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Petit Private Island
Canada is often described as a country of wilderness and vast open environs. For islomaniacs it is also a treasure trove of pristine private islands situated on fresh water lakes and adorned with quaint cottages. Advantageous foreign ownership laws combined with a stable democratic government makes Canada one of the best places in the world to purchase a private island.
Quebec, the francophone part of Canada is an often overlooked island region that has many unique properties available. One of the newest properties in Quebec to emerge on the international island market is Ile de la Baie Bertrand. This 4.1 acre island which is located on 31-Mile Lake is known for being the most desirable lake in the Gatineau and is just 90 minutes from Ottawa Airport.
Situated on the island is an immaculate four-bedroom main house (built in 2003) and fully-equipped two-bedroom guest house with sleeping loft (2004), both constructed with best quality materials and careful attention to detail, fit and finish. Other facilities include:
- Solar-powered from roof-top panels, with propane generator backup and state-of-the-art inverter and battery system in free-standing structures.
- Direct telephone line to the mainland and satellite internet connection with Wi-Fi.
- Propane stoves, ovens and water heaters.
- Both houses insulated for winter use.
- Separate septic system for each house, cleaned and serviced in 2009.
- Stone firepit and terraced herb and vegetable garden.
- Cedar tree house in the woods behind the guest house.
- Double main dock with adjacent boat house, and second dock in private bay.
- Boats and furnishings also available if desired.
For more information on this property visit Private Islands Online.
Maude Island Alaska
With the weather getting warmer in the Northern Hemisphere people’s attention is shifting from the tropical islands of the south to the cooler islands of the north. It comes as a surprise that arctic Alaska is actually one of the hottest island markets. It is also one of the best locations in the world to get great value for your investment.
Maude island is one of the gems currently on the market. Located in Sitka, Maude Island offers sweeping views of the ocean that can be viewed from the exclusive island home. When not exploring the one acre island launch off your private dock to enjoy a day of fishing, boating or just exploring the incredible scenery of Sitka.
For more information on this property visit Private Islands Online.
Musha Cay: Exotic Luxury
With advances in communication, transportation and other techologies exploring private islands has never been so accessible. However there are some private islands that will forever be out of reach for all except the most affluent of the planet’s citizens. One such island is Musha Cay.
Recentlty a journalist with Industry Leaders Magazine explored the 150 acres of luxury that makes up Musha Cay here is what they had to say.
Owned by illusionist David Copperfield, Musha Cay in the Bahamas, presents itself as a super regal, uber exclusive luxury private island that allows you to invite your guests to make the most of the island’s lush green surroundings, a state-of-the-art giant outdoor movie theatre and exquisitely designed customized accommodations in addition to the private beaches.
The price ? $37,500 per day for upto 12 persons for a 4-night minimum. Steep? Maybe, but most definitely worth the “lap-up-the-luxury” experience we say!
With a staff of thirty-plus to attend to your every need, guests at Musha Cay have the option to stay in the commanding 10,000 square foot manor house on the cliff, the thatched roof beach house away from sight, or one of the two guest villas that hosts two bedroom suites in each, all of which have access to their own private beaches.
To read the full article visit Industry Leaders Magazine.
Ambiguity
Some people have made the mistake of seeing Shunt’s work as a load of rubbish about railway timetables, but clever people like me, who talk loudly in restaurants, see this as a deliberate ambiguity, a plea for understanding in a mechanized world. The points are frozen, the beast is dead. What is the difference? What indeed is the point? The point is frozen, the beast is late out of Paddington. The point is taken. If La Fontaine’s elk would spurn Tom Jones the engine must be our head, the dining car our esophagus, the guard’s van our left lung, the cattle truck our shins, the first-class compartment the piece of skin at the nape of the neck and the level crossing an electric elk called Simon. The clarity is devastating. But where is the ambiguity? It’s over there in a box. Shunt is saying the 8:15 from Gillingham when in reality he means the 8:13 from Gillingham. The train is the same only the time is altered. Ecce homo, ergo elk. La Fontaine knew his sister and knew her bloody well. The point is taken, the beast is moulting, the fluff gets up your nose. The illusion is complete; it is reality, the reality is illusion and the ambiguity is the only truth. But is the truth, as Hitchcock observes, in the box? No there isn’t room, the ambiguity has put on weight. The point is taken, the elk is dead, the beast stops at Swindon, Chabrol stops at nothing, I’m having treatment and La Fontaine can get knotted.
— Art Critic
Ambiguity. Medicine, like art, is filled with ambiguity, at least the way I practice it. Most of my practice is in the hospital. I am sometimes called to see patients that other physicians cannot figure out. And that puts me at a disadvantage, because the doctors who were referring patients to me are all bright, excellent doctors. Often the question is ‘Why does the patient have a fever?’ or ‘Why is the patient ill?’ Sometimes I have an answer. Most of the time I do not.
I am happy, however, to be able to tell the patient what they don’t have. I can often inform the patient and their family that whatever they have is probably not life-threatening or life-damaging, just life-inconveniencing, and most acute illnesses go away with no diagnosis. I always put the ‘just’ in air quotes, because illnesses that require hospitalization are rarely ‘just.’ Just without quotes is reserved for the antivaccine crowd and applied to the small number of deaths from vaccine preventable diseases in unvaccinated children. John Donne they ain’t.
We are excellent, I tell them, at diagnosing life-threatening problems that we can treat, and terrible at diagnosing processes that are self-limited. Of course diagnostic testing is always variable. No test is 100% in making a diagnosis, and often with infections I cannot grow the organism that I suspect is causing the patient’s disease. So for hospitalized patients, ambiguity and uncertainty are the rule of the day.
However, the situation is much better than they used to be. I am now one of the oldest physicians practicing in my hospital. After 21 years most of the prior old guard has retired or died, leaving me. I have gone from being the young whippersnapper to the old geezer in what to me seems to be a blink of an eye.
However, the advantage to being old is you get to bore people with the stories of your gloried past. I remember a time, I tell the residents, before CAT scans, before third-generation cephalosporins, before PCR diagnostics. I remember the beginning of the AIDS epidemic, when we saw young men dying of an unknown illness. I still vividly remember my first AIDS patient, dying from disseminated MAI, who offered me a chocolate from his box of candy. I declined. I told him I wasn’t hungry. He told me “I would have to spit in your mouth to give you AIDS.” I did not know that at the time. No one did. Today I would eat the candy.
Times have changed, mostly for the better. AIDS has gone from an unknown disease with a short life expectancy to a mostly chronic manageable illness whose pathophysiology is understood in remarkable detail. Medicine advances. It is often an uncomfortably slow and aggravating process, because diagnostics and therapeutics that look promising at the beginning often turn out to not live up to their promise. Kind of like many people I have known.
