Archive for: August, 2010

How can we answer important questions?

Aug 31 2010 Published by under Medicine, [Medicine&Pharma]

A recent commenter asked the following question:

If you are a clinical researcher, how do you test a treatment for recurring body-wide pain and extreme fatigue that has lasted more than a year? How do you use science to test whether X treatment works? What measurement(s) do you make pre- and post-treatment to produce a clinical study that supports or indicates the underlying reality?

In this hypothetical, let’s say the reality is that the treatment produces significant reductions in the body-wide pain and fatigue in 98% the afflicted. How do you produce a legitimate, science-based study that supports this?

For someone who is suffering, the details of designing a clinical study may not be the first thing on their mind.  But for researchers, it must be.  Clinicians must then be able to assimilate relevant data to use in treating their patients.

The first task in looking at this question is, "what is the question?"  In this case, we need a disease or syndrome with a useful operational definition.  Since the commenter hasn't given us one, we'll choose "fibromyalgia".  This syndrome is difficult but not impossible to study.  It's difficult because it is syndromic; we can define a list of signs and symptoms and create an operational definition, but we cannot pathologically define the illness.

In this case, we can measure exactly what the commenter asks.  We can choose an intervention, say, a sleep aid called Miraculum, and design a randomized controlled trial.  Patients can be recruited, randomized to placebo or Miraculum, and outcomes of interest can be measured.  There are many tools to measure these outcomes including visual analog pain scales and quality of life measures.  The numbers can be crunched and interpreted, and voila, we have an answer (and usually more questions as well).

I hope this helps our curious commenter.

14 responses so far

Blog business

Aug 31 2010 Published by under Medicine

Thanks, everyone, for all the comments on my recent posts.  A blog is much more interesting when people actually stop by to discuss things.

Some reminders on where to find me online. If you look up to the top right-hand corner of this blog you will see buttons for both my twitter page and my rss feed.  If you look down the right column a bit you will find a link to the WCU facebook page.  All of these links will supply you with regular updates from the blogs, and my occasional typographic ejaculations.  I also contribute twice monthly to Science-Based Medicine and occasionally to the Forbes Science Business Blog, both of which has excellent writing every day (except perhaps the first and third Thursday of each month).

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Cannabis for chronic pain: Are we there yet?

Aug 31 2010 Published by under Medicine, [Medicine&Pharma]

Marijuana is pretty popular stuff, and for good reason.  It is a potent drug, capable of both making someone feel good and of reinforcing dependence pathways in the brain.  Cannabis has been lauded for its ability to treat nearly any unpleasant symptom (except perhaps dry mouth), but so far evidence other than the anecdotal has been meager.

One of the areas where research has been a bit promising is in the treatment of certain types of nerve pain.  Small studies have shown some possible benefit in certain groups of patients, but robust studies are lacking.  In the U.S., this is certainly due at least in part to restrictions on cannabis research, but only in part.

Still, chronic nerve pain is an important problem, with imperfect treatments.  Opiates such as morphine are effective but come with significant side-effects.  Some anti-seizure medications such as gabapentin and pregabalin have shown some promise, but they are relatively expensive (although the price on gabapentin is dropping) and only somewhat effective.  Finding effective drugs, to be used either alone or in combinations, would help people suffering from a frustrating and sometimes disabling problem. Continue Reading »

14 responses so far

Fascism and the New Right

Aug 30 2010 Published by under Politics

As the years that separate us from European fascism increase, there is an growing tendency to use the term “fascism” in an imprecise way, taking away from it its potency.  In fact, it has become so insipid as to have lost much of its meaning.  Many will hear the word and think “Nazi”, but this is a gross oversimplification, an undue narrowness.  The word “fascism” is at once too broad and too precise, as Umberto Eco has written.

There are good reasons to use this term more carefully, to apply it judiciously.  But to do this, we have to understand what it really means.  The term itself arose out of Italy and described a totalitarian regime that had little else in common with Nazism.  That doesn’t mean it cannot be applied to other political systems.  As Eco has pointed out, many of these systems share common features, or share common ideals or origins.  But recognizing these, especially in the early stages of a movement can be difficult.  It was not so difficult in Nazi Germany, with its explicit inculcation of the entire population beginning at birth, but Nazism is not the only type of fascism.

