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Measles gets a helping hand

In a recent post I shared a bit of my personal, near-death experience with measles during the US epidemic of 1989-1991. As I describe in that post, I contracted a very serious measles infection at the end of medical school, and was highly infectious when I interviewed for a residency position at Seattle Children’s Hospital. Like others my age who received an ineffective, killed measles vaccine between 1963 and 1967, I had not been adequately protected. The MMR vaccine was not yet available, and no boosters were recommended at the time. Unfortunately, though my measles titers (a test of immunity to measles) were checked when I entered medical school, the school’s student health department failed to notice or respond to the results – I was not immune and did not receive a booster dose at that time, as I should have. That mistake was huge, and could have cost me my life. It also caused me to potentially sicken many vulnerable children during my tour of the hospital, as well as others I may have inadvertently exposed during the window of communicability as I walked the streets of Seattle. The Department of Health had to be called to trace all of my steps and attempt to track down and protect any potential contacts.
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Posted in: Epidemiology, Medical Ethics, Politics and Regulation, Public Health, Science and Medicine, Vaccines

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The Canadian National Breast Screening Study ignites a new round in the mammography wars

The last couple of weeks, I’ve made allusions to the “Bat Signal” (or, as I called it, the “Cancer Signal,” although that’s a horrible name and I need to think of a better one). Basically, when the Bat Cancer Signal goes up (hey, I like that one better, but do bats get cancer?), it means that a study or story has hit the press that demands my attention. It happened again just last week, when stories started hitting the press hot and heavy about a new study of mammography, stories with titles like Vast Study Casts Doubts on Value of Mammograms and Do Mammograms Save Lives? ‘Hardly,’ a New Study Finds, but I had a dilemma. The reason is that the stories about this new study hit the press largely last Tuesday and Wednesday, the study having apparently been released “in the wild” Monday night. People were e-mailing me and Tweeting at me the study and asking if I was going to blog it. Even Harriet Hall wanted to know if I was going to cover it. (And you know we all have a damned hard time denying such a request when Harriet makes it.) Even worse, the PR person at my cancer center was sending out frantic e-mails to breast cancer clinicians because the press had been calling her and wanted expert comment. Yikes!

What to do? What to do? My turn to blog here wasn’t for five more days, and, although I have in the past occasionally jumped my turn and posted on a day not my own, I hate to draw attention from one of our other fine bloggers unless it’s something really critical. Yet, in the blogosphere, stories like this have a short half-life. I could have written something up and posted it on my not-so-secret other blog (NSSOB, for you newbies), but I like to save studies like this to appear either first here or, at worst, concurrently with a crosspost at my NSSOB. (Guess what’s happening today?) So that’s what I ended up doing, and in a way I’m glad I did. The reason is that it gave me time to cogitate and wait for reactions. True, it’s at the risk of the study fading from the public consciousness, as it had already begun to do by Friday, but such is life.
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Posted in: Cancer, Clinical Trials, Diagnostic tests & procedures, Public Health

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Even in 2014, influenza kills

I don’t think it can be repeated too many times during flu season: People can die of the flu.

The flu vaccine is one of the two vaccines most easily demonized by the antivaccine movement. The first, of course, is Gardasil (or Cervarix), the vaccine against HPV. The reason why Gardasil is so easily demonized is because it protects against an infection whose end result of cancer is many years in the future. Alt-med fans frequently castigate “conventional medicine” for not emphasizing prevention enough, but HPV vaccines put the lie to that. HPV vaccines protect against an infection that is usually fairly harmless in and of itself but has the long term effect of vastly increasing the risk of at least one potentially deadly cancer, and likely several others. Also, HPV infections are commonly sexually transmitted, allowing the moralistic wing of the antivaccine movement and misguided religious people in essence to “slut shame” the vaccine by arguing that it will encourage promiscuity by removing one of the consequences of sexual intercourse, one of the stupidest arguments against the HPV in existence. (Seriously, does anyone think teens and young adults, when their hormones are raging, worry about maybe the possibility of maybe getting cancer 20 years down the road when on the verge of a night of passion now? I don’t.) (more…)

Posted in: Public Health, Vaccines

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Expanding the scope of practice of advanced practice nurses will not endanger patients

