The problem with strep throat

I read the following opinion in the WSJ today and was reminded of a rather simple issue I see every day which is a kind of "fractaloid" mirror for the issues this post raises.

As you might imagine, I treat a lot of sore throat. I mean a lot. You might think illnesses like sore throat are simple, that all the issues around them are known, that something as trivial as sore throat should not raise any eyebrows. And as long as you cover over most of the details of the issues, you would be correct. But of course, the devil is always in the details. Further every detail can be approached from almost any viewpoint, and we all know this makes all the difference.
What is true for information as a whole, is just as true for the rabbit hole which is sore throat.
So let me jump to the answer for a moment: I do not think strep throat should be treated. While I would not say "ever", I would certainly say "most of the time". But let me also add that I always treat strep throat. In other words, knowing what I know, I continue to practice in a manner contrary to what I believe best. It is a most frustrating catch 22 for which I have no answer.


Let me explain by first stating a few "facts" everyone agrees on:

1. 90-95% of pharyngitis is viral
2. Except for a very few viruses, there are no specific anti-viral medications for viral pharyngitis
3. The sensitivity of rapid strep testing is about 80% (meaning 1 in 5 people with strep throat will have a falsely negative test even when they have strep pharyngitis)
4. Throat cultures are very sensitive (>90%) and considered a gold standard in diagnosing strep throat.
5. Throat culture results can take 3 days
6. If someone has strep pharyngitis, they can (should?) be treated with antibiotics
7. The antibiotic we use should usually be a penicillin derivative like amoxacillin (unless the patient is allergic).

Using these simple facts, which the medical profession unanimously agrees on, we of the medical cloth have developed decision/treatment algorithms any emergency physician/mid-level provider worth their salt knows backwards and forwardsfor. These algorithms represent a so called "standard of care"/"best practices"/"evidence based medicine" approach to care we should all follow accordingly. Hence I still treat strep throat. ;-)

So far I hope I have said nothing controversial.

The problem of course is that there is a problem. Lots of details were ignored by the people who made these recommendations- I do not suggest mean to imply this was done for nefarious reasons, they had to do it. And of course if you think about it much, points 6 and 7 are not really facts act all.

So if you look at points 1-7, a couple of thoughts should come to mind:
A. From whose viewpoint were these algorithms developed?
B. What were the assumptions that went into the observation/analysis/recommendations?
C. Why should we treat strep throat with antibiotics anyway?

This is a rabbit hole and the post would get very long if I dealt with even a few of these details/issues. As we are all busy, I will simply focus on points 6 and 7 the following way:.

Assume you have strep throat, a test has confirmed this and we believe the test results. Should you be treated with antibiotics?

My bottom line is "no".

Why?

It is VERY clear from data that the risk/harm of treating someone with antibiotics is one (maybe two) orders of magnitude greater than doing nothing at all. And yet the medical profession still treats strep throat. Indeed I still treat it stating what I believe to be true.

Why?

The Rise and Fall of Empires

Hat tip Paul Kedrosky of Infectious Greed...

Visualizing empires decline from Pedro M Cruz on Vimeo.

Bad Analogy or "The Time of the Fractal" (thoughts on symmetry)

First I want to say thanks to Street Dog for helping direct me to the following wiki: renormalization. I must say I am having a hard time following most of it, and am hopeful he will give us a simple translation, but it is where my latest inquiry in understanding fractals has arrived. It has generated the following thoughts on the drive home from work this morning.

Anyway...

Fractals are formed when chaos is broken and symmetry (or cooperation) is created (and/or vice versa)- hat tip SD. Further, this time or moment or space (or whatever you want to call it) of fractal formation- what I will hence forth refer to as "the time of the fractal"- is a very special time/moment/space/event/period/epoc/region/etc...

For if you think about it, this time of the fractal has been called many things by many people in many languages from many viewpoints since language and thought was first introduced.

If you are not following me, a few examples may jog your neurons: phase transition(s), boundary condition(s), time of change(s), moment of transformation(s), point of conversion(s), etc...

Are you getting the idea?


