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One of the most common criticisms of this blog has been that it is mean, unkind, or unfair of me to critique claims about conventional and alternative medicine made by vets and others. I have addressed this subject before:

Are Homeopaths Innocent Victims of Skeptical Attacks?

CAM Vets Attacking Conventional Veterinary Medicine

Who’s Behind the The Truth About Pet Cancer?

These posts, and the quotes they contain from many proponents of alternative medicine, including Mr. Habib, illustrate how the people who are upset by my criticism are frequently loudly proclaiming that science-based medicine is useless or harmful and that conventional vets are ignorant, dupes or shills for industry, or otherwise knowingly providing poor patient care compared to that provided by these advocates of alternative medicine. They base their work and advocacy around the notion that everyone else is wrong, and then they feel unfairly treated when someone disputes their claims.

Nobody likes to be criticized, or even to have their claims disputed in a fact-based, impersonal way. However, when you make a point of publicly attacking mainstream science or medicine, or when you promote unproven or demonstrably ineffective treatments and claim they are safe and effective, it is fair and appropriate for others to challenge these claims and attacks. I try to be fair and focused on ideas and claims, not personality or other irrelevant personal characteristics, but I don’t feel it is inherently wrong to push back against efforts to denigrate science-based medicine or convince pet owners to fear it and to turn instead to unproven or ineffective alternatives. Complaints that challenges to their claims is unkind or meanspirited are just a self-serving way for alternative medicine advocates to try and insulate themselves from criticism.

Most of the angry reaction to my critiques has taken the form of comments or emails, but social media personality and activist Rodney Habib has used his communication skills to take this self-righteous and hypocritical outrage to a new level. In a slick video of a series of talks he has apparently given to students interested in veterinary medicine, he refers to the suicide crisis in veterinary medicine. In this talk he implies that I am partly responsible. (Interestingly, this video was posted well before my recent article specifically discussing the individuals, including Mr. Habib, who participated in the Truth About et Cancer videos.)

Mr. Habib’s video suggests that I “slam” vets who dare to “think outside of the box.” This not only mischaracterizes my substantive critiques of pseudoscience, but it ignores the attacks and criticisms the folks I write about make against conventional veterinary medicine. It also infantilizes veterinarians by suggesting that disagreement and debate about these issues is harmful to our mental health.

Additionally, this kind of sideways attack on my work here trivializes the serious problem of mental health and suicide in veterinary medicine by using the topic as a vehicle to attack me just because Mr. Habib dislikes what I have to say. It also directs attention away from real and addressable causes of the problem. There are many factors that contribute to the mental health crisis in veterinary medicine, from work environments, financial stresses, and cultural factors, but the refusal of skeptics and mainstream veterinarians to allow pseudoscience in our field to pass unchallenged is not one of them.

There are many thoughtful discussions of the mental health problem in veterinary medicine that deserve to be taken much more seriously than Mr. Habib’s comments. Here are just a few:

Suicide in veterinary medicine: Let’s talk about it

AVMA Article on Suicide in Veterinary Medicine

AVMA Wellness and Peer Assistance Resources

Additional AVMA Coverage

Incidence of suicide in the veterinary profession in England and Wales

Mental health resource list for veterinary teams

Canadian veterinary health and wellness resources

 

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I have been asked several times in the last few months to evaluate a new series of videos called The Truth About Pet Cancer. I actually purchased the full transcript of this series and am in the process of investigating the general themes and specific claims. It is an enormous undertaking, and doing it justice will take a while.

To get started, I have been looking into the participants to get a sense of their background, perspective, and agenda. Though this is quicker than going through the full content of the videos, it has still taken me several weeks! I will present what I have found here to help provide context for my investigations of the videos themselves.

Though not all participants express the same views or emphasize the same points, there are a number of general themes in this series:

  1. Cancer is rampant in dogs and cats, much more so than in the past when our pets were healthier.
  2. Causes for this include
    a. our toxic environment, commercial pet diets, vaccines, conventional parasite preventatives and medicines, GMOs, wifi and other emf sources, and many other bad things
    b. mitochondrial damage and metabolic effects of high-carbohydrate diets
  3. Conventional methods for preventing and treating cancer in dogs and cats are (depending on the person being interviewed) useful but insufficient, totally ineffective, or actually a cause of more harm than benefit.
  4. The solution involves
    a. avoiding the toxins mentioned above or detoxing with food and alternative therapies
    b. complete overhaul of feeding practices, with an emphasis on fresh, raw, ketogenic diets
    b. supplementing, minimizing, or eliminating most conventional medical interventions (again, depending on who’s talking)

The following profiles of the organizers and participants will include comments, from this series and from other sources, that illustrate these themes and the general perspective of each of the participants towards these issues. The claims made in the videos must, of course, be evaluated on their own merits, most importantly the relevant scientific research evidence. My purpose in discussing the background, affiliation, and other advocacy efforts of the participants is not to use this information to judge the specific claims they make in the videos. However, understanding their overall perspective on science and medicine, and uncovering the personal, institutional, and financial relationships between them will help inform consideration of the videos.

The fact, for example, that the organizers and many participants are vehement advocates for alternative medicine is relevant to their claims about both conventional veterinary nutrition and alternative nutritional approaches. The repeated attacks on science-based medicine, the pet food industry, government regulators, and other groups made by many figures in these videos suggests an iconoclastic, maverick-outsider perspective that should be taken into account when evaluating the type of bias behind statements they make in these videos.

A lot of people were involved in this project! Some were key drivers of the effort, others contributed only brief interviews. They seem to fall into several broad categories: 1) Proponents of pseudoscience and critics of science-based approaches in human health.  2) Proponents of pseudoscience and critics of science-based approaches in the veterinary field, and 3) Mainstream veterinarians or researchers in legitimate scientific fields with an interest in or sympathy for “integrative medicine” or for unconventional nutritional approaches, such as ketogenic diets.

Individuals in the first two categories are clearly the architects of this bit of propaganda. Many will be quite familiar to regular readers of this blog as I have addressed their anti-scientific and pseudoscientific claims before. Some I haven’t written much about in the past, since their activities are primarily confined to human health. Several of these are not only evangelists for alternative medicine and lifestyles but purveyors of quite astonishing and bizarre conspiracy theories.

Those in the third category seem like pretty reasonable people, so their reasons for participating in this project are less clear. Some have been so blinded by their enthusiasm for a particular idea, such as ketogenic diets, that they are willing to overlook the use of the videos to promote pseudoscience and attack science and science-based medicine. Others may have been misled as to the nature of the project and how their participation will be used. Many say perfectly reasonable and science-based things in their interviews, though these comments are often interwoven with more extreme or unscientific comments to build a narrative that might not accurately reflect these views.

I have spoken to one person in this group who was actually quite angry about how their words were used and the implications which was created that they support claims they do not actually support. Others I have communicated with indicate that they stand by their own comments but take no position for or against the claims made by others.  It is undoubtedly true that not every individual who participated agrees with every claim made by all of the other participants. It may well be that some participants are not even aware of how bizarre and anti-science in their views some of the organizers and other participants are.

Regardless of how the more reasonable folks interviewed came to be associated with this project, however, their reputations are now tied to it to some degree, and it is their responsibility to disavow any aspects of the project they feel are inaccurate or untruthful or that misrepresent their views in some significant way. Failing to do this gives tacit approval and support to the project, and to the many falsehoods, errors, and attacks on science-based medicine it contains.

In addition to the affiliations of many participants with alternative medicine and their personal relationships through alt med advocacy, there are a couple of specific organizations which connect multiple participants. One of these is Ketopet Sanctuary. Supported by a ketogenic diet advocacy group called the Epigenix Foundation, this is a project organized around the belief that a ketogenic diet, hyperbaric oxygen, and some other practices can significantly improve the lives, and long-term outcomes, of dogs and cats with cancer. Quite a few dramatic and specific claims are made about research done at the facility, but none of this has been published in the scientific literature as of yet.

Another organization which connects several participants is DogRisk. This is a group of veterinarians and nutrition researchers led by Dr. Hielm-Bjorkman, a faculty member at the University of Helsinki. The organization is independent of the university, and it appears to focus on generating evidence to support raw diets, supplements, and other unconventional nutritional interventions. While the members are all legitimate scientists, they also have a clear agenda to generate evidence supportive of their beliefs in unconventional diets. They have conducted an online survey and presented a few posters, but as yet no peer-reviewed published research has been provided to make the general case that raw diets are healthier than conventional feeding practices.

Finally, several fringe organizations connect several of the organizers and participants. Mike Adams’ site Natural News, the web site of Joseph Mercola, and Alex Jones’ InfoWars are three prominent outlets promoting and selling quackery and anti-science propaganda, and all three are heavily represented here. Mr. Adams and Dr. Mercola are both involved, and Dr. Karen Becker is a veterinarian who runs the animal side of Dr. Mercola’s site. Several participants have been associated with the right-wing conspiracy project InfoWars. Mike Adams has been a guest host, Dr. Mercola has promoted his site and books on Jones’ show, and Edward Group has been a longtime contributor as well as the provider of many supplements sold by InfoWars.

I will briefly outline relevant information about each participant and try to provide some examples of comments made by these folks that illustrate the perspectives they each bring to this video series. Detailed analysis and fact-checking of their comments in the videos will have to wait for subsequent posts. My purpose here is to elucidate the perspectives and agendas of the participants and some of the links between them, so that the specific claims they make, and which I will evaluate in future posts, can be understood in a complete context.

Promoters of Pseudoscience in Human Health

Mike Adams
The individual behind the infamous Natural News web site, Mike Adams is one of the most prominent quacks of our era. He promotes and markets all manner of snake oil, viciously attacks science and scientists, and proselytizes for some bizarre conspiracy theories. He opposes almost all conventional medical treatment, most vociferously vaccinations and pharmaceuticals, and he frequently claims that healthcare professionals, researchers, and of course the biomedical industry, deliberately create disease in order to profit from treating it. He also promotes fringe conspiracies, such as arguing the 9/11 terrorist attacks were “an inside job,” Barack Obama’s birth certificate is a fake, and the Sandy Hook school shooting massacre was faked.

The inclusion of this person in this video series illustrates the deep lack of concern for science or objective truth on the part of the organizers, and it should embarrass anyone associated with the project regardless of their own contributions. Reasonable people can disagree about many of the subjects in this series, but there is nothing reasonable about Mike Adams or his quack evangelism, attacks on legitimate science, and general lunacy. His comments on his own site, and in these videos, undermine the credibility of any ideas and any participants. Here are some examples:

From the video series-

“’So, if your dog gets diagnosed with cancer, the doctor says “Oh, they have to have chemotherapy.’ You put the dog on chemotherapy, and immediately their health starts to deteriorate because they’re being poisoned, right?”

The doctor says, ‘Look how bad the cancer’s getting.’ This is a fraud. It’s actually—it’s worse than a stage magician in Vegas hiding a tiger in the back of a cage, and then putting a curtain on, and then ‘Boom! There’s a white tiger here all of a sudden. It’s magic!’ This is charlatanism. This is con artistry in medicine that is more deceptive than any kind of stage magic.”

