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Archive for Science and Medicine

Psychology and Psychotherapy: How Much Is Evidence-Based?

psychology gone wrong
Despite all those Polish jokes, Poland has its share of good scientists and critical thinkers. A superb new book illustrates that fact in spades:

Psychology Gone Wrong: The Dark Side of Science and Therapy, by Tomasz Witkowski and Maciej Zatonski, Witkowski is a psychologist, science writer, and founder of the Polish Skeptics Club; Zatonski is a surgeon and researcher known for debunking unscientific therapies and claims in clinical medicine. Together, they turn a spotlight on research and treatment in the field of psychology. They uncover distressing flaws, show that many commonly accepted psychological principles are based on myths, argue that psychotherapy is a business and a kind of prostitution rather than an effective evidence-based medical treatment, and question whether psychotherapy should even exist, since in most cases it offers no advantage over talking to a friend about one’s problems, and in some cases can cause harm. (more…)

Posted in: Book & movie reviews, Neuroscience/Mental Health, Science and Medicine

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Separating Fact from Fiction in the Not-So-Normal Newborn Nursery: Chiropractic and Craniosynostosis

cranialsutures

Pediatricians, particularly those who spend a significant amount of time caring for newborns, see a lot of babies with unusually-shaped heads. Although to be fair, the fact that the overwhelming majority of vaginally-delivered babies, and quite a few born via Caesarean section, will have a transient and abnormal shape to their heads makes it, well, not unusual. In fact, I rarely make it out of the room without some discussion and reassurance regarding the lumps and bumps of a new arrival’s head.

The potentially lumpy and misshapen head of the newborn occurs for a variety of reasons, some common and some extremely rare. It often is related to the development of the bones of the skull but can also involve the surrounding tissues of the scalp. A vaginal delivery, and some difficult Caesarean births, subject a baby’s head to a lot of pressure. This pressure frequently results in swelling of the scalp that can be quite impressive, but tends to resolve in a day or two.

This same pressure can also cause bleeding, perhaps because of an insufficient amount of vitamin K available to optimally activate clotting, that collects under the top layer of one or more of the bones of the skull. These cephalohematomas can also be impressive and may take weeks to completely resolve. Rarely the trapped blood becomes calcified and requires surgical correction to remove the otherwise-permanent lump and restore a normal contour to the head.

Newborns very frequently have a molded skull. Depending on the timing and severity of the pressure experienced during delivery, the shape and size of the uterus and positioning of the baby in the womb, the newborn can emerge with a variety of head shapes. The most common one that I see is a cone. If you’re thinking of a classic Saturday Night Live sketch right now, you’ve got the correct mental image.

Babies who are breech also have a distinct pattern of molding which involves a flattened and elongated top of the head because of pressure against the uterine wall. Abnormal positioning in the womb can also result in asymmetric molding of the head and facial structures like the jaw, nose and ear. Fortunately these pressure-induced and positional deformities usually resolve without intervention, often within a few days, but some are serious enough to require intervention and even surgical correction.

Why are the cranial bones of newborns so easily molded by the pressure of birth? This is a question I answer frequently for new parents and inexperienced medical students. The answer will segue us into the primary topic of this post, but before I discuss craniosynostosis, and the sadly unsurprising claims of some in the chiropractic community, a review of normal cranial anatomy is in order. (more…)

Posted in: Science and Medicine

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Lyme: Two Worlds Compared and Contrasted

The Lyme tick

The western black-legged tick, carrier of the Borrelia burgdorferi bacteria which causes Lyme disease.

The practice of infectious disease (ID) is both easy and difficult. If you read my ID blog on Medscape you are aware of my trials and tribulations in diagnosing and treating infections.

ID is easy since, at least in theory, diseases have patterns and an infecting organism has a predictable epidemiology and life cycle. So if you can recognize the pattern and relate it to the life cycle and exposure history, you can often make a diagnosis before the cultures come back.

My favorite story is the time I was asked to see a young girl with endocarditis. The history was she had a week of fevers, headache and myalgia that went away for five days, returned for a week, went away for five days and returned yet again.

So I asked her “How was your vacation at Black Butte?”

The look of astonishment on her face as she asked how I knew she had been to Black Butte was so satisfying. (more…)

Posted in: Legal, Naturopathy, Politics and Regulation, Public Health, Science and Medicine

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Making One’s Own Reality – Food Babe Edition

Vani Hari, aka the "Food Babe".

Vani Hari, the “Food Babe”.

The default mode of human activity is to construct our own internal model of reality based upon our desires, biases, flawed perceptions, memories, and reasoning, and received narratives from the culture in which we live. That model of reality is then reinforced by confirmation bias and jealously defended.

