Archive for: May, 2010

In memoriam

May 31 2010 Published by under Medicine

According to my family's recollection, none of our relatives has died fighting for the United States. My grandmother was from a small town in what is now Belarus and most people in the family were born, lived, and died there. One of her brothers, though, did something remarkable. If family memories are correct, he left town and went to the Sorbonne in Paris. After being there a short while, the Great War broke out, and he joined the French army to fight for his new home. He was killed, and my father and two of his cousins are named for him (in an Anglicized way).
I am in the first generation of men in my family to have been able to choose not to go to war. My father was in Korea as a doctor. His father joined the army shortly after immigrating to U.S., but the Great War ended shortly thereafter. My one American-born grandfather tried to join the army for World War I but was too skinny, so he went home and gorged on bananas until he was heavy enough to get in the army. He used to sing me WW I drinking songs when I was a kid. He was very patriotic, and tried to join up again for WW II but was rejected for being too old. He's lucky he was, or my grandmother might have killed him herself. She seemed to understand something my very patriotic grandfather did not---war is dangerous. Even those who survive are often wounded in ways that is not easy to see.
When I was a medical resident I had my own patients at the V.A. hospital. I had vets from WW II, Korea, Viet Nam, and all the times in between. Many of the Viet Nam vets would come to me with the same story: they had headaches, or nightmares, or depression, and had never really talked about it. I would ask them frankly if they thought they had PTSD, and usually they would say they did. Some did very well, some did not. I would always ask them what the did in the war, expecting "infantry" or "marines" etc, but more often than not the answer I got was, "some really bad shit, Doc."
Around that same time I used to stop at a watchmaker's shop down the street from my apartment. The watchmaker was a veteran of the war in the Pacific, where he was a Marine officer. He was wounded several times, spoke of the war often, and had scrapbooks about the war and his buddies. But what he would mention most often was the men he'd killed. He didn't regret it as such, but the memories of killing seemed to haunt him. He would tell me over and over how they'd had to kill or be killed, how they'd had to kill to win the war, to keep their country safe. It was all true. I'm not sure how much it mattered.
As we try to absorb back into society the veterans our latest wars have created, we are facing new and old challenges. Many have the same invisible wounds, but many have additional problems. Traumatic brain injuries and amputations have been very common in the last fifteen years or so due largely to IEDs. And soldiers, sailors, and marines are serving multiple tours year after year, increasing the risk of PTSD and other injuries.
Just as we cannot forget those who have fallen, we must not forget those who have gotten up again, but slowly. Many of them will fall again and again during their civilian lives and we must be prepared to pick them up. It is the very least we can do. The bare minimum, actually.

9 responses so far

Blogkeeping

May 31 2010 Published by under meta-blag

I'm off to watch my daughter march in some sort of neo-fascist parade (Daisy scouts) and then off to the hospital, but first some quick housekeeping issues:

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A cruel hoax

May 28 2010 Published by under Medicine

As summer approaches and people spend more time outdoors, many parts of the country will start to see cases of Lyme disease. It is carried by deer ticks and is especially common in the Northeast. Tick bites often go unnoticed, but the rash of Lyme disease is pretty characteristic and occurs in about 70-80% of those who are infected.

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Erythema migrans, the typical rash of Lyme disease. Source.

It's easily cured with antibiotics, but if untreated can have significant complications, such as arthritis, and various neurologic problems. As most of my readers know, there is also a movement that supports a diagnosis called "chronic Lyme disease" (CLD), which is, in most cases, not related to Lyme disease at all.

 

The controversy regarding CLD can get a bit bizarre, but the core reality is that real people are suffering, and real people are being misled. When a set of protean and debilitating symptoms are mislabeled as CLD, other diagnoses and treatments are left behind, and patients are often subjected to invasive and ineffective treatments.

Those of us who practice science-based medicine are often the targets of the CLD activists, and CLD activists are often our targets. I am very critical of health care professionals who mislead patients (intentionally or otherwise), and I receive plenty of hate mail from readers who think I'm being dismissive of their suffering. But I am not critical of patients who believe they have this disease. They are the victims of this controversy. And when the arguments and strategies get ugly, it is they who suffer. That is why I was especially angered by the email I received earlier this week.

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9 responses so far

More Kafka-eque health care absurdities

May 26 2010 Published by under Health care reform, Medicine

As my regular readers know, I'm not a big fan of our current health care system. Our bloated, industry-driven system manages to deliver less effective care at a higher cost than most other industrialized nations. The system is Byzantine, unnavigable, and dangerous, and is kept that way in the name of the Holy Market. But health care can benefit from practices that are decidedly un-capitalist, at least in the Milton Friendman or Ron Paul sense.

