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HPV vaccination misinformation and bias in Medscape

Like many physicians, I often peruse Medscape. It’s generally been a convenient and quick way to catch up on what’s going on in my field not directly related to my research, for which I tend to rely on pre-configured RSS feeds for PubMed searches to highlight any articles related to my areas of interest. Since these searches routinely flag hundreds of articles a week whose titles and abstracts I end up perusing, sometimes only cursorily to identify the articles I might want to read, it is impractical for me to rely on this approach for areas that are even only a bit out of my field. That’s where, at least so I thought, services like Medscape came in handy. I could look over stories and quickly find out about research and medical of interest to me, only occasionally needing to look up the actual journal articles. Like a fair number of physicians, I rely on it fairly regularly. I should also point out that Medscape sometimes even tries to go against the tide of woo, as it did when it published an article by authored by two of my co-bloggers, along with two others. The article, authored by Kimball C. Atwood IV, MD; Elizabeth Woeckner, AB, MA; Robert S. Baratz, MD, DDS, PhD; and Wallace I. Sampson, MD, entitled Why the NIH Trial to Assess Chelation Therapy (TACT) Should Be Abandoned, was a tour de force deconstruction of why TACT is bad science and unethical to boot.

So how to explain an article published in Medscape last week and authored by Alison Gandey entitled HPV Vaccine Adverse Events Worrisome Says Key Investigator?
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Posted in: Politics and Regulation, Public Health, Science and the Media, Vaccines

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Science, Reason, Ethics, and Modern Medicine, Part 4: is “CAM” the only Alternative? And: the Physician as Expert Consultant

Dr. Moran Weighs In

In last week’s post, I dubbed Dr. Peter Moran the “conscience” of SBM, citing his commitment to doing what’s best for individual patients even if, in theory at least, that may involve some manner of benign but fanciful treatments. I countered with my own opinion that honesty and integrity are necessary parts of any discussion with a patient, and that they, in turn, must not conflict with science and reason.* I added passages from a couple of key medical ethics treatises to support my assertion. Dr. Moran’s response, thoughtful and provocative as always, was buried in the midst of other commenters’ tangential arguments about the theory of evolution. Rather than continue its exile there, I reprint it here to give it the exposure that it deserves:

A blatant appeal to authority, but one that I mostly agree with. The difference between us is that I insist that medicine is about an infinite number of individual contexts and I see many examples where ethical absolutes (actually these are ethical guidelines rather than directives) do not apply or don’t seem to apply very well.

We scientists are ever-so cautious when making scientific judgments about complex matters; let’s not pretend that arriving at absolutes in medical ethics is a piece of cake, especially when it is not quite clear how anything done with the undiluted welfare of the individual patient in mind can be entirely unethical. I mean, why are we obliged to consider the impact of our decisions upon the fate of the planets (or whatever) when THIS patient needs help? In fact, at least one medical ethicist has gone so far as to state that it is not unethical for a doctor to prescribe a placebo treatment, so long as the doctor believes it will benefit the patient. I don’t quite agree with that bald statement — there should be a rider specifying that this may apply to *some* contexts where there is no obviously superior evidence-based method.

Here are some examples of the intellectual minefield we have to negotiate.

1. All the doctors I know would be prepared to call in the witch-doctor if it would help assuage the fears, or help in the management, of a seriously ill primitive tribesman. It seems we are prepared to pander to the superstitions of SOME cultures while despising any similar inclinations in our own.

2. I have previously asked this question which has to do with public policy in relation to safe “alternatives”. Take my word for it that every pharmacy in Europe displays “Homeopathie” (or language equivalents) in large letters outside. Would skeptics prefer those using such remedies for their minor and self-limiting complaints to be using NSAIDs or antibiotics or antidepressants instead, treatments that will often in such contexts themselves perform no better than placebo, but at substantially greater risks? Behind the usual healthfraud position there is both an exaggeration of the capacity of modern medicine and insufficient recognition of the harm that it can do. We definitely do not yet have entirely safe and 100% effective solutions to all of mankind’s ills, and certain imperfections of everyday medical practice can heighten the risks of the use of unnecessarily powerful pharmaceuticals. So what is the safest and most pragmatically realistic position here?

