Neuropsychiatry: January 2009 Archives

In yet another news story about autism and its therapy, Jane Brody of the NYT reports on the anecdotal use of a slew of unproven and potentially risky alternative therapies for the severely autistic son of a lawyer couple. Their train of interventions over the years included several dietary changes, a truckload of supplements, glutathione cream, chelation, and hyperbaric oxygen treatments.* With reference to the last invention, Brody writes about the couple's perception of its efficacy for their son.

Only well into the article does Brody allude to the unproven nature of these interventions, by introducing Dr. Michael Fitzpatrick, a general practitioner in London who also has an autistic son. Fitzpatrick is the author of MMR and Autism and the recently published Defeating Autism: A Damaging Delusion. Brody quotes Fitzpatrick, when he likens the use of alternative therapies for autism as a return to "medicine's dark ages."

And in the last 4 paragraphs of her article, Brody finally (finally) describes the use behavioral therapy for autism, a scientifically validated (but labor-intensive) approach to improve an autistic child's communication skills. Brody would have performed a greater journalistic service by describing this intervention and highlighting its benefits from the get-go.

* At least Brody didn't imply any relation between autism and the boy's vaccination status.

For patients with idiopathic Parkinson disease (PD), deep-brain stimulation (DBS) may be the best thing since levodopa, but the procedure is relatively risky.

In the latest issue of JAMA, a large, multicenter, randomized, rater-blinded VA study reveals that DBS, when compared with best medical therapy, significantly improved several motor and functional outcome measures* at 6 months, in 255 patients with advanced PD. These efficacy data essentially mirror those of a smaller, randomized study of DBS vs medical therapy in a younger set of PD patients.

However, in the latest study, DBS was more frequently associated with falls, gait disturbance, imbalance, depression, and dystonia than medical therapy, and surgical-site infection and pain were respectively experienced by 10% and 9% of patients who received DBS. These patients were also more likely to experience serious adverse events, most of which related to surgery, the stimulation device, or stimulation therapy. One patient who received DBS died as a result of cerebral hemorrhage. Nevertheless, an important finding of the study is that younger and older (≥70 years of age) patients tolerated DBS equally well.

The procedure, which has become increasingly popular for PD during the last decade, involves the stereotactic placement of stimulation electrodes in the bilateral subthalamic nucleus or globus pallidus internus under local anesthesia. The exact site of electrode implantation is ultimately determined by its intraoperative clinical effect on PD symptoms at the lowest possible level of stimulation. Each electrode is connected to a pulse generator (eg, Medtronic's Kinetra), which is implanted just below the clavicle under general anesthesia. According to Deuschl et al, the standard pulse setting for DBS stimulation in PD is 60 μsec at 130 Hz (C below "middle C"?); voltage settings are individualized per patient.

DBS is intended to modulate activity of the basal-ganglia loop, a complex neuronal circuit that is involved in the genesis of higher cortical behavior—including motor and cognitive tasks. The substantia nigra, which degenerates in PD, activates this circuit. In the case of PD, loss of substantia-nigra input into the basal-ganglia loop results in the overactivity of some cell groups, like those in the subthalamic nucleus or globus pallidus internus. DBS is intended to attenuate this overactivity. (The second phase of the JAMA study will specifically compare the separate effects of DBS on these 2 different subcortical areas.) 

What isn't known is the optimal timing of DBS and its long-term effects, including neuropsychiatric effects. According to Deuschl (in an accompanying JAMA editorial), most patients undergo the procedure more than 10 years after disease onset, when PD is advanced. He anticipates that the use of DBS for PD will increase, as the population ages. Data from 55 medical centers are currently available for more than 5300 PD patients who have undergone DBS.

For more info about DBS and PD, see the web sites for the NINDS and the National Parkinson Foundation.

VA = Veterans Affairs.

* Mean "on" time without troubling dyskinesias (the primary endpoint), motor function, and quality-of-life measures.

Depiction of DBS from the FDA.

Whether you believe that Bruce Ivins perpetrated the 2001 "anthrax letter attacks," one assertion is difficult to refute: The guy was more than just an affable oddball; he was chronically and seriously disturbed.

In yesterday's NYT, Scott Shane profiles the USAMRIID microbiologist, who is alleged to have mailed spores of Bacillus anthracis, the cause of anthrax, in block-letter-addressed envelopes to news organizations and congressmen shortly after 9/11. Shane's profile is not so much an examination of the scientific evidence against Ivins but a character portrait derived from, in part, interviews with family and friends and Ivins's own e-mails.

