August 2008 Archives

Physicians have been arguing about pharma's influence on postgraduate medical education for at least 50 years, reveal Scott Podolsky, MD, and Jeremy Greene, MD, PhD, in last week's JAMA. The Harvard physicians' commentary, "A Historical Perspective on Pharmaceutical Promotion and Physician Education," is intended to provoke cautionary thought about the future of medicine, given industry's longstanding involvement in and financial support of the dissemination of drug information.

However, the fact that a 50-year argument on the subject goes on merely indicates this: There's still no tangible evidence that pharma's potential influence on continuing medical education (CME) alters physician competence or patient outcomes—for better or worse. (For that matter, there's no evidence that CME generally alters physician competence or patient outcomes.)

In the closing of their JAMA commentary, Podolsky and Greene quote advertising executive Pierre Garai from 1963: "We know what the doctors are today. What will they be tomorrow?" This originally rhetorical question cannot be answered, of course, for today's physicians; but it can be addressed for physicians who were practicing during the early 1960s.

Therefore we can ask, what untoward healthcare event has occurred during the last 45 years as a result of pharma's influence on CME?

The only event that comes to mind (to which Podolosky and Greene also allude) is the overuse or misuse of antibiotics, ostensibly as a result of pharma marketing injected into industry-funded CME. However, a search of the medical literature does not support this contention (although an exhaustive search, for the purposes of this blog post, cannot be guaranteed).

On the other hand, a survey of Georgia pediatricians, discussed in a 1999* issue of Pediatrics, indicates that the decision to prescribe antibiotics for children is influenced by 1) diagnostic uncertainty (ie, Is the illness viral or bacterial?); 2) sociocultural and economic pressures (eg, consideration for time-strapped working parents); 3) fears of malpractice litigation; and 4) parental expectations. While the surveyed physicians may have been reluctant to admit to the influence of pharma-funded CME on their prescribing behavior, it seems unlikely that this potential influence would supersede the practice considerations cited by the surveyed physicians.

So the debate will continue, until there is compelling evidence that pharma's influence on CME—influence that has clearly been moderated during the last several years—has caused some undeniably beneficial or untoward healthcare outcome. 

* Arguably the height of pharma's influence on CME, before the institution of stricter firewalls between pharma marketing and CME.

Photo of the pop duo Sonny & Cher, who charted with the 1967 hit "The Beat Goes On," from Wikipedia.

Addendum: Some may cite the exuberant use of off-label fen-phen in the 1990s as an example of the adverse influence of pharma-funded CME. However, the fen-phen mess doesn't seem to be easily distilled to a single factor. Nevertheless, I am certainly receptive to any evidence that Wyeth funded CME activities in which the drug combination and supportive studies were discussed. 

In a welcome study of poorly regulated dietary supplements, investigators in Boston report the presence of toxic heavy metals—namely lead, mercury, or arsenic—in one fifth of US- or Indian-made Ayurvedic products. Results of a metal survey of these Internet-sold drugs were published in the latest issue of JAMA.

Among 199 of 230 randomly selected Ayurvedic medicines available for web-based purchase,* nearly 21% contained metals per x-ray fluorescence spectroscopy, wrote the authors, with no appreciable difference between US- and Indian-made products. Rasa shastra drugs—which combine herbs with metals, minerals, and gems—were significantly more likely to contain metals than non-rasa shastra products (41% vs 17%) and contained significantly higher median concentrations of lead (11.5 vs 7.9 µg/g) or mercury (20,800 vs 34.5 µg/g).

The amount of metals detected in metal-containing products consistently exceeded one or more standards for acceptable daily intake. These drugs were much more likely to be sold at US web sites (Table), and 75% claimed Good Manufacturing Practices, wrote the authors. In some cases, products were specifically recommended for pediatric use.

