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How to make a difference – Responsible vaccine advocacy

I lost a patient this season, an infant, to pertussis.  After falling ill he lived for nearly a month in the intensive care unit on a ventilator, three weeks of which was spent on a heart/lung bypass machine (ECMO) due to the extent of the damage to his lungs, but all our efforts were in vain.  The most aggressive and advanced care medicine has to offer couldn’t save his life; the only thing that could have saved him would have been to prevent him from contracting pertussis in the first place.

He was unvaccinated, but that was because of his age.  He was part of the population that is fully dependent on herd immunity for protection, and that is exquisitely prone to a life-threatening course once infected.  This is a topic we’ve covered ad nauseum, and I’m not inclined to go into greater depth in this post.  Suffice it to say his death is a failure at every level; we, both as medical professionals and as a society at large need to do a better job of protecting our children from preventable diseases. (more…)

Posted in: Public Health, Science and Medicine, Vaccines

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Californians give a whoop – or I hope they do.

I’m certain by now many of our readers have come across news of the current pertussis, aka whooping cough, epidemic in California.  Beginning this February and accelerating dramatically through May and June, California has so far seen a ~500% increase in pertussis cases compared to last year, and only two days ago announced the death of a sixth baby from infection.  Public health officials in California are currently working to control its spread and determine the factors that allowed this outbreak to occur, unfortunately, at this time the available data is very rough.

The number of confirmed cases as of 6/30/2010 is growing rapidly (1,377), with an additional ~700 cases pending investigation.  General geographic location, ages, and ethnicity have been identified, and general vaccination rates and exemption rates are known, but other important demographic and epidemiologic data, including vaccination status of infected children and adults, has yet to be fully described.  Lack of data notwithstanding, I have read equally hasty stories and comments blaming the outbreak on vaccine refusal, a large immigrant population, an inadequate adult vaccination program, and normal cyclical variation in pertussis incidence, among other factors.  Finding where the system has broken down enough to allow this resurgence is exceedingly important, but in this situation pointing fingers is not as important as taking action. (more…)

Posted in: Science and Medicine

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Snake oil for snakebites (and other bad ideas)

Spring is here.  I don’t say that because of the warmer weather, the blooming tulips in my back yard, or the current effect of the earth’s axial tilt on the Northern hemisphere.  No, in my somewhat warped world of the pediatric ICU seasons are marked by illnesses and injuries with an annual rhythm.  Fall begins with a spike in cases of bronchiolitis, Summer with a near-drowning in a swimming pool.  Winter has arrived when seasonal influenza reappears.  And Spring, well, Spring has several harbingers, including auto vs bicycle accidents, falls from windows, and snakebites.

Sure enough, this week we admitted our first child of the year bitten by a venomous snake who, like most people unfortunate enough to be envenomated by a North American pit viper, has done very well.  This child fell prey not only to our local limbless fauna, but also to one of several common myths or misunderstandings about snakebites that place the victim, rescuer, or both at higher risk for injury and complications.  This post will explore some of the more common mistakes people make during North American snakebite encounters (being limited to snakes native to North America, the following does not necessarily apply to snakes from other areas).

File this post under Science-Based-You’re-Not-Helping-Please-Don’t-Do-That.

Myth #1: You Need to Know the Species / Kill the Snake

North America has around 120 species of snake, over 20 of which are venomous.  With so many species, it may seem important to ID the snake so the docs in the ED can give the appropriate anti-venin.  Fortunately, that isn’t the case. (more…)

Posted in: Science and Medicine

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Dr. Jay Gordon: Full of sound and fury, signifying nothing

There is a trend in the media when presenting a contentious topic to provide balance.  For topics not founded upon objective facts this serves the media well; provide both sides of the argument, and let the viewer decide.  The problem is that not every issue is evenly balanced, particularly in science.  Covering the discovery of a new extra-solar planet by giving equal airtime to astronomers and astrologers, for example, would be the height of absurdity, yet this is precisely how the media approaches scientific topics with frightening regularity.  You need look no further than the coverage of evolution, or 2012, or global climate change (that list should derail the comments nicely) for excellent examples of the same type of false balance in mainstream media outlets.

It was with trepidation, then, that I waited to see how PBS’s Frontline handled the topic of vaccination.  I was pleasantly surprised.  “The Vaccine War” introduced the most common concerns expressed about vaccination, and then presented the evidence addressing each concern in turn clearly and concisely.  It gave airtime to some rather prominent anti-vaccine personalities, but the bulk of the program was dedicated to the data, the science, the evidence, and where answers are available it did not hesitate to present them baldly and clearly. “The Vaccine War” was not a comprehensive review of every perspective, every theory, every vaccine and study, but it did provide a fair discussion balanced by the science.

