Wakey wakey rise and shine 5am start today as we head for Shanghai airport in our hotel taxi much safer than travelling in a local taxi. At least our driver sticks to the speed limit even though driving on the wrong side of the road The airport is badly organised the information monitor instructs us that we need to go to D area to check in. There we discover that its in fact E area. We ch
Last night in Korea
I39ve been in Seoul for four nights now. Before Seoul I spent two nights in Jeonju a city in the southwest of the country. Jeonju didn39t have too much going on so I39ll keep it brief. There was a district right next to my guesthouse with several cultural and historic sites. Besides that it was just another city. There was a gate from when the city was walled in the past a few
Crossing Russia on the TransMongolian
Many thanks to my cabin mate Stan for sending me these photos he took as my camera got stolen later The train station is Permi II in Russia.
Tour por Mongolia. Parte 2.
La segunda parte de mi andadura por Mongolia fue igual o mejor que la primera. La dinmica es casi siempre la misma. Nos levantamos a las 830h. ms o menos nos traen el desayuno recogemos los brtulos montamos en la furgo y listos.Al final le pillas el tranquillo a los viajes revientaespaldas en la furgoneta pero cuesta lo suyo. De hecho yo este da lo hice de copiloto porque no m
Rihla 4
1. The article that I choose was LBGT and homeless. The reason I choose this article was because I have a family memb who is gay and I am very sensitive about this issue.2. When I read this article I was in complete shock. I was already aware that LGBT teens had a hard life but when i read the statistic it really sadden me. 58.3 of LGBT teens are raped when they are homeless compared to the 33.
British Hipsters and Wiggers
As mentioned many times I do not travel for culture breathtaking scenery and gaining appreciation.I am fully aware this alienates me from 99 of Travelblog and the 1 who read my shit are lonely single men who havent discovered free online porn dating sites or craigslist hookers and sit there whacking off as they read about me whacking off to some girl I havent even got
Castaway on a Desert Island and Cracking Whips on a Cattle Station
I spent two weeks in Agnes Water and had some of the most chilled funniest and generally best days of my life. I worked for two hours every morning and then had the rest of the day to surf kayak in the sea lie in the sun and hang out with my new friends. Last Monday I went on a scenic flight to a desert island near Agnes Water where we were left overnight to fend for ourselves. The flight itsel
Two Long Days in Las Vegas
Well here is an attempt to get up to date. By the time we got back our hotel last night or early this morning it was just too late and we were too knackered to spend time doing anything but sleeping so I39ll try to do a catch up.Friday morning we met up with Robyn and Trevor around 9.30am and headed to a nearby mall for breakfast. Joy was good and had cornflakes and fruit while I pigged out
Tiger Balm will cure everything…..
According to the Cambodians Tiger Balm will cure everything. If you have mosquito bites use Tiger Balm. If you have a cold or sinus issues use Tiger Balm. If you have any pain anywhere use Tiger Balm.....its a miracle cureall .............apparently. Not surprisingly we all have pots of Tiger Balm in our kits now as it really does ease the itch of mozzie bites. Talking mozzies the
Typhoons LKF and one big Buddha
I realise my blogs are getting longer and longer and this is not cool. I have started dividing the blogs into chunks so if you start a story and get bored you can skip to the next story in the next chunk. I will try to cut down in the futureThursday brought about a little wind. In Hong Kong this is defined as a type 8 typhoon resulting in the closure of all transport shops and general amenit
Understanding and Treating Colic
Parenting an infant can be totally overwhelming. One of the earliest challenge many face is learning to deal with periods of intractable crying. I often speak with sleep deprived parents when they’re looking for something — anything — to stop their baby from crying. They’ve typically been told by friends of family that their baby must have “colic” and they’ve come to the pharmacy, looking for a treatment. Colic is common, affecting up to 40% of babies in the few months of life.
While distressing, colic is a diagnosis of exclusion — that it, it is given only after other causes have been ruled out (hunger, pain, fatigue, etc.). The most common definition for colic is fussing or crying for more than 3 hours per day, more than 3 days per week, for more than 3 weeks. These criteria, first proposed by Morris Wessel in 1954, continue to be used today. However, scientific evidence to explain the cause is lacking. Ideas proposed include:
- changes in gastrointestinal bacteria/flora
- food allergies
- lactose intolerance
- excess gas in stomach
- cramping or indigestion
- intolerance to substances in the breast milk
- behavioural issues secondary to parenting factors
Despite its intensity, colic resolves on its own with no interventions. By three months of age, colic has resolved in 60% of infants. By four months, it’s 90%. It sounds harmless and short-lived, but colic’s ability to induce stress in parents cannot be overstated. Parents may be angry, frustrated, depressed, exhausted, or just feel guilty, ascribing their baby’s cries to some parenting fault.
Given our lack of understanding of the true cause of colic, there’s no shortage of cures that have been proposed. From drugs, to supplements, to manual therapies, everyone has their preferred intervention. As a pharmacist, I’m usually asked about drug and non-drug treatments. In particular, I’m often asked about gripe water — a cocktail of different ingredients, involving some combination of herbs, sodium bicarbonate, sugar, and alcohol. Invented by pharmacist William Woodward in the 1800′s, gripe water was originally develop to treat the fevers of malaria. Over time, it was felt to be helpful for babies with colic — though no rigorous evaluation has ever been conducted [PDF].
So what does work for colic? My usual advice to parents starts with reassurance. It’s not bad parenting, and it will pass, given enough time. But the lack of a clear cause and simple solution is not satisfying to many that I speak with. A discussion of stress management, dietary changes, or feeding changes (all usually recommended as first-line approaches) leaves few satisfied. Some are determined to leave the pharmacy with something. “What about this?” they’ll say, gesturing to a product on the shelf. “Will this help?” And that’s when it’s time to distill the evidence. Nicely, we have two new complementary (I don’t mean that in the CAM sense) systematic reviews published in 2011 that, together, cover most of the common treatments. The first review, Infantile colic: A systematic review of medical and conventional therapies by Belinda Hall and associates in Victoria, Australia, looked at “conventional” treatments — drugs, behavioural therapy, and dietary changes. The second, Nutritional Supplements and Other complementary medicines for infantile colic: A systematic review, is from Rachel Perry, Katherine Hunt, and Edzard Ernst. It looked at CAM therapies — supplements, nutritional products, and manual therapies. The two reviews overlapped with respect to nutritional products. Both papers are behind paywalls — I’ll summarize the highlights of both reviews.
The Hall paper was published the Journal of Pediatrics and Child Health earlier this year. A systematic review, it sought to examine all randomized interventions, cohort studies, and quasi-experimental studies for colic. Despite the ubiquity of colic, there have been few proper evaluations done. In a 30-year search of the literature, only 19 published trials were identified: five on drug treatments, ten on nutritional interventions, and four on behavioural interventions. All studies of drug products had significant quality limitations, including a lack of blinding and randomization information, unclear statisitical analyses, and in one case, no comparison of baseline demographics.
- Simethicone is an “anti-foaming” agent believe to help consolidate air bubbles, leading to their expulsion. It’s found in dozens of products. Two trials compared crying duration — neither showed any significant effect. Overall, there’s fairly good evidence to suggest it is ineffective.
- Dicyclomine is an old drug, now used most frequently (with limited success) to treat irritable bowel syndrome. Again, like simethicone, there are two trials, neither of which suggest there’s any meaningful effects. In addition, it has a nasty side effect profile. On balance, the risk-benefit profile suggests it should be avoided.
