Archive for the ‘medicine’ Category

How intelligent are politicians?

Thursday, March 12th, 2009

I have previously questioned the intelligence of Republican politicians since most smart Republicans go into business.That’s no reflection on those who choose politics after a successful career in business or a profession. Somebody has to do these things and Tom Coburn, or my former Congressman and friend, Ron Packard, have obviously made a sacrifice to contribute. As a general rule, Democrats see government as the most important component of our economy so they should attract a better overall level of candidate. They may not know much economics but many are very intelligent and well informed in other spheres I used to think Bill Clinton, whatever his problems with his impulse control and honesty, was one of them. That’s why it’s a bit of a shock to learn that he doesn’t know what an embryo is.

Clinton: I think – the answer is I think that we’ll work it through. If – particularly if it’s done right. If it’s obvious that we’re not taking embryos that can – that under any conceivable scenario would be used for a process that would allow them to be fertilized and become little babies, and I think if it’s obvious that we’re not talking about some science fiction cloning of human beings, then I think the American people will support this….

The embryos that are used in stem cell research are not fertilized !!!! ?

What the f**k does he think an embryo is ????

Military Medicine

Wednesday, February 18th, 2009

Here is a powerful account of a doctor’s tour in Afghanistan. Ironically, it from Mother Jones web site but a great account anyway.

The health care crisis (not)

Thursday, January 15th, 2009

You know that the health care crisis is getting critical. The University of Chicago Hospitals have eliminated Michelle Obama’s $300,000/year job. She wasn’t there much the past year anyway. The New Republic thinks this is a serious problem. Nobody else does.

The 1918 flu pandemic

Wednesday, December 31st, 2008

Genetic engineering may have explained the mortality of the 1918 flu. Apparently, three genes are responsible for the viruses ability to infection lung and not just bronchus.

“We wanted to know why the 1918 flu caused severe pneumonia,” Kawaoka said in a statement.
They painstakingly substituted single genes from the 1918 virus into modern flu viruses and, one after another, they acted like garden-variety flu, infecting only the upper respiratory tract.
But a complex of three genes helped to make the virus live and reproduce deep in the lungs.
The three genes — called PA, PB1, and PB2 — along with a 1918 version of the nucleoprotein or NP gene, made modern seasonal flu kill ferrets in much the same way as the original 1918 flu, Kawaoka’s team found.

There was a second reason for the high mortality in 1918-1920. The principles of thoracic surgery, including the physiology of respiration were not understood at the time. Thousands of flu cases, those with pneumonia, developed a secondary bacterial pneumonia and then developed empyema. Empyema is a collection of infected fluid in the space between the lung and the chest wall. We now know how to treat this condition. The principles of treatment are here. Note the observation that Hippocrates understood the principle of empyema; namely that thin fluid in the collection could be drained by an opening in the chest wall but the patient would die. Hippocrates didn’t understand why. The knowledge of lung physiology would not come until the 19th century. However, Hippocrates did observe that draining thick pus through an opening in the chest did not result in the death of the patient in all cases, as it did in those where the fluid was thin and watery. What was the reason ?

We now know that a relative vacuum exists between chest wall and lung. The chest wall is rigid and, during respiration, it changes its volume by using the “bucket handle effect” of the ribs.

The space between lungs and chest wall is shown along with the general anatomy. That space is what fills with fluid in cases of pneumonia that develop empyema.

The ribs are curved and, when the muscles of the chest wall pull up on them, as shown by the arrows, the cross section of the chest cavity increases because of the “bucket handle” effect. With expiration, the ribs move back down and the volume of the chest cavity decreases. This volume shift, aided by the piston effect of the diaphragm, moves air in and out of the chest. The lungs are not attached to the chest wall, allowing them to slide up and down and accommodate their shape to the shape of the chest wall. If there is a hole in the chest wall, the air can move into the space between the lung and chest wall, collapsing the lung. This is called a “sucking chest wound” in trauma care. If the hole in the chest wall is larger than the trachea, air will move more easily in and out of the chest and respiration through the trachea will stop. This was the great barrier to chest surgery that was not overcome until the 1920s. The flu epidemic, and the research into the cause of death in so many cases, led to the understanding of how the chest works.

