Ed’s corner of the web

It’s been one heck of a month.  Turkey was great - more to follow - but I already feel like I need another vacation.  Too much work, too much long-distance driving, a GI bug, a ten-day course of Tamiflu for an H1N1 exposure, and a death in the family on top of all of that.  I’m beat.

But then two of my readers tell me personally (the other three couldn’t be bothered, I guess) that they noticed I hadn’t updated in a while, so here I am, dragging myself back in front of the keyboard.  Must…post…

Actually, today’s subject of posting is too interesting to pass up.  I hold a special place in my heart for Zicam.  It’s the non-homeopathic homeopathic remedy.  Unlike “conventional” homeopathic remedies, which are diluted so much that you’d be lucky to get a single molecule of active ingredient in a dose, Zicam actually contains biologically active amounts of zinc.  The product manages to squeak by FDA regulation, though, because the product makers finagled a “homeopathic” designation.  (More on this subject from Steven Novella here.)  As if it wasn’t enough to have homeopathic remedies masquerading as medicine, now you have not-so-homeopathic remedies masquerading as masquerade medicine.  All yours for the low low price of $10.  Oh how far we’ve fallen.

Now, as you’ve probably heard, the FDA put the kibosh down on Zicam today.  Seems it could make you lose your sense of smell, permanently.  Not good.  Can you smell what Matrixx Initiatives (the two “x”’s mean they’re extra extra cool) is cooking next?

You guessed it!  Denial!  Matrixx asserts that, “There is no reliable scientific evidence that Zicam causes anosmia.”  In other words, “We didn’t want to have to do that science stuff to prove safety or efficacy when we brought this junk to market, but we demand that you peform rigorous science-y experiments to take us down.  Neener neener.”  How’s that for a double standard?  In all seriousness, this sort of post-market surveillance for adverse events is the FDA’s job.  If they suspect that there are unreported side effects or adverse events cropping up, then their responsibility is to consumer safety first.

Am I passing early judgment on this?  Yes.  I’d be lying if I denied it.  All the data should be laid out on the table, and Zicam should be given the chance to make its case.  But I’d also be lying if I said I wasn’t getting a great deal of schadenfreude out of today’s news.  It’s very satisfying when a company that tries to get by on disingenuous practices finally gets its comeuppance.

Another speed post from Turkey - this time from the super-cute town of ??rince.  I´m using a Turkish keyboard with some extra characters (stuff like ?, ?, Ü, é, and €) and alternate key placements (ö instead of a comma, ç ?nstead of a period), so typing is a bit of a challenge.  I´ve even got a secondary Alt key to handle the extra stuff.  I´m not even sure this is go?ng to display anyth?ng but gibberish, but I thought it would be a fun experiment to try out.

Here’s a little international post for you.  I’m writing to you now from Esbelli Evi, a cute little hotel in the cute little town of Urgup (there should be little dots over the u’s - I can’t figure out how to do it right now) in the Cappadocia region of Turkey.  We’ve been  in this great country for several days now and have been having a great time.  Today we traveled from Istanbul, a city of over 15 million, to this little town of 15 thousand.  In doing so we crossed from Europe to Asia, which would’ve been more cool had we not already crossed from Europe to Asia and back again just for dinner the other night.  If I could post a couple pictures, I would, but I didn’t want to drag my laptop with me this time around.  Rest assured that there will be a full assault of photos once we return.  And in case you’re wondering, we haven’t run into any swine flu over here.  With any luck, things will burn out stateside before we come back.  I’ve got my N95 respirators packed just in case.

Had to take another little break there to wait for the comment spam to die down.  Sorry for the pause and thanks for your patience.

Got a little doozy of a story going on in Boston that has even caught the attention of the national news providers.  The “Craigslist killer” is allegedly a second year BU Medical School student.  This story really has it all - a dark murder; a young, smart, promising suspect engaged to be married; trips to casinos; possible related crimes in another state; potentially damning evidence.  The cherry on top?  A handgun hidden in a cut-out copy of Gray’s Anatomy.  Not to be crass, but you really can’t make this stuff up.

I think every med school class has those one or two students where you wonder, “Now how the heck did he/she get into med school.”  I know mine did.  This, of course, is a very extreme example.  For the record, I really like BU med students.  They’re bright, hardworking, and don’t have the sense of entitlement you can sometimes see from other schools.  My interactions with them have been almost entirely positive.  I hope that this episode doesn’t prove too difficult for the rest of the class and the rest of the school.

Carisa brought to my attention a recent paper in the journal Environmental Health that details an inquiry into the mercury content of high fructose corn syrup, a ubiquitous food additive (fervently disliked by this blogger).  As the story goes, an Environmental Health Officer (EHO) at the FDA was trying to track down some missing mercury in the chlor-alkali industry starting in 2003.  During this process, the EHO learned that two products created by the chlor-alkali industry, sodium hydroxide and hydrochloric acid, could contain small amounts of mercury depending on the processes used in their manufacture.  The EHO then went on to discover that these two products were used mainly in the production of high fructose corn syrup (HFCS).  It wasn’t a huge leap of insight from there to surmise that mercury might, as a result, end up in HFCS and thus the country’s food supply.  Sure enough, government labs, followed subsequently by an independent lab, found mercury in HFCS samples.  The paper mentions that out of twenty samples from three production facilities tested by the independent lab, nine contained detectable amounts of mercury.  Of course, being smart people, your next question is how much?  The dose makes the poison, after all.  Well the range was 0.012 to 0.570 micrograms mecury per gram of HFCS, with an average of 0.252 micrograms Hg/gram HFCS.

