Sunday, February 24, 2013

The NEW Value Chain in Medicine

( A thinking person's landscape of the current DSS (Decision Support System) in Medicine! )

Diseases are wrapped in the human shell. The upstream is the collective whips and scorns of time; the lifestyles of smoking, drinking, excess eating and lounging, all abuses of the norm. The upstream catalogs the slings and arrows. It harbors the time afforded decay. It is the repository of the vices and the occasional nature’s sideswipe of misfortune.

The downstream is the processed collections of remedied individuals. Their diseases discarded; a virtual memory buried in the depths to keep the psychical trauma from reemerging and whisking away joy. The downstream has its rudiments of unsound or unresponsive processes that share the scattered and tattered remains, the broken but whole, the hidden but scarred, the scattered temperaments of volatility, the shards that prick and burst any joys of the present. But mostly through all that, there are the large numbers of joyous lights that glow.

Somewhere in the middle between the two streams, are the Processing plants. The shiny, white truths of reality. Somewhere in the vast landscape are the thousands of minds striving to make sense of life’s perilous journey. Somewhere, where the nights and days merge into a blur of grey. Somewhere where time lapsed moments of truths are reminders that this beautiful symphony has many broken strings of dissonance. Where sleep comes on a wink and the constant barrage of demand is a deep flowing river, in there somewhere, are the physicians, toiling to the demands of the hour. Bereft of those moments of recognition, of acceptance, of truths, their lives virtually have faded into the treadmill of perpetuity. That grey has lost its tones. In the dark quarters of these dungeons the physicians continue to slave away,  they are likened to the Morlocks by the lever-controlling elite, angered in their frustrations and looking for a way out.

Past the downstream flow is the Assessment and Evaluation station that periodically churns and learns from the information contained within this stream. Some processors are pardoned and others are punished, based on the visible array presenting to those that control the levers of the flow. These evaluators multiply in numbers from the self-ratified and self-confirming excess needs. They create the cornerstones and landmarks for others to circumnavigate. These landmarks are landmines created from a prejudicial, selected bias based on any number of reasons. The current throw rug of comfort is the cost factor. Any process with even an optimal result, mush less a suboptimal one, which everyone would concede, is subject to the coffee grinder of fiscal truth, which leads to the virtual “head on a tall stick.” Expense has become the arbiter and not the byproduct of the process.

Reflecting on the entire value-chain of medicine, one finds the Elves have been replaced by Grinches. Where the onerous weight falls is not in the processing itself but in the cost-controlling industries of self-interests.

Anyway life has changed and it needs to be changed again for the better. The polish on this paradigm has faded, exposing the naked reality.

Sunday, February 17, 2013



H: Health ~ Yours and Mine 
I: Insurance (Information) ~ Yours and Mine
P: Portability ~ Take the health insurance and information everywhere from anywhere
A: Accountability ~ For Physicians’ hide Only!
A: Act ~ Oh yeah plenty of that.

Missing from the dialog and discussion: 

1. Missing: The Business Entity (anyone designated as a Business Entity, including lawyers, administrators, business related entities, strangers etc.) who can have full access.

2. Missing: The aggrieved family members who were accidentally left off the HIPAA form and now cannot get information about their loved ones ~ creating a gulf and a distress between the family and the physician.

3. Missing: The Information technology (IT) Thieves that make the portability a profitable venture.

4. Missing: The hapless patient caught in the middle of a 173 page regulatory legalistic  boondoggle ~ is told it is for his or her benefit but has no idea of its ramification.

5. Missing: The hapless physician office staff that spends inordinate amount of time explaining the regulatory need.

6. Missing: The Presidential seal of approval for physician to report firearms data from patient about their family members. A perilous dichotomy in that road less traveled!

7. Missing: The Physician Penalties including losing their license privileges enforced by the Board of Medial Examiners for any and all minor or major breaches. Sorry is not an option nor an acceptable refrain. Oh and our dear beloved AMA states that HIPAA is getting tougher on physicians. And then wrings its bejeweled hands. (A little snark)

Who Wins: The Lawyers, The Regulators, The Big Data Administrators, The Licensing Authorities, HHS Attorneys.

