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Archive for Science and Medicine

A natural product of his environment

I’m delighted to have the opportunity to join this outstanding group of medical professional bloggers in adding my natural products angle to the application of science-based medicine.  With the exception of Dr. Gorski, who holds MD and PhD degrees, I believe I am the first “only a PhD” to be invited to SBM.  However, I have spent much of my career training, and training with, physician-scientists; so enthusiastic am I about the special qualities of the physician-scientist that I married one (or, rather, she chose to marry me, truth be told.).  Conversely, I view the invitation to write here as a responsibility in representing what my fellow basic scientists bring to bear on discussions of the scientific arguments for and against modalities classified broadly as complementary and alternative medicine or integrative medicine.

Why write about herbal medicines and natural products?

I have long been interested in bringing objective scientific information to the public, perhaps as early as my college years in bars while visiting my working-class hometown of Wallington, NJ, or while shooting darts with Philadelphia cops across from my undergrad apartment.  Any chat I’d have with an old buddy or bartender about drugs, cancer, or drugs and cancer would invariably draw some interest from fellow patrons overhearing my discussions.  These were usually followed by, “Hey, aren’t you Frankie Kroll’s boy?,” or “I’ve heard the government is hiding the cure for cancer – do you have any inside dope on that?”
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Posted in: Herbs & Supplements, Medical Academia, Pharmaceuticals, Science and Medicine, Science and the Media

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Is there no end to unscientific treatments for autism?

OK, it’s true that I’m only scheduled to post every other week or so, but I couldn’t resist sharing this one with you (which I’ve cross-posted over at denialism blog).  I promise to get back to my assigned schedule after this one.  Thanks for your indulgence.  –PalMD

If you’ve been a regular reader of SBM or denialism blog, you know that plausibility plays an important part in science-based medicine.  If plausibility is discounted, clinical studies of improbable medical claims can show apparently positive results.  But once pre-test probability is factored in, the truth is revealed—magic water can’t treat disease, no matter what a particular study may say.  So it was with great dismay that I read an email from a reader telling me about parents buying hyperbaric chambers for their autistic children.  Let’s review some science.

In Breathing 101, we talked about how the oxygen delivered to your lungs depends on both the percentage of oxygen in the air, and the air pressure.  We looked at how diminishing atmospheric pressure, for example at altitude, makes it harder to breathe.

Of course it is also possible to expose people to increased atmospheric pressure, which has therapeutic uses in the form of hyperbaric oxygen therapy (HBOT).

Oxygen delivery to tissue depends on several factors.  We already talked about the air itself.  Once air gets enters the lungs, most of the oxygen transported to your tissues is carried by the hemoglobin molecules in your red blood cells (under normal conditions).  A small amount is directly dissolved in the blood.  The amount dissolved in the blood is dependent on (no surprise) the percentage of oxygen and the atmospheric pressure.  By increasing the atmospheric pressure from 1 atm (760 torr) to 3 atm, the amount of oxygen dissolved in the blood is enough to meet your body’s needs independent of heme-associated oxygen.

This is a good thing.
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Posted in: Neuroscience/Mental Health, Science and Medicine

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Fake diseases, false compassion

Hi,  everybody!  I’m PalMD (although my byline says differently), and you may remember me from such other blogs as WhiteCoat Underground and denialism. The folks around here were kind enough to give me a regular gig dispensing my brand of medical information transfer, and I’m going to start out with a basic question: what is a disease?

Human beings have some pretty powerful pattern-recognition software—so powerful that it can over-perceive patterns, sometimes causing us to confuse randomness for order.  This impacts all aspects of human thought, including medicine.

In the realm of medicine, we define disease as alterations in physiology, anatomy, biochemistry, etc. that causes significant discomfort, disability, or increased risk for same.  OK, really, I sort of cobbled that together, but you get the idea — a disease is a definable alteration in normal function.  A corollary to this is that to define a disease, we must know something about what is normal (a discussion for another time).  A related term is syndrome, which we usually define as  “a set of signs or a series of events occurring together that often point to a single disease or condition as the cause.”  What this effectively means is that we use the word “syndrome” to indicate a set of abnormal findings without a clear cause, and “disease” to indicate the abnormal findings with a putative cause.

(All this verbosity is leading somewhere—I promise.)

“Syndrome” is sometimes a useful place-holder term for a nascent disease.  Sometimes, however, a set of signs and symptoms is simply coincidence that we erroneously recognize as a pattern.

In popular culture there’s a lot of talk about “overmedicalization”, that is, calling things abnormal that are simply slight variations in the wide range of human health.   You’ll find people who argue that treating ADHD with medications is tantamount to abuse (and lost in the hysteria is the real possibility that we are over-medicating some kids). You’ll also find groups that argue that deafness or autism are simply “other”, but not “abnormal” as such.  This, of course, is wrong.  While a deaf or autistic person is just as valuable as a “normal”, and may have just as much to contribute to society, they are very far from normal human health.