“That’s what these people are doing. They’re conning pet owners into chemically poisoning their dogs and cats and calling it medicine. But it isn’t. It’s animal cruelty. It’s the worst form of animal cruelty because that dog trusts you. You’re their owner.”

From other sources-

“If you’re being forced to take a vaccine against your will (by a totalitarian medical regime like California), are there things you can do to protect yourself from vaccine toxins? [….] The key to surviving this assault on your body is to eliminate these chemicals quickly. In this video…I reveal nutritional strategies for accelerating your body’s natural detox so that you can safely survive a vaccine assault that’s forced upon you by a coercive, fascist medical regime.”

“the AIDS industry is much like the breast cancer industry… or the prostate cancer industry: Most of what they push onto people is medically unjustified, scientifically unproven and actually harms more people than it helps. But it’s great for generating more profits for Big Pharma.

And that’s the point of all this. AIDS is just another profit center for the drug industry”

“Mammograms — which claim to “detect” breast cancer — actually cause breast cancer. So if you get enough mammograms, eventually you’ll develop breast cancer and require expensive cancer treatments.”

Dave Asprey
Mr. Asprey describes himself as “a Silicon Valley investor and technology entrepreneur who spent two decades and over $1 Million to hack his own biology.” Without the benefit of any formal biomedical expertise or controlled research evidence, he claims to have discovered the secret to “taking control of and improving your biochemistry, your body and your mind so they work in unison, helping you execute at levels far beyond what you’d expect, without burning out, getting sick, or allowing stress to control your decisions.”

These secrets mostly involve untested and unproven beliefs about ketogenic diets (a recurring theme throughout the video series). Asprey is a true believer in not only ketosis but a variety of other alternative medicine practices, and he relentlessly proselytizes for these without much concern about facts or the evidence and arguments of most experts in the fields he dabbles in.

Like most evangelists for unproven fads, he cherry picks legitimate science to find bits that seem to support his belief and ignores any contrary evidence. He relies the probative value of anecdotes, especially his own, despite the inherent unreliability of anecdotal evidence. His blog promotes various pseudoscientific positions, including claiming wi-fi and other electromagnetic fields cause cancer, the quackery of Emotional Freedom Technique (EFT) and homeopathy, and the idea that some foods are “toxic” and others magically beneficial.

Here are some discussions of Mr. Asprey and his claims: 1, 2, 3.

From the video series-

“Everything about you is driven by the something called the exposome, which is the set of things in the environment you’re exposed to. All of the toxins, all of the stress, all of the emotional stuff, all of the light, heat, sound. Every variable that there is, that is what your body’s listening to. That’s what drives epigenetics.”

“When you’re buying commercial dog food, they are taking the lowest quality fats. They don’t even care really where the fat comes from, what the ratios of the different types of fat are. Then they’re exposing it to heat, and light, and air. And they’re rendering it, and they’re cooking it, and then they put weird preservatives in it that prevent your body from using the fat right. So, what you are getting is the equivalent of margarine, which we all know is bad for us. It is unacceptable to put that stuff in your dog’s mouth. It has no place in our food supply. It should be used as biodiesel.”

“Inflammation is at the root of every single disease.”

From other sources-

“[ask] for an IgG/IgE blood panel testing for food allergies. You’ll get a report listing the foods that you’re sensitive to—your list of personal Kryptonite.”

“mold makes your immune system more sensitive to the damaging effects of gluten.”

“The same drive that makes someone want to run a company can also make them want to complete an Ironman triathlon. But all that exercise on top of a stressful job will drive up your cortisol levels. This causes weight gain, muscle loss, a decline in testosterone, and burnout.”

“There is a reason that stressed women crave fatty and salty foods—adrenal exhaustion.”

“If you’re not feeling amazing, there is always a reason!”

Ty Bollinger
Another notorious peddler of pseudoscience and bizarre conspiracies, Mr. Bollinger not only participates in the videos, he is one of the authors of the project and a primary inspiration for the series, having previously produced his own video propaganda piece entitled The Truth About Cancer, which consists largely of attacks on science-based medicine and promotion of unproven or quack alternatives. Mr. Bollinger, like Mike Adams, opposes almost everything about mainstream medicine, from  vaccines and cancer treatment to the idea that infectious organisms cause disease.  Also like Adams, Bollinger is a promoter of multiple wacko conspiracy theories,  from 9/11 to some that are so bizarre and incoherent you have to hear him talk about them to really appreciate how unhinged he is.

This is the kind of guy the term ”lunatic fringe” was invented to describe. The fact that he not only participates in this series but was organizer and inspiration for it severely reduces any credibility the project might have.

Here is some more information about Mr. Bollinger and his oeuvre: 1, 2, 3

From the video series-

“They say “Beware of Zika. It causes microcephaly.” And then they bombard us with chemicals that we know causes microcephaly, and then they blame it on the virus instead of the chemicals. It’s the same thing they do with chemotherapy, isn’t it?”

“The big round of vaccines for the dogs and the cats….when they get like six or eight vaccines in one day….a month or two, inevitably, they bring their dog back and they’re itching, they’ve got allergies, and it’s all—I’m thinking the same thing that happens with the babies after the shots. A couple months later, they’re having autistic symptoms or reactions or whatever. It’s the same with the pets.”

“The similarities that I see between you know the pets, preventing disease, preventing illness, preventing whatever it might be, and actually causing that very thing or causing something worse. We see that with chemotherapy, that we try to treat cancer with chemotherapy but that actually causes cancer, right? We try to prevent disease with vaccines, but they actually cause disease, actually cause cancer.”

“You look at the tribes of people worldwide that eat raw food diets and never get sick until they come to eat our food and then they get sick. You know you’ve got the animals in the wild, there’s very little cancer in the wild, there are still sick animal but not many. Very seldom do they get sick but then you bring them into captivity, they start getting sick.”

“We’ve got an industry that seems to be driven by the dollar as opposed to trying to help pets. Just the same way the cancer industry with people is driven by profit motive and they don’t care about the cancer patients. It seems the vet practice is the same.”

From other sources-

“Non-toxic, effective, natural treatments for cancer are being systematically suppressed and cancer patients are dying due to lack of this vital knowledge. Why? Because the Medical Mafia and their “leg breakers” (like the FDA and FTC) control the flow of information and regulate the “approved” treatments.”

“We realized that the “official story” about 9/11 is about as believable as the Easter Bunny, Keebler Elf, Santa Claus, and fairies with wings of pixie dust. It’s a monumental myth… a ruse… a fable… a “tall tale” concocted to deceive the masses. And it worked like a charm on me and my wife – we swallowed it “hook, line, and sinker” – at least for a while. But sooner or later, we all must wake up from the dream.”

“As it turns out, many pharmaceuticals are offshoots of various chemical weapons developed and used during the two major world wars, and some were even tested on prisoners in Nazi concentration camps. “

“If we sit back and allow the government to enslave (and dehumanize) us in these areas, then we will gladly allow them to violate the Constitution and take our health freedom. Just look at a few recent examples the FDA raid on Rawesome Foods for selling raw milk the Detroit SWAT team kidnapping (and raping) of Maryanne Godboldo’s daughter for refusing to keep using psychiatric drugs the “gunpoint” forced chemotherapy of Jacob Stieler (a child) who showed no signs of cancer and the list goes on and on and on.”

“We are witnessing the end of America as a nation-state right now, and with these changes, none of our domestic laws or constitutional rights are secure. We are facing a frightening future, not to mention the fact that children born after 1990 have no clue about their food, water, vaccinations, or anything else. Our food supply is full of irradiated food, pasteurized milk and juice, viruses sprayed on our meat, chemicals sprayed on fruit and vegetables, and now we’re being forced without our consent to eat genetically modified foods.”

Travis Christofferson
Mr. Christofferson is a promoter of ketogenic diets, hyperbaric oxygen therapy, and several other unproven therapies, which he believes are not only superior to conventional cancer treatment but will ultimate cure cancer as a whole. He claims cancer therapy is practically useless and that attacking the metabolism of cancer will be more fruitful. While it is possible this avenue will someday lead to significant breakthroughs in cancer treatment, plenty of real scientsists are investigating the area, and Mr. Christofferson routinely cherry picks evidence and ignores the work of many within mainstream oncology in order to buttress his particular beliefs.

Mr. Christofferson is a popularizer of the work of Dr. Thomas Seyfried, and both are zealously devoted to one particular hypothesis and willing to work with quacks like Mike Adams and Ty Bollinger to promote it. While not all of their claims are unreasonable, they lose credibility with their single-mindedness and their association with peddlers of pseudoscience. Mr. Christofferson is not out on the fringes with the likes of Adams and Bollinger, but he makes it into the category of promoters of pseudoscience because of his obsession with the One True Cause of cancer, his frequent association with outright quacks, and his attacks on conventional cancer research and treatment.

From this video series-

“For an MD, they’re taught “For me to do something to change standard of care I need a phase three, double blind, placebo-controlled trial to point to, to do that.” So, you can’t do that with a dietary therapy, there’s no way. There’s no funding to pull it through and they’re very difficult to get through anyway.”

“So, Linus Pauling, you know two-time Nobel Prize-winning scientist has said, “Cancer research is the most fraudulent branch of research in the world.” And just we encourage this narrow thinking, non-reproducible results. Guys that have very bold visions that may lead to cures don’t get funded typically. So yeah, we’re stuck in this dogmatic, narrow-minded view about what cancer is and it’s just not working.”

From other sources-

“The most important statistic, the one that told the story with the most unbiased clarity, was that the..

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I have been covering the subject of low-level, or “cold” laser treatment for many years. While there is some plausibility to the idea that laser light might have beneficial effects on tissue, very little convincing evidence of actual benefits in real patients. This is not surprising since the majority of good ideas that look promising on paper or in the lab fail to ever turn into safe and effective clinical treatments. Real life is more complicated than the research lab.

There have been very few clinical trials in dogs and cats, and most have had significant methodological limitations, so we can’t have much confidence in their findings. These findings, such as they are, have been mixed, with little consistent or compelling evidence of real-world benefits.

While this doesn’t mean lasers can’t be useful, it does mean that claims made for them by proponents, and the widespread use for many problems in dogs and cats, are based primarily on theory and anecdote, not on reliable research evidence. For something that is promoted as a dramatic breakthrough and is heavily marketed and widely used, it is surprising that it has been so difficult to actually demonstrate the supposedly amazing benefit in controlled research.

Another study has recently been published which follows up on the laboratory research suggesting laser might improve healing of bone and soft-tissue wounds. This is a well-conducted study with a reasonable number of patients, good control for bias and error (randomization, blinding, placebo controls, etc.), and reasonably reliable outcome measures. To steal my own thunder, it doesn’t look very good for laser therapy.

Renwick SM. Renwick AI. Brodbelt DC. et al. Influence of class IV laser therapy on the outcomes of tibial plateau leveling osteotomy in dogs. Veterinary Surgery. 2018: epub before print.

