Thursday, August 31, 2006

Law stuff: SCOTUS prefers vanilla

Dahlia Lithwick at Slate is one of my favorite law-related pundits. Today, she writes on the decline in the number of women selected for super-prestigious short-term gigs as judicial clerks for Supreme Court justices (yesterday, NYT ran a story on the subject by Linda Greenhouse). Snip from Dahlia:
The real problem here, of course, is that there is just no way to measure what makes for "better" clerks. What makes for a good clerk is that her boss likes her. And assuming that they aren't drinking and cite-checking at the same time, most clerks thus do just fine. But evidently some older male judges still feel uncomfortable with young women. Or their wives do. Some just prefer to hang out with those who share their political or ideological views. Many judges have quirky personal preferences (for tennis players or history buffs). Others just don't think there's any benefit to diversity in their chambers. And so, not unlike the guys at the Sigma Chi house, some judges just go with their instinct, and in some cases that means their choices are overwhelmingly male. That has little to do with personal politics, by the way. If Clarence Thomas has one of the court's best records for diverse hiring, liberal icon William Brennan had one of the worst.

As usual, Dahlia's got it right. As a former (non-SCOTUS) clerk, I know that there are loads of qualified candidates for every spot, so a judge has the luxury of making a hire based on a hunch that the candidate will be a good "fit," a person the judge will feel comfortable with. So why don't some of the justices feel comfortable working with women (or other people who aren't white men)?

In the news: Medical practices organized around faith

WaPo has a piece about the growing number of medical practices that provide care according to the faiths of the practitioners. Mostly, this plays out in the context of family planning. Snip:
[The practices] tailor the care they provide to the religious beliefs of their doctors, shunning birth-control and morning-after pills, IUDs and other contraceptive devices, sterilizations, and abortions, as well as in vitro fertilization. Instead, doctors offer "natural family planning" -- teaching couples to monitor a woman's temperature and other bodily signals to time intercourse.

Proponents say the practices allow doctors to avoid conflicts with patients who want services the practitioners find objectionable, as well as to provide care that conforms with many patients' own values. The approach, they say, provides an alternative to mainstream medicine's reliance on drugs and devices that, they argue, carry side effects and negatively affect couples' relationships. 'I want to practice my faith,' said John T. Bruchalski, the obstetrician-gynecologist who started Tepeyac. 'I'm not interested in pushing it on other people. But this allows me to practice medicine without having to do something that I wouldn't see as positive or healthy.'

Critics, however, worry that the practices are segregating medicine along religious lines and may be providing inadequate care by failing to fully inform patients about their options. The critics are especially alarmed about the consequences in poor or rural areas with few alternatives.

Hypothetically, if a patient knew exactly what she was forgoing by going to one of these practices, then fine, I guess. But is it possible to get a patient's informed consent in advance to all of the choices the doctor has already made about what is appropriate for that patient?

Wednesday, August 30, 2006

Shout out: BrainTalk progress?

I was a frequent visitor to the BrainTalk MS forum, and its recent server outage has been frustrating. For a couple months, the only sign of life has been an ASCII message promising to have the server up as soon as possible. Now, there are signs that BrainTalk may be on the mend:
UPDATE 08.24.06 It has taken me much longer than expected to at least get the front page here and chatrooms running. I ran into the need to update the operating system, which caused more problems (the OS is broken to the point where I cannot run incremental updates). I'm waiting for the latest full version of OSX Server on CDs so I can do a full wipe of the drives and reinstall everything from scratch. Disks should arrive in the mail on Sept 5th the latest. Once that's here, I'll install the newest version of vBulletin and recover as much of the data from backups as I possibly can. I'm so sorry the system has been down for as long as it has. Every step forward I've taken to try and restore things seems to knock me 2 steps back, plus I have been travelling for work a great deal the past month. But I think I see the light at the end of the tunnel. Thanks for hanging in there. To get to the BrainTalk chatrooms, please visit:

My recollection is that BrainTalk was run on a shoestring budget funded by donations from users. When the forums come back, I think I'll make a contribution; I've missed them, and maybe more money will help keep the lights on.

