Monday, January 31, 2011
Where Can Read Naruto Yaoi
new prize,
This blog remains for me a wonderful haven where you always find a reason to rejoice, a follower, your comments and from time to time, any awards that come from people who appreciate me very excited. And this is the case of Regina's blog http://farfaladecora.blogspot.com / which has so much talent and adds the courage to put a workshop and store and a living. Thanks, Carinet. You have to make a trip to Oviedo just to meet you.
And I have to tell seven more stuff to know and there you go:
- I get excited easily. With Christmas ads almond and even The Simpsons, if I have a day flojillo ...
- need to work order. Then loose things so quiet anywhere, but if I have to focus I need.
- I admire people who can wear (and do) jewelry and ornaments in general, but I'm a mess and I do not wear anything.
- it relaxes me doing puzzles, crosswords .... mental fitness!
- unfortunately for me, I'm greedy, we're going to do. Luckily I love the vegetables.
- believe that certain objects have their own life (why it I like both "Toy Story"?)
- and as the mother of Amelie, often empty my bag, I order everything and refill ...
and finally, you know I always customize awards but now I really would like to share with each and every one of the blogs I follow. So if I am fan of yours, the prize is for you.
And I have to tell seven more stuff to know and there you go:
- I get excited easily. With Christmas ads almond and even The Simpsons, if I have a day flojillo ...
- need to work order. Then loose things so quiet anywhere, but if I have to focus I need.
- I admire people who can wear (and do) jewelry and ornaments in general, but I'm a mess and I do not wear anything.
- it relaxes me doing puzzles, crosswords .... mental fitness!
- unfortunately for me, I'm greedy, we're going to do. Luckily I love the vegetables.
- believe that certain objects have their own life (why it I like both "Toy Story"?)
- and as the mother of Amelie, often empty my bag, I order everything and refill ...
and finally, you know I always customize awards but now I really would like to share with each and every one of the blogs I follow. So if I am fan of yours, the prize is for you.
Sunday, January 30, 2011
How I Read Papers
Last year I blogged about how I write blog posts. I don't really have anything to add to that, so here's some advice on how I read scientific papers - both the ones I read for my day job, and the ones I blog about.
Software: If you read papers you need PubCrawler. It's free, and it's the best thing since PubMed, because it automatically searches PubMed for you and emails you the results. Second, you need a reference manager program. I use EndNote, but there are others, including various free ones. They're indispensable.
PubCrawler sends you lists of new papers you might want to read. A reference manager lets you to keep track of what you've read, and what you need to read in future; it lets you make notes on papers (see below), search them etc. and best of all it lets you insert them into Word or whatever and automatically generates a References list. If you're not using these tools, you're making life much harder than it should be.
Deciding What To Read: There are a lot of papers out there. My PubCrawler includes a search term for "antidepressants", which nets about 10 per day; one for "autism", about 5 per day; one for various brain regions I'm interested in, up to 50 per day, another for neurotransmitters I'm into, also 50...
So you need a triage system. I mentally put papers into 3 categories, based purely on the titles:
Reading papers: Start with the abstract. Then read the Introduction, as it's usually a pretty good summary of previous work. I'll skip this only if I know all the existing literature (very rare). Then, head to the first paragraph of the Discussion: this typically contains a summary of the main results in non-technical language.
Finally, I'll skim the Methods and the Results. If something seems unusual, dodgy, or especially interesting, I'll go back and read these fully, but most of the time I don't bother. The remainder of the Discussion is generally just speculation, and rarely worth reading.
All that applies to original experimental articles. For review papers, if I read them at all I read them straight through; a well-written review should all be useful. A bad review is no use at all. If you start reading a review, and by the end of the first page you're wondering "But what's the point of all this?", it's probably the latter.
Making notes: This is the key to memory, for me at least. If I just read something, I barely remember it the next day let alone next month. Making notes forces you to actually understand it, and then it sticks. I make notes in EndNote for every paper, and even every abstract, I read. Once you get into the swing of it it's a natural part of reading and doesn't take much time.
