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Taking Control of Death

Science isn’t the only game in town. Literature can teach us things about the world that science can’t. It can give us vicarious experience and insight into other minds. Two recently published novels illuminate why perfectly rational people might reject the help of scientific medicine and prefer to die a little sooner but to die on their own terms. (more…)

Posted in: Book & movie reviews, Cancer, Medical Ethics

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Genetic Testing for Patients on Coumadin

Anticoagulation is advised for patients who have had a blood clot or who are at increased risk of blood clots because of atrial fibrillation, artificial heart valves, or other conditions. Over 30 million prescriptions are written every year in the US for the anticoagulant warfarin, best known under the brand name Coumadin. Originally developed as a rat poison, warfarin has proved very effective in preventing blood clots and saving lives; but too much anticoagulation leads to the opposite problem: bleeding. A high level of Coumadin might prevent a stroke from a blood clot only to cause a stroke from an intracranial bleed. The effect varies from person to person and from day to day depending on things like the amount of vitamin K in the diet and interactions with other medications. It requires careful monitoring with blood tests, and it is tricky because there is a delay between changing the dose and seeing the results.

In his book The Language of Life, Francis Collins predicts that Coumadin will be the first drug for which the so-called Dx-Rx paradigm — a genetic test (Dx) followed by a prescription (Rx) — will enter mainstream medical practice. FDA economists have estimated that by formally integrating genetic testing into routine warfarin therapy, the US alone would avoid 85,000 serious bleeding events and 17,000 strokes annually.
A recent news release from the American College of Cardiology described a paper at their annual meeting reporting a study of

896 people who, shortly after beginning warfarin therapy, gave a blood sample or cheek swab that was analyzed for expression of two genes — CYP2C9 and VKORC1 — that revealed sensitivity to warfarin. People with high sensitivity were put on a reduced dose of warfarin and had frequent blood tests. People with low sensitivity were given a higher dose of warfarin.

During the first six months that they took warfarin, those who underwent genetic testing were 31 percent less likely to be hospitalized for any reason and 29 percent less likely to be hospitalized for bleeding or thromboembolism than were a group that did not have genetic testing.

Epstein said that the cost of the genetic testing — $250 to $400 — would be justified by reduced hospitalization costs.

At this point, I don’t believe this study. I’ll explain why I’m skeptical. (more…)

Posted in: Clinical Trials, Pharmaceuticals

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Brief Note: Followup on Spinal Decompression Machines

In September 2008 I wrote a post on Misleading Ads for Back Pain Treatment. with particular attention to the bogus claims for the DRX 9000.

The Canadian Broadcasting Company (CBC) show “Marketplace” has just done a scathing exposé of so-called nonsurgical spinal decompression treatment with machines like the DRX 9000 and of some of the unscrupulous practitioners who offer it.  Between the hidden camera footage and the weasel words of the chiropractor they interview, it’s quite entertaining.

Posted in: Chiropractic, Health Fraud

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A Sleep Remedy with Proprietary Secrets

A new product, Dream Water, is designed to help one relax, fall asleep and improve the quality of sleep using the all natural ingredients melatonin, GABA and 5-HTP (tryptophan). A single-dose 2.5 oz bottle retails for $2.99. They also offer a more dilute formulation in an 8 oz bottle. They suggest drinking half a bottle, keeping it at your bedside, and drinking more if you wake during the night. What dosage will you get from half a bottle? From a whole bottle? There’s no way to know. They offer a money back guarantee, free shipping, free samples, and lots of testimonials; but they refuse to disclose how much of what is in their product.

The DSHEA only permits structure and function claims like “supports prostate health,” but this product is clearly being promoted as a remedy for insomnia. The “Quack Miranda warning” is not displayed on the home page, but the “Dream Responsibly” page says “These statements have NOT been evaluated by the Food and Drug Administration. This product is NOT intended to diagnose, treat, prevent or cure any disease.”

