Category: Uncategorised

What’s an orthopod like you doing in a joint like this?

I was honoured this year to be awarded the Order of Australia Medal for service to medicine, and to the promotion of immunisation. The most common question I’ve been asked, however, is how or why an orthopaedic surgeon became so interested and involved in immunisation. As many of you would know, I have several degrees to my name, and the one that sparked my interest in this field was the Masters of Clinical Epidemiology. For those of you who know what epidemiology is, please stop yawning. For those of you that don’t, it’s the study of how medical research is carried out, and how it is analysed and conclusions reported. You may now commence yawning.

The thing is, the vaccination rates in Australia have been steady for many years, somewhat lower than the ideal 95%, and also alarmingly low (<50%) in some communities. Despite the best efforts of professional vaccination researchers, nothing seemed to have an effect on this rate. Children were suffering and in some cases dying because they were not vaccinated, or worse, because the people around them were not.

Enter Meryl Dorey and the Australian Vaccination Network (AVN). Meryl sold a message of false concern for children’ health, and often promoted herself as an “expert” in vaccination. Far from it, she and her ilk would misquote research, use unlikely stories of “vaccination damage” and, of course promote, the discredited idea that vaccination was responsible for a whole range of diseases. This last idea has been proven false more times than I’ve had hot dinners. She even suggested that “battered baby” syndrome was due to immunisations and not domestic violence. The sad truth is that Meryl and people like her spread misinformation and fear to parents who often didn’t know any better.

This all came to a head about five years ago when she made it onto national television at the same time as a real immunisation expert, as well as the parents of a child who had died of whooping cough (she was too young to be immunised). A Facebook group, Stop the AVN, was formed and shortly afterwards I joined it. The rest, as they say, is history. We lobbied, we cajoled, we argued and we lobbied some more. We exposed the media to the lies the AVN spread and effectively had it banished from the news. No longer was Meryl an “expert” but now she was an “anti-vaxxer”. The membership plummeted, the income fell, and the AVN is now only a shadow of it’s former self.

Of course, others have tried to step into the breach and get a slice of the money and fame, but for a couple of years now they have been duly recognised by the mainstream as charlatans, liars and not people whose words can be trusted. Judy Wilyman, who was awarded a PhD by the University of Wollongong, has been widely criticised for the content of her thesis, and for writing a document based on false assumptions about vaccination. It was never examined by anyone with real expertise in immunisation. My thoughts can be read in an opinion piece in the Australian, which you can read here. She is still emailing myself, journalists and UoW academics demanding that someone pay her attention.

Sadly for her, no one has.

But what of the positive side? Beginning with a newspaper campaign called “No Jab No Play” restricting day care to immunised children, the Federal Government took the scheme one level further and implemented “No Jab No Pay”, closing a loophole that vaccination refusers were using to get government payments that they were not entitled to. As a result, vaccination rates have risen more than they have in ten years because there’s less parents refusing vaccination, but also because those who found it difficult to get their children vaccinated are now much more motivated to do so.

Vaccination has finally been given the priority it deserves. Denialists, liars, fear mongers and rogues have been put in their place. Children are safer now than they were a year ago.

And we will count the number of lives saved by the small graves that will not need to be dug.

John

Metal or PEEK? Pass me the Cellular Titanium…

To many of you having a spinal fusion, you may not be aware of the enormous biomedical engineering research and design effort that goes into the every implant used. Titanium and its alloys are metals which have a long track record of being biocompatible. We use titanium throughout the skeleton for trauma, dentists use it for implants, and of course we use it for the screws and rods for fusions.

For reasons that may be historic, however, for many years we’ve been using PEEK – a form of plastic – in the interbody space where the disc is removed. By itself it does not cause any artefact when X-rayed, and has some other theoretical advantages too. Some doubt has been cast though on the effectiveness of PEEK and whether or not it may inhibit bone formation – the exact opposite of what we want to create a fusion.

I’ve been very fortunate this year to have been involved with a Dutch/German company called EIT who asked me to help design their interbody cages for PLIF. The cages are made using a 3D printing technique called Selective Laser Melting and then treated with a process that roughens the surface making it more attractive for osteoblasts, and that’s what you want to make a fusion. You can see an explanatory video here.

