Category: Medicine

  • Syphilis!

    Southeast Michigan’s Genesee county is experiencing an outbreak of syphilis. The largest city in the county is Flint, made (in)famous in Michael Moore’s film Roger and Me.

    Syphilis is a nasty sexually transmitted disease with an interesting history. It may have originated in the New World. It was the subject of the infamous “Tuskegee Experiment”. It has enough different symptoms that it is sometimes called “the great imitator”.

    In 2007 there were 15 reported cases in the county; so far in 2008, there are 33. According to the county health department:

    Certain risk behaviors that increase the likelihood of contracting syphilis have been associated with this outbreak. These include having unprotected sex with multiple partners and participating in the exchange of sex for drugs or money. Transmission of syphilis is also being seen among men who have sex with men in Genesee County.

    About 13% of the county’s population is below the poverty line, and in Flint the number is over 26 percent. This is not a coincidence.

    As Michigan’s economy has continued to circle the drain, educational and health care systems have be strained and broken. Without access to information, jobs, and hope, STDs flourish.

    I received the notification in an email with the presumption that the outbreak is headed my way. As Michigan continues to suffer, we’ll see what walks in the door here. I’ll let you know.

  • Homeopathy Awareness Week?

    Skepchick has apparently discovered that, as of yesterday, this is World Homeopathy Awareness Week. (Yes, starts on a Thursday…they were going to start on Monday, but the succussion took a while.)

    Well, I can get behind a public service like this. My contribution will be a side-to-side comparison of a homeopathic treatment and a real one. Let’s pick a fun disease, say, heart attacks (the website I found offered homeopathic remedies for anthrax, but I think I’ll skip that).

    Unfortunately, this will require a brief tutorial on myocardial infarctions (MIs, heart attatcks). As is usual with my medical posts, this will be a gross oversimplification, but good enough to explain the issue.

    An MI occurs when part of your heart muscle stops receiving enough oxygenated blood. There are a variety of possible ways for this to happen, but most of the time we are talking about a typical acute MI, where a specific artery becomes suddenly occluded. When this happens, a person usually experiences chest pain, and, if the heart attack is serious enough, heart failure, arrhythmias, and death.

    Over the last couple of decades we’ve figured out how to interrupt the natural history of MIs. Clot-dissolving medications or angioplasty can be used to quickly open up an artery, hopefully saving the heart muscle from death. In addition, several medications can be used to help save lives. Beta-blockers, aspirin, angiotensin-converting enzyme inhibitors and statins have all been proved to help in an acute MI or to prevent further MIs. The literature to support these practices is quite voluminous but just to give you a sampling, see the references below.

    Now let’s examine the homeopath’s guide to heart attacks…
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  • Bill Maher is a crank

    I must admit I have a love-hate relationship with Bill Maher. He is a funny guy, he is good at mocking some of the more ludicrous aspects of politics, and he has been an effective critic of this administration and some of its more egregious policies.

    However, I’ve also long held the position that both liberals and conservatives alike must own up to their own extremists. Liberals must own up to the fact that they don’t have a universally-solid grasp on scientific truth, and just like the right wingers, we have people and movements within the left wing that are cranky and denialist. I would say left wing crankery includes animal rights extremism, altie/new age woo, and anti-technology Luddites.

    Bill Maher is one of these cranks (he scores 3/3), and if the liberals want to represent themselves as truly pro-science we must make a concerted effort to reject the unscientific beliefs of these crackpots. We must call out Bill Maher on his BS (we have before as has Orac), and call him a crank for his unscientific, and frankly insane beliefs about medicine, disease, “toxins” and health.

    As PAL has already pointed out and I wholeheartedly agree, Bill Maher made an outrageous statement Friday night on his show Real Time. In an interview with Arlen Specter, who’s life was saved by medical science, he said:

    Because President Bush actually brings up a good point, because you can’t catch cancer, but people in this country treat it like you can. What you do is you hatch cancer by human behavior. Most cancer, there is of course some genetic cancer, but most of it is by behavior…

    But doesn’t that tell you something about our system, why do you have so much faith in Western medicine when they get it so wrong, when the third-leading cause of death in this country the health care system itself. Isn’t the paradigm wrong?