I recently reviewed a book about the history of the 1918 flu epidemic and, because it ignored the issue of empyema, I could not finish it. They had only half the story. The story of empyema, and the cause and cure, resulted from work of the Empyema Commission, chaired by Evarts Graham, professor of surgery at Washington University of St Louis medical school. Here is one of many scholarly works describing his great accomplishment. Unfortunately, little of this has penetrated the general history of the epidemic in spite of 90 years. In a recent article about the military cases during the First World War, it states: During World War I, the overall empyema mortality rate among US military forces was 61%. The same, or greater, mortality was seen in the flu cases that occurred in the same period. Untreated empyema was virtually 100% fatal.

During World War I, empyema treated by thoracotomy was associated with a mortality of > 30%. This prompted the establishment of the Empyema Commission, which recommended chest tube drainage for treatment.

The surgeons who were treating the flu cases, just as those treating empyema due to war wounds, used the old Hippocratic treatment of draining the pus from the empyema. Note that in the war wound cases, 70% of these patients survived. The flu cases were different and almost all died in a few hours after the fluid was drained. The difference was that the empyema in flu cases was due to streptococcus infection, which produces a thin fluid and does not cause the lung to stick to the chest wall. When the chest was opened, the lung collapsed and these already sick patients succumbed. Hippocrates had predicted this. The war wound cases did better because the staph infections of the pre-antibiotic days (“Laudable pus”) caused the lung to stick to the chest wall and it would not collapse.

Eventually, Graham learned that using a tube instead of an open hole to drain the pus, and placing the chest tube under water at its lower end, would seal the air leak but allow drainage of the pus. His work opened the door to thoracic surgery and, today, would save most of the cases in a new flu epidemic. Graham was also the first to warn of the association between smoking and lung cancer, a disease he was to die of 1957. He performed the first successful removal of a lung for cancer and his patient attended his funeral 24 years later.

Genetics is a powerful tool in the treatment of disease but physiology is still as important. Scientists understand the first but may not be aware of the other factors. There is no substitute for the experience of treating patients.

Neuroscience, the next medical frontier

Monday, December 15th, 2008

When I was a freshman medical student, I spent a summer working in the VA psychiatric hospital in west Los Angeles. While there, I spent many hours talking to chronic schizophrenic patients, some from World War II and one even from World War I. I watched electro-shock therapy for psychosis and spent hours listening to the professor there, George Harrington. He was one of the two or three most impressive men I met in medicine. He was convinced that psychosis was an organic disease and had no confidence in psychoanalysis to explain anything to do with psychosis. I was very interested in psychiatry for a while but my exposure to other psychiatrists in medical school soon ended my enthusiasm.

Now, neuroscience is one of the most promising areas in medicine. We have increasing evidence of the anatomy of mental illness. Obsessive-compulsive disorder can now be cured with a surgical interruption of a feedback loop in the brain. Functional MRI can show differences in the response to stimuli between schizophrenic and non-schizophrenic twins.

Now, we are getting to the analysis of normal function. The visual cortex seems to have a map of the retina contained in it. By analyzing the fMRI of the visual cortex in a subject looking at a picture, it has now been possible to reconstruct the image from the fMRI. We can look at the brain in a functional way and read what it is seeing.

The next step, and it is coming fast. is to create a biological-electronic interface. We already have one called the cochlear implant. It is able to restore hearing by stimulating hair cells in the ear. A visual implant would stimulate the optic nerve when the rods and cone cells are lost.

