It’s that time of year when every day I can expect to see at least one patient with a concern about Lyme disease. In Lyme-endemic regions such as Western Massachusetts, where I practice pediatrics, summer brings a steady stream of children to my office with either the classic Lyme rash (erythema chronicum migrans, or ECM), an embedded tick, a history of a tick bite, or non-specific signs or symptoms that may or may not be due to Lyme disease. Sometimes the diagnosis is relatively straightforward. A child is brought in after a parent has pulled off an engorged deer tick, and there is a classic, enlarging ECM rash at the site of the bite. More often the presentation is less clear, requiring detective work and science-based reasoning to make an informed decision and a diagnostic and therapeutic plan based on the best available evidence. Depending on the story, the plan may include immediate treatment without any testing (as in the straightforward case described above), immediate testing without treatment pending test results, or waiting as we watch and see how a rash progresses before doing anything. An example of this latter course of action would be when a patient comes in with a pink swelling at the site of a new tick bite. In this case, it may not be clear if the swelling is a Lyme rash or simply a local reaction to the bite, a much more common occurrence. The classic ECM rash (an enlarging, red, circular, bull’s-eye rash at or near a tick bite) typically develops 1-2 weeks after a tick bite, but can occur anywhere from 3-30 days later. It then expands and darkens over another 1-3 weeks before fading. This classic rash is not the most common rash of Lyme disease, however, as it occurs in only about 30% of cases. Instead, the rash may be uniformly pink or red (or even darker in the center) without the target-like appearance, or may be a linear rash, expanding outward from the tick bite site. In the case of a patient who comes in with a vague, pink swelling within a day few days of a tick bite, we will typically wait and see what happens to the rash. If it is a local reaction, it will likely resolve within another few days. With Lyme disease, the rash will continue to enlarge and declare itself as an ECM rash. Another unclear and not uncommon situation is when a patient comes in with non-specific symptoms such as fatigue, musculoskeletal pains, and headache. If warranted by the history and the physical exam, we may in this case order Lyme testing. This may not give us an answer even if the patient has Lyme disease, because results are often negative in the first few weeks of the disease. In this case, if symptoms persist or evolve, we will repeat the testing in another few weeks at which point true Lyme disease will test positive and can then be treated. The good news is that the treatment of Lyme disease, particularly in the early, localized phase of the disease, is extremely safe and effective with a 14-day course of antibiotics. The testing is also relatively straightforward, with very good sensitivity and specificity when performed correctly. And this is where the bad news comes… (more…)
Posts Tagged CAM
I know by now I shouldn’t be, but I am still amazed by how readily so many people buy into the seemingly endless array of bogus sCAM nostrums. Many are marketed and hawked for the treatment or prevention of diseases that are poorly managed by science-based medicine. There are countless examples of dietary supplements that are purported to effectively treat back and joint pains, depression, anxiety, autism, chronic pain, and chronic fatigue; the list goes on and on. The lure for these treatments is at least understandable and, although frustrated that scientific literacy and rational thought loses out, I empathize with the desire to believe in them. On the other end of the spectrum is the even more ethically corrupt substitution of safe and effective treatments with products that are not. I encountered what I find to be possibly the most frightening and dangerous example of this recently at my practice. A family new to the area called to schedule a routine health-maintenance visit for their 5-year-old daughter. When our nurse reviewed the medical records the mother had faxed over, she noted that the child was unimmunized and explained to her that she would need to begin catch-up vaccinations. The mother matter-of-factly stated that her daughter was actually fully vaccinated with a vaccine alternative. She had received a series of homeopathic vaccines from a naturopath. I am not going to discuss this egregious example of sCAM here, though it was addressed in previous SBM posts.1,2 Instead I’d like to focus on another part of the sCAM spectrum. Here lies a form of sCAM that, in some ways, is even more difficult for me to comprehend. These are products invented, marketed, and sold solely for the treatment or prevention of fictitious diseases or problems that exist only in the realm of fantasy. (more…)
Imagine a retail pharmacy where some of the medicines on the shelves have been replaced with similar-looking packages that contain no active ingredients at all. There is no easy way to distinguish between the real and the fake.