    Where to begin with such a pair of despicable statements? For one, this is a classic crank attack on medicine, using the IOM report, as PAL mentioned, to attack medicine ironically in the midst of one of its attempts to be self-correcting. The misunderstanding that anti-medicine cranks are exploiting in this report are that the overwhelming majority of “mistakes” in that report were things like failure to rescue (failing to recognize when a patient starts circling the drain) and hospital acquired problems like decubitus ulcers and nosocomial infection. What does that mean? That means the failure of medicine that the IOM is being critical of reflect failures to save the lives of people that are critically, critically ill. These are failures in saving people from death. These are mistakes in a population that are actively dying (failure to rescue), or so sick that they are unable to even move under their own power (decubitus ulcer), or immune compromised enough that they can’t defend against infections (nosocomial infections). These mistakes are a problem, and I don’t seek to diminish the importance of finding ways to avoid them. The IOM report represents the efforts of medicine to correct preventable failures in medical care that are very serious, and we’ve spent the last decade trying to resolve (we will likely spend many more). For example the recent War Games video I posted was an example of attempts to train medstudents and interns how to recognize and deal with rescue situations more quickly and effectively.

    But Bill Maher makes it sound like doctors are stalking healthy people in the streets and beating them to death with ball-peen hammers. You don’t go into your doctor’s office for a routine visit and acquire a c. difficile infection or MRSA or decubitus ulcers or a “failure to rescue” mistake. We’re talking about very sick people who often wouldn’t be alive in the first place without medical intervention, who doctors, albeit for some preventable reason, are failing to keep alive or inadvertently make worse. That doesn’t stop Maher from making it sound like we’re running people down in the parking lot, and I don’t appreciate the implication that doctors who sacrifice so much time and effort saving lives are heedlessly killing people.

    Further it is exceptionally ignorant for ignoring the incredible net contribution of medicine to extending and improving life. Why do we live longer on average than any generation in human history? Childbirth no longer represents a major threat to a woman’s life. Children don’t die from ordinary illnesses and infections. Major traumas like gunshots, fractures and massive blood loss no longer are an instant death sentence – we often can put people right back together after amazing injuries. How have we managed to cure diseases like polio, or cure Senator Specter’s Hodgkin’s lymphoma? Evidence-based medicine and the applied science of modern medical care is the answer to all those questions. No magic crystal, acupuncturists needle, or diluted tincture has accomplished these feats.

    Bill Maher is a Luddite, who has tried to blame the death of bees on cell phones has engaged in anti-vaccine wingnuttery, routinely complains of mysterious “toxins”, supports animal rights extremists, and generally has a disgusting “blame-the-victim” mentality towards health. Lung cancer may be a largely self-inflicted illness, but the other big cancer killers? Breast cancer? Prostate cancer? Pancreatic and colorectal cancers? Each may have a small environmental component, but most cancers aside from those caused by cigarettes have much more minor contributions from lifestyle and environment. That is not to say these contributions do not exist, but compared to cigarettes the relative risks of misbehavior are astronomically smaller. Most of these cancers have overwhelmingly genetic risk factors and the number one risk factor is almost always family history. Maher’s statement that cancers are “hatched” or that there is only “some” genetic component is typical of his ignorance of medicine, his blame-the-victim mentality towards disease, and is just as despicable as his depiction of medicine as a killer.

    Liberals have to own up to the fact that they have cranks in their midst as well. Bill Maher is the left-wing version of Dinesh D’Souza or Jerry Falwell. His views on science are no more elevated, and when in conflict with his ideology, no less hateful towards science, or the people he disagrees with.

  • The message and the messenger

    ResearchBlogging.orgI’m not sure what to make of this. An article in the latest Journal of the American Medical Association (JAMA) reports some potentially good news for type II diabetics. Type II diabetes has been extensively studied (detailed post to follow), and one area of difficulty has been reducing the incidence of macrovascular disease (heart attack and stroke, primarily). Treating blood pressure and cholesterol aggressively in diabetics helps, but controlling blood sugars closely doesn’t seem to help with these particular sequelae of diabetes.

