Resources for Evidence-Based Veterinary Medicine

I write extensively about the ways in which alternative therapies are justified, and the problems with much of the evidence used to promote them. I talk less here about the way all veterinary therapies should be evaluated and appraised, through the processes of evidence-based veterinary medicine (EBVM). This is a subject I write and speak about often elsewhere, but which hasn’t been a major focus of this blog, though it is the EBVM approach which I use to evaluate all the therapies I do write about.

Since I suspect many readers will be interested in how the veterinary profession can do the best possible job determining the risks and benefits of the therapies we offer, I thought I would highlight a few resources that illustrate the EBVM approach. Even though these do not directly address the issues of alternative medicine, they demonstrate the kind of critical, science-based evaluation that should be applied to all veterinary treatment. It is this kind of appraisal which often reveals how little substance there actually is behind the claims made for many CAM practices.

The Evidence-Based Veterinary Medicine Assocation (EBVMA) is the main organization promoting EBVM here in the U.S., and it is a great resource for learning more about EBVM and for veterinarians seeking to support an evidence-based approach.

The Centre for Evidence-Based Veterinary Medicine (CEVM) at the University of Nottingham is a robust and vibrant center of research and teaching in EBVM. They have recently launched a couple of tools for veterinarians that illustrate the possiblities for the future of our profession.

The first is their new critically appraised topic database BestBETs for Vets  “BET” stands for Best Evidence Topic. The BestBETs concept was first developed for doctors working in emergency medicine (http://www.bestbets.org/). In collaboration with our medical colleagues, the folks at CEVM have developed a freely accessible database of BestBETs for veterinarians. Though the number of topics is currently small, this is a dynamic project which will eventually be an important resource for veterinarians interested in making the best, most evidence-based decisions.

The team at CEVM has also launched VetSRev. VetSRev is a freely-accessible online database of citations for systematic reviews of relevance to veterinary medicine and science.  As regular readers know, a systematic review is the most comprehensive and unbiased assessment of the total body of clinical research on any given subject. The number of systematic reviews in veterinary medicine has exploded in recent years, which makes it much easier for veterinarians to quickly and reliably find the “bottom line” for many diagnostic tests and treatments.

Posted in Science-Based Veterinary Medicine | 11 Comments

Animal Naturopathy

Naturopathy is a pleasant-sounding term for an approach to health and disease that is quite different from that of science-based medicine. It is an example of an alternative philosophy that has great appeal for from a certain perspective but which, when examined closely, has little real substance.

What Is It?
According to the American Council of Animal Naturopathy (ACAN), naturopathy is an ancient practice, “naturopathy has been around since the fall of Adam and Eve.” According to more neutral and skeptical sources, it took shape in Europe in the late 19th century. ACAN defines naturopathy as:

a philosophy and system of prevention of disease first and then treatment of disease that avoids drugs and surgery and emphasizes the use of nature or natural agents such as exercise, water, herbs, etc. to assist the body in bringing its self back into balance and health.

As is often the case with alternative therapies, this is contrasted with a rather caricatured description of conventional veterinary medicine:

Today’s veterinarians are in the business of disease care, they hold doctorate titles from colleges that teach them anatomy, biology, chemistry and surgery. They are taught how to use modern, high tech equipment to diagnose while the pharmaceutical companies teach them which drug to prescribe or use to treat or suppress the symptoms of the dis-ease or illness the animal is presenting with.

The Six Principles of Naturopathy, identical to those espoused by human naturopathic organizations such as the American Association of Naturopathic Physicians (AANP),  describe the philosophy in more detail. Some key points are:

The body has the inherent ability to heal itself. This healing process is intelligent and ordered.

Every illness has a cause. Causes may occur on the physical, mental or emotional level. Symptoms are expressions of the body’s attempt to heal, but are not the cause of illness.

Animal Naturopaths use nature’s methods that minimize the risk of harmful side effects. Methods designed to suppress symptoms but not remove the underlying cause are usually harmful, their use is always avoided. [by which they mean most scientific medical therapies]

All aspects of that animal (physical, mental and emotional) are taken into account.

Illness is due to improper diet, habits, exposure to toxins and general lifestyle. 

Does It Make Sense?
The assumptions upon which naturopathy is based are questionable. The distinction between “natural” and “unnatural,” and the suggestion that the former is equivalent to “healthy” and the latter to “unhealthy,” is an appealing but ultimately vacuous idea. There is no clear line dividing natural from unnatural. Are cooking, farming, tool-making, wearing clothes, or other human behaviors that alter the world we live in inherently unnatural and unhealthy? Is it a matter of degree? Is it ok to cook plants as part of preventative or therapeutic medicine, but not ok to extract medicinal compounds from plants? It quickly becomes clear that the distinction between natural and unnatural is capricious and arbitrary, and it is not a sound basis for deciding what is healthy and what is unhealthy for us or our pets.

