Monday, 23 May 2016

Doubt

Occasionally wrong, but never in doubt.
The above quote was said by my chairman during my surgical training more than once.  While at first glance it may sound somewhat tongue-in-cheek, trust me, he most assuredly didn't mean it that way.  Surgeons, he explained, must always be sure of their diagnosis, even if it's wrong.  As long as we never wavered in our diagnosis, we would never be criticised.  Or so he would have us believe.

It made no sense then, and it makes even less now, and the more I think about it, the crazier it makes me.  When I'm seeing a patient, whether for the first time or for follow-up, I'm constantly thinking and revising and double checking and self-regulating.  In fact, I'm doing it right now.  I revised and rewrote that last sentence 6 times before I got it right.  There's a slight chance that's an exaggeration, but you get the idea.  The point is that I'm always in doubt, and it is that very doubt that keeps me thinking, keeps me honest, and prevents me from becoming lazy and complacent. 

My experience with Ruby (not her real name™) demonstrated this rather convincingly.

Ruby was minding her own business playing Scrabble in the back seat of a car, when (in her words) "all of a sudden . . . BOOM."  Her car rear-ended another car, her seat belt tightened, and the sudden deceleration constricted her 80-year old abdomen between the belt and her spine. 

Ouch. 

When she got to me her blood pressure was normal but her heart rate was high, around 110.  She had a rather impressive abrasion on her neck from the shoulder belt and an even-more impressive abrasion across her entire lower abdomen.  I gave a little push on her belly and she winced.

In the vast majority of cases, this is nothing more than an abdominal wall contusion, and further testing confirms it.  Ruby's high heart rate was somewhat worrying, but it also isn't abnormal right after a huge scare.

The rest of her examination was fairly benign.  I palpated her chest, but she only said her abdomen hurt.  I lifted both arms, and her abdomen hurt.  I palpated down both legs, and her abdomen hurt.  I palpated her spine, and her abdomen hurt.

After a touch of pain medicine her heart rate improved to the 90's, so off we went to the CT scanner.  I watched the pictures come up, and something immediately struck me in the right lower abdomen.  There wasn't free fluid (ie blood), the bowel didn't look thickened, but something just looked wrong.  There was fat stranding (which denotes inflammation) in the area, though nothing else looked distinctly abnormal.

Hm.

I sat right down at the adjacent computer and looked through the pictures carefully.  I couldn't see a specific problem with the bowel itself, but it still was just . . . different.  Abnormal.  Wrong.  And then I saw what looked like three little black dots in the middle of her abdomen where they didn't belong.  Black on a CT scan is air.  And air outside the bowel means there's a hole somewhere.  And holes in the bowel are bad.

I'm not a radiologist, but it looked bad. 

Since I wasn't sure I was seeing what I thought I was seeing, I walked across the hall to the radiologists' reading room and found Dr. Bob (not his real name™), a radiologist I know as someone who could see anything on a scan as long as it's there.  When Dr. Bob is looking at a scan, it appears to me that he's looking into the Matrix.  He sees everything.  And Dr. Bob saw nothing.  Don't misunderstand - he saw the stranding, but he didn't see the little black dots.  No free air.  WHEW.  My eyes had apparently deceived me, and I went back to Ruby to tell her the good news.

Her abdomen was still hurting.  A lot.  I explained to her that though the scan was essentially normal, I was going to keep her for observation just to be on the safe side.  I was still concerned about her abdomen, and bowel injuries can be very difficult to diagnose until patients start to deteriorate.

Satisfied that she was ok for the moment (though not letting my guard down), I went to the lounge to get a coffee (decaf . . . grrr).  As I was stirring in the sugar, one of Dr. Bob's colleagues came up to me. 

Dr. E: Hey Doc, Dr. Bob was just looking for you.
Me: I know, I talked to him.
Dr. E: No, he was just looking for you, like 10 seconds ago.
Me: This can't be good . . .
Dr. E: He showed me that scan you were looking at.
Me: (under my breath): Shit.
Dr. E: He thinks he sees some free air, and I agree.

I went back to Dr. Bob, and he pointed out those three little black dots that I had thought I had seen but then had not seen and was now seeing again.  The hole in her bowel that I suspected she had but then was mostly convinced she didn't have was now probably there.

I thought about my chairman's stupid little adage as I told Ruby I wasn't 100% convinced that my diagnosis was correct, and I was most definitely in doubt.  She wasn't thrilled about her impending surgery, but with the amount of pain she was having she didn't argue one bit.

Despite the five other "emergency" cases pending in the operating theatre, Ruby was under anaesthesia about 45 minutes later and waking up 45 minutes after that with her small bowel laceration, which was about 1 cm in length about midway through her ileum, repaired.

Thinking back on Ruby's case, my initial impression had been that something was wrong.  My doubt made me consult the radiologist, and his doubt caused him to look at Ruby's scan a second time.  That's how good science works - evaluate, evaluate your evaluation, then re-evaluate everything until you're damned sure you're right.  This is a pretty important concept in medicine, but it's vitally important in surgery when the difference between "pretty sure" and "positive" is a major operation. 

Which leads me to one conclusion: What the hell was my chairman thinking?

Monday, 16 May 2016

Miracle worker

Let's get one thing straight at the beginning here: I AM NOT A MIRACLE WORKER.  I know I like to extol my own virtues and give myself virtual pats on the back every once in a while because it's
nearly the only validation I ever get, but I can not work miracles, despite what this t-shirt says.  Don't get me wrong, I do try on a regular basis.  But invariably I fail.  I suppose I would make a pretty terrible religious icon.

Despite this admitted fact, people still expect me to perform miracles on a regular basis despite my protests.  Two recent cases highlight this rather well.

I was asked to see Mathilda (not her real name™), a very pleasant and sharp almost-90-year-old who had an abnormal finding on a CT scan of her abdomen.  She had been admitted to hospital with weakness and vague abdominal pain, and the CT scan showed that a bomb had gone off inside her.  Well not really, but that's what it looked like.  She had a large collection of fluid and air adjacent to her caecum (the first portion of her colon in the right lower quadrant of the abdomen), and this collection had invaded the abdominal wall.  I took one look and swore under my breath.

Perforated colon cancer.  Shit.

I wasn't 100% sure of the diagnosis, but I'm also not 100% sure that Donald Trump isn't an alien comedian and secretly amused that millions of people are actually supporting his presidential bid.  But my sureness in both is pretty damned close.  Despite the horridness of the scan, Mathilda looked and felt surprisingly good.  When I examined her, she had minimal tenderness over the area in question, and she wasn't systemically sick.  In fact, she felt pretty darned good (her words).  I told her what my suspicions were, how we were going to have to confirm it (colonoscopy and biopsy), and that she would most likely require a very large surgery to remove the affected colon, perform an ileostomy, and clean up and completely reconstruct her abdominal wall.  Her face remained impassively pleasant during my explanation, and she listened dutifully and quietly to everything I had to say.  I've seen that look before, and I know exactly what it means.  As soon as I finished she smiled and failed to surprise me.

"Listen Doc, I'm almost 90-years old.  I've had a good life.  A really good life.  I feel fine, I know what's going to happen, and I don't want any surgery."

I explained very carefully, though without pushing, what the inevitable outcome would be without surgery.  She would most assuredly die, possibly unpleasantly.  Some surgeons would probably try harder to talk her into surgery, but not me.  My job was to explain not only the diagnosis and the details of surgery, but also the ramifications of not doing surgery.  Once I did that and was absolutely certain she understood, she remained polite but firm - no surgery.  "We all have to die someday, Doc," she explained with another kind smile.  I smiled back, thanked her, shook her hand warmly, and left, making sure to document the entire conversation in her chart.

I got a phone call the following day from her GP, who asked me when the surgery was going to be.  My groan was not meant to be audible, but I'm fairly certain it was.  Apparently someone didn't bother reading my detailed (and admittedly excellent) note I had written in her chart the previous day.  When I explained exactly why there would be no surgery, the GP got very upset with me.  "WHAT?  Doesn't she know she'll die?  Didn't you try to talk her into it?"

"Yes she does, and no I didn't", I explained slowly.  Mathilda had made it very clear that she didn't want surgery.  She also made it clear why she didn't want surgery.  Why in the world would I try to convince a very nice (and very old) woman to undergo a procedure that she doesn't want, especially a huge one that would leave her with an ileostomy?

