HIV denial making a comeback

According to the June Nature Medicine, Dr. Matthias Wrath is promoting the misguided notion that vitamin supplements are superior to antiretroviral medicines in treating HIV and AIDS. Conveniently, he also sells a line of vitamin supplements.

He bases his work on a legitimate study showing vitamin supplementation did slow HIV progression, but doesn’t mention that the researchers who conducted that study see vitamins as a adjunct, not a replacement for antiretrovirals.

The efficacy of antiretroviral therapy in patients with HIV and AIDS is nothing short of amazing. Many people, including myself, no someone who was hospitalized, seemingly near death from AIDS and is now living a near normal life. But does that stop the quacks? Nope.

I think we can lump these folks with creationists as not responsive to evidence. It would be bad enough if these were isolated idiots running around, but they’ve made inroads into African health officials such as the South African health minister who, according to the article, recommends

raw garlic and the skin of a lemon, not only do they give you a beautiful face, but they also protect you from disease

An accompanying article notes the equally troubling resurgence of those who doubt HIV causes AIDS.

Book Reviews

Here are brief reviews of the books I read while on vacation

Harry Potter and the Sorcerer’s Stone, Harry Potter and the Chamber of Secrets- I deliberately held off reading these until my son Colin was old enough to read them so we could talk about them. Suddenly he is finishing up the fifth one and eagerly awaiting #6! How time flies. Anyway these are both really good. JK Rowling uses language well and the books are exciting, and rich, but without much extraneous detail (so much so you worry about every new character, since something bad will probably happen to them). While obviously fantastic, the stories are not so outrageous as to be beyond belief once you accept the premise of a secret society of "magic" people. I got #3 from the library yesterday. Highly recommended.

Swimming to Antarctica. This book tells of multiple long-distance, cold-water swims undertaken by the author, Lynne Cox. The book is okay, but a bit repetitive: in each swim she worries she won’t make it but calms her mind and picks up her pace to finish. These kind of achievements require a lot of dedication and focus, and it shows. It is all about the author and her swims. Other swimmers and those around her are noted only as they pertain to her swims. This book isn’t horrible, but I didn’t get much out of it either. I suspect those not particularly interested in endurance would get even less

Shadow Divers: The story of divers who found a German U-boat (WWII vintage German submarine)off the coast of New Jersey and their quest to identify it. The two main divers told their story to a writer who wrote the book, which works well. I learned a lot about both SCUBA diving (very dangerous in deep water and around shipwrecks) and U-boats. I don’t have particular interest in either, but enjoyed the book tremendously. Highly recommended.

Shoeless running

I'm sorry but this "article" is mostly a press release from Nike:

Surprisingly, even Nike now sees the sense of running "shoeless." Just one year after releasing its most structured shoe ever - the Air Max 2004, with airbags and a motion-control footbridge - the company has switched tack by offering the Nike Free 5.0, a shoe it claims will "re-evolutionize" running by enabling people to run as if they were barefoot. With its gauzy heel, stockinglike upper, and thin sole, the Free 5.0 looks more like a slipper than a sneaker.

I'm shocked to find that scientists employed by Nike feel running in less supportive shoes may be helpful at THE VERY SAME TIME Nike is bringing just such a shoe to market. Who would of thought?

And Nike consultants and Nike sponsored athletes thing the shoe is great! The wonders never cease.

Seriously this idea seems plausible. I know that the Inov8 shoes, which are relatively minimalist for trail shoes are very popular among ultrarunners. I myself have found all the talk of straight and curved lasts, motion control vs. stability etc. is not much use to me. I can run in a wide variety of shoes without problems. I am a bit skeptical of the Nike Free for trails just because I think you need some protection from rocks

Ten Commandments

I know I've vowed to stick to what I know, but I just can't help it:

A fractured Supreme Court on Monday, struggling to define a constitutional framework for the government display of religious symbols, upheld a six-foot-high Ten Commandments monument on the grounds of the Texas Capitol while ruling that framed copies of the Commandments on the walls of two Kentucky courthouses were unconstitutional.

Is this really the best use of our highest courts time? To dissect out tiny differences between displays of the Ten Commandments to decide which are and are not legal? If the decision is such a fine thing, couldn't someone else, like say legislators elected by citizens make these distinctions?

I'm Back

I'm back from vacation, so usual rate of posting should resume.

We had a great time in the Santa Cruz area, including 2 great runs and a hike in the Forest of Nisene Marks State Park which has lovely paths and beautiful redwoods, mostly second growth, but a few big, first growth trees. We also visited Big Basin Redwoods Park, which was also nice, but a bit of a drive from where we were staying (my kids are prone to car sickness but did well).

We also visited the beyond category Monterey Bay Aquarium. It is a truly awesome place to visit, for kids and adults. I really enjoyed that as did my kids. Next time we'll plan on two full days.

I finished three books, waded in the ocean, found sea shells, ate good food (too much), drank good wine and played volleyball and croquet before heading off to Auburn for my stint as doctor/pacer at Western States.

Western States Doc

Saturday, I spent most of the day as "medical director" of the Foresthill aid station at mile 62 of the Western States 100 Mile Endurance Run (I always wonder why they put "endurance" in the title, as if there could be a 100 mile sprint). I showed up just as they were setting up the aid station, the first medical person to arrive.

Luckily, a bit later some more help arrived, including 2 ED nurses, who had a number of years experience at this and other ultras, thereby knowing much, much more than me about what to do and expect.

I had made a list of all the really bad things that we could see (syncope, seizure, mental status changes, chest pain, respiratory distress, etc) and what we should do about each. Luckily the list was unnecessary. The temperatures were relatively cool (highs maybe in the upper 80s, 15-20 degrees cooler than typical) so runners did well. We didn't start a single IV and had to have very few people sit and rehydrate.

Runners are weighed the day before the race and then at various aid stations. For 3-5% weight loss they are encouraged to drink more, from 5-7% they have to drink more before leaving and for 7+% they must drink and regain weight over 20-30 minutes before leaving.

We had several runners who came in >5% down, sat, drank, rested and were able to continue and finish. There were a couple who just couldn’t keep fluid down and had to drop.

Mostly we just checked weights and encouraged the runners to keep eating and drinking. Foresthill is right after the toughest and hottest part of the course, with most runners coming in in the late afternoon or evening, so if they didn’t look too bad we figured they’d do okay.

