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Feet of Clay

It has been tough in Portland this year. The Trailblazers, our NBA, and only professional team, started out on a tear, then went right down the toilet. It is painful to see such promise dribbled away. Sigh. Why is elation always followed by disappointment? Everyone and everything has feet of clay. Except Cassius Marcellus.

At the beginning of March the NEJM had a wonderful essay, What’s the Alternative? The Worldwide Web of Integrative Medicine by Ranjana Srivastava. The essay concerns a patient who is ‘diagnosed’ with cancer at an integrative medicine exhibition and the resultant diagnostic and therapeutic debacles that follow.

The quotes of note:

“At one time, the worst offense one encountered was someone prescribing a few herbs to a desperate patient who’d exhausted all other means of treatment. The usual thinking was, “At this stage, it can’t do any harm.” But insidiously and alarmingly, “alternative medicine” has crept from offering last-ditch treatments to making diagnoses. As the cancer armamentarium has expanded with targeted therapies, unscrupulous practitioners of alternative therapy have devised competing offers that sound at least as impressive to the average patient, who is often marginally health-literate and eager to embrace the promise of a cure without toxicity. But the radical, completely unregulated, and often dangerous options on offer can and do cause harm.

and

Alternative therapies need meet no burden of proof except a patient’s gullibility. One never hears of alternative therapies that failed: the patient merely waited too long to try them.

and

Physicians would be naive to ignore the elephant in the room. Integrative medicine comes in many forms — some useful, but many dangerous. It also comes at tremendous personal and societal cost. The initial expenditure may come from patients’ pockets, but often the health care system eventually inherits the problem. Although there’s probably no way of calculating the psychological cost, for many it is high and unending.

Well said. This editorial and patient story concerns cancer, not a relatively trivial problem, but the concepts are widely applicable to all manner of SCAMs. I am not a big fan of slippery slope arguments, but I am always concerned when useless or unproven therapies are recommended. I am also not a fan of ideological purity, a foolish consistency being the hobgoblin of little minds, adored by little statesmen and philosophers and science bloggers. The key word I suppose is foolish. There is nothing foolish about being serious in protecting your patients life, health, and, given the cost of care, wealth.

Fast forward a mere two weeks to Clinical Practice. Uncomplicated Urinary Tract Infection by Thomas M. Hooton. I suppose the editors of the NEJM were experiencing an F. Scott Fitzgerald moment  when first they published

The phenomenon of questionable health practices is not limited to the developing world; my patient’s encounter occurred in a medically sophisticated city. Patients can even be duped at home, from the safety of their Internet connection.

only to be followed 14 days later with a review of the treatment of UTI where the editors were evidently paying no attention to the prior content of the Journal. I saw no disclaimer that the views of the Ranjana Srivastava were not those of the NEJM, so I assume the editors agreed. I know. Naive.

For in the table on prevention for UTI we find the following recommendations:

Cranberry juice, capsules or tablets

Biologic plausibility is based on the inhibition of uropathogen adherence to uroepithelial cells; clinical data supporting a protective effect have been limited by design flaws; a recent randomized, placebo-controlled trial showed no benefit from cranberry juice.

Adhesion blockers (D-mannose, available in health-food stores and online, is occasionally used as preventive therapy)

UTIs caused by E. coli are initiated by adhesion of the bacteria to mannosylated receptors in the uroepithelium by means of FimH adhesin located on type 1 pili; theoretically, mannosides could block adhesion; however, D-mannose has not been evaluated in clinical trials.

and it is noted in the discussion (talking in part about mechanical solutions such as voiding after intercourse as well as Cranberry juice and D-mannose)

Although data supporting the effectiveness of these strategies are sparse or nonexistent, they carry a low risk of adverse effects and may be helpful.

and

…although data on the efficacy of these measures are mostly lacking, they pose little risk.

Why not suggest homeopathy, reiki, acupuncture, purging and bleeding? The same concepts apply. I know that there are ‘sarcasm marks’, but on occasion I need ‘voice dripping with contempt’ marks or ‘I am so disappointed I want to cry’ marks when I write.

The data is negative or does not exist. Yet the NEJM recommends it anyway.  It can’t hurt; what’s the harm? For those of you not in medicine, the word of the NEJM is close to that of god. In clinical medicine, there is the NEJM then everyone else.  The recommendations are in a table that will be cut and pasted into a thousand Powerpoint talks and disseminated far beyond the readership of the NEJM.

To paraphrase:

The phenomenon of questionable health practices is not limited to the developing world; my encounter occurred in a medically sophisticated Journal. Doctors can even be duped at home, from the safety of their Internet subscription.

Years ago the Annals of Internal Medicine published a hideous series on alternative medicine and I lost confidence in the Annals and they have slid into personal irrelevance. When referring to the journal to housestaff I often pronounce it as if it had one ’n’, such is my ongoing irrational, immature, contempt for the Annals. Perhaps it is confirmation bias on my part. I expect the Annals to publish third rate articles and that is what I see. The NEJM isn’t Annals level. Yet. But it lies at the heart of my ongoing problem with all media: if they get it wrong in an area in which I am knowledgeable (Infectious Diseases, SCAMs) how can I trust them in areas in which I need to defer to the expertise of others (just about everything else)?

Is it me, or does the clay now extend to midthigh for the NEJM? Is there anyone I can trust?

Posted in: Health Fraud, Medical Academia, Pharmaceuticals

Leave a Comment (9) ↓

9 thoughts on “Feet of Clay

  1. Mrs. N. says:

    There is negative evidence (i.e. did worse than placebo)? Drinking cranberry juice was part of a regimen I tried to stop frequent UTIs. Obviously, I’d like to know if it were the other things that caused the cessation so I don’t neglect them!

