Category: Uncategorized

From our anonymous insider…

The Saturday Friendsgiving has thinned the ranks of Monday and Tuesday lecture attendees. At least five of us, including me, are down with an upper respiratory infection.

Instead of watching the recorded lectures, I watch Pathoma and read Robbins & Cotran. Chronic kidney disease (CKD) is an irreversible loss of kidney function defined by a GFR of less than 60 milliliters per minute for more than three months. Pathoma explains the process of hyperfiltration, where loss of one group of nephron units, from e.g., infection, inflammation, hypoperfusion (low blood flow), causes the remaining functioning nephron units to increase GFR.

I return Wednesday for two hours of CKD treatment strategies by the nephrologist from last week: “What I love about nephrology is there are only four diseases that I have to know: diabetes, hypertension, pyelonephritis (kidney infection), and hereditary kidney disease. 95 percent of all CKD is caused by one of these and they are all covered in First Aid.”

He discussed some exceptions to this rule, starting with an unsolved mystery in Central America “Certain agricultural communities have up to 20 percent incidence of CKD. We do not know why.” (see “Chronic Kidney Disease Epidemic in Central America: Urgent Public Health Action Is Needed amid Causal Uncertainty”, Ordunez, et al., PLOS, 2014). He also described an outbreak of “Chinese herbal nephropathy” from a weight loss supplement that used aristolochia instead of stephania. This is the same compound that caused the 1965 Balkan Endemic Nephropathy in the Soviet Bloc. Aristolochia grows in wheat fields along Danube river Valley. This contaminated flour. “When I was in medical school, this was huge news. Now the region has 65 times the risk of getting uroepithelial cancer.”

We learned about the various types of dialysis for end-stage renal disease. “We tell our patients it is fine to travel. One of the beauties of effective government regulation is that all dialysis machines are standardized. We use the same settings for each machine. Our patients travel all over the country, and we are able to handle dialysis for visitors from anywhere in the world.”

The nephrologist concluded: “You will each briefly do a nephrology rotation. One of the things I wish you could see is the patients that are doing well. If patients do not take care of themselves there are serious consequences. You see these patients in the hospital. But if they do take care of themselves they can be healthy and productive members of society. You don’t see the patients who have jobs, families, and a good quality of life. I wish we could show you what it is like on the outpatient side. Come join us for a day!”

Our patient case: Jenny, a recently married 24-year-old manager at a fashion designer store. She was fresh out of college, had moved with her husband for new jobs, and purchased a house, all within one year. Jenny presents for one month of joint pain and an expanding rash over her face and torso. She was worked up for Lyme Disease. “I got a call a few days later by the nurse who referred me to a rheumatologist.” The earliest appointment was in two months.

“The next week I could not get out of bed because the pain was so bad. I had to lie like a coffin. I thought I was dying. We had to cancel our honeymoon! That’s when my husband realized that the problem was more than natural laziness.” She chuckled, and continued: “I called my family friend who is a doctor. He gave me a list of tests to get. I called to get another appointment with my PCP, but I could only see a PA. I think she was insulted when I presented my long list of labs and tests.” Her labs showed abnormal urinalysis including albuminuria and red blood cells in the urine. “They now wanted me to see a nephrologist instead of the rheumatologist! I saw the nephrologist the same day.”

Her short, sarcastic 40-year-old nephrologist said that she had immediately suspected systemic lupus erythematosus (SLE or “lupus”) given Jenny’s age, sex, kidney function, and the expanding characteristic butterfly rash now covering her face. She started Jenny on several drugs, including an immunosuppressant, high dose NSAID, and steroids to bring her lupus into remission. Jenny has been in remission for almost three years since the initial flare up at age 24.

Jenny said, “My husband is a saint. Once I got the diagnosis, I immediately went to the Internet. WebMD is a dark hole of death. I thought every little ache or sniffle spelled death. After a week, My husband forbade me from looking up any information about lupus. If I was concerned about something, I told him, and he would search it.”

After roughly six months, Jenny began tapering down the powerful immunosuppressants. Her lupus is controlled now only with high dose NSAIDs. “The drugs I was on had terrible side effects, but I was just as scared about relapse. Weaning off the drugs takes months. My husband was the only reason I was able to follow the strategy. He reminded me every day, and kept track of the dosing schedules.” (Roughly half of individuals with chronic illnesses do not take their medications correctly.)

