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From our anonymous insider…

Monday morning begins with an introduction to gynecology from an energetic 36-year-old Ob/Gyn. She began at the end: menopause. “Menopause occurs between 45 and 55, with the average age at 51.” She explains that hormone replacement therapy (HRT) is one of the most effective mechanisms to treat vasospasm (hot flashes) in postmenopausal women. “Estrogen is the fertilizer, progesterone is the lawn mower. Remember that. If the patient has a uterus, you must give combination [estrogen/progesterone] to thin the endometrium. If the patient underwent hysterectomy, she can just take estrogen. Nothing to grow!”

“Menopause symptoms typically last no more two years, but can last up to 13 years. Every three years we reevaluate the HRT and medications. Usually we take them off for a month and restart if needed. Some patients just feel better on HRT so they request to continue.” Birth control pills contain the identical hormones. Straight-Shooter Sally, commenting on a controversy over requiring private employer-provided health insurance to offer zero co-pay contraception: “I wish people would recognize that birth control pills are used for a lot more than just birth control.”

Particular Patrick asked why so many older women have hysterectomies [removal of the uterus]: “Hysterectomies have fallen out of favor in the past decade or so. The history of hysterectomies is fascinating, especially the regional variation. Where there were a lot of Ob/Gyns, there were a lot of hysterectomies. Same exact pattern for laminectomies [removal of part of the vertebrae to alleviate back pain]. Where there were a lot of neurosurgeons, there were a lot of laminectomies.”

In our small groups, we discussed the costs and benefits to HRT in treating menopause symptoms. Laid-back Larry, a San Francisco native with a soothing voice, presented on a Women’s Health Initiative (WHI) study on the side effects of HRT in 160,000 postmenopausal women aged 50-79. In our age of identity politics, before talking about the medical conclusions of the study, Larry delivered an encomium about Dr. Bernadine Healy, the founder of WHI and one of ten women (out of 120 students total) in the Harvard Medical School Class of 1966 and later appointed by Ronald Reagan to be director of NIH.

After we finished celebrating women overcoming gender barriers, we returned to the study per se. WHI concluded that the lowest dose of combination HRT should be used to minimize the risk of coronary artery disease and breast cancer. Larry: “For anyone who says that investment in public health is not worth it, and that we need more military spending, look at this economic analysis. The study cost $625 million. That’s five F-35 fighters.” Our facilitator asked, “So you do not think we should have the F-35 program?” Larry: “No, I do not think we should have the F-35 program or any military spending until we can get our domestic policies in order.” Larry cited “Economic return from the Women’s Health Initiative estrogen plus progestin clinical trial: a modeling study” (Annals of Internal Medicine, 2014), describing the results of an add-on $260 million study:

The WHI scenario resulted in 4.3 million fewer CHT users, 126,000 fewer breast cancer cases, 76,000 fewer cardiovascular disease cases, 263,000 more fractures [no free lunch, unfortunately], 145,000 more quality-adjusted life-years, and expenditure savings of $35.2 billion. The corresponding net economic return of the trial was $37.1 billion ($140 per dollar invested in the trial) at a willingness-to-pay level of $100,000 per quality-adjusted life-year.

The 95% CI [confidence interval] for the net economic return of the trial was $23.1 to $51.2 billion.

[Why did this cost nearly $1 billion? It is expensive to follow patients for years.]

Wednesday morning, a pathologist led a two-hour workshop on breast cancer, which 1 in 8 women will develop. Breast cancer prognosis depends on several factors:

• Type: lobular (epithelial cells that form the milk-producing lobules) or ductal (epithelial cells that form the ducts that transport the milk to the nipple).
• Stage: TNM method – Tumor size, Nodal involvement and presence of Metastasis.
• Grade: histologic characteristics of the biopsy and genetic profile on the tumor sample. If the ductal or lobular carcinoma has not invaded outside the glandular structure, the cancer is called in situ (e.g., ductal carcinoma in situ, DCIS). If the cancer cells have spread past this barrier into the connective tissue of the breast, the cancer is called invasive. Invasive ductal carcinoma classically presents with dimpling of the skin.

The easiest breast cancer to treat is estrogen-positive and her2-positive (proto-oncogene receptor). We can inhibit the estrogen signal with endocrine therapy (e.g., aromatase inhibitor or estrogen-modulator tamoxifen) and the her2 growth signal can be inhibited with trastuzumab (Herceptin, antibody against her2).

Straight-Shooter Sally: “We’re getting all the low hanging fruit. All the cancer signal is going through this bad apple. I just cannot envision us ever getting ahead of cancer with multiple aberrant cross-talking pathways like in triple-negative breast cancer. Good luck!” (Triple-negative cancer does not express estrogen receptors, progesterone receptors, or her2 receptors.)

Our patient case: Kim, a 39-year-old nonsmoker premenopausal college professor, presents for a discrete hard mass in her left breast detected on self-examination. She undergoes ultrasound-guided needle biopsy which reveals a ER+/Her2- ductal carcinoma in situ with a high risk of recurrence. She undergoes radiation followed by a mastectomy and adjuvant chemo with tamoxifen (the estrogen modulator discussed above).

Kim, now 45, is in remission after five years of tamoxifen. She came in with her surgeon, a 40-year-old who specializes in breast reconstruction.

Type-A Anita asked How has this experience changed your perspective on life? “It has not really changed my perspective. I am not someone who creates a bucket list… The main thing this diagnosis did was prevent me from adopting a child. I knew before the cancer that I would not be able to have children so my husband and I began the adoption process. The agency requires both parents be home for a random drop-in session. My husband traveled a lot for his job so he quit, taking a large pay cut. By the time we were settled, I got this breast cancer diagnosis. I remember talking to a woman at the [government-licensed] adoption agency: ‘You think we would give you a child with this gravestone over your head?’” The surgeon answered: “It’s somewhat dark and morbid, but dealing with patients has made me realize that we rarely recognize the hardships of people around us. I am not talking about just cancer, but any serious health complication.”

Kim added: “There is always light in darkness. Chemotherapy is tough. I would get up at 6:00 am to go to the chemo center and get to work by 8:30 am. After a few weeks, I was just exhausted. My husband was gone many days. I remember getting home every weekday to find a fully prepared dinner in a basket delivered by some unknown mensch. To this day I do not know if it was my church, coworker, neighbor. That helped so much.” [Kim was not Jewish, but apparently had picked up the Yiddish term mensch.]

Kim passed around her various accessories from her mastectomy. “I would wear a lot of scarves. My students must have thought I was a crazy scarf lady. I would wear scarves in the summertime to hide my mastectomy. One afternoon, my husband and I were doing yardwork and I was not wearing my special bra. The neighbors passing by would stare at me. I wanted to curl up into a ball.”

Lanky Luke asked Why did Kim go on tamoxifen instead of an aromatase inhibitor? Kim’s surgeon: “You are correct that tamoxifen has more significant side effects such as embolic events and risk of uterine cancer. However, AIs [aromatase inhibitor] are generally avoided in the premenopausal patient group because of the risk of ovarian activation [producing estrogen, which could stimulate proliferation of the breast cancer cells].”

Pinterest Penelope asked What would determine if you get a lumpectomy or radical mastectomy? “Well, radical mastectomy is a thing of the past,” Kim’s surgeon replied. “A true radical mastectomy included complete removal of the breast tissue, all axial lymph nodes, and pectoralis major muscle. What you mean is a modified radical [mastectomy] where we remove the entire breast tissue and all axial lymph nodes.” She continued, “Only in advanced stage breast cancer would we perform this. We try to preserve as many lymph nodes as possible to prevent peripheral edema in the arm. We do a sentinel lymph node biopsy where we resect a single lymph node at a time to see if there are any cancer cells. If the pathologist does not see any, we can leave the distal lymph chains. I will add that most women these days elect for a mastectomy even when a lumpectomy would give clear margins. It is very difficult to match the lumpectomy breast to the other breast.”

