The State of Medicine: A Critical Review


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Review ARTICLE

Other data suggest that it normalizes the protein expression profile of the hypothalamus caused by neuropathic pain [ 50 ] and exerts neuroprotective effects on dopaminergic neurones [ 51 , 52 ].

These measures enjoy substantial theoretical support.

All this goes a long way towards defining acupuncture's mode of action. However, the theories are not undisputed. Some investigators could not replicate the findings that underpin them [ 53 - 55 ]. About half of these investigations show an analgesic effect whilst the other half fails to do so [ 57 ].

If the theories were correct, should not the response to acupuncture in experimentally induced pain, be more reproducible? The effectiveness of acupuncture has been tested in several hundred controlled clinical trials, and numerous systematic reviews of these studies are now available. This table was generated on the basis of a systematic review of the literature with searches in Medline, Embase, Cochrane Library, up to July , and my own files. Numerous overviews of systematic reviews have also been published [ 9 , 28 , 96 - ]. Their conclusions range from optimistic enthusiasm to reserved scepticism.

For migraine, low back pain, and temporomandibular disorders the results are considered positive by some and difficult to interpret by others. For a number of conditions such as fibromyalgia, osteoarthritis of the knee, and tennis elbow the evidence is considered promising, but more and better quality research is needed. For conditions such as chronic pain, neck pain, asthma, and drug addiction the evidence is considered inconclusive and difficult to interpret. None of the overviews available to date is based on the totality of data from systematic reviews of controlled clinical trials.

Furthermore, inconclusive results are usually interpreted in opposite ways: acupuncture enthusiasts tend to suggest that they are consistent with the notion of effectiveness [ ] whilst sceptics view them as demonstrating the lack of effectiveness [ ]. In all this, one ought to remember, of course, that the absence of evidence is not the same as evidence of absence of an effect. Heterogeneity and variable methodological quality are prominent features of systematic reviews of acupuncture [ 97 ].

It is nevertheless noticeable that remarkable agreement often exists between rigorous attempts to generate an overall conclusion on acupuncture's effectiveness for a given indication. Similarly, four systematic reviews conclude that acupuncture is effective for nausea [ 97 ].

This is probably because of methodological differences; some of these reviews included trials with neck pain patients [ , ]; some failed to be comprehensive [ , , ]; others employed different techniques of combining data [ , ]. Some experts therefore hope that the large studies currently emerging from Germany will clarify some of the questions left open by systematic reviews. In addition, all patients received medical care as usual. One such study [ ] involved patients with migraine headaches. The results show that acupuncture was no more effective than minimal acupuncture but both generated better results than experienced by patients on the waiting list.

Its results were almost identical with those of the previous study. A further trial included patients with osteoarthritis [ ].

Highlights

However, these benefits decreased over time. Whilst these studies provide valuable information, they have been criticized, e. More importantly, they fail to conclusively answer the question whether acupuncture helps patients through a specific or a nonspecific effect. On the level of clinical trials, one of the most noticeable characteristic is the high level of statistical and clinical heterogeneity [ 97 , 98 ].

Acupuncture trials vary in virtually every conceivable way.

Their methodological rigour can be high [ ], but more often than not it is low [ ]; in particular, studies from Asian countries have been noted to frequently lack methodological quality [ , ]. The type of acupuncture e. Even when considering only one indication, the nature of the condition treated is far from uniform. In addition, the nature of the complaint could be acute, subacute or chronic. Acupuncture can be used as a sole therapy or as an adjunct to other treatments. The type of control interventions ranges from no treatment at all, to other therapies of known or unknown effectiveness, to various types of placebo interventions.

The therapist will not, however, normally be masked as to treatment allocation, and this remains a source of potential bias. Of the 13 studies available to date, nine show no significant difference between real and sham acupuncture in the primary outcome measure. Thus the majority of these trials suggests that the effects of acupuncture could after all be mostly due to a placebo response. Acupuncture has occasionally been associated with several serious adverse effects, in particular, trauma to internal organs e.

These studies also show that mild, transient adverse effects, e. The data revealed 2. Serious adverse effects may be a consequence of poor training and the large number of paramedics exercising the technique.

Acupuncture is now a widely accepted intervention for the treatment of a range of conditions, many of which are associated with pain. Several tantalizing but not fully proven theories have emerged which could explain how acupuncture works. The question whether it works remains controversial. However, these data could turn out to be false positive due to inadequate control of placebo effects in most of the clinical trials. If acupuncture alleviates suffering through a powerful placebo effect which theoretically could exceed the total therapeutic effect of conventional therapeutic options, it should be accepted as a useful treatment.

Some scientists, however, might find this notion difficult to accept.

