Archive for August, 2009

Would Nietzsche have taken Prozac?

migraine-voodoo-doll

My existence is a dreadful burden: I would have rejected it long ago, had I not been making the most instructive experiments in the intellectual and moral domain in just this condition of suffering and almost complete renunciation — this joyous mood, avid for knowledge, raised me to heights where I triumphed over every torture and all despair.  On the whole, I am happier now than I have ever been in my life. And yet, continual pain; for many hours of the day, a sensation closely akin to seasickness, a semi-paralysis that makes it difficult to speak, alternating with furious attacks (the last one made me vomit for three days and three nights; I longed for death!). F. Nietzsche, Letter to Dr. O. Eiser, January 1880

Would Nietzsche have taken Prozac? The intensity and frequency of his migraine attacks would certainly make him a candidate for modern preventive therapy. [1] Virgina Woolf, Miguel de Cervantes, Lewis Carroll, and Peter Tchaikovsky might also be given the nod. According to a review article published in the May 2009 Mayo Clinic Proceedings [2] preventive therapies are commonly underused in patients who may be appropriate candidates and who may benefit from treatment. The American Migraine Prevalence and Prevention survey states that 38.8% of migraineurs “should be considered for preventative treatment.” However, the Mayo Clinic article makes no mention whatsoever of Prozac and goes on to praise the anticonvulsant topiramate for headache prevention.

There seems to be a great deal of confusion about the best preventive medications for migraine. Prozac (fluoxetine) is just one of many drugs that have been and are being tried on suffering patients, everything from feverfew to ergotomine to botulinum toxin. Research is ongoing, of course. But despite gaps in the literature and promising evidence for some of the competition, Prozac is commonly prescribed for migraine prophylaxis. [14] A little casual investigation reveals that hard evidence to support its use is, in fact, lacking. Moreover, what evidence there is comes from a few studies done more than a decade ago.

The two most relevant Cochrane reviews are inconclusive. Cipriani, et al. (2005) found statistically significant differences in terms of efficacy and tolerability between fluoxetine and certain other antidepressants, but concluded that the clinical meaning of these differences was uncertain and that no definitive implications for clinical practice could be drawn from them. [3] Moja, et al. (2005) found that selective serotonin re-uptake inhibitors (SSRIs) like Prozac were no better than placebo for preventing migraine. [4]

One of the leading headache textbooks, the aptly named Wolff’s Headache, takes no heed of the Cochrane information and confidently asserts the prophylactic efficacy of Prozac. The studies it cites are from the early 1990s. [5,6,7] Curiously, in its own review of Prozac for migraine prevention, the US Headache Consortium cites completely different studies from the same decade. [9,10] The Consortium’s guideline [8] cautiously approves the use of Prozac based on some favourable outcomes from the cited studies.

Borkum’s Chronic Headaches (2007) barely mentions fluoxetine prophylaxis. [11] Another text, Migraine and Other Headache Disorders (2006) merely nods in the direction of SSRIs, [12] admitting that the mechanism by which antidepressants work to prevent headache is uncertain (p. 319). The editors of The Headaches (2006) also make a brief mention of the 1994 Saper study [7] which “found fluoxetine 20 to 40 mg/d more effective than placebo in the last month of a 3-month study.” [13] In his chapter on chronic migraine in Advanced Therapy of Headache (2005) Silberstein asserts that Prozac is “coming into wider use for daily headaches” (p. 104). [14]

But here is the summary from BMJ Clinical Evidence:

Compared with placebo SSRI antidepressants may be no more effective at reducing headache symptoms (very low-quality evidence).

Compared with amitriptyline We don’t know whether SSRI antidepressants are more effective at reducing headache duration (very low-quality evidence).

I could go on …

So why is Prozac being prescribed to thousands for relief of their migraine headaches? Beats me. Especially when harms associated with the use of Prozac are well described. (See the alerts published on the FDA website.) What would Nietzsche do?

David Healy’s warning is still relevant:

Since the development of anesthesia, physicians have been prepared to do harm to a few patients in order to benefit a majority of patients. The de facto Hippocratic Oath has always been: Do no harm to a majority of your patients. In the case of the SSRIs, the clinical trial evidence indicates that we may benefit some patients. None of this evidence shows us what proportion of patients benefit from SSRI treatment and what proportion are harmed by it. In the case of anesthesia, much less than 1% of takers are at risk. In the case of the SSRIs, there is a serious risk to far more than 1% of takers, but neither society nor the psychiatric profession has expressed a view as to what constitutes an acceptable minority of harmed patients. [15]


References

1. Hemelsoet D, Hemelsoet K, Devreese D. The neurological illness of Friedrich Nietzsche. Acta Neurol Belg. 2008 Mar;108(1):9-16.

