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One of my moles inside the undergraduate mill at MIT got a mass email recently from three bureaucrats: the Provost, the Chancellor, and the VP of Human Resources:

As President Reif recently wrote in a letter to the MIT community, MIT is taking a number of actions to prevent and respond to sexual misconduct. We write today to update you on an expanded conflict of interest policy on consensual relationships among community members.

The new policy was initiated and championed by the Institute’s Committee on Sexual Misconduct Prevention and Response (CSMPR), led by Professor David Singer, Political Science, and has been adopted by MIT’s senior administration. We appreciate the many faculty, students, and staff who provided valuable input during the development of the policy. The final policy is stronger thanks to your engagement, and your commitment to advancing a culture of respect, fairness, and equality.

The last part is an interesting example of groupthink. How do these three bureaucrats know that all 4,500+ undergraduates have a “commitment to advancing a culture of respect, fairness, and equality”? Maybe some of them are committed only getting a degree and starting to repay their loans? Or maybe some of them think that a “culture of respect” prevents frank discussion of scientific errors and engineering shortcomings? Or maybe some of them support equal opportunity, but not “equality” (equal outcomes)?

The policy itself raises an interesting question. For example:

No MIT faculty or staff member may have a sexual or romantic relationship with any undergraduate student. [emphasis added]

In the age of Tinder, who decides what constitutes a “romantic relationship”?

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From our anonymous insider…

Exam week with three exams.

The main three-hour multiple-choice NBME exam consisted of 100 microbiology questions and 50 immunology and dermatology questions. Lanky Luke: “This was the hardest block since the beginning of medical school.” Several students complained about the emphasis on tropical diseases. “There must have been 10 questions on leishmaniasis. Every time I saw that as an answer, I would choose it.” Another student added, “I just felt it was not representative of what we will see on Step I. There were so few on hepatitis.” Several students reflected that they will never understand immunology. Type-A Anita: “I knew going in that I would take a hit on immunology. Oh well.”

The case-based exam asked about five hypothetical patients. It tested appropriate use of antibiotics, and classical “alarm” signs of serious imminent danger, for example, patient with sore throat who has difficulty swallowing and drooling may have epiglottitis with the potential to close off the airway. The clinical exam tested adult immunization schedules, screening guidelines, and dermatology pictures. Type-A Anita: “I know we need to know these, but I crammed the day before for immunizations and screening. I’ve already forgotten them!”

The clinical exam consisted of interviewing standardized patients (paid humans recruited from the community as actors) presenting for pneumonia. We used simulated stethoscopes to hear abnormal breath sounds. The clinical exam tested the same immunization schedules and screening guidelines as the case-based exam.

Recall that we meet three times per week for two-hour “case sessions.” Our facilitator is the redheaded hematologist/oncologist. This is the first time that our six-student group met off campus, sharing margaritas as a Mexican restaurant with our facilitator. We were joined by another case session group and their young emergency medicine facilitator.

Our heme/onc attending described the abrupt shift between fellowship and attending. “Even as a fellow, you have someone to bounce ideas off of, to confirm a diagnosis or treatment plan. It takes a little while to get confidence in yourself as an attending.” She had just returned from her first vacation since becoming an attending. “My husband forced me to go on the trip to the Dominican Republic. It was scary leaving my patients. I remember sitting on the beach with a mamajuana [local drink] and feeling completely relaxed. I realized that I had not felt relaxed since beginning my residency six years ago. And probably not since beginning medical school too!” [Hurricanes Irma and Maria passed through the D.R. a few weeks later.]

The other facilitator brought his wife, an Ob/Gyn, and their three children, the oldest aged eight. When should physicians have children? “We made an active decision not to have children during residency. My wife knows all too well that it is best to begin having children by age 35. This can be a serious constraint for women if they start medical school late. Residency is your training and you need to dedicate yourself to it.” The EM physician said he enjoys shift work. He can dedicate everything when he is there, and upon leaving the ER, “I am clear-headed and can focus on my children and wife.”

“A lot of my residents struggle if they have children,” continued the EM attending. “You will have to sacrifice something. Most of the time it means you will miss soccer games and friends’ birthdays. I find it is especially hard if their significant other is not in the medical world. Nonmedical spouses do not understand that once residents are off their 12-hour shifts, they are not done. After your shift, you hit the books. You study. The one exception is a resident I have now. He will not sacrifice his time with his children so after work he plays with his kids. When they go to bed, he hits the books. He just does not sleep and seems to functions fine thus far… I am not like that.”

