Morning Faces Therapy Improvements

Seth Roberts3 Comments

A friend with bipolar disorder writes:

I began the morning faces therapy in April, 1997. I can think of only two significant changes over the years in my use of the therapy: 1) I use a mirror instead of videotapes, and 2) I accept that once or twice a week I’m too tired to start as early as I’d like (so I get more sleep instead). To elaborate:

1) When I restarted the treatment in 2006 after having been hospitalized, I was too depressed to deal with videotaping. In fact, I was too depressed to get out of bed so early. The mirror solved both problems, because I could easily prop it on my mattress top. After a few days I was able to get up, allowing me to listen to music, use bright lights, etc., during the treatment.

2) Whether for lack of discipline or the proper genes, I simply can’t go to sleep early enough so that I can get up early every morning. (Granted, I haven’t tried everything, but for the sake of the argument, let it stand.) This shortcoming used to bother me a great deal. Then on October 6th, 2011, I read in this blog about someone else who didn’t always start the treatment early, because he was “too tired to get up early ”. Well! It didn’t seem so bad if someone else had the same problem. Over the years I’ve found that starting 30-60 minutes late once or twice a week doesn’t seem to perturb my mood enough to cause great concern.

Interview with Daniel Wolfson of Choosing Wisely

Seth Roberts2 Comments

The new Choosing Wisely campaign is centered on lists of “unnecessary” medical tests and procedures. The hope is that these lists will reduce waste in the health care system. I wondered what “unnecessary” meant so I interviewed Daniel Wolfson, who is Executive Vice President and Chief Operating Officer of the American Board of Internal Medicine, located in Philadelphia.

At the heart of my question was: why these procedures and not others? Each list has five items. How were they chosen? Here is how the five items on the American College of Physicians’ list were selected:

The American College of Physicians (ACP) formed a workgroup of eleven experienced internal medicine physicians with specific skills in the assessment of evidence. . . . The group collaboratively identified and narrowed down screening or diagnostic tests commonly used in clinical situations where they are unlikely to provide high value or improve patient outcomes. The results were further reviewed and narrowed by clinically active ACP staff physicians before being placed for review into a randomly selected internal medicine research panel. Representing 1 percent of ACP members, the panel selected five scenarios that represented the greatest potential for overuse or misuse of a diagnostic test leading to low value care.

I said this sounded like a popularity contest. Mr. Wolfson said, no, the recommendations are based on evidence. “Do you know what a randomized trial is?” he asked. What evidence? I said. It’s not on your website.

Yes, it’s there, said Mr. Wolfson. He pointed me to the “sources” at the end of the ACP list. Here is one of those sources:

2011 USPSTF screening for coronary heart disease with electrocardiography (draft) guideline; 2011 AAFP recommendations for preventive services guideline; 2010 ACCF/AHA assessment of cardiovascular risk in asymptomatic adults guideline.

This is evidence? I said. It’s very vague. At this point Mr. Wolfson ended the interview.

So I continue to think it is a popularity contest. Who knows how the doctors on that “randomly selected internal medicine research panel” made their decisions.

I think the Choosing Wisely campaign is worthwhile, in spite of Mr. Wolfson’s implausible claims (he also said the doctors who created these lists were “courageous”). Here’s what I would say: The items on these lists are things that many doctors in that specialty think are done too often. The lists are like a free second opinion.

 

 

 

Paging Dr. Google: Magnesium, Constipation, and Subarachnoid Hemorrhages

Seth Roberts7 Comments

Did you know that magnesium can reduce constipation? I didn’t. Did you know that constipation can cause bleeding under your skull (subarachnoid hemorrhages), which are earth-shatteringly painful? Apparently a lot of doctors who treat subarachnoid hemorrhages don’t know this. Here is a story from Metafilter:

A year after [cancer] chemo ended I had . . . 4 aneurysms (subarachnoid bleeds) in 12 days. These aneurysms (subarachnoid hemorrhages) were serious agony, the most pain I’ve ever experienced. . . . It’s like the World Trade Center falling down in one’s head, involuntary non-stop screaming, passing out from the pain kind of thing. . . . None of the docs could figure out what these aneurysms were from. They all seemed totally mystified. They gave me a very risky test, brain surgery basically, a brain endoscopy that meant putting a probe into my brain. I had to sign papers that it wasn’t their fault I came out a vegetable.

