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Should the healthy elderly be taking daily aspirin?

It has become quite fashionable for healthy people to take low-dose aspirin daily to reduce the risk of heart attack and stroke (primary prevention) , although most of the evidence on which this is based comes from trials in people who have already suffered from cardiovascular disease (secondary prevention). It's not clear if the possible benefit outweighs the risk of bleeding for those who are healthy.

A new paper in the New England Journal of Medicine looks at the question in relation to older people (those over 70). The use of low-dose (100mg) enteric-coated aspirin over a median 4.7 year period did not prolong disability-free survival in this group. There was an increased incidence of serious bleeding in those taking aspirin (DOI: 10.1056/NEJMoa1800722).

In memoriam: Dr Peter Fisher

I 've just received the sad news of the death of Dr Peter Fisher in a cycling accident in High Holborn, near The Royal London Hospital for Integrated Medicine, where he had been a leading clinician for many years.

Peter was a good friend and colleague in my years at the hospital, where he was consultant physician and Director of Research, as well as Editor-in-Chief of the journal Homeopathy. He was a convinced homeopath but always took an evidence-based approach to the subject; for example, he criticised opposition to vaccination on the part of some homeopaths as unscientific (and contrary to homeopathic principle).. Nevertheless he was largely responsible for changing the name of the hospital from The Royal London Homeopathic Hospital to its present form in 2010. This was a wise move which reflected the fact that the hospital now offers a range of complementary treatments, always in the wider context of modern clinical medicine.

Peter's death will be an irreplaceable loss to British homeopathy.

Book review: An Introduction to Western Medical Acupuncture (Adrian White, Mike Cummings, Jacqueline Filshie)

See 570 other reviews

This is a book about the modern medical version of acupuncture, often called Western medical acupuncture (WMA) which is widely practised by health professionals today. It is the second edition of the work (the first appeared in 2008) and is described as a companion to Medical Acupuncture: A Western Scientific Approach (Elsevier, Edinburgh, 2016), now also in its second edition. The authors are all among the foremost proponents of WMA in Britain and so are well placed to produce a book of this kind.

Its primary intended audience is health professionals who have recently completed a training programme in modern acupuncture and want to consolidate and extend their knowledge of the subject. But it will also interest more experienced practitioners, because it includes a large amount of up-to-date research evidence for acupuncture that is otherwise not easy to find gathered together in an accessible form.

The book has 19 chapters. Chapter 1 is an introduction and provides a description of WMA and how it differs from traditional Chinese medicine (TCM). The remaining chapters are divided into five sections: 1. Principles; 2. Effects Mechanisms Techniques; 3. The Evidence Base; 4. Practical Aspects; 5. Treatment Manual. There are also five detachable cards illustrating classical acupuncture points, myofascial trigger points, and pain referral zones. As this summary will indicate, there is a progressive shift in focus throughout the book, from evidence for acupuncture as a science-based treatment to the practical aspects, but this is not a rigid separation and even the more research-oriented sections bring out the practical implications of what they describe.

I shall now look at the individual sections in more detail.

Section 1 has three chapters (Chapters 2–4). The first is a preliminary overview of what WMA is and how it is thought to work. Acupuncture is mainly although not wholly a treatment for pain, and Chapter 3 looks at the modern understanding of pain mechanisms in the nervous system and how these relate to acupuncture. Chapter 4 describes some basic acupuncture techniques, to be elaborated later.

Acupuncture modernists always have to decide where they stand on the question of classical acupuncture points. Some, of whom I am one, prefer to avoid that terminology almost completely, but here the authors do use it, although with reservations. 'This book uses classical acupuncture point names as a convenient convention, though each point's effects are not as specific as traditionally believed, and nerves may be stimulated effectively almost anywhere in the body.'

What I found particularly welcome both in this section and throughout the book is the absence of dogmatism. The authors state their views but they recognise the existence of different approaches to treatment within the broad scope of modern medical acupuncture: 'nothing in acupuncture should be standardized—except safety.'

Section 2 is concerned with the mechanisms of acupuncture—how it works. A lot of new research on the question has become available since the first edition in 2008. The physiological mechanisms are discussed under a number of headings: local effects, segmental (spinal) effects, and general (central) effects. There is too much information here to summarise in a review, but this is an important section because it provides much of the support for the authors' treatment recommendation in later chapters.

This section includes a description of myofascial trigger points (MTrPs), which figure prominently in WMA. This is particularly useful for doctors, who are unlikely to have encountered the subject in their ordinary clinical training. It is treated here both theoretically and practically, including an account of how to diagnose and treat MTrPs.