Is it legal to sell this as a remedy for insomnia? I guess the legality depends on whether you define insomnia as a disease. Maybe they define it as an impairment in a function that needs supporting. Maybe they can get away with it. (more…)

Posted in: Herbs & Supplements

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Diagnosis, Therapy and Evidence

When Dr. Novella recently wrote about plausibility in science-based medicine, one of our most assiduous commenters, Daedalus2u, added a very important point. The data are always right, but the explanations may be wrong. The idea of treating ulcers with antibiotics was not incompatible with any of the data about ulcers; it was only incompatible with the idea that ulcers were caused by too much acid. Even scientists tend to think on the level of the explanations rather than on the level of the data that led to those explanations.

A valuable new book elaborates on this concept: Diagnosis, Therapy and Evidence: Conundrums in Modern American Medicine, by medical historian Gerald N. Grob and sociologist Allan V. Horwitz. They point out that 

many claims about the causes of disease, therapeutic practices, and even diagnoses are shaped by beliefs that are unscientific, unproven, or completely wrong. (more…)

Posted in: Book & movie reviews, Science and Medicine

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Halsted: The Father of Science-Based Surgery

One (dark and stormy?) night in 1882, a critically ill 70 year old woman was at the verge of death at her daughter’s home, suffering from fever, crippling pain, nausea, and an inflamed abdominal mass. At 2 AM, a courageous surgeon put her on the kitchen table and performed the first known operation to remove gallstones. The patient recovered uneventfully. The patient was the surgeon’s own mother.

This compelling story is the beginning of an excellent new biography of William Halsted, the father of modern surgery, Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted, by Gerald Imber, MD.

When Halsted went to medical school, surgeons still operated in street clothes, with bare hands, and major surgical procedures carried a mortality rate of nearly 50 percent. Suppuration of wounds was called laudable pus. Lister had recently introduced carbolic acid dips and sprays (that were irritating and toxic), but hand washing was discouraged because it was thought to force germs into skin crevices. (more…)

Posted in: Book & movie reviews, History, Surgical Procedures

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Zeo Personal Sleep Coach

 Sleep that knits up the ravelled sleeve of care
The death of each day’s life, sore labour’s bath
Balm of hurt minds, great nature’s second course,
Chief nourisher in life’s feast.   
 –William Shakespeare, Macbeth

Zeo

The company that makes the Zeo Personal Sleep Coach  kindly sent me one of their devices to try out. It’s a nifty little gadget, and if you are a techno geek, you would probably love it. It’s a fascinating toy; but for insomnia, there’s no evidence that it provides any benefit over standard treatment with sleep logs and sleep hygiene advice.

Polysomnography is done overnight in a sleep lab and costs around $1000. It records multiple parameters: EEG, EKG, EMG, breathing, O2, CO2, and limb movements. It is most commonly used to diagnose obstructive sleep apnea (OSA), a serious condition that is linked to hypertension, heart disease, diabetes, metabolic syndrome, stroke, and increased mortality. OSA can be effectively treated with CPAP and other measures. About 50% of snorers have sleep apnea. We typically think of it as a disease of obese, loudly snoring older men, but even young children can have it: snoring is probably never normal in children and should be investigated.

The Zeo is the first sleep monitor available for consumers to use at home. It doesn’t pretend to do what polysomnography does. It can’t diagnose sleep apnea. It is billed as an educational and motivational tool, not intended for the diagnosis or treatment of sleep disorders. A unit that looks sort of like an alarm clock sits on your bedside table and communicates wirelessly with a comfortable soft elastic headband that positions embedded sensors over your forehead to pick up your brain waves. (more…)

Posted in: Health Fraud

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Chronic Fatigue Syndrome and Retroviruses: Jumping the Gun

When I first heard that a retrovirus had been identified as a possible cause of chronic fatigue syndrome, I withheld judgment and awaited further developments. When I heard that two subsequent studies had failed to replicate the findings of the first, I assumed that the first had been a false alarm and would be disregarded. Not so.

