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Folks protest the Redskins football team for a purportedly racist name, but the “Patriots” are celebrated, at least here in Boston. One of the main agenda items for the American Revolutionaries (not to be confused with “rebels”) was stealing land from Native Americans west of the Proclamation Line, established down the spine of the Appalachians by the British in 1763. Many of the actual “patriots” stood to gain what would today be billions of dollars in wealth if this ban on white settlement could be eliminated. (start with “Washington as Land Speculator” from the Library of Congress)

Shouldn’t folks who care about football and Native Americans be demanding that the New England Patriots change their name? And be more passionate on this issue than on the Redkins?

Separately, what about the T-Mobile ad where babies with different skin colors were featured to illustrate the company’s commitment to various virtuous values, e.g., “you come with open minds and the instinct that we are equal. … You’ll demand fair and equal pay.” The company advocating equality pays its CEO 178 times more than a median employee (payscale.com). What about the context in which the ad appeared? What would be “fair and equal pay” for most of us to run out on the field and participate in an NFL game? Does it make sense to say “we are all equal” in the middle of a sport in which few of us can compete? How long would a 100 lb. 70-year-old TV viewer last on the scrimmage line?

Readers: What were your personal Super Bowl highlights? My most vivid memory is the communal kissing of the trophy at the end of the contest. A ritual in which each person touches or kisses a metal object seems like a bad idea during flu season!

Related:

• the Superb Owl party legal dispute
• Superb Owl Sunday photo gallery
• Why isn’t the Super Bowl always in a tax-free state?
• All you have to be is white (to be credited with Super Bowl victory)?

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“Will America yield its position as the world’s leader in science and technology?” (Boston Globe) is by Eric Lander, one of MIT’s top biologists:

Finally, are we prepared to expand science and technology opportunities for all Americans? The United States has only 5 percent of the world’s population. To stay ahead, we’ll need to use all our assets. That means leveling the barriers for women in science and engineering, and closing the participation gap for underrepresented minorities.

He complains that Donald Trump doesn’t Tweet about science and technology and isn’t spending 24/7 lobbying Congress to increase funding for folks like Eric Lander. But if there are “barriers” to women and minorities in science and technology, who put them up if not guys like Professor Lander and institutions such as MIT? Isn’t he admitting that America’s science and tech institutions are sexist and racists on a continuing basis (the barriers are still in place and are yet to be leveled, according to the Globe article)? If so, why would taxpayers want to give more money to sexists and racists? Why not fund some sector of the U.S. economy that is already open to women and minorities?

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Fans of Zoolander will be pleased to know that the Predator drone is not an ambi-turner: it is pre-programmed to orbit left around a point.This was an issue when the $1 million pod that the US slung underneath the originally-Israeli-developed aricraft required right turns. The pilots have to manually build up flight plans for nearly every operation.

I learned this during a talk by a retired USAF pilot to a gathering of local pilots.

According to this guy, who was recalled after a long career to fly drones, the Predator can take off at up to 2,500 lbs and climb to 25,000′ with a feeble 115 hp turbocharged Rotax engine. The biggest cause of loss of the $4 million aircraft was turbocharger failure that would then take out the engine due to a shared oil system. The second most common reason for loss was icing due to the fact that the aircraft lacks anti-ice or de-ice equipment: “You get into the clouds in the mountains of Afghanistan and you instantly ice up.” The aircraft did have an ice detector and alarm for the pilot.

When the drone loses communication via the KU satellite it takes 12 minutes for the link to be reestablished. During these 12 minutes the drone will fly its flight plan.. including right into a thunderstorm (this happened to the speaker once).

Takeoff and landing were usually handled by a local team right at the airfield where the Predator was based. “Pilot-induced oscillation on landing was common. The nose gear would collapse and the $1 million sensor ball underneath the aircraft would be destroyed.” Once above 3,000′ AGL a U.S.-based crew would take over. If the job is sitting and drinking a large Starbucks beverage, what happens during bathroom breaks? You might think that control of the drone is zapped to another crew’s workstation, but instead the break crew comes in and physically sits in the chairs just vacated by the pilot and enlisted guy (“sensor operator”) who head out for McDonald’s. The speaker explained that, because the Predator is firing a weapon, the pilot must be an officer under current USAF rules.

The Predator lacks any kind of traffic avoidance or warning system. “We would get advisories from ATC.”

Pilots who transitioned to the Predator from traditional aircraft did better than pilots for whom flying was purely a desk job. The drone-only pilots would put in huge rapid power changes at high altitude, rather than making the smooth throttle adjustments of an experienced turbocharged piston pilot, and the result would be cracking, oil loss, and a $4 million hole in the ground.

Due to the turbocharger failures and losses from icing encounters, the Predator has been replaced with the larger and vastly more expensive turbine-powered Reaper, but the Reaper cannot match the Predator’s 22-hour loiter time.