If I were a medical student today, I would be looking very hard at this field. When I was a medical student 46 years ago, I decided that the science of the brain and the immune system were too primitive at the time to have any implication for clinical work. I decided that, if I wanted to go into research, I would be better off as a physical chemist. That was true then but is no longer true.

Is Blagojevich crazy ?

Thursday, December 11th, 2008

There is some speculation that Governor Blagojevich must be crazy to have been so brazen in his telephone conversations when the possibility of wiretaps had to be considered. He even seemed to dare the authorities to wiretap his conversations.

Here is a good discussion of his mental state. I have had some experience with psychotic and sociopathic patients. A few years ago, one of my medical students was assigned to interview a patient in the County Hospital who was diagnosed with manic depressive psychosis. In the chart of this patient was a letter from his brother warning doctors that the patient was so convincing in his story, and so well organized in his psychotic delusion, that someone who did not know him could easily be deceived. The story he told was that he was a businessman who was on his way to Korea to close a ten million dollar deal. He had reservations on KAL for five days from now and was in the hospital because of a misunderstanding with his family. He was absolutely convincing. Fortunately, there was also confirmed evidence that he had attacked his mother and other relatives and was psychotic.

I don’t know if Blagojevich is a well organized manic psychotic but the arguments in that article I linked are also compelling. He comes from a culture where corruption is a way of life. Obama comes from the same culture and has had close associations with Blagojevich, an association which will now be denied.

I tend to the sane conclusion.

Former Assistant United States Attorney Bill Otis also invokes his professional experience to answer the question:

No, he’s not nuts. Having been an AUSA for a long time, one thing I noticed is that normal, honest people have difficulty understanding how criminals think. (This shows up, for example, in the death penalty debates I do, where abolitionists simply don’t grasp the heartlessness and cruelty that some killers display. It’s simply beyond their experience).

Blago’s world is merely corrupt; it’s not insane. To him, a Senate seat is not a public trust, it’s a commodity. It has a price, and the most efficient mechanism for determining that price is to put it on auction, which is what he did. Far from being insane, it’s perfectly clear-headed — just venal. Mortgage markets should operate as well.

I tend to agree. There will be lots of disinformation and he might even choose an insanity defense in an attempt to get off without jail. It will be interesting to see what happens. Here is another analysis by an informed observer.

Homelessness

Thursday, July 31st, 2008

I have had strong opinions about the origin of homelessness for a long time. In 1962, I spent a summer working in the VA psych hospital in West Los Angeles. It was one of the more interesting experiences of my life. The professor and chief of the service was George Harrington, one of the most colorful and impressive people I have met in medicine. At that time, psychiatry was dominated by the psychoanalysts and schizophrenia treatment was just starting to use anti-psychotic drugs like Thorazine. Harrington had been trained as an analyst but had a funny story about how he had learned as a medical student that analysis just didn’t work. He was convinced, he told me, that psychosis, particularly schizophrenia which constitutes the vast majority of cases, was an organic disease, possibly even an unknown vitamin deficiency. Time has proved him correct and present-day treatment is with drugs that target specific receptors for neurotransmitters like GABA and serotonin. There are theories of the cause that may be startling to those who have not spent time reading the literature. For example:

Schizophrenia and prehistory: the price we pay for language?
Robert Kaplan
Graduate School of Medicine
Wollongong, Australia
liaison3@bigpond.com
ABSTRACT
The defining characteristic of humans is language: the expression of the capacity to handle abstract symbols. A growing body of evidence shows that the essential hu-man features did not occur in a ‘big bang’ in Europe around 50Ka, but developed over a 100-200Ka period in Africa.

Schizophrenia, the most severe psychiatric illness, is remarkably consistent in all populations – average 2% – regardless of climate, geography and industrial conditions. As the Australian Aboriginals, who have the same incidence of schizophrenia, were separated by rising seas from early humans, it is clear the illness is genetic and arose sometime between 137,000 and 60,000 years ago..
The other unique feature of the schizophrenia is that it occurs during the reproductive age; despite the obvious disadvantage, it remains prevalent. This suggests that there is a balancing factor which overcomes the reduced reproductive capacity of patients.