The new cages are safe to use, don’t require any changes to surgical technique, and have minimal impact on post operative imaging, which is often a concern with solid metal implants. As you can see below, even with PEEK cages below, there is significant “noise” from the tantalum markers inserted into the PEEK. The EIT titanium cage inserted at the level above though has none of this noise and it’s relatively east to see the fusion progressing.

This is a cage that bone grows towards, and through, and I believe represents the next step in fusion technology.I’m now using EIT titanium cages for PLIF, TLIF and ACDF procedures, and have been very satisfied with the results.

John

Declaration: I do not receive any royalties from EIT but obviously have a research and development agreement with them.

Name the Virus!

There once was a Dave who thought it would be desirous,

That instead of decorating his lab with a bearded iris,

He’d run a competition

to help fund completion

of his study, so he made “Name the Virus“.

As you probably realise now, I’m not very good at limericks, but to be fair, “virus” isn’t the easiest word to rhyme.  “Name the Virus” is a funding opportunity you have to help the Florey Institute raise funds to complete some of their projects.  For the first time, YOU can donate money and be rewarded by the scientists of the Institute.    Apparently cookies are offered, and if you donate enough, you can also decide the name of one of their virus vectors!  For only $2,500…

You get to “Name the Virus”!

As each viral vector is created it will be named. The Name must be 10 letters or less and be socially acceptable. E.g. If the name “noodles” was chosen the viral vector would be called “pNoodles” and this name will appear in any publications or presentations in which it is used. Each rewardee will be sent a copy of the “map” of the viral vector they named.

Of course, there’s rewards for smaller amounts to, all the way down to $20.

Surely some of you reading this could spare a few bob to help Dave take over the world… oops!  I mean Name the Virus.

 

The Outraged CAA and Other Outages.

Before I go on, please do not read this as a criticism of all chiropractors.  You need to understand that there are two bodies that represent chiropractors within Australia.  There is the Chiropractic and Osteopathic College of Australasia (COCA), and the Chiropractors’ Association of Australia (CAA).  I believe that anybody practicing in the health professions should always employ evidence-based techniques and treatment regimes, myself included.  If you want a chiropractor who practices based on evidence, you’ll be more likely to find one within the ranks of the COCA than you will in the ranks of the CAA though.  For example, of the fifty chiropractors openly expressing anti-vaccination lies on their websites documented here, most of them are members of the CAA.  None are members of COCA.

recent article in The Age, by Julia Medew and Amy Corderoy, has outraged chiropractors, or more specifically, the CAA.  If you want to know how much it has outraged them, you only need to read this press release by the CAA, and see the report on their outrage here.  The Age hasn’t even acknowledged their outrage, which must add disappointment to their already overflowing cup of emotion.

Why?

The article was startling for several reasons.  Firstly, it described the case of a four-month old baby treated by a chiropractor with a fractured neck.  Yep – a fractured neck.  Did the chiropractor cause it?  We don’t know, but suffice to say that it appears from the information available, that the parents took the baby to a hospital ED after an “adjustment” by a chiropractor, and the baby was found to have a fracture in his or her cervical spine.  I was not and am not part of the treating team.  Maybe the fracture occurred before the adjustment.  In that case the chiropractor possibly missed the signs and symptoms of a fractured neck – disappointing for someone who’s had “five years of university training” as we keep hearing.  The other option is that the chiropractor caused the fracture.  Either way, it’s not a shining endorsement.

The other startling aspect of the story was the claim that chiropractors visit hospitals and provide adjustments without the hospital’s permission.  More can be read on those allegations here.

So what is the reaction of the CAA?  Outrage.  Take a read of the media release.  They appear to know in great detail the results of the investigation of the case by AHPRA, despite those results being confidential.  Yet, they know.  And they tell us that The Age article “smeared the Chiropractor” – despite the name of the chiropractor not being mentioned.  Kinda hard to smear someone when you don’t name them.  This sort of confusion occurs when you are outraged.

Then we get to,

“National President of the CAA, Dr Laurie Tassell said, “It remains the case that not a single serious adverse event has been recorded in the medical literature (world-wide) involving a qualified Chiropractor treating a child since 1992.”

This Claim is obviously part of the gift pack you receive when you join the CAA, as it’s the same Claim made by Tony Croke on Catalyst.  The CAA lodged a complaint against Catalyst for criticising this Claim, and the complaint was only today dismissed by an independent investigator.  More outrage.  Lots of it.

