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Alternative Microbiology

A man of science rises ever, in seeking truth; and if he never finds it in its wholeness, he discovers nevertheless very significant fragments; and these fragments of universal truth are precisely what constitutes science.

~ Claude Bernard.

I almost never have to search for material for this blog. The Secret always seems to provide topics. Subject matter appears unbidden out of the ether. But not this week. I enjoy deconstructing the nonsense of SCAM papers or blog entries more than any other type of blog entry. Perhaps the glee that last week’s entry provided had to be countered by some kind of cosmic balancing mechanism. Although the rational part of my mind objects to the personification of random existence, I suppose the Universe just does not want me to have that much fun two entries in a row. Probably explains why I have a viral URI and my brain has slowed almost to the point of functional inactivity. There is no shortage of SCAMs to write about, they are just not created equal in their ability to generate a passionate rant. (more…)

Posted in: Epidemiology, Evolution, Science and Medicine

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Obamacare, the Oregon Experiment, and Medicaid

Tomorrow, as mandated by the Patient Protection and the Affordable Care Act (PPACA, often called just the Affordable Care Act, or ACA, or “Obamacare”), the government-maintained health insurance exchanges will open for business (that is, assuming the likely government shutdown doesn’t stop them temporarily). We here at SBM have written about the ACA quite a few times, but I would like to write about it in perhaps an entirely different context than you’re used to now that the biggest change mandated by the law is here. Just to see the contrast, I’ll mention that Jann Bellamy has written about the ACA in the context of how provisions have been inserted by promoters of “complementary and alternative medicine” (CAM) could potentially provide an “in” for requiring reimbursement of CAM practitioners for their services by insurance plans sold through the exchanges or even how CAM practitioners might promote themselves as primary care providers (PCPs) under Obamacare, as did Matt Roman. I myself warned about legislative meddling that might permit funding of religion-based health care in the exchanges, and Kimball Atwood sounded early warnings about insertion of the provisions that Jann warned about. Instead, view this discussion as a follow-up to a post I did almost a year ago that used a statement by Mitt Romney during the height of the Presidential campaign as a jumping off point to look at the relationship between health insurance status and mortality. While we at SBM try to remain more or less apolitical, in some cases (licensing of naturopaths, for example) it is not possible to disentangle science from politics, and we have to dive in. Also, politics is the art of the possible; so, policy-wise, what is best as determined by science might well not be what is possible politically.

The reason I wanted to revisit this topic is because of a political battle that went on for quite some time over the last several months to expand Medicaid in Michigan according to the dictates of the ACA. The reason that this battle is occurring in many states is because when the Supreme Court ruled last year that the individual mandate requiring that citizens have health insurance was Constitutional, one provision that it ruled unconstitutional was the mandatory expansion of Medicaid in states participating in the Medicaid program to cover all people under 65 up to 133% of the federal poverty level. States thus had to decide whether or not they would accept the Medicaid expansion. In our state, Governor Rick Snyder supported the expansion. Even though he is Republican, he is also a businessman and realized that it was a good deal, with the federal government covering 100% of the cost for the first three years and then phase down to 90% of the cost in 2020. The bill to expand Medicaid managed to pass the House of Representatives, but then it stalled in the Senate. Unfortunately—and this is what got me involved—my state Senator Patrick Colbeck led the opposition to the Medicaid expansion in the Senate, much to my chagrin and disappointment. His argument, which is being repeated elsewhere in the blogosphere, is that Medicaid is worthless and doesn’t improve health outcomes. Instead, he endorsed an alternative that (or so he claimed) places Medicaid-eligible patients into in essence low cost, high deductible concierge practices, with health savings accounts. This was a plan promoted by practices like BlueSky Health. Ultimately Mr. Colbeck lost, and Medicaid was expanded in Michigan in a plan that was characterized by John Z. Ayanian in this week’s New England Journal of Medicine as “a pragmatic pathway to link Republican and Democratic priorities for health care.”

