Archive for the 'Science and Medicine' Category

Feb 18 2016

Practicing Medicine Without a License

fake-diploma1

After four years of rigorous study in medical school, which includes grueling class work and then clinical rotations in which you may work 80 hours a week, followed by killer exams to demonstrate you have mastered a vast body of knowledge, you are not yet competent to practice medicine. Those four years only prepare you for your real training as an intern and then resident, another three or more years.

Even then, newly minted attendings who are supposed to be able to practice independently may appreciate having access to more experienced colleagues.

Further, as you accrue invaluable experience over time your fund of knowledge can actual degrade, because the science of medicine is quickly advancing under your feet. It is a struggle to keep up, which is partly why so many physicians specialize.

This is why one of the most important lessons we teach medical students and doctors in training is to have a very good sense of your own limitations. You need to have some sense of how deep any particular specialty is, so that you can gauge your own relative ignorance. The bottom line is – don’t practice out of your depth.

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Feb 16 2016

3D Printing Body Parts

3dprintbodypartsA new study published recently in Nature Biotechnology reports a significant advance in the technology of 3D printing body parts designed to be implanted in human patients. This is an exciting technology, but we are still in the early phase of development.

3D Bioprinting

Printing body parts is one approach to creating tissue and organs to replace those lost, damaged, or diseased. This is a top down approach, directly constructing the body part. The other approach is bottom up – growing a body part from stem cells.

The 3D printing technology itself is more than adequate for this task. That is in no way the limiting factor – we can create objects of precise size and shape sufficient for implantation. We can, for example, make an exact replacement for a missing piece of bone.

The biggest limiting factor in creating body parts of “clinically relevant size, shape, and structural integrity,” is keeping the cells alive. The problem is when we print body parts we are printing the skin, muscles, bone, and cartilage, but not nerves or blood vessels. Without blood vessels, the only way for the cells to get oxygen and nutrients is through direct diffusion, which has a limit of 100-200 micrometers. This is too small to be clinically useful.

This was the specific advance reported in the recent study. The researcher incorporated pores or microchannels into the printed tissue, allowing for far greater diffusion. The tissue became more like a sponge.  The bottom line is that this technique worked, they were able to create cartilage, for example, of 3.2 cm x 1.6 cm x 0.9 cm which survived in vivo without necrosis.

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Jan 26 2016

The Zika Virus

aedes mosquitoThe World Health Organization (WHO) and Center for Disease Control (CDC) are warning about yet another virus epidemic, the Zika virus. It may seem like such warnings are overblown, but they do need to be taken seriously.

Zika Virus

The Zika virus (Flaviviridae, an arbovirus) is spread through Aedes mosquito bites, the same mosquitoes that also spread Dengue fever. The infections themselves are usually mild, causing fever, rash, joint pain, and conjunctivitis. Many of those infected may even have a subclinical infection, meaning they do not notice any symptoms.

However, the infection can have complications. There is one case report of Guillain-Barre Syndrome (GBS) following a Zika infection. GBS causes inflammation of the lining of nerves resulting primarily in weakness with variable recovery. This does not appear to be a huge risk, but something to monitor.

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Jan 19 2016

Charlie Sheen’s HIV Quack

charlie-sheen-dr-oz-show-regular-guest-ppCharlie Sheen is HIV positive. As was revealed on the Dr. Oz show, when diagnosed his viral load was 4.4 million. After six months of the a standard anti-HIV cocktail his viral loads were undetectable.

This does not mean he is HIV negative or free of this virus. As part of the viral life-cycle it goes into hiding inside of cells. It is undetectable while hiding, and also cannot be eradicated by medications. This is a major challenge to curing HIV, or even pushing the efficacy of our current treatments further. Researchers are looking into ways to force the virus out of hiding so that anti-retroviral medications can go to work.

With current anti-HIV treatment someone who is HIV positive can expect to live an almost normal life expectancy free of any major complications of the disease and will not go on to develop AIDS from the virus. The big challenge now is to get this modern medicine to those who are HIV positive in the third world, or to those who cannot afford it.

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Dec 15 2015

Contaminants Found in 92% of TCM Herbal Products

Chinese-herbs4A new study out of Australia looked at 26 different Traditional Chinese Medicine (TCM) products purchased from stores. They performed three types of analysis: heavy metal screening, toxicological analysis, and DNA sequencing. They found that 92% of the products tested had at least one type of contaminant.

This adds to a growing list of studies and revelations about how poorly the supplement industry is regulated, and raises further concerns about the overall quality of herbal and supplement products.