As it got later, the runners looked less well, but I was glad to watch the final couple of hours at the finish to see that many I thought wouldn’t make it (there is a 30 hour cutoff) actually rallied and finished under the cutoff.

We had two moderately interesting cases. One was a woman with blurry vision. Her husband let me know about her before she showed up, and from his story it sounded like allergies (red eyes, history of allergies, etc) but she didn’t look that allergic when I actually saw her (eyes not really red or puffy). She mentioned corneal edema, as she’d had the same problem at altitude in the past, but had attributed it to contacts then (this time she was wearing glasses).

I told her my impression was that corneal edema was usually only seen at high altitudes (WS elevation profile here) and that she would probably do better as she got lower. She had a bit of blurred vision which she found annoying, but otherwise was running well. Her husband had bought her some Claritin. I don’t know if it helped but she went on to finish sub-24 hours, so I guess she did okay.

The second was a woman who dropped at an earlier aid station “vomiting black.” Someone from that aid station wondered if we’d like to see her and we said yes, the worry being that this was degraded blood. Of course it is rare to vomit broken down blood, usually it is black stool, or melena that we worry about. Blood in vomit is almost always fresh and bright red. She had apparently eaten a lot of red grapes and looked great with stable vital signs so we sent her home (with her husband) to seek medical care if it recurred.

After our station closed at about 11:45, I hightailed it to the 80 mile checkpoint and picked up my runner to pace him in for his first 100 mile finish. Nice job, Gord.

My colleague, Geoff Kurland also finished, overcoming cancer, old age and trouble with the heat on Sunday morning. Nice job, Geoff (Geoff’s book is here)

I was so tired after staying up all night I had to stop on my drive into Reno on Sunday afternoon for a ½ hour nap at a rest stop. After that I felt much better, although I did go to sleep before 8.

Running a 100 miles

My much needed vacation is going great; we have an idyllic house south of Santa Cruz overlooking Monterey Bay. The kids have loved playing in the ocean, althoug it is a bit cold for me. I've had two beautiful runs as well.

Anyway, since many people think I'm crazy for running ultras, I thought I'd post links to two descriptions of my experiences: my first at Umstead in 1998 and my Western States experience 2 years ago.

Here is an incredible story of one person's struggle to finish a 100. Best quote:

By the time you're training for a 100 mile run you just don't have that much in common with mainstream America anymore. There's a certain solace in that.

Diet update

As regular readers of Dr. Andy know, I've embarked on a crazy diet: one day per week I fast, taking in only non-caloric liquids like water and black coffee.

I've been going for about 5 weeks and have lost 8-10 lbs so far in total (this is base weight, not what I way after fasting which is down a few lbs due to water loss). I try to weigh myself every am and the last 3 days I've been in the 202-204 range

I think this is okay, but I've been running and training more (145 miles running in June) and eating better in general, so I'd probably have lost some weight anyway. I am running dramatically stronger and faster, but how much this is training and how much weight loss is hard to know.

The fasting itself is pretty easy. As I've noted the social part is much harder than the physical part. You notice you are hungry, but the hunger itself isn't too bad. But at dinner time it is weird to just sit there and not eat. It is also an effective alarm clock as I'm eager to get up and break the fast.

The one thing that is hard is working the fast day around training. I've noticed that working out the morning of the fast if anything makes me less hungry, but if I do too much, fasting dramatically slows recovery since those glycogen depleted muscles are sitting around not being replenished. The day after, I notice I'm weaker, too, so you have two consecutive days where you can only train gently (the runs post-fast, even after eating a bit, are an adventure and even if I wait until the evening, I still notice I'm not as strong). This could be an increasing problem as I ramp up training, with the goal of a 100 mile race in the fall.

I've read a bunch of crazy fasting sites on the web and some suggest taking vegetable juices to give a few calories to keep you from putting your body in starvation mode and I might experiment with that.

I'm fasting today and it strikes me that this is the perfect diet for those who travel a lot. Unless you are really careful, eating when careful is a ton of unhealthy calories which you don't really enjoy (rushed fast food or airline meals). Fasting just on travel days (or while travelling only) might be really effective.

I'd hate to be this resident:

According to a memo prepared by the Department of Veterans Affairs for members of Congress, the surgical resident contracted TB sometime between June 2003 and June 2004.

After a positive skin test, she was referred to the Boston Public Health TB clinic by Boston Medical Center, but never showed up for her July 2004 appointment for a chest X-ray.

The memo said she first showed symptoms in January, but it is not clear whether she revealed the earlier skin test. Other tests were negative, so she was treated for pneumonia.

The resident then developed a cough and other symptoms in mid-May, and a chest X-ray on June 2 and additional tests revealed infectious TB. No information on how she contracted the disease has been released.

Apparently this resident was walking around with TB for at least a couple weeks and maybe six months. I wonder what those "other tests" were, specifically if they included a chest x-ray.

I predict the "official response" will involve
1. Demonizing the resident
2. A new time-consuming protocol to prevent this exact thing from happening again (doctors with a positive PPD will not be allowed to work until they have a chest x-ray) but won't address the underlying issues that allow things like this to happen (like resident's not having enough time to take care of their health).

One other thing seems odd about this. This resident worked 80 or more hours per week in a hospital, but when she had a positive PPD she was referred to some sort of public health clinic. Why in the world didn't they have her get a chest x-ray at work? Being able to walk down and get it done when she had a few minutes would have greatly increased the chance of her getting it and thereby detecting the TB before she became infectious (or at least a lot sooner). Would you want to take a day off work to go to some TB clinic where you'd probably waste 1/2 a day and risk catching TB? I wouldn't

Vacation

Posting will be light until the end of the month as I am on vacation. I am writing this from the Pittsburgh Airport, where we are waiting for our flight to DFW and then San Jose, CA. We are sharing a house with friends near Santa Cruz and then next weekend I drive to Foresthill for my adventure as medical director of the Foresthill aid station at mile 62 of Western States.

Posting until I return will depend on how much I feel like it and how good internet access is.

Innumeracy

From an AP article on Republican National Committee fundraising:

The Republican National Committee has taken in $52.9 million from January through May, maintaining its strong fundraising despite a ban on six-figure donations. The RNC raised $10.3 million last month alone, it said Friday.

