Migraine: how often do meds work?

Siri Hustvedt writes of a life with very severe migraines. After many referrals and medication trials she gets by with biofeedback-trained relaxation techniques and, I would guess, some over the counter analgesic.

This prompts me to confess that, in my days of seeing patients, I felt very unsuccessful treating migraine.

Now that was over 10 years ago, but the medications haven't changed all that much. I used the medications I'd read about, and some of my patients even sat through several rotations, but nothing seemed to stick.

Some meds worked for a while, but then the patient would return. Sometimes a med stopped working, sometimes the side-effects were worse than the headaches, sometimes they were too expensive.

I know others claimed much more success, but I'm suspicious. I know quite a few people with migraine, and they mostly seem to live with them. They often have meds that help about as much as the ones I used to prescribe, and sometimes they need stronger narcotics, but by and large they, like Siri, live with migraine.

Maybe I wasn't imagining things long ago. Maybe we really don't have any great medical treatments for migraine. If so, then it might be useful to admit that in print ...

Cringely provides a sane justification for Microsoft's acquisition of Yahoo!

Cringely makes Microsoft's acquisition of Yahoo! sound potentially rational ...

I, Cringely . The Pulpit . The Men Behind the Curtain | PBS

... BUT KILLING GOOGLE ISN'T THE POINT FOR MICROSOFT.

What we have here at Microsoft is a generational transition like we've seen in many other industries as leading companies go from robber barons to industry stalwarts. ...

Cringely claims that Microsoft wants to become GE 2.0 - a finance and management company rather than a software and services company.

I imagine if this were to succeed we'd see Gates return at age 60 to oversee Microsoft's acquisition of GE 1.0.

I think he's on to something. Ballmer is many things, but stupid is not one of them.

Strict control of type II diabetes increased mortality in one (big) study

I left longitudinal primary care practice before metformin. Back then tight control of Type II diabetes was just about impossible. If we pushed insulin patients just got heavier. In the rare event that we got reasonable control we feared the that occasional hyopglycemia could be deadly.

Times changed. Metformin and subsequent medications transformed Type II DM care. Now it's possible, with a dedicated and disciplined patient, to achieve tight control. Studies of intermediate measures (heart disease, renal failure, eye disease) in patients with both Type I and Type II diabetes showed the value of tight control. Physicians were financially penalized for patients who didn't get good control, and roundly chastised for a lack of energy in pursuing this goal.

There was only one problem. We didn't really know that reducing the rates of nerve, kidney, heart, vessel and eye disease would actually reduce mortality. It certainly seemed that it should...

Diabetes Study Partially Halted After Deaths - New York Times

For decades, researchers believed that if people with diabetes lowered their blood sugar to normal levels, they would no longer be at high risk of dying from heart disease. But a major federal study of more than 10,000 middle-aged and older people with Type 2 diabetes has found that lowering blood sugar actually increased their risk of death, researchers reported Wednesday...

Even the control group, who weren't under "tight" control, had very low glucose levels by the standards of the bad old days. So we're not talking about a return to the dark ages. The question instead is how hard to push, I think this study alone will cause payors to back off on financial penalties for "good" rather than "great" glucose levels.

Incidentally, a similar finding has come up many times over the past 20 years in studies of cholesterol reduction and all cause mortality. We know that reducing cholesterol lowers the risk of heart disease, but it doesn't reduce the risk of death in patients who do not have known heart disease or diabetes (1990:

... Mortality from coronary heart disease tended to be lower in men receiving interventions to reduce cholesterol concentrations compared with mortality in control subjects (p = 0.06), although total mortality was not affected by treatment. No consistent relation was found between reduction of cholesterol concentrations and mortality from cancer, but there was a significant increase in deaths not related to illness (deaths from accidents, suicide, or violence) in groups receiving treatment to lower cholesterol concentrations relative to controls (p = 0.004).

Later studies suggest that, on balance, persons with diabetes or known vascular disease benefit from simvastatin. Maybe a lot. There's still the suspicion that the harm may outweigh the benefit for non-diabetic patients with no known vascular disease (primary prevention) though.

These are tough questions, and in this domain my much loved animal model studies aren't that helpful. All cause mortality can only be studied in humans.