After the facilitators left, Jane, Mischievous Mary, Deeva Debbie and I walked over to our favorite burgers and beer spot to work on our 100-beer card. After drinking 100 different beers at this restaurant, you are awarded with an embroidered mechanic shirt. Debbie is a a young Indian-American who dominates the class SnapChat story and Instagram. She journeyed to Portugal over the most recent break for a trip with two high school friends.

The women continued the conversation of children over beers. Debbie lamented, “I have no idea when I will be able to have children.” Mary reflected, “I now understand why my parents got divorced. My father was a internal medicine resident when they had two children. He was always gone. My mom had to everything: feed us, drive us, discipline us. She always felt like the bad guy. When my father was home, he would just want to play with us. There was just no time for my parents.” It always surprises me how many male physician lecturers in their 40s are not wearing a wedding ring. [Editor’s note: Our young medical student might want to read Real World Divorce and learn about the world of sexual and financial freedom opened up by no-fault divorce to any plaintiff suing a physician.]

After a well-deserved nap, Jane and I attended our classmate’s housewarming party. He and his wife, a marriage counselor, recently moved into a spacious new downtown loft. While people danced in the center, I talked on the sidelines with a 25-year-old classmate whose parents are Iraqi Kurds. His last trip to Iraq was in 2010, his freshman year of college.

I asked for his perspective on Iraq and the Kurdish people. “It’s hard for me to say. Everything I know is from my dad. My family was comfortably settled in the US when it happened. I just remember my father being glued to the TV during the Iraq invasion. He would cheer the U.S. army every step of the way. Saddam gassed my people.” Why has it gone so wrong for both the U.S. and Iraq? “I don’t know. It comes down to the Iraqi people as a whole were not ready for democracy.”

He is eligible to vote in the upcoming referendum on independence (held September 25, 2017; result: 93 percent in favor). “I think now is the best time for independence. We are ready. The state institutions are there and the Peshmerga will defend us against any invader — Turkey, Iran’s militias. It doesn’t matter that we are dispersed in Iraq, Syria, Turkey, and Iran. Everyone might invade us. I am concerned about the state of elections in Kurdistan. Unfortunately the only politicians come from just two families, but it is now or never. I’m voting yes for independence.”

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From our anonymous insider…

One week before exams.

“We are going back to preschool,” said the young female dermatologist. “Dermatology is another language. We start with vocabulary.” She spoke in a monotone voice and enjoyed sadistic humor. “It helps if you know Latin. How many of you took Latin?” Two students raised their hands. She chuckled, “Well… that is too bad.” We went through several images, and described the lesion with the help of a handout with common terms: umbilicated nodule, erythematous maculopapular, scaly serpiginous plaque. The class was surprised to hear that erythroderma (diffuse erythema covering the body) is a “dermatological emergency”. This massive inflammatory response can cause a drop in blood volume and hypotension.

A dermatologic pathologist gave two hour-long lectures on skin histology (study of the microscopic structure of tissues) with slides of normal and diseased skin. I enjoyed seeing how certain skin issues manifested themselves so clearly on histology compared to other organ systems where the pathological manifestation is more subtle. He ended: “Gastroenterologists and dermatologists always argue with each other about what is the largest organ. There is a huge amount of blood flow to the skin. Inflammation frequently leads to skin changes. Think of the skin as a window into the body.”

“Dr. Joel”, a brilliant pedantic rheumatologist in his late 30s with a heavy Jamaican accent, discussed infectious diseases of the skin and immune disorders that manifest with skin symptoms. Roseola (“Sixth Disease” or “three-day fever”) is caused by human herpes virus 6 (HHV6). It is characterized by high fever, which can cause seizures in children, followed by a maculopapular (flat and raised erythematous dots) rash. Several of these childhood illnesses cause serious damage to a fetus if the mother becomes infected during pregnancy. A congenital rubella infection (German measles infection while pregnant) leads to the fetus having microcephaly and a patent ductus arteriosus (PDA). A male student commented, “Could you imagine living two hundred years ago before we understood the role of congenital infections? Your baby comes out as a dwarf or with microcephaly. Must be God’s will.”

