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White Coat Underground

Musings on the intersection of science, medicine, and culture


profilepaddle.jpgPalMD is a practicing internist in the Great Lakes region of the U.S.. Aside from the great joy he finds in his family and his work, he likes communicating some of that joy to others. He has a special interest in the ways patients---and we are all patients at one time or another---are deceived by charlatans. He aims to change the world, one reader at a time. Previous writings can still be found here, and here. I also write twice a month for Science-Based Medicine

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March 10, 2010

Dr. Kaiser responds

Category: Medicine

I was pleased to see that Dr. Kaiser responded to post from earlier this week. If you'll recall, Dr. Jon Kaiser is a doctor in California who is promoting a nutritional supplement to help treat HIV disease. I was hoping his response would be substantive, containing references to data I had missed in my research of the story. In this I was disappointed.

Dr. Lipson,

I was surprised when I read your recent blog about my career, expertise and perspective on HIV treatment.

Facts and science can be manipulated to support any opinion, so it is a fruitless exercise to engage in a point by point correction of your numerous mischaracterizations. But I will speak to a few of the core issues you raised.

Translation: "I have no actual data to refute your points, but I am about to drag you through a tangled heap of rhetorical mis-steps and logical fallacies."

I arrived in San Francisco during the height of the AIDS epidemic. Since that time, I have treated over two thousand HIV-positive patients and have dedicated my life to helping individuals with this condition live normal life spans. Back in the days before any effective drugs were available to treat this condition, and HIV infection was regarded as 100% fatal, I decided reject that belief. I then began exploring ways to help my patients outlive that prediction. Many of these patients are still healthy and alive today.

As I stated in my original piece, a number of older HIV docs were internists or other type of specialists, such as hematologist/oncologists, rather than infectious disease specialists and had to invent the field of HIV medicine as the epidemic developed. Not that Kaiser is an internists, having completed only one year of post-graduate training, but arriving in SF during the height of the epidemic would give any doctor an interesting, frightening, and humbling experience. Except Kaiser wasn't humbled in the face of disease; he "decided to reject" the fact that before anti-retroviral therapy became available, HIV was almost uniformly fatal. There have always been a few long-term non-progressers, some of whom may have certain genetic protection against HIV, such as a CCR5 mutation. But I view with some skepticism his claim that he yanked patients away from certain death with his revolutionary ways.

I would be surprised if the seven pharmaceutical companies who have enjoyed my participation as a consultant or speaker, the American Academy of HIV Medicine on whose Reimbursement Committee I have served, the International Journal of Infectious Diseases on whose editorial board I have participated, or the World AIDS Conference which invited me to present my research study results, share your perspective on my expertise and legitimacy as an HIV researcher and treatment specialist.

None of those facts actually make one an "HIV expert". I'm not saying he isn't an expert, but serving on the "reimbursement committee" of a lower-tier HIV organization hardly makes one an expert. As for his presentations, well, one traditional definition of "expert" is someone from out of town with slides. He seems to fit this definition, but having only one peer-reviewed publication in his field, one that required an editorial note to explain his conflict of interest, argues against him being an expert by other standards.

Despite your belief that a micronutrient supplement can't possibly act as a potent immune modulator, several pharmaceutical companies have already expressed interest in investigating K-PAX's Immune Support Formula in combination with their drugs.

Perhaps he hasn't read my piece all that carefully, or he just has a thing for straw men. I have no way of knowing what is in his heart, but I never argued against the plausibility of micronutrients assisting in the treatment of HIV---just that the data and claims he presented were not good evidence to support it. Perhaps some day evidence will support the use of his supplement, but that day has not yet come.

March 8, 2010

A nutritional approach to the treatment of HIV infection---same old woo?

Category: Medicine

I get all sorts of mail. I get mail from whining Scientologists, suffering patients, angry quacks---and I get lots of promotional material. I get letters from publishers wanting me to review books, letters from pseudo-bloggers wanting me to plug their advertiblog---really, just about anything you can imagine.

