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Archive for Science and Medicine

Why we don’t prescribe bark for cancer

My valued colleague, Dr. Antonio Baines, recently invited me to speak for his graduate course in Toxicology.  Dr. Baines’ course is one of the most highly-regarded graduate classes at North Carolina Central University for M.S. students in Biology and Pharmaceutical Sciences.  Antonio asked that I discuss the pharmacology and toxicology of herbal and non-botanical dietary supplements but pretty much gave me free reign as to the mechanism by which I would do so.

In the past, I have often introduced herbal supplements to students who already know a bit about drug and toxicant action by taking the example of the anticancer drug, taxol (Note: Little “t” taxol was the name originally given to this chemical by its co-discovers but the corporate sponsor used it as a registered trademark for the brand name, big “t” Taxol, and the USAN proposed the use of the cumbersome paclitaxel as the generic name.).  As I noted in my previous post, taxol is an anticancer drug isolated from the bark of the Pacific yew tree, Taxus brevifolia, and was the first compound shown to kill cancer cells by promoting microtubule polymerization (and preventing depolymerization).

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Posted in: Herbs & Supplements, Science and Medicine

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How State Medical Boards Shoot Themselves (and You) in the Foot

This is almost the final entry (for now) in a series of posts about the pitfalls of regulating physicians who peddle quackery.† In previous entries we’ve seen how quacks have portrayed an illegal and pseudoscientific treatment, intravenous hydrogen peroxide, as legitimate; how a physician who practiced that and other dubious methods eluded definitive regulatory sanctions for years; examples of quacks banding together to form pseudomedical pseudoprofessional organizations (PPOs) and bogus board-certification schemes to establish the appearance of professional legitimacy, for protection from regulatory scrutiny, to garner political clout, to attract funds from interested businesses, to dupe the Accreditation Council for Continuing Medical Education into granting continuing medical education credits (CMEs) for pseudoscientific conferences, and more.

Now we’ll look at several examples of how state medical boards in the U.S. have abdicated their responsibility to protect the public from such practitioners. A few caveats: first, in most cases I can only guess why that has happened. Some of it has probably been due to naiveté, or to political or legal pressures. To some extent it has probably been due to faddism and its close relative, misleading language. Next, the examples given here are by no means exhaustive. Next, a state medical board can only be as effective as the language in the state’s medical practice act allows it to be, and that is determined by legislators (politics), not board members. Finally, state medical boards have not uniformly made the wrong choices regarding quack practices and practitioners.

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Posted in: Health Fraud, Homeopathy, Medical Ethics, Politics and Regulation, Science and Medicine

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Functional Medicine – New Kid on the Block

New Kid on the Block

Well, I’m not sure how new, but it was to me 6 months ago when I heard about Functional Medicine (FM) on a doc call-in program originating in Santa Cruz, Calif. The doc often presents a plurality of approaches to the callers’ problems, most of whom call because they seek self-help methods, supplements, or other short-cuts to help, or who share the utopian dream/meme of sectarian health claims through rearranging implausible ideas on the deck of the good ship Nature. (There could be a mixed metaphor in there somewhere but I go on…)

The radio call-in host, a middle-age sounding woman with a holistically oriented practice in a nearby town seems quite intelligent, grounded in real physiology, biochemistry, and mechanics of the body. I sometimes can catch her in errors but not as often as one could a more typical quacky doc, such as a chelationist. What I can hear is an intermittent string of recommendations I had never heard of, or sometimes had heard of and known to be false.  The program beams to a wide area – from Santa Cruz/San Jose area to the central coast in San Luis Obispo. It broadcasts on KUSP FM Saturday mornings at 9 AM Pacific time for those who want to listen on the net (Ask Dr. Dawn.)

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Posted in: Science and Medicine

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Knowledge Versus Expertise: The View From Consumer Land

“The internet, in democratizing knowledge, has led a lot of people to believe that it is also possible to democratize expertise.”

- SBM Commenter, yeahsurewhatever

I’ve spent the last few years of my life in Internet “Consumer Land,” doing what I can to bring accurate health information directly to patients. Of course, I have been surprised by the push-back, and the demand for misinformation. When I first left full time clinical work, it never occurred to me that people would prefer to read falsehoods when provided a clear choice between truth and error. I guess I was pretty naïve.

