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October 16, 2007
Breastfeeding and allergies
Being the father of two breastfed sons with asthma and allergies and another two with atopy, I often wondered about the strength of the breastfeeding link. A recent study in BMJ (by Canadian and Belorussian researchers) found that breastfeeding is not protective against the development of allergies or asthma.
The Promotion of Breastfeeding Intervention Trial (PROBIT) did increase the number of women breastfeeding in Belarus. And these breastfed children did not show any advantage over bottle fed children in allergic problems at age 6.5 years. These results contradict other studies, including the Australian 1999 study. The problems with the study are many, not least of which include the low native rates of allergies in the tested population, the 3000 lost to follow-up (out of 17,000-- almost one out of six), or the results of the skin tests thrown out from 6 of the 31 test centers -- one out of five).
Perhaps the biggest problem is that we have drowned the baby in statistics.
Posted by Robert Maddox at 02:40 PM | Comments (0)
October 11, 2007
Flu Giddy
I am almost giddy with appreciation to the authors of a study in Lancet, reviewed by Medscape, suggesting that the flu vaccine is overrated for the elderly. Though I still disagree with some of their reasoning, and with their assertion that it is still beneficial for the young, healthy population, it is refreshing that one can still read such a challenge to the prevailing insanity in a prestigious journal.
"In 1960, US policy began targeting influenza vaccination at individuals at high risk for poor outcomes by virtue of chronic comorbid conditions and/or advanced age. Other high-income countries have followed suit, and the World Health Organization has endorsed these policies. From 1980 to the present, vaccination coverage increased from 15% to 65%, but recent excess mortality studies have not documented a corresponding decrease in influenza-related mortality."
To be fair, the authors hold out the possibility that better studies could reveal the benefit to the elderly, as their critics maintain. And perhaps understanding the immune system of the elderly better will lead to better vaccination modalities.
Or perhaps we will find that we have overrated the whole vaccine phenomenon.
Posted by Robert Maddox at 05:51 PM | Comments (0)
Wise Blood
"Nobody with a good car needs to be justified," according to Hazel Motes, the preacher escaping from his fundamentalist upbringing in Wise Blood. He starts the Church Without Christ, trying to escape from the Christ who haunts him and the whole South. In his sermon to the crowd leaving the Theater, as he stands on the hood of his car, he proclaims that there was no Fall, no Redemption, nor any need for any of that.
The medical profession, and its willing victims, has adapted Hazel’s sentiments. No one with a scalpel, or access to medicines, or stents and CABG and joint replacements, or vitamins and minerals, or a certain exercise routine, needs justification. Flannery wrote to Cecil Dawkins in 1958: “The Liberal approach is that man has never fallen, never incurred guilt, and is ultimately perfectible by his own unaided efforts. Therefore, evil in this light is a problem of better housing, sanitation, health, etc. and all mysteries will eventually be cleared up. Judgement is out of place because man is not responsible.”
It is an unreal world in which we live. We have convinced ourselves that only what we see and can prove is real. But worse, we ignore very obvious evidence that our efforts have little effect on the suffering we combat. One of the most glaring examples is CABG. From the beginning known to be life-saving for very few subgroups of coronary artery disease, repeatedly demonstrated to be over-utilized by any criteria, the procedure continues to be done on millions, ignoring what is a known reality and promoting the fantasy that has been created.
The reality which medicine ignores ultimately amounts to a denial of Jesus. If Jesus came in the flesh, and was who he said he was, the Anointed of God and God in the flesh, the very image of the Father, then we cannot ignore his impact on the world. If Jesus was raised from the dead, than nothing is the same. Everything in the world has to be seen through that fact. We cannot pretend for the sake of good science, good medicine, that there is no resurrection, that there is no spirit, that things just happen according to mechanical laws. The world is intrinsically personal, in that all things cohere in the person of Jesus.
Posted by Robert Maddox at 04:14 PM | Comments (0)
October 09, 2007
Help from Flannery
Although a few doctors have become famous novelists, and many novels are about doctors, few novelists speak to the problems of modern medicine as clearly and concisely as Flannery O'Connor. She did not write about medicine at all, though there are a few doctors as minor characters, and a office setting for a story. But she wrote against the perversions of modernity, of which medicine is one of the chief.
Ralph Wood's book has been very helpful as I have re-read her stories. The first few times through, I thought they were great stories, about people I know, and well-written, though frequently disturbing. Her letters reveal some of what she was trying to accomplish in her stories, and reveal much of her delightful and delighting personality. Credenda has a good issue on her work.
