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The 2010 Lorne Trottier Public Science Symposium
I really have to give those guys at McGill University’s Office for Science and Society credit. They’re fast. Remember how I pointed out that I’ve been away at the Lorne Trottier Public Science Symposium? This year, the theme was Confronting Pseudoscience: A Call to Action, and I got to share the stage with Michael Shermer, Ben Goldacre, and, of course, our host, “Dr. Joe” Schwarcz. Sadly, I couldn’t stay to see The Amazing Randi do his thing yesterday evening, but at least I did get to have breakfast with him before I left.
In any case, the reason I have to hand it to Dr. Joe and his team at McGill is because they’ve already uploaded all the videos for symposium events. Here’s the main page with the videos (the 2010 Trottier Symposium occurred on October 17, 18, and 19), and here are the individual links:
- 2010 Lorne Trottier Roundtable (moderated by Dr. Joe Schwarcz)
- 2010 Lorne Trottier Public Syposium (Drs. Ben Goldacre, Michael Shermer, and David Gorski; note that my talk is the second talk)
- Investigating Pseudoscientific & Paranormal Claims with James Randi
And, because I can’t resist, here are some photos taken with various people’s cell phone cameras. First, we have a lovely poster of woo that I saw at the restaurant where we had lunch on Sunday and just had to snap a quick picture of:
Bummer that we missed the event.
Sadly, even the McGill University Bookstore is not entirely immune to woo. Fortunately, the alternative medicine section was quite tiny compared to the science and medicine sections, and Dr. Joe is around McGill to try to make sure that things don’t get too far out of hand. But it did exist, and Michael Shermer and I couldn’t resist mugging a bit with a reflexology book while Dr. Joe observed off camera with a bemused look on his face:
I also got to hang out a bit with Ben Goldacre, who is a really fun guy. Sadly, our schedule was so packed that I never got a chance to hit a pub and hoist a pint with him. I did, however, manage to persuade Ben that he really does need to check out a certain obscure British SF show from the late 1970s/early 1980s that continues to inspire a “friend” of mine:
I also got to meet Dr. Richard Margolese, who is a huge name in breast surgery, having been a major player in many of the classic NSABP studies that defined how we treat breast cancer today. Foolishly, I never got my picture taken with him, but you can see him in the roundtable discussion we had as proof that I was in the same room with him, at least.
Finally, here’s the crew:
From left to right: Dr. Joe Schwarcz, James Randi, Dr. Ben Goldacre, yours truly, Lorne Trottier, and Dr. Michael Shermer.
Not pictured is Emily Shore, who did incredible work organizing the event, herding the cats, and making sure speakers got to where they needed to be when they needed to be there. A great time was had by all, and I can’t begin to express how grateful I am to Dr. Joe Schwarcz, Dr. Ariel Fenster (to whose chemistry class I gave a talk on Tuesday), Dr. David Harpp, Emily Shore, and, of course, Lorne Trottier, who funds this conference every year and, I hope, will continue to fund it for years to come.
Heart disease: one of science-based medicine’s great successes
Sixty years ago, the world was full of miracles. Western Europe was recovering from the devastation of World War II, an agricultural revolution promised to banish the fear of starvation in large parts of the world, and the mythical Mad Men era gave Americans a taste of technology-dependent peace and prosperity unlike any in the past. Despite the technological progress that would soon send animals into space and return them relatively unharmed, Americans, and westerners in general, were still dying of heart disease at a frightening rate. If you, as a middle aged American, experienced chest pain and were lucky enough to make it to a hospital (about 20% of all sufferers would die immediately), you would probably be given nitroglycerin and morphine to control you pain, put on bed rest, and could expect to live a few more years, with limited physical activity.
Heart disease continues to be a top killer of Americans, but there has been a dramatic decline in heart disease mortality in the last 60 years, with age-specific mortality rates dropping 60%. Fewer people are developing heart disease, and those that have it are living longer. It is estimated that in 2000 alone, there were 341,745 fewer heart disease deaths than would have been expected if rates had remained unchanged. This decline has not been driven by a renaissance of alternative medicine. It has been driven by science.
The trend has been going on for many decades, and has been accelerating, although current trends in diabetes and obesity put us at risk for more overall cases of heart disease in the future. So what are we doing right? How have we managed to cut the death rate from heart disease so dramatically?
So-called alternative medicine practitioners seem hell-bent on finding evidence-free ways to prevent and fight disease. No lie is too blatant in the pursuit of their ideology. For example, one chiropractic website claims that everything we think we know about prevention of heart disease is wrong:
The tyical risk factors include high cholesterol, smoking, high blood pressure, and diabetes. Prescription drugs serve as these programs’ centerpiece, with counseling and education as adjunct treatments. They are spearheaded by the American Heart Association, the American Medical Association, local and state governments, and even the federal government.
Yet 10 years ago study results by the Cochrane Heart Group and The Cochrane Collaboration (http://www.cochrane.org/) showed that treating risk factors was “ineffective in achieving reductions in total or cardiovascular disease mortality (death).”
Of course, we don’t get a real citation to follow. One of the most offensive investigations into heart disease prevention is the TACT trial, an unethical trial asking a question that doesn’t require an ethics-free clinical trial to answer. We know a lot about heart disease. And we know this because of well-designed trials and studies that ask the right questions. The medical literature over the last 30 years has seen a flood of studies of heart disease. As would be expected, most are incomplete, answering only one or two questions, and studies often conflict. But over time, trends emerge, and the truth precipitates from the noise.
In reducing heart disease mortality, there have been different relative contributions from primary prevention (preventing new cases of heart disease) and secondary prevention (preventing recurrent cases). A recent study in the American Journal of Public Health analysed data from 1980-2000. The authors found that most of the reduction in deaths from heart disease (nearly 80%) were due to primary prevention, specifically decreasing smoking rates, and improvements in blood pressure and cholesterol levels. Society-wide reductions in smoking, blood pressure, and cholesterol are saving hundreds of thousands of lives in the U.S. every year. This is a different conclusion than that of the Virginia chiropractors who once read an un-citable Cochrane review.
What’s best about these data is they give us guidance; real science gives us real predictions. The smoking rate in the US is still hovering around 24%. More than half of people with known high blood pressure do not have their blood pressure under control. Evidence shows us that we can easily prevent more heart attack deaths through education and through better adherence to extant treatment guidelines. Behavioral changes such as smoking cessation, diet and exercise, and the proper use of medications can all contribute to the fight against heart disease. Reducing heart disease deaths isn’t all that complicated, and it won’t take miracles. We just have to follow the evidence.