I wouldn't.  I didn't.  There have been times when I have tried (successfully) to convince someone with an immediately life-threatening problem to have surgery, but Mathilda was different.  She was very old, she felt well, and she wasn't actively dying.  Touching Mathilda with a scalpel would have been not only malpractice, but assault with a deadly weapon and possibly attempted murder.  Not to mention unethical, and therefore wrong.

The GP seemed to get the message at that point. Unfortunately it got worse.

Two days later (really) I was asked to see Helene (not her real name™), a woman in her 50s with severe progressive multiple sclerosis who had been bedbound for over 10 years.  In addition to being severely contracted, she was nonverbal, unresponsive, completely dependent on others for all her care, and just stopped eating several days prior.  She was sent to the hospital by her nursing home to get a feeding tube placed.  A gastroenterologist had attempted to insert a PEG for tube feeding, but due to anatomic difficulties he had been unable to.  She was therefore referred to me for a surgical gastrostomy.  Through her decline over the previous several weeks, no one had sat down with Helene's mother and spoken candidly about her condition.

So I did.

Over the next 45 minutes I learnt that her mother had been her primary caregiver over her entire life.  She had watched Helene, her only child, progressively deteriorate over time.  She knew exactly how sick Helene was, she knew that she was in a state of decline, and she knew that nature would take its course at some point, probably sooner rather than later.  And she was, however difficult it may be, ready for that eventuality.  In addition to all that, I also learnt that she hadn't really wanted the feeding tube for Helene in the first place, but her GP had talked her into it.

Sound familiar?

Now that that procedure had failed, Helene's mother explained quite convincingly and in no uncertain terms that she didn't want invasive surgery.  Helene had been able to eat about 50% of her lunch the previous day, though it took a lot of time and effort.  I discussed her options, the best ones being A) continuing to try to feed Helene orally, and B) hospice.  But again, I did not try to talk her into it.  She thanked me for being the first one to sit and talk to her like a person.

Later that day as I was rounding I ran into the internist in the hospital who was caring for Helene, and just like with the previous patient, he asked when the surgery would be.  I again found myself explaining that (and why) no surgery would be done.  Discussion, conclusion, done.  Right?

If that were the case, I wouldn't be writing about it here.

The following day I was glancing through her chart to see how much she had eaten when I saw this little passage written by the gastroenterologist:
"Recommend second surgical opinion.  Patient is not eating well and is malnourished."
Wait, wait, wait . . . what??  

"No surgery" wasn't my opinion, it was the patient's mother saying she didn't want it!  What was the second opinion supposed to say?  "Doc Bastard was wrong because the patient's mother should be forced to do something she doesn't want for her daughter who is circling the drain and passively dying"?  Looking through her chart further, I saw that one of my colleagues had already seen her as the second surgical opinion.  I'm paraphrasing slightly, but the gist of his opinion was "Doc is right, so leave her the fuck alone."

This may sound strange coming from a surgeon (though hopefully it doesn't), but not everyone needs surgery, even if it means they will die without it.  Though it may seem on its surface hypocritical coming from a guy who readily admitted that he's talked someone into surgery who initially didn't want it, but hopefully you can see the great chasm of difference between the cases.  Neither Mathilda nor Helene could have been reasonable helped by anything I could do.  Only a miracle could have helped them.

And I am not a miracle worker.

Postscript: Mathilda refused all surgery and walked out of the hospital a few days later to spend whatever time she has left with her family.  Helene's mother met with the palliative care doctor, and she ultimately decided to pursue hospice care.  

Monday, 9 May 2016

Nurses

I've said it before but it bears repeating: nurses are among the best people on the planet who deserve our utmost respect.  The only profession I see as deserving just slightly more esteem is teachers, who are responsible for bringing up our children from age 3-18 (or so).  Many children have more contact with their teachers during this time of their lives than with their parents.  In 2016 the folks in both professions are still predominantly women.  I don't say that to be sexist, it is simply factual and it leads directly into the point of this post.  As usual, I do have one.

Which leads me to Halloween.

Wait wait, Halloween?  That's quite a leap.  What the hell are you smoking, Doc?

Stay with me.  It'll all connect up, though you will be angry about it by the end.  At least I hope you are, otherwise I will not have done my job properly.  Trust me, just like in "The Usual Suspects", it will all line up by the time we're finished.  And for the record, no I am not Keyser Söze.

As I was saying, Halloween.  Ah, Halloween, that wonderful time of year when children dress up as Elsa from Frozen and witches and Yoda and ghosts and Elsa from Frozen and Chewbacca and Elsa from Frozen and princesses and ninjas and Elsa from Frozen and Yoda and Elsa from Frozen.  But it isn't only children that dress up - adults do their best to wear garments that they would otherwise have no excuse to wear.  Some people, for example, seem to think that any profession can be made "sexy".  Witness Yandy.com, a website that has an entire section dedicated to sexy costumes.  FORTY FOUR PAGES of sexy costumes.  There are some, like Wonder Woman, who was sexy to start with:
Other than the high heels, I have no problem with this (she wore boots, Yandy).  But they also have sexualised other characters like Captain America (really?), Tinkerbell (really?), and Elsa from Frozen (REALLY??!):


But then they have other costumes that make one think, "What the fuck were they thinking?  How is a crayon or Mr. Peanut or an M&M or Sully from "Monsters Inc" sexy?"
But then they get to the one that I knew would be there and finally (as the title strongly suggested) gets to the damned point of this stupid post (FINALLY!) - the sexy nurse.
Lest you think I exaggerate, there are 158 different "sexy nurse" costumes on that site alone.  ONE HUNDRED FIFTY EIGHT.  Now I've worked in many different hospitals in many cities at all times of the day, and I've never seen a nurse dressed like that.

Before anyone starts to rebel and revolt and leave comments about how stupid I am and how I'm totally overreacting, I fully understand what you're thinking.  At this very moment I can hear several people moaning and complaining, "Everyone knows nurses don't actually dress like that!  I mean, they sell a sexy Ebola costume too! {yes, really}.  But it's just Halloween, Doc!  It's just a costume!  Don't be such a stick-in-the-mud!  It's just harmless fun, Doc!"   I hear you.  I've heard the arguments before, and I've contemplated this issue for years.
But that's just the thing - it isn't just harmless fun.  Trust me, I understand the "nurse fantasy" very well.  When I had my appendix removed in college, I readily admit I fantasised about a hot nurse coming in to check me out.  You know . . . check me out, wink wink, nudge nudge.  But that never happened for one very important reason: because just like doctors, nurses are professionals.  

Nurses don't deserve to have their occupation demeaned degraded and sexualised so they look much more like prostitutes than professional healthcare workers.  These women and men do nothing but take care of patients (in between bouts of pounding on the computer trying to get it to work).  Every day they come in, they take care you people no matter how rude or dirty or stinky, they go home, and then the next day they do it all over again.

But just in case you still think I'm overreacting, hopefully THIS will change your mind:
On the off chance you can't see the picture well, that is a 5 or 6-year-old girl wearing a nurse costume, complete with pockets strategically placed over the breasts, a fake tapered waistline, and fake cleavage.  FAKE CLEAVAGE.  And what makes it worse (as if that were even possible) is the name of the costume: "Sexy Nurse Toddler T-Shirt".  And who it was made for?  Two to six year-olds.  This was on sale at Amazon.com until it was rightly taken down recently.

As a doctor, I was outraged.  As a father, I am horrified and disgusted on many levels: 1) Someone out there thought it would be a good idea to make a costume that sexualises both nurses and children, 2) someone else then heard that thoroughly revolting idea and thought "Yes, I'll make this for you", 3) someone at Amazon then said, "Yes, we'll sell this item", and then 4) someone else (god only knows how many) thought, "Yes, I'll buy this for my little girl."  And at no time during this process did anyone ever say, "Wait . . . what the fuck are we doing here?"

What the hell is wrong with these people?  What is . . . wait, no.  I can't even finish that sentence or this paragraph because my ire has risen above the level of my eyebrows and is preventing me from seeing the keyboard properly.

Though Amazon removed this particular item in response to complaints, a 0.273 second Google search found several other "sexy nurse" toddler T-shirts that are still for sale.  Do little girls not have enough to contend with growing up these days without utter garbage like this adding onto the pile?  What in hell are we teaching them with this shit?

