Science-based medicine conference, part 4: evidence-based medicine and homeopathy

This is part four of my summary of the Science-Based Medicine conference at TAM7, which will be followed by a summary of TAM7 itself. Part one, Dr. Steven Novella's introduction, is here. Part two, Dr. David Gorski on cancer quackery, is here. Part three, Dr. Harriet Hall on chiropractic, is here.

The next session was Dr. Kimball Atwood, an anesthesiologist who is also board-certified in internal medicine and associate editor of the Scientific Review of Alternative Medicine. He spoke on "Why Evidence-Based Medicine is not yet Science-Based Medicine," or "Do Clinical Studies of Highly Implausible Methods Help or Hinder?"

Dr. Atwood's talk made some points right at the start similar to the critique of evidence-based medicine (EBM) given in Dr. Novella's introduction--that EBM makes the mistake of devaluing what he called "pre-clinical knowledge." Unlike Dr. Novella, however, he also stated that random controlled trials (RCTs) "cannot, by themselves, overturn well-established medical principles." I'm not sure that his talk actually demonstrated that point--as stated, it sounds like "well-established medicalscientific principles" are part of a "hard core" of medical theory (in Imre Lakatos' sense) that cannot be refuted even if found to be in conflict with empirical results, because they are shielded by the addition of auxiliary hypotheses to salvage it. I don't think that was his intent, as surely even "well-established medical principles" should be eligible for revision in light of contrary empirical evidence. Instead, what I think he meant by "pre-clinical knowledge" and "well-established medical principles" is really more like a demand for consilience with the rest of scientific knowledge, adherence to logic and mathematical principles, and having a plausible mechanism (or at least not having a purported mechanism in conflict with other known facts). More on that in the "Q&A" section, below. [UPDATE (July 21, 2009): As Dr. Atwood notes in the comments, I incorrectly transcribed what his slide said. Also note his further discussion on what he means by a "plausible mechanism.]

He began his talk with an overview of EBM--EBM advocates, to quote EBM pioneer David Sackett, "use of the best available evience, especially from patient-centered clinical research." It relies on randomized controlled trials and systematic reviews. Dr. Atwood gave two examples of successes of EBM. First was the standard practice of giving heart attack patients anti-arrhythmia drugs post-myocardial infarction, which EBM trials showed causes excess deaths and was an incorrect practice. Second was the Women's Health Initiative study on hormone replacement theory, which showed that risks exceed benefits for taking estrogen. (I'm no authority, but I am skeptical of this claim based on my understanding of the flaws in that study from conversations with the late Chris Heward, who is co-author on a paper in Fertility and Sterility that challenged the WHI study for methodological flaws which made it unable to detect cardioprotective effects.)

The four steps of "pull" EBM are:

1. formulate an answerable question
2. track down the best evidence
3. critically appraise the evidence
4. individualize, based on clinical expertise and patient concerns

Atwood stated that those in practice the longest perform the worst, by not keeping up to date with their fields.

Cochrane Collaboration
Atwood next turned to the Cochrane Collaboration, the organization that maintains a library of EBT results, classified by type of evidence and evaluated with reviews in the form of evidence statements and recommendations. He gave a few examples, such as a statement about the effect of physical activity on dementia: "[There is] insufficient evidence to determine the effectiveness of ... physical activity programs in managing or improving ... dementia." And a seemingly equivalent statement about the use of homeopathy for the same purpose: "In view of the absence of evience, it is not possible to comment on the use of ... homeopathy in treating dementia." This, according to Dr. Atwood, is B.S. -- Bogus Science. Why don't they just say that homeopathy doesn't work? Because there are no sound clinical trials in the database.

EBT categorizes evidence into three classes. Class I evidence involves randomized controlled trials (RCTs). Class II involves controlled trials without randomization (or several other forms of case-control studies). Class III involves one or more case studies of a treatment without a control group and is considered insufficient for a treatment to be called "evidence-based medicine." Within each class there are further divisions, for example, Class I is broken down further, with systematic reviews of RCTs at the top (1a), followed by individual RCTs (1b), and so forth.

Atwood objected that this devalues pre-clinical knowledge by making "evidence" synonymous with clinical trials, and that therefore EBM "is not based on all of the evidence." He provided a few more examples of complementary and alternative medicine (CAM) treatments from Cochrane, described with terms like "Not enough evidence to ...," "little evidence," and, in the case of laetrile as a cancer treatment, "No studies found that met inclusion criteria." There was, however, a 1982 New England Journal of Medicine clinical trial on 180 patients which yielded a negative result and the conclusion that the treatment is dangerous, but this constituted a case study at the lowest level of evidence in EBM.

Atwood quoted a statement from Edzard Ernst, co-author with Simon Singh on the chiropractic-critical book, Trick or Treatment, to the effect that "a priori plausibility has become less and less important" as a result of EBM (which Ernst advocates).

He then continued with more CAM treatments in Cochrane, such as craniosacral therapy, reflexology, Kirlian photography ("may be more reliable than chance"), and therapeutic touch ("remains controversial").

Homeopathy
Atwood then described the case of homeopathy in order to make his central argument critical of EBM. Samuel Hahnemann invented homeopathy in 1796, on the basis of two principles. The first principle is "similia similibus curantur," or "like cures like," or the "law of similars." This claims that if you find a substance that gives you symptoms similar to an illness, that's the substance you use to cure that illness. Hahnemann read in William Cullen's "A treatise of the materia medica" that cinchona bark could be used to treat malaria (now known to be true because of quinine in the bark). He gave himself a sample of that bark while healthy and observed that he developed symptoms that were similar to malaria. From this single example, he concluded that all medicines produce symptoms in healthy people similar to the symptoms of diseases they effectively treat.

The second principle of homeopathy is the "law of infinitesimals." He reasoned that dosages sufficient to produce overt symptoms were too high, so the substances should be diluted in order to provide an effective treatment, and in fact the more diluted, the more powerful the cure. Homeopathic remedies of 24X (or 12C) are the equivalent of diluting 0.36mL of salt into a volume of water the size of the Atlantic Ocean. Hahnemann most commonly recommended an even greater dilution of 60X (30C). For all intents and purposes, homeopathic remedies of standard dilutions are indistinguishable from the water used to dilute them.

Atwood went on to note that homeopaths do not agree on prescriptions for various maladies.

On top of that, the outcome of all trials to date have been failures. This is a long list of powerful reasons for rejecting homeopathy, but the last one is the only one EBM considers relevant. There is clearly a very low degree of plausibility for homeopathy independently of such trials, and homeopathy is a clear case in point that "some hypotheses are too implausible to spend time on (or spend more time on)."

Prior Probabilities
Atwood offered the following set of broad categories of prior probability and types of treatments that fall into them:

Prior probability of about zero: homeopathy, neurocranial restructuring (putting balloons up your nose and inflating them).

