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129 posts from September 2004

September 30, 2004

Listen to the lizard brain

BushchimpClick to enlarge.

You should know who won the debate tonight. Suppose you don't, though. If not, don't listen to your cerebral cortex. Listen to your lizard brain. Watch the video without the sound. Get in touch with your ancestors. Think way back. Don't even think. Thousands of years of evolution have prepared you for this decision. You are ready for justified true belief. If you must, consult the following reference, Nonhuman Primate Models to Study Anxiety, Emotion Regulation, and Psychopathology.

The grimacing, the lip-smacking, the rapid-fire blinking... How many glasses of water did George W. Bush have under the lip of the podium? He was downing them like Mescal shots towards the end. You all know how the sympathetic nervous system shuts down the salivary glands during extreme stress, right? (cf. Relationships Between Various Measures of Stress and Salivary Flow Rates)

As a vertebrate, a primate, and as a citizen you know it was crushing victory.

Defining "Neoconservative"

Juan Cole gives an excellent definition of "Neoconservative":

Warning: The text below will use the word "Neoconservative." In my lexicon, a Neoconservative is a person from a social group that typically voted Democrat before 1968 but now votes Republican. Neoconservatives include all the white southern Christian denominations, such as the Southern Baptists, that emigrated from the Democratic Party to the Republican Party as a result of the Nixon strategy, as well as the Reagan Democrats (largely working-class Catholics) and Jewish Americans who trod the same path. Neoconservatives tend to be far-right Zionists in the Jabotinsky tradition, whether they are Jews or Christian Zionists, and they are associated with a desire to ethnically cleanse the Palestinians from the West Bank or at least to so circumscribe their existence there as to render them nonentities. The latest Neoconservative to enlist in the cause is Zell Miller, and he typifies the anger, recklessness and disregard for open, democratic values that characterize the movement.

Neoconservatives have gained allies for themselves from some rightwing Realists, such as Dick Cheney and Donald Rumsfeld, to the extent that it may well be that the latter two have been converted to the Neoconservative ideology, which is distinctive because of its historical origins on the right of the old Democratic Party and in some cases in the far left (Christopher Hitchens is another example). Some have attempted to argue that the very term "Neoconservative" is a code word for derogatory attitudes toward Jews. This argument is mere special pleading and a playing of the race cared, however, insofar as only a tiny percentage of American Jews are Neoconservatives, and only a tiny percentage of Neoconservatives are Jews. The Neoconservative movement is an example of what social scientists call cross-cutting cleavages, which are multiple loyalties and identities typical of complex urban political societies.

Merck pulls Vioxx off the market

Merck Pulls Vioxx Painkiller From Market, and Stock Plunges [NYT]:

Merck & Company announced today that it was immediately pulling its arthritis and acute pain medication Vioxx from the worldwide market after data from a clinical trial showed that the drug produced an increased risk for heart attacks and strokes.[...]

Merck's shares plunged by more than $12 to as low as $32.46 when trading opened on the New York Stock Exchange this morning, and the stock remained down by about 25 percent in early trading — reducing the company's market capitalization by about $26 billion.[...]

Serves them right. Now, why don't we have better science journalism? The real question is why Merck acted so precipitously? Vioxx was one of their best selling drugs. I think it's because they're afraid of lawsuits. Merck has know about the CV risk of Vioxx for years. I wonder why these particular data finally convinced them to pull the drug.

According to the NYT:

The Vioxx risk came to light during a three-year trial designed to evaluate the efficacy of taking the drug in preventing a recurrence of colorectal polyps in patients with a history of benign colorectal tumors, the company said.

The latest data came to light this week, but the evidence has been mounting for years. JAMA dropped the inital bombshell in 2001: Risk of cardiovascular events associated with selective COX-2 inhibitors. The authors wrote, "The available data raise a cautionary flag about the risk of cardiovascular events with COX-2 inhibitors. Further prospective trial evaluation may characterize and determine the magnitude of the risk."

