Talk:Acupuncture

Wording of lede needs to stick close to sources

The most recent revision to the lede is a substantial change to what had been stable wording consistent with sources. Now it says that the evidence says acupuncture is no more effective than placebo, and this statement is not sourced to the best quality MEDRS's, which also happen to be old ('05, '05, '08). The new wording uses these sources to rebut several sources saying acu is effective, but none mention the UK NHS source, a superior MEDRS that postdates them all; this is a bad change that introduces OR and strays from sources. Additionally, the article body cites better MEDRS's that says it is effective, e.g several at Acupuncture#Pain. Reverting to this revision from Oct. 27. Please get consensus here before making substantial changes. --Middle 8 (talk) 11:19, 30 October 2013 (UTC)

"Some scientists" is OR. So you are not sticking close to the source. Do all or any of the sources say "Some scientists". QuackGuru (talk) 17:37, 30 October 2013 (UTC)

I agree with QG. The previous version was alt med POV-pushing, and so I reverted back to the more neutral version to avoid the acupuncturist slant. jps (talk) 19:21, 30 October 2013 (UTC)

The blatant OR I tagged has been removed. QuackGuru (talk) 19:30, 30 October 2013 (UTC)

I'll take the blame for that one. ;) jps (talk) 19:47, 30 October 2013 (UTC)

"Independent researchers have criticized these "endorsements"...

Is there a better way to describe it than using the word "endorsements"? Maybe recommendations or reports will work. QuackGuru (talk) 20:01, 30 October 2013 (UTC)

"Recommendations" or "reports" is good. "Independent scientists" is fine. One-liner "rv alt-med POV pushing" ES's don't address the concerns I raised above, viz.: The new wording uses these sources to rebut several sources saying acu is effective, but none mention the UK NHS source, a superior MEDRS that postdates them all; this is a bad change that introduces OR and strays from sources. Additionally, the article body cites better MEDRS's that says it is effective, e.g several at Acupuncture#Pain. Let's not fall into WP:IDHT again. Comments? --Middle 8 (talk) 22:04, 30 October 2013 (UTC)

Actually, I think the discussion did deal well with your concerns, though you seem to not understand the problem with using poor sources as these. jps (talk) 00:33, 31 October 2013 (UTC)

Your IDHT is showing... NHS vs. other sources? Bueller? Bueller? --Middle 8 (talk) 05:52, 31 October 2013 (UTC)

Endorsements is descriptive. Why the change? IRWolfie- (talk) 23:59, 30 October 2013 (UTC)

But it's misleading. These groups didn't *endorse* acupuncture. They described standard practices for its use. The statements are quite broad. jps (talk) 00:33, 31 October 2013 (UTC)

I removed the OR. Don't know why it was restored. QuackGuru (talk) 02:49, 31 October 2013 (UTC)

There was no endorsement. Why is this continuing. QuackGuru (talk) 03:46, 31 October 2013 (UTC)

Hmmm. The problem is that some of them did actually endorse it, however, the NHS didn't... Alright, let's stick with "recognized". Cheers, --Mallexikon (talk) 03:55, 31 October 2013 (UTC)

NHS should be separate from that sentence; it's not what "some independent scientists" (or whomever we're calling them) are talking about. Heck, it postdates them, IIRC. --Middle 8 (talk) 05:52, 31 October 2013 (UTC)

Poor sourcing on the Pain section

Thanks to User:Middle 8 for pointing out that the Acupuncture#Pain section has been using cherry-picked and poorly-vetted sources to try to claim that there is something more to acupuncture than the placebo effect. I notice that the gold-standard study by Ernst is being marginalized. And the Journal of Saudi Medicine? Tsk, tsk. The lack of mechanistic basis is enough to preference a null hypothesis in a Bayesian sense, so Ernst's review remains the best. Sorry. I've POV-section tagged the thing until it can be cleaned up. There is no evidence for acupuncture being effective for anything but people who are wide-eyed and credulous believers in the subject. jps (talk) 02:06, 31 October 2013 (UTC)

I'll always cheer a skeptic stance. But if you try to ignore newer review results (like the one listed in the efficiency section) in order to deny "that there is something more to acupuncture than the placebo effect" that's not skeptic - that's just plain POV. --Mallexikon (talk) 02:24, 31 October 2013 (UTC)

The null result is the preference and there are no good studies (the newer ones are compromised and in shitty third-rate journals -- this isn't "JAMA", this is just an internal medicine journal under the umbrella of JAMA, but sorta a JAMA-in-name-only thing) that pass the WP:REDFLAG test. Wikipedia is not supposed to be innovative. There is no evidence that acupuncture is better than a placebo. Studies attempting to say as much have been roundly criticized by independent analysts. No omnibus review has gone past Ernst's conclusion that I stated in the first sentence. That's where this article will be fixed to say with the appropriate work. jps (talk) 02:27, 31 October 2013 (UTC)

FYI, JAMA Internal Medicine (formerly Arch. Int. Med). If it sucks as bad as you say, RS's will have said so. If you can meet the WP:BURDEN to make your Ernst quote the default position, great. Show (rather than assert the existence of an abundance of) the (non-blog) sources that outweigh the others. Try and do this civilly, without drama and edit-warring. --Middle 8 (talk) 05:52, 31 October 2013 (UTC)

I already showed it. And you accuse me of WP:IDHT? This is ridiculous. Ernst is the gold standard and he has pointed out that the Vickers source does not even contradict him, so by doing a this-and-that or this-or-that treatment, this article is extremely biased. jps (talk) 11:44, 31 October 2013 (UTC)

Removing Vickers

On the basis of this:

Edzard Ernst, emeritus professor of complementary medicine at the University of Exeter, said the study “impressively and clearly” showed that the effects of acupuncture were mostly due to placebo. “The differences between the results obtained with real and sham acupuncture are small and not clinically relevant. Crucially, they are probably due to residual bias in these studies. Several investigations have shown that the verbal or non-verbal communication between the patient and the therapist is more important than the actual needling. If such factors would be accounted for, the effect of acupuncture on chronic pain might disappear completely.”

jps (talk) 02:24, 31 October 2013 (UTC)

Source of quote? And is Ernst talking about the source you removed? Per NPOV we need to depict disputes fairly, not delete one or the other side. --Middle 8 (talk) 03:00, 31 October 2013 (UTC)

The claim that NPOV demands "two sides" is spurious because here one side is conflicted and the other side is independent. In this case we can say that acupuncturists and their supporters claim efficacy uncontroversially, but Vickers is not a MEDRS-quality source. Ernst is.

I should point out that MEDRS policy demands that we do this as well: Wikipedia:Identifying_reliable_sources_(medicine)#Use_independent_sources. The fact is that this source is promulgated by acupuncture supporters in a way that is highly problematic and very gaming-the-system. Ernst said this here: [1]. The source has been roundly impeached. It should be removed. jps (talk) 02:41, 31 October 2013 (UTC)

Hmmm, assuming stuff about editorial motivation is kinda NPA-ish. What is, and how does one idenfify, an "acupuncture supporter"? Good editors find good sources, and weight and stick close to them. And it would be better if you would propose changes at talk and seek consensus here rather than your current approach. --Middle 8 (talk) 03:00, 31 October 2013 (UTC)

Okay, let's leave it more simply: anyone here supporting the inclusion of Vickers is in violation of WP:MEDRS since the source is clearly not independent enough. I think it will be clear to outsiders that the current crop of editors here has created a page that is far too biased towards claiming efficacy of acupuncture. And I still think you need to tread more lightly in articlespace since you have a professional stake in making sure the subject is advertised well. jps (talk) 03:07, 31 October 2013 (UTC)

"... anyone here supporting the inclusion of Vickers is in violation of WP:MEDRS"? And trying to silence Herbxue? Interesting... --Mallexikon (talk) 04:38, 31 October 2013 (UTC)

No, we don't remove one source because another disagrees (where have I read that before...?). --Middle 8 (talk) 05:27, 31 October 2013 (UTC)

The source has been criticized. QuackGuru (talk) 06:04, 31 October 2013 (UTC)

This source you present is a mere letter to the editors... And it criticizes Vickers in such a general way that I have troubles even formulating its rationale... I'm afraid you'll have to come up with something a little more substantial in order to throw out a MEDRS that you don't like. --Mallexikon (talk) 06:17, 31 October 2013 (UTC)

There is a lot more criticism of the article. See Placing Acupuncture in Perspective. QuackGuru (talk) 06:23, 31 October 2013 (UTC)

This is another letter to the editors... It's not even criticizing Vickers et al. (on the contrary, it calls it a "well-conducted analysis"); it just says "that 2 important issues are not considered in their article or in the Invited Commentary that would help place acupuncture in better perspective for clinicians who wish to consider this modality as a possible treatment for chronic pain..." Your grasping at straws here. --Mallexikon (talk) 08:00, 31 October 2013 (UTC)

But the issue with the Vickers source is one of interpretation. These are straws, these are very real rejoinders which Vickers tried to address in the journal later on in the way fringe proponents often do, attacking the messengers as "skeptics" (as if such was a bad thing). Anyway, the source is duly impeached. We will be removing it or at least contextualizing it, it's clear to me. The question is now just how we will go about doing that. jps (talk) 11:48, 31 October 2013 (UTC)

Right now we have one RS (Ernst's quote -- from wherever it came originally) disagreeing with Vickers. In both EBM and MEDRS, expert opinion is at the lower end of the tier of evidence, while meta-analyses of RCT's are at the high end, so we'd weight accordingly. If the other sources (non-RS blogs) are making really good points, someone will publish them in an RS eventually. --Middle 8 (talk) 15:59, 31 October 2013 (UTC)

Shoddily done meta-analyses, I would hope, we would tend to avoid. As it is, Vickers has been roundly criticized by medical doctors and professors of complementary and alternative medicine for problems with interpretation. So, I'm unclear as to how you are declaring Vickers et al. to be reliable as anything other than an opinion of a credulous acupuncturist. Where is the evidence that this study is considered a good study? Where are the citations to it in the literature by independent sources? Because I see absolutely none. This is in contrast to Ernst's excellent track record and huge number of citations to his work from both believers and independent analysts alike. So I say it's pretty clear that Vickers et al. is impeached, and should only be used in context, not as some sort of declaratory work that acupuncture is effective, as the text currently reads. jps (talk) 18:22, 31 October 2013 (UTC)

Neither criticism, Barrett or the latter, truly refutes Vickers' conclusions. To say that NSAID's do better against pill placebos than acupuncture does against sham acupuncture is apples and oranges. Additionally, the GERAC study and others conclude that acupuncture beats standard of care (including NSAIDS) for knee and back pain. I still see nothing that convincingly discredits Vickers.Herbxue (talk) 06:33, 31 October 2013 (UTC)

The refutation is on the interpretation that Vickers irresponsibly provides. Much of their reporting of other work is true in the sense that the other work they report on exists. They simply aren't very good at meta-analysis, is all. That's Ernst and all the others' points. jps (talk) 11:46, 31 October 2013 (UTC)

"Funding/Support:The Acupuncture Trialists' Collaboration is funded by an R21 (AT004189I from the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) to Dr Vickers) and by a grant from the Samueli Institute. Dr MacPherson's work has been supported in part by the UK National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0707-10186). The views expressed in this publication are those of the author(s) and not necessarily those of the NCCAM NHS, the NIHR, or the Department of Health in England."[2]

It looks like the study was funded or ran by alternative medicine promoters. I am not sure. QuackGuru (talk) 18:05, 31 October 2013 (UTC)

Well, NCCAM funding is notoriously indicative of very shoddy research. There was an expose of this in the Skeptical Inquirer. [3]. jps (talk) 18:25, 31 October 2013 (UTC)

Safety

The entire article is littered with old references. There are newer sources on safety, for example. QuackGuru (talk) 03:01, 31 October 2013 (UTC)

This probably should be incorporated somehow. jps (talk) 03:09, 31 October 2013 (UTC)

