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780.6

You can tell what a doctor does for a living by the ICD-9 codes they have memorized. There is an ICD-9 code for nearly every medical condition. Weightlessness is 994.9. Must be there for NASA, I have yet to see a weightless patient. Decapitation by guillotine is E978. There, I suppose, in case Marat returns from the dead. There is an ICD-9 code for the initial visit after being sucked into jet engine (V9733XA) and one for subsequent visits (V9733XD). Why do I suspect V9733XD has yet to be used?

780.6 is my personal favorite. Fever. All my patients have fever and 780.6 was certainly the first ICD-9 code I committed to memory. I have an endless interest in fever and after last Fridays post I thought I would toss in my two cents worth. I will remind my readers that I am an adult ID doctor (who I treat, not necessarily how I behave) and unless specifically mentioned, all that follows applies to those who can legally drink, vote and serve in the military.

98.6 F. It is not normal body temperature. Well it is. But it is not. 98.6 F as average body temperature is an enduring medical myth. (more…)

Posted in: Basic Science, Evolution, History, Science and Medicine

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A truly homeopathic defense of homeopathy

I realize that I’ve said it many times before, but it bears repeating. Homeopathy is the perfect quackery. The reason that homeopathy is so perfect as a form of quackery is because it is quite literally nothing. On second thought, I suppose that it’s not exactly nothing. It is, after all, water or whatever other diluent that homeopaths use (usually ethanol). However, thanks to some basic laws of physics and chemistry and a little thing known as Avogadro’s number, any homeopathic dilution greater than 12C (twelve serial 100-fold dilutions) is incredibly unlikely to contain even a single molecule of starting compound. That unlikeliness reaches truly astonishing levels as we reach the common homeopathic dilution of 30C, which is the equivalent of a 1060-fold dilution. Given that that little thing known as Avogadro’s number, which describes how many molecules of a compound are in a mole, is only approximately 6 x 1023, a 30C dilution is on the order of 1036- to 1037-fold higher than Avogadro’s number. Even assuming that a homeopath started with a mole of remedy before diluting (unlikely, given the high molecular weight of most of the organic compounds that can serve as homeopathic remedies), the odds that a single molecule could remain behind after the serial dilution and succussion process is infinitesimal. Appropriately enough, the “law” in homeopathy that states that diluting a remedy will make it stronger is the law of infinitesimals.

It is also the reason that homeopathy is nothing.

Homeopaths have known these facts for many decades. Anyone who is any sort of a scientist or has an understanding of science, when confronted with these simple, well-established physical laws, might—just might—start to rethink his belief in something that is so utterly implausible from a scientific standpoint. Indeed, homeopathy is about as close to impossible as anything I can imagine, because for it to “work” multiple well-established laws of physics and chemistry would have to be not just wrong, but spectacularly wrong. Yet, as Richard Dawkins famously put it, undeterred, homeopaths bravely paddle up the river of pseudoscience and invent explanations to “explain” how homeopathy could work, the most famous of which is the so-called “memory of water,” in which the water in the homeopathic remedy remembers all the good bits meant to heal but, as Tim Minchin so famously put it, somehow forgets all the poo that’s been in it. Homeopathy is truly magical thinking, which is why I love to use it as an illustrative example of quackery. Not only is it magical thinking, but because it is nothing but water, it’s a very useful educational example for placebo effects and the general types of fallacious arguments quacks and pseudoscientists make. Apparently it’s time for another one.
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Posted in: Basic Science, Homeopathy

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The NIH funding process: “Conformity” and “mediocrity”?

When we refer to “science-based medicine” (SBM), it is a very conscious choice to emphasize that good medicine should be based on a solid foundation of science. The name was coined to contrast the difference between the current evidence-based medicine (EBM) paradigm, which fetishizes randomized clinical trial evidence above all else and frequently ignores prior plausibility based on well-established basic science, and the SBM paradigm, which takes prior plausibility into account. The purpose of this post will not be to resurrect old discussions on these differences, but before I attend to the study at hand I bring this up to emphasize that progress in science-based medicine requires progress in science. That means all levels of biological (and even non-biological) basic science, which forms the foundation upon which translational science and clinical trials can be built. Without a robust pipeline of basic science progress upon which to base translational research and clinical trials, progress in SBM will slow and even grind to a halt.

