There won't be a cure for autism

I came upon an article in the Huffington Post about Dr Mark Hyman's account of a child who seemed to have been "cured" of his childhood autism: "Autism Research: Breakthrough Discovery on the Causes of Autism". (December 11, 2010 11:37 AM). Dr Hyman attributed the child's "cure" to intense nutritional intervention aimed at correcting gut flora and metabolic functions concerning absorption. In making this connection, he referred to this exploratory research by Dr Cecilia Giulivi and colleagues of University of California, Davis.
I note that it is titled by the authors as a "Preliminary Communication" only and was not meant to be the final answer to any specific problem.
The paper is about "Mitochondrial Dysfunction in Autism", which means it's about how the cells of the body process energy or nutrients which are absorbed from the blood, after they enter the body via the gut. Dr Giulivi and colleagues did a laboratory experiment with some white blood cells belonging to autistic and normally developing children- they didn't use their brain cells. In autism research the processes that happen in white blood cells are used as an analog or model of how brain cells work. So their research is NOT on autistic children who are present in the lab, and is only about cells, not the whole living, breathing child. You should note that none of the authors work in a clinic or school for autistic children, so they are certainly not claiming they have even the beginnings of a cure. Their basic research conclusion is "In this exploratory study, children with autism were more likely to have mitochondrial dysfunction, mtDNA overreplication, and mtDNA deletions than typically developing children."

Please, dear readers and parents, don't put too much hope on this piece of research. There has been 50 years or more research on possible metabolic influences on autism- I was involved in some myself on serotonin/dopamine metabolism.

My own conclusion from the research is firstly that I am not very confident white blood cell metabolism is a very good representative of the areas of the brain I believe may be damaged pre-natally in autism spectrum disorders. Also, I imagine that the damage to the developing brain occurs to varying degrees and reaches different projections of nerve pathways in each child's brain, interacting with the rest of their potential for brain development, making it very unlikely that any one "treatment" or combination of strategies could ameliorate autistic thought and behaviour.

The appealing little boy featured in Dr Hyman's video seems rather normal and delightful and he also resembles several children I have interacted with who were similarly autistic when they were toddlers. As several people commented on the Hyman post, brain development reaches a certain level of maturity around 6 years old and kids become able to learn in class groups rather than alone or one-to-one. After this time lots of connections are possible between areas of the brain, but hardly any more new cortical cells develop or migrate. I think this little guy was rather bright originally and was able to benefit from his brain maturation plus good therapy.

Some high-functioning autistic children learn the rules, or how to simulate the rules, of normal social interactions and communication during the early school years, particularly if they have had attentional training and helpful parents. I remember a youngster whom I used to collect from his home to travel to the Flinders Medical Centre laboratory where we asked him to do some attention-grabbing tasks while recording his EEG/brain waves. He was a nice, quiet young boy (around 10 to 11 years old) and would talk during our journey if I spoke to him. He had very few twitchy movements or strange habits and could have been taken for "normal" by anyone we met. However, until he was about 8 he was the weirdest kid his parents had ever met! His habits, noises, bizarre reactions to people and situations had held the household to ransom since he was about 8 months old and became mobile! He had received a lot of individual speech, cognitive training and behavioural therapy so he could attend a mainstream school, because he could read and count at age level. His brain activity during the tasks was very similar to the other autistic people we tested, and was unlike that of the "normal" kids we had matched to them on several criteria. I'm sure Dr Hyman would have considered him "cured" given his everyday behaviour, just as his teachers did; his mum could still see his little quirks.

If you're interested in the idea of pre-natal brain development problems as an explanation for different degrees of autism, have a look at some early work from 1982 and some much more recent work in Italy which recaps the same theme, but with greater detail.

