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Overprescribing Antibiotics

Phial of penicillin from 1946, marking the advent of the now-closing "antibiotic era".

Phial of penicillin from 1946, marking the advent of the now-closing “antibiotic era”. Image from the Wellcome Trust via the Wikimedia Commons.

Recently I had a cutaneous abscess which was treated (quite painfully) with incision and drainage. My doctor told me that antibiotics were not strictly necessary, but I could have them if I wanted. The idea of any treatment that could resolve the abscess more quickly was appealing, but I did not want to contribute to the unnecessary use of antibiotics so I declined.

The use of antibiotics in cutaneous abscess is not straightforward, as there are indications – signs of systemic infection, failure to resolve quickly with just I&D, or in immunocompromised patients. Antibiotics may also reduce the risk of recurrence. These are, after all, bacterial infections.

If I were not very familiar with the issue of antibiotic overuse and emerging resistance I probably would have caved and accepted the antibiotics, and I suspect most patients do. Many patients probably request antibiotics or at least ask about them. I declined, and everything turned out fine. (more…)

Posted in: Guidelines, Public Health

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Sharks Get Cancer, Mole Rats Don’t: Clues to Understanding Cancer

sharks
We think of cancer as caused by mutations. Mutations are necessary, but not sufficient, to cause cancer. New research indicates that it’s the body’s response to mutant cells that determines whether cancer will develop. James S. Welsh, MD, a radiation oncologist and researcher, has written a book on the immunology of cancer, Sharks Get Cancer, Mole Rats Don’t: How Animals Could Hold the Key to Unlocking Cancer Immunity in Humans. In it, he pieces together clues from animals, pregnancy, Ebola virus, infections, organ transplantation, parasites, and human cancer patients, weaving a web of insights that point to a better understanding of cancer biology and treatment.

Sharks do get cancer

Shark with cancer

Shark with cancer

The first book claiming that sharks don’t get cancer came out in 1992. It persuaded so many people to take shark cartilage that the world market exceeded $30 million and shark populations decreased by as much as 80%. Sharks do get cancer, as you can see in this picture.

Ironically, sharks can even get cancer of the cartilage! And of course shark cartilage supplements don’t prevent cancer in humans. Welsh explains how that myth got started. It was magical thinking based on extrapolation from a legitimate scientific study on angiogenesis where tumor growth in lab animals was suppressed by placing rabbit cartilage next to the tumors.
(more…)

Posted in: Basic Science, Cancer

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Medical exemptions to vaccine mandates for sale after SB277! Get ’em before they’re gone!

NOTE: Anyone who has seen several derogatory articles about me on the web and is curious about what the real story is, please read this and this.

SB277, which eliminates nonmedical exemptions to school vaccine mandates in California, is a very good law, but it's not perfect. Unfortunately, one provision allows the issuance of medical exemptions based on the say-so of doctors using antivaccine misinformation and pseudoscience.

SB277, which eliminates nonmedical exemptions to school vaccine mandates in California, is a very good law, but it’s not perfect. Unfortunately, one provision allows the issuance of medical exemptions based on the say-so of doctors using antivaccine misinformation and pseudoscience.

I realize that it’s a cliché to say so, but some clichés are true. Time really does fly. It’s hard to believe that a year ago California—and, by proxy, the rest of the country—was in the throes of a major political war over the bill SB277. SB277, you will recall, was a bill introduced into the California Assembly in the wake of the Disneyland Measles outbreak in early 2015 that eliminated non-medical exemptions to school vaccine mandates beginning with the 2016-2017 school year. Ultimately, SB277 passed and was signed into law by Governor Jerry Brown last July. It was an uncommon victory for science and public health, and already appears to be having a positive effect on vaccine uptake in kindergarten children.

Unfortunately but not unexpectedly, to say that the proposal and passage of SB277 into law drove the antivaccine movement into even greater fits of crazy in response is to put it mildly. It became a common trope on antivaccine websites and blogs to see SB277 compared to fascism, in particular the Holocaust. Robert F. Kennedy, Jr. and “Dr. Bob” Sears explicitly compared SB277 to the Holocaust. Truly, the Godwin was strong in the antivaccine movement. One particularly offensive meme that went around at the time consisted of antivaccinationists suggesting that SB277 was a major step in the direction of requiring unvaccinated children to wear a badge or armband to identify themselves, the way that the Nazis required Jews to wear badges or armbands with a yellow Star of David on them. One, Heather Barajas, even went so far as to be photographed with her children wearing such an “unvaccinated” badge and juxtapose that photo with photos of Jews from the Third Reich wearing yellow Stars of David.
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Posted in: Homeopathy, Politics and Regulation, Public Health, Vaccines

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Chiropractors, Blind Pigs, and Acorns

Sometimes you need to help the blind pig.

