Saint Nickanuck of the Tundra

image by virtualreality on Flickr

“If holistic-health advocates were content with encouraging sensible preventive medicine or with criticizing the economic organization of American medicine, we might be enthusiastic, but they are not. If the movement were without influence on American life, we would be indifferent, but it is not. Holistic medicine is a pablum of common sense and nonsense offered by cranks and quacks and failed pedants who share an attachment to magic and an animosity toward reason.

Too many people seem willing to swallow the rhetoric—even too many medical doctors—and the results will not be benign. At times, physicians may find themselves in sympathy with the holistic movement, because some fragment of the rhetoric rings true, because of certain practices and attitudes they encounter in their daily work with colleagues and patients, or because of dissatisfaction with the economic and social organization of medicine. One hopes they will speak bluntly, but it does no good to join forces with cranks and quacks, magicians and madmen.”

-C. Glymour and D. Stalker from “Engineers, cranks, physicians, magicians”; N Engl J Med. 1983 Apr 21;308(16):960-4

I’ll be on with Chris Samples tomorrow morning on 98.3 KXDA radio out of Perryton, Texas, talking about the current state of the influenza season, and the 2009 H1N1 virus in particular. I’ve had the pleasure of being on Chris’s show twice last year, and our conversations have been both fun and insightful – I’m looking forward to it.

My segment will go on at 10:20 EST (09:20 CST). You can listen to the live stream here.

Many end-of-year medical commentaries for 2009 have naturally taken a look back at the 2009 H1N1 influenza virus, as I did, in part, last week. Unfortunately, some are losing sight of the fact that while we are currently in a lull in influenza activity, the “flu season” isn’t over yet, and so drawing conclusions about the impact of the 2009 H1N1 virus is quite premature.

The US has currently seen two peaks of H1N1 activity, the first being shortly after its discovery, and the second ending just a few weeks ago. From the CDC’s site, the current trends in positive influenza tests being reported tell the tale:

In addition to this, the CDC has reported a mid-range estimate of 47 million people infected with the novel H1N1 virus, and 9,820 H1N1-related deaths from April 14 through November 14. When compared to traditionally cited estimates that seasonal influenza typically infects 5-20% of the US population and is responsible for ~36,000 deaths annually, this seems to paint a picture that the 2009 virus is panning out to be overall less lethal than the typical seasonal varieties. It has even been suggested that perhaps we should stop vaccinating against the new virus, to allow it somehow to “overtake and replace” the traditional viruses in circulation for this reason.

These latter conclusions are just plain bad, let alone unscientific, for a number of reasons:

• we’re only halfway through the traditional influenza season – “Flu season” is tracked from October through May, so any numbers at this point are useful for tracking the disease progress, but too incomplete to make any conclusive statements from. Furthermore, seasonal influenza over the last couple of years hasn’t peaked until February or March, so it’s entirely possible that there’s more activity in store for us ahead.

• comparing pandemic influenza statistics to seasonal flu stats during a pandemic is akin to comparing apples to oranges – As the WHO rightly points out, the numbers for people who are infected by, or die from, season influenza are based on statistical models that look back on the affected population and influenza season as a whole. In contrast, during this new H1N1 pandemic, the primary data reported on are the number of positive tests, not estimates based on complete data. While the CDC has been reporting the number of people affected as estimates, their margin of error in the April to November numbers quoted above is huge due to the fact that the season is still unfolding (between 34 and 67 million cases, and 7 to 14,000 deaths). Accurate numbers to estimate from won’t be available until we are well out of this flu season.

• the novel H1N1 virus may return again, possibly in a more lethal form – Previous pandemics have taught us that there can be at least three “waves” of spread of a new influenza virus through a population, and that mutations the circulating viruses can pick up can make it cause more serious illness. While a post-holiday spike in cases that some predicted (due to increased travel, and increased clustering of people together) hasn’t shown itself yet, this pandemic is spreading in a strikingly similar way to that of 1957, which had another peak in January.

• it is impossible to predict how this will impact seasonal influenza viruses – The usual seasonal varieties of influenza have yet to show themselves, although as mentioned before, it is earlier in the season than they are usually seen. It is impossible to say at this point if or when they may surface, and eventually if the 2009 H1N1 will join or supplant them over the coming years, or simply fade away. The answer to this lies in numerous complex factors that we can’t accurately model for right now, including viral genetics, population immunity from infections and vaccinations, and environmental components.

We may be in the eye of the 2009 H1N1 pandemic storm (or it may, in fact, have already passed us by), but it is still too soon to meaningfully analyze how “bad” it is on its own, or compare it to recent seasonal influenza. That said, this is an excellent time to look back at some of the human factors involved in the pandemic to date, and some lessons learned… which I will be doing shortly.

