Vitamin C and Vitamin E Do Not Prevent Eclampsia

A friend of mine recently asked me “Is regular soda or diet soda better for you?”

I tried to probe for details.  “Are you talking about calories?  Obviously, if you’re watching your weight or restricting carbohydrates, you should have the diet soda.”

“No, I don’t mean the calories.”

“Oh, you mean the concern that the citric acid might leach calcium out of your body?”

“No.  I just mean overall, are they good or bad for you?”

This precipitated an important revelation that had been percolating in my head for years but that never actually crystallized until now.  People think of things we ingest as generally “good for you” or “bad for you”.  But nothing is globally good or bad.  Everything has specific effects, some positive and some negative.

Amoxicillin is great for Strep throat.  It’s not very useful for lupus or seizures.  Beta blockers are terrific to prevent heart attacks, but make for lousy asthma medicine.  Even water, which is essential for life, is life-threatening if inhaled.  The most universally positive health intervention I can think of is cardiovascular exercise, and even that has some risks, like muscle sprains.

With that in mind I found an interesting study in this week’s New England Journal of Medicine.  The study attempted to prevent a serious potential complication of pregnancy – eclampsia – which is dangerous to both the mother and the baby.  It was thought that antioxidants, like vitamins C and E, could prevent the chemical abnormalities that lead to eclampsia.  And besides, aren’t antioxidants good for you?

The study randomized about 10,000 pregnant women in their first pregnancy.  Half received a daily vitamin E and vitamin C supplement, and half received placebo.  The women and their babies were followed for any signs of eclampsia or pre-eclampsia.  The outcome was disappointing.  The women on the vitamin supplements did no better than the women on placebo.

So vitamin C and E don’t help prevent eclampsia.  Does that mean they’re “not good for you”?  No.  Vitamin C is essential in preventing or treating scurvy.  So if you have scurvy, I strongly recommend it.

Oh, and to answer my friend’s question about sodas, artificial sweeteners are safe as far as we know.  So I would prefer diet sodas to avoid the calories of non-diet sodas.  The only health benefit of sodas is that they contain water, which can be obtained from other sources.

Learn more:

New England Journal of Medicine article:  Vitamins C and E to Prevent Complications of Pregnancy-Associated Hypertension

More

Pitfalls in Prostate Cancer Prevention

My regular readers know the controversies and challenges posed by prostate cancer.  It is very common.  Over half the men who die at advanced age of other causes will have prostate cancer on autopsy.  It is very slow.  From the time that prostate cancer is detectable on biopsy to the time that it causes symptoms or shortens life can be as long as a decade.  It is not very lethal.  Because it tends to affect older men, most men diagnosed with it tend to die of other causes.  Though it does kill tens of thousands of men annually, it kills fewer (and older) people than colon cancer, lung cancer or breast cancer (or traffic accidents).

This confluence of a very common but very indolent disease that strikes mostly older men has made screening, diagnosis and treatment very challenging.  Should we be testing for a disease that lots of people will get but that most people won’t be harmed by?  No one knows yet.

These challenges have prompted some researchers to consider prevention.  What if instead of testing, diagnosing and treating we could give men at high risk of prostate cancer a medicine that made prostate cancer less likely?  To be more cynical, the finances are also tempting since many more “at risk” men would have to take a preventive medicine than would actually get prostate cancer.

A large study published in this week’s New England Journal of Medicine shows that dutasteride, sold under the brand name Avodart, can decrease the incidence of prostate cancer in some men.  This has received much media attention.  (See links below.)  But let’s review the details before prescribing it to your uncle and grandpa.

The study enrolled over 8,000 men who were thought to be at high risk for prostate cancer because of their age or an elevated PSA.  (PSA is a not-very-accurate blood test used to test for prostate cancer.)  They all had a prostate biopsy at the beginning of the study and only those with negative biopsies (i.e. no detectable cancer) were enrolled.  Half the men were randomized to take Avodart daily, and half to placebo.  All the men had prostate biopsies two years and four years after enrollment.  The study sought to find if there was a difference in the numbers of prostate cancers found in the biopsies of the two groups.

Sure enough, Avodart seemed to decrease the incidence of prostate cancer found in the biopsies.  20% of the men taking Avodart were found to have prostate cancer versus 25% of the men taking placebo.  But so what?  Not a single person in either group died of prostate cancer, and they wouldn’t have been expected to since the study lasted four years and prostate cancer takes much longer than that to cause harm.

