Friday, December 7, 2012

Nursing the Flu With Help From Apps - NYTimes.com

I wasn't my usual self earlier this week. Some nasty flu bug had beaten me, reducing your usual quirky, chipper columnist to a feverish, bedridden shadow. It's never fun being ill, and I've never been a good patient because all the sensible advice to stay warm, hydrated and in bed leads to boredom.

During this bout I was much better behaved because my smartphone, jammed with entertaining apps and Internet access, was a great sickbed companion. Apps can do more than keep you company; they can give you medical advice. And as the season of coughs and sneezes settles in, an app may even help you determine what's wrong.

For a medical app that covers a plethora of icky illnesses, WebMD is probably your best bet (free for iPhoneiPad and Android). It's jammed with data, and can present it to you in a number of ways. A hypochondriac's dream, the app's Symptom Checker first asks that you tap on the corresponding part of an image of the body and then, choosing from detailed lists, specify which symptom you have. Once you select a symptom, the app leads you through a short question-and-answer session to refine your input, like exactly what kind of cough you have. You can input a number of symptoms, perhaps adding sneezes, for example, and then press the "view possible conditions" button.

The app lists all the conditions your symptoms may match, so you need to read each one earnestly to see if it describes your situation. It's written in plain language, and links help you find treatment or more information online. A tab takes you to pages describing symptoms in more detail, and another takes you to detailed articles about the condition.

This app also works well if you already know, or suspect, what's wrong with you: you can simply consult its alphabetical index of illnesses. A section with drugs and treatments even has a "Pill ID" feature to help you identify a medication by its shape and color or the letters printed on it. Finally there's a quick-access First Aid section for emergencies.

The WebMD app is powerful and full of detail. This is obviously handy, but you can get a little lost navigating its sub-menus. You also need to be online so it can acquire data to meet your requests.

An alternative app on iOS, also free, is iTriage. It too has a comprehensive list of illnesses, and a symptom-checker section where you tap on a body image to input each symptom you're experiencing. But iTriage also provides information on a list of medical procedures. And you can record in a "my iTriage" section details of your insurance, health record, previous ailments and so on. The app is more graphical than WebMD, and is thus a little easier to use. A page on influenza, for example, has data carefully organized under a long list of headings. Some sections even have video links to help you, but again, you need an Internet connection to get the most benefit.

One way to avoid seasonal illnesses like the flu is to avoid being exposed. The Centers for Disease Control and Prevention's official Influenza app (free on iOS or Android) is jam-packed with data, including graphs, maps and medical terminology. It is mainly intended for professionals, but ordinary users can use it to find out where the flu is prevalent in the United States. It also has useful information about vaccination and flu prevention. But its interface is old-fashioned, it's easy to get lost in the various sections and data presentation is sometimes not the most accessible.

A much simpler and possibly more useful app, is called FluDefender (free on iOS). This app's main attractions are detailed information about influenza, a built-in link to the CDC's Twitter feed about flu and a map that shows how common flu infections are state by state.

While the apps have their uses, if you're really sick, seek professional help. Doctors can recognize symptoms you can't. And apps can't write prescriptions.

http://www.nytimes.com/2012/12/06/technology/personaltech/nursing-the-flu-with-help-from-apps.html?

Comfort for doctors and patients alike - The Globe and Mail

Canadian medical law may begin to resolve some contentious issues about patients' control of their care on Dec. 10, when the Supreme Court of Canada hears the case of Hassan Rasouli.

Mr. Rasouli has been on ventilator life support at Toronto's Sunnybrook Health Sciences Centre since October of 2010 following postsurgical complications and bacterial meningitis that led to severe brain damage. His doctors considered him to be in a persistent vegetative state but acknowledged that he might be minimally conscious, aware of his circumstances, yet still incapable of expressing preferences. His wife acts as his substitute decision-maker, pursuing his best interests because he was never able to tell her what he would want.

The doctors anticipate no improvement in Mr. Rasouli's condition and, considering active treatment futile, proposed to remove his life support and administer palliative care for comfort until natural death occurs. But his wife disagreed, saying continued life support is in her husband's best interests.

The doctors claim that discontinuation of ineffective treatment does not require consent by or on behalf of a patient. They asked a court to confirm that withdrawing futile life support is a medical decision for them, not the patient, to make. The trial judge decided that, on the terms set out in Ontario's Health Care Consent Act, doctors' withdrawal of treatment from a patient is part of their "plan of treatment" and that this can be implemented only with consent given by or on behalf of the patient.

The judge ruled that, if the doctors consider that the substitute decision-maker is not acting in the patient's best interests, as the act requires, they should refer the case to Ontario's Consent and Capacity Board. The board may uphold a decision it considers competently made by or on behalf of a patient, or substitute its own decision. The Ontario Court of Appeal upheld the trial result, paving the way for the doctors' final appeal to the Supreme Court.

The Supreme Court must decide on the basis of the Ontario legislation, but the doctors argue that this mainly codifies the background general law. As a national court, the Supreme Court is likely to reflect on how the case fits within the wider Canadian legal framework. Under the general law, patients may decide to accept or reject treatments offered according to their doctors' clinical judgment but can't insist on treatments that aren't so offered, usually because their doctors consider them inappropriate. Doctor-patient interactions are not acts of government, so claims are unlikely to arise of denials of rights under the Charter of Rights and Freedoms.