Several lumbar punctures. 2 CT scans then an MRI. Then my neurologist wanted me to do a really risky test, that involved stopping my heart momentarily. . . . The chances of surviving just one of these aneurysms isn’t good: “An estimated 10-15% of patients die before reaching the hospital. Moreover, mortality rate reaches as high as 40% within the first week, and about 50% die in the first 6 months.” So I felt forced to take this dangerous test. . . .

[I] looked at when the aneurysms happened and the relief I experienced in the Emergency Ward when I’d been injected with magnesium. I googled magnesium and realized its help in treating constipation. I’d been constipated for over a year from the chemo and pain meds for the chemo pain. I realized I had these aneurysms after trying to go to the toilet, from straining. The neurologist didn’t want to hear about constipation . . . . None of the docs asked me about constipation. . . .

I self medicated with magnesium citrate, which relieves constipation in a different way than laxatives, it brings water into the colon, which helps the evacuation process a lot. Calcium and magnesium citrates combined, to be exact. And that did the trick, instantly. No more aneurysms. No more dangerous tests. No more brain surgeries.

I wonder if blood tests showed she was magnesium deficient. I also suspect fermented foods would have helped. Chemo causes constipation, I’m guessing, because it kills intestinal microbes, which fermented foods replace.

If you are nickyskye (the author of this) I hope you will contact me, I would like to write more about it and I have some questions.

Thanks to Melissa McEwen.

The American Dietetics Association Wants No Competition

Seth Roberts4 Comments

Michael Ellsberg has an excellent article about the American Dietetic Association’s attempts to make it illegal for anyone they haven’t approved to give nutritional advice. In this document, they are frank that this is their goal. After Ellsberg drew attention to it, it was taken down. I look forward to learning why it was taken down.

The Washington State chapter of the ADA, now called the Washington State Academy of Nutrition and Dietetics, is responsible for taking down the document. The organization has this mission statement:

Empowering the people of Washington to improve health with safe, effective and reliable food and nutrition information.

Our Vision: Optimize the health and well being of Washington State individuals through food & nutrition.

Our Mission: Empower members to be Washington State’s food and nutrition leaders.

Long ago, in the civil rights or suffrage movements, for example, empowerment meant removal of barriers. This organization preaches empowerment by creation of barriers. Their empowerment is someone else’s disempowerment.

Assorted Links

Seth Roberts4 Comments

Thanks to David Cramer and Nadalal.

Science in Action: Unexplained Changes in Brain Speed

Seth Roberts6 Comments

This is me a few days ago. I did a choice reaction time task many times. Each dot is a session with enough trials to supply 32 correct answers.The y axis is in “percentile” units, meaning speed relative to recent performance. If my speed was at the average of recent performance, the percentile would be 50, for example. Higher percentiles = better performance = faster (shorter reaction time). Each point is a mean; the vertical bars are standard errors. The dotted line is the median of the means.

The graph shows that Friday afternoon I was suddenly unusually slow. After dinner, I returned to normal. A change from 60%ile to 20%ile to 60%ile resembles an IQ change from 105 to 87 to 105 (an 18-point change).

At the same time accuracy was roughly constant:

Because accuracy was roughly constant, the change in speed was not due to a shift on a speed-accuracy tradeoff function.

There are two puzzles here. 1. Why were my scores low Friday afternoon? 2. Why did they recover after dinner? On Friday I didn’t feel well. As a result, I didn’t eat much. Maybe my blood sugar was lower than usual. I usually eat 30 g butter twice/day. On Friday I didn’t have any. At dinner I did have moderate amounts of pork fat (but not butter) and sugar (in lemon citron tea). Friday 6 pm I had a cup of black tea. Although I haven’t noticed effects of tea on these scores, there’s a first time for everything.