I’m proceeding from the assumption that all fascism is bad, something to be prevented and fought.  Not everyone will believe this, else fascism would hold little popular appeal.   But I believe it, and I also believe that the New Right in the U.S. represents a fascist risk unlike any we’ve seen since the 1940s, when World War II largely destroyed the proto-fascist movements in the U.S.  Greater even than McCarthyism, the ideology espoused by Glenn Beck, Sarah Palin, Michelle Bachmann, and those who hang with them are a threat to American democracy, a fascist movement further evolved than many might think.

Fascism, while populist in a sense, does not have to originate in “the people”.  As Eco noted of Italian Fascism:

The Fascist Party was born boasting that it brought a revolutionary new order; but it was financed by the most conservative among the landowners who expected from it a counter-revolution.

This has certainly been true of the Tea Party movement. While the Tea Party does not clearly resemble Nazism and is not a copy of older fascist movements, it shares with them many of the characteristics of what Eco calls “Ur-Fascism”, the components that go in to the formation and perpetuation of most fascist movements.

Not all fascists have all of the characteristics of Ur-Fascism, but most, when considering the “template”, are recognizable as fascist.  The danger is not in under-applying the term, but in failing to recognize it early.  While Eco’s analysis is certainly not the only thing to say on fascism, it does serve as a valid and useful guide.

Cult of tradition

Americans certainly have a love of tradition, a uniting national identity.  We have our own liturgy in our founding documents.  But this is not cult-like.  Eco describes a traditionalism that is false, in a sense, in that it combined mutually incompatible traditions, creating from them a unifying identity.  Believing in the Bill of Rights, while simultaneously calling for the repeal of the 14th Amendment; believing in the Constitutional protection of religion but denying the secular origins of this principle, and creating a false mythology of the Founders as Believers---these create a false, new American tradition.

Rejection of Modernity

Modern ideas, such as the expansion of the term “equality” to explicitly apply to everyone, is rejected out-of-hand as violating fictional traditions.  Rejection of the rights of gays to marry, of women to have equal pay, of Blacks to frequent any business they wish---these would seem to violate our founding principles, but when you create your own fictions, such as the influence of the 10 Commandments on American law, then contradiction is meaningless.  Contradiction only exists when historical truths are acknowledged.  When they become fluid, all bets are off.

Cult of action for action’s sake

The preservation of the 2nd Amendment, in contrast to the destruction of the 14th, fits in well with the current shortage of ammunition in the U.S. The fetishism of firearms, at a time in history where our true state of national security has rendered them moot, is telling.  It not only speaks of a powerlessness felt by the New Right, but serves as an explicit threat to those who would dare disagree with them. Since personal firearms are irrelevant in fighting foreign enemies, their only real use can be the fight against domestic ones.

Disagreement is treason

The New Right knows, cynically, that their ideas cannot stand up to honest analysis, and so demonize those who disagree with them.  It creates a Muslim Non-American of the President; a rampaging horde of immigrants, and tells us that to vote for universal health care is a choice between freedom and tyranny.

This is part and parcel of the fear of diversity, the inherent racism in fascist ideas.  There must always be an “other” and in the case of the New Right, the other is distinctly brown.

Appeal to frustrated middle class

During times of economic uncertainty, someone must be to blame for the decline in what seemed to be endless prosperity.  Despite the fact that wealth in the U.S. has continued to concentrate in the wealthiest, these same wealthy successfully convince the middle class that it is really concentrating among The Others, those who are taking “our” jobs, raising taxes, etc.  Despite the fact that our tax structure favors the rich rather than the middle or lower economic classes, it is the poorest or brownest that must be to blame.  Them, and the bankers, whose names all seem to share some ethic similarities when repeated over and over.

Creation of a shared social identity

The New Right is distinctly envious of ethnic minorities and their shared sense of identity.  Since much of the “redneck” vote lacks such an identity, then they must be united by having been born in the same country.  The are Real Americans, and everyone else, by definition, is not.  Real Americans aren’t afraid of the Confederate Flag.  They aren’t afraid of immigrants.  They aren’t afraid of gays. They aren’t afraid.    Anyone who would object to the Stars and Bars or to anti-gay rhetoric must fail to understand what it is to be a Real American.

Sense of humiliation

Rather than the meme of the Eternal Rich Jew which was common in European fascism, the New Right is humiliated by the underclass who is ruining them economically, by making them pay taxes, by collecting welfare, by funding public schools.  And when One of Them succeeds, perhaps even becoming President, it is because the system has favored them unfairly.