Here's my notes on one recent paper:
Here's an uncensored extract from my notes on a paper I didn't like:
Again - when I wrote these, I didn't expect to ever read them. The point is that by writing down my comments, I forced myself to make them coherent, and hence made myself remember them. This is crucial: if you only remember what the paper said, and not the fact that when you read it, you burst out laughing in disbelief, you'll go away thinking that the paper must have been fine.
Software: If you read papers you need PubCrawler. It's free, and it's the best thing since PubMed, because it automatically searches PubMed for you and emails you the results. Second, you need a reference manager program. I use EndNote, but there are others, including various free ones. They're indispensable.
PubCrawler sends you lists of new papers you might want to read. A reference manager lets you to keep track of what you've read, and what you need to read in future; it lets you make notes on papers (see below), search them etc. and best of all it lets you insert them into Word or whatever and automatically generates a References list. If you're not using these tools, you're making life much harder than it should be.
Deciding What To Read: There are a lot of papers out there. My PubCrawler includes a search term for "antidepressants", which nets about 10 per day; one for "autism", about 5 per day; one for various brain regions I'm interested in, up to 50 per day, another for neurotransmitters I'm into, also 50...
So you need a triage system. I mentally put papers into 3 categories, based purely on the titles:
- Irrelevant - don't even click on it. I'd say about 80% of PubCrawler hits fall into this category.
- Somewhat interesting - read the abstract. 15%.
- Very interesting - read the whole thing. 5%.
Reading papers: Start with the abstract. Then read the Introduction, as it's usually a pretty good summary of previous work. I'll skip this only if I know all the existing literature (very rare). Then, head to the first paragraph of the Discussion: this typically contains a summary of the main results in non-technical language.Finally, I'll skim the Methods and the Results. If something seems unusual, dodgy, or especially interesting, I'll go back and read these fully, but most of the time I don't bother. The remainder of the Discussion is generally just speculation, and rarely worth reading.
All that applies to original experimental articles. For review papers, if I read them at all I read them straight through; a well-written review should all be useful. A bad review is no use at all. If you start reading a review, and by the end of the first page you're wondering "But what's the point of all this?", it's probably the latter.
Making notes: This is the key to memory, for me at least. If I just read something, I barely remember it the next day let alone next month. Making notes forces you to actually understand it, and then it sticks. I make notes in EndNote for every paper, and even every abstract, I read. Once you get into the swing of it it's a natural part of reading and doesn't take much time.
Here's my notes on one recent paper:
Abstract. NRG1 --> ErbB4 promotes the formation of glutamatergic --> GABA interneuron synapses via stabilizing the PSD-95 at these synapses, but NOT at other synapses i.e. glut --> glut. Therefore, NRG1 contributes to the development of inhibitory signalling. The authors say this is interesting re: SCZ [but I think it's interesting re: autism as well!]This makes sense, if you're me. Actually, though, I rarely ever read these notes. The point is to make them. You could scribble them on toilet paper and flush them once you're finished and they'd still do their job of boosting your memory.
Here's an uncensored extract from my notes on a paper I didn't like:
Less "medication resistant" patients did better [well that's AWESOME for a treatment that's meant to be an alternative to meds isn't it, you fuck]. They admit that the actual performance was crap NNT=12, but say it would be better if concomitant meds allowed [....well yeah either that or the effect would DISAPPEAR] and that it is equivalent to what would be expected if you gave a new drug or augmentation to this population [but you DIDN'T did you, you are referring to the literature, which is shit]. There's so many conflicts of interest it's almost tragic.It deserved it, seriously. My comments are [in brackets], obviously.
Again - when I wrote these, I didn't expect to ever read them. The point is that by writing down my comments, I forced myself to make them coherent, and hence made myself remember them. This is crucial: if you only remember what the paper said, and not the fact that when you read it, you burst out laughing in disbelief, you'll go away thinking that the paper must have been fine.