    Further complicating the picture was some data released last year about rosigitizone (Avandia), an oral diabetic drug. This showed possible increased cardiac mortality with the use of this medication, although the numbers weren’t too convincing.

    So, the new article reports on pioglitizone (Actos), a close relative of Avandia. The data seem to indicate that, versus another type of oral diabetes medication, Actos reduced incidence of death, heart attack, and stroke.

    Hmmm. Dr. Steve Nissen, who has always been out front in denouncing potentially dangerous drugs was a lead author on this study. He was also very noisy about the harm of Avandia.

    It just seems like an odd coincidence that he should be out front decrying the (possible) harm of one drug, and then be the lead author of a study supporting the use of its main competitor. Nissen has an excellent reputation, so nefarious motives are probably out. But it does show that who says something can be almost as important as what is said.

    Nissen, S.E., Nicholls, S.J., Wolski, K., Nesto, R., Kupfer, S., Perez, A., Jure, H., De Larochelliere, R., Staniloae, C.S., Mavromatis, K., Saw, J., Hu, B., Lincoff, A.M., Tuzcu, E.M. (2008). Comparison of Pioglitazone vs Glimepiride on Progression of Coronary Atherosclerosis in Patients With Type 2 Diabetes: The PERISCOPE Randomized Controlled Trial. JAMA: The Journal of the American Medical Association, 299(13), 1561-1573. DOI: 10.1001/jama.299.13.1561

  • I love bacon

    Blogging on Peer-Reviewed ResearchA reader, who happens to write one of the best-named blogs on teh tubes, pointed me toward an article I never would have seen. This parallels a news story we had here in the States late last year. So, since the story is getting press overseas (albeit late), it’s time to dust off the old post and update it a bit.

    The story repeats the finding that processed meats increase the risk of colon cancer. This news comes from a large report published by the World Cancer Research Fund, which looks at data surrounding diet and cancer. It states that there is no safe level of processed meat consumption when it comes to colorectal cancer risk. It’s going to take a long time to parse through all the data, but since I love my processed meat, I’ll start there, and once again, my scientist colleagues will please forgive me for oversimplifying.

    First, this is a huge report, pooling tons of data. One of the most important conclusions is regarding obesity and cancer risk, but that will have to wait until later.

    Per USAToday, “every 1.7 ounces of processed meat consumed a day increases the risk of colorectal cancer by 21%.” Per the Daily Mail, “[e]ating just one sausage a day raises your cancer risk by 20 per cent.” What does that mean? “Risk” is a complicated concept in medicine. It is easy to draw overbroad conclusions from bits of data. When risk is measured, it is rarely intuitive–small percentages can indicate large increases in risk, large numbers can refer to small increases in risk–it depends quite a bit on the base line incidence and prevalence of the disease. A 50% increase in a disease sounds big, but in the right situation it can be big or small. For example, if your “usual” risk of disease A is 2/100, then a 50% increase makes your risk 4 in 100, meaning out of 100 people, 2 more get the disease then they would without the extra risk. If the “usual” risk is 10/100, then a 50% increase means 5 more people get the disease.

    I hope you haven’t given up on me here. Keep reading…trust me…

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  • Hey! Look! Science works! Zetia, not so much.

    ResearchBlogging.orgI love this story because it shows how evidence-based medicine works, even in the face of corporate greed.

    A while back I told you about a cholesterol study with negative results; that is, it failed to show a drug to be helpful. Intimately entwined with the study design was a potential conflict of interest on the part of the drug company, but science won out—data, after all, is data.

    Then, few months ago, another set of (preliminary) cholesterol data was released by Merck and Schering-Plough, after much prodding, regarding their drugs Vytorin and Zetia.

    Zetia has been quite popular. A certain number of patients do not tolerate “statin” cholesterol medicines, and are put on Zetia as an alternative. Zetia lowers cholesterol, but it has never been shown to improve important outcomes such as mortality, heart attack, stroke. That isn’t to say it might not do these things, it just hadn’t been studied. Statin cholesterol drugs have been studied, and have an excellent effect on outcomes.

