Poll: Belief in pseudoscience/paranormal phenomena
- Thread starter IH8THEEVILEMPIRE
- Start date
Not quite. While overall most are negative, it's true that there are some positive studies for specific treatments, however one or two studies alone does not establish proof (in addition, sometimes the controls in some positive tests have been questionable). Also, if a specific treatment from an alt therapy/medicine has proven to be effective, it does not validate the wider use of that alternative therapy. For example, there is scientific proof for very specific Chiropractic procedures (I think lower back if I remember correctly) however this does not validate the whole of Chiropractic so we must be careful in saying some treatment has been proven when it is only the specific procedure which has been validated. It's why I think scientific Chiropractic should change its name and call itself something else in order to become disassociated from the unproven stuff. People will likely see that a specific treatment has been scientifically validated and then extrapolate that proof to the whole.
AlexisInfectious®
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- Apr 17, 2009
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Good point Wry,
Many people lump all treatments (western and CAM) together and say "well if this was proven/disproven all must be proven or disproven" There are western methods that are not "entirely proven" yet they work better than other medical alternatives. This can also be the case with some CAM therapies while in lab results they are not entirely "proven" they work and (in some instances) are better than other western (or even other CAM) alternatives.
Take for example the common cold, western therapies are (usually, but this trend is changing in the US) quick to prescribe Antibiotics, regardless of whether the condition is Viral, Fungal, or bacterial. While I AGREE this is can be effective 100% of the time as tx (only if it is bacterial), it is 0% effective if viral, fungal (or could even be parasites). But ultimately both ways are destructive to the human body and enviornment.
It is destructive to the human body b/c antibacterials are not specific, in other words it is a "shotgun" approach killing all bacteria within the human body. This includes good intestinal floura that is vital for digestion etc. It is like using a bacterial nuclear bomb.
For the enviornment it is starting to show up that Antibiotics are in our water supply, bacteria will evolve to survive and this in turn in making "super bugs" that modern antibiotics cannot deal with. In fact, "super bugs" from hospitals can be extremely deadly and is responsible for quite a few deaths after being in a hospital even for simple procedures. This also does not mention all the side effects possible with synthetic drugs.
http://en.wikipedia.org/wiki/Antibiotic_resistance
Now where herbal medicine and acupuncture come in for the common cold is mostly herbal formulas. For example we would use one formula known as Yin Qiao San, this herbal formula has 10 different herbs in it, of which 6 at least are shown to have Anti-viral, Anti-bacterial, and anti-parasitic effects. B/c these are not in strong doses or high concentrate we are able to have 6 different Anti-s within the formula.
This is beneficial b/c it makes it impossible for the bacteria or virus to evolve to numerous Anti-bacterial/viral components. Also as far as common cold goes, if it is viral, bacterial or parasitic (even fungal with this particular formula) it will have an effect. Though, it does still remain that this is not "bacteria specific" and will also damage intestinal flourna, though at a much smaller rate, b/c of lower concentrations.
Also enviornmentally, these are nothing but plants, so when they do go into water or earth supplies they are merely absorbed and broken down b/c there are no synthetic materials to them. On a grander scale, (granted herbal medicine is easier to prove) this is an example where a CAM therapy can be a better alternative to western meds. In addition to these there is the cost factor as well.
CK,
Isn't that part of the discussion though? Wouldn't placebo effect fall under someone's belief structure? So maybe shamanism would heal them via placebo effect and if placebo effect is estimated to account for 1/3 of the effect of all txs then it belief would fall under 33% of all trials. To that individual that belief is true b/c it worked for them.
http://en.wikipedia.org/wiki/Placebo_effect
B/c of such a high estimate for placebo effect doesn't this mean at BEST that all clinical trials can only show a 66% effective rate? Even for this to be true, that means then that the medicine would be 100% effective as the rest is placebo. But this is not the case as usually you have trials where anywhere between 10-25% are not helped.
So being generous most things shown in trial for medicine are 56% effective, slightly better than half. This is being generous, so to somewhat answer your question ( I know you did not really mean it as a question ) Yes, I think belief plays a major role in all clinical trials and medicines.