Some therapeutic interventions have remained in limbo my entire practice. Steroids, as an example, have been tried for every illness except for Cushing’s disease. In almost every instance they have been found wanting. When I was an intern, every patient with a neurologic event was put on aspirin and Persantine. I don’t think Persantine is used much anymore. Common admission diagnoses were an aminophylline toxicity and digoxin toxicity; both drugs are rarely used today since we have less toxic and superior alternatives.
Certainly my practices changed dramatically over the last 21 years. I used to make a living from diseases that are rapidly becoming of historical interest. Ventilator-associated pneumonia, line-related sepsis, AIDS opportunistic infections, neutropenic fever’s, diabetic foot infections in smokers, all used to be common admitting diagnoses that resulted in infectious disease consultation. No longer.
Despite the wackaloon opinion that doctors are in it for the money, combined with big pharma greed, the last 21 years has seen a concerted effort on the part of the medical industrial complex to decrease the diseases we treat for living. This is not only true in infectious diseases, but cardiologists have been at the forefront of stop smoking and lipid control. The same is true of pulmonary doctors. Every physician fights the battles of obesity in the outpatient clinic. Much of the time physicians try to put themselves out of work. And in infectious diseases it seems to be successful. That is why at TAM 9 this year I plan on letting everyone buy me a beer. I’m sure the rest of the SBM crew would feel the same way. But no lite beers, puh-leaze.
Medicine does advance.
There is an infectious disease therapy that superficially resembles acupuncture and homeopathy: ribavirin. A drug with few proven benefits. Like most SCAMs, case reports, uncontrolled series and wishful thinking has kept ribavirin alive and around for my entire practice. I say superficially as most SCAMs now have a proven lack of benefit. Ribavirin is an antiviral medication that has probably been tried on virtually every virus, but has never been shown to have efficacy by itself in almost any infection. It is of benefit in RSV, and combined with interferon for the treatment of hepatitis C.
Ribavirin is a broadly active antiviral has rarely been tested in randomized controlled trials. Many of the infections that are allegedly treated with ribavirin are not common in the United States. So when a question of West Nile virus, dengue virus, Tick-borne Encephalitis Virus, Yellow Fever Virus, Lassa fever, Crimean-Congo hemorrhagic fever, or Hantavirus appears, the answer is ribavirin. But is the answer the correct?
This leads to an interesting editorial from several years ago in the journal Clinical Infectious Diseases entitled How Medicine Advances. How?
The editorial concerned an article on a study that looked at the efficacy of ribavirin in the treatment of Japanese encephalitis virus. Significant time, money and effort has been expended using ribavirin for diseases like Japanese encephalitis. But there have never been randomized clinical trials to demonstrate or deny the efficacy of ribavirin in the treatment of Japanese encephalitis. Until 2009 that is.
In CID that year they published a randomized placebo-controlled double-blind study that evaluated the effectiveness of ribavirin in the treatment of children who had Japanese encephalitis. And ribavirin was found to do nothing.
What was striking about this trial, as pointed out in the editorial, was that the study was done in the poorest part of India, it was done in children, and it was done with a definitive rigor that allowed the issue of ribavirin (always with the caveats of orally and at the dose given) to be put to rest for the treatment of this one infectious disease. A little more ambiguity in medicine has been removed.
I think the final paragraphs of the editorial sum up nicely why we do science-based medicine and the importance of doing clinical trials to determine what does and does not wor:
Kumar et al., whose study is published in this issue of Clinical Infectious Diseases, are to be commended for refusing to bow to any of the complexities reputed to make clinical trials impossible. In Uttar Pradesh, India’s most populous and poorest state, Kumar and colleagues sustained over 3 years the first randomized, placebo-controlled, doubled-blind trial of ribavirin for the treatment of the most vulnerable patients—children (age, 6 months to 15 years)—to be hospitalized with acute febrile encephalopathy, and they per- formed seroreactive testing for IgM anti-bodies to Japanese encephalitis virus. By so doing, they established that oral ribavirin, at the dosage used in their study, did not improve either early or late outcomes. By demanding scientific justification for investment in this mode of therapy, they have both encouraged searches for more-effective interventions and prevented the expenditure of scarce resources ineffectively.
Both faith and science are important components of the art of medicine. We ought not to mistake one for the other.
I wish, besides sarcasm punctuation marks, we had whiny little baby tags punctuation marks, since the lament of many a SCAM proponent is that their particular intervention can’t be tested because of “complexities reputed to make clinical trials impossible.” Riiiiggghhhhttttt, Mr. Powers. It is easier to curse the darkness than to light a candle.
There is then the more difficult application of applying the data. If someone has a long history of being committed to a treatment, it is surprisingly difficult to get individuals and groups to alter their behavior. I expect the urge to give ribavirin for Japanese encephalitis will rapidly fade. Not so the urge to balance qi, fix subluxations, or realign the energy flux. Wait. The last is either reiki or Galaxy Quest. The latter at least is recognized as fiction. Unfortunately, there are many other infections for which people will try ribavirin and for which there are no randomized placebo-controlled clinical trials. Ribavirin will continue to be a drug mostly searching for a disease.
But still medicine progresses. Studies get done, there is an incremental improvement in our understanding of the diagnosis or treatment of the disease. And slowly and painfully medicine changes. Emphasis on slowly. Change has to be balanced with the knowledge that much of the information we have in medicine is not final. When I talk about studies with residents, I try and be careful to mention the often endless caveats about the applicability of the results beyond the study population. Back in the day it seemed that all coronary artery disease studies were done in old, white male veterans. Probably widely applicable, but maybe not. But at least as an old white man, I can be taken care of.
There’s an old saying that goes something like ‘be neither the first to abandon the old nor be the first to use the new.’ I certainly feel that way about antibiotics. Over the years new drugs have been approved, released into widespread use, and then found to have serious side effects that resulted in their being withdrawn from the market. So I’m always a little leery about new medications and new treatments unless I do not have other options.
So I look back on 21 years of infectious diseases 25 years of being a physician and note the incredible changes that have occurred. Diagnostics that have improved, therapies that have improved, and more importantly diagnostics and therapies that have been abandoned. Abandoned because they were shown not to work. Medicine advances.
Contrast that with the bête noire of this blog: supplements, complementary and alternative medicine. Anybody who subscribes to reality-based medicine would say at this point that the preponderance of data strongly points to the conclusion that most SCAMs do not work. Acupuncture, homeopathy, energy medicines, etc. do not materially alter disease. Yet has any of these ever been abandoned? Nope.
It would seem that they are being embraced, at least in academic institutions. SCAMs are an archetype example of failing up. It has been noted that with SCAMs that better and better studies show less and less effect until well-designed studies show no effect. For the last decade it would seem the greater the failure, the greater the spread into academia and the more popular the SCAM. By the same standards we should be using internal mammary artery ligation for coronary artery disease, high dose chemotherapy with bone marrow transplant for breast cancer, and continue to suppress all abnormal cardiac rhythms in heart attack patients. All the interventions failed spectacularly, and so should be embraced, each with their endowed Chairs.