Mr. Rasouli's doctors fear that, if they require patients' consent to withdraw care that's proving of no benefit, refusal of consent may compel them to use scarce resources in worthless treatments. Worse, treatment devoted to patients it can't help would be denied to patients it would benefit. They also worry that, if initiated care can't be withdrawn as doctors judge appropriate, then care that might prove helpful might not be started. The Court of Appeal considered these fears groundless, since it was "prepared to accept that the [Ontario] Act does not require doctors to obtain consent from a patient or substitute decision-maker to withhold or withdraw 'treatment' that they view as medically ineffective or inappropriate."

But the Court of Appeal did rule that removing a patient from a ventilator and placing him on a program of palliative care until he dies is "treatment." Consent is accordingly required, from the patient, substitute decision-maker or the independent Consent and Capacity Board. The Supreme Court will address the competing autonomy of doctors and patients in medical care, and implications of replacement of historical medical paternalism ("doctor knows best") by patients' informed choices.

One issue not addressed was the possible impact of patient choices on health-care costs. With Canada's aging population and an accumulation of health-care costs in prolonged end-of-life care, patient autonomy may conflict with doctors' ability, and willingness, to act as gatekeepers of public health-care resources.

Doctors are required to use the means available to them to care for individual patients in the patients' best interests. Even when responsible for the care of several patients dependent on the same resources, they must give priority to the patient with whom they're immediately engaged. They can't sacrifice the interests of that patient to preserve resources that may benefit another patient. Equally, however, they can't indulge that patient with treatment they believe is futile or extravagant. Their fear of being required to accommodate the unrealistic hopes of patients or their families justifies more relief than the Court of Appeal offered.

The Supreme Court faces the challenge of providing comfort, to doctors and patients alike, that health-care resources will not legally have to be deployed with no realistic prospect of benefit. The alternative is trusting that provincial legislatures can resolve competing interests of doctors required to practise to professional standards, and patients wanting the care they believe will benefit them, with greater clarity than the legislation at the centre of this appeal achieved.

Bernard Dickens is professor emeritus of health law and policy at the University of Toronto.

http://www.theglobeandmail.com/commentary/comfort-for-doctors-and-patients-alike/article6001684/?

Wednesday, December 5, 2012

BBC News - Cancer: Not only a rich-world disease

Dr Jackson Orem is on the front line of the change. He directs the Uganda Cancer Institute - the only dedicated cancer treatment facility in a country of 33 million people.

He's a busy man, but he makes time to see patients like Musa Settimba.

Settimba is in for a check-up. He has something called Gist, a type of gastrointestinal cancer that is often fatal, even in the West.

Orem has arranged for Settimba to get a very effective and costly new cancer drug free of charge, courtesy of the manufacturer. There's paperwork involved, and drugs for only a few cancers are available this way. It's a godsend for Settimba, who has been doing very well.

"You are getting one of the best treatments for this disease," a smiling Orem tells his patient.

Unfortunately, Settimba is the rare exception.

The survival rate for patients who make it to the Uganda Cancer Institute is astonishingly low. It treats about 22,000 patients a year, and of those, 20,000 die within a year.

Orem says most Ugandans don't have a real concept of cancer as a set of diseases that can be diagnosed and treated. In some tribal languages, there is no word for it. "They don't have early diagnosis. They don't actually even know that they have cancer," he says.

And most don't see the value of seeking care. "Once you are diagnosed with cancer, they think that it's already a death sentence."

They're partly right. Most people don't see a doctor until the very last stages of cancer. At that point, no hospital anywhere could do much for them.

Orem studied oncology in the US and returned to Uganda to head the government-owned cancer institute in 2004. For several years, he was the only oncologist in the country.

Orem doesn't complain about the hard work, but some things make him cringe. One of them is a comment he's heard expressed by people from developed countries - that cancer doesn't hit poor people.

"People think that malaria kills [and] other diseases are killing people from a low socio-economic status. But cancer is the same," he says. "The truth of the matter is that cancer is a disease of the African person just like any other person elsewhere in the world."

The misconception affects funding. "When you ask for funding for cancer, nobody is going to give [it to] you," Orem says. "But if you ask for funding for these other diseases, they say, 'All right, your priority is correct, we are going to give you some funds.'"

There is also a perception that cancer is too expensive to treat, and treatment is too hi-tech to be done in poor countries. Orem says that's not necessarily true - surgery and chemotherapy, for example, don't require million-dollar machines.

The result is that the amount of money available for cancer care in the developing world is only a fraction of the sums spent on HIV, TB and malaria.

More ...

http://www.bbc.co.uk/news/magazine-20524606

With sensors, apps & data, my smartphone is (almost) my doctor — Tech News and Analysis

If you think the Jawbone Up and Nike FuelBand are changing our perception of personal health, then wait until you see what Scanadu, a Mountain View, Calif.-based company, has planned for you. The two-year-old old company is the brainchild of Walter de Brouwer, a Belgian-born serial entrepreneur (EUnet-Quest and Star Lab) and member of TED, who in the recent past worked with Nicholas Negroponte on the One Laptop Per Child project.

His team of a dozen-odd people, including biologists, chemists, data scientists and semiconductor engineers, is planning to develop a series of personalized health products that want to capitalize on the rapidly falling prices of sensors and other technologies and combine them with data and easy to use smartphone apps.

The inspiration for the company, de Brouwer said, came from the time he spent taking care of his son in a hospital. That experience made him realize that people need access to more information about their own health in an easy-to-understand manner. "What I was looking to do was build a tricorder to scan and get all the relevant medical data," he joked during a conversation.