Another section of the store offers a number of remedies with fantastic claims, such as “boosting” the immune system, “detoxifying” the body, or “cleansing” you of microscopic Candida. They look sciencey, unless you realize that they treat imaginary medical conditions.
A corner of the store offers unpurified drugs supplied as tinctures and teas. The active ingredients aren’t known, and the batch-to-batch consistency of the product is unclear. The store will suggest products for you based on your symptoms.
Walk past the enormous wall of vitamins and other supplements and you’ll find a nutritionist who will tell you what products you should be taking. You’ll also find a weight loss section. From a science-based perspective, this shouldn’t even exist, given no product has been shown to offer any meaningful benefit. But there are dozens of products for sale.
At the back of the store you’ll finally find the pharmacist. A sign on the counter offers blood- and saliva-based tests for food “intolerance” and adrenal “fatigue”, claiming to test for medical conditions that actually don’t exist or lack an evidence base. The pharmacy also offers a large compounding practice, advertising what it calls “personalized” approaches to hormone replacement with “bioidentical” hormones.
Welcome to the “integrative” pharmacy.
You may not see all these features in your local drug store, but they’re coming: claims of a new “integrative” way to provide health care that is changing the face of retail pharmacy. Unfortunately, it’s harkening back to the era of patent medicines and snake oil. It’s not good for the pharmacists and the profession of pharmacy, and it’s even worse for patients. (more…)
As a pediatrician I have an opportunity to observe a wide variety of unusual and sometimes alarming parental efforts meant to help children through illness or keep them well. I have recently noticed one particular intervention that seems to be becoming more prevalent, at least in my practice. I’ve begun to see more and more infants sporting Baltic amber teething necklaces. These consist of multiple small beads of amber on a string that is worn around a baby’s neck, and are supposed to relieve the discomfort of teething. Before I had any idea what these necklaces were for or how they were supposed to work, my first reaction was to inform these parents of the dangers of necklaces or anything placed around an infant’s or young child’s neck. Strangulation is a known cause of accidental injury and death in children, and pediatricians are trained to discuss this as part of the routine anticipatory guidance we give to parents. In addition, we strongly advise against giving infants or young children any small items that could be accidentally aspirated, such as the beads found in a necklace of this sort. But I was equally surprised to learn that these necklaces are not intended for babies to chew or gum. Instead, they are supposed to ease a baby’s teething discomfort simply by lying against the skin.
I will not discuss teething here, or the many myths that surround it; that was well covered in a previous post. I will reiterate that there is little-to-no evidence that the majority of concerns parents have about teething are actually due to teething, including fever and diarrhea. The irritability associated with teething also tends to wax and wane for only several days before and after the emergence of a tooth. But let’s assume for the moment that these necklaces actually work to ease the discomfort of teething, and whatever other problems parents tend to associate with the long period of time during which infants and young children develop their teeth. Assuming these necklaces work as recounted in the glowing testimonials on countless websites and parent blogs, how do they produce their dramatic results?
I would like to preface this post by stating that I have worked with many DOs (Doctors of Osteopathy), and I have helped train many pediatric residents with DO degrees. I have found no difference in the overall quality of the training these students have received, and some of the very best clinicians I have ever worked with have been DOs. I would never prejudice my assessment or opinion of a physician based on whether they have an MD or a DO after their name.
Now, on to the discussion at hand.
