrassed by my surgical alma mater's whole-hearted embrace of woo (described here), back in the day there used to be a fierce rivalry between UH and its wealthier, tonier competitor just up Carnegie Avenue, The Cleveland Clinic. Now, if UH has embraced quackademic medicine recently, even going so far as to host a conference on "integrative" oncology. That's nothing, however, compared to the CCF, which has had a huge head start in "integrating" quackery with real medicine to produce a toxic brew of quackademic medicine.

Not too long ago, someone sent me a link to a webpage on the CCF site that was depressing to behold called Acupuncture for Kids: A surprisingly effective choice. I wanted to say that it would be a surprise if it had any effect beyond placebo at all, but apparently that's not what the CCF means. Sadly, that doesn't stop the article from going straight to woo:

Acupuncture has surprising advantages for kids with health problems. One of the biggest? No side effects. “A lot of kids are medication-sensitive, and acupuncture doesn’t have the side effects of medication,” explains Cleveland Clinic Children’s Hospital physical medicine and rehabilitation specialist Benjamin Katholi, MD.
Another advantage is fewer doctor visits. “We can address multiple symptoms in a single treatment just by different point selection,” says Dr. Katholi.

Oh really? Acupuncture results in fewer doctor visits? Dr. Katholi bases this claim on...what evidence? None. No evidence is listed on the CCF web page, just Dr. Katholi's burbling about how great acupuncture is and how it can be used for the following conditions:

Sleep problems
Anxiety
Fatigue
Headaches
Reflux, nausea and stomach pain
Bone and joint pain
ADHD
Asthma and allergies
Bedwetting
Drooling

As I frequently ask: Is there anything acupuncture isn't good for? Apparently there is, according to Dr. Katholi:

Acupuncture doesn’t replace traditional medical treatment, says Dr. Katholi. “Acupuncture can’t treat everything; if you have diabetes, you still need insulin. If you have seizures, you still need epilepsy medications. So there’s a place for both.” -

Imagine my relief.

Of course, this is yet another example of the fallacy of "integrative" medicine, in which quackery is "integrated" with real medicine. But to paraphrase an old song, nothing plus something leaves something. Unfortunately, it doesn't add anything to that something. As Mark Crislip once put it, "If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse." Sadly, CCF likes to mix lots of cow pie with its apple pie.

oracknows Wed, 02/27/2013 - 03:30

Categories

Medicine

If you threaten your kid with a beating for bed wetting it's child abuse. If you drag him to be pocked with needles it's CAM.

Hey kid, stop drooling or I'll stick more of these pins in you. Yes, I could see that being effective. Ethical? Maybe not so much.

Of course since it's all placebo effects, clinically proven to be no more effective than "Hey kid, stop drooling or I’ll pretend to stick more of these pins in you".

Wonder how/who is going to pay for these treatments since acupuncture is not recognized by most insurance companies as a reimbursable, ie valid, treatment.

The state I live in does not consider acupuncturists to be healthcare providers (thankfully).

Acupuncture results in fewer doctor visits?

I can actually believe that there is a correlation, because the sort of parent who would send his kid to an acupuncturist would have the acupuncturist, rather than a real doctor, treat any future minor complaints. But yes, this is a garden variety correlation vs. causation flub.

I've just posted a comment directly at Dr. Katholi, who was quoted in article that Orac linked to:

http://health.clevelandclinic.org/2013/02/acupuncture-for-kids/

I accused Dr. Katholi of promoting quackery and encouraging vulnerable credulous parents to agree to the abusive practice of sticking needles into their children.

No side effects, eh?

http://cid.oxfordjournals.org/content/43/1/e6.full

(here's a case where you needed a whole boatload of IV antibiotics in addition to the insulin).

That's a good one Chris Hickle. :-)

How about joining me on the Cleveland Clinic blog and linking to that Oxford Journal site?

Oops, Chris Hickie.

The "Harvard Women's Health Watch" newsletter for March 2013 features the article "Needling Away Chronic Pain: Research finds acupuncture is an effective pain reliever." The article highlights the research by Dr. Lucy Chen, an assistant professor at Harvard Medical School and attending physician in the department of Anesthesia, Critical Care, and Pain Medicine at Massachusetts General Hospital.

