Archive for: December, 2010

New frontiers

Dec 30 2010 Published by under Medicine

If you are a regular reader, you may have noticed a drop in the frequency of posts at this blog.  There is a good reason for that.  Several weeks ago I announced a blog hiatus, which I honored more in the breach, the reason for which was a major career conundrum.  I had been spending about half my time directly treating patients, and the other few halves teaching and supervising resident physicians.   Then, a friend called---a local internist had decided to move away (something that young, educated Michiganders do quite a bit of) and the group was looking for a full-time doc to take over his patients.

Decisions about such big changes take a lot of time and energy, and writing isn't how I make my living.  Still, I do love it, and though my posts will be less frequent, I'm not planning on quitting.

So, I moved to the new digs.  I joined up with a small group of very busy, very talented internists in an awesome location.  And our office has a window.  I like that part a lot.  From the first day, I've been very, very busy, and I've learned a few things about myself (or re-learned, perhaps). My handwriting is not wonderful, and being busier doesn't seem to improve it.  This weekend I'm going handheld voice recorder shopping.  I have to get one that uses actual magnetic tape, but in return I will have beautifully typed (and consistently legible) notes.

Oh, and did you hear about Mississippi governor Haley Barbour's foray into transplant medicine?  As many of you know, transplanting a solid organ, say, a kidney, is not like changing a spark plug.  You can't just grab one and plug it into someone else.  For a kidney transplant to work, all sorts of fancy medical stuff has to happen.  Not only that, but there are one or two ethical issues involved in solid organ transplantation, not the least of which is the risk of coercing people to give up organs for donation.

But check out what Barbour did: for unclear reasons, one of which was the financial burden of medical care on the state, the Gov released two sisters from prison---on the condition that one donate her kidney to the other.  There are, to no one's surprise, a few racial issues involved here.  But from the medical end, there is nothing remotely ethical about this.  Anyway, it's quitting time.  A happy, healthy New Year to all my readers.

16 responses so far

Sunday morning reflections

Dec 26 2010 Published by under Medicine, Uncategorized

I'm currently reading Maryn McKenna's Beating Back the Devil, and her chapter on West Nile Fever really resonated with me.  This is a brief reflection on my experience originally published in July, 2010.  --PalMD

The Midwest loves extremes. Our spring is a quick, cold bucket of water to the face, and the fall a brief but intense set of umber and auburn brush strokes on the landscape. Today is neither of those, but still, hot, and humid enough to make breathing uncomfortable. So I'm looking out the window, rather than sitting outside, and I see something heartening: a crow.

I've noticed---really noticed---the crows and blue jays this year. Several years ago, when I was a young attending physician, the hospital seemed filled with a new ailment. The victims were often elderly, had high fevers, paralysis, confusion; they often died, or were left permanently disabled. There were younger people too, but they usually had a bad headache and a fever which resolved without incident. That's when the crows and jays died.

They died in huge numbers. On a hike with my parents, I found a dead crow lying in the middle of the path, an experience that would be repeated over and over. The bird had succumbed to West Nile Virus, as had a number of my patients.

I haven't seen a serious case of West Nile in years. I've seen suspected mild cases, but I wasn't about to do a spinal tap to find out for sure. And this year, the crows and jays are everywhere. West Nile is probably a regular part of our hot, humid summers, although we don't see the same number of severe cases that we saw in that first year. Still, when the sun sets, and the temperature becomes bearable outside, I am much more aware of each mosquito buzzing around my ankles.

No responses yet

You wouldn't lie to me, would you?

Dec 24 2010 Published by under Medicine

"Fake Pills Can Work, Even If Patients Know It"

"Irritable Bowel Syndrome: Placebo Works Even if Patients Know"

"Knowingly taking a placebo helps, study finds"

"Sugar Pills Work Even When People Know They Are Fake"

That's just a sample of the headlines accompanying a new study on placebos published in PLoS ONE.  The study attempts to nail down some questions about the placebo effect, especially regarding how to harness it ethically, without deception.  The placebo effect, a medical improvement not due to a biologically active treatment, is a difficult concept.  Some of it is stochastic or artifactual, that is, any time you study human beings, it is possible to measure statistical "improvement" that may not have real clinical meaning.  The other part of placebo is the response to being cared for independent of other biological interventions.  Journalist Steve Silberman (with whom I have disagreed about placebo in the past, and I'm still not sure who's right) quotes anthropologist Dan Moerman (emphasis mine):

"I was really surprised at how well the non-placebo group did,” Moerman says in email. “Note I don’t call them a ‘no treatment group’ because they, and everyone else, received exemplary treatment here: they were listened to, examined, encouraged, supported. They were able to talk with, and be taken seriously by, people who understood their issues, things they probably had serious difficulty discussing with their own families. I think it likely that the effectiveness of the placebos above and beyond all the other treatment would have been diminished without the whole system of compassionate care.”

So the non-artifactual part of placebo isn't really "no treatment", it is less tangible treatment.  In the current study, this distinction becomes important.  There are really two types of placebo: the kind used as a "dummy" treatment in placebo-controlled trials, and the placebo effect observed when we treat people well.  In attempting to harness placebo as an actual treatment, we run into a number of problems.  The first is teasing out what we mean by "placebo", the second the ethics of deceiving patients.  The current study by Kaptchuck, et al attempts to tease out the second question in order to answer the first.

