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Alcohol and Pregnancy

We know that drinking alcohol during pregnancy can cause birth defects; the government-mandated warnings on alcoholic beverage labels constantly remind us of that fact. But toxicologists remind us that the poison is in the dose: what is the dose of alcohol that causes birth defects? Heavy drinking can cause fetal alcohol syndrome, but there is no evidence that light to moderate drinking can cause it. Alcohol has been implicated in a number of other adverse effects on pregnancy and on the fetus. We simply don’t know if there is a threshold dose below which alcohol intake is safe, so the default position of most medical authorities has been to advise total abstinence during pregnancy. This is not a truly evidence-based recommendation, but rather an invocation of the precautionary principle. Those advising complete abstinence have been accused of paternalism and bias by wine-lovers and other critics, for instance here and here.

The literature on alcohol and pregnancy is extensive and confusing. It addresses many different endpoints, looking at effects on children and on the pregnancy itself. The studies are inconsistent in how they define “moderate” or “light” drinking, and they rely on self-reports that may not be accurate.

It would be impossible to read and accurately summarize such a large body of literature (over 21,000 hits on PubMed!), but here are a few examples that illustrate the scope, diversity, and conflicting results of these studies: (more…)

Posted in: Obstetrics & gynecology

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The latest chapter in the seemingly never-ending saga of dichloroacetate as a cancer treatment

The road from an idea to a useful drug is a long one, and in cancer it is often particularly long. One reason is that to be able to tell whether a given treatment is effective against cancer often takes several years at a minimum, in order to determine if patients receiving the new treatment are surviving their disease longer than those who are not. Surrogate endpoints are usually not enough. Tumor shrinkage in response to a drug often does not correlate with prolongation of survival, although the converse (i.e., lack of tumor shrinkage in response to a new drug) does strongly correlate with failure of a treatment to prolong survival. In other words, effects observed on surrogate endpoints are not enough to judge whether a cancer therapy is working or not.

Three years ago, predating the existence of this blog by nearly a year, I became aware of a story that involved many of the issues in bringing a compound from the laboratory to the clinic. The case was unusual in that is is very rare to see the scientific process by which new drugs progress through the stages of cancer research, from concept to testing in cell culture to testing in animals to testing in humans challenged so strongly by patients themselves. The reason that this normally doesn’t occur is that new cancer treatments are almost always the product of either university-conducted research, pharmaceutical company-conducted research, or partnerships between the two. This case was markedly different in that it involved a chemical that was not only easy to synthesize, but cheap and long out of patent. Even more intriguing, it targeted a metabolic abnormality found in many cancer cells, an abnormality first described nearly 80 years before by Otto Warburg in 1928. This latter aspect of the drug gave it every appearance of a “rediscovery” of old wisdom that big pharma had ignored for 80 years, and that only added to its mystique.

The chemical was dichloroacetate (DCA), and three years ago it created a world-wide sensation. Last week, it created a sensation again, as breathless news reports once again overhyped its promise. Since I’ve been following the story since early 2007, I appear to be in as good a position as anyone to tell the story thus far and put the new findings into context. To begin that process, let’s head back to January 2007.
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Posted in: Cancer, Clinical Trials, Health Fraud

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Snake oil for snakebites (and other bad ideas)

Spring is here.  I don’t say that because of the warmer weather, the blooming tulips in my back yard, or the current effect of the earth’s axial tilt on the Northern hemisphere.  No, in my somewhat warped world of the pediatric ICU seasons are marked by illnesses and injuries with an annual rhythm.  Fall begins with a spike in cases of bronchiolitis, Summer with a near-drowning in a swimming pool.  Winter has arrived when seasonal influenza reappears.  And Spring, well, Spring has several harbingers, including auto vs bicycle accidents, falls from windows, and snakebites.

Sure enough, this week we admitted our first child of the year bitten by a venomous snake who, like most people unfortunate enough to be envenomated by a North American pit viper, has done very well.  This child fell prey not only to our local limbless fauna, but also to one of several common myths or misunderstandings about snakebites that place the victim, rescuer, or both at higher risk for injury and complications.  This post will explore some of the more common mistakes people make during North American snakebite encounters (being limited to snakes native to North America, the following does not necessarily apply to snakes from other areas).