The RAE is on the order of 5 in a million, which is why basically everyone agrees that it's safe. --Middle 8 (talk) 05:35, 31 October 2013 (UTC)

There are many people who have been injured. The rate is not well-calibrated and Ernst has pointed out that there are some very bad actors. The problem is that because acupuncture is not able to be regulated like normal medical practice, there are some opportunities for bad actors. Given the normal "minimal invasiveness" of typical acupuncture proceedures, the number of safety issues is alarmingly high. jps (talk) 11:42, 31 October 2013 (UTC)

Sounds like an assumption. You're basing this on....?Herbxue (talk) 15:43, 31 October 2013 (UTC)

@JPS -- who says the "rate is not well-calibrated"? According to whom is acu "not able to be regulated like normal medical practice"? In practice it may not be well-regulated, and IIRC most adverse events are in Asia, with poorly-trained practitioners -- bad actors, as you say. Most of the AE's are preventable. "Alarmingly high"? Are you sure? That's like the 10th thing you've said is alarming today. --Middle 8 (talk) 15:50, 31 October 2013 (UTC)

Hmm, did you read QG's citation? jps (talk) 17:26, 31 October 2013 (UTC)

There is no specific argument against including this source. So I am going to add the source to the article. QuackGuru (talk) 17:37, 31 October 2013 (UTC)

Recommend reverting

This edit summary seems to be referencing Vickers which is a source that does not trump Ernst in the least. I recommend reverting the revert. This is terrible POV-pushing. Really disgraceful. jps (talk) 03:25, 31 October 2013 (UTC)

Well, I recommend you tone your language down a little, or we'll be having an argument about incivility at the appropriate place. Nobody's pushing a POV here. Your claim that Vickers' meta-analysis should be an unreliable source is just not well supported. If you think differently, take it to the Reliable sources noticeboard. --Mallexikon (talk) 04:20, 31 October 2013 (UTC)

I removed the OR in the sentence. QuackGuru (talk) 04:09, 31 October 2013 (UTC)

Ernst says the following: "Some findings are encouraging but others suggest that its clinical effects mainly depend on a placebo response." [4]. You just tried to distort a source here in order to push a certain POV. Now I'll assume Good Faith here - maybe you didn't do this on purpose, but just didn't read his article careful enough before stating that he can be used as a source for "Its effects are mainly due to placebo." Because, if you would have done this on purpose, this would certainly be a case for the noticeboard. --Mallexikon (talk) 04:31, 31 October 2013 (UTC)

Using Vickers without qualification is essentially POV-pushing because the source is SO bad. jps (talk) 11:40, 31 October 2013 (UTC)

The source does not say anything about "may be". QuackGuru (talk) 04:39, 31 October 2013 (UTC)

Then what would your close paraphrasing of Ernst's original sentence look like? --Mallexikon (talk) 04:49, 31 October 2013 (UTC)

"Most studies show its effects have not been reliably distinguished from that of a placebo."

Well, no. Ernst doesn't say most studies. --Mallexikon (talk) 05:24, 31 October 2013 (UTC)

"Its effects are suggested to be mainly due to placebo."

Well, only by some. Ernst himself writes that "some findings are encouraging".

There are different ways to write the text. QuackGuru (talk) 05:14, 31 October 2013 (UTC)

Yes, sure. But if you find that "may be" is not true to the source, you'd have to come up with something that is. Your above suggestions clearly are not. --Mallexikon (talk) 05:24, 31 October 2013 (UTC)

Source: "The majority of studies using such devices fails to show effects beyond a placebo response."[5]

Proposal: "Most studies show its effects have not been reliably distinguished from that of a placebo."

"Most" and "majority" mean the same thing. QuackGuru (talk) 05:30, 31 October 2013 (UTC)

Not enough context, and not close enough to the source. Source: "Some findings are encouraging but others suggest that its clinical effects mainly depend on a placebo response." - that statement is in line with a previous line in the abstract that there is "heterogeneity" in the research. The statement about a majority failing to show significant difference between sham and verum specifically refers to a specific subset of studies. Therefore, using Ernst to state that the "majority of studies suggest it is no more than placebo" is an example of original research and not true to the source. Herbxue (talk) 05:46, 31 October 2013 (UTC)

Yes. To complicate matters, this source of Ernst we talk about is from 2006... The high-quality reviews we have that show efficiency of acupuncture are much younger than, so he hasn't even taken them into account. --Mallexikon (talk) 05:57, 31 October 2013 (UTC)

I removed OR from two sentences. QuackGuru (talk) 06:02, 31 October 2013 (UTC)

"Research appears to imply ..." is weaselly. --Middle 8 (talk) 15:46, 31 October 2013 (UTC)

Source: The emerging clinical evidence seems to imply that acupuncture is effective for some but not all conditions. The close paraphrasing is supported by the source. The previous version without the context was OR. QuackGuru (talk) 17:17, 31 October 2013 (UTC)

The current text: Emerging research appears to imply acupuncture is effective for some but not all conditions.[8] Some research is encouraging but others suggest its effects are mainly due to placebo.[12]

Middle 8, do you still think the text is still weaselly or I was only being faithful to the sources? QuackGuru (talk) 17:08, 2 November 2013 (UTC)

I meant that the "seems to imply" part could just be pared down to "implies", but let me think about the broader context a little.... Thanks Middle 8 (talk) 02:31, 3 November 2013 (UTC)

Mass MEDRS violations

The dated references must go. QuackGuru (talk) 17:51, 31 October 2013 (UTC)

I agree. This is not good practice. We have some excellent meta-reviews by Ernst which should be explained clearly as the only basis for evidence (or, really, lack of evidence) and some controversies over whether governments should pay for acupuncture. That's about it, I'd say. jps (talk) 18:23, 31 October 2013 (UTC)

But you want to keep Ernst from 2006? What is your criteria? There is no justification for this edit. This is clearly cherry picking.Herbxue (talk) 22:50, 31 October 2013 (UTC)

Recent is almost always better, but some things don't change, and the inherent safety of needling (with proper training and precautions) seems like one of those things. Maybe there are better newer studies, but really good older ones ought to do, IMO. Anyway, a more recent source: "Acupuncture can be considered inherently safe in the hands of well trained practitioners." (WHO Bulletin, 2010, incl. everyone's favorite alt-med EBM guy as coauthor). --Middle 8 (talk) 01:42, 3 November 2013 (UTC)

Ah, QG added this already! Sorry, I missed that. --Middle 8 (talk) 10:14, 3 November 2013 (UTC)

Proposal

Instead of reducing this article into a Vickers vs. Ernst quarrel, why dont we summarize the scientific consensus from reputable institutions instead? If we can't agree on using the World Health Organization's statement about acupuncture, than we should try citing from a similarly neutral institution like this one. I don't understand why Vickers or Ernst should be considered more trustworthy than a national health organization. -A1candidate (talk) 18:29, 31 October 2013 (UTC)

There isn't much that can be said about evidence for the efficacy of acupuncture in terms of institutions. Most institutions don't speak to the profound lack of evidence for its efficacy except to make unsupported nods in the direction that "we think it might work".... but invariably they cite poorly considered or even withdrawn studies. While I agree that institutional support for acupuncture is relevant to this page, the fact that institutions support acupuncture says nothing about the evidence for acupuncture's efficacy. jps (talk) 18:51, 31 October 2013 (UTC)

These groups have their own experts who are better qualified than self-selected groups of WP editors, which is why they are top-tier MEDRS's and WP isn't even an RS. --Middle 8 (talk) 00:20, 2 November 2013 (UTC)

@A1Candidate, yes, the larger bodies carry more weight, although we should still use other MEDRS's too, from meta-analyses to expert opinion. Another good independent, institutional source -- as big as they get, probably -- is the National Health Service, currently mentioned in the lede but incorrectly noted as being disparaged by some sources who criticized the older WHO source. --Middle 8 (talk) 00:20, 2 November 2013 (UTC)

Dr. Nancy Snyderman information repeatedly removed

The following information has been repeatedly removed:

Nancy Snyderman, chief medical editor for the Today Show, finds acupuncture to be safe and effective. She states that doctors have found it to be effective for treating chronic pain, nausea, and migraines; she also uses it in the treatment of many of her cancer patients.[6] Snyderman states, "We know that acupuncture, when the needles are placed correctly, can affect the nervous system of the body. Though the reason that acupuncture helps may be somewhat of a mystery, it is a serious study that deserves attention."[7]

The summary notes given were "Using anecdotes as evidence?" and the other called the information "nonsense". While a couple of Wikipedia editors may not agree with Snyderman, apparently the Today Show finds her opinions credible or they wouldn't employ her as the spokesperson for their medical information. It is not Wikipedia's place to censor the veiws of very well-known medical experts. Gandydancer (talk) 18:34, 31 October 2013 (UTC)

Why should Snyderman's opinions about a procedure she has neither researched nor actually done be relevant on this page? I think they make more sense to include on the Nancy Snyderman page. Please explain. jps (talk) 18:48, 31 October 2013 (UTC)

No, it would be WP:UNDUE to include this mention of this one individual's view. An independent secondary source demonstrating that Snyderman's view on this topic is particularly well-recognized, influential and notable would be required. Otherwise we run the risk of the article filling up with a huge list of hand-picked quotes. There are surely holders of named chair positions at top-tier universities who we should be citing for their opinions before we're looking for that of a TV personality. This kind of thing should fail WP:MEDRS under the "popular press" clause. Zad68 18:53, 31 October 2013 (UTC)

There is simply no justification for treating a spot on Good Morning America as a serious reference. Even if the individual speaking were (hypothetically) the foremost expert in the world, we have no reason to consider that the show's editing and fact-checking processes are reliable, or that the statements went to air fully intact. Then there's the minor point that Snyderman's expertise lies elsewhere. LeadSongDog come howl! 21:01, 31 October 2013 (UTC)

We can't delete this and then keep the other nonsense in the article. QuackGuru (talk) 03:19, 1 November 2013 (UTC)

QG, of course you're right those aren't MEDRS's. And I think I see what you're getting at. They may be OK as RS's, but we don't need RS's to criticize acu, because we already have MEDRS's that do. We only use RS's to clobber fringe topics that are so fringe they're not even in the sci literature.... that's the import of WP:FRINGE. Now, if we're gonna quote RS opinion to depict how acu is received culturally (which could be a small part of the article), then we should quote both proponents and critics, per usual WP:WEIGHT standards. regards, Middle 8 (talk) 00:31, 2 November 2013 (UTC)

Disagreement with Vickers

Just in case you missed it, I added the disagreement with Vickers. QuackGuru (talk) 19:05, 31 October 2013 (UTC)

A good start. Thanks, QG. jps (talk) 19:13, 31 October 2013 (UTC)

And a good end. QuackGuru (talk) 19:13, 1 November 2013 (UTC)

I have no problem "balancing" Vickers with Ernst as long as we don't do it this way: "A peer-reviewed meta-analysis concluded so-and-so, BUT Distinguished Professor X said he disagrees, and here is his exact quote ...(....)." --Middle 8 (talk) 02:00, 3 November 2013 (UTC)

I've tried to fix the weight issue; it's a start, anyway. We all know that meta-analyses have much more weight than statements of expert opinion -- that per MEDRS, and the EBM standards on which MEDRS is rightly based. No gurus in EBM. Rather than prune Ernst, I've expanded Vickers, including the finding of significant difference between sham acu and true acu. There are other reviews cited that find no difference between true and sham acu, and it's crucial that we depict the state of the literature fairly and cover details from both + and - studies.