Of course, the smartphone boom happened. That marriage of cloud-based data analytics, simple to use apps and falling prices of sensors made the idea of a tricorder seem attainable. In fact, de Brouwer's tricoder dream matches up with smartphone chipmaker Qualcomm, which launched the Qualcomm Tricorder X Prize earlier this year. It wants scientists and developers to figure out a handheld device that can diagnose 15 medical ailments based on sensors in the device.

De Brouwer's idea was enough to raise a few million dollars from his deep pocketed friends and since then, his crew has come up Scanadu Scout, a square shaped device. that can be held next to the left temple when holding it with thumb and the index finger of the left thumb. The device communicates with your iPhone via bluetooth and a few seconds later you get a readout of your vitals such as heart rate, level of oxygen in your blood, pulse and body temperature.

It is one of the many devices the company plans to build, de Brouwer said. In addition to Scanadu Scout, the company is working on two more devices — one that you be used for a urine test and another  that can help you identify if you have flu. All of these devices have been built with off the shelf components, de Brouwer said. The secret sauce for the company is its algorithms, he added.

Scanadu Scout designed by fuseProject.

Dr. Alan Greene, who is the chief medical officer of Scanadu, points out that the when it comes to medicine and information, the center of gravity has shifted from hospitals to outpatient centers to homes. And with smartphone, it is going to move to individuals. The healthcare system isn't really changing with the times fast enough, he added. "What we want to do is give people access to better data about themselves so they can engage with their physicians better," Dr. Greene said.

As someone who lives with a medical condition, I can say Scanadu Scout will be part of my life the minute the Food and Drug Administration approves it and the company starts selling this device at my Walgreens. Today, I travel with a blood pressure machine. I spent a lot of time trying to measure my pulse and figuring out my heart rate. The convenience of getting all that information with one scanner and have it analyzed over a period of time is worth the price – whatever it might be.

http://gigaom.com/2012/11/29/with-sensors-apps-data-my-smartphone-is-almost-my-doctor/

Software Programs Help Doctors Diagnose, but Can’t Replace Them - NYTimes.com

The man on stage had his audience of 600 mesmerized. Over the course of 45 minutes, the tension grew. Finally, the moment of truth arrived, and the room was silent with anticipation.

At last he spoke. "Lymphoma with secondary hemophagocytic syndrome," he said. The crowd erupted in applause.
Professionals in every field revere their superstars, and in medicine the best diagnosticians are held in particularly high esteem. Dr.Gurpreet Dhaliwal, 39, a self-effacing associate professor of clinical medicine at the University of California, San Francisco, is considered one of the most skillful clinical diagnosticians in practice today.

The case Dr. Dhaliwal was presented, at a medical conference last year, began with information that could have described hundreds of diseases: the patient had intermittent fevers, joint pain, and weight and appetite loss.

To observe him at work is like watching Steven Spielberg tackle a script or Rory McIlroy a golf course. He was given new information bit by bit — lab, imaging and biopsyresults. Over the course of the session, he drew on an encyclopedic familiarity with thousands of syndromes. He deftly dismissed red herrings while picking up on clues that others might ignore, gradually homing in on the accurate diagnosis.

Just how special is Dr. Dhaliwal's talent? More to the point, what can he do that a computer cannot? Will a computer ever successfully stand in for a skill that is based not simply on a vast fund of knowledge but also on more intangible factors like intuition?

The history of computer-assisted diagnostics is long and rich. In the 1970s, researchers at the University of Pittsburgh developed software to diagnose complex problems in general internal medicine; the project eventually resulted in a commercial program called Quick Medical Reference. Since the 1980s, Massachusetts General Hospital has been developing and refining DXplain, a program that provides a ranked list of clinical diagnoses from a set of symptoms and laboratory data.

And I.B.M., on the heels of its triumph last year with Watson, the Jeopardy-playing computer, is working on Watson for Healthcare.

In some ways, Dr. Dhaliwal's diagnostic method is similar to that of another I.B.M. project: the Deep Blue chess program, which in 1996 trounced Garry Kasparov, the world's best player at the time, to claim an unambiguous victory in the computer's relentless march into the human domain.

Although lacking consciousness and a human's intuition, Deep Blue had millions of moves memorized and could analyze as many each second. Dr. Dhaliwal does the diagnostic equivalent, though at human speed.

Since medical school, he has been an insatiable reader of case reports in medical journals, and case conferences from other hospitals. At work he occasionally uses a diagnostic checklist program called Isabel, just to make certain he hasn't forgotten something. But the program has yet to offer a diagnosis that Dr. Dhaliwal missed.

Dr. Dhaliwal regularly receives cases from physicians who are stumped by a set of symptoms. At medical conferences, he is presented with one vexingly difficult case and is given 45 minutes to solve it. It is a medical high-wire act; doctors in the audience squirm as the set of facts gets more obscure and all the diagnoses they were considering are ruled out. After absorbing and processing scores of details, Dr. Dhaliwal must commit to a diagnosis. More often than not, he is right.

When working on a difficult case in front of an audience, Dr. Dhaliwal puts his entire thought process on display, with the goal of "elevating the stature of thinking," he said. He believes this is becoming more important because physicians are being assessed on whether they gave the right medicine to a patient, or remembered to order a certain test.

Without such emphasis, physicians and training programs might forget the importance of having smart, thoughtful doctors. "Because in medicine," Dr. Dhaliwal said, "thinking is our most important procedure."