Many people lump all treatments (western and CAM) together and say "well if this was proven/disproven all must be proven or disproven" There are western methods that are not "entirely proven" yet they work better than other medical alternatives. This can also be the case with some CAM therapies while in lab results they are not entirely "proven" they work and (in some instances) are better than other western (or even other CAM) alternatives.
Take for example the common cold, western therapies are (usually, but this trend is changing in the US) quick to prescribe Antibiotics, regardless of whether the condition is Viral, Fungal, or bacterial. While I AGREE this is can be effective 100% of the time as tx (only if it is bacterial), it is 0% effective if viral, fungal (or could even be parasites). But ultimately both ways are destructive to the human body and enviornment.
It is destructive to the human body b/c antibacterials are not specific, in other words it is a "shotgun" approach killing all bacteria within the human body. This includes good intestinal floura that is vital for digestion etc. It is like using a bacterial nuclear bomb.
For the enviornment it is starting to show up that Antibiotics are in our water supply, bacteria will evolve to survive and this in turn in making "super bugs" that modern antibiotics cannot deal with. In fact, "super bugs" from hospitals can be extremely deadly and is responsible for quite a few deaths after being in a hospital even for simple procedures. This also does not mention all the side effects possible with synthetic drugs.
http://en.wikipedia.org/wiki/Antibiotic_resistance
Now where herbal medicine and acupuncture come in for the common cold is mostly herbal formulas. For example we would use one formula known as Yin Qiao San, this herbal formula has 10 different herbs in it, of which 6 at least are shown to have Anti-viral, Anti-bacterial, and anti-parasitic effects. B/c these are not in strong doses or high concentrate we are able to have 6 different Anti-s within the formula.
This is beneficial b/c it makes it impossible for the bacteria or virus to evolve to numerous Anti-bacterial/viral components. Also as far as common cold goes, if it is viral, bacterial or parasitic (even fungal with this particular formula) it will have an effect. Though, it does still remain that this is not "bacteria specific" and will also damage intestinal flourna, though at a much smaller rate, b/c of lower concentrations.
Also enviornmentally, these are nothing but plants, so when they do go into water or earth supplies they are merely absorbed and broken down b/c there are no synthetic materials to them. On a grander scale, (granted herbal medicine is easier to prove) this is an example where a CAM therapy can be a better alternative to western meds. In addition to these there is the cost factor as well.
CK,
Isn't that part of the discussion though? Wouldn't placebo effect fall under someone's belief structure? So maybe shamanism would heal them via placebo effect and if placebo effect is estimated to account for 1/3 of the effect of all txs then it belief would fall under 33% of all trials. To that individual that belief is true b/c it worked for them.
http://en.wikipedia.org/wiki/Placebo_effect
B/c of such a high estimate for placebo effect doesn't this mean at BEST that all clinical trials can only show a 66% effective rate? Even for this to be true, that means then that the medicine would be 100% effective as the rest is placebo. But this is not the case as usually you have trials where anywhere between 10-25% are not helped.
So being generous most things shown in trial for medicine are 56% effective, slightly better than half. This is being generous, so to somewhat answer your question ( I know you did not really mean it as a question ) Yes, I think belief plays a major role in all clinical trials and medicines.
supacallieetsupercutet
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- Mar 4, 2008
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Taoquan
While I agree with your points about treating viral and fungal infections with antibiotics, the 'common cold' is only caused by viruses, although bacteria and fungi can cause other upper respiratory tract infections.
I know, I'm nitpicking, but there it is!
As an aside, here's a picture of Rhinovirus, isnt he cute!
While I agree with your points about treating viral and fungal infections with antibiotics, the 'common cold' is only caused by viruses, although bacteria and fungi can cause other upper respiratory tract infections.
I know, I'm nitpicking, but there it is!
As an aside, here's a picture of Rhinovirus, isnt he cute!
Wry if there is clinical evidence then I am not against it... I believe I have stated this clearly. To save you the bother of looking:
"I'm not against alternative medicines existing nor am I against therapeutic treatments being offered on the NHS (this would include so called alternative treatments such as acupuncture were they are proven to have an effect beyond the placebo effect)."
"I too agree that CAT's can be a very positive experience and help people. I don't argue that people shouldn't use them I simply suggest that hospitals should only be using ones that have been shown to offer a legitimate beneficial effect over and above the placebo effect."
