Wednesday, February 29, 2012

A Follow-Up to The Psychological Profile of TJ Lane

Yesterday, I posted a psychological profile of Chardon school shooter, T.J. Lane (pictured to the left). As always happens, the day after such incidents, more detailed information emerges about the shooter. So far, everything I have read confirms the information I posted yesterday. Lane has already confessed to prosecutors that he shot his victims at random and did not know them (although he apparently knew one in middle school). 

This is consistent with the pattern of many school shooters, and the theory that he was lashing out against a “system,” be it society, government, the educational system, or all three. This type of behavior actually transcends school shooters and fits into a broader category of mass murderers who commit terrorist acts. For example, I remember walking through the Oklahoma City Memorial and seeing the tiny shoes of the babies who lost their lives after Timothy McVeigh bombed the federal building. McVeigh did not view the babies as innocent individuals who he had a personal problem with but saw them as necessary casualties of war in his fight against the government. In this sense, the victims are actually symbolic representations of a much larger system that the aggressor is upset about.

Although violence prediction is difficult, for Lane’s lawyer to say that this could never have been predicted is simply not true. Lane clearly was in a high risk category for this type of behavior based on what was noted yesterday. Part of this high risk comes from a troubled family life. More specifics regarding this have emerged that fits yesterday’s profile. Specifically, Lane's father has been arrested several times for violent crimes against female acquaintances, including his mother. For the first two years of Lane's life, his parents (who divorced in 2002) were both arrested for domestic violence against each other. His father also served prison time for assaulting a police officer and was charged with holding another woman under running water and bashing her head into a wall. He has been charged with kidnapping, felonious assault, attempted murder (eventually dropped), and disrupting public service. His father had been warned by law enforcement officials to stay away from him on multiple occasions. Thus, Lane clearly had a role model in life for violent behavior as a means to solve problems and lacked proper parental role models.  

It was noted yesterday that Lane attended an alternative H.S. and that this made it likely that he had academic and behavioral problems. Information disclosed today revealed that his alternative H.S. was a place for "at risk" students who are "reluctant learners" with problems such as "substance abuse /chemical dependency, anger issues, mental health issues, truancy, delinquency, difficulties with attention/organization, and academic deficiencies." Thus, there clearly were concerns that people had about him but it is unclear yet if any mental health professionals evaluated him and if anyone made any connections between his family background, belief systems, and tendencies for aggressive behavior.

On the 911 tape, Lane was described as a quiet kid who did not really talk to anyone, which, according to one friend, was associated with a Goth phase he became involved in as a freshman. Neighbors described him as very sullen, rarely showing his face and always wearing a hoodie, the latter being yet another symbol of alienation from society (when interpreted in the context of everything else that is known about him) as the hood can serve as a shell for him to hide in. It is noted that he wore a gray hoodie (again note the absence of bright colors) on the day of the school shooting based on 911 witness accounts. Another student noted that he would sit in the lunch room and no one knew he was there. That is interesting considering that the shooting occurred in the lunchroom. The school lunchroom is one of the most stigmatizing locations in school because this is where the student body becomes segregated into cliques. Students sitting by themselves in the lunch room (either by choice or through not being accepted) can be another sign of social alienation. Thus, he may have chosen an area that symbolized his social alienation as an area for the school shooting. The large availability of students to chose from in the lunchroom setting may have also played a roll.

Suggested Reading: Without Conscience: The Disturbing World of the Psychopaths Among Us

Tuesday, February 28, 2012

A Psychological Profile of Chardon School Shooter, TJ Lane

Nowadays, it seems like a school year does not pass by without a school shooting and the death of innocent children. When I was younger, the most other kids had to worry about was the school bully or maybe a gang, but no one ever feared that they could get killed in their classroom. It is difficult to say why school shootings have become so common these days.

It is likely some combination of increased access to firearms, worsening forms of bullying (such as cyberbullying), the influence of violent revenge themes in the media and entertainment venues (e.g, music, movies, video games), the breakdown of the family structure, and the increased availability of subculture movements such as Gothic and Emo that foster a sense of alienation from mainstream society. None of these factors by themselves is likely to trigger a school shooting. For example, there are many Gothic children and people who play violent video games who do not commit school shootings but the more of these variables are present, I believe that the likelihood of a school shooting increases.

Like many people, I am always interested in learning more about the shooter and the specific motive(s) behind the attacks. Before I know anything about the individual, however, there are a few things that I can usually make some safe assumptions about: 1) The person feels angry with and alienated from his peers and society (especially when the shooters attack people at random), 2) There were traumatic events (e.g., bullying, abuse, significant family dysfunction) in the person’s past that led to these feelings (which is not to excuse the shootings of course), 3) There is usually something in the person’s appearance (e.g, style of dress, physical characteristics) that shows that they are different in some way from their peers, 4) The person usually sends some signal ahead of time that the shooting was to occur. As it turns out, it seems that all of these criteria appear to have been met in this case. The reader should know that I have never met T.J. Lane and that I am not a professional criminal profiler. The profile of Lane that I put together is based on what I could gather from his Facebook page, early media reports (some of which may later be modified), knowledge of clinical psychology, and common sense.

When I first saw the picture above of the shooter, TJ Lane, my first reaction was that it fit the psychological profile I have of these shooters. The picture comes from his Facebook profile. Of all the pictures, he could choose, he picked one that was black and white, thus devoid of color. Color symbolizes positive emotions whereas black and white symbolizes the absence of such emotions and conveys a sense of despair and alienation, especially when other themes associated with this are present. This dark theme goes along with his black jacket, which may be related to the Gothic culture he became involved in. Note how he is looking to the side and not to his audience (Facebook friends). In this picture, he is showing that he does not want to look at you or have to look at you because he does not feel connected with you. The side profile picture also bears resemblances to side profile mug shots. You will notice that he is not smiling but instead looks disninterested, annoyed, and possibly angry. Self-esteem is likely low, which accompanies feelings of insecurity. His hands are in his pockets. Hands and fingers symbolize a sense of control (since we mostly control our environment with our hands and fingers) and thus hands in the pockets may indicate that he feels a loss of control in his life. Taking a gun and shooting people is a maladapative way to re-exert control and gain attention, which can improve his own feeling of self-importance. He is thin and one is left to wonder if he was picked on for his appearance, which was later confirmed via media reports. Other pictures on his Facebook page showed him shirtless with his arms folded and a defiant look on his face and he is never smiling. Thus, the only times where he does look at his audience, he is conveying a sense of anger. The profile picture was updated last, however, indicating a growing sense of alienation from others.

Initial media reports stated that Lane had family problems, was being constantly teased by many of the kids in school (e.g., about his hair, clothes, quiet demeanor), often had a sad look in his eyes, was upset about a girl in school, was quiet, very guarded, and a loner who did not belong to any particular group.  Some students assumed he was normal but admitted they did not know much about him. One student stated he got into the Goth phase in the 8th grade. He lived with his grandparents, his older brother was in prison, and he attended an alternative school, which indicates he had a history of academic and/or social emotional difficulties requiring alternative school placement. He may have had a split with a girlfriend on Valentine’s Day and may have been upset that she was dating a former friend. In fact, on 2/17/12, he posted a song on his Facebook page entitled “Blood on the Dancefloor” that centered around an angry male figure with a demonic Gothic appearance trying to break the spell of a female lover. This included lyrics such as “Now is the time, now is the hour. To take back my heart, to take back my power. This is the moment to break your spell. I see right through you... Burn in hell witch.”

