Denialism Blog

As a physician, I have a lot of politically conservative colleagues. Much of this stems from our experience with the government. The influence of Medicare helps set prices, which we are not at liberty to change, and affects how we practice. On the other hand, Medicare is usually pretty good at paying its bills—except when it doesn’t. If our costs go up, say in increased rent, we can’t raise our prices. And if we get together with a group of doctors to try to negotiate fees, it can be considered collusion, and as such, illegal. So we’re in a bind.

On the other hand, the current system of multiple payers causes no end of headaches and paperwork. A single payer system could reduce costs through having us deal with a single entity. But Medicare is also subject to the whims of politics, as when earlier this year, Medicare held onto all physician payments while Congress and the President negotiated a new Medicare fee structure. This had a real world impact of making it hard to pay our bills.

But this isn’t about the advantages and disadvantages of a single payer system—neither candidate is proposing such a thing. This is about the disaster the McCain plan would wreak on all of us.
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I’ve written quite a bit about diabetes here and at my old blog, and I’ve explained to you how controlling blood pressure and cholesterol in diabetics prevents macrovascular disease, such as heart attack and stroke. I’ve also explained how controlling blood sugar prevents microvascular disease such as kidney failure and blindness. In type II diabetics, controlling blood sugar prevents disability and sometimes death. In type I diabetics, controlling diabetes with insulin is the only way to prevent a swift and painful death. Most non-diabetics, however, don’t know the details of how we control blood sugar.

Let’s take an example. A typical type I diabetic, who is completely dependent on insulin, will take a long acting (basal) insulin to keep glucose levels down between meals, and will also take a short acting insulin at meals to account for the extra glucose load. In order to know how much short-acting insulin to take, a diabetic has to insert a test strip into their glucometer, prick their finger with a small needle, and touch the drop of blood to the test strip. This is usually done (at least) on waking, before every meal, and at bedtime—at least four times per day. Thankfully, blood glucose monitors are quite inexpensive and last a long time. Test strips, however, are expensive and disposable. How expensive? Depending on the brand of meter being used, and how many times you need to test, $30-$200 per month. These strips are usually not covered by insurance.

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Yesterday, we looked at how real science works; today, in a repost from my old blog, we look at some really bad science. –PalMD

I’ve been meaning to touch on “Morgellons disease” (a form of delusional parasitosis) for a while, but haven’t figured out how to approach it. Thankfully, others have. In the first referenced discussion, a paper was cited. This paper was such a great example of how not to approach medical science that I just had to address it in detail, section by section…

Background

The authors argue for a newly described illness which they call “Morgellons”. It resembles in all ways except name delusional parasitosis, a condition where a person is falsely convinced that they have parasites in their skin. In general, if you wish to describe a possible new illness, you should start by coming up with a useful operational definition. This doesn’t happen. Instead we get anecdotes.

It begins with a single practitioner’s experiences. It’s hard to overstate how problematic this is. Early in the HIV epidemic, solo practitioners in a few cities found unusual diseases, communicated with each other, and discovered the AIDS epidemic—the difference was that the discovered real diseases with shared characteristics.

This physician saw some patients who shared similar characteristics, and, rather than picking the most likely diagnosis, went straight for the zebra. A more apt metaphor might be a unicorn—she made her diagnosis based on a “research foundation” devoted to an illness made up out of whole cloth.

History

The next mistake is in linking the new “disease” with an account from a 17th century observer. The observations are old, non-specific, and based on no current medical science. He described an odd constellation of symptoms, and the Morgellons Movement adopted it. There is no way to validate 400 year old observations.

After co-opting a 400 year-old name, one of the authors started a foundation which “began accepting registrations from people with symptoms of this unrecognized disease.” They lay out no clear case definition, and change the characteristics of the disease to fit the patient. “…[I]t soon became evident that other symptoms within this patient group, such as disabling fatigue, life-altering cognitive decline, joint pain, and mood disorders…” sometimes accompanied the skin symptoms. Shifting the goalposts in order to make your case definition more inclusive is not great science.

Symptoms

This section of the paper is devoted to a long list of symptoms which once again fails to give a case definition. In this paper, which purports to report an important emerging disease, it is disturbing that half-way through the paper, no disease has yet been defined. Perhaps one of the worst sins of this section is the confusion of correlation and causation based on a false premise. The authors assume (or beg the question) that Morgellons exists. Based on that assumption they assert that:

[t]he high incidence of psychopathology, which appears to be directly attributable to this disease, confounds the clinical picture for these patients as the seek validation for an insidious dermatologic condition that defies logic, while sometimes exhibiting obvious symptoms of mental illness.

Might they have put the cart before the, er, unicorn? If someone acts mentally ill, and has a bizarre set of illogical symptoms, why not put the blame where it belongs? To take a disease of the mind, and simply assert that it is a disease of the body, will help no one.

The next assertion is truly horrible. “It appears that the putative underlying infectious disease, which has been unrecognized and untreated, can cause psychopathology in many patients.”

