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Precision Medicine: The Coolest Part of Medicine

QuellosOne size rarely fits all. Most medical knowledge is derived from studying groups of subjects, subjects who may be different in some way from the individual who walks into the doctor’s office. Basing medicine only on randomized controlled studies can lead to over-simplified “cookbook” medicine. A good clinician interprets study results and puts them into context, considering the whole patient and using clinical judgment to apply current scientific knowledge appropriately to the individual.

CAM practitioners claim to be providing individualized treatments. Homeopaths look up symptoms like “dreams of robbers,” “sensation of coldness in the heart,” and “chills between 9 and 11 AM” in their books, and naturopaths quiz patients in great depth about their habits and preferences; but they don’t have a plausible rationale for interpreting the information they gather. And they have not been able to demonstrate better patient outcomes from using that information.

A new concept, “precision medicine,” was recently featured in UW Medicine, the alumni magazine of my alma mater, the University of Washington School of Medicine. Precision medicine strives to provide truly individualized care based on good science. It identifies the individual variations in people that make a difference in our ability to diagnose and treat accurately. Peter Byers, MD, director of the new Center for Precision Diagnostics at the University of Washington, calls it “the coolest part of medicine.” (more…)

Posted in: Basic Science, Cancer, Diagnostic tests & procedures

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Gary Taubes and the Cause of Obesity

Gary Taubes has written two books explaining why people get fat and why a low-carb diet is the solution to preventing and treating obesity. He didn’t like what I had to say about his books on this blog back in 2011. I was not the only one to criticize. Another reviewer accused him of “abandon[ing] journalistic and scientific integrity in place of observational data, straw men and logical fallacy.” He says he agrees with Taubes’ premises but that his “arguments made me cringe,” and he goes into considerable detail to explain why. His analysis is worth reading.

photo by Fj.toloza992 [CC-BY-SA-3.0], via Wikimedia Commons]

photo by Fj.toloza992 [via Wikimedia Commons]

Rather than engaging in the Comments section, Taubes complained to me in a somewhat offensive personal e-mail, saying I had failed to understand what he wrote. Recently he e-mailed me again, condescendingly suggesting that I might understand his arguments better if I read an article he wrote last year for the British Medical Journal. I read it, and confirmed that I had understood perfectly well the first time around and that it was Gary Taubes who didn’t understand my criticisms. I pointed out some omissions and inconsistencies, but my major criticisms boiled down to two:

  1. The clinical evidence isn’t yet sufficient to convincingly prove his thesis. (He himself admitted this.)
  2. He strongly recommended that everyone adopt a low-carb diet, essentially insisting that we act on insufficient evidence. And this was after he had devoted whole chapters of his books to demonizing the low-fat diet advocates for doing exactly that: acting on insufficient evidence.

(more…)

Posted in: Nutrition

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Lice

If you have children, there’s a good chance you’ve had experience with head lice. Head lice affects as many as 12 million people in the US each year, mostly children. Compared to other health conditions, it is a trivial problem; but it is common and annoying. It can cause itching, notes sent home from school, and often a strong “yuck” reaction. Fortunately, several effective treatments are available, including enough “natural” options to please any critic of Big Pharma.

Louse diagram, Micrographia, Robert Hooke, 1667

Louse diagram, Micrographia, Robert Hooke, 1667

The critter

Pediculosis humanus var capitis is a bloodsucking parasitic insect specific to humans. It is 2.5-3 mm long and flattish. It can’t jump or fly or even walk efficiently, but is easily transferred, usually by head-to-head contact with an infected person or less often with an infected person’s headgear, comb, towel, or other object. Infestation is not a sign of poor hygiene.  Lice bite and suck blood 4-5 times daily, injecting an anti-coagulant in their saliva. Mommy lice live for up to 3 months and lay up to 300 eggs at a rate of 3-4 a day. They glue the eggs individually to a hair shaft, usually close to the scalp but in warm climates as far as 6 inches from the scalp. They hatch in 6-10 days, after which the empty egg cases move further and further from the scalp as the hair grows out. The diagnosis can be made by seeing live, moving lice and finding nits (the egg or young lice) on the hair. The best place to look for them is behind the ear and at the nape of the neck. Nits can be confused with dandruff and debris, but these can usually be brushed away while nits remain firmly stuck to the hair shaft. Nits alone are not enough to make the diagnosis of active infestation. They may be either alive or dead: empty or nonviable egg cases may still be present long after the infestation has resolved. (more…)

Posted in: Pharmaceuticals

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Dr. Joe Writes About Quackery

Not long ago I wrote about the free online “Food for Thought” course. Joe Schwarcz (“Dr. Joe”) was one of the three professors teaching that course. He also has a radio show, a blog, a podcast, and he writes books. His newest book will be of particular interest to SBM readers: Is That a Fact? Frauds, Quacks, and the Real Science of Everyday Life.

dr-hoe-is-that-a-fact

I reviewed an earlier book of his, The Right Chemistry, for Skeptic magazine. You can read my review online here. I called him “The Carl Sagan of Chemistry” for his ability to popularize science and make it not only palatable but fascinating and entertaining. In the new book, Dr. Joe turns his attention to exactly the kind of subjects we cover on this blog. He is a chemist and most of us are physicians, but we reach the same conclusions because we look at the evidence from the same rigorous scientific viewpoint.