Tuesday, August 29, 2006

In the news: Cooling products, better late than never

Just in time for the dog days of, um, autumn, WaPo brings us a comparison of several products intended to keep the body cool. Doesn't sound like any of these products is a slam-dunk solution, but I might look into the evaporative-cool vest, though not as a part of the Village People ensemble pictured here.

Something like the vest might have come in handy this past Sunday. I went for a paddle with my dad and my brother on a crisp, cloudless day, and got warm enough that by the end up the trip I was partially discombobulated, wobbly, and ready for bed. Snip:
We pulled the canvas-colored vest ($34.99, on sale from $69) out of its bag and couldn't figure up from down. The hook-and-loop straps took a little untangling (and still we didn't know which way was inside out). It looked like it might inflate into a raft; instead, it expanded into something a nattily attired highway flagman might wear.

After soaking the garment in cold water (the greedy polymers in the lining lapped it up), we strapped it on. It felt cool but not wet; the added pound of weight was hardly noticeable. The cool effect lasted more than 50 minutes, or else we just got numb.


Thursday, August 24, 2006

In the news: Rational opposition to new technique?

Well, early signs are that taking one-eighth of a blastomere for use in stem-cell research will not pass the moral objections of the president or congressional science foes. Snip from NYT:
With the approach of midterm elections, in which some candidates are already making the research a central theme, some scientists speculated that President Bush might embrace the new method as meeting his principal objection to the research and showing that he had been right all along to wait for a better technique to turn up.

But Emily Lawrimore, a White House spokeswoman, suggested that the new procedure would not satisfy the objections of Mr. Bush, who vetoed legislation in July that would have expanded federally financed embryonic stem cell research. Though Ms. Lawrimore called it encouraging that scientists were moving away from destroying embryos, she said: “Any use of human embryos for research purposes raises serious ethical questions. This technique does not resolve those concerns.”
Congressional Republicans who led the resistance to the embryonic stem cell legislation that had bipartisan support in the House and Senate also said the new technique did not ease their opposition. Brian Hart, a spokesman for Senator Sam Brownback, Republican of Kansas and a prominent opponent of federal financing for embryonic stem cell research, said Mr. Brownback's moral objection remained.
"You are creating a twin and then killing that twin," Mr. Hart said.

Really, this smacks of the same kind of thinking that opposes birth control methods that prevent the implantation of a fertilized egg in the uterus on the ground that a fertilized egg is a teeny tiny person, a microscopic Haley Joel Osment swimming around in the mysterious human hot tub that is the female reproductive system. On the other hand, it's hard to be surprised by Sam Brownback's weirdness, after the whole snowflake thing.

Link to NYT.

Wednesday, August 23, 2006

Research: Embryo-friendly embryonic stem cells?

Interesting article in the NYT on a new method for obtaining embryonic stem cells. Snip:
The new technique would be performed on an embryo when it is two days old, after the fertilized egg has divided into eight cells, known as blastomeres. In fertility clinics, where the embryo is available outside the mother in the normal course of in-vitro fertilization, one of these blastomeres can be removed for diagnostic tests, such as for Down’s syndrome, and the embryo, now with seven cells, can be implanted in the mother if no defect is found. Many such embryos have grown into apparently healthy babies over the ten years or so the diagnostic tests have been used.

Up to now, human embryonic stem cells have been derived at a later stage of development when the embryo consists of about 150 cells. Harvesting these cells destroys the embryo. Last year, Dr. Lanza reported that embryonic stem cell cultures could be derived from the blastomeres of mice, a finding others have confirmed. He now says the same can be done with human blastomeres.