"I'm simply advocating that whatever treatment is used even things like massage or yoga or acupuncture should have some evidence that they help."
I hope the quotes above make it clear I'm only arguing agains things that DO NOT have convincing clinical evidence- I know that some alternative medicines have been shown to treat some things effectively, where that is the case I think it is fine for them to be advocated. I would however argue that the case FOR various alternative medicines is often grossly exaggerated- with preliminary poorly controlled studies being cited as irrefutable proof (when the studies themselves acknowledge they aren't!). I read the studies people link to and while some of them are indeed legitimate and provide real evidence for an effect the vast majority I, at least, have read are not the irrefutable proof people say they are. Basically I am arguing for evidence based medicine and I take the exact same position as George Lundberg former editor of JAMA who eloquently summed up:
"There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. Whether a therapeutic practice is 'Eastern' or 'Western,' is unconventional or mainstream, or involves mind-body techniques or molecular genetics is largely irrelevant except for historical purposes and cultural interest. As believers in science and evidence, we must focus on fundamental issues—namely, the patient, the target disease or condition, the proposed or practiced treatment, and the need for convincing data on safety and therapeutic efficacy."
I would not seperate spiritual from the mental. What sort of spiritual treatments are you advocating?
You misread... I suggested that any treatment offered in a hospital should have clinical evidence of effectiveness which would entail research.
"I'm not against alternative medicines existing nor am I against therapeutic treatments being offered on the NHS (this would include so called alternative treatments such as acupuncture were they are proven to have an effect beyond the placebo effect)."
"I too agree that CAT's can be a very positive experience and help people. I don't argue that people shouldn't use them I simply suggest that hospitals should only be using ones that have been shown to offer a legitimate beneficial effect over and above the placebo effect."
"I'm simply advocating that whatever treatment is used even things like massage or yoga or acupuncture should have some evidence that they help."
I hope the quotes above make it clear I'm only arguing agains things that DO NOT have convincing clinical evidence- I know that some alternative medicines have been shown to treat some things effectively, where that is the case I think it is fine for them to be advocated. I would however argue that the case FOR various alternative medicines is often grossly exaggerated- with preliminary poorly controlled studies being cited as irrefutable proof (when the studies themselves acknowledge they aren't!). I read the studies people link to and while some of them are indeed legitimate and provide real evidence for an effect the vast majority I, at least, have read are not the irrefutable proof people say they are. Basically I am arguing for evidence based medicine and I take the exact same position as George Lundberg former editor of JAMA who eloquently summed up:
"There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. Whether a therapeutic practice is 'Eastern' or 'Western,' is unconventional or mainstream, or involves mind-body techniques or molecular genetics is largely irrelevant except for historical purposes and cultural interest. As believers in science and evidence, we must focus on fundamental issues—namely, the patient, the target disease or condition, the proposed or practiced treatment, and the need for convincing data on safety and therapeutic efficacy."
I would not seperate spiritual from the mental. What sort of spiritual treatments are you advocating?
You misread... I suggested that any treatment offered in a hospital should have clinical evidence of effectiveness which would entail research.
I thought I must have misread.
It is not "spiritual treatments" as much as an extension of counsiling. I do not advocate spiritual healings alone and if someone wants someone else to do a laying on of hands or some such, then that is a fine addition to more traditional methods. However, every person tends to have some spiritual needs that are as important as social and psychological needs. Clergy and the equivalent are trained to handle those needs.
It is not "spiritual treatments" as much as an extension of counsiling. I do not advocate spiritual healings alone and if someone wants someone else to do a laying on of hands or some such, then that is a fine addition to more traditional methods. However, every person tends to have some spiritual needs that are as important as social and psychological needs. Clergy and the equivalent are trained to handle those needs.
LookItsJay
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- Feb 17, 2008
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Taoquan... I think you are usually thorough in your research but you last post seems to betray a distanct lack of thoroughness which is a bit disappointing, to highlight some problems:
No it doesn't and this shows a lack of research on your part. In the wikipedia article YOU linked to it not only explains why the 33% figure is now considered to be false, it also explains why the kind of conclusions you have drawn are false.