It is the waning hours of the year, and as such it is customary for many to make “Top xxxx Lists!” as a way of making 2009 into an artificial entity that we will shortly wave a fond farewell to, for better or worse, and leave behind in favor of the uncertain newness of 2010. Trying to craft any such a list for the year in medicine is a mad folly, given the sheer amount of news and discoveries that happened every week of these past 12 months. That noted, what follows is my completely subjective shortlist of medical stories that received media attention in 2009.

The dominant story of the year was clearly the new strain of H1N1 influenza virus. From it’s discovery at the end of March, through its spread throughout the world and official classification as a pandemic by the World Health Organization, no other issue came close to the “swine flu’s” saturation of the media. Unfortunately, much popular news coverage of the outbreak has ranged from barely adequate to frankly horrible (ABC2’s H1N1 Day of Answers was an excellent event, and a notable exception to this). Often focused on fearful hype or dismissive ignorance, many media reports chose to sensationalize and misrepresent certain aspects of the pandemic (vaccines side effects, for one) while not actually doing their job – objectively reporting facts in an informed way. Coupled with some poor choices in government communication to the general public, and a failure of manufacturers to deliver vaccine on the promised timetable, the end result was unnecessary public fear, confusion, and public health inadequacy where there should have been a smooth, strong response. In this, we are fortunate that the 2009 H1N1 strain is less virulent than it might have been. I’ll be taking a much closer look at the pandemic to date, and future prospects, next week.

If there is one thing that rivaled influenza in terms of media coverage this year, it was the process to craft legislation for United States health care reform. As I type this, both the US House of Representatives and the Senate have passed separate reform bills after months of deliberation, and now face the difficult prospect of merging them together. To call what has led up to this point a “debate” would be particularly generous – the amazing variety of agenda-driven nonsense that has spewed out from various political factions and interest groups is staggering, and has often threatened to drown out the basic facts involved. Add to this that said basic facts are rather complex, and that there is no “right answer”, and you end up with a media message that just cannot report the issues involved adequately. The process, and the conversations it has generated, say alot about we as a people, and both the strengths and weaknesses of our political process. Our current health system (cue cutting glare at most insurance companies here) is quite deficient in some ways, and the proposed legislation is an imperfect tool to bring about needed change, but it is a start.

In the midst of this incendiary health care mess, the US Preventative Services Task Force released a long-prepared update to their mammography screening guidelines in November. Based on solid science and cost-benefit analyses, they changed their recommendations to be that women at low risk of breast cancer should start discussing mammograms with their physicians at age 40 and get them routinely starting at age 50 (as opposed to just starting at age 40), and once started, getting them every two years instead of annually. What was done in order to reduce the costs and harms (due to false positive results leading to unnecessary surgery, among other things) to a population of women in whom mammography as a screening tool doesn’t work as well to detect breast cancer was then portrayed by some elements of the media as a womens’ rights issue or an example of healthcare rationing (neither being true). The fundamental point that many seemed to miss is that guidelines such as these for certain populations of people are not mandates for individual patients or physicians. At the end of the day, it is unlikely that many physicians will change their breast cancer screening practices based on these recommendations alone, and hopefully more women will have informed discussions with their physicians about mammography. I’ll also be going into more detail on these and other screening recommendations in future weeks.

The last two medical media-related stories on my hit list have to do with interesting research that was reported to be far more significant than it actually was. October saw headlines about a study from Thailand that finally demonstrated an “effective” and “promising” HIV vaccination strategy using a combination of vaccines. Upon examining the study however, the results were that 31% less of the patients that had the vaccine combination acquired HIV when compared with those who did not, and after correction for leaving out some who were already HIV infected, this dropped to a 26% difference. This is a potentially interesting result, but given the variables and statistics involved, hardly qualifies for language like “promising” or “effective.” October also brought reporting on another paper that described a virus called XMRV that was reported to be associated with chronic fatigue syndrome. The study described finding this pathogen in 3.7% of healthy patients, but in 67% of people diagnosed with CFS. While the paper itself was appropriately conservative in suggesting the association, several news outlets and at least one of the paper’s authors were outspoken on this being a clear infectious link to a rather unclear syndrome. The problem with such bold statements here is that this study, while interesting, is certainly not definitive; patients labeled as having chronic fatigue syndrome may comprise multiple groups of people with different underlying disorders; XMRV is a poorly understood virus; and as with life in general, in medicine it is vastly important not to confuse correlation (saying that the virus is there in many of the patients that have the syndrome) equals causation (saying that the virus is the cause of the syndrome). Both of these stories do have merit behind them, and I look forward to further progress here in the coming year.

