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June 28, 2007
Ear infections
Ear infections are always a great concern of parents, who don't want to see their children suffer, and would do almost anything to help them. An old review, updated recently by Prof. Del Mar for BMJ, gives a picture not commonly understood by even most doctors.
Middle ear infections ( known as AOM-Acute Otitis Media) always get better, with or without treatment. There are few complications from AOM anymore (for whatever reasons), and antibiotics do not prevent them anyhow.
80% of children feel better by the next day, whether they are treated or not.
Starting an antibiotic early in the course would reduce the chance of pain by a third. IOW, from 20% to 14% (there's that relative risk reduction again). This means that 100 children would have to be treated to benefit 6, for a NNT (number needed to treat) of 17 for 1 to benefit by less pain days 2-7.
And if that were the whole story, we might all conclude that the cost and trouble of taking an unnecessary antibiotic would be worth it.
But what about the harm of antibiotics? The diarrhea, the abdominal pain, the rash? 30% So 5 of our 17 will be harmed in some way by the unnecessary antibiotic. To help one with pain, we harm five. That is iatrogenesis. Medicine is harming more than it helps.
Posted by Robert Maddox at 05:40 PM | Comments (0)
Diverticular shift
Medical knowledge is shifting sand and many have estimated the frequency of the cycles as 5-15 years. Diverticular disease has undergone at least one shift in my careerlife from high fiber to no fiber and back again.
Now there is a study that reverses the dogma of no seeds for diverticular disease. Popcorn and nuts might not only not cause or aggravate diverticular problems. They actually were shown to decrease the risk of diverticulitis.
I only have the news blurb and don't see that the study was published but the way I read it, they found almost 1200 cases of bleeding or diverticulitis over 18 years in 47,000 men. Back-calculating means 1/4000 risk over two decades. A reduction of 20% means that eating seeds lowers the risk from 4/16000 to 3/16000, meaning that 1/16000 are helped by eating seeds.
The big point is that it never really mattered and like much of preventative medicine, it is much ado about nothing.
Posted by Robert Maddox at 11:15 AM | Comments (0)
June 26, 2007
yet more on mammograms
A very astute reader, one who has a dog in this fight, sent me a commentary that appeared in Lancet last year (Vol 368 p1854-6) (but still premium content which one must pay to read) which was basically a defense by Zahl etal of their study debunking the Swedish Two-County trial of screening mammography. There appears to be some significant editorial policy violation, in which their article was removed, contrary to accepted editorial and business policy. (Lancet was not the journal that removed their article.)
But more, it is evident that mammography is a third rail, the sacred cow, of medicine. There are many, of course, but this is a big one.
Posted by Robert Maddox at 01:37 PM | Comments (0)
echinacea
Lancet has published a meta analysis of echinacea to prevent and treat the common cold. There are 1 billion colds a year in the US. I will not pay for this article online and do not have access to the article so I am relying on the news articles (of which there must have been thousands). They found (not clear if this was over the whole meta-analysis or in one of the 14 studies reviewed) a 58% reduction in colds and shortened the course by a day and a half. Are they implying that there could be less than half a billion colds next year if we all took echinacea?
Did they study the percentage who had bad allergic reactions? The absolute worst case of anaphylaxis I have ever seen in 20 years of ER was from echinacea. And an Australian study showed up to 20% of atopics had severe allergic reactions of one type or another. Do we really want 4% of the population to have life-threatening reactions just to prevent the common cold?
I personally hate a cold. And I occasionally take Vit C and Zinc based on Art Robinson's research back in Linus Pauling's lab, thinking I am warding off a cold a few times a year. But I am not sure that even that pill-popping is worth the trouble.
Posted by Robert Maddox at 01:14 PM | Comments (2)
June 21, 2007
more on mammograms
Following this chain of evidence on mammograms yielded an interesting confirmation of the unwillingness of the medical profession to see clearly past the data cloud. A study in the Journal of the National Cancer Institute dealing with breast cancer screening was accompanied by an editorial by a Professor Baum, MD. He commented that once during an address he gave on mammographic screening, when he suggested that maybe screening does not benefit the premenopausal woman at all, his comments were not well received. He learned "that some topics, particularly breast cancer screening, do not lend themselves to polite and rational scientific debate."