Our speaker had served in Vietnam and said that he and his age cohort enjoyed killing the “bad guys” (of course, the jihadis are entitled to their own opinion regarding which side is “bad”!). So they’d clock out after blasting a house with a Hellfire missile and enjoy hanging out with friends and family. The young guys, on the other hand, complained of myriad psychological problems and are retiring at a 100 percent disability rate due to PTSD.

Speaking of psychological problems, I am not sure that the snowflake generation would have felt safe at the pilot gathering. Jokes told over the PA involved prostitutes and lawyers, for example. The tamest example:

One guy has a 7-year-old Goldendoodle who is addicted to humping females of the canine persuasion. The animal’s name is “Marvin,” but for the last few months the family has been calling him “Marvey Weinstein”.

More typical:

Bill and Hillary are at a Yankees home game, sitting in the first row, with the Secret Service people directly behind them.

One of the Secret Service guys leans forward and whispers something to Bill.

At first, Clinton stares at the guy, looks at Hillary, looks back at the
agent, and shakes his head “no”.

The agent then says, “Mr. President, it was a unanimous request of the entire team, from the owner of the team to the bat boy.

The agents tells Bill that the fans would love it.

Bill shrugs his shoulders and says, “Ho-Kay! If that is what the people want.
C’mere Hilly baby.”

With that, Bill gets up, grabs Hillary by her collar and the seat of her pants and throws her over the wall onto the field.

She gets up kicking, swearing, screaming, “Bill you”!$#@&!”. The crowd goes absolutely wild. Fans are jumping up and down, cheering, hooting and hollering, and high-fiving. Bill is bowing, smiling and waving to the crowd.

He leans over to the agent and says, “How about that; I would have never believed how much everyone would enjoy that!”

Noticing the agent has gone totally pale, he asks what is wrong.

The agent replies, “Sir, I said they want you to throw out the first ‘pitch’.”

Related:

• “Confessions of a Drone Warrior” (the young pilot becomes “angry, isolated, depressed”)

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Bitcoin is volatile, but traveling back in time to 2010 to buy Bitcoin instead of going to medical school is still a great career plan (helpful calculator).

The question for today is whether we can expect our least deserving rich folks to depart the U.S.

The typical rich bastard with unrealized capital gains can’t renounce U.S. citizenship, move to a tax-free jurisdiction, and then cash in, tax-free. The U.S. charges an “exit tax” for anyone trying to flee. Also the U.S. can disregard the renunciation and continue to try to collect taxes if it deems the citizenship renunciation to be insincere.

Consider the bitcoin billionaire (or at least $100 millionaire). His or her wealth is on a Post-It and nobody else knows about it. So the person who was clever enough to buy bitcoin in 2010 renounces in 2018, becomes a citizen of a country without income tax or one that doesn’t tax foreign holdings, and then starts cashing in without the U.S. government ever becoming aware.

Readers: What do you think? Will an American with secret-from-everyone Bitcoin gains stay and pay the tax? Or develop a sudden fondness for life abroad?

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From our anonymous insider…

Exam week: two standardized patient (SP) encounters, clinical multiple choice exam, NBME multiple choice exam, and case-based exam.

Interviews with “patients” are done solo with a faculty member observing and grading in real-time via video. My first “patient” presented for shortness of breath and 15 lb. weight gain over one month. I heard heard Bibasilar inspiratory crackles listening to the lungs, and an S3 gallop listening to the heart, suggestive of congestive heart failure. After the exam, I confirmed the diagnosis by reading a chest x-ray showing bibasilar infiltrates and congestion in the hilar vessels. The diagnosis was further confirmed by interpreting a difficult EKG with Q waves (prior MI), RVH (right ventricular hypertrophy), biatrial enlargement, and right axis deviation with potential hemiblock. Each of us then had 45 minutes to write a one-page H&P (history and physical) note. Nobody reported finishing the H&P note early and, in fact, some students said that they ran out of time.

The second patient presented for pneumonia with pleurisy (inflammation of the pleural membrane). While listening to her lungs with the wireless simulated stethoscope, I heard the classic sound for pleurisy: “walking on fresh snow” on inspiration and expiration.

The 50-question clinical multiple choice exam included 35 questions on EKG interpretation and pediatric cardiology findings. For example:

• A woman collapses while dancing at a party. Her husband states she has had three drinks and several cups of coffee. The astute medical student runs over and realizes she may be suffering from what condition? What could you do to fix this? Answer: the combination of caffeine, alcohol, and dancing led to paroxysmal supraventricular tachycardia-induced syncope (fainting). This can be easily resolved via carotid massage to induce vagal response. [Editor: note the heteronormative bias of the question; why was it the woman’s husband who accompanied her to the party rather than a female lover?]
• A systolic murmur that radiates to the back is heard at a baby’s two-month check up. Three months later it goes away. Is the diagnosis pulmonary stenosis or an innocent murmur. Answer: peripheral pulmonary stenosis is an innocent murmur and normal finding during the first few months of life as the pulmonary circulation opens up.
• What is the most likely site of MI for a patient with an EKG remarkable for Q waves in leads II, III and aVF. Answer: inferior infarct of the right coronary artery.
• A week after a heart attack, a patient suddenly becomes hypotensive (low blood pressure). On cardiac auscultation (listening with stethoscope), a systolic murmur with an opening snap is heard. What artery was most likely blocked? Answer: right coronary artery leading to posteromedial papillary muscle rupture.

