In search of science in medicine

Teasing out the facts

The importance of being able to understand real patterns and realtionships among biological processes has become glaringly critical in light of the innumerable contradicting, supporting, and partially supporting pieces of data available for study in relation to medical outcomes. The lack of more than just a superficial comprehension, even in the medical community, of epidemiology and statistical analysis leaves a huge vacuum when attempting to separate the real from the perceived. Without a working knowledge of disciplines like these, how can we discern what works from what does not?

We are constantly exposed to a “conclusive study” that seems to support the latest theme or idea du jour imaginable. A parade of sometimes knowledgeable doctors, PhDs’, Institutes, and organizations are often hopelessly entangled in an incredibly complicated web of meaning. To make matters worse, many of these official terms (i.e., “Doctor”, “Center”, and “Institute”) have been compromised and do not necessarily represent any type of unbiased source of information. It is very easy under these circumstances to see how even "studied" people can be led astray. It is more important than ever that individuals have the education and the mechanisms necessary to be able to differentiate for example, a quality study from a poorly designed one. Unfortunately, too many people have minimal competence in the nuances of endpoints, meta analysis, cohort studies, quality ratings, and many other analytical skills that enables one to place these findings into proper perspective. Indeed, not to belie the point, even well educated scientifically oriented professionals can find it hard to wade through this quagmire.

Additionally, there is a deficient understanding of how the scientific method sifts information and knowledge, filtering innumerable pieces of information into a meaningful flow of integrated understanding .Science proceeds sometimes haltingly within a communal process, somewhat analagous to a filter funnel where information is sifted through several stages, and where the human endeavor of observation and interpretation, often replete with contradictory claims of truths about the world eventually yields a little trickle of fairly clear understanding. This can be an inexorably tedious and cumbersome process. Understanding how it works, and works so well can be a huge problem.

This problem stems in part from the weak science based education in the formative years of even highly educated people. Ursula Goodenough, professor of biology at Washington University in St. Louis relates that “science continues to be taught from K-12 to the college and university levels, in fragmented, incoherent bits and pieces rather than a coherent narrative, a history of nature.” She adds that “a primary concern is that students come to understand and appreciate both how science is done and some of what scientific inquiry has discovered.”

Another basic concern is that science education, both as articulated in the Standards and as practiced in American schools, basically fails to convey to students what Goodenough refers to as the scientific worldview: a narrative account, with supporting empirical evidence, of current understandings of the origins and evolution of the universe, the planet, and life (including humans), as brought to us from what are often called the historical sciences.”

In spite of these problems, it is critical that this education is done. Goodenough co-teaches a course at Washington University presenting a science worldview and has observed “students report that their interest in, and mastery of, scientific concepts is greatly enhanced when such larger contexts are provided. We’ve become convinced that a robust and mindful grasp of the scientific worldview generates a more abiding commitment to scientific inquiry, to environmental sustainability, and to societal responsibility.”

Another thought is that a significant amount of initial analytical observations and studies may be given unwarranted importance and significance due to misplaced criteria when determining the level of meaningful relationships. According to Colorado State University physicist Victor Stenger, the common level of significance when studies are published in the medical field is at about a p value of p=0.05. The p value has two important caveats to take into account. First, the p value is often misinterpreted to mean the “probability for the result being due to chance”. In reality, the p-value makes no statement that a reported observation is real. “It only makes a statement about the expected frequency that the effect would result from chance when the effect is not real”.

Second, p= 0.05 may be far too lenient a level of significance. It may be time to reconsider the traditional significance level from p= 0.05 to the much more stringent levels of physics researchers of p= 10^-4, especially with trials dealing with little scientific basis. This criterion, or something like it, could then be applied within the realm of medical research- especially in those cases that require extraordinary claims not consistent with our understanding of science (Some of the attributed powers of the placebo, the dualistic mind/body and quantum consciousness connections fall into this realm).

At any rate, the scientific medical community is faced with the looming challenge of teaching to a larger public- and to themselves- how the complex cogs of the scientific process reveals natures truths and how they are interpreted effectively and usefully within our human community. If we don't, we run the risk of being victims of our own success.

Malaria today

and homeopathic travesties

“Malaria now affects more people than ever before. It’s endemic to 106 nations, threatening half the world’s population.”