Life as struggle

Mein Kampf spoke of constant struggles.  Eco noted that in Fascist Italy, it was taught that there were always more enemies to fight, that warfare was the default form of existence.  This is how we prove our strength, our superiority.

This fits in well with the Christian Apocalyptic thinking that seems to dovetail so well with the New Right.  It also fits well with the War on Terror, a war that is eternal, because it can never truly be won.

Popular Elitism

When you accept that you are a Real American, you are among the exceptional, the elite.  You are no longer among the weak, the degenerate.  Those who are become worse than the enemy, because the weaken they state from the inside.

Machismo

To succeed in constant war and struggle, and to remove the taint of failure, everyone is a hero, every man a Real Man.  To be a real man, there can be no “deviant” sexual practices, no equality for women, no backing down.

Will of the people through the One

The will of the people is paramount in fascism, but the only way the People can have a united will is to express it through a single voice, a Leader, not through the irrational and fickle exercise of elections and representation.  This can lead to the election of improper leaders who must be dealt with.  If the people were foolish enough to elect a non-American, then this non-American must be de-legitimized and removed.  So-called representatives who don’t act like Real Americans must be impeached and removed before they can consolidate their power through another election.  Congresses and Parliaments are inherently corrupt.

Newspeak

Fascism distorts language.  Suddenly, the lawful payment of lawfully-enacted taxes becomes “oppression” and those who were not born here become “illegals.”  News outlets belonging to the New Right use this new language regularly.  The economic crisis, clearly precipitated by the policies of the right, is now the fault of these “illegal taxes” rather than failed policies of deregulation and destruction of progressive taxation.

Fascism is in some ways quite democratic;  a critical mass of people must believe in it for it to take hold, but once it does, consent of the governed is no longer needed.  The apparatus of the State will take care of obtaining consent, with the help of Real Americans.   Beck, Bachmann, Palin, and others are not Nazis.  Not all fascism is Nazism.  But they are fundamentally un-democratic, believing in the power of a mythical People in the service of a mythical America, one which they have built in the minds of their followers.

This New America is not one I wish to live in, and for it to flourish all we must do is nothing.

44 responses so far

The real thing

Aug 28 2010 Published by under Politics

I am happy to join with you today in what will go down in history as the greatest demonstration for freedom in the history of our nation.

Five score years ago, a great American, in whose symbolic shadow we stand today, signed the Emancipation Proclamation. This momentous decree came as a great beacon light of hope to millions of Negro slaves who had been seared in the flames of withering injustice. It came as a joyous daybreak to end the long night of their captivity.

But one hundred years later, the Negro still is not free. One hundred years later, the life of the Negro is still sadly crippled by the manacles of segregation and the chains of discrimination. One hundred years later, the Negro lives on a lonely island of poverty in the midst of a vast ocean of material prosperity. One hundred years later, the Negro is still languishing in the corners of American society and finds himself an exile in his own land. So we have come here today to dramatize a shameful condition.

In a sense we have come to our nation's capital to cash a check. When the architects of our republic wrote the magnificent words of the Constitution and the Declaration of Independence, they were signing a promissory note to which every American was to fall heir. This note was a promise that all men, yes, black men as well as white men, would be guaranteed the unalienable rights of life, liberty, and the pursuit of happiness.

It is obvious today that America has defaulted on this promissory note insofar as her citizens of color are concerned. Instead of honoring this sacred obligation, America has given the Negro people a bad check, a check which has come back marked "insufficient funds." But we refuse to believe that the bank of justice is bankrupt. We refuse to believe that there are insufficient funds in the great vaults of opportunity of this nation. So we have come to cash this check — a check that will give us upon demand the riches of freedom and the security of justice. We have also come to this hallowed spot to remind America of the fierce urgency of now. This is no time to engage in the luxury of cooling off or to take the tranquilizing drug of gradualism. Now is the time to make real the promises of democracy. Now is the time to rise from the dark and desolate valley of segregation to the sunlit path of racial justice. Now is the time to lift our nation from the quick sands of racial injustice to the solid rock of brotherhood. Now is the time to make justice a reality for all of God's children.

It would be fatal for the nation to overlook the urgency of the moment. This sweltering summer of the Negro's legitimate discontent will not pass until there is an invigorating autumn of freedom and equality. Nineteen sixty-three is not an end, but a beginning. Those who hope that the Negro needed to blow off steam and will now be content will have a rude awakening if the nation returns to business as usual. There will be neither rest nor tranquility in America until the Negro is granted his citizenship rights. The whirlwinds of revolt will continue to shake the foundations of our nation until the bright day of justice emerges.