If this works, then it would seem to overcome the ethical objections to research that would result in the destruction of discarded human embryos, right? Well, almost. See, the technique still requires the fertilization of human egg by human sperm outside the darkened confines of a marital bedroom, and there are still some people out there with moral objections to in vitro fertilization. Snip:
Catholic bishops, in particular, oppose both in-vitro fertilization and P.G.D. testing, and therefore still object to the research, even though the cells would be derived from an embryo that is brought to term.

Richard Doerflinger, deputy director for pro-life activities at the United States Conference of Catholic Bishops, said the church opposed in-vitro fertilization because of the high death rate of embryos in fertility clinics and because separating procreation from the act of love made the embryo seem “more a product of manufacture than a gift.” Asked if he meant the parents of an in-vitro child would love it less, Mr. Doerflinger said he was referring to the clinic staff. “The technician does not love this child, has no personal connection with the child, and with every I.V.F. procedure he or she may get more and more used to the idea of the child as manufacture,” he said.

So there are some people for whom this slope is so perilously slippery that they really would prefer that you didn't even shower after sex. One hopes that someone--perhaps one of the gazillion frustrated childless couples giving up vacations and cars in order to pay for IVF--will be able to adequately explain to our President that IVF does not cross his moral line in the sand, that this kind of research must be funded.
New Stem Cell Method Avoids Destroying Embryos - New York Times

Research: Extensive remyelination?

Autopsies indicate that some 20% of MS patients have been busy remyelinating their lesion areas. I'd just like to say cheers to the specimens who, um, participated in this research. First, kudos to you for remyelinating. I wish I knew how to do that. Second, thanks for your generous foresight in donating your recently-vacated corporeal forms. Here's a snip from the abstract:
The extent of remyelination was variable between cases. In 20% of the patients, the extent of remyelination was extensive with 60-96% of the global lesion area remyelinated. Extensive remyelination was found not only in patients with relapsing multiple sclerosis, but also in a subset of patients with progressive disease. Older age at death and longer disease duration were associated with significantly more remyelinated lesions or lesion areas. No correlation was found between the extent of remyelination and either gender or age at disease onset. These results suggest that the variable and patient-dependent extent of remyelination must be considered in the design of future clinical trials aimed at promoting CNS repair.


Tuesday, August 22, 2006

In the news: The future health care economy

For those who are interested in big-picture trends, the NYT has a story about the predicted growth of the share of GDP spent on health care. It's gonna get a lot bigger, and maybe that's not a bad thing, economically speaking. Snip:
By 2030, predicts Robert W. Fogel, a Nobel laureate at the University of Chicago Graduate School of Business, about 25 percent of the G.D.P. will be spent on health care, making it the driving force in the economy, just as railroads drove the economy at the start of the 20th century.

Unless the current system is changed, most health care costs will continue to be paid by insurance, especially Medicare, which means that the taxpayers will foot the bill. But Dr. Fogel says he is not alarmed. Americans can afford it, he says, because the nation is so rich. "It takes so little of household income to satisfy expenditures on food, clothing and shelter," he explains. "At the end of the 19th century, food, clothing and shelter accounted for 80 percent of the family budget. Today it's about a third."
Still, Victor R. Fuchs, also an economist at Stanford, notes that buying health care is fundamentally different from buying a television or a car. “Most of it involves transfers from the young to the old,” he said. “Down the road, most medical care will be for people over age 65, and most of the payments will be from taxes on younger people.” Dr. Fuchs calls it the restaurant check problem. “You go out to a restaurant with a bunch of friends and you sort of understand that you will split the check,” he said. “The waiter comes along and says, ‘The lobster looks very good, and how about a soufflé for dessert?’ The restaurant check balloons, but you are not so careful because you figure everyone is splitting it. “That’s the way medical care gets paid for,” he said.

To me, this is interesting stuff, but the more important question has to do with efficiency. How much of the money we spend buying health care is wasted? In our current system, there are commercial interests influencing spending. What additional value do we get from our market-centric approach?

