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Wednesday, August 31, 2005
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Avoiding scientific delusions
Alties are frequently unhappy about medicine's growing insistence on well-designed clinical trials to test their claims, considering it evidence of the "elitism" that they despise in "conventional" medicine. What they don't understand is that the reason that the scientific method and clinical trials are so important is not because scientists and "conventional" doctors are any wiser than "alternative" practitioners or even the general population at large. They most certainly are not; they are just more highly educated and trained. The reason the scientific methods and clinical trials are so important in developing and evaluating new therapies is because doctors are human and therefore just as prone to bias and wishful thinking as the worst pseudoscientist or quack. They are just as prone to falling victim to the trap of wanting so badly to believe that an experimental result is valid or that a treatment is effective that they fool themselves into believing it or to resisting change because "always done it this way." (Altie practitioners tend to be prone to a different kind of self-deception, namely the Galileo gambit, in which they believe themselves akin to Galileo, persecuted because they are so far ahead of their time.)
Last Sunday's New York Times had a very good example of a "conventional" treatment that demonstrates why clinical trials are so important. The treatment is vertebroplasty using spinal cement to treat vertebral fractures due to osteoporosis:
No one is sure why it helps, or even if it does. The hot cement may be shoring up the spine or merely destroying the nerve endings that transmit pain. Or the procedure may simply have a placebo effect.Sound familiar? If not, consider this quote:
And some research hints that the procedure may be harmful in the long run, because when one vertebra is shored up, adjacent ones may be more likely to break.
But vertebroplasty and a similar procedure, kyphoplasty, are fast becoming the treatments of choice for patients with bones so weak their vertebrae break.
The two procedures are so common, said Dr. Ethel Siris, an osteoporosis researcher at Columbia University, that "if you have osteoporosis and come into an emergency room with back pain from a fractured vertebra, you are unlikely to leave without it." She said she was concerned about the procedures' widespread and largely uncritical acceptance.
"I struggle with this," said Dr. Joshua A. Hirsch, director of interventional neuroradiology at Massachusetts General Hospital in Boston. He believes in clinical trials, he said, but when it comes to vertebroplasty and kyphoplasty, "I truly believe these procedures work."
"I adore my patients," Dr. Hirsch added, "and it hurts me that they suffer, to the point that I come in on my days off to do these procedures."
Unfortunately, personal observation is prone to far too many biases, the worst of which is selective thinking or confirmation bias. In short, we remember successes (or seeming successes) and observations that confirm our expectations, and tend to forget or discount failures and observations that do not confirm our expectations. Small pilot studies are also prone to bias and confounding factors, which is why they are generally good only as a means of determining if a treatment shows an inkling of effectiveness worth following up with a larger trial. As the claim spreads, it can then become accepted through communal reinforcement, regardless of the poor quality of the initial data. Apparently this is happening now with vertebroplasty.
In studies of pain relief treatments or procedures, one particularly nasty bias that cannot be eliminated without good placebo controls is regression to the mean:
For example, he said, patients come in crying for relief when their pain is at its apogee. By chance, it is likely to regress whether or not they are treated. That phenomenon, regression to the mean, has foiled researchers time and time again.
But Dr. David F. Kallmes, one of her partners, wanted a rigorous test. He began a pilot study, randomly assigning participants to vertebroplasty or placebo. To make it more appealing, he told patients that 10 days later they could get whichever treatment they had failed to get the first time.
It was hard to find subjects, and Dr. Kallmes ended up with only five. For the sham procedure, he pressed on the patient's back as if injecting cement, injected a local anesthetic, opened a container of polymethylmethacrylate so the distinctive nail-polish-remover smell would waft through the air and banged on a bowl so it sounded like he was mixing cement.
In 2002, he reported his results: three patients initially had vertebroplasty and two had the sham. But there was no difference in pain relief. All the patients thought they had gotten the placebo, and all wanted the other treatment after 10 days. One patient who had vertebroplasty followed in 10 days by the sham said the second procedure - the sham - relieved his pain.
It turns out that the bulk of the evidence that is being used to argue that vertebroplasty is effective are in essence testimonials, rather uncomfortably like the "evidence" being used to promote Dr. Buttar's "transdermal chelation" therapy and other altie treatments. We have no idea whether vertebroplasty actually works, for which patients it does and doesn't work, what the long term results are in terms of durable pain relief, whether it increases the risk of additional fractures, or what the potential complications are. To find that out would require clinical trials, and, barring such trials, we can never be certain whether vertebroplasty or kyphoplasty are anything superior to elaborate placebos. The difference, of course, is that at least vertebroplasty has a biologically and anatomically plausible rationale to lead us to think that it might work. The same most definitely does not apply to Dr. Buttar's treatment. Read this and tell me that this story of a doctor giving a talk about vertebroplasty to a skeptical audience of doctors doesn't sound familiar:
Can you picture this sort of scene in an infomercial for an herbal remedy? I can.
"I could tell by looking at the audience that no one believed me," she said. When she finished, no one even asked questions.
Finally, a woman in back raised her hand. Her father, she told the group, had severe osteoporosis and had fractured a vertebra. The pain was so severe he needed morphine; that made him demented, landing him in a nursing home.
Then he had vertebroplasty. It had a real Lazarus effect, the woman said: the pain disappeared, the narcotics stopped, and her father could go home.
"That was all it took," Dr. Jensen said. "Suddenly, people were asking questions. 'How do we get started?' "
So what's wrong with testimonials? Well, as I like to say, the plural of "anecdote" is not "data," and testimonials usually don't even rise to the level of anecdotes. Testimonials are often highly subjective, and, of course, practitioners can and do pick which testimonials they present. Even in the case of cancer "cure rates," testimonials often mean little because they are given for diseases that surgery alone "cured." (Also, dead patients don't provide good testimonials.) Worse, testimonial-based practice tends to preclude the detailed observation and long-term followup necessary to identify which patients benefit from treatments and which do not, complication types and rates, or long-term results of the treatment. Anecdotes are really good for only one thing, and that's developing hypotheses to test with basic scientific experimentation and then clinical trials. Vertebroplasty may indeed be very effective at pain relief with a low risk of complications. Or it may not. We simply don't have the data to know one way or the other, and now we may never have it. What is odd is that Medicare and insurance companies are usually pretty firm about not paying for an experimental procedure (which is what vertebroplasty should be considered), yet somehow third party payers have been persuaded to pay for this procedure.
