Prostate cancer treatment and Alzheimer’s

Once again the treatment for a cancer can have cruel results. This will not be good news for a lot of people.
From the NY Times:

Hormone therapy, a common treatment for prostate cancer, is associated with an increased risk for Alzheimer’s disease, a new study has found.

The goal of hormone therapy, also known as androgen deprivation therapy, is to lower the level of male sex hormones, or androgens, that stimulate the growth of prostate cancer cells.

Researchers used records of 16,888 people with prostate cancer, of whom 2,397 were treated with hormone therapy. Over a median follow-up of 2.7 years, there were 125 new diagnoses of Alzheimer’s disease.

Over all, those treated with hormone therapy had an 88 percent increased risk of Alzheimer’s compared with other patients. The longer the hormone treatment, the more the risk increased, and patients with at least 12 months of treatment had more than double the risk. The study is in The Journal of Clinical Oncology.

The finding persisted after adjusting for race, smoking, cardiovascular disease, diabetes, prior cancers and other factors.

“It would not be appropriate to change the way we treat patients now,” said the lead author, Dr. Kevin T. Nead, a resident in radiation oncology at the University of Pennsylvania. “Androgen treatment is life-extending treatment, and very important. We found an association, but there is no evidence that hormone therapy causes Alzheimer’s.”

Androgens have been shown to affect the accumulation of amyloid plaques, one of the features of Alzheimer’s disease, and this may be one mechanism that could explain the finding.

How to get better pain treatment in the ER?

I have a problem with pain management. Ordinary otc pain medication doesn’t work well, and often regular doses of pain shots don’t have enough effect. But I formed a helpful hypothesis this fall in an ER and then subsequently in the hospital. I hope it works for others not getting enough pain relief. What I learned is that the magic number is 7 (SEVEN). It is very standard practice to ask one to rank one’s pain from 0 to 10. A few quick tests indicated that at 7 and above one gets codeine; below that you are in the tylenol region.

I’m white, so it may not help with the following shocking problem reported in the NYT, but the authors of the relevant studies say that communication may be a central problem:

White patients receive more pain treatment in emergency rooms than African-Americans and other minorities, a new study reports.

Researchers studied four years of data collected nationwide by the Centers for Disease Control and Prevention. They used a sample of 6,710 visits to 350 emergency rooms by patients 18 and older with acute abdominal pain.

White and black patients reported severe pain with the same frequency — about 59 percent. But after controlling for age, insurance status, income, degree of pain and other variables, the researchers found that compared with non-Hispanic white people, non-Hispanic blacks and other minorities were 22 percent to 30 percent less likely to receive pain medication. Patients were also less likely to receive pain medicine if they were over 75 or male, lacked private insurance or were treated at a hospital with numerous minority patients. The study is in the journal http://journals.lww.com/lww-medicalcare/Abstract/2015/12000/Analgesic_Access_for_Acute_Abdominal_Pain_in_the.3.aspx. …

The journal linked to gives one only the abstract, but that makes available a good sense of the studies and their scope. And the urgency of the problem.

Twelfth woman to win Nobel Prize for Meds

3 researchers have won this year’s Nobel Prize for medicine. Youyou Tu, a Chinese woman who began her work during the cultural revolution, developed Artemisinin, which has had a highly significant impact in limiting cases of maleria.

The other two researchers, “William C. Campbell and Satoshi Omura won for developing a new drug, Avermectin. A derivative of that drug, Ivermectin, has nearly eradicated river blindness and radically reduced the incidence of filariasis, which causes the disfiguring swelling of the lymph system in the legs and lower body known as elephantiasis.”

The report of the prize in the NY Times is well worth reading. It contains details of research, such as searching through ancient texts from Chinese herbalists to recover lost knowledge about herbal properties, or testing thousands of soil samples.

Brain scans reveal: babies can feel pain

One would have thought that it is completely obvious that babies can feel pain. Of course, it can be argued that there’s a gap between behavioural evidence and pain states. Still, isn’t that worry really just a philosophical one, as one hears doctors say?

Unfortunately, common sense appears to have failed in the case of infants and pain.

In the early 1980’s it was revealed that babies react chemically as adults do to what adults count as painful circumstances. It also turned that neonates needing surgical interventions were given NO pain relief. “Well that is completely horrible but,” one might have thought, “At least that will end now.”

