Archive for the 'Medicine' category

Mental Health and the Combat Veteran: It's Not All PTSD

Mar 25 2009 Published by under Medicine

Yesterday, I went off a little on David Dobbs. He wrote an article on PTSD in Scientific American that I was somewhat less than impressed with, and I made my displeasure fairly clear. There were points raised by Dobbs that I do agree with, and which I think deserve much more discussion than they've received so far. One of the most important of these, I think concerns the extent of the psychiatric cost of war.

For many - possibly most - of you, I suspect that "PTSD" was the first thing to pop into mind when you read "psychiatric cost of war." It certainly seems to get the lion's share of the attention, and that's not necessarily a good thing. As Dobbs points out in his article, PTSD is only one of a range of psychological symptoms that combat experiences can produce. Focusing on PTSD to the point where it interferes with the proper diagnosis of other conditions can be as bad as failing to acknowledge the reality of PTSD.

One of the studies that's frequently mentioned in the context of PTSD and the current conflicts is a 2007 paper by a team of researchers based out of Walter Reed, and lead by Dr. Charles Milliken. The paper appeared in JAMA, and received a great deal of attention. Most of that attention focused on their finding that many soldiers who reported having no mental health problems when they returned reported problems when they were re-evaluated months later, but that's only part of the picture. The paper was about much more than just PTSD and delayed reactions. It was a fairly comprehensive look at overall mental health in the population of new veterans shortly after their return, and it identified quite a few issues that are worth noting.

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5 responses so far

PTSD, Mental Health, and the Military: Problematic Reporting at Scientific American and ScienceBlogs

Mar 24 2009 Published by under Medicine, Treatment

Author (and fellow ScienceBlogger) David Dobbs has an article on PTSD in the latest Scientific American, and has several related posts on his blog here at Sb. Dobbs' primary argument seems to be that PTSD is being widely overdiagnosed, in part because the condition itself is poorly defined, and in part as the result of various social and economic factors. At least a couple of other bloggers enjoyed his writing on the topic. Personally, I'm not so sure.

As many of you know, I've got some fairly significant ties to the US military. My wife has deployed twice, and has had close and personal experiences with combat. Our family has dealt with her deployments well, all things considered, but that does not mean that it's been an easy process. The first-hand experiences have encouraged me to take a much closer look at both the military healthcare system in general and at mental health issues in the military in particular than I probably would have otherwise. I'm bringing this up not because I'm hoping that you'll think I'm some sort of authority on the topic (I'm not), but because I'd like to make sure that my potential biases are out in the open from the start.

Dobbs' Scientific American article is certainly thought-provoking, and it raises a number of valuable and important issues. Unfortunately, the important and valid points are found mixed in with far too much poor reporting. Although Dobbs admits that the issue of PTSD diagnosis is complex and the subject of scientific debate, his report is almost entirely one sided. It also contains some apples-and-oranges comparisons, and conflates several different problems. His blog articles continue that trend.

For the sake of simplicity, fairness, and a cliche, I'm not going to go through the article point by point. Instead, I'm going to look at the good stuff first, then the bad, then (naturally) the ugly.

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6 responses so far

Federal Judge Slaps FDA Around; Plan B will be Available Without Prescription to 17 Year-Olds

Back in 2005 and 2006, I wrote a few posts about the insanely arbitrary decision making process that the FDA was pretending to use to justify its obviously pre-determined conclusion to restrict the availability of the Plan B "morning after" pill as much as they thought they could get away with. The FDA ultimately decided to deny applications to fully move Plan B to over-the-counter status, but finally accepted a request to waive the prescription requirement for patients 18 years old or older. That was in August of 2006, and that's been the status quo ever since. Until this morning.

Earlier today, Judge Edward Korman of the Eastern District of New York issued a ruling on a lawsuit brought by individuals who had petitioned the FDA to make Plan B available without prescription or age limitation. It would be a bit of an understatement to say that Korman was highly critical of the FDA's alleged process in this case. The ruling stopped short of being everything that the plaintiffs asked for, but not by much.

Here's the bottom line:

1: Korman ruled that the entire Plan B over-the-counter decision making process was arbitrary and capricious. He also ruled that the FDA did not act in good faith, and that the process was clearly tainted by inappropriate political considerations. He vacated the FDA's denial of the petition to make Plan B available without prescription or age restriction, and has ordered the agency to go back and try to address the petition properly.

2: Korman also ruled that the FDA's decision to deny Plan B to 17 year olds was based on something so "implausible" that there is no need to order the FDA to review the decision. He's given the FDA 30 days to issue an order permitting the manufacturer to make Plan B available to 17 year olds without prescription.