The surgeon explained that breast reconstruction is a two-part surgery. “The first surgery involves placing an expandable implant. We then go back a few months later to reconstruct the expanded space with a silicone implant or a saline bag. Silicone feels more realistic, but there are more side-effects compared to the saline bag. Autologous fat implants are very difficult due to preservation of the vasculature. This leads to sections of the fat graft to become necrotic, which has all sorts of complications such as infection.”

[Lawsuits regarding silicone implants in the 1980s and 1990s resulted in nearly $10 billion in awards to women who thought that they had developed diseases such as lupus and rheumatoid arthritis from these devices. Dow Corning, founded in 1943, went bankrupt as a result of these lawsuits. No scientific link was ever established, however, and silicone implants are once again on the market. (See “Panel Confirms No Major Illness Tied to Implants,” June 21, 1999, New York Times.)]

Our Ob/Gyn lecturer returned Friday for a talk on STDs, an evolving subject: “When I was in medical school, fluoroquinolones were the first line treatment for gonorrhea. When I started residency, fluoroquinolones were no longer acceptable, and we transitioned to ceftriaxone. Now we are seeing ceftriaxone is not adequate so we added azithromycin in combination with ceftriaxone. There are already macrolide-resistant [azithromycin] strains, we just hope they will not get together with ceftriaxone-resistant ones. Long term this is going to be a serious concern, especially with the rise in IUDs [because people aren’t using condoms].” She continued: “Right now we can assume someone who is treated is cured. I see that paradigm shifting in 5 or 10 years. We will need to confirm successful treatment. That is a problem when our current tests require 4 weeks to confirm cure after treatment [PCR amplification will detect DNA of dead bacterial cells]. Asking a patient to not have sex for a month is a lot more difficult than asking a patient to not have sex during the one-week treatment window.”

After learning about every kind of STD, it was time for lunch with Luke, Jane and Persevering Pete. Pete graduated college in three years and runs a small real-estate business “flipping houses” with his family who lives three hours away. He spent the last two weekends building a deck and painting the interior. He is in a long-term relationship with his college girlfriend who is an M3 at our school. Pete asks, “What is your biggest problem?” Jane responds: “Figuring out when I will do all my rotations with the Army’s constraints.” Luke: “Marriage and money.” Pete chuckles: “Marriage for me too. My girlfriend wants to get married. What do you think about marriage at our age?” Luke: “Stay away.” Pete: “I just do not think I should even consider marriage until I can envision where I will be in five years and until I am financially stable.” Jane: “You’re confusing having children with getting married.”

A handful of states had elections this week, in which Democrats generally prevailed. Students congratulated Anita

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The Friendly Orange Glow: The Untold Story of the PLATO System and the Dawn of Cyberculture (Brian Dear 2017; Pantheon) is strong when it comes to describing the collaboration features of what today we would call a “platform” (it was just a “computer” then!):

Experimental chat programs existed in various time-sharing environments prior to PLATO IV, even including a primitive TALK program on PLATO III. Most followed the line-by-line style of messaging programs that arose in the decades to come, including Unix’s Internet Relay Chat, AOL’s Instant Messenger, Apple’s Messages, Google Chat, and Facebook Messenger. This meant that when you typed in your message to someone, the recipient did not see your message until you were done typing all of it and then sent it. Brown hated this type of typed communication, and was determined to design Talkomatic to exploit PLATO’s Fast Round Trip. The result: character-by-character chat using TUTOR’s “common” function to share one user’s typed message with another. As one user typed some text, the other user saw those text characters appear live, one by one.

What made online consults particularly remarkable was the fact that they took advantage of another new feature the systems staff added. TERM-talk required modifying the system code so that the typed output from one user showed up on another user’s screen, and vice versa. Well, what would happen if you sent all of the output of one user’s screen to the other user’s screen? Today it’s called “screen sharing,” but on PLATO, decades earlier, the feature was known as “monitor mode.” With monitor mode and online PSO consultants, it was possible for a TUTOR programmer to get expert help within seconds.

Perhaps the most significant feature was “notesfiles”:

Over the next three years, Woolley would continue to add features to the Notes program. By far the most notable change occurred in the early winter of 1976, when Woolley announced to the world that he was expanding Notes so that there would no longer be just three “sections” of the program, one for system announcements, one for help notes, and a general notes repository, but, instead, the program was being redesigned so that there could be any number of notesfiles, on any subject imaginable. The Notes program would become the engine that managed and presented these notesfiles, but there could be, and soon would be, thousands of notesfiles, each dedicated to a specific subject.\

They had Facebook and Twitter, essentially, in the early 1970s:

Dave Woolley added a DATA key option that enabled users to go through notes and responses chronologically. Another systems programmer released a special -jumpout- feature that enabled PLATO authors to write their own programs that took advantage of a “cycler” tool that would roll through a given list of notesfiles and only show you what you had not already read. … Rick Blomme then directed John Matheny, another CERL systems programmer, to create a centralized, more efficiently designed, system-supported utility, which got the name “Notesfile Sequencer.” It was an enormous jump forward— another catalyst that not only accelerated a PLATO user’s productivity, saving them enormous amounts of time, but in a way contributed to the general “acceleration” of PLATO users themselves. As the sheer amount of information and conversations kept growing, users could not keep up, and needed new tools to help them cope. With the Sequencer, users could create a personal list of favorite, must-read notesfiles, be it five or five hundred long, and the Sequencer would then automatically step through every single notesfile and only show the user those notes and responses the user had not yet seen.

Consider the impact of another PLATO system feature, Access Lists, on the online community. Access Lists were customizable lists of users for whom access should or should not be granted or restricted to some file on the system. The notion of access control had been around forever— starting with passwords on files to protect who could view or edit a file. Every time-sharing computer system had to deal with security features like these; PLATO was no different. With the explosion of new notesfiles on PLATO in 1976, it was possible to designate one or more “directors” of a notesfile, as well as who had and who didn’t have read/ write, read-only, or even write-only access to it (= psonotes = would be write-only to all users except the PSO staff, and served as a place to privately ask a question or report a concern to the PSO consultants). That led to a general-purpose Access List facility that could even be applied to a TUTOR lesson. A file’s owner could specify custom definitions of access, which might have special relevance for that file only.

The author doesn’t over-sell this, though:

Woolley argues that the center of the universe in PLATO was the “what”— be it a game, a lesson, a notesfile on a certain subject, or whatever. Present-day social networks like LinkedIn and Facebook are completely different, having architectures entirely focused on the “who”— you as user are the center of the universe for these services. You can “friend” or “follow” other people, and the system will keep track of them and aggregate their status updates on your “feed.” PLATO did not have social networking tools like friending, following, sharing, or likes.

Ray Ozzie, the creator of Lotus Notes, was an undergraduate at the University of Illinois and worked as a PLATO programmer.

Ozzie was by now [1980s] keen on doing his own new program relating to online collaboration among teams, which he initially called “MX,” the ideas of which had been floating around for a while but were now beginning to dominate his focus. MX eventually got a new code name, “Echo,” only to eventually get another, “Notes,” named intentionally after PLATO Notes. Ozzie wanted to take the ideas he had seen work so well on PLATO— tools for team collaboration and productivity— and bring them to the workplace, where it was abundantly clear by the mid-1980s that workplaces everywhere were going to be filled with networked PCs.

Lotus Notes, the official name of the product when it finally shipped, offered email, calendaring and scheduling, an address book, access lists, document commenting, online forums, anonymous notes, the equivalent of a Notesfile Sequencer, a database, and programming tools to build custom applications within the Notes environment. The Iris team took a pile of PLATO ideas they’d lived and breathed at CERL and transferred them into a Microsoft Windows environment for the PC. But however impressive the final product, it was the kind of tool that required an entire organization to be trained on and commit to— it didn’t work if only small clusters of employees used it. That meant an entire organization had to change their behavior and reengineer itself in order to fully exploit Notes’s features. Lotus decided that even though the product was for workgroups, it was not going to work well for small workgroups— who would install it? Who would administer it? No, it was better suited for an enterprise. To make that abundantly clear to the marketplace, the company set the starting price for the product at $ 64,000. Their first customer was Price Waterhouse, who were so impressed with the product they ordered a historic ten-thousand-user license, the largest single order for a software program in the computer industry up to that time. Other corporations soon followed with their own orders.

