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Data signatures in the brain: adding up the evidence

7/29/2017

 
Not too much news from the 2017 Alzheimer's Association International Conference seemed newsworthy. You know what it is like watching an interview and you are waiting for THE question to be asked but it seems lost in all of the softballs being swung at and missed? That should be the theme. Full disclosure I am still skeptical about the entire premise of hunting for monotherapeutic cures in Alzheimer's disease. For one, they keep measuring the wrong thing. But if we are about to pivot towards prevention? Sign me up! 
The Alzheimer's Association today announced the launch of a $20 million U.S. two- year clinical trial to test the ability of a multi-dimensional lifestyle intervention to prevent cognitive decline and dementia in 2,500 older adults with no current cognitive symptoms but who are at increased risk for later cognitive decline. The announcement was made at the 2017 Alzheimer's Association International Conference (AAIC 2017) in London.
The large U.S. study to PrOtect through a lifestyle INTErvention to Reduce risk (US POINTER) will include physical exercise, nutritional counseling and modification, cognitive and social stimulation, and improved self- management of medical conditions. Recruiting for the study will begin in 2018.--Press Release AAIC 2017
First, how much "protection" can we offer 60-79 year olds with co-morbid dementia risk factors "(e.g. hypertension and other cardiovascular events, elevated blood sugar)?  We also forget collectively that the eponymous disease  actually described early onset Alzheimer's--not what we talk about in our aging populations.

​Why does it seem like diabetes and metabolic derangements are the data signature in so many chronic diseases? I would like to see this study extended to additional social determinants of health in younger at-risk populations but I remain hopeful.
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I don't have the answer but I do like to look at trends. Starting with a diabetes data signature and digging a little deeper seems like an interesting place to become curious.
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In looking for data to see if obesity, sugar consumption, or dementia might show similar patterns--knowing  correlation is not causation--but why not look where the hypothesis generation is ripe? 
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There is also interesting information from a brain donation program of 202 American football players. Results from the neuropathology and clinical features include evidence of cognitive decline and presence of phosphorylated tau and amyloid in addition to unique pathology associated with chronic traumatic encephalopathy. My thoughts are always perhaps the brain makes tau and amyloid in response to insults to the brain including trauma associated with head injury and the as yet not characterized trigger in Alzheimer's disease? "Deposition of amyloid-β was present in a subset of participants at all stages of CTE pathology, predominantly as diffuse amyloid-β plaques, but neuritic amyloid-β plaques and amyloid angiopathy were also present".
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Click the title to download a free PDF of a report from The National Academies Press


Preventing Cognitive Decline and Dementia: A Way Forward
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RCTs are the gold standard in evidence generation but require large investments of money and time. Moreover, while they are particularly effective for testing single-intervention solutions, the apparent complexity of the pathophysiology underlying cognitive decline and dementia suggests that a multifaceted approach may be most effective.  

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The U.S. "Great place to get sick, but terrible place to stay well"

6/27/2017

 
Easing back into writing from my home office (at last) after months of travel is always welcomed--but a bit unfamiliar. Working between meetings, conferences, and scheduled collaborations requires a level of discipline not typically required from your home base. I do well if I remain on my east coast time zone regardless of where I end up (within reason). I always walk to my destination whenever possible (within 3 miles) and carry healthy snacks such as avocados, jerky, or nuts.
As many citizens can attest, the U.S. is a great place to get sick, but a terrible place to stay well. This requires a shift in the way both doctors and patients approach health maintenance and disease prevention.--Rob Wittman

Most of us do the best we can. Our lives are busy and our responsibilities are many. The easiest thing to do is to sacrifice a work-out, grab a quick snack--albeit not the healthiest option, or cut back on sleep to meet busy deadlines. But what about "staying well"?
From a historical perspective the US healthcare system had stellar results when the assaults were tuberculosis and acute infectious agents. The discovery of antibiotics provided small molecule solutions for acute disease. One pill could save large numbers of patients reliably and consistently.

