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Medicine past, present, and future: Star Trek versus Dr. Kildare and The Knick

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I’ve been a big Star Trek fan ever since I first discovered reruns of the original Star Trek episodes in the 1970s, having been too young (but not by much!) to have caught the show during its original 1966-1969 run. True, my interest waxed and waned through the years—for instance, I loved Star Trek: The Next Generation, while Star Trek: Enterprise and Star Trek: Voyager pretty much left me cold—but even now I still find myself liking the rebooted movie series. In the original series, my favorite characters tended to alternate between Spock, the Vulcan first officer and science officer on the Enterprise, and Dr. Leonard “Bones” McCoy, the ship’s chief medical officer. I sometimes wonder if my love of these two characters had anything to do with my becoming a doctor and researcher myself. It probably did.

One aspect of all the Trek shows that always interested me was its portrayal of medicine in the 23rd and 24th centuries. After all, what doctor wouldn’t like to have a device like the tricorder that he could wave over the patient and come up with an instant diagnosis and course of treatment? Who knew, of course, that nearly 50 years after the first Trek episode first aired, we would have technology that makes the communicators on the original series (TOS, for those Trek non-fans) look primitive and large by comparison and that we’d be well on the way to developing devices that can do some of what tricorders did on the show. Throughout all the shows and movies, the medical technology of a few hundred years in the future is portrayed as vastly superior to what we have now, with 20th century medicine at times denigrated by “Bones” McCoy and other Star Fleet medical personnel as barbaric quackery.

A confluence of events and media led me to want to explore a couple of questions. First, which procedures that we consider state-of-the-art science-based medicine will be considered “barbaric” 50 or 100 years from now? Second, is the contempt expressed for the medicine of the past (e.g., by “Bones” McCoy) justified? These are questions that I’ll explore a bit with the help of the Star Trek universe, a recent new cable television drama series, and a couple of articles that appeared on medical sites as a result of the premier of that series.
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Posted in: Cancer, History, Science and the Media, Surgical Procedures

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Dental Management Of Obstructive Sleep Apnea

[Editor's Note: I'm pleased to announce that Grant Ritchey has agreed to join SBM as a regular. He'll be writing about dental science and pseudoscience every four weeks on Sunday. (I swear, we'll get up to seven day a week publishing if it kills me—or the other bloggers.) Grant will be starting with science, but I'm sure he'll soon be discussing all the sorts of claims about dentistry and dental disease that are—how shall I put it?—less than science-based soon enough.]

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder in which the airway is partially or completely blocked during sleep. Although little or no air is flowing, the person continues to attempt to breathe. Typically, cessations in breathing last longer than 10 seconds per episode, but can last over a minute and usually occur multiple times during sleep. This can lead to poor sleep quality and precipitous drops in blood oxygenation levels over an extended period of time. This potentially life-threatening condition is frighteningly prevalent, especially in adults over 40, and it is estimated that 80-90% of OSA goes undiagnosed, further compounding the problem.

When a person experiences multiple apneic episodes during the night, the brain responds by alerting the body, resulting in increased efforts to breathe, gasping, and arousal from sleep. These frequent waking events, combined with lowered oxygen levels, can lead to the signs, symptoms, and sequelae of obstructive sleep apnea. Typically, OSA sufferers snore loudly, then are silent for 10-30 seconds as the airway is blocked. This is followed by choking, snorting, or gasping sounds when their airway reopens.
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Posted in: Dentistry, Surgical Procedures

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Science-based medicine throughout time

As 2013 comes to a close, because this probably will be my last post of 2013 (unless, of course, something comes up that I can’t resist blogging about before my next turn a week from now), I had thought of doing one of those cheesy end-of-year lists related to the topic of science-based medicine. Unfortunately, I couldn’t come up with anything I haven’t already done. I even thought of coming up with a list of New Year’s resolutions for 2014. In fact, I even thought of making the first one—in a self-deprecating manner, of course—to be to stop being so mean, nasty, and dogmatic, the better to satisfy my detractors. But then I remembered that nothing is likely to satisfy my detractors and, besides, my ever-lovin’ cuddliness is what makes me so popular. Besides, I have to be me and gotta be true to myself, and all that rot, so that idea went out the window. Of course, what was worse than my inability to come up with something was that I couldn’t think of a way to make it funny. When you’re trying to be funny following the inimitable Mark Crislip, you’d damned well better be funny. So, until my humorous instincts come back, serious it has to be.

