The effect of different radiological models on diagnostic accuracy and lung cancer screening performance.


High false-positive (FP) scan rates associated with low-dose computed tomography (LDCT) lung cancer screening result in unnecessary follow-up tests and exposure to harm. The definition of a ‘positive’ scan can impact FP rates and screening performance. We explored the effect of Lung Imaging Reporting and Data System (Lung-RADS) criteria, PanCan Nodule Malignancy Probability Model and varying nodule size thresholds (≥4 mm, ≥6 mm, ≥8 mm) on diagnostic accuracy and screening performance compared with original trial definitions (National Lung Screening Trial (NLST) criteria) in a secondary analysis of a lung cancer screening cohort. We found Lung-RADS criteria and the PanCan Nodule Malignancy Probability Model could substantially improve screening performance and reduce FP scan rates compared with NLST definitions of positivity but that this needs to be balanced against possible risk of false-negative results.

source: BMJ THORAX

Daniel Dennett’s Science of the Soul.

The tree of life grew, its branches stretching toward complexity. Organisms developed systems, subsystems, and sub-subsystems, layered in ever-deepening regression. They used these systems to anticipate their future and to change it. When they looked within, some found that they had selves—constellations of memories, ideas, and purposes that emerged from the systems inside. They experienced being alive and had thoughts about that experience. They developed language and used it to know themselves; they began to ask how they had been made.

 This, to a first approximation, is the secular story of our creation. It has no single author; it’s been written collaboratively by scientists over the past few centuries. If, however, it could be said to belong to any single person, that person might be Daniel Dennett, a seventy-four-year-old philosopher who teaches at Tufts. In the course of forty years, and more than a dozen books, Dennett has endeavored to explain how a soulless world could have given rise to a soulful one. His special focus is the creation of the human mind. Into his own he has crammed nearly every related discipline: evolutionary biology, neuroscience, psychology, linguistics, artificial intelligence. His newest book, “From Bacteria to Bach and Back,” tells us, “There is a winding path leading through a jungle of science and philosophy, from the initial bland assumption that we people are physical objects, obeying the laws of physics, to an understanding of our conscious minds.”

Dennett has walked that path before. In “Consciousness Explained,” a 1991 best-seller, he described consciousness as something like the product of multiple, layered computer programs running on the hardware of the brain. Many readers felt that he had shown how the brain creates the soul. Others thought that he’d missed the point entirely. To them, the book was like a treatise on music that focussed exclusively on the physics of musical instruments. It left untouched the question of how a three-pound lump of neurons could come to possess a point of view, interiority, selfhood, consciousness—qualities that the rest of the material world lacks. These skeptics derided the book as “Consciousness Explained Away.” Nowadays, philosophers are divided into two camps. The physicalists believe, with Dennett, that science can explain consciousness in purely material terms. The dualists believe that science can uncover only half of the picture: it can’t explain what Nabokov called “the marvel of consciousness—that sudden window swinging open on a sunlit landscape amidst the night of non-being.”

Late last year, Dennett found himself among such skeptics at the Edgewater Hotel, in Seattle, where the Canadian Institute for Advanced Research had convened a meeting about animal consciousness. The Edgewater was once a rock-and-roll hangout—in the late sixties and seventies, members of Led Zeppelin were notorious for their escapades there—but it’s now plush and sedate, with overstuffed armchairs and roaring fireplaces. In a fourth-floor meeting room with views of Mt. Rainier, dozens of researchers shared speculative work on honeybee brains, mouse minds, octopus intelligence, avian cognition, and the mental faculties of monkeys and human children.

At sunset on the last day of the conference, the experts found themselves circling a familiar puzzle known as the “zombie problem.” Suppose that you’re a scientist studying octopuses. How would you know whether an octopus is conscious? It interacts with you, responds to its environment, and evidently pursues goals, but a nonconscious robot could also do those things. The problem is that there’s no way to observe consciousness directly. From the outside, it’s possible to imagine that the octopus is a “zombie”—physically alive but mentally empty—and, in theory, the same could be true of any apparently conscious being. The zombie problem is a conversational vortex among those who study animal minds: the researchers, anticipating the discussion’s inexorable transformation into a meditation on “Westworld,” clutched their heads and sighed.


Dennett sat at the seminar table like a king on his throne. Broad-shouldered and imposing, with a fluffy white beard and a round belly, he resembles a cross between Darwin and Santa Claus. He has meaty hands and a sonorous voice. Many young philosophers of mind look like artists (skinny jeans, T-shirts, asymmetrical hair), but Dennett carries a homemade wooden walking stick and dresses like a Maine fisherman, in beat-up boat shoes and a pocketed vest—a costume that gives him an air of unpretentious competence. He regards the zombie problem as a typically philosophical waste of time. The problem presupposes that consciousness is like a light switch: either an animal has a self or it doesn’t. But Dennett thinks these things are like evolution, essentially gradualist, without hard borders. The obvious answer to the question of whether animals have selves is that they sort of have them. He loves the phrase “sort of.” Picture the brain, he often says, as a collection of subsystems that “sort of” know, think, decide, and feel. These layers build up, incrementally, to the real thing. Animals have fewer mental layers than people—in particular, they lack language, which Dennett believes endows human mental life with its complexity and texture—but this doesn’t make them zombies. It just means that they “sort of” have consciousness, as measured by human standards.

Dennett waited until the group talked itself into a muddle, then broke in. He speaks slowly, melodiously, in the confident tones of a man with answers. When he uses philosophical lingo, his voice goes deeper, as if he were distancing himself from it. “The big mistake we’re making,” he said, “is taking our congenial, shared understanding of what it’s like to be us, which we learn from novels and plays and talking to each other, and then applying it back down the animal kingdom. Wittgenstein”—he deepened his voice—“famously wrote, ‘If a lion could talk, we couldn’t understand him.’ But no! If a lion could talk, we’d understand him just fine. He just wouldn’t help us understand anything about lions.”

“Because he wouldn’t be a lion,” another researcher said.

“Right,” Dennett replied. “He would be so different from regular lions that he wouldn’t tell us what it’s like to be a lion. I think we should just get used to the fact that the human concepts we apply so comfortably in our everyday lives apply only sort of to animals.” He concluded, “The notorious zombie problem is just a philosopher’s fantasy. It’s not anything that we have to take seriously.”

“Dan, I honestly get stuck on this,” a primate psychologist said. “If you say, well, rocks don’t have consciousness, I want to agree with you”—but he found it difficult to get an imaginative grip on the idea of a monkey with a “sort of” mind.

If philosophy were a sport, its ball would be human intuition. Philosophers compete to shift our intuitions from one end of the field to the other. Some intuitions, however, resist being shifted. Among these is our conviction that there are only two states of being: awake or asleep, conscious or unconscious, alive or dead, soulful or material. Dennett believes that there is a spectrum, and that we can train ourselves to find the idea of that spectrum intuitive.

“If you think there’s a fixed meaning of the word ‘consciousness,’ and we’re searching for that, then you’re already making a mistake,” Dennett said.

“I hear you as skeptical about whether consciousness is useful as a scientific concept,” another researcher ventured.

“Yes, yes,” Dennett said.

“That’s the ur-question,” the researcher replied. “Because, if the answer’s no, then we should really go home!”

“No, no!” Dennett exclaimed, as the room erupted into laughter. He’d done it again: in attempting to explain consciousness, he’d explained it away.

In the nineteenth century, scientists and philosophers couldn’t figure out how nonliving things became living. They thought that living things possessed a mysterious life force. Only over time did they discover that life was the product of diverse physical systems that, together, created something that appeared magical. Dennett believes that the same story will be told about consciousness. He wants to tell it, but he sometimes wonders if others want to hear it.

“The person who tells people how an effect is achieved is often resented, considered a spoilsport, a party-pooper,” he wrote, around a decade ago, in a paper called “Explaining the ‘Magic’ of Consciousness.” “If you actually manage to explain consciousness, they say, you will diminish us all, turn us into mere protein robots, mere things.” Dennett does not believe that we are “mere things.” He thinks that we have souls, but he is certain that those souls can be explained by science. If evolution built them, they can be reverse-engineered. “There ain’t no magic there,” he told me. “Just stage magic.”

It’s possible to give an account of Dennett’s life in which philosophy hardly figures. He is from an old Maine family. By the turn of the eighteenth century, ancestors of his had settled near the border between Maine and New Hampshire, at a spot now marked by Dennett Road. Dennett and his wife, Susan, live in North Andover, Massachusetts, a few minutes’ drive from Tufts, where Dennett co-directs the Center for Cognitive Studies. But, in 1970, they bought a two-hundred-acre farm in Blue Hill, about five hours north of Boston. The Dennetts are unusually easygoing and sociable, and they quickly became friends with the couple next door, Basil and Bertha Turner. From Basil, Dennett learned to frame a house, shingle a roof, glaze a window, build a fence, plow a field, fell a tree, butcher a hen, dig for clams, raise pigs, fish for trout, and call a square dance. “One thing about Dan—you don’t have to tell him twice,” Turner once remarked to a local mechanic. Dennett still cherishes the compliment.

