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Motivations

We received the following letter:

Your blog, the SBM page, has come up for me several times in my research. I’m an RN trying to research cancer treatment, for myself, I am the patient. I’m also a licensed massage practitioner with a 30 year history using “alternative” or “complementary” medicine successfully to treat myself for various things. When your blog has come up I’ve read into it, picking up some useful information.

My question is, why the sarcasm? Why do you and the responders on your site have such disdain and anger? Why do you feel threatened? Your physician status gives you the top of the totem pole, the extensive training, the authority and the privilege. Very doubtful you are going to be knocked off the top of that totem pole in this or any several more lifetimes to come. (more…)

Posted in: Science and Medicine

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You can’t beat the common cold, and that’s a fact

>> Disclaimer: nothing in this post is meant to be taken as medical advice. Always consult your own provider.

For those of us dedicated to supporting science-based medicine and fighting the ever-widening reach of sCAM, pseudoscience, and health fraud, finding a new woo-filled claim or a dangerous, evidence-lacking trend to write about is relatively easy. Many of us may not realize, however, that some of the most commonly used and recommended treatments, one of which at least is probably sitting in your medicine cabinet as you read this, is equally devoid of evidence to support its use.

Every drug store has row upon row of medicines designed to treat or prevent an acute upper respiratory tract infection, otherwise known as the common cold. Despite this, very few are able to live up to their promise. In most cases, particularly where children are concerned, the side effects of these medicines can be worse than the symptoms they are intended to treat. Because I am a pediatrician, and because the evidence for cough and cold medicines (I will refer to them here as CCMs) for children is particularly absent and because adverse events due to CCMs are most frequently seen in children, I will focus mainly on this population. (more…)

Posted in: Pharmaceuticals, Science and Medicine

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More evidence that routine multivitamin use should be avoided

If scientific evidence guides our health decisions, we will look back at the vitamin craze of the last few decades with disbelief. Indiscriminate use is, in most cases, probably useless and potentially harmful. We are collectively throwing away billions of dollars into supplements, chasing the idea of benefits that have never materialized. Multivitamins are marketed with a veneer of science but that image is a mirage – rigorous testing doesn’t support the health claims. But I don’t think the routine use of vitamins will disappear anytime soon. It’s a skillfully-marketed panacea that about half of us buy into.

Not all vitamin and mineral supplementation is useless. They can be used appropriately, when our decisions are informed by scientific evidence: Folic acid prevents neural tube defects in the developing fetus. Vitamin B12 can reverse anemia. Vitamin D is recommended for breastfeeding babies to prevent deficiency. Vitamin K injections in newborns prevent potentially catastrophic bleeding events. But the most common reason for taking vitamins isn’t a clear need, but rather our desire to “improve overall health”. It’s deemed “primary prevention” – the belief that we’re just filling in the gaps in our diet. Others may believe that if vitamins are good, then more vitamins must be better. And there is no debate that we need dietary vitamins to live. The case for indiscriminate supplementation, however, has never been established. We’ve been led to believe, through very effective marketing, that taking vitamins is beneficial to our overall health – even if our health status is reasonably good. So if supplements truly provide real benefits, then we should be able to verify this claim by studying health effects in populations of people that consume vitamins for years at a time. Those studies have been done. Different endpoints, different study populations, and different combinations of vitamins. The evidence is clear. Routine multivitamin supplementation doesn’t offer any meaningful health benefits. The parrot is dead. (more…)

Posted in: Herbs & Supplements, Science and Medicine

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5 out of 4 Americans Do Not Understand Statistics

Ed: Doctors say he’s got a 50/50 chance at living.
Frank: Well there’s only a 10% chance of that
Naked Gun

There are several motivations for choosing a topic about which to write. One is to educate others about a topic about which I am expert. Another motivation is amusement; some posts I write solely for the glee I experience in deconstructing a particular piece of nonsense. Another motivation, and the one behind this entry, is to educate me.

I hope that the process of writing this entry will help me to better understand a topic with which I have always had difficulties: statistics. I took, and promptly dropped, statistics 4 times a college. Once they got past the bell shaped curve derived from flipping a coin I just could not wrap my head around the concepts presented. I think the odds are against me, but I am going to attempt, and likely fail, in discussing some aspects of statistics that I want to understand better. Or, as is more likely, learn for the umpteenth time, only to be forgotten or confused in the future. (more…)

Posted in: Basic Science, Science and Medicine

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Separating Fact From Fiction in the Not-So-Normal Newborn Nursery: Vitamin K Shots…..