About a hundred dogs undergoing a TPLO (a common orthopedic surgery for cruciate ligament disease) were randomly assigned to receive laser treatments or placebo laser after the procedure. Though it’s not entirely clear if the people conducting the actual treatment were blinded to whether they were giving actual laser or placebo, everyone else (owners, surgeons, staff reading x-rays, etc.) appears to have been. The study used a couple of questionnaires to evaluate owners’ perceptions of comfort, function, and wound healing and had a surgical specialist evaluate the healing of the cut in the bone made as part of the procedure. Overall, none of these outcome measures showed any difference between real and fake laser treatment.

A subset of one questionnaire, looking at gait, did show a statistically significant difference between the treatments. This is not surprising since it is common for at least one outcome measures compared to show a statistical difference between treatments when many things are measured and compared. However, without a consistent pattern of such difference across outcomes, and with the difference in this particular measure being so small it is doubtful that it would be meaningful to the patients in terms of their comfort or function, the study provides pretty strong evidence against any value of laser therapy in these patients.

The authors, not surprisingly, emphasize the one small difference seen and suggest this might provide at least “mild clinical justification” for using lasers in patients undergoing TPLO. Personally, I think it is more reasonable to view the difference as a statistical fluke and to emphasize the failure to find any benefit in all the other measures evaluated, as well as the failure to show strong results in other clinical trials. Of course, there are many different techniques for using laser therapy, and proponents can always claim any single negative study is only negative because the technique used wasn’t quite right. This is the kind of “Yes, but….” Argument that supports the use of a lot of therapies even when clinical trial results consistently fail to find benefits. It is a reasonable argument up to a point, but eventually the failure to find positive effects does begin to suggest that there are none to find.

Absence of evidence can be evidence of absence once we’ve tried hard enough and long enough to find support for a scientific hypothesis. I don’t think we have reached that point yet with cold laser, and I do think more research is justified. However, it would be worthwhile for veterinarians and animal owners to be mindful that all the time and money being spent on laser treatment has so far not been proven worth it by good research, and in fact the balance of the evidence is not that encouraging.

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Introduction
Science is a process for developing and refining our understanding of nature over time. The work of a community of scientists, often with vigorous competition and conflict between individuals, gradually improves the accuracy of our understanding. Perfect comprehension of something as complex as the health of living organisms seems unachievable, but little by little we get better at knowing how nature works and how we can influence natural phenomena. This progress often involves realizing that some aspects of our current understanding are actually wrong, and that our strategies for manipulating nature based on this flawed knowledge may turn out not to be effective.

In medicine, this process creates a kind of life cycle for medical interventions. The popular conception of this life cycle is the story of effective treatments. An insight or accident leads to a hypothesis, which is tested at various levels from in vitro to animal model to clinical use, and ultimately we validate the hypothesis and conquer the original problem.

Unfortunately, this is the exception rather than the rule. Far more often, the life cycle of medical therapies involves an insight or accident leading to a hypothesis which early, flawed evidence appears to support but which ultimately turns out to be wrong. This is a well-established phenomenon of the clinical trial literature, often called the Decline Effect or the Proteus Effect.1-2

Treatments based on such hypotheses are eventually abandoned in most cases, though some prove quite tenacious. Anecdote and personal experience frequently lend ineffective interventions a prolonged post-mortem existence, therapeutic zombies that stagger on long after the scientific evidence should have put them to rest. A great example of the life-cycle of an ineffective treatment is the use of L-lysine for the prevention and management of feline herpesvirus (FHV-1).

Herpesvirus & Lysine: The Scientific Evidence
Early in vitro work on human herpesvirus (HHV-1) suggesting lysine might inhibit replication and could potentially have clinical utility first appeared in the mid 1960s.3 This was followed by the first clinical studies of lysine for HHV-1 about ten years later.4 By the 1980s, the literature on lysine and HHV was glowing, and it seemed a safe and effective therapy had been found.5

Veterinary medicine caught the coattails of this process in the 1990s, with the first published in vitro study of lysine for FHV-1 appearing in 1995.6 Clinical studies followed in the early 2000s, and lysine quickly became a widely available supplement used for FHV-1 management.7

However, the scientific process rolled on, and despite the enthusiasm of clinicians and researchers, cracks in the lysine narrative soon appeared. Limitations and potential sources of bias in the early literature were addressed in subsequent studies, and the apparent benefits melted away. The most recent reviews in human medicine have concluded that there is no reliable evidence to support the use of lysine for herpesvirus management, and it is not included in current treatment guidelines.8-10 Lysine supplements are still available and marketed for this use, of course, because patients and some clinicians cling to their belief in the efficacy of this treatment despite the evidence, based predominantly on anecdotal experience. That patients do this is understandable, but it is always disappointing to see clinicians choose anecdote over science when they have the training to know better.

The story has played out in a similar way in veterinary medicine, with the usual time lag. The initial theoretical rationale for use of lysine, for example, has not held up to subsequent study. According to the theory, lysine should antagonize arginine and reduce the level of this amino acid. This, in turn, should inhibit FHV-1 replication and reduce clinical symptoms and viral shedding. However, research in cats has failed to validate any of the steps in this chain of reasoning. Oral lysine does not appear to antagonize or reduce intracellular levels of arginine, and it does not seem to inhibit FHV-1 replication under normal physiologic conditions.7

A similar fate has befallen the initial claims for clinical effects of lysine Early studies, with small numbers of patients and methodological limitations, produced some positive results which could not be reproduced in larger, better-controlled research.7

The most recent comprehensive reviews of the evidence for lysine in FHV-1 patients are not encouraging.7,11 The more optimistic of the two states that “there is considerable variability” it the research results and that while “data from these studies suggest that lysine is safe when orally administered to cats and, provided that it is administered as a bolus, may reduce viral shedding in latently infected cats…the stress of bolus administration in shelter situations may well negate its effects and data do not support dietary supplementation.”11

A comprehensive systematic review of the subject by Bol and Bannik (2015) is considerably more blunt, systematically rejecting every aspect of the rationale for lysine use:

There is no evidence for lysine-arginine antagonism in the cat.

Lysine supplementation does not have an inhibitory effect on FHV-1 replication in the cat.

The claim that lysine supplementation is effective for the prevention or treatment of herpetic lesions in humans cannot be supported by scientific evidence.

Lysine supplementation is not effective to prevent cats from becoming infected with

FHV-1, it does not decrease the chance of developing clinical signs related to active FHV-1 infection, and it does not have a positive effect on the clinical course of its disease manifestations.

Based on the complete lack of scientific evidence for the efficacy of lysine supplementation, we recommend an immediate stop of lysine supplementation for cats.

The accumulation of evidence against the use of lysine for FHV-1 cases has had an impact. Some shelter medicine specialists, for example, now recommend against this practice.12-13 However, there has also been resistance to abandoning this treatment despite the evidence. Unfortunately, such resistance has not been based so much on any substantive dispute about the science but instead on the seductive power of anecdotal evidence.

When the review by Bol and Bannik (2015) was reported in Veterinary Practice News, for example, objections from some respected veterinarians explicitly cited anecdotal experience as a reason for continuing the use of lysine:14

Anecdotal evidence should not be discarded…I have clients who tell me that every time they take the cat off lysine the problem returns…Maybe it’s just as well to leave those cats on lysine if the clients genuinely feel that it’s making a difference.

[Lysine] is used frequently by many of my clients at the recommendation of Dr. Google…Some cats have a very convincing response in spite of what the science says…Its use should be based on response, whether scientific or not.

Science is, by nature, a competitive community process. Disagreement between individuals is healthy and an integral part of this process, spurring replication of research that helps compensate for the inevitable blind spots and biases we all suffer from. However, the explicit preference for anecdote over controlled research evidence is counterproductive and lends itself to the retention of treatments that do not truly help our patients and which deserve to be abandoned.

There is some limited evidence suggesting lysine could actually exacerbate FHV-1 symptoms, which would certainly make abandoning it the right choice.7 Even if it is completely harmless, however, wasting resources on treatment that has been through the scientific vetting process over 50 years and has still failed to show convincing evidence of benefits is not justified.

As I argued last month, evidence-based medicine is a necessary pillar of effective and ethical clinical practice. This means we must be willing to acknowledge our limitations and set aside anecdotal evidence, even our own, when appropriate research evidence indicates we are mistaken.

References

  1. Lehrer J. The truth wears off: Is there something wrong with the scientific method. The New Yorker. 2010. pp. 52-7.
  2. Alahdab F. Farah W. Almasri J. et al. Treatment Effect in Earlier Trials of Patients With Chronic Medical Conditions: A Meta-Epidemiologic Study. Mayo Clin Proc. 2017. Epub before print. Available at: http://www.mayoclinicproceedings.org/article/S0025-6196(17)30836-4/pdf Accessed February 21, 2018.
  3. Tankersley Jr RW. Amino acid requirements of herpes simplex virus in human cells. J Bacteriol. 1964;87:609–13.
  4. Griffith RS, Norins AL, Kagan C. A multicentered study of lysine therapy in Herpes simplex infection. Dermatologica. 1978;156(5):257–67.
  5. Griffith RS. Walsh DE. Myrmen KH. Et al. Success of L-lysine therapy in frequently recurrent herpes simplex infection. Treatment and prophylaxis. Dermatologica.1987;175(4):183-90.
  6. Collins BK. Nasisse MP. Moore CP. In vitro efficacy of L-lysine against feline herpesvirus type-1. Proc 26th Ann Meeting Amer Col Vet Opthalmologists. Newport, RI. 1995;141.
  7. Bol S. Bunnik EM. Lysine supplementation is not effective for the prevention or treatment of feline herpesvirus 1 infection in cats: a systematic review. BMC Vet Res. 2015:11:284.
  8. Chi CC. Wang SH. Delamere FM. et al. Interventions for prevention of herpes simplex labialis (cold sores on the lips). Cochrane Database of Systematic Reviews.2015;8. Art. No.: CD010095.
  9. Mailoo VJ. Rampes. S. Lysine for herpes simplex prophylaxis. Integrative Medicine. 2017;16(3):42-46.
  10. WHO Guidelines for the Treatment of Genital Herpes Simplex Virus. Geneva: World Health Organization; 2016. Available from: https://www.ncbi.nlm.nih.gov/books/NBK396232/
  11. Thomasy SM, Maggs DJ. A review of antiviral drugs and other compounds with activity against feline herpesvirus-1. Vet Opthalmology. 2016;19(Suppl 1):119-130.
  12. UC Davis Koret Shelter Medicine Program. Feline upper respiratory infection aka URI. 2015. Available at: https://www.sheltermedicine.com/library/resources/?utf8=%E2%9C%93&search%5Bslug%5D=feline-upper-respiratory-infection-aka-uri Accessed February 21, 2018.
  13. Slater M. Interpreting research (and making it work for you): Is lysine a good investment for shelters wanting to prevent URI in cats? Available at: https://www.aspcapro.org/blog/2017/05/03/interpreting-research-and-making-it-work-you-lysine-good-investment-shelters-wanting Access February 21, 2018.
  14. Niedziela K. Researchers question lysine use in FHV cases. Vet Pract News. 2016;28(1):36-7.
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The relationship between evidence-based medicine (EBM) and ethics may not be immediately apparent. EBM focuses on facts and data, safety and efficacy, and determining what we know and don’t know. Veterinary ethics is about what is right or wrong to do in the context of veterinary practice. The values that inform ethical principles are subjective and not always shared between individuals or different segments of the profession. The evidence used to evaluate the safety and efficacy of medical treatments, in contrast, should ideally be produced by methods broadly agreed to be the most objective and reliable possible. However, EBM turns out to be a key tool for achieving ethical clinical practice.