Science itself and randomized clinical trials are designed to combat such biases. In preclinical studies, the scientific method uses the careful formulation of hypotheses and testing of those hypotheses with experiments that can either confirm or falsify the hypothesis, experiments that include appropriate control groups to rule out results due to factors other than what the researcher is studying. The scientific method, rigidly adhered to, helps investigators protect themselves from their own tendency to see what they want to see, to correct mistaken results, and recover from stupidity faster. The same is true of randomized clinical trials, which accomplish this in much the same way by using four factors: strict inclusion criteria, so that only patients with the disease being studied are admitted; close measurement of endpoints that are as objectively and reproducibly measured as possible; careful, statistically valid randomization, so that the control group and experimental groups resemble each other as closely as possible; and a placebo control (or a comparison against the standard of care treatment for disease in which a placebo control would be unethical, as in cancer trials). Whenever possible, double blinding is advisable, so that neither the patients nor the doctors know which patient is getting which treatment, so that doctors don't treat patients in either group differently or look more closely for (and therefore find) treatment effects in the experimental group and so that patients don't pick up cues from the doctors' interaction with them. This maximizes objectivity and minimizes bias.
It should also be remembered that one study is not enough, either. Single studies can be wrong one-third or even one-half of the time. I've often joked that, if you look hard enough, you can almost always find a study that supports whatever conclusion about a clinical question that you want to make. Alties don't understand this and will cite one or two carefully selected reports that seem to support their claims, ignoring the many that do not. Illustrating this example is chelation therapy for another disease, namely athersclerotic vascular disease, for which chelationists will cite old papers with inadequate controls that seemed to show a benefit. For example, there was one randomized study in 1990 that appeared to show a benefit for chelation therapy over placebo, but this was a study that looked at only 10 patients. Multiple much larger randomized studies have been done since then, such as this one, and none of them has shown a benefit. Guess which studies alties like to cite? (Hint: It isn't any study newer than 1991 or so.) Hopefully an ongoing NCCAM study will resolve the study once and for all, although there is little doubt in my mind that chelationists will not believe the study if, as is likely, it fails to find a beneficial treatment effect.
What really needs to be considered in clinical decision-making is the totality of data from well-designed clinical studies, something the Cochrane Collaboration tries to facilitate by evaluating the literature concerning important clinical questions and synthesizing it into recommendations and a summary of the quality of available evidence to support their recommendations (or the lack thereof). The bottom line is that evidence-based medicine, far from being a way for "conventional" doctors to assert their superiority over "alternative medicine," is a in actuality means for doctors to try to avoid medical and scientific self-delusion about the effectiveness of a favorite treatment. Just because the medical profession all too often doesn't do a good job of practicing evidence-based medicine is not a reason to throw these scientific standards out in favor of fluffy, feel-good, testimonial-based treatments like Dr. Buttar's or to give advocates of such treatments a pass in terms of supporting their claims. Rather, it is a strong reason to strive to do a better job at improving the science behind our treatments and the scientific rigor of our clinical trials. Evidence-based medicine may not be without problems itself (and perhaps I shall try to address some of its shortcomings in future posts). However, it is far better than the alternative.
Tuesday, August 30, 2005
Last call for submissions to the Skeptics' Circle
Vacation dispatches, part I: Drivers to avoid
Date: Friday, August 12, 2005
Time: Approximately 7 PM
Location, I-75 North in Michigan, approximately 15 miles north of the Ohio border
My wife and I were cruising along, happy that we had finally gotten through the massive traffic jam on the Ohio Turnpike near Toledo, our final destination rapidly drawing nearer, when we noticed it. There, ahead of us, I noticed an RV towing a car. By itself, this was nothing unusual. Lots of people go camping in RVs and tow their car for use as transportation while they are on vacation. I see it all the time on long road trips during the summer.
I wouldn't have even given it another look if it weren't for something odd that I noticed as we gained on the RV. It looked as though the owner had painted some words on the back of the car being towed. It looked as though he or she had used poster paint of the type that teenage kids use to decorate their cars for high school graduation or that young couples use to paint "Just Married" on their car on their wedding day. As I gained on the car, I was able to read the words on the back of the car:
"Car in toe."
I rapidly passed the RV and its towed car. I wanted to stay as far away as possible from the vehicles. I figured that anyone crappy at spelling probably can't read speed limit or road signs very well. I didn't want to be anywhere near them when bad consequences resulted from that.
Monday, August 29, 2005
What I did on my summer vacation: "Proof of "intelligent design" (and an old friend)
Yes, I know I blogged a fair amount while on vacation, my promise to restrain myself notwithstanding. Nonetheless, with the exception of the posts about the traffic wreck that screwed up our trip home and the tragic death of an autistic boy receiving chelation therapy this week, it was mostly fluff or carnival barking. Think of it this way: I enjoy blogging so much that, if I had spent the two weeks at home rather than traveling to various places in the Midwest (and putting over 2,000 miles on my car in the process), I probably would have blogged a lot more than normal because I would have had the time.
One thing about being on vacation is that I had some time to sit back and think about things that I normally take for granted. For example, I spend a fair amount of time poking fun at adherents of "intelligent design" creationism, the claim that there are some biological structures that are too complex to have come about through evolution by natural selection (a concept they term "irreducible complexity") and therefore must have been "designed" by some "intelligence." (Who or what this "intelligence" is, they studiously avoid saying to secular audiences, sometimes going so far as to leave open the possibility of aliens being the force behind evolution, while on the side they admit the truth to fundamentalist Christian audiences. Is the "designer" God? Nahhh. Couldn't be. Wink, wink, nudge, nudge.) Frequently cited examples of biological structures or systems that could not have come about without some "design" include the eye, the bacterial flagellum, and the clotting/complement cascade. Sadly, instead of working to look for actual evidence or to do actual experiments to test their mushy claim (which doesn't even rise to the level of a scientific hypothesis or theory), ID advocates instead use their resources to bring political pressure to bear on scientifically ignorant school boards either to teach the (scientifically nonexistent) controversy, to cast doubt upon how well-supported evolution is as a scientific theory, or to actually teach ID as an "alternative theory" to conventional evolution.
