“I don’t seem able to get it straight in my mind….”
― Ken Kesey, One Flew Over the Cuckoo’s Nest
Influenza is going gangbusters at the moment. I like going to Google Flu trends as well as the CDC flu site to see what flu is doing. Using Google searches as a surrogate for infections is an interesting technique that public health officials have tried with less success in other illnesses but is not without utility. Behaviors of populations can presage a problem, my favorite example is the first hint of the 1993 massive Cryptosporidia diarrhea outbreak in Milwaukee was a sudden shortage of Kaopectate and Peptobismol. It appears there are more patients with flu like symptoms this year than at the height of the H1N1 epidemic of 2009. We have lots of flu like illness, and per the CDC there are buckets of confirmed influenzaflu, but so far the season, while probably having more cases than 2009, the outbreak is clinically not the same.
Compare and contrast, the two words that defined undergraduate liberal arts essay assignments. Get out your blue books and compare and contrast influenza outbreaks from 2009 and 2013. You have one hour. (more…)
Chiropractors are trying to rebrand themselves as primary care physicians, a topic both Harriet Hall and I have addressed (here and here) on SBM. Toward this end, they are seeking the expansion of their scope of practice, via the magic of legislative alchemy, to include the prescription and administration of drugs. Not drugs that any self-respecting M.D. would use, but drugs nonetheless. That effort succeeded to an extent in New Mexico. Recently Colorado got into the act. Other states have followed suit.
Chiropractors have claimed from the very beginning they are primary care physicians. Chiropractic was born in 1895 with the notion that virtually all diseases could be resolved with chiropractic treatment. This was Daniel David Palmer’s original contention, that the interruption of “nerve flow” by “subluxations” caused disease which could be remedied by spinal adjustment to restore the flow, thereby allowing the body to heal itself.
State chiropractic practice acts have always given chiropractors a broad scope of practice which allows them to diagnose and treat virtually any condition as long as they can squeeze the treatment into the “chiropractic paradigm.” If they can pretend the condition is amenable to chiropractic treatment via the detection and correction of subluxations, they can diagnose and treat it legally. This is how they are able to claim, falsely, that asthma, allergies, colic, and many other health problems can be resolved by chiropractic care. This is how “straight” chiropractors still practice.
In 2010, following the H1N1 pandemic and the vaccination campaign to reduce its impact, researchers noted a significant increase in a rare neurological disorder, narcolepsy, in Sweden and Finland. Since then researchers have been studying a possible association between a specific H1N1 flu vaccine, Pandemrix by Glaxo-Smith-Kline (GSK) and a sudden onset of the sleep disorder narcolepsy. In those two countries the association seems strong, but the full story is still complicated with many unknowns.
Narcolepsy is a neurological disorder marked by excessive sleepiness, cataplexy (sudden loss of muscle tone, usually triggered by emotions) and disordered sleep. Almost all cases are associated with low levels of hypocretin in the hypothalamus – this is a hormone involved in sleep regulation. Further there is a strong HLA (human leukocyte antigen) association – specifically DQB1*0602. HLA is a group of proteins involved in regulating immune activity. An HLA association strongly suggests that narcolepsy may be an auto-immune disease.
The current synthesis of this information is that narcolepsy occurs in genetically susceptible individuals after some environmental trigger, such as in infection, that causes the immune system to attack and destroy hypocretin cells in the brain.
A commonly misunderstood aspect of autism and autism spectrum disorders (particularly by antivaccinationists and believers in the quackery known as “autism biomed”) is that autism is not a condition of developmental stasis. It is a condition of developmental delay. Autistic children can and do exhibit improvement in their symptoms simply through growth and development. However, parents who subject their children to “autism biomed” quackery of the sort championed by Jenny McCarthy and others seem to view autism as a condition of developmental stasis. That’s why they so easily and predictably attribute any improvement in their children to whatever quackery du jour they are using on them. It’s also why, in order to determine whether a given intervention in autism has any real effect, randomized controlled trials are required. Indeed, it’s not so difficult to see why, if you take into account the widespread belief that autistic children do not improve, along with parents’ imperfect human memories riddled with confirmation bias, confusing correlation with causation, and other confounders like regression to the mean, so many parents believe that “autism biomed” treatments have actually helped their children. Moreover, improvements observed in autistic children tend to be uneven, with periods of little change interspersed with periods of rapid development. Should such a period of rapid development appear after a “biomed” intervention, guess what gets the credit for the improvement?