Unfortunately we seem to apply that model of research and pharmacology to chronic disease. Chronic disease demonstrates inherent complexity not likely solved by a monotherapeutic cure. Metabolic derangements are common to heart disease, diabetes, and Alzheimer's disease. We search for cures that mirror successes from our past. We fund research for symptom management but not at the necessary scale for prevention.
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If you are a data professional you might enjoy FlowingData. Jonas Scholey re-envisioned data to demonstrate the relationship between cause of death not only as we age but also as a historical perspective.

An immediate observation is that as we age the predominant cause of death is chronic disease. Just 20 or 30 years ago we had more infectious disease in the top 5, now the majority are chronic in nature. Click on the interactive image below. It will take you to The Burden of Disease and the Changing Task of Medicine 200th anniversary article in NEJM.
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In many respects, our medical systems are best suited to diseases of the past, not those of the present or future. We must continue to adapt health systems and health policy as the burden of disease evolves. But we must also do more. Diseases can never be reduced to molecular pathways, mere technical problems requiring treatments or cures. Disease is a complex domain of human experience, involving explanation, expectation, and meaning. Doctors must acknowledge this complexity and formulate theories, practices, and systems that fully address the breadth and subtlety of disease.--NEJM Jones et al.
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The advancement in preventing or curing chronic diseases like Alzheimer's disease reside in adaptive clinical trial designs and modernization of how we cure advanced disease frameworks with complex deranged pathways. Prevention clinical trials are not well funded but their findings are important. We are ready for a new model of health--not just symptom relief but a "realistic understanding of determinants of disease".
Disease is always generated, experienced, defined, and ameliorated within a social world. Patients need notions of disease that explicate their suffering. Doctors need theories of etiology and pathophysiology that account for the burden of disease and inform therapeutic practice. Policymakers need realistic understandings of determinants of disease and medicine's impact in order to design systems that foster health. The history of disease offers crucial insights into the intersections of these interests and the ways they can inform medical practice and health policy.--NEJM

Neurodegeneration and proteins--“Here’s business enough for you"

4/4/2017

 
Its impossible to study neuroscience and not know about Phineas Gage. What I didn't know was how handsome he was--even with scars from being impaled through the brain by an iron rod in an 1848 explosion. In fact he greeted the first doctor on the scene by deadpanning "Here is business enough for you." He surprisingly survived eventually dying from seizures years later--likely as a result of catastrophic neurodegeneration.  

The relevant finding for neuroscience was the abrupt change in personal and functional ability. Not unlike the decline in cognition experienced in Alzheimer's disease--it seems to also portray the heterogeneity of not only dementia but brain injury as well. Phineas Gage may have regained a degree of normalcy and routine in his life. It made me think that although Alzheimer's disease diminishes cognition there are many patients where poor ambulation is the profound symptom--or language processing. A recent podcast, Two Scientists Walk into A Bar, examines The Degenerating Brain. Genentech brilliantly produces the podcast and surprisingly Geoff Kerchner, Neurologist and Medical Director of Early Clinical Development at Genentech is one of the first industry experts to discuss the brain in a matter-of-fact informative discussion. He is both a practicing neurologist AND a research scientist. I think this makes all the difference. 
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Modern neuroscientific knowledge makes the idea of Gage’s recovery all the more plausible. Neuroscientists once believed that brain lesions caused permanent deficits: Once lost, a faculty never returned. More and more, though, they recognize that the adult brain can relearn lost skills. This ability to change, called brain plasticity, remains somewhat mysterious, and it happens achingly slowly. But the bottom line is that the brain can recover lost functions in certain circumstances.--Slate
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Because we are bombarded by media accounts of amyloid deposits in the brain being the potentially causative agent in Alzheimer's disease we may fail to see the forest through the proverbial "tangled and globby" trees.