How I Read Papers
Last year I blogged about how I write blog posts. I don't really have anything to add to that, so here's some advice on how I read scientific papers - both the ones I read for my day job, and the ones I blog about.
Software: If you read papers you need PubCrawler. It's free, and it's the best thing since PubMed, because it automatically searches PubMed for you and emails you the results. Second, you need a reference manager program. I use EndNote, but there are others, including various free ones. They're indispensable.
PubCrawler sends you lists of new papers you might want to read. A reference manager lets you to keep track of what you've read, and what you need to read in future; it lets you make notes on papers (see below), search them etc. and best of all it lets you insert them into Word or whatever and automatically generates a References list. If you're not using these tools, you're making life much harder than it should be.
Deciding What To Read: There are a lot of papers out there. My PubCrawler includes a search term for "antidepressants", which nets about 10 per day; one for "autism", about 5 per day; one for various brain regions I'm interested in, up to 50 per day, another for neurotransmitters I'm into, also 50...
So you need a triage system. I mentally put papers into 3 categories, based purely on the titles:
Reading papers: Start with the abstract. Then read the Introduction, as it's usually a pretty good summary of previous work. I'll skip this only if I know all the existing literature (very rare). Then, head to the first paragraph of the Discussion: this typically contains a summary of the main results in non-technical language.
Finally, I'll skim the Methods and the Results. If something seems unusual, dodgy, or especially interesting, I'll go back and read these fully, but most of the time I don't bother. The remainder of the Discussion is generally just speculation, and rarely worth reading.
All that applies to original experimental articles. For review papers, if I read them at all I read them straight through; a well-written review should all be useful. A bad review is no use at all. If you start reading a review, and by the end of the first page you're wondering "But what's the point of all this?", it's probably the latter.
Making notes: This is the key to memory, for me at least. If I just read something, I barely remember it the next day let alone next month. Making notes forces you to actually understand it, and then it sticks. I make notes in EndNote for every paper, and even every abstract, I read. Once you get into the swing of it it's a natural part of reading and doesn't take much time.
Here's my notes on one recent paper:
Here's an uncensored extract from my notes on a paper I didn't like:
Again - when I wrote these, I didn't expect to ever read them. The point is that by writing down my comments, I forced myself to make them coherent, and hence made myself remember them. This is crucial: if you only remember what the paper said, and not the fact that when you read it, you burst out laughing in disbelief, you'll go away thinking that the paper must have been fine.
Software: If you read papers you need PubCrawler. It's free, and it's the best thing since PubMed, because it automatically searches PubMed for you and emails you the results. Second, you need a reference manager program. I use EndNote, but there are others, including various free ones. They're indispensable.
PubCrawler sends you lists of new papers you might want to read. A reference manager lets you to keep track of what you've read, and what you need to read in future; it lets you make notes on papers (see below), search them etc. and best of all it lets you insert them into Word or whatever and automatically generates a References list. If you're not using these tools, you're making life much harder than it should be.
Deciding What To Read: There are a lot of papers out there. My PubCrawler includes a search term for "antidepressants", which nets about 10 per day; one for "autism", about 5 per day; one for various brain regions I'm interested in, up to 50 per day, another for neurotransmitters I'm into, also 50...
So you need a triage system. I mentally put papers into 3 categories, based purely on the titles:
- Irrelevant - don't even click on it. I'd say about 80% of PubCrawler hits fall into this category.
- Somewhat interesting - read the abstract. 15%.
- Very interesting - read the whole thing. 5%.
Reading papers: Start with the abstract. Then read the Introduction, as it's usually a pretty good summary of previous work. I'll skip this only if I know all the existing literature (very rare). Then, head to the first paragraph of the Discussion: this typically contains a summary of the main results in non-technical language.Finally, I'll skim the Methods and the Results. If something seems unusual, dodgy, or especially interesting, I'll go back and read these fully, but most of the time I don't bother. The remainder of the Discussion is generally just speculation, and rarely worth reading.