Despite inevitable controversy and disagreement, there are some ethical principles broadly accepted by most veterinarians. Some of these are articulated in statements such as the American Veterinary Medical Association’s Principles of Veterinary Medical Ethics.1 This document was adapted from the principles established for physicians by the American Medical Association, and similar statements have been adopted by veterinary associations around the world.2-6

Other widely accepted ethical standards are simply common elements of more basic cultural norms. For example, most of us would likely agree that we should try to help our patients and our clients, we should be honest with clients, and we should do our best to be technically competent and familiar with the current scientific knowledge that underlie clinical medicine.

These basic ethical precepts are formalized in the domain of medical ethics as several core principles, which usually include:

Beneficence–  Clinicians should attempt to help their patients, to benefit them.7

Non-maleficence– Clinicians should attempt to avoid harming their patients or to do more good than harm.7

Autonomy– Patients (or in veterinary medicine, their owners) have the right to accept or reject treatment. This is the foundation for the more specific concept of informed consent.7

Informed Consent– Clients have the right to make choices about the treatment of their animals based on accurate, relevant information they can understand.8

So what does EBM have to do with meeting these ethical obligations? Well, ethical judgements cannot be made without facts. The best path to abide by one’s ethical principles cannot be determined without an accurate understanding of the context. EBM informs ethical practice by giving us, and our clients, an accurate understanding of the risks and benefits of our actions as well as the degree of uncertainty about these.

In terms of beneficence and non-maleficence, for example, one cannot successfully help patients and minimize harm without an accurate understanding of the causes of disease and the effects of our treatments. If we attribute illness to the wrong cause, we are unlikely to stumble across an effective remedy. And if our treatments don’t actually work, or if they have risks that we are not aware of, then we are less able to do good and avoid harm to our patients.

Similarly, we deny clients their right to informed consent if we give them incorrect information about diagnosis, prognosis or the likely outcome of our treatments. This is equally true whether we are deliberately lying or are simply mistaken. The history of medicine is a long, frightening tale of incorrect beliefs about disease and of ineffective, even harmful treatments enthusiastically applied by well-meaning doctors. We are no smarter or better intentioned than our predecessors, but thanks to science, we are better informed.

Evidence-based medicine, then, is arguably a necessary component to ethical veterinary practice. It serves to provide clinicians with the most current and accurate understanding of the causes of disease and the risks and benefits of our therapies. EBM also helps us quantify the inevitable uncertainties we must accept and communicate to our clients.

There is rarely optimal evidence, so the most conscientious practitioner of EBM will often not be able to accurately predict the outcome of his or her treatments. However, even in this situation, EBM is useful because it supports truly informed consent. If the evidence supporting a particular therapy is weak, I may well still offer that therapy. However, I am able, even obligated, to understand the limitations of the evidence and share this with the client to help support informed decision making.8

There is often anxiety among veterinarians about disclosing uncertainty to clients. We fear they may not trust in our competence or may eschew beneficial treatment if we express any uncertainty or discuss the limitations of our knowledge. However, there is evidence that may allay this anxiety. Surveys have shown that clients expect to be told about the uncertainty associated with our recommendations and that they do not lose confidence in us as a result.9 Even more significant from an ethical perspective, clients in one study emphasized that their central expectation for the information they were given by their veterinarians was that it be the truth.10 EBM helps us meet the ethical obligation and client expectation that we communicate truthfully about our recommendations and our uncertainty.

So far, this idea that EBM can facilitate ethical veterinary practice by giving us the most accurate information and helping us measure our uncertainty may not seem especially controversial. Unfortunately, if we commit to EBM as the best source of information to support effective and ethical medicine, we eventually enter more tendentious territory.

For example, EBM includes the presumption that some sources of evidence are more reliable than others.11-12 This often leads to a conflict between what we believe, based on anecdote or personal experience, and what scientific evidence supports. Clinicians dislike being told that therapies which seem and effective in use are either scientifically unproven or have significant evidence against their safety or effectiveness. Yet our obligation to be informed and competent, and to provide accurate and truthful information to clients, can sometimes mean accepting the unreliability of anecdotal experiences, even our own.

An even more contentious topic is the ethical appropriateness of theoretical systems and treatment methods with core principles that conflict with established science. Much of what is often called alternative medicine consists of beliefs about the causes of illness and methods of treatment that are either scientifically unproven or even demonstrably incorrect based on research evidence.13-14 Alternative medicine raises many complex ethical issues,15 and it has been argued, in both human and veterinary medicine, that the use and sale of such approaches, however honest and well-intentioned, violate some broadly held ethical principles.14-19

Informed consent and autonomy are denied when clients are given information about their animals’ health that is inaccurate by the best available standards of evidence and scientific consensus. Beneficence and nonmaleficence cannot be maintained if ineffective treatments are offered.16

Often of course, there are legitimate disagreements about the meaning or strength of the evidence. However, there must be some generally accepted standard of proof required beyond simply the personal belief of the individual clinician to justify our treatments. If not, then there is no purpose to the systems of licensing and regulation intended to protect the public from unsafe and useless medical treatment. The caveat emptor free-for-all of medicine in the 18th and 19th centuries was ultimately rejected in the 20th as unsafe, and this was predicated on the belief that scientific evidence could provide a common basis for evaluating medical practice. This is a key pillar of the ethical structure of modern medicine, and EBM is an important tool for supporting ethical, science-based practice.

References

  1. AVMA Principles of Veterinary Medical Ethics. Available at: https://www.avma.org/KB/Policies/Pages/Principles-of-Veterinary-Medical-Ethics-of-the-AVMA.aspx Accessed January 31, 2018.
  2. AMA Principles of Medical Ethics. Available at: https://www.ama-assn.org/delivering-care/ama-principles-medical-ethics Accessed Access on January 31, 2018.
  3. CVMA. Principles of Veterinary Medical Ethics. Available at: https://www.canadianveterinarians.net/documents/principles-of-veterinary-medical-ethics-of-the-cvma Accessed January, 31, 2018.
  4. FVE. European Veterinary Code of Conduct. Available at: http://www.colvetalbacete.es/images/contenidos/cecv.pdf Accessed on January 31, 2018.
  5. AVA. Code of Professional Conduct. Available at: http://www.ava.com.au/conduct Accessed January 31, 2018.

6.Veterinary Council of India. Code of Ethics. Available at: http://www.tnsvc.org/forms/codeethics.pdf Accessed January 31, 2018.

7.Beauchamp TL. Childress JF. Principles of biomedical ethics. 5th Ed. (2001) New York, NY: Oxford University Press.

  1. Fettman MJ. Rollin BE. Modern elements of informed consent for general veterinary practitioners. J Amer Anim Hosp Assoc. 2002;221(10):1386-1393.
  2. Mellanby RJ. Crisp J. De Palma G. et al. Perceptions of veterinarians and clients to expressions of clinical uncertainty. J Small Anim Pract. 2007;48(1):26-31.
  1. Stoewen DL. Coe JB. MacMartin C. et al. Qualitative study of the information expectations of clients accessing oncology care at a tertiary referral center for dogs with life-limiting cancer. J Amer Vet Med Assoc. 2014;245(7):773-83.
  2. McKenzie B. A new perspective on evidence-based medicine. Vet Pract News. July, 2017. Available at: https://www.veterinarypracticenews.com/a-new-perspective-on-evidence-based-medicine/ Accessed January 31, 2018.
  3. Cockroft, P. Holmes, M. (2003). Handbook of Evidence-Based Veterinary Medicine. Oxford: Blackwell.
  4. McKenzie, BA. Is complementary and alternative medicine compatible with evidence-based medicine? J Amer Vet Med Assoc. 2012;241(4):421-6.
  5. Ramey, DW. Rollin, BE. (2004). Complementary and Alternative Veterinary Medicine Considered. Ames: Iowa State Press.
  6. Nuffield Council on Bioethics. Complementary medicine: ethics. 2014. Available at: http://nuffieldbioethics.org/wp-content/uploads/Complementary_medicine_FINAL_FL_paper-1.pdf Accessed January 31, 2018
  7. Smith K. Against homeopathy-A utilitarian perspective.Bioethics. 2012;26(8):398–409.
  1. Ernst E. Cohen MH. Stone J. Ethical problems arising in evidence based complementary and alternative medicine. J Med Ethics. 2004;30:156-9.
  1. Milstein M. The case against alternative medicine. Can Vet J. 2000;41:769-72.
  1. Macdonald C. Gavura S. Alternative medicine and the ethics of commerce. Bioethics, 30: 77–84.
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Last summer, I was asked to take over the Evidence-based Medicine Column (previous the Alternative Medicine Column) in the trade magazine Veterinary Practice News from Dr. Narda Robinson. This was an excellent opportunity to  illustrate the principles and techniques of evidence-based medicine in action, evaluating specific medical practices and discussing general issues related to EBM. Some of these columns will cover alternative therapies, but many focus on conventional medical therapies as well, since I have always advocated evaluating all therapies by the same, science-based standards. I will keep a running collection of links to these columns here as each becomes available to the public, as well as occasionally posting those with content that hasn’t appeared here before. Enjoy!

A new perspective on evidence-based medicine
July 27, 2017

Cannabis-based remedies lack reliable clinical evidence for veterinary use
August 9, 2017

Pros, cons of surgical sterilization, neutering options for females
September 14, 2017

Surgical sterilization, neutering options for male cats, dogs
November 21, 2017

Yunnan baiyao for patients with hemorrhage, neoplasia
December 11, 2017

Probiotics and today’s pets
January 10, 2018

Why do we run diagnostic tests?
February 7, 2018

Pheromones’ therapeutic use in animals
March 14, 2018

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It will come as no surprise to readers that I receive a steady stream of hate mail in the form of email and comments on the blog. Occasionally, someone calls me up at work, sends me a snailmail letter, but the vast majority of the negative comments I get are anonymous through the internet. In contrast, the positive comments I get, which are often accompanied by the name of the reader or given to me directly in person. Something about the anonymity internet frees people to say the darkest things in their heart without the usual social restraints that prevent us from being shitty to one another. (Before anyone cries “hypocrite” let me point out once again that this blog is not anonymous. My identity and credentials are easily found here and online, and I take ownership of the blog openly in my public lectures. I choose not to make myself the center of attention here, since I think the ideas and evidence should be the focus, but I am not hiding behind any serious attempt at anonymity).

I don’t, of course, allow people to post abusive comments directly on the site. Civil and substantive disagreement is welcome, but I am under no obligation to give people a platform to rant or abuse me or my profession. However, I do periodically review the best of my hate mail for several reasons. On one level, it is instructive to see the patterns in how people respond to my critiques of unproven or quack therapies. These comments give an insight into how people think and why they are attached to these kinds of treatments, which is useful for anyone trying to oppose pseudoscience.