That’s why, in the U.S., the National Institutes of Health (NIH) is so critical. The NIH funds large amounts of biomedical research each year, which means that what the NIH will and will not fund can’t help but have a profound effect shaping the pipeline of the basic and preclinical research that ultimately leads to new treatments and cures. Moreover, NIH funding has a profound effect on the careers of biomedical researchers and clinician-scientists, as having the “gold standard” NIH grant known as the R01 is viewed as a prerequisite for tenure and promotion in many universities and academic medical centers. Certainly this is the case for basic scientists; for clinician-scientists, having an R01 is certainly highly prestigious, but less of a career-killer if an investigator is unable to secure one. That’s why NIH funding levels and how hard (or easy) it is to secure an NIH grant, particularly an R01, are perennial obsessions among those of us in the biomedical research field. It can’t be otherwise, given the centrality of the NIH to research in the U.S.
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Posted in: Basic Science, Clinical Trials, Politics and Regulation

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Getting NCCAM’s money’s worth: Some results of NCCAM-funded studies of homeopathy

As hard as it is to believe, the Science-Based Medicine blog that you’re so eagerly reading is fast approaching its fifth anniversary of existence. The very first post here was a statement of purpose by Steve Novella on January 1, 2008, and my very first post was a somewhat rambling introduction that in retrospect is mildly embarrassing to me. It is what it is, however. The reason I mention this is because I want to take a trip down memory lane in order to follow up on one of my earliest posts for SBM, which was entitled The National Center for Complementary and Alternative Medicine (NCCAM): Your tax dollars hard at work. Specifically, I want to follow up on one specific study I mentioned that was funded by NCCAM.

Even though I not-so-humbly think that, even nearly five years later, my original post is worth reading in its entirety (weighing in at only 3,394 words, it’s even rather short—for me, at least), I’ll spare you that and cut straight to the chase, the better to discuss the study. It is a study of homeopathy. Yes, in contrast to the protestations of Dr. Josephine Briggs, the current director of NCCAM, that NCCAM doesn’t fund studies of such pure pseudoscience as homeopathy anymore (although she does apparently meet with homeopaths for “balance”), prior to Dr. Briggs’ tenure NCCAM actually did fund studies of the magic water with mystical memory known as homeopathy. Two grants in particular I singled out for scorn. The principal investigator for both grants was Iris Bell, who is faculty at Andrew Weil’s center of woo at the University of Arizona. The first was an R21 grant for a project entitled Polysomnography in homeopathic remedy effects (NIH grant 1 R21 AT000388).
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Posted in: Basic Science, Clinical Trials, Homeopathy

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Thumbthing Worth Reading

I intended to read Sam Kean’s new book The Violinist’s Thumb: And Other Lost Tales of Love, War, and Genius as Written by our Genetic Code  just for fun. I was expecting a miscellany of trivia loosely gathered around the theme of DNA. But I found something much more worthwhile that I thought merited a book review to bring it to the attention of our readers. Kean interweaves entertaining stories into a somewhat disjointed but nonetheless valuable history and primer of genetics. The title refers to Paganini, whose DNA created the unusual joint flexibility that facilitated his unprecedented feats of virtuosity on the violin.

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Posted in: Basic Science, Book & movie reviews, Evolution, History

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Mouse “avatars”: New predictors of response to chemotherapy?

Over the years, I’ve written a lot about “personalized medicine, mainly in the context of how the breakthroughs in genomic medicine and data pouring in from the Cancer Genome Atlas is providing the raw information necessary for developing truly personalized cancer therapy. The problem, of course, is analyzing it and figuring out how to apply it. Another problem, of course, is developing the necessary targeted drugs to attack the pathways that are identified as being dysregulated in cancer cells. Oh, and there’s that pesky evolution of resistance to antitumor therapies. Indeed, most recently, the Cancer Genome Atlas is bearing fruit in breast cancer (a study that I’ve been meaning to blog about).