Product(s)	Manufacturer	US Web Site	Metal(s) Detected†
Prana-Breath of Life	Ayurherbal Corporation	By the Planet	Lead and/or mercury
AyurRelief, GlucoRite	Balance Ayurvedic Products	Balance Ayurvedic Products	Lead
Mahasudarshan	Banyan Botanicals	The Ayurvedic Institute	Lead
Kanchanar Guggulu, Shilajit	Banyan Botanicals	Banyan Botanicals	Lead
Acnenil, Bakuchi, Brahmi, Chairata, Cold Aid, Trifala Guggulu, Heart Plus, Jatamonsi, Kanta Kari, Licorice, Praval Pisti, Prostate Rejuv, Sugar Fight, Tagar, Yograj Guggulu	Bazaar of India	By the Planet	Lead, mercury, and/or arsenic
Energize	Bazaar of India	Bazaar of India	Lead
Hingwastika	Bazaar of India	Herbal Remedies	Mercury
Lean Plus, Neem Plus	Tattva's Herbs	Tattva's Herbs	Lead

These findings are consistent with those of a previous report, in which 20% of 70 Ayurvedic products made in South Asia and sold in Boston contained higher-than-regulatory amounts of lead, mercury, or arsenic. Scores of clinically symptomatic cases of heavy-metal intoxication due to the ingestion of Ayurvedic drugs have been reported since 1978.

* One web-based supplier of Ayurvedic products refused to fill an order for 14 products after recognizing that the purchasers were authors of a previous study.

† Measurement greater than reporting levels for x-ray fluorescence spectroscopy (ie, lead, ≥5 microg/g; mercury, ≥20 microg/g; arsenic, ≥10 microg/g).

A cautionary note to gray panthers: take it easy on the denture cream. Zinc in the grippy goo may lead to copper deficiency and associated neurologic illness.*

In this week's Neurology, physicians from the University of Texas Southwestern Medical Center report 4 patients with neurologic abnormalities in the setting of copper deficiency (hypocupremia) and high zinc levels (hyperzincemia). All presented with clinical myeloneuropathy, and all demonstrated low levels of serum copper and high levels of serum zinc. 

Neurologic symptoms followed the excessive use of denture cream, 2 or more tubes per week for several years. In samples of Fixodent (P&G) or PolyGrip (GSK) denture cream, the authors found zinc levels that ranged from 17 to 34 mg/g and identified no other plausible source of zinc or reason for copper deficiency.

Moreover, in the 3 patients who discontinued the use of denture cream, serum zinc levels dropped. Copper supplementation normalized copper levels in all 4 patients and was associated with mild clinical improvement in 2 patients.

The neurologic conditions in these patients are believed to be due to zinc-induced copper deficiency. Excess zinc—either unintentionally or intentionally swallowed by the denture-cream user—acts as a functional copper chelator, by upregulating the production of copper-binding metallothionein. (The metallothionein-copper complex is excreted in the feces, thereby causing copper deficiency.)

Removal of zinc from denture creams may be problematic, because the saliva-activated adhesive is generally a calcium-zinc polymer. Replies to e-mail inquiries sent to P&G and GSK, asking for comment on the Neurology case reports, are pending.

* Clinically similar to subacute combined degeneration associated with vitamin B12 deficiency.

Photo: iStockPhoto.

Addendum: In a formulaic-type e-mail, GSK, maker of Poligrip products, writes, "When someone uses Super Poligrip for their dentures, the vast majority of the zinc in the product remains in the adhesive and is not released into the mouth. Absorption through the gums, if any, is minimal. This is because the pH level of saliva [generally weakly acidic to neutral] in the mouth prevents the zinc from being released." GSK adds, "Swallowing small amounts of denture adhesive when used as directed is not harmful," and notes that there are Poligrip products that do not contain zinc.

In a more complete account of last week's "anthrax" science briefing by the FBI, USA Today describes how the incriminating flask of Bacillus anthracis at USAMRIID, RMR-1029, became so genetically distinctive.

