What social media platform should doctors use first?

I’m proud to introduce the KevinMD minute, where I share my thoughts in 1-minute videos.  They will be shared first on my YouTube channel. Below is a transcription. Enjoy. Which social media platform should doctors use first? My recommendations are LinkedIn or Doximity. These are professional social networking sites where a profile on one of […]

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Doctoring to the test. Look to education for a cautionary tale.

A few weeks ago I wrote a piece about performance metrics in medicine.  People asked me:  “Well, if you don’t like the metrics, what would you use?”  So I thought about this, and the best way I can think of to explain what I mean is to use an example from a different field: education. […]

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Funtabulously Frivolous Friday Five 106

Funtabulously Frivolous Friday Five 106

Question 1

Which drug is derived from the saliva of the Gila Monster

Reveal Answer

• Exenatide
• The hormone exendin-4 occurs naturally in the saliva of the Gila monster, a large venomous lizard native to the southwestern United States and northwestern Mexico.
• Exenatide is a glucagon-like peptide-1 agonist (GLP-1 agonist) medication, belonging to the group of incretin mimetics, approved in April 2005 for the treatment of diabetes mellitus type 2

Question 2

Who first described the potential therapeutic use of botulinum toxic?

Reveal Answer

• Dr Justinus Kerner in the 17th century
• Dr Kerner, a noted German poet and physician provided an accurate description and theory for botulism. He recognised that the “sausage toxin” has potential clinical application in cases of “muscle hypercontractions, hyperhidrosis and hypersalivation.”
• He started animal experiments and clinical experiments on himself, developed hypotheses on the pathophysiology of the toxin, suggested measures for prevention and treatment of botulism, and, finally, developed visions and ideas about future perspectives regarding the toxin, including its therapeutic use [Reference: The Lancet]

Question 3

A 30 year old chronic migraine sufferer stumbles into emergency following a mechanical fall and facial injury…his wounds ooze what can only be described as ‘green blood’. What is the potential cause of this?

Reveal Answer

• Sulfhaemoglobinaemia
• Sulfhaemoglobinaemia, arises from the (irreversible) incorporation of sulphur into haemoglobin (rendering it useless for oxygen transport).
• First descibed in 2005 when a 42 year old man gave everyone a shock when he bled green blood during an operation. Cases are caused by taking large quantities of sulphur-containing medications. In this case the culprit was thought to be sumatriptan.[Reference: The Lancet]

Question 4

What is this, and where might you find one in the body?

Photo taken at British Museum by Mike Young

Reveal Answer

• The hat is a phrygian cap
• An anatomical variation of the gallbladder can give it a folded tip appearance, resembling the cap. This the most common anatomical variation of the gallblader. It is thought to have no significant clinical implications. [Reference]

Question 5

Dick Ket (1902-1940) was a Dutch painter who is known for his self-portraits. What congenital condition is most commonly depicted?

Reveal Answer

• Tetralogy of Fallot
• Known to suffer from a heart defect, the clubbing, plethora and cyanosis noted in several of his paintings have led to the suggestion that he had the tetralogy of Fallot.

 

…and always remember – home is where the heart is

The post Funtabulously Frivolous Friday Five 106 appeared first on LITFL.

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Resistant hypertension? Or failure to take blood pressure correctly?

I recently read a discussion by three hypertension specialists, Drs. Jan Basile, Dominic Sica and David Kountz, on how to treat resistant hypertension. Resistant hypertension is blood pressure that remains above goal despite treatment with three drugs, from different classes, one of which must be a diuretic. 10 to 15 percent of patients with high […]

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Yoga For Neck Pain & Shoulder Pain Relief – 20 Minute Stretch Workout - Joy Scola

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My 4 Favourite Resources for a Natural & Holistic Pregnancy

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End-of-life care: What I learned from a pet’s death

It has taken me almost two years to be able to write this. We said goodbye to our beloved dog in early May of 2013. I grieved for well over a year. About a month-and-a-half prior to his death, we had a big medical scare with him. I wrote at that time about how dealing […]

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As an under-represented medical professional: Lean in

While reading the book Lean In by Sheryl Sandberg, I was mesmerized by her insight about the self-perpetuating difficulties women face during their careers; however, something was missing. Mrs. Sandberg, the COO of Facebook, wrote an enlightening novel about the differences in mindset between the genders and how this hinders women in their career. I […]

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Bill Maher: Still an antivaccine crank after all these years

Bill Maher (right) pays rapt attention to Robert F. Kennedy, Jr. (left) as he gives pointers about how to be a crankier antivaccine crank.

It is with reluctance that I decided to write about this topic again, given how many times I’ve written about it over the last decade, both here and at my not-so-super-secret other blog and given how little his fans seems to care when I do. I’m referring to the antivaccine stylings of comedian and political pundit Bill Maher, something I’ve been writing about for over a decade now. Indeed, a little more than five years ago, I stirred up a bit of trouble in the skeptical community through some particularly harsh criticisms of Bill Maher, in particular of the Atheist Alliance International’s (AAI) decision to award Maher the Richard Dawkins Award. More than once, I’ve likened giving Bill Maher an award that lists “advocates increased scientific knowledge” anywhere in its criteria, not to mention being named after Richard Dawkins, to giving Jenny McCarthy an award for public health, given that, at least when it comes to medicine, Maher is anti-science to the core. Along the way, I’ve ruffled the feathers of some of both Dawkins’ and Maher’s fans.

Arguably Maher reached his peak of antivaccine advocacy through his weekly HBO talk show, Real Time With Bill Maher, five years ago, when the H1N1 pandemic was going on and public health officials were working hard to persuade people to get vaccinated against H1N1 influenza. Indeed, it got so bad that his own guests, such as Bill Frist and Bob Costas, were openly dissing him on his own show for his antivaccine views. Perhaps my favorite example came from Bob Costas, who in response to a wild claim by Maher that he doesn’t worry about getting the flu, even in the crowded confines of an airplane because of his superior lifestyle that apparently made him immune, blurted out, “Oh, come on, Superman!” Even worse, a friend of Maher, Michael Shermer, published an “Open Letter to Bill Maher on Vaccinations” in—of all places—The Huffington Post, which led Maher to respond, both on his show (in which he referred to vaccination as a “risky medical procedure”) and in a post on HuffPo himself entitled “Vaccination: A Conversation Worth Having“. It was, as a certain “friend of the blog” put it, a pyre of stupidity.

After early 2010, however, Maher seemed to drop (or at least deemphasize) his promotion of antivaccine viewpoints and quackery on Real Time, to the point where I seldom felt “inspired” to write about Maher, with no posts here primarily about him and his antivaccine stylings and only a precious few over at my not-so-super-secret other blog. Would that it would have stayed that way! Unfortunately, on Friday, Maher “topped” himself, surpassing nearly any antivaccine segment he’s done since he was last seen asserting, “I would never get a swine flu vaccine or any vaccine.” On Friday, he had Robert F. Kennedy, Jr. on his show. Yes, Robert F. Kennedy, Jr., the man whose unhinged conspiracy theories about thimerosal in vaccines causing autism, published in Salon.com and Rolling Stone ten years ago, arguably sucked me into writing about the myth that thimerosal in vaccines causes autism and about the broader myth that vaccines cause autism. Oddly enough, at least one pundit seemed surprised at the depths of antivaccine nonsense to which Maher would descend. He shouldn’t have been. Maher’s been at this well over a decade, at least since I started paying attention.

