Transplant surgery: quote of the day

From a recent study:

 

"We find that an organ allocation policy giving priority on waiting lists to those who previously registered as donors has a significant positive impact on registration."

 

This seems like a no-brainer to me.   

 

Link to the study:

http://papers.nber.org/papers/w17324

Americans are pre-revolutionary

“Americans’ lack of confidence in their leadership is so fervent that they are now ‘pre-revolutionary,’ according to pollster Pat Caddell… A new Rasmussen poll shows that just 17 per cent of Americans believe that the U.S. government has the consent of the governed, an all time low. This dovetails with a record low for Congress’ approval rating, which stands at a paltry 6 per cent, while 46 per cent of Americans think most members of Congress are corrupt, with just 29% believing otherwise.”

The author goes on to talk about the possibility of black swan events which could disrupt the American republic in unforeseen ways. Rick Perry talked about succession previously. Who knows, maybe he is right. Dividing The Union in two might allow some of the inter-party hatred to be swept away enough so that things could be accomplished.

We have a winner!

This is an awesome article:

 

http://www.economist.com/node/18989175

 

This needs to happen in the USA!  More efficient nation, lower taxes, less oil money for terrorists.

Obama and the Debt Ceiling

I do have to say that I am fairly taken aback by the remarkable lack of strategic planning that went into Obama's approach to the debt ceiling battle.  As I said before, he was in a position from which he could have easily won a confontation with Republicans and probably humiliated them in the process.  Their bargaining position was very weak, and their hubris *should* have left them quite exposed.

 

The idea that Obama wouldn't have wanted to win a battle is crazy, too.  I can appreciate value of a strategic retreat, which is what I figured the capitulation over the Bush-era tax cuts was.  At some point though if Obama wants to advance any of his political goals at all, he will need to stop and reverse the GOP momentum.  This was his opportunity, and he totally blew it.

 

Such an obvious demonstration of incompetence, apathy, or perhaps both explains quite a lot.

Too good to not post: costly gas = thinner people

We can save ourselves money, reduce funding for terrorists, help the environment, reduce the debt, AND make Americans healthier.

http://web.hbr.org/email/archive/dailystat.php?date=080111

Naturally, this has no chance of passing through the US Congress.

Are we winning the war on drugs?

Check out this Washington Post article:

"In Sonora state, Mexico’s military said Saturday that troops seized five metric tons of marijuana near the U.S. border in Puerto Penasco, a beach city popular with visitors from Arizona."

When the drug cartels are moving their shipments aliquots of 5 metric tons, its a good sign that they aren't really having trouble bypassing our border and/or law enforcement counter measures.

What a waste of effort.

Time to see if I was right

Over 3 months ago, I posted my predictions for the debt ceiling battle over the horizon. Well, judgment day is here. A recap of two essential points:

1. Republican intransigence was, and continues to be, unwarranted. The Republicans were always holding a weak hand, although it actually shocks me that apparently none of them figured this out. When they approached this debt ceiling issue as a battle, they set themselves up for defeat. At this very moment, the pressure is relentlessly building. The House is being inundated with angry phone calls from constituents. The IMF and credit agencies are warning of a downgrade and economic calamity. Obama is taking to the bully pulpit nightly to (rightly) berate the GOP for being uncompromising. And at the end of the day, the Tea Party isn't playing chicken with Obama. Rather, Boehner and powerful GOP backers are playing chicken with the 41 most liberal members of the senate, led by recently re-elected Harry Reid.

2. This in particular turned out to be true:

I absolutely believe that if Republicans put partisan battles aside, Democrats would join them and real progress on spending could be made. There are tons of low-hanging fruits that could be plucked to get real reductions in government spending.

Obama was offering Republicans a bill that cut the debt by FOUR TRILLION DOLLARS. It was something like 85% spending cuts, including cuts to entitlements. 85% is a very historically fair figure when looking at austerity situations. Democrats were furious at Obama for making such an offer, but luckily the GOP bailed them out by refusing Obama's deal. The Economist, a right-of-center newspaper, had a few good editorials about what a great deal the GOP passed up.