In August, news emerged from Vanderbilt University that four cases of a rare bleeding condition seen in young infants had been diagnosed since February. Three of these infants suffered intracranial hemorrhages, requiring surgical intervention to evacuate the blood and save their lives, although there will almost certainly be neurological and developmental repercussions down the road. The fourth child presented with gastrointestinal bleeding and also survived. The parents of all four babies had refused an extremely safe and effective intervention on the day that they were born, one recommended by pediatricians since the early 1960′s, that would have prevented these outcomes.

When a baby is born, there are a number of rituals that parents and medical professionals take part in. Some are largely ceremonial, more rites of passage than anything medically necessary, such as the first bath or the assignment of APGAR scores. As a physician, I play my part in some of these rituals, the baby’s first exam being the most important. Unlike many medical examinations that pediatricians perform, the newborn exam involves a good deal of showmanship. It’s the only exam where I make a point of talking through each aspect with the parents, showing them all the normal but sometimes surprising (at least to new parents) things that babies do and common physical exam findings that many folks don’t know about and might lead to unnecessary concern. Really hammering home how healthy a new baby is can go a long way towards relieving parental anxiety. And anticipating and addressing common newborn issues during the exam helps save me a lot of time on the back end as well.
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Posted in: Science and Medicine

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You be the judge

Jann Bellamy recently recapped her experience attending a meeting sponsored by her local Healing Arts Alliance. As you re-read her article pay particular attention to the language used by the Alliance to describe themselves and the treatments they offer. For me, there is one word that really stands out. It is emblematic of the attitude of the complementary and alternative medicine community. A word meant to represent a virtue is really a self-serving recusal of critical-thinking. Not wanting to misinterpret their intent, I went the website of the Healing Arts Alliance to get the full context. Here is the mission statement, in full, pasted from their website: (more…)

Posted in: Science and Medicine

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A Rational Approach to Managing Acute Pain in Children

Pain is one of the most common reasons for a parent or caregiver to seek medical attention for their child. Children experience pain for a wide variety of reasons, many that are similar to if not exactly the same as causes of adult pain, but historically pediatric patients have been grossly undertreated. I am 37-years-old and, sadly, if I had undergone a surgical procedure as an infant there would have been a significant chance that I would have received no analgesia at all. Things are better now, but there remains a large gap between what is recommended and how pediatric pain management is practiced in the real world.

The appropriate management of a child’s pain is a vital aspect of compassionate and high quality care, and it is simply the right thing to do. Failing to treat pain effectively is ethically no different than purposefully causing pain in a child, and it can have serious repercussions. Poorly controlled pain can interfere with a child’s recovery because of the negative impact of catecholamine surges and other stress-related chemicals, and impair the ability to take part in physical or occupational therapy. It can also make future encounters with health care professionals more challenging because of anxiety and mistrust.

Untreated pain can interfere with deep breathing, potentially leading to prolonged need for supplemental oxygen and increased risk of pneumonia. It can prevent restful sleep, which has myriad health consequences beyond just cognitive impairment. Pain can interfere with the family unit by significantly increasing parental or caregiver anxiety, which can lead to neglect, abuse, and increased utilization of healthcare resources. Poorly-managed acute pain can increase the likelihood of a patient, even a child, developing chronic pain. There is even good evidence in neonates (my next post I think), that poorly managed acute pain can lead to increased sensitivity and an increased pain response to future occurrences of procedural pain, such as routine immunizations.

Multiple reports throughout the 1970′s and 1980′s revealed that pediatric patients received substantially less pain treatment compared to adults for equivalent conditions, such as broken bones and hernia repair. Despite steady improvement in pain management in kids over the past few decades, we still have a long way to go. Though appropriate anesthesia is now standard of care in children of all ages, many physicians are uncomfortable with evaluating and treating acute pain (chronic pain is another topic) in children. And many parents are resistant to the use of safe and effective pain medications.

Even with physicians that might profess their comfort with recognizing and treating pediatric pain, my admittedly personal experience is that many still allow kids to be in pain at times for a variety of reasons. However, it isn’t that these physicians and caregivers are heartless or enjoy watching their patients, or their children if it is a parent putting up a roadblock, suffer. Even knowing a child is in pain can sometimes be challenging. And there are many misconceptions regarding pain in children that interfere with appropriate treatment. The bulk of these misconceptions involve the use of opioids. All of these misconceptions and false beliefs should be amenable to education and increased awareness of science-based guidelines.

