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Archive for 2013

Patient Participation in Decision-Making

“Patient-Centered” decision-making is a new buzz-word in medicine. It is a metaphor for a general approach to care that puts the patient’s experience and needs at the center, as opposed to the needs of the physician or the system.

While this is an effective marketing term, and a useful principle as far as it goes, as a guide to medical practice it is a bit simplistic. It needs to be viewed in the context of the overall medical infrastructure and the net effect specific practices have on the cost and effectiveness of medical care.

A 2012 NEJM editorial by Charles Bardes nicely summarizes the issues. He notes that patient-centered care represents the next step in a general trend (a good trend) in the medical profession over the last half-century:

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Posted in: Science and Medicine

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Coconut Oil

In a former life, when I was an Air Force doctor, one of my duties was to give “Healthy Heart” briefings with a script furnished by Air Force experts. It covered the scientific consensus of the time (the early 80s) about diet. It recommended a low fat diet, restricted cholesterol and saturated fat, and demonized tropical oils like palm oil and coconut oil. (Trans fats weren’t yet on the agenda.)

Times have changed. Today we are more lenient about cholesterol in the diet, less concerned about total fat and saturated fat, and more concerned about trans fats. While many major health organizations still discourage its use, coconut oil has not only been rehabilitated in the public mind, but all kinds of health benefits are being claimed for it.

The fats in coconut oil
Coconut oil is high in saturated fats; it contains more saturated fatty acids than any other non-hydrogenated oil. It is stable and has a long shelf life. It is used in movie theaters to pop popcorn and in South Asian cuisine for dishes like curries. A hydrogenated version of coconut oil is an ingredient in non-dairy creamers. Much of the research done on coconut oil studied hydrogenated or partially hydrogenated forms. According to an article in the New York Times:

Partial hydrogenation creates dreaded trans fats. It also destroys many of the good essential fatty acids, antioxidants and other positive components present in virgin coconut oil. And while it’s true that most of the fats in virgin coconut oil are saturated, opinions are changing on whether saturated fats are the arterial villains they were made out to be. “I think we in the nutrition field are beginning to say that saturated fats are not so bad, and the evidence that said they were is not so strong,” Dr. Brenna said.

Coconut oil contains lauric acid, which raises both HDL and LDL cholesterol levels. This may improve the cholesterol profile, although there are concerns that it may promote atherosclerosis by other means. Virgin coconut oil contains medium-chain triglycerides, which are not as risky as some other saturated fats.
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Posted in: Herbs & Supplements, Nutrition

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“Alternative Medicine: Sense and Nonsense” Upcoming Lecture by Dr. Paul Offit

For those of you in the NYC/LI area:  An Invitation from the Cold Spring Harbor Laboratory for a Free Public Lecture!

Please join us for the 2013 Lorraine Grace lectureship on societal issues of biomedical research:

Alternative Medicine: Sense and Nonsense

Saturday, June 8, 2013

3:00pm

Grace Auditorium

One Bungtown Road

Cold Spring Harbor, NY 11724

Americans love alternative medicine, and they are paying a high price for that devotion. From regular visits to acupuncturists, chiropractors and naturopaths to the daily ingesting of homeopathic remedies, Chinese herbs, and megavitamins, the use of alternative therapies has become a $34 billion-a-year business. Fifty percent of Americans use some form of alternative medicine, with ten percent using it on their children. Celebrities routinely hawk their benefits. But, does any of it really work?

In the upcoming lecture, Alternative Medicine: Sense and Nonsense, Dr. Paul A. Offit will take a critical look at the field of alternative medicine and separate fact from myth. Drawing on current research he will examine popular alternative therapies and discuss the issues of medical ethics involved in alternative medicine, which is a largely unregulated industry under no legal obligation to prove its claims or admit its risks.

“Making decisions about our health is an awesome responsibility,” writes Dr. Offit. “If we’re going to do it, we need to take it seriously. Otherwise we will violate the most basic principle of medicine: first do no harm.”

Come join us for a lively discussion!

The recipients of many awards and honors, Paul A. Offit, M.D. is Chief of the Division of Infectious Diseases and Director of the Vaccine Education Center at the Children’s Hospital of Philadelphia, as well as the Maurice R. Hilleman Professor of Vaccinology and Professor of Pediatrics at the University of Pennsylvania School of Medicine. He has appeared on The Today Show, Good Morning America, The Early Show, The Colbert Report, CNN, 60 Minutes, MSNBC, Dateline NBC, the Jim Lehrer NewsHour, CSPAN, FOX News, and National Public Radio, and is often interviewed in the New York Times, Washington Post, LA Times, Wall Street Journal, Chicago Tribune, and USA TODAY.

NOTE: In June,  Dr. Offit’s book, Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine will be released by Harper Collins.  Our own Dr. Harriet Hall has a review in an upcoming issue of Skeptical Inquirer.