The idea that natural things, even if we could agree on what these are, must be healthier than unnatural things is pretty obviously false. Uranium, arsenic, botulism, rattlesnake venom, and many other “natural” things are harmful or even deadly. And clearly artificial things, like the growing of food crops, sanitation and water treatment, and medical interventions such as vaccines and antibiotics have improved the length and quality of human life far more dramatically in the last few centuries than all the efforts of the tens of thousands of years before we developed a scientific approach to understanding and manipulating our world. The fact that some of the things we create are harmful doesn’t validate the belief that anything human made is unhealthy and anything unchanged from its natural state must be healthy.

Naturopathy is, itself, a complex and purely artificial set of beliefs and practices that no other animal employs and that humans invented along with all of our other unique beliefs and behaviors. Calling it natural, and labeling scientific medicine unnatural is simply s statement of belief, not a factual or verifiable claim.

Because the philosophical basis for naturopathy is so vague and ill-defined, the actual practice of naturopaths encompasses almost any form of alternative therapy. Among the practitioners listed on the ACAN website as Certified Animal Naturopaths, you find practitioners of homeopathy, Traditional Chinese Medicine, iridology, and other therapies that are questionable or completely lacking in any validity. Whatever a particular practitioner chooses to define as “natural” is apparently acceptable within a naturopathic approach apart from vaccines, pharmaceutical medicine, and many other conventional therapies.

It is important to point out that this “board certification” in naturopathy is not recognized by the American Board of Veterinary Specialties which regulates veterinary medical specialties. It is equivalent to similar certifications for homeopaths, psychics, and astrologers in that it is invented by naturopaths to legitimize themselves and is not recognized by mainstream veterinary medicine. In fact, there is no requirement that those who take the various certification courses the ACAN offers be veterinarians or trained healthcare professionals. The ACAN web site states,

as long as you are 18 years of age or older, these courses are designed to educate no matter what level of current knowledge you may have. They prepare you to be certified in animal health coaching, nutrition consulting or animal naturopathy consulting or to inform and educate you just for your own knowledge to help your own pets if that is what you are looking for.

It seems implausible that a powerful approach to healthcare superior to modern medicine is also so simple that it can be learned and practiced by anyone without any scientific or medical knowledge. Surely such a method would have replaced all other medical practices before now?

Historically, naturopathy has been a vitalist philosophy, identifying disease as a state of imbalance in not only the physical body but the mind, spirit, or vital essence of a creature. This philosophy rejects predominantly physical causes of illness and instead considers the root of disease to be in non-physical, spiritual factors. As one proponent has put it, “vitalists analyze bodily illness mainly in terms of the spiritual factors that might be contributing to it…Disease, according to vitalists, is simply a more advanced stage of the stress that we exhibit when we persistently fail in the pursuit of physical and spiritual goals.”

Because this essentially dismisses all the progress made by science in understanding the causes and treatment of disease, and because it identifies naturopath as a purely faith-based practice, naturopaths often de-emphasize this element of their philosophy and talk more vaguely about the “inherent healing power” of the body rather than the “vital force” or spirit. It is true that the body has a remarkable capacity to heal itself and many ailments resolve without treatment, or in spite of treatment, which is one of the reasons ineffective therapies can appear to work even when they do nothing. However, naturopaths claim this inherent healing power is “intelligent and ordered,” which is a faith-based claim that cannot be examined or tested in any objective way. They also claim that this healing power can be supported by their recommendations and impeded by scientific medical therapies, which is contrary to a great deal of actual evidence.

One major problem with vitalism as a foundation for medical therapies is that its principles have to be accepted or rejected entirely on faith, which makes any claim one chooses to make immune from any objective evaluation. Given the unprecedented success of science-based medicine compared to all the methods that went before it, it seems unwise to go backwards away from the practice of objectively and critically evaluate medical claims by established scientific means.

Does It Work?
Of course the first step in answering this question is to define what “it” is, which as we’ve seen is difficult because there is no consistency to the specific interventions naturopaths employ. I have written before about homeopathy, TCM, herbal medicine, and many of the specific treatments naturopaths recommend. Many of these are unproven or clearly ineffective. Others, like herbal remedies, probiotics, and some dietary supplements may have some benefit. Categorizing them all as “natural” tells us nothing about which are helpful and which aren’t.

However, many of the recommendations naturopaths give, especially for humans, are identical to those given by conventional doctors. No one disagrees with the idea that clean, healthy food is essential for life, though what exactly this means may not be open to dispute. Similarly, clean fresh air and water, appropriate exercise, and a positive attitude are undoubtedly good for everyone, though they may not be the key to perfect health or immortality. The fact is that much of what naturopaths recommend may be perfectly reasonable, or even supported by good scientific evidence despite the fact that they are recommending it regardless of the evidence and based on a philosophy incompatible with science.

