Tuesday, June 28, 2016

Desensitization therapy for dogs with fear of thunder, lightning and, of course, firecrackers

This is the season for traumatized dogs. We’ve had two husky mixes, the first (Molly Thunderpaws Squirrelbane) ended up needing oral valium during storms. She wanted under our bed but couldn’t quite fit. Which was why the feet of the bed rested on four hockey pucks.

I often wondered what visitors made of the hockey pucks. It probably livened our reputation.

Kateva Rose Cupcake (young kids did naming by then) isn’t so bad, but as she ages she’s more worried. She’s also having more trouble getting under the bed. So, again, hockey pucks.

So a NYT article caught my attention …

Why Thunder and Fireworks Make Dogs Anxious

… at least 40 percent of dogs experience noise anxiety, which is most pronounced in the summer. Animal shelters report that their busiest day for taking in runaway dogs is July 5…

… the first drug approved by the Food and Drug Administration for canine noise aversion (a term encompassing mild discomfort to phobia) came on the market. The drug, Sileo, inhibits norepinephrine, a brain chemical associated with anxiety and fear response…

…  a micro-amount of a medication approved as a sedative for minor veterinary procedures —- a flavorless gel, measured in a syringe, that is squeezed between the dog’s cheek and gum and absorbed within 30 minutes.

Orion, the Finnish company that developed it, tested it on several hundred noise-averse dogs during two years of New Year’s fireworks. Three-quarters of the owners rated the dogs’ response as good to excellent; their pets remained unperturbed. The drug lasts several hours, after which another dose can be administered.

A syringe costs about $30 and holds several weight-dependent doses. Sileo’s main side effect, in 4.5 percent of dogs, is vomiting…

… The optimal solution, vets say, is catching the response early, and desensitizing the dog with calibrated recordings of the offending noise, and positive conditioning…

You know, they could have mentioned the deconditioning part earlier. I found more on that from a reputable source …

Fear of Thunder and Other Loud Noises : The Humane Society of the United States

Begin by exposing your dog to an intensity level of noise that doesn't frighten her and pairing the noise with something pleasant, like a treat or a fun game. Gradually increase the volume as you continue to offer her something pleasant. Through this process, she'll come to associate "good things" with the previously feared sound.


Make a tape with firecracker noises on it.
Play the tape at such a low volume that your dog doesn't respond fearfully. While the tape is playing, feed her dinner, give her a treat, or play her favorite game.
In your next session, play the tape a little louder while you feed her or play her favorite game.
Continue increasing the volume through many sessions over a period of several weeks or months. If she displays fearful behavior at any time while the tape is playing, STOP. Begin your next session at a lower volume, one that doesn't produce anxiety, and proceed more slowly.
For some fears, it can be difficult to recreate the fear stimulus. For example, thunder is accompanied by lightning, rain, and changes in barometric pressure; your dog’s fearful response may be to the combination of these things and not just the thunder….

Sounds like the desensitization routine could be tricky, but I’ll give it a gentle try.

There are web sites that sell recordings, but a search on iTunes found several $1 recording from “Nature Sounds”. I’ll buy one, probably one with rain and thunder. It’s easy then to play it softly over the kitchen speakers while Kateva eats a treat-enhanced dinner.

Sunday, June 19, 2016

Traffic skills for cyclists: MSP options

Just did some research on bicycle traffic training options for St Paul and Minneapolis (MSP, Twin Cities). I found:

See also:

Update 6/21/2015. I did the Houston City online version of the TS 101 class. It took about 20 minutes (not 5 hours), but I knew the material already. I wrote some quick reactions in an email to a friend who teaches this class…

… I passed so I can now access the reference material on http://bikeed.org/studentDashboard.aspx.

The course is a neat introduction to cycling, but for me it was a bit of an odd mix. The sections on maintenance, bike types and purchase aren't really part of traffic safety. Rock dodge and Instant Turn are neat technical moves, but really almost nobody is going to learn those.

