Wednesday, February 18, 2004

Newsday.com - Study: Pox Vaccine Loses Punch

Newsday.com - Study: Pox Vaccine Loses Punch
A study published today suggests that the effectiveness of the chicken pox vaccine decreases significantly in the first year after it's given but also notes that most vaccinated children who subsequently came down with the disease had mild illnesses.

A team led by Dr. Marietta Vazquez of the Yale University School of Medicine found that the vaccine was 97 percent effective in preventing chicken pox in the first year after the shot was given, but 84 percent effective two to eight years after it was administered.

This was always the argument against vaccinating children for chicken pox. As is true with several viral diseases, chicken pox is far more dangerous in adults then children. If by vaccinating we've defered infection into adulthood we'll have injured more people than we've helped.

Monday, February 16, 2004

War and the survivors - NYT Magazine

The Permanent Scars of Iraq
It may be impossible, however, to fully counteract the shock of going from a 24-hour state of generalized fear-apprehension-paranoia, sustained for a year through wartime, to evenings at home on the La-Z-Boy, asked to fulfill the requirements of love and tenderness needed to sustain a family. In a well-publicized string of incidents in 2002, three Special Forces soldiers returned to Fort Bragg, N.C., from Afghanistan and killed their wives in a span of six weeks. All three soldiers committed suicide.

The long magazine article describes the psychic and viscious physical wounds of the Iraq and Afghan wars -- from the American perspective. Many who would have died in previous conflicts live with post-traumatic brain syndromes, obvious disabilities, and psychic trauma.

Breast Cancer and Antibiotic use: responsible reporting!

Study Suggests Breast Cancer Is Linked to Use of Antibiotics
Frequent use of antibiotics has been linked to a greater risk of breast cancer, say researchers who studied thousands of American women and found that those who took the drugs most often had twice the risk of the disease.

The study uncovered a relationship between greater use of antibiotics and a heightened risk of breast cancer, but researchers sought to temper their findings by cautioning that they had only highlighted an association, not a causal link.

Astoundingly this was reported responsibly! The journalist made clear this was an association, and that most researchers don't think the antibiotics are causing breast cancer. Instead the interest is what's special about these women that they use so many antibiotics and/or that they are so susceptible to infection requiring antibiotic therapy.

Since I first read this news report I actually did read the JAMA article:JAMA -- Abstracts: Velicer et al. 291 (7): 827. They found a very strong statistical association between increasing use of oral antibiotics and increased risk of breast cancer -- about doubling risk -- even after "ruling out" other associated factors.

This is roughly similar to the efffect of other things known to increase breast cancer risk, such as frequent periods (infertility, etc). However there are lots of issues and oddities with this study:

1. These association studies don't have a great track record. Over the past 20 years I've guess more than 50% don't pan out. It usually turns out that the there was a missed cofactor that was the real agent.

2. WHY were these women using SO many antibiotics? Did they all have something wrong with their immune system? Did they have some "bad habits" -- like smoking or alcohol use that predisposed them to infection?

3. Because of where they got their data, the researchers have no information on either smoking or alcohol use. Both of these will increase antibiotic use, and both are risk factors for breast cancer. Smoking is getting more attention lately.

4. ALL the antibiotics had very similar effects, despite being very different medicines with very different actions. This suggests that the real cause was not the antibiotics, but something related to these women's need for them.

5. Do we see a relationship in animal models between antibiotic use and breast cancer?

My gut suspicion is that this is spurious, and and that smoking and/or alcohol use are the real actors that are producing an association between breast cancer and antibiotic use.

Frank Rich: My Hero, Janet Jackson (NYT)

Frank Rich: My Hero, Janet Jackson
Two weeks after the bustier bust, almost no one has come to the defense of Janet Jackson. I do so with a full heart. By baring a single breast in a slam-dunk publicity stunt of two seconds' duration, this singer also exposed just how many boobs we have in this country. We owe her thanks for a genuine public service.

Frank Rich is rockin and rollin in this terrific column. He rips everyone but JJ, and does so with gusto, glee and a bit of outrage.

Saffire's recent column on media consolidation is a good companion to this one.

Go Janet!

