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Minnesotans rarely miss an opportunity to link their fair state with a national or world event. Such as, “Minnesota mom among missing in South American air crash” and that sort of thing. Therefore, I found it interesting that Minnesotans have missed their intimate connection to events pertaining to monuments and their removal, in the broader context of white supremacy and resistance against it. This is not a trivial connection, but a deeply important one that leads to many considerations beyond what I can wrangle here. But, I can give you the gist.

In 1857, US Supreme Court Justice Roger B. Taney ruled that a person who is black and of African ancestry can never be thought of as an American citizen, and therefore, has no standing to bring a law suit in federal court. In the same decision, Taney determined that a previous act of Congress that prohibited slavery in most of the territory north of a certain latitude, in land that was in the United States but not in a given state, was unconstitutional. In so doing he decided and determined that the US Congress could not prohibit slavery.

This decision was made in response to a suit filed by a slave named Dred Scott, who lived for a while, during a very important part of his life, just south of the Twin Cities.

Mr. Scott had been born a slave in Missouri, but later lived in various non-slave territories, as one of his owners was in the military and moved around a lot. During that time, he met and married Harriet Robinson, who was also a slave. Mr. Scott was owned by a military doctor stationed at Fort Snelling, which had been built on Lakota-Dakota land known as B’Dote (or Bdote) near what is now Bloomington Minnesota, home of the Mall of America. Ms. Robinson’s owner was Lawrence Taliaferro, who was the fort’s Indian Agent. Since Taliaferro was a Justice of the Peace, it was he who both gave his slave the permission to marry her fiance, and it was he who performed the ceremony.

The basement quarters of the Scott family at Fort Snelling.

At the time, Fort Snelling was in “Wisconsin Territory,” which is why, I suspect, Minnesotans by and large don’t know that Dred Scott lived here. Wisconsin Territory included parts of North and South Dakota, all of Minnesota, Wisconsin, and possibly tiny bits of adjoining lands. But if you come across a reference to Dred Scott in a history book, the word “Wisconsin” is right there, and Minnesotans think of the Green Bay Packers and move on.

Previous legal decisions, and a certain amount of common logic sprinkled with a sense of humanity, had already determined that a slave who then lived as a free person for a while got to be a free person for the rest of their lives. Since slavery was not legal in what was to eventually become Minnesota, and other territories in which Scott lived, he had a pretty solid legal case to make that he should be freed even after his owner moved him back into a slave state at a later time.

In order for Justice Taney to determine that Scott’s case was invalid, he had to create law that made the federal abolition of slavery in all non-state territories impossible, and to make all blacks non-citizens. Taney’s ruling was only the second time the Supreme Court had found an act of Congress unconstitutional, and of all the SCOTUS decisions ever made, this one had by far the greatest and most negative ultimate consequence.

Mr. Scott’s history is more complicated. There were changes in who owned him. He had tried to buy his freedom. He and his wife had children, including children born in non-slave territory. Abolitionists got involved. The Dred Scott vs. Sandford supreme court case, and all the legal events that preceded it, were major news at the time. The final result of Taney’s decision sealed the fate of the United States, set back civil rights by a century and a half, and contributed materially to the violent deaths of about a million people.

Fast forward to 1879.

From the time of the birth of the nation, but with greater intensity staring around 1830, and getting more and more intense in subsequent decades, the United States continuously wrestled with the issue of slavery. Abraham Lincoln had always thought slavery was bad, but he was enamored with the US Constitution and could see no easy direct way to make slavery illegal country-wide. He felt it would eventually die out as a practice, through a combination of legal and social changes.

But reducing or eliminating slavery had become an order of magnitude more difficult than it ever had to be because of Taney’s Supreme Court ruling. When Abraham Lincoln was elected to be president of the United States, slave owners felt that their ownership of other humans, and their right to spread that practice to the other sates simply by moving to them (with their property, their slaves) was threatened. This threat was sufficient that they assembled armies, caused their states to separate from the Union, and attacked the US Federal government with military force. The ensuing Civil War is the reason most of the previously mentioned million people died, but many others, blacks, have been killed before, during, and after the war by white supremacists. (This includes Union soldiers who were black, who were routinely killed on the spot when taken prisoner by Southern soldiers.)

After the war, there was a rapid and remarkable shift in society and politics in the south. Federal authority made it possible and relatively safe for southern Blacks to run for office and to vote in elections. Suddenly there were black faces in state legislatures and the US Congress.

But at the same time organizations like the Klu Klux Klan formed, and these organizations and their supporters infiltrated local and state governments. In some cases, they set up separate governments. On election day, in some jurisdictions, there were two voting boxes, and you could pick which one to cast your ballot in. The white supremacists had their vote, everyone else had a different vote, and when the results were different, the federal government would enforce the correct vote. At times, these disputes turned into small shooting wars, and were sometimes accompanied by random slaughter of blacks living in local communities.

Eventually the new fight over the old south fully evolved at the federal level and things got really strange.

In 1876, the United States had its most contentious election for president ever. Democrat Samuel Tilden, a Democrat (and thus of the party of the South) from New York (and thus maybe not so much from the party of the south) won 50.9% of the vote to Rutherford B. Hayes’ 47.9%. Hayes is credited with having had 185 electoral votes to Tilden’s 184.