So what of the Claim?  I contacted Bevan Lisle, Communications Director of the CAA today about the claim, and his response was, well, less than satisfactory in my opinion.  You see, The Claim, as we shall refer to it as, has several weak points.  Firstly, a health practitioner who claims to have no adverse events is someone who does not practice.  Secondly, as they have no systematic method of compiling adverse events, they simply aren’t looking for them.  It’s like claiming there’s no stars out while you’re down a mine shaft.  Thirdly, by Claiming that there has never been even a single adverse event, the documentation of just one is enough to falsify the Claim.  Lastly, the word “involving”, or as Bevan put it, “associated with”, doesn’t mean they caused the event – it just means the chiropractic treatment was “connected” with the event.  So how does the Claim stand up?

It doesn’t.

As defined by the FDA, a Serious Adverse Event (SAE) can be of several types. One is

Disability or Permanent Damage: Report if the adverse event resulted in a substantial disruption of a person’s ability to conduct normal life functions, i.e., the adverse event resulted in a significant, persistent or permanent change, impairment, damage or disruption in the patient’s body function/structure, physical activities and/or quality of life.
I had to help Bevan today with his definition of SAE, so let’s be clear in case anyone else doesn’t know it.
A slipped capital femoral epiphysis is a serious event, and a delayed diagnosis meets the criteria of a SAE.  The paper here describes 12 delayed diagnoses because of attendance at either a physiotherapist or a chiropractor.  Remember, we only need one case “associated” with chiropractic care after 1992 to disprove the Claim.  Hence, the Claim is apparently false.
This paper also describes fractured ribs associated with chiropractic care.  Published after 1992, associated with chiropractic care.  The Claim is therefore false.  Surely?
This paper also describes a litany of SAE’s associated with chiropractic care.  The events were all in 1992 or before, so technically lie outside the Claim, but still make for shocking reading.
The CAA, when asked for comment, stands by the Claim.  It’s like a mantra.  Even in the face of the investigation of the four-month old baby, they still repeat the Claim.  It happened after 1992, was associated with chiropractic care, and is a SAE.  Time to retract the Claim?
Instead of expressing outrage at one of their members, the CAA prefers to express outrage at journalists, and probably now myself, at what they see as a smear against an unnamed chiropractor.  In fact, in a brilliant example of double talk…

CAA president Dr Laurie Tassell (Chiro) said there was no doubt the baby had a hangman’s fracture.  “The official report made it quite clear that the chiropractor did not cause the injury but unless AHPRA releases the report we can’t use those findings,” he told Medical Observer.

See what he did there?  He can’t use the findings, but here they are anyway.  But he can’t use them, OK?

And we’re meant to believe him.  We’re meant to trust the CAA to have the public’s interest in mind.  We’re meant to see them as a peak representative body whilst they repeat the apparently false Claim, talk in double talk, and rather than express sympathy or even a whim of accountability, prefer to express their own outrage.

Here’s my message to the CAA: instead of expressing outrage, why don’t you start behaving like professionals, start regulating yourselves, start looking for adverse events and start reporting them openly like other medical professionals do, stop tolerating anti-vaccination garbage, encourage evidence based care, and for once, take responsibility.

John

Chiropractors and the reflex arc

Many of you may have seen the episode of Catalyst that aired on 11 July, 2013, which discussed the chiropractic profession.  It can also be seen here.

I’ve been pleasantly surprised by the positive reaction of many members of the public and indeed chiropractors to the show.  It confirms what I pointed out in my previous post – that the chiropractic profession here in Australia is currently divided between those who cling to the concept of the subluxation as a cause of extra-spinal disease like colic, asthma, diabetes and even cancer (the “straights”) and those who are struggling to establish an evidence based chiropractic scope of practice.  To the latter, as I’ve said before, I say go forth and publish!

I’m fairly critical of research papers I study, and that includes my own.  For example, one of my own studies that was published recently lacks randomisation, is a single surgeon series, and has quite a wide range of followup periods.  That indicates that one must be careful about what conclusions we draw from it.  That’s me criticising my own work, as a short example.

Pardon me?

In response to the programme, several papers have been presented to me as evidence that chiropractic can cure deafness, ala William Harvey Lillard.  One study is a hypothetical discussion of a complex neurological pathway involving the spine and the middle ear causing Ménière’s disease.  See the word hypothetical there?  It’s not evidence.