However, the whole kerfuffle got me to thinking. In my post a year ago, I basically asked what the evidence was that access to health insurance improves health outcomes, but I didn’t really stratify the question into kinds of health insurance. Rather, I just looked at being uninsured versus having health insurance. After my little Facebook encounter with one of my elected representatives, I wondered what, exactly, was the state of evidence. So I decided to do this post. In the U.S., currently we have in essence three kinds of health insurance, broadly speaking: private insurance, Medicare, and Medicaid. Medicare, for those of our readers from other countries, is a plan that covers the medical care of people 65 and over and those receiving Social Security disability benefits. It is funded through payroll taxes and directly paid for by the federal government. Medicaid, in contrast, is a plan designed for low income people who fall below certain income levels. Also in contrast, it is jointly funded by the states and the federal government with each participating state administering the plan and having wide leeway to decide eligibility requirements within the limits of federal regulations that determine the minimal standards necessary for states to receive matching funds. Indeed, the loss of this leeway to determine the income level at which a person is eligible for Medicaid is one of the reasons the provision for Medicaid expansion was part of the Supreme Court challenge to the ACA. These days, most Medicaid plans hire private health maintenance organizations (HMOs) to provide insurance. Finally, what needs to be understood is that, compared to private insurance, Medicare reimbursement rates tend to be lower and Medicaid reimbursement rates are lower still, which is part of the reason why a lot of doctors don’t accept Medicaid. Increases in reimbursement under the ACA might well help this situation. (more…)

Posted in: Clinical Trials, Epidemiology, Politics and Regulation, Science and the Media

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What are words for?

Do you hear me

Do you care

Do you hear me

Do you care

My lips are moving and the sound’s coming out

The words are audible but I have my doubts

That you realize what has been said

You look at me as if you’re in a daze

It’s like the feeling at the end of the page

When you realize you don’t know what you just read

What are words for when no one listens anymore

What are words for when no one listens

What are words for when no one listens it’s no use talking at all

I might as well go up and talk to a wall

‘Cause all the words are having no effect at all

Missing Persons on blogging. Or so I thought. I was surprised to learn the song was written by the brothers Gibb.

Words are important. I try and choose my words carefully when writing so that they accurately reflect not only my thoughts but reality. When I speak, not so much. My frontal lobe filters often fail if I think might I might get a laugh.

I tell housestaff, precision of writing reflects precision of thought. It is one of the reasons I write; the act of writing forces some coherence into what can be muddled and inchoate thoughts. Even though I have residents who write notes, I always write my own. Often I do not make a final decision as to a plan until I put pen to paper, or electrons to screen. Writing crystallizes thought.

Not, evidently, for everyone, as 10 Facts About the Flu Vaccine and the Flu nicely demonstrates. (more…)

Posted in: Epidemiology, Vaccines

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I refute it thus

Reality is one honey badger. It don’t care. About you, about your thoughts, about your needs, about your beliefs. You can reject reality and substitute your own, but reality will roll on, eventually crushing you even as you refuse to dodge it. The best you can hope for is to play by reality’s rules and use them to your benefit. Combined with a little luck (nothing quite as beneficial as being a white, middle class male in the US) you might have a reasonably healthy health.

The most reliable way to understand reality is science and the scientific method. Used wisely you may have a shot at minimizing morbidity and mortality. Deny or ignore it and reality don’t care. Reality will get us all.

We all have our biases, recognized and unrecognized. I often see the world in terms of infectious diseases. When I read Team of Rivals: The Political Genius of Abraham Lincoln I enjoyed the politics and personalities but I was struck by how people constantly died young of infectious diseases. We don’t see mortality in the young anymore for a variety of reasons: better nutrition, an understanding of the pathogenesis of disease, clean water, flush toilets and vaccines.
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Posted in: Epidemiology, Public Health, Science and Medicine, Vaccines

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Animal Therapy

Animal-assisted therapy is a huge topic: almost 1500 hits using those terms alone. There is no way I am going to cover all of them and do them justice. Instead I am going to cherry pick, er, I mean, select references of interest to illustrate issues surrounding animals in the hospital. Sometimes I get the impression that readers of the blog expect encyclopedic knowledge and understanding of a topic whenever we put pixel to screen. That is only true of the other contributors to the blog, not me.

I would like to mention that I do, in fact, like animals, even dogs. I loathe most dog owners, as confirmation bias suggests there is no such thing as a considerate dog owner. But I never have contact with the dogs that don’t bark, that don’t crap on my yard, that don’t run up to me to nip at my legs. I only see the dogs that their owners allow to behave in ways I would never allow a human to behave.

