?No self breast exams?

The recommendation *not* to teach exams throws the whole report into question for me. If we are changing the frequency of mammograms, should we also change the recommendation to do self exams? Won't the first change the effectiveness of the second?


In the news, the report by the Agency for Health Care Research and Quality. The "conventional wisdom" about breast cancer screening was turned on its head - or, at least tweaked, this week.

I think we might have been over doing the mammograms ("MMG"), but the old recommendation to do a "baseline" MMG between 35 and 40, with self exams each month and MMG each 2 years from 40 to 55 and then one a year or each 2 years according to risk, made sense to me.

What I absolutely don't get is the recommendation to stop teaching self exams. Teaching self breast exams received a "Grade D" recommendation - meaning there's no empirical evidence that the procedure is "effective." In other words, it has "moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits." The practice would be "discouraged" -- considered bad medicine, and actually put the doctor at risk for criticism. It most certainly won't be paid for.

There's a reason to find masses: it will change what we do, we have treatment that we can and should do for positive changes. Any mass that's fast growing and lasts over a month is highly suspicious and any mass we can feel should be biopsied. Even though the sensitivity may be low (compared to MMG), patients who do regular exams have been proven to be more likely to find masses earlier and smaller than the doc would at an annual exam, and it's non-invasive, cheap, and accessible. Teaching the self exam gives me something to talk about while I'm doing my own exam of the patient and is an opportunity to explain what I've written, above.

It looks like the fuss over the recommendation will be the first test of the realities of "Comparative Effectiveness Panels" which was funded by $1 Billion allocated in the 2009 "Stimulus Package."  Emotions and reactions are high, with Health and Human Services Secretary Sebelius,  Medicare and most insurance companies already reporting that their policies (paying for annual MMG and recommending teaching at doctors' exams) won't change. The Mayo Clinic has absolutely renounced the recommendations.

For more information on the policies of other nations, see this article.

Obama will fund more losing embryonic stem cell research (New Yellow Brick Award to the President)

Just days after we hear about functioning induced Pluripotent stem cells from adult skin cells, cells that can produce dopamine, the proteins missing in Parkinson's disease, we read that President Obama is going to overturn the limits on funding for embryonic stem cell research. Despite the fact that these cells match the patient because they come from the patient, that they will be cheaper, more accessible and we believe have less risk of causing cancer, this Monday morning, the 9th of March, 2009, the White House plans a quiet ceremony to sign the Executive Order.

Follow the Yellow Brick Road, Mr. President. The great embryonic Oz will get you home. Do not look behind the curtain, ignore that little man.

"Stroke of the pen, law of the land. Kinda cool!" (Thank you, Paul Begala.) We've been trying to spend a Trillion dollars every 10 days in the Obama administration. Let's just throw more good money after bad.

Typical of the news articles, is this one, from the US News and World Report, entitled (sigh)"Obama to End Stem Cell Ban Monday
Researchers applaud his action, which is expected to kick-start efforts to unlock therapeutic potential."

I recommend that you read that link above, in order to compare reality with what the proponents of destructive embryonic stem cell research believe.

The article is so full of holes. The title and first paragraph say "ban." There never was a ban. Ask Daley and Melton of Harvard who have been creating embryos for destruction to harvest the parts.

And then, there's this gem of an emotional non sequitor, I'm afraid from my State of Texas:

"It's going to remove an embarrassment for American science," said Dr. Darwin Prockop, director of the Texas A&M Health Science Center College of Medicine Institute for Regenerative Medicine at Scott & White Hospital in Temple, said in February. "It's a statement that we're going to again believe in science."

Prockup must have been teased too much about his name as a child. Seriously, who among us stopped and now started to believe in science again?

We are not behind, we are not embarrassed, unless it's in imposing regulations. Even the "Progressives" are calling for more restrictions. The UK has more regulations on regenerative medicine and embryonic research than the US. France, Germany and Israel have similar limits on funding. Germany, at one time had criminal charges and fines attached to their ban.

CIRM has $3 Billion which must be spent on cloning and embryonic stem cell research. Their "Strategic Plan?" (This is a pdf, for a review, read this article at the CIRM website.) One cure and 2 trials in ten years. Who thinks the US is going to top their billions in embryonic research, when results with induced Stem Cells are bounding ahead?