Like many alternative medicine proponents, naturopaths are happy to cite scientific research when it supports their beliefs and claims, but they are likely to dismiss any which does not. Because naturopathy is a vague philosophy encompassing many different practices, it is difficult to study in a controlled manner, and there is relatively little research on the general approach. A recent attempt at a systematic review of naturopathy found 12 studies that met the inclusion criteria, and while they appeared to show some benefits, they all had significant weaknesses and limitations that made it impossible to draw and reliable conclusions. The National Center for Complementary and Alternative Medicine (NCCAM), the American Cancer Society, and other government and private organizations have stated that there is currently no real evidence to support the claims of naturopaths. There also appears to be absolutely no controlled clinical research on naturopathy in veterinary species.

That leaves only the inevitable testimonials. For reasons I’ve discussed many times before, individual anecdotes provide no real evidence to support or reject medical therapies. At best they can suggest potential benefits or risks to be examined more closely, but despite the fact that they are highly persuasive, they are not a trustworthy source of information about naturopathy or any other medical practice.

Is It Safe?
Again, it is difficult to comment on the safety of naturopathy as a general approach because it is so ill-defined and specific therapies are not consistent between practitioners. The risks of particular practices, such as homeopathy, herbal medicine, TCM, and all the particular alternative therapies employed by naturopaths can be considered separately. The biggest risk of the philosophy itself is that it often involves counseling people against seeking and using conventional medical diagnostics and treatments. Naturopaths are frequently opposed to vaccination, for example, which is a position that clearly places people and animals at unnecessary risk of illness and death from preventable diseases. Naturopathy, like any other pre-scientific and unproven medical practice, is not a safe or reliable substitute for scientific medical care, and eschewing conventional care in favor of naturopathy risks losing the opportunity to receive effective therapy in a timely way.

Naturopaths often present themselves as appropriate substitutes for primary care doctors, for humans and animals, despite the fact that many of them lack of any real scientific or medical training. Even in those instances when the therapy they recommend is reasonable (such as diet and exercise advice) or harmless in itself (such as homeopathy), these individuals are not qualified to detect and respond to serious health problems.

Bottom Line
Naturopathy is a vague vitalist philosophy that identifies the causes of disease as imbalances in the vital life force or spirit and in supposed dietary deficiencies or undefined environmental toxins. The basic principles of the approach are unproven and, in the case of the claim that the roots of disease are spiritual, untestable.

Naturopaths use a hodgepodge of different alternative therapies according to their personal training and inclinations. Some of these are clearly ineffective nonsense (e.g. homeopathy, iridology), others are merely unproven but at least plausible (e.g. herbal remedies, dietary supplements), and some are consistent with conventional medical recommendations (e.g. exercise, some dietary advice). It is difficult to study the overall risks and benefits of naturopathy due to the varied and inconsistent treatment offered by individual practitioners. There is little research evidence in humans and none in veterinary species to support naturopathy as an effective approach.

The risks of individual therapies offered by naturopaths are also varied. Some, such as homeopathy, have no direct effect at all, for good or ill. Others, such as herbal remedies, can cause harm directly. The greatest risk, however, from naturopathic treatment is that naturopaths often recommend avoiding conventional medical care, include vaccines, surgery, and pharmaceutical medicine. Substituting unproven, untested, or ineffective therapies for scientific medicine is not an appropriate way to seek health or treat disease.

 

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An Evidence-Based Medicine Anthem?

Posted in Humor | 2 Comments

U.K. May Ban Unlicensed TCM Drugs

I’ve written about so-called Traditional Chinese Medicine (TCM), which is not actually traditional and which is a collection of untested folk beliefs that are inconsistent with much established scientific knowledge. The biggest problem with TCM, however, is that the remedies used are real drugs. They are combinations of plant and animal ingredients which are frequently mislabeled and sometimes completely secret, and they are often found to contain unidentified pharmaceuticals mixed in with the “natural” ingredients, or toxic heavy metals like lead and mercury. A list of reports on the dangers of these remedies can be found here.

Despite frequent acknowledgement from the government here in the U.S. that current regulations of herbal remedies generally are inadequate and not effectively enforced (1, 2), little political will exists to better protect the public from these products. However, it appears that the government of the U.K. is more willing to meet this challenge.

A recent news story indicates the U.K. equivalent of the FDA, the Medicines and Healthcare Products Regulatory Agency (MHRA) has asked vendors of unlicensed herbal products, including TCM remedies, to report their inventories in preparation for a ban on the sale of such remedies to be introduced next year. If true, this would represent a huge step towards treating such remedies as they should be treated, as drugs which need to pass the same scientific scrutiny for safety and efficacy as any conventional medication.

 

 

 

 

 

 

Posted in Herbs and Supplements | 4 Comments

2014 Roy Montgomery Research Award

The Evidence-Based Veterinary Medicine Association (EBVMA) announces the availability of an award of $3,000 to a single recipient (a person or group) designed to support research that promotes the understanding, development and application of evidence-based medicine (EBM) in veterinary medical research, practice, and education.

More information and eligibility requirements can be found at:

Roy Montgomery Research Award

The deadline for applications is Oct. 4, 2013.