SCAMs probably are growing for the financial benefit. Since standard medicine has declining reimbursement and most alternative therapies are out-of-pocket, it’s a good cash cow for institutions that want a flow of money and are not picky about their intellectual standards. Not only are the standard SCAMs proliferating, they often combine in most peculiar ways to come up with new variations. Doctor Moreau would be impressed with the slow mutant reassortments: acupuncture (at least 6 kinds) morphing into acupressure, laser acupuncture, acupuncture with tuning forks and color, and soon there will be dark energy acupuncture. You heard it here first. Don’t get me wrong, I am jealous. I would love to combine ID with cardiac bypass surgery and make some real cash, but they just don’t mix. Sigh.
It is said that the majority of medical practice has no basis in science-based medicine. Certainly in the practice of infectious diseases in the hospital, that is often the case. I will see an organism in a odd place, for example a Gemella endocarditis, and there are no long-term randomized placebo-controlled clinical trials to determine what the best therapy is for the treatment of a Gemella endocarditis. There probably never will be. It is so rare that it is probably impossible to generate enough cases to do a clinical trial. I am stuck with the basic principles of biologic plausibility and in vitro antibiotic susceptibilities and that is often enough. I know that if I can kill the bug in the test tube, I can often kill it in the patient as well. In the absence of clinical trials, reality can reliably determine effective therapy.
It is quite a stark contrast between SCAMs and of medicine and how they are practiced. Medicine changes. Or perhaps it would be better to say medicine evolves. The old is be shown to be worthless. It is abandoned, and patient care overall improves. Even when there are no good clinical trials to guide therapies, often we have prior plausibility and biologic plausibility to help guide our therapies. Not always, as ribavirin demonstrates, but we have to fight the war with the armies we have. Advances have not been without their side effects and bad consequences, as no good deed ever goes unpunished, but medicine still adheres to the Victorian principle that human societies are perfectible. And while we always fall short of our goal, what has accomplished has been admirable.
SCAMs persist with no improvement, no evolution, and are increasingly discredited by reality. Nothing is ever abandoned, instead persisting, mutating and growing. With alternative memes, what determines replicative fitness is not, apparently, the real world. Oh well, it gives me something to write about.
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Anti-vaccine warriors vs. research ethics
Three weeks ago, the anti-vaccine movement took a swing for the fences and, as usual, made a mighty whiff that produced a breeze easily felt in the bleachers. In brief, a crew of anti-vaccine lawyers headed by Mary Holland, co-author of Vaccine Epidemic: How Corporate Greed, Biased Science, and Coercive Government Threaten Our Human Rights, Our Health, and Our Children, published a highly touted (by Generation Rescue and other anti-vaccine groups, that is) “study” claiming to “prove” that the Vaccine Injury Compensation Program (VICP) had actually compensated children for autism. As is typical with such “studies” generated by the anti-vaccine movement, it was bad science, bad law, and just plain bad all around. The authors intentionally conflated “autism-like” symptoms with autism, trying to claim that children with neurological injury with “autism-like” symptoms actually have autism. Never mind that there are specific diagnostic criteria for autism and that, if the children actually had autism, many of them would have been given a diagnosis of autism. Never mind that what they were doing was akin to claiming that all patients with “Parkinson’s-like symptoms” have Parkinson’s disease. (Hint: They don’t.) Never mind that all they did was to demonstrate a prevalence of autism spectrum disorders among the VICP-compensated children that was clearly within the range of what would be anticipated if there were no relationship between vaccines and autism. Never mind all that. This was Holland’s big chance, but it went over like the proverbial lead balloon. No one bit, other than FOX News.
The study rapidly faded into the obscurity it so richly deserves, in spite of mighty efforts by Generation Rescue, SafeMinds, and the likes of Ginger Taylor to keep it alive and use it as a rallying point to persuade legislators to pass anti-vaccine-friendly legislation. You could feel the frustration in its backers as Holland’s study, into which groups like Generation Rescue had apparently poured their hopes of being vindicated, crashed and burned.
However, there’s one aspect of this study that I didn’t discuss. In fact, I thought of it as I read it, but I wasn’t sure. What I (and others) have noticed is that there was no statement in the article that approval had been obtained from the relevant institutional review boards (IRBs) to do human subjects research. For those not familiar with what an IRB is, an IRB is a committee that oversees all human subject research for an institution. It is the IRB’s responsibility to make sure that all studies are ethical in design and that they conform to all federal regulations. Basically, IRBs are charged with weighing the risks and benefits of proposed human subject research and making sure that
- risks are minimized and that the risk:benefit ratio, at least as well as it can be estimated, is very favorable;
- to minimize any pain, suffering or distress that might come about because of the experimental therapy; and
- to make sure that researchers obtain truly informed consent.
During the course of a study, regular reports must be made to the IRB, which can shut down any study in its institution if it has concerns about patient welfare.
Of course, I know this all because I happen to be involved in human subjects research. It’s part of what I do while doing research in breast cancer. Clinical trials are obviously human subjects research. After all, their very purpose is to test a new drug or treatment on human subjects in order to determine if it works. However, human subjects research encompasses a lot more than just clinical trials; in fact, it encompasses almost any research study that involves either human subjects or human subjects’ protected health information (i.e., medical charts). Basically, any human subject experimentation requires approval by a properly constituted IRB. There is no documentation in Holland et al that IRB approval had been obtained, either from the for NYU (given that Mary Holland is a research scholar at the NYU School of Law) and/or Pace University, given that Pace Law School is cited as having “provided significant research support for this study” in the footnotes of the paper:
Mary Holland, Research Scholar and Director of the Graduate Legal Skills Program, NYU School of Law; Louis Conte, independent investigator; and Robert Krakow and Lisa Colin, attorneys in private practice. Pace Law School provided significant research support for this study.
Autism News Beat and Sullivan are already all over this issue, but I thought I’d throw in a bit from my perspective, given that I actually have to work with IRBs and, before my career is over, will probably be roped into serving on an IRB. In any case, as is true of any researcher who is involved in human subjects research, I had to undergo specific training regarding the “rules of the road,” so to speak, as a requirement of being an investigator on any study involving human subjects research.
How is human subjects research defined? According to 32 CFR 219.102(d), research means “a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge,” and according to 32 CFR 219.102(f) a human subject is defined as ” living individual about whom an investigator (whether professional or student) conducting research obtains data through intervention or interaction with the individual, or identifiable private information.”