I'd have wanted to see more on visibility issues (fog, dark shadow, use of daytime lights, twilight), identifying and managing distracted drivers, assessing risks of rear ending at stops from distracted drivers, route selection (google maps is good), traffic speed and risk of death, watching for poor/angry/impaired drivers, trail etiquette expansion, specific recommendations on hideous yellow/orange vs. generic "bright colors", more on reflective gear and clothing, more on bike light choice and blinkies, more on reflective helmets, etc.

Single biggest omission was route selection and assessing road risks explicitly. Biggest change in last few years is smartphone-distracted drivers, but probably hasn’t been time to respond to that.

I think some of this material is sensitive because course is a mixture of advocacy (bicycling great!) and risk management (human drivers incompetent). So maybe reluctant to say "You are engaged in a risky activity. To minimize risk stay on bike trails and watch for incompetent cyclists. When you drive with cars you are taking more risks. Here is how to minimize them if you decide you still want to do this..."

RelatedBe the Best You Can Be: Special needs urban bicycling - what streets are safe?

Thursday, June 09, 2016

Driving under the smartphone influence: changing my bicycling style and changing laws

Emily was waiting to turn left when she was rear-ended. Our Subaru survived with injuries, the distracted driver’s car was badly damaged. At the body shop she was told their rear-end business used to be seasonal, but now it’s year round.

That fits with what I see driving and bicycling, and with my city’s one a day pedestrian and cyclist toll. Humans were never good at driving, but smartphones have made us much worse. Computers are indeed having mixed effects on our economic productivity.

As usual the fix for a technology failure is more technology. One day, maybe twenty years from now, autonomous cars will drive us (until they demand the vote). Today automatic braking systems reduce rear-end collisions 40%. These braking systems should be mandatory on all new cars; but they should also be required to recognize bicycles waiting in a line for a light to change.

That’s because I’m not as tough as our Subaru. If I’d been on my bike, instead of Emily in our Forester, that distracted driver would have killed me. If she couldn’t see a car with a blinking turn signal she definitely wouldn’t see me.

Smartphone-impaired drivers have changed the way I ride my bicycle. Bicycling with cars has always been a matter of calculated risk, and now those risks have shifted. A few years ago it often made sense to move into a line of cars, particularly when turning left or straight but sometimes even when turning right.

It’s still risky to be on the curb side at a light, or to pass stopped cars on the right, but now being the car line is newly dangerous. There are too many impaired drivers on the road.

So I’m changing my strategy. I’m shifting to the curb side more often, moving in front of a car line only when rear-end risks are relatively low. Really I should shift to running the red light when cross traffic is clear — that eliminates much of the rear-end and right turn risks. Unfortunately that angers drivers too much to be a great idea.

We desperately need new approaches to deal with our transition period before the AIs take over, a period when humans are much worse drivers. We need mandated collision avoidance systems that detect pedestrians and cyclists. We need more segregated bike lanes. We need to eliminate right turns on red lights (sorry fellow drivers, we’re the ones with the substance problem). We need to drop speed limits. We need panopticon traffic cameras to automatically cite drivers who violate crosswalk and intersection laws. We need ongoing “sting” operations to generate thousands of traffic citations, because nothing motivates drivers like a ticket.

We’ve got a lot of work to do.

Wednesday, June 08, 2016

Dissecting drug price leaps: The hydroxychloroquine story

Hydroxychloroquine (HCQ) is an old drug. It’s a descendant of chloroquine, which is as old as dirt:

Chloroquine was discovered in 1934 by Hans Andersag and coworkers at the Bayer laboratories, who named it “Resochin".  It was ignored for a decade because it was considered too toxic for human use. During World War II, United States government-sponsored clinical trials for antimalarial drug development showed unequivocally that chloroquine has a significant therapeutic value as an antimalarial drug. It was introduced into clinical practice in 1947 for the prophylactic treatment of malaria.

HCQ largely replaced chloroquine in the 1940s; when it was on patent it was sold as Plaquenil. Today it’s still used for malaria, but it’s mainstay drug for Lupus (increasingly popular) and rheumatoid arthritis. Some rheumatologists use it for osteoarthritis because it’s thought to slow cartilage erosion (few studies, mixed results).

