The Rest of the Story

PTSD May Persist in Combat Veterans for Decades

2006-04-23T02:00:00.000-04:00

The April 2006 edition of the American Journal of Psychiatry has an article about the longitudinal course of Posttraumatic Stress Disorder. The abstract is here; the full version is here, but requires a subscription. Additionally, there is a Medscape article based upon the original paper, here (free registration required). From the Medscape synopsis:

The study was done with Israeli soldiers who served in the 1982 war with Lebanon. The results are at least vaguely consistent with my own observations of soldiers in the US who served in Viet Nam, but one would need to be cautious about generalizing the results.
The Israeli investigators compared PTSD symptoms exhibited at 1, 2, 3 and 20 years after the war among 131 veterans diagnosed with combat stress reaction and 83 soldiers in the same units who did not develop an acute stress reaction. The researchers note that the two groups did not differ significantly in their premilitary screening of physical and psychiatric symptoms. [...]

At year 1, subjects in the combat stress reaction group had a 10.57-fold higher odds of meeting PTSD criteria than the comparison subjects. At years 2, 3 and 20, the odds were reduced to 5.15, 5.41, and 3.09, respectively.

Those with a combat stress reaction also had significantly more PTSD symptoms at all four time points.

The authors observed that 19.8% of the combat stress reaction group and 61.4% of the comparison group did not meet PTSD criteria at any of the four tests. However, members of the comparison group were more vulnerable to delayed onset.

What they did was to divide the soldiers into two groups: those who had shown "combat stress reaction" immediately during or shortly after combat, and those who did not have obvious symptoms in the immediate aftermath of combat. Note that they used DSM-III criteria, since the DSM-IV did not exist in the early '80s. If they had used the DSM-IV, they probably would have used the term Acute Stress Disorder. (Acute Stress Disorder was not defined in DSM-III.)

There are a few key points here. One is that, in this study, they did not find premorbid psychological factors that were associated with the subsequent development of combat stress reaction. Another is the unsurprising observation, that the persons who had the most symptoms early on, also had more symptoms over time.

Perhaps the more interesting finding is that the soldiers who did not have combat stress reaction were more susceptible to delayed onset of PTSD. That is, some soldiers deal with the stress well on an acute basis, but then are more vulnerable to have problems later on.

"Our findings suggest that (war veterans) need long-term monitoring and professional attention," the investigators conclude.

I hope that the people in charge of disability determinations for the VA system are paying attention. Often, veterans who turn up years after war, claiming disability for PTSD, are greeted with skepticism. That merely adds insult to injury. The situation is already difficult enough for veterans who have delayed-onset PTSD. For them, one of the most vexing things about the condition is that it seems inexplicable to them, to have done well acutely, but to develop problems later on. When they take note of that apparent paradox, they tend to ascribe meaning to it. These faulty attributions usually are self-deprecating.

Delayed-onset PTSD can occur also in civilians, although a quick Medline search did not turn up very much information of this. There might be articles out there that I did not find, but if not, I would think this would be an important question to look into more thoroughly.

(update here.)

Candidate's Forum

2006-04-07T00:31:00.000-04:00

This is a quick report on the Washtenaw County Democracy for America Candidates Forum, held on April 5, 2006, at the Superior Township hall. The purpose of the Forum was to have Democratic Party candidates for State of Michigan offices answer questions about themselves and their campaigns. This forum was small; there were three candidates there, two for the Attorney General spot, and one for the Secretary of State (SoS). They invited three attorney general candidates, but only two agreed to come. Scott Bowen is the one who did not come. Amos Williams and Alexander "Sandy" Lipsey did come. Geoffrey Fieger also may be running, but nobody even mentioned him. For reference, here are their campaign sites:

http://www.bowen4ag.com/
http://www.amoswilliams.com/
http://www.citizensforalexanderlipsey.com/
http://www.fiegerlaw.com/

Actually, Fieger's site is not a campaign site, it is the general site for his law practice ("the nation's premier law firm").

Scott Bowen apparently is Grandholm's pick for the AG spot. The two who were there were asked if they knew why Bowen did not come. Williams said that the rumor is that Bowen is on vacation in South Carolina. I don't think anyone knew for sure.

At the end of the Forum, I found that someone had placed little fliers under the windshield wipers of all the cars. It was a notice that said that Scott Bowen in pro-life.

Ron Suarez is making a podcast of the Forum; a link should be posted here soon (or here).

I enjoyed the candidate's forum. Both candidates for attorney general were impressive; I would have no trouble supporting either of them. Sandy Lipsey is currently a State Representative. Amos Williams is an attorney, a retired cop, and a military veteran. Both name civil rights as important issues, although Williams was a little more vocal about that topic. Both are strongly pro-choice. Lipsey talks a little faster, and gives a better global impression, but Williams comes across as more thoughtful. He sometimes ran out of time while responding to questions (all candidate's responses were limited to two minutes.) Both candidates often drew applause from the audience. Both seem intelligent and well-educated. Lipsey has a bachelor's degree in physics, graduated for the Kennedy School of Government, and Michigan Law. Williams graduated from the FBI National Academy, and Detroit College of Law. Both make an issue of consumer protection. Both characterized the current AG, Mike Cox, as being excessively pro-business and weak on consumer protection. They characterized Cox as being a man of little action. They claim that his centerpiece accomplishment -- the increased aggressiveness in collection of child support -- as an unnecessary duplication of efforts already carried out by individual counties.

The SoS campaign is less interesting. The site, http://www.uselections.com/mi/mi.htm, lists Mary Waters as the only active Democratic candidate for SoS. She is hoping to unseat the incumbent, Terri Lynn Land. She mentioned that one of the reasons she is running, is that people asked her to run. The other reason she gave is that the current SoS had an important position in Bush's campaign, which is a conflict of interest. Waters currently is a State Rep, and has asked for legislation that would prevent such conflicts of interest. The main concern that she expressed was that the SoS in the chief elections officer in the State, and it is important to have someone with no conflicts of interest. She exhibited some awareness of the current concerns about the integrity of the voting process. However, I would have preferred to hear from her a greater understanding of the complex issues involved.

For reference, the current SoS, Terri Lynn Land, was interviewed previously by Jack Lessenberry (1 2). She has the idea of having picture ID voter registrations, that could be swiped in a machine at the voting precinct. Her idea is that all of those machines would be connected together, so that all could be machine-verified, and no voter ID could be used more than once on a given day. That sounds like an expensive proposition to combat voter fraud, when we all know that election fraud is the real problem.

After hearing the interview with Land, I wondered how anyone could propose to set up hundreds of nodes in a secure network on Monday, and expect it all to work at 7AM on Tuesday. It is one of those things that is a nice idea, but anyone who has tried to set up any large network, not even a secure network, would probably tell you it would be foolish to expect it to work right away. To expect to be able to set it up and have it be secure, and then to verify the security and functionality, in a short period of time, seems nutty to me. It might work, but it might not, and what do you do if it doesn't work? (Not that I am an expert, but I think I know enough to be able to say that much.) Sure, you could set it up weeks ahead of time, but that gives it more time to fail, and creates a problem of how to make sure no one tampers with it in the meantime.

Is it strange to have two opposing candidates, one named Land, the other Waters?

Collateral Damage in the War on TerrorismMedical Ethics in Inaction

2006-04-05T00:07:00.000-04:00

This post is about the case of a patient with Duchenne Muscular Dystrophy, whose life-prolonging medication was intercepted at the border by Homeland Security agents. The post includes a long excerpt from the Grand Rapids Press. I would not ordinarily excerpt so much of an article, but I think the article will disappear behind a firewall in a couple of weeks.

Boys' medicine held up by Homeland Security
Monday, April 03, 2006
By Pat Shellenbarger
The Grand Rapids Press

Tyler Fehsenfeld's doctors said the 6-year-old needs a drug from a company in England to delay his deterioration from muscular dystrophy.

The U.S. Department of Homeland Security said he couldn't have it.

Only after U.S. Rep. Vern Ehlers' office intervened last week did the U.S. Food and Drug Administration release it.

Tyler's parents, Anessa and Scott Fehsenfeld, of Rockford, were relieved but perplexed the federal agencies blocked a medication vital to their son's health.

"I'm choosing to give this drug to my son that a doctor says he needs, and my country says he can't have it," Anessa Fehsenfeld said. "As if the diagnosis isn't bad enough, and then you have this to deal with."

She ordered the drug, Deflazacort, in late January after Tyler's doctor prescribed it to slow rapid muscle decline and perhaps prolong his life. On March 6, the couple received a letter from Homeland Security's border protection division saying it confiscated the medicine because it is not approved by the FDA.

"I was shocked," Fehsenfeld said, frantic that her son soon could lose his ability to walk. "You think of sneaking it over the border. You're willing to do whatever you have to."

Several other parents of boys with an aggressive form of muscular dystrophy called Duchenne received the same form letter. In November, Customs began cracking down on shipments of prescription drugs from outside the United States.

While Deflazacort is available in Canada and throughout Europe, the company that makes it has not sought FDA approval to sell it here. The reason, some doctors and advocates for muscular dystrophy patients believe, is because it is an "orphan drug," with a market too small to be profitable.

An estimated 12,000 U.S. children have Duchenne, which affects only boys, said Pat Furlong, president of nonprofit Parent Project Muscular Dystrophy. [...]

Margaret Wilkinson, of Spring Lake, said she was notified Dec. 23 that the Deflazacort she ordered for her 14-year-old son, Jeffery, was confiscated. The FDA released it a month later after she called U.S. Rep. Pete Hoekstra's office. [...]

Without the drug, Duchenne patients typically lose their ability to walk between the ages of 6 and 12, said Marianne Knue, a nurse practitioner who works with Wong. Since the disease also affects the heart and breathing muscles, they often die in their teens.

"But with Deflazacort, we are finding boys are able to ambulate much longer, well into their teens," Knue said, adding she has patients on the drug still living in their late 20s.

Knue said she has heard from several parents whose Deflazacort orders were impounded. She began calling Customs and the FDA.

"They wouldn't give me a straight answer," she said.

Ehlers had better luck. After a Press reporter called his Washington office this week, a staff member contacted the FDA on the Fehsenfelds' behalf.

Tyler Fehsenfeld is the grandson of Press Publisher Dan Gaydou. [...]

In the USA, a drug can be sold only if it is approved by the FDA. The approval process is excruciatingly complex, and costs millions of dollars to do. And the longer the clinical trials take, the more expensive it is. Because MD develops so slowly, the trials for this drug, in this disease, would take many years. In order for it to be worthwhile getting the approval, the potential profits from the drug sales would have to be greater that the profits that could be gotten merely by investing those same millions of dollars for the same number of years. Evidently, the analysis of the potential profits failed that test, so approval was never sought here.

Now, obviously, nobody would have thought that this kind of outcome, bizarre and inhumane as it was, would come from the Global and Perpetual War on Terrorism. Call it collateral damage. Still, in any massive, complex undertaking, there are bound to be unanticipated consequences.

The thing is, intercepting unapproved drugs really has nothing to do with terrorism. In this case, the War on Terrorism was merely a cover for another part of the Administration's agenda. The Department of Homeland Security surely has better things to do than confiscating some terminally-ill patients medication. It is difficult to figure out exactly how this fits in with their mission. Sure, stopping some overseas drug shipments might protect pharmaceutical industry profits, but that clearly does not apply here, even though it would be consistent with the mission of our current Administration. Likewise, stopping shipments of abusable drugs would fit in with their puritanical notions, but that clearly does not apply in this case. No, this case was the result of a mindless power struggle.

All ethical questions eventually boil down to the central question: who gets to make the decision? That is, who is in charge here? Who has the power? Clearly, the Administration has decided that it has the power. Not the doctor. Not the patient. Rather, some nameless Customs agent who has no idea what the drug is for, or why it is being imported, or whose lives will be affected by the confiscation. None of that matters. The only thing that matters is that it is that the Administration has to be in control of all things, at all times. The War on Terrorism is used to justify this power grab.

In this case, the patient was the grandson of a newspaper publisher. He eventually got the drug, but you have to wonder what would have happened if he hadn't had such an influential relative, and a Congressman had not gotten involved.

This case arose from a longstanding problem with the FDA approval process. The thing is, the system has been broken for a long time, and it still is broken. It's just that for decades, doctors and their patients acted in accordance with common sense. The government, rather than fix the broken system, simply looked the other way. That was a fair solution, until some ideologically-driven zealots decided that they would not look the other way. Instead, they now insist that the rules be followed, even thought the rules don't make any sense.

Blogworthy Articles in NEJM

2006-03-26T21:37:00.000-05:00

The most recent (3/25/06) issue of the New England Journal of Medicine contains several items that deserve a mention here at Corpus Callosum. It is worth noting that there are three items related to psychopharmacology; this degree of attention is unusual in a general medical journal. All require a subscription for the full text.

There are two papers that report on results from the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) project. One study shows what happens when patients are switched from one antidepressant that is not working for them, to a different one. The other shows what happens when a second drug is added to the first one.

The significance of these studies stems from the fact that it is a common decision point in the application of psychopharmacology, to have a patient who has not responded to the first drug tried. The question then comes up: Is it better to stop drug A, and try drug B (switch); or, to stay on drug A, and add drug B (add)? Although the studies do not provide a really definitive answer to the question, they at least provide some useful information.

One of the studies examined the question of what happens when the drugs are switched (Bupropion-SR, Sertraline, or Venlafaxine-XR after Failure of SSRIs for Depression). Briefly, the result is that about 25% of the patients achieve remission. It did not matter which f the three drugs was chosen:

Results Remission rates as assessed by the HRSD-17 and the QIDS-SR-16, respectively, were 21.3 percent and 25.5 percent for sustained-release bupropion, 17.6 percent and 26.6 percent for sertraline, and 24.8 percent and 25.0 percent for extended-release venlafaxine. QIDS-SR-16 response rates were 26.1 percent for sustained-release bupropion, 26.7 percent for sertraline, and 28.2 percent for extended-release venlafaxine. These treatments did not differ significantly with respect to outcomes, tolerability, or adverse events.

A few observations are in order. First, conventional practice has been to switch from one family of drugs to another family, when employing the switch strategy. In this study, all of the patients had not responded to an SSRI, citalopram. It did not matter if they were switched to another SSRI, or a similar class (SNRI), or a completely different class (buproprion). Note that the "conventional practice" was never based upon empirical evidence; up until now, there simply wasn't much empirical evidence to go on. Second, the study does not tell us which patients would be better off with one drug over another. We are still waiting for that study.

The second study examined what happens when a second drug is added (Medication Augmentation after the Failure of SSRIs for Depression). Briefly, the study took a group of patients similar to those who enrolled in the other study; they all had not improved sufficiently on citalopram. Briefly, about 30% attained remission:

Results The sustained-release bupropion group and the buspirone group had similar rates of HRSD-17 remission (29.7 percent and 30.1 percent, respectively), QIDS-SR-16 remission (39.0 percent and 32.9 percent), and QIDS-SR-16 response (31.8 percent and 26.9 percent). Sustained-release bupropion, however, was associated with a greater reduction (from baseline to the end of this study) in QIDS-SR-16 scores than was buspirone (25.3 percent vs. 17.1 percent, P<0.04), a lower QIDS-SR-16 score at the end of this study (8.0 vs. 9.1, P<0.02), and a lower dropout rate due to intolerance (12.5 percent vs. 20.6 percent, P<0.009).

Note that the bupropion group did somewhat better. This is interesting. In common practice, it is much more common for psychiatrist who employ the add strategy to add bupropion, even though there previously was no specific empirical guidance for this:

Background Although clinicians frequently add a second medication to an initial, ineffective antidepressant drug, no randomized controlled trial has compared the efficacy of this approach.

The common practice was guided by intuition, more or less. In this case, the intuition appears to have been correct.

The third psychopharmacology paper in the NEJM issue is a "Perspective" piece on the cardiovascular safety of stimulants used in the treatment of ADHD. That paper is available only as a (180KB) PDF download. Their conclusion:

Although the committee recognized that there are important potential benefits of these drugs for certain highly dysfunctional children, we rejected the notion that the administration of potent sympathomimetic agents to millions of Americans is appropriate. We sought to emphasize more selective and restricted use, while increasing awareness of potential hazards. We argued that the FDA should act soon and decisively.

This sounds a bit harsh to me, but I would still take it seriously. It may be that we need to start systematically monitoring blood pressure in all patients who are getting these drugs. The number of deaths reported was extremely small, given the millions of patients who receive these drugs. Even allowing for vast underreporting, it still means the risk is small. But since the potential consequences are great, and the monitoring is so easy, it would make sense to do it.

On The Authenticity Of Human Personality

2006-03-06T00:54:00.000-05:00

I am just an amateur at this kind of thing, but sometimes I just blurt things out. One argument that people sometimes raise, against the use of psychotropic medications, is that the state of mind that results from the use of such substances is somehow not authentic. Part of this argument is seen in the controversy about so-called enhancement technologies, in which people argue about the propriety of using technology to make people "better than well." That phrase seems to be used particularly in the context of persons using medical technologies when they are not ill, in order to enhance some functional capacity.

It has been reported that some nondepressed persons taking SSRI antidepressant medication become better than well. Some may argue that there is a problem with such a mental state. One of the arguments is that such a mental state is not authentic, and thus it is to be avoided. It turns out, though, that for the vast majority of persons, any such enhancement is subtle. In fact, it is barely measurable. Certainly, no one has documented any large flux of nondepressed persons flocking in to their doctors, trying to get prescriptions for SSRIs. Granted, there is no reliable way to prove that it isn't happening, but it is hard to base an argument on evidence that does not exist. Could it happen? Sure: it would not be difficult for someone to read up on the symptoms of depression, and go in to get a prescription. Moreover, someone could order such medications over the Internet, without a prescription (which I don't recommend, by the way.) Having said that, I am fairly sure that the majority of physicians would not expect this to happen. The most likely outcome, if a person were to try this, would be for the person to take the medication for a few weeks, maybe months, then stop. Any changes probably would be so small that they would not be apparent to casual observation. In order to see the changes, one would have to do careful studies of various parameters, and take averages among a large group. The changes in any one individual probably would be so small as to be clinically insignificant.

If we agree that any such changes are small, does that make the ethical concern go away? In my view, it does. For those who still wonder, consider the following study on nonpharmaceutical compounds, as noted on the blog, Crumb Trail:

Omega 3 fatty acids influence mood, impulsivity and personality, study indicates

DENVER, March 3 – Omega-3 polyunsaturated fatty acids may influence mood, personality and behavior, according to results of a study presented today by University of Pittsburgh School of Medicine researchers at the 64th Annual Scientific Meeting of the American Psychosomatic Society in Denver.

In a study of 106 healthy volunteers, researchers found that participants who had lower blood levels of omega-3 polyunsaturated fatty acids were more likely to report mild or moderate symptoms of depression, a more negative outlook and be more impulsive. Conversely, those with higher blood levels of omega-3s were found to be more agreeable.

"A number of previous studies have linked low levels of omega-3 to clinically significant conditions such as major depressive disorder, bipolar disorder, schizophrenia, substance abuse and attention deficit disorder," said Sarah Conklin, Ph.D., a postdoctoral scholar with the Cardiovascular Behavioral Medicine Program in the department of psychiatry at the University of Pittsburgh School of Medicine. "However, few studies have shown that these relationships also occur in healthy adults. This study opens the door for future research looking at what effect increasing omega-3 intake, whether by eating omega-3 rich foods like salmon, or taking fish-oil supplements, has on people's mood." [emphasis added]

Note that the study participants were identified as "healthy volunteers," so presumably none had a diagnosable mood disorder (See this link for more detail on the study). The study is suggestive (although not conclusive) in that it does not tell us for sure whether a healthy person could become better than well by deliberately increasing the intake of omega-3 fatty acids. Although not conclusive, the study raises the question: if deliberate dietary supplementation with an ordinary food can cause a person to be better than well, is that better-than-well mood state inauthentic? Or is the enhanced mood state inauthentic only if it is produced by an artificial chemical? If there seems to be a difference in authenticity, why does the source of the chemical matter?

Credit goes to aspazia for the inspiration for this post, as well as some of the background information.

Early Hurricane Season in Florida

2006-02-25T21:46:00.000-05:00

Those of us who have been following the news about global warming are worried about the upcoming hurricane season. But now another storm is brewing in Florida, and it has nothing to do with global warming.

The storm is being generated by Black Box Voting, which describes itself as "a nonpartisan, nonprofit, 501c(3) organization. We are the official consumer protection group for elections, funded by citizen donations." They have released a report of their inspection of voting machine logs from Palm Beach, Volusia, and Broward County, used in the November 2, 2004 elections. Their report shows that the logs contain over 100,000 error messages. In addition, the logs show many votes were recorded in October 2004, even though the specific machines were not used for early elections.

After investing over $7,000 and waiting nine months for the records, Black Box Voting discovered that the voting machine logs contained approximately 100,000 errors. According to voting machine assignment logs, Palm Beach County used 4,313 machines in the Nov. 2004 election. During election day, 1,475 voting system calibrations were performed while the polls were open, providing documentation to substantiate reports from citizens indicating the wrong candidate was selected when they tried to vote.

Another disturbing find was several dozen voting machines with votes for the Nov. 2, 2004 election cast on dates like Oct. 16, 15, 19, 13, 25, 28 2004 and one tape dated in 2010. These machines did not contain any votes date-stamped on Nov. 2, 2004. [...]

The Palm Beach County Supervisor of Elections, Arthur Anderson, said that his staff had looked into the problem and that the votes were normal, it's just that the dates somehow changed. [...]

"The votes were normal, it's just that the dates somehow changed." If that was intended to be reassuring, I would say Anderson failed rather miserably. If, as he says, his staff looked into it, then there should be a written report. Anderson should say to the journalist, "We prepared a report, and I would be happy to send you a copy," or something like that.

Google News lists about 100 news articles that reference the Black Box Voting article. Most of these are reprints of an Associated Press article dated 2/23/2006, by Brian Skoloff. The AP article was picked up mostly by small organizations, although some of the big media outlets, such as The Washington Post, also printed it. A couple of conservative sites printed it as well, including Town Hall and The Conservative Voice. Another news article on the subject appeared in the South Florida Sun-Sentinel, dated 2/24/2006, by Kevin Connolly.

Both news articles are disappointing, although they live up to the usual journalistic standards.

The AP writer, in a superficial effort to be fair and balanced, contacted the spokesperson for the manufacturer of the voting machines, and asked for a reply:

Sequoia spokeswoman Michelle Shafer disputed the findings, saying the company's machines worked properly. Sequoia's machines are used in five Florida counties and in 21 states.

"There was a fine election in November 2004," Shafer said.

She said many of the errors in the computer logs could have resulted from voters improperly inserting their user cards into the machines. The remaining errors would not affect the vote results because each unit has a backup system, she said.

The problem with that, is that there is no analysis of the adequacy of Sequoia's response. The Black Box Voting article indeed does cite voting card errors, but that is only one type of error that they document. There are many more kinds of error reported, and most of them have nothing to do with the voting cards. Furthermore, a reasonably inquisitive reporter could wonder how it is that the machines handle these card errors, and what the procedures are for responding to the errors. One might wonder why the logs do not show what was done to correct the error. Furthermore, the respons that "The remaining errors would not affect the vote results because each unit has a backup system" is inadequate. How does that address the problem of incorrect date stamps?

Many such errors that Black Box Voting reported simply are not addressed in the AP article. For eample:

Polls closed and results report messages would be expected to appear on every voting machine at the end of the voting cycle, but these revealed problems with poll worker training and procedures at the administrative/training level. Some logs reported one report printed, some two, three, four or five, and several not only had no results tape printed but showed no closing of the polls. (Closing the polls tells the voting machine not to accept any more votes).

Card encryption bad and Card read fail errors also appeared, with the encryption error message the more frequent of the two.

Some logs show that no results were printed, indicating that there is no paper record of the votes that the machine recorded. Some show that the machine was not properly shut down at the end of the polling session. That would not neceassirly be a problem, if all the votes had reliable date stamps; and vote recorded after the polls were closed could be discarded. But as we have seen, the date stamps are not reliable. I would like to think that a vigilant reporter would notice this, and ask about it.

Likewise, the South Florida Sun-Sentinel article is only a superficial report. They quote a Volusia County official:

Volusia officials said the charges are groundless and questioned Harris' credibility.

"If you wish hard enough for a problem, your mind can imagine it," said former Volusia County Election Supervisor Deanie Lowe, who ran the 2004 election.

"I don't know of any election or of any voting system she has ever programmed, so she does not understand the situation. . . . She doesn't know what she's talking about."

I think it is fine to give the County officials a chance to respond, but the reporter could do better than that, by pressing for specifics. Lowe's response is a sweeping rejection of all claims, based upon a vague dismissal of the credibility of the Balck Box Voting director, Bev Harris. Vague ad hominem attacks tell us nothing. I want to know what the county officials have to say about the individual error messages. I want to know what happens when error messages occur while votes are being cast. Are poll workers aware of the errors? Is there a log kept by poll workers, showing when the errors occurred, what was done in response, and which poll workers responded? Is there a policy and procedures manual that specifies how these situations are handled? If so, how can citizens get access to that manual? What does it say a poll worker should do, if, for example, a voting machine reports a card encryption error?

Bloggers have been commenting on this, typically with a high degree of skepticism. For example, an IT guy, Truthspew, writes:

Can a president elected through fraudulent means be tossed out?

Because Black Box Voting is really going gangbusters identifying serious election hanky panky.

For example, while I find the grammar and syntactical skills of the journalists at the Associated Press to be very disappointing, this article ineloquently states what the problems encountered happened to be.

Even during the 2000 Judicial Fiat we knew something was wrong. Same happened in 2004 and Dubya's plunging numbers only reinforce the notion that something is seriously rotten in Denmark.

Elisabeth, writing on Infomanic, picked up on the story, and got a useless comment:

Um, Elisabeth. We need to talk. The DUmmie FUnnies has LONG chronicled the foibles of the veracity challenged Bev Harris. Even the Democrat Underground has BANNED her from their leftwing site. Check out our December 2004 archivies of the DUmmie FUnnies and then do a search on the MANY references to Bev Harris and that should get you up to speed on the whole Black Box Voting thing.

The only thing Bev Harris and Black Box Voting are really good for is as a reliable source for comedy material and for that we thank her.---P.J.

Again, attacking Bev Harris may be interesting, but it is a different story. We need to see an analysis of the specific claims made by Black Box Voting, and a credible explanation of each claim. Harris provided the actual logs -- the raw data -- that were used by Black Box voting. If someone wants to complain about her reporting, that person needs to look at the logs and explain what all those error messages mean, and show why they should be disregarded.

Independent Report picks up on the story, and points out:

Does this sway the election results any? No, probably not. However, we find it curious that the voting machine manufacturers fought, kicking and screaming, against providing their source code or the machine's capabilities. "Trade secrets" they claimed, while also claiming the machines worked wonderfully well and could not be sabotaged. Well, we know they can be hacked pretty easily, and these irregularities point to some fishy business going on somewhere.

Bev Harris does not claim to know if election results would have been any different had these errors not occurred. From the AP artiicle:

However, Harris said it was impossible to determine what information was altered or if votes were shifted among candidates.

That, in itself, is newsworthy. The fact is, the results of the election cannot be verified, because the machines do a lousy job of telling us what actually happened on voting day. As one comment states here:

I started reading the actual log files... as far as I can tell, it doesn't look like the numbers were manipulated to benefit a specific candidate. It does look like the company is totally inept, and isn't qualified to count jellybeans.

Some people read the Black Box voting article and concluded that there were problems, but the problems probably did not change the election results. Others looked at the same article and concluded that the problems do indicate election fraud, such as this post at What a Mockery: Concrete Evidence that 2004 Vote was Rigged in Florida. Some echo the report, and imply that the report indicates fraud, but do not state that explicitly; Ranting and Venting: Florida Voting Machine Logs Reveal Anomalies, by Mindwolf, is an example of this approach.

It seems like all this work the GOP is doing is just to make it easier to stage an election so they can seize power and make it look like it was legal.

Others merely report on the findings, without adding anything; presumably, they are content to let readers draw their own conclusions. For example, Rob Galgano, at The Great Leap Forward, does exactly that. In a way, that approach is preferable to the approach taken by news writers who provide a half-hearted attempt at being fair and balanced, but no analysis of their findings.

What I notice about this situation, is that the Black Box Voting article, and the news stories about the findings by the Black Box Voting (BBV) organization, both illustrate similar concepts. What BBV found, is that one of the fundamental guarantors of our democracy -- accurate vote counting -- is no longer credible. Similarly, another fundamental guarantor of our democracy -- good journalism -- suffers from a credibility problem. Both of these problems are serious, but having the two together is especially bad. Together, the lack of credible voting, and the lack of credible journalism, threaten to create a new storm system in our political ecosystem.

Prozac OTC?

2006-02-21T22:47:00.000-05:00

Aspazia left a comment with some questions, pertaining to my last post. Since the response is way to long to fit into a comment box, I've responded here. Note that the response might not make a lot of sense unless you first read the original post, and the comment, here.

Yes, the term hysteroid dysphoria is attributed to Donald Klein, from the late 60's. At this point (year 2006), it is more of historical and sociological interest, than medical interest. As for the question of whether MAOIs or Prozac would be better for treating rejection sensitivity, the answer is the predictable one: it depends on the patient, and to some extent, on the doctor.

I am confident that the magnitude of the therapeutic effect is greater with MAOIs, and that a higher percentage of patients will respond. But at least 30-35% will stop taking an MAOI because of adverse effects, compared to 10-15% with Prozac.

From the psychiatrist's perspective, the judgment about which is "better" will depend upon a number of factors. MDs who see a lot of young, relatively healthy patients, with clean diagnoses, and without a long history of multiple medication trials, will naturally see Prozac as the better choice for their typical patient. MDs who see patients with multiple diagnoses (e.g. depression and panic disorder and PTSD), patients who have had multiple trials on modern antidepressants, will tend to think of MAOIs as better. That's because there is no point in starting yet another trial of yet another SSRI in such a patient. (If that was going to work, it would have worked already.)

Some younger psychiatrists have little or no experience prescribing MAOIs, and would need to do their homework before doing so. Some will do their homework, while others will not.

Psychiatrists vary considerably in their practice patterns, thus there are systematic differences in their patient populations. It is important to keep this in mind when listening to a psychiatrist talk about his or her own experiences. This is because it is impossible to know what conclusions can be drawn from those experiences, unless you know something about the population of patients among whom those experiences occurred.

As for whether patients can pressure doctors into prescribing antidepressants, I would like to think that it would not happen very often. It is pretty easy to say to someone, "Look, I know you think this would be best, but I really have to prescribe according to my own judgment..."

A bigger concern is that it is fairly easy for someone to come in and give all the correct answers, to manipulate the doctor into prescribing an antidepressant. There is no good defense against that. As a physician, one has to assume that the patient is acting in good faith, and the suspicion level is going to be low unless the patient seems to be fishing for a controlled substance.

Make SSRI's available without a prescription? First you would have to get a company that would be willing to sell them without a prescription, and I tend to doubt that anyone would do that in the USA; the liability issues would be horrendous. But I realize that is a different issue. Assuming that a company would do it, would it be advantageous for society? The issues I see are these:

1. Selling antidepressants over the counter (OTC) might do something to destigmatize depression, and mental illness in general, and there could be benefit there.

2. It could trivialize mental illness, which would be bad.

3. A lot of people who don't need them would end up taking them. Most of those people would suffer no harm, except for the wasted money, and would stop taking them after a while.

4. Some people with bipolar disorder would became manic or hypomanic, and that would be a problem; in some cases, it would be a big problem.

