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November Hodgepodge

There have not been a lot of topics of late that warrant extensive analysis and discussion.  But there are a number of little topics of interest, each worthy of a few paragraphs of discussion, archetypes of issues in medicine, science based and otherwise.

Xigirs. No, it is not whale vomit, but close.

Last month Xigris  was pulled from the market by Lilly.  Yes, I understand the shock. Xigris, we hardly knew ye.   Xigris is the brand name for drotrecogin alfa, or activated protein C.  It is an enzyme in the clotting cascade that is/was given for the treatment of sepsis. (more…)

Posted in: Acupuncture, Energy Medicine, Pharmaceuticals, Science and Medicine

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Random Flu Thoughts

I normally write the first draft of this blog the weekend before it is due, and this is no exception.  However, I am ill this weekend.  Headache, myalgias., painful cough, but only mildly ill.  The worst part is the interferon induced brain fog; my thoughts flow with all the speed of pudding and I was not appreciably better as the week progressed, although no cracks about how  you can’t any difference in my writing over baseline.

I doubt the cause of my symptoms is influenza.  According to the CDC site and Google flu trends there is little influenza activity in the US at the moment, so it is probably one of the innumerable viruses that can cause a flu-like illness.  I am also not ill enough to think I have influenza, but I could be having a modified course as I was vaccinated a month ago.  Of course, the doctor who treats herself has a fool for a patient and an idiot for a doctor. Flu season approaches, so from my interferon addled brains, flu thoughts.

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Posted in: Public Health, Science and Medicine, Vaccines

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Alternative Vaccination Schedules

Evidently the 7 billionth human is going to be born on October 31. Happy birthday and welcome to the Earth.  If you were unfortunate enough to be born into a developing country or a affluent California family, you may not receive your vaccinations, and may join one the 57 million who die each year of vaccine preventable diseases (VPD).

I totally misread the table.  It’s about 4,320,000 who die of VPD. Well, I said I was no damn good at stats.

And if you are doubly unlucky, you may be exposed to illness from an unvaccinated friend, family or health care worker before you can get your vaccines, and join the ranks of the ‘only’s.’  The ‘only’s’ are those who die of vaccine preventable diseases and are mentioned in anti-vaccine literature in a sentence like ‘VPD X is a mild illness in most children and only kills Y% of cases ’.  As I have said before the anti-vaxers do not care for whom the bell tolls.

I am no good at statistics.  I signed up for, and dropped, statistics at least 4 times in college.  Once they got past the bell shaped curve, it was one incomprehensible huh?  Part of the problem with statistical concepts such as risks, both relative and absolute, is that it is often impossible to get a feel from what they represent. For me it is like metric measurements.  I know what a 8 mile hike represents, but not an 8 kilometer hike.  Same with centigrade and liters.  I have been unable to internalize what metric means in my daily life. (more…)

Posted in: Vaccines

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The Prostrate Placebo

I seem to be writing a lot about the urinary tract this month. Just coincidence, I assure you. As I slide into old age, medical issues that were once only of cursory interest for a young whippersnapper have increasing potential to be directly applicable to grumpy old geezers. Like benign prostatic hypertrophy (BPH). I am heading into an age where I may have to start paying attention to my prostate (not prostrate, as it is so often pronounced, although an infection of the former certainly can make you the latter), so articles that in former days I would have ignored, I read. JAMA this month has what should be the nail in the coffin of saw palmetto, demonstrating that the herb has no efficacy in the treatment of symptoms of BPH: Effect of increasing doses of saw palmetto extract on lower urinary tract symptoms: a randomized trial.

It demonstrated that compared to placebo, saw palmetto did nothing. There have been multiple studies in the past with the more or less the usual arc of clinical studies of CAM products: better designed trials showing decreasing efficacy, until excellent studies show no effect. There is the usual meta analysis or two, where all the suboptimal studies are lumped together, the authors bemoan the quality of the data, and proceed to draw conclusions from the garbage anyway. GIGO.