​Neurodegenerative diseases all seem to have a protein problem. Alzheimer's has tau and amyloid--not to be outdone, frontotemporal dementia is known for TDP-43 (also in ALS), and Parkinson's disease
α-synuclein. All present in some capacity in the "normal" brain as well.
But what if the "diagnostic" protein accumulation is just the low-hanging fruit? Is aggregation a cause, or a bystander effect, of the disease? Neurodegenerative diseases have different symptoms but one unifying concept at the biologic level--abnormal protein accumulation in nerve cells. In Alzheimer's disease a variety of proteins including TDP-43 are associated with abnormal aggregation leading to death of these cells. We aren't talking about foreign proteins--these are proteins normally found within our bodies. In many instances, the human brain can withstand a lot of damage but this isn't usually the case in the motor cortex. Think of the neurodegenerative process in ALS--the number of neurons is so low in this area that even minimal damage can yield profound effects. 

No surprise that the brain is the least understood organ of the body. The interconnectivity alone is vastly complex. Experiential  influencers transmit to neurons as well. Research has demonstrated this by studying the brain of multi linguists  musicians and creatives, as well as other "active" disciplines. So we do crosswords, learn foreign languages, and enjoy music when time allows. Clearly AD does not look the same in all individuals. Geoff Kerchner, MD PhD shares how common themes like memory loss are seen in many of his patients although other patients report visual spatial and navigation impairment as the most profound symptom. He reminds us that aggregating proteins is what our brain does when it is assaulted. Who is to say which of the proteins is actually driving the dysfunction? 
My research question is if brain biologically responds to insult with protein accumulation, perhaps we need to  look at earlier phenotypic traits of neurodegeneration like metabolic derangements and mitochondrial dysfunction. I believe the answer will be a network solution--definitely not a monotherapeutic intervention targeting only one signal in a complex mechanism. 

March 23rd, 2017

3/23/2017

 

Paula Wolfert and the complex questions of dementia...

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My neighbor sent me the link to a recent NY Times article. I was excited after reading the title albeit bristling at "fighting" once again used to separate winners from losers--to be greeted by a smiling face. Articles about Alzheimer's disease and dementia are typically sturm und drang without hope or possibility unless you donate or face your fate and the upcoming zombie apocalypse.

You might not recognize the face or even the name but her seminal cookbooks focused on middle eastern dishes were groundbreaking in the days before celebrity chefs and mindless cooking themes shows. In the midst of a dire diagnosis, she is publishing a biography Unforgettable: The Bold Flavors of Paula Wolfert's Renegade Life.
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Thus, the so-called bulletproof coffee she makes every morning and the squares of dark chocolate she eats after lunch, in the belief they will bolster her brainpower. In between, she eats a carbohydrate-free diet built on salmon, berries and greens, along with extracts of turmeric, cinnamon and eggplant.
The cookbook will focus on brain-centric healthy dishes and stories about memory and food. Her Kickstarter campaign quadrupled its initial goal and I am so happy to order this beautiful book--It appears to be a recipe for joy, hope, and acceptance--and a delicious cous cous.
The gripping narrative traces the arc of her career, from her Brooklyn childhood to her adventures in the farthest corners of the Mediterranean. Anecdotes and adventure stories come Paula's extensive personal archive, from over 50 interviews with Paula herself, and from dozens of interviews with food writers and chefs whom she influenced and influenced her—from Alice Waters and Thomas Keller to Diana Kennedy, André Daguin, and Jacques Pépin.--unforgettablepaula.com

Remembering how to forget...

2/12/2017

 
The best documentaries are the ones you stumble upon quite by accident. The title of First Cousin Once Removed didn't reveal much as I meandered through the offerings of HBO--an often disappointing way to look for a good documentary film. What caught my interest was a face, a smile, and the name of an accomplished poet--Edwin Honig.
...I say hello
to myself

and to break
the terror

of nonexistence
I restore my self

to existence whatever
the consequence--
Excerpt from To Infinite Eternity by Edwin Honig
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Finding Poetry in Memory Loss: Alan Berliner's 'First Cousin Once Removed'
Edwin Honig was many things to many people. A really complex person with a traumatic history of his own revealed through interviews and conversations with his cousin, Alan Berliner, an accomplished filmographer. Although the stories I tell aren't about me, they are written by me--and I am fairly critical of storytellers of Alzheimer's disease. The zombie apocalypse isn't coming and there is humanity in every life experience.