Who Loses: The Patient, The Family, The Physician.

 ‘Nuff said!

The 562 page HIPAA Law and the AMA interpretation below:

Saturday, February 9, 2013

Signal to Noise Ratio

Imagine as it were, that you were facing the choice between leaping into a chasm with a glint of water below or hoping the root of the sapling was going to keep you hanging and the only thing that was running through your mind was the film of the Acapulco divers, diving. And then there are the huge waves that come crashing onto the beach and you are caught in the riptide as the water-roiled sand surrounds you as you tumble over and over. Or you are ready to jump out of the door of aircraft, you breath shallow and your heart thumping against your chest and you jump but the parachute gets caught on the door edge and there you are caught in the frenzy of a hurricane size breeze. 

These are the unfiltered signals that the brain plays out in the mind's eye every now and then. In dreams, in moments of reverie, in contemplation or at rest. These are the images filtered through the experiences of the day. They are Noise!

Ever happen to you?

Probably never happened to you, but it could? Hey these are the random thoughts that come pestering your mind as you try to relax. These are the random noises that prevent a coherence of thought.

Is it ever that one misconstrues real signal for noise?

Background Microwave Cosmic Radiation (BMCR)

Remember Penzias and Wilson (Nobel Prize winners 1978) who initially misconstrued the Big Bang chatter (Background microwave Cosmic Radiation or BMCR) for noise? Yeah, they did, but to their credit, they had the smarts to separate the bird poop error from the signal. Here the signal was the background noise!

But that is a rare story. More to reality are the signals that get drowned out by the noise.

Wall Street Trading

Ever hear about a guy named Jesse Livermore? Jesse Lauriston Livermore (July 26, 1877 – November 28, 1940)?

Well now here is a story for the ages. This guy had made a science of trading in Wall Street. At one time his net worth was in excess of $100 million. So what happened? Ah therein lies the story. There are books about his trading methods that I will glance at to keep this interesting but there is a lesson in this for all of us.

Let me begin with Jesse’s quote, “All through time, people have basically acted and reacted the same way in the market as a result of: greed, fear, ignorance, and hope. That is why the numerical formations and patterns recur on a constant basis.”
Oh! he had the human psyche very well understood and used it to his advantage.

While in Paris, where he lived a while, Jesse communicated with his broker on a weekly basis. He bought and sold stocks on the basis of rigid criteria that he himself had established. If the stock went below a predetermined value, his broker was to sell the stock immediately and if the stock remained above a predetermined value or “within the box” he stayed with it. So in all, he made few transactions. But the ones that he made and held onto rewarded him greatly. In 1905 and then again in 1929 he realized the oncoming economic collapse and shorted the market and made huge sums of money using his formulas.

Then he moved to New York, and that being in the proximity to the hub of economic activity, he got caught up in the day to day cries of the millions of reasons propounded by experts at what makes the Dow go up or down. He lost his fortune, got depressed and ultimately committed suicide. His net worth at the time of of his death was $5 million. He cried in his suicide note, "Ï cant do it anymore!"

Jesse as you might imagine, veered from his well thought out and successful form of trading and got caught up with the daily noise of Wall Street. In that loud and intense noise, he lost the signal. And without the signal, he was unable to navigate through the noise! Sad but true! The noise became the death of his dreams.


In medicine, (You are thinking, there he goes again, aren’t you?) there are equally potent examples of losing the signal for the noise. How many times have you heard, for instance, that alcohol is good for you and then simultaneously the opposite of that. Or that Vitamin D is beneficial against all sorts of diseases and then one by one negating all that. Or have you heard that coffee helps you fight against this and that cancer one day and the very next it is implicated in another cancer. Better yet now there are experts of observational studies that mock the science of probabilities and pronounce everyday things like, a longer index finger is associated with prostate cancer and the crease in your ear is associated with heart disease or, and this one takes the cake, high carbohydrate diet makes you slim. 