A 2008 study found that about 20% of ayurvedic herbal products contained heavy metal contamination, often at levels high enough to be toxic.  Continue Reading »

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Nov 27 2015

There is no Right to Experimental Treatments

From time to time courts are called upon to determine whether or not desperate patients have a right to experimental treatments. In the US we are also currently in the middle of the spread of “right to try” laws from state to state. The issue has recently come up in Brazil over patient access to an experimental cancer drug, phosphoethanolamine.

This is an unfortunate issue, because over the last century experts have developed a thoughtful system that attempts to carefully balance patient autonomy, hope for very ill or terminally ill patients, patient safety, and the good of society. Now thoughtless legislators or misguided courts are attempting to bypass this system with predictably horrible results.

However, on a superficial emotional level it is much easier to persuade people to bypass the system than respect it.

Here are the issues:

First, most experimental drugs will eventually not work. They will either fail to produce a clinically relevant result, or they will cause more toxicity than benefit. Even drugs that are promising when studied in cell cultures or animals will often fail human trials. It has to be understood, then, that what we are talking about is giving patients access to drugs that probably won’t help them and may harm them.

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Nov 23 2015

Health Advice from the 1950s

One of the pillars of alternative medicine propaganda is historical revisionism. Proponents often claim that they were ahead of the curve on diet and exercise advice, while the medical establishment lagged behind. They go as far as to take credit for the entire field of nutrition by labeling it “alternative.”

The fact is, the disparity between mainstream and alternative advice has not changed much for the past 60+ years. There are even some elements that are literally centuries old – using “natural” as a marketing angle, for example.

The alternative narrative is not based on reality, however. Fortunately we have records from the first half of the 20th century that document exactly what the scientific mainstream and alternative culture were saying. It is a good idea to frequently question your own narrative and check the actual facts. I sought to find some historical documents that would demonstrate what the medical mainstream were saying in the 1950s.

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Nov 20 2015

Vitastiq – Indiegogo Pseudoscience

Crowdfunding is an excellent application of social media and the web. Anyone with a great idea, who can sell their idea, can get funding from the public. You don’t necessarily need big investors.

But of course, any tool or application that can be used for good can also be used for ill. Crowdfunding sites have been used to fund pure pseudoscience. A recently example was sent to me by a reader – Vitastiq. The campaign was 185% funded, for over $210,000.

What the product claims to do is measure vitamin and mineral levels non-invasively by simply touching a small probe against a specific location on the skin. I was immediately skeptical of these claims – how can the blood level of vitamin B12, for example, be measured on the skin? Further, the probe just has a simple electrical conductor. At best it is measuring skin conductance, which can be used to measure sweat levels but not much else.

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Nov 19 2015

Gene Editing Humans

A Chinese team of researchers recently announced that they attempted to edit the genes in human embryos with the genetic disease beta-thalassemia. They used the CRISPR-Cas9 technology, which they said was not successful enough in this application to be used. Some of the embryos resulted in mosaics, with only some of the cells being fixed, and other resulted in unwanted mutations.

While the attempt to fix the genetic disease in embryos was unsuccessful, the announcement has prompted discussion over the ethics of gene editing in humans.

CRISPR

First for some background, because I have not yet written about the CRISPR technology, this is an exciting gene-editing technology that allows for rapid, accurate, and inexpensive gene editing.

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Nov 16 2015

David Katz Does Not Understand Science-Based Medicine

David Katz is a prominent proponent of integrative medicine. We in the science-based medicine (SBM) community have on several occasions over the last seven years critically addressed some of his claims, for the purpose of public intellectual discourse on topics of vital interest to the public, namely health care. When Katz has responded, he has typically done so by attacking a strawman rather than the actual SBM position.

He has now done so again, in a transparent fashion. I suspect he is responding to our criticism of him from a couple of week ago. He has now written an article in the HuffPo in which he makes specific claims about SBM that are demonstrably false. When criticizing some one or group who advocates a position with which you disagree, it is critical to be fair, even charitable, to their position. At the very least you should endeavor to properly understand the position you are criticizing. Failing to do so falls somewhere on the spectrum from intellectually dishonest to lazy. Usually the pre-existing narrative holds sway and runs roughshod over the evidence, even when in plain sight.

Katz in his recent article is responding to an article in JAMA that reviews 10 standard practices the authors believe are not supported by evidence and should be questioned. This is exactly the kind of process that we support at SBM – examining all practices from a science-based point of view. The first half of Katz’s article is also quite reasonable, and in fact is something that could easily be found on the pages of SBM.