This is a beautiful documentary--even when it becomes painful to watch--the journey remains hopeful and magical.
Since Honig was a poet, Berliner felt it was important to honor his cousin's memory by making the film an exploration into the life of a poet, and his film was conceived in poetic terms. "Poets' lives are not arbitrary," Berliner states. "For poets, it's all or nothing. They are the translators of human experience. They're the people we turn to in order to put words and images to the feelings, emotions and experiences we don't understand or know how to deal with. He even says at one point in the film,

​'What you're doing is like writing a poem. You're changing what people are thinking and making them think what you want them to think.' So I felt challenged to make a work of cinematic poetry because of who Edwin was. And not only do I believe that Edwin was a poet right through his last day of life, but I realized Edwin was experiencing what might otherwise be called 'A Poet's Alzheimer's.'
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The Poet's Alzheimer's reveals a mind lost to Alzheimer's disease returning to recite a forgotten passage, detail, or clarification. My father was a musician. He played the double bass in symphonies and local orchestras and retained an abiding love for classical and jazz his entire life.

​This documentary highlights the unique journey of a mysterious diagnosis. I have never been a fan of continually interrogating patients with dementia. A barrage of frightening questions, "Do you know who I am?" "What day is it?"-- to what purpose? Perhaps rather than thinking about memory as a construct, they are just living it. Acting out an activity that is limited by its definition.

Alzheimer's: Every Fact Counts

1/26/2017

 
Alzheimer's: Every Minute Counts opens dramatically. A brightly lit cityscape slowly becomes dim as one by one--lights go out and leave total darkness. Cue the dramatic music and opening scene of a family in the midst of caring for a declining Alzheimer's patient and bam--you can't get to your check book fast enough.This documentary feels like an awareness of marketing campaign. Fear? Check. Dramatic music? Check. Heartbreaking scenarios? Check. Mention (multiple times) of need for funding but no mention of the amount of money already sunk into unsuccessful drug pipelines.

​The problem? The opening scene depicts a woman with early onset Alzheimer's disease. A rare form of the condition that strikes fear in everyone--especially since the recent blockbuster Still Alice. The real truth lives somewhere between normal senescence and whatever triggers the abnormal pathology of Alzheimer's disease. You may be surprised to learn that we actually have no idea.
I particularly found the haunting warning of a zombie apocalypse a bit toothless. Especially since JAMA Internal Medicine recently published the data on the decline of dementia rates. A Comparison of the Prevalence of Dementia in the United States in 2000 and 2012
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Findings In this observational cohort study of more than 21000 US adults 65 years or older from the nationally representative Health and Retirement Study, dementia prevalence declined significantly, from 11.6% in 2000 to 8.8% in 2012.
Meaning Population brain health seemed to improve between 2000 and 2012; increasing educational attainment and better control of cardiovascular risk factors may have contributed to the improvement, but the full set of social, behavioral, and medical factors contributing to the improvement is still uncertain. 

I don't know. The PBS documentary seemed like nothing more than a marketing campaign to increase fundraising efforts for Alzheimer's disease. I agree it is a formidable task but we certainly need to fail better and quicker. Wouldn't the funding be better utilized in prevention or symptom management? Do we really think there is a mono-therapeutic cure for comorbidity at the end of our lifespan? I suggest a more meaningful documentary Monster in The Mind. Here we learn about hope, prevention, and healthy aging.

Here is the current pipeline as reported recently in Alzheimer's & Dementia: Translational Research & Clinical Interventions
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I will quietly hope for better outcomes but I will actively bring awareness to prevention and social correlates of health. Stay-tuned...

Learning to fail gracefully or at least not go broke in the process...

1/6/2017

 
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I first attended the Lown Conference a few years ago in San Diego. It was an amazing time to meet other industry stakeholders questioning overdiagnosis and overtreatment in healthcare. John Ioannidis spoke about questionable research findings with dubious ties to industry and profit mechanisms.