He added: "Getting better at diagnosis isn't about figuring out if someone has one rare disease versus another. Getting better at diagnosis is as important to patient quality and safety as reducing medication errors, or eliminating wrong site surgery."

Clinical Precision

Dr. Dhaliwal does half his clinical work on the wards of the San Francisco V. A. Medical Center, and the other half in its emergency department, where he often puzzles through multiple mysteries at a time.

One recent afternoon in the E.R., he was treating a 66-year-old man who was mentally unstable and uncooperative. He complained of hip pain, but routine lab work revealed that his kidneys weren't working and his potassium was rising to a dangerous level, putting him in danger of an arrhythmia that could kill him — perhaps within hours. Anultrasound showed that his bladder was blocked.

There was work to be done: drain the bladder, correct the potassium level. It would have been easy to dismiss the hip pain as a distraction; it didn't easily fit the picture. But Dr. Dhaliwal's instinct is to hew to the ancient rule that physicians should try to come to a unifying diagnosis. In the end, everything — including the hip pain — was traced to metastatic prostate cancer.

"Things can shift very quickly in the emergency room," Dr. Dhaliwal said. "One challenge of this, whether you use a computer or your brain, is deciding what's signal and what's noise." Much of the time, it is his intuition that helps figure out which is which.

An expert clinical diagnostician like Dr. Dhaliwal might make a decision without being able to explain exactly what is going on in the back of his mind, as his subconscious continuously sifts the wheat from the chaff.

While computers are good at crunching numbers, people are naturally good at matching patterns. To make a decision, physicians must combine logic and knowledge with their pattern-matching instincts.

Across the hall was a different case. A 65-year-old man had arrived confused and feverish, with blisters on his thigh. Dr. Dhaliwal suspected herpes encephalitis, but the blisters looked a bit too large, and in an unusual location for such a diagnosis.

The man's condition stabilized and no definitive diagnosis was made. Dr. Dhaliwal continued to follow the case. "Following up to know that nothing was missed was one of the most important aspects of that case," he said. "And not ever arriving at a final diagnosis is fine. Being O.K. with uncertainty is a big part of medicine."

Isabel, the diagnostic program that Dr. Dhaliwal sometimes uses, was created by Jason Maude, a former money manager in London, who named it for his daughter. At age 3, Isabel came down with chickenpox and doctors failed to spot a far more dangerous complication — necrotizing fasciitis, a flesh-eating infection. By the time the disease was identified, Isabel had lost so much flesh that at age 17 she is still having plastic surgery.

Mr. Maude said that while someone like Dr. Dhaliwal would probably have thought of necrotizing fasciitis, his daughter's doctors were so stuck in what is called anchoring bias— in this case, Isabel's simple chickenpox — they couldn't see beyond it.

Had they entered her symptoms — high fever, vomiting, skin rash — into a diagnostic program, Mr. Maude said, the problem would probably have been identified.

Thousands of diseases are known, and many are rare. "Low-frequency events are hard to put on the brain's palette, and that's part of Isabel's strength," Mr. Maude said. "It's impossible for any one person to remember how each of those diseases presents, because each presents with a different pattern."

He added that Isabel was aimed not so much at the Dr. Dhaliwals of the world, but at more typical physicians.

Dr. David J. Brailer, chief executive of Health Evolution Partners, which invests in health care companies, agreed. "If everyone was a diagnostic genius, we wouldn't need these decision support tools," he said.

Diagnostic mistakes account for about 15 percent of errors that result in harm to patients, according to the Institute of Medicine. Yet diagnostic software has been slow to make its way into clinical settings, and Dr. Dhaliwal, who uses Isabel as a "second check," said he could understand why.

Not only is it hard to integrate software into an already busy daily work flow, he said, but "most of us don't think we need help at diagnosis, especially with routine cases, which account for the majority of our work."

Dr. Henry Lowe, an internist at Stanford University and director of its Center for Clinical Informatics, doubts that a computer could ever replace a diagnostic wizard like Dr. Dhaliwal, or even a competent clinician.

"Designing computer systems that work well with incomplete or imprecise information is challenging," Dr. Lowe said. "Particularly in medicine, where the consequences of defective decision-making may be catastrophic."

Mimicking Human Analysis

I.B.M.'s Watson for Healthcare has yet to focus directly on diagnosis. The company is working with Memorial Sloan-Kettering Cancer Center to teach Watson to interpret clinical information and, eventually, help determine treatment. I.B.M. also recently began a collaboration with Cleveland Clinic to broaden Watson's analytical capabilities into the area of medicine.

Dr. Martin Kohn, chief medical scientist for I.B.M. Research, is careful to point out that Watson for Healthcare is intended to be "neither omniscient nor omnipotent." Yet, Dr. Kohn noted, most physicians set aside five hours or less each month to read medical literature, while Watson can analyze the equivalent of thousands of textbooks every second. The program relies heavily on natural language processing. It can understand the nature of a question and review large amounts of information, such as a patient's electronic medical record, textbooks and journal articles, then offer a list of suggestions with a confidence level assigned to each.

For physicians, Dr. Kohn said, one problem is what he calls "the law of availability."

"You aren't going to put anything on a list that you don't think is relevant, or didn't know to think of," he said. "And that could limit your chances of getting a correct diagnosis."