“Seriously, lady, at this hour you’d make a lot better time taking the subway

In the course of a few summers, he fixed up the Blue Hill farmhouse himself, installing plumbing and electricity. Then, for many years, he suspended his academic work during the summer in order to devote himself to farming. He tended the orchard, made cider, and used a Prohibition-era still to turn the cider into Calvados. He built a blueberry press, made blueberry wine, and turned it into aquavit. “He loves to hand down word-of-mouth knowledge,” Steve Barney, a former student who has become one of the Dennetts’ many “honorary children,” says. “He taught me how to use a chain saw, how to prune an apple tree, how to fish for mackerel, how to operate a tractor, how to whittle a wooden walking stick from a single piece of wood.” Dennett is an avid sailor; in 2003, he bought a boat, trained his students to sail, and raced with them in a regatta. Dennett’s son, Peter, has worked for a tree surgeon and a fish biologist, and has been a white-water-rafting guide; his daughter, Andrea, runs an industrial-plumbing company with her husband.

A few years ago, the Dennetts sold the farm to buy a nearby waterfront home, on Little Deer Isle. On a sunny morning this past December, fresh snow surrounded the house; where the lawn met the water, a Hobie sailboat lay awaiting spring. Dennett entered the sunlit kitchen and, using a special, broad-tined fork, carefully split an English muffin. After eating it with jam, he entered his study, a circular room on the ground floor decorated with sailboat keels of different shapes. A close friend and Little Deer Isle visitor, the philosopher and psychologist Nicholas Humphrey, had e-mailed a draft of an article for Dennett to review. The two men are similar—Humphrey helped discover blindsight, studied apes with Dian Fossey, and was, for a year, the editor of Granta—but they differ on certain points in the philosophy of consciousness. “Until I met Dan,” Humphrey told me, “I never had a philosophical hero. Then I discovered that not only was he a better philosopher than me; he was a better singer, a better dancer, a better tennis player, a better pianist. There is nothing he does not do.”

Dennett annotated the paper on his computer, and then called Humphrey on his cell phone to explain that the paper was so useful because it was so wrong. “I see how I can write a reaction that is not so much a rebuttal as a rebuilding on your foundations,” he said, mischievously. “Your exploration has helped me see some crucial joints in the skeleton. I hope that doesn’t upset you!” He laughed, and invited Humphrey and his family to come over later that day.

He then turned to a problem with the house. Something was wrong with the landline; it had no dial tone. The key question was whether the problem lay with the wiring inside the house or with the telephone lines outside. Picking up his walking stick and a small plastic telephone, he went out to explore. Dennett has suffered a heart attack and an aortic dissection; he is robust, but walks slowly and is sometimes short of breath. Carefully, he made his way to a little gray service box, pried it open using a multitool, and plugged in the handset. There was no dial tone; the problem was in the outside phone lines. Harrumphing, he glanced upward to locate them: another new joint in the skeleton.

During the course of his career, Dennett has developed a way of looking at the process by which raw matter becomes functional. Some objects are mere assemblages of atoms to us, and have only a physical dimension; when we think of them, he says, we adopt a “physicalist stance”—the stance we inhabit when, using equations, we predict the direction of a tropical storm. When it comes to more sophisticated objects, which have purposes and functions, we typically adopt a “design stance.” We say that a leaf’s “purpose” is to capture energy from sunlight, and that a nut and bolt are designed to fit together. Finally, there are objects that seem to have beliefs and desires, toward which we take the “intentional stance.” If you’re playing chess with a chess computer, you don’t scrutinize the conductive properties of its circuits or contemplate the inner workings of its operating system (the physicalist and design stances, respectively); you ask how the program is thinking, what it’s planning, what it “wants” to do. These different stances capture different levels of reality, and our language reveals which one we’ve adopted. We say that proteins fold (the physicalist stance), but that eyes see (the design stance). We say that the chess computer “anticipated” our move, that the driverless car “decided” to swerve when the deer leaped into the road.


A running joke among people who study consciousness is that Dennett himself might be a zombie. (“Only a zombie like Dennett could write a book called ‘Consciousness Explained’ that doesn’t address consciousness at all,” the computer scientist Jaron Lanier has written.) The implicit criticism is that Dennett’s account of consciousness treats the self like a computer and reflects a disengagement from things like feeling and beauty. Dennett seems wounded by this idea. “There are those wags who insist that I was born with an impoverished mental life,” he told me. “That ain’t me! I seem to be drinking in life’s joys pretty well.”

Dennett’s full name is Daniel Clement Dennett III. He was born in Boston in 1942. His father, Daniel C. Dennett, Jr., was a professor of Islamic history, who, during the Second World War, was recruited by the Office of Strategic Services and became a secret agent. Dennett spent his early childhood in Beirut, where his father posed as a cultural attaché at the American Embassy. In Beirut, he had a pet gazelle named Babar and learned to speak some Arabic. When he was five, his father was killed in an unexplained plane crash while on a mission in Ethiopia. In Dennett’s clearest memory of him, they’re driving through the desert in a Jeep, looking for a group of Bedouins; when they find the camp, some Bedouin women take the young Dennett aside and pierce his ears. (The scars are still visible.)

After his father’s death, Dennett returned to the Boston suburbs with his mother and his two sisters. His mother became a book editor; with some guidance from his father’s friends, Dennett became the man of the house. He had his own workshop and, aged six, used scraps of lumber to build a small table and chair for his Winnie-the-Pooh. As he fell asleep, he would listen to his mother play Rachmaninoff’s Piano Prelude No. 6 in E-Flat Major. Today, the piece moves him to tears—“I’ve tried to master it,” he says, “but I could never play it as well as she could.” For a while, Dennett made money playing jazz piano in bars. He also plays the guitar, the acoustic bass, the recorder, and the accordion, and can still sing the a-cappella tunes he learned, in his twenties, as a member of the Boston Saengerfest Men’s Chorus.

As a Harvard undergraduate, Dennett wanted to be an artist. He pursued painting, then switched to sculpture; when he met Susan, he told her that she had nice shoulders and asked if she would model for him. (She declined, but they were married two years later.) A photograph taken in 1963, when Dennett was a graduate student, shows him trim and shirtless in a courtyard in Athens, smoking a pipe as he works a block of marble. Although he succeeded in exhibiting some sculptures in galleries, he decided that he wasn’t brilliant enough to make a career in art. Still, he continued to sculpt, throw pots, build furniture, and whittle. His whittlings are finely detailed; most are meant to be handled. A life-size wooden apple comes apart, in cross-sections, to reveal a detailed stem and core; a fist-size nut and bolt turn smoothly on minute, perfectly made threads. (Billed as “haptic sculptures,” the whittles are currently on display at Underdonk, a gallery in Brooklyn.)

Dennett studied philosophy as an undergraduate with W. V. O. Quine, the Harvard logician. His scientific awakening came later, when he was a graduate student at Oxford. With a few classmates, he found himself debating what happens when your arm falls asleep. The others were discussing the problem in abstract, philosophical terms—“sensation,” “perception,” and the like—which struck Dennett as odd. Two decades earlier, the philosopher Gilbert Ryle, Dennett’s dissertation adviser, had coined the phrase “the ghost in the machine” to mock the theory, associated with René Descartes, that our physical bodies are controlled by immaterial souls. The other students were talking about the ghost; Dennett wanted to study the machine. He began teaching himself neuroscience the next day. Later, with the help of various academic friends and neighbors, Dennett learned about psychology, computer programming, linguistics, and artificial intelligence—the disciplines that came to form cognitive science.

“I’ll go shop around for a doctor.”

One of Dennett’s early collaborators was Douglas Hofstadter, the polymath genius whose book about the mind, “Gödel, Escher, Bach: An Eternal Golden Braid,” became an unlikely best-seller in 1979. “When he was young, he played the philosophy game very strictly,” Hofstadter said of Dennett. “He studied the analytic philosophers and the Continental philosophers and wrote pieces that responded to them in the traditional way. But then he started deviating from the standard pathway. He became much more informed by science than many of his colleagues, and he grew very frustrated with the constant, prevalent belief among them in such things as zombies. These things started to annoy him, and he started writing piece after piece to try to destroy the myths that he considered these to be—the religious residues of dualism.”

Arguments, Dennett found, rarely shift intuitions; it’s through stories that we revise our sense of what’s natural. (He calls such stories “intuition pumps.”) In 1978, he published a short story called “Where Am I?,” in which a philosopher, also named Daniel Dennett, is asked to volunteer for a dangerous mission to disarm an experimental nuclear warhead. The warhead, which is buried beneath Tulsa, Oklahoma, emits a kind of radiation that’s safe for the body but lethal to the brain. Government scientists decide on a radical plan: they separate Dennett’s brain from his body, using radio transmitters implanted in his skull to allow the brain, which is stored in a vat in Houston, to control the body as it approaches the warhead. “Think of it as a mere stretching of the nerves,” the scientists say. “If your brain were just moved over an inch in your skull, that would not alter or impair your mind. We’re simply going to make the nerves indefinitely elastic by splicing radio links into them.”