Now since the RNC has raised 52.9 million in 5 months, its average take per month is 52.9/5 or 10.6 million per month. In what way, then is it remarkable or unusual that it raised 10.3 million in May?

By the way, I'm glad to see we've gotten the money out of politics.

Almost done

Well my 15 day inpatient attending stint ended this morning. I am still on call for allergy until tommorow at 5PM at which point I'll have been in the hospital for 19 straight days and on call for nearly 500 straight hours.

Ouch.

Needless to say I'll be ready for my vacation, which starts tomorrow. California, here I come.

What is mental illness

I thought I had already blogged on this, but apparently not. (Blame Blogger! ed.) More likely my screw up).

I think it is a good question what does and doesn't constitute a mental illness. See previous post for my own annoying problems.

In a report released last week, researchers estimated that more than half of Americans would develop mental disorders in their lives, raising questions about where mental health ends and illness begins.

In fact, psychiatrists have no good answer, and the boundary between mental illness and normal mental struggle has become a battle line dividing the profession into two viscerally opposed camps.

On one side are doctors who say that the definition of mental illness should be broad enough to include mild conditions, which can make people miserable and often lead to more severe problems later.

On the other are experts who say that the current definitions should be tightened to ensure that limited resources go to those who need them the most and to preserve the profession's credibility with a public that often scoffs at claims that large numbers of Americans have mental disorders.

I have scoffed myself at attempts to impose diagnostic categories on what I'd consider normal behavior, but this kind of logic is compelling

Dr. Robert Spitzer, a professor of psychiatry at Columbia University and the principal architect of the third edition of the diagnostic manual, wrote in a letter to The Archives of Psychiatry, "Many physical disorders are often transient and mild and may not require treatment (e.g. acute viral infections or low back syndrome). It would be absurd to recognize such conditions only when treatment was indicated."

I'm not sure what the answer is, but it does seem we should focus limited resources on those who are really suffering. But read the article and see what you think.

My own minor mental illness

My previous post regarding what actually constitutes mental illness versus normal variation made me think about one very irritating habit I have: making minor decisions.

This is partially inherited as my family must always analyze every possible scenario before making a decision. I once sent my father into a 2 day funk by pointing out a scenario regarding rental cars and additional drivers by which he could have avoided paying a $10 feel.

Anyway, one reason I bring lunch almost every day is that if I don't I can be nearly paralyzed by indecision. If I know what I want that day I'm okay, but I've occasionally walked around for a half hour trying to decide what restaurant I want to get food from. Very annoying

Unclear on the concept

I enjoyed reading an article recently about how not only does Starbucks sell a lifestyle (cool, hip) not just coffee (most Starbuck's drinkers couldn't choke down real coffee without the mocha, ice, cream, sugar, and whipped cream) but the "non-Starbucks" coffee shops were selling their own alternative lifestyle as well, for contrarians like me who don't like Starbucks either because the coffee tastes like a burnt match (me) or just because (those who insist on getting non-fat triple mochachinos or whatever).

Anyway, I patronize a local non-Starbucks for my afternoon large (sorry, "macho") after making my own at home in the mornings. All I can say is this place is very non-Starbucks with staff who will happily discuss their mental illnesses and are never, never in a hurry. The coffee, however, is excellent.

Today I noticed a sign saying they would no longer accept $20 dollar bills. How stupid is that? The default bill from ATM's is the 20 (at least outside Las Vegas) and they are turning people away. I asked if I could use a $20 today as it is all I have and the guy told me I was fine (maybe because I'm a regular?). He said he just had to be careful in the morning because they had limited change and everyone (I knew he meant all those people with, you know, regular jobs) wanted to pay with $20s. In general, I wouldn't invest in a business which tried to keep you from giving them money.

"Lawmakers Urging Prostate Cancer Screening"

Apparently they're doing such a marvelous job running the country, they need to start giving medical advice:

Chambliss, a Republican, learned he had prostate cancer last summer as part of an annual physical given to members of Congress. He has since had a surgical procedure, and the disease is in remission.

"We're on the road to winning our battle," Chambliss said. "I want to make sure I communicate my story to men all across Georgia and all across the country. It just proves if you have cancer and find out early about it, you can be cured."

Chambliss has plenty of colleagues to help him spread the message. Fellow prostate cancer survivors in the Senate include both Alabama's Republican senators, Richard Shelby and Jeff Sessions, Idaho Republican Mike Crapo and South Dakota Democrat Tim Johnson. Congressmen who were diagnosed with it include Jim Marshall, D-Ga., and Duke Cunningham, R-Calif.

I don't mean to be too snarky about this, it is just that they are all coming out recommending screening at the same time there is a big debate among docs about whether prostate screening in general and PSA in particular are useful or lead to too much workup of people who are either healthy or will die with not from their prostate cancer.

Sessions said screening is an easy procedure that takes only about 10 minutes.

"They draw blood, may check your cholesterol and PSA at the same time," Sessions said. "If that comes back positive, they can do a biopsy that will confirm the PSA."

No mention of the digital rectal exam at all. Funny.

More race and medicine

I made a long post on race and medicine a while back, now BiDil, which seems to be effective for heart failure only in blacks, is under review by the FDA:

The drug's maker, Nitromed Inc., says its decision to test and market BiDil as a drug for African-Americans is based on solid science. But BiDil's application has engendered controversy, with many scientists convinced that race is too broad and ill-defined a category to be relevant in determining a drug's approval, especially since geneticists have failed to identify a biological divide separating one race from another.

As I said in my original post, patients should be treated with whatever medicines will help them the most, without regard for political correctness. That said, I think it is reasonable to be skeptical of claims of race based effectiveness, if for no other reason than the vast majority of drugs work in all races. As one of the cardiologists in the article says:

"I don't believe for a second that this drug combination is only going to prove to be beneficial in African-Americans; it's just not conceivable,"

I wouldn't say it isn't conceivable, but I can see why one would need very strong proof of a racial difference (as opposed to this case, where you have one trial where it didn't work in the general population, and another, later trial, where it did work for blacks--there are many meds for which some trials show benefit and others don't).

The pro-obesity function

I now think there are advocay groups for every possible cause in the United States. I don't think that is necessarily a good thing.