2/15/2008: It occurred to me that results like these could suggest the possibility of unsuspected quality issues with the medications we consume.

Omega-3 fatty acid flop - in transgenic mice

A few months ago Omega-3 fatty acids were promoted as the cure for everything from reading disabilities to autism to dementia -- often based on retrospective case-control studies.

Naturally this has put me on the alert for negative studies. You see, I've heard this story before. Many times. Almost always involving retrospective case-control studies.

Pshaw! Give me transgenic animal model studies any day ...

A diet high in omega-3 fatty acids does not improv...[Neuroscience. 2007] - PubMed Result

Although a number of epidemiologic studies reported that higher intake of omega-3 fatty acids (largely associated with fish consumption) is protective against Alzheimer's disease (AD), other human studies reported no such effect. Because retrospective human studies are problematic and controlled longitudinal studies over decades are impractical, the present study utilized Alzheimer's transgenic mice (Tg) in a highly controlled study to determine whether a diet high in omega-3 fatty acid, equivalent to the 13% omega-3 fatty acid diet of Greenland Eskimos, can improve cognitive performance or protect against cognitive impairment. Amyloid precursor protein (APP)-sw+PS1 double transgenic mice, as well as nontransgenic (NT) normal littermates, were given a high omega-3 supplemented diet or a standard diet from 2 through 9 months of age, with a comprehensive behavioral test battery administered during the final 6 weeks. For both Tg and NT mice, long-term n-3 supplementation resulted in cognitive performance that was no better than that of mice fed a standard diet. ... While these studies involved a genetically manipulated mouse model of AD, our results suggest that diets high in omega-3 fatty acids, or use of fish oil supplements (DHA+EPA), will not protect against AD, at least in high-risk individuals...

Now that's more like it. Nice and negative.

Eons ago I used to teach evidence-based medicine. Back then we had a hierarchy of evidential goodness. The very bottom was "Dr. Schmo at Harvard loves this surgery" [1], the very top was randomized, double-blind case control studies. Retrospective case-control studies were lower tier but respectable given suffient statistical wizardry.

Later "meta-analysis" slipped in, perhaps higher than it deserved [2].

Doing it today I'd want to put retrospective case-control much closer to Dr. Schmo (low, that is), and I'd like to see transgenic animal model studies much closer to the top (wasn't even on the list in my day). Of course this is just my opinion speaking (like Dr. Schmo); I haven't seen any (retrospective) research on how well results from transgenic animal studies hold up 3-5 years later. Hope someone does that in the next year or so.

[1] This never goes well.

[2] Gets messed up by unpublished studies though now the meta-analysts struggle mightily to find the unpublished.

Lessons for MN DFL caucus attendees

Minnesota is, in many ways, an exemplary state.

But not in every way.

I just sat through another Minnesota DFL caucus. This consisted of three parts:

1. Presidential preference. Our candidate received 210 ballots, Hillary Clinton 88, Dennis Kucinich 1.
   
2. Selection of delegates for the next stage in the caucus system on Saturday March 8th, where the real decisions are made. Delegates need to be able to take a Saturday off.
3. Resolutions. Before these were presented our caucus leader passed a resolution that "all DFL resolutions" would be passed unanimously. I confess I didn't quite grasp what this meant, I thought it referred to some sort of official party process. Turns out it applied to anything anyone resolved during the caucus.

There was one good resolution. The rest can be most succinctly summarized as "give me and my buddies some money". They all passed "unanimously". I slowly grasped that they would all die a quiet death at the right time, though I was sorely tempted to add a resolution to "end the caucus system" -- since it would have passed with the rest.

Has any state ever escaped the trap of a caucus system? If any have, how did they do it?

Ah well, the key lessons for future caucus activity are that there are two times to leave:

1. After the presidential preference ballot, which runs from 7pm to 8pm.
2. If you want to be a delegate, after the sign up.

There's no sane reason to sit through the resolutions, that's what the all day meeting is for.

I really need to remember this for next time ...

Update 2/14/08: Caucuses are stupid everywhere. We just need to get rid of them.

Strategic packaging- or just supplier contracts? The 16GB iPhone.