When would a nephrologist rather than a rheumatologist manage a patient with lupus? “It depends on what condition is the most urgent. If lupus is impacting the kidney, a nephrologist will manage the case until the kidneys are safe. The rheumatologist manages the day-to-day stuff, we get involved only to evaluate the kidney.”

Straight-Shooter Sally asked Jenny to summarize her care. “To be honest, I was not impressed with my PCPs. I felt like they failed me. But, I love my specialists. They know so much. Any question or concern, they have seen before and know exactly what to do.”

Surfer Saul asked Jenny if she is able to have children. Jenny’s rheumatologist does not want her to get pregnant due to the risk of a flare up from the hormone surge. Her nephrologist: “I think it is okay. I’ve had a few SLE patients get pregnant.” Mischievous Mary asked if pregnancy would stress Jenny’s kidneys because of the sudden increase in blood volume and hyperfiltration? “Oh no, pregnancy is good for your body, good for the kidney. Pregnancy is a protective risk factor for lots of cancers. I tell Jenny she can get pregnant.”

Gigolo Giorgio asked if Jenny, in light of her current knowledge of lupus, could remember pre-diagnosis flare-ups. “Yes, I got really sick in college once. Terrible. It had to be a flare up. I also remember being allergic to all these random things like yellow dye.”

A student asked the nephrologist what her patients can you eat on a renal-restricted diet? “Wonder bread and lettuce. There are no good options. Every food has things the kidney struggles to excrete. I have patients come in to me complaining of having Wonder Bread stuck to the top of their mouth.”

Our class discussed the proposed Republican tax plan at lunch. Students did not understand the changes to the mortgage interest deduction. One student believed that the new tax plan would increase the mortgage deduction limits “to benefit the wealthy in their McMansions.” Luke attempted to correct the group by stating the new tax bill would restrict and cap the mortgage interest deduction at $10,000. (This was also incorrect; it was state and local taxes that were limited to $10,000 while mortgage interest would remain deductible on loans of up to $750,000.) Socialist Sam, a 23-year-old self-described “Democratic Socialist,” responded: “Well, then, the deduction would distort the housing market. It would make it more expensive for people to move up in housing market, exacerbating racial housing discrimination.” (Decades of government subsidies to homeowners via the mortgage interest deductions apparently did not constitute a “distortion” to the housing market!)

Curiously for someone whose future paychecks will be coming from insurance companies, Gigolo Giorgio supported getting rid of the Obamacare “individual mandate” requiring citizens to purchase health insurance. “A bunch of my college friends took the $2,000 hit instead of purchasing health insurance.”

The argument continued on Facebook. Type-A Anita shared a Bustle article, “The GOP Senate Tax Bill Will Make It Much Harder To Be A Woman In America” underneath “hi warning friends only read this if ur ready to get good and depressed because IDK WHAT I EXPECTED FROM THE TITLE but wowie wow wow.” The main point of the article is that people who don’t currently pay taxes will be denied the opportunity to claim tax credits:

Millennial moms would also be impacted because the bill excludes 10 million low-income children from claiming tax credits. Because women still mainly shoulder the responsibility for child care, families in the lowest income bracket won’t receive tax benefits for their children when they’re the ones who need it the most.

[Editor: Let’s see if single moms are so discouraged by this new tax law that they turn over custody, and the child support cash that comes with custody, to the respective fathers!]

Some of our female classmates thank her for educating them (8 angry faces; 14 likes). Sample comments:

My brain cannot even comprehend the sheer cruelty of this bill

I just…don’t understand. I DON’T UNDERSTAND HOW ANYONE CAN DO THIS AND SLEEP AT NIGHT

Facebook also brought news from my college classmate who decided to leave the United States for enlightened Brussels due to Trump’s election (see Year 2, Week 3). His coworker in Belgium has been “jokingly” calling him by a variety of anti-gay slurs:

I refuse. I will not be defined by your words and I will not be forced to accept them as “business as usual”.

His friends commented that Trump could be blamed for this outbreak of homophobia in Brussels.