After the surgery, Dennett is led into the brain-support lab:

I peered through the glass. There, floating in what looked like ginger ale, was undeniably a human brain, though it was almost covered with printed circuit chips, plastic tubules, electrodes, and other paraphernalia. . . . I thought to myself: “Well, here I am sitting on a folding chair, staring through a piece of plate glass at my own brain. . . . But wait,” I said to myself, “shouldn’t I have thought, ‘Here I am, suspended in a bubbling fluid, being stared at by my own eyes’?” . . . . I tried and tried to think myself into the vat, but to no avail.

Toward the end of the story, the radio equipment malfunctions, and Dennett’s point of view is instantly relocated. It is “an impressive demonstration of the immateriality of the soul, based on physicalist principles and premises,” he writes, “for as the last radio signal between Tulsa and Houston died away, had I not changed location from Tulsa to Houston at the speed of light?” The story contains only neurons and machines, and is entirely materialist; even so, it shows that you aren’t situated “in” your brain the same way you’re situated “in” a room. It also suggests that the intuitions upon which philosophers so confidently rely are actually illusions created by an elaborate system of machinery.

Only rarely do cracks in the illusion of consciousness appear through which one might see the machinery at work. Proust inspected the state between sleep and wakefulness. Coleridge experimented with mind-altering drugs. Neuroscientists examine minds compromised by brain injury. Dennett’s approach has been to look back into evolutionary history. In the minds of other animals, even insects, Dennett believes, we can see the functional components upon which our selfhood depends. We can also see the qualities we value most in human selfhood in “sort of” form. Even free will, he thinks, evolves over evolutionary time. Your amygdala, the part of the brain that registers fear, may not be free in any meaningful sense—it’s effectively a robot—but it endows the mind to which it belongs with the ability to avoid danger. In this way, the winding path leads from determinism to freedom, too: “A whole can be freer than its parts.”

Along with Richard Dawkins, Sam Harris, and the late Christopher Hitchens, Dennett is often cited as one of the “four horsemen of the New Atheism.” In a 2006 book called “Breaking the Spell: Religion as a Natural Phenomenon,” he argued that religion ought to be studied rather than practiced. Recently, with the researcher Linda LaScola, he published “Caught in the Pulpit: Leaving Belief Behind,” a book of interviews with clergypeople who have lost their faith. He can be haughty in his dismissal of religion. A few years ago, while he was recovering from his aortic dissection, he wrote an essay called “Thank Goodness,” in which he chastised well-wishers for saying “Thank God.” (He urged them, instead, to thank “goodness,” as embodied by the doctors, nurses, and scientists who were “genuinely responsible for the fact that I am alive.”)

“You’d think a celebrity sex tape would display a higher degree of showmanship.”

Yet Dennett is also comfortable with religion—even, in some ways, nostalgic for it. Like his wife, he was brought up as a Congregationalist, and although he never believed in God, he enjoyed going to church. For much of his life, Dennett has sung sacred music in choirs (he gets misty-eyed when he recalls singing Bach’s “St. Matthew Passion”). He and Susan tried sending their children to Sunday school, so that they could enjoy the music, sermons, and Bible stories, but it didn’t take. Dennett’s sister Cynthia is a minister: “A saintly person,” Dennett says, admiringly, “who’s a little annoyed by her little brother.”

The materialist world view is often associated with despair. In “Anna Karenina,” Konstantin Levin, the novel’s hero, stares into the night sky, reflects upon his brief, bubblelike existence in an infinite and indifferent universe, and contemplates suicide. For Dennett, however, materialism is spiritually satisfying. In a 1995 book called “Darwin’s Dangerous Idea,” he asks, “How long did it take Johann Sebastian Bach to create the ‘St. Matthew Passion’?” Bach, he notes, had to live for forty-two years before he could begin writing it, and he drew on two thousand years of Christianity—indeed, on all of human culture. The subsystems of his mind had been evolving for even longer; creating Homo sapiens, Dennett writes, required “billions of years of irreplaceable design work”—performed not by God, of course, but by natural selection.

“Darwin’s dangerous idea,” Dennett writes, is that Bach’s music, Christianity, human culture, the human mind, and Homo sapiens “all exist as fruits of a single tree, the Tree of Life,” which “created itself, not in a miraculous, instantaneous whoosh, but slowly, slowly.” He asks, “Is this Tree of Life a God one could worship? Pray to? Fear? Probably not.” But, he says, it is “greater than anything any of us will ever conceive of in detail worthy of its detail. . . . I could not pray to it, but I can stand in affirmation of its magnificence. This world is sacred.”

Almost every December for the past forty years, the Dennetts have held a black-tie Christmas-carolling party at their home. This year, snow was falling as the guests arrived; the airy modern shingle-style house was decorated like a Yuletide bed-and-breakfast, with toy soldiers on parade. In the kitchen, a small robotic dog-on-wheels named Tati huddled nonfunctionally; the living-room bookshelf displayed a set of Dennett-made Russian dolls—Descartes on the outside, a ghost in the middle, and a robot inside the ghost.

Dennett, dapper in his tuxedo, mingled with the guests. With a bearded, ponytailed postdoc, he considered some mysteries of monkey consciousness; with his silver-haired neighbors, many of whom had attended the party annually since 1976, he discussed the Patriots and the finer points of apple brandy. After a potluck dinner, he called everyone over to the piano, where Mark DeVoto, a retired music professor, was noodling on “O Come, All Ye Faithful.” From piles on a Dennett-built coffee table, Dennett and his wife distributed homemade books of Christmas carols.

“Hello!” Dennett said. “Are we ready?” Surrounded by friends, he was grinning from ear to ear. “Let’s go. We’ll start with ‘O Come, All Ye Faithful.’ First verse in English, second in Latin!”

Earlier, I’d asked Susan Dennett how their atheism would shape their carol-singing. “When we get to the parts about the Virgin, we sometimes sing with our eyebrows raised,” she said. In the event, their performance was unironic. Dennett, a brave soloist, sang beautifully, then apologized for his voice. The most arresting carol was a tune called “O Hearken Ye.” Dennett sang the words “Gloria, gloria / In excelsis Deo” with great seriousness, his hands at his sides, his eyes faraway. When the carol faded into an appreciative silence, he sighed and said, “Now, that’s a beautiful hymn.”

Dennett has a philosophical arch-nemesis: an Australian named David Chalmers. Chalmers, who teaches at N.Y.U. and at the Australian National University, believes that Dennett only “sort of” understands consciousness. In his view, Dennett’s theories don’t adequately explain subjective experience or why there is an inner life in the first place.

Chalmers and Dennett are as different as two philosophers of mind can be. Chalmers wears a black leather jacket over a black T-shirt. He believes in the zombie problem and is the lead singer of a consciousness-themed rock band that performs a song called “The Zombie Blues.” (“I act like you act, I do what you do. . . . / What consciousness is, I ain’t got a clue / I got the Zombie Blues.”) In his most important book, “The Conscious Mind,” published in 1996, Chalmers accused Dennett and the physicalists of focussing on the “easy problems” of consciousness—questions about the workings of neurons or other cognitive systems—while ignoring the “hard problem.” In a formulation he likes: “How does the water of the brain turn into the wine of consciousness?” Since then, the “hard problem” has been a rallying cry for those philosophers who think that Dennett’s view of the mind is incomplete.

“Could we move the piece representing ourselves a little farther away from the battle?”

Consider your laptop. It’s processing information but isn’t having experiences. Now, suppose that every year your laptop gets smarter. A few years from now, it may, like I.B.M.’s Watson, win “Jeopardy!” Soon afterward, it may have meaningful conversations with you, like the smartphone voiced by Scarlett Johansson in “Her.” Johansson’s character is conscious: you can fall in love with her, and she with you. There’s a soul in that phone. But how did it get there? How was the inner space of consciousness opened up within the circuits and code? This is the hard problem. Dennett regards it, too, as a philosopher’s fantasy. Chalmers thinks that, at present, it is insurmountable. If it’s easy for you to imagine a conscious robot, then you probably side with Dennett. If it’s easier to imagine a robot that only seemsconscious, you’re probably with Chalmers.

A few years ago, a Russian venture capitalist named Dmitry Volkov organized a showdown between Dennett and Chalmers near Disko Island, off the west coast of Greenland. Before making a fortune investing in Shazam and in the Russian version of PayPal, Volkov was a graduate student in philosophy at Moscow State University, where he wrote a dissertation on Dennett’s work. Now he chartered a hundred-and-sixty-eight-foot schooner, the S/V Rembrandt van Rijn, and invited Dennett, Chalmers, and eighteen other philosophers on a weeklong cruise, along with ten graduate students. Most of the professional philosophers were materialists, like Dennett, but the graduate students were uncommitted. Dennett and Chalmers would compete for their allegiance.