5. Some people would try to abuse them. Most of those people would get no appreciable effect, and would stop, no harm done. Some would combine them with other substances, and that could be very dangerous.

6. Some people report that antidepressants intensify the effect of alcohol. That is not directly dangerous, assuming that the person does not intentionally overdose, but it can be hazardous because the person may not realize how much impairment there is. (Of course, that can happen with alcohol alone, but it is more likely to happen with some kind of CNS drug involved.)

7. Some people who need treatment, but who for some reason will not see a doctor to get treatment, might end up getting beneficial treatment. While not optimal, that would be more good than bad, except for #8...

8. Some people who are at risk for suicide would try to treat themselves in isolation. Isolation is very bad for persons who are suicidal. Self-treatment almost certainly would be a bad idea, and could have disastrous consequences.

Policy wonks may have some way of estimating the magnitude of those good and bad factors, and coming up with some kind of pronouncement about whether the good would outweigh the bad. Personally, I would be highly skeptical of any such analysis. So, to answer the question about whether SSRIs should be available OTC, I would not attempt a numerical analysis. Rather, I would rely on the following kind of judgment:

In general, it is a bad idea to make a radical change in how a medication is used, unless the likely consequences can be anticipated and quantified.
Selling antidepressants OTC would be a radical change in how they are used.
The likely consequences cannot be anticipated, nor quantified.
Therefore, it would be a bad idea.

I realize that that is a simplistic analysis, but even so, it pretty much sums up what I think about the idea.

It Has Been Bugging Me All Day

2006-02-20T23:53:00.000-05:00

Yesterday, ambling around the Internet, I read an article, and a blog post, that seemed to call for some kind of response. The article is on The Nation's website: Brave Neuro World: The Ethics of the New Brain Science, by Kathryn Schulz; the blog post is Prozac Feminism?, by Aspazia. What was bugging me, is that my intuition was telling me that there is some kind of important connection between the themes of the two pieces, but I could not quite put my finger on it.

Tonight, I am going to try to clarify for myself what the connection is. This is not a post that was thought out before writing it. Rather, I let my unconscious mind wrestle with it, and now I am going to sit down and start typing and see what comes out. Ah, the joy of blogging!

I will refer to the Schulz' article as BNW, and Aspazia's as PF, just as a kind of shorthand.

In BWN, Schulz poses a number of questions that are created by advances in neuroscience, and in our ability to control what the brain does. Essentially, she points out that the prospect of enhancement technologies will pose ethical quandaries. If enhancement is possible, to what extent will humans be free to make use of those enhancements? Will it be possible, or proper, for anyone to coerce another to make use of such enhancements? What are we to do about the inevitable unequal access to enhancement technologies?

Schulz can no more answer these questions that anyone else. Admittedly, I was sort of hoping that she would venture some answers, no matter how speculative or premature.

Aspazia takes a different approach. Not surprisingly, she ends up with different questions. Rather than viewing Prozac as an enhancement technology, she views it as a means of promoting conformity to social expectations. In that way, Prozac becomes a metaphor for the social pressures that promote conformity and compliance in women.Viewed in that way, Prozac is only an "enhancement" technology to the extent that conformity and subservience are improvements over the original.

I will leave aside the question of whether Prozac actually does that, or can do that.

What occurs to me first, is sort of an odd parallel. I realize that understanding this requires some specialized knowledge, and that I am too impatient to expand on all of the prerequisites in sufficient detail, so I may loose some readers by not explaining things sufficiently.

In the 1950's, three particular new molecular entities were developed for the treatment of depression: phenelzine, isocarboxazid, and tranylcypramine. These were marketed successfully as Nardil, Marplan, and Parnate, respectively. All three are monoamine oxidase inhibitors (MAOIs). Although there are highly effective, they were supplanted rather quickly by the tricyclic antidepressants (TCAs). The reason is that all of them required that the patient follow a special diet, in order to avoid an interaction with a chemical found in certain foods. (See the Wikipedia article for details.) MAOIs also tended to cause weight gain, sexual dysfunction, and various other adverse effects.

Although the MAOIs were supplanted by the TCAs, and the TCAs were supplanted by Prozac, they continue to excel in one respect. MAOIs have particular efficacy for the treatment of atypical depression. Atypical depression is characterized by a cluster of four symptoms: overeating, oversleeping, leaden fatigue, and rejection sensitivity. Ordinary depression, in contrast, tends to involve loss of appetite, insomnia, intentional social isolation, and fatigue that does not have a peculiar somatic sensation associated with it. MAOIs are particularly effective at reducing the symptom of rejection sensitivity, and thus are the preferred agents for treatment of Social Phobia.

As an historical aside, there is a disused term lurking in the dustbin of psychiatry: hysteroid dysphoria. The term hysteroid was used in reference to an ancient (but not ancient enough) belief that certain emotional symptoms were caused by a wandering uterus. (Really. People actually believed that.) It was thought that certain emotional symptoms tended to cluster together, along with rejection sensitivity. That cluster was given the name hysteroid dysphoria. In the 1980s, someone got around to analyzing the statistics, and it was found that the proposed symptom cluster had no validity. The term has been abandoned since then. In retrospect, it seems that it was merely a term of disparagement that was applied to women who had emotions that were inconvenient to men. (As a part of the process of discarding pejorative terminology, the symptom of rejection sensitivity now is often referred to as mood reactivity. The two are not exactly synonymous, but close enough for some purposes.)

Anyway, in the 1950's, the treatment of mood reactivity was hard: the patient had to memorize a list of foods to avoid, learn new recipes, get the family to accept a new menu, and scrupulously avoid dietary indiscretions. Likewise, in the 1950's, housework was hard.

Prozac changed the treatment of mood reactivity, sort of like the way the microwave oven changed housework. Just push a button, and you're done. Nothing hard about it. That is the odd parallel that I referred to earlier in this insufferable stream of consciousness.

Both BNW and PF pose questions about bioethics. Specifically, they ask how society should deal with the fact that we are developing new ways to alter brain function. Both essays point out that there is a potential for coercion.

BNW concludes with this:

If we fail to have that discussion, we risk winding up with a social policy for neuroscience based on tactical decisions, not ethical ones; benefiting the few, not the many; and obscuring the complex relationship between personal decisions about our minds and public decisions about our culture. That is a social policy we need like a hole in the head.

PF concludes with this:

What sort of culture do we become when we can gender engineer ourselves right into the sort of personality types that kick ass in business, that make us less sentimental about sex, and less overly sensitive to the needs of others?

Are we ready for this medically enhanced post-modern Feminism?

I think these issues are important. What is important to note, though, is that society does not put people on medication. Doctors put people on medication. Society may exert unarticulated pressure on companies to develop products, on doctors to prescribe those products, and on people to go to their doctors to get those products, but ultimately it is the responsibility of the physician to be aware of those pressures, counteract them, and to make the prescribing decisions based on clinical grounds, with the patient's interest and value system in mind.

I have mixed feelings about this. On the one hand, many medical decisions are complex. With that in mind, it seems that the need for a physician to sort out sociological and gender issues and consider them in the prescribing decision is no more complex than the decision about who should get bypass surgery. On the other hand, the medical profession has a spotty record when it comes to that kind of thing. It has been reported that women with heart disease have not gotten treated as aggressively, or as appropriately, as men. There are other examples of bias in medical decision-making, such as racial or class biases. I don't think the problem of potential biases is intractable, but I do think it requires some attention.

It is not something that worries me, really, because I do think that the medical profession is responsive when such biases are documented. If we are paying attention, we should be able to avoid such biases, so hopefully they will not occur in the first place. The authors are correct to point out the potential for such biases.

Why I'm No Good At Cryptography

2006-02-18T23:09:00.000-05:00

One of my favorite stories from the World War II era is that of the cracking of the Enigma ciphers. Individuals such as the Polish mathematician, Marian Rejewski, figured out how the Enigma machine worked to scramble information. But even after that discovery, it was not simple to figure out how to decipher each message. That is due to the fact that Nazis changed the key for the cipher every day. Even knowing how the machine worked, it was necessary to figure out what key had been used, in order to decipher the message.

There are many interesting details to the story, but the main point is that the cryptanalysts working on the problem could not rely only on their math skills. A certain amount of intuition was necessary. For example, the keys were supposed to be combinations of letters that were chosen at random. But people being what they are, it was common for non-random factors to intervene. One such departure from randomness occurred when the Enigma machine operation would spontaneously make up a pseudorandom sctring by typing arbitraty keys. But since the machine operators fingers generally started from the home positions on the keyboard, the home keys were much more likely to be pressed. Furthermore, it was common for the operators to alternate keypresses between the fingers of the left and right hands.

On the Enigma machine, the home keys are asdfghjk. So an operator who is not careful might choose a-k-a as a key. Cryptanalysts often used intuition to help them narrow down the list of possible keys. Rudimentary computing devices could help, but the intuition of the cryptanalyst often resulted in saving a great amount of time in the process.

Now that computers have become much more advanced, it might seem that there would be no place for intuition. Just set up the computer to do a brute-force attack, trying every possible key in order to crack the cipher. But that turns out to be wrong. A good illustration of this comes from the story of the Chinese mathematician, Xiaoyun Wang. She has been working on cracking the MD5 and SHA-1 hash functions. From an article posted on MAA Online, Cracking the Code, by Keith Devlin:

Wang's approach was to input to the algorithm two strings that differ by just a few bits and look closely at what happens to them, step-by- step, as the algorithm operates on them. This led her to develop a "feel" for the kinds of strings that will result in a collision, allowing her to gradually narrow down the possibilities, resulting eventually in her developing a procedure to generate a collision. Others working in the field remark that her ability to intuit which of the many possible paths to follow, coupled with her tenacity, is remarkable. Commenting to the magazine New Scientist, which covered the story in its 17 December, 2005 issue, Charanjit Jutia, a cryptographer at IBM's Watson Research Center in Yorktown Heights, New York, described the challenge of cracking a hash function like SHA-1 as being "like a giant puzzle." Referring to Wang, he added, "Most people get tired and give up. She did not"

I don't want to spur a mass panic, by starting a rumor that SHA-1 has been cracked. I know full well, what pandemonium would break out if that turned out to be the case. So, I will clarify that, so far, Wang has only reduced the number of steps required to guess the key. It had been thought that 2^80 steps were needed. Wang found some shortcuts that got that down to 2^63 steps. So SHA-1 still works to effectively obscure private information.

Following the announcement at Crypto 04, Wang and Yu teamed up with Yiqun Lisa Yin, now an independent security consultant based in Greenwich, Connecticut, and started work on the crown jewel of current hash functions, SHA-1. This proved a much harder nut to crack, but to the general dismay (and admiration) of the computer security community, at the annual RSA security conference in San Francisco in February last year, they were able to announce that they had developed an algorithm that could generate two SHA-1 colliding files in just 2^69 steps.

Unlike MD5, Wang and her colleagues have not (yet) cracked SHA-1, they have just produced a method that could crack it in far fewer steps than was previously believed possible. That number 2^69 is still sufficiently high to provide some degree of confidence in the system's security - for now. So too is the even lower number of 2^63 steps that Wang and other collaborators managed to achieve in the months following the February 2005 announcement.

A lot of computing power is still needed to get the key. Even so, it is evident that successful cryptanalysis gets a boost from intuition. And that is why I am not good at it: I don't have the right kind of intuition.

Ann Coulter As Metaphor

2006-02-14T22:52:00.000-05:00

Peter Westre, of Left in the Heartland, recently asked for some commentary about Ann Coulter, from a clinical perspective. This is an interesting topic. In fact, one could write a book about the subject.

I am not going to write a book, but I will make a few comments.

First, the requisite disclaimers. I have never met Ann Coulter, and I cannot actually make a clinical diagnosis pertaining to someone I've never met. Second, if I had met her in a clinical context, I neither could nor would say anything about it. Third, the only information I have is what is available on the Internet, and I haven't read all of that. What I can do, though, is use the public persona of Ann Coulter as a metaphor for the dark side of the Republican Party. It would be appropriate for me to say that I do not think that Ms. Coulter is at all representative of members of he Republican Party. Rather, I would say that the Party has been infiltrated and co-opted by mean-spirited persons who have sociopathic characteristics. Thus, Ms. Coulter can be used as a convenient metaphor to describe this phenomenon.

Ann Coulter has made some remarks that could be taken as evidence that she is a sociopath. Editor and Publisher picked up on a few in this article. Max Blumenthal has more on Huffington Post. Back in 2001, The Washington Monthly put together a decent collection of some of her earlier and more offensive comments. Indeed, some of these are highly suggestive.

On Rep. Christopher Shays (d-CT) in deciding whether to run against him as a Libertarian candidate: "I really want to hurt him. I want him to feel pain."--- Hartford Courant 6/25/99

The thing is, in order for someone to be a sociopath, they have to actually do some bad things, not just talk about doing bad things. Of course, I have no idea if Ms. Coulter ever has done bad things. Probably not; surely the media would pounce on it if she had. But the fact is, it is not normal for someone to state openly that they want someone else to feel pain. The fact that she makes such statements openly is not normal. It is not normal for someone to say openly, even in jest, that a Supreme Court Justice should be poisoned. While not conclusive, diagnostically, for someone to make such statements does suggest the possibility of some kind of personality disorder.

Technically, there are four types of personality disorder that might cause a predilection to make such statements. If one cared to attempt to establish such a diagnosis, in a casual, armchair-musing kind of way, that could be done. One would first read the general criteria for a personality disorder. (The list of criteria can be found on Wikipedia, here.) If the general criteria are met, one then would read the specific criteria for those personality disorders that tend to be associated with people doing bad things. Those would be the Cluster B personality disorders: Antisocial, Narcissistic, Histrionic, and Borderline. Antisocial Personality Disorder is the one that is most closely synonymous with sociopathy.

To meet criteria for Antisocial Personality Disorder, the person in question has to have a history of repeatedly doing bad things. But what about someone who does not actually do those bad things, but does talk about them in public, repeatedly?

Looking at the question from a clinical perspective, I would wonder about the Narcissistic and Histrionic personality disorders. Narcissism can be understood as being pathologically self-centered. Histrionic Personality Disorder can be thought of a being pathologically attention-seeking, especially if done in a theatrical manner.

Narcissistic persons have a massive failure of empathy, but typically do not go out of their way to cause harm to others. On the other hand, if they do happen to cause harm to others (say, by accidentally shooting them in the face with a shotgun), it is no big deal. After all, it is just "collateral damage."

Histrionic persons tend to be so theatrical that they may, perhaps without really meaning to, cause great insult to others. Like the narcissist, if they do happen to insult someone, they typically feel no shame; they may even take pride in it. After all, it is "just a joke."

With those points in mind, now, ignore Ms. Coulter. Instead, consider the extent to which the Narcissistic and Histrionic personality disorders can be used, collectively, as a metaphor for the dark underside of a perverted political party.

Here are the formal criteria for the two disorders:

Diagnostic criteria for 301.81 Narcissistic Personality Disorder
(cautionary statement)
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

(3) believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

(4) requires excessive admiration

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) is often envious of others or believes that others are envious of him or her

(9) shows arrogant, haughty behaviors or attitudes

Reprinted ~~with~~ without permission from the Diagnostic and Statistical Manual of Mental Disorders, fourth Edition. Copyright 1994 American Psychiatric Association

Diagnostic criteria for 301.50 Histrionic Personality Disorder
(cautionary statement)
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) is uncomfortable in situations in which he or she is not the center of attention

(2) interaction with others is often characterized by inappropriate sexually seductive or provocative behavior

(3) displays rapidly shifting and shallow expression of emotions

(4) consistently uses physical appearance to draw attention to self

(5) has a style of speech that is excessively impressionistic and lacking in detail

(6) shows self-dramatization, theatricality, and exaggerated expression of emotion

(7) is suggestible, i.e., easily influenced by others or circumstances

(8) considers relationships to be more intimate than they actually are

Reprinted ~~with~~ without permission from the Diagnostic and Statistical Manual of Mental Disorders, fourth Edition. Copyright 1994 American Psychiatric Association

Consider the question, of whether there are elements within the Republican Party that reflect these criteria for mental disorders. Are there frequent instances of the Party have a grandiose sense of self-importance? Has any member of the Party ever stood on an aircraft carrier, with a large banner proclaiming "Mission Accomplished?" Do any of them ever seem preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love? Well, forget the ideal love part, and think about the rest of it.

What about the third criterion for NPD? Any hint of exclusivity in the statement about the "haves and the have-mores?"

“What an impressive crowd: the haves, and the have-mores. Some people call you the elite. I call you my base.”

I could go through most of these criteria, and find numerous suitable examples for each, but that merely would be feeding the vampire.

The Truth About Logging In This Universe

2006-02-10T23:08:00.000-05:00

Maybe, in a parallel universe, I became a naturalist and ended up studying forest ecology. As it happens, I live in this Universe, and I did not think I could get anyone to pay me to study forest ecology. Maybe, in a parallel universe, I became a politician. But I live in this Universe, and in this Universe, I dislike politics. But I never realized just how much poolitics there is in forest ecology. So if there is a parallel universe, with a j7uy5 studying forest ecology, I sure hope there isn't so much politics in that one, too, because that j7uy5 would be pulling his hair out right now.

This all started last year, when a graduate student at Oregon State University (OSU) submitted a short paper to the journal, Science.

Post-Wildfire Logging Hinders Regeneration and Increases Fire Risk
D. C. Donato,1* J. B. Fontaine,2 J. L. Campbell,1 W. D. Robinson,2 J. B. Kauffman,3 B. E. Law1

We present data from a study of early conifer regeneration and fuel loads after the 2002 Biscuit Fire, Oregon, USA, with and without postfire logging. Natural conifer regeneration was abundant after the high-severity fire. Postfire logging reduced median regeneration density by 71%, significantly increased downed woody fuels, and thus increased short-term fire risk. Additional reduction of fuels is necessary for effective mitigation of fire risk. Postfire logging can be counterproductive to the goals of forest regenration and fuel reduction.

1 Department of Forest Science, Oregon State University, Corvallis, OR 97331, USA.
2 Department of Fisheries and Wildlife, Oregon State University, Corvallis, OR 97331, USA.
3 Institute of Pacific Islands Forestry, U.S. Department of Agriculture Forest Service, Pacific Southwest Research Station, 60 Nowelo Street, Hilo, HI 96720, USA.

* To whom correspondence should be addressed. E-mail: dan.donato{at}oregonstate.edu

Originally published in Science Express on 5 January 2006
Science 20 January 2006:
Vol. 311. no. 5759, p. 352
DOI: 10.1126/science.1122855

When the study was published, it genrated some interest in the mainstream media, and some among bloggers:

(Note that the fifth item there was picked up on Tangled Bank.)

But the intrigue actually started before the paper was even published. As outlined in an article published on The Scientist, in turns out that some scientists -- including some faculty at OSU -- tried to get the publication supressed. This was highly unusual, according to a senior editor at Science:

Wildfire logging debate heats up
Controversial Science paper lacked appropriate caveats, some forestry scientists say

[Published 27th January 2006 06:21 PM GMT]

Nine scientists wrote a letter to Science asking the journal to withhold a one-page article on the potential risks of post-wildfire logging, arguing the article was short on qualifiers and context. But some forestry scientists say they support the conclusions, and last week, the journal published the paper. [...]

Science editors have never considered delaying publication of an article after it has passed peer review and been accepted, Science editor-in-chief Donald Kennedy told The Scientist in an E-mail. Kennedy said that he can recall only one other case where someone has requested publication delay of another group's paper and that "it is an unusual way for senior faculty members to behave, especially with respect to a graduate student." [...]

"Unusual" way to behave, indeed. Most faculty advisors would be thrilled if one of their students got a paper published in Science.

Unfortunately, that is not the end of the story. After the paper was published, the federal funding for the folks doing the research was pulled. A Congressman was irritated by this, and asked for an investigation:

Lawmaker Seeks Probe of Logging Study
By JEFF BARNARD , 02.07.2006, 06:12 PM

Questioning whether the Bush administration is manipulating science for political ends, Rep. Jay Inslee, D-Wash., called Tuesday for an inspector general's investigation into why federal funding was suspended for a study that goes against White House-supported legislation to speed up logging after wildfires on national forests.

In a letter and a speech on the floor of the U.S. House of Representatives, Inslee called for an investigation by the inspector general of the U.S. Department of Interior into whether the U.S. Bureau of Land Management was punishing researchers from Oregon State University for coming up with findings that don't fit with White House policy goals.

"Unfortunately, it's very apparent to most neutral observers that under this administration in a variety of ways that the scientific process has been corrupted by political influence," Inslee said in a telephone interview. "We saw that when the administration and their political forces tried to shackle distribution of information by the chief climate scientist in the United States, Dr. James Hansen, two weeks ago." [...]

Mr. Inslee must have been on to something. In fact, just one day after he asked for an investigation, the funding was restored.

Agency Restores Funding for Logging Study
By JEFF BARNARD
Associated Press Writer

February 8, 2006, 11:09 PM EST

GRANTS PASS, Ore. -- A federal agency restored funding Wednesday for a study that has provided evidence for conservationists opposing the Bush administration's policy of logging after wildfires.

The U.S. Bureau of Land Management's decision to lift its suspension of the final year of a three-year grant to Oregon State University came a day after a congressman called for an investigation of the funding cutoff.

Rep. Jay Inslee, D-Wash., had asked the Interior Department's inspector general to examine whether the bureau was punishing the researchers for their findings. [...]

"The key to effective censorship is to make sure no one's looking, and this time everyone was watching," said Andy Stahl, director of the Forest Service Employees for Environmental Ethics, an environmental group in Eugene.

So all's well that ends well? Not exactly. This is not over, and will not be over until there is a sensible occupant in the White House. Personally, I hope that Inslee continues to press for an investigation. The whole thing stinks of cronyism and corruption. We need to find out who was pulling strings to get the funding cut, and why. If this turns out to be the way it appears to be, it would mean that someone in the Administration was yielding to pressure from industry groups, in a manner inconsistent with the public interest. That is corruption, and if that is what happened, we need to stop it from happening again. The culture of corruption has gone too far. The only way to put an end to it is to find the individuals who are responsible for each instance, and put them out of government service.

I would like to think that graduate students doing innocent research would not have to be bothered by this kind of thing. But we have a government that knows no boundaries when it comes to meddling in other people's business for the sake of industry profits.

Although, to be fair and balanced, I have learned that there is no career that is insulated from political influence, and none ever has been. Imagine, I once thought that going into medicine would keep me safe from meddling politicians. Now, I laugh at that quaint notion. And now, I wonder if I could get some federal funding to go looking for one of those parallel universes.

RR4 Experience

2006-02-05T00:19:00.000-05:00

I decided to take a break from the usual political and science/medicine fare. Greg, from the Information is Free blog, asked some questions about RR4/64, which I will answer here, along with some unsolicited information.

The computer I am using now has three operating systems on it, and two hard drives. Windows XP was installed first, on the first drive. Second, Suse 9.3 was installed, by resizing the NTFS partition to make room for the new operating system. All of the critical data were backed up to the second drive before doing the repartitioning. Suse automatically installed a boot loader with a menu that made it easy to choose an OS at startup. I installed Suse 10.0 later, in the same space that 9.3 had been (on the first drive.)

On the second drive, I left some space to use specifically for trying out different types of Linux. About 20GB is available for that purpose. I won't bore you with my "life list" of distros I've tried.

More recently, I installed RR4 on the second drive. That worked OK, but when I installed the boot loader, it only included items for booting Windows and RR4; it did not include Suse on the menu. I fixed that using the Suse installation disk, which has a "repair" option. The Suse repair reconfigured the boot loader, and appropriately included items for Windows, Suse, and RR4.

Over the last couple of days, a new version of RR4 came out. I deleted the partition for the old one, and installed the new one. This time, I did not have the RR4 installation program install a boot loader. After the installation, I merely edited the menu item in GRUB to reflect the new boot files in RR4. That worked fine, although I found that some of the aspects of the boot menu are counterintuitive (at least using my brand of intuition).

RR4 offers several options. The easiest is to simply boot from the live DVD. I think that most fairly recent computers will do this by default. That is, you do not have to change any esoteric settings. If there is a bootable DVD in the drive when the system is started, it will boot from the DVD, rather than from the hard drive.

Booting from the DVD is slower than booting from the hard drive, and launching programs is slower, but it is very simple to do. The DVD includes programs for email, web browsing, and typical office functions such as wordprocessing and spreadsheets. Therefore, a user can do almost anything one ordinarily would do with a computer, even if the hard drive does not work. I think that the live DVD option is what the author of RR4 was referring to with the mention of getting up and running in 5 minutes.

Another option for using RR4 involves installing it to the hard drive. That requires making two partitions, at least; one for the OS, and another for swap space. This has advantages and disadvantages. The big advantage is that the system starts and runs more faster than it does if running a live DVD. The disadvantage is that it takes up space on the hard drive. Also, since (almost) no computer that is operational has extra unpartitioned space on a hard drive, it is necessary to resize an old partition and make new partitions before the new OS can be installed. This is not something one does casually, since it is easy to really mess things up and lose data in the process. It requires an intermediate level of knowledge and a bit of confidence to do.

Actually, the partition took in the installation program is not difficult to use, and I think a beginner could do it, but I would not recommend it unless you are using an old computer that you don't care much about, or have a really good friend who can bail you out if you mess up. In any case, a backup of all important data is a really really good idea. It helps to have two hard drives, because if you mess up during the partitioning process, and have a fully operational operating system on the other drive, it is pretty easy to recover from an error. It also makes it easy to back up a lot of data.

Installing RR4 to the hard drive can be done using different methods. The easiest is to use precompiled binaries. Note that you do not have to actually understand what that means in order to do it. Just pick that option. The Gentoo installer then creates all the necessary directories and puts the necessary files in the correct places. With that option, there are very few choices to make in order to prepare for the installation. You choose some things like your time zone, language, and whether or not to install a boot loader. Unless you are very familiar with configuring boot loaders (GRUB -- grand unified boot loader -- in this case) you will want to let the installer set up the boot loader for you. It will recognize a Windows installation automatically, if one exists. Then, when you reboot, you first see a menu that lets you choose whether to boot Windows or RR4. Unfortunately, if you have another kind of Linux, you will have to add that to the menu somehow. (note: this was true for my setup, but I did not experiment to see if it always is true.) This is not much of an issue, since presumably anyone who is going to run three or more OSs is prepared to manually edit a boot menu.

Using precompiled binaries, the installation takes some time, I would estimate about 20 minutes, but frankly I did not keep track, and could be off by quite a bit. The time is spent unpacking the binaries from archive files. The installation does not download or compile anything.

The reason that Greg asked about the details of the installation, is that RR4 and RR64 are based on Gentoo. Gentoo is a type of Linux that has a (well-deserved) reputation for being the most versatile Linux, but also is the most technically demanding for the user. Prior to the development of the Gentoo graphical interface for installation, most people would install Gentoo using scripts that download the source code and compile everything. That is a very time-consuming process, and requires a great deal of technical knowledge. However, it enables the user to customize the operating system in ways that sometimes are highly desirable. A full discussion of that is not something I want to get into right now. The point is that RR4 allows a user to do that, if desired, but also allows a user to sidestep the most difficult and time-consuming aspects of the installation.

What some people want to get from reading a post like this, is advice on whether or not they should try a new version of Linux. I will address that now.

RR4 is good for beginners, since it is easy to set up. Although the easiest installation does not give you all the advantages, it works fine and would be adequate for the majority of casual computer users. RR4 is also good for advanced users who want the convenience of a graphical installer, but who could do the installation using a command line if they wanted to. RR4 is also good for anyone who wants to mess around with a highly configurable system, regardless of skill level. I am using it specifically to acquire a greater skill level, but since I probably will make mistakes, I am not planning to use it as my primary operating system...at least for now.

I would not recommend that someone switch from a different, functioning version of Linux, to RR4. Greg mentioned that he uses Fedora, and presumably he is pretty happy with that. I doubt that there would be any pragmatic reason for him to switch. Likewise, I am happy with Suse, and don't have a specific reason to stop using it. But RR4 gives me more options to play around with, so it is fun to have. It is sort of like a automobile hobbyist who has one car that he or she takes to work every day, and another that he or she tinkers with in the garage. It is the same kind of thing, only a lot cheaper. In fact, it doesn't cost anything.

Another Rambling Post:A Psychiatrist's Own Free Associations

2005-12-25T00:02:00.000-05:00

Environmentalists are bothered by the EPA's latest proposed air quality standards:

John Kirkwood, president and CEO of the American Lung Association commented that the EPA plan is "disappointing."

"If EPA adopts the standard as proposed," Kirkwood said, "the agency will have failed the most fundamental task required by the Clean Air Act - to protect public health from one of the major air pollutants."

For the first time, he said, the EPA will have ignored recommendations from its own staff scientists and from its official outside review panel of scientists. Both groups have advised setting a stronger standard than EPA has proposed.

Frank O'Donnell, president of Clean Air Watch, called the proposed standards a giveaway to industry.

One of the standards in question is that which regulates emissions of fine particles, those with a diameter of 2.5 microns or less. Although very small, they are particularly dangerous. If you care about the details, here is why (Medscape, free reg. req.):

Environmental exposure to airborne particulate matter of 2.5 microns in diameter or less (PM2.5) has been associated with reductions in HRV, a measure of cardiac autonomic regulation, and increased cardiovascular mortality in the elderly, Dr. Holguin and colleagues explain in the second issue of the December American Journal of Respiratory and Critical Care Medicine.

"We and others theorize that PM2.5-associated reductions in HRV are a potential mechanism by which PM2.5 leads to increased cardiovascular morbidity and mortality," Dr. Holguin said.

By the way, the Medscape article that the excerpt was from, provides 0.25 hrs of CME credit. The article is a summary of a study done on elderly nursing home residents of Mexico City, to see if fish oil supplements would reduce the cardiac risk caused by air pollution. The study was too small to be conclusive, but the results suggest that there is a protective effect.

In case it is not immediately obvious why this would be, here is the mechanism:

The cardiovascular effects associated with particulate air pollution include an increase in systemic inflammation, deregulation of the coagulation system, and impaired endothelial-mediated vasodilatation and microvascular inflammation. These mechanisms may be blocked by omega-3 fatty acids and hence, omega-3 fatty acids may provide a preventative measure to reduce the risk for arrhythmia and sudden death in elderly subjects exposed to air pollution.

Ironically, the (Taiwanese) EPA just issued a report advising people to decrease their intake of fish, because of concerns about mercury pollution. And the Secretariat of NAFTA has determined that US mercury emissions should be investigated. And environmental groups are critical of the (US) EPA for not performing routine monitoring of mercury in sea life.

So, as Tom Lehrer said, don't drink the water, and don't breathe the air. Whatever. Nothing new there.

What might be news to readers is this: essential fatty acids (such as those found in fish oil) are not important only for their anti-inflammatory effects. There are other kinds of essential fatty acids that are necessary for nerve signals to work properly in the brain. From the online textbook, Psychopharmacology - The Fourth Generation of Progress, we learn the following:

A schematic picture of the ways in which arachidonic acid and its metabolites may act in regulating neuronal activity is shown in Fig. 1. Arachidonic acid is released from phospholipids in cells stimulated by many first messengers, including neurotransmitters, neuromodulators, and neurohormones. The free fatty acid has, as such, a short lifespan, during which it may interact with and affect the activity of ion channels and protein kinases within the cell. Alternatively, it may be transformed to a family of metabolites—the eicosanoids—which may also produce important effects on intracellular targets. In both cases, the arachidonic acid cascade affects neuronal excitability by fulfilling the primary criteria defining a second messenger system—that is, receptor-dependent formation and intracellular site of action. Where the eicosanoids differ from "classical" second messengers is in their ability to cross the cell membrane, diffuse through the extracellular space, and interact with high-affinity receptors located on neighboring neurons (Fig. 1). Eicosanoid receptors have been characterized in the brain and have been shown to be linked to second messengers, such as cyclic AMP, very much like the receptors recognized by dopamine, noradrenaline, and so on.