I love the work done by Simon Baron-Cohen on "theory of mind" and autism. While I agree with it up to a point as I can see that most autistic people behave as though they have no idea how the world appears from my point of view. However, my own pet theory is that the brains of autistic people are damaged sufficiently to leave them with a deficit in understanding what is important to attend to in the world, in order to function and survive. I call this a problem with "salience"- I think there is something wrong with the connections amongst the parts of their brains responsible for visualising movements and relating what they can see others doing, to their own body in motion. To me they seem as though they don't get the idea that speech is for communicating and that there is a lot of information in other people's faces that they should be using to decipher what happens. It's as though a basic biological connectedness is missing or damaged, so that they don't really "get it" the same way as ordinary people. They experience the world in different ways to the rest of us- it is quite difficult for us to explain to anyone how WE experience the world (we take it for granted; it's natural)- so how can we expect them to convey to us how THEY experience it? A super BIG ASK! All we can do is try to teach them to behave and reason about things like the rest of us so they and their families can have a calmer time.

There is a lot of research and therapy development at the Autism Research Centre in London, UK, which has a whole website devoted to it.

NB. It might be a little hard to include this as a "public health" post, but to me it is important that we balance the spending of health dollars amongst things which are likely to have an effect on a lot of people versus on special programs we might ration amongst only those likely to derive maximum benefit. It can be a cruel reality for parents when their autistic child is rated as "too impaired" to enter a special social skills or language program. For higher functioning kids, this sort of program might enable them to eventually live independent lives in the community whereas there is little hope of this for the children with the worst symptoms.

Out damned paradigm!

I have decided that whatever double blind crossover placebo-controlled# trials can do for sorting out the good treatment from the bad, they're completely beyond the pale* in mental health!
My starting points are roughly these:
1. Taking major depression as an example:
a) every case has individual real-life occurrences as contributing factors: maybe being totally neglected emotionally as a child, or having a string of teenage relationships ending in "betrayal".
b) every case happens to a different brain

c) every case has a certain set of present/absent, good/bad liver enzymes
d) whatever the age, size or shape of the person, they have a different "felt response" to the same dose of a drug
e) everyone has different ways of reasoning
f) we all afford differential salience to "stimuli" such as words, happenings, situations and other people's moods.
g) if interpersonal therapy happens, each person will have a different first impression (therapist AND client), which will influence the course of the relationship;
h) therapists all have different interpretations and ways of implementing different therapies (their "style")
i)different client vs. therapist personality combinations either work or don't work in particular therapies, no matter what the therapist thinks about their own "objectivity" in the interaction.
j) clients have differing "stickability" in their regularity and timing of visits to a therapist.
k) additional contributors may/may not occur DURING treatment by any mode eg. parent dies, husband leaves etc.
l)many factors contribute to what "dose" of therapy or medication will alter core symptoms, regardless of liver enzymes etc.
m) many people on medication never get a good therapeutic effect because of recommended dosing levels, especially if they are not referred to a specialist after partial response. Specialists can observe the person while pushing the medication to the biological limit and achieve complete remission (or rule out that medication).
n) people have different "feeling criteria" of when they are "OK" again after an amount of treatment- it may be quite different to what a therapist concludes.

Anyway, having committed heresy, I'll slink away to gather some evidence!

I'm starting to get worried!

Here comes the good old Lancet with the latest look at risk factors for stroke, worldwide:
Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study by Martin J O'Donnell & multiple colleagues. [If you create an identity and password you have access to this article even if you don't subscribe].
Although I wish they'd come up with something different, the verdict was:

"Phase 1 of INTERSTROKE suggests that hypertension, smoking, abdominal obesity, physical inactivity, and diet are the most important modifiable risk factors for stroke. These important findings should help to inform stroke prevention strategies around the world and to reduce the global burden of stroke." (Comment: Reducing the global burden of stroke: INTERSTROKE by Jack V Tu, The Lancet, Volume 376, Issue 9735, Pages 74 - 75, 10 July 2010)

Yeah sure mate- "help inform stroke prevention strategies"- I think most moderately health-conscious societies are quite well informed on this already- but how the hell do you get us (the at risk people right now) to exercise against that awful, ingrained "physical inactivity". We are NOT MOTIVATED YET!! I think someone has to come up with something new to get us all off our bums!