This last one comes from the days of the food “Pyramid” that the heart experts were claiming as the health-nirvana and then it all changed to the food “Plate.” Oh well!

Our ignorance is advanced not by real science but by the manipulation of it. You might not remember that back in 1893 smoking was considered a cure for bronchitis and Hollywood “doctors” posed in campaigning for brands of cigarettes.

These historical references are the depictions of the noise that accumulates and even in the most brilliant of people it prevents an orderly transformation of a cohesive thought. The noise kills the signal of reason.

The Digital World

Let me digress to the digital world a bit. You are familiar with viruses, worms, Trojan horses and spy-bots, I am sure. These are the fanciful but extremely disruptive software programs that can bring the computing world onto a screeching halt. But have you heard of “Denial of Service” or DoS? Some probably are nodding as they read this. Well good for you. But did you know that DoS occurs as a direct result of a tremendous surge of “noise” that shuts down the servers. In other words, if the “spy-bots” floating around as zombies hiding in millions of computers suddenly are alerted into action and start sending a signal to a particular website to overrun the site’s ability to handle the “requests,” the site computer, unable to differentiate between signal and noise, will have no recourse but to shut down. Thus a 10-year old computer savvy kid can mess the proprietary system of a large corporation by increasing the “noise.”


And if you are still here with me (Thank you, by the way), one last  “jump” into the world of the human mind. As you know that the brain triggers an event memory of the past only when enough recruitment of the neuronal signals has occurred. Let me explain, if you smell a familiar faint aroma, it might not trigger an event, but a strong aroma with the fading sunlight might conjure up a romantic past event. This is the simplified version of Deja vous. But now even with a strong aroma that lurks, when it is associated with the sounds of the cars passing by with their horns blaring, the signal is lost and is unable to override the noise and conjure up that past event, even with the fading sunlight is at hand. The brain looks for signals, for direction and finding too many shuts down with its own version of DoS.

Do not underestimate the power of the “noise.”

It limits comprehension!

It subverts reason!

It creates de-coherence!

The only utility left in these days of plenty (of noise) is “Focus!”

Let me leave you with the wisdom of Yeats:

“Turning and turning in the widening gyre
The falcon cannot hear the falconer;
Things fall apart; the centre cannot hold;
Mere anarchy is loosed upon the world,
The blood-dimmed tide is loosed, and everywhere
The ceremony of innocence is drowned…” (The Second Coming)

Tuesday, February 5, 2013


Stochastic Resonance

Stochastic = Random

Resonance = Excited state of stability.

The beach is a perfect place to unwind your thoughts and let the warmth of the sun bathe the concepts that are trying to germinate within. Don’t you think?

The Beach 

It was one of those days many moons ago, the sand was soft where the water had not yet reached and where it had, it had firmed a bit. As I walked, I saw the frothy bubbles that emerged and then laid themselves down in a frenzy bursting into nothingness. The waves kept coming, one right after the other, crashing gently onto the beach; the water welling over the sand and then quietly receding, some into the sand and the rest going back to organize and return. And as I walked just proximate to the watered down edge of the sand, a larger oncoming wave forced me to adjust my path. After all I was wearing my new flip-flops.

Why did that happen?

Time Zones and Jet Lag.

You see there is a periodicity of rhythms that keep the flow of life in synch. The biorhythms for instance keep you into the wake-sleep cycle. You can’t sleep when you are fully alert and try as you may cannot keep your eyes open when it is time to sleep (Ignoring caffeinated samples for this monologue of course). And here I would be remiss, if I didn’t bring in the quick and dirty subject of jet-lag. You fly off to Timbuktu and upon return your eyes are half-mast at noon while the rest of the world is going about its daily ventures. There is obvious disruption that has been encountered by the biorhythmic center of the brain and it is trying to self-regulate its cadence against time-zones.

Getting back to those waves that tried to wet my flip-flops. You see the periodicity of the rhythmic waves was offset by a chance rogue wave that decided to ride on top of it thus culminating in a larger wave. So the random wave culprit jacked-on to the periodic one and gave it a ride. Ok well that is quite simple isn’t it?