- Cimetropium is backed by a single study noting a significant decrease in individual colic episodes, but reported side effects of increased drowsiness. That’s not surprising, given it’s a derivative of belladona. Cimetropium does not appear to be available in North America, the UK, or Australia, however. And in the absence of studies reproducing the effects, and a better evaluation of the toxicity, I’d be hesitant to recommend it anyway.
Nutritional interventions suffer from the same methodological limitations as the drug studies. A lack of proper blinding was the most common bias. Other deficiencies included a lack of baseline characteristics, and unclear definitions of colic. Keeping this in mind, the data look somewhat more promising than drugs. There are mixed results with low-allergenic formulas, with some trials showing modest effects, and others showing no improvements. Promising results were found in breastfed infants who were switched to casein hydrosylate formulas, reducing colic from over 7 hrs/day to just under 3 hrs/day. This finding seems consistent with other studies, but comparisons are complicated by different designs and products used. Low-allergen maternal diets have also been associated with improvements in several studies, though they all are subject to bias due to a lack of blinding. Bottom line: promising but unproven. At least these interventions have minimal risk.
What doesn’t work? High-fibre diets had no effect when evaluated. Nor does lactase (Lactaid). Behavioural interventions have not been shown to suggest any meaningful effects. Examples include modified parent-child interaction, contingent music, and that old standby, “car ride simulation”.
“Alternative” Treatments
From a science-based perspective, “alternative” medicine is a misnomer: when clinical evidence emerge to demonstrate unproven therapies are effective, they become accepted as part of medicine. In short, effective treatment is “medicine,” while ineffective or unproven treatments are not medicine. Yet many are used in the absence of evidence, under monikers like “alternative”, “complementary”, and more recently, “integrative”. In the second review, the authors also conducted a systematic review, identifying randomized controlled trials of children diagnosed with colic, and treated with any form complementary or alternative medicine. Trials needed some form of control (placebo, no treatment, etc.) and needed to measure an outcome like severity, quality-of-life, physiologic parameters, or a reduction in the need of medication or other consequence of treatment. Fifteen trials met inclusion criteria — and were too different to permit meta-analysis. About half were deemed to be of good methodologic quality. Few collected or reported safety data: reinforcing the erroneous assumption that that natural products are inherently safe.
Spinal manipulation — Four studies were found, with three showing results that were statistically significant, yet all three positive trials were noted to have multiple methodologic issues (lack of blinding, etc). The highest quality trial was the only double-blind, placebo-controlled study conducted. It showed no effect in outcomes according to parent reports or crying diaries. (As most of you are aware, Simon Singh has made the lack of evidence of chiropractic for colic quite well known.)
A double-blind comparison of Colimil (fennel, lemon balm, and German chamomile) was evaluated to be more effective than placebo. Again, methodologic problems and a lack of duplicative studies makes an evaluation difficult. Another small trial of fennel tea suggested a beneficial effect, too.
I’ve blogged previously how sugar solutions can provide analgesic effects to reduce vaccination distress. They’ve also been evaluated for colic. Like other interventions, some promising results are watered down by methodologic issues.
Is it a lack of beneficial bacteria in the gastrointestinal tract? Probiotic studies have reported positive effects, albiet with quality issues that included a lack of blinding. This paper also looked at nutritional studies, and flagged the same issues that the other review identified.
In a study of massage, both massage and a vibrating bed were reported to have beneficial effects. The improvement over the duration of the trial may have been due simply to the natural course of the condition. A single reflexology trial had problems with entry criteria and so many flaws it was not possible to drawn conclusions beyond the possible beneficial effects of touch alone.
Conclusion
It’s easy to give the TL;DR version of both reviews: Nothing has been convincingly demonstrated to be effective. And that shouldn’t be surprising. Given we don’t know the actual cause of colic (if there even is a single cause), our interventions are simply shots in the dark, meaning there’s little prior probability — and the data that emerge from these isolated trials becomes much less persuasive. With weak study designs, the probability of publication bias, and the lack of confirmatory data for most treatments, we’re left with some promising areas that require further study – and that’s about it.
But we can draw some conclusions of exclusion: There’s little evidence that conventional drug treatments are safe or effective. There’s also no evidence to suggest behavioural interventions, or manual therapies like chiropractic and massage have any effect. Dietary interventions appear to be the most promising type of treatment, followed by sugar solutions, and remotely, herbal products like fennel tea. While there are significant data quality issues with all trials, at least dietary interventions and sugar solutions have little risk. So for parents determined to try something, these interventions seem to offer the best risk/benefit perspective. But the best, most effective intervention for colic remains the passage of time. Colic will pass. Reassurance is probably the best advice of all.
References
Hall B, Chesters J, & Robinson A (2011). Infantile colic: A systematic review of medical and conventional therapies. Journal of paediatrics and child health PMID: 21470331
Perry R, Hunt K, & Ernst E (2011). Nutritional supplements and other complementary medicines for infantile colic: a systematic review. Pediatrics, 127 (4), 720-33 PMID: 21444591
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Does Weight Matter?
Determining the net health effects of independent factors can be tricky, especially when those factors cannot be controlled for in experimental studies. For things like body mass index (BMI) we must rely on observational data and triangulate with multiple studies to isolate the contributions from BMI. But it can be done.
The data, however, are likely to be complex and noisy, and therefore there is plenty of opportunity for ideology to trump objectivity in interpreting the data. There are those who, for whatever reason, deny that we are having an obesity epidemic in the West, and those who deny the health implications of being overweight as an independent factor.
BMI
The terms overweight and obesity have had various definitions in the past, but in recent years the various health organizations have settled on consensus operational definitions (for obvious practical reasons). Their definition relates to body mass index, which is a person’s weight in kilograms (kg) divided by their height in meters (m) squared.
It should be noted that BMI is a measure of weight, not fat (adiposity). BMI is used for convenience, as height and weight data are often available, but more direct measures of body fat are not. It is widely recognized and admitted that BMI is problematic as applied to individuals. Muscular and athletic people may have a high BMI and not have excess adiposity, for example. Also at the extremes of height the BMI becomes harder to interpret.
But this does not mean the BMI is useless. In fact, for most people BMI correlates quite well with adiposity. In one study researchers compared BMI to a more direct measure of body fat percentage using skin-fold thickness. They found that when subjects met the criterion for obesity based upon BMI, they were truly obese by skin-fold thickness 50-80% of the time (depending on gender and ethnicity). When they were not obese by BMI they were not obese by skin-fold 85-99% of the time.
So BMI is a rough but useful estimate, good for large epidemiological studies where more elaborate fat percentage measurements are not practical. However, those who wish to deny the “obesity epidemic” have found BMI to be a convenient target for sowing doubt.
There is ongoing research into the utility of supplementing BMI with other easy measures, like waist circumference. This seems to be a more accurate measure of adiposity, and specifically risk from being overweight. So going forward we may see more meaningful measured routinely captured, and BMI may be replaced or supplemented with these measures. But for now we will continue to see many studies based upon BMI.
Overweight and Obese
Because BMI is a convenient measure, it has become the measure of choice in defining overweight and obesity. For children and adolescents overweight is defined as a BMI in the 85-95% percentile by age and gender, while obesity is >95% percentile BMI. For adults overweight is defined as a BMI of >=25.0 but <30.0, obese is defined by BMI >=30.0 and < 40.0, and extremely obese is defined as BMI >=40.0.
These cutoffs, like all such cutoffs for medical definitions, are partly arbitrary (they constitute drawing a line to demarcate a spectrum) but are evidence- based. This is similar to definitions for hypertension, for example. Researchers typically will set the cutoff to capture most people who are at risk for medical complications.
