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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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“Extreme poverty in America: read the UN special monitor’s report” (Guardian):

The proposed tax reform package stakes out America’s bid to become the most unequal society in the world, and will greatly increase the already high levels of wealth and income inequality between the richest 1% and the poorest 50% of Americans. The dramatic cuts in welfare, foreshadowed by Donald Trump and speaker Ryan, and already beginning to be implemented by the administration, will essentially shred crucial dimensions of a safety net that is already full of holes. It is against this background that my report is presented.

The United States is one of the world’s richest and most powerful and technologically innovative countries; but neither its wealth nor its power nor its technology is being harnessed to address the situation in which 40 million people continue to live in poverty.

The Federal War on Poverty began 54 years ago (Wikipedia). As a percentage of GDP, the U.S. spends more on its welfare state than any other country on Planet Earth other than France (Forbes). Thus, due to our larger population, we actually run the world’s largest welfare state. Is it thus fair for the Guardian to say that our wealth isn’t being harnessed for poverty relief? What about the fact that the evil Donald Trump might assist Congress in changing the way some of this money is spent? If tens of millions of Americans are desperately poor despite the river of poverty relief cash that has been flowing for 54 years, what is bad about change? Is it too early to declare that the old methods have failed? It is plain that we were just about the turn the corner on poverty?

Unless these folks were suggesting that currently poor Americans were actually doing great prior to Donald Trump’s election, I think the only logical inference that one can draw from the above is that War on Poverty hasn’t been given a fair chance. That seems also to be the general feeling among New York Times readers. See, for example, “The U.S. Can No Longer Hide From Its Deep Poverty Problem” (nytimes), by a Nobel-ish economist:

it is precisely the cost and difficulty of housing that makes for so much misery for so many Americans, and it is precisely these costs that are missed in the World Bank’s global counts.

(So if we already have too much demand for too few houses and apartments, how is population growth via immigration supposed to make low-income Americans better off?)

The readers respond to this with comments demanding that we double-down on the Big Welfare State:

(the very top-rated-by-readers comment) Nancy Parker, Englewood, FL: … we should tax the rich until they yell out loud, because they are privileged, not entitled to the chunk of wealth they lay claim to. Not until every poor person has the basics can they live the lives of excess and extreme that they do.

(the next one, which 951 people recommended) Susan Sheeley, Salem, MO: … Poverty isn’t the result of immigration. It is the result of the very wealthy leaving the rest of America behind.

flyoverprogressive, Michigan: The 1.5 trillion that will mainly stuff the coffers of the wealthy should have been used to provide universal healthcare, affordable college, daycare for working moms and immediately infrastructure repair. Where I live, the roads, bridges, water and sewer systems are little better than the ‘shithole’ countries of Africa.

alan haigh, carmel, NY: … Americans are sold a mythological identity of a self reliant, individualistic people always capable of pulling themselves up by the bootstraps when sufficiently motivated. If this was true, poverty would not so stubbornly pass from generation to generation here. Poverty breeds poverty, not a lack of motivation- any lack of motivation is a symptom. [i.e., he is denying the science of heritability of success!]

T.A.S. Milwaukee, WI: … If the minimum wage were a living wage, so many fewer would be on welfare. If we had reasonable public transportation, people could get to work. Etc.

Among the highly-rated comments there is only one that shows some evidence of thoughtcrime:

Don P, New Hampshire: … During the past 50 years there has been tremendous action at the federal, state and local level to address poverty and many programs yet the number of Americans in poverty still grow.

The one glaring area that no one has attempted to address and certainly no politician will even speak about is the high birth rate. In 2015 the birth rate for women with income less than $10k was 64.7 as compared to 52 for women earning $50-76k, 46 for women earning $100-140k, and 43.1 for women earning $200 k.

The clear fact is that those with the least financial means are having the most children who are being born into poverty and are opportunistically disadvantaged from they day they are born. And far too often being born into poverty results in a lifetime of poverty.

(But of course he is not enough of a thought criminal to ask “Why would people who get paid by taxpayers to have kids have a lot of kids?” or “Is it possible that when a child is born to two parents who have never worked the child will be less likely than average to seek a job?” (See The Son Also Rises: Policy Implications and The Son Also Rises: economics history with everyday applications))

Readers: Why do Americans, after having spent so many trillions of dollars over so many decades, and observing the continued presence of tens of millions of their fellow citizens still “in poverty,” still have faith that the stuff that hasn’t worked for 54 years will suddenly start working?

