Isabel Rangel Baron: The Wrong Sleep Posture Can Be a Pain in the Neck

Troubled by a neck pain? You’re not alone. A 2017 population-based study determined the prevalence of neck pain in a population of adults aged 20 and above was 20.3% or 1 in 5 people. Although a variety of risk factors for neck pain have been identified, including your posture/positioning while at work, one risk factor that isn’t often talked about how you position yourself when you sleep. A study published in the Journal of Physical Therapy Science on June 29, 2017, was specifically aimed at identifying the effects of sleep posture on neck muscle activity.

The authors found that the activity of the affected muscles was significantly different in each of the three main sleeping positions: supine with both hands at the side (BHS), supine with both hands on the chest (BHC), and supine with the dominant hand on the forehead (DHF). The authors concluded that

“sleep posture is important and prevents neck and shoulder musculoskeletal pain.”

8 Ways to Relieve Neck Pain from Sleeping in the Wrong Position

Based on these findings and other research detailed below, here are 7 ways to relieve neck pain from sleeping in the wrong position:

1. Don’t sleep in the supine DHF position

If you’re one of those people who put one hand on their forehead while sleeping, you’re may be contributing to your neck pain. When you sleep in this posture, the upper trapezius and scalene muscles are activated on one side. The imbalanced activation of the muscles causes a rotation in the neck, and that leaves you with a misalignment of the cervical spine.

      2.  Avoid the supine BHC position

The supine BHC position is more symmetrical than the DHF since you have positioned both hands on the chest while lying on your back. The difference in the activity between the scalene and upper trapezius muscles is lower. Still, this position of the arms causes some level of tightness of the upper trapezius, which can cause numbness and neck pain.

3.  Get used to the BHS position

The researcher found that the difference in muscle activity was the smallest in the supine BHS (both hands at the side) position. When you go to a relaxation course, they tell you to lay in the so-called Savasana or corpse pose. You lay on your back, with the legs slightly separated and both arms relaxed by the side. The head is in a straight continuation of the neck, without falling to either side. It’s a balanced position, and it turns out it’s the best posture for sleep.

4. Your pillow makes a difference

The pillow you use affects the shape of the cervical spine. With that, the pillow has a direct effect on muscle fatigue and pain in that area. A study from 1997 made a comparison of three types of pillow: the usual pillow, a roll pillow, and a water-based pillow. They found that the water-based pillow not only improved the quality of sleep but also led to pain relief and reduced intensity of neck pain in the morning. Although this study is not fully reliable because it doesn’t take body position into account, most people would probably agree that sleeping on the right pillow can make a big difference.

5. Use a pillow with an adaptable shape

The most important thing to look for in a pillow is flexibility. When you put your head on it, it should change its shape to perfectly support your neck. When you change your position, the shape of the pillow should change also. If you don’t like a water-based pillow, you can opt for a more traditional choice. Feather pillows are good in terms of conforming to the neck’s shape, however, they tend to collapse with continued use so it’s important to change them once per year. A high-quality memory foam pillow is another good choice. It will last longer and continue to conform to the shape of your head and neck.

6. Do something About that insomnia

If you suffer from both insomnia and neck pain, you may be interested to learn that there is apparently a reciprocal relationship between these two factors:

Neck pain can interfere with sleep and insomnia heightens your perception of pain the next morning.

A 2015 study published in the journal Pain found that sleep problems “significantly increase the risk for reduced pain tolerance.” So, if you suffer from insomnia, you should seriously consider taking action to address the problem. Some experts feel that the most reliable improvement in the quality of sleep comes from psychological and behavioral therapy.

Related article: Sleeping Pills Not Working? Here’s What You Need to Know

7. Try stretching in the morning

If you’re waking up with stiffness in your neck and the entire body, morning stretches can help. Gentle Hatha yoga, for example, will improve the mobility of all muscles and joints and will make you feel relaxed. A randomized-controlled trial identified the effects of home-based yoga practice for chronic neck pain. The participants who practiced yoga reported significantly less neck pain when compared to the participants who did another type of exercise. Yoga seemed to influence the functional status of the muscles in the neck area as it improved the physiological measures of neck pain.

8. Consider acupuncture

If you suffer from chronic neck pain that doesn’t go away no matter how much you try to improve your sleeping position or the pillow, perhaps it’s time to consider acupuncture which can be an effective treatment for cervical pain. A controlled trial showed that relevant acupuncture treatment combined with heat resulted in a reduction in neck pain.

The Bottom Line

There’s no doubt that neck pain causes a huge amount of discomfort. When you wake up with stiffness and pain, your entire day can be impacted by how you feel. But remember that you do have options to make the pain go away or at least reduce it to a significant degree. Hopefully, the eight methods suggested above will help.

If you have tried something that worked for you and is not on this list, please share it in the comment section below.

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Isabel Rangel Baron: How to Reduce Medication Errors by 82%

According to the US Department of Health and Human Services, adverse drug events account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year. Hospital pharmacists are uniquely positioned to prevent medication errors in the hospital because of their centralizing function for medications prescribed and dispensed within the hospital setting.

It was with the goal of understanding the role hospital pharmacists can play in preventing medication errors that I interviewed Steven Meisel, PharmD, who is a patient safety expert at the Institute for Health Care Improvement (IHI) and the Director of Medication Safety at Fairview Health Services in Minneapolis.

