Monday, December 31, 2007

Support reason in politics

An oxymoron?

Many hope a grassroots call for a presidential candidate science debate

Happy new year!!

Sunday, December 30, 2007

Shades of bullshit

The saga continues

The terms used to describe the plethora of non-science based medical modalities has changed and transformed over time. Descriptors using the word “holistic” have given way to “alternative, complementary, and integrative” perhaps in an attempt to find ways to penetrate more effectively into mainstream consciousness.

Interestingly, Dr Novella and others have interesting posts about this phenomenon finding analogies in evolution-like processes where fringe pseudo-sciences continually mutate their appearance in an attempt to become “accepted” into the scientific fold much like creationism dressed itself in the mantel of intelligent design. This is reminiscent of the mimicry used by the chameleon and, unfortunately, has met with a measure of success.

The bottom line is, no matter how much complementary and alternative medicine or veterinary medicine (CAM or CAVM) would like to pretend they are something they are not; the concept of “holism” remains a steadfast pillar of this world view. Supporters of the The CAM model constantly remind us that they examine the “whole” patient with the obvious implication that science based medicine does not.

The fact is the claim that CAM is based on a true holistic foundation is nothing but a paper tiger. Though, an often discussed theme here, the importance of this fatal flaw deserves frequent mention. Much of CAM deals with rather nebulous concepts that involve often indefinable energy flows, channels, bizarre concepts and belief based philosophies. Approaches to therapeutic plans are often broad and unspecified. For example, straight chiropractic deals with yet to be identified subluxations, and much of acupuncture depends on undetectable meridians. Any holism here relates more to each practitioner’s particular orthodox and inflexible philosophy rather than a coherent medical model.

On the other hand, science based medicine works within a true holistic framework as a matter of routine. Done well, it takes into account a patient’s condition in the context of whole systems utilizing tried, tested, and effective methods. At the same time, the crucial pillars of science based medicine involve change, flexibility, and self-doubt which guard it, for the most part, against becoming excessively rigid.

Granted, there are huge problems, especially in human medicine with respect to the organization of health care. Though this is a topic well worth discussion, it has nothing to do with what science based medicine is. Unfortunately, this is an area where CAM attempts to wedge its way into the mainstream by confounding “traditional” science based medicine with larger political and socio economic problems- really a non sequitor.

Ramey and Rollins in their book “Complementary and Alternative Veterinary Medicine Considered” state CAVM practitioners may assert that it is necessary to consider an almost limitless number of factors in deciding which approach or combination of approaches is best suited for the diagnosis and treatment of the patient. However, all of the available evidence suggests that this is not the case. That is, a huge body of research has demonstrated that human judgment can not compete with a more objective process that involves evaluating a small number of relevant variables….There is, in fact, no indication that CAVM practices offer any diagnostic or therapeutic advantage over science-based approaches and every reason to believe that no such advantages exist or will be forthcoming, given the long history of their use and concomitant lack of supporting evidence.”

In essence, because of this, CAM and CAVM now more often seem be taking the tact of attempting to blend in as “complementary” or “integrative” to science based medicine; subtly infiltrating areas of science based medicine including academic institutions and hospitals in a bid for legitimacy.

Sadly, as they succeed, the doors towards medical anarchy open a little wider.

Saturday, December 29, 2007

Feline Vaccines and relative risk

Towards separating the chaff from the wheat

Blogging on Peer-Reviewed ResearchThis 2007 retrospective cohort study “Adverse events after vaccine administration in cats: 2,560 cases (2002-2005)”comes from the University of Purdue School of Veterinary Medicine in association with Banfield veterinary hospitals. It evaluated the incidence of vaccine associated adverse events (VAAEs) diagnosed within 30 days of vaccination in cats and attempted to determine risk factors for their occurrence. This is one of the largest studies of its kind to date reviewing 496,189 cats vaccinated at 329 hospitals. The study followed these cases for up to two years post incident and revealed pertinent information for practitioners.

The general conclusion of this study reinforces the increasing data base that confirms VAAE rates are actually very low. Additionally, it found no association between vaccinations and an increased incidence of tumor associated vaccine reactions- a relation that has been long overblown by anti-vaccination advocates.

To be clear, vaccinations work and thus have the potential for adverse reactions including the possiblity in cats of being associated with vaccine associated tumors (although even if you assume a link, the national incidence appears low at approximately 1 to 2 sarcomas/ 10,000 cats).

What is not made clear or somehow seems to be buried away in the publics statistical ignorance is that a growing number of studies are revealing that vaccine related adverse reactions are indeed rare and when they do occur, they are overwhelmingly mild reflecting observations seen across many animals including humans. Yes there are rare potentially devastating effects that need to be carefully considered when developing what should not be forgotten is the ultimate strategy- that of of protecting innumerable animals from very common and far more devastating diseases.

The Purdue/Banfield study came up with some interesting data that may influence general practitioners towards modifying vaccination protocols slightly in light of these findings. They conclude that “Although overall VAAE rates were low, young (below one year) adult neutered cats that received multiple vaccines per office visit were at the greatest risk of a VAAE within 30 days after vaccination. Veterinarians should incorporate these findings into risk communications and limit the number of vaccinations administered concurrently to cats.”