​I participated in panel discussions about end of life care, mental health issues, and reporting risks as well as benefits associated with medical interventions.

Many one on one discussions would end up along the water. We walked along the sea listening to each other's stories, motivation for attending, or lingering barriers to critical thinking in a healthcare framework that may or may not have the provider or patient's best interest top of mind.

I recall a discussion about how Alzheimer's Disease was captured on a death certificate. A mid-career physician treating many patients with dementia admitted the criteria was not clear. Yes we have many patients with dementia--what we don't have is a lot of patients dying from dementia.

This may surprise you if you have been listening to the media and the claims of the pending zombie apocalypse. A recent article in the Washington Post succinctly stated Too Many Medical Trials are Moonshots in the Dark. A powerful update on the Eli Lilly drug solanezumab provides context for the debate.
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The episode underscores that it is time to rethink how we pursue biomedical research and drug development. This shift is especially pressing for diseases of the brain, such as autism and Alzheimer’s disease, which are becoming increasingly important for our society but lack effective treatments. One reason for this lag in treatments is that we have failed to invest enough in obtaining a fundamental understanding of diseases. Instead, we have spent too much on costly clinical trials and studies on human patients that, for ethical reasons, have to be guided by the interests of the patients rather than research goals.-- Thomas C Sudhof, Nobel Prize in Medicine 2013

If you follow the blog, you are familiar with the head scratching and arched eyebrow directed at R&D investments in monotherapeutic solutions for complex chronic disease, metabolic derangements, and illness toward the end of life. Clearly I am not discussing hereditary or early onset AD or dementia--the statistics often reported are referring to the later years--and they have many of us frightened and feeling helpless.
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These powerful images from What Does it Take to Produce a Breakthrough Drug published in Nature Reviews | Drug Discovery are visual reminders of the failed framework for evaluating drug candates for Alzheimer's Disease. The only reason for the anemic push forward could be described as the sunk cost fallacy.
The Misconception: You make rational decisions based on the future value of objects, investments and experiences.
The Truth: Your decisions are tainted by the emotional investments you accumulate, and the more you invest in something the harder it becomes to abandon it.--David McRaney, You Are Not So Smart 
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These are clearly contemplative thoughts lacking immediate answers but deserving of better questions. 
Some people see a focus on basic research as insistence on wastefully pursuing knowledge for its own sake. That assessment is false. Basic research provides the underpinnings for any understanding of disease, so we need to reassess how we spend our precious funds for development of therapies. 
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The wisest investment in many cases may be to understand disease biology first and move into clinical trials second, only after we have conceived a rational plan for how to treat a disease. Otherwise, clinical trials risk continuing to be shots in the dark, costly and frustrating not only for scientists but also for patients who badly need new treatments.--Thomas C. Südhof professor of neurosurgery, psychiatry, neurology, and molecular and cellular physiology at Stanford University. He received the 2013 Nobel Prize in medicine.

Social Determinants of Health: A Blockbuster Solution Waits in the Wings

10/15/2016

 
I recommend either full participation or at least a cursory review of literature provided in a free online course at Future Learn. Social Determinants of Health: What is Your Role? Much of the data integrated into real world evidence pulls from environmental and economic factors that have been demonstrated to impact health outcomes. 
Do you find it impossible to envision a mono-therapeutic solution to a complex framework of chronic disease? Pathways of metabolic derangements nestled within a socioeconomic and political context don't seem amenable to a pharmaceutical panacea. Diseases of aging remind us of how little we know about healthy senescence and the pathology of age.
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Consistent with the prevailing ideology of disease, adequate access to healthcare has long been identified as a credible goal for medicine. Not as much credence has been attributed to governance, social position, material circumstances, or social cohesion. Healthcare costs most specifically drug prices are being defended as the price we must pay for innovation. A recent article in Forbes presents a short-sighted view of drug industry pricing--described as a kerfuffle!? Here is where my thoughts land.