A bigger example that might attract your attention would be the recent “Super-Storm” (By the way, technically there is no such thing except for the Hollywood imbued media). So “Sandy” and what a gutsy call for a name to begin with that was, happened to lurk as a Category-1 hurricane over the Atlantic Ocean for a few days giving fair warnings for what it was about to do. You know that 1 in a million, 90-degree left turn when it was supposed to go straight up with a veer to the right and away from the land-mass, as all its previous brethren had done.

But, Sandy was a typical storm that got squeezed between a High pressure area over the Atlantic, a Cold-front over the Mid-west and then it took a ride on the split Jet-stream up through the Northeast quickly and disappeared leaving behind untold misery.

The periodicity of the hurricane was not uncommon. They do arise from the heat over the African Sahara and carry the energies across the Atlantic to the Caribbean  Islands and then depending on the Jet-stream and other high and low pressure areas go through Florida or ride up the East Coast. And Sandy was no different until it hit the roadblock of the Atlantic Ocean High Pressure that funneled it into New Jersey and then squeezed it between the Cold front and onto the split jet-stream that rode it out to the Canadian maritime.

Jersey Shore Casino Pier after Sandy

The hurricane periodicity was predicted, the East Coast ride was predicted and then with the other two elements of High pressure, Cold front and the jet-stream everything else became possible. Now add to that the forward speed of Sandy, which was slow, and the 2 high tides it encountered over the New York harbor, Sandy Hook and Mantoloking region and the disaster story was writ large.

Mantoloking, NJ after Sandy

So Sandy was a clear example of a single Stochastic events riding atop multiple periodic events.


Now to my favorite subject of medicine. Do stochastic events mess with periodicity in the medical field and does that affect our health. If you have your head buried in the book, the answer would be difficult to come by, but hear me out and we might come to a mutually compatible understanding.

Neural Stem Cell


Cells have a rhythm too. Let us look at the Nerve cell for instance. The electrical spark generated by the initial stimulus may or may not generate transference of energy across the synapse. 

Nerve Cells transmission

The voltage maybe too low and the action potential may not occur.  Imagine sitting in a loud café where everyone is talking, some hushed and others in their extroverted full-Monty fashion and behind it all is the “clink-clank” of the hostess carrying her silverware and you think you hear your name being called. You look around and there is no one looking for you. 

Brodmann's Area

You go back to your own conversations with whomever but that lingering thought remains and then once again you think someone has called upon you. No it is not Tinker Bell whispering in your ear, but the stochastic of the cacophony around you and the persistent thought within you. 

Your brain is on a semi-high alert. Any admixture of sound in that café that comes close to your name will elicit an action potential to carry from your Brodmann’s Areas 41 and 42 through the Temporal Cortex and via the Corpus to the other side and from there to the Prefrontal region of the Frontal Cortex to invoke an action of turning your head and looking from whence that sound emerged.


Speaking about brains, brain cells and nerve conduction, Alzheimer’s comes to mind. Imagine the malfunctioning tau protein on its Genghis Khan type approach plundering and pillaging the neural sheaths and preventing the transmission of the electrical current feeding into the various parts of the brain that assimilate various stored memories. These malfunctioned tau protein instead of assisting the transfer of electrical stimuli becomes a “roadblock” where even the password doesn’t work to drive through.

Malfunctioned tau interference


But before I go there let me take some liberties with memory. Memory is nothing more than the “Rut” in the brain. Repetitive motion, thought, action all cause alterations in the proteins within the neuronal cell body. Evoking that memory is the cluster of stimuli strong enough to make that particular neuron and its neighbor to get excited and through  that excitation the brain relives the past in the form of memory. A dream is nothing more than the brain trying to make sense of the daily world as it tries to juxtapose events into an illogical format (without full cortical supervision of course); “riding a tall bicycle on a narrow lane,” or “bending steel with the power of the mind.” 

