In a recent post I shared a bit of my personal, near-death experience with measles during the US epidemic of 1989-1991. As I describe in that post, I contracted a very serious measles infection at the end of medical school, and was highly infectious when I interviewed for a residency position at Seattle Children’s Hospital. Like others my age who received an ineffective, killed measles vaccine between 1963 and 1967, I had not been adequately protected. The MMR vaccine was not yet available, and no boosters were recommended at the time. Unfortunately, though my measles titers (a test of immunity to measles) were checked when I entered medical school, the school’s student health department failed to notice or respond to the results – I was not immune and did not receive a booster dose at that time, as I should have. That mistake was huge, and could have cost me my life. It also caused me to potentially sicken many vulnerable children during my tour of the hospital, as well as others I may have inadvertently exposed during the window of communicability as I walked the streets of Seattle. The Department of Health had to be called to trace all of my steps and attempt to track down and protect any potential contacts.
Diets fail. Not just often, but almost always—90% of the time. If diets worked we wouldn’t have a worldwide obesity problem. And obesity is a problem that needs to be solved. The prevalence of obesity has doubled since 1980. As a public health issue, there are few determinants of illness that are more destructive, as obesity contributes to the growing rates of diabetes, heart disease, and even cancer. There’s no “one true cause” of all illness, but obesity comes pretty close. When people ask me for the single most important thing they can do for their health, my advice (after quitting smoking) is to (1) ensure you keep your weight under control and (2) exercise in any way possible.
Despite its tremendous impact on health, I’ve only blogged about obesity in an indirect way—by pointing out what doesn’t work. Dr. Oz is my perpetual source of bad health information with his regular promotion of bogus “weight loss” supplements like the green coffee bean “miracle”. I’ve also criticized eating programs like the fads of “Eating Clean”, gluten “intolerance”, or harmful diet delusions like “detox”. It’s the typical skeptical science blogger approach—spot pseudoscience, debunk it, and hope you did something good. But none of my posts have focused on what one should do—just what you shouldn’t. Weekly SBM contributor Dr. Mark Crislip recently commented that what we (SBM) support manifests in what we oppose. He’s right, because that’s the easy approach. Using the principles of science-based medicine, there’s an awful lot to oppose in the current writing and popular opinion on how to treat obesity. And my professional advice in the role of a pharmacist has been limited to steering people away from supplements, and then giving some basic advice about dietary planning. Anecdotes and platitudes. I admit that I’ve told patients to “eat less and exercise more”.
PLOS (the Public Library of Science) is a non-profit open access publisher of science articles. Their goal is to make scientific data accessible to everyone, in the name of transparency and open communication. Now they have taken their approach one step further, announcing their policy that all articles published in a PLOS journal must submit their original data so that anyone can access and analyze it for themselves.
In an effort to increase access to this data, we are now revising our data-sharing policy for all PLOS journals: authors must make all data publicly available, without restriction, immediately upon publication of the article. Beginning March 3rd, 2014, all authors who submit to a PLOS journal will be asked to provide a Data Availability Statement, describing where and how others can access each dataset that underlies the findings. This Data Availability Statement will be published on the first page of each article.
They allow for exceptions—when subject confidentiality is an issue, sensitive information related to endangered species, and when the authors do not own the data. In such cases, however, data must be available upon request, and not controlled by the authors. Otherwise the raw data must be made available.
Depression affects approximately 10% of Americans. It can be fatal; I found estimates of suicide rates ranging from 2-15% of patients with major depression. When it doesn’t kill, it impairs functioning and can make life almost unbearably miserable. It is a frustrating condition because there is no lab test to diagnose it, no good explanation of its cause, and the treatments are far from ideal.