Posted in: Announcements

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A brief note on killing cancer cells in a dish

I am taking the Memorial Day holiday off. I will return next week (or even earlier if something comes up that I can’t resist blogging about). In the meantime, here’s a general principle that needs to be remembered in cancer research:

I would also add to that list: So does bleach. So does acid. So does alkali. So does pouring the media out of the dish and letting the cells dry out. So do a variety of lethal poisons. So does heat. So does cold. The list goes on.

The point, of course, is that it’s very easy to kill cells in a cancer dish. What is difficult is selectively killing cancer cells in the human body while not harming normal cells.

See you all next week!

Posted in: Basic Science, Cancer

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A closer look at vitamin injections

Vitamins are magic. Especially when they’re injected. Roll up the sleeve, find a vein, insert a needle and watch that colourful concoction flow directly into the bloodstream. It may sound somewhat illicit, but that person infusing it is wearing a white coat, and you’re sitting in a chic clinic. There must be something to it, right? Intravenous vitamin injections are popular with celebrities and have even been described by Dr. Oz as “cutting edge”. Advocates claim vitamin injections can benefit serious conditions like cancer, Parkinson’s disease, macular degeneration, fibromyalgia, depression, and that modern-day obsession, “detoxification”. And vitamin infusions aren’t just for the ill. They’re also touted as helpful for preventing illness, too. A search for vitamin injections brings up millions of hits and dozens of advertisements. There is no question that vitamin injections are popular. But despite all the hype and all the endorsements, there is no credible evidence to suggest that routine vitamin infusions are necessary or offer any meaningful health benefit. Vitamin infusions are a marketing creation, giving the illusion you’re doing something for your health, but lacking any demonstrable efficacy. What’s more concerning, providers of vitamin therapies target their marketing at those fighting life-threatening illnesses like cancer, selling unproven treatments in the absence of good scientific evidence that they are beneficial.

The intravenous vitamin industry is a sideshow to science-based health care. Yes, there is an established medical role for injectable vitamins, though it’s no energy-boosting cure-all – they’re used to replace what we should obtain in our diet. As a hospital-based pharmacist I used to prepare sterile bags of total parenteral nutrition (TPN), a mixture of vitamins, carbohydrate, protein and fat that completely replaced the requirement to eat. TPN is effective, but not without risks, and far less preferable than getting your nutrients the old fashioned way – by eating them. There’s also the routine use of injectable vitamins like B12, or iron, all of which can be science-based when used to address true deficiencies, or to manage specific drug toxicities. And there is the therapeutic use of high-dose minerals like intravenous magnesium for acute asthma attacks. But there is no medical justification to infuse vitamins into a vein when you can more appropriately obtain those nutrients in your diet.
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Posted in: Herbs & Supplements, Naturopathy

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DSM-5 and the Fight for the Heart of Psychiatry

The fifth edition of the Diagnostics and Statistical Manual (DSM-5) was recently released. This is the standard reference of mental disorders and psychiatric illnesses released by the American Psychiatric Association (APA).

As with previous editions there is a great deal of discussion and wringing of hands over the details – which disorders were created or eliminated. For example hoarding is now considered its own disorder, rather than part of obsessive compulsive disorder (it has its own reality TV show, why not its own DSM diagnosis?).

This time around, however, the debate over the DSM goes much deeper than the particulars of specific diagnoses. The real debate is about the very existence of the DSM – its validity and utility. While this discussion is nothing new, it has taken on an unprecedented dimension with the rejection of the DSM by the National Institutes of Mental Health (NIMH). Director Thomas Insel wrote:

The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

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Posted in: Neuroscience/Mental Health

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Progressive Mythology

In their book Science Left Behind: Feel-Good Fallacies and the Rise of the Anti-Scientific Left, Alex Berezow and Hank Campbell counter allegations of a Republican war on science by pointing out how political progressives are equally anti-science. According to Berezow and Campbell, progressives hold opinions that are not based on physical reality, and claim that their beliefs are based on science even when they are not.

I try to stay out of politics, but anti-science attitudes should be discouraged wherever they are found, and the mythology of progressives as described by Berezow and Campbell is very much like the thinking of alternative medicine:

  1. Everything natural is good
  2. Everything unnatural is bad
  3. Unchecked science and progress will destroy us
  4. Science is only relative anyway

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Posted in: Book & movie reviews, Politics and Regulation

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Angelina Jolie, radical strategies for cancer prevention, and genetics denialism

I had been debating whether to blog about Angelina Jolie’s announcement last week in a New York Times editorial entitled My Medical Choice that she had undergone bilateral prophylactic mastectomy because she had been discovered to have a mutation in the BRCA1 gene that is associated with a very high risk of breast cancer. On the one hand, it is my area of expertise and was a big news story. On the other hand, it’s been nearly a week since she announced her decision, and the news story is no longer as topical as it was. Also, I’ve already written about it a couple of times on my not-so-super-secret other blog, making the division of blogging…problematic. So, if some of this is a bit repetitive to those who are also fans of my more—shall we say?—insolent persona, I apologize, but try to be patient. I will be doing more than just rehashing a couple of posts from last week (although there will unavoidably be at least a little of that), because there have been even more examples of reactions to Jolie’s announcement that provide what I like to consider “teachable moments.” I will start by asserting quite bluntly that in my medical opinion, from the information I have available, Angelina Jolie made a rational, science-based decision. How she went about the actual mechanics might have had some less than scientific glitches along the way (more about that later), but the basic decision to remove both of her breasts to prevent breast cancer associated with a BRCA1 mutation that she carried was quite reasonable and very defensible from a scientific standpoint.