In this clinical education podcast, Dr. Meisel discussed how hospital pharmacists can prevent medication errors. (His transcribed quotes have been lightly edited for readability.)

Here are his five recommendations for accomplishing this:


  • First, recognize that you may have medication errors

Dr. Meisel’s hospital recognized they had a problem with medication errors related to patients receiving opioids. As he explained:

“I think the first piece of advice is to recognize that there is a problem. Just like the alcoholic can’t change his ways and get better before he admits he is an alcoholic, the hospital can’t reduce its risk for narcotic oversedation until it believes that there is a risk for narcotics oversedation.”

Meisel’s hospital realized that they had an issue related to opioid administration because they recognized the implications of naloxone usage. He explained,

“It’s very interesting, we started our journey on this about 15 years or so ago. One of the things that we learned in talking to physicians, anesthesiologists, surgeons, even our vice president for medical affairs at the time was the same story that you just mentioned, that we didn’t have a problem here with narcotics oversedation. Then we looked at the naloxone administration and said, ‘well, gee, we’re using an awful lot of this.’ And the response was ‘Well, of course, we are because that’s what naloxone on is on the market for. People aren’t suffering because we have this antidote.’

 And so it is important to change the mindset that the use of naloxone is not a cost of doing business. That it’s not a choice of good pain control versus somebody being over sedated or stopping breathing. You can have both, you can have good respiratory function and good pain control, but the use of naloxone is not a cost of doing business. And I think when people say they don’t have a problem, it may be because people are not dying or not becoming comatose with long-term central nervous system problems or whatever, but gosh if they stop breathing and they’ve got to be given naloxone, that is something you’d not want for yourself or your spouse or your parents and therefore it is not the cost of doing business.”


 Because of their recognition of the problem, Dr. Meisel’s hospital was able to lower their medication errors by 82%:

“We have not, thankfully, had any patient deaths, at least not in a recent time. But I can tell you that, yes, we have seen an impact on narcotic-related adverse events. In fact, at our university hospital alone, from 2008 through 2016, we had an 82% reduction in our narcotic-related adverse events. 


  • Second, use standardized order sets.

Standardized order sets help eliminate errors making sure they are not caused by human error:

“We have to make sure that we implement every known best practice that is out there, and there are lots of them, as you know. From the Institute for Safe Medication Practices or from the IHI or from other professional organizations. There are lots and lots and lots of best practices and, unfortunately, way too many of them are just not deployed to the extent that they should be. I think it’s very important that we deploy all those best practices and we deploy them in ways that can assure that they’re actually operationalized throughout the organization. You build them into order sets in your electronic health records, you build them into your pharmacy computer system, you build in forcing functions such as IV tubing that can’t be connected inappropriately to an intravenous line or vice versa, you have pumps that are different for epidural versus IV and those sorts of things.” 

One of the forcing functions that Dr. Meisel’s hospital built into their order sets was the need to continuously electronically monitor all patients for the first 24 hours following surgery:

“In the acute post-op setting, we require that any adult inpatient who has an order for narcotics undergoes a continuous capnography monitoring for the first 24 hours after the surgery and then longer depending upon if the patient is doing well or poorly or whatever, and then we also apply continuous pulse oximetry in that setting as well. So, they have both continuous pulse oximetry and capnography for the first 24 hours after surgery for all of our adult inpatient patients. 


  • Third, think innovatively to develop best practices

When faced with an obstacle that may cause a medication error, think innovatively to develop best practices. Dr. Meisel described this example of how they innovated to prevent oversedation events:

 “I think you’ve got to innovate, you’ve got to invent new best practices. What we have learned is that you could deploy everything that’s out there, but you will still suffer adverse events and your patients will suffer adverse events. So you’ve got to dream up new ways of doing business, new approaches to the care of the patients that you’re seeing whatever the condition may be and identify new ways of doing business.

 So for example, in the narcotic world, you want to prevent oversedation events and one of the risk factors might be that hydromorphone comes in 1-milligram and 2-milligram prefilled syringes, but the normal dose is about 0.2  or 0.4 milligrams. So, why would you buy 2-milligram syringes for use in most parts of your hospital? That’s a risk and so one of the solutions that Fairview deployed for a decade was to repackage every hydromorphone syringe into 0.4-milligram sizes and we did that for a decade until a 0.5-milligram size became commercially available. That was innovation, it was inventing a new best practice to try to eliminate the risk of that 10-fold overdose that, albeit rare, was always there.


  • Fourth, measure to see how well you’re doing

Dr. Meisel recommends keeping track of how you are doing:

“You can’t improve what you can’t measure, at least not very well. For the last ten years or more, we have run charts every quarter showing the number of narcotic-related adverse drug events plotted over time, by hospital, and as an aggregate. We post the results regularly to be reviewed by our pain committee, our pharmacy and therapeutics committee, and others. Because we have that measure, we know whether we’re getting better, staying the same, or in some cases, at times, getting worse, if that’s the case. You’ve got to measure, I think that’s very important. 


  • Fifth, be committed to patient safety

Make sure that your hospital is committed to patient safety, and this starts from strong leadership:

“I think it, first of all, starts with strong leadership and strong culture. From the top of the organization right through the all the rungs of the organization.

There has to be a belief that safety is important value, that it is as important as quality and finance and all the rest.

There’s got to be good training, good recognition, good rewards and good expectation setting. It needs to be a part of the report and discussions at every level from the board all the way on down, that’s very important.”

