I’ve written several times about how proponents of alternative therapies appear to view science and evidence-based medicine. (1, 2, 3)  I think it is critical in evaluating these practices, as pet owners or  veterinarians, to understand the philosophy and approach behind them. Alternative medicine advocates will frequently talk about their respect for science, and will laud studies that appear to support their claims. But in many cases, they are fundamentally not convinced that science is superior to personal experience or faith as a method of evaluating medical therapies, and they are virtually never willing to abandon a practice they believe they have seen work no matter how clear the evidence against it is. If people wish to apply such practices, of course they are free to make that choice. But they should be fully and honestly informed when they are being asked to choose belief and opinion over science and evidence.

The following are comments veterinarians who are advocates for alternative veterinary therapies and critics of conventional medicine. These illustrate some of the views that should concern those of us committed to a scientific approach to evaluating the treatments we use for our patients and animal companions. I will be adding to this collection of comments over time, just to have examples available of the kinds of misconceptions those of us committed to a science-based approach to medicine need to address in our efforts to educate and to promote evidence-based medicine.

Evidence-based Medicine
“Remember evidence based science is last to know.”

“#AHVMF strongly supports scientific process, but in seeking real answers we recognize that scientific practice is last to know. #pioneers”

“Since evidence based medicine can’t know what hasn’t been studied, a false separation of proven vs unexamined data fields arises.”

“Evidence based medicine is being miss used according to its creators. It was about integrative informed decision processes.”

“The evidence said the case would die, the people felt otherwise. They tried, they lived, they danced together & finally all died. Life! :-)”

“Evidence should inform decision making but not limit treatment options. Combining experience and evidence is called evidence based practice, an excellent model for advancing veterinary care in areas with less evidence. Patients need access to all options and guardians and clinicians want to know.”

Placebo
“At the root a healing from placebo IS real healing from the person. How do we improve self healing? Can we align w/ Nature simply powerfully.”

“Perhaps love is the basis of placebo. In that case let’s fill the world and to hell with the research. Ascendant mindfulness finds healing.”

Anecdotes/Stories
“Stories have an important place in discovery of new approaches and therapies in medicine. No cure? Find the stories and follow those paths.”

“Narrative medicine allows the telling of a story, the discovery of truth, its sharing and consequences. Help write a happy ending.”

Leading integrative veterinarian Richard Palmquist will describe how he went from skeptic to champion of integrative veterinary medicine through witnessing miraculous outcomes from integrative approaches, after conventional options were exhausted.

“I suggested we apply a dose of Caulophyllum 30c…about 45 minutes later a live calf was eased into the world.

I readily accept this is not a scientific experiment that would satisfy the cynically minded, but when one saw this repeatedly over a period of 15 years it held much greater sway for us than any scientific experiment.”

“As a veterinarian now practicing homeopathy and chiropractic almost exclusively,  I have all the proof I need every day in my practice to justify these modalities.”

Science
“It might take science >100-1000 years to categorize and understand some basic healing principles. Pioneers go first, science comes later.”

“#RealSearch is actual scientific pursuit of truth without interference in design or reporting of data. It seeks causal discovery. Support it. We don’t look because we believe, we believe because we have seen so many people and animals benefit from integrative therapies. Did you know the word believe means we find truth in or feel affection for an area? It’s an interesting word when we consider its origin. When we find something true, we love. When we love we find truth. These go hand in hand with healing, too. First we look, then we test, then we believe. THEN we LIVE. BE LIVE!”

“Universities exist to provide a circle for the exploration & perfection of love. At their core each subject, each expert is examining this.”

“Pearls of wisdom handed down through the generations, scientific studies, and Chinese terminology bring together knowledge that is most certainly true. Modern science and the trend toward evidence based medicine has many pitfalls, whereas the “tried and true” passed through centuries holds as much truth for me.”

“Science is powerful and wonderful and so important. We must not lose ourselves in the game of science while ignoring healing.”

Alternative Medicine
“Holistic medicine addresses the patient as a whole – body, mind, and SPIRIT. There is a level of reality beyond, and yet enmeshed in, the physical, material universe. If I did not have an appreciation of the spiritual aspects of my patients and their caregivers, they and I would become little more than robots.

Don’t settle for treatment by a robot.”

“There is evidence-based research that holistic medicine works, but many people are quick to dismiss it because the studies are not funded by pharmaceutical companies,” she says, “the research is there if people would just do it.”

“If your veterinarian (or medical doctor for that matter) is relying strictly on published medical information for his prescribed treatment options, then his therapy will be 90% flawed. In other words, he will get it right 10% of the time.”