Initially, however, the count was Tilden with 184 electoral votes, Hayes with 165, and 20 votes from that special category of votes that involved the multiple voting boxes and other shenanigans. The states with the bad votes were Florida (of course), Louisiana, and South Carolina (and there was a small problem in Oregon as well).

Eventually, a deal was struck. This deal was almost certainly illegal and extra constitutional, but even if that wasn’t the case, the deal was bad. But it is hard to say because the process and even details of the decisions made in the deal were kept secret and to this day we are not entirely sure what happened.

Rutherford Hayes, the Republican, was awarded all the messy votes, and became president. But, in return for keeping the Presidency out of the hands of the Party of Slavery, the federal authorities that were in the South keeping the white supresists at bay were withdrawn.

This is the beginning of the Jim Crow era, the era of terror and and harassment, hate and murder, bestowed by southern whites on southern blacks.

OK, fast forward to 1879 but for real this time, now that you have the context.

Slavery, a fight against slavery, Roger Taney personally ensures the continuation of slavery for a few, as well as the many, and produces the most bone-headed court decision ever, which is on the top list of three or four reasons that definitely led to the Civil War, followed by a lot of white supremacist whinging about, followed by the Jim Crow era.

And that is when art and antiquities collector William Walters (of the Walters Museum), who had hid out in Europe during the Civil War and seems to have been involved in about zero political activities as far as I can tell, paid for the erection of a monument to Roger Taney in Baltimore.

Go figure.

Now, fast forward a bit farther to March 6th, 2017. That is when this happened:

This is Charles Taney III, a great great grand whatever of Roger Taney, hugging Jynne Jackson, a great great grand whatever of Dred Scott, in front of the Taney statue. This photograph was taken at a ceremony in which Taney publicly apologized to Jackson.

Lynne M. Jackson winced outside the Maryland State House on Monday as she listened to Charlie Taney repeat some of the words his great-great-grand-uncle wrote in the U.S. Supreme Court’s Dred Scott decision 160 years ago.

Black people cannot be U.S. citizens and have no rights except the ones that white people give them. Whites are superior to blacks. Slavery is legal.

“You can’t hide from the words that [Roger Brooke] Taney wrote,” Charlie Taney said, standing a few feet from a statue of his ancestor, who lived in Maryland and was chief justice of the nation’s highest court from 1836 until his death in 1864.

“You can’t run, you can’t hide, you can’t look away. You have to face them.”

Then Charlie Taney turned to Jackson, the great-great granddaughter of Scott, an enslaved man who sued for his freedom. He apologized — on behalf of his family, to the Scott family and to all African Americans, for the “terrible injustice of the Dred Scott decision.”

And just a few short months later. during the early morning hours of August 18th, as a result of civil unrest stemming from pro-Nazi and pro-white supremacist remarks made by President Donald Trump, that Taney statue was removed:

Many of the Southern statues related to the Civil War, or, I suppose,pro-slavery supreme court decisions, were installed at about the same time as the Taney sculpture. The motivation behind the Taney statue, and possibly, who was really behind it, are an enigma, but in many cases, statues or monuments were erected by local governments under pressure (from within or elsewhere) by organizations like the KKK or other post war white supremacist groups and individuals. These statues were put up after the election of 1876 and the start of the Jim Crow era and their erection was very much part of that social movement.

A second wave of statue building and memorializing of things Southern happened during the 20th century Civil Rights Era. At this time, many schools were named after southern notables.

So at the start of Jim Crow, blacks living in southern cities were served up a reminder of their place in southern society. During the Civil Rights Era, black students were served up a reminder of their place in southern society, during the period of forced integration of schools.

No wonder so many northerners require southerns to prove that they are not a) assholes or b) stupid before giving them a break. Considering that our least racists and overall best presidents have come from the South, and Donald Trump comes from Queens, New York, northerners should give southerners more of a break. But we can do that while at the same time noting that there are a lot of people in this country that don’t deserve anyone’s respect because of their hateful views.

Meanwhile, in Bloomington, MN, you can find a memorial to Dred Scott, as well as a Dred Scott miniature golf course, a playground, and a car repair place.

I’d tell you what the plaques in Bloomington say, but I can’t find the text. I will visit the park soon and report back, it is not too far from me.

Meanwhile, if you live in or near the Twin Cities, get over to Fort Snelling and visit the place where Harriet and Dred lived. There is some interpretive history there, and the rest of the historic site is pretty interesting too.

The Dred Scott Case: Its Significance in American Law and Politics

Dred Scott’s Revenge: A Legal History of Race and Freedom in America

Dred Scott v. Sandford: A Brief History with Documents (Bedford Series in History & Culture)

Dred and Harriet Scott: A Family’s Struggle for Freedom

I, Dred Scott: A Fictional Slave Narrative Based on the Life and Legal Precedent of Dred Scott

Am I Not A Man? The Dred Scott Story

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“A candidate is not going to suddenly change once they get into office. Just the opposite, in fact. Because the minute that individual takes that oath, they are under the hottest, harshest light there is. And there is no way to hide who they really are.” -Michelle Obama

The most massive stars in the Universe are true behemoths, rising to hundreds of times the mass of our Sun and burning at temperatures upwards of 30,000 K at their surface. But there are stars out there that are even hotter, despite only being 10% or less as massive: Wolf-Rayet stars. The key to their cosmic success? Blowing off their outer layers of hydrogen.