Under these criteria, I believe that the Pace study clearly qualifies as human subjects research. First of all, as poorly designed as the study was, it was clearly intended as a systematic investigation designed to contribute to generalizable knowledge and testing a hypothesis, namely that autism is associated with vaccine-induced brain injury. The authors claim to have found data in the VICP-compensated cases indicating that there is a higher incidence of autism in these children. Never mind that they found nothing of the sort, they set out to test that hypothesis and their methods were designed to support it. Moreover, as Autism News Beat pointed out, members of the Elizabeth Birt Center for Autism and Legal Advocacy (EBCALA) administered the Social Communication Questionnaire (SCQ) to the parents or caregivers of 22 children. This clearly makes the parents who answered the questionnaire (and their children) human subjects, as identifiable protected health information about the children is being solicited and used to test their hypothesis.
To be fair, I have to point out that there are types of studies that are exempt from full IRB approval. In fact, there are six categories of so-called “exempt” studies. I frequently use category four, which involves the use of already existing clinical information that has been de-identified. I also note that this particular exemption involves research that does not involve interacting with living humans about their health information; rather, these sorts of studies tend to involve chart reviews or the examination of human tissue specimens that have already been collected. Be that as it may, there is one potential exemption that EBCALA might claim. First, number two:
Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures or observation of public behavior, unless:
- information obtained is recorded in such a manner that human subjects can be identified, directly or through identifiers linked to the subjects; and
- any disclosure of the human subjects responses outside the research could reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects financial standing, employability, or reputation.
Unfortunately for Holland et al, the first “unless” probably kills this exemption. The information they obtained was obtained in a manner such that the human subjects can be identified. The second “unless” might or might not kill the exemption; I note that both criteria are used to decide whether an exemption is not permissible. However, even if this research could potentially be considered exempt – and I highly doubt that a reputable IRB operating within the law and the Common Rule would find it exempt, particularly since IRBs are charged with taking special care to protect human subjects considered to be vulnerable, such as children, and that the survey is in fact a screening/diagnostic tool, making the results protected health information – it should also be noted it is not the investigators who get to decide whether a protocol is exempt or not and therefore whether a protocol requires IRB evaluation and approval. Period. Investigators do not have the power to determine whether their research falls under one of these exempt categories; only the IRB can make that determination, usually in an expedited review that determines whether a potentially exempt protocol meets the standards of one of the categories that are exempt from full IRB approval. It’s right there in the rules:
Only the IRB may determine which activities qualify for an exempt review. Investigators do not have the authority to make an independent determination that research involving human subjects is exempt and must contact the IRB concerning the status of proposed research or changes in ongoing research.
Also note that the research cannot begin until after IRB approval is obtained.
Personally, unlike the case with the Geiers, my guess is that as lawyers Holland et al were simply ignorant that what they were doing constituted human subjects research and that’s why they didn’t bother with a little thing (to them) like obtaining IRB approval before doing their study. Indeed, when Autism News Beat inquired at Pace Law School about whether the EBCALA study had IRB approval, this is what he was told:
When asked if the Pace study had IRB approval, Pace Law spokesperson Lauren Rubenstein referred the question to the study’s co-author, Louis Conte. In an email, Rubenstein wrote “Louis Conte has told me that there was no human subjects research in this study.”
Which reveals Conte’s utter cluelessness about human subjects research. Investigators interacted with the parents of these children, administering a questionnaire to them for purposes of looking for data to support their hypothesis. It’s human subjects research until judged otherwise–by an IRB, not by Conte, Holland, or any of the other of the merry band of anti-vaccine lawyers who put this travesty of a study together. Not surprisingly, attempts to get Conte to respond to e-mails regarding IRB approval of the study were not returned.
Of course, ignorance of the law is no excuse; as lawyers the authors of Holland et al should know. I also find it rather hard to believe, whether or not they were ignorant of federal law and regulations regarding human subjects research, that at some point either Holland and her coauthors weren’t made aware somehow by someone that what they were doing constituted human subjects research under federal law. Surely someone must have realized this, given that questionnaires about protected health information were being administered to living human beings. If they did not, then, quite frankly, I find the level of incompetence and lack of concern about basic ethical standards that every investigator in the U.S. who engages in human subjects research knows as basic information because they are required to know them and abide by them as part of ethics and the law.
This lack of concern about such niceties of the ethical treatment of human subjects is nothing new in anti-vaccine studies. Andrew Wakefield demonstrated it with his callous treatment of children at a party, whom he basically bribed for blood samples and whose fear he made light of. The Geiers père et fils demonstrated it when they created an IRB to oversee their own research, sat on that IRB themselves with Dr. Geier himself chairing the committee (a massive conflict of interest), and packed it with their anti-vaccine cronies.
There’s one more “out” that Holland et al might try for, and that’s to say that their research was not federally funded and is therefore not covered by the Common Rule. However, most universities that accept federal funding for research agree to be bound by the Common Rule for all research carried out by their faculty, students, and trainees. Even if Holland et al tried to justify their failure to obtain IRB approval this way and argue that they are not legally bound to follow the Common Rule, their failure to obtain IRB approval for their study and submit to IRB oversight is a massive ethical failing. I characterized Holland et al as evidence that that when the anti-vaccine movement can’t win on science, it will appeal to the law. It also appears that when it can’t win on ethics, it will appeal to the law as well.
While Holland et al tout “unanswered” questions about autism and the VICP, the only question I have is: Will Pace University and NYU will investigate how such a study could be performed without its investigators obtaining the requisite IRB approval? Or will they sweep this massive ethical (and possibly legal) breach under the rug and hope it goes away?
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Pragmatic Studies – More Bait and Switch
The course of research into so-called alternative medicine (CAM) over the last 20 years has largely followed the same pattern. There was little research into many of the popular CAM modalities, but proponents supported them anyway. We don’t need science, they argued, because we have anecdotes, history, and intuition.
When media attention, which drove public attention, was increasingly paid to CAM then serious scientific research increased. A specific manifestation of this was the National Center for Complementary and Alternative Medicine (NCCAM). CAM proponents then argued that their modalities were legitimate because they were being studied (as if that’s enough). Just you wait until all the positive evidence comes rolling in showing how right we were all along.
But then the evidence started coming in negative. A review of the research funded by NCCAM, for example, found that 10 years and 2.5 billion dollars of research had found no proof for any CAM modality. They must be doing something wrong, Senator Harkin (the NCCAM’s major backer) complained. They engaged in a bit of the kettle defense – they argue that the evidence is positive (by cherry picking, usually preliminary evidence), but when it is pointed out to them that evidence is actually negative they argue that the studies were not done fairly. But then when they are allowed to have studies done their way, but still well-controlled, and they are still negative, they argue that “Western science cannot test my CAM modalities.”
But at the same time, they cannot shake the need for scientific evidence to continue to push their modalities into the mainstream. The “your science can’t test my woo” defense only goes so far. So they have put themselves into a pickle – they demanded funding for CAM research, but now have to deal with the fact that the research is largely negative. CAM proponents are mostly not interested in finding what really works, and abandoning what does not work (I have an open challenge to anyone who can point to a CAM modality that was largely abandoned, rejected, or condemned by CAM proponents because of evidence of lack of efficacy). They are interested in using science to support and promote what they already believe works (a cardinal feature of pseudoscience).
