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The continuum of surgical research in science-based medicine

Editor’s note: Three members of the SBM blogging crew had a…very interesting meeting on Friday, one none of us expected, the details of which will be reported later this week–meaning you’d better keep reading this week if you want to find out. (Hint, hint.) However, what that means is that I was away Thursday and Friday; between the trip and the various family gatherings I didn’t have time for one of my usual 4,000 word screeds of fresh material. However, there is something I’ve been meaning to discuss on SBM, and it’s perfect for SBM. Fortunately, I did write something about it elsewhere three years ago. This seems like the perfect time to spiff it up, update it, and republish it. In doing so, I found myself writing far more than I had expected, making it a lot more different from the old post than I had expected, but I guess that’s just me.

In the meantime, the hunt for new bloggers goes on, with some promising results. If we haven’t gotten back to you yet (namely most of you), please be patient. This meeting and the holiday–not to mention my real life job–have interfered with that, too.

The continuum of surgical research in science-based medicine

One of the things about science-based medicine that makes it so fascinating is that it encompasses such a wide variety of modalities that it takes a similarly wide variety of science and scientific techniques to investigate various diseases. Some medical disciplines consist of mainly of problems that are relatively straightforward to study. Don’t get me wrong, though. By “straightforward,” I don’t mean that they’re easy, simply that the experimental design of a clinical trial to test a treatment is fairly easily encompassed by the paradigm of randomized clinical trials. Medical oncology is just one example, where new drugs can be tested in randomized, double-blinded trials against or in addition to the standard of care without having to account for many difficulties that arise from difficulties blinding. We’ve discussed such difficulties before, for instance, in the context of constructing adequate placebos for acupuncture trials. Indeed, this topic is critical to the application of science-based medicine to various “complementary and alternative medicine” modalities, which do not as easily lend themselves to randomized double-blind placebo-controlled trials, although I would hasten to point out that, just because it can be very difficult to do such trials is not an excuse for not doing them. The development of various “sham acupuncture” controls, one of which consisted even of just twirling a toothpick gently poked onto the skin, shows that.

One area of medicine where it is difficult to construct randomized controlled trials is surgery. The reasons are multiple. For one thing, it’s virtually impossible to blind the person doing the surgery to what he or she is doing. One way around that would be to have the surgeons who do the operations not be involved with the postoperative care of the patients at all, while the postoperative team doesn’t know which operation the patient actually got. However, most surgeons would consider this not only undesirable, but downright unethical. At least, I would. Another problem comes when the surgeries are sufficiently different that it is impossible to hide from the patient which operation he got. Moreover, surgery itself has a powerful placebo effect, as has been shown time and time again. Even so, surgical trials are very important and produce important results. For instance, I wrote about two trials for vertebral kyphoplasty for ostoporotic fractures, both of which produced negative results showing kyphoplasty to be no better than placebo. Some surgical trials have been critical to defining a science-based approach to how we treat patients, such as trials showing that survival rates are the same in breast cancer treated with lumpectomy and radiation therapy as they are when the treatment is mastectomy. Still, surgery is a set of disciplines where applying science-based medicine is arguably not as straightforward as it is in many specialties. At times, applying science-based medicine to it can be nearly as difficult as it is to do for various CAM modalities, mainly because of the difficulties in blinding. That’s why I’m always fascinated by strategies by which we as surgeons try to make our discipline more science-based.
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Posted in: Clinical Trials, Science and Medicine, Surgical Procedures

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Our fearless leader Steve Novella gets the best responses to his posts!