They chose to study irritable bowel syndrome (IBS), an common, unpleasant disorder of unknown cause.  It is often exacerbated by stress and anxiety, and the natural course of the syndrome and of its attacks is to come and go spontaneously.  This fact itself makes studying interventions difficult, as it is harder to decide whether a treatment worked, or the patient simply got better as they would have.  Since IBS is often made worse with stress, it is also possible that simply comforting a patient may improve the symptoms.  Can this comfort be labelled "placebo" simply because it is non-pharmacologic?

All of this points to the difficulty of defining what a "placebo treatment" actually might be.  Giving comfort and care is active treatment.   The current study did not compare "placebo" to no treatment as they claim, but an active intervention, albeit one that was non-pharmacologic:

The provider clearly explained that the placebo pill was an inactive (i.e., “inert”) substance like a sugar pill that contained no medication and then explained in an approximately fifteen minute a priori script the following “four discussion points:” 1) the placebo effect is powerful, 2) the body can automatically respond to taking placebo pills like Pavlov's dogs who salivated when they heard a bell, 3) a positive attitude helps but is not necessary, and 4) taking the pills faithfully is critical.

Both groups were treated  "in the context of a warm supportive patient-practitioner relationship," but the subjects were essentially told that the pills would work, negating any real claim that this is a "placebo without deception."

This study simply shows what we already know: treating patients well helps them.  All the rest is commentary; don't bother to go and learn it.

References

Kaptchuk, T., Friedlander, E., Kelley, J., Sanchez, M., Kokkotou, E., Singer, J., Kowalczykowski, M., Miller, F., Kirsch, I., & Lembo, A. (2010). Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome PLoS ONE, 5 (12) DOI: 10.1371/journal.pone.0015591

Two other excellent discussions online:

Ed Yong at NERS

Orac at Respectful Insolence


10 responses so far

The medium is not the message---is it?

Dec 21 2010 Published by under Medicine

There's a bit of a heated discussion going on online, one that conflates conflicts about the nature of medical debates with the nature of journalism.  If this sounds stultifyingly boring, it is, but some of the underlying issues are not.

It starts with a piece in the Chicago Tribune by Patricia Callahan and Trine Tsouderos.  The award winning pair have been among the few reporters to consistently "get it right" about alternative medicine. Tsouderos is well-respected among critics of quackery for her willingness to look at the science and report the truth, without resorting to false balance*.  Callahan and Tsouderos' investigation into the dangerous and deceptive practices of alternative autism doctors, practices that include chemical castration, won cheers from those  screaming out against this unethical mistreatment of children.  These reporters have got the bona fides amongst both journalists and scientists.

Stories like the one on fake autism treatments have a lot of background.  To those of us who have been following the stories and writing about them for years, the stories and the players are well known.  The best ongoing critical discussions of alternative medicine have been going on in the blogosphere rather than print media.  Blogs such as Respectful Insolence, Neurologica, and Science-Based Medicine have been tracking alternative medicine trends for years and doing it well.  The success of these outlets are in no small part due to the fact that they are written by medical experts.  These writers may not have formal training (or even informal training) in journalism, but they know medicine and they know how to write in a compelling style.

In general, bloggers write frequently, often on the same or related topics.  This serialization of sorts, along with the convention of linking/hypertext allows bloggers to reference rather than rewrite when discussing complicated topics such as autism, lyme disease, or homeopathy.  Many mainstream journalists are aware of these tools and would like to use them, but they may face technological and corporate constraints (and I welcome any comment from journalists that may help clarify this point).

In their recent piece Tsouderos and Callahan recently got it right about so-called chronic Lyme disease (CLD), and they are catching some flack.  I'm going to use my powers as a blogger here to refer you to more in-depth discussions of Lyme disease, but I'll give you a quick run-down.  Lyme disease is caused by a bacterium spread to humans by tick bite.  When treated properly with antibiotics, it resolves completely.  When not treated early, it can cause a number of problems ranging from annoying to serious, including joint pain, heart, and neurologic problems, which also respond well to antibiotic therapy.   Over the last several years, a number of doctors and patient-advocacy groups have recognized something called "chronic Lyme disease" which is a collection of various symptoms that are attributed to Lyme disease despite absence of any evidence of ongoing infection.

It is difficult to explain briefly the intense animosity advocates of CLD have for the medical establishment.  They often state that doctors are actively involved in a conspiracy to deny "proper" treatment, and have convinced politicians to take legal action to circumvent and even punish those who uphold medical consensus.  The real victims here are suffering patients who are taken advantage of by so-called Lyme-literate doctors, doctors who are willing to ignore medical evidence and give dangerous and costly treatments to people who don't need it.

It is in this context that the Tribune piece should be viewed, and it is this context that was ignored by critics of the piece, especially Paul Raeburn of Knight Science Journalism Tracker, an excellent website, and Pam Weintraub, an editor at Discover Magazine.  We'll explore each of their critiques separately.

Raeburn's beef with the Trib piece appears to be a "lack of balance":

This is what happens when reporters make up their minds about a controversial story before beginning to write. In a Dec. 8 Chicago Tribune piece on Lyme disease, reporters Patricia Callahan and Trine Tsouderos write that while Lyme disease is real, so-called “chronic” Lyme disease, said to last for years, “is an illness that might not even exist.”

