Saturday, May 21, 2016


Imagine accidentally falling off of an abyss. One simply cannot fully understand the gravity of the situation! You might skip a beat thinking about it while sitting on a chair in your living room, if you have tons of empathy, as you try to get into the shoes that are flailing for survival.

But there he was ashen as if impaled by a spear through his heart. He sat motionless, ossified as his thoughts tumbled end over end. I could see the fine tremors on his fingers. His eyes bloodshot from the riot in his brain, the cacophony of cries, the chaotic mixture of black and white, of right and wrong, of good and bad, of fear and strength, of a past and a finite future, of children, of this and that and of time. I sat on a chair by his bedside and on the other side was his wife of a few years putting a brave face on. Her eyes too were bloodshot holding back the deluge that would be spent in the bathroom alone. Her face red from a mix of emotions; anger, frustration, denial and absolute fury at fate that would befall upon them soon. Her one love, stranded alone against all odds of his overall good health, slipping away. Her knuckles paled as she fought her emotions against reality. She held firm, mouth pursed in defiance and her body arched and angry.

“So doc, how long do I have to live?” he asked. His voice a whisper between dried words that took an effort to escape his lips with the limited force of the breath that wished not to be heard.

What do I say to him?

How do I answer that question?

Do I cite the statistics and tell him the median survival rate? Or do I simply tell him that 50% of the people with his diagnosis live less than x-months and the other 50% live longer than that? Or do I tell him the average survival rate, which was slightly lower than the median in his case? What would that do to him? And as much, what about his wife? How would she interpret her future? What about the unborn child that gave her the tiny bump in her belly? How would she interpret that answer? Do I simply state the statistics? But then he might be one of those outliers that we all live to tell about in medical conferences. He might have a certain unknown mutant gene in him that could be exploited by one or the other drugs available that could lend him more time. Do I play the nice card and say something so banal as “As long as you want to live?” Trite as it sounds, it has some truth to it too. But then the respect between us three, might be lost. Wouldn't it?

I did not realize that my hands were clenched tightly too cutting off the circulation in the capillaries turning my knuckles a shade whiter. I shifted in the chair, uncomfortable with the demands placed on me, measuring the impact of my words, his life and the gravity of the situation oozing through ever corner of that four walled room. Time seemed to stand still. The seconds creeped and still my thoughts were end over end; a state of turmoil. The ghosts in both our human machines seem to have lot to say.

“What I am about to tell you has to be understood carefully by both of you. I don't offer false hopes. I cannot offer the permanency of a cure, but what I am suggesting are the facts as they exist today. These facts might change over the course of your illness and propel us to a better future tomorrow, but today, I can offer you only these facts.”

He relaxed as I drew some graphs of survival data. I showed him the slightly fat tail in the graph where the outliers lived. I explained to both that therapy in its current form could offer him some relief but the limits were imposed upon the data by arbitrary numbers based on 95% Confidence Intervals and assumptions (as all statistical probabilities are). As our conversation proceeded, he relaxed, his eyes shed some isolated tears, the color on his face returned. I do not know how the subject of Stephen Jay Gould came up but I found myself quoting him, “All evolutionary biologists know that variation itself is nature’s only irreducible essence…I had to place myself amidst the variation.” The evolutionary biologist, I told him was given six months to live and after research he realized that the outliers could live well past 10 years with the disease that he had. He did! There was hope for time. More color filtered back into his face and as confidence built, a partial smile broke out, I said, “Do some of of your own research and run that by me. I will help you along.” 

The next day, I walked by his room and found that he had been discharged from the hospital. I cared for him after that hospital day for a fairly long time. He defied the odds against him. He fought the battle and won his outlier status. He saw the birth of his child and a few birthdays to boot. He created a company that employed ten employees and was lucrative in the first few months. Ah life the eternal source of human innovation was in full bloom. He lived life well or that finite time he was allotted.

Hope fights despair. It encourages choices, it readies us for the necessary toil. Hope is the first step on an uphill climb. How can we in good conscience empty that priceless ether of goodwill from a living being. What a person can do with a finite amount of time can change the world.