To learn more about these and other recommendations for preventing medication errors in the hospital, please listen to the clinical education podcast with Dr. Meisel, by clicking here.

Recommended by Isabel Rangel Baron.
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Isabel Rangel Barón: ASCO endorses the integration of quackery into breast cancer care

Last week, I was perusing Twitter, which has become a primary source these days for blog fodder, when I came across this:

Yes, it was the President of the Society for Integrative Oncology, Linda Balneaves, crowing about how ASCO has endorsed its guidelines for therapies for the “integrative” medical care of patients with breast cancer, something she did on her own Twitter feed as well:

ASCO itself had announced this endorsement, too:

Elsewhere, even some National Cancer Institute-designated comprehensive cancer centers were touting the news. For instance, here’s the University of Washington with perhaps the worst Tweet of all from a “respectable” cancer center:

Unfortunately, the Hutch isn’t entirely wrong. ASCO (the American Society of Clinical Oncology) is one of the largest medical professional societies devoted to cancer in the world, if not the largest. Its meeting every year, usually beginning the weekend after Memorial Day, inevitably generates lots of press coverage and news stories about the latest clinical trial results for new cancer therapies. You might recall the flurry of news stories two weeks ago about the TAILORx trial, which clarified the use of the OncoType DX test to determine which patients with the most common subtype of breast cancer can safely forego chemotherapy. ASCO also publishes a number of guidelines for cancer care. Basically, when ASCO endorses a treatment or another organization’s guidelines, it’s a big deal. It’s hugely influential. Now ASCO has endorsed the “integration” of quackery into the treatment of breast cancer patients. To paraphrase David Byrne, “And you may ask yourself, well, how did we get here?”

The SIO clinical guidelines for breast cancer care, round one: Rebranding SBM and integrating quackery

When the first version of the SIO’s Clinical Practice Guidelines on the Use of Integrative Therapies as Supportive Care in Patients Treated for Breast Cancer was published in December 2014, I commented in detail about it in my usual inimitable fashion. First, I noted that the guidelines were published as a part of a monograph in the Journal of the National Cancer Institute (JNCI). Along with the guidelines, there were multiple other articles designed, among other things, to exaggerate the evidence base for the use of “integrative” therapies in cancer, to promote the “brand” of integrative oncology, and to tout the NCI’s portfolio of “complementary and alternative medicine” (CAM) research through its office with the most inappropriate acronym ever, the Office of Cancer Complementary and Alternative Medicine (OCCAM), whose budget has traditionally been roughly the same size as that of the National Center for Complementary and Alternative Medicine (NCCIH). OCCAM serves the same purpose in cancer research and treatment as NCCIH does for medicine in general: To fund mostly dubious studies on “integrative medicine” and to promote “education” and use of “integrative medicine.” The monograph also taught me that the NCI Community Oncology Research Program (NCORP) has been co-opted such that nearly one-third of NCI-sponsored clinical trials through the NCORP are for “integrative oncology.” Comparing the evidence base for integrative oncology to conventional oncology, it boggles the mind that such a huge chunk of an important resource for testing is diverted in this way.

As a prelude to discussing the updated guidelines, I have to ask: What about the original guidelines themselves?

I found them notable for the modalities that the SIO panel charged with developing the guidelines had excluded because they had become “mainstream,” such as cognitive-behavioral therapy, psychoeducation, counseling, and support groups. Of course, these modalities were never considered outside the mainstream, although admittedly some overblown claims have been made for support groups and cognitive-behavioral therapy as being able to improve cancer survival, claims that have not held up to scrutiny. Similarly, prayer and spirituality were also excluded for unclear reasons.

The treatment modalities that remained were subjected to a literature analysis in order to determine whether they can be recommended or not based on existing clinical evidence. The SIO used a scale adapted from the U.S. Preventative Services Task Force to grade the evidence that ranged from A (“Recommends the modality. There is high certainty that the benefit is substantial.”) to H (“Recommends against the service. There is moderate or high certainty that the harms outweigh the benefits.”). Of course there are also I (insufficient evidence) and various gradations between A and H, such that it’s probably worth reposting the table to guide the rest of this discussion:

Tellingly, the only grade A recommendations were for meditation, yoga, and relaxation with imagery for routine use for common conditions, including anxiety and mood disorders (Grade A). There were no grade A recommendations for anything having to do with pain, but only for symptoms with an even heavier subjective component, namely anxiety and mood. Of course, yoga is a form of exercise and therefore nothing out of the realm of conventional medicine, given the number of studies that have shown the benefits of exercise in cancer patients. Similarly, the only grade B recommendations included stress management, yoga, massage, music therapy, energy conservation, and meditation for stress reduction, anxiety, depression, fatigue, and quality of life. Interestingly, again, none of these, with the possible exception of meditation, can be considered in any way “alternative,” thus once again demonstrating how integrative oncology specifically and integrative medicine in general have co-opted treatments that should be considered conventional as somehow “alternative”. As for music therapy, massage, and the like, these represent modalities that I like to point to as examples of what we used to call supportive care that have been “medicalized” by CAM and turned into therapies when in reality they’re just activities and modalities that help patients feel a bit better or help pass the time, no specific effects intended. Oddly, SIO lumped massage together with “healing touch.” Healing touch, of course, is a form of “energy medicine” very much like reiki and thus total quackery. It was also telling that there was no acupuncture use that was rated grade B or above, except for “electroacupuncture” for chemotherapy-induced nausea and vomiting, and, as I’ve discussed before, that evidence is shaky at best.