True, ID advocates often richly deserve the mockery that gets sent their way, but (I asked myself) have I ever tried to look at the controversy through their eyes? No! So, I set about to look for evidence of "design" in nature as we tooled about through the Midwest. Anything that looked as though it couldn't have come about through random natural processes alone was what I had in mind. After all, one of the key arguments of ID advocates is that we can recognize "design" in nature when we see it, even though they tend not to be too specific about exactly what criteria can be used to recognize "design." In fact, that High Priest of Intelligent Design, Michael Behe himself, has used Mount Rushmore as an example of how we can "know design when we see it" and distinguish "design" from natural processes. Maybe I could find similar examples if I looked hard enough. Scoff all you want, those of you who point out that such reasoning would lead one to conclude that the Old Man of the Mountain was "intelligently designed"! I would not let my attempt to follow Behe's reasoning be deterred by such annoying intrusions of reality-based thinking! No!
So, at every stop during our last two weeks of travel, from the Detroit area, to Nepessing Lake in Lapeer, to rural Ohio, to Chicago, and all points in between, I looked diligently at every natural object, plant, and creature I saw, searching carefully for evidence of design, evidence that it could not have come about without the intervention of intelligence, without some sort of "design" behind it.
Although I had a fine time on vacation, visiting family, old friends, and favorite places, on the drive home, this failure haunted me. It cast a pall over the return trip. OK, the pall wasn't so much due to my failure to find strong evidence of "design" in nature that depressed me, but rather the thought of facing the end of my vacation and having to confront the massive pile of paperwork, various patient problems, and writing tasks that were no doubt waiting for me back at the lab and office, as well as the fact that I would be on call today. But stay with me here for the sake of the story.
On our second day back, after having taken a day to recover from the 11 hour drive, my wife and I were trying to get our neglected yard into some semblance of decent shape. Fortunately, the brown grass hadn't really grown much, given the lack of rain and the fairly hot weather that had predominated the first week we were gone, which made the task a bit easier. I was about to head back inside for a moment, when my wife came up to me. She handed me something.
"Hey, check it out. This looks pretty cool," she said.
It was a rock. but not just any rock. I stared, dumbfounded. "Do you realize what this is?" I said. I was practically giddy with joy, not unlike Gollum at Mount Doom after he bit the One Ring from Frodo's hand and danced his way to the edge of the precipice beyond which lay the fiery lava of the Crack of Doom. (It was all I could do to keep myself from hissing, "My Precioussss!") "It's what I've been looking for all along!"
It was this:
Could it be? I looked it over at different angles:
I thought. I had been looking all over the Midwest for something like this, and there it was, right in my own back yard, the proof I had been looking for! Look at the face! Surely this could not have been the product of random natural forces. Surely this was evidence of intelligent design in nature! And if there could be "design" in geology to produce a stone like this, a stone that looks like a face, then what about the evolutoin of life? I made plans to send photos of this find to William Dembski and Michael Behe. Surely they would be very interested!
My giddiness at my discovery subsided, and my wife stopped looking at me as though I had lost my mind. It was a difficult feat to accomplish for her. I then took an even closer look at the rock.
And a realization dawned on me.
It wasn't just any face. There was something familiar about that face. Something it reminded me of. But what? I knew it! I immediately went to work. First, a little Magic Marker:
Do you see where I'm going yet? No? (Admittedly, my attempt at artwork didn't turn out too good.) How about a little Photoshop? (I'm not too good at Photoshop, either, but this looks a bit more convincing.)
Do you see it now? Do you?
Yes! It's our old friend the Hitler zombie! Not only had I discovered strong evidence of "design" in nature, but I had discovered who the "intelligent designer" must be! None other than the Hitler zombie, that undead eater of politicians' brains and lover of overblown analogies to Hitler, the Nazi, or the Holocaust to be used to slime one's political opponents with, of course! I know I promised to try to keep the Hitler zombie in his crypt for a while, but this was just too big a coincidence!
So why not the Hitler zombie? It makes just as much sense as any other candidates for the title of the "intelligent designer" of "intelligent design creationism," including even my personal favorite up until this discovery, the Flying Spaghetti Monster. The rotting Führer is even a deliciously appropriate candidate, given how Michael Ruse himself has fallen victim to the monster's hunger for brains, himself bringing up bad Nazi analogies while apparently endorsing the mistaken notion that Darwinian evolution implies atheism.
What, you say? You can't believe that a fictional device created to make fun of people who make exaggerated and inappropriate analogies to the Nazis could be the "intelligent designer"? If you believe William Dembski when he says that the "designer" doesn't necessarily have to be God, then why couldn't the "designer" be the Hitler zombie, space aliens, or even the Flying Spaghetti Monster? If "intelligent design" makes no assumptions about who or what the "designer" is, as many of its adherents claim while trying to argue that it is a scientific, not a religious, idea, then the "designer" could be anything.
And my evidence that the "designer" was the Hitler zombie is just as convincing as the evidence presented by any advocate of "intelligent design." Perhaps it's even more so, given that I actually have a piece of physical evidence. That is better than ID advocates can produce.
Sunday, August 28, 2005
The NYT fisks "intelligent design"
The focus on intelligent design has, paradoxically, obscured something else: genuine scientific controversies about evolution that abound. In just about every field there are challenges to one established theory or another. The legitimate way to stir up such a storm is to come up with an alternative theory that makes a prediction that is crisply denied by the reigning theory - but that turns out to be true, or that explains something that has been baffling defenders of the status quo, or that unifies two distant theories at the cost of some element of the currently accepted view.
To date, the proponents of intelligent design have not produced anything like that. No experiments with results that challenge any mainstream biological understanding. No observations from the fossil record or genomics or biogeography or comparative anatomy that undermine standard evolutionary thinking.
Yes. "Intelligent design" advocates try to convince the lay person, who usually doesn't know much about evolution or even how science operates, that there is a genuine debate when there is not, at least not scientifically speaking (politically speaking, of course, is another matter). Dennett also nails it as far as why ID is not taken seriously by scientists:Instead, the proponents of intelligent design use a ploy that works something like this. First you misuse or misdescribe some scientist's work. Then you get an angry rebuttal. Then, instead of dealing forthrightly with the charges leveled, you cite the rebuttal as evidence that there is a "controversy" to teach.
Note that the trick is content-free. You can use it on any topic. "Smith's work in geology supports my argument that the earth is flat," you say, misrepresenting Smith's work. When Smith responds with a denunciation of your misuse of her work, you respond, saying something like: "See what a controversy we have here? Professor Smith and I are locked in a titanic scientific debate. We should teach the controversy in the classrooms." And here is the delicious part: you can often exploit the very technicality of the issues to your own advantage, counting on most of us to miss the point in all the difficult details.