So how does one answer the question, “How long do I have?” It depends on the individual asking the question and the physician answering it. There must never be barriers between the two. Eye to eye contact and a controlled tincture of empathy. There should never be the burden on either during the conversation. No impediments to confiscate that precious time between a patient and his/her physician in discussions of such weighty matter. None!

Monday, May 16, 2016


Consider this logic; “I think therefore I am.” Rene Descartes was the father of those words and yet everything we do seems to come from those words. Our thoughts become actions and then those become habits and they eventually develop our character.

So let us look at it in matters of aviation safety. Two pilots from the same household develop differing characteristics of behavior. One is judicious in thought and action, careful in planning and argues within himself all observable points of view with an eye towards flexibility due to changing environments, thus creating various scenarios and plans of action. The other pilot is laissez faire. He gets up, looks out the window at the sun peaking though the clouds ands heads to the airport. He is our “kick the tire and light the fire, barnstormer.”

The logic of decision making is based on information primarily. Asymmetry of information is the main reason for our first pilot to have deliberation over multiple plans of action. He deals with the Boolean logic of “If this then that.” The barnstormer cares a wit about information per se. He believes he is the epitome of an aviator and the sky is his oyster. So to each, thought is his own way.

Both the pilots are borne of the discovery and justification process. The discovery of biases and the justification to do things. The careful pilot has turned information into knowledge and understanding, while the barnstormer is, shall we say more about his own fully developed sense of “greatness,” then any sense of reality. 

While the former takes in all the available bits of data and compiles them into a cohesive sense of the environment, both past and future, the latter has built within himself the fire-walls of confidence rich in confirmatory bias. 

Ah I am glad you asked about confirmatory bias. Basically if you do something repetitively and it works, you consider that as a successful and repeatable enterprise. Not withstanding Taleb’s “Black Swan” effect the barnstormer can go on for a finite period of time with that bias lingering within him, until one day the ailerons fly off the hinges. An example would be a pilot who scud runs. As he continues to press on while the cloud ceiling lowers the boom and confirmatory bias continues to ride the wave, until one day the pilot mangles himself on a cell tower or becomes a statistic of a CFIT (obscured mountain). That happens quite a few times a year unfortunately. Justification of actions are a human mechanism steeped in hubris and confirmed through the passage of time by similar acts of carelessness. Its like the teenager who after watching a video of an expert skateboarding champion decides he can go down the rails on flat concrete surface, only to break some young bones in the process, trying to up the ante down a steep staircase.

On the other hand the careful pilot looks at the weather briefing diligently, has acquired the instrument rating, is always instrument proficient and even then takes into consideration the weaknesses of his own skills with “what if scenarios.”

How do we make decisions?

Carefully with as many pieces of information as are available!

Daniel Kahnemann a Nobel laureate has grafted the idea that we have two internal systems in our brain that are employed in the decision making process. System 1 is a knee-jerk type, quick on the pedal to the metal with little reverence to the conditions of the equipment or the surroundings. System 2 is a more careful, slow, methodical and judiciously employed consideration of all available pieces of information that go on to making a decision.

While System 1 is more of the emergent nature that triggers the frontal lobe of the brain into quick-firing of electrical stimuli, System 2 is the careful process that takes into account from the temporal, visual, auditory and parietal lobes of the brain before committing the fire from the frontal lobe. So in essence with deliberate care.

Which is correct?

If you have to ask that question as a pilot then, I suggest, you take some classes to govern your impulsive, hazardous attitude.

The old story about that, “there are no old, bold pilots!” is a truism. There are only the methodical careful ones that define the risks, mitigate as many known hazards as possible and only then undertake an action.

Conquering space did not happen because someone decided to tie a rocket on their back and lit the fuse. It happened because of hundreds of scientists, mathematicians, astronomers, physicists and a few brave astronauts took on the arduous task of understanding space.

Pilots are not all pioneers in space. Most of us are just pilots. There are a few aviators amongst us, not mere technicians in flight but who understand each motion as they are strapped into the seats of an aircraft flying at many hundreds of miles per hour across space.