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Of course, the scientific study of placebo effects and mechanism is both feasible and important [ - ], and the results of such research may significantly contribute to our understanding of how acupuncture works. But, if nonspecific factors are that relevant, we should not study them with a view to harnessing them for clinical practice in general and not just for acupuncture? It seems important to define the therapeutic value of acupuncture more closely and understand its mode of action if any more fully.

Volume , Issue 2.

Skeptical Journal Club: How To Read A Medical Study

The full text of this article hosted at iucr. If you do not receive an email within 10 minutes, your email address may not be registered, and you may need to create a new Wiley Online Library account. If the address matches an existing account you will receive an email with instructions to retrieve your username. Journal of Internal Medicine Volume , Issue 2.

Free Access. Tools Request permission Export citation Add to favorites Track citation. Share Give access Share full text access. Share full text access. Please review our Terms and Conditions of Use and check box below to share full-text version of article. Introduction Acupuncture can be defined as the practice of inserting one or more needles into specific sites on the body surface for therapeutic purposes [ 1 ].

Modern concepts Several theories have attempted to explain how acupuncture causes analgesia and other clinical effects. Clinical effectiveness The effectiveness of acupuncture has been tested in several hundred controlled clinical trials, and numerous systematic reviews of these studies are now available.

Agreement with WHO document? First author year [Ref] Condition treated No. Studies confounded by electrical stimulation are excluded from this list.


  • Body Psychotherapy.
  • Fusion. The Energy of the Universe.
  • Between the World and Me.

Safety Acupuncture has occasionally been associated with several serious adverse effects, in particular, trauma to internal organs e. Comment Acupuncture is now a widely accepted intervention for the treatment of a range of conditions, many of which are associated with pain. Conflict of interest statement No conflict of interest was declared.

Some have speculated that the delivery of high-quality Addictions training in psychiatry has been hampered by multiple roadblocks endemic to the Canadian medical education system van Boekel et al. Although illness of any kind need not define an individual, mental and physical illnesses are often regarded differently, and nowhere is that more apparent than in Addictions. A recent systematic review found that negative attitudes of physicians towards patients with substance use disorders were not only highly prevalent, but also a key contributor to suboptimal health care delivery for these patients van Boekel et al.

Thus, the undue propagation of stigma towards Addictions is a likely culprit. However, the inherent characteristics of Addictions also contribute to the difficulties in providing high-level training to the next generation of physicians. For example, the inherent multidisciplinary and interprofessional demands of Addictions mean that it is impossible to assign a single discipline or role to accept the full responsibility of its management. These issues may be propagated further by the current infrastructure of subspecialty training in Canada and the United States, where there are two competing medical disciplines dedicated to Addictions — Addiction Medicine and Addiction Psychiatry.

While it is important to create training pathways in Addictions, this divergence suggests there is a substantive distinction between Addiction Medicine physicians and Addiction Psychiatrists that does not exist. Leading specialists in both disciplines agree on the definition of Addiction and that its treatment is both an art and a science, which requires a multidisciplinary approach. Despite this extensive accord, practitioners of each draw sharp distinctions between Addiction Medicine and Addiction Psychiatry to serve historical, economic, and professional interests, revealing the importance to both disciplines of recognition from their distinctive colleges, and thus, jurisdiction over the medical treatment of addiction.

Despite this, the findings of some key ethnographic research studies have been particularly staggering. These findings suggest that providers may be unfamiliar with the sociodemographic factors that patients inevitably return to upon discharge from hospital, which exponentially increases the odds of recidivism. This, then, informs the so-called vicious cycle of addiction Mazhnaya et al. Additional barriers lie in bureaucracy around access to Addictions treatments.

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For example, while physicians must receive extensive training and certification before they are able to prescribe opioid agonist therapies like methadone and buprenorphine , similar requirements are not currently in place for the prescription of other controlled substances, such as psychostimulants, benzodiazepines, and even other opioids like fentanyl.

This discrepancy discourages training in and pursuit of clinical work in Addictions, which is already heavily steeped in stigma from multiple levels. Unfortunately, internalized stigma towards Addictions exists within psychiatry, too. Historically, the relationship between psychiatry and addictions has been complicated by divergent ideologies and attitudinal beliefs and has resisted the inclusion of Addictions in the Diagnostic and Statistical Manual of Mental Disorders American Psychiatric Association, Although there is a gradual move towards integrated care, the remnants of a longstanding tradition that Addiction is not truly a psychiatric illness persist, even today Avery et al.

Thus, the division between Addictions and psychiatry is ever present. With that in mind, the multidisciplinary and inherently complex nature of Addictions makes it difficult to generate an entrustable professional activity or discipline-specific tasks. This suggests that there are possibilities of applying the CBME model to Addictions, even though it may not efficiently address the full breadth of Addictions.