So is it strategic packaging - or just related to contracts, suppliers and channel status? Apple's evil genius is such that none of us know for sure.

Apple increases iPhone, iPod touch storage capacity - The Unofficial Apple Weblog (TUAW)

The iPhone is now available with 8GB (at $399US) or 16GB (at $499US) of storage. The iPod touch is now available in three models; 8GB ($299US), 16GB($399US) and 32GB($499US).

Note that the 16GB iPhone and the 32GB iPod touch are both $499, while there's a one hundred dollar difference between the 16GB iPhone and the 16GB iPod model...

The strategic message here is that there won't be any more iPhone changes until iPhone 2.0 due sometime in 2008 (I'm guessing September/October, but I wouldn't be shocked if it slipped into 2009).

So those of us waiting for a sign have it. I don't need that extra 8GB for music or video of course, I want room for old-fashioned locally resident applications to grow.

Now all that remains is to see that the SDK is real, and that Apple is giving developers the (secure and signed-for-in-blood) keys to the kingdom -- including the calendar and contacts data stores and the synchronization frameworks.

Why must I wait for the real SDK?

The MacBook Air is proof positive (the I/O limits in particular) that Apple isn't making products for the likes of me. Happily I know there's a world of developers who are eager for a paying customer -- and who can live off a smaller base. A working SDK means they'll be beating down the door to my open wallet.

The BlackBerry is jam

As in a fruit squished between the iPhone and Windows Mobile, then spread on toast.

I'm surprised the BlackBerry lasted this long, the old Microsoft would have squished RIM eons ago. Now though, the day of reckoning at hand.

I base my cruel judgment on my personal experience with the BlackBerry Pearl and my knowledge of what Microsoft is selling to large corporations.

First, a step back. I have known for years that the BlackBerry is a terrific Microsoft Exchange peripheral. Nobody I knew, however, could explain whether it was anything more. For that I had to buy my wife the BlackBerry Pearl.

The answer is that it's very slightly more than an Exchange peripheral. Emily's Pearl has 64MB of memory available and a JVM; the combination can run several Google Apps that give it proto-Android features. You can even install ePocrates -- but then you hit the 64MB barrier hard (which I last encountered on a Commodore 64 around 1983). True, the BB can hold a 2GB memory card installed, but it can only store media - nothing useful.

Beyond the severe memory limitations, the BB's built-in applications are crude. They show none of the elegance and loving attention to excellence seen in the original Palm, the pre-multifinder Mac, or the new iPhone. The only thing that impresses in any way is the simple built-in push email app. It works, and for geezers it's an improvement over instant messaging.

Still, as a consumer device, the BB is a step up over, say, the despised Motorola RAZR. Unfortunately, it's not competing against the RAZR. It's going up against the iPhone, and there's no comparison.

So, the BB has no future on the consumer side.

What about the massive business franchise? Every executive worth their weight (not me by the way!) carries a BlackBerry and lives by it. Well, to be precise, they use email, calendar and contacts -- nothing more. Still, it works.

Except that Microsoft is now selling complete communications solutions to corporations that are built around Exchange, Sharepoint, and various messaging technologies. Microsoft's phone OS (whatever it's called today) is a major component of this package, and they'll shove it down everyone's throats. It won't be hard for Microsoft to break BlackBerry's Exchange server integration now that they're making their play for this space.

So, end of story. The BB is nowhere near good enough to compete with the iPhone on the consumer side. On the corporate side the axe is finally coming down.

RIMM's shares are doing pretty well. Maybe they could survive on patents alone. I would like to figure out how to short them though ...

Should I vote for Clinton or Obama?

Like Rebecca Traister, we're Edwards supporters who can't figure out who to vote for tomorrow.

So let's review the list, including, for this purpose, the GOP:

Smartest: Hillary Clinton

Best policies: Hillary Clinton

Most disturbing choice for American democracy: Hillary (Bush Clinton Bush) Clinton

Least bad republican: John McCain

Best executive and management skills: Mitt Romney

Supports torture: Mitt "thumbscrews" Romney

Most disastrous choice: Mitt Romney

Most inspirational: Barack Obama

Toughest fighter: Hillary Clinton (John McCain is next)

Republican most likely to win: John McCain

Best president: Hillary Clinton ties with Barack Obama -- for different reasons. Obama may win overall because slavery is the historic American curse, and Obama can be a part of a cure.