*Similar trends have been seen in other English-speaking countries
References
Hurlburt CW (1927). THE CARDIAC CRIPPLE. Canadian Medical Association journal, 17 (11), 1305-9 PMID: 20316574
Sytkowski PA, Kannel WB, & D’Agostino RB (1990). Changes in risk factors and the decline in mortality from cardiovascular disease. The Framingham Heart Study. The New England journal of medicine, 322 (23), 1635-41 PMID: 2288563
FRY J (1964). CORONARY HEART DISEASE IN GENERAL PRACTICE: NATURAL HISTORY OVER TWELVE YEARS (1950-1961). Proceedings of the Royal Society of Medicine, 57, 39-42 PMID: 14114173
Centers for Disease Control and Prevention (CDC) (1999). Decline in deaths from heart disease and stroke–United States, 1900-1999. MMWR. Morbidity and mortality weekly report, 48 (30), 649-56 PMID: 10488780
Young, F., Capewell, S., Ford, E., & Critchley, J. (2010). Coronary Mortality Declines in the U.S. Between 1980 and 2000 Quantifying the Contributions from Primary and Secondary Prevention American Journal of Preventive Medicine, 39 (3), 228-234 DOI: 10.1016/j.amepre.2010.05.009
Wijeysundera HC, Machado M, Farahati F, Wang X, Witteman W, van der Velde G, Tu JV, Lee DS, Goodman SG, Petrella R, O’Flaherty M, Krahn M, & Capewell S (2010). Association of temporal trends in risk factors and treatment uptake with coronary heart disease mortality, 1994-2005. JAMA : the journal of the American Medical Association, 303 (18), 1841-7 PMID: 20460623
Influenza Vaccine Mandates
I have been involved in infection control and in what is now called quality for my career. Since infection control issues can occur in any department, my job involves being on numerous quality related committees (Medical Executive, Pharmacy and Therapeutics, etc) where I have witnessed or participated in what seems to be innumerable quality initiatives.
It always gripes my cookies when someone says “Get your own house in order,” because that is a person who evidently is arguing from ignorance. Since To Err is Human was published at the turn of the century, the hospital systems in Portland and across the country have invested significant time and money into quality improvement. Do a Pubmed on ‘Hand Hygiene Compliance’ in the last decade; there are over 400 references. Or ‘deep venous thrombosis prophylaxis’ — over 5,000 references. Or ‘ventilator associated pneumonia prevention’ — over 750 references. Pick a topic related to safety and quality and search the literature, and you will find a remarkable amount of research into the best ways to decrease morbidity and mortality in the hospital.
Hospitals, at least those in my city, take safety and quality very seriously, and by applying the results of these studies, there has been a marked decrease in mortality and morbidity in my institutions. Compared to historical controls, we estimate we have, in the last 2 years, prevented about 600 hospital acquired infections and over 200 deaths. Those numbers are not fudged, but real progress. I make, or made, a large chunk of mortgage payment from hospital acquired infections. Not any more.
Not a single intervention we have implemented has required the use of a SCAM. We did not need to introduce reiki or homeopathy or acupuncture into the hospitals to get these benefits. Nope. Not a one. Just the application of science-based medicine. It did require an immense amount of time and energy, because human behavior and hospital systems are complex and making changes that are effective and can be incorporated into in the busy work environment of the hospital is not as easy as one would think.
Not only has the implementation of all our quality initiatives not required the input of any SCAMs, it is difficult to find a reference where the SCAM community is making any efforts to improve their quality. Take hand hygiene, probably the most important intervention you can do to decrease the spread of infectious diseases.
In the chiropractic literature there is one study. Acupuncture and naturopathy? None. These are the three fields that are often associated with Institutions of <sarcasm> Higher Learning </sarcasm> and they are not publishing in areas of quality. Of course, evaluating quality interventions requires a firm understanding of the scientific method, not, given their curricula, one of their strong points.
There is one quality indicator where we still lag: influenza vaccine compliance. Locally and nationally, it is rare to get influenza vaccine rates above 50%. It is a condition of employment in health care, or at least in hospitals, that all the workers are vaccinated, or immune from prior illness, to a number of infections including chicken pox, mumps, hepatitis B, and measles. Most of the infections are those that can be transmitted from the health care providers (HCP) to their vulnerable patients. All the employees are immune to these diseases and, if at the time of employment they refuse the vaccines, they get the opportunity to find employment elsewhere. No exceptions.
The influenza vaccine is different; at most institutions it is not mandated and compliance is low. In recent years I have gone on the wards with the flu cart and given influenza vaccinations to the staff. It is fun and you get the opportunity to talk with your colleagues about the importance of vaccination and answer their questions. There are always one or two who will not make eye contact and avoid me so they do not need to get the shot or to engage in conversation with me. But most people, even those who may refuse the vaccine, will talk to me and, even if I do not convince them on the spot, I will give them something to think about. Some websites trumpet the low compliance of health care workers (HCW) as evidence that the HCW’s know something that the rest of us do not, and that is why they are not vaccinated. I have yet to hear a compelling reason outside of Guillian Barre and anaphylaxis. Instead I hear a variety of myths or misunderstandings. I address those arguments with a slightly more snarky tone over on my Medscape blog, A Budget of Dumb Asses. It is worth the every penny of the free registration for the opportunity to read it.
There is a movement to make flu vaccine mandatory, a condition of employment, for health care providers as well. The Society for Healthcare Epidemiology of America (SHEA) released a position paper, supported by the Infectious Disease Society of America, that recommends the influenza vaccine be mandatory for HCP’s. To the surprise, I am sure, of no one, I would support such a move.
There are three reasons to make the vaccine mandatory: two evidence-based, one philosophical.
There are careers where you are expected to place the needs of others ahead of your own. The most extreme example is the military or the secret service, where it is expected that you might die as a result of your job. Less extreme examples include policemen, firemen, and, yes, health care providers.
Medicine is more than a job. It is a calling, which is a weird thing for me to say, because it is a calling to what? Or whom? Got me. But it is. In medicine the expectation is that I will care for anyone who comes my way and that I will place the patients needs before my own.