Another is this paper from 1995, on the association of late whiplash injury syndrome (LWIS) and tinnitus.  It was in the second ever issue of a biannual journal, and the author was the journal’s founding editor.  Hmmmm.  It may be the case that people with LWIS get tinnitus, but LWIS is clearly not a simple diagnosis.  In fact, when you remove the medicolegal implications of having a chronic injury, it’s found that “Expectation of disability, a family history, and attribution of pre-existing symptoms to the trauma may be more important determinants for the evolution of the late whiplash syndrome.”  Neither is the cause of the tinnitus clear – it’s could very well be the temporomandibular joint!

Scoot forward to 2008 and you find that,

With respect to hearing and balance problems due to whiplash, the exact nature of the lesion is not known but the following have been put forward as possible explanations: Transient ischaemia or haemorrhage in the labyrinth as a result of transient compression of the vertebral artery, direct labyrinthine concussion, brain stem concussion, the noise of the collision causing acoustic trauma or psychological triggering of a pre-existing hearing disorder. With so many suggestions it is a cynical truism to say we do not know the exact cause and site of the lesion.

We do not know.  We just don’t know.

Another paper that was sent to me was on a case series of people with hearing improvement after chiropractic treatment.  Without a control group, it does little to provide evidence of efficacy.  As the authors themselves said,

Further research in this area is required, in the form of a well designed randomised controlled trial.

So that was in 2006.  It’s been seven years, and still no followup study.  Why not?  If I wanted to do a research project, this would be my first one – interesting topic, straight forward design, short time period.  Why hasn’t it been done?  Why?

Yet another paper, in German, discusses a condition “vertebragenic hearing disorder”.  The author himself admits that the condition’s very existence is disputed.  The hearing testing is poor and so is the description of the intervention.  No control group, once again, means that it is not to be regarded with any sense of gravity.

Protecting their turf

As predicted, several chiropractors wrote to me attempting to denigrate my profession.  Claims of high morbidity and mortality rates of conventional medicine abound, yet what these people fail to appreciate is the logical fallacy they had fallen into: tu quoque.  Criticising my profession doesn’t validate yours.

The other irony is that, at least in my practice, I rarely treat patients with back pain alone, or, for that matter, asthma, autism, deafness or colic.  I treat patients who have pathological conditions that are demonstrable on imaging studies, and therefore, I have no vested interest in the chiropractic subluxation.  I have no turf to protect.

Safety

The chiropractic profession in Australia, as far as I know, does not have a systematic way of collecting adverse events.  Conventional medicine doctors are subject to regular peer review of our practice, as part of our registration.  I attend monthly review meetings of both hospitals I practice at.  The RACS runs the Australian and New Zealand Audit of Surgical Mortality.  We’re open, transparent, and provide reliable data.

If you don’t look for something, you can’t claim it’s not there.  Before we looked for exoplanets (planets outside our solar system), there was discussion based upon poor quality data about how many are out there.  Since we’ve been looking, we’ve found over 900.  How many adverse events are there from chiropractic therapy?  Let’s start looking.  Maybe there’s none, maybe there’s lots, but until you look systematically, I can’t see how you can make any claims.  But that’s just me.

As I’ve said before, unless you base your practice upon good evidence, then you’re not necessarily practicing evidence based medicine.

John

Conflicts of interest

Further to my last article “Can back pain be cured with antibiotics?”, remember how I said talk of a Nobel prize might be premature, and that we need to see if these results can be repeated?  Well, today I came across this article:

http://www.theage.com.au/national/health/back-pain-study-fails-to-declare-link-20130526-2n5cz.html

Unfortunately, the authors of the two papers discussed apparently didn’t declare a conflict of interest.  No matter how small it may appear to themselves, any conflict should always be declared when authoring a paper.  Whilst it doesn’t necessarily mean that we should ignore their results, it does raise a shadow over their results.  Many people have unfortunately made this mistake previously, notably Andrew Wakefield, when he failed to declare his financial interest in a mono-valent vaccine that stood to profit by discrediting the MMR vaccine that was in use.

Declaring a conflict of interest does not negate that conflict, but it does, at least, make it public knowledge.  The bigger sin is to not declare it.  Now, unfortunately, this paper has lost some credibility.

As I said before, let’s wait and see if it can be repeated.

John