But serious doesn’t necessarily mean heavy. The end of a year is a time both to look back on the year before and look forward to the year to come. This year in many ways was a good year for us here at SBM. We launched a Facebook page, reinvigorated our Twitter feed, and have experienced a significant growth in our traffic. Those who know me and/or follow me on various social media know that I’m a big Doctor Who fan, I have been since the 1980s. So the last two big events of the year, the 50th anniversary special in November and the Christmas special on, well, Christmas got me to thinking about time travel, and thinking about time travel revived memories of a topic I covered on my not-so-super-secret other blog four years ago and had been meaning to treat here sometime. It’s a fun topic to finish out the year, not to mention a way for me to blatantly sneak Doctor Who references into an SBM post.

Being a Doctor Who fan and all, not surprisingly, I’ve often wondered what it would be like to be able to travel through time and visit times and places in history that I’m most interested in. For instance, being a World War II buff, I’d certainly want to be able to check out what everyday life was like here in the U.S. during World War II. Given my affinity for psychedelic music and that I was only four years old during most of the Summer of Love, I’d think it cool to check out Haight-Ashbury, although I suspect my reaction to the reality of it would be similar to that of George Harrison when he checked it out for the first time. I guess, if pushed, I’d have to admit that if I were old enough to have been a high school or college student in 1967, I probably would have been one of those straight-laced, short-haired types destined either to go to college to become a doctor or engineer, or to go to Vietnam to fight. Despite loving the music, I never had any interest in experimenting with the drugs. Beer, wine, and—occasionally—a martini or two are my drugs of choice and then only for medicinal purposes, as they say. Heck, I never even tried to smoke tobacco. Even as a child I couldn’t stand the smell of cigarette smoke to the point where it was never even really a temptation.

In any case, what provoked my original bit of musing was a post a few years ago by Martin Rundkvist, who wrote about Fear of Time Travel, where he imagines what it would be like for a modern person to be transported back in time:

First, imagine that you’re dropped into a foreign city with only the clothes you wear. No wallet, no hand bag, no money, no cell phone, no identification. Pretty scary, huh? But still, most of us would get out of the situation fairly easily. We would find the embassy of our country of origin, or if it were in another city, contact the local police and ask to use their phone. A few days later we would be home.

That’s not the scary scenario I rehearse. Imagine that you’re dropped into the city you live in with only the clothes you wear. No wallet, no hand bag, no money, no cell phone, no identification. And it’s 500 years ago. (Or for you colonial types, 300 years ago in one of your country’s first cities.)

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Posted in: Cancer, Critical Thinking, Science and the Media, Surgical Procedures

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On humility, confidence, and science-based surgery

Every so often, the reality of trying to maintain a career in science-based medicine interferes with the fun that is writing for this blog. Basically, what happened is that I spent the entire weekend working on three different grant applications and, by the time Sunday night rolled around, I was too exhausted to write what I had originally planned on writing. Fortunately, one advantage of having been blogging so long and also having blogged under a pseudonym over at my not-so-super-secret other blog is that there’s a lot of material which is pretty damned good, if I do say so myself, that I can draw on for just these situations. Even better, it’s old enough that it’s unlikely that most of you have actually come across it before, which makes it new to you (well, at least most of you). As a special bonus, the jumping off point was a post by an occasional contributor to this blog, Peter Lipson. Actually, I wish Peter would contribute more regularly, but he’s too busy moving on to bigger things at Forbes.

This time around, I’m half-recycling, half-revising a post that was a bit more navel-gazing than usual. However, as the only surgeon on SBM I think it’s actually useful every now and then to discuss the trials and tribulations of practicing science-based surgery. It began when Peter wrote an excellent meditation on a topic that’s always been a difficult issue for me to face as a surgeon, namely how one balances confidence in one’s ability with humility in the face of disease and uncertain science. He started with a spot-on observation:

The practice of medicine requires a careful mix of humility and confidence. Finding this balance is very tricky, as humility can become halting indecision and confidence can become reckless arrogance. Teaching these traits is a combination of drawing out a young doctor’s natural strengths, tamping down their weaknesses, and tossing in some didactic knowledge.