    Now, interesting new data is emerging. First, according to a study in the New England Journal of Medicine (NEJM) the companies’ marketing campaign appears to be working, at least in North America. Prescribing patterns have changed, with an increase in Zetia prescribing and in costs.

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  • Cell Phones and Cancer – Scaremongering from the Independent

    The Independent has yet another hysterical article about the potential link between cell phones and brain cancer. And I’ve been asked, what are we seeing here? Is this the early reporting of a potential public health threat? Or is it just more nonsense from a newspaper that wouldn’t know good science if it sat on it’s head? Both Ben Goldacre and I have felt the need to take on some piece of nonsense from the Independent, and their previous writing on “electrosmog”, a repeatedly disproven piece of crankery, diminishes their credibility on this issue.

    And guess what else diminishes their credibility here? Only about every single aspect of this article. For one they start out with an irresponsible claim about the risks of cell-phone use that I won’t bother to repeat since it will just reinforce an unproven statement.

    Second, where is this study? I looked for it. I searched for the author’s name in pubmed, and while he’s well-published, there’s nothing about cell phones.

    Yet they claim the study has been published:

    The study, by Dr Vini Khurana, is the most devastating indictment yet published of the health risks.

    But then we find out that this study isn’t “published”, the results are just on a “brain surgery website”. After a little more digging I found it here published on Dr. Khurana’s webpage. Just a little reminder for the Independent, putting a paper on a webpage does not make it “published” in a fashion equivalent to publication in a scientific journal, and they would do well to correct this in their article. I know they won’t because I’ve noted a total lack of journalistic responsibility in their science coverage, but one can dream. Then I see this:

    Professor Khurana – a top neurosurgeon who has received 14 awards over the past 16 years, has published more than three dozen scientific papers – reviewed more than 100 studies on the effects of mobile phones. He has put the results on a brain surgery website, and a paper based on the research is currently being peer-reviewed for publication in a scientific journal.

    Currently being peer-reviewed? This means this paper is unpublished and merely submitted for review. Further, it’s a very strange move to take a paper that is being considered for publication to put it into the public domain. This means that it’s either been rejected from wherever was supposed to take it, or the author doesn’t realize this will likely sabotage its chances of being published. I simply don’t understand this move. Dr. Khurana appears to be a legitimate scientist, but that doesn’t make this any less inappropriate a method of publishing such a result. Since he hasn’t gone through proper peer-review channels before making this article available I think this means it’s fair game for me to criticize, and there’s plenty of room for that.

    For one, he has an entire section on “Popular Press and the Internet” which consists of anecdotal reports of cancer clusters in the press, crank websites repeating false claims about cell phones and second-hand reporting on scientific articles. This is hardly a scientific approach to epidemiology or risk assessment, and should be dismissed out of hand as unworthy of discussion in a scientific paper. A review of the literature does not include citations of “www.EMF-Health.com”, no kidding, this is one of the sources he mentions. A website that sells the Q-link, a quack remedy for a nonexistent malady!

    Then I see this statement:

    In other words, if cell phones interfere with aircraft and hospital electrical equipment (even at quite a distance), how can it be that they don’t interfere with the electrical equipment of the head (i.e., the brain, when held for extended periods of time right next to this
    organ)?

    Who’s done with this guy now? Do you even have to go on after a statement so absurd? This reflects a fundamental misunderstanding of physics and biology and a terrible argument from analogy. It’s an especially bad analogy as the evidence seems to be that cell phones have no effect on plane equipment to the point the FAA has long considered dropping the ban. Finally there is very little physical basis for a carcinogenic link between these radiofrequencies and cancer, so what would be the mechanism? The EM bands used by cell phones are non-ionizing, and do not have a physically plausible mechanism for causing cancer.

    So far we only a couple pages in, have incredibly questionable sourcing and a terrible argument from analogy, l’ve already dismissed this as unworthy of consideration, should we bother to keep going? Ok, maybe a little further.
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  • Sexually transmitted diseases—they're successful, we're not

    Sexually transmitted diseases (STDs) are frighteningly common, as highlighted by a study released by the CDC earlier this month. The U.S. is in a unique position: few countries have the resources we do to prevent and treat STDs, and few countries squander such resources so effectively.