And so they have entered the next phase of CAM research – the post-RCT (randomized controlled trial) phase. They have discovered the “pragmatic” study. You have to give it to them for their cleverness. A pragmatic study is meant to be a comparison of treatment options in real-world conditions. It studies treatments that already have proven efficacy from RCTs to see how they work, and how they compare, when applied in the less controlled environment of real-world practice. Pragmatic studies are useful for addressing the weaknesses of RCTs, mainly their somewhat contrived conditions (having strict inclusion criteria, for example).
But pragmatic studies are not efficacy trials themselves. They cannot be used to determine if a treatment works, because they do not control for variables and they are not blinded, so they are susceptible to placebo and non-specific effects. It is an abuse of the pragmatic study design to test a treatment that is not proven or to make efficacy claims based upon them. That has not stopped CAM proponents from doing just that.
In the news recently is just the latest example. Let me tell you the results of the study before I tell you what the study is of – just look at the data (I replaced the name of the treatment in the tables with just the word “treatment”):
This is what you need to know about the trial. There were two groups, treatment and control. Subjects were those with frequent doctor visits for symptoms that have not been diagnosed. While they were randomized, they were completely unblinded – everyone involved with the subjects knew who was getting treated and who wasn’t. At 26 weeks the control group was crossed over to receive treatment – so the difference up to 26 weeks is most important.
On two of the measures, quality of life and general practitioner consultation rates, there was no difference. In the other two measures there was a slight improvement in the treatment group, barely statistically significant. If this were an efficacy trial, this data would be unconvincing. What can fairly be concluded from this trial is that the treatment has no to minimal effect, and the tiny and inconsistent effect seen cannot be separated from placebo or non-specific effects. Further, it shows how anemic even placebo effects are for this treatment in this patient population. As a pragmatic trial, it’s essentially negative. As an efficacy trial, it’s worthless.
The study author’s, however, concluded that their treatment was effective and recommended it be incorporated into general practice.
The treatment in question is five-element acupuncture – acupuncture designed to balance the five elements of fire, water, metal, earth, and wood. This is the equivalent of balancing the four humors – in other words, it is pre-scientific superstitious nonsense. The study authors are all proponents. What is most amazing is how they got their paper, complete with unsupported conclusions, past peer-review.
The study authors are using the “part of this nutritious breakfast” con. Even as a child I understood that the sugary cereal, or whatever the commercial was trying to sell to me, was only “part of this nutritious breakfast” because the rest of the breakfast was nutritious all by itself. A doughnut would be “part of this nutritious breakfast.” So the authors of this study include five-point acupuncture with an hour of kind attention from a practitioner along with lifestyle advice and encouragement. They admit that they cannot separate out the variables here. Then they conclude that acupuncture is “part of this healthy regimen.” There is every reason to believe that it is an irrelevant part – as irrelevant as the doughnut is to the nutrition of a complete breakfast.
Conclusion
The pragmatic study bait and switch is here – it is now a firm part of the CAM strategy for promoting implausible therapies that don’t work. Editors and peer-reviewers need to be more aware of this scam so they don’t fall for it and inadvertently promote it, as they did in this case. Further, the results of this trial are not impressive even at face value – it’s basically negative, so it’s a double swindle.
All of this has not stopped the headlines from declaring that “acupuncture works” – which appears to be the only goal of such research.
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The Believing Brain
A common question of skeptics and science-based thinkers is “How could anyone believe that?” People do believe some really weird things and even some obviously false things. The more basic question is how we form all our beliefs, whether false or true.
Michael Shermer’s book Why People Believe Weird Things has become a classic. Now he has a new book out: The Believing Brain: From Ghosts and Gods to Politics and Conspiracies: How We Construct Beliefs and Reinforce Them as Truths It synthesizes 30 years of research into the question of how and why we believe what we do in all aspects of our lives.
Some of the content is repetitious for those of us who have read Shermer’s previous books and heard him speak, but the value of the new book is that it incorporates new research and it puts everything together in a handy package with a new focus.
Shermer says
I’m a skeptic not because I do not want to believe, but because I want to know. How can we tell the difference between what we would like to be true and what is actually true? The answer is science.
He includes a pithy quotation from Richard Feynman that I had not seen before:
If it disagrees with experiment, it is wrong. In that simple statement is the key to science. It doesn’t make any difference how beautiful your guess is, how smart you are, who made the guess, or what his name is. If it disagrees with experiment, it’s wrong. That’s all there is to it.
Our schools tend to teach what science knows rather than how science works. The scientific method is a teachable concept. But
our most deeply held beliefs are immune to attack by direct educational tools, especially for those who are not ready to hear contradictory evidence.
This is a problem. Shermer does not offer a solution.
The brain is a belief engine. It relies on two processes: patternicity and agenticity. It finds meaningful patterns in both meaningful and meaningless data. It infuses patterns with meaning, and imagines intention and agency in inanimate objects and chance occurrences. We believe before we reason. Once beliefs are formed, we seek out confirmatory arguments and evidence to justify them. We ignore contrary evidence or make up rationalizations to explain it away. We do not like to admit we are wrong. We seldom change our minds.
Our thinking is what Morgan Levy has called “intelligently illogical.” If our ancestors assumed that the wind rustling the bushes was a lion and they ran away, that wasn’t a big problem. If there really was a lion and they didn’t run away, they were in trouble. Natural selection favors strategies that make many false causal assumptions in order to not miss the true ones that are essential to survival. Superstition and magical thinking are natural processes of a learning brain. People believe weird things because of our evolved need to believe nonweird things.
Belief comes quickly and naturally, skepticism is slow and unnatural, and most people have a low tolerance for ambiguity.
We rely on a feeling of conviction, but that feeling can be uncoupled from good reasons and good evidence. Science hopes to counteract false beliefs by recoupling through counterarguments with even better reasons and evidence.
As science advances, the things we once thought of as supernatural acquire natural explanations. Thunderstorms are caused by natural processes of electricity in clouds, not by a god throwing thunderbolts.
Belief in God is hardwired into our brains through patternicity and agenticity. We see patterns even when they are not there (the Virgin Mary on a toasted cheese sandwich), and we interpret events as having been deliberately caused by a conscious agent (the AIDS virus was created in a government lab for genocidal purposes). God is the ultimate pattern and agent that explains everything. And religious belief had survival value for human groups, encouraging conformity, group cooperation, and altruism.
Shermer covers a variety of subjects, from alien abductions to cosmology, from economics to politics, from belief in the afterlife to evolution, from ESP to morality, with a lot of entertaining examples. He doesn’t give much space to medical topics but he does mention AIDS denial, the vaccine/autism brouhaha, and alternative medicine, which he calls “a form of pseudoscience.”