Is this just all in my head and a gross overreaction?  Mrs. Bastard doesn't seem to think so, and she has a much better head on her shoulders than I do (as you all have seen).  I fully welcome opposing views.  Someone here please tell me I'm wrong.

Tuesday, 3 May 2016

124 papers that DO NOT prove vaccines cause autism

It seems like all I use Twitter for these days is arguing with antivaxxers.  And occasionally flat earthers . . . no, seriously.  Unlike "effective homeopathy", they exist.  That's not at all why I started tweeting - in fact, I created my account solely for the purpose of shamelessly advertising this stupid blog which you good people are valiantly reading.  But alas, I discovered very quickly that Twitter is a wretched hive of scum and villainy like nowhere else in the universe (as far as we know).  Antivaxxers are not only present but also obnoxiously vocal, spreading various lies, half-truths, misinformation, and malinformation.  They make the same tired (read: wrong) arguments repeatedly, never seeming to learn from the many mistakes they make:
And there it is.  It nearly always comes down to that link (unless they give up and throw it out at the outset).  I've mentioned this particular Gish Gallop in passing (it was formerly 99 papers but has now been rounded out to a nice even 124), but I've never really attacked it head on.  This list of papers was compiled by rabid antivaccine lunatic Ginger Taylor, and Liz Ditz previously produced a nice compilation of refutations of many of them.  And The Logic of Science blog just wrote a very comprehensive and well-written summary of the supposed evidence against vaccines which addresses several of them as well.

However none of them goes over each of the 124 papers individually.  Moreover I've been feeling increasingly uneasy lately about using other folks' blog posts to shoot down this "proof".  To that end I've decided to do my own.  I'm not saying that the others aren't good enough, it's just that I'm apparently a masochist and enjoy wasting my time by reading irrelevant and/or nonsensical papers for hours at a time.  Or something.  As you've probably guessed, I've now read every . . . single . . . one of these 124 papers and will address any and all concerns I found relevant.  Despite the fact that many of Ginger's links were broken, the titles here are all clickable and go to the original abstract (or the full paper for some of them).

If you'd like the short short version, click here:

WARNING:
This post will be long, painful, difficult to get through, heavily laden with citations, and most likely fruitless.  I'm doing it anyway because I'm tired, I'm grouchy, and it's either this or help my son take apart and put back together the Lego jet for the 23rd time.

*sigh*

And here we go.

Thimerosal has been removed from all childhood vaccines in most countries since 2001, yet autism rates continue to rise.  It is only present in certain multi-dose influenza vaccines.  Plus, Taylor et al performed a meta-analysis that included over 1.2 million children that found no relationship between vaccination and autism or ASD, no relationship between MMR and autism or ASD, no relationship between thimerosal and autism or ASD, and no relationship between mercury and autism or ASD.  There was also a study done in California that tracked autism rates after thimerosal was removed, and it confirmed the same result - thimerosal does not cause autism.

I'll repeat for those too slow to get it the first time: THIMEROSAL DOES NOT CAUSE AUTISM.

This is a recurring theme, as you will see.

2) Hepatitis B vaccination of male neonates and autism diagnosis, NHIS 1997-2002.
This is a study of 31 children with autism.  *31*.  And the "study" relied on parental reports of their children's autism.  Really?  REALLY?  Drawing any kind of conclusion over a paper with such a small subset of subjects and that relies on parental reports (rather than doctors' diagnoses) is ludicrous.

3) Gender-selective toxicity of thimerosal.
Thimerosal again?  Nope.

4) Mercury toxicokinetics--dependency on strain and gender.
Curiously this one starts with "Mercury (Hg) exposure from dental amalgam fillings and thimerosal in vaccines is not a major health hazard".  I suppose they missed that little gem.  Anyway, it's mercury again, so . . . nope.

5) A Review of the Differences in Developmental, Psychiatric, and Medical Endophenotypes Between Males and Females with Autism Spectrum Disorder
A very curious entry.  First, the word "vaccine" appears exactly nowhere in this review.  Second, the article highlights how autism/ASD is much more common (four times more common, in fact) in boys.  Since boys are not vaccinated four times more often than girls, this would point to a genetic origin and away from environmental triggers.  I'd probably take this one off if I were Ginger (which, fortunately I am not).

6) Do aluminum vaccine adjuvants contribute to the rising prevalence of autism?
The Tomljenovic and Shaw paper always comes up.  They not only abuse statistics but also use misdirection and multiple leaps to conclusions by impling that aluminum causes inflammation, people with autism have signs of increased inflammation, and therefore aluminum may cause autism.  They found a correlation, but there is no causation to be found.

7) Administration of aluminium to neonatal mice in vaccine-relevant amounts is associated with adverse long term neurological outcomes
Tomljenovic and Shaw again, this time basing a paper on the ecological study #6 above, which as we know is incredibly weak.  Anyway, this is a study on mice given "high" or "low" doses of subcutaneous aluminum.  They exhibit some vague differences on certain mice tests.  Does this translate to humans?  Hardly.

8) Aluminum-Induced Entropy in Biological Systems: Implications for Neurological Disease
Hey look, it's Tomljenovic and Shaw again!  This time it's a review of just how bad aluminum is for us.  They list all the ways we are exposed to aluminum (food, water, medicine, vaccines, occupational exposure, etc) and this is bad, they say.  What they don't say is that the amount of aluminum in one vaccine is about the same as in 1 liter of infant formula (unless it's soy-based formula, which has 3x the amount).  People are exposed to orders of magnitude more aluminum in food, water, and air (no, not chemtrails) than in vaccines.

9) A comparison of temporal trends in United States autism prevalence to trends in suspected environmental factors
This is a purely speculative article that lists 10 environmental toxins (everything from glyphosate to aluminum adjuvants to car exhaust) and how children's exposure has correlated with their use.  There is no causation even implied here, and the article ends with "Environmental factors with increasing temporal trends can help suggest hypotheses for drivers of autism that merit further investigation."  It doesn't even suggest the hypothesis that aluminum vaccine adjuvants may be causing the increase in autism, it is merely the suggestion of a suggestion.

10) Autism: A form of lead and mercury toxicity
I don't know where to start with this one.  This paper suggests, no it flat out states that lead and mercury cause autism, and they know this because they are two of the most common heavy metals and because autism can be treated with chelation.  First of all, what?  And second of all, WHAT??  Ok now seriously, elemental mercury is not and has not ever been in vaccines and neither has lead, and as we know there is no thimerosal in childhood vaccines.  And there is no evidence that chelation can do jack shit for people with autism.  You think mercury and/or lead cause autism?  Great, first go prove it, and second go fix it, because neither has anything to do with vaccines.

11) Toxic Metals and Essential Elements in Hair and Severity of Symptoms among Children with Autism
Another curious paper.  This one found that autistic children (only 44 of them were analysed) had higher levels of aluminum, arsenic, cadmium, mercury, antimony, nickel, lead, and vanadium in their hair.  What does this have to do with vaccines?  Nothing.  If they were intimating that it was aluminum from vaccines, 1) we know we get much more aluminum elsewhere than from vaccines, and 2) prove it's not vanadium first.  Or cadmium.  Or is it antimony?  Which is it?  Go ahead, I'll wait.

12) Assessment of Infantile Mineral Imbalances in Autism Spectrum Disorders
This is another paper documenting elevated levels of various metals (including aluminum (of course), cadmium, lead, mercury, and arsenic) in autistic children's hair as well as lower levels of zinc and magnesium.  They postulate that one or more of these high or low levels of something may be doing something to some genes that causes autism.  It's a plausible hypothesis, but that's all it is: a hypothesis.

13) Abnormal measles-mumps-rubella antibodies and CNS autoimmunity in children with autism
This is one of the more controversial papers on this list for several reasons.  It has been charged that 1) the laboratory test that author Vijendra Singh used to detect these abnormal antibodies didn't actually detect them, 2) he used "unsubstantiated and un-validated biochemical techniques", and 3) his work has never been replicated.  In fact several other trials have directly refuted his findings.

14) Infection, vaccines and other environmental triggers of autoimmunity
Yet another curious addition since the word "autism" is found nowhere in the abstract.  What does appear are the words "MMR vaccination" and "autoimmunity".  Ginger seems to make a giant leap from this to autism.  However autoimmune diseases are much more common in females, and autism is more common in males.  I'd love to hear Ginger explain that one.