Most of the time I just hit "delete"; it's obvious that they've never read my blog and they're just casting a wide net for some link love. But a recent email from a PR firm piqued my interest: (it's a long letter, and I won't be offended if you simply reference it rather than read the whole thing now):

March 7, 2010

Coming up at WCU

Category: meta-blag

For some reason I'm really excited about tomorrow's post. I don't usually write very far ahead of time, but this one took a little bit of extra research. You see, I got this letter from a PR firm hyping some altmed doc, and it was much more interesting than the usual similar things I get. It highlights some of the subtleties at the intersection of science-based medicine and the other stuff.

The post is going up here tomorrow morning, and at Science-Based Medicine in the afternoon.

One thing I've found about blogging, though, is a piece I really work hard on and like a lot may go over like a real dud, and a post I crank out in five minutes may end up with more hits than I've seen in months. Go figure.

March 5, 2010

Friday writer's block open thread

Category: Medicine

Things have been rather busy at Pal's place. For whatever reason, the complexity of patients has been pretty high lately, so I haven't had a chance to get in my usual once or twice a day post.

I'm told that "back in the day" internal medicine patients were a bit less complicated. These days, to get admitted to the hospital, you have to be pretty damned sick. The hospital has to be able to justify your admission based on "severity of illness" and "intensity of service". In simple terms, you have to be sick enough to need care that cannot be provided elsewhere. The days of being admitted for "rest" or for "a workup" are gone.

It's not uncommon for a typical hospitalized patient to have several illnesses, and for the treatment of one to be incompatible with the treatment of another. Many, many patients are treated with various sorts of medications to prevent blood clotting. People with a common heart rhythm problem called atrial fibrillation are usually on a potent anticoagulant called warfarin. Patients with drug-eluting stents in their coronary arteries are often treated with an anti-platelet drug called clopidogrel. If a patient on these drugs develop gastrointestinal bleeding---a common enough problem even without blood thinners---treating them becomes a real dilemma. Stopping the blood thinners may lead to devastating clots, but failing to may lead to life-threatening bleeding.

Patients with atrial fibrillation may have a risk of stroke as high as 8-10% per year, a risk that can be cut in half with warfarin. The risk of severe gastrointestinal bleeding is lower than that (depending on a number of factors), but it still happens. Given this, we're going to see a lot of people with atrial fib in the hospital, either for GI bleeding or for stroke (not to mention for control of the arrhythmia itself).

All this is my way of saying medicine is never boring. But it's sometimes busy.

In addition to hospital rounds, I'm going to a birthday party for a five year old buddy of my kid. Other than that, who knows?

So, what are you up to this weekend?

March 3, 2010

Hey, guys, this one is for you

Category: Medicine

Sexual violence is a huge problem in the US.  Among college-age women, for example, 20-25% report an attempted or completed rape while in college.  Assault itself is prevalent enough to constitute a major public health problem, but add to that the sequelae---STIs, PTSD, fear, etc.---and sexual assault isn't just a major public health problem; it's one of our most common and devastating public health problems.

Given that most perpetrators of sexual violence are men, we have a target population for prevention.  Now, some might argue that focusing on preventing sexual violence by educating men is the wrong approach.  After all, why not teach women how not to get raped.  Right?

This common argument is one of the reasons we men need education.  So let's take a few minutes, guys, and go over a few things, things I've spent a lot of time trying to learn and to understand.

March 1, 2010

Running out of pigeons

Category: Medicine

Here in the U.S. our rich are very rich and all but our poorest live better than most Haitians. In this context it's easy to lose perspective and to be a bit naive about the survival needs of the people in post-quake Haiti. 

Or maybe that's being too generous. How hard could it be for an adult to realize that finding food, water, shelter, and basic medical care for yourself and your family take precedence over any other needs?  Does it really take being subjected to life-threatening conditions yourself to have such a basic level of empathy?  

The hordes of medical cultists descending on Haiti probably represent both ignorance and frankly cynical self-promotion.  There have been many reports of the Church of Scientology's faith healers walking around in yellow t-shirts trying to "assist" people's nervous systems.  Homeopaths, the folks who sell water panaceas, have been offering to "help" as well.