O-class stars are the hottest main-sequence stars, but by expelling their outer hydrogen layers, as this illustration shows, they can achieve even greater temperatures. The star illustrated here is the first Wolf-Rayet star to be found with a disk. Image credit: NASA, ESA, and G. Bacon (STScI); Science Credit: NASA, ESA, and J. Mauerhan.

By only leaving the dense, massive core of already-fused elements, Wolf-Rayet stars burn helium, carbon, oxygen or even heavier elements at their centers, while the journey to the surface “only” cools the star down to ~200,000 K by time the edge of the photosphere is reached. Elements like carbon, nitrogen, and oxygen may be ionized up to four times when their spectra are viewed.

The Wolf-Rayet star WR 102 is the hottest star known, at 210,000 K. In this infrared composite from WISE and Spitzer, it’s barely visible, as almost all of its energy is in shorter-wavelength light. The blown-off, ionized hydrogen, however, stands out spectacularly. Image credit: Judy Schmidt, based on data from WISE and Spitzer/MIPS1 and IRAC4.

Come learn the secret – and get the spectacular images and descriptions – of the hottest stars in the Universe for today’s Mostly Mute Monday!

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by Dominika Heusinkveld, MD, MPH

Researchers at NASA and the University of Arizona, among others, are hoping to make real-time air quality forecasting a reality in the next few years. The NASA Health and Air Quality Applied Sciences Team, or HAQAST, is collaborating with health departments, county and state agencies, and university researchers to get the word out about its satellite data. The data, available for free online, can help track air quality indicators, heavy metals in air, dust, and other atmospheric components which can affect human health.

Photo courtesy of NASA Image Library

NASA satellites have been collecting data for years on nitrogen dioxide, ozone, particulate matter, and sulfur dioxide. The time period of available data depends on when the individual satellite was launched. The HAQAST team hopes to encourage local stakeholders to make use of it.

NASA HAQAST Team Leader Dr. Tracey Holloway says,  “Hopefully when [agencies] see that satellite data and other NASA resources can answer their [public health] questions, they will take advantage of all the amazing satellite and other data available.”

A past NASA project, the Air Quality Applied Sciences Team (AQAST), was the genesis of the current HAQAST project. AQAST aimed to increase the utility of satellite data to researchers and public agencies while improving communication with stakeholders such as the public and government officials.

“We publish papers in journals but it’s not really percolating into policy,” said Avelino Arellano, Jr., Associate Professor of Data Assimilation and Atmospheric Chemistry at the University of Arizona’s Department of Hydrology and Atmospheric Sciences.

The AQAST project was an important way to connect the data to stakeholders. One of the AQAST projects resulted in a brief video with President Obama explaining how satellite data has been helpful in tracking nitrogen dioxide, a common air pollutant. Arellano sees the video as one of the success stories of AQAST.  Another was improving communication and relationships between agencies like NASA, the EPA, and NOAA.

“AQAST was instrumental in showing how satellites can ‘see’ trends in air pollution, even in areas where no other monitors exist. As a result, the EPA used satellite data in their public report on clean air trends for the first time in 2016,” says Holloway.

HAQAST plans to build on those successes with a wider emphasis on human health, says Holloway. Input from satellite data can greatly improve current air quality forecasts, but these are still not accurate on a local scale and require finer resolution to be more useful.

“We don’t really have a good forecast for air quality yet,“ says Arellano. For instance, air pollution is worse during rush hour, but many of the older satellites only pass over an area once a day, so the differences in air quality between morning and afternoon rush hour are not seen.

A new satellite, called GOES-16, should fill in some of the blanks and provide finer resolution data. According to a NASA website its instruments “can provide a full disk image of the Earth every 15 minutes, one of the continental U.S. every five minutes, and [have] the ability to target regional areas…as often as every 30 seconds.”

In addition, more research will be needed to fully utilize the data and to integrate it with human health.

“In forecasting I’m not really sure that there’s a connection between what the satellite sees and what you breathe,” Arellano says. “We need to connect studies on air quality and data on air quality to health.”

For example, while pollution has been linked to cardiac events (such as heart attacks) and lung disease, more studies need to be done on the relationship between air quality and hospitalization events. These relationships are extrapolated in much of the current research; direct correlations would provide a clearer picture.

Arellano would like to see public health agencies and federal agencies such as the National Weather Service utilize the satellite data.  He would also welcome collaborations with nonprofit agencies. The main limitation he encounters is lack of connections between researchers and nonprofits. Fortunately, outreach is an important part of HAQAST’s mission.

“We have a Twitter account (@NASA_HAQAST), the new website, a semi-monthly newsletter, and even a YouTube channel,” Holloway says. In addition, the team hosts two meetings per year with a variety of local and national agencies.