But how much improvement is possible? Do autistic children “recover,” and, if they do, how much can they recover? The autism biomed movement is rife with stories of “recovered” children, but often, if you investigate these stories, they turn out to be less than convincing, not unlike the way that alternative medicine cancer “cure” testimonials tend not to be so impressive when examined closely. However, in the case of autism, this isn’t always the case. There are clearly children who lose their diagnosis of autism or ASD, with observations published as far back as 1970, when Rutter reported that 1.5% of adults who had been diagnosed with autism were functioning normally, while 30 years later Sigman et al reported that 17% of autistic children in their group lost their diagnosis and 10 years after that Kleinman et al reported that up to 19% of autistic children “lose their diagnosis.” The reason for this observation is hotly debated, and until fairly recently it was often assumed that these children’s recoveries were in fact not true recoveries but children who were either misdiagnosed or overdiagnosed. Such an assumption made intuitive sense because such an outcome is more likely with children diagnosed with Asperger’s disorder or pervasive developmental disorder, not otherwise specified (PDD-NOS), both of which are categories that resulted from the expansion of the diagnostic criteria for autism. Be that as it may, when you boil it all down, it is estimated that between 3% and 25% of autistic children “lose their diagnosis.” However, few of these studies explicitly address whether the social and communication abilities of these children are fully typical.
Vaccines, and flu shots in particular, have been covered ad nauseum on this blog; but the anti-vaccine propaganda never stops, so forgive me for bringing it up again. A correspondent inquired about a podcast by Steve Wright on Revolution Health Radio entitled “The Truth About Flu Shots (and What to do Instead).” You can either listen or read the transcript. It’s just too funny to pass up. That is, it would be funny if it weren’t endangering our public health by spreading misinformation. (more…)
Quacks detest science-based medicine (SBM) in general, but there are certain specialties that they detest more than others. For instance, you won’t find too many quacks attacking trauma surgery because even they know that when a person’s body has been on the losing end of a confrontation with a bullet or a car, no amount of laying on of hands, homeopathic nostrums, “energy healing,” or herbal remedies are going to stop the hemorrhage, mend broken bones, or repair holes in various internal organs. That’s why even homeopaths will concede that “allopathic medicine” is good for emergencies. It’s also why sketches like this one resonate:
However, from there the distrust of promoters of unscientific and pseudoscientific medical systems and treatment modalities for SBM appears to increase in direct proportion to the urgency and need for direct physical repair of damaged organs, with the possible exception of cancer, for which the standard physical treatment (surgery) is attacked nearly as much as chemotherapy.
Be that as it may, arguably the specialty most attacked by quacks is psychiatry. Many are the reasons, some legitimate, many not. For example, the Church of Scientology in particular despises psychiatry, even going so far as to maintain through its anti-psychiatry front group the Citizens’ Commission on Human Rights (CCHR) a risibly nonsensical “museum” in Hollywood dedicated to psychiatry that they charmingly call Psychiatry: An Industry of Death. It’s so ridiculously, painfully over-the-top, a veritable self-parody of anti-psychiatry hyperbole, that it inadvertently undermines the very attacks on psychiatry frequently leveled by Scientologists and quacks that it’s meant to reinforce. Indeed, not having visited its website for several years, I notice that the CCHR has totally revamped it, now including a virtual 3D tour of the museum, along with video clips from its many “exhibits” available online. I’ll have to file that away for later blog fodder, because the misinformation, cherry picking, and pseudoscience flow freely, as one would expect from a Scientology propaganda project. In the meantime, suffice to say that it’s not just the Church of Scientology that despises psychiatry. It’s founder L. Ron Hubbard and his disciples merely represent the most ridiculously over-the-top and vociferous anti-psychiatry group that I’m currently aware of.
