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Topical NSAIDs

I have a mental basket of drugs that I suspect may be placebos. In that basket were the topical versions of non-steroidal anti-inflammatory drugs (NSAIDs). When the first products were commercially marketed over a decade ago, I found the clinical evidence unconvincing, and I suspected that the modestly positive effects were probably due to simply rubbing the affected area, or possibly due to the effects of the cream or vehicle itself. Frankly, I didn’t think these products worked. So when I recently noticed a topical NSAID appear for sale as an over-the-counter treatment for muscle aches and pains (seemingly only in Canada, for now), I was confident it would make a good case study in bad science.

It’s not that I’m partial to the oral NSAIDs. Yes, they’re among the most versatile, and probably most well-loved drugs in our modern medicine cabinet. They offer good pain control, reduce inflammation and can eliminate fever. We start using it in our sick and feverish infants, through childhood and adulthood for the aches and pains of modern life, and into our later years for the treatment of degenerative disease like osteoarthritis, which affects pretty much everyone as we age. An astonishing 17 million Americans use NSAIDs on a daily basis, and this number is expected to grow as the population ages. In the running groups I frequent, ibuprofen has the affectionate nickname “Vitamin I”, where it’s perceived as an essential ingredient for dealing with the consequences of training.

But NSAIDs have a long list of side effects. Not only do they cause stomach ulcers and bleeding by damaging the gastrointestinal mucosa, there are heart risks, too. It was the arrival (and departure) of the drugs Bextra and Vioxx that led to documentation of the potential for cardiovascular toxicity. And now there’s data to suggest that these effects are not limited to the “COX-2” drugs – almost all NSAIDs, including the old standbys we have used for years, seem capable of raising the risks of heart attacks and strokes.

So despite my initial skepticism, I took another look at the topical NSAIDs. The data were not what I expected.

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Posted in: Pharmaceuticals, Science and Medicine

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Placebo Effect for Pain

It has long been recognized that there are substantial multifactorial placebo effects that create real and illusory improvements in response to even an inactive treatment. There is a tendency, however (especially in popular discussion), to oversimplify placebo effects – to treat them as one mind-over-matter effect for all outcomes. Meanwhile researchers are elucidating the many mechanisms that go into measured placebo effects, and the differing magnitude of placebo effects for different outcomes.

For example, placebo effects for pain appear to be maximal, while placebo effects for outcomes like cancer survival appear to be minimal.

A recent study sheds additional light on the expectation placebo effect for pain. The effect is, not surprisingly, substantial. However it does not extrapolate to placebo effects for outcomes other than pain, and the results of this very study give some indication why. From the abstract:

The effect of a fixed concentration of the μ-opioid agonist remifentanil on constant heat pain was assessed under three experimental conditions using a within-subject design: with no expectation of analgesia, with expectancy of a positive analgesic effect, and with negative expectancy of analgesia (that is, expectation of hyperalgesia or exacerbation of pain).

What they found was that the positive expectation group reported twice the analgesic effect as the no expectation group, and the negative expectation group reported no analgesic effect. This is a dramatic effect, but not surprising.

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Posted in: Neuroscience/Mental Health, Pharmaceuticals

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Questioning the Annual Pelvic Exam

A new article in the Journal of Women’s Health by Westhoff, Jones, and Guiahi asks “Do New Guidelines and Technology Make the Routine Pelvic Examination Obsolete?”

The pelvic exam consists of two main components: the insertion of a speculum to visualize the cervix and the bimanual exam where the practitioner inserts two fingers into the vagina and puts the other hand on the abdomen to palpate the uterus and ovaries. The rationales for a pelvic exam in asymptomatic women boil down to these:

  • Screening for Chlamydia and gonorrhea
  • Evaluation before prescribing hormonal contraceptives
  • Screening for cervical cancer
  • Early detection of ovarian cancer

None of these are supported by the evidence. Eliminating bimanual exams and limiting speculum exams in asymptomatic patients would reduce costs without reducing health benefits, allowing for better use of resources for services of proven benefit. Pelvic exams are necessary only for symptomatic patients and for follow-up of known abnormalities. (more…)

Posted in: Obstetrics & gynecology

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Skepticism versus nihilism about cancer and science-based medicine