Pediatric pain is a challenging entity. So much so that many institutions have pediatric pain teams. My wife is an expert on pediatric pain and spends her days, and often nights, as a palliative care pediatrician helping to manage pain and other symptoms in children who are approaching the end of life. Her insights and expertise on this topic have been invaluable in my own encounters with pain as a pediatric hospitalist. Her experience, like mine, is that even at major academic institutions pain management is regularly not approached systematically, nor based on the best available evidence.

So what is pain exactly, and how is it assessed in kids?
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Posted in: Science and Medicine

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Do vitamins prevent cancer and heart disease?

It is a triumph of marketing over evidence that millions take supplements every day. There is no question we need vitamins in our diet to live. But do we need vitamin supplements? It’s not so clear. There is evidence that our diets, even in developed countries, can be deficient in some micronutrients. But there’s also a lack of evidence to demonstrate that routine supplementation is beneficial. And there’s no convincing evidence that supplementing vitamins in the absence of deficiency is beneficial. Studies of supplements suggest that most vitamins are useless at best and harmful at worst. Yet the sales of vitamins seem completely immune to negative publicity. One negative clinical trial can kill a drug, but vitamins retain an aura of wellness, even as the evidence accumulates that they may not offer any meaningful health benefits. So why do so many buy supplements? As I’ve said before, vitamins are magic. Or more accurately, we believe this to be the case.

There can be many reasons for taking vitamins but one of the most popular I hear is “insurance” which is effectively primary prevention – taking a supplement in the absence of a confirmed deficiency or medical need with the belief we’re better off for taking it. A survey backs this up – 48% reported “to improve overall health” as the primary reason for taking vitamins. Yes, there is some vitamin and supplement use that is appropriate and science-based: Vitamin D deficiencies can occur, particularly in northern climates. Folic acid supplements during pregnancy can reduce the risk of neural tube defects. Vitamin B12 supplementation is often justified in the elderly. But what about in the absence of any clear medical need? (more…)

Posted in: Herbs & Supplements, Nutrition, Science and Medicine

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Irritated by the Skeptical Inquirer. Again.

I have a confession. I have been interested in issues skeptical since high school when I came across a copy of the Zetetic at Powells. In the pre-digital era I had a complete library of Zetetic-Skeptical Inquirers (SI) that a decade ago was tossed in the recycle bin along with a similar collection of MacWorlds. I have been interested in skepticism a long time and, here is my confession, I no longer find much of the subject matter covered by SI all that interesting. Even big ticket topics like the existence of God are uninteresting. It is not that the topics are not important, they are, and each generation has to relearn why Bigfoot or haunted houses or UFO’s are nonsense. But for me it is a large serving of been-there, done-that.

So while I subscribe to SI, it is more from a sense of obligation to support institutions I think are important than from an expectation that I will be either educated by the content or entertained by the style of the writers. I usually skim the magazine while accomplishing tasks that do not require my full attention probably because SI is the only magazine I still receive in dead tree format, the rest of my life being digital.

So I ran across “Taking our medicine: What hope for skepticism in healthcare?” by Kenneth W. Krause and after skimming it I was irritated. So I read it again and I was more irritated, which is often a good sign. But I could not quite put a finger on what it was. So I read it again and then went for a walk and thought about it.

All the facts were fine. I had no issue with the content of the article. It was the adjectives that irritated me. And the essay was, from my perspective, incomplete. It was like reading a relationship/birth control article by the Pope. Sure, he knows the facts of the situation, but not being an active participant in the process and with an agenda to promote, vital information will be missing or distorted. (more…)

Posted in: Science and Medicine, Science and the Media

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The Nuances of Informed Consent

Modern medical ethics are built upon the concept of informed consent. This is not, however, as straightforward a concept as it may seem.

Physicians and health care providers have a duty to provide informed consent to their patients or their patients’ guardians, which means that they have to inform them appropriately about the risks and benefits of their recommendations and interventions. This includes informing them about the risks of not treating an illness.

This principle is, in turn, based largely upon the principle of autonomy – people have the right to control their own lives, and one cannot have control without information.

This is all simple enough, but where it becomes tricky is in deciding how much information to give patients, and how to present it. (more…)

Posted in: Critical Thinking, Medical Ethics, Science and Medicine

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