Saturday, December 15, 2018

The 60th. BIRTHDAY

When they were young, Jim and Mirium never thought about it. It was all about the fun and frolic. Then came the raising of the children and seeing them grow and prosper. But now as the years ticked on there was the ominous feeling that entered Mirium’s mind and would not recede. It lay on her like a dark heavy blanket, blinding, perhaps even taunting her. She didn’t know what to do with it. She couldn’t talk about it with him to alarm him nor with any other members of his family. But there it was morning, noon and night like a colicky baby, screaming, inconsolable. 



Jim was entering his sixtieth year and she had planned a birthday party for him. Trying to drown her sorrows, she simply immersed herself in the planning phases and threw every fiber of her being into directed attention to the slightest bit of detail; the color of the flowers, the placeholders, the orchestra, the uniform of the waiters, etc. Nothing was left to chance. And yet as she turned every page of detail over, the dreaded thought crept back in like a slithering snake full of cold-blooded venom, forever hissing. 

It was the summer of that year, one afternoon when the hammer hit. Numb with disbelief and fearful of the impending loss that she had anticipated for several years, seemed to be coming true. Jim, her beloved husband had just received news after a “wellness” examination that he had to have a Computerized Tomography (CT) examination of his abdomen and pelvis. She had just nodded. No reply was needed. Even a word of encouragement seemed so futile in its existence that expressing it would be a sacrilege and a betrayal of her carefully crafted inner strength and any weakness would show her inner frailty. She kept the brave face in front of her husband. Her husband meanwhile seemed quite oblivious to all her angst and seemed to take it in stride, “nothing to it, after all I go to the gym 5 days a week and last week I bench pressed 240 pounds. You can’t do that if you are sick. Right? Right?” She just nodded ruefully as she twisted the cloth she was holding over and over again. She knew better. Or did she? There was hope. Wasn’t there? Clutching to straws, she prayed.

Jim’s father had died of a cancer of the throat that caused a “carotid blowout” one day late in the winter. With blood pulsing out onto the carpet and the linen, it seemed like a horror movie playing out in their bedroom. Shortly after, Jim’s mother fell ill with Ovarian cancer. The trauma of the loss was still raw with emotions when the foreboding of yet another malady seemed all to certain. There were multiple hospital visits and many debilitating chemotherapy sessions that laid bare the raw damage of the human body, once the belle of society dressed to the ninth, became the whimper of a human shadow. All dignity that could be preserved, was, until there was none left. Life became a long sleep as the withering frail body left only the skeletal raised relief underneath the freshly laundered linen. Her time grew shorter and shorter until one day when hope left.

Nature’s rebuke of the wonderful life, lived through the lens of pomp and circumstance seemed hard, relentless and outright cruel. But not till their first born, a strapping healthy man in his fifties was diagnosed with a fast-growing lung cancer. This malady seemed to come from nowhere and have total control of him. Yes, he was a smoker of a pack of cigarettes a day but he had not indulged in them for more than 10 years. Now he was left coughing in fits and spells, wishing he had never touched the vile weed. He knew his time was short after the radiation treatments failed to control the growing crab within his chest. He had just enough time to see his estranged child and try to reason with the unreasonable thought that life was a strange torture, painful in its suddenness and ruthlessness. He would never see him grow older. He was gone a few weeks later, having witnessed the horror of the loss of one of his parents earlier.

But he was not alone to suffer the trauma of nature’s cruelty alone. The middle child, a girl who had grown up with nary a desire that remained unfulfilled and always had the world at her feet. A smattering of beaus lining up outside the door testing the angry yet constrained eyes of her doting father. She had been spoiled with the embarrassment of riches she had grown up with, which seemed to constantly surround her even in the darkest of her moods that swung like a monkey on a tree branch. Yet here she was still primed for another 30 some odd years of fun and frolic after the loss of her parents and the enormous wealth that splattered around her like a massive welcome rainfall. Out of the blue the lightning struck and a mammogram revealed a tiny but angry looking whitish crab-like anomaly stuck deep with her bosom. The surgeon had their day and so did the radiation therapist followed by the oncologist, each whispering about the potential of future that was never to be. The crab-like radiological nemesis continued its march, swimming through blood streams and finding haven in places where imaginations of seasoned cancer specialists feared to tread. The once tiny crabby monster made its way to the pelvis, to the ear lobe and even to the bones in both her legs, leaving her bed ridden. Life could not imagine its domicile in that thinned shell for long and decided to leave quietly on a quiet cold fall’s morn. Gone like the breeze, the once vibrant youth who could be found collecting flowers from the flower beds as she did boyfriends from the handsome and striking airline captain crowd. Gone like the orange orchards and the grapevines from the scourge of a deadly virus. Gone were the memories of the ones whom she knew and who knew her. All gone.