I've mentioned before that I do not accept that acupuncture is fundamentally fringe and that it therefore follows that all positive findings are bunk. This view is putting the "conclusion-cart" before the "evidence-horse", and essentially anti-science. A robust debate and positive findings are what demonstrates that acu is not as fringe as some editors (and bloggers) imagine. I point to the discussion at WT:MEDRS, at which consensus emerged that Vickers was indeed a good source, and that the notion that it should be removed was perhaps facetious at best. --Middle 8 (talk) 11:21, 3 November 2013 (UTC)

Note

https://www.ncbi.nlm.nih.gov/pubmed/23573135

If this source is not already in the article then we could it. QuackGuru (talk) 03:46, 1 November 2013 (UTC)

Sure, even if 294 adverse events had occurred in 1 year in the U.S. it would still show acupuncture is incredibly safe, BUT, the article actually shows 294 adverse events in 12 YEARS in 25 COUNTRIES! Acupuncture is obviously one of the safest interventions available to the public.Herbxue (talk) 03:53, 1 November 2013 (UTC)

Unless you are ill, and need something to fix it !! --Roxy the dog (resonate) 04:18, 1 November 2013 (UTC)

Don't conflate issues. Safety data is crystal clear - acupuncture adverse events are exceedingly rare, especially relative to conventional medical interventions. When it comes to efficacy, the most recent reviews are increasingly positive. No one is suggesting acupuncture for fractures or sepsis, so unless you have a sense of context and scale you will sound foolish making sweeping generalizations.Herbxue (talk) 04:39, 1 November 2013 (UTC)

The safety data has been updated. The text "acupuncture adverse events are exceedingly rare" is a MEDRS violation. QuackGuru (talk) 05:38, 5 November 2013 (UTC)

I removed the citation needed tag on the lead re "and carries a very low risk of serious adverse effects." I think this is supported adequately by the citations in the Safety section. If you (User:QuackGuru or others) disagree replace it with explanation here. Alternatively suggest (or boldly edit) a more appropriate phrasing. If the tag was in reference to the entire sentence which starts with "There is general agreement" and there is no source stating there is any such general agreement then by all means replace the tag. Not trying to be contentious just trying to keep the article readable. - - MrBill3 (talk) 14:01, 5 November 2013 (UTC)

I am also unclear on the MEDRS tag on the Adams 2011 article. Is it because it is a study on pediatric acupuncture being used on a more broad statement? Does using it to support the general safety of acupuncture (in conjunction with the other refs) WP:OR or not in keeping with policy for medical articles? - - MrBill3 (talk) 14:08, 5 November 2013 (UTC)

The Adams 2011 article passed MEDRS but was not about general safety of acupuncture. I recently updated the sentence in the lede with a newer source. QuackGuru (talk) 19:14, 5 November 2013 (UTC)

Adverse events needs updating

Serious adverse events are exceedingly rare—on the order of five in one million—[27][unreliable medical source?][8][9]

I added two newer sources to the article but I did not rewrite text or deleted the older sources. The text needs to updated and the sources need to be formatted. See Acupuncture#Adverse events. QuackGuru (talk) 16:59, 2 November 2013 (UTC)

There was no specific objection to updating the text using the newer source. QuackGuru (talk) 05:38, 5 November 2013 (UTC)

Not sure

"Proponents believe acupuncture can assist with fertility, pregnancy and childbirth, attributing various conditions of health and difficulty with the flow of qi through various meridians.[132]"

Not sure why this is in the article. QuackGuru (talk) 04:43, 1 November 2013 (UTC)

I think it is important and encyclopedic to cover what the proponents say it is useful for, however I am not sure this particular source covers that. At the very least the statement should be ascribed to Zita West, the author of the book cited, and not "proponents" (unless Zita West is making that general statement in her book, and the book is a reliable source for such a statement... the ref just cites the whole book and at 100+ pages that's not helpful). Zad68 14:26, 1 November 2013 (UTC)

I replaced the acupuncture book with a 2013 review. QuackGuru (talk) 01:23, 5 November 2013 (UTC)

Notable critics

I tried a compromise. QuackGuru (talk) 19:26, 1 November 2013 (UTC)

As I mentioned above, I agree with QG that per WP:FRINGE, we don't need RS's to speak to acu's efficacy or lack thereof when we already have MEDRS's that do that. --Middle 8 (talk) 00:34, 2 November 2013 (UTC)

It looks like there was not enough support to delete the section so I must restore it according to WP:CON. I renamed the section and also have expanded it a bit. QuackGuru (talk) 18:39, 21 November 2013 (UTC)

News article about modern study on acupuncture

• Acupuncture Meets West: Harvard Med School Teams up with Korea for Research - It shows brain scan differences between acupuncture patients and control patients. It's a good source, but I don't know how people would choose to use it here. - Sidelight12 ^Talk 02:21, 2 November 2013 (UTC)

Could not verify the text

"A 2007 review article noted that superficial needling, the primary form of traditional acupuncture in Japan, can stimulate endogenous production of opioids which could result in non-specific analgesia.[119]"[10]

Not sure about the text. QuackGuru (talk) 16:49, 2 November 2013 (UTC)

Low level details

Low level details are not encyclopedic. We are not going to add an author's name to every source. QuackGuru (talk) 06:06, 3 November 2013 (UTC)

Of course not. But since Ernst is now mentioned twice (each time at length, and with wikilinks) as an important critic of acupuncture, him co-authoring an overview that finds evidence that "acupuncture is effective for some but not all kinds of pain" is of interest to the reader. --Mallexikon (talk) 06:24, 3 November 2013 (UTC)

I think it would be better to avoid the unencyclopedic quotes and low level pointy details. Because Ernst is now mentioned twice is not a reason to add low level details. QuackGuru (talk) 06:44, 3 November 2013 (UTC)

The nonsense continues. QuackGuru (talk) 06:12, 3 November 2013 (UTC)

Don't be uncivil, please. It's not nonsense. I agree with Mallexicon. Ernst has written a variety of things and if we're only going to use his name with "acu is placebo" type statements, that's a WP:WEIGHT vio plain and simple. I'm reverting, but I'd rather we get consensus rather than edit-war, and it's obvious enough from the edit history who's edit-warring the most. --Middle 8 (talk) 10:30, 3 November 2013 (UTC)

Quotes

If possible editors should try not to add quotes. I rewrote the text without the low level details about Ernst. QuackGuru (talk) 06:44, 3 November 2013 (UTC)

Which policy says quotes are bad? Quotes are a good way of maintaining accuracy. And I don't know what a "low level detail" is; you seem to be saying that Ernst's name is a "low level detail" about him, which I find very strange. --Middle 8 (talk) 10:34, 3 November 2013 (UTC)

Adding Ernst's name to the review is wrong. The other reviews are not done this way. Quotes are a bad way to write text for an encyclopedia. Which policy says quotes are better than summarising the text? QuackGuru (talk) 17:00, 3 November 2013 (UTC)

"The other reviews are not done this way"? We wouldn't be having this discussion if we hadn't already mentioned Ernst's name elsewhere, right? Doesn't matter if it's a review or other source; we should have some consistency in whether we cite names of experts. Quotes: yes, I understand your expressed preference, but again -- does it say this in MOS? BTW, I noticed you did add Ernst's exact quote re Vickers; how is that different? --Middle 8 (talk) 00:29, 4 November 2013 (UTC)

"The study's conclusions are disputed by professor Edzard Ernst, who stated that the meta-analysis "impressively and clearly" demonstrated that the effects of acupuncture were largely due to placebo.[104]"

The text is a summary of the disagreement with a brief statement from the researcher. I noted who specifically disagrees with the review. The source is not a review. I can't say it was a review because it would be OR. It is different because a notable researcher publicly disagreed with a specific review. QuackGuru (talk) 00:56, 4 November 2013 (UTC)

But still, re quotes, you seem to be expressing a preference rather than following a guideline. That's fine but clearly up for consensus. Re naming Ernst in his comment re Vickers, we could easily have said "one prominent researcher" disagreed, and left it at that with no quote. But we didn't. Which is OK, but then we can't reasonably argue for the omission of other quotes, or naming of authors. And quotes are obviously fine on WP, QG... we see 'em all over the place; they add nuance and ensure accuracy. And re naming authors, again, we shouldn't put Ernst's name only beside his negative conclusions. He's had at least one review finding efficacy for pain in '11 (3 years post Trick or Treatment, btw). --Middle 8 (talk) 03:11, 4 November 2013 (UTC)

The quotes were deleted but now there is quotse with the reference. I can justifiable argue for the omission of other quotes, or naming of authors when it was not a specific response to another author or source. Quotes are good when it is from a specific person but not a review. QuackGuru (talk) 17:04, 4 November 2013 (UTC)

Notes

AFD

German Acupuncture Trials seems to be non-notable. What is it doing in articlespace? QuackGuru (talk) 06:10, 3 November 2013 (UTC)

Yeah, usually we use reviews, but it was a very big study. (they used sham needling controls at verum points) --Middle 8 (talk) 02:55, 4 November 2013 (UTC)

Looks like a soapbox. All the refs fail MEDRS and there is nothing notable about it. QuackGuru (talk) 00:44, 5 November 2013 (UTC)

I think it is time to AFD it. QuackGuru (talk) 02:12, 19 November 2013 (UTC)

Certainly not. The GERAC are notable because on their basis, acupuncture was included in the services paid for by the German statutory health insurances. Good luck with AfD. --Mallexikon (talk) 03:03, 19 November 2013 (UTC)

That is not what the article is mainly about. QuackGuru (talk) 03:13, 19 November 2013 (UTC)

Lede

In the lede of Traditional Chinese medicine there are seven references to verify the text.[1][2][3][4][5][6][7][unreliable medical source?]

This seems pointy. QuackGuru (talk) 06:56, 3 November 2013 (UTC)

Refs in lede are optional but they may have been put there to discourage other editors from saying "hey there are no refs for this claim" --Middle 8 (talk) 02:55, 4 November 2013 (UTC)

You have not given a reason for 7 references to verify one sentence. It could be WP:SYN to use that many references. QuackGuru (talk) 17:06, 4 November 2013 (UTC)

It was recently fixed. No longer 7 references in the lede. QuackGuru (talk) 00:44, 5 November 2013 (UTC)

"Significant", "effective", "improvement", "benefit"

I'm a bit concerned by the lack of clarity around the use of the above terms in the pain section of this article. For instance, in their review, Vickers et al. make it clear the significance they discern in the effect of acupuncture is statistical significance, and their comments about the modesty of the effect, while not saying anything explicit about clinical significance certainly allows that the effect is clinically insignificant. Laymen will read "effective" differently than researchers. A researcher will describe an intervention as effective if only a miniscule, clinically irrelevant, statistically-reliable improvement can be demonstrated. A layman is likely to read "effective" as meaning at least of some practical use. Similarly "improvement" and "benefit".

Saying blankly, "effective for some but not all conditions", "effective for the treatment of chronic pain", "effective for some but not all kinds of pain", "more effective than routine care in the treatment of migraines," "benefit for acupuncture combined with exercise in treating shoulder pain after stroke", "pain relief and improvement compared to no treatment or sham therapy", and "effective for chronic low back pain" without an indication of the clinical relevance of the effect, improvement or benefit is at best remiss, and almost certainly misleading most of our readers.

I really can't be bothered reading the above discussion, so if this has been touched on already, I apologise, but my superficial reading of the sources in the pain section tells me that they are surprisingly consistent, when you clarify what each author says or implies about effect significance. --Anthonyhcole (talk · contribs · email) 09:57, 3 November 2013 (UTC)

Interesting points, Anthony. Maybe we can look to the "plain text summaries" of Cochrane reviews for more layperson-accessible phrasing? And then work backwards from that to figure out how to extract it from full reviews? --Middle 8 (talk) 10:37, 3 November 2013 (UTC)

I can't do the reading needed just now - I shouldn't really be even looking at Wikipedia: I'm procrastinating. But the reviews I did read in the pain section are very clear about the kind of significance they're referring to, and its p value. If all of the reviews in that section are consistent about the strength of evidence, the statistical significance and the clinical significance, it should be possible to boil all that "this review said x but that review said y" down to a statement of what they all (or most) say in common about chronic pain (be sure they're all addressing chronic pain) with a paragraph or two giving specifics about reviews that differ from the common finding.