In The Right Chemistry, Dr. Joe explains that “chemical” does not mean “bad stuff” — chemicals make up the entire world, and we are made of chemicals that our own body manufactures. He shares his encyclopedic store of obscure and intriguing scientific facts. Have you ever heard of kangatarians? Did you know asparagus can grow up to 10 inches a day? Can you explain why crystals of Epsom salts crumble if you yell at them? Do you think explosives can’t be made on a plane with small amounts of liquids? (Dr. Joe thinks they can, but for obvious reasons he’s not divulging the recipe.) You probably didn’t know that in World War II the U.S. military developed a mixture called “Who Me?” that smelled like feces and was dispensed with an atomizer. French Resistance fighters were supposed to surreptitiously spray it on German officers to embarrass them, but it wasn’t a great success since the sprayer ended up as stinky as the sprayee.
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Posted in: Book & movie reviews

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Curing Hepatitis C: A Success Story and a Price Tag

Most people know about hepatitis B; babies get vaccinated for it at birth. But fewer people know about hepatitis C. C is actually more common than B, but most chronically infected people don’t know they have it. You might think ignorance is bliss, but patients who have no symptoms today may have liver cancer or a liver transplant in their future. Until recently, treatment for this stealth disease was disappointing, but according to three recent, large controlled studies published in The New England Journal of Medicine, the virus has been tamed. A short course of a new antiviral drug with few side effects was 99% effective in removing the virus from the blood.

History

In the beginning, there was jaundice. Patients turned yellow, developed flu-like symptoms, and sometimes died. Eventually doctors figured out that jaundice was a sign of liver disease and the condition was named hepatitis; and by the time I graduated from medical school in 1970, scientists had identified two viruses that caused infectious hepatitis: hepatitis A and B. Hepatitis A infection was transmitted by the fecal-oral route, usually by contamination of food; hepatitis B was transmitted by needles and blood products. Prevention was limited to good hygienic practices; treatment of acute hepatitis was limited to bed rest, supportive care, and IV fluids. Contacts could be given gamma globulin. In fulminant cases and chronic hepatitis, steroids were used. No treatment was very effective. Death and cirrhosis often ensued.
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Posted in: Clinical Trials, Pharmaceuticals

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Risk of Intussusception with Rotavirus Vaccines

intussuceptionRotavirus is the leading cause of severe diarrhea in infants and children worldwide, leading to more than half a million deaths each year in children under the age of 5. Before the introduction of the rotavirus vaccine, almost all children in the US were infected by the age of 5, and rotavirus infections were responsible for 400,000 doctor visits, 200,000 ER visits, 55,000-70,000 hospitalizations, and 20-60 deaths each year. The first rotavirus vaccine, RotaShield, was found to have an association with intussusception. Two newer vaccines, Rotateq and Rotarix, were thought not to carry that risk, but two new trials have shown that they do. Still, the risk is small and the benefits of the vaccines are great.

What is intussusception?

Intussusception is a “telescoping” of the intestine where one section slides inside another section. This can cut off the blood supply, block the intestine, and cause tears, infections, and death. Most cases are in young children. They have severe abdominal pain (intermittent at first), and pass blood in the stool, typically mixed with mucus and having the appearance of currant jelly. A barium enema can confirm the diagnosis and simultaneously treat it. Sometimes surgery is needed. (more…)

Posted in: Vaccines

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Ridiculous Warning from Chiropractors About Alleged Health Effects of Texting

Too Much Texting?

Too Much Texting?

The United Chiropractic Association has warned that using mobile phones for texting could cause poor posture that could shorten your life. They claim that poor posture is as big a health risk as obesity and that it increases the risk of an early death, especially in elderly people. Chiropractors have said a lot of silly things, but this ranks right up there among the silliest. They are just making stuff up and using scaremongering as a practice-building technique.

They say these claims are based on research studies. They aren’t. They are fanciful imaginings built around a tiny grain of truth that is just large enough to confuse a medically naive public. When people text, they usually bend their head forward; and if you hunch over for long periods, your back is likely to hurt. I have to keep reminding myself not to sit at the computer too long in one position. (more…)

Posted in: Chiropractic

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Water Birth (Again)

Note: I had just finished writing this article when I discovered Dr. Jones had beat me to the punch with his March 28th article on the same subject. He did an excellent job, and of course reached the same conclusions I did (it’s not that great minds think alike, but that we base our conclusions on the same body of evidence). Rather than let my efforts go to waste, I decided to go ahead and publish my shorter, more idiosyncratic article. If it’s worth saying, it’s worth saying twice; and different approaches may appeal to different readers.