My first clue that Frontline had acquitted itself well was when Dr. Jay Gordon, pediatrician to Jenny McCarthy’s son, tweeted his opinion of the show:

PBS show about vaccines. Don’t bother to watch it.” (more…)

Posted in: Science and Medicine, Vaccines

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Homeopathy – Failing Randomized Controlled Trials Since 1835

I’m sad to say that this is the last day of World Homeopathy Awareness Week.  We’ve tried to give homeopathy its due honor, providing it the attention its practitioners clearly desire, while continuing to cover pertinent news in the world of homeopathy and providing a somewhat more sober, rational discussion of it on our homeopathy reference page.

Of course, most of this has not been news in the literal sense of the word.  There hasn’t been anything truly new in homeopathy since its invention (no, not discovery; discovery implies that something actually exists to be found) by Hahnemann in 1796.

Well, perhaps that’s not quite fair.  As our knowledge of reality (medicine, pharmacology, chemistry, physics, etc) has steadily improved, homeopathy’s plausibility has dwindled to the point of being indistinguishable from the roundest of numbers (0).  And I suppose the recent contortions of logic, abuses of legitimate science, and pure magical thinking put forth to protect homeopathy from the relentless assault of science are far more impressive than that laid out by Hahnemann.  So that’s news of a sort.

There’s also homeopathy’s long and rich tradition of abject failure in randomized controlled trials to consider.  The overwhelming mountain of evidence showing homeopathy to have no effect beyond placebo is impressive and definitive.  That’s data Hahnemann didn’t have, so that’s news too.

Each of these properly conducted studies and analyses demonstrates the scientific method’s utility to help us understand reality and protect us from our own delusions, but frankly, at this point they are about as exciting and useful as proving that the sun will rise in the east tomorrow morning.  News?  Not so much. (more…)

Posted in: Homeopathy

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Mercola, Gardasil, and Toyota?

Joseph Mercola, D.O. should be well known to readers of SBM for reflexively opposing science-based medicine while providing an endless stream of misinformation on his blog, advocating detoxification, homeopathy, the tapping of meridians chiropractic and more at his clinic, and peddling a treasure trove of vitamin supplements, foods, and Mercola-endorsed devices (on sale at his site for your convenience, no conflict of interest there!).

Nothing seems to personify the evil of modern medicine to Dr Mercola more than the concept of vaccination, and Gardasil, the vaccine against human papillomavirus (HPV), has been drawing a good deal of his ire of late.  Case in point is this train-wreck of a post comparing the recent Toyota recall to Gardasil entitled “Time for the Truth About Gardasil.”  The post is ill-named.

It begins:

Cervical cancer accounts for less than 1 percent of all cancer deaths — so it was somewhat surprising when the U.S. Food and Drug Administration fast-tracked approval of Gardasil, a Merck vaccine targeting the human papilloma virus that causes the disease. (more…)

Posted in: Science and Medicine, Vaccines

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The Evolving Science and Guidelines of CPR

Pearl of wisdom for the day: If given the option, don’t let your heart stop.  Very Bad Things soon follow if your heart stops.

In spite of what the entertainment industry would have you believe, it is extremely difficult to save the life of someone in cardiac arrest.  A few random breaths, slow rocking chest compressions, even the ever-so-dramatic overhand blow to the chest accompanied by the scream “Don’t you die on me, dammit!” are unlikely to successfully resuscitate someone following an arrest, and even if it does, they won’t be in any shape to go chase Locke across the island with Jack and Kate five minutes later.

Even with properly performed CPR, started within seconds of an arrest, in a hospital with all the required expertise and support equipment, only roughly half survive their initial arrest event.  Even fewer (25-33%) survive to discharge from the hospital, and ~75% have a good neurologic outcome.  For arrests out of the hospital, where there can be huge delays in treatment, mere survival is significantly lower, often measured in the single digits.