National Geographic Magazine has an excellent cover story discussing the scourge of malaria throughout human history including the present plight of so many. Unlike other diseases (polio, smallpox, plague…etc), malaria will affect nearly half a billion people, mostly in Africa, where there are strains resistant to most antimalarial drugs.

Michael Finkel describes in detail many of the complex issues regarding this disease, its control, and the often excruciating failures in combating and managing this ancient disease, including mismanaged population growth and socio-economic pressures that have exacerbated today’s sad state of affairs.

However, there are now promising campaigns designed to regain the upper hand. Zambia, for example, has implemented a national campaign utilizing a combination of pesticides, mosquito nets, and artemisinin^*-based combination therapies (ACT), and is looking to possible future novel vaccinations in a bid to do battle against this “archenemy”.

The article is a well put together description of malarial treatments appropriately emphasizing national pubic health strategies that hold the most promise for establishing a firm therapeutic beachhead. Unfortunately it fails to mention some of the more egregious approaches pretending to “treat” malaria, but succeeding only in misdirecting meager resources towards worthless therapies.

One salient example is the SHEAF Trust, an organization with the following goals:

“The Sheaf Trust aims are:

Professional training in naturopathy/homeopathy

Healthcare in Africa using complementary and traditional remedies

Training local people in the use of homeopathy, for emergencies and acute situations

The education of local people in basic nursing skills, nutrition and home-based care”

Le Canard discusses the travesty of homeopathic malarial treatments and the dangerous implications they bring in a continent that is in desperate need of real and effective therapies. His subsequent post discusses iatrogenic medicine in a proper context and describes the concept of a more dangerous homeopathic iatrogenesis- a dangerous modality lacking any reality base, tools, or self correcting mechanisms that lead ever better and more effective treatments. In fact these critical components seem anathema to homeopathy (and CAM) in general.

As the true battle against malaria takes form, we need to keep present those, who through ignorance or self interest, strive to stifle and diminish the honest and open scientific discourse that promises to save so many lives.

* In fact, artemisinin derived from the sweet wormwood is one of the success stories of historical herbal medicine. It has been incorporated into the modern armamentarium because it works, like so many other plant based active ingredients.

64th Skeptics' Circle

Ignore the hackers and apply to the New Truth University (NTU) because... the truth is out there....

Of memes and consciousness

A theory of memeplex and self

According to Susan Blackmore, the world is full of memes ; replicating elements of information that exist in a myriad of forms and whose sole purpose is simply to be. They can persist as single entities, but often conglomerate and coalesce with other “similar” memes propagating synergistically through time. They can be basic entities such as an idea, saying, and fad or can organize into whole societal systems such as religious faiths and government structures.

The conceptual origin of the meme has roots in Richard Dawkins 1976 book, “The Selfish Gene” where he introduces the gene (a particular version of the gene still debated today) as the primordial replicator. Here the replication of information is the sum total goal and in the larger scheme these replications occurred sometimes with variations and pressures that essentially come to describe a kind of universal evolution. That is, anything that had the capacity to persist; to replicate, acted like the Dawkins gene concept and opened the door to evolutionary pressures.

In essence, this is what Blackmore calls the meme constructing an intriguing theory that argues our very “self”; the “I” in me, are basically a vast group of collaborating memes; a memeplex or “selfplex” if you will, that ultimately creates the illusion of self. Blackmore notes “Related memes tent to form mutually supportive meme-complexes such as religions, political ideologies, scientific theories, and new Age dogmas. Some of these may be hugely hugely beneficial to human society, but others are pernicious because they infect people and demand their resources in spite of being false.” She adds “The most powerful and insidious of all memeplexes is, I shall argue, your own self.”

According to this theory, the selfplex is the origin of the illusion of human consciousness and free will. These are illusions, myths of the memes within the context of the human mind- a human meme machine capable of allowing the flowering of ever more complex memes to succeed by replicating.