“We’ve found…that listening is the most important part – we need to hear where new information could be helpful… then the scientists on our team work to figure out new ways to answer open questions,“ Holloway says.

She encourages interested agencies to contact the team. “Our mission is to serve the public and maximize the benefit of satellite data for health and air quality. ”

 Want data? Here’s where to get it:

  • Worldview: Users can make layered maps from daily, monthly, and yearly data.   Good for new users, and user-friendly.
  • Giovanni: Users can make maps, map plots, and download data.  Also good for new users.
  • ARSET: the Appled Remote Sensing Training program. Offers online training on how to use satellite remote sensing data.
  • For more advanced users: download the data files for mapping or plotting from https://earthdata.nasa.gov/earth-observation-data/near-real-time. Will require the use of advanced data management software.

Dominika Heusinkveld, MD, MPH is currently a graduate student in the University of Arizona’s Environmental Science and Journalism programs. Her interests are environmental health, health communication, and science journalism.

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Alternative medicine, by definition, consists of medicine that either has not been shown to work or has been shown not to work. To paraphrase an old adage yet again, medicine that has been shown to work with an acceptable risk-benefit ceases to be “alternative” and becomes simply “medicine.”

Unlike the case for many conditions commonly treated with alternative medicine, whether or not a treatment works against cancer is determined by its impact on the hardest of “hard” endpoints: Survival. A patient either survives his cancer or he does not. Even the “softer” endpoints used to assess the effectiveness of cancer treatments tend to be much harder than for most other diseases, such as progression-free survival (the cancer either progresses after treatment or it does not) or recurrence-free survival (a cancer either recurs after treatment eliminates it, or it doesn’t). Yes, although there are lots of other aspects of cancer treatment to be assessed, such as quality of life and adverse reactions, at the very heart of evaluating any treatment for a specific cancer are the questions: Does the therapy save the lives of cancer patients? Does it prolong survival, and, if it does, by how much and at what cost?

One might reasonably predict that, for alternative medicine and any given cancer, the answer to both questions will be no. However, the question is much harder to study than one might guess if you don’t do cancer research yourself. For one thing, it is unethical to do a randomized, controlled clinical trial of a treatment with no evidence of benefit. So, except for very uncommon situations (e.g., the Gonzalez protocol, which was tested in a clinical trial against pancreatic cancer and failed miserably), leaving Nicholas Gonzalez to make all sorts of excuses, we have to use other methods to investigate the effect of alternative medicine use on survival in cancer patients. Yes, anecdotes like that of Michaela Jakubczyk-Eckert, who died a horrible potentially preventable death from breast cancer because she chose the quackery of Ryke Geerd Hamer’s German New Medicine and stopped her neoadjuvant chemotherapy, which allowed the tumor to grow back bigger and deadlier than ever, are powerful and very likely representative of what happens, but this is science-based medicine. What are the actual numbers. Yes, I’ve seen at least a dozen women like Ms. Jakubczyk-Eckert through my career, but what is the effect of choosing alternative medicine beyond my clinical experience and in cancers that I personally do not treat?

Such were the thoughts going through my mind as I was made aware through social media of a study published online ahead of print in the Journal of the National Cancer Institute by Skyler et al, entitled “Use of Alternative Medicine for Cancer and Its Impact on Survival.” In it, Skyler B. Johnson, Henry S. Park, Cary P. Gross, James B. Yu, all from the Department of Therapeutic Radiation (basically radiation oncology) at Yale, seek to answer the question: What is the effect of choosing alternative medicine as the primary treatment for a potentially curable cancer on a cancer patient’s chance of surviving his or her disease?

The newest study showing that alternative medicine kills cancer patients

The latest study, by Skylar et al, is a good demonstration of how difficult it is to study alternative medicine use in cancer patients. I’ll show you why in a moment. First, however, the authors introduce why it is so important to study this:

Delay or refusal of conventional cancer treatment (CCT), when done in favor of alternative medicine (AM), may have serious survival implications for cancer patients (1–7). However, there is limited research evaluating the use and effectiveness of AM, partly due to data scarcity or patient hesitance to disclose nonmedical therapy to their providers (8,9). To address this knowledge gap, we used the four most prevalent cancers (breast, prostate, lung, and colorectal) in the United States (10) from the National Cancer Database (NCDB) between 2004 and 2013 to identify the factors associated with AM selection and compared survival outcomes between AM and CCT.

Yes, there is a paucity of studies evaluating the use of alternative medicine in cancer. (I will cite some of the other studies that exist after I discuss this one.) The reason is clear. It’s hard, and data are lacking. This brings me to the National Cancer Database.

There are two very large databases in the US that are commonly mined for cancer outcomes. One, of course, is the Surveillance, Epidemiology, and End Results (SEER) database, which is maintained by the National Cancer Institute. The program began in 1973 and consists of cancer registries all over the country that enter data regarding cancer outcomes in a standardized format, which includes patient demographics, primary tumor site, tumor morphology and stage at diagnosis, first course of treatment, and follow-up for vital status. Mortality and patient survival are tracked, with the mortality data coming from the National Center for Health Statistics and population data coming periodically from the Census Bureau. As large as it is, though, because of many gaps in coverage SEER only reports cancer outcomes for 28% of the US population. Still, it is a large database that’s been around for 45 years. However, working with it in collaboration in the past, I’ve found that it has notable oddities and omissions. Often it is behind the times in tracking important variables, such as HER2 status in breast cancer, which SEER didn’t begin tracking until 2011 or so, even though HER2 status had been used for at least a decade before that.