It is also worthwhile to point out that advocates of the practices I challenge are hardly peaceful, saintly individuals minding their own business when vicious skeptics like myself come along to attack them. As I’ve discussed in detail before. Alternative therapies are marketed primarily by attacking the safety and efficacy of science-based medicine and the motives of mainstream doctors. Skeptics such as myself are responding to the assault of pseudoscience on scientific medicine, we are hardly the instigators of conflict. And apart from the occasional slip into sarcasm, most of my critique is aimed at claims and arguments and based on reason and evidence. I am far more likely to be the subject of vicious personal attacks than the perpetrator.

Finally, I have to admit that much of the angry feedback I get is amusing in its own right. Just as Jimmy Kimmel turns his hate mail into comedy I enjoy a chuckle over some of the outrageous things people say to me from the safety of their keyboards.

Some of the trends in the negative comments I get are obvious. There is a constant drumbeat of paranoia and conspiracy theorizing, blaming “Big Pharma” and the greed and immorality of mainstream medicine for all sorts of horrors which supposedly justify quack alternatives. There is the deep distrust of government and regulators, scientists and intellectuals, and anyone who makes a living in medicine except alternative medicine practitioners, supplement companies, and others who profit from “alternative medicine.”

There is also an obvious but rage in many of these comments that is harder to understand. Apart from a few individuals I have written about directly, the majority of those who write furious, hateful comments have no particular reason to be taking what I say here so personally. My blog doesn’t come into people’s living rooms or business. They have to search the internet, find the blog, and choose to read it. If they disagree, they are free to ignore me with no harm done. But even those who shout “No one cares what you think!!!” clearly do care enough to spend time writing angry comments (though they clearly don’t take much time to proofread these comments). I still find that puzzling.

Lastly, I have to point out that not once have any of these folks I’m quoting ever presented a piece of scientific research evidence to support their objections or challenge my claims. Plenty of commenters say “I don’t care what you/science/anyone says, I’ve seen XX work for myself.” None, however, have backed up their anger with anything other than anecdote or argument from authority.

Here are my previous hate mail collections:
Hate Mail 2011

Hate Mail 2015

I have organized the selections below into broad, loosely defined categories, and I will occasionally insert comments like so: [SV: Xxxx] Enjoy!

Being Nice?
[SV: Some commenters don’t seem to appreciate the strange and humorous inconsistency in tone when they simultaneously chastise me and wish me well. Perhaps they recognize that they are being much harsher than would ever be acceptable in person and are trying to soften the message, or maybe just make themselves look like they are taking the ”high road?”]

You are such a rabid skeptic and that keeps you from some great things in life. By the way, the crap works- do more research on it- ask a client if they want to try it- One that has NOTHING to lose and see. Hope your life gets better and you quit being so negative. Wishing you the best.

You are clearly uneducated…Bless you though.

After reading a few articles on this page, I come to the conclusion that it is not necessary to read the other’s content, as anything and everything mention here the author is clearly AGAINST. Its a bit pitiful, I think to be SO sceptical, how can you enjoy life at all.

i can feel the intense negative emotion you are feeling toward Dr. Plechner and other doctors that don’t follow the herd. I am sorry you are festering in this emotion. Does it upset you to think of all the success stories?

are just a Big Pharma shill. That’s OK. Everyone has the right to protect their interests. I wish you luck in your endeavor to frighten people away from innexpensive therapies which might save their termial pets’ lives. If it makes you happy, I wish that for you sincerely.

your ignorance and pride is a disgusting excuse for lack of wisdom. You obviously must be carrying a lot of disease in your own body and soul. Bless your heart, poor thing. Hope you get well soon.

You sound like a pompous ass. ..I don’t think anyone stands a chance of turning on a light for you at all. Just had to express my irritation on wasting my time trying to find an unbiased opinion from your site. Good luck with your journey on the narrow path you travel.

Hahahahahahahahahaha. You think that you’re enlightened, hahaha, you’re not, you’re nescient at best and ignorant at worst. Enjoy your pontificating though.


IN MY HUMBLE OPINION, YOU ARE PURE EVIL, MAKING MONEY OFF YOUR BLOG’S, AND SCREWING OVER THOUSANDS OF DOGS AND CATS, AND OTHER CREATURES, WITHOUT A SINGLE PIECE OF EVIDENCE SUPPORTING YOUR CLAIMS IT DOESN’T WORK ANY BETTER THAN A PLACEBO,..

I hope that GOD FORGIVES YOU for YOUR NONSENSE, MISLEADING PEOPLE, CAUSING THEM TO END UP GIVING UP, WITHOUT TAKING A MINOR CHANCE ON GIVING THEIR LOVED ONE’S A DAMN CHANCE AT LIVING LONGER!!!

IMHO, YOU CAME STRAIGHT OUT OF HELL!

AGAIN, THIS IS STRICTLY MY OPINION,…

The Shill/Evil Industry Conspiracy Tactic
[SV: This is, by far, the most common objection raised. The idea that someone could honestly disagree with their beliefs after careful, open-minded evaluation of the arguments and evidence is apparently inconceivable for these people. They accuse me or arrogance freely yet imagine that any belief other than theirs is willful ignorance or deliberate dishonesty. Irony meter broken!]

FDA are the real killers of USA that only approve side effect medications to cause more problems in your body. I agree with Alex Corp. FDA stands For Death Administration and that to the point. FDA should be banned from the whole of USA. They just as corrupt as the Government!!!

You are correct about herbalist? Seriously? They why are so many being killed off? Around 100 within a year as of May of 2016. Read about it already. I guess it is because what they practice and treat never works?????

Homeopathy has worked for me many times in treating both my family and our pets. It is safe, effective, and inexpensive if you choose the right remedy. It is so diluted that there is almost nothing left of the original substance in the remedy. Those who don’t want to use it don’t have to, but those of us who recognize how miraculously effective it is have the right to continue to buy it easily, cheaply, and over the counter. It’s just the exorbitant pharma companies who want to rub out their much more effective competition.

The only reason I don’t follow up on this is I’m afraid the FDA will get a hold of these and find out how well they work and shut them down! As a typical bumbling corrupt (Paid off by the pharmasudical industry) government agency should!

If I want to live long and healthy I almost always do the exact opposite of what the government, media and scientific communities tell me to do.
Seriously. Yeah.
Big pharma underwrites the nation’s medical schools.

It’s a shame you and so many other conventional veterinarian’s are brainwashed by Big Pharma, The Big Pet Food companies, the FDA, the USDA, the CDC, and the media!!.. WAKE UP from your brainwashed, sheeple coma and gain some knowledge before writing an article you know nothing about!

But you must get paid well by druggies as I call the big pharm guys.
This is not funny, this is criminal brain washing of the gullible for the purpose of gazillions made on ignorance of the many. Good job.

This blog is paid for by drug companies either directly or indirectly. Any time you see the word “Skeptic” you know the website is written by paid liars and shills for the drug cartels.

I remarked to my wife when I ordered tha stuff that if it actually worked it would would either disappear from the market or sales forbidden. Why, you might ask?

There are two obvious reasons :- first, if it worked, if would deprive doctors, nut press, opticians and a whole host of other of MONEY. The entire medical profession is a giant hamster wheel. If CURES were actually found for things like cancer ‘flu, and a whole host of other diseases, it would throw millions of people out of their jobs. Just think about it. Learned professors spouting the bullshit that the Govt tells then to, doctors, nurses, drug companies, high street pharmacies. We can’t have that now can we?

I remarked to my wife when I ordered tha stuff that if it actually worked it would would either disappear from the market or sales forbidden. Why, you might ask?

There are two obvious reasons :- first, if it worked, if would deprive doctors, nut press, opticians and a whole host of other of MONEY. The entire medical profession is a giant hamster wheel. If CURES were actually found for things like cancer ‘flu, and a whole host of other diseases, it would throw millions of people out of their jobs. Just think about it. Learned professors spouting the bullshit that the Govt tells then to, doctors, nurses, drug companies, high street pharmacies. We can’t have that now can we?

You have to be a guy paid by pharmaceuticals to bash these people and their products. What are you afraid of? That millions will stop taking your drugs with mike long lists of side effects? Lots of money at stake right?  I say go f yourself! Clinical studies you want? Are you really satisfied with the non transparency of clinical studies used to validate the safety of the pharmaceuticals prescribed by docs like candy? I am not! You know why? Because there is no money in telling the truth! The money is in misinformation!

So I tell you what! Your bitch ass should go to your doc and refill your script for statins, psycho drugs and dick hardeners and let those who want to take bogus supplements do so!

Please help me understand why you would write such a horrible article.
Do the vets and pharmaceutical companies just want to make more $ at
the expense of our best friends?… I’m really disgusted by your article. Your
thoughts?
Most vets are against Raw feeding because they have been brain washed by Big Business in their training to sell bags of dried ‘food’ to pets (to make money on) instead of proper food.

I think Skeptvet ought to change his handle to PhillipMorrisVet or perhaps ExxonMobilVet.

Mainstream vets are like mainstream vets under the FDA – they discourage you from the truth about products that work and encourage you to the harmful drugs that keep them in business.

Stick with your chemicals and I’ll stick with my natural plants that God created, not man. Don’t give a hoot about clinical trials or what the FDA says because none of you want a cure for cancer cuz there’s too much money to be made.

This person is obviously blinded by the pro big med drugs training/our system ( anti biotics are big biz people)… This article is a blatant lie and so, so, so many people have gotten fabulous results with this supplement, but what’s the problem – no kick backs from the med company for you?

Who is getting paid by the pharmaceutical companies to do fear mongoring ah??? that would be you. You are an uninformed moron who has NO experience what so EVER in what you talk about! what a joke! go do something useful that would really help the animals!!! there’s a thought! but no too busy getting paid off arnt you…


Vaccines CAUSE allergies. You are nothing but a pHARMa shill.

some vets are upset because this product works better than their surgery attempts and they are bitter enough to call the FDA to stop the production and sale of this lifesaving product dooming thousands of pets to an agonizing death! The FDA and Big Pharma are in bed with each other and totally corrupt!

Big Pharma, and their lackeys like skepvet like to use clinical trials as a bludgeon for their own distortions. If you are not pimping one of their patented drugs they will tell you [ypur evidence isn’t good enough].
What a nasty article full of menace and lies… It is only the studies of the articles and videos of vets like the one you are battering unjustly, that I realize how the crooked pharma and commercial petfood industry lies to us, owners, making our pets sick while earning more by ‘treating’ them even sicker medicine, creating thus a viscious circle, making us feel dependent on them.

Simplicity and Creative Writing
[SV: Some commentators go straight for the simple, direct approach without a lot of complex thinking or argument. Others engage in a bit of creative writing at my expense.]

You know SkypeVet , you have to be connected to the world of Big Pharma and anything natural is beyond your way of thinking ..

I’ve read your negitive articles for a very long time now. I hope ppl see you for what you really are… Your a complete joke !

All pets under your care will suffer because of your ignorance and arrogance. You should have studied accounting.