Quite honestly, I have been exhorting myself to exercise regularly since the age of 15 when my family doctor handed me the old XBX exercise paperback and said "Start here!". For no more than 14 days of my life have I exercised vigorously EVERY DAY- and that's when I have gone on holidays specifically to walk at least 10km/day over someone else's hills! I have plenty of photos to prove it, too!
Here I am at the famous Beseggen Ridge in Norway in mid 2004, a cardiovascular treat if ever there was one!

I see absolutely nothing in my neighbourhood, which is full of middle aged and older citizens, prominently encouraging us to come along to exercise sessions or enrol in a government-sponsored walking program. I have deliberately sought out suitable programs on the internet and discovered a Heart Foundation Walking Program, but I haven't managed to get along yet. There is also an early morning exercise class for "Seniors" at a local community centre, but it's at 7am and that is just dumb for most people who have blood pressure medication to take with breakfast!

At the other end of the spectrum, my neighbour has a 13 year old girl who rather fancies herself as Australia's answer to Paris Hilton (without the hotels, unfortunately), but I haven't seen her doing regular exercise around the neighbourhood, either. Isn't there a school health and fitness program to get these kids enjoying regular exercise as a normal part of their daily routine? Evidently not! This young lady HAS been attracted into a program where appearance is important- a cheerleading team- where some calisthenic moves are combined with a great deal of ribbon-waving and strutting around in glittery costumes! Are we missing something in the marketing department about what motivates regular exercise these days? Obviously, the promise of a glittery costume is not going to get me to the community centre at 7am any time soon, but I wonder what would?

I daresay I have quite a few risk factors for a stroke later in life:

1. I have had elevated blood pressure all my life, even during childhood.

2. Both my parents had high blood pressure- mum from her 50s, dad from his 70s.

3. I'm on some medication for another problem which actually CAUSES elevated blood pressure, but I have no alternative at the moment.

4. My mum started having mini-strokes/TIAs [transient ischaemic attacks] from her late 60s and died as the result of a stroke during an unrelated operation at 81.

5. I am rather physically inactive, though not as much as most people my age who I know.

6. Although currently at the upper limit of normal weight for my height, my weight is concentrated around my middle.

7. I weigh 157% of my weight on leaving highschool!

OK- I have a few helpful factors going for me- I've been prescribed (and take) a pill for hypertension and it works moderately, but not all the way back to "normal"; I haven't used sodium salt sprinkled on food for nearly 40 years- we used to have a container of 50/50 sodium/potassium salt for me to use on potatoes (the only thing I liked a bit of salt on), but it took 10 years to use it up!; I eat a diet which others would regard as fairly healthy and I rarely eat anything prepackaged like sweet biscuits, frozen meals; I have never had artificial sweeteners as I thought they might be bad for my liver- I had weird ideas that they must be taking up a metabolic pathway that should have been utilised by another foodstuff, goodness knows what- and I figured if I didn't like an unsweetened version of something I could just give it up!; my diet is almost vegetarian but I believe I need animal meat because I am an animal born to utilise eaten muscle to maintain my own muscle; my diet is also rich in raw fruit and vegetables containing lots of anti oxidants, plus I eat raw, fresh nuts of various sorts for lunch every day- also a 30-year habit. The only cheese in the house is low-fat and I drink plenty of water and black tea, rarely coffee or soft drink. Lastly, my father lived to the age of 95, despite having a congenital heart valve problem, which did lead to heart failure in the end- but you'd hardly say he had the usual kind of cardiovascular disease!

SO!!! What will persuade me and others like me to exercise regularly? I know that when I went to aquarobics twice a week with friends, it was the social contact and the regular expectation that got me there. Now I don't earn a living and don't qualify for government assistance, paying $40/week to attend is out of the question. However, this would be a good way to go for people with a normal income. I still like my idea of having community fitness trainers/leaders who are paid out of the national health budget to get people into regular exercise programs to the extent of thumping on the front door and yelling at them to come out!

The National Heart Foundation walking program for seniors should be what I attend, as it's free (mainly), but I haven't managed to get there despite several tries! I haven't seen the new video publicising the walks on TV, either- where is it?? Since it's about dog-walking, it's not really for me, but might encourage plenty of others.