Anyway, as additional background, we know the conservation of energy implies that in a closed system, everything is connected to everything else. For discussion purposes on this post, we will pretend the universe is a closed system... Yes, yes, I can already hear some of you complaining, especially with the universe expanding at an accelerated rate and all. I want you to know I hear your concerns (these are simply thoughts after all), but we need to create some boundary conditions to the discussion in order to even have a discussion so let's keep it to the universe just to make it simple.

Further, if you think about it, everything connected to everything else also implies a kind of infinite network between everything and everything else. Of course the links in this (infinite?) network are hard for most of us to see...

So anyway, we have an infinite network in a closed system, and we further have smaller boundary conditions within this network, and then a change happens from at least one viewpoint- voila! We have fractals!

And this is where we get back to the theory of renormalization.

For if something changes in a closed system- e.g. symmetry is either broken or created (really can be either and probably the creation of one means the creation of the other), a break in symmetry must be felt everywhere else.

Really another viewpoint on zero-sum so nothing special here, but here is where I am going:

Does this mean the newest element in the periodic table, humanium, is subject to the same laws as every other element in the periodic table?

When humanium moves from one boundary condition (or phase transition) to another, will it display the same wave-particule duality we see with every other element in the periodic table?

Does humanium display quanta properties? e.g. individual properties?

Does humanium display wave like properties? e.g- collective/cooperative properties?

Neuroanatomist Jill Taylor suggests it does



Thoughts appreciated

Some (insane ?) ramblings on the city

No, I am NOT talking about that hyper chic ghetto in London where the bankrats are glued in front of their screens getting instant gratification in the form of $$$$$££££€€€€€ SIGNS (he he) while mindlessly pressing buttons in Pavlovian fashion, I am talking about the... city.

The place where lots of people live (together), more or less peacefully.

Goody, now I get to don my rabbi's hat. (I am no less contradictory than anyone else here... Judaïsm taught me how to think. The rabbis have always been the world's greatest thinkers. And Jewish rabbis' thought is on a parr with Greek philosophy, although in an entirely different direction. (And by the way.... Herbert was steeped in monotheistic religious tradition. His books are like... textbooks in monotheism. I hope that he knew this, as he was a really smart cookie, smarter than us street rats, I think.)

So, on to the cities.

And back to Genesis (where it all started for us, by the way).

The first mention of cities in the Bible is right after... the first murder. Cain kills Abel, God says to Cain : because you have spilled your brother's blood into the earth, the earth will no longer.... COOPERATE with your efforts to cultivate it, so... In other words, we could say, Cain was just no longer cut out for farming, and he was going to have to find ANOTHER form of subsistance. (By the way, simplistic thinking likes to intimate that God... PUNISHED Cain for the first murder, but this is not true. God didn't NEED to punish Cain for the first murder because.... he knew that Cain would do the job just fine for him. We could say that Cain's restless wandering/nomadism on the earth is an attempt to flee what we moderns call his.. conscience. Abel is gone. Nothing will bring him back again. I think that Thai will appreciate that the temptation to turn what IS into what SHOULD BE is sometimes overwhelming. Because we are just itching for God to punish Cain, we attribute our own desire to God. Not good. )

So. It is in THIS context that the descendants of Cain start to huddle together in places called... cities. The first cities were inhabited by descendants of Cain.

So. I will interpret that the Genesis author thought that men who inhabited cities were estranged from agriculture, and the earth to a certain extent. (Careful, I too am not saying that this is good or bad, I am observing.) And it seems obvious to me that at least the way that our cities are currently organized, this estrangement is quite evident. (We could diminish it by creating... tracts of land FOR farms right in the center of our cities, by the way... This would be a good idea, I think.) The Genesis author also posited that people living in cities felt a certain... rootlessness, too.

Lots of people now living in liberalland would just LOVE to pretend that since they don't believe in God... the Bible has no importance whatsoever to them in their daily lives.

This attitude, in my book, is extremely.... STUPID. It is a little bit like being in a car, driving along in it, and when being questioned, saying "Car, what car ? I'm moving, aren't I ?"

We are STILL products of our ancestor's beliefs, so, in my book we are better off learning about these beliefs in order to be able to more or less "choose" in an informed manner.