I have no doubt that he is right. But I will persist in attempting.
In their response to Dr. Baum, the authors of the study commented, "We assumed a benefit for mammography among women aged 50-74 years but also assumed that the benefit is small enough that it is important to do screening correctly." A NNS of 838 to prevent one breast cancer death over 14 years is indeed a small benefit.
It is telling that so much time and ink is spent debating the data, when the very point in question, at least the one that should matter, is assumed without proof. Worse, the NNS is available, and the benefit deemed small enough that better efforts should be made. "It is not worth the effort to do this thing, so let's make a better effort to do it right."
Posted by Robert Maddox at 04:30 PM | Comments (0)
June 20, 2007
Commons
JAMA 297, 22 p 2518 is a commentary entitled, Managing Medical Resources: Return to the Commons? I must admit, this taxes my powers of understanding. They refer back to Hiatt's article adapting Hardin's "Tragedy of the commons." Somehow they seem to twist it backwards. The commons (which is destroyed should every farmer graze his livestock freely) is the health care system under fee-for-service. They examine various proposals as to why the commons is destoyed. They conclude, "Physician engagement in a medical commons, ideally with communities of consumers, is arguably the only approach that will ensure proper allocation of health care resources."
Why speak of a commons? What have I missed? I thought the point was that each patient acting in his own best interest, advised by a doctor with that patient in mind, was the goal of medicine.
Posted by Robert Maddox at 12:31 AM | Comments (0)
Value
JAMA 297,22 has a commentary on value-based insurance benefits, which makes alot of sense but will probably be misapplied, in light of simple hubris like the previous entry on mammograms. The concept is simple: pay more for less effective interventions, and less or nothing (in terms of co-pays or deductibles) for more effective ones.
Would it not be even more effective to let the consumer make this decision himself?
Posted by Robert Maddox at 12:22 AM | Comments (0)
June 19, 2007
mammograms
Please remember that I am not giving advice. Rather, I am recording information and trying to think through these issues.
Mammograms are one of the givens of modern medicine. A recent review in American Family Physician states correctly, "Breast cancer is one of the most significant health concerns in the United States. It is the most commonly diagnosed cancer in women and the second leading cause of cancer death in women." (So it is madness for me to challenge this sacred cow. But mad I am and challenge I must.)
Over the past few decades, several methods of screening have been advocated. Screening makes prima facie sense. Find the cancer early and you can prevent more significant problems. With this reasoning, any screening method is better than none. So we have the options of Breast self-examination (BSE), clinical breast examination (CBE), mammography, ultrasonography, MRI, scintimammography, PET and ductal lavage.
Compared to other conditions for which one might screen, at least breast cancer is relatively common. A woman has a one in 11 risk of developing breast cancer, so the saying goes.
Posted by Robert Maddox at 10:32 PM | Comments (0)
June 07, 2007
Rivers North
I have finally starting reading The Rivers North of the Future: the Testament of Ivan Illich as told to David Cayley. It is fascinating, a conversation more than a treatise. There are some rather broad historical summaries, much like Rosenstock-Huessy. What follows are gross oversimplifications of his gross oversimplifications.
He states at one point that he did not go far enough in Medical Nemesis, that he missed the major point. The problem is not iatrogenesis as now commonly understood. It is rather that our bodies now are doctor-created. We think of ourselves in terms given to us by medicine. These great illustrations (that pretend they are depicting reality but are really artists’ renditions of various physico-chemical models) and the House animations of disease mechanisms give us a body that is very different from what our forebears were.
All of this comes from the change in the 12th century of the tool as an independent entity. It took doctors another 6-8 centuries to view disease as an independent entity. All of this is related to the change in understanding about the Real Presence of Christ in the supper.
Illich views all of this as a perversion of the Church, and of the Incarnation, that was built into it from the very beginning. He refers to this as the “mystery of evil,” using Paul’s phrase to the Thessalonians. So Western Civ, modernism, is not post-Christian or developed Christian thought, but anti-Christian thought that is built into the very fabric of the Church. He wonders why God would do this. It seems to me that it is to mature us as a people.
Posted by Robert Maddox at 08:11 AM | Comments (0)