15) Impact of environmental factors on the prevalence of autistic disorder after 1979
I'll forgive Ginger's broken link (the first of many) because I managed to find the article with a 0.113-second Google search.  This is what I imagine will be the first article by Theresa Deisher, a fundamentalist Chrisitan with a PhD in molecular and cellular physiology who tries desperately to say that aborted fetal DNA is responsible for autism.  No, seriously - according to Theresa it isn't thimerosal, aluminum, heavy metals or autoimmunity - it's aborted fetal DNA.  Honestly, I wish they would make up their minds.  Anyway, Theresa doesn't even waver about it: "rising autistic disorder prevalence is directly related to vaccines manufactured utilizing human fetal cells" she says.  Perhaps, but there is a reason why we constantly say that correlation doesn't equal causation since the rise in autism is also strongly correlated to organic food sales:

Does this mean organic food causes autism?  Of course not.  Moreover it is a highly implausible and improbable theory as it would require 1) any tiny amount of DNA present in vaccines to 2) just happen to make it into the the nucleus of enough neurons in the brain to make a difference, 3) actually recombine with the native DNA, 4) just happen to be useful aborted fetal DNA that produces some protein that 5) just happens to be expressed on the cell surface and that 6) just happens to be identified as "foreign" and that 7) just happens to cause an immune reaction that would 8) somehow cause autism, and 9) it would have to do this in all children with autism.  Does this sound like a likely scenario?  It sounds more like a fundamentalist desperate for fetal DNA to be evil.

16) A positive association found between autism prevalence and childhood vaccination uptake across the U.S. population
Curiously the author has a PhD not in any scientific field, but in finance.  Hm.  At the time this was published she also happened to be on the board of SAFEMINDS, a rabidly anti-vaccine group that is convinced vaccines cause autism.  Hmm.  She also happens to be the mother of two autistic girls.  Hmmmmmmm.  Lest you think that I'm just shooting the messenger (though we've seen with mechanical engineer Brian Hooker that non-vaccine-scientists probably shouldn't being doing vaccine research), the dataset she uses is unreliable, and she lumps in children with Specific Language Impairment with autistic children to inflate the results.  Bad science.  Bad, bad science.

17) Neonatal administration of a vaccine preservative, thimerosal, produces lasting impairment of nociception and apparent activation of opioid system in rats
Fascinating.  But there is no thimerosal in childhood vaccines.

18) Transcriptomic analyses of neurotoxic effects in mouse brain after intermittent neonatal administration of thimerosal
Again, no thimerosal in childhood vaccines.

19) Lasting neuropathological changes in rat brain after intermittent neonatal administration of thimerosal
That's three irrelevant papers in a row.  Care to make it 4?

20) Persistent behavioral impairments and alterations of brain dopamine system after early postnatal administration of thimerosal in rats
I guess that's a yes.  Do I hear 5?

21) B-lymphocytes from a population of children with autism spectrum disorder and their unaffected siblings exhibit hypersensitivity to thimerosal
This is getting old

22) Thimerosal-Derived Ethylmercury Is a Mitochondrial Toxin in Human Astrocytes: Possible Role of Fenton Chemistry in the Oxidation and Breakage of mtDNA
*sigh*

23) Thioredoxin: a novel, independent diagnosis marker in children with autism
Finally, something not thimerosal-related.  This paper is about a redox-regulating protein which is a marker for oxidative stress and which correlates with autism.  What does this have to do with vaccines?  Absolutely nothing.  Perhaps they got confused and saw "thioredoxin" as "thimerosal".  But this is the first in a series of papers that tries to correlate oxidative stress with autism.

24) Inhibition of the human thioredoxin system. A molecular mechanism of mercury toxicity
Wow, mercury and thioredoxin at the same time.  Again, this has nothing to do with vaccines.

25) Effects of selenite and chelating agents on mammalian thioredoxin reductase inhibited by mercury: implications for treatment of mercury poisoning
Uh, well.  Hm.  Another one that has no involvement with vaccines.  It's like they're not even trying.

26) Serological association of measles virus and human herpesvirus-6 with brain autoantibodies in autism
This is another study by Vijendra Singh (see paper #13) which has not been replicated.  They found that anti-measles IgG and anti-HHV6 IgG levels were the same in autistic children as in normal children, but that the majority those who were positive for either were also positive for two brain anto-antibodies.  Two problems - first, levels of these antibodies were statistically the same in autistic and normal children.  Second, the presence of IgG means either prior exposure or immunity, so this study made no effort to differentiate vaccinated children versus not.  In other words, it has nothing to do with vaccines and proves exactly nothing.  I'm sensing a trend here.

27) Metabolic biomarkers of increased oxidative stress and impaired methylation capacity in children with autism
On the surface this paper has nothing to do with vaccines, until you dig a little deeper into the assumed reason it's included.  Essentially autistic children (20 subjects) were found to have impaired methylation and higher oxidative stress than controls (33 subjects).  The implication here (I think) is that these children were incapable of handling environmental insults and thus "primed" for developing autism due to some insult, and vaccines were that insult.  However, this has not been proved, and as Taylor showed with their study of 1.2 million children, vaccination is not associated with autism.  Any "oxidative stress" that they purport isn't from vaccines.

28) Porphyrinuria in childhood autistic disorder: Implications for environmental toxicity
Another article regarding "environmental toxicity" without mentioning vaccines explicitly.  In this one, urine porphyrin is used as a surrogate for serum mercury, as levels are supposedly increased in people with impaired mercury metabolism, so levels are supposed to correlate with mercury exposure.  Seeing the problem here?  Right, no mercury in childhood vaccines.  Father-and-son team Geier and Geier (another series of papers antivaxxers like to bring up) seem to be hooked on this hypothesis as well, so I will be entirely unsurprised if I find their papers on this list.  Next!

29) An investigation of porphyrinuria in Australian children with autism
This is the same as #28, except looking at Australian children.  They found consistent elevated porphyrin in autistic children and implicate mercury as possibly causative.  Great - so go after mercury, because childhood vaccines don't have any.

30) Porphyrinuria in Korean children with autism: correlation with oxidative stress
A Korean study which confirms #28 and #29.  While is's nice to replicate prior studies, it is worthless in this discussion.

31) Uncoupling of ATP-Mediated Calcium Signaling and Dysregulated Interleukin-6 Secretion in Dendritic Cells by Nanomolar Thimerosal
Ugh, I thought we were done with Thimerosal.  Next.

32) Myeloid dendritic cells frequencies are increased in children with autism spectrum disorder and associated with amygdala volume and repetitive behaviors
The authors say that the immune system is dysfunctional in autism.  Fascinating.  Vaccines are not mentioned.

33) Comparison of blood and brain mercury levels in infant monkeys exposed to methylmercury or vaccines containing thimerosal
Another broken link, another thimerosal/mercury paper.  Next.

34) The retention time of inorganic mercury in the brain — A systematic review of the evidence
This has even less to do with vaccines than Ginger probably realises.  I almost laughed as I read this.  Inorganic mercury is extremely toxic, that is undisputed.  However thimerosal (ethylmercury) is an organic mercury compound, it is rapidly metabolised, and it is rapidly excreted.  That is a long-winded way of saying "Nothing at all to do with vaccines, not even a little bit".

35) Brain and tissue levels of mercury after chronic methylmercury exposure in the monkey
What?  What?  Even if thimerosal were in vaccines (which it isn't), that's ethylmercury, not methylmercury.  Methylmercury is different than ethylmercury, and not just because it has an "M" at the beginning.  That's like saying methanol and ethanol are the same thing because they sound almost the same, because they pointedly are not.

36) Increases in the number of reactive glia in the visual cortex of Macaca fascicularis following subclinical long-term methyl mercury exposure
That's two methylmercury stupidities in a row.  I think I just lost a few brain cells.

37) Neuroglial activation and neuroinflammation in the brain of patients with autism
This paper suggests that some proportion of autistic patients (not all of them, mind you) have neuroinflammatory reactions.  They couldn't estimate the proportion because they only examined 11 patients.  Regardless, vaccines are again not mentioned nor even suggested.