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Posted in: Medical Academia, Science and Medicine, Surgical Procedures

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Knee Osteoarthritis: Thumbs Down for Acupuncture and Glucosamine

Osteoarthritis is the “wear and tear” kind of arthritis that many of us develop as we get older.  Cartilage becomes less resilient with age, collagen can degenerate, and inflammation and new bone outgrowths (osteophytes) can occur.  This leads to pain, crepitus (Rice Krispie type crackling noises with movement), swelling and fluid accumulation in the joints (effusion), and can severely limit activity for some patients.

Since knee osteoarthritis is such a ubiquitous annoyance, home remedies and CAM offerings abound.  Previously we have covered a number of CAM options on this blog, including glucosamine, acupuncture, and several others. The American Academy of Orthopaedic Surgeons (AAOS) has just issued a 1200 page report evaluating the evidence for various treatments for knee osteoarthritis short of total knee replacement surgery. A 13 page summary is available online. They have done the heavy lifting for us, reviewing all the available scientific studies for evidence of effectiveness. Here’s what the science says: (I’ve highlighted the ones where the evidence is strong.)  (more…)

Posted in: Acupuncture, Herbs & Supplements, Surgical Procedures

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New AAP Policy on Circumcision

Back in 2008, I tried to look objectively at the scientific evidence for and against circumcision.  I got a lot of flak from commenters who focused on the ethical issues rather than the scientific evidence. I concluded that the evidence showed small benefits and small risks, and I didn’t advocate either for or against the procedure. At the time, the American Academy of Pediatrics’ position was:

Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child.

On August 27, 2012, the American Academy of Pediatrics issued a revised Circumcision Policy Statement saying that the benefits outweigh the risks.

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Posted in: Surgical Procedures

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RISUG: Birth Control for Men

According to an enthusiastic article on the Internet, “The Best Birth Control In the World Is For Men.”

It’s called RISUG: Reversible Inhibition of Sperm Under Guidance. It involves a minor surgical procedure in which the vas deferens is exposed and pulled outside the scrotum by the same techniques used for a vasectomy. A copolymer, powdered styrene maleic anhydride (SMA, for which the method was previously named) combined with dimethyl sulfoxide (DMSO) is then injected into the vas deferens. The polymer coats the walls of the vas and kills the sperm as they swim by. The mechanism is not understood, but the developer thinks the polymer’s mosaic of positive and negative charges causes the membranes of the sperm to burst, rendering them immotile.

RISUG is rapidly effective: in a phase II clinical trial in India, viable sperm were absent as soon as 5 days after the procedure. They say there have been no pregnancies in the first months “other than a handful of cases in which the RISUG was not injected properly.” (One wonders how they determined that it was not injected properly: by the fact that pregnancy occurred? Could this be just a rationale to explain away failures? Or to spare patients the embarrassment of discovering the wife had another sperm donor?) The contraceptive effect is said to last for a decade or more; it might require repeat injections every 10 years.
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Posted in: Surgical Procedures

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Tonsillectomy Indications and Complications

Tonsillectomy remains a common surgical procedure with over half a million cases in the US per year, the most common surgical procedure in children. The indications and effects of tonsillectomy remain a matter of research and debate, as is appropriate. It is also a subject of popular misinformation and alarmism.

A recent article by Seth Roberts raises many of the issues with tonsillectomy, but also reveals the pitfalls of non-experts trying to understand the clinical literature and the effects of bias on evaluating a complex medical question. Throughout the article Roberts displays a persistent bias toward downplaying the benefits and exaggerating the risks of tonsillectomy, while accusing the medical establishment of doing the exact opposite.  The purpose of this post is not to defend the practice of tonsillectomy but to review some of the relevant issues and explore how bias can affect an assessment of the evidence.

Indications for Tonsillectomy

Roberts tells the story of Rachael who was offered tonsillectomy for her son and so did some research on her own. She looked on Pubmed (a good place to start) and found a Cochrane review from 2009.

The Cochrane Review that Rachael found (“Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis”) was published in 2009. It describes four experiments that compared tonsillectomy to the care a sick child would otherwise receive. All four involved children like Rachael’s son, and all four had similar results: Tonsillectomies had only a small benefit. (Contrary to what Rachael was told.) During the year after random assignment to treatment — the point at which some children had their tonsils removed, other children did not — children whose tonsils were removed had one less sore throat than children who were not operated on (two instead of three for children like Rachael’s son).

