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A Report from the Bariatric Trenches

The American Society of Bariatric Physicians recently invited me to speak at their continuing medical education (CME) conference on obesity in Seattle. They got my name from Stephen Barrett of Quackwatch and asked if I could speak about questionable weight loss treatments like HGH, MIC (methionine, inositol and choline), and the HCG Diet. I seized the opportunity to discuss how to evaluate any medical claim, with examples from alternative medicine as well as from weight loss. My title was “Questionable Evidence for Questionable Treatments.” I talked about some of the things that can go wrong in clinical trials and why simply finding reports of positive randomized controlled trials (RCT) is not enough. I advocated rigorously science-based medicine and recommended the SBM website.

Several people came up afterwards to express their thanks and their agreement, but some of the questions from the audience were rather hostile. One man said he was a military doctor and he was using and teaching acupuncture (which I had criticized as a bad example of “tooth fairy science” in my talk). I asked for his opinion of battlefield acupuncture and he just said “No comment.” A couple of people thought science wasn’t enough and thought it was okay to prescribe questionable treatments when there was no proven effective treatment. I responded that I had no objection as long as the patient was told the facts and not given the false impression that the questionable treatment had been tested and shown to work.

I was glad for the chance to meet some of the ASBP members. I had never met a bariatric physician and was interested to learn about their practices and philosophies. I had never really thought about the fact that most obese patients had associated diseases like hypertension and diabetes, so their overall management could be very complex. I attended the whole obesity course: some of what I heard was educational, some of it was questionable, and some of it was frankly disturbing. (more…)

Posted in: Herbs & Supplements, Nutrition, Science and Medicine

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Nine Breakthroughs and a Breakdown

In his new book Breakthrough! How the 10 Greatest Discoveries in Medicine Saved Millions and Changed Our View of the World Jon Queijo describes what he believes are the 10 greatest discoveries. 9 of them are uncontroversial discoveries that have been on other top-10 lists, but his 10th choice is one that no other list of top discoveries has ever included. He realizes that, and even admits in his introduction that a former editor of The New England Journal of Medicine refused to review his book because there is no such thing as alternative medicine, only treatments that work and treatments that don’t. But he “respectfully disagrees.”

Hippocrates’ discovery that disease had natural causes, sanitation, germ theory, anesthesia, X-rays, vaccines, antibiotics, genetics, and treatments for mental disorders are all worthy candidates for the list. But Queijo ludicrously lists the “rediscovery of alternative medicine” as the tenth “great discovery.” He presents no evidence (because there is no evidence) that alternative medicine has “saved millions” or that it has saved anyone. He doesn’t realize that alternative medicine represents a betrayal of exactly the kind of rigorous scientific thinking and testing that led to all the other discoveries. His list of ten breakthroughs is actually a list of 9 breakthroughs and one breakdown. (more…)

Posted in: Book & movie reviews, History, Science and Medicine

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Breastfeeding Is Good but Maybe Not THAT Good

An article entitled “The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis,” by Bartick and Reinhold, was published in Pediatrics 2010 April 5. According to this news report, it showed that 900 babies’ lives and billions of dollars could be saved every year in the U.S. if we could get 90% of mothers to breastfeed for at least 6 months. It says breastfeeding has been shown to reduce the risk of stomach viruses, ear infections, asthma, juvenile diabetes, Sudden Infant Death Syndrome and even childhood leukemia.

This new study did not provide any new evidence. It simply took risk ratios from a three year old government report, extrapolated, and estimated the costs.
(more…)

Posted in: Nutrition

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Taking Control of Death

Science isn’t the only game in town. Literature can teach us things about the world that science can’t. It can give us vicarious experience and insight into other minds. Two recently published novels illuminate why perfectly rational people might reject the help of scientific medicine and prefer to die a little sooner but to die on their own terms. (more…)

Posted in: Book & movie reviews, Cancer, Medical Ethics

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Genetic Testing for Patients on Coumadin

Anticoagulation is advised for patients who have had a blood clot or who are at increased risk of blood clots because of atrial fibrillation, artificial heart valves, or other conditions. Over 30 million prescriptions are written every year in the US for the anticoagulant warfarin, best known under the brand name Coumadin. Originally developed as a rat poison, warfarin has proved very effective in preventing blood clots and saving lives; but too much anticoagulation leads to the opposite problem: bleeding. A high level of Coumadin might prevent a stroke from a blood clot only to cause a stroke from an intracranial bleed. The effect varies from person to person and from day to day depending on things like the amount of vitamin K in the diet and interactions with other medications. It requires careful monitoring with blood tests, and it is tricky because there is a delay between changing the dose and seeing the results.

In his book The Language of Life, Francis Collins predicts that Coumadin will be the first drug for which the so-called Dx-Rx paradigm — a genetic test (Dx) followed by a prescription (Rx) — will enter mainstream medical practice. FDA economists have estimated that by formally integrating genetic testing into routine warfarin therapy, the US alone would avoid 85,000 serious bleeding events and 17,000 strokes annually.
A recent news release from the American College of Cardiology described a paper at their annual meeting reporting a study of

896 people who, shortly after beginning warfarin therapy, gave a blood sample or cheek swab that was analyzed for expression of two genes — CYP2C9 and VKORC1 — that revealed sensitivity to warfarin. People with high sensitivity were put on a reduced dose of warfarin and had frequent blood tests. People with low sensitivity were given a higher dose of warfarin.