    Let me give you a brief front-line perspective.

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  • Some skills in medicine are harder to teach

    Teaching facts is easy. Medical students eat facts like Cheetos, and regurgitate them like…well, use your imagination. Ask them the details of the Krebs cycle, they deliver. Ask them the attachments of the extensor pollicis brevis, and they’re likely to describe the entire hand to you. Facts, and the learning of them, has traditionally been the focus of the first two years of medical school. The second two years deals with putting facts into action. Teaching medical students and residents is very different from being a school teacher, something with which I have first-hand knowledge and experience. Fetal doctors want to learn…they’re too scared not to. In general, give a med student a book, and she’ll read three, and write a paper before you see her again. But some things in medicine are harder to teach.

    Medical education in America underwent a revolution at the beginning of the 20th century, when texts were written, schools formed, and methods standardized. Now, 20 some-odd years into the evidence-based medicine revolution, medical education is improving once again.

    MarkH describes a method being tested to teach doctors to think under pressure. The big difference between this and the way these things have traditionally been done is that people are measuring them. They are forming hypotheses about learning and testing them. And it’s about damned time.

    My current teaching responsibilities are primarily those of teaching nascent internists how to practice their profession. The facts are (usually) there, but the judgment is not. This is also a field ready for evidence-based evaluation, but some things really do require repetition and mentoring.

    I supervise residents at an outpatient clinic. They see their own patients, and they see patients who either walk in or make appointments for immediate problems. Treating patients you know is one thing—treating a complete stranger is another.

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  • War Games!

    One of the problems with medical education is that while you are intellectually trained to deal with medical problems and emergencies, actual experience with how to respond to emergent clinical situations is difficult to teach and usually only comes with experience. Further, real clinical experts make medical decisions almost by reflex. You see this in medical school that while you as a medical student have to actively think about what is going on in any given situation, medical experts act more by pattern recognition and have an instant reflexive response to clinical situations. And how do you teach reflexes?

    Here at UVA, Jeff Young, a trauma surgeon and researcher in clinical decision making has published on a new strategy of assessing and improving the response of doctors in training to high-risk medical situations. His strategy is rather than stressing cognitive experience, which much of medical school and resident training emphasizes, the goal is to build reflexive responses to critical situations. In an emergency, the ability to generate differential diagnoses and recall complex information is secondary to knowing how to acutely assess patients, resuscitate and stabilize them. Clinical experts do this without even thinking about it. Young’s goal is to train medical students, interns and residents by simulation of critical care situations so that when they end up involved in charge of a critical patient they will reflexively perform the correct actions to resuscitate and stabilize patients. After all, practice makes perfect.

    The result is what Dr. Young calls “War Games” – simulations in which students and residents are drilled in their responses to medical emergencies. By putting students under some stress and making them think fast about critical care, reflexive responses to emergent situations are drilled into the subjects, and hopefully when the situations are encountered in real life they’ll know what to do without even thinking about it.

    So enough talking about it. Here’s what one looks like – me being drilled by the chief resident on a patient presenting with hypotension.

    You notice that rather than going for diagnosis the goal is to start with the basics. First you evaluate the airway, breathing, and circulatory status, resuscitate the patient as necessary, gain IV access, get basic vitals and check tests. Only after you’ve stabilized a patient should you start thinking about what the exact diagnosis is, whether you need to operate etc. It also emphasizes things you don’t necessarily learn in class, like the need to call the attending when some disaster has occurred. It seems like things like this should be obvious (they probably are to EMTs and paramedics), but the reality is that these kinds of practical skills are difficult to relate in a classroom setting. You also quickly realize that when you are under pressure, it’s completely different from all those sessions you remember from 2nd year where you sat around thinking about differential diagnosis with 5 other people in the room. I clearly screw up a few times during the simulation, but hey, that’s why I’m in training and why I appreciate these sessions.

    This also demonstrates something I think we can appreciate about evidence-based medicine. Not only do we emphasize a scientific basis for the treatments we use, but we also actively use science to figure out the best ways to train doctors to be better clinicians. I found this strategy to be incredibly useful, and I hope other medical schools around the country also adopt War Games to help train their students to be better docs.