Here is a clue to what makes my brain work well (= fast), I conclude. Butter causes sudden improvement, I have found; which makes it plausible that lack of butter (and other animal fat) could cause sudden degradation. Another possibility was that my blood sugar was low Friday afternoon. (I didn’t think of this at the time, and didn’t measure it.) I’m surprised that something as important as brain function would be as fragile as these results imply. When various nutrient deficiencies are studied with conventional measures, it generally takes weeks or months without the nutrient for the bad effects to become apparent. It takes many weeks without Vitamin C to get scurvy, for example.

These results raise the intriguing possibility that everyone has sudden ups and downs in brain function and that these ups and downs can be detected at high signal/noise ratios. If so, we can use these ups and downs to learn how to make our brains work well. These results also imply — because my choice reaction time test required only a laptop — that anyone can detect them, study them, and learn what causes them. No experts needed. What a change that would be.

 

Gene Linked to Autism?

Seth Roberts2 Comments

An article in the New York Times describes research that supposedly linked a rare gene mutation to autism:

Dr. Matthew W. State, a professor of genetics and child psychiatry at Yale, led a team that looked for de novo mutations [= mutations that are not in the parents] in 200 people who had been given an autism diagnosis, as well as in parents and siblings who showed no signs of the disorder. The team found that two unrelated children with autism in the study had de novo mutations in the same gene — and nothing similar in those without a diagnosis.

“That is like throwing a dart at a dart board with 21,000 spots and hitting the same one twice,” Dr. State said. “The chances that this gene is related to autism risk is something like 99.9999 percent.”

It is like throwing 200 darts at a dart board with 21,000 spots (the number of genes) and hitting the same one twice. (Each person has about 1 de novo mutation.) What are the odds of that? If all spots are equally likely to be hit, then the probability is about 0.6. More likely than not. (Dr. State seems to think it is extremely unlikely.) This is a variation on the birthday paradox. If there are 23 people in a room, it is 50/50 that two of them will share a birthday.

When Dr. State says, “The chances that this gene is related to autism risk is something like 99.9999 percent,” he is making an elementary mistake. He has taken a very low p value (maybe 0.000001) from a statistical test to indicate the likelihood that the null hypothesis (no association with autism) is true. P values indicate strength of evidence, not probability of truth.

One way to look at the evidence is that there is a group of 200 people (with an autism diagnosis) among whom two have a certain mutation and another group of about 600 people (their parents and siblings) none of whom have that mutation. If two instances of the mutation were randomly distributed among 800 people what are the odds that both instances would be in any pre-defined group of 200 of the 800 people (defined, say, by the letters in their first name)? The chance of this happening is 1/16. Not strong evidence of an association between the mutation and the actual pre-defined group (autism diagnosis).

Another study published at the same time found an link between autism and a mutation in the same gene identified by Dr. State’s group but again the association was weak. It may be a more subtle example of the birthday paradox: If twenty groups of genetics researchers are looking for a gene linked to autism, what are the odds that two of them will happen upon the same gene by chance?

If the gene with the de novo mutations is actually linked to autism, then we will have insight into the cause of 1% of the 200 autism cases Dr. Smart’s group studied. When genetics researchers try so hard and come up with so little, it increases my belief that the main causes of autism are environmental.

Thanks to Bryan Castañeda.

Do Sonograms Cause Autism? New Evidence

Seth Roberts5 Comments

A female American engineer named Parrish Hirasaki has started a website devoted to the idea that prenatal ultrasound is a major cause of autism. It includes a long list of supporting research. In spite of all this research, “as of spring 2011, analyzing the ultrasound results was not among the 23 hypotheses [about the cause of autism] being tested by the National Children’s Survey”, says the website.

I first heard this idea from Caroline Rodgers, a science writer, and have blogged about it several times. Nevertheless, the website’s home page taught me several things I didn’t know:

1. “A recent major study of twins supports earlier studies in concluding that environmental exposures during or shortly after gestation cause a majority of autism cases.” This is inconsistent with many other explanations (e.g., vaccine, genetic).