There’s absolutely no way to know if the men taking Avodart will live longer or be spared the symptoms of prostate cancer without following them for a much longer time.  There is good reason to suspect that the men taking Avodart won’t do much better than the men taking placebo.  The number of very aggressive tumors (as measured by their Gleason score, a quantitative score related to the tumors’ microscopic appearance) was the same in each group.  It was only the least aggressive tumors that were decreased in the Avodart group.

Moreover, about 5% more men in the Avodart group than in the placebo group developed problems with libido or with erections.  So for every 20 men who take Avodart rather than placebo for 4 years, one fewer man develops prostate cancer on biopsy which may or may not ever harm him, but one additional man develops sexual side effects.  Add to that a small additional risk (about half a percent) of heart failure in the Avodart group, and the numbers are very discouraging.

An editorial in the same issue of the New England Journal of Medicine concludes that Avodart should not yet be prescribed for prostate cancer prevention.  We need to know much more about the outcomes of men who take it for decades, not years.

Learn more:

New England Journal of Medicine article:  Effect of Dutasteride on the Risk of Prostate Cancer

New England Journal of Medicine editorial:  Chemoprevention of Prostate Cancer

Los Angeles Times article:  Prostate drug may work as a preventive

Associated Press article:  Study finds possible heart risk with prostate drug

More

Erroneous Evidence about Enough Exercise

This week, a study in the Journal of the American Medical Association received a lot of undeserved media attention.  The study wanted to examine the relationship between exercise and long-term weight changes among women who were eating a normal diet (i.e. not dieting).  It followed for over a decade 34,000 women who were 45 years old or older and correlated their self-reported physical activity and body weight.

The study found that on average, the women gained about 6 lb during the study.  Among women who initially had normal weight (body mass index less than 25) there was a significant correlation between amount of exercise and maintenance of weight.  Women with initially normal weight who did at least 60 minutes a day of moderate to intense exercise maintained their weight, while those who did less tended to gain weight during the study.

The authors therefore concluded that for middle-aged women who are not dieting, 60 minutes of moderate exercise daily is necessary to prevent weight gain.  This conclusion was repeated in much of the media coverage (links below) trumpeting that women should be exercising much more than we previously thought necessary.

But hold on a minute!  First of all, the study is observational, not randomized.  If you really wanted to know the effect of different amounts of exercise on weight you would randomly assign women to different quantities of exercise, make sure they were doing the assigned amount, and follow their weight.  That’s not what happened here.  The women exercised as much or as little as they wanted, and that amount was correlated with their weight change.  But that means that anything that affects both exercise and weight could have skewed the results.  Women with chronic illnesses that cause weight gain (hypothyroidism, heart failure) would tend to feel too tired to exercise and also gain weight.  These women would tend to make the statistics look worse for sedentary women, though their weight gain had nothing to do with being sedentary.

Also, the amounts of exercise was self-reported, not observed by someone objective, making it possible that women with stable weights are simply more likely to exaggerate their reported exercise.  (Which reminds me, I have to take it easy this weekend after running 3 marathons and swimming up the Mississippi River this week.)

Finally, the correlation between exercise and weight gain was only found in women with normal weights.  In women who started with a BMI over 25, there was no connection found between how much they said they exercised and how much weight they gained.  Does that mean that overweight people shouldn’t exercise?  No.  It means that there’s nothing to learn from correlations and that we can only learn from a randomized experiment.

So this tells us nothing about how much women should be exercising to maintain their weight.  Perhaps it tells us that some conditions cause weight gain and inability to exercise.  Perhaps it tells us that thin women exaggerate when reporting their exercise habits.  Perhaps it tells us nothing.

So how can you tell how much exercise you need to maintain your weight?  Weigh yourself.  If you’re gaining weight, you should exercise more.

Learn more:

Journal of the American Medical Association article: Physical Activity and Weight Gain Prevention

Los Angeles Times article:  Women should exercise an hour a day to maintain weight, study says

Wall Street Journal article:  New Exercise Goal: 60 Minutes a Day

More

More Match Day Misery

… or, If We Beg, Will You Go Into Primary Care?

