Tuesday, January 31, 2006

Important announcement

I've been dropping vague and ominous-sounding hints about this for the last couple of weeks, but it's more or less official now: Big changes are coming to Respectful Insolence. Don't worry; they're not bad changes. Quite the contrary, in fact, I'm hoping they'll be great changes.

It began back in November, when Christopher Mims of Seed Magazine asked me if I would be interested in joining a new project, a conglomeration of science bloggers (now known as ScienceBlogs). The idea intrigued me, but I was hesitant. No, I wasn't hesitant because I didn't think it was a good idea. I had been planning on moving to different host and using a different blogging platform sometime during the next few months, anyway. Heck, to be able to move to a better blogging platform for free, to be free of having to worry about the costs of hosting, and even to get paid a little bit to blog represented an opportunity that was very tempting right from the beginning, especially since his reassurances that he didn't want me to change a thing seemed sincere and I would not have to sign away all the rights to my work. I think the guys at Seed "get it," as evidenced by how well the first group of blogs have done after moving over.

Unfortunately, I was concerned about my university's reporting requirements for outside income. Given the modest amount of income offered from the advertising, at the time I wasn't sure it was even worth the effort to jump through the necessary hoops to get permission. (This was the reason I never tried signing up for Google Adsense--that and the fact that altie ads frequently pop up on other medical blogs that do use Google Adsense, and I didn't want them showing up on mine.) Then the holidays came, and other things intruded. ScienceBlogs.com launched a couple of weeks ago, and I realized that I had blown it. I had missed out on the opportunity to be in on the ground floor of something that could turn out to be great. Fortunately, Seed Magazine still wanted me; so I took advantage of the opportunity to correct my mistake and seize this opportunity to reach a wider audience. I jumped through the hoops my university set before me and finally got permission late last week.

I will likely be moving over to the new host sometime in the next two or three weeks, depending on when Seed is ready to help me get set up. (Hopefully it won't be much longer than that.) Another announcement will be made when the change is imminent, and the new link will be announced on the day of the transition. As I mentioned before, to ease the transition, I registered the domain respectfulinsolence.net and had it redirected to this blog. I will set it to redirect traffic to the new blog URL after I officially make the jump.

My plan for now will be to continue as I have done for the last 13 months. After the transition, I will leave the Blogspot blog up as an archive and a place to post occasional announcements (not to mention as a safety net in case I fail). It's not going anywhere, although I may rename it to "Archives of Insolence" or something like that. Also, I have no plans to give up organizing the Skeptics' Circle. It will continue more or less as it has for the last year, and the present Skeptics' Circle site will remain as it is now. Indeed, I'm hoping that the higher profile that I hope to attain by joining ScienceBlogs will improve traffic to each host and help me and future hosts push the Circle to even greater heights in its second year.

Finally, one thing that I cannot and do not promise is that there will be no changes resulting from my decision. Even if I didn't want to change, plopping Orac down in the midst of folks like PZ Myers, Chris Mooney, Tim Lambert, Ed Brayton, and the rest of the stable of top-rate bloggers that Seed Magazine has lined up thus far can't help but result in at least a subtle change--hopefully a change for the better. Surgeons are by nature a bit competitive, and being featured next to the high quality bloggers who are already ensconced within the ScienceBlogs servers will, consciously or unconsciously, almost certainly goad me to improve, if only for the reason that I don't want to look like a doofus next to my fellow ScienceBlogs compatriots.

I plan on explaining my vision of where I want to take this blog in a bit more detail as my very first post on ScienceBlogs. However, I will answer one question right now. While there will be a higher percentage of posts on science (particularly medical science), I have no intention of abandoning my other usual topics, namely skepticism, quackery, creationism and Holocaust denial (and, yes, a certain mascot). Indeed, in the case of Holocaust denial, perhaps I'll get into some discussions of the misuses of forensic science that deniers routinely use to justify their lies. They use pseudoscience every bit as ridiculous as creationism or the worst quackery, and they use it for a despicable purpose. (I may, however, wait a while before springing the Hitler zombie on readers again. I'm not sure that ScienceBlogs is quite ready for a brain-eating undead Führer to make an appearance on its servers yet.)

Stay tuned, and thanks to all my readers. Nothing will happen for several days at a minimum, and regular blogging will continue apace here until shortly before the transition, when I may take a couple of days off in order to set up the new blog. I hope you'll stay with me as I try to take this blogging thing to another level. I might fall flat on my face, but the opportunity is worth taking the chance.

Monday, January 30, 2006

Another perspective on Abubakar Tariq Nadama

Recently, I took Dr. Mary Jean Brown, Chief of the Lead Poisoning Prevention Branch of the Centers for Disease Control to task for some ill-considered and ill-advised comments about the death by chelation therapy of a five year old autistic boy named Abubakar Tariq Nadama in August. I wasn't the only health care professional who thought her remarks to be pretty off base. Indeed, Dr. Kimball Atwood also thought her remarks were pretty poorly considered:
Roy Poses was absolutely correct that Dr. Mary Jean Brown, the CDC’s “expert in chelation therapy,” missed the real point of the tragedy: that the child was a victim of quackery, not merely of “medical error.” The truth is even more disturbing than that, however. Dr. Brown may have been technically correct that if calcium-disodium EDTA had been used instead of disodium EDTA, the child would likely not have died of hypocalcemia (though he might have died of another complication; calcium-disodium EDTA is also a dangerous drug). But this was not a simple case of mistaken drug identity, or "look-alike/sound-alike medications," as Dr. Brown supposed. Disodium EDTA is the form of EDTA preferred by the major advocacy group for all implausible uses of "chelation therapy," the American College for Advancement in Medicine (ACAM)*—the same organization that the FTC had cited in 1998 for “false or misleading” claims regarding “chelation therapy” and atherosclerosis.

The reason for that preference seems to be that when EDTA was first being pushed as a miracle cure for atherosclerosis (‘60s-‘70s), its purported mechanism was to leach calcium from plaques. That claim, which can still be found in pro-chelation literature, has largely given way to the theory that chelation works as an anti-oxidant by removing heavy metals such as mercury, lead, copper, and iron. Both of these theories are implausible on stoichiometric and physiological grounds. The disodium form of EDTA persists as the ACAM-recommended preparation, not only for atherosclerosis but for arthritis, Alzheimer’s, Parkinson’s, psoriasis, high blood pressure, scleroderma, cancer, macular degeneration, and more. The rationale for “chelation therapy” in autism, according to advocates, is that the disease is caused by mercury poisoning—mainly from childhood immunizations. This claim is not supported by epidemiologic studies.
More damning, he points out the NIH-funded trial looking at chelation as a "therapy" for atherosclerotic disease and sees Dr. Brown's remarks as an unintentional indictment of the NIH for funding that trial:
The NIH language implies that disodium EDTA for any other purpose is merely “off-label” and is safe, which is what chelationists and their influential champions assert (see p.2 of this slow-loading document). But this is misleading, because the FDA has specifically contraindicated disodium EDTA for atherosclerosis, and a “black box” warning states: “The use of this drug in any particular patient is recommended only when the severity of the clinical condition justifies the aggressive measure associated with this type of therapy.” Thus the numerous unapproved uses of disodium EDTA, prescribed by that strange subculture of practitioners who preach “detoxification” as a near-panacea, do not meet FDA standards for off-label use. On p. 37 of the TACT protocol, version 2, NIH investigators refer to such practitioners as “prominent experts.”

Perhaps unbeknownst to Dr. Brown, her statements would seem to challenge the NIH to explain why it would expose human subjects to a drug that the CDC considers highly dangerous, when a less dangerous substitute is readily available. The larger question is why the NIH would expose 2300 human subjects in a Phase III study of a treatment that has yet to successfully graduate from Phases I or II, and that has not been substantially studied in animals. Federal Code states: “Phase III studies…are performed after preliminary evidence suggesting effectiveness of the drug has been obtained…” The Declaration of Helsinki states: “Medical research involving human subjects must…be based on a thorough knowledge of the scientific literature…and on adequate laboratory and, where appropriate, animal experimentation.”
Indeed. It has never ceased to amaze me that a therapy like chelation therapy for cardiovascular disease, a disease for which there is no evidence that it works and plenty of evidence to suggest that it is no better than placebo, has graduated to a major NIH-funded Phase III study without having passed through the usual hurdles required of new therapies, namely evidence of effectiveness in animal models and then Phase I and/or Phase II studies. Alties frequently complain that "conventional medicine" doesn't give them a chance, doesn't let them prove themselves on a level playing field. It's true that alternative medicine doesn't compete on a level playing field with conventional medicine, but not in the way alties think. In actuality, alternative medicine is held to much lower standards than conventional medicine. In fact, the chelation therapy trial described above is perhaps the best example of giving alties a pass on the usual standards of evidence before funding a major Phase III trial. It is in essence affirmative action for "alternative medicine" and quackery. No drug developed by big pharma, not even Vioxx, got that big a pass. If I were to submit a grant application to fund a trial to test the efficacy of a conventional medication based on evidence as thin as the evidence that got this trial funded and the even thinner evidence that got the trial for the Gonzalez therapy for pancreatic cancer funded, I'd be laughed out of the study section and my application filed in the circular file.

