Happy blogiversary to me!

I almost forgot! It’s my blogiversary! On May 21st of 2007, I opened my WordPress blog after keeping a few notes on Blogger, which I didn’t love. I started out blogging about the abomination that is Conservapedia, added my own medical musings that I had collected over the years, and then branched out into the world of medical science, skepticism, and whatever else I wanted to do. In the 10 months I was at WordPress, I published 332 posts. In my first full month online, I had 381 visits. In August of 2007, I had almost 22,000 page views.

In March of this year, the Hoofnagle brothers invited me to come over to denialism blog here at ScienceBlogs, and the opportunity to work with other dedicated writers has been terrific.

I love to write, and the blogsphere has been very good to me. Thanks for visiting.

Connecticut Attorney General practicing medicine without a license

A rather opinionated reader made me aware of a disturbing issue. In Connecticut–the state whose city of Lyme gave the name to the tick-borne disease–the Attorney General decided that the nation’s foremost infectious disease experts have their heads up their arses. Apparently responding to pressure from questionable advocacy groups, the AG launched an “investigation” into the Infectious Disease Society of America’s Lyme disease treatment guidelines. The excuse for the investigation was alleged anti-trust violations.

Let’s step back a little. As discussed yesterday, there is some controversy surrounding so-called “chronic Lyme disease”. The overwhelming majority of experts agree that there is no role for long-term antibiotics. There has been no evidence to support either the diagnosis of chronic Lyme disease (as it is used by advocacy groups and some physicians) or the use of expensive and dangerous therapies to treat it. The guidelines on treatment of infectious diseases issued by the ISDA are just that—guidelines. Physicians are not required to follow these guidelines, but insurance companies often use them to determine what therapies they will pay for. These guidelines are, however quite influential, as we physicians count on our specialist colleagues to help sort out these difficult issues.

The CT AG decided that these guidelines were tainted by anti-trust violations. I’m not sure how evidence-based guidelines put together by a diverse group of experts can violate anti-trust laws, which were designed to prevent corporate monopolies, but the AG tried to pull it off.

More below the fold—>
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Fake diseases, part deux–chronic Lyme disease

New diseases are pretty rare these days. It used to be that a good observer could travel to the great unknown and acquire/discribe scads of new (to them) diseases. In the interconnected world of the present, “new” diseases spread rather quickly, and become old. When I was a young attending physician, I had heard of West Nile Fever from small chapters in medical school books. When I took over an inpatient medical service in the summer of 2002, I was taking care of several patients with the disease. It was new to me, but hardly new. Sometimes I wonder if people miss the great days of disease discovery, and try to make up for it by inventing their own diseases.

Here at denialism blog we’ve occassionally written about “fake diseases”, that is, diseases that are not recognized by science-based medice, have no clear definitions, and attract quackery. One of these diseases is Morgellons syndrome, an ill-defined malady recognized by no one other than patient advocacy groups and their stooges. Another plays on a real disease, but tries to stretch that disease’s definition to include just about any symptom you could imagine.
Continue reading “Fake diseases, part deux–chronic Lyme disease”

It’s zebra season at the NIH

The NIH announced today that it is launching its “Undiagnosed Diseases Program”. This program will evaluate patients who are referred by physicians. They will also ask for input from so-called advocacy groups.

This should be interesting. I’m sure they will be receiving requests from people with “chronic Lyme disase”, “Morgellons syndrome”, and “chronic fatigue syndrome”. From what I can tell from reading the press release, the program is aimed at the individual patient, and is does not focus on epidemiology. This has it’s pluses and minuses. The individual patient is the smallest “unit” of disease, and for very rare diseases, sometimes one patient is all you can find. On the other hand, it is more common to see an odd variant of a common disease, than a brand new strange disease.

The other interesting bit is that this counts on doctors to refer patients. Will regular docs like me do most of the referring? Or will it be docs that are aligned with “advocacy groups” who practice at the “outer limits” of medicine?

Either way, they will only be evaluating a handful of patients yearly. It will be interesting to follow their progress. Hopefully they will find a good way of reporting their findings.

Dr. Bernadine Healy—what else has she been up to?

As discussed yesterday, former NIH director Dr. Bernadine Healy has been saying some very strange things lately. Since crank-ism doesn’t usually pop up out of nowhere, I decided to poke around a little. In an amazing co-incidence, some of Healy’s forays into the world of crankery neatly parallel the hot-button issues of the Association of American Physicians and Surgeons.

For example:

1) As discussed yesterday, Healy thinks thimerosal is toxic. So does AAPS.

2) Healy tried to interfere inappropriately in the Terry Schiavo case. So did AAPS.

3) Healy isn’t so fond of science and evidence guiding medical practice. Neither is the AAPS.

On the other hand, she has come out against the Bush administration in supporting condom use, and helped fight the battle to make the morning-after pill available.

So, perhaps Dr. Healy isn’t a simple crank, but a complex and developing crank. Perhaps there is still hope. Unfortunately, folks who walk the crank path rarely look back.

Come back, Bernadine, come back!

It’s got electrolytes – Real Medical Case Presentation Number Two

But why? Why does Brawndo have electrolytes?