At this moment there is what, a week left before D-Day? I think the Democrats have the advantage at this moment. The Republicans WILL jump, but it remains to be seen whether the Democrats get scared and jump first.

Fact of the day: lung cancer

Something like 80% of lung cancers can be linked to smoking. However, only 15% of heavy smokers will develop lung cancer. 86% of those people will be dead within 5 years of diagnosis. I actually am shocked at how low that number is, though. That most people, fully 85% of them, could smoke a pack per day for decades and not get cancer is remarkable. It is a testament to how resilient the human body is.

So should you play the odds and smoke? There are only two games that I enjoy at the casino: Texas Holdem Poker and craps. If you're a smoker, your odds of getting cancer are the same as your opponent catching his open-ended straight draw on the river...or the same as tossing 7 and crapping out. Those things sure seem like they happen more than they do, and that's only when there is a little money on the line.

Why I love oncology

This applies to medicine as a whole, but in particular to oncology.  A lot of people "question my sanity" when I tell them that I want to be in a field like oncology.  "Wouldn't it be depressing to be treating cancer patients all of the time, especially when ones that you become close with ultimately have unsuccessful treatments?"

It is all about how one looks at things.  For starters, maybe cancer as a disease is a depressing thing but oncology as a specialty is amazing.  Before 1950 or so, all cancers had the same prognosis:  zero, give or take a few hundredths of a percent.  Now, we save people all of the time.  Colon cancer can be resected and cured with surgery and chemo.  Testicular cancer has a 95% survival rate when only a few decades ago it was 5%.  Many pediatric leukemias we can treat with some efficacy.  For cancers we can't cure, we can certainly make the remaining life better.  In oncology, is it isn't about who you lose - its about who you don't.  Those are the cases where, after, you can look Mother Nature in the eyes and say "we beat you."

The other thing about oncology, although this applies to other fields as well (for example, transplant surgery, which I am on right now), is the effect it has on me as a person.  Its so easy to go home at night and be tired and think, "I want to do nothing", or "I am too tired to go on a run."  Then you remember the stage IV cancer patient who is bed-ridden and beyond cure, without long to live.  Or you might remember the young guy who is stuck in the ICU.  He already had a liver transplant once to save his life, but his immune system has systematically destroyed it despite our best efforts.  Each day we see the new numbers, each day more abnormal, as the liver functions less and less. 

Remember those things and all of the sudden, you have the energy to go for a run or to go out and socialize - because you can.  Because you are so aware that someday, you won't be able to.  Think forward - many of us will be in that very position some day.  What would we give for the chance to come back and be 28 and be healthy enough to do those things?  If that time comes for me, I will smile when it does, because I will know I did.  With the right perspective, oncology is an incredibly uplifting discipline.

Reason as a weapon

A recent NYT article about reason summarized viewers responses as thus:

"Reason Seen More as Weapon than Path to Truth".

The NYT went on to describe the title: "a description, that implied that reason is not, as we generally think,  directed to attaining truth, but rather to winning arguments."

I recently heard a quote by some physician which has become one of my all-time favorites. Roughly, it is:  "Humans are forced to choose between truth and certainty. We can have one, or the other, but we cannot have both." 

A person who would prefer certainty over truth would definitely perceive reason to be a weapon. If such a person were interested in 'truth' in the first place, then 'certainty' would not have been their priority all along. To be interested in truth is to be interested in reason. To be interested in certainty is to be indifferent at best, or hostile at worst, to reason.

This is why so many religious people are hostile to science these days (actually the cause is more a product of manipulative religious leaders creating a false enemy to inflate their own sense of importance, but I digress). When people are told that the theory of evolution undermines their religious beliefs (it shouldn't), they are instinctively hostile to the logic and reason of the theory.  To let any of it in would be to suspend their certainty about how the world was created. 

Another interesting thing about this quote (that we can have truth or certainty but not both) is that it is reflected in the physical world by the Heisenberg Uncertainty Principle.  The principle states that we may know the position of a subatomic particle, or we may know the momentum of the particle, but we can never know both.