At the time, I characterized the offerings as giving little or no support for real “alternative” treatments (e.g., homeopathy), although they did give mild support for a few potentially science-based modalities rebranded as CAM/”integrative oncology” and ,tellingly, insisted against evidence on including the quackery (or, if you prefer, the theatrical placebo) known as acupuncture in the guidelines. I wonder if it was because one of the authors of the guidelines, Misha Cohen, is an acupuncturist and practitioner of traditional Chinese medicine (TCM), and Gary Deng is also into TCM.

The SIO clinical guidelines for breast cancer care, round two: A pointless and unnecessary update

About a year ago, for reasons that eluded me then (and were partially why I didn’t do a follow-up post on this topic for SBM), the SIO decided to update its clinical guidelines for breast cancer care. Then, as before, the author list included MDs, some of them respected (e.g., Debu Tripathy). The current SIO President, Lynda Balneaves, was also an author. The author list also contained quacks (e.g., Misha Cohen, TCM practitioner and acupuncturist). It also contained three naturopaths, starting with the first author, Heather Greenlee. Dugald Seely is on the author list again, as well. We’ve met Seely before on multiple occasions. Indeed, he’s quite the flush little naturopathic quack, complete with millions of dollars donated by an anonymous donor to fund “integrative oncology” research at the Ottawa Integrative Cancer Center (OICC). Then there’s Suzanna Zick, who’s even worse than a naturopath. She’s a naturopath at my alma mater, the University of Michigan Medical School. It always depresses me to contemplate that U. of M. actually has a naturopath working for it, but, then, it also has an anthroposophic medicine program. So I guess it’s not a stretch any more for there to be naturopaths there.

Upon reading the introduction to the 2017 update to the SIO guidelines, I also couldn’t help but note that what the SIO apparently means by “recommendation” is not what most doctors producing evidence-based guidelines mean by the word:

Of note, it is important to define the use of the term recommendation in these clinical practice guidelines. In many settings, a clinical guideline recommendation suggests that it should be used as the standard of care and is favorable or equal compared with all other options based on best clinical evidence for benefit/risk ratio. Here, in the setting of integrative oncology, we use the term recommendation to conclude that the therapy should be considered as a viable but not singular option for the management of a specific symptom or side effect. Few studies have conducted a head-to-head comparison of a given integrative therapy against a conventional treatment, and most integrative therapies are used in conjunction with standard therapy and have been studied in this manner. Moreover, combination-based approaches and the interactions of the numerous permutations of integrative and conventional treatments have not been formally investigated, such that recommendations must account for this limitation of our knowledge. Despite these limitations to evaluating the use of integrative therapies in the oncology setting, there is a body of well conducted trials of specific therapies for specific conditions that provides sufficient evidence to warrant recommendations on the therapies as viable options for treating specific conditions.

Ah, “integrative medicine,” where even “recommendation” doesn’t mean what it does in real medicine. I couldn’t help but be reminded of the famous quote by Humpty Dumpty in Lewis Carroll’s Through the Looking Glass, “When I use a word, it means just what I choose it to mean—neither more nor less.” In clinical guidelines in real medicine, though, “recommendation” means just that: a recommendation to use the treatment in question, graded, of course, according to the strength of the evidence. Yet here in the world of integrative medicine, “recommendation” means something…squishier. One can’t help but make the analogy that integrative medicine’s evidence standard is squishier than that of real medicine. Of course, the answer to that question of whether the new studies included in the 2017 update to the SIO clinical guidelines added much of anything to the 2014 clinical guidelines was, as I suspected, no, at least as far as I could tell.

I can’t help but mention that, by embracing the newer SIO guidelines, ASCO has also put its imprimatur on language like this:

Acupuncture involves the stimulation of specific points, (ie, acupoints) by penetrating the skin with thin, solid, metallic needles.[154, 155] A variation of acupuncture includes electroacupuncture, in which a small electric current is passed along acupuncture needles to provide a stronger stimulus than acupuncture alone, with distinct effects suggested by functional magnetic resonance imaging.[156, 157] Acupuncture has been practiced in Asia for thousands of years as a component of traditional medicine systems (eg, traditional forms of Chinese, Japanese, and Korean medicine) and is thought to stimulate the flow of a form of energy called qi (chee) throughout the body. Traditional Chinese acupuncture, which is commonly used in North America, requires needle manipulation to produce a de qi sensation (a soreness, fullness, heaviness, or local area distension[157, 158]), along with a period of rest with the needles in place.[159] It is posited that this removes energetic blockages, thus reestablishing homeostasis. The mechanisms for acupuncture’s effects are not well understood but are thought to function in part through modulation of specific neuronal/cortical pathways.[160]

Neither SIO nor ASCO appear to be aware of how much revisionist history (or, as I like to call it, retconning) is contained in the passage above about acupuncture. The claim here was that acupuncture has been practiced “thousands of years,” most commonly for at least a couple of thousands of years. Yet two thousand years ago the technology to produce thin needles of the sort used by acupuncturists today didn’t exist. In fact, it’s unclear when acupuncture in something resembling its current form evolved, but it appeared to have evolved from bloodletting. Harriet Hall once related the story of Dugald Christie, a Scottish surgeon who served as a missionary doctor in northeastern China from 1883 to 1913, and his experiences observing traditional Chinese medicine (TCM), including acupuncture. Let’s just say that acupuncture practiced 100 years ago was rather brutal. In fact, acupuncture began as nothing more than a Chinese version of bloodletting, very much like “Western” bloodletting and has been called “astrology with needles.” In reality, acupuncture and TCM achieved their current form under Chairman Mao Zedong, who promoted their use when he couldn’t supply enough scientifically-trained doctors for his people and exported to the world, something China is still doing. It’s a history that’s been retconned, and the SIO panel just repeated that retconned revisionist history. No wonder there are so many forms of acupuncture.

