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Archive for 2009

“Move along. Nothing to see Here”- F. Drebin

I am, I think, the slowest writer in the  SBM stable.  I start each entry about 10 days before it is due, and work diligently on it through the week.  As such, I run the risk that events may make my work pointless. Case in point.  I have been slogging away at this entry for the last week and had the final draft up and ready to go, only to find this morning that the Health Care Reform bill no longer carries the language that was the crux of this entire post.  So what is a poor, slow, SBM writer to do? Chuck the whole thing?  Repost my 12 reasons you are a dumb ass not to get the flu vaccine yet again? Leave a hole in the SBM line up? No.

Lets pretend we are in a parallel universe, perhaps an evil universe  where I have a goatee, and the language was not removed from the bill. Lets all pretend that this post is still relevant. Since the Christian Science Church has indicated they will try to get the bill amended to reinstate payment for their services, this post may be relevant again.

Or you could go read  Respectful Insolence instead. Don’t say you were not warned.
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Posted in: Faith Healing & Spirituality, Humor, Politics and Regulation

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What’s in the water at waterbirth?

Waterbirth has been touted as an alternative form of pain relief in childbirth. Indeed, it is often recommended as the method of choice for pain relief in “natural” childbirth. It’s hardly natural, though. In fact, it is completely unnatural. No primates give birth in water, because primates initiate breathing almost immediately after birth and the entire notion of waterbirth was made up only 200 years ago. Not surprisingly, waterbirth appears to increase the risk of neonatal death.

Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey was published in the BMJ in 1999. Out of 4,030 deliveries in water, 35 babies suffered serious problems and 3 subsequently died. It is unclear if any of the deaths can be attributed to delivery in water. However, of the 32 survivors who were admitted to the NICU, 13 had significant respiratory problems including pneumonia, meconium aspiration, water aspiration, and drowning. Other complications attributable to water birth include 5 babies who had significant hemorrhage due to snapped umbilical cord. In all, 18 babies had serious complications directly attributable to waterbirth. The risk of serious complications necessitating prolonged NICU admissions was 4.5/1000.

Hospitals in Ireland suspended the practice of waterbirth after a baby died from freshwater drowning after delivery in a waterbirth pool.

The most nonsensical aspect of waterbirth is that it puts the baby at risk for freshwater drowning. The second nonsensical aspect is that the baby is born into what is essentially toilet water, because the water in the pool is fecally contaminated. In Water birth and the risk of infection; Experience after 1500 water births, Thoeni et al. analyzed the water found in waterbirth pools both before and after birth. The water in a birth pool, conveniently heated to body temperature, the optimum temperature for bacterial growth, is a microbial paradise.
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Posted in: Obstetrics & gynecology, Science and Medicine

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The USPSTF recommendations for breast cancer screening: Not the final word

Preface: On issues such as this, I think it’s always good for me to emphasize my disclaimer, in particular:

Dr. Gorski must emphasize that the opinions expressed in his posts on Science-Based Medicine are his and his alone and that all writing for this blog is done on his own time and not in any capacity representing his place of employment. His views do not represent the opinions of his department, university, hospital, or cancer institute and should never be construed as such. Finally, his writings are meant as commentary only and are therefore not meant to be used as specific health care recommendations for individuals. Readers should consult their physicians for advice regarding specific health problems or issues that they might have.

Now, on to the post…

“Early detection saves lives.”

Remember how I started a post a year and a half ago starting out with just this statement? I did it because that is the default assumption and has been so for quite a while. It’s an eminently reasonable-sounding concept that just makes sense. As I pointed out a year and a half ago, though, the question of the benefits of the early detection of cancer is more complicated than you think. Indeed, I’ve written several posts since then on the topic of mammography and breast cancer, the most recent of which I posted a mere two weeks ago. As studies have been released and my thinking on screening for breast cancer has evolved, regular readers have had a front row seat. Through it all, I hope I’ve managed to convey some of the issues involved in screening for cancer and just how difficult they are. How to screen for breast cancer, at what age to begin screening, and how to balance the benefits, risks, and costs are controversial issues, and that controversy has bubbled up to the surface into the mainstream media and public consciousness over the last year or so.

This week, all I can say is, “Here we go again”; that is, between downing slugs of ibuprofen for the headaches some controversial new guidelines for breast cancer screening are causing many of us in the cancer field.
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Posted in: Cancer, Diagnostic tests & procedures, Politics and Regulation, Public Health

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Evidence in Medicine: Correlation and Causation

There are two general approaches to subverting science-based medicine (SBM): anti-science and pseudoscience. Anti-scientific approaches are any that seek to undermine science as the determinant of the standard of care, often overtly advocating for spiritual or subjectively-based standards. Some attack the validity of science itself, usually with post-modernist philosophy.