The NEJM study from 2006 demonstrated that saw palmetto was no better than placebo but it was suggested that perhaps the dose of saw palmetto was not high enough or that the patients were not treated long enough to demonstrate an effect, and the JAMA study hoped to remedy that defect. (more…)

Posted in: Clinical Trials, Herbs & Supplements, Science and Medicine

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Recycle

Like most people who grew up after April 22, 1970, I think it is important to be as environmentally responsible as possible.  Like many I fail miserably much of the time, but at least I feel guilty about it.  Recycling offers the opportunity to feel good about my environmental impact with little effort, since the garbage collection infrastructure in Portland makes recycling easy.

Some products are best extensively reprocessed before reused. Urine, as an example. There are proponents of topical and/or drinking urine as a treatment/cure for nearly any illnesses.  The kidneys are mostly responsible for fluid and electrolyte balance and I realize that normal urine is mostly water, salts, urea and a smattering of other very dilute molecules. I have the urine tox screen to prove it.  Urine is not a particularly noxious body fluid, but it is not high on my list of liquids to drink under normal circumstances.

Urine is mostly water but not an optimal source of water if it is your only source for fluids.  Urine drinkers love to mention the occasional trapped earthquake victim who survives, in part, from drinking their own urine.  For the first several days the urine would be dilute enough to keep people reasonably hydrated, as humans cannot concentrate urine as well as, say, a camel.  So I can see where consuming urine for a short period of time would delay progressive dehydration and death. A couple days of drinking urine neat, shaken not stirred, would be harmless and, if there were no alternative sources of water, beneficial. I do suffer from the societal taboo that piss is icky, and for aesthetic reasons urine is not something I would want to consume, even when it is referred to as its more common designation ‘Coors Light’. (more…)

Posted in: Herbs & Supplements, Science and Medicine

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Gullible George

I get the occasional email.  Very little hate mail, unfortunately, since hate mail is often more amusing.  I read what little email I receive, and usually do not respond, mostly as I do not have the time.  I am a slow writer and a slower typist, and there are just so many hours in the day, and the older you get, the shorter th0se hours become.

Recently, over at the center of the growing Mark Crislip multimedia empire, I had the following in the feedback section:

Just thought you’d like to know:

My kids watch the PBS show “Curious George” which usually does a good job with introductory Physics, Astronomy, scientific method, etc. Interspersed with the cartoons they have scenes with real children that do a real-life parallel investigation of what happened on Curious George.

Today’s episode involved the Man with the Yellow Hat catching a cold, and Curious George going to the pharmacy and picking up various drugs to assist in making the guy feel better, mainly to have him sleep and be comfortable.

The interspersed skit, however, had the children visit a naturopath, where they learned:
* Oregano cures infections
* Various pressure points that correspond to energy lines
* And that taping magnets to these points is really effective.

I sat here simply amazed.

Me, not so much.  Alternative medicine has always been a blind spot for PBS.  While PBS  would not show perpetual motion machines,  suggest that astrology is legitimate, or give credence to a flat earth, alternative medicine, as it is for many otherwise thoughtful people, is exempt from even cursory critical thinking. PBS has broadcast  Drs. Chopra and North, so its track record with science based medicine is not so good. My children are long past the Curious George part of their lives, but I read them the books when they were kids.  Not my favorite (I like the Madeleine books better; 6 weeks in hospital for an acute appendix never failed to amuse me) but they were a quick read when the kids wanted a story at bedtime and I was too tired for a longer exposition. (more…)

Posted in: Naturopathy, Science and the Media

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The Annals of Internal Medicine Qualifies for Fail Blog.

As most readers of the blog know, I am mostly an Infectious Disease doc. I spend my day diagnosing and treating infections and infectious complications. It is, as I have said before, a simple job. Me find bug, me kill bug, me go home. Kill bug. It is the key part of what I do everyday, and if there is karmic payback for the billions of microbial lives I have erased from the earth these past 25 years, my next life is not going to be so pleasant. I will probably come back as a rabbit in a syphilis lab.