But there is something that I must say to my people who stand on the warm threshold which leads into the palace of justice. In the process of gaining our rightful place we must not be guilty of wrongful deeds. Let us not seek to satisfy our thirst for freedom by drinking from the cup of bitterness and hatred.

We must forever conduct our struggle on the high plane of dignity and discipline. We must not allow our creative protest to degenerate into physical violence. Again and again we must rise to the majestic heights of meeting physical force with soul force. The marvelous new militancy which has engulfed the Negro community must not lead us to a distrust of all white people, for many of our white brothers, as evidenced by their presence here today, have come to realize that their destiny is tied up with our destiny. They have come to realize that their freedom is inextricably bound to our freedom. We cannot walk alone.

As we walk, we must make the pledge that we shall always march ahead. We cannot turn back. There are those who are asking the devotees of civil rights, "When will you be satisfied?" We can never be satisfied as long as the Negro is the victim of the unspeakable horrors of police brutality. We can never be satisfied, as long as our bodies, heavy with the fatigue of travel, cannot gain lodging in the motels of the highways and the hotels of the cities. We cannot be satisfied as long as the Negro's basic mobility is from a smaller ghetto to a larger one. We can never be satisfied as long as our children are stripped of their selfhood and robbed of their dignity by signs stating "For Whites Only". We cannot be satisfied as long as a Negro in Mississippi cannot vote and a Negro in New York believes he has nothing for which to vote. No, no, we are not satisfied, and we will not be satisfied until justice rolls down like waters and righteousness like a mighty stream.

I am not unmindful that some of you have come here out of great trials and tribulations. Some of you have come fresh from narrow jail cells. Some of you have come from areas where your quest for freedom left you battered by the storms of persecution and staggered by the winds of police brutality. You have been the veterans of creative suffering. Continue to work with the faith that unearned suffering is redemptive.

Go back to Mississippi, go back to Alabama, go back to South Carolina, go back to Georgia, go back to Louisiana, go back to the slums and ghettos of our northern cities, knowing that somehow this situation can and will be changed. Let us not wallow in the valley of despair.

I say to you today, my friends, so even though we face the difficulties of today and tomorrow, I still have a dream. It is a dream deeply rooted in the American dream.

I have a dream that one day this nation will rise up and live out the true meaning of its creed: "We hold these truths to be self-evident: that all men are created equal."

I have a dream that one day on the red hills of Georgia the sons of former slaves and the sons of former slave owners will be able to sit down together at the table of brotherhood.

I have a dream that one day even the state of Mississippi, a state sweltering with the heat of injustice, sweltering with the heat of oppression, will be transformed into an oasis of freedom and justice.

I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character.

I have a dream today.

I have a dream that one day, down in Alabama, with its vicious racists, with its governor having his lips dripping with the words of interposition and nullification; one day right there in Alabama, little black boys and black girls will be able to join hands with little white boys and white girls as sisters and brothers.

I have a dream today.

I have a dream that one day every valley shall be exalted, every hill and mountain shall be made low, the rough places will be made plain, and the crooked places will be made straight, and the glory of the Lord shall be revealed, and all flesh shall see it together.

This is our hope. This is the faith that I go back to the South with. With this faith we will be able to hew out of the mountain of despair a stone of hope. With this faith we will be able to transform the jangling discords of our nation into a beautiful symphony of brotherhood. With this faith we will be able to work together, to pray together, to struggle together, to go to jail together, to stand up for freedom together, knowing that we will be free one day.

This will be the day when all of God's children will be able to sing with a new meaning, "My country, 'tis of thee, sweet land of liberty, of thee I sing. Land where my fathers died, land of the pilgrim's pride, from every mountainside, let freedom ring."

And if America is to be a great nation this must become true. So let freedom ring from the prodigious hilltops of New Hampshire. Let freedom ring from the mighty mountains of New York. Let freedom ring from the heightening Alleghenies of Pennsylvania!

Let freedom ring from the snowcapped Rockies of Colorado!

Let freedom ring from the curvaceous slopes of California!

But not only that; let freedom ring from Stone Mountain of Georgia!

Let freedom ring from Lookout Mountain of Tennessee!