In any event, it turns out that, after over five years of not saying that much about vaccines and autism, RFK, Jr., too, has resurrected his antivaccine conspiracy theories, first with a book entitled Thimerosal: Let the Science Speak: Mercury Toxicity in Vaccines and the Political, Regulatory, and Media Failures That Continue to Threaten Public Health released last summer and now more recently through his promotion of the antivaccine “documentary” (more specifically, anti-thimerosal fear mongering) Trace Amounts: Autism, Mercury, and the Hidden Truth.

How bad was RFK, Jr.’s appearance on Real Time with Bill Maher? You’ll see in a moment, but I’ll give you a brief preview. It was so bad that not only did Maher happily let RFK, Jr. in essence spew every major antivaccine talking point about thimerosal, with his favorite conspiracy theories sprinkled in, but Maher actually ended up looking somewhat reasonable by comparison by disingenuously asking softball “skeptical” questions about the movie. Personally, I would have asked RFK, Jr. why he’s been going around California speaking in opposition to SB 277, a bill currently under consideration that would eliminate nonmedical exemptions to school vaccine mandates, in apocalyptic terms, even making analogies to the Holocaust. But, then, that’s just me. Let’s step back and look at how Maher’s resurrected his promotion of antivaccine pseudoscience this season.

Prelude and buildup

This isn’t the first time this season that Maher has let his antivaccine freak flag fly again, although it’s the most egregious. Why Maher decided to resurrect his antivaccine stylings on his show this season is an interesting question to consider, but I suspect part of it might be because this year’s flu vaccine was disappointing in its efficacy. Because every year health officials at the World Health Organization basically have to make an educated guess based on the epidemiology of which flu strains were in circulation several months in advance, the efficacy of the flu vaccine varies from year to year based on how good the match between the strains included in the vaccine and the strains actually circulating during the flu season turn out to be. This most recent flu season, unfortunately, due to antigenic drift, the match was not very good, and the vaccine efficacy was low compared to prior years.

Consequently, on the January 16^th episode of Real Time Maher interviewed Dr. Atul Gawande about flu vaccine efficacy, challenging Dr. Gawande with questions such as, “It’s a big scam to make money, but flu vaccines are bullshit. I was right, wasn’t I, Doc?” and responding to Gawande’s patient explanation of how the antigens for the flu vaccine are chosen every year with, “Meaning if you’re guessing what would work and you don’t know and you’re going to inject that into your body, that’s a good plan?” Maher, as usual, revealed himself to be as antiscience as they come with respect to the flu vaccine on that episode, or, as I like to put it, still an antivaccine wingnut after all these years.

Three weeks later, on the February 6^th episode, Maher revisited the topic of vaccines:

Hilariously, in the introduction to the segment, Maher tried to claim the mantle of science—and failed:

When I start these conversations, I always have to say: I’m not an antivaxer. I never have been. I’m an anti-flu shot guy I think that’s bullshit, and the fact that it was only 23% effective this week bears that out. But if Ebola was airborne, I’d get the vaccine tomorrow.

Wrong, wrong, wrong, wrong.

It got even worse when Maher immediately started complaining about the “attitude of the media,” which he characterized as “just a lot of shut the fuck up.” (Apologies to those sensitive to profanity, but this is a direct quote.) He even compared media coverage of vaccines to the first weeks of the Iraq war. This led Marianne Williamson, who ran for Congress last year and is some sort of author and “spiritual teacher” to chime in that the implication was that “if you had any skepticism whatsoever, you were antiscience.” That’s a nice straw man, because it’s not skepticism about vaccines that produces charges of being antiscience, it’s “skepticism” without evidence supported with pseudoscientific arguments. By that standard, Bill Maher has demonstrated himself time and time again to be anti-science with respect to vaccines, even though he views himself as totally pro-science. So Maher lapped this up, particularly when Williamson followed it up with the self-serving Maher-approved observation that there is a “difference between having skepticism about science and having skepticism about the pharmaceutical industry.”

This is a tactic taken straight from the playbook of the antivaccine movement, to conflate (disingenuously) reasonable suspicion of the pharmaceutical industry’s previous misdeeds with suspicions of vaccines. Indeed, Maher and RFK, Jr. revisit this strategy in the most recent episode, as you will see. They are not the same thing, nor is one as reasonable as the other. Whatever misdeeds the pharmaceutical industry might be guilty of, they do not cast doubt on the safety and efficacy of vaccines. There is plenty of independent evidence to support the conclusions that vaccines do not cause autism, they do not cause neurodevelopmental disorders, and they do not cause sudden infant death syndrome, allergic conditions, or any of the other problems frequently ascribed to them by antivaccinationists. Also, the claim that you “can’t question” is a favorite cry of the crank.

Help, help, I’m being repressed!

Maher even made this ludicrous analogy:

The analogy that I see all the time is that if you ask any questions, you are the same thing as a global warming denier. I think this is a very bad analogy, because I don’t think all science is alike. I think climate science is rather straightforward because you’re dealing with the earth. It’s a rock. I’m not saying I know how to deal with it, but climate scientists, from the very beginning, have pretty much said the same thing, and their predictions have pretty much come true. It’s atmospherics, and it’s geology, and chemistry. That’s not true of the medical industry. I mean, they’ve had to retract a million things because the human body is infinitely more mysterious. People get cancer, and doctors just don’t know why. They just don’t know why, and they don’t know how to fix it. And they put mercury in my teeth. My father had ulcers and they treated it wrong when I was a kid. Thalidomide. I mean I could go on about how many times they have been wrong. To compare those two science is, I think, just wrong.

And magnets, how do they work?

Seriously. This is nothing more than the “science was wrong before” gambit. Let’s just put it this way. Physics has gone through many iterations and has had to “admit” that many of its prior theories were wrong. Does Maher doubt, for instance, the theory of relativity, which supplanted Newtonian physics? His analogy is just so utterly, breathtakingly wrong-headed that I did the double facepalm upon hearing it. In fact, doubting the safety and efficacy of vaccines is very much like climate science denialism. Both are areas of science that are well accepted by the scientific community and backed by enormous quantities of evidence.

Maher’s next argument was even worse, in which he likened vaccines to antibiotics and asked, “Can you just do too much of a good thing?” and “Is it limitless? Is there no amount that is too much?” At another point, he seemed to imply that scientists were surprised that antibiotic resistance has become so widespread, when in fact it was scientists warning about overuse of antibiotics who foresaw this problem. This led Williamson to repeat the tired old antivaccine trope of “too many, too soon” in the form of JAQing off. Maher did acknowledge that vaccines don’t cause autism and that he “accepts that,” but then pivoted to the classic antivaccine trope that there are no long term studies of vaccinated versus unvaccinated children and “wondered” if people who’ve had a lot of vaccine have “robust immune systems.” He linked this to more diagnoses of allergies, autoimmune diseases, and the like because, he’s just asking questions, you know—and confusing correlation with causation.

As my good bud Mark Hoofnagle notes, Maher did some serious mental gymnastics in which he argued that if you don’t use your immune system, you’ll lose it. The problem, of course, is that vaccines activate the immune system by stimulating it with the same antigens that one finds in the pathogens that cause disease. They wouldn’t work if that weren’t what they do. So Maher couldn’t even keep a coherent train of thought. On the one hand, supposedly we have all these autoimmune diseases, presumably because vaccines stimulate the immune system too much, but then people who have been vaccinated don’t have as “robust an immune system.” Which is it Bill?