What if tomorrow 30% of the nation’s plumbers disappeared?  Perhaps they vanish due some fantastic science fiction experiment gone horribly wrong.  What would happen?  Would a national plumber group call for making plumbing a more attractive profession?  Would there be a cry for greater federal plumbing subsidies to draw more people from other fields into plumbing?

No.  (Or at least, I hope not.)  In the short term, there would be a terrible shortage of plumbers.  The plumbers available would have more work available then they could possibly complete.  They would have to raise their rates to match demand to supply.  This would have two important benefits.  First, it would force customers to conserve on plumbing services.  As plumbers got more expensive, less important or less urgent jobs would be deferred, since only those with a need that justified the expense would want to pay the higher fees.  Second, plumbers would make much more money than they used to, attracting more people to the field.  People who previously were having a hard time deciding between plumbing and some other field would be more likely to go into plumbing.

Within a very short period of time the number of plumbers would be very close to what it had been before the Horrible Plumber Vanishing of 2010, and their fees would be almost back down to what they were before the HPV.  Things would quickly be more or less back to normal.

Well, a similar but much slower vanishing is happening to primary care doctors.  Yesterday was Match Day, the day on which all graduating US medical students find out the residency to which they have been accepted.  The numbers for primary care continue to look bleak.  The number of medical students that matched to an internal residency was 2,772, up 3% from last year, but 30% lower than in 1985.  Despite this year’s small increase, the overall trend is one of medical students fleeing from primary care into higher-paying specialties.

This is occurring at the same time as our population ages, the baby boomers reach Medicare eligibility, and health care reform promises to add thousands more to the rolls of the newly-insured.  National groups have been warning of a looming primary care shortage for years, and this year’s Match Day numbers only reinforce that concern.

The American College of Physicians (ACP), the national organization of internal medicine doctors (of which I am a member) issued a press release expressing concern about this trend.  Dr. Steven Weinberger, an executive in the ACP, said “it is critical to begin making careers in internal medicine attractive to young physicians”.  Is it?  But why isn’t the problem fixing itself, like the imaginary plumber problem?

The reason is that most doctors can’t increase their fees.  Their fees are set by insurance companies.  The normal market response to a shortage — higher fees followed by more people entering the field — isn’t happening.  So Dr. Weinberger is left urging that Medicaid and Medicare payments should be increased to primary care physicians, a bitter prescription when the costs of these programs are already skyrocketing.

Dr. Weinberger would serve ACP members and our patients more effectively if he realized that pressuring insurers to increase payments to doctors is a tactic that has run its course.  Bankrupting the nation with ever-increasing costs is not a sustainable way to promote primary care.  The surest way to attract more physicians to primary care is to have patients decide for themselves with their own dollars how much primary care they need and how much they are willing to spend for it.  Dr. Weinberger should be encouraging doctors to work directly for their patients.

After all, that’s how we ensure that we have enough accountants and lawyers and plumbers.

Learn more:

American College of Physicians press release:  Residency Match Results Not Encouraging for Adults Needing Primary Care

Los Angeles Times Booster Shots:  Primary care still isn’t an attractive choice for new doctors

More

Are Bisphosphonates to Blame for Baffling Bone Breaks?

This week ABC World News aired a story about a possible side effect of osteoporosis medications.  The family of medications involved in this story is called bisphosphonates and includes Fosamax, Actonel and Boniva.  These medications have been proven to prevent fractures in patients with osteoporosis (very low bone density).  Apparently, some doctors had noticed the occurrence of an unusual kind of fracture, a break in the thigh bone between the hip and the knee, in some women who had been taking bisphosphonates for over five years.  Also unusual was that these fractures seemed to be happening with fairly small traumas, without the major impact expected to break a thigh bone.

So, faced with these reports, since television news is known for sober and uncontroversial reporting of well-researched information, ABC decided to hold this story until they checked out whether these fractures have anything to do with these medicines.

Ha!  Just kidding!  Of course ABC ran the story, frightening countless women into believing that they may be at risk for breaking a leg because they are taking a medication specifically to reduce such a risk.  (Actually given the declining broadcast news ratings, perhaps they only frightened the last dozen Americans without cable or internet access.)

Obviously, the important question is:  Are these rare fractures happening more frequently to women on bisphosphonates than to women with osteoporosis who are not taking bisphosphonates?  The most honest answer is:  nobody knows.  Nobody has yet done the counting.

