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Archive for Science and Medicine

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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Adherence: The difference between what is, and what ought to be

One of the most interesting aspects of working as a community-based pharmacist is the insight you gain into the actual effectiveness of the different health interventions. You can see the most elaborate medication regimens developed, and then see what happens when the “rubber really hits the road”: when patients are expected to manage their own treatment plan. Not only do we get feedback from patients, there’s a semi-objective measure we can use — the prescription refill history.

The clinical trial, from where we derive much of our evidence on treatments, is very much an idealized environment. The relationship to the “real world” may be tenuous. Patients in trials are usually highly selected, typically those that are able to comply with the intervention planned. They may need to be free of any other diseases which could complicate evaluation. Patients that qualify for enrollment enter an environment where active monitoring is the norm, and may be far more intense than normal clinical practice. All of these factors mean that trial results may be meaningful, but not completely generalizable to the patient that may eventually be given the intervention. It’s for this reason we use the term “efficacy” to describe clinical trial results, while “effectiveness” is what we’re more interested in: those real-word effects that are far more relevant, yet more elusive to our decision-making.  Efficacy measures a drug’s effect on an endpoint, and estimates risk and benefit in a particular setting. Effectiveness adds in real-world tolerance, the ability to tolerate the regimen, and all the other factors that are present when real patients take a drugs under less-than-ideal conditions. Consequently, effectiveness is a much more useful predictor of outcome than efficacy. Unfortunately, measurements of real-world effectiveness, possibly as a “phase 4″ or real-world trial, are rarely conducted.

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Posted in: Science and Medicine

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The Application of Science

It all seemed so easy

In 2010 an article was published in the New England Journal of Medicine, Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus .  Patients were screened for Staphylcoccus aureus ( including MRSA, methicillin resistant Staphylococcus aureus) and those that were positive underwent a 5 day perioperative decontamination procedure with chlorhexidine baths and an antibiotic, mupirocin, in the nose.  The results were impressive.  Before the intervention the infection rates were 7.7 % and after the intervention it was 3.4 %.  That is an impressive drop in surgical infections.

One of the orthopedic groups approached us (us being the hospital administration, pharmacy, nursing  and infection control, of which I am Chair) to implement the protocol in their patients, citing a similar study on an orthopedic population.  Great.  It should be an easy enough intervention.  I should have known better, of course, long experience has continually demonstrated that what appears to be simple never is.

First was the question as to whether the study was applicable to our patients.  Resources were going to be devoted to an intervention, so going forward we had to demonstrate that the bang would be worth the buck.  These are financially lean times, with cutbacks and declining reimbursement, so every expenditure of time and money needs to be justified.  In the bizarro accounting of health care, not every hospital administration will include money saved in the evaluation of interventions, only the money spent.   I work in a hospital system with a remarkably strong commitment to patient safety and quality, so there was little  worry on that point. (more…)

Posted in: Basic Science, Clinical Trials, Science and Medicine

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When To See a Doctor

Two weeks ago I wrote about the demise of the traditional annual physical for healthy adults who have no symptoms.

The First Step: Identifying a Symptom

People who do have symptoms should see a doctor. They should have appropriate evaluations that may or may not include a partial or complete physical exam. One problem is that people may not be able to decide what qualifies as a significant symptom. Could the heartburn actually be a heart attack? Is the fatigue a normal result of exertion, or could it be a sign of something serious? Could my headache be a sign of brain tumor, or should I just take an aspirin? My spouse says I’ve been snoring more: could that be a sign of sleep apnea? What if I just “don’t feel right”?

This is a real dilemma, because minor transient symptoms are a normal part of life. Some of them are due to trivial conditions that spontaneously resolve; some are sensations due to the normal functioning of the body. Some people are more aware of these sensations than others. Paying attention to them tends to make them worse. Some people barely let these minor sensations intrude on conscious thought; others fixate on them and obsess about them. There is a spectrum of human reactions ranging from the stoic denier to the hypochondriac. (more…)

Posted in: Science and Medicine

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The Marino Center for Integrative Health: Hooey Galore

Two weeks ago I promised that I would discuss the Marino Center for Integrative Health, identified in the recent Bravewell report as having a “hospital affiliation” with the Newton-Wellesley Hospital (NWH) in Newton, Massachusetts, which is where I work. I also promised in that post that I’d provide examples of ‘integrative medicine’ practitioners offering false information about the methods that they endorse. I’d previously made that assertion here, and Jann Bellamy subsequently discussed its legal and ethical implications here. The Marino Center is a wellspring of such examples.

A Misleading ‘Affiliation’

Let’s quickly dispel the “hospital affiliation” claim. According to the Marino Center website:

Hospital Affiliations

In support of our services and to ensure that our patients have access to exceptional tertiary care, the Marino Center maintains deeply established relationships and affiliations for referrals and admitting privileges with major medical facilities in the Boston area.