RMR-1029 started out as spores from an original Ames strain isolate, which was obtained from a dead Texas calf in 1981. At the US Army's Dugway Proving Ground, 13 production runs were initially conducted with this Ames isolate. Then USAMRIID scientist Bruce Ivins ran another 22 runs, to produce 164 liters of spores in 1997. Later Ivins concentrated the spore collection, called at this time RMR-1029, to 2 flasks in 2001 and then one 1-liter flask in 2004.

Because RMR-1029 had therefore been produced from so many generations of B. anthracis (Paul Keim of Northern Arizona University estimated that one spore colony might represent up to a trillion generations, wrote the paper), subpopulations of spores in the collection harbored distinctive mutations.* Four of these mutations were used by investigators to trace the letter spores back to RMR-1029.

*Strains of B. anthracis are usually highly genetically conserved, because spores in the wild typically remain dormant in the soil for such a long period of time before growth in an infected animal.

Scanning electron micrograph of spores of Ames strain of B. anthracis from CDC/Janice Haney Carr.

Addendum: USA Today, unlike other media outlets, also provided the FBI's list of scientific publications that relate directly to the anthrax investigation.

• Read TD et al. Comparative genome sequencing for discovery of novel polymorphisms in Bacillus anthracis. Science. 2002;296:2028-2033.
• Cummings CA, Relman DA. Genomics and microbiology: microbial forensics—"cross-examing pathogens." Science. 2002;296:1976-1979.
• Read TD et al. The genome sequence of Bacillus anthracis Ames and comparison to closely related bacteria. Nature. 2003;423:81-86.
• Whiteaker JR et al. Quantitative determination of heme for forensic characterization of Bacillus spores using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Anal Chem. 2004;76:2836-2841.
• Easterday WR et al. Specific detection of Bacillus anthracis using the TaqMan mismatch amplification mutation assay. Biotechniques. 2005;38:731-735.
• Beecher DJ. Forensic application of microbiological culture analysis to identify mail intentionally contaminated with Bacillus anthracis spores. Appl Environ Microbiol. 2006;72:5304-5310.
• Van Ert MN et al. Strain-specific single-nucleotide polymorphism assays for the Bacillus anthracis Ames strain. J Clin Microbiol. 2007;45:47-53. (Discussed in a previous post, here.)
• Brewer LN et al. Forensic analysis of bioagents by X-ray and TOF-SIMS hyperspectral imaging. Forensic Sci Int. 2008;179:98-106.

Young and Innocent (1937): a not-terrifically-well-known-but-still-terrific Hitchcock joint, in the style of The 39 Steps.

A constable's daughter (Nova Pilbeam) comes to champion the innocence of a young writer (the nicely coiffed Derrick de Marney) in a starlet's murder. The film version of Westlake Entertainment's DVD could stand some audio and visual restoration, though nothing can be done about a swing band in wince-inducing* black face. Ouch.

* Ha. Watch the movie, and you'll realize that's kind of a double entendre.

Poster image (NB: The Girl Was Young was the US title) from Wikipedia and reproduced under fair-use law.

At last count, the number of Americans who had contracted measles this year was 127. Now add 4 more cases.

This week, the CDC's MMWR reports a total of 131 cases of the highly contagious infection in 15 US states and the District of Columbia from January 1 to July 31 (Table). The overwhelming majority of these cases were imported* (13%) or linked to imported disease (76%). (It is important to note that the number of imported measles cases in the United States has not changed appreciably over the years, but that the number of importation-associated cases accounts for this year's dubious record.) A large percentage (81%) of measles cases were related to 7 outbreaks (≥3 cases). Fifteen individuals, including 4 children younger than 15 months, were hospitalized for disease; however, there have been no deaths—yet. 

Most important, however, is the fact that a whopping 91% of cases occurred in individuals who had not received vaccination or whose vaccination status was unknown. Among these 112 patients, 85% were eligible to receive vaccination, but 66% had declined because of "philosophical or religious beliefs." 