Prior probability significantly lower than (<<) 1: metabolic therapies for cancer, detoxification, chiropractic for any purpose other than back pain Prior probability very low: acupuncture for pain most popular herbal claims (St. John's wort, echinacea) Prior probability moderate to high: massage, relaxation techniques for anxiety reduction and chronic pain Prior probability depends on:

• basic science
• cogency of theory
• previous studies
• source

He then discussed Bayes' Theorem, which says that the odds of a hypothesis being true given certain evidence is equal to the odds of the hypotheses (prior probability) multiplied by the Bayes factor, which is the probability of the evidence given the hypothesis divided by the probability of the evidence given the null hypothesis. If the prior probability is near zero, then much greater evidence is needed in the Bayes factor to result in a probability of the hypothesis being true. (Note that Atwood gave the theorem partly in terms of odds rather than probability for the purposes of his talk. Odds = probability / (1 - probability).)

When Bayes' Theorem is taken into account, the p-value of a statistical result can become much less impressive. For example, with a p-value of .05, which means that a result would be expected to occur by chance 5 times in 100 with a Bayes factor of 2.7, if the prior probability is only 1%, that result only raises the posterior probability to 3%. If the prior probability is 20%, it raises it to only 40%. With a p-value of .01, a result expected to occur by chance only 1 time in 100, and a Bayes factor of 15, a prior probability of 1% is raised to 13%; a prior probability of 20% raised to 78%. Dr. Atwood provided a table with more detail that went up to p=.001 (result expected by chance 1 in 1000 times).

Dr. Atwood advocated that "prior probability ought to be formally considered in EBT," and gave the further example of a "positive" trial for intercessory prayer in the critical care unit (CCU) with an 11% reduction in some harm with a p-value of .04, and noted that if the prior probability was 1%, this still produces less than 6% odds of a genuine effect. A few other similar examples were given involving acupuncture, homeopathy, and distant healing, the final example of which had Edzard Ernst as a study co-author and concluded that it "warrants further study," but which he subsequently backed away from after "some positive trials [were] found to be fraudulent."

Finally, he noted that pre-trial knowledge is not sufficient, but is necessary for a treatment claim.

Q&A
I asked Dr. Atwood if, in his final statement, he was saying that you have to have a plausible mechanism for a treatment in order for a treatment to be justified (a positive requirement), or if he only wanted to impose a negative requirement that the proposed mechanism or method did not contradict known facts from other realms. His initial answer was that he thought those would be equivalent, but I observed that we can discover cause-effect relationships without having any knowledge of the underlying mechanism, such as Mendel's discovery of genetics. At that point, he agreed that he just wanted to require the negative condition. Another audience member then suggested that this might be accomplished by creating a categorization scheme for levels of plausibility that in some way parallels the levels of evidence scheme.

Another questioner asked how to standardize assignment of prior probabilities and address bias, to which Dr. Atwood said that you could just pick neutral prior probabilities, since if you do enough studies the posterior probability of each study becomes the prior probability for the next.

EXTRA: As appropriate for a talk that touched on homeopathy, prior to Dr. Atwood's presentation this excerpt from the fourth episode of season three of "That Mitchell and Webb Look" was shown to the audience:



(Part five of my conference summary, on chronic Lyme disease, is here. Part six, on online health and social media, and the closing Q&A panel, is here.)

Science-based medicine conference, part 3: chiropractic

This is part three of my summary of the Science-Based Medicine conference at TAM7, which will be followed by a summary of TAM7 itself. Part one, Dr. Steven Novella's introduction, is here. Part two, Dr. David Gorski on cancer quackery, is here.

The next session was Dr. Harriet A. Hall, the "SkepDoc," a retired family physician and former Air Force flight surgeon, on "A Scientific Critique of Chiropractic."

Chiropractic
Dr. Hall began her talk by observing that 10% of Americans see a chiropractor some time each year, and said that her talk would address the questions of when you should see a chiropractor, what they really do, is it based on science, and why isn't it part of regular medicine.

Chiropractic, she said, is a pre-scientific system that was discovered on a single day (September 18, 1895) by D. D. Palmer, a grocer and magnetic healer. On that day, he performed a spinal manipulation on a deaf janitor and allegedly cured his hearing, and based on that single case, claimed that he had found the cause of all disease. Hall noted that in 1895, Pasteur had just died, X-rays had just been discovered, and the germ theory of disease was just catching on. For perspective, she noted that 1900 was the first year in which you would have a 50% chance of having a beneficial outcome from a visit to a doctor.

Chiropractic theory says that all disease is caused by subluxations, or dislocated joints, causing nerve impairment, thereby impacting the flow of "Innate," a mystical force that flows through us. There are real subluxations, which are visible on X-rays, but chiropractic subluxations have never been demonstrated to exist. The chiropractic finding of "Boop"--bone out-of-place--can't be documented on X-rays, and chiropractors have claimed that they are as small as 1/10,000,000 mm.

The current chiropractic definition of subluxation (as defined by the American Association of Chiropractic Colleges) has been adjusted to be more vague: "a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system and general health."

Palmer said that 95% of ill health and disease is caused by spinal subluxations, and 5% from misalignments of other bones. Hall suggested that if this were true, invertebrates wouldn't get sick, though perhaps chiropractors would say that Palmer was only speaking of the causes in humans. She went on to point out that a ruptured disc is an example of a spinal injury which causes pain without subluxation, directly refuting Palmer's claim.

The chiropractic theory of nerve impingement often uses a garden hose analogy, that a kink in the hose causes water to back up on one side of the kink. But this analogy is not correct, because nerve conduction speed is only affected at the point of compression, as seen in carpal tunnel syndrome. While such nerve dysfunctions do exist, they don't work the way chiropractic says, and they are not the cause of most disease.

A further problem for chiropractic is that 12 cranial nerves and 5 sacral nerves are out of reach for chiropractic manipulation.

Hall showed a diagram about the flow of "Innate" which showed the doctor's "Innate" influencing the patient's "Innate," but for which there was no described mechanism. There is, of course, no evidence that "Innate" exists, and it's now rejected by many chiropractors.

The audible crack from chiropractic manipulation, Hall said, is just like knuckle cracking, and has no therapeutic effect except perhaps for its psychological impact. She noted that at least one chiropractor cracks her own wrists and doesn't actually touch her patients!

Osteopathy and Chiropractic
Hall compared osteopathy to chiropractic with this chart:

Osteopathy	Chiropractic
restoring blood flow minimize spinal manipulation therapy (SMT) adopted science	restoring nerve flow maximize SMT nope

Spinal manipulation therapy, said Hall, works as well as other treatments in treating back pain, and there is no evidence that it assists in treating anything other than back pain. A problem in testing SMT is that good placebo controls are impossible, because the patient can tell when SMT is occurring or not. Single blinding is impossible, let alone double blinding. There are also many variations of technique possible.