3. Following on from that — what is the evidence-based answer to non-specific tiredness and unhappiness? If people feel better for taking a multivitamin or an innocuous herb, why should we care? We keep on offering the public temporary answers to these things, prescribing (historically) amphetamines, cocaine, opiates, barbiturates and phenothiazines in massive quantities, only to take them away when problems such as addiction ensue. Is it right to then turn around and say, well you didn’t really need these things anyway, even denying them any relief that they may derive from “pretend medicines”. The science that matters will be argued out in other arenas.

That’s to give you some idea of the kind of thing that I am on about. You seem to think I am talking about doctors promoting CAM or placebo treatment as a matter of policy. I am not prepared to go that far, although I think I understand why some doctors might do that.

I agree that “medicine is about an infinite number of individual contexts and [there are] many examples where ethical absolutes do not apply or don’t seem to apply very well.” Nor did I really think that Dr. Moran was “talking about doctors promoting ‘CAM’ or placebo treatments as a matter of policy.” We disagree elsewhere, but he makes some interesting points.

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

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HIV Treatment Extends Life Expectancy

ResearchBlogging.org

People with HIV are living longer on the latest anti-retroviral therapy. This is something any infectious disease specialist knows from their own clinical experience – but it’s reassuring (I would even argue necessary) to have objective data to support experience. A study published in the latest issue of Lancet provides this objective data. (Lancet. 2008 Jul 26;372(9635):293-9.)

The press release from Bristol University, academic home of the lead author, says:

Professor Jonathan Sterne of Bristol University’s Department of Social Medicine and Professor Robert Hogg of British Columbia Centre for Excellence in HIV/AIDS and Simon Fraser University, Vancouver, Canada and colleagues from The Antiretroviral Therapy Cohort Collaboration (ART-CC) compared changes in mortality and life expectancy among HIV-positive individuals on cART.

This collaboration of 14 studies in Europe and North America analysed 18,587, 13,914, and 10,584 patients who started cART in 1996-99, 2000-02, and 2003-05 respectively.

A total of 2,056 patients died during the study period, with mortality decreasing from 16.3 deaths per 1000 person-years to in 1996-99 to 10.0 in 2003-05 – a drop of around 40 per cent.

Potential life years lost per 1000 person-years also decreased over the same time, from 366 to 189 — a fall of 48 per cent. Life expectancy increased from 36.1 years in 1996-99 to 49.4 years in 2003-05, an increase of more than 13 years.

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Posted in: Clinical Trials, Public Health

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An Herbal Cure for Peanut Allergy?

Peanut allergy is uncommon but devastating. Even a tiny trace of peanut can cause an anaphylactic reaction and death. That’s why labels specify “produced on shared equipment with nuts or peanuts” or “produced in a facility that also processes nuts.” There is no effective treatment: patients have to rely on avoiding peanuts and carrying emergency epinephrine injectors. Parents of peanut-allergic children live in fear that their child will be inadvertently exposed at school or at a friend’s house. Wouldn’t it be great if we could fix it so they could eat peanuts with impunity?

There is a ray of hope. Studies are underway on a Chinese herbal medicine (FAHF-2) that shows promise. I generally shy away from Chinese herbal remedies, because they are marketed without adequate testing and the products are not quality controlled. The typical course of events is (1) a preliminary study or a history of use in China, (2) marketing in the U.S. with overblown claims.

This is different. (more…)

Posted in: Herbs & Supplements

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Cell phones and cancer again, or: Oh, no! My cell phone’s going to give me cancer!

Before I start into the meat of this post, I feel the need to emphasize, as strongly as I can, four things:

  1. I do not receive any funding from the telecommunications industry in general, or wireless phone companies in particular. None at all. In other words, I’m not in the pocket of “big mobile” any more than I am in the pocket of big pharma.
  2. I don’t own any stock in telecommunications companies, other than as parts of mutual funds in which my retirement funds are invested that purchase shares in many, many different companies, some of which may or may not be telecommunications companies. (I should probably go and look at the list.)
  3. None of my friends or family work for cell phone companies.
  4. I don’t have a dog in this hunt. I really don’t.

