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Yes, But. The Annotated Atlantic.

Reposted on 11/8 with multiple typo corrections.

The Atlantic recently published an article called “Does the Vaccine Matter?.” The quick answer is “yes”. If you want to know more, keep reading. They concluded, based on a narrow interpretation of a small subset of the data, that vaccines probably do not matter. The tone suggests that the vaccine is a vast boondoggle perpetuated on the American people by frightened doctors and greedy pharmaceutical companies. At least that is my take on the article, your mileage may vary. Lets look at that article, and its review of the influenza vaccine, and see whatthe authors  say, how they say it, and, perhaps more importantly, what they don’t say.

Unfortunately, I do not have a good story to tell with protagonists and antagonists and lone voices protesting the evil medical industrial complex. I don’t have a morality tale to tell, with good guys and bad guys. I have the medical literature, with its numbers and uncertainties and nuance. I also have patients I have to treat and have to apply the medical literature to as best I can.
This entry may be a bit of a repetition for those who read my previous entry on vaccine efficacy, but my entry hit the blogosphere a few days before the Atlantic article, so I did not get a chance to incorporate it into my entry. (more…)

Posted in: Science and the Media, Vaccines

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What’s the right C-section rate? Higher than you think.

Editor’s Note: Dr. Mark Crislip has been kidnapped by anti-vaccinationists. Fortunately, we have sent our black Illuminati, pharma-funded, vaccine-wielding helicopters to rescue him, but unfortunately, as a result of his trauma, his usual Friday post is likely to be delayed either until this afternoon or Saturday. In any case, fortunately for us our latest addition to the SBM crew, Dr. Tuteur, was willing to fill in on short notice; so here she is. Dr. Crislip will post by tomorrow. To whet your appetite for his patented sarcasm, let me just say that he will be having a little fun with a certain article from The Atlantic about flu vaccines. There, now doesn’t that make you want to check back tomorrow to find out what his take is on the article? I thought it would.

Buried in the midst of it new report, Monitoring emergency obstetric care; a handbook, the World Health Organization acknowledges what obstetricians have been saying for some time. The WHO’s goal of a 10-15% C-section rate lacks any empirical basis.

Earlier editions of this handbook set a minimum (5%) and a maximum (15%) acceptable level for caesarean section. Although WHO has recommended since 1985 that the rate not exceed 10–15%, there is no empirical evidence for an optimum percentage or range of percentages …

Of course, they’re not going to give up their recommendation simply because there is no science that supports it, insisting that “a growing body of research that shows a negative effect of high rates.”

Dr. Marsden Wagner, former head of the Perinatal Division of the WHO, appears to be responsible for the purported optimal C-section rate of 10-15%, the level at which both maternal and neonatal mortality rates are supposedly the lowest. Ironically, Dr. Wagner is a co-author of a recent study that actually demonstrates the opposite.
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Posted in: Obstetrics & gynecology, Science and Medicine

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The Tragic Death Toll of Homebirth

More than 10,000 American women each year choose planned homebirth with a homebirth midwife in the mistaken belief that it is a safe choice. In fact, homebirth with a homebirth midwife is the most dangerous form of planned birth in the US.

In 2003 the US standard birth certificate form was revised to include place of birth and attendant at birth. In both the 2003 and 2004 Linked Birth Infant Death Statistics, mention was made of this data, but it was not included in the reports. Now the CDC has made the entire dataset available for review and the statistics for homebirth are quite remarkable. Homebirth increases the risk of neonatal death to double or triple the neonatal death rate at hospital birth.

As this chart shows, the neonatal mortality rate for DEM (direct entry midwife, another name for homebirth midwife) assisted homebirth is almost double the neonatal mortality rate for hospital birth with an MD. This is all the more remarkable when you consider that the hospital group contains women of all risk levels, with all possible pregnancy complications, and all pre-existing medical conditions. An even better comparison would be with the neonatal mortality rates for CNM assisted hospital birth. The risk profile of CNM hospital patients is slightly higher than that of DEM patients, but CNMs do not care for high risk patients. Compared to CNM assisted hospital birth, DEM assisted homebirth has TRIPLE the neonatal mortality rate.
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Posted in: Obstetrics & gynecology

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The Skeptical O.B. joins the Science-Based Medicine crew

I’m very pleased to announce that Dr. Amy Tuteur, otherwise known as The Skeptical O.B., has joined Science-Based Medicine. Dr. Tuteur will fill in an area where we are lacking, namely an expert in women’s health and childbirth. For those of you who don’t know Dr. Tuteur, she is an obstetrician-gynecologist. She received her undergraduate degree from Harvard College and her medical degree from Boston University School of Medicine. Dr. Tuteur is a former clinical instructor at Harvard Medical School. Her book, How Your Baby Is Born, an illustrated guide to pregnancy, labor and delivery was published by Ziff-Davis Press in 1994. She runs the website AskDrAmy.com and has her own iPhone app, the Ask Dr. Amy Am I Pregnant Quiz. Dr. Tuteur blogs at The Skeptical OB.