Dr. Dhaliwal agreed, citing the recent outbreak of hantavirus at Yosemite. Ten people contracted the virus, and three died. "It's a febrile illness that looks like the flu," he said. "It's so rare, the last time you might have seen it was your medical school classroom."

Had Isabel or a similar program been used, the deaths might have been prevented, Dr. Dhaliwal said. "You might think you're in familiar territory, but the computer is here to remind you there are other things."

http://www.nytimes.com/2012/12/04/health/quest-to-eliminate-diagnostic-lapses.html?pagewanted=all&_r=0

What Neuroscience Really Teaches Us, and What It Doesn't : The New Yorker

In the early nineteen-nineties, David Poeppel, then a graduate student at M.I.T. (and a classmate of mine)—discovered an astonishing thing. He was studying the neurophysiological basis of speech perception, and a new technique had just come into vogue, called positron emission tomography (PET). About half a dozen PET studies of speech perception had been published, all in top journals, and David tried to synthesize them, essentially by comparing which parts of the brain were said to be active during the processing of speech in each of the studies. What he found, shockingly, was that there was virtually no agreement. Every new study had published with great fanfare, but collectively they were so inconsistent they seemed to add up to nothing. It was like six different witnesses describing a crime in six different ways.

This was terrible news for neuroscience—if six studies led to six different answers, why should anybody believe anything that neuroscientists had to say? Much hand-wringing followed. Was it because PET, which involves injecting a radioactive tracer into the brain, was unreliable? Were the studies themselves somehow sloppy? Nobody seemed to know.

And then, surprisingly, the field prospered. Brain imaging became more, not less, popular. The technique of PET was replaced with the more flexible technique of functional magnetic resonance imaging (fMRI), which allowed scientists to study people's brains without the use of the risky radioactive tracers, and to conduct longer studies that collected more data and yielded more reliable results. Experimental methods gradually become more careful. As fMRI machines become more widely available, and methods became more standardized and refined, researchers finally started to find a degree of consensus between labs.

Meanwhile, neuroscience started to go public, in a big way. Fancy color pictures of brains in action became a fixture in media accounts of the human mind and lulled people into a false sense of comprehension. (In a feature for the magazine titled "Duped," Margaret Talbot described research at Yale that showed that inserting neurotalk into a papers made them more convincing.) Brain imaging, which was scarcely on the public's radar in 1990, became the most prestigious way of understanding human mental life. The prefix "neuro" showed up everywhere: neurolaw, neuroeconomics, neuropolitics. Neuroethicists wondered about whether you could alter someone's prison sentence based on the size of their neocortex.

And then, boom! After two decades of almost complete dominance, a few bright souls started speaking up, asking: Are all these brain studies really telling us much as we think they are? A terrific but unheralded book published last year, "Neuromania," worried about our growing obsession with brain imaging. A second book, by Raymond Tallis, published this year, invoked the same term and made similar arguments. In the book "Out of our Heads," the philosopher Alva NoĆ« wrote, "It is easy to overlook the fact that images… made by fMRI and PET are not actually pictures of the brain in action." Instead, brain images are elaborate reconstructions that depend on complex mathematical assumptions that can, as one study earlier this year showed, sometimes yield slightly different results when analyzed on different types of computers.

Last week, worries like these, and those of thoughtful blogs like Neuroskeptic and The Neurocritic, finally hit the mainstream, in the form of a blunt New York Times op-ed, in which the journalist Alissa Quart declared, "I applaud the backlash against what is sometimes called brain porn, which raises important questions about this reductionist, sloppy thinking and our willingness to accept seemingly neuroscientific explanations for, well, nearly everything."

Quart and the growing chorus of neuro-critics are half right: our early-twenty-first-century world truly is filled with brain porn, with sloppy reductionist thinking and an unseemly lust for neuroscientific explanations. But the right solution is not to abandon neuroscience altogether, it's to better understand what neuroscience can and cannot tell us, and why.

The first and foremost reason why we shouldn't simply disown neuroscience altogether is an obvious one: if we want to understand our minds, from which all of human nature springs, we must come to grips with the brain's biology. The second is that neuroscience has already told us lot, just not the sort of things we may think it has. What gets play in the daily newspaper is usually a study that shows some modest correlation between a sexy aspect of human behavior, with headlines like "FEMALE BRAIN MAPPED IN 3D DURING ORGASM" and "THIS IS YOUR BRAIN ON POKER"

But a lot of those reports are based on a false premise: that neural tissue that lights up most in the brain is the only tissue involved in some cognitive function. The brain, though, rarely works that way. Most of the interesting things that the brain does involve many different pieces of tissue working together. Saying that emotion is in the amygdala, or that decision-making is the prefrontal cortex, is at best a shorthand, and a misleading one at that. Different emotions, for example, rely on different combinations of neural substrates. The act of comprehending a sentence likely involves Broca's area (the language-related spot on the left side of the brain that they may have told you about in college), but it also draws on the parts of the brain in the temporal lobe that analyze acoustic signals, and part of sensorimotor cortex and the basal ganglia become active as well. (In congenitally blind people, some of the visual cortex also plays a role.) It's not one spot, it's many, some of which may be less active but still vital, and what really matters is how vast networks of neural tissue work together.

