Tuesday 31 May 2016

Regarding Novella's "Science-based Medicine" blog criticisms of Tobinick - the bigger picture

As we understand it, Dr Steven Novella is an academic clinical neurologist at the Yale University School of Medicine.  He maintains a widely-read blog ( https://www.sciencebasedmedicine.org/enbrel-for-stroke-and-alzheimers ) said to be motivated by medical skepticism that since May 2013 has included his persisting negative opinion of the pioneering approach used for the past 12 years or so by Dr Edward Tobinick and his staff to treat neurodegenerative disease and neurogenic pain with etanercept (enbrel).  This treatment has led to some 25 peer-reviewed papers authored by Tobinick, including an internal-control case (i.e. detailed comparisons of pre and post-treatment states) study of over 600 patients.  All of these publications advocate that double-blind trials should be performed to take this work further. The scientific arguments on which it is based are well-known in the peer-reviewed scientific literature, e.g. see http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4110406, and are quoted objectively in the neuroscience literature, including by Yale-based researchers.  The patient welfare and commercial implications of such a treatment proving successful are obviously huge.

Novella maintains, indeed defends in court, that his negative opinion is legitimate scientific criticism, made available on the web for general public enlightenment, and protected as free speech. But facts matter in this field, and unfortunately his grasp of basic uncontroversial science on display in his blog is, on the face of it, quite fragmentary.  It could have easily been corrected by an hour’s diligence searching PubMed, the freely available Library of Congress website.  Examples are given below.  For his case to be plausible, we demonstrate here, he would need to possess a much higher standard of basic scientific competence in this area than his blog displays. We also outline the motivation of a bigger picture within which Novella's blog sits.

Scientific replies to Novella’s criticisms

Example 1.
Novella’s criticism is based on misunderstanding a fundamental property of TNF
Novella's widely disseminated opinion that enbrel is a specific anti-inflammatory drug and is therefore wrongly being used by Tobinick in neurological conditions not known to be immune mediated is scientifically quite wide of the mark.  This makes many of his criticisms groundless.  In the brain, as elsewhere, TNF has in fact been appreciated, for many years, to be just as large a player in normal physiology as in inflammation and immunology, even though it may still routinely, from tradition, be described as an inflammatory cytokine.  Enbrel is one of the specific anti-TNF agents, and at appropriate doses simply neutralizes excessive TNF.  Lowering excess TNF levels in the brain in this way restores a normal functional balance, or homeostatic equilibrium, and therefore normal function is regained.  This is very important in the brain, particularly in synapses, the connections between neurons.  TNF also controls production of glutamate, an amino acid central to neurotransmission, particularly in synapses, but toxic in excess.

Example 2.
Novella’s criticism of time of treatment since damaging event
Novella states: "Significant improvement was noted [by Tobinick] irrespective of the length of time before treatment was initiated; there was evidence of a strong treatment effect even in the subgroup of patients treated more than 10 years after stroke and TBI. This, if anything, is evidence that the observed treatment effect is mere placebo. It is very implausible that stroke or TBI deficits will be equally responsive to an anti-inflammatory treatment (or any treatment) regardless of time since the stroke or trauma."

In fact reactive microglia, the cells that generate excessive TNF, have been shown to be present in stroke and trauma brains up to 17 years after the event. See as examples, in peer-reviewed journals, Neurology 2000: 55; 1052-1054 and Brain 2013: 136; 28–42.  These authors discuss the concept of possible therapeutic intervention that Novella, with the apparent weight of Yale’s Neurology Department behind him, criticizes as implausible. 

Example 3.
Novella’s criticism of treating many cerebral conditions with one therapeutic agent
Through deprecating the concept of treating many conditions with one therapeutic agent, Novella's blog content reveals no more than fleeting reading of the scientific literature on TNF and chronic neurodegenerative diseases.  In 2015 a peer-reviewed text (Neuronal Plasticity 2015:Article ID 358263, Open Access in PubMed, see http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4510439/pdf/NP2015-358263.pdf) gave reference, from the past 10 years, to 11 chronic brain disease states (Alzheimer's disease, Parkinson's disease, Huntington disease, post-LPS cognition, post-operative cognition, post-irradiation cognition, post-chemotherapy cognition, rheumatoid arthritis cognition, sarcoidosis cognition, post-stroke therapy, and traumatic brain injury) in which specific anti-TNF therapeutic agents such as enbrel are in various stages of proposal and experimental development for therapeutic use.  This is part of a scientific revolution in the genesis of disease of which Novella, as an academic, should be concerned about advertising that he is unaware.

