The Secret Lair

CC BY-NC-SA image from Brandon Koger via Flickr

Anyone who is familiar with the goings-on here at the Lair knows that I tend to work with Minister Lynn on his Crackpot Schemes and Unfortunate Synergies. And by “work with”, I mean “clean up the worst of the mess after the fact, and hopefully limit the loss of life and equipment”. To wit, we recently had the following conversation:

Minister Lynn: “It strikes me that our audio podcast is better than most things that air on the radio. It’s funny. Educational. Informative.”

Bad Doctor: “Agreed. We do some seriously good work there, and I know it improves the lives of anyone who listens to it. I mean, just look at the minions! We pipe the podcast feed into their private chambers on a continuous loop, and it clearly enriches their existence. Each new episode increases their work efficiency by over 79% compared to control subjects who are forced to listen only to a constant track of ‘A Man and His Unicorn’.”

ML: “This is something that needs to be better recognized by the world at large. If only there was a way to pipe audio from The Lair out to the global populus…”

Lynn sucks thoughtfully on the tail of the reptosquirrel he has tucked under his arm.

BD: “Did… you just lick that reptosquirrel?”

Lynn stares into the distance for a moment, glassy-eyed.

ML: “Yes. Yes, I did. It helps center me.”

BD: “That explains quite a bit. And not just why the reptosquirrels in The Menagerie have been avoiding all human contact of late.”

Lynn gives the tail a final slurp.

ML: “What? I mean, right, so I have already have been putting hundreds of hours into a virus that will let us infect our podcast episodes on to every portable MP3 player in existence. It works by piggybacking on both Windows Updates and Google Ads. I’m still fighting with a few firewall issues, however…”

BD: “Or, we could just stick with iTunes, like we have been for years-”

ML: “…so I’ve decided to take another, more ambitious track. Now, I know you enjoy doing medical outreach on Doctoring, both Good and Bad.”

Doctor nods, sagely.

ML: “I’ve repurposed some of our orbital satellites that make up the communications and defense grid, and will use them to transmit audio of your pontifications to all the peoples of the world into their most private of settings, where they least expect it – into their homes, cars, and even their personal computers! It will be a grand task, and require much labor and upkeep, but in the end it will spread your sonic emanations far and wide! It will be glorious!”

BD: “Or, I could just infiltrate an established radio station as a regular guest.”

ML: “Oh, come now, doc. That’s just crazy.”

Lynn takes a slow, long lick on the reptosquirrel.

BD: “Stop that.”

ML: “I really should. It’s hypnoslime is about depleted anyway. Can you get me another from The Menagerie?”

BD: “How about this – you hand me that poor traumatized reptosquirrel, and I’ll give you this bottle of Purell.”

ML: “Oh, that’s even better!”

Lynn squirts several shots of Purell into his greedy mouth.

BD: “NO! THAT’S NOT what I… meant.. Actually, go town with that. It might be for the best.”

And so it came to pass¹ that yours truly, The Bad Doctor, is now the new monthly health guest on the Midday with Dan Rodricks show on 88.1 WYPR radio in Baltimore. My first stint will be today at 1pm EST, where I will be chatting with Dan about the Human Papilloma Virus and the vaccine that prevents the strains of it that are responsible for cervical (and other) cancer. There has been plenty of manufactured controversy in the media about the HPV vaccine, especially with the recent recommendation that it be given to young men as well as young women, so I expect there to be a lively discussion.

You can listen to the audio stream online at the appointed time here, or download the show after the fact here. Additionally, you can follow Dan on Twitter @DanRodricks, WYPR @WYPR881FM, and the Midday show @MiddayWYPR.

To quote a former Lair military advisor, I love it when a plan comes together.

1. Clearly, this is an accurate representation of events. [↩]

Image via Wikipedia

This week, I was a guest on the Living Proof Brew Cast, hosted by John Taylor Williams and Thomas Gideon.  Their show notes are replicated below:

Before we got into the thirsty work of my recent trip update, we poured and discussed our beers for the evening. As a foreshadowing on our main topic with Chris, he had a St. Peters Sorghum Beer. The beers John and I enjoyed were a good introduction to my thoughts on Brussels. John had the New Belgium 1554 and I had the New Belgium Trippel. Both ales reminded me strongly of the many beers–dubbels, trippels, blonds, brunes–that I enjoyed every day during my week in Belgium.

The reason for my trip, a business trip, was the EU Hackathon. Some of you may have seen the video I sharedthe really captured the spirit of the event. My Untappd stream reflected almost all of the beers I had while abroad. The highlight of my trip was definitely Moeder Lambic, the one at Place Fontainas. Not only was there an amazing profusion of beers on offer but beer culture is definitely in the very DNA of this establishment. The photos from the very end of the set on my Flickr account are from this venue.

From early on in my trip, I shared how I learned what Belgians consider a black ale versus what we call a black beer here in the states. This experience was from Cafe Leffe and the beer in question was the Westmalle Abbey Dubbel. The 1554, which is very close to the black, or more accurately brown, ales reminded John of another New Belgium, Snow Day, that he had recently.

The best beer of the trip, bar none, a beer that still haunts me was the Val-Dieu Grand Cru. This is a specialty beer, on researching it, from the Abbey du Val-Dieu which may make it hard to find either through an online or a local retailer or importer. The top spot of this beer is saying something considering some of the others I had at Moeder Lambic like the Cantillon Rose du Gambrinus, a two year old framboise lambic, and the Kerkom Winterkoninkske. Bret, our friend and the brewmaster at Growlers, recommended checking with his friends atHalftime Beverage.

One of the other beers I had on the trip, a 12 year old Trappist ale, has just been announced as coming to the states.