Statistics for the week… Study: 25 hours. Sleep: 6 hours/night; Fun: none. We leave Wednesday after class for Thanksgiving break. Students complain that the administration scheduled exams for the week after Thanksgiving.

More: http://fifthchance.com/MedicalSchool2020

Full post, including comments

After two storms that knocked out power for hundreds of thousands of people in Massachusetts, where we agree to disagree with the Germans on the merits of underground power cables, folks are talking about their backup solutions. Here’s one message thread:

• Exurbanite: We have no power. They are talking Tuesday or wed.
• Me: How long can your gen run? [he is not on a gas line]
• Exurbanite: About three weeks if I don’t get more fuel. But I can get fuel any day I want. My friend got a stupid Tesla power wall. I told him not to. I calculated that the Tesla battery is equal to one gallon of propane.
• Exurbanite: I have 500 gallons.
• Exurbanite: After the first night he woke up. Battery was at 18 percent. And that was with him conserving.
• Our mutual friend: I am sure the UI is nice!

Readers: From the perspective of a single home, are power outages actually more common and/or longer than in the good old days? Or are we just more addicted to our electrically powered conveniences?

Personally I still like the idea of rooftop solar plus battery (though maybe not too useful after a big snow!). It is silent and does something useful when there is no outage. But my friend’s 500:1 comparison makes it seem ridiculous!

Related:

• Why not use a rooftop solar system instead of a backup generator?
• Rooftop solar panels considered harmful?
• Tariffs on Chinese solar panels + subsidies = recipe for infinite size government?
• Do rooftop solar and insulation payback periods need to be adjusted for income and property tax rates?

Full post, including comments

On a recent Nor’easter-tinged odyssey from Boston to Seattle, Dallas, Washington, D.C., and back home to Boston, I took quite a few Uber rides. All of my drivers across three cities were immigrants from either Ethiopia or Somalia, with two exceptions: a Bangladeshi and a while male in his 30s.

In Dallas there is a lot of Presidential history, starting with the unfortunate memory of JFK being shot (by a guy who fired just three bullets; not like our modern AR-15 sprayers) and ending with the George W. Bush Presidential Library. I asked one of the Ethiopian drivers what he thought of President Trump: “Obama was in office for 8 years and didn’t change anything, so now I don’t pay attention to who is president or what he says.” What about on immigration? “Trump is not bothering me.”

In Seattle there is an infinite supply of virtue. People there say that they will do anything for homeless people… except provide homes for them. So the streets are packed with folks who are camping in the cold rain. (Contrast to Dallas, where nobody talks about their love for the vulnerable, yet the conservative Christians have set up “missions” that provide services, including beds, for the homeless. I didn’t see anyone sleeping in the street.) One of my Uber drivers, however, was that white male native-born American. He lived in Marysville, just north of the Boeing factory in Everett, Washington. He had voted for Trump because he thought that (a) welfare programs were enabling Americans to spend their lives as drug addicts, and (b) immigrants were reducing the wages of people such as himself (MIT has been looking into the net income of Uber/Lyft drivers and, if their initial number of $3.37 per hour is correct, the availability of Ethiopian and Somalian labor has indeed had a negative effect on this Deplorable!).

Separately, the Seattle airport requires drivers to show up in an electric or a hybrid car. In practice that means every Uber on an airport run is a Prius. I was shocked at how noisy the Prius is on the highway (my airport trips were at midnight and at 6:00 am and therefore we were able to exceed the usual 5 mph practical speed limit on I-5).

Related:

• Harvard prof George Borgas’s analysis of how immigration affects low-wage Americans

Full post, including comments

From our anonymous insider…

A reproductive endocrinologist begins Monday morning with a one-hour lecture on infertility. She explains that 15 percent of couples experience infertility, defined as more than one year of unprotected intercourse without conception. Fecundability, the probability of achieving pregnancy in a single menstrual cycle, should be about 25 percent. Infertility is on the rise in America: “More and more of my practice is managing PCOS [Polycystic Ovarian Syndrome, driven by obesity].”

An obstetrician finishes the day with three hours of lectures (four hours total for the day, so we were done at noon). “Spontaneous abortions occur in 20 percent of all pregnancies,” she notes. “Most people do not even realize fertilization has occurred because the abortion occurs in the first trimester. At eight weeks of age with heart sounds, there is less than 5 percent risk of spontaneous abortion.” The risk of miscarriage doubles every 5 years after the age of 35. (My female classmates, especially those who didn’t come straight from college, have been talking about this since M1. They may be residents well into their 30s so when do they have children?)