Crow, a leading schizophrenia researcher, has put forward the provocative hypothesis that schizophrenia is a disturbance of language, resulting from problems in development of brain asymmetry. A gene on the short limb of the X chromosome has been identified as the possible site that leads to brain asymmetry, an essential development for language. As a result, the speech centre is located in the dominant [left] hemisphere, eliminating the delay from sending a signal across the commissure.

In view of the earlier onset in males, Crow has postulated homologous X and Y genes.
The ‘psychosis’ gene may be a consequence of the development of language: is schizophrenia the price we pay for language? Recent discoveries at MSA sites in Southern Africa coastal regions – such as the cross-hatched ochre from Blombos – give rise to hopes that further evidence of first human capacity to utilise symbols will be found in this region.

Anyway, treatment was severely disrupted about 40 years ago when the politics of mental illness trumped medicine and the state mental hospitals were emptied onto the street. Some of the sad story is described here. The “homeless problem” arose from this action and has persisted since then, garnished with Maxist rhetoric and vapid social theories. Now sense may slowly be returning.

The homeless population continues to decline, by an estimated 12% per year between 2005 and 2007, according to a new report released Tuesday.

Why ?

Homelessness is one of the few corners of public policy in which traditional liberal ideas have gone largely unchallenged. But Mangano believes that many professional activists, though well intentioned, have given up on ending homelessness. They have accepted the problem as intractable and fallen back on social work and handouts as a way to make broken lives more bearable. In doing so, he says, they have allowed “a certain amount of institutionalism” to take root. The Bush Administration proposes to solve the problem by beginning with the hardest cases: the 10 percent who are severe addicts or mentally ill, and consume half of all resources devoted to homeless shelters. Mangano believes that by moving these chronic cases into “supportive housing”—a private room or apartment where they would receive support services and psychotropic medications—the government could actually save money, and free up tens of thousands of shelter beds. The Bush Administration, spotting an opportunity to increase the return on its investment, is seeking to end chronic homelessness within ten years.

It seems to be working. What is unknown is what the next president will do with this program. This is a subtle way of returning to the institution care of severely psychotic individuals and that may be too much like sense for Obama’s liberal theology

What does the Fannie Mae collapse have to do with 9/11 ?

Monday, July 14th, 2008

UPDATE #2: The Wall Street Journal also offers a suggestion on what to do now. Place them in receivership and restructure the management. That is another way of saying to get the politicians out of the boardroom and executive suite. Run them like businesses. Combined with the energy crisis, and considering who has been controlling them, this could be another issue for the GOP in the fall. If they can work up the right narrative. And that’s a big if.

UPDATE: The Wall Street Journal comments on Why Fannie Mae and Freddie Mac were immune to critics even back in the Reagan Administration.

Mr. Wallison, who went on to become White House counsel, decided to devote himself to exposing the potential risks posed by the mortgage giants after he retired from law practice and joined the conservative American Enterprise Institute in 1999.

Almost immediately, he said, he experienced political pressure of the sort that—until now—has made Fannie Mae largely invulnerable to new legislative oversight and left it under the supervision of a weak financial regulator.

At the time, he sat on the board of a mortgage-insurance company that did extensive business with Fannie Mae. When the company’s officials noticed that they weren’t being chosen to insure some mortgage pools, Fannie officials told them it was because of Mr. Wallison’s new project at AEI, he said.

The original WSJ article is behind the subscription wall.

We are seeing a meltdown in the mortgage market as it was reconstituted after the S&L crisis of the 1980s. One of the two huge “market makers” for home mortgages is Fannie Mae or Federal National Mortgage Association. It was originally founded in the Depression to assist in increasing home ownership and decreasing foreclosures, many of which involved people who had little debt on their homes but no income to pay the interest. In 1968, it was rechartered and began to buy “conforming” mortgages from originating banks and S&Ls, then bundle them into bonds containing many mortgages, and sell them in a secondary market that gradually grew.

In 1969, when I bought my first home for $36,000. The minimum down payment was 20%. The loan was made by Home Savings and Loan at an interest rate of 4% and my house payment was $204/ month. The seller, who had already bought another house, was willing to take back a 10% second TD of $3500, on which I paid $35/month until I paid it off two years later. The primary trust deed was held by Home S&L in their own portfolio so they had an interest in determining that I was a good risk. In those days, the S&Ls loaned money at 4% or so and borrowed it from depositors at 2.5 to 3%. It was considered a safe, although rather dull, business. The profit was the difference and they were bared from riskier investments.

Then came Jimmy Carter and interest rates of 18%. At first, inflation took off as spending was high and the economy was stuck in what was called “stagflation.” The bear market of 1974 halved the value of the stock market. The 1960s bull market was over. People who had their savings in S&L accounts watched as inflation ate them up. They were collecting interest of 3% and inflation was 12%. They did the rational thing and withdrew their savings. They found unusual investments for them. My partner and I invested our pension account funds in second trust deeds that were steered to us by a real estate broker we knew and who made sure that we only bought good loans. These paid as much as 18% for two or three years. I also bought Treasury bonds that paid 16% coupon rate and I bought them at a discount so the real return was 18%. That was good money.

Others bought gold although it was still illegal until 1974. The inflation led to a flurry of decisions to avoid the dollar including buying antiques and crystal art pieces. It also led to the first inflation of home prices. The S&Ls were in serious trouble but it all came to a head when, in 1980, Fernand St. Germain, chairman of the House Banking Committee, lit the match that burned the S&Ls down.

One night in 1980, Representative Fernand St Germain (D-Rhode Island), whose $10,000-to-$20,000-a-year restaurant and bar tab was paid for by the S&L industry’s chief lobbyist, proposed raising federal insurance on S&L savings accounts from $40,000 to $100,000- even though the average size of an S&L account was $6,000. He waited until after midnight, when only eleven representatives were still on the floor of the House; they approved his proposal unanimously.


But St Germain was just getting warmed up. In 1982, he cosponsored a bill that removed all controls on what S&Ls could charge for interest and released them from their century-old reliance on home mortgages.
Around the same time, the Reagan administration ended the requirement that S&Ls lend money only in their own communities, allowed them to offer 100% financing (i.e. no down payments), let real estate developers own their own S&Ls, and permitted S&L owners to lend money to themselves.


These changes were like taping a sign to the S&Ls’ backs that read, “Defraud me.” In fact, it’s widely rumored that Mafia lawyers and accountants carefully monitored the progress of this bill as it worked its way through Congress, ready to pounce the moment it became law.

I don’t agree with the conspiracy theory here but the facts are correct and the reader can draw his or her own conclusion.

The result was disaster by 1985. My ex-wife worked for the Resolution Trust Commission managing bankrupt S&Ls and selling off their assets. She had a background in mortgage banking and told me some amazing stories. The self dealing and criminal behavior was astonishing.

The recovery of the housing market was nursed by Fannie Mae and Freddie Mac, both of which restructured the entire mortgage industry. No longer did local banks and S&Ls loan their own money to worthy borrowers, collecting the payments and amortizing the loan over 20 or 30 years. They “packaged” the loan and resold it to one of the big national bundlers like Fannie Mae. Sometimes the loans were sold to private investors.

Things did not begin to heat up again until the end of the Clinton Administration. The internet stock bubble left a lot of people with money to invest but few good opportunities. Many had taken their money out of the stock market after making plenty of money. Secondly, after 9/11, the Bush Administration was determined to avoid a recession brought on by the huge capital loss of the WTC collapse. The Panic of 1907 was precipitated by the San Francisco Earthquake and the huge losses to insurance companies. The Great Depression was partly a reaction to the default of war loans from World War I and the reparations demanded of Germany. There was fear that another severe financial panic would follow 9/11. In fact, that may have been a large part of the plan by Osama bin Laden. As a result, the banks had a lot of money to lend and they soon ran out of worthy borrowers. What to do ? Lend it to people with less than sterling credit. After all, houses were going to keep going up in price, weren’t they ?

Enter the chislers and scammers. Some of whom were former Clinton Administration members who got themselves appointed to the boards of the two big mortgage lenders. Did they have a broad background in mortgage banking ? No. They were politicians, like Jim Johnson who recently left the Obama campaign where he had been serving as the co-chair to vet potential VP nominees. What was his background ? Politics, not finance.

James A. Johnson is a United States Democratic Party political figure. He was the campaign manager for Walter Mondale’s failed 1984 presidential bid and chaired the vice presidential selection process for the presidential campaign of John Kerry. In the 2008 election, he is a member of the vice-presidential selection process for the presumptive Democratic nominee, Senator Barack Obama.

From 1991 to 1998, he served as chairman and chief executive officer of the Federal National Mortgage Association (Fannie Mae), the quasi-public organization that guarantees mortgages for millions of American homeowners. Previously, he was vice chairman of Fannie Mae (1990-1991) and a managing director with Lehman Brothers (1985-1990).

Franklin Raines at least had some financial background. His tenure at Fannie Mae, however, did not inspire confidence. For a while it looked like he might be indicted. Then the Democrats took over Congress and all was forgiven.

Jamie Gorelick, former Clinton Deputy Attorney General, however, had no background in finance. She is a lawyer. She did very well for herself, though. Now we are at the next big crisis and Fannie Mae is in trouble. Where is Gorelick ? Back at her law firm. What is the connection between Fannie Mae and 9/11 ? The link is Jamie Gorelick. What a career !

She helped bring the attack on 9/11 by blinding the intelligence agencies, then she profits from the easy money that follows the attack. She still has a few fingers in the pot, as you will seen in the Volkh piece. You can tell it’s all politics because the defenders are out already. Thank God for Mickey Kaus.

The National Vaccine Injury Compensation Program has lost its bearings

Wednesday, May 14th, 2008

There was a recent flurry of interest in the fact that a government program “admitted” that vaccines may be related to autism. This article explains why that is and suggests that the VICP has gone off the reservation and is now accepting non-scientific input. That is very bad news when measles epidemics are returning for the first time in 30 years and a school has to close because of whooping cough. Children are going to die because of this nonsense.

The manual life

Tuesday, May 13th, 2008

When I applied for a surgery residency, only one professor asked me questions about my manual dexterity. He asked if I played a musical instrument (I had but not well) and whether I worked with tools. I had been working with tools since I was a child. One of my earliest memories was smashing my thumb with a hammer. When I was a medical student, we had real labs. In Physiology and Pharmacology we would inject rabbits with drugs and measure the effect. Sometimes we constructed preparations with a frog’s leg and its nerve. Sometimes it was a heart beating in a dish of nutrient solution.

In recent years, some students have begun to complain about the use of animals in research and in biology labs. The lab benches have disappeared from medical schools. Students don’t even use microscopes anymore. I wonder if an applicant to a surgery program is asked about manual dexterity now.

This essay discusses the disappearance of shop class in high school (my Catholic high school didn’t have shop) and the decline of the manual arts as vocational choices. A Mercedes mechanic can earn $150,000 a year in a dealership position but college graduates earning 14 dollars an hour will look upon him as a “blue-collar worker.” The essay points out that many of the people described in the book, “The Millionaire Next Door” are in fact the products of such technical trades.

It has been said that India was for many years held back in its development because the British educational system had left a tradition of contempt for such manual trades. India had plenty of doctors but few auto mechanics. I wonder if we are headed the same way?