Archive for: May, 2010

The Pill and altmed idiocy

May 17 2010 Published by under Medicine

We're now fifty years into the history of oral contraceptive pills, and we've learned an enormous amount. We've learned about various therapeutic uses of the Pill and unanticipated risks. We've learned to adjust the amount of medication to a lower effective dose. We've given women the opportunity to very effectively control their own fertility in a safe, private, and effective manner. But we haven't ended the controversy.
Leaving aside idiotic moralist rantings about the Pill, the alternative medicine movement has treated it harshly. The decision to use or avoid any intervention involves a balance of risks and benefits. Science helps quantify many of the risks and benefits, but a certain component will always be subjective. I can't demand that a patient choose to take a certain dose of morphine for cancer pain because the patient has to decide what level of pain and side effects are acceptable. Oral contraceptive pills (OCPs) have few but real risks: they can increase the risks of significant blood clots, especially in smokers and women over 35. At the same time, it decreases the risk of certain cancers.

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59 responses so far

Bad science, done badly. It's bad.

May 13 2010 Published by under Medicine

So-called "morgellons syndrome" is an interesting phenomenon. This syndrome is not at this point generally recognized by the medical community, but its sufferers describe many different systemic symptoms, such as "brain fog" and fatigue, and characteristic skin lesions which they describe as containing or extruding an unknown substance. The patients are most often diagnosed as having delusions of parasitosis, a diagnosis which understandably is not often acceptable to the patient.

One of the most consistent facts to date about the disorder is that there has been no significant scientific literature published about morgellons as a distinct entity. In the literature---such as it is---morgellons suffers one of two fates: it is attributed to delusions of parasitosis; or it is presented as unverified and unverifiable opinions from self-appointed experts. But there is a hint and a trickle of information. The CDC has an ongoing investigation into "unexplained dermatopathy", and a recent commenter has sent a new article my way.

The article, entitled, "Morgellons disease: Analysis of a population with clinically confirmed microscopic subcutaneous fibers of unknown etiology" was published this month in the Journal of Clinical, Cosmetic, and Investigational Dermatology. I would give you a PMID or DOI, but the journal is not indexed by PubMed. The publisher describes it as "open access" and emphasizes that, "[t]he journal is characterized by the rapid reporting of clinical studies, reviews and original research in skin research and skin care." The journal even has a "testimonials" page. That's unique. I'm pretty sure most of the journals I read don't have that. All of the testimonials agree that the service is excellent. In addition, the journal appears to publish very efficiently:

"I was very impressed with how promptly the paper was published."

"I was impressed at the rapidity of publication from submission to final acceptance."

When evaluating a study, it's important to note the source and the authors first. This journal would appear to value rapid communication over quality. That's not generally a favorable quality, but it isn't a deal-breaker either.

What about the authors?

Raphael Stricker is a disgraced hematologist who after losing his career to data manipulation took up the chronic Lyme disease banner. He is part of ILADS, which has been demanding that actual experts shut up and get out of the way so they can continue their evidence-free treatment of supposed chronic Lyme disease. Savely has written earlier crappy articles about morgellons. She is a nurse practitioner who "treats" people with "chronic Lyme disease" and morgellons.

None of this means the authors can't do some serious science, though, so let's look at the article itself.

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69 responses so far

It’s not my fault!

May 12 2010 Published by under Politics

You know that big oil spill in the Gulf of Mexico?  It turns out that the folks who drilled it, the folks who pumped it, and the folks who worked on it weren't at fault---at least according to their sworn congressional testimony.  And I sure as hell know it's not my fault.  I mean, I do commute to work alone in my car, and I do like my air conditioner.  And my livelihood depends to a certain extent on an auto industry whose mileage standards haven't really changed in the last few decades.  But it's not my fault.

Anything as complex as drilling for oil a mile under the ocean thousands of times over is going to go wrong from time to time.  It may very well turn out that some corporate idiot---because corporations are just like individuals and can be idiots---cut corners to get us our yummy, yummy crude.  And we love every drop of it.  We're perfectly happy to change nothing about our way of life to prevent this sort of disaster.  If bp, or Halliburton, or some Jean Doe from the Bayou was behind this, we share their culpability.  This was no accident---it was an inevitable result of our hunger for oil.

