Although I write the definitive entries on topics in this blog, new information trickles in after publication. The new studies are often not worth an entire entry, recapitulating prior essays, but the new information is still worth a mention. What follows are updates on topics covered in prior SBM posts.
In Oregon we are having a small outbreak of infections from consumption of raw milk. Not a surprise, since milk is a wonderful culture media and the udder is just down the gravity well from the cows anus. Raw milk violates the classic dictum “Don’t shit where you eat” although I understand the saying concerned dating in its original conception.
Although the sale of raw milk is illegal in muchof the US, the law can be bypassed by owning the cow rather than buying the milk, a reverse of dating advice. Such is the case in Oregon, where 48 people are time sharing the cows responsible for the current outbreak. There has been the spread of pathogenic E. coli to at least 5 people, mostly children, and has lead to the hospitalization of at least 3 children.
Of course, it is hard to get infected. Humans have lived in Filth and Squalor (like Minneapolis and St. Paul or Buda and Pest) for centuries, drinking and eating contaminated food and enough survived perpetuate the species. Most infections in the past would have been from consuming contaminated food and drink. I have wondered if the reason fevers are often associated with diarrhea and/or vomiting is that it an evolved response for removing infected material as soon as possible.
I spend most of my time taking care of hospitalized patients with acute infections and issues of public health are, outside of infection control, not a high priority. Vaccinations in training were always like clean water and fresh food: their benefit was a given and I never needed to consider the benefits and subtleties of vaccination. There is just so much time in a day and I was more concerned with AIDS, endocarditis and meningitis to worry about the ins and outs of vaccination.
One of the many benefits of writing for SBM, and being the Chair of Infection Control, is it is a stimulus to keep up on aspects of medicine that I might not otherwise pay close attention to, like vaccines. I have been far more interested in vaccines, especially influenza vaccines, since starting practice in 1990 than I ever was in the decade I spend in training.
Vaccination and the efficacy of vaccines is not as straightforward as I would have thought 30 years ago. It was give a vaccine, generate an antibody, and, viola, the patient is protected. The vagaries of the flu vaccine are even more pronounced, since response to the vaccine is variable and the population has never been vaccinated at levels, more than 90%, where herd immunity would likely kick in.
My ideal flu vaccine study, which would be both impossible and unethical, would be to vaccinate everyone West of the Mississippi and no one to the East (no coincidence that me and mine live in the West) and study the short and long term effects. Until that day, I am stuck with the hodgepodge of medical studies that look at the results of influenza vaccination and add insights into the disease.
I thought this week it would be fun to mention some interesting studies about influenza, the vaccine and flu immunity that have come out in the last 2 years. This is not meant to be anything more than a compilation of articles I thought were interesting, and the only purpose is to give a hint as to the complexities of influenza and vaccination. (more…)
It has been tough in Portland this year. The Trailblazers, our NBA, and only professional team, started out on a tear, then went right down the toilet. It is painful to see such promise dribbled away. Sigh. Why is elation always followed by disappointment? Everyone and everything has feet of clay. Except Cassius Marcellus.
At the beginning of March the NEJM had a wonderful essay, What’s the Alternative? The Worldwide Web of Integrative Medicine by Ranjana Srivastava. The essay concerns a patient who is ‘diagnosed’ with cancer at an integrative medicine exhibition and the resultant diagnostic and therapeutic debacles that follow.
I do not understand the interest many appear to have in their bowels and the movement there of. But then, I pay little attention to most of my body functions as long they are functioning within reasonable parameters, and as I get older the definition of reasonable is increasingly flexible.
The elderly especially seem to obsess about their bowels. My theory is that since they have often lost taste, smell, hearing and are alone with little direct human touch, a good BM is the only remaining physical joy left, and when it is compromised they are understandably upset.
Still, the concept of colonics for ‘detoxification’ strikes me as more humorous than repellent, despite the lack of efficacy and documented complications of the procedure. Under normal circumstances, when it comes to the colon it is probably better to be removing substances than to be introducing them. (more…)
It all seemed so easy
In 2010 an article was published in the New England Journal of Medicine, Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus . Patients were screened for Staphylcoccus aureus ( including MRSA, methicillin resistant Staphylococcus aureus) and those that were positive underwent a 5 day perioperative decontamination procedure with chlorhexidine baths and an antibiotic, mupirocin, in the nose. The results were impressive. Before the intervention the infection rates were 7.7 % and after the intervention it was 3.4 %. That is an impressive drop in surgical infections.
One of the orthopedic groups approached us (us being the hospital administration, pharmacy, nursing and infection control, of which I am Chair) to implement the protocol in their patients, citing a similar study on an orthopedic population. Great. It should be an easy enough intervention. I should have known better, of course, long experience has continually demonstrated that what appears to be simple never is.
First was the question as to whether the study was applicable to our patients. Resources were going to be devoted to an intervention, so going forward we had to demonstrate that the bang would be worth the buck. These are financially lean times, with cutbacks and declining reimbursement, so every expenditure of time and money needs to be justified. In the bizarro accounting of health care, not every hospital administration will include money saved in the evaluation of interventions, only the money spent. I work in a hospital system with a remarkably strong commitment to patient safety and quality, so there was little worry on that point. (more…)
I’m not here to convince people that we are right, although it would be nice if it turned out that way. I’m here to tell the truth and let readers decide for themselves.“
I had been too inarticulate to formulate what is essentially my approach to this blog: to tell the truth. That would appear to be simple enough. Of course it gets down to what constitutes the truth, and whether you can handle the truth.