Dr. Poses of the same blog also has a take on this issue that I should have thought of before, namely how a CAM misadventure with a therapy that was being used for a disease for which it should never have been used is attributed to a "drug mixup," just as if it were a medical error:
Chelation therapy for conditions other than lead poisoning has been advocated widely in the complementary and alternative medicine (CAM) community, as per this post in Quackwatch. It is easy to find CAM web-sites that tout chelation therapy for autism, e.g., here and here. There is no good evidence from clinical research to support the use of chelation with calcium disodium EDTA for autism. Substituting a similar, but more dangerous medication for an anecdote-based CAM treatment was not a medical error, because it did not occur in the course of conventional medical treatment. So perhaps it should have been called a "CAM error."

Physicians who attempt to base their practice on science have already been saddled with the responsibility for innumerable medical errors. They do not deserve to also be made responsible for the misadventures of alternative practitioners.
I wish I'd said that.

Even if Dr. Roy Kerry, the quack who killed Abubakar, did mix up the medications, the bottom line is that attributing Abubakar's death to a "medication error" partially lets Dr. Kerry off the hook. It implies that, if he had simply not screwed up the medication (a contention that is not at all clear or proven) that it would then have been acceptable for him to use a potentially lethal medication for a condition for which there is no credible scientific or clinical evidence that this medication does any good. It wouldn't have been acceptable, and it wasn't. Dr. Brown's remarks in essence excuse Dr. Kerry's quackery.

Dubious therapy of the week: "Touchless" chiropractic

I've been looking critically at various claims of alternative medicine practitioners and outright quacks for a while now. I thought I had heard everything. I didn't think there was a claim that I could come across that was so outrageous, so obviously and ridiculously bogus, that it would still have the power to surprise or shock me.

Then I came across "touchless" chiropractic manipulation.

Touchless? Yes touchless:
The popping sound, the grunting and the hands all belong to Dr. Johanna Hoeller. What she does has been described by some as nothing short of a miracle.

Dr. Hoeller is a chiropractor who specializes in a procedure where the atlas or C1 – the small doughnut-shaped ring at the top of the spine – is carefully adjusted back to center, thus balancing the spine.

This practice is part of NUCCA – National Upper Cervical Chiropractic Association.
But it's how the doctor does the adjustment that leaves many of her patients wondering.

Mike West, the morning DJ for KMTT, has been seeing Hoeller for more then 7 years.

“I remember going on the radio and all of sudden, click, and I would have to crawl off the floor to go to the doctor to get her to fix,” he said. “I don't know what she does but it works.”

What has West and other patients – some from as far away as Alaska – scratching their heads is the fact that Joanna Hoeller does not really touch them.

“I'm not a witch doctor,” said Hoeller.
But wait, you say. Isn't chiropractic dependent upon spinal "manipulation" to treat everything from back problems to, say, migraines or asthma? And doesn't that manipulation or "spinal adjustment" depend upon the chiropracter's supposed skill in realigning your spinal column using good old-fashioned muscle? At least that's what I always thought chiropractic involved.

You can learn about it from a video segment done by a particularly credulous host named John Curley for a show in Seattle called Evening Magazine. After the Curley's introduction, in which he describes how his wife had been suffering neck pain after an auto accident and had given up on getting relief, the video segment went to a photo of Joanna Hoeller leaning over a patient moving her hands over his neck and grunting. We hear popping sounds. It certainly seems as though she's doing something. But what? No movement of the patient's neck or head is observed.

"I'm not a miracle-worker," she says. "The miracle is the human body. It's just a gentle procedure, and, when it's gentle, people have a difficult time with it sometimes."

The procedure is apparently so gentle that it doesn't even require Dr. Hoeller to touch the patient.

No, Dr. Hoeller, I don't have a difficult time with your procedure because it's so "gentle," but rather because there's no physical basis for it to work unless you believe in some sort of magic or "energy transfer." Even by the stated basis of chiropractic of realigning the spine as a means of treating disease, it can't work. Indeed, one of her patients interviewed on the segment unintentionally seems to nail it on the head when he said, "I used to try to figure out what she did, and how she did it. I do believe she has some sort of magical powers. I just think she's that kind of a person."

Another patient: "Like I said, if it works I like it. I don't care what it is. Hocus-pocus, whatever. If it takes the pain away, hooray."

Hocus-pocus indeed, Hoeller's claims sure sounds like magic or hocus-pocus, and it would take such a belief in magic to think that such a ridiculous "therapy" could work. (Calling the Amazing Randi!) For one thing, it's not the patient's neck that's popping, but Dr. Hoeller's wrists, something Curley himself narrates later in the segment, when he says that Dr. Hoeller will keep doing the adjustment until the "popping in her wrist stops." Says Hoeller, "My body is my instrument, so to speak. When the atlas and the structure is correct, my hand tends to stop popping. So that's how I generally have a feedback of whether something is now locked, and then no more force can get in there." Worse, she takes before and after X-rays of the patient's skull and cervical spine. The first one shows (of course) that the patient's spine is horribly "out of alignment," with her head sitting at least a 2 cm lateral to where it should be relative to the atlas (never mind that if her head were truly that much out of whack relative to her spine, her spinal cord would probably have been crushed or severed). And--miracle of miracles!--the second one is almost "perfectly" aligned. In fact, if you look closely at the two X-rays, all that changed is where Dr. Hoeller drew her blue and red lines, as Skepdic showed very nicely here.

Hard to believe that anyone falls for this, isn't it? What's even harder to swallow is the part where Curley shows Dr. Hoeller a videotape of herself in action, and she claims she had never realized that she wasn't touching the patient. Come on, give me a break! What we have here is simply confirmation bias and self-deception on Dr. Hoeller's part, probably with a dash of magical thinking thrown in for good measure, and the placebo effect on the part of the patients. There's almost certainly a bit of regression to the mean (also known as the regressive fallacy) in there as well.

Of course, even if Hoeller could do what she claims without touching her patient, there is no basis in science to assume that upper cervical adjustment will do anything. She uses a method called N.U.C.C.A (for National Upper Cervical Chiropractic Association). This flavor of chiropractic teaches that many diseases can be treated by "adjusting" the upper cervical spine, specifically C1 (the atlas) back to "center," thus supposedly "realigning" the spine. To quote Joanna Hoeller, "Just when you thought you have tried everything, have you checked to see if your head is on straight?"

No, Joanna. Have you?

To see a whole bunch of pseudoscientific altie claims, one need only look at NUCCA's website, which greets visitors with:
An era of amazing recoveries from illness began over 100 years ago, with the discovery of Chiropractic by an American, Dr. Daniel David Palmer. Thousands of patients, who had given up hope of finding any help, recovered from their illness by the improvement of their nervous system function.

Sixty years ago, a study of upper-cervical cases revealed that sick folk, possessed by over 5,000 different types of diseases, were in large measure restored to good health and long life by restoring a good communication link between the brain and body!
Over 5,000 types of diseases can be restored to good health with this method? Apparently so, according to NUCCA:
After an upper cervical correction...

"An 80 year old man, suffering from numbness in both legs, receives an upper cervical adjustment and immediately experiences a return of normal feeling and mobility in his legs."

"A new scientific research study just concluding reveals Chronic Fatigue Syndrome and Fibro Myalgia cases have recovered in 3-12 months, but the Mayo Clinic reports 3 years of drug treatment with no improvement or hope."

"ADD (Attention Deficit Disorder) and similar cases have shown remarkable recovery with neck correction, enabling the freedom from the harmful drugs used in such cases... drugs now suspected of addicting some children."

"A thirty year old father was sent by his neurologist for an upper cervical analysis and correction. He had suffered from migraine headaches for ten years with severe side effects which disabled him from his work for 3 to 5 days per week. No treatment which he had received had helped him. Two adjustments left him symptom free for two years. A truck accident caused a temporary relapse but for over 5 years he has been symptom free!"

"A child with bronchial asthma breathes normally again, the acute attack stilled by a chiropractic adjustment!"
Nothing but testimonials.