This is where the controversy comes into play with overweight and obesity. In 1998 the NIH decided to lower the cutoff for BMI for overweight, from 28 for men and 27 for women to 25 for both sexes. This was based upon an expert panel review of hundreds of studies. It also brought the NIH definition in line with the World Health Organization and other health organizations. The BMI 25 cutoff has now become generally accepted. The cutoff for obesity was not changed – it was and remains a BMI of 30.
Of course this means that any estimates of overweight (but not obesity) based upon the newer lower cutoff of BMI 25 would be greater than estimates based upon the previous criteria. This raised a bit of a kurfuffle, as it always seems to do when medical definitions are altered. This happened with the lowering of the cholesterol cutoff, blood pressure for hypertension, and blood sugar for diabetes.
This event in 1998 now has become a central argument in the arsenal of obesity deniers. If you search on “obesity statistics”, on the first page you will get this apparent libertarian site which quotes a “food industry spokesman” as saying:
In 1998, the U.S. Government changed the standards by which body mass index is measured. As a result, close to 30 million Americans were shifted from a government-approved weight to the overweight and obese category, without gaining an ounce, Burrita said.
This is slightly misleading, as the obese category was not changed. But the main point is that this 1998 redefinition is being used to argue that the obesity epidemic is all smoke and mirrors. The article goes on to quote this gem from William Quick:
According to an American Medical Association report, 14.5 % of Americans in 1980 were obese, a total of 32,700,000 (based on a population of 226,000,000). If, as the above article states, the numbers of obese Americans have “doubled” in the past twenty years, this would mean there are now about 66 million of them. But thirty million of those fatties were created by a change in definition, so by the standards of 1980 [we would calculate an] obesity percentage of 12.85 percent, an actual decrease in obesity percentage since 1980.
That’s some massively flawed reasoning. Again we see the confusion of the overweight and obese categories. But also there are many false assumptions in that back-of-the-envelope calculation. Quick is mixing statistics from different sources and contexts, and the result is a mess.
What we really need is a look at the numbers over time using the same definition. Fortunately, most epidemiologists are not dolts and they get this very basic concept. In fact, it doesn’t get much more basic than this, and it would take some pretty naive incompetence to use inconsistent definitions over time.
The CDC has crunched the numbers for us, and using the modern cutoffs for overweight, obese, and extremely obese applied to BMI data for the last few decades they document a pretty steady increase in American fatness over time. Take a look at the video on the site to see this data presented graphically. Also, it is summarized in the graph here.
As you can see, the lines go steadily up – with the exception that the overweight category has decreased in the last decade. However, it seems that this is due to the shifting of people from the overweight category to the obese category, not to the normal weight category.
Of course, you could cherry pick by just looking at the overweight category. Looking at all the data, however, tells the real story.
The Health Risks of Overweight
Is being overweight and obese an independent risk factor for any specific illness? The answer is an overwhelming yes. There are many diseases for which being overweight is a risk factor, such as type II diabetes, obstructive sleep apnea, pseudotumor cerebri, heart disease, and other illnesses. The data is clear – but complex, and so allows for those motivated to deny the connection to distort and cherry pick the data to create the impression they wish.
From a website advocating size acceptance we read:
There is actually no evidence that being fat will give you diabetes or cancer or PCOS or any other health issues. Being obese tends to correlate with some health problems, but the causes of the health problems may be multiple, and they certainly aren’t thoroughly understood in current medical research.
It must be pointed out that many obese people are perfectly healthy, if you look at the numbers that matter. This seems to refute the idea that fat alone causes artery clogging, diabetes, or anything else it’s often blamed for – clearly, there are at least other factors besides fat, and it may even be the case that fat’s nothing to do with it at all. As long as your other numbers are good, your weight does not impact your health. If you can possibly afford to get your numbers tested once a year, or even every few years, do so. If the numbers that matter are good, your weight is fine
Here we see a couple of logical fallacies. The first is the denial of cause based upon an overapplication of the “correlation does not equal causation” fallacy. It is true that correlation alone does not prove causation, but causation may be the answer, and we can test this hypothesis by testing multiple correlations. For example, if weight is reduced will the risk of the disease decrease.
Also, the fact that being overweight and obese may cause health problems through intermediary effects is irrelevant. If being overweight causes insulin resistance which causes diabetes, it is not meaningful to say that weight is not causing diabetes.
We also see confusion between weight as a risk factor vs being an absolute cause. Weight is one factor among many, such as genetics. There are obese people who are otherwise healthy, just like there are heavy smokers who never get lung cancer. This is entirely irrelevant to the claim that weight is a risk factor for various diseases. The lack of 100% correlation does not justify the conclusion that weight has “nothing to do with it at all.”
Conclusion
There is an obesity epidemic in the US and in developed nations generally, and this increase in adiposity is an independent risk factor for many diseases and disorders. Exactly what role weight is playing in specific diseases is a complex question that is the subject of ongoing research, but there is already overwhelming data in many condition to show that being overweight is a health risk.
Further – this has nothing to do with size acceptance. We can separate the question of social stigma from the medical facts. It is also folly to tie a social/ethical issue to a specific factual premise – because when the facts don’t come out the way you wish that either weakens your ethical stance, and/or forces you to deny the scientific facts. We can simultaneously treat overweight and obesity as the health problem that it is, while addressing the social and psychological aspects of weight in our society.
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Andrew Weil and “integrative medicine”: The ultimate triumph of quackery?
A board certification in woo?
I’ve been harshly critical of the entire concept of “integrative medicine” (IM), which has over the last few years nearly supplanted the former term used for non-science-based medicine or medicine based on prescientific ideas represented as though it were scientific medicine, “complementary and alternative medicine” (CAM). Indeed, just last week I pointed out how IM is far more about marketing than it is about science or medicine, and over the last three years I’ve been particularly harsh on the concept of “integrative oncology,” which is actually being represented as a “subspecialty” of IM. Despite the utter lack of a rationale based on science or the scientific basis of medicine, IM has still been making inroads into academic medical centers, where I tend to refer to it with the unapologetically disparaging term “quackademic medicine.” Even worse, now, increasingly, such woo has been insinuating its way into community medical centers as well.
Arguably, the man who has done more than any individual to promote the quackification of science-based medicine is Dr. Andrew Weil. (At least, I can’t think of any single person who’s done more during his lifetime to promote the infiltration of quackery into medicine. Readers are free to chime in if they know of someone who could challenge Weil for the title of King of Quackademic Medicine.) As I pointed out the last time I discussed him, Dr. Weil doesn’t really like science-based medicine. Oh, no, he doesn’t like it at all. Unfortunately, he’s been very successful in promoting quackademic medicine. He’s also arguably been the single most successful person at legitimizing what used to be viewed as quackery. Master of the domain of “integrative medicine,” having formed a model of an “integrative medicine in residency” that’s spread like kudzu through quackademia, all from his redoubt at the University of Arizona, Dr. Weil has now announced his intention for the next phase of his “integrating” pseudoscience with SBM. I learn this from The Integrator Blog, which has as a recent headline from last week Special Report: “Strategic Change in Direction” as Weil’s Arizona Center Commits to Creation of American Board of Integrative Medicine:
In a major strategic shift, the University of Arizona Center for Integrative Medicine (ACIM) has announced that it will lead the creation of a formal specialty for medical doctors in integrative medicine. ACIM, founded by Andrew Weil, MD and directed by Victoria Maizes, MD, is in dialogue with the American Board of Physician Specialties toward establishing an American Board of Integrative Medicine. They are collaborating with leaders of the American Board of Integrative and Holistic Medicine (ABIHM). Here is the ACIM announcement, a statement from two ABIHM leaders, a brief interview with Maizes and the list of 18 founding Board members. Is this the right strategic choice? What impact will this have on integrative medicine and the broader integrative healthcare movement?