The Judge Korman's decision provides an excellent overview of the politically tainted process that led to the treatment of the Plan B process. I'll probably have more to say about that tomorrow, after I have a chance to read the decision again while more fully awake.

2 responses so far

Abstinence Only? Not During World War II

Mar 22 2009 Published by under Medicine, Picture Posts

Reeve 078948-36, originally uploaded by otisarchives1.

Another picture from the Walter Reed collection. This one comes from a series of really cheesy military issue anti-VD posters.

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Scientific Equipment of Unknown Purpose.

Mar 18 2009 Published by under Medicine

One of the pictures in a Walter Reed Army Medical Center collection of historic photographs is a simple, black-background shot of what we can only assume is some sort of scientific equipment:

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The question is, what is it? According to the caption, it's a 1984 picture of a "mouse-tail wash table". My guess is that it was used to wash the tails of mice used in scientific experiments, presumably after said tails had been removed from their original owners. Exactly which lab used the device, and for what sort of research, is not so clear.

(HT: Wired Science)

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Massive Academic Fraud in Anesthesia Research

Mar 12 2009 Published by under Medicine

Several news agencies are reporting that a massive academic fraud case has surfaced. A single researcher apparently fabricated data used in the publication of at least 21 journal articles published over a 12-year period.

After an internal reviewer raised concerns, Baystate Medical Center conducted an investigation into research conducted by Dr. Scott S. Reuben, who was - at that time - the chief of their acute pain service. As the phrase "at that time" suggests, the results of the investigation did not exonerate Dr. Reuben. Anything but, in fact. In late January, Baystate sent out a letter to a number of journals recommending the retraction of articles, and Dr. Reuben is now reported to be on "medical leave".

I'll tack the full list of affected articles on the end of this post for those who are interested, but the problems go well beyond just those 21 papers. The extent of the revealed fraud will necessarily call into question all of the work that Reuben has ever published. Any other work - clinical protocols, published articles, ongoing research - that relies on the veracity of Reuben's articles will also need to be re-examined.

All academic misconduct is bad, but this particular case is particularly destructive. Dr. Reuben's work has served as the basis for the use of what's known as "multimodal anesthesia" - using a combination of NSAIDs and neuropathic pain medications after orthopedic and spinal operations instead of narcotics. This practice has become very common in the field, and the vast majority of the evidence-based support for these protocols no longer exists.

Anesthesiology News' report on the case provides a good description of the extent of the problem:

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9 responses so far

Scientific Misconduct and the Autism-MMR Vaccine Link

Feb 07 2009 Published by under Medicine, Public Perception of Science
A series of articles just published in The Sunday Times reports that it appears likely that Andrew Wakefield falsified much of the data that was used in the 1998 Lancet article that first identified the MMR vaccine as a potential cause of autism. If the charges leveled by the paper are remotely accurate, Wakefield is guilty of homicide - perhaps not legally, but certainly morally. If previous claims made by the paper are accurate, Wakefield may have acted for financial gain.

If even a fraction of the accusations leveled by The Times are true, Wakefield engaged in absolutely outrageous academic misconduct, if not outright fraud. In order for any of the accusations to not be accurate, The Times would have to be lying about the contents of medical records.

In the original journal article, Wakefield and his co-authors reported on a series of 12 children who presented to the hospital exhibiting symptoms of what the authors referred to a a "syndrome" of combined gastrointestinal disorders and developmental setbacks. According to Wakefield, these symptoms presented in these patients developed shortly after the children received the MMR vaccine.

According to The Sunday Times, that is factually incorrect in the majority of the cases presented.

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16 responses so far

Surgeon General Gupta?

There are widespread reports out right now suggesting that President-Elect Obama has selected CNN's medical correspondent Dr. Sanjay Gupta has selected to be the new Surgeon General. The reaction to this seems to be mixed. PZ, Orac, Chris, Paul Krugman and Dr. Val are variously unimpressed and/or opposed. Jake is ambivalent. Revere seems to be cautiously optimistic, while both Dr. Pal and Abel Pharmboy are happy. Personally, I'm a little bit more optimistic than cautious.

Some of the reasons that people are concerned about this choice are legitimate. There have been issues that have come up during Gupta's coverage of various issues that are concerning. His coverage of the whole vaccine/autism thing is certainly a prime example. Gupta has said things that sound somewhat sympathetic to the anti-vaccine movement. It's easy to dismiss those as being the end product of the media's propensity for telling both sides of a story - even when there's really only one - but the truth is that we don't really know where Gupta stands, and that's concerning.