Basically, it seems that when problems are noted, they tended to occur more frequently in younger neutered cats given multiple vaccines. The authors also note “…the factor associated with the greatest increase in VAEE risk was the number of concurrently administered vaccines or the total vaccine volume administered during the office visit.” This is consistent with another more limited study done in dogs where a vaccine/volume association was found in animals less than 10kg. The canine study by the way also indicated a very low adverse incident rate.

This information can be used to fine tune vaccination protocols and further reduce already low risks. For example, a simple strategy for the veterinarian here would be to split vaccine doses in young cats and assess each individual animal based on the risks/benefits. Vaccine producers can take this information into account when designing vaccinations, especially in light of the probable development of future vaccines against serious feline disease.

Incidentally, the reactions noted consisted of two types. One was characterized by a nonspecific systemic reaction with clinical signs of anorexia, lethargy, fever, or general soreness. The other consisted of a local (injection-site) reaction. As mentioned, this particular study found no association with vaccine related tumors through the study range of one to two years post vaccination. Other longer term studies will help continue to reduce the gaps in our knowledge regarding potential vaccine related effects. Anti vaccine advocates will surely continue to take a “God in the gaps” approach and insist vaccinations cause any number of maladies while ignoring the obvious huge benefits they bring.

The authors state that “Vaccinations are the most cost- effective method of preventing infectious diseases, but VAAEs can sometimes raise more concern among veterinarians and cat owners than do the diseases the vaccines are intended to prevent.” This study adds to the increasing understanding of where our priorities should be and helps quiet the loud fear mongering anti-vaccine advocates by countering their claims with facts.

The goal here, as in all medicine, is to understand all that we can about a particular intervention and balance the risk versus benefits to provide the most reasonable and effective protection. This animal study serves to illustrate how practitioners evaluate real evidence to critically examine and re-examine their ability to improve, modify, or fine tune whatever intervention is being examined- feline vaccinations this case.

Friday, December 28, 2007

On the origin of humans

Interesting observations regarding brain evolution

Homo sapiens distinguish themselves among the general primate lineage in three distinct ways- bipedalism, smaller modified jaws and teeth, and a very large brain. It is likely that at some point these principal developments coalesced functionally allowing for new opportunities in the game of evolutionary dynamics. It is not hard to imagine this unique combination beginning to form ever strengthening feedbacks with each other and eventually becoming the critical ingredients enabling, in time for the creatures we are today.

In fact, it may very well be this interplay that set one distant hominid ancestor off on the road to becoming Homo sapiens. The common belief that brain size or brain to body size relates to intelligence (at least the kind of intelligence we would consider human) is too simplistic. The elephant brain is four times larger than ours yet they posses no where near the interactive complexity of humans, therefore brain size does not equal complexity or correlate to human like intelligence. A straight brain to body size ratio do not work either as for example the mouse lemur has a brain to body ratio of 3% whereas humans come out at 2%.

Brain size grows as bodies become larger, albeit more slowly as body size increases, but ultimately there is no direct link to increased intellectual complexity and just larger brain size. The real relation between brain and body size is best described by a non-linear power ratio which is 0.75. With this ratio, humans indeed have the largest brains relative to body size.

Among all mammals, Homo sapiens have the largest brains, and primates in general tend to have larger brains than other mammalian species. It is interesting to note that there are exceptions and overlaps with other mammals though. For example, simian primates generally have relatively larger brains than prosimians but there is overlap at this level with some large brained prosimians and other mammals such as seals.

As primates go, contrary to what many think, the gorilla has a small brain size relative to body ratio compared to monkeys and the New World capuchin monkey has the highest non-human relative brain to body size ratio. This interesting capuchin fact offers researchers an opportunity for study that could potentially reveal some evolutionary insight into the brain expansion of our own ancestors.

One fascinating observation when considering brain size in mammals is, even though Homo sapiens have a much higher brain/body ratio (three times larger) than expected, it is not the fact that we have larger brains that stands out first from an evolutionary perspective.As previously implied, mammals in general tend to have larger brains, which seems to be a favorable quality for this branch of animals.

In fact, endocast studies of mammalian brain fossils has led to the incredible realization that, through time, brains have tended to increase in size across all lineages. This is indeed a humbling thought for the hominid line. The differences in modern species brain sizes have come about through differing rates of brain expansion. It seems what really set us apart in the mammalian world is the rate of expansion- just a few million years to gain our present brain size- that is truly unique.

The brain is a very expensive organ to develop and maintain. It seems the mammalian way of life facilitated the selection of a type of brain complexity that favored their survival. This then begs the question of how a hominid line was pressured towards attaining such a large brain.

Here, there is much speculative thought that revolves around the uniquely human evolutionary triage previously mentioned. Probably by serendipity and the inexorable flow of evolutionary pressure, this tiny hominid lineage stumbled upon a formula that allowed it the ability to feed its brain beyond the capacity of other mammals.

It seems then that our humanness is, at least in large part due to the inseparable interplay between bipedal walking, a remodeled jaw for eating high energy food, and a ready predisposition for large brains.


Jones S, Martin R, et al. Human evolution. Cambridge university press. Cambridge, UK. Part three 107-108.