Last Friday, Mark Crislip posted an excellent deconstruction of a very disappointing article that appeared in the most recent issue of Skeptical Inquirer, the flagship publication of the Committee for Skeptical Inquiry (CSI). I say “disappointing,” because I was disappointed to see SI (Skeptical Inquirer, not Sports Illustrated) publish such a biased, poorly thought out article, apparently for the sake of controversy. I’m a subscriber myself, and in general enjoy reading the magazine, although of late I must admit that I don’t always read each issue cover to cover the way I used to do. Between work, grant writing, blogging, and other activities, my outside reading, even of publications I like, has declined. Perhaps SI will soon find itself off my reading list. Be that as it may, I couldn’t miss the article that so irritated Mark, because it irritated me as well. There it was, emblazoned prominently on the cover of the March/April 2011 issue: Seven Deadly Medical Hypotheses. I flipped through the issue to the article to find out that this little gem was written by someone named Reynold Spector, MD. A tinge of familiarity going through my brain, I tried to think where I had heard that name before.

And then I remembered.

Dr. Spector, it turns out, first got on my nerves about a year ago, when he wrote an article for the January/February 2010 issue of SI entitled The War on Cancer: A Progress Report for Skeptics. I remember at that time being irritated by the article and wanting to pen a discussion of the points raised but don’t recall why I never actually did. It was probably a combination of the fact that SI doesn’t publish its articles online until some months have passed after the paper version has been released and perhaps my laziness about having to manually transcribe with my own fingers any passages of text that I might want to cite. By the time the article was available online, I forgot about it and never came back to it–until now. I should therefore, right here, right now, publicly thank Mark (and, of course, Dr. Spector) for providing me the opportunity to revisit that article in the context of piling on, so to speak, Dr. Spector’s most recent article. After all, Deadly Hypothesis Seven (as Dr. Spector so cheesily put it) is:

From a cancer patient population and public health perspective, cancer chemotherapy (chemo) has been a major medical advance.

Dr. Spector then takes this opportunity to cite copiously from his 2010 article, sprinkling “(Spector, 2010)” throughout the text like powdered sugar on a cupcake. There’s the opening I needed to justify revisiting an article that’s more than a year old! And what fantastic timing, too, hot on the heals of my post from a couple of weeks ago entitled Why haven’t we cured cancer yet?
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Posted in: Cancer, Science and Medicine, Science and the Media

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An ICD Code for the Running Piglets!

… animals are divided into (a) those that belong to the emperor; (b) embalmed ones; (c) those that are trained; (d) suckling pigs; (e) mermaids; (f) fabulous ones; (g) stray dogs; (h) those that are included in this classification; (i) those that tremble as if they were mad; (j) innumerable ones; (k) those drawn with a very fine camel’s-hair brush; (l) etcetera; (m) those that have just broken the flower vase; (n) those that at a distance resemble flies.

— Jorge Luis Borges (1899–1986)1

Not too long ago, I came across a disease taxonomy proposed by a certain East-West Medical Research Institute (EWMRI), that includes the kind of fantastic afflictions — such as “running piglet” disorder — fit for the best Borgesian list.

This obscure institute, located at Kyung Hee University in Seoul, Korea, is one of the 800 WHO Collaborating Centres designated to carry out various activities in support of the Organization’s programs. With the collaboration of China, Japan, Vietnam, Australia, and the US, this center is working to incorporate medieval Asian disease nomenclature to the 11th version of the International Classification of Disease (ICD-11).
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Posted in: Acupuncture, Basic Science, Science and Medicine

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Deadly Indeed

There are sources of information I inclined to accept with minimal questioning.  I do not have time to examine everything in excruciating detail, and like most people, use intellectual short cuts to get through the day.  If it comes from Clinical Infectious Diseases or the NEJM, I am inclined to accept the conclusions without a great deal of analysis, especially for non-infectious disease articles.  Infectious disease publications I have to read more closely; its part of passing as an expert.

Outside of medicine, I am predisposed to accepting at face value many of the articles in Skeptic and Skeptical Inquirer. They are trusted sources.  Some topics, like haunted house or Big Foot investigations, I barely skim. After all these years, I doubt there will be any new insights into the subject.  Other topics, depending on my interest, I may read more carefully.

I  often read longer articles  many times.  First a quick skim to see if it offers anything of interest.  If it does, then I may read it carefully.