Sunday, February 15, 2004

The chemistry and biology of love -- how complex are we? (The Economist)

Economist.com | The science of love
If this doesn't keep you awake at night, you're on better drugs than I. Although most Economist articles require a subscription to access, I think this is one of the public articles. I've excerpted portions below. When you read the full article, think about (Science fiction readers, of course, have seen all these discussed in some depth. We didn't really believe, however, that this knowledge would have near-term applicability.):

- why and how children love parents and how one could treat reactive attachment disorder
- the suggested effect of SSRIs (Prozac, etc) on children and adults
- the nature of mass movements, from Hitler to Stalin to Putin to Mao to Moon to ... Did those people not love their master?
- how to make someone, or many people, completely and utterly loyal to a person or a cause - forever
- or, how to make a sociopath
- what it would mean to be susceptible to one sort of behavior (lust or love or caring but not another), and what the social implications are? Are nuns born as well as made?
- the relationship of smoking (nicotine) use and sex may be more than hollywood fancy ...
- someone is going to put oxytocin and/or vasopressin in perfume, and in nasal inhalers
- what do vasopression and oxytocin do in bees and other colony insects?
- would you like to scan your partners DNA and know their capacity for fidelity? I'm sure a biological fluid would contain an adequate sample ...
- how this is part of a trend that suggests much of what we have thought of as complex (love) may have very simple mechanisms (though complex interactions), and what that implies about our nature and how hard it would to create something like us
... understanding the neurochemical pathways that regulate social attachments may help to deal with defects in people's ability to form relationships. All relationships, whether they are those of parents with their children, spouses with their partners, or workers with their colleagues, rely on an ability to create and maintain social ties...

The scientific tale of love begins innocently enough, with voles. The prairie vole is a sociable creature, one of the only 3% of mammal species that appear to form monogamous relationships. Mating between prairie voles is a tremendous 24-hour effort. After this, they bond for life. They prefer to spend time with each other, groom each other for hours on end and nest together. They avoid meeting other potential mates. The male becomes an aggressive guard of the female. And when their pups are born, they become affectionate and attentive parents. However, another vole, a close relative called the montane vole, has no interest in partnership beyond one-night-stand sex. What is intriguing is that these vast differences in behaviour are the result of a mere handful of genes. The two vole species are more than 99% alike, genetically.

... When prairie voles have sex, two hormones called oxytocin and vasopressin are released. [jf: oxytocin is also used in uterine contraction vasopressin constricts vessels -- the meaning of a biological message (hormone,etc) is utterly context dependent, and the human body contains many isolated contexts.] If the release of these hormones is blocked, prairie-voles' sex becomes a fleeting affair, like that normally enjoyed by their rakish montane cousins. Conversely, if prairie voles are given an injection of the hormones, but prevented from having sex, they will still form a preference for their chosen partner...

... when this magic juice was given to the montane vole: it made no difference. It turns out that the faithful prairie vole has receptors for oxytocin and vasopressin in brain regions associated with reward and reinforcement, whereas the montane vole does not. The question is, do humans (another species in the 3% of allegedly monogamous mammals) have brains similar to prairie voles?

[excerpted section -- unsurprisingly the actions of oxytocin and vasopressin are mediated, like all addictive behaviors, but the dopamine reward system. Nicotine and cocaine are the two drugs of abuse that have the most direct action on this system.]

... Dr Young and his colleagues suggest this idea in an article published last month in the Journal of Comparative Neurology. They argue that prairie voles become addicted to each other through a process of sexual imprinting mediated by odour. Furthermore, they suggest that the reward mechanism involved in this addiction has probably evolved in a similar way in other monogamous animals, humans included, to regulate pair-bonding in them as well.

Sex stimulates the release of vasopressin and oxytocin in people, as well as voles, though the role of these hormones in the human brain is not yet well understood. But while it is unlikely that people have a mental, smell-based map of their partners in the way that voles do, there are strong hints that the hormone pair have something to reveal about the nature of human love: among those of Man's fellow primates that have been studied, monogamous marmosets have higher levels of vasopressin bound in the reward centres of their brains than do non-monogamous rhesus macaques.

Other approaches are also shedding light on the question. In 2000, Andreas Bartels and Semir Zeki of University College, London, located the areas of the brain activated by romantic love. They took students who said they were madly in love, put them into a brain scanner, and looked at their patterns of brain activity.