Arachidonic acid is an essential fatty acid, like those in fish oil, in that the human body cannot produce it. In order to have it, you must get it by putting it in your mouth and swallowing it. It and its derivatives are then incorporated into the cell membrane, and do interesting things.

I mention this because the model of neurotransmitter action that is commonly presented in the media is grossly oversimplified. Often, one will see a simple diagram that shows how serotonin, for example, is released by one cell and interacts with a receptor on the next cell. This completely ignores what happens after the transmitter binds to the receptor. After the transmitter binds to the receptor, a whole series of events is created by what are called second-messenger systems. There are several second messengers, and all interact in complex systems. The arachidonic acid cascade happens to be one of the most complex:

The arachidonic acid cascade is arguably the most elaborate signaling system neurobiologists have to deal with. Not only can it generate multiple messenger molecules (at least 16, according to a conservative estimate limited to the brain), but these molecules may act both within and without the neuron, bringing into play intracellular as well as extracellular targets.

Furthermore, simplified models of neurotransmission do not account for the many factors that regulate the release of the first messenger:

A novel arachidonic acid derivative was recently isolated from brain and was identified as the ethanolamide of arachidonic acid (Fig. 4). This compound was shown to (a) inhibit the specific binding of a radiolabeled agonist to the cannabinoid receptor and (b) produce inhibition of the twitch response in mouse vas deferens, a typical response to cannabinoids. These properties have led to the suggestion that arachidonoylethanolamide (dubbed "anandamide" after the sanskrit word for bliss, "ananda") may act as the endogenous ligand for brain cannabinoid receptors (13). The pathways leading to the biosynthesis and the degradation of anandamide in the CNS are not known.

In order to understand how complicated this makes things, consider the following:

Antidepressant-like activity and modulation of brain monoaminergic transmission by blockade of anandamide hydrolysis

Here, we show that URB597, a selective inhibitor of the enzyme fatty-acid amide hydrolase, which catalyzes the intracellular hydrolysis of the endocannabinoid anandamide, exerts potent antidepressant-like effects in the mouse tail-suspension test and the rat forced-swim test. Moreover, URB597 increases firing activity of serotonergic neurons in the dorsal raphe nucleus and noradrenergic neurons in the nucleus locus ceruleus. These actions are prevented by the CB1 antagonist rimonabant, are accompanied by increased brain anandamide levels, and are maintained upon repeated URB597 administration. Unlike direct CB1 agonists, URB597 does not exert rewarding effects in the conditioned place preference test or produce generalization to the discriminative effects of {Delta}9- tetrahydrocannabinol in rats. The findings support a role for anandamide in mood regulation and point to fatty-acid amide hydrolase as a previously uncharacterized target for antidepressant drugs.

Thus the release of serotonin is regulated, in part, by anandamide, a derivative of arachidonic acid. And when serotonin is released, it regulates the release of other arachidonic acid derivatives.

I guess the real reason I wrote this is, in part, a response to a comment left on one of my prior posts about antidepressants.

Your understanding is nearly as superficial as Mr. Cruise's. While the data do show that neurotransmitter concentration seem to be a function of depressed state, correlation is not causation. The full data, which do not show up in a blithe web search, also show that "fixing" the neurotransmitter levels has zero immediate effect on depression. This is in stark contrast to a true chemical imbalance disorder, such as loss of the sense of smell due to zinc deficiency, where administration of zinc fixes the problem quickly and dramatically.

In general, the therapeutic effects of antidepressants (as well as their side effects) take weeks or months to show up. That shows rather conclusively that depression involves large multi-part control systems that are slow to change. The best current guess is that it results from the absence of entire nerve cells in a part of the brain called the hippocampus, and that antidepressants trick the cells into being born more rapidly. Conversely, destroying those cells with x-rays in mice causes the mouse version of depression regardless of neurotransmitter levels.

Furthermore, Mr. Cruise is absolutely right that vitamins are an antidepressant drug. That's because of the placebo effect: if a depressed person believes that something might help them, there is a substantial chance that it will.

The person who left the comment was pointing out that "correlation is not causation," and implies that my post was superficial because there is a lot more to the chemical imbalance in depression than merely the regulation of serotonin. Well, duh!, no kidding: it is a lot more complex. More that you probably imagined. More than anyone can hope to understand, at this point in time. I know this. That is why I base treatment decision upon empirical evidence, not poorly-delineated hypotheses such as the serotonin hypothesis of depression. It is also why I ignore -- and everyone else should ignore -- those cute little drug company ads with the cartoon neurons and neurotransmitters. They don't really tell you anything interesting. They are true, to the extent that science permits, but they are so oversimplified as to be meaningless.

Another interesting point, illustrated by the arachidonic acid story, is that all parts of a biological system are dynamic. Nothing just sits there. Simplified descriptions of cell biology often portray the cell membrane as just sitting there, being a membrane. Nothing could be further from the truth. The cell membrane is an active part of the cell, interacting with the cell's interior, the cell's environment, and nearby cells in an eloquent dance of incredible subtlety and complexity.

So what can we conclude from all this? The EPA is useless, anatomy and physiology are really complex, don't drink the water and don't breathe the air, don't pay attention to drug company ads (except for their entertainment value), and be careful leaving snarky comments on blogs where the blogger actually knows something about the subject. Oh...and Tom Cruise is better at jumping on sofas than sniping at scientists.

Think Your Pain Away, for $2 Million

2005-12-13T01:01:00.000-05:00

I just read an article today. First I'm going to tell you what is not interesting about it, then I'll get to the interesting part.

Thinking the Pain Away

By Ingrid Wickelgren
ScienceNOW Daily News
12 December 2005

Researchers have developed a potentially powerful new tool that allows patients to fight pain by literally thinking it away. Volunteers put inside a functional magnetic resonance imaging (fMRI) machine were able to control the activity of a brain region responsible for pain perception, suggesting that the technology may someday provide a drug- and side-effect-free way to calm troubled nerves. [...]

This is basically an enhanced form of biofeedback. If people who are experiencing pain can see the level of activity in a certain pain center in the brain, they can learn to make that center less active, thus reducing the pain. The author mentions that the technique seems promising, except that the machines that make it possible cost two million dollars.

The finding that patients can control pain with this kind of biofeedback is interesting, but the fact is, we already know that biofeedback works for other things, and it is not terribly surprising that this would work, too.

What provokes my curiosity is this:

By contrast, volunteers who were asked to change their rACC activity without fMRI feedback, or with sham feedback from another brain region or from another volunteer's rACC, could not effectively do so, and also failed to control their pain, the researchers report online this week in Proceedings of the National Academy of Sciences. "We feel this is very strong evidence that the real-time fMRI information was necessary for this effect," deCharms says.

What this means, assuming it turns out to be replicable, is that there is something critical, not just about the feedback process in general, but about the particular kind of feedback that patients get from fMRI. It does not work if you simply tell people to think their pain away. I guess that is obvious, because if it were possible, we'd all be doing it routinely. So what is it about the fMRI feedback that makes it work?

But that is not the interesting part; this is:

It is extremely common for the friends and family of patients to feel frustrated and perplexed, that the patient is "letting" the symptoms or the illness get the better of them. To the bystanders, it seems that it should be possible for the patient to think their way out of the problem. The bystanders, in their ignorance, assume that the patient must have some motive for not doing so.

This attitude is somewhat understandable. After all, if it were possible to think one's way out a problem, and one did not do so, then it would be reasonable to assume that there must be some reason. For example, if you believe that it is possible to think yourself out of pain, or depression, or anxiety (to use three common examples), and you remain afflicted by the pain/depression/anxiety, then there would have to be a reason.

What the fMRI study shows is that the reason people don't think their way out of the pain is that they can't (without a $2,000,000 machine, and the assistance of some highly trained specialists.) Give them the resources, and they do it, just like you would expect. This would sugget that it is not necessary, or helpful, to assume that there must be a hidden agenda. It is really quite simple. The reason they don't do it, is that they can't do it.

Autism Epidemic Revisited

2005-12-11T22:46:00.000-05:00

I am ambivalent about writing an autism post, since there has been so much blogbuzz on the topic. Much of the controversy has to do with two things: the notion that the incidence of autism is increasing, and the notion that mercury in vaccines has contributed to the increased incidence of the disorder. The mercury issue has been pretty well hashed out by Orac, Paul, Skeptico, Autism Diva, and others...too numerous to count. The "autism epidemic," likewise, had led to an epidemic of writing -- most of it bad. A Google search on "autism epidemic" (with the quotes) turns up over 66,000 hits.

And now I've come across another one. It isn't new. It was published in July 2005 on Medscape. (Medscape articles require registration, which is free. It is a bit of a nuisance, but Medscape is a pretty good resource, so it is worth the trouble.) I mention this article because it may be one of the better articles on the question of whether the incidence of autism is increasing. Furthermore, it illustrates some good general points about one of my favorite topics: skepticism.

Autism "Epidemic?" A Newsmaker Interview With Morton Ann Gernsbacher, PhD, And Craig J. Newschaffer, PhD

Laurie Barclay, MD
July 15, 2005

— Editor's Note: Despite heightened media attention on the autism "epidemic," a report published in the July issue of Current Directions in Psychological Science offers three arguments against a true increase in autism prevalence. These include changes in diagnostic criteria for autism, with current criteria being more inclusive than when the diagnosis was first defined in the 1940s; methodological flaws in an unpublished California study widely cited as showing dramatically increased prevalence; and problems in using the U.S. Department of Education's annual "child count" data.
To find out more about this issue and its clinical implications, Medscape's Laurie Barclay interviewed lead author Morton Ann Gernsbacher, PhD, a Vilas Research Professor, the Sir Frederic Bartlett Professor at the University of Wisconsin-Madison, and President-Elect of the American Psychological Society.

For an alternate viewpoint, Dr. Barclay also interviewed Craig J. Newschaffer, PhD, an associate professor of epidemiology at the Center for Autism and Developmental Disabilities, Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. Dr. Newschaffer is lead author of a study using cohort curves to suggest that autism prevalence has been increasing with time, as reported in the March issue of Pediatrics. [...]

The article provides a nice balance of viewpoints, all from persons with decent qualifications. Reading it is a good exercise in critical thinking. Reading it correctly requires good analytical skills. To illustrate:

Medscape: What are the significant changes in diagnostic criteria for autism between 1980 and 1994?

Dr. Gernsbacher: Whereas the 1980 DSM-III entry required satisfying six mandatory criteria, the more recent 1994 DSM-IV offers 16 optional criteria, only half of which need to be met. Moreover, the severe phrasing of the 1980 mandatory criteria contrasts with the more inclusive phrasing of the 1994 optional criteria. For instance, to qualify for a diagnosis according to the 1980 criteria, an individual needed to exhibit ''a pervasive lack of responsiveness to other people." In contrast, according to 1994 criteria, an individual must demonstrate only ''a lack of spontaneous seeking to share.... achievements with other people'' and peer relationships less sophisticated than would be predicted by the individual's developmental level. The 1980 mandatory criteria of ''gross deficits in language development'' and ''if speech is present, peculiar speech patterns such as immediate and delayed echolalia, metaphorical language, pronominal reversal'' were replaced by the 1994 options of difficulty ''sustain[ing] a conversation'' or ''lack of varied ...social imitative play." ''Bizarre responses to various aspects of the environment'' became ''persistent preoccupation with parts of objects."

Furthermore, whereas the earlier 1980 (DSM-III) entry comprised only two diagnostic categories (infantile autism and childhood onset pervasive developmental disorder), the more recent 1994 (DSM-IV) entry comprises five. [...]

You will see a lot of people debating this point, without really knowing the details. Some people will say that the increase in reported rates of autism "couldn't" be explained by changes in diagnostic methodology or criteria. But it is clear -- once you understand all the verbiage, that is -- that the changes in diagnostic criteria were substantial. Not only that, but the diagnostic categories were broadened, such that milder cases now qualify for a diagnosis. These are really important points. The point I am making here is this: you have to know the details, if you are going to make an informed comment on the subject. This is not one of those areas where an intuitive guess about the numbers will have any validity; you can't say the numbers are just too big to be explained by one factor, and expect anyone to find that persuasive.

Another point is illustrated by the article, one that has nothing to do with autism. Specifically, skepticism is not merely oppositional thinking; a good skeptic is comfortable saying "I don't know," when the evidence is not sufficient to draw a firm conclusion. Similarly, a good skeptic is comfortable making a tentative decision. Of course, when one makes a tentative decision, is is necessary to remember that the decision is not based on solid evidence. Then, one can avoid the error of establishing complex, important decision trees that do not have solid roots.

Medscape: Why should we be cautious about this label ["epidemic"], given changes in diagnostic criteria and in heightened awareness and recognition of this condition?

Dr. Newschaffer: [...] I believe that there currently is little strong evidence supporting either hypothesis (real risk versus diagnostic bias) and that proponents of one versus another hypothesis seem to hold their view based mainly on the basis of beliefs that are fallacious – either that the increase has been so large [that] some of it has to be real, or that the heritable component of autism is so large [that] the increase over time must be due to diagnostic changes.

Notice the phrase: "little strong evidence supporting either hypothesis." In other words, she just plain does not know, and will not say, which hypothesis is correct. If the evidence is not there, it is not there. Deal with it. Just don't try to browbeat others into believing something that is not supported by sufficient evidence, merely because you have decided to make a tentative decision on the subject.

PNAC Sucks, Part II

2005-12-07T02:35:00.000-05:00

What do the following people have in common?

Elliott Abrams, Roger Barnett, Gary Bauer, William J. Bennett, Alvin Bernstein, Jeb Bush, Steven Cambone, Dick Cheney, Eliot A. Cohen, Dvn Gaffney Cross, Midge Decter, Paula Dobriansky, Thomas Donnelly, David Epstein, David Fautuna, Steve Forbes, Aaron Friedberg, Francis Fukuyama, Frank Gaffney, Dan Goure, Fred C. Ikle, Donald Kagan, Fred Kagan, Robert Kagan, Zalmay Khalilzad, Robert Killebrew, William Kristol, Mark Lagon, James Lasswell, I. Lewis Libby, Robert Martinage, Phil Meilinger, Phil Meilinger, Norman Podhoretz, Dan Quayle, Peter W. Rodman, Stephen P. Rosen, Henry S. Rowen, Donald Rumsfeld, Gary Schmitt, Abram Shulsky, Michael Vickers, Barry Watts, Vin Weber, George Weigel, Paul Wolfowitz, Dov Zakheim

In addition to being persons in positions of power, they all are morally bankrupt. Each one either wrote, or contributed to the document, Rebuilding America's Defenses (PDF link), or signed the Statement of Principles for the Project for the New American Century (PNAC).

PNAC is a so-called think tank, that describes itself thus:

Established in the spring of 1997, the Project for the New American Century is a non-profit, educational organization whose goal is to promote American global leadership. The Project is an initiative of the New Citizenship Project (501c3); the New Citizenship Project's chairman is William Kristol and its president is Gary Schmitt.

Remember Jeb Bush getting all morally high-roadish about Terri Schiavo? Now tell me, what kind of morality would enable someone to sign off on this:

And advanced forms of biological warfare that can “target” specific genotypes may transform biological warfare from the realm of terror to a politically useful tool.

That is at the bottom of the right-hand column of page 60 (page 72 of the PDF) of Rebuilding America's Defenses. I notice that they do not come right out and say that they advocate the development of such weapons, so perhaps I am reading too much into this; however, it is a chilling statement, regardless of the intent. It is very much like someone mentioning, casually, that someday genocide might become "politically useful." Although it may not amount to an overt endorsement of an atrocity, it implies a covert acceptance.

Furthermore, the notion of genotype-specific biowarfare is extremely far-fetched from a scientific point of view. If such a thing were to become feasible, the USA would be extremely vulnerable, due to the diversity of its population. We would be the last nation on Earth that could make use of such a weapon (unless we decide that a certain portion of our population is expendable). And then there is this little thing called mutation. In order to be effective as a weapon, a microbe has to have a long enough incubation period, so that infected persons can spread it around before they die. During that time, mutations will occur. Anyone who thinks they can design a microbe that will be an effective weapon, and that it can be guaranteed to not mutate to spread to other populations, is seriously deficient in scientific knowledge. Trying to rely an a vaccine to protect your own population would be equally foolish.

One commentator has remarked:

If not already implemented Congress should enact a law stating that any research into genotype specific weaponry must only be conducted with a goal towards developing a defense against such weapons and that the research be conducted only with strict Congressional oversight. At the same time America should go to the world and attempt to get a similar formal ban enacted via treaty.

This is a good sentiment, but does not go far enough. There is no way to research defense against such weapons, without advancing the development of such weapon. But I assume that current prohibitions on the development of biological warfare in general, would also cover this specific kind of research. Even so, making the prohibition explicit in this area would not hurt, and may close some kind of unforeseen loophole.

Another point: how is this for a moral high road?

Consider just the potential changes that might effect the infantryman. Future soldiers may operate in encapsulated, climate-controlled, powered fighting suits, laced with sensors, and boasting chameleonlike “active” camouflage. “Skin-patch” pharmaceuticals help regulate fears, focus concentration and enhance endurance and strength.

We spend over 45 billion dollars per year on the war on drugs, presumably due to the notion that it is immoral for people to use mind-altering drugs...but it's OK to use them to enhance your ability to kill people?

As an amusing aside, you may want to view this short video clip, for a bit of comic relief from this dreadful subject.

Personally, I think that the members of PNAC have already developed encapsulated, climate-controlled suits, and they wear them all the time. It protects them from that nasty environment known as reality.

Sunday Roundup: Uncertainty, Science, and Public Policy

2005-11-27T23:32:00.000-05:00

There are two interesting essays on the evolution/ID debate in today's newspapers. Nobody is going to be persuaded one way or the other by either article, but perhaps they can bring much-needed perspective to the debate. Christians can't afford to oppose evolution, by Richard Colling, published in the Chicago Tribune, attempts to bridge the gap in understanding between both sides. Borrowing from the style of George Lakoff, the author presents the objections each side had to the other's viewpoint. In God and Darwin We Trust, by Dan Neil, in the LA Times, presents the view of the debate as described by inhabitants of Patagonia. There, religion is taught in public schools, but students do not have to attend. There is not much controversy there:

Perhaps landscape is destiny. Here in postcard Patagonia, the distinction between Nature and God seems so manufactured and irrelevant, so easily transcended by people of goodwill. The Patagonians actually seem a little bewildered that the most advanced nation on the planet cannot manage this low hurtle of imagination.

Hot on Parkinson's Tail, also in the LA Times, describes the current thinking about the possible relationship between exposure to pesticides, and Parkinson disease.

Now, with Parkinson's, this medical detective work has edged closer to proving the case than with almost any other human ailment. In most patients, scientists say, Parkinson's is a disease with environmental origins.

Scientists are "definitely there, beyond a doubt, in showing that environmental toxicants have to be involved" in some cases of Parkinson's disease, said Freya Kamel, an epidemiologist with the National Institute of Environmental Health Sciences who has documented a high rate of neurological problems in farmers who use pesticides.

"It's not one nasty thing that is causing this disease. I think it's exposure to a combination of many environmental chemicals over a lifetime. We just don't know what those chemicals are yet, but we certainly have our suspicions."

Climate talks - hoops and hot air, by Richard Black, posted at BBC News, is a nice display of British humor:

November 2005: the Kyoto Protocol has been in force for six years, emissions of greenhouse gases are falling fast, and all governments accept the message of urgency coming from mainstream climate science.

With the Kyoto targets already achieved, the Montreal summit will focus on the next round of commitments for developed and developing countries alike.

Richer states are preparing to pledge cuts of 30% by 2020, as a step towards their declared aim of 90% reductions by 2050; while developing nations have agreed an initial target of 5%.

There is consensus across the board that every citizen of the planet should be entitled, in the long term, to the same allowance for emitting greenhouse gases.

The only potential problem Montreal delegates may face is the number of flying pigs migrating north-eastwards from Lake Ontario.

He is talking about the prospects for progress at the 11th round of international talks on the Kyoto Protocol, taking place in Montreal.

One of the burning questions of the moment is what constitutes dangerous climate change?

All countries present, even the Kyoto naysayers, have a duty under the Framework Convention to stabilise greenhouse gases at levels which do not cause "dangerous anthropogenic interference with the climate system".

But what "dangerous" means has not been defined [...]

All four articles have something in common: they all deal with the boundary between certainty and uncertainty. Furthermore, they all address questions of how the general public deals with uncertainty in science, as applied to public policy. Figuring out how best to handle uncertainty would be a good topic for a long blog post. It would be difficult to write, "hard work," in the words of a recent President. Fortunately, much of the hard work has already been done. The UK's Parliamentary Office of Science and Technology has written what they call a POST note on the subject: Handling Uncertainty in Scientific Advice.

The POST note was written at the request of Parliament, in the aftermath of their investigation into the bovine spongiform encephalopathy crisis:

The Phillips Inquiry into BSE recommended a shift in the relationship between scientific advice and policy-making. Increased emphasis has since been placed on the explicit and systematic handling of scientific uncertainties by advisers, officials, ministers and parliamentarians.

For those of us who follow science and public policy, and who cringe every time a politician opens his or her mouth about something that has to do with science, this is a refreshing thing to read. What a concept! Acknowledge openly the fact that there is uncertainty in all matters scientific, and deal with it. Another breath of fresh air:

Scientific uncertainties may be underplayed or overplayed for political advantage.

Yes. Exactly so. And let's quit doing that already. That is one place where the POST note falls short. They refer to guidelines for the communication of risk assessments to policy makers, but they do not address the more troublesome matter of policy makers communicating risk assessments to their constituents:

OST’s Code of Practice for Scientific Advisory Committees (the Code) in 2001 provided explicit instructions on the reporting of uncertainty and divergent opinions. The Code recommends that scientific advice to decision makers should make clear the sources and extent of uncertainty. This includes the assumptions on which judgments are based as well as alternative scenarios and interpretations of the data.

What is needed is an open acknowledgment of the fact that it can be politically expedient to overplay or underplay risk assessments. When this is done, it is a form of deception, also known as lying. What also is needed here is for people to learn to recognize this form of deception. And not put up with it.

Propaganda 99

2005-11-20T01:22:00.000-05:00

"The Chinese People's Liberation Army is the great school of Mao Zedong Thought"
circa 1969
From Stefan Landsberger's Chinese Propaganda Poster Pages.

We may find artwork such as the Mao poster to be amusing, and feel at least faintly proud that our government, here in the USA, does not publish things like that. Those of you who are amused and faintly proud might be interested in this remedial course, Propaganda 99.

Probably all governments engage in propaganda. Surely, any of the Administrations in the history of US government could be accused of such infractions. To some extent, any communication from the government could be considered propaganda, but it would render the word meaningless to give it such a broad definition. How, then, can we define propaganda, at least for the purposes of this essay? Start with the Merriam-Webster Online Dictionary definition:

propaganda
Main Entry: pro·pa·gan·da
Pronunciation: "prä-p&-'gan-d&, "prO-
Function: noun
Etymology: New Latin, from Congregatio de propaganda fide Congregation for propagating the faith, organization established by Pope Gregory XV died 1623

1 capitalized : a congregation of the Roman curia having jurisdiction over missionary territories and related institutions
2 : the spreading of ideas, information, or rumor for the purpose of helping or injuring an institution, a cause, or a person
3 : ideas, facts, or allegations spread deliberately to further one's cause or to damage an opposing cause; also : a public action having such an effect

The M-W definition seems a bit weak, or at least insufficiently detailed; to understand the word fully, one must appreciate not only what the word strictly denotes, but also the connotations of the word. Propaganda is understood generally to have a connotation of something underhanded, sneaky, improper, and insufferable. In short, propaganda is wrong. In some cases, it is an effort to influence people to agree with your opinions, without openely asking them to agree with you. In that way, it is manipulative.

It may contribute to the understanding of propaganda, to examine closely the meaning of the term, manipulation. Again, referring to Merriam-Webster, to manipulate means "to control or play upon by artful, unfair, or insidious means especially to one's own advantage." I would propose a different definition, again for the purposes of this essay: to manipulate is to attempt to influence another person's behavior without making a clear statement of intent to the person, and without giving them a clear and uncoerced opportunity to decline to cooperate. As illustration, consider the following two statements:

Gee, the grass sure is getting long out there...
Honey, I think the grass is getting too long. Would you please mow the lawn today?

The first statement is manipulative, albeit mildly so. The second statement is different: it is clear that the person making the request has an agenda to influence the listener's behavior, explains the rationale, and gives that listener a clear opportunity to accept or decline. According to this definition, this site would not be a propaganda site, despite being designated as such here.

In contrast, there are many examples of true propaganda, gleaned from recent headlines: Catapulting the Propaganda or Wagging the Dog?, Buying of News by Bush's Aides Is Ruled Illegal, George Bush's Leveraged Buyout of Social Security, The Man Who Sold the War, Former CPB Chairman Ken Tomlinson Resigns, and The Office of Strategic Influence Is Gone, But Are Its Programs In Place?

Much of the art of living peacefully is the practice of the habit of avoiding manipulation. Likewise, government in a democracy should be government by consent; manipulation has no place in a democracy. It goes without saying that propaganda has no place in a democracy.

Of course, governments do what they do. Once elected, politicians and their appointees behave as they please. Citizens would be well advised to try to elect only persons who do not engage in propaganda. Once the leaders are elected, those same citizens would be well advised to remain watchful for, and intolerant of, all efforts at propaganda. Indeed, they would be well advised to resist all forms of manipulation. This has two benefits. For one, it helps keep the government in line, operating in a manner consistent with democratic principles. Two, it helps citizens interact gracefully with each other.

Source Watch, a site put up by The Center for Media and Democracy, has a nice collection of propaganda tactics here. They also have a page, PR Watch, where they publish examples of propaganda. Their blurb:

PR Watch, a quarterly publication of the Center for Media & Democracy, is dedicated to investigative reporting on the public relations industry. It serves citizens, journalists and researchers seeking to recognize and combat manipulative and misleading PR practices. It specializes in blowing the lid off today's multi-billion dollar propaganda-for-hire industry, naming names and revealing how public relations wizards concoct and spin the news, organize phony 'grassroots' front groups, spy on citizens, and conspire with lobbyists and politicians to thwart democracy. We expose the hidden activities of secretive, little-known mega-firms such as Hill & Knowlton, Burson-Marsteller and Ketchum PR--the "invisible men" who control our political debates and public opinion, twisting reality and protecting the powerful from scrutiny.

This is good. But they release their collections quarterly. Bloggers can do much better, if only because examples taken from current events have a much greater emotional impact, and thus provide better illustrations for teaching purposes. For example, The War Is Over, by Ron Beasley of Middle Earth Journal, dissects the use of the faux antiwar resolution in the US Senate, showing how it was essentially a propaganda ploy.

It has occurred to someone who thinks bigger than me that it might be useful to have a blog that performs such dissections on a daily basis. That could be a lot of work, so I would like to invite anyone who is interested to let me know (joseph/dot/j7uy5/at-sign/gmail/dot/com) if they might be willing to contribute content. Or just let me know if anyone would be interested in even reading such a thing. If there is enough interest, I would set up the blog and give publishing permission to some selected individuals or groups. It might be fun, as well as serving an educational purpose. If I could get a half-dozen people, each person would have to write something about once per week to make it fly. I would welcome input from all points in the political universe. In fact, ideally it would include content from the right as well as the left.

Medicare Part D Will Complicate Things

2005-11-13T23:11:00.000-05:00

A lot of blogging has been done regarding the Medicare prescription drug benefit, so much so, that there is no point in rehashing it. You may recall the allegations that the budget projections were falsified, that unseemly political arm-twisting was done to get the votes in the House, and that the plan is a giveaway to pharmaceutical companies because it prohibits negotiation for better prices. Now, the big theme is the complexity of the Plan. It is turning out to be difficult for people to figure out exactly what they should do and how they should do it. Headlines on the subject (as aggregated by Google News) include: US "greatest advance" in health care puzzles elderly, Medicare Prescription Plan Confuses Elderly, Medicare drug plan confusing seniors, CONFUSED BY COVERAGE CHOICES, New drug plan is prescription for confusion, the Medicare maze, Drug plan's side effects: Confused seniors, and Medicare's Part D as Plan B. Just looking at the headlines, you get the impression that a lot of people are having trouble figuring this out.

The one point that I have not seen covered in all of this is the problem that will occur after everyone gets signed up for one of the plans. People think that the real problem is figuring out what plan to choose, but that is just the start.

In order to understand the problem fully, it is necessary to look at this from the doctor's point of view. All of these plans have one thing in common: they provide good coverage for some drugs, and no coverage for others. As a result, the patient's doctor will, in many cases, be unsure what prescription would be best for the patient.

Most patients are expected to choose the plan that provides the best coverage for the drugs that they are taking when they first sign up. That would make sense, as that strategy will result in the lowest out-of-pocket cost -- as long as the prescriptions do not change. However, when a change is necessary, the doctor often will be in the position of trying to help the patient figure out whether to stay on a given drug, which is no longer doing a good job, or change to something that might work better, but that might not be covered by the plan. There are so many different plans, that it will not be possible for anyone to keep track of what plans cover what drugs. Sure, lists will be available, but those lists are not always accurate; they sometimes are incomplete, or misleading, or just plain wrong.

If these new plans work the way that existing insurance formularies work, it will be possible for the doctor to file an appeal, in those cases that an uncovered drug is needed. But this is time-consuming, generates a profusion of paperwork, and it increases the risk of lapses in treatment. Furthermore, by complicating the process of writing and filling prescriptions, it increases the risk of medication errors. Also, the appeals usually are processed by clerks who use checklists to see if certain pre-established criteria are met. They are not able to make independent, professionally-informed medical decisions. In order to get an actual pharmacist or physician to review the case, you have to get to the second level of the appeal process. And those people often do not listen to reason.

To illustrate, here is an example: a patient is stable, on an established regimen of medication. The patient, for whatever reason, changes from one plan to another. The coverage is different, so now one of the medications is not covered. The doctor can either expose the patient to a high out-of-pocket cost, or risk having the patient become unstable by changing the drug. Naturally, an appeal would be appropriate. I've done this many times, always arguing that it would not make any sense to change the drug and expose the patient to that risk. Some companies go along with it, but others do not.

There would be little point in complaining about all of this, without offering a suggestion for improvement. If one accepts that something has to be done to control the costs of prescription medication, then clearly some kind of restriction is necessary. Now, the idea that is said to underlie the profusion of Part D plans, is the notion that having many different companies competing will somehow result in the evolution of a more efficient way to get the job done. The problem is, that the more complex the system is, the more duplication of effort there will be, and the more time it will take for doctors, patients, and pharmacists to figure out what they should do. Thus, in the pursuit of efficiency, the system actually creates more inefficiencies.

The solution is to find a way to use an existing system, one that is already up and running fairly well, then try to improve it. One of the most perplexing things about Part D is that the government chose to ignore this obvious point.

I can't speak for all 50 states, but I can say that most if not all states already have a managed prescription drug plan, in Medicaid. Those plans already exist, the doctors and pharmacists have figured out how to work with them, and the plans have been in operation long enough, that many of the bugs have been worked out. There is no reason to have dozens of companies go out and duplicate all the effort that already has gone into the establishment and debugging of the Medicaid plans. The solution is to have each state simply extend the existing Medicaid plans to cover Medicare recipients.