“Lack of ‘adequate’ research is why alternative medicine is considered alternative and is excluded from EBM. This lack of “evidence” is also an excuse for the rejection and criticism of many helpful alternative therapies by well-meaning, conventional practitioners. This attitude may lead your veterinarian astray.”

“Critics of homeopathy like to throw up the term “evidence based medicine”, as if to suggest that pharmaceutical drugs are more scientifically arrived at. If they are evidence based, why are they always being withdrawn after causing injury and death? Let’s explore the actual evidence.

Bottom line: Drug companies commit fraud in drug testing, lie about drug effectiveness and safety, publish positive articles in peer reviewed journals and then sell those drugs to the public. The FDA redacts the wrong doing from their reports.

Now you know…. pharmaceutical drugs are NOT evidence based… period.”

“How does acupuncture work? We know that it does work from thousands of years of experience.”

“Traditional Chinese Veterinary Medicine (TVCM) has been used in China for about 3000 years. Originally the practice was handed down from father to son and you were only paid if you made your patient well. So you either got good at it or your family line died out. “

“Holistic practitioners believe that vital life energy is the most important factor in the health of the patient…Because medical science has defined itself on a strictly physical basis, it is true that vitalism is unscientific. By definition, vitalism embraces a concept about a nonphysical force that can never be understood within the current scientific, medical paradigm.”

I recently gave a lecture at the Western Veterinary Conference called “What You Know that Ain’t Necessarily So.” The purpose of this was to take some common or controversial beliefs and practices in veterinary medicine and discuss the scientific evidence pertaining to these. This was not intended as a definitive, “final word” on these subjects, but as an illustration of how weak and problematic the evidence often is even behind widely held beliefs. In some cases, these practices or ideas may actually be valid, but without good quality scientific evidence, we should always be cautious and skeptical about them.

Eventually, I will post recordings of the presentations themselves, but for now I am posting a summary of each topic.

Each starts with a focused clinical question using the PICO format.

P– Patient, Problem Define clearly the patient in terms of signalment, health status, and other factors relevant to the treatment, diagnostic test, or other intervention you are considering. Also clearly and narrowly define the problem and any relevant comorbidities. This is a routine part of good clinical practice and so does not represent “extra work” when employed as part of the EBVM process.

I– Intervention Be specific about what you are considering doing, what test, drug, procedure, or other intervention you need information about.

C– Comparator What might you do instead of the intervention you are considering? Nothing is done in isolation, and the value of most of our interventions can only be measured relative to the alternatives. Always remember that educating the client, rather than selling a product or procedure, should often be considered as an alternative to any intervention you are contemplating.

O– Outcome What is the goal of doing something? What, in particular, does the client wish to accomplish. Being clear and explicit, with yourself and the client, about what you are trying to achieve (cure, extended life, improved performance, decreased discomfort, etc.) is essentially in evidence-based practice.

This is then followed by a summary of the evidence available at each of the levels in the following pyramid (which is a pragmatic reinterpretation of the classical pyramid of evidence that is a bit more useful for general practice veterinarians).

Finally, I list the Bottom Line, which is my interpretation of the evidence.

Antibiotics, Endocarditis, & Dentistry

1. Clinical question

P- dogs & cats with periodontal disease

I- prophylactic antibiotics with dentistry

C- no antibiotics with dentistry

O- incidence of bacterial endocarditis

2. Synthetic Veterinary Literature

a. No systematic reviews:
b. No critically appraised topics

c. Guidelines-

…use of a systemically administered antibiotic is recommended to reduce bacteremia for animals that are immune compromised, have underlying systemic disease (such as clinically-evident cardiac, hepatic, and renal diseases) and/or when severe oral infection is present.

American Veterinary Dental College

3. Primary Veterinary Literature

Retrospective review of records for ~59,000 dogs with periodontal disease

periodontal disease was associated with cardiovascular-related conditions, such as endocarditis and cardiomyopathy.

• Concerns about diagnostic criteria
• Many data inconsistent with previous findings
• Study design not appropriate to establish causal relationship

Glickman, L.T. (2009)

• Retrospective case (70)/control(80) study
• No association between dental disease or Tx and endocarditis

Peddle, G.D. (2009)

4. Human Literature

a. Systematic Reviews

There remains no evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure. It is not clear whether the potential harms and costs of antibiotic administration outweigh any beneficial effect.