Who so ever is the author of the article is an ass of the highest order.


Get lost loser


Who ever wrote this information on this website is an idiot.


Skepvet here is just a dinosaur coughing up a death rattle.

I find you a worthless drug pusher…and you need to seek another profession,


You slam all who disagree with you, are you related to Donald Trump?

I have seen miracles at Dr. Plechner’s hands, so take your contempt and put it where the sun don’t shine.

Skeptvet is a moron.

I found your comments/post/whatever to be obnoxiously close to exactly
what I’d expect to hear from another incompetent, undereducated, but
still egomaniacal, “old school” veterinarian

Ur ignorant idiot

skepvet is a quack…Skepvet is a shill for Big Pharma,

Skeptvet. You are a complete moron… Shut down and shut up. The people have spoken.

Your a fear mongering putz!

Arsehole! arsehole arsehole

To be honest you sound like a frustrated raving idiot… Your qustions are a rant of arrogance and self importance. See ya. Wouldn’t want to be ya.


If your practice was worth a crap you wouldn’t have time to babble on here

What a load of old rubbish.

You are full of shit.

You are all ignorant idiots.,,The traditional medical system and vets are crooks and under trained and under exposed. Shame on you

One should remind you that anyone with an Average IQ can Discern that you are What you are Complaining about, and that Morally, if not Ethically, and possibly Legally; you engage in Freely Committing Slander.


you are a real fool and an idiot. As stated you are the biggest fool I have EVER seen in my 30 years of using ozone in my practice.


You have both demonstrated you are nothing but babbling blow hogs with nothing better to do than babble about something you know nothing about. Get a job and stay off the internet!

What a sad human you are and I’m glad I found your blog so I can safely steer clear of you in the future.


This blogger is merely weaving a carpet of self enhancement thinking perhaps it will take him to the White House or some delusion of grandeur !
Someone is paying you to discredit vitamins, glandulars and minerals as beneficial remedies. You probably are a stupid medic. Breast feeding at age 80 off the pharmaceutical TIT. Die quickly so u can be reborn and do something to help someone.go pop a pill. You are an idiot.


So my remedy for someone like you and your advice…is to shut it.

What a pedantic piece of dog poop…. You sir apparently have a hidden agenda or are trying to prove your self esteem to yourself.

Maybe u should do like I was raised…if you can’t say something nice then keep ur mouth shut.

You are such a pompus ass egomaniac… I was trying to give you benefit of doubt until you went to espousing the global warming bullshit. You have shown your true colors – brown like the bs you write.

OMG, do you have any idea what sort of fool you sound like writing this post? Get your head out of your ass

You are probably one of the most arrogant people I have encountered on a forum that is meant to help people. You are not a help to anyone with your condescending attitude. EGO- look it up. Your lack of compassion is a testiment.

I read your article in its entirety and have to ask: what rock did you just crawl from under?

i cured high blood pressure arthritis and arithmia with these supplements – this article is moronic

Are you living under a rock dude?

Really Mad
[SK: Obviously, all of the critics here are mad. But with some comments, the visceral rage radiates from the monitor like heat. Whether it’s the use of ALL CAPS, exclamation marks!!!!!! Or just the language, these folks are making it clear that they are REALLY MAD!!!!!!!]

To say that I find this piece appalling, unprofessional and slanderous is an understatement… I would ask out of respect and decency that before publishing such a slanderous, potentially damaging piece you would at LEAST have the courage and courtesy to call your colleagues before marring their reputation and being so utterly vitriolic. As you have made it your life’s mission to brutally eviscerate anyone who speaks out in favor of any holistic modality. Which is especially admonish able considering the high rate of suicide and anxiety in our profession.

[SV: This is actually one of the few comments from an individual I have written about (1, 2 While I understand that no one appreciates being criticized, public comments are fair game. I did respond to Dr. Conway offering to have a more thoughtful and civil dialogue about our disagreement (**see below), but she never responded.]

Big devious lie of an article!!!…in my opinion it’s like a miracle medicine and it’s a must habe for all pets with kidney failure!!!!!!any !, any one telling u otherwise is Probably working for the misinformation industries!!!!!!
THANK U THESE PEOPLE R JUST JEALOUS THEY DIDNT COME UP WITH #NZYMES
.I START NEXT WEEK… GO TO HELL SKEPTVET

This article you have written skepvet is absolute rubbish, oozes with hatred, ignorance, pouting, sulking and immaturity.

Once again an stupid, narrow minded and unedcuated article by THE conventional vet that has more time on his hands than he should…. What has troubled your childhood that badly that you just can’t stop your endless fight against mother nature and you need to voice your opinions, that truly nobody cares about… Dr Xie. He trains thousands of vets on planet earth yearly, yet have the atrocity to criticize a man in a field you have ZERO KNOWLEDGE about. Why are you opening your mouth?

Wake up. The world doesn’t care about your opinion.


THIS IS MY OPINION OF SKEPTVET and HIS BLOG!!!!!!! HE IS MAKING MONEY FROM THESE MISLEADING STATEMENTS!!!!!

Here is what I believe,.. I believe that YOU are MAKING MONEY from a BLOG, from the advertisements, and that is why you continue to say something but say ABSOLUTELY NOTHING,…. STOP MISLEADING PEOPLE, WITH YOUR OWN SNAKE OIL CLAIMS, BECAUSE YOUR MAKING MONEY OFF A BLOG’s AD’S, and AT THE END OF THE DAY, YOU GO TO BED, PROBABLY ALLOWING THOUSANDS OF DOGS AND CATS GO TO THEIR DEATHS, WITHOUT HAVING ONE LAST CHANCE AT LIFE!


Once again old man skeptvet is bashing another product. You want to keep killing dogs with Rimadyl. Just shows what a worthless vet you really are… As I have said before, your opinion is irrelevant. You have made a fool of yourself time and time again. You think you are a know it all but you are a know nothing. Nobody cares what you have to say anyway.


Slept-vet you remind me of a man named Hitler that everything he said was taken as the truth and no-one else was correct.

What shocks me – and I consider particularly evil – is the fact that [my name] went after the blood bank. Ridicule all you want, [my name]. But you, [my name], as a vet, should know better. You put dog lives in danger by refusing veterinary emergency medicine. Your statements, [my name] DVM of Northern California, make you ultimately a pet killer. Dr. [my name], you are on the same level as Kristen Lindsey, the veterinarian who killed the cat with an arrow. You, Dr. [my name] probably agree that cats should have arrows through their heads and wave them gallantly over your head in triumph, [my name] aka SkeptVet. [SV: This person apparently felt very clever in discovering my name and imagined inserting it repeatedly in this comment would show me a thing or two.]

Just wanted to let you know you are a fraud….your science sources
are all either anonymous, just like you to avoid all accountability
for your fraudulent non-advice or obvious industry sites. You should
be ashamed of yourself. You are a disgrace! Disgusting!

MD’s and vets are lying criminal drug pushers who do not cure anything. They pump unnatural crap into gullible people’s pets and still sleep at night in satin sheets.

SkeptVet, You sound like the precise commercial kibble peddling Vet that has ended up killing dozens of dogs with your conventional passive income steroid therapies and regular income generating..

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Here are the notes and slides for a recent presentation on placebo effects in veterinary medicine.

WHAT IS A PLACEBO?
Despite the fact that most people have heard of the placebo effect and feel they have some understanding of what it means, the concept is a complex and contentious one. There is no consensus definition of a placebo or of the placebo effect. However, it is generally accepted that placebos are inert, and they have no direct physiologic effect on a patient’s disease or symptoms. Placebo effects, then, are effects associated with the administration of an inert substance or treatment, and these effects are perceived as beneficial by the patient or observers. Negative effects associated with inert treatments do occur, and these are referred to as nocebo effects.1

There are a number of mechanisms by which an inert treatment can lead to reported or observed responses. Many placebo effects are psychological responses based on belief and expectation, which influence a patient’s perception of his or her symptoms or have physiologic effects through centrally mediated changes in autonomic function.1-2 Placebo effects may also be caused by classical conditioning, in which physiologic responses to active treatments are paired with inert stimuli that are eventually able to elicit the same responses as the active treatment.2

Some effects associated with inert treatments in clinical research studies are actually not placebo effects mediated by conditioning or expectations. Research subjects in a placebo control group may experiences changes in their symptoms or other outcomes for a variety of reasons, and the use of an inert treatment can reveal that these changes are not due to the active treatment. However, not all such changes are true placebo effects.

For example, the Hawthorne Effect is a phenomenon in which subjects improve simply as a consequence of being enrolled in a research study.3 Subjects get more care and attention, they tend to be more compliant with existing treatments because they are being monitored, and their condition may improve due to better overall care regardless of any active test treatment or expectation-based placebo effects.3

Regression to the mean and the natural course of disease are other phenomena that can be seen in subjects receiving placebos in a research study which is not actually a true placebo effect.4 With chronic conditions, symptoms tend to wax and wane spontaneously. And some conditions may resolve spontaneously Patients are more likely to seek care, or enroll in research studies, when their symptoms are waxing, and thus they tend to improve after receiving care or beginning a study due to the natural course of disease. This, again, can be revealed by placebo assignment, but it is not an effect of the administration of the inert treatment.

It is worth noting that all of the factors that cause placebo effects and apparent response to inert treatment can also be seen with active treatments. Pain relievers with direct physiologic activity can elicit a greater reported response than explained by the pharmacological effects of the treatment. Part of the purpose of inert treatments in research trials is not only to assess whether treatments have specific effects but what proportion of the apparent response may be explained by concurrent non-specific effects and placebo responses.

In general use, placebo effects refer to those changes in reported or measured symptoms associated with beliefs or expectations about treatment. However, in the context of medical research, any effect seen in the placebo control group is classified as a placebo effect even if it is due to other factors.1 This complicates the clear use of the term and an understanding of what effects can be attributed to inert treatments and the associated mechanisms. It also impacts the relevance of placebo effects to veterinary patients, in which the relative role of various causes for non-specific treatment effects likely differ from human patients.

PLACEBO EFFECTS IN ANIMALS
It is clear that animal subjects in research studies exhibit changes in symptoms commonly identified as placebo effects when seen in human research subjects. These include subjective symptoms reported by owners or observed by investigators and clinicians as well as objectively measured outcomes.2,5-8 There is no clear research evidence showing such effects in clinical veterinary patients not participating in research. However, the circumstances and variables responsible for placebo effects seen in veterinary research studies are usually also present in the clinical context, so it is likely such effects exist in clinical patients as well as research subjects.

Animals receiving inert treatments often show improvement in subjective outcomes, such as pain, which are assessed by caregivers, clinicians or researchers. While it is generally accepted that most animals are not cognitively capable of having beliefs and expectations about their medical care, and so cannot have the classic direct placebo response, caregivers and other humans involved in these studies are susceptible to such effects. The caregiver placebo effect, in which humans report improvement in subjective  symptoms for animals receiving inert treatment, has been clearly demonstrated.5,7

It is also likely that animals receiving inert treatments may show improvement due to causes other than direct placebo effects. Research has shown human contact has predictable effects on behavioral and physiologic responses in domesticated animals, and these effects can easily be interpreted as improvement in clinical symptoms.2,9 And just as classical condition contributes to placebo effects in humans, such conditioned responses are certainly present in other animals and likely generate changes in the condition of animal patients and research subjects receiving inert treatments.