2. Buse DC, Rupnow MF, Lipton RB. Assessing and managing all aspects of migraine: migraine attacks, migraine-related functional impairment, common comorbidities, and quality of life. Mayo Clin Proc. 2009 May;84(5):422-35.

3. Cipriani A, Brambilla P, Furukawa T, Geddes J, Gregis M, Hotopf M, Malvini L, Barbui C. Fluoxetine versus other types of pharmacotherapy for depression. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004185.

4. Moja L, Cusi C, Sterzi R, Canepari C. Selective serotonin re-uptake inhibitors (SSRIs) for preventing migraine and tension-type headaches. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD002919.

5. Silberstein SD, Lipton RB, Dodick DW. Wolff’s headache and other head pain. 8th ed. New York: Oxford; 2008. p.353.

6. Bussone G, Sandrini G, Patruno G, et al. Effectiveness of fluoxetine on pain and depression in chronic headache disorders. In Headache and depression: serotonin pathways as a common clue (G Nappi, G Bono, G Sandrini, et al., eds), pp. 265-272. New York, Raven Press;1991.

7. Saper JR, Silberstein SD, Lake AE, et al. Double-blind trial of fluoxetine: chronic daily headache and migraine. Headache 1994;34:497-502.

8. Ramadan NM, et al. Evidence-based guidelines for migraine headache in the primary care setting: pharmacological management for prevention of migraine. US Headache Consortium. Available from: http://www.aan.com/professionals/practice/pdfs/gl0090.pdf

9. Adly C, Straumanis J, Chesson A. Fluoxetine prophylaxis of migraine. Headache. 1992;32(2):101-104.

10. Steiner TJ, Ahmed F, Findley LJ, MacGregor EA, Wilkinson M. S-fluoxetine in the prophylaxis of migraine: a phase II double-blind randomized placebo-controlled study. Cephalalgia. 1998;18(5):283-286.

11. Borkum JM. Chronic headaches: biology, psychology, and behavioral treatment. Mahwah NJ: Lawrence Erlbaum; 2007.

12. Lipton RB, Bigal ME. Migraine and other headache disorders. New York: Informa Healthcare; 2006.

13. Olesen J, Goadsby PJ, Ramadan NM, Tfelt-Hansen P, Welch KMA. The headaches. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2006.

14. Silberstein SD. Chronic migraine without medication overuse. In, Purdy RA, Sheftell FD, Rapoport AM, Tepper SJ. Advanced therapy of headache. 2nd ed. Hamilton ON: BC Decker; 2005.

15. Healy D. Let them eat Prozac. Toronto: James Lorimer; 2003. p. 380

prozac-don't-worry

The weaponization of music

scream-hand
Sir Thomas Beecham was once asked if he had ever conducted any Stockhausen. His quick reply: “No, but I’ve trodden in some.” Beecham made no bones about his dislike of the German composer’s spiky oeuvre, an opinion probably shared by many of us. Jarring and tuneless as much of Stockhausen sounds, his music was created to express something, even if, as Stravinsky has said, all it achieved was to express itself. The hapless listener exposed to it for any length of time may feel he or she has undergone martyrdom, but Stockhausen would have been shocked and affronted to learn that his music was being piped into a prison cell for no benign purpose.

I am not aware that the CIA has subjected any of its “clients” to Stockhausens’ aleatory serial compositions, but there is ample evidence that certain kinds of music have been used extensively both as torture and as a weapon of war. Although much has been written on this subject, there is scarcely a mention of it in the literature of medicine or psychology, another of those gaps in clinical knowledge that leave one with questions about possible ideological determinants. Yet a simple Google search will quickly provide answers for anyone wondering what the songs of Britney Spears, Eminem, AC/DC, Bruce Springsteen, Metallica and Nine Inch Nails have in common with the theme tunes of the children’s television shows Barney and Sesame Street. The disturbing truth is that all have been used to break people – to degrade them and crush their will to resist.

Suzanne Cusick’s article Music as torture / Music as weapon traces current practice back to experiments conducted in the 1940s by US, British and Canadian intelligence at Yale, Cornell and McGill. Researchers discovered that sonic disturbances – so called “no touch” torture – induced feelings of helplessness and could be more effective on prisoners than beatings, starvation or sleep deprivation. Armies have been jangling the nerves of opponents with acoustic weapons since the battle of Jericho, but the deliberate use of recorded music in psy ops and as an instrument of torture is a recent development of the American military. Cusick also points to other disturbing historical precedents, not least the cruel musical rituals at Nazi concentration camps.

