Bow Hunter's Syndrome Part 3: Wresting diagnosis and treatment from the jaws of modern medicine

The author, probably a horse

Doctors are trained, when faced with an unusual set of symptoms, to diagnose the patient as having an unusual presentation of a common problem, rather than a rare disease presenting in its normal way. As my pediatrician-mother likes to put it, "When you hear hoof beats, don't think of a zebra, it's probably a horse." This advice likely serves many doctors well. That odd looking rash on the baby's bum really is more likely to be an atypical diaper rash than amoebic tushitis.

The problem with this policy is those patient who truly are zebras. We are inevitably mistaken for, and treated as, horses. Before I knew of Bow Hunter's Syndrome, I saw two primary care physicians at the same office about my vertigo-dizziness- tinnitus-faintness-etc. symptoms. The first was sure I was depressed, asked if I had "heard of psychosomatic," and walked out when I insisted I was a zebra. The second, two weeks later, told me I was terribly allergic to my new home and would have to move out of town, closer to the sea, immediately. Shortly thereafter I had my first, and worst, "Bow Hunter's Stroke."

Luckily, none of the doctors at the clinic were free to see me that day, and I was shunted to their nurse practitioner. Nurse-practitioners, unlike M.D.s, have listening skills. I described the whole thing to her, and she immediately saw my stripes. I was no horse. She sent me for an ultrasound of my carotid arteries (to check if the main blood supply to my head was obstructed) which gave me a vital clue. While checking the carotid arteries, the technologist always did the vertebral arteries too. While both looked normal on the ultrasound (which was taken with my head in neutral position) this was my first inkling that a blockage of vertebral arteries was even possible.

I'm not going to describe in detail the extraordinarily stressful process of literature searching, doctor-switching, insurance switching, specialist bouncing, bureaucracy fighting, scans, rescans, etc. In short, I found Rotational Vertebral Artery Compression Syndrome in the literature, was struck by how exactly the case studies approximated me, and spent a year actively working toward official diagnosis and treatment, culminating in a near-fatal but successful surgery. There are several key lessons I learned along the way that I want to share with other putative sufferers of Bow-Hunter's Syndrome:

1. No doctor is going to bother to manage your care, but you have to let them pretend they are going to manage your care. Managing your own care is a full time job you have to do. Keep lists. Call every day to find out if a slot has opened up, remind people of things they already know, catch their errors, force them to communicate with you and each other, advocate for yourself. This difficult process was somewhat ameliorated by the fact that I am a white male with a greying beard. Bring an old white man with you, there are plenty of us around.

2. Bow Hunter's Syndrome can only be definitively diagnosed by comparing blood flow through your vertebral arteries when you head is in a neutral position to when it is in a position that brings on your symptoms. Make sure your doctor is explicit about this need in ordering imaging. Medical technologists are often not willing to take imaging with your head turned. They are trained to do everything in a neutral position, and if you explain why it has to be done with your head turned, they will worry you are going to pass out in their expensive machine or onto their legally-liable floor. Call ahead several days before your x-ray, CT, MRI, whatever, and insist on talking with the technologist to be sure it will be done as ordered. They will tell you they need to consult with the radiologist, who will want to talk to your doctor, who won't be available, etc.

On the day of your scan, if the technologist won't unequivocally confirm that your scan will be done both straight and with your head turned far enough to induce symptoms, you must refuse to get in their machine. Stand there shivering in the buttless gown and calmly insist that they do the scan the way your doctor ordered it. If they tell you their MRI machine doesn't have space for you to turn your head, tell them they have to put on the coil after your head is already turned. If they insist the condition you are describing doesn't exist, whip out a published description. Walk out if you have to. Failing to do this once delayed my care by four months and cost me several thousand dollars because once the scan was done wrong, my insurance wouldn't approve the same scan again. I had to change to more expensive insurance and doctors, start the process from scratch, and learn to insist.

3. The ultimate confirmation of Bow-Hunter's Syndrome comes from fluoroscopic angiography with arterial catheterization. This means they take video of x-ray dye moving through your vertebral arteries, with your head in various positions. The dye is delivered through a small tube that is inserted through an incision into your thigh and wormed up as far as the back of your brain. I found the moments when they were squirting dye into my brain to be the most painful of the entire experience, despite the sedation and pain killers. However after this procedure no one questioned my self-diagnosis.

4. The most common surgery for Bow Hunter's Syndrome is called decompression. This means they made more space around one of my vertebral arteries (one unobstructed vertebral artery is generally enough to keep your brain stem ticking) by removing a piece of the bone that wraps around it on the side of my first cervical vertebra. Such decompressions are done for a variety of syndromes that are more common than Bow Hunter's Syndrome, and it is this fact that very nearly killed me.

Surgeons are very busy people, and generally make physicians look like excellent listeners. My surgeon performs a fair number of decompressions, but mine was his first for Bow Hunter's Syndrome. His protocol for this surgery starts with having another surgeon carve a path to the bone. Then he takes over and turns the patient's head for a clearer view of his work grinding away bone without damaging other important bits. You know, and I know, and he knew, that turning my head cut off the blood supply to my brainstem. He did it anyway. That was the next step in his protocol, he had not had time to think this through, and I had failed to manage my own care on this point. Several minutes later, when they checked, no blood was flowing through my vertebral arteries. He guessed it was measurement error, and had another machine sent. Still no blood flow. They righted my head, glued me up in a hurry, and went to scare the life out of my poor wife. Luckily, they frappéd jargon with indirectness and she didn't understand what had happened until after it was clear that I hadn't been killed. My brain stem responded well to the return of blood and I was out of the hospital the next morning. Recovery to the point of feeling better than before surgery took me about three months.

5. Finally, as this is now long, they insisted I would need opioids after my spine surgery. I did not. Accept them if you need to, don't assume that you will need to.