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FDA Warns Consumers About Unsupported Claims for Hyperbaric Oxygen Therapy

I reviewed the evidence for Hyperbaric Oxygen Therapy (HBOT) recently after a series of conversations on a popular veterinary discussion forum (Veterinary Information Network: VIN) in which quite strong claims were put forward about the potential value of this therapy for pets. While HBOT is a plausible therapy for which there is some good evidence of benefit in specific situations, there are unfortunately many people promoting and selling this treatment with claims that go well beyond anything supported by real scientific evidence.

Such promotion has apparently become sufficiently extensive that the Food and Drug Administration (FDA) has come out with a new consumer warning emphasizing that HBOT is not approved or proven effective for most of the conditions for which it is advertized. This warning includes a specific, though not complete list of conditions for which HBOT has not been scientifically proven effective nor approved by the FDA. Several of these conditions were presented in the VIN discussions as being approved by the FDA, so I thought it would be useful to post the FDA statement here for clarification.

No, hyperbaric oxygen therapy (HBOT) has not been clinically proven to cure or be effective in the treatment of cancer, autism, or diabetes. But do a quick search on the Internet, and you’ll see all kinds of claims for these and other diseases for which the device has not been cleared or approved by FDA.

HBOT involves breathing oxygen in a pressurized chamber. The Food and Drug Administration (FDA) has cleared hyperbaric chambers for certain medical uses, such as treating decompression sickness suffered by divers.

HBOT has not, however, been proven to be the kind of universal treatment it has been touted to be on some Internet sites. FDA is concerned that some claims made by treatment centers using HBOT may give consumers a wrong impression that could ultimately endanger their health.

“Patients may incorrectly believe that these devices have been proven safe and effective for uses not cleared by FDA, which may cause them to delay or forgo proven medical therapies,” says Nayan Patel, a biomedical engineer in FDA’s Anesthesiology Devices Branch. “In doing so, they may experience a lack of improvement and/or worsening of their existing condition(s).”

Patients may be unaware that the safety and effectiveness of HBOT has not been established for these diseases and conditions, including:

  • AIDS/HIV
  • Alzheimer’s Disease
  • Asthma
  • Bell’s Palsy
  • Brain Injury
  • Cerebral Palsy
  • Depression
  • Heart Disease
  • Hepatitis
  • Migraine
  • Multiple Sclerosis
  • Parkinson’s Disease
  • Spinal Cord Injury
  • Sport’s Injury
  • Stroke

Patel says that FDA has received 27 complaints from consumers and health care professionals over the past three years about treatment centers promoting the hyperbaric chamber for uses not cleared by the agency.

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How HBOT Works

HBOT involves breathing oxygen in a pressurized chamber in which the atmospheric pressure is raised up to three times higher than normal. Under these conditions, your lungs can gather up to three times more oxygen than would be possible breathing oxygen at normal air pressure.

Patel explains that your body’s tissues need an adequate supply of oxygen to function. When tissue is injured, it may require more oxygen to heal. “Hyperbaric oxygen therapy increases the amount of oxygen dissolved in your blood,” says Patel. An increase in blood oxygen may improve oxygen delivery for vital tissue function to help fight infection or minimize injury.

Hyperbaric chambers are medical devices that require FDA clearance. FDA clearance of a device for a specific use means FDA has reviewed valid scientific evidence supporting that use and determined that the device is at least as safe and effective as another legally U.S.-marketed device.

Thirteen uses of a hyperbaric chamber for HBOT have been cleared by FDA. They include treatment of air or gas embolism (dangerous “bubbles” in the bloodstream that obstruct circulation), carbon monoxide poisoning, decompression sickness (often known by divers as “the bends”), and thermal burns (caused by heat or fire).

 

Posted in General, Science-Based Veterinary Medicine | 4 Comments

Evidence Update–Canine Cognitive Dysfunction

Canine Cognitive Dysfunction (CCD) is a common and significant disease in older dogs which resembles, in many ways, some forms of dementia in humans. I have written about proposed therapies several times (1, 2, 3). Because there is no highly effective therapy for this disorder, it is a condition for which many unproven treatments are marketed based almost entirely on anecdotes or theoretical rationale. A new study adds a little to our understanding of this disease
 Fast, R., Schütt, T., Toft, N., Møller, A. and Berendt, M. (2013), An Observational Study with Long-Term Follow-Up of Canine Cognitive Dysfunction: Clinical Characteristics, Survival, and Risk Factors. Journal of Veterinary Internal Medicine, 27: 822–829. doi: 10.1111/jvim.12109

The study involved evaluating geriatric dogs presenting to a general practice for routine care or minor health problems and classifying them as having CCD, borderline CCD, or no evidence of CCD based on a questionnaire. The dogs were characterized by symptoms, breed, and potential risk factors and then followed for 3 years to determine survival to this point.

The authors identified four primary clinical symptoms most consistently present in CCD dogs- sleeping during the day and restless at night, altered interaction, signs of disorientation at home, and anxiety. They did not find that eliminating indoors was a common symptom, which is important since this is often intolerable to owners and leads to considerations of euthanasia.