Comment on the implication of the above three criticisms by Novella
Unfortunately, a peer reviewed article correcting such fundamental errors as these three, which any reasonably-read neuroscientist would recognize, would be ineffectual, since it could not hope to reach the target audience of a widely accessed populist non-peer-reviewed blog.  Thus much of the damage this blog causes to the quality of knowledge acquired by its readers is very difficult to repair.  Moreover, Novella’s blog has now had close to three years to correct these errors, but shows no sign of doing so. In contrast, genuine skeptics, such as scientists conscientiously seeking accuracy, closely monitor the literature and evaluate it in order to acquire new knowledge that allows them to maintain the health of the skepticism that is part of their job description. Accordingly this present article, a one-off blog by researchers who otherwise restrict their comments to the peer-reviewed literature, declares Novella to be a pseudoskeptic with a non-scientific agenda, as discussed below.

Key elements of the bigger picture
The second intention of this article is to acquaint readers with the outline of a bigger picture, of which Novella's blog is but a part.  His blog content cannot be understood unless it is appreciated to be one of three like-motivated linked strands of an orchestrated campaign to discredit Tobinick and his approach to treating chronic neurodegenerative diseases at all costs.

Industrial scale internet denigration campaign against Tobinick
The second of the three strands, an industrial scale internet denigration campaign directed against Tobinick's publications in peer-reviewed journals has, in our experience, no precedent.  Currently, April 2016, Google gives almost 1700 hits on Tobinick/fraud and almost 900 hits on Tobinick/quack.  It is evidently orchestrated, with much of the wording on Novella’s blog word for word, or paraphrased, in many similar "fraud exposure" web pages, often with eye-catching bylines likely to increase the hit rate.

An attempt to have Tobinick de-registered to practice medicine
The third of the three known strands of this interlinked campaign began in June 2013 when a Dr Stephen Barrett made an official 25 page complaint to the Medical Board of California, received at its Sacramento office on 27 June at 1.25pm, that Tobinick was involved in unprofessional conduct, and thus should be disbarred from practice.  Barrett is an associate and co-author with Novella, for example on a joint "Quackwatch" publication (see http://www.quackwatch.com/01QuackeryRelatedTopics/Cancer/conspiracy.html).  In the face of evidence from independent academic neuroscientists who had, in contrast to Novella or Barrett, observed patient outcomes at Tobinick’s two clinics, this attempt to have him de-registered to practice medicine failed, including on appeal (Medical Board of California, Case No. 04-2012-222007, 22 May 2015).  Tellingly, as well as ruling no case to answer in terms of guilt, wrong-doing or negligence, the Judge, the Honorable Samuel D. Reyes, found that this mode of treatment of neurodegenerative disease with enbrel was a rational off-label approach.  Specifically, the ruling, espoused by the Medical Board of California, stated that there was “sufficient data and research about the drug's safety and potential effectiveness to support the treatment espoused by Dr. Tobinick.” The Medical Board of California issued an order withdrawing the accusation on June 16th 2015.  Novella continues to maintain his professed opinion-based blog in the face of, and without reference to, these court findings, which surely would have influenced a genuine skeptic, as they did the Medical Board of California.  Meanwhile, Tobinick's Wikipedia entry has been extensively doctored, including removal of a summary of this court case outcome, by a group traceable to Novella. These individuals, in the words of a warning by InvestmentWatch, http://investmentwatchblog.com/science-skeptics-use-guerilla-warfare-tactics-and-racketeering-behavior-to-infiltrate-wikipedia-and-spread-corporate-propaganda/" regularly use unprincipled behavior to edit Wikipedia.

Comment of these three parallel strands of attack against Tobinick
In our considered view these three interwoven attempts to discredit Tobinick: the Novella blog that provides misinformation purporting to have Yale backing; the large continuing internet campaign; and attempting through the courts to have him barred from practicing (even to the extent of taking the trouble and expense to appeal against the Judge's initial decision) are, in terms of intent, complexity and cost, far beyond the usual scale of website denigration of medical practitioners that the public have come to expect from Novella.  It also allows the public to see Novella's blog in a much more serious light than merely as an isolated personal opinion expressing what he defends as legitimate scientific criticism.

How might all this have come about? A comparison with the origins of the first use of an enbrel-like agent in a human disease in 1993 is instructive.  The steps in this process followed what patients should expect, and indeed demand, as standard procedure.  In that year a comparably small but startling open trial with the first specific biological anti-TNF agent, remicade, to treat rheumatoid arthritis was reported (see Arthritis and Rheumatism 1993: 36; 1681-1690).  Without any equivalent of the web attack, derogatory blog, and accusations in court meted out for years to Tobinick, it was formally tested through an industry-funded random double-blind study by the same researchers, using their original protocol, the very next year (see Lancet 1994: 344; 1105-1110).  Thus the first practical, FDA-approved, use of an anti-TNF therapy began.

The key question, still unresolved, is why Tobinick's equally startling open trial of a similar size and duration using enbrel against a neurodegenerative disease, by a novel administrative route he developed (See Medscape General Medicine Neurology and Neurosurgery 2006: 8; 25), did not followed the same path as did remicade for treating rheumatoid arthritis.  Instead, and as yet unaccountably, the makers of enbrel formally distanced themselves from Tobinick's open trial, leaving, as is often the case, off-label treatment as an interim until controlled trials are funded.  As described above, this has been met by a combined attack consisting of (a) large scale internet derision, begun in 2008 and still present (b) the Novella blog, begun in 2013 and still present, and (c) an attempt to de-register Tobinick through the courts, begun in December 2014 and dismissed in May 2015.  All this implies a financial backer prepared to go far on several fronts.