Friday, August 18, 2006

Journal: Assigning homework

I went out for tacos the other day. Mom lives on the other side of town, but we don't see a whole lot of each other, and this is a source of worry and insecurity for Mom.

My relationship with Mom has been dodgy since I was 12 or so, and getting MS hasn't helped. I know she's worried about me and genuinely want to help, but the time I spend with her exhausts and frustrates me. We seem to spend our time together either talking about how I'm feeling or about our dysfunctional relationship.

Here's the gist of our conversation at the taco place:

Mom: Mmmm. This is really good, isn't it?
Me: Yeah, the smoked pork is wonderful.
Mom (making exaggerated eye contact, with great sympathy): So how have you been feeling lately?
Me (hoping to get this part over quickly): I've been feeling pretty tired and weak, but that comes with the territory.
Mom (eyes moistening): So what does your neurologist say when you tell him that? Is there anything he can do for you?

At this point, I begin a short lecture about the various drugs I'm taking, about treatments that affect the natural history of the disease versus treatments aimed at symptom management, etc. And I sound a little exasperated, and my eyes wander over the old album covers that decorate the walls, and then I excuse myself to use the restroom. Where I have a rather good idea.

On the way home, I tell Mom that when she gets back from her trip to Budapest, I'm going to give her a book about MS, and I think she needs to read it, because I feel like she still doesn't understand the basics about MS, and it's a little frustrating to me that 13 years into my illness she hasn't taken the time to learn that stuff. And I tell her that when I was first diagnosed, I read absolutely everything I could about MS, that it was a minor obsession, that it was empowering to learn as much as I could because there was so much uncertainty involved in the disease itself.

Mom says that she thinks it is a fine idea, and that for the first five years after I got sick, she couldn't bear to read anything about MS, which is hard for me to understand, but okay, whatever.

I wonder what book I should give her.

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Wednesday, August 16, 2006

In the news: Talking to your doc

Interesting little piece in the NYT about doctor-patient communication, with some good suggestions. The best one, I think, comes last. Snip:
Doctors don't like confrontation any more than patients do; they may give in to a patient's request if it is made in an assertive manner. In a study under review for publication, Dr. Bylund found that patients who persistently asked for a specific treatment or test, based on Internet research, were more likely to get it than patients who came in with a vague list of symptoms, or who were more deferential to the doctor.

But be careful, she warned. Anyone who treats a doctor as a dispensary instead of a trusted medical guide loses the advantages of the physician's experience. Negotiating to win, in this case, may get you what you want, but not what you need.


Monday, August 14, 2006

Research: MS fatigue linked to DHEA levels

God help me, I'm thinking of going down to Walgreen's this afternoon to buy some DHEA and conduct my own N=1 study of DHEA supplementation. For the last couple weeks, my legs (especially the left one) have felt like a couple of oversized rubber chickens attached to my hips.

Mult Scler. 2006 Aug;12(4):487-94.
Fatigue in progressive multiple sclerosis is associated with low levels of dehydroepiandrosterone.Tellez N, Comabella M, Julia E, Rio J, Tintore M, Brieva L, Nos C, Montalban X.
Unitat de Neuroimmunologia Clinica, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain.
BACKGROUND AND OBJECTIVE: Fatigue is one of the most limiting symptoms in multiple sclerosis (MS) and the mechanisms underlying its origin are poorly understood. Our aim was to test whether fatigue in MS is associated with endocrine markers. METHODS: We longitudinally studied 73 progressive MS patients. Fatigue was assessed at baseline and at 3, 6, 12 and 24 months using the Fatigue Severity Scale (FSS). Given the longitudinal design of our study, patients were labelled as sustained fatigued when FSS scores were >5.0 at all time points, and as non-fatigued when FSS scores were < or = 5.0 at all time points. Serum levels of dehydroepiandrosterone (DHEA), its sulphated conjugate (DHEAS) and cortisol were measured at each time point. RESULTS: Twenty-nine patients scored >5.0 in the FSS at all time points, and 9 patients (12.3%) scored 5.0 at all time points. Mean baseline levels of DHEAS and DHEA were lower in MS patients with sustained fatigue when compared to patients without fatigue (P = 0.01 and P = 0.03 respectively). Analysis of DHEAS and DHEA over time showed significantly lower hormone levels in patients with fatigue [F(1,31) = 6.14, P=0.019 for DHEAS; F(1,32) = 6.63, P=0.015 for DHEA]. CONCLUSIONS: Fatigue in progressive MS could be related to low serum levels of DHEA and DHEAS. Our results suggest that these hormones should be considered as biological markers of fatigue in MS patients and that hormone replacement may thus be tested as an option to treat fatigue in MS patients.