Maybe my random sampling has misled me, but I'll be surprised if you can't say in Wikipedia's voice that there appears to be a modest benefit above placebo from acupuncture in the treatment of at least some forms of chronic pain, though it's not clear if any benefit is significant enough to be worth the expense and effort. --Anthonyhcole (talk · contribs · email) 11:36, 3 November 2013 (UTC)

Dunno, I'm not good with statistics, but seems like it could be WP:SYN for us to say that... again, I'd be inclined to use the Cochrane plain-language summaries to guide our wording. Wouldn't their translation of the statistics to lay readers be reliable? (same here re procrastination btw; I should be checking in here less often) --Middle 8 (talk) 00:18, 4 November 2013 (UTC)

Duplication

The text is in effectiveness section: "A 2012 meta-analysis found significant differences between true and sham acupuncture, which indicates that acupuncture is more than a placebo when treating chronic pain (even though the differences were modest).[103]"

Since it is in the effectiveness section I removed the duplication. QuackGuru (talk) 17:30, 3 November 2013 (UTC)

Since "Pain" is a subhead under "Effectiveness", maybe it would be better to have the ref under "Pain"? And then simply se the paragraph above "Pain", etc., as an intro to that section, summarizing the subheads?--Middle 8 (talk) 00:08, 4 November 2013 (UTC)

"A 2012 meta-analysis found acupuncture is effective for the treatment of chronic pain, specifically back and neck pain, osteoarthritis, and chronic headache.[103]"

Here is the current text under "Pain". I'm not sure what you want to do. The ref is used in two separate places. QuackGuru (talk) 01:09, 4 November 2013 (UTC)

The specific dispute was deleted

The specific dispute with the conclusions was deleted. Now the reader will not know what was disputed. QuackGuru (talk) 03:01, 4 November 2013 (UTC)

I restored the text but did not restore the quotes. I summarized the dispute. The previews version did not tell the reader anything. QuackGuru (talk) 00:20, 5 November 2013 (UTC)

That looks better than the version I reverted, thanks.Herbxue (talk) 15:24, 5 November 2013 (UTC)

The text has been changed. See diff. Both diffs I can live with. Keep on editing if you can think of a way to make it better. QuackGuru (talk) 17:58, 5 November 2013 (UTC)

References with quotes should be notes

The reference section is loaded with extensive quotes. It should be broken out into a notes section and a references section using for example the Refn template. If I have the time I will try and work on it but if someone else has the time by all means go for it. - - MrBill3 (talk) 00:26, 5 November 2013 (UTC)

I've done this and in the process found that there were unneeded quotes. It is not necessary to place a quote of the material paraphrased. Notes 3-6 are not needed and if there is no objection here I will remove them. They do not provide any additional useful details or clarification of the material in the article. - - MrBill3 (talk) 03:47, 5 November 2013 (UTC)

Thanks for the hard work, Mr. Bill. No objection from me. --Mallexikon (talk) 05:24, 5 November 2013 (UTC)

Templates

I don't see any more discussion going on... Can we remove the templates that were put up a month ago? Cheers, --Mallexikon (talk) 01:24, 7 November 2013 (UTC)

Alright, I'll take that as a yes. --Mallexikon (talk) 02:19, 12 November 2013 (UTC)

Needs updating

Both peer-reviewed medical journals, and acupuncture journals reviewed by acupuncturists, stated that acupuncture can be painful.[87][88][89][90][not in citation given]

The ones most commonly reported occur at the site of needle insertion: minor bleeding (3%), hematoma (2-3%), and pain from needling (up to 3%). Dizziness is reported in about 1% of treatments.[175][176][177][178][179][not in citation given]

These sentences need updating using the newer sources. The older sources must go. QuackGuru (talk) 01:59, 7 November 2013 (UTC)

Glad you mentioned these. I've long been dubious about some of them, as their discussion of the subject -- pain from needling -- is peripheral at best. For example, an article on post-operative dental pain might say "... and acupuncture is sometimes used as a treatment, but it is painful". A MEDRS for one topic isn't necessarily a MEDRS for another. IMO, the prose here is rather POINT-y (sorry) and OR-ish; the edit would never have stuck if the topic had been efficacy instead of adverse effects. We already have some good sources on the subject. I'll remove the poor ones unless someone else beats me to it, or objects. --Middle 8 (talk) 06:13, 13 November 2013 (UTC)

I think the older ones were recently removed and the text was rewritten. Of course, there could be some older ones left that editors missed. QuackGuru (talk) 06:18, 13 November 2013 (UTC)

A large part of the Safety section was deleted

These mass changes deleted MEDRS compliant references and deleted relevant safety information. QuackGuru (talk) 16:45, 7 November 2013 (UTC)

I think I restored the relevant text. QuackGuru (talk) 17:16, 7 November 2013 (UTC)

Relevant details deleted

"The vast majority of adverse events from acupuncture are minor, and are estimated to occur in approximately 7% to 12% of treatments, both in adults and children.[174] The ones most commonly reported occur at the site of needle insertion: minor bleeding (3%), hematoma (2-3%), and pain from needling (up to 3%). Dizziness is reported in about 1% of treatments."

The text should be restored but rewritten using newer sources. QuackGuru (talk) 19:17, 7 November 2013 (UTC)

Sure, knock yourself out. For now, the text you restored is contradicting (and trumped by) the material from the newer source; I think the text would have to reflect that. --Mallexikon (talk) 03:45, 8 November 2013 (UTC)

The details like this one was deleted Dizziness is reported in about 1% of treatments.

The details about the numbers should be restored using newer sources. QuackGuru (talk) 03:52, 8 November 2013 (UTC)

I can't find a newer source with the specific numbers for the adverse events. QuackGuru (talk) 04:30, 8 November 2013 (UTC)

I moved the text around a bit and included the review's conclusion for proper context. Your last edit said that pneumothorax and subarachnoid bleeding were "routine" occurrences with acupuncture. I did not see that in the source. However, my edit summary "avoids OR" is referring to my own previous edit, not yours.Herbxue (talk) 08:18, 8 November 2013 (UTC)

"The most frequent adverse events were pneumothorax, fainting, subarachnoid haemorrhage and infection, while the most serious ones were cardiovascular injuries, subarachnoid haemorrhage, pneumothorax and recurrent cerebral haemorrhage."[11]

The most routine' or common can be used in the text. There are also more serious adverse events. QuackGuru (talk) 17:15, 8 November 2013 (UTC)

Ok, thanks for the explanation. I still think it suggests more than it means so if you don't mind I would prefer to leave the word 'routine' out.Herbxue (talk) 20:56, 8 November 2013 (UTC)

The word routine is out but I included a bit more context from the source. QuackGuru (talk) 21:25, 8 November 2013 (UTC)

Looks good to me.Herbxue (talk) 16:08, 9 November 2013 (UTC)

Vickers's reply to Ernst

Vickers published a reply to Ernst and other critics in the journal Acupuncture in Medicine[12], which is a journal published by BMJ. Here's what he said:

(possible copyright vio removed)

Passing along in case it's useful. TimidGuy (talk) 11:46, 8 November 2013 (UTC)

Thanks for this! (an aside, fwiw -- we don't need to include Vickers' remarks on the laser study; that's a job for a review article.) --Middle 8 (talk)

Seems like Vickers's response could be included in the article. (Note that Vickers's remarks were refereed and published in a journal, whereas Ernst's remarks were simply a quote in a newspaper.) Perhaps we could add a sentence: "Vickers responded by citing evidence that suggests that the effect is not the result of a placebo." TimidGuy (talk) 11:20, 15 November 2013 (UTC)

What evidence did Vickers cite? Vickers response was his own opinion that has not been proven. QuackGuru (talk) 17:15, 15 November 2013 (UTC)

Well, so was Ernst's. --Mallexikon (talk) 04:20, 16 November 2013 (UTC)

Vickers cited a double-blinded study by Irnich that found a statistically significant difference that couldn't be attributed to a placebo effect, thus refuting Ernst's speculation. TimidGuy (talk) 11:58, 16 November 2013 (UTC)

Well, so was Ernst's? You are correct but what is included in the article is the opinion of Ernst that passed V. Vickers response was also his own opinion. But the proposal made by TimidGuy failed verification. You putting words in Vicker's mouth. "Vickers responded by "citing evidence that suggests"... That is original research. Editors do not make up there own conclusions about what Vicker's said. Where in the text did Vicker's say he "suggests" there is evidence.

"Vickers cited a double-blinded study by Irnich" Did Vicker's say this or are editors conducting there own review.

This is closer to the source: "Vickers responded by saying there was no bias in the study because investigators found a way around the problem of therapist blinding.[13]"

This is what Vickers said but Middle 8 said we don't need to include Vickers' remarks. There could of been consensus if Middle 8 did not reject the response by Vickers. But consensus can change. QuackGuru (talk) 19:42, 16 November 2013 (UTC)

"....we don't need to include Vickers' remarks on the laser study" was what I said, because we don't usually discuss single studies, and a letter to the editor isn't a good springboard for doing so (compared to a review article). But aside from that, I am in favor of summarizing Vickers' reply. --Middle 8 (talk) 18:45, 21 November 2013 (UTC)

However we word it, I think the essential point of Vickers is that the results can't be attributed to a placebo effect. Let's check with Middle 8. I didn't get the impression that he thought we should exclude Vickers's response. There's no policy reason for excluding it, and NPOV would suggest it be included. Also, it's unclear that a quote in a newspaper satisfies MEDRS, which disallows popular media as sources. And personally, I don't understand the opposition to Vickers, since the section already cites a number of research reviews that found a reduction in pain. TimidGuy (talk) 11:38, 18 November 2013 (UTC)

Middle8 only said that we wouldn't have to include Vickers' remark about the laser study, I think QG misunderstood him. Of course you can include Vickers' response if you want to. I personally don't think it is necessary, though. --Mallexikon (talk) 01:54, 19 November 2013 (UTC)

Why don't you think it's necessary? As it stands, it gives the impression that treatment is no better than a placebo, but Vickers study showed otherwise, and Vickers effectively refuted Ernst's speculations regarding why it might not be better than a placebo. TimidGuy (talk) 10:56, 20 November 2013 (UTC)

It would help your cause if you rewrote your proposal without putting words in Vicker's mouth. QuackGuru (talk) 16:54, 20 November 2013 (UTC)

Of particular importance is that Vickers is citing a single study, this does not apply to the Meta Analysis overall. Also clinical significance is of primary importance. A back and forth between two individuals should be limited in a WP article. Does Vickers allege that the Meta Analysis is not compromised by the general lack of blinding or that the results indicate clinical significance? These would be important points. Has another source commented on the Meta Analysis? - - MrBill3 (talk) 05:44, 21 November 2013 (UTC)

Hi, to clarify, I certainly believe Vickers' reply to Ernst should be cited in just as much detail as Ernst's comment. That is simple WP:WEIGHT. But in summarizing Vickers' reply, I do not think we should touch on his remarks about the later study. BTW -- let's not lose sight of the fact that Vickers' meta-analysis vastly out-weighs the followup comments of either Ernst or Vickers. So we might end up with 2-4 sentences on the meta-analysis, and then a single sentence on the back-&-forth. And sure, we can use expository text in footnotes, per an earlier edit by Mallexicon. -Middle 8 (talk) 17:10, 21 November 2013 (UTC)

Considerable undue weight to Ernst

At the moment (this version), we have a big undue weight problem: Vickers' meta-analysis is dwarfed by Ernst's remarks. (Vickers' reply to Ernst does not yet appear.) Remember that in the evidence-tier for both evidence-based medicine (EBM) and WP:MEDRS, meta-analysis ranks at the top and expert opinion at the bottom. Vickers' review is mentioned twice, and each time Ernst's reply gets not less weight, but considerably more. Note also WP:WTA in framing Ernst ("however"; "commented"), not to mention stating the title and position (when a wikilink would do) for one party but not the other.