Understanding natural science and the design of science that is created to embark through that nature is as important as knowing when to apply the force on the rudder to prevent a slip and when to create a slip in flight.

Decisions are made on a daily basis in life. We decide to buy, to sell, to go to movies, to read a book, to cook a meal, to wash clothes. All these decisions have a precedent of understanding and need. Similarly flying has a precedent and need. The need however must be met with an equal tincture of understanding of the surrounding space and its vagaries.

All flights are possibilities and as they proceed in space and time, they become probabilities and then are added to the ledger of understanding based on the information gleaned from those flights. These flights then become the justification for future ones. It is equally easy to fall into the trap of hubris as it is into the comforts of a carefully crafted methodology. Therefore it is important to learn about good habits from others and discern about bad habits. Accident cases abound in the aviation literature, most (70%+) point against the pilot actions as the causality of aircraft accidents. One would even consider the number higher. But then I digress.

How not to fall into the System 1, knee-jerk, barnstorming trap?

Develop good habits
Employ careful and methodical Instructors to give instructions.
Create a log of all flights outside than those in the logbook, detailing each flight and errors.
Critique every flight and what was learnt from each.
Point out to other’s bad habits (you might save their lives one day).
Rash car drivers make bad pilots.
Egocentric machoism is dangerous to a pilot’s health.
Keep learning. Get all that aviation certification has to offer. Get the Instrument rating if you are a private pilot, a commercial ticket and all the way to the Airline Transport rating. Then consider sea pilot rating, Soaring, Upset training, etc.. All these fill your bag of tricks when one day, you might need them.
Always emulate good behavior.
Do not drink and fly (Consider more than 8 hours from bottle to throttle, because you as pilot might be a slow metabolizer of alcohol).
Consider the FAA’s IMSAFE (Illness, Medication, Stress, Alcohol, Fatigue and Eating) before each flight.

Tuesday, May 10, 2016


Ever heard of “Helicopter Money?” No? Ok the skinny on this is the TARP and then the QEs. TARP stands for Troubled Asset Relief Program and QE (I,II,III, IV) all denote Quantitative Easing or in other words Printing Money to devalue it. (Total TARP + QEs since 2009 = $4.5 Trillion (4 followed by 12 zeros). These monetary mechanisms are designed to bring Liquidity to an illiquid market. Liquidity is implied as a means for the banks to have the money to loan to people and companies to make the business cycle function. Oh but a tiny bit of wrinkle sets in when the QEs start flying…the banks use the free money (since the interest rates were/are down to ZERO or 0%) to shore up their own balance sheets so they can survive a “Run on the bank” in case the plebeians decide to withdraw their savings, which have been leveraged to gain big gains for the banks in risky derivative markets (enter Lehman Brothers with $600 Billion assets declaring bankruptcy in September 2008) The net result of all these machinations at the Federal Reserve to prevent “pain and suffering” to other financial institutions and to the gentry was to blow up the balloon to its popping point from it’s sub-sub popping point. You see, currently, given these ballooning opportunities, the more the experts in Davos delay the inevitable of paying the piper, the more they postpone from what could have been a sustainable downturn with pain into a collapse the likes never seen. No, not even the 1929 depression will match this one.

On equal footing is the top-down machination of the healthcare policy makers headed by some geniuses who have begun helicoptering mandates akin to the QEs. The QEs in Medicine are no different. They have used a single point of reference (Costs) as their ends and used their personal genius means (like Mr. Gruber) to come up with a complex series of unintelligible verbiage to confuse and obfuscate the basic reasoning beneath; reduce cost at whatever the cost (notwithstanding patient’s real care). The demographics are changing as aging population in the US continues to grow. Controlling costs via simple-mindedness fails to realize the issues of tomorrow.

How do these mandates and policies effect medicine. Well, they are no different than the monetary QEs. They bloat the policy ledger creating a widespread net of regulatory reasonings to entrap an individual - patient and physician. Acronyms abound; PCORI, SGR, APM, MACRA, PQRS, etc. that have little do with the health of any individual but more to do with the flawed reasonings of a few. Let me throw in for gratuitous reasons the good ol' 5-6 PhD Quants of the 1998 who nearly took down the world economy with their asymmetric exploitation shenanigans. These same Quant incarnations are working hard with their statistical models in medicine today. Just Saying!