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Posted in: Clinical Trials, Surgical Procedures

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Steve Jobs’ cancer and pushing the limits of science-based medicine

Editor’s note: There is an update to this post.

An Apple fanboy contemplates computers and mortality

I’m a bit of an Apple fanboy and admit it freely. My history with Apple products goes way back to the early 1980s, when one of my housemates at college had an Apple IIe, which I would sometimes use for writing, gaming, and various other applications. Indeed, I remember one of the first “bloody” battle games for the IIe. It was called The Bilestoad and involved either taking on the computer or another opponent with battle axes in combat that basically involved hacking each other’s limbs off, complete with chunky, low-resolution blood and gore. (You youngsters out there will be highly amused at the gameplay here.) Of course, it’s amazing that nothing’s changed when it comes to computer games except the quality of graphics. Be that as it may, this same roommate was one of the first students to get a hold of the new Macintosh when it was released in early 1984. I really liked it right from the start but only got to play with it occasionally for a few months. After using a Macintosh SE to do a research project during my last year of medical school, I have used the Macintosh platform more or less exclusively, and the first computer I purchased with my own money was a Mac LC back in 1990 or 1991. Today, I have multiple Apple products, including my MacBook Air, my iPhone, and my old school iPod Classic, among others. Oddly enough, I do not have an iPad, but that’s probably only a matter of time, awaiting software that lets me do actual work on it.

All of this is my typical long-winded way of explaining why I was immensely saddened when I learned of Steve Jobs’ death last week. Ever since speculation started to swirl about his health back 2004 and then again in 2008, capped off by the revelation that he had undergone a liver transplant for a rare form of pancreatic cancer in 2009, I feared the worst. Last week, the end finally came. However, there is much to learn relevant to the themes of this blog in examining the strange and unusual case of Steve Jobs. Now, after his death five days ago, which coincidentally came a mere day after the launch of iCloud and the iPhone 4S, it occurs to me that it would be worthwhile to try to synthesize what we know about Jobs’ battle with cancer and then to discuss the use (and misuse) of his story. Of course, this is a difficult thing to do because Jobs was notoriously secretive and I can only rely on what has been published in the media, some of which is conflicting and all of which lacks sufficient detail to come to any definite conclusions, but I will try, hoping that the upcoming release of his biography by Walter Isaacson in couple of weeks might answer some of the questions I still have remaining, given that Isaacson followed Jobs through his battle with cancer and was given unprecedented access to Jobs and those close to him.

In the meantime, I speculate. I hope my speculations are sufficiently educated as not to be shown to be completely wrong, but they are speculations nonetheless.
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Posted in: Cancer, Medical Ethics, Nutrition, Science and the Media, Surgical Procedures

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Honey

I cram for TAM, and, combined with other commitments, not the least of which is that it is finally sunny and warm in Portland, after a year that has resembled All the Summer in a Day,  which leads to a relatively short post.  There are just so many hours in a day and if possible those days need to be spent in the sun.

In my first year in practice I was sitting on a nursing station writing a note when a patient started howling in pain.  Further investigation revealed that the patient had a chronic, open surgical wound and the (old) surgeon had ordered sugar poured into the wound as part of wound care.  The cafeteria mistakenly sent up salt, and a metaphor became reality.  It did pique my interest in both sugar and honey for wound care,  an area where you have to be careful not to fall prey to all the errors in CAM thinking: a reliance on anecdotes, using suboptimal studies as evidence, mistaking a gobbet of basic science as a meaningful clinical application, and not realizing the warping effect of confirmation bias.

That being said, I have suggested honey and sugar for years for patients, and many patients with prior refractory wounds had healing.  And what are the three most dangerous words in medicine?  In my experience.  I have recommended honey less in the era of the wound vac, but there are not an insignificant number of people with insufficient financial resources who cannot afford even simple wound care supplies. Many  of the ointments, creams and special bandages for wound care costs too much.  Patients also like honey as it is natural (people do love to fall for the naturalistic fallacy) and inexpensive, and I always tell patients that the data is iffy, but not stupid. (more…)

Posted in: Herbs & Supplements, Science and Medicine, Surgical Procedures

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