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A peculiar kind of living agony must be had by those who are diagnosed with psyche-robbing disorders, like Alzheimer's disease, while they remain aware that they're being robbed of whatever makes them them. A recent case in point is that of Pat Summitt, legendary coach of the UT women's basketball team, who was recently diagnosed with early-onset AD.In this Washington Post clip (along with a funny and moving write-up by the coach's friend and the coauthor of Summitt's 1999 autobiography), there are subtle, but definite, halts in Summitt's speech that hint at her early, mental disability—which troubled family (primarily her incredibly stalwart son), friends, and UT colleagues early on and ultimately brought Summitt to the attention of physicians at the Mayo Clinic—where she received her diagnosis 3 months ago.
Photo of Summitt on one of many of her days of basketball victory; from the UT website.
What the JH authors* are receiving implied credit for, though, in online posts and forums (see here, for example) is a compelling proposal that a sagittal view of the brain, complete with brainstem and vertebral artery, surrounds God in the Creation of Adam (above). But that argument was originally made (and the JH authors did acknowledge this in their 2010 Neurosurgery article) by Meshberger way back in 1990 (An interpretation of Michelangelo's Creation of Adam based on neuroanatomy. JAMA. 1990;264:1837-1841). What the JH authors proposed last year, riffing on the hidden-anatomy-in-Michelangelo's-painting theme, was a much more complex, ventral view of the brainstem in God's neck in The Separation of Light From Darkness (below). It's a less compelling argument, IMO, but one that remains plausible. Even less convincing, however, was their proposal that the artist embedded an image of the optic nerves in God's robe (read the free article to make your own judgment).
A popular, diverting hobby seems to be the hunt for hidden anatomic elements in Michelangelo's Sistine Chapel works (which is somewhat more highbrow than the hunt for horsies in clouds...but just somewhat). Eknoyan, a nephrologist at Baylor, argued in 2000 that the artist, who suffered with renal stones, surrounded God with a big kidney (not a brain) in the panel Separating Light From Darkness. (It may well be that God's environment is dependent on the medical specialty of the viewer.) And two Brazilian physicians, Barreto and Oliveira, have written an entire book (but in Portuguese) on hidden anatomy in Michelangelo''s work.* One of whom has a joint appointment in the Department of Neurosurgery and the Department of Art as Applied to Medicine. (There's a department for that?)
It is difficult, if not impossible, to focus on any blog-relevant news in the wake of the death of Osama bin Laden, who died simply of this: a gunshot wound to the head delivered by a US military operative. The mastermind, or really inspirator, of the 9/11 attacks was 54.
05/02/11 addendum: The Great Beyond blog explains "How DNA may have confirmed bin Laden's death." At least one expert guesses that the US government had already sequenced some of UBL's surreptiously confiscated DNA for a quick postmortem comparison.
No. 9: Sports-Related Concussions—No More Walking It Off
Despite the fact that neurologist Ira Casson, former co-chairman of the NFL's panel on brain injury, essentially denied a relationship between repeated head injury and lasting brain damage in January,* the prevailing zeitgeist 11 months later is this: That sports-related concussions should be taken very seriously, and that safeguards should be in place to allow for recovery—at all levels of play.
Casson's functional denial was based on the fact that scientific data are limited on the subject, but that deficiency is being answered by clinical and pathologic studies from, among others, investigators at the Center for the Study of Chronic Traumatic Encephalopathy (CTE)—the raison d'etre of which is to examine the very issue of CTE in sports and, by extension, to be an advocate for athletes who put themselves at risk of acute or chronic brain injury.
The Center's latest, and perhaps most controversial, proposal is that the CTE associated with collision sports increases the risk of motor neuron disease (aka ALS, aka Lou Gehrig's disease). Ongoing data from others, which were highlighted in a recent, dedicated issue of Sports Illustrated, suggest that the risk of lasting brain injury is not confined to concussed players, but that functional damage can be demonstrated in completely asymptomatic jocks who've sustained nonconcussive head blows.
Of course, the study of sports-related head injury is nothing new—despite the rising sensitivity to its potentially lasting consequences among NFL officials specifically and the general public, well, generally. A PubMed search with the terms "concussion" and "football" produces 273 English-language articles, dating back to 1970 (when Brett Favre was just a wee babe!). About three quarters of these articles were published within the last 10 years.