You may recall that Steve has been criticizing a certain homeopath named John Benneth for his incredible flights of–shall we say?–fancy used in defending homeopathy. As a result, Mr. Benneth (whose website is called The Science of Homeopathy) has produced a series of amazing videos that he’s posted on YouTube. Although we have a very serious mission here at SBM, we are not without a sense of humor, and that’s why we thought our readers might be interested in the sorts of commentary we have received in response to some of our efforts. The first video is called HOMEOPATHY: Jew of Nazi Medicine:

Note how Benneth likens the criticism of his pseudoscience to the persecution of Jews by the Nazis. When you see something like this, you know that Godwin’s Law has been thoroughly invoked. The second video is just as outrageous and probably NSFW given that it drops the N-word. Don’t play it if that offends you. You have been warned:
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Posted in: Homeopathy, Humor

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“Vaccines didn’t save us” (a.k.a. “vaccines don’t work”): Intellectual dishonesty at its most naked

If there’s one thing about the anti-vaccine movement I’ve learned over the last several years, it’s that it’s almost completely immune to evidence, science, and reason. No matter how much evidence is arrayed against it, its spokespeople always finds a way to spin, distort, or misrepresent the evidence to combat it and not have to give up the concept that vaccines cause autism. Not that this is any news to readers of this blog, but it bears repeating often. It also bears repeating and emphasizing examples of just the sort of disingenuous and even outright deceptive techniques used by promoters of anti-vaccine pseudoscience to sow fear and doubt about vaccines among parents. These arguments may seem persuasive to those who have little knowledge about science or epidemiology. Sometimes they even seemed somewhat persuasive to me; that is, at least until I actually took the time to look into them.

One example of such a myth is the claim that “vaccines didn’t save us,” also sometimes going under the claim that “vaccines don’t work.” The anti-vaccine website Vaccine Liberation has a large set of graphs purporting to show that the death rates of several vaccine-preventable diseases, including whooping cough, diptheria, measles, and polio were falling before the vaccines for each disease were introduced. The the article quotes Andrew Weil:
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Posted in: Science and Medicine, Vaccines

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The case of John Lykoudis and peptic ulcer disease revisited: Crank or visionary?

One of the themes of SBM has been, since the very beginning, how the paradigm of evidence-based medicine discounts plausibility (or, perhaps more appropriately, implausibility) when evaluating whether or not a given therapy works. One of our favorite examples is homeopathy, a therapy that is so implausible on a strictly scientific basis that, for it to work, huge swaths of well-established science supported by equally huge amounts of experimental and observational evidence would have to be found to be all in serious error. While such an occurrence is not per se impossible, it is incredibly unlikely. Moreover, for scientists actually to start to doubt our understanding of chemistry, biochemistry, pharmacology, and physics to the point of thinking that our understanding of them is in such serious error that homeopathy is a valid description of reality, it would take a lot more than a bunch of low-quality or equivocal studies that show no effect due to homeopathy detectably greater than placebo.

On Friday, Kim Atwood undertook an excellent discussion of this very issue. What really caught my attention, though, was how he educated me about a bit of medical history of which I had been completely unaware. Specifically, Kim discussed the strange case of John Lykoudis, a physician in Greece who may have discovered the etiology of peptic ulcer disease (PUD) due to H. pylori more than a quarter century before Barry Marshall and Robin Warren discovered the bacterial etiology of PUD in 1984. One reason that this story intrigued me is the same reason that it intrigued Kimball. Lykoudis’ story very much resembles that of many quacks, in particular Nicholas Gonzalez, in that he claimed results far better than what medicine could produce at the time, fought relentlessly to try to prove his ideas to the medical authorities in Greece at the time, and ultimately failed to do so. Despite his failure, however, he had a very large and loyal following of patients who fervently believed in his methods. The twist on a familiar story, however, is that Lykoudis may very well have been right and have discovered a real, effective treatment long before his time.
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Posted in: Basic Science, Clinical Trials, Science and Medicine

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An update on our search for new SBM bloggers

Three and a half weeks ago, Amy Tuteur announced her departure from SBM. Three weeks ago, I announced that we were recruiting new bloggers to replace Amy, to bolster areas of weakness among our bloggers, and expand our repertoire. I thank those of you who have responded.