To formulate a competing hypothesis, you have to get down in the trenches and offer details that have testable implications. So far, intelligent design proponents have conveniently sidestepped that requirement, claiming that they have no specifics in mind about who or what the intelligent designer might be.
And what makes ID any more worthy than any other concept that has not yet reached the science classroom? Nothing:
It's worth pointing out that there are plenty of substantive scientific controversies in biology that are not yet in the textbooks or the classrooms. The scientific participants in these arguments vie for acceptance among the relevant expert communities in peer-reviewed journals, and the writers and editors of textbooks grapple with judgments about which findings have risen to the level of acceptance - not yet truth - to make them worth serious consideration by undergraduates and high school students.They won't, even though, as Dennett points out:
SO get in line, intelligent designers. Get in line behind the hypothesis that life started on Mars and was blown here by a cosmic impact. Get in line behind the aquatic ape hypothesis, the gestural origin of language hypothesis and the theory that singing came before language, to mention just a few of the enticing hypotheses that are actively defended but still insufficiently supported by hard facts.
If intelligent design were a scientific idea whose time had come, young scientists would be dashing around their labs, vying to win the Nobel Prizes that surely are in store for anybody who can overturn any significant proposition of contemporary evolutionary biology.
Yeah, and monkeys might fly out of my butt.
I'm probably going straight to hell for posting this...
Saturday, August 27, 2005
Kirby tries to cover his posterior
I tried not to write anything during this last weekend of my vacation, but then I became aware of David Kirby's CYA response to the tragic death of a boy during chelation therapy for his autism last week:
But even as the grieving immigrant mother makes funeral arrangements for her beloved boy, opponents of the theory that drew the family to America (the theory that mercury triggers autism, and removing it through chelation may improve symptoms) are holding his death up as proof that the idea is bogus. They claim that the use of chelation to treat autism is foolishly dangerous, and should be shut down at once.
Some people have come perilously close to exploiting this tragedy to further their own political or personal agendas. Some blame the boy’s death on his mother, who has been labeled as reckless and “desperate.” Others blame the Pennsylvania doctor -- and any autism doctor willing to try chelation (the use of certain chemicals to remove heavy metals from the body) – for the tragedy. Some fault me, for writing a book that dared to include the topic of chelation and autism within its pages.
Give me a freakin' break! It's way more than "possible" that the chelation treatment killed the boy. It's highly likely. Otherwise healthy five year olds don't just drop dead of cardiac arrest for no apparent reason, particularly while sitting in a doctor's office. It happens, but it's extremely rare. For this boy to have just happened to have droppped dead of a cardiac arrest while he was receiving a therapy that can lower serum calcium and magnesium levels to levels low enough to cause cardiac arrest is one a hell of a coincidence. Unfortunately, the autopsy results may never conclusively show that chelation killed the boy. Electrolyte abnormalities leading to sudden cardiac arrest (the most likely cause of death in this case) can be hard to pin down in an autopsy. If the autopsy fails to find conclusive evidence for this cause of death, it will allow the chelation advocates wiggle room to claim "reasonable doubt" over whether their pet treatment killed the boy.First of all, only an autopsy will reveal the actual cause of death, and I think it is prudent to wait before jumping to any conclusions about the general safety of chelation and autism. That said, the boy did die while undergoing the procedure, and it’s possible the controversial treatment is what killed him.
Worse, Kirby is now trying to blame the scientific community for Abubakar's death, rather than where the blame should be placed if chelation killed him, at the hands of the doctor who administered the chelation for a condition for which it is not indicated and those who support this quackery. (At least he properly asks the question why this doctor was using intravenous EDTA, rather than other, safer methods.)
He goes on:
Just think, if the government had listened to the very IOM report it commissioned back in 2001, we might know a lot more about chelation and autism than we know today. If clinical trials had gotten underway then, we would know with certainty whether chelation could heal, or kill.
Finally, Kirby says:
If hard scientific proof had been uncovered that chelation was 100-percent worthless in the treatment of autism, no parent or doctor would still be pursuing the therapy today. If evidence had surfaced in clinical trials that children could be harmed or even killed by chelation, no one would be using it today. The doctor in Pennsylvania would have halted chelation therapy long ago, and this poor grieving family would never have crossed the ocean from the UK in pursuit of its false promise.How reasonable-sounding. How charmingly naïve. (I also have to wonder if Kirby is aware that it's pretty rare for a clinical study to provide 100% evidence of any conclusion. Medicine deals with probabilities, and those probabilities only very rarely turn out to be 100%.) Kirby clearly doesn't have much experience with "alternative medicine." Studies don't matter to alties, and that goes triple for conditions for which conventional medicine does not yet have highly effective treatments. Study after study showed that Laetrile didn't help advanced (or even early stage) cancer back in the 1970's and early 1980's. Altie practitioners still use it, and patients still seek it. Recent studies have shown that homeopathy does no better than placebo for a variety of conditions, but do you think that homeopaths will stop using it or people stop seeking it? Studies have come out showing that echinicea doesn't help common colds, but I wouldn't sell my stock in companies selling the herb if I were you. Study after study have shown that chelation therapy does no better than placebo for coronary and peripheral vascular disease. It's still being used, and NCCAM has even funded a large study to see if it works, not because of the science so much but because of its popularity. If the NCCAM study fails to show a benefit for chelation over placebo, you can bet that alties will dismiss the study and that chelation will continue to be used for heart disease. If a study ever conclusively shows that chelation does no good for autism, you can further bet that it won't be believed by the mercury/autism advocates and that chelation will continue. None of this means that we physicians and scientists shouldn't do the studies, of course. That's how science progresses and ineffective treatments are slowly weeded out of our medical armamentarium. However, Kirby's faith that such studies can cause such a rapid halt to the use of dubious treatments is almost touching in its naïveté.
This comment by Kirby, however, is not so touching or naïve:
But what if the opposite were true? What if the “rigorous science” recommended by the IOM had yielded proof that chelation can indeed help some kids -- provided that it’s done with the safest agents, at the safest doses, and through the safest routes of administration (not to mention in combination with other therapies)?
Either way, if America had done its scientific homework, as recommended by its top science professors, Abubakar might still be alive today.