I keep returning to the research on depressed young people, where researchers found that regular exercise was quite therapeutic and wonder how this sort of program could be financed and monitored locally. It could be quite attractive to public health campaigners as it literally kills two birds with one stone! There is plenty of good research on psychological health and exercise for older people as well, even for those who already have heart disease!

Goodness knows why I'm still here, sitting on my proverbial and not out there treating myself to a dose of free depression treatment while lengthening my expected life span!

Depressing news about depression

It all sounds really good- in Australia we have Mental Health as one of the Health Priority Areas (along with diabetes, asthma and heart disease

Gout- a very ouchy problem!

I hadn’t ever expected to blog about gout, but a few things have pushed it to the forefront of my attention lately.

One- I discovered that a friend my age has it quite badly and two: I didn’t realize this is just one of the many forms of arthritis (there are more than 100- yikes!)!

Having decided to inform myself, I found it was a timely topic- The Lancet has just had a leading article on it and most of it is pretty readable for an educated person, not just for medicos. Here’s a link to the Abstract, but you’ll have to use your connections in the business or a science library to read the whole caboodle:
Richette P and Bardin T (2010) Gout. Lancet. Jan 23;375(9711):318-28.

The docs have provided a beaut explanation of the current state of gout knowledge and how to treat it and relieve the symptoms. Sufferers are [rightly] much more vocal about the symptoms themselves- gout hurts to high heaven wherever you get it! [Insert loud groans and screams here]. It certainly laid low my friend on several recent occasions when he would far rather have been out enjoying himself. It also seems to make him and others quite depressed- which I guess can also be the result of taking a lot of pain killers.

All I knew before researching this topic was that some crystals accumulated in the joints somehow; that they were sharp, and that they maybe scratched the bones and thus hurt a lot! Apparently, that’s almost true, except for the fact that gout is really a form of arthritis, (meaning inflammation of joints: Greek ‘arthro’= joint and ‘itis’= inflammation), and that the crystals irritate the joint linings which makes them swell up and produce pain- it’s not the physical scratching from some great chunky quartz-type crystals, but tiny little pointy things in spaces they shouldn’t be. Here’s a pic from the internet:

Monosodium urate crystals

The traditional spot for gout to show up is in the big toe- here’s a diagram to show where the crystals deposit.

Now I know why I saw a lot of old guys with the toe cut out of their shoes when I was a little kid growing up in a country town! The pain is felt all over the toe and really gets bad if your shoe rubs the end of it.

Unfortunately, gout can cause arthritis in most joints- my friend has it in the knees, for instance. What can add to the pain and discomfort is the occurrence of swelling and heat around the joint such that ice packs are very welcome, as well as pain killers and anti-inflammatories (like aspirin).

I wondered where the crystals came from or why they accumulated in the joint spaces, rather than in the kidneys (like other crystals I’d heard about, eg. kidney “stones”). Well the uric acid crystals actually come from processing proteins we eat- I won’t explain the whole process as you can look it up. The folklore about gout being caused by a diet that is “too rich” and “having too much to drink” is not all true.

Most gout has some inherited component- it “runs in families” and researchers are identifying some possible target genes. It is a metabolic problem where the usual pathways though and out of the body for the urate crystals are disrupted or diverted. Instead of all the extra uric acid we don’t need getting ferried out through the kidneys, too much of it hangs around in the blood permanently. With ageing, the concentration is more difficult for the body to cope with and the crystals percolate out of the blood and into the tissues, accumulating in the joint spaces where they hurt. Also, if it isn't treated properly you could end up with permanently damaged joints and need joint replacements. Alternately, if you become dependent on steroids to control the symptoms, you get all sorts of nasty side effects which wreck other aspects of your health! Bad scene- better to change your diet!

Most of the foods that contain the protein that causes uric acid build-up are also nice tasty, popular foods like: red meat, shellfish, other popular fish, roe/caviar, asparagus, cauliflower, mushrooms, peas, beans and lentils; plus there is the traditional culprit alcohol.