That’s an arguable point, and a fair conclusion to come to–if the writers came to it fairly.

When it comes to truth, it doesn't matter how Paul Raeburn perceives the process.  A medical fact is a medical fact, and while he may not like the way they came to their conclusion, the truth remains.   He goes on to make a number of somewhat fair criticisms of the piece, arguing that many ideas were left unattributed, although as I pointed out above, to give the entire back story to this debate would be nearly impossible in a single piece.  He accuses them---unfairly, I think---of writing a hit piece with little real reporting:

It goes on. Note that none of this is attributed. The reporters are saying, in their own voice, that chronic Lyme disease belongs squarely with all kinds of risky and unproven cures for cancer and other ailments. With that kind of opening, most readers don’t have to wade any further through the reporting to know what conclusions the story is going to come to. The writers have conveyed their sneering skepticism without, so far, more than a few shreds of reporting. And none from anybody we might consider an expert on the disease.

"Sneering skepticism", in the face of well-known, previously documented quackery is not a fault.

Raeburn displays a profound ignorance of the Lyme debate and of the players involved, in favor of a desire for false balance:

Again and again, Callahan and Tsouderos give far more space to advocates making questionable claims than they do to experts who refute those claims, allowing the serious case for chronic Lyme disease, whatever that might be, to be buried under the dubious claims of advocates.

There are many researches working on Lyme disease, but so-called chronic Lyme disease is a different thing altogether.  It is by definition a condition that isn't really Lyme disease, but a bunch of symptoms that someone feels like calling Lyme disease despite no evidence of infection.  There is no serious debate here, and the advocates who Tsouderos and Callahan quoted are the major players---they got it right.

The heart of  Reaburn's agenda seems to be a form over substance:

A far better approach would have been to report the evidence, pro and con, and to quote the most persuasive advocates for and against chronic Lyme disease–not the least persuasive. And to give both sides equal time to speak.

The piece did not just find "the least persuasive" CLD advocates in order to make a point---that is the reality out there.  The expert consensus is that the thing being called CLD has nothing to do with Lyme disease, subjects patients to harmful treatments, and distracts from real work on Lyme disease. It's a conclusion that I as a clinician share.  I'm not a "real" journalist, and if real journalists approach all stories like Raeburn, I'm glad I'm just a hobbyist.

Pamela Weintraub's criticism is a bit different.  It was apparently her concerns that prompted Raeburn to write his piece, and she chimed in in the comment section.  I'm going to quote her at length, because she is an editor and presumably a stickler about these things:

The problem, as I see it, is that these journalists have conflated two issues: One issue, a look at the predators abusing patients carrying the diagnosis of chronic Lyme disease, is a worthy endeavor. The second, an examination of the debate over why symptoms persist after short-term antibiotic treatment, is also a worthy endeavor. But these issues –thought interrelated because a dearth of knowledge leaves a vacuum for predators– are not the same.

In order to examine the possible reasons for chronic symptoms after treatment for Lyme disease, one would need to quote credible, university-based scientists on the range of views and interpretations. Instead, the journalists quote scientists with one view, but when it comes to balancing that view, they attempt to do so by quoting the very criminals, predators, and crazies they are trying to expose. The implication, of course is that these sources must provide the counterweight because there ARE no credible, university-based scientists who disagree with the contention of the article, or the experts quoted. Of course, this is blatantly untrue –and one does not need to look far or even make many phone calls to find a range of views among credible academic experts with high visibility in the peer review.

These reporters have not conflated anything.  The predation and other nonsense that accompanies the chronic Lyme debate is the story.   This is a fairly classic moving of the goalposts, one which, perhaps, Tsouderos and Callahan might have avoided by citing more sources, but I doubt it.  The science is settled: vague and protean symptoms in people without microbiological signs of Lyme disease do not have Lyme disease and are not aided by long-term antibiotic therapy.  The "other side" here is populated by predators and wackos, not by credible university scientists.  Those scientists have already done the work and published it.

As clinicians, we see many, many patients with difficult or impossible to explain symptoms, a problem frustrating to doctors and horrifying to patients, and looking for better way to diagnose and treat these patients is a daily occurrence.   It is also an area wide open to quacks, who want to call it chronic fatigue syndrome (which really exists, but can be overdiagnosed) or Lyme disease (same), etc.

Weintraub continues:

Either these reporters started out with an agenda –and thus were satisfied to ignore like-weight experts with alternate views—or else they failed to realize these experts exist. In other words, either they were biased or they were incompetent.

And it is too bad –because an expose on predatory practices in this arena is sorely needed.

A final note: The issue of Lyme disease, in general, is confounded by co-infections carried by Lyme ticks, and by a range of Lyme disease strains, only recently described in the peer review. Some of our top scientists now suggest these strains may present variably in terms of symptom sets, in terms of testing –and yes, perhaps even in terms of length of treatment to kill. It is too bad that these journalists failed to attend the recent Institute of Medicine conference, Lyme Disease and Other Tick-Borne Diseases: The State of the Science, or even watch the webcast, where many of the nuances and complexities were discussed by the top experts in the world.

This is simply wrong.  Weintraub is either intentionally or erroneously confusing the debate over so-called chronic Lyme disease and the real medical problem of Lyme and other tick-borne disorders.   She is in over her head.  Medical science cannot rule out that some of the patients currently carrying the diagnosis of "chronic Lyme disease" may actually be found to have a problem related to tick-borne infections, but on the whole, this does not appear to be the case.