Review of Lane’s Facebook page showed that he claimed to work for a non-profit organization called “Free the Slaves,” which claims to liberate slaves around the world and attack the systems that allow slavery to exist. Note the phrase “attack the systems” which generally refers to governmental systems (which includes school). He could have taken this phrase literally in carrying out an attack against “the system.” This may sound like wild speculation, but consider the following. He clearly seems to have felt alienated from the educational system as indicated by the fact that under “College” he listed “We don’t need no education.”  Even more troubling was that under High School, he wrote “We don’t need no thought control.” Thus, he seems to have believed that his school was controlling his thoughts, all of which sounds eerily similar to the video of Jared Loughner walking through Pima County College, ranting about mind control, loss of freedom of speech, the school’s control of the grammar, and his “genocide school” before he shot, injured, and killed several people at a governmental event.

The phrases “We don’t need no education” and “We don’t need no thought control” come from the famous Pink Floyd Song, “Another Brick in the Wall” which partly has to do with a protest against rigid schooling. Incidentally, Pink Floyd is listed as one of his favorite music groups. The music video for the song portrays a teacher reprimanding a young student (who bears some resemblance to Lane) for writing poems in class, which Lane liked to do (see end of this blog entry). The child then engages in fantasies of destroying the school and killing his teacher.

This begins to suggest the possibility of a psychotic disorder in which one is detached from reality. This is again speculation, but further suggestive of this was that he listed one of his favorite philosophers as David Icke, who has described himself as being the most controversial speaker in the world based on his belief that a secret group of reptilian humanoids called the Babylonian Brotherhood is controlling the world. Icke’s worldview is replete with conspiracy theories, which is common among people with paranoid belief systems.

Lane also listed Credo Mutwa as a favorite philopher. Credo Mutwa is a Zulu sangoma (spiritual healer) who is know for his writings against the African government in his pursuit to see the “truth.” In Mutwa’s own words, “I am one of the scums of this earth, a creature dejected and ridiculed by university professors” and “I have been scorned; demonise lied about by conspirators…” This is another reference to alienation and anger towards educational systems. Interestingly, Credo Mutwa writes about listening to David Icke. One of Lane’s favorite books listed was David Icke’s “Guide to the Global Conspiracy and How to End It.”

Another book Lane listed as a favorite was “Alice in the Country of Hearts.” The book centers on an insecure main character (who Lane likely identified with) in a strange world named Wonderland and is forced to interact with the inhabitants. Everyone in Wonderland is reckless as to who lives or dies, everyone distrusts each other, and has an instinct to kill. Sound familiar? Continuing with Lane’s seeming immersion into a bizarre fantasy life was that another favorite book listed was the “Death Note” series, which centers around a high school student who finds a book called the Death Note that allows the reader the ability to kill anyone whose name and face they know by writing the name in the book and picturing their face. To date, several students across the country have been caught and disciplined for possessing Death Note books containing the names of other students. I will not be surprised at all if Lane had one as well.

In terms of movies, Lane listed the movie “Let Me In,” which tells the story of an adolescent boy who is continuously harassed by bullies, neglected by his parents, and develops a relationship with a vampire child (re: Gothic association).  He also liked “Fight Club,” which is a violent movie that was designed to serve as metaphor for the conflict between the younger generation and the traditional values of society. Lane’s sense of disconnection from society is emphasized by him writing that one of his interests and activities is “wandering aimlessly.”

Lane’s Facebook page also contained dark poetry that he wrote in class and posted on 12/30/11: "In a quaint lonely town, sits a man with a frown. No job. No family. No crown. His luck had run out. Lost and alone. His thoughts would solely consist of “why do we exist?” His only company to confide in was the vermin in the street. He longed for only one thing, the world to bow at his feet. They too should feel his secret fear. The dismal drear. His pain had made him sincere. He was better than the rest, all those ones he detests, within their castles, so vain. Selfish and conceited.” He goes to discuss how the castle kept the peasants at bay and did not keep the enemies away and how he castle’s every story “was just another chamber in Lucifer’s laboratory.” The story continued to attack society and desires for the castle to fall. He wrote about going through the castle, past guards, and making others beg for mercy and ending with "Feel death, not just mocking you. Not just stalking you but inside of you. Wriggle and writhe. Feel smaller beneath my might. Seizure in the Pestilence that is my scythe. Die, all of you."

This story is clearly the writings of an angry and insecure individual who has strong revenge fantasies. The castle was likely a metaphor for his school and he was foreshadowing events to come. Unfortunately, as in many similar cases, no one put the pieces together before hand. In fact, four of his Facebook friends liked the story and 49 shared it with other friends. No one wrote a public comment of concern or disapproval. For a follow-up to this blog entry on TJ Lane, click here.

Suggested Reading: Without Conscience: The Disturbing World of the Psychopaths Among Us
Related blog entries:
A Psychological Profile of Wade Michael Page: The Sikh Shooter
A Psychological Profile of James Holmes: The Joker Killer
Cannibal Icepick Killer Luka Magnotta was Not Born Evil.

Monday, February 27, 2012

Restaurant Impossible Shines Light on the Need for Health Department Reform

A TV show I enjoy tuning into is Restaurant Impossible. To those who may be unfamiliar with it, the show revolves around all-star chef, Robert Irvine (pictured to the left), who goes to failing restaurants and tries to save them in two days with a $10,000 budget. This often involves improving customer service, redesigning menus, improving kitchen cleanliness, improving marketing, and/or redesigning restaurant.

One of the patterns I have noticed on the show is that many of these failing restaurants have filthy kitchens. But last week, I saw the most extreme and appalling version of filth when I watched the episode called “Anna Maria’s” in which Chef Irvine tried to fix a restaurant that bears this name in Dumore, Pennsylvania. Among the problems noted during the show were a) layers and layers of food and grease covering stove tops, pots, overhead vents, and kitchen appliances (which included a pot on the stove that was caked in so much black grime it looked like something you would find in a dungeon); b) bacteria, slime, and old food on the floors, and behind/under/on restaurant equipment, c) filthy refrigerators with open containers of food, and c) a basement with food (e.g., flour) stored next to chemicals. Of all the shows, I never saw Chef Irvine so upset. He nearly vomited in the kitchen on screen and suggested that he actually did vomit later in the show. I could go on describing the horrors of this kitchen but you really have to see the show to believe it.

The advertisement for the show on my DVR said that the kitchen had not been cleaned in about 25 years. I am not sure if that was hyperbole, but regardless, the kitchen clearly had not been cleaned in a long time. When I heard this and saw the state of the kitchen, I was shocked and upset that the government could allow a restaurant to continue to serve food to the public like this and put them at risk of food poisoning (e. coli). But I was even more shocked when I read an article stating that the restaurant actually passed a health inspection nine months prior. The restaurant owner’s son claims that the Food Network exaggerated the state of the restaurant for the purposed of TV.

While I am fully aware the not everything on TV is how it seems, it simply stretches all credulity for me to believe that the Food Network planted the dirty pots, coated the kitchen equipment with bacteria-laden slime, made the refrigerators filthy, planted old food behind equipment, and brought food in the basement to put it next to chemicals. There is too much evidence the other way, such as that a) the chef (Rudy) said on camera that the kitchen had been in that condition for four years, b) the owner and her son allowed Irvine to send customers home after he tossed out a filthy stove vent for them to see, c) the owner and son admitted that the kitchen had fallen into an embarrassing state, d) the show normally does not spend this much time focused on kitchen clean-up needs, e) no one has sued the Food Network over false presentation, f) Chef Irvine genuinely appears to want to help people, and g) the visual evidence of the state of kitchen clearly indicates this was a process that took a very long time to create.