The smallest element of a brain image that an fMRI can pick out is something called a voxel. But voxels are much larger than neurons, and, in the long run, the best way to understand the brain is probably not by asking which particular voxels are most active in a given process. It will instead come from asking how the many neurons work together within those voxels. And for that, fMRI may turn not out not to be the best technique, despite its current convenience. It may ultimately serve instead as the magnifying glass that leads us to the microscope we really need. If most of the action in the brain lies at the level of neurons rather than voxels or brain regions (which themselves often contain hundreds or thousands of voxels), we may need new methods, like optogenetics or automated, robotically guided tools for studying individual neurons; my own best guess is that we will need many more insights from animal brains before we can fully grasp what happens in human brains. Scientists are also still struggling to construct theories about how arrays of individual neurons relate complex behaviors, even in principle. Neuroscience has yet find its Newton, let alone its Einstein.

But that's no excuse for giving up. When Darwin wrote "The Origin of Species," nobody knew what DNA was for, and nobody imagined that we would eventually be sequencing it.

The real problem with neuroscience today isn't with the science—though plenty of methodological challenges still remain—it's with the expectations. The brain is an incredibly complex ensemble, with billions of neurons coming into—and out of—play at any given moment. There will eventually be neuroscientific explanations for much of what we do; but those explanations will turn out to be incredibly complicated. For now, our ability to understand how all those parts relate is quite limited, sort of like trying to understand the political dynamics of Ohio from an airplane window above Cleveland.

Which may be why the best neuroscientists today may be among those who get the fewest headlines, like researchers studying the complex dynamics that enter into understanding a single word. As Poeppel says, what we need now is "the meticulous dissection of some elementary brain functions, not ambitious but vague notions like brain-based aesthetics, when we still don't understand how the brain recognizes something as basic as a straight line."

The sort of short, simple explanations of complex brain functions that often make for good headlines rarely turn out to be true. But that doesn't mean that there aren't explanations to be had, it just means that evolution didn't evolve our brains to be easily understood.

Gary Marcus, a professor of psychology at N.Y.U. and the author of "Guitar Zero: The Science of Becoming Musical At Any Age", has written for newyorker.com about moral machines, Ray Kurzweil's new book, and deep learning.

http://www.newyorker.com/online/blogs/newsdesk/2012/12/what-neuroscience-really-teaches-us-and-what-it-doesnt.html

Tuesday, December 4, 2012

New Meaning and Drive in Life After Cancer - NYTimes.com

When people hear the words "You have cancer," life is suddenly divided into distinct parts. There was their life before cancer, and then there is life after cancer.

The number of people in that second category continues to grow. In June, the National Cancer Institute reported that an estimated 13.7 million living Americans are cancer survivors, and the number will increase to almost 18 million over the next decade. More than half are younger than 70.

A new book, "Picture Your Life After Cancer," (American Cancer Society) focuses on the living that goes on after a cancer diagnosis. It's based on a multimedia project by The New York Times that asked readers to submit photos and their personal stories. So far, nearly 1,500 people have shared their experiences — the good, the bad, the challenging and the inspirational — creating a dramatic photo essay of the varied lives people live in the years after diagnosis.

For Susan Schwalb, a 68-year-old artist from Manhattan, a diagnosis of early-stage breast cancer at the age of 62 led to a lumpectomy, followed by a mastectomy and then failed reconstruction surgery. She discovered that cancer was not only a physical challenge but a mental one as well, and she turned to friends and support groups to cope with the emotional strain. When she saw the "Picture Your Life" project, she submitted a photo of herself wearing a paint-splattered artist's apron.

"What cancer made me do in my own professional life is to pedal faster," Ms. Schwalb said in an interview. "I've encountered some people who decide to enjoy life, retire, work in a garden. I decided I had to have more of what I wanted in life, and I better move fast because maybe I don't have the long life I imagined I would have."

Indeed, a common theme of the "Picture Your Life" project is that cancer spurs people to take long-delayed trips, seek out adventure and spend time with their families. Photos of mountain climbs, a ride on a camel, scuba diving excursions and bicycle trips are now part of the online collage.

Dr. David Posner, associate program director of pulmonary medicine at Lenox Hill Hospital in Manhattan, says a diagnosis of metastatic colon cancer at the age of 47 has helped him relate to his own patients with cancer. The past decade has included nine operations, six recurrences and three rounds of chemotherapy, but Dr. Posner said he never missed more than three weeks of work.

"My salvation has been my family and my work," he said. "When I was at work I wasn't thinking about myself, and it was very therapeutic. I see my share of cancer patients, and I motivate them and they motivate me."

Dr. Posner said he decided to be part of "Picture Your Life" because he wants to get the word out that a cancer diagnosis — even a dire one like his — doesn't have to define your life.

"I think about someone asking me, 'So how was your last decade — was it wasted or was it a life filled with a lot of happiness and joy?' " he said. "The cancer thing was a pain, but for the most part I've had a pretty good time."

The "Picture Your Life" collage includes photo after photo of survivors with their pets. Sandra Elliott, 59, of Claremont, Calif., submitted a picture of herself with her two golden retrievers, Buddy and Molly. They were just puppies when she received a diagnosis of Stage 2 breast cancer in 2003. During her recovery from surgery and chemotherapy treatments, she took the dogs to romp on the Pomona College campus, near her home, and one day a professional photographer snapped the picture.

"No matter how bad I felt that day, no matter how many chemo treatments or doctors appointments, those two little puppies with these big black eyes would look at me with their tails wagging as if to say, 'It's time. It's time. It's time to go out!'  " Ms. Elliott recalled.

"I felt so physically horrible, and I'd look at them and the pure joy on their faces and in their bodies for just being out in nature and being able to smell the air, smell the trees, chase a squirrel — that sheer in-the-moment love of life they showed me really lifted my spirit on a daily basis."

