The science fo spit testing and toilet training

The Case for Evidence-Based Toilet Training
Edward R. Christophersen
Arch Pediatr Adolesc Med 2003;157 1153-1154
http://archpedi.ama-assn.org/cgi/content/full/157/12/1153?etoc

Commenting on the title (I'm not an AMA member and the abstract was not available on Medline) this is hilarious. I think there is a tendency for us skeptics to insist on documented studies that demonstrate reliable consequences before we label any intervention as worthwhile. While we can insist our practice of medicine be evidence based, there has to be room for action, intervention, and decision that is based on common sense and expert opinion. The wisdom is in knowing when we can apply "common sense" and when we should be insisting on better study outcomes. Especially when inaction results in discomfort and soiled linen.

It is unfortunate that our post modernistic attitudes today do insist that anyone's opinion is considered equally expert. My point, however, was that skeptics who get hung up over the best way to potty-train, should not forget that the child should be trained, particulars of technique put aside. The same way a good skeptic would not take any randomized placebo controlled cross-over clinical trial as credible without first putting the methods and implications in context, the good skeptic would not expect this kind of study before approaching the task of potty-training.

In context, it's already understood that in our society, the vast majority of children potty-train successfully with no apparent direct negative results regardless of the method used. Unless some new information changes this understanding, there may be no scientific appeal for intensive clinical study.

Comment to the speculative reply of the Spit testing advocate:

I think my main point was about using wisdom in deciding what influences our actions. Skeptics who get hung up over the best way to potty-train, should not forget that the child needs to be trained, particulars of technique put aside.

Right on topic was an awesome article with a related point of view linked by a fellow HF list-member.

http://www.betterhumans.com/Features/Columns/Change_Surfing/column.aspx?ArticleID=2003-12-08-4&sendToAFriendID=2003-12-08-11

Beyond Doctors. Computers, capitalism and nurses are bringing us higher quality medicine By James Hughes

12/8/2003

There should be a wise place for acceptance of any medical intervention that is between the "holy grail" and anecdote. The elusive wisdom is finding that place for any given technology. I'd like to suggest that in most cases it can't be determined by the individual, who will be prone to bias based on their personal realm of knowledge and experience. The cardiac surgeon will insist on coronary bypass, the invasive radiologist will likewise insist on coronary brachytherapy. Consensus of understanding seems to be the way of learning and science.

In your HRT case, Dr. Lee (creator of this spit test) may be 100% on target, but when I followed Internet links for the applications of the theories he is promoting I found what appeared to be quick-buck health scams that all but suggest we all need testing and we all need supplements for things that may or may not be ailing us. Science theory all aside, my "wisdom" tells me I want to see health outcomes and know that my apparently significant long-term monetary sacrifice will likely guarantee a better, or less sick life.

As noble as Dr. Lee's intent is, his ideas are apparently being applied rather dubiously to sell tests and supplements. HMO's are about paying for health care, with finite resources. They are about money. Their wisdom tells them there could be a financial impact on claims should they begin to reimburse a new kind of testing or related HRT services. The mail-order testing company is about money, and the HRT supplement company is about money. Their wisdom tells them that if the HMO pays for this, they become multi-billionaires. Money drives the industry. The only neutral party becomes the body of scientific evidence and it's practical application. The wisdom for requiring either anecdotes or "holy grails" before accepting a technology is perhaps not often and never solely; but, rightfully influenced by the amount of money that could potentially be involved.

Another influence on the degree of evidence required for acceptance of a new technology, in no specific order, is the apparent degree from which the new technology goes against current standards of care. This may have very little to do with evidence based medicine in the beginning. For example, there is much practiced in medicine that has very little backing by clinical studies and scientific literature. But, it's been practiced without a hitch for several years and seems to offer predictable outcomes. When the next latest-greatest comes in to replace the standard, only clinical evidence may off-set the tendency to say "why fix something that doesn't appear to be broken?" or "why change something that appears to always have had acceptable predictable outcomes?"

Current protocols for HRT, although recently rather dynamic in their application, are very accepted standards of care. A revolutionary approach to hormone therapy is, I think, going to require a body of research before today's medical society accepts it. It has been said that for every genius that is crying in the wilderness there are a hundred charlatans. Those who label Dr. Lee may be just playing the odds. If Dr. Lee's ideas are indeed 100% correct, evidence based medicine and the scientific process is the medium by which this will come to light and be accepted in western medicine practice.