I recently stumbled upon an article entitled, “Effect of osteopathic manipulative treatment on length of stay in a population of preterm infants: a randomized controlled trial”. There is nothing particularly exciting or interesting about this study, as there have been many published on the use of osteopathic manipulative therapy (OMT) in children. There aren’t that many RCTs, however, and this particular one, although published in the open-access BioMed Central Pediatrics (impact factor 1.98), was chosen to be included in AAP Grand Rounds. AAP Grand Rounds is a publication put out by the American Academy of Pediatrics (AAP) to help pediatricians “Stay current and save time with monthly critical, evidence-based summaries of clinical content from nearly 100 journals.” Because the AAP found this important enough for mention in this widely read publication, with a distribution of 19,000 (source: AAP, 2014), I thought it would be interesting to take a closer look at it. I am also interested in the very odd existence of the two, distinct paths to becoming a physician in this country, osteopathic and traditional medical school training. The distinction between the two is rarely discussed, even within the halls of academia or in our health care centers. That’s not to say that the topic isn’t discussed at all (in fact it was highlighted very recently right here on SBM), it has just remained a somewhat politically incorrect subject, sliding mostly under the radar. Having worked with and trained pediatricians with osteopathic degrees, I can tell you that discussions about this are considered taboo. This is primarily because osteopathic physicians have become mainstreamed over time (see below), and discussing the validity of the existence of their “specialness” is an awkward proposition. After taking a look at the paper in question, I’ll address this issue some more as I think it deserves additional attention.
Effect of osteopathic manipulative treatment on length of stay in a population of preterm infants: a randomized controlled trial.
This was a single-blinded RCT conducted at Santo Spirito Hospital in Pescara, Italy to explore whether OMT could shorten the length of stay among premature infants in their neonatal ICU (NICU). Secondary outcomes studied were the differences in daily weight gain and total cost of the NICU stay.
I’ll discuss the methods in a moment, but first let’s review the results.
Note: This was written as a book review for Skeptical Inquirer magazine and will be published in its Jan/Feb 2014 issue.
Medicine is chock-full of philosophy and doesn’t know it. Mario Bunge, a philosopher, physicist, and CSI (Center for Skeptical Inquiry) fellow, wants to bring philosophy and medicine together for mutual benefit. He has written a book full of insight and wisdom, Medical Philosophy: Conceptual Issues in Medicine.
Whether doctors recognize it or not, medicine is firmly based on the philosophical principles of materialism, systemism, realism, scientism, and humanism. Bunge explains that:
Without materialism, both diseases and therapies would be taken to be purely spiritual.
Without systemism, every disease would be attributed to an independent module.
Without realism, diseases would be viewed as either imaginary or as social flaws.
Without scientism, either nihilism or dogmatism would prevail, and all the achievements of biomedical research of the last 500 years would be consigned to oblivion.
Without humanism, all medical practice would be mercenary, and there would be no public health care. (more…)
Last week I posted a list of 30 rebuttals to many of the recurrent criticisms that are made by people who don’t like what we say on SBM. I thought #30 deserved its own post; this is it. At the end, I’ve added a few items to the original list.
What’s the harm in people trying CAM? Science-based medicine has been criticized for being too rigid and intolerant. Why do we insist on randomized placebo-controlled trials to prove that a treatment is safe and effective? Isn’t it enough that patients tell us they feel better? Isn’t that what we all want, for our patients to feel better? Even if the treatment only works as a placebo, isn’t that a good thing? What’s the harm in that?
The albuterol/placebo study
I would argue that we don’t just want our patients to think they are better, we want them to actually be better. A study that illustrates that principle has been discussed on this blog before, here and here.
A group of patients using an effective albuterol asthma inhaler was compared to 2 placebo groups (a placebo inhaler group and a sham acupuncture group), and to a group that got no treatment at all. Patients reported the same relief of symptoms with each of the two placebo controls as with the albuterol inhaler; all three groups reported feeling significantly better than the no-treatment group. It could be argued that placebos are an effective treatment for the subjective symptoms of asthma. (more…)
Some people don’t like what we have to say on Science-Based Medicine. Some attack specific points while others attack our whole approach. Every mention of complementary and alternative medicine (CAM) elicits protests in the Comments section from “true believer” users and practitioners of CAM. Every mention of a treatment that has been disproven or has not been properly tested elicits testimonials from people who claim to have experienced miraculous benefits from that treatment. In previous articles I have compiled the criticisms of what I wrote about Protandim and Isagenix. It’s instructive to read through them. We welcome rational and substantive criticism, but most of these comments are neither.