The cardiovascular risks of Vioxx are no suprise to Merck. FDA warns Merck over its promotion of rofecoxib [BMJ]:

In its [2001] letter the FDA criticised Merck for playing down the possible risk of stroke associated with rofecoxib and for minimising potential drug interactions of rofecoxib with warfarin.

The risk of stroke was found in an analysis of a large study, dubbed the VIGOR (Vioxx gastrointestinal outcomes research) trial, which compared 50 mg a day of rofecoxib with 500 mg twice a day of naproxen in patients with rheumatoid arthritis (New England Journal of Medicine 2000;343:1520-8).

The VIGOR trial was a randomised, double blind, placebo controlled study of 4047 patients taking rofecoxib and 4029 taking naproxen. Patients were followed for an average of nine months.

The study found that rofecoxib was significantly less ulcerogenic than naproxen and that patients taking rofecoxib had a 60% lower risk of serious gastrointestinal eventssuch as perforations, obstructions, and upper gastrointestinal bleedsthan patients taking naproxen. The relative risk was 0.4 (95% confidence interval, 0.2 to 0.8; P=0.005).

The annual rate of these events was 1.4% among patients taking naproxen, compared with 0.6 % among patients taking rofecoxib.

However, an analysis of the VIGOR study by cardiologist Eric Topol and colleagues at the Cleveland Clinic in Ohio (JAMA 2001;286:954-9) showed that patients taking rofecoxib had a higher relative risk of developing adverse cardiovascular events such as ischaemic strokes, unstable angina, and myocardial infarctions than the patients taking naproxen (relative risk 2.38 (95% confidence interval 1.39 to 4.00; P=0.002).

Their study suggested that rofecoxib might be prothrombotic and urged further research to see if this was so. The FDA charged that Merck was aware of the cardiovascular risk associated with rofecoxib and minimised it in a press release and in its promotional materials.

In a press release Merck responded that the VIGOR study's data falsely inflated the cardiovascular risk of rofecoxib because it compared the drug with naproxen, which has blood thinning properties similar to aspirin. [Emphasis added.]

Note Merck's specious justification for the elevated incidence of cardiovascular evenets in rofecoxib patients. They suggested that the rofecoxib patients had more strokes because the comparator medication (naproxen) has slight cardioprotective effects. I should add that before Merck's experts started theorizing, nobody believed that naproxen had any cardiovascular benefits.

In fact, Merck's apologia would be almost as damning as if Vioxx actually caused thromboses. The rationale for taking Vioxx instead of a traditional NSAID is that Vioxx is less likely to cause ulcers in longterm users. But other studies have shown that patients taking COX-2 inhibitors and low-dose aspirin have the same risk of ulcers as patients taking NSAIDs. We know that low dose aspirin saves lives. So, if Merck's hypothesis is true, Vioxx patients would have to forgo other potentially lifesaving treatments in order to use their product.

The whole COX-2 industry is largely a marketing phenomenon. [BMJ] These drugs aren't more effective painkillers than the old, cheap NSAIDs. Yet, doctors prescribe billions of dollars worth of COX-2s every year. Worse, they often prescribe them to young, healthy people with acute pain. There is simply no evidence that the GI benefits of the COX-2s extend to anyone except very longterm users.

The COX-2s soured me on big pharma and industry-sponsored research. These drugs are costing insurers and consumers billions of dollars for marginal benefits supported by dubious research. I used to work on a Celebrex-related project. It was embarassing because the largest and most impressive study, CLASS, suffered from methodological irregularities that less delicate commenters would have described as fraud. Sometimes I just want to scream "The emperor has no cyclooxgenase!"


September 29, 2004

Soft bigotry of low expectations

"Polite" prelude to the debates. [LA Times]

Speaking of which, more damning by faint praise in the LA Times.

Expert farming

I'm not an expert, but I make 'em. Seriously. In the comments, someone asked me what I do for a living. I'm a medical writer--at least until I get into a philosophy PhD program. You might also call me an expert farmer. Not as in someone who has farming expertise, but as in someone who farms experts as part of the vertical integration of big pharma. It's a sort of genteel plagiarism, really. Each firm has a marketing team to pinpoint high-prescribing doctors with academic aspirations. (Maybe one of these days I'll blog about how they drug companies know who prescribes what. It's very creepy.)