Defending Yourself by Complimenting Your Enemy

2005-11-11T23:40:00.000-05:00

There's a fairly good article in Salon today. I don't necessarily recommend that you read it, unless you are willing to watch one of their annoying advertisements first. Besides, the article is only fairly good. In the War Room column, Tim Grieve writes:

The president attacks his critics

We said it was coming, and here it is: On Veterans Day, George W. Bush is defending his administration's use of intelligence in the run-up to the Iraq war, not by rebutting the charges that have been made, but by attacking those who have made them.

In a speech in Pennsylvania today, the president accused his critics of making "baseless attacks," rewriting history and throwing out "false charges" that serve only to undercut the troops now serving in Iraq. Although a Wall Street Journal/NBC News poll released this week showed that 57 percent of the American public now believes that the president deliberately misled the country about the case for war in Iraq, Bush marginalized those concerns as the wild charges of "some Democrats and anti-war critics." He said it's important to remember that "more than 100 Democrats in the House and the Senate who had access to the same intelligence voted to support removing Saddam Hussein from power." [...]

How would the prewar debate have gone if everyone knew what the administration knew before the war started: that stories from an al-Qaida member about an Iraq connection had been called into question; that warnings Colin Powell delivered about mobile weapons labs weren't based on solid evidence; that claims about an Iraq-Niger had been debunked within the CIA before Bush made them; that pronouncements Condoleezza Rice made about aluminum tubes had been discredited before she spoke? [...]

It is true that Mr. Bush's approach to the antiwar movement has involved some elements of argumentum ad hominem. To be clear, though, that was not the main thrust of his Veteran's Day speech. No, the main thrust is a lesser-used, but equally fallacious form of argument. It may even have Latin name, although if it does, I do know know what it is. The main argument he makes, one that is parroted endlessly in the Blogosphere, is a more peculiar one. One of the classic forms of the ad hominem argument goes like this (from Wikipedia):

Ad hominem abusive

Ad hominem abusive (also called argumentum ad personam) usually and most notoriously involves merely (and often unfairly) insulting one's opponent, but can also involve pointing out factual but damning character flaws or actions. The reason that this is fallacious is that — usually, anyway — insults and even damaging facts simply do not undermine what logical support there might be for one's opponent's arguments or assertions; argumentum ad personam short-circuits these potential arguments from logic in favor of a direct attack on the opponent's authority.

Example 1:

    "You can't believe Jack when he says there is no God because he doesn't even have a job."

Example 2:

    Person A: "There is a God and archaeological records of the Middle East prove it."
    Person B: "Well, that's what I'd expect a fundamentalist Christian preacher to say. His livelihood depends on it."

Bush's ploy is the reverse: instead of saying that those gosh-darn Democrats said X, therefore X must be wrong, he says essentially: 'even the Democrats believed it, so it must be true.' Or, if it isn't true, then 'at least I can be excused for having believed it.' Or something like that. Now that I think about it, it isn't exactly the reverse of the ad hominem argument, since he isn't really complimenting his enemy. Rather, he is linking his opinion to those of his opponents, so that it would seem that one could not attack his opinion, without also attacking his opponents. If you generally agree with his opponents, that would create an uncomfortable cognitive dissonance.

This technique can be effective, when used against persons who are not in the habit of thinking clearly. Nobody likes cognitive dissonance; often, people shy away from a line of reasoning that generates such discomfort. But those in the habit of thinking clearly are not put off by such sloppy rhetorical tactics.

Grieve's rejoinder is to assert that the Democrats who agreed with Bush did not have access to all of the same information. Therefore, the argument goes, they can be forgiven if they agreed with what is now known to be a false conclusion (that war was justified).

The problem with that is, at this point, those of us in the general public do not necessarily know what facts congressional Democrats had access to. Personally, I suspect that many of them did have access to the pertinent information, and chose to go along with the whole scheme anyway. If that is the case, they should be voted out of office, dissonant as that conclusion may seem.

Just a Thought on Harriet Miers' Withdrawal

2005-10-30T00:01:00.000-04:00

A future History, wherein three Unrelated Tales turn out to be Related:

It's just a thought, but maybe there's something to it. Some of you may recall that, a while back, President Bush nominated Harriet Miers to be an associate justice on the US Supreme Court. She withdrew herself from consideration. President Bush claimed that the the reason for the withdrawal was that the Senate demanded internal White House documents that were protected by executive privilege. He was quoting from her letter to him, announcing the withdrawal.

Legal analysts pounced on this. In an incisive essay, a professor of Law at UNC, Eric Muller, stated "The spin: she's withdrawing to protect executive privilege. What a load of crap." The rationale for the withdrawal was reported duly by various news outlets. From MSNBC:

In her letter on Thursday to President George W. Bush, Harriet Miers wrote that she was withdrawing her Supreme Court nomination to protect the rights of the executive branch.

Mr Bush echoed that view, saying it was clear "that senators would not be satisfied until they gained access to internal documents concerning advice provided during her tenure at the White House – disclosures that would undermine a president's ability to receive candid counsel".

Providing a bit more detail, another legal analysis was posted at Legal Ethics Forum:

During the run-up to the Roberts confirmation hearings, I put up a post concerning the application of the attorney-client privilege to lawyers working in the executive branch of government. The two leading cases both arise out of investigations of the Clinton administration by Independent Counsel Ken Starr — they are In re Lindsey, 158 F.3d 1263 (D.C. Cir. 1998) and In re Grand Jury Subpoena, 112 F.3d 910 (8th Cir. 1997). In both cases the courts denied the claim of privilege, as against the Independent Counsel investigating allegations of criminal wrongdoing by executive branch officials. It is important for the analysis of these cases to keep in mind that they both involved possibly unlawful conduct. In both cases the courts reasoned that communications between an executive branch official and a government lawyer might be, prima facie, protected by the attorney-client privilege, but that the privacy interests underlying the privilege would be subordinated to other, weightier interests where a federal grand jury is considering allegations of wrongdoing under investigation by an Independent Counsel.

This would imply the Bush and Miers have nothing to worry about. They can withhold the documents. If it came down to a legal battle, the courts would agree that the documents are protected. Unless, of course, there are serious allegations of criminal behavior, and the documents in question might have some probative value.

In lieu of full access to the documents, the Senate indicated that it would accept a subset of documents, plus oral testimony:

But late Monday Senate Judiciary Committee Chairman Sen. Arlen Specter, R-Pa., told reporters he was negotiating with White House officials to try to reach a compromise in which some documents would be given to the committee.

"We've not asked what advice she gave him. That's the privileged area; we've not asked for that," Specter said. He said that he'd asked the White House for a list of the subject areas that Miers worked on as counsel to the president. [...]

Specter repeated statements he has made before: "The whole confirmation process is in her hands. If she does well (in her public testimony) she will be confirmed. It's up to her as to how well she does."

OK, that's all on Miers...for a moment, anyway. In seemingly unrelated news, Independent Counsel Patrick Fitzgerald indicted Scooter Libby. Apparently, his investigation is ongoing, either via an extension to the term of the current Grand Jury, or the impaneling of a new one. In yet other, seemingly unrelated news, Murray Was (HT: Dr. Forbush) revealed in an article in the National Journal:

Vice President Cheney and his chief of staff, I. Lewis "Scooter" Libby, overruling advice from some White House political staffers and lawyers, decided to withhold crucial documents from the Senate Intelligence Committee in 2004 when the panel was investigating the use of pre-war intelligence that erroneously concluded Saddam Hussein had weapons of mass destruction, according to Bush administration and congressional sources. [...]

Now tie those three news items together: Alan Specter, speaking for the Senate, tells Miers she does not have to turn over all the documents, but does have to give public testimony about the topics covered in the documents. There is legal precedent saying she does not have to turn them over, unless there is an Independent Counsel investigating possible wrongdoing. But she withdraws anyway. Then we learn that the guy who just got indicted, previously refused to turn over some documents, "overruling advice from some White House political staffers and lawyers."

Imagine this alternate future: Miers does not withdraw. She gives testimony about her White House experience, testimony that cannot be refuted because the documents are protected by executive privilege. But then, the Independent Counsel gets the documents (on already has them) in the course of a criminal investigation. Miers is confirmed and ascends to the Bench. Then it comes to light that her public testimony is contradicted by the documents. Suddenly, you have a Supreme Court Justice who is known to have committed perjury.

That's a little far-fetched, but there are more plausible scenarios.

Let's say Miers does not withdraw, she does give testimony, and does not perjure herself. But in the course of the testimony, some upstart Senator recalls that Libby withheld documents, over the objections of White House counsel, and asks about that subject. Did she give any advice regarding those documents? Has she seen them? Because the nomination is controversial, the testimony is televised. Everyone is watching this, including Patrick Fitzgerald. Fitzgerald decides he is curious about the matter, gets the documents, finds something bad, then Cheney goes down in flames too.

I suppose one could come up with many possible scenarios here. Regardless, I do wonder about this. Bush and Miers claimed that her withdrawal was necessary to protect the principle of executive privilege. That claim was widely regarded as a red herring. But perhaps it was not. Perhaps it was not so much about the principle of executive privilege, but a sudden realization that something they want to hide, may come under scrutiny. It's just a thought, but maybe her withdrawal is a sign that the White House really does have something to hide.

Categories: politics: armchair musings
Tags: Politics, Patrick Fitzgerald, Harriet Miers

Grand Rounds 2.05 Up

2005-10-25T21:43:00.000-04:00

Grand Rounds 2.05 is up, at Hospital Impact. H.I.'s banner poses the question: what will it take for our hospitals to be the best run organizations on the face of the planet? It's a good question. Right now, according to the WHO, the American healthcare system ranks 37th in the world. Just ahead of Cuba, in fact.

Actually, hospitals are just a part of the healthcare system, and there are serious people who are trying to improve them, and doing a good job of it. The problem with health care in the USA is not a lack of bang; rather, it's the old bang:buck ratio thing. The point of sites such as Hospital Impact is to figure out how to get more bangs for fewer bucks.

Grand Rounds is a celebration of those bangs, and it doesn't cost any bucks. The host this week is to be commended for an arduous task of compiling the submissions, and presenting them in a nice, palatable format.

Readability hint: Sitemeter tells me that 70% of you are still using Internet Explorer. Don't do that. It is no way to read a carnival. Instead, use a tabbed browser, such as Firefox. Set the preferences to 1) open new tabs in background, and 2) load middle-clicked URLs in tabs; then, just middle-click on all the links. You get all the posts open in individual tabs, ready for you to read at your leisure.

They Seldom Limp and Quack This Early

2005-10-22T02:33:00.000-04:00

Sometimes The Economist comes up with some hilarious stuff. Unfortunately, this howler is subscription-only, but perhaps a few quotes will convey the idea.

Lexington
Et tu, Brute?
Oct 20th 2005
From The Economist print edition
The waning of the imperial presidency

[...] Mr Bush has turned himself into the most powerful president since Richard Nixon, whose “Imperial Presidency” was anatomised by Arthur Schlesinger in 1973. Mr Bush and his consuls came into office determined to restore the prerogatives of the chief executive (Dick Cheney and Donald Rumsfeld were particularly zealous, having served in Gerald Ford's post-Nixon, tethered presidency). Even before September 11th 2001, they took every opportunity to concentrate power in the executive branch, but after the terrorist attacks Mr Bush's advisers seized on the crisis to restore the imperial presidency to its full purple—so much so that Chuck Hagel, a Republican senator, complained that they treated Congress as a mere “appendage”. [...]

As Andrew Rudalevige points out in “The New Imperial Presidency”, all presidents have tried to erode the post-Watergate constraints on them; Mr Bush didn't so much erode them as blow them out of existence.
Now, however, Mr Bush is beset by woes on all fronts. Five separate polls this month have put his job approval-rating below 40%. And the emperor's Praetorian Guard is terrified that Patrick Fitzgerald, a special prosecutor, may indict leading members of the administration.
All second-term presidents become lame ducks (though they seldom limp and quack this early). [...]

Despite the humorous turns of phrase, the article is a serious one. They point out that, in response to a series of political missteps, Congress and the Supreme Court are acting to reign in the Executive Branch. Not only that, but religious conservatives and fiscal conservatives are breaking ranks as well. And, FINALLY, the American press is loosing faith in the President:

But the most vigorous opposition will come less from Congress (where the Republican majority is still tied to the president) than from the fourth estate. There is a noticeable mood of shame in the Washington press corps: shame that it failed to ask tough questions about weapons of mass destruction; shame that it was not quick enough to dig into the murky world of lobbying; shame that it was used to smear critics of the Iraq war. That shame is congealing into a desire for revenge. The press will be asking a lot more hard questions—and this time it will find eager sources among disillusioned conservatives.

The Economist doesn't adequately address one interesting question, though: Exactly what happened to turn the press against the President? Is it true that the press has turned against Bush because of their own shame? Perhaps that would explain the about-face of a few reporters. But with the exception of Fox News (HT: For Real Things I Know), it seems that most media outlets are rushing to criticize the Administration; it is not just a few reporters. A more comprehensive explanation is needed.

The shame was just the beginning. This was highlighted when bloggers called attention to the Downing Street Memo. The mainstream media did their best to ignore it, as the White House still had control of the media's agenda. Then Cindy Sheehan's campaign captivated the media, causing the White House to loose control over the media. Sheehan's campaign also made it acceptable to at least mention criticism of Bush, even if that criticism was not wholeheartedly endorsed. It was this sequence of events that set the stage for the transformation of the media, from Bush's lapdog, to Bush's gadfly.

With the stage set, there came an avalanche of bad news: investigations and indictments, hurricanes, mismanagement of just about everything, the quagmirization of Iraq, deficit spending, environmental stupidity, propaganda revealed, and a bunch of other stuff, perhaps culminating with the Commission of Inquiry on Crimes of the Bush Administration. With the media free to set their own agenda, and the prohibition against criticism of Bush lifted, it was not possible for the White House to manage the reporting on these events. Thus, it was not merely the shame of reporters who had failed to question the War, that led to the media turning against the President. If that had been the only factor, the Presidency would have its Imperial splendor still intact.

Categories: politics, armchair musings
Tags: Bush, Politics, Cindy Sheehan, dsm, downing street memo, BBA, Economist

Evidence-Based Legislation, Part I

2005-10-18T23:19:00.000-04:00

Recently, the US FDA has been criticized extensively for failing to adhere to scientific principles. However, one fact has gone unnoticed: For all its failings, the FDA is the most scientifically-based part of our government, and the rest of the government could learn a lot from how they do things. In this essay, I examine the differences between the approval process for new drugs, and the process for crafting new laws. I demonstrate that the FDA uses the scientific method, to great advantage, whereas Congress uses a cumbersome, unscientific, and unnecessarily dangerous process to develop new legislation. When I get around to it, I will post a Part II, describing a proposal for a new way to draft laws: evidence-based legislation.

When the FDA receives a new drug application (NDA), they start out with the assumption that they do not know whether the drug is safe or effective. The burden of proof is on the pharmaceutical company to prove that the drug does work, and that it has an acceptable safety profile. The FDA will accept only certain kinds of evidence. Evidence that does not meet quality standards is not accepted and cannot be used. The FDA receives information about safety and effectiveness, then has a panel of experts review the information. Only if a majority of experts recommend that the drug be approved, does the drug proceed forward in the approval process.

When the drug is marketed, only some statements can be made to promote the use of the drug. Statements that can be disproved are prohibited. Statements that are not in full accordance with FDA guidelines cannot be used. For example, a pharmaceutical company cannot promote a drug for a purpose other than that for which it has been approved by the FDA.

Once the drug is approved, the manufacturer is supposed to monitor the outcome of patients treated with the drug. If there is an indication of a possible problem, the drug is reviewed again. Continued approval of the drug is contingent upon the outcome of surveillance studies. It is true that the system does not always work correctly, but at least the basic framework is sound. For example, the drug Mellaril was taken off the market a few years ago, when new evidence emerged that it had the potential to cause fatal irregularity of heartbeat. That action was taken about 40 years after the drug was put on the market. It took a long time, but the system eventually did work.

To summarize: In the process of drug approval, the starting assumption is an assumption of ignorance: we do not know if the drug is safe or effective. Evidence is presented to support the hypotheses that it is safe, and effective. The drug is put on the market, but ongoing surveillance is required. If the surveillance detects a possible problem, the drug comes under greater scrutiny. If a problem is found, the drug is withdrawn.

Contrast this to the process of making legislation: In the making of legislation, the starting assumption is that the legislators know a priori what is right and what is wrong. For example, murder is wrong. It would follow, logically, that legislation that prohibits murder would be the right thing to do. When legislation is proposed, legislators, lobbyists, and others can make any claims they want about the bill under consideration. The claims do not have to meet be testable; indeed, they do not have to meet any quality standards at all. Claims can be made that are outright lies, and there is no penalty. The assumption is that the deliberative nature of the legislative process will expose any flaws in the legislation. But the deliberative process follows only a loose outline. There is no requirement that testable hypotheses be advanced, then subject to rigorous, structured scrutiny. It is not necessary to define ahead of time what outcomes can be expected from the legislation; nor is there any surveillance after the legislation is passed.

Clearly, the drug approval process is superior to the legislative process. We jump all over the FDA if they screw up, yet we let Congress jump all over us with bad legislation, without giving it a second thought. Most laws have the potential to affect every citizen, whereas even a blockbuster drug has the potential to affect only a small proportion of the citizenry. Bad legislation can be extremely hazardous to our health. Why do we let Congress get away with lower standards for themselves, than the standards they set for the FDA?

Categories: politics, armchair musings
Tags: politics, scientific method, legislation, Congress, FDA

The Other March of the Other Penguins

2005-10-15T21:28:00.000-04:00

The recent National Geographic film, March of the Penguins, has generated a tremendous amount of controversy: an avalanche of deconstructionism that surely was not intended by its creator. It seems that the controversy started when Micheal Medved claimed, in an NYT interview, that MOTP is "the motion picture this summer that most passionately affirms traditional norms". Andrew Sullivan was quick with a rejoinder, pointing out that some penguins have been observed to engage in homosexual behavior. Others pointed out that some penguins engage in a form of prostitution. Maggie Gallagher jumped in (1 2) when it turned out that some penguins in zoos that previously had been reported to be homosexual, later started to engage in heterosexual behavior.

I am not sure how the disclosure that the penguins are in fact bisexual, rather than homosexual, was supposed to salvage the point made by the Christian conservatives, but that did appear to be their line of argument. Many bloggers and editorialists joined in the fray. (1 2 3 4 5 6 7 8 9 10 11 12)

Having an entire Saturday to consider this issue, I realize now that all of these commentators are missing the point completely.

You see, there is a whole nother (another whole) group of penguins, on an entirely different kind of march...and these blokes won't stop for anything...not even global warming. And the lesson they teach, about the controversy over evolution vs. creation, is far more profound.

THE REAL MARCH

Dell offers "open source ready" desktop PC Dell today announced that it is reacting to "growing consumer demand for open source ready" computers and now offers a version of its n510-series desktop PC that ships with an empty harddrive and a FreeDOS disc. Read more...

Brazil's Serpro: Migration to Open Source Complete by Year-End

Friday - October 14, 2005

Brazil's federal data processing agency Serpro, responsible for assisting government entities with migration to open-source platforms, expects to complete its own migration to open-source software by year-end 2005. In the first quarter of 2005, Serpro had 60 percent of its systems running on open source. [More...]

Haiku's first employee

Haiku, an in-development open source version of BeOS, now has its first full-time paid employee. Axel Dorfler, famed for his rapid work on the kernel and other low-level Haiku components, announced that donations to the project will help him to work full-time on the code until the end of November. He has started a blog with progress updates.

Haiku is a hugely promising open source desktop OS, and you can find it on issue 72's cover DVD. The project's website is outdated in places; you can find recent screenshots on BUG-NORDIC.

OpenOffice.org 2.0 not here (but Happy Birthday anyway!)

The OpenOffice.org team has postponed the expected release of version 2 of the pioneering open source office suite due to the discovery of a 'show stopping bug.' The plan was to unleash the software today (Oct 13th) to commemorate the fifth anniversary of the project's founding.

It's likely that the third release candidate will be made available tomorrow. The bug in question results in incorrect attributes being applied to graphics when saved in the .odt format; it was fixed quickly, but the developers say a new RC is a sensible precaution.

The official version 2.0 should be out before the end of next week. Site: OpenOffice.org

LQ ISO Linux Download Site Reaches One Million Downloads
on Wed 24 Aug 2005, 11:24 AM

From our recent press release:

LinuxQuestions.org is proud to announce that LQ ISO has now facilitated over 1,000,000 Linux downloads. Founded in August of 2004, LQ ISO allows users to find and rate fast local download mirrors. The site currently allows you to download almost 120 different Linux distributions from over 430 different mirrors. The site now utilizes GEO IP data to help you find the fastest local download mirror.

Of course I could go on and on, but you get the point. Open-source software is on the march, with Linux leading the way. From its humble beginnings as an alternative to Unix, Linux has evolved to the point that it is a serious threat to Microsoft OS's.

Another threat to Microsoft is that posed by the open-source applications: Firefox, Thunderbird, and OpenOffice. Linux itself is probably in the same position as Windows 3.1 was, with respect to usability by novices. That is, it is perfectly intuitive to use, but it is easy to break if you mess around very much. If you try to optimize it, add weird software, or use exotic hardware configurations, you can run into problems. If all you do is wordprocessing, web browsing, and email, you'll be fine. Notice, though, that those three applications are all that most people ever do with their computers. And there are full-featured, readily-usable programs that are available freely, for those three functions.

Speaking of the humble origins of Linux, there has arisen considerable debate about the its origins. Several creation myths have been documented (see: Was Linux Forged in Mordor? and An Out of this World Theory). The fact, that mutually contradictory myths exist, raises the question: Was Linux created, or did it evolve? If it evolved, did it evolve randomly, or was there a Guiding Hand, or Guiding Appendage?

Those who believe it was created tend to argue that there is nothing else like it in the natural world. Ordinary star-stuff consists of matter and energy. But Linux transcends those mere things. It consists of intellectual property, which is neither matter nor energy. In fact, no one can really define exactly what it is. The courts say that, even though nobody knows exactly how to define it, they know it when they see it. I suppose that if the explanation is good enough for the Supreme Court, it should be good enough for the rest of us. But serious theologians are not satisfied with SCOTUS. They believe that when something cannot be defined, it must be evidence of a higher power.

Those who believe Linux evolved point to the numerous animal-like features found in close association with Linux. They say that close examination of its code base reveals similarities to the genetic code. Information theorists talk about the similarity between the four-base system (GATC) in DNA, and the hexadecimal (base-16) system in Linux. This, obviously, implies that Linux is more highly evolved than humans.

Advocates of the evolutionary theory also point to the rapid change that occurs in successive generations of Linux. New forms appear all the time. Studies have shown that all of these forms share a great deal of common sequences in their code, with just a few important differences. Within each species, the code usually changes gradually. Every once in a while, however, there is a sudden, massive shift in the code. When this happens, important new capabilities arise, as if by magic.

The creationists point to the sudden, seemingly-magical appearance of whole new chunks of code, with the accompanying new features, as evidence of a creator. They do not see how little chucks of code, that serve no purpose by themselves, could arise by random chance. Even if they serve some clear purpose when assembled, how could the individual sequences come into being? The answer, of course, is that the process is not random. There are elements of randomness, but the process as a whole is structured. New code sequences are tried in various environments, and if they turn out to be helpful, they are incorporated into the whole. If they turn out to be harmful or useless, they do not appear in the finished product. However, if they are harmful or useless, the sequences themselves often are kept in reserve somewhere, in case they turn out to be useful at a later date. Sometimes, the useless chunks undergo further modification to make them useful.

Novices are likely to be perplexed by this debate, given all the complexities involved. In actual practice, most people just take a superficial look at the technical stuff, then make a decision based on their gut instinct. They decide that the explanation that sounds right, must be right. With so many creation myths to choose from, such an approach is understandable. Sloppy, but understandable.

Those who would like to experience wonder and mystical qualities the real March of the Penguins should download a copy of Knoppix here. Burn the ISO image to a CD or DVD (depending on which image you get) and boot it. You will need a PC that can boot from the optical drive. Watch as it boots, detects your hardware, and launches the operating system. It really does seem like magic. Do this every six months or so, and watch as the system evolves to adapt to the changes in the computer environment. You will become a believer, I guarantee it. A believer in what, I do not know, but you will be a believer.

Unpolished Ideas About Neuroscience Discovery...and Other Stuff

2005-10-03T00:41:00.000-04:00

Every once in a while I take some ideas out of the tumbler before they are polished, and inflict them on the world, complete with grit and rough surfaces.

Those who read the Ann Arbor News, and perhaps some other sources, may have heard about this study. One of the neuroscientists at the University of Michigan did a brain scan study on the placebo effect, showing that there are visible changes in the functioning of the brain when a person has a positive response to a placebo. (For an interesting tangent, see also this study concerning gender differences in pain perception.)

U-M neuroscientist
Jon-Kar Zubieta, M.D., Ph.D.

[...] The study provides the first direct evidence that the brain's own pain-fighting chemicals, called endorphins, play a role in the phenomenon known as the placebo effect — and that this response corresponds with a reduction in feelings of pain.

Previous studies at U-M and elsewhere have shown that the brain reacts physically when a person is given a sham pain treatment, which they believe will help them.

The study provides the first direct evidence that the brain's own pain-fighting chemicals, called endorphins, play a role in the phenomenon known as the placebo effect — and that this response corresponds with a reduction in feelings of pain.

Previous studies at U-M and elsewhere have shown that the brain reacts physically when a person is given a sham pain treatment, which they believe will help them.

But the new study is the first to pinpoint a specific brain chemistry mechanism for a pain-related placebo effect. It may help explain why so many people say they get relief from therapies and remedies with no actual physical benefit. And, it may lead to better use of cognitive, or psychological, therapy for people with chronic pain.

The results will be published in the August 24 issue of the Journal of Neuroscience by a team from the U-M Molecular and Behavioral Neurosciences Institute (MBNI). The research was funded by the National Institutes of Health.

“This deals another serious blow to the idea that the placebo effect is a purely psychological, not physical, phenomenon,” says lead author Jon-Kar Zubieta, M.D., Ph.D., associate professor of psychiatry and radiology at the U-M Medical School and associate research scientist at MBNI. “We were able to see that the endorphin system was activated in pain-related areas of the brain, and that activity increased when someone was told they were receiving a medicine to ease their pain. They then reported feeling less pain. The mind-body connection is quite clear.” [...]

Naturally, it would be a matter of great practical interest to learn how the placebo effect works, so that it can be harnessed for therapeutic effects. For example, it would be great if we could learn to use the placebo effect to reduce pain, reliably, without drugs.

However, it seems to me that there could be another, perhaps more important, practical application to this type of research. One possibility is this: One of the biggest problems in drug discovery is the problem of separating active drugs from those with no effect. When studying conditions with a high placebo response rate, the placebo effect can be quite a problem. It can lead to the unnecessary discarding of drugs that have a definite positive effect on a small subgroup of patients. If we had some objective means of discerning when a study participant was having a placebo response, we might be able to salvage some of the new molecular entities that otherwise could not be demonstrated to separate from placebo.

But wait! There's more! In studies of the effectiveness of psychotherapy, the placebo effect is especially difficult to factor out of the analysis. We know that some studies have shown that patients placed on a waiting list for psychotherapy show improvement that appears to be spontaneous; that is, they show improvement that cannot be attributed to a therapeutic intervention. They do not even receive a placebo. Why do these patients improve? Could the improvement be like a placebo response, in some obscure way, or is there some other factor at work?

There are two things about the wait-list patients that are different than people with the same problems, who have not been placed on a waiting list. One is that the patients on the waiting list have a positive expectation of change. That would be similar to the effect of a placebo. Another difference is that the waiting-list patients have taken an important step toward recovery: they have made a decision to do something about their problems.

These musings suggest two new lines of research. For one, would it be possible to demonstrate that there are neurochemical changes in the brains of people who have a positive expectation of improvement, even when no placebo is given? For another, would it be possible to detect neurochemical changes in the brains of people who have made a decision to try to get some help?

Personally, I think the latter question is more interesting. Psychotherapists have known for decades that there is something powerful about the act of making a decision. Indeed, they devote a great deal of effort to coaxing people to make firm, unequivocal decisions to make changes in their lives. Could it be that it is not so much the changes the patient make, that are therapeutic, but the decision itself? That is an interesting hypothesis, although it would be difficult to test.

Is it possible to detect brain changes in response to psychotherapy? Yes, for example, this study shows that patients with obsessive-compulsive disorder, who are treated with and who respond to psychotherapy, have brain changes that are smaller than, but similar to, changes that are seen in those who respond to medication.

Caudate glucose metabolic rate changes with both drug and behavior therapy for obsessive-compulsive disorder.

Baxter LR Jr, Schwartz JM, Bergman KS, Szuba MP, Guze BH, Mazziotta JC, Alazraki A, Selin CE, Ferng HK, Munford P, et al.

Department of Psychiatry, UCLA School of Medicine.
Arch Gen Psychiatry. 1992 Sep;49(9):681-9.

We used positron emission tomography to investigate local cerebral metabolic rates for glucose (LCMRG1c) in patients with obsessive-compulsive disorder before and after treatment with either fluoxetine hydrochloride or behavior therapy. After treatment, LCMRG1c in the head of the right caudate nucleus, divided by that in the ipsilateral hemisphere (Cd/hem), was decreased significantly compared with pretreatment values in responders to both drug and behavior therapy. These decreases in responders were also significantly greater than right Cd/hem changes in nonresponders and normal controls, in both of whom values did not change from baseline. Percentage change in obsessive-compulsive disorder symptom ratings correlated significantly with the percent of right Cd/hem change with drug therapy and there was a trend to significance for this same correlation with behavior therapy. By lumping all responders to either treatment, right orbital cortex/hem was significantly correlated with ipsilateral Cd/hem and thalamus/hem before treatment but not after, and the differences before and after treatment were significant. A similar pattern was noted in the left hemisphere. A brain circuit involving these brain regions may mediate obsessive-compulsive disorder symptoms.

This demonstrates, at least, that it is possible to use PET scans to see changes in brain function that occur as a result of psychotherapy. We do not know how generalizable this finding is, so we do not know if it would be possible to see such changes in conditions that are not as well defined as OCD.

Even if the changes are great enough to be discerned by PET scans, I cannot think of a study protocol that would enable us to separate all the pertinent variables and test the hypothesis cleanly. So maybe this is not such a great idea. But it is interesting to think about.

categories: science, armchair musings
tags: neuroscience, science, medblogger

Ypsilanti 1971

2005-10-01T21:57:00.000-04:00

Whilst in junior high, the author of CC had the nickname, Moose.

Moose was fond of reading, thus visited the Ypsilanti public library often. He rode his bicycle there, leaving it unlocked at the bike rack behind the building. Nobody ever bothered it.

In 1971, the library got its first coin-operated Xerox machine. Moose made a copy of a picture of a Nike missile, from a book about military history. It cost 10 cents: real money, back then. It took about thirty seconds to make one copy, then the paper had to be left in the rack while hot air dried the toner. Truly, a marvel of modern technology.

In 1971, no one could have imagined how many trees ultimately would be felled, to satiate the hunger of the Xerox machines churned out by American industry. We did know, however, that American industry knew no bounds. We'd gone to the moon, and back, several times. The National Aeronautics and Space Act had been passed in 1958, the year Moose was born. By 1969, the astronauts of Apollo 11 bounded upon the Moon. In 1971, the Apollo program was winding down, but teenage boys were chattering excitedly about the plans for a space station.