The lunar effect

Hard to keep a good myth down

Blogging on Peer-Reviewed Research

recent study done at the Colorado State College of Veterinary Medicine was reported this year in the July publication of the Journal of the American Veterinary Association. Canine and feline emergency room visits and the lunar cycle: 11,940 cases (1992-2002) evaluating whether the full moon influences activity at the emergency hospital is a retrospective study that includes 11,940 dogs and cats over an eleven year period. A variety of emergency admissions were associated with their corresponding lunar phase based on the date of the visit. The lunar phases were divided into new moon, waxing crescent, first quarter, waxing gibbous, full moon, waning gibbous, last quarter, or waning crescent. The effect of lunar phase on the frequency of these visits was evaluated by calculating relative risk.

The authors conclude that there is indeed an association with emergency admissions and the lunar cycle. They identified a significant increase in admissions of both species during “fuller” moon days (waxing gibbous to waning gibbous). Interestingly, the clinical relevance section of the study notes that “It is unlikely that an attending clinician would notice the fractional increase in visits (0.59 and 0.13 more canine and feline visits, respectively) observed in this study at a facility with low caseload.” They do suggest that this data set implies that at a “larger facility with a robust emergency caseload, these results may lead to reorganization of staffing on fuller moon dates.” However, we need to take a step back and take a larger look at this whole lunar association issue before accepting these findings as relevant.

The idea that there is some association between the fluctuating phases of the moon and animal or human behavior goes back eons and is fairly well established within the pages of common folklore crossing all kinds of cultures and continents. Even now, in modern times it is not uncommon to associate the phases of the moon with changes in any number of activities, including those found in a medical setting such as emergency visits at a veterinary hospital.

Therefore, this Colorado study joins a long and interesting lineage of similar studies that concern themselves with the possible effects of the lunar cycle with animal or human medical events. This is an important detail as it will become apparent that this particular study needs to take its place among the plethora of other such studies and be considered a small part of a larger body of information before actions such as adjusting the veterinary staff can be made.

A comprehensive review by Kelly et al 1 went over a variety of human studies that examined a possible relation between the cycles of the moon and abnormal behavior. Using statistical methodologies including meta-analysis and additionally reanalyzing previous published studies, the authors found a variety of significant errors that biased many conclusions in favor of a positive association. As noted by the authors, a meta-analysis is only as good as the information on which it is based (garbage in/garbage out), and it is crucial to make an effort to evaluate each study for any statistical errors. Besides being only one study, the Colorado conclusion needs to be evaluated carefully for errors or confounding factors. All these items will help shake out its ultimate value among the sea of data out there.

Another non-meta-analysis review2 in humans found “no evidence of a trend for more calls to be reported around the full moon. The majority of studies yielded no relationship between lunar phase and crisis calls and the positive findings contradicted each other.” Interestingly a 1996 study3 as well as others found a correlation between weekly, annual, and semi-weekly cycles (i.e.; Time of day and weekdays- makes sense) but no relation to lunar cycles. Additionally, a variety of related studies (birth rates, personality traits, aggression in sports) also reveal no significant relationship between lunar cycle and the data points being considered.

This year, there was another recent animal study regarding the full moon and veterinary emergency visits done at the University of Melbourne Veterinary Clinic and Hospital Australia. This retrospective study evaluated 12,102 animal admissions between 2003 and 2006 on full moon and non-full moon days adjusting for the day of the week and public holidays.

This study found no significant difference between the number of animals presented to the emergency clinic between full and non-full moon days. This study is especially interesting because of the adjustments they make for days of the week and holidays which may be a confounding factor in the Colorado study not accounted for.

As a whole, these findings put a damper on any definite positive conclusions the Colorado study might have found, however slight. The overall conclusion at this point then continues to be that there is no significant relation between the lunar cycle and a variety of associations in humans or animals including emergency admissions.

1 The Moon was Full and Nothing Happened. Skeptical Inquirer Winter 1985-86, updated 1996.

2 Byrnes, G & Kelly, I. Crisis calls and lunar cycles: A twelve year review. Psychological Reports, 71,779-785.

3 Bickis M , M Kelly I, et al. Crisis calls and temporal and lunar variables: a comprehensive examination. The journal of psychology 1995 , 129,701-711.

Thursday, December 27, 2007

Scientific consensus: a communal crossword puzzle

Always open for re-assessment, it’s the best we got

There are some interesting posts today regarding the difference between a skepticism bound by reasoned evidence and that which broaches these confines extending deep into denialism and crankery.

The discussion belies a level of skeptical angst due to the existence of a broad general consensus, a “super structure” of knowledge if you will, upon which we must rely that helps define the scientific community. This might immediately bring to mind a rigid and dogmatic towering institution hell bent on world domination.

Fortunately, these dark thoughts quickly dissipate as it becomes quite clear that the concept of a scientific consensus acts much more like a communal effort; like many people working on a huge crossword puzzle. This analogy, put forth by Susan Haack (Defending Science: within reason) is not a bad analogy because it takes into account the critical essence that describes scientific consensus.

That is, gathering data, observations, evidence, and then combining these to form coherent theories that actually work and explain things - and are examined by others doing similar things. This slow building up of interrelated information indeed resembles a jigsaw puzzle. Dogma not required, needed, nor wanted.

It is important to note that there are different levels and strengths of consensus depending on the level of knowledge or field of study. There might be weaker consensuses on the fringe of that knowledge, or regarding the less science based fields such as the social sciences. Even so, these areas need to rely on the preponderance of the evidence as the basis for whatever level of consensus it allows. In other words, it is important to follow a critical methodology that takes away as much of ones bias and personal ideologies in the interest of getting closer to the truth of things.