Interestingly, they did not find a difference in 3-year survival between dogs with and without CCD. The dogs with CCD received active therapy (selegilene, therapeutic diets, and behavioral stimulation), which might have had an impact on their outcome, though it isn’t possible to say from these data.

Finally, the authors evaluated Vitamin E levels in the different groups since it is often hypothesized that oxidative damage plays a role in the disease, and some prior studies have found decreased vitamin E levels in the brains of dogs and humans affected by dementia. In this study, however, no association between CCD and Vitamin E level was identified.

As is always the case, there are a number of limitations to this study, in particular the potential bias in how subjects were selected and the lack of systematic control for potential differences between subjects other than CCD. It is essentially a descriptive study, and as such provides some information about the characteristics of this population, but it cannot be used to draw definitive conclusions about the cause or treatment of CCD.

Posted in Science-Based Veterinary Medicine | 1 Comment

British Vets Denounce Homeopathy-But Refer Clients for it Anyway?

This is a guest post from a colleague in the United Kingdom, Arlo Guthrie

As the editor of VetSurgeon.org, the leading online community for veterinary surgeons in the UK, I thought it would be interesting to assess British vets’ attitudes to homeopathy. So I joined forces with Alex Gough MA VetMB CertSAM CertVC MRCVS, Head of Medicine Referrals at Bath Veterinary Referrals to conduct a survey of our members.

The survey generated a response from 460 veterinary surgeons, which equates to about 2.4% of all 18,000 or so vets in the UK, including those that don’t work in general practice. So, a good sample size. First we asked whether respondents practised homeopathy themselves. 6.2% did, which means that there was some bias in favour of homeopaths (a survey carried out in 2006 found that 4.6% of British vets claimed complementary medicine as a speciality). We also asked whether homeopathy is routinely available to clients through the respondent’s practice. 7.7% said it was.

So to the first question to assess practitioners’ attitudes to homeopathy. We asked: ‘In your opinion, are there any veterinary medical conditions for which homeopathy could be an effective treatment? We deliberately couched this question in the broadest possible terms: ‘any’ and ‘could’. Despite this, a resounding 83.4% said ‘NO’.

In our next question, we sought to judge the depth of disbelief surrounding homeopathy. We asked: ‘Which would best describe your opinion of veterinary homeopathy?’. 77.4% answered ‘An ineffective form of veterinary medicine’. 9.5% said: ‘A rarely effective form of veterinary medicine’. 8.6% said: ‘An occasionally effective form of veterinary medicine’, and a paltry 4.5% said: ‘A reliably effective form of veterinary medicine’.

As a further indication of how strongly British practitioners believe that homeopathy is ineffective, 73% said that they believe that owners should sign a statement that they understand that in trials, homeopathy has been shown to be ineffective.

We also asked: ‘Do you feel it is appropriate for veterinary surgeons to practise homeopathy?’. 78.5% said ‘NO’.

All in all, a unequivocal result. Simply put, the overwhelming majority of British veterinary surgeons think homeopathy is wholly ineffective.

But how do they respond when asked by a client to refer a pet for homeopathy? In our survey, 24.3% of respondents said they would refer to a homeopath. A further 33.8% said they would explain that homeopathy does not work, but refer the case anyway. So that’s nearly 60% that would be prepared to refer, despite the majority believing that homeopathy is completely ineffective. 17.6% said they would explain that homeopathy does not work, and that the client will need to self-refer. 24.3% said they would explain that homeopathy does not work, and recommend the client does not self refer.

There are a number of possible hypotheses as to why vets may be prepared to refer clients for homeopathy, including a belief that they may retain some measure of control over the case, a fear of alienating the client, and the oft-stated argument that ‘it’s water, it’ll do no harm’.

We would argue that it’s the bigger picture that general practitioners need to consider; that the very act of referring endows homeopathy with a cloak of respectability which is simply not supported by science (on the contrary, it would require that we dismiss most of the proven laws of physics and chemistry).

It’s estimated that over £40M is spent on homeopathy annually in the UK, including £4M by the National Health Service. The sooner that more veterinary surgeons and their colleagues in human medicine are prepared to join the 24% of vets that refuse to endorse homeopathy, the sooner this money could be spent on effective methods of relieving suffering, both human and animal.

 

 

 

Posted in Guest Posts, Homeopathy | 93 Comments

The Marketing of Veterinary Homeopathy

There has been quite a bit of public discussion and debate about veterinary homeopathy this year. This is due in large part to the Connecticut Veterinary Medical Association (CVMA) resolution presented to the American Veterinary Medical Association (AVMA) House of Delegates identifying homeopathy as an ineffective and unscientific therapy. Though the resolution was ultimately relegated to “consideration” by a committee unlikely to act on it in any substantive way, it did expose the overwhelming evidence that homeopathy is nothing more than a placebo. The resolution also stimulated a vigorous, often highly emotional response from supporters of homeopathy, and several complex but ultimately unconvincing attempts to present homeopathy as scientifically valid and legitimate.