Given that none of you have heard anything from us other than perhaps an acknowledgment of receiving your application, I thought it reasonable to give a brief update. Due to a combination of the death crud (of which those of you who are my Facebook friends may be aware), a challenging couple of weeks at work, and various other concerns, I haven’t made as much progress in evaluating potential new bloggers as I had hoped. I had hoped that we would have at least been able to start sending out an offer or two by now. All I can ask is: Be patient. And, if you know of any quality bloggers who haven’t been proposed already, please let me know. We are evaluating candidates, and it shouldn’t be long before I start communicating with the top applicants.

Posted in: Announcements

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J.B. Handley and the anti-vaccine movement: Gloating over the decline in confidence in vaccines among parents

UPDATE, 4/25/2011: I can’t resist pointing you to a hilariously misguided attack against me that proves once again that, for the anti-vaccine activists, it’s all about the ad hominem. Clifford Miller, a.k.a. ChildHealthSafety, was unhappy that I showed up in the comments of Seth Mnookin’s post complaining about J.B. Handley’s attacking him solely based on his having once been a heroin addict, an addiction that Seth managed to beat. In response, Miller writes. Not only was he unhappy about a post of mine that was over a year old, but he regurgitated Jake Crosby’s fallacious pharma shill gambit that he used against me last summer. Thank you, Mr. Miller, for, in your utterly irony challenged manner, proving my point that to the anti-vaccine movement it’s all about the ad hominem. You did it better than I ever could. Now, back to my post.

One of the key talking points of the anti-vaccine movement is to repeat the claim, “I’m not ‘anti-vaccine.’” Indeed, one of Jenny McCarthy’s favorite refrains has been “I’m not ‘anti-vaccine.’ I’m pro-safe vaccine,” or “I’m ‘anti-toxin.’” In doing so, the anti-vaccine movement tries very hard to paint itself as being made up of defenders of vaccine safety, as if the Centers for Disease Control (CDC), the American Academy of Pediatrics (AAP), and all the regulatory agencies don’t support safe vaccines. Many are the times that we have seen examples of this particular denial, both on this blog and elsewhere. For which specific anti-vaccine activists this is self-deception, delusion, or outright lie is a complicated question, but one thing that is clear to me is that the very existence of this talking point demonstrates that, at least for now, being anti-vaccine is still viewed unfavorably by the vast majority of people. If it were not, there would be no need for vaccine conspiracy theorists to use this particular line over and over again. Also, if the rhetoric from the anti-vaccine movement didn’t demonize vaccines so viciously as the One True Cause of autism, asthma, and a variety of other conditions, diseases, and disorders, leaders of the anti-vaccine movement wouldn’t be so anxious to assure us at every turn that, really and truly, they aren’t “anti-vaccine.” Oh, no, not at all.

Unfortunately for them, their rhetoric and activities betray them. For one thing, the anti-vaccine movement is not monolithic. There are indeed anti-vaccine zealots who are not afraid to admit that they are against vaccines. Many of them showed up to Jenny McCarthy’s Green Our Vaccines march on Washington two years ago with signs bearing slogans such as “Danger: Child Vaccine (Toxic Waste)”; “We found the weapons of mass destruction”; “Stop poisoning our children”; and, of course, “No forced vaccination! Not in America!” In the run-up to that march, I lurked on several anti-vaccine discussion forums, and I saw first hand how the organizers of the march were trying to keep people with these signs in line and less visible, not so much because they don’t agree with them but because they promoted the “wrong” message. In this, they remind me of political parties trying to rein in their most radical elements.

Among these groups, Generation Rescue has supplanted the former most influential anti-vaccine group, the National Vaccine Information Center (NVIC). It has achieved this largely through somehow attracting a scientifically ignorant washed-up model, actress, and comedienne named Jenny McCarthy who, most recently before having a son diagnosed as being on the autistic spectrum had been promoting “Indigo Child” woo on her IndigoMoms.com website, complete with a “quantum prayer wheel” invented by William Nelson, inventor of the quackalicious EPFX-SCIO. Back in 2007, just prior to the release of her first autism book, Louder Than Words: A Mothers’ Journey in Healing Autism, McCarthy’s “indigo” website disappeared from the web in a futile attempt to send it down the memory hole, but thankfully The Wayback Machine knows all. In any case, thanks to Jenny McCarthy and, at least as much to her boyfriend, the massively more famous Jim Carrey, Generation Rescue has been tranformed from an ignored fringe anti-vaccine group to a famous and influential fringe anti-vaccine group with all sorts of ins among the Hollywood elite, just as it’s been tranformed from just Generation Rescue to Jenny McCarthy and Jim Carrey’s Autism Organization – Generation Rescue.
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Posted in: Science and the Media, Vaccines

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Is there a role for speculative journals like Medical Hypotheses in the scientific literature?