All that applies to original experimental articles. For review papers, if I read them at all I read them straight through; a well-written review should all be useful. A bad review is no use at all. If you start reading a review, and by the end of the first page you're wondering "But what's the point of all this?", it's probably the latter.
Making notes: This is the key to memory, for me at least. If I just read something, I barely remember it the next day let alone next month. Making notes forces you to actually understand it, and then it sticks. I make notes in EndNote for every paper, and even every abstract, I read. Once you get into the swing of it it's a natural part of reading and doesn't take much time.
Here's my notes on one recent paper:
Abstract. NRG1 --> ErbB4 promotes the formation of glutamatergic --> GABA interneuron synapses via stabilizing the PSD-95 at these synapses, but NOT at other synapses i.e. glut --> glut. Therefore, NRG1 contributes to the development of inhibitory signalling. The authors say this is interesting re: SCZ [but I think it's interesting re: autism as well!]This makes sense, if you're me. Actually, though, I rarely ever read these notes. The point is to make them. You could scribble them on toilet paper and flush them once you're finished and they'd still do their job of boosting your memory.
Here's an uncensored extract from my notes on a paper I didn't like:
Less "medication resistant" patients did better [well that's AWESOME for a treatment that's meant to be an alternative to meds isn't it, you fuck]. They admit that the actual performance was crap NNT=12, but say it would be better if concomitant meds allowed [....well yeah either that or the effect would DISAPPEAR] and that it is equivalent to what would be expected if you gave a new drug or augmentation to this population [but you DIDN'T did you, you are referring to the literature, which is shit]. There's so many conflicts of interest it's almost tragic.It deserved it, seriously. My comments are [in brackets], obviously.
Again - when I wrote these, I didn't expect to ever read them. The point is that by writing down my comments, I forced myself to make them coherent, and hence made myself remember them. This is crucial: if you only remember what the paper said, and not the fact that when you read it, you burst out laughing in disbelief, you'll go away thinking that the paper must have been fine.
Friday, January 28, 2011
Premature Brain Diagnosis in Japan?
Nature has a disturbing article from their Asian correspondent David Cyranoski: Thought experiment. It's open access.
In brief: a number of top Japanese psychiatrists have started offering a neuroimaging method called NIRS to their patients as a diagnostic tool. They claim that NIRS shows the neural signatures of different mental illnesses.
The technology was approved by the Japanese authorities in April 2009, and since then it's been used on at least 300 patients, who pay $160 for the privilege. However, it's not clear that it works.
To put it mildly.
It's a lot cheaper and easier than MRI. However, the images it provides are a lot less detailed, and it can only image the surface of the brain. NIRS has a small but growing number of users in neuroscience research; it's especially popular in Japan, for some reason, but it's also found plenty of users elsewhere.
The clinical use of NIRS in psychiatry was pioneered by one Dr Masato Fukuda, and he's been responsible for most of the trials. So what are these trials?
As far as I can see (correct me if I'm wrong), these are all the trials comparing patients and controls that he's been an author on:
So we have 342 people in all. Actually, a bit less, because some of them were included in more than one study. That's still quite a lot - but there were only 5 panic patients, 30 depressed (including 9 elderly, who may be different), 38 eating disordered and just 17 bipolar in the mix.
And the bipolar people were currently feeling fine, or just a little bit down, at the time of the NIRS. There are quite a lot of other trials from other Japanese groups, but sticking with bipolar disorder as an example, no trials that I could find examined people who were currently ill. The only other two trials, both very small, were in recovered people (1,2).
Given that the whole point of diagnosis is to find out what any given patient has, when they're ill, this matters to every patient. Anyone could be psychotic, or depressed, or eating disordered, or any combination thereof.
Worse yet, in many of these studies the patients were taking medications. In the 2006 depression/bipolar paper, for example, all of the bipolars were on heavy-duty mood stabilizers, mostly lithium; plus a few antipsychotics, and lots of antidepressants. The depressed people were on antidepressants.