I remember the old days, standing at the bedside of AIDS patients, with no idea what caused the disease or how it was spread, hoping that the (it turned out excessive) gowns and gloves would prevent transmission of the disease to me. But I, and my colleagues, did the work. And should plagues, known and unknown, strike again, as they will, I expect that most of my colleagues will be at my side, tending to the ill, regardless of the personal risk. Society expects that we will be there.
HCP’s have an moral obligation to minimize the chance that will harm will occur to patients, many of whom are particularly vulnerable. This duty is summed up in the three laws of health care:
- A HCP may not injure a human being or, through inaction, allow a human being to come to harm.
- A HCP must obey any orders given to it by SBM, except where such orders would conflict with the First Law.
- A HCP must protect its own existence as long as such protection does not conflict with the First or Second Law.
SHEA summed it up:
Those in support of mandatory programs argue that influenza vaccination is an ethical responsibility of HCP, because HCP have a duty to act in the best interests of their patients (beneficence), to not place their patients at undue risk of harm (nonmaleficence), and to protect the vulnerable and those at high risk of infection. The duty to put patient interests first is outlined in nearly every professional code of ethics in medicine, nursing, and other healthcare fields.
The influenza vaccine is safe. Serious side effects are extremely rare and the risks from influenza are much greater. The vaccine is far safer than driving (30,000 deaths a year), taking a bath (450), or standing under a coconut tree (130). Of course people are not good at evaluating relative risks. I had a patient with a heart valve infection from heroin use who smoked 2 packs a day, drank a fifth a day, and rarely showered; but when he came in with new shortness of breath and I wanted to get a chest x-ray, he refused because he was worried about the radiation exposure. So it is with vaccine. Some people have a feeling, unsupported by the literature, that vaccines are unsafe, and if they were unsafe, I would not and could not recommend mandatory vaccination.
In adults
In placebo-controlled studies among adults, the most frequent side effect of vaccination was soreness at the vaccination site (affecting 10%–64% of patients) that lasted less than 2 days. These local reactions typically were mild and rarely interfered with the recipients’ ability to conduct usual daily activities. Placebo-controlled trials demonstrated that among older persons and healthy young adults, administration of TIV is not associated with higher rates for systemic symptoms (e.g., fever, malaise, myalgia, and headache) when compared with placebo injections. One prospective cohort study indicated that the rate of adverse events was similar among hospitalized persons who either were aged 65 years and older or were aged 18–64 years and had one or more chronic medical conditions compared with outpatients. Among adults vaccinated in consecutive years, reaction frequencies declined in the second year of vaccination. In clinical trials, serious adverse events were reported to occur after vaccination with TIV at a rate of less than 1%. Adverse events in adults aged 18 years and older reported to VAERS during 1990–2005 were analyzed. The most common adverse events reported to VAERS in adults included injection-site reactions, pain, fever, myalgia, and headache. The VAERS review identified no new safety concerns. Fourteen percent of the TIV VAERS reports in adults were classified as serious adverse events, similar to proportions seen overall in VAERS. The most common serious adverse event reported after receipt of TIV in VAERS in adults was GBS. The potential association between TIV and GBS has been an area of ongoing research (see Guillain-Barré Syndrome and TIV). No elevated risk for prespecified events after TIV was identified among 4,773,956 adults in a VSD analysis.
Then there is efficacy. I have discussed the efficacy of the flu vaccine before. In the hospital, there is no single intervention that will prevent the spread of infection. One of the hallmarks of anti-science/anti-vaxers is a binary approach: either the medical intervention is 100% effective or it is 100% useless. It is rare to see a nuanced discussion of the science behind the efficacy of the flu vaccine on the anti-vax web sites. Success in decreasing transmission of disease is always multifactorial: hand hygiene, cough etiquette, not coming to work when ill (an all-too-common problem), proper isolation for those who may have influenza, and more are part of a multifaceted approach to prevent the spread of infection in hospitals. Vaccines are like Captain Crunch: only part of a healthy breakfast.
The rationale for vaccinating HCW’s is also multifaceted.
We do not want health care providers to be disease vectors for our patients, most of whom are at high risk for bad outcomes from influenza.
Many of our patients may not be vaccinated or be unable to respond to the vaccine (the old and immunoincompetent) and are not protected from influenza.
There are 4 studies that demonstrate when HCW’s are vaccinated, mortality declines in residents of long term care facilities (the current phrase for nursing home). While similar studies have yet to be done in hospitals, there are multiple lines of data that converge on the same conclusion: the more people that are vaccinated against the flu, the fewer people who die.
The Cochrane review, as always with influenza, gets it wrong. While noting that “pooled data from three C-RCTs showed reduced all-cause mortality in individuals >/= 60.”, they go on to say “The key interest is preventing laboratory-proven influenza in individuals >/= 60, pneumonia and deaths from pneumonia, and we cannot draw such conclusions.” No, it is not the key interest. Most deaths from influenza are secondary deaths from exacerbation of underlying medical problems. All-cause mortality is an important endpoint, especially if you are the one dying.
The recent Skeptics Guide to the Universe podcast (#274) had an interview with Ben Goldacre, author of Bad Science and discussed big pharma malfeasance, of which there are endless examples. They noted that the makers of olsetamivir (Tamiflu) did not want to give the unpublished data from clinical trials to the Cochrane group for fear they would make a botch of the data. For once I am sympathetic to big pharma, given the bias and spin (i.e. they do not agree with me) of the Cochrane reviews on influenza treatment and prevention. I would not give my influenza data to the current crop of Cochran flu reviewers if I were a drug company, and I am no fan of the shenanigans that so often define the interactions of pharmaceutical companies and science.
I can, at some level, understand the opposition to mandatory vaccination as a philosophical position, although I see it on par with opposition to mandatory sterile technique in the OR. Many philosophical positions are at odds with reality. But you will excuse me if I neither let you operate in my hospital nor take care of my patients. I cannot see where your philosophy gets to triumph the material safety of patients.
Several institutions and health care systems have instituted mandatory vaccination with good results, achieving 96% and greater vaccination rates.
I get the sense that those who rail against the morbidity and mortality of modern medicine are the same who would decry mandatory vaccination, even though it would improve the safety in the hospital that they so fret about.
I completely support the SHEA/IDSA position. The vaccine is safe, effective, and HCP’s have a ethical and professional imperative to prevent the spread of infection to their patients.