Let freedom ring from every hill and molehill of Mississippi. From every mountainside, let freedom ring.

And when this happens, when we allow freedom to ring, when we let it ring from every village and every hamlet, from every state and every city, we will be able to speed up that day when all of God's children, black men and white men, Jews and Gentiles, Protestants and Catholics, will be able to join hands and sing in the words of the old Negro spiritual, "Free at last! free at last! thank God Almighty, we are free at last!"

4 responses so far

Which food has more fairy dust, and which journalist will report it?

Aug 27 2010 Published by under Medicine, [Medicine&Pharma]

In his now-famous New York Times magazine piece, Michael Pollan told us to "Eat food. Not too much. Mostly plants."  What is often forgotten is that this was not a prescription for eating as much as it was an admonition against "nutritionism", the idea that foods are nothing more than a vehicle for the delivery of certain nutrients.  While it is not entirely incorrect to view food this way, it is incomplete.  Food is more than the sum of its parts.  Some of the vitamins present in foods are necessary in small amounts to maintain health, a fact that has over the years led us to think that there are more magic substances in food.  This has not been borne out by science.  None of the myriad “antioxidants” and other magical substances discovered in foods has ever been found to provide some sort of revolutionary health benefit.

Antioxidants are probably the most commonly cited magic nutrients in foods, despite the lack of evidence of their ability to miraculously affect health.  The idea that antioxidants can perform important physiologic functions is not implausible, but it appears to be a naive and incomplete belief.

This is one of the reasons I let out a big yawn every time the latest food source of antioxidants is discovered.  There is little evidence that any single food performs significant health miracles.  What has been noted in studies is that diets lower in calories, and higher in plants seem to be beneficial.  Studies on flavinoids and other substances are interesting and may eventually lead to medical advances, but no one should rush to start a high-chocolate diet. 

This is one of the several reasons I was disappointed to read the following headline on the CBS website:

Black Rice: Low-Cost Grain Packs Bigger Antioxidant Punch than Blueberries.

What does this even mean?  If this is true, does it even matter?  The “writer” of the piece states that black rice might be a good source of antioxidants for health-conscious consumers who are tired of the high price of berries.  “Writer” is in scare quotes because, as you may have surmised, the article is cribbed directly from a press release.

What is left unasked and unanswered is “what is the clinical relevance of these findings?”  Does it matter that black rice has more fairy dust than blueberries?  Should this finding affect consumer behavior?  

These unanswered questions distract from a potentially interesting science and health story, an opportunity to raise the level of dialog about nutrition. 

12 responses so far

How sleepy are you?

Aug 26 2010 Published by under [Medicine&Pharma]

I've been reading a terrific book called The Twenty-four Hour Mind by Dr. Rosalind Cartwright.  Dr. Cartwright is one of the giants of sleep research, and for years ran the sleep program at my medical school.  But this isn't a book of simply parochial interest.  It's a fascinating longitudinal history of sleep research in the U.S., a history that I'd guess many physicians know little about.  I hope to get a full review up sometime soon. (I received a free copy of the book from the publisher at my request.)

Anyway, I've been thinking about sleepiness a lot lately, and I'd like to share a fun little tool with you.  The Epworth Sleepiness Scale is a commonly used tool to evaluate---you guessed it---sleepiness.  A high score may indicate a severe sleeping disorder, one that puts the patient at risk not only for medical problems such as hypertension, but also decreased work performance, and auto accidents.  One of the most common sleep disorders is "obstructive sleep apnea", an easily diagnosed and treated problem.  The Epworth scale is not a test for sleep apnea, but a high score may indicate a serious sleep problem of one sort or another, depending on a number of factors.  Try it.

11 responses so far

You gotta have heart---Just ask PZ

Aug 25 2010 Published by under Medicine, [Medicine&Pharma]

(Updated)

About a year and a half ago I injured my back fairly severely. I was relatively immobile for several days (although I continued to work), and one night the pain became so unbearable that I took a (appropriately-prescribed) narcotic pain reliever. A short while later I was able to move around a bit better, but as I was climbing down the stairs I began to experience some shortness of breath and a pressure sensation in my mid-chest.

I've been putting off writing about certain aspects of heart disease for a long time. I'm very comfortable writing about the medical prevention and treatment of heart disease---this is a big part of my practice, and I'm pretty familiar with the literature. But when medication either fails or is not the optimal treatment, the literature explodes with huge, well-done studies often with conflicting conclusions.