File this post under Science-Based-You’re-Not-Helping-Please-Don’t-Do-That.

Myth #1: You Need to Know the Species / Kill the Snake

North America has around 120 species of snake, over 20 of which are venomous.  With so many species, it may seem important to ID the snake so the docs in the ED can give the appropriate anti-venin.  Fortunately, that isn’t the case. (more…)

Posted in: Science and Medicine

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Rx, OTC, BTC – Wading into Pharmacy’s Alphabet Soup

Imagine you’re an FDA reviewer looking at a new drug application. Drug A relieves a symptom, but doesn’t cure any disease. It doesn’t conflict with other medications. It’s considered safe in pregnant and breastfeeding women. At normal doses, there are virtually no side effects. There’s one unfortunate problem: If you take ten times the dose, liver damage is very likely and may be fatal. In other countries, Drug A is the number one cause of acute liver failure.

Should Drug A be available without a prescription?

Now consider another drug. Drug B also treats a symptom, but can also be used to treat a number of acute and chronic conditions, some of which require monitoring by specialist physicians. Drug B should generally be avoided in children, as it is associated with a rare but fatal toxicity. Even at normal doses, it can cause an array of side effects, and severe digestive system toxicity, resulting in hospital admission, is not uncommon. It interacts with other prescription drugs, and can be fatal in overdose situations.

Should Drug B be available without a prescription?
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Posted in: Pharmaceuticals, Politics and Regulation

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A Pair of Acupuncture Studies

Two recent acupuncture studies have received some media attention, both purporting to show positive effects. Both studies are also not clinical efficacy trials, so cannot be used to support any claims for efficacy for acupuncture – although that is how they are often being presented in the media.

These and other studies show the dire need for more trained science journalists, or science blogging – they only make sense when put into a proper context. No media coverage I read bothered to do this.

The first study comes out of South Korea and involves using acupuncture in a rat model of spinal cord injury. The researchers used a standard method of inducing spinal cord injury in rats, and compared various acupuncture locations to no-acupuncture control. They followed a series of metabolic outcomes, as well as the extent of spinal cord injury and functional recovery. They conclude:

Thus, our results suggest that the neuroprotection by acupuncture may be partly mediated via inhibition of inflammation and microglial activation after SCI and acupuncture can be used as a potential therapeutic tool for treating acute spinal injury in human.

The notion that acupuncture will actually improve outcome after acute spinal cord injury is, of course, extraordinary. This goes far beyond a subjective decrease in pain or some other symptomatic benefit. Therefore similarly extraordinary evidence should be required to support such a claim – and this study does not provide that.

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Posted in: Acupuncture

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Welcoming a new blogger to SBM

It is my pleasure to announce the addition of a new SBM blogger. Impressed by his dedication to applying scientific principles to the profession of pharmacy, we have recruited Scott Gavura, who is currently best known for his work on Science-Based Pharmacy. You can find out a bit more about his background at his new page on SBM, and his first post is scheduled for Thursday, May 13. In the beginning he will be posting approximately once every four weeks.

Please join me in welcoming Scott to the SBM team.

Posted in: Announcements

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Medicine’s Beautiful Idea

For most of human history, doctors have killed their patients more often than they have saved them. An excellent new book, Taking the Medicine: A Short History of Medicine’s Beautiful Idea, and Our Difficulty Swallowing It, by Druin Burch, MD, describes medicine’s bleak past, how better ways of thinking led to modern successes, and how failure to adopt those better ways of thinking continues to impede medical progress.

The moral is not that doctors once did foolish things. The moral is that even the best of people let themselves down when they rely on untested theories and that these failures kill people and stain history. Bleeding and mercury have gone out of fashion, untested certainties and overconfidence have not.