At first, I wasn’t aware that this was, in fact, any sort of “strategic shift.” Being recognized as a medical specialty, complete with standards for an educational curriculum during residency or fellowship and board exams for certification, is the ultimate validation of legitimacy as a medical specialty, at least as far as medical education, regulation, and the overall medical world goes. If Dr. Weil could achieve this, it would become virtually impossible to eliminate woo from medicine, at least in the United States. It would be codified as a medical specialty by one of the three major certifying boards that certify physicians as being qualified in specific specialties, in this case the American Board of Physician Specialties (ABPS). The other boards include American Osteopathic Association Bureau of Osteopathic Specialists (which only certifies doctors with the DO degree) and the American Board of Medical Specialties. Of these, the last one, the ABMS, is the board that really matters in most states. For instance, the board under which I’m Board-certified in Surgery is, appropriately enough, the American Board of Surgery. The ABS is the umbrella board that certifies surgeons in General Surgery, Vascular Surgery, Pediatric Surgery, Surgical Critical Care, Hand Surgery, and others. In addition, the ABMS certifies 23 other specialties, including Anesthesiology, Emergency Medicine, Internal Medicine, Pathology, Pediatrics, and many others. These boards set up minimum standards for knowledge and skills and devise tests and documentation necessary to be “certified.” Generally, board certification requires an MD or DO degree, completion of an accredited residency in the relevant specialty, and the passing of written and oral examinations. Some specialties require documentation of practice results (such as plastic surgery, which requires a case log, complete with “before and after” photos)
One thing that our non-U.S. readers might find odd (and that a surprising number of U.S. residents don’t even know) is that there is no national licensure of physicians in the United States. Each state writes its own laws and has its own medical board. It is also necessary to understand that board certification is an entirely separate process from state licensure. In fact, you don’t have to be board-certified to have a medical license; in most states, all you have to have is a medical degree and a year of postgraduate training (internship). Indeed, I got my first medical license during my residency, long before I ever achieved Board certification in Surgery. In fact, in the old days, it was entirely possible to practice for an entire career without being board certified, and many physicians did just that. There are even a few older physicians left who still practice without board certification, having in effect been “grandfathered” into the system. These days, however, if you want to be on the staff of a hospital or be an approved provider on an insurance plan, you pretty much have to be board certified in your specialty. If you’re not, you’ll be permanently consigned to a lower tier of practice, such as moonlighting jobs or jobs as “house physicians” who cover patients in hospitals without residents during nights and weekends. Exceptions are sometimes made in rural hospitals that are desperate for physicians, but even these exceptions are disappearing. Basically, in order to practice as a fully independent professional in the United States, you have to be board-certified or board eligible.
So why would Dr. Weil want to change course and seek a form of board certification for IM? Here’s how Dr. Weil himself describes the reason in the University of Arizona press release:
We are writing to let you know about an important decision that we recently made — a decision that represents a strategic change in direction for our Center. For many years we have resisted the idea of board certification in Integrative Medicine (IM). We have always believed that the principles and practices of IM should inform all specialties, rather than be developed into a new field. In other words, that dermatologists, surgeons, and family physicians alike all need to learn the principles of nutrition and mind-body medicine, and to value the innate healing capacity of the body. We still hold that belief.
But…
Earlier this year we approached the American Board of Physician Specialties (ABPS) to discuss creating a board in IM. We did so for many reasons; chief among them was to help patients discern who truly has training and expertise in IM. It is now popular in the marketplace to say you practice IM — yet anyone can say so, whether they studied for an hour, a weekend, or ten years.
This is actually pretty hilarious in its own way. This is almost the same reason that virtually every subspecialty that has ever applied to have a board certification process has cited as its reason for doing so. The reasons such a consideration almost inevitably come down to protecting the reputation of the specialty by defining who is and is not a member of the specialty. Apparently the desire to infuse all medical specialties with his woo cannot stand up to the cold, hard reality of how medicine really works. So now he wants his own boarded specialty, because he realizes that the only way IM will ever be taken seriously by patients is for it to be its own boarded specialty. Never mind where the board certification comes from, which currently is a highly dubious “board.”
The actual board that would be overseeing any board certification in IM would be, according to the press release the American Board of Integrative Holistic Medicine (ABIHM). This board was first formed in 1996 as the American Board of Holistic Medicine. A quick perusal of its FAQ regarding certification reveals a number of interesting things. First, the only qualifications necessary to sit for the ABIHM boards are (1) and MD or DO; (2) a current medical license in the U.S. or Canada; and (3) board certification or board eligibility in a specialty accredited by the Accreditation Council for Graduate Medical Education (ACGME). That’s it. No training program. No residency program in “holistic medicine,” “integrative medicine,” “complementary and alternative medicine,” or anything at all. You could be a radiologist, pathologist, or other specialties that don’t generally directly care for patients. In other words, if you’re a physician who’s board-certified or board-eligible in any currently recognized medical specialty, all you have to do to be board certified in IM is to take the test and pass it, which 85-90% of those who take it do on the first try and those who don’t can try again. Indeed, the ABIHM sends applicants its Course Curriculum Study Guide (CCSG) and recommends that applicants “be very familiar with the material in the CCSG before you sit for the exam.” The ABIHM also provides a review course but doesn’t require it.
You know, it’s half tempting for me to register for the exam and see if I can become a board-certified practitioner of IM. There’s nothing that says I can’t do it, and I’d get access to the review materials, which, I suspect, would be most illuminating. For example, how much homeopathy would I be expected to know? Acupuncture? Would I have to memorize meridians and acupuncture points? Would I have to know how to do reiki? Inquiring minds want to know, although this inquiring mind doesn’t want to know badly enough to pay the $800 it would take to register. Perhaps there are other, richer physicians who might want to go that route. If so, the deadline to get the cheap rate to take the test on November 12 is October 3.
John Weeks of The Integrator Blog describes a “town versus gown” divide in IM, in which the “townies” (i.e., the private practice, non-academic IM practitioners) very much wanted some sort of board certification, while the “gowns” (i.e., the centers of quackademic medicine) did not. He doesn’t really elaborate on the reasons for this conflict but points out that the name change to ABIHM was driven by a desire to “raise standards.” Of course, when one is discussing healing modalities not based in science but rather in prescientific mystical thinking, such as acupuncture, reiki, homeopathy, and the like, one can’t help but think that “raising standards” would involve eliminating such modalities from medicine altogether. Be that as it may, I find it rather telling as to why Dr. Weil chose to go the route he did, choosing a third rate certifying board over the certifying board that is generally recognized by every state, hospital, and insurance company:
Unlike the American Board of Medical Specialties (ABMS), which would require approval by every single specialty board, ABPS is interested in creating a single pathway, recognizes fellowship training, and is an innovator. We had hoped the ABMS would consider a Certificate of Added Qualification in IM — such as exists for geriatrics — which can be applied for by different residency specialties; but ABMS is eliminating that concept.
Our goal is to have all graduates of our 1000-hour fellowship become board certified. At the same time we have not relinquished our goal of bringing IM training to all physicians. The success of our Integrative Medicine in Residency makes us comfortable and confident that IM will become a part of all physicians’ basic training. This 200-hour program is being used in 22 family medicine and two internal medicine residencies. In 2012 we will begin a pilot in two pediatrics residencies.
This is an exciting step for the field of Integrative Medicine (IM). Board certification is widely recognized by physicians and the public alike as a critical step in establishing a field. The first meeting of the American Board of Integrative Medicine will take place in Tampa, Florida, October 10-11. Over a two-year period, we will set criteria for sitting for the board exam and develop a validated exam.
