It’s a seldom mentioned aspect of my professional history that I used to do a lot of trauma surgery in my youth. I did my residency at a program that included a county hospital with a busy trauma program where I saw quite a bit of vehicular carnage and an urban hospital (which has since closed) where I saw a fair amount of what we in the surgery biz call gun and knife club action. During my time as a PhD student, I moonlighted as a flight physician for the local helicopter rescue service, Metro Life Flight, where I took care of patients with everything from cardiac disease requiring transfer to the Cleveland Clinic to near-drownings during the summer at the Lake Erie resorts, particularly Put-in-Bay, to obstetrical transfers (which terrified me) to, of course, the unfortunately copious run-of-the-mill vehicular trauma. I saw the sort of tragedy that could result. Then, in the late 1990s, as I did research for my surgical oncology fellowship in Chicago, I also moonlighted as a trauma attending at a local suburban level II trauma center.
At that point, I realized that trauma was not my thing, as I couldn’t see myself at my present advanced age doing the sort of physically and emotionally demanding work that required fast decisions. It stressed me out too much; which is part of the reason why I went into surgical oncology in the first place. However, I have an appreciation for those who do do trauma. I also realize that trauma is, in a way, the “purest” form of surgery in that it involves taking a body broken by mechanical forces and trying to repair it, all the while keeping the patient alive until the repairs can heal. I will, however, miss the enjoyment I get hearing presentations on tree stand falls during hunting season.
I don’t mention my youthful flirtation with trauma surgery so much because I think it’s something so fascinating that I must tell it. (If that were the case, I’d have been mentioning it much more frequently in my blogs and social media than I have before.) Rather, it lets you know why I was so distressed when this story was forwarded to me a few days ago. It’s a Reuters report entitled “Injuries soar after Michigan stops requiring motorcycle helmets“:
Caring for a young infant, although a potentially rewarding means of producing a labor force for chores and minor home repairs, can be a trying ordeal for both new and experienced parents. The peaks and valleys of parental experience can leave a caregiver both exhilarated and agonizingly frustrated during a single hour of childcare, let alone the first few months. It is not an uncommon experience for a parent to rapidly alternate between extreme states of emotional arousal, one minute gazing down at their sleeping baby with seemingly limitless feelings of joy and love, and the next panicking at the perception that it has been too long since their baby’s last breath.
Babies, especially stupid ones, require near constant attention during the first several weeks of life, and that’s if it is going well. There is no user manual for the care of the newborn human that could possibly describe every situation and how to effectively respond to it in each individual child. A trial and error approach is always necessary to some degree, and it tends to result in a lot of sleepless nights, with many parents finding themselves more exhausted than they ever dreamed possible. So it shouldn’t be surprising that parents are a particularly vulnerable population when it comes to the marketing claims of bogus technology aimed at making their lives even the slightest bit easier. (more…)
One of the most satisfying parts of being a health professional is the opportunity to help people make better health decisions. In between the emails suggesting I’m a paid lackey of the Pharmaceutical-Industrial Complex™ for not endorsing coffee enemas, vitamin C, or homeopathy, I do receive the occasional note thanking me for my advocacy, or for writing about a subject in a way they found helpful. I’m also sent questions – too many to answer, but occasionally opening my eyes to new “concepts” in alternative medicine. And while I spent years working in a pharmacy with a huge “holistic” health section, containing products that, if they worked, would have defied one or more laws of physics or chemistry, I can still be surprised at novel alternative-to-medicine approaches to health care. Last week I was sent a questions about hydrogen peroxide – not for first aid use (where it may not be as useful as thought), but for oral consumption, as some sort of health “cure-all”. I was baffled, but the concept does exist – and the Big Pharma Overlords apparently don’t want you to know about it. There must be a rule 34 of alternative medicine – if it exists, there is an (inappropriate) alternative medicine use for it. The active ingredient in hair bleach and teeth whitening strips is no exception. (more…)
The public fight over the human papillomavirus (HPV) vaccine is still raging. The debate partly reflects the underlying logic of health prevention measures, which is essentially a statistical game of risk vs benefit. Unfortunately thrown into the mix are ideological opponents to vaccines who are distorting the facts at every turn.