Conspiracy theories abound, from Holocaust denial to 9/11 Truthers to the spread of AIDS. This is a result of wide-open pattern detection filters and to the assumption that there must be a conscious agent behind everything. Shermer provides a handy list of 10 characteristics of a conspiracy theory that indicate that it is likely to be false; for instance, the more people who would have to have been involved in a cover-up, and the longer the alleged cover-up has lasted, the less likely that no one would have spilled the beans by now.
He provides a useful discussion of the various biases we are prone to, from confirmation bias to the status quo bias, and points out that science is the ultimate bias-detection machine. He revisits the “Gorillas in our midst” video to remind us that we don’t see things that we’re not looking for. (In case you don’t know, that was an experiment demonstrating inattentional blindness: a gorilla walks through a group of people playing basketball and we don’t see him because our attention is fixed on counting the number of times the players in white shirts passed the ball.) He quotes Upton Sinclair:
It is difficult to get a man to understand something when his job depends on not understanding it.
When I read that, Dana Ullman came to mind.
I particularly got a kick out of one of Shermer’s examples. Galileo used an early telescope to observe 4 moons around Jupiter. One colleague of Galileo’s refused to even look through the telescope, calling it a parlor trick, saying he didn’t believe anyone else would see what Galileo saw, and saying that looking through glasses would only make him dizzy. Other colleagues who did look were similarly dismissive; one tested the telescope in a series of experiments and said it worked fine for terrestrial viewing, but when pointed at the sky it somehow deceived the viewer. One professor of mathematics accused Galileo of putting the moons of Jupiter inside the tube.
We are beginning to develop a new understanding of how the brain generates beliefs and reinforces them. Mr. Spock is science fiction; humans are often illogical and emotional. We need emotion to motivate us and help us function. An emotional leap of faith beyond reason is often required for us to make decisions or just to get through the day.
This thought-provoking book is a good read and a good reference. Takeaway lessons:
- Beliefs come first, reasons follow.
- False beliefs arise from the same thought processes that our brains evolved to enable them to learn about the world.
- Our faulty thinking mechanisms can’t be eliminated but our errors can be corrected by science.
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Measles outbreaks, 2011
We frequently write about the consequences and costs of not vaccinating and how the anti-vaccine movement is causing real harm to real people through its assaults on public health. For example, through his fear mongering in the U.K., Andrew Wakefield, aided and abetted by a credulous and sensationalistic British media, managed to reverse decades of progress that had resulted in measles having come under control; as a result of plummeting vaccination rates in the wake of his 1998 Lancet case series, measles came roaring back in the U.K. Now it appears to be roaring back in Europe as well.
It’s bitterly ironic that news of measles outbreaks in the U.S. and Europe have come to the fore even as, over the long Memorial Day weekend, promoters of the scientifically discredited notion that vaccines cause autism gathered in a suburb of Chicago to sell “biomedical” treatments for autism and promote an anti-vaccine world view as part and parcel of the yearly autism quackfest known as Autism One. Adding to the grim irony is that last Thursday Nature published an issue with a special section devoted specifically to vaccines. The timing seemed just too deliciously appropriate to ignore. Think of it. In the Chicago area, there was a collection of anti-vaccine crackpots meeting to present fallacious “science” claiming that vaccines cause autism and all manner of chronic health problems. In contrast, one of the oldest and most distinguished scientific journals in existence publishes several articles in a single issue about vaccines. The karma was even stronger, given that the week before the CDC published a new Morbidity and Mortality Weekly Report (MMWR) last week discussing the status of measles in the U.S.
The Nature vaccine issue has a number of articles on the topic of vaccines, ranging from an editorial, to news items, to scientific articles. For my purposes, three articles caught my attention:
The article discussing the case of measles is particularly relevant today, as we are in the middle of a resurgence of measles cases, both here in the U.S. and a much worse outbreak in Europe. In the U.S. we have had thus far this year 118 cases of confirmed measles, the most cases since 1996. Of these cases, 47 resulted in hospitalization and 9 in pneumonia. Fortunately, none had encephalitis, and none died, but that’s only because the risk of encephalitis is between 1:1,000 and 1:5,000. In an outbreak of 118, there’s only around a 10% chance (at the most) of having a case of measles encephalitis among the children. However, the more children there are who are infected, the greater the chance of complications such as encephalitis, and let’s not forget that we already have an 8% pneumonia rate.
Fortunately, MMR vaccine uptake in the U.S. remains generally high, although there are increasingly pockets of low uptake susceptible to outbreaks. Indeed, that’s what appears to be happening. As reported in Nature and the MMWR report cited above, measles was in essence eliminated from the U.S. in 2000. This was not easy to do; measles is one of the most contagious viruses that exist. Indeed, it’s the contagiousness of the measles virus that has allowed it to find its way back into the U.S. from other countries, as described in the MMWR report:
Among the 118 cases, 105 (89%) were import-associated, of which 46 (44%) were importations from at least 15 countries (Table), 49 (47%) were import-linked, and 10 (10%) were imported virus cases. The source of 13 cases not import-associated could not be determined. Among the 46 imported cases, most were among persons who acquired the disease in the WHO European Region (20) or South-East Asia Region (20), and 34 (74%) occurred in U.S. residents traveling abroad.
More worrisome, of the 47 hospitalized patients, all but one were unvaccinated, and the statistics were:
Unvaccinated persons accounted for 105 (89%) of the 118 cases. Among the 45 U.S. residents aged 12 months?19 years who acquired measles, 39 (87%) were unvaccinated, including 24 whose parents claimed a religious or personal exemption and eight who missed opportunities for vaccination. Among the 42 U.S. residents aged ?20 years who acquired measles, 35 (83%) were unvaccinated, including six who declined vaccination because of philosophical objections to vaccination. Of the 33 U.S. residents who were vaccine-eligible and had traveled abroad, 30 were unvaccinated and one had received only 1 of the 2 recommended doses.
Do you see the pattern here?
Leaving a child unvaccinated leaves that child at a greatly increased susceptibility to measles and therefore a highly elevated risk of catching the virus when exposed. This is particularly true when enough people refuse vaccines to compromise herd immunity, so that the unvaccinated can no longer rely on the herd, which they’ve gotten away with doing in the past. Nowhere is this more evident than in Europe, where more than 6,500 cases were reported in 2010, and we have Andrew Wakefield to thank for decreased vaccination rates that are only now starting to recover, as this story in–of all places–The Huffington Post describes:
To prevent measles outbreaks, officials need to vaccinate about 90 percent of the population. But vaccination rates across Europe have been patchy in recent years and have never fully recovered from a discredited 1998 British study linking the vaccine for measles, mumps and rubella to autism. Parents abandoned the vaccine in droves and vaccination rates for parts of the U.K. dropped to about 50 percent.
The disease has become so widespread in Europe in recent years that travelers have occasionally exported the disease to the U.S. and Africa.