The all important communal quality of scientific consensus safeguards it against the ever present pitfalls of dogmatic thought and belief. In this way an honest skeptic can retain their status as inquirers and still confidently rely on a consensus that can flex and grow like a living breathing organism.

Orac nicely describes the difference between an honest skeptic as compared to those that work the data with prejudice and make empty claims against this living communal scientific consensus.

“Scientific skepticism looks at the totality of evidence and evaluates each piece of it for its quality. Cranks are very selective about the data they choose to present, often vastly overselling its quality and vastly exaggerating flaws in current theory, in turn vastly overestimating their own knowledge of a subject and underestimating that of experts. This is perhaps the key characteristic of cranks and the biggest difference between a crank and a true skeptic...

...What a lot of this distinction boils down to is that crankery, denialism, pseudoskepticism, or whatever you want to call it tends, either intentionally through ideology or unintentionally through an ignorance of the scientific method, to conflate and/or confuse nonscientific, ideological arguments with scientific arguments. This is not to say that scientists and skeptics are free from their own biases, whether ideological or simply a desired result that they hope to find. Far from it. However, skepticism means applying the scientific method to claims, whatever its faults, scientific method is the best method thus far devised to minimize these biases. As scientists, the reason we use the scientific method is not because we consider ourselves superior to the cranks, but rather because we recognize that we are human too and thus just as prone to falling into the same traps as they. Moreover, we know that science is a work in progress and that what is considered correct today may well be modified tomorrow. This change, however, is not brought about by cranks cherry-picking data but by rather skeptical scientists probing for weak spots in our current understanding, making hypotheses, and then testing whether current theory or the new hypotheses make the better prediction.”

NOTE: In a past post “The Skeptic’s Dilemma” , I touch on some of the pitfalls that impede the skeptic from achieving an honest intensity of inquiry

Wednesday, December 26, 2007

On the Stem Cell Controversy

Crossing the rubicon

During a recent conference this summer in Aspen, Colorado Sam Harris described human happiness as falling into a “region” within a spectrum or gradient of human behaviors that tended to embrace more optimal cooperative and altruistic qualities of social interaction. In this way, he noted true happiness is separable- not necessarily independent - from the many cultural, religious, and political pressures that may pull human behavior away from this probabilistic “ideal” region.

Although addressing the many pitfalls and dangers of religious dogma, Harris speaks to other forms of thinking that create similar inflexible positions. As such, when debating a sensitive topic, there are certain intractable opinions; especially those oblivious to the concept of gradients and spectrums, nor those aware of just how messy biology can actually be that one is immediately confronted with nonstarters- debate dies before it can even begin.

So it is with the “hot button” controversy of stem cell research in this country. The necessarily arbitrary "lines in the sand" today’s society struggles to declare as acceptable, as in the abortion issue, have created an epic struggle between dogmatic and pragmatic decisions. This is another area where scientific education and an honest and dispassionate consideration of the information would prove invaluable towards reaching a prudent determination.

One way to begin a truly constructive dialogue would be to become better informed of the issues surrounding stem cell research. Michael Ruse and Christopher Pynes book “The Stem Cell Controversy” seems to provide an important resource towards this end.

According to a review in the July/August Skeptical Inquirer Magazine by Kenneth Krause, this book provides “a balanced anthology recent commentaries, official decrees, and, most important, expert analysis addressing each of these crucial issues.”

Ruse and Pynes describe some of the fascinating advances in stem cell research involving adult stem cells (i.e.; skin cell & umbilical origin) and addresses both their current limitations such as small numbers and lack of pluripotency as well as some potential advantages including a greater specialization- a possible advantage in certain cases such as in central nervous transplants.

On the other hand, the sheer power of embryonic stem cells pluripotency provide the promise of offering a wider range of treatments for a plethora of diseases. These cells also offer a glimpse into the etiological mechanisms of cancer and genetic disorders.

The current US stem cell policies confine embryonic stem cell research to those currently in existence while conversely allowing parents to utilize in vitro fertilization, where many embryonic stem cells are discarded in the process.

The authors go on to describe the complex political and ethical landscape of what a stem cell is and where they fall within the realm of research, treatment, and cures. This will increasingly become that “rubicon” that needs to be crossed in order for this country to attain a reasonable base for stem cell advancement.

This struggle is reminiscent of Sam Harris’ description of that region or spectrum where, through open dialogue and honest assessment of the facts, modern society might attain a balanced and educated position, albeit arbitrary, allowing stem cell research to flower and reach its great promise.

Remembering the Legacy of Sagan

Belated tribute to Carl Sagan
Carl sagan passed away on December of 1996. A great and gentle mentor for so many of us, he still sparks the embers of honest inquiry and fires the excitement of our imaginations. May those of us standing on his shoulders continue the quest for truth and honor a legacy bigger than all of us.

Ann Druyan, in "Billions and Billions: Thoughts on Life and Death at the Brink of the Millenium" offers this touching account of Carl's last days that reflects who he was to the end:

"Contrary to the fantasies of the fundamentalists, there was no deathbed conversion, no last minute refuge taken in a comforting vision of a heaven or an afterlife. For Carl, what mattered most was what was true, not merely what would make us feel better. Even at this moment when anyone would be forgiven for turning away from the reality of our situation, Carl was unflinching. As we looked deeply into each other's eyes, it was with a shared conviction that our wondrous life together was ending forever." D. 1996.

i of the vortex

With an often mischievous smile and penetrating eyes, well known neuroscientist Dr Rodolfo Llinas elaborates an incredible tale of how the "i" in us came to be. He discusses the importance of movement as a primal trigger for the kind of cellular evolution that eventually allows for colonization and cooperation and the subsequent development of the nervous system.

