Archive for the ‘Biology & Medicine’ Category

MEDICAL MYOPIA

Monday, June 20th, 2016

“There are none so blind as those who will not see.” -John Heywood (1546)

We humans spend approximately two-trillion dollars annually to defend ourselves militarily against others of our own kind. We spend a relative pittance to defend ourselves medically against microbes potentially more deadly than many of our supposed enemies. Such behavioral deficits can have consequences rather ugly.

“The woman Folly is riotous; She is thoughtlessness and knoweth nothing.” -Proverbs 9:13

Congratulations, humanity! Our folly knows no bounds; for example, the consequence of our wanton misuse of antibiotics. A recent report told of the first case of totally-resistant, bacterial infection here in these United States of America. It will not be the last.

Some observers have looked away from their electronic devices and “apps” of the moment to ask, “Why aren’t there more new, novel antibiotics?”

Why, indeed? Well, Biobehavioral Science has the answer — schedules of reïnforcement. They control our behavior every day in every way.

“Schedules of reïnforcement? What are those?” someone with a modicum of curiosity might ask.

B = f(x) under c. Behavior is a function of its consequence in a given context. Want more of a behavior? Reward it. Want less? Don’t reward it or, unappealingly, punish it.

Consequences, such as pay following work, usually occur pursuant to a schedule. The schedule that generates the highest rate of behavior is the Fixed Ratio (FR); e.g., piecework, which is the reason unions hate it. The lowest rate? Fixed Interval (FI); e.g., midterm then final exams generating studying only just before the events, which is the reason that it is less effective than a Variable Ratio (VR) schedule .

For those interested in a detailed, yet entertaining, discussion of schedules of reïnforcement, read the semi-fictional novel, Inescapable Consequences. Worth the price and effort? You bet!

With regard to invention of new, novel antibiotics, consider the following, two examples:

1) Acute, pharyngeal infection by Streptococcus; i.e., “Strep throat”. A brief course lasting only ten-days of inexpensive penicillin cures the illness. Not a lot of profit there for the pharmaceutical company — unfavorable response:reïnforcer ratio.

2) Chronic, severe psoriasis. Lifelong treatment with very expensive medication. A lot of profit there — favorable response:reïnforcer ratio.

For which illness does a pharmaceutical company prefer to pursue new and novel treatments? You guessed it! Why? Schedules of reïnforcement.

Vaccines? Pharmaceutical companies find the schedule of reïnforcement really unfavorable.

Even when successfully developed and tested — given massive, oppressive, governmental regulations — the response:reïnforcer ratio remains unfavorable. Consider the following, two reasons:

1) Lawsuits from parasitic, avaricious lawyers who are crippling American industries if not killing them outright. Next time that a loved one is dying from a non-treatable infection, take a moment to thank the lawyers before suing the attending physician.

2) So-called humanitarian demands to surrender — essentially without charge — to the “vulnerable” of the world the fruits born of American capital, labor, creativity, and productivity.

So, should you bother considering the potential fate awaiting humanity from the next, virulent plague, blame not the alleged greed and malevolence of those in the pharmaceutical industry. Instead, think not only of the avaricious lawyers but of the self-styled, “humanitarian” ideologues; power-hungry politicians; and self-serving bureaucrats who paved your Path to Perdition. Also, do not forget to include your own response, or lack thereof, to the malicious, myopic behavior of those who paved your way to a destination that you are bound to find most disagreeable.

What’s it all about? No, not pharmaceutical profiteers — greedy or not; either here or abroad.

See “Secret Deal Squeezes Mexico Drug Sector

What’s it really all about? Context. Consequences. Schedules of reïnforcement.

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A Paradox?

Monday, February 15th, 2016

NOTE (22FEB2016): Today, we mark the anniversary of the birth of George Washington (1731-1799). Actually, he was born on the 11th of February, but the colonies switched calendars from Julian to Gregorian; thereby, advancing the date of his birth.