Tooth Fairy Science
Dr. Hall argued that chiropractic study is something like what she called "tooth fairy science." You could perform tests of the tooth fairy, by putting lost teeth into baggies vs. facial tissue before putting it under the pillow, comparing the amount of money received for the first lost tooth to the last lost tooth, looking for correlations with parental income, and so forth, but none of this would tell you anything about an entity called the Tooth Fairy.

She gave an anecdote of a man suffering from back pain who made an appointment with a chiropractor for the following Monday. Over the weekend, his pain went away--if he had made his appointment for Friday, he would have attributed the pain going away to the chiropractic treatment and perhaps ended up as a believer and regular patient.

She compared this to the "blue dot cure," a treatment by painting a blue dot on your nose (any nonsensical treatment suffices for the illustration). If the patient gets better, that's evidence that it worked. If the patient stays the same, that's evidence that the treatment kept him from getting worse. And if the patient gets worse, that's evidence that the disease was too far advanced, and if only he had come sooner it would have been treatable. (Or, alternatively, it's evidence that more treatment is required--say, upping the dosage of the remedy or painting a darker blue spot on the patient's nose.)

What chiropractors do well, Hall said, is help with back pain and act as good psychologists. But they've gotten thumbs down the New England Journal of Medicine, Consumer Reports, The Medical Newsletter, Canadian neurologists, and many other sources, not just because of claims to be able to treat things that it can't treat, but because of safety issues.

The Big Downside of Chiropractic
Chiropractic manipulation of the head and neck turns out to be dangerous. It can compress or tear vertebral arteries, resulting in strokes, perhaps as frequently as in one in a million manipulations, and perhaps 20% of basilar strokes are caused by spinal manipulations. Hall pointed out that mobilization is as effective as manipulation, yet is safe--so there's no reason to use the riskier method.

The Canadian neurologists mentioned above have recommended that signs warning signs be posted in chiropractic offices and that neck manipulation of children be prohibited.

Insurance data on payouts for chiropractic malpractice show that about 9% of payouts in 2002 were for "CVA," or cerebrovascular accident.

The numbers are likely under-reported, since there may be some time between a manipulation that causes damage and a stroke.

Chiropractors as Quack Magnets
A further problem with chiropractic is that practitioners are "quack magnets," promoting all sorts of bogus diagnostic methods and treatments such as moire contour analysis, use of a "neuroscope" that measures temperature differences and pressure, biofeedback as a form of electrodermal testing, applied kinesiology (pseudoscientific muscle strength testing), unnecessary dietary supplements, homeopathy, and reflexology. Hall also mentioned B.J. Palmer's (D.D. Palmer's son) "Atlas Adjustment" technique, or "hole in one" technique, which suggests that manipulation of the Atlas vertebra is sufficient to cause the rest of the spine to fall into alignment.

Chiropractors also tend to overuse X-rays, such as taking full-spine X-rays which expose the reproductive organs and inevitably produce overexposed or underexposed areas. Proper X-raying focuses on smaller areas to get the right exposure.

Chiropractors offer bad advice, frequently discourage immunizations and other medical treatments, and they frequently miss diagnoses of real illnesses. In one test of chiropractors, patients were sent in to describe classic heart attack symptoms, but none of the chiropractors in the test recognized it or its significance, and none suggested that the patient visit an emergency room.

Types of Chiropractor
There are three major chiropractic groups. The International Chiropractors Association (ICA), or "straights," who practice only chiropractic. The American Chiropractic Association (ACA), or "mixers," who mix chiropractic with other diagnostic and treatment techniques. And the National Association for Chiropractic Medicine (NACM), who are attempting to reform chiropractic by disassociating it from Palmer's pseudoscience and using only evidence-based scientific medicine.

Chiropractic Thinking and Hallmarks of Pseudoscience
Hall gave some examples of chiropractic thinking that is blatantly wrong or harmful:

• If spine is straight, we can't die.
• Germs don't cause disease, or we'd all be dead.
• Muscle testing to find allergies. (In one case, a patient was tested for job-related stress with applied kinesiology, by pushing down on his arm while he thought of work.)
• Spinal adjustments as the only treatment for meningitis, resulting in the child's death--and it was the chiropractor's own child.
• A "no-touch" chiropractor (cracking own wrists, mentioned above).

And examples of how chiropractic exhibits the hallmarks of pseudoscience:

• "If science disproved it, I'd still use it."
• It doesn't give up ineffective treatments.
• It's made no progress over the last century.
• It doesn't matter whether it's true as long as it makes you feel better.

Dr. Hall concluded her talk by giving several three examples of concrete harm from chiropractic taken from Tim Farley's "What's the Harm" website, which lists 312 specific cases of chiropractic harm:

Kristi Bedenbaugh: Suffered a stroke and died.
Sandra Nette: Suffered multiple strokes and was left paralyzed with locked-in syndrome.
Laurie Jean Mathiason: Fell into a coma and died after receiving 186 neck manipulations in a six-month period.

Dr. Hall recommended the Quackwatch site and Chirobase.org as online resources on chiropractic, and the book Inside Chiropractic by chiropractor Samuel Homola and Quackwatch founder Stephen Barrett.

Q&A
In the Q&A session, Dr. Hall was asked whether chiropractors are required to follow a standard of care and whether informed consent is required. She said that informed consent is not required, it is voluntary, and the informed consent forms that she's seen are very bad. She was also asked how many chiropractors meet the good and safe criteria, and she made a guess of under 10%.

(Part four of my conference summary, on evidence-based medicine and homeopathy, is here. Part five, on chronic Lyme disease, is here. Part six, on online health and social media, and the closing Q&A panel, is here.)

Science-based medicine conference, part 2: cancer quackery

This is part two of my summary of the Science-Based Medicine conference at TAM7, which will be followed by a summary of TAM7 itself. Part one is here.

David Gorski, surgical oncologist and associate professor of surgery at Wayne State University, perhaps better known as Orac of the Respectful Insolence blog, spoke next on "Case studies in cancer quackery: Testimonials, anecdotes, and pseudoscience." He began with a disclaimer (he doesn't speak for his employer) and some disclosures (he receives no pharma funding and isn't paid to blog).

His talk was about misrepresentations by cancer quacks, who use exaggeration and misrepresentation and make false promises. To illustrate exaggeration, he showed a cartoon that described "three approved paths to the graveyard," "cut" (surgery), "burn" (radiation), and "poison" (chemotherapy) (the exaggeration is in the title rather than the descriptions, which are he admitted were accurate). To illustrate the latter, he showed a series of book covers by Hulda Clark--"The Cure for All Advanced Cancers," then "The Cure for All Cancers," and then "The Cure for All Diseases." She thinks that all cancers and diseases are caused by liver flukes, to be diagnosed with a "Syncrometer," a device similar to a Scientology E-meter, a galvanometer that measures electrical resistance of the skin, and cured with the "Zapper," a low voltage electrical device.