Research: Stress and MS

A couple new studies look at the relationship between stress and MS. The gist:
The number rather than severity of stressors was most important in relation to MS relapse risk, along with coping responses that utilized social support, suggesting that MS patients should avoid situations that are likely to generate multiple stressors or which provide few avenues for social support. Link.

Life-event stress impacts to a small degree on MS relapse. The number and not the severity of acute stressors are most important; chronic stressors do not predict later relapse. Males and those with early stage disease are also at greater risk of relapse. MS patients should be encouraged to reduce acute stressors during times of high stress, and feel reassured that disease-related chronic stressors do not increase their relapse risk. Link.

Journal: Blueish

When I don't post, I know it's a sign that I'm depressed. It means I'm getting overwhelmed by everyday tasks, that I'm too busy writing the insufferable interior monologue to write much else. My wife told me it would easier if I cried when I feel bad; that way she'd know I wasn't just being sulky.

My big chore today is to call the design/build firm we hired to do some remodeling to tell them we're not going to sign the contract that came in 11% over their initial estimate, which was actually 25% more than what we said our budget was. Yeah, it's a pretty high-class problem, but it feels like so much wasted effort, not to mention the money we've already paid them.

Sometimes I think it takes more energy to make a 10-minute phone call than to mow the lawn (which I don't do anymore).

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Monday, August 07, 2006

Journal: Admiring a disappointed man

Last week, I stumbled across the remarkable writings of W.N.P. Barbellion, a.k.a. Bruce Frederick Cummings. A hundred years ago, Cummings was a brilliant young Englishman with a prodigious interest in zoology and rather modern sensibilities. Cummings kept an intensely candid diary of his ambitions, desires, and despairs, and later, his illness: "disseminated sclerosis," an old-fashioned term for MS. In 1919, when Cummings was 29 years old and just months before his death, his diary was published as The Journal of a Disappointed Man under the pseudonym W.N.P. Barbellion. It's being republished on the net as a blog.

Reading the Journal, I recognized some of my own deepest fears and obsessions, albeit expressed more completely by Cummings' lucid Edwardian prose. Snips:
July 1, 1913. Returned to London very depressed. Am not so well as I was three weeks ago. The sight of one eye is affected, and I am haunted by the possibility of blindness. Then I have a numb feeling on one side of my face, and my right arm is less mobile. Left darling Mother in a very weak state in bed, with neuritis and a weak heart. She cried when I said ‘Goodbye,’ and asked me to go to Church as often as I could, and to read a portion of Scripture every day. I promised. Then she added, ‘For Dad’s sake;’ just as if I would not do it for her. Poor dear, she suffers a deal of pain. She does not know how ill I am. I have not told her.

January 22, 1913. This Diary reads for all the world as if I were not living in mighty London. The truth is I live in a bigger, dirtier city — ill-health. Ill-health, when chronic, is like a permanent ligature around one’s life. What a fine fellow I’d be if I were perfectly well. My energy for one thing would lift the roof off...