Fast forward.

When he was fourteen years old, Adolf Hitler's poor father left home (a small town or village) with a bundle on his back and headed for Vienna in hopes of finding work. Vienna then was an extremely cosmopolitan BIG CITY, and the young man after several hardships managed to get a job with the government bureaucracy as a customs official, and headed back to his home (border) town, proud of having made something of himself. When he got "home", nobody remembered him. Trauma. Major trauma.

When Adolf set off for Vienna about 40 years later, the city had changed a lot, and the worst of industrialized evils had created the massive unemployment which is looming before us even now. On the streets in Vienna, the young Adolf saw what the young Debra saw on the Champs Elysées thirty years ago : throngs of anonymous faces of every color, people of every shape and size, speaking every language imaginable. Where Debra was fascinated and impressed with cosmopolitanism at 25, Adolf was overwhelmed with estrangement at 14 (admit it, he was a little young to be all on his own...). (And it was not a piece of cake, this rootlessness for Debra at 25 either...) And Adolf could NOT manage to make something of himself like his Daddy had. Because of what/who HE was. But also because of what Vienna had become. And... this rootlessness is a major factor in what happened after...

Tragedy of the Commons (part 3)

HA !!

I bet Thai never thought that I would invade the territory of his game, but I am doing it NOW.

In my own fashion, with my own method, and observations, but I am doing it. (And... when will Thai invade MY territory, lol... ?)

As always with me, let's start with the... clinical examination.

Yesterday I headed off on my bicycle to do my bi-weekly shopping at the farmer's market (there is a post here on the farmer's market, my first, for Street Dog, if he is interested. End of ad.). I have enormous bags fixed to my bike so that I can haul up to 30-40 kilos at any stretch, so it works well for not using that... polluting four wheeled vehicle.

Three quarters of the way down the little semi dirt track that the local town hall installed for the Dubai folk in our commune (off limits to through traffic, only the OWNERS have access, you call that democracy ???), a man was rapidly approaching on foot the barrier that blocks car traffic, and that I had to get through in order to continue.

He was.... walking in the middle of the road, just... RIGHT to block my passage.

So I cheerfully called out "beep beep" (I no longer have an official "bell", I don't like them, and think it's kind of fun to produce my own sound effects...), and he moved over, grudgingly, and telling me off, even though (I think...) I thanked him for doing so.

Comment :

Why do people walk in the middle of the road ?

They do so, because WHEN THERE IS NO-ONE ELSE THERE they move out to occupy all the space (or territory...). Why... cramp yourself in when you can spread yourself out ?

But when an incident happens like the one above, all of a sudden, territory gets.... redistributed.

If the situation had permitted it, I would have taken several deep bows, said "excuse me excuse me, I would like to get around you in order to continue moving on my bike", but... you can guess that the situation DID NOT permit that kind of social sniffing.

So he was peeved. He felt that my "beep beep" was an offensive INVASION of his (drum roll, here comes the BIG word) INDIVIDUAL RIGHT to occupy the whole road the way he wanted to.

He was incapable of seeing that my "beep beep" was intended to help BOTH OF US find a suitable compromise that would permit BOTH OF US (individuals) to continue moving without sacrifice on either part, within the PUBLIC realm of the commons.

This incident is, of course, symptomatic of what is going on at all levels in our society these days.

Tragedy of the Commons is the tragedy that Rousseau got the best grasp on (sorry Thai, don't scream...).

It's all in your head (stupid)

Dring... the experiment is beginning.

After at least two years on my loony forum of desperately trying to break through to my loonies, in missionary fashion, as to WHY their ideas about the mind/body relationship are tainted by the eternal prejudices of our time, I have decided to see if... YOU GUYS, the cream of the crop, the medical elite, the A+ students of top American colleges will... GET it better than "my" loonies do.

Here goes :

A little background. A week ago I got pounded into the ground following a news post about a chiantific experiment highlighting the... nocebo effect. You know, the... nocebo, which has the opposite effect of a placebo.