Weintraub goes on to appeal to the authority of her own experience and to the lack of journalistic expertise of bloggers, all of which is simultaneously quixotic and boring.   She and Raeburn are right about one thing though: the problem here is one of journalism.  Science journalism that insists on the convention of false balance over truth isn't worth reading.

(Friend Orac has also added his thoughts to this issue.)

____________________

*I was going to footnote a bunch on what I mean by "false balance", but then I ran out of steam.  If it's not clear by now, let me know and I'll clear that up.

17 responses so far

Stick a needle in your eye?

Dec 15 2010 Published by under Medicine

I was talking to a Reuters reporter the other day and learned of a new acupuncture study out of China, this one about amblyopia, or "lazy eye".   Amblyopia is a common and interesting visual problem.  During development of the visual system if an eye is understimulated, the brain will not process data coming from that eye correctly, leading to a decrease in vision in the eye, despite the eye itself being structurally normal.   There are several types of amblyopia, the most common of which is called "anisometropic", but we'll use the simpler word "refractive".

Refractive amblyopia can be treated successfully, even when detected relatively late.  Standard treatment involves correcting "normal" visual problems (that is, making sure the child is using glasses if they need them) and encouraging use of the lazy eye, often by patching the good eye.  The authors of the current study reasoned that because it can be difficult and embarrassing for children to wear eye patches, and because they believe in acupuncture, a randomized controlled trial of acupuncture for amblyopia would be a good idea.

It's actually a spectacularly bad idea, but you shouldn't take my word for it.  Let's examine the study.

Plausibility

Let me first reassure you that the techniques used did not involve inserting needles into children's eyeballs.  But that's about all the reassurance I can give.  This study fails the initial "sniff test" for plausibility.  There is no anatomic or physiologic reason that sticking needles into a child should affect their amblyopia (although I suppose if the needles were sufficiently painful and placed only in the visual field of the lazy eye...).

This fact in and of itself essentially invalidates the study.  But let's just suppose for a moment that there was some valid reason for thinking that acupuncture might work.

Not-So Blind, Not So Random

This particular study lends itself to far too many puns, but one of the first and most obvious problems with this study is its lack of blinding, that is, every researcher and patient knows what treatment is being given.  Also, subjects (or victims?) of this experiment were recruited from eye clinics.  They were not, for example, chosen serially (at least as reported).  This can introduce bias into the experiment.  For example, parents responding to recruitment announcements might be more predisposed to "believe in" acupuncture, and therefore be more responsive to placebo effects.

All subjects of the experiment were wearing the usual corrective lenses for several months on entry to the study.  They were measured for new glasses if needed, and then randomized to either eye patching or acupuncture.  Both sets of patients continued to use corrective lenses.  The control (patching) group was instructed to use the patch for two hours a day and do near-vision activities.  This is reasonably standard, although longer periods are often used.

The test group was subjected to acupuncture an also instructed to do near-vision activity, but without the patch.

Results--Look Closely

What the researches found was that the groups had similar improvements in vision, or in study-speak, that acupuncture was non-inferior to patching.  They interpret this as meaning that acupuncture may be a nice alternative to patching for similar kids with lazy eye.   Is that what the results really say?

Well, no.  In studies of amblyopia, especially in older children as in this study, many (about a quarter) improve significantly with eyeglasses alone.  Children in both groups received this standard therapy.  Also, although two hours of patching has in some studies been found to be as good as longer periods, this is the bare minimum of patching time that is used.   This study did not include longer (and perhaps more typical) patching times.

This is one of the serious flaws in this study and any conclusions drawn from it---this study says nothing about acupuncture, because there was no adequate control group.   It might have been interesting to compare the two groups to a spectacles-only group---perhaps both acupuncture and 2-hour eye patching were equally ineffective, rather than equally effective.

But of course the fatal flaw is the one stated by the authors:

Although the treatment effect of acupuncture appears promising, the mechanism underlying its success as a treatment for amblyopia remains unclear.

The underlying mechanism is unclear because there is none.  No effect has been shown, and if it were, given the biologic implausibility, almost any explanation would be preferred to "the acupuncture did it".

While a better-designed study might be intellectually interesting, it would be ultimately useless and immediately unethical.  Acupuncture is more invasive than standard therapy and there is no reason to think it has any real advantages.  I find little comfort in the fact that the study was approved by an institutional review board and published in a major peer-reviewed journal.

References

Zhao, J., Lam, D., Chen, L., Wang, Y., Zheng, C., Lin, Q., Rao, S., Fan, D., Zhang, M., Leung, P., & Ritch, R. (2010). Randomized Controlled Trial of Patching vs Acupuncture for Anisometropic Amblyopia in Children Aged 7 to 12 Years Archives of Ophthalmology, 128 (12), 1510-1517 DOI: 10.1001/archophthalmol.2010.306

11 responses so far

Pregnant and high: new treatments?