Like aviation, health care must apply risky and expensive practices to large numbers of people in dangerous situations. This process is made safer by certain sorts of standardization, such as checklists. Data suggest we would also benefit from developing widely applied, evidence-based best practice guidelines, and from increasing the use and interoperability of electronic health systems. But that's not how we do things here.

Our culture is strongly biased against centralized anything, which is often a useful instinct. But in health care, the market does not necessarily drive best practices, but most profitable ones. One of the worst hybrids of the ultra-free market ideal and the more communitarian ideal is the HMO. It's not that the idea is inherently bad, but its implementation has often been problematic.

An HMO is an agreement between a patient, a physician, and an HMO. The patient pays a premium to the HMO, and co-pays to doctors and other providers.  These fees are usually significantly lower than in other types of plans. The HMO assigns them to a primary care physician and agrees to pay for care the PCP recommends, within the guidelines of the plan.  This puts the PCP in the position of "gatekeeper" for more complex medical care.  The doctor is often payed less to care for HMO patients, but in exchange the HMO sends them patients and keeps them busy. But this system is often a loss for both the doctor and the patient. 

A common way doctors get paid by HMOs is "capitation", that is, getting paid per head. An HMO will offer a doctor x dollars per month per patient.  This reduces the incentive for the doctor to provide unnecessary but potentially profitable care.  In fact the incentive is exactly the opposite: the more patients the doctor enrolls, and the fewer services she provides, the more she and the HMO will profit.  Basically, HMOs are designed (in their classic form) to give the appearance of providing efficient low cost care, while actually providing inefficient, low cost care that can be minimalist at best.

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21 responses so far

Quack updates

May 25 2010 Published by under Medicine

A few news items of import:

  1. Andrew Wakefield, formerly a licensed to practice medicine in England, has officially lost that privilege.  Others have covered this more comprehensively than I'd ever be able to, but this is big news.  Wakefield is the father of the modern anti-vaccine movement.  His study of a putative relationship between the MMR vaccine and autism led to mass rejection of vaccination and a resurgence in many vaccine-preventable diseases.  After decades of relative quiescence, anti-vaccination ideas became popular again, especially among the rich and famous, but also among those struggling to understand their children's health and development.  Wakefield's study was retracted. He was found to have falsified data, and now the British General Medical Council has given him the axe for unethical behavior, including subjecting children to unnecessary invasive procedures as part of his study.  Undoing the damage he has done is daily work for those of us on the front lines of medicine.  He of course has the unqualified support of the American antivax movement and and has taken up residence in Texas.
  2. Speaking of Texas, the nurses in Winkler County who were fired and prosecuted for (properly) blowing the whistle on Dr. Rolando Arafiles are suing, and the trial starts this fall.  The hospital has already been fined in relation to the case, and a Texas TV station is reporting that Arafiles is being fined and put on probation by the state medical board.  Arafiles may be running out of places to practice.  He's already surrendered his license in New York State, and given his history, he may eventually wear out his welcome in Texas.  But Texas is pretty close to Arizona, and he can always get a license as a homeopath down there. Maybe he can take correspondence courses from Dana Ullman.

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Too many too soon?

May 24 2010 Published by under Medicine, Vaccination inanity

Too many too soon: that's Jenny McCarthy's rallying cry.  The disingenuous activists of the antivaccine movement use this motto as a foot in the door, claiming that they are not truly "anti-vaccine", just pro-"safe vaccines".  This is despite the fact that vaccines have proved themselves to be one of the safest and most effective medical interventions in human history. 

Pediatricians in the community are struggling with the fallout of the antivaccine propaganda, having to spend their finite patient-care hours trying to explain to parents why they should vaccinate their children properly.  While they are fighting this difficult but good fight, popular celebrity doctors such as Dr. Bob Sears and Dr. Jay Gordon are shouting about the horrors of evidence-based vaccination and offering their own made-up alternatives.

In addition to promoting the resurgence of several infectious diseases, these "activists" have forced the medical and scientific community to waste valuable resources studying the same questions again and again.  And when the question is answered, the infectious disease promoters yank up the goalposts and start running.  There is no data set that will ever convince Jay Gordon, Jenny McCarthy, or Bob Sears that current vaccine recommendations are safe and effective.  There is also no external evidence that will cause them to alter their own recommendations for "alternative schedules". 