“As a very important source of strength and security, cherish public credit. One method of preserving it is to use it as sparingly as possible;” -George Washington’ Farewell Address (1796)

How does ObamaCare correspond to that directive of the Father of these United States of America? How can we employ a system of medical delivery that does? How can we protect the future of our youth, who represent the future of this nation now on fire?

“Life outside society would be solitary, poor, nasty, brutish, and short.” -from Thomas Hobbes (1588-1679)

What can be more important to an individual than life and health? In that regard, what single advance most has improved the human lot — for the individual and for society? Sewage.

Ah, but what about medicine? Has it, too, not improved the human lot? Yes, for the individual. For society? Yes — and no.

It may seem paradoxical that a physician would give such an answer. It is not.

The well being of society depends upon the overall health of its truly creative and truly productive members. The goal of Public Health is to have maintained the health not of the individual but of the society, as a whole. Sewage has done more to fulfill that goal than any other, single measure. Moreover, the cost:benefit ratio had been enormously favorable.

In contrast, the goal of Medicine is to have relieved the suffering of the individual as a consequence of disease and trauma. All well and good until one looks at the cost:benefit ratio. It has become dreadfully unfavorable.

The average American now expends half the cost of his medical care during his entire lifetime during the last year of his life — a year in which kindness often becomes cruelty — a year that, from the perspective of society, typically is pathetically uncreative and unproductive; from the perspective of the patient, typically is progressively enfeebling and painful; from the perspective of family and friends, typically is unrelentingly burdensome and depressing.

You might comment, “Wait! In these United States of America, the individual has no obligation to be either creative nor productive. We are not Nazi Germany where the individual exists for the State. Here, the State exists for the individual — doesn’t it?”

Even so, does the individual have the right to rob his productive neighbor to pay for his own medical care, the end result of which will be of no use to that neighbor or to society and likely of little use, if any, to family, friends, and himself? If so, what are the limits of such theft?

Should the individual be paying with his own money, he very well may be entitled to the most expansive and expensive care that he can afford. Is he so entitled when it is his productive neighbor who is paying — and paying involuntarily via taxes collected by the government at the point of a gun if need be?

When medical care is limited to basic care at a primary level — especially of acute medical problems such as fractures and infections — the cost:benefit ratio becomes tolerably favorable. When medical care is expanded to advanced care at a secondary level — especially of chronic medical problems among the elderly, problems  such as non-healing wounds; failing hearts; and, worst of all, dementias — the cost:benefit ratio becomes intolerably prohibitive as witnessed by Medicare/Medicaid well on the way to bankrupting this declining nation now of fire. Once having bankrupted the nation, Medicare/Medicaid will leave precious little medical care for any but the richest.

You might ask, “There must be some humane alternative between callous disregard and misguided ‘humanitarianism’, mustn’t there?”

Fortunately, yes. The alternative is a medial system that delivers care universal but affordable, partially governmentally funded, provided by the private sector under medical supervision, acceptable to insurance companies, and scientifically based and scientifically driven.

For a description of such a system of medical delivery, see Chapter 17 in the semi-fictional novel, Inescapable Consequences. It is drawn from a detailed plan initially presented in the non-fictional book, Healthcare Reform D.O.A., nominated for two, national awards by The American Risk & Insurance Association — an academic arm of the American insurance-industry.

Americans need not be saddled with the ill-conceived ObamaCare favored by the socialistic, irresponsible Democrats nor the hodgepodge of misguided proposals by the feckless, inconsistent Republicans. The choice really is theirs. It is yours.

Choose selflessly and wisely, and your grandchildren will bless you. Choose selfishly and foolishly, and your grandchildren will curse you.

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CHICKEN OR EGG?

Monday, December 14th, 2015

Note (21DEC205): What are you as a person if you neglect to consider who you are in the overall scheme of the cosmos? In the past, Christianity and, to a much lesser extent, Judaism provided Westerners with a foundation and a framework to define themselves, although not necessarily explicitly, in terms of human purpose and personal meaning.

See “Science And Human Purpose And Meaning.”