We expect great things from Dr. Tuteur, and hope you will join us in welcoming her to the fold. She will begin tomorrow and will post new material every Thursday. Finally, with the addition of Dr. Tuteur, it should also be noted that, due to the demands of her day job, Dr. Val Jones will decrease her posting frequency from every Thursday to every other Thursday. She will thus not be posting this week, and her next post will be on Thursday, November 12.

Posted in: Science and Medicine

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It’s All in Your Head

I have never used those words to a patient or about a patient.  I have also never heard a colleague use any similar term to a patient. And yet on many occasions I have had patients ask me, “So you’re telling me it’s all in my head?”

The concept of what are now called psychogenic symptoms is a tricky one for various reasons. There is an unfortunate stigma attached to the notion that our brains can cause physical symptoms. Making the diagnosis is complex. Outcomes are variable and are hampered by the difficulty in communicating the diagnosis to patients. Psychogenic symptoms often mask underlying physiological disease. And the risks of both false positives and false negatives are high.

This complexity leads some to argue, in essence, that psychogenic symptoms do not exist at all – that the diagnosis is a cop out, a way to blame the patient for the failings of the physician. But this approach, ironically, is a cop out, because it seeks to white wash what is a real and complex disorder with an overly simplistic and moralistic approach.

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Posted in: Neuroscience/Mental Health

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When Loud Wins: Will Your Tax Dollars Pay For Prayer?

Today the LA Times described a bizarre and troublesome healthcare reform bill provision that would require Medicare to pay for Christian Science Prayer as a medical treatment:

…a little-noticed provision in the healthcare overhaul bill would require insurers to consider covering Christian Science prayer treatments as medical expenses.

The provision was inserted by Sen. Orrin G. Hatch (R-Utah) with the support of Democratic Sens. John F. Kerry and the late Edward M. Kennedy, both of Massachusetts, home to the headquarters of the Church of Christ, Scientist.

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Posted in: Faith Healing & Spirituality, Politics and Regulation, Science and the Media

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All Medicines Are Poison!

That’s the title of a new book  by Melvin H. Kirschner, M.D. When I first saw the title, I expected a polemic against conventional medicine. The first line of the Preface reassured me: “Everything we do has a risk-benefit ratio.” Dr. Kirschner took the title from his first pharmacology lecture in medical school. The professor said “I am here to teach you how to poison people.” After a pause, he added, “without killing them, of course.” 

He meant that any medicine that has effects has side effects, that the poison is in the dose, and that we must weigh the benefits of any treatment against the risks. Dr. Kirschner has no beef with scientific medicine. He does have a lot of other beefs, mainly with the health insurance industry, the pharmaceutical industry, and alternative medicine. (more…)

Posted in: Book & movie reviews, Pharmaceuticals

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The cancer screening kerfuffle erupts again: “Rethinking” screening for breast and prostate cancer

I see that the kerfuffle over screening for cancer has erupted again to the point where it’s found its way out of the rarified air of specialty journals to general medical journals and hence into the mainstream press.

Over the last couple of weeks, articles have appeared in newspapers such as the New York Times and Chicago Tribune, radio networks like NPR, and magazines such as TIME Magazine pointing out that a “rethinking” of routine screening for breast and prostate cancer is under way. The articles bear titles such as A Rethink On Prostate and Breast Cancer Screening, Cancer Society, in Shift, Has Concerns on Screenings, Cancers Can Vanish Without Treatment, but How?, Seniors face conflicting advice on cancer tests: Benefit-risk questions lead some to call for age cutoffs, and Rethinking the benefits of breast and prostate cancer screening. These articles were inspired by an editorial published in JAMA last month by Laura Esserman, Yiwey Shieh, and Ian Thompson entitled, appropriately enough, Rethinking Screening for Breast Cancer and Prostate Cancer. The article was a review and analysis of recent studies about the benefits of screening for breast and prostate cancer in asymptomatic populations and concluded that the benefits of large scale screening programs for breast cancer and prostate cancer tend to be oversold and that they come at a higher price than is usually acknowledged.