Sadly, it appears that Kirby is more interested in spinning this tragedy to decrease criticism of him and the mercury/autism hypothesis that he's become so enamored of than in critically looking at the claims that underlie the use of this dubious "therapy" for autism.
ADDENDUM: Peter Bowditch weighs in on the death of Abubakar Tariq Nadama. Stand back. He's really pissed off.
ADDENDUM #2: More information here and here.
ADDENDUM #3: On January 5, 2006, the coroner announced the results of the autopsy, concluding that it was indeed EDTA chelation that killed Tariq.
Friday, August 26, 2005
I want one of these!
Check it out, and while you're at it, there's nothing like this logo as well, which is a bit less abstract and more classically artistic.
Sadly, it was only a matter of time: An autistic boy dies during chelation therapy
However, this story, e-mailed to me by more than one person, compelled me to do change my plan:
An update to this story can be found here. My heart goes out to these parents, who no doubt thought that they were doing something positive for their child. Unfortunately for Abubakar and them, they found out in the hardest way possible that they were not.A 5-year-old autistic boy died Tuesday in a Butler County doctor's office while undergoing an increasingly popular though controversial medical treatment touted by some as a cure for the lifelong neurological and developmental disorder.
Abubakar Tariq Nadama died while receiving chelation therapy, an intravenous injection of a synthetic amino acid that latches onto heavy metals and is then passed in the urine.
State police at Butler are investigating Nadama's death, which occurred at about 10:50 a.m. Tuesday in the office of Dr. Roy Eugene Kerry in Portersville.
Authorities said Kerry's office reported that the child was receiving an IV treatment for lead poisoning when he went into cardiac arrest.
Now, I realize that I'm a couple of days late commenting on this topic. I even wondered whether I have anything left to say that hasn't already been said. Indeed, Prometheus, Kev (1, 2, 3), Autism Diva, and numerous others have already commented ably on the story. Given that I've written before about chelation therapy as used to treat atherosclerotic heart and peripheral vascular disease in adults, how randomized double-blind studies have shown it to be no better a treatment than placebo, and how there is not a single study showing that it decreases the size of atherosclerotic plaques or improves blood flow through diseased vessels, I thought I should add my 2 cents.
Sadly, since learning of chelation therapy being used to "treat" autistic children, I've feared that it was only a matter of time before a child died during therapy, and now it has happened. It was inevitable, given that more and more parents of autistics, desperate to do anything to help their children, are opting for this unproven and ineffective therapy. Unfortunately, they usually do so on the basis of incomplete or erroneous information promoted by various organizations like Generation Rescue, whose literature states quite bluntly that "childhood neurological disorders such as autism, Asperger's, ADHD/ADD, speech delay, sensory integration disorder, and many other developmental delays are all misdiagnoses for mercury poisoning" (which also makes it puzzling why it is being reported that Dr. Kerry was treating the child for "lead poisoning," given that even the thimerosal/autism advocates don't generally argue that lead causes autism). If you accept that premise that mercury exposure during infancy causes autism, then chelation therapy sounds reasonable. However, even if that premise were true, one has to remember that brain damage is usually permanent and it is hard to propose a plausible biological mechanism by which removing mercury months or even years later would improve neuronal function.
The purpose of chelation is to bind ("chelate") heavy metals with a molecule that allows them to be secreted more rapidly in the urine. EDTA is fairly avid at chelating calcium ions, and that was the original rationale for the use of EDTA in "dissolving" calcified atherosclerotic plaques by "leeching" the calcium out of them. Given that children tend to develop electrolyte imbalances more easily than adults and to be more sensitive to them, utilizing a therapy designed to chelate electrolytes is not something to be undertaken lightly in children. What most likely happened in Abubakar's case is that he suffered a fatal arrhythmia due to hypocalcemia brought on by chelation of the calcium ions in his bloodstream. It may be possible that he died of another cause and that the timing of his death was merely a coincidence, but that would have to be a hell of a coincidence, given how rare it is for an otherwise healthy 5 year old boy to drop dead suddenly from a cardiac arrest.
I'm not going to get into the issue of whether or not mercury in the thimerosal used to preserve childhood vaccines has a role in the pathogenesis of autism yet again. My position on this issue should be abundantly clear to anyone who's read my blog regularly over the last few months, and, if it isn't, you can always check out some of my older articles (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16). Suffice it to say that the preponderance of evidence presently existing does not support a role for exposure to mercury as a major cause of autism in the vast majority of cases. Mercury may be a neurotoxin, but overwhelming evidence fails to support a role for it in the pathogenesis of autism. Given that the mercury hypothesis represents a biologically implausible explanation for the pathogenesis of autism, any therapy based on "removing" mercury is likely doomed from the start to be ineffective, and any doctor who administers such a treatment for autism (in this case, Dr. Roy Eugene Kerry) should be considered guilty of negligence at best and malpractice at worst.
For the sake of argument however, let's play Devil's advocate for a moment and discuss this tragic case operating under the assumption that mercury does play a major role in the pathogenesis of autism. Even in that case, if the child's death can be shown to be due to electrolyte imbalances caused by chelation therapy, this doctor still should be considered guilty of unethical conduct at best and malpractice at worst. Why? First, as has been pointed out, in physiologic conditions in the body EDTA is a relatively weak chelator of mercury ions compared to the -SH group-containing proteins in the body's tissues. This means that, at equilibrium, mercury ions will remain preferentially bound to -SH group-containing tissue proteins in the body and EDTA will not be effective at competing for binding mercury. Effective mercury chelators contain -SH groups and have higher affinity for mercury than body tissues. Examples include compounds such as 2,3-dimercaptosuccinic acid (DMSA) and 2,3-dimercaptopropane-1-sulfonate (DMPS). In comparison, EDTA is a poor choice as a therapeutic agent to remove mercury from the body, even though in the test tube it binds mercury more avidly than calcium. (Perhaps this is one reason why Dr. Kerry was reported to have claimed to investigators that he was treating the child for "lead poisoning," for which EDTA is approved). In contrast, EDTA is a strong chelator of calcium and magnesium ions, which is why dangerous hypocalcemia is a risk when using EDTA intravenously. Similarly, EDTA chelation therapy can also lead to kidney failure, anticoagulation resulting in bleeding, vasculitis, autoimmune reactions, and depletion of serum zinc ions (which EDTA binds more strongly than calcium or magnesium), leading to compromise of the immune system. Anyone administering chelation therapy in an office not connected to a hospital needs to be prepared to deal with immediately life-threatening complications like cardiac arrhythmias right then and there, because there won't be time to get the patient to a hospital in time to save his life if such complications ensue. At minimum, this would require a fully stocked crash cart and personnel well trained in ACLS and (if treating children) PALS. If Dr. Kerry did not have these resources available, plus cardiac monitoring equipment, it would have been quite reckless of him to be administering intravenous chelation therapy in his office.
