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Anecdotes: Cheaper by the Dozen

A loan officer sets up a meeting with an aspiring entrepreneur to inform him that his application has been denied. “Mr Smith, we have reviewed your application and found a fatal flaw in your business plan. You say that you will be selling your donuts for 60 cents apiece. “Yes” says Mr. Smith, “that is significantly less than any other baker in town. This will give my business a significant competitive advantage!” The loan officer replies, “According to your budget, at peak efficiency the cost of supplies to make each donut is 75 cents, you will lose 15 cents on every donut you sell. A look of relief comes over Mr. Smith’s face as he realizes the loan officer’s misunderstanding. He leans in closer, and whispers to the loan officer “But don’t you see, I’ll make it up in volume.”

If you find this narrative at all amusing, it is likely because Mr. Smith is oblivious to what seems like an obvious flaw in his logic.

A similar error in logic is made by those who rely on anecdote and other intrinsically biased information to understand the natural world. If one anecdote is biased, a collection of 12 or 1000 anecdotes multiplies the bias, and will likely reinforces an errant conclusion. When it comes to bias, you can’t make it up in volume. Volume makes it worse!

Unfortunately human beings are intrinsically vulnerable to bias. In most day to day decisions, like choosing which brand of toothpaste to buy, or which route to drive to work, these biases are of little importance. In making critical decisions, like assessing the effectiveness of a new treatment for cancer, these biases may make the difference between life and death. The scientific method is defined by a system of practices that aim to minimize bias from the assessment of a problem.

Bias, in general, is tendency that prevents unpredjudiced consideration of a question (paraphrased from dictionary.com). Researchers describe sources of bias as systematic errors. A few words about random and systematic errors will make this description clearer.
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Posted in: Clinical Trials, Science and Medicine

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Blonde Blood

Two scientists walk into a bar
The first one says “I’ll have some H2O.”
The second one says, “I’ll have some H2O too.”
Then he dies.

I have come to believe in my own version of The Secret.

The Secret describes the law of attraction as a natural law that determines the complete order of the universe and of our personal lives through the process of “like attracts like. The author claims that as we think and feel, a corresponding frequency is sent out into the universe that attracts back to us events and circumstances on that same frequency.

Obviously not true as I have yet to win Powerball. But a variant of the Secret is kind of creepy. As soon as I learn about a new concept, in medicine or life, I start to see it. All the time. Perhaps my learning a new concept causes it to spring forth like Athena. I would have said instantiate, but I got all sorts of grief when I used that word last time. For example, shortly after reading a review of infections in patients with Osler-Weber-Rendu,  I saw a case. Creepy. As I drive from hospital to hospital I listen to Audible books and it is equally creepy how often I see a word in my visual field that is identical to the word I am listening to. (more…)

Posted in: Science and Medicine

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CAM Docket: Functional Endocrinology

 

One of the signature abilities of CAM practitioners is the creation of new diagnostic methods and treatments which convincingly demonstrate they have only a superficial understanding of human physiology. Here at SBM, posts have addressed such sterling examples of this phenomenon as cranial sacral therapy, applied kinesiology and chiropractic neurology. Now we have a new one on the horizon: functional endocrinology.

I don’t know who thought up this idea, but a primary promoter appears to be a Colorado chiropractor, Brandon Credeur, a 2002 graduate of Parker Chiropractic College in Texas. In additional to operating the Functional Endocrinology Center of Colorado, in Denver (where he practices with his wife, Heather Credeur, D.C.), he sold (and may still be selling) practice-building courses on functional endocrinology to other chiropractors.

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Posted in: Science and Medicine

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“Moneyball,” the 2012 election, and science- and evidence-based medicine

Regular readers of my other blog probably know that I’m into more than just science, skepticism, and promoting science-based medicine (SBM). I’m also into science fiction, computers, and baseball, not to mention politics (at least more than average). That’s why our recent election, coming as it did hot on the heels of the World Series in which my beloved Detroit Tigers utterly choked got me to thinking. Actually, it was more than just that. It was also an article that appeared a couple of weeks before the election in the New England Journal of Medicine entitled Moneyball and Medicine, by Christopher J. Phillips, PhD, Jeremy A. Greene, MD, PhD, and Scott H. Podolsky, MD. In it, they compare what they call “evidence-based” baseball to “evidence-based medicine,” something that is not as far-fetched as one might think.