These lectures should help us to answer multiple choice Board questions, but we are doubtful about being able to diagnose patients. Lanky Luke: “I feel much of medicine is getting the approval by society to witness disease. This ordained selection process entails paying it to the Man.” Luke thinks that more of our medical training should be an apprenticeship rather than lecture-based.

He got his wish when we went in for an afternoon to the dermatology clinic. Four-person groups crowded into each small examination room to spend 15 minutes with a patient volunteer and a dermatology attending or resident. My group first saw a 30-year-old female who has suffered from neurofibromatosis since she was a teenager. Only when the patient took her gown off did we see the copious neurofibromas (benign tumor of nerve sheaths) covering her body with the peculiar exception of her head and distal extremities (arms and legs). She could walk around in a long-sleeve shirts and slacks without anyone noticing. The patient allowed each of us to palpate her skin. Neurofibromas are thimble-sized fleshy cylindrical nodules with a dark brown color that sag from the skin. They feel mushy, almost like a fluid-filled vesicle. The attending noted, “A lot of patients first try to scratch them off. They return much worse.”

We rotated to the next room and a normal-appearing 50-year-old female. As we examined her more closely, we saw signs of scleroderma. She had sclerodactylyl (localized thickening of skin on fingers and toes) preventing full extension of her fingers. Her lips were permanently pursed with six or seven valley and ridges on the skin adjacent to her lips. “Before treatment with steroids, I could barely move any of my joints because the skin was so tight. I now live a normal life with my family.” Our patient did not have any of the life-threatening manifestations of scleroderma, which can include pulmonary hypertension and pulmonary fibrosis.

We then rotated through a case of eczema and psoriasis. Eczema, also known as dermatitis, is characterized by pruritic (itchy), erythematous (redness that blanches with touch), oozing vesicles (fluid-filled sac) with edema (swelling) typically occurring on flexor surfaces. It is commonly caused by an over-reaction to an exposure such as poison ivy or the metal nickel (e.g., touching dime). Interestingly, eczema is more common in asthmatics. Psoriasis is an inflammatory condition without a known trigger characterized by acanthosis (keratinocyte hyperplasia; thickening of the skin) leading to scaly plaques on the extensor surfaces (e.g., the outside of the elbow). The attending confirmed the psoriasis diagnosis by eliciting the Auspitz sign, bleeding after a pinprick.

Our patient case: Fiona, a 42-year-old female elementary school teacher, presenting for bilateral stiffness and pain in her wrists, fingers, and knees that is worse in the morning. She had her thyroid gland removed (thyroidectomy) in her 20s after diagnosis of Graves’ disease: antibodies that bind to thyroid stimulation hormone receptor causing excessive thyroid hormone release. Her condition is now well-managed with synthroid.

She has been to her doctor several times over the past few years for joint pain in her hands. “I was originally diagnosed with arthritis. I got frustrated with my doctor. He would take an x-ray, prescribe physical therapy, and never follow up.” Over the last two months she has been unable to do several daily activities at work and the pain has begun to interfere with her sex life with her husband. Her proximal interphalangeal joints (proximal knuckle) and wrists are swollen and warm to the touch.

Fiona has rheumatoid arthritis (RA) defined by synovitis (inflammation of the synovium or fluid within joint capsule). The pathogenesis of rheumatoid arthritis is unknown, but some people are predisposed genetically and there are environmental risk factors, e.g., smoking, which increases the risk of RA up to 40 times in individuals with Shared Epitopes (SE) gene variants of MHC proteins.

Fiona never smoked, although she had the positive ACP titer (measure of antibody concentration in serum) that is typical of smoking-induced RA. She also had other hallmarks of chronic inflammation such as elevated C-reactive peptide (protein produced by liver suggestive of systemic inflammation). The Rheumatologist explained, “The ACP is helpful to know what kind of rheumatoid arthritis I am dealing with. However, once it is present I no longer care about it — think of ACP as a pregnancy test. You can’t get more pregnant once you test positive. Instead, I listen to Fiona’s symptoms and follow her C-reactive peptide levels.”