But we also have the capacity to transcend this pathway of least resistance. Philosophy is the discipline of thinking carefully and systematically about ideas to see if they at least are internally consistent. Science is the discipline of systematically and carefully comparing our internal models of reality against objective reality, and then changing those models to suit the evidence.

Everyone engages in a combination of bias, superstition, logic, and evidence-based reason to varying degrees – the question is, to what degree? The goal of science-based medicine is to increase the proportion of science and reason in the mix with respect to the practice of medicine and public health.

There are many forces at work in society, however, that explicitly oppose the role of science because, in my opinion, they find it inconvenient to their internal model of reality or whatever narrative they are selling.

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Posted in: Science and Medicine

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Bias and Spin

We all construct our narrative based on our biases and spin the facts so that the narrative confirms our biases. Among other characteristics, what separates an SBM provider from a SCAM provider is realizing that biases are always active and apply to me as well as everyone else.

My biases are simple: I am skeptical that humans can reliably understand reality without assistance and the best source of assistance is science.

I have a job where the expectation is that I will change practice as information changes. How I practiced medicine 30 years ago is very different from how I practice it today. Still, I note it is harder and harder to change my approaches as I get older. I get more set in my ways and it takes more effort to change as new studies are published. Sometimes it seems almost physically difficult.

Again, it is expected that not only will I change my mind over time, as the sole ID doctor at my hospitals, I will be the one to lead the change. Imagine how much harder it would be to change your mind if you were committed to a universal truth such as those that are alleged to underlie reiki or chiropractic. Years committed to a pseudo-medicine probably renders changing one’s mind virtually impossible. (more…)

Posted in: Chiropractic, Science and Medicine

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Personal Belief Exemptions for Vaccines

vaccinationRates

Click to enlarge

Positive change not only requires a valid argument, it requires political will. My colleagues and I have been pointing out for years that vaccines are safe and effective, and the anti-vaccine movement, which is built largely on misinformation, threatens the public health by eroding herd immunity. These arguments are no more valid today than they were five or ten years ago (except that new scientific evidence continues to support our conclusion).

We also predicted that it will likely take the significant return of vaccine-preventable diseases to muster the political will to effectively push back against the anti-vaccine movement. Parents need to be more afraid of infectious disease than the false fearmongering surrounding vaccines. We, of course, did not want this to happen, we just thought this was a likely scenario.

I did not think, however, that it would be so sudden and dramatic. The Disneyland measles outbreak created an undeniable media and popular backlash against the anti-vaccine movement. Recent evidence for this is the Jimmy Kimmel segment in which he blasted anti-vaxxers and showed a fake PSA in which real doctors express their frustration over vaccine refusers. Anti-vaxxers replied with their usual shrill nonsense, comparing Kimmel’s statements to hate speech and falsely accusing him of attacking autistic children. Kimmel responded with still more ridicule, making a mockery of anti-vaxxer tweets attacking him. Being the butt of late night comedian jokes is a reasonable sign of popular backlash.

Popular opinion, which is turning against vaccine refusers for threatening the public health, translates into political will. In the case of vaccines there is a specific focus for this political will – state laws allowing exemptions from the requirement for children to be up to date on their vaccines in order to attend public school.

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Posted in: Science and Medicine, Vaccines

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IOM Recommends Replacing CFS with SEID

Exertion intolerance

Exertion intolerance

Chronic fatigue syndrome (CFS) is a controversial diagnosis that has also been called myalgic encephalomyelitis (ME or ME/CFS), post-viral fatigue syndrome (PVS), chronic fatigue immune dysfunction syndrome (CFIDS), Iceland disease, “yuppie flu,” and many other names. A new report from the Institute of Medicine (IOM) says that none of those names really fit the disease and recommends it be re-named systemic exertion intolerance disease or SEID.

ME/CFS is thought to affect as many as 2.5 million Americans. The cause remains unknown, but in many cases it appears to have been “triggered by an infection or other prodromal event, such as immunization, anesthetics, physical trauma, exposure to environmental pollutants, chemicals and heavy meals, and rarely blood transfusions.” Some doctors question its very existence and interpret the symptoms as imaginary or psychological.

The IOM examines the evidence base

At the request of several government agencies including the NIH and the FDA, the IOM convened a committee of 15 experts to examine the evidence base for ME/CFS. They reviewed over 9,000 published studies and heard testimony from patients and advocates. Before publication, an additional 15 experts were asked to provide peer review. The full text of the report is available free online. (more…)

Posted in: Science and Medicine

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SSPE: A Deadly and Not-That-Rare Complication of Measles

From the CDC Public Health Image Library #132 via the Wikimedia commons.  Child with classic measles day-four rash.

From the CDC Public Health Image Library #132 via the Wikimedia commons. Child with classic measles day-four rash.