Ozzie’s little company was purchased by Lotus for $84 million in 1994 and then Lotus was purchased by IBM in 1995 for $3.2 billion. Eventually more than 120 million people would use Lotus Notes.

More: Read The Friendly Orange Glow: The Untold Story of the PLATO System and the Dawn of Cyberculture

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From our anonymous insider…

Gastrointestinal topics began with four one-hour lectures on the liver. Jane and I did not attend. We took a morning trail run, then watched 65 minutes of liver lectures on Pathoma (“First-Aid of M2”). Jane: “I feel like I have accomplished so much.”

We went to Dr. House’s Tuesday lecture on GI pathogens. “As medical students you will be a valuable member of the team performing digital rectal exams and fecal blood smears. It seems like grunt work, but it is essential to determine the course of diarrhea treatment. The fecal smear for leukocytes is a vastly underutilized, quick and dirty test.” According to Dr. House, the most important step in managing diarrhea is to determine if a patient has invasive or toxigenic diarrhea. Invasive diarrhea is caused by a pathogen invading the mucosa (epithelial lining of the gut tube), which recruits leukocytes [white blood cells] to the infection. These white blood cells end up in the feces. Whereas, toxigenic diarrhea will not have any white blood cells in the stool sample. “Most diarrhea causes are treated with supportive care – hydration.”

Vibrio cholerae causes profuse, toxigenic rice-water diarrhea. “Does Haiti have cholera?” asked Dr. House. “Not before 2012. The earthquake hit in 2010. UN troops from Nepal, where Vibrio is endemic, brought in cholera. One in ten individuals exposed to cholera are asymptomatic carriers shedding it in stool. Without adequate filtration systems in earthquake-ravaged Haiti, cholera spread all over.” How do you treat cholera? Hydration. “Cholera is a self-contained disease if you can survive the extreme dehydration from loss of water. Volume-in must equal volume-out. On the wards you will hear, ‘hang the IV at 125 mL per hour.’ 125 mL per hour is 3 liters over 24 hours or the amount of insensible water loss [sweat, metabolism, etc.]. So hydration would need to be greater than 125 mL/hr in a cholera patient.”

“When I trained Clostridium difficile was segregated to antiquated case reports in journals that no one read.” Dr. House continues, “C. diff is now a hospital’s bane of existence. Studies show that 13 percent of individuals have C. diff spores in the gut. They just lie dormant until a stress such as an antibiotic knocks out the normal gut flora. A severe C. diff patient can have 30 bowel movements per day with a high fever. Talk about dehydration. The best treatment is fecal transplant, ideally from a housemate, otherwise the new poop pill [OpenBiome’s FMT G3 capsule].”

Dr. House cautioned to not jump to antibiotics for every patient with diarrhea. “Some toxigenic diarrhea cases are made worse by an antibiotic. For example, a patient with hemolytic uremic syndrome, a serious complication of shigella and E coli O157:H7, can be killed by toxins released from dead bacteria. I see this all the time: a patient with pneumonia or meningitis is given penicillin. The patient then crashes because of the sudden antigen [molecule to which immune system responds] release.”

We ended a few minutes early so he asked some causal questions: “Has anyone heard of Saccharomyces cerevisiae?” A quite Asian volunteered: “It’s used in brewing beer.” “Yes! Cerveza is beer in Spanish. This fungus is also implicated in exacerbating Crohn disease. Why? We do not know. But that’s the mystery of Infectious Disease medicine!”

Dr. House noticed Type-A Anita’s MacBook Air decorated with five stickers: “I’m with Her”, “Nevertheless, she persisted”, “Nasty woman”, “Change”, etc. “Anita, how are you going to fit more stickers on the laptop next election?” Anita: “I don’t know, I never thought of that.”

At 10:00 am, Dr. House left and we began learning about genetic diseases of the GI system. Our early-40s pediatrician-turned-geneticist explained that she is consulted whenever a genetic disorder is suspected, or “when physicians have no idea what is going on.” She manages several families whose members share a rare genetic defect and also coordinates care for patients with complicated diseases such as Down syndrome, Prader-Willi syndrome, and Angelman syndrome.

She introduced two genetic GI diseases that we’ll see on the Boards: Lynch syndrome and Familial Adenomatous Polyposis (FAP).

Lynch syndrome (also known as HNPCC for “hereditary nonpolyposis colorectal cancer”) is an inherited defect in a DNA repair protein. Lynch syndrome is characterized by a high risk of cancer including colorectal, endometrial, gastric, and sebaceous carcinoma.

FAP results from a defect in the APC gene that is necessary for the transformation of normal colon tissue into a colonic polyp (adenoma-carcinoma sequelae). FAP is characterized by the formation of thousands of polyps in the GI tract. Patients have such a high risk of colorectal cancer that they undergo prophylactic colectomy in early adulthood.

She described some of her daily dilemmas. “Ten percent of patients do not have a paternal relationship to their believed father, don’t rely on paternal medical history. We refrain from testing children for likely genetic disorders that won’t result in symptoms until adulthood. If waiting will not compromise care, we want to maintain the patient’s autonomy. I am also extremely careful with documentation for a potentially afflicted child. For example, what if a child eventually wants to join the military? If I document a 50-percent risk of having Lynch syndrome due to an afflicted father, lights out.”

Our patient case: Jerry, a 50-year-old former truck driver on disability for liver cirrhosis due to chronic hepatitis C infection, presents to the ED for rectal bleeding and anemia. Twenty-five years earlier, te was in a motor vehicle accident (“MVA”) requiring transfusions. A more recent MVA led to the diagnosis of hepatitis C, likely due to the transfusion in the 80s prior to hepatitis C screening for blood donations (1992). [Hepatitis C is transmitted via blood and sex.]

Physical exam shows a distended abdomen with ascites (fluid in abdomen), scleral icterus (yellowing of the eye), and several bruises over his arms and legs. His liver is enlarged, and the tip of the spleen is palpable. CBC and CMP reveal anemia, thrombocytopenia (low platelet count) and hypoalbuminemia (low serum albumin, a protein that creates osmotic gradient to keep fluid in the blood vessels). PCR testing shows an active Hep C viral load. Jerry tests positive for Hep C antibodies. Serum alpha-fetoprotein (AFP) levels are high, suggestive of hepatocellular carcinoma (liver cancer). An abdominal CT shows two liver nodules. Biopsy confirms hepatocellular carcinoma.

Jerry undergoes radiation therapy and surgical resection of the operable masses. Jerry died last year from rupture of esophageal varices while waiting for hepatitis C treatment and a liver transplant.

Our South American hepatologist went over Jerry’s case and discussed the rise of hepatitis C infections in the United States driven by heroin use. Particular Patrick asked her opinion about needle exchange programs (popular in his home state of California). “Hep C rates are skyrocketing due to IV sharing. Every needle shared leads to nine Hep C infections. I cannot understand why needle exchange programs are resisted by conservative legislators. Yes, I understand the idea of traditional values and that drugs are bad. But you don’t simply tell your child ‘NEVER have sex, period.’ No, you say, ‘Sex is bad… but if you are going to engage in it use a condom.’ Otherwise, you’ll get a pregnant child… with Hep C.” Students chuckled. Lanky Luke: “I bet she does not want a needle exchange in her backyard.” [“Do needle-exchange programs really work?” (Amy Norton, March 11, 2010, Reuters) summarizes research that casts doubt on a link between needle exchanges and preventing disease transmission.]

Drug treatment for Hep C costs roughly $90,000. “The first thing I ask my patients is if they have insurance,” said our hepatologist. “If they are uninsured, I tell them, ‘No problem. You will just have to pay maybe $30 for the blood tests. You’ll get the pills free.’ If they do have insurance, I tell them there is no guarantee. I say, ‘I will fight for you, but it will take time and there is no guarantee.’”