I can see how one might--I repeat, might--get relief from spinal manipulation for nerve root compression or back pain, but no chiropracter has yet been able to explain to me how it can do anything for asthma, migraines, ADD, or chronic fatigue syndrome, or any other disease not related to the spine. The NUCCA site (like every other chiropractic site I've seen) is long on testimonials and impressive-sounding jargon about nerves and the spine and short on actual data from scientific studies and clinical trials.

What's next? Autism? Yes, chiropractors even claim they can treat autism and hiatal hernias. Is there any disease chiropractors can't treat by manipulating the spine?

Apparently not. And at least one of them doesn't even need to touch the patient to do it.

Traditional Chinese medicine healers who practice qigong (energy healing) had better watch out. It looks as though at least one chiropracter is getting ready to muscle in on their business.

Skepticism busting out everywhere!

After having plugged a good skeptical blog over the weekend (whose proprietor has now, by the way, agreed to host the Skeptics' Circle in May), I've now found yet another one. This one's called Unintelligent Design, and the blogger, Clark, introduces himself thusly:
I am a skeptic. In fact I don't believe in anything without cold hard facts. And to be honest It makes me mad that I am forced to have my astrological sign and Zodiak animal from Chinese mythology on my profile. It's all crap. And don't even get me started on Alternative medicine. I also like sunny days and puppy dogs.
Sounds like a man after my own heart.

Particularly enjoyable is his debunking of the Aqua Detox System.

Let's hope the rate of growth of the number of skeptical blogs continues.

Whittling away the Americans With Disabilities Act

I don't often do this, but at the request of a reader of mine who happens to have reason to be intimately familiar with this issue I am posting this plea:
It seems that the restaurant industry is leading to fight to keep America inaccessible to people in wheelchairs. There was a problem in Kansas (where else?) last year that was shot down.

These businesses have had nearly 15 years to make the small changes that are needed for accessibility. Some of these businesses were established after the ADA was law, and ignored it. Now, they want to have up to another year to make things accessible, and not be otherwise penalized for their indifference (I am being charitable).

This measure should never reach the ballot:

Building and Restaurant Industries Trying to Stop Disability Rights Enforcement

The California Building Industry Association and California Restaurant Association started out 2006 by submitting a proposed ballot initiative to the California Attorney General for inclusion on the November 2006 ballot.

The proposed initiative, which is awaiting Attorney General approval and will then require signature collection before it can be put on the ballot, would amend the California disability rights laws and construction defect laws to make it much more difficult for Californians to enforce the law.

The proposal would require people injured by discrimination in disability access, or by construction defects in their homes, to notify the building owner or builder by certified mail, and wait 30 business days (amounting to 40 days total) for the owner to respond. The owner/builder can then choose to (1) ignore the notice or reject the claim (in which case the injured party can proceed to court) or (2) respond by promising to make improvements within 120 business days (200 actual days ( 6.6 months)) or by demonstrating that the violations have already been corrected after the incident occurred. If the building owner cannot get the corrections made in 120 days, he can get an extension of another 120 business days - thus delaying compliance by up to 13 months!

If the owner's modifications have fixed or will fix the access violation, the injured person will have NO RIGHT to seek compensation for the initial discrimination or injuries caused by it. He or she will not be compensated for injuries and will not be reimbursed for having to pay an attorney to investigate the case. Over 15 years after the passage of the Americans with Disabilities Act (and more than 20 years after the California disability rights laws), building owners will be exempt from compensating victims for their ongoing discrimination.

If the owner's modifications are inadequate, the owner can force the injured party to go into a "prelitigation procedure" where a neutral access specialist (paid, in part, by the injured party) reviews the property or the owner/builder's proposal to fix the property and approves it as complying with access requirements. This process has no deadlines and will presumably extend the 120 day period for making improvements. At the end, if the neutral reviewer approves the modifications, the injured person will have no rights to compensation for the initial discrimination or injury, will have no right to reimbursement for attorneys fees and costs for participating in the "prelitigation procedure", and will, in fact, have to spend additional money to pay the neutral reviewer.

Notably, this initiative, applies to new construction and alterations, even though owners and builders have no defenses to providing access in new buildings. Moreover, the initiative will let both private businesses and state and local governments off the hook for new and ongoing access violations. This proposal would make people with disabilities the forced, unpaid consultants for business and governments - people with disabilities will, in effect, have to subsidize building owners' compliance (we will have to pay all of their access consultants!) with the law and will have no ability to enforce disability civil rights.

The Disability Rights Legal Center will work actively to oppose this ballot initiative in every possible way. Your support will be essential to this effort, which will require us to educate voters across the state about why disability rights should not be restricted and why, after decades of laws requiring disability access, building owners should not be encouraged to ignore those laws even longer and to place responsibility for compliance on us.
It's already bad enough for someone to be confined to a wheelchair, but part of what makes it so bad is the difficulties put in their way when they try to go to public facilities, businesse,s adn restaurants, difficulties that are not that onerous to correct. More when I find out more.

Sunday, January 29, 2006

International Internet-free Day?

I hadn't been planning on posting anything at all today; I usually like to take at least one day off a week from posting (and in the future may stop posting anything on the weekends at all).

Then I was made aware of this:
Have you started tilting your head sideways to smile? When you check your e-mail and it says "No new messages", do you immediately check again? Do you dream in HTML? You could be spending too much time on the Internet. So Sunday January 29th has come along at the right time, as it is International Internet-Free Day.

An idea promoted by the online democratic think-tank the Global Ideas Bank, Internet-Free Day is a day to log off, get out and enjoy the real world.

Why an Internet-Free Day?
  • Because it's all too easy to miss out on face-to-face interaction with your family, friends and neighbours.
  • Because the net can be addictive, and a day of cold turkey won't hurt.
  • Because blogging doesn't provide your daily vitamins and minerals.
  • Because you've got RSI coming on in your mouse arm.
  • Because we all need time to reflect.
  • Because the real world is a wonderful place.
  • Because if the mere idea of it enrages you, you definitely need it
Contrarian that I am, I decided right then and there that I had to post something today; so I did.

That is all.

Saturday, January 28, 2006

Prometheus wants your skepticism!

Since I'm plugging skepticism today, I should take this time to remind everyone that on Thursday Prometheus is hosting the 26th Meeting of the Skeptics' Circle at A Photon in the Darkness, but he's not happy. At least not yet. Here it is, the weekend before he's scheduled to host, and he still needs more skepticism. After all, a guy who can write something like A Field Guide to Quackery and Pseudoscience won't be satisfied until he's scoured the entire skeptical blogosphere for the very best critical thinking and put together an Amazing Meeting of his own.

So give a skeptic a hand and send him your best skeptical blogging by Wednesday night!

More Saturday morning blog housekeeping

Inspired by the cybersquatting of J. B. Handley a couple of months ago, I finally got off my behind and registered the domain name respectfulinsolence.net. No, I never got back oracknows.com (J. B. hates me too much ever to do the right thing in that respect, and yes, oracknows.com still redirects traffic to a Site I Will Not Name.) It doesn't much matter anyway. I had been planning on phasing out the "Orac Knows" part of my blog title for a while now, although I will continue to use "Orac Knows" on the sidebar to group my list of favorite past posts.

In any case, I've set www.respectfulinsolence.net to redirect traffic right here to the blog. So, if you change your bookmark to the above URL, as long as the domain remains registered to me, it will always direct you right here to your fix of the finest respectful insolence in the universe. (If you're using a newsfeed aggregator, my feed remains the same.) Finally, if you happen to be a blogger and have me in your blogroll, please keep using the old Blogspot URL http://oracknows.blogspot.com. I'd hate to see my TTLB Ecosystem rank plummet because of this, you know.

An announcement describing the big changes in this blog that I've been hinting at the last couple of weeks will finally be posted either Monday or Tuesday, and my reasons for registering that domain may become more clear then.

Skeptico on Deepak Chopra and EoR on credulous circles

I love it when Skeptico fisks New Ager Supreme Deepak Chopra and his pseudoscientific appeal to other ways of knowing. My favorite part is where he rebuts Chopra's claim about "subtle bodies" that "whatever is invisible has little standing in a materialistic culture where reality is defined by science":
Yes, science has no time for invisible things like radio waves, atoms, MRIs etc. – all things discovered by science incidentally, not by drips like Chopra. Of course, what he means is that science is only interested in things that have a measurable effect – things that can be tested. If something has no measurable effect (for example, this "subtle body" he’s talking about), then it might just as well not exist. So does his "subtle body" have a measurable effect or is it just too damn subtle to measure?

While Orac is in a mood to plug other people's work (perhaps being too lazy today to write some of his own), there's a new skeptical blog in town that I've been meaning to plug for a month or so now. The blog is The Second Sight, and any blogger who can title a series of posts Going Around in Credulous Circles (Parts 1, 2, 3, and 4) or write a post entitled The More Things Change (the Less Homeopathy Does)... (or, for that matter, list his comments as "psychic responses," in the same sort of way that I list mine as "attempts at insolence") is definitely a someone who belongs on my blogroll.