These days it's very chic to recruit high-prescribers for the medical equivalent of the Tupperware party. These events are known as "lunch 'n learns." The doc gives a half-hour talk at the local hospital, the company supplies monogrammed bagel caddies and tubs of cream cheese. The company writes the doc a check for upwards of $1000. Where do busy clinicians find the time to make their own polished PowerPoint presentations? They don't, I do.

I can assure you, the company gets their memetic money's worth. The same slides will be repurposed for continuing medical education modules, conference talks, and even reviews for medical journals. I might add that these reviews often bypass peer review because their ostensible authors are such big experts. Thankfully, the experts sign their names to the commercials and not me.

"Experts Mock Kerry Tan"

Too bad the online edition of the NY Post omits this subhead of the print edition: "Experts Mock Kerry Tan".

So many experts, so little time. (All due respect to SC, of course.)


September 28, 2004

The water cooler

Every so often, I try to work on my social skills. Today, I decided to strike up a conversation with my coworker. She is planning her wedding, so that seemed like a good opener.

ME: How's the wedding planning going?

COWORKER: Pretty good. But everyone has an opinion. Like, we're trying to go with a French Bistro theme, but my in-laws keep saying "Everyone likes cocktail weenies."

ME: Yeah, everyone's got to throw in their two cents. Like when Ted Williams died.

CW: [puzzled silence]

ME: You know how, when he died his family started arguing about whether they were going to cryogenically freeze all of him or...[at this point I realize the conversation has gone way off-track, but it's too late]...just his head, or cremate his entire body. And the Boston Metro ran this man-on-the-street feature, where they asked people "Should they cryogenically preserve or cremate Ted Williams?" And one guy said "I think they should bury him at Fenway Park."

CW: Oh.

ME: It's like, everybody's got an opinion, whether it's appropriate or not....

Blog motives: ranting recreationally

My day job is interfering with higher cognitive processes. Even in my benumbed state, I can appreciate Steve Gilliard's defense of professionalism and sponsorship in the blogosphere.

In the interest of fairness and balance, I have also included an influential anti-professionalist stance towards blogs and their role in political discourse: Edroso of Alicublog:

"Before blogs," he said, "tendentious cranks such as myself had no outlets for our ill-informed opinions, besides Letters to the Editor and soapbox rants at parties that were winding down. Also we could not count on our reputations as fuckwads to extend much past the physical borders of our respective communities." He broke the seal on a fresh pint of Jim Beam and took a long swig. "But now," he continued, "we can all write Letters to the Editor round the clock, and see them published immediately, unedited and misspelled. And at three in the morning, we can get drunk by ourselves, and vomit forth our prejudices without having to yell ‘hey, where ya goin’?’ at people who suddenly decided they have to get home before the sitter gets nervous. And our names are curses on the lips of people who never even met us. " He raised his bottle grandly. "To technology!" he roared. "All hail the mighty microchip and modem! All hail the --" He looked at me, surprised. "Hey," he said, "who’re you?"

Edit: With a view to explaining the lack of expert bloggers Matt Yglesias jokingly wonders what could motivate academics to blog:

Academics have real jobs and will only perform the great public service of blogging about what they know if they happen to be egomaniacs.

Dan Drezner is not amused. I see Matt's point about the relative dearth of exerpt bloggers. I subscribe to a kind of "drive reduction" model of blogging. Alicublog is another proponent of this model. Real experts probably just have less pent-up expertise to discharge into the blogosphere.

The Arepa Lady is a judge

Good article on street food in New York. If you read Jim Leff's Chowhound, you've probably heard of the Arepa Lady. A journalist interviewed her for this piece. Her name is Maria Piedad Cano and she was a judge in her native Columbia.

Street Corner Cooks Have Names, Too [NYT]

[Broken link fixed, thanks David.]

September 27, 2004

Pirate flags: beyond the Jolly Roger

RedotoastBatholomew "Black Bart" Roberts 

RedskeletonEdward Low

More pirate flags.

[Via Geisha asobi blog.]