There's a deeper problem. Fukuda says that NIRS corresponds with the clinical diagnosis in 80% of cases. Let's assume that's true. Well, if the NIRS agrees with the clinical diagnosis, it doesn't tell us anything we didn't already know. If the NIRS disagrees, who do you trust?
I think you'd have to trust the clinician, because the clinician is the "gold standard" against which the NIRS is compared. Psychiatric diseases are defined clinically. If you had to choose between 80% gold and pure gold, it's not a hard choice.
Now NIRS could, in theory, be better than clinical diagnosis: it could provide more accurate prognosis, and more useful treatment recommendations. That would be cool. But as far as I can see there's absolutely no published evidence on that.
To find out you'd have to compare patients diagnosed with NIRS to patients diagnosed normally - or better, to those randomized to get fake placebo NIRS, like the authors of this trial from last year should have done. To my knowledge, there have been no such tests at all.
So what? NIRS is harmless, quick, and $160 is not a lot. Patients like it: “They want some kind of hard evidence,” [Fukuda says], especially when they have to explain absences from work. If it helps people to come to terms with their illness - no mean feat in many cases - what's the problem?
My worry is that it could mean misdiagnosing patients, and therefore mis-treating them. Here's the most disturbing bit of the article:
While NIRS is a Japanese speciality, other brain-based diagnostic or "treatment personalization" tools are being tested elsewhere. In the USA, EEG has been proposed by a number of groups. I've been rather critical of these methods, but at least they've done some trials to establish whether this actually improves patient outcomes.
In my view, all of these "diagnostic" or "predictive" tools should be subject to exactly the same tests as treatments are: double blind, randomized, sham-controlled trials.
Cyranoski, D. (2011). Neuroscience: Thought experiment Nature, 469 (7329), 148-149 DOI: 10.1038/469148a
In brief: a number of top Japanese psychiatrists have started offering a neuroimaging method called NIRS to their patients as a diagnostic tool. They claim that NIRS shows the neural signatures of different mental illnesses.The technology was approved by the Japanese authorities in April 2009, and since then it's been used on at least 300 patients, who pay $160 for the privilege. However, it's not clear that it works.
To put it mildly.
*
NIRS is Near Infra-Red Spectroscopy. It measures blood flow and oxygenation in the brain. In this respect, it's much like fMRI, but whereas fMRI uses superconducting magnets and quantum wizardry to achieve this, NIRS simply shines a near-infra-red light into the head, and records the light reflected backIt's a lot cheaper and easier than MRI. However, the images it provides are a lot less detailed, and it can only image the surface of the brain. NIRS has a small but growing number of users in neuroscience research; it's especially popular in Japan, for some reason, but it's also found plenty of users elsewhere.
The clinical use of NIRS in psychiatry was pioneered by one Dr Masato Fukuda, and he's been responsible for most of the trials. So what are these trials?
As far as I can see (correct me if I'm wrong), these are all the trials comparing patients and controls that he's been an author on:
- Matsuo et al (2000) n=9/10 elderly depressed/controls
- Suto et al (2004) n=10/13/16 depressed/schizophrenia/controls
- Kameyama et al (2006) n=17/11/17 bipolar/depression/controls
- Nishimura et al (2007) n=5/33 panic disorder/controls
- Takizawa et al (2008) n=55/70 schizophrenia/controls
- Uehara et al (2007) n=11/11 eating disorder/controls
- Suda et al (2010) n=27/27 eating disorder/controls
So we have 342 people in all. Actually, a bit less, because some of them were included in more than one study. That's still quite a lot - but there were only 5 panic patients, 30 depressed (including 9 elderly, who may be different), 38 eating disordered and just 17 bipolar in the mix.
And the bipolar people were currently feeling fine, or just a little bit down, at the time of the NIRS. There are quite a lot of other trials from other Japanese groups, but sticking with bipolar disorder as an example, no trials that I could find examined people who were currently ill. The only other two trials, both very small, were in recovered people (1,2).