How does Hep C treatment compare in other countries? “Australia has a great coverage program. Every Australian gets the drug, no questions asked. Canada and most European countries have similarly good coverage.” Does the drug cost as much? “No, America pays for the Hep C treatment of the world. One of my old patients pioneered going to Canada for treatment because it cost so much less there.” She concluded: “I am hopeful coverage will increase as there are more and more competing drugs. It is truly amazing how science has advanced. A decade ago there was no cure, only poor management with short-lived transplants and drugs with severe side effects such as kidney damage. Now we have several options with over 90-percent cure rates for all genotypes [DNA sequence of the virus].”

This week included three afternoon workshops on nutrition and lifestyle medicine led by a fit 35-year-old internist specializing in weight loss, her blond hair tied in a ponytail ready for her next workout. She began by asking the class, “What percentage of the population does not smoke, has a BMI less than 25, eats 5 servings of fruits and vegetables daily, exercises 30 minutes five times per week? What we would consider healthy?” The class was silent. “Three percent,” she answered. “Meanwhile, 35 percent of the US population is obese.”

She was scornful of the government’s nutrition advice. “Why is diary the only food required in a school lunch?… The milk lobby. Why are grains at the bottom of the food pyramid? The grain lobby. The original 1992 pyramid had grains third from the bottom. Imagine how many lives could have been changed if that guidance was not issued!” Lanky Luke: “Maybe times have changed and people have less faith in institutions, but does anyone really shape their diet based on the pyramid and now plate?”

Students were offered to get free DEXA [Dual-energy X-ray absorptiometry] scans in preparation for the next workshop. Over half the class volunteered for the 10-minute procedure after class. DEXA scan shoots two different energy x-ray photons at the entire body. In addition to providing a measurement of bone density, commonly used to diagnose osteoporosis before a fracture, DEXA scans also calculate percent body fat and fat distribution.

Pinterest Penelope: “I think the DEXA scans were wrong. I’ve been going to the gym everyday this year.” Jane, as she squeezes her stomach into a mouth shape: “This is bad for my mental health, 26 percent fat.” A retired Army physician told her that you do not want to be a fat doctor in the Army. Physical performance is evaluated in the military. “If you are fat, you do not get promoted, you do not get your preference on where you are stationed, and you do not get respected by peers.”

“I never use the word ‘Diet’. Diet implies a temporary strategy. Long-term weight loss requires lifestyle changes. However, as a physician your patients will ask you about common diets. There are copious studies that try to evaluate Low fat versus Low Carb versus Mediterranean, etc. The key is to get them thinking about their intake and outtake.” She cited, “The largest diet study found attendance at group sessions was the greatest predictor for weight loss and reduced cardiovascular events.”

Students filled out a lifestyle goal on scratch paper. Most students promised to lose a few pounds, go to the gym, or make fruit/veggie smoothies daily. (Two weeks later Jane and I accompanied most of these people to Taco Bell and then the local ice cream shack.)

Thursday at lunch students discussed Harvey Weinstein and Kevin Spacey. Everyone had seen the headlines, but not everyone knew the details. What did Harvey Weinstein actually do? “He raped women. He attacked young actresses.” Type-A Anita: “It’s more like what hasn’t he done.” Wildflower Willow: “I have become so disgusted by Hollywood. Power corrupts all men.” What did Kevin Spacey do? “He attempted to molest young male actors. Now he cowardly comes

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“Yale Student Found Not Guilty in Rape Trial” (nytimes) is about a 25-year-old defendant who was found “not guilty” by a jury (but the journalists and editors refer to his unnamed accuser as “the victim” in the last paragraph; what was the unnamed person a victim of, if no crime was committed?). Saifullah Khan was, according to the article, suspended from Yale. Does the school now take him back so that he can finish the degree toward which, presumably, hundreds of thousands of dollars have already been paid? Or do they pocket the money and say “You don’t meet our standards for enrollment”?

What has this guy been doing for 2.5 years? Has he been a full-time defendant or did someone want to hire him to pump septic tanks or do HVAC system maintenance? Did he go back to his native Afghanistan and Skype with his legal defense team as needed? If he does graduate from Yale, who will hire him after doing any kind of Google search? Can he do a legal name change to “Billy Bob Cone” and thus thwart employers or graduate schools that might be interested in this background?

“A New Survey Finds 81 Percent Of Women Have Experienced Sexual Harassment” (PBS) suggests that a significant number of Americans might be cast out of society by the time all of these complaints have been adjudicated. Can those accused and subsequently acquitted worm their way back in? What are the aggregate economic effects?

[Update: Looks like the NYT has edited the article. It now says “Maura Crossin, executive director of the Victim Rights Center of Connecticut, which, along with the state’s attorney’s office, represented the complainant, declined to comment.” So they’ve replaced the word victim with complainant. Also they’ve added the fact that, after a two-week trial, the jury deliberated for three hours, comparable to the 2.5 hours that the jury took to acquit the defendant in the trail chronicle in the Missoula book (see below)..]

Related:

• Missoula: Rape and the Justice System in a College Town (a.k.a. majoring in partying and football)
• “Khan was charming, ambitious — but dogged by allegations” (Yale News), with some background
• How was the immigration of Sayfullo Habibullaevic Saipov supposed to benefit native-born Americans? (another person named “Sayfullo” who can probably benefit from a name change, once free of the U.S. judicial system)

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A lot of folks are in situations where they either don’t pay for electricity or pay a flat rate. Why aren’t they all mining Bitcoin? How about office workers? Nobody complains if they plug in a space heater, a Lava lamp, an aquarium, or a personal phone charger. Maybe the landlord is paying the electric bill in any case. Why wouldn’t there be a Bitcoin miner that “flies under the radar” by consuming less than 500 watts? Supposedly it takes about 13,000 kW/h to mine one coin (source), so that’s about three years at 500 watts per hour. Three years is a long time to wait (we could get lucky and earn a Bitcoin after 1 day, right?), but on the other hand a $10,000 bonus once every three years would be welcome!

How about folks who live in apartment buildings where the landlord hasn’t installed individual electric meters? If there are indeed any of these buildings left, why don’t the tenants replace all of the bulbs with LEDs, refrain from using the electric stove, and then run two 1500-watt Bitcoin miners 24/7?

Here’s a miner designed for home use: the AntMinerR4. It consumes 845 watts of power and generates “52 dB” of noise (actually 52 dBA?).

Related:

• Bitcoin-mining space heater?
• Bitcoin vs. Medical School

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From our anonymous insider…

Those of us who passed the last block’s exams on our first try are back from a week of vacation. Wildflower Willow, a free-spirited outdoors enthusiast from Oregon and founder of our school’s wilderness club, went on a three-night solo backpacking trip. Pinterest Penelope spent the week in Banff with her family. Gigolo Giorgio crashed his parents’ trip to Europe. “I was planning to go home, but my father had a last-minute business trip to London and Brussels. He called me up to cancel my trip. I asked if I could come along for the ride. He reluctantly agreed. I think he had been excited to spend quality time with my mother.”

Jane and I skipped the Monday morning lecture, so our GI pathology week begins with a new 8-person “small group.” “You look too happy to be medical students” remarked a gentleman in a wheelchair as Jane and I take the elevator to the third floor. The 57-year-old retired orthopedist is our facilitator. Five years ago he had a bike accident that left him paralyzed from the waist down. “I expect a comprehensive differential. Don’t just blurt out syndromes. Tell me why you are thinking that. Do not expect to be leaving early with me.” Geezer George, a 32-year-old Boston native who is our oldest classmate, commented “It is refreshing to have someone hold us to high standards. Most of the facilitators have been more casual.”

Our group discussed celiac disease and common GI pathogens. Celiac disease, an autoimmune disease due to hypersensitivity reaction against gliadin (component of gluten), is most associated with Northern European ancestry. Type-A Anita: “White people have to pay somehow.” The immune reaction produces IgA that frequently cross-reacts with proteins in the dermal papillae (junction of dermis and epidermis) creating the characteristic dermatitis herpetiformis (grouped fluid-filled sacs, named after the similar appearance to a herpes outbreak). The IgA antibodies do not lead to GI pathology, but serve as a useful biomarker for diagnosis.

