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Acupuncture CME

Some Universities have more cachet than others. On the West coast it is Stanford that has the reputation as the best. There is Oxford, Yale, MIT, and maybe Whatsamatta U. I would wager that in most people’s mind the crème de la crème is Harvard. Harvard is where you find the best of the best. If Harvard is involved, a project gains an extra gobbet of credibility. Brigham and Women’s Hospital also has a similar reputation in the US as one of the hospitals associated with only Harvard and the New England Journal of Medicine. Premier university, premier hospital, premier journal.

So if Brigham and Women’s Hospital and Harvard Medical School are offering continuing medical information (CME) for acupuncture, there must be something to it, right? A course called “Structural Acupuncture for Physicians” must have some validity.

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Posted in: Medical Academia, Science and Medicine

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Medical Voices: Always in Error, Never in Doubt

I have discussed two articles from the web site Medical Voices, one with 9 questions, the other on mumps. There are, I think, 18 web pages of articles about vaccines on that web site. I am uncertain as to the true number of pages of information as the navigation buttons at the bottom of the pages do not always seem to function correctly. That such a problem exists suggests that no one has bothered, like me, to go through the web site to read all the essays. Or maybe it is me and the price of using the Chrome browser. Anyway, there are a large collection of essays that serves as a rich vein of iron pyrite to mine for topics. At about 5 entries to a page, evaluating at a pace of about one monthly, it would take years to analyze all the misinformation on Medical Voices.

It occurs to me that at the center of each article is a nut of misinformation (or sometimes as many as nine) that serves as the core fallacy of that article. I want to emphasize that I am using ‘nut’ as a metaphor for seed, not in its other, more colloquial, meaning. So rather than an in-depth evaluation of each article (although some will warrant a future, more through review), I thought it would be interesting to identify the nut in each article and why it is wrong. So, in the spirit, but not the intellectual rigor, of Generation Rescue‘s “14 Studies“, let’s sort through the nuts …

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Posted in: Science and Medicine, Vaccines

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Mumps

I write this post with a great deal of trepidation. The last time I perused the Medical Voices website I found nine questions that needed answering. So I answered them. One of the consequences of that blog entry was the promise that Medical Voices was poised to “tear my arguments to shreds.” Tear to shreds! Such a painful metaphor.

They specified that the shred tearing would be accomplished during a live debate, rather than a written response. While Dr. Gorski gave excellent reasons why such a debate is counterproductive, I am disinclined for more practical reasons. I am a slow thinker and a lousy debater and have never, ever, won a debate at home. If I cannot win pitted against my wife, what chance would I have against the combined might of the doctors and scientists at Medical Voices? My fragile psyche could not withstand the onslaught.

Still, there is much iron pyrite to be mined at Medical Voices and it may provide me for at least a years worth of entries. Please forgive me if I seem nervous or distracted. I have a Sword of Damocles hanging over my head and it may fall at any time. My writings may, without warning, be torn to pieces by the razor sharp logical sword of Medical Voices. Or maybe not. It is my understanding that Medical Voices will only answer with a debate, so maybe I am safe from total ego destruction.

This month, as I perused Medical Voices, I found it difficult to choose an article. So much opportunity and I have limited time to write. I finally decided on Why the New Mumps Outbreak Puts You At Risk by Robert J. Rowen, MD.
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Posted in: Science and Medicine, Vaccines

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Lying Liars and their Lying Lies

Carlyle said “a lie cannot live.” It shows that he did not know how to tell them.

— Mark Twain

There is an infamous hoax from last century called The Protocols of the (Learned) Elders of Zion, an anti-Semitic text purporting to describe a plan to achieve global domination by the Jewish people. Despite the fact that the Protocols is a work of fiction, there have been and still are folks who believe it to be real, from Hitler on down. (Or is that “on up”? Can one be lower than Hitler? And have I already committed a breach of Godwin’s Law?)