It is all too easy to blame the Food Network for exaggerating the state of restaurant as part of some type of conspiracy theory. How about two alternative and more parsimonious explanations: 1) The restaurant owners are embarrassed and understandably concerned that no one is going to come to their new restaurant after seeing an expose of it on television (which is a public relations disaster) and so they blame the Food Network for exaggerating it as a form of damage control; 2) The Health Department is not doing their job.

Explanation number one does not need a further explanation, but consider number two a bit further. Not only did this restaurant pass health explanation nine months prior, but not a single violation or risk factor was found. How can that possibly be true? It is possible that the inspection was either never done but signed off on or that an inspector signed off on the report knowing there was a deficiency. Why would that be? Sometimes, restaurant owners have political connections with health inspectors that allows the process to be circumvented. This is more likely to be the case in small cities such as the one this show was filmed in.

All in all, I now have no confidence that health inspections mean anything and have become increasingly careful about the types of restaurants I frequent, preferring to go to ones with an open kitchen that I can see for myself or ones where I can peak into the kitchen. If I cannot see the kitchen, then I use proxy indicators such as how clean the bathrooms are, floors, tables, walls, ceilings, the dining ware, the staff, and the food as an indicator of the state of the kitchen. State, county, and city governments need to revisit the health inspection process to make reforms so that the process works as intended and the public can once again have confidence in how the system works. I also believe there should be a law that allows customers to view the kitchen of restaurants before placing an order.

Friday, February 24, 2012

Cookie Monster Is Not Autistic

In 1984, an article was written in the publication, Children Today, in which Cookie Monster was labelled by children with disabilities as autistic because he ate messy and only said "Cookie." Scientific understanding of this condition has greatly improved since then and at this point, I do not believe Cookie Monster would meet diagnostic criteria for autistic disorder (also known as autism).

RECOMMENDED BOOK: Autism: A Practical Guide for Parents

One of the essential criteria for autistic disorder is that the affected individual has a qualitative impairment in social interaction. This can be manifested by at least two of the following: a) marked impairment in nonverbal behaviors to regulate social interaction, b) failure to develop peer relationships appropriate to developmental level, c) lack of spontaneous seeking to share enjoyment, interests, or achievements with people (e.g., by pointing out objects of interest), or d) lack of social or emotional reciprocity.

Cookie Monster clearly demonstrates adequate social interaction. For example, in the interaction below with Kermit The Frog, he uses very good eye contact and hand gestures to facilitate communication. He clearly demonstrates social reciprocity in playing the guessing game with Kermit and it is clearly established in Sesame Street that he has developed good relationships with other Muppets such as Kermit, The Count, and Prairie Dawn.

The next criteria that would need to be met is a qualitative impairment in communication. This would be evidenced by at least two of the following: a) delay or total lack of the development of spoken language, b) marked impairment in the ability to initiate or sustain a conversation with others, c) stereotyped and repetitive use of language or idiosyncratic language, or d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level.

While Cookie Monster does have some problems speaking with proper grammar (e.g., “Me Want Cookie!”) he does not truly meet any of the criteria mentioned above. Someone may want to make an argument that his language is idiosyncratic and that he can sometimes be repetitive (e.g., “Om, om, om, om, om”) when he eats a cookie, but I just chalk that up to him being extremely happy that he is eating cookies. Clearly, Cookie Monster is very capable of carrying on lengthy conversations, initiating them (as he does in the video clip with Kermit), and sustaining them.

Lastly, to meet criteria for autistic disorder, Cookie Monster would need to have a repetitive or stereotypes pattern of behavior, interests, and activities, as manifested by at least one of the following: a) an encompassing preoccupation with one of more stereotypes and restricted pattern of interest that is abnormal in intensity and focus, b) an apparently inflexible adherence to specific, nonfunctional routines or rituals, c) stereotyped and repetitive motor mannerisms, and d) persistent preoccupation with parts of objects.

Cookie Monster can be said to meet some of the latter criteria (a and b) because he is clearly pre-occupied with cookies to an abnormal degree and it seems that he has to eat his cookies each day and is not too flexible on the matter. However, anyone can meet one or two criteria of various mental health disorders without having the condition of interest due to not meeting full diagnostic criteria. That is the case with Cookie Monster. I have not seen any convincing evidence that he meets criteria c or d.

So what does our furry little blue friend have wrong with him? Obsessive compulsive disorder (OCD) is technically possible in which his compulsive cookie eating may be a way to relieve anxiety caused by recurrent and persistent thoughts to devour cookies. However, to answer this would really require a good clinical interview with him to see if he meets all the criteria of true obsessions and compulsions. Furthermore, he would need to engage in compulsive cookie eating for more than an hour a day and we do not know if he does that. Another possibility is bulimia nervosa, in which someone binge eats a large amount of food and then uses inappropriate mechanisms to prevent weight gain, such as vomiting or laxative use. We have no idea if Cookie Monster is running to the bathroom afterwards but if he is trying to prevent weight gain, it does not seem that it is working as he does seem overweight.

My impression is that Cookie Monster has impulse control disorder not otherwise specified.  This is a failure to resist an impulse, drive, or temptation to perform an act that is harmful (e.g., causing obesity, diabetes mellitus) to the individual or others. Most people with this condition feel an increasing sense of tension or arousal before committing the act and then experience pleasure, gratification, or relief at the time of committing the act.

Related Blog Entry: Why Kermit the Frog Rules.

Thursday, February 23, 2012

Whitney Houston Death Photo Is No Surprise

A major controversy has erupted over the National Enquirer publishing a supposed death photo of Whitney Houston on the cover. Some people are upset because they believe that it is disrespectful to the dead to publicize such photos. However, so many people have a fascination with death and morbidity that even though they may agree that there is something wrong with publicizing the photo, they will look anyway.

RECOMMENDED BOOK: Remembering Whitney

This is why people rubberneck at car accidents. They don’t really want to see an injury or death, but they look anyway. This public fascination with death is why we Michael Jackson’s death photos can be found on the internet, why there was a public broadcasting of the dead bodies of Saddam Hussein’s adult children, why the documentaries The Faces of Death were so popular, why horror movies are popular, and why there was a clamoring for the release of Osama bin Laden’s death photos, the latter of which the U.S. government did not release.

But back to Whitney Houston and the National Enquirer. This was all so predictable. It is well known in psychology that past behavior is a great predictor of future behavior. In 1977, the National Enquirer posted a death photo of another famous singer, Elvis Presley. As you can see from the photo below, even the same exact catch phrase (“The Last Photo”) was used on the cover:

Wednesday, February 22, 2012

A Doctor's Touching Experience on Ash Wednesday

Today is Ash Wednesday. Whether you are religious or not, below is a touching story of one medical doctor’s (Dr. Richard Pesce’s) experience on Ash Wednesday with a patient named Drew.

Entering the intensive care unit (ICU) to begin rounds after a weekend off call, I found a patient of mine had been admitted in respiratory distress. We had known each other since his coronary bypass surgery several months earlier. This surgery had been followed by multiple complications, including sternal breakdown due to staphylococcal infection. This was followed by four sternal repair attempts and finally omental flap closure before Drew could be weaned from the ventilator. The repairs were more difficult than usual because he had received radiation therapy to his mediastinal area for Hodgkin's disease many years before. This left him with a compromised blood supply to the sternum and a restrictive cardiomyopathy. After 2 months and many hours of worry on both sides, he could finally be discharged to home. He had been at the office a half dozen times since to control his pleural effusions by thoracentesis. The effusions finally began responding to combination diuretic therapy. The last time I saw him prior to admission he had improved and, although still weak, he was beginning to enjoy life and being with his family.