• First instance:
  • Text devoted to meta-analysis: A 2012 meta-analysis found significant differences between true and sham acupuncture, which indicates that acupuncture is more than a placebo when treating chronic pain (even though the differences were modest).[14]
  • Text devoted to expert opinion: However, Edzard Ernst, emeritus professor of complementary medicine at the University of Exeter, disagreed with the study's conclusions and commented that it demonstrated that the effects of acupuncture were principally due to placebo.Footnoted text: In an article in The Guardian, Alok Jha stated:[15] Edzard Ernst, emeritus professor of complementary medicine at the University of Exeter, said the study "impressively and clearly" showed that the effects of acupuncture were mostly due to placebo. "The differences between the results obtained with real and sham acupuncture are small and not clinically relevant. Crucially, they are probably due to residual bias in these studies. Several investigations have shown that the verbal or non-verbal communication between the patient and the therapist is more important than the actual needling. If such factors would be accounted for, the effect of acupuncture on chronic pain might disappear completely".
• Second instance:
  • Text devoted to meta-analysis: A 2012 meta-analysis found acupuncture is effective for the treatment of chronic pain, specifically back and neck pain, osteoarthritis, and chronic headache.(source as above)
  • Text devoted to expert opinion: However, the study is disputed by professor Edzard Ernst, who commented that the meta-analysis demonstrated that the effects of acupuncture were largely due to placebo, since the difference in results from real or sham acupuncture were small and clinically irrelevant. Footnoted text: (cites to same footnote as above)

Enough said. Of course this is easy enough to fix; I'm just out of time right now. Will try later, or if someone else wants to, go for it. --Middle 8 (talk) 18:37, 21 November 2013 (UTC)

Ernst is not the only person to comment on Vicker's meta-analyis. Which of these comments, published in JAMA Internal Medicine, warrant inclusion? An "Invited Commentary" (this seems to give some weight) by Andrew L. Alvins, Needling the status quo: Comment on “Acupuncture for chronic pain” which has the text, "The conclusion that most of acupuncture's observed clinical is mediated by placebo effects..." and "...critics correctly note that a new pharmaceutical agent that fails to show superiority over placebo will not be approved. Why should the bar be lowered for acupuncture?" Placing acupuncture in perspective by Ziegelstein which questions the lack of context in comparison of effect size (and has another point behind the paywall). Acupuncture's elephant in the room by Barrett and London which points out the difference between study and practice as does Complexity of sham acupuncture (Huang et al.) which also notes some issues with the sham controls.

In terms of weight Vicker's reply to Ernst mentioned ONLY ONE study among those in the meta-analysis this does not support the entire analysis as using double blinded studies that overcome the placebo effect. As above Alvins seems to have the same opinion as Ernst. I know in general we use substantially stronger MEDRS but criticism of the meta-analysis published in the journal which published it seems applicable. Note Vickers also had a reply in JAMA Internal Medicine to the above (I don't have access to it right now).

Regarding the balance of meta analysis vs Ernst's commentary I think you have a valid point we should be able to reach some consensus on editing down the material from Ernst. I do think material in the notes section should be allowed but I remain open to input on that (everything else too for that matter).

refs

Best. - - MrBill3 (talk) 07:56, 22 November 2013 (UTC)

Here's the text of Vickers's reply:

(possible copyright vio removed)

With all these published, refereed sources available, it seems unnecessary to use a newspaper as a source. We can probably leave out Ernst (which in fact may not comply with the MEDRS proscription against popular media). TimidGuy (talk) 11:30, 22 November 2013 (UTC)

Of all the criticisms it seems Alvins is the one that has weight and bearing. Ernst may still qualify as expert opinion. - - MrBill3 (talk) 11:53, 22 November 2013 (UTC)

More great finds, thank you! (Boy do I wish I lived closer to a good library.) Agree, we should cite (and properly weight) the most substantive reply or replies, i.e. those that explain their positions, ideally in a journal. To be continued.... regards, Middle 8 (talk) 13:19, 22 November 2013 (UTC)

Still not clear in what way Ernst complies with MEDRS. Non-evidence-based expert opinion is nearly at the bottom of the MEDRS hierarchy. Ernst doesn't offer any evidence. He is simply speculating about what future studies might show. In addition, MEDRS says, "The popular press is generally not a reliable source for scientific and medical information in articles." TimidGuy (talk) 12:11, 25 November 2013 (UTC)

I tend to agree with TimidGuy's argument. Ernst's newspaper statements deserve low weight. He is a highly published, well recognized authority so a mention of his statement might still be warranted. BTW most of the text of the other refs I gave is available on their "preview" pages. - - MrBill3 (talk) 15:40, 26 November 2013 (UTC)

Thanks. Send me an email if you'd like to see pdfs of any of the sources. TimidGuy (talk) 11:25, 27 November 2013 (UTC)

I'll propose some new wording. And in the spirit of compromise, I'm open to including Ernst's statement. But I just wish there were something in MEDRS that supports using it. I can't see that there is. Non-evidenced-based opinion is at the bottom of the hierarchy. TimidGuy (talk) 12:06, 2 December 2013 (UTC)

Thanks for refocusing on this; I'll have a closer look. Agree re deprecating Ernst; I'd prefer to include something else, something with substantive criticism/comment, not just opinion. And not overdo the commentary's weight relative to the source (something I'm pretty sure you already agree with; just saying). --Middle 8 (talk) 13:05, 2 December 2013 (UTC)

So maybe we should go ahead and replace Ernst with the Avins commentary that appeared alongside the Vickers review. TimidGuy (talk) 15:53, 8 December 2013 (UTC)

This is a notable controversy and there is a disagreement with Vickers. There was a previous discussion to include the disagreement. See Talk:Acupuncture#Disagreement with Vickers. NPOV policy seeks some form of balance. When there is an opposing POV, we try to let each get the coverage according to RS, without allowing the article to become either a hit piece or a hagiographic sales brochure. The WP:SECONDARY source used in the article is a critique of the Vickers meta-analysis reported in The Guardian. The Ernst statement is the opinion of an expert which does have WP:WEIGHT. QuackGuru (talk) 18:03, 8 December 2013 (UTC)

The Ernst source simply doesn't comply with MEDRS. It's at the bottom of the hierarchy. Avins is a much better source for the disagreement. It complies with MEDRS and the criticism is more substantial. TimidGuy (talk) 12:07, 9 December 2013 (UTC)

The article is summarising a real world controversy which included comments from Avins. "At least in the case of acupuncture, Vickers et al have provided some robust evidence that acupuncture seems to provide modest benefits over usual care for patients with diverse sources of chronic pain," wrote Avins.[16] Avins is mostly in agreement with Vickers. The conclusion that most of acupuncture's observed clinical is mediated by placebo effects..." is not really explaining the controversy and the article is also supportive of Vickers.[17] QuackGuru (talk) 21:02, 10 December 2013 (UTC)

Ok we obviously have a pundits' controversy here... And I see two questions: 1.) If we want to include this controversy, what rational criteria do we chose in regards to which opinion to include? (Because we obviously can't include all letters to the editors we can find. And while Avins probably ranks very high in terms of MEDRS criteria... not sure where Ernst would be placed) 2.) We don't usually include commentaries about reviews and I'm a little concerned about creating an original precendent... Should we maybe leave this controversy out altogether? --Mallexikon (talk) 03:18, 11 December 2013 (UTC)

Are letters to the editor compliant with MEDRS? No. Some people think that every utterance from Ernst should be the main body of every article on CAM subjects. Thats ridiculous. Either we only accept secondary sources (systematic reviews) on the subject of efficacy or we don't. If we don't, then primary sources are fair game right? Ernst's letter is a fucking letter and does not belong as a source here. Herbxue (talk) 06:05, 12 December 2013 (UTC)

Well, it's not a letter as far as I understood it, it's a quote from him in a newspaper article... thus, the newspaper article would constitute a secondary source. --Mallexikon (talk) 06:13, 12 December 2013 (UTC)

MEDRS says not to use popular media as a source, so The Guardian shouldn't be used. Ernst simply speculates that future double-blinded studies may show that acupuncture is no better than a placebo. It seems silly to include this speculation in the article. On the other hand, while I disagree with Quackguru, who characterizes this review as controversial, I do feel there are clarifications and qualifications that could be added. For example, Vickers says that the results compared to treatment as usually are clinically significant. The commentary (which is not a letter) by Avins questions whether the results are clinically significant. Also, Vickers emphasizes the finding that acupuncture has a statistically significant effect compared to a placebo, but his characterization of the effect as "modest" glosses over the fact that it's not clinically significant. I vote for clearly stating Vickers's findings and then citing Avins to qualify them somewhat. TimidGuy (talk) 11:36, 12 December 2013 (UTC)

Thank you for pointing this out. I believe that this is an issue of undue weight (WP:UNDUE) and dispute that, in the midst of so many great sources used in the article, an editorial like this would be used (WP:MEDRS). I can't think of any articles of GA or B class in WPMed which use this structure: "A metaanalysis found that... However, in an editorial, X said...". I had a look at this article following the discussion on WP:MED and have left a comment below to this regard. Kindly, --LT910001 (talk) 10:49, 16 December 2013 (UTC)

Alright, that kind of answers my questions... So do we have consensus to leave the Vickers/Ernst controversy out altogether? --Mallexikon (talk) 11:29, 16 December 2013 (UTC)

I support leaving out Ernst. I just don't see how it possibly complies with MEDRS. It's not clear to me that Avins isn't compliant, but I'd go along with leaving it out. I would, however, like to reword the presentation of Vickers so it's clear that he found a clinical significant reduction in pain and that there was a statistically significant difference between acupuncture and a placebo. TimidGuy (talk) 12:19, 16 December 2013 (UTC)

I fixed the structure and weight concerns. The text is shortened to satisfy weight. QuackGuru (talk) 16:54, 16 December 2013 (UTC)

Well, no, the weight concern is not fixed. So far, consensus indicates to leave Ernst's comment out altogether, for the reasons given above. --Mallexikon (talk) 05:00, 17 December 2013 (UTC)

A 2013 meta-analysis did not determine acupuncture is cost-effective

"A 2013 meta-analysis determined that acupuncture is a cost-effective treatment strategy in patients with chronic low back pain."

The source: "Acupuncture as a substitute for standard care was not found to be cost-effective unless comorbid depression was included."

• Taylor P, Pezzullo L, Grant SJ, Bensoussan A. (2013). "Cost-effectiveness of Acupuncture for Chronic Nonspecific Low Back Pain". Pain Practice: The Official Journal of World Institute of Pain. doi:10.1111/papr.12116.. PMID 24138020. {{cite journal}}: Check |doi= value (help)CS1 maint: multiple names: authors list (link)

The current text is not accurate. QuackGuru (talk) 21:35, 8 November 2013 (UTC)

Actually, it is accurate. The source distinguishes between acu being cost-effective according to a given WHO benchmark (it is), and acu being cost-effective as a substitute for standard care. Quote:

“ ....According to this threshold, acupuncture as a complement to standard care for relief of chronic LBP is highly cost-effective, costing around $48,562 per DALY avoided. When comorbid depression is alleviated at the same rate as pain, cost is around $18,960 per DALY avoided. Acupuncture as a substitute for standard care was not found to be cost-effective unless comorbid depression was included. According to the WHO cost-effectiveness threshold values, acupuncture is a cost-effective treatment strategy in patients with chronic LBP. ”

Should we leave text as is or elaborate? --Middle 8 (talk) 06:41, 13 November 2013 (UTC)

Current text: "A 2013 meta-analysis found acupuncture as a substitute for standard care was not cost-effective but as a complement to standard care it was cost-effective for chronic low back pain.[169]"

I did elaborate on it but left out the low level details. The old text was not accurate when it was taken out of context. QuackGuru (talk) 17:55, 13 November 2013 (UTC)

A little clearer grammatically, with respect to the "for chronic low back pain" prepositional phrase which modifies both kinds of cost-effectiveness (i.e. as complement and substitute to standard care): "A 2013 meta-analysis found that acupuncture for chronic low back pain is cost-effective as a complement to standard care, but not as a substitute for standard care." --Middle 8 (talk) 19:09, 21 November 2013 (UTC)

That is not how it was summarizes. It first said acupuncture as a substitute for standard care was not cost-effective. QuackGuru (talk) 19:20, 21 November 2013 (UTC)

Wrong, read the quote above, that's the order it uses and is what I followed. Yours was grammatically unclear, as I said. --Middle 8 (talk) 19:35, 21 November 2013 (UTC)

It was a study. Failed MEDRS. QuackGuru (talk) 19:45, 21 November 2013 (UTC)

"The objective of this study was to assess the cost-effectiveness of acupuncture in alleviating chronic LBP either alone or in conjunction with standard care compared with patients receiving routine care, and/or sham."[18] This study does not meet MEDRS. QuackGuru (talk) 19:45, 21 November 2013 (UTC)

The study failed MEDRS. QuackGuru (talk) 19:50, 21 November 2013 (UTC)

Not true; don't be deceived by semantics. The source is a meta-analysis and does meet MEDRS. See the abstract keywords. "Study" is a general word that can be used to refer to meta-analyses, as does the author of the piece quoting Ernsts's comments on Vickers.[19]. --Middle 8 (talk) 19:56, 21 November 2013 (UTC)

"For acupuncture and standard care vs. standard care and sham, a weak positive effect was found for weeks 12 to 16, but this was not significant."[20]

They state "for weeks 12 to 16...". That is what studies do. The source says study not meta-analysis. You have not shown it passes MEDRS. This was OR and a MEDRS violation. QuackGuru (talk) 20:07, 21 November 2013 (UTC)

QG, you're simply wrong, and I hope you self-rv (if applicable). Read the abstract: "The objective of this study was to assess ... To determine effectiveness, we undertook meta-analyses which found ...."