It is no surprise that my kids have grown up mostly animal free. My eldest did wear me down and I bought him a hamster. It promptly bit me, drawing blood. Great, I thought, LCM. Just what I need. Then in the dead of winter it escaped, fell down a heating duct (we were putting in new floor) and electrocuted itself on the heating coils so every time the heat turned on we smelled rotting, roasting hamster. It cost $500 to take the furnace apart and clean it. Good thing it wasn’t a beagle. That was enough pets in the house for me. (more…)

Posted in: Epidemiology, Science and Medicine, Veterinary medicine

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Uneasy Lies the Head That Wears the Flu

Infectious diseases (ID), as those who read my not-so-secret other blog know, is without a doubt the most interesting speciality of medicine. Every interesting disease is infectious in etiology. What is cool about ID is that it has connections into almost every facet of human culture and history.

I note that at some point I have gone from being the young whippersnapper to the Grandpa Simpson at my hospitals and am one of the few who has been around long enough to be a repository of institutional memory. I remember what it was like 20 plus years ago, when no one consistently washed their hands, when all S. aureus (S. aureui?) were sensitive to beta-lactams and we wore an onion on our belt, as was the style of the day. Oh the changes I have seen.

Besides remembering the not so good old days of my professional career, ID keeps me reminded of how the world used to be in the past. Medicine used to be about the epidemics that would routinely sweep across the world. Polio, measles, mumps, scarlet fever, rheumatic fever, tuberculosis and on and on. I occasionally see TB but thanks to modern medicine many of these scourges have mostly faded from medical practice in the US. Not a one, I might add, has faded due to the efforts of alt med practitioners.

Influenza still gives me pause. It is, as infections go, quite the tricky virus and it remains a difficult beast to treat and prevent. Which is a drag as it remains one of the more consistent causes of infectious morbidity and mortality. (more…)

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

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The final nail in the coffin for the antivaccine rallying cry “Too many too soon”?

There are some weeks when I know what my topic will be—what it must be. These are weeks in which the universe gives the very appearance of handing to me my topic for the week on the proverbial silver platter with a giant hand descending from the clouds, pointing at it, and saying, “Blog about this, you idiot!” Usually, it’s because a study is released or something happens or a quack writes something that cries out for rebuttal. Whatever it is, it’s big and it’s unavoidable (for me, at least).

This is one of those weeks.

The reason it’s one of those weeks is because just last Friday, as I was driving to work, I heard a news story on NPR about a study that had just been released in the Journal of Pediatrics. The story, as it was reported, noted that the study being discussed looked specifically at a certain antivaccine trope and found for yet the umpteenth time that vaccines are not correlated with an increased risk of autism. Normally the news that a study had once again failed to find a link between vaccines and autism would be as surprising as a study finding that the sun rises in the east and sets in the west, or finding that water boils at 100° C at sea level. At this point, the evidence is so utterly overwhelming that there is not a whiff of a hint of a whisper of a correlation between vaccines and autism that it has become irritating that antivaccine activists keep pressuring scientists to do the same study over and over again, coming up with the same results over and over again, and then seeing antivaccinationists fail to believe those same results over and over again. Apparently, antivaccine activists think that if the same sorts of studies are done enough times, there will be a positive result implicating vaccines as a risk factor for or contributing cause to autism. By sheer random chance alone, this might happen someday, given the definition of statistical significance, but so far there has not been a single large, well-designed epidemiological study by reputable researchers that has found a link.
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Posted in: Epidemiology, Public Health, Vaccines

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Behold the spin! What a new survey of placebo prescribing really tells us

One of the recurring topics here at SBM is the idea of the placebo: What it is, what it isn’t, and how it complicates our evaluation of the scientific evidence. One my earliest lessons after I started following this blog (I was a reader long before I was a writer) was that I didn’t understand placebos well enough to even describe them correctly. Importantly, there is no single “placebo effect”. They are “placebo effects”, a range of variables that can include natural variation in the condition being studied, psychological factors and subjective effects reported by patients, as well as observer bias by researchers studying a condition. All of these, when evaluated in clinical trials, produce non-specific background noise that needs to be removed from the analysis. Consequently, we compare between the active treatment and the placebo to determine if there are an incremental benefits, to which we apply statistical tests to determine the likelihood that the differences between the intervention and the placebo groups are real. Removed from the observational nature of the clinical trial, we can’t expect the observed “placebo effects” to persist, as they’re partially a consequence of the trial itself. A more detailed review of placebos is a post in and of itself, so I’ll refer you to resources that describe why placebo effects are plural, that placebo effects are subjective rather than objective and there is no persuasive evidence to suggest that placebo effects offer any health benefits. What’s most important is the understanding that placebo effects are a measurement artifact, not a therapeutic effect.