Our critics keep bringing up the same old memes, and it occurred to me that rather than try to answer them each time, it might be useful to list those criticisms and answer them here. In future, when the same points are raised, we could save time and effort by linking to this page and citing the reference number. I know this list is not comprehensive, and I hope our readers will point out anything I’ve omitted. Here are some of the criticisms we keep hearing:
1. Big Pharma is paying you to promote their products and discredit CAM.
No it isn’t. We are not Pharma shills. We are not paid anything for writing this blog. We do not get money from pharmaceutical companies. We do not accept gifts from drug companies. We do not get kickbacks for prescribing certain drugs. We have no incentive to favor drugs over other treatments. Incidentally, critics who prefer natural remedies to pharmaceuticals should note that many CAM diet supplements are sold by subsidiaries of Big Pharma. (more…)
Medicine is a collaborative practice. Hospitals are the best example, where dozens of different health professionals work cooperatively, sharing responsibilities for patient care. Teamwork is essential, and that’s why health professionals obtain a large part of their education on the job, in teaching (academic) hospitals. The only way that all of these different professions are able to work together effectively is that their foundations are based on an important, yet simple, principle. All of us have education and training grounded in basic scientific principles of medicine. Biochemistry, pharmacology, physiology – we all work from within the same framework. As a pharmacist, my role might include working with physicians and nurses to manage and monitor medication use. A team approach is only possible when you’re working from the same playbook, and with the same aim. And in medicine, that playbook is science.
That’s why “integrative” medicine frightens me so much. Integrative medicine is a tactic embedding complementary and alternative medical practices into conventional medical care. Imagine “integrating” a practitioner into the health system that doesn’t accept germ theory. Or basic disease definitions. Or the effectiveness of vaccines. Or even basic biochemistry – perhaps they believe in treatments that restore the body’s “vital force” or manipulate some sort of “energy fields”. Instead of relying on objective signs and symptoms, they base treatments on pre-scientific beliefs, long discarded from medicine. There may be entirely different treatment goals, which are potentially antagonistic to the scientific standard. Imagine a hospital or academic setting where this occurs, and the potential impact on the quality of care that is delivered. (more…)
“Alternative medicine,” so-called “complementary and alternative medicine” (CAM), or, as it’s become fashionable to call it, “integrative medicine” is a set of medical practices that are far more based on belief than science. As Mark Crislip so pointedly reminded us last week, CAM is far more akin to religion than science-based medicine (SBM). However, as I’ve discussed more times than I can remember over the years, both here and at my not-so-super-secret-other blog, CAM practitioners and advocates, despite practicing what is in reality mostly pseudoscience-based medicine, crave the imprimatur that science can provide, the respect that science has. That is why, no matter how scientifically implausible the treatment, CAM practitioners try to tart it up with science. I say “tart it up” because they aren’t really providing a scientific basis for their favored quackery. In reality, what they are doing is choosing science-y words and using them as explanations without actually demonstrating that these words have anything to do with how their favored CAM works.
A more important fundamental difference between CAM and real medicine is that CAM practices are not rejected based on evidence. Basically, they never go away. Take homeopathy, for example. (Please!) It’s the ultimate chameleon. Even 160 years ago, it was obvious from a scientific point of view that homeopathy was nonsense and that diluting something doesn’t make it stronger. When it became undeniable that this was the case, through the power of actually knowing Avogadro’s number, homeopaths were undeterred. They concocted amazing explanations of how homeopathy “works” by claiming that water has “memory.” It supposedly “remembers” the substances with which it’s been in contact and transmits that “information” to the patient. No one’s ever been able to explain to me why transmitting the “information” from a supposed memory of water is better than the information from the real drug or substance itself, but that’s just my old, nasty, dogmatic, reductionist, scientific nature being old, nasty, dogmatic, reductionist, and scientific. Then, of course, there’s the term “quantum,” which has been so widely abused by Deepak Chopra, his acolytes, and the CAM community in general, while the new CAM buzzword these days to explain why quackery “works” is epigenetics. Basically, whenever a proponent of alternative medicine uses the word “epigenetics” or “quantum” to explain how an alternative medicine treatment “works,” what he really means is, “It’s magic.” This is a near-universal truth, and even the most superficial probing of such justifications will virtually always reveal magical thinking combined with an utter ignorance of the science of quantum mechanics or epigenetics.