The Evidence

Rational Veterinary Medicine:

Home Papers Media RVM articles Contact

On Sale now!

Papers, listed by lead author: I-J

I

Imrie, R.H. and Ramey, D.W, (2000) ‘The evidence for evidence based medicine’, Complementary Therapies in Medicine, vol. 8, pp.123–126.

Homeopaths and other anti-scientific types are fond of claiming that hardly any modern medicine is based on proper, scientific evidence. This is errant nonsense, loads of it is evidence based, as demonstrated in this most elegant article by two veterinary surgeons of great renown.

Links: [abstract, pubmed]:[full text, SRAM]

Imrie, R.H., Ramey, D.W., Buell, P.D., Ernst, E., and Basser, S.P. (2001) ‘Veterinary Acupuncture and Historical Scholarship: Claims for the Antiquity of Acupuncture’, The Scientific Review of Alternative Medicine, vol. 5, no. 3. [permalink]

“Abstract: Claims for the antiquity of acupuncture are ubiquitous in both the human and veterinary acupuncture and popular literature. These claims are not supported by the historical record. Evidence for therapeutic “needling” (zhen) of any kind dates back at most just over 2100 years, and even this evidence is ambiguous. The earliest clear-cut references to human acupuncture can be reliably dated only to the fifth to eighth centuries C.E. There is no unmistakable evidence for what may be therapeutic “needling” in the Chinese veterinary tradition until around 1000 C.E., and it is not entirely clear what was meant by the term in the early literature. Material describing veterinary “needling” in more detail does eventually appear, but the references are clearly to bleeding, lancing, cauterization, and even surgical intervention, rather than to acupuncture in the modern sense. Contrary to the assumptions of modern acupuncture proponents, the term zhen, as used in the original literature, is not synonymous with acupuncture. Not only is there no evidence of widespread application of fine needle acupuncture in animals prior to the mid to late 20th century, but the historical record has apparently been distorted or ignored. Examination of the original texts suggests that animal “needling” is more a Eurasian development than an original Chinese veterinary tradition.”

Links: [full text SRAM, pdf]

J

Jacobs, J., Jimenez, L.M., Gloyd, S.S., et al. (1993) ‘Homeopathic treatment of acute childhood diarrhea: a randomized clinical trial in Nicaragua’ British Homeopathic Journal, vol. 82, pp. 83-86.

For commentary see below

Jacobs, J., Jimenez, L.M., Gloyds, S.S., Gale, J.L. and Crothers, D. (1994) ‘Treatment of acute childhood diarrhea with homeopathic medicine; a randomized clinical trial in Nicaragua’ Pediatrics, vol. 93, no. 5, pp. 719-725.

Links: [abstract, pubmed]:[abstract, pediatrics]:[full text, pediatrics, pdf]
For commentary see below

Jacobs, J., Jimenez, L.M., Malthouse, S., et al. (2000) ‘Homeopathic treatment of acute childhood diarrhoea: results from a clinical trial in Nepal’ [alternate title (ENHR) - Acute Childhood Diarrhoea - A Replication], Journal of Alternative and Complementary Medicine, vol. 6, pp. 131-139.

Links: [abstract, pubmed]
For commentary see below

Jacobs, J., Jonas, W.B., Jimenez-Perez, M. and Crothers, D. (2003) ‘Homeopathy for childhood diarrhea: combined results and metaanalysis from three randomized, controlled clinical trials’, Pediatric Infectious Disease Journal, vol. 22, no. pp. 229-234.

Links: [abstract, pubmed]:[full text, wellandtrulyhealthy, pdf]

Dr Jennifer Jacobs is, at the time of writing, assistant professor of epidemiology at the University of Washington. Among her interests she lists alternative medicine, she can be contacted via an organisation called 'Harmony Research and Consulting' and every one of the selected publications on her University biography page is concerned with homeopathy.

