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Archive for December, 2010

Compare and Contrast

I have been in Infectious Diseases for almost 25 years. I have two major jobs: I see inpatient consults and I chair the Infection Control program. I have been involved in quality improvement, especially as it relates to hospital acquired infections, for my entire career. It has been an interesting quarter century. Year after year we have driven down infection rates and other kinds of mortality and morbidity in hospitalized patients. Everyone recognizes that medicine is difficult and dangerous and its biggest problem is medicine is practiced by humans, who, I would venture to observe, are prone to mistakes and any number of cognitive errors.

It has not been a easy journey. People hate change and there has not always been certainty as to the best options to choose to solve a problem, a problem that continues today. For example, how best to treat a patient with potential methicillin resistant Staphylococcus aureus colonization (MRSA). Should we screen everyone? Screen high risk patients? Surgical patients? Do we decolonize, with the long term consequence of accelerating antibiotic resistance? Do we place everyone with MRSA in isolation, with the known decrease in care that patients in isolation may have? Everything we do has potential downsides and unintended consequences. No good deed ever goes unpunished.

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Posted in: Acupuncture, Chiropractic, Science and Medicine

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A Disconnect between cell phone fears and science

Disconnect: The Truth About Cell Phone Radiation, What the Industry Has Done to Hide It, and How to Protect Your Family by Devra Davis, PhD is touted as a book about the issue of cell phones and health. It is instead a tract that conspiracy theorists will love that sheds no objective light on the often confusing scientific data in this area. The tag line on the jacket sets the tone: The TRUTH about cell phone RADIATION. What the INDUSTRY has done to hide it, and how to PROTECT your FAMILY. In the area of EMF and health, there are a certain number of studies that appear to find biological “effects”. This is perfect fodder for alarmists like Davis, who ignore the fact that virtually none of these “effects” have been reproduced in follow up studies. If you were expecting an objective review of the often confusing scientific data in this area, you should avoid this book.

Disconnect focuses almost exclusively on studies that support its alarmist conclusions while either ignoring or falsifying information about studies showing no harm. The quality of scientific studies varies greatly. Disconnect is highly selective and totally biased in discussing only studies that support its point of view, it rejects contrary studies accepted by the majority of mainstream scientists as the product of some vast conspiracy, and it completely misstates the findings of key studies that find no harm from cell phones. She interviewed only a relatively small group of dissident scientists who are outside of the mainstream. The book is completely lacking in objectivity.

Major Factual Misstatements

There are so many things wrong in Disconnect that it is difficult to know where to begin. We will start by reviewing a few of the most blatant examples of how it misrepresents key findings of some of the most important cell phone studies.
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Posted in: Book & movie reviews, Cancer, Epidemiology

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The Acupuncture and Fasciae Fallacy

Let us be certain of a fact before being concerned with its cause. It is true that this method is too lengthy for most people who naturally run to the cause and overlook the certitude about facts; but at last we will avoid the ridicule of finding the cause of what does not exist.1

Bernard le Bovier de Fontenelle (1657-1757)

Amidst the plethora of flawed, implausible, and wasteful research on acupuncture and Chinese medicine, a 2002 study on the “Relationship of Acupuncture Points and Meridians to Connective Tissue Planes” stands out as the height of factual neglect. In it, Helene Langevin and Jason Yandow of the University of Vermont’s College of Medicine claim to have matched real anatomical structures with the elusive acupuncture “meridians.” It should be noted that the widely accepted term “meridian” is a metaphor coined by George Soulié de Morant (1878 – 1955), a French delegate to China, and has no semantic relationship with the original Chinese word.2 The original designation is the composite word jing luo (經絡), which literally means “channel-network.” The term has been translated to English as chinglo channels, channels, vessels or more commonly, meridians. Debunking this study is of particular relevance because it is often used by acupuncturists and a wide range of other CAM providers to legitimize the meridian lore. The principle author, Helene Langevin, is a CAM celebrity and a member of the “Scientific Committee” of the International Fascia Research Congress, an organization dedicated to the “emerging field of Fascia Studies.” She is an Associate Professor of Neurology and the Director of the Program in Integrative Health at the University of Vermont; and has conducted multiple NCCAM-funded studies on the role of connective tissue in chronic pain, acupuncture and manual therapies.
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Posted in: Acupuncture, Medical Academia

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CAM Use by Brain Tumor Patients

A recent article in the journal Neurology reports the results of an observational study regarding the use of so-called complementary and alternative medicine (CAM) by patients with an incurable brain glioma. They found that 40% of patients sought some type of CAM treatment. These results are in line with prior surveys, but require closer inspection.