She was initially prescribed naproxen (nonsteroidal anti-inflammatory marketed as “Aleve”; similar to Advil) without any symptom relief. She currently takes methotrexate, a folate synthesis inhibitor used to treat several cancers and inflammatory conditions. “I will still get flare-ups if I over-exert myself, but I am able to be active. I even exercise three times a week on the elliptical.”

Describe the pain before your treatment? “My joint pain was unbearable before I was referred to Dr. Joel. Our family goes to the beach once a year… my one break from teaching. We always have a crab leg feast. I had to stop eating the crabs because my pain would be terrible for several days afterwards. I was bedridden. Perhaps it is punishment for the gluttony.”

Does anyone else in your family have immune disorders? “I know my mother had joint problems. She was never diagnosed with rheumatoid arthritis though.”

How does RA affect your family? “I’ve learned my limits now and my husband and kids are truly great about understanding. In the beginning they were a little confused. I still sometimes hear my kids half joke, ‘Oh, Mom isn’t cooking dinner? She is so lazy.’ Even with treatment I still have to be careful how much strain I put on my joints. Scrubbing or cutting too much will cause a bad flare-up that lasts for a few days.”

Dr. Stein, an internist who has been in practice for over 40 years, followed up on the “Motivational Interviewing: Eliciting Patients’ Own Arguments for Change” lecture from two weeks ago. “There are 5 stages of change: precontemplation, contemplation, preparation, action, and maintenance. We also no longer use the word compliance to describe the degree of a patient following prescriptions and medical advice. We now use the term adherence because it suggests an active role and collaboration of the patient with the doctor and treatment process.”

After one hour and fifteen minutes of theory, Dr. Stein brought in one of his longstanding patients, an overweight female in her late 40s who quit smoking six months ago. She began smoking a pack a day when she was 14. “Smoking was a part of my life. I felt that I would not know what to do if I did not smoke. It helped keep peace in the house. It kept me calm during work.” She described how Dr. Stein would bring up smoking “every single time” she went in. “He said all the right things, but I was just not ready up in the head. The key was I felt comfortable with Dr. Stein. He was not judging me, pointing a finger. When I finally was ready, Dr. Stein leveraged this motivation to help me.” What made you quit smoking? “If you have a big enough why, you will figure out how to quit. I hated seeing my children grow up with me smoking. My father recently had a heart attack — I am sure smoking all his life did not help. I had these two drivers in my mind and I just went cold turkey.” We congratulated her for her smoke-free six months.

Afterwards we divided into four-person groups to present a patient from our clinical shadowing experience. We were fortunate to be presenting to Dr. Stein. Our goal was to practice how to present patients to attendings for Rounds next year and how to write a medical note. The general format of a note: chief complaint in the patient’s own words, History of Present Illness (HPI), Past Medical History (PMH), Medications, Family History, Social History, Review of Systems (RoS), Physical Exam (PE), Assessment, and Plan. The transgender wave has reached daily Rounds: “Don’t use male or female in HPI anymore,” said Dr. Stein. “It’s frowned upon.” After Dr. Stein revealed his fondness for “complementary medicine” (accupuncture, yoga, etc.), Gigolo Giorgio said that Dr. Stein reminded him of someone who had a “midlife crisis and suddenly turned Zen.”

We wrapped up the week by reflecting on a three-week prescription simulation. Students were divided into two groups: diabetics and HIV patients. The faculty gave us pill bottles filled with M&Ms. Our class president sent periodic GroupMe messages about various simulated issues. Example: “Update: your throat is burning and your chest is on fire! wait an additional 35 minutes after taking your pills before eating.” Some students ate all the M&Ms the first day. Some abandoned the simulation. Everyone forgot to take at least one pill.

Straight-Shooter Sally recounted the awkward conversation after her new roommates, a nursing student and college-educated bartender, accidentally read a message: “You forgot to take your HIV antiretrovirals for today. Double up.”

Mischievous Mary, a smart, petite jewish girl who dyed her hair pink last year because “it was the last time I could do something stupid before we start clerkships — unlike a tattoo, this is reversible.” She began school aspiring to follow in her father’s footsteps as an internist, but is now determined to become a heart surgeon. Mary responded to Sally’s story: “I realized this weekend that I have lost all sense of decency. I was in this quaint coffeeshop by my apartment studying STDs looking at pictures of penises on my computer, easily seen by the other patrons.” Jane added, “I was walking with Giorgio on the Greenway. We somehow got on the topic of syphilis. It took us several minutes to understand why people were looking at us strangely.”