Location	Measles Cases
Illinois	32
New York	27
Washington state	19
Arizona	14
California	14
Wisconsin	7
Hawaii	5
Michigan	4
Arkansas	2
DC	1
Georgia	1
Louisiana	1
Missouri	1
New Mexico	1
Pennsylvania	1
Virginia	1

The MMWR highlights outbreaks in 2 locations, Washington state and Illinois, in which affected children had not been vaccinated on the basis of personal-belief exemptions. A sizable portion of these children were home schooled, which obviates the vaccination requirement for traditional-school enrollment.

In an editorial note, the CDC advises that the current national vaccination rate for measles is adequate to prevent the "sustained spread of measles," but that importation-associated outbreaks are likely to continue as long as there are geographic clusters of unvaccinated individuals. Unfortunately this information will probably be used by parents who forego vaccination to maintain their behavior.

Most affected by the deferral of measles vaccination are immunocompromised children and children younger than 12 months of age, who rely on adequate herd immunity. It appears to be a mere matter of time before a measles outbreak will cause a known, severe complication of the disease, like encephalitis or death, in the United States. Such an event has already occurred in the United Kingdom.

* Genetically or epidemiologically linked to cases in Italy, Switzerland, Belgium, India, Israel, China, Germany, Pakistan, the Philippines, and Russia.

Photo of child with measles rash from the CDC.

While sympathies for anyone with an untreatable and ultimately fatal condition—like Duchenne muscular dystrophy (DMD)—are undeniable, the right for such a person to access an experimental, proprietary therapy is not clear. There's the issue of unproven safety (not to mention efficacy) and the violation of numerous clinical-trial protocols (on which evidence-based medicine rests) that control important variables—like an enrollee's health status, the double-blind process, and randomization of treatment.

Nevertheless, a New Jersey federal judge ruled yesterday that a 16-year-old boy with DMD, Jacob Gunvalson, should have access to PTC124, a drug in clinical-phase development by PTC Therapeutics. According to PTC's web site, a phase 2b trial of the drug is being conducted in ambulatory DMD patients with a nonsense mutation. PTC124 is an orally administered, small molecule that targets this particular mutation type.

It has not been reported if Gunvalson even harbors a DMD nonsense mutation (if not, the use of PTC124 would be, well, nonsense). Also photographs in news reports suggest that the teenager, shown in a wheelchair, is not sufficiently ambulatory at his age to qualify for the PTC trial. Confirmed particulars of the case, expected to be available in the judge's forthcoming written order, should answer these and other issues* that may have implications for anyone seeking access to experimental treatments.

According to the NYT, PTC Therapeutics plans to appeal the decision, and federal regulators must still approve Gunvalson's application to use PTC124.

* For instance, will Gunvalson even be considered an enrollee in the phase 2b trial, should he receive PTC124?

Thanks to insomnia and NBC's late-night/early-morning coverage of the Beijing Olympics, BMX racing now has at least one more fan.

真牛!

Photo of BMX race crash: Carl de Souza/Getty Images.

How and when the potentially fatal contaminant oversulfated chondroitin sulfate wound up in lots of Baxter's Chinese-made heparin remain unknown. The synthetic contaminant, probably introduced at the workshop level, is believed to have caused more the 80 deaths and hundreds of adverse reactions in Americans during the last year. However, the longstanding process of producing heparin from pig intestines—a process susceptible to the introduction of infectious and foreign substances—may be threatened in the long term.

The laboratory production of heparin was reported Monday by Robert Linhardt, PhD, from the Rensselaer Polytechnic Institute at the ongoing meeting of the American Chemical Society in Philadelphia. At a press briefing, Linhardt described investigators' small-scale production of synthetic heparin by using the bacterial strain Escherichia coli K5. The bacteria naturally produces the polysaccharide backbone of heparin, heparosan,* which can be modified by recombinant mammalian enzymes and cofactor recycling to create a substance that is identical to the USP form of heparin.

