Oct 09 2017

The Perfect is the Enemy of the Good

Voltaire-quoteThis aphorism has been around since about 1600, originating with Voltaire in French. I have found it to be a useful concept – not an iron-clad rule, but an excellent guiding principle. The perfect is the enemy of the good (sometimes “good enough”).

What this means is that we should not be paralyzed into inaction because we cannot achieve a perfect solution to a specific problem. The idealized perfect solution becomes an obstacle to solutions that are adequate, or at least an improvement on what we have now.

In reality this can be a tricky principle to apply, however. Like the informal logical fallacies, or any informal guideline for clear thinking, there are no rigid rules or definitions. Judgement is required, which means that subjectivity and bias are also involved.

There are two specific ways this principle is either applied to not applied that tends to come up with skeptical topics. The first deals with our own activism – when should we apply this principle?

For example, over the years I and some of my medical colleagues have had a disagreement about how best to approach topics like vaccine exemptions. We all agree that non-medical exemptions decrease vaccine compliance and are a threat to public health. We all agree that in a perfect world states would not allow non-medical exemptions (only exemptions for children who medically are unable to be vaccinated).

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Oct 06 2017

Unnecessary Medical Interventions

clinical-decision-making-46-638A recent JAMA article is an update on a systematic review of overused interventions in medicine. They list the top ten overused tests and treatments, meant to highlight this problem in medicine. They conclude:

The body of empirical work continues to expand related to medical services that are provided for inappropriate or uncertain indications. Engaging patients in conversations aimed at shared decision making and giving practitioners feedback about their performance relative to peers appear to be useful in reducing overuse.

You can read a summary of the ten overused interventions here.  The one you are likely already familiar with is antibiotic overuse. The others are very specific tests or interventions in specific situations, like Computed Tomography Pulmonary Angiography to help diagnose acute pulmonary embolism.

Reviewing each of these interventions in the top ten list would require a deep dive into the literature and detailed discussion, which is not my intent here. If you want that level of detail, read the original article. What I want to discuss is, in general terms, why this is a problem in the first place.

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Comments: 5

Oct 05 2017

The Gun Debate Revisited

Gun-deathsAfter every mass shooting there is a renewed debate and call for better gun control, and pushback from gun owners who say, “Now is not the time to get political,” and “There’s nothing we can do to stop gun violence, it’s the price of freedom.” Then precisely nothing happens until we get distracted by something else and forget about gun violence until the next headline-grabbing shooting.

Clearly whatever we are doing is not working, and it is the oft-cited definition of insanity to do the same thing and expect a different outcome. So what are we doing wrong?

First, we have to acknowledge that there is a problem. There are about 33,000 gun deaths per year in the US. This is more than any other wealthy country – only war-torn banana republics have higher rates of gun deaths. There were 477 mass shootings in the US in 2016.

About two thirds of gun deaths are from suicides. That is a large portion, but that still leaves 11,000 non-suicide gun deaths each year in the US. Gun homicides are a huge problem, not diminished at all because gun suicides are an even bigger problem. About 20% of gun deaths are crime and gang-related homicides, mostly young men killing other young men. Also, about 1,700 women are killed each year from gun-related domestic violence.

I reject the notion that this is the best we can do, that this is the price of freedom. Other Western democracies seem to enjoy freedom without anything close to the same rate of gun violence. So why has this been such a hard problem to solve?

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Comments: 112

Oct 03 2017

Nobel in Medicine for Circadian Rhythm

Nobel 2017-MedicineRemember that time Sarah Palin said:

“[tax] dollars go to projects that have little or nothing to do with the public good — things like fruit fly research in Paris, France. I kid you not.”

OK, she was actually referring to the olive fruit fly, Bactrocera oleae, not the staple of genetics research, Drosophila melanogaster. The comment is still a legitimate target for criticism because it is not clear that Palin understands the difference (or she wouldn’t have said it that way), her statement seems to imply that scientific research into the humble “fruit fly” is a waste, and she is generally anti-science (when it conflicts with her ideology).