One problem with modeling the pathways based on next generation sequencing data and expression profiling is testing whether therapies predicted to work from these analyses actually do work without actually testing potentially toxic drugs on patients. Cell culture is notoriously unreliable as a predictor. However, there is another way that’s intriguing. Unfortunately, as intriguing as it is, it has numerous problems, and, unfortunately, it’s being prematurely marketed to patients. Although I had heard of this technique as a research tool before, I learned about its marketing to patients when I came across an article by Andrew Pollack in the New York Times entitled Seeking Cures, Patients Enlist Mice Stand-Ins. Basically, it’s about a trend in science and among patients to use custom, “personalized’ mouse xenograft models in order to do “personalized” therapy:
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Posted in: Basic Science, Cancer, Clinical Trials, Diagnostic tests & procedures

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Is shameless self-promotion of your science a good idea?

As part of my ongoing effort to make sure that I never run out of blogging material, I subscribe to a number of quack e-mail newsletters. In fact, sometimes I think I’ve probably overdone it. Every day, I get several notices and pleas from various wretched hives of scum and quackery, such as NaturalNews.com, Mercola.com, and various antivaccine websites. I think of it as my way of keeping my finger on the pulse of the antiscience and pseudoscience wing of medicine, but I must admit that I don’t really read them all, but they do allow me to know what the quacks are selling and what new arguments they’re coming up with without actually going to each of their websites. I can then judge by the headlines and the blurbs included in the e-mails whether I think it’s worth it to go to the website itself and, of course, whether the topic might represent fodder for a good blog post. I will admit that not all the sites I monitor are as loony as the Health Ranger’s. In fact, I monitor the blogs and websites of the National Center for Complementary and Alternative Medicine (NCCAM), various naturopath organizations, and the like in order to learn of the “respectable” arguments being used to tout various nostrums.
Sometimes—albeit rarely—I even learn about some interesting new science.

One of the most common themes (besides antivaccine hysteria, claims that diet can prevent 95% of all cancers, etc.) tends to be one of a variety of pitches for various “cures” of serious diseases like cancer and heart disease that “they” don’t want you to know about; i.e., the Kevin Trudeau gambit. Who this “they” is can range from doctors to pharmaceutical companies to universities to the government, but the central message is that someone out there doesn’t want you to know The Truth. A variation of this sort of appeal is the claim that there is a promising new therapy, a cure even, usually natural, that is languishing somewhere because it can’t be patented, because pharmaceutical companies would lose money if it were ever validated and brought into clinical use, or because it goes against current medical dogma. It doesn’t even have to be natural. After all, dichloroacetate (DCA) is not exactly “natural.” After it was shown to have promise in animal models, a pesticide salesman named Jim Tassano sold DCA bought from chemical companies to desperate cancer patients from a website that claimed to be selling it only for pets with cancer, a ruse that fooled no one. Yet the “natural treatment” crowd embraced it whole-heartedly because it looked as though sellers of DCA were sticking it to The Man.
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Posted in: Basic Science, Cancer, Clinical Trials

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Low Level Lasers: N-Rays in action.

I do not want to get all angsty and omphaloskeptic, but I have been thinking more of late about the purpose of the blog and my role in it.  Blogs,and the people who write them,  are ephemeral.  It takes a unique personality and commitment to churn out these essays and commit them to the ether.  Especially since Michelson and Morley.

I have never given much thought as to who our readers are, at least as a composite.  I read most of the comments on every entry and have certainly developed a mental picture of some of our regular commenters, although I suspect I probably do not have even the gender correct most of the time.  The commenters represent a tiny fraction of the regular readers and an even smaller fraction of occasional readers.  It occurs to me I haven’t a clue who the real audience of this blog is.

I write  first for my own education and entertainment, then for the slightly bored and overwhelmed medicine resident, since that is who I spend most of my time educating at work.  Someone educated with an understanding of basic medicine but has more important things on their mind than a need for a detailed understanding of why homeopathy is complete nonsense.  I doubt the majority of my readers are health care workers and I suspect  continuing medical education is not a major part of the blog.