Democrat most likely to win against McCain ...

Ahh, the last is the reason we struggle.

Today Hillary energizes the "independents" -- to vote for McCain. Given time I think she might win over many of the women "independents". Overall I think Hillary can win nationally among women, even if men vote for McCain.

I don't trust white (including, in this case, Hispanic) Florida democrats for vote for Obama -- no matter their silence today.

If they had equal odds against McCain I'd vote for Obama - because slavery really is the curse at the heart of America. If he were a white guy with a similar story he'd still be an astounding person and potentially an excellent president, but he wouldn't be in this race.

I fear McCain would beat Obama though, even though the Giants did win the Super Bowl.

I'm still undecided.

Update: Krugman is pushing me closer to Hillary.

Update: A colleague claims Obama is being smart about mandates -- knowing what Americans would accept. Good point.

Update: My most influential friends are pushing me to Obama. Krugman, another Edwards orphan, feels that electability, my main issue, favors neither. If it's Obama I don't think Nader, despite his GOP funding, will have any traction.

So, for the moment, Obama.

Update 2/5/2008: My reading of James Fallows analysis is that he's in the same spot as Emily and I. Straining the tea leaves, he too favors Obama. The riskier bet, the greater return -- if it works.

What happens when an ATM dispenses free money?

Apparently ATM malfunctions are fairly rare, and most often limited to "eating" an ATM card. Rare is not impossible though, and yesterday my bank's ATM failed.

It gave me too much money.

At first, after much noise and delay, it coughed up a solitary twenty. I indignantly waved the bill in the face of the video camera. Then, after several more minutes of grinding and retching, the abashed machine retched up another pile of cash. I managed to pull it free of a jam and found $60 more than I'd asked for (the receipt matched my request).

I have to cash some checks tomorrow, so I'll see what my bank does. I wonder how often this happens? I doubt that I'll get to keep the money, I suppose I'd have to donate it to charity if they don't want it.

Update 2/4/08: Here's what happens:

1. Claims of ATM underpayment are not unusual.
2. Claims of ATM overpayment are, unsurprisingly, unusual.
3. The bank investigates then corrects with an additional debit.
4. There's a presumption the customer is being honest when they claim an overpayment. I suspect that varies by age, ethnicity, race, dress and appearance when one claims underpayment.
   

Top Al Qaeda leader killed - best commentary

15 rows in the table, and counting ...

Making Light: Top Al Qaeda Leader Killed (again)

It’s like being the drummer for Spinal Tap...

Features that sell products are often useless

This is the curse of product design. The features that sell a product are most often ignored. More precisely, they are not used by the people who buy the product.

It's a curse because, as most of us have noticed by now, we live in a universe where resources are finite. The features that are not used, hence useless, have a cost. That cost is either paid by increases in product price, or by taking away from features customers don't realize they need, or by using lower quality inputs, or by spending less on quality control.

Product managers, developers and designers learn this painful lesson -- sooner or later. They put features in products that won't be used, skimp on the things that don't sell, mourn that they deliver less value than they could.

The only answer is smarter customers, but that may take a long long time ...

Of course similar behaviors are seen in mate selection as well ...

Another dumb article on exercise and aging

I'm guessing Gina Kolata has entered the death zone of middle-age and has started grasping at straws. It's the only explanation for the credulous tone of her article on how exercise can slow our entropic decline:

Staying a Step Ahead of Aging - New York Times:

...Their results are surprising, even to many of the researchers themselves. The investigators find that while you will slow down as you age, you may be able to stave off more of the deterioration than you thought. Researchers also report that people can start later in life — one man took up running at 62 and ran his first marathon, a year later, in 3 hours 25 minutes.

It’s a testament to how adaptable the human body is, researchers said, that people can start serious training at an older age and become highly competitive. It also is testament to their findings that some physiological factors needed for a good performance are not much affected by age...

...But Dr. Hagberg found that studies of aging athletes sometimes were distorted because they included people who had cut back on or stopped training...