Geezer George brought up a norovirus outbreak while discussing common GI pathogens: “I was at ground zero in Boston. I lived across the street from the Chipotle where half our school got lunch.” (the illness was traced to a sick employee and it was unrelated to an earlier E. coli outbreak at Chipotle) A student replied, “Chipotle gets a bad wrap… no pun intended. You do not have an increased risk of getting a GI bug at Chipotle compared to any other restaurant, just so many people get meals there. It’s like the Toyota brake scandal.” A student described getting a Staphylococcus aureus enteritis characterized by profuse vomiting and diarrhea: “It’s like you don’t know whether to sit on the toilet or to stand next to it.”

A 45-year-old gastroenterologist specializing in hepatology (liver) gave Tuesday’s lecture on GI pathology: gastroesophageal reflux disease (GERD), peptic ulcer disease, Boerhaave syndrome, and inflammatory bowel disease (IBD).

She explained that “36 – 77 percent of Americans experience GERD throughout their life. The severity of the symptoms do not correlate with the severity of GERD. Patients are not faking the pain. Some just have more sensitive mucosa than others. Avoid caffeine, smoking and late night meals.” She detailed how the use of proton pump inhibitors (PPI), such as Prilosec (omeprazole) has gone through cycles. “Patients and providers have become skeptical about the use of PPI. The problem is that we overprescribed them for some time and they started to be linked to everything without evidence. I had a patient post-MI [heart attack] with a peptic ulcer. The CCU staff took him off the PPI out of fear of reinfarction. [Once off the PPI] The ulcer bled so much he required transfusion. The link has been proven false.”

Peptic ulcer disease, ulcers that form in the stomach and duodenum (proximal small intestine), is associated with nonsteroidal anti-inflammatory (NSAID; aspirin and ibuprofen are examples) use and chronic Helicobacter pylori infection. “20 million people take NSAIDs daily including 70 percent of people over 65. As long as people use NSAIDs, I have a job.” Why do doctors ask if the abdominal pain gets better or worse after eating? “Gastric ulcers worsen after eating. Eating stimulates acid production in the stomach. Duodenal ulcers become better after eating. Eating causes release of bicarbonate in the duodenum that neutralizes irritants.”

Boerhaave syndrome, a condition where intense vomiting leads to esophageal rupture, is caused by binge drinking. “Chronic vomiting such as in alcoholics and bulimics typically does not rupture through the esophagus,” she explained. Boerhaave syndrome is associated with a 35 percent mortality, “the most of any GI perforation.” Gigolo Giorgio: “I’m surprised that none of my college friends got Boerhaave syndrome.”

“Do not get IBD [inflammatory bowel disease] confused with IBS [irritable bowel syndrome]. Much different. IBS comes and goes and is not as severe as IBD,” she explained. The two most common IBD conditions are Crohn disease and ulcerative colitis (UC).

Nervous Nancy has Crohn disease. “My doctor is convinced I am Jewish. I keep telling him I am not. Infliximab [tnf-alpha inhibitor] has been a Godsend. I usually let my roommate inject it into me every three weeks. It’s like ripping a band-aid – easier if someone else does it quickly. He was trying to impress his new female friend by winding up before stabbing me. He ejected prematurely, wasting half the dose. I am freaking out. That’s like $4,000. My insurance won’t give me another prescription so I am going to try to make the next few doses last longer. I can already feel my hands and legs swelling and getting hot.”

Crohn disease, a transmural (entire thickness of gut tube) granulomatous inflammation of the GI system, usually occurs in the ileum [terminal small intestine]. Because Crohn Disease is transmural inflammation it can lead to performation and fistualization (connection between two tubes). If the colon ruptures it can create a connection to the bladder, called a colovesical fistula. Gigolo Giorgio: “Could you imagine peeing feces?”

Our patient case is Rebecca, a high-school swimmer who began seeing our gastroenterologist/hepatologist lecturer when she was 15. Rebecca presented for bloody diarrhea with mucous, fatigue, and a seven-month history of crampy abdominal pain. Over the preceding week she has experienced sharp right-upper quadrant (RUQ) pain. On physical exam, Rebecca appears pale with an enlarged liver palpable six centimeters below the costal margin and a palpable spleen. No scleral icterus (yellowing of the sclera) is noted. CBC shows pancytopenia (low red and white blood cell count) with a normocytic anemia (normal red blood cells, but not enough of them) and high reticulocyte count. Stool sample tests positive for white blood cells, red blood cells, but negative for pathogens. After a colonoscopy, Rebecca is diagnosed with ulcerative colitis.

What is causing her enlarged liver and spleen? Ten percent of patients with UC develop primary sclerosing cholangitis (PSC). PSC is an inflammatory reaction that causes fibrosis of the biliary tree connecting the liver to the duodenum. Over time this causes incurable cirrhosis (hardening of the liver), which clogs portal circulation of blood returning to the liver.

“The treatment of PSC is liver transplantation. That is how serious a disease it is. Liver transplant is not even a cure,” explains her doctor (our lecturer). Rebecca is placed on the liver transplant list.

Patients on the liver transplant list are ranked according to the Model for End-Stage Liver Disease (MELD) score, which predicts three-month mortality among liver failure patients based on three lab values: creatinine (kidney function), bilirubin (liver’s ability to breakdown and excrete heme), and the international normalized ratio (liver’s ability to synthesize clotting factors). Rebecca was at 12 out of 40. “PSC patients are screwed over by the MELD score,” explained our hepatologist. “Their lab values do not reflect their deterioration. I told Rebecca’s family that she would not make it to the expected donation time.” Her family and doctor petitioned the UNOS (United Network for Organ Sharing) to no avail. Pinterest Penelope whispered, “This story reminds me of Denny from Grey’s Anatomy losing the heart transplant by 17 seconds.”

Her mother described searching for a living donor. Live donor liver transplant (LDLT) is a procedure where a liver section from a living donor is removed for transplantation. The liver is able to regrow to normal function over time. LVLT has several ethical dilemmas. Who gives consent for a pediatric donor? A cousin or uncle who matches may experience immense family pressure to donate, compounded by the fact that many liver transplants require immediate decisions. Pinterest Penelope whispered again, “This is just like Grey’s Anatomy! Remember that episode where the son of an abusive father has to decide to give him part of his liver?” Rebecca’s real-life situation was more serious, but less dramatic. There was no abusive father and nobody in her immediate family was a match.

Rebecca waited three years for a liver while enduring serious complications such as hyperammonemia (high serum ammonia causing mental status changes). One evening she presented to the ED for severe hematemesis (vomiting blood). The dilated veins in her esophagus ruptured. (Esophageal hemorrhage is the most frequent cause of death in liver cirrhosis patients.) Rebecca underwent banding endoscopy (put rubber bands around the veins) to stop the bleeding. After these episodes, the family and doctor petitioned UNOS, who increased her MELD score.

Rebecca underwent a domino liver transplant the summer before her freshman year of college . The first domino was a cadaver (dead person) whose liver is transplanted into a patient with a genetic disease such as familial amyloidotic polyneuropathy (FAP) or Maple Syrup Urine Disease (MSUD). The second domino is the liver removed from that patient, which can be installed in Rebecca’s body and then function normally. We saw a picture of the domino family smiling next to each other: the widowed wife of the cadaveric donor, the mother holding an 8-year-old daughter with MSUD, and Rebecca.

Rebecca’s PSC returned three years later. Her mother said, “We knew the system better the second time around. We listed at a transplant center that did not have a national reputation and in a state with high donation rates.” Rebecca showed us her scars. The scar from the first transplant was roughly 4 inches long on her right side. The scar from the second liver transplant went across her entire abdomen. Her transplanted liver had enlarged to cover her spleen. The extensive fibrosis also adhered parts of her liver to the diaphragm making it difficult to remove. As a result, she experienced pain for several months requiring high dose IV opioid painkillers and neurontin. Two years out she is dealing with opioid tolerance and withdrawal symptoms as she tapers off. Rebecca, now a rising senior at college studying chemistry, plans to return to school after a semester break. “I hope to get back in the water next month. It symbolizes, sort of, returning to normalcy.”