All this is right there in the abstract, the same one that you read and found the word "study" in.

I don't appreciate having to spell this all out to an editor who's been around for years. It is disruptive to IDHT and ignore what the eye can plainly see. If you're having a hard time focusing on stuff, please take a break from editing instead of wasting other editors' time. If you don't have the scientific literacy necessary to know what "study" means, etc., why make things difficult for those who do? WP:COMPETENCE. --Middle 8 (talk) 21:19, 21 November 2013 (UTC)

From the full text of the the article: "Study Design: We sought to establish the effectiveness of the interventions over the comparators described in Table 1 by undertaking a literature review and meta-analysis. The literature review included clinical trials and systematic reviews. Search terms included...". The study is indeed a meta-analysis and thus is consistent with MEDRS. Puhlaa (talk) 23:32, 21 November 2013 (UTC)

This may need expert comment from someone who has access to the full study. The abstract of the study states, "For acupuncture and standard care vs. standard care and sham, a weak positive effect was found for weeks 12 to 16, but this was not significant." Does this mean when an analysis was done of studies that included sham treatment there was no significant effect? Wouldn't that mean the analysis this study used to draw conclusions was not one based on comparison of actual vs sham treatment studies? The abstract states, "we undertook meta-analyses" note the plural. Did the authors of the study cherry pick amongst analyses? What was the methodology of the "meta-analyses" and how did the authors choose which of them to base their results on? In my opinion any citation of this study should include that, "standard treatment with acupuncture vs standard treatment with sham acupuncture showed no significant results." Again I think someone with research expertise needs to examine the full text of this study. To me it is clear that this study is not "A Meta-Analysis" but used multiple analyses to find specific results. - - MrBill3 (talk) 05:36, 22 November 2013 (UTC)

How is that clear to you if you haven't read the paper? --Middle 8 (talk) 12:03, 22 November 2013 (UTC)

Because the abstract spells it out. How could they have used the meta-analysis that showed no significant effect to demonstrate cost effectiveness? Cost effective at having no effect? Also the abstract say, "we undertook meta-analyses" that means multiple and clearly as before the meta-analysis showing no significant effect could not have been used, thus they must have selected out that meta-analysis among the multiple meta-analyses they undertook. All stated in the abstract. I will read the paper at my earliest convenience. - - MrBill3 (talk) 12:19, 22 November 2013 (UTC)

I share your puzzlement at how they found cost-effectiveness without much in the way of effectiveness. I don't think the plural "meta-analyses" likely implies cherry-picking; sounds more like statistics-talk. But sure; TBD (FWIW.... probably not that big a deal as sources go). regards, Middle 8 (talk) 13:31, 22 November 2013 (UTC)

Removed from article & sticking here, pending resolution (re cost effectiveness vis-á-vis efficacy).

“ A 2013 meta-analysis found that acupuncture for chronic low back pain was cost-effective as a complement to standard care, but not as a substitute for standard care. ”

--Middle 8 (talk) 01:31, 23 November 2013 (UTC)

I have added some excerpts from the full-text of the article for your review. It seems to me that this is a MEDRS-compliant source that carried out 3 different meta-analyses and is quite acceptable for inclusion in this article:

• METHODS
• "Study Design: We sought to establish the effectiveness of the interventions over the comparators described in Table 1 by undertaking a literature review and meta-analysis. The literature review included clinical trials and systematic reviews. Search terms included keywords “acupuncture”, “chronic low back pain”, and “nonspecific low back pain”. We searched PubMed from its inception to 30 Jan 2012. The bibliographies of seven systematic reviews were searched for additional references. We included all randomized controlled trials that included acupuncture with manual or electronic stimulation. Clinical trials were included if a comparator of standard or usual care was utilized in the study. Standard care included one or more of the following:... Most of the studies were not relevant to this analysis because of the comparator; for example, studies were excluded that compared acupuncture alone with sham alone or placebo. All studies included in the analysis were randomized controlled trials. We excluded studies without intention to treat analysis."
• "Meta-Analysis Methodology': To estimate the health gain that could be attributed to each intervention, we conducted a meta-analysis to determine the efficacy of the interventions. We undertook three meta-analyses (one for each category in Table 1) to investigate the differential impact of the intervention vs. the comparator using Comprehensive Meta-analysis software (Version 2.2.050. 2009, Biostat Inc., Englewood, NJ, USA... We use effect size as the main measure of efficacy. We calculated standardized mean differences (SMD) using Hedge’s g, because it includes an adjustment to correct for small sample bias and is used in Cochrane Collaboration systematic reviews. Random effects models were applied because of expected heterogeneity. Studies were grouped according to length of follow-up."
• "Cost-Effectiveness Analysis: Cost-effectiveness ratios were determined as the incremental cost of the intervention divided by the incremental benefit and presented as incremental cost ($A)per DALY saved. The incremental cost is defined as the difference between the cost of the intervention (for example, the cost of acupuncture as a complement to standard care) and the cost of the comparator (for example, standard care). Higher incremental cost-effectiveness ratios indicate lower cost-effectiveness (ICER) . The DALY was chosen as the outcome measure of health gain as it captures both morbidity and mortality effects, and the DALY is used in baseline information on health status for Australia..."
• RESULTS
• "Cost-Effectiveness Analyses: The cost-effectiveness analyses are summarized in Table 5. Acupuncture as a complement to standard care is cost-effective, with a mean cost per DALY avoided of $48,562 (90% confidence interval $28,500 to $76,900). Where comorbid depression is alleviated at the same rate as pain, it is even more cost-effective, with a mean cost of $18,960 per DALY avoided (90% confidence interval of $11,100 to $30,000). In general, acupuncture was not found to be cost-effective when used as a replacement for standard care based on the trial conducted by Cherkin (32). However, when comorbid depression is included in the analysis by Haake (33), acupuncture is cost-effective compared with standard care ($62,946-well below three times GDP per capita)."

Puhlaa (talk) 21:39, 23 November 2013 (UTC)

Thank you for those excerpts. I think the article does qualify as MEDRS and supports the statement, thus it can be replaced in the article. Perhaps some caveat or explanation of the fact that there was no difference between sham and non sham should accompany it. The authors did find it important enough to place it in the abstract. - - MrBill3 (talk) 15:45, 26 November 2013 (UTC)

Yes, thanks for those excerpts, and I agree, restoring with explanation makes sense. --Middle 8 (talk) 15:00, 28 November 2013 (UTC)

Rate of serious adverse events

Restored[21] a source from 2004 that estimated a rate of SAE's of 5 in one million. For this area of research, 2004 seems fine, since it's consistent with later reviews like Xu et.al.,2013, which just didn't mention a specific number. Some things change quickly; this doesn't appear to be one. --Middle 8 (talk) 21:35, 21 November 2013 (UTC)

The 2004 is too old. It failed MEDRS. That is your opinion that the source from 2004 is consistent with recent reviews. The recent reviews covering safety did not think it was important to discuss the specific numbers. You were using the older source to argue against the later reviews. You thought the recent reviews were wrong so you used the 2004 source to argue against recent reviews. QuackGuru (talk) 21:46, 21 November 2013 (UTC)

It's not a MEDRS failure for the reasons I stated; it is consistent with recent reviews. There is no basis in fact for your other assertions, nor have you even attempted to provide one. --Middle 8 (talk) 12:06, 22 November 2013 (UTC)

You know there are recent reviews covering safety including the 2013 you mentioned. QuackGuru (talk) 18:00, 22 November 2013 (UTC)

You know that older sources are fine under MEDRS in a lot of situations. A1candidate put it well just below. --Middle 8 (talk) 01:43, 23 November 2013 (UTC)

I haven't got the time to study both articles in-depth, but I think its wrong to remove a source just for being several years old, especially when taking into account the lack of similar reviews published in medical literature. Unless there's an overwhelming increase in the number of acupunctural reviews being published in the previous weeks/months that explicitly contradicts this particular review, I don't see why it should be removed. Scientific consensus usually takes years, if not decades, to be shaped. A 2004 publication year seems to be fine. -A1candidate (talk) 15:37, 22 November 2013 (UTC)

Your comments show that the reference is indeed several years old. There is no compelling reason to ignore MEDRS. QuackGuru (talk) 18:00, 22 November 2013 (UTC)

And still more IDHT from you. I'm restoring the ref. If other editors agree with me, they'll make sure it stays. Don't expect your edits (inclusions or removals) to stick unless you're willing and able to discuss them. --Middle 8 (talk) 01:43, 23 November 2013 (UTC) Follow-up comment: haven't yet put it back in. More good reasons to add the source have emerged below. --Middle 8 (talk) 12:30, 26 November 2013 (UTC)

I agree with Middle 8 - no BS making up criteria on the fly - discuss here first please.Herbxue (talk) 03:09, 23 November 2013 (UTC)

Per WP:MEDRS:

• Look for reviews published in the last five years or so, preferably in the last two or three years. The range of reviews you examine should be wide enough to catch at least one full review cycle, containing newer reviews written and published in the light of older ones and of more-recent primary studies.
• Within this range, assessing them may be difficult. While the most-recent reviews include later research results, do not automatically give more weight to the review that happens to have been published most recently, as this is recentism.
• Prefer recent reviews to older primary sources on the same topic. If recent reviews do not mention an older primary source, the older source is dubious. Conversely, an older primary source that is seminal, replicated, and often-cited in reviews can be mentioned in the main text in a context established by reviews. For example, the article genetics might mention Darwin's 1859 book On the Origin of Species as part of a discussion supported by recent reviews.

According to WP:MEDRS we use recent reviews. Wikipedia does not engage in death pacts with almost ten-year-old sources. We don't have to say anything about the numbers. The recent reviews decided what is important. There is never a requirement that dubious, potentially misleading, but sourced text must appear, simply because an old source mentioned something several years ago when we know the recent reviews did not make the same point. Even if true, there is no reason to use the older source. Some things may change or may not change; but this is not the job of Wikipedians to make that determination. QuackGuru (talk) 06:29, 23 November 2013 (UTC)

MEDRS also says:

• "These instructions are appropriate for actively researched areas with many primary sources and several reviews and may need to be relaxed in areas where little progress is being made or few reviews are being published."