The choice of music, chiefly metal and rap at full blast, is frightening enough with its repetitive thrashing, high distortion, and guttural invective. One could imagine a 12-tone quartet or free jazz being equally effective. But, as Adam Shatz observes in a recent article in the London Review of Books, not many military interrogators listen to Stockhausen or Cecil Taylor. The choice of torture music generally reflects the taste of the torturers. To hear a selection of the kinds of music preferred by the US military, see this post from last May on Blog Me No Blogs. Mother Jones has also published a “torture playlist.” Jonathan Pieslak has recently published a book on American soldiers and music in the Iraq war in which he recounts the sonic attack on Fallujah in 2004 and how soldiers would get pumped up or “crunked” for combat with the same tunes they later projected towards the enemy using a Long Range Acoustic Device.

A year ago Reprieve, a British human rights law group and the U.K. Musicians Union launched Zero dB, a “silent protest” over the use of music in interrogations. Through zero dB, musicians are speaking out against the use of music for torture and calling on the American administration to outlaw it. There is a growing list of musicians objecting to the practice and calling for the humane treatment of prisoners. This list includes Tom Morello of Rage Against the Machine and Trent Reznor of Nine Inch Nails.

Andy Worthington, writing on AlterNet, reports that some artists (for example, James Hetfield of Metallica) have been supportive of the use of their music by the military. Others, like Eminem, AC/DC, Aerosmith, the Bee Gees, Christina Aguilera, Prince and the Red Hot Chili Peppers, have chosen to remain silent.

References

Allbright B. Am I a torturer? Mother Jones 2008 Mar. Available from: http://www.motherjones.com/politics/2008/03/am-i-torturer

Bayoumi M. Disco Inferno. The Nation 2005 Dec 7. Available from: http://www.thenation.com/doc/20051226/bayoumi

Cloonan M. Bad vibrations. New Humanist 2009 Mar/Apr;124(2). Available from: http://newhumanist.org.uk/2014

Cusick SG. Music as torture / music as weapon. Revista Transcultural de Música / Transcultural Music Review 2006 Dec;10. Available from: http://www.sibetrans.com/trans/trans10/cusick_eng.htm

Cusick SG. “You are in a place that is out of the world. . .”: music in the detention camps of the “Global War on Terror”. Journal of the Society for American Music 2008 Feb;2(1):1-26. Available from: http://journals.cambridge.org/action/displayIssue?jid=SAM&volumeId=2&issueId=01#

Davies C. Torture music leaves no marks but destroys minds. Reprieve [Online]. 2009 Jun 15. Available from: http://www.reprieve.org.uk/chloemusictortureblog

Ford P. Music and torture. Dial “M” for musicology: music, musicology and related matters [Online]. Available from: http://musicology.typepad.com/dialm/music-and-torture/

Pellegrinelli L. Scholarly discord. Chronicle of higher education [serial online] 2009 May;55(35):B6-B9.

Pieslak J. Sound targets: American soldiers and music in the Iraq war. Indiana University Press; 2009.

Ross A. Futility music. The New Yorker [serial online] 2008 May 29. Available from: http://www.newyorker.com/online/blogs/goingson/2008/05/futility-music.html

Shatz A. Short cuts. London Review of Books [serial online] 2009 Jul 23;31(14):21. Available from: http://www.lrb.co.uk/v31/n14/shtz01_.html

Stafford Smith C. Torture by music. New Statesman [serial online] 2006 Nov 26. Available from: http://www.newstatesman.com/200611060029

Worthington A. A history of music torture in the War on Terror. AlterNet [Online] 2008 Dec 17. Available from:
http://www.alternet.org/rights/113479/a_history_of_music_torture_in_the_war_on_terror_/?comments=view&cID=1084926&pID=1084880

Prostate free Fridays

latex-glove

The other day I dropped into a supermarket with my sig other to pick up some laundry detergent. I decided I wanted something less harmful to the environment. After browsing through the vast selection on hand, I discovered a brand whose pleasantly green label promised a combination of vigorous cleaning action and ecological rectitude. “Oh look,” I said. “This detergent is prostate free.”

Now I’m prone to the occasional solecism, malapropism or sheer, hand-flapping howler, and this one brought a blush to my face as two or three other nearby shoppers looked my way with arched eyebrows. Sig other was swift on the uptake: “Lovely. It should work quite well on my sweater. You know, the one with all the colours of the rectum.”