The Marino Center:

  • Is a proud member of the Partners Healthcare family
  • Is affiliated with Newton Wellesley Hospital
  • Makes referrals to Mass General Hospital, Dana Farber, Children’s Hospital and more

Well, it wouldn’t surprise me if the Marino Center is a ‘member’ of the Partners Healthcare family, which includes not only the Newton-Wellesley Hospital, but lesser known entities such as the Massachusetts General Hospital and the Brigham and Women’s Hospital. After all, there are already unfortunate pseudomedical schemes involving Partners entities, such as the Osher Center for Complementary and Integrative Medical Therapies and, even under my own roof (I shudder as I write this), a Reiki Workshop. Nevertheless, it’s telling, I hope, that not only does the Marino Center fail to appear under any list of Partners affiliates, Community Health Partnerships, Wellness, Prevention, or any other conceivable category, but it fails to yield a single ‘hit’ when entered as a search term on the Partners website (the term ‘integrative’ yields seven hits, but none appears to be about ‘CAM,’ except possibly for an RSS feed that I’ve no patience to peruse. Is it possible that Partners is embarrassed by the Osher Center? I hope that, too).

I’ve previously asserted that the NWH is not affiliated with the Marino Center, other than that some Marino Center physicians have been—against my judgment, not that I was consulted—granted hospital staff privileges. I made this assertion in my original Bravewell post a couple of weeks ago, after having questioned the NWH Chief Medical Officer, Dr. Les Selbovitz, who verified it; nothing on the NWH website suggests otherwise.

I’ve no reason to doubt the Marino Center’s third bullet above, “makes referrals to Mass General Hospital,” etc., but this is something that any physician can do, regardless of affiliation. I suspect that if there were an ‘integrative hospital‘ in Boston, reason forbid, the Marino Center would make referrals to it.

False and Misleading Information about ‘Services’

Let’s get to the meat of the problem.

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Posted in: Acupuncture, Homeopathy, Medical Ethics, Science and Medicine, Science and the Media

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Is gluten the new Candida?

Much of the therapeutics I was taught as part of my pharmacy degree is now of historical interest only. New evidence emerges, and clinical practice change. New treatments replace old ones – sometimes because they’re demonstrably better, and sometimes because marketing trumps evidence. The same changes occurs in the over-the-counter section of the pharmacy, but it’s here marketing seems to completely dominate. There continues to be no lack of interest in vitamin supplements, despite a growing body of evidence that suggests either no benefit, or possible harm, with many products. Yet it’s the perception that these products are beneficial seem to be seem to continue to drive sales. Nowhere is this more apparent than in areas where it’s felt medical needs are not being met. I covered one aspect a few weeks ago in a post on IgG food intolerance blood tests which are clinically useless but sold widely. The diagnosis of celiac disease came up in the comments, which merits a more thorough discussion: particularly, the growing fears over gluten consumption. It reminds me of another dietary fad that seems to have peaked and faded: the fear of Candida.

It wasn’t until I left pharmacy school and started speaking with real patients that I learned we are all filled with Candida – yeast. Most chronic diseases could be traced back to candida, I was told. And it wasn’t just the customers who believed it. One particular pharmacy sold several different kits that purported to eliminate yeast in the body. But these didn’t contain antifungal drugs – most were combinations of laxative and purgatives, combined with psyllium and bentonite clay, all promising to sponge up toxins and candida and restore you to an Enhanced State of Wellness™. There was a strict diet to be followed, too: No sugar, no bread – anything it was thought the yeast would consume. While you can still find these kits for sale, the enthusiasm for them seems to have waned. Whether consumers have caught on that these kits are useless, or have abandoned them because they don’t actually treat any underlying medical issues, isn’t clear.

The trend (which admittedly is hard to quantify) seems to have shifted, now that there’s a new dietary orthodoxy to question. Yeast is out. The real enemy is gluten: consume it at your own risk. There’s a growing demand for gluten labeling, and food producers are bringing out an expanding array of gluten-free (GF) foods. This is fantastic news for those with celiac disease, an immune reaction to gluten, where total gluten avoidance is essential. Only in the past decade or so has the true prevalence of celiac disease has become clear: about 1 in 100 have the disease. With the more frequent diagnosis of celiac disease, the awareness of gluten, and the harm it can cause to some, has soared. But going gluten free isn’t just for those with celiac disease. Tennis star Novak Djokovic doesn’t have celiac disease, but went on a GF diet. Headlines like “Djokovic switched to gluten-free diet, now he’s unstoppable on court” followed. Among children, there’s the pervasive but unfounded linkage of gluten consumption with autism, popularized by Jenny McCarthy and others. Even in the absence of any undesirable symptoms, gluten is being perceived as something to be avoided. (more…)

Posted in: Basic Science, Diagnostic tests & procedures, Nutrition, Science and Medicine

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