Category: New York Times

Thousands of Toddlers Are Inapprorpiately Medicated for A.D.H.D., Report Finds, Raising Worries

On By A.P.In A.D.H.D., Adderall, ADHD, Alan Schwarz, American Academy of Pediatrics, Anita Zervigon-Hakes, attention deficit hyperactivity disorder, C.D.C., CDC, Doris Greenberg, Food and Drug Administration, Georgia Mental Health Forum, Keith Conners, Lawrence H. Diller, Medicaid, methylphenidate, Nancy Rappaport, National Institute of Mental Health, Neuropsychiatric Disease, New York Times, NIMH, psychiatrist, Psychiatry, psychologist, psychology, Ritalin, Susanna N. VisserLeave a comment

By ALAN SCHWARZ

More than 10,000 American toddlers 2 or 3 years old are being medicated for attention deficit hyperactivity disorder outside established pediatric guidelines, according to data presented on Friday by an official at the Center.

The report, which found that toddlers covered by Medicaid are particularly prone to be put on medication such as Ritalin and Adderall, is among the first efforts to gauge the diagnosis of A.D.H.D. in children below age 4. Doctors at the Georgia Mental Health Forum at the Carter Center in Atlanta, where the data was presented, as well as several outside experts strongly criticized the use of medication in so many children that young.

The American Academy of Pediatrics standard practice guidelines for A.D.H.D. do not even address the diagnosis in children 3 and younger — let alone the use of such stimulant medications, because their safety and effectiveness have barely been explored in that age group. “It’s absolutely shocking, and it shouldn’t be happening,” said Anita Zervigon-Hakes, a children’s mental health consultant to the Carter Center. “People are just feeling around in the dark. We obviously don’t have our act together for little children.”

Dr. Lawrence H. Diller, a behavioral pediatrician in Walnut Creek, Calif., said in a telephone interview: “People prescribing to 2-year-olds are just winging it. It is outside the standard of care, and they should be subject to malpractice if something goes wrong with a kid.”

Friday’s report was the latest to raise concerns about A.D.H.D. diagnoses and medications for American children beyond what many experts consider medically justified. Last year, a nationwide C.D.C. survey found that 11 percent of children ages 4 to 17 have received a diagnosis of the disorder, and that about one in five boys will get one during childhood.

A vast majority are put on medications such as methylphenidate (commonly known as Ritalin) or amphetamines like Adderall, which often calm a child’s hyperactivity and impulsivity but also carry risks for growth suppression, insomnia and hallucinations.

Only Adderall is approved by the Food and Drug Administration for children below age 6. However, because off-label use of methylphenidate in preschool children had produced some encouraging results, the most recent American Academy of Pediatrics guidelines authorized it in 4- and 5-year-olds — but only after formal training for parents and teachers to improve the child’s environment were unsuccessful.

Children below age 4 are not covered in those guidelines because hyperactivity and impulsivity are developmentally appropriate for toddlers, several experts said, and more time is needed to see if a disorder is truly present.

Susanna N. Visser, who oversees the C.D.C.’s research on the disorder, compiled Friday’s report through two sources: Medicaid claims in Georgia and claims by privately insured families nationwide kept by MarketScan, a research firm. Her report did not directly present a total number of toddlers 2 and 3 years old nationwide being medicated for the disorder, however her data suggested a number of at least 10,000 and perhaps many more.

Dr. Visser’s analysis of Georgia Medicaid claims found about one in 225 toddlers being medicated for A.D.H.D., or 760 cases in that state alone. Dr. Visser said that nationwide Medicaid data were not yet available, but Georgia’s rates of the disorder are very typical of the United States as a whole.

“If we applied Georgia’s rate to the number of toddlers on Medicaid nationwide, we would expect at least 10,000 of those to be on A.D.H.D. medication,” Dr. Visser said in an interview. She added that MarketScan data suggested that an additional 4,000 toddlers covered by private insurance were being medicated for the disorder.

