I find myself in need of a way to get to beaches and islands that are not accessible by car. The expense of a boat or a jet ski does not appeal to me. So a kayak seems the most natural option. Ah, but do you think it is easy to choose the right kayak [...]
Life on the Farnes
Stunning: adult Roseate Tern on Inner Farne (Paul Hackett) 
A shag sunning itself (David Andrews)
Life above ground - a Puffin chick (David Andrews)
Nearly there - Pied Wagtail brood at Longstone (David Andrews)
Inner Farne (David Andrews)Sunday 17th July comments: Some pictures from recent weeks to share.... life on the Farnes and everything that happens. Enjoy the photos.
Summer madness
Not like this today - a nice sunset over the islands 
Food galore - adult Puffin with prey (David Andrews)
The harsh realities of island life - a chick lost to a GullWednesday 20th July comments: Where has the summer gone? This week has brought rain, wind and cold temperature and it’s meant to be mid-July, not October! The seabird season is drawing to a close as successful family parties are starting to head off. The Puffins are massing and it won’t be long before they are all gone – so be warned, its your last chance to see them this year!
Other than that, the seawatching season has picked up with a reasonable count of Manx Shearwaters yesterday whilst wader numbers are increasing considerably.
Tuesday 19th July highlights: Manx Shearwater 335 north in evening, Arctic Skua 5N, Shoveler 1N, Black-tailed Godwit 1 on Knoxes Reef, Dunlin 26, Golden Plover 270, Sanderling 2 summer plumage adults, Knot 316, Purple Sandpiper 16 and Turnstone 200.
End game
First Fulmar chicks have started hatching (Ed Houlcroft)
Young Kittiwake on the wing (Ed Houlcroft)
Arctic Tern chick and fledger (Ed Houlcroft)Saturday 16th July comments: Where now heading for the 'end game' as the breeding seabirds start preparing for life away from the islands. Hopefully results will support the opinion that the season has been a huge success and it won’t be long before the islands change and the wardens can start various management work in preparation for next year
Recent days has seen a real increase in cetacean sightings, as following the two Risso’s Dolphins, we had six White-beaked Dolphins (through Inner Sound) which performed well just a few days ago. This was backed by a feeding Minke Whale off Brownsman – never a dull moment on the Farnes.
For the avid ‘seawatchers’ amongst the team, the first Sooty Shearwater has been logged whilst Arctic Skuas are now daily. It won’t be long before we welcome back our first migrant passerines and then the excitement will really begin. Role on the autumn.
Update at last!
Welcome to the world...Puffin chick emerges (Mark Breaks) 
I'm out! (Mark Breaks)
A white winger... (Mark Breaks)Tuesday 12th July comments: I keep saying it, but where has time gone? I’ve been away for just over a week and thought it was time for an update from the Farnes.
The breeding seabird season is almost over as the early nesters have now fledged chicks the the majority of other seabirds are almost done for the season. Although we’ve yet to crunch numbers, it appears to have been a very successful season for all seabirds concerned.
The majority of Arctic Terns have fledged two chicks per nest whilst good numbers of Sandwich tern young are now on the wing. Huge crèches of Shag young can be seen whilst vast numbers of fledged Kittiwakes indicates a brilliant season. The cliff-tops are also boasting great successes as Guillemots and razorbills have long gone (with good numbers of young)
As for the Puffins – despite the patchy weather, it’s been another good year and the number of chicks leaving under the cover of darkness has been staggering. It all indicates that the breeding season is almost at an end and we can all breath a big sigh of relief.
The islands are now starting to produce some interesting sightings and recent highlights included:
Risso's Dolphin – two south through inner Sound at 18:15 on 11th July
Spoonbill – one south over Longstone on 10th July
Roseate Tern – up to three are present daily with family parties expected to arrive over the next week or two
Wader passage is now underway with Green Sandpiper the highlight so far.
Nick Lachey and Vanessa Mannillo’s Wed on Private Island
According to People Magazine, choosing the location came just as easily for the couple
“We love to travel and we love Necker Island,” Lachey, 37, tells People. “We’ve vacationed there multiple times, and when we got engaged, we both immediately thought of the island as the perfect place to have our wedding.”
Adds Minnillo, 30: “We were on a boat, on vacation, passing the island and we both looked at each other and he said, ‘Yes!’ I was so glad he said what I was thinking. Nick saw it in my eyes.”
The 74-acre island was the picture perfect backdrop for their intimate nuptials, which were filmed for a TLC special.
“We used a lot of what the island had,” says Minnillo. “It was timeless, beautiful and romantic.”
