Hey Arizona, ur doin' it 'rong...

Gail Collins comes up with a stunning, refreshing rebuke of the idiocy of Arizona's new approach to cut $4.5 million dollars from its state Medicaid expenditures by denying certain types of organ transplants.  The bottom line: government bureaucrats allowed the plug to be pulled on a 32 year-old father.  No, seriously.  This is from a state run by people who said "Obamacare" was going to do just that; when in fact health care reform was put in place, in part, to avoid such devastating consequences of cost cutting in the setting of poor information.

Update (12-17-2010): still sounds like death panels to me.  Wasn't this kind of thing supposed to happen under the watch of "liberals"? Never a state like AZ...

I was, am, and hope to always be naïve.

I hope you think the picture is pretty, but I don’t expect you to be as taken away as I am: I understand that discovering the sight was part of the fulfillment’s process. I take that back, actually. I didn’t discover anything. I just observed some already-well-characterized phenomena.

A couple of months ago, when I just started my PhD training, I saw this image under the microscope. I forgot how much time I spent staring at all the different motor neurons, how they extended their processes to hold figurative hands and pass along chemical love messages. I spent more time taking the highest resolution picture I could, which has been edited to its current state.

If I gave this image to a polite, random neuroscientist, he/she would give me a coy smile and say that the picture was “nice and the TUJ1 antibody stained very well.” If I gave this image to an impatient and nasty, random neuroscientist he/she would scowl at the piece of paper and ask me why I was wasting his/her time: I’m not showing anything new!

I hope this figure will be as stunning to me in a few years, when I’ve read more literature and seen more figures and done more research and graduated with a PhD. Sure I’ll see a lot of similar images; I might be bombarded by them. But I hope to appreciate that the ordinary is beautiful too: because you see it once, doesn’t mean the allure has to fade.

Monday afternoon football update

This weekend in American football:

1. A Rutgers' University student athlete was paralyzed from the neck down after an in-game incident against Army.
Update (10-19-2010): The most recent medical literature says that 90% of patients with complete tetraplegia (aka quadraplegia) at one month post-injury remain complete tetraplegics for good.  After 6 months, there is little change in a person's neurological status caudal to the spinal injury.  In other words, the coming days and weeks will be hugely informative of the athlete's function long into the future.  Here's hoping he regains function.  Also, from what I have gleaned from the news reports, it does not appear that therapeutic hypothermia (TH) was tried.  Recall that TH was used when Buffalo Bills' player Kevin Everett was injured back in 2007.  Although the use of TH in his case is still being debated, he was able to walk within ~one month of the injury.


2. Yesterday's NFL games featured several instances of traumatic brain injuries.

walking, chewing gum

In my recent interactions with one of UCLA's true physician-scientists, I start to get the sense, more than ever before, how this journey is about learning to walk and chew gum...at the same time! Hackneyed cliche aside, I guess I have begun to realize how all of this research and medicine "stuff" isn't so incredibly difficult, but juggling different responsibilities requires intra- and inter-personal patience: transitions are hard, and a deep breath and calm go a long way.  But it's still hard work.

Rethinking traumatic brain injury and its consequences: “repeated brain injury can change your life and your family’s life forever.”

I watch the NFL most weekends, and I won’t lie: I’m mesmerized by the horrific collisions and the looped instant replay that progressively slows down so that I can see faces grimace on impact. After most hits, the players bounce back up, dust and readjust their jerseys, and run back into position to get hit again. After the bad hits -- a lot of the times on the quarterback -- the trainer and then the team physician and then the medics come to the field. An awkward fall or collision can cause a player’s helmet to hit the ground at a ridiculous velocity.

In 2009 Roger Goodell, the NFL commissioner, testified in front of the House Judiciary Committee and did not recognize an association between head trauma suffered in games and brain diseases later incurred by those players. The league promised to “do better” and later that year issued “stricter” concussion guidelines.

Since Goodell’s testimony, the NFL has slowly changed its outlook regarding traumatic brain injury. A sobering poster in team locker rooms acknowledges that concussions can cause “problems with memory and communication, personality changes, as well as depression and early onset of dementia.”

Omitted in the list of concussion-associated conditions is a Lou Gehrig’s-like disease. Lou Gehrig’s disease (amyotrophic lateral sclerosis (ALS)) is a progressive, neurodegenerative condition that affects upper and lower motor neurons. Patients, like Stephen Hawking, are left weakened and atrophied to the point where they can no longer support breathing. The etiology of ALS was thought to be primarily organic. Current studies, however, suggest head trauma can cause a similar disease state. So Lou Gehrig may not have had Lou Gehrig’s disease. A New York Times article reviews his well-documented history of head trauma. Spinal cord pathology samples have shown that others athletes -- boxers and football players -- have been misdiagnosed with ALS. It is hypothesized that the neurodegeneration related to chronic traumatic encephalopathy (CTE) is mediated by neurofibrillary tangles, which are also seen in Alzheimer's.

Whether the neurofibrillary tangles and neurodegeneration are taking place in the motor neurons or temporal or frontal lobes, the fallout is real and serious. Chuck highlighted the sad story of Chris Henry, a former wide receiver for the Cincinnati Bengals, who demonstrated behavioral changes leading up to his accidental death. An autopsy revealed CTE. Malcolm Gladwell surveyed some of the NFL’s horror stories:

“Mike Webster, the longtime Pittsburgh Steeler and one of the greatest players in N.F.L. history, ended his life a recluse, sleeping on the floor of the Pittsburgh Amtrak station. Another former Pittsburgh Steeler, Terry Long, drifted into chaos and killed himself four years ago by drinking antifreeze. Andre Waters, a former defensive back for the Philadelphia Eagles, sank into depression and pleaded with his girlfriend—“I need help, somebody help me”—before shooting himself in the head.”

The sad stories aren’t limited to professional sports. This past April a University of Pennsylvania football player committed suicide. An autopsy revealed CTE, a surprising finding considering his age. These stories are receiving more and more attention, and congress is listening. House committees are working on the Concussion Treatment and Care Tools, and Protecting Student Athletes From Concussions Acts.

While the sports community has slowly increased the awareness of traumatic brain injury, the US Army has some work to do. An NPR investigation reported that Army officials have denied Purple Hearts to soldiers who suffered concussions following explosions. The denial is not a surprise to Gen. Peter Chiarelli who acknowledges the “ongoing resistance to awarding the Purple Heart for so-called ‘invisible’ wounds.” The Purple Heart is a “badge of courage” and a medical resource: recipients receive prioritized medical care from Veterans Affairs hospitals.

Soldiers shouldn’t need a Purple Heart, though, to receive appropriate medical care. Physicians should investigate the association between psychiatric and neurological conditions and traumatic brain injury. Soldiers should be warned of the risks. And the institutions should provide the appropriate medical and social resources. The consequences of traumatic brain injury do not happen overnight.

Friday food for thought

Med students/schools ur doin' it wrong.  Some ideas.  I'm too tired to have an opinion right now.

It gets better

Advice columnist and openly gay activist Dan Savage found himself so moved by the recent suicide of a 15 year-old, bullied and picked-on boy in Indiana, that he started a youtube channel called the "It gets better project."  It's wonderful to see multimedia having potentially life-saving effects; and in the young (particularly openly gay or lesbian), suicide is a leading cause of death.

The creepy cashier and lessons in a heteronormative society

On the occasion of the United States Senate filibustering a repeal of "Don't Ask, Don't Tell" I thought I would share an anecdote from several weeks ago.

I waited in line at the grocery store as the middle-old aged clerk (65-70 years old) struck up this conversation with the young daughter (~6 years old) of a woman buying groceries ahead of me:

Clerk: Hello there young lady.  Do you have a boyfriend?

Girl: No. [giggles, looks away.]

Clerk: Do you want to have a boyfriend?

Girl: I don't know. Maybe.  [looks away]

Clerk: Will you be my boyfriend?

Girl: NO!

Clerk: Why not? You'll get free groceries...

Girl: No.  [looks away].

Clerk: How about this, I'll give you a week to decide.

[Genuinely amused, the mother shakes her head, mumbles a few words about the girl being high maintenance, and then looks up as she hears her daughter, upon leaving yell:

Girl: Good luck, sucker!

Now, I laughed too.  The clerk was just silly. The girl was predictable.  The mother was amused.  And I got to thinking, would people have reacted this way had the girl instead been a boy?  What if the elder clerk was in fact a homosexual, and thus innocently struck up the same conversation with the woman's son.  I doubt anyone (I included) would have acted the same way.  People would say, "Oh, how dare he try to make her son GAY!" "God, he's such a creepy molester!" "What is he, a Catholic priest or something?"  In other words, they are afraid of such behavior, because it might influence the boy.  It might shatter his world view of boys + girls = love.  Quite simply, when the heterosexual "norm" of our society is enforced, even by slightly creepy, but good-natured clerks, we all laugh and move on.  Because we think that society is grooming everyone to be either gay or straight.  Straight is ok.  Gay? No homo.

I doubt it's so straightforward that society's influences play such a large role.  If they did, we wouldn't have had people identify with homosexuality in the dark ages of sexual identity (pre-gay rights/civil rights movement, which is by the way ongoing: see the link above).

I hope my (future) children grow up in a world that embraces both the straight and the gay clerk.  I have enough faith they will know how to figure out their own sexual identity, regardless of some old grocery store clerk's influence.

Kids and antipsychotics

I read bits and pieces of the “Diagnostic and Statistical Manual of Mental Disorders IV” (DSM-IV) during medical school, which was an informative yet frustrating experience: one that I would like to revisit and expand upon when DSM-V is released. My understanding of psychiatric illnesses and their diagnoses and treatments is extremely limited. I can only imagine how difficult it is to care for some psychiatric patients, let alone, children.

Enter Kyle. The NYTimes paints a grim portrait of his struggle with antipsychotic drugs:

“Kyle’s third birthday photo shows a pink-cheeked boy who had ballooned to 49 pounds.”

“Kyle smiles at the camera. He is sedated.”

“He was sedated, drooling and overweight…”

Kyle isn’t alone.

“Texas Medicaid data ... showed a record $96 million was spent last year on antipsychotic drugs for teenagers and children — including three unidentified infants who were given the drugs before their first birthdays.”

Kyle and other children from low-income families “were four times as likely as the privately insured to receive antipsychotic medicines” because it is “cheaper” than psychotherapy, according to a Rutgers U. study.

I wonder what things are like in the prison systems.

20-Somethings

This piece about "20 somethings" and the movement toward recognizing one's 20s as a period unique - not adolescence, not true adulthood - is worth a read, especially if you're a 20-something.

In a way, doing extended post-college schooling may provide exactly what 20-somethings need: a transitional phase, gradually introducing more responsibility, life choices, and adult activities.

Who knows? As for me, I feel as though I identify much more with a "20-something" than a "young adult."

I know what I would want...

Early palliative care with usual treatment.  As the piece by Atul Gawande (linked to in Anthony's earlier post) suggested, early palliative care (hospice) reduced the costs of care, without negatively affecting patient outcomes.  Now this NEJM-published study on metastatic lung cancer shows that it even extends the lives of terminally ill patients.

WTF is up with...

1. Counseling on a patients' goals of care/end of life wishes/advance directives = "Death Panels" ?

2. Building a Islamic community center (which includes a prayer center; by a subdivision of Islam which has NEVER been supportive of or involved in terrorism) two blocks from the former WTC site in lower Manhatten = "Ground Zero 9/11 Victory Mosque" ?




People babble over issues of which they have no understanding.  And worse, they don't even try to understand.  They just babble.


::sigh::

As you know end-of-life care is a big deal...

... that can improve quality of life for dying patients and save the government a lot of money. Chuck C has written about the so-called “death panels”; the NYTimes and other news outlets have expanded the dialogue; now Atul Gawande has written an essay for the New Yorker.

I’d like to focus on one particular part of Gawande’s essay, where he refers to Stephen Jay Gould’s remarkable recovery from abdominal mesothelioma, which inspired Gould’s essay “The Median Isn’t the Message.”

Gould beat a normally lethal cancer. He is the exemplar patient that all physicians would like to have and treat. Gawande admits this sentiment himself:

I think of Gould and his essay every time I have a patient with a terminal illness. There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.

The reality, as Gawande alludes to, is grim: optimistic hope in sexy, new treatments against diseases that we don’t completely understand. The grim reality, though, funds our futures as physician-scientists. A lot of basic research in a lot of different fields is needed to know which patients will benefit from which treatments. And some times the treatments will be palliative.

Gould studied patient-survival curves. He saw “himself surviving far out in that long tail.” But what does it mean to be in the “long tail”? People are hard at working doing this, particularly with breast and prostate cancer.

First day for first years

Welcome, first years.  On the first day of orientation, we at mstpla.blogspot.com welcome you to the UCLA MSTP.  This is a great city, school, and program.  Here's to productive MD/PhD training!

Longevity, with disparities

The two sentence, data-filled abstract of this article says it all.

"The Advantage of Being Helpless"

Is the human brain as advanced, in part, because of how slowly it develops?  New research suggests maybe so.


Updated, 7/21/2010: Title changed from "The Advantage of Being Hapless" to "The Advantage of Being Helpless." At least I didn't make up a word like "refudiate."

Preventative tests at no cost

Sometimes I wonder whether this blog is simply a link-dump for NYTimes articles.  But nevertheless, here goes:

New rules from the U.S. Government's Executive Branch that insurance companies will be required to cover all costs associated with basic preventative and diagnostic medical tests.  Good news indeed.  Will save the ~100k lives, as quoted in the article and will probably also lower costs.  This, like many other things, is incremental, but it's another notch on the belt.

Challenges, frustrations

Challenges and frustrations -- especially the kind that infuriate us -- tend to provide us with "teachable moments."

That is, if we're ready to learn.

Being ready is easier said than done.

This week in WTF

I'm speechless.

Hospitals as efficient factories of healing

This is so cool!  Taking the genius/efficient/successful and DATA-DRIVEN approach to running companies and making hospitals operate more smoothly is long overdue.