Because there are no good studies that demonstrate its efficacy in treating autism, chelation therapy for this purpose should be considered at best an experimental therapy (at worst it is a completely ineffective therapy). As such, chelation is not and cannot be considered the standard of care. Also, it is generally considered dubious at best and unethical or even malpractice at worst to administer unproven experimental therapies outside the context of properly designed and conducted clinical trials, which brings up the issue of informed consent. Did Dr. Kerry tell the parents the truth of the situation, which is that there is no evidence from even minimally controlled trials that chelation therapy does any good whatsoever for autism and that, in addition, intravenous chelation therapy has the risks of dangerous electrolyte imbalances, sometimes fatal cardiac arrhythmias, kidney failure, etc.? It is impossible to say with the information available, but my guess is that, like most altie doctors, Dr. Kerry probably played up the perceived "benefits" of chelation therapy for autism on the basis of almost zero supporting scientific or clinical data and understated its risks. If there is a lawsuit (as there should be if chelation did kill Abubakar), this issue will become very important. Another issue that will become important is that Dr. Kerry is apparently an otolaryngologist, not a pediatrician or a pediatric psychiatrist. What's an Ear, Nose, and Throat doctor who also claims to specialize in allergies doing administering chelation therapy for autism? Where and how did he learn to administer it safely? What are his qualifications to be treating "lead poisoning" or autism? Or did he just start doing it on his own? (I note that the University of Pittsburgh has apparently removed Dr. Kerry from its website; however, the cached page can be found here.)
But, say chelation advocates, no one has died from chelation therapy in decades until now. Well, that's not entirely true. Nonetheless, reply chelation advocates, the risk of death is very small when chelation is properly administered. Maybe so, but it still comes down to a risk-benefit ratio. In the case of serious and often fatal diseases such as cancer, we accept a higher level of risk of treatment-related complications, such as immunosuppression from chemotherapy, and a lower chance of success, because the consequence of no treatment is death. In contrast, in the case of a condition such as autism, where quite a few children improve over time to lead normal or near-normal lives without such interventions as chelation therapy, even a very small risk of death is unacceptable. This is even more true when the treatment risk being taken is due to a therapy whose efficacy is dubious at best, that is likely completely ineffective, and whose premise is not even based on sound science, as is the case for chelation therapy for autism.
Before I leave you temporarily for the last weekend of my vacation, please consider two things. First, one of the hallmarks of quackery is seen when a single therapy is touted as the remedy for a wide variety of diseases of unrelated pathogenesis. For anything other than documented cases of heavy metal or iron poisoning, chelation therapy definitely fits that description. Indeed, chelation is touted as a treatment for atherosclerotic coronary artery and peripheral vascular disease, autism, Alzheimer's disease, kidney stones, diabetes, osteoporosis, skin ulcers, multiple sclerosis, psoriasis, muscular dystrophy, arthritis, poor memory, and even cancer. Ask yourself: How can one simple treatment possibly work for such a wide variety of diseases of vastly differing causes? Is it reasonable to believe that it can? No, it is not. Second, in these cases the question comes up about whether the doctor administering the therapy is a huckster. I have no information on which to base an opinion in this case. However, in most cases I have encountered, the doctor is usually a true believer in the quack therapy he or she is advocating. More than likely, Dr. Kerry genuinely believes in chelation therapy for autism, regardless of the paucity of evidence that mercury causes autism or that chelation therapy makes autistics more "normal." It's easy to lose one's objectivity as a physician when one deals with conditions or diseases that do not have good "conventional" treatments. As has been pointed out by Gregory L. Smith, the very reason medicine has come to insist on evidence-based approaches to evaluating treatments through randomized clinical trials is not because doctors and scientists are wiser than the general population, but rather because they are human and can be just as easily deceived (or just as easily deceive themselves) into believing in a treatment they desperately want to be efficacious. Even so, that does not excuse Dr. Kerry, nor should it stop the State of Pennsylvania from taking immediate action to strip him of his medical license or the parents from suing him for malpractice if the autopsy results demonstrate that Abubakar's death was indeed caused by chelation therapy.
Sadly, such an outcome seems unlikely at present:
The boy's mother, Marwa Nadama, said she did not blame the therapy, but was waiting for results of an autopsy.
ADDENDUM: A followup post can be found here.
ADDENDUM #2: On January 5, 2006, the autopsy results were announced, and the coroner concluded that EDTA chelation killed Tariq.
Comment spam: a solution (I hope)
As a temporary measure until I manage to get off my duff and switch to a different blogging platform, I've turned on Word Verification on Blogger, something I only just noticed today. Word Verfication means you will have to recognize and type a word before you post your comment. Sorry for the inconvenience of the added step to post a comment, but I got tired of wasting my precious vacation Internet access time deleting comment spams. Blame the comment spammers, who, like e-mail spammers, are the utter scum of the Internet.
We'll see how it works.
Thursday, August 25, 2005
Calling all skeptics!
As always, I'm still looking for hosts for the Skeptics' Circle. E-mail me at firstname.lastname@example.org if you're interested in hosting a meeting!
Nooooo! Not you too, McCain!
Nooooooo! Say it ain't so!
Via Pharyngula, I learn that the only remaining reasonable Republican Presidential hopeful (leaving aside his advocacy of campaign finance reform that restricts free speech around the time of elections, something I've always disagreed with him about), John McCain, has sold his soul to the creationists:
On Tuesday, though, he sided with the president on two issues that have made headlines recently: teaching intelligent design in schools and Cindy Sheehan, the grieving mother who has come to personify the anti-war movement.
McCain told the Star that, like Bush, he believes "all points of view" should be available to students studying the origins of mankind.
The theory of intelligent design says life is too complex to have developed through evolution, and that a higher power must have had a hand in guiding it.