Everything’s Bigger in BC
The province of British Columbia Canada is home to a temperate climate, stunning scenery and an abundance of big, beautiful islands.
In addition to being their bountiful size, BC islands are also relatively easy to purchase weather you are a local or foreign buyer. One of the newest islands to come on the market is West Ballenas Island. Over 100 acres in size, West Ballenas Island is the northernmost of the two magnificent Ballenas Islands located in the Strait of Georgia. Situated off of Vancouver Island’s beautiful east coast and only 10 km northwest of the city of Nanaimo, this spectacular private island provides a breathtaking setting. Easily accessible by boat and floatplane, this island is only minutes away from services and amenities and is well priced at less than $20,000 per acre!
For more information on this property visit Private Islands Online.
Travels with my shirt
What do you do when you’ve had a bad year? As Simon Fenton states, “I decided to do what any normal person would: cross the Sahara, by any means possible.” And, ‘by any means possible’, he was serious. But, you’ll have to find out for yourself if a donkey and a camel were really modes of transportation. Oh, and gris gris is usually very good mojo – at least from Simon perspective.
© Gretchen for TravelBlogs, 2011. |
Travels with my shirt |
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Post categories: Blogs
Post tags: Africa, cultural experiences, overland travel, solo travel
Sophie’s World
Anne-Sophie Redisch has been writing and traveling most of her life. She hasn’t always written about travel but she’s always been going somewhere – the more obscure, the better – but not always alone either. In her words, “I’ve travelled as a single mum for many years. In my experience, children and travel are easily combinable.” There are many who would agree wholeheartedly.
© Gretchen for TravelBlogs, 2011. |
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Post categories: Blogs
Post tags: Asia, cultural experiences, Europe, female travellers, parenting, Single Parenting, travel with kids, travel writer, USA
Galectin Therapeutics Taps Into University of Michigan Expertise – Genetic Engineering News
 Genetic Engineering News | Galectin Therapeutics Taps Into University of Michigan Expertise Genetic Engineering News Galectin_Therapeutics entered into a research collaboration with Jose Jalife, MD, of the University of Michigan Medical School, to better understand the relationship of galectin-3 to cardiac fibrosis in chronic cardiac arrhythmias. ... Galectin Therapeutics Announces Research Collaboration with Dr. Jose Jalife of ...MarketWatch (press release) |
OSU med school taps Yale prof as dean; Lucey leaving – Bizjournals.com
Columbus Dispatch | OSU med school taps Yale prof as dean; Lucey leaving Bizjournals.com Meanwhile, Dr. Catherine Lucey, who had been interim dean, is leaving Ohio State to become vice dean for education at the medical school of University of California at San Francisco, where she had served her residency in internal medicine. ... Ohio State medical school taps Yale professor as new deanMedCity News OHIO STATE NAMES YALE LEADER AS NEW DEAN OF MEDICINEDOTmed.com |
Program marks early step toward valley med school – Bakersfield Californian
Merced Sun-Star | Program marks early step toward valley med school Bakersfield Californian Christina Thabit's decision to attend medical school was largely influenced by doctors she met in her Bakersfield hometown, many of whom encouraged her to one day practice in the valley. ... UC Merced sees its first medical studentsABC30.com UC medical students introducedMerced Sun-Star 5 students admitted to UC Merced medical programVisalia Times-Delta KMPH Fox 26 all 9 news articles » |
UNR closer to buying home in Clark County for medical school dean – Las Vegas Sun
UNR closer to buying home in Clark County for medical school dean Las Vegas Sun Schwenk, who comes to Nevada from the University of Michigan Medical School, started work this month. He has decided to live in Reno, purchasing a home with his money, spokeswoman Anne McMillin said. However, Schwenk would divide his time and attention ... |
Halamka to resign from Harvard Med School CIO post – Mass High Tech
Mass High Tech | Halamka to resign from Harvard Med School CIO post Mass High Tech John Halamka, chief information officer at both Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School (HMS), is stepping down from his post at HMS. He announced the news Thursday on his blog, “Life as a Healthcare CIO ... Halamka To Leave Harvard Med School CIO PostInformationWeek |
UC Merced chief finds support for med school – Fresno Bee
Modesto Bee | UC Merced chief finds support for med school Fresno Bee There's overwhelming support for a medical school at University of California at Merced, the school's chancellor said Thursday during an editorial board meeting with the Sun-Star and The Modesto Bee. ... Medical students prep for programStockton Record Chancellor: Many roles for UC MercedSacramento Bee |
Small-Town Doctors Made in a Small Kansas Town – New York Times
New York Times | Small-Town Doctors Made in a Small Kansas Town New York Times The eight students at the University of Kansas medical school in Salina on Friday. Front, from left, Rany Gilpatrick, Claire Hinrichsen and Sara Ritterling; second row, Kayla Johnson, Erik Dill and Tyson Wisinger; back, Jill Corpstein and Daniel ... |