As I entered his ICU room I saw that things had quickly deteriorated. Staphylococcal endocarditis, acute and bacteremic, had taken hold. Drew looked gray, he was barely able to whisper, and his breath sounds were hardly audible.

"Drew, I have to help you breathe!"-he nodded in response. As we laid his head down for intubation he calmly submitted. I could not use any sedatives because of his hemodynamic instability. I needed to place an endotracheal tube and obtain venous access, but sternal surgery had caused contraction of his neck muscles, so no usual access was available. I continued, however, through radiation-toughened skin, and with care because his clavicles were out of alignment. I was able to obtain a femoral artery blood gas and place a femoral intravenous line. But I saw that this had caused him discomfort despite local anesthetic.

"My God," I thought. "I am taking part in a crucifixion." This man lay in front of me awake and suffering. I was unable to relieve his pain just then and had to continue to do procedures to stabilize him.

Drew's family had arrived, and quick exchanges took place. We had met many times before and had discussions regarding the "what ifs" of his condition. His family was wonderful and supportive. There was not anything they would not try to accomplish for their father and husband. His daughter asked if anything else could be done, knowing what the answer would be. (Even during his first surgery his aorta could not be cross-clamped because it was so friable. To attempt valve replacement was not possible.) As the patient's pressure continued to fall, episodes of bradycardia began. He would respond to boluses of epinephrine and then fade again. His wife asked that their priest be called to administer the Sacrament of the Sick and that comfort measures be taken.

They were. Father Mike arrived quickly. He had known this family for many years and had been in school with some of the children. As he began the service, Drew's family gathered at his bedside and prayed out loud the Lord's Prayer. Each person told Drew that he should feel free to go to his reward, thanking him for having loved and cared for them so well. As the priest continued the annointment, I could see the heart monitor record slower and slower beats. They all then kissed him goodbye. At the end of the last word of the last prayer the monitor became flatline. At 9:20 AM, it was over.

As the family said their last goodbye, each one thanked me for trying to help Drew. I was speechless. Seldom had I witnessed such closeness in a family, and seldom had I felt so powerless to do anything that may have been of benefit. Yet to have these people thank me was more than I could bear.

Later that morning, I attended the Ash Wednesday service at the hospital's chapel. Drew's family was there and Father Mike was saying the Mass. Ash Wednesday is the day most Christians begin to spiritually prepare themselves for the celebration of the death and resurrection of Christ on Easter Sunday. It culminates in the placement of ashes on the forehead to remind us that we are from the earth and shall return to it when we die. It is a time of sacrifice and reflection. I was the last person to receive the ashes. Father Mike looked at me and said, "From dust thou art and to dust thou shall return, Doctor."

As I acknowledged him, I thought, "Yes, I will accomplish this. But have I accomplished my mission 'To cure sometimes, alleviate suffering often, and comfort always'?" At that moment, Drew's wife approached me: "Thank you for always being there for us, you will always be in our prayers." At that moment my question was answered and doubt resolved.

On this Ash Wednesday, I felt the uplifting spirit of a family's love for their father and husband and the hope for a better life. I have been privileged. Thank you, Drew.

The above article is publicly available here.

Monday, February 20, 2012

Did Abraham Lincoln Have a Genetic Disorder?

February is a month where we not only celebrate the birth of George Washington, but also Abraham Lincoln. In a recent blog entry, I discussed some fascinating aspects surrounding Washington’s death. Today, attention turns to Abraham Lincoln. Unlike Washington’s death, many people are aware of Lincoln’s untimely demise via assassination.

FEATURED BOOK: Abraham Lincoln: Vampire Hunter

Many people are also aware that Lincoln had a distinguished yet unusual look about him. As you can see from the picture above, Lincoln’s distinguished look consisted of hollow eye sockets, long thin lips (with an m-shaped curve on the upper lip and a blubbery lower lip), and a long drawn out face. He was also tall (6’4), thin, and had large feet.

It has long been suggested that Lincoln had Marfan syndrome. Marfan syndrome is a genetic disorder of connective tissue which causes unusual tallness, long limbs, and long thin fingers and toes. Cardiac problems are common, with shortness of breath during exertion. While Lincoln was tall, he was not abnormally tall.  His fingers seemed proportional to his body (as is seen in the picture to his left) but did not look as long as what fingers typically look like in Marfan syndrome (see picture to the right). He was known as an excellent axeman, rail fence builder, and wrestler, which would have required good cardiac functioning. Geneticists now think it is unlikely that Lincoln actually suffered from Marfan syndrome.

More recently, a new theory emerged from Dr. John Sotos in a book known as The Physical Lincoln. The theory is that Lincoln actually suffered from a different genetic disorder that has skeletal features almost identical to Marfan syndrome, known as multiple endocrine neoplasia type 2B (MEN2B). Individuals with this condition tend to be tall, thin, with a long face, and protruding blubbery lips. All patients develop benign tumors of the mouth, eyes, and connective tissue that supports mucous membranes throughout the body. Cancer of the thyroid almost always occurs and cancer of the adrenal grand occurs in about half of the cases. Chronic constipation is a common symptom.

Lincoln clearly was tall and thin, had a long face, and protruding lips. Other characteristics Lincoln was known to have that occur in MEN2B include constipation, low muscle tone, lumpy lips, and possible cancer. The right cheek mole, facial asymmetry, droopy-eyelids, and depressive-like symptoms were also considered to be consistent with the diagnosis. Lincoln may have also grown a long beard later in life to cover up benign facial tumors. People with the condition usually die young, which is the main challenge to this theory. However, Dr. Sotos believes that Lincoln would have died within a year from cancer if he was not assassinated at age 56.

Genetic testing can confirm a diagnosis of MEN2B. The “problem” is that no one is going to allow for a U.S. President’s body to be exhumed (especially not someone as iconic as Lincoln) to test such a hypothesis. In addition, Lincoln’s coffin was encased in steel and concrete after a theft attempt and the last wishes of his family was for Lincoln’s body to be left alone. However, there is one other possibility where a DNA sample can be taken from: a blood stained Lincoln relic. One option was the bloodstained pillow (pictured below) that Lincoln laid on after being assassinated, which is stored in a Philadelphia museum. The museum eventually denied a request to test it.

Dr. Sotos eventually joined forces with a geneticist at the Cleveland Clinic (Dr. Charis Eng) and they were able to secure a sample of a dress worn by Laura Keen. Keen was an actress who rushed to Lincoln’s side after he was shot, causing blood stains to transfer to her dress. After months of work the testing was only able to find some genetic mutations that could be minor contributors to MEN2B but no conclusive evidence that he had the disease. Only by obtaining further samples from other sources will it be possible to come to a definitive answer.

Friday, February 17, 2012

Did Physicians Kill George Washington?

President’s Day, also known as Washington’s birthday, is a celebration of the life of George Washington. While it is well known that he was the first U.S. President, crossed the Delaware River, and helped defeat the British, many people do not know about the noble and fascinating medical aspects surrounding his death (see comparison story on Abraham Lincoln).

On December 12, 1799, Washington had been riding his horse at Mt. Vernon for a prolonged period of time (10:00 am to 3:00 pm) in cold weather and precipitation. He came in and ate dinner without changing his clothes. Washington denied that his clothes were wet but his secretary, Tobias Lear, stated his neck seemed wet and that there was snow in his hair. At night, he reportedly appeared well.