Although overall vaccine uptake rates are high, thanks to Andrew Wakefield, there are pockets of children whose parents fear the vaccine more than measles and have therefore not vaccinated. These pockets have been enough to allow measles not just to come roaring back in Europe, but to allow Europe to export its measles to the U.S.
Perhaps the most interesting perspective this week on the issue of vaccine rejectionism is the second article I cited above, Vaccines: The real issues in vaccine safety by Roberta Kwok, who notes in the beginning of her article that “hysteria about false vaccine risks often overshadows the challenges of detecting the real ones.” She begins by citing the case of John Salamone. We’ve met him before in the context of my review of Paul Offit’s most recent book, Deadly Choices: How the Anti-vaccine Movement Threatens Us All. Salamone’s son is an example of a real adverse reaction to a vaccine. Basically, his son got polio from the live oral polio vaccine, a known complication. His son got that vaccine, even though an inactivated polio virus vaccine known to be safer was available at the time, because the oral polio vaccine was cheaper and more easily administered. As a result, Salamone became a real vaccine safety activist, in contrast to the anti-vaccine activists at Generation Rescue masquerading as “vaccine safety” activists. He and other parents worked together to effect change, and the U.S. shifted to the safer vaccine in the late 1990s.
Kwok’s overall point is that these fake vaccine safety scares, such as the widespread belief that vaccines cause autism, have made it more difficult to identify real vaccine safety issues:
Vaccines face a tougher safety standard than most pharmaceutical products because they are given to healthy people, often children. What they stave off is unseen, and many of the diseases are now rare, with their effects forgotten. So only the risks of vaccines, low as they may be, loom in the public imagination. A backlash against vaccination, spurred by the likes of Andrew Wakefield — a UK surgeon who was struck off the medical register after making unfounded claims about the safety of the measles, mumps and rubella (MMR) vaccine — and a litany of celebrities and activists, has sometimes overshadowed scientific work to uncover real vaccine side effects. Many false links have been dispelled, including theories that the MMR vaccine and the vaccine preservative thimerosal cause autism. But vaccines do carry risks, ranging from rashes or tenderness at the site of injection to fever-associated seizures called febrile convulsions and dangerous infections in those with compromised immune systems.
Serious problems are rare, so it is hard to prove that a vaccine causes them. Studies to confirm or debunk vaccine-associated risks can take a long time and, in the meantime, public-health officials must make difficult decisions on what to do and how to communicate with the public.
It’s true, too. So much time and effort of legitimate researchers, not to mention scarce research funds, have been wasted demonstrating again and again that there is no detectable link between vaccines and autism suggestive of a causative relationship. None of it is enough to convince the believers. Whenever yet another in a long line of studies is published that fail to find any detectable link between vaccines and autism or vaccines and other chronic conditions or diseases, the anti-vaccine believers brush it away and demand “more research.” Either that, or they demonize the researchers and those who point to those studies as being “pharma shills” or somehow possessing of nefarious motives of some sort or another. And so it goes.
The article then goes on to describe how public health officials have become increasingly vigilant about vaccine side effects, setting up intensive surveillance systems, most recently and famously for the 2009 H1N1 pandemic. Specifically, scientists were looking above all for evidence of a link between the H1N1 vaccine and Guillain-Barré syndrome, based on studies that suggested a link between the 1976 swine flu vaccine and this debilitating neurological syndrome. Studies thus far have not shown a link between the latest H1N1 vaccine and Guillain-Barré, which is good, but vigilance continues, not just for H1N1 vaccines but for every vaccine. The result of this surveillance has been to find a link between a rotavirus vaccine and intestinal intussusception, as well as a link between the measles, mumps, rubella and varicella (MMRV) vaccine and febrile convulsions. As a result, the MMRV was no longer recommended as a preferred choice.
Unfortunately, links are often not clear, and during the period of uncertainty between the first report of a possible vaccine complication and studies that either confirm or refute the link, public health officials are forced to make decisions on incomplete evidence. One current example is the possible link between the H1N1 vaccine Pandemrix and narcolepsy in young people. It is not yet clear whether this association is spurious or likely to indicate causation. Another aspect of this issue is whether there are genetic susceptibilities to adverse reactions due to vaccines. Contrary to what the anti-vaccine movement claims, scientists have never denied that there might be genetic factors resulting in increased susceptibility to vaccine injury. However, in science actual evidence is required, rather than speculation, and what we have now on this issue is, for the most part, speculation. It’s also not at all a straightforward issue to determine genetic determinants of increased risk for adverse reactions. Just as finding a genetic cause of autism has been difficult and full of dead ends, despite clear evidence of a strong heritable component, finding evidence of a genetic predisposition to vaccine injury is anything but a trivial task. Moreover, even in children who might have such a hypothetical predisoposition to vaccine injury, when the risk-benefit calculation is done it may well end up that the benefits of vaccines still outweigh the risks. Such would seem to be the case for children with mitochondrial disorders.
So how do we convince parents that the fear mongering by the anti-vaccine movement about vaccines and autism (or vaccines and all the other the movement tries to link with them, for that matter) is without basis in evidence and science and that it is safe to vaccinate? I agree with Julie Leask is at the National Centre for Immunisation Research and Surveillance, Discipline of Paediatrics and Child Health, School of Public Health, University of Sydney, New South Wales 2006, Australia, who wrote the last article that caught my interest, Target the fence-sitters. This is the way to go; the hard core anti-vaccine believers are not going to change their minds, no matter how much evidence you throw at them. We’ve seen this time and time again right here on this very blog, right here in the comments, stretching back over six years.
That’s why it’s a waste of time and effort to try to change the mind of the likes of J.B. Handley, Jenny McCarthy, Barbara Loe Fisher, Ginger Taylor, and others. There was a time when I thought that I could, but six and a half years of beating my head against the wall has taught me that I’m about as likely to succeed in changing their minds as I am to convince the Pope to become an atheist. It’s just not going to happen. What does happen is that I (and others) are attacked for our efforts. The bottom line is that I no longer care about changing, for example, J.B. Handley’s mind; I only care about countering his influence whenever possible. The fence-sitters can still be reached. They haven’t (yet) fallen down the rabbit hole of pseudoscience, autism “biomed,” and conspiracy mongering. There’s still hope to reach them, and reach them I try to do, using a variety of techniques ranging from pure sarcasm and full frontal assault to humor to dispassionate discussions of scientific papers. What works the best? I really don’t know, because I have no way of measuring. I do, however, keep trying. So do several other members of the SBM blog, who all have different styles, different levels of—shall we say?—aggressiveness in attacking pseudoscientific and unscientific claims about vaccines.
In the meantime, as the MMWR report on the 2011 measles outbreak in the U.S. and the articles in Nature demonstrate, the anti-vaccine movement is doing real damage as it reverses hard-won gains made against measles over the last four decades.