Some of the frequent claims of cancer quacks are that they are "wholistic" and treat the whole patient rather than a part or a symptom, that "we treat the real cause of cancer," that their treatment is "natural," and that "cancer is not the disease, it's a manifestation of something else" such as psychological conflict. And, of course, the ever-popular generic "toxins." They also claim that natural cures are being suppressed because Big Pharma can't make a profit from them.

Testimonials
Gorski next turned to the role of testimonials in cancer quackery, which he said are being used for several reasons, the first N of which are "to sell a product." Two other reasons are "to persuade others" and "to attack standard evidence."

He gave Gorski's Laws of Testimonials:

1st Law: When a believer in Alternative-Based Medicine (ABM) uses a combination of both science-based medicine (SBM) and ABM and gets better, it's always the ABM that gets the credit.

2nd Law: When a believer in ABM uses a combination of both SBM and ABM and dies or gets worse, it's always SBM that gets the blame.

He next described two cases of testimonials, the first of which was an example of a "not cancer" testimonial. This was a testimony of a man who felt a lump on his chest which he claimed to be breast cancer, which was successfully treated by some quack remedy. But this was never diagnosed as cancer, and Gorski noted that from the description it actually sounded like a case of gynecomastia rather than cancer. His second case was that of Daniel Hauser, a 13-year-old boy with Hodgkin's lymphoma, who went through one round of chemotherapy with good results, but then stopped taking it because he and his mother wanted to use an alternative treatment from "Chief Cloudpiler." The judge ordered chemotherapy to be continued, and he and his mom took off, though ultimately returned and re-started chemotherapy. During the time chemotherapy stopped, the tumor grew to larger than it was originally, and when it was restarted, it again responded to treatment--but of course his mother gave credit to the alternative treatment.

The problems with testimonials are that there may not have been a diagnosis of cancer, there may have been a misunderstanding of the diagnosis (e.g., "I was sent home to die"), there may be important information withheld, the diagnosis may have been done by quack tests with no validity (e.g., the Syncrometer or live blood cell analysis), and there may be a selection bias. As an example of the latter, he noted that dead people don't give testimonials.

Questions for Evaluating Testimonials
He provided a modified version of Dr. Moran's questions to ask in order to evaluate testimonial evidence. These questions include:

• Was cancer definitely present?
• Did it go away?
• Was the advocated treatment the only one used?
• Was the alternative therapy a replacement for primary or for adjuvant therapy?

At this point, he distinguished primary, adjuvant, and neo-adjuvant therapies. The primary therapy for most cancer treatments is surgery, to remove as much of it as possible. Adjuvant therapy is designed to reduce the risk of recurrence, where radiation is used to reduce the risk of local recurrence (cancer in the same place, to make sure you get rid of it all) and chemotherapy is used to reduce the risk of a systemic recurrence (cancer that may have spread to other parts of the body). Neo-adjuvant therapy is designed to shrink a tumor prior to surgery, and may reduce complications and produce better results from surgery.

Suzanne Somers
To illustrate the importance of these questions and distinctions, he used the case of Suzanne Somers, who was diagnosed with breast cancer at the age of 54, probably at stage I. She had no positive lymph nodes and underwent a lumpectomy, radiation, and a lymph node biopsy, but refused chemotherapy with tamoxifen in favor of mistletoe extract and other supplements.

In her case, the answers to the questions were:

• Was cancer present? Yes.
• Did it go away? Yes--it was removed by surgery.
• Was the alternative medicine the only or primary treatment? No.

He then examined her probable survival rates with and without chemotherapy, and noted that if the tumor was small, the benefit of chemotherapy for her 10-year survival rate could be as low as 1%. With a larger tumor, her 10-year survival rate improvement could still be as low as 4% (and would already be at 90% prior to chemo). But, Gorski noted, most women say that they would go with chemotherapy even for as little as a 1% increase in survival rate.

Surgery cures most cancers that can be cured, up to stage III, and the corresponding benefits of chemo and hormonal therapy increase with more advanced stages of cancer.

Gorski then observed that there may be cases where a person is diagnosed with cancer by a biopsy, declines further treatment, and has a good survival rate, where they fail to realize that the biopsy itself has been a surgical primary treatment that has excised all of the cancer--an excisional biopsy may be equivalent to a lumpectomy. He also noted that many people say to go ahead and take out the tumor but don't touch my lymph nodes, and he agreed that lymphedema, which can be caused by surgical or radiation treatment of the lymph nodes, is "not a fun thing." But the new standard of care is to use blue dye and a radiotracer procedure to find lymph nodes likely to be positive for cancer ("sentinel lymph nodes"), and treat accordingly.

Kim Tinkham
Kim Tinkham is a woman who saw The Secret, had stage III breast cancer, and declined all treatment. She now claims the cancer is gone, based on a quack blood test, even though the lump is still present, and has written a book about it. She is a follower of Mormon naturopath Robert O. Young, who claims that acid is the cause of all disease and alkalinization is the cure for everything. He says there is no such thing as a cancer cell, just a healthy cell spoiled by acid. Two years after her initial diagnosis, Tinkham is still alive.

Gorski pointed out that for a case like hers, expected survival for five years with treatment could be over 50%, but at ten years it goes way down. Data about untreated cancer comes from 250 cases of "large palpable tumors" from 1805-1933 at Middlesex Hospital in Connecticut. At 10 years, 3% were still alive, and at 15 years, 0.8% were still alive; the median survival rate was 2.87 years.

He noted that breast cancer biology is "highly variable in clinical behavior" and in some cases may be "indolent, slow-growing, and slow to metastasize."

The answers to the testimonial questions for Tinkham are:

• Was cancer definitely present? Yes.
• Did it go away? No.
• Was the alternative treatment the only one? Yes.

Time will no doubt soon tell how (in)effective this alternative treatment has been, unfortunately.

Testimonials as Conversion Stories
Gorski suggested that these testimonies are really part of "cult medicine" and seem to follow a pattern like religious conversion stories. The specter of death comes like a "bolt out of the blue," the person repents and says "I brought this upon myself," they face temptation in the form of standard medical care, they search for enlightenment, and then they find enlightenment in the form of some alternate description of their ailment which they then want to evangelize.

Michaela Jakubczyk-Eckert
Dr. Gorski concluded his talk with the story of Michaela Jakubczyk-Eckert (warning, graphic images), who was born on November 14, 1964 and died on November 12, 2005, just two days short of her 41st birthday. She had a T4 lesion eating through the skin of her breast, a case of "classic delayed diagnosis." She received neo-adjuvant chemotherapy treatment which shrank the tumor considerably, but then discovered Ryke Geerd Hamer, the inventor of German New Medicine, who argued that cancer is caused by psychological conflict rather than anything biological. She stopped her chemotherapy, and suffered a horrible relapse. As Gorski put it, she "died a horrible, horrible death" with her final days being subjected to the pain of a rotting-away body of skin and bones--a death far worse than chemotherapy. It was a vivid depiction of the alternative that cancer quacks can cause for their victims. Her husband has put up a website to try to dissuade others from being fooled by Hamer's theories (see link above to her story).