Several lectures by Duane Garner and Steve Wilkins this past weekend made some of the brilliance of her stories even clearer. Flannery wrote Southern literature, a genre so far superior to its predecessors and contemporaries that it is frequently derided and ignored. She concurred with Walker Percy that the peculiar advantage of Southron writers was that the South had lost the War. That, together with her personal suffering from SLE, her loss of her father to the same, and her other peculiar circumstances all combined to allow her a clear insight to the ills of modern society.
Good Country People and Greenleaf are both short stories with a hard message for modern medicine. I suspect that each of the stories have a significant message for us, even and particularly for Christians in the medical field. Many of the "villains" of the stories are good Christian people, who, like Mrs. May in Greenleaf, believe that "Jesus" should be kept private, like other words used only in the bedroom. Mrs. Greenleaf, on the other hand, is a careless, gross, even grotesque Christian, who does shocking and impolite things. But in the end, Mrs. May, gored in the heart by that bull standing in for Jesus, she sees clearly, and can't stand the sight.
That reminds me of a patient that CutOnTheDottedLine wrote about. It is so easy for us to hypocritically judge the apparently misplaced and confused faith of others. (I am not suggesting that Alice does, but rather myself). God will be their judge. They frequently have an insight that we need to learn, and God has let them be fools for our sake, even as Paul was willing to be for us.
Most of Flannery's short stories can be read in a blink. They are so tightly and carefully crafted that every word is important, and I know that I missed much the first few times I read in a hurry. So I intend to read back through a few and perhaps jot the medical lessons.
Posted by Robert Maddox at 05:38 PM | Comments (2)
October 02, 2007
Spinal Manipulation Therapy
A friend recently asked about spinal manipulation and chiropractors. Cortlandt Forum had a summary of the evidence.
One of the articles they cite is a metaanalysis of RCTs on acupuncture, massage and spinal manipulation for back pain. Another article in the same issue drew a similar conclusion.
What is most interesting is the risk of harm. "The most common serious adverse events are vertebrobasilar accidents, disk herniation, and cauda equina syndrome. Estimates of the incidence of serious complications range from 1 per 2 million manipulations to 1 per 400,000. Given the popularity of spinal manipulation, its safety requires rigorous investigation." (from Am J Med)
It seems that chiropractic is being held to a different standard of first doing no harm.
Posted by Robert Maddox at 01:11 PM | Comments (1)
coffee
I have recently started drinking coffee. Prior to this year, I probably consumed three cups, all as a social performance. With all the hype about its health effects, I have broken down and decided to indulge myself some. (Granted that none of that makes any sense, but it speaks to why the following forum question caught my eye.)
This is the question, from a medical forum magazine: "Should we or should we not drink coffee? What are the health benefits? What are the negatives?"
The respondent answers with a series of studies. He concludes, "Overall, it is likely premature to tell patients they can sip with impunity, but the weight of evidence seems to contrast with the supposition that coffee addiction is another bad habit."
So, the questioner apparently intends to decide whether to engage in this particular behavior based on the medical studies, which are mixed and inconclusive. What to do now? How can one live one's life this way?
Rather, all things in moderation. Don't be mastered by anything, except Christ.
Posted by Robert Maddox at 12:32 PM | Comments (1)
ACS Outcomes
An interesting study in Annals of Emergency Medicine demonstrates a few points that I have been exploring lately. There has been a strong bias in favor of admitting all patients with Acute Coronary Syndrome (ACS- anything that sounds like a heart attack that hasn't been proven to be yet) to the Coronary Care Unit or some special cardiology floor.
This study challenges that demand. They found that the group admitted to the noncardiology service did just as well in all outcome measures (recommended therapies, ED revisits and rehospitalizations, functional status, and adverse cardiovascular events). The only difference was that the cardiology group were much more (2-4 times) likely to undergo evaluation for ischemic heart disease.
So for more worry, more money and more tests, the outcome was the same.
But the best part of this study ("best" as in the punchline of this joke), like most studies, is the exclusions. Anyone who presented to the ED with symptoms that sounded cardiac was initially considered. But they excluded anyone with a known non-cardiac condition (which included panic attacks among others), with inability to give informed consent, who left the ED prior to enrollment, or was medically unstable, or had trauma, or was unreachable at follow-up. 2,817 were excluded and only 544 were included, for a Terrell's ratio of 1:6. For every six patients that were considered for the study, only one was eligible.
So although this study confirms common sense, and confirms my studied opinion of the (lack of) value of cardiac interventions (which I am reviewing in tedious detail currently), it still falls prey to the common pitfall of the modern scientific medicine -- it does not deal with reality. By eliminating the majority of patients from the study, it purports to narrow the scientific question and isolate the one factor that they wish to study. But ironically, it simultaneously makes the results irrelevant to the population in question.
Posted by Robert Maddox at 11:27 AM | Comments (0)