The chemical production of heparin from E. coli, however, is presently limited to mg quantities (the current world market consumption of heparin is 100 metric tons per year), and Linhardt advises that the next step is to ramp up synthetic heparin production to the kg level during the next 5 years to enable preclinical and clinical study. He anticipates that the biggest hurdles to the large-scale production of heparin will relate to the downstream modifications of the polysaccharide backbone. Peer-reviewed details of the production process will be presented in an upcoming issue of the Journal of the American Chemical Society.

Linhardt admitted to interest from pharma and biotech companies in the production of synthetic heparin but warned that commercial entities are awaiting further development—ostensibly because heparin produced by current methods is so cheap.

* The only other organism, outside of animals, that is known to produce heparosan is the pathogen Pasteurella multocida.

Image of heparin chemical structure from Wikipedia.

HT: MedPage Today 

Yesterday's FBI press briefing on the 2001 "anthrax" letter attacks was intended to rectify a few erroneous pieces of information in press reports and to bolster confidence in the science linking Bruce Ivins to the mailed Bacillus anthracis spores. However, several media outlets (eg, NYT) and Senator Tom Daschle, a target of one of the anthrax letters, continue to express skepticism that the FBI undeniably had its man. Specifically, to highlight the FBI's ineptitude, much is being made of an initial, unusable spore sample that was provided by Ivins to the FBI in 2002 and later destroyed by the agency.*

In an opening statement at the press briefing, Vahid Majidi, PhD, Assistant Director of the FBI's Weapons of Mass Destruction Directorate, clarified that the mailed spores had not been "weaponized" with silicon—contrary to numerous, previous reports. Specifically Joseph Michael, PhD, at the Sandia National Laboratories (who was present at the briefing), concluded that silicon had been naturally incorporated into the spores after examining them with transmission electron microscopy. Majidi also further outlined the genetic investigation that led to the RMR-1029 flask of B. anthracis at USAMRIID (as graphically presented in a recent post).

An initial, preliminary analysis of the letter spores at the CDC revealed a mixture of several phenotypes. This discovery led to the extraction of DNA from these phenotypic variants at Northern Arizona University and full sequencing of the DNA samples at The Institute for Genomic Research (TIGR). Majidi further advised that additional scientific information would be available in peer-reviewed publications and asked the audience to "respect the integrity of this process." He also acknowledged the FBI's inability to quell all suspicions related to the FBI's case against Ivins and added, "There's always going to be a spore on a grassy knoll," wrote the NYT.

Other panel scientists at the briefing included FBI Laboratory Director Chris Hassell, PhD; Paul Keim, PhD (Northern Arizona University); James Burans, PhD (National BioForensic Analysis Center); Rita Colwell, PhD (University of Maryland; Johns Hopkins Bloomberg School of Public Health), Claire Fraser-Liggett, PhD (University of Maryland); and Jacques Ravel, PhD (University of Maryland).

Meanwhile, Slate blogger Glenn Greenwald—evidently forsaking all other evidence—believes the FBI's case against Ivins is completely undermined by the agency's inability to pinpoint exactly when Ivins drove from USAMRIID in Fort Detrick, Maryland, to Princeton, NJ (160 miles), on 2 occasions to mail the anthrax letters postmarked 9/18 and 10/9 of 2001.

* However, Paul Keim's lab at Northern Arizona University reportedly kept a sample of these spores for later analysis.

Additional source: ScienceNOW Daily News.

Scanning electron micrograph of spores of Ames strain of B. anthracis from CDC/Janice Haney Carr.

The percentage of childless American women aged 40-44 years doubled during the last 30 years—from 10% to 20%—according to 2006 survey data released yesterday by the US Census Bureau. The survey also revealed that women of this age group had an average of 1.9 children, which is below "replacement level," and 13.5% had never married.

Childless women were more likely to be 40-something non-Hispanic whites (22.5%), be native born (21.4%), and have a graduate or professional degree (27.4%).