As for me, I always choose truth over certainty.  I am 100% certain of that.  Or am I?

On Surgery, etc.: The Part-Time Doctor

I thought this was a good read: a surgeon explains what he thinks makes a good doc. 

On Surgery, etc.: The Part-Time Doctor

Cancer in transplant patients

I meant to include this in the previous post but forgot.

Another interesting thing is that being on immune suppression drugs after having an organ transplant drastically raises the chances of developing some (but not all) cancers.  In particular, we see the sort of cancers that are a product of chronic viral infection and genomic irritation.  Squamous cell carcinomas of the skin are a big one.  Women can get these in their cervix from HPV; immune suppression makes everyone all the more vulnerable to HPV.  Other viruses, like Epstein-Barr that healthy people will clear without a problem, will fester in the body and provoke the development of lymphomas and the like.

The fact that some cancers appear in light of a weakened immune system but not others is a useful demonstration of the fact that we really don't know what causes cancer in every case.  Sometimes it seems environmental; enough radiation and anyone will get cancer; smoking cigarettes can cause lung cancer too.  Cancer can be caused by infection:  transplant patients get lymphomas and squamous cell carcinoma; AIDs patients get characteristic neoplasia (cancer) as well.  Genetic deficiency of appropriate anti-cancer genes (BRCA mutation, hereditary adenopolyposis coli, other familial cancers) can be a cause.  Maybe bad luck has something to do with it too.

The yin and yang of immunology

One of the tricky things about cancers is that they have figured out how to evade the police force of the body, the immune system.  The immune system should destroy cancer cells, and yet obviously it doesn't always.  How exactly cancer cells figure out how to evade the immune system is something that is being extensively studied.  The goal of cancer immunotherapy is to re-train the body's immune system to target and destroy cancer.  The best model for this is melanoma, a lethal form of skin cancer.  Right now, the best option to treat metastatic melanoma in humans is essentially to infuse patients with IL-2 (the immune equivalent of cocaine-laced red bull) and hope for the best.  With IL-2, the body's immune system changes from a local sheriff and his deputies to a full-fledged SWAT team.  The immune-swat team still isn't sure what it is hunting for, but it ends up killing a lot, including the cancer if the patient is fortunate.  (Giving the swat team specific cancerous targets is the ultimate goal.)

Transplantation immunology is precisely the opposite.  Instead of encouraging the immune system to attack the tissue in question, we are doing everything in our power to hold the immune system back.  This can be accomplished by drugs which prevent lymphocytes (immune cells) from replicating, block signaling and stimulation, or just kill the lymphocytes outright.  Obviously, if the police force is eliminated then a lot of criminals will end up running around; transplant patients are chronically dealing with infections (especially viruses like CMV, HSV, and EBV).  Despite these immune-destroying efforts, chronic rejection of transplanted organs by poorly understood mechanisms seems almost inevitable.  In humanity's defense, huge strides have been made in dealing with acute transplant rejections, which occur through better understood mechanisms.

It is really interesting if one thinks about it:  cancer cells have figured out how to avoid immune destruction, and so the answer to better transplantation immunology is potentially right in front of us and we just can't see it.  Another interesting scenario is this:  if we took a kidney from a child and transplanted it into the child's mother, the mother would reject the kidney unless appropriate immunosuppressive drugs were given (as in any other case).  How then did that child manage to survive in the mother's womb in the first place?  Why did the mother's immune system not immediately attack the fetus and destroy it?

The answer is lots of theory backed by some evidence, much of it conflicting.  This is the same state of affairs as most other things in medicine.  Humility makes a whole lot of sense. 

A way to cut everyone on the liver waiting list

Kidney transplantation, as it compares to liver transplantation, strikes me as a much lower stress affair. For starters, there are more kidneys than there are livers available for transplant (although this is somewhat negated by the fact that more people need kidneys than livers). More importantly, we can keep people alive who have no kidney function via dialysis. This affords time to search for an organ that is a really good match for the recipient. A good match minimizes immune differences (we focus on major antigens like ABO and HLA) and results in a longer lifespan of the graft (transplanted organ).