A key organization involved in promoting and defending homeopathy is the Academy of Veterinary Homeopathy (AVH). I have written about them several times in the past, including a detailed look at their recommended Standards of Practice and coverage of the AVH lawsuit against the American Association of Veterinary State Boards (AAVSB) attempting to force recognition of their continuing education courses when the AAVSB ruled they did not meet acceptable scientific standards. The most recent issue of the Journal of the Academy of Veterinary Homeopathy provides some useful insights into how the members of this organization think and how they plan to continue promoting this discredited therapeutic approach.

As I have discussed before, proponents of alternative therapies generally, including homeopaths, tend to rely heavily on case reports as supporting evidence. Case reports are simply structure, published anecdotes, and while they are useful for suggesting hypotheses to test, they prove absolutely nothing. They are no more reliable than any other medical miracle story.

Yet the AVH goes so far as to call their annual meeting “The AVH Annual Case Conference,” and the journal reports almost exclusively anecdotes and no formal, controlled studies. Though there are controlled clinical trials done to investigate homeopathy (which, when looked at carefully, do not support any real effects), homeopaths still rely on uncontrolled individual observation as the core type of evidence both to validate specific homeopathic interventions and to guide the development of the discipline. This is fundamentally inconsistent with scientific and evidence-based medicine, which recognizes the low reliability and high risk of bias associated with such evidence.

Many of the case reports share some common elements:

  1. There is no objectively confirmed definitive diagnosis.
  2. Conventional therapy (whether appropriate or inappropriate) is identified as having failed.
  3. Conventional medical practices are frequently implied to have caused or worsened the problem.
  4. Homeopathy is claimed, or implied to have cured the problem.

All of these cases are therefore emotionally compelling arguments against conventional medicine and for homeopathy which, unfortunately, include absolutely no control for bias or error and actually prove nothing. This is marketing, or perhaps more accurately proselytizing, masquerading as science.

Here are a couple of examples:

a three-year-old miniature stallion…presented with acute and persistent seizure activity which occurred a week after a rabies vaccination coupled with a very traumatic tooth floating experience. The complementing video clips clearly demonstrated the symptoms, patient care and the progression to full recovery!

a two-year FS, mixed breed dog presented after an array of suppressive and intensive therapy (including a ligated carotid artery) for a chronic purulent and bloody nasal discharge. Once every(!) diagnostic and therapeutic technique had been tried, [the owner] turned to homeopathy. [The homeopath], using Aurum, guided [the pet] and her guardian through the re-emergence and eventual clearing of suppressed skin, emotional, digestive and nasal symptoms.

A family crisis results in a serious symptom emerging [in a MN DSH]: a suspected nasal squamous cell carcinoma…Gradual, ascending potencies (along with nutritional support from CoQ10, Standard Process Cataplex ACP and Feline Immune Support) resolved all symptoms. Since the last remedy, he has remained well for over a year. [This illustrates] Aphorism 17 regarding cure: “through taking away the entire complex of perceptible signs and befallments of a disease, the internal alteration of the life force which is lying at its base (consequently the totality of the disease) is simultaneously lifted.”

one of her patients was sent home to die in an anemic almost comatose state after diagnosis with inoperable bleeding tumors. Her courage and patience in prescribing assisted this very fragile individual to make what so far is a complete and miraculous recovery.

Apart from a misleading emphasis on uncontrolled anecdotes, the AVH journal illustrates the inconsistent attitude of the veterinary homeopathy community towards science and the disingenuous use of scientific research as a marketing tool.

Dr. Shelley Epstein is one of the most prominent homeopaths claiming that homeopathy is a proven and scientifically legitimate field. I have responded to her arguments in detail before (The Science of Homeopathy?, The Evidence for Homeopathy-A Close Look). Essentially, she simultaneously claims that randomized clinical trials support the efficacy of homeopathy (referring primarily to poor quality positive trials with high risk of bias and completely ignoring better quality negative trials and the systematic reviews of the literature which show no convincing evidence of a clinically measurable effect beyond placebo) and argues that typical RCT design is inappropriate to apply to “individualized” homeopathic therapy.

In this issue of the AVH journal, Dr. Epstein is reported as continuing to assert that there is consistent and reliable evidence for the mechanism and benefits of homeopathy, despite the lack of acceptance of this evidence by anyone in the scientific community, apart from practitioners of alternative therapies:

We have moved well beyond whether homeopathy can be measured, into being able to measure nanoparticle quality control issues among the starting homeopathic products; measure specific frequency differences between remedies and their potencies; measure variation in particle and aggregate size and shape; and measure elemental composition of the homeopathic particles. Studies are finding out how nanoparticles remain dispersed in solution via the hypotheses that trituration generates nanofraction formation, lactose acts as stabilizer to prevent aggregation, dilution allows larger raw particles to settle out and nano-clusters to disperse freely in the medium. Other research involves remedies as nanomedicines and how their dissolved silicate structures carry remedy information into the body.