At the time of her statement many scientists and reporters delighted in pointing out how central fruit fly research has been to scientific advancements. Well, we can add another example from this year’s Nobel Prize in Physiology or Medicine. The prize goes to three American scientists, Jeffrey C. Hall, Michael Rosbash and Michael W. Young, for their work on the circadian rhythm.  Continue Reading »

Comments: 5

Oct 02 2017

Rocket Travel

BFRElon Musk is an interesting guy. Also, because of the success of SpaceX, when he makes promises about future technology, it is at least worth a listen. At a recent meeting of the International Astronautical Congress Musk stated that he plans on developing SpaceX’s rocket technology for commercial transportation between cities on Earth. He also made a promotional video.

The idea of using rocket travel for long distances (instead of jets) is not new. It has been featured in various science-fiction views of the future or even alternate realities of the present. The obvious advantage to rocket travel is that it is fast. A suborbital trajectory can get you between almost any two cities on Earth in 30 minutes or less.

This is all part of SpaceX’s new project, the BFR (I could not find anywhere exactly what that stands for – just the implication that it’s “Big Fu**ing Rocket”, which is awesome). Musk wants to stop developing his Falcon series of rockets and focus entirely on one rocket system to do everything they need to do – the BFR. The idea is that this will help reduce overall costs.

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Comments: 9

Sep 29 2017

GM Wheat for the Gluten Sensitive

gluten (1)Celiac disease is a serious disorder that affects about 1% of the population worldwide. The disease results from an immune reaction to gliadin, which is part of the gluten protein found in wheat, rye, and barely. Glutens are stretchy proteins that give breads their sponginess and allow breads to rise.

Those with celiac disease make antibodies to gliadin, which causes inflammation of the lining of the small intestine and a number of painful and harmful symptoms. It can now be accurately diagnosed with blood tests for the anti-gliadin antibodies, but the only treatment is a life-long diet free of any gluten.

Gluten has also caught the attention of the clean-eating food fad crowd, who have convinced many people they have non-celiac gluten sensitivity. As I discussed previously, this entity is controversial at best and probably doesn’t exist. However, it is always important to point out that many people who end up falling into an ultimately false diagnosis may have a different real disease. Some people who now get labeled as gluten sensitive may actually have wheat allergies. There are other possible culprits as well, such as FODMAPs (fermentable, oligo-, di-, monosaccharides, and polyols).

Regardless, life for those with celiac disease can be challenging. The diet is rigorous, and even the smallest amount of gluten can trigger a reaction in those truly sensitive.  Continue Reading »

Comments: 12

Sep 28 2017

Health Blogger Gibson Fined

BelleGibsonBelle Gibson is an Australian wellness blogger who made a lot of money selling her cookbooks and apps for healthy eating. What elevated her profile above the sea of competitors, however, was her claim to have cured herself of brain cancer with her diet. The problem with her story, however, is that she never had brain cancer.

Now an Australian court has fined Gibson $410,000 for  fraud.

Gibson doesn’t really tell a coherent story, and it is full of red flags, but here is what she says. She claims she was diagnosed with terminal brain cancer by a German alternative medicine practitioner. She believed the diagnosis, and was just “living her truth.” Therefore, she says, she never lied to her followers, she was lied to herself.

But her story of being a victim does not really hold together. In 2011 she was given a brain scan which found her to be perfectly healthy. So she knew at that time that she never had brain cancer. However, two years later she launched her wellness app in which she claimed her diet cured her of brain cancer. She also claims that she was about to come clean with her readers, but the media got to her first. Right.

Her claim of being a victim also doesn’t explain why the money that was apparently donated to charity via sales of her app never made it to the charity.

Those are a pretty damning set of facts, and her explanations don’t really cover them. I guess the Australian court agreed.

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Comments: 115

Sep 26 2017

Brain Stimulation in Coma

VNA for comaThe link to the article from the BBC Science News page reads, “Therapy “Wakes” Vegetative-State Patient.” The headline of the article was a bit more conservative, “Vegetative-state patient responds to therapy.” Annoying click-bait aside, what is actually going on here?

Like every such case so far, the improvement in neurological function in this patient with severe coma is extremely limited. This is mostly a proof of concept study, and the results are interesting, but the term “wakes,” even is quotations, is not even close to being justified.