The core information supporting science-based medicine resides in the scientific literature. There, scientists and physicians publish the results of experiments and clinical trials that seek to understand the biological mechanisms by which the human body functions and through which disease forms and to apply this understanding to test new treatments for diease. Consequently, the quality and integrity of the biomedical literature are topics of utmost importance to supporters of science-based medicine. We’ve discussed problems with the scientific literature before here, ranging from how pseudoscientific “complementary and alternative medicine” journals have insinuated themselves into the medical literature and how drug companies have managed exercise undue influence over clinical trials and journals.

One question that perhaps we have not dealt with so much is the question of the very nature of a good scientific journal, particularly what is suitable material for such a journal. For purposes of this discussion, I will focus mainly on the biomedical literature, which spans a range from basic science journals dealing with biomedical science to clinical journals, which mainly report the results of clinical trials and clinical research. Of these journals, there are in general two types, journals that primarily report original research and those that present reviews of existing research. Most journals do a mix of the two, the majority tending towards a form where most of the articles are reports of orginal research mixed in with a much smaller number of review articles.

There is one journal, however, that is different. It is a journal known as Medical Hypotheses. It is a journal that (or so it claims) exists to present radical scientific ideas, the more radical the better. Here is how the journal is described on its website:
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Posted in: Medical Academia, Science and Medicine, Science and the Media

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Biologie Totale and other bastard offspring of Ryke Geerd Hamer’s German New Medicine

A few months ago, I wrote about a particularly nasty form of cancer quackery known as the “German New Medicine” or Die Germanische Neue Medizin in German. As you may recall, the German New Medicine is based on the nonsensical idea that cancer arises from an internal emotional conflict. This conflict then results in what is called the “Dirk Hamer Syndrome” (DHS) or “Dirk Hamer focus” in the brain, named after Dr. Ryke Geerd Hamer‘s son Dirk, who was tragically shot in his sleep by Vittorio Emanuel, the last crown prince of Italy. After a prolonged course requiring multiple operations, Dirk succumbed to his wounds and died. Three years later, Dr. Hamer developed testicular cancer, and, in a perfect case of post hoc ergo propter hoc, Hamer decided that it was the psychic shock of his son’s death that had caused his cancer. Thus was born Die Germanische Neue Medizin, which, according to Hamer, promises a 95% or more chance of curing any cancer, no matter how advanced. Never mind that Hamer apparently underwent a combination of surgery and other “conventional therapies for his testicular cancer. Also never mind that these “Dirk Hamer Focus” to which Hamer pointed on CT scans of the brain appeared, more than anything else, to be artifacts of the imaging process and nothing real.

As I described in my previous post in October, the German New Medicine is a seriously dangerous form of cancer quackery that is not only worthless but in many cases blames the patient for having developed cancer. Evidence can be found in this video, where a proponent of German New Medicine gives as examples of psychic stress a “cancer blow” that comes from menopause, in which loss of estrogen supposedly leads women to feel that they “aren’t the woman they used to be” and that that conflict is manifest in the bone or an athlete’s anger because of an injury that screws up his ability to perform leading to an osteosarcoma of extremity.

Unfortunately, cancer quackery frequently evolves under the selective pressure of competition with other cancer quackeries and based on the unique environments in which various forms of quackery come to land. Since I first wrote my post about Die Germanische Neue Medizin, I’ve been meaning to address one of its offshoots. The particular offshoot that I plan to address is, in essence, the French cousin of Die Germanische Neue Medizin, and it’s called Biologie Totale, or Total Biology (Claude Sabbah’s official site is here, but it’s all in French). I first became aware of Biologie Totale about a year and a half ago through this news story:
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Posted in: Cancer, Health Fraud

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Meet me in St. Louis?