The brain works in such a way that a series of regions, mechanisms, and interactions create an experience of self. There is no central depository, or neural eminence that is the self. The package of memes work “together” using the human brains unique ability to imitate and speak (language) to create a flourishing environment that produces an effect- human consciousness. Blackmore goes on to say that “The implications of consciousness are this. The whole problem of consciousness stems from making a distinction between the world that is perceived and the self who is perceiving it, but if this self is just a myth, then this distinction must be false” She later adds “Our consciousness is the way it is because of the success of the memes that make up the selfplex.” With the ever more interactive and complex growth of human society comes more complicated meme interactions and further opportunity for them to replicate and persist.

This is an interesting concept and may carry the seeds for an ultimate understanding of the self . Even one of the interesting arguments against this theory discussed by Mary Midgley seems to perhaps misunderstand its intent and describe a false impression that there is a distinction between her idea of reductionalism and qualitative concepts such as the study of behavior.

Overall the meme theory will need to fit into the realm that describes a sense of self. According to Rita Carter (Exploring Consciousness) these are “first, a boundary in space- an elastic one which may incorporate things and people beyond our body, but one that is firm enough to provide a point of view and thus “ownership: “ of our individual slice of consciousness. Second, a sense of agency, such that our acts seem to be signatures of some entity distinct from mere physical processes, and finally a sense of unity and continuity that allows us to create an autobiography.”

It seems that this intriguing concept of the selfplex might hold promising gems in the continuing effort to expand our knowledge of how consciousness emerges and could provide another toe hold in the deepening quest to understand the “self”.

Doctor and patient: a special bond

When the “best” just isn’t…

Yesterday our hospital received a call from our local specialty clinic regarding a mutual patient I referred for chronic shoulder lameness. Usually, these calls are the routine requests for histories, notes on the patient’s progress, discussion of a pending surgery, or surgical follow ups.

This call though, was a bit different and brought home the importance of the doctor/patient bond. From the doctors point of view, the essence of this relationship is to be true to the patients own unique needs. The patient (patient’s owner in our case) needs to feel they are not being judged or coldly analyzed, but that they are in a receptive relationship- you could say, almost intimate with respect to the information shared- where their concerns and problems are acknowledged and considered.

The call from the clinic was regarding a blood test level of a replacement hormone they thought was too high. The “best” and ideal level needed to be lower. In and of itself, this was no problem, as reviewing the dynamics of blood tests, or for that matter, the moving dynamics of any illness is an important part of keeping on top of things. What was frustrating was that this was the second call from the clinic. Earlier, I had had a detailed conversation with the patient’s owner regarding this test, what it meant, and what we together were going to do about it.

You see Matilda, our patient, had a looming problem- she was getting on in years and her limp was getting worse. Both issues were feeding on themselves as exercise had always helped keep an old shoulder injury fairly stable and pain free. Recently, we had found she was developing hypothyroidism, a common condition in geriatric dogs, which complicated the matter.

In addition, her owners had recently been going through a huge life changing transition. Life, as happens so often, had sucked them into survival mode as a family crisis, a job loss, financial demands all left Matilda with less walks. This added layer of problems occurred just as her condition worsened.

So, we had a fat, painful, and unhappy dog with very concerned and loving owners who were reaching out to find any way to make things better. Through time, we had tried a series of approaches from pain management, thyroid supplementation, special diets, and varying exercise regimes with minimal effect. The owner’s personal situation eventually improved, but Matilda was now stuck in her own rut.

The fascinating thing about many medical situations is that they are hardly ever a straight black and white affair. Often, careful consideration and communication between practitioner and, in this case the owners, often helps dial in on the best approach to a problem. So it was with Matilda, as we decided to increase her hormone medicine and continue pain control with the goal of getting her to lose some weight as exercise was what helped the most for her.

We evaluated her for any other potential risks and issues and together with the owners developed a plan for the next year. A referral to the specialty clinic confirmed there was no other concern we needed to be aware of and they concurred that pain management and weight loss were the main issues.

During the following months, Matilda began to improve, at first slowly, then at a quicker pace to the point she had lost significant weight, was actually sound (not lame), frisky, and “her old self” according to her proud owners.

So needless to say, when we received a second phone call from the referral clinic about the follow up blood value it was a bit frustrating. Though, they were just doing there job, they were implicitly wanting us to lower those dosages. We let them know things were under control and - in a nice way- told them to bug off.