Meanwhile life’s trauma had gnawed at Mirium slowly about the “what ifs” until the request for a diagnostic CT scan was made. She knew then, the serpent was near. She kept up the stoic exterior in front of her four children and silently cried herself to sleep in the darkness of her bedroom, where her only love, Jim breathed comfortably, oblivious to the growing darkness that was to arrive soon enough and overwhelm him.

“Why,” Oh God, why?” But there were no answers. It was in the stars or in the genes or somewhere in-between the heavens and the earth. Jim had just turned 60 as his father had and his mother and his older brother and his older sister, who had all succumbed to the vagaries of this awful and ruthless monster called cancer. And now, right on-cue just like the rest of them he would be faced with the enormous task of living through the infamy of the constant indignity.  The answer seemed to arrive as Jim’s health declined. He had, had a coronary bypass graft surgery for the “widow-maker” successfully until it was revealed that he had developed a case of an inflammation of the liver. The hepatitis symptoms after an acute phase seemed to abate and for several years only “minor blood tests” were done to determine the viral activity in the liver. Yet one day, the virus triumphed over the liver creating the wayward cellular multiplication and ensuing liver cell destruction leaving in its wake the crabby monster!

There were a spate of experts and specialists alike who opined about the best care. Jim was wealthy in his own right as well as the beneficiary of his parent’s fortune. Everyone thought the best mechanism of cure was a liver transplant. They brushed aside the CT scan findings of enlarged perihepatic lymph-nodes. “No,” the experts said, “During the abdominal surgery for the liver transplant, that he,” the able surgeon “would also do a thorough lymphadenectomy (removal of the lymph nodes) and that would result,” as the surgeon said, “in an R0 state.” 
Jim was all for it. As the preparation for the liver search grew with a fervor. Soon the liver was acquired from an unlikely source; a Chinese young man killed in the service of humanity by a freak motorcycle accident. Lo and behold the liver was grafted and all rejoiced. But shortly after the immune-suppressive therapy with Cell-Cept was begun another shadow appeared on the follow-up CT scan of chest and abdomen then another and another till all hope was thrown to the wind. Another of the misfortune family member shriveled into a ghostly apparition. It seemed that the cure of the transplant required immune suppression and suppressing that, caused the cancer to grow with abandon.

Mirium’s worst nightmare had come alive like the fire breathing dragon, which consumed her life, leaving in its wake the charring remains of tattered dreams.

Jim died in her arms surrounded by his four daughters. No sooner had his blood turned cold, did the youngest son, the angry rebel filed a law suit to gain all his brother’s fortune for himself. Ruthless like nature, he preyed on the father-less four children with a team of pin-striped suits parading through the court houses. Like leeches they sucked on every possible loophole in the will and like vermin they trolled poor bereaved Mirium. This human monster of a child, the last born of this once wealthy family had a penchant for money squandering. He spent and spent and spent to console an emptiness within that could not be satiated. Yet he persisted. 

He would turn 58 that summer.

Epilogue:
A fault in their stars was the causal determinant of the malady that was to befall them at their birth. A multi-gene mutation on one allele of the chromosome? A shortened tandem repeat of the Telomere?  Whatever the abnormality it sat quietly until smartly and quite purposely the second hit took place at the approximate appointed hour of the sixtieth birthday. Meanwhile the youngest one still awaits as the hours and minutes slowly tick away time into that dreaded 60thbirthday. He refuses genetic testing, because, “it is unnecessary.” 

That dread is something that only the medical-knowledge naïve, Mirium realized, but could not do anything about.

Saturday, November 17, 2018

AIRCRAFT ENERGY MANAGEMENT


A strange thing happened after a 4-hour IFR flight in the soup, the other day. The strange part was not the visual approach or the 6-mile visibility and the 6000 feet of runway ahead, but the energy momentum. I’ll add a bit of physics here, I was contemplating a nice landing with three souls on board and bags. In that contemplative mood, I turned a 1-mile final for traffic considerations as per the Tower at 800 feet. No biggie, one might say, and it shouldn’t have been. By the time Garmin’s faithful melodious voice stated “500-feet,” I was already looking at 4 white lights on the PAPI. And by the time I heard “minimums, minimums” (I program that on every flight where approach is available), I was rushing in at 85 knots or 9% over the VSO1.3.