Birthday shoutout

I'd just like to take this opportunity to send a birthday shoutout to my Mom. Here's hoping you have a great day and many more like it!

I know you're reading...

Friday, January 27, 2006

Oprah slaps down James Frey

I normally don't watch The Oprah Winfrey Show. Oh, I occasionally catch part of it when my wife watches it, as it's on at 7 PM on one station in our market, but I don't generally watch it. But I really wish I had seen this episode here, when Oprah slapped down dissembling "memoirist" James Frey for his making up a large part of his supposed memoir A Million Little Pieces and lambasting his publisher for not doing even the most rudimentary fact checking, all the while apologizing to her viewers for having been taken in.

As enjoyable as the spectacle might have been, I can see one consequence of this dustup that I don't look forward to seeing. Recently, Oprah picked Elie Wiesel's book about Auschwitz Night as her next Book Club selection. I can already see the Holocaust deniers chomping at the bit to take James Frey's exaggerations and made-up incidents being represented as nonfiction and use them to attack Elie Wiesel's book about Auschwitz. It's coming.

Just wait.

Holocaust Memorial Day: The 61st anniversary of the liberation of Auschwitz

Today, the 61st anniversary of the liberation of Auschwitz, the most notorious of Nazi camps, by the Red Army, is also Holocaust Remembrance Day in the U.K. The theme this year is the celebration of the courage of rescuers who helped the persecuted:
The stories of the rescuers show everyone how even small actions can make a difference to the persecuted and hunted. It also highlights the dangers of indifference to the plight of those in danger. As last year we hope that learning about the courage of the rescuers will enable everyone of us, young and old, of whatever faith or no faith, to change our attitudes to our fellow man. We must be aware that each individual is responsible for his/her own actions and we must not be indifferent to our neighbour’s pain. We will then have learnt one of the most valuable lessons of the Holocaust – that ‘One Person Can Make a Difference’.
It occurs to me that I've never written about rescuers, and perhaps I should do so sometime. In the meantime, for those of you who weren't regulars or never saw this article, I thought I'd direct you to what I wrote a year ago on this occasion. Given that back then I only got at most a few dozen visits to this blog per day, it's unlikely that the vast majority of my present readership has seen or read it. On this particular day, I think it's worth checking out and hope that you will do so and perhaps comment here. (Because the article is a year old, I closed comments on it long ago.) Perhaps it will explain some of the reasons for my interest in Holocaust denial.

Finally, I present a list of links to relevant posts that I have written over the past year or so. Hopefully, it will acquaint newcomers with my previous writings on the subject and remind longtime readers of why we should never forget.


  • 60 years ago today: The evacuation of Auschwitz and start of the death march
  • 60 years ago today: The liberation of Buchenwald
  • Sunday afternoon history lesson
  • 60 years ago today: The liberation of Bergen-Belsen
  • 60 years ago today: The liberation of Dachau
  • Eugenics and involuntary euthanasia
  • 67 years ago tonight: Kristallnacht
  • Oprah goes to Auschwitz
  • You can't make stuff like this up: Mel Gibson is planning a TV miniseries about the Holocaust

  • Holocaust denial:

  • The 60th Anniversary of the Liberation of Auschwitz: How I discovered Holocaust denial
  • How David Irving became a Holocaust denier
  • A truly offensive use of Halloween
  • Taboos of Holocaust deniers
  • Schadenfreude
  • More schadenfreude: Irving now admitting there were gas chambers?
  • David Irving to stand trial in Austria)
  • The President of Iran: Holocaust denier and anti-Semite
  • An unexpected analogy
  • The loon running Iran

  • More on David Irving

    I hadn't gotten around to this, but today seems an appropriate day to point to an article in Der Spiegel in which David Irving, now in prison for Holocaust denial in Austria, was interviewed. Some choice excerpts follow.

    On why David Irving went to Austria, even though he knew there was a warrant for his arrest there:
    Before leaving London for Austria, he left behind 60 blank checks and packed eight shirts, even though the trip was only scheduled to take two days. He is always prepared for anything, says Irving, meaninfully raising his bushy eyebrows. "Be prepared," the motto of the Boy Scouts, is apparently also his motto.

    He knew that there was a warrant for his arrest in Austria. In 1989, then Chancellor Franz Vranitzky personally threatened Irving with immediate arrest if he ever showed his face in Austria again. But the stubborn Hitler apologist saw Vranitzky's threat as an invitation to return to Austria as quickly as possible. "I come from a family of officers," he growls from behind the plate glass, "we march towards cannon fire." But he did make a mistake when it came to picking suitable shoes. Prisoners are allowed to walk in the prison yard every day, but Irving has, "unfortunately, only one pair of very expensive shoes," and they're slowly falling apart.
    Speculations on what may be part of his motivation:
    British historian Paul Addison described Irving as "normally a giant when it comes to research, but often a schoolboy when it comes to judgment." As horrific as it sounds, there is reason to believe that he is not just driven by the lucrative business of the Holocaust denial industry, but also by a scurrilous and ultimately banal delight in provocation.

    This delight is not uncommon among the upper classes in England, as Prince Harry's recent appearance at a party wearing a swastika armband demonstrates. Irving takes advantage of the considerable tolerance of his countrymen, whose regard for freedom of opinion protects even the most tasteless pronouncements of an eccentric.

    It is no coincidence that a man like Irving comes from a country where "Führer" jokes are still part of the standard repertoire of the tabloid press, and where delight in provocation is considered acceptable even in polite society. Irving undoubtedly has as many detractors in Britain as anywhere else. But statements such as "more people were killed in the back seat of Edward Kennedy's car in Chappaquiddick than in the gas chambers at Auschwitz," with their blend of sexual innuendo and deliberate affront, are a reflection of the trivial ignorance with which many a product of the British boarding school system tries to show the world belongs to him. "He is a megalomaniacal class tyrant," says Holocaust expert Deborah Lipstadt, against whom Irving filed a spectacular lawsuit six years ago, at the end of which, however, the judge in the case declared him an anti-Semite, a racist and a liar.

    "Yes, I did many silly things", says Irving simply, noting that the British way of doing things isn't always polite.
    Irving, who grew up without a father, started rebelling against the established order when he was a schoolboy. When he won a book award at school, he asked for Hitler's "Mein Kampf" as his prize. It was the same impetus that prompted him to drape a Soviet flag over the gate of his school. He had merely intended to shock people, Irving told Britain's Observer newspaper in 1992. "It was all in good fun, and when I write, I try to introduce a bit of fun onto each page." In 1993, he told another interviewer that he had no political agenda apart from enjoying seeing "other historians make fools of themselves."
    Finally, the writer speculates that Irving's admiration for Hitler comes from his yearning for empire and his view of history as a panorama of "eating or being eaten":
    Irving is unaware of moral or even human contradictions. He is too amoral to even understand that jokes such as the one about Kennedy's car are an affront to the survivors of the Holocaust. Irving's understanding of history is not unlike that of the Nazis. History is a panorama of eating or being eaten. Only the strong can win, and Irving reserves his unabashed admiration exclusively for the strong.

    One of those people is "Bomber" Harris. In his first book, Irving turned the world's attention to the horrors of the bombing of Dresden. Nevertheless, he insists that Air Marshall Sir Arthur Harris was a great man. "I'm talking about a commander. Like Dönitz," he explains, his eyes flashing. "Someone who can send 20,000 young people to their deaths each day is a great commander." Given these views, Irving's admiration for Hitler comes as no great surprise.
    Indeed it doesn't, and Irving has been more explicit about his admiration, saying about Hitler, "He's like the curate's egg - good in parts." Nonetheless, as odious as his views are, Irving should not be in prison for them. As Professor Deborah Lipstadt said, "Let him go home and let him continue talking to six people in a basement."

    Thursday, January 26, 2006

    A most uncomfortable question

    [NOTE: This story is loosely based on a real patient encounter, but some details have been changed, and there's no way for the reader to know when the event upon which the story is based actually happened.]


    I paused. I had been on my way out the door of the examining room, having completed the visit. I turned around again. "Yes." I said. Maybe I had turned around too soon after having asked if she had any more questions.

    "Do you believe in God?"


    The patient list had simply listed her as having an abnormal mammogram. That's probably the most common complaint of breast patients that come in to see me. They have their regular mammogram and are told by their primary care physician that it is abnormal. The next thing they know, they're sitting in one of my examining rooms. However, the patient list is quite brief. It's just meant to be a quick capsule of what patient has what basic complaint. Nothing on the list prepared me for the woman I greeted when I walked in the examination room.