So if you know someone with gout, don’t make fun of them, as gout is definitely NOT a fun thing! Be sympathetic when they have an attack and either help them out with rest and ice packs or leave them alone for a day or two to get over it. By all means encourage people to seek expert care, as there is a lot more treatment available these days than when those old men cut the toes out of their shoes!

Where can I claim my reward?

As a sufferer from depression and pretty much unemployed for 2.5 years, I have been feeling a terrible lack of opportunity to be rewarded- either with money or something else I favour. People tell me (and I have started telling myself) not to WANT things. I really do have what I NEED for basic sustenance- sufficient food, a roof over my head, clothing, warmth, a partner, sex, 3 cats and friends. But despite telling myself to concentrate on how lucky I am (ie. think Haitian kids, one of whom I sponsor through World Vision), I have this terribly human trait of WANTING stuff/experiences/different stuff. Well now the people in the labs, those white-coated loonies of popular folklore, have discovered that our brains need enough of a particular substance to actually FEEL rewarded by anything. Not surprisingly, this substance is serotonin, the stuff that your neurons like to bathe in regularly, so you don't feel depressed. These guys (along with a host of others) found that serotonin was the vital part of the brain's REWARD system.

Now, how can we get more rewards? Do things and eat foods that increase the free-floating serotonin levels in the brain. There is a lot of bullshit, "natural", nutrition and New Age claptrap around, but the truth seems to be that foods containing plenty of tryptophan (trip-to-fane) are the go. These are mostly tasty proteiny things like, lean red meat, turkey, chicken, nuts, cheese, beans and pulses (eg. lentils, chick peas). As part of a normal diet, we need to consume these with a little carbohydrate (which is hard to avoid, given the composition of most food)- the more complex ans slower to burn in our systems, the better. So- no added sugar, but good complex carbohydrates such as in vegetables, grainy breads and some fruits. Traditionally they say chocolate and bananas increase serotonin, but they're better with some protein as part of a meal, not an EXTRA snack on the side! Appropriate fats are good too- mono-unsaturated oils like olive oil, omega 3 and 6 oils like fish oil/some nut oils, and recently some authorities have recommended pure cold-pressed coconut oil (which I find good). There seems to be little about dietary coconut oil, except as an antioxidant- by which the scientists mean that the components of coconut oil roam around our blood stream "scavenging" those things called "free radicals" which seem to age us and may play a role in the beginning of cancer. So even if the virgin coconut oil is not yet proven to help with depression and reward experiences, the mere thought that it's doing you good may help anyway!

Now, I'm no medical authority, so don't call me to account for this one, but there were recent reports that a pediatrician (children's doctor) in the USA was treating her prematurely dementing husband with coconut oil and getting promising results. There is nothing in the conventional medical literature as yet, but I'm waiting with interest.

However, leaders in the field of cognition in ageing caution that there is no clear or longterm proof of the worthwhile use of various oils and other substances in slowing brain decline.

Light REALLY DOES make migraines worse

As an ex-migraine sufferer I was interested to see this article in the latest Nature magazine which demonstrated that light definitely makes migraine headaches worse. I always felt that it did and would always try to stay away from bright light when I had a migraine, but some people thought it was just a function of screwing up my eyes in the light making my head muscles tense up more. Plenty of migraine sufferers out there can now declare they're not as neurotic as their friends think!

The researchers in the Nature article compared blind people with migraines with normal-sighted people also suffering regular migraines, who had been matched on age, age of onset (most started around age 17 to 18, give or take several years), occurrence of an aura and other medical factors. They found that only the blind people with an intact optic nerve had their migraine exacerbated by light, along with the seeing people. The blind people whose optic nerves were still Okay (ie. they could transmit information to the brain about light vs. dark, but not about lines, shapes and colours) had their migraines made worse whereas the blind people without optic nerves and/or no eyeballs did not.

The authors give really detailed information for the knowledgeable about the nerve pathways involved, but I won't go into any of that. I think the fact that the study appeared in such a prestigious scientific publication is good evidence that the research is quite sound and migraineurs can be assured they're not crying wolf!

Doing Health Policy in Australia

Doing Health Policy in Australia
This sounds good- I wonder if I can get hold of a copy?