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Archive for Science and Medicine

Stop Making Sense

I usually rely on the Secret.  Every two weeks or so the Universe offers up some bit of wacky whimsey and I have a topic for an SBM blog entry.  This week the Universe has failed me. Nothing has crossed my LCD so I have no studies to evaluate and I have been unusually busy at work preventing my browsing the Interwebs for material.  But try telling that to the Managing Editor.   I write half to amuse myself, half to learn about the topic, and half to clarify in my own mind the topics at hand (1).  So this week  is content free idle thoughts for my own benefit.

I have been reading 13 Things That Don’t Make Sense by Michael Brooks. The book concerns topics in science that are unexplained by the current understanding  of the laws of the universe or contradict the dominant paradigm. Well, almost.  His final topic is homeopathy, and it is the one topic whose conclusions, while qualified, belong on Failblog.  The first chapter concerns dark matter and dark energy and how what we can see makes up only a small fraction of the content of the universe.   (more…)

Posted in: Book & movie reviews, Homeopathy, Science and Medicine

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Funding CAM Research

Paul Offit has published a thoughtful essay in the most recent Journal of the American Medical Association (JAMA) in which he argues against funding research into complementary and alternative therapies (CAM). Offit is a leading critic of the anti-vaccine movement and has written popular books discrediting many of their claims, such as disproved claim for a connection between some vaccines or ingredients and risk of developing autism. In his article he mirrors points we have made here at SBM many times in the past.

Offit makes several salient points – the first being that the track record of research into CAM, mostly funded by the NCCAM, is pretty dismal.

“NCCAM officials have spent $375,000 to find that inhaling lemon and lavender scents does not promote wound healing; $750,000 to find that prayer does not cure AIDS or hasten recovery from breast-reconstruction surgery; $390,000 to find that ancient Indian remedies do not control type 2 diabetes; $700,000 to find that magnets do not treat arthritis, carpal tunnel syndrome, or migraine headaches; and $406,000 to find that coffee enemas do not cure pancreatic cancer.”

The reason for the poor track record is fairly simple to identify – by definition CAM includes treatments that are scientifically implausible, which means there is a low prior probability that they will work. If the treatments were scientifically plausible then they wouldn’t be alternative.

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Posted in: Clinical Trials, Herbs & Supplements, Medical Ethics, Politics and Regulation, Science and Medicine

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The Skeptical Clinician

All scientists should be skeptics. Serious problems arise when a less-than-skeptical approach is taking to the task of discovery. Typically the result is flawed science, and for those significantly lacking in skepticism this can descend to pseudoscience and crankery. With the applied sciences, such as the clinical sciences of medicine and mental therapy, there are potentially immediate and practical implications as well.

Clinical decision making is not easy, and is subject to a wide range of fallacies and cognitive pitfalls.  Clinicians can make the kinds of mental errors that we all make in our everyday lives, but with serious implications to the health of their patients. It is therefore especially important for clinicians to understand these pitfalls and avoid them – in other words, to be skeptics.

It is best to understand the clinical interaction as an investigation, at least in part. When evaluating a new patient, for example, there is a standard format to the “history of present illness,” past medical history, and the exam. But within this format the clinician is engaged in a scientific investigation, of sorts. Right from the beginning, when their patient tells them what problem they are having, they should be generating hypotheses. Most of the history taking will actually be geared toward testing those diagnostic hypotheses.

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Posted in: Science and Medicine

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The Future of Medicine

Eric Topol, MD, has written a book about the convergence of the digital revolution and medicine. It is full of fascinating information and prognostication, but I wish he had given it a better title.  He called it The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. Medicine will not and cannot be “destroyed.” It will be improved and transformed, perhaps, but not destroyed. And any new developments will have to be evaluated for safety and effectiveness by the good old time-tested methods of science.

The future world of medicine is really exciting: science fiction is becoming real. As I read Topol’s  book I serendipitously found it paraphrased by a character in another book I was reading, Chop Shop, by Tim Downs.

I see a world where no one ever dies from an adverse drug reaction; where physicians have an entire range of medicines to choose from to treat a deadly disease; where medications target tumors like smart bombs and leave surrounding tissues unharmed; where genetic susceptibility to disease can be determined in childhood, and possibly even prevented.

(If you haven’t yet discovered Downs’ hilarious “Bug Man” detective series about a crazy forensic entomologist, you have a treat in store.)