The concluding chapter in this section is on traditional Chinese medicine (TCM). There is a succinct account of the ancient ideas and the authors consider how relevant, if at all, TCM concepts are to modern practice. 'A rational approach based on knowledge obtained scientifically can explain many of the concepts of TCM.'

The authors provide a fair summary of TCM but I question whether it is still necessary to include it in a book on WMA. I think we are rapidly approaching, or have already passed, the point where the subject can be regarded as of purely historical interest, in which case it could be omitted or at least relegated to an appendix.

Physiology is important in modern acupuncture but we also need clinical evidence of efficacy, and this is the subject of Section 3. Critics sometimes claim that acupuncture is 'just a placebo' because many trials find little or no difference between 'real' and 'sham' acupuncture. But this begs many questions, especially the problem of what constitutes a 'sham' acupuncture treatment. The authors show convincingly why it is so difficult to devise an adequate placebo treatment in acupuncture. Nor is this the only practical difficulty that attends clinical trials in this field. For example, 'blinding' of patients can be difficult (blinding of the practitioner is all but impossible). In spite of these difficulties there is good evidence of efficacy in at least some disorders.

Safety is a literally vital consideration in acupuncture and Section 3 concludes with a chapter reviewing the evidence on this question. The authors find that acupuncture is generally safe if done by adequately trained practitioners and is usually safer than most other treatments that are available. Aggravation of symptoms may occur but is seldom severe and is certainly not required for effective treatment, as is sometimes claimed, so the risk should be reduced as much as possible.

Questions of safety again figure prominently in Section 4. The first three chapters in this section (14, 15, 16) 'are essential reading for clinical practice'. They cover preparing for treatment, effective needling techniques, and safe needling. All the safety issues mentioned here are incontrovertible, but (as noted earlier) there is room for discussion about some of the techniques described.

For example, the authors advise the use of guide tubes for beginners because they make needle insertion easier. This is true, but many experienced acupuncturists dislike guide tubes and don't use them, and I'm not sure that it is necessary to impose them on beginners. I think that most newcomers to acupuncture quickly learn to insert the needles without them, at least the standard (30mm) needles; the longer (50mm) needles are probably best used with guide tubes, at any rate to start with.

On the question of how long the needles should be left in situ ('retention'), there is a widespread idea that this should be 20 minutes, and the authors think that this may be because it takes this length of time for beta-endorphin levels to reach a maximum in the central nervous system. However, they think that 10 minutes is often long enough for a clinical response. I should say that much briefer insertion is usually effective in most cases, and the authors do acknowledge the use of this technique by some practitioners. Needle retention is probably one of the most widely debated subjects in acupuncture.

The concluding chapter in Section 4 deals fairly briefly with other techniques often bracketed together with acupuncture, such as moxibustion, auricular acupuncture, and the use of lasers. The authors find little advantage in embarking on most of these.

Section 5 is a 'Treatment Manual' describing various possible approaches to try in different disorders. To avoid any misunderstanding, the authors emphasise that this section only makes sense if you have read everything that precedes it; they are not providing 'recipes' or rules to be followed without thought. 'You have discovered the principles of acupuncture in the previous chapters; here you find some guidelines to point you in the right direction.'

The book is very well produced, with abundant diagrams, and is written in an approachable style that makes it easy to read. Each chapter begins with headlines summarising its contents to indicate what the student should learn by reading it, and concludes with a useful review of its main message.

Some acupuncture enthusiasts want to emhasise what they perceive as its differences from mainstream medicine. The alternative view is that acupuncture should be reinterpreted in the light of modern knowledge and integrated with mainstream methods of treatment, and that is the present authors' opinion. 'It is time to reconsider acupuncture and its strange phenomena in ways that are credible to Western science.'

22-07-2018
%A An Introduction to Western Medical Acupuncture (second edition)
%A White, Adrian
%A Cummings, Mike
%A Filshie, Jacqueline
%I Elsevier
%C Edinburgh
%D 2018
%G ISBN 978-0-7020-7318-2
%P viii + 234pp
%K acupuncture
%O illustrated; pull-out reference cards

Breast screening error: disaster or blessing in disguise?

The NHS computer error that has resulted in some 450,000 women aged around 70 not having received an appointment for a final breast screen is obviously, and understandably, deeply worrying for the women concerned. Predictably, the media have headlined the estimate that up to 270 of them may have developed cancers that are more advanced and difficult to treat than they would have been if diagnosed earlier. But this depends on a number of assumptions. Leaving aside the fact that this is the upper limit of an estimated 135-270 range (compare the "up to" speeds quoted by ISPs - how many customers achieve them?), the situation, as usual, is more complicated than the headlines imply.