With the advent of the electronic age in the form of mind-numbing television and, more recently, attention-numbing, digital devices and with the decline of religion, we Westerners have been moving towards returning to our non-human roots of being confined in time and space to the here-and-now. In that context, we increasingly are coming under attack by a growing religion that regards contemporary, Western trends as an abominable affront to God Himself. Its members are willing to fight and die for their convictions.

Are we Westerners willing to fight and die for ours? By the way, what are our convictions, anyway?

Which came firstly — the chicken or the egg? Age-old question now with a new-age answer.

Which is the true life-form — the organism or its germ-plasm, or are they one and the same? Same question but in a slightly more contemporary form. Its origin firstly expostulated by the Germanic biologist, August Weismann (1834-1914), who was one of the main defenders of Charles Darwin’s theory of natural selection; which, at the time, had fallen into decline.

“As for man, his days are as grass;
As a flower of the field, so he flourisheth.
For the wind passeth over it, and it is gone;
And the place thereof knoweth it no more.” -Psalms 103:15

Consider spiders in which the offspring devour their own mothers with her assistance. Consider salmon, which reproduce once then rapidly disintegrate and die.

In both instances, does the organism exist merely as a shell that functions as a vehicle for the propagation of its germ-plasm? Does our germ-plasm author the play of life while we humans merely are passing actors in it?

What inferences can be drawn? Do we — as a species, for example — have any special purpose? Do our individual lives have any meaning?

See “Science And Human Purpose & Meaning” below.

entropy n.: the degradation of the matter and energy in the universe to an ultimate state of inert uniformity. –Webster’s New Collegiate Dictionary

One possible inference relates to the seeming existence of a cosmic force that functions opposite to entropy, a force the consequence of which is increasing levels of organization. Among life-forms on Earth, we humans are the uppermost example — at least, for the moment; at least, whilst we last. To the best of our current knowledge, we are the only entities in the cosmos that can recognize our own existence and that of the cosmos itself. The late astronomer, Carl Sagan, opined that intelligent life such as we represent is the means by which the universe recognizes itself.

“I looked, and there before me was a pale horse!
Its rider was named Death,
and Hades was following close behind him.” -Revelation 6:8

Therein lies a lethal potential; namely, that, unlike any other species, our species can author its own self-destruction. Of doing so, we now find ourselves on the brink.

See “The Exterminators” below …

What can we do to avert that ultimate denouement — a denouement, perhaps, authored by our own germ-plasm? Paradoxically, we can employ the very means that have brought us to this precarious point to save us from ourselves — Science and Technology; specifically the Science of Human Behavior and its derivative Biobehavioral Technology.

Ah, but what shall we do? Will this chicken kill its own progenitor — its own egg?

Science says, “Behavior has its consequences.”

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GOT PAIN?

Monday, October 5th, 2015

“The two enemies of human happiness are pain and boredom.” -Arthur Schopenhauer (1788-1860)

pain n.: usually localized physical suffering associated with bodily disorder. -Webster’s New Collegiate Dictionary

Pain is the opposite of pleasure. Each involves different neurobiology.

Neuroanatomically, pleasure involves the ventral tegmental area and nucleus acumbens, neither of which subserves pain. Neurochemically, pleasure involves dopamine, which does not subserve pain directly. The dopamine-mediated signal cascades from the limbic system to the cortex.

Subserving the emotion of pain is nociception; that is, the production of afferent, neuronal signals created by depolarizing the membranes of projections from neurons in the dorsal ganglia just outside the spinal cord and, thereby, activating their voltage-sensitive sodium channels; transmitting those signals via axons to neurons in the dorsal horn of the spinal cord; then having the signals ascend via the spinothalamic tract to the thalamus in the brain. The thalamus acts as a relaying station among various parts of the brain. In animals with more highly developed nervous systems, the thalamus relays the signal to the limbic system, which, in turn, relays it to the neocortex. The specific, responding characteristics of primary, afferent neurons reflect their specific receptors and channels.