After Rebecca and her mother left, a student asked the hepatologist, “Given that there is such a long waiting list for transplants, what are your thoughts on a single patient receiving two livers?” She passionately responded: “Rebecca deserved this liver. I just came back from the AASLD [American Association for the Study of Liver Diseases] conference. UNOS just approved liver transplants for alcoholics who are three months sober [Hepatitis C from IV drug use is another common reason for requiring a transplant]. I have never met someone who is more motivated and wants to be a productive member of society. Throughout her first transplant recovery she kept going to college. Can you imagine the drive that requires? A lot of potential liver transplant patients just sit at home on disability. What do they do after the transplant. They continue to sit at home on disability. No, she deserved this second liver.”

For each of the next six weeks we will write a two-page single-spaced ethics essay. “I am really excited about doing this ethics course with you,” explained our

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“Married prominent Harvard professor with tenure is placed on administrative leave following 18 accusations of sexual harassment spanning decades” (Daily Mail) concerns a guy to whom Harvard was obligated to keep sending paychecks until his death. Considering all of the virtuous Silicon Valley guys (example: Sundar Pichai) who start their pronouncements with “Because I have daughters…”, this part of the article is disturbing: “The 72-year-old is married and has two daughters.”

The tenure system was established at a time when it was legal and conventional to have a mandatory retirement age. So it was a job guarantee from age 35-65, not from 35-90. Will the #MeToo movement be the catalyst for meaningful access to university jobs for young people?

[Update: They didn’t even have to fire the guy… “Harvard Professor Resigns Amid Allegations of Sexual Harassment” (nytimes).]

Related:

• the original Chronicle of Higher Ed article that led to this guy’s downfall (“Karl believes the stress she suffered as a result of Domínguez’s harassment was harming her already fragile health. By December 1982, the disks in her lower back had ruptured, and she needed surgery.”)
• Tim Hunt, Ellen Pao, and how to get rid of old tenured faculty (the Nobel laureate was cast out for a definitely-not-funny joke)
• Four physics professors killed at University of Iowa (friend with a physics Ph.D. says that as soon as the news hit the wire, the department’s FAX machine was flooded with job applications and ran out of paper)

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The Friendly Orange Glow: The Untold Story of the PLATO System and the Dawn of Cyberculture (Brian Dear 2017; Pantheon) exhaustively chronicles the first popular multiplayer computer games.

From a software engineering point of view, the PLATO shared mainframe wasn’t that different from Amazon’s game servers today. The client (terminal)had a lot less capability than today’s PC or Web browser, but the basic idea of a central shared memory holding the state of the game hasn’t changed.

PLATO was the first system that gathered up a lot of simultaneous users on terminals with reasonable graphics capability (512×512 resolution in the early 1970s!) and allowed them to burn up precious computer time. The PLATO terminals also had a touch screen with 16×16 resolution.

John Daleske wrote a hugely popular game inspired by Star Trek:

The first version of Empire was primitive: one screen containing one “universe” consisting of eight planets. It only supported eight people at a time, but that was six more than any other game of the era. (Indeed, this first version of Empire may be the first graphical, interactive multiplayer computer game anywhere that supported more than two players simultaneously.) If you weren’t one of the lucky eight players, you had to settle for “lurking,” standing in line, watching the game from the outside.

“In the first version of Empire,” Warner says, “eight players could play against each other. They were not allied in any way.” No Klingons, Feds, Romulans, or Orions— all that would come later. “Just players, one to a planet. They were in fact controllers of each planet.” Like later versions of Empire, the first version of the game had little icons representing the spaceships. But instead of piloting the spaceships, players would simply direct the spaceship to go from one planet to another, and when a ship arrived at another planet, a player could trade with that planet, or fight with that planet, or drop bombs, and so forth. Spaceship combat was automatic: if two spaceships got within a certain distance you would either have the choice of passing or fighting. If they fought, the battle was automatic. “That version of Empire was actually continued after the second version, under the name Conquest,” Silas recalls. His version evolved to support six universes, each a sort of separate level of the game, where you could jump from one to the other. “Usually, universe 1 was always full,” Warner recalls. “Universe 2 was sort of halfway there, and there might be a pickup, an arranged game, in universe 4.”

It didn’t work out too well when an actual Star Trek hero arrived on the scene:

Spock without his Vulcan ears. A few days’ start on a beard. Smelling like booze.

It was Tuesday, May 7, 1974. Actor Leonard Nimoy was in town, on a press junket, meeting with reporters, grabbing a bite in the back room of a local restaurant (where Nimoy, more interested in talking about his serious acting, grew aloof at reporters’ incessant Star Trek questions— didn’t they realize the Trek series had ended five years earlier?), …

(when it was PLATO demo time) to the shock and dismay of the gathered onlookers, the ultra-logical Spock in real life knew nothing about chess. “I didn’t expect Nimoy to actually compete with the computer,” says Frankel, “but I figured he’d move a few pawns around and be amused that the computer could interpret his actions and respond. Plus our graphics were pretty sweet— most chess programs at the time were purely alphanumeric.” Nimoy’s Vulcan counterpart was celebrated as not only an expert at playing chess, but an expert at 3D chess. To discover that in real life the actor didn’t know chess at all was devastating to the gathered Trek fans.

PLATO offered the first mass-market flight simulation game:

Brand Fortner, located right at CERL, had already written Airfight, which seemed destined from the very start to be an insanely popular game. There had been nothing like it before. It was another PLATO first, in the long, long line of PLATO firsts: a first-person-perspective, multiplayer, shoot-’ em-right-out-of-the-sky flight simulator. And until Empire came along, it had ruled the PLATO gaming world. Fortner had stumbled upon a simple PLATO game called Air Ace, where you could type in some parameters, press NEXT, and “about ten seconds later,” says Fortner, “it would redraw line graphics of the cockpit and you would see outside of the plane. And I thought, Well, that is an interesting idea, but gee, wouldn’t it be nice if you could fly a lot faster and shoot down other people?” By today’s standards, Airfight’s graphics and realism, like every other PLATO game, are hopelessly primitive. But in the 1970s Airfight was simply unbelievable. These rooms full of PLATO terminals weren’t “PLATO classrooms,” they were PLATO arcades, and they were free.

You’d hit “9” to set the throttle at maximum, “a” for afterburners, “w” a few times to pull the stick back (using those PLATO arrow keys again), and then NEXT NEXT NEXT NEXT NEXT NEXT NEXT to update the screen as you rolled down the runway, lifted off, and shot up into the sky to join the fight. It might be seconds or minutes, depending on how far away the enemy airplanes were, before you saw dots in the sky, dots that as you flew closer and closer turned into little circles and triangles.

Bruce Artwick, another University of Illinois graduate student, used PLATO terminal parts to make a more realistic flight simulator in the mid-1970s. He stuck with this area and eventually licensed his work to become Microsoft Flight Simulator.

Everything bad that people say today about computer games and computer games they said in the 1970s about PLATO games and PLATO gamers. Addicts stayed up all night to play games, got bad grades, dropped out of school, withdrew from face-to-face socializing.

There was another unexpected outcome. At some point, a point that varied depending on the person, PLATO became more than a novelty in the lives of its more obsessed users. These users would cross an invisible line beyond which being on PLATO became one’s life. There were countless examples of this. One was Mark Eastom, says Bruce Maggs, one of the authors of Avatar. Maggs roomed with Eastom during one of his undergraduate years, and Eastom became one of Avatar’s operators, contributing by managing the monster data. “He was a real character,” says Maggs. “PLATO was his life, he was one of these guys for whom this was it. This was all they had in their lives: their PLATO programming and PLATO game playing and PLATO friendships. There were a lot of people like that.” Living the PLATO life could turn into an addiction, a dangerous path to take. A PLATO-addicted college student risked grades suffering, possibly delaying graduation, or, worse, expulsion or dropping out. All of these outcomes were, sadly, commonplace.