“There were a few poorly worded questions,” said Jane, “but nothing to get uptight about.” As I walked out, a horde of students led by Type-A Anita were complaining to the clinical coordinator (administrative assistant to the physician-director) about the questions and the quality of the images.

The 3-hour 120-question NBME exam featured numerous questions on heart failure and chronic obstructive pulmonary disease (COPD). I should have studied the basic physiology from last year as there were several easy questions that I struggled with. I will study this for Step 1. The questions on cancer and hemostasis disorders were straightforward, e.g., a patient with sudden weight loss, night sweats, and an enlarged lymph node mass biopsy revealing Reed-Sternberg cells (diagnosis: Hodgkins lymphoma). The class agreed that this was easier than the last block. Straight-Shooter Sally: “Microbiology was the hardest.”

On Thursday we started at 8:00 am with a case-based exam presenting H&P notes, test results, and images for four patients: COPD exacerbation, CHF, dilated cardiomyopathy, and an anemic elderly woman presenting to ED after she fell down. The elderly woman was the most challenging for the class. Pinterest Penelope: “It caught me off guard. I was not thinking about MSK []musculoskeletal] material.”

Most people finished the three-hour exam early, so eleven of us headed over to our favorite burger-and-beers spot for the 11:00 am opening. Composed Catherine, a short, intelligent Catholic with long black hair, was the center of attention showing off pictures of her new shepherd-mix puppy, who is being cared for by her new husband, a work-from-home engineer.

We spent the afternoon conducting a financial intervention with one of Jane’s sisters. She takes home $2,500 after taxes each month working as a neurotrauma nurse. [Editor: she needs to come to Boston; nurses at Tufts went on strike in 2017 to protest wages that averaged, pre-strike, $114,500 per year and topped out at $152,000.] Although she graduated debt-free from a state university, she has accumulated $4,000 in credit card debt at 20 percent APR, a $15,000 car loan with a $350 monthly payment, and a $10,000 Lowes loan in her name for improvements of her ex-boyfriend’s house. She has paid nearly $5,000 in interest payments over the past year towards the Lowes loan, but has not touched the principal. “I feel like I am struggling to stay afloat in a dark ocean. What do I do?”

Jane has been in the U.S. military’s Health Professions Scholarship Program, which pays for all tuition, fees, and health insurance. Last year she got a $20,000 signing bonus and started receiving roughly $27,000 per year in cash. Jane agreed to dip into her “war chest” to loan her sister $4,000 interest-free to pay off the credit card debt. “You have to promise me that you will talk to [ex-boyfriend] about dealing with this Lowes loan.”

Criticism of President Trump’s condolence phone call to Myeshia Johnson, widow of fallen soldier La David Johnson, energizes several classmates. Type-A Anita wrote on the class GroupMe: “For anyone who has a military family, I am so sorry.” Pinterest Penelope: “Such a sad time to be an American.”

Grades are released on the school’s Blackboard website on Friday at 11:00 am only if all class members have completed evaluations of the block and each lecturer (see Year 1, Week 28). This takes about an hour, especially if you’re careful to avoid generating false alarms via the forced “inappropriate conduct” boxes (four for each lecturer). I’ve been careful with evaluations ever since the first exam week of M1 year, I awoke at 10:45 am on Friday morning after an evening of downtown bar hopping. My phone showed several emails from the examination coordinator reminding me to complete the evaluations. However, the power had failed in my apartment and I had to walk to the nearest Starbucks. I am waiting until graduation to admit to classmates that I was the reason they had to wait until 2:00 pm before leaving campus for their vacation (students who fail will stay an extra week and take an exam again).

Statistics for the week… Study: 20 hours. Sleep: 8 hours/night; Fun: 1 night. During drinks and dancing on Thursday night to celebrate completion of this block, I spoke with the Kurdish classmate who was excited about the independence vote (see Year 2, Week 7). What was his reaction to media reports of the Iraqi military re-taking Kurdish territory? “My family in Kurdistan and their neighbors don’t care about the prospect of war. They are used to it.”

More: http://fifthchance.com/MedicalSchool2020

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Happy February everyone.

Folks worldwide will be watching the Winter Olympics in Pyeongchang, South Korea.

I wanted to take a moment to ask readers to invest in thoughts and prayers for the safety of athletes who are threatened by a mentally unstable madman in command of a massive nuclear-and ballistic-missile equipped military (and also the athletes may be threatened by that North Korean guy).