The very next week, on the February 13^th episode, Maher couldn’t resist resurrecting the issue in the context of the Disneyland measles outbreak. He trotted out the same analogy of “too many” vaccines to too many antibiotics leading to antibiotic resistance. As usual, his guests, who included David Duchovny, Baratunde Thurston, and Zanny Minton Bedoes, were either unable (due to insufficient knowledge) or unwilling (due to wanting to be invited back to be on the show) sometime to challenge Maher other than very weakly. In the show, Maher implicitly (actually not that implicitly) likened vaccine manufacturers to tobacco companies that worked to deny and cover up the dangers of smoking decades ago, a trope we’ve seen “Dr. Jay” Gordon use before, among many other antivaccine advocates.

Here’s a particularly telling segment:

THURSTON: I think antibiotic resistance—I’ll talk to both of you [gesturing to Maher and Duchovny]. Antibiotic resistance is not the same as your skepticism about vaccines. It’s just not. We’ve saved so many lives from sanitation, clean water, and vaccines.

MAHER: This is the straw man I’m always fighting. I am not skeptical that vaccines “work” [air quotes]. I get it that they work. Lots of things work. Antibiotics work—at a cost. Chemotherapy works. It might get rid of my tumor…

THURSTON: But what is this cost you’re talking about for vaccines?

MAHER: OK. I said this last week. This is a scientific fact. There have been no long-term studies done on vaccinated versus unvaccinated, long term health outcomes. If you never give your immune system a chance to fight a disease…

THURSTON: That’s not a cost, that’s a question.

MAHER: That is a question that science has not answered.

THURSTON: But the studies that have come in so far have not proven any distinct issues.

ZANNY MINTON BEDOES [Editor-in-Chief of The Economist]: What we do know is that vaccines have prevented an enormous number of diseases.

MAHER: No one is saying that’s not true.

One notes that doing a “vaxed/unvaxed” study in the way Maher advocates is unethical, and there already exist plenty of epidemiological data to show that neither the MMR vaccine nor thimerosal-containing vaccines cause autism.

Not long after this, Maher states outright, “Measles is not really that deadly a disease.” This is a trope that I sometimes like to refer to as “argumentum ad Brady Bunch,” in which, based on a 1969 episode of The Brady Bunch, in which all six children, the father, and the maid Alice come down with the measles, a situation that is played for laughs, antivaccinationists argue that measles isn’t such a big deal, that it’s a harmless childhood illness that everyone accepted before the MMR vaccine. Another term for it is the “measles is harmless” gambit. It’s a favorite trope of the antivaccine crank blog Age of Autism, “Dr. Bob” Sears, and “Dr. Jay” Gordon. Unfortunately for them (and the children getting measles because pockets of vaccine-averse parents have driven down MMR uptake), measles is not benign.

You get the idea. Bad Bill Maher, the one who denies science with respect to vaccines, is back. Boy, is he ever!

Maher and RFK, sitting in a tree…

Now we get to the interview with RFK, Jr. that aired on the April 24^th episode of Real Time With Bill Maher. It comes quite strategically after the monologue:

Note that the YouTube clip above only contains less half of the interview, with the video and sound fading out as RFK, Jr. answers a question. Why Real Time didn’t put the whole interview on YouTube, I don’t know, but it didn’t. To be honest, I rather suspect it’s because it was near the end of the interview that RFK, Jr. went full conspiracy mongering mode and Maher joined in. Whatever the reason was, if anyone can find me the whole clip, I’ll add a link. In the meantime, let’s look at how painful the interview above is, if you’re a supporter of science. Also note how, for at least part of the interview, Maher disingenuously takes the role of the “skeptic” of RFK, Jr.’s position, asking seemingly challenging questions that you will soon see to be softball questions designed to let RFK, Jr. hit it out of the park. The funny thing is, though, that even those questions at times seemed to fluster RFK, Jr., who, it must be said, is a terrible interviewee, apparently even if you like and agree with him, as Maher clearly does.

In fact, Maher shows his admiration for RFK, Jr. right at the beginning of the interview, when he characterizes him as “one of the greatest environmental crusaders we’ve ever had,” adding “I don’t think anyone would dispute that” (to lots of audience applause) and pointing out how his “history with mercury goes back a long way.” This led to this exchange:

RFK, Jr.: I got dragged into the vaccine issue kicking and screaming because I was going around the country suing coal-burning power plants and talking about the dangers of mercury coming from those plants, and almost everywhere I stopped or I spoke there were women there—very eloquent, articulate, grounded people—who said, ‘You have to look at the biggest factor of mercury in American children now, and it’s vaccines, and we need you to look at the science. And I resisted for a long time but I started reading the science after a while, and I’m very comfortable reading science. I’ve brought hundreds and hundreds of successful lawsuits, and most of them have involved scientific controversies. I’m comfortable reading science and dissecting it, and discerning the difference between junk science and real science. When I started looking at it, what I saw was very alarming, which is we were giving huge amounts of mercury to our children. A lot of it has been taken out of vaccines, but there’s still an extraordinary amount in vaccines—in particular the flu vaccine.

This has to be about as good an example of the Dunning-Kruger effect, wherein a person with no training in a subject falsely overestimates his expertise in the subject, to the point where he feels he can challenge experts. There is also a lot of information that RFK, Jr. asserts as fact is, in fact, erroneous. For instance, he is correct that thimerosal is still used as a preservative for the flu vaccine. However, the flu vaccines used in children these days rarely contain thimerosal, the thimerosal-free versions of the vaccines or the nasal live attenuated influenza virus (LAIV) vaccine being the preferred vaccine for most children. This vaccine does not contain thimerosal, because thimerosal kills the virus in live virus vaccines. The bottom line is that the thimerosal content of vaccines in the childhood vaccine schedule has plummeted dramatically since 2001, and there has not been a decrease in autism diagnoses beginning three to five years later, as we would expect if thimerosal-containing vaccines were a major contributor to autism.

To see how bad RFK, Jr.’s arguments are, it is instructive to look at this exchange:

MAHER: If that’s true, then why is everyone lined up against you? Why are you so alone on this? I mean, a lot of people say—the book is called Let the Science Speak—and so many people say, “The science has spoken. We have studied this over and over, not just in America, other countries, and we say it is not the mercury.”

RFK, Jr.: Well, there’s a difference between the bureaucratic regulatory establishment and scientists, and if you look at the scientific literature we were able to find for this book—we spent three years looking at the scientific literature—and the scientific literature is virtually unanimous about the dangers of thimerosal and the links between thimerosal and an epidemic of neurological disorders that are now afflicting American children: ADD, ADHD, speech delay, language delay, hyperactivity disorder, ASD, and autism, all of which began in 1989, which was the year that they changed the vaccine schedule. And we’ve seen animal studies, toxicological studies, clinical studies, cadaver studies. They all say the same thing.

In other words, RFK, Jr. spent three years cherry picking the literature to find dubious studies, such as studies by Mark and David Geier, a primate study by Laura Hewitson (who, by the way, has recently published a study that showed no effect of thimerosal-containing vaccines—or the MMR vaccine—on primate development, thus refuting her previous study), and the like. As now numerous studies have shown, there is no detectable association between thimerosal-containing vaccines and autism or neurodevelopmental disorders.