Pearce delays med school to sign with Wings – Detroit Free Press
Pearce delays med school to sign with Wings Detroit Free Press Jordan Pearce won't be heading to medical school for at least another two years. The Red Wings re-signed Pearce, 24, to a two-year, two-way contract Thursday. The goaltender originally signed as an undrafted free agent in 2009 ... |
Asthma, placebo, and how not to kill your patients
A number of years ago I was walking along Lake Michigan with a friend (a fellow medical resident) when she turned to me and said, “are you wheezing? Do you have asthma?” I had always been physically active and assumed my breathlessness while walking down the trail was due to the thirty extra pounds of pizza and doughnuts I’d acquired during residency. But she was right: I was wheezing and breathless and it didn’t feel good at all. I made an appointment with one of the hospital’s lung docs who took a good history, did a physical, and ran some pulmonary function tests. And I did have asthma. And it felt much, much better when I used proper medication, a feeling confirmed by my improving lung function tests. (Not too surprisingly, the asthma got even better when I lost 40 lbs and started treatment for my acid reflux.)
I still get mild asthma symptoms from time to time, especially when I get sick, but for many others, the picture isn’t so pretty. Asthma kills at least a quarter of a million people every year around the world. If you’ve ever worked in an ER and seen a kid with a bad asthma attack, you’ve earned a healthy respect for the disease. If you’ve ever watched your own kid gasping for breath, begging you to make it better, you’ve learned to fear it.
As our understanding of asthma has improved, so has our ability to treat it (an ability that is strongly linked to a patient’s socio-economic status. Mortality has been rising despite the discovery of better treatments. Wait: let’s pull this out of the parentheses…)… Asthma deaths and hospitalizations are largely preventable, and disproportionately affect Black and Hispanic Americans. We know how to treat the disease asthma, but don’t know how to treat the people who are affected most.
We understand that asthma is not just a tightening of the airways but also an inflammation that can cause long-term damage. Not only can we treat asthma, but we have objective ways of measuring how well our patients are doing. It’s easy and inexpensive to measure airway obstruction and response to medications. We know what works.
For this reason, a new study in the New England Journal of Medicine seems both wise and foolish.
(I thought I was so on the ball. I really did. But while I was busy riding my bike, playing with my kid, and looking at rentals with my wife, David Gorski and my other medical blogger pals were out in Las Vegas at TAM discussing the very study I wanted to tell you about.)
The study, called “Active albuterol or placebo, sham acupuncture, or no intervention in asthma,” was done for reasons that are not clear to me. It may have been done not to test the effectiveness of asthma therapy but to look at what a “placebo” might really be or do. At least, I think that was the idea. When reading the abstract and full text, it’s not actually clear why the study was done. At first it seems as if it were done to see why asthmatics treated with placebo improve:
In prospective experimental studies in patients with asthma, it is difficult to determine whether responses to placebo differ from the natural course of physiological changes that occur without any intervention.
Why ask such a question? We know that poorly-treated asthma is deadly, and well treated asthma much less so. Why do we care about placebo effects here? The authors explain further:
Placebo effects (i.e., benefits resulting from simulated treatment or the experience of receiving care) are reported to improve signs and symptoms of many diseases in clinical trials and in clinical practice. On this basis, the accepted standards for clinical-trial design specify that the effects of active treatment should ideally be compared with the effects of placebo. Despite this common practice, it is unclear whether placebo effects observed in clinical trials (or those that presumably occur in clinical care) influence both objective and subjective outcomes and whether placebo effects differ from the natural course of disease or regression to the mean.
In other words, the authors want to know what placebos actually do to real people, and they chose asthmatics because they are easy to study (there are symptom-assessment tools for subjective data and spirometry for objective data). This makes asthma both the right and wrong choice for the study. It’s an excellent model to assess the affect of placebo, but one in which the use of placebo is hard to justify on an ethical basis.
Not surprisingly, they found that “doing something” worked better than doing nothing. More specifically, they found that any placebo will make a patient feel subjectively better than doing nothing at all. They also found that all three placebos (sham acupuncture, fake inhaled medicine, and simply being enrolled in the study without treatment) improved objective measures of lung function, but not nearly as much as real medicine (in fact, not much at all).