That’s probably why the authors chose the National Cancer Database, which is a joint project of the American College of Surgeons and the American Cancer Society. It is a clinical oncology database sourced from hospital registry data collected by the more than 1,500 facilities accredited by the American College of Surgeons Commission on Cancer (CoC). Data cover more than 70% of newly diagnosed cancer cases nationwide and are used to develop quality improvement initiatives and set quality standards for cancer care in many hospitals across the US.

Now, imagine that you want to look at the effect of alternative medicine use on cancer mortality, and you had access to a large database like this. How would you go about doing it? There are a lot of things you have to consider. First, you would want to look at potentially curable cancers, because you want to find out if patients with curable cancers who choose alternative medicine die at a much higher rate than those who use conventional therapy. Thus, you have to exclude patients who had metastatic disease at the time of diagnosis. Another important thing you have to do is to choose cancers that have a reasonable rate of cure using conventional therapy. Choosing pancreatic cancer, for instance, wouldn’t make much sense, since the vast majority of pancreatic cancer patients, even those without metastatic disease at diagnosis, die of their disease. Even though we know from the Gonzalez trial that patients with pancreatic cancer still do much worse, dying faster and suffering more, than those treated with conventional medicine, such a difference would be unlikely to show up in a database study like this. So the authors chose four common cancers, nonmetastatic breast, prostate, lung, or colorectal cancer.

Similarly, how do you identify patients in the database who underwent alternative medicine treatment rather than conventional therapy? This is a question that is not as easy to answer as it sounds. For one thing, many databases don’t include that information. One statewide database with which I worked, for instance, didn’t even have a field for alternative medicine (or even “complementary and alternative medicine”), even though it had over 750 elements tracked for each patient. This is almost certainly the reason the SEER database was not used for this study.

Fortunately, the NCDB has data fields that can help:

Patients who underwent AM were identified as those coded as “other-unproven: cancer treatments administered by nonmedical personnel” and who also did not receive CCT, defined as chemotherapy, radiotherapy, surgery, and/or hormone therapy. Patients with metastatic disease at diagnosis, stage IV disease based on the American Joint Commission on Cancer (AJCC) staging system (11), receipt of upfront treatment with palliative intent, and unknown treatment status or clinical or demographic characteristics were excluded.

The authors identified only 280 patients who fit the criteria, and noted that patients in the alternative medicine group were likely to be younger, female, and have a lower Charlson-Deyo Comorbidity Score (CDCS, a measure of preexisting comorbidities or of how “sick” the patient is at the time of diagnosis). In multivariate analyses controlling for clinical and demographic factors, the authors found that patients undergoing alternative cancer treatments were more likely to have breast cancer, higher education, Intermountain West or Pacific regions of residence, stage 2 or 3 disease, and a lower CDCS. All of this jibes with the usual impression that patients who choose alternative cancer cures tend to be of higher socioeconomic status and education, as well as healthier than average.

So what were the results? Not surprisingly, the risk of death was higher for three out of the four cancers. Overall, the hazard ratio (HR) for death was 2.5 (95% confidence interval [CI] 1.88 to 3.27); 5.68 for breast cancer (CI 3.22 to 10.04); 2.17 for lung cancer (CI 1.42 to 3.32); and 4.57 for colorectal cancer (CI 1.66 to 12.61). The differences observed were not significant for prostate cancer, likely because the survival with conventional therapy was so high to begin with. Prostate cancer tends to have a long natural course, and in this study numbers were small and follow-up too short.

As the cliché goes, a picture is worth a thousand words. Here are the survival curves (click to embiggen):

Survival curves for (A) all patients, (B) breast, (C) prostate, (D) lung, and (E) colorectal cancers.

Obviously, this study has a lot of limitations. For one thing, the use of conventional medicine is likely to have been under-ascertained (i.e., undercounted or incompletely identified). After all, as I’ve discussed with other patients, some of those who choose alternative medicine to treat their cancer ultimately realize that it’s not working and come back to conventional medicine. Such patients could also have gone to different institutions that aren’t covered by the NCDB. However, if such a bias occurred, it would have tended to make the differences in survival between the alternative medicine group and the conventional treatment group smaller, not larger, meaning that if such a bias occurred in this study the harm caused by choosing alternative medicine is likely to be significantly worse than reported.

Other studies

Obviously, this study by Skyler et al is just one study, and the most recent. There are other studies showing similar results, but unfortunately they are relatively few. For example, the first study I remember encountering after I had started blogging about medicine and alternative medicine that addressed the question of the effect of alternative medicine on cancer survival was published in 2006 in the American Journal of Surgery by Chang et al. This study used a different methodology to study the effect of alternative medicine on breast cancer survival. Specifically, the authors did a chart review of patients who refused or delayed recommended treatment of their breast cancer to pursue alternative therapies and compared their survival to that expected in patients with disease of their type and stage.