Now in all likelihood most of us have done that one time or another. Maybe? And I have too, plenty of times, but determinately? Almost, never! Yet here I was plowing the slight cross wind hankering to take me off the runway. Nope, that was not going to happen. Even with a forward slip, I leveled off around 79 knots and then held and held and held till the lift dissipated and I touched down 750-800 feet past the threshold and ran the wheels for another 1400-1500 feet and then on to the third taxiway (and not a high speed one either). Hmm, I thought hope no one was watching.

One might say, so what? 

Let us look at energy as a stored form of force. As in potential energy that one gains by appropriating first the chemical energy (burning of fuel) and translating it to the mechanical energy (turning the prop and creating thrust) into stored potential energy as altitude. You go up in the air with a whole bunch of fuel burn and then coast down with a bunch less. But in that bunch less is a major wizardry of airmanship. How we manage that energy is what determines the difference between the sound generated by the repeating doppler-effect-engine-power-hog-jock and an aviator. The slow dissipation of energy by carefully manipulating the Throttle to achieve a steady state loss of that potential energy transformed into kinetic energy, is the key to good airmanship. When the Landing configuration is best at 1.3 VSo for normal landings and 1.2 VSo for short field landings, there is a specific need to adhere to that tenet. Or else you run the gauntlet of what might be. And most times it won’t be pretty.



Many a pilot has ventured past the runway end carrying more than needed energy. A case in point is the recent Falcon crash at Greenville Airport that killed both the pilot and copilot in their haste to land while the runway kept shortening in front of them. The NTSB has yet to finalize on that fatal accident, therefore, this statement is a hearsay opinion based on the video of that flight while in the landing phase.



Remembering that speed is a form of kinetic energy and it dissipates at a certain rate when thrust is eliminated: The stored energy is a thief of time and space. Knowing only through practice, conditions a pilot in it’s judicious use.

Let’s look at the correlations between Speed and Energy…
 Assuming a 3000-pound aircraft arriving at a runway at the given speeds creates the resultant force. (Kinetic Energy + ½ mass * Velocity squared)
65 knots of airspeed = 562,128 ft-lb of kinetic energy. 0% Baseline
80 knots of airspeed = 851,508 ft-lb of kinetic energy. +52%
50 knots of airspeed = 332,620 ft-lb of kinetic energy.  -41%
Given those dynamics, it behooves us to maintain the appropriate energy on final approach to the runway.

Additional benefits of proper speed/energy management also include:
The sudden deceleration, say, hitting a parked truck or a deer on the runway or a structure requires tremendous energy dissipation… 
Stopping a 60kt aircraft at 18 feet distance leads to a 9G force on the body (The limits of the FAA certified seat belts). 
Stopping that same force/energy in 9 feet distance leads to an 18G force on the body (limits of sustainability). 
And a sudden stop at 1-foot distance leads to 159 G force (unsustainable for the human body).

So, going back to my landing, I came in with near 10% higher speed/energy than required and I paid the price in runway used. Mind you, with that much stored/kinetic energy, I would certainly have taken out the runway end identifier lights on a 2000-foot runway.

A word of advice - Translate appropriate power and pitch for climb/cruise, appropriate power reduction and constant pitch for descent and zero power and changing pitch for level over runway and thence a smooth landing flare. Always concentrate on the VSo1.3 on normal landings and VSo1.2 on short field landings.

Fly by the numbers appropriate for the aircraft you fly and always fly safe.

7 Landings in 7 Minutes -VIDEO
https://youtu.be/ozrowvQYv_M

Wednesday, September 5, 2018

CHASING MIRAGES - "IS CAUSALITY DEAD?"

The evening was a welcome cool from the day’s sun. Summer was hesitant to give way. Perhaps it had a few more thunderstorms up its sleeve or was mostly tempting Fall. I couldn’t say. It was a magical evening nonetheless. As the fading light of the setting sun caressed the tall pine trees and disappeared ever so slowly a cacophony arose from the trees. The cicadas had arisen from their deep slumber and now vibrating their tymbals were taunting their predators with their rhetoric. It became constant and sort of annoying. It reminded me of the itinerant intellectuals who pass along their confined boxed-set knowledge as the truth. 