I’m sure we could also find that men taking medication for baldness get sunburns on the tops of their heads more often then other men.  But that might be a consequence of the baldness, not of the medicine.  Similarly, women with osteoporosis are at higher risk of fractures than other women, and every study done so far shows that bisphosphonates reduce that risk.  Whether this unusual thigh fracture is an exception should be the subject of a careful study.  Until then, we just don’t know.

The FDA released a statement (link below) urging women not to stop their osteoporosis medicines without a discussion with their doctors, and reminding doctors that these new reports do not change the indications for using bisphosphonates.

The rest of us got a useful reminder not to get information from TV news.

(Thanks to my patient Joyce for pointing me to the ABC News story and to my friend and colleague Mark for pointing me to the FDA statement.)

Learn more:

FDA Drug Safety Communication: Ongoing safety review of oral bisphosphonates and atypical subtrochanteric femur fractures

Reuters article: FDA rules out bisphosphonate, thigh fracture link

ABC World News story:  Osteoporosis Drugs, Like Fosamax May Increase Risk of Broken Bones in Some Women

More

American Cancer Society Revises its Guidelines for Prostate Cancer Screening

About a year ago I reviewed the controversies of prostate cancer screening, especially the conundrum that we still don’t know whether finding prostate cancer early saves any lives.  I concluded by citing the US Preventive Services Task Force (USPSTF) recommendations that the evidence is insufficient to recommend for or against screening for prostate cancer in men age 50 to 75.  The USPSTF recommends against screening men older than 75 as the evidence suggests that harms outweigh benefits in these men.

What does screening for prostate cancer mean?  There are two tests that are used to test for prostate cancer.  One is a blood test called prostate specific antigen (PSA).  The second is the not-always-popular digital rectal exam (DRE) in which a physician physically palpates the prostate in an attempt to feel an abnormality.

In contrast to the USPSTF, the American Cancer Society (ACS) has traditionally recommended more aggressive prostate cancer screening than was strictly supported by the evidence.  This week, the ACS issued revised prostate cancer screening guidelines that better reflect the current uncertainties in the science.  The new guidelines are much closer to the USPSTF recommendations.

The major changes in the new ACS guidelines are:

  • A discussion with the patient explaining that the benefits of screening are uncertain and explaining the possible benefits and risks of screening should occur before screening is performed.
  • For men who choose to be screened for prostate cancer, DRE is now optional.  Screening can occur with a PSA with or without DRE.
  • For men who choose to be screened for prostate cancer and who have a PSA less than 2.5, screening can occur every two years rather than annually.

I understand that for many of my patients avoiding the DRE will be the highlight of their annual exam.  But the bigger point that these guidelines struggle with is the fact that we have no idea whether or not we should be testing men for prostate cancer.  Even worse, we are sure that some of the men who will be tested will be found to have prostate cancer and will be harmed by side effects of the subsequent treatment much more than their prostate cancer would have hurt them.

We will have better studies in the next few years that will attempt to answer if prostate cancer screening saves lives.  In the meantime we have to make difficult decisions in the absence of adequate information.

Learn more:

American Cancer Society Revised Prostate Cancer Screening Guidelines: What Has–and Hasn’t—Changed

Los Angeles Times article:  Education should accompany prostate screening, new guidelines say

Wall Street Journal Health Blog post:  New Prostate Cancer Guidelines: Routine Screening Still Unneeded

My last post about prostate cancer screening:  Screening for Prostate Cancer May Harm More than Help

More

Carotid Stenting Still Controversial

Almost 800,000 Americans suffer a stroke every year.  Strokes are the third most common cause of death in the US, and are frequently disabling to those who survive.  These sobering numbers are despite the substantial improvement in recent decades in stroke prevention through the use of medications that lower blood pressure and cholesterol.

This week’s hubbub relates to carotid arteries, the large arteries in the neck that carry blood to the brain.  But before we dig into the details we have to understand that most strokes have nothing to do with any problem with the carotid arteries.  Strokes have many different causes, including high blood pressure, aneurisms, and abnormal heart rhythms.  One of these many causes of strokes is a buildup of cholesterol inside the walls of the carotid arteries.  This fatty plaque buildup can break off the artery wall and float to the brain, where it occludes a small artery and causes a stroke.