Glenny, A.M. (2013)

b. Clinical Practice Guidelines

Today, antibiotics before dental procedures are only recommended for patients…who have:

• A prosthetic heart valve or who have had a heart valve repaired with prosthetic material.
• A history of endocarditis.
• A heart transplant with abnormal heart valve function
• Certain congenital heart defects

American Heart Association

Antibiotic prophylaxis against infective endocarditis is not recommended:

• for people undergoing dental procedures
• for people undergoing non-dental procedures at the following sites:
• upper and lower gastrointestinal tract
• genitourinary tract
• upper and lower respiratory tract

Chlorhexidine mouthwash should not be offered as prophylaxis against infective endocarditis to people at risk of infective endocarditis undergoing dental procedures.

National Institute for Health & Care Excellence

Bottom Line

• Endocarditis is rare
• Dental treatment is probably not a major risk factor for endocarditis
• Antibiotics with dentistry are probably not useful in preventing endocarditis

Fun Fact!

• Antibiotics with dentistry are probably not useful in preventing endocarditis
• Overall bacteremia in 6 blood samples-
• Extraction + amoxicillin- 56%
• Extraction + placebo- 80%
• Toothbrushing- 32%

Although amoxicillin has a significant impact on bacteremia resulting from a single-tooth extraction, given the greater frequency for oral hygiene, toothbrushing may be a greater threat for individuals at risk for infective endocarditis.

Lockhart, P.B. (2008)

References
Glenny AM, et al. Antibiotics for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database Syst Rev. 2013 Oct 9;10:CD003813.

Lockhart, PB. et al. Bacteremia Associated With Toothbrushing and Dental Extraction. Circulation. 2008; 117: 3118-3125.

Peddle GD, et al. Association of periodontal disease, oral procedures, and other clinical findings with bacterial endocarditis in dogs. J Am Vet Med Assoc. 2009 Jan 1;234(1):100-7.

Glickman LT, et al. Evaluation of the risk of endocarditis and other cardiovascular events on the basis of the severity of periodontal disease in dogs. J Am Vet Med Assoc. 2009 Feb 15;234(4):486-94.

I recently gave a lecture at the Western Veterinary Conference called “What You Know that Ain’t Necessarily So.” The purpose of this was to take some common or controversial beliefs and practices in veterinary medicine and discuss the scientific evidence pertaining to these. This was not intended as a definitive, “final word” on these subjects, but as an illustration of how weak and problematic the evidence often is even behind widely held beliefs. In some cases, these practices or ideas may actually be valid, but without good quality scientific evidence, we should always be cautious and skeptical about them.

Eventually, I will post recordings of the presentations themselves, but for now I am posting a summary of each topic.

Each starts with a focused clinical question using the PICO format.

P– Patient, Problem Define clearly the patient in terms of signalment, health status, and other factors relevant to the treatment, diagnostic test, or other intervention you are considering. Also clearly and narrowly define the problem and any relevant comorbidities. This is a routine part of good clinical practice and so does not represent “extra work” when employed as part of the EBVM process.

I– Intervention Be specific about what you are considering doing, what test, drug, procedure, or other intervention you need information about.

C– Comparator What might you do instead of the intervention you are considering? Nothing is done in isolation, and the value of most of our interventions can only be measured relative to the alternatives. Always remember that educating the client, rather than selling a product or procedure, should often be considered as an alternative to any intervention you are contemplating.

O– Outcome What is the goal of doing something? What, in particular, does the client wish to accomplish. Being clear and explicit, with yourself and the client, about what you are trying to achieve (cure, extended life, improved performance, decreased discomfort, etc.) is essentially in evidence-based practice.

This is then followed by a summary of the evidence available at each of the levels in the following pyramid (which is a pragmatic reinterpretation of the classical pyramid of evidence that is a bit more useful for general practice veterinarians).

Finally, I list the Bottom Line, which is my interpretation of the evidence.

Immune-mediated Blood Disease & Vaccination

1. Clinical question

P- healthy dogs & cats

I- routine vaccinations

C- no vaccination (fewer)

O- incidence of Immune-mediated hemolytic anemia (IMHA) and immune-mediated thrombocytopenia (ITP)

1. Synthetic Veterinary Literature
   a. No systematic reviews:
   b. No CATs
2. Primary Veterinary Literature

• Case/control study
• Cases more likely to be vaccinated in previous month (26%) than controls (7%)
• Did not r/o pre-existing disease

Duval, D. (1996)

• 10% of cases vaccinated within 1 month
• No difference between cases and controls in time from vaccination to presentation

Carr, A.P. (2002)

• Proportion of dogs vaccinated within 2 months of onset not different between cases and controls
  • Cases- 16.1%
  • Controls- 44.4%