Statistics for the week…

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Now that Apple is going to pay some Federal income tax (previous post), what would cost $38 billion that President Trump could name in honor of the company? Here are some ideas:

• The Apple Computer Border Wall (estimated cost $21.6 billion, so it wouldn’t consume this one-time payment)
• The Tim Cook nuclear-powered aircraft carrier (complete with fighter jets and rescue helicopters)
• rename Interstate 280 to the “Android is No Good at All National Highway” (what has Junipero Serra done for anyone lately?)

Readers: any good ideas? Why not show some love to what I assume will be the nation’s biggest taxpayer in 2018?

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I happened to be driving by the Cambridge Common on Saturday just as a “women’s march” was officially starting. Attendance was limited, with crowd covering only about one third of the Common (so the local media used a tight shot to make it look like it was jammed; see boston.com for example). I assumed that there was a big march over in Boston proper (on the vastly larger Boston Common) and that this was just a local march for people insufficiently outraged to ride a few stops on the Red Line. But it turned out that Cambridge was the official location for anyone #Resisting in the Boston area.

The boston.com story is interesting because it says that a top state official, Maura Healey, “wore a T-shirt that read The Future is Female.'” I understand that the majority of voters are women, but I wonder what would happen if a politician anywhere in the U.S. had worn a T-shirt reading “The Future is Male.”

[Separately, Healey “referenced the many lawsuits her office has filed against the Republican president’s administration over the past year.” (no mention that Massachusetts taxpayers get to pay for legal fees on both sides of any such lawsuit!).]

Here’s an image from a Facebook friend in Manhattan. It seems that marchers in New York were more cash-oriented…

… though maybe not one particular marcher: “Just saw a chihuahua in a pussy hat.” (update from NYC at 1:40 pm)

[She posted a photo of herself in front of a cardboard sign painted “RESIST!” and the comments from her friends were kind of interesting. 3 out of 4 of the female-named commenters (of course I can’t know their true gender IDs!) mentioned her appearance, e.g., “Too cute!”, “You are beautiful.”, “super cute”. Isn’t one of the complaints that #Resisting women have voiced that they don’t want to be judged based on their physical appearance?]

Readers: What did you see in terms of a Women’s March in your area?

Related:

• Are women the new children?
• Donald Trump-themed mini golf course? (see Hole 7)
• The Indian-American perspective on the Women’s March
• Will the women’s march have the opposite effect of what is intended?
• Why you’ll get your next electronic device from Asia

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Everyone loves aerobatic champion Patty Wagstaff. And everyone loves Navy fighter jets landing on carriers (well, as long as we ignore the price tag). Suggested reading: “Making Traps: The Thrill Of Landing An F/A-18 On An Aircraft Carrier” (Plane&Pilot, January 2018). I don’t think that King Bush II had to do this when he went out in a utility plane to give his “Mission Accomplished” speech:

Flying to a carrier however, the training was mandatory. As a swimmer, surfer and beach girl, I was excited about it. I thought it would be a breeze, but, boy, was I in for a surprise. When I jumped in the water in full U.S. Navy flight gear—flight suit, survival vest, G suit, helmet and boots—and was told to swim the length of the Olympic size swimming pool, I thought, “Swim? You’re kidding me!” I had lead weights attached to my extremities. The Navy Seal Instructors were encouraging but said no swim, no fly. They told me there were no rules how I got there—back stroke, side stroke, freestyle—as long as I made it to the other side of the pool, an eternity away.

By sheer will and motivation, I raised my feet into a horizontal position and started moving slowly, like a turtle, across the pool. I wasn’t sure I could do it, but several instructors stood cheering me on as I placed my hands on the ledge at the far side of the pool. Next we had to tread water for a full 5 minutes in our gear. The Instructors gave me some tips—relax, conserve energy and get a little air under my helmet and use that to float upside down. Another task was swimming, blindfolded, through a narrow cage with a 90-degree bend, simulating a fuselage. The catch was that another swimmer would be coming from the opposite direction, and you would meet up somewhere in the middle.

It is a quick read and I recommend it!