Speaking of travel, Chris shared his thoughts on his travel plans for the coming year. He is thinking of trying to head out some place interesting at least once a month. Ideally 2012 will see some great reports from the field by him as well as another brew day with accompanying social time to hang out, relax, and catch up in person.

The subject of brewing with Chris again segued us into a brewing update from him. He shared his thoughts on a pale ale he made and several instructive failures from his experimentations since he last collaborated with us in the beer kitchen. The pale ale, a Bells Two Hearted clone from TastyBrew.com, sounded like a challenging beer while young but may be aging out to something very special, what John dubbed a “hop wine.” The impetus for an experiement so heavily hopped was 10oz of home grown hops from a friend of Chris’. John offered that the experience with this beer was very similar to his with the Green Grass and High Tides.

We ended up chatting a bit about what we’ll be brewing next. As fun as the idea of The Mongrel was, I think John and I want to put the Summer of protest beer behind us and return to familiar responses and new experiments. We are due to brew in my kitchen next. I want to tackle a recipe we tasted and discussed in our triangulation episodes, the Sun-Dial in the Shade Oatmeal Stout.

Chooch told us how to cheer in China, in both Mandarin and Cantonese.

We turned to the reason we invited Chris on, a discussion of gluten free beers and brewing. Chris shared his experiences and impressions from about half a month so far of drinking only gluten free beers. He reminded us why he is doing this for the month of November. In addition to the St. Peter”s he mentioned at the outset, Chris has also tried RedBridge, Lakefront New Grist, and Bard’s.

John has mentioned William Davis’ “Wheat Belly” before, when we were ruminating on the effectiveness of Evo’s brew diet. He brought it up again as being relevant to why wheat may cause some people grief even in the absence of celiac or an actual allergy. Chris offered a similar read that provokes thought around food culture and industry, “In Defense of Food” by Michael Pollan. In addition to reading and research, Chris is taking a very considered approach that includes journaling his experiences and impressions.

Bolstering the idea that there are unexplored flavors beyond wheat and barley, John had the Great Divide Samurai, a rice beer that definitely compares well to any beer, gluten free or otherwise. He has also brewed with rye and is a fan of its presence in spirits. Basic Brewing Radio had a fantastic episode on gluten free brewing that delved in the flavors available from these ingredients. Search for Desiree Knott of High Gravity in Tulsa to find the episode in question. All three of us are great fans of everything James and company do on that podcast.

Chris explained the thought behind the name he decided to brew under, Speculative Brewing, that captures the adventurous and experimental spirit he brings to brewing. If you want more from Chris specific to beer, check out his recent review of pumpkin ales. He is planning a similar review in December of Christmas and holiday ales. Feel free to participate in the conversastions around both pieces by contributing your thoughts on a related beer in the comments. John or I will add a comment with our impressions of Flying Dog’s The Fear, an outstanding and unusual local pumpkin beer. You can expand the beers Chris is able to review by donating and sending him something local or regional near you. That holds true if you want John and I to try something on mic. Either way, feel free to contact us for details of how to get us beers.

Podcast: Play in new window | Download (Duration: 1:13:11 — 83.8MB)

The Beardless Overlord

Dr. Cmar and I have shaved off our facial hair for the 2011 How Not To Grow A Beard Month festivities.  As part of this, we are also accepting donations for the annual Beards4Boobs drive, wherein we ask you to sponsor a beard to raise money for Breast Cancer research.

Please donate on the Beards4Boobs page. Be generous and save the mammaries. 

What is How Not To Grow A Beard Month? I’ll let Kris Johnson explain in his own words.

How Not To Grow A Beard Month owes its existence to three things: National Novel Writing Month, Evo Terra, and genetics.

National Novel Writing Month (or NaNoWriMo, as it is known to participants worldwide) is an annual challenge in which would-be novelists attempt to write 50,000 words in the span of 30 days. Since its inception in 1999, NaNoWriMo has grown from a mere 21 participants to more than 101,000 in 2007. The 30-day challenge has also spawned a host of imitators, among which HoNoToGroABeMo can be unabashedly included.

Dr. Cmar in his native habitat, albeit beardless

But applying the NaNoWriMo formula to facial hair would likely not have happened if not for Evo Terra’s largely unsung 5 O’clock Shadow project. In March of 2007, the podcaster and new media entrepreneur began including a photo of himself with his blog posts; specifically, a photo taken at 5 o’clock in the evening. The project continued on a more or less daily basis until Mr. Terra had amassed 100 photos of his early evening stubble.

And this is where genetics comes into play. When Evo began his 5 O’clock Shadow project, I decided it might be fun to do the same. Only in my case, it quickly became clear that the paltry stubble I managed to grow between my morning shave and 5 o’clock wasn’t visible in my self-portraits. Some of the blame could be cast upon the low-resolution cameraphone I was using at the time, but the truth of the matter was that I was not genetically disposed to beard growth.

So, in November of 2007, I decided to combine the month-long-challenge aspect of NaNoWriMo with the facial hair of Evo’s 5 O’clock Shadow into a single, cohesive event. Given my less-than-impressive record with growing anything beyond a simple goatee, I dubbed the challenge “How Not To Grow A Beard Month”.

The concept was simple:

1. Shave every bit of hair off my chin, cheeks and upper lip on October 31st.
2. Don’t shave again until December 1st.
3. Take a photograph of the “progress” at roughly the same time every day and post it to the Internet.

 

I made two small (but necessary) exceptions to this rule: the front of the neck may be shaved for the sake of comfort, and basic beard grooming (trimming along the jawline and upper lip; minor trimming to make the beard length even) is acceptable for the sake of not looking like the Unabomber.

Mr. Johnson on Dec. 1, 2008, bearded in all his Finnish glory.