Inventing apparently legitimate information is a useful propaganda device not limited to anti-Semites. Having people appear evil or uncaring using their own words is far more effective than calling them evil and uncaring.

There are many in the community who suffer from a variety of complaints that I cannot diagnose, and, as people do not like uncertainty about their health, they will find someone who will give them a diagnosis. Not infrequently they will come upon the idea of chronic Lyme disease.

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

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Epiphany

The Institute of Medicine report is a frequent ‘rebuttal’ to science based/real medicine. The argument is usually phrased something to the effect that since medicine can be dangerous, SCAM’s are legitimate. Of course, one does not follow the other. It is the equivalent of saying since you are old, bald and pudgy, I am young, have a full head of hair, and are thin. If every doctor and hospital were to vanish tomorrow like an episode of the Outer Limits, SCAM’s would be just a ineffective.

Despite the flawed logic of the comparison, I have always had an affinity for the estimates that 44,000 to 98,000 were (note the deliberate use of the past tense) killed each year in hospitals. There may be methodological flaws in the estimate but the ballpark figure is probably correct.

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Posted in: Public Health, Science and Medicine

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Nine Questions, Nine Answers.

This is not an easy blog to write.  Doctors Novella and Gorski want the entries to be formal, academic, referenced, with a minimum of snark.

For the most part I comply. But sometimes. Sometimes. It is hard, so hard,  not to spiral into sarcastic diatribes over the writings that pass for information on the interwebs. How should one respond to profound ignorance and misinformation?  I wish, sometimes, that I could be an irascible computer as well.

What brings on this particular bit of angst is a bit of whimsy on the Internet called “9 Questions That Stump Every Pro-Vaccine Advocate and Their Claims.”  by David Mihalovic, ND. Mr. Mihalovic identifies himself as “a naturopathic medical doctor who specializes in vaccine research.” However, just where the research is published is uncertain as his name yields no publications on Pubmed.  BTW. I specialize in  beer research.  Same credentials.

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Posted in: Vaccines

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NDE Update

Back in 2008 I wrote on Near Death Experiences (NDE’s). I have an interest in this topic as I have frequent exposure to near death; my wife has a predilection for watching Judge Judy. Since 2008 there have been a few studies on the topic of NDEs as researchers try and find evidence that consciousness transcends the brain, if that is what a NDE represents. I have also been ill for most of the last week and have not had the usual time to spend generating typos to drive some readers to distraction. Fortunately, I have a miracle cure that is 100% effective in resolving all my self-limited illnesses: time. It passed and with it the illness. As a result I am about 10 days behind in the commitments in my life, so this will be a shorter than usual post.

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Posted in: Basic Science, Faith Healing & Spirituality

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Outbreaks

There have been, in the last 20 years, natural, or perhaps unnatural, experiments that have helped shed light on the efficacy of vaccines.  Many societies, for reason of political unrest, religion, or a lack of understanding of science and medicine have seen the rates of vaccination decline and, with that decline, an increase in the cases of vaccine-preventable diseases.

Infectious disease spread in populations is not simple.  Hygiene, nutrition, access to health care, and education all play a role in the spread of communicable diseases.  Vaccines have been critical in driving the rates of vaccine preventable illnesses to almost zero, but they are not the only intervention in our armamentarium. (more…)

Posted in: Public Health, Vaccines

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Just the Facts

Get your facts first, and then you can distort them as much as you please.

—Mark Twain

There is an educational approach to becoming a doctor. It involves learning massive amounts of basic science, followed by massive amounts of pathophysiology, which barely prepares you for the clinical years of the last half of medical school and subsequent residency, with the massive knowledge dump you will have to absorb. Much of the information is given by experts in the field, usually MDs or PhDs (or both), who lecture formally and informally. Being considered an expert in infectious disease (ID) at a teaching hospital, I now spend hours a day yammering on about infections to anyone who will listen, students in all the medical fields who rotate through our hospitals. I value the facts I have learned in my field and respect those who have worked to provide me with the information. I greatly value facts and the people who provide them.