“Moneyball,” as baseball fans know, refers to a book by Michael Lewis entitled Moneyball: The Art of Winning an Unfair Game. Published in 2003, Moneyball is the story of the Oakland Athletics and their manager Billy Beane and how the A’s managed to field a competitive team even though the organization was—shall we say?—”revenue challenged” compared to big market teams like the New York Yankees. The central premise of the book was that that the collective wisdom of baseball leaders, such as managers, coaches, scouts, owners, and general managers, was flawed and too subjective. Using rigorous statistical analysis, the A’s front office determined various metrics that were better predictors of offensive success than previously used indicators. For example, conventional wisdom at the time valued stolen bases, runs batted in, and batting average, but the A’s determined that on-base percentage and slugging percentage were better predictors, and cheaper to obtain on the free market, to boot. As a result, the 2002 Athletics, with a payroll of $41 million (the third lowest in baseball), were able to compete in the market against teams like the Yankees, which had a payroll of $125 million. The book also discussed the A’s farm system and how it determined which players were more likely to develop into solid major league players, as well as the history of sabermetric analysis, a term coined by one of its pioneers Bill James after SABR, the Society for American Baseball Research. Sabermetrics is basically concerned with determining the value of a player or team in current or past seasons and with predicting the value of a player or team in the future.
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Posted in: Clinical Trials, Politics and Regulation, Science and Medicine, Science and the Media

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The Trial to Assess Chelation Therapy: Equivocal as Predicted

The ill-advised, NIH-sponsored Trial to Assess Chelation Therapy (TACT) is finally over. 839 human subjects were randomized to receive Na2EDTA infusions; 869 were randomized to receive placebo infusions. The results were announced at this weekend’s American Heart Association meeting in Los Angeles. In summary, the TACT authors report a slight advantage for chelation over placebo in the “primary composite endpoint,” a combination of five separate outcomes: death, myocardial infarction, stroke, coronary revascularization, and hospitalization for angina:

 

Although that result may seem intriguing, it becomes less so when the data are examined more carefully. First, it barely achieved the pre-ordained level of statistical significance, which was P=.036. Second, none of the individual components of the composite endpoint achieved statistical significance, and most of the absolute difference was in coronary revascularization–which is puzzling:

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Posted in: Clinical Trials, Health Fraud, Medical Ethics, Politics and Regulation, Science and Medicine

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The Light Fantastical

What would you do if your swimming pool was dirty?  Clean it of course.  But how?  Would you take out a few pails of water, treat the water in the buckets, then toss the water back into the pool and declare the pool clean?  And if it were the bathroom that needed cleaning, would you clean it by treating a few bucket fulls of water from the pool?  Seems an odd approach to me, but, metaphorically speaking, it is the approach used by ultraviolet (UV) and laser treatment of blood.

A weird bit medical therapy, I get the occasional ‘Hey Dr. Smartypants, what do you think of this treatment?’ email. UV blood irradiation is an odd treatment, with an peculiar history.

UV light does have many effects on tissues, as a trip to Hawaii can rapidly demonstrate to a pasty Oregonian. In my world UV is used to sterilize the environment and UV kills off everything from MRSA to C. difficile to tuberculosis.  We vent potentially microbially contaminated air to the outside in part to dilute any infection but more importantly  we know that most pathogens will die when exposed to solar UV light. Do not use UV light on people as a rule, since it causes tissue damage and we fret about injury to eyes and skin.

Back in the 1930’s a physician named Knott had two patients, one with a brain abscess and one with sepsis, who he evidently cured by irradiating the patients’ blood and returning it to them.*  His rationale was since cutaneous TB can be cured by UV light (the discovery resulted in the 1903 Nobel Prize in medicine and physiology), perhaps other infections would be amenable to the therapy as well (1). (more…)

Posted in: Science and Medicine

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CAM and Creationism: Separated at Birth?