Dr. Gorski has written a blog post at the Science-Based Medicine blog on alternative medicine testimonials that covers some of the above subjects in more detail.

(Part three of my conference summary, on chiropractic, is here. Part four, on evidence-based medicine and homeopathy, is here. Part five, on chronic Lyme disease, is here. Part six, on online health and social media, and the closing Q&A panel, is here.)

Science-based medicine conference, part 1

This year's "The Amazing Meeting" (TAM7) was preceded by a Science-Based Medicine conference, organized by Steven Novella and the Science-Based Medicine blog; the speakers were all contributors to that blog. This summary is from my hand-written notes--I've tried to quote and summarize accurately, but keep in mind that some of the quotations and bulleted items may not be verbatim. The conference was videotaped and may become available via DVD or online video; keep an eye on the SBM blog for that. Steven Novella has posted a short summary of the SBM conference at the SBM blog.

I am in the process of posting a summary of TAM7 itself, which begins here. (I summarized 2008's TAM6 here.)

Novella's Introduction
The SBM conference began with Novella's presentation, titled "Science-Based Medicine: Science and Pseudoscience in Clinical Decision Making," which distinguished science-based medicine (SBM) from the recently popular "evidence-based medicine" (EBM) and explained the motivation for promoting the SBM concept.

Novella, assistant professor of clinical neurology at Yale University School of Medicine, began with a slide titled "Foundations of Medicine" which described some historical varieties of medicine:

• Superstition/philosophy-based medicine.
• Scientific medicine.
• Evidence-based medicine (EBM).
• Eastern vs. Western medicine.
• Complementary and alternative medicine (CAM).

He made the point that modern scientific medicine, which arose in the western world, is relatively young, though attempts to put it on a more scientific footing go back much farther.

Next, he discussed "What is science," first observing that "scientifically formulated" is a meaningless marketing label, then noting that there is a battle of memes about science between its defenders, who use it as a label connoting "objective truth, quality, and professionalism," and its critics, who use it as a label connoting "arrogance, oppression, and elitism." Marketers also use it "to imply product safety, effectiveness, and overall value."

He argued that we should adopt "common sense standards" which require that treatments "reasonably account for all available evidence," use "valid and internally consistent logic," have been rigorously and methodically investigated and judged with fair and unbiased criteria, and are conducted by practitioners who adhere to "standards of ethics and professionalism."

Evidence-Based Medicine
Next, he looked at evidence-based medicine, a term of art in use for the past couple of decades. EBM begins with the premise that "products and practices that work and are safe are better than those that don't work or are unsafe," an uncontroversial premise. It promotes scientific investigation as the measure of what works and is safe. But, according to Novella (and later, other speakers), EBM has "too much focus on evidence, and not enough on logic and prior probability, and good science must consider both." He argued that EBM made sense at the time it was introduced, because practices were being used largely "because they made sense, not because of supporting evidence." The introduction of EBM effectively "leveled the playing field, but also opened it up to implausible treatments," with bad timing due to the rise of complementary and alternative medicine (CAM).

The standard reference for evidence in the EBM framework is the Cochrane Reviews. The data reported in the Cochrane Reviews includes not only tests of legitimate medical treatments, but of completely implausible research such as chiropractic treatment for migraine. The problem with the framework is that it assumes that everyone is "playing fair," it does not account sufficiently for fraud or publication bias (such as the "file drawer effect"), it ignores prior probability, and it "doesn't adequately consider the big picture of the entire literature." According to Novella, with EBM it is typical to see the quality of studies decline over time, in order to continue to yield positive results for implausible treatments.

He then discussed "The Work of John Ioannidis," who argues that "most published research findings are false." The reasons are that

• The majority of highly-cited initial medical research is later refuted.
• There's a bias towards publishing positive studies.
• There's a bias towards researchers publishing provocative research.
  

And a "low prior probability worsens the effect," i.e., studies of treatments with low prior probability are more likely to be refuted.

Science-Based Medicine
By contrast with EBM, Novella identified the following features to distinguish Science-Based Medicine, SBM:

• It affirms high-quality science as a basis for standard of care in medicine.
• It acknowledges the consilience of science.
• It considered scientific medical plausibility of an intervention when weighing evidence.
• It considers the overall pattern in the literature.

In other words, SBM considers prior probability in a Bayesian sense as part of the evaluation, it looks at whether there is other scientific evidence that casts doubt on the plausibility of a suggested treatment (like violating the laws of physics or including unknown entities and mechanisms), in addition to merely looking at the specific results of controlled trials of the particular treatment. CAM, in particular, is loaded with claims that have extremely low and near-zero prior plausibility, as evidenced by the fact that $1.2 billion of U.S. taxpayer funding to the National Center for Complementary and Alternative Medicine since its founding in 1991 (originally as the Office of Alternative Medicine) has so far yielded zero effective treatments for anything.

He stated that finding anomalies argues for deeper research, and we can't have two inconsistent views that both work. Here, I think he overstated his case, since we have had cases in science where there are mutually inconsistent theories that both work, though we also take the inconsistency as grounds that something is wrong and ultimately needs to be reconciled (e.g., light wave/particle duality, quantum field theory vs. general relativity). Even theories that are wrong at some level can still work for solving certain kinds of problems (e.g., Newtonian physics)--and I'd agree with Novella's claim that scientific medicine is still in its infancy. A point Novella didn't make that I would like to insert here is that when you have two inconsistent views that doesn't mean that only one of them must be wrong--they could both be wrong.

Novella did go on to mention two cases where things that seemed initially implausible or lacking in mechanism have turned out to be correct, the postulation of dark energy in physics, and, more directly relevant to the topic at hand, the use of botulinum as a treatment for migraine. This treatment seemed to him completely implausible even though the evidence of trials suggested its effectiveness, and now a mechanism has been discovered and is understood. (My Google searching on this subject, however, yielded some recent evidence that it is not a good treatment for migraines and is no better than placebo, so this appears to me to still be somewhat controversial.)

Clinical Decision-Making
Novella ended his talk by talking about the process of clinical decision-making and pitfalls that arise as a result of human psychology and limitations. While clinical decision-making "individualizes the best available evidence to a specific patient" and "considers risk vs. benefit in both therapeutic and diagnostic intervention," this evaluation needs to include not acting as an alternative. In some cases, screening for certain diseases causes more harm than not performing the screening test, because conducting the test will yield far more false positives than true positives. (This is an effect discussed in some detail in John Allen Poulos' book, Innumeracy, and is a reason not to do things like mandatory HIV screening as a condition of a marriage license, drug testing of grade school students, and certain kinds of security screening for terrorists--if your baseline prevalence of what you're testing for is very low, your false positive results will swamp your true positive results.)

He briefly discussed the claim that "surgery kills more people than car accidents," noting that it doesn't really compare against the outcomes that would occur without surgery--far more deaths.