If created, this may staunch ongoing criticism that the medical profession has divorced competence from promotion Prost, Surveys of trainees in Addictions Fellowship Programs have identified preferred curricula. For example, reflection techniques were endorsed as extremely valuable by students, especially in the development of professional attitudes that will help clinicians effectively engage and provide appropriate care for individuals suffering from Addictive disorders. These reflective practices could be used more extensively in psychiatric training in order to build and establish reflexive self-awareness as a core professional competence, which is essential to working effectively in clinical practice, especially in the most demanding contexts Ballon and Skinner, As the management of Addictions is a multidisciplinary endeavor, provision of care for individuals with Addictive should be a shared responsibility between physicians and health care providers of diverse backgrounds.

Several organizations have made concerted efforts to promote addictions stewardship and education among multiple specialties Lagisetty et al. They provide free open-access information about models of addiction care, clinical addiction tools for health care providers, resources for patients, and information about rapid access addiction medicine RAAM clinics across the province. As innovative approaches to Addictions are desperately needed, interdisciplinary collaboration will be key.

Collaboration with public health specialists, epidemiologists, and community services may very well be the missing piece in addressing the educational deficiencies in Addictions. By exploring patterns of Addictions-related health service use at population and community levels, this will enable our medical education system target and address its own deficiencies. Collaboration between provincial and local health organizations can address challenges in operationalizing Addictions services, such as RAAM clinics. Collaboration with knowledge translation agencies, like the Canadian Society of Addiction Medicine, will be helpful in disseminating the evidence-based in Addictions and in unifying our approaches to national issues, such as position papers regarding the implications of the recent legalization of cannabis Fischer et al.

Collaboration between hospitals and academic institutions will identify the most cost-effective interventions to maximize finite resources, and can address the local impacts of Addiction; for example, Addictions training on the psychiatric management of bacterial endocarditis related to injection drug use has enabled local cardiac surgeons to be more aware of addictions and understand addictions a bit better Yanagawa et al.

Ideally, we should respond to Addiction in a manner akin to cancer, where recovery is celebrated and even encouraged, and the individual is not blamed for their current state. Admittedly, individuals with Addictive disorders often cut an intimidating figure — with a formidable combination of psychosocial shortcomings, medical frailties, and bold personalities, and often, this rationalizes stigma.

But ultimately, they are still regular people, as are addicted women who become pregnant — they have the same right to a healthy pregnancy as any other woman and could do without incessant reminders that they are morally bereft. But physicians are people too, and we must be kind to each other if we are to move forward. We increasingly understand that removing the stigma associated with Addictions is a timely solution as the humanity we all share is more important the illness we may not. The American Society of Addiction Medicine has posted extensively about stigma on their website, which is informed by the findings of international research, such as the decriminalization of illicit drugs in Portugal Laqueur, Such harm reduction programs have unequivocally demonstrated that stigma can be reduced by focusing on rehabilitation, which Canada has emulated with the recent legalization of cannabis.

Harm reduction approaches like these respects the frailties of the human condition and acknowledges that unwanted outcomes still happen even with best intentions and best services. However, harm reduction is the first step on the continuum of Addictions recovery, which also includes prevention, treatment, post-treatment, reintegration into society, and ways to inspire others.

There is a tremendous need to implode the myths of Addiction — to put a face on it and to show people that having an Addiction does not have to lead to a painful and oblique life. In recent years, there is a move to recovery capital — the lifelong journey of self-treatment and discipline that guides many Addictions programs. Fifth Edition. Avery, J. Bahji, A. Ballon, B. Butler, M. Carlson, R. Crockford, D. Revue canadienne de psychiatrie , 60 12 , pp.

This narrative review summarizes the mechanisms and set-up of extracorporeal life support ECLS including extracorporeal membrane oxygenation ECMO and extracorporeal carbon dioxide removal ECCO 2 R , its indications, complications, goals of treatment, and the need to build on evidence base for the intervention so it is used nationally and in a standardized fashion. This case report describes a woman in her early 50s with a history of hypertension, diabetes, and new-onset heart failure who had occasional left frontal periodic discharges with superimposed generalized slowing.

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This study examines the increasing costs of pediatric hospitalizations for cases of severe sepsis using the Nationwide Readmissions Database. This multicenter cohort study of adults who have survived hospitalization for sepsis assesses whether abnormalities in the host immune response during hospitalization for sepsis persist after discharge. This systematic review and network meta-analysis compares and ranks different therapeutic strategies to identify the best intervention associated with a reduction in mortality in adult patients with moderate to severe acute respiratory distress syndrome ARDS.

All Rights Reserved. Critical Care Medicine Explore the latest in critical care medicine, including management of respiratory failure, sepsis, HAI prevention, end-of-life care, and more. Add to My Interests. All Publications. Check All. Uncheck All.

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