I'm happy to be your support group of one if you're wondering if this diagnosis is yours. I'm a Ph.D. though, not an M.D., so be aware that I can only offer one zebra's perspective.

Bow Hunter's Syndrome Part 2: What, with a dab of why

Bow Hunter's Syndrome is named for people who shoot arrows at wildlife. In order to do so, they have to turn their heads hard to one side and hold that position until they are ready to shoot. Attempting this with Bow Hunter's Syndrome lands them in the emergency room, and sometimes gets the actual attention of a doctor, who will occasionally figure out what is going on, possibly provide treatment, and if they've gone to that much bother, almost certainly publish a report mentioning said venery.

That case study might refer to this condition as Rotational Vertebral Artery Compression Syndrome. The vertebral arteries are the main blood supply to the brain stem, one of those body parts humans can't do without, not even for a few seconds. There is one vertebral artery on each side of your spine, running up through tunnels in your cervical vertebrae, the spine bones in your neck. When a healthy person moves their head, each artery has enough space to wiggle in these tunnel, so that it doesn't get compressed, kinked, stretched, or otherwise lose flow. Rotational Vertebral Artery Compression Syndrome means that rotating your head pinches your vertebral arteries, usually at the joint between the two uppermost vertebrae, reducing or eliminating flow of blood to your brain stem. The various other names this condition goes by mostly include the word "insufficiency" referring to the shortage of oxygen in your brain stem, which is what causes the actual symptoms.

About those symptoms: tinnitus (a buzzing sometimes in both ears, sometimes just in my left), vertigo, dizziness, mental fatigue, and faintness, increased gradually over several years during which I did not notice that head position had anything to do with it. I would consistently feel dizzy while shopping in the grocery store, not noticing any connection to turning my head from side to side trying to find unsweetened pickles. Long after others had recovered from some cold, I would have lingering vertigo and a sense of mental fog. I gave up my habit of sleeping on my belly, which allowed me to fall asleep very quickly, but from which I eventually decided I was waking feeling tired and unwell. My first autumn in Wisconsin I wondered if I was wrapping my scarf too tight because I would start to feel like I was going to faint every time I tried to back my car out of the driveway. Attempts to discuss all of this with doctors were frequent but unproductive.

The symptoms became debilitating only after an accidental blow to the top of my spine that winter. I was diagnosed with a concussion, and because most of the symptoms of Bow Hunter's Syndrome are consistent with a concussion, I looked no further. Most of a year later, having recovered only slightly, I was a passenger in my moving van (on the way to California) when it turned over on the highway, flexing my neck too far forward. After that, the observation that the position of my neck had both immediate and lingering effects on my symptoms became unavoidable.

The blaring clue to my addled brain came from my new neighbors' fig tree. Having permission to pick, I was straining to reach a fig well above my head. I looked up, turned my head to the side, stretched my arm, and collapsed. My eyeballs were shaking, my vision went black, and the tinnitus became unimaginably loud, louder than the human ear could withstand if real sound was involved. I was breathing, but felt the urgent need to come up for air. I brought my head back to neutral and the screeching tsunami gradually receded, light started to return, the spinning slowed. I had survived my first "Bow Hunter's Stroke." I put that phrase in quotes because unlike a real stroke, no tissue damage showed on scans afterwards. My brain stem hadn't lost living tissue, just power. The medical jargon for such an event is a transient ischemic attack. My doctors were no more than puzzled.

In the fifteen months since then, I went through thousands of abstracts, scores of full scientific papers, two insurance companies, four primary care providers,  three neurologists and a wide variety of other specialists, countless imaging studies, three interventions including a poorly planned major surgery that nearly killed me right there on the table, and months of recovery before I could considered myself past Bow Hunter's Syndrome. All worth it. I'll dig around in the key pieces of that in Bow Hunter's Syndrome Part 3: Wresting diagnosis and treatment from the jaws of modern medicine.

Bow Hunter's Syndrome Part 1: A Survivors' Support Group of One

My doctor looked like I had just puked in his shoes, but eventually took the papers I was holding out to him. This was a better response than I had expected, but still I could tell he would not look at them. I switched doctors, and with the next one emailed him the papers after our appointment. He wrote the referral I needed but declined to see me for months thereafter, going so far as to change an in-person appointment for a possible broken wrist to a phone appointment, after I was already in his parking lot.

The only thing a doctor likes less than a patient walking in with an obscure self-diagnosis they found on the internet is when the patient brings the medical literature about that diagnosis for the doctor to read. I knew this, but also that my doctors had not heard of Rotational Vertebral Artery Compression Syndrome, and that I needed treatment for it. Adding insult to injury, my obscure self-diagnosis would eventually be unquestionably confirmed and successfully treated.

This same condition goes by multiple names in the medical literature including Rotational Vertebral Artery Compression Syndrome, Positional VertebrobasilarIschemia, Positional Vertebrobasilar Insufficiency, and Bow Hunter's Syndrome. This last name is the least descriptive, but also the shortest and least jargony, so I tend to use it.

Bow Hunter's Syndrome is quite rarely diagnosed. There are perhaps a few hundred cases documented in the medical literature, total, globally. This could mean that it is a rarely occurring condition, but given the lengths I had to go to get it diagnosed, the severity of those cases that are documented, and the peculiar circumstances that allowed me to reach diagnosis, I suspect rather that it is an only slight uncommon condition which generally goes undiagnosed. As a neurological condition not caused by any neurological defect, Bow Hunter's Syndrome tends to fall through the cracks.