Dr. Visser said that effective nonpharmacological treatments, such as teaching parents and day care workers to provide more structured environments for such children, were often ignored. “Families of toddlers with behavioral problems are coming to the doctor’s office for help, and the help they’re getting too often is a prescription for a Class II controlled substance, which has not been established as safe for that young of a child,” Dr. Visser said. “It puts these children and their developing minds at risk, and their health is at risk.”

Very few scientific studies have examined the use of stimulant medications in young children. A prominent 2006 study found that methylphenidate could mollify A.D.H.D.-like symptoms in preschoolers, but only about a dozen 3-year-olds were included in the study, and no 2-year-olds. Most researchers on that study, sponsored by the National Institute of Mental Health, had significant financial ties to pharmaceutical companies that made A.D.H.D. medications.

Some doctors said in interviews on Friday that they understood the use of stimulant medication in 2- and 3-year-olds under rare circumstances.

Keith Conners, a psychologist and professor emeritus at Duke University who since the 1960s has been one of A.D.H.D.’s most prominent figures, said that he had occasionally recommended it when nothing else would calm a toddler who was a harm to himself or others.

Dr. Doris Greenberg, a behavioral pediatrician in Savannah, Ga., who attended Dr. Visser’s presentation, said that methylphenidate can be a last resort for situations that have become so stressful that the family could be destroyed. She cautioned, however, that there should not be 10,000 such cases in the United States a year.

“Some of these kids are having really legitimate problems,” Dr. Greenberg said. “But you also have overwhelmed parents who can’t cope and the doctor prescribes as a knee-jerk reaction. You have children with depression or anxiety who can present the same way, and these medications can just make those problems worse.”

Dr. Visser said she could offer no firm explanation for why she found toddlers covered by Medicaid to be medicated for the disorder far more often than those covered by private insurance.

Dr. Nancy Rappaport, a child psychiatrist and director of school-based programs at Cambridge Health Alliance outside Boston who specializes in underprivileged youth, said that some home environments can lead to behavior often mistaken for A.D.H.D., particularly in the youngest children.

“In acting out and being hard to control, they’re signaling the chaos in their environment,” Dr. Rappaport said. “Of course only some homes are like this — but if you have a family with domestic violence, drug or alcohol abuse, or a parent neglecting a 2-year-old, the kid might look impulsive or aggressive. And the parent might just want a quick fix, and the easiest thing to do is medicate. It’s a travesty.”

Medicine’s Top Earners Are Not the M.D.s

On By A.P.In Aetna, Affordable Care Act, Barnabas Health, business, Cathy Schoen, Elisabeth Rosenthal, Ellen Greene, Mark T. Bertolini, Medicine, New York Times, Ray Gaudette, Ronald J. Del MauroLeave a comment

Though the recent release of Medicare’s physician payments cast a spotlight on the millions of dollars paid to some specialists, there is a startling secret behind America’s health care hierarchy: Physicians, the most highly trained members in the industry’s work force, are on average right in the middle of the compensation pack.

That is because the biggest bucks are currently earned not through the delivery of care, but from overseeing the business of medicine.

The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor.

And those numbers almost certainly understate the payment gap, since top executives frequently earn the bulk of their income in nonsalary compensation. In a deal that is not unusual in the industry, Mark T. Bertolini, the chief executive of Aetna, earned a salary of about $977,000 in 2012 but a total compensation package of over $36 million, the bulk of it from stocks vested and options he exercised that year. Likewise, Ronald J. Del Mauro, a former president of Barnabas Health, a midsize health system in New Jersey, earned a salary of just $28,000 in 2012, the year he retired, but total compensation of $21.7 million.

The proliferation of high earners in the medical business and administration ranks adds to the United States’ $2.7 trillion health care bill and stands in stark contrast with other developed countries, where top-ranked hospitals have only skeleton administrative staffs and where health care workers are generally paid less. And many experts say it’s bad value for health care dollars.