The Science Studio put together this fascinating conversation where Dr Llinas touches on some of the conclusions his neurological research has revealed. He weaves an enticing and plausible tapestry threading together the simple to the complex and deftly describes what the very core of human consciousness might actually be.

Indeed, some of the conclusions of his research may have breathtaking implications regarding free will and whether human consciousness as we sense it is in fact something real or a spectacular illusion.

Listen to "A conversation with Rodolfo Llinas". It is well worth considering as part of ones study of human consciousness.

Tuesday, December 25, 2007

A small case of cognitive dissonance

This recent commentary on a skeptic thread reveals how polarized thinking can be offered up as “balanced” reasoning:

"The following is a direct quote from the Dec. 6th issue of NEJM:

In recent weeks, over-the-counter cough and cold medications for children have received unprecedented attention from regulators, physicians, the media, and parents. This scrutiny represents a long-overdue reassessment of products that were purchased by 39% of U.S. households during the past 3 years. It also reflects an important evolution in the standard of evidence for medications used in children.

Over-the-counter cough and cold preparations include various combinations of antihistamines, decongestants, antitussives, and expectorants. There is no standard for describing these products; two products marketed similarly may have different types of ingredients. Consumers purchase about 95 million packages of such medication for use in children each year. Within the pediatric community, however, concern over the effectiveness and safety of such drugs has been growing for more than two decades.”

“I think there's a similarity here with some of the criticisms made of CAM products on this List. Not identical, nor perhaps as extensive, but similar; in particular market driven, and taking decades to rectify, while clearly taking advantage of citizen's vulnerabilities in the area of health care. Most notable perhaps is the much greater degree of harm caused here as compared to CAM treatments; much less of an effort to hold anyone accountable as compared to the reactions to lesser frequencies and/or degrees of harm when these occur from CAM; and, it seems to me, the much greater level of tolerance or permissiveness over a prolonged period toward direct harms from these cough and cold products as compared to problems occasionally reported from direct harms from CAM products.”


Here are a few comments with respect to some of the cognitive dissonance noted in these remarks:

"Most notable perhaps is the much greater degree of harm caused here as compared to CAM treatments"

Imperfect though it may be this process seems to reflect a critical scrutiny not often observed in non evidence based modalities. These substances have real actions and as harms are measured, evaluated, and taken into account, there are mechanisms for change.

It appears to me that non evidence based approaches (homeopathy prevention for Malaria and AIDS, chiropractic for subluxations, nutrition schemes for cancer cures....) open doors for significant harms of their own. What critical mechanisms are in place to scrutinize them (The NCCAM hasn't seemed to have had much impact yet)?

"much less of an effort to hold anyone accountable as compared to the reactions to lesser frequencies and/or degrees of harm when these occur from CAM"

Not so sure about this. Accountability is critical, so is honesty and transparency in scientific endeavours. Pharmaceuticals & industry have lots of dirty laundry here. In the same vein though, "CAM" has been given huge leeway and liberty to ply all kinds of questionable practices and make a lot of $$ under a veneer of "science". This is significant harm.

"and, it seems to me, the much greater level of tolerance or permissiveness over a prolonged period toward direct harms from these cough and cold products as compared to problems occasionally reported from direct harms from CAM products."

This "direct" harm comparison is confusing. How do we compare a treatment with known effect (implying risk/benefit) with a placebo for example? If a placebo harms even one person, doesn't that have huge implications?

Anecdotally, we just referred a client’s dog to surgery for known disk herniations being treated with homeopathy and acupuncture...and this morning I talked to a new mother who refuses to vaccinate her child (doesn't "believe" in them)preferring the "immune boosting effects" of aromatherapy.

It seems harms loom heavy all over...

Wednesday, July 25, 2007

Medicine and optimism

To be or not to be
This NY Times article was sent to a skeptical internet discussion group. It provides interesting insight into some challenging philosphical considerations regarding phsyciatric medicine and is food for thought when thinking about medicine and science in general.

Medicine, Constantly Redefined and Redefining Lives

"About 15 years ago, I had a shy patient who ate nothing but white foods and
who assaulted anyone who entered her air space on the hospital ward. She was
mute but not uncommunicative, and with a little effort it was possible to
learn her language.

Some of her problem was her psychosis. Most of it was her mother, who was her
legal guardian, appointed by a court to monitor her medications. But the
mother was also convinced that psychiatric medications were poison; the
patient would go home on weekend passes and return with all her pills in
bottles and without a shred of sanity.

This continued for months. Her mother brought a notebook listing side effects
to each visit. She said the medication caused seizures, diabetes and heart
disease, though the studies at the time showed none of these side effects
associated with the drug we were giving. We thought she was sadistic, intent
on standing between her daughter and independence. She thought we were evil
experimentalists. The patient herself dreaded controversy and wished,
wistfully, to please everyone.

Finally, we petitioned to remove the mother as guardian. It was controversial,
against nature, to question a family member's competency or guidance. When we
met before a judge, both sides were filled with strong emotion. But we were
also filled with strong data.