I was able to diagnose my own case because I have a Ph.D. in biology, loquacious physicians as parents, and extensive experience finding obscure scientific literature outside my field of expertise. I knew I had something, as most patients do, but I also knew how to search the scientific literature for conditions associated with terms like "cervical vertigo," "rotational stenosis," "positional tinnitus," and "nystagmus,"  then skim through the results, read those papers that seemed most relevant, follow citations back and forth, improve my search terms, and so on to a diagnosis. What I had to figure out was how to then navigate Earth's most wasteful medical system (USA! USA!) to arrive at an official diagnosis and ultimately treatment, and I had to do all of this while suffering the symptoms of Bow Hunter's Syndrome (including vertigo, ringing in my ears, dizziness, intermittently blurred vision, and faintness).

The good news is that I am largely recovered from it, and from the surgery that resolved it.

The bad news is that I will be posting here a series of short essays with the hope of making this process slightly easier for other sufferers of Bow Hunter's Syndrome, a purpose which I do hereby gleefully acknowledge will horrify all medical professionals that happen upon this. There are, so far as I can tell, no popular accounts, no support groups, no blog posts written for the uninitiated, describing what Bow Hunter's Syndrome is, what it feels like, how to approach being a patient with it. Perhaps soon more patients will be wobbling into their doctors' offices mumbling about the blood supply to their brain stem and a condition the doctor has never heard of. One can hope.

Next: Bow Hunter's Syndrome Part 2: What, with a dab of why

Then: Bow Hunter's Syndrome Part 3: Wresting diagnosis and treatment from the jaws of modern medicine

Why we cosleep with our infant and you (perhaps) should too

The feeling of a soft little one gradually melting into my arms is lovely, and I wouldn't soon give up rocking my baby to sleep. That said, shifting from foot to foot in the dark several hundred times night after night can get repetitive. So tonight, as I was rocking little Peregrine, I set myself an intellectual challenge. I was going to simultaneously count how many times I shifted from foot to foot and plan out this blog post. It turned out that after only 564 rocks he woke up and demanded to be nursed, but I will write what I planned anyway.

Peregrine is now almost two months old, and we've slept with him in our bed with us from the very beginning, as we did with both his older sisters. I can hear the million voices crying out in horror, but hold on and let me explain why. The benefits, I hope are obvious (snuggles, not needing to wake up to nurse the baby, baby sleeping better, family bonding, etc.) but most people (in the US anyway) don't sleep in the same bed as their baby, don't feel allowed to, because the public health advice is that it can cause the infant to strangle or suffocate.

Zero day old Peregrine cosleeping (don't tell the nurses)

Our three children were born in Germany, Denmark and Wisconsin, respectively, and we have learned to be quite skeptical of official advice and cultural mandates that vary wildly from place to place. Advice regarding infant suffocation risk certainly depends on where one lives. When we told our Japanese friends how strongly Americans are cautioned against cosleeping, they were surprised and amused. In Japan, apparently, the official advice and common practice is for the baby to sleep between the mother and father, like Lancelot's sword (misplaced cultural reference, I know.) Our German friend warned us strongly against letting our cat near our baby, as a smothering would surely ensue.

Tigerlily and Flopper, dressed for Halloween

As an American scientist with a professional interest in early mortality, and with kids, I of course looked up the science upon which the American advice is based. The most common reference regarding the risks of cosleeping is:
Blair et al. (1999). Babies sleeping with parents: case-control study of factors influencing the risk of the sudden infant death syndrome. British Medical Journal. 319, 1457-1462.
There are more recent papers on this conducted in several countries, and as far as I can see none of them have basically contradicted Blair et al.'s clearly stated "Key messsages" (sic):

Key messsages

• Cosleeping with an infant on a sofa was associated with a particularly high risk of sudden infant death syndrome
• Sharing a room with the parents was associated with a lower risk
• There was no increased risk associated with bed sharing when the infant was placed back in his or her cot
• Among parents who do not smoke or infants older than 14 weeks there was no association between infants being found in the parental bed and an increased risk of sudden infant death syndrome
• The risk linked with bed sharing among younger infants seems to be associated with recent parental consumption of alcohol, overcrowded housing conditions, extreme parental tiredness, and the infant being under a duvet

Now, my wife and I do not smoke, do not drink, are not sleeping on a sofa, do not put the baby under a duvet, do not have overcrowded housing conditions and are merely very, rather than extremely, tired. As this 2016 study makes clear, cosleeping is often associated with overcrowding because people in poverty don't have the money for an extra room or an extra bed. Poverty increases the risk of almost all causes of death, especially infant deaths, and much of the risk from cosleeping may actually be risk from poverty. Our baby is under 14 weeks, but according to Blair et al.'s findings, without these other risk factors (particularly smoking), there is no increased risk associated with cosleeping, even for neonates.

Not child endangerment (with Tigerlily)

Other studies have added parental obesity and extreme youth as risk factors. I am certainly overweight by the standard definition, but not obese. We are not particularly young parents. But still, if there is any risk at all of rolling over onto the baby, wouldn't it be safer to have him in a crib in another room? Emphatically, disastrously, not. Blair et al. write, "There was an increased risk for ... infants who slept in a separate room from their parents." Their estimate, that having the baby sleep in another room increases risk by about ten times, has been revised by more recent research to increasing risk by about half. Long story short, having the baby in a separate room is dangerous, while having him in our bed with us presents no documented risk compared to a good modern crib.

This presents two obvious questions: How should parents who aren't trained in interpreting regression tables make this decision? And, why is the official US advice (which resembles that in several other countries) what it is?
My interpretation, based on Blair et al., and the studies that have followed from their work: Always sleep in the same room as the baby. (Shockingly, this has only now become the advice from the American Academy of Pediatrics)  Never sleep on the couch with the baby (they tend to roll into the cracks, and this is truly dangerous). Don't cosleep with a baby under 14 weeks old if you are a smoker, are under the influence, are obese, are overcrowded (which is associated with poverty and all its ills), or are otherwise difficult to wake. If those risk factors don't apply to you, there are hundreds of hours of baby snuggling available to you, and you can decide to take them or leave the baby in a proper crib in your room. Quitting smoking is astoundingly good for your children's survival, even if you don't smoke inside the home.