During the first six months that they took warfarin, those who underwent genetic testing were 31 percent less likely to be hospitalized for any reason and 29 percent less likely to be hospitalized for bleeding or thromboembolism than were a group that did not have genetic testing.

Epstein said that the cost of the genetic testing — $250 to $400 — would be justified by reduced hospitalization costs.

At this point, I don’t believe this study. I’ll explain why I’m skeptical. (more…)

Posted in: Clinical Trials, Pharmaceuticals

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Brief Note: Followup on Spinal Decompression Machines

In September 2008 I wrote a post on Misleading Ads for Back Pain Treatment. with particular attention to the bogus claims for the DRX 9000.

The Canadian Broadcasting Company (CBC) show “Marketplace” has just done a scathing exposé of so-called nonsurgical spinal decompression treatment with machines like the DRX 9000 and of some of the unscrupulous practitioners who offer it.  Between the hidden camera footage and the weasel words of the chiropractor they interview, it’s quite entertaining.

Posted in: Chiropractic, Health Fraud

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A Sleep Remedy with Proprietary Secrets

A new product, Dream Water, is designed to help one relax, fall asleep and improve the quality of sleep using the all natural ingredients melatonin, GABA and 5-HTP (tryptophan). A single-dose 2.5 oz bottle retails for $2.99. They also offer a more dilute formulation in an 8 oz bottle. They suggest drinking half a bottle, keeping it at your bedside, and drinking more if you wake during the night. What dosage will you get from half a bottle? From a whole bottle? There’s no way to know. They offer a money back guarantee, free shipping, free samples, and lots of testimonials; but they refuse to disclose how much of what is in their product.

The DSHEA only permits structure and function claims like “supports prostate health,” but this product is clearly being promoted as a remedy for insomnia. The “Quack Miranda warning” is not displayed on the home page, but the “Dream Responsibly” page says “These statements have NOT been evaluated by the Food and Drug Administration. This product is NOT intended to diagnose, treat, prevent or cure any disease.”

Is it legal to sell this as a remedy for insomnia? I guess the legality depends on whether you define insomnia as a disease. Maybe they define it as an impairment in a function that needs supporting. Maybe they can get away with it. (more…)

Posted in: Herbs & Supplements

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Diagnosis, Therapy and Evidence

When Dr. Novella recently wrote about plausibility in science-based medicine, one of our most assiduous commenters, Daedalus2u, added a very important point. The data are always right, but the explanations may be wrong. The idea of treating ulcers with antibiotics was not incompatible with any of the data about ulcers; it was only incompatible with the idea that ulcers were caused by too much acid. Even scientists tend to think on the level of the explanations rather than on the level of the data that led to those explanations.

A valuable new book elaborates on this concept: Diagnosis, Therapy and Evidence: Conundrums in Modern American Medicine, by medical historian Gerald N. Grob and sociologist Allan V. Horwitz. They point out that 

many claims about the causes of disease, therapeutic practices, and even diagnoses are shaped by beliefs that are unscientific, unproven, or completely wrong. (more…)

Posted in: Book & movie reviews, Science and Medicine

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Halsted: The Father of Science-Based Surgery

One (dark and stormy?) night in 1882, a critically ill 70 year old woman was at the verge of death at her daughter’s home, suffering from fever, crippling pain, nausea, and an inflamed abdominal mass. At 2 AM, a courageous surgeon put her on the kitchen table and performed the first known operation to remove gallstones. The patient recovered uneventfully. The patient was the surgeon’s own mother.

This compelling story is the beginning of an excellent new biography of William Halsted, the father of modern surgery, Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted, by Gerald Imber, MD.

When Halsted went to medical school, surgeons still operated in street clothes, with bare hands, and major surgical procedures carried a mortality rate of nearly 50 percent. Suppuration of wounds was called laudable pus. Lister had recently introduced carbolic acid dips and sprays (that were irritating and toxic), but hand washing was discouraged because it was thought to force germs into skin crevices. (more…)

Posted in: Book & movie reviews, History, Surgical Procedures

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Zeo Personal Sleep Coach

 Sleep that knits up the ravelled sleeve of care
The death of each day’s life, sore labour’s bath
Balm of hurt minds, great nature’s second course,
Chief nourisher in life’s feast.   
 -William Shakespeare, Macbeth

Zeo

The company that makes the Zeo Personal Sleep Coach  kindly sent me one of their devices to try out. It’s a nifty little gadget, and if you are a techno geek, you would probably love it. It’s a fascinating toy; but for insomnia, there’s no evidence that it provides any benefit over standard treatment with sleep logs and sleep hygiene advice.

Polysomnography is done overnight in a sleep lab and costs around $1000. It records multiple parameters: EEG, EKG, EMG, breathing, O2, CO2, and limb movements. It is most commonly used to diagnose obstructive sleep apnea (OSA), a serious condition that is linked to hypertension, heart disease, diabetes, metabolic syndrome, stroke, and increased mortality. OSA can be effectively treated with CPAP and other measures. About 50% of snorers have sleep apnea. We typically think of it as a disease of obese, loudly snoring older men, but even young children can have it: snoring is probably never normal in children and should be investigated.

The Zeo is the first sleep monitor available for consumers to use at home. It doesn’t pretend to do what polysomnography does. It can’t diagnose sleep apnea. It is billed as an educational and motivational tool, not intended for the diagnosis or treatment of sleep disorders. A unit that looks sort of like an alarm clock sits on your bedside table and communicates wirelessly with a comfortable soft elastic headband that positions embedded sensors over your forehead to pick up your brain waves. (more…)

Posted in: Health Fraud

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