I've blogged a lot about obesity related issues and health and this article profiles an advocacy group mostly funded by restaraunts and processed food manufacturers that promotes obesity. Well, not really, but it opposes attempts to regulate these industries:

In recent years, Mr. Berman, who is not a scientist, has emerged as a powerful and controversial voice in the debate over the nation's eating habits. In some ways, he has become the face of the food industry as it tries to beat back regulations and discourage consumer lawsuits. Food and restaurant companies, he says, are being unfairly blamed for making Americans fat and unhealthy; he adds that people are smart enough to make their own well-informed choices

The libertarian in me generally agrees with giving people choices, but I do support, for example, bans on junk food sales in school cafeterias

Viva Pittsburgh

Yesterday evening we had one of those cool experiences where things just work out well. Adrianne and the kids headed for the Phipps Conservatory, our local botanical garden. They stopped at the library on the way and discovered a Brazilian jazz concert with free food and drink. They called me and I walked over to meet them.

They munched on lamb chops (only left 1/2 a one for me) and Brazilian sausage (I got my share) and Adrianne and I enjoyed free Penn beers. The music was great and Colin discovered Mad magazine. The music was great. Apparently this is a new monthly series "designed for adults who haven't visited a library since their graduation." They let us in even though we are regular users.

The place was hopping, with a mix of a few families, a number of young people and then a fair number of folks who looked like they had trouble deciding between Kucinich and Nader for president.

After that we headed to Phipps where we had a good time looking at all the plants and the kids played in the kids garden. Very cool and all within walking distance.

Canadian health care

Boy, reading the NEJM, BMJ and Lancet, I thought Canada was a medical utopia where everyone had free, efficient care at an overall cost much less than that of the United States. I guess not:

The Canadian health care system provides free doctor's services that are paid for by taxes. The system has generally been strongly supported by the public, and is broadly identified with the Canadian national character. Canada is the only industrialized county that outlaws privately financed purchases of core medical services.

But in recent years patients have been forced to wait longer for diagnostic tests and elective surgery, while the wealthy and well connected either sought care in the United States or used influence to jump medical lines.

The court ruled that the waiting lists had become so long that they violated patients' "life and personal security, inviolability and freedom" under the Quebec charter of human rights and freedoms, which covers about one-quarter of Canada's population.

"The evidence in this case shows that delays in the public health care system are widespread, and that, in some serious cases, patients die as a result of waiting lists for public health care," the Supreme Court ruled. "In sum, the prohibition on obtaining private health insurance is not constitutional where the public system fails to deliver reasonable services."

The case was brought to the Supreme Court by Jacques Chaoulli, a Montreal family doctor who argued his own case through the courts, and George Zeliotis, a chemical salesman who was forced to wait a year for a hip replacement while he was prohibited from paying privately for surgery

Kerry's records

Well, Kerry signed SF-180 and released all his military records. They apparently showed that some Swift Boat Veterans for Truth, who criticized his Vietnam service during the election, had praised him at the time. Perhaps embarrasingly, however, his grades at Yale were comparable to W's.

I can think of two explanations for his reluctance to release these records earlier, which would have strongly refuted the SBVT charges when it actually mattered

1. He is so vain he didn't want everyone to know about the grades.

2. He has so much pride, he refuses to muck it up with SBVT.

I'd have a lot of respect if it was #2, but everything else about him makes me think #1. Either way it seems like a horrible miscalculation. A strong refuation of the SBVT charges would have helped him immensely during the campaign and I don't think anyone except those already committed to Bush would have cared about the grades.

What I'll never understand about Kerry is why he never made peace with his critics prior to running for Presisdent. It seemed clear that the primary objection was not his service in Vietnam (which seemed clearly honorable, albeit perhaps a bit exaggerated over time) but his activities when he came back, particularly certain statements that could be construed to suggest American serviceman were all or mostly war criminals (regardless of if that is what he actually meant).

Why in his 20 year Senate career didn't he seek out John O'Neil and others and work things out? I'm sure, say 6 or 8 years ago, he could have made some sort of public statement, that he continued to think he was right to protest the war, but he regretted any suggestion that the fault lay with the American soldiers instead of the politicians and O'Neil and many others would have accepted it and that would be that.

It seems like a win-win situation as it would also have given him and his war record publicity as well as prevented the kind of controversy that actually occurred.

Changing the rules

Is acupuncture effective? In general, acupuncture vs. control rarely shows dramatic benefit when the control is "sham" acupuncture, where needles are placed at points not indicated by the underlying acupuncture theory. More dramatic results may be seen when the control used is sitting at home. This suggests that the therapeutic benefit of acupuncture is more in the time spent with the practioner and/or a placebo effect, rather than any actual benefit of the needles themselves. It is possible that just jabbing needles into someone has an effect as well.

When you think about the underlying idea of acupuncture, that there are energy lines running through the body that can be manipulated by needles, the lack of efficacy is not so surprising, as this is pretty far from what I’d consider mainstream biology.

But a commentary in BMJ rejects the whole idea of studying acupuncture using randomized trials:

In order to use a placebo or sham controlled design, an intervention has to be divided into characteristic (specific) and incidental (placebo, non-specific) elements. However, recent research suggests that it is not meaningful to split complex interventions into characteristic and incidental elements.

The idea is that the process of acupuncture (seeing the therapist, etc.) is not distinguishable from the act of placing the needles.

Of course, seeing a doctor, apart from any intervention, is helpful. If you have a rash and think it means you have cancer and go to your doctor and she tells you it's from a virus, you feel better, even though she didn't do anything to help the rash. Why is acupuncture different? Here is what they argue:

In a trial of acupuncture, however, the biomedical diagnosis that precedes the trial is not the theoretical understanding that guides treatment. The acupuncturist, through questioning and examination, will make a Chinese diagnosis during the first treatment session and will review and amend that diagnosis at each subsequent session. . . .

During subsequent treatment sessions needle insertion and healthcare advice are often varied to take into account any new concerns, whether physical, emotional, or social. This type of talking and listening may result in an increasingly participative interaction in which the whole burden of illness can be shared and partially relieved.

See, it it the Chinese diagnosis!

Seriously, there are two problems with this formulation.

First, what is claimed to be special about acupuncture is the needles, not the talking and handholding. Second, western medicine is also an iterative undertaking with successive rounds of testing, treatment, and revision of the diagnosis.