We seem to live in a world inhabited by Sophists; the Protagoras and Thales kind; forever drifting in the sea of their own making. Constantly deducting from a set of false premises. Plato would have set them free, but alas, very few ascribe to those ideals. Their drumbeat resonates in more ears with their tymbals than tongues splashed from the taste of fine wine poured from the vineyards of reality. Relativism seems to play a large part in our society. Be it moral, metaphysical or scientific. In every corner of the inhabited land a call for relativism is trumpeting the ever increasing vigilance of “All things are equal.” “There is no good nor bad, only thinking makes it so.” Hmm, where have I heard that before?



You see dear friend and reader, when we start preaching from that diamond-studded lectern and profess an intellectual high ground that is fortified only by false premise, someone, some day, with an average intellect will eventually find the key to the falsehoods. 

Now imagine the falsehoods being churned out in large numbers in science. And, I am speaking strictly about Medical Science. Causality is inferred through an elaborate scheme of statistical fiat. From the simple and easily understood Kaplan Meyer Curve that showed survival in a graphic form; The survivors in the treatment arm vs. in the untreated arm of a study. We have now launched into Forest Plots, Propensity Scores, Instrumental Analyses, p-Values and other elaborate probable causality forms. We continue to draw strong inferences from weak correlations. One can reach logical conclusions through reasoning based on any premise. And that is where the fly in the ointment sits. As the term “garbage in, garbage out” is used in computer input/output results, so are the conclusions based on inferences. Statistical Inference on the other hand provides us with a probabilistic “determinist reasoning” where predictability is circumspect in most cases relying on percentages. No wonder IBM’s Watson failed to provide the correct treatment in cancer cases - a failure of AI dependent on limited and incongruous data. Similarly having a false premise and even worse, falsified variables lead to false conclusions. By simply masquerading as a statistician or being one employed to determine a firm value to take to the bank, one can herald a meaningless treatment protocol costing hundreds of thousands of shekels to prove that an occasional survivor from an n of 14 will come forth and brighten the balance sheet. The data so incurred is as flippant as the coin being flipped. The cicadas are vibrating their tymbals ever louder as average people view the data through a clear lens and say, “What gives?”



What do we do. Should we let causality be an inferred determinant from correlated inferences? Should we simply bow down to these itinerant composers of rhetoric and their daily fusillade of useless information couched as “landmark studies?” We should reason! However, knowing well, If one questions the motives of these falsehoods, moral relativism will come into play and virtue-signaling, now an art form for some, will blind you, deafen you and vilify you to shut you down. Perhaps we might consider using the correlational inference as the intermediate step and then look hard for the proof on causality? Something akin to finding the Anopheles mosquito as the vector in Malaria, or lone star tick for Lymes Disease.



This storm of falsehoods and intemperate pseudo-scientific behavior will come to an end, one day. More transparency is being demanded by those that inhale this form of information because the links between therapy and disease outcome seem to move farther apart that neither the statistician nor the scientist/author can bring the opposing factions together in a cohesive bundle. Numbers can’t pull together what common sense says does not belong. After all, adding more salt or sugar will not displace the aged and oxidized fruit to a better shelf. Medicines that are used as treatment of disease are all the more of concern. Especially when lives and billions of dollars are at stake. Hiding behind the Progression Free Survival instead of Overall Survival will simply not do. After all, by the magic of “timed evaluation” a PFS can vouch for a “markedly significant” response although overall survival of the patient remains unchanged. Meanwhile billions of dollars go down the drain and precious lives are lost for the want of time. Read the literature and I promise, if you do it with clear eyes and open mind, a tear of sadness shall flow unannounced.

So once again I get back against their (Sophists) ideal, that there are some absolutes in this world. Vanquishing disease for instance, delaying disease as the next best, or simply creating comfort are the three modalities of care in cancer medicine and most other diseases. One should not have to pay dearly in finances and lose a fortune in the hopes of living longer when the ticking of the clock suggests that time-determinant survival is not prolonged, except on the bias of variables, a code for snake oil and the fiat of statistics. Those patient’s finances are better left in the hands of the individual and the family to be used for better purposes than in the hands of wealthy bureaucrats. Free Market is free only when there are no controls in place that displace the real cost of "something." Calling the current scenario in medicine as free market is tantamount to calling the sickle and hammer flag a beacon of Democracy.