I remember looking at the mother across the courtroom while testifying about
the hazardous nature of her beliefs and their effects on the patient's mental
state and future. Her size had changed. When she visited the hospital,
something vibratory and angry about her made her seem to swell, so that
neither her daughter nor I could look her in the eye. From the secure height
of the witness box, though, she seemed to be shrinking - an ineffectual old
woman, laboring under false beliefs, growing smaller as these beliefs were
exposed one by one.

The judge listened without expression and took the case under consideration.
We had no doubt about the power of our presentation. Within a week he had
ruled in our favor. The new guardian did not oppose our antipsychotic drug,
and the patient flourished. It was like time-lapse photography: in what seemed
like only a day, she smiled, spoke, became lucid, joined a day program, began
overnights in a residential house and was discharged.

We were full of public satisfaction, and private righteousness. Some aspects
of psychiatry are clear-cut; they can be counted on. There might be no proof
of the existence of Freud's ego and id. But antipsychotic medications treat
psychosis - this can be proven - and the patient's life was going to be better
for taking them.

It was, too. For a while, she sent happy, mostly intelligible letters from her
residential house. The letters became holiday cards, and eventually, in the
fullness of her world, they stopped. Someone else told me, years later, that
she had developed diabetes and required insulin. The research by that time was
clear: there was no doubt whatsoever of an association between her
antipsychotic and diabetes and other metabolic problems. The studies had been
confirmed again and again.

Kierkegaard wrote that we understand backward but live forward. Politicians
say - using a tense so passive that it slinks out of the room before it can be
noticed - "Mistakes were made."

The facts we had then were incomplete, even if we didn't know it at the time.
We were right but we were wrong, innocent but at fault, acting in good faith
with bad results. The ground beneath professional feet should grow firmer over
time - one ought to feel more certain of what one knows. But the more I know,
the more I am afraid."

This story is interesting on a few levels:

It is reminiscent of other "state vs guardian" under age face offs like the Abraham Cherrix or Katie Wernecke cases where the legal system wrestled with the concept of informed choice and the meaning of responsible parental guidance among other things (such as what constitutes acceptable medical treatment?). Very broad grey areas of meaning an intent, especially in older children makes it very difficult to navigate on generic terms- what precedence should be used? The interests of the child from the courts or the parents point of view? Is it a case by case issue? The age old canard of medical "free choice" can be heard rumbling in the background; but does take a back seat to a bigger issue here. (Incidentally, with the increasing societal awareness of possible animal abuse/human abuse correlations, along with expanding knowledge of veterinary forensic science, the guardians leeway for "proper and acceptable care" of animals may become more limited or at least better defined- certainly could have obligatory implications for vets).

Interestingly, today I was reading the history of the Apollo One tragedy . Although on a different scale, it seems to resonate with Dr Elys' story. It manages to describe through tragedy a larger point of view reflecting a way of thinking, of achieving goals through critical analysis, expanded understanding, and knowledge. So maybe "mistake" may not be the best descriptor of Dr Elys story given a larger context- though the legal realm (i.e.; often an "answer the question- yes/no" scenario) might describe it this way. Scientific evidence can be exceptionally difficult to explain and interpret and inappropriate assumptions can be made even by "experts". On the other hand, if you take a more strict approach (i.e.; take away historical context, balanced intent, past knowledge levels) you could almost call Dr Elys' experience an example of gross neglect and abuse of power.

Though philosophy of science discussions often revolve around fascinating "what is true scientific observation and what does it mean?" teleological knots, the scientific grunt work goes on and some times manages to improve the human condition (i.e.; Norman Borlaug).

In this vein, phsycology is now probing huge unknown mental territories in new ways. Neuroscience and neuropshycology are shedding light on cognition, brain region dynamics, and neurological functional parameters unimagined a few short years ago and promising new treatments and therapeutic modalities may loom close.

Though Dr Elys' angst is understandable- most doctors (or anybody for that matter), are often tormented by "what ifs", "I thought", or "if only"s', she seems to take a rather pessimistic view of what can be known. Dr Ely mentions Kierkegaard and seems to (at least implicitly) concur with his "subjectivity is reality" form of existentialism by expressing doubt regarding the firmament of medicines knowledge base; a "the more you know, the less you know" restrictive perspective. Many would disagree and posit a "the more you know, the more you need to re-know, then the more you need to know" expansive perspective. Perhaps neuroscience will bring more empirical insight into some of these apparently metaphysical matters.

At any rate, if Dr Elys' goal is to remind us that medicine is a sometimes equivocal and uncertain affair- all well and good. But where Dr Ely seems to give way to fear when faced with doubt, change, and the unknown, others might be humbled, excited, and awed.

Monday, July 23, 2007

Glimpsing the Origin of life

A look at an interesting theory

Theories regarding the ancient elemental substances that gave rise to the origin of life as we know it remain clouded in the shrouded mystery of time. Even the infinite evolutionary permutations and adaptation of life itself have, as one effect of success, brushed away many of the “footprints” that lead back to this far off ancient epoch.

Even so, here and there, scattered throughout the interactive biochemical and physiological reactions of the myriads of structural and functional elements, there are hints and glimpses of just how present life may have once been like. In fact, some of these clues may provide the beginnings of a general theory, of not just evolutionary development, but of the foundation of possible mechanisms that allowed for life to become life.