To illustrate:
"The original 1955 article of Beecher "The Powerful Placebo" claimed a 35% placebo effect in 15 studies. The original article was in 1997 re-analysed and "no evidence was found of any placebo effect in any of the studies" used by Beecher"
In terms of why your figure would not apply the placebo effect is an 'effect' but it is not necessarily the same effect which would be observed by a legitimate treatment. Say for instance a pill was made which was thought to decrease biliribin level in the bloodstream, the placebo effect is very unlikely to be able to replicate that effect... if you told people that this may make them feel itchy you would however find that some people who were not given the real treatment would report increased itchiness.
Or for another example if you pretended to treat 100 patients with breast cancer the placebo effect would not mean that 33 would survive... that's just bad logic. It would mean that a certain percentage would believe the treatment was helping and their body may react in a positive way but the sad fact is that thinking positive is not going to be enough to stop an aggresive cancer. So if a treatment for breast cancer was found to work in 66% of the patients it was trialled on it does not mean that 33% can be attributed to the placebo effect. That's a poor argument that even the wikipedia page dismisses!
Next antibiotics... They are not really a "shotgun approach", antibiotics from microbes have few side effects and are highly effective at targeting specific areas. Perhaps your referring to broad-spectrum antibiotics which are used only in specific cases? Again from wikipedia:
"Most anti-bacterial antibiotics do not have activity against viruses, fungi, or other microbes."
This is not to say that you are not correct about antibiotics potentially damaging the amount of intestinal flora but I fail to see how a tea with anti-bacterial components could not cause the same effect? Unless the concentration is much smaller in which case the effect is also likely to be smaller- despite what homeopathy says it is not true to say that the smaller amount of active ingredient the greater the effect. Wouldn't it be much more accurate to say that you are advocating a shotgun approach by suggesting that your herbal remedy can cover all aspects of the common cold and other related illnesses (given that the common cold is caused by a virus like ninjabelly pointed out)?
Anyhow, all of the above is made somewhat irrelevant by the fact that antibiotics are not a treatment for the common cold! Just looking up on wikipedia would have told you that! In fact typing in 'antibiotic common cold treatment' into google brought me up the following information on the first page:
Antibiotics do not have any beneficial effect against the common cold. Their use in cases of common cold infection is ineffective and may contribute to antibiotic resistance of bacteria present in the patient's body.
from Wikipedia
Never take antibiotics to treat a cold because antibiotics do not kill viruses. You should use these prescription medicines only if you have a rare bacterial complication, such as sinusitis or ear infections. In addition, you should not use antibiotics “just in case” because they will not prevent bacterial infections.
from National institute of Health
Are antibiotics a suitable treatment for the common cold?
No. Antibiotics play no role in treating the common cold. Antibiotics only work against illnesses caused by bacteria and colds are caused by viruses. Not only do antibiotics not help, but they can also cause allergic reactions that may be fatal (1:40,000).
from Medicinenet
And I could go on... but I think you get the picture. You have however just highlighted one of the issues I have with alternative medicine i.e. that its pracitioners often criticise modern medicine and promote alternative treatments based on false information.
No it doesn't and this shows a lack of research on your part. In the wikipedia article YOU linked to it not only explains why the 33% figure is now considered to be false, it also explains why the kind of conclusions you have drawn are false.
To illustrate:
"The original 1955 article of Beecher "The Powerful Placebo" claimed a 35% placebo effect in 15 studies. The original article was in 1997 re-analysed and "no evidence was found of any placebo effect in any of the studies" used by Beecher"
In terms of why your figure would not apply the placebo effect is an 'effect' but it is not necessarily the same effect which would be observed by a legitimate treatment. Say for instance a pill was made which was thought to decrease biliribin level in the bloodstream, the placebo effect is very unlikely to be able to replicate that effect... if you told people that this may make them feel itchy you would however find that some people who were not given the real treatment would report increased itchiness.
Or for another example if you pretended to treat 100 patients with breast cancer the placebo effect would not mean that 33 would survive... that's just bad logic. It would mean that a certain percentage would believe the treatment was helping and their body may react in a positive way but the sad fact is that thinking positive is not going to be enough to stop an aggresive cancer. So if a treatment for breast cancer was found to work in 66% of the patients it was trialled on it does not mean that 33% can be attributed to the placebo effect. That's a poor argument that even the wikipedia page dismisses!