Sigh.

So these researchers showed that athletes who don't stop doing intense exercise can be more fit that most middle-aged people.

Gee, I wonder why most athletes stop doing intense exercise. Injury? Aging?

There's nothing surprising about these results, and they hold no new lessons for us. We know not everyone ages at the same rate. We know some people have better athletic genes than others. We expect some people get both sets of genes. We know even demented 80 yos in nursing homes improve their lives when put on a weight training program.

Gina, you can do better than this. You must by now know the difference between an observational and an experimental study ...

Michael Vick's dog Georgia - a description

Reading this description, I wondered what Michael Vick was doing now:

Given Reprieve, N.F.L. Star’s Dogs Find Kindness - New York Times

A quick survey of Georgia, a caramel-colored pit bull mix with cropped ears and soulful brown eyes, offers a road map to a difficult life. Her tongue juts from the left side of her mouth because her jaw, once broken, healed at an awkward angle. Her tail zigzags.

Scars from puncture wounds on her face, legs and torso reveal that she was a fighter. Her misshapen, dangling teats show that she might have been such a successful, vicious competitor that she was forcibly bred, her new handlers suspect, again and again.

But there is one haunting sign that Georgia might have endured the most abuse of any of the 47 surviving pit bulls seized last April from the property of the former Atlanta Falcons quarterback Michael Vick in connection with an illegal dogfighting ring.

Georgia has no teeth. All 42 of them were pried from her mouth, most likely to make certain she could not harm male dogs during forced breeding...

Wikipedia has the answer. Still in prison, with another trial pending in 2008. Financially broken with many lawsuits pending. Unlikely to play in the NFL; particularly if Georgia appears in a commercial or two.

Has any human as cruel as Michael Vick ever been redeemed? I'm unable to think of an example.

Mahoo! - hope Google feels threatened

So Microsoft is acquiring Yahoo -- one way or the other.

Yahoo's been a disappointment for years, so that's no great loss for me. Really, Microsoft's recent work is much better than anything Yahoo's done.

The big upside though will be if it scares Google. Google needs a serious competitor, their pile of half-finished work is starting to smell a bit. I'm hoping Mahoo! puts the squeeze on ...

Charlie Stross profiles today's UK teens. Slashing?

Charles Stross, a top-rank science fiction writer almost as old as me, decided his business requires a profile of today's 18 year old. He's published a UK version of the Beloit College list he references:

Charlie's Diary: Youth of today:

I am a forty-something, which means I am out of touch with what passes for common knowledge among 18 year olds today. (Dodgy joke about keeping in touch with 18 year olds deleted in the interests of good taste.) Beloit College in the USA used to maintain a list for their staff, to explain what the world looks like to an 18 year old freshman: here's their 2006 list. It's heavily biased towards (obviously) American 18 year olds, but it got me thinking...

...Lots of people take antidepressants. Everyone slashes themselves; it's no big deal. (Statistics show a third of UK teens self-harm at some stage.)...

...There have always been cameras in shops and schools and other public places, although there are more of them than there used to be. Old folks grumble about privacy, but really, you're being watched wherever you are. If you don't like it, get a hoodie.

Slashing?! Geez, I really am a geezer. I don't think the US frequency is that high but I expect I'll find out (my oldest is 11). Forearm scars are not currently a winning point in job interviews.

Soon 18 year old Americans won't remember when smoking tobacco was a socially acceptable adult activity, but from a recent visit to the UK I know that's not true there.

Update: The comments are great, including some from the target demographic. I particularly liked Alex Gurney's remarks:

The word "digital" feels strange in "digital camera", "digital TV", "digital music", etc., since of course these things are digital. You have no idea why a "digital watch" or "digital alarm clock" would ever have seemed exciting or futuristic.

You either do not care about politics, or you obsessively follow political news, polls and statistics. Either way, you probably do not vote.

You think nothing of changing your phone handset or provider every few months. It would never occur to you to repair, rather than replace, broken electronic equipment. Even so, your data is far more important than the device, since you view phones, cameras and computers as essentially disposable.

You have never had to wait to get photos developed.

Anything which you have and don't want will probably get sold on eBay.