But given the public health importance of vaccination, we are forced to counter the propaganda.  A new study in the journal Pediatrics does just that.  This study appears to have been designed to answer the questions frequently raised by antivaccine activists.  When thimerosal was proved to be innocuous they moved on to "toxins".  When this gambit failed, they moved on to "too many too soon". As this argument has unraveled, they have called for "vaccinated vs. unvaccinated" studies, prospective studies which follow children who are and are not vaccinated and look at different rates of autism.  Epidemiologists have been all over the question of causation, but not surprisingly, the antivax crowd hasn't been satisfied with them to date.  The new study adds another layer of evidence to what we already know: vaccines do not cause autism. 

But this study goes one step further and asks the question, "is it really 'too many too soon?'" The study's conclusion is in its title: "On-time Vaccine Receipt in the First Year Does Not Adversely Affect Neuropsychological Outcomes."  The authors used vaccine data from several thousand children.  They compared children who followed the recommended vaccination schedule in the first year of life vs. those who did not, and compared neurological outcomes 7-10 years later.  The data were unequivocal: there were no significant neurologic problems present in the "off-schedule" group compared to the on-time group.  This very strongly argues against "too many too soon". 

There are two rational complaints likely to be raised by the antivaccination crowd.  One is potential conflicts of interests in the authors.  Both authors have disclosed various types of financial support from drug companies in either research funding or speaking fees.  This does not mean the data are tainted, but it does mean the data require close scrutiny.  Neither the data nor conclusions in this study seem to suffer from undue influence, as far as I can tell from my reading. There is always the possibility of outright fraud, something that would be hard to detect in reading a study, but I see no reason to suspect this.  Also, their data and conclusions track very closely with what we know from previous studies on vaccination and neurologic problems.

The second question likely to be raised is whether this study captured the correct populations.  The data make clear that when the recommended vaccination schedule is followed in the first year of life, there are no significant neurological sequelae in later childhood.  But the study did not specifically look at "alternative vaccine schedules" such as those proposed by alternative doctors.  It also did not specifically look at vaccination outside the first year of life.  It did however divide the children into "most timely" and "least timely" groups too look for effects that might be missed in aggregate.

This is a strong study.  It seems likely that if vaccines given according to the recommended schedule during infancy were to lead to autism or other severe neurologic disorders, this study would have found an effect.  Since autism usually manifests by age 2, it is unlikely that an exposure in the second or third year of life would contribute significantly to the development of autism.  There is no such thing as "too many too soon"; it is simply another evidence-free attack on one of our safest and most effective public health measures.

References

Michael J. Smith, & Charles R. Woods (2010). On-time Vaccine Receipt in the First Year Does Not Adversely Affect Neuropsychological Outcomes Pediatrics, 125 (6), 1134-1141 : 10.1542/peds.2009-2489

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Mmmm.... #baconblogwars

May 21 2010 Published by under Narcissistic self-involvement

Of all the crappy things I eat, bacon is probably the crappiest. Thankfully, I eat it only rarely, but if you were to put a pound of cooked bacon in front of me, I would eat a pound of cooked bacon and ask for more.
But since I want to live long enough to watch my kid grow up, it's better to wax nostalgic on previous bacon encounters than to accrue new ones.

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How can something so good be so bad?

On Sunday mornings, my dad and I used to drive down to the car wash and then over to the bagel store. We'd pick up fresh bagels, and sometimes smoked fish, and usually, by the time we got home, my mom had bacon going on the stove (OK, not terribly jewy, but...). The smell of fresh-baked bagels and bacon frying reminds me of a warm house with fogged windows and good food. It's a comfortable smell of my childhood.
When I was a kid teaching canoeing up in Ontario, I used to take some of the advanced students on early morning cookouts. We would get up as the mist was was just lifting, get in our cedar-strip canoes, and paddle to one of the islands in the middle of the lake. The kids would collect wood and show me they could make a fire. Then I would take out a loaf of fresh-baked bread and hand each kid a couple of pieces and show them how to bite a hole in the middle.
Then I fried up a mess o' bacon. Lots. Each kid would give me their bread and I'd set it in the pan full of grease and drop an egg in the hole. The smell of bacon, sweat, and woodsmoke is a smell of the transition from adolescence to adulthood.
Now, as someone who may or may not be middle-aged, I still love bacon, but I will be content to keep the memories and associations I have and keep the bacon to a minimum.