“At large hospitals there are senior V.P.s, V.P.s of this, that and the other,” said Cathy Schoen, senior vice president for policy, research and evaluation at the Commonwealth Fund, a New York-based foundation that focuses on health care. “Each one of them is paid more than before, and more than in any other country.”

She added, “The pay for the top five or 10 executives at insurers is pretty astounding — way more than a highly trained surgeon.”

She said that executive salaries in health care “increased hugely in the ‘90s” and that the trend has continued. For example, in addition to Mr. Del Mauro’s $21.7 million package, Barnabas Health listed more than 20 vice presidents who earned over $350,000 on its latest available tax return; the new chief executive earned about $3 million. Data released by Medicare show that Barnabas Health’s hospitals bill more than twice the national average for many procedures. (In 2006, the hospital paid one of the largest Medicare fines ever to settle fraud charges brought by federal prosecutors.)

Hospitals and insurers maintain that large pay packages are necessary to attract top executives who have the expertise needed to cope with the complex structure of American health care, where hospitals and insurers undertake hundreds of negotiations to set prices.

Ellen Greene, a spokeswoman for Barnabas Health, said Mr. Del Mauro’s retirement package was “a function of over four decades of service and reflects his exceptional legacy.” Nearly $14 million was a cumulative payout from a deferred retirement plan, she said, and the remainder included base compensation, a bonus and an incentive plan

Ms. Greene also said Barnabas’s compensation program follows I.R.S. rules and is established by an executive compensation committee with “guidance from a nationally recognized compensation consultant.”

In many areas, the health care industry is home to the top earning executives in the nonprofit sector.

And studies suggest that administrative costs make up 20 to 30 percent of the United States health care bill, far higher than in any other country. American insurers, meanwhile, spent $606 per person on administrative costs, more than twice as much as in any other developed country and more than three times as much as many, according to a study by the Commonwealth Fund.

As a result of the system’s complexity, there are many jobs descriptions for positions that often don’t exist elsewhere: medical coders, claims adjusters, medical device brokers, drug purchasers — not to mention the “navigators” created by the Affordable Care Act.

Among doctors, there is growing frustration over the army of businesspeople around them and the impact of administrative costs, which are reflected in inflated charges for medical services.

“Most doctors want to do well by their patients,” said Dr. Abeel A. Mangi, a cardiothoracic surgeon at the Yale School of Medicine, who is teaming up with a group at the Yale School of Management to better evaluate cost and outcomes in his department. “Other constituents, such as device manufacturers, pharmaceutical companies and even hospital administrators, may not necessarily have that perspective.”

Doctors are beginning to push back: Last month, 75 doctors in northern Wisconsin took out an advertisement in The Wisconsin State Journal demanding widespread health reforms to lower prices, including penalizing hospitals for overbuilding and requiring that 95 percent of insurance premiums be used on medical care. The movement was ignited when a surgeon, Dr. Hans Rechsteiner, discovered that a brief outpatient appendectomy he had performed for a fee of $1,700 generated over $12,000 in hospital bills, including $6,500 for operating room and recovery room charges.

It’s worth noting that the health care industry is staffed by some of the lowest as well as highest paid professionals in any business. The average staff nurse is paid about $61,000 a year, and an emergency medical technician earns just about minimum wage, for a yearly income of $27,000, according to the Compdata analysis. Many medics work two or three jobs to make ends meet.

“It’s stressful, dirty, hard work, and the burnout rate is high,” said Tom McNulty, a 19-year-old college student who volunteers for an ambulance corps outside Rochester. Though he finds it fulfilling, he said he would not make it a career: “Financially, it’s not feasible.”

Elisabeth Rosenthal is a reporter for The New York Times who is writing a series about the cost of health care, “Paying Till It Hurts.”

Thanks to Ray Gaudette for bringing this to the attention of the It’s Interesting community.

Science shows that camels weren’t domesticated as early as The Bible states

On By A.P.In archeology, Bible, camel, Christianity, Erez Ben-Yosef, John Noble Wilford, Lidar Sapir-Hen, Nature, New York Times, Noam Mizrahi, Religion, Tel Aviv, The Bible2 Comments

subCAME-master1050

By JOHN NOBLE WILFORD

There are too many camels in the Bible, out of time and out of place.