  2. DKlein says:

    My husband would be surprised about the lack of evidence, as well. His urologists have recommended cranberry juice and/or capsules for years. He purchases a straight cranberry juice that costs $4/bottle 2 x wk. His mother’s MD even ordered daily cranberry juice when she was admitted to a stroke rehab as she gets frequent UTIs. Their idea of cranberry juice is Ocean Spray cocktail so we’re bringing the expensive stuff when we visit. The recommendations noted in NJEM will most certainly end up in Natural News and publications like it. Sigh.

  3. annappaa says:

    I had fun researching the evidence for cranberry products when I wrote this piece for Planned Parenthood Advocates of Arizona‘s blog. It seems that there might be some plausibility behind the claims, but so far the evidence just doesn’t support it. Now, it’s true that drinking cranberry juice won’t do any harm … unless, of course, you’re receiving your advice from one of those sadists who thinks that you must suffer for your health, in which case they recommend unsweetened, 100% cranberry juice rather than a nice pleasant cranberry juice cocktail.

    I’m really curious about the claim that one must void after intercourse to avoid UTIs. I’ve never found confirmation for this oft-repeated women’s health advice. Of course the vagina and urethra are two separate openings, but I’ve also heard people say that the friction can push cells into the urethra anyway. Does anyone here know about evidence for the efficacy (or lack thereof) in urination after vaginal intercourse in preventing UTIs?

  4. Mark Crislip says:

    I have to confess that I have never looked into the original literature re: mechanical issues for the prevention of UTI, and have repeated the advice for 30 years. The advice probably predates the antibiotic era, given the antiquity of the UTI. The one exception is sex leading to UTI, and there I like to sneer at the outdated concept of honeymoon cystitis, as if sex starts at the honeymoon. Of which there are only 6 hits on pubmed. Whether fiction, due to friction or exposure to new E. coli strains is not known.

  5. Alia says:

    I used to have a lot of problems with UTIs when I was a kid. And then it went away, when my doctor decided to try a rather non-standard drug for it. It hasn’t returned in the last 15 years, during which time I happened to get married, so honeymoon cystitis does not seem a valid concept to me. The only thing I do to protect my urinary tract is drinking a lot of water but I suppose it’s really one of the basics.

  6. Calli Arcale says:

    Mark — I know that I was getting plenty of UTIs before I got married and became “active”. Mechanical prevention strategies (voiding after intercourse, wiping front to back) *seemed* to help. But I did not collect data systematically. Complete voiding is probably the most important one; I have a urinary diverticulum which makes this difficult, and is believed to be why I have recurrent cystitis. On average, I get 1-3 infections a year; not quite enough to justify routine antibiotics, for which I am grateful.

    In the excerpt of the NEJM article, I, a patient, have to wonder why the first step contemplated for this patient seems to be taking cranberry supplements. Why not first make sure they actually killed the damn bug? After my last pregnancy, I got several bouts of cystitis, treated with sulfa because I was breastfeeding and that’s considered a relatively safe one for nursing moms. The last time, it didn’t make a dent, and so they sent a specimen in for culture, had me wean the baby (she was losing interest in the breast anyway, so it was timely), and put me on ciprofloxacin. Sure enough, culture came back that the specimen was resistant to sulfa — I’d bred me some sulfa-resistant e. coli. Maybe this lady’s system has managed to breed sulfa-resistant bacteria, and the right thing to do would be to culture it, find out it’s weaknesses, and really hit it hard to kill it all off. Is she finishing her antibiotic courses, or stopping as soon as she feels better? Did they verify she actually had a bacterial infection each time, or just treat based on symptoms?

    One more thought regarding voiding after intercourse . . . this is gonna sound grody. Fair warning. When I do this, I notice that it is more difficult to get the stream started, with a sensation not unlike trying to blow a really stuffed up nose. I find it pretty plausible that stuff does get pushed up there. It should be fairly straightforward to study; the only difficulty would be recruiting test subjects. ;-)

  7. Calli Arcale says:

    I reread the excerpt. So, this hypothetical woman got a three-day course of sulfa a month ago and has UTI symptoms again . . . if both UTIs were confirmed by tests, then the first suspect has to be that the last infection wasn’t really killed off by that pretty wimpy treatment.

    Another thought: if the UTI diagnoses are based on symptoms alone, we have another confounder that I think may be responsible for a lot of the anecdotal reports of alt med working for UTIs: it is not that unusual for some women to experience burning during urination during certain portions of the menstrual cycle. It must also be considered that this may not be an infection at all. “A 30-year-old woman calls you to report a 2-day history of worsening dysuria and urinary urgency and frequency. She reports having no fever, chills, back pain, or vaginal irritation or discharge.” I used to get that too, but annoyingly, the UA would be negative. And then I’d get my period, and the symptoms would disappear. My doctor put me on hormonal birth control, and I haven’t had it since. (Just the actual UTIs.)

  8. Alia says:

    Well, for me things like urinary urgency and frequency are usually just a sign of high stress level, not of UTI. So if I get it, I analyse what is going on around me and usually find a reason.

  9. Quill says:

    Dr Crislip writes:

    “I am also not a fan of ideological purity, a foolish consistency being the hobgoblin of little minds, adored by little statesmen and philosophers and science bloggers.”

    and

    “For those of you not in medicine, the word of the NEJM is close to that of god. In clinical medicine, there is the NEJM then everyone else.”

    Well, there you go. You’ve been hoping in a foolish consistency at NEJM, that they would always publish science-based articles while simultaneously reporting its words are regarded in much the same way as the utterances of an invisible being standing apart from everything else. How can expectations of scientific consistency be reconciled with analogous notions of belief in an exceptional being and the revelations from it? ;-)

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