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From our anonymous insider…

Heart failure week begins Sunday evening. Jane and I watch (at 1.75x speed) three hour-long lectures on hypertension and ischemic heart disease (due to obstructed arteries the heart is starved for oxygen causing chest pain d). The lecturer is a 35-year-old cardiologist who comes in Monday morning for a two-hour case workshop. “I get excited when I see 30-year-olds with hypertension. I can change their lives. When I see a 70-year-old patient with three decades of uncontrolled hypertension, the damage is already done.”

Hypertension is categorized by disease acuity. Malignant hypertension is a severe acute elevation of blood pressure that causes end organ damage, particularly in organs with dense capillaries, e.g., the kidneys and retina. Benign hypertension, over 95 percent of cases, is a progressive mild elevation of blood pressure. Our lecturer explained that Amazonian tribes with no exposure to Western diet typically show blood pressures of 80/50. Normal blood pressure for an occasional McDonald’s customer is 120/80. Greater than 140/90 mmHg constitutes benign hypertension. Over 200/120 mmHg is malignant.

“The vast majority of benign hypertension is simply caused by chronic excess of salt intake,” said the cardiologist. “Our bodies have evolved complex mechanisms to retain fluid by holding onto salt. Recommended salt intake is about 4 grams; most Americans consume about 10 grams per day.” About 30 percent of the US adult population has hypertension compared to 45 percent of the Japanese adult population with their salt-heavy fish diet.

He explained that, although salt intake is a serious driver, “there are many risk factors that interplay with this volume overload state. It is well-established that African Americans have an increased risk of hypertension. The current theory is that there was an evolutionary adaptation to holding onto salt in Sub-Saharan Africa. These adaptations helped individuals survive as young children in a dry environment with little access to salt.” He continued, “The unintended consequences of chronic hypertension that develop when you are 50 do not really matter from an evolutionary standpoint. Our genetics are most adapted to getting to reproductive age.” There is nothing that humans can do after age 50 to increase their genetic success? “I would like to think there is some selection that occurs during your 50s as you take care of your child, perhaps even into grandchildren-rearing age.”

Why is hypertension bad? “A misconception about hypertension is that the heart is at fault. Hypertension is not a disease of the heart, but a disease of the vasculature and kidneys. Cardiologists get stuck dealing with many of the serious complications.” The endothelial cells and smooth muscle cells of vessels do not respond well to chronically elevated hypertension. Over time, the increased pressure within the vessels hardens and narrows both large and small arteries (atherosclerosis and arteriosclerosis, respectively). The increased resistance decreases perfusion to tissues and increases the risk for thrombus (clot) formation leading to embolic events such as heart attack and stroke. Further, the left ventricle undergoes hypertrophy (thickening) as it struggles to pump against an increased total peripheral resistance.

“For most of my patients, losing weight is the most effective method,” said the cardiologist. “Unfortunately, only six percent of patients told to lose weight actually keep weight off at one year. I give HTN medications first and tell them that they can get off them once they lose the weight.” What about reducing salt? “Americans are so far to the extreme that taking away the salt shaker will do nothing. Shake away. Chronic benign hypertension needs antihypertensive medications.”

Where is HTN treatment going? “We are in the dark ages of hypertensive treatment and pharmacology in general. Most of us hope that in twenty years we will have a renaissance in pharmacogenetics to personalize treatment. Right now it is just black or white.” (White patients may respond to single drugs, but certain monotherapies are contraindicated in African Americans due to poor response rates. Black patients will be started on lisinopril in combination with a diuretic.)

The cardiologist concluded: “On a brighter note, we are at a unique point in human history that we are no longer dying from microbes and predators. Instead, we are eating, drinking and smoking our way to death. Not bad.”

The rest of the week was dedicated to the diagnosis and management of heart failure. First we learned multiple classifications:

• Diastolic v. systolic (relaxation versus contraction)
• Ischemic versus non-ischemic (oxygen supply to the heart muscle)
• Preserved versus decreased ejection fraction (percentage of blood pumped out of heart)
• Hypertrophic cardiomyopathy versus dilated cardiomyopathy

Retired Navy Physician: “Cardiology is not rocket science. It is just common sense.”

We were prepared for our patient case with a lecture on dilated cardiomyopathy, a systolic non-ischemic problem. The heart is enlarged due to growth of muscle cells, but the resulting thin-walled muscle is unable to pump enough blood. This can be caused by genetic defects, viruses (Coxsackie B), parasites (Trypanosoma cruzi causing Chagas disease), alcohol abuse, cocaine, and poorly understood autoimmune mechanisms.