Between 1993 and 2006 she published four papers which are listed immediately above this commentary (a fifth paper, published in 2006 is cited below). Two were published in peer reviewed journals, two in alternative medicine publications. The fourth paper (Jacobs 2003) was a metanalysis of the first three (Jacobs 1993, 1994 and 2000). These papers are closely related and will be addressed as a group.

When considered as they are (a series of similar trials) there are multiple accounts of these papers' various flaws and deficiencies to be found throughout the web, from sceptic commentaries to critiques in professional journals, including Paediatrics, the journal in which the 1994 study was published (Samson and London 1995). Yet they are still, despite this, being touted even today by homeopathic profiteers and apologists as evidence that homeopathy works.

To summarise the main criticisms is hard - sometimes one can have too much choice! But RationalVetMed will bravely attempt to do so on your behalf. For full details have a look at the links below.

According to Wallace Sampson (2009) of Science Based Medicine, in the first two papers (Jacobs, 1993 and 1994) the statistical analysis chosen by the authors was inappropriate for the types of data which were obtained - the fact that chosen end points were vague and a variety of different remedies were used were among the factors which rendered the chosen analysis inadequate. Although it was claimed that participants were randomised into 2 groups there were considerable and statistically significant differences between the 2 groups, with the homeopathic group being both older and heavier, which would have meant it was likely that members of this group would show a quicker recovery from diarrhoea anyway, regardless of the type of treatment.

By way of explanation the authors claimed, not unreasonably, that this (statistically significant) discrepancy was as a result of chance variation (and they later applied a statistical trick to work around the problem). In contrast, at the end of the trials, when the alleged benefits of homeopathy were announced in the conclusion, this claim was justified, even though the actual differences between groups were slight, on the basis that the results of the trial also were statistically significant. No mention that the results themselves were just as likely to have been as a result of chance as the initial disparity between groups.

Another difference between the groups in one of Jacob's trials was that there was significantly fewer bacterial isolates from the stools of the participants in the homeopathic group than there were in the placebo group - one reviewer has speculated this could have been as a result of treatment with antibiotics which apparently is common practice in some areas and which the researchers may or may not have been aware of. Obviously it is not impossible this could have affected the outcomes.

The authors suggest that this series of papers is confirmation that homeopathy could be of use in the fight against the scourge of diarrhoea in the third world. In fact it is nothing of the sort - all the really severe cases presented were treated properly - in hospital with conventional fluid therapy and medication.

The trials conducted by Jacobs et al dealt only with mild cases which are often self limiting anyway. It is noteworthy that the authors use the correct clinical term for such cases by describing them as “acute” - the strict, technical meaning of this term is “rapid onset and short lasting”, not, as lay readers may assume “severe”. The term “acute” in the medical context has no bearing on whether a condition is severe or mild. Thus the trials had questionable clinical and public health significance despite grandiose claims to the contrary.

Dr Jacobs herself acknowledges the lack of statistical power in her first three trials when embarking on the metanalysis (2003). There are also a number of discrepancies carried over from the three trials in the metanalysis which appear magnified when the figures are combined. Again, an inappropriate statistical analysis is used, there are imbalances between the homeopathic and the placebo groups and the end point for which such great significance is claimed is a minute difference between homeopathic and placebo groups such as could be accounted for by pure statistical noise - variations in times of sampling for example. The difficulty of making accurate measurements in diarrhoea trials is highlighted in a paper by Johnson et al (2010).

As Wallace Sampson (2009), “what actually occurred, even at maximum difference between homeopathy and controls, was a difference between having 3 (or slightly more) stools per day and no more than 2 stools per day for 1 day or so at only one of four measured periods of the study. The calculated difference in terms of days to the end point was slightly more than a half a day. Most patients and most family members would hardly be aware of such a small difference.”

Yet, on the back of this measley finding when tested, not against real, proven medicines but against a plain sugar tablet the authors are suggesting that homeopathy has a major part to play in controlling third world epidemics - if that wasn't so murderously irresponsible it would be laughable.