 It’s a classic case of wishful thinking outweighing good judgment. One unconfirmed report of an association between the XMRV virus and chronic fatigue syndrome (CFS) resulted in a rush to test for the virus, speculation about possible implications, and even suggestions for treatment. And the subsequent negative studies did little or nothing to reverse the trend. 

XMRV is Xenotropic murine leukemia virus-related virus. In the past, there were reports that this retrovirus was associated with prostate cancer, but then other reports found no link. In 2009 a study was published in Science, “Detection of an Infectious Retrovirus, XMRV, in Blood Cells of Patients with Chronic Fatigue Syndrome” by Lombardi et al., reporting an association with CFS:

we identified DNA from a human gammaretrovirus, xenotropic murine leukemia virus–related virus (XMRV), in 68 of 101 patients (67%) as compared to 8 of 218 (3.7%) healthy controls. (more…)

Posted in: Basic Science, Science and Medicine

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Questioning Colonoscopy

Everybody knows that colonoscopy is the best test to screen for colorectal cancer and that colonoscopies save lives. Everybody may be wrong. Colonoscopy is increasingly viewed as the gold standard for colorectal cancer screening, but its reputation is not based on solid evidence. In reality,  it is not yet known for certain whether colonoscopy can help reduce the number of deaths from colorectal cancer. Screening with fecal occult blood testing (FOBT) and flexible sigmoidoscopy are supported by better evidence, but questions remain.  It seems our zeal for screening tests has outstripped the evidence. 

Statistics show that the life-time risk for an adult American to develop colorectal cancer (CRC) is approximately 6%. Colorectal cancer is the second leading cause of cancer deaths in the United States. In the US there are currently 146,970 new cases   and 50,630 deaths each year. Between 1973 and 1995, mortality from CRC declined by 20.5%, and incidence declined by 7.4% in the United States.  

The US Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years.   (more…)

Posted in: Cancer

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Time to Care: Personal Medicine in the Age of Technology

In 1925, Francis Peabody famously said “The secret of the care of the patient is in caring for the patient.” A new book by Norman Makous, MD, a cardiologist who has practiced for 60 years, is a cogent reminder of that principle.

In Time to Care: Personal Medicine in the Age of Technology, Dr. Makous tackles a big subject. He attempts to show how modern medicine got to where it is today, what’s wrong with it, and how to fix it. For me, the best part of the book is the abundance of anecdotes showing how medicine has changed since Dr. Makous graduated from medical school in 1947. He gives many examples of what it was like to treat patients before technology and effective medications were introduced. He describes a patient who died of ventricular fibrillation before defibrillators were invented, the first patient ever to survive endocarditis at his hospital (a survival made possible by penicillin), a polio epidemic before polio had been identified as an infectious disease, the rows of beds in the tuberculosis sanitariums that no longer exist because we have effective treatments for TB. He tells funny stories: the patient who was examined with a fluoroscope and told the doctor he felt much better after that “treatment.” He describes setting up the first cardiac catheterization lab in his area. No one who reads this book can question the value of scientific medicine’s achievements between 1947 and 2010. Today we can do ever so much more to improve our patients’ survival and health. But in the abundance of technological possibilities, the crucial human factor has been neglected.

Individualized care, which involves the use of science-inspired technology, is not personal care. Alone, it is incomplete. It does not provide the necessary reassurance that can only be provided through a trusted physician who focuses upon the totality of the person and not just upon a narrow technological application to a disease. Time and personal commitment are needed to build the mutual understanding and trust that are fundamental to personal care….the continued acceleration of science, technology, and cost has intruded on personal care in our country. This has also occurred during a time in which American individualism and its accompanying sense of entitlement have become more of a cult than ever before. In the absence of personal attention, patients demand more testing, but testing does not satisfy the need for personal interaction.

Makous invokes the Golden Rule: “Over the course of my career, I learned to treat patients as I would like to be treated under similar circumstances.” (more…)

Posted in: Book & movie reviews, Diagnostic tests & procedures, History

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