Ed’s corner of the web

This is great news.  It’s a little late in coming – well, actually a lot.  But truth and the self-correcting nature of scientific inquiry have finally won a little victory.  There has still been irreparable harm done to autism research and treatment as a whole, not to mention the fight against vaccine-preventable illness, but hopefully this is a reflection of the turning tide.

Great gutsy opinion piece from Barbara Ehrenreich of the LA Times.

Choice quote:

What we really need is a new women’s health movement, one that’s sharp and skeptical enough to ask all the hard questions: What are the environmental (or possibly lifestyle) causes of the breast cancer epidemic? Why are existing treatments such as chemotherapy so toxic and heavy-handed? And, if the old narrative of cancer’s progression from “early” to “late” stages no longer holds, what is the course of this disease (or diseases)?

What we don’t need, no matter how pretty and pink, is a ladies’ auxiliary to the cancer-industrial complex.

Regardless of how you feel about Bart Stupak’s amendment to the health care bill, I think Ehrenreich makes a very valid point about the need for skepticism and reason.

Before this theme gets too old, I want to reserve a special shout-out for Wired Magazine.  Thank you, Wired, for having the bravery and integrity to do what the rest of mainstream media was unwilling to do: put “Vaccines don’t cause autism” on your cover, highlighted in fluorescent green, for the whole world to see.  And not only that, you backed that statement with a well-crafted, reasoned, non-hysterical article inside.  It makes me want to go out, buy extra copies, and put them in my hospital waiting rooms.  Bravo.  The rationality is very, very refreshing.

We’re going to continue today’s theme of thanks by sending some gratitude towards Minnesota.  Just like every other state in the nation, Minnesota is faced with a shortage of primary care physicians.  It doesn’t take a rocket scientist to figure out one of the big reasons: a graduating medical student has little reason to become a family physician if he or she can make two, three, or even more times as much money by choosing a more lucrative specialty, like dermatology or radiology.  This financial disincentive comes even more into play when considering the staggering six-figure debt that most medical school graduates are faced with today.  Part of the solution, Senator Franken realizes, is to provide loan forgiveness to those graduates who choose to enter primary care or work in underserved areas.  It’s a no-brainer that unfortunately hasn’t caught on very well in the power circles.  Here’s some hope that it gains some traction.

My little corner of the pediatric world seems to be rather occupied of late with a recent study published in the BMJ.  The study looked at a group of 240 kids in the Netherlands who were given either amoxicillin (an antibiotic) or placebo for treatment of otitis media (ear infection).  Looking back 3.5 years later, the researchers discovered that those kids who were randomized to receive amoxicillin had a 2.5 times higher risk of recurrent ear infection.

The trend in recent years has been for less and less antibiotic treatment of ear infection, opting instead for a “wait and see” approach for uncomplicated cases.  This has been a reflection of data that shows that most ear infections are caused by viruses (not helped by antibiotics), and that it doesn’t seem to make much difference whether one treats simple ear infections with antibiotics or not.

So you would think that docs would be receptive to this additional data further reinforcing the lack of need for antibiotics in many, if not most, ear infections.  You would think that, but you would be wrong.  Pediatricians and family medicine physicians have spent a lot of time on the intertubes resisting reduction of their antibiotic usage in ear infections, citing personal experience and anecdotal evidence (“back in my day…”) while giving wild exhortations in CAPITAL LETTERS.

The one thing that these docs don’t use to make their point is data – real data.  By that I mean large, randomized, well-controlled studies that seek to eliminate confounding variables and answer a specific clinical question.  At what point does personal experience become real data?  Never.  How long does one have to practice before their anecdotes become a valid basis for policy?  Let’s just say longer than anyone is willing to wait.

I pause here to realize that even doctors, for all their education, for all the trust placed in them by their patients, are just as prone as anyone to having “blind spots” – areas of thought that refuse to accept evidence contrary to their beliefs.  For some doctors, it’s vaccines and autism.  For others it’s herbal medicine.  For these docs, it just happens to be antibiotics and ear infections.

So what will it take to shed enough light on the issue to get these docs to change?  A large part of it, I think, is getting people to take their blinders off.  But this, unfortunately, is something you can’t do for them.  It’s not easy to self-criticize, but I firmly believe that opening your own practice and knowledge to critique can only help you become  more knowledgeable, more humble, and a better doctor.  Failing to do so might preserve a frail ego, but it does disservice to everyone else.

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.

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.

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.

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.

We’ve already heard about measles outbreaks, both domestic and abroad, due to reduced to vaccination rates.  Now we have new case reports of another vaccine-preventable disease cropping back up: Haemophilus influenza type b (aka. Hib) infection.

Hib is one of those bugs from the bad old days.  Thanks to a vaccination program begun in the 90’s, I’ve never personally seen a case, and this is a very, very good thing.  Basically every pediatrician from the pre-Hib vaccine era has a horror story of some terribly sick kid with Hib meningitis or epigottitis*.

But now, it seems, thanks to well-intentioned but misinformed parents refusing vaccination for their children, Hib infection is making a comeback.  In 2008, five kids in Minnesota – aged 5 months to 3 years – contracted invasive Hib disease.  Three of these kids were unvaccinated due to parental refusal.  One of these – a 7 month old – died.  Of the other two to contract the disease, one was too young to have completed the intial 3 vaccine series, and the other one had an immunodeficiency.

I’ve said before, and I’ll say it again.  As this trend of refusing vaccines continues, herd immunity will continue to drop to dangerous levels, and we will continue to see increasing numbers of “breakthrough” cases of vaccine-preventable illnesses.  And the tragedy is, there’s really no reason for this happen.

The antivaccine crowd justifies some of their vaccine avoidance like this: why should we provide protection against simple childhood illnesses like measles and chicken pox?  Let kids get immunity the old fashioned way, by contracting the disease.  If I have the choice between autism and a self-limited viral illness, I’ll take the viral illness any day.

Of course, this choice is a false dichotomy.  And there are very good reasons for preventing measles and chicken pox (which I won’t get into here for the sake of brevity).  This argument for avoiding vaccines sucks.  But in this case, the antivaccine case sucks even more.  Measles or chicken pox might not be a huge deal for most kids, but get this: about 1 in 20 kids who get invasive Hib die.  Of those who survive, many are afflicted with deafness, developmental delay, seizure, or other neurocognitive ailments.  In this day and age, with a safe, effective vaccine, there is no reason for any child in this country to suffer from invasive Hib disease.  And it is for this reason that every case like this is a tragedy.  Unfortunately, it looks like we will have many more tragedies like this to deal with before the tide of irresponsible antivaccination is (hopefully) turned.

* The epiglottis is the cover to your windpipe that swings down into place whenever you swallow.  It keeps food and drink from going down the wrong tube.  Epiglottitis is inflammation/infection of the epiglottis, which can lead to swelling severe enough to cause complete airway obstruction.  Yeah – bad.