Burch’s conversation with his rowing coach epitomizes the problem:

“I want you to keep your heart rate at 85% of max for the next hour and a half.”
“Why?”
“Because it’s the best way to improve your fitness.”
“How do you know?”
“Because I’ve done it before and it worked. Because that’s what the people who win the Olympics do. I know, I’ve trained some of them.”
“But has anyone actually done an experiment?”
“What on earth are you talking about?”

This book is Burch’s answer to his coach’s question. Medicine’s “beautiful idea” is that we should test all hypotheses and beliefs using the kind of tests that are reliable for determining the truth. Instead of going by tradition, authority, theory, common sense, or personal experience, we now have effective tools to find out for sure whether a treatment really works. (more…)

Posted in: Book & movie reviews, History, Science and Medicine

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The 2008-2009 Report of the President’s Cancer Panel: Mostly good, some bad, and a little ugly

Mark Crislip is always a hard act to follow, particularly when he’s firing on all cylinders, as he was last Friday. Although I can sometimes match him (and, on rare occasions, even surpass him) for amusing snark, this time around I’m going to remain mostly serious because that’s what the subject matter requires. I’ve said it before and I’ll say it again: I’m a bit of an odd bird in the world of cancer in that I’m both a surgeon and I run a lab. Sadly, there just aren’t very many surgeons doing basic and translational research these days, thanks to declining NIH funding, increasing clinical burden necessitated by declining reimbursements, and the increasing complexity of laboratory-based research. That’s not to say that there aren’t some surgeons out there doing excellent laboratory research, but sometimes I feel as though I’m part of an endangered species, particularly years like this when grants are running out and I need to renew my funding or secure new funding, the consequence of failure being the dissolution of my laboratory. It’s a tough world out there in biomedical research.

As tough as biomedical research is in cancer, to my mind far tougher is research trying to tease out the relationship between environmental exposures and cancer risk. If you want complicated, that’s complicated. For one thing, obtaining epidemiological data is incredibly labor- and cost-intensive, and rarely are the data clear cut. There’s always ambiguity, not to mention numerous confounding factors that conspire to exaggerate on the one hand or hide on the other hand correlations between environmental exposures and cancer. As a result, studies are often conflicting, and making sense of the morass of often contradictory studies can tax even the most skillful scientists and epidemiologists. Communicating the science and epidemiology linking environment and cancer to the public is even harder. What the lay person often sees is that one day a study is in the news telling him that X causes cancer and then a month later another study says that X doesn’t cause cancer. Is it any wonder that people are often confused over what is and is not dangerous? Add to this a distinct inability on the part of most people, even highly educated people, to weigh small risks against one another (an inability that has led to phenomena such as the anti-vaccine movement), and the task of trying to decide what is dangerous, what is not, how policy is formulated based on this science, and how to communicate the science and the policy derived from it to the public is truly Herculean.
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Posted in: Cancer, Politics and Regulation, Public Health

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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, to not spiral into sarcastic diatribes over the writings that pass for information on the interwebs. 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 am a beer researcher.

The nine questions show up frequently on the interwebs, similar to questions on is to ask when you want to stump an evolutionist.  Like the supposed stumpers for evolution, the vaccine questions are grounded in either misinformation or laziness. Let’s go through them one at a time.

1. Could you please provide one double-blind, placebo-controlled study that can prove the safety and effectiveness of vaccines?

One trial? It took me 55 seconds to find 20211953, and that includes time to boot the browser and mis-spell the search terms.  Vaccine efficacy randomized placebo control trial gives 416 pubmed results; add safety to the search term, you 126 returns. The are easily more than one.  Of course, to find them you have to look.

Of course, I am a highly educated adult who constantly searches the web for medical information.  For hoots and giggles, I asked my 12 year old son, whose passions are basketball and filming comedy videos, to find me a reference that met the same criteria and I timed him.

22 seconds to find Randomized, Placebo-Controlled Trial of Inactivated Poliovirus Vaccine in Cuba from the NEJM.

12 yo one,  Mihalovic 0.  Served.

As long as we are on the topic, since he evidently place great store in science, could Mihalovic please provide one double-blind, placebo-controlled study that can prove the safety and effectiveness of naturopathy?  I would be happy at this point to know you could do a pubmed search corruptly just to make me look the fool.