I have discussed the subject of “nanoparticles” as a validation of homeopathy elsewhere. I have also previously addresses the subject of “hormesis,” which Dr. Epstein also attempts to stretch from a narrow scientific phenomenon having nothing to do with homeopathy into some kind of scientific validation of homeopathic principles. Such misuse of nanoparticle physics, quantum physics, and other obscure but legitimate scientific fields is a hallmark of pseudoscientific rationalizations of alternative therapies.

However, even more dramatic examples of pseudoscience taken seriously are available in the AVH journal.

One speaker openly discusses the true nature of homeopathy as a form of spiritual healing, a religious belief rather than an approach to medicine compatible with science:

Let’s look at Aphorism11 of the Organon:”…initially only the spirit-like, autonomic life force…is mistuned… Only the life principle…can induce in the organism the irregular functions that we call disease.” We know this, but it is still easy to get lost in the perceptions of material agents as causes of disease. When we use vision in homeopathy, it is not to observe the causal agent but to perceive the effects of this disturbance of the life force….Homeopathy is right in the mix with a growing evidence base to show that homeopathic preparations can affect gene expression. While gene expression is in the physical realm, it can be altered via an energetic medicine.

And in his presentation, the legendary veterinary homeopath Richard Pitcairn

continues to stretch our perceptions of time and reality. Thought provoking indeed was the discussion of multiple personalities. Some with individual disease processes were definitely confounding. In one personality there would be a documented severe eye injury which would completely and instantly disappear as he shifted to his other personality….Some multiples changed eye colors between the personalities.

How the AVH can simultaneous claim scientific legitimacy and promote nonsense like this is truly mysterious. However, the AVH appears to recognize that homeopathy has an image problem (though not that this problem is that too many vets recognize it for the pseudoscience that it is). The journal editor speaks directly to this subject:

holistic or CAVM or integrative veterinary medicine is taking a more prominent role. With that increased visibility and scrutiny comes the need to act and practice responsibly. We have often been viewed as the insurgents in veterinary medicine and…it behooves us to present ourselves in a more conventionally professional way. I think we need to be aware that every column we write, every blog we post or forum letter we write can have a far-reaching impact. This is doubly true if we are venting or criticizing colleagues, organizations or disciplines. 

I certainly support respectful, substantive disagreement within the veterinary profession, and I have often been disturbed by the extreme, sometimes religious zeal with which proponents of alternative therapies sometimes respond to quite polite and evidence-based critiques of their methods. For example, one prominent supporter of homeopathy responded to the CVMA resolution presented to the AVMA by linking it to the Holocaust. Another once responded to a post of mine criticizing the American Holistic Veterinary Medical Association (AHVMA) by calling me a “shill for the pharmaceutical companies” and claiming that “threatened financially and ideologically, [he] must resort to political tactics of attack, shock and awe using headlines inspired by the National Inquirer or some other ladies gossip rag.”

To be fair, I too have sometimes been guilty of letting my emotions get the better of me and expressing my objections to specific practices in an excessively personal and inflammatory way, especially in the early days of blogging about the subject. However, I think it is a greater problem that healthy debate about the merits of alternative therapies is often impossible due to the passionate hostility that often greets any criticism of such approaches. It would be better for our profession if we could keep our disagreements civil and focused on ideas and evidence.

Unfortunately, I suspect this call for a more thoughtful tone in responding to critics of homeopathy may be more about perception and public relations than a true desire for substantive and respectful engagement. This suspicion is heightened by the announcement in the AVH journal that,

The AVH has hired a public relations representative. Peter Gold has experience working with the National Center for Homeopathy (NCH) and other organizations. Our goals are to increase awareness about homeopathy, build membership and raise funds for AVH.Your contributions (case testimonials, anecdotes, homeopathy tips etc.) are also needed….

AVH is blessed to have marketing director Peter Gold, who has been very helpful promoting AVH and homeopathy. His latest accomplishment was establishing a connection with Dogs Naturally magazine. I’d like to give everyone a gentle push to submit your success stories to Peter and the magazine. This is an excellent opportunity to get the word out about homeopathy.

The summer issue of the AVH journal also provides an update on the AVH lawsuit against the AAVSB. The AVH lost their case at every level, including a final failure on appeal to the Virginia State Supreme Court. However, they still consider it a worthwhile effort:

There was speculation that perhaps the AVH’s stand against AAVSB may have been the instigation for much of the current interest in homeopathy, reorganization of the holistic review committee of RACE and the impetus for other similar suits from holistic veterinary organizations.it was well worth the fight and achieved some worthy goals.

It is telling that the AVH has a legal advisor who has helped them pursue a 4-year lawsuit and now a marketing and public relations advisor, both employed to promote homeopathy by means other than rigorous scientific research. This illustrates the purpose of this organization, which is to function as an advocacy and marketing agency and a support group for practitioners of homeopathy, not as a scientific “academy” investigating homeopathy in an objective way. Homeopathy is a faith-based system in which scientific evidence is never a reason to question or reject existing dogma. The selective use of research findings by the AVH is not about discovering the truth but about developing marketing tools to create the impression of scientific validity.