Even eleven years later, this study remains interesting to me because it’s the first one that I can recall encountering that explicitly looked at the outcomes of patients who chose “alternative” therapies as their primary treatment. There are lots of studies out there looking at alternative medicine use in cancer patients, but these mainly look at patients who use it in addition to conventional therapy (i.e., as “complementary” therapy). This study does have one strength, too, compared to most such studies, in that the patient population comes from a community practice, not an academic medical center. Consequently, it can be viewed as more representative of the “real” world situation than many studies done in academic medical centers, where the patient population may be self-selected as people as either motivated enough to seek out tertiary care centers or sick enough that their community surgeons and oncologists refer them.

One thing that was also rather fascinating about the study was the variety of alternative therapies that the study population opted for, including coral calcium, coenzyme Q10, herbs, dietary therapy, high dose vitamins, mushrooms, chelation therapy, poison hemlock (I’m not kidding), and a variety of unspecified therapies. Because of the sheer variety of therapies used and the low number of patients using each individual therapy, it was not possible to “identify particular alternative modalities that were particularly ineffective,” as the authors put it.

Who says scientific papers don’t occasionally have sarcasm in them?

Basically, the study identified 47 breast cancer patients who opted for alternative therapy, but follow-up information was only available for 33. These were divided into patients who refused surgical treatment altogether; patients who delayed appropriate surgical treatment to pursue alternative treatments; patients who refused adequate sampling of the lymph nodes; patients who refused procedures to ensure adequate local control (additional surgery and/or radiation therapy); and patients who refused chemotherapy. I’m going to concentrate first on patients who refused or delayed surgery, for the simple reason that surgery is what is curative for breast cancer and differences in survival due to adjuvant therapy can be as low as the single digit percentages, depending upon the stage of the cancer.

Of patients who refused surgery, none of the six patients identified were Stage IV (metastatic disease) at initial diagnosis. However, five out of these six patients who returned to the surgeons doing the study had progressed to stage IV, with a median time of follow-up of 14 months, with one death within a year. That’s pretty amazing, given that two of these patients were Stage I upon initial presentation. There were also five patients identified who initially refused surgery in favor of alternative medicine, all of whom were Stage II or III. The median time between diagnosis and surgery was 37 months. All five demonstrated progression of their disease, with three progressing to Stage IV disease and one of these dying of metastatic disease. Thus, 10/11 patients who refused surgery experienced significant disease progression, with 8/11 of these progressing to stage IV disease, which is incurable, and 2/11 dying within the short time frame of the study.

Not surprisingly, patients who declined chemotherapy or hormonal therapy fared better because, as I’ve explained before, for operable breast cancer, the single most efficacious intervention is surgery, and it is not that uncommon for patients with even fairly large tumors to be “cured” with surgery alone. Indeed, the benefits of chemotherapy are fairly modest in many cases, particularly those with early stage disease. In a small number of patients, it was difficult to quantify the effect of choosing alternative medicine over conventional chemotherapy, but the authors were able to estimate that the relative risk of death in 10 years in those who refused chemotherapy was 1.54; i.e., a 54% higher chance of dying within 10 years compared to those treated with conventional medicine.

A few years later, there was followup study published in the Annals of Surgical Oncology examining the same question, this time with 61 patients to study and ten year follow-ups available. Again, a retrospective chart review was performed, with telephone interviews conducted when possible. Again, authors calculated an estimated expected 10-year survival rate and/or 10-year relapse rate of each patient if they used recommended therapy and compared it to what was actually observed in the alternative medicine group. For patients who delayed surgery, the prognosis at initial presentation was compared with the prognosis based upon return presentation.

The results were just as grim. As before, patients were divided into two groups, those who refused or delayed surgery (n=26) and those who refused adjuvant therapy, such as radiation and chemotherapy (n=35). In the group that refused surgery, 96.2% of patients experienced progression of their cancer, and 50% died of their disease. The mean stage at diagnosis in this group was II. The mean stage when patients in this group re-presented after primary treatment with alternative medicine was IV, which is, again, incurable. In the group refusing adjuvant therapy, progression occurred in 86.2% of those in the ASG, and 20% died of disease. Overall, in the surgery group, the expected mean 10-year survival calculated for those omitting surgery was 69.5%. In comparison the actual observed 10-year survival for these patients was 36.4% at a median follow-up of 33 months. For the patients who delayed surgery to undertake alternative treatments, the figures were 73.6% expected 10-year survival versus a 60% observed 10-year survival.

The authors also noted that, for the patients refusing adjuvant chemotherapy or hormonal therapy, the median tumor size at presentation was 2 cm and that the mean calculated 10-year relapse-free survival at initial presentation was 59.2%. Using a commonly utilized online tool to calculate the benefit of chemotherapy based on aggregated clinical trials, the authors noted that, had recommended adjuvant therapy been followed, relapse-free survival would have improved to 74.3%. However, the observed relapse-free survival was only 13.8%. They also noted that, although the patients’ intent was to avoid traditional therapy, ultimately, 6 patients in this group started endocrine therapy to control breast cancer recurrence, and 21 had salvage chemotherapy to attempt to control recurrent disease.