Even relatively objective outcome measures have been shown to change in response to the administration of inert treatments. Seizure frequency, heart rate, and other objectively measurable outcomes show non-specific treatment effects in animals just as in humans.2,8 Conditioning, the Hawthorne Effect, general response to human contact, and other variables are likely responsible for these apparent placebo effects.

 CLINICAL IMPLICATIONS
The presence of placebo effects and other responses to inert treatments has several important implications for clinical care. One is that apparent responses to treatment, especially in subjectively experienced symptoms such as pain, nausea, and fatigue, may reflect placebo effects rather than true improvement in the underlying condition. Human asthma patients, for example, may report improvements in the symptoms experienced during an asthma attack when given a placebo inhaler.10 However, such responses are not typically seen in objective signs of disease, especially in patients not in clinical trials receiving more intense and comprehensive monitoring and care than clinical patients. For example, the asthma patients who reported feeling better with placebo inhalers had no measurable improvement in lung function, unlike those patients receiving bronchodilator therapy.10

This demonstrates that placebo effects generally improve the perception of symptoms but not the actual physical disease. Such effects can fool patients, caregivers, and clinicians into believing they have provided effective treatment while allowing the disease to remain of progress. Asthma patients consistently treated with an ineffective medication would likely perceive some relief, but they could also be experiencing ongoing lung damage and ultimately have poorer outcomes due to the lack of objectively effective treatment. It is critical, then, that clinical therapies be demonstrated to be truly effective through clinical trial research because uncontrolled clinical observation is an unreliable guide to efficacy.

There are also ethical implications to placebo effects.11-12 In human medicine, there may be some benefit to improving the perception of uncomfortable symptoms, with a placebo or with placebo effects attached to active treatments. However, such effects are typically negligible if patients are informed that they are receiving inert treatments. Obtaining the subjective benefits of placebo effects requires misleading patients into believing they are receiving an active therapy, which is arguably unethical.11

In veterinary patients, placebo effects are largely obtained by proxy through caregivers.5,7 This creates an additional ethical challenge since caregivers and clinicians may perceive benefits the patients are not actually experiencing. This makes the necessity of objective research validation for treatment efficacy even more critical in veterinary medicine.

CONCLUSIONS
Placebo effects, and other related factors that create true or perceived improvement in clinical symptoms, are manifest in veterinary patients and animal research subjects. Controlling for these effects in research studies is crucial to identifying the true benefits of the treatments we employ. The existence of such effects also makes clinical observation of response to therapy highly unreliable as a measure of the true efficacy of our treatments. We, and our clients, often see what we hope or expect to see in response to the therapies we employ, and it is possible to be fooled into believing ineffective treatments are working without appropriate controlled research evidence. This creates an ethical imperative to base our interventions on good-quality research evidence rather than uncontrolled observations. Fortunately, some kinds of non-specific effects seen with inert treatments can also add to the real benefits of active treatments, and we can take advantage of this to maximize the benefits of our therapies once we have established objective efficacy.

REFERENCES

  1. De Crae AJM. Kaptchuk TJ. Tjissen JGP. et al. Placebos and placebo effects in medicine: historical overview. J Royal Soc Med. 1999;92:511-15.
  2. MacMillan FD. The placebo effect in animals. J Amer Vet Med Assoc. 1999;215(7):992-9.
  3. McCarney R. Warner J. Iliffe S. et al. The Hawthorne Effect: a randomised, controlled trial. BMC Med Res Methodol. 2007;7(30).
  4. McDonald CJ. Mazzuca SA. Mcabe PG. How much of the placebo ‘effect’ is really statistical regression? Statistics Med. 1983;2:417-27.
  5. Conzemius MG. Evans RB. Caregiver placebo effect for dogs with lameness from osteoarthritis. J Am Vet Med Assoc. 2012;241(10):1314-9.
  6. Malek S. Sample SJ. Schwartz Z. et al. Effect of analgesic therapy on clinical outcome measures in a randomized controlled trial using client-owned dogs with hip osteoarthritis. BMC Vet Res. 2012;4(8):185.
  7. Gruen ME. Dorman DC. Lascelles BDX. Caregiver placebo effect in analgesic clinical trials for cats with naturally occurring degenerative joint disease-associated pain. Vet Rec. 2017;180(19):473.
  8. Muñana KR. Zhang D. Patterson EE. Placebo effect in canine epilepsy trials. J Vet Intern Med. 2010;24(1):166-70.
  9. Zulkifli I. Review of human-animal interactions and their impact on animal productivity and welfare. J Anim Sci Biotech. 2013;4(1):25.
  10. Wechsler ME. Kelley JM. Boyd IOE. Et al. Active albuterol or placebo, sham acupuncture, or no intervention in asthma. N Engl J Med 2011;365:119-126.
  11. Asai A. Kadooka Y. Reexamination of the ethics of placebo use in clinical practice. Bioethics.2013;27(4):186-93.
  12. Gold A. Lichtenberg P. The moral case for the clinical placebo. J Med Ethics. 2014;40(4):219-24.

Placebos in Veterinary Medicine Slides

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Here are the notes and slides for a recent presentation on strategies for effectively choosing diagnostic tests.

GOALS OF DIAGNOSTIC TESTING
Ultimately, the goal of any test we run should be obtaining information that allows us to more effectively treat or prevent health problems in our patients. This seems obvious, but it is all too easy to lose sight of this core purpose. We may feel obligated to run tests to confirm a diagnosis even when the level of confidence is already high and the outcome of the test won’t change what the client chooses to do. We may employ diagnostic tests as a preemptive defense against litigation or because of a perceived pressure from the client to do something even when our action likely won’t change the outcome for the patient. In some situations, we may be completely confused by a case and throw a bunch of tests at it hoping for some insight to emerge.

All of these are understandable, and all too common, reasons for using diagnostic tests, but unfortunately such approaches reduce the reliability and utility of the tests themselves. Effective testing requires not only an understanding of the strengths and weaknesses of the tests we use but also a clear understanding of how to employ them and how to integrate the results into our clinical decision making. We need a rational strategy for when and how to test, how to interpret results, and somewhat counterintuitively, when not to test at all.

BEYOND SENSITIVITY AND SPECIFICITY
The most common measures used to describe diagnostic test are sensitivity and specificity . These are characteristics of the tests themselves, and they indicate how likely, compared with some gold standard, a test is to correctly identify a disease which is present or to correctly identify that a patient does not have the disease. Unfortunately, the meaning of these numbers is often misunderstood. If a test has, for example, a 98% sensitivity, this is the proportion of patients with the disease who will correctly test positive. It is NOT an indication that any patient who tests positive has a 98% chance of having the disease. Under certain conditions, the majority of patients testing positive on such a test may actually not have the disease even with such a high sensitivity.

More clinically useful measures of a test’s reliability are the positive predictive value and the negative predictive value (Fig. 1). These are, respectively, the probability a patient with a positive test actually has the disease and the probability a patient with a negative test result does not have the disease. These numbers depend not only on the test but also how common the disease is in the population being tested.

As an example, if a population of feral cats has an FIV prevalence of 2%, 2/100 cats tested will test positive with a perfectly sensitive test (sensitivity=100%). If the test also has a specificity of 98%, then about 2/100 cats will test positive even though they do not have FIV. The positive predictive value, then, is 50%, meaning half of the cats who test positive do NOT have FIV. Even with a great test, this is a pretty big error rate, especially if we are planning on euthanizing cats diagnosed with FIV!

This example illustrates how important it is we have some idea how likely a disease is to be present before running a test for that disease if we want our test results to be reliable. Which brings us to a new and somewhat fashionable way to look at diagnostic testing….

BAYESIAN ANALYSIS FOR THE MATHEMATICALLY CHALLENGED
The work of 18th-century mathematician Thomas Bayes is enjoying something of a renaissance as an alternative, in some respects, to the frequentist statistical methods most of us were taught in vet school. The details of the math involved are complex, but the logic of the approach is simple and intuitive. Diagnostic tests should not be viewed as determining whether or not a disease is present. They should be viewed, instead, as one piece of evidence shifting the existing probability of a diagnosis higher or lower.

If, as in the example above, I know that the prevalence of FIV is 2% in this population of cats, I can say the probability of any given cat having FIV is very low. A positive test does not mean a cat has FIV, only that the probability it might have the disease has increased a bit. The test doesn’t make or break the diagnosis, it simply shifts out understanding of the likelihood of the diagnosis.

In a practical sense, then, a Bayesian approach means estimating the probability of a diagnosis based on all of the usual factors we consider (signalment, personal history, prevalence rates, physical exam findings, other test results, etc.). If this probability is high enough or low enough to make or rule out a diagnosis, no additional test is needed. If, however, the probability leaves significant uncertainty, then we should select a test that will meaningfully raise or lower that probability to help us make the diagnosis.

SCREENING
Screening is a special case in which we are testing asymptomatic individuals with the idea of detecting preclinical disease so we can more effectively intervene to reduce symptoms and mortality. Because the prior probability of disease is usually very low by definition in screening, since patients have no symptoms, the positive predictive value of even very good tests is low. It has been recognized in human medicine that screening can often lead to overdiagnosis and overtreatment, which can waste medical resources and ultimately do more harm than good for patients.1There are, therefore, requirements for screening programs, and these include not only accurate tests but proven interventions that actually improve outcomes for patients diagnosed with the disease and rational plans for confirming and following up both positive and negative test results.

In veterinary medicine, we often employ diagnostic tests in asymptomatic patients “just in case” we might find subclinical disease. Whether or not such testing improves outcomes for patients or leads to significant overdiagnosis is almost never evaluated, so the benefits and risks of screening are often assumed but not truly known. This means that significant caution is warranted in conducting screening and interpreting the results of diagnostic tests in clinically well individuals.

CARDINAL RULES OF DIAGNOSTIC TESTING

Based on this understanding of the limitations of diagnostic testing, there are a few cardinal rules we can apply to reduce the potential mistakes and harms resulting from our tests:

Cardinal Rule #1

If the results of the test isn’t going to change what you do, don’t run the test.

Cardinal Rule #2

If the prior probability of a diagnosis is very high or very low, don’t run the test.

Cardinal Rule #3

Don’t screen (test asymptomatic individuals) without a plan of action based on solid evidence that the benefits of testing and diagnosis outweigh the risks.

REFERENCES

  1. McKenzie, BA. Overdiagnosis. J Amer Vet Med Assoc. 2016;249(8):884-889.

Choosing and Using Diagnostic Tests Slides

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Here are the notes and slides for a presentation I recently gave comparing various surgical sterilization and neutering techniques.