There is just no avoiding the fact that the insertion of a medical term into a conversation is inherently funny, either due to its peculiar-sounding Greek or Latin root or especially when it refers to a taboo body part. I know. Just try saying “prostate” loudly in public, even in a hospital corridor. The word has a straightforward etymology, entering our language from the identical word in French, which in turn evolved from the Latin prostata, which itself echoes the Greek word prostates, “one standing in front,” a reference to the prostate gland’s position at the base of the bladder.

Men’s complexes over the state of their prostate gland (which, like many things with men, may be traced back to generalized genitalia anxiety) have produced a rich mine of humour. Here is just one example grabbed off the web:

“What is the difference between a prostate and a garden hose? There’s a vas deference.”

Which doesn’t even make any sense anatomically. But it still gets a laugh.

“Rectum” is another squirmer, even in its Latin guise not quite suitable for civilized company. “Rectum” is derived from the Latin intestinum rectum, “straight intestine,” in contrast to the convolution of the rest of the bowels. The comic overtones of this word and its cognates have not escaped the attention of humorists of every variety. Consider this old Woody Allen joke:

“They tried to expel me for cheating on my Ethics exam, when all I did was look into the rectitude of the boy next to me.”

I am digressing, but that is the point here. Computers too have been known to produce some good howlers. If you’ve ever used Google Translate you’ll know what I mean. But automated translation has improved a great deal in the past twenty years. Way back in the 1980s I saved an article about a state-of-the-art package being used by a major German auto maker to translate one of their technical manuals into English. Things got a bit out of hand. The German word for “suction pipe” (Saugleitung) became “pig gliding” (through misreading this compound word as Sau + Gleitung instead of Saug + Leitung). The overactive dictionary also turned Kathoden (cathodes) into “cat testicles.” German veterinarians would wince.

Medical terms have shown up in some limericks. Here is a good one:

Whenever he got in a fury, a
Dyspeptic from Upper Manchuria
Had pseudocyesis,
Disdiadochokinesis,
And haemotoporphyrimuria.

Too much to tweet, but great fun to share with medical students. If you haven’t Googled the terminology yet: pseudocyesis is false pregnancy, disdiadochokinesis is the loss of the ability to perform rapid alternate movements, and haematoporphyrimuria is the presence of porphyrins in the urine. Our poor Manchurian would have presented a rather pitiful sight with an enlarged abdomen, morning sickness in addition to heartburn, the loss of the ability to wind up his watch, and discoloured urine.

And here is a limerick for the pharmacologically minded:

There was an old lady from Leicester,
Whose numerous ailments obsessed her.
She found no allure
In a medical cure,
And sedatives simply depressed her.

Not leaving our topic too far behind, I am reminded of an anecdote about the Victorian poet Alfred Tennyson, which I had occasion to post about a couple of years ago. As a young man Tennyson was afflicted with a painful attack of piles. He visited a youthful but well-known proctologist and was so successfully treated that for many years he had no further trouble. However, after he had become a famous poet and had been raised to the peerage, he suffered a further attack. Revisiting the proctologist, he expected to be recognized as the former patient who had become Britain’s Poet Laureate. The proctologist, however, gave no sign of recognition. It was only when the baronial drawers had been dropped and the patient had bent over for examination that the proctologist exclaimed, “Ah, Tennyson.”

Improving PubMed: parerga and paralipomena

pubmedskeleton
A few weeks ago I posted about ways to improve PubMed in terms of both functionality and interface. At our “table talk” about this issue at the Canadian Health Libraries Association conference there were many wish list candidates and just as many pet peeves – more than could be stuffed into a single blog post. Some of the more incidental items not included in the top five – we can dignify them by calling them the parerga and paralipomena – are still of interest. I’ve dusted off the dog days hair from a nice selection. It should make for some undemanding beach reading in this season of sunshine, the Zen of tanning, and the sound of one synapse snapping.

For serious PubMed acolytes, satori has been an ever-receding prospect. In May we were told that change is coming to the PubMed interface; and the wait continues. The suspense is killing us, although just today I hear from the Krafty Librarian that enlightenment will come in September. Any moment now the new academic year will be sharking round the corner and sloping in fast. Soon the library will be filled with the slapping of flip-flops, the rattle of back pack straps, and the incessant digital smoke-signalling of smart phones as our students return to their colleges and coffee shop queues like Deleuzian nomads. (It must be my age, but teaching PubMed these days feels rather like trying to give a workshop on needlepoint at a skateboarding convention.)