Causal inferences should be drawn from verified and validated data. If only 6 of 53 “landmark studies” could be validated by Amgen then something is wrong and twisted, in the land of numbers. And now with the Genomics at hand where thousands of genes are in play and perhaps thousands more of epigenetic forces (RNAs) are modulating that play, statistical paradise might have some more bad calls as we muddle through treatment of diseases.

Harkening back to the days when I was in my teens, I thought all knowledge about disease had been collated and complete, that there was no more knowledge to be had...

Oh man, was I wrong! 

I come back to the original correlational question, “Is Causality dead?” As Dylan answered, “the answer my friend, is blowin in the wind.”

Sunday, August 26, 2018

The STORM


The other day, sitting by the window, I was gazing at the sunny outdoors, I noticed the bright light dimmed slowly and then precipitously to claim the twilight time in midday. Clouds overhead turned quickly from white to grey to mammatus black. The quiet breeze remained quiet no more. It started to blow. The leaves that had felt the stir were now in a state of panic as the branches of the trees roiled and rolled, swayed to the gusty wind that came upon so suddenly. Soon I could see the wind as the branches were forced to defoliate and the leaves swirled slapping against their brethren and onto walls and lampposts. It grew darker still and an eerie greenish hue circumscribed the neighborhood. Thunder advanced the agenda of this brewing storm. Lightening flashed its 5 mm bolts around the clouds arcing through the air ripping apart space and sending loud booming messages of what was to come. Soon large droplets crushed against the windowpane, splattering and flowing down to the pull of gravity. Then larger droplets still, arrived, each with more crushing strength and ferocity. The view was utter chaos. A few packets of unsustainable weighty hail pelted the ground dissolving on the warm grass, followed by more heavy rain. As the wind velocity increased so did the horizontal nature of the rain. Sheets upon sheets of linearities coalesced together hit without mercy, any and all natural and man-made objects. The drubbing continued for a while and as always, such trauma is never lasting, an hour later the wind soothed down, the rain became vertical and the trees breathed a sigh of relief. As quickly it came, so it moved east and away onto the ocean. The day turned from dark of the eve to light of midday again and the gathering of the clouds dissipated. A few stragglers of white puffy clouds, like the little ducklings walking behind mother duck pulled by the invisible tether followed suit, leaving behind the bright and clean beautiful hour. Such is the nature of storms. They come and go under the forces of nature, mostly announced via the weather stations but sometimes they popup without notice.

Life is like that. A bit of rain must fall in each life. It must, I say, because nature as life does not like monotony, stagnation and boredom. The clean and shine that follows is a new birth of ideas, demand and productivity. Humans are in a constant state of flux, moving and shaking the order of the current impulse. Those entrenched and stagnant in their ideation resist such change and are fearful of it. Those resilient, pliable, flexible with exposure of their minds to new thoughts disrupt the status quo and create a new worldview. Such change is what humanity needs.



Physicians are fighting such a storm these days, as entrenched profitable agencies well-endowed and improperly enriched create the chaos to resist the higher order of newness. Those firm and rigid physicians, unfortunately either lose heart, leave, get burned out or in some sad cases give up on life. These hardworking physicians who are forced by the nature of a few bureaucratic mindset ivory-tower-policy-makers, creating mandates, wear the badge of loss as they give up on life. Their whole meaning being to care for those in need is upended by needless hurdles. The pursuit of the storm makers on the other hand is to further enrich their enterprise to the detriment of all others. The dichotomy of purposes is like the storm, what creates the leaves swirling in the wind, lost in the sea of chaos and humility to an untimely exit. The resolute and flexible ones meanwhile plot their next strategy. Create new paradigms hatched from a conspiracy of multivariate thoughts. Once alignment of thoughts and process is nigh, execution is a mere action. Success arrives. “Fall down seven, get up eight,” is a reminder about resiliency and fight.

As Van Gogh said about storm aftermaths, "...there must be a little bit of air, a little bit of happiness, but chiefly to let the form be felt, to make the lines of the silhouette speak. But let the whole be sombre."

So, my dear friends, it is never too dark for too long. Neither is it torment forever. All of past is a memory. Choose the right memory to fight another day and get up and carry on to the next adventure.