Now why is the official advice a simple, "Never cosleep," or starker versions thereof? Because official advice has to be short and simple to be effective. My paragraph of advice, above, is 150 words. "Never cosleep" is two. "Don't live in poverty," would be great, if people were given the opportunity of escaping. People are, on the whole, really bad at following complex advice, and really good at finding reasons why things don't apply to them. Have my wife and I really never used a duvet with a baby? Questionable. Am I really overweight rather than obese? I haven't weighed myself in over a year. How tired is "extremely?" Have I ever fallen asleep on the couch with a baby? Certainly. You see, it gets messy, and it is easier for officialdom to just say, "No."

Baby Kestrel sleeping on the couch with Big Sister. Closely supervised.

So my message to you, should you be in the position of choosing where to sleep your baby is to make an informed decision. Good slogans are rarely good advice, and extensive snuggles are one of the things babies need most.

This baby (Kestrel) is not asleep. A desk drawer is not a proper crib.

Hear Ye

I've created a website for myself.

There are already sites* about me and my science, but these are boilerplate formatted things that are not really useful in communicating what I do and why. Sensible suggestions on improvements or additions to the new site are welcome.

*such as:
http://findresearcher.sdu.dk:8080/portal/da/person/levitis
http://www.demogr.mpg.de/en/institute/staff_directory_1899/daniel_a_levitis_2233.htm

More D

Old dried fruit bits mixed with crumbs of my daughter's favorite crackers, all spilling from a torn, unmarked plastic bag: an excellent find. Pumpkin seeds scattered on the shelf along with some paprika and vegi-broth powder: perfect. The back of the pantry is just the place when the bird-seed runs low. I have these bursts of energy, enough to refill the bird-feeder, before the coughing and the need to clutch the nearest wall return. The antibiotics have basically cleared the mycoplasma out of my lungs and ears, but the underlying virus is still there.

When the vitamin D deficiency was diagnosed, the nurse told me to take 10µg of supplement a day and come back in three months for another blood test. I didn't entirely expect to continue being sick for that whole three months, but that seems to be the result. A friend at work told me he takes 70mg of vitamin D a day, which is 7,000 times as much as I am taking, so I decided to do some research about dosage. He must mean 70µg, as he is still alive. 

Different countries recommend somewhere between 10µg and 30µg per day for a healthy adult, and levels up to 100µg per day are considered entirely safe, and EU guidelines recommend this level for patients with very low serum vitamin D levels (which I have). So my piddling 10µg plus whatever tiny bits I get from my diet (they don't add vitamins to dairy here, and I'm a vegetarian) and the no sunlight I encounter probably isn't alleviating my deficiency all that fast. So I've decided to take dosage into my own hands. I'm going to start taking 50µg per day, and scale back if and when my blood test shows that I have a healthy level. I would need to take thrice that much for several months to risk vitamin D toxicity. 

In the mean time, I will slump against this wall and watch the birds on the feeder. The magpie really likes those paprika-flavored raisins.

Have I mentioned?

I'm now the Secretary/Treasurer of the Evolutionary Demography Society, which now exists. I'll be starting as an Assistant Professor at the University of Southern Denmark in January. We'll be moving to Odense the middle of the month. I have a terrible head cold and need to catch up on sleep. I'll soon have my first lab group that officially exists. My daughter can finally use a spoon without getting most of the food on everything but her mouth. The African violet on my desk is blooming very nicely. My cat is down to a relatively healthy weight, but I am not. I am going to sleep.

I, flotsam.

Certain relatives of mine cling to the fantasy that I will be able to decide where I get a job, so as to live within a few miles of them. While the sentiment is appreciated, and shared, the reality is that I have almost no say in where I end up.

Let's review a few facts. First, the US economy is still in the shitter, if slightly less deep in than a few years ago. Lots of people, regardless of their industry, are moving wherever for whatever job they can get. Maybe there is some profession where you can just up and move where you want and be confident of making a living there, but I'm not sure what profession that would be at this point.

Second, even in good times, academics can almost never pick a city and get a job there. For hundreds of years academics have been moving to whatever University has a position for them. I'm reading a book about Alexander von Humboldt, who was one of the greatest scientists of the late 1700s and early 1800s, and even he keeps going from country to country looking for a patron and encountering academics working far from their own countries. There are extraordinarily few academics who can simply contact a University of interest and based on their scientific reputation be confident of getting a job there. Once you've won a Nobel Prize your chances are good. Barring that, good luck.

Third, I have done what most of the academic establishment says scientists should do, but very few fully do, because it makes publishing and job-hunting that much harder. My work is so damn interdisciplinary and specific that I am unlikely to fit the particular job description a small disciplinary department at a college or university is likely to write. I am on an email list for an online bulletin board for evolutionary biologists called EvolDir, and every few days I get an email for some position somewhere in the world that they are trying to fill. Here are a few of the most recent entry-level faculty positions:
•"There are several openings for Bioinformaticians and Software Developers at the University of Glasgow (UK)."
•The City University of New York seeks candidates with expertise "in tropical ecology, biogeography, evolutionary ecology, and conservation biology."
•" Tel Aviv University (ISRAEL) invites ... applicants who apply modern approaches to investigate fundamental problems in the general area of Plant Ecology. "
•UC Riverside "invites applications for a faculty position in plant evolutionary developmental biology."