All of this makes it very difficult to swallow what RFK, Jr. says when he asserts that he’s “very pro-vaccine,” echoing the claim that he is “fiercely pro-vaccine” that he made when he appeared with Dr. Mark Hyman on The Dr. Oz Show last September to promote his book. It is a ludicrous claim. As if to try to inoculate himself further against the charge of being antivaccine, RFK, Jr. then volunteers that he fully vaccinated all of his children. That observation is meaningless with respect to whether RFK, Jr. is antivaccine now or not. His last child was born in 2001, which was before he “discovered” the threat of thimerosal and four years before his infamous “Deadly Immunity” article. A better question to ask him is whether he would, if he had another child this year, vaccinate that child according to the CDC schedule. Given that RFK, Jr. appears not to be a very good liar, it would be obvious, even if he answered yes, what he really believes. After all, he actually goes on to say that he supports government policies to promote full coverage of vaccines, a claim that is rather belied by his having jetted about California to oppose a law that would do just that (SB 277) with an analogy to the Holocaust, an analogy for which he later had to apologize.

Next up, conspiracy theories. The next part of the interview consists primarily of a rant about how corrupt the CDC supposedly is. It’s at this point that Maher lobs another softball question at him along the lines of, “But even if the CDC is corrupt, why is the World Health Organization and the National Academy of Sciences and the American Pediatricians’ Society and scientists from other countries, why are they lining up on the other side of the issue?” What is RFK, Jr.’s response? What do you think it was? It was to double down on the conspiracy mongering, portraying the CDC as completely corrupt, citing “Congressional” investigations with those findings. Gee, I wonder if he’s referring to antivaccine Rep. Dan Burton’s hearings back in the day or to the mummer’s farce that was Rep. Darryl Issa’s “autism” hearing in 2012. He also cites an investigation by the HHS Office of Research Integrity into CDC misconduct last year. I strongly suspect that what he’s referring to is the manufactroversy known as the “CDC Whistleblower scandal” that isn’t a scandal and didn’t show that the CDC covered up data showing an alleged link between the MMR vaccine and autism in African American boys. Brian Hooker, Andrew Wakefield, and James Moody did write a letter to the HHS ORI last October. I suspect it’s getting all the attention it deserves. None of this stops RFK, Jr. from describing the CDC as a “cesspool of corruption” that’s been completely taken over by vaccine manufacturers. That, according to RFK, Jr., is why the childhood vaccine schedule has expanded so much, rather than because there are more vaccines protecting against more childhood diseases.

It’s rather amusing to note that RFK, Jr. can’t even get his facts right. He claims that in 1989 it became very lucrative to manufacture vaccines because the year before Congress passed a law that made it illegal to sue vaccine manufacturers. I assume he’s referring to the National Childhood Vaccine Injury Act of 1986, which established on October 1, 1988 the National Vaccine Injury Compensation Program (VCIP), which didn’t make it illegal to sue vaccine manufacturers. Rather, it required that families seeking compensation for vaccine injury go first through a special Vaccine Court, with compensation funded by a $0.75 excise tax on vaccines. Moreover, as I’ve described many times before, the VICP actually makes it easier for children with true vaccine injuries to obtain compensation, because it lists specific “table injuries” that are almost always compensated and even pays the complainants’ court costs. Antivaccinationists (and especially lawyers who want to sue vaccine manufacturers) really, really hate the VICP, mainly because, even though it tends to give parents the benefit of the doubt and allow somewhat more questionable injuries to be compensated, it does generally do a pretty good job of sticking to the science. That means it doesn’t compensate for “vaccine-induced autism,” because there is no good scientific evidence that vaccines can cause autism.

RFK, Jr. even goes so far as to lie about Dr. Paul Offit:

In 1999, Dr. Paul Offit, who’s the consummate vaccine insider, and he’s the leading voice for the vaccine industry. He sat on one of these committees that added the rotavirus vaccine to the schedule. And he owned a rotavirus patent. And he voted—he didn’t recuse himself. He voted to add them to the schedule. Six years later he sold his patent for $182 million.

It is a lie that Offit voted on adding a vaccine for which he had an interest. The real story goes thusly:

Dr. Offit was a member of an entirely different committee at the Centers for Disease Control, the Advisory Council on Immunization Practices (ACIP). He was invited to join because of his expertise in rotaviruses and intestinal immunology. He served from October 1998 until June 2003.

A previous vaccine against rotavirus, RotaShield, was voted onto the US immunization schedule early in 1998 (note: before Dr. Offit was on the ACIP). He did vote to approve Rotashield for the Vaccines for Children program, which subsidizes vaccines for low-income families.

The ACIP voted to approve RotaTeq in February 2006, two years and 9 months after Dr. Offit had left the committee.

The facts laid out above have been public knowledge for years. Ms. Dorey is either knowingly misrepresenting the facts, or is unable to take in new information.

Nor was Offit reprimanded by Congress, as some antivaccinationists have claimed. In fact, he recused himself from the vote on whether to remove RotaShield from the schedule, saying, “I’m not conflicted with Wyeth, but because I consult with Merck on the development of rotavirus vaccine, I would still prefer to abstain because it creates a perception of conflict.” It is a myth that Paul Offit abused his position on the ACIP to approve his own vaccine. It’s just one of the common myths, among many other smears against Paul Offit, promulgated by the antivaccine movement.

And RFK, Jr. repeated it on Bill Maher’s show. Maher obliged by saying:

Why can’t we have a kind of grand bargain on this? It just seems like we’re calling each other kooks and liars. It seems like common sense that vaccines, even thimerosal, probably don’t hurt most people—if they did, we’d all be dead, because they’re in a lot of vaccines that we all took—but some do. Obviously some minority gets hurt by this stuff. I don’t understand why this is controversial. Why we have this emotional debate about something that—there is science there. It astounds me that liberals, who are always suspicious of corporations…and defending minorities, somehow when it comes to this minority that’s hurt, it’s like, “You know what? Shut the fuck up and let me take every vaccine that Merck wants to shove down my throat.”

This sounds very familiar to anyone who’s followed Maher’s antivaccine views. In fact, he said more or less the same thing in February. It’s also false equivalency. The reason antivaccinationists like RFK, Jr. and Bill Maher are subjected to being called kooks and liars is because they are at least kooks, and RFK, Jr. is a liar, at least about Paul Offit. Either that or he has such a reckless disregard for the truth that what he says is not distinguishable from a lie.

Maher even concludes the interview by saying, “I applaud you for championing this, because we need to talk about this more,” to which RFK, Jr. responded by praising Maher for his “bravery” and complaining how the networks won’t let him on. Conspiracy mongering at its finest!

The bottom line

Bill Maher and his admirers, most of whom admire him for his vehement anti-religion stances, frequently clutch their pearls in indignation or make excuses whenever skeptics quite correctly call him “antivaccine.” Maher himself has proclaimed that he’s “not antivaccine” more times than I can remember, and RFK, Jr. has taken it one step further to declaring himself “fiercely pro-vaccine.” Maher’s apologists not infrequently take him at his word, claiming that because he says he’s not “antivaccine” he’s not antivaccine. Whenever I hear this claim, I can’t help but point out that, using this argument, these same skeptics would have to conclude that Jenny McCarthy is not anti-vaccine. She’s said many, many times that she is “not antivaccine” but rather “pro-safe vaccine.” McCarthy, for instance, probably does really believe that she is not antivaccine. Yet the evidence from her own words and deeds is overwhelming that she is definitely antivaccine. If you’re willing to accept Bill Maher’s word that he’s not antivaccine, then you shouldn’t consider Jenny McCarthy to be antivaccine either.