The OB lecture covers the placenta, the organ that exchanges oxygen, nutrients and waste between the maternal and fetal circulation. “The placenta regulates all the blood flow to the baby. If you lined 100 placentas up, I could tell you exactly which mother was smoking or using cocaine. Preeclampsia, eclampsia and HELPP [Hemolysis, elevated liver enzymes, low platelet count syndrome] syndrome all involve issues with the placenta.” We discussed placenta previa, where the placenta partially overlies the cervix. Cesarean section is performed at 39 weeks because of the increased risk of hemorrhage prior to delivery. “If a third trimester pregnant woman presents for painless vaginal bleeding, DO NOT perform a vaginal exam. During my residency, I saw another resident stick his finger right through the placenta causing hemorrhage.” [Editor: maybe don’t go to a teaching hospital?]

The rest of the week is devoted to three hours of daily lectures on nephrology. A 34-year-old soft-spoken nephrologist begins with a one-hour review of last year’s kidney physiology. The block director, a PhD in molecular biology, is charged with ensuring we get our LCME-mandated 10-minute break after 50 minutes of class. During the break female classmates discuss how good-looking the lecturer is, emphasizing his fitness and broad shoulders.

Pinterest Penelope (recently broken up from her M3 boyfriend): “I love younger physicians. They understand what we are going through. Our fondness of First-Aid, our cluelessness about residency, our anxiety about Step I. Older physicians live in a different world.”

Lecture continues with two hours on acute kidney injury (AKI). Every minute, 100 mL bleeds out of our capillaries through the glomerulus, a biological filter, into the kidney tubule system and finally the bladder. Over 99 percent of the filtered volume is reabsorbed through active transport of solutes creating an osmotic gradient for fluid reabsorption to maintain the body’s electrolyte and fluid balance. Kidney aging, drugs (e.g., antibiotics, and NSAIDs), and autoimmune diseases decrease the summed rate of filtration, glomerular filtration rate (GFR), and the proportion of electrolyte reabsorption. The nephrologist explains: “You lose about ten milliliters GFR every ten years after the age of 30. As long as you do not have a comorbidity, you will never lose enough to confer disease. The problem is most Americans will develop a comorbidity.”

Kidney injury is divided into several categories:

1. Acute versus Chronic
2. Location of insult: pre-renal (e.g., decreased blood flow), post-renal (e.g., ureter obstruction) or intra renal (e.g., inflammation of tubule system)
3. Urine character: Nephrotic (protein wasting) versus Nephritic (red blood cell wasting)

Our patient case: 4-year old Baby Nora and her family hosted a family reunion cookout filled with beer, burgers and brats. Three days later, Nora develops a fever, abdominal pain, vomiting, and diarrhea. She is taken to the ED that evening, given IV fluids for dehydration and discharged home. The following day, Nora is brought back to the ED after her family notices bloody diarrhea.

On physical exam, Nora appears lethargic. She has tachycardia (high heart rate), tachypnea (fast breathing), a 101 degree fever, and hypotension (low blood pressure, 80/60). Given the bloody diarrhea and lack of symptom improvement, a “rainbow” is drawn. The tube for each test has a different color and when EM physicians are stumped, each tube is filled with blood. CMP (Complete Metabolic Panel) shows hyponatremia (decreased blood sodium) and uremia (elevated blood urea). ABG (arterial blood gas) reveals a primary anion-gap metabolic acidosis with respiratory compensation. CBC (complete blood count) shows leukocytosis (elevated white blood cells), thrombocytopenia (low platelets) and anemia (low red blood cells). Peripheral blood smear reveals the presence of schizoschites, suggestive of a vasculopathy. Urinalysis shows the abnormal presence of protein and red blood cells.

Her doctors are concerned about hemolytic uremic syndrome (HUS), the most common cause of acute kidney injury in children. The disease is caused by ingestion of Shiga toxin from E. coli O157H7, which typically accumulates in colonized food rather than being produced by bacteria that have colonized the gut. Also, if there is an infection, killing the bacteria all at once can release a flood of Shiga toxin. Thus antibiotics are not started and doctors will rely on the patient’s immune system to kill any remaining bacteria. Shiga toxin damages small blood vessels and causes formation of small blood clots (microthrombi). These blood clots shear red blood cells creating the characteristic schiztoschites seen on a peripheral blood smear.