SHEA views influenza vaccination of HCP as a core patient and HCP safety practice with which noncompliance should not be tolerated. It is the professional and ethical responsibility of HCP and the institutions within which they work to prevent the spread of infectious pathogens to their patients through evidence-based infection prevention practices, including influenza vaccination. Therefore, for the safety of both patients and HCP, SHEA endorses a policy in which annual influenza vaccination is a condition of both initial and continued HCP employment and/or professional privileges.
Sounds good to me.
SBM Host Change
Tonight (Friday Night) we will be moving SBM to a new faster host. This will improve the performance of SBM, which has been sluggish recently, and give us the ability to increase our resources as needed as SBM continues to grow.
Comments posted between Friday night and approximately Sunday morning may be lost in the gap as the location of the new servers propagates through the internet. The site will be up throghout this process, but comments may be lost during this period. We are making the move over the weekend because that is when traffic is lowest. SBM should be fully functional by Monday morning, and in any case I will update this post when it appears that the move is complete.
Thanks for your patience.
At the Lorne Trottier Symposium…
I have to apologize. There won’t be one of my usual epic posts this week. Fear not, however. I did get another SBM blogger to pinch hit for me in a post that will appear later today. I also had time to write a quick post announcing an initiative we here at SBM are planning for early November.
The reason for the rare occasion of my missing a week, of course, is that I’m participating in the 2010 Lorne Trottier Public Science Symposium in Montreal. Between all the travel, a two hour roundtable discussion featuring Michael Shermer, Ben Goldacre, and yours truly, among others, all organized by the McGill University’s Office for Science and Society. The event was videotaped, and a webcast of the event will be available, as will a webcast of our talks tomorrow. You can trust that I will certainly post links to them after they have been posted on the McGill website, in particular the symposium itself, so you can for yourselves see how much better speakers Michael Shermer and Ben Goldacre are when compared to me.
I’ll also be on the radio on CJAD AM 800 at 10 AM Monday morning with Michael Shermer and “Dr. Joe” Schwarcz to talk about pseudoscience in medicine and other areas.
Yes, I’m having a blast here, having had the opportunity at a leisurely dinner to discuss differences between the quackery situation in England compared to the U.S. and to meet Lorne Trottier. Now I have to fine tune my talk for tomorrow, and it’s late. Oh, well…
Acupuncture and history: The “ancient” therapy that’s been around for several decades
Make the lie big, make it simple, keep saying it, and eventually they will believe it
– A. Hitler
It seems that just about every article about acupuncture makes some reference to it having been used in China for thousands of years. The obvious reason for such a statement is to make the implication that since it’s been around for so long, it must therefore also be effective. Of course, longevity doesn’t argue for efficacy, otherwise everyone would likely agree that astrology is the way to chart one’s life; astrology has been practiced for many more years than acupuncture.
What’s maddening about the acupuncture longevity myth is that it isn’t true, and demonstrably so. In human medicine, “needling” was illustrated in the 17th century by western observers: no points, no “meridians,” just a big awl-like “needle,” driven in with an ivory-handled circular hammer. In addition, the rationale for hammering these little spikes into various spots (of the practitioner’s choosing) was said to be “exactly the same” as Greek humoral medicine (see, Carruba, RW, Bowers, JZ. The Western World’s First Detailed Treatise on Acupuncture: Willem ten Rhijne’s De Acupunctura. J Hist Med Allied Sci (1974) XXIX (4): 371-398).
The same fallacious assertion is repeated (repeatedly) in veterinary medicine. Acupuncture proponents may assert, for example, that acupuncture is “4,000 years old.” While the assertion isn’t true, it’s also ridiculous, since the Chinese hadn’t invented writing 4,000 years ago. Even if the assertion were true, there would be no way to possibly know about it, since no one could have written anything down about the practice.
Regardless, recently, we published the first detailed research paper on the history of veterinary medicine in China. The paper was published in July, in the historical journal Sudhoffs Archiv (Buell, P, May, T, Ramey, D. Greek and Chinese Horse Medicine: Déja Vu All Over Again. Sudhoffs Archiv. 2010: 94: 31-60). It is one of the first papers published that looks at the actual historical source material, and the only one that compares the veterinary medicine of ancient China to contemporary practices in the ancient world.
Based on the historical source material, it can be stated that Chinese veterinary medicine isn’t unique, and it isn’t even particularly Chinese. That is, what is presented to the eager public as the essence of Chinese thought and practice is, in fact, just an adaptation of contemporaneous practices in Greece and the Middle East. In fact, most Chinese practices, such as bleeding, and burning at points, appear in Greek, Egyptian, and Arabic sources long before they were ever mentioned in China. Such practices first appear in China during a period of maximal western influence on China, corresponding with regular traffic on the Silk Road (during Han times, approx. 200 BCE – 200 AD), as well as with the coming of Buddhism, which brought in influences from Indian traditions.
It’s remarkable – and particularly so in the face of all of the modern crowing about the antiquity of acupuncture in animals – that there is no reference to what can even be remotely considered as modern acupuncture in any of the pre-modern Chinese veterinary works (which deal mostly with horses, camels, and water buffalo). This may be due to incorrect translation of the Chinese word zhen, which means “incision” or “penetration,” and also used to describe cauterization and bleeding, but which has been apparently somehow morphed into “acupuncture” anytime that the word appears in Chinese sources. It’s absolutely clear that zhen has nothing to do with modern acupuncture, even as it’s equally clear that acupuncture proponents will insist on misinterpreting the Chinese language to suit their preconceived notions.
The Chinese, as with every other ancient culture, didn’t have much of an idea of horse physiology, and their treatments were based on anecdote and tradition. The fact is that the Chinese didn’t have any better idea about what caused conditions such as colic (abdominal distress) or foot pain than did other cultures, and they really didn’t treat them much differently. Until scientific investigations came along, people didn’t really know what they were doing when it came to practicing medicine. There’s no reason to try to go back to such traditions; there’s especially no reason to do so when they didn’t exist in the first place.
Joe Mercola and Barbara Loe Fisher declare November 1-6, 2010 “Vaccine Awareness Week”? Not so fast!
As I pointed out earlier, a rare thing happened this week, namely I don’t have a full post ready for Science-Based Medicine because I’m at the Lorne Trottier Symposium. Not only have the organizers have packed my day with skeptical and science goodness, but I only have Internet access when I’m back at the hotel, which isn’t very often. I suppose I could pay outrageous international roaming charges by activating international roaming on my iPhone, but why on earth would I do that except in urgent circumstances? Fortunately, David Ramey stepped in with his usual excellent work.