The next day, it snowed heavily. Despite developing a cold and sore throat, Washington still went outside to do some yard work. According to George Washington Custis (a relative), Washington came inside, developed chills and nausea in the afternoon, changed his wet clothes, and continued to work. At night, he did not feel well and drank a cup of tea to soothe his hoarse throat, which had worsened. Lear told him to take something for his cold at night, but Washington declined. He tried to rest at night, but he tossed and turned with fever and pain. He awoke his wife between 2 to 3 am to say he was sick. He could barely speak and had labored breathing. Despite his discomfort, he did not want outside help to be called because he did not want to disturb anyone else’s rest.

On 12/14/79, Washington allowed for help to be sought at dawn. Lear came to the scene and stated he could hardly utter an intelligible word. He requested that an employee be called to help him by bloodletting. Bloodletting was a common medical practice for over 2,000 years and involved drawing blood out of the patient’s body (usually through a vein in the arm or neck) with the hopes that it would cure or prevent disease by removing the offending agent. This ancient medical practice was based on the belief that a woman’s menstruation purged the body of bad substances. Despite the good intentions of bloodletting, it was usually harmful to patients. As such, it was not helpful to Washington and his conditions worsened.

A molasses-butter-vinegar mixture was prepared for his sore throat, but he could not swallow it. Any attempt to do so caused distress, convulsions, and near-suffocation. He was bled again. His wife tried to intervene, questioning whether this was appropriate treatment, but Washington insisted more blood be let out. After half of a pint of blood was removed, the blood letting was stopped as it provided no relief and his wife remained uneasy.

Since oral intake was impossible and the standard treatment of the day (bloodletting) was not working, his throat was gently bathed with a salve. His feet were bathed in warm water. neither treatment helped. Another doctor tried to treat his throat with a blister of Cantharides, more blood letting, and inhaling steam from water and vinegar. He almost suffocated when trying to gargle. As the day progressed, Washington did not speak much but stated he was very ill. He was bled two more times. The blood came out slow and thick at this point, but he did not faint. His multiple doctors then treated him with calomel and tartar emetic.

A book in 2002 entitled Doctors Killed George Washington alleged that doctors took a “mild” complaint and bled Washington to death. It has been suggested that the focus of bloodletting may have killed Washington by preventing a search for other remedies. However, Washington did not have a mild complaint, but had clearly been severely ill before the bloodletting. He likely became ill in the first place by making his body more vulnerable to illness after prolonged exposure to the winter elements. Third, other remedies were indeed tried as noted above and by Custis:

“The medical gentlemen spared not their skill, and all the resources of their art were exhausted in unwearied endeavors to preserve this noblest work of nature.”

While the bloodletting was clearly excessive and would not be done today, doctors were treating Washington with the limited medical techniques of colonial times and should not be accused of killing him anymore than doctors of today should be accused of killing patients who have incurable diseases with current technology yet attempt to treat it with methods that will be considered outdated hundreds of years from now.

At 4:00 pm, Washington provided instructions for his will and wake. He was in great pain and distress in the afternoon, had difficulty breathing, and was restless. When his secretary tried to reposition him for comfort, he was concerned about causing his secretary fatigue. He thanked his doctors and others for help but asked that they let him die in peace. Regardless, at 8:00 pm, the doctors tried to treat him with a hot medicated cloth and applied wheat brain to his legs and feet.

Custis describes Washington’s very last moments in such an elegant way that it would be a disservice to paraphrase it. As you will read, the founding father left the world between 10 and 11pm that evening in the noble way that he lived it,

“The patient bore his acute sufferings with fortitude and perfect resignation to the Divine will, while as the night advanced it became evident that he was sinking, and he seemed fully aware that 'his hour was nigh.' He inquired the time, and was answered a few minutes to ten. He spoke no more - the hand of death was upon him, and he was conscious that 'his hour was come.' With surprising self-possession he prepared to die. Composing his form at length, and folding his arms on his bosom, without a sigh, without a groan, the Father of his Country died. No pang or struggle told when the noble spirit took its noiseless flight; while so tranquil appeared the manly features in the repose of death, that some moments had passed ere those around could believe that the patriarch was no more."

Thursday, February 16, 2012

The Heart Attack Grill

If you go to Las Vegas, one of the many restaurants you will encounter is the Heart Attack Grill. It is probably the most extreme and unhealthy place to eat in the United States and deliberately courts controversy with its use of extreme menu item names, unusual promotions, and unique themes. An example of the extreme food names include Flatliner Fries (French fries made with pure lard), Butter-Fat Shakes, and the Bypass Burger (which comes in Single, Double, Triple, or Quadruple Bypass sizes), the latter of which contains 12 slices of bacon, two pounds of beef, and four layers of cheese. No lettuce is allowed. Burgers can be as high as 8,000 calories (i.e., 4 days worth of calories in one burger). Obese customers over 350 pounds eat for free if they weigh in with a scantily clad “nurse” (waitress) or “doctor” (waiters). Orders are called “prescriptions” and customers are called “patients.” Finishing a triple or quadruple bypass burger allows customers to be wheeled out to their car by their own personal nurse. On 2/11/12, one customer was wheeled out a real stretcher when he suffered an apparent heart attack after eating a triple bypass burger.

The knee jerk reaction to the Heart Attack Grill concept is to either laugh or become angry. Either reaction plays into the hands of the owner (Jon Basso), which is to gain attention by purposely and cleverly courting public controversy by turning political correctness about medical issues on its face.

For those who are upset by the Heart Attack Grill concept, it is important to remember that the owner is at least being blatantly out front and honest about the food he serves, rather than other fast food restaurants that do not take this approach. For example, should you be more upset at The Heart Attack Grill’s Bypass Burgers that blatantly indicates how bad it is for you based or at Burger King’s Triple Whopper Sandwiches which requires some searching to find out that they are 1140 calories?

To be clear, I am not saying people should not be bothered about the Heart Attack Grill. Personally, I have mixed and vacillating feelings about it. On the one hand, it is certainly justified to be upset that someone would sell an 8,000 calorie menu item but on the other hand we do live in a free country where people have the right to eat unhealthy if they want to.

While eating one burger during your life time from the Heart Attack Grill on vacation will likely not kill you, eating these burgers on a regular basis likely will, a point the owner readily admits. However, if someone does dies from eating at the Heart Attack Grill regularly the primary blame falls to the patient for doing so despite knowing the risks. After all, the slogan of the Heart Attack Grill is “Taste Worth Dying For.” All of thie being said, Basso cannot absolve himself from all blame because he is peddling this type of extreme food to the public.

Ultimately, the success or failure of the Heart Attack Grill depends on market forces. That is, if enough people decided not to eat there due to the health risks, then the company will go out of business. If people flock to the restaurant, then it will flourish. It’s as simple as that. The Heart Attack grill has been open since 2006, indicating that the concept attracts customers.

Wednesday, February 15, 2012

Heart-shaped lesion in the brain: Neurosarcoidosis

Yesterday was Valentine’s Day. A day of love and happiness, often symbolized by Cupid, chocolate, and of course hearts. Just about everything you can imagine can be found in a heart shape for Valentine's Day. While heart-shaped objects are expected within this context, it is not something you expect to see when taking a picture of the inside of someone’s brain. But that is exactly what two neurologists from Baylor School of Medicine found when a 27-year old man underwent a brain MRI (magnetic resonance imaging) scan.

The picture to the left shows an axial slice of the brain, which is a top-down view. The heart shaped lesion (abnormal area) can be seen on the bottom. The picture to the right is a saggital slice of the brain, meaning it shows the brain from the side. The heart-shaped lesion is clearly visible in white towards the right of the image.