Camels probably had little or no role in the lives of such early Jewish patriarchs as Abraham, Jacob and Joseph, who lived in the first half of the second millennium B.C., and yet stories about them mention these domesticated pack animals more than 20 times. Genesis 24, for example, tells of Abraham’s servant going by camel on a mission to find a wife for Isaac.

These anachronisms are telling evidence that the Bible was written or edited long after the events it narrates and is not always reliable as verifiable history. These camel stories “do not encapsulate memories from the second millennium,” said Noam Mizrahi, an Israeli biblical scholar, “but should be viewed as back-projections from a much later period.”

Dr. Mizrahi likened the practice to a historical account of medieval events that veers off to a description of “how people in the Middle Ages used semitrailers in order to transport goods from one European kingdom to another.”

For two archaeologists at Tel Aviv University, the anachronisms were motivation to dig for camel bones at an ancient copper smelting camp in the Aravah Valley in Israel and in Wadi Finan in Jordan. They sought evidence of when domesticated camels were first introduced into the land of Israel and the surrounding region.

The archaeologists, Erez Ben-Yosef and Lidar Sapir-Hen, used radiocarbon dating to pinpoint the earliest known domesticated camels in Israel to the last third of the 10th century B.C. — centuries after the patriarchs lived and decades after the kingdom of David, according to the Bible. Some bones in deeper sediments, they said, probably belonged to wild camels that people hunted for their meat. Dr. Sapir-Hen could identify a domesticated animal by signs in leg bones that it had carried heavy loads.

The findings were published recently in the journal Tel Aviv and in a news release from Tel Aviv University. The archaeologists said that the origin of the domesticated camel was probably in the Arabian Peninsula, which borders the Aravah Valley. Egyptians exploited the copper resources there and probably had a hand in introducing the camels. Earlier, people in the region relied on mules and donkeys as their beasts of burden.

“The introduction of the camel to our region was a very important economic and social development,” Dr. Ben-Yosef said in a telephone interview. “The camel enabled long-distance trade for the first time, all the way to India, and perfume trade with Arabia. It’s unlikely that mules and donkeys could have traversed the distance from one desert oasis to the next.”

Dr. Mizrahi, a professor of Hebrew culture studies at Tel Aviv University who was not directly involved in the research, said that by the seventh century B.C. camels had become widely employed in trade and travel in Israel and through the Middle East, from Africa as far as India. The camel’s influence on biblical research was profound, if confusing, for that happened to be the time that the patriarchal stories were committed to writing and eventually canonized as part of the Hebrew Bible.

“One should be careful not to rush to the conclusion that the new archaeological findings automatically deny any historical value from the biblical stories,” Dr. Mizrahi said in an email. “Rather, they established that these traditions were indeed reformulated in relatively late periods after camels had been integrated into the Near Eastern economic system. But this does not mean that these very traditions cannot capture other details that have an older historical background.”

The New York Times had a mistake on its front page every day for over a century

On By A.P.In Aaron Donovan, Math, New York TimesLeave a comment

2nyt

The dodgy arithmetic of one employee at the New York Times resulted in inaccurate issues numbers on the front page of every newspaper for over 100 years.

It seems that back in 1898 someone added one to 14,499 and got 15,000, with the huge jump in issues not being noticed until 2000.

How exactly the mistake was made isn’t clear, but how it was spotted was cleared up in the mother of all correction notes published in the Times on the first day of the new millennium, and rediscovered by The Atlantic this week.

It read:

“The error came to light recently when Aaron Donovan, a news assistant, became curious about the numbering, which he updates nightly when working at the news desk. He wondered about the potential for self-perpetuating error. Using a spreadsheet program, he calculated the number of days since The Times’s founding, on Sept. 18, 1851.