In other words, simply attending to a patient makes them feel better. But to get a significant objective improvement (in asthma at least) you must also give them real medicine. Real medicine comprises both active medications and attending to the patient. There is no separate “placebo” that can be given to treat asthma effectively.
This is actually a quite beautiful study. It demonstrates that “placebo effect” is not the same as a real treatment, that real treatment always includes whatever benefit placebo provides, and that placebo is mostly an effect on subjective rather than objective measures of health. You can’t fix asthma with placebo, only with real treatment. But we’ve already known that from decades of studying asthma. So what other justification is there for doing this study?
Our research has important implications both for the treatment of asthma and for clinical-trial design in general. Many patients with asthma have symptoms that remain uncontrolled, and the discrepancy between objective pulmonary function and patients’ self-reports noted in this study suggests that subjective improvement in asthma should be interpreted with caution and that objective outcomes should be more heavily relied on for optimal asthma care. Indeed, although improvement in objective measures of lung function would be expected to correlate with subjective measures, our study suggests that in clinical trials, reliance solely on subjective outcomes may be inherently unreliable, since they may be significantly influenced by placebo effects. However, even though objective physiological measures (e.g., FEV1) are important, other outcomes such as emergency room visits and quality-of-life metrics may be more clinically relevant to patients and physicians. Although placebos remain an essential component of clinical trials to validate objective findings, assessment of the course of the disease without treatment, if medically appropriate, is essential in the evaluation of patient-reported outcomes. (Emphasis mine, PalMD)
This is folly. First, we have a huge literature on quality of life metrics in asthma. Huge. And we also know that objective changes in asthma are what save patients’ lives. Yes, I care how my patient feels, but it is not more “clinically relevant” than how they are actually doing physiologically. Both are important, but not equal. And the idea that comparing active treatment to placebo is not ideal is not new to researchers. It’s simply that following the natural history of the disease as a “control” is not usually appropriate (cf. Tuskegee syphilis experiment).
No good clinician would consider treating an asthmatic with placebo. Improper treatment of asthma leads to debility and death. This study chose mild asthmatics, but I still feel very uncomfortable with the ethics of the study design. Rather than using a disease we know how to treat to study placebo, we should be finding ways to get treatment to the millions of people who aren’t getting it.
References
Wechsler ME, Kelley JM, Boyd IO, Dutile S, Marigowda G, Kirsch I, Israel E, & Kaptchuk TJ (2011). Active albuterol or placebo, sham acupuncture, or no intervention in asthma. The New England journal of medicine, 365 (2), 119-26 PMID: 21751905
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Dummy Medicines, Dummy Doctors, and a Dummy Degree, Part 1: a Curious Editorial Choice for the New England Journal of Medicine
Background
This post concerns the recent article in the New England Journal of Medicine (NEJM) titled “Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma.” It was ably reviewed by Dr. Gorski on Monday, so I will merely summarize its findings: of the three interventions used—inhaled albuterol (a bronchodilator), a placebo inhaler designed to mimic albuterol, or ‘sham acupuncture’—only albuterol resulted in a clinically important improvement of bronchial airflow; for that outcome the two sham treatments were equivalent to “no intervention.” For all three interventions, however, self-reported improvements were substantial and were much greater than self-reported improvements after “no intervention.” In other words, dummy treatments made the subjects feel better, whereas real medicine not only made them feel better but actually made them better.
Before proceeding, let me offer a couple of caveats. First, the word ”doctors” in the flippant title of this post refers mainly to two individuals: Daniel Moerman, PhD, the anthropologist who wrote the accompanying editorial, and Ted Kaptchuk, the Senior Author of the trial report itself. It does not refer to any of the other authors of the report. Second, I have no quarrel with the trial itself, which was quite good, or with the NEJM having published it, or even with most of the language in the article, save for the “spin” that Dr. Gorski has already discussed.
My quarrels are the same as those expressed by Drs. Gorski and Novella, and by all of us on the Placebo Panel at TAM. This post and the next will develop some of those points by considering the roles and opinions of Moerman and Kaptchuk, respectively.
A True Story
Late one night during the 1960s a friend and I, already in a cannabis-induced fog, wandered into a house that had been rented by one of his friends. There were about 8-10 ‘freaks’ there (the term was laudatory at the time); I didn’t know any of them. The air was thick with smoke of at least two varieties. After an uncertain interval I became aware of a guy who was having trouble breathing. He was sitting bolt upright in a chair, his hands on his knees, his mouth open, making wheezing sounds. He took short noisy breaths in, followed by what seemed to be very long breaths out, as though he was breathing through a straw. You could hear the wheezing in both directions. Others had also noticed that he was in distress; they tried to be helpful (“hey, man, ya want some water or somethin’?”), but he just shook his head. He couldn’t talk. My friend, who had asthma himself, announced that this guy was having an asthma attack and asked if he or anyone else had any asthma medicine. No one did.