Because you need electrolytes to live. Every cell in your body uses electrolytes like sodium (Na), Potassium (K), Calcium (Ca), Magnesium (Mg) and other critical ions for cellular functions, proper osmotic gradients, enzymatic activity and even coordination of complex functions like muscle contraction and nerve conduction. All the cells in your body are full of little ion channels that are importing or exporting (or passively diffusing) these ions for physiological functions, and several organ systems (pituitary, adrenals, kidneys) in your body are in charge of maintaining tight control of their concentration in the blood. Very small changes in their concentration – often as little as a doubling or halving of their normal concentrations – can lead to disaster. If, for instance, you became profoundly low in calcium your heart will very quickly fail to beat as muscle requires calcium gradients for contraction.

The measurement of the electrolytes in your blood is a critical component of the evaluation of the health of almost every patient in the hospital. The basic metabolic panel is collected on most inpatients every single day as a critical tool in understanding what’s going on with your patient’s overall health. It provides vital clues into what their kidneys are doing, how their endocrine system is functioning, what disease processes may be at play, and occasionally whether someone is in acute need of rescue. We usually present the data like so:

Na+ | Cl – | BUN
——————————–< Glucose K+ | bicarb | Creatinine 135-145 | 98-106 | 7-18 ------------------------------------< 70-115 3.5 - 5.1 | 22-29 | 0.6-1.2 (BUN = Blood Urea Nitrogen) Seeing this little diagram gives you a great deal of information about what's going on with your patient in a minimum of space. Also of note is what is called the anion gap. The primary cation - Sodium (Na) - and the primary anions (cloride and bicarbonate) don't balance out in terms of charge. Usually if you add the chloride concentration to the bicarb concentration (e.g. 104 + 22 = 126), and then subtract this from the sodium (138 - 126 = 12) you get a value called the "gap" which represents other cations in the blood that are not measured in the basic panel. I realize this seems complicated but it's really not. Basically if it's in the normal range (12 +/-2) it means there likely isn't some hidden anion not being measured and causing trouble - like the ketoacids that run amok in diabetic ketoacidosis. So with that little introduction it's time to go over electrolyte troubles, and because you guys liked the last case presentation so much, I think it’s time for another. This one will be much more challenging. Let’s start with the case, again, based on a true story but jumbled/scrubbed for privacy.

Chief complaint:
Shortness of breath (SOB)

History of Present Illness: A 53 year old white male farmer with a 5 year history of chronic obstructive pulmonary disease (COPD) and three year history of type II diabetes presented to his doctors office with SOB of 5 days duration. His primary care doctor had managed several previous episodes of COPD exacerbation with 2-4 week courses of prednisone, and nebulizer treatments (bronchodilators). Concerned that the patient was failing to adequately oxygenate after several such treatments in her office his doctor refers him to the ER for admission to the hospital.

The rest of the case, and more fun with electrolytes below the fold.
Continue reading “It’s got electrolytes – Real Medical Case Presentation Number Two”

Bernadine Healy: new crank on the block

I love Saturday mornings. I usually get up early, make coffee, hang out with my daughter. Before my daughter wakes up and makes me change the channel, I usually catch a few minutes of CNN, which, at that time of day, features fellow Michigander Dr. Sanjay Gupta. Today, he started out talking about women and heart disease, an important topic. Then he moved on to a discussion with Dr. Bernadine Healy about vaccines. This is where it got ugly. In fact, I was emailing Orac about an unrelated matter, and I began to rant incoherently. Orac reeled me back in, and was kind enough to send me a few additional links regarding Dr. Healy.
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Case study—now, with fewer abbreviations!

MarkH recently gave us a case to play around with. Since this is usually great fun, I thought we could try another one. I’ll start you off with very little information, and I’ll answer any questions you bring up.

I’ll warn you that this one is complex, and shows off the type of intricate problems that internists deal with every day.

A woman in her 60’s came to the ER complaining of weakness and light headedness. This is one of my favorite places to stop. For the non-physicians in the crowd, I’ll give you a head start. Light headedness is often a sign of insufficient blood flow to the brain.

Perhaps this isn’t enough, but let’s start here.

Another of our failures as science educators

There’s been much written around here about the NYT’s David Brooks’ foray in to non-materialist neuroscience. Well, today the letters to the editor are in, and some of them are interesting (although most aren’t particularly sophisticated).

One in particular highlights some failures we’ve had as science educators (including a failure to educate editors):

To the Editor:

As an engineer, lawyer, computer programmer and Roman Catholic, I have a problem with the concept that the evolution of the species just happened. From an evolutionary perspective, we are probably somewhere in the chicken and egg debate.

As man supposedly evolved from a single-cell amoeba to the complex organism that he is today, we had to develop a complex brain to manage the process.

The first problem facing a self-developing species in its early stages would be the need to know that there is something out there to see, feel, hear, touch or taste. The second problem is that a complex brain could not survive the incredibly complex development process without the five senses in operational mode. And you can’t get the senses in operational mode until you have developed a sophisticated brain with the ability to communicate and interact with the senses.

Therein lies our chicken and egg dilemma.

Ken LeBrun
Stony Brook, N.Y., May 13, 2008

Ken has a few gaps in education, and it’s worth a bit of fisking:

Continue reading “Another of our failures as science educators”

A little HIV knowledge

A few months ago, I gave you a short primer on the immunology of vaccines. It’s time now for another short, oversimplified primer, this time on the immunology of HIV. This was originally up on the old blog, but it will provide some necessary background for upcoming posts (I think).

HIV denialists form a persistent little cult, and one of their newest leaders is Gary Null. Despite their small size and dearth of academic heavy-weights, they are quite loud, and can affect health policy.

Let’s delve into the immunology, and, once again, please forgive the over-simplification.

HIV—nasty non-critter
Continue reading “A little HIV knowledge”