A historic gem from 1983 ("Concussion incidences and severity in secondary school varsity football players") provides the results of a survey of more than 3000 high school football players in Minnesota, circa 1977. In the age of overtly endorsed disco and surreptitiously endorsed butt-blocking and face-tackling, the concussion rate was 19%, and nearly 70% of affected athletes returned to play the same day. A prior history of concussion was found to increase the risk of subsequent concussion 4-fold. As a result of head trauma, 6 high schoolers sustained permanent disability, ranging from "extensive" brain dysfunction to quadriplegia to death.
* In front of a House Judiciary Committee, no less.
The rising interest in brain injury among American football players has spilled over into Sports Illustrated. In the November 1 issue, out today, writer David Epstein profiles a complex study conducted by Purdue researchers, who fitted 11 Indiana highschoolers' helmets with impact sensors. Using the NFL-endorsed ImPACT neurocognitive test and fMRI, the researchers determined, to their surprise, that repetitive nonconcussive* head blows are not without consequence. The visual memory scores of some players who sustained these types of hits,** usually frontal and often exceeding 100 Gs, dropped significantly and appeared to correlate with changes in fMRI brain activity (in the dorsolateral prefrontal cortex).
The disturbing finding: On the sidelines and off the field, these players were clinically asymptomatic, at least by crude measures. They could carry on conversations, did not demonstrate memory impairment, and appeared to be fine by their parents' observations.
The reassuring finding: These players' ImPACT scores returned to baseline off-season.
The remaining uncertainty: No one really knows what the long-term toll of repetitive, nonconcussive, frontal head blows is, season after season. The Purdue researchers hope to follow up their subjects throughout their high school athletic careers and perhaps into college.
In addition to SI coverage, the Purdue study was published in the peer-reviewed Journal of Neurotrauma last month.
fMRI = functional MRI.
* Meaning, not impairing consciousness.
** Frontal head blows can be distinguished from the brainstem-torquing side blows associated with concussion.
From the whimsically mundane (crystallized soy sauce) to the obligatory (Drosophila compound eye) to the just plain weird (I'm still trying to figure out the mosquito heart), scientists from the big Earth coned down on animals, vegetables, and minerals with light microscopes in Nikon's Small World Photomicrography Contest.
My favorite from this year's recognized pics: trazodone, alpha-estradiol 7256a (100X under polarized light) as a tiny Godzilla. The "Image of Distinction" is from Dutchman Lars Bech, who's evidently been photographing pharmaceutical products on a microscopic scale since at least the mid-1990s. Bech won the contest in 1996 with his museum-worthy abstraction of doxorubicin.
The deadline for next year's entries: April 30, 2011.
First: Donald Trump is "dealing with" Bret Michaels's absence from "The Apprentice" reality show.
[Pause for universal brow mop.]
Second: The latest on the Poison singer is that he's suffered a "minor setback" while hospitalized with a subarachnoid hemorrhage (SAH). The 47-year-old Michaels reportedly has a "lack of sodium," or hyponatremia, reports the BBC News. The cause of Michaels's SAH, which occurred almost 1 week ago, is evidently still unknown.*
Hyponatremia occurs in 10%-30% of patients with SAH, according to the latest AHA guidelines on the management of the condition, and is more common in patients with a poor clinical status or hydrocephalus. The condition appears to be related to the inappropriate urinary excretion of sodium. The major concern with hyponatremia in SAH is that it is associated with reduced intravascular volume, which is linked to cerebral vasospasm (see below).
To reduce the risk of hyponatremia in SAH, the guidelines recommend that large volumes of hypotonic fluids and volume contraction should be avoided. Intensive-care monitoring of the circulatory volume is also advised. When hyponatremia occurs, the administration of hypertonic saline and fludrocortisone (Florinef) is "reasonable" to achieve euvolemia.
Other issues to concern Michaels's treating doctors are cerebral vasospasm and rebleeding—both major contributors to SAH-associated death.
Cerebral vasospasm, seen in 30%-70% of patients with SAH, typically occurs 3-5 days after the initial bleed and gradually resolves during the next 2-4 weeks. The calcium-channel blocker nimodipine (Nimotop; Bayer) has been shown to reduce the risk of poor outcomes associated with post-SAH vasospasm.
Efforts to reduce the risk of rebleeding in SAH include bed rest and the control of circulatory volume and blood pressure to some sort of equilibrium that avoids both hypertension and volume contraction. There are data suggesting that the risk of rebleeding is reduced with an early, short course of antifibrinolytic therapy (Amicar).