Most of the information I get in medicine is from those in the field. It is rare for people to write about aspects of medicine that I will take seriously. Yes, there are a lot of people who write on the web about medicine, but given what it takes to achieve even a solid knowledge in medicine, much less develop expertise, I usually can’t take them too seriously. Call me arrogant, but if you want to be a legitimate source of information there are dues that have to be paid.

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Posted in: Science and Medicine, Vaccines

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Changing Climate, Changing Infections

I will state my bias up front.  I am convinced by the preponderance of data in favor of man made global warming.  At the most simplistic level, I can’t see how converting humongous tons of fossil fuel into C02 and dumping it into the the atmosphere cannot have effects on the climate.  To my mind its like determining vaccine efficacy or evolution.  Plausible mechanism(s), good basic science, multiple studies using different lines of evidence that all come to the same conclusion.  There are lots of fine points and nuances to be worked out, but the basic truth is reasonable and well defined. Infectious diseases lend some validation to the concept that world is warming, since with global warming will come a variety of infectious diseases.
It is one big IF THEN statement.  IF global warming, THEN infections.  Of course the if the IF is not true, then the THEN doesn’t follow.
There is the weather, which the Action Channel News never seems to get right, and I will spare you the Mark Twain quote even though I think he is our best writer ever,  and there is the climate, the summation of weather over time.
Interestingly, infections have probably altered climate for short periods of times.  Through history humans burned trees releasing C02, chopped down forests for agriculture and raised animals, releasing methane.  As humans populations increased, both C02 from burning and methane from animals increased as well.  Every now and then large numbers of people have died off.  It happen when Columbus et. al. brought infections to the New World and when plague came to the Old.  People died.  Maybe 90% in the Americas (estimates vary widely) and 2/3’s of Europe died.  As a result, burning and agriculture decreased, decreasing emissions and forests grew back, sequestering C02.  And temperature rise slowed or decreased (http://stephenschneider.stanford.edu/Publications/PDF_Papers/Ruddiman2003.pdf).
“Abrupt reversals of the slow CO2 rise caused by deforestation correlate with bubonic plague and other pandemics near 200-600, 1300-1400 and 1500-1700 A.D. Historical records show that high mortality rates caused by plague led to massive abandonment of farms. Forest re-growth on the untended farms pulled CO2 out of the atmosphere and caused CO2 levels to fall. In time, the plagues abated, the farms were reoccupied, and the newly re-grown forests were cut, returning the CO2 to the atmosphere…Moreover, if plague caused most of the 10-ppm CO2 drops… it must also have been a major factor in the climatic cooling that led from the relative warmth of 1000 years ago to the cooler temperatures of the Little Ice Age.”
Like all good scientists, he notes the problems with his conclusions
“A more complete assessment of the role of plague- driven CO2 changes in climate change during the last millennium would require a narrowing of uncertainties in both the spatial and temporal occurrence of plague and in the amount of farm abandonment (and reforestation), as well as a resolution of the inconsistencies among the CO2 trends from different Antarctic ice cores.”
This kind of study will never be reported in the Atlantic; too much nuance.
It is not the correction for global warming I would suggest, an Earth Abides die off of humans.  But it is an fascinating association between infectious human deaths and global warming.
As the weather changes, for a week, a season, or a over longer period of time, the incidence and distributions of  infections change.  Infections could increase or decrease due to something as simple as temperature or humidity.
Or it could be more complex.  Increase rainfall could lead to more food, which could lead to a boom in the rodent population leading to more interactions of humans and mice and the next thing you know you have bubonic plague in India or Hanta virus outbreak in the four corners of the US.
The daily weather makes a difference in infection risk.  My favorite example is Legionella pneumonia, which increases shortly after thundershowers and humid weather.  It explains why we do not have a lot of Legionella in the NW despite all the rain; it is rarely hot and humid.
