Yes we candida

I love making silly puns, so I had to, but this is a serious topic in the pseudo-medical realm. Candida infestation of various bodily cavities is suggested as a cause of disease by many non medical practitioners, and the treatments offered can be harmful. So tonight, we discuss the dread fungus.

What is Candida? Well, Candida is a species of mono-cellular fungi, or yeasts, that are part of our environment and are also part of the normal flora of humans. That’s right, we carry them everywhere we go, in our guts, genital tracts and on our skin. The most common of those is the genus Albicans, and it is the one most commonly grown when the fungus actually infects humans by passing through the barriers of our skin or gut. This disease is usually mild and treatable with topical antifungals, but can be more severe in immunocompromised hosts.

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Staying alive

I’m back from a short hiatus, and I’m here to talk to you about something which is very medicine and completely non alternative. It’s a treatment that is neither questionable, nor new, nor rare nor stupid or implausible. It’s a common, useful, life saving device that has become extremely common and can be used by laypeople using a semi-automatic variant that tells the person what to do, and can enable a complete layperson to save someones life before an ambulance arrives. I’m talking, of course, about the defibrillator and specifically the automatic external defibrillator, the AED.

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What is the harm?

there are, unfortunately, no shortcuts, no single cure for most cancers and some alternative therapies can harm the patients taking them, taking up hope, money and precious time and leading them away from real treatments that can help them.

One of the biggest question asked by people who hear that something is complete woo is – but what’s the harm? I mean, if you take homeopathy, which is just water what’s the worst you do to yourself, and if you believe it works it makes you feel better, no? This is a very common line of thinking, and it’s occasionally not completely wrong – usually when you use regular care plus a therapy with no chance of harm. But a lot of times harm comes from both ignoring regular care and using woo instead and from using harmful woo. The fact it doesn’t heal doesn’t mean it can’t kill you. If you’re interested, the wonderful whatstheharm.net covers many such cases. Today, I want to cover one, high profile case, as a glaring example of harm that had cost the human race quite an inspiring person, and this person – his life. I want to talk to you about Steve Jobs. Well, no, I don’t want to talk about Jobs himself, but rather about the validity of alternative pancreatic cancer treatments.

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Hepatitis 3 – A new hope

Medicine is amazing and complex and difficult because both the human body and its attackers are amazing and complex and difficult. Hepatitis C (hence the 3 in the headline, a bad star wars pun), a viral disease that is transmitted through blood and sexual contact is one of the more complex and difficult ones. It’s a virus, which means that it uses the body’s mechanisms to replicate – and thus is harder to counter than a bacteria, and it has a mean streak of evading the immune system and creating a chronic viral disease that over a course of years leads to liver failure or cirrhosis and sometimes liver cancer. We know of 5 viruses causing hepatitis – A and E being acute food borne and rather trivial in the modern world. B,C (D is an co-infector with B) – are chronic blood borne illnesses. But hep B has a very effective vaccine, so it’s not as large a threat, and that leaves the hepatitis C virus in a category of it’s own. It is a disease afflicting drug users and sex workers disproportionately because of its method of transmission and so, together with HIV, it is a major reason to support needle exchanges and free condoms.

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A new approach to science based medicine and a whiff of black cohosh.

One study is never good enough, because medicine and statistics are complex, scientists are fallible and external pressures are swaying – so here is a way to present the bulk of literature in a handy visual way

Science based medicine, a term coined by Dr. Steven Novella (of neurologica, skeptics guide to the universe and SBM blog fame), is the idea that medicine should be based on scientific prior knowledge and not only evidence, when evaluating new concepts. This challenges a few notions in regular clinical practice but it is world shaking when it’s woo time. The idea is such: if you claim that water has memory, that carries the energy of a single lost molecule of a substance that magically removes the symptoms it would cause were it in a large dose than you can’t just do a study to prove it right. For it to be right you need to overturn all physics, all chemistry, all biology and all medicine, so you would need an enormous effect size, conclusive evidence under the most rigorous of examinations and then still you would need to explain all the science that says it can’t be. Science based medicine is a tall shield against inane pseudo-scientific bullshit.

There is one problem, and that it convincing patients that their favorite brand of woo is not based on anything real. This problem stems from an axiom: Disproving any bullshit is an order of magnitude more difficult than presenting it was. For any silly claim you need the body of evidence, rigorous reading of the scientific literature and parsing it for the willfully ignorant, and that takes time and effort. There isn’t just “one study that shows X works” for any given X be it woo or science. You need preliminary studies that become better studies as knowledge advances that become high quality, blinded, randomized clinical trials with many participants. You need to reproduce your results a few times. You need to see the big picture. One study is never good enough, because medicine and statistics are complex, scientists are fallible and external pressures are swaying.

So here is one possible, interesting solution I was presented with, and I would like to take the time to present to you. It is called Treatment Scores, and the whole explanation can be found in this blog. I will be using this format from now on to present the summary of my results. It is an attempt to transform clinical decision-making into a more scientifically based process, that is easier to understand and easier to explain to patients. What I love about this is the way it presents information in an easy to understand manner, that is transparent to clinicians and patients alike. I like my patients to be able to understand the way I came to a conclusion on the best management for their illness and I think that doctors would like to introduce more transparency of the process they took. I think transparency inspires trust and better doctor-patient communication. This application is far from finished, and should become more automated as time goes by, but I think that for now it is a very interesting idea, worthy of time and effort to support and spread the word about. Hopefully, in the future, this will become an almost automated tool for quick review of the scientific basis for the various treatments available for most diagnoses.