For regular readers of SBM, none of this should come as a major surprise, as I have been writing about just such issues for quite some time. Indeed, nearly a year and a half ago, I first wrote The early detection of cancer and improved survival: More complicated than most people think. and then followed it up with Early detection of cancer, part 2: Breast cancer and MRI. In these posts, I pointed out concepts such as lead time bias, length bias, and stage migration (a.k.a. the Will Rogers effect) that confound estimates of benefit due to screening. (Indeed, before you continue reading, I strongly suggest that you go back and read at least the first of the aforementioned two posts to review the concepts of lead time bias and length bias.) Several months later, I wrote an analysis of a fascinating study, entitling my post Do over one in five breast cancers detected by mammography alone really spontaneously regress? At the time, I was somewhat skeptical that the number of breast cancers detected by mammography that spontaneously regress was as high as 20%, but of late I’m becoming less skeptical that the number may be somewhere in that range. Even so, at the time I did not doubt that there likely is a proportion of breast cancers that do spontaneously regress and that that number is likely larger than I would have guessed before the study. Of course, the problem is that we do not currently have any way of figuring out which tumors detected by mammography will fall into the minority that do ultimately regress; so we are morally obligated to treat them all. My most recent foray into this topic was in July, when I analyzed another study that concluded that one in three breast cancers detected by screening are overdiagnosed and overtreated. That last post caused me the most angst, because women commented and wrote me asking me what to do, and I had to answer what I always answer: Follow the standard of care, which is yearly mammography over age 40. This data and these concerns have not yet altered that standard of care, and I am not going to change my practice or my general recommendations to women until a new consensus develops.
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Posted in: Cancer, Diagnostic tests & procedures, Public Health, Science and the Media

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When homeopaths attack medicine and physics

I must admit, it is possible that our fearless leader Steve has a more robust constitution than I do. I say this because he actually managed to sit through an entire video full of the most bizarre pseudoscience and mangling of physics and medicine that I’ve seen in quite some time.

And that’s saying a lot.

So, behold, Dr. Charlene Werner, an optometrist (apparently) and a homeopath. I warn you, however. If you have any understanding of physics or chemistry whatsoever or if you’ve ever read (and liked) Stephen Hawking’s book A Brief History of Time (or anything else he’s ever written), sit down now. Take a deep breath. Heck, crack open a bottle of wine and down at least half of it before you watch this video. I’m serious. You’ll need it. You might need to lie down, too. In fact, you might need to lie down with a cool washcloth across your eyes.

Don’t say I didn’t warn you:

Truly, the woo doth flow. Like a river. Like the energy from a supernova. From Bozeman, Montana, where, apparently they don’t have enough woo and have to import it from Texas. I haven’t seen such a massive pseudoscientific abuse of physics and chemistry in quite a long time.
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Posted in: Homeopathy, Humor

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J.B. Handley of the anti-vaccine group Generation Rescue: Misogynistic attacks on journalists who champion science

There’s been something I’ve been meaning to write about all week, but only just got around to it. There were lots of other things going on at my other online locale, and this topic is such old hat for so many that I really wasn’t sure if it was worth bothering with. My reluctance may also be, sadly, because I’ve become a bit jaded at the nastiness that anti-vaccine groups such as Generation Rescue (i.e., “Jenny McCarthy and Jim Carrey’s Autism Organization”–at least these days) and its erstwile founder J.B. Handley routinely lay down when someone points out that the emperor has no clothes, that vaccines do not cause autism. I’m referring, of course, to Amy Wallace, who wrote what is the best example of an article in the mainstream media about the anti-vaccine movement that “gets it.” The article was called An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All and appeared in WIRED Magazine.

It was a thing of beauty. There was no false “balance” that puts cranks pushing dangerous pseudoscience on the same plane as real scientists like Paul Offit. There was even a section calling out purveyors of vaccine misinformation. Several luminaries of the the anti-vaccine movement were there, including ones discussed frequently on this blog, like Jenny McCarthy and Jim Carrey, and Robert F. Kennedy, Jr. But that wasn’t all! There was even a section on how to debunk anti-vaccine canards. What more could an advocate of science-based medicine ask for?
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Posted in: Science and the Media, Vaccines

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