I disagree that EBM is about black and white. Practicing medicine is an art, and therefore subjective. An offered medical treatment is seldom presented as the right treatment, but rather the best treatment. Out of necessity, things in medicine often become absolute. Your HMO either will, or will not pay for saliva testing. EBM's goal is termed "best practice" and best is defined by wise analysis of scientific evidence.

P.S. in proofreading I can addend a couple of things. When I say that "money drives the industry" I do not imply that "greed" drives the industry. Also, akin, or even preferable to the estrodial patch, the woman now has the options of beads or the "Femring."

Hormone supplements and mail order saliva testing

I wrote this an a subtle approach, but in actuality it's fierce slam against testing. The reply resulted in further debate that I attach below the original writ.-dras


I followed hits from a google search for "saliva" and "hormone"; and, putting scientific debate of HRT aside, the whole notion of having one of a dozen common symptoms as just need to send money along with spit in return for a recommendation to take a costly mail order nutritional supplement seems dubious. Especially in the presence of nationally accepted medical standards for diagnosing and treating age related disease (http://www.aace.com).

I quickly put together some summary questions that may need to be answered before many like me will jump on the saliva hormone testing bandwagon.

Is saliva consistently able to provide technically comparable testing results in the presence of changing factors that influence saliva make up? Has the published discussions about these factors been resolved? (Binding affinity for specific protein carriers; saliva flow; use of pharmacologic agents that may displace bound hormones; hormone metabolism by salivary gland epithelial cells or oral bacteria; circadian rhythms; and contamination of the saliva specimen with blood, food, gingival fluid or tissue debris.) If so, are there standardized protocols for measuring hormone levels in saliva?

Has testing sensitivity, specificity, or positive and negative predictive values for salivary hormones when used related to menopause or aging been established?

Are the results of salivary hormone testing an integral part of a clinical pathway to direct patient treatment of conditions related to menopause or aging?

Finally, are there enough clinical or other advantages of salivary hormone testing to justify its use over any established alternative?

Most of the answers will need to come from studies and clinical trials, some with health impact outcome measurements to be influential.

1.	Saliva as a diagnostic fluid. Conference proceedings. Panama City Beach, Florida, October 22-25, 1992. Ann N Y Acad Sci 1993;694:1-348
2.	Lawrence HP. Salivary markers of systemic disease: noninvasive diagnosis of disease and monitoring of general health. J Can Dent Assoc 2002;68(3):170-4
3.	Vining RF, McGinley RA. The measurement of hormones in saliva: possibilities and pitfalls. J Steroid Biochem 1987;27(1-3):81-94

Further response to a proponent of spit testing:
I admit I am not well read on HRT, saliva testing and supplemental hormone or alternative hormone therapy. I glanced over the long list of references you provided. In past study, it seemed I had a much shorter and much more relevant list of references using a MEDLINE online search.

I think it's demonstrated that clinical studies and expert opinion are interpreted and disputed for different arguments. This is the essential process for the advancement of the technology. This process also should take time. Today's "cutting edge" of theory and understanding is often later put aside. It's important to understand what the cumulative knowledge thus far tells us about practical intervention. Accepted clinical pathways are those that offer the most predictable end results.

I do think that basing a need for supplement prescriptions on saliva testing is a high risk for being charlatanism. I don't understand the significance that the NYS approved a lab that does saliva testing. And, the economic benefits for convenience of testing becomes moot if the tests' sensitivity, specificity, or positive and negative predictive values for salivary hormones when used related to menopause or aging have not been established.

In the absence of a high-level dissertation on hormonal interactions within the human body, I will turn to published assessments of the clinical technology from an organized group of leading professional nutritionists. The American Association of Clinical Endocrinologists' (AACE) recently organized Nutrition Guidelines Task Force "consists of endocrinologists who are experts and practitioners in the field of clinical nutrition. More than 50% of their practice is in the area of nutritional medicine, and they are active members of AACE. Each contributor has published in the field of nutrition and is active in one or more of the major nutrition societies in the United States."

"Overall, AACE recommends that only proven therapies (grades A, B, and C in Table 3) be used to treat medical conditions. A patient’s uncertainty may be clarified by helping the patient to understand the different levels of provability and scientific substantiation. Furthermore, the clinical evidence can guide therapeutic recommendations for a specific diagnosis. If the patient becomes argumentative, and simply cannot prioritize scientific substantiation over testimonial data or excessive risk, then the encounter should end."

http://www.aace.com/clin/guidelines/Nutraceuticals2003.pdf

BBC Fool your senses test (link only)

BTW: I scored 10 for 20 on the fool-your-senses BBC test http://www.bbc.co.uk/science/humanbody/body/interactives/senseschallenge/)

JAMA on oxygenated water

Below is a link to the Seattle Times report because you need a subscription for the JAMA article itself. I bet everyone isn't surprised at the study's conclusions.

