The bar on this blog is set high. The entries are often complete, with no turn left unstoned. Yet, not every topic needs the full monty with every post. The blog has extensive evaluations on many topics, and new medical literature doesn’t require another complete analysis. Many new articles add incrementally to the literature and their conclusions need to be inserted into the conversation of this blog, like a car sliding into heavy traffic. My eldest son just received his driver’s license, and car metaphors are on my mind. As are crash metaphors and insurance metaphors.

So in response to this need, a need only recognized by me, I give you Short Attention Span SCAM. Occasionally I will summarize a few recent studies and their key points as they relate to prior posts at SBM.

Influenza

…any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bells tolls; it tolls for thee. — John Donne

Influenza season will be starting soon. There are multiple misstatements made about influenza and its treatment in the SCAMosphere. The first concerns death. Flu does not kill, or so it is asserted, or it only kills a thousand people a year. During last year’s H1N1 season I took care of a pair of patients who died of acute influenza, not its complications. Direct deaths from influenza are always a fraction of the deaths from indirect causes: worsening of heart failure or lung disease or a secondary infections. I try to never use the word ‘only’ when discussing direct flu deaths; perhaps I take it too personally. Not patient of mine was ever an ‘only’ and it annoys me no end when the deaths of others are diminished.

How influenza deaths are calculated was discussed in the past, but the CDC released new information on influenza deaths from 1976 to 2007. Calculating flu deaths is not easy. The number lies somewhere between direct deaths from flu, and the deaths from other acute, but related causes:

Deaths from pneumonia and influenza causes are highly correlated with the circulation of influenza and can be considered a lower bound for deaths associated with influenza. However, a diagnosis of influenza virus infection often is not confirmed with sensitive and specific laboratory diagnostics, particularly among older persons, and even when identified is rarely recorded on death certificates (5). Many deaths associated with influenza infections occur from secondary infections such as bacterial pneumonia or complications of chronic conditions such as congestive heart failure and chronic obstructive pulmonary disease. Therefore, estimates using underlying respiratory and circulatory mortality data (which include pneumonia and influenza causes) can provide an upper bound for influenza- associated deaths.

The striking result is that, on average, there is no average flu season. Deaths vary from year to year and depends on the circulating strain of influenza.

Over 31 consecutive flu seasons, on average there were about 23,600 deaths a year linked to the flu varying from a low of 3,349 deaths in 1986-1987 to a high of 48,614 in 2003-2004.

When H3N2 predominated, deaths were 2.7 times higher than compared to other strains. As a comparison, 8,330 to 17,160 are estimated to have died from H1N1.

The ‘classic‘ number given is about 36,000 deaths a year, but the number is an average and, like so much in medicine, it depends. As the CDC says,

A single estimate should not be used to summarize influenza-associated deaths; a range of estimates should be described in the context of circulating virus strains and underlying causes of death among age groups.

Death is often a bad outcome and it is better to not die of the flu or its complications. A recent case controlled study compared flu vaccinated vs unvaccinated and found that the receipt of the flu vaccine decreased the risk of heart attack.

We included 78 706 patients, of whom 16 012 were cases and 62 694 were matched controls. Influenza vaccination had been received in the previous year by 8472 cases (52.9%) and 32 081 controls (51.2%) and was associated with a 19% reduction in the rate of acute myocardial infarction (adjusted odds ratio [OR] 0.81, 95% confidence interval [CI] 0.77-0.85). Early seasonal influenza vaccination was associated with a lower rate of acute myocardial infarction (adjusted OR 0.79, 95% CI 0.75-0.83) than vaccination after mid-November (adjusted OR 0.88, 95% CI 0.79-0.97).

The authors do not speculate on the mechanism of the protection, but that will not stop me. Infections are pro-inflammatory and pro-thrombotic. Myocardial infarctions, strokes and pulmonary embolisms are increased during and after acute infections, perhaps in part due to increased stress on the heart, but also, perhaps due to the pro-thrombotic state. It is reasonable to suggest that flu leads to increased inflammation and thrombosis which leads to MI. No flu, no pro-thrombotic state, no MI. If one could “boost the immune system“, and you can’t, what you would get is a inflammatory/thrombotic state that should lead to more vascular events: strokes, MI and pulmonary embolism.

Vitamin D

Dont get the vaccine, many a site will say, all you need is vitamin D to prevent and treat flu. I am not going to deny the importance of having sufficient vitamin D to keep immune function optimal.

Having higher vitamin D serum levels does decrease the risk of a viral infection, although the effect is modest.

During 114 days of the fall and winter in a temperate zone a serum concentration of 25-hydroxyvitamin D of 38 ng/ml or higher was associated with a two-fold decrease (p<0.0001) in the risk of developing acute viral infections of the respiratory tract.

A modest decrease in risk, and enough to keep me drinking milk shakes all winter to keep my vitamin D levels elevated.

The question is, if you supplement vitamin D in patients, can you treat or prevent influenza? There is zero data for influenza. But there is data for viral upper respiratory tract infections. In Finland they they did a placebo-controlled double-blinded study in 164 young Finnish men (1828 years of age) who were randomly assigned to 400 IU (10 mg;) vitamin D3 daily or placebo.

The treatment and placebo group had the same initial levels of Vitamin D and a difference in levels at the end of the trial.