Pseudoscientific proponents, on the other hand, praise science, they just do it wrong. In reality there is a continuum along a spectrum from complete pseudoscience to pristine science, and no clear demarcation in the middle. Individual studies vary along this spectrum as well – there are different kinds of evidence, each with its own strengths and weaknesses, and there are no perfect studies. Further, when evaluating any question in medicine, the literature (the totality of all those individual studies) rarely points uniformly to a single answer.

These multiple overlapping continua of scientific quality create the potential to make just about any claim seem scientific simply by how the evidence is interpreted. Also, even a modest bias can lead to emphasizing certain pieces of evidence over others, leading to conclusions which seem scientific but are unreliable. Also, proponents can easily begin with a desired conclusion, and then back fill the evidence to suit their needs (rather than allowing the evidence to lead them to a conclusion).

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Posted in: Science and Medicine

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Environmental Medicine – Not Your Average Specialty

I recently received an announcement for a conference on “Inflammation and Autoimmunity.” The topic sounded interesting, but as I read further I saw some red flags:

A gathering of healthcare leaders with a shared vision.

This event focuses on the the [sic] true causes and effects of inflammatory and autoimmune diseases, including new treatments available for this rapidly emerging crisis.

Both of these comments sound ideology-driven. I would not expect to find language like this for, say, a conference organized by the American Academy of Pediatrics or the American Academy of Allergy, Asthma and Immunology. This conference was organized by the American Academy of Environmental Medicine. I did some checking, and it seems the AAEM is not your average academy, and environmental medicine is not your average specialty.

The AAEM is not recognized by the American Board of Medical Specialties.
It is listed as a questionable organization on Quackwatch. And the American Board of Environmental Medicine is listed as a dubious certifying board. (more…)

Posted in: Science and Medicine

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H1N1 Pandemic Update

In a special episode of the Skeptics’ Guide to the Universe podcast, I host a discussion with David Gorski, Mark Crislip, and Joe Albietz about the flu, the H1N1 “swine” flu pandemic, and the controversies surrounding the flu vaccine.

You can download or stream the episode here. You can also subscribe to the podcast via iTunes or other popular aggregators.

Posted in: Announcements

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Cancer prevention: The forgotten stepchild of cancer research?

The New York Times has been periodically running a series about the “40 years’ war” on cancer, with most articles by Gina Kolata. I’ve touched on this series before, liking some parts of it, while others not so much. In particular, I criticized an article one article that I thought to be so misguided about how the NIH grant system leads researchers to “play it safe” and how we could cure cancer if we could just fund “riskier” research that I had to write an extended screed about the misconceptions in the article. The latest installment, Medicines to Deter Some Cancers Are Not Taken, also by Kolata, is much better in that it discusses a problem at the heart of cancer, namely that we have developed drugs that can decrease the risk of specific cancers but they are not as widely used as they could be.

The first part of the article contrasts a seeming incongruity:

Many Americans do not think twice about taking medicines to prevent heart disease and stroke. But cancer is different. Much of what Americans do in the name of warding off cancer has not been shown to matter, and some things are actually harmful. Yet the few medicines proved to deter cancer are widely ignored.

Take prostate cancer, the second-most commonly diagnosed cancer in the United States, surpassed only by easily treated skin cancers. More than 192,000 cases of it will be diagnosed this year, and more than 27,000 men will die from it.

And, it turns out, there is a way to prevent many cases of prostate cancer. A large and rigorous study found that a generic drug, finasteride, costing about $2 a day, could prevent as many as 50,000 cases each year. Another study found that finasteride’s close cousin, dutasteride, about $3.50 a day, has the same effect.

This is indeed a contrast. Think about it. Millions of Americans take statins, for instance, to lower their cholesterol and thereby try to prevent the complications of elevated cholesterol, such as heart disease, vascular disease, and strokes. Yet, for at least two common cancers, there are proven effective drugs that will lower the risk of cancer considerably with a side effect profile at least as favorable as that of statins.
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Posted in: Cancer, Clinical Trials, Herbs & Supplements, Nutrition, Politics and Regulation

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Conflicts of interest in science-based medicine