There’s nothing inherently wrong with promoting a practice one believes in, of course. It is simply worthwhile for anyone evaluating the claims or evidence put forward by the AVH and its members to be aware that the organization is not interested in questioning or investigating the dogma of homeopathy in any objective way, and that scientific evidence is only employed by this group as a marketing tool, not as an impartial guide to what is true or false. While the group may claim that science supports homeopathy, this claim is inconsistent with

  1. The AVH’s promotion of blatant mysticism and pseudoscience such as illustrated by this journal
  2. The AVH’s use of litigation and public relations efforts to gain acceptance for a practice that cannot be effectively promoted on the basis of its scientific merits
  3. The selective and biased use of scientific research to promote an unshakable belief rather than to identify effective and ineffective therapies.

The AVH purports to represent the mainstream beliefs and attitudes of veterinary homeopaths. If this is true, then there is no better illustration of why homeopathy as a discipline is inconsistent with science and should not be viewed as a legitimate veterinary therapy. The scientific evidence is clear and consistent that homeopathy is nothing more than a placebo, and all the litigation and public relations spin the AVH generates can do nothing to alter this.

Posted in Homeopathy | 16 Comments

Benefits and Risks of Neutering, An Evidence Update: Age at Neutering and Risk of Obesity

This is another in my series of evidence updates on the risks and benefits of neutering in dogs and cats. I will be updating the evidence and conclusions of my original 2010 review as relevant new findings become available. This update concerns risk of being overweight or obese, which is one of the most common medical problems faced by veterinary patients.

Lefebvre, SL. Yang, M. Wang, M. Elliott, DA. Buff, PR. Lund, EM. Effect of age at gonadectomy on the probability of dogs becoming overweight. Journal of the American Veterinary Medical Association. 2013;243(2):236-43.

Objective-To determine whether gonadectomy or age at gonadectomy was associated with the risk that dogs would subsequently become overweight.

Design-Retrospective cohort study. Animals-1,930 dogs gonadectomized between 1998 and 2001 at ? 6 months of age (n = 782), > 6 months to ? 1 year of age (861), or > 1 to ? 5 years of age (287) and 1,669 sexually intact dogs.

Procedures-Dogs were followed-up through medical records for ? 10 years or until a diagnosis of overweight (defined as overweight, obese, or having a body condition score ? 4/5) was recorded. Information extracted included age at study entry, sex, breed, breed-size category, hospital visit frequency, and diagnosis (yes or no) of overweight or diseases that might affect body condition. Relative risk of a diagnosis of overweight was assessed among age groups of gonadectomized dogs and between gonadectomized and sexually intact dogs.

Results-No difference was detected among dogs grouped according to age at gonadectomy with respect to the risk of being overweight. This risk was significantly greater in gonadectomized dogs than in sexually intact dogs, but only during the first 2 years after gonadectomy. Sexually intact male dogs were approximately 40% less likely to have this diagnosis (hazard ratio, 0.61; 95% confidence interval, 0.52 to 0.72) than were sexually intact female dogs; no difference in risk between the sexes was evident for gonadectomized dogs.

Conclusions and Clinical Relevance-Gonadectomized dogs had a greater risk of being overweight than did sexually intact dogs, but this risk was not influenced by age at gonadectomy

Previous research discussed in my original review has indicated that neutered animals are at greater risk of becoming overweight than intact animals. Interestingly, there is some indication that this is not due to a change in the calorie needs or activity or neutered animals but possibly a change in the satiety mechanism, the system which tells an animal when it is no longer hungry. Neutered animals appear to eat more after neutering, which leads to weight gain. In any case, regardless of the true mechanism, the weight gain associated with neutering can be avoided by proper restriction of the calories fed to our pets.

What has been less clear is whether the age of neutering influences the risk of obesity. This study has added some evidence to help answer that question, and the results appear to show that there is no effect of the age of neutering on the obesity risk.

There are a number of limitations in the conclusions we can draw from retrospective studies in general, and from the particular data set used here, and the authors discuss some of these in the paper.  Overall, however, this study provides yet another bit of useful data to help inform neutering decisions. If there are compelling reasons to neuter early (less than 6 months of age), as is often the case for unowned animals in shelters, we can be fairly confident that this will not greatly increase the risk of later obesity so long as the dogs are appropriately fed.

A somewhat surprising finding was that neutered animals appeared to be less likely to be diagnosed with osteoarthritis than intact dogs. Even more surprisingly, dogs diagnosed with arthritis in the study were less likely to be diagnosed as overweight. These findings contradict the usual understanding that obesity can predispose to osteoarthritis and that arthritis can reduce activity and possible worsen obesity. However, due to a number of methodological limitations, it is not possible to say if there is truly an increased risk of arthritis in intact dogs or, if so, why that might be. This provides an interesting question for further research, but not a reason to change current neutering practices.

Posted in Science-Based Veterinary Medicine | 5 Comments