Innovation in healthcare and medicine is somewhat limited by biology at the interface of technology and trade-offs in quality of life. Instead of gargantuan investments in R&D or biotech company acquisitions--why don't we look at the real problems. If drug companies stop investing in "innovation" because their billion dollar collective bonuses are being slashed--what will be there new business model? 

There is historical precedence for regulations and governance to help direct the "invisible hand" described in 1776 in the Wealth of Nations. Our modern society indeed has evolved into a holistic denial of social determinants of health and their impact on health inequities. 

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Unfortunately, discussions of investments in healthcare cluster around the medicalization of disease vs. preventative policy and oversight. Data presented by Yale Global Health Leadership Institute highlights the low investment in social service spending by the US. Interesting to note that we spend more on healthcare than any other nation, have the worst outcomes, and one of the smallest--if not the smallest--investment in social determinants of health.
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The animals we eat--domesticated or wild--contain PCBs, hormone disruptors, and radioactivity, the fish has too much mercury, the tap water tastes of chlorine and contains copper, some tap water from fracking areas catches fire, buildings have toxic indoor air, we breathe in dust and nitrogen oxides, and there's too much ozone near the ground but tool little up in the stratosphere where it should be. The oceans are going acidic. Temperatures have gone off the charts. Forests are burning and fertile soil is getting depleted, eroded, or drought stricken. The entire atmosphere seems to have caught some kind of fever, which is gradually infecting the oceans. The lament and complaints over nature's disruptions go on and on. The earth and the sky have now become full of seemingly meaningless symptoms and suffering.-What We Think About When We Try Not to Think About Global Warming
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This is the world we live in. But we are anxiously waiting for an even smaller cohort of a previously unsuccessful clinical trial ,(EXPEDITION, EXPEDITION2, and EXPEDITION3 (ongoing) in patients with mild Alzheimer's disease. Basically Eli Lilly seems to be looking for a problem--for its 25 year 3 billion dollar solution.

Thoughts on World Alzheimer's Day...

9/21/2016

 
Today is the designated World Alzheimer's Day. Held  on September 21st of each year, organizations and advocacy groups focus efforts on raising awareness--advocacy speak for marketing and fundraising.
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"Although advocacy groups have some legitimate interests in common, industry is the one with the deep pockets, usually much more than these organizations can raise from individuals or foundations.

​Therefore advocacy organizations have increasingly been shown to advocate for clinical guidelines, drugs, and policies that are not in the best interests of patients--but more in line with industry sponsors."--from book proposal Alzheimer's Disease: The Brand


As the Alzheimer's Association struggled for an identity, the name evolved and with it--the role of public sources of funding.
“We are the world’s leading voluntary health organization in Alzheimer’s care,
support and research.”—Alzheimer’s Association
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Additional topics discussed in the evolving book, Alzheimer's Disease: The Brand, include the balance sheets of a well-funded non-profit patient advocacy group as well as how funds are channeled to local chapters. Many of the largest advocacy chapters have separated from the Alzheimer’s Association in the last year, disagreeing with their priorities of research, and centralization of resources. The deprioritized local programs actually help people and families dealing with dementia.
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I recently discovered an article originally published in Harvard Business Review in 1977. The discussion of organizational learning sheds insight on how "change" can most effectively be initiated--if the current culture is supportive.
Organizational learning is a process of detecting and correcting error. Error is for our purposes any feature of knowledge or knowing that inhibits learning. When the process enables the organization to carry on its present policies or achieve its objectives, the process may be called single loop learning. Single loop learning can be compared with a thermostat that learns when it is too hot or too cold and then turns the heat on or off. The thermostat is able to perform this task because it can receive information (the temperature of the room) and therefore take corrective action. 
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If the thermostat could question itself about whether it should be set at 68 degrees, it would be capable not only of detecting error but of questioning the underlying policies and goals as well as its own program. That is a second and more comprehensive inquiry; hence it might be called double loop learning. When the plant managers and marketing people were detecting and attempting to correct error in order to manufacture Product X, that was single loop learning. When they began to confront the question whether Product X should be manufactured, that was double loop learning, because they were now questioning underlying organization policies and objectives. -- Double Loop Learning in Organizations by Chris Argyris Harvard Business Review 1977
Think about first-loop learning as our short-sided approach to Alzheimer's Disease prevention or research. We think if we develop diagnostics or prescribe drugs to remove amyloid plaques and neurofibrillary tangles--viola! The target was defined and we adjusted actions to be able to measure our success. 