What else are we to call Maher, however, given how antivaccine tropes fly fast and furious out of his mouth and he sycophantically interviews an antivaccine wingnut like RFK, Jr. on his show? What Maher has said on four of his shows over the last four months would have been perfectly at home on the websites of antivaccine groups, such as Generation Rescue (Jenny McCarthy’s group), Age of Autism, SafeMinds, VaxTruth, and the National Vaccine Information Center:

• Anti-pharma conspiracy theories? Check.
• The “too many, too soon” gambit? Check.
• Claims that vaccines are loaded with toxins (excuse me, “chemicals”) and therefore harmful? Check.
• The call for a vaccinated/unvaccinated study? Check.
• Ignorant nonsense about how the immune system works? Check.
• Blaming pharma and government for the parental suspicions of vaccines? Check. If you don’t believe me, consider this “classic” quote from Jenny McCarthy: “I do believe sadly it’s going to take some diseases coming back to realize that we need to change and develop vaccines that are safe. If the vaccine companies are not listening to us, it’s their fucking fault that the diseases are coming back. They’re making a product that’s shit. If you give us a safe vaccine, we’ll use it. It shouldn’t be polio versus autism.” This is, not surprisingly, very similar to what RFK, Jr. said when he blamed the CDC for parental distrust of vaccines.

After this season of incredibly embarrassing anti-science rants by Bill Maher, my retort to his wounded indignant cries that he’s “not antivaccine,” is simply to say: If you’re not antivaccine, then stop repeating long discredited antivaccine talking points as though they were scientifically valid and stop doing credulous interviews with antivaccine activists like RFK, Jr. That’s what antivaccinationists do, and if you continue to do such things, then you shouldn’t be surprised when people conclude that you are antivaccine. It’s a reasonable conclusion based on your own words and failure to be educated over the course of many years.

 

 

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Airway Courses Galore!

Everyone who looks after critically ill patients needs to be able to manage airway crises. We all want to be better at it. We all can get better at it. Fortunately, there are plenty of courses around to help us become ‘expert enough‘. Fortunately, you can’t do too many airway courses

Here are the courses I’m teaching on this year:

• I’ve designed a simulation-based course called the Critically Ill Airway course run by The Alfred ICU and Monash University. It focusses on cross-specialty team-based management of airway crises in the critically ill, beyond the operating theatre. It fulfils CICM requirements for difficult airway management training requirements and  is strictly for those with prior airway experience. The next course in May is sold out, however dates have just been released for the next one: December 8th and 9th 2015. Get in quick, as this is likely to rapidly sell out again.
• If you can’t wait that long, I’m also teaching on Adriano Cocciante’s ACE course on Saturday July 18th 2015. I had a great time on this course last year – it is ideally suited to emergency medicine trainees. Joe Rotella wrote a review on LITFL from a trainee’s persective here: Are your airway skills ACE? Learn more about the ACE course, and how to register, at the ACE website.
• Just before SMACC Chicago, I’ll be teaching on Rich Levitan’s Yellowstone Airway course. This sold out long ago, but you should keep an eye out for future events.
• Finally, if you’re planning to head to EuSEM in Torino, Italy in October 2015, anticipate a satellite workshop involving Rich Levitan, Reuben Strayer and myself (among others)…

Hope to see you on the handle end of a laryngoscope soon!

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How mobile technology can improve clinical trials

I recently discussed both the merits and needs for the use of mobile technologies in clinical trials. Recruiting patients via social media is now a reality and has been a topic of discussion in many forums, including mainstream medical journals.  There is no question that online patient support groups serve unique purposes. There are regulatory issues involved in […]

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The low-hanging fruit of health care costs

I just finished reading the Journal of Hospital Medicine article called “The highest utilizers of care: individualized care plans to coordinate care, improve health care service utilization, and reduce costs at an academic tertiary care center.” Using a multidisciplinary team of volunteers including members from hospital medicine, ER, psychiatry, ambulatory care, social work, nursing and […]

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LITFL Review 179

Welcome to the 179th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

If you do one FOAM-centred thing this week, spend 5 minutes watching this video on patient-centred care. Thanks to the International Forum on Quality and Safety In Healthcare 2015 [SO]

 

The Best of #FOAMed Emergency Medicine

• Ken Milne and Salim Rezaie team up on REBEL Cast for a critical appraisal of active compression-decompression CPR with augmentation of negative intrathoracic pressure in out-of-hospital cardiac arrest. [AS]
• Excellent pocket reference from Boring EM on skin and soft tissue infection (SSTI) management. [AS]
• Two more discussions on SWIFT-PRIME, REVASC, etc in the form of great blog posts from Ryan Radecki and Rory Spiegel dissecting this stroke literature. [AS]
• Another great podcast from EM Basic on non-pregnant vaginal bleeding. [SL]
• Does bupivacaine really last longer than lidocaine? Find out over at REBEL EM. [MG]
• This week the SGEM takes on remote ischemic conditioning for STEMI. (For two more great discussions on this topic, check out this post over at A Medic’s Medicine and this episode of the ED ECMO podcast.) [MG]
• Taming the SRU has a great pre-hospital TBI case with curated expert commentary; also available as podcast. Read the case before the commentary for maximum learning. [MG]

The Best of #FOAMcc Critical Care

• A brilliant talk from Kenji Inaba discussing lower extremity trauma from Essentials of Emergency Medicine. [AS]
• Do you TRUST your tube placement? A nice review of using POCUS to confirm that your tube is in the appropriate location within the trachea. [AS]
• A recent article suggested apnoeic oxygenation doesn’t work in the critically ill, but Josh Farkas from Pulmcrit takes this to task. Don’t abandon “o’s up the nose” just yet… [SO]
• Here’s an interesting conversation with Professor Darren Heyland on critical care nutrition from the JICSCast team. [SO]

The Best of #FOAMtox Toxicology

• Thanks to The Poison Review for reviewing a recent article on the increased risk of acute kidney injury with PPI use. [SO]

The Best of #FOAMus Ultrasound

• Beautiful image from Jacob Avila’s Ultrasound of the week 45. One to store in the memory banks. [SO]
• Here’s a reminder from echo.guru that our larger patients can still make good transthoracic echo images. I guess size doesn’t matter so much? [SO]

The Best of #FOAMim Internal Medicine

• Dr Lederer’s case-centered lecture-and-slides on Na, K, and diuretics really does help clarify serum and urine electrolytes from an internist’s perspective. For those with greater urgency, the same nephrologist focuses on Electrolyte Emergencies, specifically hyponatremia and hyperkalemia. [ML]

The Best of Medical Education and Social Media

• A guest post from Rob Orman on the EM Mindset from EMDocs.net. Remember to be humble, keep learning and set the tone. [AS]
• Excellent podcast from Anton Helman, Chris Hicks, Walter Himmel and David Dushenski on risk tolerance, decision making and what we really mean (or should mean) when we say diagnosis. [AS]
• A really interesting and thought provoking situation posed on ALIEM on the use of FOAM and the Case of the FOAM Faux Pas, exploring the criticism we may face as FOAM early adopters and quoting FOAM resources on the shop floor. Add your comments to the (at time of writing) 42 comments. On May 1 AKIEN will post the Expert Responses and Curated Community Commentary for the Case of The FOAM Faux Pas. [SL]

News from the Fast Lane

• The SMACC 2015 Schedule is now available!! [AS]
• Check out another jammed packed edition of Research and Review in the Fast Lane 079 [ML]

Reference Sources and Reading List

• Emergency Medicine and Critical Care blog/podcast list
• LITFL Global Blogroll
• FOAMEM RSS feed syndication for global FOAM
• Twitter: #FOAMed – #FOAMcc – #FOAMtox – #FOAMped – #FOAMus – #FOAMim

Brought to you by:

• Anand Swaminathan [AS] (EM Lyceum, iTeachEM)
• Brent Thoma [BT] (BoringEM and Academic Life in EM)
• Chris Connolly [CC]
• Chris Nickson [CN] ( iTeachEM, RAGE, INTENSIVE and SMACC)
• Joe-Anthony Rotella [JAR]
• Kane Guthrie [KG]
• Mat Goebel [MG]
• Segun Olusanya [SO] (JICSCast)
• Simon Laing [SL] (HEFTEMCast)
• Tessa Davis [TRD] (Don’t Forget The Bubbles)
• Marjorie Lazoff [ML]

The post LITFL Review 179 appeared first on LITFL.