To understand how much patients and neuroscience stand to lose should Tobinick not prevail against this attack, which has actively prevented his method of delivery being formally tested for years, and tried to shut him down, the reader must understand that the battle is actually about possession of a technique to get large therapeutic molecules through the blood-brain barrier, a widely-sought goal.  Never mentioned by Novella, this is the logical driving force behind all three lines of attack on Tobinick (see Drug Discovery Today 2009: 14; 168-177 and  Bioengineering Bugs 2010: 1; 231-234).  An internet search finds an example of a large well-funded investor consortium whose current goal is to develop a technology for this purpose (see http://www.prnewswire.com/news-releases/armagen-technologies-inc-announces-17-million-series-a-financing-181460481.html).  Should Tobinick's novel route of injectionused in his patients long before this consortium's modified enbrel was used experimentally in mice, and convincingly logical to qualified witnesses who defended him and thence the Judge who presided over the Medical Board of California case No. 04-2012-222007 cited earlier – be formally trialed and accepted, the need for the consortium's technology probably no longer exists, placing its investors in jeopardy.  This is a compelling example of a motivation to fund discrediting Tobinick's work (which is applicable to getting many other large molecules into the brain) on as many fronts as possible, no expense spared. 

Actions from within the university associated with this investor consortium
It is not likely to be coincidental that the medical school department hosting this investor consortium's research funding (see Crossing the Barrier in http://www.neurology.ucla.edu/research/programs/stroke) to allow it to adapt Tobinick's unacknowledged findings to Trojan Horse delivery technology, is the very one from whence was hatched the plan to terminate his work through the above court case.  In contrast, the university itself has praised the advance that Tobinick's work represents (see http://www.newsroom.ucla.edu/in-the-news/ucla-headlines-jan-11-2008-43001).  This did not prevent written claims from this university department that Tobinick was a fraud and a quack, and that his treatment of stroke with enbrel was scientifically unsound, being systematically distributed to the clinical neurology world and to journalists, even after Tobinick's peer-reviewed study of over 600 patients before and after treatment had been published (see CNS Drugs 26: 1051-1070, 2012 at http://www.ncbi.nlm.nih.gov/pubmed/23100196)In addition, others within the same university had published an in-principle mouse Trojan Horse study (see J Cereb Blood Flow Metab 32: 1933-1938, 2012) that was consistent with Tobinick's earlier results, so recipients of these claims were being knowingly misled.

As noted above, the content of Novella’s blog regarding Tobinick, claimed to be written in the interests of science-based medicine, falls very short of accepted international academic standards.  Recall that neither Novella, nor any of the people who brought and made the failed case against Tobinick through the Californian Medical Board, has ever observed the outcome of treatment.  Hence, as part of a wider pattern of events designed to denigrate Tobinick and his work, the content of this Novella's blog can be validly described as malicious intent, for commercial reasons, posing as genuine ignorance allowable as harmless free speech.  This Novella blog is part of a wider pattern of activity that can be characterized as orchestrated, without regard for scientific fact or patient welfare, for extremely large-scale financial gain.  Clearly, the intent of Novella's blog, is, as was bringing the California court case outlined above, to deny Tobinick credit for and involvement in a treatment route he pioneered over a decade ago, and to halt its formal development.  This would close down a sorely-needed advance towards effective patient care for otherwise untreatable long-term neurodegenerative conditions. 

Summary
As demonstrated above, the scientific standard of Novella's blog is unacceptable as the genuine knowledge level of someone the internet describes as a Yale-based academic clinical neurologist informing the public for altruistic reason.  For a genuine skeptic, it would be an academic embarrassment.  This widely disseminated erroneous material appears to be intended to influence lay people who might otherwise be philanthropic towards funding a random double blind trial based on Tobinick's approach, or families of patients who might otherwise volunteer to take part in such a trial, or ask for off-label treatment.  Meanwhile, Novella's blog argues that Tobinick's treatment is meaningless until the very trial Novella is actively discouraging through his blog has been done. 

Novella's blog is to be viewed as part of a plan to shut down a small scale player who has developed a key original idea, and is attempting to follow it through the correct procedures to have it registered as an approved treatment.  Since it shows every sign of promise in 1000s of off-label treatments, it has, if left to develop undisturbed, the potential to help very many patients and their families.  As a side effect it would put a very large competitor, later than Tobinick on the TNF/neurodegenerative disease scene, in jeopardy.  It is most disturbing that ousting competitors is considered by some as infinitely more important than helping present patients and their families, as well as advancing neuroscience for the benefit of future patients.

By a group of academic TNF scientists with no commercial interest in this matter.