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Commentary |

Thimerosal Disappears but Autism Remains

Eric Fombonne, MD
Arch Gen Psychiatry. 2008;65(1):15-16. doi:10.1001/archgenpsychiatry.2007.2.
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Since autism was described in the 1940s, multiple unfounded theories of causation and corollary “treatments” have been offered. Psychiatry, then a psychoanalytically oriented discipline, posited a psychosocial explanation that blamed “refrigerator” mothers for the child's withdrawal into the autistic bubble, only to be reached by the interpretations of therapists engaged in long-term play therapy. To name only a few more recent such theories taken from both the psychosocial and biological realm of explanations, facilitated communication and secretin infusion enjoyed widespread support up to the point when the systematic accumulation of carefully controlled clinical trials consistently failed to provide support for their efficacy.1,2 In the last decade, 2 hypotheses on autism-immunization links were raised that have had a profound impact in the field of autism research and practice and on public health at large. One incriminated the measles component of the triple measles-mumps-rubella (MMR) vaccine,3 the other the amount of thimerosal (about 50% of which is ethylmercury) contained in most other childhood vaccines.4 The 2 hypotheses are separate, since MMR vaccines never contained thimerosal. Both hypotheses relied on the claim of an autism “epidemic” that apparently coincided with the introduction of MMR and/or the increased exposure to ethylmercury due to the increased number of recommended childhood immunizations in the first 3 years of life.

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Nutrition and stroke outcomes: alternative view
Posted on February 29, 2008
James M Gordon, MD, FRCPC, FAAN
(1)Northwest Hospital, Seattle WA; Clin Assoc Professor, University of Washington, Seattle, WA
Conflict of Interest: None Declared
The conclusion by Badjatia and Elkind (1) that "providing adequate caloric intake early in the course after ischemic stroke may now be seen as a therapeutic intervention used to minimize disease severity, reduce complications, and favorably affect patient outcomes" overstates the more modest conclusions of Yoo et al, that "patients with baseline undernutrition are being undernourished during hospitalization" and that "strategic nutritional support...may improve clinical outcomes."(2) Concluding that aggressive nutritional intervention would improve outcome risks mistaking cause for effect. An alternative interpretation of the data in Yoo et al's Tables 2 and 3 might be that baseline-undernourished (and therefore presumably already-debilitated) older patients with larger strokes do worse than better nourished younger patients with smaller strokes, particularly if those strokes cause worsening undernutrition at 1 week. The notion that prevention of worsening undernutrition in already-debilitated elderly patients with large strokes would change outcome is not addressed by Yoo et al's data, seems to contradict the FOOD studies,(3,4) and risks mandating presumptive overtreatment of devastated, elderly patients at the end of life. Given that enteral feeding of such patients is neither necessarily simple or benign, the issue is not trivial. Aggressive nutritional support, like other forms of treatment of neurologically devastated patients, must be individualized carefully, in response not only to physiological considerations, but to the wishes, values, and life-context of the person lying in the bed.
(No conflicts of interest to report.)
1. Badjatia N, Elkind MSV. Nutritional Support After Ischemic Stroke: More Food for Thought. Arch Neurol.2008;65(1):15-16.
2. Yoo S-H, Kim JS, Kwon SU, Yun S-C, Koh J-Y, Kang D-W. Undernutrition as a predictor of poor clinical outcomes in acute ischemic stroke patients.Arch Neurol.2008;65(1):39-43.
3. Dennis MS, Lewis SC, Warlow C, FOOD Trial Collaboration. Routine oral nutritional supplementation for stroke patients in hospital (FOOD): a multicentre randomised controlled trial. Lancet.2005;365(9461):755-763.
4. Dennis MS, Lewis SC, Warlow C, FOOD Trial Collaboration. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet. 2005;365(9461):764-772.
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