The reasonings fit perfectly well from the middling manager’s point of view since they reward larger and larger benefits to the intermediation between the two parties involved in healthcare (patient and physician). If you have doubts consider that the average CEO of healthcare industry makes $11.7 million in annual salary. The average Insurance agency makes $1-2 Billion (with a B as in 1 followed by 9 zeros) annually in revenue and a handsome bonus to its managers and the patients get denial for services and the patient gets denial of services for cost reasons arbitrarily created and physicians gets an annual cut in their reimbursements.

Therein lies the network of cables that push and pull within the net to warp the landscape of healthcare similar, I might say to what is going on in the financial sector, the FED and its bank-comforting policies that ultimately lead to the detriment to the working class.

Meanwhile both in the financial and the healthcare sectors there is a constant barrage of media reports of the blame game. The finger points and moves on to the next target as the distractions keep the citizenry occupied. “Yes,” the media and the spokespersons claim, “the Regulatory bodies are doing a yeoman’s work to preserve and protect the innocent citizen.” All this as the ground beneath is shifting, poised for a tectonic upheavel.

Helicoptering money and ideas is an old game, “keep the gentry happy and the bourgeois distracted,” practiced by evil pseudo-scientists whose weightless thoughts are all about the self and their cronies. We know money works for a while and similarly ideas manufactured in the marbled silos handed down as mandates work for the same duration until the citizenry reaches a breaking point and then all hell breaks loose, when “Let them eat cake” does not suffice.

One finally asks the question, “How will it end?”

The answer is not a happy one.

“There’s a special providence in the fall of a sparrow. If it be now, 'tis not to come; if it be not to come, it will be now; if it be not now, yet it will come. The readiness is all.” - Shakespeare

Tuesday, May 3, 2016


Radon, the environmental carcinogen is ubiquitous. The EPA estimates levels of 4 PcI/L (4-Picocuries/liter) or more are hazardous to health. By hazardous to health they mean cancer inducing.

Uranium238 with a 4.1 billion years of half life and the only naturally occurring fissile isotope, decays to Thorium232 and that decays to Radium226 ultimately yielding Radon222. Radon emits alpha particles into the air. Humans breathing a high concentrations of these Radon particles into their lungs can develop Lung Cancer.

In 1898 from a Uranium ore, Marie Curie (Maria Sklodowska 1867-1934) discovered radioactivity after grinding, dissolving, filtering, precipitating, collecting, redissolving, crystallising and recrystallizing the uranium ore into tiny parts of Radium (she is the only woman to have received a Nobel Prize in Physics and Chemistry). Thus began the journey of radioactivity that cost her, her life to Aplastic Anemia and her daughter’s life to Leukemia while studying the properties of Uranium and its decay products. Both illnesses a consequence of the radioisotope exposure!
"Nothing in life is to be feared; it is only to be understood."  - Marie Curie

15,000 to 22,000 cases of Lung Cancer are estimated as consequence of Radon exposure from over 200,000 cases of Lung cancer a year in the United States. The Radon gas is emitted from the soil and is based on the Uranium/Thorium concentrates within the soil. The highest concentrations within homes appear in the unventilated basements located over Uranium/Thorium rich-soils. Radon emits high energy He2+ ions as Linear Energy Transfers or LET.
The alpha particle is helium nuclei, composed of two protons and two neutrons. Because the nuclei have no electrons, they have a +2 charge. Because of its mass, alpha radiation does not penetrate healthy skin. However, entry of alpha radiation via the mouth or nose, may cause cancers in lungs. These emissions breathed into the lungs disrupt the alveolar/bronchial cell DNA Mutations, Single and Double stranded Breakage due to disrupted phosphate bonds, Single Nucleotide Polymorphisms, Cell Cycle disruptions, Mismatch DNA Repair ( NER -Nucleotide Excision Repair, BER -Base Excision Repair, MMR -Mismatch Repair))mechanism function (cells have the ability to repair the damage done to DNA by radiation, chemicals, or physical trauma. The effectiveness of these cellular repair mechanisms depends on the kind of cell, the type and dose of radiation, the individual and other biological factors), over expressions of oncogenes or suppression of tumor suppressor genes and even successful apoptosis if the p53 gene is fully functional and not overwhelmed or any combination of above can start the nidus of the cancer within the lung. Since alpha particles are massive and highly charged, they are extremely damaging to living tissue. Alpha particle emissions from decay of radon progeny in the lungs cannot reach cells in any other organs, except breathed into the lungs. Even with a fully functional DNA Repair mechanism intact, a single genetic aberration passed down to the cellular progeny can play havoc and create the malignancy. Additionally the active Alpha Particles also inexact with whole cells and their mitochondria releasing Oxygen Reactive Species and creating oxidative stresses thru direct cell damage leading to molecular disturbances within the genome and thus propagation. Thus lungs are the main target of developing cancers.