Ms. Elliott still lives with chronic pain as a result of nerve damage from her cancer treatment, and she can relate to others in the "Picture Your Life" project who worry that their cancer will recur or that they'll never feel completely normal again. But she says a stronger theme runs through all the pictures and stories.

"We have all been forced to find the joy in the smallest things," she said. "I'm sitting here looking at a geranium about to bloom. These things are out there — we just have to be reminded to look at them. And cancer is a big reminder."

http://well.blogs.nytimes.com/2012/12/03/new-meaning-and-drive-in-life-after-cancer/

New Faces Of Meth Ads Are Utterly Harrowing - Business Insider

Eight years ago, the Multnomah County Sheriff's Office launched a campaign called "the Faces of Meth" to address Oregon's methamphetamine problem. The images showed the jarring effects of meth on addicts' faces through before-and-after pictures from their arrest records.

Rehabs.com recently followed suit with this infographic. Warning: these images are disturbing.


http://www.businessinsider.com/new-faces-of-meth-ads-are-utterly-harrowing-2012-12

Sunday, December 2, 2012

MiniManuscript

Imagine if each person in the world took just a few papers and read them, between us we could cover the lot. And that's exactly what MiniManuscript does - we've created a worldwide academic superbrain (Jake had a dream about that once) that uses a collaborative approach to reading papers so we can pool our resources, increase efficiency and free up valuable time for the finer things in life, like data collection (or Facebook). MiniManuscript is a website where users write summaries of research papers that they've read. By reading the summaries, you can spend 2 minutes rather than 2 hours deciding whether a paper is relevant to you.

http://www.minimanuscript.com/

Folk Medicine - Photo Essay - NYTimes.com

Dr. Ye Jiangsheng's home in Nanping Village, in Yixian county, is also his office, where, like nearly everyone else in the ancient town, he cultivates silkworms. A sign outside says "No. 2 Clinic" in Chinese, with "The Doctor's" written in English. The town is a warren of narrow alleys, stone and carved wood, ideal for kung fu heroes to jump from rooftop to rooftop or for tragic characters in Chinese costume dramas to wander from one darkened room to another. It's no surprise that the director Zhang Yimou is one of many to use Nanping Village as a film set.

A gray phalanx of fortresslike walls and terra- cotta roofs opens onto interior courtyards, Hui-style, as the local architecture is called. Life in Nanping Village unfolds inward, revolving around these age-old atria, like so many town squares, which locals decorate with paintings of the mountains they can't see over their windowless walls.

In Iwan Baan's photographs, Ye, the perfect country doctor, attends to his garden under his skylight, makes house calls over the cobblestones on an old bicycle, dons a lab coat to check a patient's sore throat and retires with his wife to sleep in a tiny, pitch-black bedroom, which, with its curtained platform below an enormous painted canopy, is like the insideof a lacquered puzzle box.

The peripatetic Dutch-born Baan went to capture this scene of a vanishing China for a photo festival last month. Chinese officials canceled the festival at the last minute, as they often do. But Baan was determined to show the pictures anyway.

Baan is prized as an architectural photographer and knows how architecture speaks formally. But whether documenting a vertical slum in an unfinished office tower in Caracas or Lower Manhattan blacked out by Hurricane Sandy, Baan photographs not just steel, brick and concrete. In the umbrella hung from the weathered wood screen in a patient's courtyard, as in the jumble of homely remedies on the bedside table, Baan celebrates real lives lived, architecture as humanity.

http://www.nytimes.com/interactive/2012/12/02/magazine/nanping-village.html?ref=magazine

Adderall, a Drug of Increased Focus for N.F.L. Players - NYTimes.com

The first time Anthony Becht heard about Adderall, he was in the Tampa Bay locker room in 2006. A teammate who had a prescription for the drug shook his pill bottle at Becht.

" 'You've got to get some of these,' " Becht recalled the player saying. "I was like, 'What the heck is that?' He definitely needed it. He said it just locks you in, hones you in. He said, 'When I have to take them, my focus is just raised up to another level.' "

Becht said he did not give Adderall another thought until 2009, when he was playing in Arizona and his fellow tight end Ben Patrick was suspended for testing positive for amphetamines. The drug he took, Patrick said, was Adderall. Becht asked Patrick why he took it, and Patrick told Becht, and reporters, that he had needed to stay awake for a long drive.

Those two conversations gave Becht, now a free agent, an early glimpse at a problem that is confounding the N.F.L. this season. Players are taking Adderall, a medication widely prescribed to treatattention deficit hyperactivity disorder, whether they need it or not, and are failing drug tests because of it. And that is almost certainly contributing to a most-troubling result: a record-setting year for N.F.L. drug suspensions.

According to N.F.L. figures, 21 suspensions were announced this calendar year because of failed tests for performance-enhancing drugs, including amphetamines like Adderall. That is a 75 percent increase over the 12 suspensions announced in 2011 and, with a month to go in 2012, it is the most in a year since suspensions for performance-enhancing drugs began in 1989.

At least seven of the players suspended this year have been linked in news media reports to Adderall or have publicly blamed the drug, which acts as a strong stimulant in those without A.D.H.D. The most recent examples were Tampa Bay cornerback Eric Wright and New England defensive lineman Jermaine Cunningham last week.