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From our anonymous insider…

Leukemia/Lymphoma week. A spunky 40-year-old hematologist/oncologist hung up her phone as she arrived five minutes late for the first lecture. “Sorry! Sorry! My husband is incompetent at getting the children ready for school. I had to leave earlier than normal to get here. He can’t find my son’s shoes! The whole house is in chaos.” (She rejected three additional calls from the husband during the lecture.)

Leukemia, a cancer of bone marrow blood cells, is classified according to (1) stem cell lineage (myeloid versus lymphoid), and (2) chronic versus acute. Disease severity is determined by symptoms and the percentage of immature cells (called blasts) in the marrow and blood.

She began the lecture with an impassioned speech on the advances in treatment of chronic myelogenous leukemia (CML). “This is the coolest story of the century! It is an amazing time to be in medicine. In the 1990s, CML had 100 percent mortality within five years.” Dr. Brian Druker’s lab linked CML to the Philadelphia Chromosome, a translocation between chromosome 9 and chromosome 22 resulting in the constitutively (constantly) active BCR-ABL fusion protein. Druker developed imatinib, a targeted therapeutic agent, that inhibits the function of BCR-ABL protein. “This is what bench to bedside medicine is all about. Imatinib was the first successful targeted therapeutic in cancer treatment. The trials of the drug that became Gleevec showed complete hematologic response in 94 percent of patients versus 55 percent for standard of care. We never see these numbers. The coolest thing is it is a small pill. This is Nobel Prize-worthy.” The class, one week before exams and exhausted after three hours of lecture, showed little reaction. “Guys, come on, get excited!”

Imatinib is a nearly complete cure, with CML patients now as likely to live to a ripe old age as anyone else, but nobody wants to do a clinical trial investigating whether patients can stop taking Gleevec. “Would you sign up to be randomized to stop the drug that saved your life? Who is going to fund it? Not Novartis.”

She continued with the childhood disease of acute lymphocytic leukemia: “ALL is a parent’s worst nightmare. An 8-year-old falls on the playground and starts to complain of bone pain. When you go to the pediatrician, ALL is not on their radar. There is no fracture on x-ray, but the pain does not resolve.” After several tests including an abnormal CBC, the child is referred to a pediatric oncologist who then performs a bone marrow biopsy to diagnose ALL.

Induction therapy (initial treatment) involves 30 days of intense chemotherapy (typically, methotrexate) to get the child into remission. Due to ALL’s tendency to metastasize to the brain, chemo drugs are introduced via lumbar punctures every three days. “We fortunately have a fantastic prognosis for ALL. Children are resilient. We are able to use doses and treatment frequencies that are not achievable in adults.”

Lectures conclude with an overview of common chemotherapy agents and a discussion of side effects: “An overlooked area of chemotherapy is managing nausea. I had a patient vomit when she saw me at the grocery store. These drugs cause such visceral reactions. We’ve developed much better antiemetics in the last few decades.” She is a strong proponent of medical marijuana having trained in Seattle. “Even with the newer antiemetics, Marinol [synthetic THC] is one of the most effective agents I have seen to control nausea and appetite.”

We need to memorize the major complications of several drugs. Doxorubicin has a 11 percent risk of developing acute dilated cardiomyopathy. This rises to 35 percent if higher doses are used. Vincristine, a microtubule inhibitor, can disrupt the highway system of the neuron. This can lead to peripheral neuropathy (sharp pain in the extremities), one of the most common side effects of chemo. Certain breast and ovarian cancers requires hormonal agents. “Some of the estrogen modulators and aromatase inhibitor makes the patient feel like he or she is going through menopause. Testosterone inhibitors for prostate cancer causes this similar menopause sensation with hot flashes and all.” Straight-Shooter Sally: “All an oncologist does is hope the poison kills the cancer before the patient.”

Our patient case: George, a 31-year-old owner of a small construction firm, presents for a painless mass on the right side of his neck he noticed showering a week earlier. He has lost 10 pounds over the last month, which he attributes due to training for an upcoming bike race. He reports occasionally waking up sweaty in the middle of the night, which he attributes to anxiety from his 100-hour work week. He has intermittent back pain, which worsens when he consumes two or three beers. Physical exam reveals a 4 cm x 3 cm mass in the right supraclavicular fossa (space just above the collarbone) and an unbeknownst 5 cm x 5 cm mass in the right axilla (armpit). George undergoes a lymph node resection (removal). Biopsy reveals pathognomonic binucleate Reed-Sternberg cells on histology. George is diagnosed with Hodgkin lymphoma (formerly “Hodgkin’s lymphoma,” but the trend is to get rid of the apostrophe S when a disease is named after a physician who discovered it, as opposed to being named after a patient).