For the most part, we’re not working with cadavers this year, However, this week we go into the anatomy lab to dissect the preserved hearts that we removed from our cadavers last year. Several students expressed frustration that they had to resurrect their anatomy outfits. Pinterest Penelope: “I thought we were done with anatomy lab. Another pair of scrubs will be tossed.” Our favorite trauma surgeon and an M4 helped with the dissection. We first weighed each heart and found that two-thirds weighed more than the normal 500 grams. The trauma surgeon attributed this to “pervasive hypertension”.

We used a scalpel to open the right atrium. We used angled probes to identify the veins draining the body: inferior vena cava, superior vena cava, and the barely visible coronary sinus. We then opened the left atrium with its four pulmonary veins draining oxygenated blood from the lungs. One student found a patent foramen ovale (PFO) type of atrial septal defect (ASD). You could see a hole connecting the left atrium to the right atrium. (The trauma surgeon expected more: “I would expect to have several PFOs. It is expected to be present in 25 percent of the population. Look closer!” We then opened the left and right ventricles to observe the heart strings connecting to the valves. Afterwards we went over to the “Tray of Horrors,” collected over multiple years. We looked at the severely dilated thin walls of dilated cardiomyopathy, a bicuspid aortic valve, and a heart with several stents in the left anterior descending coronary artery. “Good haul!, I am very impressed,” said our trauma surgeon. She suggested that our class contribute to the school’s archive: “Put the mechanical aortic valve and aortic dissection on the tray.”

Our patient case: Jonathan, 53-year-old construction manager and father of two, presents to the ED for progressive shortness of breath and swelling in his legs associated with a 15-pound weight gain over two weeks. Lung auscultation (listening with a stethoscope) reveals bibasilar (base of both lungs) crackles. Heart auscultation reveals a S3 gallop, an extra heart sound that sounds like a horse’s gallop, suggestive of rapid ventricular filling.

Feeling for the location of the heart under Jonathan’s left nipple revealed a laterally displacement. Chest xrays showed an enlarged cardiac silhouette and bilateral infiltrates (pathy whiteness at the base of the lungs) with accentuated vasculature at the hilum (connective tissue where the pulmonary artery, pulmonary vein and bronchi pierce through the pleura). EKG shows sinus rhythm with a left bundle branch block, left ventricular hypertrophy, and biatrial enlargement. An echocardiogram (ultrasound of the heart) shows dilation with a 30 percent ejection fraction (normal > 55 percent). Jonathan is diagnosed with dilated cardiomyopathy secondary to viral myocarditis (infection of heart). (“Viral myocarditis and dilated cardiomyopathy,” Kearney, et al. Post-Graduate Medical Journal, 2001 ).

Jonathan, his wife, and their 25-year-old son were joined by his cardiologist. Jonathan and the son rarely spoke; the wife, a middle school teacher, led the conversation. “We did not know what hit us. It came out of nowhere,” explained the wife. “I did not know what to say to my children or husband for weeks.” The son was clearly uncomfortable. When asked about his perspective on two separate occasions, he repeated: “I try to stay optimistic, and hope for the best. I just have to believe my father will pull through this.”

Jonathan’s symptoms rapidly deteriorated at the hospital to a point he underwent a LVAD (left ventricular assist device) implantation to improve his cardiac output while he waits for a heart transplant. “We would have liked to do the surgery at a larger hospital that does maybe 100 per year. There was just no time, he was on his deathbed,” explained the wife. “The surgeon had done maybe two in his life. We put our faith in him, and it fortunately went great.”

Jonathan has been on the heart transplant list for five years. He appears tired, worn out, although he still looks imposing in his burly 6’5″ frame. “It is hard to find a heart that fits his size,” added the cardiologist. His wife is convinced he will get one soon. She recounted the scariest day in her life: “I got a phone call from my husband telling me he got in a car accident. A truck veered into his lane, striking the car in front of him. He swerved off the road hitting a tree. “I believe God has a plan for him. He wouldn’t have come out of that car accident without any scars.” Jonathan: “I am realistic. I have lowered my expectations.” There is clearly a disconnect.

Jonathan’s symptoms have improved remarkably from his deathbed with the LVAD. His progress has pushed him down in the transplant list for more urgent cases. He is maintained on diuretics and antihypertensive medications. He quickly gets out of breath from walking. He has had to retire on disability, while his wife has picked up hours working at Starbucks after her job.