Notice that I said this was a “public” fight, because it is not a serious scientific dispute. There is sufficient evidence to confidently conclude that the HPV vaccines currently available are safe and effective. All medical interventions will contain some risk, it is never zero, but vaccines in general, and the HPV vaccine specifically, have minimal risks and clearly prevent disease.
In addition there is a social angle to the HPV vaccine in that it is given to children to prevent a sexually transmitted disease.
The science of the HPV vaccine
What’s the best route to this happy outcome?
Doctors used to insist “once a C-section, always a C-section.” Today it is standard practice to allow vaginal births after C-section (VBAC) for appropriately selected patients. The American Congress of Obstetricians and Gynecologists (ACOG) has issued a Practice Bulletin to guide obstetricians in determining which patients are appropriate candidates for VBAC.
We frequently hear criticisms of practice guidelines like these. The doctors who write the guidelines are accused of conflict of interest, turf protection, and biased evaluation of the evidence. For those who believe doctors put profits before patients, this should be an eye-opener. It would presumably be in the best financial interests of obstetricians to do as many C-sections as possible, since they can charge more for them than for vaginal births. It would have been easy for the ACOG to put a spin on the data to make repeat C-sections look like a better choice. The fact that they offer VBACs despite their conflict of interest makes me think that their evaluation of the evidence was probably fair and unbiased.
So just how safe is VBAC? What are the pros and cons? What does the evidence say? (more…)
We frequently write about placebo effects here on Science-Based Medicine. The reason is simple. They are an important topic in medicine and, at least as importantly, understanding placebo effects is critical to understanding the exaggerated claims of advocates of “complementary and alternative medicine” (CAM), now more frequently called “integrative medicine” (i.e., integrating pseudoscience with science). Over the years, I (and, of course, others) have documented how CAM advocates have consistently moved the goalposts with respect to the efficacy of their pseudoscientific interventions. As larger and better-designed clinical trials have been done demonstrating that various CAM therapies without a basis in science—I’m distinguishing these from science-based modalities that have been co-opted and “rebranded” as CAM, such as exercise and nutrition—have no specific effects detectable above placebo effects, CAM advocates move the goalposts and claim that CAM works through the “power of placebo” and do their best to claim that “harnessing” that “power of placebo” is a justification to use their treatments. It turns out, however, that when placebo effects are examined rigorously there’s just not a lot of there there, so to speak. Results are underwhelming, and trying to “harness the power of placebo” without an intervention that actually impacts the pathophysiology of disease can even be dangerous. That’s not to say that learning to maximize placebo responses (whatever they are) while administering effective medical treatments isn’t important; rather, it’s to point out that, by themselves, placebo effects are not of much value.
Unfortunately, none of this has stopped what Steve Novella refers to as the “placebo narrative” from insinuating itself into lay discussions of medicine. That narrative proclaims in breathless terms (as Steve put it) the “surprising power of the placebo effect” without putting it into reasonable perspective or even really defining what is meant by “placebo effect.” First, as we have tried to explain time and time again here, there is no single “placebo effect.” There are placebo effects. Second, the only really correct reference to “the placebo response” or “placebo effect” is the outcome measured in the placebo arm of a clinical trial. The problem is that, all too often, discussions of placebo responses conflate the placebo effect measured in a clinical trial with all the other various placebo effects that add up to the response that is measured in that trial. Those effects include reporting biases, researcher biases, regression to the mean, conditioning, and many other components that contribute to what is measured in the outcome of a clinical trial. Another common misconception about placebo effects is that they are somehow “mind over matter,” that we can heal ourselves (or at least reduce our symptoms) through the power of will and mind. This is not true. Placebo effects are not the power of positive thinking.