Over the last several days, well-known blogger PZ Myers of Pharyngula has written of his new journey into the world of heart disease. He's written a very humorous and human account of his own angioplasty (contributing to the evidence against the claim that he is demon-spawn).   This seems a unique opportunity to try to shed a bit of light on the invasive treatment of coronary heart disease.

The Disease

The heart requires an uninterrupted source of oxygen in order to function properly.  This is supplied by the coronary arteries, which take off from the aorta immediately after it exits the heart.  These vessels receive blood when it is at it's highest pressure and highest oxygen content (more or less).

Anterior view of coronary arteries and veins

Over time, these arteries can develop plaques on their inner surfaces (atherosclerosis).  These plaques are caused by a combination of factors, including inherited an genetic predisposition, hypertension, diabetes, and tobacco use.  All of these can contribute to inflammation of the plaque, which can rupture, blocking the artery and cutting off the blood/oxygen supply to part of the heart muscle. Without oxygen,  this part of the muscle will soon stop beating and die.   We call that a myocardial infarction, or heart attack.

Prevention

We know a great deal about primary and secondary prevention of heart disease.  The risk factors we can control (i.e., not the patient's genetics) can be treated aggressively with life style modification and medication. (I've addressed this extensively in earlier posts.) But acute and established heart disease can also be treated invasively.

Treatment

It's not unusual for the first recognized symptoms of coronary heart disease to be a heart attack, but often their are warnings such as chest pain or difficulty breathing with physical activity.  These symptoms often lead to some sort of intervention.

"Angioplasty"

This is a procedure that can be used either in a heart attack or in symptomatic heart disease that hasn't yet resulted in a heart attack.  The current terminology, preferred because it is a general term, is "percutaneous coronary intervention" (PCI).  In PCI, the procedure that PZ just underwent, a catheter is placed in an artery in the arm or groin, and threaded into the heart.

http://commons.wikimedia.org/wiki/File:Hk_coronary_bionerd.jpg

Coronary Arteries seen during PCI

If blockages are identified, the cardiologist can inflate a balloon to open the artery and (usually) place stent, a sort of metal scaffolding.

Bypass

Coronary artery bypass grafting (CABG, or "cabbage") is a procedure where the chest is cut open and the blockages are bypassed by placing a vein or artery to take blood from above the blockage and deliver it below.

From the description, it's pretty clear that CABG is far more invasive than than PCI, but these procedure have different roles, and as I mentioned earlier, the data are often conflicting.

Heart Attacks

In places were angioplasty is not available, clot-dissolving drugs can be given to stop a heart attack in progress.  Both procedures effectively halt a heart attack, but a follow up intervention such as PCI or CABG is usually needed for more definitive therapy.  CABG is occasionally done in this setting, but that's another story.

Symptomatic Coronary Heart Disease

In patients having symptoms caused by blocked arteries, the data become more difficult.  Often, medical therapy alone is as good as PCI.  In cases where intervention seems more appropriate, there are several factors to consider in choosing PCI vs. CABG.  Part of this depends on the outcome you look at.  If you look at the need for re-intervention, you get one answer; mortality, another answer; future heart attack, yet another answer.  Also important is the extent of the disease and concurrent risk factors.  Some patients simply don't have an anatomy amenable to PCI.  If they have multiple vessels involved or are diabetic, there is evidence that CABG is a better choice (once again, depending on the outcome we're looking at).

PZ described having been called to the hospital for an angiogram, after a visit to the hospital for an episode of suspicious chest pain.  He told us that several stents were placed.  These may have been placed in a single vessel or multiple vessels.  These days, chances are the stents are coated with drugs that help prevent re-occlusion of the artery, and these types of stents require prolonged use of anti-platelet drugs.  These drugs are very both useful and necessary, but come with their own set of problems.

Our understanding of heart disease, its prevention, and treatment has expanded rapidly over the last three decades.  We have never had so many useful tools available for the treatment and prevention of heart disease, and despite the inconsistencies in the data, people are doing much better than they ever have.  In the year 2000 alone, approximately 340,000 heart disease deaths were prevented by the modern approach to heart disease, even with the uncertainties.