Image of tau (blue colored)

In Alzheimer’s as the dysfunctional tau protein blocks transmission, the recruitment process becomes difficult, thus to evoke a stimulus and rationalize the present with the past. In the initial phases the recruitment is easy jumping over a few jumbled circuits (axons) and with effort one can use detour connections to evoke the transmission, but then it becomes difficult later. And much later a significant event evokes potential through resonance from like-minded neurons and voila a completely discombobulated tale is rehashed that merges past, present, future and is imagined as a non-cohesive but to the person telling, a true story.

The neural recruitment is the basis of transmission and memory. It is also the basis of Grand-mal seizures too, when an abnormal focus of electrical stimulus arises through disease, trauma, or cancer it can through recruitment cause the seizures of the human body. 

The brain and the EEG in a seizure activity

The collection of the surrounding neurons that start firing in concert leads to the rhythmic tonic-clonic seizures.

Now lets delve a little into the stochastic of disease. For there is that too. Cells as I am reminded are a repository of historical facts. They may labor in their capacity to do what they do in terms of function, but they do remember. For instance if you expose your skin to sun, it will tan over time, or burn with too much sun intensity and if you have had many sun burns as a child your risk of Melanoma exceeds the norm during your adulthood. But leaving that aside, since the cells are going about their periodicity of harmonized behavior, every once in a while a random act of interference will take place…

Allow me to explain…

Genetics and Cancer

Knudsen's Hypothesis and cancer

Suppose one of the cells in the organ has a weakened genetic basis, meaning that there is an allelic mismatch, (a good gene (a cancer suppressor gene), which is normally present on both arms of the chromosome is only present on one arm) and this occurs through the cruelty of nature in the division process during the embryological times of one’s life. Life does go on peacefully and in total oblivion to this resident harbinger of “hell.” The cell continues to chatter along, taking inventory, adding and subtracting time from the ledger based on lifestyle behavior and one day a virus comes along and buries itself deep in the tissues. The virus links a piece of its DNA directly into the human cellular DNA right at the level of where the good gene (the tumor suppressor) sits and in doing so, it disrupts the latter’s function of tumor (cancer) suppression. Nothing really happens immediately, but a minor exposure to say cigarette smoke that had previously been un-hurtful because of the protective gene, now, which not having makes the cell vulnerable and turns the faucet of disaster on. The proliferation of the wayward cell begins. 

The cells in the cancer make up

Oh it will be a billion of those nasty germ-line cells admixed with their EMT cousins, before it will be recognized and diagnosed and more than 2/3rds of the cancer lifetime would have passed before medicine will come to the rescue. This chance, rogue and random event will have chided the well orchestrated, well oiled protective machine.

One more question in medicine before we take a break to contemplate our navels. Why do some people contract an infection and others don’t, given similar circumstances of exposure?

Immunity and Resistance to Infection

The simple answer would be immunity and a set of two perfectly functioning (alleles) pair of genes. Having discussed one, lets look at the other; immunity’s role in all this mischief, because a person with lowered immunity will have lowered resistance then one with intact immunity. But there is more than that. There is also the size of the viral load (speaking strictly about viruses) that impacts the immunity. The less viral load the likelihood of infection is low, since the Interferons are there to quickly and expeditiously rid them, However in patients with Acquired Immune Deficiency secondary to the Human Immunodeficiency Virus the ability to generate the Interferons is limited as the protective Lymphocyte (Immune white cells) ratio has been disrupted by the virus. These patients, therefore have a higher predilection to infections and to cancers because the random attacks on their periodic defenses is more than the body can handle on a steady basis.

Thus the resonance of a range of complex events especially in living cells allow for periodic strengthening with coalescence amongst the weak signals to generate a strong signal. Accompanying these weak periodic signals and coinciding with random peaks of a random event and you have the beginnings of a new deadly paradigm.

In fact, and I wasn’t going to go into this, but the whole Lamarckian story of nurture is based on the precept of the human body constantly butting heads with its environment and thus transforming. Okay more on that later, enough said.

The emotional residue of a lingering past blanketed by the color of a random event, transforms!

Creativity is the ability to introduce order into the randomness of nature.~Eric Hoffer