Dec 09 2010 Published by under Medicine

Many years ago a woman came to OB triage at my hospital.  She was about 28 weeks pregnant and feeling horrible.   As the nurses hooked her up to monitors and started an IV, she clutched a pink, kidney-shaped emesis basin, her boyfriend holding her hair back and away.  A few minutes later, she called for the nurse urgently---she had to go to the bathroom.   The nurse detached her from her IV and her monitors.  The patient shuffled to the bathroom, basin in one hand, purse clutched in the other.  She returned from the bathroom and lay back on the gurney, appearing much more comfortable.  I watched the nurse get her settled back in, and as the patient turned, her purse fell on the floor and a syringe rolled out.

Drug dependence among pregnant women is tough to track. By some reports, about 4% of pregnant women admit to illicit drug use.  I haven't been able to find statistics on opiate dependence in pregnancy, but opiate misuse is not an uncommon problem.  In addition to heroin, misuse of prescription drugs such as Vicodin and oxycodone has been on the rise among adults.

While drug use has obvious effects on the mother, maternal opiate dependence has health consequences for the newborn as well.  One of these consequences is "neonatal abstinence syndrome" (NAS), basically opiate withdrawal in the newborn.  In addition to increased risk for viral hepatitis and HIV if intravenous drugs are used, babies born to opiate-dependent mothers can be underweight, and can have significant irritability and feeding problems.  They can also have vomiting, diarrhea, dehydration---a wide variety of problems that would be uncomfortable for an adult but can be potentially life-threatening for an infant (although mortality rates are probably quite low).

For many years, methadone has been used to help control opioid dependence in pregnant women.  If patients have safe access to methadone, they are less likely to seek illegal drugs or to inject drugs.   But methadone is a "regular opiate", strongly binding to and stimulating the mu-opioid receptor, giving us the effects we classically associate with morphine and heroin.  Methadone can lead to NAS, and infants born to methadone-dependent mothers can require long-term use of opioids themselves.  Another drug, buprenorphine, binds opioid receptors differently and among its effects is a reportedly less severe withdrawal syndrome.  Buprenorphine is gaining some acceptance in maintenance therapy for opiate dependence, and a new study in the New England Journal of Medicine examines its potential to reduce the incidence of neonatal abstinence syndrome.

Researchers recruited opiate-dependent pregnant women and randomly assigned them to double-blind use of either methadone or buprenorphine.  A significant number of women dropped out of the study, but study was otherwise pretty good.  The authors looked at five outcomes: number of neonates requiring treatment for NAS, peak NAS score, total amount of morphine needed for treatment of NAS, length of hospital stay, and head circumference.   Infants in both groups were just as likely to require treatment for NAS, and their NAS was equally severe.  But the buprenorphine group required less total morphine and shorter hospitalizations.  While these results are interesting, the authors took a bit of a leap in their conclusions (emphasis mine):

In summary, our findings are consistent with the use of buprenorphine as an alternative to methadone for the treatment of opioid dependency during pregnancy. Although there were no significant differences in overall rates of NAS among infants exposed to buprenorphine and those exposed to methadone, the benefits of buprenorphine in reducing the severity of NAS among neonates with this complication suggest that it should be considered a first-line treatment option in pregnancy.

Here, they seem to be wiggling around with the definition of "severity".  Be that as it may, it's an interesting study.  One of the interesting findings was that women more often dropped out of the buprenorphine group, citing dissatisfaction.   It would be useful to investigate the relative risks and benefits of a treatment that may be marginally better but is associated with worse patient adherence.

Working with people with opiate use disorders can be difficult for a variety of reasons.  This study gives us a bit more data, but I don't see it as dramatically changing the way we practice.

References

Jones, H., Kaltenbach, K., Heil, S., Stine, S., Coyle, M., Arria, A., O'Grady, K., Selby, P., Martin, P., & Fischer, G. (2010). Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure New England Journal of Medicine, 363 (24), 2320-2331 DOI: 10.1056/NEJMoa1005359

No responses yet

Breathe deep?

Dec 07 2010 Published by under Medicine

Winter has come to the Great Lakes, no matter what the calendar says.  This morning I walked out the door to take out the trash and the cold took my breath away.   I warmed up the car while I had breakfast, perhaps not the most environmentally friendly practice, but...

On my way to work, depending on my mood, I listen either to CBC Radio 2 or NPR.  This morning it was Morning Edition, a choice I regret.  This morning's health story was a credulous pile of poorly researched word salad about yogic breathing practices.

Yoga is very popular in these parts, and folks seem to love it.  According to my sources, it's both relaxing and a good workout.  According to NPR's story, though, it's much more.  We'll skip over the poor reporting aspect of this story, except to note that the reporter did not ask any pointed, skeptical questions, and didn't question any of the underlying assumptions and claims made by the people she interviewed.  And what were these claims and assumptions?

There are plenty of ways to relieve stress — exercise, a long soak in a hot bath, or even a massage. But believe it or not, something you're doing right now, probably without even thinking about it, is a proven stress reliever: breathing.

As it turns out, deep breathing is not only relaxing, it's been scientifically proven to affect the heart, the brain, digestion, the immune system — and maybe even the expression of genes.

This sounds pretty far-fetched, but let's see what they are actually talking about.

Mladen Golubic, a physician in the Cleveland Clinic's Center for Integrative Medicine, says that breathing can have a profound impact on our physiology and our health.

"You can influence asthma; you can influence chronic obstructive pulmonary disease; you can influence heart failure," Golubic says. "There are studies that show that people who practice breathing exercises and have those conditions — they benefit."

The reporter then talks to an instructor of pranayama---traditional yogic breathing---who describes some common techniques.