First-loop learning identifes a drug or drug class that lowers the targeted plaques or tangles. Now when we consider the second-loop learning--things get uncomfortable. We need to question the defined target. Our first-loop brain has verified that the problem is "solved". But what about patients with normal cognition having brains riddled with plaques? Do we have the right target? Is it possible to identify a monotherapeutic target for a chronic disease with metabolic derangements?
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What we actually need is whole-system redesign.

Hand in Hand--Couple Fights Alzheimer's Together

Even when one is diagnosed with an illness, it should not define them.
Photographer Allison Hess
I am choosing to celebrate today thinking about the day to day with my dad during his Alzheimer's journey. Not all bad days, not all good days, but precious memories all the same. Read the article above for a heartfelt series of photographs and observations by Allison Hess.

"It's not what you look at that matters, it's what you see"--Thoreau

8/31/2016

 
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I wasn't clear if I wanted to write this post here or over on data & donuts. I have been quiet here as I prepare the book proposal for review although a google alert informs me of potentially buzz worthy information about Alzheimer's disease research. If you are like me, and interested in the science of discovery filtered with statistical rigor and scientific evidence--consider this post a useful tool offering insights applicable to a variety of therapeutic interests but faithful to clinical evidence regardless of your lens.

The quality of the research in many disease states is low but particularly misleading in Alzheimer's disease. My thoughts are a discussion around challenges making the best clinical decisions at the point of care with a fire hose of published literature reporting disparate findings aimed at your head.

The article below discusses the results of an 18 question survey evaluating the rates of risks and benefits of medical interventions, confidence in responses to questions, knowledge of statistical terms, and awareness of campaigns reporting high-value care recommendations.

Physician Understanding and Ability to Communicate Harms and Benefits of Common Medical Treatments

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To make educated decisions, patients must understand harms and benefits of treatments. Unfortunately, patients consistently overestimate benefits and underestimate harms of medical tests and procedures.(Hoffmann  and Del Mar)   Likewise, physicians are poor at assessing treatment effect size and other aspects of numeracy.-- Krouss, Croft, and Morgan
Shared-decision making has evolved from a good idea to a business model. Seriously, did we actually need policy to remind us that patients are an integral part of their care decisions? But here is the problem. There is a lack of context and benchmark understanding of fundamental considerations such as numeracy and the risk/benefit profile of many interventions.

In addition, before we can find value in patient survey findings we must understand the research methodology. Were the questions designed to capture the right data to answer your research questions? Did the measurement include value statements from both the healthcare providers AND the patients? Remember it is called "shared decision making" and we can't underestimate the need to integrate both sets of needs and awareness. Select your domains carefully. It doesn't make much sense to explore domains that never integrate if we hope to bring collaborative care forward as a framework or ideal.

The graphic below includes responses to survey questions evaluating harms and benefits of listed interventions. Each dot represents a physician response to the survey question-- green dots indicate correct answers, red are incorrect, 
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Number needed to treat (NNT), number needed to harm (NNH), and number needed to screen (NNS) are all point of care effect size estimations. Many of the groups I work with are surprised by the ease of calculating from data often provided in the clinical literature.
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I wrote a guide book to help improve numeracy in medicine. It reminds me of a Lonely Planet travel guide you might pick up before your trip to Paris. Can you make the trip without tailored advice? Perhaps but you might not find the insights and destinations unique to your journey.

Travel well my friends. 
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    Bonny

    A medical writer and insight analyst focuses the lens on the evolution of Alzheimer's Disease as a diagnosis into a billion dollar healthcare juggernaut

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