My thoughts and prayers are for you and with you!!

Friday, August 17, 2018

The QUESTION of WHY?

Most arguments begin with the question “why?” No, not the arguments as in shutting down someone’s ability to speak or break down windows in someone’s property or set someone’s automobile on fire. Not those kinds. Here we are talking about the intellectual “why.” The one that requires reason and thinking, not the force of anger and vitriol.




I came across a “why,” recently and it had me in a vertigo, spinning in different directions. Without much ado, let me spell it out a bit.

Here is the portion of the article in question…

“Dr. Presley and colleagues used the Flatiron Health Database to identify patients with advanced NSCLC who received care at 191 oncology practices across the United States during 2011-2016. The 5,688 patients studied had stage IIIB, stage IV, or unresectable non-squamous NSCLC and received at least one line of treatment.

Overall, 15.4% received broad-based genomic sequencing of their tumor, while the rest received routine testing for EGFR and/or ALK alterations only, according to the results reported.

In the broadly tested group, merely 4.5% were given targeted treatment based on testing results. Another 9.8% received routine EGFR/ALK-targeted treatment, and 85.1% did not receive any targeted treatment.

The 12-month unadjusted mortality rate was 49.2% for patients undergoing broad testing, compared with 35.9% for patients undergoing routine testing.

In an instrumental variable analysis done to account for confounding, the 12-month predicted probability of death was 41.1% after broad testing and 44.4% after routine testing (P = .63).
Findings were similar in a propensity score–matched survival analysis(42.0% vs. 45.1%; hazard ratio, 0.92; P = .40), although there was some suggestion of a benefitof broad testing over routine testing in a Kaplan-Meier analysis among the entire unmatched cohort (HR, 0.69; P less than .001).”

And while one could easily glide through this information and come to some quasi understanding of it with a lurking intuitive prick in the temporal lobe of the brain. The question of “why” seems to dog the door open for a wider discussion one would think. And that is where we lay our scene…

The two most pressing arguments in these prediction-based paragraphs are:
1. Instrumental variable analysis
2. Propensity score–matched survival analysis
Big words that a statistician loves to go to sleep thinking about and the clinician or any other scientist either gets tortured or simply ignores and takes it as a matter of fact.

Well then! What do we do about these two posers of great intellect and coruscating aura?

Perhaps dissect them to their innards. You know the ad reduction absurdum and see what cellular cilia are left behind that make these notions tick.


I’ll blindly take the second argument first in my coin toss. The term “propensity score–matched survival analysis” is pretty hifalutin when you get down to it. But as Albert Camus asked… “but what does it all mean…?”

The “Propensity score–matched survival analysis” (A tool for causal inference in non-randomized studies) a fine idea to take a cohort of patients in the control group and rate them from 0 to 1 and another identical group of patients under the treatment arm and rate them between 0 and 1. Where 0 implies no effect and 1 implies 100% success. You then place the distributions of these two groups in opposing sides of a horizontal line (Top and Bottom) as in below…



Here comes an interesting and very clever part. If there is marginal or very little overlap one can consider those people on either side of the spectrum (perhaps called outliers in other statistical methodologies) as being “trimmed off” the discussion. 



In other words, we, (the smart intellectuals) will learn nothing from them because well they did not “match.” Ok so far so good! Did I? Hmm I meant to say So far so good? You see the dilemma that unfolds in a simple mind. Like (as millennials love to say), what the hell?



But continuing on our journey, moving further down this clearly tortuous rabbit hole we then after “trimming” the excess (fat, or unmatched cohorts) from the matched groups we then measure the standard deviation Here comes the next leap of faith, based solely on the enterprising decision-making-value-based interpretation of the statistician par excellence: Using a “Caliper” one can then multiply that standard deviation by an arbitrary number (most used 0.2 or 20%) but it can be changed to suit the motive of the designer to get the appropriate result and make the experiment a wild success. Using 0.15 (or 15%) increases that threshold while raising it 0.25 (or 25%) decreases the threshold of the “Aha” moment. So, the Propensity of this “controlled” experiment is done on the comfortable cushioned chair of an expert, as you can see.

Caliper? No Not This one!


This one!