Not sure what any of this has to do with the price of tea in China—other than 1) it might provide you're-not-alone solace to 40-something childless women and 2) it might signal the time to learn Mandarin or Spanish.

Despite the discovery in 1993 of the altered gene that causes Huntington's disease (HD), treatment for this dismal illness remains purely symptomatic and supportive. In the United States, medical therapy for HD chorea has been limited to traditional dopamine-receptor-blocking neuroleptics; however, these medications are associated with a high incidence of extrapyramidal side effects (eg, Parkinsonism) and irreversible tardive dyskinesia.

On Friday, the FDA approved tetrabenazine (Xenazine; Prestwick Pharmaceuticals), a well-known dopamine-depleting agent, for the treatment of HD chorea. The drug, which was granted "orphan drug status," is the first medication approved in the United States for the movement disorder; although tetrabenazine has been in use for HD chorea in Canada, Europe, and other parts of the world. The agent, which probably has limited dopamine-receptor-blocking properties at therapeutic dosages, has not been associated with the development of tardive dyskinesia.

Tetrabenazine was approved for HD chorea on the basis of a multicenter, prospective, double-blind, placebo-controlled study of ambulatory patients with HD (N = 84). Randomly assigned tetrabenazine* was associated with a 3.5-unit relative reduction of the chorea score (Unified HD Rating Scale) at 12 weeks. Five tetrabenazine-treated patients withdrew from the study, and 5 serious adverse events—drowning suicide, complicated fall, restlessness/suicidal ideation, and breast cancer—were reported with treatment. Nevertheless, another controlled study (industry sponsored) and open-label studies support the drug's use in HD.

With the approval of tetrabenazine, the FDA requires a company-supplied Risk Evaluation and Mitigation Strategy (REMS) to manage any serious risks associated with the drug.

* Titrated up to a maximum of dosage of 100 mg/d.

Public-domain photo of American folk legend Woody Guthrie, who died of complications due to HD in 1967.

Affecting a w-for-r accent,* Sir Alec Guinness is an unassuming banker who attempts a bullion heist in The Lavender Hill Mob. The movie climaxes in (or degenerates into, depending on your viewpoint) a farcical police chase. Oh, cwazy English bobbies wunning awound! How dwoll!

P.S. Don't blink or you'll miss Audwey Hepbuwn.

* Or is that just Alec Guinness?

The techniques used to trace the Bacillus anthracis spores from the 2001 "anthrax" letter attacks to the USAMRIID laboratory at Fort Detrick, Maryland, weren't particularly novel, according to a report in this week's Science. By using documents released by the DoJ last week and expert speculation, writer Martin Enserink proposes the series of events that led to the source of the B. anthracis (Ames strain) that killed 5 people.

The first major task was to genetically distinguish the letter spores on the basis of phenotypic differences in cultured bacterial subpopulations, if at all possible.

The second task was to match the letter spore makeup to known, available Ames strain samples.

The FBI likely identified the USAMRIID lab as the source of the letter spores given that it was the only lab within the area where the "federal eagle" envelopes used in the attacks were distributed and sold. Although this very sound conclusion does not completely rule out the possibility that the spores came from another lab, it is the confluence of evidence (including Ivins's alleged submission of sabotaged or false B. anthracis samples to the FBI) that indicts the former USAMRIID scientist.

SNPs = single nucleotide polymorphisms.

* Sequencing work was likely performed by scientists at Northern Arizona University and The Institute for Genomic Research (TIGR) in Rockville, Maryland.

08/18/08 update: According to ABC News, 8 of the positive samples originated from 2 US labs. One is presumed to be USAMRIID, and the other is not named. The original (2002), "usuable" sample of B. anthracis provided by Bruce Ivins to the FBI—a portion of which was retained by Paul Keim at Northern Arizona University—later tested positive for the 4 "letter" mutations.