After 30 days, my beard was (as predicted) less than impressive. Some of the words and phrases that were not used to describe it include thick, Norris-like, lush, Lincolnian and brawny. Despite this, I determined that HoNoToGroABeMo would be an annual event, and that I would invite anyone foolish enough to set aside their razor for a month to join me in my quest.

I was content to confine the scope of HoNoToGroABeMo to my personal blog, but wily web developer Bob Voegerl decided that the challenge was just ludicrous enough that it deserved a home of its own, and so created HoNoToGroABeMo.org, a place where beards of all shape, color and density can come together and grow in unison and harmony.

Last week during my usual work commute traffic/weather check-in with WTOP radio, I repeatedly heard a soundbyte about how a freshly published study demonstrated that many vitamin supplements were found to be associated with increased death in elderly people who take them.¹ Calcium alone, they reported, was shown to increase lifespan in the elderly. The segment was only 30 seconds long, and offered no further comment or critique.

CC BY image from bradley j via Flickr

A sterling example of excellent medical reporting? Somehow, I suspect not. Let’s take a look.

Bookends – The article in question today is Dietary Supplements and Mortality Rate in Older Women (abstract here for free access, full article here imprisoned behind a paywall), which was published in the October 10, 2011, issue of the Archives of Internal Medicine. Archives is a peer-reviewed journal published by the American Medical Association, which also publishes the better known JAMA, the Journal of the American Medical Association; while JAMA covers many broad aspects of medicine, Archives focuses more on clinical aspects of internal medicine practice. Archives is number 8 on the list of general medical journals rated by impact factor, meaning that articles published therein tend to be cited rather frequently compared to most other journals in the field.

In terms of the article in question, the authors all have non-medical graduate degrees and are primarily affiliated with the University of Minnesota, without any major conflicts of interest.² The funding for the study came from unbiased sources, as grants from National Cancer Institute and the Academy of Finland. As such, there is no obvious financial agenda behind the study.

Background – Vitamins are biologically active, organic compounds that humans cannot synthesize enough of ourselves to remain healthy, and so we need to consume in our diet. For the vast majority of people, a normal balanced diet of different foodstuffs will give us all of the vitamins we require to stay healthy without needing to take additional supplements. Having a deficiency of a particular vitamin can cause specific diseases – scurvy is the classic example in those consuming too little vitamin C, for instance – and those with a poor diet or certain medical conditions may require a vitamin supplement to make sure they have normal levels in the body to prevent these diseases.

There has long been an idea that taking a general multivitamin or specific vitamins in high doses on top of an already balanced diet can somehow do any one of a number of amazing things, including preventing certain diseases, boosting one’s energy level, or even extending lifespan. Despite the claims of the multi-billion dollar vitamin and supplement industry, scientific studies have repeatedly shown no benefit and some possible harm³ in giving supplemental vitamins to healthy, well-nourished people. This study sought to look at the question of whether women taking any one of a number of vitamins would have a lower death rate than those who did not:

“The aim of the present study was to assess the relationship between supplement use and total mortality rate in older women in the Iowa Women’s Health Study. Our hypothesis, based on the findings of a previous study by some of us, was that the use of dietary supplements would not be associated with a reduced rate of total mortality.”

Methods — This paper was an analysis of data from the Iowa Women’s Health Study, which was a prospective observational cohort study designed to look at how various diet and lifestyle factors affected the incidence of new cancers and death in women after menopause. The study design involved enrolling 41,836 women between the ages of 55 and 69 in 1986, and having them complete questionnaires about their health every few years. Since it was observational, there were no interventions carried out on the patients and no attempt was made to influence their health habits. This particular paper focused on 38,772 of the women who gave adequate information about their dietary habits and vitamin use in 1986, and look at the same information when 29,230 of them completed a followup survey in 1997, and 19,142 who did so in 1984. Notably, 99.2% of these women were of Caucasian descent.

Questions were asked on each survey about whether a general multivitamin or any of 14 specific vitamin supplements were used, as well as general questions about medical problems such as diabetes or high blood pressure, physical activity, and details about their diet. Any participants who died were classified as their death being due to cardiovascular disease, cancer, or other causes. General demographic data was also gathered. Several standard and appropriate statistical tests were used to analyze the data, and control for different variables involved.

Results – As is want to happen in studies of this type, large amounts of data were generated, with several interesting results. At baseline in 1986, 62.7% of participants reported using at least 1 supplement, which increased up to 85.1% in 2004. Those who used supplements tended to have less problems with diabetes and high blood pressure, be more physically active, and have better diets. Statistically, 7 of the 15 supplements studied – multivitamins, vitamin B6, folic acid, iron, magnesium, zinc, and copper – were associated with slight but significant increased risk of total mortality when compared with those not using them. Taking calcium supplements showed a statistically significant decreased risk of mortality. In running different statistical tests over shorter time periods, the association of less death with calcium and more death with iron use remained, and seemed to be more profound with higher doses, especially for iron.

Discussion – The article’s discussion noted that for many of the vitamins associated with an increased risk of death when taking them, there aren’t any obvious plausible reasons why that would be the case. Furthermore, they note that previous studies have shown concerns about long-term calcium use increasing death from heart disease, which they did not see here. With regards to the increased association of mortality seen with iron, they note that other studies haven’t shown this to be a strong issue. They noted the interesting fact that those who took vitamins seemed to have healthier habits than those who did not, but still had an increase in mortality; the authors speculate this might be due to that fact that those patients had other illnesses to begin with, causing them to actively take supplements and do healthier things, but still have a greater mortality rate.

