Science has found no evidence that vaccines cause autism; but the true cause(s) of autism have not yet been determined. So far the available evidence has pointed towards a largely genetic cause with possible interaction with environmental factors. A new study supports that interpretation. It also supports previous evidence that autism is triggered prior to birth, rather than at the time of vaccinations.
Schmidt et al. published a study in Epidemiology on May 23, 2011, entitled “Prenatal Vitamins, One-carbon Metabolism Gene Variants, and Risk for Autism.” It was a population-based case control study of 566 subjects comparing a group of autistic children to a matched control group of children with normal development. They looked at maternal intake of prenatal vitamins in the 3 months before conception and the first month of pregnancy, and they looked for genotypes associated with autism. They found that mothers who didn’t take prenatal vitamins were at greater risk of having an autistic child, and certain genetic markers markedly increased the risk. There was a dose/response relationship: the more prenatal vitamins a woman took, the less likely she would have an autistic child. There was no association with other types of multivitamins, and no association with prenatal vitamin intake during months 2-9 of pregnancy. (more…)
I was asked to review the book Make an Informed Vaccine Decision for the Health of Your Child by Mayer Eisenstein with Neil Z. Miller. Fortunately my public library had it so I didn’t have to buy a copy. Reading it was a painful déjà vu experience. I can honestly say it met all my expectations: I expected that its concept of “informed decision” would equate to deciding not to vaccinate, and that it would rely on the same tired old fallacious arguments that have been heard before and rejected by knowledgeable scientists. The only thing that surprised me was a warning/disclaimer statement that admitted
this book tends to find fault with vaccines, therefore readers are advised to balance the data presented here with data presented by “official” sources of vaccine information, including vaccine manufacturers, the FDA, CDC and World Health Organization.
The fact that the book omitted all that balancing data undermines its pretense that it is intended to help readers make a truly informed decision.
A common question of skeptics and science-based thinkers is “How could anyone believe that?” People do believe some really weird things and even some obviously false things. The more basic question is how we form all our beliefs, whether false or true.
Michael Shermer’s book Why People Believe Weird Things has become a classic. Now he has a new book out: The Believing Brain: From Ghosts and Gods to Politics and Conspiracies: How We Construct Beliefs and Reinforce Them as Truths It synthesizes 30 years of research into the question of how and why we believe what we do in all aspects of our lives.
Some of the content is repetitious for those of us who have read Shermer’s previous books and heard him speak, but the value of the new book is that it incorporates new research and it puts everything together in a handy package with a new focus.
I’m a skeptic not because I do not want to believe, but because I want to know. How can we tell the difference between what we would like to be true and what is actually true? The answer is science.
Explanatory studies are done under controlled conditions to determine whether a treatment has any efficacy compared to a placebo. Pragmatic studies are designed to assess how the intervention performs in everyday real world practice. Pragmatic studies measure practical success but don’t determine actual efficacy: that requires a proper randomized controlled trial (RCT) with an appropriate control. Pragmatic studies have their place, but they can sometimes make an ineffective treatment look good: a phenomenon I have christened Cinderella Medicine.
In my recent review of Peter Palmieri’s book Suffer the Children I said I would later try to cover some of the many other important issues he brings up. One of the themes in the book is the process of critical thinking and the various cognitive traps doctors fall into. I will address some of them here. This is not meant to be systematic or comprehensive, but rather a miscellany of things to think about. Some of these overlap.
Everything is attributed to a pet diagnosis. Palmieri gives the example of a colleague of his who thinks everything from septic shock to behavior disorders are due to low levels of HDL, which he treats with high doses of niacin. There is a tendency to widen the criteria so that any collection of symptoms can be seen as evidence of the condition. If the hole is big enough, pegs of any shape will fit through. Some doctors attribute everything to food allergies, depression, environmental sensitivities, hormone imbalances, and other favorite diagnoses. CAM is notorious for claiming to have found the one true cause of all disease (subluxations, an imbalance of qi, etc.).
A friend asked me to look at the evidence for hash oil as a treatment for glioma. His teenage daughter was recently diagnosed with brain cancer: a grade 3 anaplastic ependymoma. It recurred very rapidly after surgery and radiotherapy and the latest tissue diagnosis shows an aggressive grade IV glioma. Her prognosis is not good. No further attempts at curative therapy are indicated; the oncologist prescribed only palliative therapy with temozolomide. Her father, who had recently lost his wife to cancer (breast cancer metastatic to lungs and brain), was understandably devastated. As he puts it, he remains “focused on the belief that just maybe a cure can be found.” He stumbled on what he calls “earth-shattering news” regarding hash oil. He and his friends established a private wiki website which they are constantly updating with information about THC (tetrahydrocannabinol, the active ingredient in marijuana and hash) and other possible cancer cures: everything from curcumin to diet. He asked me to look at the information he has accumulated. He said
I hope to convince you in the same way I have done with my daughter’s GPs and her neuro-oncologist at BC Children’s Hospital.