Given that the whole point of diagnosis is to find out what any given patient has, when they're ill, this matters to every patient. Anyone could be psychotic, or depressed, or eating disordered, or any combination thereof.
Worse yet, in many of these studies the patients were taking medications. In the 2006 depression/bipolar paper, for example, all of the bipolars were on heavy-duty mood stabilizers, mostly lithium; plus a few antipsychotics, and lots of antidepressants. The depressed people were on antidepressants.
There's a deeper problem. Fukuda says that NIRS corresponds with the clinical diagnosis in 80% of cases. Let's assume that's true. Well, if the NIRS agrees with the clinical diagnosis, it doesn't tell us anything we didn't already know. If the NIRS disagrees, who do you trust?
I think you'd have to trust the clinician, because the clinician is the "gold standard" against which the NIRS is compared. Psychiatric diseases are defined clinically. If you had to choose between 80% gold and pure gold, it's not a hard choice.
Now NIRS could, in theory, be better than clinical diagnosis: it could provide more accurate prognosis, and more useful treatment recommendations. That would be cool. But as far as I can see there's absolutely no published evidence on that.
To find out you'd have to compare patients diagnosed with NIRS to patients diagnosed normally - or better, to those randomized to get fake placebo NIRS, like the authors of this trial from last year should have done. To my knowledge, there have been no such tests at all.
*
So what? NIRS is harmless, quick, and $160 is not a lot. Patients like it: “They want some kind of hard evidence,” [Fukuda says], especially when they have to explain absences from work. If it helps people to come to terms with their illness - no mean feat in many cases - what's the problem?My worry is that it could mean misdiagnosing patients, and therefore mis-treating them. Here's the most disturbing bit of the article:
...when Fukuda calculates his success rates, NIRS results that match the clinical diagnosis are considered a success. If the results don’t match, Fukuda says he will ask the patient and patient’s family “repeatedly” whether they might have missed something — for example, whether a depressed patient whose NIRS examination suggests schizophrenia might have forgotten to mention that he was experiencing hallucinations.Quite apart from the implication that the 80% success rate might be inflated, this suggests that some dubious clinical decisions might be going on. The first-line treatments for schizophrenia are quite different, and rather less pleasant, than those for depression. A lot of perfectly healthy people report "hallucinations" if you probe hard enough. "Seek, and ye shall find". So be careful what you seek for.
While NIRS is a Japanese speciality, other brain-based diagnostic or "treatment personalization" tools are being tested elsewhere. In the USA, EEG has been proposed by a number of groups. I've been rather critical of these methods, but at least they've done some trials to establish whether this actually improves patient outcomes.
In my view, all of these "diagnostic" or "predictive" tools should be subject to exactly the same tests as treatments are: double blind, randomized, sham-controlled trials.
Cyranoski, D. (2011). Neuroscience: Thought experiment Nature, 469 (7329), 148-149 DOI: 10.1038/469148a
Premature Brain Diagnosis in Japan?
Nature has a disturbing article from their Asian correspondent David Cyranoski: Thought experiment. It's open access.
In brief: a number of top Japanese psychiatrists have started offering a neuroimaging method called NIRS to their patients as a diagnostic tool. They claim that NIRS shows the neural signatures of different mental illnesses.
The technology was approved by the Japanese authorities in April 2009, and since then it's been used on at least 300 patients, who pay $160 for the privilege. However, it's not clear that it works.
To put it mildly.
It's a lot cheaper and easier than MRI. However, the images it provides are a lot less detailed, and it can only image the surface of the brain. NIRS has a small but growing number of users in neuroscience research; it's especially popular in Japan, for some reason, but it's also found plenty of users elsewhere.
The clinical use of NIRS in psychiatry was pioneered by one Dr Masato Fukuda, and he's been responsible for most of the trials. So what are these trials?
