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Archive for Science and Medicine

The Syndrome Syndrome

Have you ever heard of heavy leg syndrome? I hadn’t, until I read this BBC article about it – the British are apparently amused at this peculiarly French medical malady. Heavy leg syndrome is a common diagnosis in France, which alone consumes one third of the world’s drugs for this diagnosis.

Diseases certainly vary from population to population based upon genetics, environment, and lifestyle. But can it also vary just based upon the culture of diagnosis? It seems so.

Ever since it was recognized that there exists diseases – that different people can suffer from the same entity, rather than everyone having their own unique illness, the medical profession has described certain clinical presentations as syndromes. This is legitimate, but it must be recognized that this use of the term syndrome is purely descriptive. (As an aside, the term “syndrome” has a different and very specific use in describing certain genetic diseases.)

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How SHOULD We Discuss Quackery with Innocents and the Not-so-Innocent?

Recents posts by Drs. Albietz and Gorski have highlighted questions that are recurrent on SBM. We are convinced that medicine should be based on real knowledge, to the extent that it exists, and that physicians should be honest; these are matters of science and ethics. How do we reconcile that with heartfelt, if misguided beliefs of patients, their families, and others? When Dr. Albietz wrote that it might have been better for the chiropractor to visit in the same way that “priests, imams, prayer sessions, rabbis, etc visit children within the PICU,” it was reminiscent of Dr. Peter Moran’s hypothetical “witch doctor.” When he lamented academic medicine’s current dalliances with quackery, it brought to mind the NCCAM, David Katz, Andrew Weil, Bravewell , and their enablers.

Dr. Albietz argued that when talking to credulous patients or their families, taking a hard line against quackery is likely to be counter-productive. Most of us would agree with that. Dr. Gorski described a different scenario: after calling a quack “a quack” when talking to a friend of a friend who is a scientist, he concluded that he had been too “blunt.” Several commenters disagreed, but all would probably agree with Dr. Gorski that “you have to know when to pick one way over another; i.e., diplomacy over all out war or vice versa.”

Another Case of Foot-In-Mouth Disease

I recently had an experience strikingly similar to Dr. Gorski’s, during which I castigated myself for my rancor even as I was incapable of moderating it. Fellow blogger Dr. Val Jones was a witness!

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Posted in: Medical Academia, Medical Ethics, Science and Medicine

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Now there’s something you don’t see on TV every day…

I rather like Late Night with Conan O’Brien. Unfortunately, I seldom get to watch, mainly because I usually show up at work sometime between 7:00 and 7:30 AM, and I don’t like watching more than a few minutes of video on my computer.

However, Hugh Laurie, star of House, was interviewed by Conan and revealed himself to be not unlike me in that he’s definitely a booster of reason and science in medicine over irrationality and dubious “complementary and alternative medicine” (CAM) therapies. In fact, his attitude towards CAM appears to be not at all unlike that of the character he plays on House. Check out the interview. (If you want to watch, the relevant part of the interview begins at about 23:50 into the show.)

For those who might have problems playing Internet video, I’ve found a transcript:
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Posted in: Health Fraud, Humor, Science and Medicine, Science and the Media

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Credulous medical reporting

Science and medicine reporting is hard. In this space and otherswe’ve dealt with some of the problems that arise when “generalist” reporters try to “do” science and medicine. And now, CNN has shut down its science unit. Given the increasing complexity of medical and scientific knowledge, this is very bad news.

As a fine example of poor medical reporting, let’s look at a local business magazine. The article, called “The Fatigue Factor”, is about fibromyalgia, and manages to get it wrong from the very beginning.

Some medical reporting is destined to be bad simply because the topic is too complex for a generalist reporter. But sometimes, a reporter succumbs to journalistic sloth. In this story, for instance, if the reporter had spoken to a recognized local expert rather than a self-proclaimed expert, she would have written a much different article.

Let’s start with the headline:
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Posted in: Science and Medicine, Science and the Media

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Direct-To-Consumer Science

Dr. Olivier Ameisen is a prominent French cardiologist who believes that the muscle-relaxant drug baclofen relieves the cravings of alcoholism. This is indeed an interesting, and as yet unsettled, scientific medical question. Dr. Ameisen has decided to take his personal scientific opinion directly to the public in his book – Le Dernier Verre (The Last Glass). The result has been a surge of interest among alcoholics for this new “miracle cure” for their affliction.

Increasingly the medical community is caught between two opposing imperatives. There is the desire to make medical information freely available and the process of medical research transparent. On the other hand, the public is best served when new ideas in medicine are put through the mill of science before they become part of medical practice. As we enter headlong into the information age these two imperatives are increasingly at odds.

Problems arise when a new treatment, syndrome, intervention, or concept in medicine is promoted to the public prior to undergoing a reasonable degree of scientific vetting. What is the point, after all, of spending tremendous resources on medical research if proponents are going to bypass the process altogether to market their modalities and promote their ideas directly to the public?

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H. influenzae—it ain’t the flu, but it’s still pretty cool

I’ve been thinking about an interesting organism lately, an organism that illustrates some basic principles in science-based medicine.

The organism is called Haemophilus influenzae (H flu), a gram-negative bacterium discovered in the late 19th century. H flu has a great story, both in historic and modern times.

The brilliant microbiologist Richard Pfeiffer isolated H flu from influenza patients in the late 1800′s (hence its name) and for many years, it was believed to be the cause of the epidemic illness, and when the flu pandemic of 1918 hit, researchers worked tirelessly to develop anti-sera against H flu.