The overall message of the paper is that it’s unfair to expect alternative approaches to compete with the big boys like medicines which have real biological effects and plausible underlying biological rationales. Any attempt to actually study alternative medicine is unfair! Those who study alternative medicine have to throw off the shackles of actual testing and design trials where acupuncture can’t fail:

A sham controlled trial is only appropriate for comparing two acupuncture interventions—for example, to compare the effects of different needling techniques. In such a trial it is the effect of needling that is being compared rather than the total characteristic effect of the acupuncture.

But how can one study the effect of different techniques of acupuncture without knowing if it is effective to start! It's like saying you should only study two doses of a new drug because it is too hard for the drug to be compared to placebo or an effective alternative.

It’s because the system is biased! One tip-off to ridiculous articles is they inevitably descend into jargon (unfortunately, so do some reasonable articles).

This reticence in challenging the status quo may be because the assumptions that underlie dominant or commonly held theories such as biomedicine are invisible until they are illuminated by a body of primary research.

What exactly is the meaning of this sentence? I only have two doctoral degress, but my guess would be "the system is stacked against the wacky therapies we believe in; therefore we have to fight against the system."

My general belief is that much of so-called “alternative” medicine is effective, to the extent it is, because of the “hand-holding” effect. From a biological perspective the disease isn’t treated, but the patient feels much better from a psychological standpoint, since someone has spent time with them, talked about their feelings, and probably laid hands on them. And for many chronic conditions, one should never underestimate the power of positive thinking (which among other things may improve compliance with more mainstream therapies and encourage healthier lifestyles).

I don’t find it surprising that s mainstream medicine has become increasingly technical and doctors have less and less time to spend with patients, things like acupuncture and chiropractic are increasingly popular. The challenge going forward will be to identify what it is truly efficacious in these alternative therapies, avoid adverse outcomes, and help integrate more socially based therapies into mainstream practice.

UPDATE: I am not intrinsically opposed to acupuncture. If good quality trials show it works, I'm all for it. But those trials need to be rigorous.

Brain sarcasm areas found

Why is it, that when this story hit:

The researchers found that participants with prefrontal-lobe damage were significantly less able to understand sarcasm than those in the two other groups. Within the prefrontal group, people with damage in the right ventro-medial area, on top of the orbits of the eyes, had the most problems comprehending sarcasm. Those with the greatest damage to this area had the most difficulty.

more than one person commented that an easier way to find sarcasm centers in the brain was to do an MRI of my head and see which regions were bigger than normal? Let's just say my right ventro-medial prefrontal cortex is more than intact.

Attending day #9

Attending is like a death of a thousand cuts. There is no one thing that kills you, but all the little things start adding up. Our offices are across the street from the hospital and I ended up walking back and forth 4 times today: once to see the inpatinets on my service, once to teach for an hour, and 2 more times to see allergy consults. Plus I still see patients in clinic, so I'm running around like crazy

I'm also starting to run out of things to teach about. I've exhausted all my already prepared talks and am starting to have to take significant time to prepare.

We also had a site visit for our fellowship program which was very stressful for everyone, particularly my boss. I think it went as well as could be expected under somewhat difficult circumstances, which I won't go into here.

That said, attending on the inpatient service stops any self-pity pretty quickly.

The interns and residents have a busy, crappy life all year round, not just for two weeks. They have to get in at 6:30 every morning and are constantly getting harrassed by pages while trying to get things done.

Beyond that, of course, are the patients and parents. When you see a previously healthy kid with a new diagnosis of cancer or a near-drowning you stop feeling sorry for yourself pretty quick.

Well, for better or worse, 6 more days and I'm done, 8 more days and I'm off for a well deserved vacation.

Surgery for back pain

is probably no better than intensive rehab for chronic lower back pain according to a study in the May 28 BMJ. Patients considered good candidates for either spinal fusion surgery or rehab were randomized to one or the other. The patients who had surgery were significantly improved (compared to rehab) on only one measure of disability, others were comprable. My reading of the data is that neither group did that well, with substantial ongoing disability.

A cost-benefit analysis of the same patients showed increased cost in the surgery group, but the authors astutely noted that if many of the patients randomized to rehab go on to have surgery that could drive their total costs sky high, since they would have undergone both treatments.

This area remains controversial and there may be a group of patients for whom surgery is beneficial but, if so, they are hard to define prospectively.

This reminds me of one of my favorite articles, in the NEJM. It compared results of acute lower back pain according who the patient saw: primary care provider, orthopedic surgeon or chiropractor. Outcomes were similar, and good, among all three groups, but costs were much higher for orthopedic surgeons (patients all got MRIs) and chiropractors (patients had to come back multiple times for adjustments). Despite similar outcomes, patient satisfaction was highest with chiropractors! perhaps reinforcing my belief that patients like having practitioners spend time with them.

This guy

reminds me of the Seinfeld episode where George refuses to be fired:

First, his employees stopped reporting to him. Then his supervisors stopped returning his calls and now he does not know whom to report to. His secretary left, he said, and he was moved to an office near Pfizer's security department. . . . Dr. Rost turned on his computer Monday and tried for the first time in almost two weeks to log into his Pfizer e-mail account.

Access denied.

Because his corporate cellphone also was suddenly not working, Dr. Rost was reduced to using his Hotmail account to send e-mail messages to reporters to report his electronic exile.

Having to use you own hotmail account to pass negative information about your employer on to reporters? I guess the corporations really are running the country!

I can't say I have too much sympathy for someone who works for a pharmaceutical company and then makes a big deal about how they are charging too much for medicines and advocates reimportation. I don't see why this guy feels entitled to continue drawing a paycheck from Pfizer. If he has so many problems with the way Pfizer and other pharma companies act why not just quit? It would probably take him about 2 minutes to get an academic job with tenure.

More on gay sperm donation

I am called out as "poorly informed, at best, and downright homophobic at worst" based on this post, by Iatrogenic Causes, an anonymous blogger, who drops the intriguing hint that she has met me personally. Based on certain details in other posts I am 98% sure I know who he/she is, but his/her secret is safe with me.