What is truth, small ’t’? Truth with a big ’T’ is provided by belief systems that originate in a personal epiphany and you suddenly understand the meaning of life, the universe and everything. Or conjure up reiki or chiropractic. I suspect I was either born without the part of the brain that allows me to appreciate the mystical/spiritual aspects of human existence, or perhaps it was my upbringing. Probably a bit of both, although having raised two kids in the eternal nurture/nature debate has swayed me heavily towards the nature side of the fence. I bet I was born that way. But I am totally tone deaf to issues of spirituality and the surrounding issues of big ’T’ Truths, so I am going to stick to the little ’t’ truths. (more…)
I start these entries about a week before their due date, and when I saw Dr Hall’s Applied Kinesiology (AK) post from Tuesday, I thought the heck, there goes my post for Friday. After reading Harriet’s post, I think mine will be both complementary and alternative, and perhaps even integrative, to her entry. I do have one quibble with her post. She said
“we skeptics don’t dismiss AK just because it sounds silly.”
AK doesn’t just sound silly, it is silly. I have found over the years writing for SBM that I have developed an increasing bias around the concept of prior probability. As best I can tell there is a well described reality, and that reality constrains what is not only probable, but what is possible. Within the limitations of our current understanding of reality, some processes are impossible, i.e. have zero prior probability. AK’s prior probability is exactly zero. I sometimes think the blog should be called Reality Based Medicine. Science gives us understanding of reality and AK, like many a SCAM (Supplements, Complementary and Alternative Medicine) discussed in this blog, parted company with reality from the beginning.
This blog has two often overlapping purposes. Blogs offer timely commentary on contemporary issues, and this blog certainly fills that role. More than other blogs, SBM also has the opportunity to be a reference source on various SCAM’s . I have had the recent opportunity to reread the entire oeuvre of SBM, and it is impressive in the breadth and depth of topics covered in its three plus years. It is not yet encyclopedic and there are many topics not yet reviewed in the blog, such as Applied Kinesiology. So many many SCAM’s, so little time. (more…)
Medicine is simultaneously both easy and hard. As an Infectious Disease doctor, my day can be summed up with the phrase “me find bug, me kill bug, me go home.” Sometimes it is just that simple. A lot of the time it isn’t. I may not be certain what the infection is, or even if the patient has an infection, or allergies and/or antibiotic resistance limit therapeutic options, the host has co-morbidities that limit effectiveness, and the patient has no financial resources for the needed treatment.
I am lucky, since most infections are acute, make people feel terrible, and require a relatively short course of therapy during which the patient feels better. I rarely have to worry about compliance with the treatment plan; it is the rare patient, usually a heroin user or a particularly irascible old man, who will not follow through with their antibiotic course. I do not have to worry about chronic or symptomless diseases like diabetes or hypertension or the complications of obesity where long term compliance often limit therapeutic success. Long term it is difficult for many people to stick with their therapeutic plan, much less their diet and exercise resolutions.
It is hard to Sokalize alternative medicine. The closest has been buttock reflexology/acupuncture, but that is a tame example. Given the propensity for projections of the human body to appear on the iris, hand, foot, tongue, and ear, postulating a similar pattern on the buttocks are simple variations on a common SCAM (Supplements, Complementary and Alternative Medicine) theme. The buttocks? Not really different from any of the other focal acupunctures. Most of SCAM does not concern itself with application of reality and physiology, anatomy, biochemistry, etc can all be expected to be ignored with virtually all SCAM modalities.
Every time I think the heights (or depths) of absurdity has been reached, I discover a Braco the Starer or Himalayan Salt Inhalers. This blog is not affiliated with the British Medical Journal in any way, and although this is being published near Christmas, I want no one think that what follows is a hoax. I am not, I repeat not, making up what follows. It is not fiction. Well, it is fiction, but not written by me and believed and practiced by some who really should know better.
I have never belonged to the American Medical Association. As a student I didn’t want to pay the dues. As a practicing physician I am of the opinion that the AMA has two often mutually exclusive goals (promoting physician income and patient care) and they are doing both badly.
In the 1990’s the AMA entered into a contract with Sunbeam to get an AMA seal of approval for Sunbeam products, but due to objections the AMA backed out of the deal, in the end costing them almost 10 million dollars.
As was noted at the time:
“I think if we’d gone to trial,” Dr. Relman said on Saturday, ”probably a lot more relevant information would have been uncovered and made available to the membership. As a result of this settlement, we will never know the truth of what happened. It does not let the sun shine in.”
Yeah AMA. It is probably for good reason that only around 29% f of US physicians belong to the AMA; I have never seen them as representing me or my patients. Whether the AMA or physicians, I am automatically suspicious of any person or institution who puts their seal of approval on a product. I figure they are only doing it for the money. Not that there is anything wrong for that; I am for sale if anyone can meet my price. Trusting endorsements is like George Carlin’s (I think) observation that he did not like doing standup for stoners since you never know if was the act or the dope that lead to the laughter. I know celebrities are paid for their endorsements; it is not conflict of interest when it is your job to sell a product. At least actors say they only play a doctor on TV. But when professionals use their authority to recommend products, I would love to see a conflict of interest statement in the recommendation.
When I give a lecture I have to mention my conflicts of interest (COI)* and I have to specifically confirm or deny that I will mention products in which I have a financial interest^. The COI rules are nice, so you know, sort of, who has an interest in pleasing their corporate masters, although I suspect most doctors do not take COI statements seriously. At IDSA this year most of the speakers gave their COI statements with a short, dismissive sneer and a roll of the eyes. Me? Potentially Biased? Puh-please. (more…)