No one had a car, either, and for obvious reasons no one, not even the wheezing guy himself, was about to call 911. The nearest hospital was about 5 miles away. My friend said that the thing to do when someone has an asthma attack is leave him alone so he won’t get too excited, and he’ll get through it. Yeah, that must be right, we all figured; he has asthma too so he knows. We were all blowing smoke into the wheezing guy’s face as we expressed our concern.
At some point my friend and I left. The next day I heard that the guy with the asthma attack was eventually taken to the ER after another freak had come along who happened to have a car. The guy did alright, I guess. I don’t really know, but if he’d died I probably would’ve heard about it.
Several years later I went to medical school and began to learn about asthma, and as an internal medicine resident I saw enough patients with acute asthma attacks to realize, in a way that still makes me cringe, just how sick that guy had been and how totally clueless and selfish were we, his supposedly concerned companions. If the freak with the car hadn’t shown up…
Cultural Anthropology and Cultural Relativism
All of which has something to do with the surprise I felt a few days ago upon reading the following in the aforementioned editorial in the NEJM, the world’s most prestigious medical journal:
For subjective and functional conditions — for example, migraine, schizophrenia, back pain, depression, asthma, post-traumatic stress disorder, neurologic disorders such as Parkinson’s disease, inflammatory bowel disease and many other autoimmune disorders, any condition defined by symptoms, and anything idiopathic — a patient-centered approach requires that patient-preferred outcomes trump the judgment of the physician. Under these conditions, inert pills can be as useful as “real” ones…
Let’s see: asthma is a “subjective and functional condition”? In the bad old days of paternalistic medicine, the term “functional” meant “without demonstrable pathology.” It was usually synonymous with ”in your head”—whether the physician openly expressed that opinion or not. Doesn’t sound very “patient-centered” to me. I’m happy to report that you hardly ever hear ”functional” anymore, which reflects at least some measure of social progress for the profession. Since the term’s other possible meanings are nearly limitless and therefore vague beyond utility—every complaint or medical condition is in some way “functional,” after all—it seems reasonable to assume that the editorial’s author intended the old meaning, even if it and “subjective” are redundant.
Yet asthma is based in demonstrable pathology, as are most of the other named conditions, and in most of those (migraines, Parkinson’s disease, inflammatory bowel disease, and “many other autoimmune disorders”) there are specific treatments based on pathophysiology that, like albuterol for asthma, effect substantial, objective and subjective improvements. ”Idiopathic” refers to any condition whose cause is unknown, which includes most of those already mentioned and many other diseases for which medicines are effective for both objective and subjective outcomes (diabetes, Grave’s disease), and even some that are, for practical purposes, curable: Hodgkin’s disease, acute lymphocytic leukemia in children, some testicular cancers (remember Lance?), temporal arteritis, pernicious anemia, and many more. How could the author of a NEJM editorial be unaware of such commonplace medical facts?
The answer is that the author, Daniel Moerman, is not a doctor or even a biomedical scientist. He’s an anthropologist who seems to have confused sentimental and poetic aspects of his major academic interests—native American culture, medicinal plants, and healing rituals—with modern science and medicine. I urge you to consider his CV and the excerpts from his book Medicine, Meaning and the “Placebo Effect,” discussed by Dr. Gorski a few days ago. In the very first chapter he betrays more ignorance of medicine when he expresses surprise that a gastroenterologist didn’t find it odd that in a cohort of experimental subjects given only placebos for peptic ulcer disease, nearly half demonstrated healed ulcers after 4 weeks—about the percentage, I’d wager, whose ulcers would have healed with no trial intervention.
Regarding Prof. Moerman’s view of the sort of science that physicians need to know, along with Dr. Gorski I detect shades of Deepak Chopra, although I also detect a bit of down-home, folksy, isn’t-he-wise midwestern ambiguity, possibly delivered in a Mr. Ed voice, such as to give the good professor a way to deny it all. Consider this excerpt from the NEJM editorial, also noted by Dr. Gorski:
What do we learn from this study? The authors conclude that the patient reports were “unreliable,” since they reported improvement when there was none — that is, the subjective experiences were simply wrong because they ignored the objective facts as measured by FEV1. But is this the right interpretation? It is the subjective symptoms that brought these patients to medical care in the first place. They came because they were wheezing and felt suffocated, not because they had a reduced FEV1. The fact that they felt improved even when their FEV1 had not increased begs the question, What is the more important outcome in medicine: the objective or the subjective, the doctor’s or the patient’s perception? This distinction is important, since it should direct us as to when patient-centered versus doctor-directed care should take place.