The morals of performing such trials on vulnerable individuals in developing countries using medicines which have been thoroughly proven as ineffective by other, less partisan authors is a whole topic of its own and is dealt with by David Gorski (2008) in Science Based Medicine (link below).

The final nail in the coffin of this woeful series of studies was picked up by Andy Lewis (2009), writing on his 'Quackometer' blog in response to one of Dana Ullman's data dumps. At the end of the series of original papers Dr Jacobs acknowledged the low statistical power of the three studies which went to make up the metanalysis (2003) and called for other, larger trials to be carried out in the future. Three years later she carried just out such a trial herself (Jacobs, 2006 - see below) and, guess what - there was no difference between placebo and verum groups! This final trial in the set is, of course the one that all homeopaths have amnesia about and which never appears on the vast lists of references trotted out by the homeopathic intelligencia (if that isn't a contradiction in terms!), nor has it ever featured in a revised version of the 2003 metanalysis - too much to hope for really. The 2006 trial was however considered by Altunc et al in their 2007 systematic review of trials investigating the use of homeopathy in childhood ailments - the authors weren't impressed, and neither is RationalVetMed.

Responses: [Gorski, D., 2008 in SBM - On the ethics of clinical trials of homeopathy in Third World countries]:[Sampson, W., 2009 in Science based Medicine (SBM) - Homeocracy]:[Sampson, W., 2009 in SBM - Homeocracy 2]:[Sampson, W., 2009 in SBM - Homeocracy 3]:[Sampson, W., 2009 in SBM - Homeocracy 4]:[Lewis, A., 2009 in Quackometer - The Society of Homeopaths are a Shambles and a Bad Joke]:[Barnett, D.R., 2001 Clinical Research in Homeopathy: A Limited Skeptical Review and Analysis (Part I) in The North Texas Skeptic]

Jacobs, J., Guthrie, B.L., Montes, G.A., et al. (2006) ‘Homeopathic combination remedy in the treatment of acute childhood diarrhea in Honduras’, Journal of Alternative and Complementary Medicine, vol. 12, pp. 723-732.

“There was no significant difference in the likelihood of resolution of diarrheal symptoms between the treatment and placebo groups... The homeopathic combination... did not significantly reduce the duration or severity of acute diarrhea in Honduran children...”

Links: [abstract, pubmed]
For commentary see above

Jacobs, J., Springer, D.A.. and Crothers, D. (2001) ‘Homeopathic treatment of acute otitis media in children: a preliminary randomized placebo-controlled trial’ Pediatric Infectious Disease Journal, vol. 20, pp 177–183.

A magnificent excercise in homeopathic straw-clutching if ever there was one. According to the authors of this under powered trial “There were fewer treatment failures in the group receiving homeopathy after 5 days, 2 weeks and 6 weeks, with differences of 11.4, 18.4 and 19.9%, respectively, but these differences were not statistically significant. Diary scores showed a significant decrease in symptoms at 24 and 64 h after treatment in favor of homeopathy”. Well, “treatment failure” is a strange way to describe improvement or lack of it following a placebo but the real message here is that this trial was a complete wash-out for homeopathy - there was no difference between homeopathic treatment and treatment with a sugar pill.

And it’s not surprising when you’re comparing one placebo with another that some days one will appear to do better than another, that’s what is known as statistical noise and is simply due to random variation, although, typicaly it doesn’t stop the homeopaths mentioning it as if it was some great positive finding at “24h and 64h” . Significantly, there is no mention of the rest of the hours - the number of converse instants when placebo “outperformed” homeopathy is omitted completely from the abstract.

Yet again though this nonsense is consistently trotted out as evidence in favour of homeopathy!