“Humani nihil a me alienum puto.”

Nothing human should be alien to me, and I can understand why people do most of the strange things they do, but water birth is something I have really had difficulty with. Why would anyone want a baby to be born underwater? Why would they want to buy a special pool, set it up in the living room, fill it with water, keep the water at the right temperature, and then have to deal with emptying the pool and cleaning up afterwards? I read about it and tried to understand, and now I have some insight into their reasons; but I think they are poor reasons, and the whole concept remains pretty alien to my mind.

The claims

I found a fuzzy feel-good rationale on the Waterbirth International website. Mothers feel it is the gentlest of gentle births. Warm, luxurious water cradles you and gives you complete freedom to move during the greatest achievement of your life. “The women who have experienced the support and comfort of water for their labors and held their newborns in their arms speak more than any scientific article or paper on the subject.” In other words, “We don’t need no stinkin’ science!” (more…)

Posted in: Obstetrics & gynecology

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Point-of-Care Ultrasound: The Best Thing Since Stethoscopes?

A bit of good news for a change: a “Perspective” article in the New England Journal of Medicine describes how point-of-care ultrasound devices are being integrated into medical education. The wonders of modern medical technology are akin to science fiction. We don’t yet have a tricorder like “Bones” McCoy uses on Star Trek, but we are heading in that direction, and the new handheld ultrasound devices are a promising development.

The stethoscope has become iconic, a symbol of medical expertise draped proudly around the neck by doctors and other medical personnel. Before it was invented, doctors could only try to listen to a patient’s heart by direct application of ear to chest. In 1816, Laennec interposed a tube of rolled paper between ear and chest, and the stethoscope was born. It quickly became an essential tool, allowing us to hear the distinctive murmurs produced by different heart valve abnormalities, to take blood pressures, to detect the wheezing of asthma or the collapse of a lung , to hear the bruits caused by atherosclerotic narrowing of blood vessels, to detect intestinal obstructions by listening for borborygmi (I love that onomatopoeic word!).

The stethoscope allows us to hear sounds produced by the body, but sound also allows us to see inside the body. Diagnostic ultrasound has a multitude of uses. With prenatal sonograms, we can determine the sex of a fetus, watch it suck its thumb, and even take its picture for the family album. With echocardiography we can evaluate heart valves, see fluid accumulation in the pericardium, observe the thickness and motion of the heart wall, and even quantify the efficiency of the pumping process. Ultrasound lets us see clots in blood vessels and stones in the gallbladder, evaluate abdominal organs, detect cysts, screen for carotid artery narrowing and abdominal aortic aneurysms, and guide needles into the body for therapeutic and diagnostic purposes. (more…)

Posted in: Diagnostic tests & procedures, Medical Academia, Medical devices

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Nature vs. Technology

For those who dismiss advocates of the “natural” as ignorant of science and deluded by the logical fallacy that natural = best, Nathanael Johnson’s new book is an eye-opener: All Natural: A Skeptic’s Quest to Discover if the Natural Approach to Diet, Childbirth, Healing, and the Environment Really Keeps Us Healthier and Happier. If nothing else, it is a testament to the ability of the human mind to overcome childhood indoctrination in a belief system, to think independently, and to embrace science and reason.

Nathanael Johnson was brought up by hippie parents who subscribed to every “natural” belief and fad. His mother nearly died of a postpartum hemorrhage when he was born at home (he weighed 11 pounds!). His parents didn’t report his birth, and he didn’t have a birth certificate. He co-slept with his parents, never wore diapers (imagine the clean-up!), was allowed to play in the dirt and chew on the snails he found there, was fed a Paleolithic diet, was never allowed any form of sugar, didn’t know there was such a thing as an Oreo cookie, was home-schooled, and did not know that public nudity was taboo until he and his brother shocked the folks at a church picnic by stripping naked to go swimming in the lake. Nudity was customary in his home, and he was encouraged to “let his balls breathe.”

As he grew up, he started to question some of the dogmas he had learned from his parents. He had been taught that good health resulted from forming connections with nature, but he found that nature “generally wanted to eat me.” Now an adult and a journalist, he understands science and how to do research. He tried to read the scientific literature with an unbiased mindset, asking questions about the subjects in his book’s title rather than looking for evidence to support any prior beliefs, and he arrived at pretty much the same conclusions we science-based medicine folks did. But he still appreciates that a natural approach has value, and he seeks to reconcile nature with technology. He calls his book a comfortable refuge from people who are driven to extremes. (more…)

Posted in: Book & movie reviews, Nutrition, Obstetrics & gynecology

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