I say this because these are the most common accusations I hear whenever I venture into this particular topic area, and I thought I’d just clear that up right away in order (hopefully) to preempt any similar comments after this post. Indeed, one of the favorite retorts to anyone who criticizes fearmongering about cell phones is to try to insinuate that that person is only doing so because he or she is in the pocket of industry, and I’ve been at the receiving end of such claims. Unfortunately, I’m sure someone will probably show his or her lack of reading comprehension and post one of those very criticisms of me. It’s almost inevitable. Even though posting such disclaimers never works against the “pharma shill” gambit when I write about vaccines or dubious cancer cures, nonetheless hope springs eternal.

Now that that obligatory unpleasantness is out of the way, let me move on to say that I’m very puzzled about something that happened last week.

I know that being puzzled isn’t particularly unusual for me. Indeed, I’m frequently puzzled about a great many things. I can’t figure out how, for example, anyone with the slightest bit of reason or critical thinking ability can believe that homeopathy is anything other than water treated with, in essence, magical spells accompanied by shaking or do anything other than laugh when informed what homeopathy really is and how it supposedly “works.” I can’t figure out how anyone can look at the mass of interlocking evidence from multiple different scientific specialties supporting evolution and reject still reject one of the most powerful scientific theories ever to spring from the human mind, deciding instead that creationism or its bastard offspring, “intelligent design” creationism is anything more than pure religion or rank religion-inspired pseudoscience. I can’t figure out why American Idol or Survivor is so amazingly popular.

And I can’t figure out why on earth the University of Pittsburgh Cancer Center released this warning about cell phones last week:

PITTSBURGH July 24, 2008, 07:13 am ET · The head of a prominent cancer research institute issued an unprecedented warning to his faculty and staff Wednesday: Limit cell phone use because of the possible risk of cancer.

The warning from Dr. Ronald B. Herberman, director of the University of Pittsburgh Cancer Institute, is contrary to numerous studies that don’t find a link between cancer and cell phone use, and a public lack of worry by the U.S. Food and Drug Administration.

Herberman is basing his alarm on early unpublished data. He says it takes too long to get answers from science and he believes people should take action now — especially when it comes to children.

“Really at the heart of my concern is that we shouldn’t wait for a definitive study to come out, but err on the side of being safe rather than sorry later,” Herberman said.

Dr. Herberman is a highly respected cancer center director whom I’ve in general thought well of, and the University of Pittsburgh Cancer Institute is a highly respected cancer center. I know a few people there, and in the past I’ve worked closely with two surgeons who trained there. One in particular remains my collaborator, even though I’ve moved on from the institution where we were once partners.

That’s why I can’t help but wonder just what on earth Dr. Herberman was smoking when he decided to issue this warning, given my general respect for the University of Pittsburgh to the point where I once even tried to land a faculty position there. His announcement strikes me as being rash in the extreme, especially given that its text even admits outright that the published data at present do not appear to support a link between cell phone use and brain tumors. Consequently, I conclude that this is alarmism that, I suspect, even a prominent blogger known to be somewhat receptive to the claim that cell phones cause brain tumors (Revere) would have a hard time supporting, because it goes far beyond the published evidence and is based on “early unpublished data.” Scaring the nation based on “early unpublished data” that can’t be examined by the entire medical and scientific community is generally not a good idea. That’s why I’ve been asking over the last few days: Why on earth did Dr. Herberman do it?
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Posted in: Cancer, Public Health, Science and Medicine, Science and the Media

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Science, Reason, Ethics, and Modern Medicine, Part 3: Implausible Claims and Formal Ethics Statements

The Ethics of Implausible Medical Claims (IMC)

In Part 2 of this series* we learned from David Katz, MD, a key member of the Yale School of Medicine’s “integrative medicine” program, that he had been “pushed toward integrative medicine by the needs of [his] patients.” We also learned that Dr. Katz’s rationale for this decision justifies a wide range of quackery—both in principle and in fact. I had previously alluded to arguments like those of Dr. Katz in a comment on SBM several months ago:

…we must be true to medical ethics, no matter what else we do. If that means losing a few patients, so be it. Patients are free agents, and we can only do so much to influence them. To the extent that we don’t do that as well as we might (which is obviously true in some cases), we might do better. But our ethical obligation is to science and truth; it is not, as many modern physicians would have it and as much as we may lament sometimes losing patients to woo, to seducing patients to stick with us no matter what, if the “what” includes engaging in a charade about “integration” or “complementary therapies”…