Links: [abstract, pubmed]:[Cochrane review]:[NHS review of OM treatments]:[NICE report on antibiotic use in OM]

Jaeger, G.T., Larsen, S., and Moe, L. (2005) ‘Stratification, blinding and placebo effect in a randomized, double blind placebo-controlled clinical trial of gold bead implantation in dogs with hip dysplasia’ Acta Veterinaria Scandinavica, vol. 46, pp. 57-68. [permalink]

“The purpose of this study was to investigate the... effects of blinding and placebo in a clinical experiment. Eighty dogs with canine hip dysplasia (CHD) were included in a randomized, placebo-controlled and double blind clinical trial... Thirty-eight dogs were allocated to gold bead implantation and 42 to placebo. After six months, 33 of the 42 placebo-treated dogs received gold bead implantation in an open study lasting a further 18 months. The main outcome variable in the study was change in pain signs of CHD as assessed by the owner. No significant difference in the main outcome variable, regardless of the treatment given, could be detected... The blinding procedure used in the study, in which 60% of the owners correctly guessed the treatment given, was found sufficient. Of those who guessed the treatment erroneously, 88% believed the treatment given was gold bead implantation. The treatment efficacy after six months in the blinded treatment group was found to be significantly larger compared to the efficacy obtained in the open study. A significant placebo effect was therefore detected.

Conclusion and Clinical Relevance: The age of the dogs influenced the outcome of the CHD treatment, and is recommended as a stratification factor. A significant placebo effect has to be expected and an optimal blinding procedure is necessary in similar clinical studies.”

Links: [abstract pub med] - [full text PMC] - [full text pdf]

Jarvis, W.T. (2000) ‘Misuse of the term “allopathy”’ National Council Against Health Fraud [online]

Introduction: The term "allopathy" was invented by German physician Samuel Hahnemann (1755-1843). He conjoined allos "opposite" and pathos "suffering" as a referent to harsh medical practices of his era which included bleeding, purging, vomiting and the administration of highly toxic drugs. These practices were based on the ancient Greek humoral theory which attributed disease to an imbalance of four humors (i.e., blood, phlegm, and black and yellow bile) and four bodily conditions (i.e, hot, cold, wet and dry) that corresponded to four elements (earth, air, fire, and water)...

Links: [full text - NCAHF]

Johnson, S.B., Park, H.S., Gross, C.P. and Yu, J.B. (2018) 'Use of Alternative Medicine for Cancer and Its Impact on Survival', Journal of the National Cancer Institute, vol. 110, no. 1, (https://doi.org/10.1093/jnci/djx145). (First published online August 10, 2017). [permalink]

“… alternative medicine (AM) use was independently associated with greater risk of death compared with conventional cancer treatment (CCT) overall and in subgroups with breast, and colorectal cancer. Although rare, AM utilization for curable cancer without any CCT is associated with greater risk of death.

“… AM was associated with worse five-year survival and remained an independent predictor of greater risk of death  when controlling for clinical and sociodemographic factors. When stratified by cancer type, receipt of AM was associated with statistically significantly worse five-year survival for breast, lung, and colorectal cancer...”

When apologists are challenged over the dubious ethics and motives which underly homeopathy and other forms of CAM they tend to drift off into the realms of abstruse philosophy, cultural relativism and the sins of ‘scientism’, collegiality, fair-play and occasionally, if they’re really desperate, the nature of the soul itself.

Then a paper like this comes along and brings the whole debate back down to earth, with a great thump.

To quote from the news report at VetSurgeon.org (link below):

“Overall, cancer patients who used alternative medicine were 2.5 times more likely to die within a 5 year period than those who chose conventional cancer therapy. However, people with breast cancer were 5.7 times more likely to die in the same period if they used alternative medicine rather than conventional medicine. This evidence flies in the face of the British Association of Veterinary Homeopathic Veterinary Surgeons' claim that homeopathy cures cancer.”

But some homeopaths don’t even want to read that simplified version of events, so perhaps just the title of the report will give a pithy enough summary: “Choose Alternative Medicine and Die Early”

Yes, I think that covers it nicely.