... a relatively small area of the human brain is active in love, compared with that involved in, say, ordinary friendship. ... The second surprise was that the brain areas active in love are different from the areas activated in other emotional states, such as fear and anger. Parts of the brain that are love-bitten include the one responsible for gut feelings, and the ones which generate the euphoria induced by drugs such as cocaine. So the brains of people deeply in love do not look like those of people experiencing strong emotions, but instead like those of people snorting coke.

... Last year, Steven Phelps, who works at Emory with Dr Young, found great diversity in the distribution of vasopressin receptors between individual prairie voles. He suggests that this variation contributes to individual differences in social behaviour -- in other words, some voles will be more faithful than others. Meanwhile, Dr Young says that he and his colleagues have found a lot of variation in the vasopressin-receptor gene in humans. "We may be able to do things like look at their gene sequence, look at their promoter sequence, to genotype people and correlate that with their fidelity, he muses."

It has already proved possible to tinker with this genetic inheritance, with startling results. Scientists can increase the expression of the relevant receptors in prairie voles, and thus strengthen the animals' ability to attach to partners. And in 1999, Dr Young led a team that took the prairie-vole receptor gene and inserted it into an ordinary (and therefore promiscuous) mouse. The transgenic mouse thus created was much more sociable to its mate.

Scanning the brains of people in love is also helping to refine science's grasp of love's various forms. Helen Fisher, a researcher at Rutgers University, and the author of a new book on love*, suggests it comes in three flavours: lust, romantic love and long-term attachment. There is some overlap but, in essence, these are separate phenomena, with their own emotional and motivational systems, and accompanying chemicals. These systems have evolved to enable, respectively, mating, pair-bonding and parenting.

Lust, of course, involves a craving for sex. Jim Pfaus, a psychologist at Concordia University, in Montreal, says the aftermath of lustful sex is similar to the state induced by taking opiates. A heady mix of chemical changes occurs, including increases in the levels of serotonin, oxytocin, vasopressin and endogenous opioids (the body's natural equivalent of heroin) ///

Then there is attraction, or the state of being in love (what is sometimes known as romantic or obsessive love). This is a refinement of mere lust that allows people to home in on a particular mate. This state is characterised by feelings of exhilaration, and intrusive, obsessive thoughts about the object of one's affection. ... Dr Fisher's work, however, suggests that the actual behavioural patterns of those in love -- such as attempting to evoke reciprocal responses in one's loved one -- resemble obsessive compulsive disorder (OCD). [jf -- SSRIs are used to tread OCD and, the article suggests, could treat infatuation or unwanted love... The author also notes a side-effect ...]

... Drugs such as Prozac work by keeping serotonin hanging around in the brain for longer than normal, so they might stave off romantic feelings. (This also means that people taking anti-depressants may be jeopardising their ability to fall in love.) ...

There's quite a bit more, it's a long article. The scientists and authors don't feel it will be nearly so easy to manipulate these behaviors in humans as it is in voles. I'm not so sanguine, but they're the experts. We'll find out soon enough ...

Friday, February 13, 2004

Kerry and the babes

BBC NEWS | Americas | Kerry wins support from ex-rival
On Friday Senator Kerry dismissed a claim by an internet gossip site that he had had an affair with a female intern.

'Well there is nothing to report, so there is nothing to talk about,' he told MSNBC television. 'There's nothing there. There's no story.'

The gossip site is Drudge Report, and the rumor is that the "intern" was whisked off to Africa. This has to be gotten out now; the worry about Kerry has always been that he would have the Clinton problem (the rest of us don't have the temptations they have).

It doesn't matter what's right or wrong, private or public. What matters is beating Bush. An intern problem should rule Kerry out, so let's get at it now.

If Kerry is out, then is it Edwards? What's his history?

Or, with everything in flux and delegates floundering, time for another to enter the race? Someone who's been fully investigated and harassed and exposed?

No, Hilary can't win.

But Al won once. And Dean could still be a VP candidate ...

Bush: The Character Issues and the Campaign to Come

Krugman: The Real Man
There is, as far as I can tell, no positive evidence that Mr. Bush is a man of exceptional uprightness. When has he even accepted responsibility for something that went wrong? On the other hand, there is plenty of evidence that he is willing to cut corners when it's to his personal advantage. His business career was full of questionable deals, and whatever the full truth about his National Guard service, it was certainly not glorious.