5 responses so far

You pulled that out of where?

May 11 2010 Published by under Absurd medical claims, Medicine

Last week I gave you a refresher course on the invalid arguments used by altmed boosters. The Turf Battle Fallacy and Pharma Shill Gambit are classics for a number of reasons. The most amusing thing about these gambits is their hypocrisy.   The alternative medicine movement is  essentially a collection of businesses selling unproven supplements and interventions (not "therapies", as Steven Novella aptly observes).  

Of course, that's an incomplete analysis.   Altmed is also a religion, with zealous adherents.  The arguments made by these adherents are never about the data, but about beliefs.  When asked for data, they often resort to two more of my favorite gambits: moving the goalposts, and the argumentum ex culo. I'm going make an example out of a recent commenter, not because I have anything against him, but because he's just that hilarious.

Our commenter, in defending alternative medicine (but giving few specific examples) states that:

In mentioning diet, I was referring to Pal's own admission that he does not normally bring up diet with his diabetes patients.

I mention this as being ex culo as I have written frequently about lifestyle modification, which is not in any way "alternative", but a normal part of medical practice.  I have many times written that advising lifestyle modification is often insufficient. For example (since Nathan gives none):

The truth is that diabetes can, and often is, well-controlled by medicine alone. This isn't because real doctors prefer it that way; it is because many diabetics cannot adhere to diet and exercise programs, and many diabetics do not have enough pancreatic beta cell function left to avoid medications.

When called out on his pulling a "fact" out of the vacuum, he backpedals---and the picks up his goalposts and starts to run:


Pal: I may have inferred wrongly from what you wrote earlier.
Dietary adjustments that effectively treat illnesses are rarely mentioned by physicians, in my experience, and are routinely downplayed. If your experience differs, I'm interested to hear about it. Do you ask H. simplex patients about their diet?

"In my experience" is of course a placeholder for, "wait, my rectum is still full of unsupported assertions."  Dietary modification is the mainstay for the treatment of many common diseases: coronary heart disease, hypertension, sleep apnea, obesity, type II diabetes, hyperlipidemia, just to name a few.  It is not "downplayed" but real doctors recognize that real patients should not be punished for their inability to make significant enough lifestyle changes.

I had trouble deciding if the final phrase was truly a "moving of the goalposts" or simply an idiotic non sequitur.  I concluded that it is both.  In my eyes it is a non sequitur because it literally does not follow.  It makes no sense.  It is devoid of reason.  To Nathan, however (who, we should remember, is simply giving us typical examples to work with) he has raised the bar.  Now that he sees that I may actually use dietary advice in my practice, his response is, "yeah, but did you do it for this other disease? Huh?  Didya?"
This simultaneous running away with the goalposts and birthing ideas ex culo leads to some disturbing imagery, but more important is that it reveals the poor thinking habits of those who would critique the need for medicine to be based on science.  There is no "alternative" to medicine.  There is simply that which can be shown to work, and that which cannot.  The humane application of what we know is the art of medicine.  The humane application of alternative medicine is quackery with a smile.

34 responses so far

Who doesn't hate smallpox?

May 07 2010 Published by under Medicine

Smallpox was one of the world's most devastating diseases, and its eradication one of medicine's most spectacular successes. Over the course of a couple of centuries, this disease went from killing and maiming millions (200-500 million in the 20th century alone), from helping to depopulate the Americas of their original populations, to an historical artifact. The history of the eradication of smallpox is generally pretty well-known. Most of us learned at some point about Jenner's discovery of smallpox vaccination and the eventual disappearance of the disease due to the efforts of the WHO. But what is less well-known is the history of opposition to smallpox prevention.
Smallpox is a nasty not-so-little virus (Variola major and minor) that not only causes permanent disfigurement, but often kills about a third of its victims. There hasn't been such a victim since 1977.
Early battles against smallpox were based on early understanding of disease and on acute observation of patients. Our early colleagues were pretty good observers, and relied on both their historical readings and their own observations. Dr. Andrew Cantwell, an English physician working in France in the mid-18th century, rejected earlier beliefs and observed that:

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12 responses so far

Your doctor's only in it for the money. Right?