One notable feature of the NYT piece is the observation that Ivins led a highly compartmentalized life, in which he kept his long-time obsession with sororities in general and Kappa Kappa Gamma in particular from his family. His consuming thoughts about the sorority are germane to a behavioral study of the anthrax-letter perpetrator, because the Princeton, NJ, mailbox, from which all of the letters were posted, is 60 feet from a ΚΚΓ office.

Ivins's obsession materialized most disturbingly and concretely in his fixation on microbiologist and ΚΚΓ member Nancy Haigwood, a fixation that manifested in criminal activity according to Haigwood—namely, the vandalism of personal property and the usurpation of Haigwood's identity in the early 1980s. This information has been previously reported by other news sources (for instance, here). Also, like reporters before him, Shane reveals that Ivins spent an inordinate amount of time posting online about sororities by using the names kingbadger, jimmyflathead, and goldenphoenix.

Notably jimmyflathead's contributions to Wikipedia* include mention of Haigwood as an eminent ΚΚΓ member. Below are excerpts (not mentioned in the NYT article) that contribute to Bruce Ivins's very sad, strange, and enduring legacy:

Eelmonkey, I'm not a member of KKG, but at one time I had a copy of the Book Of Ritual. I'm familiar with their secrets and rituals, but I don't think that the organization would want them revealed. I would respectfully suggest you ask the opinions of some of the Kappas who have posted here. jimmyflathead 19:40, 7 July 2007 (UTC)

Eelmonkey, I also want to add that unless you have a copy of the KKG Cipher (decoder), or you have a decoded copy of the Book of Ritual, simply having the Book of Ritual won't do you any good...unless you got the information from the Fraternitysecrets.com message board which has now been down for quite some time. For example, do you know about the ***** room and *** room services? Do you know the secret names of the chapter officers? Do you know the terms for voting "yes" and "no?" Do you know what the Three Ideals of KKG are and what the Spirit is? Do you know what the ΚΚΓ Greek letters stand for? (It's NOT Key to the Kingdom of God, by the way.) The ritual book without the cipher is useless to you.jimmyflathead 19:19, 8 July 2007 (UTC)

Also, I'd like to see some Kappas put down for their scientific achievments[sic]. It's not my job to do it, but I can think of Dr. Nancy Haigwood and Dr. Gail Williams Wertz immediately as alumae who have distinguished themselves. It would look good, but I'm not about to go create a Wikipedia page for them just so they can be on the Kappa page. I just get tired of seeing lots of TV and moviestars, but scientists get short shrift. jimmyflathead 03:14, 15 August 2007 (UTC)

Last, I created a stub for Nancy Logan Haigwood, but she does not currently meet the criteria of having a wiki page. If we are going to keep her on the list, I think it at least makes sense for a page to be created. I don't know enough to make one - but jimmyflathead

I'm not in favor of removing Dr. Haigwood's name from the list of notable Kappas. I believe that her accomplishments warrant her inclusion and I know for certain that she is not only a KKG member, she was the chapter adviser (University of North Carolina at Chapel Hill) while in graduate school. I don't believe that fame or renown must derive from an individual's GLO membership and, as such, we may barely see a reference to it when describing the chief of neurosurgery at Johns Hopkins, or a Nobel lauriate[sic] in one of the scientific fields. There is certainly sufficient knowledge that the public can obtain (such as college yearbooks and the student newspaper, "The Daily Tarheel," to verify membership. jimmyflathead 00:25, 17 September 2007 (UTC)

* After Haigwood reluctantly struck up an e-mail correspondence with Ivins in 2006 at the behest of the FBI.

N.B. The NYT reveals that Ivins had stolen the KKG ritual book and cipher device during one of his 3 uninvited, post-college visits to a university chapter house. It is not known by me how or if Ivins ever knew Gail Wertz, PhD. Update: According to Wikipedia, there was no known relationship between Wertz and Ivins.

Public domain photograph of Daschle "anthrax" letter from Wikipedia.

Addendum: More about Ivins's activity as jimmyflathead at Wikipedia can be found here. His edits at the online encyclopedia almost exclusively concerned ΚΚΓ and escalated into an editing war, in which Ivins threatened to post derogatory or confidential information about the sorority if his additions were deleted or edited by another contributor. In at least one instance, Ivins attempted to add (and possibly re-add) information about hazing incidents. 

The subject is important vis-a-vis Ivins, because a 1983 letter to the Frederick News-Post, signed by "Nancy L. Haigwood" defended the practice of hazing; however, Haigwood recently claimed to news sources that she never wrote the letter and suspects that Ivins did—several months after he allegedly spray painted "KKG" on property at her Gaithersburg, MD, home.