Through the newspaper’s archives, he learned that in its first 500 weeks, The Times published no Sunday issue. Then, for 2,296 weeks from April 1861 to April 1905, the Sunday issue was treated as an extension of the Saturday paper, bearing its number. In the early days, the paper skipped publication on a few holidays. No issues were published for 88 days during a strike in 1978. (During five earlier labor disputes, unpublished issues were assigned numbers, sometimes because catch-up editions were later produced for the archives.)

Finally, by scanning books of historic front pages and reels of microfilm, Mr. Donovan zeroed in on the date of the 500-issue gap.”

The issue number was eventually adjusted, but not before the publication congratulated itself on its 50,000th issue, which was actually number 49,500.

http://www.independent.co.uk/news/world/the-new-york-times-had-mistake-on-front-page-every-day-for-over-a-century-9063702.html

R.I.P. Frederick Sanger, Two-Time Nobel-Winning Scientist, died yesterday at age of 95

On By A.P.In Addenbrooke’s Hospital, Adrian Penrose, Cambridge, Denise Gellene, DNA, England, epigenetics, Frederick Sanger, gene, human growth hormone, Inventions, Medical Research Council, New York Times, Nobel Prize, Sanger sequencing, Science, Swaffham BulbeckLeave a comment

sanger

By DENISE GELLENE

Frederick Sanger, a British biochemist whose discoveries about the chemistry of life led to the decoding of the human genome and to the development of new drugs like human growth hormone and earned him two Nobel Prizes, a distinction held by only three other scientists, died on Tuesday in Cambridge, England. He was 95.

His death was confirmed by Adrian Penrose, communications manager at the Medical Research Council in Cambridge. Dr. Sanger, who died at Addenbrooke’s Hospital in Cambridge, had lived in a nearby village called Swaffham Bulbeck.

Dr. Sanger won his first Nobel Prize, in chemistry, in 1958 for showing how amino acids link together to form insulin, a discovery that gave scientists the tools to analyze any protein in the body.

In 1980 he received his second Nobel, also in chemistry, for inventing a method of “reading” the molecular letters that make up the genetic code. This discovery was crucial to the development of biotechnology drugs and provided the basic tool kit for decoding the entire human genome two decades later.

Dr. Sanger spent his entire career working in a laboratory, which is unusual for someone of his stature. Long after receiving his first Nobel, he continued to perform many experiments himself instead of assigning them to a junior researcher, as is typical in modern science labs. But Dr. Sanger said he was not particularly adept at coming up with experiments for others to do, and had little aptitude for administration or teaching.

“I was in a position to do more or less what I liked, and that was doing research,” he said.

Frederick Sanger was born on Aug. 3, 1918, in Rendcomb, England, where his father was a physician. He expected to follow his father into medicine, but after studying biochemistry at Cambridge University, he decided to become a scientist. His father, he said in a 1988 interview, “led a scrappy sort of life” in which he was “always going from one patient to another.”

“I felt I would be much more interested in and much better at something where I could really work on a problem,” he said.

He received his bachelor’s degree in 1939. Raised as a Quaker, he was a conscientious objector during World War II and remained at Cambridge to work on his doctorate, which he received in 1943.

However, later in life, lacking hard evidence to support his religious beliefs, he became an agnostic.

“In science, you have to be so careful about truth,” he said. “You are studying truth and have to prove everything. I found that it was difficult to believe all the things associated with religion.”

Dr. Sanger stayed on at Cambridge and soon became immersed in the study of proteins. When he started his work, scientists knew that proteins were chains of amino acids, fitted together like a child’s colorful snap-bead toy. But there are 22 different amino acids, and scientists had no way of determining the sequence of these amino acid “beads” along the chains.
In 1962, Dr. Sanger moved to the British Medical Research Council Laboratory of Molecular Biology, where he was surrounded by scientists studying deoxyribonucleic acid, or DNA, the master chemical of heredity.

Scientists knew that DNA, like proteins, had a chainlike structure. The challenge was to determine the order of adenine, thymine, guanine and cytosine — the chemical bases from which DNA is made. These bases, which are represented by the letters A, T, G and C, spell out the genetic code for all living things.