The oncologist was not exactly convinced. He didn’t say he thought hash oil was likely to work; he only said it would be reasonable to try it as a complementary therapy. He said
the data published so far appears very preliminary, most of its potential effectiveness in vivo so far appears in colonic disease, having said that there doesn’t appear to be any obvious down side as a complementary therapy and may have synergistic effect, so may be reasonable as add on to temodal if she tolerates it
I wasn’t convinced either.
I will discuss two issues here:
- What does the evidence say about gliomas and hash oil?
- When is it reasonable to try an unproven treatment as a last resort?
When an article is published in a medical journal, the authors must disclose any conflicts of interest. This is important, because even if they think owning stock in the drug company won’t influence their scientific judgment, we know that subtle biases can creep in to somehow affect the findings of studies. It has been shown that studies funded by drug companies are more likely to get positive results for their drug than studies funded by independent sources. Andrew Wakefield, author of the infamous retracted Lancet study suggesting a relationship between MMR vaccine and autism, was severely chastised for not disclosing that he received money from autism litigators and expected to earn a fortune from his own patented products if the MMR vaccine could be discredited.
I was recently contacted by an acupuncturist who plans to critique an article I wrote. It was a commentary in the journal Pain that accompanied a systematic review of systematic reviews of acupuncture by Ernst et al. For details of Ernst’s and my articles, see my previous post. He challenged my statement that I had no conflicts of interest to report. He apparently thinks I should have said I have a conflict of interest in that I am anti-CAM and anti-acupuncture. When he writes about my article, he plans to attack me for not declaring this alleged conflict of interest and he plans to set a good example with a conflict of interest statement of his own, divulging that he makes his living practicing acupuncture, has financial investments in it and many personal relationships, that his self-identity and prestige are dependent on his belief in acupuncture’s efficacy, and that he is biased towards constructivism and away from positivism. (I think this is a fancy way of saying he favors experience over the scientific method.) I agree that he has conflicts of interest, but was I wrong to say I had no conflicts of interest? I don’t think so. (more…)
Some of our readers have complained that we pick on alternative medicine while ignoring the problems in conventional medicine. That criticism is unjustified: we oppose non-science-based medicine wherever we find it. We find it regularly in alternative medicine; we find it less frequently in conventional medicine, but when we do, we speak out. A new book by Dr. Peter Palmieri is aimed squarely at failure to use science-based medicine in conventional practice.
Dr. Palmieri is a pediatrician who strives to provide the best compassionate, cost-effective, science-based care to all his patients. Over 15 years of practice in various settings, he observed that many of his colleagues were practicing substandard medicine. He tried to understand what led to that situation and how it might be remedied. The result is a gem of a book: Suffer the Children: Flaws, Foibles, Fallacies and the Grave Shortcomings of Pediatric Care. Its lessons are important and are not limited to pediatrics: every health care provider and every patient could benefit from reading this book.
The chapters cover these subjects:
- How doctors mishandle the most common childhood illnesses
- How doctors succumb to parental demands
- How they embrace superstition and magical beliefs
- How they fall prey to cognitive errors
- How they order the wrong test at the wrong time on the wrong patient
- How financial conflicts of interest defile the medical profession
- How doctors undermine parents’ confidence by labeling their children as ill
- A prescription for change
Before we had EBM (evidence-based medicine) we had another kind of EBM: experience-based medicine. Mark Crislip has said that the three most dangerous words in medicine are “In my experience.” I agree wholeheartedly. On the other hand, it would be a mistake to discount experience entirely. Dynamite is dangerous too, but when handled with proper safety precautions it can be very useful in mining, road-building, and other endeavors.
When I was in med school, the professor would say “In my experience, drug A works better than drug B.” and we would take careful notes, follow his lead, and prescribe drug A unquestioningly. That is no longer acceptable. Today we ask for controlled studies that objectively compare drug A to drug B. That doesn’t mean the professor’s observations were entirely useless: experience, like anecdotes, can draw attention to things that are worth evaluating with the scientific method.
We don’t always have the pertinent scientific studies needed to make a clinical decision. When there is no hard evidence, a clinician’s experience may be all we have to go on. Knowing that a patient with disease X got better following treatment Y is a step above having no knowledge at all about X or Y. A small step, but arguably better than no step at all. (more…)