So what are these heart shaped areas? They are areas of inflammation caused by an inflammatory condition known as neurosarcoidosis. Headache is the most common symptom but seizures can also occur. Both occurred in this patient. The final diagnosis in this case was made upon a biopsy. The condition is treated with medications that reduce inflammation (corticosteroids) such as Prednisose but chemotherapy drugs or medications that suppress the immune system are used in some cases that do not respond to corticosteroids.

The reference for the study is: Suárez Zambrano GA, Hutton GJ. (2008). Heart-shaped lesion secondary to neurosarcoidosis.Arch Neurol. Oct;65(10):1388-9. The images are copyrighted by the American Medical Association.

Monday, February 13, 2012

The Trick to Low Sodium Chicken Soup

It’s winter in Syracuse in NY, and although it has been a very mild winter, a nice bowl of chicken soup always feels good this time of year. I headed off to the grocery store this weekend to make a batch of chicken soup for the family. Obviously, one of the key ingredients in chicken soup is broth. Chicken soup recipes almost always call for chicken broth and if you are not going to make your own broth, then you need to purchase some in the store. So I was looking at the sodium levels for every chicken broth brand I could find (including the one reduced sodium item), including those in the all-natural section of the store. On average, each product had about 500 mg of sodium per serving (some over 700 mg), with each product containing 4 to 5 servings. If you are making enough soup for a small family that means you will use about 24 ounces of broth. That translates to a whopping 4000 to 5600 mg of sodium in the soup, which is completely unnecessary.

Then I picked up a box of low sodium vegetable broth, which only contained 140 mg of sodium per serving with 4 servings per 12 ounce box. That’s only 1120 mg of sodium for 24 ounces of soup. Compared to 4000 to 5600 mg of sodium for chicken broth, that is a big difference. So, I figured why not just toss all the ingredients into the vegetable broth, let the natural juices of the chicken cook out, which would then make the broth taste like chicken broth anyway, with much less sodium. I tried it out and it was a rousing success. The broth was delicious, was infused with the juices of the chicken, and best of all, I knew I was feeding my family something much healthier. Please pass this on to others, try it yourself and comment here on how it went, and feel free to pass on your own health eating tips for others.

Friday, February 10, 2012

Progeria: Children with an Elderly Body

If you have ever seen the movie, The Curious Case Of Benjamin Button, you may have been under the impression that it has no connection to reality. In fact, however, there a medical condition known as progeria (technical name = Hutchinson-Gilford Progeria Syndrome).


Old Before My Time: Hayley Okines' Life with Progeria
Old at Age 3, the story of Zachary Moore

Progeria comes from the Greek words “pro” meaning “before” and “geras” meaning “old age”. It is a reference to a disorder in which the signs of old age are present before they should be -- when the person is a young child. In essence, in progeria, an elderly person is present in a child’s body, both physically and genetically. Progeria is extremely rare, only occurring in one out of every 8 million births. There are only 80 known children with progeria in the entire world.

Diagnosis of progeria is based on clinical examination of the child and can be confirmed with a genetic test. Signs of progeria include hair loss, wrinkles, missing teeth, delayed growth, lack of weight gain, dry scaly skin, vision loss, fragile bodies, pinched nose, and a small jaw. As the child ages, signs of progeria become more advanced. Interestingly, cognitive impairment is usually intact despite the increased risk of cognitive impairment in the normal aging population. Motor functioning is usually also preserved. Most children with the condition only live until 12 years of age. The main cause of death is atherosclerosis (hardening of the arteries), which can lead to a heart attack or stroke. Ninety percent of children with progeria die from one of these two causes.

The cause of progeria itself is caused by a mutation (change) in the LMNA gene. This gene provides instructions for the Lamin A protein, which holds the skeleton of the cell’s nucleus (headquarters) together. The changed gene alters instructions to the Lamin a protein, causing instability of the cell’s nucleus, which leads to premature aging. Unfortunately, there is no treatment of cure for progeria although attempts are made to reduce cardiovascular problems.

Thursday, February 09, 2012

Ayumu the Chimpanzee, Incredible Memory, and Skepticism

One of my Facebook friends recently posted an article about Ayumu the chimpanzee, who is world renowned for his memory feats in the laboratory setting. If you watch the video of what Ayumu can do in the laboratory, it seems absolutely incredible and is no doubt impressive. You can see a good demonstration that is well worth watching below of what Ayumu can do.

As impressive as this video is, I could have sworn I remembered some controversy over this after seeing this several years ago. So I went to PubMed, which is the best online repository for peer-reviewed research articles and I found the following.

Silberberg A, Kearns D. Anim Cogn. 2009 Mar;12(2):405-7. Epub 2008 Dec 30.  

Memory for the order of briefly presented numerals in humans as a function of practice.

Inoue and Matsuzawa (Curr Biol 17: R1004-R1005, 2007) showed that with an accuracy of approximately 79%, the juvenile chimpanzee Ayumu, could recall the position and order of a random subset of five Arabic numerals between one and nine when those numerals were presented for only 210 ms on a computer touch screen before being masked with white squares. None of nine humans working on the same task approached this level of accuracy. Inoue and Matsuzawa (2007) claimed this performance difference was evidence of a memorial capacity in young chimpanzees that was superior to that seen in adult humans. While the between-species performance difference they report is apparent in their data, so too is a large difference in practice on their task: Ayumu had many sessions of practice on their task before terminal performances were measured; their human subjects had none. The present report shows that when two humans are given practice in the Inoue and Matsuzawa (2007) memory task, their accuracy levels match those of Ayumu.

Moral of the story: When sometimes seems very out of the ordinary, approach with a degree of skepticism. Nevertheless, I'm still very impressed with Ayumu!

Wednesday, February 08, 2012

Neurocysticercosis: Tapeworm Infestation of the Brain

One of the most frightening medical conditions in the neurosciences is neurocysticercosis. In this condition, the brain becomes infested with the larvae of the pork tapeworm, known as Taenia solium. It is called a pork tapeworm because it infects pigs as well as humans. It has several hundred segments that are capable of releasing thousands of eggs when it reaches maturity. To the top left is a picture of the pork tapeworm under the microscope.

Pigs eat the eggs of these tapeworms when they eat food contaminated with feces. The eggs hatch in the pig intestines and develop into cysticerci in the muscles. Cysticerci are the larval form of the tapeworm.When people eat undercooked meat that is contaminated by cystocerci, they develop into adult tapeworms in the small intestines of humans and release thousands of eggs. Cysterici can also travel to the brain and form cysts when this happens it is known as neurocysticercosis. To appreciate what this looks like, first, here is a picture of a normal slice through the middle of the brain:

Here is a picture of a similar area of the brain contaminated with the pork tapeworm showing cysts:

On the left is a normal picture of the brain on a brain MRI (magnetic resonance imaging) scan. On the right is a brain MRI showing neurocysticercosis:

The appearance of neurocysticercosis in the brain depends on which of the four stages the person is in. In stage 1 (vesicular stage), the worm is alive and there is not a significant response from the immune system so there is minimal edema (fluid build up). In stage 2 (colloidal stage), the worm dies, causing the cyst to weaken, the worm to leak out, and the immune system responds, causing significant inflammation. In stage 3 (granular nodular stage), the immune response causes the cysts to harden and collapse. In stage 4 (calcified stage), the cysts calcify and the immune response/inflammation decreases. At any point, abnormal areas in different parts of the brain can be all in one stage or at either of the 4 stages.