Jonathan Rottenberg is a psychologist and research scientist who began to study depression after his own recovery from a major depressive illness. He teaches psychology at the University of South Florida, where he is the director of the Mood and Emotion laboratory. He has launched the Come Out of the Dark campaign to start a better, richer national conversation about depression. In a new book The Depths: The Evolutionary Origins of the Depression Epidemic, he reviews insights from recent experiments and asks a number of difficult questions, such as why humans evolved to be subject to incapacitating depressions. He comes up with some startling hypotheses, including the idea that evolution favored depression because of its survival value and that depression is essentially a good thing. He offers his ideas as the basis of a paradigm shift. (more…)
Note: Some of you have probably seen a different version of this post fairly recently. I have a grant deadline this week and just didn’t have time to come up with fresh material up to the standards of SBM. This left me with two choices: Post a “rerun” of an old post, or recycle something. I decided to recycle something for reasons explained in the first paragraph of this post.
As I was deciding what to write about this week, I realized that, surprisingly, there is precious little on Science-Based Medicine about the granddaddy of modern cancer quackery, Laetrile. Given that the final nails were placed in the coffin of the quackery that was Laetrile more than 30 years ago in the form of a clinical trial that didn’t show a hint of a whiff of benefit in cancer patients, many of our younger readers might not even know what Laetrile is. But, as I explained when I wrote about Stanislaw Burzynski’s early years in the 1970s, which happened to be they heyday of Laetrile, in cancer quackery everything old is eventually new again, and Laetrile is apparently soon to be new again. True, it’s never really disappeared completely, because, again, no matter how discredited a cancer quackery is, someone somewhere will keep selling it and some poor cancer patient somewhere will be taken in. In any case, it occurred to me that we at SBM have discussed the politics of Laetrile. Indeed, Kimball Atwood once referred to it as the “the most lucrative health fraud ever perpetrated in the United States.” Moreover, Kimball makes a convincing case that the Laetrile controversy was an important precursor that laid the groundwork for advocates of “alternative medicine”—or, as it later became known, “complementary and alternative medicine” (CAM) or “integrative medicine—to successfully lobby for the founding at the National Institutes of Health of what later was named the National Center for Complementary and Alternative Medicine (NCCAM). However, there didn’t appear to be a post dedicated to discussing Laetrile itself, and something happened last week that allows me to rectify that situation.
So how is Laetrile about to become new again? Remember our old buddy Eric Merola? He’s the guy who made two—count ’em—two conspiracy-laden, misinformation-ridden, astonishingly bad bits of “great man” propaganda disguised as documentaries about a Houston cancer doctor peddling unproven cancer treatments and charging his patients tens and even hundreds of thousands of dollars for the privilege of being under his care while receiving this magic elixir, known as antineoplastons. Over the last several months, ever since he unleashed Burzynski: The Sequel on an unprepared and uninterested world, Merola has been hinting about his next project. Given Merola’s involvement in Zeitgeist: The Movie and his primary role in throwing together two hack propaganda pieces that were so blatantly worshipful of Burzynski that Leni Riefenstahl, were she still alive and able to see them, would have told Merola to cool it with the overheated hero worship and portrayal of his movie’s subject as a god-man a bit, I knew his next movie would be more of the same. I also knew it would not be about Burzynski.
Almost 10 years ago, a thoughtful article, entitled “Chiropractic as spine care: a model for the profession”, appeared in the journal Chiropractic & Osteopathy. The authors were a group of both academic and practicing chiropractors, as well as representatives from a health insurer specializing in coverage of CAM provider services. Another article, under different authorship, appeared the same year deploring some aspects of chiropractic education. In 2008, a third article came out with a similar theme, “How can chiropractic become a respected mainstream profession? The example of podiatry.” All three are open access and worth reading. The authors are to be commended for taking on an extremely contentious subject in their own profession.
The first article is a refreshingly honest look at the current state of chiropractic. The authors note the inability of chiropractors to consistently define who they are and what they do, which results in public confusion (including among those in the healthcare industry) about just what role chiropractors should play in the healthcare system. The authors deplore the continued existence of the “subluxation” in chiropractic and it’s accommodation by no less than the Association of Chiropractic Colleges. And they thoroughly deconstruct any notion that such a thing exists. The idea that chiropractors are capable of acting as primary care physicians is given equally short shrift and debunked as well.