And now, lets get started and discuss Black cohosh for menopausal symptoms. Black cohosh is a plant originating in north america that was allegedly used by native amercians to treat infections, kidney problems and depression. Today it is a popular herbal supplement used to treat menopausal symptoms in women, especially the bothersome hot flashes. I include a few studies here, as usual, and in the end I will present the summary through Treatment scores.

First is a study of black cohosh on 99 women (with 16 who dropped after baseline and another eight who dropped out after 5 weeks) which is double blind, placebo controlled crossover study. The symptoms were evaluated using symptom diaries, and a questionnaire called the Greene Climacteric scale (GCS). There was no difference between the groups, nor was there difference per patient on both arms of the cross-over. So this is a generally high quality study albeit with a large drop-out rate with a negative result. This study, of course, gives black cohosh a score of 0.

Another study of black cohosh for menopause, this time regarding anxiety in menopause. It is a small (30 patient) study, randomized, double blind and placebo controlled and its population was post-menopausal women with diagnosed anxiety without other psychiatric comorbidities . The total follow-up was 12 weeks and 75% of participants completed the study, one was due to side effects but the general side effect rates were not significantly different from placebo. The results – Black cohosh was no different from placebo and was actually worse on one scale, the GCS!. The treatment score here is 0, and this goes as a secondary statistic.

A four arm study of black cohosh vs red clover vs placebo vs hormone replacement therapy for hot flashes. It was double blind, randomized, and had 22 patients in each arm for a total of 88. The symptoms were evaluated using a symptom diary and the GCS, previously mentioned, and the follow up was 12 months. The results – only hormone replacement therapy had significant benefit, black cohosh occasionally did significantly worse than placebo and was worse in a non significant manner throughout follow-up, so a treatment score of 0 is alloted. There was no change in bone density or any side effects between groups. This had a daughter study that tested cognitive functions on the same population and found no benefit over placebo for black cohosh or red clover. This is a secondary statistic with a treatment score of 0.

Another study, published in a low impact korean journal, compared a St. John’s wort and black cohosh preparetion vs placebo for all symptoms of menopause. It was double blind, placebo controlled, and was supported by the company that produces the supplement. The results are rather positive on the general menopausal KI score measurement, but the hot flash results, though significant and positive, are not very clinically impressive: on a scale of 1-10, both groups began at around 7.5 and finished at 1.5 ± 1.97 for the supplement and 3.54 ± 3.38 for placebo so there is a large overlap and very large placebo response. This 20% improvement over placebo is suspect due to conflict of interest, and the supplement is made of two different plants. I can still give it a careful score of +5.

A double blind, placebo controlled study, published in the annals of internal medicine used a naturopathic (eye roll) approach and gave patients either black cohosh, multi-herb supplements, herbs and soy rich diet, placebo or hormone replacement therapy. This study measured all menopause symptoms using a questionnaire and measured hot flash frequency and severity, and had 351 participants. The results for all interventions except for the hormone replacement therapy were as good as placebo, and the HRT was significantly better at reducing hot flash frequency and ameliorating all symptoms. This well done study gives a treatment score of 0. No significant adverse events were observed.

At this point I was satisfied with the results. I found no large, high quality studies other than those included. I decided to go check the side effect profile:

A longitudinal prospective study with 12 months of follow up saw no liver toxicity in 87 post-menopausal women.

A review of published cases reported a few tens of severe autoimmune hepatitis cases linked to black cohosh consumption. These are rare, severe side effects, that are correlated with the herb, but making a cause and effect statement here is difficult.

Not much besides that and what was already covered.

So, my summary would be: Black cohosh gets a treatment score of 0 due to multiple high quality studies showing no effect for ameliorating hot flashes in menopause. It has been linked to a few rare cases of hepatotoxicity inconclusively, and has monetary cost, so it has negative secondary scores. I summarized it as a treatment with a total score of -10 due to no effect, possible side effects and cost. The way it is displayed in the treatment score application:

treatment black cohosh

As you see, Treatment scores provides a handy visual guide to aid in decision making. I think this program has a great future ahead of it.

Hope you enjoyed this demonstration and review, I am, as always,

A wide eyed skeptic.

Bad science

I fucking love science. Really. Not in the facebook “omg look at this thing how magnets work it’s magic” kind. But in the dirty, nitty gritty, statistics and data laden meticulous science. I find it amazing that we can piece together great truths about the universe and everything in it using tiny clues. It’s like a sudoku game, only, you know, kinda harder.

So when a dear friend and fellow skeptic sent me this study, I felt a thousand scientifically literate voices wail at once, and be suddenly silenced. This cosmic monstrosity is titled “Acupuncture vs intravenous morphine in the management of acute pain in the ED“, and it is everything that can go wrong with medical science at once.

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Something new about fibromyalgia

Fibromyalgia is an ill defined entity that presents with persistent pain, fatigue, hypersensitivity to touch, muscle spasm and weakness and also sleep disturbances and neurological signs. It has a prevalence of around 3% in the population and affects mostly women. It’s a hard diagnosis to make, and requires ruling out many inflammatory diseases, and has no specific objective findings (blood tests, CT findings etc.) although there are some changes evident on fMRI scans. Due to the difficulty of diagnosis and lack of objective signs it’s been debated if it’s real at all, and if it is – what’s the process behind it.

Now, this is a disease I get to see as a primary care physician, and I try to get those patients the care they need, but it’s quite unclear what that care is. Fibromyalgia has been treated with everything from exercise and diet to psychiatric drugs, since it’s quite established to coincide with anxiety and depression. Long story short, though, those treatments are usually not very effective. Most patients with fibromyalgia suffer from the disease, our failure to aid them and occasionally suspicion from doctors that they’re just faking it or lazy or weak.

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