The .Plan

Some physicians are suggesting caution when it comes to performing epidurals on women with lower back tattoos.

Krzysztof Kuczkowski, chief of obstetric anesthesia at the University of California San Diego Medical Center, published an account in 2004 of a 34-year-old patient with tattoos covering her mid-lumbar area who received an epidural. Afterward she experienced unusual burning, tenderness and swelling where the epidural catheter had been placed. Dr. Kuczkowski believes the tattoo was the culprit. “It’s possible there’s a release of small particles that could contain metals or toxic compounds,” he says.
–Rachel Zimmerman, “Why Some Expectant Moms Are Worried About Tattoos”, Wall Street Journal, September 18, 2007

I have to admit that this possibility never occurred to me. When I was on the inpatient medicine and neurology services, it was a boon when a patient needing an LP happened to have a lower back tattoo. Figure out your landmarks, no need to X-marks-the-spot — voila, bullseye! (Came in really handy one day when I admitted a patient who for various reasons received 3 LP’s over the course of two weeks.)

Why is it important to be thoughtful? Because otherwise you look like a fool.

As a result, the march on Jena was a bit unfocused. It’s telling that the demonstrators moved between the courthouse where Bell was tried for an offense no one denies he committed and the site of the “white tree” that, with all-too-fitting symbolism, has since been cut down. “Free the Jena 6″ has become a rallying cry, perhaps because, “Stop Informal Segregation and Prosecutorial Overzealousness That Disproportionately Affects African-Americans Here and Elsewhere” won’t fit on T-shirt or a placard.
–Richard Ford, “The Wrong Poster Children”, Slate, September 24, 2007

In 1996, Patricia Huston and David Moher published an article in the Lancet entitled, “Redundancy, disaggregation, and the integrity of medical research”. In this article they describe one particularly egregious example of “salami science” in which the results of a single study of risperidone in the treatment of chronic schizophrenia was reported in six different publications and cited in several unpublished forms, and each iteration featured different numbers of patients and different co-authors.

Last year, while doing some research for a journal club presentation, I came across the “ARISe-RD” study in which the researchers attempt to widen the indications for atypical antipsychotics by featuring it in an open-label study of patients with “treatment-resistant depression”. I kept finding different references to the paper, and by the end of the day I had located 8 different abstracts, published between 2003 and 2006. At some point during the paper’s meandering journey through time and space, Charlie Nemeroff (labeled by T.E.N. magazine as “boss of bosses” in the field of psychiatry) had mysteriously become senior author. Equally mysteriously, Martin Keller (regarded by some as a bigwig) — who was, according to the authorship rosters, not involved with the study prior to 2006 — makes an appearance on the final manuscript in which he is credited with “study concept and design”.

Gawd. And we’re pushing these drugs on kids on the basis of these kinds of schlock researchers?

Rapaport MH, Canuso CM, Loescher A, Lasser R/.Gharabawi G : Preliminary results from the ARISe-RD (Risperidone Augmentation in Resistant Depression) trial 156th Annual Meeting of the American Psychiatric Association, May 17-22, San Francisco CA 2003, NR179

Rapaport M, Canuso CM, Loescher A, Lasser RA, Gharabawi G : Preliminary results from the Risperidone Augmentation in Resistant Depression) trial 156th Annual Meeting of the American Psychiatric Association, May 17-22, San Francisco CA 2003, P. 184

Rapaport MH, Canuso CM, Rouillon F, Leblanc J, Young AH, Loescher A, Bossie C, Turkoz I, Gharabawi G : Results from the augmentation with risperidone in resistant depression trial 157th Annual Meeting of the American Psychiatric Association; 2004 May 1-6; New York, NY 2004, NR799

Canuso C, Gharabawi G, Bouhours P, Leblanc J, Dunbar F, Rapaport MH. Results from open-label phase of ARISe-RD (augmentation with risperidone in resistant depression) [abstract]. Int J Psychopharmacology 2004;7(Suppl 1):S345

Gharabawi G, Canuso C, Greenspan A, Bossie C, Loescher A, Turkoz I, Alexopoulos G : Remission and maintenance effect of risperidone augmentation for older patients with resistant depression. Neuropsychopharmacology 2004, 29 Suppl 1, S87

Nemeroff CB, Canuso CM, Mahmoud R, Loescher A, Turkoz I, Rapaport MH, Gharabawi GM : Augmentation with risperidone in chronic resistant depression:A double-blind placebo-controlled maintenance trial. Neuropsychopharmacology 2004, 29 Suppl 1, S159

McIntyre RS, Canuso CM, Bossie CA, Turkoz I, Gharabawi GM : Symptoms of anxiety and relapse in patients with resistant depression. 45th Annual NCDEU (New Clinical Drug Evaluation Unit) Meeting; 2005 June 6 - 9; Boca Raton, FL 2005, 170

Rapaport MH, Gharabawi GM, Canuso CM, Mahmoud RA, Keller MB, Bossie CA, Turkoz I, Lasser RA, Loescher A, Bouhours P, Dunbar F, Nemeroff CB : Effects of risperidone augmentation in patients with treatment-resistant depression: Results of open-label treatment followed by double-blind continuation. Neuropsychopharmacology 2006, 31(11), 2505-13

What happens when you produce complex, non-accessible research:

In a case involving a merger in the petroleum industry, Professor George Stigler, a Nobel laureate in economics, filed an expert report demonstrating that the prices moved in parallel in multiple cities throughout the nation. Stigler’s report concluded that the entirety of the United States constituted a single geographic market for purposes of the case — a position that, if accepted, would decisively affect the outcome of the case.

During a lengthy cross examination, Professor Stigler explained the theory underlying his report. The district judge, completely misunderstanding Stigler’s theory, inquired how the United States could be one market because the Rocky Mountains ran down the middle of the country — and there was no pipeline across the Rockies to move petroleum back and forth. After several fruitless attempts to explain the theory, Professor Stigler responded that he didn’t care whether the petroleum was carried over the Rocky Mountain by fairies; what mattered was that prices moved in parallel across the country. The District Court judge subsequently wrote an opinion, concluding that the United States was not one geographic market, that did not even mention Professor Stigler’s testimony. According to Judge Easterbrook, the District Court judge privately indicated that he gave no weight to Professor Stigler’s testimony because Professor Stigler believed in fairies.
–David Hyman, “Five reasons why health care quality research hasn’t affected competition law and policy”, International Journal of Health Care Finance and Economics, June 2004

We showed Olivia the XKCD on shopping teams. Her response:

“That’s YOU GUYS!”

Now for this week’s XKCD (click for full size):