Does he really believe that the subjective is the more important outcome? It certainly seems so; next he writes:
In a number of other trials in which both sham and actual treatments were evaluated, results were very similar. In one study of major depressive disorder, placebo, hypericum (St. John’s wort), and sertraline all resulted in about the same level of improvement on the Hamilton Rating Scale for Depression. Similarly, in studies of low back pain in both the United States and Germany, true acupuncture and sham acupuncture had about the same effectiveness yet were substantially better than usual medical care in relieving the pain. A number of surgical procedures — such as arthroscopic knee surgery and spinal vertebroplasty — have led to similar results with actual and sham treatments. In these studies and many more, inert treatments have had effects similar to their “active” analogues.
Woah! Sure, the subjective results of those trials “were very similar” to those of the albuterol trial, but so what? What distinguishes those trials from the albuterol trial is that there were no objective outcomes to measure! Moerman has missed the point of the distinction. He seems to prefer that medicine be about “a profound meaning response,” as he explained in an article written jointly with homeopath Wayne Jonas a few years ago, which comes awfully close to asserting that all “healing” is culturally determined:
Anthropologists understand cultures as complex webs of meaning, rich skeins of connected understandings, metaphors, and signs. Insofar as 1) meaning has biological consequence and 2) meanings vary across cultures, we can anticipate that biology will differ in different places, not because of genetics but because of these entangled ideas…
In the NEJM editorial Prof. Moerman doesn’t seem bothered by an inconvenient truth about objective outcomes. That is, maybe he doesn’t:
Maybe it is sufficient simply to show that a treatment yields significant improvement for the patients, has reasonable cost, and has no negative effects over the short or long term. This is, after all, the first tenet of medicine: “Do no harm.”
Prof. Moerman, what about the harm that comes from the NEJM seeming to judge treatments that offer favorable subjective outcomes as being equivalent to those that offer favorable objective outcomes? This kind of harm, for example. Asthma isn’t just a “subjective and functional condition,” whatever that is. It’s a real and potentially lethal disease. Oh, but you wrote “maybe.” Silly me.
Dr. Drazen, Where art Thou?
It is especially puzzling, considering the identity of its Editor-in-Chief, that the New England Journal of Medicine asked Daniel Moerman to write the editorial to accompany the report of the albuterol study. Jeffrey Drazen is not only a pulmonologist, but an expert in the pathophysiology of asthma. He has been instrumental in developing new drugs for asthma, drugs whose effects—I’m willing to bet, but I’ve no time to research right now—have been demonstrated objectively. If memory serves, Dr. Drazen trained at the old Peter Bent Brigham Hospital under ‘Reggie’ McFadden, whose chapter on asthma in my 2001 edition of Harrison’s Principles of Internal Medicine includes this passage:
The most effective treatment for acute episodes of asthma requires a systematic approach based on the aggressive use of sympathomimetic agents and serial monitoring of key indices of improvement. Reliance on empiricism and subjective assessment is no longer acceptable.
I’d be surprised if Dr. Drazen had ever heard of Moerman before the albuterol report was accepted for publication, and I wonder who recommended him. Kaptchuk, perhaps? Heh.
Unfortunately, someone isn’t minding the NEJM store when it comes to certain dubious topics, as Dr. Gorski mentioned and as I’ve written about previously.
Good News, Bad News
Perhaps Dr. Drazen imagines that the editorial won’t do any real damage, because real doctors will immediately identify it for what it is: Bullshit. That is probably true, except for the small but possibly growing number of “integrative” aficianados out there. I worry more about other Dummy Docs, such as naturopaths (ND=Not a Doctor, according to one apostate), who already believe wholeheartedly what Prof. Moerman “maybe” believes, and a lot more:
For an acute asthma attack try a steam inhalation (draping a towel over your head and a bowl of hot water) with a few drops of eucalyptus oil in the water. Be careful that the water is not so hot that the steam burns your face. Some doctors recommend taking baths with a cup or so of 3% hydrogen peroxide in the water to bring extra oxygen to the entire surface of the skin, thus making the lungs somewhat less oxygen hungry. This method can be performed preventively. Another technique for an acute attack is to drink some hot water with the juice of one clove of garlic. [etc.]