Let’s face it, psychiatry hasn’t always had the best history. It’s a very hard to study human behavior and disorders of human behavior in a rigorous fashion, but to my mind that didn’t excuse the the widespread acceptance for many decades of the ideas of Sigmund Freud, which were little removed from pseudoscience in many respects. Also, psychiatry has not always had the best history, particularly in the early part of this century. Too often, psychiatry has been used as a tool of control rather than a means of helping people who are suffering. Perhaps the worst example is the misuse of psychiatry by various totalitarian regimes, be it the Nazis using it as a primary tool of its T4 euthanasia program or the Soviet Union declaring enemies of the state to be mentally ill and shipping them off to Gulags.
Although there is a ways to go, however, psychiatry in 2012 is much better than psychiatry, say, 50 or 75 years ago. It wasn’t so long ago that, popularized by Walter Freeman, thousands of “ice pick lobotomies” were performed for all manner of indications, few of which had what we would consider to be compelling scientific support to back them up. Over the last half-century, better psychiatric drugs to treat different conditions have been developed, leading to their widespread use for a number of indications. (more…)
Earlier this year, Australia’s anti-vaccine lobby, the Australian Vaccination Network (AVN), took the NSW Government to the Supreme Court. In dispute was their license to fundraise which had been revoked and a public warning, issued because they refused to put a Quack Miranda on their website.
The public warning was posted after the NSW government investigated their website following two complaints, one from a concerned citizen and one from the parents of a 4 week old girl who had died of pertussis.
The complaints accused the AVN of peddling dangerous health misinformation including that vaccines were linked to autism and that pertussis was “nothing more than a bad cough”.
The AVN had always insisted that the HCCC did not have jurisdiction over them because they were not health care providers or educators in the “traditional sense”. It is true that health legislation in NSW is very much out of date in the Internet age. The rules say you can complain only if you can demonstrate direct harm as a result of taking someone’s dodgy advice. For example you had a stroke because of a chiropractor’s adjustments or a punctured lung from acupuncture. Just having a website full of woo-woo wasn’t really covered.
So the AVN challenged the HCCC on these grounds and, to the surprise of many of us, they won. Those who were present in the court that day recall the Judge urging the HCCC Barrister to present evidence for direct harm. And the worst thing was the HCCC apparently had this information, but for reasons unknown to us, did not present it. Those who were there said the HCCC Barrister dropped the ball big time that day. And they were right.
Within hours the public warning was expunged and shortly after that the authority to fundraise was returned. As if nothing ever happened. (more…)
Like every state, Oregon is struggling with the unsustainable costs of taxpayer-funded health care programs. In an attempt to tame this beast, Oregon recently established a system of coordinated care organizations, or CCOs, to (as the name suggests) coordinate medical, mental health, and dental care for residents enrolled in Oregon Health Plan, the state’s Medicaid program. The new system requires supervision of this coordinated effort by the participant’s primary care physician (PCP). Not one of the 15 newly-minted CCOs has credentialed a naturopath as a PCP even though naturopaths are licensed as such by the state. Needless to say, the naturopaths are not pleased by this development.
The big stumbling block appears to be the state’s requirement that CCOs practice evidence-based medicine as a cost control measure. Unfortunately for naturopaths, evidence-based medicine is not their strong suit. Apparently scientific plausibility is not much of a concern either.
We have an obligation to the state and to the community that the providers on our panel will deliver the evidence-based care required by the Oregon Health Plan. . . . We need to make sure that all of the providers who are empanelled meet those basic standards of care.