New Scientlst has a good discussion of the question (Why breast screening error stories are getting death stats wrong). This article makes the important point that, for some women, the failure to notify them may have done them a favour. The current NHS estimate is that, for every 200 women in the 50-70 age range screened, one will be spared an early death but three will have unnecessary treatment for cancers that would not have been a problem in their lifetime.


... it means that up to 800 women may have been saved from harm by not sending them their final screening appointment letter, as they avoided possible reduction in their life expectancy through unnecessary treatment.


The New Scientist article makes the important point that the women who received unnecessary treatment would never know this and would presumably be forever grateful, believing that their lives had been saved by the 'harrowing treatment process'. So this is an 'invisible' harm that is difficult to quantify.

An interesting paper, possibly relevant to acupuncture

Structure and Distribution of an Unrecognized Interstitium in Human Tissues
doi:10.1038/s41598-018-23062-6

This paper is very interesting in its own right and I think may have relevance to acupuncture. Although the focus is mainly on internal organs the findings also relate to the skin and connective tissue generally. The authors describe a previously unknown but widespread system of fluid-carrying channels of potential clinical significance.


"We propose here a revision of the anatomical concepts of the submucosa, dermis, fascia, and vascular adventitia, suggesting that, rather than being densely-packed barrier-like walls of collagen, they are fluid-filled interstitial spaces. The presence of fluid has important implications for tissue function and pathology. Our data comparing rapidly-biopsied and frozen tissue with tissue fixed in a standard fashion suggest that the spaces we describe, supported and organized by a collagen lattice, are compressible and distensible and may thus serve as shock absorbers."


This mechanism is thought to occur in the skin under mechanical compression and in the musculosketal system during activity.


"In sum, while typical descriptions of the interstitium suggest spaces between cells, we describe macroscopically visible spaces within tissues – dynamically compressible and distensible sinuses through which interstitial fluid flows around the body. Our findings necessitate reconsideration of many of the normal functional activities of different organs and of disordered fluid dynamics in the setting of disease, including fibrosis and metastasis."



Whether this discovery will ultimately prove to have relevance for acupuncture remains to be seen, but it's certainly something we need to be aware of. For example, it may be an additional reason for rejecting skin pressure as a valid control in acupuncture trials. So watch this space (literally).


Water companies use dowsing to find leaks

Today's Daily Mirror reports that an engineer working for the Severn Trent water company used dowsing to search for a leak at a property. The property owners' daughter, who is studying for a Ph.D in evolutionary biology at Oxford University, contacted the water company; they confirmed that some of their engineers practise dowsing and they have no objection. She then wrote to other water companies and found that nine of them used dowsing.

Dowsing is generally regarded as pseudo-science. Wikipedia lists a number of scientific studies of the practice that have been conducted since the early twentieth century; they have almost uniformly found the results were no better than chance.

A number of homeopaths use dowsing, usually with a pendulum, to choose their medicines. In the 1980s, when I was a physician at The Royal London Homeopathic Hospital (now The Royal London Hospital for Integrated Medicine), I contacted a dowsers' society to ask if their members were willing to take part in a trial to see if they could distinguish real homeopathic medicines from placebos. They agreed to do this and I started to set up the trial, but unfortunately they then backed out.

Evolutionary aspects of cancer - Mel Greaves

On my book reviews page there is a review of Cancer: The Evolutionary Legacy by Mel Greaves. Anyone who is interested in this important topic should see Greaves's lecture to an audience of biologists published in 2013.

Greaves is Professor of Cell Biology at the Institute of Cell Biology in London. Two important messages emerge from his lecture. One is that the fundamental importance of Darwninian evolution for our understanding of disease in general and cancer in particular is still not fully recognised, and the other - which is a consequence of the first - is that much of the research in cancer treaement at present is missing the real point and is unlikely to provide a lot of benefit. The research effort needs to be directed differently. We also need to do more to achieve early treatment and improve prevention, both of which are achievable right now. The treatment of more advanced cancers is likely always to be difficult.

The history of the RCT

Many of us probably think of the randomised controlled trial (RCT) as a largely British invention dating from shortly after the second world war, but an interesting short paper in the NEJM shows that its antecedents go back much further (The Emergence of the Randomized, Controlled Trial: Laura E. Bothwell, Ph.D., and Scott H. Podolsky, M.D. N Engl J Med 2016; 375:501-504 August 11, 2016 DOI: 10.1056/NEJMp1604635).