One advantage of waiting nearly a week to write about this story is that it provided me with the opportunity to sit back and observe the reactions that Jolie’s decision provoked. One thing that I really didn’t expect (although in retrospect maybe I should have) is the pure denialism on display that genes have any effect whatsoever on cancer. I say “in retrospect I should have” because I’ve written at least a couple of times before about how quacks use and abuse the term “epigenetics” in the same way that they abuse the word “quantum” and how they seem to believe that wishing makes it so (through epigenetics, of course!) to the point where they believe that genetics is irrelevant to cancer. Indeed, they go far beyond that, asserting that, in essence, environment is all. From what I’ve been reading thus far, the second strongest strain of reaction to Jolie’s announcement (after revulsion at the “mutilation” of women that it represented to certain quacks) is pure denial that mutations in BRCA1 and BRCA2 genes portend such a high risk of ultimately developing breast cancer. This denial is often accompanied by conspiracy mongering about BRCA1 and BRCA2 mutations being a “conspiracy” on the part of the “cancer industry” and Myriad Genetics & Laboratories, the company that holds the patents on BRCA1 and BRCA2, to increase genetic testing and preventative mastectomies. Myriad happens to have a complete monopoly on BRCA1 and BRCA2 testing because of this patent and has been criticized for its high prices and stifling of competition. There is currently a case before the U.S. Supreme Court regarding whether human genes are patentable under the law. I’m not a big fan of Myriad, and I’ll tell you why later. (Not that it matters; I’m stuck with them for now.) My personal distaste for Myriad Genetics aside, this sort of conspiracy mongering is part and parcel of the quack approach to denying the significance of BRCA1 mutations.

This denial is usually coupled with confident blather that Angelina Jolie didn’t need to undergo “disfiguring” surgery to prevent BRCA1-associated breast cancer but instead could have achieved the same—or even better!—risk reduction if only she had used this magic herb or that miracle supplement and making certain “lifestyle” changes. It’s utter nonsense, of course, but it’s everywhere.

Before I get to the reactions to Jolie’s announcement, let’s first take a look at what she did, why, and the science behind it.
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Posted in: Basic Science, Cancer, Medical Ethics, Science and the Media

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Whack em hard/Whack em once and Stroke

There is no satisfaction in hanging a man who does not object to it.
~ George Bernard Shaw

I work in a 5-hospital system and many of us practice at several hospitals. The residents rotate through at least three of the hospitals and the peripatetic nature of health care allows word of curious cases to percolate through the system.  My current resident mentioned that there was a case of a vertebral artery dissection in a young female shortly after chiropractic neck manipulation.

Man, that’s awful. Is she doing OK?

Evidently there were no permanent neurologic sequelae. She dodged that bullet. Or perhaps that noose, as I once calculated that the force of a neck crack is about 40% that of hanging by the neck and it has the same pathologic changes if it goes wrong. Every time I see a death in the movie where the neck is twisted to break it, I think chiropractic, although some tolerate it better than others.

I have not written on CNS events related to chiropractic since 2008, although the topic has been covered by Dr. Hall.  I still suspect that occasionally there is a perfect storm of bad luck, the forces are perfectly aligned in a susceptible patient and they get an embolic stroke or a vertebral artery tear.
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Posted in: Chiropractic, Clinical Trials

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FDA v. Jack3d: Round 2

Jack3d is a dietary supplement manufactured by USPlabs and promoted by the giant supplement retailer GNC as producing “ultra-intense muscle-gorging strength, energy, power and endurance.” A key ingredient is DMAA, which the FDA doesn’t think is a proper dietary supplement ingredient at all and wants Jack3d and other products containing it removed from the shelves and the web. The FDA also questions its safety.

As discussed in a previous post on the subject, both USPlabs and GNC maintain Jack3d (pronounced “jacked”) is safe when properly used. Apparently few agree with them on this point: not the FDA, not the U.S. military, not the countries and athletic associations which have banned DMAA. And certainly not the parents of Michael Lee Sparling, a 22-year-old Army private. The Sparlings filed a lawsuit alleging Jack3d caused the death of their son, who went into cardiac arrest and died after using it.

Here is where we left off the last time we looked at DMAA:

Last April [2012], the FDA sent warning letters to several supplement manufacturers saying it had no evidence DMAA is a legitimate dietary ingredient and citing its risks. (Health regulators in other countries, such as Sweden and Denmark, have actually banned DMAA-containing supplements.) Heart attacks, heart failure, kidney failure and liver failure were among the health problems reported to the FDA, as well as 5 deaths. GNC responded that it was “completely opposed to this unilateral, factually and legally unfounded action by the FDA.”

Now to Round 2.
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Posted in: Herbs & Supplements, Legal, Politics and Regulation

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