    This patient was enormous, and I do mean enormous. Morbidly obese, she told me she wasn't sure how much she weighed, but that it was at least 450 lbs. Sitting in a wheelchair massive enough to support her, rolls of fat hung over the armrests, and her breath wheezed like a mortally wounded Darth Vader near the end of Return of the Jedi, right before he took his helmet off and revealed Anakin Skywalker beneath the mask. Indeed, on the same theme, I could not help but be reminded of Jabba the Hutt. Yes, I know that physicians aren't supposed to think that way about their patients, and, honestly, I tried not to. However, we're human, just like everyone else, and even our years of professional training can't entirely suppress our baser thoughts. At least I managed to keep enough self-control to restrain myself from voicing such thoughts to my nurse or any of the clinic staff. Not all clinicians exercise such self-restraint, and, I'm embarrassed to say, there have been times in the past when I didn't either.

    Normally, dealing with a patient with suspicious microcalcifications on her mammogram is fairly simple. A biopsy is indicated, and there are basically two techniques to choose from. You can do a mammotome or stereotactic biopsy, which is in essence a mammogram-guided core needle biopsy, or you can do an old-fashioned wire localization (or needle localization) breast biopsy. Given that even the surgical option is usually a same day surgery using local anaesthesia and sedation, even that isn't so hard. The surgery can sometimes be a little trickier than one might think, but even then it's not all that hard. Oh, sometimes you get patients with multiple abnormalities, and you have to decide if you want to go after them all or if you want to perform a triage and decide that some of them need to be biopsied and some of them don't, all the while realizing that if you miss a cancer it can be a major disaster for the patient.

    Of course, a 450+ lb. patient adds a new level of challenge. For one thing, she was way too heavy for the table; so stereotactic biopsy wasn't even an option. Not surprisingly, her health was horrible. She was a smoker, and had severe chronic obstructive pulmonary disease (COPD) and sleep apnea, plus hypertension, type II diabetes, and a history of congestive heart failure. Her medication list read like the Physicians' Desk Reference. I needed to examine her. However, I had a very real fear that, even if we could manage to get her up on the examination table (which, so sturdy before, now looked pathetically inadequate for the task of supporting this woman), she would have a high chance of damaging it. So I made do and did my best to examine her while she was sitting in her wheelchair. It was a suboptimal examination, but, given the size of the room, it was all I could manage. Morbidly obese patients, because of their size, frequently make it very difficult to provide optimal care to them.

    By the time I was done, I felt profoundly sorry for this woman. How on earth does such a person live, given her physical and medical problems? Despite my sympathy, I maintained the professional bedside manner that we're all trained to keep up and explained what was abnormal about her mammogram, that she would need a biopsy, and how the biopsy would be done. I also explained the risks (which, for her, were much higher than the minuscule risks most patients undergoing this procedure face), and arranged for her to be seen by her pulmonologist and cardiologist in case something more than local anaesthesia were needed.

    When finished, I asked if there were any more questions, gave her my card, and made my way past the family members to the door. Although it was near the end of the day, there were still a couple of more patients to see.


    "Do you believe in God?"

    I was still standing there, hesitating. To be honest, my first thought was: Why on earth should it matter whether I believe in God or not? Belief in God has nothing whatsoever to do with whether I'm a competent surgeon or not. Personally, if I needed surgery I'd prefer a surgeon who is a flame-throwing militant atheist like PZ or Richard Dawkins, as long as he or she is highly competent and has a bedside manner that doesn't bother me (and, of course, doesn't push his or her beliefs on me), over a believer who is not as competent. In the same vein, it wouldn't matter to me if the surgeon is a Bible thumper, again as long as he or she is highly competent, easy for me to get along with, and doesn't push fundamentalist beliefs on me. To me, the question of belief in God is utterly irrelevant to the question of whether a surgeon is skilled or not, but apparently not everyone sees it this way. Thinking back on this incident, I can't help but remember an interview I had heard with Eddie Tabash, an atheist attorney who mentioned during the interview that he sometimes defended prostitutes. During the interview, he went on to mention that it was not infrequent for prostitutes to become very uneasy about having him as their attorney when they found out about his militant atheism. I had never encountered this phenomenon among my patients, however.

    My second thought was: Why on earth would this woman still believe that there was a benevolent God looking down on her? She was a mess. She couldn't walk more than a few feet without assistance; she could hardly breathe; and she was on enough medications to stock a Walgreens. Her health was so bad that even a minor surgical procedure such as a breast biopsy could put her life at risk.

    Worse, the question brought into sharp focus a question that I myself have been wrestling with myself for the last three years or so, a question whose answer seems to be yes one day and no on others. There's nothing like being trapped in a small examination room with a 450 lb. woman and three members of her family, with nowhere to run and no way to dodge the question. I was trapped. A believer might have said that the woman's question was God's way of making me face my fluctuation between belief and disbelief; an atheist might say that such an assertion is wishful thinking. Whichever was the truth, that didn't prevent the formation of a little bead of sweat that was rapidly enlarging on my brow. I suspect the question would have still been uncomfortable for me to answer even if I were as religious as I was when I was younger, as even then I tend to view religion as a private matter, one I didn't usually talk about much.

    What if I were to tell her that was an atheist, that I didn't believe in God? Would she have sought out another surgeon? For a fleeting moment, I was sorely tempted to say just that. It might have been an out, a way of not having to do the case. On the other hand, this woman had no insurance and had to rely on charity care/Medicaid, which meant that she probably didn't have the option of going to a different surgeon. (Working for a state institution, I take care of quite a few Medicaid patients.) If that were the case and I said I was an atheist, she would then be going into surgery with no confidence in her surgeon, clearly an undesirable situation. Besides, saying that I was an atheist wouldn't really be the truth; so I couldn't say that anyway.

    So what did I finally say?

    I punted. "I'm Catholic," I said. A pause. "But, to be honest, I don't go to Mass much anymore."

    This answer was perfectly true. It also seemed to answer her question, but in reality didn't. Not really. The truth is much more complicated, but she didn't need to know that. Fortunately, because the patient was Catholic herself, my answer seemed to satisfy her. "God will guide your hand," she said.

    "I hope so," I replied. Bullet dodged successfully.

    I walked out of the examination room not looking forward to the day when this patient and I would meet again in the operating room--or to contemplating her question seriously when the day was done.

    Wednesday, January 25, 2006

    Orac applies some Respectful Insolence™ to a comment spammer

    I hate spammers.

    On the scale of Internet scumbags, spammers rank just one notch above pedophiles (barely). When they're not busy flooding your e-mail In Box with ads for "herbal Viagra" or various pyramid schemes, they're cluttering up my blog with comment spam. Unfortunately, some spammers seem to have found a way to get around Blogger's Word Recognition feature. Normally, I just delete such spams without comment as soon as I see the e-mail notification that they have arrived. Also, if the posts to which the spam comments were added are over a month old, I usually shut down comments for them. Rarely have I considered it worth devoting precious blog space to slapping down a spammer.

    Until now.

    What makes this spammer different? Take a look (I left one spam intact to let you see):
    While I was searching through Blogger I came past your site, it is not really the information I was after about breast cancer research but I did stay to read your blog and found it interesting and well done. Keep up the good work and hopefully I will visit again sometime and also find the information on breast cancer research that I was looking for in my travels.
    Great. An altie spamming my blog! I got this same comment on 10 different comments in about an hour yesterday, and I just got a couple more this morning. Time to put off the straight medblogging I had intended for Monday (and then Tuesday) at least one more day. Damn.

    From the page listed, I quickly found this link, with these claims (text maintained):
    It gets worse, though. Get a load of these claims:
    Learn about more than 350 drug-free, natural cancer treatments used by thousands to cure their cancer:
    • Documented proof these treatments work - with over 2,000 testimonials you can read for free
    • Almost all treatments are non-specific, that is, they work with any cancer anywhere in the body
    • Treatments based on little-known scientific studies and inventions
    • Amazing insights revealed - people with advanced breast, prostate, colon and lung cancer do not live longer after receiving chemotherapy
    • There are alternatives to harmful chemotherapy*
    • Discover best-priced and inexpensive sources of the treatments - some are free!
    • You can commence many treatments immediately
    • All contained in a set of 4 e-Books and Reports quickly and easily downloadable to your computer
    • Inexpensively priced to reach the maximum number of people who need the information
    • 100% refund if you are not satisfied
    • Order and download now and this vital information can be yours in less than 5 minutes!
    Great. Same old overblown and unsupported altie claims for miracle cures, same use of testimonials rather than evidence, same ridiculous claims of a treatment that works for "any cancer anywhere in the body." Do these people work with Hulda Clark or something? All of the above claims are so obviously without scientific support or clinical trial evidence to back them up and are all the sort of snake oil that I've debunked time and time again, that I didn't really want to bother with them at first, even if the company selling them is a spammer that irritated me by spamming my blog.