Every teenage boy wanted to be an astronaut. Moose had wispy stands of facial hair on his chin. He could not wait to get old enough to be an astronaut. By then, surely, we would be building cities on Mars.

James Taylor's song, You've Got a Friend, won a Grammy Award for Best Male Pop Vocal Performance. The song had captured the preeminent emotion of the Nation, for that period of time. An upstart pizza chain, Dominoes, was flourishing after having been started in Ypsilanti. The explosive growth of Dominoes was due to a simple innovation: quick home delivery, using -- of course -- the automobile.

In 1973, there was a little group of upstarts, known mostly to policy wonks. They went by the acronym OPEC. The Average Citizen of our Great Nation had little reason to know about OPEC, much less worry about them. On so they thought. From Wikipedia:

The 1973 oil crisis began in earnest on October 17, 1973, when Arab members of the Organization of Petroleum Exporting Countries (OPEC), during the Yom Kippur War, announced that they would no longer ship petroleum to nations that had supported Israel in its conflict with Egypt—that is, to the United States and its allies in Western Europe.

At around the same time, OPEC members agreed to use their leverage over the world price-setting mechanism for oil in order to quadruple world oil prices. The complete dependence of the industrialized world on oil, much of which was produced by Middle Eastern countries, became painfully clear to the U.S., Western Europe, and Japan, requiring Western policymakers to respond to international economic constraints that were qualitatively different from those faced by their predecessors.

During the middle third of the twentieth century, the I-94 corridor, running west from Detroit, had been populated with factories serving the automobile industry. Ypsilanti was no exception. If I recall correctly, about one-third of economic activity in Ypsilanti was related directly to the automobile industry. OPEC changed that. By the end of 1973, auto plants and storefronts were closing, as unemployment lines were growing.

Moose and his family moved out of Ypsilanti. It was no longer possible to leave a bicycle unlocked downtown. The nickname Moose was nearly forgotten. In fact, it was no longer appropriate. Moose was shaving pretty much daily by then.

Ypsilanti did recover, eventually. EMU built a business school in the downtown area, boosting the revitalization efforts. Later, they erected a fountain on their central campus: a memorial to the influential labor leader, Cesar Chavez.

New Dominoes pizzerias sprouted like mushrooms, each one standing as a memorial to American ingenuity and the centrality of the automobile in American life.

Fast forward to 2005. The Nike missile on the old Xerox copy has long since faded, having been printed on flimsy facsimile paper with first-generation toner. And the headlines tell us that the Visteon plant in Ypsilanti is closing. The article answers some of our questions. The good news is that the employees will be transferred to the Rawsonville plant, so the impact on the city will not be so great as what was seen in 1973. The bad news is that the tax base in the city will shrink, and the businesses that provided goods and services to the plant and its employees will be affected.

The unanswered question: is this when the dominoes start to fall?

More Protest Notes

2005-09-27T23:17:00.000-04:00

I haven't yet uploaded the pictures I took at the rally, but I have collected some from around the 'net. John Conyer's blog pointed to this collection. Other Flickr collections are here and here. Another collection is here. The C-Span video is here: ANSWER Coalition Rally Against War in Iraq (09/24/2005) -- but it would not work for me, giving a page not found error.

Some pro-war sites have pictures as well: here, here, and here. Global Cop has more here; Global Cop was liveblogging, so you have to go to his several posts from 9/25/2005 to find the pictures. There are photos from the LA protest here.

Naturally, I cannot merely find, organize, and post links. My right hemisphere demands equal time. Accordingly, I am going to respond to a comment left here, by Callimachus (Done With Mirrors, The Sciolist)...

That's a thoughtful post. But as one who is not convinced by the anti-war rhetoric, but is open to a reasonable discussion about it, I find the presence of so many "radicals" at the microphone and the bullhorn off-putting.

Even if I know most of the people there were not as fierce as the leaders and speakers, I'd be concerned about a movement that lets the fringe rush the stage and hold it all day.

You might want to consider the ultimate goal of the rally: Was it to expose the already-converted to even more radical agendas? Then why make a media spectacle of it?

Or was it to convince the not-yet convinced that there's a good case to be made for -- immediate withdrawal from Iraq, impeachment, whatever it is that the rally is addressing.

It's an age-old problem for groups in this situation. Back in the '60s, was middle America turned against the Vietnam War by the antics of Abbie Hoffman, or by its own reflection on the casualty list and by institutions like Life magazine and Walter Cronkite?

If what I suspect is correct, and the hippie street theater made it more difficult, not easier, for straight-laced America to turn against its government, then why repeat the mistake?

The fact is, I am close to the last person on the planet who would engage in any kind of "street theater," and I knew perfectly well who was sponsoring the event. I do not agree with much of what they had to say. So why go? The reason is that quiet moderate types do not seem to have any inclination to organize this kind of thing. When they do, I'll go to their rallies instead.

From my perspective, the problem is not how do we avoid alienating moderates? Rather, the problem is, how do political moderates find a way to make their voices heard? One way is to latch on to people who know how to get their message across. Perhaps it is not ideal, but it one way to address the problem. Moreover, and again speaking purely from my own perspective, the fact that a quiet moderate type of guy would go so far as to associate with radicals, is a way of showing the people I know, personally, that I am serious about my antiwar sentiment. I would not put myself in that position unless I felt strongly about it.

In that way, the street theater put on by others is something that accentuates the message I sent to my friends and coworkers by attending the rally. My decision to go to the rally had nothing to do with the national media. I was not trying to change the world by going to Washington. Instead, it was a way for me to influence the small groups of people that I realistically can influence: those who know me personally. Perhaps there will be a bit of influence on those who read this blog, and who know that I am a pretty serious guy, not prone to extravagant display of emotion. But that really is not high on my agenda.

The reason that I emphasized, in my previous post, the small-group interactions that took place at the rally, is that I believe that it is personal influence in small groups that is the most powerful agent of change. In fact, there is reason to believe that it is persons who have loose ties, with multiple small groups, who have the greatest social impact. Such persons act as channels through which ideas can flow from one group to another. See The Strength Of Loose Ties. American Journal of Sociology, 78, 1360-1380. Granovetter, Mark S. (1982). It is not in the public domain, but you can find out about the concept by Googling "The strength of loose ties" with the quotes. (I have a PDF copy of the paper somewhere, and it probably would fall into a "fair use" category for me to share it with a small number of interested individuals.)

Will there be some people who are put off by the street theater? Sure, but they will forget about it after a short while. In contrast, the persons whom I can influence will not forget quickly, because one does not readily forget the actions taken by those whom they know personally. I cannot prove that the latter affect outweighs the former, but I tend to think it does.

Corrective Emotional Experience

2005-09-25T20:01:00.000-04:00

Looking through the photos that are available, so far, from the 9/24/2005 peace rally in Washington DC, it appears that three basic themes predominate. One is the size of the crowd; another, the intensity of expressed emotion; the third, the incidence of people who dressed funny. The problem is, those three categories of photo do not convey the core of the experience of being there; nor do they capture what, to me, is the area of greatest human interest.

The crowd was massive. But early in the morning, the crowd was not so dense as to preclude freedom of movement. It even was possible for individuals and small groups to have moments of relative privacy. I noticed that people in general were aware when others were having an emotional moment, and respected the appropriateness of privacy and boundaries.

There were a lot of individuals who ended up having moments of intense feelings. I did not photograph any of those. Even if I had, I would not post them.

Those of you who have had emotional reactions, based upon the photos posted online so far, may be in need of a corrective emotional experience. Actually, come to think of it, that is not exactly the correct term to convey what I am trying to convey. It is not a formal term (yet), but I guess what I am thinking is that people may need a supplementary emotional experience. So here are three pictures to supplement what has been posted elsewhere.

One of the most important aspects of the experience of being at the rally, was the sharing that occurred in small groups. The photo above was taken while I was sitting on the ground, and I did not hold the camera up to my eye, so it is not framed very well. Even so, it captures a moment in the experience of a small group of young women....girls, I guess, if that term is still politically acceptable.

Another small group: these people were, I think, associated with Camp Casey. They made a lengthy chain with pictures of the troops who have died in combat. They later carried it along the march route. I'm reasonably sure that the experience of doing that was emotionally evocative for those who participated.

These are people ambulating among the crosses. Notice the couple holding hands. I'm sure they have a story to tell, although I have no idea what it is. Notice how the rest of the crowd was giving them some space. There must have been a reason for that.

I was not close enough to see the expressions on their faces, and did not want to be intrusive by waiting until I could get a good telephoto shot.

I did see a lot of individuals crying. One in particular, whom I would have liked to have photographed, was a youngish woman sitting on the ground, by a display of empty military footwear: boots on the ground. She was weeping quietly. People gave her the physical space to do so, granting that particular kind of privacy that one can sometimes get, even in the midst of a couple hundred thousand people.

My moment came when I happened to see a picture of a woman receiving a flag from an Army officer, during the course of a military funeral.

When I was 17, I was a bit of a jock, a teenage boy, not yet very aware of my own emotional states. My uncle, who had been in the Coast Guard during WWII, died. I was in a speech class at the time, and my family came to get me. They must have called the college to find out where I was. A couple of days later, I went to the funeral. I still remember the feeling of the cold steel of the coffin handle, having been one of the pallbearers.

Despite being an active participant in the ritual, I did not experience much emotion. Not much, that is, until the officer handed the flag to my aunt. She burst into tears. At that moment, I became a little bit more of an adult.

In my first post about the rally, I emphasized the need for people to get the pertinent information, and evaluate it individually, critically. Naturally, the raw data present only half the story. The emotional experience of being at the rally is the other half. Some of those emotions were shared among the crowd. But some were entirely private. Some had nothing to do with the stated purpose of the rally, or were related only peripherally.

In order to grow into adulthood, or to continue one's growth as an adult, we need to use our intuition to seek out those experiences that generate resonance in our emotional lives. Shielding yourself from such experiences is maladaptive. Dismissing the experiences of others is mean-spirited and unhelpful.

Corrective Emotional Experience

2005-09-25T18:20:00.000-04:00

Initial Responses to Antiwar Rally in D.C.

2005-09-25T12:11:00.000-04:00

First, the observations, then the hypotheses; the conclusions follow.

The rally/march/concert/speeches were mainly sponsored and organized by radical groups. However most of the attendees were not radicals. The antiwar aspect of the rally was merely the focal point, since the Iraq war was the most egregious of the alleged offenses perpetrated by the Administration.

Several speakers at the rally before the march commented specifically on the diversity of the crowd, and made the explicit point that people do not all need to have the same slogan in order to get together for a common cause. Several attendees made it clear that they had agendas of their own.

One of the most frequent chants, and the one that energized the crowd most effectively, was "IMPEACH BUSH NOW;" nobody chanted, "CONVICT BUSH NOW." Many of the people there dressed funny.

Most of the people there looked pretty normal. Most had a protest t-shirt, or something like that, but otherwise looked like any pedestrian.

All of the events held so far (more events are taking place as this is being written), have been complex interactions between thousands of people. I think that any generalizations that could be drawn would necessarily be rather limited in their utility.

Different news organizations have reported on the events in various ways, covering some events but not others Some were presented with a slant or a spin; others objectively.

What conclusions can be drawn from those observations? A few hypotheses have been advanced in the Blogosphere (1 2 3 4 5 6 7 8 9 10 11 ). Let us examine some of the hypotheses and see what conclusions can be drawn.

Does it "taint" the reputation of, or the points made by, the nonradicals, since the activities were organized by radicals? (If a conservative student speaks up on a liberal campus, are her points less valid because the campus is liberal? If liberals attend a conservative University, does that make the entire University more credible? Less? )

Does the diversity of those participating in the events mean anything? {If you need to move a sofa to a new house, is it necessary that all the people who help, be members of the same political party? If they all have a common purpose, why can't they get together and cooperate for a little while? The sofa still gets moved, even if Jane Fonda is carrying one end, while Donald Rumsfeld carries the other. (Stranger things have happened.)}

Does the variability in news coverage mean anything?

Does the fact that reporters sometimes do some of their writing before the event diminish the credibility of the reporting?

From my standpoint, the main general conclusions are these:

1. A bunch of people are pissed off at the Administration, and want the President and vice-President to be impeached and convicted, for a variety of reasons. (But even the President and vice-President are entitled to due process under the law.)

2. Some people enjoy wearing funny clothes and getting their picture taken. (But the messenger is not the message. Everyone knows that already.)

3. The media choose to cover (or not) various events in various ways. Liberals think the media are too conservative; conservatives think they are too liberal. I think the media outlets each have a little bit of their own agenda, and the rest of the variation is due to factors that are either random or trivial. (One such factor is the fact that reporters have deadlines, as a result, they may do some of the writing before the event; each instance of this should be judged separately.) Trying to draw meaningful conclusions based upon random or trivial factors can be fun for bloggers, but it is not particularly meaningful. If there is a general conclusion to be drawn about this, it is that the media are not very reliable.

People cannot sit back and expect information that is spoon-fed to them to be objective; they need to do their own research and their own analysis. Hey, maybe we should try listening to what people actually said. Or reading the text of Cindy Sheehan's speech.

Start with the observations.

It turns out that there are few if any useful generalizations that can be made concerning the rally, or those who were at the rally, or those who have reported on the rally. However, there was a lot of information presented at the rally; that is where are attention should be.

Sleep Apnea Updates

2005-09-21T23:34:00.000-04:00

There are three: one from WebMD; the other two, from the WebMD professional companion site, Medscape (free reg. req.). I used to post fairly often on medical topics that show that illness are often much more complex processes that they appear to be. Today, I stick to more practical "clinical pearl" matters.

Treatment for Sleep Apnea May Ease Depression
Symptoms of Depression Often Overlap With Obstructive Sleep Apnea; CPAP May Help

By Miranda Hitti
WebMD Medical News
Reviewed By Brunilda Nazario, MD
on Monday, September 12, 2005

Sept. 12, 2005 -- People with obstructive sleep apnea often show signs of depression, and treatment that prevents snoring and breathing disruptions may help, new research shows.

According to the national sleep foundation, obstructive sleep apnea is a disorder in which breathing is briefly and repeatedly interrupted during sleep. It occurs because muscles in the throat are not able to keep the airway open.

The treatment called CPAP (continuous positive airway pressure) is a device that helps people with obstructive sleep apnea breathe more easily during sleep.

At a Florida sleep center, 50 patients were recently asked to use CPAP for four to six weeks. The patients' depression symptoms improved during that time, according to a study in Chest.

The researchers' recommendations:

    * Screen people with depression symptoms for obstructive sleep apnea.
    * Screen people with obstructive sleep apnea for depression. [...]

Obstructive Sleep Apnea Associated With Early Signs of Atherosclerosis

By Will Boggs, MD

NEW YORK (Reuters Health) Sept 02 - Otherwise healthy middle-aged patients with obstructive sleep apnea (OSA) show early signs of atherosclerosis, according to a report from Brazil. "Our findings support the hypothesis of a direct link between obstructive sleep apnea and cardiovascular diseases," Dr. Luciano F. Drager told Reuters Health.

Dr. Drager and associates at the University of Sao Paolo measured early atherosclerosis indicators -- that is, pulse wave velocity (PWV), carotid diameter, and intima-media thickness (IMT) -- in 30 patients with untreated OSA and 12 matched healthy volunteers. None of the participants had previous evidence of cardiovascular disease.

All three indicators of early atherosclerosis showed a trend toward direct correlation with the severity of OSA, the investigators report in the September 1st issue of the American Journal of Respiratory and Critical Care Medicine. [...]

Long-Term Effects of Nasal Continuous Positive Airway Pressure Therapy on Cardiovascular Outcomes in Sleep Apnea Syndrome
Liam S. Doherty, MD; John L. Kiely, MD; Valerie Swan, RgN; Walter T. McNicholas, MD, FCCP

Background: Obstructive sleep apnea syndrome (OSAS) has been associated with increased morbidity and mortality, principally from cardiovascular disease, but the impact of nasal continuous positive airway pressure (CPAP) therapy is unclear.
Methods: We performed a long-term follow-up study of 168 patients with OSAS who had begun receiving CPAP therapy at least 5 years previously, most of whom had been prospectively followed up, having been the subject of an earlier report on cardiovascular risk factors in OSAS patients. The average follow-up period was 7.5 years. We compared the cardiovascular outcomes of those patients who were intolerant of CPAP (untreated group, 61 patients) with those continuing CPAP therapy (107 patients).
Results: CPAP-treated patients had a higher median apnea-hypopnea index score than the untreated group (48.3 [interquartile range (IQR), 33.6 to 66.4] vs 36.7 [IQR, 27.4 to 55], respectively; p = 0.02), but age, body mass index, and time since diagnosis were similar. Deaths from cardiovascular disease were more common in the untreated group than in the CPAP-treated group during follow-up (14.8% vs 1.9%, respectively; p = 0.009 [log rank test]), but no significant differences were found in the development of new cases of hypertension, cardiac disorder, or stroke. Total cardiovascular events ( ie , death and new cardiovascular disease combined) were more common in the untreated group than in the CPAP-treated group (31% vs 18%, respectively; p < 0.05).
Conclusions: The data support a protective effect of CPAP therapy against death from cardiovascular disease in patients with OSAS. [...]

The take-home points seem fairly straightforward.

There is overlap in the symptoms presented by patients with OSA, and in those presented by patients with depression. Often they coexist. So from the doctor's perspective, if you see one, you should look for the other. From the patient's perspective, if you are treated for one and do not get as much improvement as you think you should get, ask about the other. I would add that in a secondary or tertiary care setting, these correlations are going to be stronger than in a primary care setting.

OSA is associated with accelerated atherosclerosis. So it might be worth treating, even if the cardinal symptom of daytime sleepiness is not very bad. Of course, you might not want to do that unless you have some evidence that the treatment actually does some good. To expand on that point: If a study shows an association between factor A and effect B, and there are good theoretical reasons to believe that factor A plausibly could be a cause of effect B, then it is tempting to try to correct factor A in an effort to prevent effect B. But, alas, that is not always the case.

That is where the third study comes in. Careful readers will see that the second and third studies presented here do not provide proof that it is worthwhile to treat OSA patients who have minimal symptoms. But together, the two studies are highly suggestive. Assessment and treatment of OSA can be costly, but the third study indicates that the potential benefits are large.

Obstructive sleep apnea, at first glance, appears to be a fairly simple problem. Something in the airway constricts under conditions of reduced pressure, caused by inspiration. That blocks air flow. Use a machine to increase the pressure, and the problem is solved. It turns out, though, that the pathophysiology of OSA is not so straightforward. In fact, a more technical article at Medscape refers to it as follows: "Sleep apnea is a conundrum of causes and effects. New studies show that many causes become effects, and vice versa." That "conundrum" is the kind of thing I used to blog about more often. But today I am more inclined to stick to practical matters.

Buprenorphine Explainer:Subutex and Suboxone

2005-09-15T23:04:00.000-04:00

As I go about my days, I get the impression that there is a lot of confusion out there about the treatment of opiate abuse and dependence. Wes Clark (not that Wes Clark, the other one) has written an article to help us understand this nettlesome issue.

First, I summarize some point from his article, and a few others, then add a few bits of my own.

Dr. Clark provides us with some historical background in his article, Office-Based Practice and Opioid-Use Disorders (H. Westley Clark, M.D., J.D., M.P.H.: NEJM, Volume 349:928-930, September 4, 2003)

In the case of Webb v. United States, the U.S. Supreme Court ruled that the 1914 Harrison Narcotic Drug Act made it illegal for physicians to prescribe narcotics for the purpose of keeping a patient "comfortable by maintaining his customary use." For more than 80 years, it remained illegal in the United States for physicians to prescribe opioid medications for the treatment of opioid dependence. [...]

The Harrison Narcotic Drug Act and decisions such as Webb v. United States essentially gave the following message to physicians: "Treat an addict; go to jail." Physicians consequently were reluctant to address the medical needs of those with opioid-use problems. [...]

On October 17, 2000, the Drug Addiction Treatment Act of 2000 was signed into law in the United States. This act allows Schedule III, IV, or V narcotic medications that have been approved by the Food and Drug Administration (FDA) for the treatment of narcotic-use disorders to be administered for either medically supervised tapering (detoxification) or long-term maintenance. On October 8, 2002, the FDA approved the use of buprenorphine (see Figure) and of buprenorphine in combination with naloxone — both Schedule III drugs — for either detoxification or maintenance.

Dr. Clark spares us the additional political dimension, that of the "War on Drugs." Those interested in that orthogonal may wish to review the commentary in the Blogosphere at Pornographical Physics and INDC Journal.

Those interested in yet another dimension may wish to see what the artistically inclined have to say about the subject.

Collapsing back to the Flatland of neurochemistry, let's review what is known about buprenorphine. It acts on the mu (µ) opioid receptors in complex way. It is a mixed agonist-antagonist (or partial agnonist), meaning that it partly stimulates the receptors, but prevents them from receiving further stimulation.

Buprenorphine is available in three formulations: Buprenex ®, is an injectable form of buprenorphine hydochloride that is suitable for treatment of acute pain in persons who are not opiate dependent; Subutex ®, a tablet for sublingual usage, contains buprenorphine hydochloride as the only active ingredient; Suboxone ®, also a sublingual tablet, contains two ingredients: buprenorphine HCl and naloxone HCl. (1, 2) For the purposes of this article, I will refer to Subutex and Suboxone collectively by the informal term, "Bup," which is short for buprenorphine.

Subutex and Suboxone are manufactured by Reckitt Benckiser Pharmaceuticals (whose main claim to fame is that they are the World's #1 producer of household cleaning chemicals.) What is the rationale for including Naloxone in the Suboxone formulation? Naloxone is a mu opiate antagonist. It is not active when taken by mouth, so it does nothing if the drug is used as intended. However, if someone attempts to abuse it via injection, the naloxone blocks the opiate receptors, preventing the buprenorphine from acting. If that person happens to be opiate dependent, it puts them into abrupt withdrawal. Few people do that more than once.

Subutex and Suboxone were developed specifically under the aegis of the National Institute on Drug Abuse's Medication Development Division; this involved collaboration between NIDA, the FDA, and private industry. It was developed in response to some practical difficulties that arose with the use of methadone. Every once in a while, good things happen when people sit down and talk to each other. As the FDA puts it:

Subutex and Suboxone are the first narcotic [usage note - ed.] drugs available for the treatment of opiate dependence that can be prescribed in an office setting under the Drug Addiction Treatment Act (DATA) of 2000. Until recently, opiate dependence treatments in Schedule II, like methadone, could be dispensed in a very limited number of clinics that specialize in addiction treatment. As a consequence, there have not been enough addiction treatment centers to accommodate all patients desiring therapy. Under this new law, medications for the treatment of opiate dependence that are subject to less restrictive controls than those of Schedule II can be prescribed in a doctor's office by specially trained physicians. This change is expected to provide patients greater access to needed treatment.

Indeed, Bup has been shown to be helpful for persons with heroin dependence. The NEJM article summarizing the seminal study is this one: Office-Based Treatment of Opiate Addiction with a Sublingual-Tablet Formulation of Buprenorphine and Naloxone. The results actually were underwhelming, at least at first glance:

The proportion of urine samples that were negative for opiates was greater in the combined-treatment and buprenorphine groups (17.8 percent and 20.7 percent, respectively) than in the placebo group (5.8 percent, P<0.001 for both comparisons); the active-treatment groups also reported less opiate craving (P<0.001 for both comparisons with placebo). Rates of adverse events were similar in the active-treatment and placebo groups. During the open-label phase, the percentage of urine samples negative for opiates ranged from 35.2 percent to 67.4 percent. Results from the open-label follow-up study indicated that the combined treatment was safe and well tolerated.

So persons treated with placebo stayed straight about 5% of the time; whereas those who were treated were successful about 20% of the time. Like I said, that may not seem impressive. But when you consider the awful consequences of heroin abuse, any improvement in the rate of success is welcome. Note, however, that Bup is not limited to use in treatment of heroin dependence. It can be used for treatment of dependence or abuse of any opiate. Furthermore, it can be used in three ways. It can be used to detoxify patients, i.e., taper them entirely off the use of an opiate. It can be used for long-term maintenance of opiate abusers. Also, it can be used for long-term treatment of chronic pain, even if the patient was not actually abusing whatever opiate they were treated with initially.

Over the next few days, I plan to go into more detail about these various uses of bup. In the meantime, if you find yourself craving more medical writing, check out the 51st Grand Rounds at Sneezing Po.

----------
usage note: the term narcotic is actually a legal term, under law that defines certain drugs as drugs of abuse; it is not really a medical term. The term narcotic referes to a pharmacologically diverse group of drugs, including heroin, cocaine, and cannabis. The more precise term for morphine-like drugs is opiate.

Time for Investigative Journalism?

2005-09-12T02:13:00.000-04:00

Something reminded me of a couple of old chapters in my life. I've been thinking about that, and I realized that there are two stories here. One is personal, and not very interesting to anyone who does not know me. The other is important to everyone who lives in Michigan.

In 1976, having just finished my freshman year at college, I needed a summer job. I had no job experience to speak of, but some decent skills. Specifically, I had learned photography, and was good at electronics. There was an opening for a student extern at the Center for Forensic Psychiatry (1 2), in their audio-visual department.

The CFP is basically a state hospital for persons with mental illness, who are in trouble with the law. It also serves as a training site for the University of Michigan, primarily their Department of Psychiatry. The AV Dept. produced educational material for use in orientation of patients and staff, as well as for the training program.

Back, then, the Government actually thought it was appropriate to provide jobs for people, and I was lucky enough to get one of them. Unemployment in the area was still pretty high, because the auto industry had taken a big hit during and after the OPEC oil embargo.

In 1976, there were plans to build a new CFP, but the plans were put on hold because the State economy was not so good. In 1977, I worked there again in the summer. The economy was still improving, but the plans were still on hold.

In 1989 and 1990, I worked there again, although in a different capacity. I was a fourth-year medical student, and they had some externships for M4's. Basically, we would go there in the evening, perform and write up two admission history-and-physical exams (H&P's) , then sleep the rest of the night. If any medical problems arose, I'd have to get up and triage them, then call a report to the attending. It only paid something like $9/hr, but I pretty much got paid for sleeping. It was close enough to my townhouse that I could ride my bike to work. A pretty good deal, actually.

Both of those jobs required me to go to every unit in the place, so I got to see most of it. It was in pretty bad shape, in 1976; by 1990, it was much worse.

By 1990, the need for a new CFP had gotten so acute, that plans to build a new one were underway in earnest. The old one was really just a cordoned-off part of the Ypsilanti Regional Psychiatric Hospital, otherwise known as "Ypsi State."

A sociological aside: "Ypsi State" had an Ypsilanti mailing address, and CFP had an Ann Arbor mailing address, even though they both were on the same land; yet, both actually are closer to Milan, than to either Ann Arbor or Ypsilanti.

No community wanted its name associated with a state psychiatric hospital. Ypsilanti, being lowest on the prestige scale, got that dubious privilege. CFP, by virtue of its association with UM, deserved the more prestigious address.

None of that has anything to do with a need for investigative journalism.

After 1990, the State decided to save money by eliminating the student externships. But due to various regulations, the job still needed to be done. Since there were no more externships, they hired, not medical students, but residents. That ended up costing a lot more.

But that is routine government stupidity; if that were all there was to it, it would not call for investigative journalism.

Our State Government, at the time, decide to do the taxpayers another favor. They took the lowest bidder -- an out-of-state contractor -- for the construction of the new CFP. So instead of having millions of dollars stay in Michigan, they shipped much of that money away, where it does no good for Michigan residents. I'm no economist, but I know that was a dumb thing to do. But that is not all. The outstate contractors botched the job rather badly. That led to a two-year delay in the construction, and massive cost overrun.

The land that the old CFP was sitting on was bid on by Toyota, a deal which held the promise of many new, high-paying jobs for the area. The deal was almost lost because of the delay. Even with the deal finally going through, those jobs are not here yet.

The new CFP finally opened, earlier this year.

One might wonder why the new CFP needs that massive glass part in the middle. One might be annoyed to learn that it leaked terribly, and was one of the things that led to the delay and cost overrun. It wouldn't have been so bad if it had been a necessary part of the design, but the fact that it was wasteful to begin with, makes the additional waste much more regrettable.

I don't know much about the specifics. In fact, most of what I know is hearsay; it may not be reliable. Therefore, I tried to get more reliable information.

Oddly, a Google News search on "Michigan Center for Forensic Psychiatry" turned up only four hits: none interesting; none informative. Yet there is a story there that should be told. We just need someone who knows how to do real journalism, instead of mere blog journalism, to look into it.

categories: rants, politics
tag: Michigan

Bertrand Russell on Transition;Real Risk of Totalitarianism in a Democracy

2005-09-11T00:58:00.000-04:00

In The History of Western Philosophy, Bertrand Russell makes makes interesting comments on the transition from the end of thoughtful contemplation of St. Thomas Aquinas to that philosophically bankrupt era known as the Dark Ages. I am going to write about that, as soon as I either find my copy of the book, or get a new one.
--j7uy5

I wrote that a week ago, but never actually posted it; instead, I wrote this. (You may need to read the older post to put this one in context.) Now that I actually have the book and have read the chapter, I can proceed to write what I had planned all along.

I received The History of Western Philosophy a few days ago. Becoming reacquainted with it, I am surprised it did not make the list of Ten Most Harmful Books of the 19th and 20th Centuries. Maybe the people who made up that list are not as well-read as they like to think they are.

The passage in Russell that I was trying to remember is this, at the end of Part I, Chapter IV:

It is strange that the last men of intellectual eminence before the dark ages were concerned, not with saving civilization or expelling the barbarians or reforming the abuses of the administration, but with preaching the merit of virginity and the damnation of unbaptized infants. Seeing that these were the preoccupations that the Church handed on to the converted barbarians, it is no wonder that the succeeding age surpassed almost all other fully historical periods in cruelty and superstition.¹

I first read that in 1975. The book is over 800 pages long, and I am not blessed with a photographic memory. So one may wonder why, in 2005, that passage would come to mind; and come to mind with such an emotional overtone that I would feel compelled to buy another copy of the book. That is exactly the sort of introspective observation that fascinates me.

Sometimes these seemingly random recollections do have meaning.

No doubt, the passage came to mind because of a similarity to our current times. The parallel is not exact. For one thing, I do not mean to imply that we are about to enter another Dark Age, although we must not forget that such a thing is possible.

The parallel is not exact, because it would be difficult to argue that the current political leadership in the USA consists of "men of intellectual eminence." Moreover, they do seem to have a concern with expelling "the barbarians;" although "barbarian" has come to hold a judgmental implication that I would not apply myself; rather, I use it to express the Administration's view of illegal immigrants, poor people, and certain political refugees.

I would say, however, that a case could be made for the view, that the Administration is not particularly concerned with saving civilization, nor with reforming their own abuses; clearly, they do have a preoccupation with preaching the merit of virginity.²

Perhaps it is not obvious why a casual blogger would advance the notion that the Administration of the United States of America is not concerned with saving civilization. Is this merely a partisan snipe? Hardly. The Corpus Callosum is much more interested in promoting dialog, forming connections, and advocating compromise. Plus, I happened to notice that a moderately conservative blogger (an American living in China, which no doubt gives him an interesting perspective) at Banana Oil has expressed some of the same concerns, taking care to point out that a dictatorship could arise in either party, with de facto single-party rule being the primary risk.

Theoretically, it is true that this could happen with either of the major political parties. If either party came to hold an irrepressible dominance, it could lead to totalitarianism. But of course, at this time, the actual risk comes from the Republican party. This risk will not be perceived, readily, by the (shrinking) number of citizens who still trust the individuals who lead the Republican party at this time. The problem is, that if such a concentration of power develops and matures to the point that there is no credible challenger, it is only a matter of time before some truly ruthless people maneuver themselves to the center of power. Such an entity obviously would not be concerned with reforming its own abuses.