Here’s a summary of the patients who refused surgery (AWD = “alive with disease; NED = “no evaluable disease,” or basically no detectable disease) [click to embiggen]:

You get the idea. This is far worse than what would be expected in patients undergoing standard treatment. As before, this study shows that refusing surgery results in the worst outcomes, which is something that has been known for a long time. For instance, this 2005 study utilizing data from the Geneva Cancer Registry. This study did not look at alternative treatments but rather at just the refusal of patients to undergo surgery for their breast cancer. The results were very similar to what the other studies I discussed showed (click to embiggen):

Another study, this time published in the World Journal of Surgery in 2012 examined women in the Northern Alberta Health Region who declined recommended primary standard treatments and included 185 women who refused standard treatment, resulting in a median delay in instituting effective treatment of up to 101 months. The survival graphs look depressingly the same (click to embiggen):

Both Scott Gavura and I discussed this study in detail when it was published. Of note, quoth the authors:

Our data showed that almost all the patients who initially refused treatment progressed to a higher stage on later presentation at the cancer center. The majority of the patients (57%) in our series initially chose CAM as the primary treatment instead of surgery. Those who had chosen CAM had disease progression with particularly poor disease-specific survival when compared to those who received standard treatment.

Finally, a recent study from Malaysia found a strong correlation between CAM use and delays in diagnosis and treatment in breast cancer patients, although this study also suggested that the reason many women use alternative medicine is because they don’t have good access to high quality medical care.

As an aside, I will note that one tendency in some of these studies that drives me up a wall is the authors’ tendency to refer to alternative medicine used as primary treatment for a cancer “CAM.” It is not CAM. CAM, by definition (you know, the “complementary” in “complementary and alternative medicine”) is not used as primary treatment for cancer or anything else. If an unproven or ineffective treatment “outside the mainstream” is being used to treat a cancer, it’s not CAM. It’s alternative medicine. I don’t like the term “CAM,” because it was designed as a means to slip unproven treatments into conventional medicine by adding them to conventional therapy when they are unnecessary, but it is the language we have.

Finally, compare the curves above to this curve, which I use frequently. This is from a famous study from 1962 by Bloom and Richardson that calculated the survival of patients with untreated breast cancer. It was carried out long before mammographic screening became the norm, which means that the cancers were detected by palpation and other clinical signs. The point is that survival in untreated breast cancer is longer than you might guess:

Survival of untreated breast cancer.

The authors compared their data with previous studies..

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“Maybe that is our mistake: maybe there are no particle positions and velocities, but only waves. It is just that we try to fit the waves to our preconceived ideas of positions and velocities. The resulting mismatch is the cause of the apparent unpredictability.” -Stephen Hawking

So, you’ve got a black hole in the Universe, and you want to know what happens next. The space around it is curved due to the presence of the central mass, with greater curvature occurring closer to the center. There’s an event horizon, a location from which light cannot escape. And there’s the quantum nature of the Universe, which means that the zero-point-energy of empty space has a positive value: it’s greater than zero. Put them together, and you get some interesting consequences.

Particle-antiparticles pairs pop in-and-out of existence continuously, both inside and outside the event horizon of a black hole. When an outside-created pair has one of its members fall in, that’s when things get interesting. Image credit: Ulf Leonhardt of the University of St. Andrews.

One of these is Hawking radiation, where radiation is created and moves away from the black hole’s center. It occurs at a specific rate that’s dependent on the black hole’s mass. But another is black hole growth from the mass and energy that falls through the event horizon, causing that black hole to grow. At the present time, realistic black holes are all growing faster than they’re decaying, but that won’t be the case for always.

As a black hole shrinks in mass and radius, the Hawking radiation emanating from it becomes greater and greater in temperature and power. Once the decay rate exceeds the growth rate, Hawking radiation only increases in temperature and power. Image credit: NASA.

Eventually, all black holes will decay away. Come find out the story on when evaporation will win out on this week’s Ask Ethan!