May 06 2010 Published by under Medicine

Alternative medicine is very profitable. Herbs and supplements are a multi-billion dollar industry. The practice of primary care medicine is not terribly lucrative, and adding on some "integrative medicine" can turn that around. A primary care doc can significantly increase their income by selling supplements and offering unproven tests and treatments. These are not covered by insurance, so patients must pay cash---and who doesn't love cash? But how can you get your pigeons to fly in the door?

The folks out there selling miracle cures and spreading the ideology to support them have some serious reach. Regardless of whether one is a "true believer" or simply a cynical leech out to make a buck, it's easy to spread the word and bring in the suckers. Supplement companies fund tons of advertising, the government allows all sorts of unproven claims to be made, and certain media outlets (such as the Huffington Post) vigorously spread the good word.

There are many myths that help spread the gospel of alternative medicine. Most of them are negative statements about real medicine rather than affirmative evidence for an alternative. It sometimes seems the fight against quackery is never-ending. It's been a while since we've reviewed some of the tactics of the opposition, so let's go over a few.

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60 responses so far

Update on Web2.0 and disaster management

May 06 2010 Published by under Medicine

So I gave that talk yesterday at the Great Lakes Homeland Security Expo. It went better than I had expected, as the audience was willing to be interactive and ask tough questions. The audience was a mixed group of health care professionals, first responders, communications directors, and disaster planners. Most had facebook accounts, and many read blogs at least a few times a month. A few were familiar with twitter. I incorporated some of the ideas you folks sent my way, including issues of Twitter hashtag integrity, etc.
Participants helped identify some interesting questions. During the presentation I recommended that agencies interested in a Twitter presence should tweet rather frequently. The federal Homeland Security Agency tweets about once or twice a week---not enough to get caught on the stream that I check from time to time. A communications director from a medium-sized city wondered if tweeting too much could simply seem spam-y. I'd think possibly, but it's a tough balance.
Another participant from a university health service recounted having an H1N1 influenza Q&A via twitter, but wondered how to collect the conversation into a useful format. We talked about what many science bloggers had done with twitter data after ScienceOnline10, where several bloggers used hashtag searches to find and summarize twitter conversations.
I hope to hear back from some of the participants and find out how much of what we talked about may cause a change in the way they do things.

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A spring day

May 04 2010 Published by under Fatherhood, Narcissistic self-involvement

Most mornings, I get up with my daughter, or more accurately, I wake her up. We have our little morning rituals---I turn on her lamp (or this time of the year, open her shade), pick her up and take her downstairs (something I might not be able to do for much longer). I turn on the TV and let her wake up slowly---she's not the morning person I am. Usually, there's a good deal of whining and moaning, stalling and kvetching. This morning, though, she was up and ready to go. Today, her family was coming to see her in a school play, and she had memorized her lines and just about everyone else's. When I dropped her at school, there was no hesitation, just a quick "Bye, Daddy" and a leap out of the car.
The play was, of course, cute, and her mother signed her out from school afterward citing "fun" as a reason. We ate lunch together at a local deli and then I got on the road to Grand Rapids, a town I've driven by but never visited.
Driving across Michigan in the spring is, it turns out, quite nice. After passing through the remainder of my own metropolitan area, a typical Midwestern countryside opened up, with tractors in the fields, horses grazing, large windowless pig farms (at least I think that's what they were) and occasional auto-related factories sprouting out of the otherwise bucolic landscape. The diversity of farmsteads that I could see from the highway was fascinating. Some were large complexes with many metal silos and huge John Deere machines turning up dust. Others were a farmhouse and a shed on a couple of acres with a tractor pulling a plow. They were all beautiful.
And then I arrived in Grand Rapids. Michigan isn't a state with a lot of navigable rivers, being an old sea basin, but the riverfront here is beautiful, with well-kept pedestrian walks, gentle rapids, occasional fishermen, and some sort of prolifically-breeding spring insect.
All this is giving me a nice bit of distraction before my conference presentation tomorrow which I might otherwise be worrying over obsessively.
Before pulling out of the driveway, I told my kiddo I'd Skype her tonight. Her surprised smile was the best part of the day.