You can read both posts and decide if I'm really homophobic. I would certainly deny that charge. Iatrogenic Causes goes on to make a fairly convincing case that rules against gays donating sperm are not rational. As I hope was clear from my original post, I am in no way a priori against gays donating sperm, but feel the overriding concern has to be to prevent HIV transmission: if excluding gays helps accomplish that I'm for it, if not I'm against it.

IC notes this article from the American Council on Science and Helath, laying out the case for gay sperm donation. If IV drug users and straight men who use prostitutes are not excluded, as the article claims (I can't find the actual rules anywhere on the FDA site) they should be. I do not however, find the argument that becasue some gay men are at lower risk than some straight men the ban is irrational, convincing

In contrast, here is the argument against gay blood donation, laid out in a publication from Gay Men's Health Crisis of all places(I'm aware this article is in regards to gay blood donation but the issues are similar):

the problem with allowing gay men to donate blood can be considered in a simple arithmetical way: Gay men continue to be at very high risk for HIV and there are relatively few gay men. Depending on which study you believe, gay men comprise certainly no more than 10 percent of the population and probably less than 5 percent.

Of course safe sex works, and many gay men are in monogamous relationships. But HIV prevention is not perfect. Gay men continue to become infected with HIV in substantial numbers, despite the best prevention efforts. Researchers put the annual infection rate for urban gay men in their teens or twenties as 1 to 3 percent annually. This number sounds small, but it is cumulative. In some major cities, like New York, around 15 to 20 percent of gay men are now infected with HIV -- and the prevalence is higher in some regions and ethnic groups. Furthermore, gay men in monogamous relationships still become infected. People cheat on their lovers, whether gay or straight, but the risks of such cheating, especially if unsafe sex is involved, are increased for gay men because of the high prevalence of HIV in the pool of potential sex partners.

I think the best agrument for allowing gay sperm (and blood) donation would be that gay men pose no additional risk of HIV transmission. Unfortunately, that argument is untenable in the face of the above numbers. Statistically, the gay man who thinks he is in a monogamous relationship but whose partner cheats on him is at much higher risk than a similar heterosexual man in the same situation.

So opponents of the ban fall back on the argument of the form "some men allowed to donate sperm under current guidelines are at higher risk of HIV than some gay men," which is a much less convincing argument. Of course no set of guidelines will be perfect and one could come up with exceptions to even very complex critieria for donation. I remain unconvinced by this argument.

The article also points out the potential risk of other, perhaps unknown viruses in gay men and cites that as one of the reasons the FDA declined to loosen blood donor eligibility in 2000.

Note also that exclusion critieria for blood and sperm donation has been changed to only exclude men who have had homosexual sex in the last 5 years; previously it was anytime since 1977, which is clearly archaic.

I think this is a tough issue and resent accusations of homophobia just because I don't toe the politically correct line. My final impression is that the risk from any donor is extremely low, but that excluding gay men may lower the risk even further. I remain receptive to evidence to the contrary.

Grand Rounds XXXVI

a graduation special is here

Rip currents

Sounds like a pretty cool thing to study. I once talked to a meteorology researcher at a party and he told me in that field there are so many problems and so few researchers there isn't really competition to be first, since no one works on the same problems. Very different from biomedical science

Anyway, remeber this advice:

But unwary bathers may wade into the water only to find themselves suddenly swept away. If they keep their heads and swim across the current, parallel to shore, they can escape its grip and make their way back to the beach.

But swimmers who try to fight rip currents quickly exhaust themselves and may drown.

The rip tides are generally narrow, so just swim out of them; strong swimmers die every year trying to swim against them

Fermented peanuts

Sounds like a bad idea for a new alcoholic drink, but in fact it may be a way to lessen the allergenicity of peanuts.

Now researchers have discovered that a special fermentation process can cut levels of major allergy-triggering proteins in peanut flour by up to 70 percent. The hope is to refine the processing method to the point where it can render the culprit proteins completely non-allergenic

This sounds great, but is a very long way from clinical usefullness. First a 70% production is barely relevant as even tiny amounts of peanut protein can cause fatal and near-fatal reaction in those with peanut allergies.

Second, according to the article they only measured reduced levels of two peanut allergens Ara h1 and Ara h2 and there may be other, unaffected, allergens to which people are sensitized.

ALLERGY TRIVIA: allergens, the proteins allergic individuals react to are named as follows: the first 3 letters of the genus followed by the first letter of the species and then a number to distinguish the allergens from one another.

So peanuts scientific name is Arachis hypogaea, hence Ara h1 and Ara h2 for the first two discovered allergens.

Similarly the major cat allergen is Fel d1 from Felis domesticus (official name now felis catus according to this site)

Embryonic stem cells without cloning

may be closer than imagined.

In recent months, a number of researchers have begun to assemble intriguing evidence that it is possible to generate embryonic stem cells without having to create or destroy new human embryos.

The research is still young and largely unpublished, and in some cases it is limited to animal cells.

The article goes on to describe several promising techniques. Like any emerging area of science there are lots of possibilities and only time will tell what will work and what won't. Obviating the moral objections to using cloning and thereby creating an at least theoretically viable embryo, would be a big step forward. Personally, I think we should pursue all promising avenues and see what works best

Vaccine for hemorrhagic fevers

This article (probably only free for subscribers but NYTimes article here) reports the development of vaccines for both Marburg and Ebola viruses, which are closely related members of the filovirus family.

The researchers used another, minimally pathogenic, virus that generally doesn't infect humnas, called vesicular stomatitis virus. They then used genetic engineering so the vaccine viruses would express a protein from the outer coat of either Marburg or Ebola. They vaccinated 6 cynomolgus monkeys with each vaccine, and then challenged 4 of 6 with high doses of the virus they should be protected against (Ebola for the Ebola immunized and vice versa) and used the other 2 as a control group, challenging them with the virus they were not vaccinated against (Marburg for the Ebola group and vice versa).

All the monkeys tolerated immunization without obvious symptoms and no live vaccine virus was detected in swabs from various monkey surfaces and orifices. Live vaccine virus was detected in the blood of monkeys, which was expected since the idea was that the vaccine virus would cause an infection and thereby generate a vigorous immune response

All 8 monkeys challenged with the wild-type filovirus (Ebola or Marburg) they had been vaccinated with were protected from infection (didn't have virus in the blood, get sick or die), but the four that were challenged with the other virus died with high levels of virus in their blood. While numbers are small (monkeys are near prohibitively expensive to do research on) the results are impressive.