On the night I had trouble breathing, I thought I was having a panic attack.  It seemed logical that the narcotic---a drug I'm not accustomed to taking---was contributing to my "not feeling right".  But I couldn't talk myself down from my symptoms.  My relative inactivity put me at risk for developing a blood clot in my leg which could travel to my lung, and my high cholesterol put me at risk for heart disease.  I spent the evening at the ER, and a number of tests confirmed my original hypothesis---my heart an lungs were fine, so I was probably having a panic attack, an experience I hadn't had either before or since.

Selected References

Hlatky, M., Boothroyd, D., Bravata, D., Boersma, E., Booth, J., Brooks, M., Carrié, D., Clayton, T., Danchin, N., & Flather, M. (2009). Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials The Lancet, 373 (9670), 1190-1197 DOI: 10.1016/S0140-6736(09)60552-3

Hansson, G. (2005). Inflammation, Atherosclerosis, and Coronary Artery Disease New England Journal of Medicine, 352 (16), 1685-1695 DOI: 10.1056/NEJMra043430

Serruys, P., Morice, M., Kappetein, A., Colombo, A., Holmes, D., Mack, M., Ståhle, E., Feldman, T., van den Brand, M., Bass, E., Van Dyck, N., Leadley, K., Dawkins, K., & Mohr, F. (2009). Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease New England Journal of Medicine, 360 (10), 961-972 DOI: 10.1056/NEJMoa0804626

5 responses so far

Every patient is an experiment

Aug 24 2010 Published by under Medicine, [Medicine&Pharma]

Mrs. Charbin's blood pressure just kept going up.  She felt fine---no chest pain, no shortness of breath, no headaches---but the numbers put her at risk.  At 55, her risk of developing heart disease at some point in her life is high, and is made even higher by her hypertension.  For each 20 mm Hg rise in systolic blood pressure (the "top" number), the risk of heart disease doubles.  Her systolic blood pressure has consistently been in the 160's.  She did a great job cutting down on salt, and she was already exercising as much as her arthritis would allow. It was time to try medication.

The data on the treatment of hypertension is extensive.  We not only have a wide range of medication options, but we know the risks and benefits of treatment. We also know that most people with high blood pressure will need at least two medications to bring their blood pressure to goal, a goal based on decreasing the risk of complications such as heart attack and stroke.

Based on this data, I started Mrs. Charbin on a thiazide-type diuretic.  These are inexpensive, effective, and well-tolerated.  Except in her.  When she came to see me two weeks later, her blood pressure was much better, but she was feeling a bit weak, and a little dizzy.   I drew some blood and found that her sodium level was pretty low.  This is a known complication of thiazide diuretic therapy, so I changed her to a dihydropyridine calcium channel blocker.  Two weeks later her blood pressure was fine, but her legs were uncomfortably swollen---once again, a known complication of the medication.  So I again changed her therapy, this time to an ACE inhibitor.  Any physicians reading will know what happened next---she developed a dry, nagging cough, a side effect requiring cessation of therapy.

Finally, I changed her to an ARB.  This class of drugs is related to ACE-I's.  I had to call her insurance company and explain why a more expensive drug was required (including the fact that I did not try beta blockers because of a resting low heart rate).  Once it was approved, she did great.  About two months after deciding to start drug therapy for her blood pressure, we'd found a regimen that worked.

Science-based medicine relies on data from large studies, but these data do not create a cookie-cutter approach to medicine.  The data tell me what is likely to happen when I fail to control blood pressure, and guide me toward success at reducing the risks of hypertension.  What the data don't tell me is how much my patient can afford to spend on medicine, how well they're able to remember their medicine, whether they will tolerate a particular medicine or not.  Each patient is an experiment, but one based on an extensive and living repository of data.

One of the lessons we've learned from science is that it works.  A failure of one particular science-based intervention does not invalidate all of science.  Science embraces failure, explains it in a way that makes sense and helps one improve.  I'm always fascinated by the argument that goes, roughly, "my medicine is different, and not susceptible to your science."  The argument often goes with a pitch for some alternative medicine technique that hasn't managed to get itself validated by scientific investigation.

One of these techniques is acupuncture, a technique that in aggregate has not been found to work better than placebo.  But true believers will not be deterred by the absence of supportive data (there are lots of good data, just not supportive data).  At the New York Times Well Blog, Tara Parker-Pope had a piece yesterday that repeats some of the misunderstandings of these true believers.

The most telling quote is the one from Dr. Alex Moroz, a trained acupuncturist:

There is a body of literature that argues that the whole approach to studying acupuncture doesn’t lend itself to the Western reductionist scientific method.