Possible explanations for McCain's statement include (1) that McCain really believes that "intelligent design" creationism is worthy of being taught alongside evolution as an "alternative explanation"; (2) that he doesn't have enough knowledge to form an opinion on the issue and so took the easy course of endorsing the mushy platitude of teaching "all points of view" in the schools; or (3) that he doesn't believe that ID is sufficiently supported to be taught in science class but is willing to go against that belief in order to pander to the fundamentalists that dominate the Republican Party. None of these explanations make McCain look good. #1 and #2 imply an ignorance of biology and #3 implies a willingness to go against his beliefs in search of votes.
Three years until the 2008 election, and I'm already screwed as far as picking a candidate.
Rant ended. Time to go back to enjoying the last few days of my vacation.
Tangled Bank XXXV
Tangled Bank XXXV has been posted at Cognitive Daily, and, as usual, there's lots of excellent science blogging there, which you should check out forthwith!
As an aside, though, I hate to say it, but I have to quibble a little bit with the way Dave Munger has handled it this time around. He's decided to try to remain completely apolitical, separating the posts that have to do with "intelligent design" creationism and other posts that deal more with the politics of science than with pure science from the main carnival and instead posting them on his personal blog, Word Munger. I can understand his sentiment, which can be summed up the way PZ put it: "You may like your science untainted by politics or the slime of creationism." I can also fully agree for scientific issues that are less well-settled scientifically than the evolution/creationism debate. Although I sympathize with such a view, unfortunately the "slime of creationism" is unavoidable these days, thanks to the fundamentalists who continue to push it against all scientific evidence for evolution. Also, evolution is such a well-founded and well-established theory, that this truly is a debate of scientific fact against pseudoscience. If fundamentalists and politicians didn't keep pushing it, the antiscience that is ID would have withered long ago. Science blogs represent one force that can be harnessed to slap down this invasion of antiscience in the classroom.
Tuesday, August 23, 2005
Vacation carnival barking, week 2
It figures. It's just my luck to get deluged with comment spam during the very period of time when I'm least able to deal with it, mainly because I'm away on vacation and have limited and sporadic Internet access. Maybe I shouldn't have blogged about my weekend encounters with Derek Jeter yesterday, as even the mere mention of the vile Yankees seemed to attract all sorts of scummy comment spammers to this blog, necessitating my wasting precious vacation and Internet time deleting them.
Don't worry, Orac-philes. I'll begin to deal with this problem when I get back home late this week. In the meantime, I only have enough dialup Internet access time for a little carnival barking today. Yesterday, RINO Sightings was posted at The World According to Nick, and today Grand Rounds XLVIII was posted by Dr. Kevin Pho at Straightfromthedoc. Enjoy the bloggy goodness.
And fear not! In less than a week, Orac will be back to his usual medical, scientific, and skeptical topics!
Monday, August 22, 2005
Dispatches from the road, part VI: Vacation purity contaminated
But all was not entirely well. On Friday morning after getting up, I looked out the window to my hotel, the Westin on Michigan Avenue just north of the Hancock Tower. There, as usual, was a lovely view of Michigan Avenue facing south and the base of the Hancock Tower:
Then, I panned to the left and down, to E. Delaware Place, right across the street. This is what I saw:
Odd. What was with the guy in the Yankees jersey? I then remembered that the Yankees were in town to play the White Sox for the weekend, and took no further notice of it, other than taking a picture. (A premonition, perhaps?) Perhaps even then I realized this might mean something. (And it did, but more on that later.) I even wondered if I could get tickets for one of the games, as the series was expected to be a good one. When I lived in Chicago, I used to like to go to Comiskey Park--I refuse to call it by its abominable new name, U.S. Cellular Field, as all Chicago baseball fans, even Cubs fans, should--when the Indians came to town. I went downstairs to the lobby to get some coffee and to use the free wireless Internet access to check my e-mail, generally farting around and killing some time, while my wife slept in a little longer. About an hour later, I came upstairs. Yankee boy was still there in the same spot on Delaware Place.
This is kind of strange, I thought. An hour later, when my wife and I left for brunch, Yankee boy was still there.
Odder still, Yankee boy (or someone who looked eerily like him) was back again on Saturday morning in the very same place, just in a different set of Yankees gear. I observed him while I was sitting in the lobby, soaking in the great feeling of being back in Chicago again and blasting Bill Frist for advocating the teaching of “intelligent design” in classrooms. Weird, I thought. Then a kid in a Yankees hat walked by. And then another. And another. Then a couple of giggly teenage girls in full Yankees regalia. What was going on here in Chicago? I thought I had managed to escape the Yankees and their insufferable fans by heading more than 800 miles west, to the heartland.
I was wrong. But this large number of Yankee fans seemed odd even for a weekend with the Yankees in town to play the Sox. Having lived in Chicago until six years ago, I knew there weren't enough Yankees fans there for a random sampling of them to produce this large a gathering at the Westin on Michigan Avenue hanging out for so long. I suppose it was possible that they had traveled to Chicago just to see the Yankees, but even accounting for that it seemed like an awful lot of Yankees fans. Something was definitely up.
A brief word of explanation for non-baseball fans and my non-U.S. readers is in order about why this disturbed me. If you're a baseball fan and grew up in an American League city east of the Mississippi river as I did, you must hate the Yankees. It's the law (of baseball, anyway). I grew up in Detroit, watched the Tigers take the 1968 and 1984 World Series; later lived in Cleveland during the years when the Indians stopped being a doormat (although they still lost the 1997 World Series in a typical heart-breaking fashion); and then lived in Chicago long enough to start to like the White Sox and Cubs. (I admit I was more partial to the Cubs, mainly due to Wrigley Field). It's part of my DNA to detest the Yankees and particularly their arrogant fans. True, I don't hate the Yankees nearly as much as a Boston Red Sox fan would. No non-Red Sox fan does. I just don't have that raging, burning hatred that only a century of stark rivalry and the curse of the Bambino can produce. But I hate them enough. In fact, I hate them even more now that I live within media range of the Barad-Dur of baseball, Yankee Stadium, and the annoying triumphalism and sense of entitledness that Yankees fans routinely express so colorfully.
So, there I was, wondering why there were so many Yankee fans milling about in the lobby of my hotel, when I noticed a group of them gathered around a tall young man, who appeared to be signing autographs. I didn't recognize him at all, but my wireless Internet connection and a hunch allowed me to determine quickly that this is who he was:
Argggghhh! The rookie second baseman of the New York Yankees, Robinson Cano!