Holy crap! Now it’s an infectious disease?!? Based on what? And it’s an infectious disease that affects the skin and central nervous system? Maybe it’s a variant of syphilis! How can these few clinicians (OK, only one is a clinician) have stumbled onto something so important and end up ignored?

Epidemiology and Transmission

OK…time for more unfounded assertions. “The total number of registrations on the Morgellons Research Foundation website is presently 2200, which is believed to be a fraction of the actual number of cases.” Believed by whom?

Then of course they run into the same problem they’ve had from the beginning: “There is some evidence to suggest that skin lesions and fibers may not be readily apparent in all individuals with this disease… .” Then what defines the disease? How does one track the epidemiology of a disease with a name and no definition?

Pathophysiology

And here is the real coup de grace.

Skin biopsies of patients with Morgellons disease typically reveal nonspecific pathology or an inflammatory process with no observable pathogens…In general, pathologists look for signs of known diseases and, thus, may miss clues of Morgellons disease in biopsies.

OK. I can’t go on. It’s not just that a mainstream journal would publish such crap. It’s that it makes my head hurt. But I will form a logical hypothesis that my headache has something to do with reading, sitting at the computer, and being frustrated. It seems unreasonable to posit that it is due to some unknown infectious agent that can be neither measured nor defined.

In the discussion section of the paper, the authors invoke Vienese physician Ignaz Semmelweis, a physician criticized as a crank in his own time, but later lauded as a hero. Robert Park said, “to wear the mantle of Galileo it is not enough that you be persecuted by an unkind establishment, you must also be right.” This paper is not right—it’s not even wrong.

References

Savely, V., Leitao, M. (2006). The Mystery of Morgellons Disease: Infection or Delusion?. American Journal of Clinical Dermatology, 7(1), 1-5.

In my earlier post about HIV therapy (a post I strongly recommend), I wrote, “After entering a cell (never mind how for now), HIV needs to find a way to makes copies of itself, which requires DNA.” Because of some recently released data, it’s time to look at how HIV enters the cell, and to expand a bit on the biology of HIV infection (but this is really a “Part II” so please refer to the above-linked post, even though this should stand on its own). This will also allow us another glimpse into how real science works. proceeding from observation, though hypothesis, and hypothesis testing.

Once again, as in all of my science-y posts, please forgive any oversimplification.

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As I continue to fight the good fight against my first respiratory infection of the season, I will serve you a few portions of learnin’ from the old blog. –PalMD

Cupping goes back millennia. In the U.S., the marks of cupping are often seen in immigrant communities, particularly those from Southeast Asia, and are often mis-identified as signs of abuse.

It’s an interesting practice, with many different explanations, depending on the culture. It’s often used to do the cultural equivalent of drawing out “ill humors”. Of course, there is no scientific basis for this. Historically it is interesting. At least, one would hope the interest were purely historic. Unfortunately, that’s not the case. Despite that fact that cupping is based on ancient, invalid ideas about health and disease, it is popular in cult medicine circles.

Take, for instance, this website.

Cupping therapy has been further developed as a means to open the ‘Meridians’ of the body. Meridians are the conduits in the body through which energy flows to every part of the body and through every organ and tissue. There are five meridians on the back that, when opened, allow invigorating energy to travel the whole length of the body. It has been found that cupping is probably the best way of opening those meridians.

Could someone please show me a meridian? If they truly “transport energy” it should be reasonably easy to find one.

Cupping has also been found to affect the body up to four inches into the tissues, causing tissues to release toxins, activate the lymphatic system, clear colon blockages, help activate and clear the veins, arteries and capillaries, activate the skin, clear stretch marks and improve varicose veins. Cupping is the best deep tissue massage available. Cupping, the technique, is very useful and very safe and can be easily learned and incorporated into your family health practices.

I actually like to see evidence of any of that. Colon?!? I never thought I’d see a connection between cupping and poo woo, but then, the cultists seem to be obsessed with the colon.

Cupping is an ancient medical technique based on pre-scientific understandings of human health. When you don’t have much to offer in the face of death and disease, you might naturally develop your own ideas about how the body works, and how to affect change.

Thankfully, we are no longer in a pre-scientific era. Most of us do not think its better to live in grass huts, hunt and eat disease ridden carcasses, and drink unsafe water. What is it about medicine that attracts such idiocy? Alternative medicine? What about alternative flying? Alternative physics? Alternative engineering?

References:

Journal of Pediatric Health Care. Volume 18, Issue 3, May-June 2004, Pages 123-129. DOI:10.1016/j.pedhc.2003.11.004.

As I continue to fight the good fight against my first respiratory infection of the season, I will serve you a few portions of learnin’ from the old blog. –PalMD

We’ve spoken a bit lately of the micro- and macrovascular complications of diabetes. Let’s see what that means in real life. One of the most devastating complications of diabetes is amputation, which is often due to the microvascular complication of peripheral neuropathy. This can begin as a tingling, burning pain in the feet, but can lead to loss of sensation. Small injuries can rapidly become limb-threatening…(Warning: Yucky picture under the fold)
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