From PubMed, reviews on adverse events in acupuncture, most recent first:

• Xu, 2013-03 (English language, 6 databases, systematic, 25 countries & regions, 2000-2010; sequel to earlier review up to 2000)
• He, 2012-10 (Chinese language, 1956-2010)
• Wheway, 2012-01 (U.K., review of reports to National Patient Safety Agency, 2009-2011)
• Adams, 2011-12 (Pediatric, all languages, 18 databases, systematic, inception-Sept. 2010)
• Ernst, 2011-04 (Serious adverse events, all languages, 11 databases, 2000-ca.2010)
• Zhang, 2010-12 (Chinese language, 3 databases, 1980-2009)
• Capilli, 2010-01 (clinical trials focusing on pain)
• White, 2004-09 (Review of reviews; computerised databases, previous reviews of case reports, population surveys, prospective surveys, textbooks; English language; inception- 1990-2000)) (note: this is the one I propose to restore; includes estimated rate of serious AE's = 5 in 10^6)
• ... and six or seven more, from 1999-2003.

So since White's general review (2004), there were seven reviews, three of which (Wheway, Adama and Capilli) were about subsets of acupuncture care (pediatric, specific databases), and thus not comparable to White. Of the remaining four, two were in the Chinese literature and thus also not comparable to White, since there are fewer adverse effects in the West. That leaves two comparable to White: Xu-2013 and Ernst-2011. That would certainly qualify as a case of "few reviews are being published", i.e., reasons given in MEDRS to relax to five-year window. I think that pretty much settles the issue. Comments? --Middle 8 (talk) 15:30, 23 November 2013 (UTC)

I think you clarified this very nicely. --Mallexikon (talk) 05:03, 24 November 2013 (UTC)

I think the "few reviews are being published" exception is to allow a 5 year plus review when there is not a more recent one, or a more recent one that is comparable available. Why would it be appropriate to use a 10 year old review when there is one that is from this year and one that is from two years ago? That you have shown seven reviews from 2010 to the present pretty much negates the idea that few reviews are being published. But again the relaxing of the 5 year rule IMO is to allow use of a older study when there is not a more current one available.

If the more recent one doesn't have all the data you are looking for I would suggest a statement about Xu 2013 or Ernst 2011 followed by a mention of the data from White 2004. Alternatively you could argue that White 2004 is a superior source as a review of reviews and the most recent source at that level. - - MrBill3 (talk) 07:08, 24 November 2013 (UTC)

I wasn't suggesting ignoring Xu 2013 or Ernst 2011, but rather augmenting them with White 2004's "5 in one million" figure (for rate of serious AE's). (White is otherwise consistent with Xu and Ernst.) I did explain why the other five reviews aren't comparable to White: there are many different places to dig for data, e.g. language and databases, type of AE, population treated, care setting. Given all those variables, reviews are scarce. --Middle 8 (talk) 12:30, 26 November 2013 (UTC)

This proposal to use the fringe journal Acupuncture in Medicine makes no sense. There is information in the article about the numbers. Why include the same information twice in the article? I already explained that the recent reviews cover this. I think I clarified this very nicely. QuackGuru (talk) 18:48, 24 November 2013 (UTC)

Thanks for putting that number in the article, QG, but the source you used -- Adams 2011, the Pediatrics review -- credits it to White 2004; we should cite the latter since it's the original source. The very fact that Adams cites White shows that Acupuncture in Medicine is not a "fringe journal". Its publications are also used by, e.g., the Cochrane Collaboration[22], and Adams and Vickers each cite it multiple times. We should leave the judgement about "fringe-ness" to the literature. (Some of the stuff published by Acupunct. Med. might not pass MEDRS, but that's true of any journal, e.g. case reports). --Middle 8 (talk) 12:30, 26 November 2013 (UTC)

I agree that if Adams is citing a number from White it should be sourced to White. With that change, as the numbers are in the article, have we reached consensus. - - MrBill3 (talk) 15:49, 26 November 2013 (UTC)

See WP:MEDDATE: Look for reviews published in the last five years or so, preferably in the last two or three years.

The fringe journal Acupuncture in Medicine is still a fringe journal. We must use independent sources. There is no reason to use the 2004 source when we have a much newer source for the numbers. We don't cite older sources unless it is a good source like a Cochrane review. QuackGuru (talk) 17:19, 26 November 2013 (UTC)

QG, I think you are too quick with damning sources you don't like, especially with your assessments regarding "fringe". This is a reliable source as pointed out several times above, even though you think anything acupuncture is evil. If you believe the consensus here is unacceptable, please take it to the reliable sources noticeboard. --Mallexikon (talk) 05:00, 27 November 2013 (UTC)

Acupuncture in Medicine is published by BMJ Group, which can hardly be characterized as fringe. TimidGuy (talk) 11:23, 27 November 2013 (UTC)

I pointed out the source is way too old. In 2014, it would be 10 years old. QuackGuru (talk) 19:28, 27 November 2013 (UTC)

If the source (White 2004) is being cited by Adams in 2011 that supports its use as the best review currently available per the MEDRS exceptions discussed above. I agree that blanket condemnation of a journal as a source is inappropriate and / or a matter that should go to the RS Noticeboard. A published article should be evaluated on its merits for a specific article or fact therein. If a fact / number is used, the reference should not be a citation of that number but the original study. The citation of the number in a more recent source is a matter for editorial discussion about including that fact. - - MrBill3 (talk) 11:01, 28 November 2013 (UTC)

@QG: Your concerns about the age and mainstream-ness of the source have already been addressed, QG. No need to go in circles; consensus isn't always unanimity, and by all indications we have a consensus. I'll restore White 2004 per my earlier edit when I get a chance. --Middle 8 (talk) 13:35, 28 November 2013 (UTC)

MrBill3 said "a matter that should go to the RS Noticeboard." I thought you wanted to include the source. Your earlier edit deleted text from a 2011 source that was not about the numbers. There is a big difference between including the source and rewriting the text. You have not given a reason to rewrite the text.

"A 2011 meta-review showed that serious adverse events, including death have been reported, are frequently due to practitioner error, is rare, and diverse.[16]"

I object to deleting this text or replacing it with the dated source. I don't see an argument to replace the 2011 meta-review. QuackGuru (talk) 17:52, 28 November 2013 (UTC)

Again you're repeating yourself and ignoring points made above (e.g., that White is the original source for the 5-on-one-million number, and as such, should be cited). You also mischaracterize my edit, which did not "delete text from a 2011 source"; you may have misread the diff. That can happen, but with you it's been happening a lot. When you keep misreading/misrepresenting policies and edits, it gets disruptive. --Middle 8 (talk) 03:14, 29 November 2013 (UTC)

Your edit replaced the 2011 meta-review and your edit was OR. For example, the "exceedingly" rare was OR. Replacing the meta-review was against MEDRS. Your proposal does not seem to match your edit. You did not give a good reason to replace the the meta-review when it is a newer source. The 2011 meta-review said nothing about the 5-in-one-million number. IMO, your proposal does not make much sense. QuackGuru (talk) 03:34, 29 November 2013 (UTC)

You're misreading that diff. And above (early in this thread) you misread WP:MEDDATE; in fact, the bullet points that you pasted in come right after the "few reviews being published" exception, so I can't see how you could have missed that without being careless or bad-faith. This is disruptive. --Middle 8 (talk) 03:56, 29 November 2013 (UTC)

Where is your explanation for deleting/replacing the 2011 meta-review. I thought your proposal was to include the numbers but you still want to do this? Again, the meta-review is not about the numbers so what reason is there to replace it. Your original proposal was to include the numbers because you thought the newer sources just don't mention a specific number. But the newer sources do. There are two sources that mention the numbers. I included the numbers using one of the newer sources that explicitly states the 5 in 1 million numbers. The source you used does not explicitly state the 5 in 1 million numbers. QuackGuru (talk) 04:29, 29 November 2013 (UTC)

Enough! We have consensus; you've excluded yourself from it with persistent IDHT. And I think we're near the point where we need some local or global user-conduct consideration. Locally, it might simply involve an emerging understanding that you, QG, aren't the most trustworthy editor and therefore your mainspace edits won't stick unless there's explicit consensus; globally, well, the usual. But that may not be necessary unless you continue disrupting the talk page. --Middle 8 (talk) 10:02, 1 December 2013 (UTC)

To be clear, there's nothing personal here, nor am I generalizing unfairly. QG is good at finding sources, and frequently makes reasonable edits. It's just that he also frequently gets sidetracked, makes factual errors (the correction of which he tends to ignore), and IDHT's (intensely). --Middle 8 (talk) 10:44, 1 December 2013 (UTC)

The 2011 meta-review does not discuss the numbers but you did replace the source with an older source. Are you planning to delete/replace the 2011 meta-review again? The newer source that is about the numbers gives a better explanation about the numbers. The newer source does specify the numbers, including children and adults. See Adams 2011. I did explain the older source you wanted to restore does not explicitly state the 5-in-1 million number. QuackGuru (talk) 18:49, 1 December 2013 (UTC)

The White 2004 dated source is confusing because it said "acupuncture is estimated to be 0.05 per 10 000 treatments, and 0.55 per 10 000 individual patients."[23] This shows the older source did not explicitly state it was 5-in-1 million.

"The authors did not specify if this estimate included adults and children,..."[24] according to the newer Adams 2011 review. The newer review does specify the numbers, including children and adults.

Current text: "The incidence of serious adverse events was 5 per one million, which included children and adults.[166]"

The current text in the article is well written using the Adams 2011 review. The older text is indeed confusing and therefore not appropriate for inclusion in this article. QuackGuru (talk) 05:20, 2 December 2013 (UTC)

@QuackGuru: (1) You've just claimed (twice) that it's too confusing to convert 0.05/10,000 to 5/1,000,000. Among science editors. What do you take us for? (2) Re the newer source, you ignore this, from right above: Thanks for putting that number in the article, QG, but the source you used -- Adams 2011, the Pediatrics review -- credits it to White 2004; we should cite the latter since it's the original source. Then you ignore another editor's agreement with that comment. Pretending not to understand math is trolling for sure, and repeated IDHT-ing of comments (in the same thread) is probably also trolling, or else extreme incompetence. I've engaged you this far to allow you a choice, and you've repeatedly chosen disruption. Why should you be trusted? I won't engage your IDHT or "misunderstandings" further. As long as you behave this way, consensus will and should move along without you. --Middle 8 (talk) 07:10, 2 December 2013 (UTC)

@QG: Middle8 has a point. I would usually post this on your user page but you delete everything written there... We all honor your contributions here but I, too, feel kind of frustrated with your style. How about some good ol' WP:AGF from your side? --Mallexikon (talk) 07:28, 2 December 2013 (UTC)

@QuackGuru: I generally find your contentions reasonably well supported. I respect and value your editing and in many cases your opinion. I think you bring a sharp editors pencil to many places it is needed. That said I find your conduct on talk pages disruptive. Your level of IDHT at times defies belief and your follow up comments can be repetitive without any additional information. I am personally offended that you quoted me out of context. I was clear that if you contested White 2004, you should take it to the RS Noticeboard. Your comments and edit summaries all too often show a lack of civility. I encourage you to continue to contribute to WP but urge you to consider behaving in a more genial and constructive manner. Not wanting to get beyond the appropriate boundaries of a talk page I just want to add there are times and states of mind not conducive to editing. I hope all is well with you and look forward to a time when your participation in talk pages matches your acumen in editing. - - MrBill3 (talk) 07:36, 2 December 2013 (UTC)

However

The same review concluded that acupuncture can be considered inherently safe when practiced by properly trained practitioners.[168] "The same review also stated: However, there is a need to find effective ways to improve the practice of acupuncture and to monitor and minimize the health risks involved."[25]

The text may not summarise the source accurately. The text does not explain the "however" part. QuackGuru (talk) 19:59, 27 November 2013 (UTC)

Do you have a proposal for explaining the statement? I think one may be appropriate. We should provide a paraphrase and explanation per policy (IMO). - - MrBill3 (talk) 11:06, 28 November 2013 (UTC)

Looks good, QG. --Middle 8 (talk) 15:35, 28 November 2013 (UTC)

"exceedingly" rare is original research

"One might argue that, in view of the popularity of acupuncture, the number of serious adverse effects is minute. We would counter, however, that even one avoidable adverse event is one too many. The key to making progress would be to train all acupuncturists to a high level of competency."[26]

A 2011 meta-review showed that serious adverse events, including death have been reported, are frequently due to practitioner error, is rare, and diverse.[16]

I removed the original research. I recommend we keep this source. A 2004 cumulative review should not be used to replace the 2011 meta-review. See WP:MEDDATE. QuackGuru (talk) 18:09, 28 November 2013 (UTC)

I think you might be pushing the definition of OR too far. 5 in one million can fairly be called "exceedingly rare", IMO, compared to the rates of SAE's in other areas. How else to summarize it without just saying it directly (which is OK, but sometimes grammatically unwieldy)? --Middle 8 (talk) 02:30, 29 November 2013 (UTC)

The 2011 meta-review did not cover say anything about the 5 in one million. I read the full text. Please don't try to delete this 2011 meta-review against MEDRS. You don't have consensus to delete the 2011 meta-review. The current text is now accurate. QuackGuru (talk) 03:21, 29 November 2013 (UTC)

White 2004 -- remember that one? -- is the source for the 5-in-one-million number, and you're misreading the diff. Your "not getting it" is classic IDHT, and the effect (intentional or not) is trollish. Nobody wants to haggle over distracting misunderstandings. This is just too disruptive. --Middle 8 (talk) 04:00, 29 November 2013 (UTC)

"A 2004 cumulative review showed that serious adverse events (SAE's) are frequently due to practitioner error, exceedingly rare, and diverse.[168]" The dated source was added by Middle 8.