They note that the strengths of their study include the large number of participants, and the multi-survey design over a period of years. There were many identified weaknesses, however. Nearly all the participants were women of Caucasian descent, making it hard to generalize the results to the general population. While doses of some vitamins were recorded in general ranges on the patient surveys, the specific formulations and exact doses were not reported or analyzed in detail. No questions were asked about concurrent medication use along with vitamins or about most other medical problems beyond cancer, heart disease, high blood pressure, and diabetes, all of which could have played a role in the results.

The investigators put their findings in context thusly:

Among the elderly population, the use of dietary supplements is widespread, and supplements often are used with the intention of attaining health benefits by preventing chronic diseases. Although we cannot rule out benefits of supplements, such as improved quality of life, our study raises a concern regarding their long-term safety. Also, cumulative effects of widespread supplement use, together with food fortification, have raised concern regarding exceeding upper recommended levels and, thus, regarding long-term safety. It is not advisable to make a causal statement of excess risk based on these observational data; however, it is noteworthy that dietary supplements, unlike drugs, do not require rigorous RCT testing, and observational studies are often the best-available method for assessing the safety of long-term use. Based on existing evidence, we see little justification for the general and widespread use of dietary supplements. We recommend that they be used with strong medically based cause, such as symptomatic nutrient deficiency disease.

My Critique – Many people want vitamins to be magic things that give energy and prevent disease. Not only does the medical evidence and basic biology show this to be untrue, but there may be risks involved from taking unneeded vitamin supplements, especially at high doses. That said, it’s worth noting that there is little in the way of conclusions that can be drawn from this particular study. Large, observational cohort studies are excellent at looking for strong positive or negative associations of certain exposures or interventions with health outcomes, such as with vaccines and autism, mobile phone use and brain cancer, or vitamin supplementation with mortality. Results of a single study of that type, be they positive or negative, are certainly interesting… but given the missed variables and lack of controls involved, making any guess about correlation of taking vitamins with one’s chances of dying isn’t a valid thing to do. Nonetheless, further studies will undoubtedly be done that will hopefully shed a bit more light on the idea that in post-menopausal women, taking some vitamins might somehow increase the chance that they would die.

Studies such as these are the grist for many popular media medical stories, and they really shouldn’t be. Given the variables involved, and the fact that the conclusions aren’t anything solid that doctors would rely on to change how they advise their patients at this point, having a very brief, nuance-free news story that implies that giving vitamins to the elderly is a “death panel-ish” thing to do is irresponsible reporting. Interestingly, the original story I heard on WTOP mentioned only that elderly patients were involved, not specifying further that they were post-menopausal Caucasian women, which was clearly a huge error.

The most important message of this paper is to remind both patients and physicians that vitamins are essential substances that our bodies need to function that we can’t make ourselves, but that for the vast majority of them, there is no evidence that taking higher doses than required for our essential biological functions gives any added benefit, and may carry some risk. It is possible to take too much of a vitamin such that you experience a toxic disease state, such as with the increasing cases of hypervitaminosis D being seen with the increased popularity of high-dose vitamin D supplementation in recent years. Whether or not getting just “little bit extra” is truly correlated with increased mortality for some reason remains to be seen, and certainly isn’t proved here.

Reference: Bjelakovic G, & Gluud C (2011). Vitamin and Mineral Supplement Use in Relation to All-Cause Mortality in the Iowa Women’s Health Study: Comment on “Dietary Supplements and Mortality Rate in Older Women”. Archives of Internal Medicine, 171 (18), 1633-4 PMID: 21987193

1. Oddly, I am unable to find this exact story on WTOP’s website for reference. Poo on you, WTOP. [↩]
2. One of the authors is “unpaid member of the Scientific Advisory Board of the California Walnut Commission”, which seems to have little bearing here, beyond being a possibly humorous thing to have to disclose. [↩]
3. Both in terms of health outcomes, like death, and one’s pocketbook. [↩]

Tablets, smartphones, gewgaws!

They’re the new shiny, the must have, the new toy. I get caught up with the new technology, just like many of us out there. In fact, I am writing this post on a Motorola Xoom tablet. Many of my friends and colleagues have the new shiny, tablets, a smartphone, etc. Laptops and net books are replaced by the newer and the smaller.

Why do most of the people who have these not want them anymore?

I work as a mobile and rich internet application developer. I work with the new shiny all the time. It’s a fun job, filled with changes. At the same time, the people who I have worked with, and friends in related industries, want to get out of it. They want to stop coding. They want to disconnect from the net. They want to have less technology.

Why is that?

For some it’s burnout. They’ve been pushed to code to hard and too long. For others, I don’t know. I’ve even felt the siren’s call of a quiet house, a place in the country or at least away from technology for a while.

Is it about the distractions? Is it about the insistent and instant way people can interrupt when they want to communicate with you? Is it the need for a physical presence of other people, which is lacking when talking on the ‘net?

Is it age, or is it just me?

Don’t get me wrong. I love the technology. Living in the proto Star Trek age with Picard’s tablet in my hands. I love that the tech is promoting change in politics around the world. (Hopefully for the better of all.) I look forward to the future.

Things just seem out of balance. Perhaps science is just beyond where we can fully grasp it’s implications. Maybe the Singularity is here, but we can’t quite see it.

Not everyone has this same malaise that many around me seem to have. It’s possible it’s a combination of age and who I hang out with. I’d like to know though, what is it?

Why does the new shiny not seem as shiny to me anymore?

The short story was once, perhaps, the cornerstone medium for telling genre fiction tales. It’s no secret that as of several years ago, there was concern about whether the market for speculative short fiction was dying a slow death, with a number of publications disappearing and dwindling subscriptions to old stalwarts like Analog and Asimov’s. Of late, there seems to have been a resurgence of paying venues for science fiction and fantasy short stories, from podcast audio magazines like Escape Pod to e-book and traditional print media. But this reinvigoration of the short story comes at a time when the publishing industry is in an unprecedented state of flux, as the general public is slowly but surely moving away from paper and towards digital text in their reading habits.