These are positions I would bother applying for. This is not to say that I won't find anything, but rather that even if Near My Relatives U does decide to advertise for a new professor, they are more likely to be looking for an expert in the genomic analysis of primate fecal samples than they are a developmental evolutionary demographer. When I am ready to apply for positions, the question will not be, "Is that biking distance from my relatives?" but rather, "am I plausibly qualified for that position and is it a place where my wife is willing to live?" If it is, I'll need to apply. It is most likely that positions I do apply for will be among the relatively few broadly defined positions in evolutionary biology, with no further disciplinary restrictions. I very much approve of such broad-net casting, but it tends to lead to many hundreds of applications, as everyone in the field qualifies, so my chances with any one such position are slim.

If the economy were to improve dramatically, I could plausibly limit my search to within 1000 miles of my family. As it is, that limit will be about 12000 miles.

Spanning the vastness

When I was but a lad, my siblings and I used to accuse my father of knowing everything, a charge he would always deny, observing that even excluding those things which are not known to anyone or are secret, and restricting ourselves to academic knowledge, there is more to know than any one person or any thousand people could possibly know.

To see why this is so, consider the sheer volume of scientific literature being produced. ISI Web of Knowledge, an online tool used primarily by scientists for finding scientific literature relevant to their work, indexes the contents of over 23,000 academic and scientific journals. Many lesser known, newer or otherwise less main-stream or traditional journals are not indexed at all. One needs to go to other databases to find information published in books, or in dissertations, or, or, or.

Like my father (as I am in most things), I find myself far too mortal to know any meaningful fraction of anything, even if we restrict ourselves just to academic biology. I'd say there are roughly 8000 peer-reviewed journals in which biological work is regularly published, and if you add up all the papers I skim through, it is probably the equivalent number of pages of the output of two or three of these. The papers I read in detail if assembled together would surely make up much less than the output of a single journal. And I put more time into reading and therefore less into writing than is optimal for my career.

One result of this is that I frequently find out that there exist thriving sub-disciplines of biology of which I have almost no knowledge. For example, only last week I for the first time heard the word "metabolomics." Google Scholar lists over 6000 papers in the last year on this rapidly expanding field about which I know no more than I could guess based on the name.

My knowledge of transcriptomics was quite as absent three years ago. Transcriptomics is the study of RNAs in the cell, generally in the context of gene expression patterns. I became interested in transcriptomics because I proposed that mortality risk during embryonic development would be highest at those stages at which gene expression patterns were changing fastest. I was a doctoral student at the time, and my adviser asked me if there was any way of testing this idea. I had to admit I didn't know if it was possible to test because I didn't know enough about the field I have since learned is called transcriptomics. The answer is that yes, there is a way of testing the idea, but it will cost a couple of hundred thousand dollars, and require collaboration with people who read different journals than I do. I will never be an expert in transcriptomics, but I can find a colleague who is, but has little knowledge of evolutionary demography, and invite him to collaborate on a project that combines our expertise. And this is why science can be a somewhat unified pursuit despite having far more product than one person can read even the titles of.  

I referred in my last post to one of my advisers at Berkeley, and one of my all around favorite human beings, Ron Lee. Ron would always advise me to think about my relative advantage, by which he meant I shouldn't just work on the most interesting or best questions, as there are far too many. Rather, I should choose among them by considering which questions I was better placed, given my strengths and resource, to answer than was anyone else likely to work on the question. Ron's advice has always served me well, and so I do consider this before starting any project. Frequently, as with this developmental transcriptomics and demography project, my relative advantage arises from the fact that I am combining two fields separated enough that no one else is likely to ask the question any time soon. Evolutionary demography and developmental biology do not, as a rule, talk to each other. Many fields of biology have almost no communication with each other, leaving vast unexplored interdisciplinary territories (unless that is all in some set of journals I haven't come across yet).

33 weeks LMP

There is a certain irony to being to a researcher who studies mortality risk early in life, and also a soon-to-be father. Sometimes I feel I know way too much about certain topics.

Blame the vehicle

I'm on a medicine that helps tremendously with the neuropathic pain associated with Levitis Syndrome. It is often prescribed for neuropathies associated with diabetes, and while there apparently no similarity between the two disorders other than the peripheral neuropathies they cause, this stuff seems to help with both. I recently went to my doctor for a refill, and she prescribed the tablet form, where I had been taking the slow-release capsule in the same dosage. Two days after switching to the tablets, I suddenly started getting these sharp distinctive pains in my hands and wrist again, and the surgical scars on my palms are looking angry. So this morning I went back to my doctor, and this being Germany got to see her within 20 minutes. I am back on the capsules, and I hope the problem is solved. I really would love to understand what is going on with my neurophysiology that the difference between a tablet and a capsule makes such a difference. I don't think it is even understood why neuropathic pain happens, or why some compounds interfere with it, so I don't have much hope of understanding the pharmacokinetics. I just hope the stuff keeps working.

Passed round one

They said they would get back to me in December, but I was starting to doubt, as today is effectively the last working day of the year for those few Germans who aren't already on vacation. But I got the email this morning.

I've been invited to give a short talk on my research to the committee deciding which applicants will be invited to form Research Groups. The interview will be mid-February in Berlin, and I should know very shortly after that if my application was successful.

This means I have a month and a half to write a talk, make impressive figures and graphs, and so forth. The hardest part for me in writing the talk is figuring out who my audience is. The committee that wants to interview me is from the Human Sciences Section. This includes institutes focusing on anthropology, economics, art-history, law, religious and ethnic studies, linguistics, sociology, the history of science and the study of cognition. It also includes demography, evolutionary anthropology and a fair bit of other natural sciences. I can't simply give the same talk to a group of biologists and demographers that I would give to a committee of lawyers and ethnographers. I don't yet know if the committee as a whole will be judging my talk, in which case I have to assume a great diversity of background, or if they will have a smaller group of specialists assigned to each talk. I can give a good talk either way, but not both simultaneously. I've got some thinking to do.