Researchers found acupuncture more effective at relieving pain from osteoarthritis, chronic headaches, and shoulder, neck, and back aches than either sham acupuncture (needles that do not pierce the skin or are inserted in non-therapeutic points on the body) or no treatment.

Regardless of how or why it occurs, acupuncture does appear to reduce pain when compared with no treatment or conventional treatments (such as medicine, physical therapy, and exercise). It can also improve function and well-being in people with chronic pain, Dr. Chen says. Plus acupuncture offers some advantages over drugs and other pain treatments - particularly in that it carries a very low risk of side effects.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Chen%2C+Lucy[Full+Author+Name]…

http://www2.massgeneral.org/painresearch/center.html#top

From the Clinical Infectious Diseases paper:

Mechanical injuries range from benign to lethal. There are >90 reports of pneumothorax, the most commonly reported mechanical injury, including 2 cases of lethal tension pneumothorax [2]. In 1 series from Japan, 9% of pneumothoracies seen in an emergency department case series were caused by acupuncture [2]. There are 6 reports of cardiac tamponade, 2 of which were fatal. There are >10 case reports of spinal cord or nerve damage and several reports of spinal subarachnoid hemorrhage.

'tis posted over at Cleveland Clinic.

Anyone claiming "no side effects" forgets that a side effect of living is dying.

Regardless of how or why it occurs, acupuncture does appear to reduce pain when compared with no treatment or conventional treatments (such as medicine, physical therapy, and exercise).

Not surprising that a treatment, even if itself of no efficacy, would perform better than no treatment or standard of care treatments: this is common enough observation as a consequence of placebo effects that appropriate controls must be included when designing stuides to rule placebo effects out. A critical question that needs to be addressed is how acupuncture performed, not compared to no treatment, but to an appropriate faux-acupuncture control (.g., retracting needles, needling the wrong meridian points, etc.),

@ Chris Hickie: Here's a Reuters news story about a misplaced acupuncture needle, that required emergency surgery to retrieve it from the patient's lung.

http://www.reuters.com/article/2011/05/03/us-korea-roh-idUSTRE7420XB201…

'tis posted back at you on the Cleveland Clinic blog. :-)

@ JGC:

It's notable that part of an "appropriate" control is being double-blind. Notable since a bit further up, sham acupuncture is indeed mentioned. And of course, the quote and links don't go into that at all.

@JGC - They seem to be basing their opinions off of the 2012 meta-analysis.

http://archinte.jamanetwork.com/article.aspx?articleid=1357513

@ S: That "meta-analysis has already been discussed.

Here...

http://www.sciencebasedmedicine.org/index.php/an-acupuncture-meta-analy…

And here...

http://scienceblogs.com/insolence/2012/09/12/can-we-finally-just-say-th…

But to paraphrase an old song

I am desperately fond of the 'fro Preston was sporting in the early '70s. (Sadly, that's almost certainly a lip-sync; the version from Burt Sugarman's "The Midnight Special" is legit, but sans 'fro. Of course, if I continue down Sugarman road, it inevitably leads to the most amazing "Play that Funky Music" performance ever.)

@ Narad:

I'm thinking of another 1970s roots hair trend: do you perchance know a little ditty by Bob: "Natty Dread"?
I would bet good money that you do.

You are fighting a losing battle, Orac.

And Marg returns....evidence-free as usual.

I have a feeling it's going to take people dying before this trend gets fully reversed....

Really, Marg? and yet, acupuncture is not covered by insurance in the US, nor is it on the list of approved medical practices under the new health care law.

@Shay - It is covered under some major insurance plans. Some plans only offer partial reimbursement for an acupuncture session. In some cases, I have seen an acupuncture clinic falsely billing their services as a massage in order to receive more compensation.

“Using acupuncture has been very rewarding,” says Dr. Katholi.

Oh, I'll bet it has been, doctor.

I’m thinking of another 1970s roots hair trend: do you perchance know a little ditty by Bob: “Natty Dread”?

Dreads are still pretty popular around here, although they're sometimes clearly just hair extensions, which is cheating. They can look very good, so long as one doesn't make scalp stripes, but the maintenance must be hell.

What worries me is the new ladies' trend of a Mohawk with only one side of the head trimshaved.

You are fighting a losing battle, Orac.