Dr. Sanger decided to study insulin, a protein that was readily available in a purified form since it is used to treat diabetes. His choice of insulin turned out to be a lucky one — with 51 amino acids, insulin has a relatively simple structure. Nonetheless, it took him 10 years to unlock its chemical sequence.

His approach, which he called the “jigsaw puzzle method,” involved breaking insulin into manageable chunks for analysis and then using his knowledge of chemical bonds to fit the pieces back together. Using this technique, scientists went on to determine the sequences of other proteins. Dr. Sanger received the Nobel just four years after he published his results in 1954.

Dr. Sanger quickly discovered that his jigsaw method was too cumbersome for large pieces of DNA, which contain many thousands of letters. “For a while I didn’t see any hope of doing it, though I knew it was an important problem,” he said.

But he persisted, developing a more efficient approach that allowed stretches of 500 to 800 letters to be read at a time. His technique, known as the Sanger method, increased by a thousand times the rate at which scientists could sequence DNA.

In 1977, Dr. Sanger decoded the complete genome of a virus that had more than 5,000 letters. It was the first time the DNA of an entire organism had been sequenced. He went on to decode the 16,000 letters of mitochondria, the energy factories in cells.

Because the Sanger method lends itself to computer automation, it has allowed scientists to unravel ever more complicated genomes — including, in 2003, the three billion letters of the human genetic code, giving scientists greater ability to distinguish between normal and abnormal genes.

In addition, Dr. Sanger’s discoveries were critical to the development of biotechnology drugs, like human growth hormone and clotting factors for hemophilia, which are produced by tiny, genetically modified organisms.

Dr. Sanger shared the 1980 chemistry Nobel with two other scientists: Paul Berg, who determined how to transfer genetic material from one organism to another, and Walter Gilbert, who, independently of Dr. Sanger, also developed a technique to sequence DNA. Because of its relative simplicity, the Sanger method became the dominant approach.

Other scientists who have received two Nobels are John Bardeen for physics (1956 and 1972), Marie Curie for physics (1903) and chemistry (1911), and Linus Pauling for chemistry (1954) and peace (1962).

Dr. Sanger received the Albert Lasker Basic Medical Research Award, often a forerunner to the Nobel, in 1979 for his work on DNA. He retired from the British Medical Research Council in 1983.

Survivors include two sons, Robin and Peter, and a daughter, Sally.

In a 2001 interview, Dr. Sanger spoke about the challenge of winning two Nobel Prizes.

“It’s much more difficult to get the first prize than to get the second one,” he said, “because if you’ve already got a prize, then you can get facilities for work and you can get collaborators, and everything is much easier.”

New Study Ties Autism Risk to Creases in Placenta

On By A.P.In autism, Biological Psychiatry, Center for Autism Research at Children’s Hospital of Philadelphia, Cheryl K. Walker, Chris Mann Sullivan, Dr. Rajadhyaksha, Harvard Medical School, Harvey J. Kliman, Jonathan L. Hecht, Marbles, Medicine, MIND Institute, Neuropsychiatric Disease, Neuroscience, neuroscientist, New York Times, Placenta, Science, Tara Wenger, The Brain, trophoblast inclusions, UC Davis, University of California, Yale UniversityLeave a comment

placenta

After most pregnancies, the placenta is thrown out, having done its job of nourishing and supporting the developing baby.

But a new study raises the possibility that analyzing the placenta after birth may provide clues to a child’s risk for developing autism. The study, which analyzed placentas from 217 births, found that in families at high genetic risk for having an autistic child, placentas were significantly more likely to have abnormal folds and creases.

“It’s quite stark,” said Dr. Cheryl K. Walker, an obstetrician-gynecologist at the Mind Institute at the University of California, Davis, and a co-author of the study, published in the journal Biological Psychiatry. “Placentas from babies at risk for autism, clearly there’s something quite different about them.”