    And then I saw this link on the site:
    There exists a technology that can detect an issue YEARS before a tumor can be seen on X-ray or palpated during an exam. This technology has been approved by the FDA as an adjunctive screening tool since 1982 and offers NO RADIATION, NO COMPRESSION AND NO PAIN. For women who are refusing to have a mammogram or those who want clinical correlation for an existing problem, digital infrared thermal imaging may be of interest.

    There are very strict protocols both for testing and interpreting. Perhaps due to these guidelines, thermography (as with all digital technology) has exploded in its technique and capabilities. Thermal cameras detect heat emitted from the body and display it as a picture on a computer monitor. These images are unique to the person and remain stable over time. It is because of these characteristics that thermal imaging is a valuable and effective screening tool. Tumors or other breast diseases measures warmer than surrounding tissue and can thereby alert a physician to a problem before a tumor is actually palpable.

    Medical doctors who interpret the breast scans are board certified thermologists. Thermography is not limited by breast density and is ideal for women who have had cosmetic or reconstructive surgery. Thermography, because it analyzes a developing process, may identify a problem several years before mammography. DITI may allow women time and opportunity to support their immune system, change their lifestyle and give their body the best chance to alter their fate.

    DITI has an average sensitivity and specificity of 90%. An abnormal thermogram carries a 10x greater risk for cancer. A persistently abnormal thermogram carries a 22x greater risk for cancer. Thermography, as well as mammography is a personal choice for women. This decision ideally should be made in collaboration between you and your physician. However, thermography does not require a physician’s order.
    The company's name is Proactive Health Solutions, and it's selling a technology called Digital Infrared Thermography Imaging (a.k.a. DITI).

    Oh, boy. These guys sure spammed the wrong blog this time! I do breast surgery for a living, as well as cancer research, after all, and I don't like claims that are unsupported by evidence. In fact, I detest such claims so much that I started a blog, a large percentage of whose content is devoted to shooting down dubious health claims. Clearly, it's time to apply some of Orac's brand of Respectful Insolence™ to this obnoxious spammer.

    First, to be fair, I should mention that thermography has indeed been the subject of legitimate study as a means of diagnosing breast cancer for decades. The reason thermography might work is because tumors have increased blood flow (angiogenesis) compared to normal tissue. Its problem has always been a lack of resolution and specificity. Recent advances in computing power and detection technology may have made thermography more attractive as a test to detect breast cancer. (Indeed, I've even been involved in a research protocol that looked at a device that uses infrared light to do something similar to DITI, but with a clever twist.) However, even with better technology, there are still some major hurdles to overcome, and thermography is nowhere near ready for prime time.

    Judging from its spamming (or from its hiring a spammer to advertise its wares) and the statements on its website, though, this company is probably not interested in determining whether or not thermography is a useful tool to detect breast cancer. It's interested in making a buck by selling a screening test that has not yet been validated in large clinical trials and is not covered by insurance companies, much as the breast MRI companies did a couple of years ago selling MRI as a screening test. Proactive Health claims a 90% sensitivity and 90% specificity for thermography but does not cite any articles in the peer-reviewed literature to support these estimates, which, if true, would definitely be better than mammography. Indeed, I searched PubMed and was unable to find a single reference to support such an extravagant claim for the sensitivity and specificity of thermography. I also know from personal experience and my knowledge of the literature that thermography as a technology to detect breast is cancer is still very much an experimental modality. In fact, although thermography was FDA approved in 1982 as a supplement to mammography, it never gained widespread acceptance because of its many limitations. These days, the only modalities that are FDA-approved for screening for breast cancer are screening and diagnostic mammography, and the only FDA-approved adjuncts to mammography are ultrasound, MRI, scintimammography (seldom used these days--in fact, I've never ordered one), and electric impedance imaging (almost never used either).

    So, what are the problems with thermography and technologies based on thermography, like DITI or computerized thermal imaging? For one thing, they're very difficult to read, something Proactive's literature seems to acknowledge. Also, the literature shows that, because of the lack of spatial resolution, they produce a lot of false positives, making the claim of 90% specificity seem highly unlikely. Finally, unlike mammography, it can't detect microcalcifications, which are sometimes a harbinger of breast cancer and are detected quite well by mammography. Another thing to consider is that, because thermography doesn't produce the fine spacial resolution that mammography, ultrasound, and particularly MRI can, one has to wonder what its value could possibly be compared to MRI, which can detect increased blood flow in tumors quite well and give a nice detailed picture of it. This article says it best:
    While thermography may be appealing to some women because it is a pain-free exam, most physicians do not recommend thermal imaging. Scientific research over the last 20 years has shown that thermography is not reliable for detecting breast cancer. In 1977, the Beahrs Committee of the National Cancer Institute (NCI) recommended that thermography be discontinued as a routine screening modality in the NCI’s Breast Cancer Detection Demonstration Project.

    Since then, studies have failed to show a clear benefit of thermal imaging in helping to detect breast cancer. In their 1998 document, "Evaluation of Common Breast Problems: Guidance for Primary Care Providers," Barbara Smith, MD, PhD and her colleagues wrote, "currently, thermography has no role in breast cancer screening or diagnostic evaluation." Several other reports have drawn similar conclusions. That is not to say that improved thermography technology may not one day aid in the breast cancer diagnostic process (see computerized thermal imaging sections below); however, at the moment, thermography is not widely accepted as an effective means of detecting breast cancer.
    Indeed, it It might not be so bad if this company were only selling thermography as a possible adjunct to mammography, but that's not the impression I get from its literature. Indeed, Proactive Health Solutions seems to be implicitly selling it as a replacement for mammography. Oh, the e-mail I got when I registered on the site says that, honestly, really, and truly, they aren't saying that thermography should replace mammography at all, but this statement makes me wonder:
    Many women are now refusing to have another mammogram for various personal reasons. Although that is a personal decision, we do not encourage this practice. In fact, when both breast thermography and mammography are used together, detection rates improve up to 95-98%.
    Nudge, nudge, wink, wink. Orac's translation: "We're not actually saying that it's OK for you to give up mammography, but, if you happen to decide you want to, we think thermography is just super as an alternative and would love to sell it to you. Know what I mean?" Nudge, nudge, wink, wink. Say no more.

    I wonder what studies demonstrate such an astounding sensitivity when the two techniques are combined. It doesn't help my skepticism any to see that this technique is being marketed through a site that pushes all sorts of altie nonsense and includes the standard "cover your ass" disclaimer: "Do not delay in seeking advice from a qualified licensed medical professional about treatment for your cancer. The information is provided for educational and informational purposes only, and is not intended to be a substitute for the diagnosis, treatment and advice of a qualified licensed medical professional. We are not doctors, and shall have neither liability nor responsibility to any person or entity with respect to any loss, damage, or injury caused or alleged to be caused directly or indirectly by the information provided." It also doesn't help (me, at least) that there are claims that one can diagnose fibromyalgia and chronic fatigue syndrome using thermography, all presented without any references in the peer-reviewed literature to support them.

    With new advances in technology, detectors, and imaging, could thermography turn out to be a useful adjunct to mammography and other imaging studies? There's certainly that possibility, but my opinion is that that particular ship sailed long ago. Other technologies have taken over its potential niche, like MRI, a study that can do more or less what thermography does (measure blood flow) and produce much more detailed images. There's a big difference between a technology having the potential to be useful and its actually having been shown to be useful. Before any test can be widely used to screen an asymptomatic population for a disease like cancer, it has to be validated in large trials to show its level of sensitivity and specificity in the population at large with the existing prevalence of the disease in question. Thermography hasn't, meaning it's very premature to be marketing it to women or to be claiming that it is more sensitive and specific than the existing standard, mammography.

    In any case, Proactive Health Solutions is marketing its thermal imaging technology using a site that pushes all sorts of medical misinformation and through comment spamming of blogs, leading me to ask: If its technology is so great, why is it resorting to such lowlife spamming techniques to market it?

    ADDENDUM: I've been laying down a lot of Respectful Insolence (and not-so-respectful insolence) lately. Perhaps too much. After all, there is such a thing as too much of a good thing. It might be time for a change of pace tomorrow...

    ADDENDUM #2:To anyone from either company who might be annoyed by my little smackdown: Remember that you fired the first shot by spamming my blog. (In actuality, I toned down the final post in comparison to the first version that emerged from my keyboard.) If you hadn't spammed me, chances are that, even if I had somehow come across your websites, I probably wouldn't have bothered with them. In any case, I could have been much nastier. As far as I'm concerned, spammers and comment spammers are among the lowest of Internet scumbags; so perhaps it's a misguided sense of restraint that prevented me from really unloading.