Poor and less-industrialized countries are a target-rich environment for alternative medicine cults. Since many alternative medicines don't require an industrial base, they can be made readily available anywhere.  Homeopathy is just water;  if a homeopath can simply provide a water remedy that contains fewer fecal coliforms than the local water, they can get away with quite a bit before people realize they've been duped.  In fact, unless a population has had exposure to real medicine, the altmed folks can fool people for a very long time. But hungry people can also be very pragmatic, and they know that eating grass will only give a false satiety.  The same may be true of medical help.

February 25, 2010

Are animal rights activists violence fetishists?

Category: Medicine

Ambivalent Academic made a fascinating observation today about certain parts of the animal rights movement:

What really strikes me is that a lot of this rhetoric reads like snuff-porn.


There is an undercurrent of appetite for the kind of violence they describe. It reads as if they take pleasure in imagining the violence they describe,... and they are inviting the reader to join in that sadistic pleasure. You can almost hear the drool.

I'm sure any sophisticated psychiatrist might have made this sort of observation, but I'm not even an unsophisticated psychiatrist. The images and language at websites such as Camille Marino's is violence-obsessed, and, as AA put it, almost erotic. Marino's loving and frantic depictions of violence are pornographic. Her enemies are portrayed bound, naked, and bloodied. Her use of words and image manipulation is full of masturbatory zeal.

And I don't think she is unique in this. Animal rights activists revel in violent imagery and language like very few other activists movements (save, perhaps, the anti-abortion movement). Their fantasies are far more disturbing than any slaughterhouse or laboratory.

February 24, 2010

Animal Rights Terrorists Target Children

Category: Medicine

I have this friend. She used to be a scientist, but changed fields, earning a Ph.D. in philosophy. She now studies and teaches the ethics of the practice of science. I'm sure most of my readers understand how important this is. Without transparent, thoughtful, and informed discussions of ethics, the practice of science and medicine would be a disaster. The past has seen many egregious practices, such as the Tuskegee Syphilis Study, Nazi medical experimentation, and the historical abuse of the poor and minorities by science, but ethical dilemmas and disasters are not a detail of history.  Many of the historical abuses in the name of science and medicine, for example experimentation on prisoners and the mentally ill, were normative at the time.  This doesn't make them right, but it provides context, and reminds us that some of our current normative practices may later be judged wanting.

Ethicists don't simply sit around a conference table discussing useless theory (although I'm sure they do from time to time).  They help develop policies and solve problems.  Ethical questions arise as a natural course of my work as a physician, and being able to consult experts not only helps me, but helps my patients.  

February 23, 2010

Platelet rich plasma

Category: Medicine

Several months ago, Dr. Val Jones wrote about a growing fad in the treatment of musculoskeletal disorders. The therapy, called platelet rich plasma (PRP) injection, involves taking a small amount of blood from a patient, spinning it down in a centrifuge, and then injecting the plasma component into...somewhere. This treatment is becoming increasingly popular, and can be very lucrative for doctors. But does it work?

Blood platelets are very biologically active particles and plasma is not a bland fluid. Platelets and plasma contain many biologically active molecules, some of which may be implicated in "healing". This gives PRP at least a veneer of plausibility, but like any other treatment, plausibility is only the first step.

There have been a few human studies of PRP. A recent article in the Journal of the American Medical Association (JAMA) showed no difference between PRP and saline injections for chronic Achilles tendon problems.

A small pilot study looked at PRP for the treatment of a particular periodontal disease, and found some possible benefit.

Another interesting study looked at PRPs affect on the healing of anterior cruciate ligament (ACL) grafts in the knee. This study included long term (two year) follow up, and found no benefit.

And that's really about it. There is little evidence to support platelet rich plasma for the treatment of anything. And yet it is being hyped and sold everywhere as a miracle cure for musculoskeletal injuries. Perhaps more studies will enlighten the issue further, but at this point, PRP is nothing but expensive snake oil, and those who promote and use it should re-examine the data and their ethics.


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