Researchers will not know until at least next year how many of the children, who are between 2 and 5, whose placentas were studied will be found to have autism. Experts said, however, that if researchers find that children with autism had more placental folds, called trophoblast inclusions, visible after birth, the condition could become an early indicator or biomarker for babies at high risk for the disorder.

“It would be really exciting to have a real biomarker and especially one that you can get at birth,” said Dr. Tara Wenger, a researcher at the Center for Autism Research at Children’s Hospital of Philadelphia, who was not involved in the study.

The research potentially marks a new frontier, not only for autism, but also for the significance of the placenta, long considered an after-birth afterthought. Now, only 10 percent to 15 percent of placentas are analyzed, usually after pregnancy complications or a newborn’s death.

Dr. Harvey J. Kliman, a research scientist at the Yale School of Medicine and lead author of the study, said the placenta had typically been given such little respect in the medical community that wanting to study it was considered equivalent to someone in the Navy wanting to scrub ships’ toilets with a toothbrush. But he became fascinated with placentas and noticed that inclusions often occurred with births involving problematic outcomes, usually genetic disorders.

He also noticed that “the more trophoblast inclusions you have, the more severe the abnormality.” In 2006, Dr. Kliman and colleagues published research involving 13 children with autism, finding that their placentas were three times as likely to have inclusions. The new study began when Dr. Kliman, looking for more placentas, contacted the Mind Institute, which is conducting an extensive study, called Marbles, examining potential causes of autism.

“This person came out of the woodwork and said, ‘I want to study trophoblastic inclusions,’ ” Dr. Walker recalled. “Now I’m fairly intelligent and have been an obstetrician for years and I had never heard of them.”

Dr. Walker said she concluded that while “this sounds like a very smart person with a very intriguing hypothesis, I don’t know him and I don’t know how much I trust him.” So she sent him Milky Way bar-size sections of 217 placentas and let him think they all came from babies considered at high risk for autism because an older sibling had the disorder. Only after Dr. Kliman had counted each placenta’s inclusions did she tell him that only 117 placentas came from at-risk babies; the other 100 came from babies with low autism risk.

She reasoned that if Dr. Kliman found that “they all show a lot of inclusions, then maybe he’s a bit overzealous” in trying to link inclusions to autism. But the results, she said, were “astonishing.” More than two-thirds of the low-risk placentas had no inclusions, and none had more than two. But 77 high-risk placentas had inclusions, 48 of them had two or more, including 16 with between 5 and 15 inclusions.

Dr. Walker said that typically between 2 percent and 7 percent of at-risk babies develop autism, and 20 percent to 25 percent have either autism or another developmental delay. She said she is seeing some autism and non-autism diagnoses among the 117 at-risk children in the study, but does not yet know how those cases match with placental inclusions.

Dr. Jonathan L. Hecht, associate professor of pathology at Harvard Medical School, said the study was intriguing and “probably true if it finds an association between these trophoblast inclusions and autism.” But he said that inclusions were the placenta’s way of responding to many kinds of stress, so they might turn out not to be specific enough to predict autism.

Dr. Kliman calls inclusions a “check-engine light, a marker of: something’s wrong, but I don’t know what it is.”

That’s how Chris Mann Sullivan sees it, too. Dr. Sullivan, a behavioral analyst in Morrisville, N.C., was not in the study, but sent her placenta to Dr. Kliman after her daughter Dania, now 3, was born. He found five inclusions. Dr. Sullivan began intensive one-on-one therapy with Dania, who has not been given a diagnosis of autism, but has some relatively mild difficulties.

“What would have happened if I did absolutely nothing, I’m not sure,” Dr. Sullivan said. “I think it’s a great way for parents to say, ‘O.K., we have some risk factors; we’re not going to ignore it.’ ”

Thanks to Dr. Rajadhyaksha for bringing this to the attention of the It’s Interesting community.