One of my New Year’s resolutions for 2014 for the blog, besides looking for talented bloggers to add to our pool of awesome bloggers, was to try to look at areas of science-based medicine that we don’t often cover (or haven’t covered before), such as the delivery of health care. Fear not, I’ll certainly do enough posts on the usual topics, but I am going to make a conscious effort to diversify a bit, if only for my own personal growth. Ironically enough, in the couple of months before the end of 2013, just such an issue came up in my state. Uncharacteristically (for SBM at least) the topic I’m going to take a look at has nothing to do with the infiltration of the pseudo-medicine known as “complementary and alternative medicine” (CAM) or “integrative medicine” into academia or CAM practitioners like naturopaths or chiropractors trying to lobby state legislatures for greater scope of practice to ply their pseudo-medicine on an unsuspecting public. It does, however, have to do with expanding the scope of practice of a group of medical professionals, and, unexpectedly and disappointingly, it’s a proposal that’s had considerable resistance from various physicians’ societies in the state. I’m referring to advanced practice nurses (APRNs), often referred to as nurse practitioners (NPs).

Before I go on, it’s necessary for me to point out my conflict of interest. No, I haven’t received funding from the all-powerful American Association of Nurse Practitioners (whose influence, actually, is dwarfed by state medical societies and various physician groups). I do, however, have a very personal relationship with a nurse practitioner, namely my wife. However, I would point out that she hasn’t been an NP that long, and I routinely worked with NPs collaboratively long before the idea of becoming a nurse or even an NP was even a germ of a thought in my wife’s brain. Make of that admission what you will as you read on.
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Posted in: Politics and Regulation, Public Health

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Facebook’s reporting algorithm abused by antivaccinationists to silence pro-science advocates

This is not what I had wanted to write about for my first post of 2014, but unfortunately it’s necessary—so much so, in fact, that I felt the obligation to crosspost both here and on my not-so-super-secret other blog in order to get this information out to as wide a readership as possible.

I’ve always had a bit of a love-hate relationship with Facebook. On the one hand, I like how easily it lets me stay in contact with family and friends across the country, people whom I would rarely see more than once or twice a year, if even that. On the other hand, I have the same privacy concerns that many other people have with respect to putting personal information, as well as pictures and videos of myself, family, and friends, onto Facebook. Now that I’ve become a (sort of) public figure (or, as I like to refer to myself, a micro-celebrity), I’ve thought that I should cull my friends list to just real friends with whom I have a connection (or at least have met in person or had private e-mail exchanges with) and set up a Facebook page for my public persona, to prevent people whom I don’t know or barely know from divebombing my wall with arguments. As I tell people, I don’t want obnoxious arguments on my Facebook wall; that’s what my blogs are for.

My personal social media preferences aside, Facebook does indeed have many shortcomings, but until something else comes along and steals the same cachet (which is already happening as teens flee Facebook to avoid their parents) and even after, Facebook will remain a major player in social media. That’s why its policies matter. They can matter a lot. I was reminded of this about a week ago when Dorit Reiss (who has of late been the new favored target of the antivaccine movement, likely because she is a lawyer and has been very effective thus far in her young online career opposing the antivaccine movement) published a post entitled Abusing the Algorithm: Using Facebook Reporting to Censor Debate. Because I also pay attention to some Facebook groups designed to counter the antivaccine movement I had already heard a little bit about the problem, but Reiss laid it out in stark detail. Basically, the merry band of antivaccinationists at the Australian Vaccination Network (soon to be renamed because its name is so obviously deceptive, given that it is the most prominent antivaccine group in Australia, that the NSW Department of Fair Trading ordered the anti-vaccine group to change its misleading name) has discovered a quirk in the algorithm Facebook uses to process harassment complaints against users and abused that quirk relentlessly to silence its opponents on Facebook.

I’ll let Reiss explain:

Over the weekend of December 21-22, an unknown person or persons used a new tactic, directed mainly at members of the Australian organization “Stop the Australian Vaccination Network” (The Australian Vaccination Network – AVN – is, in spite of its name, an anti-vaccine organization – see also here; SAVN had been very effective in exposing their agenda and mobilizing against them). In an attempt to silence pro-vaccine voices on Facebook, they went back over old posts and reported for harassment any comment that mentioned one person’s name specifically. Under Facebook’s algorithm, apparently, mentioning someone’s name means that if the comment is reported it can be seen as violating community standards. Which is particularly ironic, since many commentators, when replying to questions or comments from an individual, would use that individual’s name out of courtesy.