I never considered SBM to be a consumer protection group, but this week my wife showed me a half page advertisement in the local paper, and I realized that not only was the advertisement a good topic for blogging, but consumer protection is a fundamental result of this blog.  There really is no site on the interweb that looks at both SCAM and real medicine with quite the same skeptical eye.  Here is the headline:

A Special Wellness Report

New Medicine Based On An 88- Year Old Theory By Albert Einstein Can Help Almost Everyone Who Is Sick Or Injured! (more…)

Posted in: Basic Science, Energy Medicine, Health Fraud, Science and Medicine, Science and the Media

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Jurassic Farce

It feels like I live in the real world example of Ray Bradbury’s All the Summer in a Day but for the last two weeks we have had sun and heat and it has been glorious. I get Christmas and Thanksgiving and New Years as vacation, but who needs that? I need July and August to live the vida loca in the Oregon summer. Who wants to blog when I can be outside, at concerts, golfing, hiking and…

Yes Dr. Gorski. I did agree to write an entry every other Friday. Yes Dr. Gorski. I know you have the documentation. Yes Dr. Gorski, I do not want any of that information made public. No one needs to know that I wanted to be a naturopath when I was young. Sigh. Yes, Sir, I will get to blogging. Damn those youthful indiscretions. Let’s see how little I can do and meet my obligations with the powers that be.

My professional career is based upon inflicting death, and in my time I  have obliterated uncountable numbers of unicellular organisms. If there were such a thing as Karma, I would certainly return in the next life as a rabbit in a syphilis lab. But there isn’t, and I can kill and kill with a clean soul. There is no guilt or hesitation in killing unicellular life, or even multi-cellular life, as long as it cannot be seen without a microscope. I start to get a wee bit squeamish as soon as I can see a life form. I tend to not kill bugs or animals, unless, of course, they can be eaten. If it tastes good, all bets are off. But as a tree hugger, I tend to look upon killing wildlife and extinctions as a bad thing. (more…)

Posted in: Basic Science, Humor

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The Plausibility Problem

From the very outset, the founders of Science Based Medicine have have emphasized the importance of plausibility in the critical evaluation of scientific claims in medicine. What exactly does “plausibility” mean, and how should we apply it in science? My simple definition of plausibility would be “the likelihood that a premise is true.” The application in science is a little more complicated.

Consciously or unconsciously, we all consider plausibility in interpreting events in our lives. For example, if one of your coworkers showed up late for work and grumbled about a traffic jam, you would likely accept his story without question. If, instead, the same coworker attributed his tardiness to an alien abduction, you would not be so charitable. In each case, he has provided the same level of evidence: his anecdotal account. You are likely to accept one story and reject the other because of a perceived difference in the plausibility. The skeptic’s mantra “Extraordinary Claims Require Extraordinary Evidence” expresses this concept in a qualitative way.

Evidence-based medicine has traditionally ignored plausibility when interpreting the evidence for a medical intervention. Science-based medicine, as envisioned by the creators of this blog, includes plausibility when making these judgements.

Since experiment research employs rigorous controls, and statistical criteria, you might assume that plausibility is not an issue, however, this is not entirely true. An article written by John Ioannidis entitled “Why Most Published Research Findings Are False” is cited frequently as a reference for the impact of plausibility on the interpretation of research results. This article enumerates numerous factor leading to erroneous research conclusions. Most of them have been dealt with on this blog at one time or another. To me, the most eye-opening aspect of the paper was a quantitive approach to the influence of plausibility in interpreting positive research findings. I was never taught this approach in medical school, or in any other venue. When it comes to implausible hypotheses, the traditional P-value can be very misleading.

As good as Ioannidis’ article is, it is not easy reading for the statistically or mathematically challenged. What I attempt to do in this post is to demonstrate the importance of plausibility in graphic format, without a lot of complex math. If you can grasp the concepts in this post, you will have an understanding that many researchers, and consumers of research, lack.
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Posted in: Basic Science, Clinical Trials

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