Perhaps you should try beaming psychological distance-healing energy to rectify the situation. You can get a photo easily enough. That should fix things right up.

@ Narad:

"What worries me is the new ladies’ trend of a Mohawk with only one side of the head trimshaved."

That's not a new trend, Narad. My 42-year-old daughter *buzzed * her hair in 1984, when she was in a private Catholic all-girls high school. Sister Kathy, the dean, at that school had my phone number on *speed dial*. :-)

That’s not a new trend, Narad. My 42-year-old daughter *buzzed * her hair in 1984

Ah, but fashion runs in cycles. I could well argue that the fellow at the grocery store sporting a serious DT was doing something "new." Ish. On the other hand, the guy in the neighborhood who has been wearing a Pompadour for a decade is doing something old and tired.

You are fighting a losing battle, Orac.

Perhaps you should try beaming psychological distance-healing energy to rectify the situation. You can get a photo easily enough. That should fix things right up.

@Marg - Do you claim to be a better healer than Edgar Cayce? He didn't even need a photo to heal people sight unseen. What's up with you requiring a photo? Was Cayce scamming people?

My Beatle haircut in 8th grade was going to cause the downfall of Western Civilization. Actually, maybe they were right! Who knew it'd take so long, though?

My Beatle haircut in 8th grade was going to cause the downfall of Western Civilization.

It was a Dorothy Hamill outcome that caused me never to see a hairstylist again.

@marg

Guess that since your position is so untenable, you have to resort to delusion and falsehoods to keep your morale up.

lilady:

My 42-year-old daughter *buzzed * her hair in 1984,

My college age daughter got a haircut so short, that if she had an extra half inch removed her hair would have been just like her grandfather's flat top crew cut.

I must have the world's greatest hair genes. Amazing that I am not bald now in my dotage. During my early teen years, I was changing my hair color every week...and the results were bizarre.
Pink hair, orange hair, pale blonde hair that became green hair after I swam in a heavily chlorinated pool.

@ Novalox: Marg's last statement, "You are fighting a losing battle, Orac", reeks of Thingy.

@lilady, did you stop after the green hair?

I had a similar experience in my teens - peroxided my fringe white, then put a red rinse through the hair (one of those semi-permanent ones that come out after a few washes). My fringe went flouro orange - yes, it glowed in the right light.

I've never dyed my hair since. Too many bad memories.

And let's not even THINK about perms. Oh damn, I have, why do I do this to myself?!

@ Christine: Nah, Clairol was my *friend*, back then.

Wait until you become a *senior*...you'll soon change your mind about color *enhancement*.

I'm having bad memories of a different kind brought up. I was taken to a chiropractor in my youth, to treat persistent headaches that followed a traumatic brain injury. The quack's treatment involved mashing on pressure points on my forehead with his thumbs, applying pressure that was intensely painful. I left the office with my stomach twisted up in knots from the pain every time. Didn't do a damn thing for my headaches, but I can understand the urge to lie and say you've gotten better so you don't have to go back. I'd have little trouble describing that process as torture, do that to me long enough and I'd be willing to say or do many things just to make the suffering stop.

I can certainly see kids saying that they're feeling better to make acupuncture stop. You're feeling poorly Johnny, well we'll we'll just stick a bunch of needles into you until you look like a porcupine, and then if that doesn't work we'll do it again until you do say you feel better.

It gets better though because I don't think I ever even lied and claimed that it was working, but my mother thought it was. I mean I kind of get it, her child was suffering and she wanted to fix it, and lacking an adequate way to accomplish that she turned to quackery and convinced herself it was helping to relieve the feeling of helplessness. I understand that the feeling of helplessness sucks, but... what I had to go through as a result of this vicious psychological shortcut sucked too. So if parents are reporting the outcomes of acupuncture I can easily see them reporting improvements that don't actually exist.

And let’s not even THINK about perms. Oh damn, I have, why do I do this to myself?!

In point of fact, I don't think I've ever seen my mom's hair in its natural state. Not Toni home perm, at least, but her attachment to the stuff sometimes drives me bats. Like when she rejects chemotherapeutic agents that might make it fall off for a while because it's too hot to wear a wig.

Oh, and I continue to recommend henna, and not just for courtship purposes (although it's dandy for that, young gentlemen).

I can certainly see kids saying that they’re feeling better to make acupuncture stop.