Neurocysticercosis is the most common parasite disease of the nervous system and the main cause of acquired epilepsy (repeated seizures) for people in developing countries. This is because of poor hygiene in many developing countries, especially where pigs and humans live close together. The condition rarely happens in Muslim countries, where eating pork is forbidden. In addition to seizures, other signs and symptoms include headaches, dizziness, stroke (rupture or blockage of a blood vessel in the brain), increased blood pressure in the brain, severe impairment of thinking skills, double vision, difficulty speaking, weakness and/or sensory loss on one side of the body, increased or decreased reflexes, difficulty walking, movement disorders, and increased fluid in the brain.

Neurocysticercosis is treated by administering medications to kill the tapeworms, although these medications are often not used in patients with severe edema because the medication causes additional inflammation. Corticosteroids are administered to reduce inflammation. If seizures occur, anticonvulsants will be used to treat them. In some cases, neurosurgery is performed to remove accessible cysts.

Related Story: Stupid Diets: Infesting Yourself with Tapeworms

Tuesday, February 07, 2012

Bizarre Images of Cutaneous Horns

If you thought that people could only have horns growing out of their body in science fiction movies, think again. Many people do not know that some people can literally grown horn-like projections out of their body. The reason many people are unaware of this is because the stigma associated with the condition leads people to try to conceal it from others with clothing, bandages, or becoming a recluse until they can be surgically removed. When horn-like structures grow out of people’s skin, they are referred to as cutaneous (skin) horns and sometimes referred to as Devil’s horns. Below is a picture of a 69-year old lady with a 17-cm cutaneous horn protruding from her forehead. This is why she is known as The Unicorn Lady.

RECOMMENDED BOOK: Skin Disease Diagnosis and Treatment

Cutaneous horns are a mysterious medical condition but they may be caused by radiation exposure since they occur more in sunlight exposed areas (face, hands). They could arise from burn scars and some have reported an association with a common disease known as human papillomavirus (HPV). Probably the largest cutaneous horn was the one that was on Madame Dimanche, a French woman from the 19th century whose forehead horn measured 9.8 inches (24.9 cm). It was successfully removed via surgery. A wax model of her head was taken before surgery and is pictured here:

Cutaneous horns are benign in 80% of cases but malignant (cancerous) in 20% of cases. Pain at the bottom of the horn usually indicates malignancy. Believe it or not, these horns can also be present on the penis and when this happens, it presents almost double the risk of cancer. Here is one example of a cutanoeus horn growing out of a 102-year-old woman’s head in China. As of last year, this horn measured 10-cm in length.

Cutaneous horns are made of keratin, which is the same substance that hair and fingernails are made of. While the horns can be removed with a sterile razor, the underlying condition still needs treatment.
The most severe case, however, is that of The Tree Man, whose real name is Dede Koswara and lives in Indonesia. His body has been taken over by warty growths and cutaneous horns because of a genetic defect that prevents his body from containing them:

As you can see, the horns also took over the feet and toes:

Related blog entry: Lionel the Lion Man: A Case of Hypertrichosis 

Monday, February 06, 2012

Superbowl Loss for Your Team? You May Be Dead in Two Weeks Research Suggests

If your team lost in the Superbowl last night, research suggests that you are at increased risk of dying in the next two weeks. One known risk of cardiac failure is acute stress, be it physical stress, emotional stress, or both. This is because puts part of the nervous system into overdrive and causes a release of chemicals known as catecholamines that prepare the body for the “fight or flight response.” The result can be increased heart rate, blood pressure, blood sugar (i.e., glucose), abnormal heart rhythms, too many platelets (leading to blood clots), and/or contractures of the heart’s ventricles (which pump blood to the body). Increased oxygen demand can occur and oxygen supply to the heart can be decreased. If a person has a buildup of plaque in the arteries (a condition known as atherosclerosis) increased blood pressure can shear off a piece of plaque and lead to a heart attack or ischemic stroke. In an ischemic stroke, there is a blockage of an artery, preventing enough blood from getting to the brain.   

Researchers have noted that there was an increase in total deaths and cardiac related deaths in Los Angeles when the L.A. Rams lost the Superbowl on 1/20/1980. Of note, that game was played locally in Pasadena, California. The game was high-intensity, involved 7 lead changes, and the game was decided in the last quarter (final score 31-19). The team was much loved by the fans and had been in the city since 1946. By contrast, the number of total deaths in Los Angeles decreased when the L.A. Raiders won the Superbowl on 1/22/1984. The L.A. Raiders had only been in the city since 1982 (having moved from Oakland) so there was less emotional attachment by the L.A. fans. The game was not played locally (it was played in Tampa, FL) and was also a blow-out, with the Raiders winning 38-9.

Researchers from Los Angeles studied the degree to which age (65 or older vs 65 or less), sex (men vs women), or race (white vs Hispanic) played a role in deaths shortly after the Superbowl. They examined death certificates from 1980 to 1988. They considered Superbowl days (days in which the effects of a the Superbowl may be felt) to be the date of the Superbowl and the next 14 days. The other days in January and February of 1980, 1981, 1982, and 1983 were considered non-Superbowl days. The same analyses were done for the 1984 Superbowl. Total and cardiac deaths from January 1 to January 14 were not analyzed due to a known increase in deaths around the holidays.

The researchers used statistical techniques to assess if there was a difference in total and cardiac related deaths on Superbowl days vs non-Superbowl days. They also used a statistical procedure known as regression analysis to determine which variables best predicted death rate: Superbowl days vs non-Superbowl days, race, sex, age, or combinations of race, sex, and age with Superbowl vs non-Superbowl days.

The results showed that after the Superbowl loss, daily death rates increased for both males and females. The circulatory death increase was 15% for men and 27% for women. People aged 65 or older had a larger increase in all causes of death during Superbowl days compared with those who were less than 65 years old. Whites and Hispanics had increased death rates on Superbowl loss days. There were statistical trends suggesting less death in older patients and females associated with a Superbowl win but the findings were not statisitically strong enough to state this association more firmly.

The researchers concluded that a Superbowl loss triggered increased deaths in both men and women and especially in older patients, whereas a Superbowl win reduced death more in those aged ≥65 years and in women.

However, Dr. Viktor Culic from Croatia was not so impressed with these conclusions based on a criticism with how the study was conducted. Specifically, he published a response saying that the 2-week post-Superbowl period was too long for one to reasonably be able to associate deaths during that period to the Superbowl. He stated that the true risk of death after an emotionally related stressor is one to two hours after the stressor. He stated that any extension of the period to two weeks would be purely based on hypothetical disease mechanisms. He stated that cold weather and air pollution could be associated with the increased deaths after the Superbowl, especially in the elderly. He stated that perhaps the weather was colder and the air more polluted in two weeks after the Superbowl loss than the comparison days. He also stated that there may have even been more deaths in the weeks that were excluded before the Superbowl because it may have been even colder then.

The authors of the original study replied that they picked a 14 day period after the Superbowl because they believed that the emotional effects may linger after the day of the game. They stated that most of the deaths occurred in the first week after the game. They disputed the usefulness of examining death rates in the weeks before the Superbowl. They stated that cold weather and air pollution could not explain their findings. They correctly point out that the two Superbowl games were played at nearly identical times of the year, yet there were different death rates. The temperatures were also mild in L.A. both times, with an average of 52.9 on the day of the 1980 Superbowl and 54.5 on the day of the 1984 Superbowl. Temperatures were also very close in January and February of 1980 and 1984. In addition, analysis of air pollution data did not show more air pollution in 1980 than 1984.