The study defined CAM as:

Complementary therapy was defined as methods or compounds not used in routine clinical practice and not scientifically evaluated.

This is a problematic definition, but reflects the fact that there is no universally accepted and clean definition of CAM. CAM is a hodge-podge of therapies and modalities that have only one thing in common – they have not met the science-based standard of care. It is not accurate to say that they are “not scientifically evaluated.” Some CAM therapies have not been evaluated, but many have, and have already been adequately found to lack efficacy. In the current study homeopathic remedies were the most commonly reported. Homeopathy has certainly been studied – and found to be indistinguishable from placebo.

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Posted in: Epidemiology

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Lest We Forget: Influenza Can Be Devastating

One of our readers suggested that I review the book The Great Influenza: The Epic Story of the Deadliest Plague in History, by John M. Barry. It’s not a new book (it was published in 2004) but it is very pertinent to several of the issues that we have been discussing on this blog, especially in regards to the current anti-vaccine movement. It’s well worth reading for its historical insights, for its illumination of the scientific method, and for its accurate reporting of what science has learned about influenza.

In the great flu epidemic of 1918, influenza killed as many people in 24 weeks as AIDS has killed in 24 years. It’s hard to even imagine what that must have been like, but this book helps us imagine it. It tells horror stories: children found alone and starving beside the corpses of their parents in homes where all the adults had died, decomposing bodies piling up because there was no one left who was healthy enough to bury them. Sometimes the disease developed with stunning rapidity: during one 3 mile streetcar trip, the conductor, 3 passengers, and the driver died. In another incident, apparently healthy soldiers were being transferred to a new post by train; during the trip, men started coughing, bleeding, and collapsing; and by the time it arrived at its destination, 25% of the soldiers were so sick they had to be taken directly from train to hospital. 2/3 of them were eventually hospitalized in all, and 10% of them died. The mind boggles. (more…)

Posted in: Book & movie reviews, History, Public Health

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Placebo effects without deception? Well, not exactly…

In discussing “alternative” medicine it’s impossible not to discuss, at least briefly, placebo effects. Indeed, one of the most common complaints we at SBM voice about clinical trials of alternative medicine is the lack of adequate controls — meaning adequate controls for placebo and nonspecific effects. Just type “acupuncture” in the search box in the upper left hand corner of the blog masthead, and you’ll pull up a number of discussions of acupuncture clinical trials that SBM bloggers have written over the last three years. If you check some of these posts, you’ll find that in nearly every case we spend considerable time and effort discussing whether the placebo or sham control used was adequate, noting that, the better the sham controls, the less likely acupuncture studies are to have a positive result.

Some of the less clueless advocates of “complementary and alternative medicine” (CAM) seem to realize that much of what they do relies on placebo effects. As a result, they tend to argue that what they do is useful and good because it’s “harnessing the placebo effect” for therapeutic purpose. One problem that advocates of SBM (like those of us at SBM who have taken an interest in this topic) tend to have with this argument is that it has always been assumed that a good placebo requires on some level at least some deception of the patient by either saying or implying that he is receiving an active treatment or medicine of some kind. This, we have argued, is a major ethical problem in using placebos in patients, and advocates of placebo medicine appear to agree, because they frequently argue that placebo effects can be harnessed without deception. Indeed, just last week there was an example of this argument plastered all over multiple news outlets and blogs in the form of stories and posts with headlines and titles like:

Except for one, every one of these articles or blog posts discussing a new study in PLoS ONE that purports to have found that placebo effects can be elicited in irritable bowel syndrome (IBS) without deception buys completely into that very thesis. For example, here is an example, taken from the Reuters story about this study:

Placebos can help patients feel better, even if they are fully aware they are taking a sugar pill, researchers reported on Wednesday on an unusual experiment aimed to better understand the “placebo effect.”

Nearly 60 percent of patients with irritable bowel syndrome reported they felt better after knowingly taking placebos twice a day, compared to 35 percent of patients who did not get any new treatment, they report in the Public Library of Science journal PLoS ONE.

“Not only did we make it absolutely clear that these pills had no active ingredient and were made from inert substances, but we actually had ‘placebo’ printed on the bottle,” Ted Kaptchuk of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, who led the study, said in a statement.