Recent data from Scandinavia seems to suggest that there is a slightly higher incidence of “blood cancers” (Leukemia, Lymphoma and other Bone Marrow Disorders) in women. The authors did a meta-analysis and discovered a 60% increase of such cancers in women that showed a dose response curve to the Radon exposure. The Author of the study, Dr. Teras stated, “The overall lifetime risk of hematological cancers in the United States is about 2%, so even a 60% relative increase would still mean a relatively small absolute risk.” The data came from an analysis including 140,652 participants among whom there were 3,019 hematologic cancers during 19 years of follow-up. The entry of the alpha particles via the pulmonary vasculature and into the bone marrow may if proven in future studies turn out to be the proposed mechanism.

The logical question that follows is what if anything that can be done about risk mitigation strategies to limit Radon exposure:

1. Have surrounding soil samples checked for Uranium/Thorium levels.

2.Vacuum the dust over a period of 30-90 days in the home’s basement and using a Geiger counter determine the extent of the exposure. A crude but reasonable estimate can be made. Nowadays Test Kits are sold in various stores. The reliability is never completely guaranteed. 

3. Ventilate the basement and the first floors periodically with fresh air. For more information review the website provided below.

Can we eliminate all risks? Probably not. But mitigate a percentage of the risk? Probably so.


Darby S, Hill D, Deo H, et al. Residential radon and lung cancer: Scandinavian Journal of Work, Environment and Health 2006; 32(Suppl 1):1–83. Erratum in Scandinavian Journal of Work, Environment and Health 2007; 33(1):80.

Field RW. A review of residential radon case-control epidemiologic studies performed in the United States. Reviews on Environmental Health 2001; 16(3):151–167.

Harley NH, Robbins ES. Radon and leukemia in the Danish study: another source of dose. Health Physics 2009; 97(4):343–347.

Möhner M, Gellissen J, Marsh JW, Gregoratto D. Occupational and diagnostic exposure to ionizing radiation and leukemia risk among German uranium miners. Health Physics 2010; 99(3):314–321.

Lauren R. Teras et al, Residential radon exposure and risk of incident hematologic malignancies in the Cancer Prevention Study-II Nutrition Cohort, Environmental Research (2016)DOI: 10.1016/j.envres.2016.03.002

Saturday, April 30, 2016



See that word up there in the headline? It has the overbearing overhang like a bushy eye-browed, heavyset red-faced teacher hanging over the desk, peering down at you with menacing eyes. Foreboding to say the least. But there is some truth in it. It conjures up wild images of ideology, anger and destruction. Doesn't it? Our first thoughts move oceans away into dark corners of the world where grim faces beset with hatred fill clean slates with squiggles of confusion and ill-willed determination.

Now look at what happens in an idealized world of civility. The daily ritual of a mother and father speaking to a preteen, telling her about the vagaries of human nature, of where not to go for fear of danger, of when not to go for a similar foreboding. But more than the voice of reason the learning upon which such nurture thrives is the action of the adult. Thus life long Democrats and Republicans are nurtured growing into the temporary space of life and filling more tiny brains with similar ideology. The specter of anger slowly and imperceptibly grows and divisions among humanity take place. So indoctrination is a common thread in the flow of generational information; surreptitiously capricious. But as the doubters are constantly vilified and demonized the indoctrination evolves especially as "evidence" is created for a greater good.