Sometimes you need to help the blind pig.

When people are at the end of their life they like to pass on their life lessons. One thing I have never had a patient say is “Doc, I sure wish I had spent more time at work.”

I try and keep that in mind, but then there are those work commitments that are hard to avoid. I need to have a talk with Drs. Gorski and Novella. No one should have write a blog entry any week their team is in the play-offs. The Blazers were not meant to win more than 25 games, much less be the 5th seed in the West with a chance to make the conference finals. I know. Trailblazers fans are not always grounded in reality. But we are up on the Clippers 3–2 and heading home to close out the series tonight. For the record I wrote the preceding sentence during the game 5 tip-off. I really should not have to do any work this week. Basketball is simply more important.

Take this case report. Anywhere else.

Case reports are a tradition in medicine. Usually they are unique or unusual cases, diseases you are likely to see but once in a career, if that. There are all sorts of medical curiosities that need to be reported. I have a blog over at Medscape devoted to Infectious Disease case reports.

Some case reports, however, inspire eye rolls and sniggers. Why are these even reported? (more…)

Posted in: Chiropractic, Clinical Trials, Humor

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What (if anything) does “natural” mean?

"When I use a word," said Humpty Dumpty said in a rather scornful tone, "it means just what I choose it to mean -- neither more, nor less." Lewis Carroll, "Through the Looking Glass"

“When I use a word,” said Humpty Dumpty in a rather scornful tone, “it means just what I choose it to mean — neither more, nor less.”
Lewis Carroll, “Through the Looking Glass”

What does the term “natural” mean on a label? Does it mean anything? Should it mean anything? Good questions. And complicated ones, judging from the list of questions the FDA needs your help in answering.

The FDA has resisted defining “natural” in food product labeling, including whether foods that are genetically engineered, or contain genetically engineered ingredients, can use the term. Back in 1991, the agency set out to issue regulations but abandoned the effort and has since held to an informal policy that “natural” means

nothing artificial or synthetic (including color additives regardless of source) has been included in, or has been added to, a food that would not normally be expected to be in the food.

The only official legal requirement for using the description “natural” on a food label is that it not be misleading or false, which is forbidden by the Food, Drug & Cosmetics Act of 1938. In that appetite-suppressing way of statutory language, “food” is defined by the Act as

articles used for food or drink for man or other animals, chewing gum, and articles for used for components of any such article.

For regulatory purposes, dietary supplements are also considered foods in most cases. (more…)

Posted in: Genetically modified organisms (GMOs), Legal, Nutrition, Politics and Regulation

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Parents Convicted in Death of Toddler

Stephans

David and Collet Stephan, parents to the now-deceased Ezekiel Stephan.

This is a very sad and tragic case, and I have great sympathy for the extended family of Ezekiel Stephan, the 19-month-old who died of meningitis four years ago. In my opinion, there are many victims in this case.

The jury, apparently, agreed. Yesterday they returned a guilty verdict for Ezekiel’s parents, David and Collet Stephan, who now face sentencing for failing to provide the basic necessities of life to their son. It is reported that many of the jurors were crying when the verdict was given – clearly this was a difficult and emotional case.

Just the facts

As is often the case, there are different narratives of what happened, depending on your perspective. It is likely the jury had access to more facts than the public, and so their verdict, which was clearly difficult, needs to be taken seriously. Here are the basic facts as being reported:

In March of 2012 Ezekiel became ill with flu-like symptoms. His parents report that they thought this was a normal childhood illness and would pass. His mother reported to police that she thought he had croup. They treated him with natural remedies, mostly supplements. (more…)

Posted in: Ethics, Herbs & Supplements, Naturopathy

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Is the Annual Physical Unnecessary?

Quality

I was approached by The Wall Street Journal to write an article for their Big Issues in Health Care debate series. The subject was “Is the annual physical unnecessary?” I was to take the “yes” side and an internist was to take the “no” side. I wrote the following article. The editor wrote me a couple of times with questions. The internist pointed out the value of preventive medicine, developing a personalized healthcare plan, and developing a meaningful doctor-patient relationship. I said I wholeheartedly agreed, but I thought those goals could be accomplished just as well (arguably even better) with a periodic health maintenance interview or consultation. I pointed out that the traditional “physical” exam with stethoscope, routine lab tests, etc. provides no further advantages and can be counterproductive, with false positive or harmless findings leading to unnecessary worry, further testing, and expense. I said there was nothing magical about the interval of a year. I don’t know what the optimum interval would be; that could be studied. I suspect it would vary with the patient’s age, medical conditions, risk factors, and other considerations, and might be left up to the judgment of patient and doctor deciding together.