But back to non-fiction. Our world is changing almost too rapidly to comprehend: the Internet reaches everywhere, and there are far more mobile phones in the world today than toilets.  We have hardly begun to tap the current potential of new technologies, and unimagined further developments await us. Topol is a qualified guide to this new world: he is a respected cardiologist and geneticist who ha s been on the forefront of wireless medicine and who was a major whistleblower in the Vioxx fiasco. He knows whereof he speaks, and he writes lucidly and accessibly.
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Posted in: Book & movie reviews, Science and Medicine

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Low-Back Pain: Causes, Care, and Consequences

Low-back problems are one of the most common reasons for visits to doctors’ offices and the most common cause of disability among persons under the age of forty five. Most of the time, acute low-back pain is the result of simple strain and is a self-limiting condition that will resolve in four to six weeks, with or without treatment. But since back pain can be a forerunner of disability or a symptom reflecting serious pathology, every effort should be made to seek appropriate care that is based on a definitive diagnosis. Failure of physicians to ease the concerns of back-pain patients by explaining their problem and advising them in the care of back pain often results in dissatisfied patients who may be attracted by the approach of alternative medicine practitioners who tout a spurious quick-cure treatment based on a dubious diagnosis. Misinformation provided by such practitioners may contribute to disability by allowing progression of disease or by exaggerating the seriousness of the problem in the mind of the patient. Thus, while back pain is rarely serious, it should always be carefully evaluated to reach an accurate diagnosis and to determine if specialized care is needed. Care should be taken to inform the patient in a positive manner─to avoid unnecessary surgery as well as inappropriate or unnecessary treatment.

Something to Consider When You have Back Pain

Almost everyone will experience acute low back pain at least once during a lifetime. Much of what must be done to care for a bad back must be done by you. It would certainly help to be well informed about the causes of back pain when seeking appropriate treatment.

It goes without saying that when incapacitating back pain occurs as a result of a serious accident or injury, you should seek emergency medical care. When back pain grows progressively worse, persists unrelieved for longer than a week, or is worsened by rest, you may need the services of a specialist. Back pain that occurs for no apparent reason and does not affect movement may be a symptom referred from an internal organ. Once a diagnosis has ruled out a serious problem and it has been established that you have nonspecific or uncomplicated mechanical-type back pain, self-help measures designed to relieve your symptoms and to protect and strengthen your back may be the only treatment needed. If there is no active pathological process and your back pain lasts three months or longer, you may have a “chronic” back problem that can lead to recurring back pain, requiring ongoing vigilance and self help.

Time is the most important part of treatment for uncomplicated back pain caused by injury. It’simportant, however, to be aware of red flags indicating that back pain might be the result of something more serious that a simple strain. In the absence of red flags, imaging studies or special testing might not be indicated during the first four weeks of low back symptoms. When a red flag is present, you should not delay in reporting your symptoms to your family physician.

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Posted in: Chiropractic, Science and Medicine

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Drinking from the Fire Hose: Odds and Ends on the Gasping Oppression

I spend most of my time taking care of hospitalized patients with acute infections and issues of public health are, outside of infection control, not a high priority. Vaccinations in training were always like clean water and fresh food: their benefit was a given and I never needed to consider the benefits and subtleties of  vaccination. There is just so much time in a day and I was more concerned with AIDS, endocarditis and meningitis to worry about the ins and outs of vaccination.

One of the many benefits of writing for SBM, and being the Chair of Infection Control, is it is a stimulus to keep up on aspects of medicine that I might not otherwise pay close attention to, like vaccines. I have been far more interested in vaccines, especially influenza vaccines, since starting practice in 1990 than I ever was in the decade I spend in training.

Vaccination and the efficacy of vaccines is not as straightforward as I would have thought 30 years ago. It was give a vaccine, generate an antibody, and, viola, the patient is protected. The vagaries of the flu vaccine are even more pronounced, since response to the vaccine is variable and the population has never been vaccinated at levels, more than 90%, where herd immunity would likely kick in.

My ideal flu vaccine study, which would be both impossible and unethical, would be to vaccinate everyone West of the Mississippi and no one to the East (no coincidence that me and mine live in the West) and study the short and long term effects. Until that day, I am stuck with the hodgepodge of medical studies that look at the results of influenza vaccination and add insights into the disease.

I thought this week it would be fun to mention some interesting studies about influenza, the vaccine and flu immunity that have come out in the last 2 years. This is not meant to be anything more than a compilation of articles I thought were interesting, and the only purpose is to give a hint as to the complexities of influenza and  vaccination. (more…)

Posted in: Basic Science, Science and Medicine, Vaccines

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Are Cell Phones a Possible Carcinogen? An Update on the IARC Report

EDITOR’S NOTE: Because I am at the annual meeting of the American Association for Cancer Research in Chicago, between the meetings, working on a policy statement, working on a manuscript, and various other miscellaneous tasks, I alas was unable to produce a post worthy of the quality normally expected by SBM readers. Fortunately, Lorne Trottier, who’s done a great job for us twice before, was able to step in again with this great post about “safe” cell phone cases. Speaking of the manufactroversy over whether cell phone radiation causes brain cancer, there’s a session at the AACR that I’ll have to try to attend entitled Do Cell Phones Cause Brain Cancer? Who knows? It might be blogging material. I also might post something later that those of you who know of my not-so-super-secret other blog might have seen before. However, I often find it useful to see how a different audience reacts. Now, take it away, Lorne…

In May of last year, the International Agency for Research on Cancer (IARC) issued a press release (1) in which it classified cell phones as Category 2B, which is “possibly carcinogenic to humans“. This ruling generated headlines world wide. Alarmist groups seized on it and now regularly cite this report to justify their concerns for everything ranging from cell phones to WiFi and smart meters.