In June, when the Arctic sun never sets, the lowlands of Disko are covered with flowering angelica. The philosophers piled into inflatable boats to explore the fjords and the tundra. The year before, in the Journal of Consciousness Studies, Dennett had published a paper called “The Mystery of David Chalmers,” in which he proposed seven reasons for Chalmers’s resistance to his views, among them a fear of death and a pointless desire to “pursue exhaustively nuanced analyses of our intuitions.” This had annoyed Chalmers, but on the cruise the two philosophers were still able to marvel, companionably, at the landscape’s alien beauty. Later, everyone gathered in the Rembrandt’s spacious galley, where Volkov, a slim, voluble man in sailor’s stripes, presided over an intellectual round-robin. Each philosopher gave a talk summarizing another’s work; afterward, the philosopher who had been summarized responded and took questions.

Andy Clark, a lean Scottish philosopher with a punk shock of pink hair, summarized Dennett’s views. He wore a T-shirt depicting a peacock with a tail made of screwdrivers, wrenches, and other tools. “It obviously looks like something quite colorful and full of complexity and ‘peacockness,’ ” he said. “But, if you look more closely, that complexity is actually built out of a number of little devices.”

“A Swiss Army peacock!” Dennett rumbled, approvingly. He was in his element: he loves parties, materialism, and the sea.

After the introduction and summarizing part was over, Chalmers, carrying a can of Palm Belgian ale, walked to the front of the room and began his remarks. Neurobiological explanations of consciousness focus on brain functions, he said. But, “when it comes to explaining consciousness, one needs to explain more than the functions. There are introspective data—data about what it’s like to be a conscious subject, what it’s like experiencing now and hearing now, what it’s like to have an emotion or to hear music.” He continued, “There are some people, like Dan Dennett, who think that all we need to explain is the functions. . . . Many people find that this is not taking consciousness seriously.” Lately, he said, he had been gravitating toward “pan-proto-psychism”—the idea that consciousness might be “a fundamental property of the universe” upon which the brain somehow draws. It was a strange idea, but, then, consciousness was strange.

Andy Clark was the first to respond. “You didn’t actually give us any positives for pan-psychism,” he said. “It was kind of the counsel of despair.”

Jesse Prinz, a blue-haired philosopher from cuny, seemed almost enraged. “Positing dualism leads to no further insights and discoveries!” he said.

Calmly, nursing his beer, Chalmers responded to his critics. He said that he couldmake a positive case for pan-proto-psychism, pointed out that his position wasn’t necessarily antimaterialist (a pan-psychic force could be perfectly material, like electromagnetism), and declared that he was all in favor of more neuroscientific research.

Dennett had lurked off to the side, stolid and silent, but he now launched into an argument about perspective. He told Chalmers that there didn’t have to be a hard boundary between third-person explanations and first-person experience—between, as it were, the description of the sugar molecule and the taste of sweetness. Why couldn’t one see oneself as taking two different stances toward a single phenomenon? It was possible, he said, to be “neutral about the metaphysical status of the data.” From the outside, it looks like neurons; from the inside, it feels like consciousness. Problem solved.

Chalmers was unconvinced. Pacing up and down the galley, he insisted that “merely cataloguing the third-person data” could not explain the existence of a first-person point of view.

Dennett sighed and, leaning against the wall, weighed his words. “I don’t see why it isn’t an embarrassment to your view,” he said, “that you can’t name a kind of experiment that would get at ‘first-personal data,’ or ‘experiences.’ That’s all I ask—give me a single example of a scientifically respectable experiment!”


“There are any number of experiments!” Chalmers said, heatedly. When the argument devolved into a debate about different kinds of experimental setups, Dennett said, “I think maybe this session is over, don’t you? It’s time to go to the bar!” He looked to Chalmers, who smiled.

Among the professional philosophers, Dennett seemed to have won a narrow victory. But a survey conducted at the end of the cruise found that most of the grad students had joined Team Chalmers. Volkov conjectured that for many people, especially those who are new to philosophy, “it’s the question of the soul that’s driving their opinions. It’s the value of human life. It’s the question of the special position of humans in the world, in the universe.”

Despite his affability, Dennett sometimes expresses a weary frustration with the immovable intuitions of the people he is trying to convince. “You shouldn’t trust your intuitions,” he told the philosophers on the Rembrandt. “Conceivability or inconceivability is a life’s work—it’s not something where you just screw up your head for a second!” He feels that Darwin’s central lesson—that everything in biology is gradual; that it arrives “not in a miraculous, instantaneous whoosh, but slowly, slowly”—is too easily swept aside by our categorical habits of mind. It could be that he is struggling with the nature of language, which imposes a hierarchical clarity upon the world that’s powerful but sometimes false. It could also be that he is wrong. For him, the struggle—a Darwinian struggle, at the level of ideas—continues. “I have devoted half a century, my entire academic life, to the project, in a dozen books and hundreds of articles tackling various pieces of the puzzle, without managing to move all that many readers from wary agnosticism to calm conviction,” he writes, in “From Bacteria to Bach and Back.” “Undaunted, I am trying once again.”

For many years, I took Chalmers’s side in this dispute. I read Dennett’s “Consciousness Explained,” but I felt that something crucial was missing. I couldn’t understand how neurons—even billions of neurons—could generate the experience of being me. Terrence Deacon, an anthropologist who writes about consciousness and neuroscience, refers to “the Cartesian wound that separated mind from body at the birth of modern science.” For a long time, not even the profoundly informed arguments that Dennett advanced proved capable of healing that wound.

Then, late last year, my mother had a catastrophic stroke. It devastated the left side of her brain, wrecking her parietal and temporal lobes and Broca’s area—parts of the brain that are involved in the emotions, the senses, memory, and speech. My mother now appears to be living in an eternal present. She can say only two words, “water” and “time.” She is present in the room—she looks me in the eye—but is capable of only fleeting recognition; she knows only that I am someone she should recognize. She grasps the world, but lightly.

As I spent time with my mother, I found that my intuitions were shifting to Dennett’s side of the field. It seems natural to say that she “sort of” thinks, knows, cares, remembers, and understands, and that she is “sort of” conscious. It seems obvious that there is no “light switch” for consciousness: she is present and absent in different ways, depending on which of her subsystems are functioning. I still can’t quite picture how neurons create consciousness. But, perhaps because I can take a stance toward my mother that I can’t take toward myself, my belief in the “hard problem” has dissolved. On an almost visceral level, I find it easier to accept the reality of the material mind. I have moved from agnosticism to calm conviction.

On a morning this past winter, Dennett sat in an armchair in his Maine living room. The sky and the water were blue and bright. He’d acquired two copies of the Ellsworth American, the local newspaper; later, he and Susan would sit by the fireplace and compete to see who could finish the crossword first. In the meantime, he was thinking about the nature of understanding. He recalled a time, many years ago, when he found himself lecturing a group of physicists. He showed them a slide that read “E=mc2” and asked if anyone in the audience understood it. Almost all of the physicists raised their hands, but one man sitting in the front protested. “Most of the people in this room are experimentalists,” he said. “They think they understand this equation, but, really, they don’t. The only people who really understand it are the theoreticians.”

“L.L. Bean.”NOVEMBER 26, 2007
“Understanding, too, comes in degrees,” Dennett concluded, back in his Maine living room. “So how do you take that last step? What if the answer is: ‘Well, you can only sort of take it’?” Physics, Dennett said, tells us that there are more than three dimensions, and we can use math to prove they’re there; at the same time, we struggle to picture them in our heads. That doesn’t mean they’re not real. Perhaps, he thought, the wholly material soul is similarly hard to imagine. “I’m not ready to say it’s unimaginable, because there are times when I think I can imagine it,” he said, “and then it doesn’t seem to be such a big leap at all. But—it is.”

Before the morning slipped away, Dennett decided to go out for a walk, down to where the lawn ended and a rocky beach began. He’d long delighted in a particular rock formation, where a few stones were piled just so, creating a peephole. He was disappointed to find that the tides had rearranged the stones, and that the hole had disappeared. The dock was pulled ashore for the winter, its parts stacked next to his sailboat. He walked down the steps anyway, occasionally leaning on his walking stick. For a few minutes, he stood at the bottom, savoring the frigid air, the lapping water, the dazzling sun.


We should never have told people to start taking vitamins.

It seems like simple, obvious advice: Eat your vegetables, get some exercise, and, of course, take your vitamins.

Or not.

Decades of research has failed to find substantial evidence that vitamins and supplements do any significant good.

Nevertheless, several shiny new pills and powders have materialized in recent years that promise to deliver health and wellness in ways no other vitamin has before.


One of them, called Ritual , arrives at your doorstep in a bright white and highlighter-yellow box. Inside, you’ll find a 1-month supply of pills. These aren’t your grandma’s vitamins. Each pill is a clear, glass-like capsule filled with a handful of tiny white beads that float suspended in oil.

Despite the fact that each pill is practically a work of art, Ritual’s pills don’t differ much from your standard vitamin. They contain less of some traditional vitamin ingredients that decades of research have shown we don’t need, but have similar amounts of magnesium, Vitamin K, folate, Vitamin B12, iron, boron, Vitamin E, and Vitamin D as a standard Alive-brand vitamin.