Far be it for me to delve into such a deep topic, yet I have over the years found a perfect corollary in the field of medicine, which is similarly nuanced.

When I was a resident, our main aim was health followed by life must be our focus. No matter the disease, illness, malady we as young physicians were charged with understanding and curing the ills and rendering individual patients with such afflictions healthy. We were told not everyone will survive the ordeal but a concerted all-out effort must be made towards that aim. And we did; breaking the textbook spines, jotting information on note books and coalescing the information to guide the individual patient. Those were heady times. Those were freer times. Those were responsible times.

As time went on, the learned lessons continued but the environment changed, slowly at first and then gaining break-neck speed. The suggestions of what to do and when to do started popping in and out of the medical literature. And as surely as the slow pavlovian reflexes were being developed through a concerted effort in the ivory tower silos, the paradigm of care started to shift.

Everyone started pointing to the cost of healthcare and comparing it with the Western world. Spurious correlations later, almost everyone had agreed that indeed the cost was too high and something had to be done about it. Happy in their numerical discovery, they set out with statistical impertinence to prove their bias, not one of these voices however looked at the factors that were raising the cost of patient care. Not one.

Where does one look to control costs? The finger pointing started and of course the physicians were on the standby to take the blame and reap the maligning. The malignant zeitgeist spread tentacles into the seats of power and congressional beasts rose with booming voices filibustering their way into the mental landscape. And so it was set in stone, temporarily, that all manner of costs in healthcare were borne of the greed and complicity of the human physician. Armies of well-meaning intellectuals rose up in arms to defy such augury. They proclaimed that they for a hefty price of a few extra zeros at the end of 1 would change this abomination. They would bring in the new era of non-human and unbiased mechanisms into place and take away the arbitrariness and self-aware needs of the human and use the mountains of data contained in the Big Data networks as a repository base to change the paradigm. The digital universe of the promised cheap care took hold and many fortunes were made and many lives were destroyed in the process. Yet the constant pounding of the vices of the humans and the virtues of the machines slowly and perceptibly changed the human belief albeit with lingering skepticism. Man was indeed flawed and machines with their unbiased view were more in keeping with the future all ready at hand. The young medical students spent countless hours studying their vocation on computers, barely listening to the lectures given by aging teachers. They used algorithms to answer questions to pass the tests and arrived at the threshold of patient care with little experience. Their “work” was decidedly in favor of arriving at work at 9 O’clock and departing from their “shift” at 5 O’clock to spend their free time, freed of all burdens. While at work they became adept at typing furiously on the computer keyboards to fulfill their contractual obligations with their employer for reimbursements. The game was afoot and the loser in the grand bargain was none other than the vulnerable.

Meanwhile housed in a small cottage in the far rural corner of the middle western state an aging physician sat on the creaky chair holding the hand of a weakened soul, speaking softly about the malady that afflicted the patient and comforting her in how it could be addressed. These were the dying breed of human physicians, cast aside by the runaway train of progress. These few, happy few band of brothers, were determined to hold their ground till their last breath and promised to care for the people of their community that they had lived amongst. The small creaky cottage industry of the dying breed of physicians was being overtaken by the shiny glass and steel buildings of tomorrow where industrial-sized medicine was being processed. In these esthetically beautiful architectural abodes was the circuitry of efficiency. The human physicians, once called "providers" now termed as "scribes," feverishly input information of every encounter and the digital output was almost immediate. Guidelines were printed out for the patient, who walked out with a folio of information that he or she could not decipher, but happy in beholding a meaningless treasure trove of something. Contained within the thousands of repetitive words were the potential seeds of the ill, the affliction, the disease and that made the patients happy. After all it was all about information. Management was based on age and morbidity and if both were immodestly extreme according to the algorithm then a comforting prescription of sedatives and analgesics were contained within the package, if not then a time in the future was mentioned to show up at another shiny building where robotically the malady would be handled. Modern medicine had achieved the pinnacle of human caring. One could assuage a fear from the computer screen by telecommunicating via the computer with an expert. Ah life was so rich!