The reference for the original study is:

Kloner RA, McDonald SA, Leeka J, Poole WK. Clinical Cardiology. 2011 Feb;34(2):102-7. Role of age, sex, and race on cardiac and total mortality associated with Super Bowl wins and losses.

The reference for the response and author reply are:

Culić V. Clinical Cardiology. 2011 Jul;34(7):461-2; author reply 462. Response to 'Role of age, sex, and race on cardiac and total mortality associated with Super Bowl wins and losses'.

Friday, February 03, 2012

Women's Health and Politics: Planned Parenthood vs Susan G. Komen

Despite the adversarial political climate that divides so many Americans, there are some topics that most people can agree on regardless of politics. One of those is that early detection and screening for cervical cancer and breast cancer are important initiatives that should be supported because early detection leads to earlier treatment which, in turn, saves lives. While many women have such exams paid for by their health care insurance, those without insurance often rely on funding from non-profit organizations to fund these types of early clinical, screening, and diagnostic exams.

Problems emerge, however, when one of these health care organizations takes a position on a topic as controversial as abortion, either pro or con. For example, Planned Parenthood is a non-profit organization that relies heavily on donors to fund women’s healthcare services, which includes clinical breast exams and mammograms. However, the organization also conducts about 300,000 abortions a year and lobbies for pro-abortion legislation. In doing so, Planned Parenthood intertwines funding for activities that almost everyone would support (breast exams) with funding for an activity (abortions) that deeply divides Americans.

When this happens, such an organization can expect to be the target of people who have strong opposing views on abortion. This is exactly what has happened to Planned Parenthood, as they have been frequently audited and targeted for defunding by Congressional Republicans. Most recently, the largest breast cancer organization in the U.S. (Susan G. Komen for the Cure) decided to cut its funding to Planned Parenthood. Although the money donated from Susan G. Komen was for clinical breast exams and mammograms, Republicans criticized the group for supporting a group that supported abortions. Susan G. Komen claimed that the reason for their decision was because they developed a new rule prohibiting donations to organizations that are under congressional investigation. However, critics claim that this is a contrived excuse, especially since it only affected funding of Planned Parenthood.

Delving into the politics of this issue in more detail gives reason to suspect that this was a contrived excuse by Susan G. Komen when the real issue involved giving into political and financial pressures. Specifically, the founder of Susan G. Komen is Nancy Brinker, who has long-standing connections to the Republican party, served as an Ambassador for George W. Bush, donating money to the Republican party (including George W. Bush’s first presidential campaign), and partnered with the policy-making branch of the George W. Bush presidential library. In fact, the decision to cut off funding to Planned Parenthood was made soon after the latter partnership was established. To make the situation even more politically interesting, the leader of Planned Parenthood is Cecile Richards, who was the daughter of former Texas Democratic governor, Anne Richards. Richards is widely remembered for ridiculing George W. Bush when he ran against her for governor. Thus, it is not much a stretch to imagine that a condition for partnership with Susan. G. Komen (which is worth 3 million dollars and is funded by Merck, a known campaign donor to current Texas governor, Rick Perry) could have been dependent on defunding Planned Parenthood. Susan G. Komen has denied that their decision has anything to do with politics, which is hard to believe, and this brings me to my last point.

If Susan G. Komen truly wanted to defund Planned Parenthood because they did not want to support a group that also funded abortions, that is well within their right to do. Planned Parenthood has to understand that when they fund both non-controversial healthcare services and controversial services, that the non-controversial services will suffer funding cuts from organizations who are pressured to stop contributing to them. Separating these services into different groups would at least prevent this problem from occurring, regardless of one’s position on abortion. In cases where funding is cut off, it is misleading to paint the organization that cuts the funding as creating barriers to women’s health because the problem would not exist if Planned Parenthood did not simultaneously fund controversial and non-controversial health services. They are within their right to do so, but it will cause problems as a result.

At the same time, it is not a mystery that Planned Parenthood pays for abortions. Thus, if another organization is truly opposed to abortions, they should simply not make a contribution in the first place. Once an organization makes a contribution and then stops contributing after known pressure and associations with opponents of Planned Parenthood, the decision is going to appear politically and financially motivated even if by some chance it was not. Interestingly, due to political pressure (particularly on social media), Susan G. Komen announced a restoration of funds on 2/3/12. Komen had successfully been cast as an organization not committed to saving women's lives and did what they had to do to reverse what had become a public relations nightmare. This is an excellent case study on how politics on both sides of the aisle affects women's health care.

Thursday, February 02, 2012

Birth Control Recall and the Impact of Litigation on Medication Costs

On 1/31/12, the world’s largest research-based drug company, Pfizer, announced that an automated packaging error led to a recall of the birth control medication, Lo/Ovral-28 and the generic counterpart, Norgestrel/Ethinyl Estradiol. The packaging issue had to do with the placebo pill being placed in the wrong order in the 28-day cycle and an inexact number of placebo (should be 7) or active forms (should be 21) of the medication. The placebo pill is one that does not contain the drug’s active ingredient, and thus, does not lead to birth control. The placebo pills are a different color than the active pills. This led a consumer to detect the error when she noticed a discolored pill in the middle of the package. Pfizer has advised that women who have taken these medications over the last several months to talk with their physician about beginning a non-hormonal barrier method (e.g., condoms) of birth control immediately. Switching pills would be another option of course, although Pfizer does not mention this for obvious reasons.

One million packs were recalled throughout the U.S. even though only 30 packages were affected and there are no known immediate health risks besides according to Pfizer. However, Pfizer does acknowledge that an unplanned pregnancy could result. An unplanned pregnancy does come with possible health risks, with the worst case scenario being death of the mother and/or child. Pfizer stated the following in a press release the next day:

“Because of our high quality standards, should we identify even one package that does not meet our high standards, we will voluntarily recall the entire lot.”

While this quote sounds good from a customer relations perspective, one is left to wonder if this recall still would have happened if it was not for the threat of litigation. Plaintiff attorneys did not waste any time trying to find women to sue Pfizer who may have suffered an unplanned pregnancy or health problems as a result of the unplanned pregnancy. Imagine, for example, the type of lawsuit that would emerge from a man alleging that he is widowed due to his wife dying in labor as a result of a pregnancy caused by a packaging error? Or the type of lawsuit that would emerge from a parent claiming that they want Pfizer to reimburse them for the entire cost of raising a child, including a college education?

Examining this in more specific financial detail, one online drugstore sells a pack of Lo/Ovral for 59.99. Other sites charge more and generics will cost less so for the sake of this example, take $60.00 as the average cost per package. This means Pfizer takes a roughly 60 million dollar loss as a result of this recall. A 60 million dollar loss for 30 packs? A 60 million dollar loss to maintain high quality business standards? Or a 60 million dollar loss to reduce the chance of one or more (e.g., class action) lawsuits for hundreds of millions of dollars that could literally end a company's existence. Lawsuits regarding unplanned pregnancies from faulty vasectomies, for example, have sought awards of over 600 million dollars. If you are the largest drug company in the world, would you rather take a 60 million dollar loss or increase the risk of a 600 million dollar loss? The answer is easy, especially for a drug marketed as being almost 100% effective in eliminating pregnancies.

Although Pfizer will take a temporary financial loss in this instance, the cost of the recall will likely be made up for by increasing the prices of other medications in the future. This is one reason why medications in the U.S. are generally more expensive than they are in other countries. One can have cheaper medications if they are willing to accept less research on their safety and efficacy and fewer attempts to quickly correct packaging errors when they arise.