As a further experiment, the investigators challenged the four monkeys who had been vaccinated against Ebola and survived Ebola infection with another Ebola strain. Unfortunately only one of four monkeys survived, indicating the vaccine is pretty specific for the strain chosen. An ideal vaccine would probably express proteins from several Ebola strains and Marburg to give protectin against all of these with one vaccination.

One interesting point about this experimennt is how the vector virus (the one which is used to express the Ebola or Marburgh protein) is chosen. The immune system reacts much more strongly to a true infection that to just injecting proteins into the body. An ideal vector virus would establish infection but not cause significant symptoms or be easily spread to others, all properties possesed by VSV. Additionally, the exposure of the human population to the virus should be low, otherwise many people will have already be infected and vaccination will not lead to productive infection nor a good immune response. This is one problem with adenovirus which is commonly used in similar trials. While minimally pathogenic, VSV infection rates naturally in humans are quite low, at least according to this article.

This vaccine, while still some time from human use, might be particularly useful for vaccinating people in areas of an outbreak, especially those with known exposure and health care workers.

Female ultramarathon runners

This is one of those articles, like the annual spring time one about allergy sufferers, that doesn't tell us anything new.

Pam Reed is a very good ultrarunner, as was Ann Trason (and she may be again if she can get healthy), but that isn't news. The article describes the usual vague speculation about whether women have more endurance than men, but doesn't even bother to tell us what that means:

Researchers have cited several possible explanations for why some women fare better than men in long-distance events. Women have more fat to burn, allowing them to conserve carbohydrates. They may also process heat more effectively. Also, studies have shown that women may cope with pain better than men

It also fails to give any data whatsoever, that women fare better in ultramarathons than men do, or that such events are increasingly popular with women.

I'm always happy to see ultras get main-stream media attention that doesn't portray them as some sort of death-defying, incredible extreme event undertaken only by societal outcasts or cult members, but this doesn't add much.

BTW, I think one reason women may fair better at ultra distances is that they are better at pacing early. Too much testosterone can lead to too fast an early pace which can kill you in an ultra.

Stem cell research and the US

According to this article, the US is more hospitable to embryonic stem cell research than many other countries where cloning is actually a crime:

In Canada, scientists who violate the ban can be jailed for 10 years and fined $500,000. "You can bet that with these harsh sanctions scientists are complying," said Rosario M. Isasi, an attorney who works on medical ethics issues at the University of Montreal.

Under German law, scientists who even e-mail or telephone cloning instructions to colleagues in other countries can be thrown into jail for three years and fined more than $60,000.

Of course, our goal should be to lead the world and the fact that other countries are even worse than us is small consolation.

Waiting and scheduling

Dr. Kevin has this post on the trade-off between waiting for your doctor and brief appointments:

Are you, fellow physicians, the type who is always on time, every 15 minutes? Or do you spend as much time as it takes with each patient?

Do you, as a patient, want a physician who runs on time, every time? Or do you mind waiting 1 hour for a visit where all your problems are addressed?

Because you can't have both. It is impossible. Hence, the spectrum of waiting.

I'm not so sure I completely agree. Office schedules could be made realizstic, such that patients were generally seen on time. If several patients with particularly complex problems came in a row, the practitioner might get a bit backed up, say 1/2 hour, which I would guess is the wait at which people don't really seem to mind.

One thing I sense most physicians don't do enough is have people back for another visit. When I used to moonlight for a pediatrics practice, people would come in for "sick visits" on the weekend and then want to discuss various non-urgent issues (should they see an gastroenterologist for the constipation that had been present for the last two years, getting school physical forms filled out). If I had time I'd spend it addressing their needs as best I could (hey, I was getting paid) but if we were getting backed up I'd politely, but firmly tell them that I had to move on and they should come back and see their regular pediatrician. People seemed to accept this and patients were eternally grateful that I ran near on time (seeing 3 patients per half hour).

One thing I don't think most patients realize is how much time physicians can spend waiting when patients don't show up for their appointments and don't bother to call and cancel. This is frustrating for everyone because a physician is sitting around with no patients to see and therefore not generating any revenue. I suspect this is worse in an academic center and particularly one, like mine, that cares for a lot of disadvantaged patients. All these no-shows create the temptation to overschedule, but then if everyone shows up, we run way behind.

In Canada, there is the following solution: if you miss an appt. with a specialist without cancelling >24 hours, you are charged a fee (about $125). If you show up, the visit is free. I suspect such a system would result in a lot less no-shows and might allow more physicians to move to realistic schedules, confident everyone would actually show up.

The empire strikes back II

Weighing a little too much may not kill you, but there is nothing healthy about it, the head of the nation's health agency said yesterday, distancing herself from a controversial report suggesting that being overweight is not so bad.

At a news conference, CDC Director Julie L. Gerberding acknowledged potential flaws in the study and pledged to get scientists and the public back on track.

This issue will sort itself out over time with more studies. I'd just point out that Julie Gerberding is head of the CDC, but is not involved in the research or a particular expert in this area. Her hedging in no way means the actual authors of the study are reconsidering their conclusions. Second, so far most of the vocal critics of the study have their own reason to oppose their findings, mostly because they have done studies that came to different conlcusions.

Attending, day 3

So far it is not so bad.

Unlike what some have implied, the amount of a**-kissing is quite low. The reason for this is that everyone is at the end of their year, and no longer feels the need.

The medical students are almost done with the worst year of their life (so far) and are a bit burned out.

The interns are almost done with the worst year of their life (ever). They are completely burned out and don't want to be here anymore.

The junior resident is ready to be a senior and the senior resident is ready to start his practice and be done with residency.

The plus side of the situation is that everyone is very good at their jobs. The interns can get things done quickly w/o guidance, the medical students are actually useful to everyone else and the more senior residents are very on top of things.

I'll take competent underlings in the place of smooching anytime.

The Lancet

The Lancet, which is the British equivalent of the New England Journal (i.e. a very prestigious general journal) has a certain annoying combination of anti-Americanism, provincialism and anti-market beliefs expressed in its editorials. The latter I find particularly amusing since articles in the Lancet are not made available free of charge on-line, only because otherwise no one would pay the ~$200/yr subscription.