Journalist Lesley Stahl provided me with some helpful insights during a recent conference. She explained that the Internet has catalyzed a new method of information transfer – speed trumps accuracy, the line between pundits and journalists is blurred, and anyone who can get to a microphone can become an “expert.” Gone are the days of careful sourcing and fact-checking. And gone is the public trust in “mainstream media.”

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Posted in: Health Fraud, Humor, Public Health, Science and Medicine, Science and the Media

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Fake Treatments for Fake Illnesses

I wrote previously on NeuroLogica blog about Morgellons disease. Both Peter Lipson and Wallace Sampson have also covered this interesting syndrome here on SBM. Briefly, sufferers of this dubious syndrome believe they have foreign material exuding from their skin, causing chronic itching and sores. The evidence suggests that in truth they suffer from something akin to delusional parasitosis – the false belief of foreign parasites in their skin, leading to chronic itching which causes the sores and also works clothing fibers into the skin, which are later exuded.

Morgellons, in short, is a fake disease, a false and somewhat far-fetched explanation for symptoms that have a much more prosaic, if undesired, explanation.

Those who believe they have Morgellons, however, are legitimately ill and are an extremely vulnerable population. They feel they have a serious and mysterious illness, and worse the medical profession does not understand their illness and so denies that it exists. This is a perfect setup for snake oil-peddling con-artists.

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Posted in: Herbs & Supplements, Science and Medicine

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Another Useless NCCAM-Funded Study

Sometimes I read an article in a medical journal that makes me say, “Well, duh! I could have told you that without a study.” Sometimes I read collected data that make me ask, “So what?” Sometimes I read an article that makes me wonder what kind of pogo stick they used to jump from their data to their conclusions. Sometimes I read a study that is so poorly conceived that you couldn’t hope to get any useful information from it. Sometimes I read a study that reminds me of class projects or term papers where you just thought of something easy to do to fill the squares to get credit. Sometimes I read a study funded by the NCCAM that makes me very angry that they wasted my tax dollars. Sometimes all these things coincide in one article.

“Ophthalmology Patients’ Religious and Spiritual Beliefs: An Opportunity to Build Trust in the Patient-Physician Relationship” is such an article. A questionnaire was anonymously filled out by 124 consecutive return patients in one ophthalmologist’s practice. It asked about their religious and spiritual beliefs and their understanding and level of concern about their eye condition. (more…)

Posted in: Faith Healing & Spirituality, Science and Medicine

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Do physicians really believe in placebos?

ResearchBlogging.orgIn a previous post, I argued that placebo is an artifact of certain clinical interactions, rather than a treatment that we can exploit. Apparently, there are a whole lot of doctors out there who don’t agree with me. Or are there?

A recent study published in the British Medical Journal is getting
a lot of enk (e-ink) in the blogosphere. As a practicing internist, I have some pretty strong opinions (based in fact, of course) about both this study and placebos in general.

The Study

The current BMJ study defines placebo as “positive clinical outcomes caused by a treatment that is not attributable to its known physical properties or mechanism of action.”  I’ve got a lot of problems with this definition, but we’ll get to that later.  It also allowed physiologically active medications to “count” as placebos.  Oops.

The study surveyed internists and rheumatologists practicing in the U.S. They tried to control negative responses to the term “placebo” thusly (from the Methods section):

Because the term “placebo” and behaviours surrounding its use can be contentious, we devised a series of non-judgmental questions beginning with broad questions that avoided the term “placebo” and then gradually gained more specificity, culminating in items whose responses used a clear definition of a “placebo treatment.” By constructing a series of items in this manner we allowed respondents to describe their attitudes and experiences as accurately as possible.

The first set of three items began with a hypothetical scenario in which a dextrose tablet was shown in clinical trials to be superior to a no treatment control group (thus establishing its efficacy as a placebo treatment). To avoid biasing responses these three questions did not use the term “placebo,” “placebo treatment,” or “placebo effect.”