Another one of these newly-designed vitamins is Care/of , whose personalized daily vitamin packets come in a box that looks like a tea-bag dispenser with the words “Hi [your name],” printed on the top right corner. Again, the ingredients don’t differ drastically from those in conventional vitamins.

No matter how colorful their packaging or personal their messaging, all of these vitamin formulations fall prey to the exact same problem: We simply do not need vitamins to be healthy. Instead, we should be getting the nutrients that vitamin-makers peddle from the foods we eat.

“We use vitamins as insurance policies against whatever else we might (or might not) be eating, as if by atoning for our other nutritional sins, vitamins can save us from ourselves,” writes science reporter Catherine Price in the book ” Vitamania.

Here’s the thing: They can’t.

Virtually any registered dietitian, doctor, public health expert , or physician will likely reiterate some version of the advice health professionals have been giving for decades. Eat real food. Eat fruits and veggies. Eat in moderation. Stay away from processed foods and sugary beverages when you can. Or, in the words of the well-known journalist and food writer Michael Pollan , “Eat food. Not too much. Mostly plants.”

There’s another reason to stay away from most pills and powders: Some can be harmful. Several supplements have been linked with an increase in certain cancers , for example, while others have been associated with arisk of kidney stones .

In her book, Price suggests that this knowledge about vitamins might help us “rediscover something both surprising and empowering: that, while nutrition itself is amazingly complex, the healthiest, most scientific, and most pleasurable way to eat is not that complicated at all.”

Beauty Parlor Stroke Syndrome

beauty parlor stroke syndrome

Story at-a-glance

  • Vertebral artery dissection from hyperextension of the neck, otherwise known as beauty parlor stroke syndrome, can occur after having your hair washed in a salon
  • When your neck is hyperextended over the edge of a shampoo bowl, the pressure and/or whiplash-like motions on your neck can lead to a tear in the vertebral artery, which supplies blood to your brain
  • Many other common activities, including sneezing, coughing, vomiting, painting a ceiling and practicing yoga, can also cause this condition

In 2013, Elizabeth Williams, a California mother of two, did something you’ve probably done many times yourself: visited a hair salon for a cut and routine wash. Several days later, she began experiencing strange symptoms indicative of stroke, including weakness on her left side.

Doctors ultimately diagnosed her with a relatively rare condition called vertebral artery dissection from hyperextension of the neck,1 otherwise known as beauty parlor stroke syndrome.

The act of extending her neck over the shampoo bowl was deemed to be the culprit, although it’s unclear if the condition resulted solely from a kink in the neck or in combination with a certain head movement caused by the stylist.2

Smith, who subsequently filed a lawsuit against the salon, conducted an informal poll of her friends’ stylists and found 80 percent were familiar with the possibility that you could have a stroke while getting your hair washed.3

What Causes Beauty Parlor Stroke Syndrome?

When your neck is hyperextended over the edge of a shampoo bowl, the pressure and/or whiplash-like motions on your neck can lead to a tear in the vertebral artery, which supplies blood to your brain. Dr. Steven R. Zeiler, head of stroke research at Johns Hopkins, told BuzzFeed:4

“When one of those cervical arteries is damaged in some sort of way, you can get what’s called a dissection, which is damage of the inside of the blood vessel, leading to abnormal flow and clotting, and then those clots can shoot north into the brain and cause a stroke.”

Having your hair washed is not the only act that can cause this — far from it — although it’s very rare, even when all potential causes are considered.

In a conversation with The Atlantic, Dr. Richard Bernstein, medical director of the Comprehensive Stroke Center at Northwestern Memorial Hospital in Chicago, explained that the phenomenon can occur due to innocent stretching, sneezing or even getting out of bed wrong in the morning, noting, “It is so rare that it’s a waste of time to worry about it. It’s so unlikely, and there’s really nothing you can do to prevent it.”5

Other Confirmed Cases of Beauty Parlor Stroke Syndrome

Beauty parlor stroke syndrome is not unheard of in the medical literature, and some studies even dispute the phenomenon’s supposed rarity.

In the International Journal of Stroke, for instance, a 2016 study found that hairdresser-related ischemic cerebrovascular events (HICE) “occur frequently in females without a predilection for the posterior circulation.”6

The researchers noted that while some cases may occur by chance, in other cases hairdresser visits may have a causal role.

A 2006 case study also relates the case of a 63-year-old woman who developed sudden dizziness, nausea and vomiting while having her hair shampooed at a beauty parlor. She was diagnosed with beauty parlor stroke syndrome with the researchers noting:

“Taken together, hyperextension combined with hanging the head backwards in a hair washbasin can be seen as a risk factor for posterior circulation ischemia. It probably occurs more often than assumed …”7

Case in point: In December 2016 a U.K. man was awarded a more than $100,000 settlement from a hair salon after suffering a stroke two days after having his hair washed. The Daily Mail also reported another British woman who suffered a stroke in 2000 after having her hair washed at a salon.8

Cervical Support Reduced Dizziness and Other Symptoms During Hair Washing

Another study, this one published in 2002, examined symptoms of beauty parlor stroke syndrome among 25 volunteers who had previously reported dizziness during salon shampoos.

Among this population, significant dizziness, neck pain and carotid blood flow were reported while extending their necks over a salon sink, but the symptoms were significantly reduced when additional cervical support was used.

“Individuals with a history of such symptoms should probably exercise caution when deciding whether to receive a salon sink shampoo,” the researchers concluded.9

Yet another study in 2000 linked the hyperextended neck position during salon shampoos to cerebellum vascular insufficiency and recommended that “public education should lead to avoidance of this position during hair shampoo treatment at hair dressing salons.”10

While the risk of being injured during a salon shampoo is generally minimal, if you have experienced dizziness or other symptoms while having your hair washed previously, you may want to forgo the risk and wash your hair at home instead.

At the very least, some have suggested that adding a thick layer of towels to support your neck and reduce hyperextension may help.

Are There Risks to Getting Your Nails Done?

Hair washing is not the only potential risk at the beauty salon, particularly if you plan on getting your nails done. Nail salon services are big business in the U.S., amounting to $8.54 billion in spending in 2014.11

The fumes released by nail care products (and other beauty care products) is one concern, particularly for salon workers; however, the nail treatments themselves can also cause damage or infection to your nails.

Writing in The Journal of Clinical and Aesthetic Dermatology, researchers identified nail disorders that are induced by nail cosmetics via procedures meant to beautify the nail.12 On the contrary, many may lead to poor nail appearance and other risks.

“Known risks of traditional manicures include procedure-related infections (bacterial, fungal, mycobacterial and viral, including human papilloma virus and herpes simplex virus).

Inadequately sterilized instruments, such as clippers, blades, abrasive files, electric drills and footbaths, may harbor and abet the growth of micro-organisms.

Micro and macro-traumas may be induced through the cleaning, filing and trimming of cuticles, thus allowing the infiltration of micro-organisms.

Materials, such as nail polish and nail enhancers, contain certain chemicals that can serve as contact sensitizers when accidentally applied to periungual skin [skin around the nail].

Chemicals, including acrylates, formaldehyde and toluene sulphonamide-formaldehyde resin, may lead to contact dermatitis and chronic paronychia [an inflammatory disorder of the nail folds]. Primers and polish removers, which are largely solvents, can dry nails and contribute to brittleness.”13

Less common disorders that can be caused by a trip to the nail salon include:14

Mycobacterial infection, which can particularly occur from pedicure footbaths using equipment that is not properly sterilized or maintained with regular filter changes.

Peripheral neuropathy, a type of nerve damage that is a rare complication of acrylic nails, possibly due to methacrylates that are sometimes used in artificial nail products.

Nail thinning, weakness, brittleness, pseudo leukonychia (white spots), and onychoschizia lamellina (nail splitting), which may occur due to the removal of gel polish.

Worn down or overfilled nails, which is due to the mechanical trauma that occurs when acrylic nails are removed.

Traumatic onycholysis, the separation of the nail plate from the bed, is very common in people with acrylic nails.

It’s caused by inserting thin sharp objects in order to clean under the nails. According to the study, “These patients usually wear very long nails, and adhesion of the acrylic nail to the nail plate is stronger than adhesion of the nail plate to the nail bed.”

What Else Can Cause Vertebral Artery Dissection From Hyperextension of the Neck?

As mentioned, having your hair washed is only one precipitating factor. Dr. Wouter I. Schievink of the Cedars-Sinai Neurological Institute in Los Angeles suggested that every year 1 to 1.5 per 100,000 people may suffer from spontaneous vertebral artery dissection from hyperextension of the neck and may account for up to one-quarter of nonhemorrhagic strokes in young and middle-aged adults.15

Aside from having your hair washed in a beauty salon, other possible causes include chiropractic spinal manipulation, lifting heavy objects or even drinking a shot of alcohol (which is known as “bottoms-up dissection,” according to The New York Times).16

In the case of chiropractic manipulation, it’s thought that up to one-fourth of people who suffer an arterial dissection may have an underlying disorder or defect that predisposes them to the dissection, and related pain may be what prompts them to seek chiropractic care in the first place. The Times continued:17

“A champion swimmer developed a dissected carotid from doing too much backstroke. Dr. Schievink also lists precipitating events associated with hyperextension of the neck, including ‘’practicing yoga, painting a ceiling, coughing, vomiting and sneezing,’ as well as medical procedures like receiving anesthesia or being resuscitated and traumatic causes like motor vehicle accidents or sports injuries.