Research has shown that breathing exercises like these can have immediate effects by altering the pH of the blood, or changing blood pressure

OK, hold it right there.  Let's examine these first claims.  Breathing is part of the way we regulate our body's pH (acidity).  Our body only functions within a very narrow pH range centered on the slightly basic 7.40.  Various insults to the body, such as overwhelming infection, can disturb the pH, and the kidneys help regulate this in the long term, but brief corrections can be made by the lungs.  The lungs, in addition to absorbing oxygen, help dispense with carbon dioxide.   Carbon dioxide acts as an acid in the body, so rapid or deep breathing removes acid, raising the blood's pH.   The ability of the lungs to do this is quite limited, no least by the fact that blowing off acid consumes a lot of energy, and patients can tire, and then stop breathing completely.  Almost all alternative health claims that talk about pH and "acidity" are complete bunk.

That breathing techniques might lower blood pressure isn't far-fetched but it's unclear to me what clinical utility there is to briefly lowering blood pressure this way.  The piece goes on to make certain claims about being able to calm oneself with breathing techniques, which sounds like a good idea, but once again, I'm underwhelmed with what long-term clinical impact that might have.

But the real problem comes at the end of the piece.

In his new book, Relaxation Revolution, Benson claims his research shows that breathing can even change the expression of genes. He says that by using your breath, you can alter the basic activity of your cells with your mind.

"It does away with the whole mind-body separation," Benson says. "Here you can use the mind to change the body, and the genes we're changing were the very genes acting in an opposite fashion when people are under stress."

This "whole mind-body separation" problem is not unknown to the rest of us---most real doctors understand that the brain and the rest of the body are interdependent.  The real problem here, though, is this idea that yogic breathing somehow changes the basic fabric of our being, our genetic instructions.   There are some very important distinctions that were blurred here.  First, there is the difference between "genes" and "gene expression", a difference which Dr. Benson surely knows.  Genes are nucleic acids that encode instructions for making proteins.  Genes can be actively coding for these proteins, or can be "turned off" either permanently, or temporarily based on signals from feedback loops and other stimuli.  For example, if you drink a lot of milk, it's worth the energy expenditure for you to make lactase, the enzyme that helps digest milk sugars.  If you don't drink milk, it would be wasteful to make lactase, and the gene can be shut down.

So it's not beyond the pale to imagine that various stimuli can have an affect on gene expression (but no on the genes themselves).  The question becomes is there truly a measurable effect, and does that putative have any clinical significance (beyond lining the pockets of the author).  I was able to find one recent article that took a very small sample of patients who had leukemia, and made certain measurements of gene expression. While intriguing, the results are clinically irrelevant.

I said I wouldn't harp on the reporting, but I have learned to expect more from NPR.  This wasn't reporting, it was an infomercial.

References

Kumar, A., & Balkrishna, A. (2009). To study the effect of the sequence of seven pranayama by Swami Ramdev on gene expression in leukaemia patients and rapid interpretation of gene expression Journal of Clinical Pathology, 62 (11), 1052-1053 DOI: 10.1136/jcp.2008.061580

Raghuraj P, Nagarathna R, Nagendra HR, & Telles S (1997). Pranayama increases grip strength without lateralized effects. Indian journal of physiology and pharmacology, 41 (2), 129-33 PMID: 9142556

Pramanik, T., Sharma, H., Mishra, S., Mishra, A., Prajapati, R., & Singh, S. (2009). Immediate Effect of Slow Pace on Blood Pressure and Heart Rate The Journal of Alternative and Complementary Medicine, 15 (3), 293-295 DOI: 10.1089/acm.2008.0440

SINGH, V. (1990). Effect of yoga breathing exercises (pranayama) on airway reactivity in subjects with asthma The Lancet, 335 (8702), 1381-1383 DOI: 10.1016/0140-6736(90)91254-8

Cooper, S. (2003). Effect of two breathing exercises (Buteyko and pranayama) in asthma: a randomised controlled trial Thorax, 58 (8), 674-679 DOI: 10.1136/thorax.58.8.674
Bhargava R, Gogate MG, & Mascarenhas JF (1988). Autonomic responses to breath holding and its variations following pranayama. Indian journal of physiology and pharmacology, 32 (4), 257-64 PMID: 3215678

Pratap V, Berrettini WH, & Smith C (1978). Arterial blood gases in Pranayama practice. Perceptual and motor skills, 46 (1), 171-4 PMID: 25412

KOCHUPILLAI, V. (2005). Effect of Rhythmic Breathing (Sudarshan Kriya and Pranayam) on Immune Functions and Tobacco Addiction Annals of the New York Academy of Sciences, 1056 (1), 242-252 DOI: 10.1196/annals.1352.039

18 responses so far

Why haven't we cured it yet?

Dec 05 2010 Published by under Medicine

I was watching one of the 24-hour news stations last night (no, not that one) and saw a breast cancer activist wondering why we don't devote  resources to an all-out fight to cure breast cancer as we did with polio, leading to its eradication in the US.  I often hear questions like this: if we can (send a man to the moon, wipe out polio, etc) then why can't we cure cancer?

It's a good question, in context.  When one of the diseases you care most about is still out there, while others are on the wane, it can add to fear and to frustration.  I don't wish to minimize the political choices behind research funding, but there are good biological explanations for why some diseases are "wiped out" while others still plague us.