I love Krugman's comment about the missing photo of Bush swimming the Yangtze River (Mao's old standard). Twenty-seven Bush photos in the Federal budget .... that's a cult of personality, reminescent of Reagan.

I don't think Bush is evil, but he's as dishonest as any President and a better liar than most. He also has been venerated (literally) by the evangelical right; they believe he has been anointed and appointed by God. To challenge Bush's integrity is to challenge either their understanding of God or to challenge God Himself.

It will be a very nasty campaign.

Thursday, February 12, 2004

Mob scams 200 million in small charges, shades of Netfill

Officials Say Mob Stole $200 Million Using Phone Bills
Officials Say Mob Stole $200 Million Using Phone Bills
By WILLIAM K. RASHBAUM, NYT
Published: February 11, 2004

Forget gambling, loan-sharking and labor racketeering. New York organized crime figures bilked millions of unsuspecting consumers out of more than $200 million over five years by piggybacking bogus charges on their telephone bills, federal authorities said yesterday.

The scheme, involving a network of companies stretching from Midtown Manhattan to Overland Park, Kan., marked what federal authorities believe was the first time organized crime figures have been charged with using the billing fraud known as 'cramming' to fill mob coffers.

The nationwide scheme was sophisticated, officials said, but the idea was simple: Callers responding to advertisements for free samples of services like psychic phone lines, telephone dating services and adult chat lines were unknowingly charged up to $40 a month on their phone bills for services they never requested and never used...

Small regular charges fraudulently placed in a hard-to-detect fashion across large numbers of victims. Shades of the NetFill scam of the late 90s, with which I had more than a passing acquaintance.

These scams work because the complexity and transaction volume of modern life exceeds the capacity of we mortals. They also work because the intermediaries typically don't suffer (in this case the phone companies, in related scams it's banks and credit card companies), so they're not strongly incented to implement costly security measures.

They'll only increase ...

MAUREEN DOWD: The Khan Artist (NYT)

Op-Ed Columnist: The Khan Artist
Has Maureen Dowd gotten an infusion of journalism from the (lately silent and possibly ill) Molly Ivins? After years of mediocrity this is the second column in a month or so that's really worth reading.

Even the title is clever. The Khan artist she speaks of is not Khan the brilliant and evil Pakistani scientist, but rather George Bush. She does a wicked job of showing the bizarre contradictions between his words and deeds. GWB's greatest talent, among his many talents, may be an extraordinary capacity to lie successfully. If Clinton could lie as well as Bush, he'd never have been impeached.

PS. I suspect a rather large amount of US resources are now being spent investigating Dr. Khan. His relationship to al Qaeda is a topic of vast and urgent interest.

Wednesday, February 11, 2004

Photonic computing at silicon prices - Intel may have changed the world ...

NYT: Intel Says Chip Speed Breakthrough Will Alter Cyberworld
SAN FRANCISCO, Feb. 11 — Intel scientists say that they have made silicon chips that can switch light like electricity, blurring the line between computing and communications and presenting a vision of the digital future that will allow computers themselves to span cities or even the entire globe.

The invention demonstrates for the first time, Intel researchers said, that ultrahigh-speed fiberoptic equipment can be produced at personal computer industry prices. As the costs of communicating between computers and chips falls, the barrier to building fundamentally new kinds of computers not limited by physical distance should become a reality, experts said.

The advance, described in a paper to be published on Thursday in the scientific journal Nature, also suggests that Intel, as the world's largest chipmaker, may be able to develop the technology to move into new telecommunications markets...

... Intel said the technical advance, in which the researchers use a component made from pure silicon to send data at speeds as much as 50 times faster than the previous switching record, is the first step toward building low-cost networks that will move data seamlessly between computers and within large computer systems.

... The device Intel has built is the prototype of a high-speed silicon optical modulator that the company has now pushed above two billion bits per second at a lab near its headquarters in Santa Clara, Calif. The modulator makes it possible to switch off and on a tiny laser beam and direct it into an ultrathin glass fiber. Although the technical report in Nature focuses on the modulator, which is only one component of a networking system, Intel plans on demonstrating a working system transmitting a movie in high-definition television over a five-mile coil of fiberoptic cable next week at its annual Intel Developer Forum in San Francisco...