2. “In a recent study, autistic children had reduced connectivity between the two sides of the brain.” Which supports the idea that neural misdevelopment is a cause of autism.

3. “Twenty years ago, the FDA increased the allowable intensity of prenatal ultrasound 8-fold to improve images. Autism rates have risen dramatically since that time.”

4. There is “widespread misunderstanding among ultrasound operators of the safety guidelines.”

5. “A fast-growing commercial business is keepsake ultrasound photos. Franchisers advertise that no medical background or certification is required.”

I asked Hirasaki a few questions.

How did you become interested in this?

My age and my profession led me to the theory that the rise in autism is caused by exposure to prenatal/neonatal ultrasound.
  1. When my last child was born in 1978, there was one ultrasound machine serving the entire population of Houston.
  2. My work experience in the industrial and aerospace industries was extensive in heat and vibration.
  3. For several decades, my work included industrial instrumentation in chemical plants and refineries. Most such instruments require routine calibration to stay accurate.
  4. In the space program, there are always redundant devices because mechanical and electrical equipment may malfunction.
  5. A first cousin died at age 6 of cancer caused by x-ray overdose in the 1940′s. I am old enough to remember getting my feet x-rayed at the shoe store.

Who else, in addition to Caroline Rodgers, has independently had this idea and written or posted about it?

Manuel Casanova, a neurologist. Nancy Evans, a science writer.

When you started looking into possible causes of autism, did you look into other possible explanations?

No. I asked myself what had changed about having a baby. Ultrasound seemed to be the obvious major change. Exposure to caffeine, smoking, alcohol and medications had all decreased.

Was there any particular evidence that you found especially persuasive?

On my website, there are 37 papers pertinent to the topic. My primary theory is that overexposure is the cause. The most persuasive evidence that points to this is:

  1. The girls in the Kaiser-Permanente study who have the highest exposure to ultrasound during the second trimester have more than double the expected rate of autism.
  2. Interruption of the neural migration patterns in the brains of the overexposed mice in the Yale study.
  3. A known cause of autism is the mother having an infection. One theory is that as the mother’s body fights the infection with a fever, the rise in temperature of the fetal brain causes the damage. The temperature rises in tissue exposed to ultrasound are reported in a paper which calls for the FDA to examine the current allowable limits.
  4. The much higher rate of autism for children who weighed less than 4.5 pounds at birth. The medical and AIUM protocol for infants this small is an immediate head ultrasound.
What has made it difficult for the research community to find this?
  1. The researchers have education and experience [and funding — SR] in medicine, biology, genetics. This is where they look.
  2. In the 1950′s, the FDA turned the regulation of medical ultrasound over to the American Institute for Ultrasound in Medicine (AIUM) which is funded by the government and the manufacturers. In November 2011, I expressed my concerns via email to the AIUM Bioeffects Committee. The chair responded that the AIUM monitors the topic and has conducted a thorough search of existing literature (2008) and found no link except the “weak association” in the Kaiser-Permanente study. The report states that there are potential risks to administering ultrasound tests, which include “postnatal thermal effects, fetal thermal effects, postnatal mechanical effects, fetal mechanical effects, and bioeffects considerations for ultrasound contrast agents.” Another section says “the long-term effects of tissue heating and cavitation have shown decreases in the size of red blood cells in cattle when exposed to intensities higher than diagnostic levels. However, long-term effects due to ultrasound exposure at diagnostic intensity is still unknown.” In 1992, the AIUM and the FDA increased the allowable intensity of prenatal ultrasound 8-fold without knowing whether it was safe. Twenty years later, they still don’t know.
  3. Engineers who could do such research receive funding from the manufacturers. Such a researcher would be unlikely to propose research that could decimate the industry.
  4. This is the classic search for a needle in a haystack. Less than 1 in 300 ultrasounds is causing noticeable brain damage.

I would add that links between sonograms and left-handedness are more evidence that sonograms can cause important brain changes. Here is a doctor who does sonograms dismissing the connection but what I find important is that the connection has been found repeatedly.

What is “Unnecessary” Medicine?