Basically, there’s not much new in these guidelines. Relatively uncontroversial modalities like meditation, music therapy, stress management, and yoga are given the highest recommendations. However, acupuncture and its bastard offspring electroacupuncture (which really has no basis in TCM, given that there was no electricity hundreds or thousands of years ago to hook needles up to) consistently get B or C recommendations for several indications, despite acupuncture being nothing more than a theatrical placebo that hasn’t convincingly been shown to work for any clinical indication. That includes acupressure.

As is the case with most systematic reviews of integrative medicine, there are some head scratchers. For instance there’s this level C recommendation, meaning that they can be considered:

Acupuncture,[49-51, 91, 92] healing touch,[93, 94] and stress management[36-38, 95, 96] can be considered for improving mood disturbance and depressive symptoms.


Acupuncture,[119-124] healing touch,[93] hypnosis,[125, 126] and music therapy[31, 34] can be considered for the management of pain.

Healing touch is the rankest quackery. It’s energy medicine that postulates that practitioners can manipulate human life energy fields. It’s such a silly form of quackery that even a 12-year-old girl could disprove it.

Basically, these guidelines, now endorsed by ASCO, were even more unnecessary and pointless than the first set of guidelines published in 2014. It’s not as though clinical studies have advanced knowledge enough to justify a new set of guidelines, and these guidelines suffer from the same issue that integrative medicine itself suffers from, mixing cow pie with apple pie as though they were equivalent.

The SIO clinical guidelines for breast cancer care, round two: Enter ASCO

So now we arrive at ASCO’s contribution to this sad saga. This time around, several of the authors are the same, but there are some additions. For instance, Dr. Lorenzo Cohen of the University of Texas-M.D. Anderson Cancer Center is senior author. I’ve discussed him before here on SBM a few times. Suffice to say that he is a heavy hitter in the world of “integrative oncology” and co-authored the introduction to the original JNCI monograph that contained the first iteration of the SIO breast cancer guidelines. He’s also edited a book on “integrative oncology” that was favorably reviewed in the New England Journal of Medicine by one of his friends. He’s also popped up as a strong advocate for integrative oncology in various news stories. He also co-authored an article using the Delphi method to try to define just what “integrative oncology” is. (He and his co-authors came up with a vague, pretty much useless definition.) Finally, relative to ASCO, Dr. Cohen was one of the main speakers for a session on integrative oncology at the ASCO meeting in 2014 where he argued that stress and mental state contribute to cancer development and progression and that reversing those “bad” mental states can contribute to the improved survival of cancer patients, citing a raft of dubious science to do it. (That was the first time I noticed that ASCO was starting to delve into woo.) Overall, I got the impression that Dr. Cohen believes in the central dogma of alternative medicine, namely that wishing makes it so.

As for the rest of the co-authors, naturopath Heather Greenlee is back. Another co-author, Judith Fouladbakhsh, is on the board of trustees of SIO and is an advanced practice nurse who developed the CAM Healthcare Model©. Overall, there are a lot fewer quacks on this author list (one naturopath versus three, for instance) than there were on the SIO guidelines author list, which in its own way is pretty depressing because it suggests that critical thinking skills are lacking in the very highest levels of academic oncology, so much so that these august authors concluded:

The ASCO Expert Panel determined that the recommendations in the SIO guideline—published in 2017—are clear, thorough, and based on the most relevant scientific evidence. ASCO endorsed the guideline with a few added discussion points.

Basically, ASCO updated the SIO literature review (yet again). You can read ASCO’s discussion and endorsement of recommendations for yourself. ASCO’s treatment suffers from the same problems as the original SIO recommendations did. As a result, I’m not going to go into incredible detail, but I am going to touch on some highlights (or lowlights if you prefer) of the ASCO discussion. One section in particular struck me, specifically the part on the results of the ASCO updated literature review, where it was noted that 26 publications considered potentially relevant to the updated analysis were reviewed by Heather Greenlee, and nine given to the panel for further discussion.

For example:

Quality of life: Caregiver-delivered reflexology during treatment of advanced breast cancer was compared with attention control in an RCT among 256 patient–caregiver dyads. Patients in the reflexology arm experienced reductions in average symptom severity and interference over 11 weeks. There were no significant differences between study arms in functioning, social support, quality of relationship, or satisfaction with life at weeks 5 and 11.17

One notes that this trial was not blinded and basically showed that a nice placebo foot massage made patients feel a bit better. Another study cited was a worthless single-blind study of two forms of acupressure versus waitlist control. In any case, the ASCO panel concluded that the studies they found “support, and in some cases may strengthen, current recommendations.” Given how poor most of the cited studies are, this is thin gruel indeed.