Davidow, E.B. (2004)

• Proportion of dogs vaccinated within 42 days of onset not different between cases and controls-
  • Cases- 8%
  • Controls- 14%

Huang, A.A. (2012)

• 4% vaccinated within 2 weeks
• Not primary purpose of study

Reimer, M.E. (1999)

• 2.4% vaccinated within 2 weeks
• Not primary purpose of study

Klag, A.R. (1993)

3. Human Literature
a. Systematic Reviews

• Database of 4.2 million children
• 55 cases of IMHA reported 1991-2001
• No association with vaccination

Naleway, A.L. (2009)

• ITP only associated with MMR
• 1-3 children per 100,000 doses
• This is lower than the rate of ITP caused by the diseases MMR prevents! (1:3000 to 1:6000 cases)

Cecinati, V. (2013)

Bottom Line

• Little evidence vaccination causes IMHA/ITP
• No consistent temporal association
• Data are weak
• Overwhelming majority of vaccinated animals do not develop these diseases
• Infection can be a greater risk for IMHA/ITP than vaccination
• Don’t vaccinate more than necessary
• Don’t vaccinate less than necessary
• Don’t avoid vaccination out of fear of IMHA/ITP

Reference

Carr AP, et al. Prognostic factors for mortality and thromboembolism in canine immune-mediated hemolytic anemia: A retrospective study of 72 dogs. J Vet Internal Med.2002;16:504-509.

Cecinati V. Hum Vaccin Immunother. Vaccine administration and the development of immune thrombocytopenic purpura in children. 2013 May;9(5):1158-62.

Davidow EB, et al. Risk factors for development of IMHA-A prospective case-control study. Abstract. VECCS 2004.

Duval D et al. Vaccine-associated immune-mediated hemolytic anemia in the dog. J Vet Internal Med. 1996;10:290-295.

Huang AA, et al. Idiopathic immune-mediated thrombocytopenia and recent vaccinations in dogs. JVIM 2012; 26: 142-148.

Klag AR, et al. Idiopathic immune-mediated hemolytic anemia in dogs: 42 cases (1986-1990). J Am Vet Med Assoc. 1993;202:783-788.

Naleway AL. et al. Risk of immune hemolytic anemia in children following immunization. Vaccine. 2009 Dec 9;27(52):7394-7.

Reimer ME, Troy GC, Warnick LD. Immune-mediated hemolytic anemia: 70 cases (1988-1996). J Am Anim Hosp Assoc. 1999;35:384-391

I recently gave a lecture at the Western Veterinary Conference called “What You Know that Ain’t Necessarily So.” The purpose of this was to take some common or controversial beliefs and practices in veterinary medicine and discuss the scientific evidence pertaining to these. This was not intended as a definitive, “final word” on these subjects, but as an illustration of how weak and problematic the evidence often is even behind widely held beliefs. In some cases, these practices or ideas may actually be valid, but without good quality scientific evidence, we should always be cautious and skeptical about them.

Eventually, I will post recordings of the presentations themselves, but for now I am posting a summary of each topic.

Each starts with a focused clinical question using the PICO format.

P– Patient, Problem Define clearly the patient in terms of signalment, health status, and other factors relevant to the treatment, diagnostic test, or other intervention you are considering. Also clearly and narrowly define the problem and any relevant comorbidities. This is a routine part of good clinical practice and so does not represent “extra work” when employed as part of the EBVM process.

I– Intervention Be specific about what you are considering doing, what test, drug, procedure, or other intervention you need information about.

C– Comparator What might you do instead of the intervention you are considering? Nothing is done in isolation, and the value of most of our interventions can only be measured relative to the alternatives. Always remember that educating the client, rather than selling a product or procedure, should often be considered as an alternative to any intervention you are contemplating.

O– Outcome What is the goal of doing something? What, in particular, does the client wish to accomplish. Being clear and explicit, with yourself and the client, about what you are trying to achieve (cure, extended life, improved performance, decreased discomfort, etc.) is essentially in evidence-based practice.

This is then followed by a summary of the evidence available at each of the levels in the following pyramid (which is a pragmatic reinterpretation of the classical pyramid of evidence that is a bit more useful for general practice veterinarians).

Finally, I list the Bottom Line, which is my interpretation of the evidence.