The New York Yankees must be staying at my hotel! It all became clear. Yankee boy and the numerous Yankees fans suddenly made sense! My mind reeled.Then I thought back to a time two or three years ago when I stayed at the Westin for a meeting and ran into several Florida Marlin players in the elevator. The Westin must be the hotel in Chicago where Major League Baseball teams stay when they are in town to play the Sox or the Cubs. And now the dreaded Dark Lords of Baseball themselves were at the Westin, spending the night under the very same roof my that wife and I were! What to do? I decided it was time to head upstairs to the room and tell my wife about this development. I stood and waited at the elevator. It opened.
And this greeted me:
Just kidding. It was actually this man:
There he was, getting off the elevator, the Prince of Baseball Darkness himself, the very personification of the hated Yankees, their team captain and longtime shortstop Derek Jeter! There he was, the most prominent Yankee, more so than other Yankees stars because he was a career-long Yankee, not a free agent who just happened to join the Yankees, like Alex Rodriguez or Randy Johnson.
I stood there stunned for a moment. Before I could react (or pull out my camera phone for a quick picture), Jeter quickly walked past me, heading to the team bus to go to the stadium. It had happened so suddenly that I almost hadn't recognized him. A chubby guy in a Yankees cap pointed and yelled, and instantly a swarm of Yankee sycophants descended upon Jeter, buzzing like gnats, and the moment passed. I thought momentarily about following to see what other Yankees I could see, but decided that enjoying a coffee and telling my wife about what was going on was more important. As the elevator rose, two teenage girls who had also seen Jeter get off the elevator squealed back and forth about what they had just seen and literally jumped up and down with excitement. With difficulty, I held back the urge to vomit.
As annoyed as I was by the infiltration of our Chicago getaway by the hated enemies of all that is good and pure in baseball (God only knows how I would have reacted if I had seen the Dark Lord himself, George Sauron-brenner--I mean Steinbrenner--on that elevator), our Chicago sojourn was quite enjoyable. During our three days there, we hit the Art Institute of Chicago, Millenium Park to see the "Bean" (which, unfortunately, was covered by a huge tent to protect it as it was being polished) and the Crown Fountain, and other places. We did some shopping up at W. Belmont and N. Halstead (Belmont Army Surplus is a great place, by the way, having the best selection of Doc Martens shoes I've found anywhere). Saturday night, we headed to the Kinzie Chophouse for a fine meal (and a chance to regale our friends, even more inveterate Yankee-haters than we, with our tale and commiserate with them about the horrific performance of the White Sox during the first two games of the series) before heading back to the hotel.
Getting back to the hotel around 10 PM, we found a swarm of activity. This is where we discovered that there was at least one advantage to having the Yankees stay at our hotel: sheer entertainment value and people watching (not to mention blog fodder). Instead of heading back to our room, we just sat across the street on Delaware Place and watched the activity. A swarm of Yankees fans were hovering around the door, hoping to catch a glimpse of the players either coming or going from the hotel. Around 10:15 PM, a black town car with very chrome, very shiny, very large Pimp My Ride-style wheels pulled up, and Joe Torre got out, a couple of doormen trying to hold back the crowd as he fought his way back into the hotel. A player who looked like Alex Rodriguez (I'm not entirely sure it was him) got into a cab, and a bunch of fans actually chased the cab on foot, including two who got into a car to continue the chase. Finally, the Chicago Police arrived to control the situation, and the amusement more or less ended. I thought that would be the end of our Yankees experience.
Sunday morning, we packed up and were getting ready to check out. I was a little annoyed because we were running a little late for our date to meet my sister, her husband, my cousin, and my wife's friend for brunch. I was even more annoyed when we got on the elevator and, instead of going down to the lobby, it went up to the 16th floor, cursing myself for not having noticed that the elevator we were getting in was going up. The door on the 16th floor opened, and the people riding up with us got out.
The elevator began to descend.
And stopped on the 15th floor. The door opened. And who should be standing there waiting for the elevator but:
Argghhh! It was Jeter again, perfectly coiffed and impeccably groomed wearing a brown designer suit, an attractive woman in an expensive-appearing dress accompanying him. I wondered if she was a starlet, but didn't recognize her. (NOTE: My wife dissents about this part of the story, having gotten a better look at the woman than I did; she doesn't think the woman was with Jeter, but rather just happened to get on the elevator at the same time. She also estimated the woman to be in her mid-30's, way older than Jeter's usual proclivities when it comes to dating starlets. Sadly, my wife's likely more accurate account of the actual situation makes for a duller story than my version, which, had I had the presence of mind to snap a picture, might have gotten me a nod from the tabloids. Oh well. Maybe I need to get my glasses prescription adjusted.) They stepped on the elevator. We rode down in complete silence, my wife, myself, Derek Jeter, the woman, and our luggage. My wife and I tried not to be too obvious as we smirked at each other. Fifteen floors later, the elevator door opened, and Jeter and the woman stepped out, followed by my wife and me. We followed Jeter because we had to go the same direction anyway to get to the parking garage to pick up our car. We saw Jeter head out to the bus and watched with amusement as a mob of fans waiting behind a velvet rope accosted him. He started signing autographs, then got in the bus.
Friends, even as the proprietor of the Skeptics Circle, and a die-hard advocate of rationalism, science, and skepticism in all things, at times like this I have to wonder if there is such a thing as fate. Consider: Of all the weekends we could have taken a trip to Chicago this summer, we chose this one, when the Yankees just happened to be in town. Of all the hotels we could have stayed at in downtown Chicago, we ended up at the Westin, where the Yankees were staying. (Our other favorite downtown hotel, the Sheraton, happened to be booked solid because of its proximity to the lake and because this was the weekend of the Air and Water Show. Coincidence?) Of all the times Saturday morning I could have chosen to head back up to our hotel room, I chose the exact time when Jeter was coming down the very same elevator that I needed to use. But the capper is this: On Sunday morning, if we hadn't both been running late and gotten on the wrong elevator, we would never have gotten this "opportunity" to share 20 seconds in an elevator with Derek Jeter. It wasn't enough for me to run into Jeter once this weekend. I had to run into him twice, the second time much longer than the first! Spooky, eh?
Don't worry, though. I'm not going soft as a skeptic. I still don't think there is such a thing as fate, even when curious incidents of this sort seem to suggest that there might be, taunting me twice with the personification of the hated Yankees. It's all just coincidence. But if fate does actually exist in any form, particularly in baseball, I'm now convinced of one thing.
Fate was laughing its ass off at me this weekend.