As we are looking at this week in The Lair, Angry Robot Books is tackling this changing business with excellent tales and innovative ideas, and their approach to short fiction is no different.

In December of 2010, Angry Robot debuted their short fiction store, where they have available Nano Editions: short fiction authored by novelists in the Angry Robot stable. There are currently 27 Nano Editions available which cross the entire spectrum of authors and genres in the Angry Robot catalog, providing a good way to explore a particular author in short form before trying out their book, or discovering new stories by an old favorite. The pricing scheme is very competitive at £0.59 apiece or 10 for £3.49, and all of the files are in unrestricted DRM-free ePub format, which the website provides helpful instructions on converting to reading on a Kindle if that is your gadget of choice.

As I’m still exploring many of the authors that call Angry Robot home, I decided to check out one of the Nano Editions by Guy Haley. Both stories were swift and thoroughly enjoyable reads, and I look forward to delving in to some of his longer work as a result.

• Man of Stone – A grizzled veteran of countless battles, embroiled in his last fight, stumbles across a god; neither are what they each expect the other to be, but both are what the other needs.
• Kasimir Larkin’s Final Sale – On a remote mining world, a shopkeeper’s daily routine is interrupted by what might very well be his second to last customer.

One thing that I would enjoy seeing them incorporate into the Nano Edition store is a feedback or rating system to help new customers overcome the potential intimidation of a long list of stories, and make a more informed selection if they are new to the authors involved. This aside, I think the way that Angry Robot is handling it’s short fiction is an excellent compliment to their novels and other offerings, and I have no hesitation in recommending you to check them out for a quick fiction fix.

The Hugo, CC BY-SA image from gruntzooki via Flickr

I attended the World Science Fiction Convention this past weekend, and had a delightful time. For those that have never been, Worldcon has a different vibe than more media-soaked, crowded affairs like San Diego Comic-Con or Dragon*Con. It was first held in 1939, which makes it the second oldest science fiction convention in the United States by most reckonings.¹ Founded originally as a venue for fans to meet with authors (who counted themselves as fans as well), Worldcon continues to remain primarily focused on science fiction in literature, as opposed to movies, computer games, or other media.

Given it’s storied history, Worldcon tends to have an older demographic than most other conventions. Over the last few years, I’ve been astounded by the observation that some members of that older group of fans, despite being interested in tales involving scientific advances and future technology, seem to be technophobic and to be actively against Shiny New Things. Now, this is an observation about a few individuals, and by no means is categorizing an entire group – many older fans listen to podcasts and are just as much into geeky tech as anyone else. However, this topic comes up enough in both formal and informal ways to be worthy of pondering.

The most formal setting that exposes this divide is the Hugo Awards. These are given out yearly at Worldcon, are voted on by fans who are members of World Science Fiction Society (WSFS),² and are considered to be the most noteworthy award for works of science fiction. While most categories pertain to word-based fiction³ or art, some have the capacity to include audio or video media, such as the Dramatic Presentation⁴ or Best Related Work categories. As I will visit below, there is currently a hefty debate among some as to where new forms of media, such as podcasts, fit into the Hugos in particular and fandom in general.

A couple of examples:

• Aversion of email and the Internet – I’ve met several older fans who don’t use email, and never go online. This seems to be more than just disinterest; those I’ve talked to about it are quite vitriolic when the topic comes up. One in particular is very explicit that the only way he will ever keep in touch with anyone is via postal mail, and does not now or will ever in the future own a computer. Of note, these people have all struck me as highly intelligent people who are very interested in both science fact and science fiction. The person previously mentioned was on a panel about the future of space exploration with the Moon Ranger at a con last year, and certainly displayed no technophobia when it came to that topic.

• Lack of acceptance of podcasted work- At both 2010’s NASFiC and the last two Worldcons, there has been a very clear bias against podcasts among some older fans. This usually comes from those who have been active in fanzines: publications created by fans that are unofficial, do not pay contributors, and are labors of love for those involved. Fanzines have been around approximately as long as conventions have, and historically have provided a way for fans to share their experiences and opinions when not at a convention. Although originally created with manual typewriters and mailed out to readers – and some still are, even here in 2011 – many modern ‘zines are created digitally and published online or as PDF documents.You may notice that my brief definition above can be equally applied to most podcasts. However, there is a vocal group of older fans who do not believe that fanzines and podcasts are equivalent. While it’s clear that the fannish content of both forms of expression is the same, it’s equally clear that those critical of podcasts-as-fan-publications view the art of fanzine creation as something more work intensive and more important to fandom – a contention which I think is completely unfounded. Said critics are most vocal when it comes to the official Fanzine category of the Hugos, which is currently described as follows:
  

  This is the other serial publication category. This Award is for anything that is neither professional nor semi-professional. The publication must also satisfy the rule of a minimum of 4 issues, at least one of which must have appeared in the year of eligibility.

  Interestingly, last year the audio podcast Starship Sofa made a bit of Hugo history by becoming the first podcast ever to win a Hugo, in the Fanzine category.⁵ This caused podcast critics to prompt WSFS to reconsider whether podcasts should be allowed to compete in the same category as fanzines, and it seems that there may be a Best Fancast trial category at next year’s Hugos as a result. A concern is that this might lead to all podcasts being ghettoized into a single, separate category as opposed to competing in appropriate categories based on content; I think there is some legitimacy to this concern, as those seeking to separate podcasts typically have not listened to any, aren’t interested in finding out more about them, and have made statements like “Are there even enough podcasts in existence to fill up a category?”