Next antibiotics... They are not really a "shotgun approach", antibiotics from microbes have few side effects and are highly effective at targeting specific areas. Perhaps your referring to broad-spectrum antibiotics which are used only in specific cases? Again from wikipedia:
"Most anti-bacterial antibiotics do not have activity against viruses, fungi, or other microbes."
This is not to say that you are not correct about antibiotics potentially damaging the amount of intestinal flora but I fail to see how a tea with anti-bacterial components could not cause the same effect? Unless the concentration is much smaller in which case the effect is also likely to be smaller- despite what homeopathy says it is not true to say that the smaller amount of active ingredient the greater the effect. Wouldn't it be much more accurate to say that you are advocating a shotgun approach by suggesting that your herbal remedy can cover all aspects of the common cold and other related illnesses (given that the common cold is caused by a virus like ninjabelly pointed out)?
Anyhow, all of the above is made somewhat irrelevant by the fact that antibiotics are not a treatment for the common cold! Just looking up on wikipedia would have told you that! In fact typing in 'antibiotic common cold treatment' into google brought me up the following information on the first page:
Antibiotics do not have any beneficial effect against the common cold. Their use in cases of common cold infection is ineffective and may contribute to antibiotic resistance of bacteria present in the patient's body.
from Wikipedia
Never take antibiotics to treat a cold because antibiotics do not kill viruses. You should use these prescription medicines only if you have a rare bacterial complication, such as sinusitis or ear infections. In addition, you should not use antibiotics “just in case” because they will not prevent bacterial infections.
from National institute of Health
Are antibiotics a suitable treatment for the common cold?
No. Antibiotics play no role in treating the common cold. Antibiotics only work against illnesses caused by bacteria and colds are caused by viruses. Not only do antibiotics not help, but they can also cause allergic reactions that may be fatal (1:40,000).
from Medicinenet
And I could go on... but I think you get the picture. You have however just highlighted one of the issues I have with alternative medicine i.e. that its pracitioners often criticise modern medicine and promote alternative treatments based on false information.
CK,
I will admit, that I was in a hurry and just blankly recalled the research ideas and not the right numbers this is my fault and my fault alone. Though this also illustrates my point as well that we should not dismiss "Alternative therapies" b/c of lack of knowledge by the practitioner b/c the "alternative therapy" is nothing more than a tool. You cannot blame a tool for poor craftsmanship.
Now that it has been pointed out to me that most "common colds" are caused by viruses. I remember this from my microbio class and apologize as I used a poor example. Though the idea was correct, the execution was poor Though this also illustrates how easily anyone can make mistakes when it does come to medicine, I for one feel almost any "healing" treatment (western or otherwise) is mostly pretty in depth and does require good amounts of training. It is just in what areas of training and what it may be good for.
I apologize for my poor execution, hey we all make mistakes eh?
I will admit, that I was in a hurry and just blankly recalled the research ideas and not the right numbers this is my fault and my fault alone. Though this also illustrates my point as well that we should not dismiss "Alternative therapies" b/c of lack of knowledge by the practitioner b/c the "alternative therapy" is nothing more than a tool. You cannot blame a tool for poor craftsmanship.
Now that it has been pointed out to me that most "common colds" are caused by viruses. I remember this from my microbio class and apologize as I used a poor example. Though the idea was correct, the execution was poor Though this also illustrates how easily anyone can make mistakes when it does come to medicine, I for one feel almost any "healing" treatment (western or otherwise) is mostly pretty in depth and does require good amounts of training. It is just in what areas of training and what it may be good for.
I apologize for my poor execution, hey we all make mistakes eh?
Did I say this? No, it didn't!
It certainly doesn't mean that the boy would not have died had he stayed on scientific medicine, as recommened by the his doctors, however the point being made is the boys chances of survival would have been far far greater. His cancer when into remission so where was a good chance he would have survived. By taking the person off scientific medical care his parents significantly reduced the boys chance of survival.
It certainly doesn't mean that the boy would not have died had he stayed on scientific medicine, as recommened by the his doctors, however the point being made is the boys chances of survival would have been far far greater. His cancer when into remission so where was a good chance he would have survived. By taking the person off scientific medical care his parents significantly reduced the boys chance of survival.