In other words, the ABMS had standards that were too high for Dr. Weil, whereas the ABPS is not. Let’s just put it this way. “Innovation” is not really what I want in a certifying board for a medical specialty. I prefer a boring dedication to science-based practice and a caution that leads new specialty acceptance to be evolutionary rather than revolutionary.
An end run around standards
Believe it or not, before I saw Dr. Weil’s press release and started doing a bit of research for this post, I had never heard of the AAPS or its companion board the ABPS. After all, the ABMS is the gold standard board through which the vast majority of physicians in this country are certified. Indeed, my very own specialty, surgical oncology, is not a boarded specialty at present. There are training programs approved by the Society of Surgical Oncology, but these fellowships do not lead to sitting for boards, and surgical oncology is viewed mainly as an offshoot of general surgery. Indeed, ever since I decided that I wanted to go into surgical oncology in the mid-1990s (and long before my entry into the field), there has been a debate over what surgical oncology is as a specialty and whether it should be fully distinct from general surgery. Remember that most cancer operations for breast cancer, GI malignancies, melanoma, and some other cancers have long been the purview of general surgeonss and even today in the U.S. most such operations are still carried out by general surgeons in the community. Surgical oncology, as envisioned, was originally going to cover more complex cancer operations, those needed by patients referred to tertiary medical centers and cancer centers like Memorial Sloan-Kettering and M.D. Anderson Cancer Centers. There was also, let’s face it, the question of turf. For example, multiple surgical specialties claim colon cancer as part of their areas of special expertise, including (now) general surgery, colorectal surgery, surgical oncology, and, increasingly, minimally invasive surgery.
The lack of board certification for surgical oncology is a situation that will not last much longer, though. It was announced at the SSO Meeting in March 2011 that, after decades of trying, the SSO had finally managed to win board certification for surgical oncology from the ABMS. The new board certification will be called Complex General Surgical Oncology and will be a subspecialty board under the ABS. It will require board certification in general surgery, plus fellowship training of at least two years beyond that in an approved fellowship program, followed by passing a board examination in surgical oncology.
Another interesting aspect of board certification in Complex General Surgical Oncology is that current practitioners and graduates of even approved surgical oncology training programs will not be grandfathered in. Whenever a new subspecialty peels off from an established, more general specialty, such as when vascular surgery peeled off of general surgery to become a recognized specialty, inevitably there are cries from current practitioners of that specialty for a mechanism to “grandfather” them in and provide a means for them to become board certified too without having to undergo residency or fellowship training again. For example, I am rapidly finishing my fifth decade of life; going back to a fellowship is not practical, nor would it be for the vast majority of mid-career surgeons like me with a lot of experience but also 15-20 years (or even more) left in their careers. This would be the case even if there were enough fellowship slots to accommodate them and surgeons finishing residency, which there are not. In marked contrast, every report I’ve seen about the new certificate in Complex General Surgical Oncology at SSO meetings over the last few years indicates that current surgical oncologists will not be able to take the examination and be grandfathered in. That includes even the eminent surgical oncologists who are the founding members of this new board. Unless I go back and do a surgical oncology fellowship again, I can never be board certified in surgical oncology. (No doubt some quack will attack me for that ten years from now, after the new system has started to crank out a significant number of board certified surgical oncologists.)
Readers might be thinking to themselves right now, “That’s all very interesting, Gorski (well, not really), but why are you explaining this? What does any of this have to do with board certification in IM?” I answer: Compare and contrast, my friends. Compare and contrast. Dr. Weil could have tried to partner with the much more respected and authoritative ABMS. Why didn’t he? Because, at least for now, the ABMS wouldn’t touch this “integrative” woo with the proverbial ten foot pool (Weil et al. even admit that in their press release). Don’t get me wrong. Given the infiltration of quackademic medicine into so many medical schools and academic medical centers, I’m under no illusion at all that the ABMS is so science-based that this situation might not change in the future and it might not become more “open” to IM, but at least for now, the ABMS appears not to be interested in pseudoscience-based medical pseudo specialties. That is, of course, a good thing. In contrast, the AAPS is apparently—shall we say?—more “open minded.” Indeed, take a look at this video from the AAPS website describing board certification through the ABPS:
Notice the arguments? “Who’s got your back?” Fight against unfair “discrimination against deserving physicians.” The ABPS has a “big tent approach to medicine.” “You’re not a mere number” with ABPS. I don’t know about you, but I know that I want a “big tent” approach to medicine. A “big tent” approach is a major reason why quackademic medicine has gotten as far as it has. For example, apparently the AAPS has been having difficulty getting its emergency medicine boards recognized because it doesn’t require a specific emergency medicine residency and is mounting a major public relations and lobbying campaign to change that, with the goal of being recognized in every state (which of course means ABPS certifications in emergency medicine are not recognized in some states:
“We have a very aggressive and active governmental affairs program for 2010,” said Timothy Bell, the AAPS director of governmental affairs. “Our strategic plan for 2010 includes Alaska, Montana, Idaho, Utah, and North and South Dakota. It will put us on the path of achieving the goal of being recognized in every state.”
The plan puts ABPS on a collision course with the American Board of Medical Specialties as well as the Bureau of Osteopathic Specialists and Boards of Certification of the American Osteopathic Association, the most widely accepted agencies for medical specialty certification. Nowhere is the clash more evident than in the field of emergency medicine, perhaps because of the Daniel v. ABEM suit that spanned 15 years, casting a shadow over the field’s attempt to move from grandfathering for the field’s pioneers, who had no chance to enter an emergency medicine residency, to a residency-based approach. While ABEM bases board certification on completing an emergency medicine residency and testing, ABPS’s certifying body, the Board of Certification in Emergency Medicine (BCEM), allows applicants to have completed a primary care or anesthesiology residency along with 7,000 hours of experience in an emergency department.
Hmmm. Maybe I should see if the ABPS will set up a competing board in surgical oncology, so that I can be board-certified too! In any case, New York and Oklahoma, at least, have recently thwarted the ABPS initiative. Meanwhile, relatively few hospitals recognize ABPS certification as being “board certified,” and the American College of Emergency Physicians does not recognize the ABPS as a valid certifying body. Neither does the American College of Surgeons.
Seen in the light of the example of emergency medicine, it’s very clear why Dr. Weil and the ABIHM chose the ABPS. First, unlike leaders in surgical oncology, Dr. Weil didn’t want to go through what could be a decades-long (or more) process of convincing the ABMS that “integrative medicine” is a valid and distinct medical specialty. Second, the ABMS has made it clear that it’s not going to “grandfather” practitioners in, whereas the ABIHM almost advertises that you should take its test now while things are still easy, before the ABIHM institutes an IM residency requirement for its board certification:
Within the next few years, the ABIHM has plans to phase out the certification of physicians without formal training from an integrative medicine residency or fellowship program. We will also be raising the benchmark for passing the exam. Thus, physicians without formal training have a time limited opportunity to become Diplomates before the new standards are implemented. Our intent is to offer “grandparent” status to those who underwent certification prior to the installment of the upgraded requirements.
Get yer IM board certification while they last at this low, low price of $800 and no special residency needed!
The bottom line
There is little doubt that Dr. Weil has realized that his specialty of IM is, despite his massive success in infiltrating quackademic medicine into medical academia, still not taken seriously where it matters, namely by certifying boards, state medical boards, and, of course, insurance companies. If he can succeed in creating a medical specialty that appears legitimate based on board certification, then recognition by state medical boards and, more importantly, third party payers might well follow. If it takes partnering with an umbrella organization for various medical boards that aren’t as well-accepted and well-respected as those under the umbrella of the ABMS, so be it. Most of the public doesn’t know the difference, anyway. So Dr. Weil and a bunch of buddies, including people we’ve discussed before on SBM such as Dr. Mimi Guarneri (who was the pro-IM counterpoint to Steve Novella when he was on The Doctor Oz Show last spring), Dr. Brian Berman (who’s managed to slip bad acupuncture papers past reviewers into high impact journals), and Dr. Benjamin Kligler (who’s the research director in integrative family medicine for the Beth Israel-affiliated Continuum Center for Health and Healing), among others, got together and formed the American Board of Integrative Medicine.