Several of the people so reported received 12-hours bans. Some of them in succession.

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Posted in: Computers & Internet, Public Health, Vaccines

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An experiment in paying through the nose for “unnecessary care”

Rats. Harriet stole what was going to be the title of this post! This is going to be something completely different than what I usually write about. Well, maybe not completely different, but different from the vast majority of my posts. As Dr. Snyder noted on Friday, it’s easy to find new woo-filled claims or dangerous, evidence-lacking trends to write about. Heck, I did it just last week, much to the continued consternation of one of our regular readers and commenters. Examining certain other health-related issues from a science-based perspective is more difficult, but I feel obligated to do it from time to time, not just for a change of pace but to stimulate the synapses and educate myself—and, I hope, you as well—about areas outside of my usual expertise.

We spend a lot of time writing about the scientific basis of medicine, clinical trials, what is and isn’t quackery, and how “complementary and alternative medicine” (CAM) subverts the scientific basis of medicine. However, SBM goes far beyond just that. At least I think of it this way. That’s why I’ve looked at issues that go more to the heart of health policy, which should be based on sound science and evidence. That evidence might take different forms than it does for determining, for example, whether Medicaid results in better health outcomes and by how much health insurance does the same. As is the case with policy issues and economics, conclusions are muddled and messy. The error bars are huge, and the number of potential confounders even huger. (more…)

Posted in: Clinical Trials, Diagnostic tests & procedures, Politics and Regulation, Public Health

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An Apple a Day

We (the authors and editors) at SBM get accused of many nefarious things. Because we deliberately engage with the public over controversial medical questions, we expect nothing less. It goes with the territory. In fact, if there were a lack of critical pushback we would worry that we were not doing our job.

Still, it is disconcerting to see the frequently-repeated ideological accusations in response to simply evaluating and reporting the evidence. That is what we do here – follow the science and evidence. When that trail leads to a conclusion that some people do not like (usually for ideological reasons) a common response is to accuse us of ideology, malfeasance, being part of a conspiracy, or having conflicts of interest or ulterior motives. That is easier, I suppose, than engaging with us on the science.

One common accusation is that we are shills for the pharmaceutical industry, and downplay or ignore the benefits of diet and “natural” treatments. A search through the SBM archives demonstrates that this accusation is false – we criticize bad science and poor-quality control, regardless of who is committing it. Sometimes pseudoscience is used to promote a drug, sometimes a nutritional supplement, and sometimes pure magic. (more…)

Posted in: Nutrition, Public Health

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Vaccines work. Period.

Over my blogging “career,” which now stretches back nearly nine years, and my hobby before that of engaging in online “debates” on Usenet newsgroups back before 2004, I developed an interest in the antivaccine movement. Antivaccinationism, “antivax,” or whatever you want to call it, represents a particularly insidious and dangerous form of quackery because it doesn’t just endanger the children whose parents don’t vaccinate them. It also endangers children who are vaccinated, because vaccines are not 100% effective. The best vaccines have effectiveness rates in the 90%-plus range, but that still leaves somewhere up to 10% of children unprotected. Worse, because herd immunity requires in general approximately 90% of the population and above to be vaccinated against a vaccine-preventable disease to put the damper on outbreaks, it doesn’t take much of a degradation of vaccination rates to put a population in danger of outbreaks. That’s why, even though overall vaccine uptake is high in the US, we still see outbreaks, because there are areas with pockets of nonvaccinators and antivaccinationists who drive vaccine uptake down to dangerous levels. We’ve seen this in California and elsewhere. Other countries have observed even more dramatic examples, the most well-known being the way that fear of the MMR vaccine stoked by Andrew Wakefield’s bad science and the fear mongering of the British press led MMR uptake to plummet. The result? Measles came roaring back in the UK and Europe, from having been considered under control in the 1990s to being endemic again by 2008.

As much as I get chastised by concern trolls for saying this, to antivaccinationists it really is all about the vaccines. Always. They blame autism, other neurodevelopmental conditions, and a wide variety of chronic diseases on vaccines, without evidence that there is even a correlation. They even falsely blame sudden infant death syndrome (SIDS) on vaccines, even though there is no evidence of an association and, indeed, existing evidence suggests that vaccines likely have a protective effect against SIDS more than anything else. No matter what happens, no matter what the evidence says, antivaccinationists will always find a way to blame bad things on vaccines, even going so far as to claim at times that shaken baby syndrome is a misdiagnosis for vaccine injury.