Nora’s urine output continues to decline, and hemodialysis is started and continued for five days until her creatinine levels improve. Creatinine is a muscle protein product excreted by the kidneys at a constant rate used to measure kidney function. She requires one unit (300 mL) of packed red blood cells to maintain her hemoglobin above 7.5.

Nora gradually recovered during a 10-day hospital stay and, now age 9, does not remember the incident. Her parents reflected how scary the experience was. “I was furious at the doctor who sent us home when we brought her the first time. After the emotions simmered down, I have forgiven her. There wasn’t any sign that it was more serious than just a typical food poisoning.”

Nora’s kidney function, as measured by GFR, is back to normal, placing her among the lucky 70 percent who recovery fully.

Our two hour ethics workshop focuses on disability. We read Enforcing Normalcy: Disability, Deafness, and the Body by Lennard Davis, “a nationally and internationally known American specialist in disability studies [an academic discipline]” and English professor at University of Illinois at Chicago (Wikipedia). Our ethics professor: “He uses the Marxist perspective. The disabled population is oppressed, and thus must be be given justice. Davis argues as long as society uses an ableist mentality, we will be unable to correct the injustice. He exaggerates slightly, but within the pieces are an immense amount of insight into the human experience.” From the 1995 book:

When I talk about culturally engaged topics like the novel or the body I can count on a full house of spectators, but if I include the term disability in the title of my talk or a session the numbers drop radically. … our goal should be to help “normal” people to see the quotation marks around their assumed state. The fact is that disability as a topic is under-theorized — a remarkable fact for this day when smoking, eating a peach, or using a bodily orifice are hyper-theorized. Because of this under-theorization, which is largely a consequence of the heavy control of the subject by medical and psychosocial experts, the general population does not understand the connection between disability and the status quo in the way many people now understand the connection between race and/or gender and contemporary structures of power.

… The category itself is an extraordinarily unstable one. There is a way in which its existence is a product of the very forces that people with disabilities may wish to undo. As coded terms to signify skin color — black, African-American, Negro, colorized — are largely produced by a society that fails to characterize ‘white” as a hue rather than an ideal, so too the categories “disabled”, “handicapped” “impaired” are products of a society invested in denying the variability of the body.

In the process of disabling people with disabilities, ableist society creates the absolute category of disability. ‘Normal’ people tend to think of ‘the disabled’ as the deaf, the blind, the orthopedically impaired, the mentally retarded. But the fact is that disability includes, according to the Rehabilitation Act of 1973, those who are regarded as having a limitation or interference with daily life activities such as hearing, speaking, seeing, walking, moving, thinking, breathing, and learning. Under this definition, one now has to include people with invisible impairments such as arthritis, diabetes, epilepsy, muscular dystrophy, cystic fibrosis, multiple sclerosis, heart and respiratory problems, cancer, developmental disabilities, dyslexia, AIDS, and so on.

… In ‘talking’ with Deaf colleges on e-mail particularly those whom I have never ‘seen’, I often ‘forget’ that my interlocular is deaf. Recently, in planning to attend a session at the Modern Language Association on disability, I received and sent a welter of messages on email to a number of people involved. I had no way of knowing which of these people was disabled, or in which way. When speaking on the telephone with a person who uses a wheelchair, I have no way of knowing if that person is unable to walk.

When the ethics professor was busy with another small group, Geezer Greg said, “I could have learned more by watching Curb Your Enthusiasm. Larry David calls a mechanic to bring his car in. When he brings his car in and meets the mechanic in person, Larry is surprised to find that the mechanic is black: ‘You did not sound like it on the phone.’.”

Persevering Pete: “I am not sure what Davis is arguing. On one hand he does not want people to consider disabled individuals as a separate group, but he wants more financial assistance for the disabled.”

Luke: “Where does Davis draw the line on collecting disability checks? Am I on the spectrum?” Greg: “That’s a Curb Your Enthusiasm episode also! The girlfriend claims her son is on the Asperger’s spectrum, but Larry David thinks he is just a spoiled brat.” (The wife sues for divorce during Season 8, taking the house and putting Larry back on the dating market.)