We had a breather after the dot com crash, but this may take us back into the steep exponential. Intel's share price is up 2% on early news. We're talking about greater than an order of magnitude decrease in the cost/performance equation. That kind of drop is not merely progress, it may constitute revolution.

Distributed photonic computing. Inevitably one wonders about the implication for quantum computing. The hype about "the network is the computer" may become trite wisdom.

This is one of those things that might make it into the history books.

KRISTOF: Watching the Jobs Go By - his weakest column in years

Op-Ed Columnist: Watching the Jobs Go By
Subject: watching the jobs go by: not your best column
Date: February 11, 2004
To: nicholas@nytimes.com

Nicholas,

Get more math and science education -- so you can work for $10 a day?

The whole point of outsourcing is that it's easiest to do for jobs that require technical skills. In rural China, India, Latin American and Africa there are hundreds of thousands, probably millions, of people with IQs over 160. Given ubiquitous connectivity, most will be able to quickly learn english, mathematics, science and just about anything else that one can learn by reading. Sure, there are thousands of americans with the same gifts; but they'd be working at the high class sub-Saharan African wages.

The outsourcing of technical work is the greatest boon the world will ever see. It will also induce very great disruption to societies in which, historically, a university degree was a path to success.

You should have been advising our young to study roofing and plumbing. Much harder to outsource -- they need only compete with illegal aliens.

The real answer is to smooth the transition to a future society including:

1. Separate all benefits from employment so people easily move between work and non-work.
2. As part of social security reform, eliminate the idea of age-specific retirement. Income has mandatory contributions to tax-deferred funds and non-work (study, vacation, job seeking, whatever) draws from those funds.
3. Tax reform to reflect a future tax base.
4. Look to the Scandinavians for the rest.

Monday, February 09, 2004

The Pentagon prepares for the climate crash, but there's more fun ahead in the 21st century ...

Fortune.com - Technology - The Pentagon's Weather Nightmare
Even as right wing idealogues strive to avoid the idea of global warming, the Pentagon prepares for the wars to come ...
Global warming may be bad news for future generations, but let's face it, most of us spend as little time worrying about it as we did about al Qaeda before 9/11. Like the terrorists, though, the seemingly remote climate risk may hit home sooner and harder than we ever imagined. In fact, the prospect has become so real that the Pentagon's strategic planners are grappling with it.

The threat that has riveted their attention is this: Global warming, rather than causing gradual, centuries-spanning change, may be pushing the climate to a tipping point. Growing evidence suggests the ocean-atmosphere system that controls the world's climate can lurch from one state to another in less than a decade—like a canoe that's gradually tilted until suddenly it flips over. Scientists don't know how close the system is to a critical threshold. But abrupt climate change may well occur in the not-too-distant future. If it does, the need to rapidly adapt may overwhelm many societies—thereby upsetting the geopolitical balance of power.

Though triggered by warming, such change would probably cause cooling in the Northern Hemisphere, leading to longer, harsher winters in much of the U.S. and Europe. Worse, it would cause massive droughts, turning farmland to dust bowls and forests to ashes. Picture last fall's California wildfires as a regular thing. Or imagine similar disasters destabilizing nuclear powers such as Pakistan or Russia—it's easy to see why the Pentagon has become interested in abrupt climate change.

Climate researchers began getting seriously concerned about it a decade ago, after studying temperature indicators embedded in ancient layers of Arctic ice. The data show that a number of dramatic shifts in average temperature took place in the past with shocking speed—in some cases, just a few years.

The case for angst was buttressed by a theory regarded as the most likely explanation for the abrupt changes. The eastern U.S. and northern Europe, it seems, are warmed by a huge Atlantic Ocean current that flows north from the tropics—that's why Britain, at Labrador's latitude, is relatively temperate. Pumping out warm, moist air, this "great conveyor" current gets cooler and denser as it moves north. That causes the current to sink in the North Atlantic, where it heads south again in the ocean depths. The sinking process draws more water from the south, keeping the roughly circular current on the go.

But when the climate warms, according to the theory, fresh water from melting Arctic glaciers flows into the North Atlantic, lowering the current's salinity—and its density and tendency to sink. A warmer climate also increases rainfall and runoff into the current, further lowering its saltiness. As a result, the conveyor loses its main motive force and can rapidly collapse, turning off the huge heat pump and altering the climate over much of the Northern Hemisphere.