The article points out that, whatever the confusion among chiropractors about who they are and what they do, the public has decided on its own: the public perception of chiropractors is that of back pain specialists. Back-related problems account for over 90% of the reason patients see chiropractors. They also argue that chiropractic must embrace evidence-based healthcare and stop relying on their clinical experience, noting the many reasons (e.g., regression to the mean) that a chiropractor’s observations may be explained by something other than treatment effectiveness. They admit that the chiropractor’s stock-in-trade, spinal manipulation, might not hold up under an evidence-based standard. (A possibility that is becoming a reality.) They even quote Marcia Angell’s observation on “alternative” medicine:
There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work.
The word “paradigm” is over misused and overused, diluting its utility. Thomas Kuhn coined the term in The Structure of Scientific Revolutions to refer to an overarching explanatory system in science. Scientists, according to Kuhn, work within a paradigm during periods of “normal science,” punctuated by occasional “paradigm shifts” when the old explanatory model no longer sufficed, and a radically new explanatory system was required. The term has since come into colloquial use to mean any scientific breakthrough, which marketers quickly overused to refer to just about any new product.
I am therefore cautious about using the term, but I think it is appropriate in this case. In medicine I would consider a new paradigm to be an entirely new approach to some forms of illness. Common treatment paradigms include nutrition, physical therapy, surgery, and pharmacology. A new paradigm is emerging in my field of neurology – directly affecting brain function through electromagnetic stimulation.
The brain is a chemical organ, with many receptors for specific neurotransmitters. This has allowed us to use a pharmacological approach in treating brain disorders – using drugs that are agonists (activators) or antagonists (blockers) of various neurotransmitter receptors, or that affect the production or inactivation of the neurotransmitters themselves. There are limits to this approach, however. First, neurotransmitters are not the only factor affecting brain function. The brain is also a biological organ like any other, and so all the normal physiological factors are in play. Further, there is only so much evolved specificity to the neurotransmitters and their receptors.
I’ve always thought of Tylenol (AKA acetaminophen in the US and paracetamol in the UK) as one of the safest drugs around, with essentially no side effects when used as directed. But it has been in the limelight lately. Several SBM articles have addressed it here, here, and here. We know there is a risk of liver damage and death with acetaminophen overdose or accidental ingestion (458 deaths a year in the US). Since it is included in many other products (painkillers, cold and cough remedies, etc.) consumers may not realize how much they’re taking. The FDA has addressed this problem, and reformulations and lower daily dose recommendations are being implemented; but there is still no guarantee that consumers will realize that their “non-aspirin pain reliever,” pain pills like Vicodin, and many cold, sinus, and cough remedies have the same ingredient as Tylenol.
We have gradually become aware of other dangers not associated with overdose. Acetaminophen has been associated with kidney damage (especially with long-term use), gastrointestinal symptoms, and cardiovascular events. Combining the recommended dose with alcohol ingestion can lead to liver failure. It can also interact with some other drugs, for instance isoniazid. Allergic reactions can occur, and 7% of patients who are allergic to aspirin or NSAIDs also react to acetaminophen. It is excreted in breast milk, but in very low concentrations. The manufacturer’s professional product information includes detailed listings of reported reactions, drug/drug interactions, and safety studies in patients with various diseases. There is no need to adjust dosage for the elderly or for those with liver or kidney disease. For most patients, including those with chronic disease, acetaminophen is the pain-reliever of choice due to its low risk. But recently a draft recommendation from the UK’s NICE (National Institute of Health and Care Excellence) has warned us against using it, at least to treat the pain of osteoarthritis. (more…)
The last couple of weeks, I’ve made allusions to the “Bat Signal” (or, as I called it, the “Cancer Signal,” although that’s a horrible name and I need to think of a better one). Basically, when the Bat Cancer Signal goes up (hey, I like that one better, but do bats get cancer?), it means that a study or story has hit the press that demands my attention. It happened again just last week, when stories started hitting the press hot and heavy about a new study of mammography, stories with titles like Vast Study Casts Doubts on Value of Mammograms and Do Mammograms Save Lives? ‘Hardly,’ a New Study Finds, but I had a dilemma. The reason is that the stories about this new study hit the press largely last Tuesday and Wednesday, the study having apparently been released “in the wild” Monday night. People were e-mailing me and Tweeting at me the study and asking if I was going to blog it. Even Harriet Hall wanted to know if I was going to cover it. (And you know we all have a damned hard time denying such a request when Harriet makes it.) Even worse, the PR person at my cancer center was sending out frantic e-mails to breast cancer clinicians because the press had been calling her and wanted expert comment. Yikes!