Seth Roberts1 Comment

An organization called the American Board of Internal Medicine Foundation has launched a campaign to reduce the cost of health care by reducing “unnecessary” tests, drugs, and procedures. A bare-bones website lists them. For example:

Don’t routinely do diagnostic testing in patients with chronic urticaria [hives].

Here is the explanation of that recommendation:

In the overwhelming majority of patients with chronic urticaria, a definite etiology is not identified. Limited laboratory testing may be warranted to exclude underlying causes. Targeted laboratory testing based on clinical suspicion is appropriate. Routine extensive testing is neither cost effective nor associated with improved clinical outcomes. Skin or serum-specific IgE testing for inhalants or foods is not indicated, unless there is a clear history implicating an allergen as a provoking or perpetuating factor for urticaria.

Not clear. Are they trying to say the tests are useless (“not associated with improved clinical outcomes”)?

My broad question about the campaign is: What does “unnecessary” mean? This is not explained on the website nor in a Washington Post article about the campaign.

A nearby article on the Post website is about “the downside of mammography”. It says:

A study published Monday in the Annals of Internal Medicine adds to a growing body of evidence that the potential risks of routine breast-cancer screening via mammography might in fact outweigh such screening’s benefits.

That’s clearer. It seems to be saying the costs outweigh the benefits. (What are “potential” risks? I thought all risks were potential.) But that doesn’t mean that breast cancer screening is “unnecessary”, it means it is a bad idea.

If the foundation is trying to say that a lot of medicine does more harm than good, then, please, say so. If they are trying to say that a lot of medicine is useless, then, please, say so. Stop being polite.

I contacted the foundation to ask them about this.

Thanks to Bryan Castañeda.

Lack of Repeatability of Cancer Research: The Mystery

Seth Roberts14 Comments

In a recent editorial in Nature (gated), the research head of a drug company complained that scientists working for him could not repeat almost all of the “landmark” findings in cancer research that they tried to repeat. They wanted to use these findings as a basis for new drugs. An article in Reuters summarized it like this:

During a decade as head of global cancer research at Amgen, C. Glenn Begley identified 53 “landmark” publications — papers in top journals, from reputable labs — for his team to reproduce. Begley sought to double-check the findings before trying to build on them for drug development. Result: 47 of the 53 could not be replicated.

Yet these findings were cited, on average, about 200 times. The editorial goes on to make reasonable suggestions for improvement based on differences between the findings that could be repeated and those that could not. The Reuters article goes on to describe other examples of lack of reproducibility and includes a story about why this is happening:

Part way through his project to reproduce promising studies, Begley met for breakfast at a cancer conference with the lead scientist of one of the problematic studies. “We went through the paper line by line, figure by figure,” said Begley. “I explained that we re-did their experiment 50 times and never got their result. He said they’d done it six times and got this result once, but put it in the paper because it made the best story.

Okay, cancer research is less trustworthy than someone just barely outside it (Begley) ever guessed. Apparently careerism is one reason why. What is unexplained in both the Nature editorial and the Reuters summary is how research can ever succeed if things aren’t reproducible. Science has been compared to a game of Twenty Questions. Suppose you play Twenty Questions and 25% of the answers are wrong. It’s hopeless. In experimental research, you generally build on previous experimental results. The editorial points out that the non-reproducible results had been cited 200 times but what about how often they had been reproduced in other labs? The editorial says nothing about this.

I can think of several possibilities: (a) Current lab research is based on experimental findings of thirty years ago when (for unknown reasons) careerism was less of a problem. Standards were higher, there was less pressure to publish, whatever. (b) There is a silent invisible “survival of the reproducible”: Findings that can be reproduced live on because people do lab work based on them. The other findings are cited but are not the basis of new work. (c) There is lots of redundancy — different people approach the same question in different ways. Although each individual answer is not very trustworthy their average is considerably more trustworthy.

Leaving aside the mystery (how can science make any progress if so many results are not reproducible?), the lack of reproducibility interests me because it suggests that the pressure to publish faced by professional scientists has serious (bad) consequences. In contrast, personal scientists are under zero pressure to publish.

Thanks to Bryan Castañeda.