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Posted in: Clinical Trials, Neuroscience/Mental Health, Pharmaceuticals, Science and the Media

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Vaccines are a pain: What to do about it

As much as I support vaccines, I see the short term consequences. Vaccines can be painful. Kids don’t like them, and parents don’t like seeing their children suffer. That this transient pain is the most common consequence of gaining  protection from fatal illnesses seems like a fair trade-off to me. But that’s not the case for every parent.

Today’s post isn’t going to focus on the extremes of the anti-vaccination movement. Rather, it’s going to look at ways to make vaccines less painful and more acceptable to children. The pain of vaccines can lead to anxiety, fear, and even nonadherence with vaccination schedules. Fear of needles and injections is not uncommon, it’s estimated that 10% of the population avoids vaccinations for this reason.

The vaccine schedules are intense. Where I live, the public vaccination schedule specifies seventeen injections of six different products over six visits in the first 18 months of life, plus influenza vaccinations and one-offs like H1N1. That’s a lot of visits, and a lot of tears if a child doesn’t handle them well.

In light of what’s known about the prevalence of needle fears, their potential effect on vaccination adherence (that could persist through adult life), and the possible impact on public health because of unvaccinated individuals, it makes sense to do whatever we can to minimize the pain and discomfort of vaccines, increasing their acceptance to children and their parents. But what works? I’ve personally found Smarties (the real ones) and Dora the Explorer stickers are effective distractions and bribes. But I’m not about to call my n=2 trial good science. Nicely, there’s much more evidence to guide our recommendations.

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Posted in: Vaccines

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Like a Car Accident, Slow Down and Stare.

I gave a lecture last fall on The Vaccine Pseudocontrovery for Oregonians for Science and Reason.  There are evidently Oregonians against Science and Reason, hence the title.  My Dad went and said it was a good talk. You going to argue with Dad? I think not.

Someone with a handheld camera recorded it, edited it, and put it up on the YouTubes in four parts.  The first part is here:

http://www.youtube.com/watch?v=yAMZF7iaTcQ&feature=related

It was also Quackcast #45 as well, so you may have heard it all before.

If you can’t be self-aggrandizing, what’s the point of having a blog?

Posted in: Announcements

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Echinacea for Cold and Flu

Echinacea continues to be a popular herbal product, used primarily for treating and preventing colds and flus. Sales were estimated at $132 million in the US alone in 2009, an increase of 7% over the previous year. Reports of major negative clinical trials have had only a modest and temporary effect on the popularity and sale of this herb, contradicting claims that the utility of such research is to inform consumers.

In the current issue of the Annals of Internal Medicine there is a new study of Echinacea for the treatment of cold symptoms: Echinacea for Treating the Common Cold, A Randomized Trial. I won’t hold out the punchline – the study was completely negative. But let’s put the results of this study into the context of the history of Echinacea and the clinical evidence.

History of Echinacea

Modern proponents of Echinacea frequently cite as support the claim that this plant has been used for centuries by many Native American cultures. This much is well-documented, but what is not clear is what Echinacea was used for. For this there is no clear answer, except that Echinacea was used for 15-20 different and unrelated conditions, from fatigue to snake bites. Let us consider the value of the claim for traditional use of any treatment.

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Posted in: Herbs & Supplements

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A New Perspective on the War against Cancer

 Myths and misconceptions about cancer abound. Oncologists are frequently criticized for torturing patients by burning, cutting and poisoning without making any real progress in the war against cancer. Siddhartha Mukherjee, an oncologist and cancer researcher, tries to set the record straight with his new book The Emperor of All Maladies: A Biography of Cancer.  

It is a unique combination of insightful history, cutting edge science reporting, and vivid stories about the individuals involved: the scientists, the activists, the doctors, and the patients. It is also the story of science itself: how the scientific method works and how it developed, how we learned to randomize, do controlled trials, get informed consent, use statistics appropriately, and how science can go wrong. It is so beautifully written and so informative that when I finished it I went back to page 1 and read the whole thing again to make sure I hadn’t missed anything. I enjoyed it just as much the second time.

 Mukherjee says

It will be a story of inventiveness, resilience, and perseverance against what one writer called the most “relentless and insidious enemy” among human diseases. But it will also be a story of hubris, arrogance, paternalism, misperception, false hope, and hype, all leveraged against an illness that was just three decades ago widely touted as being “curable” within a few years. (more…)

Posted in: Book & movie reviews, Cancer, History

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