One potential consequence of this effort might well be ticking off non-MD practitioners of woo such as naturopaths. John Weeks even mentions this as a possibility:
This strategic decision by ACIM has many dimensions. There are clear public health implications. The ACIM-ABIHM alliance represents a significant new alignment. Grassroots access to the “integrative medical doctor” title or at least board certification may disappear. There are guild dimensions here, ground claiming, and not just for IM doctors. Many naturopathic doctors and acupuncturists and chiropractors use the term. The brand “integrative medicine” may become even more closely associated with, and effectively owned by, medical doctors. New clarities will emerge, new boundaries will be drawn, new possibilities empowered.
Indeed. I rather suspect that this is a blatant effort of the “MD wing” of the alternative medicine world to claim the specialty for itself and push out all the “riff raff,” like naturopaths, homeopaths, chiropractors, acupuncturists, and the like by preventing them from using the term “integrative medicine” to describe what they do. One potential result, if Weil and his merry band of woo-meisters are successful, is to marginalize non-MD practitioners, which might not be a bad thing from the point of view of science-based medicine. What would be a bad thing is that it would simultaneously allow MDs like Weil to lay claim to the woo inherent in IM in order to give it the patina of legitimacy that, despite 20 years of the best efforts of doctors like Weil, IM or CAM or whatever the pseudorespectable nom du jour is still doesn’t have and doesn’t deserve because much of it consists either of Trojan horses or pseudoscience.
Whatever happens, one consequence that will not result from this effort is any improvement in patient care.
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Benedetti on Placebos
There has been an ongoing debate about placebos on SBM, both in the articles and in the comments. What does it mean that a treatment has been shown to be “no better than placebo?” If our goal is for patients to feel better and they feel better with placebos, why not prescribe them? Do placebos actually do anything useful? What can science tell us about why a patient might report diminished pain after taking an inert sugar pill? The subject is complex and prone to misconceptions. A recent podcast interview offers a breakthrough in understanding.
On her Brain Science Podcast Dr. Ginger Campbell interviewed Dr. Fabrizio Benedetti, a physician and clinical neurophysiologist who is one of the world’s leading researchers on the neurobiology of placebos. A transcript of the interview [PDF] is available on her website for those who prefer reading to listening. The information Dr. Benedetti presents and the expanded remarks by Dr. Campbell after the interview go a long way towards explaining the placebo phenomenon and its consequences for clinical medicine. Dr. Campbell also includes a handy list of references. I’ll try to provide a summary of the main points, but I recommend reading or listening to the original.
A common misconception is that the response to placebos is a purely subjective psychological response involving only the cortical level of the brain; but evidence is accumulating that real, measurable, objective subcortical neurophysiologic phenomena are involved. One of the first hints was a 1978 study showing that the placebo response to pain could be blocked by naloxone, a narcotic antagonist drug, indicating that the placebo must have actually caused an increase in endogenous opioids.
Placebos are used in clinical trials methodology, where a placebo group is compared to an active treatment group. Typically, about a third of subjects in the placebo group show improvement, but this doesn’t mean all of them have responded to the placebo. There are many other factors that can cause improvement after administration of any treatment, whether effective drug or placebo, including spontaneous remission, regression to the mean, and various kinds of bias on the part of patients and experimenters.
Clinical trials are done to look for a difference between the outcomes with placebo and the outcomes with the drug. Researchers in those trials are not interested in trying to understand why there is an improvement in the placebo group. That requires a different kind of study. Dr. Benedetti is using “placebo balanced design” to tease out the influence of verbal suggestions — expectations — on the action of drugs. Subjects are divided into four groups. The first group of subjects receives the active treatment and is told it is the active treatment (the truth). The second group receives the active treatment and is told it is placebo (a lie). The third group receives placebo and is told it is the active treatment (a lie). The fourth group receives placebo and is told it is placebo (the truth). This design allows researchers to separate the specific effects of the active treatment itself from the nonspecific effects of suggestion and expectation.
In studies of surreptitious vs. open IV morphine administration, patients experienced less pain relief from the morphine when they were unaware that they were getting it. In one brain imaging study, the metabolic response to methylphenidate decreased by 50% when subjects were told they were getting a placebo.
The placebo response is not limited to pain. In Parkinson’s disease, placebos have been shown to cause a 200% increase in dopamine release in the brain, with an alteration in the activity of neurons and a corresponding clinical improvement in motor function. Dr. Benedetti has even documented a physiologic placebo response at the level of single neurons. In deep brain stimulation studies, the stimulator doesn’t work as well if patients are told it is off when it is actually on.
There is not just one “placebo effect,” but many different placebo effects that work by different mechanisms, including (1) anxiety reduction, (2) activation of the reward mechanism (with dopamine release in the nucleus accumbens), and (3) learning.
Placebo responses can be divided into two types: conscious and unconscious. Conscious responses involve suggestion and expectation. Unconscious responses occur with classical Pavlovian conditioning. If you give morphine 3 days in a row and on the 4th day you replace it with a placebo, almost 100% of patients will respond to the placebo as if they had received morphine. When a pill is administered, there is a completely unconscious association between two stimuli: the pharmacologic effect and the psychosocial context, which may include such things as the color and shape of the pill. Unconscious conditioning has been demonstrated in both animals and humans.
Conscious expectations are important for conscious physiological functions like pain and motor performance. Unconscious conditioning is more important for unconscious physiological functions like hormone secretion and activation of different immune mediators. Dr. Benedetti gives this example: if you give a patient a placebo and tell him it will increase his growth hormone levels, nothing happens. But if you give a drug that really does raise GH levels for two days and on the third day replace it with a placebo, the levels will rise with the placebo.
Clinical Implications
Dr. Benedetti gives placebos to subjects in a research setting; he doesn’t recommend giving them to patients in the doctor’s office. Placebo studies are important for understanding how the brain works, but Dr. Benedetti is not sure that they will lead to any clinical application. He says
the take-home message for clinicians, for physicians, for all health professionals is that their words, behaviors, attitudes are very important, and move a lot of molecules in the patient’s brain. So, what they say, what they do in routine clinical practice is very, very important, because the brain of the patient changes sometimes… there is a reduction in anxiety; but we know that there is a real change…in the patient’s brain which is due to… the ‘ritual of the therapeutic act.’
Experimentally, morphine requirements can be reduced by starting with morphine, substituting a placebo for later doses and periodically reinforcing the conditioning with morphine. This sounds like a good thing, but before it could become a useful option in clinical practice, it would have to overcome a number of ethical and practical hurdles. The unconscious placebo responses require conditioning and the conscious ones are problematic too. Even if some patients might get a degree of pain relief from just being handed a sugar pill with a strong suggestion, the effects can’t compete with effective pain treatments: the response is generally smaller, less reliable, less predictable, and not sustainable over the long term. I can’t imagine that ever becoming standard medical practice, and not just because of the ethical issues.