The use of cardiac death (as opposed to brain death) to obtain organs for transplantation has been accepted practice for more than a decade in the United States.* According to various protocols, cardiac death in the context of organ harvesting is defined as asystole for 2 or more minutes after the withdrawal of life support. The criterion is based on the fact that autoresuscitation has not been observed after 65 seconds of asystole. However, a logical problem arises when considering the transplantation of a heart after cardiac death.

As ethicist Robert Veatch writes in this week's NEJM, it should be impossible to transplant a heart after the irreversible cessation of cardiac function. If the heart can be restarted in the graft recipient, then the donor could not have been dead in the first place on the basis of cardiac death. Moreover, the very act of removing the "restartable" heart from the donor is equivalent to killing the donor by means of organ removal. Veatch concludes that it is therefore impossible to legally harvest a heart in the setting of cardiac death and proposes 2 ways by which the paradox can be resolved.

One is to alter laws to permit heart removal from living donors. In such cases, however, strict scenarios—such as terminal illness or previous consent—would have to be explicitly defined. The other is to redefine brain death as the loss of higher cortical function (ie, consciousness), which may have popular support. Until then, Veatch argues, "[A]ny successfully transplanted heart cannot have come from a person who was declared dead on the basis of irreversible stoppage of the heart."

Veatch's editorial appears in the same NEJM issue in which Denver physicians report their experience with cardiac transplantation in 3 infant recipients following cardiac death in pediatric donors.

* Although the management of end-of-life care, especially if left to transplant surgeons, can go horribly wrong—for example, as in the case of Ruben Navarro.

Update: Further debate on the controversy of heart donation after cardiac death, particularly in the case of infants, was explored by The Washington Post. Veatch further defined the procedure as "homocide," according to the paper, but a Denver cardiologist involved in the pediatric transplantations called Veatch's assertions "fussy semantics." 

Asked on behalf of mothers everywhere, given Michael Phelps's crazy calorie consumption.

HT: NY Post by way of the WSJ Health Blog and every other conceivable media outlet.

Taking a break from identifying the women they love, the editors at Esquire have decided that the magazine's September cover will feature an animated, black-and-white electronic image—evoking the moving pictures in Harry Potter's newspaper, The Daily Prophet. But some say the distinctive cover, made possible by E-ink,* is a misguided gimmick.

* Which is used in Amazon's Kindle.

The stereotypical expressions of pride and shame after athletic competition are probably biologically hardwired, say behavioral researchers. Their conclusion, published in the latest issue of PNAS, is based on an assessment of physical displays among sighted, blind, or congenitally blind athletes who just won or lost judo matches at the Olympic or Paralympic Games in 2004.

The investigators found that both sighted and blind athletes from a wide range of cultures consistently showed the prototypical pride display after winning—back head-tilt, smile, arms out or raised, hands in fists, chest expanded, torso pushed out—and shame-consistent behaviors after losing—chest narrowed, shoulders slumped. These data suggest that spontaneous pride and shame behaviors are unlikely to be culturally determined, given their consistent presence in athletes from different nations and in congenitally blind competitors who cannot model their behavior on visual cues.

One curious note, however, is the observation of a weaker shame display among sighted athletes from Western European or North American countries. The authors conjecture that characteristic shame behaviors are suppressed in these individuals "in accordance with cultural norms that stigmatize the display of shame and emphasize asserting oneself and maintaining a high quality of life."

The observed pride display in humans is similar to that of other victorious primates (eg, a chimpanzee who has defeated a rival) and may be evolutionarily advantageous by increasing one's apparent physical size. Conversely a shame display, by conveying the acceptance of another's superiority, averts energy-consuming and potentially injurious conflict.

For numerous examples of the universal pride display, just visit the NYT's Winner's Spotlight for the 2008 Summer Olympics.

HT: NPR

Photo of Man Zhong winning the gold medal at the 2008 Summer Olympics: Daniel Dal Zennaro/European Pressphoto Agency.