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One week to go before plunging into the slippery world of statistics and the bizarre syntax of R (previous post). Loyal reader Karen was kind enough to send me “Are Blue States Better at Exemplifying Red State Values? The Data Might Surprise You.” (Big Think), a topical look at how statistics can be misleading.

You get one answer if you look at data aggregated by state:

The National Campaign to Prevent Teen Pregnancy data shows that teenagers in Mississippi, the reddest of red states, are more sexually active than the teens of any other state. While the teenagers of liberal New York are the least active. Similar data can be found for teen pregnancy, with nine of the ten worst states for teen pregnancy rates being “red” states.

The same can be found for the divorce rate. Of the states with the ten highest divorce rates, eight of them are solid red, while the state with the lowest divorce rate is bright blue Massachusetts. This study shows the five states with the highest rates of divorce for women all being red, with four of the five lowest rates found in the bluest states.

(I’m not sure what it means to talk about “the highest rates of divorce for women“; it is more common to for a wife to sue a husband than vice versa (data from Massachusetts, for example), but both a man and a woman will be equally “divorced” after the process of litigation is complete.))

Then you get a different answer if you aggregate by county:

when you zoom in to the county level the data reverses, with red counties across the country having more stable marriages and fewer divorces. The worst statistics, given this analysis, are to be found from blue voters in red states.

[Separately, the article reinforces the “white privilege” stereotype:

And, of course, the teenagers who are most likely to have a stable family in the United States are the children of well off, intact, families, while poor, non-white teenagers are the least likely to be in a home with married parents. There is more to the story than mere ideology.

Compared to Asian-Americans, whites are frequent flyers in American family courts and are much more likely to divorce, have an out-of-wedlock child and harvest the child support, etc. Yet the article implies that whites are some sort of paragon of stability and putting interests of kids first.]

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It has been a year since President Trump took office. What do readers think are the main changes, positive and negative, that can be attributed to him? (as distinct from stuff that Congress has done, e.g., cutting the corporate tax rate to a European level)

When Mom and I were on our September 2017 cruise, the non-Americans on the ship always asked us what we thought of Trump. My parents still live in Bethesda, Maryland where the only problem with Big Government is that it isn’t quite big enough. From Mom’s perspective, Trump is, like his supporters, deplorable. There is no need to look at specifics. I responded that I thought the biggest change occasioned by Trump was that he broke the pattern of Americans worshiping their President like an Egyptian pharaoh. As Trump was plainly mortal, Americans now realize that they will have to exert some personal effort if they want to become better off. The god-like Great Father in Washington is not going to do it all for them.

Readers: What do you see as the most significant effects from the first year of Donald Trump in the White House?

Related:

• Bill Murray in What About Bob? describing his psychiatrist (similar to how a lot of Americans would have described previous presidents)

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From our anonymous insider…

Hematology and immunology. Immunology is one of the class’s least favorite topics. Gigolo Giorgio: “I accept just taking a hit on the exam. It makes no sense to me.”

An enthusiastic 39-year-old immunologist kicked off the lectures. She explained, “We need about 100 million unique antibodies to be immune competent. We have about 30 billion B cells in the blood. That means we only have 300 potential B cells that need to become activated if we are to mount an antibody attack against a given antigen. This is the key dilemma in adaptive immunity: How do you find them!”

Our first-year perspective on the immune system was cell-centric. This week we learn that the story is more complex and includes smaller-scale proteins from the complement system and larger-scale tissues such as the spleen filtering blood-borne pathogens.

Our current understanding of a typical bacterial infection:

1. The innate immune system recognizes common pathogens. Complement proteins (smaller than cells and made by the liver) mark bacteria for opsonization (trigger for phagocytosis or cellular ingestion).
2. Resident macrophages (cells) phagocytose (ingest) marked intruders resulting in an inflammatory “cytokine storm”. This causes systemic changes such as fever and increased production of immune cells in the bone marrow (lymphocytosis) and local changes such as blood vessel dilation to increase tissue perfusion and neutrophil infiltration into the tissue.
3. Neutrophil infiltrate the inflamed tissue. Neutrophils, the most abundant leukocyte (white blood cell), are the immune system’s pawns that kill bacteria by eating them and producing high concentrations of hydrogen peroxide in the phagosome (walled off vesicle containing the bacterial cell inside the neutrophil). After the neutrophil has worn itself out, it will explode in a process called netosis. The neutrophil’s DNA acts like a spider web (called neutrophil extracellular traps) to prevent the bacteria from escaping the site of inflammation. Pus is dead bacteria and dead neutrophils.
4. Adaptive immunity activated (if needed).
5. If necessary, the spleen will filter bacteria in the blood (bacteremia) through small capillary beds called sinusoids.