"A 2011 meta-review showed that serious adverse events, including death have been reported, are frequently due to practitioner error, is rare, and diverse.[16] Current text.

I object to using the 2004 cumulative review. Obviously no reason was given in this thread to replace the 2011 meta-review. I support the current text using the newer source. I object to the MEDRS violation. QuackGuru (talk) 04:29, 29 November 2013 (UTC)

More repetition and IDHT. Please stop disrupting this page. --Middle 8 (talk) 10:03, 1 December 2013 (UTC)

Where is your explanation for deleting the 2011 meta-review against MEDRS? This source was not about the numbers. Did you make a mistake when you edited the article? QuackGuru (talk) 18:26, 1 December 2013 (UTC)

You misread the diff. --Middle 8 (talk) 05:43, 2 December 2013 (UTC)

Seems like both sources are fair game, which means that "exceedingly rare" is not original research. Quack Guru, please don't insult everyone else's intelligence. Just add good new info if it is sourced well, but don't dick around with the other good, well-sourced material before discussing it here first. Herbxue (talk) 05:51, 2 December 2013 (UTC)

Both sources are not fair game according to WP:MEDDATE. I don't see a good reason to delete the text from the newer 2011 review and replace it with text from a dated 2004 source. It seems like you did not provide verification for the text that failed verification. The part "exceedingly" is indeed unsourced when no editor provided verification. QuackGuru (talk) 05:59, 2 December 2013 (UTC)

There are separate issues here: First,whether the 2004 source is reliable or not. The link you provided is in a section titled "basic advice" not "strict policy" - the goal is reliability. Does the 2011 source meaningfully and convincingly contradict the 2004 source? No, they both basically say acupuncture is generally safe, but you prefer the wording of the 2011 source. That is the second issue: Does the more recent source automatically trump the older source? Not really but of course the newer source should be included. I am not for deleting new sourced material in favor of old, but deleting material that is still valid and not specifically disproved by recent work should be discussed here first.Herbxue (talk) 08:17, 2 December 2013 (UTC)

Agree. --Mallexikon (talk) 08:21, 2 December 2013 (UTC)

Agree, and just to be clear: contrary to QG's repeated description of my edit that added White 2004, I didn't delete the Ernst 2011 review, I simply moved it to a place where it better fit the text. Ernst 2011 doesn't discuss and shouldn't be cited for rate of SAE's; what he does is give a raw number for SAE's -- that is, a numerator but no denominator. (And as mentioned, his # is consistent with White and other reviews.) The first sentence appearing in the diff was originally sourced to White; I know, because I wrote it, and consensus at the time supported it. Today, all but one of us seem to be fine with including White 2004, so I will redo/improve upon this edit. (Re MEDDATE's guidelines -- the bullet points that say to use < 5.y.o. reviews happen to come immediately under the sentence that says we can user older ones when not many are extant.) struck; already made that point; once is enough... don't feed the IDHT --Middle 8 (talk) 10:14, 2 December 2013 (UTC) (edited 13:11, 2 December 2013 (UTC))

Use this primary source?

An editor recently added material on the cost-effectiveness of acupuncture that was sourced to this large RCT conducted in Germany and published in 2008 in the European Journal of Health Economics. [27] There are some errors in the material added, but I don't want to take the time to fix the errors if the material will eventually be deleted due to this being a primary source. Thanks. TimidGuy (talk) 12:05, 5 December 2013 (UTC)

Significance

Just looking at Acupuncture#Pain. I'm finding an unacceptable vagueness in our portrayal of the significance of treatment effects. Can someone who has access to the Saudi review [28] please tell me whether they are using "significant" in their conclusion to refer to statistical significance or clinical significance, and whether they (or anyone else commenting on their review) say anything about the clinical significance of the difference between acupuncture and control? --Anthonyhcole (talk · contribs · email) 05:34, 8 December 2013 (UTC)

Without looking at that source, there's very few trials caring about clinical significance. It's not usually a term appearing in efficiency discussions. --Mallexikon (talk) 05:53, 8 December 2013 (UTC)

In my limited experience, recent good medical studies and reviews make it very clear whether they are using "significant" to mean statistical or clinical. Given the vast difference in meaning, it's important that we convey to the reader which meaning to assign to the term wherever we use it. --Anthonyhcole (talk · contribs · email) 06:12, 8 December 2013 (UTC)

I'll see if I can get the Saudi review. TimidGuy (talk) 15:46, 8 December 2013 (UTC)

Their meta-analyses found that acupuncture was both clinically and statistically significantly better than sham acupuncture, usual care, and wait list controls. I can send it to you, if you like. TimidGuy (talk) 17:18, 8 December 2013 (UTC)

You've got mail. :o) --Anthonyhcole (talk · contribs · email) 18:24, 8 December 2013 (UTC)

I went ahead and added that the reduction was clinically significant. TimidGuy (talk) 11:41, 12 December 2013 (UTC)

New meta-analysis

• PMID 24146995
• Some commentary from Ernst

Alexbrn ^{talk|contribs|COI} 08:22, 15 December 2013 (UTC)

Commentary from individuals

I had a look at this article based on a discussion in WP:MED and found this article's use of quotations very odd. In particular, it seems to selectively quote from individuals in several places, which not only is an issue under WP:UNDUE and WP:MEDRS but also somewhat strange to read in a medical article. Here is a list of the quotations:

• "A report for CSICOP on pseudoscience in China written by Wallace Sampson and Barry Beyerstein said:...". This particularly concerns me: "A few Chinese scientists we met ..." (?!!)
• "Acupuncturist Felix Mann, who is the author of the first comprehensive English language acupuncture textbook Acupuncture: The Ancient Chinese Art of Healing,[73] has stated in lectures that ..."
• "A delegation of the Committee for Skeptical Inquiry reported in 1995:[48]"
• "but it remains controversial among medical researchers and clinicians.[10] In 2006, a BBC documentary Alternative Medicine filmed a patient "
• "Psychologist John Jackson stated that, "Acupuncture, both as a field of study and in practise, contains many of the hallmarks of pseudoscience. It is based on untenable principles and the small amount of evidence there is to support its use in pain relief can also be called into question"
• "Steven Salzberg, director of the Center for Bioinformatics and Computational Biology and professor at the University of Maryland stated that,"
• " Steven Novella, Yale University professor of neurology, and founder and executive editor of the blog "
• "However, Edzard Ernst, emeritus professor of complementary medicine at the University of Exeter, disagreed with the study's conclusions "
• "The consensus statement and conference that produced it were criticized by Wallace Sampson..."
• "Brent Bauer comments on the Mayo Clinic website that it "it may be worth trying acupuncture" if other, more conventional treatments haven't helped in the treatment of low back pain, while noting that there was no difference in effectiveness between sham and real accupuncture.[187]"

Acupuncture may be effective in some domains, however there appears to be enough medical evidence (WP:MEDRS) for the lack of efficacy in many areas that many of these selective quotes could be replaced with sources more in keeping with WP:MEDRS. Kind regards, --LT910001 (talk) 11:04, 16 December 2013 (UTC)

Thanks for your input. I'm not sure if you a aware of the situation here though... We do have enough MEDRS for both effectiveness of acupuncture in some fields and non-effectiveness for other fields already. However, most skeptics still find the article somehow too pro-acupuncture. Almost all the quotes you listed above were included in order to satisfy the skeptics camp and to present more criticism. I don't see how we can remove these quotes without starting another edit war. --Mallexikon (talk) 11:25, 16 December 2013 (UTC)

Have flagged this on WP:MED. I understand this may be a matter of some contention, but I would point out that MEDRS is not a threshold for an article as a whole, but a guideline for the use of every single source in a medical article. Sources from individuals are not reliable medical sources, and including full quotes from such sources is an example of WP:UNDUE. There appears to be enough reliable sources in the article that reliable sources and quotes could be substituted instead of these claims. --LT910001 (talk) 12:57, 17 December 2013 (UTC)

To be picky MEDRS is not quite "a guideline for the use of every single source in a medical article" but (to quite the guidance) for "biomedical information in all types of articles". Articles on "medical" topics may contain material that doesn't need MEDRS sources, and conversely articles on "non-medical" topics may contain health information which does. Alexbrn ^{talk|contribs|COI} 13:09, 17 December 2013 (UTC)

Editorial discretion is involved in articles. For example, discredited studies from dated German acupuncture trials are allowed to remain in an article. Editors know the primary sources fails WP:MEDRS and low levels details fails WP:WEIGHT. It was is not simply background information dumped into the coat rack article. See WP:COATRACK. QuackGuru (talk) 16:51, 17 December 2013 (UTC)

I think LT910001 made his case very clear and there's actually no rational argument against it. I'll start removing the material he cited. --Mallexikon (talk) 07:59, 22 December 2013 (UTC)

Absolutely not, on ALL counts. LT910001 is wrong about the application of MEDRS, and you would do well to not remove any properly sourced material without consensus. Alexbrn is quite correct about MEDRS. -- Brangifer (talk) 08:11, 22 December 2013 (UTC)

You've got to be f****g kidding! You make such an absurd statement of intention, and one minute later you actually dare to do it! Have you no idea what vandalism is? Deletion of properly sourced material amounts to vandalism. Don't do it. EVER. Discuss your intentions first, and wait (a long time) to see what reaction you get. You must have extremely good reasons for deleting properly sourced material, and usually it's better to tweak the content, rather than delete it. Violating NPOV by deleting opposing POV is very wrong. -- Brangifer (talk) 08:19, 22 December 2013 (UTC)

And you do it again, after I had reverted you with a BRD notification. To make sure the record is clear, I have notified you about edit warring/vandalism on your talk page. -- Brangifer (talk) 08:29, 22 December 2013 (UTC)

Comment - Agree with User:LT910001. Commentary fails WP:MEDRS -A1candidate (talk) 08:58, 22 December 2013 (UTC)

They are flat out wrong. You don't understand MEDRS. It does not cover all content, only direct medical claims. Commentary, opinions, and controversies are not covered by MEDRS. -- Brangifer (talk) 09:15, 22 December 2013 (UTC)

@Brangifer: I made 2 different edits based on the rationales raised here and at Wikipedia talk:WikiProject Medicine#Arbitrary section break - rationales that show very clearly that the material is not properly sourced. Now you've both used profanity ("You've got to be f****g kidding!") and accused me of vandalism. WP:IDENTIFYUNCIVIL comes to mind, and I feel that you try to intimidate me. Would you bother to apologize? --Mallexikon (talk) 09:18, 22 December 2013 (UTC)