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Archive for 2010

Is breech vaginal delivery safe?

Between 3-4% of babies begin labor in the breech (bottom first) position, increasing the risk of neonatal morbidity and mortality. Pre-emptive C-section has become the preferred method of delivery for breech babies, but now some are questioning this recommendation. The controversy is fueled by differing appraisals of the danger and by differing assessments of the whether any risk of neonatal death can be justified in the age of the safe Cesarean.

The best conducted and most important study comparing breech vaginal delivery with elective C-section is the Term Breech Trial (TBT) conducted by Mary Hannah and colleagues. It is the only randomized control trial of its kind.

… [W]e found that the fetuses of women allocated planned caesarean section were significantly less likely to die or to experience poor outcomes in the immediate neonatal period than the fetuses of women allocated planned vaginal birth. Although some of the deaths in the planned vaginal birth group were related to difficulty with vaginal breech delivery, others were clearly associated with problems during labour. Thus the avoidance of labour and vaginal breech delivery could have contributed to better outcomes with planned caesarean section…

A more recent trial, the PREMODA (PREsentation et MODe d’Accouchement: presentation and mode of delivery) study produced different findings and as a result, some obstetricians have been calling for a re-evaluation of the standard recommendation for C-section delivery of a breech baby. (more…)

Posted in: Obstetrics & gynecology, Science and Medicine

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The War on Salt

The problem with the Western diet is not one of deficiency, but one of excess. We get too much of a good thing – too many calories, too much of the wrong kind of fat, and too much salt. As a result obesity, diabetes, and hypertension are growing health problems.

There also does not appear to be an easy solution – voluntary diets founded primarily on will power are notoriously ineffective in the long term. Add to that is the marketplace of misinformation that makes it challenging for the average person to even know where to apply their (largely ineffective) will power.

It can be argued that this is partly a failure, or an unintended consequence, of market forces. Food products that provide cheap calories and are tasty (sweet, fatty, or salty) sell well and provide market incentives to sell such products. Consumers then get spoiled by the cheap abundance of tempting foods, even to the point that our perspective on appropriate portion sizes have been super-sized.

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Posted in: Science and Medicine

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The Water Cure: Another Example of Self Deception and the “Lone Genius”

A correspondent wrote:

I hear all day long on my local radio station commercials for The Water Cure, which was created by a Dr. Batmangelli (I have no idea how to spell his name) promising wonderful cures by eliminating caffeine and alcohol and drinking water and sprinkling sea salt on your food. If you REALLY want to get cured even faster, swim in the ocean everyday.

That’s Dr. Fereydoon Batmanghelidj. His Big Idea was that dehydration is the main cause of disease. It was untenable to begin with, is supported by no evidence, was debunked on Quackwatch several years ago, and Dr. Batmanghelidj died in 2004, so I was surprised to hear it was still being vigorously promoted. But not very surprised. After all, homeopathy is still around.

The Water Cure is another in a long list of alleged miracle cures discovered by “lone geniuses” who are allegedly persecuted by a resistant medical establishment. These stories follow a pattern, and I think it is worthwhile looking at this prime example to understand something of the psychology of self-deception that is involved. (more…)

Posted in: Science and Medicine

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Be careful what you wish for, Dr. Dossey, you just might get it

If there’s one thing about the so-called “complementary and alternative medicine” (CAM) movement that I’ve emphasized time and time again, it’s that its adherents have a definite love-hate relationship with science. They hate it because it is the single greatest threat to their beliefs system and the pseudoscience that underlies it. At the same time, they crave the legitimacy that science confers. They crave it not because they have any great love for science. Quite the contrary. It is simply that they recognize that science actually delivers the goods. Of course, they believe that they deliver the goods too, but they come to this belief not through science but rather through all the cognitive shortcomings and biases to which humans are prone, such as confusing correlation with causation, confirmation bias, not recognizing regression to the mean, and being fooled by the placebo effect. Whether it’s through a misunderstanding of science or less innocent reasons, they go to great lengths to torture it into superficially appearing to support their claims through a combination of cherry-picking of studies that seem to support them and misrepresenting ones that don’t, discussions of which abound right here in this very blog.

The other thing I’ve emphasized about the CAM movement is that, even more than scientific credibility, they crave legitimacy. To them, however, science is but one pathway to legitimacy, because, unlike practitioners of science-based medicine, they are more than willing to bypass science to obtain the legitimacy–or at least the appearance of the legitimacy–they so crave. If it means doing an end run around science by trying to hijack the Obama health insurance reform bill that is currently being negotiated to resolve the differences between the Senate and House versions, so be it. Indeed, earlier this year, I described how Senator Tom Harkin has tried to promote CAM through the National Center for Complementary and Alternative Medicine (NCCAM) and trying to insert provisions into the bill that would mandate that government-subsidized insurance exchanges pay for CAM. Meanwhile, prominent CAM advocates have been carpet-bombing the media with dubious arguments in support of CAM, as in when Deepak Chopra, Rustum Roy, Dean Ornish, and Andrew Weil teamed up in different combinations to promote the idea that CAM is all about “prevention” and that science-based medicine, in all its reductionistic evil, is nothing more than pushing pills.