The C3 protein is fundamental to the complement system and will bind to almost any biological molecule. How does the body avoid its own proteins being marked for phagocytosis? The liver releases anti-complement factors that bind to sialic acid, a component on human cell membranes. Streptococcus pyogenes, the bacterial strain causing strep throat and necrotizing fasciitis, expresses M protein to mimic sialic acid. The immunologist explained, “Although this molecular mimicry decreases the efficacy of the innate immune system, it is also Strep’s greatest weakness.” Our adaptive immune system readily produces antibodies that target M protein. The problem is that this antibody can cross-react with our own tissue causing a rare complication of sore throat: rheumatic fever (inflammatory disease that leads to skin rash, joint pain, and destruction of heart tissue).

If the innate immune system mechanisms are insufficient for clearance, the adaptive immune system will be activated. Resident macrophages will migrate to lymph nodes and present phagocytosed segments of foreign material on major histocompatibility complex (MHC) proteins to lymphocytes (T cells and B cells) that circulate among lymph nodes. Because the body can’t anticipate all of the epitopes (protein shapes) we might encounter, we use a game of probability. The immunologist explained, “We are finally unlocking the adaptive immune system. When I was an undergraduate in the late 80s, how our adaptive immune system generates this antibody diversity was still not accepted let alone in textbooks. MIT Professor Susumu Tonegawa won the Nobel Prize for discovering VDJ [variable, diversity, and joining] recombination. He showed that each B and T cell mutates its own DNA to rearrange the genes encoding the B cell’s antibody or T-cell receptor. Each B and T cell clone has different DNA than your typical cell in your body! If this B cell antibody or T cell receptor recognizes a sequence presented on MHC, it will become activated. The activated cell will undergo clonal expansion [reproduction by division], and, in the case of B cells, will differentiate into a plasma cell secreting gobs of antibody against this specific antigen into the bloodstream.”

Our patient case: Georgia, a 46-year-old female presenting to her internist for a routine physical. Medical history is unremarkable except for well-controlled hypothyroidism. She has swollen lymph nodes (lymphadenopathy) in her neck. Routine blood tests reveal elevated protein. Serum protein electrophoresis, a technique that separates proteins based upon electric charge, reveals an “M-spike” in the immunoglobulin (antibody) zone, suggesting an increase in concentration of a single clonal variant of immunoglobulin. “Georgia had a rogue plasma cell producing gobs of a single type of antibody. It is essential you understand the significance of clonal expansion to her condition versus the antibody response to an infection. During an infection, several B clonal species will get activated, each with a different antibody that binds to different sites of a pathogen. Infection causes a general increase in globulin concentration but not a spike.” The risk is as this single clonal variant continues to expand, it could push out the normal functioning bone marrow cells.

Georgia was referred to heme/onc (hematology/oncology) for further evaluation for this monogammopathy of unknown significance. One of my favorite lecturers, the young redheaded hematologist, followed Georgia for one year during which she began to have anemia, proteinuria (protein in urine), and bone lesions on routine tests. George was diagnosed with multiple myeloma (MM) at the age of 47 and, based upon her genetics and stage, given eight years to live. (Type-A Anita uses the helpful mnemonic “CRAB” to remember the classical signs of MM: hyperCalcemia, Renal impairment, Anemia, Bone lesions.) After her diagnosis, she quit her job as a secretary for a law firm and went on disability.

Georgia underwent several weeks of intense chemotherapy and a successful autologous hematopoietic stem cell transplant (HCT) over the course of a month-long hospital stay. She explained, “I never considered that I would die during the treatment.” She is now two years into remission and maintains an active life.