I believe that it is more accurate to say that humans are fundamentally good, than to say we are fundamentally evil; even so, I am aware of the fact that some people truly are evil. Some of them are politicians.

Given that one-party rule is possible, and that truly evil persons do exist, there really could be a risk to civilization. Our political system was designed with the explicit purpose of diminishing the probability of a dictatorship emerging here. That was the rational for most of our electoral system, the Bill of Rights, and the system of checks and balances between the branches of government. Until now, the system has worked fairly well. However, there have been developments that could not have been anticipated by our Founders, developments that threaten the effectiveness of the safeguards against totalitarianism.

The current Administration has an explicit policy of gaining and keeping control of all four branches of government: The White House, Congress, The Supreme Court, and K Street. Not only is this contrary to the conceptual foundation of our democracy, it is an incredibly foolhardy policy. I would oppose this regardless of which Party controlled the four branches. Simply put, that is too much power for any one group to have. Such a concentration of power does threaten civilization. Indeed, in this post-Hiroshima age in which we live, it threatens not just civilization, but all of human life. Although the United States of America never has had such a leader as 김 정일 (Kim Jong-il), we must not forget that such a thing is possible.

Dictatorship within the United States is possible, because the safeguards within our political system are outdated.

When the Constitution and Bill of Rights were written, there were 13 states, each semi-autonomous. The tensions inherent between the states acted as part of the safeguard. Now, although states still have individual agendas, the divisions are not so great. Therefore, it is more likely that a block of states could form in such a way as to exert a dominating force.

Similarly, in the eighteenth century, rapid travel and communication across large distances were not possible. This made it much more difficult for large coalitions to form, and to remain stable. Now, communication is essentially instantaneous, and travel is pretty quick. Moreover, mass communication has been refined to an art form. (Not that is always is used for aesthetic purposes.)

Advertising and other forms of marketing have been refined, such that they now are both more powerful, and more predicable in their effects. Coupled with information technology, it is possible to derive fairly accurate lists of likely voters, and to anticipate their likely voting habits. It also is possible to direct political marketing efforts precisely where it is most likely to have the greatest impact.

Information technology has another important impact: it has made gerrymandering much more dangerous. Tom DeLay's redistricting of Texas included some very strange geometrical configurations. The configurations were so complex, that they must have used computerized mapping and modeling to generate them. This made the resulting districts more predictable and secure than they could have been otherwise.

Economic stratification and economic mobility are other factors to consider. The more rigidly stratified a society, the more stable the gerrymandered districts will be. As it happens, in the USA, within the past five years, there is more economic stratification and less economic upward mobility than there used to be. There is more home ownership; this makes people less likely to move from one place to another. There also is more homelessness, but that is not important: homeless persons rarely vote.

In order to really make the case that there is a risk of totalitarianism here, it is necessary to show, not just that there are structural problems with our political system, and that there are evil people in the world; it is necessary to show that some of those evil people really could manage to get elected.

The usual conception of an evil person corresponds roughly to the psychiatric definition of antisocial personality disorder. The psychiatric definition includes seven personality traits that, statistically, tend to come together as a package. Note that, in common usage, the term antisocial is sometimes substituted for asocial. To clarify: an asocial person is a person who avoids social interaction. An antisocial person is a person who actively disrupts social harmony, causing harm to others.

Another such statistical clustering of maladaptive personality traits is called narcissistic personality disorder.
In the political realm, narcissistic personality traits are not only common, they seem to be preferred. Some of these folks are real charmers. In contrast, most antisocial types are not particularly appealing, and would be unlikely to get elected to anything. In addition, persons with antisocial personality disorder tend to accumulate enough of a criminal history that they could not hide it from a sufficiently determined opponent.

One of the most important of the narcissistic personality traits is that called entitlement. Persons with narcissistic personality disorder believe that there is something special about them, such that they deserve to bend (or break) the rules. In actual practice, this trait tends to be cloaked in some socially presentable form. There are many different ways in which this is done, but a full treatment of that would require a small textbook. Such persons tend to believe, quite earnestly, that it really is OK for them to expect special treatment. Sometimes, their conviction in this belief is convincing to others.

Of course, in nature, personality traits are assorted in a variety of ways; nature apparently has not read our textbooks. It is common to encounter persons with an assortment of features from both the antisocial and the narcissistic categories.

The most dangerous people, in a political context, are those that have just the right mix of antisocial and narcissistic traits. They have enough narcissism to be charming, and to overshadow their sociopathic tendencies. Yet, at the core, they are antisocial. They act with casual disregard for social order, and take delight, either quietly or openly, in causing harm to others. They may even claim that they are doing good, on some level. (See Confessions of an Economic Hit Man, for examples.³)

Bertrand Russell's commentary implies that it was the tunnel vision of the predominant power in the fifth century that led to the Dark Ages. Rather than keeping their eye on the broad, critical issue of saving civilization, they focused on the overvalued specifics of sexual repression and proselytizing. This is strikingly reminiscent of the gay marriage ban, the suppression of OTC emergency contraception, the push for faith-based initiatives, and the false-flag operation known as Intelligent Design.

Although the majority of persons involved in these specific religious initiatives think they are saving civilization, I would argue the opposite. Rather that saving anything, they are focusing too narrowly, thereby missing the real threat. The real threat comes from the possibility of unchecked power, concentrated in the hands of a few, armed with nuclear weapons, elected by a people who are unable to discern the difference between a genuinely nice person and a clever antisocial narcissist.

There are three problems here: the weakening of the protection against concentration of power, the supply of evil persons, and the inability of the population to recognize a certain kind of evil. We can do nothing about the supply of evil persons. We can do something about the other two problems.

We can initiate change in our political system. It would have to be a fundamental change in order to be effective. This would be difficult. However, if I am correct about the nature of the forces that are weakening our system, the problem and the threat will only grow worse unless change is undertaken. Examples of such changes would include proportional representation, and instant-runoff voting.

We can improve our ability to recognize evil politicians. I would add, at this point, that anyone who takes part in any social system that creates or concentrates power, has an obligation to be sure that the power is used appropriately. Since we all take part in such organizations, we all share this obligation. Those who participate in religious organizations have a particular challenge, in light of the following:

When fascism comes to America, it will be wrapped in the flag, carrying a cross.
— Sinclair Lewis

I've seen that quote on somebody's sidebar, and would like to give her or him credit, but now I can't find it. In any case, recall that the clever antisocial narcissist will have a cloak for his or her sense of entitlement. The cloak does not have to be a flag and a cross, but it could be. That seems to be a popular costume, these days. Note that I am explicitly stating that not all patriotic Christians are suspect, just that within that group, there may be a few dangerous ones.

There are many Christians (1 2 3 et. al.)who are upset by their perception that their religion is being hijacked. I encourage them to remain vigilant. I can't argue that religious persons should forget the specific issues that concern them, although it perplexes me that gay marriage and contraception should be such a big deal. I just don't want anyone loosing sight of the real threat.

Like the concern seen among moderate Christians, there are many patriots who have expressed concern that there is more to being a patriot, than slapping a magnetic flag on the rear of your vehicle. They, too, are encouraged to remain vigilant.

------
¹ Russell, Bertrand, (1945) The History of Western Philosophy. New York: Simon and Schuster. p. 366
² The reader is hereby informed that the Corpus Callosum does not deny the merits of virginity; under certain circumstances, it is highly desirable. However, it is an error to preach the merits of virginity to the exclusion of the merits of latex condoms.
³ Note that I am not claiming that the author, John Perkins, has a personality disorder. The behaviors described in his account are suggestive of the type of narcissistic/antisocial character that I am describing, but the act of true confession would not be consistent with a clinical diagnosis of a personality disorder. Besides, I never met him, so cannot claim to be able to diagnose him.

Categories: politics, armchair musings

Nice Little Chat

2005-09-08T19:18:00.000-04:00

Bravomedic Blogger wrote:

Hello,

I was reading the “Grand Rounds” at your blog. I’m currently 17 years old and want to go to medical school. I’m also a volunteer at a local rescue squad. Do you have any suggestions/tips for getting into medical school? My blog at http://bravomedic.blogspot.com explains the rest in case I’m forgetting something. The important stuff is toward the bottom.

Thanks in advance,

Brandon

On 9/6/05, Joseph j7uy5 <joseph.j7uy5@gmail.com> wrote:

First, since there probably many out there with this on their minds, I’d like you permission to post your email, and my response, on my blog. If that’s OK, please email me back. Having said that, here goes:

1. After reading your blog, I would say you are off to a good start, however:
2. It is not necessary, nor even desirable, to have every aspect of your life revolve around medicine.  Volunteering in a medically-related field is great, but just about any kind of volunteer work will make an impression on the admissions committee.  What they want to see is that you are a self-starter, that you don’t just waste /all/ your time, and that you have some inclination to help others.
3. It is important to show some degree of /balance/ of interests.  If everything you do relates to medicine, that just shows that you really really want to get in to medical school.  But being a physician requires a /sustainable/ lifestyle.  Involvement in art, music, sports, debate, chess club, whatever, shows that you have at least some ability to keep a rational balance in your life.  As a physician, you’ll need that.  It also shows some versatility and adaptability; both are very important traits in any of the helping professions.
4. Keep abreast of current social issues in medicine.  I remember that a med school interviewer asked me what changes I foresaw in the practice of medicine, over the next decade.  I was able to say that there would be a big change in reimbursement (HMO’s were just getting off the ground, then), and that the average age of the population is going up, so there will be a greater demand for geriatric specialists.  (I guess that was the kind of thing they were looking for, since they admitted me.)  It shows that you are beginning to understand that, /as a physician, you play an important role in your community, and in society as a whole./  It is not sufficient to know a lot of jargon and have good technical skills.
5. Speaking of jargon, it is important to be able to communicate clearly.  I am much more impressed by a medical student who can explain to a patient that taking too much Tylenol is bad for the kidneys, than one who tries to explain to a patient what interstitial nephritis is. In my opinion, the best way to learn communication skills is to read a lot, from a variety of topics; socialize a lot, with a variety of people; and write a lot, about a variety of topics and in a variety of styles.  That, in fact, is one of the reasons that I blog about all different topics, not just medicine.  When you write in your blog, think of it as a craft.  When you read something that strikes you as being well-written, take a moment to figure out why that is.
6.  Learn to take maximum advantage of whatever opportunities you have. In your volunteer work, ask yourself /first/ how it can help you become a better person, /before/ you ask yourself how it can help you get into medical school.  If you find yourself having to take a class in Shakespeare, ask yourself how that class can help you become a well-rounded, well-educated citizen.
7.  College: study what you are interested in.  Follow your instincts when you choose some of your electives.  Pick classes that you have heard have great professors, even if those classes don’t relate directly to medicine.  Spend time at your professor’s office hours.  You don’t have to be having trouble in the class to take advantage of that. College is your one and only chance to get a good Liberal Arts education.  They’ll teach you the medicine that you need to know in medical school, as long as you have the prerequisites from college.  The one thing I might add is that it is a good idea to take statistics, even if the medical school does not list that as a prerequisite.  Also, it is a good idea to participate in a summer research program, if you can.
8.  Learn how to learn from role models.  Despite the media emphasis on high-tech advances in medicine, medical education is still pretty much an apprenticeship.  You learn as much from watching how your professors act, as /people/, as you do from memorizing everything in a textbook chapter.  Watch how your elders deal with others.  Watch how they deal with stress.  /Ask/ them how they do these things.  Some people will be better mentors for you than others.  Learn to sense this, and spend more time with the ones who are good mentors for you.  Notice that some people are good listeners.  Pay attention to how they do it.  Watch two people conversing.  See how conversation works...or how it fails.
9. MCAT: MCATs have changed, and will change again, so I’m not sure I can give specific advice.  For example, when I took it, calculators were not allowed.  Therefore, when I studied for it, I did all the calculations by hand.  (I think that has changed, though.)  If there is an essay portion, practice writing essays by hand, if that is how you have to do it on the test.  Be sure to learn what you can about the test before you take it.  There are some general pointers, that apply to any test.  The two factors that are the best predictors of success on any standardized test are: vocabulary, and algebra.  You have to be really good at algebra.  Why?  Because if you are not, then many of the chemistry and physics problems are actually two problems in one: the math problem, and the science problem.  If you are so good at algebra that the math part of the problem is utterly transparent for you, then you can focus just on the science part of the problem.
10.  Of course, #10 is the most important.  Do not go to medical school if you are not absolutely certain that it is the right thing to do. That is as big of a mistake as marrying someone, when you are not sure if you should.  At age 17, there is no way you could understand how big of a mistake that is.  Take my word for it.  Or ask your parents why it is such a big mistake.  Or ask any adult whom you respect.  They will all tell you the same thing, assuming you have good instincts for deciding whom to respect.

There’s a lot more I could say, but one rule of good communication is:
keep it short.

Comments, anyone? I’ve never actually served on an admissions committee, so I actually am not the best person to ask. Try asking the same question at some med student blogs. There are a few in my sidebar. If you get some good advice, let me know what they say.

Good luck,
JCY

Bravomedic Blogger wrote:

Thank you. Sure, you can post it.

I’m not totally “shaped” around medicine. I’m on my school’s tennis team, I’m the salutatorian of my class, and like to think that I’m pretty pretty good at math and science (took AP Calculus and AP Physics and got a 5 and 4 respectively). The reason I only got a 4 on the physics is because my class didn’t cover thermodynamics or nuclear physics (about 20% of the test), so I must’ve done well on the other parts.

I already have some research involvement. I have a mentor for biomedical engineering who I work for. As for vocabulary, I’m in my 5^th year of Latin.

Thanks again,

Brandon

Good. You are off to a great start. Biomedical engineering is a great field. In fact, I almost enrolled in the program here at University of Michigan, but decided to go to medical school instead.

JCY

A National Health Insurance Program for the United States

2005-09-05T23:27:00.000-04:00

I am going to try to write this objectively, i.e., without using the <rant> tag.

Just as 2002-2004 was the "post-9/11 world", we now live in the post-Katrina world. Everything is different now. The national political debate will shift. It will be difficult for citizens to keep in mind the fact that we can't and shouldn't make national policy on the basis of a single topic.

Prior to the last Presidential election, potential voters listed health care, education, and the environment as major concerns. But in the post-9/11 world, none of that mattered. As a result, those issues got drowned out; they played no discernible role in the outcome of the election.

This was terribly ironic, since national security actually depends upon those issues. National security, thought of broadly, is the security of our people and our land. What difference does it make if we prevent some terrorist from launching a chemical attack, yet we allow our own corporations to poison us with lead and mercury? How are we going to defend ourselves, if we don't education our children; All of our children? And what good does it do to spend hundreds of billions of dollars fighting terrorism, when the lack of universal health coverage leads to 18,000 excess deaths per year?

Most readers of Grand Rounds are educated people, people in a position to make a difference. One way we can make a difference is to insist that our leaders give us the national debate that we want, that we need, to keep our Nation great. We cannot afford to let them -- Democrat, Republican, Green, whatever -- shape the national debate.
We must shape the debate for them, not the other way around.

I am aware of the fact that many physicians oppose the concept of universal health coverage. I also am aware that many support it. My casual observations indicate that it is mostly the younger ones who support it; but of course, they are not the ones in positions of influence. Yet.

It would be difficult to outline the rationale for universal health coverage in a brief essay. Fortunately, anyone reading this has access to the Internet, and there already are several excellent sources available. Probably the best summary can be found in the online, open-access medical journal, PLoS Medicine.

If you are not familiar with it, PLoS-M has an excellent Policy Forum section. One of the earliest articles in that section was this one:

A National Health Insurance Program for the United States
The country must abandon its fragmented system

Don R. McCanne

The total projected spending on health care in the United States for 2004 is $1.79 trillion—15.5% of its gross domestic product [1]. That amounts to $6,167 per person, almost twice what most nations with comprehensive systems spend on care. Most policy analysts agree that this level of spending should be more than enough to provide all Americans with high quality, comprehensive health care. Yet the United States falls far short of these goals. What are the flaws in the United States health system that prevent Americans from receiving value from this huge health care investment? And what are the options for improvement? [...]

Dr. McCanne points out a few essential facts, such as this:

In 2000, the World Health Organization rated the United States first in its health expenditures per capita, but 37th in its overall health system performance, below most industrialized nations [9]. The United States is clearly not receiving adequate value for its health care investment.

In other words, we spend more but get less. One reason for that, is the inefficiency that is inherent in the current, highly fragmented, highly redundant health care financing system. Private insurance eats up 15 to 25% of our health care dollars. (Although some of that is offset by savings introduced by rule-based care, sometimes known as "managed" care.) In contrast, Medicare has an overhead of just 3%.

Many objections have been raised, regarding the prospect of universal health care. Most of these are addressed in a short article on the Physicians for a National Health Plan (PNHP) site: Single-Payer Myths; Single-Payer Facts.

It's not that politicians have ignored the issue. The problem is that the citizens have allowed them to demote the issue to the point that it gets lost in all the fuss about the more obvious aspects of national security. Also, persons with their own agendas have spread misinformation about the subject. Worse, citizens have not taken the time to inform themselves about the details of the subject. Instead, they draw conclusions based upon broad, but misguided, generalizations and assumptions.

John Kerry had an idea, to have the federal government pay for catastrophic coverage. Brad DeLong argued for this on his blog, here. Dennis Kucinich also had a plan, one which I think was even better:

The type of system I am proposing -- privately delivered health care, publicly financed -- has worked well in other countries, none of which spend as much per capita on health care as the United States. The cost-effectiveness of a single-payer system has been affirmed in many studies, including those conducted by the Congressional Budget Office and the General Accounting Office. The GAO has said: "If the US were to shift to a system of universal coverage and a single payer, as in Canada, the savings in administrative costs (10% to private insurers) would be more than enough to offset the expense of universal coverage."

As it happens, the crux of his plan is the same as that proposed by PNHP.

I am not foolish enough to think that that anyone is going to have a change of heart, or mind, as a result of this post. However, I am optimistic enough to think that some people will take the take the time to become more informed about the subject. Perhaps then, they will press for much-needed change, based upon their own informed positions.

Categories: science, medicine
Tags: medicine, health, medblogger

Touch

2005-09-05T08:51:00.000-04:00

What we have seen and heard over these past few days has been horrible. For the next twelve hours, I am going to focus on my sense of touch. Nothing else.

The Mourning After

Sense of touch scintillates upward, the dorsal columns of my spine
Parietal lobes are soothed by the texture of twine
The data indicate baling twine is coarse, a bit prickly, but also smooth in spots
Twine holds the hay, which is needed, by those who depend upon me

Biceps and deltoids contract, I feel them opposing the weight
Cerebellum coordinates the yin and yang of muscle groups
It is pleasing that the muscles dance together, so perfectly, despite gravity
I know that, because of this dance, those who depend can be nourished

I decide to dare, to see what is before me
Rods and cones delight the occipital lobes
Layers of water vapor, fog, have settled between the hills
The water brings sustenance, which is needed, by the farmland around me

Rays of the sun, they dash slantwise over the horizon
Retinas dutifully report via the first cranial nerve
Stalks of wheat, amber, waving in the cool gentle breeze
The dew settles on them, also cooling, also sustaining them

I do not dare, to see what is beyond this horizon

From the Sea

2005-09-04T00:09:00.000-04:00

There is a restaurant called Pelagos. The name means "from the sea," in Greek. It is underground, but has a patio open to the sky. A staircase leads from the sidewalk to the subterranean patio. The is a metal fence along the sidewalk. On the patio, there are tables with umbrellas. Large windows provide a view of the patio, from inside the restaurant. Looking out, a person might be fascinated by the geometrical shapes formed by the window frames, the the tables, the steps, and the fence; that person might also be happy to glimpse a bit of sky.

Except now it starts to rain. Unhappy patrons rush in from the patio. But some people had read the weather report, and stayed inside for their dinner.

Inconspicuous, along one wall of Pelagos, sit three men, of three generations. As is always true in this Universe, the three men sit arranged in a triangle.

All speak English as their native language. But the oldest learned Japanese; the middle, German; the youngest, Russian and Latin.

As it happens, the Latin form of Pelagos is Pelagius.

The oldest of the men enjoyed hunting and fishing, but no longer can do these things; he reads about history and the human mind, appreciates fine wine, listens to jazz. Raised in poverty, he used his intellect to complete an advanced education; then went on to build security for his family, and a good reputation for himself. This stands in stark contrast to the earlier generations of this particular lineage. The oldest moved up in society by trying to improve himself, never by trying to take advantage of others.

The middle-generation man never particularly enjoyed hunting or fishing; indeed, is not terribly fond of any sort of killing. At times, he has been known to read about history, and the human brain. He raises horses and builds computers. Although proficient at photography, he never cared so much about music or other forms of art. He drinks beer, but never more than 16 fluid ounces (about 500 milliliters). sometimes he pretends to like wine, but generally does not pretend much. One of the reasons that he does not drink much alcohol is that he hopes, someday, to live up to the reputation that his father established for the family. If you ask him, he'll say he does not care about his reputation. That is not really true, but the reason he cares about his reputation, is that he wants a better life for subsequent generations.

It annoys him that the restaurant brings a 12-ounce bottle of beer, with a 10-ounce glass to put it in, but that is a minor point. It annoys him more, that some people don't think for themselves.

The youngest, like his father, is proficient at photography; unlike his father, he prefers digital -- like most young people these days. One summer, he rode a bicycle in China, after which his father posted the pictures on the Internet. The youngest uses computers, can upgrade them, but mostly sees them as tools to be used for specific purposes; unlike his father, he is not terribly fond of the hardware side of things. At a very young age, he wanted to be an ichthyologist, or maybe a limnologist; later, he got interested in history and political science. In his honors calculus class, he wrote a term paper about public-key cryptography. Folk music is one thing he cares about, although he has chosen to not develop his innate musical talent. He'll be off to college soon. After thoughtful consideration of his many interests, he now thinks he will study virology and immunology.

The older and middle of the men have devoted a great deal of effort to alleviating the suffering of individuals. The youngest has grander plans, as a young person should. He would like to prevent the suffering of many; not limit himself to saving people one at a time.

They sit and enjoy their dinner. They talk about things. It is an ordinary time. Perhaps none of the three will, individually, make a lasting impression on the course of human events. However, geometry has a lesson for us: the triangle, expanded to three dimensions, can form an icosahedron. Perhaps the lineage of the three men will, over time, manage to build something just as elegant.

But instead of looking forward, we now look back. As we sift through history, we see that there have been many who would have changed the course of events for the better. Sometimes, the geometry of the Universe permits this; sometimes, it impedes it.

History has a lesson for us. As the Roman empire was crumbling, and the Dark Ages began, there was a great struggle among theologians. They cast aside Plato, and with him, his beloved tetrahedron, cube, octahedron, and dodecahedron. Worst of all, even the supremely elegant icosahedron was tossed back into the sea.

They thought the cross would solve everything. Alas, they could only think in two dimensions.

One of them dared to dissent. He carried the peculiar name Pelagius. He promoted the idea that humans are basically good, and that it is through their free choice of actions that they keep themselves good.

In contrast, the predominant view at the time was that of St. Augustine, who believed that humans were fundamentally tainted by the original sin, and any good they had, came from the grace of god.

The geometry of the Universe was not kind to Pelagius, although ultimately he managed to avoid the worst of fates. From Wikipedia:

When Alaric sacked Rome in 410, Pelagius fled to Carthage, where he came into further conflict with Augustine. His follower Coelestius was condemned by a church council there. Pelagius then fled to Jerusalem, but Augustine's followers were soon on his trail; Orosius went to Jerusalem to warn St Jerome against him. Pelagius succeeded in clearing himself at a diocesan synod in Jerusalem and a provincial one in Diospolis (Lydda ), though Augustine said that his being cleared at those councils must have been the result of Pelagius lying about his teachings.

Augustine's version of Pelagius's teachings about sin and atonement were condemned as heresy at the local Council of Carthage in 417.

Those are the people who told us to put away childish things. Those are the people who cast aside the icosahedron as a mere trinket. But it so doing, they brought us the Dark Ages.

The online Catholic Encyclopedia contains the following commentary about Pelagius:

Meanwhile the Pelagian ideas had infected a wide area, especially around Carthage, so that Augustine and other bishops were compelled to take a resolute stand against them in sermons and private conversations.

Imagine that, being infected with the notion that humans are fundamentally good. Is it some kind of virus?

Outside Pelagos, it rained. Those who had not familiarized themselves with local meteorology got soaked. The three generations of men, well-acquainted with the Sciences, stayed dry. One of them wants to study viruses. Perhaps there is hope.

The Great Divides in Medical Practice

2005-08-28T01:41:00.000-04:00

Today, my father-in-law and I put up a fence. It's a solar-powered electric fence, that divides our paddock in two. Why? Because it is time for Champie to be weaned.

After we put up the fence, we tested it. 135 volts. Champie can be a bit insouciant, as the picture shows, but I think 135 volts might get his attention. He won't like being separated from his mother, but sometimes you just have to do these unpleasant things.

Later, I found the picture below. For some reason, it stuck in my head. It was a little tickle of intuition: the picture symbolized something important.

This is a depiction of a planned glass bridge that juts out over the Grand Canyon. You can see across, but you can't get across. Sort of like the electric fence. Plus, both involve a certain kind of danger. Both bring you close to a distinctly unpleasant sensation.

In response to my request for thoughts about the ideas of empathy, and racial and gender disparities, in health care, I did get some email. One pointed to this, a collection of letters written in response to a newspaper article (In the Hospital, a Degrading Shift From Person to Patient). Here is one of the letters:

To the Editor:

While I was hospitalized after surgery for peritonitis, one thing really struck me: doctors and other medical staff members are human beings. And in order to perform grueling tasks like surgery or intubations, they have no choice but to do away with human feelings.

That shift from person to patient may be perceived as degrading, but it is also a vital to medical staff, because there are things you can do to a patient that you wouldn't dream of doing to a person.

Bruno Dupont
Johannesburg, Aug. 18, 2005

I should think that someone named Dupont who lives in Johannesburg could tell us quite a lot about disparities, and someone hospitalized for peritonitis ought to have something to say about empathy. (A couple of assumptions, granted.) He makes a good point: "there are things you can do to a patient that you wouldn't dream of doing to a person."

The practice of Medicine is rife with Great Divides.

There are the divisions between doctor, and patient; between the doctor's thoughts, and the accompanying feelings; between the doctor's assumptions about the patient, and the reality; and, of course, there are racial, socioeconomic, and gender divisions. All of these deserve considerable introspective thought.

So far, only one horse out of the five has touched the electric fence (October, the poor thing!). The rest saw him jump back, and now they won't go near it...

As physicians, we learn by watching our colleagues. If one of them jumps away from something, we are likely to stay away, too. That becomes habitual. Doctors may think they are smarter than farm animals, but sometimes I'm not so sure of that: we all are influenced by instincts.

...After a few days, we could turn off the fence, and the horses would still shy away from it.

During the course of medical training, how many times does a medical student see an attending shut off his or her feelings, shy away from confronting unjust disparities, or fail to challenge an unfounded assumption about a patient?

We assume that people have supportive families at home, when they may not. We assume that if they say they understand something, that they do understand it. We assume that a patient who looks cheerful could not be depressed or suicidal.

Then there are the assumptions that we are trained to make. We assume that if they deny substance abuse, that they could be lying. We assume that a young woman might be pregnant, even if she says it would be impossible. We assume that patients with bipolar disorder might have unprotected sex with strangers, even if they live in a convent.

Sometimes we offend patients with these assumptions. Sometimes the assumptions are justified, and the patient is upset even though you are being scrupulous with your assumptions This can be distinctly unpleasant. Sometimes the assumptions are not justified, and we are too proud to endure a distinctly unpleasant confession.

We may be able to see across the divide, but we can't get across.

Consider the "fact" that "there are things you can do to a patient that you wouldn't dream of doing to a person."

Is this really true, or is it just an attitude we have learned? Consider another of the letters:

To the Editor:

I spent all of January 2005 and six weeks in the spring on the transplant floor at Memorial Sloan Kettering having chemotherapy related to my acute myelogenous leukemia.

I determined to make my room a "nest," and the doctors and nurses responded to me as a person, asking questions about a photo or pointing out something of interest to a new resident.

The cleaning staff members are also important to one's well-being. At first I was a bed to clean around. As I engaged people in conversations about themselves, they began to smile when they entered my room.

I refused to see myself as a patient even though my day consisted of infusions and transfusions. I asked that hospital's alternative medicine staff members visit me. They provided soft touch, visualization techniques, meditation and music. They helped me feel alive.

The positive energy surrounding me helped me survive some very desperate days.

Janice Jeffrey
Brooklyn, Aug. 18, 2005

We may be able to see across the divide, but we can't get across.

But maybe, we can get across. Maybe we just think we can't, because we've been jolted a couple of times, or because we've seen our mentors shy away. As I mentioned before, all of these deserve considerable introspective thought.
UPDATE (8/28/2005)

I posted on this topic previously, here; and subsequently, here. As it happens, when Yvonne and I came home from grocery shopping today, we saw that Champie had jumped over the electric fence! He's not quite five months old, and never has been trained for jumping, yet he jumped right over it. Maybe horses actually are smarter than doctors; certainly, they are more courageous.

Categories: medicine, armchair musings
Tags: medicine, Health, medblogger

Grazie, Silvio

2005-08-25T23:19:00.000-04:00

I told myself that I was going to write about science today, perhaps this or this; but I got sidetracked.

You may recall that Halliburton announced, in January 2005, that it would be pulling out of Iran, citing "a poor business climate." We learned later that this was not really true.

Business As Usual?
Halliburton’s CEO says his company is pulling out of Iran. But a corporate subsidiary is still going ahead with a deal to develop Tehran’s natural gas fields

By Michael Isikoff and Mark Hosenball
Newsweek
Updated: 6:10 p.m. ET Feb. 16, 2005

Feb. 16 - Only weeks before Halliburton made headlines by announcing it was pulling out of Iran—a nation George W. Bush has labeled part of the “axis of evil”—the Texas-based oil services firm quietly signed a major new business deal to help develop Tehran’s natural gas fields.

Halliburton’s new Iran contract, moreover, appears to suggest a far closer connection with the country’s hard-line government than the firm has ever acknowledged. [...]

But in March, Halliburton reiterated its pledge, under pressure from the New York City Comptroller, who was troubled by the fact that the City invested a large sum, via its pension plans, in a company that did business with the Axis of Evil. As reported in the Washington Post:

Halliburton Won't Seek Iran Work
Company Makes Vow in Response to Shareholder Pressure

By Henry Goldman
Bloomberg News
Friday, March 25, 2005; Page E02

Halliburton Co., the world's largest oil-field services company, has pledged not to seek new work in Iran, a country accused by the State Department of state-sponsored terrorism, said New York City Comptroller William C. Thompson, a steward of pension funds holding company stock worth about $42 million.

Halliburton's vice president and corporate counsel, Margaret E. Carriere, wrote in a letter faxed to Thompson's office from the company's Houston headquarters yesterday, "Halliburton will take appropriate corporate action to cause its subsidiaries to not bid for any new work in Iran," while continuing on work previously undertaken. [...]