But some things weren’t adding up. As thousands died of the flu, doctors were isolating H flu from victims, but also other virulent bacteria such as Streptococcus pneumoniae. Influenza was decimating military camps, and was seriously degrading our ability to fight in WW I, so military bases were a focus of research. Doctors looked for H flu in patients, but could not find it consistently. For example in Camp Dodge, Iowa, an autopsy series showed H flu in only 9.6% of victims.

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Posted in: Science and Medicine, Vaccines

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Google Trends and the Interest in Alternative Medicine

USA Today has come out with a new survey – apparently, three out of every four people make up 75% of the population.

–David Letterman

How popular is alternative medicine? One way is to survey people and ask them. Like all surveys, the nature of the question determines the answer. The first, and probably most referenced, and misquoted, article on ‘alternative’ medicine to address the question was “Unconventional Medicine in the United States — Prevalence, Costs, and Patterns of Use” from the NEJM .

‘Alternative’ proponents quote this article, often as the opening sentence of the paper. “One in three respondents (34 percent) reported using at least one unconventional therapy in the past year.” No one, it appears, ever reads past the abstract. As is so often the case, the substance of the article may not reflect the spin found in the abstract.

There are many issues with this paper (see http://www.quackwatch.org/11Ind/eisenberg.html for a detailed critique) , not the least of which is the definition of unconventional therapy. To get to this huge percentage of users they had to include exercise (26%), prayer (25%) and relaxation techniques (13%) as unconventional therapies. Little did I know that I participate in unconventional therapies every day.

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Psychological support and breast cancer – again

Does the degree of efficacy is depend on the time at which it is measured? Apparently so. The case of psychological support and breast cancer longevity again.

After an original 1989 report of positive effects on metastatic breast cancer, by 2006- 7 the majority of RCTs on such effects had settled the issue in the negative. This was only after 20 years of repeated research grants and RCTs based on hunches and feelings that somehow emotional support really affected the course of cancer. Investigations continued despite analyses showing the few original positive studies had been so flawed in design or defective in reported details, that they should have been dismissed and perhaps excluded from systematic reviews. (Spiegel D, Bloom JR, Kraemer H, Gottheil E. Psychological support for cancer patients, Lancet ,1989 Dec 16;2(8677):1447., Fawzy FI, Fawzy NW, et al. Malignant melanoma. Effects of an early structured psychiatric intervention, coping, and affective state on recurrence an survival 6 years later. Arch Gen Psychiatry. 1993 Sep;50(9):681-9.)

But to advocates, conflicting results served as motive to prove the claims by repeating the studies for 20 years, “doing them right this time.” As of mid-2008, consensus was the issue was still “negative.” Now another study, claimed to be positive, makes the news.

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Posted in: Cancer, Clinical Trials, Science and Medicine, Science and the Media

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Open-Access Peer Review: Increasing the Noise To Signal Ratio

Readers of Science Based Medicine are quite familiar with the distressingly common logical leap made by disgruntled healthcare consumers into alternative medicine. It goes something like this: I had a terrible experience with a doctor who [ignored/patronized/misdiagnosed] me and I also heard something horrible in the media about a pharmaceutical company’s misbehavior [hiding negative results/overstating efficacy/overcharging for medications], therefore alternative treatments [homeopathy/acupuncture/energy healing, etc.] must be more effective than traditional medicine.

Much to my dismay, a similar logical leap is being made about online health information. It goes something like this: Peer reviewing is biased and often keeps innovative research hidden to the world at large, therefore the best kind of peer review is open-access where anyone in the world can contribute.

You may feel free to slap your forehead now.

While I have absolutely no doubt that doctors have their shortcomings, and that some have created less than pleasant healthcare experiences for their patients – the solution to these shortcomings is not to dive headlong into snake oil. Moreover, I agree that the current peer-review process has its flaws and limitations – the solution is not to ask Aunt Enid in Omaha what she thinks of the recent meta-analysis of perioperative beta blockers in patients having non-cardiac surgery.

Peter Frishauf, the founder of Medscape, recently published a webcast editorial predicting that:

“Peer review as we know it will disappear. Rather than the secretive prepublication review process followed by most publishers today, including Medscape, most peer review will occur transparently, and after publication.”

He goes on to describe a Wikipedia-like review scenario where:

“Any user can start an article, link it to related sources, and publish revisions with a click of the mouse. Anyone who reads an article can edit it.”

I know and like Peter very much, and his foresight (that publishing should become open-access), combined with the leadership of editorial heavy-weight, Dr. George Lundberg, led to the creation of the first really successful, quality, free online medical journal. This was no small feat, and a sure victory for global medical education efforts.

But the reason for The Medscape Journal’s success is not the “democratization” of peer review – but the democratization of access to trustworthy information. The quality controls are still in place – and must remain so – otherwise its value as a peer-reviewed journal will be utterly lost. Who should trust the edits of unqualified readers? Should science be determined by popular vote? Should all research be published by journals, regardless of its fatal flaws?

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Posted in: Science and Medicine, Science and the Media

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The science of purging, or the purging of science?

It’s Thanksgiving in the U.S., one of my favorite holidays.  Thanksgiving habits get set down early in life, and the while I may find your lima bean casserole execrable, to you it’s just not Thanksgiving without it.

And speaking of excrement, you can expect to see adds encouraging you to “detox” from all of your holiday excesses.  Outside the field of substance abuse, what the hell is “detox” anyway?  “Detoxification” is apparently the pinnacle of modern health care, if you believe the dozens of adds on late-night TV.

For me to explain to you why even the very idea is laughable, I have to teach you a bit of human biochemistry—just a little, I promise. My scientific readers will find this grossly oversimplified, but hopefully they will forgive me.

Detox sounds so simple, but in fact, human biology is more complex and beautiful than is dreamt of in the quacks’ philosophies.
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