Links: [abstract JNCI]:[full text (sci-hub)]

Responses: [New Scientist]:[Ars technica]:[Science daily]:[Cancer therapy adviser]:[News medical]:[Real Clear Science]:[Vetsurgeon.org]:[Pubmed health]:[Medscape]

Johnston, B.C., Shamseer, L., da Costa, B.R., Tsuyuki, R.T. and Vohra, S. (2010) ‘Measurement issues in trials of pediatric acute diarrheal diseases: a systematic review’ Pediatrics, vol. 126, no.1, e. 222-231

This paper reports that because of the difficulty of defining the parameters under scrutiny, the results of pretty much any trial of diarrhoea has to be taken with a pinch of salt. That is true of any conventional treatment, no matter how plausible it appears and it is especially true of homeopathy since it has no possible mode of action and is completely implausible. Sugar tablets don’t cure anything, least of all life threatening conditions affecting vulnerable children. Any suggestion to the contrary is simply murderous.

Links: [abstract, pubmed]:[full text, html, pediatrics]

Jonas, W.B., Linde, K. and Ramirez, G. (2000) ‘Homeopathy and rheumatic disease’, Rheumatic Disease Clinics of North America, vol. 26, no.1, pp. 117-123.

Only the abstract of this paper is available online and that is basically a great diatribe about how wonderful homeopathy is, who invented it, what its “tenets” are and why the only reason people think it doesn’t work is because they can’t get their heads past Avogadro’s law (it isn’t).

There are no indications of what the actual paper is - no methods figures, statistics or even general findings - until the last sentence where the authors have said it is an evaluation of “the controlled clinical research on homeopathy using systematic review methods”. So, no new research, just a revisiting of prevous work.

It’s always significant (and very unusual) when no indications of how a paper of this sort was written or what the inclusion criteria were, and not a hint of final conclusions are given in an abstract. Since the abstract is the only publicly visible part of the paper it’s almost as if they had something to hide!

Links: [detailed abstract - science direct]:[abstract, pubmed]:[abstract, web of science]

Jonas, W B., Anderson, R.L., Crawford, C.C. and Lyons, J.S. (2001) ‘A systematic review of the quality of homeopathic clinical trials’, BMC Complementary and Alternative Medicine, vol. 1, no. 1, p. 12.

“Conclusions: Clinical homeopathic research is clearly in its infancy with most studies using poor sampling and measurement techniques, few subjects, single sites and no replication”

Links: [abstract - BMC]:[full text - BMC, html]:[full text - BMC, pdf]

Jonas, W.B., Kaptchuk, T.J., and Linde, K. (2003) ‘A Critical Overview of Homeopathy’, Annals of Internal Medicine, vol. 138, pp. 393-399.

“... There is a lack of conclusive evidence on the effectiveness of homeopathy for most conditions. Homeopathy deserves an open-minded opportunity to demonstrate its value by using evidence-based principles, but it should not be substituted for proven therapies.”

Links: [abstract - pub med]:[full text - Ann Int Med, pdf]:[abstract, pubmed]:[full text homeovet]

A comprehensive, open access review (albiet suffering a pro-homeopathic bias) of some of the more popular trials of homeopathy. Not a conventional metanalysis as is sometimes claimed and, despite the fact that most of the papers it reviews are either inconclusive or negative for homeopathy or have inadequate methodologies the review still attempts to come to a positive conclusion about homeopathy, albeit with the help of liberal quantities of weaselly qualifiers - "may be...", "seem to be...". The final phrase says it all though, "Homeopathy... should not be substituted for proven therapies"

Jonas, W.B., Bellanti, D.M., Paat, C.F., Boyd, C,C., Duncan, A., Price, A., Zhang, W., French, M. and Chae, H. (2016) 'A Randomized Exploratory Study to Evaluate Two Acupuncture Methods for the Treatment of Headaches Associated with Traumatic Brain Injury', Medical Acupuncture, vol.  28, no. 3, pp. 113-130, (https://doi.org/10.1089/acu.2016.1183). [permalink]

Links: [full text, html]:[full text pdf]:[full text with links, pdf]

Responses: [Edzard Ernst]

History of RVM How to use the site

The Best They Can Do The Usual Suspects How to look at evidence CAM journals and evidence Scepticism about homeopathy Arguments Acupuncture references