He did not stop there, however, and used the opportunity to go on a tear against SBM and in defense of his beloved Integrative Medicine. Here is where he goes south:

At the same time, and equally important, a certain sanctimony about evidence-based medicine results in contemptuous disregard for the “unconventional.” This broad designation may, at times, refer to so-called “alternative” medicine, where detractors will suggest one is headed toward voodoo. But it also refers to lifestyle interventions that are very far from the worrisome realm of “woo.”

Katz repeats the common CAM (complementary and alternative medicine) fiction that lifestyle factors are unconventional. This is nonsense, easily debunked by simply looking at historical evidence. Scientific conventional medicine identified the relationship between specific lifestyle factors and disease risk. Lifestyle recommendations have been slowly phased into convention medicine as the evidence has come to light. Sure, this has happened slower than we would have liked – in general the medical profession is slow to adapt to the evidence. They come around eventually, but we do need to explore ways to make this process happen more quickly. In any case, CAM does not own lifestyle factors. They have simply appropriated them to have some legitimate footing to their entire endeavor.

The rest of his statement needs to be put into the context of what he also says in the article:

If evidence matters, it matters equitably, and universally.

This has been a persistent theme of David Katz – accusing critics of CAM of having a double standard. The opposite is the truth. SBM specifically calls for one universal science-based standard of care. That is our very publicly and frequently stated position.

It is the proponents of CAM who are explicitly calling for a double standard. Health care freedom laws are about creating a double standard for CAM therapies. The National Center for Complementary and Integrative Health is about creating a double standard for CAM research funding. Dr. Katz himself has called for “a more fluid concept of evidence” when considering CAM.

The fact is, when held to the light of science, CAM therapies do not hold up well. That is precisely why they are alternative. Proponents don’t acknowledge this, so they have to create the fiction that CAM therapies are being treated unfairly. Katz repeats that accusation here:

In other words, the prevailing pattern is that “we” (i.e., conventional medicine) are innocent until proven guilty, but everyone else is guilty until proven innocent. No special olfactory acuity is required to discern how bad that smells.

What Katz is referring to here is not a double standard but simply considering scientific plausibility or prior probability. Katz has directly criticized the use of scientific plausibility in evaluating medical treatments. He is wrong, but at least here he is discussing the actual issue at hand.

It is true that conventional medicine will often use a treatment because it seems plausible before there is adequate evidence to show that it actually works. That, more than anything, is the central criticism put forth by the evidence-based medicine movement. EBM specifically eliminates considerations of plausibility in order to avoid this error.

SBM recognizes the problem but does not take that approach. Rather, we argue that treatments should be based on both scientific plausibility and rigorous clinical evidence. At the very least the clinical evidence needs to be put into the context of scientific plausibility.

Another way to look at the difference between SBM and EBM is that EBM tends to follow more of a frequentist statistical approach (with its over-reliance on p-values) while we prefer more of a Bayesian approach. The latter begins with prior probability and then evaluates the effect that any new clinical evidence has on that probability. In this way SBM advocates looking at all the scientific evidence to come to one overall conclusion about the likelihood that a treatment has benefits in excess of risks.

We advocate applying this standard to all of medicine.

I honestly don’t mind that Katz disagrees with us and advocates a different approach. Let’s have it out in open discussion. That is how better ideas prevail. I do mind when he mischaracterizes what SBM does and stands for. This is what he does here:

To the best of my knowledge, a rather boisterous group in cyberspace calling itself “science based medicine” is silent on all of this. They preferentially malign all alternatives to conventional medicine, implying that problems of evidence and its application lie entirely without, and not within. This, in turn, makes it clear that such protest is itself unconcerned with the underlying evidence, and born instead of ideological zealotry. If evidence matters, it matters equitably, and universally.

The link on SBM is not to SBM but to the recent article he wrote essentially calling us fools and fanatics (to which David Gorski and I responded two weeks ago).

Prefacing his claim with “to the best of my knowledge” does not save Katz from criticism for making a blatantly untrue statement. He is saying that SBM is silent when it comes to criticism of mainstream medicine. I am not saying that Katz should be highly familiar with the thousands of articles we have published on SBM. But even a casual perusal shows this claim to be false.

He could have also plugged something like “cancer screening” into the search window on SBM. He would have been greeted with 190 articles, most of which are discussing mainstream cancer screening practice. This was one of the actual topics of the JAMA article, and ironically David Gorski has addressed the very issue on SBM.