They’re at it again.
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Posted in: Energy Medicine, Herbs & Supplements, Homeopathy, Medical Academia, Neuroscience/Mental Health, Politics and Regulation

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James Ray and testosterone replacement therapy (TRT)

For the last four years I have served in a volunteer capacity among a panel of pharmacotherapy experts queried regularly by the ABC News Medical Unit about breaking or upcoming news involving the efficacy and safety of drugs and supplements. Where appropriate, I provide background information that informs the story.

My incentive is largely to put my time where my mouth is when I say that scientists need to take a more active role in making sure medical stories are reported accurately. An additional dividend is paid to my students who then benefit from my presentation of the science behind timely medical developments.

On occasion, perhaps once or twice a year, I’ll be asked for an on-camera interview. Even when this occurs, the resulting story will contain no more than 15 seconds of the interview and some summary by the reporter of other issues we discussed. I take this responsibility very seriously and prepare as much as I can given the deadlines of the press and my daily education and research schedule.

But given airtime constraints, much of what I prepare would normally end up in the abyss of my files and come out in the classroom when I lecture about that particular topic. Blogging, however, now allows us to expand further on stories where we are consulted, giving us an opportunity to air, albeit to a smaller audience, the information we found important from our perspective. Authoring a blog, therefore, takes away the excuse some scientists and physicians have in not wanting to talk to the press: “There’s never enough airtime to tell the whole story the way I would tell it.”

This post was informed by one of those brief appearances, this time on ABC World News Sunday with Dan Harris. The interview was solicited last weekend following the release of information obtained during the execution of a search warrant in lodging occupied by the self-help guru, James Arthur Ray, who led an Arizona sweat lodge ceremony last October where three people ultimately died and almost two dozen were hospitalized. The segment was not archived to the World News website but some ABC affiliates subsequently aired truncated versions of the story.
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Posted in: Pharmaceuticals, Science and the Media

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A victory for science-based medicine

The following is a collaborative effort by Peter Lipson, MD, a usual contributor to Science-Based Medicine, and Ames Grawert, JD, a soon-to-be-sworn-in attorney working in New York City.

Proponents of science-based medicine have always had one major problem—human beings are natural scientists, but we are also very prone to cognitive mis-steps. When we follow the scientific method we have developed, we succeed very well in understanding and manipulating our environment. When we follow our instincts instead, we frequently fail to understand cause and effect. This is how people on the fringes of medicine and science survive—intentionally or otherwise, they exploit our natural tendency to have too much faith in our own non-systematic observations.

One of the most important examples of this is the anti-vaccination movement (hereafter called the “infectious disease promotion movement” or IDPM). There have always been those suspicious of medicine and science, but the IDPM has taken this a step farther. They encourage people to “go with the gut”, ignoring centuries of science and public health data in favor of superstition. It’s not hard to exploit a parent’s fears. But exploiting these fears leads to real harm as many of us in the blogosphere have documented (and documented, and documented).

The IDPM is so fixed on their false beliefs that vaccination causes some sort of serious harm that they cannot be swayed by evidence. As each piece of their hypothesis is disproved, they move on to the next. Thimerosal doesn’t lead to autism? Then maybe it’s “the toxins”. Once the idea is fixed, there is no way to dislodge it. It simply shifts around a bit.

Since there is no science to lend legitimacy to the infectious disease promoters, they must rely on appeals to emotion. Most of their websites are full of testimonials, misinformation, and outright hostility. And when they really get backed into a corner, rather than hunkering down to do some real science, they sue.

Dr. Paul Offit is a nationally known expert on vaccination. He was featured in an excellent article by WIRED reporter Amy Wallace in which he said, among other things:

She lies.

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Posted in: Science and Medicine

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The case for neonatal circumcision

Imagine if we could save lives from a dread and often fatal disease simply by performing a minor surgical procedure. People would hail this simple victory and rush to adopt it… Not exactly. The disease is HIV and the simple surgical procedure is circumcision and anti-circ activists oppose it under almost any circumstances.

In this month’s edition of the Archives of Pediatrics and Adolescent Medicine, Tobian, Gray and Quinn present a compelling case for neonatal circumcision. The paper is entitled Male Circumcision for the Prevention of Acquisition and Transmission of Sexually Transmitted Infections. The authors report:

The American Academy of Pediatrics (AAP) male circumcision policy states that while there are potential medical benefits of newborn male circumcision, the data are insufficient to recommend routine neonatal circumcision. Since 2005, however, 3 randomized trials have evaluated male circumcision for prevention of sexually transmitted infections. The trials found that circumcision decreases human immunodeficiency virus acquisition by 53% to 60%, herpes simplex virus type 2 acquisition by 28% to 34%, and human papillomavirus prevalence by 32% to 35% in men. Among female partners of circumcised men, bacterial vaginosis was reduced by 40%, and Trichomonas vaginalis infection was reduced by 48%. Genital ulcer disease was also reduced among males and their female partners. These findings are also supported by observational studies conducted in the United States. The AAP policy has a major impact on neonatal circumcision in the United States. This review evaluates the recent data that support revision of the AAP policy to fully reflect the evidence of long-term health benefits of male circumcision.