And:
How Can Homeopathy Help Asthma?
Like with Traditional Chinese Medicine, each individual is analyzed for their specific symptoms and an appropriate therapy is chosen, not for the disease, but for the person displaying signs of health out of balance. This is a very important distinction, and, very generally speaking, one of the main differences between conventional and “complementary” approaches to health care.After the homeopath, naturopath or medical doctor trained in homeopathy (they should have the title “Diplomat of Homeopathy” after their other credentials) listen carefully to your story, one of the following remedies are likely to be prescribed. [etc.]
What Kind of Subtle Energy Techniques Are Useful for Asthma?
Some folks like to work with flower essences. Some of the more popular ones to help with asthma are:
- oak
- mimulus
- larch
- wild rose
- hornbeam
- crab apple
- impatiens
- gentian
- Shasta daisy
- blackberry
- chamomile
- agrimony
- clematis
Other people find it useful to work with color, either by using thin plastic filters over light sources in their home or office environment, or by wearing clothes of specific colors. The following serves as a guide to experiment with color therapy to help asthma.
During an asthma attack try:
- purple (raises the threshold of pain and is soporific; is a vasodilator; slows heart rate) on face, throat and chest
- scarlet (acts as a stimulant to the kidney and adrenals) on kidneys
- orange (an antispasmodic) on throat and chest
- indigo or violet on throat, chest and upper back for 15 minutes
Etc., ad nauseam. Boy, do Dummy Docs love it when their pet treatments seem to be endorsed by real medicine, especially the highest bastions of real medicine. Science, even! Is it any surprise when something like this happens? Josephine Briggs, are you reading this? If so, please look here for more discussion of that case. You also won’t want to miss the sequel to this post.
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Salt: More confirmation bias for your preferred narrative
Judging by the recent press reports, the latest Cochrane review reveals that everything we’ve been told about eating salt, and cardiovascular disease, is wrong:
The New York Times: Nostrums: Cutting Salt Has Little Effect on Heart Risk
The Daily Mail: Cutting back on salt ‘does not make you healthier’ (despite nanny state warnings)
Scientific American: It’s Time to End the War on Salt
Sometimes it’s possible to completely miss this point. And that’s what’s happened here.
When it comes to health, it’s the hard outcomes we care about. We pay attention to measures like high blood pressure (hypertension) because of the relationship between hypertension and events like heart attacks and strokes. The higher the blood pressure, the greater the risk of these events. The relationship between the two is well established. So when it comes to preventive health, we want to lower blood pressure to reduce the risk of subsequent effects. Weight loss, diet, and exercise are usually prescribed (though often insufficient) to reduce blood pressure. For many, drug treatment is still required.
There is reasonable population-level data linking higher levels of salt consumption with higher blood pressure. From a population perspective, interventions that dramatically lower salt intake result in lower blood pressure. Not everyone responds in the same way — many people with normal blood pressure can regularly consume a high salt load without any apparent change in blood pressure. But not everyone, and not forever. Salt sensitivity seems to increase with age and is more pronounced in some ethnic groups, as well as in those with salt-sensitive conditions such as kidney disease. And chronic high levels of salt consumption may be associated with the subsequent emergence of hypertension. There may be additional effects, unrelated to blood pressure, too. However, the causality between salt consumption, and all of these negative effects, is less clear.
So does reducing dietary salt reduce cardiovascular events? That’s the key question. To definitively answer the question, we’d randomize patients to high- and low-sodium diets, force them to follow these diets for years or decades, and monitor consumption, blood pressure, and cardiovascular events. We’d also want to explore the factors that seem to make some more sensitive to the effects of salt than others. To ensure we could see a difference (if it exists), we’d need a large sample size — hundreds or thousands of people, ideally. See any problems with the feasibility? Like any dietary intervention trial, this type of study would be exceptionally difficult to do — forcing dietary changes is very difficult, and cannot be done in a blinded manner. Even randomization is unlikely to be effective in ensuring there’s adherence — established dietary habits don’t lend themselves to long-term change easily. So we must look to lower-quality evidence — inferences from observational studies that have tracked consumption, or indicators like blood pressure and salt consumption in the short-term. And there are fair criticisms of the data. Some see relationships, and others dismiss them.
When it comes to clinical practice guidelines, low salt diets are the mainstays of pretty much every set of guidelines on the management of high blood pressure. The evidence supporting the relationship with hard outcomes is robust, but not rock-solid. We don’t have causal data, but we do have considerable epidemiologic evidence to suggest that reducing dietary salt consumption is likely to offer net benefits in the management of hypertension.