If you could divide the Journal into beginning, middle, and end, the middle has to happen in November 1919. Snip from Wikipedia:
Cummings' life changed forever when he decided to enlist in the British Army to fight in World War I in November 1915. He had consulted his doctor before taking the regulation medical prior to enlisting, and his doctor had given him a sealed, confidential letter to present to the medical officer at the recruitment centre. Cummings did not know what was contained in the letter, but in the event it was not needed; the medical officer rejected Cummings as unfit for active duty after the most cursory of medical examinations. Hurt, Cummings decided to open the letter on his way back home to see what had been inside, and was staggered to learn that his doctor had diagnosed him as suffering from the disease now known as multiple sclerosis, and that he almost certainly had less than five years to live.

For the last few days I've been stuck with a sense that Cummings' diary said everything there was to say about having MS; that he told the gut-wrenching truth of the thing 100 years ago, obviating any story I could tell; that it served no purpose to relate the amusing story of how last night for an hour before bedtime I was seized by a fit of flatulence so foul that my dog stood up and walked into the other room (true story!). But today, I'm feeling more relevant. I'm not nearly as eloquent or handsome as Cummings, but here I am.

And furthermore, pull my finger.

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Thursday, August 03, 2006

Research: Tetanus shot lowers MS risk

Did you get a tetanus shot as a kid? I'm pretty sure I did. Researchers think the shot might lower the risk of MS. Snip:
Dr. Miguel A. Hernan and colleagues from Harvard School of Public Health pooled data from nine studies published between 1966 and 2005 that looked at the association between tetanus vaccination and MS risk. Analyses centered on a total of 963 MS cases and 3126 controls.

They found that a history of having been immunized against tetanus was associated with a 33 percent decrease in risk of MS. The results of the current meta-analysis suggest that tetanus vaccination may prevent or delay the development of MS. The investigators call for further epidemiologic research to assess the role of timing of immunization and the number of doses associated with this protective effect. Link.

Wednesday, August 02, 2006

Journal: What's in these things?

Yesterday, my wife was taking a load of laundry out of the dryer. She pulled out a pair of my cargo shorts, when she notice something very large and heavy and wettish in one of the pockets. It was, of course, a Depend Guard for Men (unused) that I'd forgotten to remove.

She brought up the shorts to show me, and I was amazed. The shorts weighed about five pounds, and the pocket where the pad had been was absolutely full of this sort of goo. I shoved my hand in the pocket to scoop it out, and it felt like the most disgusting sort of gooey mush, like wet kleenex mixed with jello. Bleh.

I dumped a handful into the garbage and expected that my hand would be moist and gooey. It wasn't. It was as if all the gooeyness had stuck to the goo. I imagine that's exactly the point. I wonder what sort of space-age polymer I have, even now, secretly tucked into my underpants. And I wonder how best to get the rest of that goo out of my pocket.
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Tuesday, August 01, 2006

In the news: A Pox on Stem Cell Research

Interesting take on embryonic stem cell research in the NYT. The author compares the present moral impasse on stem cell funding to the moral objections raised in response to Edward Jenner's R&D on a smallpox vaccine at the tail end of the 18th century. Snip:
Even some of his medical colleagues questioned whether he might have gone too far. In retrospect, one can easily imagine Jenner's brilliant idea sinking under the combined weight of moral antipathy and scientific disdain.

Instead, the doctor persevered and triumphed. Not by hyping the potential of his ideas, as some stem cell supporters occasionally have done, but by doggedly gathering more evidence based on more inoculations. Fueled by his success, the practice spread, and smallpox rates plummeted. In time, the life-saving merits of inoculation eventually overwhelmed all doubt; the evidence, Jenner wrote, became 'too manifest to admit of controversy.'

I hope we're headed in a similarly pragmatic direction with regard to stem cell research. We still have not ventured much beyond the promising preliminaries; there is no multitude of saved lives to serve as a moral counterweight to the use of embryos, even unwanted ones. Link.