The trials and tribulations of actually trying to do more than be at home, work, and blog aside, I couldn’t let this one pass. The ever-observant Mark Crislip sent his fellow SBM bloggers this little tidbit from the website of that well-known promoter of quackery Joe Mercola. Buried near the bottom of Mercola’s “newsletter” is an announcement of this intriguing (from a blog fodder perspective) initiative:
Mercola.com & NVIC Dedicating November 1-6 Vaccine Awareness Week
In a long-scheduled joint effort to raise public awareness about important vaccination issues during the week of November 1-6, 2010, Mercola.com and NVIC will publish a series of articles and interviews on vaccine topics of interest to Mercola.com newsletter subscribers and NVIC Vaccine E-newsletter readers.
The week-long public awareness program will also raise funds for NVIC, a non-profit charity that has been working for more than two decades to prevent vaccine injuries and deaths through public education and protecting informed consent to vaccination.
The November 1-6 Vaccine Awareness Week hosted by Mercola.com and NVIC will follow a month-long vaccine awareness effort in October that was recently announced on Facebook by parents highlighting Gardasil vaccine risks.
The six-week-long focus this fall on vaccine issues will help raise the consciousness of many more Americans, who may be unaware that they can take an active role in helping to prevent vaccine injuries and deaths and defend the legal right to make voluntary vaccination choices.
And remember, you can always visit Vaccines.Mercola.com and NVIC.org for the latest vaccine news updates and other important vaccine information.
“Six week” focus? Methinks Dr. Mercola meant “six days.”
Be that as it may, Mercola and Fisher apparently think that their simply declaring the first week of November to be “Vaccine Awareness Week” will make it so. Of course, there actually is an Immunization Awareness Week here in Canada, but it was six months ago. In the U.S., August is National Immunization Awareness Month. Still, if anti-vaccine loons want to make the first week of November “Vaccine Awareness Week” in order to peddle their pseudoscientific and dangerous misinformation claiming that vaccines cause autism and various maladies, I say we let them have it.
Just not in the way they expected.
So, given the power invested in me as editor of Science-Based Medicine and the power of my fellow partners in crime at SBM (which is the same power Joe Mercola and Barbara Loe Fisher, except that we have science on our side), we at SBM hereby second the call to declare November 1-6, 2010 “Vaccine Awareness Week.” As part of the activities that week, we at SBM plan on spending more time than usual–perhaps even all of our posts that week–emphasizing the dangers of the anti-vaccine movement and providing science-based rebuttals of the lies of the anti-vaccine movement. In particular, we will concentrate on whatever propagandistic misinformation Joe Mercola and Barbara Loe Fisher decide to publish that week. Given whatever persuasive power we have as bloggers at what is a well-respected medical blog, I now request that any and all medical and skeptical bloggers out there also take advantage of Vaccine Awareness Week to do the same. I’ve already taken advantage of proximity here in Montreal to speak with Ben Goldacre and will be contacting other bloggers after I arrive home from Montreal. Tomorrow I’ll have a chance to meet with Randi.
Joe Mercola and Barbara Loe Fisher want to declare a week “Vaccine Awareness Week” in order to bury readers in a deluge of pseudoscience? Let them! Surely we can do better than they can and make sure that when anyone Googles “vaccine awareness,” what is found is not the current list of anti-vaccine pseudoscience but rather a flood of rational, science-based discussions of vaccines and refutations of the lies of the anti-vaccine movement. What I’d love to see from November 1-6 are a tsunami (word choice intentional) of posts that:
- Include science-based discussions of the safety and efficacy of vaccines
- Include science-based refutations of anti-vaccine misinformation
- Specifically refute posts by Joe Mercola and Barbara Loe Fisher during that week. (You can throw in Age of Autism, too, if you like.)
Spread the word and join the crusade. Anti-vaccine pseudoscience is pseudoscience that hurts and kills children.
High Dose Flu Vaccine for the Elderly
Dr. Novella has recently written about this year’s seasonal flu vaccine and Dr. Crislip has reviewed the evidence for flu vaccine efficacy.
There’s one little wrinkle that they didn’t address — one that I’m more attuned to because I’m older than they are. I got my Medicare card last summer, so I am now officially one of the elderly. A recent review by Goodwin et al. showed that the antibody response to flu vaccines is significantly lower in the elderly. They called for a more immunogenic vaccine formulation for that age group. My age group.
One manufacturer has responded. Fluzone High-Dose vaccine contains 60 mcg of hemagglutinin antigen from each strain, compared to 15 mcg in the standard dose vaccine. This high-dose preparation has been tested in three clinical studies (here, here, and here) of 4453 healthy people aged 65 years and older. In each of these studies the high-dose vaccine produced significantly higher antibody levels than the standard dose vaccine. There was a dose-related increase in minor local side effects (arm pain, redness and swelling at the injection site) but no increase in serious adverse effects. Most recipients had minimal or no adverse effects. We don’t yet have data to prove that the increase in antibody titers will result in fewer clinical influenza illnesses and complications, but it seems logical that it would. A study comparing the effectiveness of Fluzone High-Dose to Fluzone is expected to be completed in 2012. The high-dose vaccine is more expensive, but Medicare pays for it.
The Medical Letter recently covered the 2010-2011 flu vaccines and did not recommend (or advise against) the high-dose formulation for older patients, because the clinical efficacy data are not yet available. Neither the CDC nor the ACIP has been willing to express a preference for one vaccine over another at this time. I asked our own infectious disease expert, Dr. Crislip, and he recommends the high-dose in view of its improved immunogenicity and biological plausibility.
I’m 65 and my husband is older: we opted for the high-dose vaccine. Not everyone will agree, but shouldn’t older patients be given the facts and the option?
Pharmaceutical Company Contact and Prescribing
In my group practice, the Yale Medical Group, drug-company sponsored lunches and similar events have been banned. This is part of a trend, at least within academic medicine, to create some distance between physicians and pharmaceutical companies, or at least their marketing divisions. The justifications for this are several, and are all reasonable. One reason is the appearance of being too cozy, which compromises the role of academic physicians as independent experts.