In the end, ASCO basically agreed with the SIO guidelines with three caveats. For chemotherapy-induced nausea and vomiting, ASCO basically walked back the SIO recommendation for acupuncture, at least a bit:

Induced Nausea and Vomiting
These treatment modalities received a grade B recommendation in the SIO guideline, which supports the addition of either one to a standard antiemetic regimen to improve chemotherapy-induced nausea and vomiting. This varies from the 2017 ASCO antiemetic guideline, which concluded that the evidence for complementary therapies, including acupressure and acupuncture, remains insufficient for a recommendation.7 The ASCO Expert Panel noted that the two guidelines address different patient populations—the ASCO antiemetic guideline applies to all cancer types, whereas the SIO guideline focuses only on patients with breast cancer—and also discussed the low risk of adverse events from acupressure and electroacupuncture. Nevertheless, the ASCO Expert Panel favored a grade C recommendation for these therapies. As noted in the SIO guideline, several of the cited trials were conducted before current pharmacologic antiemetic regimens became available. Furthermore, trials to date have tended to be small; two of the three cited acupressure trials20-22 and one of the two cited electroacupuncture trials23,24 enrolled fewer than 40 patients.

Grade C is the weakest of the positive recommendations: “Recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences (there is at least moderate certainty that the net benefit is small—offer/provide this modality for selected patients, depending on individual circumstances).”

There were two other quibbles by ASCO. First, it wanted to highlight SIO’s grade C recommendation for ginseng for fatigue by pointing out that the efficacy and safety of ginseng extracts can vary by type of ginseng and extraction method. The panel was also concerned that some preparations of ginseng can have estrogenic properties and that it might not be the greatest idea to use them in estrogen receptor-positive breast cancer. The second is that subcutaneously injected mistletoe extract, for which the SIO gave a grade C recommendation for improving quality of life, is not FDA-approved. ASCO was also concerned that ingestion of high doses of mistletoe berry or leaf is “known to cause serious adverse reactions.”

In other words, ASCO fully endorsed the SIO guidelines with only minor quibbles.

The emerging narrative

I know what ASCO (and the SIO) would probably say in response to this. They’d think it unfair of me to characterize them as having endorsed quackery because most of what is “recommended” (to use the SIO term) in the guidelines is fairly unremarkable: exercise, lifestyle interventions, and the like, the sort of modalities that “integrative medicine” has been co-opting and rebranding as somehow “alternative or integrative” for at least a couple of decades now. While that is largely true, I argue that they don’t get a pass on recommending acupuncture, and they certainly don’t get a pass for recommending healing touch (which is “energy medicine” mystical quackery) just because they “only” gave it these modalities a grade C (or in one case, a grade B, later downgraded to grade C) recommendation. It’s as if the SIO couldn’t bear not recommending acupuncture or healing touch and bent over backwards to make sure the two modalities got at least their weakest level of recommendation.

Through it all, the utter lack of evidence found in the SIO review for so many modalities is glossed over. Here’s the table from ASCO itself:

Then there’s the narrative. Look at how the press release about the guidelines from the Fred Hutchinson Cancer Center at the University of Washington spins it:

The first time Elizabeth Johnson told her oncologist she wanted to start folding integrative therapies into her breast cancer treatment regimen as a way to alleviate side effects, he told her “Sure, you can try, but it’s not going to help.”

He also told her that the second, the third, and fourth time she asked.

“He’s no longer my oncologist,” said Johnson, a 28-year-old homemaker from Minnesota who’s a year out from diagnosis but still in treatment. “He was great in many ways but not a good fit for me. It’s really important for me to have an oncologist who has a reasonably open mind. All he knew about and apparently all he cared to learn about was chemotherapy.”

Breast cancer patients like Johnson can now tell their doctors that integrative therapies like acupuncture, meditation, massage and yoga have been endorsed by the world’s leading professional organization of cancer doctors, the American Society of Clinical Oncology, as evidence-based ways to manage symptoms and side effects of conventional breast cancer treatment.

The endorsement, published today in the Journal of Clinical Oncology, came from an expert panel that reviewed a set of clinical practice guidelines for integrative therapies put out by the 15-year-old professional organization, the Society for Integrative Oncology, or SIO.

Co-chaired by ASCO senior statesman Dr. Gary Lyman of Fred Hutchinson Cancer Research Center, the panel did not embrace each and every one of the practices recommended in the SIO’s guidelines.

But they did send a clear signal to breast cancer patients and their care teams: It’s OK to integrate.

It gets worse. The press release takes a contemptuous swipe at “skeptics,” with a section entitled “Serving patients, not skeptics.” Indeed, it’s downright insulting and built on a huge straw man. Before the straw men, however, come the “do it for the patients” line, with Lyman saying that oncologists “who scoff at these therapies should still respect their patients’ requests, record the use of any integrative therapy in their charts and encourage them to share results, particularly if they experience side effects.” No serious medical skeptic—and that includes every physician who writes for SBM—says otherwise, but Lyman makes it a point to portray us as being contemptuous of patients and their beliefs.

Then Heather Greenlee chimes in:

Naysayers tend to lump anything alternative into one big bucket, she said, while ASCO and SIO are trying to tease these therapies apart to determine which ones work and which ones don’t.