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Top stories in health and medicine, April 30, 2015

From MedPage Today: Is This ‘Meaningful Use’? Docs Say Yes, Patients Unsure. Proposed changes to patient engagement requirements under the federal government’s Meaningful Use program are drawing praise from physician groups but are disappointing patient advocates. Point: Does the Risk of E-Cigarettes Exceed Potential Benefits? Yes. The use of e-cigarettes continues to dramatically increase, and the […]

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Legislative Alchemy: Naturopathic licensing and practice expansion 2015

Naturopathic genetics: a new specialty?

Naturopathy is chock-full of quackery. No doubt about it. Here at SBM and elsewhere, the seemingly limitless nonsense that can be incorporated into naturopathic practice has been documented time and again: detoxification, food “sensitivities,” anti-vaccination ideology, fake diseases (chronic yeast overgrowth, adrenal fatigue, chronic Lyme disease), bogus tests (also here ), homeopathy, chelation therapy, assorted other odd-ball treatments, lack of ethical standards, and just general wackiness.

So, let’s give naturopaths licenses to practice primary care! What a good idea.

This affinity for nonsense is perfectly understandable, given their pseudoscience-filled education and foundation in vitalism. Once the scientific method is chucked in favor of “philosophy,” what’s to stop them from simply making things up? As far as I can tell, nothing. But why inflict this on the public under the guise of promoting health, safety and welfare?

To be fair, naturopaths aren’t the only ones who incorporate quackery into their practices. There are chiropractors, acupuncturists, reiki masters, doctors of Oriental Medicine, and “integrative medicine” practitioners. But what sets naturopaths apart, in my mind, is the sheer range of pseudoscience they will accommodate without the slightest hint of doubt in its efficacy or safety and their unwavering belief in their ability to diagnose and treat patients with the expertise and skill of medical doctors. “Delusional” is not too strong a word to describe their utter lack of awareness of their ignorance or the danger to patients they may pose.

We “self-proclaimed guardians of the true definition of evidence-based medicine” are not the only ones to notice this:

. . . the proposed licensure of naturopathic physicians would likely increase the risk of harm to the public . . .

Florida  House Committee on Health Care Interim Project Report,  January, 2004

Available scientific evidence does not support claims  that naturopathic medicine is effective for most health problems.

. . .

Excessive fasting, dietary restrictions, or use of enemas [colonic irrigation], which are sometimes components of naturopathic treatment, may be dangerous. Naturopathic treatment  may involve taking unregulated herbs, some of which may have harmful effects. . . .

American Cancer Society

. . . little scientific evidence is currently available on overall effectiveness [of naturopathy].

Some beliefs and approaches of naturopathic practitioners are not consistent with conventional medicine. . . and their safety may not be supported by scientific evidence.  For example, some practitioners may not recommend childhood vaccinations.  The benefits of vaccination in preventing illness and death have been repeated proven and greatly outweigh the risks.”

National Center for Complementary and Integrative Medicine (although, hypocritically, NCCIM helps keep naturopathic schools afloat by giving them research funds)

Naturopathy and homeopathy are totally ineffective in preventing vaccine-preventable diseases.

Immunization Action Coalition

“. . . many naturopathic practices are based on a semi-spiritual theory (the healing power of nature), and have no foundation in science.  The reside largely in the realm of pseudoscience.”

Timothy Caulfield, Professor, Faculty of Law and the School of Public Health, University of Alberta; Comment: “Don’t  legitimize the witch doctors,” National Post (Canada)

Not exactly a bunch of wild-eyed, Big Pharma-shill bloggers are they?

So, why is it that state legislators are, once again, willing to introduce naturopathic licensing and expansion of practice bills? One reason I’ve discovered is that the “naturopathic doctors” will flat out fabricate “facts” in support of these bills, both in the form of the bills they draft (and make no mistake, it is the naturopaths who are drafting these bills) and in the information they give legislators.

(And, speaking of Big Pharma shills, naturopaths are hiring lobbyists to promote their interests in the state legislatures. In at least one Massachusetts legislative session, their state association was given $25,000 to pay for lobbying. Imagine the outcry if, say, Nurse Practitioners were given thousands of dollars by Merck to lobby for increased prescription privileges.)

For example, in  (the unfortunately successful) lobbying for licensing in Maryland last year, the Maryland Association of Naturopathic Physicians (now the Maryland Naturoapthic Doctors Association, because they are prohibited from calling themselves “physicians”) represented to the legislature that:

Research confirms that naturopathic medicine is effective in reducing chronic disease, and provides important cost savings.

Where is this “research?” As far as I can tell, it doesn’t exist. In fact naturopathic care is associated with poorer outcomes.

[A] study . . . found that the addition of naturopathic care to conventional medical care reduced incidence of metabolic syndrome and the risk of a cardiovascular event (such as a stroke or heart attack) by a third.

Not true, as David Gorski demonstrated in his deconstruction of this study.

NDs complete . . . over 1,500 hours of direct clinical patient care.

Again, not true, as we know from Britt Deegan Hermes’s revelatory post. (That this is a fiction is more extensively documented on her blog, Naturopathic Diaries.)

12 states . . . have naturopathic licensure legislation pending.

No, they didn’t. And, in fact, of the states where naturopathic licensing bills were pending, all were rejected except in Maryland.

Carnegie Commission of Higher Ed: Naturopathic Medicine Programs reviewed and designated as “Doctors Degree – professional practice” [and] included in this category [are]: MD, DO, DDS, DVM.

No it doesn’t.

New fictions

I must admit, however, that even I was surprised by the “Legislative Intent” section of New York’s latest bills to license naturopaths, fresh off the presses and recently introduced in the Senate and Assembly.

Here we learn of yet another amazing (and totally fabricated) naturopathic ability: their superior understanding of human physiology allows them to anticipate, and therefore avoid, iatrogenic consequences of conventional medical care, the latter due to conventional medicine’s failure to intervene earlier and treat the human body as “a whole living system.” At least, I think that is what they are saying. Sometime their word salads are hard to follow. Take a look for yourself:

The legislature recognizes that in the practice of naturopathic medicine the healing power of nature principle is viewed as being an inherent property in a living organism to heal itself, and is an acknowledgment that synergy results from the coordination of the many chemical and physical reactions of the living system through varied and circuitous feedback pathways making the whole function as more than the sum of its parts.

Let’s pause here to contemplate that this may well be the reason naturopaths are so sure homeopathy works, while the rest of the scientific world remains convinced that it’s nonsense. Must be all that synergy and circuitous feedback pathways only they know about.

Earlier in the bill, we learn that the American healthcare system excels at triage and responding to emergent conditions, but there is an epidemic of chronic disease and “unacceptable degree” of iatrogenic disease. Thus, we must leave the medical doctors to their triage and emergent conditions, because the naturopaths have a better idea of how to handle things:

The number of reactions and resulting complexity and synergy is viewed in the profession of naturopathic medicine as being why treatment of a given physiological process may result in unforeseen nonlocal consequences, including iatrogenic disease; and is why naturopathic doctors investigate and treat the patient as a whole living system, find and remove the cause, and prefer less invasive therapies and substances with fewer side effects. It is also why the naturopathic doctor prefers to intervene early to prevent the occurrence of disease.