38) Transcriptome analysis reveals dysregulation of innate immune response genes and neuronal activity-dependent genes in autism
This is a summary of various genes and pathways which may be implicated in autism.  It's an interesting paper, but anything to do with vaccines?   Not at all.

39) Nanomolar aluminum induces pro-inflammatory and pro-apoptotic gene expression in human brain cells in primary culture
Now we move down the list from mercury to aluminum, because if it isn't one thing in vaccines, it has to be something else.  Aluminum sulfate was found to be harmful to brain cells.  And aluminum adjuvants are in vaccines, so that's scary, right?  No, the aluminum in vaccines is aluminum potassium sulfate (aka alum), not aluminum sulfate.  And alum has been found to be safe over its 70-year use.  This bears repeating for Ginger's (and everyone else's) sake: just because two compounds sound similar, it does not mean they are the same thing or have the same effects on human physiology.

40) Aberrant NF-KappaB Expression in Autism Spectrum Condition: A Mechanism for Neuroinflammation
This article describes the molecular mechanism of neuroinflammation that was discussed in paper #37.  A protein called (NF-κB) was found to be aberrantly expressed in the brain of autistic people.  Again, vaccines are not mentioned and not involved.

41) A Study of Nuclear Transcription Factor-Kappa B in Childhood Autism
An interesting study confirming paper #40.  They found increased NF-κB DNA binding in the blood of autistic children.  Fascinating, but unrelated to vaccines.

42) Autism: A Brain Disorder, or a Disorder That Affects The Brain?
This is not a research paper but a review which does not say or suggest that vaccines cause autism.  I had a feeling the author Martha Herbert (a paediatric neurologist) would show up here at some point.  A Massachusetts superior court judge had this to say about her:
"Dr. Herbert’s method is not generally accepted in the scientific community.  Dr. Herbert’s theory of environmental triggers of autism may some day prove true.  It has not yet.  Her proffered testimony does not meet the standard of reliability required by the case law, and cannot be admitted in evidence at trial." 
Ouch.  I will mention that Herbert essentially says that many things can contribute to autism, including oxidative stress, neuroinflammation, and mitochondrial dysfunction, yet she offers no new evidence. 

43) Activation of methionine synthase by insulin-like growth factor-1 and dopamine: a target for neurodevelopmental toxins and thimerosal
Thimerosal again?  Come on, Ginger.  At least pretend to list these in some semblance of organisation.

44) Validation of the Phenomenon of Autistic Regression Using Home Videotapes
Autistic regression exists.  I'm not sure who is denying that, but I certainly am not.  Vaccines are not mentioned, and rightfully so.

45) Blood Levels of Mercury Are Related to Diagnosis of Autism: A Reanalysis of an Important Data Set
Mercury.  Next.

46) Empirical Data Confirm Autism Symptoms Related to Aluminum and Acetaminophen Exposure
I admit that when I first read the title of this one I got a bit nervous.  It certainly sounds convincing, right?  Then I actually looked at it, and before the abstract even came up there was a warning from the editors about potential bias in the authors' opinions and choice of citations in their literature review.  Uh oh - BIG RED FLAG.  And if that weren't bad enough, this paper investigates "word frequency patterns" in the Vaccine Adverse Event Reporting System (VAERS).  HAHAHAHA no, seriously.  In case you don't know, VAERS is a repository of any and every adverse event that is reported after vaccines are given.  Anyone can file a report, and some of them are downright risible (see this collection of deaths by car accident, drowning, suffocation, and even AIDS reported to VAERS).  I can't take this paper seriously.

47) Glutathione-Related Factors and Oxidative Stress in Autism, A Review
Another one about oxidative stress.  Nothing to see about vaccines here, please move on.

48) Developmental Regression and Mitochondrial Dysfunction in a Child With Autism
This is the famous Hannah Poling case.  The first author of this paper is her father Jon, an MD PhD neurologist at Johns Hopkins.  Those are indeed impressive credentials.  His daughter Hannah regressed after receiving a series of several vaccines and being diagnosed with encephalopathy due to a rare mitochondrial enzyme deficiency.  Her parents sued the Vaccine Court and won.  Is this a smoking gun?  No, not really, though it is definitely a sad case (mitochondrial enzyme deficiencies are quite rare).  Dr. Paul Offitt, a world-renowned expert (and thoroughly reviled shill according to antivaxxers) explains why this isn't the smoking gun antivaxxers want it to be.

49) Oxidative Stress in Autism: Elevated Cerebellar 3-nitrotyrosine Levels
Another broken link.  How annoying.  Another paper about oxidative stress that has nothing to do with vaccines; even more annoying.

50) Large brains in autism: the challenge of pervasive abnormality
I have no idea why this paper is included here, except perhaps that in includes the words "neuroinflammation" and "heavy metals".

51) Evidence of toxicity, oxidative stress, and neuronal insult in autism
Oxidative stress.  Yawn.

52) Oxidative stress in autism
Two in a row.

53) Thimerosal neurotoxicity is associated with glutathione depletion: protection with glutathione precursors 
Back to thimerosal again?

54) Toxic Metals and Oxidative Stress Part I: Mechanisms Involved in Metal induced Oxidative Damage
Oxidative stress again?

55) Aluminum adjuvant linked to Gulf War illness induces motor neuron death in mice
Well this is interesting.  A small study that was never replicated, has nothing to do with autism, and was done on mice.  How very not at all fascinating.

56) Enrichment of Elevated Plasma F2t-Isoprostane Levels in Individuals with Autism Who Are Stratified by Presence of Gastrointestinal Dysfunction
The researchers found that children with more severe autism symptoms have higher levels of a certain marker of oxidative stress.  Interesting!  But wait . . . how does this prove vaccines did anything?  Oh right, it doesn't.

57) Reduced levels of mercury in first baby haircuts of autistic children
Mercury.  Next.

58) A case series of children with apparent mercury toxic encephalopathies manifesting with clinical symptoms of regressive autistic disorders
Mercury again.  Moving on.

59) The Changing Prevalence of Autism in California
This is a commentary, not a scientific paper, by Mark Blaxill, an antivax lunatic who has vehemently defended Andrew Wakefield's fraudulent study which started this whole thing.  In his commentary he claims that diagnostic substitution cannot explain at least part of the increase in autism prevalence despite evidence to the contrary.  Proof?  No.

60) Mitochondrial Energy-Deficient Endophenotype in Autism
I'm kinda getting tired of the broken links.  Regardless, this paper does not mention vaccines.

61) Bridging from Cells to Cognition in Autism Pathophysiology: Biological Pathways to Defective Brain Function and Plasticity
Uh oh, two of the authors are Brian Hooker (yes, that Brian Hooker who thoroughly abused statistics in a retracted paper that didn't actually indicate that vaccines increase risk of autism in black boys and has led to the whole #CDCWhistleblower nonsense) and Martha Herbert, whom we met in #42.  Leaving that aside, this is another speculative paper that concludes that "overzealous neuroinflammation" can lead to autism.  Interesting hypothesis, but it still doesn't lend any support to the idea that vaccines cause autism.

62) Heavy-Metal Toxicity—With Emphasis on Mercury
Mercury.  Nope.

63) Evidence of Mitochondrial Dysfunction in Autism and Implications for Treatment
This article speculates that some environmental toxin causes damage to mitochondria, and this may cause autism.  The author lists those potential toxins (valproic acid, thalidomide, rubella, cytomegalovirus, pesticides, polychlorinated biphenyls (PCBs), industrial chemicals, mercury, lead, cadmium, nickel, and tin), but curiously vaccines are not on the list.  So why is it on this list?  I can only guess, but then I'd be delving into the abyss that is Ginger Taylor's addled brain.  No thanks.

64) Proximity to point sources of environmental mercury release as a predictor of autism prevalence
Mercury.

65) Epidemiology of autism spectrum disorder in Portugal:prevalence, clinical characterization, and medical conditions
Vaccines are not discussed, but the buzzwords "mitochondrial disorders" did.  Unrelated.

66) Thimerosal induces neuronal cell apoptosis by causing cytochrome c and apoptosis-inducing factor release from mitochondria
Thimerosal.  Nope.

67) Mitochondrial mediated thimerosal-induced apoptosis in a human neuroblastoma cell line (SK-N-SH)
Thimerosal again.  Nope again.