Here is the case report: Restoring consciousness with vagus nerve stimulation. Even that title is a bit misleading – they aren’t saying they actually restored consciousness, just that vagus nerve stimulation might be a viable approach to develop. For background, a vegetative state is one in which basic neurological functions, like breathing, having a sleep-wake cycle, and some automatic movements, are retained. However, the conscious part of the cortex does not appear to be working. By definition there is no reaction to the environment.

By contrast a minimally conscious state has, as the name implies, minimal response to the environment. Patients in this state might blink to threat, or turn to a voice, but cannot communicate or participate in their daily activities. There is a continuum of neurological function from this minimal state to fully conscious.

As I have discussed before, researchers are trying to improve out ability to tell how impaired individual people are who clinically appear to be vegetative or minimally conscious. The challenge is that the neurological exam is limited. If the patient cannot follow commands, we have a limited ability to directly test which circuits in the brain are functioning. The patient may be more conscious than they appear to be because they are paralyzed or deaf, for example. Using functional MRI scanning and EEGs have enhanced our ability to assess brain function in these cases. Continue Reading »

Comments: 6

Sep 25 2017

Lying About Vaccines

Robert F. Kennedy Jr. talks with reporters in the lobby of Trump Tower in New York, Tuesday, Jan. 10, 2017, after meeting with President-elect Donald Trump. (AP Photo/Evan Vucci) Robert F. Kennedy Jr. talks with reporters in the lobby of Trump Tower in New York, Tuesday, Jan. 10, 2017, after meeting with President-elect Donald Trump. (AP Photo/Evan Vucci)[/caption]

Robert F. Kennedy Jr. considers himself an environmentalist. While advocating for the environment, he has become particularly concerned about the effects of mercury on human health. This in itself is reasonable, and there is broad scientific agreement that we should make efforts to minimize human exposure to mercury.

But Kennedy goes beyond reasonable recommendations based upon scientific consensus. He has become part of what we call, “The Mercury Militia” who have become unmoored from reality in their zeal to combat the perceived evils of mercury. The mercury militia further became tied to the anti-vaccine movement when it was claimed that the mercury in some vaccines was causing harm (it doesn’t). He has become a visible example of how someone can cocoon themselves in their own reality.

In a recent interview for Stat News Kennedy tells a number of falsehoods about vaccines. In essence he is lying, although it is possible he believes the lies he tells. Kennedy has apparently dedicated a large portion of his life to this issue, publicly advocates for his position, and certainly has resources at his disposal. And yet he gets basic facts about vaccines hopelessly wrong. How does that happen?

Paul Offit has written an excellent take down of Kennedy’s interview, explaining many of his falsehoods. For example, in the interview Kennedy claims: Continue Reading »

Comments: 9

Sep 22 2017

In Defense of Elitism

ID-OnlyBiologyClassOne thing I really like about sports is that it is the ultimate meritocracy. You are judged on your skills, talents, and ultimately your performance. Professional players are evaluated by the numbers, and traded accordingly. Their salaries are a direct reflection of their value to their team.

All this has even been reduced to a science, sabermetrics, which is praised for its cold calculating approach to exactly how much each player is worth to their team. I never hear complaints about this in professional sports. I only hear comments about how one’s favorite team is doing, and the performance of various players. You can even play “fantasy football” or other sports where you get to pick your own players based on their statistics.

This approach to professional sports is the ultimate in elitism. They even refer shamelessly to “elite players” without anyone batting an eye. There is no serious criticism of the NFL for unfairly discriminating against smaller players, or for the undemocratic way in which players are recruited. The hard work that leads to elite performance is also recognized and praised.

The same is true in other spheres of life as well, such as celebrity. I will not praise celebrity culture, but it is a simple fact that celebrities are generally judged on talent, skills, performance, and persona. Critics and fans are ruthless. This is true of actors, artists, and musicians. In Hollywood, elitism is institutionalized. There are arcane rules and negotiations about the order in which credits appear on the screen, based on the perceived elite status of the actor.

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Comments: 127

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