Now it turns out that things are not going so well for Halliburton: Agenzia Gournalistica Italia has a news section, News for Arab Countries, which it describes as a "Special service by AGI on behalf of the Italian Prime Minister's office." They are reporting something about Halliburton that American news agencies are not, but that American voters, as well as certain investors, might like to know:

News for Arab Countries
Special service by AGI on behalf of the Italian Prime Minister's office

HALLIBURTON: LOSES IRAN CONTRACT DUE TO CORRUPTION CHARGES
(AGI) - Tehran, Iran, Aug 23 - US multinational Halliburton lost a 310 million dollar contract for natural gas extraction in the Iranian site of South Pars. According to Tehran authorities, Oriental Oil Kish, a subsidiary of Halliburton operating in the Middle East, won the contract last January thanks to bribes. The activities of the company in South Pars have been suspended and the contract annulled. Halliburton, once led by US Vice President Dick Chaney, is under investigation for the same contract in the US as well, on the basis of a 1996 law that punishes companies, both American and foreign, which invest more than 40 million dollars in Iran. The contract should now be passed on to the National Iranian Drilling Company, the Iranian state-owned energy company. (AGI) -
231946 AGO 05 COPYRIGHTS 2002-2005 AGI S.p.A.

(Beret tip to PA Liberal, who starts college tomorrow; congratulations, Samantha!)

Readers may want to know how Halliburton is able to do business in Iran, given that it is illegal for American firms to do so. Halliburton spokeswoman Wendy Hall has the answer:

Halliburton Set to Begin Work in Iran

DALLAS (CBS) -- Halliburton, under investigation for its operations in Iran, is set to begin oilfield services work in that country as a subcontractor for Oriental Kish, a spokeswoman said.

Halliburton shares closed at $38.19, up 35 cents. Halliburton spokeswoman Wendy Hall said that she did not know the value of the contract and noted that Oriental had won the contract, not Halliburton. Halliburton's products-and-services division is to help Oriental Kish, which is based in Iran, develop the South Pars natural-gas field.

"Halliburton's business is clearly permissible under applicable US laws and regulations," Hall said. "Also, we are in the service business, not the foreign-policy business. We have followed and will continue to follow applicable laws."

She added that Halliburton has no ownership in Oriental Kish and had played no role in its creation.

Because of Iran's suspected links to terrorism, US companies are severely restricted in their dealings with the country. The 1996 Iran-Libya Sanctions Act limits companies to an investment of $20 million or less a year in Iran's oil and gas sectors, according to the US Energy Information Administration.

However, "separately incorporated foreign subsidiaries are not included in the definition of US persons under the current Iranian executive order," a US Treasury official said. "If a US person is involved, that person may be in violation of the sanctions."

The Halliburton unit is registered in the Cayman Islands as Halliburton Products and Services.

"These entities and activities are staffed and managed by non-US personnel," Hall said.

In July, the company said in a regulatory filing that a federal grand jury was investigating Halliburton operations in Iran. [...]

Is there reason to think that a "US person" might be involved? CC reports, you decide:

60 Minutes decided to ask Halliburton's subsidiary about its work in Iran. But we weren't allowed to enter the building with a camera. So we went in with a hidden camera, and were introduced to David Walker, manager of the local Calidonian [sic] Bank, where the subsidiary is registered.

60 Minutes was expecting to find a bustling business, but, to our surprise, Walker told us that while Halliburton Products and Services was registered at this address, it was in name only. There is no actual office here or anywhere else in the Caymans. And there are no employees on site.

We were told that if mail for the Halliburton subsidiary comes to this address, they re-route it to Halliburton headquarters in Houston. [...]

It actually was the Caledonian Bank. Oddly, www.caledonian.com is not responding. Maybe it's the hurricane.

Maybe the Flying Spaghetti Monster is punishing them for doing business with a bunch of crooks.

Categories: politics, rant tangents
Tags: Halliburton

The Power of Zero

2005-08-24T00:27:00.000-04:00

Via a rather loose concatenation of links, I began reading the first page of the book, Zero: The Biography of a Dangerous Idea by Charles Seife:

An Eastern concept, born in the Fertile Crescent a few centuries before the birth of Christ, zero evoked images of a primal void, it also had dangerous mathematical properties. Within zero there is the power to shatter the framework of knowledge.

It is not so strange that I would read this eventually, although it is a bit strange that I would be reading it now. Last night, I was reading The Golden Ratio : The Story of PHI, the World's Most Astonishing Number, by Mario Livio. What is strange is the confluence of ideas thus provoked. I went from the mathematics of Zero, to the amount of postwar planning for Iraq.

In an earlier post, I quoted a snippet of lyrics from a Patti Smith song, Radio Baghdad. Here is the entire thing. Unfortunately, the lyrics do not convey the message. (You really have to hear Patti work this one over, in her own special way.)

Suffer not Your neighbor's affliction
Suffer not Your neighbor's paralysis
But extend your hand Extend your hand
Lest you vanish in the city And be but a trace
Just a vanished ghost And your legacy
All the things you knew Science, mathematics, thought
Severely weakened Like irrigation systems
In the tired veins forming From the Tigris and Euphrates
In the realm of peace All the world revolved
All the world revolved Around a perfect circle
City of Baghdad City of scholars
Empirical humble Center of the world
City in ashes City of Baghdad
City of Baghdad Abrasive aloof

Oh, in Mesopotamia Aloofness ran deep
Deep in the veins of the great rivers
That form the base Of Eden
And the tree The tree of knowledge
Held up its arms To the sky
All the branches of knowledge All the branches of knowledge
Cradling Cradling
Civilization In the realm of peace
All the world revolved Around a perfect circle
Oh Baghdad Center of the world
City of ashes With its great mosques
Erupting from the mouth of god Rising from the ashes like
a speckled bird Splayed against the mosaic sky
Oh, clouds around We created the zero
But we mean nothing to you You would believe
That we are just some mystical tale We are just a swollen belly
That gave birth to Sinbad, Scheherazade We gave birth
Oh, oh, to the zero The perfect number
We invented the zero And we mean nothing to you
Our children run through the streets
And you sent your flames Your shooting stars
Shock and awe Shock and awe
Like some, some Imagined warrior production
Twenty-first century No chivalry involved
No Bushido

Oh, the code of the West Long gone
Never been Where does it lie?
You came, you came Through the west
Annihilated a people And you come to us
But we are older than you You come you wanna
You wanna come and rob the cradle
Of civilization And you read yet you read
You read Genesis You read of the tree
You read of the tree Beget by god
That raised its branches into the sky Every branch of knowledge
Of the cradle of civilization

Of the banks of the Tigris and the Euphrates
Oh, in Mesopotamia Aloofness ran deep
The face of Eve turning What sky did she see
What garden beneath her feet The one you drill
You drill Pulling the blood of the earth
Little droplets of oil for bracelets Little jewels
Sapphires You make bracelets
Round your own world We are weeping tears
Rubies We offer them to you
We are just Your Arabian nightmare
We invented the zero But we mean nothing to you
Your Arabian nightmare

City of stars City of scholarship
Science City of ideas
City of light City
City of ashes That the great Caliph
Walked through His naked feet formed a circle
And they built a city A perfect city of Baghdad
In the realm of peace And all the world revolved
And they invented And they mean nothing to you
Nothing to you Nothing

Go to sleep Go to sleep my child
Go to sleep And I'll sing you a lullaby
A lullaby for our city A lullaby of Baghdad
Go to sleep Sleep my child
Sleep Sleep...
Run Run...

You sent your lights Your bombs
You sent them down on our city Shock and awe
Like some crazy t.v. show

They're robbing the cradle of civilization
They're robbing the cradle of civilization
They're robbing the cradle of civilization

Suffer not The paralysis of your neighbor
Suffer not But extend your hand

-- Patti Smith, Oliver Ray

The Iraq war is like some crazy TV show. Crazy in that we don't know who to believe. A fork in my link-skipping took me to this:

Secrets of the morgue: Baghdad's body count

By Robert Fisk
The Independent
17 August 2005

Bodies of 1,100 civilians brought to mortuary in July
Pre-invasion, July figure was typically less than 200
Last Sunday alone, the mortuary received 36 bodies
Up to 20 per cent of the bodies are never identified
Many of the dead have been tortured or disfigured [...]

they're robbing the cradle...

The Independent have placed most of the story into their archive, but the full version can be viewed at Information Clearinghouse. It includes this:

While Saddam's regime visited death by official execution upon its opponents, the scale of anarchy now existing in Baghdad, Mosul, Basra and other cities is unprecedented. "The July figures are the largest ever recorded in the history of the Baghdad Medical Institute," a senior member of the management told The Independent.

Fisk mentions that there are no official reports on the subject of Iraqi mortality, so it is not possible to confirm his report independently. Regardless, there is some supporting evidence.

In October 2004, the leading medical journal in Britain, The Lancet, published a controversial study (free registration) in which it was estimated that there had been 100,000 (note the large number of zeros) excess deaths in Iraq since the start of the war. By "excess," they mean that the death toll was above that which would have been expected in prior years, even under Saddam's brutal regime. Fisk's article in The Independent is consistent with the results of the Lancet report. According to Fisk, in July 2005, in Baghdad alone, there were about 900 excess deaths.

The Lancet article was released early, leading to claims that it was a politically-motivated effort to influence the results of the Presidential election in the USA. That may have been. Unfortunately, if that was the intent, it did not produce the desired result. Various people attempted to discredit the report by criticizing the methodology. Incidentally, a statistician, Tim Lambert, posting at Deltoid, took an interest in this. In my view, he successfully defended the methodology of the report.

Many of the critics of the Lancet report cited a UN report, Iraq Living Conditions Survey 2004, which estimated the number of excess deaths to be much lower (about 23,000). Note, however, that even the more favorable report is not even faint praise for the US-led effort:

12% of the Iraqi children in the age group 6 months – 5 years suffer from general malnutrition.

8% of children suffer from acute malnutrition.

23% of children suffer from chronic malnutrition.

[...]

In the two weeks prior to the survey it was found that 14% of children had had a cough or cold, 14% had had fever, and 9% had had diarrhea. Two percent had had other illnesses, and 1% had experienced an accident.

they're robbing the cradle...

According to the Washington Post, the incidence of child malnutrition was increased, compared to pre-war levels. Recall that, before the war, the general population was suffering from the effects of economic sanctions. So the fact, that child malnutrition has been worse after the war, is really, really disturbing.

Afterdowningstreet.org and various members of the BBA have reported that planning for the post-war period began in 2001. But the documents uncovered so far indicate only planning for military affairs and oilfield development. But it appears that the amount of planning for the welfare of the Iraqi people was a big, fat Zero.

categories: politics, rants
tags: downing street memo, BBA

Improving Empathy in Medical Training

2005-08-22T00:06:00.000-04:00

Used worldwide, The Empathy Belly has proven itself to be an extremely beneficial teaching tool resource for medical students, obstetrical physicians and allied professionals in the fields of Maternity Health Care and Education. By wearing The Empathy Belly they significantly increase their understanding and sensitivity about the pregnant condition. Consequently they are better trained, more effective, and more likely to establish genuine rapport with the pregnant women in their care. For obvious reasons, this is especially true for service providers who are male, or women who have never experienced a full-term pregnancy.

No thanks. But seriously, we all know that many doctors need to be more empathic. A Google search on the string, "empathy in medical training" gets about 745,000 hits (including the one above). Many medical schools have incorporated empathy training into their curricula. Even so, the problem persists. We see articles in the NYT such as Awash in Information, Patients Face a Lonely, Uncertain Road, which I was going to post about, until I saw that Shrinkette already did.

From NYT:

Ms. Gaines, bald, tumor-ridden and exhausted from chemotherapy, was reeling. "I'm not a doctor!" she shouted. "I'm a criminal defense lawyer! How am I supposed to know?"

This is the blessing and the burden of being a modern patient. A generation ago, patients argued for more information, more choice and more say about treatment. To a great extent, that is exactly what they have received: a superabundance of information, often several treatment options and the right to choose among them.

As this new responsibility dawns on patients, some embrace it with a sense of pride and furious determination. But many find the job of being a modern patient, with its slog through medical uncertainty, to be lonely, frightening and overwhelming.

From Shrinkette:

Hasn't serious illness almost always been a lonely, uncertain road? The best doctors make that road easier to bear. But this article says that many patients feel abandoned by their doctors, and adrift in the system. It's hard to imagine a satisfying solution.

Also see the NYT article, Sick and Scared, and Waiting, Waiting, Waiting, for an additional perspective on the problem.

Later, I encountered a physician's essay on the topic of empathy: Empathy: Lost or Found in Medical Education? (Medscape: free registration required) by Sonal Singh, MD; that inspired me to write this post.

What can be done about the lack of empathy among physicians? To answer that, one first must learn what already has been done. Recently, the Josiah Macy Foundation funded a study, the Macy Initiative in Health Communication. According to a report in Academic Medicine:

Sixty-five percent of medical schools teach communication skills, usually in the preclinical years; however, communication skills learned in the preclinical years may decline by graduation. [...]

The three schools use a variety of methods to teach third-year students in each school a set of effective clinical communication skills.

Moving some of the instruction to the third year is a good idea, because it is impossible to learn the skills properly, outside of a clinical context. (The first two years are spent mainly in classroom instruction.) Also, of course, communication skills are only a part of being empathic. Plus, communication is, by definition, a two-way process; you can't solve the problem by having only one person learn the skills. The solution has to involve medical training centers, medical practice settings, the physician's ongoing efforts at self-education and self-improvement, and the the patients.

First, in regard to medical training programs: the points learned in the Macy study are important. The instruction tends to loose effect shortly after it is taught, and it is more effective when taught in a clinical -- as opposed to a classroom -- context. It would make sense, then, to incorporate the instruction into residency training programs, as well as continuing medical education programs. It would not take a lot at any one time, to be effective. What would make it effective would be to give the subject at least some attention at every opportunity.

In addition, for such instruction to be effective, it would have to be pertinent. How to make it seem pertinent? Try this, from Archives of Internal Medicine (Vol. 154 No. 12, June 27, 1994):

The doctor-patient relationship and malpractice. Lessons from plaintiff depositions

H. B. Beckman, K. M. Markakis, A. L. Suchman and R. M. Frankel
Department of Medicine, Highland Hospital, Rochester, NY 14620.

BACKGROUND: The current literature does not provide an answer to the question, "What prompts patients to sue doctors or hospitals?" Not all adverse outcomes result in suits, and threatened suits do not always involve adverse outcomes. The exploration of other factors has been hampered by the lack of a methodology to contact plaintiffs and elicit their views about their experience in delivered health care. This study employed the transcripts of discovery depositions of plaintiffs as a source of insight into the issues that prompted individuals to file a malpractice claim. [...]

CONCLUSIONS: In our sample, the decision to litigate was often associated with a perceived lack of caring and/or collaboration in the delivery of health care. The issues identified included perceived unavailability, discounting patient and/or family concerns, poor delivery of information, and lack of understanding the patient and/or family perspective. Particular attention should be paid to the postadverse-event consultant-patient interaction. [emphasis added]

If that does not impress trainees with the pertinence of the subject, perhaps this would: collect evaluations, from patients, of the performance of medical students and residents. Just knowing that people are paying attention often results in improved behavior.

Second, with regard to medical practice settings, it is important for the institution to have a culture that is self-correcting. If a practitioner sees an instance of poor empathy, she or he should feel free to point it out; furthermore, the person who made the error should be receptive to corrective feedback. It turns out that there is already a good article on the subject, in an AMA Virtual Mentor Vignette, here.

Each institution has its own culture, and that culture determines what behaviors are acceptable, and what topics are acceptable topics for conversation. Physicians need to take a leadership role in encouraging others to give corrective feedback. Perhaps more importantly, they need to model the graceful receipt of such feedback. "Thank you for pointing that out," is always good. Remember the principle of Ostler's Aequinimitas.

Cultivate, then, gentlemen, such a judicious measure of obtuseness as will enable you to meet the exigencies of practice with firmness and courage, without, at the same time, hardening "the human heart by which we live."

In an essay (Medscape link), Dr. James Dykes elaborated:

Now I teach Duke medical students. I tell them that although "objectivity" is important in the practice of medicine, it is often misunderstood. When the great physician Sir William Osler (1849-1919) wrote his treatise on the importance of "objectivity," he used the Latin term "aequanimitas," which can be translated as equanimity. To practice with equanimity, we must cultivate inner peace.

Also remember: the giving and receiving of such feedback actually helps build a sense of teamwork and camaraderie. This may seem counterintuitive; at first glance, it may seem that one member of the team criticizing another would be destructive. But done properly, in the context of a healthy institutional culture, it actually is constructive.

Third, in regard to physicians' ongoing self-education and self-improvement: this is a personal thing. As physicians, we all worry about missing the next retroperitoneal abscess, or the next case of idiopathic hemochromatosis. That's why we rush home from the clinic, ignore our spouses and children, and breathlessly page through the latest copy of Archives of Medical Obscuranta, groaning every time the pager goes off.

Next time, try this: pay attention to you spouse and kids. They know more about empathy than you ever will. They will even teach you, if you would just pay attention every once in a while. Like everything else in medicine, the best way to learn it, is to watch an expert do it.

Fourth, perhaps the most difficult: just as communication is a two-way process, so is empathy. We don't have an empathy training belly that patients can wear, to learn what it is like to be a doctor.

I think what would help, would be for patients and physicians to have a shared model of what their interactions are about. I find that it helps to look at it this way: Suppose you own an auto body shop. You are an expert on auto body repair. You want to advertise your business, so you go meet with an advertising specialist. The two of you sit down. Each of you is an expert on something. Together, you combine your expertise to figure out what to do.

In a medical setting, the doctor is an expert on the subject of medicine; the patient is an expert on the subject of the patient. The patient will always know more, about himself or herself, than the doctor will. They both are experts in their respective fields, and they should interact as two experts do: each listening to the other, each respecting the other, each appreciating that the other knows more about the other's area of expertise, and each deferring to the other when appropriate.

The nice thing about empathy, is that if we all learn to do it better, we all will benefit. If it is true in medical settings, it also is true in other settings.

As Dr. Dykes said in the essay that inspired this post, "we must cultivate inner peace." It is a lifelong process.

Categories: medicine, being nice
tags: medicine, health, medblogger

CNS Update: Sleep Medicine

2005-08-11T00:07:00.000-04:00

Michael Rack, MD, (blog: sleepdoctor) scooped me on this one: ramelteon (formerly named TAK-375, now called Rozerem® - Takeda Pharmaceuticals North America) was recently approved by the USA FDA for treatment of insomnia. Check his post for details. Basically, it acts on melatonin MT1 receptors, so it should be nonaddictive and should be extremely safe in overdose. That latter point is of great interest to psychiatrists.

Melatonin is a popular "natural" substance used to treat insomnia. Success is highly variable. It helps some people, but it seems that most people get no benefit. There is no FDA quality control for nutritional supplements, so some OTC versions of "melatonin" actually contain no active ingredient. That is one reason why traditional MD's tend to be skeptical of such products. Plus, there was a small case series of patients with bipolar disorder who did not improve when treated with melatonin; one developed a free-running (unentrained) sleep-wake cycle after melatonin withdrawal. I hope Takeda is watchful for this kind of thing in their post-marketing surveillance; it's the kind of thing that is unlikely to show up in phase I-III studies, but may show up when a larger, more heterogeneous population is exposed.

Practical matters aside, it is time to move on the the fun part: pure, preclinical, science, with no obvious practical application. One such thing that caught my attention recently was this:

Regulation of brain-derived neurotrophic factor (BDNF) during sleep apnoea treatment
R Staats, P Stoll, D Zingler, J C Virchow and M Lommatzsch
Department of Pneumology, University of Rostock, Germany

Background: Patients with obstructive sleep apnoea syndrome (OSAS) often display persistent cognitive dysfunction despite effective treatment with continuous positive airway pressure (CPAP). Brain-derived neurotrophic factor (BDNF) is a key mediator of memory and cognition, but its regulation in OSAS and during CPAP treatment is unknown.

Methods: Serum and plasma BDNF concentrations, BDNF secretion by peripheral blood mononuclear cells, and overnight polysomnography were evaluated in 17 men with newly diagnosed OSAS (as defined by a respiratory disturbance index of >10/hour with >70% obstructive events and corresponding daytime symptoms) and 12 healthy control men. In the patients all the parameters were monitored after 1 night and 3 months of CPAP treatment.

Results: There was no significant difference in baseline serum BDNF, plasma BDNF, or spontaneous BDNF secretion by peripheral blood mononuclear cells between untreated patients and controls. After 1 night of CPAP treatment there was a steep fall in median serum BDNF (from 18.0 ng/ml to 4.1 ng/ml) and plasma BDNF (from 58.7 pg/ml to 22.0 pg/ml) concentrations. Following 3 months of treatment BDNF concentrations did not return to baseline. In contrast, BDNF secretion was not suppressed by CPAP treatment.

Conclusions: Patients with untreated OSAS have normal serum and plasma BDNF levels. CPAP treatment is associated with a rapid decrease in serum and plasma BDNF levels which may reflect enhanced neuronal demand for BDNF in this condition.

This is one of those really cool situations in which a biomarker is normal in both the diseased people and the normal people, but becomes abnormal when the patients are treated. This is not what one would expect, ordinarily. The authors hypothesize that this may reflect an increased need for BDNF in the patients with OSA.

In commentary on Medscape (Free registration), the authors state:

Dr. Marek Lammatzsch and colleagues at the University of Rostock note that BDNF has been shown to be essential for cognitive function and consolidation of memory. It has been speculated that the interplay between sleep and cognition may involve BDNF.

Despite successful CPAP treatment, they add, many sleep apnea patients continue to display persistent cognitive dysfunction. To investigate the effect of CPAP on BDNF, the researchers studied 17 men with sleep apnea and 12 healthy controls. [...]

The researchers hypothesize that "this phenomenon reflects increased neuronal demand for BDNF during treatment, since neurons can acquire peripheral BDNF to change neuronal activity and synaptic transmission."

Dr. Lammatzsch told Reuters Health that "deficits in memory and learning often persist even after sleep restoration in patients with sleep apnea. Our observations open the door to a completely new understanding of this condition and might thus lead to a specific therapy in the future."

I will state again, that often nonscientist-journalists conclude their articles with a statement like this: "...might thus lead to a specific therapy in the future..." I assume they do that so that the reader gets the impression that the research might have some practical significance. Personally, I deplore this practice, because the implication is that research has to have a practical application in order to be important. This is a disservice to the public. Sure, it would be great to find a way to restore cognitive function to normal in those patients with OSA who continue to have problems even after successful implementation of CPAP, but that is not why the study is important.

The thing is, there are a zillion things we would need to figure out before having any hope of developing something clinically useful, and even then, it probably would take about 10-20 years to get it to market.

First, we would have to figure out exactly why BDNF goes down when patients are treated, and find out whether it eventually goes back toward normal. We would have to figure out exactly what regulates the level of BDNF. We would have to find out if anything dreadful happens to people if their level of BDNF is increased artificially. We would have to find a practical way to increase it, and see if it actually helps anyone.

Interestingly, we already have at least a partial answer to one of these questions, uncovered by an undergraduate student at UCLA:

The Role of Serotonergic and Noradrenergic Systems in the Regulation of BDNF Expression. Autumn Ivy, (Amelia Russo-Neustodt), Department of Biology, California State University, Los Angeles
Depression, aggression, agitation, and apathy are among the most common and problematic systems in neurodegenerative diseases such as Alzheimer's disease (AD). Brain-derived neurotrophic factor (BDNF), which enhances the growth and maintenance of various neuronal mechanisms, is diminished in the brains of AD patients. Animal studies have suggested that BDNF mRNA levels are increased by physical activity in the rat hippocampus. The aim of this study is to determine whether the 5-HT and/or the NE systems are involved in the up-regulation of BDNF expression occurring with exercise. Rats were treated with either Propranolol (2 mg/kg), which blocks the NE receptors, or Ketanserin (5 mg/kg), which blocks serotonin 5HT-2 receptors. At the same time, rats underwent voluntary exercise via a running wheel. BDNF mRNA levels were quantified in the hippocampus by in situ hybridization and computer densitometry. The NE receptor-blockade agent Propranolol appeared to reduce the up-regulation of BDNF mRNA normally expressed, suggesting that the activation of the NE system may be important in BDNF up-regulation. On the other hand, the serotonergic system receptor-blockade agent Ketanserin did not attenuate BDNF expression, which suggests the possibility that the 5-HT system is not involved in the observed BDNF regulation. An understanding of the mechanism of BDNF up-regulation could lead to the development of faster acting and more effective therapeutic approaches to AD.

So it appears that BDNF, at least the BDNF mRNA, is increased by exercise, at least in rat hippocampus, and that norepinephrine (NE) may play a role. We also know that plasma norepinephrine is increased in untreated OSA patients. So perhaps the drop in BDNF after treatment of OSA reflects a normalization of plasma NE. To my mind, these findings indicate that we are looking at a complex system that does not necessarily act the way one's intuition might suggest.

There could be important clinical benefits to increasing BDNF, as indicated by this Wikipedia snippet:

Exposure to stress and the stress hormone corticosterone has been shown to decrease the expression of BDNF in rats, and leads to an eventual atrophy of the hippocampus if exposure is persistent. Similar atrophy has been shown to take place in humans suffering from long-term depression. On the other hand, voluntary exercise, caloric restriction, intellectual stimulation, and various treatments for depression (such as antidepressants and electroconvulsive therapy) strongly increase expression of BDNF in the brain, and have been shown to protect against this atrophy.
Various studies have shown possible links between low levels of BDNF and conditions such as depression, Obsessive-compulsive disorder, Alzheimer's disease, Huntington's disease, and dementia, though it is still not known whether these levels represent a cause or a symptom.

If it does improve cognition, then we have to deal with the thorny ethical issue of whether it should be given to non-diseased persons who want to improve their cognition.

However, given the complexity of the system, if anyone is planning on artificially manipulating BDNF levels in actual humans, it sure would be nice to understand the entire system beforehand. Obviously, if treating something life-threatening such as Alzheimer disease or Huntington disease, a little risk would be no big deal. But for treatment of depression, or residual cognitive impairment in treated OSA patients, we would want to see a firm assurance of safety. It is hard to get that kind of assurance until the entire system is understood.

Therefore, the reason the Staats et.al. study is important is that it brings us one step closer to understanding a complex system that may play a role in many disease states. If any actual treatment is found, that would be icing on the cake.

Lest all this neurochemisty lead us to forget why sleep is so important:

Sleep

Sleep sleep sleep
deep magnificent sleep
cradles me like
a mother holding
her newborn
for the first time.
I close my eyes and feel
the warm sensation
of precious pure sleep
immortal sleep outside
of a mixed up world.
Sweet vanilla scent
from dreams of beauty
holding me forever,
brings me everything
I need to stay a
sleep sleep sleep.

-- Charles Lara

Categories: science, sleep disorders, neurochemistry
Tags: medicine, psychiatry, sleep disorder, sleep apnea, neurochemistry, insomnia

Antidisestablishmentarianism In Action

2005-08-07T00:12:00.000-04:00

What does antidisestablishmentarianism mean?

[...] pick up the Oxford English Dictionary. Turning to page 59, we find that antidisestablishmentarianism is indeed a word. The definition is as follows: “Properly, opposition to the disestablishment of the Church of ~~Bush~~ England, but popularly cited as an example of a long word.” Catching the irony here? [...]

We will try to catch the irony.

If one were to read an essay (Darwin's Compost) that decried the influence of "the elite", meaning scientists and everyone else the author doesn't like, you might expect to find the essay on a site called 'Humility in Action,' or perhaps 'The Washers of the Feet.' Instead, it appears on the pompously-named site "The American Thinker".

This story, while ludicrously biased, contains a sign of hope: it is a measure of the elite establishment’s fear that the Darwinian grip on culture is slipping. In the elite’s frantic attempt to protect their shrinking scientific turf, they must insist on a “scientific consensus” – the phrase the Washington Post earlier this summer cited to editorialize against the showing of an Intelligent Design documentary at the Smithsonian – that doesn’t exist, and they must treat any deviation from this fictional consensus as evidence of kookery. This politically correct policing of conservative dissent is getting more aggressive because that dissent is spreading rapidly, and to precincts the elite assumed they had tamed.

I won't bother to fisk the anti-anti-Intelligent Design essay itself, that task being well beneath my elitist prétentions. Rather, I will try to explain to my humble antidisestablishmentarianist friends why scientists and other thinkers are upset by Mr. Bush's proclamation that Intelligent Design should be taught in schools. And why it is so dangerous.

Chris, posting on his excellent blog Mixing Memory, which I found via a link on Follow Me Here, comments on the roiling of the ID controversy:

But, and that's a big but, there does seem to be something somewhat disturbing going on here, of which Bush's remarks are only a symptom.

I take a similar view: Bush's remarks are only a symptom. However, my diagnosis is a bit different than Chris'. He is troubled by the notion that what is taught in school could be determined by public opinion about what constitutes valid science. Indeed, that is a problem. Personally, though, I think the bigger problem is that Bush's statements follow a pattern. The Republican hijackers have included support for ID as part of a strategy to pollute the American political system.

The danger comes, no so much from the specific case of ID, but from what it represents. The notion of teaching ID in a science class, presented as a reasonable alternative to evolution, is an example of a political tactic that appears to be part of a larger strategy.

Let me take a moment to clarify my position: I am not a believer in "the vast right-wing conspiracy." I do think there is a right-wing conspiracy; I think the conspiracy is rather small. I am one of those who thinks that the Republican Party has been hijacked, not by a vast conspiracy, but by a minority of people who make my elitist pretensions look like Dorothy's scarecrow.

My elitist pretensions

To clarify further my position: I have no beef with those who choose to believe in Intelligent Design. But I really don't want ID to be presented as an alternative to a valid scientific body of knowledge. As I have alluded, I think that it is dangerous to do so.

I would like to think that I am not, like Dorothy's scarecrow, seeing danger from every little spark. Indeed, I've been known to take a risk or two.

Corpus Callosum astride the San Andreas fault

I climbed that mountain just like Tom Cruise in the second Mission Impossible...

My mission today is to explain the what the Republican hijackers are doing. It is subtle and clever; difficult to see clearly: it is a tactic that obscures itself. All politicians do it, so I am not picking on Republicans here. I think America would be a better place if everyone would stop doing it. The Republican hijackers, though, are pushing it farther than anyone else in recent history.

To understand this tactic, we first must take a couple of little detours. First, into the land of Psychology. The human brain has numerous sensory inputs, all of which are active all of the time. There is much more information that the conscious mind could ever process. As a result, most of the information is filtered out as being irrelevant, not salient.

My favorite example is this: in July 1990, I began working in a building in Ann Arbor, on the north side of the Broadway bridge. I lived south of there, so I drove over the bridge often. One day, I noticed that there was a sign there, warning that the bridge might be icy. Naturally, I noticed it on the first cold, wet day that I drove over the bridge. In July, I hadn't noticed it; it was irrelevant. On the day that my brain decided it was relevant, I noticed it.

This is the fundamental principle used by magicians, who are adept at manipulating the perception of salience. Likewise, politicians have a similar aptitude.

The process in the brain, of sifting through the mass of information presented by the sensory system, and picking out the bits that are important, is enormously complex. Yet we all do it, all the time, mostly without thinking about it on a conscious level.
Our next detour goes into the land of Information Theory. Consider for a moment the concept of signal to noise ratio:

(Ignore the formula above; it is just a pretentious decoration. I don't actually understand it, and it is irrelevant anyway.)

In common usage, signal to noise ratio describes the ratio of useful information to false or irrelevant information. Recall that the brain is constantly flooded with information, most of which is irrelevant. Noticing the relevant bits is challenging enough, even if all you are doing is driving over a bridge. If you have to do something that is really complex, such as electing a President, it is likely that you will not be able to notice, assimilate, and process all of the relevant information. And the more noise there is, compared to the amount of relevant signal, the harder it gets.