When a stroke is caused by this severe narrowing of the carotid artery by cholesterol plaque, studies have shown that surgery (called carotid endarterectomy) to remove this plaque helps decrease the risk of a second stroke.  The surgery is not a minor procedure and carries substantial risks.

For several years, researchers have speculated that a safer way to prevent strokes in patients with carotid artery plaque is to put stents (metallic mesh tubes) inside the arteries, much like the stents used in heart arteries to keep them open.  The rationale was that placing a stent in an artery is a much less invasive and less risky procedure than actually operating on it, so the hope was that stenting would be safer and just as effective.

That hope hasn’t yet materialized.

Several earlier trials showed that surgery prevents subsequent stroke better than stenting.  Two large randomized trials which reported their results this week add confusion, not clarity to the issue.  A large study, the Carotid Revascularization Endarterectomy versus Stenting Trial, just released results suggesting that stenting is as safe as surgery for carotid narrowing.  A second trial, the preliminary results of which were just published in the British medical journal Lancet, reaches the opposite conclusion – significantly more strokes in the stenting group than in the surgery group.

So for the time being, surgery is still the proven standard for fixing narrowed carotid arteries that have caused a stroke.  But we shouldn’t forget the bigger picture – keeping blood pressure and cholesterol low prevents many more strokes than fixing carotid arteries after they’ve already narrowed.

Learn more:

Mayo Clinic patient review of stroke

Wall Street Journal article:  Big Studies On Neck-Artery Stents Show Different Findings

New York Times article:  Study Finds Stents Effective in Preventing Strokes

Study in The Lancet:  Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial

More

Alarms about Asthma Agents

(or, LABAs Relabeled)

Long acting beta agonists (LABAs) are a family of inhaled medicines used to control asthma symptoms. LABAs include the medicines in Serevent and Foradil. LABAs are also available in combination inhalers, Advair and Symbicort, which combine a LABA with an inhaled steroid.

Though LABAs dilate airways and improve airflow, they have long been associated with an increased risk of worsening asthma symptoms. It has previously been thought that using an inhaled steroid with a LABA eliminated that risk, but until this is proven definitively the FDA took action to strengthen its warnings about LABAs.

In an announcement published yesterday (see link below), the FDA stressed that LABAs should never be used alone, and should only be used with an inhaled steroid. This much is not new and had been recommended in the past. (See my post about LABAs a year ago, link below.) The FDA also recommended that even when used in combination with inhaled steroids, LABAs should only be used for the minimum duration necessary to control symptoms, and then if possible should be discontinued. Only patients whose symptoms cannot be controlled on an inhaled steroid or other asthma controlling medication should be treated with a LABA for extended periods.

So if you’re using one of the above inhalers, a conversation with your doctor is in order. Obviously, don’t stop any of your asthma medicines without your doctor’s advice.

Finally, my regular readers know that I’m a big fan of electronic medical records. This is a perfect example of an instance in which electronic records extend patient care in a way that is impossible with paper charts. My partners and I will generate a report listing all our patients on LABAs so we can contact them to discuss whether a change is appropriate. With paper charts we would have just hoped that our patients heard the FDA warning and called us.

Learn more:

Reuters article: U.S. requires new warnings for asthma drugs

FDA announcement: FDA Announces New Safety Controls for Long-Acting Beta Agonists, Medications Used to Treat Asthma

My previous post about the dangers of LABAs: Lugubrious About LABAs

More

Gastric Banding is an Effective Option for Obese Teens

What’s my advice to my overweight patients?  Eat less and exercise more.  I give this advice every day, but following this advice is much harder than giving it.  Overweight people frequently struggle with diet and exercise for years, sometimes successfully, sometimes regaining their previously lost weight.

And as we become more overweight as a nation, obesity is no longer just a problem for adults.  Over 5 million adolescents are estimated to be obese in the US, which predicts bad things for their likelihood of developing diabetes, high blood pressure and other health problems.  Being an obese teen can also be a serious social and psychological burden.  Anyone who remembers adolescence knows that teens aren’t always accepting, nurturing and ethical peers.

I’ve written in the past about the slowly amassing scientific evidence that surgery for obesity has definite health advantages over continued attempts at diet and exercise.  This week, that evidence is extended to adolescents.