No such luck. Recent brain scanning experiments show that even very young babies do indeed react much as adults do to what adults count as painful circumstances, but pain relief is not the norm.

The brains of babies ‘light up’ in a very similar way to adults when exposed to the same painful stimulus, a pioneering brain scanning study has discovered. It suggests that babies experience pain much like adults. As recently as the 1980s it was common practice for babies to be given neuromuscular blocks but no pain relief medication during surgery. In 2014 a review of neonatal pain management practice in intensive care highlighted that although such infants experience an average of 11 painful procedures per day 60% of babies do not receive any kind of pain medication.

(Journal Reference:
Sezgi Goksan, Caroline Hartley, Faith Emery, Naomi Cockrill, Ravi Poorun, Fiona Moultrie, Richard Rogers, Jon Campbell, Michael Sanders, Eleri Adams, Stuart Clare, Mark Jenkinson, Irene Tracey, Rebeccah Slater. fMRI reveals neural activity overlap between adult and infant pain. eLife, 2015; 4 DOI: 10.7554/eLife.06356)

The study comes out of the University of Oxford. I think it applies only to the UK. There has been an earler, 2011, study in Canada covering a wider age range and the results are similarly discouraging.

Narcissim: social learing theory vs psychoanaltic theory

From “Origins of narcissism in children,” in the proceedings of the national academy of sciences.

There’s an interesting theoretcal challenge here to the idea that problematic behavior is due to unconscious desires to make up for early wounds. Equally, we get some insight into how pretty rotten people can have quite nice parents.

Narcissism levels have been increasing among Western youth, and contribute to societal problems such as aggression and violence. The origins of narcissism, however, are not well understood. Here, we report, to our knowledge, the first prospective longitudinal evidence on the origins of narcissism in children. We compared two perspectives: social learning theory (positing that narcissism is cultivated by parental overvaluation) and psychoanalytic theory (positing that narcissism is cultivated by lack of parental warmth). … Results support social learning theory and contradict psychoanalytic theory: Narcissism was predicted by parental overvaluation, not by lack of parental warmth. Thus, children seem to acquire narcissism, in part, by internalizing parents’ inflated views of them (e.g., “I am superior to others” and “I am entitled to privileges”). Attesting to the specificity of this finding, self-esteem was predicted by parental warmth, not by parental overvaluation. These findings uncover early socialization experiences that cultivate narcissism, and may inform interventions to curtail narcissistic development at an early age.

Examples of implicit racial bias at work

An article in the NY Times contains important information on research into implicit bias. It also has a number of useful, though upsetting, examples. Here are some of them:

■ When doctors were shown patient histories and asked to make judgments about heart disease, they were much less likely to recommend cardiac catheterization (a helpful procedure) to black patients — even when their medical files were statistically identical to those of white patients.

■ When whites and blacks were sent to bargain for a used car, blacks were offered initial prices roughly $700 higher, and they received far smaller concessions.

■ Several studies found that sending emails with stereotypically black names in response to apartment-rental ads on Craigslist elicited fewer responses than sending ones with white names. A regularly repeated study by the federal Department of Housing and Urban Development sent African-Americans and whites to look at apartments and found that African-Americans were shown fewer apartments to rent and houses for sale.

■ White state legislators were found to be less likely to respond to constituents with African-American names. This was true of legislators in both political parties.

■ Emails sent to faculty members at universities, asking to talk about research opportunities, were more likely to get a reply if a stereotypically white name was used.

■ Even eBay auctions were not immune. When iPods were auctioned on eBay, researchers randomly varied the skin color on the hand holding the iPod. A white hand holding the iPod received 21 percent more offers than a black hand.

■ The criminal justice system — the focus of current debates — is harder to examine this way. One study, though, found a clever method. The pools of people from which jurors are chosen are effectively random. Analyzing this natural experiment revealed that an all-white jury was 16 percentage points more likely to convict a black defendant than a white one, but when a jury had one black member, it convicted both at the same rate.

A number of these can also be used as examples of white privilege.

Pregnant Deaf Woman Sues for Interpreter Access During Delivery

Cheylla Silva has filed an emergency motion in U.S. federal court (Miami) to obtain signed language interpreter access during childbirth. 