And that’s where the recommendations to cut salt come from. The vast majority of the salt we eat (75%) is from processed foods. Restaurants are a large source, too. Few foods in their original state are naturally high in salt, and in general, we don’t add that much at the table. Interestingly, when foods are reduced in sodium, we don’t tend to add the same amount back at the table. So public health initiatives have concentrated on a few strategies: education on how to reduce your own salt consumption, and putting pressure on packaged food manufacturers to reduce the amount of sodium that they use in their products. But reducing salt may hurt sales: if we’re accustomed to eating salty foods, low-salt foods taste unpalatable. Just last week Campbell Soup Company announced that it’s raising the salt content in its products in an attempt to boost sagging sales.
So do dietary intervention strategies work? That’s what a recent Cochrane review attempted to answer. But you wouldn’t know it, based on the headlines above. Scientific American described the paper as:
This week a meta-analysis of seven studies involving a total of 6,250 subjects in the American Journal of Hypertension found no strong evidence that cutting salt intake reduces the risk for heart attacks, strokes or death in people with normal or high blood pressure.
Eating less salt will not prevent heart attacks, strokes or early death, according to a major study.
Its findings contradict all recommendations by the Government and medical profession urging the public to reduce the amount of salt they consume.
Neither statement accurately describe the findings. Rod Taylor and colleagues set out to do a meta-analysis of dietary intervention studies. They analyzed only studies that measured the effects of dietary interventions that restricted salt consumption, or where the intervention was advice to reduce salt consumption. This was an update of a prior analysis.
Seven studies made up this meta-analysis, including 6,489 patients in total. Three studies looked at those with normal blood pressure, two included patients with high blood pressure, and one was a mixed population, including patients with heart failure. The overall effect? Interventions had small effects on sodium consumption, which led to small effects on blood pressure. There was insufficient information to analyze the effects on cardiovascular disease endpoints.
The authors go on to make the following point, which was ignored in the media coverage:
Our findings are consistent with the belief that salt reduction is beneficial in normotensive and hypertensive people. However, the methods of achieving salt reduction in the trials included in our review, and other systematic reviews, were relatively modest in their impact on sodium excretion and on blood pressure levels, generally required considerable efforts to implement and would not be expected to have major impacts on the burden of CVD.
The authors did not conclude that reducing salt consumption is ineffective. They concluded that interventions such as dietary advice, do not result in substantial reductions in consumption. As expected, blood pressure didn’t change much as a consequence. This finding should not be a surprise. Given the vast majority of salt is consumed via processed foods, it should come as no surprise that dietary approaches are modestly effective at reducing consumption.
Despite the modest and equivocal results, the authors seem to have lost the narrative on their own research findings:
Professor Rod Taylor, the lead researcher of the review, is ‘completely dismayed’ at the headlines that distort the message of his research published today. Having spoken to BBC Scotland, and to CASH, he clarified that the review looked at studies where people were advised to reduce salt intake compared to those who were not and found no differences, this is not because reduced salt doesn’t have an effect but because it’s hard to reduce salt intake for a long time. He stated that people should continue to strive to reduce their salt intake to reduce their blood pressure, but that dietary advice alone is not enough, calling for further government and industry action.
Conclusion
The true finding from the Cochrane review is that dietary interventions to reduce salt intake are largely ineffective at reducing salt consumption. Salt’s impact on cardiovascular events is less clear than its effects on blood pressure. And the long-term benefits of population-level interventions to reduce dietary salt consumption are not yet well established. Until the data are more clear, you can find the data to support whatever narrative you believe. If you want to demonize salt and ignore other factors that contribute to poor cardiovascular outcomes, you can do that. And if you believe that interventions to reduce salt consumption are misguided and unwarranted, and symptomatic of an overreaching nanny state, then you can find data to support that position, too.
My personal take is that most of us will ultimately end up with salt-sensitive conditions. Odds are good we’ll be hypertensive, too. Gradually reducing our chronic salt consumption would seem to be a conservative approach — not by focusing strictly on the salt, but by working to reduce the consumption of salty, processed foods, and substituting healthier, more nutritious choices instead. But I won’t worry when I finish an entire bag of chips — I’ll consider it in the context of an overall strategy: a diet that minimizes processed foods, maintaining an appropriate weight, and getting regular physical exercise.
Reference
Taylor RS, Ashton KE, Moxham T, Hooper L, & Ebrahim S (2011). Reduced dietary salt for the prevention of cardiovascular disease. Cochrane database of systematic reviews (Online), 7 PMID: 21735439
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