    Tuesday, January 24, 2006

    Grand Rounds, Vol. 2, No. 18

    A Blogger outage earlier this morning during my usual posting time (between around 6 and 7 AM) prevented me from mentioning this before. (It also made this blog unreachable for an unknown period of time.) But I'm back now and taking a minute to post my weekly plug for Grand Rounds, Vol. 2, No. 18, which has been posted at Kevin, MD. Enjoy!

    A particularly egregious misrepresentation of a study

    I was made aware of a most interesting study today appearing in the journal Cancer, which is the official journal of the American Cancer Society. However, I wasn't made aware of it through the journal itself, but rather through a very deceptive misrepresentation of the article. The title alone got my attention: 'Miracle' cures shown to work. It begins:
    Doctors have found statistical evidence that alternative treatments such as special diets, herbal potions and faith healing can cure apparently terminal illness, but they remain unsure about the reasons.
    How do I know that the study is being misrepresented? It's mind-numbingly obvious from reading the the rest of the article that it is, that's why:
    A study of patients with incurable lung cancer who were given weeks to live and received only low-dose radiotherapy to make their final weeks more comfortable found a small number recovered completely.

    Researchers who followed 2,337 patients whose disease was too advanced for curative treatment found that 25 had survived five years and 18 had achieved "an apparent cure". They appeared to have been cured by treatment that "would not normally be considered to have any curative potential whatsoever".

    The researchers, led by Michael MacManus, a consultant radiation oncologist in Melbourne, say: "Our data indicate that a chance for prolonged survival and possibly even cure exists for approximately 1 per cent of patients with non small cell lung cancer who receive palliative radiotherapy.

    "It is important that the frequency of this phenomenon should be appreciated so that claims of apparent cure by novel treatment strategies or even by unconventional medicine or 'faith healing' can be seen in an appropriate context."

    Unorthodox cancer cures have included vitamin C, laetrile extracted from apricot stones, and the Gershon diet of raw vegetables.

    The discovery of a small group of patients who unexpectedly recovered could yield new insights into the disease, the researchers say.
    Note that there was no mention in the actual study of the Gershon diet, laetrile, or any other alternative therapy "curing" anything. Instead, the study simply presented findings that a small number of "terminal" lung cancer patients (approximately 1%) were still alive five years after low dose radiation therapy given strictly for palliative purposes, even though the median survival for such patients is usually between 4 and 5 months. In fact, the study's lead author even went out of his way to state that the results of this study should allow investigators to take the claims of alternative medicine practitioners of "miracle cancer cures" in proper context, given that a small number of patients survive considerably longer than expected. If you don't believe me, look at the abstract itself, downloaded through my university (it's an e-publication ahead of print):
    Unexpected long-term survival after low-dose palliative radiotherapy for nonsmall cell lung cancer

    Michael P. MacManus, M.D., Jane P. Matthews, Ph.D, Morikatsu Wada, Andrew Wirth, Valentina Worotniuk, David L. Ball, M.D.

    Many experienced oncologists have encountered patients with proven nonsmall cell lung cancer (NSCLC) who received modest doses of palliative radiotherapy (RT) and who unexpectedly survived for > 5 years; some were apparently cured. We used a very large prospective database to estimate the frequency of this phenomenon and to look for correlative prognostic factors.

    Patients with histologically or cytologically proven NSCLC, treated with palliative RT to a dose of 36 Gy, were identified from a prospective database containing details of 3035 new patients registered from 1984-1990.

    An estimated 1.1% (95% confidence interval, 0.7-1.6%) of 2337 palliative RT patients survived for 5 or more years after commencement of RT, including 18 patients who survived progression-free for 5 years. Estimated median survival was 4.6 months. Five-year survivors had significantly better Eastern Cooperative Oncology Group performance status at presentation than non-5-year survivors (P = 0.024) and were less likely to have distant metastases (P = 0.020). RT dose did not appear to be a significant prognostic factor. Patients who survived 5 years without progression had an estimated 78% probability of remaining free from progression in the next 5 years.

    Approximately 1% of patients with proven NSCLC survived for > 5 years after palliative RT, and many of these patients appeared to have been cured by a treatment usually considered to be without curative potential. Because of the potential for long-term survival, doses to late-reacting normal tissues should be kept within tolerance when prescribing palliative RT in NSCLC.
    If you read the paper itself, you see that all the investigators did was to study patients with advanced "incurable" lung cancer treated for palliative purposes only, following them to see how long they survived. They followed 2,337 such patients, of which 2,297 completed enough of the course of radiation therapy to be counted in the final analysis, for five or more years and observed that there were 24 five year survivors, approximately 1.1%. Of these, 18 had no evidence of disease progression at five years. Of the known five year survivors, 32% survived another five years, or approximately 0.35% of the total (which means that the 24 five year survivors weren't all apparent "cures"--as the news article called them--because more than half of them still went on to die of their disease). Survival was not correlated with radiation dose. The only characteristic that survival seemed to correlate with was performance status (a measure of general health and ability to handle activities of daily living) and having no distant metastases at the time of the commencement of treatment. The authors speculate that these patients may represent a very small subset of non-small cell lung cancer patients whose tumors are either highly responsive to radiation or not biologically aggressive. The money paragraph is this:
    Our data indicate that a chance for prolonged survival and possibly even cure exists for approximately 1% of patients with NSCLC who receive palliative RT. This is a very small proportion, but lung cancer is a very common malignancy. It is important that the frequency of this phenomenon should be appreciated, so that claims of apparent cure by novel treatment strategies or even by unconventional medicine or faith healing can be seen in an appropriate context. All patients in this study had histologic or cytologic diagnoses of NSCLC in an appropriate clinical context. It is possible that errors could have been made in diagnosis in a proportion of cases, but it is very unlikely that all of the cases were misdiagnoses. In many of these patients, biopsy specimens were generous, including some surgical cases. It is well known that conventional cytologic or histopathologic tumor morphology is, by itself, a poor predictor of treatment response in NSCLC. The phenomenon reported here is potentially an important one, in that a subset of patients with NSCLC appears to have disease that is curable with minimal therapy and that prospective identification of such patients could potentially profoundly influence treatment.
    There are two possibilities. One possibility is that the reporter just straight out lied about the findings of the study. However, an equally plausible explanation is that the reporter accurately reported the results of this very interesting study, and then his editor inserted text to represent the study as supporting "miracle cures," either because of bias or just to "spice up" the story. Consider: The first sentence is jarringly inconsistent with the rest of the story. After all, the article even included the money quote about how this study demonstrates that there is a small, but real, subset of lung cancer patients who are "cured" by palliative low dose radiation therapy and how this observation should be taken into account when evaluating claims for lung cancer "cures," either due to new conventional treatment or due to alternative therapy or faith healers. Given how common lung cancer is, there are probably a fair number of these patients out there, some of whom undoubtedly attribute their good fortune to some alternative medicine or other. (Also, given how rare these long term lung survivors are, there almost certainly aren't as many such patients as there are breast cancer patients, whose testimonials I discussed long ago, but certainly enough for alties to point to.) Another obviously out of place sentence is this one: "Unorthodox cancer cures have included vitamin C, laetrile extracted from apricot stones, and the Gershon diet of raw vegetables." Nowhere in the study or even the description of the study is any mention of alternative medicine other than the one I cited, and certainly nowhere in the article is an indication that any "miracle cures" from alternative medicine were observed or even possible. In fact, it should be emphasized that every single patient analyzed received conventional therapy; i.e., radiation therapy. Consequently, even if the use of alternative medicine had been identified as a factor associated with long term survival of these patients, that observation would not have shown that alternative medicine had any value on its own for "curing" lung cancer.

    My guess is that the reporter probably interviewed Dr. MacManus and did a straightforward story about this study, and then the editor inserted the two sentences in question and gave the article its dubious title. The title is a lie, pure and simple, and the "spin" put on the article is such an obvious hack job that I stand in awe that the editor and/or the reporter could think its readers are so incredibly stupid that they won't see the disconnect between what the study actually says and how it has been represented. Nonetheless, right here I make this not-so-bold prediction: It won't be long before this news story describing this study makes appearances on altie websites, Usenet newsgroups (like misc.health.alternative), and perhaps even in other media sources, offered by alties as "proof" that alternative medicine can "cure" lung cancer.

    Just watch.

    And if you ever happen to see this study being misused that way, feel free to respond with a link to this blog posting.

    Monday, January 23, 2006

    I could have said it better

    If you're a blogger, don't you hate it when a commenter either says something better than you did or makes a point that you should have made in a post?