Still need more info?  That’s the spirit.  The average American consumes about 50 grams of HFCS per day.  Revolting, isn’t it?  Taking the worst case scenario of 0.570 micrograms Hg/gram HFCS, that means 28.5 micrograms Hg per day just from HFCS.  The FDA lists 0.1 micrograms Hg/kilogram as a “no effect” amount of intake (note that this is a very controversial number, with different values almost everywhere you look).  So for a 70 kg person (high unlikely if you’re really consuming 50 grams of HFCS per day), that means you can safely shoot for 7 micrograms of mercury a day, or about a quarter of what you just consumed in all that HFCS.  Oops.  Just for reference, that six-ounce can of albacore tuna you just ate?  The stuff that you’re not supposed to have too often?  That’s roughly twice the amount of mercury from your HFCS.

Is there room for tighter standards and regulation here?  I think so.  For sodium hydroxide intended for food use, there is an international cap of 1 microgram mercury per gram of sodium hydroxide.  Unfortunately there is no such limit for hydrochloric acid.  At the other end of the food production chain, the FDA checks a lot of the food we eat for mercury, but unfortunately carbonated sodas - a huge source of HFCS - aren’t included on the list.

Now avoiding tuna and other yummy, high-mercury fish is difficult, especially since fish is generally good for you.  But luckily, avoiding this newly-recognized source of dietary mercury is not particularly challenging, at least from the culinary or health standpoints.  Avoiding HFCS means avoiding sugary sodas, over-sweetened breakfast cereals, and a lot of the highly processed, crappy excuses for food you find out there.  You’re not missing out on anything by cutting HFCS from your diet, and you’re probably doing yourself a great deal of good.  As if you needed another reason.

As a Darwin Day “gift,” a friend of mine presented me with a copy of The Reason for God, by Timothy Keller.  The subtitle reads, “Belief in an Age of Skepticism.”  I guess I’m letting my skeptical nature show a little bit, huh?  At any rate, I love this friend dearly, and I know the gift was well meant, so I felt obliged to read the book, even if it wasn’t the sort of thing I would usually pick to curl up with.  As I made my way through the book, I began to think that it would be an interesting exercise to blog about the book as I went along.  This post, then, is an introduction to that very exercise - hopefully a series of posts about my impressions of the arguments put forth by Keller as he tries to poke holes in the common arguments against Christian belief and support the strongest reasons he sees for faith.

And just so you know how serious I am about this, I’m actually taking notes in the margins.  Close friends of mine know that I never write in books.  Even my medical school textbooks have nary a highlight or underline.  I’ve always had a hard time “defiling” a perfect printed page, and it’s still against my instinct to put pencil to the paper, even for this cause.  The things I do for you people…

As a preamble, I feel it’s necessary to give my initial impressions of the book, so that you can better know my state of mind going into this exercise.  According to the dust jacket, Keller is trying to reach out to “atheists, agnostics, and skeptics” in an attempt to make an “intellectually compelling case for God.”  Ostensibly, Keller seeks to connect with these nonbelievers, to speak in their own language and argue using their own tools - a high goal, to be sure.  But then you look at the back cover, where the first two jacket quotes come from Rick Warren and Billy Graham, with another quote further down from Christianity Today magazine - not exactly ringing endorsements from the nonbeliever crowd.  I’m not crazy enough to expect a Sam Harris or Richard Dawkins, but maybe a Francis Collins?  Ken Miller?  Maybe Keller really makes some reasonable logical arguments for faith or against skepticism, but from first impressions I am - frankly - skeptical.

On Thursday, February 12th - Darwin Day, no less - I had just finished checking in on a patient in the ICU and decided to check the news.  I was greeted on the front page by this story.  I had to read the headline twice to make sure I read it right.

The vaccine court, a special court convened to determine whether petitioners were entitled to compensation from the Vaccine Injury Compensation Program, had ruled on three test cases wherein parents asserted that their children had acquired autism through a combination of MMR vaccine and thimerosal from other vaccines.   The ruling was that the evidence presented did not prove a link between autism and childhood vaccines.  In fact, the evidence presented was “overwhelmingly contrary to the petitioners’ contentions.”

Many in the medical and scientific community waited for these rulings with bated breath, all the more concerned because the vaccine court had a lower standard of evidence than a regular civil trial.  Because of this lower standard, even though the scientific evidence clearly showed no link between autism and vaccines, there still remained a small chance that the petitioners could have received an award.  If that happened, it would have been ugly.  I don’t even like to think about what it would have meant for child health in this country.  But fortunately, science and reason prevailed, and I breathed a heavy sigh of relief that morning followed by a triumphant fist-in-the-air.  Just as fortunately, none of the ICU nurses saw me.