It has a fascinating 400 year history (emphases mine):

The Nine Lives of Hydroxychloroquine | RheumNow

The HCQ story begins in 1638 when the wife of the Viceroy of Peru, Countess Cinchona, acquired malaria while living in the New World. Rather than getting the “approved” therapy, blood-letting, she was treated by an Incan herbalist with the bark of a tree (eventually, named for the countess-Cinchona Tree). Her response was dramatic; when the Viceroy returned to Spain, he brought with him large supplies of the powder for general use, which at the time was controlled by the Church and was thus called “Jesuit’s Powder”.

It took nearly two centuries for the active substance, Quinine, to be isolated from the bark (and was eventually to make a name for itself as a tonic to be added to gin).

Over the next century, quinine would become a common component in folk medicines and patent remedies for the treatment of malaria in the southern states of America, as well as for generic malaise. By the 1940s, quinine, or rather its derivative chloroquine, was recognized for its anti-malarial properties and found use among troops fighting in the Pacific during WW-II. However, it was noted that this compound had significant toxicities. In 1945, a modification of this compound via hydroxylation led to the development of HCQ, which was found to be less toxic and remains in use, without change, to this day.

Over time, physicians began to experiment with the medication and, in the early 1950s, began to use it for the treatment of SLE. ….. combination therapy [for rheumatoid arthritis], which became popular in the 1980s and has culminated in the recent studies showing the notable efficacy of triple therapy when HCQ was combined with MTX and sulfasalazine.

Most of the science regarding HCQ’s mechanism of action falls in the realm of speculation…

..  has been clearly shown to reduce the number of SLE flares, reduce the severity of SLE flares when they occur, can in some cases lead to “remission” including lupus nephritis, increase the risk of flares when stopped, and decrease the doses of prednisone needed to control the disease. In at least one study, the use of HCQ increased survival in patients with SLE by 70%…

HCQ used to be quite inexpensive — in the range of $30 a month, covered by all insurances. It’s a generic drug and it’s been off patent for decades. Things changed in late 2014 and early 2015 - shortages developed and the price jumped. The 2014-2015 Ebola epidemic disrupted health care systems and led to a surge in malaria and then high demand for HCQ to treat it.

The demand surge ended, and the drug shortage resolved, but the price has stayed high. In the US a month’s supply now costs about $400. Why hasn’t the price come down?

There used to be at least two manufacturers, but now there is only one: Covis Pharmaceuticals. Covis was acquired by Concordia, a company that makes its money by increasing the costs of old drugs. Ranbaxy, an Indian manufacturer, had severe quality issues and has itself been acquired by another similar predator - Sun Pharma. Sun is another Indian multinational with substantial power in the US generic drug market. Sun has also had FDA warnings; it’s likely their competitive edge comes from dodging FDA rules.

With the price increase the most profitable payors, like Aetna, have dropped coverage for HCQ. So the price has gone up ten fold, but Aetna’s patients are paying out of pocket.  Aetna has been more profitable than less unethical competitors like Cigna. So Aetna is growing and Cigna is being acquired. That’s another reason why DOJ should block Aetna and Anthem acquisitions.

Hydroxychloroquine is just one drug, but it’s a classic story. Dodgy manufacturers, globalization and regulatory evasion, monopoly development, price manipulation, ruthless healthcare insurance companies — the same themes appear across the lengthy ASHP drug shortage page.

There are fixes. The DOJ should absolutely block consolidation of US payors. Voters should demand government function — which today means voting against the GOP. Governments should coordinate responses. We need the “public payor” option that had to be dropped from Obamacare to keep a few Dem senators on board (all GOP opposed of course). We need the national formulary price negotiations most other countries have. We need a mixture of regulatory actions, market forces and buyer coordination to drive competition into the drug manufacturing industry. We need to end the monopolies.

It all begins with voters. Fortunately we have a meaningful election coming up. If the GOP is routed they may reform as a “smart-government” rather than “no-government” party — and we’ll have a better chance at intelligent action going forward. Vote accordingly.