Researchers at the University of Iowa Discover Internal Trigger for Panic Attack in the Previously Fearless

On By A.P.In AM, amygdala, Antonio Damasio, BG, carbon dioxide, Carver College of Medicine, CO2, Colin Buzza, fear, Iowa, Iowa City, James Gorman, John Wemmie, Joseph E. LeDoux, Nature Neuroscience, Neuroscience, New York Times, New York University, panic attack, SM, University of Iowa, University of Iowa Hospitals and Clinics, University of Southern CaliforniaLeave a comment

panic-attack

By JAMES GORMAN
Published: February 3, 2013
New York Times

In the past few years, scientists have learned a lot about fear from a woman who could not experience it. A rare illness had damaged a part of her brain known as the amygdala and left her eerily unafraid.

Both in experiments and in life, the woman, known as SM, showed no fear of scary movies, snakes, spiders or very real domestic assaults, death threats, and robberies at knife- and gunpoint.

Although she lived in an area “replete with crime, drugs and danger,” according to an earlier study, because she lacked a functioning amygdala, an evolutionarily ancient part of the brain long known to process fear, nothing scared her.

But recently SM had a panic attack. And the simple fact that she was able to feel afraid without a working amygdala, experts say, illuminates some of the brain’s most fundamental processes and may have practical value in the study of panic attacks.

SM’s moments of fear occurred during an experiment that involved inhaling carbon dioxide through a mask in amounts that are not harmful but create a momentary feeling of suffocation. Not only SM, but two other women, identified as AM and BG, identical twins with amygdala damage similar to SM’s, showed all the physical symptoms of panic, and reported that, to their surprise, they felt intense fear.

The researchers, who report on the experiment in the current issue of Nature Neuroscience, had hypothesized that SM would not panic. John A. Wemmie, a neuroscientist at the University of Iowa and the senior author of the paper, said, “We saw the exact opposite.”

Antonio Damasio, of the University of Southern California, who had worked with SM and some of the researchers involved in this study on previous papers but did not participate in this research, said he was delighted with the results. It confirmed his own thinking, he said, that while the amygdala was central to fear generated by external threats, there was a different brain path that produced the feeling of fear generated by internal bodily experiences like a heart attack. This idea was put forth in a 2011 paper about SM on which he was a co-author.

“I think it’s a very interesting and important result,” he said.

Dr. Joseph E. LeDoux, of New York University, who has extensively studied the amygdala but was not involved in the research, said in an e-mail, “This is a novel and important paper” in an area where there is much left to learn. He said scientists still did not understand “how the brain creates a conscious experience of fear,” whether the amygdala or other systems are involved.

SM scores in the normal range on I.Q. and other tests, and she voluntarily participated in this and earlier studies, all of which showed her lacking in any sort of fear response until now. In one, for example, she walked through a Halloween haunted house and never gasped, recoiled or screamed, as others did, when a person in a costume leapt out of the dark. She also did not seem to learn fear from life experiences.

So what was so unusual about carbon dioxide?

The answer seems to lie in the way the brain monitors disturbances in the world outside the body — snakes and robbers — compared with the way it monitors trouble inside the body — hunger, heart attacks, the feeling of not being able to breathe. External threats clearly are processed by the amygdala. But she had never been tested for internal signals of trouble.

In the experiment that SM and others participated in, they took one deep breath with plenty of oxygen but much more carbon dioxide than air usually contains. Humans are actually not sensitive to how much oxygen they are breathing, but they are sensitive to how much carbon dioxide is accumulating in the body, since it builds up quickly when a person cannot breathe. The sensation is familiar to people who have tried to hold their breath.

The researchers suggest that excess carbon dioxide produces signals that may be picked up in the brainstem and elsewhere, activating a fear-generating system in the brain that a venomous snake or a mugger with a gun would not set off.

One puzzling aspect of the results is that SM and the two other women all reacted so strongly. Among people with normal brains, only those with panic disorder are reliably terrified in carbon dioxide experiments. Most people are not so susceptible, said Colin Buzza, a co-author of the study and a medical student at the University of Iowa Carver College of Medicine, suggesting that perhaps the amygdala is not functioning properly in people with panic disorder.