Finally I got an e-mail with apologies, saying they had decided not to continue with the debate because the internist and I agreed on too many important details. While I understand that stirring up a fight is good for selling newspapers, I think it’s a much better thing when people on two sides of a debate reach an agreement. It reassures me that they are converging on the truth. So I thought it would be worthwhile to publish my article here on SBM. (more…)

Posted in: Commentary, Diagnostic tests & procedures

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Reclassifying thyroid cancer and the willful misunderstanding of overdiagnosis

This is a panel showing some of the pathologic criteria for distinguishing invasive encapsulated follicular variant of papillary thyroid carcinoma from noninvasive. This is real science. Sayer Ji's rant is not.

This is a panel showing some of the pathologic criteria for distinguishing invasive encapsulated follicular variant of papillary thyroid carcinoma from noninvasive. This is real science. Sayer Ji’s rant is not.

If there’s one lesson that we here at Science-Based Medicine like to emphasize, it’s that practicing medicine and surgery is complicated. Part of the reason that it’s complicated is that for many diseases our understanding is incomplete, meaning that physicians have to apply existing science to their treatment as well as they can. The biology of cancer, in particular, can be vexing. Some cancers appear to progress relentlessly, meaning that it’s obvious that all of them must be treated. Others, particularly when detected in their very early stages through screening tests, have a variable and therefore difficult to predict clinical course if left untreated. Unfortunately, some people, such as Sayer Ji, don’t understand that. They like their medicine black and white, and if physicians ever change guidelines in order to align them more closely with scientific understanding, they write blisteringly ignorant articles like “‘Oops… It Wasn’t Cancer After All,’ Admits The National Cancer Institute/JAMA.”

Not exactly. An expert panel recommended reclassifying a specific thyroid lesion as not cancerous based on recent science. It’s called medicine correcting itself. Admittedly, this reclassification was probably long overdue, but what would Mr. Ji rather have? Medicine not correcting itself in this situation? In any case, when last I met Mr. Ji, he was happily abusing the science of genetics to argue that Angelina Jolie and other carriers of deleterious cancer-causing mutations don’t need prophylactic surgery because lifestyle interventions will save them through epigenetics, which to “natural health” enthusiasts like Mr. Ji seems to mean the magical ability to prevent any disease. Most recently, he has appeared on the deeply dishonest “documentary” about alternative medicine cancer cures, The Truth About Cancer, to expound on how chemotherapy is evil. His rant about the reclassification of a non-encapsulated follicular variant of papillary thyroid cancer as not cancer is more of the same, as you will see.
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Posted in: Cancer, Politics and Regulation, Public Health

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Separating Fact from Fiction in the Not-So-Normal Newborn Nursery: Chiropractic and Brachial Plexus Injury

Thanks to a hot tip from a follower on Twitter, I’ve once again found myself neck deep in chiropractic propaganda involving the care of a pediatric patient. The case as presented involves, among numerous specious assumptions, claims of successfully treating an infant’s paralyzed arm using chiropractic philosophy and spinal adjustment techniques. As I will explain in detail, this “miracle” is just another in a seemingly endless stream of emotional but worthless anecdotes being used for marketing purposes.

I’ll be discussing two videos, uploaded to YouTube by a father who wants to tell the world about the miracle of chiropractic. He uses that word a lot, in fact, assigning the label to no less than four outcomes and clearly setting the bar lower than my own personal threshold. The videos are a few years old, but have over 150,000 views and can still be found linked to on numerous websites and discussed in interviews. If you’re feeling generous, they serve as excellent examples of how the mind of the believer works when facing uncertainty regarding the health of a loved one.

I will provide a general synopsis of the events in question, but I do recommend watching the videos despite the fact that you will never get those 18 minutes back. They contain the details of the case and, particularly in the second video, some great examples of typical chiropractic tactics and buzzwords. (more…)

Posted in: Science and Medicine

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The Brown M&M’s of Science-Based Medicine

David Lee Roth. Quality Guru.

David Lee Roth. Quality Guru.

Medicine is constantly changing, and like most health professionals, I am required to maintain my competency to practice. I doubt pharmacists are unique in being inundated with offers of continuing medical/pharmacy education. Some courses are free, some cost hundreds of dollars, and it can be difficult to distinguish the high-quality programs from the biased or low-quality education that furthers a agenda, rather than seeking to truly educate. You can consider the reputation of the provider, or the author, and sometimes the sponsorship gives a clue. When it comes to determining if a program’s content is science-based or not, I find the learning objectives may be all I need to read. One program I saw recently referred to “integrative” approaches to the treatment of an illness. Another claimed it would teach you a  “holistic” approach to managing complex medical condition. Both programs set off skeptical alarm bells. I realized then I’d found the science-based medicine equivalent of a brown M&M. And I have the band Van Halen to thank for that association. (more…)

Posted in: Commentary, Humor, Science and Medicine

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