People with serious liver failure really cannot be kept alive without a transplant. The kidneys and the liver both perform a similar function: filtering toxins from the blood (among other things). Kidneys filter out substances that are ionic or polar; the liver deals with things that are not polar, or fat-soluble. Its been fairly easy for humans to develop a device that can separate ionic substances (dialysis machines) but not so easy to develop an artificial liver.

Anyhow, we can figure out in advance who will need a liver transplant and start looking for an organ for them before time runs out. The way this is accomplished is through a system (MELD) which accounts for a bunch of different factors, including some labs that assess liver and kidney function, as well as time spent waiting. The system works so that people who are closest to the end of their liver function get pushed up on the list.

One of the things that can happen with any organ transplant is a hyper-acute rejection. When this happens, the body's immune system launches an immediate attack on the new organ and the vessels end up getting clotted off and blocked. The only solution to this disaster is to remove and discard the transplanted organ. If this happens to a patient who is receiving a kidney transplant, that is bad, but at least the patient can leave and go back on dialysis. What happens if it happens to a liver transplant patient? There is no substitute.

Turns out, what happens is the patient gets moved to #1 on the national registry for livers. A new liver will be procured from somewhere in the country and delivered to the hospital within a matter of hours.

Guess who else thinks Netanyahu is wrong?

The former head of the Mossad.

http://m.smh.com.au/world/former-mossad-head-advocates-saudi-peace-plan-20110602-1fivf.html?from=smh_sb

The Republican Yacht

I'm honestly completely baffled by the GOP's approach to trying to reform Medicare via the debt ceiling vote.  Their strategy has zero chance of working.  Even if the GOP could get it through both houses of congress, which they can't, Obama is not going to sign a bill which repeals the ACA or Medicare just like that.

So the GOP is trying this crazy strategy, which can't work, and they are going to get politically wrecked for it anyway for even trying it.  The only way this makes sense to me is if this isn't a strategy at all.  The Republican Party is like a rudderless yacht with a hundred captains all insisting it remain at full throttle despite lack of steering. 

As a continuation of a recent post about the intent of the founders, I really question whether we live in a republic anymore.  In a republic, the representatives are supposed to be principled but also pragmatic, willing to compromise to get most of what they want even if they lose some, and above all work to secure the future of the nation as a whole.  Our representatives don't do that.  They cater to every fickle inclination of their constituents and refuse to compromise on anything at all.  It really is a form of direct democracy.

The intent of the founders: representing the people while avoiding gridlock

I've always been a moderate person who believes, contrary to Herman Cain, that the problem with America isn't too much compromise, but rather a lack of compromise. My vision of a smoothly functioning American government is when civil and well-informed representatives of the people converge on Washington, hash out their differences, and produce well intentioned legislation based on the best possible compromises. The goal is to give everyone some of what they want, nobody all of what they want, and always to move America forward.

Some people have intimated, from time to time, that it is fundamentally anti-democratic that I might wish that the representatives decide among themselves what the important issues would be and deal with them accordingly. And I fully admit that I believe that representatives should prioritize their constituents' interests, and even ignore some of them. Some would claim this position reeks of elitism, and that the truly democratic model is to elect representatives who follow their constituents' short-term inclinations to the letter.

If my view is wrong, why did the founders make America a republic? If the founders wanted direct democracy, they would have written into our constitution a form of direct democracy: but they didn't. I believe the founders understood that most Americans have better things to do than worry about politics, or alternatively, don't have the information access or facilities to really grasp the complexities anyway. Elitist? Sure, I'll cede that. But the founders counted on the people electing competent representatives who would follow the spirit of their constituents as best they could within the context of the federal government of a very large and diverse nation.

I've been trying to figure out what exactly is wrong with our political system, and it seems to me that we really almost have moved to a form of direct democracy. Especially with the advent of rapid communications, information technology, massive advertising budgets, messages matter. A hundred years ago, a well meaning representative could sacrifice some of his constituents' priorities in order to gain a compromise that was essential for the nation or one that advanced his voters' interests in other ways.