Hodgkin lymphoma begins in a single lymph node and, unlike other cancers that can pop up in random locations around the body, spreads along continuous lymph drainage, spreading first to the spleen, then the liver and finally the bone marrow. Most lymphomas afflict the elderly, but Hodgkin patients have a bimodal age distribution, peaking around 25 and 65.

George is joined by his oncologist, a 60-year-old with a slight stutter. “Oncologists are stereotyped as two-faced. We are aggressive in attacking the cancer, but the moment we give up on beating the cancer, we switch to palliative care. It could be overnight the day after receiving chemo.”

George: “I had chemo about once or twice a week for two months. Then I had a PET scan to re-evaluate.” His oncologist commented: ” George was a uniquely motivated patient. We discussed possible clinical trials. However, he wanted to preserve his lung function given his passion for biking. Clinical trials are not good for personalizing treatments. We customized a treatment regimen without standard-of-care Bleomycin.” [Bleomycin causes pulmonary fibrosis in 10 percent of patients.]

George was asked to describe the chemo center. “Chemo centers are a depressing sight. You remember the faces of the person next to you. I would try to imagine the life of the person. You can tell who will not be there next month.”

Mischievous Mary asked how George’s family managed the diagnosis and treatment. “My wife was a rock,” recounted a tearful George. “She would try to shield me. I remember one time I got up from the TV to do some task. My wife thought I would be away for 15 minutes. When I came back sooner, I found my wife and son scrubbing the whole room with bleach. I asked them, ‘What is going on?’ ‘Oh, nothing…’ they responded. I realized they were doing this out of fear I would get an infection.” He continued: “I kept working during the early chemo. After a few cycles it got unbearable to work immediately after a dose. I would take a few days off and lie in bed, then be back later in the week. My brother and his family moved into our house to help manage the business. I was upfront with my employees and clients. I am proud that not a single employee left.”

Type-A Anita asked what motivated George through his treatment. “I grew up without a father and did not plan to have children because I thought I wouldn’t make a good father. I am a Christian, but talk a lot with my neighbor who is a rabbi. One evening he told me, ‘Look at what you have accomplished.’ After that, I promised myself I would always be there for my children.”

Friday afternoon concludes with an introduction to intravenous catheters (IVs), the first workshop in our clinical procedure series to prepare us for clerkships. “Think of this as a little treat before you start exams next week,” explained the physician coordinating the series. Students have been eyeing each other’s veins all week, especially Buff Ben’s, a stereotypical class “orthopod” (aspiring orthopedist) who played baseball in college.

An ER nurse demonstrated IV insertion on a student. “The hardest part is getting the feel of advancing the catheter while retracting the needle. Access the vein by inserting the needle at 45 degrees. Once you see the flash [of blood], level out, inch forward with the needle and advance your catheter. If you lose the flash, pull the needle back and adjust.”

Students paired up and began. We adjusted… a lot. Gigolo Giorgio practiced on Particular Patrick, a fastidious and fashionable student from California. Giorgio did not level out enough and punctured the vein. He was moving the needle around aimlessly with a grimacing Patrick shaking under his dyed blonde hair (“flow” in California parlance, apparently). The ER nurse told him to just practice advancing the catheter. Patrick was not happy. “You are just shoving the catheter into my connective tissue!” Jane and I partnered. Neither of us got it. When I retracted my needle, blood gushed out. She now has a 3 cm diameter bruise from my handiwork. I snagged two unused IV kits to practice on at home under the guidance of Jane’s sister. Patrick: “We must look like heroin users.”

Our director of academic counseling emails a recipe for Goji Berry Trail Mix, including an explicit “place all ingredients in bowl and mix together” instruction in case any aspiring interventional radiologists are in doubt. We also learned about seven ways to calm our minds, e.g., reduce caffeine.

Statistics for the week… Study: 20 hours. Sleep: 7 hours/night; Fun: none. Jane and I prepared for the weekend studying sprint by stopping at a craft beer and wine shop with a bar. We’ll be concentrating on lymphoma histology and the endless list of cancer drugs.

More: http://fifthchance.com/MedicalSchool2020

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“Will America Stand Again With the World’s Refugees?” (nytimes) is by a guy who gets a paycheck for bringing refugees into the U.S. (He works for World Relief, a non-profit that paid employees up to $265,000 per year in 2016, according to their IRS Form 990.)

He says

This year, the United States is on track to resettle fewer refugees than Canada, which has a population roughly one-tenth that of the United States.

with the implication that a country should try to bring in refugees as a percentage of its population.

Why does this make sense? Suppose that refugees will provide a net boost to an economy. Wouldn’t it therefore make sense for the most thinly populated countries, such as Canada, to take in the most refugees? Imagine if Canada had a current population of only 1 person and its current land area that is larger than the U.S. The refugees will show up, take care of themselves, and boost the economy on both an aggregate and a per-capita basis. Canada could take in 36 million refugees, under that scenario, and be pretty much where they are today (except their economy would be larger because immigrants are better at working than native-born citizens).