2. Could you please provide scientific evidence on ANY study which can confirm the long-term safety and effectiveness of vaccines?

Long term is vague. What is long term?  Smallpox disappeared in 1976 thanks to the vaccine.  I have not seem a case of smallpox in my medical career, which now on it’s 31st year. No reported long term toxicities and the eradication of smallpox seems to me reasonable evidence for long term effectiveness.

No vaccine is 100% in efficacy, and whether  infected naturally or by way of a vaccine, immunity wanes with time.  In  earlier times  people would be have their immunity boosted by exposure to disease and maintain their antibody levels.  It is not the initial infection that leads to better immunity from natural infections, as posited by some antivaccine people, but the the fact that people were constantly re-exposed to wild type disease.

It is interesting what is happening with shingles.  Everyone used to get chickenpox as a child, and then, as they raised their kids and grand kids, got re-exposed to the virus and boost their immunity. Currently, due to the chickenpox vaccine and a change in the way way children are raised, older adults are not getting exposed naturally to chickenpox, immunity is waning, and there is an increase in shingles in older adults.  Part of why they need the zoster vaccine.  http://www.journals.uchicago.edu/doi/abs/10.1086/651078

Clever conspiracy, huh?

Unless exposed to new infection, immunity, as measured by antibody levels directed against the infecting agent, can wane over time. That is to be expected.  The nice thing about the immune system, unlike water, is that it remembers the infection. It is primed so that if exposed again at a later date, it can almost instantly produce large amounts of antibody to nip an infection in the bud. So rather than prevent infection, in some people far removed in time from the vaccine, may instead have a shorter, less severe illness and be infectious not as long, thereby decreasing spread.

There is a nice review in the NEJM 1798383 on duration of immunity (first search in pubmed using duration of immunity vaccine, results in 17 seconds, including correcting typos.  Seriously, just how hard is it to find this information?  As would be expected, it depends on the disease and the vaccine (live better than killed). They estimated the half life for the varicella zoster virus immunity at 50 years, 200 years for measles and mumps, and 11 years for tetanus.  If you peruse the references, you can find other studies that show variable but sustained response to vaccines,  for example 90% maintain immunity to smallpox up to 75 years after vaccination. 12925846

Long term safety was more difficult, 5 years was the limit of time I could find safety studies, for the Hepatits B.  j med virol  65 2001Most vaccine toxicities are found in the first week after the inoculation and the studies follow most patients for a year.  Probably would not cut it as long term for Mihalovic.

BTW, could you please provide scientific evidence on ANY study which can confirm the long-term safety and effectiveness of naturopathy?

3.  Could you please provide scientific evidence which can prove that disease reduction in any part of the world, at any point in history was attributable to inoculation of populations?

Smallpox? Smallpox? Smallpox? Anyone? Smallpox? Buehler? Buehler?

Again I get back to the whole binary, black and white approach that characterizes many with whom we cross medical swords.  The decrease in infectious diseases has been multifactorial, due to improved nutrition, improved hygienic (lets hear it for the flush toilet) and understanding the epidemiology of diseases.  Knowing how a disease is spread has always been critical in decreasing its spread.  Note that none, none, none of the interventions that have decreased the spread of infections in the last 200 years or so have come from alt med tradition.

The teasing out the effects of vaccines on populations is always fraught with potential controversy. There are always multiple confounders.  The best example of the effects of vaccines was from JAMA http://jama.ama-assn.org/cgi/content/full/298/18/2155

“Objective  To compare morbidity and mortality before and after widespread implementation of national vaccine recommendations for 13 vaccine-preventable diseases for which recommendations were in place prior to 2005.

Design, Setting, and Participants  For the United States, prevaccine baselines were assessed based on representative historical data from primary sources and were compared to the most recent morbidity (2006) and mortality (2004) data for diphtheria, pertussis, tetanus, poliomyelitis, measles, mumps, rubella (including congenital rubella syndrome), invasive Haemophilus influenzae type b (Hib), acute hepatitis B, hepatitis A, varicella, Streptococcus pneumoniae, and smallpox.