That is not a particularly new concept. We all get flooded by noise during any campaign, and we all get annoyed by it. Again, all Parties do it, and again, America would be a better place if they would stop doing it. It is part of the Republican hijacker strategy, but it is not the really devious part.

The devious part is this: after increasing the signal to noise ratio, they subvert the filtering process.

All sensory input is suspect; that is, we know, right from the start, that some of it is false. In order to filter out the false stuff, we use the concept of reasonable doubt. As the bits of information come in, they are organized into packets: "that's a chair," "that's a ham sandwich," etc. The packets then are examined for reliability. You can't filter out all the packets for which there is any doubt about their reliability, because that would filter out everything.* Instead, you have to let packets through the filter if the doubt about their reliability is not reasonable.

Each person has her or his own way of determining the reasonableness of a doubt. Each person's threshold for reasonableness is susceptible to manipulation. The Bush administration is doing exactly that. They do so by giving credence to individuals and small groups that promote administration-friendly positions despite have either little or no solid evidence.

The fact that the current administration does this extensively and methodically has been well documented by the Union of Concerned Scientists (1 2 3) and by US Rep. Henry Waxman (1 2). Also see my prior posts (1 2 3).

Back to the point. This is the main point of the entire post: When the President portrays ID as having some scientific validity, and when he gives equal credit to the few scientists who disagree with the notion of global warming, he manipulates people's threshold for reasonable doubt. Suddenly, all scientific findings are open to doubt.

The fact is, all areas of science, and all areas of human endeavor, have at least some controversy. If we all were to adopt Bush's proposed threshold for reasonable doubt, nothing would ever get done; no conclusions ever would be drawn. If any decisions were made, they would be made solely on the basis of charisma and persuasion. Facts would become irrelevant. This, I believe, is was Ron Suskind was getting at when he wrote, in his notorious essay:

In the summer of 2002, after I had written an article in Esquire that the White House didn't like about Bush's former communications director, Karen Hughes, I had a meeting with a senior adviser to Bush. He expressed the White House's displeasure, and then he told me something that at the time I didn't fully comprehend -- but which I now believe gets to the very heart of the Bush presidency.

The aide said that guys like me were ''in what we call the reality-based community,'' which he defined as people who ''believe that solutions emerge from your judicious study of discernible reality.'' I nodded and murmured something about enlightenment principles and empiricism. He cut me off. ''That's not the way the world really works anymore,'' he continued. ''We're an empire now, and when we act, we create our own reality. And while you're studying that reality -- judiciously, as you will -- we'll act again, creating other new realities, which you can study too, and that's how things will sort out. We're history's actors . . . and you, all of you, will be left to just study what we do.''

This is the way the Administration wants the world to work. The facts you believe are chosen for you by those to whom you have political allegiance. Whoever is better at posturing and sleight-of-hand gets to declare the truth. A case in point: Congresspersons who do not support an investigation (HR 375, Rep. Barbara Lee) into the Downing Street Memo do not see a need for an investigation. The Big Brass Alliance is wasting their time and bandwidth. After all, the People already know what they believe. A few annoying facts won't change anything, so why bother looking for the facts?

Who cares if there is evidence that Bush had already planned, by February 2001, to invade Iraq? Who cares if the Administration had, in March 2001, drawn up a list of "Foreign Suitors of Iraqi Oilfield Contracts"? Who cares if plans were in place by February 2003 to make use of Iraqi oil? Do we really need to know when all the plotting started:

From the exclusive Harper's report by Greg Palast:

Within weeks of the first inaugural, prominent Iraqi expatriates -- many with ties to U.S. industry -- were invited to secret discussions directed by Pamela Quanrud, National Security Council, now at the State Department. "It quickly became an oil group," one participant, Falah Aljibury. Aljibury is an advisor to Amerada Hess' oil trading arm and Goldman Sachs.

Who care what the "mobile labs" really were? Who cares what the aluminum tubes were for? Who cares if Iraq really tried to buy uranium from Niger? Who cares if the President deliberately lied about the uranium in his State of the Union Address? No need to investigate the Valerie Plame matter. We already know what to believe.

Who cares if the "facts" we present look like a pleasant California valley from above, but really collide like the San Andreas fault when you look under the surface. Logical inconsistencies are not really dangerous, not really a sign of trouble up ahead.

So, the uproar about Bush's promotion of Intelligent Design Theory is just the tip of the iceberg. What is upsetting to scientists is the broad disregard, not just for science, but for facts. It is not merely the rejection of one body of knowledge (evolution), rather, it is the rejection of the empirical method. The implications go beyond the realm of science; domestic and foreign policy are affected just as badly.

----------
*People smarter than me have pointed out that when you make the leap from pure logic to mathematics, you have to make at least one assumption.

Categories: science, politics
Tags: intelligent design, evolution, Downing Street Memo, BBA, Barbara Lee, Henry Waxman, Valerie Plame, Ron Suskind, Greg Palast

Pharmaceutical Advice on the Internet

2005-07-31T15:32:00.000-04:00

After writing my last serious post, I got to thinking about the issue of Pharmaceutical Advice on the Internet. Although the issue of direct-to-consumer advertising (DTCA) by pharmaceutical companies is a big issue, too, it seems to be more widely discussed. I haven't run across much that deals specifically with pharmaceutical sales and advice over the Internet, even though that is a much more serious problem. At least DTCA is regulated by the FDA, whereas there is absolutely no regulation on the Internet, other than on the sites put up by the drug companies themselves.

In this post, I cast a skeptical look at Pharmaceutical Advice on the Internet, and conclude with some advice, including pointers on how to spot pseudoscientific nonsense.

To put this in context: I first became aware of the seriousness of this problem, when using the Internet in a clinical context. Several years ago, I had admitted a patient to the hospital; the patient seemed cognitively impaired, but the usual medical workup turned up nothing. The following day, the patient admitted to heavy use of GHB. In fact, the patient's spouse was making the stuff in the basement, and selling it. Both of them started using it. Having virtually unlimited access, they got pretty badly messed up. The patient was going into withdrawal, resulting in one of the most striking cases of human misery I have ever seen.

In an effort to help, I started looking around on the Internet. I encountered a site that touted the "benefits" of this "natural substance." There was a lot of scientifically accurate information about the structure, pharmacokinetics, and synthesis of the compound. There were many references to valid primary sources of information. There also was a lot of apparently-accurate information about the pharmacodynamics of the drug. But when I looked at other, more authoritative sources, I learned that there really was not a lot of empirical data about the mechanism of action of GHB. What the author had done, was to interdigitate fact with pseudoscience. If you checked only the first few references, you might have gotten the impression that the rest of the references were valid. That was not the case. If you spot-checked, you may or may not have realized what the author was doing.

The fact is, there are some valid uses for GHB. The pharmaceutical-grade product, Xyrem, is used for narcolepsy. There is preliminary evidence that it might be useful for fibromyalgia, as well. (It is the most tightly-controlled legitimate drug on the market, which whould tell you something.) Thus, if an unscrupulous webmaster wants to sprinkle her or his site with references to peer-reviewed journals, there is plenty of fodder out there. References to valid medical journals may make a site seem authoritative, but do not provide any real assurance of validity.

I cannot find the site that I found several years ago, but there is a similar one here (International Antiaging Systems). Note that the page has eleven citations for peer-reviewed scientific articles and one for a patent application. Note also that the most recent reference is from 1997. In the field of neuroscience, 1997 is practically paleontological. What is particularly irritating, though, is that the section labeled "Long-term Studies" refers to a study by "Dr. Michael Farley," yet there are no citations in the "References" section for any articles by Michael Farley. If a person were considering using GHB, one of the first things he or she would want to know would be the long-term safety of the drug. You see a chart with numbers, and lots of jargon...

Farley noted elevations of growth hormone and IGF1, and reductions in blood sugar in all subjects. However, those who had not previously used GBL had higher levels of growth hormone and IGF1, and greater reductions in blood sugar than the "experienced" GBL users. For example, the average increase from baseline to a peak at 60 minutes ranged from 0.56 to 7.1 NG/ML for the seven GBL "non-users." The four subjects who used GBL for over one year had average values of 0.5 to 2.4 NG/ML, respectively.

...but you have no way of finding the original source material. That should be a huge red flag, signaling a credibility problem.

(Note: GBL is the precursor to GBH; it is converted into GHB in the stomach.)

There is an even more subtle danger when it comes to scientific references. Some journal articles actually are written pretty well, and thus may seem comprehensible to the nonprofessional reader. But if you do not have specific education in the interpretation of scientific reports, you very easily could end up drawing false conclusions. A crafty webmaster could prime the unsuspecting reader to jump to a certain conclusion, when in fact that conclusion is not supported by the literature.

There's another clue that the site is bogus. The site, International Antiaging Systems (IAS), purports to sell "antiaging" products. Xyrem is marketed as a drug for narcolepsy, which is a small market. Think about it for a moment. If the company, Orphan Medical, had sufficient evidence that their product had antiaging properties, wouldn't there be a rather powerful motivation for them to sell to that market instead? The fact that they do not do so, is prima facie evidence that the drug has not been proven to have antiaging properties.

What about the author? Ward Dean, MD, graduated from Han Yang University College of Medicine in Seoul, Korea. In his bio, he does not say where he did his residency, which is odd. The nature and location of his postgraduate training, if any, would be a better indicator of his qualifications. He is or has been affiliated with the Cognitive Enhancement Research Institute, and the Center for Bio-Gerontology, which appears to have no website. I was not able to find any credible evidence that would indicate that either CERI or CBG is a legitimate medical institution. He also is or was affiliated with the American Academy of Anti-Aging Medicine (A4M). Although they claim to be "at the forefront of a major movement," and state that trier second annual conference (1994) was "a landmark event in the progression of anti-aging medicine as a mainstream clinical science," the last item on their "Calandar [sic] of Events" was the "3rd Annual Conference on Anti-Aging Medicine and Biomedical Technology." Apparently, they can't boast about any "landmark events" in the past ten years.

Let's look at another example: SexandDrugs.info. The reason for choosing this one is obvious, it deals with everyone's favorite subject: dopamine. SexandDrugs.info happens to be a target-rich environment for the skeptic, but I will focus on one area: their touting of the drug, cabergoline (Dostinex®). Dostinex® is sold by Pfizer for the treatment of hyperprolactinemia. By mimicking the action of dopamine, it lowers the pituitary secretion of prolactin.

Again, we see jargon:

Prolactin is a single-chain protein hormone, closely related to growth hormone, that stimulates the secretion of milk of women. The hormone also has the effect of reducing a man’s desire for more sex by preventing new erections. Cabergoline has been found to to minimize the effects of the hormone prolactin, which is produced by men at the point of orgasm. As a result, some subjects who tried the drug found that they were able to have multiple orgasms in rapid succession.

We also see references to scientific studies:

In one study, 60 subjects, all healthy males, between the ages of 22 and 31, normally needed a break of 19 minutes between lovemaking sessions. However, after taking Cabergoline, they were able to have several orgasms within a few minutes. Medical psychologist Manfred Schedlowski, who was involved in the trials at Essen in Germany, said the drug raised the libido to enable the male to orgasm again more quickly.

The author breaks with tradition, though, and does not include any formal citations to medical journals. Again, we see information that has face validity, but we have no way of checking for content validity. the author does provide a link to a BBC News article, but that doesn't really help. It does show that he knows how to link to articles, though, so it raises the question: why is there no link to a primary source?

Are there other clues about the bogusness of the site? Of course. Pfizer is a reputable company, but they are know to be aggressive in finding markets for their products. Hyperprolactinemia is not a big market. Sexual performance enhancement certainly would be more lucrative, but it is not a market they have pursued. Why not?

More clues? The author of the site, apparently, is David jay Brown.

David Jay Brown holds a master's degree in psychobiology from New York University (1986), and a B.A. in psychology from the University of Southern California (1983). He is the author of two science fiction novels, Brainchild (New Falcon, 1988) and Virus (New Falcon, 1999), and is co-author of two volumes of interviews with leading-edge scientists and artists--Mavericks of the Mind (Crossing Press, 1993) and Voices from The Edge (Crossing Press, 1995). David's interviews have been translated into Japanese (Hachiman, 1995), Italian (Gruppo Futura, 1997), and Czechoslovakian (East Hauz, 1999). He was responsible for the California-based research in two of British biologist Rupert Sheldrake's books on unexplained phenomena in science: Dogs That Know When Their Owners Are Coming Home (Crown, 1999), which was the bestselling science book in the world for several weeks in the Fall of 2000, and The Sense of Being Stared At (Crown, 2003).

Not to be elitist or anything, but a Master's degree is not really adequate preparation for psychopharmacology. I see several publications, but none that would impress a tenure committee.

Check all the links on the page. For example, SexandDrugs.info links to this. Personally, I do not think that lends much credibility.

The final clue, of course, is in the left sidebar: "Quick Links to Purchase..." Examining the page source (view:page source, control-U in Firefox) we see that the link to purchase Dostinex goes to:

http://www.worldremedium.com/cgi-bin/ua/
clickthru.cgi?id=josephwouk&page=
http://www.worldremedium.com/
cgi-bin/ecommerce/ac/agora.cgi/agora.cgi?
cart_id=6827412.34114*h18NT1&product=Dostinex

The way this works, is that the owner of the page that refers a customer gets a percentage of the sale. See this page for an explanation of World Remedium's "affiliate program," which, by the way offers this claim: "Our payout is one of the most generous in this industry!" So the more persuasive the webmaster can make the pitch for the product, the more money she or he can make. Presumably, the link contains some identifier that enables World Remedium to tell where the money is supposed to go. So who's Joseph Wouk?

This, in and of itself, is not necessarily a shady practice. There are lots of blogs that have links to books at Amazon, etc., and the blogger gets a cut. Most of those are perfectly fine blogs, and I have no beef with them. But if the sole purpose of a site is to generate money, you really do have to wonder about the webmaster's motivation to stick to the truth.

Think of it this way: if you went to the online version of the New England Journal of Medicine and read A Comparison of Cabergoline and Bromocriptine in the Treatment of Hyperprolactinemic Amenorrhea, you might get the impression that cabergoline is a good medicine, and you would assume that the authors were telling the truth. But if, at the bottom of the page, you saw a link that would let you buy the stuff from an anonymous pharmacy somewhere, and you knew that the author got 15% of the sale, would you still trust the article? If so, I have just the product for you:

So what did we just learn about Pharmaceutical Advice on the Internet?

The inclusion of jargon and scientific references is no assurance of content validity
It is important to check the author's credentials, and to remember that you can't really be sure who the author is
Look for the interweaving of verifiable facts with unsupported claims
Check ALL the references aand all the links
View the page source to see where the links go; the text in the status bar may be misleading, and mouseover information can be changed.
If you are not a scientist, be careful when trying to interpret scientific reports.
Always find out who is making money off the deal
If a product is claimed to have wonderful properties, but the legitimate manufacturer makes no such claims, you have to wonder why not.
Look for recent references. If everything is over five years old, that's a bad sign.

And what about GHB? It's highly dangerous; don't use it unless you have polysomnographically-confirmed narcolepsy (including MSLT), or maybe severe fibromyalgia. Cabergoline? Fine for hyperprolactinemia; forget it for sexual enhancement. Read the FDA Safety Guides. And, as always, DON'T buy drugs over the Internet!

Categories: Science, medicine
Tags: quackery, pseudoscience, skeptic, medicine

CNS Update: Riluzole For Depression and OCD?

2005-07-30T18:57:00.000-04:00

Occasionally, pharmaceuticals developed for one purpose turn out to have applications that differ from the original use. This may turn out to be the case with riluzole (Rilutek® - Aventis Pharmaceuticals Products Inc.). [Package insert (PI)] I've blogged about this before, but this post has some new information, and presents a different perspective.

Riluzole was approved by the US FDA in December 2004 for treatment of motor neuron disease, known primarily as Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig disease). The chemical structure of riluzole is shown below:

2-amino-6-(trifluoromethoxy)benzothiazole

Recently, a few articles have appeared, suggesting that riluzole might be helpful for some patients with depression and/or obsessive-compulsive disorder. First, a disclaimer: the research is in a very early stage, and it would be advisable to consider such treatment only within the context of a formal clinical trial (1 2).

Current pharmaceutical treatment for depression and OCD involve almost exclusively agents that modify the action of serotonin and/or norepinephrine. In contrast, riluzole modifies the action of a different neurotransmitter: glutamate.

Glutamate is an amino acid. Its primary function in humans is to serve as a component of protein. It is often the case, however, that most things in the body serve more than one function. Glutamate serves also as a chemical messenger, sending signals between nerve cells. It is the most widely-distributed neurotransmitter in the human brain. Because it is an excitatory transmitter, excessive amounts can lead to neuronal death. It is thought that this is part of the pathophysiology of ALS, in that excessive glutamate may lead to premature death of motor neurons. Therefore, it would make sense to try to find something that inhibits the action of glutamate, and see if that helps patients with ALS.

Note that riluzole has several actions, only one of which is to inhibit release of glutamate from nerve cells in the brain. This may or may not have anything to do with how or why it works. From the package insert:

Mechanism of Action
The etiology and pathogenesis of amyotrophic lateral sclerosis (ALS) are not known, although a number of hypotheses have been advanced. One hypothesis is that motor neurons, made vulnerable through either genetic predisposition or environmental factors, are injured by glutamate. In some cases of familial ALS the enzyme superoxide dismutase has been found to be defective.

The mode of action of RILUTEK is unknown. Its pharmacological properties include the following, some of which may be related to its effect: 1) an inhibitory effect on glutamate release, 2) inactivation of voltage-dependent sodium channels, and 3) ability to interfere with intracellular events that follow transmitter binding at excitatory amino acid receptors. [...]

Superoxide dismutase is an enzyme containing in cells that protects them from damage, under certain conditions.

A lot of people with depression or OCD have a satisfactory response to standard treatments. However, a lot of people don't. Therefore, when a drug becomes available that does something to the brain, usually it is only a short time before somebody tries to use it to treat those patients who have not shown satisfactory response to standard treatments.

Currently, it is not known what role glutamate plays in either depression or OCD. However, since it is so widely distributed in the brain, it would not surprise anyone to learn that it was involved in some way. See this study in ANAS for discussion. In accordance with the notions described above, people now are trying riluzole to see if it can help treatment-resistant patients with depression and/or OCD.

The American Journal of Psychiatry has published a couple of items on the use of riluzole for depression.

Riluzole Augmentation for Treatment-Resistant Depression
Am J Psychiatry 161:2132, November 2004

Letter to the Editor

GERARD SANACORA, M.D., Ph.D., STEVEN F. KENDELL, M.D., LISA FENTON, Psy.D., VLADIMIR CORIC, M.D., and JOHN H. KRYSTAL, M.D.
New Haven, Conn.

To the Editor: Glutamate is implicated in the pathophysiology and treatment of mood disorders (1). The following case reports pertain to the use of riluzole, a putative antiglutamatergic agent indicated for the treatment of amyotrophic lateral sclerosis, as add-on therapy for treatment-resistant major depressive disorder. [...]

An Open-Label Trial of Riluzole in Patients With Treatment-Resistant Major Depression
Am J Psychiatry 161:171-174, January 2004

Brief Report

Carlos A. Zarate, Jr., M.D., Jennifer L. Payne, M.D., Jorge Quiroz, M.D., Jonathan Sporn, M.D., Kirk K. Denicoff, M.D., David Luckenbaugh, M.S., Dennis S. Charney, M.D., and Husseini K. Manji, M.D., F.R.C.P.C.

OBJECTIVE: This study was conducted to determine the efficacy and safety of riluzole, a glutamate-modulating agent, in patients with recurrent major depression. METHOD: After a 1-week drug-free period, subjects 18 years or older with a diagnosis of recurrent major depression and a Montgomery-Åsberg Depression Rating Scale score >=20 received riluzole monotherapy (100–200 mg/day) openly for 6 weeks. RESULTS: Nineteen treatment-resistant depressed patients, 53% of whom were classified as having stage 2 treatment resistance or greater, received riluzole at a mean dose of 169 mg/day. Significant improvement occurred during weeks 3 through 6 for all patients and weeks 2 through 6 for completers. CONCLUSIONS: Although preliminary, these results indicate that riluzole may have antidepressant properties in some patients.

The "letter to the editor" is a semi-formal report of two cases in which depressed patients got better when riluzole was added on to their existing antidepressant regimen. The "Brief Report" is a description of the outcome for 19 patients who received riluzole as the sole treatment. The results are encouraging. However, it is very important that the results be interpreted with caution. That is why Zarate et. al. conclude with the statement: "Although preliminary, these results indicate that riluzole may have antidepressant properties in some patients."

Regarding the potential use of riluzole for OCD, there is one preliminary study:

Riluzole Augmentation in Treatment-Resistant Obsessive–Compulsive Disorder: An Open-Label Trial
j.biopsych.2005.04.043

Vladimir Coric, Sarper Taskiran, Christopher Pittenger, Suzanne Wasylink, Daniel H. Mathalon, Gerald Valentine, John Saksa, Yu-te Wu, Ralitza Gueorguieva, Gerard Sanacora, Robert T. Malison and John H. Krystal

Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut

Case report

Background

Most patients with obsessive–compulsive disorder (OCD) show only partial reduction of symptoms with standard therapy. Recent imaging data suggests glutamatergic dysfunction in the corticostriatal pathway in OCD. We investigated the efficacy of augmentation therapy with riluzole, a glutamate-modulating agent, in treatment-resistant OCD.

Methods

Thirteen patients aged between 18 and 65 years with a primary diagnosis of OCD that had proven resistant to standard treatment were treated with the addition of riluzole to their existing pharmacotherapy. Yale–Brown Obsessive Compulsive Scale (Y-BOCS), Hamilton Depression Inventory (HAM-D), and Hamilton Anxiety Inventory (HAM-A) scores were obtained weekly.

Results

Thirteen treatment-resistant OCD patients received riluzole 50 mg twice a day. Y-BOCS scores improved significantly over time. Of 13 patients, 7 (54%) demonstrated a >35% reduction in Y-BOCS scores, and 5 (39%) were categorized as treatment responders. HAM-D and HAM-A scores for the group also significantly improved over time. Riluzole was well tolerated with no serious adverse effects noted.

Conclusions

Riluzole appears to have significant antiobsessional, antidepressant, and antianxiety properties. The addition of this agent may be of practical clinical benefit in patients with OCD.

In this study, results were more modest, but still significant. Note that in all cases, riluzole was added to pre-existing treatment. It was used in the dose that is standard for ALS, 100mg per day. The study was not designed specifically to assess the effect of riluzole on depression, or on anxiety symptoms not related to OCD, but they did find a significant effect in those symptom clusters as well.

It happens all the time that such preliminary results are reported, patients flock to their doctors wanting the new treatment, and the results may turn out to be poor. Even worse, patients may end up worse off than they were before. In the case of riluzole, there are many reasons for caution.

Recall that the FDA has been criticized recently, due to allegations that they have been too lax in assessing the safety of new drugs. Although Rilutek® has been approved by the FDA, it was approved for use in a condition that is rare, rapidly progressive, and invariably fatal. The threshold for approval in such cases is different than the threshold for other drugs. Although it is common for physicians to use drugs off-label, there are good reasons to be especially careful when doing so. The FDA thinks that Rilutek® is safe, in relative terms; that is, it is safe in relation to the disease for which it was approved. For an invariably-fatal disease, that threshold is fairly easy to meet. Note that in the Kaplan-Meier survival curve, the improvement seen in ALS patients is significant, but hardly impressive. Since all the patients died eventually, we have no way of knowing if there would have been an late-onset adverse events.

Note also that the approved dose of Rilutek® is 100mg per day. The patients in the monotherapy study got more than that; some got 200mg per day.

The Rilutek® package information contains warnings about variability in metabolism of riluzole in Japanese patients, men vs. women, smokers, the elderly, and patients with liver disease.

RILUTEK, even in patients without a prior history of liver disease, causes serum aminotransferase elevations. Experience in almost 800 ALS patients indicates that about 50% of riluzole-treated patients will experience at least one ALT/SGPT level above the upper limit of normal, about 8% will have elevations > 3 X ULN, and about 2% of patients will have elevations > 5 X ULN. A single non-ALS patient with epilepsy treated with concomitant carbamazepine and phenobarbital experienced marked, rapid elevations of liver enzymes with jaundice (ALT 26 X ULN, AST 17 X ULN, and bilirubin 11 X ULN) four months after starting RILUTEK; these returned to normal 7 weeks after treatment discontinuation.

In case that's all Greek to you...

ΡΗΛUΤΕΚ, ακόμη και στους ασθενείς χωρίς μια προγενέστερη ιστορία της ασθένειας ήπαρ, aminotransferase ορών αιτιών ανυψώσεις. Η εμπειρία σε σχεδόν 800 ασθενείς νόσου του Alsheimer δείχνει ότι περίπου 50% των ρηλuζολε-αντιμετωπισμένων ασθενών θα δοκιμάσει τουλάχιστον ένα επίπεδο ALT/$l*SGPT επάνω από το ανώτερο όριο κανονικού, περίπου 8% θα έχει τις ανυψώσεις 3 Χ UΛΝ, και περίπου 2% των ασθενών θα έχει τις ανυψώσεις 5 Χ UΛΝ. _ ένας ενιαίος μη-νόσος του Alsheimer ασθενής με επιληψία μεταχειρίζομαι με συνακόλουθος θαρψαμαζεπηνε και πχενοψαρψηταλ δοκιμάζω χαρακτηρίζω, γρήγορος ανύψωση συκώτι ένζυμο με ίκτερος (ALT 26 Χ UΛΝ, ΑΣΤ 17 Χ UΛΝ, και ψηληρuψην 11 Χ UΛΝ) τέσσερις μήνας μετά από αρχίζω ΡΗΛUΤΕΚ αυτοί επέστρεψαν σε κανονικές 7 εβδομάδες μετά από την αναστολή επεξεργασίας.

...what this means is that there is a risk of liver damage with riluzole. (I have no idea why Babelfish thinks "riluzole-treated patients" are "patients of illness of Alsheimer.") It is pointed out that about half of the ALS patients have at least some elevation of liver enzymes when they are treated with Rilutek®. They recommend regular monitoring of the levels of these enzymes, in case some patients develop overt liver damage.

They also note that there were a few patients on Rilutek® who developed low white blood cell counts.

Riluzole is broken down in the liver by several different pathways, and there are many active and inactive metabolites. It is highly bound to plasma protein. Those are indications that it has a high potential for drug interactions. Aventis did not do clinical studies to check for interactions. It is likely that they would have to do more safety and interaction studies if they asked the FDA for approval to market Rilutek® for treatment of something common, such as depression or OCD.

There has been some concern in the media about the impact of direct-to-consumer advertising of pharmaceutical products. Blog posts, such as this one, raise a more complicated issue. Most people reading this have either no idea, or only a vague idea, of who I am. The fact that I use a lot of jargon and cite reputable journals may give the impression that I actually know what I am talking about. In this post, I've tried to convey an appropriate level of caution. I am not trying to sell anything. (Note the absence of blog ads.) I don't own stock in Aventis, except maybe there is some in my 401k; I deliberately don't invest directly in pharmaceutical companies. But you don't know any of that, and you have no way of checking. You could send an email to joseph.j7uy5-at-gmail/dot/com, but even that would not provide you with any information that is more reliable that what you are reading now.

There are many sites on the Internet that include a lot of jargon and cite reputable journals, yet contain all kinds of misleading, commercially-motivated, and/or downright dangerous statements. I suggest thinking of it this way: If you might consider making a potentially life-changing medical decision based upon some anonymous blog post, ask yourself this: would you consider investing a large amount of money in an unknown company, based upon an anonymous blog post that reads like this: ΡΗΛUΤΕΚ, ακόμη και στους ασθενείς χωρίς μια προγενέστερη ιστορία της ασθένειας ήπαρ, aminotransferase ορών αιτιών ανυψώσεις? If not, good for you; if so, I suggest that you disconnect from the Internet immediately, and don't connect ever again.

No, the point here is not to urge anyone to go out and ask for a prescription. Rather, I am hopeful that some health care professionals will read this and learn something that might be useful at some later date. Nonmedical readers should take away a couple of points. One, there is ongoing research into difficult-to-treat psychiatric conditions, so there always is hope that those who do not respond to conventional treatments may, someday, have more options available. Two, there are some skills that one must acquire in order to assess medical claims. Reading this post might help sharpen those skills. And finally, always be skeptical of anything you read on the Internet, no matter how authoritative it may seem.

Спасибо за чтение Корпус Коллозум. Возвратитесь скоро. До свидания. Vielen dank dafür, Das Korpus Callosum zu lesen. Kommen Sie bald zurück. Auf Wiedersehen!. Gracias por leer la Recopilación Callosum. Vuelto pronto. ¡Adiós!. Merci de lire le Corpus Callosum. Revenu bientôt. Au revoir! These translations courtesy of Paralink.com. (I hope I didn't just insult somebody.)

Categories: Science, medicine
Tags: depression, obsessive compulsive disorder, medicine, psychiatry, mental health, amyotrophic lateral sclerosis

Resolution of Inquiry

2005-07-28T23:52:00.000-04:00

House Resolution 375, proposed by the Honorable Barbara Lee (D-CA), calls for Congress to exercise its Constitutional oversight of the executive branch, by investigating the communication that took place between the USA and the UK in the run-up to the Iraq War. Although this is unlikely to go anywhere, given the yellow-hammerlock that the Republican Party has on Congress, it is a serious matter nonetheless.

If our President indeed lied to the American people prior to the war, that would be a High Crime, by any definition. Recall that he stated, on numerous occasions, that the decision for war had not been decided until a few days before hostilities began. The gravity of the situation was underscored by the nation-wide recognition given to the Downing Street memos. This is analogous to the situation with the 16 words about "uranium from Africa." Those words were contained in a State of the Union Address, which is a Constitutionally-mandated official report to Congress. Knowingly including a lie in report to Congress is no small matter. Ol' Cranky at The Disenchanted Forest has the latest on that.

One of our servicemen, Rob, posting at The Online Magazine formerly known as Rob's Blog, provides us with an easy way to speak up:

If your Representative is not a co-sponsor, we need you to ask him or her to become a co-sponsor of H.Res. 375. Many, even possibly some Republicans, will co-sponsor this, but they have to be asked.

The link goes to a page at Democrats.com, and it provides a form that simplifies the process of sending an email to your congresspersons. It even figures out the appropriate recipients, based upon your own zip code.

Submarines have always fascinated me. The Ohio-class Trident II-bearing boomers are, arguably, the most powerful killing machines ever devised. Despite that satanic distinction, it is entirely possible that it was our superiority in undersea warfare that prevented the Cold War from killing us all. Accordingly, I have a certain kind of ambivalent respect for submariners. Rob is one of them, although I don't know what kind of boat he mans.

In fact, one of our horses, Vivid October, was named after the submarine in The Hunt for Red October. Well, at least the name was inspired by the fictional sub. His mare is named Vivid April Maiden. Yvonne's birthday is in April; mine is in October. April is female; October is male. Yvonne was not fond of the other proposed names: Trident, etc., but she could live with October, and it sort of made sense, for the reasons noted above.

Nostalgic tangents aside, I sometimes think that certain political figures fancy themselves to be as powerful and as secretive as the Ohio-class SSBN's, as they rove the halls of the West Wing. HR 375 may well torpedo that fantasy.

Others fancy themselves to be bucking stallions. I think this is a more accurate depiction:

Kinda reminds you of a certain joke told by the First Lady, about our President, doesn't it?

Categories: rants, politics
Tags: politics, Downing Street Memo, BBA, impeachment, Valerie Plame