As far as I can see (correct me if I'm wrong), these are all the trials comparing patients and controls that he's been an author on:
So we have 342 people in all. Actually, a bit less, because some of them were included in more than one study. That's still quite a lot - but there were only 5 panic patients, 30 depressed (including 9 elderly, who may be different), 38 eating disordered and just 17 bipolar in the mix.
And the bipolar people were currently feeling fine, or just a little bit down, at the time of the NIRS. There are quite a lot of other trials from other Japanese groups, but sticking with bipolar disorder as an example, no trials that I could find examined people who were currently ill. The only other two trials, both very small, were in recovered people (1,2).
Given that the whole point of diagnosis is to find out what any given patient has, when they're ill, this matters to every patient. Anyone could be psychotic, or depressed, or eating disordered, or any combination thereof.
Worse yet, in many of these studies the patients were taking medications. In the 2006 depression/bipolar paper, for example, all of the bipolars were on heavy-duty mood stabilizers, mostly lithium; plus a few antipsychotics, and lots of antidepressants. The depressed people were on antidepressants.
There's a deeper problem. Fukuda says that NIRS corresponds with the clinical diagnosis in 80% of cases. Let's assume that's true. Well, if the NIRS agrees with the clinical diagnosis, it doesn't tell us anything we didn't already know. If the NIRS disagrees, who do you trust?
I think you'd have to trust the clinician, because the clinician is the "gold standard" against which the NIRS is compared. Psychiatric diseases are defined clinically. If you had to choose between 80% gold and pure gold, it's not a hard choice.
Now NIRS could, in theory, be better than clinical diagnosis: it could provide more accurate prognosis, and more useful treatment recommendations. That would be cool. But as far as I can see there's absolutely no published evidence on that.
To find out you'd have to compare patients diagnosed with NIRS to patients diagnosed normally - or better, to those randomized to get fake placebo NIRS, like the authors of this trial from last year should have done. To my knowledge, there have been no such tests at all.
So what? NIRS is harmless, quick, and $160 is not a lot. Patients like it: “They want some kind of hard evidence,” [Fukuda says], especially when they have to explain absences from work. If it helps people to come to terms with their illness - no mean feat in many cases - what's the problem?
My worry is that it could mean misdiagnosing patients, and therefore mis-treating them. Here's the most disturbing bit of the article:
While NIRS is a Japanese speciality, other brain-based diagnostic or "treatment personalization" tools are being tested elsewhere. In the USA, EEG has been proposed by a number of groups. I've been rather critical of these methods, but at least they've done some trials to establish whether this actually improves patient outcomes.
In my view, all of these "diagnostic" or "predictive" tools should be subject to exactly the same tests as treatments are: double blind, randomized, sham-controlled trials.
Cyranoski, D. (2011). Neuroscience: Thought experiment Nature, 469 (7329), 148-149 DOI: 10.1038/469148a
In brief: a number of top Japanese psychiatrists have started offering a neuroimaging method called NIRS to their patients as a diagnostic tool. They claim that NIRS shows the neural signatures of different mental illnesses.The technology was approved by the Japanese authorities in April 2009, and since then it's been used on at least 300 patients, who pay $160 for the privilege. However, it's not clear that it works.
To put it mildly.
*
NIRS is Near Infra-Red Spectroscopy. It measures blood flow and oxygenation in the brain. In this respect, it's much like fMRI, but whereas fMRI uses superconducting magnets and quantum wizardry to achieve this, NIRS simply shines a near-infra-red light into the head, and records the light reflected backIt's a lot cheaper and easier than MRI. However, the images it provides are a lot less detailed, and it can only image the surface of the brain. NIRS has a small but growing number of users in neuroscience research; it's especially popular in Japan, for some reason, but it's also found plenty of users elsewhere.
The clinical use of NIRS in psychiatry was pioneered by one Dr Masato Fukuda, and he's been responsible for most of the trials. So what are these trials?