68) Possible immunological disorders in autism: concomitant autoimmunity and immune tolerance
I admit I laughed out loud here.  The title isn't overtly funny and it certainly sounds damning (See right there?  AUTOIMMUNITY!) , but the findings are downright hilarious.  In her efforts to prove vaccines cause autism, Ginger linked a study which found lower rates of anti-MMR antibodies in autistic children than in control children.  That made me laugh.  But what made me laugh even harder is the finding that autistic children have a higher rate of anti-casein and anti-gluten antibodies than controls.  This was the first paper I had seen linking dairy and gluten to autism.  So it isn't mercury or aluminum or whatever, now it's milk and bread!  But despite the unintended comedy ("GRILLED CHEESE SANDWICHES CAUSE AUTISM!"), it firmly points away from vaccines causing autism.  Nice one, Ginger.

69) Pediatric Vaccines Influence Primate Behavior, and Amygdala Growth and Opioid Ligand Binding
If I was laughing at #68, I was rolling on the floor after reading this one.  This was a pilot study which showed (in its preliminary data) that macaques given childhood vaccines showed some neurodevelopmental deficits.  The followup 5-year comprehensive study, which was funded by Safeminds (another rabidly antivax group) was published in 2015, showed no differences in macaques given the full infant vaccine schedule with and without thimerosal versus controls who were given saline injections.  I'll repeat for those antivaxxers too slow to understand: the full infant vaccine schedule was given, the monkeys were followed for 5 years, and there was no evidence of any neurobehavioural differences.  Feel free to use that reference (http://www.ncbi.nlm.nih.gov/pubmed/25690930) with any antivaxxer that tries to claim "BUT THE VACCINE SCHEDULE HASN'T BEEN TESTED!"  Safeminds was, as expected, not happy that their money went to fund a study that refuted their own pre-determined conclusion.

70) Thimerosal exposure in infants and neurodevelopmental disorders: an assessment of computerized medical records in the Vaccine Safety Datalink
I knew Geier and Geier would show up eventually.  Anyway, thimerosal.

71) Glutathione, oxidative stress and neurodegeneration
Another one about oxidative stress.  You want to prove that causes autism?  Fine, then do it.  But don't throw out words and expect it to stick.

72) Hepatitis B triple series vaccine and developmental disability in US children aged 1–9 years
The investigators used only data prior to 2000 specifically to look at children who were given the HepB vaccine, which at that time contained thimerosal.  Regardless, this isn't even about autism.  They surveyed parents and asked them if their children received early intervention or special education services.  THAT is their "proxy" for autism.  Really?  REALLY?  I realise I could have just said "thimerosal" and ended it, but this was way more satisfying.

73) Induction of metallothionein in mouse cerebellum and cerebrum with low-dose thimerosal injection
Thimerosal.  No.

74) Mercury induces inflammatory mediator releasefrom human mast cells
Mercury.  No.

75) Influence of pediatric vaccines on amygdala growth and opioidligand binding in rhesus macaque infants:A pilot study
This is by the same group which did #69.  Again, this was the pilot study, and the full study thoroughly negated any connection between the full infant vaccine schedule and autism.  I got another good chuckle out of this.

76) Cultured lymphocytes from autistic children and non-autisticsiblings up-regulate heat shock protein RNA inresponse to thimerosal challenge
Thimerosal.  No no no.

77) Sorting out the spinning of autism: heavy metals and the question of incidence
Essentially an opinion paper that concludes that environmental toxins shouldn't be ruled out as a causative factor in autism.  I have no problem with that statement.  It still has nothing to do with vaccines.

78) Urinary porphyrin excretion in neurotypical and autistic children
I thought we finished with the porphyrin discussion 30 papers ago?  Actually it was 48 papers ago.  God damn it this list is long, and I'm only 63% done with it.  What the fuck am I doing here.  Anyway, this is a discussion of mercury exposure.  Next.

79) Mitochondrial dysfunction in autism spectrum disorders: a systematic review and meta-analysis
Ah, finally - a systematic review and meta-analysis!  From Nature, no less!  Finally some meat!  But wait, the conclusion is that mitochondrial dysfunction is associated with autism.  Well that's all fine and dandy, but it is a huge leap in logic assuming vaccines cause or activate mitochondrial dysfunction which is associated with (but doesn't necessarily cause) autism, when no such link exists.  A fine example of putting the cart before the horse.

80) Sensitization effect of thimerosal is mediated in vitro via reactive oxygen species and calcium signaling
Thimerosal.  Someone needs to teach Ginger how to organise.

81) What's going on? The question of time trends in autism
HAHAHA!  No seriously, Mark Blaxill (again) titled this "What's going on?"  I can't even make this stuff up.  Anyway, this "article" merely documents the increase in the incidence of autism, not what's causing it.

82) Vaccines and Autism
This was written by Bernard Rimland, a psychologist (and father of an autistic child) who interestingly was the technical adviser for the movie Rain Man.  Anyway, this is not a scientific study,  rather it is merely a discussion (mainly of the evils of thimerosal).  There is no evidence here, just opinion and interpretation.

83) Theoretical aspects of autism: Causes—A review
When the title of a paper starts with "Theoretical", it probably isn't a good idea to use it as evidence of anything.  Even ignoring that, this is a terribly written piece which uses an insane antivax blog called "ChildHealthSafety" as a reference.  Twice.  At one point the author mentions how autism levels in California continued rising after thimerosal was removed from childhood vaccines (indicating that it isn't thimerosal), then ends the same paragraph with "despite its implication in autism".  What?  Are you even reading what you are writing?  Another gem is this unsubstantiated bit: "A challenge by so many vaccines while the immune system is compromised might contribute to an onset of autism."  No reference, no data, no evidence, just an unproven, uncorroborated hypothesis.  Does the author have any idea how many thousands (possibly millions) of antigens babies are exposed to on a daily basis, crawling on the floor, putting anything and everything in their mouths, smearing poop on the wall . . . orders of magnitude higher than any vaccine.

The author goes on to discuss other unproven or disproved hypotheses, including MMR, mercury, and other metals.  Eventually she hits on genetics, including a study which showed a strong concordance for autism in monozygotic (identical) twins with a much lower concordance for dizygotic (fraternal) twins.  She actually plagiarized word-for-word this sentence: "This suggests that interactions between multiple genes cause "idiopathic" autism but that epigenetic factors and exposure to environmental modifiers may contribute to variable expression of autism-related traits."

Yes, word-for-word.  Like I said, terribly written.  You know, except for the part she stole from another author.

84) Iatrogenic exposure to mercury after hepatitis B vaccination in preterm infants
This one, published in 1999, starts with "Thimerosal, a derivative of mercury, is used as a preservative in hepatitis B vaccines."  No it isn't.  It was in 1999, but that was 17 years ago.  Try to keep up, Ginger.  Next.

85) Infants born late/moderately preterm are at increased risk for a positive autism screen at 2 years of age
Two very small problems here: first, this was based on parent questionnaires, and second and just slightly more importantly IT HAS NOTHING TO DO WITH VACCINES.  Why put this one on the list?  Why?

86) Preterm birth and mortality and morbidity: a population-based quasi-experimental study
Wait, what?  An article that discusses increased risk of death and autism in severely premature infants, one that states that preterm birth is likely causal for both mortality and psychiatric morbidity (ie autism)?  How in the world does this implicate vaccines in any way?  It's the exact opposite of what they're trying to show.  Yet another good guffaw from my new friend Ginger.

87) Ancestry of pink disease (infantile acrodynia) identified as a risk factor for autism spectrum disorders
This one takes several leaps of faith: 1) Pink disease was caused by mercury exposure in the early 20th century, and 2) not every child exposed to mercury developed it, so 3) it is presumed that those children who did develop pink disease had a mercury sensitivity, and 4) it is postulated that mercury causes autism, and 5) mercury exposure is widespread (is it?), and 6) not every child exposed to mercury develops autism, so therefore 7) children who are hypersensitive to mercury may develop autism.  Whew - did you get all that?  Anyway, there's no mercury in vaccines, so this entire endeavor was a waste of my (and your) time.  Sorry about that.

88) Risk factors for autistic regression: results of an ambispective cohort study
Another one that takes a rather large leap of faith. First, vaccines are not mentioned.  However, using multiple logistic regression febrile seizures were found to be associated with autistic regression.  What I'm assuming Ginger means by including this article is that febrile seizures are associated with autism, and vaccines can cause febrile seizures, so vaccines therefore cause autism.  Or something like that.  I found a total of -0- articles which demonstrate a link between febrile seizures and autism, though there are several which refute it.