What I find strange is that I would expect all hardcore con-going fans of science fiction, not just the majority, to be positive about new technology and communication advances. I suspect the reason that some are not is due to how we socialize as humans. Back in the earlier days of conventions, the entire concept of fandom was a new phenomenon. People suddenly discovered that there were many more who shared their interests outside of the few that they might have known locally, and could be interacted with through fanzines and at conventions. Print media and fanzines became a cherished tradition that embodied the excitement of the discovery of a fan community, and so still remain very important to members of that group.

Some may see new communications methods, be they online or via podcast, as not being a part of their fan experience. As such, they may not want to actively engage in using those methods themselves. Moreso, since the Hugos represent an important part of their tradition as science fiction fans, they don’t recognize the Shiny New Things as being worthy of consideration in the same space as the traditional things that have close meaning to them. The fandom experience they discovered and fell in love with isn’t quite the same as the experience of those who have entered the community more recently, and as with all socially positive experiences, they don’t want that to change or go away. It’s just us being us. Even though the fan community is often notable for being more accepting than other groups of a various personalities and viewpoints, that doesn’t make parts of it immune from circling the wagons around the things they hold dear.

What’s the lesson here? A pragmatist might note that eventually, that segment of older fans will fade away, or be further diluted as new ones join every year. I would contend that there are two far better views to take. One is that for those of us involved in podcasting, writing, and other creative pursuits who also consider ourselves fans, we should be sure to be active in the WSFS and Worldcon – these are fan-run and democratic organizations, and if enough of us are involved, we can affect a more sensible integration of the Shiny New Things into the global fan experience. The second is to remember not to be critical of those who want to see their cherished traditions continue, because someday, that might be us. Many people have come to the fan community through podcasting or Internet media, and one day the next Shiny New Thing will come along and supercede it for the next generation.

The future is great, and it just keeps coming. Science fiction is both speculation on that and a celebration of it. As fans, we would do well to keep that in mind.

1. The oldest is Philcon, which was first convened in 1936, and is celebrating it’s 75th anniversary this year. [↩]
2. Anyone who is a member of Worldcon is automatically a member of WSFS. [↩]
3. Traditionally this means printed, although electronic publications are also included, such as websites or e-books. [↩]
4. Someone did state at a Worldcon meeting that the Dramatic Presentation categories should be discarded as Hugo categories, because only word-based fiction is, in their opinion, Hugo-worthy. Thankfully, this opinion does not seem to be widely shared. [↩]
5. It was nominated again this year, and came in second. [↩]

This article marks the beginning of a periodic new series here in The Lair: The Secret Journal Club. Journal clubs are a grand tradition in medicine, whereby physicians and students gather to critique a selection of journal articles – not merely read them and take what they say at face value, but also to dissect their techniques and message to better understand if their conclusions are valid and applicable to what we do as doctors. As previously noted, I contend that much of media reporting on medical articles is plagued with oversimplification and sensationalism, which leads to news stories that are just plain wrong. Although there are some barriers, anyone regardless of their training can approach medical articles and get some reasonable understanding from them, especially when you know what to look for.

CC BY-NC-SA image from TonioMora via Flickr

To that end, each edition of The Secret Journal Club will tackle a medical journal article and briefly look at what it says, what it’s biases are, and whether or not it’s conclusions are valid. We’ll divide each discussion up in to six sections, four of which mirror the format typical of such articles: Background, Methods, Results, and Discussion. Since the things that bookend the article – the nature of the journal itself, the affiliations of authors, and where the money comes from for the study, for example – are also critical and often overlooked, we’ll make note of those as well. Last but not least, we’ll give a critique of both the article itself and both the context and the media reporting surrounding it.

My hope is that, whenever possible, the full text of the article will be freely available for you to read; in many cases, such as today’s selection, this isn’t the case without a subscription.¹ In those cases, I will at least send you to the abstract of the article, and would encourage you to seek the full text out through your local library or other source if your interest is piqued.

Let’s do this.

Bookends – The article in question today is Active Albuterol or Placebo, Sham Acupuncture, or No Treatment in Asthma, which was published in the July 14, 2011, edition of the New England Journal of Medicine. The abstract can be read here, and the full article is sadly accessible only with a subscription.

Most people have heard of the NEJM, and it is considered to be the highest impact medical journal in the world, meaning that articles published on it’s hallowed pages are the most cited by other articles in the medical literature. This means that they win the popularity contest, but this doesn’t guarantee that the conclusions their studies come to are always valid, as we are about to see.

Interestingly, only two of the eight authors are actual medical doctors. The senior author is Ted Kaptchuk, who is not a physician but carries the title of Doctor of Oriental Medicine, and specializes in researching the placebo effect. This is important to note in terms of the agenda of the trial. It is also important to note that since the placebo effect as seen in clinical trials is really an artifact of the trial process itself, this doesn’t seem like a thing that particularly needs researching, unless one believes magical things about it… which it seems apparent that Kaptchuk does.

The study is funded by the National Institutes of Health’s NCCAM branch: the National Center for Complimentary and Alternative Medicine. NCCAM has a track record of publishing good studies on so-called CAM modalities. They also have a track record of including researchers who aren’t so much interested in doing good science to figure out if CAM modalities work, but instead already believe that said modalities are effective despite evidence to the contrary, and so end up spending taxpayer money on studies to try and justify those beliefs. All that noted, as grant sourced money through the NIH, this is pretty much as unbiased of a funding source as one can get.