Just for fun I looked at the most recent 60 articles on SBM. Forty of them dealt with CAM, pseudoscience, science denial, a fringe treatment, or the regulation of fringe treatments or professions. That is undoubtedly our expertise and focus at SBM. However, 10 articles dealt with criticism of mainstream practice, 3 dealt with the nature of medical evidence itself, and 6 were about other topics. That is 10 articles in the last couple of months that Katz says “to the best of my knowledge” don’t exist. Often “to the best of my knowledge” means “I never bothered to look.”

In addition to being demonstrably factually wrong, Katz draws the wrong conclusion from his confirmation bias. He thinks it is “clear” that our focus on alternative treatments is due to “ideological zealotry.” This is a common tactic of CAM proponents – they try to depict the defenders of a reasonable standard of evidence as the zealots, while those trying to sell treatments based on magic and pseudoscience are just being “open-minded.”

We are actually quite open about our editorial policy. We focus on pseudoscience, unconventional treatments, and fringe claims for very good reasons.

1 – In establishing what the standard of science and evidence in medicine should be, it is useful to shine the light on the most egregious violators.

2 – The mainstream media does a generally poor job of reporting on fringe topics, falling for false balance, citing outliers as experts, and hyping sensational claims. We are filling a gap and correcting a great deal of bad science reporting.

3 – Understanding pseudscience is a specialty unto itself that requires specified knowledge. This knowledge is generally lacking in mainstream science and academia. That is our specialty, so of course we focus on it.

4 – Mainstream medicine already has an infrastructure of experts examining and commenting on practice and evidence. Our efforts there would largely be redundant. When we feel they aren’t, we comment.

The core of SBM, however, is an examination of the nature of scientific and clinical evidence, and the relationship between that evidence and the practice of medicine. We feel we have a very solid position, and Katz has failed to criticize it in any meaningful way. Instead he and others attack predictable and rather tired straw men.

In fact Katz’s entire article is just another iteration of the tu quoque logical fallacy common in CAM circles – trying to avoid criticism of CAM practice by saying that mainstream medicine has problems of its own.

In fact this is where Katz gets it most wrong – in his musings about how to fix the shortcomings of mainstream medical practice. He writes:

The cleanup will certainly not come courtesy of those calling themselves “science-based,” who live within its glass walls, tossing stones outward. They produce nothing more useful than shards of glass.

It will come courtesy of those who concede, with suitable humility, that no single domain of influence has a monopoly on dirty boots. It will come courtesy of those who like a level playing field, and respect the potential for baby and bathwater in any given tub.

This is a massive exercise in rewriting history and missing the point.  SBM is, in fact, the solution to the problems he discusses. SBM is about being humble before the evidence. What I call “neuropsychological humility” is a major theme of scientific skepticism, of which SBM is a part.

I and my colleagues have written many articles on SBM about how we need to increase the standard of evidence across the board. There are too many published false-positive studies, there is publication bias and citation bias, exploitation of researcher degrees of freedom, a problem with open-access journals, a reluctance to publish exact replications, a need for greater transparency, perhaps a rethinking of peer-review, and an overall problem of prematurely adopting new treatments with later reversals. These are all criticisms of mainstream medicine. To claim we do not address this issue is astounding.

Even more astounding is the fact that within CAM all of these problems are exacerbated, by orders of magnitude. The problems with conventional medicine that Katz criticizes are far worse in the world of CAM. It is difficult to take him seriously about “cleaning house” in mainstream medicine while he is simultaneously trying to give a free pass to his “integrative medicine.” He decries a double standard, while trying to create one. He calls for humility, while CAM at its very core is based on the hubris that personal experience and wisdom trump scientific evidence.

Conclusion

David Katz has his narrative – he believes in ancient wisdom and natural therapies, and would like for them to be integrated into mainstream medicine. The problem with this position is that there is no particular reason to suspect that ancient practices were based in reality, and there is no reason to think that the very vaguely defined “natural” is an advantageous property to have.

Unsurprisingly, when actually subjected to rigorous clinical study, treatments that are not based on scientific plausibility but instead on romantic notions of ancient wisdom and benign nature, turn out to be largely worthless. They don’t work.

Faced with this stark reality, proponents of integrative medicine have been doing a furious dance, trying to distract from the facts. They have attacked the messenger, and applied an impressive array of distractions and logical fallacies. Katz has become quite adept at this dance.

His criticisms all miss the mark, and in some cases are factually incorrect.

We could have a meaningful discussion of the optimal relationship between basic science, clinical science, and best medical practice. First, however, he would need to dispense with his obvious straw men positions, and acknowledge his factual errors.

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