Watching a happy bouncing Matilda and the smiles on her owner’s faces reminded me of how important a good “family” doctor/patient bond is. Whatever the outcome (sometimes it can be quite sad), it is this type of relationship that can be most fruitful in reaching the most relevant and appropriate paths- whatever they might be.

Homeopathy: placebo's freind

It seems I am not the only one expressing recent concerns that pseudoscientific therapies are creeping their way into science based realms. Orac, Dr R.W., and retired doc have very interesting reviews of a 2005 study regarding homeopathy and its use in intensive care units. They do an excellent job dismantling the pseudo legitimacy and getting straight to the quackery.

Homeopathy has yet to be discussed in detail on this blog, mainly because so many have done such a great job discussing it already. However it seems fitting to put together a brief introduction and review of homeopathy as a backdrop to these posts.

Homeopathy

Christian Friedrich Samuel Hahnemann, the founder of homeopathy, was born in 1775 in Meissen, Germany. His father, a porcelain painter, worked to give his children the best education possible with the goal that they become “Selbstdenker”- or self-thinkers, and in fact Samuel Hahnenmann became a very inquisitive student. Through his life as a student he sustained himself by translating publications acquiring along the way, a wealth of chemistry knowledge.

He received an MD degree in 1779 and pursued an interest in chemistry. For instance, he introduced a method to unmask the sweetening of wine with lead and published a report on arsenic poisoning. By 1789, Hahnemann left medical practice and dedicated himself to research and writing and by 1805 had published 5,500 pages in books, articles, and translations. From 1811 to 1821 he lectured on his homeopathy theory in Leipzig, and in 1821 was forced to leave due to the “the hostilities of the apothecaries.” He eventually moved to Paris, where he became a very popular medical practitioner until he died in 1843.

During this point in the history of medicine a variety of archaic, mostly damaging modalities were still in use. For example blood letting, leeching, and purging were common medical therapies. Amongst these primitive and unproductive therapies Hahnemann developed an understandable disdain for this medical reality and yearned for a better way.

The problem, however is that he relied more on speculative techniques to create his homeopathic system. Dr Rijnberk (The end of homeopathy) states: “In his search for other approaches the Newtonian empiricism did not play an important role. The role model was rather the Renaissance astrologist Paracelsus, who pioneered the use of chemicals and minerals in medicine. Hahnemann always emphasized the empiric character of his method, but he had a strong passion for speculation and ontological system building.”

This is reminiscent of the Traditional Chinese Medicine pre-enlightenment period where practitioners moved away from true empiricism and moved backwards towards divination.

Simila Theory

The basic tenant of “like cures like” has a very interesting origin that illustrates the non empirical formulation of homeopathy. When translating William Cullen’s Lectures on the Materia medica into German Hahnemann disagreed with the author regarding quinine in malaria patients. Cullen thought that quinine strengthened the stomach. Hahnemann ingested quinine and experienced symptoms similar to the actual disease of malaria. He basically had an “epiphany” or occurrence that led to the subsequent formulation of the Materia medica. According to Rijnberk “This observation led him to assert the theory that “likes are cured by likes”, similia similibus curentur. Diseases are cured (or should be treated) by those drugs that produce in healthy persons symptoms similar to the disease. His work, Organon der rationellen (Orgenon of rational medicine) Heilkunst contains an exposition of his system, which he called Homoopathie.”

Potentiation

From these rather tenuous beginnings, Hahnemann continued to build his paper tiger. Rijnberk notes “Hahnemann increasingly tended to believe in dynamic rather than corpuscular interpretations of the action of drugs. He described the action of highly dilutes solutions as “dynamic”. He compared the action of drugs with warmth, magnetism, and electricity.” Through the years, he increased the dilutions; finally favoring dilutions up to C30 (100³⁰=10⁶⁰) Knowing that little of the original substance remained in these fluids, Hahnemann believed that by shaking these fluids through each dilution step, he could facilitate the “release of intrinsic curing forces.”

These remedies experienced a period of popularity as they were less harmful than many of the other archaic practices being utilized at the time. By the turn of the 20^th century, its popularity began to diminish dramatically with the introduction of the far more demonstrably efficacious science based medicine. However, the practice of homeopathy has continued to smolder and seems to have gained popularity in today’s seemingly more favorable public environment. Its effects are largely a combination of placebo effects, confirmation bias, and misinterpreting natural variations during the history of a disease process.