“But, but…” cries common sense. “Shut up” cries the sound from the ivory tower of excellence, “this is above your pay grade. Just shut up.”
Aww…



Let me not forget that other piece of formidable intelligence folded like a ball of dough ready to make flat bread. The only thing needed is some heat. Our #1 statistical analysis or “Instrumental variable analysis” has to be dealt with, with a gentle but firm hand. The term appears very “scientific and seems an attractive method to control for unmeasured confounders in observational epidemiological studies.” (Wikipedia) You get the bold words in there don’t you? It is a statistician’s dream to solve the riddle of non-compliance in finding some causal inference between a treatment and its outcome where other unmeasured confounding variables might be at play. The attempt is to limit the unmeasured confounding variables – but how? By not doing so leads to a violation of the ignorability assumption and thus effecting (biasing) the causal effect estimates. But never mind that, we are on a quest to prove. And by Golly we will prove!


Here the argument is to say that if Z modulates X (treatment) which changes Y (Outcome) and X is not changed but Y is by Z then we can measure the effect of Z on Y. Simple enough. So, it is making a causal inference of the effect on intent to treat based solely on the effect of a single variable. That simply refers to a single variable effecting change on the dependent category. The simplified formula would look like this E = Y^(Z=1) – E = Y^(Z=0). Where the presence or absence of Z effects the effect of Z on Y. But then we introduce another unbounded (unmeasured) variable U that effects both X and Y. To draw any causal inference between Z and Y or even X with U lurking around requires a pseudo-randomization between quasi equivalent parameters and not the usual Medelian Randomization required to answer the effect of Treatment on an Outcome. In other words, draw from a larger group of unmatched and fit them into the current “experiment” to create the appropriate graphs. As one’s sense gets fogged in and bogged down in this analytical enterprise, one realizes the true nature of current science which seems based more on slippery-mathematics and thought experiments through manipulation rather than on real experiments: Medelian Randomization vs. Pseudo or quasi-Randomization of ‘disparate’ groups or if I can be permitted to rake the term ‘a-priori,’ over the coals and pull the reluctant Bayes into this whole mishmash. By manipulating numbers to find causal links between treatment and disease rather than the real cause itself, aren’t we just creating false but intentional heuristic for the future harm to society? No matter how extensive a list of variables (Risks) it is, we simply cannot completely fathom the effect of a treatment and its related Outcome with using a simplified, contextually flawed, argument of using only the glaringly obvious one or two risk variables in determining where the argument goes to rest. Can we? A simplified case in point would be ascertaining Gene X mutation causes Disease X. Not knowing the Gene X modulations by other genes, epigenetic factors like RNA and Exons and the presence or absence of tumor suppressor genes, tumor promoter genes and the EMT transitions in the milieu, one simply cannot give an answer that Treatment X will have a 100% Outcome Y. What it will tell us that there is a likelihood given all other variables influencing the outcome the probability is Y% (And even that is dubious at best). And that is what patients and physicians need to know. Unfortunately given the tools mentioned above with a solid foundation of statistical tweaking, we cannot with certainty even say that. The “Y%” is a largely muddied concept of false premises and false promises. No wonder the big an upcoming poser, the Big Bluish IBM Watson failed to do render the right treatment and caused potential harm in posing as an Oncologist.
https://www.engadget.com/2018/07/27/ibm-watson-for-oncology-unsafe-treatment-plans-report

Ah my dear inanimate blue-colored friend, as Shakespeare might say, “There are more things on this heaven and earth, than are in your data-base.”

Remember the yesteryears when Jenner used Cowpox against Smallpox in 1796 and Fleming discovered a “Lysozyme in 1923 and then in 1928 discovered penicillin. Or for that matter Marie Curie (Skolodowska) discovered Radon and Polonium in 1911 after Henri Becquerel’s discovery of radioactivity in 1903. Today we make quasi discoveries by manipulating numbers and using soft correlations to get our p-values under 0.05 to win a lecturer-ship or tenure or a directorship and continued employment at a Fortune 500 company. No wonder Amgen failed to replicate 89% of the 53 landmark studies. Only 6 could be considered "validated." https://thenextregeneration.wordpress.com/2013/10/26/the-replicability-crisis-in-cancer-research/

Remembering that incidental, irrelevant concepts that breed perceptions affect our judgment and behavior. A few of these misadventures are honest but mostly they are intentional and with the verbal force behind them, are swift!

Representativeness judgments can influence estimates of probability, while Representativeness heuristics can play all kinds of havoc on a limitless number of judgments. Imagine the Azande people of Central Africa believing that burnt skull of the red bush monkey was an effective therapy for epilepsy, given the jerky and frenetic movements of the monkey itself. Or for that matter "Blood letting" as a means to cure pneumonia?