But the primary reason is the belief that “detailing” by pharmaceutical sales representatives has a negative effect on the prescribing habits of physicians. There is reason to believe this may be the case because of cases of bad behavior on the part of pharmaceutical marketing divisions – ghost writing white papers, for example. The concern, backed by evidence, is that pharmaceutical companies introduce spin and bias into the information they provide to physicians, whether though CME, detailing, literature, or sponsored lectures. Even when the information itself is not massaged, it is cherry picked, so in the end physicians are not getting a thorough and unbiased assessment of the facts.
The FDA does heavily regulate the marketing of information about pharmaceuticals, but marketers are very clever about exploiting loopholes and seem to be one step ahead of the regulators.
On the other hand there are those who argue that physicians can handle access to information and they are equipped to take it with a grain of salt and put it into context. Certainly most physicians I speak to believe this about themselves. Further, information provided by pharmaceutical companies may actually improve prescribing habits if it makes physicians aware of new products on the market and new information about the drugs they prescribe. The information itself is FDA approved (or at least should be), even if it is selective and wrapped in spin.
You can defend either position based upon plausibility, which is why I have always been most interested in direct evidence of the effect of pharmaceutical detailing on physician prescribing habits. Mark Crislip has written about this issue before, pointing out that the evidence supports a negative effect of pharmaceutical company contact on physician prescribing. While I generally agree with Mark’s opinion, the evidence seemed a bit preliminary to me. More definitive evidence would be useful in both forming my own opinions and advocating for change.
A new systematic review of the literature has been published in PLOS Medicine – an excellent opportunity to discuss what the actual state of the evidence is. The authors scoured several databases and came up with 58 studies meeting inclusion criteria. These studies looked at amount of prescribing, prescribing cost, and prescribing quality. They found:
Of the set of studies examining prescribing quality outcomes, five found associations between exposure to pharmaceutical company information and lower quality prescribing, four did not detect an association, and one found associations with lower and higher quality prescribing. 38 included studies found associations between exposure and higher frequency of prescribing and 13 did not detect an association. Five included studies found evidence for association with higher costs, four found no association, and one found an association with lower costs. The narrative synthesis finding of variable results was supported by a meta-analysis of studies of prescribing frequency that found significant heterogeneity. The observational nature of most included studies is the main limitation of this review.
There is definitely a trend in the data, skewed toward a negative effect in each of the three areas. The data seems to be the most clear with regard to frequency of prescribing, which makes sense. Physicians cannot prescribe drugs they are not aware of. There is also the availability effect – we will tend to think of things that are accessible, and that is exactly why pharmaceutical reps want to put their drug names all over promotional material. There is likely also an effect from having free samples available to give to patients. When choosing among equivalent drug options, a prescriber might go with the one that they can give as samples to their patient.
More prescribing is not necessarily bad, if it leads to better care. Underprescribing, in fact, is as much of a problem as overprescribing.
The other two measures were less definitive. Five studies showed increased cost, while five showed no association or decreased cost. Also, five studies showed decreased prescribing quality, while five studies showed no association or ambiguous results. To me these are weak outcomes, without a clear answer. While it is difficult to argue for an improvement in either outcome, these distributions of effects are compatible with there being no net association.
The authors are also careful to point out that most of these studies are observational, not experimental, and so inferring cause and effect is not straightforward. Perhaps there is something inherently different about the quality and prescribing habits of physicians who allow themselves to be detailed more often by pharmaceutical reps.
Further, there may be some situation in which detailing improves prescribing, and others where there is a detrimental effect. We cannot assume a homogeneous effect, and if these differences can be teased out this may inform ways in which regulations and policies can be improved.
Conclusion
After reading this review I am still left with the sense that the data on this important question is currently insufficient – it is mostly observational, and on the two most important questions (cost and quality) the evidence (while trending to the negative) is unclear. What is obvious is that better data would be helpful. Larger and better controlled studies are needed to really look deeply into these important questions, and the research needs to go the next step of trying to identify factors that influence the net effect of pharmaceutical companies being a source of information to prescribers.
Meanwhile I think it is prudent to limit access of drug reps to physicians and their offices, including (especially) in the academic setting. If for no other reason such limitations might motivate pharmaceutical companies to improve their behavior. Perhaps they will figure out that it is in their best interest to provide fair and accurate information about their approved drugs, rather than no information at all.
Since the industry is going through a great deal of change over these types of issues recently, it is also a good opportunity to think of ways to change the system. Like it or not, we have a capitalistic system of drug development. This system has many positives, but frustrating negatives as well. I am in favor of careful and thoughtful regulation (not necessarily more regulation) to keep the industry honest and transparent. Some obvious flaws have been exposed, like ghostwriting articles, and this behavior needs to be banned. But perhaps there are ways to allow pharmaceutical companies to fund the distribution of information about their products, and contribute to physician education about the diseases and disorders for which they sell drugs, while providing a layer of insulation from the bias and spin of those who stand to make money from physician prescribing habits.
Regardless of how we move forward, I would like to see better research data on the question of the impact of pharmaceutical marketing on medical care to help guide whatever future course we take.
There is something out there
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Seven years ago this week I was preparing one of my favorite lectures for The Formation and Evolution of Planetary Systems, a class I frequently teach at Caltech. “Preparing” is probably the wrong word here, because this lecture, called The Edge of the Solar System, was one I could give even if instantly wakened from a cold deep sleep and immediately put on stage with bright lights in my eyes and an audience of thousands and no coffee anywhere in sight. The lecture explored what was known about the edge of our main planetary system and the ragged belt of debris called the Kuiper belt that quickly faded to empty space not that much beyond Neptune. Conveniently, one of my most active areas of research at that time was trying to figure out precisely why this ragged belt of debris had such an edge to it and why there appeared to be nothing at all beyond that edge. I could wing it. So instead of preparing the lecture, I really spent that morning doing what I did whenever I had a few spare moments: staring at dozens of little postage-stamp cutouts of pictures of the sky that my telescope had taken the night before and my computer had flagged as potentially interesting. Interesting, to my computer, and to me, meant that in the middle of the postage stamp was something that was moving across the sky at the right rate to mark it as part of the Kuiper belt. I was not just lecturing about this debris at the edge of the solar system, I was looking for more of it, too.
I didn’t find more objects in the Kuiper belt every morning I looked, but that previous night seven years ago had been a good one. I quickly found two of the typical debris chunks moving slowly across the sky, and I was about ready to walk over to give my lecture, when, with only about a minute to spare, the outer solar system seemed to change before my eyes.