Ref: Rijnberk, AD, DDr.hc. The end of homeopathy. Worlds Small Animal Veterinary Association World Congress, .2006

Threads of consciousness

As the study of the mind continues to explore the labyrinth that is consciousness, fleeting images of its essence are beginning to slowly reveal it’s mysteries to us. Though the tools available for probing this elusive quality are still primitive and limited, they are providing glimpses of how the layered interactions between innumerable regions of the brain merge to produce manifestations of what we describe as conscious thought.

In broad terms, the blended layers of our brains create a fluid stream of sensory input that flows from the brainstem and mid-brain regions, spreading up throughout the limbic system and cortex. The sensory input is received through the variety of senses and is streamed along two main paths; one directed towards the limbic system, and the other to the thalamus.

The limbic region process “good or bad” reactions to the input and eventually interacts with subsequent regions of the brain that have reacted or refined other streams of input. The thalamus relays sensory input outwards in parallel paths to other brain regions specialized to process specific types of information (auditory, tactile…). These regions are packed with specific types of neurons that lie in broad regions that are comprised of sub-regions that further articulate the type of information as in vision for example, where color, motion, and form are detailed. Further, deeper into these layers there are other sub-regions that detect extremely specific inputs, such as a specific color type.

The general flow of information bits are received by other regions that are sensitive not to sensory stimuli but to combinations of these stimuli. For example, they might combine and odor and location. The general concept is that these regions begin to formulate aggregates or packages of information in increasingly complex fashion.

As this information proceeds through the cortex it is combined with regions that maintain “records” of past experiences and are integrated into “action schema” that basically ready the brain to respond physically if events so demand.

This total package represents a reflection of data from the outside world combined with this brains personal nuanced experiences, memories, and associations. This information is not a perfect reception and as Rita Carter (Exploring Consciousness) describes it is “…like information traveling along a bad telephone line, it has been subject to various errors and distortions.”

Before become a response, or a conscious thought, these stimuli are further analyzed in area such as the frontal cortex where the ‘action schemas” and the responses they ready are inhibited until these regions tumble these packages around mixing these fully formed perceptions with further “working memories” readying as Carter notes “rational response to what is going on.”

This active dance of complex events provides the glimmerings of what is described as the phenomena of consciousness. The following is a list of some of the brain regions that seem to play a role in the mysterious development of human consciousness that neuroscience is slowly unraveling.

“ Thalamus: Directs attention and switches sensory input on and off.

Reticular formation: Activity here stimulates the cortex into action-without which there is no consciousness.

Hippocampus: Personal memories are coded here and it is also responsible for spatial memory (in the right hemisphere) - two linchpins of consciousness.

Parietal/Temporal junction:This is where the brain stores its “map” of self and judges the self’s relationship to the world. Has good connections to the frontal lobes and is in a position to pull in information from sensory areas. The “locus” of consciousness?

Temporal lobe: Store personal memories, processes sound and speech. Language may be the scaffolding that supports consciousness.

Left hemisphere: The dominant side in 97% of people, and usually the only one to use language. Its ability to describe experience, and spin stories, may be the means by which we become fully conscious.

Orbitofrontal cortex: Emotion becomes conscious here. If it’s not active, emotion is reduced to a robotic reflex without feeling.

Dorsolateral prefrontal cortex/ working memory: Where different ideas and perceptions are brought together. Could consciousness depend on this type of “binding”?

Motor cortex: consciousness dependant on body awareness? If so, the motor cortex must be of central importance.

Primary visual cortex (V1): Take this away and you lose visual consciousness even if other vision-processing areas are preserved.

Supplementary motor cortex (sma): This is where actions are “rehearsed”. Was this the brain function that jacked us up to consciousness?”

Daniel Dennet puts it aptly: “You enter the brain through the eye, march up the optic nerve, round and round the cortex looking behind every neuron, and then, before you know it, you emerge into daylight on the spike of a motor nerve impulse, scratching your head and wondering where the self is.”

Ref: Carter, R. Exploring consciousness.Univ of California Press. Berkeley,California.2002