One can only imagine how annoyed Twain would have been had he known about opinion polls.
Mark Twain popularized the phrase, “There are three kinds of lies: lies, damned lies, and polls and surveys.” (He may have said “statistics” at the end, but I think this version works as well.)
A new Harris Poll on “alternative medicine” nicely demonstrates some of the problems with polls. The biggest problem is how you frame the questions. You can dramatically affect the results of the poll by exactly how a question is phrased, which other questions come before or after the question, and the overall context of the poll.
In essence a poll is a two-way form of communication. While it is meant to derive information from the subjects of the poll, those subjects are also receiving information from the poll itself. That is the very reason for “push polling” – which is the practice of disguising campaigning messages as a poll. (“On a scale from 1-5, how much are you bothered by the fact that candidate X is a misogynist?”). Yes, Prime Minister has an amusing example of this practice in action.
Interpreting the results of a poll is also not straightforward. You have to know how the subjects of the poll interpreted the questions, and what factors might affect their response. (more…)
Recently I had a cutaneous abscess which was treated (quite painfully) with incision and drainage. My doctor told me that antibiotics were not strictly necessary, but I could have them if I wanted. The idea of any treatment that could resolve the abscess more quickly was appealing, but I did not want to contribute to the unnecessary use of antibiotics so I declined.
The use of antibiotics in cutaneous abscess is not straightforward, as there are indications – signs of systemic infection, failure to resolve quickly with just I&D, or in immunocompromised patients. Antibiotics may also reduce the risk of recurrence. These are, after all, bacterial infections.
If I were not very familiar with the issue of antibiotic overuse and emerging resistance I probably would have caved and accepted the antibiotics, and I suspect most patients do. Many patients probably request antibiotics or at least ask about them. I declined, and everything turned out fine. (more…)
David and Collet Stephan, parents to the now-deceased Ezekiel Stephan.
This is a very sad and tragic case, and I have great sympathy for the extended family of Ezekiel Stephan, the 19-month-old who died of meningitis four years ago. In my opinion, there are many victims in this case.
The jury, apparently, agreed. Yesterday they returned a guilty verdict for Ezekiel’s parents, David and Collet Stephan, who now face sentencing for failing to provide the basic necessities of life to their son. It is reported that many of the jurors were crying when the verdict was given – clearly this was a difficult and emotional case.
Just the facts
As is often the case, there are different narratives of what happened, depending on your perspective. It is likely the jury had access to more facts than the public, and so their verdict, which was clearly difficult, needs to be taken seriously. Here are the basic facts as being reported:
In March of 2012 Ezekiel became ill with flu-like symptoms. His parents report that they thought this was a normal childhood illness and would pass. His mother reported to police that she thought he had croup. They treated him with natural remedies, mostly supplements. (more…)
Placebo effects help you feel better, they don’t make you actually better.
It is almost inevitable that whenever we post an article critical of the claims being made for a particular treatment, alternative philosophy, or alternative profession, someone in the comments will counter a careful examination of published scientific evidence with an anecdote. Their arguments boils down to, “It worked for me, so all of your scientific evidence and plausibility is irrelevant.”
Both components of this argument are invalid. Even if we grant that a treatment worked for one individual, that does not counter the (carefully observed) experience of all the subjects in the clinical trials. They count too – I would argue they count more because we can verify all the important aspects of their story.
I want to focus, however, on the first part of that statement, the claim that a treatment “worked” for a particular individual. Most people operationally define “worked” as, they took a treatment and then they improved in some way. This, however, is a problematic definition on many levels.
Much of the disagreement about how to define “works” comes down to placebo effects. The generally-accepted scientific approach is to conclude that an intervention works when the desired effect is greater than a placebo. When all other variables are controlled for, the intervention as an isolated variable is associated with an improved outcome. That is the basic logic of a double-blind placebo controlled trial.
Alternative medicine, like all good marketing, is largely about creating a narrative. Once you have sold people on the narrative, products essentially market themselves. That narrative has been evolving for literally centuries, although it seems to have accelerated with the advent of mass media and now the internet. It is optimized to push emotional buttons in order to sell products.
There are countless examples available on the internet, with many peaking above the crowd for their 15 minutes of fame. In my feed this morning came this typical example: “Cancer Cells Die In 42 Days: This Famous Austrian’s Juice Cured Over 45,000 People From Cancer And Other Incurable Diseases!“
The story has many of the typical alternative medicine narrative talking points: natural is good, a healthful diet can cure anything, anti-inflammatory, anti-oxidants, and detoxification are all good.
Borrelia burgdorferi, the spirochete bacteria that causes Lyme disease.