A student directly asked Jonathan, “Are you depressed?” “I feel like a failure. My whole life I provided for my family. Now I just sit and wait.” Several students went up afterwards to thank the family and look at the numerous batteries and charging devices for the LVAD. Mary asked to listen to his LVAD. “It sounded like a fish-tank pump.”

Our ethics lecturer and facilitator returned this week to introduce the topics of beneficence and nonmaleficence (do no harm). Lecture opened with the classic ethics train dilemma. “There are five people on the track who will die unless you pull the lever to divert it to the side track where one person will die. Would you pull the lever?” Most students responded via the iClickers, “Yes”. “Now you have five patients that need a transplant and a healthy tourist comes to town? Should you harvest the tourist’s organs to save your five patients?” The class responded “No”. Asked to justify the different answers, one student responded “The guy on the track got into his unfortunate situation, the tourist did not.” Lanky Luke: “Is that victim blaming?”

In our small groups, we went over the Jesica Santillan case. Jesica Santillan was treated for anemia in her hometown of Guadalajara, Mexico with iron supplements, but over the years her conditioned worsened and a heart murmur was found. She was diagnosed with restrictive cardiomyopathy, a genetic disorder requiring heart transplant. She crossed the border illegally to stay with a family member living in North Carolina and sought treatment at Duke. After she was denied Medicaid coverage, a local business owner and the community donated $500,000 to pay for a transplant. A heart and lung transplant was performed at Duke in February 2003. Unfortunately, she probably would have been better off getting the transplant in her native Mexico. The American transplant surgeon, James Jaggers, assumed that the organ program would not have contacted him unless the donor and Jesica were a match. Her body rejected the new

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My Facebook friends are still outraged that the current U.S. President used some undiplomatic words to characterize living conditions in some foreign countries. (“undiplomatic” = saying what you think!)

I think that I’ve found a young foreigner who can replace this old native-born American worker. This is from an au pair “host mom” discussion forum:

In response to question about being an AP with a single mom family, AP says “yes.” In response to question about a single father family, AP says “No. I don’t think it would be appropriate. Depending on why the father is a single parent, I don’t want to have the expectation to take on a role larger than being an au pair.” What sort of role does she think she’d take on??

If the Constitution permitted foreigners to run for President, I would vote for this young lady to be our Wordsmith in Chief!

Here’s some more fun stuff from the same list…

interestingly we know there is a single mom that hooked up with her AP Lol

I am really struck by the number of APs who don’t want to live with same sex families. Although I am straight, I use this question as a screen bc I don’t want someone living in my home who isn’t open and accepting to all my friends and family members, and who would potentially bring an anti-gay POV to my children.

I just think it’s their level of comfort not necessarily anti gay.

I am sorry but not sure I understand how that is different. Not homophobic just dont want to live [for a year] with a gay couple.

I also use the willingness to live with same-sex couples (and people of other races and religions) as a screening tool. I don’t want to live with someone who isn’t comfortable around all kinds of people.

we had some candidates who said they didn’t care about religion until they found out we were Jewish. We were shocked as one was from the UK and another from Sweden I think.

Drives me nuts when I find a good candidate who otherwise fits what I’m looking for but says they aren’t ok with LGBTQ. We have gay friends and Seattle is a supportive city for LGBTQ community and so I can’t take anything less.

I understand why young women don’t want to live with single dads. … I do not judge their discomfort with it though. I am very judgy on the other hand with APs who put a “no” to same sex couples, or have a preference for a particular sex. You are not comfortable with living with same sex, I’m not comfortable with you. Your age, where you’re from etc, doesn’t matter to me in that case. I only interview APs who would work with same sex couples. And what is it with APs not wanting to work with female couples? Do they think these women will make them googly eyes?? [Maybe the AP doesn’t want to work with statistically unhappy children?]

We also screened out boys as at first DH and I were not comfortable and later DS only wanted girl AP. Did that make us sexist I guess the answer would be yes for childcare. Do I love my husband, son, nephews, guy friends etc yes I am not a man hater but I never hired a male childcare provider.

I swear the AP life is a soap opera in our area–mom was getting high AP supervised visits of mom with kids, dad who walked into AP room drunk in middle of the night and tried to get into bed with her, AP and host mom hooking up, AP who knew mom was having an affair…

we had one who was privy to mom’s affair too. It was a disaster.

Separately, when did Americans become too lazy to type “my son” or “my husband” and need to use DH and DS?

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