“We’re reporting on therapies that have clear biological mechanisms, where we have clinical trials showing whether they are effective or not, and whether they are safe,” she said. “We need to conduct more trials and we need to publish more guidelines. We need to get the information out there for patients and clinicians to use.”

I can’t help but burn that strawman with a bit of fire of irony. After all, it’s the promoters of “integrative medicine” who try to lump all the potentially science-based treatments, such as diet, exercise, and lifestyle interventions, with the quackery like acupuncture, energy medicine, and, yes, the vast majority naturopathy. (Again, Greenlee is a naturopath, and I’d love to know if she is willing to call homeopathy, which is an integral part of naturopathic training, quackery.) No, it is the skeptics who separate out the various parts of “integrative medicine” and examine the evidence for each of them individually. That’s why it’s not so much the SIO’s recommendations for music therapy, yoga, and exercise that bother me. It’s the conflation of these patient support measures and potentially science-based interventions with quackery based on mystical pseudoscience like acupuncture and healing touch. It’s the embrace of methods that are negatively correlated with the use of effective medicine for cancer, like chemotherapy. It’s the increasing number of NCI-CCCs embracing quackery. As for “biological mechanisms,” perhaps Greenlee can tell us how qi works or how healing touch can channel “life energy” to heal patients.

In the end, you and I both know how this spin will play out. Promoters of quackery will trumpet ASCO’s endorsement of the SIO guidelines for breast cancer with a narrative like the Hutch’s other press release, “Mozart, meditation and a yoga mat: Oncologists welcome integrative therapies for breast cancer.” Those who advocate the integration of quackery into medicine will point to the ASCO endorsement as legitimizing many of their favorite dubious or quack treatments, and, unfortunately, that’s just what ASCO did. Even Greenlee and Lyman are touting this endorsement as a major “milestone” for integrative oncology, and, sadly, I can’t argue with that. I’m sure John Weeks will be adding it to his other “milestones” to his other milestones on the path to integrating quackery with medicine. In fact, I’m surprised I couldn’t find him already crowing about this. It’s only been less than a week since this new pebble in the quackademic avalanche has fallen.

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Isabel Rangel Barón: Mass suicide documented in bacteria

Mass suicide documented in bacteria

Microbes pump out acid until they burst.

Some bacteria trigger their own destruction by making their environment uninhabitable, a process that researchers have named ‘ecological suicide’.

Many microbes produce by-products that alter the acidity of their environment, but large pH changes can cause their cells to burst. Christoph Ratzke and Jeff Gore at Massachusetts Institute of Technology in Cambridge and Jonas Denk at Ludwig-Maximilian University of Munich in Germany set out to understand how such alterations impact microbes’ survival. The authors grew a soil bacterium (Paenibacillus tundrae) in test tubes and found that the microbes quickly acidified their environment to a deadly pH 4, wiping the colony out within 24 hours.

Further work showed that a sample of local soil contained five species of bacterium that could drive themselves to extinction by raising acidity to toxic levels. Antibiotics and other substances designed to harm microbes might be counterproductive if they reduce the size of microbial populations enough to prevent self-destructive pH change, the authors say.

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Isabel Rangel Barón: Reduced-calorie diet shows signs of slowing ageing in people

A study of people who reduced the calories they consumed has found the strongest evidence yet that such restrictions can slow down human metabolism. The results raise hopes that a low-calorie lifestyle — or treatments that mimic the biological effects of restricted eating — could prolong health in old age and even extend life.

Past work in many short-lived animals, including worms, flies and mice, has shown that calorie restrictions reduce metabolism and extend lifespan. But experiments in longer-living humans and other primates are more difficult to conduct and have not yet drawn clear conclusions.

The study was part of the multi-centre trial called CALERIE (Comprehensive Assessment of Long term Effects of Reducing Intake of Energy), sponsored by the US National Institutes of Health. The randomized, controlled trial tested the effects of 2 years of caloric restriction on metabolism in more than 200 healthy, non-obese adults.

“The CALERIE trial has been important in addressing the question of whether the pace of ageing can be altered in humans,” says Rozalyn Anderson, who studies ageing at the University of Wisconsin–Madison. She leads one of two large, independent studies on calorie restriction in rhesus monkeys, and began her research career studying calorie restriction in yeast. “This new report provides the most robust evidence to date that everything we have learnt in other animals can be applied to ourselves.”

Precise measurements

Published on 22 March in Cell Metabolism, the latest study1 looked at 53 CALERIE participants who had been recruited at the Pennington Biomedical Research Center in Baton Rouge, Louisiana. This facility is home to 4 of the world’s 20 or so state-of-the-art metabolic chambers, which are like small, sealed hotel rooms that measure minute-by-minute the amount of oxygen that occupants use and how much carbon dioxide they exhale. This allows researchers to track how the occupants use energy with unprecedented precision, says Anderson. The ratio between the two gases, combined with analysis of nitrogen in occupants’ urine, indicates whether the occupant is burning fat, carbohydrate or protein.

The trial participants, aged between 21 and 50, were randomized into two groups: 34 people in a test group reduced their calorie intake by an average of 15%, and 19 people in a control group ate as usual. At the end of each of the two years, they all underwent a range of tests related to overall metabolism and biological markers of ageing, including damage associated with oxygen free radicals released during metabolism. They were also placed in the metabolic chamber for 24 hours.