And now you have the proper background to approach the problem of fake diseases.

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Posted in: Science and Medicine

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Cholesterol Skeptics Strike Again

I’m really tired of arguing about cholesterol, but I feel obliged to stand up once more to defend science-based medicine from unfair calumny.

Lewis Jones’s article “Cholesterol-shmesterol” in Skeptical Briefs (December 2007) included errors and misconceptions about cholesterol. It was a re-hash of the same kind of misinformation that is being spread by The International Network of Cholesterol Skeptics (THINCS) and that I addressed in an earlier post. THINCS would like us to believe that cholesterol has nothing to do with heart disease; that low cholesterol is harmful and high cholesterol is beneficial; and they demonize statins, even falsely claiming that they cause cancer.

I answered Jones with my own article “Cholesterol Clarifications” in the June 2008 issue of Skeptical Briefs. I said I agreed that cholesterol does not “cause” heart disease, that low-fat and low-cholesterol diets have been promoted way beyond the evidence and that statins are being over-prescribed. The public has a lot of misconceptions, but thoughtful science-based doctors agree that the evidence shows: (more…)

Posted in: Nutrition, Pharmaceuticals, Science and Medicine

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Nobel for HIV Discoverers

The Nobel Prize in Medicine was awarded this week to two French virologists, Françoise Barré-Sinoussi and Luc A. Montagnier, for discovering the AIDS causing virus, the Human Immunodeficiency Virus (HIV). They will share half the prize of 1.4 million dollars, the other half going to three Dr. Harald zur Hausen for discovering the human papilloma virus and its relation to cervical cancer.

The prize comes 25 years after Barré-Sinoussi and Montagnier, working at the Pasteur Institute in Paris, published their paper identifying what was later called HIV. The last quarter of a century has proven their discovery to be a triumph of science-based medicine. The Nobel committee is correct, in my opinion, in waiting such long periods of time before granting such recognition. It reflects that fact that, even in a fast-paced arena of science such as medicine, it takes time for the meticulous process of science to work itself out. It takes decades to garner the perspective necessary to tell the difference between a crucial breakthrough and a false lead.

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Posted in: Science and Medicine

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A “Shruggie” Awakening – One Doctor’s Journey Toward Scientific Enlightenment

ED. NOTE: Circumstances have dictated an unexpected change of plans; so you’re in for a treat. Dr. Val Jones is starting two days earlier than previously announced. Beginning next week, her posts will appear regularly on Thursday mornings. Harriet Hall’s post scheduled for today will appear on Thursday this week. Be ready; it’ll be the return of the cholesterol “skeptics.” Now, Dr. Val…

Greetings, everyone. I am a proud new member of the Science Based Medicine blogging team, and have committed to one post each Thursday morning. As part of my “grand entrance” onto the skeptical blogging stage, I was hoping to introduce a new noun into our lexicon. I’ve asked permission from Steve Novella and David Gorski, and they’ve given me a wink and a nod, so here goes:

Shruggie (noun): a person who doesn’t care about the science versus pseudoscience debate. When presented with descriptions of exaggerated or fraudulent health claims or practices, their response is to shrug. Shruggies are fairly inert, they will not argue the merits (or lack thereof) of complementary and alternative medicine (CAM) or pseudoscience in general. They simply aren’t all that interested in the discussion, and are somewhat puzzled by those who are.

I’m sure you’ve encountered shruggies in your daily life. They are quite common – in fact, they may actually be in the majority among healthcare professionals. And I have a confession to make — I used to be one myself.

If you’ll indulge me, I’d like to tell you the story of how I was awakened from my unhealthy indifference toward pseudoscience. (more…)

Posted in: Science and Medicine, Science and the Media

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Pitfalls in Regulating Physicians. Part 2: The Games Scoundrels Play

A Few Things that No Doctor Should Do

When a physician is accused of DUI, “substance abuse,” being too loose with narcotic prescriptions, throwing scalpels in the OR, or diddling patients, the response of a state medical board† tends to be swift and definitive. Shoot first, ask questions later. After all, the first responsibility of the board is to the public’s safety, not to preserving the physician’s livelihood. One might therefore expect that a physician accused of using dangerous, substandard treatments would face a similar predicament. As you’ve undoubtedly guessed, such is not the case.

Here on Science-Based Medicine I’ve discussed at least 4 risky and implausible treatments: Laetrile, the “Gonzalez Regimen,” Na2EDTA “chelation therapy,” and intravenous hydrogen peroxide. Any medical board worth its salt ought to recognize each of those as dangerous and sub-standard, and therefore ought quickly to impose serious disciplinary measures upon any licensed physician found using them. Sometimes that is the case, but all too often it isn’t.