Oh, I know, CIRM thinks the NIH should buy their $400 Million in bonds, this year. No one else wants the losing proposition.

Prenatal Pain vs. "Nociception:" Psychological Construct?

The Journal of the American Medical Association (This link is to the abstract. Subscription is required for the full article) published an article this week claiming to definitively settle the problem of whether or not children feel pain before birth.

Some of you may have read that there are serious ethical questions about the authors, two of whom are involved in the abortion industry.

But, what you probably won't read in the popular press is that the definition of pain used by the authors is a little bit more convoluted that the one you and I might use. Specific and particular jargon is important for consistent communication within a profession, however it may complicate communication between specialties. And a difference in the understanding of the definition of "pain" is vital in this case, where the authors call pain a "psychological construct." I believe that their definition is constructed.

Here's the description of the definition of pain from the article:

What Is Pain?

"Pain is a subjective sensory and emotional experience that requires the presence of consciousness to permit recognition of a stimulus as unpleasant. Although pain is commonly associated with physical noxious stimuli, such as when one suffers a wound, pain is fundamentally a psychological construct that may exist even in the absence of physical stimuli, as seen in phantom limb pain. The psychological nature of pain also distinguishes it from nociception, which involves physical activation of nociceptive pathways without the subjective emotional experience of pain. For example, nociception without pain exists below the level of a spinal cord lesion, where reflex withdrawal from a noxious stimulus occurs without conscious perception of pain.

"Because pain is a psychological construct with emotional content, the experience of pain is modulated by changing emotional input and may need to be learned through life experience. Regardless of whether the emotional content of pain is acquired, the psychological nature of pain presupposes the presence of functional thalamocortical circuitry required for conscious perception, as discussed below."

In other words, does the child feel bad about being hurt?

The stimuli that the writers are describing are the same that you and I would describe as painful. The child's brain is stimulated, to varying degrees, depending on his stage of development. Using this definition, most children would not pass their test until they were over a year old.

Some have speculated that the children may experience *more* "nociception" than a child who is mature, since the nerve stimuli can't be processed.

In the case of prenatal surgery for a wanted child (which seems to be the definition far too many use for "human child") the fetal stress hormones (mentioned in the paper) and the stimulation of the nerves themselves will affected and will actually change the way those nerves and nerve pathways will develop. With consequences that we do not yet understand.

From an article on neurodevelopment and child trauma and the periodic sensitivity to stressors:

There is some evidence to suggest that prenatal or maternal traumatic stress has significant impact on neurodevelopment -- battering the pregnant mother is also battering the developing fetus (Amaro et al., 1980).

and

The abnormal pattern of stress-mediating neurotransmitter and hormone activations during development alters the brains of traumatized children. The specific nature of these fucntional alterations is seen in all of the brain functions which are directly or tangentially related to CNS catecholamine systems. Unfortunately, the CNS catecholamines (and likely other important neurotransmitter systems altered by these experiences) are involved in almost all core regulatory activities of the brain. The brainstem and midbrain catecholamines are involved in regulation of affect, anxiety, arousal/concentration, impulse control, sleep, startle, autonomic nervous system regulation, memory and cognition.

Of course, if the child is killed, there is no more development, is there?

For those of us who love science, one of the attractions is the fact that our knowledge increases as we develop better tools to measure, record, and repeat our experiments. Neuroscience is one of the most exciting fields today, because of techniques such as functional MRI and ever more focused and reliable ways to measure development, physiology and function. Within the last two years we found out that we were wrong about the old idea that no one develops new brain cells after the age of two. We also learn more each day about the effects of stimuli and "use it or lose it" on the development and function of the brain. In the last year, it was reported that infants as young as fifteen months old are able to tell the difference between false beliefs and those that are true, a cognitive skill that went against previous evidence and testing methods.

In light of these facts, shouldn't humane medical research and treatments be cautious in order to "First, do no harm?"

As noted in this blog, since when do we allow people to kill other people just because that person can't feel pain? Would a surgeon take an unconscious person to the operating room without anesthesia? Terri Schiavo was even given IV morphine while she was being starved to death.

Edited May 26, 2009 for "labels."