Scientists aren't sure what caused the warming that triggered such collapses in the remote past. (Clearly it wasn't humans and their factories.) But the data from Arctic ice and other sources suggest the atmospheric changes that preceded earlier collapses were dismayingly similar to today's global warming. As the Ice Age began drawing to a close about 13,000 years ago, for example, temperatures in Greenland rose to levels near those of recent decades. Then they abruptly plunged as the conveyor apparently shut down, ushering in the "Younger Dryas" period, a 1,300-year reversion to ice-age conditions. (A dryas is an Arctic flower that flourished in Europe at the time.)

Though Mother Nature caused past abrupt climate changes, the one that may be shaping up today probably has more to do with us. In 2001 an international panel of climate experts concluded that there is increasingly strong evidence that most of the global warming observed over the past 50 years is attributable to human activities—mainly the burning of fossil fuels such as oil and coal, which release heat-trapping carbon dioxide. Indicators of the warming include shrinking Arctic ice, melting alpine glaciers, and markedly earlier springs at northerly latitudes. A few years ago such changes seemed signs of possible trouble for our kids or grandkids. Today they seem portents of a cataclysm that may not conveniently wait until we're history.

Accordingly, the spotlight in climate research is shifting from gradual to rapid change. In 2002 the National Academy of Sciences issued a report concluding that human activities could trigger abrupt change. Last year the World Economic Forum in Davos, Switzerland, included a session at which Robert Gagosian, director of the Woods Hole Oceanographic Institution in Massachusetts, urged policymakers to consider the implications of possible abrupt climate change within two decades.

Two big environmental changes, which share some common roots, are coming towards us like a massive tidal wave: global warming and the exhaustion of fossil fuels.

By the time the boomers are shuffling off the stage we'll be feeling the effects of both fossil fuel exhaustion and global warming. It will require massive adaptation across the entire spectrum of humanity.

Over the same time we'll be dealing with widely distributed low costs weapons of mass devastation (including home bioweapons), emergent nanotechnology with its unique risks and disruptions, genetic engineering & the possible enhancement of human and non-human cognition, the post-industrialization of China and India, the emergence of Africa, a world of 11 billion humans, and the ever-lurking mega-shock of abiologic sentience. No wonder Vinge and others write of the impending singularity.

Social security and medicare are the very least of our concerns, but at least they provide some lightweight near term distractions. Nor need we worry about longterm unemployment -- rebuilding our infrastructure to adjust to the new world will keep most people occupied.

About 150,000 years ago humanity went through a "chokepoint". Only 10,000 or so survived, to then spread across the world (possibly eating other sentient hominids along the way). Our next chokepoint lies ahead. Maybe this sort of thing is why the galaxy seems so quiet.

Oh well, maybe we'll just be smacked by a meteor or cooked by a gamma ray burster.

I think I need to do my taxes.

Not the Gore you thought he was ...

Gore Says Bush Betrayed the U.S. by Using 9/11 as a Reason for War in Iraq
Mr. Gore said he was ready to break his silence about his disagreements with the Bush administration before the Sept. 11 attacks, but afterward he threw his speech in the trash.

But then the war in Iraq came, and he felt betrayed. "It is not a minor matter to take the loyalty and deep patriotic feelings of the American people and trifle with them," he declared, adding with a shout: "The truth shall rise again."

Gore is back, and not going away. During the last election he was mocked as a "phony" for what was thought to be faux populism and outrage.

Turns out, that was genuine. I can see why he endorsed Dean; Gore and Dean are kindred spirits -- save Gore has far greater political savvy. There's nothing the media can do to Gore any more; he's been savaged so much he's now untouchable.

I hope we'll hear a lot from him as he campaigns for the nominee.

Back pain: an untreatable condition? NYT

Healing a Bad Back Is Often an Effort in Painful Futility
Americans $26 billion a year, or 2.5 percent of the total health care bill, according to a new study from Duke University, and far more if disability payments, workers' compensation and lost wages are taken into account. The costs are rising, researchers say, as patients get ever more aggressive forms of treatment...

Yet for all the costs, for all the hours spent in doctors' offices and operating suites, for all the massage therapy and acupuncture and spinal manipulations, study after study is leading medical experts to ask what, if anything, is doing any good.