In Philadelphia  Legionella
“Cases occurred with striking summertime seasonality. Occurrence of cases was associated with monthly average temperature (incidence rate ratio [IRR] per degree Celsius, 1.07 [95% confidence interval [CI], 1.05-1.09]) and relative humidity (IRR per 1% increase in relative humidity, 1.09 [95% CI, 1.06-1.12]) by Poisson regression analysis. However, case-crossover analysis identified an acute association with precipitation (odds ratio [OR], 2.48 [95% CI, 1.30-3.12]) and increased humidity (OR per 1% increase in relative humidity, 1.08 [95% CI, 1.05-1.11]) 6-10 days before occurrence of cases.”
I ask the housestaff to look for Legionella after thundershowers and I usually get a case or two, although it may just be due to increased diagnostic testing.
Can you catch a cold when the weather is cold? Maybe.  It has been a topic of interest for years (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2279651/)
“The average outdoor temperature decreased during the preceding three days of the onset of any RTIs, URTI, LRTI or common cold. The temperature for the preceding 14 days also showed a linear decrease for any RTI, URTI or common cold.  (http://www.ncbi.nlm.nih.gov/pubmed/18977127).”
More interesting are the infections associated with El Nino oscillations, where the ocean temperatures vary on a 3 to seven to year cycle, leading to alternating wet and dry weather.  As a result
“In North America, El Niño creates warmer-than-average winters in the upper Midwest states and the Northwest, thus reduced snowfall than average during winter. Meanwhile, central and southern California, northwest Mexico and the southwestern U.S. become significantly wetter while the northern Gulf of Mexico states and Southeast states (including Tidewater and northeast Mexico) are wetter and cooler than average during the El Niño phase of the oscillation. Summer is wetter in the intermountain regions of the U.S. The Pacific Northwest states, on the other hand, tend to experience dry, mild but foggy winters and warm, sunny and early springs.”
Changes due to the El Nino lead to changes in the incidence of a huge variety of infections: an example, I think, from WHO.
Climate change will affect the distribution of disease vectors such as insects and snails.  Vectors may thrive with increased temperatures or they may die off, but more likely the vectors, like mosquitos, will move.  It has been estimated that half of everyone who has every died has died from a mosquito borne illness (I admit I heard this numoerous times at ID lectures but do not have reference, at least there is a solution . http://mashable.com/2010/02/12/mosquito-death-ray-video/).  As it gets warmer, mosquitos can either go up in elevation or North.  It seems that they are doing both.
– Dengue has appeared at higher altitudes than previously reported in Costa Rica (at 1,250m),and in Colombia and India (at 2,200m).The previous range was temperature limited to approximately 1,000 metres above sea level.
– In Mexico, the dengue vector (Aedes aegypti) has been detected at 1,600 metres; transmission of dengue was unknown above 1,200m before 1986. There have been cases of dengue near or above the altitude or latitude limit of transmission and would be vulnerable to the small increases in temperature that have occurred across these regions.
– Other examples of climate-related changes in the prevalence or distribution of pathogens and their vectors include the resurgence of Mediterranean spotted fever in Spain and Italy, the recent epizootic of African horse sickness in Iberia,the resurgence of plague in parts of southern Africa,increased incidence and geographic spread of algal blooms, outbreaks of opportunistic infections among seals,and the spread and establishment of pathogens and vectors in Switzerland.  http://archive.greenpeace.org/climate/impacts/erwin/3erwin.html
– Dengue has, by serology, infected 40% of the populations of Brownsville Texas, as the disease slowly moves north.
“In the fall of 2004, during a period of endemic dengue transmission, a cross-sectional survey was conducted in these two cities,4 and dengue incidence and prevalence were measured. In Brownsville, the incidence was 2%, which, if extrapolated to the 2005 population of the city (using the 95% confidence interval), projected between 837 and 5,862 recent infections. Similarly, the prevalence was 40%, with a range from 56,948 to 75,372; these values are relatively similar to those obtained from Brownsville in 2005. http://www.ajtmh.org/cgi/content/full/78/3/361″