He then recounted some examples of pitfalls in the clinical context, such as the human capacity for pattern recognition even when the pattern isn't really there (pareidolia), the tendency to be "unduly influenced by quirky experience" or to "value experience over evidence," "failure to consider alternatives," "over-reliance on non-specific signs and symptoms," and confirmation bias (e.g., the sorts of heuristics and biases discussed in Kahneman and Tversky's classic Judgment Under Uncertainty). He then listed a few logical fallacies, pointed out the confounding factor of the placebo effect, and a couple of statistical effects--regression to the mean and the fact that most diseases are self-limiting.

Q&A
In the Q&A session, someone asked what Novella thought of legislation supporting evidence-based medicine, apparently referring to $1.1 billion in the stimulus package for evidence-based medicine research. Novella said that he thought conceptually it was a good idea but wasn't familiar with the specifics of the legislation. Another question was whether, given the current state of health care and the desire for reform, SBM would be challenged or supported. Novella said that the delivery of healthcare is a separate issue from how we decide what to research or what treatments are appropriate, and that things will either get much better or much worse. If he had also added that things might also stay about the same in overall quality, I'd say he's certainly correct; without it, merely probably correct.

(Part two of my conference summary, on cancer quackery, is here. Part three, on chiropractic, is here. Part four, on evidence-based medicine and homeopathy, is here. Part five, on chronic Lyme disease, is here. Part six, on online health and social media, and the closing Q&A panel, is here.)

On my way to TAM 7

I'm in the Phoenix airport waiting for my early morning flight to Las Vegas for today's conference on science-based medicine, followed by The Amazing Meeting 7, at the new South Point Casino and Hotel.

I hope to write up a summary like I did for last year's TAM 6.

Technology tidbits

From the Technology Quarterly report in the June 6-12, 2009 issue of The Economist, a few articles of interest:

• Gasoline/compressed-air hybrid vehicles may prove more cost-effective than gas-electric hybrids.
• Bigelow Aerospace wins challenge against export control regulations that would have required non-U.S. passengers on space flights to be treated as recipients of technology transfers, which would have required an onerous approval and monitoring process. (Not reported in the story is that Robert Bigelow is now funding MUFON to pay UFO researchers.)
• Delay-tolerant network protocol (DTN), developed with assistance from Vint Cerf, has been tested to transfer data between NASA's EPOXI probe and earth-based stations, which will lead to an interplanetary internet that includes the International Space Station.
• The heart of the cockroach has been used as the model for a new type of low-cost artificial heart for humans.
• Researchers are devising a laser-based defense mechanism to shoot down mosquitoes rather than missiles. Funded by the Gates Foundation, the prototype cost is only about $100. We'd like one.
  

The Center for Public Integrity is doing great work

The Center for Public Integrity has published a slew of new investigative reports:

"Global Warming: Heated Denials" -- reporting on climate change denialism pseudoscience from the Heartland Institute.

"The Shadow Government" -- 900 little-known federal advisory committees wielding influence over public policy.

"Divine Intervention" -- how the Bush Administration's initiative to fight AIDS abroad is hampered by conservative ideology.

"Broken Government" -- an assessment of 128 executive branch failures since 2000.

Check them out, and consider providing financial support for this organization, which is one of my top organizations to support.

Blatant deception on Arizona Proposition 101

Arizona ballot proposition 101, the Medical Choice for Arizona amendment, says this:

Be it enacted by the People of Arizona:

1. Article II, Section 36: Constitution of Arizona is proposed to be added as follows if approved by the voters and on proclamation of the Governor:

ARTICLE II, SECTION 36. BECAUSE ALL PEOPLE SHOULD HAVE THE RIGHT TO MAKE DECISIONS ABOUT THEIR HEALTH CARE, NO LAW SHALL BE PASSED THAT RESTRICTS A PERSON'S FREEDOM OF CHOICE OF PRIVATE HEALTH CARE SYSTEMS OR PRIVATE PLANS OF ANY TYPE. NO LAW SHALL INTERFERE WITH A PERSON'S OR ENTITY'S RIGHT TO PAY DIRECTLY FOR LAWFUL MEDICAL SERVICES, NOR SHALL ANY LAW IMPOSE A PENALTY OR FINE, OF ANY TYPE, FOR CHOOSING TO OBTAIN OR DECLINE HEALTH CARE COVERAGE OR FOR PARTICIPATION IN ANY PARTICULAR HEALTH CARE SYSTEM OR PLAN.

2. The Secretary of State shall submit this proposition to the voters at the next general election as provided by Article XXI, of the Constitution of Arizona.

It prohibits the State of Arizona from passing any legislation that prevents individuals from choosing to purchase or decline to purchase any type of health care or health care insurance from what's available, or that imposes a penalty or fine for doing so. That's it. It doesn't introduce any new taxes, it doesn't ban any state spending on health care programs, it doesn't prevent anything except the institution of a state health care or health care insurance program that requires mandatory participation, and it guarantees your right to privately arrange for health care with your own funds from the health care provider of your own choice.

Now, this does ban some kinds of health care program that some people advocate, such as the Massachusetts Health Care Reform Law of 2006, which required all Massachusetts residents to purchase health care insurance or face legal penalties--similar to mandatory automobile insurance. That program, supported by Gov. Mitt Romney, is similar to Hillary Clinton's health care proposal, but neither Obama nor McCain advocates mandatory health care insurance. If they did, however, this proposition would not prevent such a program from being instituted at the federal level.

But the opposition to Proposition 101 has been wholly deceptive. Here's some text from a mailer sent out to most Arizona residents last week:

Top 5 Reasons To Vote No On 101

Is an unclear permanent constitutional amendment that is so poorly written that it will ensure that our health care decisions will be dictated by the courts for years to come.

Makes health insurance so expensive, employers will be unable to provide coverage for their employees.

Jeopardizes Arizona's Medicare and Medicaid programs by destroying the cost containment measures adopted to provide affordable health care.

Is opposed by Doctor groups such as the American Academy of Pediatrics.

Will increase health care costs to Arizona taxpayers by $2 Billion.

Most of these items are simply fabrications or non sequiturs put forth without argument, and the mailer conveniently fails to mention anything about what the proposition actually says. Further, this mailing contained a photograph of Gov. Janet Napolitano under the State Seal of Arizona, which is a violation of state law, a class 3 misdemeanor.

The signs by the roadside urging opposition to Proposition 101 are equally deceptive, and include the claim that it will increase health care costs to Arizona taxpayers by $2 billion.

I've also seen claims online (in the comments on about.com's discussion) that Prop. 101 is backed by the insurance industry. That's false--it's opposed by the insurance industry, because they support mandatory health insurance programs for obvious reasons. This was a grassroots effort, led by Arizona doctors Eric Novack and Jeff Singer. (I contributed to the funds for signature collection for this ballot proposition.)