Nociceptive stimulation elicits an immediate response of withdrawal to escape the stimulus eliciting the nociceptive signal. Nociception is not pain. Neuroanatomically, it involves Aδ and C fibers. Excitation also may involve non-nociceptive afferent, Aβ fibers. Nociceptive stimulation begins with the release of glutamate and substance P. Initially, glutamate binds to only receptors for α-amino-3-hydroxy-5-methyl-4-isoxaloproprionic acid; eventually, however, glutamate can begin binding to receptors for N-methyl-D-aspartate, which can elicit hyperalgesia lasting from days to months or longer; thereby, an acute response can become chronic.

Pain comes in two, basic forms — acute and chronic. Each involves different neurobiology.

Acute Pain
Acute pain activates the anterior cingulate gyrus and the posterior insula, among other sites. It directly activates the frontal cortex little, if at all.

There appear to be two, basic kinds of acute pain — 1) spontaneous, high intensity pain; and 2) spontaneous, increasing pain. In individuals with underlying chronic pain, additional acute pain can activate the medial prefrontal cortex. Of note, this cortical area subserves emotional self-representation and self-regulation; thus, chronic pain involves areas of the forebrain subserving emotions, thereby, eliciting emotional discomfort. Also of note, activity in the insula itself does not appear connected to emotions.

Chronic Pain
Chronic pain represents a serious medical condition deserving proper, medical treatment. It represents negative strain that up-regulates cortico-trophic regulating hormone. One consequence of such up-regulation is suppression of brain-derived neurotrophic factor. Neuroanatomical changes associated with chronic pain resemble those with chronic depression; for example, enlarging ventricles and volume loss especially in the hipocampal and para-hippocampal areas.

Chronic pain activates release of cytokines and other inflammatory agents. The overall effect can be activated microglia with loss of cellular integrity and apoptosis; i.e., disintegration of cells into membrane-bound particles then phagocytosed. It can induce indoleamine 2,3-dioxygenase that prevents the conversion to serotonin of its precursor. Furthermore, it can activate receptors for N-methyl-D-aspartate with the consequent release of glutamate and its further exitotoxicity; inflammation; and apoptosis. This cascade of neurochemicals is similar to that found in depression.

In fact, depression and chronic pain are closely allied enemies of the patient. Approximately 30% of patients with chronic pain suffer associated clinical depression. Approximately 20% experience suicidal ideation with the rate of suicide being three times higher than that among the general population.

As occurs with depression, chronic pain often is associated with sleeping disturbances. Such disturbances can increase the magnitude of pain experienced during waking hours.

As many as 30% of individuals experiencing an acute pain find the pain becoming chronic. The mechanisms appear complex and not well-understood.

One mechanism appears to involve central sensitization. A majority of patients with neuropathic pain (i.e., pain from pathology in the nervous system itself) seem to exhibit this phenomenon. Central sensitization is linked to several, different neurotransmitters although glutamate appears to be a primary culprit. Central sensitization appears to be a function of duration, so the longer the pain, the longer the pain — early, aggressive treatment very well may alleviate this pernicious phenomenon.

A second mechanism, associated with central sensitization, is temporal summation involving Aδ and Aβ fibers. Temporal summation is the consequence of repeated stimulation of an affected area; thereby, increasing the experiencing of pain.

A third mechanism involves the neurological inhibitory system. Nociception and pain also involve descending, inhibitory pathways from the periäqueductal area in the brainstem to the lamina of the dorsal horn in the spinal cord. Neurochemically, inhibition is subserved primarily by norepinephrine and serotonin with some input from dopamine and endocannabinoids activating endogenous opioid receptors adjacent to ascending fibers therein; thereby, dampening the nociceptive signal to the brain from below. The involvement of norepinephrine and serotonin may explain the unusually rapid, analgesic effect in chronic pain of antidepressant medication, especially amitryptilene, in dosages too low to treat depression.