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

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Cognitive Dissonance at the New York Times

Humans have the very odd ability to hold contradictory, even mutually exclusive, ideas in their brains at the same time. There are two basic processes at work to make this possible. The first is compartmentalization – the ideas are simply kept separate. They are trains on different tracks that never cross. We can switch from to the other, but they never crash into each other.

When contradictory ideas do come into conflict this causes what psychologists call “cognitive dissonance.” We then typically will relieve cognitive dissonance, which is an unpleasant state, through the second process – rationalization. We happily make up reasons why the two conflicting ideas actually don’t conflict at all. People are generally good at rationalization. It is a supreme intellectual irony that greater intelligence often leads to a greater ability to rationalize with both complexity and subtlety, and therefore a greater capacity to maintain contradictory beliefs.

In fact the demarcation between science and pseudoscience is often determined by the difference between sound scientific reasoning and sophisticated rationalization.

While cognitive dissonance refers to a process that takes place within a single mind, it is a good metaphor for the contradictory impulses of groups of people, like cultures or institutions. I could not help but to invoke this metaphor when reading two editorials published in the same day in the New York Times.

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Posted in: Clinical Trials, Science and Medicine

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A Budget of Anecdotes

Anecdotal evidence. An oxymoron? Or a valid approach to understanding data?

The problem is there are different kinds of anecdotes, used for different purposes, but the purpose of anecdotes is rarely if ever defined explicitly. Anecdotes are used for one purpose by one speaker/writer but interpreted in a different context by the listener/reader. People love anecdotes, especially if the anecdotes are about them or their beliefs. Anecdotes are how patients transmit the particulars of their disease to their health care providers. The medical history, as taken from the patient, is an extended anecdote, from which the particulars of the disease have to be extracted. Anecdotes are how physicians explain disease and treatments. Anecdotes are a tool with which teachers instruct their students. Anecdotes are how CAM proponents validate their particular system, and how skeptics invalidate them.

Anecdotes are useful tools for presenting yourself and your ideas. The convention season is over and is was striking how the candidates attempted to win over voters with anecdotes about their lives rather than the particulars of their policies. Using variations of ‘anecdote’ as a pubmed search term yields little of substance. The predominant theme on medline is to contrast anecdotes with evidence, always to the detriment of anecdotes. Anecdotes have power to influence far greater than evidence.

On The Skeptics Guide to the Universe #165 there was an interview with Ben Goldacre, who noted that there was the popular misbelief that the MMR vaccine was a cause of autism. The belief waned not when the voluminous data on the safety and lack of association with autism and the MMR was released, but when it was discovered that the primary proponent of the MMR/autism link received large sums of money to testify about that MMR/autism link. It was the anecdote about his conflict of interest that invalidated the idea, not the science.

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Posted in: Science and Medicine

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FDA approval of drugs and transparency in clinical trial results

ResearchBlogging.orgNote: The reason that I am posting today rather than my usual Monday slot is because the article I discuss here was embargoed until last night. Consequently, I asked Harriet if she would trade days with me this week, and she was kind enough to do so.

One thing that science relies on almost absolutely is transparency. Because one of the most important aspects of science is the testing of new results by other investigators to see if they hold up, the diligent recording of scientific results is critical, but even more important is the publication of results. Indeed, the most important peer review is not the peer review that occurs before publication. After all, that peer review usually consists of an editor and anywhere from one to four peer reviewers on average. Most articles that I have published were reviewed by two or three reviewers. No, the most important peer review is what occurs after a scientist’s results are published. Then, all interested scientists in the field who read the article can look for any weakness in methodology, data analysis, or interpretations. They can also attempt to replicate it, usually as a prelude to trying to build on it.

Arguably nowhere is this transparency quite as critical as in the world of clinical trials. The reason is that medications are approved on the basis of these trials; physicians choose treatments; and different medications become accepted as the standard of care. Physicians rely on these trials, as do regulatory bodies. Moreover, there is also the issue of publication bias. It is known that “positive” trials, trials in which the study medication or treatment is found to be either efficacious compared to a placebo or more efficacious than the older drug or treatment it is to replace, are more likely to be published. That is why, more and more, steps are being taken to assure that all clinical trial results are made publicly available. For example, federal law requires that all federally-funded clinical trials be registered at ClinicalTrials.gov at their inception, and peer-reviewed journals will not publish the results of a clinical trial if it hasn’t been registered there. Also, beginning September 27, 2008, the US Food and Drug Administration Amendments Act of 2007 (FDAAA) will require that clinical trials results be made publicly available on the Internet through an expanded “registry and results data bank,” described thusly. Under FDAAA, enrollment and outcomes data from trials of drugs, biologics, and devices (excluding phase I trials) must appear in an open repository associated with the trial’s registration, generally within a year of the trial’s completion, whether or not these results have been published. Although there are some practical issues over this law, for example determining how much information can be disseminated this way without constituting prior publication, which is normally a reason to disqualify a manuscript from publication.
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Posted in: Clinical Trials, Medical devices, Politics and Regulation, Science and Medicine

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