What to do? What to do? My turn to blog here wasn’t for five more days, and, although I have in the past occasionally jumped my turn and posted on a day not my own, I hate to draw attention from one of our other fine bloggers unless it’s something really critical. Yet, in the blogosphere, stories like this have a short half-life. I could have written something up and posted it on my not-so-secret other blog (NSSOB, for you newbies), but I like to save studies like this to appear either first here or, at worst, concurrently with a crosspost at my NSSOB. (Guess what’s happening today?) So that’s what I ended up doing, and in a way I’m glad I did. The reason is that it gave me time to cogitate and wait for reactions. True, it’s at the risk of the study fading from the public consciousness, as it had already begun to do by Friday, but such is life.
Pollyanna, a popular children’s book written in 1913 by Eleanor H. Porter, introduced the world to one of the most optimistic fictional characters ever created. She always saw the good in people and her approach to life frequently involved playing “The Glad Game”, where she attempted to find something to appreciate in every situation no matter how unfortunate. She was glad about receiving crutches rather than a doll one Christmas because it was great that she didn’t actually need them. She teaches this philosophy to those around her, even her cantankerous Aunt Polly, and the entire town is transformed into a veritable Mayberry, USA. Later, when she actually does require the use of crutches, her resolve is tested but she triumphantly finds a silver lining.
The Pollyanna principle, first described by Matlin and Stang in 1978 and also known as positivity bias, is a psychological tendency for people to place greater importance on, and assume better accuracy of, descriptive statements about them that are positive. This goes on behind the scenes while our conscious brain tends to dwell on what is perceived as negative stimuli. Though many folks do come across as pessimistic, we are subconsciously biased to accept praise and reject criticism. Anyone who isn’t clinically depressed is on some level more like Pollyanna than Eeyore.
This positivity bias also plays a large role in how we remember past events. As has been covered extensively in prior posts here on SBM, and on Dr. Novella’s excellent Neurologica blog, memory isn’t a replayed video or audio recording of prior events and our interpretations of them, but rather is a reconstruction that is prone to errors during processing and editing that accumulate over time. This leads to false memories that feel no less real than our recollection of what happened five minutes ago.
In this case, the Pollyanna principle results in positive information being more accurately processed and recalled than negative experiences. It also causes our memory of negative events to gradually become less negative as the years go by. I couldn’t have done that terribly during my first high school trumpet solo because I remember people telling me it was pretty good afterwards, right?
So what does this have to do with the practice of medicine? Biases that affect memory also impact how physicians and patients interact. I once assumed the overnight care of a child who had undergone a lumbar puncture performed by one of my female colleagues earlier that day. I ordered no tests and performed no procedures during my brief exposure to the family—yet over a year later when I admitted the same child for a completely different reason I was accused of being the terrible doctor who had unnecessarily subjected their baby to a spinal tap during the last hospitalization. Even after I showed them the documentation which proved that I had nothing to do with that (very appropriate) decision, and that I did not put a needle in their child’s spine, they refused to accept the evidence and had great difficulty trusting my diagnosis and recommendations.