[Editor’s note: We have two posts today, this post by our regular contributor Dr. Clay Jones, and an excellent guest post by William London about a chiropractor’s dubious neuropathy treatment protocol. Enjoy today or over the weekend!]

As a pediatrician, even one who has spent the majority of his career caring only for hospitalized children, the death of a patient has been a rare occurrence. There are certainly some pediatric specialties, such as intensive care and oncology, that because of the nature of their patient population must develop a more intimate relationship with the end of life. But compared to the adult world, even their exposure pales in comparison. The most common form of pediatric cancer, acute lymphoblastic leukemia, has a cure rate that is over 90% for example – making the unnecessary death of Makayla Sault after some worthless “treatment” at the Hippocrates Health Institute all the more tragic.

A bit more common in pediatrics are the patients that require significant intervention, and who may come close to death, but recover thanks to advances in modern medicine. These patients, however, are dwarfed by the number of children who receive routine hospital care and recover fairly uneventfully. And most children emerge into adulthood having never had more than a few self-limited viral illnesses and maybe a cavity or two. This wasn’t always the case. In 1900, 10% of 1-year-old children would not make it to adulthood. (more…)

Posted in: Science and Medicine

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Psychology Journal Bans Significance Testing

p-valuesThis is perhaps the first real crack in the wall for the almost-universal use of the null hypothesis significance testing procedure (NHSTP). The journal, Basic and Applied Social Psychology (BASP), has banned the use of NHSTP and related statistical procedures from their journal. They previously had stated that use of these statistical methods was no longer required but can be optional included. Now they have proceeded to a full ban.

The type of analysis being banned is often called a frequentist analysis, and we have been highly critical in the pages of SBM of overreliance on such methods. This is the iconic p-value where <0.05 is generally considered to be statistically significant.

The process of hypothesis testing and rigorous statistical methods for doing so were worked out in the 1920s. Ronald Fisher developed the statistical methods, while Jerzy Neyman and Egon Pearson developed the process of hypothesis testing. They certainly deserve a great deal of credit for their role in crafting modern scientific procedures and making them far more quantitative and rigorous.

However, the p-value was never meant to be the sole measure of whether or not a particular hypothesis is true. Rather it was meant only as a measure of whether or not the data should be taken seriously. Further, the p-value is widely misunderstood. The precise definition is:

The p value is the probability to obtain an effect equal to or more extreme than the one observed presuming the null hypothesis of no effect is true.

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Posted in: Basic Science, Clinical Trials, Science and Medicine

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Placebo, Are You There?

By Jean Brissonnet, translation by Harriet Hall

Note: This was originally published as “Placebo, es-tu là?” in Science et pseudo-sciences 294, p. 38-48. January 2011. It came to my attention in the course of an e-mail correspondence with the editors of that magazine, where one of my own articles was published in French translation in January 2015. I thought this was the best explanation of placebo that I had ever read. It covers the same points my colleagues and I have addressed and more. It describes the pertinent research and uses particularly effective graphs to illustrate the principles (a picture is worth a thousand words). The author, Jean Brissonnet, kindly gave his permission for me to translate it and share it with our readers.


In fact, you don’t need to give a placebo to get a placebo effect and therefore we can now think about how we can maximize the placebo component of routine care.

~ Damien Finniss, 2010

The scene takes place in a surgical suite where they are preparing to do a cataract operation. The patient is lying on the operating table. A few minutes earlier the anesthetic gel was applied to the cornea to permit an operation under simple local anesthesia. The surgeon arrives in the company of the anesthetist. They are engaged in a spirited discussion and don’t seem to be agreeing.

“It has been proven,” says the surgeon, “that 30% of the action of a medical treatment is due to the placebo effect.”

“I doubt that,” retorts his interlocutor, “I think that placebo story is one of those medical myths on a par with the idea that we only use 10% of our brain, that nails and hair grow after death, or that cellphones create interference in hospitals.”[1]

“No,” insists the surgeon with a superior tone, “the fact is established and has been proven by numerous studies.”

The anesthetist shakes his head with a slight smile, but he doesn’t reply. As for the patient, who might have much to say on the subject, he keeps quiet, because it would not be prudent to argue with someone who is about to suck the lens out of your eye.

This true anecdote would not be of interest if it didn’t concern two members of the medical profession. Why such uncertainty? Why such lack of knowledge about such a fundamental subject? This faith in an all-powerful, magical, and mysterious placebo is common among the general public and it serves as justification for resorting to unconventional medicines that have never been able to show solid proof of efficacy; but we see that it still persists among the medical profession.

To know whether the placebo effect is real or should be relegated to the same category as poltergeists, it will help to go back in history.

cartoon

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Posted in: Clinical Trials, Science and Medicine

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