What if the people who promote immigration in general and refugees in particular are lying to us? Refugees are, in fact, a net drag on an economy. Since every additional refugee will require existing residents of a country to work longer hours and pay higher taxes, then it would make sense for the most populated countries to take in the most refugees because there will be a larger base of current residents whose labor can be exploited to support those refugees, their children, and their grandchildren.

Readers: What am I missing in the above analysis? Is there a third possibility that I’ve overlooked?

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From our anonymous insider…

Hematology week. Our favorite redheaded hematologist/oncologist: “Heme is a free-for-all. Oncology is more by-the-book. Our whole practice has no idea what is causing one patient’s hematological abnormalities. We’ve been following him for 3 years. This is what makes hematology so exciting.”

Blood is composed of cells and plasma (water, electrolytes, and proteins). As introduced in the Year 1, Week 7 and Year 1, Week 16 chapters, all blood cells are derived from a single hematopoietic bone marrow stem cell that can produce either the myeloid lineage or the lymphoid lineage. The myeloid lineage includes erythrocytes (red blood cells), platelets (for clotting), monocytes (white blood cells that consume particles), and neutrophils (the most abundant immune cell that responds to infections). The lymphoid lineage includes the immune system’s T cells and B cells.

Platelets start as small cytoplasmic blebs (bulge in the cell) of megakaryocytes (large resident bone marrow cells) and eventually detach and drift away. Erythrocytes (red blood cells) mature in the bone marrow until they lose their nucleus. “If you see reticulocytes [immature red blood cells] in the blood, the bone marrow is working in overdrive producing red blood cells.”

Our lecturer explained the complete blood count (CBC), the most common blood test. Normal CBC: 45 percent of blood volume is composed of red blood cells (hematocrit), 55 percent plasma (proteins, electrolytes, water), and less than 1 percent white blood cells and platelets. “Do not forget about the peripheral blood smear [looking at a drop of blood through a microscope]. It’s vastly underutilized. You can catch iron deficiency before counts get low.” The hematologist emphasized contextualizing a CBC: “Before you jump to pathological anemia, is this patient over-hydrated? If they are hooked up to IV saline, they are going to have lower counts even though the total rbc mass may be normal.”

Anemia is divided into problems of underproduction or destruction. “Destruction anemias are caused by an intrinsic or extrinsic factor. Intrinsic anemia is caused by a defect in the red blood cell itself, such as the membranopathy hereditary spherocytosis or the oxidative damage from an enzyme defect such as glucose-6-phosphate dehydrogenase. Extrinsic anemia is due to destruction of the red blood cell from the outside.” This can be due to an autoimmune reaction against red blood cell surface proteins or a platelet disorder causing small thrombi to form in the vasculature shearing normal red blood cells.

“Use the Coombs test to differentiate between intrinsic and extrinsic disorders.” The Coombs test mixes the patient’s blood with an antibody against human antibodies. If the immune system is attacking its own cells, the anti-Ig antibody will cause the red blood cells to precipitate out of solution.

When so many red blood cells are destroyed that the body demands more, immature red blood cells that still have nuclear material (reticulocytes) are released into circulation. “Always ask for the reticulocyte count if you suspect an anemia of destruction.”

The next two lectures detailed hemostasis (clotting) disorders and the body’s two systems for preventing bleeding. Primary hemostasis plugs the damaged blood vessel with platelets. Secondary hemostasis creates a more stable clot by using clotting factors, proteins released by the liver. Primary hemostasis disorders are associated with mucosal bleeding (gums, menorrhagia, epistaxis), whereas secondary disorders such as hemophilia lead to severe internal bleeding, especially in joints (hemarthrosis).

Our patient case: Gina, a 51-year-old secretary presented to her internist after gingival (gum) bleeding from a dental cleaning. She described bruising easily and itchiness after hot showers (aquatic pruritus). A CBC reveals an elevated hematocrit (extra hemoglobin) and a high platelet count. She was surprised to be diagnosed with polycythemia vera (PV): “I did not know I was sick until the doctor told me I was sick.”

PV is a type of myelodysplastic disorder. A mutated myeloid stem cell, most commonly a JAK2 gain-of-function mutation, causes unchecked clonal proliferation of the myeloid lineage. This results in erythrocytosis (increased red blood cells), thrombocytosis (increased platelets), and leukocytosis (increased white blood cells, specifically of the the myeloid lineage).

Gina started with low-dose aspirin and biweekly phlebotomy (blood draws) to decrease her platelet function and hematocrit, respectively. Straight Shooter Sally: “Can she donate the removed blood?” The hematologist responded, “Great question, in many countries yes. In the US, the Red Cross will not accept anyone with an abnormal CBC. It is a shame because there is nothing abnormal about her denucleated red blood cells.”