As far as I can see (correct me if I'm wrong), these are all the trials comparing patients and controls that he's been an author on:
- Matsuo et al (2000) n=9/10 elderly depressed/controls
- Suto et al (2004) n=10/13/16 depressed/schizophrenia/controls
- Kameyama et al (2006) n=17/11/17 bipolar/depression/controls
- Nishimura et al (2007) n=5/33 panic disorder/controls
- Takizawa et al (2008) n=55/70 schizophrenia/controls
- Uehara et al (2007) n=11/11 eating disorder/controls
- Suda et al (2010) n=27/27 eating disorder/controls
So we have 342 people in all. Actually, a bit less, because some of them were included in more than one study. That's still quite a lot - but there were only 5 panic patients, 30 depressed (including 9 elderly, who may be different), 38 eating disordered and just 17 bipolar in the mix.
And the bipolar people were currently feeling fine, or just a little bit down, at the time of the NIRS. There are quite a lot of other trials from other Japanese groups, but sticking with bipolar disorder as an example, no trials that I could find examined people who were currently ill. The only other two trials, both very small, were in recovered people (1,2).
Given that the whole point of diagnosis is to find out what any given patient has, when they're ill, this matters to every patient. Anyone could be psychotic, or depressed, or eating disordered, or any combination thereof.
Worse yet, in many of these studies the patients were taking medications. In the 2006 depression/bipolar paper, for example, all of the bipolars were on heavy-duty mood stabilizers, mostly lithium; plus a few antipsychotics, and lots of antidepressants. The depressed people were on antidepressants.
There's a deeper problem. Fukuda says that NIRS corresponds with the clinical diagnosis in 80% of cases. Let's assume that's true. Well, if the NIRS agrees with the clinical diagnosis, it doesn't tell us anything we didn't already know. If the NIRS disagrees, who do you trust?
I think you'd have to trust the clinician, because the clinician is the "gold standard" against which the NIRS is compared. Psychiatric diseases are defined clinically. If you had to choose between 80% gold and pure gold, it's not a hard choice.
Now NIRS could, in theory, be better than clinical diagnosis: it could provide more accurate prognosis, and more useful treatment recommendations. That would be cool. But as far as I can see there's absolutely no published evidence on that.
To find out you'd have to compare patients diagnosed with NIRS to patients diagnosed normally - or better, to those randomized to get fake placebo NIRS, like the authors of this trial from last year should have done. To my knowledge, there have been no such tests at all.
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So what? NIRS is harmless, quick, and $160 is not a lot. Patients like it: “They want some kind of hard evidence,” [Fukuda says], especially when they have to explain absences from work. If it helps people to come to terms with their illness - no mean feat in many cases - what's the problem?My worry is that it could mean misdiagnosing patients, and therefore mis-treating them. Here's the most disturbing bit of the article:
...when Fukuda calculates his success rates, NIRS results that match the clinical diagnosis are considered a success. If the results don’t match, Fukuda says he will ask the patient and patient’s family “repeatedly” whether they might have missed something — for example, whether a depressed patient whose NIRS examination suggests schizophrenia might have forgotten to mention that he was experiencing hallucinations.Quite apart from the implication that the 80% success rate might be inflated, this suggests that some dubious clinical decisions might be going on. The first-line treatments for schizophrenia are quite different, and rather less pleasant, than those for depression. A lot of perfectly healthy people report "hallucinations" if you probe hard enough. "Seek, and ye shall find". So be careful what you seek for.
While NIRS is a Japanese speciality, other brain-based diagnostic or "treatment personalization" tools are being tested elsewhere. In the USA, EEG has been proposed by a number of groups. I've been rather critical of these methods, but at least they've done some trials to establish whether this actually improves patient outcomes.
In my view, all of these "diagnostic" or "predictive" tools should be subject to exactly the same tests as treatments are: double blind, randomized, sham-controlled trials.
Cyranoski, D. (2011). Neuroscience: Thought experiment Nature, 469 (7329), 148-149 DOI: 10.1038/469148a
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