Realizing that some might argue that physicians’ obligations to patients ought to trump their obligations to “science and truth,” I later revised that statement:

Several weeks ago I argued here that a physician’s primary ethical obligation is to science and truth. In retrospect I probably should have put it a slightly different way: a physician’s primary ethical obligation is the same as everyone else’s. It is to honesty and integrity. For physicians, however, that means being true to real medical knowledge, among other things, and real medical knowledge comes from science.

In spite of that revision, two readers whose opinions I respect challenged my assertion. Dr. Peter Moran’s worthy efforts to educate patients about the realities of “alternative” cancer treatments are considerable. Here on SBM he has repeatedly challenged us to explain how, when confronted with testimonials of “alternative” cures, we ought to respond without using “a high-handed, ‘we know best’ stance” and thus “appear to want to distance [ourselves] from the intimate concerns of [our] patients.” I was thinking mainly of him when I wrote the revision above, because on this key topic—how to respond ethically, but with compassion, to patients who want to believe in implausible treatments—I’ve come to think of Dr. Moran as the “conscience” of Science-Based Medicine. Those with cancer, he has reminded us, “are folk very like you and me who are simply grasping at any straw that might save or prolong their lives.” His take on why IMCs are appealing to those with less ominous problems is well-developed and agrees with my own, mostly. We part ways, however, when he concludes (also here and here) that ethical physicians might have good reasons—unlike Dr. Katz’s—to entertain benign, if implausible treatments:

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

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Parody beats political analysis

When out of town this past week I was bereft of tantalizing subjects, with our 5 other bloggers covering so many topics so well. I was about to toss in an empty towel, when two news absurdities fell into my driveway in the pages of the SF Chronicle. One was this morning’s (7/23) report that one Dragan Dabic, an alternative medicine healer had been captured in Belgrade, Serbia. He was Radovan Karadzic, former Serbian Prime Minister and acknowledged immediate archtect of the 1990s massacres of Bosnia-Herzagovena Muslims. Like Saddam Hussein, he had been a fugitive for years, and was found in an unusual place in an unusual disguise. What more need be said about this former psychiatrist and presumed war crimes mass murderer changing occupations in midlife to alternative healing? Complete with full beard and pony tail, yet. Does this give some clue to some personality types that drift toward junk medicine? One could say the disguise was intentional and had nothing to do with personality. Perhaps. Perhaps. But the situation reinforces my theory that most “CAM”mers are at least intellectual psychopaths – renegades from reason. The picture of Karadzic brings to mind pictures of others with full beards and hidden finger salutes to reason and authority.

The second absurdity was in a recent cartoon subtitled, “The lies behind the truth and the truth behind those lies that lie behind that truth…” So reads the title explanation for Don Asmussen’s “Bad Reporter” comic in the SF Chronicle.

Asmussen parodies headlines by combining them absurdly with commentaries that “explain” the absurd headlines with even more absurd hypothetical events. In these days of absurd happenings, I find Asmussen the right stuff remedy for us perplexed realists who “…cannot believe this is happening.” My mental health now depends on Asmussen and nighttime doses of Phil Hendrie Show. Nothing like satire to put into perspective interest in “alternative medicine” and qualifications and characteristics of presidential candidates.

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Posted in: Nutrition, Politics and Regulation, Science and the Media

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Autism and Vaccines: Responding to Poling and Kirby

In response to my NeuroLogica blog post on Monday, David Kirby wrote a response in the Huffington Post and Dr. Jon Poling (father of Hannah Poling) wrote an open letter to me, placed in the comment section and posted at Age of Autism. It seems only polite that I respond to their kind attention.The primary focus of my original post (which I further developed yesterday) was that the media is focusing too much attention on what celebrities and politicians are saying about the controversy surrounding the discredited notion that vaccines are a significant cause of autism. Over the past year Jenny McCarthy (now joined by her boyfriend Jim Carrey) has become the major spokesperson for a movement that, at its core, is anti-vaccine and is dedicated to the scientific opinion that vaccines are toxic and cause autism. Recently actress Amanda Peet joined the fray, professing her belief that vaccines are safe, are not associated with autism, and that parents who do not vaccinate their children are “parasites” for depending on other parents who do. (She later apologized for that remark, calling it “divisive”.)