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  • I don’t get it, safe deposit boxes, Sw. bankfack. Are they a disappearing bank service? Do I know anyone under the age of 50 who has one? What do you guys keep there?
  • Do you wonder if I’ve got my shit together? I’ll tell you. I have street maps of Helsinki from visits in 2002 and 2009 instantly retrievable from the bookshelf next to my desk. That’s how together I’ve got my shit, OK?
  • Sonja Virta: in the 1966 edition, Tolkien added to The Hobbit that Gollum is small and slimy. Illustrators had been drawing him too big.
  • New adjective: beshatten = very dirty. “Honey, can you find clean pants for Jr? His old ones are completely beshatten.”
  • WorldCon 75 restaurant guide: “Pasila is what the architects and city planners of the 1970s thought the future should look like.”
  • I hardly know any Finnish grammar, but it turns out I have this passive vocab that surprises me. A homeless man shuffled up to me and said “Something something kello“, and I actually understood immediately that he was asking for the time, not for a handout. It was 12:30. He thanked me politely and shuffled off.
  • Jrette saw seals, Perseid meteors and a big red August moon at camp.
  • “I hope you find your peas / Falling on your niece / Praying” Kesha
  • I pick up a spoon and a candy wrapper from the floor of Jrette’s room. “Are you QUESTIONING my INTERIOR DECORATION?!?!?”
  • The Federmesser is this Late Palaeolithic archaeological culture in Northern Europe. The word means “feather knife”. I’ve never studied its remains since they’re extremely rare in Sweden (Ice Age, 3 km thick ice, OK?). But I’ve assumed that the name is literally descriptive of a characteristic artefact type. Now I learn that a better translation is “quill knife”. Or as most people would put it, “penknife”. The Federmesser culture is the Penknife People!
  • Here’s an unexpected turn. Atheists are joining the dwindling Swedish Church in order to vote in the church elections and keep the Swedish Hate Party out of its governing boards. I consider myself a political opponent of both organisations, though I’m of course far, far more friendly to S. Church than to S. Hate.
  • Tomorrow I’m driving Junior and his furniture 330 km to Jönköping and engineering school. “You are the bows from which your children as living arrows are sent forth.”
  • The 45th presidency is like when your toddler messes with your laptop. Suddenly you have a Croatian keyboard map, a mouse cursor shaped like a banana and the screen is rotated 90 degrees. And you’re like “I had no idea you could do this! Now, how do you undo it?”
  • Local paper warns that rising sea level may obliterate thousands of islands in the Stockholm Archipelago. Neglects to mention that this would also recreate thousands of islands that have recently become part of larger land masses through post-glacial uplift.
  • Such a good day together with Junior. Now he’s in his new solo home. I bought him a toaster.
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I’ve mentioned at various times in the past The Coming Plague: Newly Emerging Diseases in a World Out of Balance by Laurie Garrett. This is not a new book, but it is an excellent scholarly and accessible accounting of the situation with respect to emerging diseases at the time of its publication in 1995.

One of the most interesting stories covered here is the reaction in the US to the Swine Flu, during the Ford administration. I was reminded of this when we had our tiny outbreak of Ebola. I’m sure you’ve been following the whole anti-vax thing over the years. I believe that the anti-vax philosophy in the US has its roots in the Swine Flu debacle, though I’ve never seen that addressed by the usual suspects who speak and write about that problem. Anyway, I just noticed that Garrett’s book is in Kindle form for 7.99 (though cheaper in used form in print, if you look around.

For a mere two bucks you can get the Kindle version of The Demon in the Freezer: A True Story. This is the same author as The Hot Zone, and explores small pox. This 2002 book is a bit out of date vis-a-vis recent developments in genetic research, and is probably a bit sensationalistic, but if your library of sensationalistic disease related non-fiction is missing this volume, now is is your chance!

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Over the years, the field guide and the coffee table book have merged, and we now have coffee table-ish books (but serious books) that include a species description of every critter in a certain clade. In the case of Horses of the World by Élise Rousseau (Author), Yann Le Bris (Illustrator), Teresa Lavender Fagan (Translator), while every living species of horse is in fact covered, the book is a comprehensive guide to breeds of horses.

Of which there are 570.

A horse is horse, of course, but but is a donkey or an ass? What about zebras?

Horse people are very picky about what they call a horse. It is generally thought that there are onlly three living or recent species of horse. The Prewalski’s horse (Equus ferus prezewalski), which lives in Asia, the tarpan (Equus ferus ferus) which is the European version of this animal, and went extinct when the last zoo inmate of this species died in 1909, and the modern horse, Equus ferus caballus. But if you think of a horse as a member of the genus Equus, there are more, including the donkey/ass and three species of zebra, the Kiang (a Tibetan ass), and another Asian ass called the Onager. And, since when speaking of horses, the extinct European wild horse is generally mentioned, we will add the Quagga, the half horse-half zebra (in appearance) African equid that went extinct in 1984 (having disappeared from the wild in 1883).

Since “horses” (as in Mr. Ed and friends) and Zebras can interbreed successfully, and some of these other forms can as well to varying degrees, we need to think of Equus as a close knit genus and not be exclusionary in disregarding the Zebra and Donkey.

Anyway, that is not what this book is about. As noted, there are some 570 or possibly more varieties of horse (no two experts will likely agree on that number) and Horses of the World covers them all. There is introductory material about horses, breeds, how we tell them apart, conservation status, etc. Each horse breed is then given one half of a page on each of two folios, so you see overleaf some illustrated text on one side, and a fuller and very official illustration on the other, for most breeds, with some variation.

This is one of the few books that comes with a movie, compete with some rather galloping music:

Horses of the World by Élise Rousseau, Illustrations Yann Le Bris, Translated by Teresa Lavender Fagan - Vimeo

Élise Rousseau is the author of numerous books on horses. Illustrator Yann Le Bris has illustrated numerous books.

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If you’ve ever wondered what squid ink is made of, here’s your answer:

Generally, cephalopod ink includes melanin, enzymes related to melanin production, catecholamines, peptidoglycans, free amino acids and metals.

But mostly melanin. And mucus.

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