I found that.... really really interesting, and proceeded to tie this reaction in to my all favorite anecdote about the power of.... NEGATIVE thinking, to be found in Dale Carnegie's little treasure, "The Power of Positive Thinking", book number one in the endless series of management books that has since hit the racks.

You know, the story about the guy who gets locked into a refrigerator wagon, and, after scribbling on the wall that he is expiring from the cold, promptly proceeds to freeze to death in a... disconnected wagon.

I presume that my readership here is already acquainted with this rather... remarkable incident which has no... RATIONAL explanation.

Freezing to death in a disconnected refrigerator wagon throws a loop in our carefully constructed prejudices about just HOW our thoughts manage to translate themselves into our bodies.

When Freud began opening his mouth about psychoanalysis, he had been working with hysterical patients. Mostly women. And along with Charcot, he had made some rather interesting observations.

Observation one : (this one is for the ophthalmo...) Hysterical blindness exists.

Hysterical blindness is blindness for which the doc can find no LESION. (Not finding lesions didn't stop Freud from finding other things. He found : thoughts, memories which the person had translated into corporeal language.)

Blindness exists also which is the result of organic lesions.

Now we get to the clincher...

If YOU'RE BLIND, and there is no lesion, YOU CAN'T SEE.

THE SAME WAY that

someone who has an organic lesion can't see.

So... if BOTH people can't see, then.... why the fuss about the lesion ?

Could it possibly be because... if there is NO LESION, then we say... "it's all in your head (stupid) ? (We also say this when we can find no EXPLANATION for a phenomenon.)

Freud and Charcot both discovered that people suffering from hysterical complaints had their suffering discredited/ignored/belittled by the medical caste. And they discovered this at a time when docs were doing autopsies at record paces in the attempt to LOCALIZE psychic disease in the body and brain. And... when the docs did those little autopsies on their hysterical patients.... AW SHUCKS, they just couldn't manage to find them littl' ole lesions. (Some people are still looking, by the way, or they are trying to localize in other manners...)

As it turns out, as I mentioned over here a while ago, the current DSM has totally bottomed out the diagnosis of hysteria, which is really not surprising, considering that... the epistemological position of the people who came up with the DSM leaves them with a MAJOR blind spot (hé hé...) concerning hysteria, since the PURPOSE of hysteria is to... challenge an all-knowing, all-powerful (generally masculine) MASTER, and... this is precisely the position of the DSM.

So... since there is NO lesion in your body that means that... it's all in your head (stupid).

You might think that since we came to the realization that the brain was commanding most of what is going on in our bodies, we could admit that, to a certain extent EVERYTHING is in your head, but...

This would be too easy. The logic behind this illogic goes like this : if you have a lesion which can be localized, then, you are on the side of truth. But, if you don't have a lesion you are telling a lie, you're a fake, you're a simulator, etc etc.

(And docs know just how exasperating hysterical patients can be, they are just not GOOD, REWARDING patients that you can tinker with in erector set fashion, do a little bit of manual fiddling, chop off a this, extract a that, and illico presto, magic, the person is CURED !! Good doc, good boy, you've done your job, thank you, a million thanks)

Now... since I KNOW that every advantage has its disadvantage, and every disadvantage has its advantage, I cannot say in honesty that I think that it is MAJOR PROGRESS that we have now decided that for every corporal problem there has to be an EXPLANATION of the lesion type. No. I don't think that minutely scrutinizing everybody in hopes of finding the elusive (illusive ?) lesion (or the "faulty" genome, while we're at it...) is necessarily the answer to our problems.

And... as Thai would say... it costs a HELL OF A LOT OF MONEY TO STICK EVERYBODY UNDER THE MICROSCOPE.

Can you believe it ? In the good old days, before we had all this modern medicine, Freud was such a savvy clinician that he could do an excellent clinical exam and determine whether the patient was suffering from a hysterical complaint, or not.

Don't you wish we had clinicians like that these days ? I sure do... It would save us all a lot of filthy lucre.

Thought of the day

Being angry at a central bank is like being angry at your spinal cord while you cliff dive.

"How dare you be so presumptuous as to allow me freedom of motion" laments the diver as (s)he hurtles towards the rocks below.