Background – The stated premise of the study was to see if in asthma, placebo therapies could result in objective improvements in lung function when compared to active medication. The authors attempt to redefine what the placebo effect actually is in this section of the article, including mixing up the two different scientific and therapeutic meanings of the phrase:

Placebo effects (i.e., benefits resulting from simulated treatment or the experience of receiving care) are reported to improve signs and symptoms of many diseases in clinical trials and in clinical practice. On this basis, the accepted standards for clinical-trial design specify that the effects of active treatment should ideally be compared with the effects of placebo. Despite this common practice, it is unclear whether placebo effects observed in clinical trials (or those that presumably occur in clinical care) influence both objective and subjective outcomes and whether placebo effects differ from the natural course of disease or regression to the mean.

This automatically raises concern about their agenda here – this basic premise of the article makes no rational sense. Asthma is a disease where the airways of the lungs constrict and become inflamed, which can be objectively measured with airflow testing called spirometry and can be treated with medications to ease the constriction (bronchodilators, such as inhaled albuterol) and inflammation (such as inhaled steroids). Inert, placebo therapies won’t fix these problems, and so would not be expected to make an asthma patient’s pulmonary function tests better… unless one were to believe magical things about the placebo effect.

Methods – The study was done over a two year period, and was a randomized, double-blinded, crossover pilot study. This means that in the hierarchy of evidence-based medicine, it is fairly solid – participants were randomly assigned to therapies, and both they and the people administering the therapies did not know if they were active or inert. The description of this being a pilot study implies it is a small, proof of concept study that could pave the way for larger studies in the future.

The active medication used in the trial was inhaled albuterol – a cheap, easily available and highly effective bronchodilator. One placebo intervention they used were inhalers containing no albuterol but otherwise looking and functioning identically. A second placebo intervention was that of sham acupuncture, which is a very interesting choice. “Real” acupuncture itself is considered to be effective therapy by some, although good medical evidence has repeatedly demonstrated that it works no better than placebo interventions. Even for acupuncture proponents, it is accepted that doing acupuncture “wrong” (either with needles inserted incorrectly, or using needles with retractable sleeves, similar to how a prop knife works) is a highly ceremonial but inert process.

The study screened 79 patients who met the American Thoracic Society criteria for mild to moderate asthma, and had a stable regimen of asthma medications for at least 4 weeks prior to the trial. The goal was to find people who could have their bronchodilator medications safely stopped for a period of time, but who’s lung function would worsen just enough so that the worsening could be detected by spirometry testing and then fixed by a treatment of albuterol. The specific value looked at on spirometry was the FEV1, or the amount of air a patient can forcibly bow out from their lungs in one second. 46 patient met this criteria by having their short acting bronchodilators stopped for 8 hours and long acting ones stopped for 24, having their FEV1 tested, then given an albuterol treatment and having their FEV1 improve at least 12% after the treatment.

Of those 46 patients, half (49%) were only on a short acting bronchodilator, a quarter (23%) had inhaled steroids on top of that, and the remainder had both of those plus a long acting bronchodilator or other medication. Since only the bronchodilators were stopped for the study interventions, that means that half of the patients stayed on their usual steroids for asthma therapy, which could easily have affected any results. Additionally, 62% of the patients were white, while in the general population asthma disproportionally affects those of African or Hispanic descent, meaning that the patient sample is not representative of the demographics of asthma in the real world.

The study patients then underwent four different interventions: treatment with an albuterol inhaler, treatment with a placebo inhaler, a sham acupuncture session, or no active therapy. Each patient went though a random series of the four interventions three separate times, for a total of twelve interventions each. Prior to the intervention, the patients stopped any bronchodilators they were taking as they did for the screening procedure. After undergoing the intervention, they had spirometry done to determine the change in their FEV1, as well as a questionnaire that asked whether they felt any improvement on a 1-10 scale, and to guess whether they had received effective treatment or placebo.

One major pet peeve of mine is when authors choose to include certain aspects of their study in an “online appendix”, as opposed to in the article itself. Sometimes, this can be justified in terms of space considerations or having extra data that is only peripherally related to the main point of the trial. That noted, in this case key things such as the specific sham acupuncture technique used and the criteria for patient selection were left out from the body of the text, which is inexcusable from my perspective.

Results – There were several results that were very striking. The first is that of the 46 patients randomized into the study, 7 (15%) dropped out. The striking thing about this is not that such a proportion of people left the study – this is a common occurence in any clinical trial – but rather that this is only mentioned in one of the figures and not at all in the text of the article; it is noted in the appendix that these patients were not included in the final analysis. Even there, there is no way to tell what the baseline treatment was of the dropouts, how far they made it in the study, or why they dropped out.

The next result of note was that among the four interventions, only the active treatment of albuterol caused a meaningful improvement in lung function, as measured by an increase of 20% of the measured FEV1. Both placebo interventions and the no treatment arm saw a much smaller increase of about 7%, and the difference between these and the albuterol result was statistically significant.

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The last interesting result was that with the three intervention arms, patients reporting statistically similar levels of feeling better of 45-50% on the scale used in the study. These were all statistically significantly higher than the arm that received no intervention, but it is important to note that even that arm showed a 21% improvement.

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Discussion – The discussion section of this article is fascinating, because it mixes sober assessment of the trial with frankly weird statements that seem to be spinning their results to support the beliefs of the authors about placebos. The most confusing part of this is when they describe the difference between the two placebo interventions and the no treatment arm. In the Background, they specifically describe the placebo effect as relating to “simulated treatment or the experience of receiving care”. However, in this section, they take great care to state that the no-intervention arm was not a placebo intervention, despite the fact that by their own definition, the no treatment arm still underwent the experience of receiving care and so involves the placebo effect. In particular, they state:

For the objective physiological outcome (change in FEV1), there was a powerful medication effect (drug vs. placebo) but no placebo effect (no difference between placebo and the no-intervention control). For the subjective outcome, the placebo effects were equivalent to the drug effect, and all were greater than the no-intervention effect.