Among survivors of SAH, persistent deficits—including cognitive impairment—are common. The 3 strongest predictors of death or disability are impaired consciousness on admission, advancing age, and a large bleed.
AHA = American Heart Association.
* In about 75% of cases, subarachnoid bleeding is caused by a ruptured (eg, berry) cerebral aneurysm; and in about 20% of cases, there is not an identifiable cause. According to a 2006 review, a substantial percentage of the cases with an unidentified bleeding source are defined as idiopathic in nature. The remainder, 5%, are caused by vascular malformations, arterial dissection, sympathomimetic drugs (eg, cocaine, phenylpropanolamine), tumors, or vasculitis. Notably diabetes, which Michaels reportedly has, does not increase the risk of SAH.
From Wikipedia: Horizontal cut of CT image showing hyperdense subarachnoid blood in the basal cistern. To my knowledge, this is not Bret Michaels's scan.
05/06/10 addendum: Although today's FOXNews story of Bret Michaels's release from the hospital makes it sound like the rocker was discharged to home, Michaels was actually released to a physical rehab facility, according to USA Today. The latter story makes a whole lot more sense.
Michaels SAH occurred almost 2 weeks ago, and other than the report of hyponatremia, he did not suffer any of the usual SAH-related complications—like cerebral vasospasm or rebleeding. The cause of Michaels's SAH was evidently never identified, and he apparently has not experienced any significant neurologic deficits. In the setting of being really unlucky, Michaels is a very, very lucky guy. So is Donald Trump, who must be peeing himself, given the possibility that Michaels may rejoin "The Apprentice."
Forever brainstorming, Google is now helping Americans find a flu shot (either against seasonal or pandemic influenza) through the company's beloved Maps feature. The new tool (found here) is the product of a collaboration between Google and the US DHSS, the CDC (flu.gov), and the American Lung Assocation.
For example, here's where residents of the White House can possibly get a seasonal (blue) or pandemic (red) flu shot. (To the left of the map would be a list of the locations, ordered by proximity to the entered address and labeled "A" through whatever.)
Keep in mind that the Goggle tool is in its beta stages: locations for many flu shot clinics may be missing, the company advises, and locations currently listed may be out of stock. Nevertheless, it's a starting point for consumers.
For more information about the tool's development, go here.
HT: Mashable by way of attentionusa.com.
NBA legend Kareem Abdul-Jabbar, 62, has Philadelphia-chromosome-positive (Ph+) chronic myeloid leukemia (CML), according to numerous news sources. ABC News reports that Abdul-Jabbar was diagnosed with the disorder in December of last year. What treatment Jabbar has received to date is unclear; although the LA Times states that the disease is managed with "daily oral medication" (probably imatinib [Gleevec; Novartis]) and regular "blood analysis."
Here are some facts about CML and its treatment, according to the NCCN Clinical Practice Guidelines:
- CML accounts for 15% of adult leukemias. This year, an estimated 5050 cases will be diagnosed, and 470 will die of the disease.
- The median age of onset is 67 years.
- The disease is characterized by a translocation between chromosomes 9 and 22, resulting in the formation of the Philadelphia chromosome. The translocation results in a fusion gene, BCR-ABL, which is believed to play an important role in the development of CML. The fusion protein produced by BCR-ABL is an oncogene, with unregulated tyrosine-kinase (TK) activity.
- CML occurs in 3 phases: chronic, accelerated, and blast. CML is usually diagnosed in the chronic phase.
- Untreated CML will progress to advanced disease in 3-5 years.
- First-line treatment for chronic Ph+ CML is imatinib, a selective inhibitor of the TK portion of the bcr-abl fusion protein.
- Responses to the initial treatment of CML are monitored periodically (eg, every 3 months), by assessing bone marrow cytogenetics (ie, cytogenic response [CyR]) and transcript numbers of the BCR-ABL gene (ie, molecular response).
- Long-term data (median follow-up, 60 months) for first-line imatinib: complete CyR, 87%; overall survival, 89%.
- The most common high-grade toxicities with imatinib: neutropenia and thrombocytopenia. Rare cardiotoxicity has been reported with long-term therapy.
- The most common adverse events with imatinib: GI disturbances, edema, rash, and musculoskeletal complaints.