In the midst of these developments a group of us are tasked with rewriting the library’s PubMed handout – our draggletailed effort to put something in the hand that may have sailed over the head. We’re concerned about our editorial efforts being overtaken by those promised developments this fall, resulting in useless screenshots and instructions rendered incomprehensible in the wink of an eye. What’s more, some of us are no longer convinced that printed handouts have much significance for students steeped in the culture of me, Wii and PS3. Still, we know that some will actually read the thing and find it a useful learning tool. So we persevere. We’re also rejigging seminar presentations to minimize the yawn quotient and to postpone for as long as possible the lurch of induced slumber. Essential to this project is avoidance of the irritating monotone and cruelly prolonged torpor that mar an otherwise mediocre training session.

Naturally such preoccupations lead to the kind of critical observations that come with too intimate an acquaintance with PubMed. Librarians are its most discriminating users, and so our opinions should count for something. None of the following suggestions will be cause for much flapping in the pigeon loft. But if our ultimate goal is to improve health care for all, then it is always worthwhile to expect more of our indispensable PubMed and to dream about how its beneficial influence could be extended. From what I hear so far, September’s promised changes will not be terribly exciting.

Ah well. Here, at any rate, are the parerga and paralipomena:

Foreign-language articles, or, What’s wrong with diacritics?

We’re not dummies. Why does PubMed insist on holding our hand? Let’s see the actual title of the article in the citation – in the original language. Most of us are using sophisticated computers with heaps of memory and advanced graphics. I’m not afraid of Chinese characters or Turkish accents. Being forced to browse non-English titles in translation and coddled in their chaste square brackets is as ersatz an affair as watching a dubbed film. Why can’t PubMed citations be allowed to be themselves, umlauts and all?

Make field tags work better with parentheses

A field tag should only have to be used once with a parenthetical expression. PubMed should accept a search expression of this type:

(aboriginal* OR inuit OR metis OR “first nations” OR “native people”) [TI]

It’s much less appealing to have to type all this:

aboriginal*[TI] OR inuit[TI] OR metis[TI] OR “first nations”[TI] OR “native people”[TI]

Colour it up

PubMed should improve the use of colour to highlight items added to the Clipboard as well as (optionally) items added to a Collection. The little green number – who invented that? – is too indistinct. Much more could be done with colour. Allow optional use of colour highlighting for records by publication type (RCTs, reviews, guidelines), by selected language(s), and other limits such as population, gender, country of publication, etc.

Citation display and sorting

Let’s have sorting of results in various ways: by author, date of publication, publication type, etc. Default display order for references should be an optional setting in My NCBI. Increase the default number of citations to display from the ridiculously low 20 to at least 50 or preferably 500.

Keyboard shortcuts

A useful option in PubMed would be keyboard shortcuts for selecting articles and for other functions (e.g., select tabs, change display, send to, save to clipboard, add to a collection). Better yet: make them customizable.

Clicking on tiny, fussy little check boxes is a time-wasting, synovium-damaging exercise.  (Remember the old DOS MEDLINE days, when you could highlight a record and select it by hitting the spacebar?) Currently, adding items to the Clipboard requires a two-step process (select item and then select Send To Clipboard from a pull-down menu). This process is sadly inefficient. It would be so much more convenient if items could be added to the Clipboard with a keystroke.

Email updates in My NCBI

This can’t be too hard a programming task. Let’s allow more than one email address for email updates. This can be useful for several reasons.

When an email update is requested from a saved search, PubMed currently defaults to the email address of the person whose My NCBI account created the search. This cannot be edited. It would be vastly more efficient if PubMed provided an editing option so that email updates could be sent to one or more email addresses.

The default for the number of records sent in any one email update is much too low. It should either not be set at all or should be set higher than five. This unhelpful initial setting is easily missed, and for searches that routinely retrieve more than five records, vital citations can be passed over. Yes, the emailed updates do include a link to view all results, but I would wager that many if not most end users don’t see it or don’t bother with it. This limit is an unnecessary impediment.

My Medline?

We absolutely have to rename “My NCBI” to something – anything – else. For cynics, I suggest Never Can Be Inspiring. The positive thinkers among us may prefer Nothing Can Beat It. There could be a contest to suggest a name. On second thought, that might result in a moniker similar in cutesiness to Loansome Doc.

I ask you: what’s wrong with plain old My PubMed? And for the truly adventurous, I would dare to suggest that we drop the name PubMed altogether and go back to calling the whole thing Medline.


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