More than mosquito born illnesses are changing in prevalence.  Hanta is increasing in Belgium.  There has been increased temperature which has lead to increased broadleaf trees, with increased seeds, with increased voles, which carry Hanta, which infected humans to cause renal failure (http://www.ij-healthgeographics.com/content/8/1/1).
Oceans are getting warmer and supporting infections.  Vibrio was not found in Alaskan oysters as the water was too cold.  The water temperature was always less than 15 C.  No longer.  The mean temperature has increased each year since 1997  and now supports the growth of V. parahaemolyticus with resultant outbreaks (http://content.nejm.org/cgi/content/abstract/353/14/1463).  Many other infectious diseases are increasing as well http://www.thebulletin.org/web-edition/columnists/laura-h-kahn/the-threat-of-emerging-ocean-diseases.
However, not all is doom and gloom.  Some infections may fade with global warming. For example, RSV may be disappearing as England warms.
“The seasons associated with laboratory isolation of respiratory syncytial virus (RSV) (for 1981–2004) and RSV‐related emergency department admissions (for 1990–2004) ended 3.1 and 2.5 weeks earlier, respectively, per 1°C increase in annual central England temperature ( and .043, respectively). Climate change may be shortening the RSV season. http://www.journals.uchicago.edu/doi/abs/10.1086/500208.”
Diseases that may increase in the US or become endemic again include malaria, dengue, and Leishmaniasis.  A 4 degree rise in temperature could allow dengue to exist as far north as Winnipeg and malaria to be in all of Europe. Seems to be a good trade off to me: more dengue and malaria, less RSV.
Good times for an infectious disease doctor.
These studies are representative of the literature, not a comprehensive review of the topic.  Personally, I find this adjunctive data compelling  support of global warming, at least over recent times (deliberately worded to not commit to the meaning of recent.)  This does not include all the other potential interactions between human behaviors and changes in the weather to result in an increase in infectious diseases.  Even simple local changes can lead to the unexpected increase in the risk of diseases.
“Adjustable rate mortgages and the downturn in the California housing market caused a 300% increase in notices of delinquency in Bakersfield, Kern County. This led to large numbers of neglected swimming pools, which were associated with a 276% increase in the number of human West Nile virus cases during the summer of 2007.”   http://www.cdc.gov/eid/content/14/11/1747.htm
All the neglected pools became mosquito breeding grounds, and the disease spread was exacerbated in part by a drought that altered bird populations from resistant finches to susceptible sparrows that were not immune to west nile, allowing the disease to spread.  The result, I suppose, of failed flock immunity.
Imagine how war, human migration, starvation will interact with climate change to increase or alter the spread of malaria, Tb and some infection that no one can predict.  If H1N1 proved anything, it is whatever new infection will sweep  across the county, it will not be the infection we predict. Who would have thought in 1989 that the next decade would see West Nile virus, never seen the the US, arrive to the continent in a migrating goose and become endemic.
Maybe its just the weather, the season, or the climate.  I think these are a few interesting infectious disease associations that lend credence to climate change.

“Conversation about the weather is the last refuge of the unimaginative.” – Oscar Wilde

I will state my bias up front.  I am convinced by the preponderance of data in favor of man made global warming.  At the most simplistic level, I can’t see how converting humongous tons of fossil fuel into CO2 and dumping it into the the atmosphere cannot have effects on the climate.  To my mind its like determining vaccine efficacy or evolution.  Plausible mechanism(s), good basic science, multiple studies using different lines of evidence that all come to the same conclusion.  There are lots of fine points and nuances to be worked out, but the basic truth is reasonable and well defined. Infectious diseases lend some validation to the concept that the world is warming, since with global warming comes a variety of infectious diseases.

It is one big IF:THEN statement.  IF global warming, THEN infections.  Of course  if the IF is not true, then the THEN doesn’t follow.

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