89) MMR vaccination and febrile seizures: evaluation of susceptible subgroups and long-term prognosis
Uh, Ginger?  Did you read the conclusion of this paper?  Obviously not.  Before I get to that, let's all remember that febrile seizures are common and quite scary, but they are not dangerous.  They are benign and do not increase the risk of seizure disorders.  Now with that out of the way, let me help Ginger with the conclusion of this paper: "CONCLUSIONS: MMR vaccination was associated with a transient increased rate of febrile seizures but the risk difference was small even in high-risk children. The long-term rate of epilepsy was not increased in children who had febrile seizures following vaccination compared with children who had febrile seizures of a different etiology."  Emphasis added for additional oopsies.

90) Common variants associated with general and MMR vaccine-related febrile seizures
This article nicely discusses the genetics of children who are more likely to develop febrile seizures following vaccines.  But even if we didn't learn anything from #89, this paper is irrelevant.

91) Adverse Events following 12 and 18 Month Vaccinations: a Population-Based, Self-Controlled Case Series Analysis
Another curious paper which tries to tie febrile seizures to autism, even though there is no association.  But the statistics are still interesting - several hundred thousand children who were vaccinated were followed up for several days after their 12- and 18-month vaccinations to see if emergency room visits were increased in that time period.  There was one additional ER visit per 168 12-month vaccination, and 1 additional ER visit per 730 18-month vaccination.  There was no increase in severity for these visit compared to ER visits outside the study period and no increase in children admitted to the hospital.  Most of the ER visits were for febrile seizures (SHOCKING) or viral rashes.  There were an additional 20 febrile seizures per 100,000 children vaccinated at 12 months.  For those of you bad at math (GINGER) that's 0.02%.  Oh, and this has nothing to do with autism.

92) Reduced GABAergic Action in the Autistic Brain
I've gone over this paper twice and I still can't figure out why it's here.  The only clue I have is that the word "seizures" is present in the abstract.  Other than that, I have no idea.

93) Administration of Thimerosal to Infant Rats Increases Overflow of Glutamate and Aspartate in the Prefrontal Cortex: Protective Role of Dehydroepiandrosterone Sulfate
Oh good good good, thimerosal in rats.  Good grief.  And here I thought we were done with thimerosal.  And rats.  My mistake, apparently.

94) Neonatal Administration of Thimerosal Causes Persistent Changes in Mu Opioid Receptors in the Rat Brain
Apparently we are done with neither thimerosal nor rats.  Ugh.

95) A Review of Compensated Cases of Vaccine-Induced Brain Injury
This is not a scientific paper.  It was an examination of "vaccine damage" claims paid by the vaccine court which was apparently published in a peer-reviewed law journal.  In it, they really stretch to make the case (ha ha) that because the vaccine court paid the claim, this proves vaccines cause autism.  Er, no.  Just no.  Courts and lawyers and judges don't decide on science, science does that.  In case you don't like my "just no" argument (and because I'm not a lawyer), here is an explanation by someone who IS a lawyer (and licenced to practice before the vaccine court) why that argument is so ridiculous.

96) Integrating experimental (in vitro and in vivo) neurotoxicity studies of low-dose thimerosal relevant to vaccines
Back to thimerosal, I see.

97) Hepatitis B vaccine induces apoptotic death in Hepa1-6 cells
A very curious addition.  The researchers dripped the Hep B vaccine onto mouse liver cancer cells in a petri dish (not human cells, not normal cells, but mouse liver tumour) and found that some of the cells died.  Well isn't that interesting.  Let's see if we can break this down - A) humans aren't mice, B) we aren't mouse livers, C) we aren't mouse liver cancers, D) even if we were mouse liver tumours, vaccines are not injected into the liver, E) so what?  Is this about autism?  Not remotely.

98) Thimerosal Induces Apoptosis in a Neuroblastoma Modelvia the cJun N-Terminal Kinase Pathway
Thimerosal.

99) Maternal thimerosal exposure results in aberrant cerebellar oxidative stress, thyroid hormone metabolism, and motor behavior in rat pups; sex- and strain-dependent effects
Though this is about thimerosal, I'm going to discuss it just to show you the lengths these people will go to prove some kind of link.  In this study, rats were given thimerosal while pregnant and lactating, and the pups were evaluated for motor and auditory function.  How much thimerosal?  200 μg/kg body weight.  That may not seem like a lot, especially considering an adult female Sprague Dawley rat weighs only 300 g.  For those of you bad at math (GINGER) I did it for you, and that's still 60 μg of thimerosal.  Compare that to the 25 μg of thimerosal in a flu shot (though many flu shots are thimerosal-free), which even if given to a small child weighing 10 kg, that's merely 2.5μg/kg, nearly 100X less than the 200 μg/kg given to the rats.  Seeing the ridiculous yet?

Oh yeah, and there's no thimerosal in childhood vaccines.

100) The rise in autism and the role of age at diagnosis
This article chronicles the increasing rate of autism.  They estimate that the changing age of diagnosis explains 12% of the increase, in the inclusion of milder cases 56%.  In other words, over 2/3 of the increase can be explained by how autism is diagnosed.  How are vaccines discussed in this article?  They aren't.

101) Slow CCL2-dependent translocation of biopersistent particles from muscle to brain
Finally some real meat!  A discussion on aluminum potassium sulfate (alum) and how it can persist!  About time we got something I can sink my teeth into.  Ok, let's see.  The researchers injected mice with alum and found that it can persist in distant organs (including the spleen and brain) for at least a year.  Ok, so that means . . . nothing.  Especially when they conclude that "This occurs at a very low rate in normal conditions explaining good overall tolerance of alum despite its strong neurotoxic potential".  It may be increased in an extremely small subset of the population with an anomolous CCL-2 gene.  The research there is ongoing, but the authors essentially say that alum is very well tolerated.  Another case where Ginger and her colleagues didn't understand a word of what they were reading.

102) Thimerosal and autism? A plausible hypothesis that should not be dismissed
The first thing to notice here is that it was published in the journal Medical Hypotheses.  The second is that it is written by Mark Blaxill, whom we met in #59 and #81.  The third is that oh, fuck it.  This isn't research.  Fucking thimerosal, fucking hypothesis, fucking next.

103) Autism Spectrum Disorders in Relation to Distribution of Hazardous Air Pollutants in the San Francisco Bay Area
I have to admit this was a new one for me.  I've seen antivaxxers move the goalposts so many times I've lost count, but apparently now the argument is "AIR POLLUTION!"  I mean, seriously.  Seriously.  Seriously.

104) Environmental mercury release, special education rates, and autism disorder: an ecological study of Texas
This is about environmental released (ie dumped) mercury.  Not vaccines.

105) Autism spectrum disorder prevalence and proximity to industrial facilities releasing arsenic, lead or mercury
Autism is higher near industrial facilities that release arsenic, lead, or mercury into the air.  Fascinating.  This is a rehash of the "AIR POLLUTION!" from #103, I suppose.  Vaccines aren't airborne last I checked (despite what the chemtrails nutters would have you believe), nor do they contain mercury, lead, or arsenic.

106) Inflammatory Responses to Trivalent Influenza Virus Vaccine Among Pregnant Women
Wow is this one a stretch.  Pregnant women given the flu vaccine were found to have an inflammatory response.  As much as I can't stand saying this, I have no choice: DUH.  That's exactly what the vaccine is supposed to do: elicit an immune response!  Plus, the authors note that "The inflammatory response elicited by vaccination is substantially milder and more transient than seen in infectious illness, arguing for the clinical value of vaccination."  And trying to make the leap to "transient, mild, and fully expected inflammatory response causes autism" is laughable.

107) Elevated maternal C-reactive protein and autism in a national birth cohort
Another stretch of a study which found that high maternal C-reactive protein (CRP), a nonspecific marker of inflammation, was associated with a 43% increased risk of autism in their children.  While interesting, it has nothing to do with childhood vaccines.