The ethics professor did not mention the financial aspects of being classified as disabled, nor that medical doctors are now the gatekeepers for whether or not an American can get aspect to disability payments (see “How Americans Game the $200 Billion-a-Year ‘Disability-Industrial Complex'” (Forbes)), nor that some doctors earn 100 percent of their income as disability gatekeepers. This is something that Hippocrates probably could not have imagined.

Our week concludes with the Genital Teaching Assistants (GTA) teaching us how to perform the scrotal, penis, digital rectal exam, pelvic, and breast exams. The family medicine physician coordinating the workshop introduced this opportunity: “These are professionals that travel the country teaching these exam skills. Ask them any questions you have, this is their job. And let me tell you, they are good and they are very expensive — largest item in our budget, I am talking thousands of dollars — so we are partnering with internal medicine residents to bring them.” Gigolo Giorgio learned that the female GTAs make $90 per student ($70 for vaginal exams, $20 for breast exam) or over $1,000 (3 groups of 4) in the afternoon workshop. The national standard seems to be that male GTAs are paid less, but so far there have been no demands for equal pay. Luke: “How much would you have to get paid to do that?” A few of the guys responded: “No questions asked, sign me up.” No female classmates answered.

We are divided into teams

Full post, including comments

Here’s the scariest paper that I read during a month at Harvard Medical School…

“Microbial Genomics and Infectious Diseases” (Relman 2011, NEJM):

Nearly 40,000 strains of influenza virus and more than 300,000 strains of human immunodeficiency virus (HIV) type 1 have been partially sequenced

The folks who get paid to tinker with biology keep telling us that a cure is around the corner (just send more barrels of cash!), but why can’t viruses evolve faster than we can spend money on anti-virus research? The Harvard folks seem to think that we’re losing the battle on the antibiotic front. There haven’t been any good new drugs since the 1990s, but there are plenty of pathogens that have evolved immunity to the 20th century antibiotics.

As the U.S. population trends higher (on track to more than double during my lifetime) and more urban, will germaphobes move to dry mountain towns and try to avoid physical contact with anyone who has recently come in from a big city? Lean more heavily on the (clean) Internet for work and social life?

Full post, including comments

From our anonymous insider…

A suave 35-year-old male urologist introduces diseases of the external genitalia, testicles, and prostate. A urologist completes a four-year residency with a one-year internship year, typically in general surgery. “In medical school you are not going to get much exposure to urology because we are a surgical subspecialty. If you are at all interested, come shadow us for a day. You can shadow an academic urologist or a community urologist.” Gigolo Giorgio: “That’s quite exciting. You become a specialized surgeon in five years.” (In a surgical field other than urology, six or seven years is more typical, plus, of course, four years of medical school.)

Cryptorchidism is failure of the testicle to descend from its embryological origin in the abdomen. If the testicle is not descended, it will involute (curls up) because the warmer temperature is too high for spermatogenesis (production of sperm). “We wait until age two before we surgically descend the testicle. Most undescended testicles will descend on their own in the first year. If it doesn’t, the child still won’t remember anything if he gets surgery at two. The mother bears the brunt.” Even if the testicle undergoes orchiopexy (peg it to the scrotum), there is still an increased risk of testicular cancer. “If you see cryptorchidism, immediately think testicular cancer on board questions.”

After skin malignancies, testicular cancer is the most common malignancy in 15-35 year old males. “Testicular cancer is four times more prevalent in white than in African Americans. I have never seen a black male with testicular cancer.” The mortality of testicular cancer has decreased substantially over the past two decades. “Testicular cancer is completely curable with less than a five-percent mortality rate. We hit it strong and fast, some of the highest levels of chemo, but we get it.” (Younger patients can handle higher doses of chemo.) He emphasized how every testicular mass should be considered malignant as opposed to ovarian masses that are commonly benign. We learned a common board stumper: a 20-year-old male presents for a left testicular mass. After an ultrasound confirms a mass, what is the next step? Answer: orchiectomy (removal of the testicle). “Never biopsy a testicular mass,” said our urologist. The testicles drain into a different lymph system than the scrotum. “If you shoot a needle through the scrotum, you can potentially seed a whole new lymph basin [with cancer].”