While I appreciate Amanda Peet’s support, I feel strongly that scientific questions should be handled by the scientific community. Celebrities are great when they support causes – but when they second guess the scientific community and decide to advocate for their own scientific conclusions, they are more likely to cause harm than good. (more…)

Posted in: Neuroscience/Mental Health, Public Health, Vaccines

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Can Psychosis be Prevented?

I recently read an article in Discover magazine entitled “Stop the Madness.” It was about a new treatment program that allegedly can prevent schizophrenia and other forms of psychosis. I found it very disturbing.

The PIER (Portland Identification and Early Referral) program was founded by a psychiatrist, Dr. William McFarlane, in Portland, Maine. It has recently expanded to 4 other US sites and there are similar programs in several other countries. PIER is an effort to find and treat patients in the “early stages of deterioration towards psychosis,” so as to prevent the development of psychotic illnesses like schizophrenia, bipolar disorder, and major depression. The program involves various psychosocial interventions and psychotropic drugs.

On the surface it sounds promising, but there is a dark side. I’m particularly concerned about the use of antipsychotic drugs in people who haven’t been diagnosed as psychotic. (more…)

Posted in: Neuroscience/Mental Health, Pharmaceuticals, Science and Medicine

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Resistance is futile? Hell, no! (A call to arms)

Well, I won’t back down
No, I won’t back down
You can stand me up at the gates of hell
But I won’t back down

Gonna stand my ground
Won’t be turned around
And I’ll keep this world from draggin’ me down
Gonna stand my ground
And I won’t back down

From “I Won’t Back Down” by Tom Petty, 1989

This week, in a little bit of a departure, I have a minor bone to pick with our fearless leader and his podcast partner in crime Rebecca Watson (a.k.a. the Skepchick), who both managed to annoy me a bit the other day. (Don’t worry, Steve and Rebecca, I still love you guys…)

I’ll explain. You see, I had originally had a much different topic in mind for this week. Indeed, I even had my post mostly written by Saturday morning, when I had to take care of some mundane personal business, namely getting an oil change and some minor work done on my car. Since I need my car to commute to work and the maintenance needed was relatively minor, I decided to wait for the work to be done. As is my wont when sitting in waiting rooms with nothing much else to do, I decided to plug my earphones into my iPhone and catch up on some podcasts. Since the dealer also had free wifi, I brought my laptop along as well, the better to finish up my originally intended post.

The first thing I realized as I perused the list of unlistened-to podcasts was that I had fallen far behind in listening to one of my favorite podcasts, The Skeptics’ Guide to the Universe. To begin catching up, I decided to start with what was at the time the most recently available episode, specifically the July 9 podcast, figuring I could work my way back to through the earlier ones and thereby catch up with at least two episodes before my car was ready. In the second segment (beginning around 14:31 minutes into the podcast), Steve Novella and crew discussed a bit the recent news that the National Institute of Mental Health was trying to resurrect a dubious and highly unethical clinical trial proposed to test chelation therapy as a treatment for autism, referencing his excellent post on this very blog about why the trial is scientifically dubious (at best) and totally unethical. So far, so good.

Then the conversation veered into another area that I agree with, namely the utter uselessness of National Center for Complementary and Alternative Medicine (NCCAM) and how its main purpose is more proselytization for “alternative” and “complementary” medicine than actual rigorous scientific research, as I pointed out before in one of my earliest posts for SBM. As Steve pointed out that, for all the hundreds of millions of dollars spent by NCCAM, not a single new medicine or treatment has been added to the armamentarium of modern medicine, nor, even more importantly, have CAM practitioners abandoned a single bit of unscientific medicine due to any of the negative studies. Indeed, their enthusiasm hasn’t been dampened in the least. This line of discussion led to the question of whether we, as skeptics and advocates of science- and evidence-based medicine need to rethink and refocus our efforts.
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Posted in: Medical Academia, Politics and Regulation, Science and Medicine, Science and the Media

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