Placebo effects are regular topics within in SBM posts because an understanding of placebo effects is essential to evaluating the evidence supporting (so-called) complementary and alternative medicine, or CAM. As better quality research increasingly confirms that the effects from CAM are largely, if not completely, attributable to placebo effects, we’ve seen the promoters of CAM shifting tactics. No longer able to honestly claim that CAM has therapeutic effects, “treatments” such as acupuncture or homeopathy are increasingly promoted as strategies that”harness the power of placebo” without all the pesky costs or side effects of real medical interventions. But this is simply special pleading from purveyors and promoters. Unable to wish away the well-conducted trials that show them to be indistinguishable from placebos, they instead are spinning placebo effects as meaningful and worthy of pursuit – ideally with your favourite CAM therapy. Again, I’ll refer you to posts by David Gorski and Steven Novella who offer a more detailed description of how negative results can be spun to look positive. Because CAM’s effects are indistinguishable from placebo, we should not invest time and resources into pursuing them – we should instead focus on finding treatments that are demonstrably superior to placebo.

But what if physicians are already using placebos widely in practice? Setting aside the ethical issues for now, widespread placebo usage might suggest that physicians believe that placebos are effective treatments. And that’s the impression you may have had if you skimmed the medical headlines last week:

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Posted in: Clinical Trials, Epidemiology, Science and Medicine

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Worms, Germs, and Dirt: What Can They Teach Us About Allergies and Autoimmune Diseases?

Whipworms in the intestine

Whipworms in the intestine. Click to enlarge.

Humans evolved in an environment where they were exposed to animals, dirt, and a variety of pathogens and parasites. Our immune systems evolved to cope with that environment. Now most of us live in a different environment, with safe drinking water, flush toilets, food inspection, immunizations, and public sanitation. This means that we are far less likely than our ancestors to die of infectious diseases or to harbor intestinal worms. But it seems that the cleaner we get, the more likely we are to suffer from allergies and autoimmune diseases. One hypothesis is that our immune systems evolved to require early challenges by parasites and pathogens in order to develop properly. A hygienic environment fails to give our immune system the exercise it needs, resulting in imbalances and malfunctions.

The hygiene hypothesis was first proposed to explain observations like these:

  • Hay fever and allergies were less common in large families where children were presumably exposed to more infections through their siblings.
  • Polio attack rates were higher in high socioeconomic groups than in lower ones.
  • Allergies and many other diseases were less common in the developing world.

Investigation of these and other phenomena is contributing to a better understanding of the immune system, which is a good thing. At the same time, it has led some people to deliberately infect themselves with intestinal worms in an attempt to cure their allergies and autoimmune diseases, which may not be such a good thing. These treatments are far from ready for prime time, are risky, and they have a high yuck factor. The very idea of deliberately infecting yourself with worms is unpalatable, and finding wiggly live creatures in your stool or passing a 20 foot tapeworm are not generally considered to be pleasant experiences.  (more…)

Posted in: Book & movie reviews, Epidemiology, Evolution

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One Flu Into the Cuckoo’s Nest*

“I don’t seem able to get it straight in my mind….”
― Ken Kesey, One Flew Over the Cuckoo’s Nest

Influenza is going gangbusters at the moment. I like going to Google Flu trends as well as the CDC flu site to see what flu is doing. Using Google searches as a surrogate for infections is an interesting technique that public health officials have tried with less success in other illnesses but is not without utility. Behaviors of populations can presage a problem, my favorite example is the first hint of the 1993 massive Cryptosporidia diarrhea outbreak in Milwaukee was a sudden shortage of Kaopectate and Peptobismol. It appears there are more patients with flu like symptoms this year than  at the height of the H1N1 epidemic of 2009. We have lots of flu like illness, and per the CDC there are buckets of confirmed influenzaflu, but so far the season, while probably having more cases than 2009, the outbreak is clinically not the same.

Compare and contrast, the two words that defined undergraduate liberal arts essay assignments. Get out your blue books and compare and contrast influenza outbreaks from 2009 and 2013. You have one hour. (more…)

Posted in: Clinical Trials, Epidemiology, Public Health, Science and Medicine, Science and the Media, Vaccines

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