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Overview of Ecosystem Based Management of the Bird’s Head Seascape by Joanne Wilson of The Nature Conservancy
Date:
Monday, July 25, 2011 - Tuesday, July 26, 2011
Overview of Ecosystem Based Management of the Bird’s Head Seascape by Joanne Wilson of The Nature Conservancy (July 25 and 26, Multiple times, See below). The Bird’s Head Seascape (BHS) is located in the epicentre of the Coral Triangle and is a national and global priority for marine conservation as it contains the world’s most diverse coral reefs, high levels of endemism and numerous endangered marine species. While tourism, aquaculture and artisanal fisheries are emerging as a source of income for local communities, governments are still looking to commercial industries such as large scale fisheries, coastal development, forestry and mining as the main economic drivers. From 2005-2010, The Nature Conservancy (TNC), Conservation International (CI) and WWF-Indonesia worked together with local partners to undertake 24 EBM studies encompassing biological, social, economic and governance topics to help find solutions for sustainable development, determine scales of connectivity and support the development of the BHS MPA network. During this time, the number of MPAs in the BHS increased from four to 12 and this network now covers more than 3.5 million hectares. However, additional strategies were needed to address the management of conservation features outside MPAs and the impacts of coastal development and catchment clearing on marine habitats throughout the BHS. The strong communications and capacity building components of the EBM program resulted in key decision makers requesting management recommendations for fisheries, spatial planning, species management and MPA management. The BHS now serves as a working model of EBM for the Coral Triangle, though ensuring that this strong framework continues to guide economic development decisions into the future remains a significant challenge.
Webinar #1:
July 25 at 4 pm US EDT
July 25 at 1 pm US PDT
July 25 at 8 pm GMT
July 25 at 10 am Honolulu, HI
Register for this webinar at https://www1.gotomeeting.com/register/452506745.
Webinar #2:
July 25 at 9 pm US EDT
July 25 at 6 pm US PDT
July 26 at 1 am GMT
July 26 at 8 am in Jakarta, Indonesia
July 26 at 9 am in Hong Kong, China
July 26 at 9 am in Perth, Australia
July 26 at 11 am in Brisbane, Australia
July 26 at 1 pm in Suva, Fiji
July 26 at 3 pm Honolulu
Register for this webinar at https://www1.gotomeeting.com/register/200568105.
Presentation on Integrating Climate Vulnerability Assessment and Adaptation in a Conservation Planning Approach by Patrick Crist and Ian Varley of NatureServe
Date:
Wednesday, July 13, 2011
Presentation on Integrating Climate Vulnerability Assessment and Adaptation in a Conservation Planning Approach by Patrick Crist and Ian Varley of NatureServe (July 13 at 1 pm EDT/10 am PDT/5 pm GMT). This webinar will give an overview of an approach and toolkit to help natural resource managers and conservationists assess the vulnerability of resources and infrastructure from a variety of stressors including climate change and develop adaptation alternatives for landscape scale planning. The approach is comprised of six steps ranging from initial project scoping to scenario visioning and assessment to development of strategies and alternatives and integrates established concepts from vulnerability and cumulative effects assessment, the mitigation hierarchy, and systematic conservation planning. All steps in the approach are supported by a decision support toolkit, and the process is intended to be carried out by natural resource planners and managers and GIS staff, consultants, partners, or any combination of these. The approach and toolkit are adapted from NatureServe’s work on a land-sea decision support toolkit and Refuge Vulnerability Assessment process developed in partnership with the US Fish and Wildlife Service. Learn more about the land-sea decision support toolkit at http://www.ebmtoolsdatabase.org/resource/integrated-land-sea-planning-technical-guide-integrated-land-sea-planning-toolkit. A final handbook on the approach and toolkit including pilot case studies will be available in Fall 2011. Register for this webinar at https://www1.gotomeeting.com/register/495951384. ***Please Note: This webinar will last 1.5 hours.***
Freedom House Condemns Murder of Pakistani Journalist
The brutal death of Pakistani journalist, Saleem Shahzad, is a shocking illustration of the deteriorating environment for journalists in Pakistan. Freedom House calls upon Pakistani authorities to conduct a thorough and transparent investigation into his death and to take decisive measures to ensure the protection of journalists.
Freedom House Exposes World’s Worst Human Rights Abusers
Freedom House today released Worst of the Worst 2011: The World's Most Repressive Societies, its annual report identifying the world's most flagrant human rights abusers, at a press conference during the 17th session of the UN Human Rights Council.
Freedom House Condemns Kazakhstan’s Decision to Deport Uyghur Refugee
Freedom House condemns Kazakhstan's decision to deport Ershidin Israil, a Uyghur schoolteacher who fled China in the summer of 2009 after ethnic riots in the Xinjiang Uyghur Autonomous Region.
Freedom House Condemns Latest Attacks on Protesters, Shutdown of Internet in Syria
Freedom House condemns the ever-deepening cycle of repression directed by the Syrian government against peaceful protesters throughout the country. Today, security forces opened fire on demonstrators in Hama, killing at least 40, according to Syrian human rights observers. Attacks on protesters were also reported in the southern town of Jassim and the northeastern city of Deir al-Zour, as well as other locations. The demonstrations on 'Children's Friday,' which appeared to be the largest of the 10-week uprising against the regime of Bashar al-Assad, were mainly provoked by the circulation of graphic videos documenting the murder and mutilation of a 13-year-old boy, Hamza al-Khatib, by Syrian security forces.
Call for candidates for Editor-in-Chief of A&A
Authors: Birgitta Nordström.<br />Astronomy & Astrophysics Vol. 530 , page E1<br />Published online: 26/05/2011
Water in low-mass star-forming regions with Herschel (WISH-LM)?
Authors: L. E. Kristensen, E. F. van Dishoeck, M. Tafalla, R. Bachiller, B. Nisini, R. Liseau and U. A. Y?ld?z.<br />Astronomy & Astrophysics Vol. 531 , page L1<br />Published online: 30/05/2011<br />
Keywords:
astrochemistry ; stars: formation ; ISM: molecules ; ISM: jets and outflows ; ISM: individual objects: L1448.
Evolution of the progenitor binary of V1309 Scorpii before merger
Authors: K. St?pie?.<br />Astronomy & Astrophysics Vol. 531 , page A18<br />Published online: 01/06/2011<br />
Keywords:
stars: individual: V1309 Sco ; binaries: close ; stars: late-type ; stars: evolution.
Frozen to death? Detection of comet Hale-Bopp at 30.7 AU
Authors: Gy. M. Szabó, K. Sárneczky and L. L. Kiss.<br />Astronomy & Astrophysics Vol. 531 , page A11<br />Published online: 31/05/2011<br />
Keywords:
comets: individual: Hale-Bopp ; techniques: photometric.
On Öpik’s distance evaluation method in a cosmological context
Authors: P. Teerikorpi.<br />Astronomy & Astrophysics Vol. 531 , page A10<br />Published online: 31/05/2011<br />
Keywords:
galaxies: distances and redshifts ; distance scale.