While Lyme disease itself is a real and often serious infectious illness, the existence and proper treatment of so-called chronic Lyme disease is dubious, and some would say controversial. However, like many controversies we cover, the science itself is not very controversial, but the topic is made so by a persistent minority of outliers who refuse to accept the scientific consensus.
The issue has been raised yet again by a study published recently in The New England Journal of Medicine: “Randomized Trial of Longer-Term Therapy for Symptoms Attributed to Lyme Disease.” The study was negative, but I will get into the details below.
Lyme in an infection caused by the bacteria Borrelia burgdorferi, and related species. In Europe the infecting species are B. afzelii and B. garinii. These bacteria are spirochetes, which refers to their spiral shape. They are related to the bacterium which causes syphilis, Treponema pallidum, which is also a spirochete.
Syphilis and Lyme both have three stages of illness – a primary infection, secondary symptoms, and then a persistent tertiary syndrome. With Lyme disease, stage 1 involves local infection, including headache, fever, chills, and local arthritis. Stage 2 is disseminated Lyme, including the classic target- or bullseye-shaped rash at the site of the bite, pain, weakness, fatigue, and diffuse arthritis. Stage 3 is persistent late stage infection, and includes ongoing stage 2 symptoms, heart involvement, and neurological involvement. (more…)
If your friend is getting chemotherapy, they need sympathy and support – not advice.
I understand the impulse, but you are well-advised to resist it. When someone you know has a serious illness, maybe even dying, you want to say something to them that is helpful, positive, and hopeful. The hopeful tone takes away some of the sting and the awkwardness of not knowing what to say to someone who just told you they are dying.
The problem with this approach is that you risk making the other person feel worse just so you can make yourself feel temporarily better, to ease the discomfort of that one encounter. It is really easy to rationalize this behavior to yourself; you are just trying to be helpful.
There are multiple problems with this approach, however. The first is that it makes the person with an illness feel terrible. As Steven Thrasher said in a recent excellent editorial (which you should read in full): (more…)
The company Halo Neuroscience is now offering a device, the Halo-Sport, which they claim enhances sports performance through “neuropriming.” Their website claims:
Neuropriming uses pulses of energy to increase the excitability of motor neurons, benefiting athletes in two ways: accelerated strength and skill acquisition.
Regular readers of SBM can probably see where this is going.
A proper threshold of evidence
Before I get into the details of this product, I want to back up and discuss some basic principles. There is a clear pattern that has played itself out countless times on SBM or with regular authors on SBM in their other outlets. A person, company, or industry makes a clinical medical claim. We examine the evidence and find it wanting, and state so. Believers in the claim then attack us for being shills, closed minded, and/or failing to do our research.
The heart of Federico Infascelli’s questionable claims.
Retraction Watch is a great website. As the name implies, it focuses on a key aspect of quality control in science, the retraction of scientific papers that have already passed peer-review and were published when serious concerns about those papers come to light.
Retracting published papers is similar to phase IV clinical trials – tracking side effects of drugs that have already been approved and are on the market so regulatory agencies can monitor for post-marketing concerns and recall the drug if necessary.
Recently the journal animal retracted a paper by Italian researcher, Federico Infascelli. Here is there announcement:
From late September 2015, we received several expressions of concern from third parties that the electrophoresis gels presented might have been subject to unwarranted digital manipulations (added and hidden bands or zones, including in the control samples and the DNA ladder). A detailed independent investigation was carried out by animal in accordance with the Committee on Publication Ethics (COPE) guidelines. This investigation included an analysis of the claims using the figures as submitted, and reassessment of the article by one of the original peer-reviewers in light of the results of the analysis. The authors were notified of our concerns and asked to account for the observed irregularities. In the absence of a satisfactory explanation, the institution was asked to investigate further. The University of Naples concluded that multiple heterogeneities were likely attributable to digital manipulation, raising serious doubts on the reliability of the findings.
Based on the results of all investigations, we have decided to retract the article.
The greatest strength of science is that it is self-critical. Scientists are not only critical of specific claims and the evidence for those claims, but they are critical of the process of science itself. That criticism is constructive – it is designed to make the process better, more efficient, and more reliable.
One aspect of the process of science that has received intense criticism in the last few years is an over-reliance on P-values, a specific statistical method for analyzing data. This may seem like a wonky technical point, but it actually cuts to the heart of science-based medicine. In a way the P-value is the focal point of much of what we advocate for at SBM.
Recently the American Statistical Association (ASA) put out a position paper in which they specifically warn against misuse of the P-value. This is the first time in their 177 years of existence they have felt the need to put out such a position paper. The reason for this unprecedented act was their feeling that abuse of the P-value is taking the practice of science off course, and a much needed course correction is overdue. (more…)