Realizing that the quintessential core information source of present life; DNA and its associated complex protein creations are far too complex and co-dependent to have provided the first building blocks for life, scientists have delved deeper into the biochemical cauldron for simpler structures that may have opened the doors to life.

These structures or molecular compounds would need to fulfill a primal requirement in order to be considered a viable precursor. It would have to be able to self replicate itself- thread a line of information through time- in some sustainable fashion. The implications here are huge. This simple, yet possibly improbable event would open the gateway to the process of evolutionary dynamics if enough time could pass.

Obviously, one primary candidate which may fulfill this primal role is the RNA molecule. This compound has a variety of blended functions that are DNA and functional protein “like” realizing replicating reactions, information transfer roles, and protein synthesis functions that opens the doors to theories that posit RNA as that primal replicator.

Although an original replicator theory is a very attractive possibility, it does present challenges among which is how such a relatively large molecule could have formed before evolutionary processes began as well as managing to survive in a rich organic primordial soup without being smothered amongst a plethora of chemical reaction. Research continues down this theoretical path.

However, there are other theories that are looking deeper beyond the RNA molecule for a yet simpler and possibly more plausible mechanism. These theories probe the molecular soup of what might have been a primordial earth for chemical reactions with certain life-like properties. These are known as a small molecule or metabolic approach to life origins.

These small molecule theories posit that life can be defined not in a genetic context but by describing it as a thermodynamic phenomenon. Carl Sagan noted that life could be stated as “a localized region that increases in order (decreases in entropy) through cycles driven by an energy flow.”

These approaches may provide a theoretical underpinning to a multiple origins theory for life origins and may provide for a far less improbable scenario for its beginnings. The natural constraints required for these small molecule theories to work are less complex than those necessary for RNA first approaches.

According to Robert Shapiro there are five basic conditions that would allow for the possibility of small molecular life to “congeal” and open the way for more complex forms. These conditions include:

  1. A boundary is needed to separate life from nonlife. Living cells convert energy or radiation to heat. The released heat increases the entropy of the environment, compensating for the decrease in living systems. The boundary maintains this division of the world into pockets of life and the nonliving environment in which they must sustain themselves.

  2. An energy source is needed to drive the organization process. …the transformations [producing energy] that are involved are called redox reactions. They entail the transfer of electrons from an electron rich (or reduced) substance to an electron poor (or oxidized) one.

  3. A coupling mechanism must link the release of energy to the organization process that produces and sustains life. Everyday, in our own cells, each of us degrades ponds of ATP. The energy released by this reaction serves to drive the processes necessary for our biochemistry that would otherwise proceed too slowly or not at all. Linkage is achieved when the reactions share a common intermediate, and the process is sped up by the intervention of an enzyme. One assumption of the small molecule approach is that coupled reactions and primitive catalysts sufficient to get life started exist in nature.

  4. A chemical network must be formed to permit adaptation and evolution. Imagine, for example, that an energetically favorable redox reaction of a mineral drives the conversion of an organic chemical A, to another one, B, within a compartment. I call this key transformation a driver reaction, because it serves as the engine that mobilizes the organization process. If B simply reconverts back to A or escapes from the compartment, we would not have a path that leads to increased organization. In contrast, if a multi-step chemical pathway-say, B to C to D to A- reconverts B to A, then the steps in that circular process (or cycle) would be favored to continue operating because they replenish the supply of A, allowing the continued useful discharge of energy by the mineral reaction.

  5. The network must grow and reproduce.”

To date, little validating research has been done to confirm this attractive theory there are some tantalizing studies that support its plausibility. The focus may be to seek out an example of the previously mentioned “driver reaction” which may reveal the theorized connection between this chemistry and sustainability, eventually leading to evolutionary mechanisms.

In essence, origin of life research is still in its infancy, and it is likely many new ideas and concepts will present themselves in a fascinating quest to uncover life’s most basic beginnings.

Ref: Shapiro, Robert. A simpler origin for life.Scientific American 2007. Vol 296, No6

MMR and psuedoscience

Many of today’s fringe belief based groups like those promulgating Intelligent Design, HIV & germ theory denialism, or the anti-MMR vaccine crowd have long attempted to wrap themselves with a cloak of scientific legitimacy.

That these attempts have been repeatedly exposed for the false claims and misrepresentations that they are consistently falls on the deaf ears of many “believers”- a trait rather typical of the pseudoscientific mindset. It has long become apparent these groups have agendas that do not include honest and authentic scientific inquiry.

In this age of instant media coverage and increasingly competitive news markets it seems more and more difficult to find truly balanced, well researched, and thoughtful news pieces regarding important issues of the day. Sound bits, noise, and color flood media outlets as available news information seems to dumb down to basic instinctual reactions or short lived emotional fixes. Whether this is a problem of the media or their response to consumer demand can be argued, but that this phenomenon smothers clear thinking and paused reflection is increasingly difficult to argue against.

So it is that the recent MMR article debacle at the Observer (UK) comes immediately to mind. It is well worth the effort to chase the links and follow the sequence of events and Ben Goldacres (Bad Science) response to this classic example of media misrepresenting science. Goldacre puts it succinctly after a well done critique:

“I am pretty jaded and sceptical, but this front page story has completely stunned and astonished me. The misrepresentations and errors went way beyond simply misunderstanding the science, and after digging right to the bottom of it all, knowing what I know now, I have never resorted to hyperbole before, but I can honestly say: this episode has changed the way I read newspapers.”