I just thought I’d make a brief announcement that I’m currently in St. Louis attending the annual meeting of the Society of Surgical Oncology. If any of our St. Louis readers are attending the meeting, look me up. I’d be tickled to death to know whether any of my colleagues here are even aware of SBM, much less regular readers. (If no one is aware, though, I’ll be disappointed.) Heck, if you show me your mad skillz at writing and that you share our philosophy, maybe you can even join us as another blogger here!

Also, if anyone’s interested in attempting a meetup, let me know. I’ll be in St. Louis until Sunday morning. It may or may not be possible, given that the SSO meeting fills each day quite nicely and most evenings have something booked, including meeting up with a former postdoc of mine who happens to be at Washington University now, but you never know until you ask. Unfortunately, Saturday night probably out, unless it’s before 7 PM or after 10 PM. My mentor, Dr. Mitch Posner, is the incoming president of the SSO; so I want to go to the Presidential Banquet that evening.

Posted in: Announcements, Surgical Procedures

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The future of the Science-based Medicine blog: SBM is recruiting new bloggers

It’s been a rather eventful week here at Science-Based Medicine. I apologize that I don’t have one of my usual 4,000 word epics ready for this week. I was occupied all day Saturday at a conference at which I had to give a talk, and Dr. Tuteur’s departure produced another issue that I had to deal with. Fortunately, because Dr. Lipson is scheduled to do an extra post today, I feel less guilty about not producing my usual logorrhea. Who knows? Maybe it will be a relief to our readers too.

This confluence of events makes this a good time to take a break to take care of some blog business and make formal what I alluded to on Thursday in the comments after I announced Dr. Tuteur’s departure, namely that it’s time for us at SBM to start recruiting. Our purpose in recruiting will be to make this blog even better than it is already. We have an absolutely fantastic group of bloggers here, and it is due to their hard work and talent that SBM has become a force to be reckoned with in the medical blogosphere. Our traffic continues to grow, and reporters and even on occasion governmental officials have taken notice. That’s why Dr. Tuteur’s departure makes this a perfect opportunity to build on that record and make SBM even better and a more essential as a source of medical commentary than it is already. To accomplish this goal, it’s clear that any recruitment cannot be simply to fill in a gap in our posting schedule. I would much rather have a weekday go without a post every now and then than to recruit the wrong person to take over Dr. Tuteur’s spot. As a result, I hope to make this recruitment more strategic and to do it in a more formal manner than we have perhaps done in the past. We also plan on taking our time and therefore ask your patience.

To this end, I’m going to ask for nominations, either self-nominations or nominations of others, as suggested bloggers for SBM. Please also include a link to the nominee’s blog or, if the nominee is not a blogger or otherwise known for skeptical writings regarding medicine elsewhere (such as R. Barker Bausell), samples of his or her writing about topics relevant to SBM. I will compile the list over the next couple of weeks; our bloggers will discuss and vet the candidates; and we will decide whom we want to try to persuade to join us, either as a regular weekly blogger (currently Harriet Hall, Steve Novella, and me), an every-other-week blogger (currently Peter Lipson, Mark Crislip, Val Jones, and Joe Albietz), a monthly blogger (currently Kim Atwood), or an occasional contributor (currently Wally Sampson, David Ramey, John Snyder, Tim Kreider, and David Kroll). Finally, if you’re nominating yourself, please specify how often you are interested in contributing and tell us a bit about yourself and your background. Also realize that we do require our bloggers to write under their own names. No pseudonyms will be permitted, at least not on this blog.

So where do we need the most help? A number of you, as well as a number of SBM bloggers, came up with excellent suggestions for priority areas where our readers what to see more material or where we are weak here at SBM. These areas include, in no particular order:
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Posted in: Announcements, Science and Medicine

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