Winter

This morning as Iris and I sat and ate breakfast, we watched a mixture of leaves, rain and snow swirl upwards past our 18th floor (19th by American counting) window. If the winters here were only as windy as Chicago, or cold as New York, or dark as southern Alaska, or damp as Seattle, or foggier than San Francisco, I wouldn’t mind so much. But they are all of these things. The wind howls through everything, bringing cold and wet to each cranny.

I have found that the best strategy for keeping my bad hip from minding the weather is to make sure I am absurdly over-dressed. This morning I walked to work, in temperatures above freezing, wearing high insulated shoes, long-underwear, lined pants, a heavy over-shirt, a down parka and thick gloves, hat and scarf. I was sweating the whole time, but my hip felt fine.

All of this does not endear the city to my heart, and yet I hope I will be here another five years. The grant application that is taking most of my time is to establish a research group of my own, funded by the Max Planck Society for five years. There are three responses they could make to my application. They could say no, they could say yes and let me form the research group here, or they could say yes but tell me to form it at a different Max Planck Institute, in a different city (i.e., Cologne).

I indicate in my application that my first choice is to stay here (at MPIDR), not out of love for the climate, but because of MPIDR’s, “strength in evolutionary demography would be a great benefit to me. I have ongoing collaborations with several MPIDR researchers, including members of the Research Groups on Lifecourse Dynamics and Demographic Change, and Modeling the Evolution of Aging, and of the Laboratories of Statistical Demography, Survival and Longevity, and Evolutionary Biodemography. As my project draws on evolutionary and demographic theory, on MPIDR's Human Mortality Database and Biodemographic Database, on laboratory experiments and survey data, MPIDR’s mixture of social science and biology is the ideal environment for me.”

Add to that that we have good friends, Iris enjoys teaching at the University here, we like our colleagues, we have a great apartment, and moving (which we have done far to much of) is a pain in the rear, and I am very much hoping to stay here. That said, if they offer me a group in Cologne, we will certainly go, in the spring.

Good news

As I have mentioned here before, I am applying for a big grant. (I may have more time to post here after that grant application is in.) My chances of getting that grant, or at least my personal estimation of my chances, have just gotten a lot better. This is because the review article, in which I do my best to lay out the whole field I plan to focus on, has been accepted for publication by the Proceedings of the Royal Society B. The B is for biology, as they split the journal into topics some decades back. Still the Roy. Soc. is a most venerable publisher. They published Darwin. They published Newton. They have published, well, tens of thousands of authors by now. It is the 350th anniversary of the society, But still, it is a very prestigious journal, and basing my application on a paper in press with them is a hell of a lot better than basing it on the same paper when it hadn't been accepted for publication anywhere. I wrote to a few journals (lower impact ones) who didn't even want to look at it. Having a single author, 10 page review article published with Proc. Roy. Soc. one year after I finished grad school is certainly going to improve my chances. I hope. The timing is good, as the application is due on Wednesday, and I only sent it to them three weeks ago. Most journals take months to give authors an answer. The two anonymous reviewers they sent it to had only very minor suggestions for edits (the first pointed out three typos and stopped at that), so it should be in print, or at least online, very soonish.

The point of a review article is to give an overview of the field. What is know, what is hypothesized, what are the important questions, where is the field going. I have been thinking about the topic of this one on and off for perhaps seven years, but if you put together all the time I specifically spent on it, it would be about six months of work, most in the last year. Perhaps half of that was spent just searching out the relevant literature. I must have read several thousand article titles, perhaps 500 abstracts, and maybe 200 full papers and book chapters. 91 sources made it into the final paper, and 18 more into the appendixes. The reason I had to do so much preliminary literature searching is that no one has ever written a review on this topic before, and perhaps four of the authors whose ideas and data I draw on had this general topic in mind.

Now, part of publishing with them and most other journals these days is that the paper is embargoed until they say it ain't. Embargoed means I can't tell the press what I found out, or even what the article is about, before the journal has a chance to publish it. But for the curious and bored, I can share the list of articles I reference. Just looking through them gives a sense of the range of journals I was searching in. Archiv fur Hydrobiologie, The American Journal of Tropical Medicine and Hygiene, Entomol. Exp. Appl, American Statistician, Obstetrical & Gynecological Survey, Can. J. Fish. Aquat. Sci., Experimental Gerontology, The Auk, Annals: New York Academy of Sciences, Biol. Reprod, Maturitas, Administrative Science Quarterly, J. Herpetol., Ophelia, Genetica, Journal of the Institute of Actuaries and so on. I am lucky in that I didn't have to actually scan the tables of contents of the several thousand journals that could potentially have had relevant papers. I used Google Scholar, Web of Science and other literature searching tools. I have no idea how they did this sort of thing before the internet.

Like a good playbill, in order of appearance:

Main Article:
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57. Hanley, M. E., Fenner, M. & Edwards, P. J. 1995 The effect of seedling age on the likelihood of herbivory by the slug Deroceras reticulatum. Funct. Ecol. 9, 754-759.
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59. Hallock, P. 1985 Why are larger foraminifera large? Paleobiology 11, 195-208.
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61. Greeff, J. M., Storhas, M. G. & Michiels, N. K. 1999 Reducing losses to offspring mortality by redistributing resources. Funct. Ecol., 786-792.
62. Klug, H. & Bonsall, M. B. 2007 When to care for, abandon, or eat your offspring: the evolution of parental care and filial cannibalism. The American Naturalist 170, 886.
63. Manica, A. 2002 Filial cannibalism in teleost fish. Biological Reviews 77, 261-277.
64. Lee, R. D. 2003 Rethinking the evolutionary theory of aging: Transfers, not births, shape senescence in social species. Proc. Natl. Acad. Sci. USA 100, 9637-9642.
65. Rogers, A. R. 2003 Economics and the evolution of life histories. Proc. Natl. Acad. Sci. USA 100, 9114-9115.
66. Lee, R. 2008 Sociality, selection, and survival: Simulated evolution of mortality with intergenerational transfers and food sharing. Proc. Natl. Acad. Sci. USA 105, 7124-7128.
67. Rumrill, S. S. 1990 Natural mortality of marine invertebrate larvae. Ophelia 32.
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Appendix 1.
1. Bourgeois-Pichat, J. 1946 De la mesure de la mortalité infantile. Population 1, 53-68.
2. Bourgeois-Pichat, J. 1951 La mesure de la mortalité infantile. II. Les causes de décès. Population 6, 459-480.
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4. Carnes, B. A., Holden, L. R., Olshansky, S. J., Witten, M. T. & Siegel, J. S. 2006 Mortality partitions and their relevance to research on senescence. Biogerontology 7, 183-198.
5. Siler, W. 1979 A competing-risk model for animal mortality. Ecology 60, 750-757.
6. Gage, T. B. 1998 The comparative demography of primates: with some comments on the evolution of life histories. Annual Review of Anthropology 27, 197-221.
7. Heligman, L. & Pollard, J. H. 1980 The age pattern of mortality. Journal of the Institute of Actuaries 107, 49–80.
8. Lee, E. T. & Go, O. T. 1997 Survival analysis in public health research. Annu. Rev. Public Health 18, 105-134.
9. Ndirangu, J., Newell, M. L., Tanser, F., Herbst, A. J. & Bland, R. 2010 Decline in early life mortality in a high HIV prevalence rural area of South Africa: evidence of HIV prevention or treatment impact? AIDS 24, 593.


Appendix 2
1. Bishop, M. W. H. 1964 Paternal contribution to embryonic death. Reproduction 7, 383-396.
2. Wilcox, A. J., Weinberg, C. R., O'Connor, J. F., Baird, D. D., Schlatterer, J. P., Canfield, R. E., Armstrong, E. G. & Nisula, B. C. 1989 Incidence of early loss of pregnancy. Obstetrical & Gynecological Survey 44, 147.
3. Boklage, C. E. 1990 Survival probability of human conceptions from fertilization to term. International Journal of Fertility 35, 75-94.
4. O'Connor, K. A., Holman, D. J. & Wood, J. W. 1998 Declining fecundity and ovarian ageing in natural fertility populations. Maturitas 30, 127-136.
5. Hassold, T. & Hunt, P. 2001 To err (meiotically) is human: the genesis of human aneuploidy. Nature Reviews Genetics 2, 280-291.
6. Beatty, R. A. 2008 The genetics of the mammalian gamete. Biological Reviews 45, 73-117.
7. Wilmut, I., Sales, D. I. & Ashworth, C. J. 1986 Maternal and embryonic factors associated with prenatal loss in mammals. Reproduction 76, 851-864.
8. Bloom, S. E. 1972 Chromosome abnormalities in chicken (Gallus domesticus) embryos: types, frequencies and phenotypic effects. Chromosoma 37, 309-326.
9. Forstmeier, W. & Ellegren, H. 2010 Trisomy and triploidy are sources of embryo mortality in the zebra finch. Proc. R. Soc. Lond., Ser. B: Biol. Sci.

Cold Season

"I woke today and found the frost perched on the town
it hovered in a frozen sky, and gobbled summer down."
-Joni Mitchell

Rostock has its first real frost this morning. In anticipation of this event, the first bad cold of the year has been going around. I think about half the Institute has gotten it so far. I have been sick to varying degrees for a week now. Without having actually looked at the relevant research, my understanding is that we get so many more colds when it gets colder because the airborne viruses break down much more slowly when the areas cold and dry and sunlight is weak. I've also heard somewhere that the cold air makes mucous membranes more susceptible to viruses. This all makes sense, and helps explain why that other common airborne virus that spreads every year, the flu, also concentrates in winter, but it leaves me wondering this: is the pattern the same in species that are adapted to highly seasonal climates? Humans are basically a tropical species that construct tropic-like microclimates for ourselves wherever we go. Our ancestors a few thousand generations ago would not have experienced the yearly cold season as we do today. Moose on the other hand have been living in cold climates forever. Their bodies should expect high virus conditions every winter and prepare accordingly. I speculate that the immune systems of such animals are seasonal, being better at fighting airborne viruses in the winter, and perhaps skin fungus is in the summer. I wouldn't personally want to do the experiments to find out, but I would read the paper if somebody else wrote it.

Big grant, small grant application

Applying for a grant is nothing new, but this one is big, at least by the standards of the grants have applied for previously. The Max Planck Society sponsors Independent Research Groups, headed by a promising young scientist to explore some innovative and important niche. My task is to convince them I am promising and young, and that my work is innovative and important. They don't actually say young, they say "early career," for which I qualify, as I just got my PhD last year. I'm also fairly confident that my work is innovative, as everyone I tell about my work tells me that nobody else has thought about the question. The problem is, "nobody else has thought about the question," can be taken to mean, "who could possibly be interested in that?" So I am young and innovative, and my challenge is to seem promising and important.

Assuming I can convince them of these things, more so than the many other applicants, it will be a pretty sweet deal. They will not only give me a significantly increased salary for five years and enough funding to get my experiments going, they will pay for me to hire a couple of graduate students and a postdoc or two. Frankly, this is more of a career advance than I think I am likely to receive at this point.

The nice part, other than the generosity of the award should I get it, is how little work they ask of me for the application. They want only a one-page statement of my Scientific Accomplishments (I'm not sure what these are yet) plus 2 pages of Research Plans. I could give them 20 pages of research plans with little difficulty if my hands worked well, but under the circumstances I'm much happier to give them 2.