The HCT given to Georgia is the gold standard for MM treatment. “Why do we even give bone marrow transplants to MM patients?” asked the hematologist. She answered her own question: “The purpose of a bone marrow transplant is to be able to give higher doses of chemotherapy that would otherwise be lethal. We nuke the patient.” The hematologist recounted how bone marrow transplants were first investigated after the observation that individuals exposed to radiation from Hiroshima and Nagasaki developed pancytopenia (low blood cell counts). Bone marrow transplants were thought up as a way to reverse this aplastic crisis. “Leave it to the DoD to advance science. Pretty quickly oncologists applied the research to cancer treatment.”

“The scariest part of multiple myeloma is that you are never cured,” explained Georgia, as she broke into tears. “It will come back every time. This tragic fact makes MM different from other cancers. I go to an MM support group every two months as opposed to a more general cancer group. It is such a different beast.” Georgia grew up in a large mid-West family with five siblings. “My closest sister withdrew from me after the treatment. I think it is just hard for her to accept.”

The hematologist added, “Plasma cells are the cockroaches of the immune system. They survive everything. The unfortunate truth is that the question is not if MM will relapse, but when. Further, the traditional chemotherapy we use causes the plasma cells that do survive to have more mutations. Drug resistance develops after successive relapses.” She gave an impassioned speech on the importance of research. “The life expectancy for MM has increased dramatically. Maybe ten years ago, Georgia would have had to be maintained on melphalan [nasty chemo agent that acts via a similar mechanism to mustard gas] to contain her MM.” She turned to Georgia: “Could you imagine being on melphalan, the drug used during your bone marrow transplant experience, routinely?” “Oh, God, no. My hair, the diarrhea, the sheer pain. Mostly my hair though.” The class chuckled, and the hematologist continued, “This is changing because of the extraordinary advancements in targeted therapeutics. I love this field because it changes so quickly. Cancer years are dog years. A five-year-old article or clinical trial is thirty-five years old by my standards. Even the current issues of journals are a year late; you have to go to conferences to learn about the latest breakthroughs. It is frankly hard to stay up to date on every neoplasm [cancer]. The result is that oncologists convey out of date survival expectancy to patients.”

Jane had a slight hiccup with her mentee: the day after their first meeting, rumors surfaced that her mentee had disenrolled for personal reasons. The whole class joked that Jane made the helpless M1 quit. “What did you do to her!?!” We never learned the truth, but this classmate was quickly replaced by someone from the waitlist who became Jane’s new mentee: “Rebecca,” who had majored in electrical engineering at a large public university. Rebecca had spent a week at a DO (Doctor of Osteopathic Medicine) school: “I got a call from an unknown number. When I heard I got into this school, I almost fainted. My legs went weak. I packed everything back up and drove the next day eight hours. I really want to call my undergraduate prehealth advisor who told me I would never get into medical school because of my grades. Suck it!” An M1 told Jane, “I like your new mentee better than your last. Thanks!”

Statistics for the week… Study: 15 hours. Sleep: 8 hours/night; Fun: 1 day. Example fun: Dinner party with classmate and his wife, a marriage counselor. “My favorite patients at my old job were the couples with a schizophrenic.” A classmate who worked on a psych ward before matriculating at medical schools said, “Wow! I was scared out of my mind. I had this one patient who would say, ‘There is a woman standing behind you.’ I believed her! I could never do psychiatry.”

More: http://fifthchance.com/MedicalSchool2020

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The landline is dead, of course, but is apparently still live enough that Amazon makes the Echo Connect so that the constant stream of telemarketing calls can be fed directly to the Echo (and so that one’s outgoing calls aren’t mistaken for telemarketing due to having a legit caller ID!).

As long as Alexa is connected to the phone line and able to answer the phone, shouldn’t it be possible to say “Alexa, please answer my unknown calls from now on”? Alexa can then ask “Who lives in the house” and then, if an incoming caller is not asking for one of those people (or company names perhaps), Alexa can play a prerecorded message to the caller. The caller ID would be automatically whitelisted (but could be switched to a blacklist by the user in the Alexa App’s list of recent calls). On a second call from a whitelisted number, Amazon remembers the caller ID and lets the number go to the legacy phone for conventional ringing.

For a large house maybe there needs to be a beefed-up Echo Connect that can sit in front of the conventional phones and get them to ring after the actual call has already been picked up.

What do readers think of the above? It would seem that Alex already has 99 percent of the capability necessary to make a home landline useful again.

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