The powerhouses of venture capitalists and managing partners who owned or shared in the such buildings grew large bank accounts that were off shored to some remote exotic lands. Vacations were planned and more investments were undertaken. The media constantly ran reports of the bane of human doctor’s weaknesses and the virtues of the mechanical unbiased machines that had taken over care under the strict guidelines imposed upon the machines by the experts. Ah the fruits of hard labor were being replicated to scale and enjoyed by the few. Sometime however in their hubris to multiply their fortunes, they made mistakes as exemplified in the Theranos debacle. A lesson worth learning from.

Not to be outdone, the diagnostic version of medical care was also in full bloom. promises of ultra cheap with minimal discomfort diagnostics was in full force. Again money flowed in the billions to satisfy the insatiable appetites of the middle and upper management to reap quick riches. Pharmacies rebranded themselves as care givers and pharmaceutical agencies merged to create incremental advances most times of meaningless values, touted as new discoveries and inventions costing millions but yielding very little in benefits.

The game is afoot and the process is quickly unfolding…where it will end, no one knows.

Sunday, April 24, 2016


There are the Kings and Queens, Bishops and Knights cornered by the Rooks. All are protected by the Pawns that line up in front to spill their blood in allegiance. A game of strategy, deception and aggression is in play.

But what of the Pawns?

Pushed from the rear in a single step, sometimes in deception and other times as defense, the Pawns ride the crest of the oncoming slaughter from the Bishops, Knights, Rooks and especially the unfathomable actions of the Queen. She lurks stealthily behind a facade to deceive and obfuscate the real desire of bringing the opposing King to his knees while her Lord remains quietly “Castled” behind in the protectorate. She is cunning, crafty and deceptive, she uses her Bishops and Knights to set up the Rooks in cornering the King while with equal aplomb arresting the equally devious opposing Queen. Whose charm and alacrity will win the day is anyone’s guess. But in this deep dark world of war blood is spilt and it rarely is the Queen or the King, who quietly surrender, but of the lowly pawns, the Bishops, Knights and the Rooks. Victory is pyrrhic under most circumstance. The waste of life is pronounced as Victory. The vanquished and sometime the victor are left with no armies to speak of. And therein lies the Art of War.

We are all Pawns in this game being played at higher levels. Crafted in the tidy epicenters of power the players sip on expensive wine, bid on barren canvases, satiate their desires on aged cheese while the war goes on with each move of the Pawn. They smother their squeals of laughter when deception wins and kick down the opposing Pawn in abject condescension. Such is the game that lays bare the inner desires of warring factions that stride to win at all costs.

Such is the case when a non medical self-styled intellectual becomes the boss? Actually in more ways then one. A CEO of a hospital makes “rounds” around the hospital spewing euphemisms and pleasantries while in the Board Room he or she is exhaling fiery breaths. The “revenues” are down and heads must fall. “Find the doctors that are costing the system and furnish them with threats and reprisals.” “Cut some of the ancillary staff; maybe transporters, aides and the like.” The sentences barked in extreme condescension bear little evidence to the smiling exterior that meanders the corridors. His main purpose is to increase the bottom line. His main purpose is to enhance the image and hope for a merger with a bigger hospital where he can gain a seat of power and continue the climb to even better prosperity for the self. After all isn't it always the self that a business person strives for? Of course it is. Even an accountant who finds such easy low-lying fruit is going to have a field day picking. One such personality is alleged to have done some real nasty stuff to the hospice patients to increase his bottom-line. This behavior is inhuman in a lot of respects, but if we are true to ourselves, we might find that the current push for limiting care because of costs sets up this kind of a mindset. Doesn’t it? Think about that for a bit.

Physicians have little say in the matter when it comes to the high and mighty business-mettle, hard-hitting, fierce -bottom-line protector CEOs. Patient care is exported to some ethereal realm. The only purpose is to fill the beds and empty them as soon as possible irrespective of the patient needs. The zeitgeist is how a hotel is evaluated by the shareholders by per room occupancy or an airline is viewed per passenger mile.