- Management of disease progression that occurs during imatinib therapy may include increasing the imatinib dosage; the use of an alternative TK inhibitor (dasatinib [Sprycel; BMS] or nilotinib [Tasigna; Novartis]); hematopoietic stem cell transplantation (HSCT), or enrollment in a clinical trial. Traditional chemotherapy regimens may also be considered for blast crisis.
The NCCN guidelines conclude, "The development of imatinib...has revolutionized the treatment of CML." Before the advent of imatinib, CML was treated medically with interferon alpha and low-dose cytarabine. According to ABC, Abdul-Jabbar is a spokesperson for Novartis, the manufacturer of imatinib.
The FDA approved imatinib for the first-line treatment of CML in December 2002.
NCCN = National Comprehensive Cancer Network.
Image of Abdul-Jabbar in 2007 from Flickr.
Like white on rice, rational bloggers have been all over Bill Maher's goofy ideas about vaccines and vaccination. It's too bad, though, that the man has a nationally televised show, HBO's "Real Time With Bill Maher," which affords Maher an opportunity to influence potentially gullible viewers in front of (like many a talk/variety/comedy show) an audibly fawning studio audience.
Nevertheless, begrudging props may be given to Maher for inviting retired Republican Senator and physician Bill Frist on Friday to discuss vaccination. In this segment, it's not entirely clear that Maher "gets schooled" by Frist about vaccines (despite the clip's title). Schooling requires that Maher's thick skull be penetrable. And schooling requires time—much more time than television typically allows.
But a blog provides an enduring, leisurely format for dissecting and refuting some of the utterly fallible anti-vaccine statements that Maher made on Friday and that Frist didn't have the chance to challenge.
Maher comment #1: Conservatives always say, about healthcare especially: You gonna let the government run healthcare? They screw everything up. So why would you let them stick a disease into your arm? I would never get a swine flu vaccine or any vaccine. I don't trust the government, especially with my health. [Applause.] And that seems to be a conservative opinion: not to trust the government.
Dissection: The usually liberal Maher tries to create a bit of oh-gosh irony here by aligning himself with traditionally government-distrusting conservatives. He then jumps to make a very broad and loose association between government incompetence and government-recommended vaccination. However, if Maher were familiar with the monumental benefits of historical vaccination programs (eg, against smallpox and polio), the association actually supports organized intervention into healthcare (whether instigated by a government or some other authoritative entity, like the World Health Organization).
At the same time, Maher indicates that vaccination is a process whereby "disease" is injected into the body. First "disease" is a clinical manifestation of bodily dysfunction; it is not something that can be confined in a syringe. But we sort of know what Maher's means here, so we'll give him a pass on this semantic point. What Maher is really implying is that disease-causing virus is injected during vaccination. But that idea is also false.
With respect to the injected 2009 H1N1 (swine flu) vaccine, the inoculant is a killed (actually chemically "split") virus—which is incapable of causing infection (but is capable of inducing protective immunity). The nasal-spray vaccine from MedImmune contains live, attenuated H1N1 virus. The attenuated virus is engineered (ie, cold adapted and temperature sensitive) so that it can replicate in the cooler confines of the nose to induce immunity, without causing influenza-like illness.
Maher indicates that he would never get the swine flu vaccine, which is fine (assuming that Maher isn't at baseline risk for influenza complications and doesn't care for an infant younger than 6 months of age*). The 53-year-old isn't a CDC-recommended candidate for the 2009 H1N1 vaccine (although he should get a seasonal flu shot).
Maher comment #2 (in response to a Frist anecdote about a patient dying of swine flu): I cannot believe that a perfectly healthy person died of swine flu. That person was not perfectly healthy. Medical—Western medicine misses a lot.
Dissection: Maher's just flat-out wrong here. Regardless of what he believes, serious H1N1-related disease preferentially affects persons younger than 65 years of age, and about 45% of Americans who have died of swine flu were healthy, according to the CDC. With his last sentence, Maher also betrays a broad, inherent distrust of Western (really, allopathic) medicine.
Maher comment #3: Let me read you a quote from the former control officer at the US FDA. His name is Dr. J. Anthony Morris. He said, "There is no evidence that any influenza vaccine thus far developed is effective in preventing or mitigating any attack of influenza. The producers of these vaccines know they are worthless, but they go on selling them anyway."