This incident is a good example of the potential damage a well placed, yet very misguided newspaper headline and article can do. Though I am not familiar with the Observer or its qualities as a media outlet, this type of reporting certainly does not impress.

What ever the case may be, this whole event demonstrates the effort and care it takes to respond and counteract pseudoscience in general, and highlights the urgent need to address the educational shortfalls (i.e.; in science) of the populace that give opportunity for quackery to flower beyond reason.

Friday, July 20, 2007

A way of thinking

Thoughts on science and society

Much more than a strict methodological formula or inflexible algorithm, the process of scientific discovery uses a uniquely human form of cognitive reasoning. It is a form of inquiry that pools together often seemingly unrelated perspectives and reveals profound “truisms” beyond cultural and societal constraints regarding the natural world.

Though, unlike other human activities (i.e.; song, dance, and culture) it is probably much more difficult for scientific inquiry to take root and flower in a given society. Contrary to what many might assume, it is not a particularly “western” phenomenon. Several cultures and societies gave rise to the elements necessary allowing for a scientific form of inquiry.

These conditions, however can be fleeting and temporary as Susan Haak (Defending Science-within reason) notes “As Glasglow reminds us, Arab astronomy, mathematics, and chemistry were once unrivalled; but the rise, early in the second millennium, of Taqlid, the Islamic doctrine that there are no truths beyond those revealed in the Koran, scientists and scholars were banished. And so, rather than growing and flourishing, Arab science declined- leaving its footprints on our language, however, from “alkali” to “zenith”. The ancient Chinese…invented gunpowder and the compass, and were great navigators- until in the fifteenth century they decided that nothing beyond the celestial empire was worthy of discovery, and burnt their great ships just before Columbus set forth with his tiny flotilla to discover a New World.”

Indeed, these histories threaten to repeat themselves as todays' societies struggle with many fears- whether or not they are legitimate- regarding scientific inquiry and often recoil from disturbing realities and philosophical implications. For example, the cost of research might be exorbitant compared to other demands, technological advances (cloning, genomics, and fetal research) force a re-evaluation of deeply held beliefs, and the lack of science education can lead to a profound mistrust of this way of thinking.

Further, science does seem to have limits in answering critical questions with respect to a variety of human endeavors such as politics, literature, entertainment, law, and logic. Additionally, there are a multitude of scientific questions science can not answer or has even thought of asking. Haak states “…we humans have limited intellectual and other resources: limited intellectual integrity, respect for evidence; limited imaginative powers; limited capacity to reason; and limited sensory reach.”

On the other hand there is reason to be optimistic with what this form of inquiry can offer. It should be possible to follow a dream, ride the ebb and flow of emotion; that is, live a fully human life and pursue the realities of true inquiry. Haak notes “…one of the most remarkable things about the natural sciences has been the ways they have found to overcome human limitations: instruments of every kind, extending innate human powers of observation; the calculus, statistics, computers, extending innate human powers of reasoning; metaphors, analogies, linguistic innovations, extending innate human powers of imagination.”

Many so called metaphysical questions may never have answers, but there might be a place where some of these questions may eventually blend with those of the natural world. Again Haak notes “…there is no sharp line between cosmological and metaphysical questions; nor are there very clear criteria for identifying and individualizing questions. Thinking of how cosmologists first transmuted, and then at least partially answered, the metaphysicians’ question, ‘Why is there something rather than nothing?’ when they developed their account of the accretion of matter, we might speculate that, if physicists were to find the ultimate laws, the demand for an explanation of those laws might be eventually transmuted into a kindred, yet different and more answerable, question.”

This way of thinking; that a combination of probing inquiry and honest realism might be implemented in a way to help resolve, or at least honestly consider solutions to a variety of human issues and problems heretofore assumed to be non science related may open new vistas of meaningful discovery.

Ben Goldacre probes this idea in an interesting post relating that scientific inquiry may indeed prove useful for effectively evaluating different possible solutions to societal problems. He notes “There is no sense in which I am a hardliner on trials, and I’m totally down with the idea that there can be many different kinds of evidence, but one thing has always puzzled me: in these days of “evidence based thinking” in Whitehall, why don’t we do randomised controlled trials on social policy?”

In a similar vein Haak states that “The social sciences, of course insofar as they concern themselves with local and contingent social roles, rules, and institutions, have a much more markedly historical aspect than the natural sciences. And that the historical contingencies of human societies might eventually be derivable from completely universal laws of nature seems, to put it mildly, much farther-fetched than the idea that cosmological events such as the big bang might be. Even if there are laws governing the universal aspects of human nature variously expressed in this society or that, and even if such laws were known, there would remain not only a vast array of details to be discovered, not only the ramifications of self-fulfilling (or self-undermining) predictions, but also the permanently open possibility of new manifestations of those laws in new social arrangements. So, though thus far the social sciences seem to lag far behind the natural sciences, the scope for future spurts and breakthroughs seems enormous, and the future prospects limited only by the possibility of the extinction of human societies.”

This is indeed food for thought especially considering that old societal paradigms may not provide the stable structure needed to sustain humanities present expansion into previously unexplored philosophical, mental, and physical realms.


Haak, Susan. Defending science- within reason. Prometheus books. New York. 2003