So pawns we are, as physicians, to the business minded Kings and Queens that populate and copulate within the halls of power and make policies to govern other’s behaviors to improve the bottom-lines.

Someday the White Knight will find a backbone and together with the White Queen will decimate the Maleficent dark enemies and her armies of bean counters. Someday the Pawns will rise up and gain their respect for all the daily wonders they accomplish. Someday patient care will be true patient care and not one made up of false statistical premises and arbitrary and capricious guidelines based on costs. Someday the King and Queen will have climbed the ladder of true knowledge and wisdom of medicine and become the arbiters of goodness and not grief.

Some day…

Monday, April 18, 2016


Hepatitis B Virus  (HBV) Is ubiquitous around the world. 1/3rd of the world population has been infected by it with 240 million people living with a chronic HBV infection. In the United States alone that number is 1.4 million and growing annually. HBV infection remains a serious world-wide healthcare issue.

Hepatitis B Virus (SM image)

While previously it was thought that only “high risk” individuals should be screened for the virus, the MSKCC (Memorial Sloan Kettering Cancer Center) experience teaches us that 50% of the infected individuals can be from the “low risk” category. (High Risk defined as country of birth, sexual history, blood transfusion etc. and Low Risk defined as no prior such risky behavior)

The HBV is a hepadnaviridae family of viruses. It has a partially double stranded DNA with up to 3320 nucleotides. The virus is encoded with three identified genes, The P gene or the Polymerase gene, The S gene or the Surface antigen gene and the X gene (function still debated). 

The mechanism of spread into the human body is quite simple and ingenious at the same time. After gaining entry, the viral core goes straight to the nucleus of the cell where it hijacks the cellular machinery for its own use to replicate producing a boatload of the viral cores. These cores are then shunted to the cytoplasm where the endoplasmic reticulum gives them the protein coating to move into the extracellular space to infect more cells. The process continues in perpetuity until the human body antibody defenses arrive to fight the virus colonies.

In most cases the diagnosis of past infection is established with anti-HBVs (surface antibody) or anti-HBVc (core antibody). A few people might harbor a small viral DNA load (via Polymerase Chain Reaction) but without symptoms or knowledge of the infection. 30% of the infected population does not know they ever had the infection.

In Oncology patients who undergo anti-neoplastic chemotherapy the risk of reactivation becomes a serious dilemma. Varying degree of reactivation risks are noted from 20-70% with an average of 49% associated with various immune suppressive agents.

Reactivation occurs as consequence of the suppression of the immune surveillance due to the chemotherapy, which leads to the viral cores liberation again in the liver causing the inflammation and the resultant 3x or more increase in the transaminases (the diagnostic criterion for reactivation). Although denovo infection and a reactivation can never be truly proven without a past history of the infection. The HBV reactivation can be sudden, dramatic and can occur up to 12 months after chemotherapy. The degree of inflammatory response in the liver can lead to liver failure and even death at times. Most times however it follows the traditional flare of the hepatitis with slow resolution. The derepression of the immune surveillance by the chemotherapeutic agents remains the causal key.

HBV reactivation has been noted in Breast Cancer patients following Cytoxan and Adriamycin chemotherapy, among Lymphoma patients undergoing CHOP regimens with and without the use of Rituxan an anti CD-20 drug, which on its own weight as a single agent can invoke the reactivation process and even patients taking TNFa inhibitors like Adilumumab used in Rheumatoid Arthritis and other chronic immune inflammatory diseases. 

The current recommendation is that history taking and considerations of the HBV risk must be taken into account for each individual. Screening with anti HBVs and anti HBVc should be done and if a positive Viral DNA Load is determined prior to initiation of any immunosuppressive therapy, those individuals are treated prophylactically with oral Entecavir daily through the entire course of chemotherapy. Lumividine (a cheaper drug) has been used extensively as well but Entecavir and Tenofovir are more potent HBV inhibitors to date.

It is incumbent upon the oncologist to elicit a history of potential risk and then screen for that risk prior to initiating the chemotherapeutic regimens. Prevention against reactivation, given the widespread nature of the infection worldwide, is an important tool for patient safety and good patient care.