This is a common refuge for those who hold to practices that cannot be scientifically validated.  Rather than admit that acupuncture is no more effective than randomly poking someone with toothpicks, they argue that we Westerners and our fancy science are the real failure.  And it is fundamentally bad thinking.  Science is a technique for investigating and understanding the world, one that works.  One of the basic tenets of the scientific method is that we do not get to change the rules to suit our beliefs.  If engineers design a bridge and testing shows that it will collapse under real-life conditions, they don't just change the calculations, because physics doesn't change.

Biology doesn't either.  There are no "meridians of energy" in the human body.  They don't exist, and therefore, they cannot be manipulated.  Ignoring this fact does not change it.

Every patient is an experiment, but one that obeys certain basic physical laws, and is informed by data.  But as Parker-Pope reports:

[a]cupuncture believers say it doesn’t really matter whether Western scientific studies find that the treatment has a strong placebo effect. After all, the goal of what they call integrative medicine, which combines conventional and alternative treatments like acupuncture, is to harness the body’s power to heal itself. It doesn’t matter whether that power is stimulated by a placebo effect or by skillful placement of needles.

It actually matters quite a bit.  Knowingly prescribing a treatment that is no better than placebo is not harmless.  Worse, this mindset that allows one to ignore science when it is inconvenient is dangerous.  Mrs. Charbin's blood pressure didn't get better through judicious application of placebo.  It got better through an understanding of the pathophysiology and pharmacology of the treatment of high blood pressure.   If I found these facts to be inconvenient, my patient would be the one to suffer for my arrogance.

References

Aram V. Chobanian, MD; George L. Bakris, MD; Henry R. Black, MD; William C. Cushman, MD; Lee A. Green, MD, MPH; Joseph L. Izzo, Jr, MD; Daniel W. Jones, MD; Barry J. Materson, MD, MBA; Suzanne Oparil, MD; Jackson T. Wright, Jr, MD, PhD; Edward J. Roccella (2003). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report--Correction JAMA: The Journal of the American Medical Association, 290 (2), 197-197 DOI: 10.1001/jama.290.2.197

The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group, . (2002). Major Outcomes in High-Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) JAMA: The Journal of the American Medical Association, 288 (23), 2981-2997 DOI: 10.1001/jama.288.23.2981

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Sinus infections: what we do and don't know

Aug 22 2010 Published by under Medicine, [Medicine&Pharma]

Acute sinusitis---a "sinus infection"---is one of the most common problems seen by primary care physicians.  The current preferred terminology is "acute rhinosinusitis", a term which is more descriptive of how the disease works (its "etiology").  In most cases, a patient will first develop cold or allergy symptoms including a runny, congested nose ("rhinitis").  The swelling in the nose will block off the holes ("ostia") that drain the sinuses.   Both cold viruses and allergies can cause inflammation in the nose and sinuses which will increase the flow of mucus.  As the mucus builds up in the sinuses with nowhere to go, the pressure increases causing pain in the face, forehead, and teeth.

Paranasal Sinuses

As the cold or allergies improve, the swelling decreases, allowing the mucus to flow back out of the sinuses.  But the longer the mucus pools in the sinuses without draining, the higher the chance that this nutritious fluid will become colonized and then infected with bacteria.  But most cases of sinusitis are primarily viral, and go away on their own without specific intervention, and only about 2% of colds go on to become bacterial sinusitis.

Deciding which sinus infections are viral and which bacterial is quite simple: we can puncture a sinus with a large needle, withdraw its contents, and send it to the lab for analysis.  Not surprisingly, most patients and physicians are resistant to such an approach.   Sinus X rays are abnormal in many patients with viral infections, so X rays don't help us much either, and are not recommended.  Patients who have had one-sided facial pain or tenderness, tooth pain, and thick green or yellow nasal discharge for more than a week are more likely to have bacterial sinusitis.  All of these folks should be given antibiotics immediately, right?

Not so much. Most of these patients can be treated with tylenol, decongestants, or anti-inflammatories such motrin, and they will get better on their own.  Patients who have significant symptoms that will not go away are the ones who should be treated with antibiotics.  Since most cases of acute sinusitis are caused by Streptococcus pneumoniae or Haemophilus influenzae, these can be targeted with narrow spectrum antibiotics to help prevent antibiotic resistance.

That's what the best science currently tells us.  But what is the worst science currently telling us?

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