I know a lot of doctors.  They tend to be fairly bright.  I don’t think any of them would be deceived by this scenario.  When you read “dextrose pill”, you think “placebo”.  It might as well be the same word.

Respondents were then asked to indicate which of several treatments they had used within the past year primarily as a placebo treatment, defined as a treatment whose benefits derive from positive patient expectations and not from the physiological mechanism of the treatment itself; and how they typically described placebo treatments to patients. By asking these five questions both without the term “placebo” and then using the term, we aimed to assess physicians’ practices as accurately as possible.

All docs would recognize this as a placebo scenario.  However, the definition above is rather problematic.   Is a placebo “a treatment whose benefits derive from positive patient expectations and not from the physiologic mechanism of the treatment itself”?

The validity of this study hinges on the answer to this question.

Placebo—I do not think it means what you think it means

The concept of placebo, and the way it is used in this study are both problematic.  First, we have an elephant in the exam room.  When we observe a so-called placebo effect, we are very susceptible to the post hoc ergo propter hoc fallacy.  Just because the patient’s condition changes doesn’t mean we have done anything to cause that change.  In fact, due to the remarkably inexact human pattern-recognition software, we are likely to attribute a change in a patient’s condition to something, and if we don’t know what that something is, we may label it “placebo”.  So the very concept of placebo may be an artifact of our way of thinking, a label to place on a co-incidence, rather than a “thing”.  We may have wrongly reified a rather fuzzy concept.

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Posted in: Science and Medicine

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Placebos in the news again

ResearchBlogging.orgTowards the end of last week, I was contemplating what I would be writing about for Monday. No topic had quite floated my boat, but I hated to dip into the archive of topics I’ve written about before to update a post. After all, I like to be topical whenever possible. Then what to my wondering eyes should appear (yes, I know Christmas is still two months away) but a study in the British Medical Journal by a group lead by Jon C. Tiburt at the Department of Bioethics at the National Institutes of Health in collaboration with investigators at the Osler Institute at Harvard University and the McClean Center for Clinical Medical Ethics at the University of Chicago entitled Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists.

Serendipity? Who cares? The study addresses a very important aspect of science-based medicine.
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Posted in: Herbs & Supplements, Science and Medicine, Science and the Media

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Is There a Placebo Effect for Animals?

One of the occasional arguments used in support of “alternative” approaches to human medicine is the observation that since “alternative” medicine is used (with anecdotal success) in animals, and animals don’t know anything about the treatment that they’re getting, then they must work a priori.  Of course, the fallacy of such an observation is pretty obvious to anyone with a logical/skeptical frame of mind, because it assumes that the therapies do work (even though there’s little evidence of that).

Clearly, however, some people perceive that the therapies work, including veterinarians – there are veterinary acupuncturists, chiropractors, homeopaths, etc., etc.  Since there’s very little scientific support for the idea that the therapies actually have any clinically significant effect on biological processes, including the processes that result in disease, questions arise as to whether there are other effects of “alternative” treatments on animals. Specifically, people may wonder whether or not animals can benefit from placebo effects.
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Posted in: Acupuncture, Science and Medicine, Veterinary medicine

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When Further Research Is NOT Warranted: The “Wisdom of Crowds” Fallacy

Most scientific research studies have at least one thing in common: the conclusion section ends with, “further research is warranted.” I’d say it’s about as common as the “talk to your doctor” disclaimer in TV ads for pharmaceutical products. And in a way, they both serve the same purpose. They’re a “CYA” move.

What does “further research is warranted” mean in plain English? I think it can be roughly translated: “My research study is not of the size or scope to fully explain all the phenomena described in this article. Therefore, draw conclusions beyond the data and study methods at your own risk. And yeah, my work is important and cool – so people should study it further.”

Of course, the first two sentences are reasonable – we should always remember not to draw conclusions beyond the information provided by the data we’ve collected (even though that’s about as challenging as getting a beagle not to eat a table scrap in an empty room). The real problem is the third sentence. Is the research promising enough to require further investment? How are we to know if further research is indeed warranted? I would argue that it should not be based solely on the subjective opinions of the researchers nor the popularity of the research topic to the general public. (more…)

Posted in: Clinical Trials, Science and Medicine

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