Though, on a side note, in the US antibiotics are STILL prescribed for "common cold" symptoms. Sometimes by doctors themselves, other times b/c patients "think" they work for the cold so they are asked for. You can go into a doctor's office today and most will have posted that they will not ALWAYS prescribe antibiotics b/c they are not useful. However, this was not the case even 5 years ago.
brittany_glid1890
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- Apr 6, 2008
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Its worth keeping in mind that although antibiotics are no longer regularly prescribed for viral infections, this was not always the case. Even 10 or 15 years ago plenty of GPs would prescribe antibiotics for anyone who came in with a bit of a sniffle, because people dont like to be told 'its a virus, there's nothing we can do, come back if you develop a chest infection'. This contributed in no small part to the development of bacterial resistance. Even today, if you are unlucky you can get an elderly doctor who'll still give you antib's regardless!
Edit: bah, you beat me!
Edit: bah, you beat me!
I wonder if it was really that bad 5 years ago... however we can count ourselves lucky then that the problem seems to have been addressed as I can't find any medical website promoting them as a viable treatment. Cause to rejoice, eh? Am I also to assume that people are suggesting I will find the same thing amongst alternative medicines i.e. no claims for anti-bacterial effects in cold treatments?
cadydid523
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- Feb 13, 2008
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Is this directed to me?
When I say most I mean the majority of studies undertaken tend to be negative. If most were positive, then it would be far more accepted by the scientific community, but it isn’t and there is a good reason why this is.
There are two ways of looking at this: a) CAM as a whole, and b) individual CAM treatments.
In my view while we can talk of CAM as a whole not being proven we should instead be more specific since it is such a big field. Instead we should look at individual CAM treatments and claims and when we do they also tend to be negative overall. But even then we shouldn’t refer to an individual treatment as a whole. For example we shouldn’t refer to Chiropractic as one single entity since it is so varied. You have the more valid scientific Chiro (or rather specific procedures) verses the rest of it which is more dubious. Likewise we shouldn’t refer to acupuncture as a single entity. While the basic claims of acupuncture (i.e. life force) is complete nonsense, there may be some effective application of sticking needles into someone. However proving a specific procedure does not prove the whole.
When I say most I mean the majority of studies undertaken tend to be negative. If most were positive, then it would be far more accepted by the scientific community, but it isn’t and there is a good reason why this is.
There are two ways of looking at this: a) CAM as a whole, and b) individual CAM treatments.
In my view while we can talk of CAM as a whole not being proven we should instead be more specific since it is such a big field. Instead we should look at individual CAM treatments and claims and when we do they also tend to be negative overall. But even then we shouldn’t refer to an individual treatment as a whole. For example we shouldn’t refer to Chiropractic as one single entity since it is so varied. You have the more valid scientific Chiro (or rather specific procedures) verses the rest of it which is more dubious. Likewise we shouldn’t refer to acupuncture as a single entity. While the basic claims of acupuncture (i.e. life force) is complete nonsense, there may be some effective application of sticking needles into someone. However proving a specific procedure does not prove the whole.
Absolutely cause to rejoice!
As for the antibacterial in CAM therapies I can say in herbal TCM we don't really prescribe that way (out of our scope of practice to say it is viral etc) so it would be hard to say. I do know that most herbs we prescribe for "common colds" have both anti-bacterial and anti-viral properties. This is one herb frequently used for such Ban Lan Gen (yes it also has chemical and western medical research with it):
http://alternativehealing.org/ban_lan_gen.htm
As for the physical part of acupuncture usually we select points that increase the immune system and we using cupping tech. Which basically stimulates blood flow and increase it to move throughout the body reducing inflaofftopiction etc. It can also induce sweating to get toxins out of the body that are produced by the microorganisms.
As for the antibacterial in CAM therapies I can say in herbal TCM we don't really prescribe that way (out of our scope of practice to say it is viral etc) so it would be hard to say. I do know that most herbs we prescribe for "common colds" have both anti-bacterial and anti-viral properties. This is one herb frequently used for such Ban Lan Gen (yes it also has chemical and western medical research with it):
http://alternativehealing.org/ban_lan_gen.htm
As for the physical part of acupuncture usually we select points that increase the immune system and we using cupping tech. Which basically stimulates blood flow and increase it to move throughout the body reducing inflaofftopiction etc. It can also induce sweating to get toxins out of the body that are produced by the microorganisms.