So, they no longer claim that they are educated and trained to practice primary care equal to that of MDs and DOs, they are actually better at it.

Maybe this is their secret:

The naturopathic doctor . . . relies on the scientific method in implementing vitalistic, functional, and evidence-based strategies for assessing and treating patients.

I hate to be the bearer of bad news, but there is no way you can rely on the scientific method to implement vitalistic strategies. The scientific method would, in fact, negate every last one of your vitalistic strategies.

As I sometimes do (and here) when blogging about state naturopathic legislation, I have a look around the internet to see what area naturopaths are up to even before they are licensed. This usually ends up looking a lot like what naturopaths in licensed states are doing, making one wonder why they want to bother with licensing in the first place. (Actually, we do know: a veneer of legitimacy and insurance reimbursement.)

In my New York-based browse, I came upon yet another surprise from naturopaths. There’s a whole new naturopathic specialty of which I was previously unaware: the naturopathic geneticist. Let’s take a look at “Dr. Doni’s” website.

Dr. Doni, a graduate of Bastyr, is a former Board member of the American Association of Naturopathic Physicians and former Executive Director and President of the New York Society of Naturopathic Physicians. In other words, she’s firmly rooted in the mainstream of naturopathic medicine. In addition to the usual naturopathic folderal (leaky gut, adrenal fatigue, the “Hampton Cleanse,” food “sensitivities”) we find that Dr. Doni purports to be an expert in genetics.

As we learn from her website:

Many conventional doctors are not looking at your genetics when you present certain symptoms. Fewer still know how to identify and address genetic mutations. Of those, even fewer will treat your condition naturopathically.

I don’t doubt that “conventional” doctors don’t normally look at your genetics when you present with certain symptoms, probably because those symptoms have nothing to do with genetic mutations. And I have even less doubt that they treat the patient “naturopathically” when genetic mutations are an issue. But Dr. Doni, of course, knows better.

Everyone is different, but most patients with MTHFR or other genetic abnormalities will exhibit with one or more of these symptoms.

And what are these symptoms?

• Chronic/recurring headaches or migraines
• Chronic fatigue
• Miscarriage(s)
• Abnormal pap smear
• Infertility
• Hormonal imbalances (thyroid, ovarian, adrenal, pancreatic, etc.)
• Auto-immune issues
• Chronic digestive issues
• Anxiety and/or depression
• Brain fog
• Irritability
• Sleep issues
• Aches and pains (including fibromyalgia or arthritis)
• Difficulty focusing and/or difficulty with memory

Ah, the one true cause of disease (again)! And here Mayo Medical Laboratories was thinking MTHFR testing should be reserved for patients with coronary artery disease, acute myocardial infarction, peripheral vascular artery disease, stroke, or venous thromboembolism who have increased basal homocysteine levels or an abnormal methionine-load test.

Dr. Doni is particularly focused on this MTHFR mutation. Hmmm. Where else have we heard about this from a questionable source of medical information? Oh yes, here, in Steve Novella’s post on “functional medicine” guru Dr. Mark Hyman’s “personalized medicine” for dementia. And in Orac’s take on Hyman.

Dr. Doni will, for a mere $3,000 (4 months; dietary supplements not included), shepherd you through genetic testing, help you understand your genetic mutations and formulate a “natural remedy plan” that will not only reduce or eliminate your symptoms, but also avoid “serious illness” and it’s attendant medications and surgeries. And you can do all of this without ever setting foot in her office. Yes, you can enjoy the benefits of “Dr. Doni’s MTHFR and Genetic Profiling Solutions Package” via Skype!

See what I mean: naturopaths can totally make stuff up and sell it. Of course, to be fair, so can Dr. Hyman. Then again, he’s not a former member of the AMA Board or former president of the Medical Society of the State of New York.

Now, for some good news (and bad)

Ready for some good news about naturopathy? I thought so. Not news naturopaths would consider good, but good news to those of us who take offense at the infliction of nonsense on unsuspecting patients via the licensing of faux doctors.

Idaho actually repealed licensing naturopathic doctors this year! They were licensed in Idaho in 2005, but because of difficulties with implementation, licensing never really got off the ground. A bill was introduced that not only solved that problem, but gave naturopaths an expansive scope of practice: it defined naturopathy as “primary health care,” gave them their own regulatory board and prescription privileges, and allowed their board to approve naturopathic “specialty” practices. (Genetics, perhaps?) Only “gross negligence,” as opposed to negligence (the normal standard for malpractice), could be disciplined.

The whole thing blew up in their faces. No only did the bill fail, but another passed repealing naturopathic licensing altogether and declared all current licenses “null and void.”

Another licensing bill failed in Mississippi and it appears an Iowa licensing bill will fail as well. Bills to expand naturopathic scope of practice, including varying degrees the authority to prescribe, didn’t pass in Montana, Washington and North Dakota. The North Dakota bill looked as if it might succeed until the legislature heard from Britt Hermes, who gave them the low down on the lack of naturopathic education and training in pharmacology. In Hawaii, naturopaths were unable to get a bill passed allowing them to corner the market in colon hydrotherapy by excluding others from using it.

Unfortunately, a number of licensing bills have been introduced (again) and are still pending: Illinois (for the 6^th time); Massachusetts (10 times), Nevada, New Jersey, New York (8), North Carolina (7), Pennsylvania (7), Rhode Island (5). All of these would give naturopaths a broad scope of practice similar to that of a primary care physician, although they vary in details.

For example, Pennsylvania’s bill would allow “visceral manipulation,” a term chosen perhaps to avoid the laughable “reposition body tissues and organs” used in a previous bill, although no more plausible. But it’s no laughing matter that the Pennsylvania bill actually passed in the House and has now moved to the Senate for consideration.

Colorado, a state that appears to have an endless tolerance for quackery, has increased the naturopathic scope of practice just 2 years after initially allowing them to register (but not become licensed) with the state. This time, naturopaths wanted to overthrow the ban on their seeing patients under age 2. That ban has now been removed, but with supposed protections for these patients, including providing the parent with the recommended vaccination schedule, more continuing education and recommending the child have a relationship with a licensed health care provider. Naturopaths must have a collaborative agreement with a pediatrician or family practice doctor to “ensure safety” of children under two. Of course, if oversight by a real doctor is necessary for safety, the logical corollary is that naturopathic practice is unsafe. But simple logic seems to escape Colorado legislators.

After the deadline for bill introduction passed, yet another bill was introduced, this time allowing naturopaths expanded prescription privileges. This was courtesy of the Colorado legislative leadership, which has discretion to allow such things for pet legislation. So far, the bill made it to the House floor.

California is contemplating a major expansion of naturopathic prescription privileges, sponsored by Sen. Marty Block. Sen. Block is also a co-sponsor of a bill that would eliminate California’s personal belief exemption. Perhaps someone should tell Sen. Block about naturopath’s anti-vaccination ideology and their ability to grant exemptions under California law.

Connecticut “modernized” its naturopathic scope of practice this year. As they promised, they’re back trying to get prescription privileges, or at least a committee to report to the legislature on expanded privileges, an effort blessed by Dr. David Katz. (Maryland, per last year’s licensing legislation, has a similar “Formulary Workgroup,” which will issue its report to the legislature later this year.) Finally, Oregon is considering a bill allowing naturopaths to choose whether they are “primary care” or “specialty” practitioners under health insurance policies.