Over the past weekend, I had the opportunity to attend CSICon in Nashville, Tennessee. The Committee for Skeptical Inquiry (“CSI”) combats all sorts of pseudoscience, including creationism/creation science/intelligent design and alternative/complementary/integrative medicine. Our own Team SBM was ably represented by Harriet Hall, David Gorski and Kimball Atwood, whose presentation highlighted the credulous acceptance of CAM in some medical schools, and by Steve Novella, who gave a talk on the placebo effect and its exploitation by CAM proponents. Among many other presentations were those on the Mayan calendar and the end of the world, unmasking of (supposedly) paranormal events, and the neurobiology of memory. Pseudoscience was given a well-deserved thrashing by rational minds.

On Saturday, I once again had the pleasure of hearing Eugenie Scott ,Ph.D., the virtually one-woman anti-creationism campaign who founded and heads the National Center for Science Education (NCSE). As I listened to her talk I couldn’t help but being struck by a number of similarities in the weaknesses apparent in arguments for creationism/ creation science/intelligent design (or “ID”)and those for alternative/complementary/integrative medicine (or “CAM”). I doubt the two groups like to think of themselves as ideological twins, but gosh, they sure do look alike.

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Posted in: Evolution, History, Religion, Science and Medicine

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Cyborg Therapeutics

It appears that we are near the beginning of a new modality in medicine – the use of computer controlled and powered robotics for therapeutic purposes. At present such technology is in its infancy, but is giving us a glimpse of what it will become.

Recently Vanderbilt University announced that its team at the Center for Intelligent Mechatronics has developed an exoskeleton that paraplegics can wear on their legs to allow them to sit, stand, and walk. This is essentially a mechanized orthotic that paraplegics can wear on their legs. The researchers describe it as a “Segway with legs” – referring to the computer technology that controls the exoskeleton, which responds to the user’s movement. If the user leans forward, then the legs will walk. If they lean back, then they will sit.

Like any technology, you can take either a glass half-full or half-empty view of this device. I will cover both – first the good.

Their system has some advantages over previous systems. It is about half the weight, coming in at 27 pounds while other lower extremity exoskeletons weigh 45 pounds. The exoskeleton is also small enough to fit in a standard wheelchair while being worn, and can be put on and taken off by the user alone. As described above, this system also incorporates intelligent control technology. Users with partial paralysis can have their own movements augmented, while for those with complete plegia the exoskeleton can do all the work.

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Posted in: Science and Medicine

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Andrew Weil/AAFP Article Rejected by Slate

I was asked to write an article for Slate, the on-line magazine, about Andrew Weil’s selection as the keynote speaker for the 2012 AAFP annual scientific assembly. The science and health editor, Laura Helmuth, was initially enthusiastic about what I wrote, but eventually decided not to publish it. Here is the initial draft of my article. My comments follow.

Original Draft of Article for Slate

The American Academy of Family Physicians picked Andrew Weil to be the keynote speaker at its annual scientific assembly October 16-20 in Philadelphia. What were they thinking? That’s like having an astrologer give the keynote speech at an astronomy meeting.

The AAFP stands for the best in conventional medicine, for the standard of care as determined by physicians and scientists. Weil doesn’t. The AAFP stands for evidence-based medicine. Weil doesn’t. (more…)

Posted in: Herbs & Supplements, Science and Medicine

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NIH funds training in behavioral intervention to slow progression of cancer by improving the immune system

Editor’s note: Because of Dr. Gorski’s appearance at CSICon over the weekend, he will be taking this Monday off. Fortunately, Dr. Coyne will more than ably substitute. Enjoy!

 

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NIH is funding free training in the delivery of the Cancer to Health (C2H) intervention package, billed as “the first evidence-based behavioral intervention designed to patients newly diagnosed with cancer that is available for specialty training.” The announcement for the training claims that C2H “yielded robust and enduring gains, including reductions in patients’ emotional distress, improvements in social support, treatment adherence (chemotherapy), health behaviors (diet, smoking), and symptoms and functional status, and reduced risk for cancer recurrence.” Is this really an “empirically supported treatment” and does it reduce risk of cancer recurrence?

Apparently the NIH peer review committee thought there was sufficient evidence fund this R25 training grant. Let’s look at the level of evidence for this intervention, an exercise that will highlight some of the pseudoscience and heavy-handed professional politics in promoting psychoneuroimmunological (PNI) interventions.

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Posted in: Clinical Trials, Science and Medicine

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