Main Outcome Measures  Number of cases, deaths, and hospitalizations for 13 vaccine-preventable diseases. Estimates of the percent reductions from baseline to recent were made without adjustment for factors that could affect vaccine-preventable disease morbidity, mortality, or reporting.

Results  A greater than 92% decline in cases and a 99% or greater decline in deaths due to diseases prevented by vaccines recommended before 1980 were shown for diphtheria, mumps, pertussis, and tetanus. Endemic transmission of poliovirus and measles and rubella viruses has been eliminated in the United States; smallpox has been eradicated worldwide. Declines were 80% or greater for cases and deaths of most vaccine-preventable diseases targeted since 1980 including hepatitis A, acute hepatitis B, Hib, and varicella. Declines in cases and deaths of invasive S pneumoniae were 34% and 25%, respectively.”

Milhalovic,  could you please provide scientific evidence which can prove that disease reduction in any part of the world, at any point in history was attributable to naturopathy?

4. Could you please explain how the safety and mechanism of vaccines in the human body are scientifically proven if their pharmacokinetics (the study of bodily absorption, distribution, metabolism and excretion of ingredients) are never examined or analyzed in any vaccine study?

There is, superficially, some truth in this statement.  Most pharmacokinetics are done prior to the clinical efficacy trials.  That is why there are phase 1 and phase 2 trials. The assumption being that if you exam influenza vaccine pharmacokinetic studies in one group it can be extrapolated to similar populations.  I think that is reasonable. So no, there are no pharmacokinetic studies in the clinical efficacy trials, those were done prior to the efficacy trials.  But it is not hard to find the phase 1 and 2 trials if you are so moved.

Milhalovic, could you please explain how the safety and mechanism of naturopathic nostrums in the human body are scientifically proven if their pharmacokinetics (the study of bodily absorption, distribution, metabolism and excretion of ingredients) are never examined or analyzed in any naturopathic nostrum study?  Is this getting old?  There is something to be said for repetition.

5. Could you please provide scientific justification as to how injecting a human being with a confirmed neurotoxin is beneficial to human health and prevents disease?

I presume the issue is mercury. Maybe aluminum. The latter is not in most vaccines, although as been discussed at length on this blog, the amount of mercury and aluminum found in vaccines is minimal and, at the dosing and formulation, has never been demonstrated to cause neurotoxicity from vaccines.  Of course, I am old school and think there is a dose response, and that a greater amount leads to a greater response.  Most naturopaths receive extensive training in homeopathy, where the less the amount, the greater the response.  So I would presume arguments based on chemistry would have little meaning to an ND, although I would not want my appletini made by a practitioner of homeopathy.

Of course, it is not the ‘neurotoxin’ that is being used to prevent disease, but the antigens of the potential infection. That is assuming that the author of the nine questions does not consider the antigens to be neurotoxins, and to judge from his understanding of disease later in the post, I am notes certain he warrants the benefit of the doubt.

Could you please provide scientific justification as to how applying naturopathy to a human being is beneficial to human health and prevents disease?

6. Can you provide a risk/benefit profile on how the benefits of injecting a known neurotoxin exceeds its risks to human health for the intended goal of preventing disease?

Since there is no more mercury in most vaccines, I will assume, for the sake of argument, it is the aluminum.  Risk from aluminum in the H. influenza type b vaccine, where aluminium is used as a adjuvant: zero.

The benefit from the vaccine: “From eight trials, the protective efficacy of the Hib conjugate vaccine was 84% (OR 0.16; 95%CI 0.08-0.30) against invasive Hib disease, 75% (OR 0.25; 95%CI 0.08-0.84) against meningitis, and 69% (OR 0.31; 95%CI 0.10-0.97) against pneumonia. Serious adverse events were rare.” 16491301

Seems a good trade off. No risk from aluminum, significant decrease in morbidity and mortality.

7. Could you please provide scientific justification on how bypassing the respiratory tract (or mucous membrane) is advantageous and how directly injecting viruses into the bloodstream enhances immune functioning and prevents future infections?