INTRODUCTION
Among the most common surgical procedures in small animal practice are those for sterilization (preventing reproduction) and neutering (removing the gonads). The goal of these procedures is both to prevent reproduction and to provide a net health benefit for the patient. This benefit may include avoiding the risks of reproduction, reducing the incidence of those disease that are more common in intact animals, and reducing behaviors associated with intact status that can lead to relinquishment.1-2

There are many variations on these procedures, and the specific techniques used by individual veterinarians seem to depend more on tradition, personal habit, and cultural preference than on explicit evaluation of the pros and cons from a scientific perspective.3 There is, however, research evidence concerning some of these procedures which we can use to make rational decisions about our choice of technique. We can also use this research to inform the recommendations we make to clients. Pet owners are increasingly aware that there are multiple alternatives to choose from, and they may come to us with strong opinions or misconceptions about the most appropriate procedure to their pets.

Most procedures are intended to prevent reproduction. Some also involve gonadectomy, which has a complex array of both beneficial and harmful effects that depend on breed, sex, age, timing of surgery, and many other factors. The long-term pros and cons of gonadectomy are controversial, and I have reviewed them in detail elsewhere.2 In brief, there appears to be a net health benefit for most female dogs and cats from neutering, though the details of the risks and benefits and the effect of the timing of neutering are quite variable. There is much less evidence for a net health benefit in neutering males, though there are other justifications for doing so. Today I will consider the relative advantages and disadvantages of different surgical sterilization methods for males and females.

STERILIZING FEMALES
The most common spay procedure in the United States is ventral midline ovariohysterectomy (OVH). This is an effective technique for sterilization and neutering of both dogs and cats with very low complications rates when performed by experienced surgeons.4-6 There are many minor variations with no research evidence comparing the relative merits of most.

One exception is the flank approach to ovariohysterectomy, preferred in some countries for cats and small dogs. There are theoretical advantages and disadvantages to this approach, and research evidence comparing flank and midline approaches is mixed. Some comparisons suggest the flank approach is faster with fewer complications,7 but other studies find no difference8, and some indicate more discomfort associated with the flank approach.9-10 Access to both ovaries is more difficult with the flank approach unless bilateral flank incisions are made, which significantly complicates the procedure, and hysterectomy can be difficult by this method.11 The flank and midline methods both achieve the goal of gonadectomy and sterilization.

Traditionally, ovariohysterectomy has been preferred in the United States while ovariectomy (OVE) is the more common choice in some other countries.12 Both techniques are equally effective at achieving gonadectomy and preventing mammary carcinoma and pyometra.12-14 Some studies have suggested that OVE is less painful than OVH15, however other studies have not identified any difference in post-operative pain or other complications.10,16

A relatively recent option is the laparoscopic spay. Both laparoscopic ovariectomy and ovariohysterectomy have been reported, using a variety of equipment and techniques. Comparisons are difficult given the many different approaches, equipment, and assessments used in published studies. In general, the disadvantages of laparoscopic OVE and OVH include the cost of equipment, the need for extensive training and practice to achieve proficiency, and the longer surgical time.17-20 Laparoscopic spay may have the advantage of decreasing post-operative pain, complications, and recovery time, though the literature is not consistent and there is a lack of high-quality studies.21

With a growing awareness of the potential negative effects of neutering, there has been some increased interest among breeders and pet owners in sterilization procedures that do not involve gonadectomy. For females, two such procedures are hysterectomy (sometimes called an “ovary-sparing spay”) and ligation of the fallopian tubes or uterine horns. Both procedures have been described in the literature,22-23 but neither have been widely adopted.

There are no controlled research studies comparing tubal ligation or hysterectomy to OVE or OVH. While ligation of the fallopian tubes or uterine horns can prevent reproduction, it is highly likely that any risks and benefits associated with the presence of ovaries2 are the same for females having a tubal ligation as for those not spayed at all. A complete hysterectomy, including removal of the cervix, likely eliminates the concern for pyometra while the other risks and benefits of intact status remain unchanged.

STERILIZING MALES
Despite the uncertainties, surgical neutering is the most common approach to sterilization of male cats and dogs. For dogs, frequently used techniques include closed castration (removal of the testes without opening the vaginal tunic) and open castration (which involves opening the vaginal tunic prior to ligating the vessels and ductus deferens). Both procedures can be performed through a scrotal or pre-scrotal incision, and there are a number of variations of each.

There is much debate about the relative merits of open and closed castration in dogs, but it is based mostly on theoretical reasoning and anecdotal evidence. Some argue that closed castrations are safer because there is no direct communication with the abdomen, reducing the risk of ascending infections or herniation of abdominal contents. Others claim that open castrations are less likely to lead to hemorrhage or scrotal hematomas. Typically, closed castration is recommended for small dogs and cats and open castration for larger dogs.

There is little research evidence to inform these debates. One prospective randomized trial did find more overall complications in dogs undergoing open castration.24 However, problems with recruitment of subjects for this study significantly limit the strength of this evidence. Overall, serious complications are few in dogs undergoing castration, and it is unclear if there is a consistent advantage to either technique.

The research evidence comparing scrotal and pre-scrotal approaches in dogs is also quite sparse. A randomized, prospective study comparing the two approaches found similar complication rates.25 The scrotal approach had the advantage of inducing less self-trauma and of being about 30% quicker to perform (though the absolute difference, from about 5 minutes to 3 minutes, is of doubtful clinical significance). Once again, both techniques are effective, and it is not clear that one is superior to the other.

Several techniques have been described for neutering male cats,26 but there is virtually no formal research comparing complication rates. A scrotal approach appears to be the most common, and methods for securing the ductus and vessels include suture ligation and various methods of tying the tissues on themselves. One comparative study of these ligation methods found no significant complications and no difference between methods.27

An uncommon surgical technique used for male dogs in some resource-poor countries is pinhole castration. The spermatic cord is ligated with suture percutaneously to induce necrosis of the testes.28 While this technique is less expensive than standard surgical castration and it does reduce functional testicular tissue volume, it is unclear how effective it is as a means of sterilization, and some reports suggest a higher rate of infection, pain, and other complications compared with standard techniques.29-30

Finally, surgical or laparoscopic vasectomy is sometimes recommended as a means of sterilizing male dogs and cats without neutering.26 Both approaches are effective at achieving this outcome. There have been no direct published comparisons between surgical and laparoscopic vasectomy. One small study comparing laparoscopic vasectomy with surgical castration in dogs found few differences except for a subjectively greater level of post-operative discomfort in the surgical patients.31

REFERENCES

  1. New JC. Characteristics of shelter-relinquished animals and their owners compared with animals and their owners in U.S. pet-owning households. Journal of Applied Animal Welfare Science 2000;3(3):179–201.
  2. McKenzie B. Evaluating the benefits and risks of neutering dogs and cats. CAB Reviews: Perspectives in Agriculture, Veterinary Science, Nutrition and Natural Resources. 2010;5(45):1-18. Updated version available at: https://goo.gl/pWCKYl
  3. May S. The flank cat spay: eminence-driven fashions in veterinary surgery. Veterinary Record. 2012;170:460-461.
  4. Howe LM. Surgical methods of contraception and sterilization. Theriogenology. 2006 Aug;66(3):500-9.
  5. Berzon JL. Complications of elective ovariohysterectomies in the dog and the cat at a teaching institution: clinical review of 853 cases. Veterinary Surgery. 1967;8:89–91.
  6. Burrow R. Batchelor D. Cripps P. Complications observed during and after ovariohysterectomy of 142 bitches at a veterinary teaching hospital. Veterinary Record 2005;157:829–833
  7. Kiani FA. Kachiwal AB. Shah MG. et al. Comparative Study on Midline and Flank Approaches for Ovariohystrectomy in Cats. Journal of Agriculture and Food Technology. 2014;4(2):21-31
  8. Coe RJ. Grint NJ. Tivers MS. et al. Comparison of flank and midline approaches to the ovariohysterectomy of cats. Veterinary Record. 2006;159(10):309-313
  9. Oliveira JP. Mencalha R. dos Santos Sousa CA. et al. Pain assessment in cats undergoing ovariohysterectomy by midline or lateral celiotomy through use of a previously validated multidimensional composite pain scale. Acta Cirúrgica Brasileira. 2014;29(10):633-38.
  10. Burrow R. Wawra E. Pinchbeck G. et al. Prospective evaluation of postoperative pain in cats undergoing ovariohysterectomy by a midline or flank approach. Veterinary Record. 2006;158(19):657-60.
  11. Janssens LA. Janssens GH. 1991. Bilateral flank ovariectomy in the dog—surgical technique and sequelae in 72 animals. Journal of Small Animal Practice. 32: 249– 252.
  12. Van Goethem B. Schaefers-Okkens A. Kirpensteijn J. Making a rational choice between ovariectomy and ovariohysterectomy in the dog: a discussion of the benefits of either technique. Veterinary Surgery. 2006;35(2) 136-143.
  13. DeTora M. McCarthy R. J. 2011. Ovariohysterectomy versus ovariectomy for elective sterilization of female dogs and cats: is removal of the uterus necessary? Journal of the American Veterinary Medical Association. 239: 110
  14. Okkens AC. Kooistra HS. Nickel RF. Comparison of long-term effects of ovariectomy versus ovariohysterectomy in bitches. Journla of Reproduction and Fertility Suppl 1997;51:227–31.
  15. Lee SS. Lee SY. Park S. et al. Comparison of ovariectomy and ovariohysterectomy in terms of postoperative pain behavior and surgical stress in dogs. Journal of Veterinary Clinics. 2013 30 3 166-171
  16. Peeters ME. Kirpensteijn J. Comparison of surgical variables and  short-term postoperative complications in healthy dogs undergoing ovariohysterectomy or ovariectomy. Journal of the American Veterinary Medical Association. 2011:238;189-194.
  1. Davidson EB. Moll HD. Payton ME. Comparison of laparoscopic ovariohysterectomy and ovariohysterectomy in dogs. Veterinary Surgery. 2004;33:62–69.
  2. Ataide MW. de Brun MV. Barcellos LJ. et al. Laparoscopic-assisted or open ovariohysterectomy using Ligasure AtlasTMin dogs. Ciência Rural. 2010;40(9):1974-1979.
  3. Gower S. Mayhew P. Canine laparoscopic and laparoscopic assisted ovariohysterectomy and ovariectomy. Compendium of Continuing Education for the Practicing Veterinarian. 2008;30:430–440.
  4. Case JB. Boscan PL. Monnet EL. et al Comparison of surgical variables and pain in cats undergoing ovariohysterectomy, laparoscopic-assisted ovariohysterectomy, and laparoscopic ovariectomy. Journal of the American Animal Hospital Association. 2015;51(1):1-7.
  5. Phypers C. In Cats and Dogs Does Laparoscopic Ovariectomy Offer Advantages Over Open Ovariectomy for Postoperative Recovery?. Veterinary Evidence. 2017; 2(2). doi:http://dx.doi.org/10.18849/ve.v2i2.59
  6. Grier RL. Tubal ligation-alternative sterilization operation. Iowa State University Veterinarian. 1973;35(2):49-50
  7. Belfield WO. Partial spay (hysterectomy). Veterinary Medicine. 1972;1223-1224.
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OVE, OVH, OMG: Pragmatic Review of Surgical Neutering Techniques Slides

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