RCTs thus represent the most recent outgrowth of a long history of attempts to adjudicate therapeutic efficacy. Their immediate ancestor, alternate-allocation trials, emerged as part of a trend toward empiricism and systematization in medicine and in response to the need for more rigorous assessment of a rapidly expanding array of experimental treatments. Alternate allocation represented a significant advancement for addressing clinical research bias -- but one that had limitations as long as it allowed foreknowledge of treatment allocation. Concealed random allocation merged as the solution to these limitations, and RCTs were soon supported by crucial public funding and scientific regulatory infrastructures.

This open-access paper is well worth reading.

The priesthood of public health

Richard Lehman has a blog about medical research at http://bmj.co/Lehman; extracts from this appear as Research Update each week in the BMJ.

On 16 July 2016 Dr Lehman had a nice comment on a recent JAMA article on "the theology of eating fat", in which he referred to diet pundits as "the priestbood of public health". The occasion was a recently published large-scale study of nurses and doctors in the USA, which concluded that saturated fat is bad for you.and polyunsaturated fat is good. Lehman's comment is that it "doesn't provide the priestbood with very much to preach about in my opinion".

The Greek government is endorsing homeopathy

My wife has provided this item of information from the Greek news.

A medical furore is going on because the government has appointed an eleven-member committee composed of ten doctors and one pharmacist, all of them homoeopaths, to pronounce on whether homoeopathy should be officially recognised as a valid treatment in Greece with requirements set for the qualifications needed to practise.

Dead against this are the majority of the medical community, who point out the unsuitability of the committee and the lack of evidence that homoeopathy is anything other than placebo.

From religious quarters there are also complaints that all complementary medicine is based on mystical and other undesirable ideas, all of which are considered heretical by the Orthodox Church, and as such should not be given
official recognition in an Orthodox country.

Of course, one reason for the government's enthusiasm for this idea may be the fact that homeopathic medicines are relatively cheap.

Book review: Do No Harm, by Henry Marsh

Henry Marsh is a neurosurgeon who has headed his department at a London hospital for many years and has worked in the Ukraine to help set up neurosurgery there. In this book he provides an extraordinarily vivid account of his work and its emotional impact both on himself and on his patients and their relatives. The book consists of a large number of short chapters, each of which tells a story usually linked to a particular kind of brain abnormality. Some chapters are autobiographical and tell us about events in Marsh's own life and how he came to study medicine and become a neurosurgeon.

Patients, Marsh says, invest their doctors with superhuman qualities as a way of overcoming their fears when undergoing surgery.

The reality, of course, is entirely different. Doctors are human like the rest of us. Much of what happens in hospitals is a matter of luck, both good and bad; success and failure are often out of the doctor's control. Knowing when not to operate is just as important as knowing how to operate, and is a more difficult skill to acquire.


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In Memoriam: Dr Felix Mann 1931-2014

Felix Mann

The death earlier this month of Dr Felix Mann after a long illness marked the end of an era for me, as it no doubt did for many doctors who learnt acupuncture from him in the 1970s. I first met him when I attended his course in 1977. At that time I was interested in oriental philosophies and that made me want to learn acupuncture, but I had no idea how to go about it. Then I happened to talk to a consultant who was head of the Migraine Clinic and who had recently done Felix's course. She told me it was worth while, so I registered for it.

The course was held in Felix's consulting rooms in the large house he had bought in Devonshire Place, in the West End of London. It lasted five days. There were fourteen of us. We sat in a semicircle on rather hard chairs while Felix stood in the middle and talked to us. From time to time patients would arrive to tell their stories and be treated. This was what I was expecting, but there was an early surprise.

Before starting the course we were supposed to read Felix's books. At that time they were based on traditional Chinese acupuncture and I don't think that any of us made very much of them. But this didn't matter because the first thing that Felix said to us was "I don't believe this stuff any more."

I have to admit that my initial reaction was disappointment, since, as I've said, it was an interest in Eastern ideas that had prompted me to learn acupuncture in the first place. But it was undoubtedly a relief to hear that I didn't need to struggle with all this complicated esoteric stuff, and later I was very grateful to Felix. Probably I should have come to a similar conclusion eventually, but he saved me a great deal of time. After the course I set up an acupuncture service at The Royal London Hospital for Integrated Medicine using the methods I had learnt from Felix. Modern medical acupuncture is still one of the main forms of treatment used there.

From our present standpoint in the second decade of the 21st century it is perhaps difficult to realise just how radical Felix's "acupuncture revolution" was. In the late 1950s people thought of acupuncture—if they thought of it at all—wholly in traditional Chinese terms. To describe it in the way he did required Felix to rethink everything he had been taught about acupuncture by all the 'experts' he had encountered.