So I was amused to see the following headline:

Health is the loser in the vote against Europe

above an editorial that went on to hysterically decry the fact that the lack of an EU constitution limits the ability of various advocacy groups (think anti-vaccine zealots and knife-banners) to influence laws (i.e. screw things up) across the EU as a whole, instead having to work country by country, as if no other more important issues were at stake (I am personally agnostic on the issue of an EU constitution). For example

By giving a legal grounding to the EU rhetoric that puts social values, such as health, on a par with the economic goals of the internal market, the Constitution creates a much safer environment for enhancing health policy-making at an EU level.

I am personally skeptical of anything that creates a safer environment for enhancing health policy level; it is too easy for people who think they know all the answers to screw things up.

Here are some typical Lancet editorial headlines:

Abortion drugs must become WHO essential medicines

The US National Children's Study must have more funds

Biotech quick-fixes will not end hunger in China

A tax to prevent the epidemic of lung cancer

Prostitutes are people too

You get the idea

Exhaled nitric oxide as a guide for asthma therapy

This article in the NEJM shows that by using exhaled nitric oxide (NO) as a guide to decreasing therapy, patients can achieve equivalent asthma control with less use of inhaled corticosteroids.

Nitric oxide is a marker of inflammation and increased exhaled levels in patients with asthma can indicate ongoing inflammation and therefore poor control of the asthma

The study is okay, but, unfortunately for them, may be underpowered. There was a noticeable, but not statistically significant drop in exacerbations in the group whose medicine use was adjusted by NO measurement compared to those managed conventionally by symptoms. A drop in exacerbations with less medicine use is much sexier than just a decrease in medicine usage.

The other weakness of the study is that it was designed using an older approach to clinical management focused primarily on titrating up the dose of inhaled steroids. Now we much more commonly add long acting beta-agonists like salmeterol (which is combined with the inhaled steroid fluticasone in Advair) especially patients already on relatively high doses of inhaled steroids like those in this study.
It remains to be seen if use of NO measurement enhances contol with less overall medicine use in patients managed according to this newer algorithm.

Biotech: as profitable as airlines

and almost as reliable! Such could be the motto for the biotechnology industry, which as lots of hype, a few sucesses and lots of red ink, according to this article.

Read the article if you are interested, but this quote, by economist Joseph Cortright, sums it up:

"The mistake that people make is confusing science that is really cool with something that is going to have a significant economic impact," he said.

The big problem as I see it is that there are lots of good ideas, few of which actually make it to the clinically useful (and therefore renumerative) stage. It takes a lot of research to develop each idea and that means a lot of money.

But remember the industry is expanding, so lots of money is being marked up as "losses" today that may lead to big money in the future. For the record, I don't invest in biotech or biotech companies except as they are represented in general mutual funds.

On service

Posting may be a bit light the next two weeks since I'm "on service." This means I'm the attending (responsible physician) for a variety of patients admitted to the hospital, mostly outside my specialty. At my hospital there is a seperate service with expert attendings that care for most of the inpatients, so our role is a lot of teaching, with enough patients to make me nervous. Hopefully, I'll survive.

I distributed this from Madhouse Madman about the various members of an inpatient team to all the residents and fellows. They didn't seem to be amused but I thought it was hilarious.

Defensive medicine

An excellentarticle in this weeks JAMA about how much the fear of malpractice drives doctor's to do unnecessary tests to avoid litigation. The study, by Studdert et al., examined doctors practicing in high risk specialties (emergency medicine, surgery, ob/gyn, neurosurg, orthopedics and radiology).

A total of 824 physicians (65%) completed the survey. Nearly all (93%) reported practicing defensive medicine. "Assurance behavior" such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%)

I knew things were bad but wouldn't have guessed this bad. One reason people are going off to India and Mexico for surgeries is they are so much cheaper there, but one reason they are so cheap there is the doctor's don't have to pay malpractice premiums, or if they do they don't approach the ones here.

What would happen to health care costs if we gave people the option of choosing medical care that would severely limit malpractice awards? Costs would likely go down substantially and patients might be much more assertive in assuring they are getting good care by evaluating the quality of doctors before using them.

That said, I a lot of unnecessary testing etc. is more the result of the culture of medicine which tends to emphasize caution and certainty, than fear of litigation itself. It may be that doctors order extra tests to make themselves feel more certain and use litigation as a good excuse.

Thought for the day

For yesterday is but a dream,
And tomorrow is only a vision,
But today well-lived makes
Every yesterday a dream of happiness,
and every tomorrow a vision of hope.
Look well, therefore, to this day!
Such is the salutation of the dawn.

From the Sanskrit, I believe. This came to me as I finished up my run this morning

Just so stories

This op-ed in the New York Times attributes men’s relative dominance of areas ranging from Scrabble to auto racing to evolution which has selected for the drive to excel.

I am a strong believer in evolution, but I am very skeptical of the urge to attribute every aspect of human behavior to natural selection and evolution. We have to be very careful when we seek to explain human behavior in biological terms to avoid “just so” stories in which evolution has selected for whatever trait e are trying to explain, conveniently absolving society and culture of any role. Are racial differences in achievement genetic, as some have argued, or cultural. If racial differences are not genetic, why should gender ones be?

I am very leery of ascribing human behaviors (male promiscuity, female’s doing the majority of work in the household, etc) to evolution, because it too often serves to reinforce whatever bias one starts out with, and it doesn’t look for more cultural explanations for behaviors. Many men are not promiscuous or don’t seek to dominate. Where do they fit in these evolutionary explanations?

Are men really selected to excel or is this more cultural? Since we can’t do experiments it is hard to know. Clearly, the strongest people in the world will be overwhelmingly men as they have greater muscle mass. While some women will be stronger than many men, the strongest will be men.

In other fields like mathematics, physics and Scrabble I’m not so sure. Perhaps men have more mathematical aptitude at the highest levels, but culture certainly plays a role. Until we understand a lot more about how the brain works, I think these questions will be unanswerable.

I do recommend Stefan Fatsis’ Word Freak, which is a great book about his foray into the world of top-level Scrabble play. I hate Scrabble (interminably slow) but loved this book. I find it hard to view the top Scrabble players he portrays as evolutionary success stories, since most live at home with their parents and don’t seem to have great reproductive success. Maybe the explanation for most Scrabble champions being male is just that odd males are more accepted in society than odd females.