PV increases the risk of thrombotic events (clots, stroke, heart attack) due to the increased thickness of blood. According to UpToDate, the annual incidence of thrombosis in PV patients ranged from 2-5 percent depending on risk factors such as age and hematocrit management, which compares to annual stroke risk of 5.6 percent for a 75-year-old smoker with hypertension and diabetes.

PV patients have a 20-percent lifetime risk of their PV transforming into myelofibrosis and a 7-percent lifetime risk of acute myeloid leukemia. “PV overworks the bone marrow,” explained the hematologist. “Myelofibrosis is what you get when you wear it out.” Bone marrow becomes fibrotic with collagen (fibrous protein found in bone, tendons, and ligaments) deposition displacing the stem cells. This causes an abrupt aplastic anemia with extramedullary (outside the bone) hematopoiesis. PV turning into leukemia happens because rapid clonal proliferation increases the chance of an oncogenic mutation (cancer-producing mutation).

“When it rains it pours,” recounted Gina. “I had left my husband. I was going through divorce, I had a new boss trying to cut costs at work, and my son was jobless after graduating from college. Now I have my doctor using all these fancy words and telling me I might have cancer. It was too much.” A student asked: “Did you have any issues dealing with health insurance during the divorce.” “No, I was the primary insurer.” The heme/onc added, “I have issues with insurance and divorce all the time. Also, when the patient with insurance is diagnosed with leukemia and has to stop working. The family has trouble switching primary insurance to the other spouse.”

[Editor: note Gina’s description of being involved in a divorce lawsuit that she started as “going through a divorce.” This is conventional for American plaintiffs, as though divorce litigation were a random weather phenomenon that they had stumbled into. See Real World Divorce.]

Could Gina describe the itchiness? “Every time I got out of a hot shower, I would have this uncontrollable itchiness for a few hours. It got so bad I would be afraid to shower!” The hematologist added, “There are a few theories out there to explain this phenomenon. One theory states the increased myeloid white blood cells cause increased histamine release. This doesn’t make sense because patients can get the itchiness even without leukocytosis [high WBC]. The other theory is platelet aggregation after vascular constriction in the skin after a hot shower.”

Gina, now 66, returned to her hematologist about a year ago due to acute left flank pain, fatigue, and poor appetite with a 15 pound weight loss over a two-month period. Physical exam revealed a palpable mass on her left upper flank. CBC showed pancytopenia (low cell counts across the board). A bone marrow sampling revealed diffuse fibrosis.

The hematologist explained that bone marrow sampling has two steps: “First a needle is inserted into the bone. A vacuum is created to suck bone marrow aspirate into the syringe. Then, a small sample of bone is extracted for biopsy. I am told that the aspirate step is the excruciatingly painful part.” Gina interjected, “It feels like a lightening bolt traveling through your bone.” Her bone marrow cells have been expelled from the fibrosed marrow and now reside in her spleen, liver, pleural cavity and peritoneum. The enlarged spleen is compressing her stomach, which makes her easily satiated and explains the weight loss [Editor: when will be able to buy one of these spleens on Amazon?]. She was diagnosed with myelofibrosis and informed that her life expectancy was just seven years.

The only curative therapy for myelofibrosis is an allogeneic (from a different person) stem cell transplant to replace the defective myeloid clonal population. Gina was not a transplant candidate given her age. She was started on Jakafi (ruxolitinib), a small-molecule inhibitor of JAK2. Jakafi may relieve symptoms of myelofibrosis, but does not improve survival [Editor: except for the survival of Incyte Corporation, which collects roughly $1 billion per year from this “ophan drug”].

The hematologist recounted Gina’s Jakafi-induced anemic crisis: “Jakafi is a double-edged sword. It can improve symptoms, but it also risks causing an anemic crisis. We followed the drug’s guidelines but Jakafi was such a new drug. We took her off the drug, but then she had withdrawal requiring two transfusions. We titrated her down [with smaller doses of Jakafi]. She finally has great symptom control with this lower dose.” Despite all these ups and downs, Gina is happy with her treatment. Her symptoms are managed well, and she enjoys vacationing at the beach in her retirement.

A student asked, “I apologize if this is blunt: do you struggle with the cost of Jakafi? Is making Medicare pay for such a costly medication that just improves symptoms worth it?”

“The medication makes me feel much better. I was barely eating before I started Jakafi. The pain in my stomach [spleen] got better, it allowed me to sleep. My blood tests have improved. Jakafi had a crazy price tag when I first started taking in 2012. I am fortunate that my doctor enrolled me in a charity program that pays my share.” According to “U.S. Probe Sheds Light on Charities’ Role in Boosting Drug Sales,” (Wall Street Journal, June 2017), pharma companies are the primary donors to these “charities” because “every $1 million donated to charities can lead to up to $21 million in sales for drug companies.” In other words, patients are more likely to continue having their Medicare prescriptions filled if they don’t have to pay anything out of pocket.