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15 responses so far

If Rand Paul doesn't realize how racist he is, how does he remember to breathe?

May 21 2010 Published by under Politics

I hate writing about politics, but the mainstreaming of racism since the election of Obama makes writing about politics a moral imperative. We'll start with Dr. Rand Paul, who is running for one Kentucky's senate seats. The usual racist dog whistles are apparently too subtle for Paul, which is good. I'd rather a politician be explicit about his bigotry. What I really love about the Paul case is his attempt to make his bigotry an inevitable consequence of his other beliefs. This is good, and I'll tell you why.
Paul says that he disagrees with the parts of the Civil Rights Act that forbid private commercial enterprises from discriminating against customers. He makes it clear that he would never belong to or frequent an institution that practiced policies of racial exclusion but that they should be allowed to do so. This issue was settled a long time ago, but obviously many Americans aren't so happy about it. After all, if blacks can eat at a lunch counter what's to stop them from becoming president? Paul gives these folks cover in the guise of his "libertarian" beliefs:

MADDOW: Do you think that a private business has the right to say we don't serve black people?
PAUL: I'm not in favor of any discrimination of any form. I would never belong to any club that excluded anybody for race. We still do have private clubs in America that can discriminate based on race.
But...

But?
But?!?
But what? Racism and discrimination isn't just about what's in your heart or mine, but in what we as a society do to fight or encourage it. We don't allow restaurants to keep pet rats in the kitchen, and we don't let them turn away customers who are black. We use our laws to limit some personal behaviors because we must.
Here's the "but":

But I think what's important about this debate is not written into any specific "gotcha" on this, but asking the question: what about freedom of speech? Should we limit speech from people we find abhorrent? Should we limit racists from speaking

I wish he were a moron, but he's not. He's using a whole new dog whistle, one which lets racists hide under the mantle of "libertarianism". This is a straw man. The civil rights act does not forbid racist speech, but certain discriminatory behaviors. Hate speech laws have been debated extensively in this country and so far the idea has not proved overly popular, but that's not the current point. The point is that someone who may be writing and voting on laws for the whole country is on the record as saying that in the name of "freedom" we must return to Jim Crow.
Whatever cover story he launches will not change this fundamental fact. This is not some great conspiracy to smear his great name. We don't need a conspiracy for that. He's doing just fine himself. But he is just one man. It's the people voting for him who truly make me ill.

32 responses so far

Allergies, naturopathy, and Spock's beard

May 19 2010 Published by under Medicine

If there were a parallel universe, and in that universe medicine, instead of being based on science, was simply a gemisch of various folkways and superstitions, medicine in that universe would be called "naturopathy".

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"Remember.
Hey, how come this never works with water?"

I've discussed the absurdity of naturopathy nux vomica ad nauseum, but a loyal reader mentioned hearing that naturopathy might be good for allergies. This will require a bit of science to start off (unless, of course, Spock's rocking the goatee).

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From the medical journals

May 18 2010 Published by under Medicine

  • Common osteoporosis drugs do not increase the risk of unusual fractures (probably): Bisphosphonates (such as Fosamax and Actonel), a class of medications used to prevent fractures in osteoporosis, are effective in preventing certain types of common back and hip fractures.  As we've developed more patient-years of experience with the drugs, we've found certain problems, such as damage to the esophagus (which has been reduced by developing less frequent dosing regimens) and rare episodes of destruction of the jaw bone.  Data has now accumulated that we may be able to give these medications for a set period of time (probably five years) and get just as much benefit with less toxicity.  Overall, serious side effects are rare, and generic forms of these drugs are available, making them affordable as well.  But reports of another possible side effect have started to emerge in the literature.  There have been reports that while these drugs reduce common  fractures, they may increase less common fractures.   From the New England Journal of Medicine, we have a study suggesting that this is unlikely to be the case.  The primary problem with this study is that it is underpowered. These unusual fractures are so unusual that it's difficult to draw any definite conclusions, but given the low risk of these fractures in both users and non-users of bisphosphonates, this appears to be a non-issue and shouldn't affect the decision to prescribe or withhold these medications.
  • Novel serum markers may help predict cardiac mortality: In trying to predict patients' risk of having heart attacks, we use certain lab tests such as LDL cholesterol and C-reactive protein.  A new study in Annals of Internal Medicine asks if there might be other tests to help improve our prognostic abilities.  This study looked at patients with established coronary heart disease and found that some of these markers helped predict mortality independent of more traditional tests already in use.

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