Pre-anesthetic Bloodwork in Healthy Animals

1. Clinical question

P– healthy dogs & cats

I– routine cbc/chem before anesthesia

C– no bloodwork

O– mortality, complications, change plan

2. Synthetic Veterinary Literature

a. Systematic Reviews- none
b. CATs- none
c. Guidelines- none

3. Primary Veterinary Literature-

• cbc/biochemistry profiles for 1537 dogs
• university surgery population
• variety of ASA stages
• No indication in PE/Hx for labwork in 84%
• Recategorized in ASA level- 8%
• Procedure postponed- 0.8%
• Additional therapy- 1.5%
• Change in protocol- 0.2%
• Complications in 1.9% of patients
  • Lab values normal or unrelated in 84% of these
  • 3.8% incidence with lab abnormalities
  • 1.8% incidence with normal labs (no statistical difference)

The changes revealed by pre-operative screening were usually of little clinical relevance and did not prompt major changes to the anaesthetic technique…In dogs, pre-anaesthetic laboratory examination is unlikely to yield additional important information if no potential problems are identified in the history and on physical examination.

(Alef, 2008)

• 101 dogs
• Private practice
• > 7 years of age (avg=11)
• Routine and emergent cases
• 87% had no pre-existing conditions
• New problem found- 29.7%
• Anesthesia cancelled- 12.9%
• Further tests- 5.9%
• Euthanized- 4%
• Procedure postponed- 1%
• Additional therapy- 1%
• Age did not predict abnormalities
• Abnormalities not associated with complications

This study concluded that screening of geriatric patients important and that sub-clinical disease could be present in nearly 30 % of these patients. The value of screening before anaesthesia is perhaps more questionable in terms of anaesthetic practice but it is an appropriate time to perform such an evaluation.

(Joubert, 2007)

• 100 cats > 6 years old
• Not pre-anesthetic screening, just general screening
• No know abnormalities on Hx
• Many not normal on PE
• Lots of abnormalities
  • 13% increased wbc
  • 29% increased creatinine
  • 15% increased BUN
  • 25% increased glucose
  • 4% increased T4
  • 6% increased ALT

Some new diagnoses

• 14% FIV positive
• 2% CKD
• 1% hyperthyroidism
• 1% UTI
• Relevance to pre-anesthetic screening?
• Some abnormalities were related to choice of reference interval
• Many abnormalities were clinically irrelevant
• Not truly screening since some had PE abnormalities

(Paepe, 2013)

4. Human Literature

a. Systematic Reviews

CBC

• Abnormal <1% to 5%
• Change protocol- 0.1% to 2.7%

Hemostasis

• Abnormal 3.8-15.6%
• Change protocol- rarely

Biochemistry

• Abnormal <1% to 5%
• Change protocol- rarely

Urinalysis

• Abnormal 1-35.1%
• Change protocol- 1% to 2.8%

The tests reviewed produce a wide range of abnormal results, even in apparently healthy individuals.

The tests lead to changes in clinical management in only a very small proportion of patients, and for some tests virtually never.

The clinical value of changes in management which do occur in response to an abnormal test result may also be uncertain in some instances.

The power of preoperative tests to predict adverse postoperative outcomes in asymptomatic patients is either weak or non-existent.

For all the tests reviewed, a policy of routine testing in apparently healthy individuals is likely to lead to little, if any, benefit.

The clinical importance of many of these abnormal results is uncertain.

(Munro, 1997)

b. Guidelines

• Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery
• Performing routine laboratory tests in patients who are otherwise healthy is of little value in detecting disease.
• Evidence suggests that a targeted history and physical exam should determine whether pre-procedure laboratory studies should be obtained.
• American Society of Anesthesiologists

Bottom Line

• If you test, you will find abnormalities
• The clinical significance of these abnormalities is unclear
• You will find more abnormalities if pre-test probability is high
• Indication for test in Hx
• Abnormality on PE
• There is no evidence testing healthy patients reduces morbidity or mortality

What’s the harm?

• Expense
• Risk of testing
• Overdiagnosis
• Expense
• Stress
• Direct harm

References

Alef, M.; Praun, F. von; Oechtering, G. Is routine pre-anaesthetic haematological and biochemical screening justified in dogs? Veterinary Anaesthesia and Analgesia 2008 Vol. 35 No. 2 pp. 132-140

Munro J, et al. Routine preoperative testing: a systematic review of the evidence. Health Technol Assess. 1997;1(12):i-iv; 1-62.

Paepe D, et al. Routine health screening: findings in apparently healthy middle-aged and old cats. J Feline Med Surg. 2013 Jan;15(1):8-19.

Joubert K.E., Pre-anaesthetic screening of geriatric dogs. J S Afr Vet Assoc. March 2007;78(1):31-5.