On the critical side, the study appeared in the "letters" section of the Journal if that makes a difference in the level of peer-review. Also, only 11 patients were tested and even though absolutely no significant (or non-significant) difference was found in any of the reported parameters there may be other factors influencing the variables. Maybe you're supposed to drink it 30 minutes before exercise, or during exercise. Or maybe you have to shake it up first. I bet they didn't exercise long enough, or exercise the proper muscle groups to effect a difference. For the Journal's 11 subjects that couldn't even guess a difference, I can get 11 subjects to offer testimonials that hyper O2 water makes all the difference in the world.

BTW: I scored 10 for 20 on the fool-your-senses BBC test forwarded by Dr. Hall. Case in point . http://www.bbc.co.uk/science/humanbody/body/interactives/senseschallenge/)

http://seattletimes.nwsource.com/html/healthscience/2001789256_water12.html

Study: Extra oxygen doesn't make bottled water healthier

By Judith Blake

Seattle Times staff reporter

"Researchers in Seattle and North Carolina have thrown a wet blanket on certain health claims for bottled water infused with extra oxygen.

A study published today in the Journal of the American Medical Association (JAMA) found that each of the five brands of oxygenated water the researchers tested contained less oxygen in 12 ounces than is contained in a single human breath.

The study was conducted by researchers at Seattle's Virginia Mason Medical Center and at Duke University in North Carolina. Testing 11 adults, they also found "no significant differences in exercise results" based on whether the person drank oxygenated bottled water or ordinary tap water.

Many brands of oxygenated water — a tiny but growing segment of the $8 billion wholesale bottled-water industry — claim or imply they enhance energy and athletic performance. The products are sold in some groceries and on the Internet.

Two Northwest producers of oxygenated water responded to the study in different ways. A spokeswoman for Talking Rain, of Preston, said the King County company makes no health claims for its product, called airwater, while Aqua Rush, of Coeur d'Alene, Idaho, contended its oxygen-infusing technique gives its product a higher level of "stable" oxygen than any others. …"

Should my doctor be my pastor?

John Q. Physician, MD, C.O.G. (called of God)

This topic touches on the separation of church and state as well as the separation/integration of science and religion. We should be aware about the degree that the general populous is legislatively coerced to monetarily support religion (through taxes and insurance premiums.) Popular press is saying patients are demanding "spiritual" care from the health care system. I don't get it: I don't talk to my city councilman about treating gout, I don't call an accountant when my furnace breaks down, but when I'm terminal, I'll solicit my doctor about the meaning of life?

Mortality and death (the realm of religion) are inseparable from health and cure so these may be unfair analogies. When I was working as a home health visiting nurse I often saw the patient who qualified for Hospice (less than six months to live) but refused the service, sometimes out of denial , refusal to "give up," or other lack of understanding or misunderstanding. In circumstances like this patients as well as family members can literally cling to the visiting nurse (or even the nurse's aid) for help and discussion on spiritual matters. The nurse's role in these situations can probably be defined but it can no more be a complete preaching of the Word of God than a complete refusal to acknowledge and address the situation.

Should we qualify nurses and physicians to discuss religion and expect them to present it without dumping in personal faith convictions? Do we start separating out PAYMENT for them to do this? Will this approach satisfy the patient's demands? Do we use public or insurance funds to pay religious representatives for any apparent need for spiritual discussion with patients and families?

I say don’t wait until you get sick, or qualify for Hospice to start thinking about your own mortality. Make sure you have an inner support structure of beliefs or ideals as well as external support structure of people you trust to help you through difficult times. Will this guarantee an easier time if/when circumstance comes along? No, but the odds are favorable.

Discussions of mortality, death, and in many cases morbidity are a part of healthcare, but our current empirical understanding limits the course of the discussion to the theory that they are absolute. Anything beyond this is the discussion of religion (and pseudoscience). We are unwise to expect our health care system address our spiritual ailments along with physical ones. We are unwise to look to science or a healthcare system to fill mankinds need for religion. Shame on those that would look, or have anyone look to government to provide, endorse, and/or pay for our religion.