Illnesses are caused by a variety of problems, some internal, some external, some unknown.   In the history of medicine and public health, we've only been able to eradicate a single human disease.  Smallpox was ideal in this sense.  Humans are the only natural host, and transmission was usually from person to person---there was no reservoir for the disease other than people.  In theory, then, all it would take is immunization of most humans to eradicate the disease in nature, and that's what was done.  Near the end of the pandemic, teams would travel to outbreaks vaccinating the people within the outbreak area, and in surrounding areas to contain the spread.  This way there was less need to re-vaccinate entire populations.

Polio is a little more difficult.   It only infects humans but the virus is transmitted though fecal contamination of water and sometimes from person to person via oral secretions.   One infected person and a poor water treatment system can lead to continued spread.  This meant that to eradicate polio in the US, a massive vaccination program was needed, one which began with the development of polio vaccines after WWII and essentially ended in the late 1970s when polio was no longer transmitted in the US.  As Maryn McKenna documents in Beating Back the Devil, the eradication campaign had a rocky start, with an early batch problem leading to transmission of polio in some areas.  The fact that millions still clamored for the vaccine shows how much polio was (rightly) feared.  The eventual success of vaccination saved millions from paralysis, illness, and fear.   In parts of the world where natural, economic, and military disasters are most prevalent, polio is still a problem.

Polio is a simple disease---one virus, one host, an effective vaccine---and still it's out there (although not in the US).  Cancer is so much more.  The term "breast cancer" refers to many different diseases, all of which cause abnormal growth of breast cells.  The fight against breast cancer requires improved prevention, early detection, and treatment of the disease at all stages.  And we have been improving, with death rates from many cancers decreasing.   But the disease(s) have many causes, some of which are not amenable to change.  You cannot change a family history of breast cancer.   Unlike lung cancer, there aren't a lot of strong environmental risks (such as cigarette smoking) that can be modified.  We are largely stuck with early detection and good treatment.   Breast cancers caught early can often lead to surgical cure, but our screening methods are imperfect and likely always will be.  There is no perfect test that finds all breast cancers but also avoids erroneous diagnoses that lead to unnecessary tests and treatments.  And there is no guarantee that a cancer found early will be cured---only probabilities.

Perhaps thinking of the "fight against cancer" as a win-lose battle is not all that productive.  Human health and disease is complex and there are rarely simple answers.  The simplest answers---improving economic and social justice---are often the hardest to achieve.  But that doesn't mean we can't try.

8 responses so far

Clinical Conundrum Thursday

Dec 02 2010 Published by under Medical ethics, Medicine

Mr M. is a 58 year old man with severe, chronic neck pain.  He has a history of hypertension, tobacco dependence, stomach ulcers, mild kidney disease, alcoholism (in remission for 10 years), and a "bleeding problem".  He has no history of heart disease, stroke, depression, or diabetes.  His family history is significant for heart disease in his father and alcoholism in his mother and two of his siblings. He was referred to you by a friend after expressing dissatisfaction with all his previous doctors.

His neck pain began nearly fifteen years ago after a minor traffic accident.  He has had multiple imaging studies that show significant arthritis of the spine at the level of the neck, but no compromise of the spinal cord.  There is some pressure on the nerves exiting the neck that supply the right arm.  He has some pain in that arm, but has full use of it.  His pain prevents him from keeping a steady job, and he often feels so bad that he doesn't bother to eat.

A surgeon offered to operate on several occasions, but warned the patient that the bleeding problem would increase the risk.  He takes ibuprofen tablets by the handful throughout the day, which gives him significant relief.  He says that he has been told that the ibuprofen caused his ulcer, which bled bad enough to land him in intensive care and required a transfusion of eight units of blood (that's a lot of blood).  He saw a pain specialist who tried a few different medications, but would not use any narcotics because of the risk of  "addiction".  His previous family doctor also warned him against using any narcotic pain relievers.

Today in the office, he appears tired and thin.  His blood pressure is elevated, and his brow is furrowed.  He turns his head carefully when you walk in the room.   He has full strength in all his extremities, except for some equivocal weakness in his right hand.  The rest of his exam is normal.  Laboratory examination shows mild anemia and some kidney dysfunction.  His blood is negative for alcohol and for drugs of abuse.  You review his MRIs which are consistent with what he has told you.

The patient tells you that you are the last resort; he practically begs you for help.  He has heard so many good things about you.  He has heard of some pill that starts with "V" that really helps some people.

How would you approach this case?

35 responses so far

HIV in America---where do we go from here?

Dec 01 2010 Published by under Medicine

The HIV pandemic in the US has developed a stable appearance over the last few years, and that appearance is notably non-white and non-wealthy.  When the pandemic was discovered nearly thirty years ago, it was---in the US---primarily a disease of gay men.  In Africa, the disease is everyone's.  Women make up significantly more than half of HIV cases in Africa, and tens of thousands of children are infected during childbirth or breastfeeding.

In this country, the disease hasn't as deep a hold on the general population as it might, but the factors that seem to put people at risk---poverty, lack of access to health care, lack of condom use---are not improving.  The majority population in the US has so far remained somewhat shielded from the worst of the epidemic, but this should give us little comfort.  As poverty grows, so will HIV rates.  Meanwhile, HIV is devastating certain minority populations, exacerbating and exacerbated by poverty, prejudice, and all that goes with them.