There, on my computer screen, was a faint object moving so slowly it could only have been something far more distant than what I was just going to walk into the classroom and declare to be the edge of the solar system. Maybe. The object was so faint that I didn’t know whether to believe it was real or not. If you look at enough sky – and, really, I had – you are bound to find some chance alignment of blips of noise or variable stars or cat hairs that looks just like something real.
I went into the classroom, delivered the lecture as I knew it, but stopped short at the end.
“Here is the way I was going to end this lecture,” I told them.
I proceeded to talk about how nothing existed beyond the edge of the Kuiper belt (yes, yes, you sticklers, the Oort cloud is way out there, but that is not supposed to start up until 100 or 200 times further out than the edge of the Kuiper belt).
“But I’m not sure I believe this anymore,” I said.
I told them about that morning’s blip. I couldn’t promise them that it was real, but I told them that if it was, the solar system might be very different place than I was just telling them.
That little blip, far more distant than what was supposed to have been the edge of the solar system, was indeed real. It was Sedna.
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A few weeks later, after confirming that Sedna was real and determining its unprecedentedly strange orbit around the sun, I came back, told the class all about it, and wrote down a few simple equations on the blackboard to show just how strange the orbit is and also the many different ways it might have gotten that way.
“Come back and take my class again next year, and I’ll have it all figured out,” I confidently told them.
That was seven years ago. Any poor student taking my advice would have sat through the last six years of lectures and still not learned what put Sedna where it is, since I still don’t know the answer.
What makes Sedna’s orbit so strange?
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Many objects out in the Kuiper belt have shockingly elongated orbits like Sedna. For almost all of these objects, this characteristic makes sense. These small leftover pieces of debris have been kicked around by planets throughout their existence. Whenever they come too close to one of the planets (usually Neptune, since it is the closest to these objects), they get a gravitational kick that can send them on a looping orbit to the distant outskirts of the solar system. But – and this is the key part here – unless they get kicked all the way out of the solar system, they always come back to where they were kicked. If you get kicked by Neptune, you can go zooming off into the unchartered regions far beyond the Kuiper belt, but you will come back to see Neptune again. When we look at the Kuiper belt, we see the results of all of this kicking clearly: the Kuiper belt objects that come closest to Neptune are on the most elongated orbits. Those far away are more free to go about their circular orbiting lives.
The exception to this rule is, of course, Sedna. Sedna has one of the most elongated orbits around, but it never comes anywhere close to Neptune or to any other planet. Indeed, the earth comes closer to Neptune than Sedna ever does. And the earth is not in danger of being kicked out of its orbit by Neptune anytime soon.
Something had to have kicked Sedna to have given it its crazy orbit. But what?
The answer is: something large that is no longer there, or that is there, but we don’t know about yet.
This answer is astounding. The orbit of every single other object in the entire solar system can be explained, at least in principle, by some interaction with the known planets (and, again, for you Oort cloud sticklers out there, the known galactic environment). Sedna alone requires Something Else Out There.
What is it? Seven years out, we still don’t know. The hypothesized culprits have included passing stars, hidden planets, Oort cloud brown dwarfs, and, of course, Sumerian-inspired alien conspiracy theories. Whatever it is, it is bound to answer profound questions about the origin and evolution of the solar system, as well as inspire many new questions we had never known to ask.
NEXT WEEK:
How we are trying to answer the mystery of Sedna’s origin, why we have so far failed, and why 5 year olds make more sense than 7 year olds.
Three Tips to Reduce Your Carbon Footprint and Live Longer.
Did you know that reducing your carbon footprint could help you to achieve a longer, healthier life? There are many choices in your daily life that influence both the environment and your longevity. Here are three of the most influential…
1. Reduce your consumption of convenience foods, anything in a package or can. I’m sure you’re well aware that packaging of convenience foods has an enormous, negative, impact on the environment. Do you know how it affects your health? In general, packaged foods are higher in salt, other preservatives, saturated fat, food colorings and high fructose corn syrup. These contribute to high blood pressure, heart disease, strokes, kidney disease, cancer and obesity. If you want to live a longer, healthier life, choose foods with the least amount of processing and packaging.
2. Eat less red meat. Raising livestock contributes substantially to global warming. It also contributes substantially to obesity, heart disease, and cancer. The growth hormones, saturated fat and excess iron in red meat are unquestionably bad for your health. The more you eat, the greater your carbon footprint, the greater the risk for age-related disease, the shorter your potential lifespan.
3. Avoid modern conveniences when practical. Take the stairs, walk or bike instead of drive, watch less television, use your brain instead of a calculator, hang your laundry out instead of using a dryer. You get the idea. The more active you are, the lower your blood pressure, lower your risk for stroke, heart disease, cancer, diabetes, obesity and osteoporosis. The more active you are, the lower your carbon footprint.
These are simple choices that can change your life, your world, and how long your are in it. For a more thorough description of these and other steps you can take to live longer, please visit healthspan101.com.
Thoughts, Comments, Questions...
Tree Planting
Photo by Chijo Takeda from Friends of Trees
Friends of Trees is an excellent organization in the Portland, OR metro region that focuses on bringing people together to plant and care for trees. Between 1989 and today, Friends of Trees have planted over 390,000 trees in the Portland region. As a casual bicyclist, I have witnessed the work of Friends of Trees along the I-205 Freeway bike path. I was able to recognize their work because of the signs they put up around the trees that signify their plantings.
Friends of Trees have also partnered with the City of Portland and the Oregon Department of Transportation with a goal to plant 33,000 yard trees and 50,000 street trees citywide as well as more freeway tree plantings like the ones I've witnessed near I-205.
Trees have an enormous impact that benefits property owners as well as the environment. According to Friends of Trees, a homeowners property value can increase by as much as $7000 from a tree (presumably a full grown tree) which could also lift nearby neighbors property values as well. Trees also have the added benefits of intercepting pollutants and keeping stormwater runoff from polluting rivers.
One really useful resource they have is the Neighborhood Tree Planting Program where you can register with the website and purchase trees for 70% off what a contractor would pay for plantings in your neighborhood.
All around this organization is doing really good work that helps build livable communities, cleaner air, and cleaner rivers in the Portland Metro area. Check them out, by following the link to Friends of Trees. If you are thinking about who to donate for before this tax year is over, this would be an excellent choice. Their are also volunteer opportunities listed on the site if you are interested in tree planting and have some extra time on your hands.