Silva is hoping the delivery goes smoothly because if there are serious problems, she might be at a loss to communicate with her doctors and nurses. Silva is profoundly deaf, and, for months, Baptist administrators have refused to provide her with an American sign language interpreter, she says.

“Can you imagine going to a doctor’s office and not being able to understand what they are talking about? And it’s about your care. How would you feel?”

 “One of the essential elements of personal dignity,” the pleading adds, “is the ability to obtain the necessary information to make an adequate and informed choice about one’s own medical treatment. Medical treatment and childbirth are some of the most intense and important experiences for a person.”

Then again, it should be easy enough to just write notes in one’s second language during childbirth, right?

Beware the DNR order

This post is for those of us involved in caring for ourselves or others. (If you don’t give a sh*t about anyone, don’t read on.) It comes from a blog post by a highly credentialed physician and professor of medicine.

“DNR” is supposedly just about employing CPR. Even that was somewhat surprising, but facts about how it’s used can be very upsetting:

And it’s not just in the midst of a disaster that physicians mistake “DNR” for “Do Not Treat.” Study after study has shown that physicians say they would not administer a whole variety of treatments to patients who are DNR. One representative study of 241 physicians found that they were far less likely to agree to transfer a patient to the intensive care unit or even to perform simple tests such as drawing blood.

Most recently, physicians and nurses caring for pediatric patients also told interviewers that in practice, DNR means far more than just do not perform CPR. In this survey of 107 pediatricians and 159 pediatric nurses in a hospital setting, 67% believed a DNR order only applies to what to do after a cardiac arrest—but 33% said it implied other limitations. And 52% said that once a DNR order is in place, a whole host of diagnostic and therapeutic interventions should be withdrawn, over and beyond CPR, and a small but disturbing minority, 6%, said that a DNR order means that comfort measures only are to be provided.

Note: comment 1 below draws our attention to the possibility of state variations on a DNR order. In addition, some DNR forms are part of a living will, where you specify more about what is wanted. So it is worth checking out what is available. The focus of this post is to say ‘DNR’ may not be understood as you want it to be.

I’m reminded here of the Wiittgensteinian point that you won’t find an interpretation that won’t itself need an interpretation. That’s why at some point we need community practices.

General anaesthesia (GA) for older people

I had no idea about any specific link between dementia and GA. In fact, given the announcement’s date, few people could have known about it until recently. But it seems to me the sort of thing one should know about, either as potential victim or as someone close to a potential victim. ‘Elderly’ starts at 65.

June 1, 2013 — Exposure to general anaesthesia increases the risk of dementia in the elderly by 35%, says new research presented at Euroanaesthesia, the annual congress of the European Society of Anaesthesiology (ESA). The research is by Dr Francois Sztark, INSERM and University of Bordeaux, France, and colleagues.

Postoperative cognitive dysfunction, or POCD, could be associated with dementia several years later. POCD is a common complication in elderly patients after major surgery. It has been proposed that there is an association between POCD and the development of dementia due to a common pathological mechanism through the amyloid β peptide. Several experimental studies suggest that some anaesthetics could promote inflammation of neural tissues leading to POCD and/or Alzheimer’s disease (AD) precursors including β-amyloid plaques and neurofibrillary tangles. But it remains uncertain whether POCD can be a precursor of dementia.
In this new study, the researchers analysed the risk of dementia associated with anaesthesia within a prospective population-based cohort of elderly patients (aged 65 years and over). The team used data from the Three-City study, designed to assess the risk of dementia and cognitive decline due to vascular risk factors. Between 1999 and 2001, the 3C study included 9294 community-dwelling French people aged 65 years and over in three French cities (Bordeaux, Dijon and Montpellier)…The data were adjusted to take account of potential confounders such as socioeconomic status and comorbidities.
The mean age of participants was 75 years and 62% were women. . After adjustment, participants with at least one GA over the follow-up had a 35% increased risk of developing a dementia compared with participants without anaesthesia.
Dr Sztark concludes: “These results are in favour of an increased risk for dementia several years after general anaesthesia. Recognition of POCD is essential in the perioperative management of elderly patients. A long-term follow-up of these patients should be planned.”