First, some basics.  Well over one million Americans are infected with HIV---and many don't know it.  Over 55,000 new infections are diagnosed each year, with over half of new diagnoses occurring in men who have sex with men (MSM).  This designation---MSM---is critical, as many MSM may not identify as homosexual.  Prevention strategies that target male homosexuals while ignoring other men who have sex with men are missing an important at-risk population.  African Americans make up nearly half of all people living with HIV in the U.S.  As you might surmise, black men who have have sex with men are the highest risk group, and more new infections are diagnosed in young black MSM than any other ethnic or age group.  At some time in their life, 1 in 16 black men will be diagnosed with HIV, and 1 in 30 black women.  The most common routes of transmission of HIV, in order, are male-to-male sexual contact, heterosexual contact  (about half as many), followed distantly by injection drug use.

The reasons for African Americans' unequal suffering in this epidemic are many, and probably not well-understood.  Many sources cite subjective, unmeasured suppositions, such as anti-gay bias in black churches and the African American community in general.   Homophobia has always been a factor in the US HIV epidemic, but there is much more to this.  Nearly half of HIV cases are heterosexually transmitted, and I am far from convinced that African Americans as a group are more homophobic than whites.  There are also some biological differences that may help protect Europeans from HIV disease and others that may increase the risk among people with African ancestry, but these factors seem to be much less important than brutal socioeconomic realities.

It seems likely that poverty and poor access to health care and education contribute to the disproportionate burden if HIV among African Americans.  There is also empirical evidence to back up the idea that blacks' suspicions of the majoritarian medical community contribute to poor treatment and outcomes (cf Tuskegee Syphilis Experiment, forced sterilization, and daily humiliating contacts with the health care establishment).  African Americans, who in general have less access to good health care, suffer from a higher rate of other sexually transmitted diseases, and having an STD increases likelihood of HIV transmission.

Studies have shown that culturally sensitive educations programs aimed at adolescents and young adults may decrease risky sexual behaviors.  Reducing risk of transmission is vital, but so is  testing.  The high rates people infected who don't know their status is terrifying.  How to we get people to find out their status? One study of black men living in urban areas found that having a test recommended by a primary care doctor was strongly correlated with being tested.  It seems obvious that we need to focus efforts (and money) on education (especially sexual education including condom use) and on making primary health care easily available, especially in communities that are hard-hit.  Finding primary care physicians in poor urban areas is challenging, not least because doctors like to get paid for their services.  If patients can't afford care, and the government is unwilling to pay for it, doctors will continue to avoid poor communities.   Given the impact of HIV on men who have sex with men, we must target our entire society---targeting the "gay community" likely misses a large number of people who don't feel a part of that community or have risk factors but don't identify as gay.  The CDC recommends HIV screening for everyone.  We must take this recommendation not just to those of us who have good access to care, but also to the people who do not, and we must give them the tools to deal with a positive test.

As in the rest of the world, HIV is devastating poor and minority communities in the US.  Any HIV policies that don't directly address this will be a public health and humanitarian failure.  HIV is everyone's problem, but some of us suffer the consequences of our failures more than others.

References

Jemmott, L., Jemmott, J., & O'Leary, A. (2007). Effects on Sexual Risk Behavior and STD Rate of Brief HIV/STD Prevention Interventions for African American Women in Primary Care Settings American Journal of Public Health, 97 (6), 1034-1040 DOI: 10.2105/AJPH.2003.020271

DiClemente RJ, Wingood GM, Harrington KF, Lang DL, Davies SL, Hook EW 3rd, Oh MK, Crosby RA, Hertzberg VS, Gordon AB, Hardin JW, Parker S, & Robillard A (2004). Efficacy of an HIV prevention intervention for African American adolescent girls: a randomized controlled trial. JAMA : the journal of the American Medical Association, 292 (2), 171-9 PMID: 15249566

Petroll, A., DiFranceisco, W., McAuliffe, T., Seal, D., Kelly, J., & Pinkerton, S. (2008). HIV Testing Rates, Testing Locations, and Healthcare Utilization among Urban African-American Men Journal of Urban Health, 86 (1), 119-131 DOI: 10.1007/s11524-008-9339-y

Bogart, L., Wagner, G., Galvan, F., & Banks, D. (2009). Conspiracy Beliefs About HIV Are Related to Antiretroviral Treatment Nonadherence Among African American Men With HIV JAIDS Journal of Acquired Immune Deficiency Syndromes DOI: 10.1097/QAI.0b013e3181c57dbc

Romer, D., Sznitman, S., DiClemente, R., Salazar, L., Vanable, P., Carey, M., Hennessy, M., Brown, L., Valois, R., Stanton, B., Fortune, T., & Juzang, I. (2009). Mass Media as an HIV-Prevention Strategy: Using Culturally Sensitive Messages to Reduce HIV-Associated Sexual Behavior of At-Risk African American Youth American Journal of Public Health, 99 (12), 2150-2159 DOI: 10.2105/AJPH.2008.155036

Centers for Disease Control and Prevention (CDC) (2010). Prevalence and awareness of HIV infection among men who have sex with men --- 21 cities, United States, 2008. MMWR. Morbidity and mortality weekly report, 59 (37), 1201-7 PMID: 20864920

10 responses so far