One thing, however, that is often forgotten, is that they also do their utmost to downplay the beneficial effects of vaccines. One such tactic is for antivaccinationists to claim that the pertussis vaccine doesn’t work because we are seeing resurgences of pertussis even in the face of high vaccine uptake. For example, another common trope is what I like to refer to as the “vaccines didn’t save us” or the “vaccines don’t work” gambit, in which it is pointed out that the introduction of vaccines doesn’t correlate tightly with drops in mortality from various diseases. Julian Whitaker even used this gambit when he debated Steve Novella. The fundamental flaw in this trope neglects the contribution of better medical care to the survival of more victims of disease, which decreased mortality. If you look at graphs of disease incidence you will see a profound and powerful effect of the introduction of vaccines on specific vaccine-preventable diseases. In other words, vaccines work. (more…)

Posted in: Epidemiology, Public Health, Vaccines

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The FDA and Personalized Genetic Testing

The company 23andMe provides personal genetic testing from a convenient home saliva sample kit. Their home page indicates that their $99 genetic screening will provide reports on 240+ health conditions in addition to giving you information on your genetic lineage. The benefits, they claim, are that you will learn about your carrier status and therefore the risk of passing on genetic diseases to your children. The information will also inform you about health risks so that you can change your behavior to manage them. Finally the genetic information will tell you about how you might respond to different drugs so that you can “arm your doctor with information.”

The home page also contains a link to testimonials about how their DNA testing has changed people’s lives.

This all sounds great – the promise of genomics that we have been hearing about now for about two decades. Isn’t this exactly what we were led to expect once we mapped the human genome?

Why, then, has the FDA recently sent a warning letter to 23andMe instructing them to discontinue marketing their Personal Genome Service (PGS)?

The primary reason appears to be a lack of documentation for the validity and reliability of the tests, but I have concerns that go even deeper. (more…)

Posted in: Public Health

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The new Surgeon General nominee and CAM: Is there a problem here?

Our fearless leader, Steve Novella, has informed me that he is traveling today. Unfortunately, I am preparing a talk for later today, and no one else seemed able to come up with a post; so I decided to adapt a recent post from my not-so-super-secret other blog and see what a different readership thought of it. I realize that I’m risking subjecting you all to Gorski overload, but, hey, if the world needs more Mark Crislip, why wouldn’t the world need more David Gorski too? Steve will return next Wednesday, as usual.

I don’t normally give a lot of thought to the Surgeon General because, quite frankly, in recent years it hasn’t been a position of much authority or influence. That’s why I didn’t noticed late last week that President Obama had nominated a new Surgeon General. Normally, my failure to notice isn’t such a big deal, because there really hasn’t been a Surgeon General who has really been particularly well-known or had much of an impact since Dr. C. Everett Koop, although back when President Obama first took office Dr. Sanjay Gupta’s name was floated as a possibility for the position. Obviously, he didn’t get it. (I’m guessing that being a neurosurgeon and CNN’s chief medical correspondent probably pays much better than being Surgeon General.) To be honest, I didn’t even know that the prior Surgeon General had stepped down, but apparently she did in July, leaving the position filled by an interim Surgeon General until a new one could be nominated.

The other day, I learned whom President Obama nominated to be her successor, Dr. Vivek Murthy, a faculty member at the Harvard Medical School:

President Obama will nominate Dr. Vivek Murthy of Harvard Medical School and Brigham and Women’s Hospital as surgeon general of the United States, the White House announced Thursday night.

Murthy is a hospitalist at the Brigham and is co-founder and president of Doctors for America, a Washington, D.C.-based group of 16,000 physicians and medical students that advocates for access to affordable, high quality health care and has been a strong supporter of the Affordable Care Act.

If he’s confirmed by the Senate, Murthy would replace acting surgeon general Boris Lushniak. The surgeon general serves a four-year term and the post is essentially a bully pulpit to speak out on public health issues.

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Posted in: Acupuncture, Politics and Regulation, Public Health, Science and the Media

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