Dissection: By quoting J. Anthony Morris, Maher reveals a lazy reliance on an ostensibly authoritative source, about which he probably knows nothing.
Finding reliable information on Morris (at least on the web) is a challenge; at first blush, he appears to be a quotable favorite among anti-vaccinationists—probably because of the specious appeal-to-authority angle (ie, Morris reportedly has/had a PhD in bacteriology and was an FDA employee). An archived newspaper search reveals that Morris was a virologist in the Division of Biologic Standards, which was part of the NIH until 1972 when the division was transferred to the FDA.
In the fall of 1971, Morris made news by arguing to Congress that influenza vaccines were not just useless, but dangerous (see Lyons RD. Influenza shots held ineffective. NYT. October 15, 1971). He claimed that "not only has there been little or no benefit from the use of influenza vaccine in man, but harm has resulted." However, a federally appointed, 12-person scientific committee rejected Morris's claims of incompetence within his NIH division; although the committee did concede, in ho-hum fashion, that "inactivated influenza vaccines are imperfect instruments for the prevention of influenza." (The committee may have been referring to subpotent lots of influenza vaccine that were distributed in the 1960s.) The committee then proceeded to reject Morris's claims that influenza vaccines are harmful (see Lyons RD. Charges of poor vaccine regulation rejected. NYT. November 30, 1971).
A related news story in June 1972 indicates that Morris had been demoted within his division, which was now (presumably) a part of the FDA. But later news reports indicate that Morris was appointed director of the Slow and Temperate Virus Branch of the agency.
In July 1976, Morris, then 57, was finally fired from the FDA for "insubordination" and "inefficiency." Morris claimed that he was sacked from his $35,000-a-year job because he opposed President Ford's swine flu vaccination program. FDA officials acknowledged, at the time, that it was very unusual for an FDA employee to be fired, but the process that led to Morris's departure began long before anybody recognized the swine flu threat. Later Morris showed up on fear-mongering talk shows like "Phil Donahue" and provided anti-vaccine quotes to news reporters as recently as 1988.
A phrase search of various archived newspapers fails to return a source for the exact quote cited by Maher, except in 1 instance: Donald Harte, in a November 2007 editorial for the Marin Independent Journal ("Is there a vaccine that protects against non-science?") requotes Morris from a citation in a contemporary issue of Health & Fitness magazine. The quote was described as being 30 years old, but the original source was not identified.
Morris, if alive this year (and I haven't been able to confirm whether he's alive or dead), would be about 90.
Maher comment #4: But a virus is always mutating. You would agree with that? [Frist: Yeah.] So, so the vaccine that they produce back in March—that's not really what's gonna prevent what's, what's going on now. Because—I know a lot of people on the conservative side don't believe in evolution—but—and you can't see evolution in advanced species, but you can see—[Frist interrupts: We know this vaccine is 98% effective...]
Dissection: Here Maher tries to discount the efficacy of the swine flu vaccine by implying that the virus has mutated so much since the creation of the vaccine (in March) that it will evade whatever immunity is produced by inoculation. However, on October 9 (the same day that Maher's show aired), the CDC reported that the 2009 H1N1 viruses "have not undergone substantial antigenic change since they were first characterized in April 2009 and should be well-matched to the monovalent vaccine strain."
Last month, data published in the NEJM indicated that significant antibody titers were generated in 97% of adults after 1 dose of the inactivated vaccine. Rates of antibody production among children aged 6-35 months, 3-9 years, and 10-17 years were 25%, 36%, and 76%, respectively. These data are the foundation for recommending 2 vaccine doses in children younger than 10 years of age. The suboptimal immune response in younger children is probably related to their limited immune experience with influenza viruses and is clearly not the result of viral mutation.
There have been scattered reports of 2009 H1N1 virus that is resistant to oseltamivir (Tamiflu), but all of these isolates were susceptible to zanamivir (Relenza).
Maher comment #5: Dr. Jonas Salk: "Live virus vaccines against influenza and paralytic polio, for example, may in each instance cause the disease it's intended to prevent."
Dissection: Another appeal to authority by Maher. Salk, as everyone knows, was the creator of the inactivated polio vaccine. The quote cannot be confirmed and, again, appears to be a favorite among online anti-vaccinationists. An archived newspaper search fails to return relevant hits, and without context, it's useless to interpret a statement that Salk may or may not have made.
* And don't we all hope that's the case.