Friday afternoon concluded with a practice clinical exam session. We interviewed a standardized patient with simulated heart failure (bibasilar crackles with S3 gallop). After the 30-minute encounter, we analyzed a (fake) electrocardiogram and chest x-ray, and then we spent 45 minutes writing a H&P (history and physical exam) note. Type-A Anita before the practice session: “I am so nervous. I do not know who we will have to write up. I don’t know if we should do vitals. I’m freaking out about having to read an EKG.”

Students throughout the day were checking news about the Las Vegas shooting. Pinterest Penelope updated our small group from BuzzFeed: “Isn’t that where Russian News propaganda is spread?” “Are you kidding, they have better live news updates than any other website.” “That’s because they don’t fact check anything.”

The weekly email from our director of academic counseling:

… in this Wellness Weekly section, inclusive language will be highlighted. The following details were taken directly from the University of Massachusetts–Amherst transgender terminology guide [from The Stonewall Center, “A Lesbian, Gay, Bisexual, Trans, Queer, Intersex, and Asexual (LGBTQIA+) Resource Center”]

• Hir: A non-gender specific pronoun used instead of “her” and “him.”
• Sie or Ze: A non-gender specific pronoun used instead of “she or “he.”
• Intersex: congenital variations in which development of chromosomal, gonadal, or anatomical sex is atypical (preferred term to “hermaphrodite”). About one in 1,500-2,000 children are born with an intersex variation.

She promises more information on the topic of transgender vocabulary in future editions, includes a recipes for Zucchini Parmesan Crisps (preheat oven to 450 and bake for 30 minutes), and advertises a yoga session taught by a full-fledged MD.

Statistics for the week… Study: 20 hours. Sleep: 8 hours/night; Fun: 1 nights. Example fun: Our social chair organized a 2:00 pm Saturday private wine tasting tour for $20 at a local winery attended by 15 students.

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I was working on a project this evening so wasn’t able to tune in to Donald Trump (not that I would typically want to watch a politician speak). What did he say? TIME has the transcript of the State of the Union speech.

I’ve just skimmed it so far. It seems to open with a terrifying series of natural disasters.

Hispanic American unemployment has also reached the lowest levels in history

This can’t be true, can it? Absent economic collapse, how could there be an “unemployed” lifestyle category in the days before unemployment insurance and welfare existed?

The stock market has smashed one record after another, gaining $8 trillion in value. That is great news for Americans’ 401k, retirement, pension, and college savings accounts.

My neighbors still hate Trump for making them richer! The boom will defer what had been an impending disaster in a lot of states with unfunded pension liabilities. Now they’re mostly sort of funded, thanks to the Trump Bump!

We slashed the business tax rate from 35 percent all the way down to 21 percent, so American companies can compete and win against anyone in the world.

Let’s see if we can fab chips in competition with the Taiwanese! I’m betting “no.”

All Americans deserve accountability and respect

We are showing respect to 2+ million Americans by keeping them in comfortable prisons?

America is a nation of builders. We built the Empire State Building in just 1 year — is it not a disgrace that it can now take 10 years just to get a permit approved for a simple road?

Shouldn’t this be “America used to be a nation of builders” then?

We can lift our citizens from welfare to work, from dependence to independence, and from poverty to prosperity. … And let us support working families by supporting paid family leave.

The best way to be at work and independent is by being at home on paid leave and letting other people do the work? (See Paid Maternity Leave: Employers or Taxpayers should Pay?)

The fourth and final pillar protects the nuclear family by ending chain migration. Under the current broken system, a single immigrant can bring in virtually unlimited numbers of distant relatives. Under our plan, we focus on the immediate family by limiting sponsorships to spouses and minor children. … In recent weeks, two terrorist attacks in New York were made possible by the visa lottery and chain migration. In the age of terrorism, these programs present risks we can no longer afford.

Okay, but Syed Rizwan Farook brought in Tashfeen Malik as his wife and she encouraged him to wage jihad in San Bernardino.

Ryan Holets is 27 years old, and an officer with the Albuquerque Police Department. He is here tonight with his wife Rebecca. Last year, Ryan was on duty when he saw a pregnant, homeless woman preparing to inject heroin. When Ryan told her she was going to harm her unborn child, she began to weep. She told him she did not know where to turn, but badly wanted a safe home for her baby.

In that moment, Ryan said he felt God speak to him: “You will do it — because you can.” He took out a picture of his wife and their four kids. Then, he went home to tell his wife Rebecca. In an instant, she agreed to adopt. The Holets named their new daughter Hope.

This is a heartwarming story of American success? What happened to the biological mom? [Update: Journal of Popular Studies to the rescue!]

Atop the dome of this Capitol stands the Statue of Freedom. She stands tall and dignified among the monuments to our ancestors who fought and lived and died to protect her. Monuments to Washington and Jefferson

Slaveholders Washington and Jefferson were fighting for Freedom?

Readers: What did you think of the live delivery? My friends on Facebook are outraged… because Trump.

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