The topic of conflicts of interest among medical researchers has recently bubbled up to the public consciousness more than usual. The catalyst for this most recent round of criticism by the press and navel-gazing by researchers is the investigation of Senator Charles Grassley (R-IA) of nine psychiatric researchers, one of which held $6 million in stock in a company formed to bring a drug for depression to market, but had allegedly concealed this, even though he was an investigator on an NIH grant to study the drug he was developing. From my perspective, there is more than a little politics going on in this story, given that for the last decade federal law, specifically the Bayh-Dole Act, and policy have actually encouraged investigators and universities to co-develop drugs and treatments with industry, but it does bring into focus the issue of conflicts of interest, in particular undisclosed conflicts of interest. There are two articles of note that recently appeared in the scientific literature discussing this issue, one in Science in July (about the Grassley investigation) and an editorial in the Journal of Psychiatry and Neuroscience by Simon N. Young, PhD, the Co-Editor-in-Chief of the journal and faculty at McGill University. I was more interested in the latter article because it takes a much braoder view of the issue. Science-based medicine (SBM) depends upon the integrity of the science being done to justify treatments; so it’s useful to discuss how conflicts of interest intersect medical research.

In most public discussions of conflicts of interest (COIs), Young notes, the primary focus is on payments by pharmaceutical companies to investigators. Make no mistake, this is a big issue, but COIs are not just payments from drug companies. Indeed, I’ve written about just such COIs that have arguably impacted patient care negatively right her on this very blog, for example seeding trials (in which clinical trials are designed by the marketing division of pharmaceutical companies), a case of fraud that appeared to have been motivated by COIs. What needs to be understood is that every single scientific and medical investigators have COIs of one sort or another, and many are not financial. That’s why I like Young’s introduction to what COIs are:
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Posted in: Clinical Trials, Medical Academia, Politics and Regulation, Vaccines

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The NCCAM Seeks Comments for its “Strategic Plan: 2010.” Part I

The National Center for Complementary and Alternative Medicine (NCCAM) has posted three essays about its latest “strategic planning process,” and has invited “stakeholders” to make comments. I have previously made my own opinions clear,* as have fellow bloggers Gorski, Novella, Lipson, and Sampson: the best strategic plan for the NCCAM would be to extinguish itself. Since politics makes that plan unlikely, there are strategies that could minimize the considerable harm now done by the Center, while possibly offering a modest benefit. In summary:

  • For both scientific and ethical reasons the NCCAM must dispense with trials of highly implausible claims. It should start by abandoning the ongoing Trial to Assess Chelation Therapy (TACT), its largest and most expensive trial yet, and one that has proven to place experimental subjects in considerable danger. It should publicly acknowledge such mistakes and explain why they must not be repeated—no matter how much political pressure there may be to do so.
  • The Center should use its website’s Health Information function to explain what’s known, rather than continue its customary practice of putting the best possible slant on most “CAM” claims, no matter how absurd or disproven.
  • The Center should address aspects of “CAM” advocacy that it has previously avoided, the most important being the close affiliation of such advocacy with the anti-vaccination (and autism quackery) movement. The NCCAM should consider itself an important source of rational information for a public that is currently, and dangerously, misled about immunizations. A related example of mischievous “CAM” advocacy, so far also ignored by the Center’s website, involves an imagined, sinister cartel of physicians, the AMA, pharmaceutical companies, and the FDA. The NCCAM should vigorously debunk such myths by providing facts and data.
  • The Center should pursue the question of why some people are stubbornly attracted to implausible, unproven, and/or inert treatments. Wally Sampson suggested this idea years ago. It is one of many legacies of the late Barry Beyerstein, among others, whose writings could serve as a template for legitimate NCCAM research topics.

The NCCAM’s Charter and its boosters in Congress make such strategies exceedingly unlikely, as explained here. Therefore, in this and two subsequent postings I’ll address a few of the assertions made in each of the Center’s three “big picture” essays. These will not be comprehensive critiques of those essays, which would require deconstructions of nearly every sentence.

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Posted in: Medical Academia, Medical Ethics, Politics and Regulation, Science and Medicine, Science and the Media

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Talking Science With Patient Advocates

Laurie Edwards has a rare chronic disease called primary ciliary dyskinesia. Her symptoms are quite similar to those associated with cystic fibrosis, and her young life has been punctuated by numerous hospitalizations, physical limitations and the occasional near-death experience. She is a remarkably upbeat woman, and attributes her self confidence and optimistic outlook to her loving friends and family.

Laurie is part of the patient blogging community online. She reads physician blogs with interest, and wants to protect others like her from snake oil and misinformation. She recently interviewed me about my pro-science views for a new book that she’s writing. People like Laurie play a critical role in accurate health communication, and I welcome the chance to discuss science-based medicine with them. Here are some excerpts from our chat: (more…)

Posted in: Science and the Media

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