It is always fun when my hobby, writing for SBM, crosses paths with my job. This month the Annals of Internal Medicine published “Oseltamivir Compared With the Chinese Traditional Therapy Maxingshigan–Yinqiaosan in the Treatment of H1N1 Influenza. A Randomized Trial.”

I though big pharma was good at coming up with names I do not know how to pronounce. If someone could provide a pronunciation guide in the comments, it would be ever so helpful, so I will not have to embarrass myself when this entry becomes a Quackcast. Dr. Hall wrote about this article on Tuesday, and I have avoided reading her post until this one is up, so there may be overlap in what is discussed. (more…)

Posted in: Basic Science, Clinical Trials, Herbs & Supplements, Science and Medicine

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Train Therapy

Summertime and the living is busy.  Finally we have sun in the Northwest.  While the rest of the country has been melting in heat, this year we have rarely cracked 85.  Global heating has avoided Oregon this year, and I will need some green tomato recipes.  Good weather, work is busy, and it is the last two weeks with my eldest before he is off to Syracuse, so there is little time for writing, so a brief entry this week.

I always wince at the way anything can be called ‘therapy.’ We have music therapy and garden therapy and pet therapy and art therapy.  I do not deny that it is beneficial for people to participate in those activities while in the hospital, although I am never happy to see disease vectors, er, animals in a hospital.   Dinner should be food therapy, reading should be book therapy, and using the internet should be computer therapy.  I guess it is like calling something ‘medical’ grade, and you can bill more for it.

Some ‘therapies’ are a wee bit more odd.  Indonesians are using railroad therapy.  People lie down on electric railroad tracks because “the electricity current from the track could cure various diseases.”  To date no one has been either electrocuted or squashed, but I suppose it is only a matter of time.

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Posted in: Energy Medicine, Faith Healing & Spirituality, Science and the Media

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CAM: The Beer Goggles of Medicine

It is summer, the kids are off, and time to write dwindles in the face of sun and golf. Nonsense knows no season, and in my readings this week I came across the phrase “the undeniable power of the placebo.” I will do my best to deny that power at least three times before the I crow my conclusion.

One of my first entries for SBM, back in the mists of time, was the Placebo Myth [0], where I argued that the placebo has no clinical effects, has clinically irrelevant alleged physiology and at most leads to a slight change in perception on the part of the patient that they have less pain. Essentially placebo does nothing. It has no power.

Two studies this month continue that argument: demonstrating that placebo has no practical benefit and the crowing in the media mistakenly trumpets that it does. The headline on Medscape [1] reads “Placebo Effects Modest in Treating the Common Cold.” How modest?

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Posted in: Clinical Trials, Science and Medicine

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Honey

I cram for TAM, and, combined with other commitments, not the least of which is that it is finally sunny and warm in Portland, after a year that has resembled All the Summer in a Day,  which leads to a relatively short post.  There are just so many hours in a day and if possible those days need to be spent in the sun.

In my first year in practice I was sitting on a nursing station writing a note when a patient started howling in pain.  Further investigation revealed that the patient had a chronic, open surgical wound and the (old) surgeon had ordered sugar poured into the wound as part of wound care.  The cafeteria mistakenly sent up salt, and a metaphor became reality.  It did pique my interest in both sugar and honey for wound care,  an area where you have to be careful not to fall prey to all the errors in CAM thinking: a reliance on anecdotes, using suboptimal studies as evidence, mistaking a gobbet of basic science as a meaningful clinical application, and not realizing the warping effect of confirmation bias.

That being said, I have suggested honey and sugar for years for patients, and many patients with prior refractory wounds had healing.  And what are the three most dangerous words in medicine?  In my experience.  I have recommended honey less in the era of the wound vac, but there are not an insignificant number of people with insufficient financial resources who cannot afford even simple wound care supplies. Many  of the ointments, creams and special bandages for wound care costs too much.  Patients also like honey as it is natural (people do love to fall for the naturalistic fallacy) and inexpensive, and I always tell patients that the data is iffy, but not stupid. (more…)

Posted in: Herbs & Supplements, Science and Medicine, Surgical Procedures

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