The AAP had long recommended male circumcision for prevention of urinary tract infections in young boys, but backed down in 1999, partly in response to pressure from anti-circumcision activists. According to circumcision.org:

Based on a review of medical and psychological literature and our own research and experience, we conclude that circumcision causes serious, generally unrecognized harm and is not advisable.

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Posted in: Science and Medicine

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Acupuncture for Hot Flashes

ResearchBlogging.orgIn the most recent issue of The Journal of clinical Oncology is a study comparing acupuncture to Effexor in the treatment of vasomotor symptoms (hot flashes) in women with breast cancer who cannot take hormone replacement therapy. The study found that the two treatments are equivalent, with longer duration and fewer side effects from acupuncture. However, the study is designed as a pilot study (very preliminary) and therefore the conclusions are highly unreliable – given prior research, this raises the question as to why the study was performed at all.

The study included only 50 women, which is a small number for a clinical trial and alone means this is at best a preliminary study. There were 25 women randomized to one of two arms – either acupuncture or Effexor (which is standard treatment for vasomotor symptoms in women with breast cancer). However, the two arms were not blinded in any way, and there was no acupuncture control group – no sham or placebo acupuncture.

It is unclear why the researchers undertook a small unblinded study such as this, given that previous studies were better designed.

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Posted in: Science and Medicine

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Osteoporosis Drugs: Good Medicine or Big Pharma Scam?

A recent story on NPR accused the drug manufacturer Merck of inventing a disease, osteopenia, in order to sell its drug Fosamax. It showed how the definition of what constitutes a disease evolves, and the role that drug companies can play in that evolution.

Osteoporosis is a reduction in bone mineral density that leads to fractures. The most serious are hip fractures, which require surgery, have complications like blood clots, and carry a high mortality. Many of those who survive never walk again. Vertebral fractures are common in the osteoporotic elderly and are responsible for dowager’s hump and loss of height. There is also an increased risk of wrist and rib fractures.

Bone density tends to decrease with age. Postmenopausal women are particularly susceptible to osteoporosis when their production of estrogen declines. The risk is increased in people taking corticosteroids and in people with certain diseases like rheumatoid arthritis. Other risk factors are European or Asian ancestry, smoking, excess alcohol, a family history of fractures, vitamin D deficiency, too much or too little exercise, malnutrition, and low body weight.

When a measurement like bone density varies widely in a population and decreases with age, how can we decide where to draw the line and call it abnormal? When does it become a disease requiring treatment? (more…)

Posted in: Pharmaceuticals

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The anti-vaccine movement strikes back against Dr. Paul Offit

In my five years in the blogosphere, two years blogging for SBM, and over a decade in Internet discussion forums about medicine and “alternative” medicine, I’ve learned a few things. One thing that I’ve learned is that one of the biggest differences between those whose world view is based on science and who therefore promote science-based medicine and those promoting pseudoscience, quackery, and anti-science is that science inculcates in its adherents a culture of free, open, and vigorous debate. Indeed, to outsiders, this debate can seem (and sometimes is) vicious. In other words, if you’re going to be a scientist, you need to have a thick skin because you will have to defend your hypotheses and conclusions, sometimes against some very hostile other scientists. That same attitude of a Darwinian struggle between scientific ideas, with only those best supported by evidence and with the most explanatory power surviving, is a world view that those not steeped in science have a hard time understanding.

Among those who don’t understand science, few have a harder time with the rough-and-tumble debate over evidence and science that routinely goes on among scientists than those advocating pseudoscience. Indeed, in marked contrast to scientists, they tend to cultivate cultures of the echo chamber. Examples abound and include discussion forums devoted to “alternative” medicine like CureZone, where never is heard a discouraging word — because anyone expressing too much skepticism about the prevailing view on such forums invariably finds himself first shunned by other members of the discussion forums and then, if he persists, booted from the forum by the moderators. In marked contrast, on skeptical forums, most of the time almost anything goes. True, the occasional supporter of woo who finds his way onto a skeptical forum will face a lot of criticism, some of it brutal. However, rarely will such a person be banned, unless he commits offenses unrelated to his questioning of scientific dogma, such as insulting or abusive behavior towards other forum participants or trolling. Such people may annoy the heck out of us skeptics sometimes, but on the other hand, they do actually from time to time challenge us to defend our science and prevent us from becoming too complacent. Indeed, that’s what I like about skeptics and being a scientist. Nothing or no one is sacred.
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Posted in: Chiropractic, Politics and Regulation, Public Health, Vaccines

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