This is a spin-laded interpretation. For the change in FEV1, there was a 7% improvement in the three non-albuterol groups, all of which were technically placebo groups, so there was an observed “placebo effect”. There is no such thing as a “no-intervention effect”, which the authors seem to have fabricated as a concept because it suits their beliefs about how placebos work.

In their summation, the authors do distill out the key finding of objective versus subjective improvement, which is the most important clinical take-home lesson. Then, their ruminations go off the rails again:

Many patients with asthma have symptoms that remain uncontrolled, and the discrepancy between objective pulmonary function and patients’ self-reports noted in this study suggests that subjective improvement in asthma should be interpreted with caution and that objective outcomes should be more heavily relied on for optimal asthma care. Indeed, although improvement in objective measures of lung function would be expected to correlate with subjective measures, our study suggests that in clinical trials, reliance solely on subjective outcomes may be inherently unreliable, since they may be significantly influenced by placebo effects. However, even though objective physiological measures (e.g., FEV1) are important, other outcomes such as emergency room visits and quality-of-life metrics may be more clinically relevant to patients and physicians. Although placebos remain an essential component of clinical trials to validate objective findings, assessment of the course of the disease without treatment, if medically appropriate, is essential in the evaluation of patient-reported outcomes.

This is a worrisome and telling series of statements. Here, they recognize that how asthma patients feel do not necessarily correlate with how well their lungs are doing, which is measured by the FEV1. The obvious conclusion is that the most important thing to rely on in assessing asthmatic patients are objective measures of lung function, because those will tell us how sick a patient truly is and how close they may be to a life-threatening asthma attack. Instead, the study authors suggest that these objective measures aren’t as important to patients as how they feel, so we should focus on things that assess the less-reliable indicator of how sick they may be, which is how they are feeling.

Um, what?

My Critique – This is simultaneously a great and horrible article that’s going straight into my teaching file.

It is great because it has a well-executed design that very clearly shows that albuterol helps fix the lungs of asthmatics while inert interventions really don’t, and that at the same time, patients receiving those inert interventions can still subjectively feel better after receiving them, sometimes dramatically. Often, physicians rely on asthma patients reporting their symptoms as the main measure of their clinical status, and this is good evidence to suggest this is unreliable. We need to be tracking objective measures of how well the lungs are doing instead. While spirometry to objectively assess someone’s FEV1 is not easily accessible for everyone, the simpler and inexpensive peak flow meter is a device that patients can use to track their lung function objectively at home, and this is something that all patients with asthma should do.

It is horrible both for some aspects of the study design, and the conclusions the authors draw. In terms of demographics, the patients are not a good sample of the genetic backgrounds of those who tend to develop asthma, especially severe disease (more often in people of African or Hispanic origin as opposed to Caucasian). A chunk of the patients left the study and aren’t accounted for in the text of the article. The authors want to redefine the placebo effect as being improvements seen with specific inert treatments only, that can somehow be extrapolated directly from a trial into clinical practice. Furthermore, they seem to suggest that making patients feel better with placebos is more important than actually fixing what’s wrong with them by using interventions that are proven to work.

I’m not sure about the rest of you, but as both a physician and someone who’s had asthma since 4 years of age, I think the focus of asthma management should be on making sure people’s lungs are working right and preventing hospitalization and death by using what works – objective measures, and effective medications. The fact that our taxpayer dollars are being spent by people who think otherwise is a bit of a problem, especially as they consider this to be a pilot study for future work in the same vein. The media has advertised this study as evidence that placebos are “powerful”, with the implications that doctors should start treating people with inert therapies to make them feel better. That’s both unethical and bad medicine.

Reference: Wechsler ME, Kelley JM, Boyd IO, Dutile S, Marigowda G, Kirsch I, Israel E, & Kaptchuk TJ (2011). Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma. The New England Journal of Medicine, 365 (2), 119-26 PMID: 21751905

1. While most journals aren’t at the stage of being open access yet – especially because the people who publish them are interested in making money from them – most major journals will make specific important of seminal articles available for free online. [↩]

According to the column rotation calendar which is taped to my monitor, today I am supposed to have a new column for you.

I have failed you. I would be sorry, but let me offer a most excellent media experience in trade. Instead of gracing the world with my peculiar mix of humor and geekly ennui, let me introduce you to Professor Elemental‘s song, Fighting Trousers.

If you’ve watched The Baristas, then walking into Affogato in Bellevue, PA is like walking into Cheers in Boston. You know the place, it is familiar, but some part of you is unprepared for the actual size, filled with actual people, none of them the actors you have come to know. After a moment the feeling passes, and you just feel…comfortable. Like you’ve been frequenting the places for a long time.

That’s how I felt when I met Victoria Dilliott, the owner of Affogato, for an interview this weekend past. Affogato is one of those incredible local places that is such a part of the local community that it has a soul of its own. When I found out that it would likely be closing unless Victoria finds a buyer, I wanted to learn more about the place, to write its story.

I’m still listening to the audio from that interview, still going through the pictures. The more I do so, the more I feel that letting a place like Affogato close would be a substantial loss. With the big names pushing out indy stores everywhere, finding unique Third Places is getting harder. Even though I did not personally spend any significant time in Bellevue at Affogato, I remember places like it from my past; places which are now just memories.

Your call to action: Help spread the word and help a community keep its independent coffeeshop and help a hardworking owner make back a portion of her seven-year investment in the business. Affogato is up for sale. Pass this Craigslist link around and do some good with your tweets, your Google+, your Facebook, your social graph.

Thanks,
Chris Miller

As a side note, The Baristas is gearing up for some new episodes. You should go watch the promo.