The little burrowing bacteria that bores into your pores to cause Lyme disease, EEEEEWWW!!! Darkfield 400x microscopy image of the 10-25µm long Borrelia burgdorferi spirochaete which causes Lyme disease (1993). Provided by the CDC’s Public Health Image Library (PHIL #6631) via the Wikimedia Commons
I hate those oh hell moments. I was up way too late last night, but who can pass up the opportunity to see Patti Smith playing Horses (and more) for the 40th anniversary of the album. Only 44? Behind the Eagles? No way. I would nudge it up a few more spaces. Hard to believe I was 18 when that album came out. Horses is one of the few albums that made the transition from vinyl to CD. It was a tremendous show, and at 69 Patt performs with the energy and passion of a 29 year old. And she sure can spit. I had the evening off, so food and drinks at Swine until well past midnight. First time my wife and I closed a bar. I am too old for this.
But as I was blearily drinking my a.m. coffee on a dreary PDX morning, I opened the browser to SBM and there was a post by Jann. Oh hell. That means I have a post due tomorrow and I had lost track of the time over the holidays. I thought my next post was next Friday. Oh. Hell. So unlike most posts which I write over a week, this one was done in about 4 hours. And I am sure it will show.
How do you diagnose an infection?
Not always so simple. You always start with a history and, for infectious diseases, an exposure history is paramount. People get what they are exposed to, so you want to know travel, animals, diet, water, sex etc. If you have ridden a horse to have sex in an Indian lake while drinking raw milk (not really an unusual history in my practice; people do the darndest things) you have exposure risks for a variety of infections. If you have not left the Willamette Valley it is unlikely that the cause of the illness is malaria, although you always have to consider that the infection came to the patient rather than the other way around. (more…)
One of the main, but perhaps underappreciated, reasons quackery thrives in the United States is that the states legalize it by licensing practitioners of pseudoscience as health care providers. These practitioners are placed under the regulatory jurisdiction of, well, themselves. I call the whole deplorable process Legislative Alchemy, and you can see all posts on the topic here. It gives practitioners an underserved imprimatur of state authority and leaves public protection from harmful practices to the oversight of those who are themselves engaging in the very same conduct. Each year, dozens of bills are brought before the state legislatures to establish initial licensure or, once that goal is achieved, scope of practice expansion.
Most attempts fail, but CAM practitioners are a dogged bunch, and they will come back each year until they get what they want. It took chiropractors about 60 years to become licensed in all 50 states. Acupuncturists are almost there. Naturopaths lag far behind, but are slowly gaining ground each year, even if it is only via practice expansion in states where they are already licensed. 2015 was a losing season for all, but not without advancement toward larger goals.
Lumosity is a company that provides online and mobile games that it claimed are scientifically designed to enhance memory, focus, mental flexibility, and even stave off dementia. In a recent decision, the Federal Trade Commission (FTC) concluded that Luminosity’s claims are not based on adequate scientific evidence. They imposed a $50 million judgement against Lumos Labs, the company who sells Lumosity, and allowed them to settle for $2 million.
Being mentally active
The idea behind “brain training” is not a bad one, it’s just easy to misrepresent as something it isn’t. The basic notion is that using your brain makes it function better. It is better to be mentally and physically active than inactive. This overview summarized the evidence: (more…)
Joseph Mercola, D.O., runs the website mercola.com which is full of misinformation, advocates all kinds of questionable alternative treatments including homeopathy, and discourages vaccination and other aspects of conventional medicine.
Like Dr. Oz and Andrew Weil, he is more dangerous than easily recognizable quacks in that he combines some good medical information with egregious misinformation, and readers who know he is right about the good information are likely to wrongly assume everything else he says must be equally true. He’s right about some things, but the safest course is to assume that anything on his website is false unless you can verify it as true by consulting other sources that are reliable. I tried to verify the information in his recent article on colonoscopy. I found outright errors along with fear-mongering and bias. (more…)