On a more sordid note, the Andrew Wakefield saga also deepened this month.  If you recall, Wakefield was the doctor who published a paper in Lancet in February of 1998 purporting a link between the MMR vaccine and autism.  Despite involving only 12 children, the paper’s effects tipped off a MMR vaccination scare that was felt throughout the world, with sharp dropoffs in MMR vaccination rates over the subsequent years.  The sketchy stuff comes when, over the course of the next several years, 10 out of 12 coauthors on the Wakefield paper jointly publish a retraction of the original paper’s conclusions, independent researchers are unable to replicate any of Wakefield’s data, and we learn that Wakefield was massively conflicted in his research - having filed patents for an alternate vaccine to replace MMR and having received over four hundred thousand pounds in fees from lawyers seeking to sue MMR vaccine manufacturers.

Right - scary.  But wait, it gets better.  This month, the London Sunday Times revealed that Wakefield may very well have cooked up the data for his landmark 1998 paper (more details here).  The audacity boggles the mind.  It angers me greatly to think that this one doctor, acting so irresponsibly, selfishly, and unethically, has caused so much damage to child health.  I am, however, at least grateful that science (and a tenacious journalist named Brian Deer) has finally caught up with this guy a little.  Hopefully with the efforts of further inquiries, peer review, and reeducation, science will be able to correct this injustice.  (If you want to read more, Orac talks a lot more about this issue here.  Wikipedia even has a decent bio on Wakefield detailing all the latest controversies.)

So all in all, with just three days left in the month, we’ve had one solid victory for science and a big step towards correcting a past wrong.  Perhaps not as fast as I would like, but still not too shabby.  Charles Darwin would, I think, have approved.

Here in the Boston area, we’ve been fortunate enough to have had a bunch of snow thus far this winter.  I say fortunate despite the fact that this is my first winter as a homeowner and law-mandated sidewalk-shoveler.  All too frequently in winters past, we’ve had good snowfall one day only to be followed by temps in the 40’s and a slushy mess the next day.  That’s if we had snow at all.  But this winter’s cold temps have kept the snow frozen, and I’ll take cold temps with snow over slightly warmer temps with wet slush any day.

Carisa and I have taken advantage of the snow as much as possible.  We’ve been out snowshoeing on five separate weekends…

…and we’ve done some cross-country skiing on three weekends, below with Fanti and Bob at our favorite place.

It’s been awesome.  As much as I enjoy all the outdoor possiblities of the other three seasons, moving in relative solitude through the hush of show-shrouded woods is an experience I relish greatly, perhaps all the more so for the limited window in which it is possible.

Many of my friends and colleagues are aware of my opposition to gifts from drug companies to physicians (I’ve blogged on this topic before).  You might ask how I can be so saintly in my virtues.  Is it my unerring internal ethical compass, my zen-like detachment to material accoutrements, my incorruptible moral fibre?  Ha!  I’ll tell you how I do it:

I get some sort of drug company freebie or sample maybe once or twice a year (unsolicited, mind you).  This was the latest one.  Some docs get free steak dinners, “seminars” in the Bahamas, and honoraria for “assisting with product development.”  I get free boxes of stinky tissues.  And boy do I mean stinky.  I’ve been trying to pawn this stuff off on the adult hospitalists, since it gives me a headache and makes our call room reek.  Who the heck would want to use this stuff?  I’ve been using the sandpaper-like paper towels out of the bathroom instead of these migraine-inducing failed science experiments.  With gifts like these, it’s no wonder I’m no friend of the practice of gift-giving.

Wired’s Clive Thompson wrote a nifty little piece in this month’s issue that talks about the evolution of knowledge as we rapidly increase the accessibility of information via the web.  In this context, information refers to the raw, unfiltered “stuff” - whether factual or not - out there on the web and elsewhere, while knowledge is made up of the truths we are able to ascertain from said information.  The crux of the article is the idea of “culturally constructed ignorance,” whereby knowledge that would not normally be circumspect (eg. Obama being a Christian) is attacked by special interests who benefit from sowing doubt.  The concept is compelling because of its irony: in today’s day and age, with unparalleled access to huge depth and breadth of information made possible by technology, our social knowledge may not be any better off than it was in the days before the internet.

Consider the world wide web and its infinite number of echo chambers.  No matter what floats your boat, you can find an sympathetic, agreeable, and welcoming cadre of like-minded boaters out there somewhere.  The same goes for information - and especially misinformation.  If you believe that NASA faked the moon landings, you can find (a surprisingly large number of) people on the web who will verify the truthiness of your belief and fervently support you against the gullible fools who believe otherwise.  You can do the same for the oddball, totally insane idea of your choice.  But don’t do it too much; the intertubes get very scary when you learn what’s really out there.

Thoughtful writers have already expounded on how the age of Google has made people stupider, in that we allow ourselves to forget certain bits of information when we have the crutch of an immense reference database so handy.  While I disagree with the spirit - if not all the claims - of this idea, the related idea that the internet may have caused stupidity to propagate like never before rings true.  Or at least it rings true enough to make Thompson’s article an interesting read.  Tell me what you think.