We spent the next two days focusing on the “controversial” prostate, a gland that wraps around the urethra and secretes the majority of the ejaculate fluid. Prostatitis is painful inflammation of the prostate, typically from an infection, but also from pressure. “Always ask the guy if he is a biker or motorcyclist.”

The urologist continued: “Every guy over 50 will have BPH [benign prostate hypertrophy] with varying degrees of urinary symptoms. BPH is one of the most under recognized, easily treatable health issues.”

Persevering Pete: “What could internists and family medicine Docs do better?” Our lecturer: “I think BPH screening should be part of the standard wellness check. So many 50-60 year olds have hesitancy, difficulty starting and inability to unload. Most men with BPH get accustomed to it as it is a slow decline in function, not abrupt. We have several lines of drug treatment. We used to have to perform surgery, which is now reserved for the severe refractory cases.”

Our patient case: Robert, a comedic 5’4″ 68-year-old recently retired Ob/Gyn, presents to the urology clinic after a routine wellness check discovers an elevated prostate specific antigen (PSA), a commonly used screening blood test for a protein secreted by the prostate. Robert denies dysuria, urgency, hesitancy, dribbling or erectile dysfunction. The internist was unable to palpate any prostate mass on DRE, but Robert is referred to a urologist who palpates a small nodule on the left lobule. Needle biopsy reveals an intermediate-grade prostate carcinoma. Contrast MRI of the abdomen and pelvis does not show any nodal involvement, and a PET-CT does not show any metastatic bone lesions. (First Aid: “Prostate Cancer loves the bone.”) Robert underwent radical prostatectomy with clear margins.

Robert: “The diagnosis caught us completely off guard. My wife and I were preparing for our long-awaited retirement entertaining all sorts of crazy ideas. The Caribbean, Florida, Wyoming, who knows where we would have ended up.” For 15 minutes, we discussed how he determined to get surgery. “I had fantastic doctors. I went into surgery knowing it was the right decision, even with the potential side effects. I had 2-3 years, now I am cured. I will die of my heart, not my prostate. I live a great life. I fish, enjoy walks with my wife, and celebrate being a grandfather.”

Straight-Shooter Sally: “Are you able to have sex?” The nerves that control blood flow to the penis for an erection travel travel through the prostate into the penis. Invasive prostate adenocarcinoma can invade the nerve sheaths. The radical prostatectomy can damage these nerves as the cancer tissue is removed. Robert replied, “Oh, yes. Finally, someone asked. Last year it was the very first question from the class. My wife and I had sex last night! After surgery. I had urinary incontinence and erectile dysfunction. The erectile dysfunction improved over six to seven months. My urinary incontinence has still not returned to normal, but it is improving. I stopped wearing adult diapers about six months ago.”

Gigolo Giorgio: “Does sex feel the same?” Robert replied, “Mostly. As you should know, I do not ejaculate. I still orgasm, but nothing comes out.” Classmates turned to each other. The urologist, sensing the general ignorance and confusion, explained that radical prostatectomy removes of the prostate and seminal vesicles, and ties the vas deferens.

A discussion ensued regarding the new USPTF [US Preventive Services Task Force, government-funded panel of physicians] recommendation against PSA screening? Our urologist: “I still recommend males over 50 get annual screening involving a PSA blood test and DRE [digital rectal exam]. I understand that it is not a specific test, but I see so many patients diagnosed with prostate cancer prior to metastasis. The screening saves their lives. It is the best we have.”

The urologist continued: “The challenge with prostate cancer is stratifying risk. 1 in 7 males will be diagnosed with prostate cancer… probably 75 percent of males by age 75 have prostate cancer. Most people will never be affected by their prostate cancer, but we do not have an effective screening method. Most patients present with metastatic disease when it is too late to treat. I am asking each and everyone of you to discover a better way to detect high-grade prostatic cancer. There is some hope with the new bound/unbound PSA ratio test. More and more doctor offices are offering this as a second test if an individual has an elevated PSA.”

In the small group discussions Type-A Anita expressed her displeasure that we spent much of the week on prostate cancer and male reproductive system. “It is not that serious or complicated compared to other GU issues. Typical male-dominated field.” A female group-member: “That is just because you hate men, Anita.” Anita: “Just the bad ones.”