The doctor-patient relationship is essential to medicine, and placebo effects are an inherent part of that interaction. Communication is vital. Doctors must tell patients what a treatment is supposed to do. When pain medication is given without the patient’s knowledge, it doesn’t work as well. A clear understanding of the diagnosis is important: a positive diagnosis of something menacing like cancer can make the patient anxious and more aware of symptoms, while a negative diagnosis can reassure, relieve anxiety, and divert attention elsewhere. Lying to patients would undermine a trusting doctor-patient relationship and ultimately even interfere with the ability to evoke placebo responses. Prescribing placebos is uniformly rejected by medical ethicists: instead, we can put our increasing knowledge of placebo neurophysiology to good use without lying to patients.
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Global Expansion: Singapore Ready for Launch
Are you familiar with the “slow clap” phenomenon?
It’s basically a crescendo of applause in a crowd that starts with a single hand clap. A few seconds after that first clap, you hear the second. A slow rhythm takes shape. A few people join in. The rhythm is contagious, and it starts to spread through the crowd. As more people join in, the natural tendency is for the pace to speed up as the volume increases, and within about a minute, a single hand clap becomes a huge roar of applause. In the movie Rudy, one character starts a “slow clap” on the sideline of a football game, and the cheer ends up filling the entire stadium … And that’s the visual that comes to mind when I think about the upcoming “go live” date for our Singapore data center.
Start a slow clap in your mind and think of each successive milestone getting faster and exponentially louder applause:
- In July, George Karidis posted a high-level overview of SoftLayer’s international growth.
- About a month later, I blogged with details about our network expansion into Japan.
- Three days after that post, you got your first glimpse at the Singapore data center build-out process.
- A week later, you saw updated pictures of the data center and office space.
- Last week, racks were installed and wired up by the time a press release hit the wire announcing the launch of our Asia-Pacific operations.
- From that press release, you learned that SoftLayer’s Singapore data center will go live on October 3, 2011.
If you imagined correctly, the applause in your mind should be borderline deafening … And I didn’t even mention the fact that we enabled pre-orders on select servers in Singapore last week with a Triple Double special exclusively for servers in the new SNG01 facility.
AND I haven’t said anything about the progress of our first European data center in Amsterdam. We already have a team of people there working to get that facility ready, and it’s coming together just as quickly. Don’t be surprised to see a few sneak peeks at the build-out process there in the next few weeks.
It’s almost unfathomable that we’re so close to the launch of our first facility outside the United States, and when you consider how quickly Amsterdam will come online after Singapore, you probably think you’re taking crazy pills … Or that we are. I don’t want to take any of the wind out of the sales of our launch day, so I’m just going to share a few more glimpses into the data center.
On Monday, you can light your first server at the end of this Singaporean hallway:
All of the racks are powered:
The server rails are installed:
And we thought it might be a good idea to go ahead and install a few servers:
Now all we need to do is flip the switch … Are you ready?
What’s Your KRED?
SoftLayer loves startups. The culture, the energy, the potential … It’s all good stuff. As you may remember from my 3 Bars 3 Questions interview and our Teens in Tech profile, one of the ways we support startups is through an incubator program that provides a phenomenal hosting credit and a lot of technology know-how to participating organizations.
In San Francisco, one of the flagship programs we’re excited to be a part of is called PeopleBrowsr Labs, a startup accelerator geared toward technology companies in the area. As you sit in the PeopleBrowsr office, the brilliance in the air is almost palpable … Young companies doing innovative things with everything they need to be successful at their disposal. One of the fringe benefits for participants in PeopleBrowsr Labs is that they’re actually rubbing elbows with the PeopleBrowsr team as well … Which is almost worth the price of admission.
In addition to the Labs sponsorship, SoftLayer is also the infrastructure provider for PeopleBrowsr and its unbelievable data mine of information. They’ve got every tweet that’s been tweeted since early 2008, and they’ve been able to take that content and make sense of it in unique and interesting ways … And that’s why we stopped by for a visit this week. Last night, PeopleBrowsr officially launched Kred, a dynamic and innovative social influence measurement platform, to a LOT of fanfare (see: TechCrunch).
In the midst of the launch-day craziness, we grabbed Scott Milener, PeopleBrowsr SVP of business development, to have him explain a little about Kred, what differentiates it from the other social influence measurements and what it means for users interested in engaging more effectively with their social networks. Check it out:
With the clear success of the announcement, we want to send a shout out of congratulations to the PeopleBrowsr team. It looks like a phenomenal leap forward in understanding social engagement, and we know it’s only the tip of the iceberg when it comes to what we’ll see coming out of the PeopleBrowsr office in the near future.
If you feel a little jaded by the social influence measurements you’ve seen, Kred’s transparency and community-centricity should be refreshing: http://kred.ly
A Whole New World: SoftLayer on Windows Phone 7
As SLayers, our goal is always to bring creativity in every aspect of work we do at SoftLayer. It was not too long ago when the Interface Development team was presented with a new and exciting challenge: To develop a Windows Phone 7 Series app. Like me, many questioned whether we should tap into the market of Windows Phone OS … What was the scope of this OS? What is the future of Windows Phone OS smartphones? The business relationship that NOKIA and Microsoft signed to produce smartphones with Windows Phone 7 OS will provide consumers with a new interface and unique features, so smartphone users are paying attention … And we are too.
The SoftLayer Mobile world had already made huge strides with iPhone and Android based apps, so our work was cut out for us as we entered the Windows Phone 7 world. We put together a small, energetic and skilled group of SLayers who wanted to make SoftLayer proud, and I am proud to be a member of that team!
Our focus was to design and develop an application that would not only provide the portal functionality on mobile phone but also incorporate the awesome features of Windows Phone 7. Keeping all that in consideration, the choice of using an enterprise quality framework was essential. After a lot of research, we put our finger on the Microsoft’s Patterns and Practices-backed Prism Framework for Windows Phone 7. The Prism Framework is a well-known and recognized name among Silverlight and Windows Presentation Framework developers, and since Windows Phone 7 is built upon the Silverlight and XNA Framework, our choice was clearly justified.
After selecting the framework, we wanted to make the whole asynchronous experience smooth while talking to SoftLayer’s mobile API. That’ where we met the cool kid on the block: Reactive Extensions for .NET (also known as Rx). The Rx is a library used to compose asynchronous and event-based programs. The learning curve was pretty intense for the team, but we operate under the mantra of CBNO (Challenging-But-Not-Overwhelming), so it was learning we knew would bear fruits.
The team’s plan was to create an app that had the most frequently used features from the portal. The features to be showcased in the first release were to be basic but at the same time essential. The features we pinpointed were ticket management, hardware management, bandwidth and account management. Bringing these features to the phone posed a challenge, though … How do we add a little more spice to what cold be a rather plain and basic app?
Windows Phone 7 controls came to our rescue and we utilized the Pivot and Panorama controls to design the Ticket Lists and Ticket Details. The pivot control works like a tabbed-style control that is viewable by sliding left or right. This lets us put the ticket-based-categories in a single view so users don’t have to navigate back-and-forth to see different types of tickets. It also provides context-menu style navigation by holding onto the ticket item, giving an option to view or edit ticket with one tap. Here is a screen shot of pivot control in use to view tickets by categories and device list:
Another achievement was made by using the panorama control. The control works like a long page with different relevant sections of similar content. This control was used to show a snap shot of a ticket, and the view displays basic ticket details, updates, attachments and any hardware attached to a ticket. This makes editing a ticket as easy as a tap! This is a screenshot of panorama control in use to view ticket detail:
The device list view will help people see the dedicated and virtual devices in a pivot control giving a visual distinction. The list can be searched by tapping on the filter icon at the application bar. The filtering is search-as-you-type style and can be turned off by tapping the icon again. This screenshot shows the device list with a filtering option:
To perform further hardware operations like pinging, rebooting and power cycling the server, you can use the hardware detail view as well. The bandwidth view may not be as flashy, but it’s a very useful representation of a server’s bandwidth information. Charting is not available with this release but will be available in the upcoming releases.