Ah for the good old days when we had an entire pharmacopeia -- castor oil, ipecacuana, brimstone & treacle, sennapods -- to teach kids the consequences of complaining of illness.

@HFB - Don't forget cod liver oil (although I wish I bloody could).

@S - Got to love how that Chen acupuncture study contained a lot of ailments (headaches, neck back & shoulder pain) that can occur solely as a response to psychological stressors. It's no wonder that half an hour of soothing woo would relieve symptoms.

@Nomad - Ouch. At least my mother was only a homeopath, and sugar pills don't hurt.

@Narad - That's so sad that hair > treating cancer. Up until last year I spent a couple of years sans hair, and was surprised at how comfy the latest wigs are.

Mine were running at £20 each on eBay, took me ten minutes from picking them up from the dresser, to getting out of the house each day, and came in some amazing styles. I was convinced they'd be heavy, cumbersome, hot and scratchy, but nope. Even wore one to a concert in a packed venue, and was less sweaty-faced than my girlfriend!

I ended up with three or four, and kept getting comments like "Have you dyed your hair again? Your hair will fall out!" which caused me raucous and painful (cataplexy, argh!) laughing fits. When I'm up to leaving the house again I'm going to have my hair buzzed off and go back to the wigs. So much easier than faffing with my hair for an hour.

Also, does anyone else think this (from the OP):

“A lot of kids are medication-sensitive, and acupuncture doesn’t have the side effects of medication"

might as well read:

“A lot of kids are medication-sensitive, and M&Ms don't have the side effects of medication"

The good doctor apparently doesn't realise that one of those things is not like the other.

That’s so sad that hair > treating cancer. Up until last year I spent a couple of years sans hair, and was surprised at how comfy the latest wigs are.

She doesn't want anyone to know aside from immediate family. I haven't even bothered arguing this; she's come to her decision. I'm not happy with that decision, but it seems to be considered in a fashion.

Where’s Marg?

Oh that’s right: she figured out that her arguments don’t hold water and instead of making a better case, nowadays she drops some pearl of non-wisdom and ducks out before it’s thrown back in her face.

@Narad - Fair enough. It's hard to watch, I know. My FIL made a similar set of decisions. Is coronary arteries were blocked. He was given two options - stents, if he promised to stop smoking, or a bypass.

He went with stents and was fitter than ever. He started smoking again though, and within the year he was desperately ill. They offered him a triple bypass but, because he was 75, insisted that he stopped smoking, otherwise he'd end up back at square one.

So he had the surgery and went home. And within months he was smoking again. 18 months later he was dead, heart failure.

Watching someone you love commit slow suicide, either by refusing vital care, or taking that care and actively making choices that destroy the work done. But, they're adults and have to be allowed to do that, even if tears us up. All we can do is be there.

Best of luck to you both.

re hair adventures:

As a student, I also studied art and knew many who worked in photography so of course, I was always having my picture taken.. One friend commented that I might look better being more "contrast-y". I wondered about it myself and decided to try darker hair. Having foresight- even at that tneder age- I searched around until I found a temporary product meant to darken grey hair ( French, if IIRC) and dyed my dark blonde hair very dark brown. I had a suspicion that it might work well because most of my father's family had a similar shade. And they were contrast-y.

Thus, I was Miss Hot until it faded: for some reason, men found it very attractive and I had no lack of attention and offers, most of which I turned down.

Usually I do little to my hair and let it twist away to its heart's content, only combing it when it's dried after washing. The one white strand is tinted whatever suits me when I'm in the store. Thus I'm over 50 and have hipster hair.

My hair's almost completely white, I'm only in my mid-thirties! It started when I was 19. Thank FSM for permanent dyes.

I'm really pale with blue eyes, and my hair was dark blonde to mid-brown, depending on the season.

My mother always said I'd look atrocious with dark hair, so I stuck to auburns and browns. Then, like you Denice, I went dark (Schwarzkopf Live! in Cosmic Blue). And, just like you, my look totally changed. My eyes totally "popped" (to use Project Runway jargon) and I looked younger. I'd switched to the Schwarzkopf 'Cyber Purple' just before I met the other Ms Elburto in real life for the first time, and apparently I was an arresting sight. She's been trapped in my bizarre orbit ever since, poor thing!