These days, its different. When a representative insults that small fraction of his support, he gets crucified for it. This is particularly true among the GOP today, which is more a consequence of them being the out-of-power party than anything else. Any one Republican who has bucked any one interest has paid a price. Mitch Daniels saw what most credible economists see: we cant balance the budget without some revenue increases. So why not a VAT? And yet, in today's GOP, proposing a tax of any sort is sacrilegious. Dick Lugar recognized a good START treaty with Russia and supported it along with all of the top military brass, and he was rewarded with a primary. I don't see any way that John Boehner makes it out of the 2012 election with a job. He will vote to increase the debt ceiling, and he will get primaried because of it.

In essence, the rapidity of the response to politics has moved us into an era of what is essentially direct democracy. And unfortunately, the American people don't always know exactly what they want. We want the government to keep its miserable hands off of our Medicare. We want to cut spending, but not cut medicare, social security, or defense. We think that cutting foreign aid to Pakistan will balance our budget. Direct democracy was most obvious in California, where the people consistently vote themselves more services but then refuse to increase taxes to pay for them. The founders knew that there needed to be a competent crew manning the rigging of the ship that we call America. Just let the passengers run things and there is chaos.

Many try to argue that this sad state of affairs is the fault of a misleading media or lying politicians, but I don't buy that. Politicians have always lied, and the media has always been biased. The single biggest thing that has changed is that politicians are now held in an environment where they are unable to make any sacrifices in the name of compromise whatsoever. It is this inability which has led to the intractable gridlock that we now see, and probably will continue to see, for some time. Until American politicians again act as the founders intended them to act, as representatives of a great republic rather than as mere puppets of fickle and conflicted constituents, this ship will continue to drift aimlessly at sea.

America as the no-vacation nation

Most Americans have no idea how much more vacation that people in other Western economies get each year. Which is fine, because there are lots of trade-offs here. Germans for example get six weeks of paid vacation every year, but the German economy is crumbling even as we speak.

Guess who else thinks Netanyahu is being ridiculous?

Former Israeli Prime Minister and current defense minister Ehud Barak. From Haaretz.

The Failure of Netanyahu

A good analysis from TPM:
----------------------------------
For years the top generals in the IDF have agreed that Israel can handle withdrawing to the 1967 borders in military terms. But PM Netanyahu says that's impossible because those borders are not defensible. It's an amazing level of denial, intransigence and self-destructiveness on display today -- something the pre-statehood and early statehood Zionist leadership was seldom so vulnerable to.

I agree with Gadi Taub who said recently that while peace is the ideal the highest priority for both peoples right now is partition. Netanyahu's position makes that impossible. The 1967 lines are the only practical and politically conceivable basis for such a division -- with mutually agreed upon swaps of territory along those lines. Netanyahu's plan is simply to withdraw from areas of dense population within the West Bank. In fact, I think that overstates the case. I don't think Netanyahu has a plan beyond holding his coalition together and himself in the prime ministership. The rejectionists' 'plan' is simply to hold on for as long as possible and play for time.

The man is a fool at so many levels. But there's no denying that he speaks for a very large chunk of the Israeli electorate.
---------------------------------
Bibi called the 1967 borders indefensible. Of course, Israel successfully defended those borders in 1967, and again in 1973. Meanwhile Israel has seen a foe become a friend (Jordan), its arch-foe become a non-factor (Egypt), another arch foe (Saddam's Iraq) irrevocably weakened, and an Arab world in general more concerned about a threat from Iran than from Israel. In other words, Israel's geopolitical position is far stronger now than it was forty years ago, when it was able to decisively defend the 1967 borders on two separate occasions.

When one stops to think about the threats Israel faces, it becomes even more ridiculous. There is no conventional threat to Israel. Iran has rockets, not a ground army with thousands of tanks like Egypt had in the 60's. The greatest threat to Israel is terrorism from WMDs or delegitimization. Occupying the West Bank makes Israel more vulnerable to those dangers, not less.

I used to hold Binyamin Netanyahu in such high regard, but he has proved himself to be incredibly short sighted. I wrote another post about his missed opportunities just a few months ago. Very disappointing.