Felix's acupuncture career

Acupuncture had been practised by quite a number of British doctors in the 1820s but had later fizzled out. By the twentieth century it was virtually unknown here, although it was still used quite extensively in mainland Europe, especially France and Germany. By this time it had become quite traditional, although that had not been the case in the nineteenth century.

As a young doctor Felix had to travel abroad to learn acupuncture since no one was teaching it here; this was comparatively easy for him because he was a good linguist and had plenty of contacts in Europe. He saw acupuncture being used and was impressed by the results. He studied at Montpellier in the south of France and at Munich and Vienna. Later, he even studied Chinese with the help of sinologists in Britain so as to be able to read the classic texts. So his subsequent abandonment of the traditional system wasn't due to lack of knowledge. It was based instead on fresh thinking and exact clinical observation.

By the time I met him in 1977 he had rejected practically all the traditional ideas about acupuncture. He now regarded it as a means of altering the activity of the nervous system and as a treatment that could be explained in terms of the modern understanding of anatomy and physiology. There was no need to talk about qi or yin and yang.

According to his new view, neither acupuncture points nor the so-called meridians exist as they are usually understood. Great precision in locating 'points' is unnecessary; instead we should be thinking of areas. In many cases these could be quite large: for example, in some patients needling anywhere below the knee might have the same effect as using the classic point Liver 3 (Felix's favourite site).

He introduced other departures from tradition as well. One was the use of periosteal (bone) needling, both to treat joint pain such as that due to arthritis and also to produce more generalised effects in a wide area. Another was his recognition of a subset of patients who responded particularly strongly to acupuncture, whom he designated strong reactors. Disorders that usually don't respond to acupuncture might do so in a strong reactor. But if a strong reactor were treated too vigorously the result could be a worsening of the symptoms or a feeling of general malaise lasting for some hours or even days.

As time went by Felix came to believe that many traditionalists over-treated their patients. Increasingly he favoured very gentle treatment, with the insertion of few needles — sometime only one — and the duration of needling being brief: seldom more than a minute or two and quite often just a few seconds.

While these ideas usually horrified traditionalists they were certainly easier for doctors trained in modern medicine to understand and accept. This was fortunate because more now wanted to learn. Felix had started teaching acupuncture to doctors in the 1960s although at first few came forward to learn. But in the 1970s the numbers increased, partly because attitudes to unorthodox treatments were beginning to change but also because advances in the scientific understanding of pain were making acupuncture seem more comprehensible in modern terms. Another influence was President Nixon's visit to China in 1972, which aroused interest in acupuncture on the part of a number of prominent British and American doctors.

Felix's former students constituted an informal medical acupuncture society. He used to circulate a yearly newsletter and each year, in November, he held an acupuncture meeting in his rooms for 70 doctors. There would be seven or eight speakers, usually including Peter Nathan, a well-known neurologist, and Felix provided an excellent lunch, with wine. Attendance was free to his former students; others paid a small fee which cannot have come even near to covering Felix's expenditure.

In 1980 matters were made more formal when the British Medical Acupuncture Society, constituted mainly by Felix's former students, was founded; he was its first President. It now has over 2000 members.



Felix's legacy

The fact that the acupuncture practised today by British health professionals is mostly non-traditional is largely thanks to Felix. Outside Britain the change has been more gradual. In much of Europe, apart from Sweden and Portugal, and in North and South America, traditional ideas are still influential. But the journal of the British Medical Acupuncture Society, Acupuncture in Medicine, is now a BMJ publication, so Felix's aim of making acupuncture an accepted form of treatment within mainstream medicine has mostly been accomplished. Perhaps most striking of all is the fact that an increasing number of the papers being submitted to the journal now come from China itself.

Felix wrote several books about his later view of acupuncture. The most important of these was Reinventing Acupuncture: A New Concept of Ancient Medicine. The first edition appeared in 1993 and the second in 2000. Here he described how his understanding of the treatment evolved and gave practical details of his methods. I still dip into it from time to time and continue to be impressed by how much my own experience agrees what he describes. All of us who use acupuncture today in a modern context are deeply indebted to him.

Requests for reprints of articles

I just received a request for a reprint of one of ny articles. I get these from time to time; strictly speaking I shouldn't send such reprints since they infringe the copyright of the journal, but I used to do it because the requests usually came from third-world countries where people presumably couldn't easily afford the payment.

But not once did any of these correspondents bother to thank me or even acknowledge receipt, which I take ill; it's a lot less trouble for them to reply than it is for me to find the article in question and attach it to my email. So now I no longer reply to such requests, especially when, as in today's case, the requester is a professor at a university hospital in Paris, who could no doubt easily afford the fee to the journal (which probably wouldn't come out of his own pocket anyway).