Many UI students from the 1970s and 1980s would in time confess to the havoc PLATO wreaked on their college careers. Michael Schwager was one. “I first saw Plato in 1977,” he says. “I got accepted to the U of I in 1978 and became addicted to it, playing Empire till 6 a.m. In 1979 I flunked out of school, but I got good at PLATO.” David Sides, one of the coauthors of Avatar, stared into the abyss, grade-wise, a few times thanks to overdoing it on PLATO. “I know I got into a lot of trouble sophomore year, because I was ending up too long at the computer lab, I was there until three or four in the morning, and I had real grade problems that first semester of my sophomore year because of it. I didn’t flunk out of anything, but I got a D in a midterm in chemistry, and that made a real major impression on me, and it was a real problem.”

There was, for instance, a notesfile called = addict =, dedicated to PLATO addiction. In it, users could offer true confessions of their predicament: how PLATO felt to them, how being away from PLATO felt, and how getting back online felt. One user in 1981 described his PLATO experience this way: “When I do get on… blooie…. End of sanity. End to sense of proportion. End to perspective on what is important in life. When I first got on in 1975, I used to lay awake at night thinking, ‘Gee, I can’t wait until I get on tomorrow,’ and getting an author signon was the greatest ambition I had.” Another user expressed his PLATO predicament this way: “The orange dots are more personal to me than face-to-face encounters with people I don’t know. This may be because when you leave a note with your signon attached, it is there for a long time, much longer than a spoken word is around, and therefore tends to be more thought out. Those who say computers are impersonal have never used a computer. They are far more personal than most people. P.S. Computer games are better than sex.”

Like most other users of mainframes, PLATO programmers generally failed to see the appeal of microcomputers. What is interesting about a machine with limited CPU and memory and no communications capability? Nonetheless, a few PLATO alumni become the authors of popular PC games. Silas Warner developed Castle Wolfenstein, for example. Brodie Lockard, paralyzed after a gymnastics accident at Stanford, used a mouth stick to program Shanghai.

This part of the book is interesting because we think that we are living in a new age, and maybe we are if we look at the number of people who spend a lot of their time gaming, but in reality it seems that there isn’t much new except lower prices and better graphics.

More: Read The Friendly Orange Glow: The Untold Story of the PLATO System and the Dawn of Cyberculture

Related:

• “Why Some Men Don’t Work: Video Games Have Gotten Really Good” (nytimes, July 3, 2017)… it couldn’t be because the Welfare State will give them free housing, health care, food stamps, smartphone, and cash (SSDI)!

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Massachusetts is one of the most lucrative states in which to profit from having been married or having had a child (see our family law). The profitability of marriage per se, however, was scaled back in 2012 due to an “alimony reform” that limited the period under which a plaintiff could profit from alimony based on (a) the number of years of the pre-lawsuit marriage, and (b) whether the person profiting from alimony was living in a “marriage-type” relationship. (Because alimony profits are terminated when a profiteer remarries, it has become conventional in Massachusetts to simply live together with a new sex partner while continuing to bank funds from the former sex partner.)

Following the new law there ensued dozens of lawsuits over whether the changed rules impaired alimony profits secured prior to the cut-off date. Apparently the law was ambiguous. A recent attempt to clarify the situation was killed by Will Brownsberger (lawyer) and his committee, which includes Cynthia Creem, a practicing divorce litigator who earns more than $500/hour arguing these ambiguities.

The comments on the legislator’s page “Retroactive application of new alimony rules” shed light on the experience of being a Massachusetts resident.

From the sole female commenter who seems also to be an alimony payor:

My ex is hiding behind a BiPolar disability and also collecting SSDI [genius!]. He is physically and mentally able to support himself yet I am forced to pay my abuser $550 every WEEK! Why? Because iofbantiquated laws? Because no one had the courage to do the right thing? Is there no relief for me? My children are in their mid 30’s. I shouldn’t have to support this person who is playing every angle of every system so that he can to be a freeloader. … No one is entitled to a lifetime of free support and no one should be fired into involuntary slavery… my marriage license didn’t come with directions. If I signed a contract, I wasn’t given the terms of the contract that contained a lifetime slavery clause. Isn’t that fraud? Even a pack of cigarettes come with warnings. Shouldn’t marriage licenses?? [Her “No one is entitled to a lifetime of free support” statement would be true in Texas or Germany!]

From the new female partners of the divorce lawsuit losers:

It was very clear during the ARA process in 2011 that the intention was for the changes to apply to already-settled divorces. As to the argument that payees would have negotiated differently if they had known that the terms could be changed: Trust that my husband would have negotiated differently during his divorce from his ex-wife if he had had all the facts, as well. If he had known she had been siphoning money from his paychecks during their entire marriage and had secret accounts; if he had known she had been cheating on him with women since their engagement; if he had known that she would be cohabitating for the next fifteen years …

My partner was married for just under 20 years and has been divorced for over 20 years. He has paid child support and college tuition and over $400K in alimony so far. His divorce judgment was completely unfair, as his ex-wife was perfectly capable of working and could have made a very comfortable living without all his additional money.
As we both look toward retirement, the yearly alimony cost continues to hang over our head. Why should we have to work longer to give someone else our hard-earned money. That makes no sense.
I, too, was divorced, but I am an independent, employed, self supporting parent who wouldn’t want to be dependent on anyone to support me for the rest of my life. It sets back women’s rights back a hundred years. [she needs to review the updated definition of feminism!]

I was widowed at 36 left with three young children to raise on my own. In time I remarried, never realizing that the corrupt State of MA would actually use me and my tragic situation to subsidize my husband’s adulterous ex wife who was co-habitating with her still married boyfriend. Her wicked lawyer tried to bring me into the case, trying to gain access to my deceased husband’s estate and my Fatherless children’s bank accounts. They did all this so that they could prove my husband had enough money with me contributing so he could pay her more. He gave his ex 3/4 of his money and I was left to support the household on my own. Even after we had another child together they left me without any help. I could write a book on all the injustices that the state put me and my young children through. Alimony and child support are a joke. Women use the money for fancy houses, new cars, and luxury vacations. There is something seriously flawed with a system that leaves 99 percent of women rich and the men destitute. Women are then able to go to their second marriages with 3 incomes and men who even try to get remarried can’t even contribute to their households. if they have children with their second wife, these kids are not allowed the same standard of living because they are second class citizens.

My husband is 67 years old and has no hope of retirement if his alimony burden of $400 a week, plus 25% of his yearly bonus (for a total of $25,000 a year) isn’t eliminated or at the very least reduced. His ex-wife collects disability and most likely nets more income each week than he does! His 401K was split 50/50 in the divorce. Why should he continue to pay her out of his retirement income too?

Why is it fair or correct that a person receiving alimony should live in a marriage type relationship and still collect alimony? This is not 1974 where cohabitation was considered improper.

My husband was divorced two months too early and now has a lifetime of alimony to a woman who has chosen to work part time. The 20 hours a week she works as a child-care worker is equal to the hours I spend commuting to my job at the federal courthouse in Boston, and then I work a 50-hour week. She lives in a brand-new townhome and we are residing in an attic of an 1800’s home (three-story walkup).

From the men:

my ex is now very well financially secure. She has a wonderful job, making a six figure salary, all three children are independent (ages 25-31), her home is fully paid off, no debt, a new car every few years, wonderful vacations multiple times per year, etc. She has a boyfriend of over 6 years that she refuses to marry so that she doesn’t lose the alimony payment. My divorce was finalized over 15 years ago. I had no issue with paying the alimony during the period of transition and I went above and beyond the divorce agreement by paying well over 90% of the three children’s private (2) and public college tuition costs, when my obligation was 50%. My ex is financially stable and I find it totally unfair to have to pay alimony for the rest of my life.