The scientists found that participants on the diet used energy much more efficiently while sleeping than did the control group. This reduction in their base metabolic rate was greater than would be expected as a result of the test group’s weight loss, which averaged nearly 9 kilograms per participant. All the other clinical measurements were in line with reduced metabolic rate, and indicated a decrease in damage due to ageing.

Model metabolism

Caloric restriction has been known for decades to extend life in different species. In the 1990s, scientists began to identify the genes and biochemical pathways actively involved in longevity in the short-lived worm Caenorhabditis elegans, and in the fly Drosophila melanogaster. These include pathways relevant to insulin sensitivity and the function of mitochondria — tiny structures in cells that use oxygen to generate energy. Subsequent studies revealed that calorie restrictions alter similar pathways in mice and monkeys. Mice on restricted diets can live up to 65% longer than mice allowed to eat freely, and the ongoing monkey studies hint at longer survival and reduced signs of ageing.

“The Rolls-Royce of a human longevity study would carry on for many decades to see if people do actually live longer,” says Pennington physiologist Leanne Redman, the lead author of the latest study. CALERIE ran for just two years, and was designed to see whether a calorie-restricted diet in humans induces some of the same metabolic, hormonal and gene-expression adaptations that are thought to be involved in slowing ageing in other species during long-term caloric restriction.

Few people would want, or be able, to restrict their diet as severely as the participants in the study. “But understanding the biology of how restricting calories extends life will allow us to find easier ways to intervene,” says Anderson.

Redman would like to repeat the study, combining less-ambitious calorie restriction with a diet containing antioxidant food to control oxidative stress, or with a drug such as resveratrol, which mimics key aspects of calorie restriction.

Other scientists are starting to try out the effect of restricting calories for just a few days every month. Such intermittent restriction has been found to be as effective as continuous calorie restriction in protecting mice against diseases of ageing such as diabetes and neurodegeneration2. “I think that’s going to be a way to get all the benefits, without the problems of constant dieting,” says gerontologist Valter Longo of the University of Southern California in Los Angeles, who is embarking on clinical trials of intermittent calorie restriction in various disorders.

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Isabel Rangel Barón: Mystery fiction and being a better internist

As a child, mystery fiction captivated me.  Probably the Bobbsey Twins, then the Hardy Boys and Nancy Drew started the passion.  I remember the TV show Perry Mason, which led me to reading books from the Earl Stanley Gardner series.  Lt. Columbo captivated me.  Discovering Sherlock Holmes was an epiphany.  And throughout my life, I love finding great new mystery authors.

I suspect that my love of mystery fiction made my choice of internal medicine inevitable.  While our field has many dimensions, the core of being a good internist is accurate diagnosis.  While sometimes diagnosis is straightforward, often the patient’s story unfolds much like a mystery novel.

Clinical reasoning has attracted many internists.  The field of cognitive psychology helps us understand the road to excellence and the pitfalls along the way.

But recently I have paid much attention to the brilliance of mystery fiction writers.  Literature (and yes the mystery genre is literature) often gives insights into the human condition.  As I read mysteries or watch mystery TV or film, I often see parallels to our field.  Here are a few examples:

“The world is full of obvious things which nobody by any chance ever observes.” ? Arthur Conan Doyle, The Hound of the Baskervilles

While we often see the patient, our training should teach us to really observe.

“I’ve learned over the years that sometimes if you ask the same question more than once you get different responses.” ? Michael Connelly, The Brass Verdict

We learn this truth as students and residents.  The attending physician often gets a better answer the next day.  Patients think about their situation and often recall details that did not come initially to mind.

“It often seems to me that’s all detective work is, wiping out your false starts and beginning again.”

“Yes, it is very true, that. And it is just what some people will not do. They conceive a certain theory, and everything has to fit into that theory. If one little fact will not fit it, they throw it aside. But it is always the facts that will not fit in that are significant.” ? Agatha Christie, Death on the Nile

How true this is!  Our biggest flaw is falling in love with a diagnosis.  Sometimes the diagnosis is thrust onto to the patient before we see the patient.  We must always re-examine our thoughts for our patients.  If the treatment is working beautifully and the patient’s respond fits our knowledge, we can stick with a diagnosis, but when the course wanders away from the expected we need the courage to doubt ourselves and everyone else.  We must start over from the beginning and not assume anything.

I have found many more great quotes.  Many mystery writers have great insights into the detective process.  And since we pride ourselves as detectives, I believe we can learn from their wisdom.

If you have quotes from mystery writers that make important points, please share them with me and our readers.  I will gladly share them with attribution on this blog and on twitter.

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Isabel Rangel Barón: An efficient deep-learning tool for detecting eye disease

An efficient deep-learning tool for detecting eye disease

A new artificial-intelligence tool deploys a highly efficient form of deep learning to diagnose eye disease from medical images.

Convolutional neural networks are deep-learning algorithms adept at processing images, but researchers typically need to train them on more than a million medical images before they can test how well the algorithms work. Kang Zhang at the University of California, San Diego, in La Jolla and his colleagues created a kind of convolutional neural network capable of learning with many fewer images.

The team trained the model on 108,000 images of retinas. All had been classified by experts as either healthy or showing signs of a leading cause of blindness: macular degeneration or diabetic macular edema, a build-up of fluid in the retina. The algorithm identified critical cases of these conditions as accurately as six experts in ophthalmology.

The model also identified pediatric pneumonia from chest X-rays, suggesting that the technique could be broadly applied across medicine.

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