A variety of studies have suggested that in 85 percent of cases it is impossible to say why a person's back hurts, said Dr. Richard Deyo, a professor of medicine and health services at the University of Washington. And most of the time, the pain goes away with or without medical treatment.

"Nearly everyone gets better, nearly everyone improves," said Dr. Deyo, citing evidence from large epidemiological studies. But he cautioned, "Getting better doesn't necessarily mean pain-free."

Surgery, too, is under new scrutiny, with a national study getting started at 11 medical centers. About 1,000 patients with the problems that most often lead to surgery will be randomly assigned to have surgery or not. The problems under study are herniated disks, spinal stenosis, which is a narrowing of the spinal canal that usually occurs with arthritis and aging, and degenerative spondylolithesis, a slipped vertebra.

One of the investigators in the study is Dr. James N. Weinstein, a Dartmouth professor of orthopedics and community and family medicine and the editor in chief of Spine, the professional journal that published the Duke report in its January issue.

"I've met with two groups who said they fear the results will take away their practice," Dr. Weinstein said. "I don't know how to deal with that. I don't know what the results will be."


Back experts say it is clear that surgery can make some patients feel better immediately.

"Let's say you have a herniated disk and let's say you have leg pain and let's say you are as miserable as hell and you convince somebody to operate on you," said Dr. Michael Modic, chairman of the radiology department at the Cleveland Clinic. "You have a 95 percent chance of waking up with no pain."

... Those with disabling pain for three or four months have just a 10 percent to 20 percent chance of getting better in the next year.

For this group, some doctors are now advocating a different approach altogether: teaching people to live with pain, to put aside the understandable fear that any motion will aggravate their injury. They have to learn, Dr. Weinstein said, that "hurt doesn't mean harm."

In programs often known as functional restoration, that is the goal. Patients are trained in strength, flexibility and endurance. They are counseled about their fears of re-injury and about anxiety and depression.

It can be difficult to get them back to work, noted Dr. Bigos, of the University of Washington, because many left their jobs on disability and had bitter disputes with their former employers or with insurance companies. "Usually, lines have been drawn in the sand by one or both sides," he said.

But success is possible, said Dr. Thomas Mayer, director of a clinic called Pride, for Productive Rehabilitation Institute of Dallas for Ergonomics. Among the 3,500 back patients who entered his one- to two-month program and completed it, almost all returned to work and nearly half went back to their original employer, Dr. Mayer said.

"We deal with it face on," Dr. Mayer said. "What are you going to do for the rest of your life? What are you getting from being disabled? What would you get if you were not disabled?"...

This short article is packed with a lot of interesting information. There's an unexplored backstory as well. In the 1980s a federal agency (AHCPR) published guidelines on back pain that deemphasized interventions and studies. A backlash led by orthopedic surgeons essentially destroyed the AHCPR. The AHCPR entered a witness protection program, changed its name, and now lives a quiet but useful life.

Overall the results would come as little surprise to most physicians. I think most family doctors have slowly come to much the same opinion. Exercise and weight control seem to be the only truly useful interventions. In the 1990s there was muted enthusiasm for prolonged narcotic therapy, but that appears to have waned. Chronic narcotics work for some, but misuse harms others -- overall a weak solution.

At the same time as we shift to managing chronic back pain through lifestyle changes and pain management techniques (neither of which will be adequately funded -- it's far easier to get compensation for surgery), we also have research showing a relationship between persistent pain, brain atrophy, and the development of distributed hypersensitivity to pain.

Short of radically reengineering the human back, or moving into the sea, we're stuck with back problems. It's one of our design flaws (the others relating to the fragility of cognition). A weight loss pill will help some, but many people with chronic back pain are not significantly overweight. A drug that reduced the brain's maladaptive response to chronic pain would be even better.

Update 8/1/2010: I was wrong about this. There are good interventions.

Sunday, February 08, 2004

Molecular Expressions: Science, Optics and You - Powers Of 10 - a tour of the universe

Molecular Expressions: Science, Optics and You - Powers Of 10: Interactive Java Tutorial
I saw a film of this about 20 years ago, but this version is better. They stop at quarks, I was kind of hoping they'd go down the Planck Length -- but that would be getting pretty speculative. It's a fascinating web site. Also, the first time I've used Java on the client in several years.