2009 has been a whirlwind of new medical information, hampered by frequently poor media dissemination of that information. Just as it is incumbent on various news outlets to embark on informed, non-sensationalistic science reporting, it is equally critical for the medical community and the lay public to seek out rational facts about medical issues, and evaluate media reports with a skeptical eye. May 2010 see better medicine reporting, for the more knowledgeable health of us all.

• I had the pleasure of being interviewed for a piece in Get Healthy magazine on debunking health myths.

• Otherwise, this week has been about the work, holiday relaxation, and distraction by shiny toys. I hope your holidays have been, and continue to be, full of peace and excellence.

post-feasting pre-gaming Christmasy candlelit repose, photo by John Cmar

In skimming the medical news in preparation to comment on the now slightly less insane coverage of both influenza and the new USPSTF mammography guidelines, I was distracted by this headline from Science Daily: “Hidden Sensory System Discovered in the Skin.” Hidden sensory systems, eh? Casting a dubious eye, I proceeded to read onward to see what anatomists might have been missing over the last several hundred years:

The human sensory experience is far more complex and nuanced than previously thought, according to a groundbreaking new study published in the December 15 issue of the journal Pain. In the article, researchers at Albany Medical College, the University of Liverpool and Cambridge University report that the human body has an entirely unique and separate sensory system aside from the nerves that give most of us the ability to touch and feel. Surprisingly, this sensory network is located throughout our blood vessels and sweat glands, and is for most people, largely imperceptible. (full story at ScienceDaily.com)

So far, so good, if a bit sensationally described. The existence of nerves that wire our glands to secrete the substances they produce, and blood vessels expand or contract in response to certain signals, is certainly not news. The interesting thing here is the idea that they may be somehow involved in detecting sensation from the skin, which is something that’s never been considered before – after all, we already have an extensive set of nerves in place that do just that.

This particular research came about when two unrelated patients were evaluated by the paper’s authors due to their similar, and previously unsubscribed, constellation of symptoms. Both had a congenital inability to feel pain, as manifested by the patients being unaware of significant injuries, such as broken bones, exposure to severe cold, and burns. In addition to other symptoms, both patients did have some degree of sensation to non-painful stimuli, which allowed them to accomplish their daily tasks and employment without any difficulties. The subjects underwent a detailed clinical neurological exam, as well as nerve biopsies and DNA analysis. The results show that there was an almost total absence of normal sensory nerves to the skin, but with no genetic mutations present that have been associated with other “congenital absence of pain” syndromes. The journal authors concluded:

…Our findings suggest three hypotheses: (1) that development or maintenance of sensory innervation to cutaneous vasculature and sweat glands may be under separate genetic control from that of all other cutaneous sensory innervation, (2) the latter innervation is preferentially vulnerable to some environmental factor, and (3) vascular and sweat gland afferents may contribute to conscious cutaneous perception. (abstract from Pain, 2009; 147 (1-3): 287; full article requires subscription)

Translation: (1) the genes that control different nerve systems are more complex and separate than previously thought, (2) the nerves that directly wire for sensation in the skin may be affected specifically by things in the environment that might not effect other nerve systems, and (3) the nerves that control blood vessel dilation and gland function may have a role in skin sensation as well. These are very interesting, as well as appropriately conservative, conclusions – based on two patients with extremely rare conditions, we have some new ideas about how the nervous system works. This will likely spur on more research to investigate how these different nerves intersect in terms of sensory input, and the potential genes involved.

Of course, the very preliminary nature of these observations doesn’t prevent the authors from speculating to the media on what these findings might mean for specific diseases. From the Science Daily report:

“Problems with these nerve endings may contribute to mysterious pain conditions such as migraine headaches and fibromyalgia, the sources of which are still unknown, making them very difficult to treat.” (full story at ScienceDaily.com)

The implications of this discovery for migraine headaches in particular is, admittedly, tantalizing. What causes the pain in migraines is not fully understood, and several theories involve the abnormal responses of blood vessels in the brain and surrounding tissues. Certainly, the idea that nerves connected to said blood vessels could themselves be generating pain signals might have significant importance for managing and treating such headaches.

All that said, any speculation at this point as to how this discovery may relate to specific diseases is just that – idle speculation. Much like the recent poorly reported and overblown “association” of XMRV with chronic fatigue syndrome, it is inappropriate to draw any clinical conclusions about poorly understood syndromes like fibromyalgia based on the actual content of this study. What is important is that through the description of these two rare patients, we have made a fascinating discovery at a very basic level about how our nervous system may work normally, or at least attempt to compensate when a genetic change has happened. How this plays out in the future in terms of pain disorders remains to be seen.

[Journal reference: Bowsher et al. Absence of pain with hyperhidrosis: A new syndrome where vascular afferents may mediate cutaneous sensation. Pain, 2009; 147 (1-3): 287 DOI: 10.1016/j.pain.2009.09.007]