After hours, Anita shared a “Showing Up For Racial Justice” Facebook group’s post regarding Roy Moore’s Alabama senatorial election loss:

@ white people: we need to get serious about changing minds and voting patterns. White people overwhelmingly made a disgusting choice in Alabama, and Jones’ victory was because of black voters. How long is this party going to demand the absolute fucking most from people of color and not address the real fucking problem: white people.

Also @ white women what the actual fuck.

Our Dean lead a mandatory 45-minute session to review an LCME-required survey that our class completed back in May. Highlights of the survey: 15 percent fewer students in our class report they enjoy being a medical student compared to the class of 2010. Students are surprised that only 10 percent of the class felt there was unnecessary competition amongst students. The biggest issue continues to be “work/life balance” (but nobody has a job?). Our Dean: “We created an entire department [two years ago] to improve these issues. Stay tuned for more wellness events.”

Most of the session regarded mistreatment among students and between faculty and students. The Dean just returned from the annual American Association of Medical Colleges [AAMC] meeting in Boston: “Three of the four lectures were on mistreatment in the learning environment.” He shared a PowerPoint with the LCME’s definition of mistreatment, which starts with “a behavior that shows disrespect for the dignity of others.” Examples include language that “can be perceived as” rude, sarcastic, loud or offensive.

Our school has a committee composed of two student representatives from each grade, three deans and rotating faculty that meet monthly to respond to anonymous reports of mistreatment. The accuser need never be involved unless more information is needed. Following the committee’s investigation, disciplinary action has included removal of a faculty member’s appointment.

After class, Luke, Mischievous Mary, Persevering Pete, Jane, her trauma nurse sister and I go to our weekly Thursday beers-and-burgers spot. Lanky Luke: “A student could anonymously report a perceived insult from a resident or attending, which would immediately kick off a multi-month investigation. You don’t see an issue when people feel entitled to not be offended?” After a 5-second silence, he added, “I am referring to mistreatment outside of sexual conduct. I agree you need a channel to address sexual harassment.”

Jane’s sister: “Almost every unmarried nurse on my floor is romantically engaged with another nurse or resident. Most of my coworkers who have gotten married found their spouse through work. There is nothing wrong with that. It just should not be someone you work directly with like your charge nurse, attending, subordinate, etc..”

Mary: “As a woman, I kind of take being flirted with as a norm. It’s not good or bad. It’s just life. And it serves a purpose. It lets you know who’s interested in whom. Pretty quickly you can tell if someone is interested or not.

Jane’s sister: “I flirt all the time with this Colombian critical care resident who passed through our floor. We went on a few casual dates. If you did not know him, some women would probably think what he is doing is inappropriate. His English is good, but he does not understand colloquial sayings and expressions. We tricked him to say dirty words to the new nurses. It was hilarious. In this day and age he could get fired for that. There needs to be a mechanism to report if something is inappropriate without that accused individual getting terminated. They should be given a warning.”

Mary: “Sorry, but someone who cannot figure out how NOT to sexual harrass someone is an idiot and should be fired.”

Jane’s sister: “All I am saying is there are going to be a lot fewer happy couples because of this culture.”

Pete changed the subject. Pete and girlfriend, an M3 who competes in bodybuilding competitions, co-signed an 18-month lease on an expensive apartment. She was unfaithful to him on an “away rotation” (extended interview at a different hospital system where one is interested in applying for residency). He broke up with her, but she will neither move out nor approve his removal from the lease. “I either have to move out and pay for two apartments, or stay living in misery. What do I do? Also, her brother is a lawyer and is not afraid to sue me.” [Editor: Note that, as marriage rates decline, there is a trend to allow plaintiffs to sue in family court after living with someone for at least two years (e.g., in British Columbia and Scotland). Pete can think of the extra rent as alimony.]

Later that evening, Jane and I attend an optional heart workshop led by a 55-year-old cardiothoracic (CT) surgeon and his fellow. The surgeon was crude and direct, laying frequent F-bombs. Anita

Full post, including comments

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

Full post, including comments

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

Full post, including comments

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

Full post, including comments

“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)

Full post, including comments