Intervention (78.7+- 14.9nmol/L) and placebo (74.4+- 20.8 nmol/L groups (P p .35)…after daily supplementation with 400 IU vitamin D or placebo for 6 months, the mean serum 25(OH)D concentrations were 71.6 +- 22.9 nmol/L in the intervention group and 51.3 +- 15.5 nmol/L in the placebo group.

Let’s see: moles to molecular weight to Avogadro’s number to … it’s late and I am tired and do not have there intellectual wherewithal to convert nmol/l to mg/ml. I must have a homeopaths understanding of concentrations. I will leave that as an exercise for the comments (yes, it is also fun to whitewash a fence) to see if they started at the 38 ng/ml that was effective to decreasing risk. Hey. I can’t be expected to do everything can I?

The results were, again, modest.

The main outcome variable, which was the number of days absent from duty due to respiratory tract infection, did not differ between groups. Mean number of days absent was 2.2 +-3.2 days in the intervention group and 3.0+-4.0 days in the placebo group . There was an effect during the first 6 weeks of the study, with a mean of 0.7+-2.1 days of absence in the intervention group and 1.4 +- 2.6 days absent in the placebo group. After the first 6 weeks, there tended to be no difference between groups. Nevertheless, the proportion of men remaining healthy throughout the 6-month study period was greater in the intervention group (41 [51.3%] of 80) than in the placebo group (30 [35.7%] of 80).

Not impressive, but something, and when it comes to avoiding illness, something is better than nothing. Better still, being replete in vitamin D will increase the response to the flu vaccine, so taking vitamin D, especially if you are deficient, may increase the antibody levels after the flu vaccine, still the best way to avoid the disease.

So would I suggest vitamin D? Yes, as part of a healthy breakfast and if you are deficient. It is one of a number of interventions you can use to prevent getting ill in the viral season. But is vitamin D the be-all and end-all of flu prevention and treatment. No. Not even close.

Acupuncture

Man is the only animal that blushes. Or needs to. — Mark Twain

Acupuncture is all placebo effect, what ever that is. This was re-confirmed in “A randomized controlled trial of acupuncture for osteoarthritis of the knee: Effects of patient-provider communication“.

In this trial, patients had real acupuncture or sham acupuncture (as if there is a difference) and they had neutral or enthusiastic acupuncturists. Those that had an enthusiastic acupuncturist had a better decrease in reported pain, whether the acupuncture was real or sham.

TCA was not superior to sham acupuncture. However, acupuncturists styles had significant effects on pain reduction and satisfaction, suggesting that the analgesic benefits of acupuncture can be partially mediated through placebo effects related to the acupuncturists behavior.

This result is of no surprise. Expectations will often color people’s perceptions. More expensive wine is rated higher than the same vintage labeled as cheaper. An expensive placebo is more effective than an cheap placebo.

But does perception of reality mean reality was altered?

I play golf with my kids almost every night in the summer and towards the end of the season I get right elbow tendinitis. As I make my downswing the pain fibers fire and can mess up my swing if I am not focused on hitting through the pain. If I take 400 milligrams of ibuprofen before I play, I have less pain and my swing is unchanged. Not enough to beat my son, but that is another matter.

Decreasing pain leads to improved function when pain limits function. If you have a musculoskeletal problem, you usually have a reproducible limit to your function due to the pain. If the pain is decreased, the function should improve.

As I have discussed at length, I do not think there is really a placebo effect. Certainly for objective endpoints, there is no placebo effect. Buried in the acupuncture paper were two objective end points: range of motion and the Timed Up and Go Test. For objective endpoints there were no changes in any of the groups. So it makes me wonder just what improvement these patients ‘really’ had. Subjectively better, objectively no change.

Is the placebo effect no more than a patient convincing themselves they are better when in fact nothing has changed? That is my interpretation. If function is not improved, if they are still limited by pain, is the pain really gone? Is this response a milder example of the same cognitive processes that can lead to hysterical blindness or not seeing tumors the size of a large mushroom? Man is the only animal with the ability to convince themselves that the tangible is unreal or that the unreal is tangible.

“Always keep your words soft & sweet in case you have to eat them!”

I have said numerous times that I was envious of SCAM practitioners as they live an essentially never-changing world. Once the ideas of homeopathy, reiki, acupuncture were codified, there is no change. Learn once … use forever.

Not so, it turns out, thanks to a report in Medscape (COI warning: I am a paid Medscape blogger).

New acupuncture points have been discovered! Acupuncture advances.

We generally modify acupoints to make them effective and more appropriate for cancer patients…For example, the acupoints which are predetermined places on the body where needles are inserted for therapeutic effect for hot flashes for normal menopause are “not necessarily the same ones for early menopause due to chemotherapy”.

Unfortunately, this breakthrough in acupuncture has yet to be published, although this pioneering work was done at Memorial Sloan-Kettering Cancer Center. Evidently, the only way you can learn this incredible clinical breakthrough is by paying $495 dollars and taking the online acupuncture class offered by Sloan-Kettering. I guess there are some medical cures they really dont want you to know about unless you pay first. It worked for Kevin Trudeau, it works for Sloan-Kettering.

When this phenomenal pioneering work is finally published, I suppose in the NEJM, I will have a second helping of words.

So ends the first SAS SBM.