The N.F.L. is forbidden under the terms of the drug-testing agreement with the players union from announcing what substance players have tested positive for — the urine test does not distinguish among types of amphetamines — and there is some suspicion that at least a few players may claim they took Adderall instead of admitting to steroid use, which carries a far greater stigma. But Adolpho Birch, who oversees drug testing as the N.F.L.'s senior vice president for law and labor, said last week that failed tests for amphetamines were up this year, although he did not provide any specifics. The increase in Adderall use probably accounts for a large part of the overall increase in failed tests.

"If nothing else it probably reflects an uptick in the use of amphetamine and amphetamine-related substances throughout society," Birch said. "It's not a secret that it's a societal trend, and I think we're starting to see some of the effects of that trend throughout our league."

Amphetamines have long been used by athletes to provide a boost — think of the stories of "greenies" in baseball clubhouses decades ago. That Adderall use and abuse has made its way to the N.F.L. surprises few, because A.D.H.D. diagnoses and the use of medication to control it have sharply increased in recent years.

According to Dr. Lenard Adler, who runs the adult A.D.H.D. program at New York University Langone Medical Center, 4.4 percent of adults in the general population have the disorder, of which an estimated two-thirds are men. Birch said the number of exemptions the N.F.L. has granted for players who need treatment for A.D.H.D. is "almost certainly fewer" than 4.4 percent of those in the league.

The rates of those with the disorder fall as people get older; it is far more prevalent in children and adolescents. A report from the Centers for Disease Control and Prevention, using input from parents, found that as of 2007, about 9.5 percent or 5.4 million children from ages 4 to 17 had A.D.H.D. at some point. That was an increase of 22 percent from 2003. Boys (13.2 percent) were more likely to have the disorder than girls (5.6 percent).

Of children who currently have A.D.H.D., 66.3 percent are receiving medication, with boys 2.8 times more likely to receive medication. Those 11 to 17 years old are more likely to receive medication than younger children.

But Adderall, categorized by the Drug Enforcement Administration as a Schedule II controlled substance because it is particularly addictive, is also used by college students and even some high school students to provide extra energy and concentration for studying or as a party drug to ward off fatigue.

Dr. Leah Lagos, a New York sports psychologist who has worked with college and professional athletes, said she had seen patients who have used Adderall. She said she believed the rise in its use by professional athletes mimicked the use by college students. Just a few years ago, she said, it was estimated that 1 in 10 college students was abusing stimulants like Adderall and Ritalin. That estimate, Lagos said, has almost doubled.

"It's certainly a performance-enhancing drug," Lagos said. "College kids call it the Superman drug. Take someone who is tired after a long practice, give them a stimulant. It amps up their mood and energy. It really enhances their focus, and for football players, that's crucial.

"Athletes are often taking it to fight fatigue and exhaustion. It's almost like taking 100 cups of coffee. They can take it during training camp when their bodies are especially fatigued, and the other is right before a game, to boost them. Those are two patterns that are being reported most frequently. But there is the party scene, too, and that's happening on a larger level."

The long-term effects of taking Adderall are not well understood, doctors said. While doctors prefer Adderall with a sustained release to treat adults with A.D.H.D. — so that it calms them throughout the day — Adler said that data on students who were misusing diverted medication indicated they were often using a shorter-acting version of Adderall with effects that lasted just three to five hours.

"It may not get you through a game," Adler said.

Even if it does, the players union has tried to warn its members that substances like Adderall are banned unless a player receives a therapeutic-use exemption from the league. That process includes a review of an A.D.H.D. diagnosis by an independent administrator and other specialists.

There is a poster in each locker room about banned substances, and the union sent out a memo in October that emphasized that prescription drugs like Adderall are prohibited. Birch said efforts to make players aware of banned substances had been ample, though the league wishes the union would allow it to reveal what players test positive for. Officials think that it would be a deterrent and that hearing what others are caught for reminded players of what substances were banned.

George Atallah, a union spokesman, said he expected the number of positive tests to drop because of the greater attention being paid to Adderall. Players who have recently been suspended were tested earlier in the year, before Adderall became a topic of conversation throughout the league.

"It's a reflection that the system we have in place works," Atallah said. "Given the amount of suspensions we've seen this year, we have made a greater emphasis on making players aware of the policy on this particular substance."

Will Hill, though, said he did not think the N.F.L.'s Adderall problem would go away anytime soon. Hill, a safety for the Giants, served a suspension this season for Adderall use. Hill began using Adderall for A.D.H.D. in the spring and he said he did not realize it was on the league's banned list until he had already started taking it without getting the required waiver.

Hill said that beginning in high school, he needed extra tutors because of his limited attention span. He added that he could not stay still until he began taking Adderall. With Adderall, he is calm and able to focus on his tasks, on and off the field. On Thursday, Hill said he knew many people in and out of football who needed Adderall to function properly.

Hill was suspended in October; he has since watched one player after another blame Adderall for his positive test. He guessed that among players who use Adderall, "it's 50-50" whether they need it for A.D.H.D. or are using it because it is a powerful stimulant.

Hill said that he was troubled that there were players without the disorder who take Adderall for the jolt of energy and the extreme focus it provides, and by the idea that some players may be blaming the drug when they are instead taking steroids.

"It foggies everything up," Hill said. "This person can say it's Adderall, and how do we decipher the fakers from not? When you try to get an advantage over the next person, that's why we get into these situations we're in."

http://www.nytimes.com/2012/12/02/sports/football/adderall-a-drug-of-increased-focus-for-nfl-players.html?&pagewanted=print