… There may also be an infectious factor in some cases, since the occurrence of carotid and vertebral artery dissections with no apparent cause peaks in the fall, when respiratory infections are most common.”

Writing in the Journal of Korean Neurosurgical Society, it’s suggested that many events associated with hyperextension or rotation of the neck may result in artery dissection. “Such neck movements, particularly when they are sudden, may injure the artery as a result of mechanical stretching,” the researchers noted.18 The symptoms of arterial dissection depend on which artery is affected and may include the following:19

Pain on one side of your head, face or neck Paralysis of one eye
Constant headache on one side of your head Pain behind an eye
Impaired ability to taste Tinnitus
Visual loss Temporary loss of awareness

Should You Avoid Having Your Hair Washed at the Salon?

There are many potential causes of arterial dissections, so you shouldn’t single out having your hair washed at a salon as a particularly serious risk. That being said, if you experience any discomfort or dizziness when in a position that requires over-extending your neck or looking upward for an extended period of time, you should take it seriously, change the position and seek medical attention if symptoms persist.

If you are concerned, talk to your hair dresser and ask for extra neck support during washing. Ideally, the chair and neck support should be adjustable so you can avoid hyperextending your neck. You can also forgo the process entirely and wash your hair at home. Ultimately, the risk of suffering from beauty parlor stroke syndrome is rare, but it does happen.

Worldwide trends in volume and quality of published protocols of randomized controlled trials



Publishing protocols of randomized controlled trials (RCT) facilitates a more detailed description of study rational, design, and related ethical and safety issues, which should promote transparency. Little is known about how the practice of publishing protocols developed over time. Therefore, this study describes the worldwide trends in volume and methodological quality of published RCT protocols.


A systematic search was performed in PubMed and EMBASE, identifying RCT protocols published over a decade from 1 September 2001. Data were extracted on quality characteristics of RCT protocols. The primary outcome, methodological quality, was assessed by individual methodological characteristics (adequate generation of allocation, concealment of allocation and intention-to-treat analysis). A comparison was made by publication period (First, September 2001- December 2004; Second, January 2005-May 2008; Third, June 2008-September 2011), geographical region and medical specialty.


The number of published RCT protocols increased from 69 in the first, to 390 in the third period (p<0.0001). Internal medicine and paediatrics were the most common specialty topics. Whereas most published RCT protocols in the first period originated from North America (n = 30, 44%), in the second and third period this was Europe (respectively, n = 65, 47% and n = 190, 48%, p = 0.02). Quality of RCT protocols was higher in Europe and Australasia, compared to North America (OR = 0.63, CI = 0.40–0.99, p = 0.04). Adequate generation of allocation improved with time (44%, 58%, 67%, p = 0.001), as did concealment of allocation (38%, 53%, 55%, p = 0.03). Surgical protocols had the highest quality among the three specialty topics used in this study (OR = 1.94, CI = 1.09–3.45, p = 0.02).


Publishing RCT protocols has become popular, with a five-fold increase in the past decade. The quality of published RCT protocols also improved, although variation between geographical regions and across medical specialties was seen. This emphasizes the importance of international standards of comprehensive training in RCT methodology.

A doctor discovers an important question patients should be asked

This patient isn’t usually mine, but today I’m covering for my partner in our family-practice office, so he has been slipped into my schedule.

Reading his chart, I have an ominous feeling that this visit won’t be simple.

A tall, lanky man with an air of quiet dignity, he is 88. His legs are swollen, and merely talking makes him short of breath.

He suffers from both congestive heart failure and renal failure. It’s a medical Catch-22: When one condition is treated and gets better, the other condition gets worse. His past year has been an endless cycle of medication adjustments carried out by dueling specialists and punctuated by emergency-room visits and hospitalizations.

Hemodialysis would break the medical stalemate, but my patient flatly refuses it. Given his frail health, and the discomfort and inconvenience involved, I can’t blame him.

 Now his cardiologist has referred him back to us, his primary-care providers. Why send him here and not to the ER? I wonder fleetingly.

With us is his daughter, who has driven from Philadelphia, an hour away. She seems dutiful but wary, awaiting the clinical wisdom of yet another doctor.

After 30 years of practice, I know that I can’t possibly solve this man’s medical conundrum.

A cardiologist and a nephrologist haven’t been able to help him, I reflect, so how can I? I’m a family doctor, not a magician. I can send him back to the ER, and they’ll admit him to the hospital. But that will just continue the cycle. . . .

Still, my first instinct is to do something to improve the functioning of his heart and kidneys. I start mulling over the possibilities, knowing all the while that it’s useless to try.

Then I remember a visiting palliative-care physician’s words about caring for the fragile elderly: “We forget to ask patients what they want from their care. What are their goals?”

I pause, then look this frail, dignified man in the eye.

“What are your goals for your care?” I ask. “How can I help you?”

The patient’s desire

My intuition tells me that he, like many patients in their 80s, harbors a fund of hard-won wisdom.

He won’t ask me to fix his kidneys or his heart, I think. He’ll say something noble and poignant: “I’d like to see my great-granddaughter get married next spring,” or “Help me to live long enough so that my wife and I can celebrate our 60th wedding anniversary.”

His daughter, looking tense, also faces her father and waits.

“I would like to be able to walk without falling,” he says. “Falling is horrible.”

This catches me off guard.

That’s all?

But it makes perfect sense. With challenging medical conditions commanding his caregivers’ attention, something as simple as walking is easily overlooked.

A wonderful geriatric nurse practitioner’s words come to mind: “Our goal for younger people is to help them live long and healthy lives; our goal for older patients should be to maximize their function.”

Suddenly I feel that I may be able to help, after all.

“We can order physical therapy — and there’s no need to admit you to the hospital for that,” I suggest, unsure of how this will go over.

He smiles. His daughter sighs with relief.

“He really wants to stay at home,” she says matter-of-factly.

As new as our doctor-patient relationship is, I feel emboldened to tackle the big, unspoken question looming over us.

“I know that you’ve decided against dialysis, and I can understand your decision,” I say. “And with your heart failure getting worse, your health is unlikely to improve.”

He nods.

“We have services designed to help keep you comfortable for whatever time you have left,” I venture. “And you could stay at home.”

Again, his daughter looks relieved. And he seems . . . well . . . surprisingly fine with the plan.

I call our hospice service, arranging for a nurse to visit him later today to set up physical therapy and to begin plans to help him to stay comfortable — at home.

Back home

Although I never see him again, over the next few months I sign the order forms faxed by his hospice nurses. I speak once with his granddaughter. It’s somewhat hard on his wife to have him die at home, she says, but he’s adamant that he wants to stay there.

A faxed request for sublingual morphine (used in the terminal stages of dying) prompts me to call to check up on him.

The nurse confirms that he is near death.

I feel a twinge of misgiving: Is his family happy with the process that I set in place? Does our one brief encounter qualify me to be his primary-care provider? Should I visit them all at home?

Two days later, and two months after we first met, I fill out his death certificate.

Looking back, I reflect: He didn’t go back to the hospital, he had no more falls, and he died at home, which is what he wanted. But I wonder if his wife felt the same.

Several months later, a new name appears on my patient schedule: It’s his wife.

“My family all thought I should see you,” she explains.

She, too, is in her late 80s and frail, but independent and mentally sharp. Yes, she is grieving the loss of her husband, and she’s lost some weight. No, she isn’t depressed. Her husband died peacefully at home, and it felt like the right thing for everyone.

“He liked you,” she says.

She’s suffering from fatigue and anemia. About a year ago, a hematologist diagnosed her with myelodysplasia (a bone marrow failure, often terminal). But six months back, she stopped going for medical care.

I ask why.

“They were just doing more and more tests,” she says. “And I wasn’t getting any better.”

Now I know what to do. I look her in the eye and ask:

“What are your goals for your care, and how can I help you?”

Kaminski, a family physician for 30 years, is medical director for AtlantiCare Physician Group in southern New Jersey. This article first appeared in Pulse, a New York-based online magazine that publishes personal accounts of illness and healing

This weekend, turn out your lights for Earth Hour 2017 – Climate Action Programme

A global blackout will take place this Saturday 25 March for Earth Hour 2017, which will see some of the world’s best known landmarks disappear from city skylines.

World Wildlife Foundation (WWF) Earth Hour – now in its tenth year – is the world’s largest demonstration of support for action on climate change.

Earth Hour was founded by WWF in Sydney in 2007, and is designed to increase awareness about energy consumption and environmental issues including rising temperatures and destruction of habitats on a global scale.