We don’t have thousands of dollars to oppose naturopathic bills, but we do have thousands if readers. Go to the Society for Science-Based Medicine’s “Legislative Updates,”  find out what’s pending, and contact your legislators.

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Research and Reviews in the Fastlane 081

Welcome to the 81st edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 7 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Airway, Emergency Medicine

Brown CA et al. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med 2015; 65(4):363-370. PMID: 25533140

• This article reviewed 17,583 adult ED intubations over 10 years at 13 different centers.
  The study found 95% of intubations were performed by ED physicians with good results: 99% of intubations were successful within 3 attempts.
• Orotracheal intubation with RSI was, of course, the most common technique, with 85% first pass success rate with this technique. And first pass success rates increased over time during the 10 year period, showing that we are continuing to get better!
• Interestingly, senior residents had 85% first pass rate, compared to just 72% for attendings.
• For drugs, etomidate was overwhelmingly the most commonly used induction agent, while succinylcholine ruled as a paralytic, although a notable increase in rocuronium was noted in the later years studied.
• Finally, VL use, as could be expected, increased substantially during the time of the study.
• Recommended by: Zack Repanshek

The Best of the Rest

Intensive Care, Respiratory

Kang BJ et al. Failure of high-flow nasal cannula therapy may delay intubation and increase mortality. Intensive Care Med. 2015;41(4):623-32. PMID: 25691263

• Here we go again! A nice reminder of how prolonged non-invasive oxygenation strategies are potentially harmful to patients with non-rapidly reversible causes of hypoxemic respiratory failure. In this study, patients who failed high-flow nasal cannula (HFNC) after 48 hours had significantly higher overall ICU mortality, poorer extubation success and ventilator weaning, and fewer ventilator-free days.
• Recommended by: John Greenwood

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Cardiology, Emergency Medicine Reichlin T et al. Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay. CMAJ 2015. PMID: 25869867 (FREE OPEN ACCESS ARTICLE)

• Every day a faster rule-out for acute myocardial infarction – this time, only one hour. Every day a caveat – requires new highly-sensitive troponin assays, and generated a fair number of “observation zone” results or false positives.
• Recommended by: Ryan Radecki
• Read More: The 1-Hour Rule Out (EM Lit of Note)

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Evidence Based Medicine, Cardiology

Putera M et al. Translation of acute coronary syndrome therapies: From evidence to routine clinical practice. Am Heart J 2015; 169(2):266-73. PMID: 25641536

• We often bemoan the snail-like pace of knowledge translation (KT) and this article backs up our complaints. The authors investigated the time from publication of critical articles contributing to level 1A AHA recommendations to incorporation in guidelines and translation to clinical practice. They find that translation is delayed up to 30 years in some cases. For aspirin, the time from key article publication to 90% adoption of guidelines was 16 years. There are some worrisome rapid adoptions as well. Adoption of agents like clopidogrel, prasurgel and bivalarudin into guidelines was quite rapid. Perhaps there is a role for delayed translation to allow time for safety data and subsequent validating studies to emerge.
• Recommended by: Anand Swaminathan

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Hematology
Steiner ME et al. Effects of red-cell storage duration on patients undergoing cardiac surgery. N Engl J Med. 2015; 372:(15)1419-29. PMID: 25853746 (FREE OPEN ACCESS ARTICLE)

• Prior literature suggests transfusion with fresher red blood cells (PRBCs) may be better. The RECESS trial, a prospective, multi-centered study, looked at 1098 adults undergoing cardiac surgery randomized the patients to receive blood stored for <10 days or > 21 days. Patients received a median of 3 units in the first post-op week with no significant difference in multi-organ dysfunction (MODS) or all-cause mortality at 7 or 28 days between groups. The study was only powered to look at a change in the MODS but, in conjunction with the ABLE trial, supports the efficient use of PRBCs for most patients – first in, first out.
• Recommended by: Lauren Westafer
• Read More: Special (Medical) Transfusion Situations (The Short Coat)

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Neurology, Emergency Medicine
Blok KM et al. CT within 6 hours of headache onset to rule out subarachnoid hemorrhage in nonacademic hospitals. Neurology 2015. PMID: 25862794

• This paper is a solid contribution to the concept of SAH rule out with a CT within 6h of onset. This group evaluated patients presenting with concern for SAH and a normal physical exam. All patients underwent head CT and LP. The rate of SAH in the population was 7% (52/760) and of this group, only one patient was not detected by CT; a patient with a perimesencephalic bleed and not an aneurysmal SAH. The beauty of this study is that it was performed in a community setting (not a large tertiary center) and CT were reviewed by staff radiologist, making the concept of 6h rule out also more externally valid. The NPV for SAH with a negative CT within 6h of headache onset was 99.9% (1:1000)
• Recommended by: Daniel Cabrera

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Pediatrics, General Surgery
Horst JA et al. Can Children With Uncomplicated Acute Appendicitis Be Treated With Antibiotics Instead of an Appendectomy? Ann Emerg Med 2015. PMID: 25724624

• Non-surgical treatment of appendicitis continues to gain traction in many countries around the world. This article reviews the scant pediatric literature looking at this management approach. The evidence shows that this strategy may be safe in carefully selected patients but larger, well-done studies are necessary prior to adoption.
• Recommended by: Anand Swaminathan
• Read More: SGEM #115: Complicated – Non-Operative Treatment of Appendicitis (NOTA) (The SGEM)

The R&R iconoclastic sneak peek icon key

	The list of contributors		The R&R ARCHIVE
	R&R Hall of famer You simply MUST READ this!		R&R Hot stuff! Everyone’s going to be talking about this
	R&R Landmark paper A paper that made a difference		R&R Game Changer? Might change your clinical practice
	R&R Eureka! Revolutionary idea or concept		R&R Mona Lisa Brilliant writing or explanation
	R&R Boffintastic High quality research		R&R Trash Must read, because it is so wrong!
	R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

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A geriatrics-driven health care system

We have all seen the statistics; America is an aging country. The baby boomer generation is retiring, and families are having fewer and fewer children. In health care, we often hear about this issue in the context of an inadequate health care workforce. An aging population in conjunction with the ACA has created a quickly […]

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Live Chat with Corrina Rachel! Health Q&A! Weight Loss, Diets, Nutrition

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Choosing Wisely Australia

Choosing Wisely Australia is due to launch April 29th, enabling Australian clinicians and consumers to engage in conversation to reduce unnecessary tests, treatments and procedures an ensure high quality care.

In Australia NPS MedicineWise is collaborating with medical colleges, societies and consumer groups in a National initiative to improve the quality of healthcare and facilitate better conversations between clinicians and consumers.

The aim is to identify tests, treatments and procedures that are commonly used but can often provide no or limited benefit to the patient and in some cases, lead to harm. Improving conversations about medical tests and other procedures will help support quality healthcare through appropriate use and improved patient safety.

This follows on from the US initiative, Choosing Wisely, created in partnership with the ABIM foundation in April 2012 and a steadily increasing number of countries adopting the process around the globe. Here physicians identified practices which their field overused, and engaged patients in conversations to reduce unnecessary care, and thereby reduce healthcare costs. Each recommendation created is supported by clinical guidelines, evidence, or expert opinion.

To better understand current knowledge levels and perceptions in Australia – Choosing Wisely Australia are seeking responses to a short survey. The survey findings are confidential, takes only 3 minutes to complete and will help with the design, evaluation and implementation of this important initiative.

If you are an emergency physician or trainee working in Australia, please access the survey through the following link: Choosing Wisely Medical Practitioners Survey

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