Well, things really get off the rails here.  Vaccines are not injected into the blood stream, they are infected into the soft tissues.   At a simple level, an infection enters to body, the body makes a variety of antibodies to the constituent parts of the infecting organism and next time the patient is exposed, the pre-existing antibody can, if there is a match with new strain, inactivate the new infection.

It doesn’t matter how the antigen is presented to the immune system, the response is the same. Natural influenza, inhaled influenza vaccine, or injected influenza vaccine, the same antibody will be made.

He says later

“All promoters of vaccination fail to realize that the respiratory tract of humans (actually all mammals) contains antibodies which initiates natural immune responses within the respiratory tract mucosa. Bypassing this mucosal aspect of the immune system by directly injecting viruses into the bloodstream leads to a corruption in the immune system itself. As a result, the pathogenic viruses or bacteria cannot be eliminated by the immune system and remain in the body, where they will further grow and/or mutate as the individual is exposed to ever more antigens and toxins in the environment which continue to assault the immune system.”

This is what we call in the trade, gibberish. At least it makes no sense to me.  I will leave to the readers to search, Bible Code style, for truthiness in the above selection.

8. Could you please provide scientific justification on how a vaccine would prevent viruses from mutating?

That is actually a very interesting question. It has nothing to do with why we give vaccines and  I fear our intrepid ND does not have a firm grasp on what he is talking about as he says

“Despite the injection of any type of vaccine, viruses continue circulating through the body, mutating and transforming into other organisms. The ability of a vaccine manufacturer to target the exact viral strain without knowing its mutagenic properties is equivalent to shooting a gun at a fixed target that has already been moved from its location. You would be shooting at what was, not what is!”

Mutating and transforming into other organisms. Sigh.  Either the author is a sloppy writer  (sloppy writing reflects a sloppy mind) or his understanding of microbiology is so profoundly mistaken it boggles the mind that he takes care of patients.  And in Oregon he would allowed by the state to prescribe antibiotics.

If you have a population of viruses and a specific antibody against the virus, then those naturally occurring mutants that are not recognized by the antibody should have a replication advantage.  It is possible that the vaccine can help select for new strains of an infection, but not new organisms.

Vaccines selecting for new mutants has been looked at for the Hepatitis B vaccine, and found not to be a issue 20210630.

In HIV, there is an ongoing interaction between the immune response and the virus driving mutations that escape the immune system and, in some patients leads to a marked increase in HIV replication and a clinical decline decline (9143689). Oh wait, this is a natural infection. That shouldn’t happen.  It is the vaccines that do do this.

There is nothing unique about the vaccine response acting as environmental pressure on the evolution of infections; the response from the natural infections should be the same.  I would wonder, since the response to  a natural infection is broader, with antibodies made to numerous parts of the infection, rather than the few key antibodies provided by the response to the vaccine, whether a natural infection would lead to a faster mutation rate.  As a rule in the microbial world, the more intense the stress, the faster and more varied the mutations.  More antibiotics leads to faster development of resistance in E. coli, not its delay

9. Could you please provide scientific justification as to how a vaccination can target a virus in an infected individual who does not have the exact viral configuration or strain the vaccine was developed for?

Dr. Black and White.  Antibody response is not all or nothing, there is a gradient of response between the developed antibody and the site to which it is directed.  A good example is the H1N1 influenza.  People exposed to the strains from the first half f the century had antibody that was partially protective for the 2009 strain.  The reason http://www.ncbi.nlm.nih.gov/pubmed/20049332?