IARC maintains a list of 269 substances in the 2B category, most of which are chemical compounds. A number of familiar items are also included in this list: coffee, pickled vegetables, carbon black (carbon paper), gasoline exhaust, talcum powder, and nickel (coins). The IARC provides the following definition of the 2B category (2  P 23): “This category is used for agents for which there is limited evidence of carcinogenicity in humans and less than sufficient evidence of carcinogenicity in experimental animals. It may also be used when there is inadequate evidence of carcinogenicity in humans but there is sufficient evidence of carcinogenicity in experimental animals“.

The Category 2B “possible carcinogen” classification does not mean that an agent is carcinogenic. As Ken Foster of the University of Pennsylvania pointed out to me. “Their conclusion is easy to misinterpret.” “Saying that something is a “possible carcinogen” is a bit like saying that someone is a “possible shoplifter” because he was in the store when the watch was stolen. The real question is what is the evidence that cell phones actually cause cancer, and the answer is — none that would persuade a health agency.”

None the less this ruling was highly controversial. Expert groups of most of the world’s major public health organizations have taken the same position as the European Commission’s Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) which had stated that (3  P 8): “It is concluded from three independent lines of evidence (epidemiological, animal and in vitro studies) that exposure to RF fields is unlikely to lead to an increase in cancer in humans“. The representative of the US National Cancer Institute walked out of the IARC meeting before the voting. The NCI issued a statement (4) quoting other studies stating that: “overall, cell phone users have no increased risk of the most common forms of brain tumors — glioma and meningioma“.

Immediately following the IARC decision the WHO issued a reassuring new Fact Sheet (5) on mobile phones and public health: “A large number of studies have been performed over the last two decades to assess whether mobile phones pose a potential health risk. To date, no adverse health effects have been established as being caused by mobile phone use”. Since this controversial IARC classification, several new papers have been published that substantially undermine the weak evidence on which the IARC based its assessment.

The evidence that IARC cited to support its assessment was poor to begin with. Their initial press release (1) was followed by a more complete report that was published in the July 1, 2011 issue of the Lancet Oncology as well as online (6). In this article, I will review the evidence cited by IARC in support of its conclusion. I will also review updates from new papers published over the past year that cast further doubt on IARC’s conclusion.
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Posted in: Cancer, Public Health, Science and Medicine

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Lying for the State

Quacks lie.  In some ways, that’s what separates us from them.  Real doctors are stuck with the messy truth: with bad news, with uncertain outcomes.  It’s this reliance on the truth which gives us much of our credibility.

Laws forcing doctors to lie to patients take me back to reading Kundera in the 80s; the hovering fear that everyday actions might bring the authorities to your door. These feelings affect every portion of your life, whether you are a patient or a doctor.  Lying in service of the state is pervasively oppressive.  Laws requiring doctors to lie have become a popular tactic in the abortion wars.

Let’s look at Texas’s law, it’s requirements, and internal contradictions.
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Posted in: Science and Medicine

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The Species in the Feces

I do not understand the interest many appear to have in their bowels and the movement there of.  But then, I pay little attention to most of my body functions as long they are functioning within  reasonable parameters, and as I get  older the definition of reasonable is increasingly flexible.

The elderly especially seem to obsess about their bowels.  My theory is that since they have often lost taste, smell, hearing and are alone with little direct human touch,  a good BM is the only remaining physical joy left, and when it is compromised they are understandably upset.

Still, the concept of colonics for ‘detoxification’  strikes me as more humorous than repellent, despite the lack of efficacy and documented complications of the procedure.  Under normal circumstances, when it comes to the colon it is probably better to be removing substances than to be introducing them.  (more…)

Posted in: Basic Science, Naturopathy, Science and Medicine

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How to Choose a Doctor

From an e-mail I received:

As a proponent of SBM, and a someone who places a high value on reason, logic and evidence, I would like to find a physician who shares this mindset.

He went on to ask how he could go about finding one.

Another correspondent was referred to a surgeon by her primary physician, and the surgeon inspired confidence until she started talking about using homeopathic arnica pills to improve healing post-op. How she could determine the technical competence of this surgeon? Was acceptance of homeopathy a reason to shed doubt on her judgment in other areas? Should she seek a second opinion?

I get a lot of inquiries about how to find a good doctor. I don’t have a good answer. I thought it might be useful to throw out some ideas that have occurred to me and hope that readers will have better ideas and will share their experiences about what has or hasn’t worked. (more…)

Posted in: Science and Medicine

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