    So do I.

    However, I believe in giving props to commenters who manage to one-up Orac, so much so that I even preempted my intended post for today (a rare straight medblog-style post about a rather disquieting patient encounter I had a while back--so stay tuned for it) with this post instead. So, regarding my post about "ethnoscience" and how I viewed it as nothing more than a a bunch of alties trying to change the definition of science to include their particular brand of woo-woo, much as "intelligent design" creationists did in Kansas recently, John Stone added this comment:
    Ethnoscience is just good old whacked-out postmodernism with a few twists. (When is the last time you made an appointment with your witch-doctor?) Dr. Robert Imrie did a incredibly good job of disecting one "EthnoVeterinarian" case at this location. This is one of my favorite pieces of writing on the net. http://www.vet-task-force.com/SW41Imr.htm
    He's absolutely right. That's exactly what it is, nothing other than a form of postmodernism, and the link he mentioned is well worth checking out. The best one-liner:
    As we’ll see, in the context of ERD&E, the term “research” refers not to the critical scientific investigation of traditional or folk medical practices, but to their “judgment-free” investigation and “validation” in accordance with the tenets of cultural anthropology.
    And that's exactly what advocates of "ethnoscience" want for their various unscientific and/or religious "healing arts." Indeed the Dr. Imrie nails it exactly right here:
    In any case, I’m certain that advocates of scientific biomedicine share my conviction that various “traditional medical systems” merit rigorous but open-minded scientific evaluation. Who can say what treasures these resources might yield? I suspect that conventional “Western” and even “Third World” veterinarians share Dr. McCorkle’s and my eagerness to “integrate what works in folk medicine” with “what works in scientific biomedicine.” Where we differ seems to be in how we propose to determine “what works and what doesn’t.”
    Precisely. Advocates of "ethnoscience" seem to think that we in Western medicine should just accept on faith that the various therapies they're enamored of do what the healers claim they do or that we should subject the claims of "ethnoscience" to a lesser standard of proof (special pleading again). Their underlying assumption seems to be that, because millions of people have believed for hundreds, if not thousands, of years that these therapies "work," they must have efficacy or, at the very least, there must be something to them. Well, maybe or maybe not. In many cases, that millions of people believe in something is irrelevant to whether that something is correct. For example, millions of people have believed for thousands of years that ghosts exist, among other examples of superstitious, religious, or pseudoscientific beliefs that large percentages of the population hold. Does that mean I should just accept that there might be something to the contention that ghosts exist and communicate with the living without demanding scientific evidence? No! What about astrology? Millions have believed in it for thousands of years as well? Should I just accept it as having the same validity as astronomy for that reason. Of course not! Yet the underlying assumption, usually unspoken but not always, of "ethnoscience" seems to be that we should, often with the not-so-subtle implication that, if we don't, it is due to racism or elitism. Indeed, the very coining of the term "ethnoscience" seems a conscious effort by its advocates to imply that we should accept its claims as co-equal with those of science.

    So what's wrong with anecdotes, personal experience, and folk wisdom in determining what treatments "work." It's not that anything is "wrong" with it per se; it's more that we now know that it is not the best way to determine whether a treatment works or is widely applicable. We medical researchers know from the history of science and through long and bitter experience just how easy it is for limited sample size, confirmation bias, regression to the mean, selection bias, and other confounding factors can lead us into thinking a treatment works when it does no. We also know how easy it is for doctors to allow inherent biases and their desire to help people lead them to become too attached to a therapy's supposed efficacy. What seems to be poorly understood among the lay public is that randomized clinical trials exist not because we as physicians and investigators trust ourselves or other scientists but rather because we know that human nature is such that we can't trust ourselves or other scientists to be totally objective. In addition, as hard as it might be for us to accept, we can't trust our own personal experiences to be generalizable to all patients. That's why we need objective measurements, double-blinding where possible, and randomization.

    What also infuriates me about much of alternative medicine is that the attitude seems to be that we should have to test everything, even if there is no plausible scientific basis for the proposed therapy. So, while I'm giving other bloggers props for explaining and reinforcing what I'm trying to say, I might as well point out that Dr. RW put it nicely when he decried this attitude:
    Other notions proffered for “research” are, in my considered opinion, exercises in pseudoscience---attempts to validate claims that have been debunked and have no biologic plausibility. What’s the point of looking for clinical effects of energy fields undetectable by instruments of physicists and Star Wars forces left behind in water after active ingredients are diluted out?

    A strict empiricist might object to my requirement of biologic plausibility, but I maintain a line must be drawn. Otherwise we might as well burn the chemistry and physics books and study every claim that comes along. Why stop with Therapeutic Touch, Homeopathy and Reiki? Let’s go on down the slippery slope and fund studies of astrology, telekinesis and shamanism. And while we’re on the subject of energy medicine why not resurrect Franz Mesmer’s theory of animal magnetism? If only we do enough research his claims will surely be validated. (Discredited in the 18th century, Mesmer would likely be on faculty at a medical school today).
    This is a stronger statement what I've been saying all along, but have been perhaps a bit wimpy in emphasizing. Consider, for example, the very concept of homeopathy, the "healing art" that claims that you can dilute a substance to the point where there isn't even one molecule of the original substance in the water, and that the water somehow retains a "memory" of the compound such that it is effective in treating disease. For homeopathy to work, the very foundations of our understandings of chemistry, physics, and biochemistry would have to be seriously flawed or just plain wrong. It may be possible that homeopathy works by some previously understood chemical or biological mechanism, but it's so unlikely that it does that it is incumbent upon advocates of homeopathy to produce clearcut and convincing evidence that it works, not for conventional medicine to "prove" that it does not. The same should apply to any therapy that claims to manipulate "qi," an "life energy" that no physicist or instrument can seem to manage to measure (yet which practitioners of traditional Chinese medicine assure us that they can manipulate to heal patients), or to the African shamanism that whose inclusion in an exhibit on "ethnoscience" I decried. Why should I take this seriously if practitioners cannot show me how to measure qi empirically or by what mechanism chi can lead to healing?

    Contrast this desire for acceptance without meeting the standard of science by "ethnoscience" advocates with a recent example from the world of conventional medicine, namely the discovery of H. pylori as the cause for most duodenal ulcers by Robin Warren and Barry Marshall. Yes, Marshall and Warren's ideas were met with extreme skepticism and even ridicule when they first presented their hypothesis that the cause of most duodenal ulcers was bacterial. One of the criticisms was that the proposed mechanism wasn't biologically plausible, that it didn't fit in with existing science. If Warren and Marshall had been alties, they likely would have whined that they weren't being taken seriously by the "conventional medical establishment" or perhaps tried to pull the Galileo gambit prematurely. Fortunately for ulcer patients everywhere, they were and are scientists. So they did what scientists do. They did experiments. They gathered more data. The data was convincing, so much so that other investigators started to wonder if maybe Marshall and Warren might be on to something about H. pylori after all. More investigators started looking into the possible connection and found the same thing. Over a decade, momentum gathered, until there was a paradigm shift in the late 1980's and early 1990's, and a new scientific consensus developed. Warren and Marshall earned the right to be taken seriously, and, in fact, their efforts led them to be taken so seriously that they were awarded the most prestigious prize in medicine last year.

    As I've said time and time again, I'm all for scientifically testing various alternative medicines for efficacy and examining mechanisms by which those with efficacy exert their effect. However, we don't have the unlimited resources that it would take to do clinical trials on every claim made by alternative medicine advocates, which is why we need a "triage" system to decide which are worth looking at in more detail. We need reasonable criteria for determining which ones are worth evaluating scientifically. To me, one very basic first screen should be that the therapy being proposed should have a biologically plausible mechanism by which it might work, even if somewhat tenuous. By that standard, many herbal remedies would likely be worth checking out, given that many substances herbs and plants have pharmacological activity. Energy healing would not, because this energy or "qi" cannot be measured, detected, or even objectively described in a way that science can study it. Acupuncture would fall somewhere between as possibly worth checking out. Even though we have to do a bit of handwaving to come up with a semiplausible physiologic and biologic mechanism by which it might work, such mechanisms can be proposed. Not so for homeopathy, pyramid healing, various forms of shamanistic "spirit" healing, or distance healing. The likelihood that any new or efficacious therapy would come from studying these latter alternative medicine therapies is so low that they should be at the bottom of the list in terms of dedication of resources to study them.

    It is indeed important to test alternative medical therapies, as there may indeed be hidden gems that we in medicine could appropriate and integrate into our therapies, to the benefit of our patients. However, it is equally important that we do not dilute this effort by evaluating therapies whose basis is without biological, chemical, or even scientific plausibility, unless very clear evidence of efficacy is demonstrated by their advocates.