A fourth mechanism also involves inhibition. As chronic pain increases in duration, activity in the medial prefrontal cortex increases. Addition of acute pain can activate further the medial prefrontal cortex while deäctivating the dorsolateral prefrontal cortex. This latter structure dampens chronic pain by inhibiting activity between the thalmus and midbrain, rendering pain less emotional. An increasing duration of chronic pain actually shrinks gray matter in the dorsolateral prefrontal cortex, which might be reversed by trans-cranial magnetic stimulation. Curiously, increasing duration may increase gray matter in other regions of the brain.

PART TWO

Treatment
The first choice in treatment of chronic pain is to eliminate the offending stressor. Unfortunately, doing so is often impossible. Attempts, such as multiple spinal surgeries, can do more harm than good because healing involves scarring, and scars contract; thereby, deforming surrounding structures. Put simply, the back doesn’t like to be cut.

Chiropractic
Different causes of chronic pain deserve different therapeutic approaches. One common choice for the unsuspecting is chiropractic. Chiropractors are not medical doctors. They are not physicians although, as a consequence of political lobbying, some states allow them to wrap themselves in the camouflage of “chiropractic physician”.

Chiropratic was invented by a charlatan named D. D. Palmer (1845-1913) in the late 19th-century. He proposed a theory that disease was the consequence of poor alignment of the vertebrae, which could be relieved by manipulation. He was wrong as are his followers today. Hemorrhoids, for example, are one of the most common of human maladies; yet, the nerves subserving the area emanate from the sacrum, which is fused.

Subsequent to Palmer, chiropractors employed electronic devices resembling vertical pinball-machines ostensibly to diagnose disease with a “sensor” held in the hand. Their doing so constituted obvious chicanery that prevented people from seeking proper medical treatment.

Even today, Palmer’s followers make fanciful claims while applying procedures of questionable value but unquestionable risk. Adverse consequences, including death from dissection of the vertebral artery (See, for example, Chen, WL, et al: “Vertebral artery dissection and cerebellar infarction following chiropractic manipulation”. Emergency Medicine Journal 23: e1, 2006.) are commonplace, reportedly at a rate of 30% (See, for example, Hurwitz, EL, et al: “Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study.”  Spine 30:1477, 2005.).

Pharmacotherapy
To begin, some words about opiates. Cultivation of the poppy began around 3400 BC in lower Mesopotamia. The Sumerians referred to it as the “joy plant”. Morphine, the active ingredient in opium, was not identified until the early part of the 19th-century.

Sumerians notwithstanding, opiates should be employed to relieve chronic pain only as a last resort. Not only can they be addicting although some patients report dysphoria rather than euphoria, they actually can exacerbate chronic pain by inducing hyperalgesia probably related to N-methyl-D-aspartate and protein kinase. If employed, their use should be continual not as needed and at the minimal, effective level — best <60mg. of morphine-equivalent. Methadone should be avoided. The good news, however, is that outright addiction to “drugs of abuse” is no higher than among the general population; which may bear witness to the negative strains elicited by modern society, leading to a recent, general increase in abuse of increasingly potent street-heroin..

Different stressors may require different treatments. Several treatments of proven value are available. Unfortunately, always adhering to the guidelines of the Food and Drug Administration may prevent patients from receiving optimal medication.

For the still-problematic diagnosis of fibromyalgia, recommended medications include duloxetine, a serotonin-norepinephrine uptake inhibitor, and pregabalin, an anti-epileptic that diminishes release of glutamate via blockade of a2δ subunit of voltage-sensitive, calcium channels.

For cluster-headaches, lithium appears helpful. Psychiatrically, it also is used as a medication to control mania among manic-depressives.

For migraine headaches, a newer, sometimes helpful approach is the use ziprasidone. Psychiatrically, it is used to treat schizophrenia.

As for chronic back pain, it represents a heavy burden on its sufferers clinically and upon society economically. There is no single, effective treatment. Perhaps, the most effective medication is an old one — amitryptilene begun at very low dosage that is increased slowly as tolerated. Other medications often recommended are duloxetine, nortryptilene, and venlafaxine.