6 responses so far

Papers please

May 03 2010 Published by under Narcissistic self-involvement, Politics

Many years ago, when fascist Jean-Marie Le Pen was riding a wave of racist sentiment in France, I was a young student out with friends on a perfect spring evening along the Seine. There was at that time always a vigorous national police presence in Paris. The CRS with their sub-machine guns were visible outside government buildings and patrolling the streets.
Racism was a palpable presence in Paris. A popular deli, Jo Goldenberg's, had been bombed a few years earlier, and the nearby Holocaust museum had bullet holes in one of its glass walls. One time when I tried to order coffee at a cafe, the waiter said, "Are you sure you don't want cous-cous? You look like you want cous-cous."
But on this spring night after final exams, all was well. My classmates and I were eating something good---I can't for the life of me recall what---and drinking wine. Lots of wine. One of my friends drank far too much, and was obviously soused. My friend John and I were holding her up, working on hailing her a cab, when a couple of well-armed CRS officers approached, pulled me aside, and demanded my papers. They did not ask for anyone else's. I gave them a photocopy of my passport and explained that I was an American student returning home in a few days, and not wanting to risk losing my passport I carried copies instead.
This was not the right answer.
John, who "looked" French, was still holding up our friend, but also starting to become alarmed by my encounter with the feds. The officers asked me the same questions over and over, getting the same answers. Then, they said, "you're talking funny...are you drunk?" "No," I explained, "I'm American and just don't speak good French."
They slowly walked me further and further from my friends, when a cab finally came. John got our friend in and came over to see what was going on. In his much more fluent French he repeated everything I'd told the cops, and showed his papers, also a photocopy of his passport (that was sort of the standard for students at the time). With his French looks, clear speech, and French last name, he was able to convince the CRS to let me go home.
As much as I loved Paris, I was very happy to return home to the U.S., where we don't stop people in the street and demand their papers for looking a little bit swarthy.

30 responses so far

Update on fake diseases

May 03 2010 Published by under Absurd medical claims, Medicine

I've been a bit busy lately and haven't been able to update you on some important developments in the field of imaginary diseases.
Update 1: Chronic Lyme Disease
So-called "chronic Lyme disease" (CLD) is a diverse constellation of symptoms which are often attributed to Lyme disease, but without objective evidence of infection with the organism that causes Lyme disease. Patient advocacy have been very active in insisting that reality conform to their beliefs, going so far as convincing the Connecticut Attorney General to investigate the Infectious Disease Society of America. As part of an agreement to get the AG to stop this foolishness, the IDSA agreed to review its guidelines, without any guarantee of changing them.
Their review is now complete, and they have decided against any changes. The heart of the AG's investigation was an allegation that the IDSA had too many conflicts of interest. In order to allay some of these concerns (foolishly, in my opinion, as that is akin to trying to tell the Pope not to believe in God), an outside ethicist was brought in who reviewed the panel for conflicts of interest, and found none. According to the IDSA statement:

The Review Panel concurred that all of the recommendations from the 2006 guidelines are medically and scientifically justified in light of the evidence and information provided, including the recommendations that are most contentious: that there is no convincing evidence for the existence of chronic Lyme infection; and that long-term antibiotic treatment of "chronic Lyme disease" is unproven and unwarranted. Inappropriate use of antibiotics (especially given intravenously) has been shown to lead to deadly blood infections, serious drug reactions and C. difficile diarrhea, as well as the creation of antibiotic-resistant bacteria or "superbugs."

And that settles that, right?
Update 2: "Morgellons" syndrome
So-called morgellons syndrome is a term coined by someone who felt she had unexplained skin rashes and strange fibers in her skin. Over the last couple of years, a loose group of people and one or two scientists have come together to try to find the cause of their suffering. They have managed to enlist the CDC in an investigation in an investigation which is still ongoing, but given the history of similar claims, if the CDC does not find an explanation to their liking, the conspiracy theories will make chem-trails and UFOs look rational.
So that's your update. Enjoy the discussion which is sure to erupt.

32 responses so far

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