My ex-wife has a four year college degree, she is very healthy and chooses to work 4 hours a day, and only during the school year, as I struggle to make end meet. She has no interest in becoming self sufficient, she has me supporting her for the rest of my life. She has enjoyed vacations out of the country and several cruises to the Caribbean, I work, period. I will never be able to retire, and as I am now 60 years old, having worked since the age of 14, the thought of working until I die, or my health fails dramatically is nothing I look forward to. I was under the mistaken impression the Alimony Reform Act would allow me to retire, or at least be able to work beyond retirement, and put a way money to retire, as currently my retirement money has and continues to go towards alimony.

Sorry folks but repeal of lifetime alimony must have been a devastating blow to the divorce industry, if given a choice between waiting out a perhaps unjust 10 year sentence or throwing away tens of thousands of dollars or more seeking justice in a kangaroo court, most rational people probably do the math and choose the former. More than just doing the math, a tenner in Gulag parlance is an injustice that the spirit can survive. The lifetime sentence is something that the spirit can’t survive, like a chain that bites deeper into the skin as time goes on. On the business end a slave for life is much easier to defraud than someone doing a tenner, the false hope the divorce industry sells can’t get a very good price when the victim knows he or she will walk away a free person at some point.

I wonder how you’d enjoy your ex-spouse (in my case, ex-wife) enjoying the life or Riley with her live-in boyfriend of five years, another for six years prior, while I send along her weekly checks to support her drinking habits! I am left to support one in college and saddled with all of the $80,000 tuition of the other. She doesn’t make any payments on either. She works for cash so as not to jeopardize her eligibility for alimony. You have no idea how hard this is to watch her enjoy her financial freedom, out in the bars every night with her co-habitant boyfriend!

I was a young man when I got divorced at the age of 27 years old. For over the next 30 years I was paying alimony to a spouse who was working and cohabitating all those years. … I am an old man now and am still working. I live a simple lifestyle compared to former spouse and boyfriend who have had it all.

My alimony was based on my working salary of over 100k per annum. When I retired in 2003 after 37 years of government service, my salary dropped to 65k. I have had to go through all of my 401k to support this alimony, to the point where I may have to file for bankruptcy. At 72 years of age this is grossly unfair to have to pay my ex spouse $560 per month, especially considering that she now receives a trust fund from her deceased boy friend.

I will never understand why it is that I need to continue alimony to my ex-wife through retirement when she already received 1/2 my pension and 1/2 my 401k.

I think it would be interesting to interview people preparing to get married and then live in Massachusetts and see if reading the above comments affected their enthusiasm either regarding (a) entering into a civil marriage, or (b) continuing to reside in Massachusetts and running the risk of ending up like of the commenters. [Option (c), entering into a prenuptial agreement that controls alimony, is not possible to do with any certainty in MA; see Massachusetts Prenuptial Agreements.] Is love so powerful that it can sweep away all caution? Or is it simply that most people are’t familiar with these outcomes, reasonably predictable in the event that the lower-income partner files a divorce lawsuit? (we did a quick survey in Harvard Square and found that college-educated adult residents knew virtually nothing about Massachusetts family law)

Related:

• What will people do for love?

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A Facebook friend posted “Words fail me … #Trumpanitcs” on top of “Trump Pushes Republicans in Congress to Oppose Funding Hudson Rail Tunnel” (nytimes):

President Trump is pressing congressional Republicans to oppose funding for a new rail tunnel between New York and New Jersey, using the power of his office to block a key priority for the region and his Democratic rivals, according to several people with knowledge of his actions.

Mr. Trump urged Speaker Paul D. Ryan this week not to support funding for the $30 billion project, two people familiar with the conversation said.

$30 billion for a short tunnel? The world’s longest and deepest tunnel, opened in 2016, cost roughly $10 billion (Wikipedia). I accepted the assumption that the president of a country that is $21 trillion in debt wouldn’t oppose this purely on the grounds of efficiency and a theory that, if $30 billion must be borrowed, it could be better spent elsewhere. The same friend, when professing his love for Hillary Clinton and/or hatred for Donald Trump, tirelessly beats the inequality drum. So I asked

If you’re concerned about inequality, why would you want the Federal government to subsidize this $30 billion project anyway? Wouldn’t it make inequality in the U.S. more extreme if low- and middle-income taxpayers in the Midwest or South have to pay for a train tunnel to be used by high-income residents of the NY/NJ region? If it actually does make sense to spend $30 billion, why not have NY/NJ fund this themselves?

The consensus response among the virtuous Trump-haters on the thread:

The mid-west has not pulled its own weight in federal taxes in 40 years

Pull their weight means those states get more in Federal funding than they pay

ÇA subsidizes about 5-7 of those states if you count the state budgets as well, and more like 10 if you only count federal tax xfer

In fact if these states were to pay back the coastal Blue states over the next 30 years and balance their own budgets, they would have to triple their state taxes on average

if “we are concerned about inequality,” should’t we be asking states that aren’t solvent and can’t afford the price of admission to politely exit through the rear door?

These folks don’t have any problem with individual Americans being on welfare for decades and, in fact, consistently vote to expand government handouts (free housing, free healthcare, free food, free smartphones, etc.) to individuals. But they don’t like Americans collected into a state not “pulling their weight”? [Note that the assumption that a river of cash is flowing from correct-thinkers to Deplorables may be incorrect: “Against a national average of $1,935 in intergovernmental spending per American, red states receive just $1,879. Blue states get considerably more, at $2,124 per resident.”]

Taxpayers in KY and AL don’t even fully fund the projects they receive. They fund NOTHING out of state

we give them HUGE subsidies, and yet they believe they get none.

if they are going to vote to cut the benefits they receive, let’s accommodate them

I asked why it mattered what “they” believed (assuming any of these virtuous coastal dwellers actually have personal contact with Deplorables in the Midwestern and Southern states). Would it make sense to deny state assistance to people who don’t believe the same things as the elites? Someone living in means-tested public housing has to leave and pay market rents because he or she has incorrect beliefs? They want to reduce inequality, but only among those who believe the same things that they believe?

On the subjecting of voting, I pointed out that fully one third of folks in West Virginia virtuously voted for Hillary Clinton. Why punish them because of the incorrect political beliefs of their neighbors? Aren’t they already suffering sufficiently in having to live near Trump supporters?

Maybe some of those low income states need to be depopulated?

It’s painful, but if a state’s economy for example grew around coal and coal is no longer in demand (or auto manufacturing, steel production, etc) how can one possibly fix that other than by the most artificial means?

I responded by pointing out that schoolteachers in West Virginia are on strike right now and say that they get paid less than teachers in other states. Why not give them the $30 billion so that this inequality is rectified? None of the inequality-obsessed coastal dwellers wanted to do that.

Why is it obviously fair, though, for someone in Kentucky to pay for a tunnel for use by the Wall Street folks who trashed the economy in 2008? Suppose that it were true that Kentucky has been collecting federal welfare for decades. If there is still inequality, with people in Kentucky being less wealthy than people in New Jersey and New York, wouldn’t it make sense to increase the federal welfare flow to Kentucky rather than trying to pull the money in reverse for this new tunnel?

In short, if the answer for a low-income individual is “more welfare” (not to be confused with “more cowbell”) why is the answer for a low-income state “less welfare”?

[We can’t say that the U.S. has historically run this way, can we? During the Great Depression, for example, the Tennessee Valley Authority was created to build infrastructure in a comparatively poor region of the U.S. They didn’t have a “let’s make the rich states even richer” spending plan back then, did they?]

Related:

• “The Most Expensive Mile of Subway Track on Earth” (nytimes) on how New Yorkers will pay themselves $400/hour when they do get hold of tax dollars harvested in Alabama and Kentucky
• Oresund Bridge (5-mile suspension bridge and 2.5-mile tunnel connecting Sweden and Denmark, built essentially without taxpayer funds for roughly 1/10th the cost of this proposed NJ/NY link (a 2.5-mile tunnel))

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