In 2016, millions around the world across 178 countries came together to show support for action to protect our planet.

350 major landmarks throughout the world, including the Eiffel Tower, the Empire State Building and Buckingham Palace turned off their lights in support last year.

In the UK, almost 10.5 million took part in the global blackout.

Paris was named the Global Earth Hour Capital for 2016 for is long-term vision in climate action as well as its commitment to sustainability within business, civil society and other global cities, to which it has become a role model thanks in part to holding COP21 in 2015.

The WWF Earth Hour seeks to encourage people to actively pursue a more sustainable lifestyle to reduce their carbon footprint and energy consumption.

By turning off your lights for one hour at 8:30pm (GMT) on Saturday 25 March 2017, you will be taking part in demonstrating the need for commitment to the future of our climate.


Two thirds of cancer mutations result from completely random DNA mistakes

An increased focus on early detection will be needed to effectively treat the disease

a yellow breast cancer cell on a red background

A breast cancer cell, photographed by a scanning electron microscope, which produces a 3-dimensional images.

Humans have forever questioned what causes human cancer. And we’ve come a long way: Early theories proposed by Hippocrates in the middle ages suggested the disease arose from supposed “black bile” accumulating in the body. This and other subsequent theories—like cancer cells themselves as infectious, contagious agents—have been debunked by modern research. Scientists now understand cancer arises from mutations created in our DNA when cells replicate and three factors cause those mutations: Environmental, hereditary, and random ones. However, the influence of one of those factors over another is still largely unknown.

Now, a group of researchers at The Johns Hopkins University used new statistical models to figure this out. After analyzing 32 common cancer types, the researchers estimate that 66 percent of cancer mutations are from random ones that occur when cells divide, 29 percent from environmental factors, and 5 are inherited. This means that for people with these cancers, about two thirds of all mutations that eventually result in cancer happen not because of factors in their environment or what they inherit from their parents, but rather as a direct result of how healthy cells grow and divide. The geneticists say researchers should use this new understanding to focus more efforts to detect and treat cancer as early as possible.


Cell division, in which one cell breaks apart into two cells in an effort to create new, needed healthy ones, is a natural process. But as this occurs, random mutations happen to the DNA within the cells. Other factors can cause these mutations, too. Environmental ones like smoking or eating a diet low in fiber increase the rate that these errors occur. When enough of these mutations accumulate—no matter what their cause—that’s when the cells begin dividing uncontrollably. That uncontrolled division is what we call cancer.

The researchers wanted to know how much of an influence each mutation-causing factor had on the occurrence of cancer. For 32 cancer types, they pulled together medical information from patients around the world, including those patients’ DNA sequences, information about their lifestyle, and what type of cancer they had. They combined these data sets to understand the influence of each mutation factor. Here’s how one analysis, for lung cancer, would go: Researchers already know the average number of random mutations that happen to an otherwise healthy person who eats well and never smokes. Say that number is 100. From those data sets, and from previous research, they found smokers have cell mutation rates that are three times higher than healthy, non-smokers. So you would expect to find 300 mutations in smokers. So, probabilistically, you can attribute that extra 200 to smoking. They did a similar analysis for 31 other cancers by comparing the mean number of mutations from healthy individuals to mutations attributed to known environmental and heritable causes of those cancers.

 Comparing the 32 types of cancers further demonstrated the effect random mutations have. Cancer is more common in tissues that divide often. For example, cells in the colon divide much more frequently than cells in the brain, which is why colon cancer is much more common in the population than brain cancer is. But overall, the numbers they got—66 percent random, 29 percent environmental, and 5 percent inherited—told the researchers that a majority of cancers occur from random, unpredictable “mistakes” that can’t be predicted.

causes of cancer in the body

DNA mutations, which ultimately cause cancer, result from three causes: they’re inherited, they happen randomly as cells divide, or they occur due to environmental factors like smoking. Researchers found that the cause is different for each organ, charted above. Lung cancer, for example, has a larger percentage of environmental mutations because of smoking whereas brain cancer is almost entirely a result of random errors stated in the graph as “Replicative”.

It offers comfort to the millions of patients who have developed cancer but have led near perfect lives, says Bert Vogelstein, a co-author of the study and professor of pathology and oncology at Johns Hopkins. “We want it to help people avoid feeling guilty about their cancers. These cancers would have occurred not matter what they did.” The researchers say the results could also help guide future research: Understanding how to recognize cancer early on, when its first developing, could offer a better chance at successfully treating it.

So is there anything we can do to slow down, or even completely eliminate these random mutations? Right now, the researchers say most are unavoidable, but it may be possible that some of them could become avoidable in the future. There are four ways that cells randomly mutate during cell division. One of them, called reactive oxygen species or “free radicals” could theoretically be reduced by exposing cells to special antioxidants. Vogelstein says a better understanding of these mutations could open up areas of research to develop these kinds of antioxidant preventative therapies. “It’s similar to our understanding of cholesterol,” Vogelstein says. “Before we knew about cholesterol, we didn’t know we could try to lower it to prevent cardiovascular disease.”

And perhaps this type of research couldn’t come soon enough. The researchers think that in the future, as populations continue to age, the percent of cancer cases attributable to random mutations is only going to increase. As bodies get older, their cells will have experienced more division, which increases the chances of mutations and cancer. Vogelstein says the way we are going to keep up with this increase is finding better ways to detect cancer in its early stage.

Toxic Mold Hazards and Related Illnesses Revealed

Story at-a-glance

  • Featured documentary discusses the nature of mold toxicity, why it’s so dangerous, and what it takes to recover your health
  • About 25 percent of Americans are genetically predisposed to experiencing severe illness from toxic mold exposure
  • Since the 1970s, industry has inadvertently created “super-molds” through the widespread use of synthetic chemical fungicides, such as Benomyl

“Probably every doctor in the United States is treating mold illness — they just don’t realize it.”

Mold illness may be the most prominent health problem physicians are missing today — a “hidden” pandemic that’s sweeping the nation.

Millions are suffering from mysterious illnesses for which they’ve received essentially no help from physicians. Some are referred to psychologists after being told their illness is “imagined,” while others are accused of fabrication.

Because mold toxins are so unique and their effects are so broad, symptoms of mold toxicity are complex and varied, making it difficult for physicians to arrive at the correct diagnosis.

Unable to identify the cause of their illness, sick people become much sicker over time. Marriages are devastated, livelihoods are lost, and many reach such levels of despair that they end up committing suicide.

The featured documentary, “Moldy,” explores the subject of mold toxicity through the stories of people who’ve battled this illness and won, as well as interviews with a number of top experts in the field.

The film sheds light on the symptoms of mold toxicity, why it’s so dangerous, and most importantly, how you can recover your health.

Modern Industry Has Created Dangerous ‘Super-Molds’

Mold spores are ever-present in the air. Under optimal conditions, these naturally occurring and very resilient spores can take root in your home or workplace, or in your food. Molds make toxins (mycotoxins) that can change how you feel, how you think, and even how long you live.

In my 2011 interview with Dr. Ritchie Shoemaker  (embedded below), he stated that mold toxins are even more toxic than pesticides and heavy metals and affect a greater number of body systems.

Since the 1970s, the molds in our environment have become much more aggressive due to the widespread use of a fungicide called Benomyl,1,2 through a process similar to the creation of superbugs by overuse of antibiotics.

In the agriculture industry, Benomyl killed nearly all of the fungi on crops such as strawberries and wheat, but the few surviving fungi happened to be highly toxic molds — which are now flourishing in our environment.

In the 1970s, Benomyl was also added to paints to stop the growth of mold on damp walls, especially in public buildings such as offices and schools.

Just as with food crops, a few types of dangerous mold were selectively allowed to grow unchecked, so we’re exposed to more of these dangerous fungi now than at any other time in history, as a direct result of these chemical fungicides.

In the US, 45 million people live and work in moldy buildings, and approximately half of all US buildings have water damage, which greatly increases the likelihood of hidden toxic mold.

NOT Wanted — Dead or Alive

Dead mold is just as bad as live mold. When mold dies, the cells’ walls desiccate and break apart into little fragments. The fragments carry the toxins upon them, and when inhaled, they’re absorbed into your body.

Many mistakenly believe that simply moving out of a contaminated building will solve the problem, but the toxins adhere to your belongings. If you move with everything you have, you can take the problem with you.

The toxins make their way into everything — books, clothing, bedding, furniture, you name it — and many times, personal belongings keep individuals ill.

If you have a mold-related illness, the optimal action is, unfortunately, to dispose of everything you own. Some experts say to leave and take nothing with you but your driver’s license.

Mold Is Toxic to Every Organ in Your Body

Mold affects everyone, regardless of age, ethnicity, or overall health and fitness level. Surprisingly, you are as much at risk for mold in dry climates as wet climates. The mold growing in desert regions can be even more tenacious, since it’s had to adapt to the drier air.

It turns out that 25 to 28 percent of people are genetic “canaries in the coal mine” for experiencing severe mold reactions — and in the US that amounts to about 75 million canaries.