The Limitations Of CPR

Why doesn’t CPR save more people?  Well, it really isn’t meant to; at least, not on its own.  Cardio-respiratory arrest is the common pathway of death, but it isn’t in itself a diagnosis.  The essential question to be answered is why someone stopped breathing, or why their heart stopped in the first place.  Unless you can answer that question and address the problem, even if CPR manages to restore a heartbeat it’s likely to stop again in short order. (more…)

Posted in: Science and Medicine

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A Welcome Upgrade to a Childhood Vaccine – PCV 13

Children aren’t supposed to die.  That so many of us accept this statement without a blink is remarkable and wonderful, but it is also a very recent development in human history.  Modern sanitation, adequate nutrition, and vaccination have largely banished most of the leading killers of children to the history books.  Just look at the current leading causes of childhood death in developing countries to see how far these relatively simple interventions have taken us.

As we have systematically removed the leading infectious killers of children from prominence, other organisms have naturally risen to the top of the list.  This has lead some to the fatalistic (and mistaken) conclusion that we are simply opening up niches to be inevitably filled by other virulent organisms.  This assumes that there is some mandated quota of say, meningitis, that children must suffer every year, and if one organism doesn’t meet this quota then another will fill it.  Were this the case, after vaccination we’d expect to see a shift in the causes of meningitis, but at best a transient drop in the total number of cases per year as other bugs step in to pick up the slack of their fallen, virulent, meningitis-inducing brethren.  Such is not the case.

Though new organisms are now the leading causes of invasive bacterial infections in children, and we have indeed seen some increases in non-vaccine targeted strains, as I’ll discuss below, the total number of such infections has dropped precipitously.  It’s fair to say that the vaccination program has done a remarkable job improving a child’s chance of surviving to adulthood in good health.  However, no one in their right mind would argue that the current state of affairs, as good as it is, is good enough, and so we have shifted our sights to the current leading cause of invasive bacterial infections in children, Streptococcus pneumoniae (S. pneumo, or pneumococcus). (more…)

Posted in: Public Health, Science and Medicine, Vaccines

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You can’t hide in the herd

Can you hide in the herd?  Well, I suppose the title has given away the punch line.

Herd immunity is a fascinating effect, and one of the mainstays of a public vaccination effort.  The idea is that if enough people in the community are immune to a particular disease, then those who are susceptible will rarely come into contact with a person who is contagious, and the disease will be unable (or find it difficult) to spread.  This results in a greatly reduced risk of infection for the entire population regardless of their individual immunity.

This has lead to the belief that because of the protection of the herd’s immunity, individuals now have the option to avoid even the minimal cost and risk of vaccination while having the same reduced risk of infection as if they had vaccinated.

Let’s set aside the fact that that there are people who have no choice but to rely upon herd immunity as their sole line of protection against these infections.  Forget that there is a threshold below which herd immunity collapses, and that our current vaccination rates tend to be right on the cusp of that threshold.  Pay no attention to the fact that the personal decision to not vaccinate deprives others of their sole protection from these infections.  Finally, ignore the ethics and self-defeating nature of benefiting from the sacrifice of others while simultaneously eroding the efficacy of the herd immunity being exploited.  On a small enough scale, doesn’t the tactic of hiding in the herd provide the same protection as getting vaccinated without incurring the minimal risk of vaccination?

Not so much. (more…)

Posted in: Science and Medicine, Vaccines

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Buteyko Breathing Technique – Nothing to Hyperventilate About

A reader recently sent in a link to a New York Times article that discussed an alternative breathing technique developed in Russia for the treatment of asthma called the Buteyko Method, or the Buteyko Breathing Technique (BBT), and asked for an evaluation of the claims on SBM.  This post will attempt to be a reasonably comprehensive evaluation of Buteyko and his therapy so that subsequent discussions, should they be necessary, may be more terse.

The NYT article is primarily an anecdote of a friend of the author who suffered from severe asthma, but who had improved since he began using the BBT.  The author briefly discusses asthma, the history and theory behind Buteyko and hyperventilation before wrapping up with an attempt to provide evidence to support the legitimacy of the story.  The friend’s pulmonologist is quoted to confirm that “based on objective data, his breathing has improved…”  She cites controlled clinical trials “in Australia and elsewhere” where patients have reduced their use of medications, including a purported British study of 384 patients where patients had a 90% reduction in rescue inhaler use and 50% reduction in steroids.  She ends by pointing out that the British Thoracic Society has given BBT a “B” rating, and an admonition to “the pharmaceutically supported American medical community to explore this nondrug technique.”

Never having heard of BBT before, the NYT article left me with several questions.  Who was Buteyko?  How did he develop the BBT?  What is BBT, what does it claim to do, and how does it claim to work?  Is the evidence as presented in the NYT article accurate? And finally, what evidence exists within the literature that BBT is an effective treatment for asthma?

(more…)

Posted in: Science and Medicine

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