This months Skeptical Inquirer had an article called  Seven Deadly Medical Hypotheses by Reynold Spector.  Just seeing the title and knowing the magazine, I was primed to accept the content at face value.  I enjoy a well reasoned, thoughtful rant. I relish a clever diatribe, even if I do not agree with the topic.   So I gave it a quick skim.  I was discomfited.  My first gut check was ick.  But I was uncertain why.  So I read it slowly and carefully, and still ick.  But why? (more…)

Posted in: Epidemiology, Science and Medicine, Science and the Media

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Supreme Court Saves Nation’s Immunization Program

The Supreme Court of the United States made a ruling the other day that has profound implications for the health of millions of children. Since October 12, 2010, The Court has been quietly deliberating the case of Bruesewitz v. Wyeth, inc. The case centers on Russell and Robalee Bruesewitz’s allegation that their 18 year old daughter, Hannah, was irreversibly injured by a DTP vaccine she received when she was 6 months old. What is important about this case is not the allegation itself (I will discuss its merits, or lack thereof, in a moment), but the ramifications the ruling has for the future of childhood immunization in this country. The Supreme Court’s ruling against the Bruesewitz’s and in favor of the U.S. vaccination program was the right one, and safeguards our children from the irrationality of the anti-vaccine movement. Some important background is necessary here to understand why this is so.

Prior to the development of effective vaccines, diphtheria, tetanus, and pertussis were common diseases, terrifyingly familiar to all parents. Death records from Massachusetts during the latter half of the 1800’s indicate that diphtheria caused 3-10% of all deaths. In the first part of the 20th century, these dreaded organisms still caused illness in hundreds of thousands of people each year in the United States. These are devastating diseases which, if not resulting in death, often produced severe and permanent damage to those afflicted. In the 1920’s, vaccines against each of these scourges were finally developed, and in the mid 1940’s the combined DTP vaccine was introduced. The vaccines were so effective that cases of these deadly infections were practically eliminated. Today, few parents know the terror once routinely wrought by these pathogens.

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Posted in: Legal, Science and Medicine, Vaccines

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Dr. Oz, you’re not helping diabetics

Dr. Mehmet Oz is one of America’s most influential doctors.  Just ask him.  He has a TV show and everything.  And in the past, much of his advice had been practical and mundane, the same advice you might hear from your own (perhaps less charismatic) physician.  But lately, he’s been giving out frankly bizarre medical opinions.  Not all of Oz’s recommendations are over-the-top strange, but even some of his less-bizarre stuff is hyperbolic to the point of being—in my opinion—deceptive.  Let’s explore one example close to my heart, diabetes.  As an internist, one of my most important tasks is the prevention and treatment of diabetes.  I know something about it.  As a heart surgeon, Dr. Oz deals with one of the most serious complications of diabetes, coronary heard disease, so he must know a bit about it as well.

So I was a bit surprised to learn from his website that I’ve  been going after diabetes the wrong way.  Unknown to me is the “prevention powerhouse” of coffee and vinegar.  He recommends heavy consumption of these miracle foods to prevent diabetes and to help the liver and cholesterol, whatever that means.  Reading this, two questions come to mind (a few more, really, but two that we will focus on): is this plausible, and is this true?
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Posted in: Science and Medicine, Science and the Media

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The Hidden Cancer Cure

Last week David Gorski wrote a excellent post about why we have not yet cured cancer. It turns out, cancer is a category of many individual diseases that are very challenging to treat. We have made steady progress, and many people with cancer can now be cured – but we have not discovered the one cure for all cancer. I personally am not convinced that we will discover a single cure for all cancer, at least not with any extrapolation of current technology. But if we continue to make progress as we are cancer will become an increasingly treatable and even curable type of disease.

This topic also brings up a meme that has been around for a long time – the notion that scientists have already cured cancer but the cure is being suppressed by the powers that be, to protect cancer as a source of income. In the comments to David’s article, Zuvrick writes:

So we can find a cure. It has probably happened multiple times. But nobody wants to cure cancer. Too many researchers earn a living seeking a cure by remaining inside a narrow, restricted channel of dogma. Their institutions get grant money and survive from the funding. Big Pharma makes big bucks selling chemotherapy drugs, surgeons remove tumors and various radiation devices employ radiologists and firms making these machines. MRI and CT scans would not be needed for cancer if Rife technology were available today.

I have heard or read some version of this claim since before I entered medical school.  Superficially it may sound like profound wisdom (cynicism is a cheap way to sound wise) – but the idea collapses under the slightest bit of logical scrutiny.

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Posted in: Cancer

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