Anyone can have problems from a water-damaged building, but if you’re mold-sensitive, it’s more likely that exposure can trigger a debilitating illness. Symptoms are wide ranging, from autoimmune and inflammatory issues to neurocognitive problems.

People have experienced fatigue, migraines, muscle cramps, numbness and tingling, cardiac arrhythmias, and insomnia. The list of symptoms is almost endless because the toxins can settle into so many parts of your body.

Weight gain is very common. A few experience “unexplained” weight loss, but most have rapid unexplained weight gain that doesn’t stop until they receive proper treatment.

There are numerous mental and neurological effects associated with mold toxicity, including brain fog, cognitive dysfunction, and mood disturbances. It’s not uncommon for people to have short-term and long-term memory loss, confusion, depression, and panic attacks. Children can experience drops in IQ.

Brain imaging reveals that mycotoxins can actually damage your brain — in particular, your amygdala. This can result in experiencing mood swings or rage for no apparent reason. Those with mold toxicity often describe their emotions as “out of control.” According to mycotoxin expert Dr. Harriet Ammann, indoor molds can damage the systems of your body in the following ways:3

Vascular: blood vessel fragility, hemorrhage from tissues or lungs Digestive: diarrhea, vomiting, hemorrhage, liver damage, fibrosis, and necrosis
Respiratory: trouble breathing, bleeding from lungs, and sinus infections Neurological: tremors, loss of coordination, headaches, depression and anxiety, and multiple sclerosis
Skin: rashes, burning, sloughing, and photosensitivity Urinary: kidney toxicity
Reproductive: infertility, changes in reproductive cycles Immune: Immunosuppression

Mold Illness Is Real

The good news is, once you realize you’ve been poisoned by toxic mold, with proper support your brain and body can recover. But in order to do so, it’s important to find a “mold literate” physician to guide you in every aspect of your care. Recovering from mold-induced illness requires an integrative approach under the guidance of a knowledgeable healthcare practitioner. Most primary care practitioners aren’t trained to treat mold poisoning and don’t even take a mold history. Unexplained symptoms are usually dismissed or attributed to other problems, such as psychological issues.

Those who DO believe in mold toxicity typically limit their approach to the prescribing of steroids and dangerous antifungal medications, many of which are toxic to your liver. Recovering from mold toxicity requires removing the source or sources of exposure, then starving the fungi out of your body with an antifungal diet and avoiding foods that may be contaminated with mold. Make sure your vitamin D levels are optimized, as vitamin D has been shown to be effective against mold allergies.

Top 10 Foods to Avoid If You Have Mold Sensitivity

People with environmental mold sensitivities are typically sensitive to mold in food as well. Along with a menagerie of chemicals, pollutants, and pathogens, mold further adds to your body’s toxic burden and can overwhelm your detoxification and immune systems. Even miniscule exposures can trigger major reactions once you’re sensitized — as well as triggering a relapse once you’ve recovered.

So, it’s important that you take steps to make your environment as mold-free as humanly possible, including your foods. Some foods are more susceptible to mold contamination than others. Below are the top 10 mycotoxic foods, as outlined in the book Mold: The War Within by Kurt and Lee Ann Billings. As you can see, many of top offenders are grains. For more on the Billings’ recovery plan, refer to our prior article covering natural treatments for mold toxicity.

1.  Alcoholic beverages: Alcohol is the mycotoxin of Saccharomyces yeast (brewer’s yeast), and often contains other mycotoxins from mold-containing fruits and grains 2.  Wheat and all wheat products
3.  Rye 4.  Peanuts: Often contaminated with dozens of mold types, one of which is cancer-causing aflatoxin
5.  Cottonseed and cottonseed oil 6.  Corn: Universally contaminated with a variety of fungal toxins
7.  Barley 8.  Sorghum: Used in a variety of grain products and alcoholic beverages
9.  Sugar from sugar cane and sugar beets 10.  Hard cheeses

What’s Involved in Mold Remediation?

Whether you stay in a contaminated house or leave, remediation will be necessary, and I would suggest hiring a professional mold remediator. In the case of flooding, step number one is to pump out any standing water and remove all personal belongings, which also need to be carefully cleaned and dried if you’re going to try to salvage them. As stated earlier, it’s optimal to discard all personal belongings and start over, if possible. Standard mold remediation involves the following steps:

1.  Setting up containments and sucking the air out with negative air pressure. (This is similar to turning on your bathroom vent fan.) 2.  Next, they clear the air using a HEPA filtered air purifier or scrubber. The air must be cleaned because once they start working on the mold, the spores will begin to fly everywhere like light dust.
3.  Wearing protective gear, such as HEPA filtered respirators, goggles, protective suits, and latex gloves, the remediator begins taking the affected area apart. Removed parts, such as drywall, are slowly and carefully placed into a bag. 4.  Once the affected pieces are bagged, every inch of the area is carefully HEPA vacuumed again.
5.  Once the source of the mold has been located, it’s carefully removed using hot soapy water, scrub brush, HEPA filtered sanders, chisels, or any other tool that will remove the mold. 6.  Professional remediators will typically treat the area with a disinfectant, as bacteria accompany mold growth.
7.  Next, the area is force dried. Once thoroughly dry, repairs can be made.

How to Choose a Professional Remediator

Take great care in hiring a mold remediator and make sure he or she is certified. You will find contractor or professional listings on the following websites. Both the IICRC and NORMI are certifying organizations for mold remediation, but the IICRC certification may be the most widely used. Keep in mind that a mere certification may not be enough — also evaluate the remediator’s qualifications and insurance (liability as well as workers’ compensation). With the ACAC, there are a few different levels.

  • IICRC (Institute of Inspection, Cleaning and Restoration Certification)
  • ACAC (American Council for Accredited Certification)—a certifying body that is third-party accredited.
  • The IAQA (Indoor Air Quality Association)—a membership organization with no certification program (the ACAC handles this by agreement)
  • RIA (Restoration Industry Association)
  • NORMI (National Organization of Remediators and Mold Inspectors)

Improving Your Indoor Air Quality

According to the Environmental Protection Agency (EPA), poor indoor air quality is one of the top five greatest environmental risks to public health. Amazing as it sounds, indoor air can be five to 10 times more polluted than outdoor air. This is due to inadequate ventilation, so contaminants build up and stagnant air is re-circulated. Long-term exposure to air pollution particulates has been associated with faster cognitive decline in older adults.

One of the best things you can do to improve your air quality is add a high-quality air purifier. My recommendations for air purifiers have evolved over the years, along with changing technologies and newly emerging research. At present, after much careful review and study, I believe air purifiers using Photo Catalytic Oxidation (PCO) seem to offer the best technology available. For more tips on improving your air quality, please refer to our earlier article.

More from Leading Mold Experts…

I’ve interviewed several experts on mold-related illness over the past few years, and five of those are linked below. The most recent was natural health author and actress Suzanne Somers whose latest book, TOX-SICK: From Toxic to Not Sick, includes information about recovering from mold toxicity.

Suzanne and her husband both suffered from mycotoxin exposure. For Suzanne, toxic black mold settled in her intestines, which led to a misdiagnosis of cancer. For her husband, the mold caused symptoms akin to Parkinson’s disease. Suzanne is a strong advocate for reducing your body’s toxic load, advising her readers, “Stop counting your calories and start counting your chemicals!” Sound advice indeed!

Watch the video discussion. URL:

Fluid doesn’t need feet

Fluid management is a crucial part of managing dialysis patients. Historically, this was based on clinical assessments that are “notoriously subjective”, recount two English researchers from Leeds Teaching Hospitals NHS Trust. Now, a recently introduced body composition monitor (BCM) is able to objectively quantify the volume of excess or deficient fluid in a patient; and in addition to extra- and intracellular water (ECW/ICW), the model also maps the calculated ECW, ICW and weight to a “unique combination” of normally hydrated lean tissue mass (LTM), normally hydrated adipose tissue mass (ATM) and the volume of excess or deficient fluid, explain the authors.

This measure of fluid excess or deficiency, defined as the hydration status (HS), is crucial: It gives an “easily interpretable value” that can be used next to traditional clinical assessments to guarantee an optimal fluid management. One hitch: The models used by the BCM were developed and validated using standard wrist-to-ankle bioimpedance measurements, made between electrodes on the hand and foot – which would exclude the not insignificant number of dialysis patients with ulcerated (and therefore bandaged) or amputated feet, due to the lack of accessible sites for electrodes.

But the hitch seems to have been overcome: The present study compared hydration measurements made with ‘hand-to-hand’ (H-H) to ‘hand-to-foot’ (H-F) configurations, and came to the conclusion that H-H measurements seem to be as appropriate as those with H-F: 101 patients were measured with both methods, and compared with H-F, H-H measurements showed a bias of -0.1l. For 61% of patients the difference between the readings was within 0.5 L; for 81% it was within 1.0 L.

Hand-to-hand measurements constitute an acceptable alternative protocol for BCM measurements in patients with inaccessible, sore, bandaged or amputated feet.


%d bloggers like this: