Sometimes it is bad when the science is settled

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“Big Sugar’s Secret Ally? Nutritionists” (nytimes):

When it comes to weight gain, the sugar industry and purveyors of sugary beverages still insist, a calorie is a calorie, regardless of its source, so guidelines that single out sugar as a dietary evil are not evidence-based.

Surprisingly, the scientific consensus is technically in agreement. It holds that obesity is caused “by a lack of energy balance,” as the National Institutes of Health website explains — in other words, by our taking in more calories than we expend. Hence, the primary, if not the only, way that foods can influence our body weight is through their caloric content.

When scientists agree on climate change, science is good and the process of inquiry is one of pure intellect. When scientists agree on calorie consumption and weight, science is bad and the process of inquiry is tainted by “dogmatic belief.”

British Royals in the Good Old Days

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Victoria: The Queen: An Intimate Biography of the Woman Who Ruled an Empire (Julia Baird 2016) writes about the lifestyles of the rich and royal back in the old days:

King George IV [Victoria’s predecessor] was not a popular ruler. The Duke of Wellington considered him the worst man he had ever met, without a single redeeming quality. A reactionary Tory, the king fought the ongoing reform movement and had to be forced to assent to a bill allowing Catholics to stand for Parliament in 1829. William Makepeace Thackeray dismissed him as “nothing but a coat, and a wig, and a mask smiling below it.” The extravagant king had also become a symbol of the gross excess of Britain’s rich, as he drained public funds when the country was crippled by the cost of a war with France that had ended in 1815. When he became king at age fifty-eight, he weighed 245 pounds, had a fifty-inch waist, and was addicted to opium. His belly hung to his knees.

Bertie, the future King Edward VII, was fond of gambling, horseracing, and brothels. Even as she grew old, Victoria was loath to hand over any official duties to her oldest son.

It was hard to get good help back then:

Up to two-thirds of palace servants were unsupervised at any given time, so they did much as they pleased, disappearing at will. The staff was known for rudeness. Rarely was anyone available to show guests to their rooms; many got lost in the labyrinthine corridors. Albert identified a series of scams and perks that servants had abused for decades: people outside the palace often forged the signatures of the queen’s ladies when ordering carriages, charging the cost of their ride to the royal household; fresh candles were put out each day while the footmen pocketed the previous day’s, many unlit; and expensive staff dinners were offered to those with only tenuous connections to the royal court. Albert slashed salaries, sometimes by as much as two-thirds, to account for the fact that many servants worked in the palace for only half the year. Last on Albert’s agenda was what he called the “moral dignity of the Court.” The gambling tables disappeared from Windsor. No one was allowed to sit down in the queen’s presence—or in Albert’s. (The wife of Lord John Russell—who was later prime minister—was allowed to rest in a chair after she had just given birth, “but the Queen took care when the Prince joined the company to have a very fat lady standing in front of [her].”) Ministers had to back out of the room when visiting the queen, as it was considered poor etiquette to show a monarch your backside. Court dress was obligatory. (If a woman did not want to wear the appropriate styles she needed to get a doctor’s certificate explaining how it would be injurious to her health, and then seek permission from the Lord Chamberlain’s department.)

One had to remember that the throne was not secure:

Friedrich Engels were producing The Communist Manifesto, urging the working class to “arise ye starvelings from your slumbers.” As Buckingham Palace was being enlarged and beautified, European royalty were pushed off their thrones. While Albert was surveying with pleasure his own tranquil abodes, angry hordes swarmed through palaces in Paris, Berlin, Vienna, Prague, and Budapest.

There were live threats:

One of the greatest threats to public safety came from the Fenian Brotherhood, which was founded in America in 1858 with the aim of overthrowing British control of Ireland and establishing an Irish republic. In 1866, the Brotherhood unsuccessfully tried to invade Canada from America. In 1867, they began a campaign of terror in Britain, blowing up a prison wall and killing a policeman.

Three months later, on a trip to Australia, a Fenian shot Victoria’s twenty-three-year-old son Prince Alfred in Sydney. He was on his way to Cabbage Tree Beach to “see the aboriginals, as they were then ready for some sports,” when he was shot in the back and fell on his hands and knees. The bullet lodged in his abdomen. For three days, he later told his mother, he could not breathe. The Irish assailant, who was about thirty-five, fair, and well dressed, was later executed.

Victoria had nothing like the modern-day Secret Service to protect her. Baird describes multiple assassination attempts that failed due to good luck.

Maybe we should be more grateful to Richard Nixon for signing the Environmental Protection Agency into law. Even the royals were not isolated:

A century earlier, the river named Tamesis by Caesar was clean. But when the water closet replaced the cesspool in the mid-1800s, channeling the city’s sewage to the river in large murky pipes, the water turned to black in less than half a century. At the same time, the capital’s population ballooned. In 1801, there were 136,000 houses in London. By 1851, there were 306,000. Those living near the river noticed an increasing acidity and murkiness in the water. By the mid-1850s, eighty million gallons of human waste from more than three million Londoners was draining down the Thames each year. The problem seemed insurmountable. In 1852, the chief engineer of the Metropolitan Sewers Commission, Frank Forster, died, and his death was attributed to “harassing fatigues and anxieties of official duties.” The next year, a cholera epidemic raged through the city, killing almost twelve thousand. This finally convinced scientists that disease was not borne by foul air, but by water. Yet the government, crippled by inertia and lack of will and urgency, failed to act. The royal family was insulated, but not exempt. Buckingham Palace often reeked of leaking excrement and crawled with rodents. Victoria watched her dogs chasing rats around her bedroom at Windsor, praising one for “valiantly” triumphing; “the rat made an awful noise, though he was killed right out pretty quickly.

By June 1858, the smell was so bad that lime was scattered in the river beneath the Houses of Parliament, and sheets soaked in bleach hung from ceilings inside so the gentlemen could speak without having to hold handkerchiefs over their noses. In the early summer, a long dry spell had dwindled the supply of fresh water coming from upland areas, and the water temperature was at a record high. A thick mass of black sewage stretched for eighteen miles. The resulting crisis became known as the Great Stink. Much of the city business ground to a halt; the courts rushed through cases to avoid prolonged exposure to the fumes.

(The above may explain Victoria’s fondness for Scotland!)

War concentrated a monarch’s mind:

Gladstone preached a gentler colonialism, supporting the principles of local autonomy and self-government—the same position he favored for Ireland. Gladstone even vowed to give independence to the South African Transvaal, which had been annexed by Britain in 1877. He was wary of further expansion in Africa and the Pacific, and called brutally obtained new swaths of land “false phantoms of glory.” Victoria was furious: she saw wars as a necessary means of protecting her empire.

On October 11, 1899, the Second Anglo-Boer War broke out. Few things concentrated Victoria’s mind as much as military conflict. She bade many of the troops farewell in person, and recorded details of the battles in her journal with a palpable anxiety. She was now eighty years old, but she maintained a keen interest in her army and continued to argue for more resources and men. While she did not see herself as a natural imperialist—writing of China, for example, that the world at large should not have the impression that we will not let anyone but ourselves have anything—she was eventually persuaded of the case for war in Africa. She believed that Britain should protect its subjects and territory. Her caveats were that the poor not be disproportionately burdened by a war tax and that the horses sent to fight be well treated.

Throughout the book, Baird’s main criticism of Victoria is that she did not advocate for a modern American- or European-style Welfare state. Examples:

At a time when most working-class people lived in misery, Victoria was more readily stirred by compassion for individuals she met than by reform movements. She worried about whether widowed women had enough money to live on and whether dwarves who performed for her were well treated. She worried about the well-being of orphans, wounded military veterans, and victims of sexual assault. When she saw how “lonely” child offenders jailed on the Isle of Wight spent months in solitary confinement, she was troubled by their sad existence.

The English had a deep, enduring belief in the importance of laissez-faire. The government was loath to intervene, ostensibly on the grounds that those suffering should be able to hoist themselves out of their misery and poverty without requiring aid. Kindness, it was feared, would corrupt them.

As Victoria grew older, she gradually leaned more toward conservatism. In her youth, she had taken a keen interest in the life of the poor as described by Charles Dickens, but she had not gone on to take an interest in the causes of poverty and frequently blamed those protesting against it.

For the rest of her life, she would fail to concertedly champion attempts to alleviate poverty or improve basic living and working conditions. Victoria’s problem was not lack of concern about social ills but lack of exposure to them

More: read Victoria: The Queen: An Intimate Biography of the Woman Who Ruled an Empire

 

Adventures in the English language (Dell sales chat)

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Regarding an XPS 13 2-in-1:

  • Philip Greenspun: “and [the power adaptor] plugs into one of the USB-C ports then?”
  • Agent (k_swathi_m): “The system comes with a charging port and this machine also has USB-C port.”
  • Philip Greenspun: [referring to a low-res image of the machine] “”4. USB C 3.1 with Powershare / AC Power and Display Port” is the full description of what I think is one physical connector”
  • Agent (k_swathi_m): “It means that you can use this USB C 3.1 to Powershare”
  • Agent (k_swathi_m): “or you can use to AC Power”
  • Agent (k_swathi_m): “and Display Port”
  • Agent (k_swathi_m): “You can use that port for either of the options.”
  • Philip Greenspun: “So the “charging port” you mentioned above is in fact a USB C port?”
  • Agent (k_swathi_m): “Yes, that is correct.”

Readers: Post your best please!

Trump attacks Martin Luther King, Jr.?

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I scanned the headlines in the New York Times and found “‘All Talk,’ Trump Says in Attack on Civil Rights Icon”. It worked as clickbait since the only civil rights icon that came to mind was Martin Luther King, Jr. This was a lot more shocking to me than anything Trump was accused of during the election!

It turned out that the civil rights “icon” being attacked was not, in fact, the person whose birthday we celebrate today, but rather a Democrat from Georgia who was publicly boycotting the coronation of King Donald I.

I recently finished a biography of Ulysses S. Grant (some blog entries about this book to follow), which describes the ineffectiveness of Northern/central efforts to dictate to Southerners how to think in the decades following the Civil War. This gave me even a little more respect for MLK and the challenge he faced. The framework of desegregation had been created during the Eisenhower Administration but dictating something from D.C. and what happens locally can be different. Like Grant, Eisenhower changed people’s behavior at gunpoint; MLK changed people’s minds (not everyone, of course, but even Jesus Christ and the Buddha weren’t able to convince everyone!).

Readers: share your MLK Day thoughts!

Related:

Medical School 2020, Year 1, Week 17

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From our anonymous insider…

“We live every second on the edge between bleeding to death and death by heart attack,” exclaimed the young hematologist attending.  She introduced us to the coagulation pathway and the lucrative and life-sustaining hematological drugs. Numerous clotting factors (proteins) are produced in the liver and released into the bloodstream. My favorites were the actions of fibrin and plasmin. Vascular damage initiates a cascade of clotting factors to cleave the precursor fibrinogen into fibrin. Fibrin acts as a sticky filament that forms an intricate spider web, binding platelets together, creating a thrombus (blood clot). This nanoscopic mesh traps everything from red and white blood cells to the numerous clotting factors such as plasmin to plug the vessel breach. Vascular remodeling and wound repair signals activate the entrapped plasmin which degrade the fibrin web through fibrinolysis.

Simply resting one’s arm on a table creates cuts in the microcirculation. Our finely-tuned coagulation system is able to plug these cuts to prevent severe bleeding, while not creating too many blood clots that would obstruct flow to tissues. The hematologist explained that mutations in clotting proteins lead to uncontrolled bleeding disorders such as hemophilia (factor VI, IX or XI) and von Willibrand Disease or uncontrolled thrombosis formation such as in Leiden Factor V. She finished by explaining that vitamin K is essential for the activity of a liver enzyme that is used in the production of several important clotting factors (Factors II, VII, IX, X, numbers that become ingrained into any medical student’s mind for Step I). Drugs such as warfarin target the enzyme that catalyzes the reduction of oxidized vitamin K. Without this reduction process, fewer functioning clotting factors are synthesized. This results in decreased clotting function for a given signal, the costs and benefits of which were presented in this week’s patient case.

“Gerry” is an eighty year old black male who suffers from congestive heart failure after three heart attacks. “I did not treat my body well for many years.” Gerry became an alcoholic in his twenties, and smoked two packs a day from his late teens through his 60s. Vodka was his drink of choice.

Gerry grew up fatherless in a crime-ridden neighborhood. “Ma did her best to raise my two brothers and me. She would whip us if we did anything wrong. She’d grab us by a leg, hold us upside down and smack away. If none of my brothers would turn the culprit in, she would whip us all to ensure the guilty got punished,” Gerry reflected. “Much of my neighborhood’s problem was from the destruction of the family. No one has respect for authority. When I grew up, the cops were the good guys, Ma the bad one. We grew up wanting to be cops.”

Gerry described the low point in his life as returning home to see his wife and children conducting an alcohol search. “They missed the bottle that I hid in the toilet cover.” He claimed that he was able to “drink a bottle of vodka before work and no one would notice.” His wife divorced him after catching him driving drunk with their two girls and then his unmanaged health conditions continued to deteriorate.

Gerry began to have congestive heart failure from combined systemic hypertension (high blood pressure everywhere) and pulmonary hypertension (high blood pressure in the lungs). His second heart attack in his sixties was a wake-up call. “My doctor said, ‘If you do not make drastic changes, I do not expect you will live another year.’ I went completely cold turkey. I moved back home at sixty and quit cigarettes and alcohol.” Gerry now lives in a retirement home. “I was very anxious about death, so much so I would be afraid to sleep in my bed. I would try to stay awake in my recliner. Eventually I realized when I go, going in my sleep is the best way. Now I sleep like an angel.”

Gerry’s cardiologist explained that Gerry owes his life to advances in pacemakers and fibrinolytic pharmaceutical drugs. His weakened heart, after three separate heart attacks, has less contractility. Certain areas of the his heart, such as the atrial appendages and ventricular apexes, do not fully contract. This causes “pooling” of blood or hemostasis. Still blood is more likely to form a thrombus (or blood clot). These clots, unless broken down, can travel and obstruct vessels to vital organs causing a thromboembolism. A thromboembolism lodging in a coronary artery is the most common type of heart attack; a thromboembolism lodging in a vessel supplying the brain is called a stroke. Gerry is also at increased risk of Deep Vein Thrombosis, or DVT, due to sedentary lifestyle in advanced age and poor circulation from decreased cardiac output . If a DVT in a femoral vein gets dislodged it can lead to rapid death from a pulmonary embolism, blocking blood flow to the lungs (the cause of death in at least one of our cadaver).

“Even ten years ago, the general consensus was to avoid excess bleeding,” explained the cardiologist. “This has shifted to prevention of clots. You can recover from excess bleeding by getting a transfusion or IV fluids. You will not recover from brain damage from a stroke, sudden death from a PE or heart damage from a MI.” Gerry and the cardiologist discussed how warfarin and coumadin are difficult to take and to prescribe because their effect varies with vitamin K input. “If my patient eats a lot of spinach one meal, it could throw the whole clotting system out of whack with drastic consequences.” A new age of fibrinolytic drugs are coming that are vitamin K-independent (see eliquis ads on TV). However, this new age would not alleviate a common concern for Gerry and other elderly people: “I sometimes have trouble remembering if I took my medications in the morning if I do not put them in the pillbox. If I took my meds again at night, could this kill me? This is something that gives me so much anxiety.” The cardiologist added that one occasional double dose would not kill him, but emphasized these are powerful drugs.

Jane recounted a “Women in Surgery” interest meeting she attended with other interested female medical students. A young trauma surgeon who has been an attending for three years led the discussion on the life of surgery. “Go into something else if you could be happy there. Surgery is only for people for whom nothing else would satisfy.” Jane recounted the surgeon’s main point: “There is no such thing as work-life balance. Anything not work becomes a distraction against surgery… Getting married, distraction.  Having children, distraction. I was in surgery on my son’s birthday. He waited until 10:00 pm to give me a slice of his birthday cake. His birthday was a distraction.” The surgeon recounted a story of informing the parents their 17-year old child is dead. “Women cry a lot more than men. Men are usually silent. I woke up at 3:00 am for weeks thinking about that case, of what I could have done differently. Surgery never leaves you.” The trauma surgeon said to wait for the surgery rotation (third or fourth year) before seeking to go into her specialty: “Most of you will be pulling your hair out on the first 24-hour shift, but a few of you will become captivated. Don’t force it.”

Our medical school requires students to do community service projects in six-person groups. My group chose to work with opioid addicts. The program was started by the local police department to try to fight the rise in opioid overdoses in the area. As long as there is no outstanding warrant, opioid users can bring in drugs and paraphernalia to the local police station, or a recently added clinic, and receive counseling and access to rehab programs. We met with the director, a middle-aged woman whose college son overdosed on heroin laced with fentanyl, and a nurse.

I asked how many addicts would willingly give up their drugs? The answer turned out to be three or four individuals per day. The nurse explained that based on an interview, a “program ambassador” customizes a recovery plan tapping into local, state, and federal programs: “The resources are there, just it is impossible for a non-expert to navigate them. One common complication is addicts having children. They are afraid of losing custody if they ask for help from healthcare professionals.” Our group will able to serve as ambassadors once we complete an 8-hour training program.

Tuition is due this week. I have a Graduate Plus loan at 6.31 percent. There is no federal subsidy for this loan and the interest begins accruing immediately, but payments are deferred until after graduation. If I work in a non-profit health care system, i.e., most American hospitals, monthly payments are capped at a percentage of my salary. After ten years, the principal will be forgiven (paid by taxpayers!) if it hasn’t been paid off. The program was designed for people who joined the Peace Corps, not for radiologists earning $350,000 per year, so there is some talk about the new Congress closing “the Doctor’s Loophole.”.

Statistics for the week… Study: 25 hours. With exams next week, I wish I was at this stage two weeks ago. Sleep: 7 hours/night; Fun: 1 night. Example fun: Evening watching Netflix’s The Crown followed by Sunday brunch.

The Whole Book: http://tinyurl.com/MedicalSchool2020

Medical School 2020, Year 1, Week 16

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From our anonymous insider…

A brilliant energetic attending, straight-out of fellowship and with bright red hair to go along with both her specialty and patient (see below), led the introduction to hematology. Blood plasma is almost all water with an amalgam of solutes such as protein, glucose, amino acids, hormones, cytokines and clotting factors. The cellular components suspended in this plasma include red blood cells (erythrocytes), white blood cells (lymphocytes), and platelets (thrombocytes). All of these cellular components are made in mesh-like inner bone structures, bone marrow, home to hematopoietic stem cells which can become any of the cell constituents of blood in response to growth and differentiation signals. For example, if oxygen content is low or an individual has been bleeding, the kidney secretes the hormone erythropoietin (EPO) into the bloodstream to increase differentiation towards the erythrocyte (red) lineage.

Red blood cells are an engineering marvel and a story of sacrifice for a single purpose: transporting oxygen and carbon dioxide through the vascular network.  Hematopoietic stem cells undergo a stunning transformation. The cell rearranges its membrane so the mature erythrocyte can survive intense deformations squeezing through capillary beds. The cell simultaneously begins to synthesize gobs of hemoglobin, which eventually will take up the entire intracellular volume of the cell. Hemoglobin is a marvelous contraption comprised of four oxygen-binding heme rings surrounded by four globin protein chains. Each of the four heme rings contains a reduced iron molecule at its center where oxygen binds. The globin chains are encoded in DNA and translated into an amino acid (protein) sequence. The protein scaffold modulates the oxygen-binding affinity to unload oxygen in metabolically active tissues. Genetic defects in globin genes can lead to hematological disorders such as sickle cell anemia. Lastly, red blood cells expel their nucleus and other internal organelles, such as mitochondria.  Once completed, the 7-9 micrometer biconcave cell has sacrificed its ability to replicate in exchange for a slow but inevitable death. The average circulating red blood cell lasts no more than 120 days.

Our patient case dealt with a form of hereditary spherocytosis that first manifested in a person who had seemed to be a perfectly healthy 18-year-old. “Jessica” was an A-student, high school homecoming queen, and cross-country athlete. Early in her first college semester, a flu put in her bed for several days. After an apparent recovering, she became even more ill, sleeping all day and unable to leave her dorm. She had piercing pain in her left abdomen, her eyes began to turn yellow, and then her whole body. She was stabilized by a hospital Emergency Department and the next day saw her pediatrician back home — like most young adults had yet to find an internist. Her pediatrician referred her to our hematologist.

The mother interjected, “This was the scariest moment for me. [her pediatrician] would not tell us what it was, although he clearly had some idea. I called the referral office, and got put on hold.  I still remember the lady’s recorded voice while on hold:  ‘You have reached the Hematology-Oncology office of ….’  I was speechless!  Oncology!  My 18-year-old has cancer!” Our hematologist instructor continued, “Hematologists treat both cancer patients and benign blood disorders. Cancer patients almost always have hematology issues from the cancer itself, or from the chemotherapy destroying their bone marrow. I wish we could have two offices.”

Jessica recounted the first appointment. “The waiting room was scary. Almost everyone was old. It smelled of chemo and death. When the doctor spoke to us, everything settled down. She said, ‘You most likely have some sort of anemia, not cancer.'” Blood tests showed severe anemia. The left-sided abdominal swelling and pain was caused by splenomegaly, or enlargement of the spleen. The spleen filters the blood where resident macrophages eat old or damaged red blood cells. The macrophages recycle heme rings by releasing iron and bilirubin into the bloodstream. The yellow discoloration of her eyes and skin were from an excess of toxic bilirubin in her blood, or jaundice, a common affliction for newborn babies.

A basic peripheral blood smear showed that Jessica had premature, sometimes even nucleated, red blood cells in circulation. If the signal for erythropoiesis (formation of new red blood cells) such as EPO levels is high enough, the bone marrow will release premature cells such as reticulocytes. Her symptoms immediately improved after supplements of iron and folate, required during red blood cell differentiation for synthesis of functioning hemoglobin. However, doctors and the family were still at a loss regarding the cause of this flare-up after 18 years of perfect health.

Genetic testing showed a defect in a membrane receptor that causes her macrophages to eat up healthy red blood cells prematurely. Her bone marrow, without any iron and folate, could not keep up with the destruction of red blood cells. The hematologist theorized that the flu virus triggered the immune system to increase erythrocyte destruction. Jessica is now a normal college student. She continues to take iron, folate and recombinant EPO supplements. She gets tired easily, especially around exam time. Her school has given her a single room to allow her to get more sleep. She sometimes has mild left-sided abdominal pain. Her two brothers and sister attended. They had both opted out of genetic testing. Jessica said she has two fears: “having my spleen removed and needing transfusions to live. I’ve spoken to a lot of anemic patients in the waiting room who all have had to do this. I fortunately have a less severe form of spherocytosis.” The class laughed as she struggled to pronounce “spherocytosis”! She ended by saying how it is important for doctors to be cheerful and energetic. She jumped out of her seat, long red hair waving, and hugged our young hematologist. “We are best friends, redheads stick together!”

I shadowed my physician for the afternoon seeing six patients: two cases of Chronic Obstructive Pulmonary Disease (COPD, typically from smoking), a pneumonia case, a two-week follow-up after a car accident, a knee injury, and a fainting teenager. The pneumonia patient was a female in her late 60s with severe dementia and under the care of the state. A caretaker brought her in with a complaint of wheezing. She could no longer speak, but could make grunting sounds. While she tried to grab the physician’s genitals, we listened to her lungs and noted pulmonary edema in her right upper lung. We prescribed antibiotics.

The physician and I read the car accident patient’s chart. He said, “I do not know how this patient is alive.” Crashing his Ford Fusion into a stopped car at 50 miles per hour did not result in a single broken bone. He had a neck brace and terrible lacerations over his face, chest and arm, a rare success story for airbag technology given that this 65-year-old gentleman had not been wearing a seatbelt. The chart showed a history of drug and alcohol abuse, but no evidence that either was involved in the accident.

The next patient was a mid-60s grandfather who hurt his knee while playing basketball with his grandson. “Little Johnny has gotten really good. I was defending with one leg planted, and twisted. I heard a snap. I cannot put any weight on it.” I performed a knee exam and noted anterior displacement of the tibia (lower leg) with the femur (upper leg) under stress. X-rays showed no bones broken. Diagnosis: torn ACL, which unfortunately cannot heal once separated. We referred him to orthopedics for an MRI and refrained from making any Vito Corleone references.

A mature and articulate 13-year old teenager presented with recurrent episodes of fainting and dizziness. She has had these episodes for over a year, but got much worse last week and had to be taken home from school twice. I walked in first and conducted an interview and brief cardiopulmonary physical. I did not note any abnormal heart sounds upon auscultation. The mother explained her theory that the fainting was caused by beginning menstruation. During the family history, we learned that four of the mother’s eleven uncles/aunts had a heart defect requiring open-heart surgery. The doctor joined me. He did not hear any abnormal heart sounds but was clearly concerned by the family history. He ordered several tests and sent the child home with a visibly upset mother. I’m impatient for a diagnosis but will have to follow up via email.

“Geriatricians are a dying breed,” said our lecturer the next day. “No young doctors want to treat old people.” Our class supports his theory; nobody has expressed a desire to become a geriatrician. The most challenging part of interviewing the elderly for him is breaking through their fear of losing independence. Many elderly individuals will not admit if they are struggling to perform certain instrumental activities, such as driving, cooking, taking medications and even walking. Our mid-40s geriatrician stressed, “This information is the most important. Frequently, I am able to prolong their independence but I cannot help them if they do not tell me.” For example, simply using a walker could prevent an all-too-common fall resulting in a hip fracture: “A third of all patients with hip fractures die within one year.”

The class segued into a discussion. Classmates opened up with memories of the last days of their grandparents. One classmate’s grandparents committed joint suicide shortly after being admitted to a nursing home. The geriatrician offered, “I will tell you one thing: You never want to see another horrible death once you see one. I was in the army and saw a parachuter fall. That same feeling comes over me when I see patients suffer through decisions whose consequences they do not fully understand.” He concluded, “Whatever speciality you go into, you need to define what the patient wants. Physicians too often conclude clinical decisions based upon their beliefs. Some of my patients may want to live to see their grandchildren graduate school. Some just want to be able to keep walking for another year. These desires change how I care for my patient.”

Several of Jane’s college girlfriends descended into town for her birthday weekend, arriving around 9:00 pm. At dinner we somehow got on the topic of unions. Jane’s friend was passionate on the subject of the evils of right-to-work legislation and the need to force every worker to pay union dues. It turned out that she was an intern at the American Federation of Teachers (AFT). I’ll probably share her passion for unionization once I work my first 100-hour week as a resident. Jane interjected, “Shut up… today is all about me!”

Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Movie night with Harry Potter fans to see Fantastic Beasts and Where to Find Them; Jane dragged me along.

The Whole Book: http://tinyurl.com/MedicalSchool2020

Window into how people think about pensions

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“The End of the World? In Brazil, It’s Already Here” (nytimes) is interesting for revealing how people think about pensions:

In addition to the spending cap, Mr. Temer has introduced a proposal to revamp Brazil’s pension system. His proposal will set a minimum retirement age of 65, in a country where the average person retires at 54. The law will also require at least 25 years of contributions to the social security system by both men and women.

There are good reasons Brazil hasn’t passed laws like this before. Although the average life expectancy in Brazil is 74, we’re one of the most unequal countries in the world. For example, in 37 percent of the neighborhoods of the city of São Paulo, people have a life expectancy of less than 65 years. It’s even shorter for the rural poor.

It doesn’t sound so bad, right? People retire at 54 and then drop dead around 65, so they are getting paid for 11 years, on average. Could the writer and editors have found a source for why this might not work? How about the New York Times itself! About a year ago they ran “An Exploding Pension Crisis Feeds Brazil’s Political Turmoil”:

When Rosângela Araújo turned 44, she decided that she had worked long enough.

So Ms. Araújo, a public school supervisor, did what millions of others in their 40s and 50s have done in this country: She retired, with a full pension.

“I had to take advantage of the benefit that was available to me,” said Ms. Araújo, now 65. Her government pension stands at about $1,000 a month, five times the minimum wage.

Brazilians retire at an average age of 54, and some public servants, military officials and politicians manage to collect multiple pensions totaling well over $100,000 year. Then, once they die, loopholes enable their spouses or daughters to go on collecting the pensions for the rest of their lives, too.

The phenomenon is so common in Brazil’s vast public bureaucracy that some scholars call it the “Viagra effect” — retired civil servants, many in their 60s or 70s, wed to much younger women who are entitled to the full pensions for decades after their spouses are gone.

… economists warn that the pension crisis will grow more acute regardless of whether Ms. Rousseff stays in office, ranking it among Brazil’s most vexing structural binds. Officials had expected a major shortfall in 2030, but they now say that could happen as soon as next year.

Both articles cite life expectancy at birth. Neither article mentions that life expectancy at age 54 in Brazil is about 26 additional years (source).

Related:

Map showing how to get rich off global warming

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MIT’s alumni magazine, Technology Review, has published a helpful map for where to invest if you think that global warming will be more faster and more dramatic than others expect. Set it up for 2050, for example, and Canada gets a 35 percent GDP boost compared to the “no warming” case. Russia is up 47 percent. A U.S. investment strategy doesn’t need to change; our GDP will supposedly be reduced by 5 percent in 2050 compared to if a magic wand were waved and the climate stayed the same.

[Lending support to those who are skeptical of statements by scientists, the prediction for 2099 is that Russia will be up by 419 percent compared to the “stable climate” scenario. Canada is up by 247 percent.]

Readers: What’s your best long-term climate change investment idea?

Article on rising housing costs that does not mention population growth

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“The Year in Housing: The Middle Class Can’t Afford to Live in Cities Anymore” (WIRED) is interesting to me because it demonstrates an apparent blind spot for Americans. Here was my comment on the piece:

The word “population” doesn’t appear in the article. Why isn’t this what we expect as the U.S. population has grown from about 150 million post-World War II to 320 million today? Also, demographers predict immigration-driven growth to about 441 million by 2065 (see Pew Research). Wouldn’t the real estate market also reflect expected future demand based on this growth? (Note that I’m not arguing for or against population growth, merely pointing out that if we have it we will also have a rising cost for housing.)

What do readers think? We do have a lot of land in the U.S. so in theory we could build some more vibrant cities. On the other hand, we don’t seem to excel at building efficiently, so that leaves us with the same cities that we had 100 years ago (plus a lot of exurban sprawl).

The rich bastards leading us around by the nose

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“Betsy DeVos, Trump’s Education Pick, Wields Wealth Like a Koch” (nytimes) talks about a rich family that is controlling American voters’ minds with their wealth:

In the 2016 cycle alone, according to the Michigan Campaign Finance Network, the family spent roughly $14 million on political contributions to state and national candidates, parties, PACs and super PACs.

According to the Times, some of the $14 million goes to “education activism, which favors alternatives to traditional public schools”.

Perhaps as much as $5 million then goes to advocating for changes to education policy. Can we put that number in context?

The Department of Education says that, in 2012-13, American taxpayers spent $620 billion on public schools. This analysis suggests roughly 850 hours of actual instruction per year for California schools, which are presumably representative.  Schools are thus spending 0.73 billion tax dollars per hour or $202,614 per second.

The rich bastards are purportedly significantly influencing the national debate about public schools with 25 seconds of spending.

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