Thoughts, Comments, Questions...
Electrified Parking Spaces
When people think about electric charging stations, most people think about its use as applied to electric vehicles such as the Nissan Leaf or Chevy Volt. However, their exists another side to electric charging stations that are implemented in the Pacific Northwest and gearing up for the rest of the country. A company called Shorepower Technologies has developed a specialized charging station for truck stops. The company calls the stops electrified parking spaces and they are meant to reduce dangerous emissions from idling diesel trucks.
The benefits of an electrified parking space to a truck driver is that they will pay less money on using electricity for their needs versus burning diesel fuel while idling. Shorepower estimates that truck drivers can see a savings of up to $4000 a year by using electrified parking spaces instead of idling. The video below really does more justice in explaining the benefits to the environment and the benefits to the truckers.
With charging stations setup along the I-5 corridor in the Pacific Northwest, reduced emissions are welcomed. Their is quite a bit of support from state governments to reduce emissions and greenhouse gases as well as support from NGO's. In Oregon, a non-profit called the Oregon Toxics Alliance is actively playing a role to reduce emissions from idling with partnerships from businesses and the Department of Environmental Quality. The state of Oregon as well as other states will certainly benefit economically as well as environmentally from a system wide implementation of these outfitted truck stops.
The following markers on the map are the stations that are operational in Oregon and Washington. Go to Shorepower's website for details on the exact locations of these stations.
Shorepower also does make standard electric vehicle charging stations, of which I've taken a photo of at the OMSI museum in Portland. They have an impressive network of standard EV charging stations in the Portland Metro region that can also be seen on their website as well.
Thoughts, Comments, Questions...
Biomass is not Oregon’s clean-energy future as currently promoted
Also read Biomass Energy Generation Myths
The federal Environmental Protection Agency has proposed that biomass incinerators be required to report greenhouse gas emissions when the government starts regulating carbon next year. But The Oregonian's editorial board argues that this will "shackle" the biomass industry "with hobbling costs." Is the fear that greenhouse gas reporting will expose the heavy carbon burden of burning wood to make energy?
The Clean Air Act requires that facilities measure, report and minimize air pollution and climate-altering greenhouse gases. Biomass plants should be no different in this regard than other industrial processes. The EPA decision denying the industry's request for an exemption from the Clean Air Act is based on the evidence that burning trees to generate energy can actually increase rather than help curb greenhouse gas emissions.
The EPA isn't the only agency casting doubts on the wisdom of burning biomass for energy. The state of Massachusetts' Department of Energy Resources published a decision in July to require that biomass plants report their greenhouse gas profile. Reporting will be required so that the state can meet its renewable energy standard and carbon reduction goals. Massachusetts will require, for example, that biomass energy production demonstrate maximum energy efficiency standards, a 50% reduction in GHG over a 20-year cycle, and forest practices that are measurably sustainable, and a limit on the total timber per acre eligible to be harvested for biomass fuels.
The Department of Energy was convinced by a Massachusetts study that concluded that burning forest biomass creates a "carbon debt." The debt occurs when we outpace the earth's ability to absorb carbon dioxide. The carbon debt increases as trees are removed from forests, because their ability to absorb carbon from the atmosphere is diminished, and the carbon naturally stored in their woody tissue is prematurely released by burning them in an incinerator. According to another study, the significant carbon debt can take as long as over two and a half centuries to repay if biomass is used as a fossil fuel replacement.
Burning biomass is also a dirty air problem. Even with air pollution controls, these plants will collectively pump ton after ton of toxins into the air every day -- chemicals that will rain down on the neighborhoods closest to the plant. A number of professional medical societies are warning the public that breathing sooty emissions from biomass incinerators is known as the most dangerous form of pollution and a significant health risk. The Oregon Chapter of the American Lung Association is predicting that patients, particularly children with asthma, respiratory and cardiac ailments, will experience increases in the incidence of respiratory problems. These diseases can be worsened by small micro pollutants, the type of pollution that will increase with the proliferation of biomass plants in Oregon.
The environmentalist Aldo Leopold reminded us that the first rule of intelligent tinkering was to "keep all the pieces," not burn them.
Burning biomass, a process that depletes natural resources and pollutes our neighborhoods, is not the renewable and clean-energy panacea that commercial timber companies would have us believe. If we are to go down this path, Oregon residents must call upon our elected officials to require reasonable safeguards, starting with a complete state environmental impact report, carbon life-cycle accounting, and compliance with future, tighter Clean Air Act mandates.
Lisa Arkin is executive director of the Oregon Toxics Alliance.
Editorial published from The Oregonian
Thoughts, Comments, Questions...
A Green Railroad
Many may not think of freight rail as an environmentally sound business, but it is actually the lesser of evils in terms of transportation related pollution. It is up to four times more fuel efficient versus trucking goods and in terms of carbon output freight puts out less.
To further tout their green railroad horn, Union Pacific, the major freight rail company in the western US, filters out diesel particulates by using a fancy device called a high temperature silicon carbide block to trap particulate matter in the exhaust. Tests have shown that having these diesel particulate filters (DPF's) have filtered up to 75% of particular matter.
Union Pacific, specifically, seems to have lofty and noteworthy environmental goals to reduce emissions and boost fuel efficiency. Little did I know until after reading their website that they have introduced hybrid diesel trains that further reduce nitrogen oxides and particulate matter by 80% and improve fuel efficiency by 16% over their non-hybrid trains.
Furthermore, another source of pollution from trains are from idling trains. According to the Union Pacific website, they say idling is necessary in certain conditions but they are working on solutions to reduce idling related pollution.
The railroad has developed a comprehensive plan to reduce the amount of time locomotive engines idle. Part of the plan involves using automatic stop-start equipment on newer locomotives to eliminate unnecessary idling. Older locomotives are being retrofitted with similar technology. Nearly two-thirds of Union Pacific's locomotive fleet is now equipped with this technology.
UP continues to train employees and reinforce shutdown requirements, emphasizing the impact they can have on fuel conservation and diesel emissions by reducing engine idling.
As our economy continues to hop along from the depths of a severe recession, freight traffic across the country is increasing. It is nice to know that some environmental stewardship is taking place in this important sector of commerce.
Thoughts, Comments, Questions...