Gupta's lack of administrative experience is also a concern. The Public Health service is a a large government bureaucracy. As far as I know, the largest bureaucracy Gupta has had to deal with is CNN's, and the largest one he's been responsible for has been his own little part of that. A good support staff can go a long way toward easing his administrative burdens, but he's still going to have substantial responsibilities in that area. He's clearly a smart guy, and should be able to adjust OK, but he may not. That's also a legitimate concern.

At the same time, there's an issue that's been raised in opposition to Gupta that is much less legitimate. There's also one strong argument in his favor that I don't think has been raised yet. Let's look at those.

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4 responses so far

Cause, Effect, and Cannabis.

Sep 10 2008 Published by under Accidental, Medicine, Science

You have to give Uncommon Descent poster DaveScot credit. He's not one of life's overly specialized intellects. He's a good, old fashioned generalist, able to talk about absolutely any area of science with exactly the same degree of spectacular incompetence. Today, he's turned his attention to the intersection of mental health and substance abuse.

DaveScot's uninformed ire was sparked, in this particular case, by a news report discussing a paper that recently appeared in the Journal of Clinical Psychiatry. According to the report, the researchers found a strong association between cannabis use and an earlier age for the onset of psychosis:

The results showed a significant gradual reduction in the age at which psychosis began that correlated with an increased dependence on cannabis. Compared with nonusers, age at onset was reduced by 7, 8.5, and 12 years among users, abusers and dependents, respectively, the researchers report.

In further analysis, the effect of cannabis on age at onset "was not explained by the use of other drugs or by gender," they also note. The finding was similar in the youngest patients, suggesting that this effect was not due to chance.

These results "point to cannabis as a dangerous drug in young people at risk of developing psychosis," Gonzalez-Pinto and colleagues conclude.

DaveScot, in his infinite wisdom, read this news report and immediately concluded that the research article is, "a wonderful demonstration of how crap science that supports something politically correct is used and abused all the time". I'm really not sure why Dave thinks that it's "politically correct" to believe that marijuana is potentially a dangerous drug, but that particular question is best left for another occasion. Instead, let's see why he thinks that this is "crap science":

Immediately obvious to me is the possibility that voluntary marijuana use is a symptom of an underlying problem that has nothing to do with marijuana use. People often resort to recreational drug use to escape and/or ameliorate some underlying problem. Alcohol abuse is a classic case of being symptomatic of some other problem. These researchers had no control group to rule out the very likely possibility that people who tend toward psychosis are unconsciously or consciously attempting to self-medicate. The medication isn't the cause, in other words, its a symptom. . . .

But no, the researchers in fact did nothing at all to discriminate between cause and symptom and it's obvious in seconds to even a casual observer such as myself that the study and its conclusions are flawed. Where was the peer review that should have prevented this junk science from reaching the pages of the Journal of Clinical Psychology without correction of obvious flaws?

If you actually take the time to read the research article itself, and not just the Reuters piece, you'll find that the authors of the paper wrote the following:

One explanation for this possible link is that the illness is precipitated by substance use, although it remains uncertain whether this effect is limited to people with a predisposition to psychosis. Another possible explanation is that the early onset of symptoms is a risk factor for substance use. The experience of symptoms could make patients vulnerable to substance use, perhaps in an attempt to cope with the illness or to self-medicate.

Would anyone like to guess how much of the actual paper DaveScot would have had to read to learn that the researchers were in fact aware of the possibility of self-medication as an explanation for the relationship? The answer is right below the fold

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73 responses so far

Another Bush Administration Backdoor Attack on Reproductive Rights.

Aug 01 2008 Published by under Medicine, Science and Politics

Apparently, the Bush administration has come up with another way to attack reproductive rights. The department of Health and Human Services has come up with a draft regulation that changes a number of definitions in an effort to make it easier for people to refuse to provide people with abortions, or birth control, or even with a referral to another provider who would be willing to provide these services.

The regulation is ostensibly intended to ensure that federally funded programs do not discriminate against people or institutions that have religious objections to abortion. This is a legal requirement, and it's nothing new. The Church Amendments date back to the 70s, and there are several other more recent laws that reinforce that requirement.

What the Bushites want to do is change the definitions of a few terms, so that the existing laws can be stretched to cover more people. The terms in question include "assist in the performance" and "abortion". Some of the rationales that they give would be hysterical, if this didn't have the potential to affect real people's lives.

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18 responses so far

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