A study published in this issue of The Journal of the American Medical Association enrolled 50 teenagers between 14 and 18 years of age with a body mass index (BMI) higher than 35.  (For a person who is 5 feet 8 inches tall, a BMI of 35 means a weight of 235 lb.)  The enrolled teens also had to have been attempting to lose weight through diet and exercise for more than 3 years.

The teens were randomized to two groups.  One group underwent laparoscopic gastric banding.  In this surgery, an inflatable plastic belt is wrapped around the upper part of the stomach, decreasing how much food can be ingested.  In post-operative follow up the band can be adjusted by inflating or deflating it, thereby calibrating how much it constricts the stomach.  The second group was randomized to a supervised lifestyle intervention involving an individualized diet plan and a structured exercise program.  The groups were followed for two years.

The results were dramatic.  The group that underwent gastric banding lost an average of 76 lb over two years, compared to an average 7 lb in the lifestyle modification group.  The group that underwent gastric banding also had a higher quality of life and improvement in other health-related measurements.

The authors were quick to caution that gastric banding is no “quick fix”.  Patients still have to eat differently and be willing to have periodic follow up, potentially forever.  The authors still recommend diet and exercise as the first choice for weight loss.  But now for the many teens who do not lose weight after many attempts, there is a proven alternative.

Learn more:

Wall Street Journal article:  Weight-Loss Surgery for Obese Teens Backed by Study

Journal of the American Medical Association study:  Laparoscopic Adjustable Gastric Banding in Severely Obese Adolescents

More

Twelve Years Later, the Truth about Vaccines and Autism

Ideas have consequences.  False ideas, especially popular false ideas, can cause harm.  For example, the very popular false idea “corduroy pants and wide lapels are far out, man” made an entire nation ugly for about a decade.  And some false ideas do even more harm than that.

In 1998 the British medical journal The Lancet published a paper authored by Dr. Andrew Wakefield that claimed to link autism to the vaccine against measles, mumps and rubella (MMR).  The study looked at 12 children (that’s right, twelve, not twelve thousand) with developmental abnormalities and intestinal conditions that may have presented after the administration of MMR.

This supposed association spawned a large popular movement that urged suspicion of vaccines and recommended that parents refuse vaccines or delay their children’s immunizations.  Multiple subsequent larger studies have refuted the conclusions of the 1998 article, repeatedly finding no link between vaccinations and autism.  But undeterred by the actual evidence, the anti-vaccine movement continued to spread unfounded allegations, frightening parents about vaccines.

The consequences of this false idea were predictable, and devastating.  In the UK and US, vaccination rates dropped and in the last few years epidemics of measles have occurred.  Despite the decreased vaccination rate, the incidence of autism has not decreased, and the true cause of autism remains elusive.  Meanwhile Dr. Wakefield, the author of the 1998 study, has become a celebrity in the anti-vaccine movement, as its disciples have only his small study to lean on.

Recently, The Lancet learned that the study itself was deeply flawed.  First, the 12 patients were chosen in a way that could have introduced a great element of bias.  Second, many invasive and medically unnecessary procedures were done on the children without oversight of a research ethics board and without parental consent (an important protection that is mandatory in all research on human subjects).  Finally, Dr. Wakefield did not disclose that he received funding from attorneys with litigation against vaccine manufacturers.

So this week the editors of The Lancet publicly retracted the 1998 study.  Dr. Wakefield has been discredited and the anti-vaccination movement lost their last thread of scientific credibility.

I hope that public figures like Jenny McCarthy and Robert F. Kennedy Jr. who have promoted the false and lethal idea that vaccines cause autism will take this opportunity to publically recant and find less pernicious crusades to pursue.  I’m waiting for their announcement, but I may be waiting until corduroy pants make a comeback.

Tangential miscellany:

My post last week about normal weight obesity generated many interesting comments.  One attentive reader corrected me that fat is never converted to muscle.  That’s true.  I should not have used that phrase.  Fat cells remain fat cells forever, and muscle cells remain muscle cells.  Exercise burns fat, shrinking fat cells and enlarging muscle cells.  I appreciate the correction and changed the wording of the original post.

Learn more:

NY Times article:  Journal Retracts 1998 Paper Linking Autism to Vaccines

Retraction in The Lancet:  Retraction—Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children

BBC News article from a year ago:  Rise in measles ‘very worrying’

More