I've also seen claims at about.com that Prop. 101 will deregulate the healthcare and health insurance industries. Again, nonsense--the proposition has no effect on the state's ability to regulate healthcare or health insurance, except that it can't impose mandatory insurance or prevent you from purchasing any legal healthcare service or program. It doesn't say that the state can't ban or regulate healthcare, or determine what constitutes lawful healthcare.

The opponents of Prop. 101 are engaging in the most deceptive campaign against a ballot proposition that I've seen in several years. If you think the state of Arizona should be able to impose mandatory health insurance, then that's a reason to vote no on Prop. 101. If you think the right to opt-in or opt-out of health care or health insurance coverage should be left to the individual, then that's a reason to vote yes on Prop. 101.

Clint Bolick of the Goldwater Institute has issued a press release about the deceptive arguments against Proposition 101. I've been meaning to write something about it since I received the dishonest mailing, but seeing his press release prompted me to actually do it.

UPDATE (November 12, 2008): Prop. 101 was defeated in a very close race, 961,567 votes against and 950,440 votes for.

Unintended effects of Helicobacter pylori eradication

Since the Helicobacter pylori bacterium was discovered and proven to be the cause of gastric ulcers, it has been disappearing from the developed world as it's treated with antibiotics. But multiple studies are now showing that there can be negative side-effects from its disappearance, including acid reflux, asthma, and obesity.

H. pylori helps regulate stomach acidity, the byproduct of which is sometimes ulcers. But when it is taken out of the picture, stomach acidity can increase and cause esophageal reflux disease, a disease which has increased to match the decrease in ulcers as H. pylori has been eradicated.

The asthma mechanism is less clear, but may be from H. pylori stimulating immune response. The evidence supporting the link is that U.S. children aged 3-13 who have H. pylori are 60% less likely to have asthma than those who do not.

The obesity connection is also not definitively established, but people without H. pylori produce more grehlin (which makes you feel hungry) than those who have it.

(Via "The twists and turns of fate," about the work of Martin Blaser, a microbiologist at New York University School of Medicine, in The Economist, August 23, 2008, pp. 68-69.)

Simon Singh sued and silenced; Svetlana and Steinberg's speech surmounts suppression

Science writer Simon Singh (author of The Code Book on yesterday's list of science books) is a columnist for The Guardian, for which he wrote a column critical of chiropractic titled "Beware the spinal trap." The British Chiropractic Association sued him for the column, and it was withdrawn from the Guardian's website. Svetlana Pertsovich has posted the offending column from Internet cache on her website in Russia, James Steinberg has posted it at his blog, and I've included it below.

UK libel law is still in need of reform.

Beware the spinal trap
Some practitioners claim it is a cure-all but research suggests chiropractic therapy can be lethal
Simon Singh The Guardian, Saturday April 19 2008
This is Chiropractic Awareness Week. So let’s be aware. How about some awareness that may prevent harm and help you make truly informed choices? First, you might be surprised to know that the founder of chiropractic therapy, Daniel David Palmer, wrote that, “99% of all diseases are caused by displaced vertebrae”. In the 1860s, Palmer began to develop his theory that the spine was involved in almost every illness because the spinal cord connects the brain to the rest of the body. Therefore any misalignment could cause a problem in distant parts of the body.
In fact, Palmer’s first chiropractic intervention supposedly cured a man who had been profoundly deaf for 17 years. His second treatment was equally strange, because he claimed that he treated a patient with heart trouble by correcting a displaced vertebra.
You might think that modern chiropractors restrict themselves to treating back problems, but in fact they still possess some quite wacky ideas. The fundamentalists argue that they can cure anything. And even the more moderate chiropractors have ideas above their station. The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments.
I can confidently label these treatments as bogus because I have co-authored a book about alternative medicine with the world’s first professor of complementary medicine, Edzard Ernst. He learned chiropractic techniques himself and used them as a doctor. This is when he began to see the need for some critical evaluation. Among other projects, he examined the evidence from 70 trials exploring the benefits of chiropractic therapy in conditions unrelated to the back. He found no evidence to suggest that chiropractors could treat any such conditions.
But what about chiropractic in the context of treating back problems? Manipulating the spine can cure some problems, but results are mixed. To be fair, conventional approaches, such as physiotherapy, also struggle to treat back problems with any consistency. Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic.
In 2001, a systematic review of five studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors.
More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures.
Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection.
Laurie Mathiason was a 20-year-old Canadian waitress who visited a chiropractor 21 times between 1997 and 1998 to relieve her low-back pain. On her penultimate visit she complained of stiffness in her neck. That evening she began dropping plates at the restaurant, so she returned to the chiropractor. As the chiropractor manipulated her neck, Mathiason began to cry, her eyes started to roll, she foamed at the mouth and her body began to convulse. She was rushed to hospital, slipped into a coma and died three days later. At the inquest, the coroner declared: “Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck.”
This case is not unique. In Canada alone there have been several other women who have died after receiving chiropractic therapy, and Professor Ernst has identified about 700 cases of serious complications among the medical literature. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher.
Bearing all of this in mind, I will leave you with one message for Chiropractic Awareness Week - if spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.
· Simon Singh is the co-author of Trick or Treatment? Alternative Medicine on Trial
www.simonsingh.net


UPDATE: The part about chiropractic-induced stroke is of interest to me, as I had once heard of a case of chiropractic manipulation leading to blindness. When I mentioned it at a dinner of skeptics in Tempe, Arizona in 1987 that included James Randi and Jim Lowell of the National Council Against Health Fraud, both of them suggested that this was impossible because the optic nerves don't come anywhere near the spine. But nobody at the table (including me) thought about the possibility of spinal manipulation inducing a stroke causing damage to the visual system. This article from a chiropractic journal discusses cases of visual loss as a result of spinal surgery as a sort of tu quoque defense of chiropractic for similar problems, citing this article:
Myers M, Hamilton S, Bogosian A, Smith C, Wagner T Visual loss as a complication of spine surgery. Spine June 15, 1997;22(12).
So perhaps my remark from 21 years ago is vindicated?
UPDATE (November 4, 2009): Simon Singh gave an overview and update on his case on June 3.

Simon Singh fought against the libel claim despite the state of UK law, and has successfully won the right to appeal in October.


UPDATE (April 16, 2010): Simon Singh won his appeal, and the BCA dropped their suit.

Dr. Jay Gordon's bogus anti-vaccine arguments

Orac at Respectful Insolence critiques Dr. Jay Gordon's argument that breastfeeding and eating less cheese is a better way to prevent communicable diseases than vaccination.

Fake acupuncture works better than real acupuncture

Orac discusses a recent study in the Clinical Journal of Pain that compared the effects of "real" acupuncture (with real needles) to fake acupuncture (with needles with blunt ends that retract after hitting the skin, and do not puncture it) on test subjects between 2001 and 2003.