“The pandemic influenza virus (2009 H1N1) was recently introduced into the human population. The hemagglutinin (HA) gene of 2009 H1N1 is derived from “classical swine H1N1″ virus, which likely shares a common ancestor with the human H1N1 virus that caused the pandemic in 1918, whose descendant viruses are still circulating in the human population with highly altered antigenicity of HA. However, information on the structural basis to compare the HA antigenicity among 2009 H1N1, the 1918 pandemic, and seasonal human H1N1 viruses has been lacking. By homology modeling of the HA structure, here we show that HAs of 2009 H1N1 and the 1918 pandemic virus share a significant number of amino acid residues in known antigenic sites, suggesting the existence of common epitopes for neutralizing antibodies cross-reactive to both HAs. It was noted that the early human H1N1 viruses isolated in the 1930s-1940s still harbored some of the original epitopes that are also found in 2009 H1N1. Interestingly, while 2009 H1N1 HA lacks the multiple N-glycosylations that have been found to be associated with an antigenic change of the human H1N1 virus during the early epidemic of this virus, 2009 H1N1 HA still retains unique three-codon motifs, some of which became N-glycosylation sites via a single nucleotide mutation in the human H1N1 virus. We thus hypothesize that the 2009 H1N1 HA antigenic sites involving the conserved amino acids will soon be targeted by antibody-mediated selection pressure in humans. Indeed, amino acid substitutions predicted here are occurring in the recent 2009 H1N1 variants. The present study suggests that antibodies elicited by natural infection with the 1918 pandemic or its early descendant viruses play a role in specific immunity against 2009 H1N1, and provides an insight into future likely antigenic changes in the evolutionary process of 2009 H1N1 in the human population.”

Oops.  Not simple.

But the result? http://www.ncbi.nlm.nih.gov/pubmed/20059763

” over 75% of confirmed cases of novel H1N1 occurred in persons < or = 30 years old, with peak incidence in the age range 10-19 years. Less than 3% of cases occurred in persons over 65, with a gradation in incidence between ages 20 and 60 years.The sequence data indicates that novel H1N1 is most similar to H1N1 viruses that circulated before 1943. Novel H1N1 lacks glycosylation sites on the globular head of hemagglutinin (HA1) near antigenic regions, a pattern shared with the 1918 pandemic strain and H1N1 viruses that circulated until the early 1940s. Later H1N1 viruses progressively added new glycosylation sites likely to shield antigenic epitopes, while T-cell epitopes were relatively unchanged.

CONCLUSIONS: In this evolutionary context, Original Antigenic Sin exposure should produce an immune response increasingly mismatched to novel H1N1 in progressively younger persons. We suggest that it is this mismatch that produces both the gradation in susceptibility and the unusual toxicity”

The better the antibdy fit for the epitope (where the antibody binds) the better the effect, but it doesn’t have to be all or nothing. He would probably ask, what good is half and eye, why have half a wing. Or had a brain.

He finishes

“I have never encountered one pro-vaccine advocate, whether medically or scientifically qualified, who could answer even 1 let alone all 9 of these questions. One or all of the following will happen when debating any of the above questions:

– They will concede defeat and admit they are stumped.

– They will attempt to discredit unrelated issues that do not pertain to the question.

– They will formulate their response and rebuttal based on historical arguments and scientific studies which have been disproved over and over again. Not one pro-vaccine advocate will ever directly address these questions in an open mainstream venue.”

I am neither stumped not defeated.

My response was not unrelated.

My arguments are bases on modern studies that a 12 year old can find in less than a minute.

SBM is an open mainstream venue.

I do feel like I just had a foot race with a sloth; where is the honor in that?

And people wonder why I question the wisdom of allowing naturopaths to function as primary care providers.
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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How do religious-based hospitals affect physician behavior?

Science-based medicine is, among other things, a tool.  Science helps us sequester our biases so that we may better understand reality.  Of course, there is no way to avoid being human; our biases and our intuition still betray us, and when they do, we use other tools.  Ethics help us think through situations using an explicitly-stated set of values that most of us agree upon (and in order to get wide agreement, these precepts must be pretty general).

Ethical problems are a normal part of medical practice. In medical school I received a bit of formal didactic education on ethics, and on the floors we often have formal ethical discussions to help understand and resolve conflicts.   But ethics are not a weapon used to obtain a result we want; they are a tool to give a framework for understanding and resolving dilemmas.  Ethical dilemmas can arise out of may types of conflicts, for example when our personal beliefs clash with those of our patients, or when patients’ and families’ desires conflict.  They can also arise when we as physicians are constrained in our actions by outside forces.
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Posted in: Religion, Science and Medicine

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