If you own a Windows Phone 7 device, go ahead and download “SoftLayer Mobile” and send us the feedback on what features you would like to see next and most importantly whether you love this app or not. We have and will always strive for excellence, and we know there’s always room to improve!
-Imran
Learning the Language of Hosting
It’s been a little over a month since I started at SoftLayer … And what a difference a month makes. In the course of applying for the Social Media Coordinator position I now hold, I was asked to write a few sample blogs. One was supposed to be about what SoftLayer does, and I answered it to the best of my abilities at the time. Looking back on my answer, I must admit I had no idea what I was getting into.
On the plus side, comparing what I know now with what I thought I knew then shows how much a person with zero background in hosting can learn in a short period of time. To give you an idea of where I came from, let’s look at a few theoretical conversations:
Pre-SoftLayer
| Friend: | What does SoftLayer do? |
| Rachel: | They are a hosting provider. |
| Friend: | What is a hosting provider? |
| Rachel: | It’s sort of like an Internet landlord that rents data space to clients … I think. |
Present Day
| Friend: | What is it you do? |
| Rachel: | I’m the Social Media Coordinator for SoftLayer Technologies. |
| Friend: | What does SoftLayer do? |
| Rachel: | SoftLayer is a hosting provider, however that is a generalization. We have data centers around the country and are expanding worldwide. The company offers dedicated, cloud and hybrid environments that allow us to handle companies outsourced IT. We are infrastructure experts. |
That would be a little bit of a cookie cutter explanation, but it gives a lot more context to the business, and it would probably soar above the head of my non-technical inquisitive friend.
During my first week on the job, I visited one of SoftLayer’s data centers … And that “data center” term turned out to be a little tricky for me to remember. For some reason, I always wanted to call the data center a “database center.” It got to the point where Kevin challenged me to a piggy bank deal.
SoftLayer is raising money for the American Heart Association, and everyone has a little piggy bank at their desk. One of the piggy banks essentially became a “swear jar” … except not for swearing. Every time I said “database center,” I had to put a dollar in the piggy bank. The deal was extended when I was trying to remember that 1 byte (big B) = 8 bits (little b):
With money on the line, I’m happy to say that I haven’t confused “database centers” or bits and bytes again … And the piggy bank on the left-hand side of the picture above proves it!
Back to the DC (data center!) tour: I learned about how CRAC units are used to pull air underneath the floor and cool the “cold aisles” in the DC. I learned about the racks and how our network architecture provides private, public, and out–of–band management networks on the back end to customers in a way unique to SoftLayer. Most importantly, I learned the difference between managed, dedicated, cloud and hosting environments that incorporate all of those different kinds of hosting. This is a far cry from focusing on getting the terminology correct.
I’m still not an expert on all things SoftLayer, and I’m pretty sure I’ll end up with my very own acronym dictionary, but I must admit that I absorbed more information in the past month than I thought possible. I have to thank my ninja sensei, Kevin, for taking the time to answer my questions. It felt like school again … especially since there was a whiteboard in use!
Kevin, enjoy your empty piggy bank!
-Rachel
StillSecure: Technology Partner Spotlight
Welcome to the next installment in our blog series highlighting the companies in SoftLayer’s new Technology Partners Marketplace. These Partners have built their businesses on the SoftLayer Platform, and we’re excited for them to tell their stories. New Partners will be added to the Marketplace each month, so stay tuned for many more come.
- Paul Ford, SoftLayer VP of Community Development
Scroll down to read a guest blog from StillSecure CTO James Brown. Today, StillSecure is announcing the launch of Cloud Security Monitoring Service (SMS), a free Software-as-a-Service (SaaS) offering that provides security services, monitoring and reporting for cloud or physical servers via a lightweight agent and easy-to-use UI.
More Information
Company Website: http://www.stillsecure.com/
Tech Partner Marketplace: http://www.softlayer.com/marketplace/stillsecure
Don’t Expose Your Data with B.C.E. (Before Cloud Era) Security
Securing a cloud application is harder than securing a physically hosted app. Why? It’s elastic, it spreads your assets over the face of the planet, and you probably have some physical servers in the mix, too. Isn’t it amazing that so many security vendors simply add “cloud” to their product marketing and pass them off as though you can actually be successful with them? It’s as if adding “cloud” to the data sheet magically transforms an existing product into an offering that meets the needs of the cloud.
Fortunately, StillSecure‘s Cloud Security Monitoring System (Cloud SMS) helps address all those needs: it’s platform independent (built from the ground up for cloud, hybrid, and physical deployments), it tracks all security policy changes, and it provides summary- and detail-level visibility into your security configuration.
SoftLayer challenged us to create an offering that would support not only their cloud customers, but their hybrid and purely physical customers as well … And not only support them, but manage them seamlessly, with no arbitrary borders to harm usability. What we came up with fits that bill:
No cloud solution would be complete without being elastic: when you clone a VM, your security policy must go with it, and then that policy must continue to be applied to all like VMs when you make changes later. Cloud SMS does that. Got a one off? No problem, it handles that, too. Clone your one off? The clone tracks the one off.
Cloud SMS makes it easy to secure your servers, whether they’re in Dallas, Singapore or anywhere in between. With its executive level dashboard functionality, you can see the security state of all your servers, and understand usage over time. You can also slice and dice the data to understand usage patterns over any given time period.
Designed to be auditable, auditing functionality is part the genetic makeup of Cloud SMS. It tracks all configuration changes made by any user, on any server, and provides time-based reporting that can be handed directly to an auditor.
The StillSecure Cloud SMS SaaS offering provides detailed firewall control for your physical or cloud-based servers, deep auditing, dashboard via an extremely lightweight and easy to install agent. Don’t get left in the cold with B.C.E. (Before Cloud Era) offerings that can’t handle today’s cloud requirements.
- James Brown, StillSecure
The Challenges of Cloud Security Below 10,000 Feet
This guest blog was contributed by Wendy Nather, Research Director, Enterprise Security Practice at The 451 Group. Her post comes on the heels of the highly anticipated launch of StillSecure’s Cloud SMS, and it provides some great context for the importance of security in the cloud. For more information about Cloud SMS, visit http://www.stillsecure.com and follow the latest updates on StillSecure’s blog, The Security Samurai.
If you’re a large enterprise, you’re in pretty good shape for the cloud: you know what kind of security you want and need, you have security staff who can validate what you’re getting from the provider, and you can hold up your end of the deal – since it takes both customer and provider working together to build a complete security program. Most of the security providers out there are building for you, because that’s where the money is; and they’re eager to work on scaling up to meet the requirements for your big business. If you want custom security clauses in a contract, chances are, you’ll get them.
But at the other end of the scale there are the cloud customers I refer to as being “below the security poverty line.” These are the small shops (like your doctor’s medical practice) that may not have an IT staff at all. These small businesses tend to be very dependent on third party providers, and when it comes to security, they have no way to know what they need. Do they really need DLP, a web application firewall, single sign-on, log management, and all the premium security bells and whistles? Even if you gave them a free appliance or a dedicated firewall VM, they wouldn’t know what to do with it or have anyone to run it.
And when a small business has only a couple of servers in a decommissioned restroom*, the provider may be able to move them to their cloud, but it may not be able to scale a security solution down far enough to make it simple to run and cost-effective for either side. This is the great challenge today: to make cloud security both effective and affordable, both above and below 10,000 feet, no matter whether you’re flying a jumbo airliner or a Cessna.
-Wendy Nather, The 451 Group
*True story. I had to run some there.