The result:

Both treatment groups, "true" and sham acupuncture, experienced decreases in the intensity of arm pain, arm symptoms, and noted improvement in arm function. However, patients in the sham acupuncture group improved more than patients in the "true" acupuncture group in the intensity of arm pain and just as much in measures of arm function and grip strength. The difference between the two groups was not sustained at a followup visit one month after the treatment ended, although the improvement in both groups remained detectable compared to baseline. Indeed, arm pain and arm symptoms scores declined faster in the sham compared with the "true" acupuncture group.

In this study, which was the largest, best-designed trial thus far for acupuncture for arm pain due to RSI, sham acupuncture was better than "real" acupuncture!

Read the details at Orac's Respectful Insolence blog.

Arizona paramedics change treatment of cardiac arrest

CNN reports that Arizona's paramedics have changed their processes for dealing with cardiac arrest victims, going against the recommendations of the American Heart Association, and the result has tripled the long-term survival rate:

Until three years ago, Arizona's success rate in cases like this was no better than most of the country. This past month, however, physicians in the state reported in the Journal of the American Medical Association that a new regimen by paramedics has tripled the success rate, to more than 5 percent. Among patients whose collapse from cardiac arrest was observed, long-term survival went from 4.7 percent to 17.6 percent.

In a bold departure from standard practice, paramedics in most Arizona cities do not follow the guidance of the American Heart Association. Instead, they follow a protocol that was developed at the University of Arizona's Sarver Heart Center, largely by Dr. Gordon Ewy.

Even after cardiac arrest, Ewy said, there's enough oxygen in the body to feed the brain and keep a person alive for several minutes. But that air helps only if someone compresses the heart to circulate blood. In traditional CPR, rescuers alternate 30 chest compressions with two long "rescue breaths." Paramedics are trained to start by checking the airway, and insert a breathing tube at the start of resuscitation. These extra steps, said Ewy, waste precious time.

In Arizona, paramedics skip the breathing step. They simply alternate two minutes of pumping on the chest -- 200 compressions -- with a single shock from a defibrillator.

This is similar to a story Newsweek reported last summer, which indicated that giving oxygen to cardiac arrest patients is the wrong thing to do. It's nice to see Arizona on the cutting edge, here.

Theists and atheists less depressed than agnostics?

A letter in QJM: An International Journal of Medicine suggests that theism and atheism are both correlated with "fewer reported depressive symptoms than the in-between state of 'existential uncertainty'."

Arizona doctors who question evolution

Physicians and Surgeons for Scientific Integrity is an organization of Darwin-denying doctors being touted by the Discovery Institute as evidence of growing dissent against evolution. Those on their membership list in Arizona:

Dr. Richard D. Friedman, Internal Medicine, Chandler, Arizona
Dr. Joseph M. Kezele, Emergency Medicine, Cave Creek, Arizona
Dr. William H. Noland, Neurology, Tucson, Arizona
Dr. Joel T. Rohrbough, Orthopaedic Surgery, Flagstaff, Arizona
Dr. Allan T. Sawyer, Obstetrics & Gynecology, Glendale, Arizona

Personally, given the new developments in biological science and medicine that are discovered as a result of evolutionary science, I would not want to use a doctor who denies evolution.

Arizona allows quacks to perform surgery

Orac at Respectful Insolence points out that a recent Arizona death after liposuction was a case of "minor surgery" being performed by a homeopath. And Arizona law permits these quacks to perform "minor surgery."

UPDATE (July 28, 2007): Orac has more on what Arizona allows via its regulation of "homeopathy."

Thimerosol/autism debate

In response to Crooks and Liars giving equal time to nonsense, Orac at Respectful Insolence has compiled a list of his posts on the claimed link between mercury/thimerosol and autism.

Hospitals have been treating cardiac arrest wrong?

From Newsweek:

Consider someone who has just died of a heart attack. His organs are intact, he hasn't lost blood. All that's happened is his heart has stopped beating -- the definition of "clinical death" -- and his brain has shut down to conserve oxygen. But what has actually died? "After one hour, we couldn't see evidence the cells had died. We thought we'd done something wrong." In fact, cells cut off from their blood supply died only hours later.

But if the cells are still alive, why can't doctors revive someone who has been dead for an hour? Because once the cells have been without oxygen for more than five minutes, they die when their oxygen supply is resumed.

Mitochondria control the process known as apoptosis, the programmed death of abnormal cells that is the body's primary defense against cancer. "It looks to us," says Becker, "as if the cellular surveillance mechanism cannot tell the difference between a cancer cell and a cell being reperfused with oxygen. Something throws the switch that makes the cell die."

With this realization came another: that standard emergency-room procedure has it exactly backward. [...] "We give them oxygen," Becker says. "We jolt the heart with the paddles, we pump in epinephrine to force it to beat, so it's taking up more oxygen." Blood-starved heart muscle is suddenly flooded with oxygen, precisely the situation that leads to cell death. Instead, Becker says, we should aim to reduce oxygen uptake, slow metabolism and adjust the blood chemistry for gradual and safe reperfusion.

A study at four hospitals showed a remarkable rate of success in treating sudden cardiac arrest with an approach that involved, among other things, a "cardioplegic" blood infusion to keep the heart in a state of suspended animation. The study involved just 34 patients, but 80 percent of them were discharged from the hospital alive. In one study of traditional methods, the figure was about 15 percent.

(Via jwz's blog.)

Conservapedia

The blogosphere has been making fun of absurdities at Conservapedia, Andrew Schlafly's attempt to create a conservative-oriented version of Wikipedia. Orac points out that Conservapeia promotes the anti-vaccination Association of American Physicians and Surgeons (Schlafly is their legal counsel). Mark Chu-Carroll points out that even math has a liberal bias, according to Conservapedia. P.Z. Myers looks at some of Conservapedia's coverage of evolution.

Perhaps most entertaining is Jon Swift's coverage of Conservapedia, which contains links to many of the Science Bloggers' commentaries.

Goldwater Institute: Confused priorities

In today's release from the Goldwater Institute, "The Nanny State Comes to My Mailbox," Andrea Woodmansee complains about the fact that a birthday card from Arizona Governor Janet Napolitano contained the statement "One of your most important roles as a parent is to make sure your baby is immunized."

I find it more objectionable that the state spends money to send out cards for all births instead of on more useful things (or did Ms. Woodmansee get special treatment as a result of her proximity to power?) than I am that the card contains an accurate statement about the importance of immunization.

This state contains numerous anti-vaccination conspiracy theorists who put the rest of us as well as their own children at risk by not having them vaccinated.

Failing to have children vaccinated is arguably a form of child abuse--failing to take reasonable steps to give the child proper medical treatment.

I can't bring myself to be exercised about Janet Napolitano promoting vaccination when we have a President who doesn't respect Constitutional limits on his power.

Does anyone doubt that Barry Goldwater would have prioritized George Bush's abuses of power over Janet Napolitano's birthday card promotion of vaccination as a subject of critical attention?