A few words about selective serotonin uptake inhibitors (SSRIs). In the descending fibers of the spinal cord, serotonin both may inhibit and facilitate. Accordingly, medications that inhibit the reüptake of both serotonin and norepinephrine (SNRIs) may prove more effective in treating chronic pain.

Furthermore, increasing levels of serotonin have their own consequences; e.g., cognitive dysfunction especially impairment of memory, fatigue, obesity, sexual dysfunction, and somnolence. SSRIs are no more effective and probably less effective than tricyclics (or even MAOIs) and, for males especially, less well tolerated. If SSRIs are prescribed, it should be noted that NSAIDs such as ibuprophen may anatgonize the actions of SSRIs; possibly via p11, a small protein implicated in the actions of cytokines.

Non-Pharmacological Treatments
Physical treatments other than pharmacological depend upon diagnosis made by a physician. For ailments involving the musculo-skeletal system, such as chronic back pain, physical therapy prescribed by a physician, especially a physiatrist, can bring substantial relief. Often, supplementing physical therapy with nutritional counselling, occupational therapy, and recreational therapy can add to the effectiveness.

As for any medical disorder for which there exists no single, effective treatment, a variety of problematic treatments exist for chronic, musculo-skeletal pain. These include epidural injections of steroids, radio-based ablation, sympathetic blockade, and spinal cord stimulation.

For ailments not involving the musculo-skeletal system, treatment must be tailored to the individual and to the disorder. Other than direct medical treatment, often there is little to offer except so-called supportive groups, which unfortunately can amount to the blind leading the blind.

Mental treatments remain controversial. There is some suggestion that meditation or even Relaxation Procedure can be helpful.

As for psychiatric treatment other than medication or counselling by so-called therapists, many of whom are of dubious qualifications, the picture is bleak. Few clinical psychologists even at the doctoral level and fewer psychiatrists have knowledge, training, and experience in Biobehavioral Science and Technology. In their stead, “therapists” offer that which has become popular — so-called cognitive-behavioral therapy (“CBT”); which, in terms of its basic model, often amounts to psychoanalytically-oriented therapy without the charm. For a presentation of a truly biobehavioral model and a discussion of “CBT”, see Part Two of the semi-fictional novel, Inescapable Consequences.

Conclusion
“ When sorrows come, they come not single spies but in battalions.” -William Shakespeare from Hamlet (Act IV, Scene V)

Pain and sorrow are familiar enemies attacking mankind since time immemorial. With the birth of science, as such, in the mid-19th-century, we have come far in reducing the pain and sorrow of disease and trauma. Even so, many continue to suffer the discomfort and sorrow of chronic pain and its associated infirmities.

As described, chronic pain and depression utilize many of the same anatomical, physiological, and chemical structures. Untreated medically, the toll that they exact can be ruinous — mentally, physically, economically, and socially.

Making a bad situation worse, so-called healthcare plans deny optimal treatment — treatment that can combat effectively chronic pain and its attendant sorrows [See Moss GR and and James CR: Pilot study of a behavioral medicine program in a community hospital setting. Journal of Behavior Therapy & Experimental Psychiatry 17: 3-9 (1986).]. These plans, initially demanded by the federal government and operated by profiteers, have displaced real medical insurance in favor of “managed care” that actually is “managed cost” (See Healthcare Reform D.O.A. now out of print but available used.).

Listen not to the governmentally-inspired propaganda. Real medical insurance no longer exists.

Who suffers? To some substantial extent, physicians; to a much greater extent, patients. We are witnessing the Sovietization of American medicine. In the near future, most Americans will be treated by “Dr. Nurse” instead of “Doctor Doctor”. Nurses and Physicians’ Assistants are not physicians. They are para-medical personnel not medical personnel. In this context, consider the future plight of those suffering the sorrows of chronic pain.

Is there a scientifically-based, scientifically-driven alternative? Yes. (See Chapter 17 of Inescapable Consequences.) Shall we employ it? Not likely.

-End-

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