How my health issues will work into this whole application is an interesting question. There is no doubt that I would have been more productive this year and in grad school had been healthy, but I doubt that they can or should take this into consideration. The best I can hope for is that one of my letter writers will mention something about dedication to science or gumption or the fact that I just keep coming back, like a bad case of poison ivy.

On a more philosophical level, I can ask this question: if someone has a disability which interferes with their productivity, and is likely to continue interfering with their productivity, should an employer consider how productive the worker would be without the disability, or should they simply asked of each candidate, "how productive is he/she likely to be?" I would like to say the former, but from the employer's point of view, it's hard to make the case against the latter.

On the other hand, my joint problems potentially make me better qualified to think of the questions and tell other people to gather the necessary data to answer them than I am for actual data gathering and analysis. The higher they promote me, the more qualified I may be.

The news from me

I've just started using Dragon 11, the latest version of the dictation software I've gotten used to over the last few months. I was on version 8, and over some months of using it fairly intensively it had gotten pretty good at recognizing my voice and words. This new version does about as good a job as the old one did, maybe a bit better, but without the months of training. I haven't yet tried out how it works with other applications, in Excel, PowerPoint, Firefox, etc. but at least word it seems to work surprisingly well for never having heard my voice before.

I had carpal tunnel surgery on my left hand about a month ago and am pleased to report that had very little numbness or tingling since then in that hand. I still have pain around where the incision was and some of the internal cuts but they assure me that will fade with time. I'm having the same surgery on my right hand on Monday. I'm supposed to be on sick leave for all of next week, but I suspect I'll end up coming in to use the dictation software, as I don't have it at home (I have a Mac it works on PC.) I hope that by the end of the year I'll be able to use my hands fairly normally again.

I also just found out today that a large grant application I need to submit is due on November 17. This may interfere somewhat with my plans to post here more regularly.

Look Ma, ...

I find myself unable to use my hands for very much of anything, and wondering how to be a productive scientists given this peculiar handicap. The problem is not that I lack hands, I have them and they looked perfectly complete, if slightly blue. The problem is not even I can operate them, I have full control and enough strength to do most simple tasks. Rather my problem is that I mustn't use my hands, for a fight to the swell up become quite painful and remain so for some time. It's not yet entirely clear why this is, so for the time being the blame Levitis Syndrome.

There are many jobs for which not using one's hands would be a greater problem than they are for me as a scientist. A carpenter, a cellist, or a cashier would be much less able to work around this problem and I am. Furthermore, there is extremely little short-term pressure for me to get anything done. In the long term, I have to publish papers to keep my job and move to better jobs in the future. In the short term I want to get things done simply because it is too frustrating to not do so.

I'm using dictation software which, now that I've used for some time, is quite quick and accurate for creating text. Not quite as fast as typing, but a hell of a lot faster than I thought dictation software was before I started using it. I have students to do my lab work for me, I'm not doing any field work, and I have access digitally most of the literature I need. Given all this, why should a small matter like hands make much of a difference?

In practice, there are all sorts of things that I find myself unable to do. The dictation software supposed to make it possible to use many different programs, for surfing the web, analyzing data, sending e-mails and so on; in fact many of these thing are quite difficult to do without moving the mouse or touching the keys. Writing code is extraordinarily difficult. Reading heavy paper books is quite hard. Many software tools are simply inaccessible.

My latest stratagem is to order a mouse controlled by foot. The ability to point and click should solve many of my problems, in combination with this dictation software.

The other challenge of being productive despite my hands, is one of concentration. Doing things so differently requires a lot of thought about how I do them, which distracts me from the ideas and tasks to concentrate on. In addition to that, my hands hurt, tingle, throb and otherwise distract me. I am frankly not so good at ignoring it to the point that I can think deeply.

Ultimately, my hands will probably get better with time and coddling. When that happens, I can add dictation software and foot-controlling a mouse to my long list of random and not particularly useful skills. Until then, I'll be studying the list of available voice commands and wearing slip ons.

Brain melt.

I have been sick to various degrees, and with various different bugs, continuously for the last three weeks. Tonight I am developing a fever again.

It is very hard to get any science done while I am sick. Partly there is the general lack of energy, lack of focus and slow mental activity. But I also make the weirdest mistakes while I am sick. I send people emails with the same sentence three times in a row phrased slightly differently each time, without realizing I am repeating myself. I decide that I have accidentally deleted all my emails when in fact I am just looking at the wrong mailbox. I write a thought that pertains to one paper into a different paper, then have trouble figuring out which paper it is.

I understand that my body is scaling back on certain activities (such as cognition) so as to be able to go all out on others (immune response), but honestly given the quantity of lipids I am carrying around I would think a little bit of multitasking could be supported.

Stupid Eustachian tube tricks

From Wikipedia:

Some people are born with an ability to voluntarily contract just these muscles called Voluntary Tubal Opening, similar to the ability of those who can wiggle their ears. Those who have this ability can hear "pop" or "click" sound in the middle ear when actuating these muscles, and are able to hold the muscle contraction (some refer to this as 'clicking your ears to equalize the pressure').[citation needed] Doing so will make one's voice sound louder to oneself. This ability allows such people to voluntarily equalize pressures at will when making rapid ascents or descents, typically in aircraft flights or large elevation changes in either tall buildings or mountainous treks.

I am one of these people, although clearing my ears without swallowing wasn't something I was aware I could do until I took SCUBA classes some years ago. When I do this it makes a click loud enough that my wife can hear it if she puts her head close to mine. Unfortunately this doesn't seem to help in clearing a lingering ear infection, as I can't currently get my left ear to click.