108) What is regressive autism and why does it occur? Is it the consequence of multi-systemic dysfunction affecting the elimination of heavy metals and the ability to regulate neural temperature?
The author of this "article", Graham Ewing, is not a doctor.  He is not a scientist.  He is not a psychologist.  He is a businessman and CEO of a company called Montague Healthcare, he and his wife run a website called PositiveHealthOnline, and he promotes his "Virtual Scanning" which uses a oh god damn fuck it all, I can't do it this one anymore.  Just go to his website and experience the bullshit for yourself.  Anyway, he bullshittily claims that autism is due to "subtle DNA alteration" from the "overuse of vaccines", no evidence required or supplied.

109) Neurologic adverse events following vaccination
This is a 2012 Polish review of adverse events following vaccination.  At least up to 2011 thimerosal was still present in several childhood vaccines in Poland, and this article focuses on that quite determinedly.  It also shockingly descends quite deep into the "Vaccines Didn't Save Us" pit of stupidity before making several recommendations (including eliminating thimerosal, giving a maximum of 3 vaccinations per day, and eliminating live-virus vaccines).  The authors must have missed the study from just the previous year, also from Poland, that found no link between thimerosal and autism.  Oops.

110) Immunological and autoimmune considerations of Autism Spectrum Disorders
This is a review, not a scientific research paper.  It discusses the association between inflammation and autism, but it still does not link vaccines, nor does it try to.

111) Identification of Unique Gene Expression Profile in Children with Regressive Autism Spectrum Disorder (ASD) and Ileocolitis
Not about vaccines in any way.

112) Correlations Between Gene Expression and Mercury Levels in Blood of Boys With and Without Autism
Mercury.  Not vaccines.

113) Abnormal immune response to brain tissue antigen in the syndrome of autism
A very small (N=28) study which found that 76% of autistic children may have a cell-mediated immune response to brain tissue.  1) Small sample, 2) NOTHING TO DO WITH VACCINES.  Honestly, "inflammation" does not equal "vaccines did it".

114) Detection and sequencing of measles virus from peripheral mononuclear cells from patients with inflammatory bowel disease and autism
Oh this study.  I was so hoping Ginger would include it.  Happy day!  The lead author, Hideyuki Kawashima, studied nine children diagnosed with autistic enterocolitis and found measles genes in three of them.  This seems to confirm Andy Wakefield's research!  Stop the presses!  Wakefield is exonerated!  But wait wait wait . . . who diagnosed these nine children with autistic enterocolitis?  You guessed it - ANDY FUCKING WAKEFIELD.  These are nine of the same children from his original fraudulent study.  And study after study after study after study after study has found no evidence of measles in autistic children.

115) Mechanisms of aluminum adjuvant toxicity and autoimmunity in pediatric populations
This one from Tomljenovic and Shaw is a favourite of antivaxxers.  However, it is not a scientific study, just a series of hypotheticals which concludes that "a rigorous evaluation of the vaccine-related adverse health impacts in the pediatric population is urgently needed."  That's a fine idea - I'll wait until that comparison of vaccinated and unvaccinated children is done.  Oh wait - they have been done, and they show 1) no difference in allergic diseases or non-specific infections, 2) lower rates of asthma among vaccinated children, 3) increased cognitive scores among vaccinated children, 4) fewer preterm births and higher birth weights, and 5) fewer heart attacks.  (Thanks to thoughtscapism for compiling that list).

116) Etiology of autism spectrum disorders: Genes, environment, or both?
Tomljenovic and Shaw again.  This is another speculative piece about how aluminum might perhaps maybe vaguely do something, but again no direct evidence of its evils is presented.

117) Thiol-modulated mechanisms of the cytotoxicity of thimerosal and inhibition of DNA topoisomerase II alpha
I was kinda hoping to get an easy one on thimerosal.  Doing this is freaking exhausting.

118) Topoisomerases facilitate transcription of long genes linked to autism
Yet more goalpost moving.  Topoisomerase is an enzyme which regulates the winding of DNA.  It's been found to be mutated in some people with autism, and topotecan (which inhibits topoisomerase) reduces the expression of long genes.  And many potential autism genes are long.  So . . . wait, what does this have to do with vaccines?

119) Aluminum in the central nervous system (CNS): toxicity in humans and animals, vaccine adjuvants, and autoimmunity
It's our friends Tomljenovic and Shaw again, and it's yet another not-a-scientific-paper, but hypotheses and conjecture.  This is the time when I should point out that this study was funded by the Dwoskin Family Foundation, which was founded by Claire Dwoskin.  Mrs. Dwoskin is a board member of the horribly misnamed National Vaccine Information Center, a public charity anti-vaccination advocacy group.  Shaw and Tomljenovic  have been speakers at conferences with such other speakers as antivax neurosurgeone Russell Blaylock, MD, NVIC founder Barbara Loe Fisher, and Andrew Wakefield.  As I'm not terribly fond of ad hominems, I'll stop there.

120) Behavioral abnormalities in young female mice following administration of aluminum adjuvants and the human papillomavirus (HPV) vaccine Gardasil.
I'll let the abstract on this one (on which Tomljenovic and Shaw are both authors) speak for itself.  Oh wait, there is no abstract.  In the place where the abstract should be is only this:
"This article has been withdrawn at the request of the Editor-in-Chief due to serious concerns regarding the scientific soundness of the article.  Review by the Editor-in-Chief and evaluation by outside experts, confirmed that the methodology is seriously flawed, and the claims that the article makes are unjustified.  As an international peer-reviewed journal we believe it is our duty to withdraw the article from further circulation, and to notify the community of this issue."  
I have nothing to add other than HAHAHAHAHAHAHAHA.

121) Transcriptomic analyses of neurotoxic effects in mouse brain after intermittent neonatal administration of thimerosal
Thimerosal.

122) Self-Organized Criticality Theory of Autoimmunity
Repeated immunisation can cause autoimmunity.  IN MICE.  No definitive link between autoimmunity and vaccines has ever been shown.  Oh, and this has nothing to do with autism anyway.

123) Can Awareness of Medical Pathophysiology in Autism Lead to Primary CareAutism Prevention Strategies?
Let's start by saying that this was published in the North American Journal of Medicine & Science.  What, you've never heard of it?  Neither had I, and neither has anyone else apparently, since it has an impact factor of 0.  Yes, ZERO.  Even "Homeopathy" has an impact factor of 0.76 (by comparison BMJ's is 17.4, Lancet's is 45.2, and New England Journal of Medicine's is 55.9).  That aside, the author Elizabeth Mumper (who coincidentally has a terribly unfortunate name for an antivax paediatrician) is the CEO of Rimland Center for Integrative Medicine who runs a hyperbaric oxygen chamber to treat children with autism.  Shockingly (not really), HBO has been shown not to be effective for autism.  Anyway, back to the "study".  Dr. Mumper introduced an alternative vaccine schedule to her patients and had a 0% rate of autism among 294 subjects.  Note these children were not unvaccinated (though they did not get Hep A, Hep B, rotavirus, or flu vaccines).  So does this prove vaccines cause autism?  Er, no.

124) Autistic disturbances of Affective Contact
This is Leo Kanner's seminal description of autism from 1943.  I'm honestly shocked Ginger would include this article, since it was published several decades before most current childhood vaccines were introduced (polio 1955, measles 1963, mumps 1967, rubella 1969, HiB 1977, meningitis 1978, hepatitis B 1981, varicella 1984 rotavirus 2006).  I can only assume this article was included because Kanner describes one of the case studies as getting "an attack of diarrhea and fever, from which he recovered in somewhat less than a week" after getting a smallpox vaccine.  Now that is the ultimate stretch, considering routine smallpox vaccination hasn't been done since the 1970's.  So what, according to Ginger and her friends, caused autism before vaccines?  Hmm??

AND THAT IS IT.  As I was going through every single paper in this list, it became increasingly clear that Ginger simply went to Pubmed, typed in her search terms (thimerosal, mercury, oxidative stress, autism, heavy metals), and copied the links without bothering to read or understand what the hell she was reading.  Of the 124 papers presented, exactly -0- of them proves any link between vaccines and autism, and a few even disprove any link.  I sincerely doubt that any antivaxxer who sprays this list around the Twitterverse (or anywhere else) has read any of these papers, let alone all of them.  Having now read every single one, I feel . . . well, I feel exactly the same.

A hearty congratulations (and a heartfelt 'thank you') to anyone who actually got this far.  Hopefully this will be the longest blog post I ever write.  I never intend to do this again.  Ever.  EVER.