Topics, as I noted a fortnight ago in my uniquely misspelled and ungrammatical way, never die**. Or even fade away. There are popular ideas that persist in the world that have little to do with reality. In the reality based world of medicine there are concepts that refuse to die. Atelectasis causing fever or the need to ‘double cover’ Pseudomonas. Neither are true, yet every year medical students tell me that is what they have been taught. It is said the only way new ideas take hold is for those that hold the old ideas to die off. So maybe 50 years from now those medical myths will be gone.
Popular culture also its myths. Take the immune system. Please. It is not a bicep that can be made stronger with a little exercise. It is a complex network of cells and proteins. There are antibodies (IgG (with five subtypes, IgM, IgA, IgE),the complement pathway, polymorphonuclear cells, monocytes, lymphocytes in a profusion that rivals beetles. God, I think, has an inordinate fondness for lymphocytes. There is the Toll system, the cytokines and lymphokines, the non-specific defenses like cilia and mannose binding lectin and on and on and on.
I have a journeyman’s understanding of the immune system, what is needed to understand why a given patient has an infection, although there is little I can do to reverse the immunologic defects: abnormal antibodies from Waldenström’s or low mannose binding lectin levels from liver disease are not amenable to clinical intervention. (more…)
As I mentioned recently, as hard as it is to believe, this blog is rapidly approaching the end of its fifth year of existence. Our first post was delivered to the anxiously waiting world on January 1, 2008; so thus upcoming January 1 will represent our fifth anniversary. In the blogging world, that’s almost the equivalent of a fiftieth anniversary, given how fast most blogs turn over. Something that is even more satisfying than mere longevity is that we really have found a niche in the medical blogosphere to the point where we’ve become quite influential. People notice us. Our targets notice it when we discuss them. Sometimes even the press notices us. This is all a very good thing.
Unfortunately, even though we’ve been at this for just shy of five years, there are still topics we haven’t covered, or at least haven’t covered in sufficient depth. The topic of my post today is one of the latter topics. We’ve mentioned it before; we’ve alluded to it before (for instance when discussing the antivaccine website Medical Voices and the Ayn Rand-worshiping Association of American Physicians and Surgeons; but there hasn’t been a post dedicated to this particular topic. I find this particularly odd because it was one a piece of misinformation promoted by elements of the antivaccine movement that truly shocked and disgusted me. Before I learned of this particular myth, I was surprised to learn that there are really people who think that vaccines are dangerous and cause autism, but I viewed it as being of a piece of a lot of other quackery I was discovering at the time.
Way back in the day, when I first encountered antivaccine views in that wretched Usenet swamp of pseudoscience, antiscience, and quackery known as misc.health.alternative (m.h.a.), there was one particular antivaccine lie that disturbed me more than just about any other. As I mentioned, it wasn’t the claim that vaccines cause autism, which is more or less the central dogma of the antivaccine movement. Even ten years ago, before the series of studies that have been released since then that fail to find a hint of a whiff of causation between vaccines and autism, that wasn’t a particularly difficult myth to refute. Indeed, given newer studies, refuting that myth has only gotten easier over the years. Emblematic of how far into the depths that particular myth has been pummeled, I know it’s gotten pretty easy when even the mainstream media start to accept that the claim that vaccines cause autism is a myth and report matter-of-factly on issues such as Andrew Wakefield’s fraud and don’t give nearly as much copious and prominent media time to the likes of Jenny McCarthy. Let’s just put it this way. When the hosts of a “morning zoo”-type radio show in Salt Lake City pummel the latest antivaccine celebrity to make a fool of himself, Rob Schneider, you know that, from an informational standpoint at least, the tide appears to have turned from several years ago, when the media took this myth a lot more seriously. That’s not to say that we don’t still have a problem. After all, “philosophical” exemption rates are going up based on a lot of this sort of misinformation, but at least the media are less insistent on “telling both sides” of a science story that doesn’t really have two sides. (more…)