It is important to remember that concepts begotten of such Representativeness Heuristics oscillate in elegant and opposing waves and only time gives each side the temporary podium to win over the society of humans. Consanguinity of thought begotten from a intentionally biased point of view leads to monstrous results, ask the Habsburg(s) and their collapsing empire, their jutting jaws and their intermixed (Consanguinous) DNA short lives.


Chasing the pool of money with such manipulative fervor is harming us all. We need a better handle on reality rather than exist in the virtual world of “IF THIS THAN THAT.”

Sunday, July 29, 2018

MEDICINE AND RACKETEERING


We are, after all, all humans. We share a common ancestry. If you know a bit of molecular medicine, you would know that there is a “Mitochondrial Eve.” That, all share the same mitochondrial DNA from the “Last Common (Human) Ancestor,” a woman. And yet there are legions of humans who believe otherwise. Perhaps their greed beckons them, or shades their eyes, or perhaps it blinds them to their common end. But there is no doubt that such a progeny of the bureaucrats has arisen and continues to flourish and grow, like weed, to overtake the once plush garden of that Eve.

On looking at the definition of the word, “Racketeering,” one finds this, “dishonest and fraudulent business dealings.” Hmm…simple enough, right?
It is if you have your eyes wide open.

But alas, all the goodness is interred in the sub-level surfaces of human activity, it seems. We define success as the men and women with the best toys. The race to that top of the mountain seems apace at breakneck speed. People climbing on other’s shoulders not to see further in the adventures of innovation and productivity but in the act of stomping on other’s heads to crush and bury them and their meek protests. And if protests do arise, they quickly demonize and or vilify the broadcaster of such protest. Charlatans have indeed gained a copious landscape and a highly visible lectern to pontificate the “Benefits” of their managerial swag.

Kris Held, MD @kksheld and Alieta Eck, MD @AlietaEck deserve the credit to bring this video across my visual horizon. It details the cozy relationship between the government and the private sector all cobbled together by the money bag exchange. It is all about self serving heuristics of those with the power to do so. The politicians want money to keep their enriched power base and other perks of “legal insider trading,” free jet-service to the Cayman Islands and the French Riviera all in the name of “Public Good.” Indeed, any and most actions doled out by these power-hungry trolls in the private sector and the government are marquee events under the euphemistic banner of “Public Good.” So, watch out for those words.

https://youtu.be/aQhsPLcFwN8


This video, encapsulates the racketeering in one sector of Medicine today; Cost of Medicines. And by the way, we are at the pinnacle of this act since the total cost of healthcare in the United States currently stands at $3.4 Trillion and escalating. That number alone is juicy enough to invite the eyeballs of some very wealthy individuals like Buffett, Bezos and Dimon to the stage. After all, why not partake in the health-palooza while the going is good to raise the topline and bottomline of their respective businesses.

Patients meanwhile are being told that their medical care is not “preauthorized” because of such and such reasons…mostly pointing fingers to doctors who it appears never seem to make the correct decisions for their patients. And if should one of those services be rendered then an automatic denial of 12%+ is served up by the insurance company, for the doctor to fight over for the next few months to get “reimbursed." The doctors meanwhile are forced to hire legions of paper pushers in their low revenue offices just to get paid. And that, dear fellow if you do a look back, is the reason why in 2014 thru 2016 the fastest gains in employment, while the whole rest of the world was asunder, was the medical field, was awash with new applicants, (that and bar tenders it seems) lowering the spurious unemployment rate.

Meantime the costs of medicines, if you surely have noticed, was going up. A hoax that seemed to have inadvertently been exposed by the greediest of all the hedge fund and Pharma bro, by the name of Martin Shkrelli.


But he wasn’t alone. He was closely followed by Heather Bresch the CEO of Mylan who did the same with the Epipen; an emergent supply of epinephrine for children and adults in the throes of an Hyperallergic reaction. 


Recently thais was followed by another pretty face called Elizabeth Holmes of Theranos. All these and many more in the business of racketeering, it seems. You guessed it, these people have no virtues, save, extract lives and money, just like a over-taxing, over-regulating, mightier than thou governments.

https://www.vanityfair.com/news/2018/06/elizabeth-holmes-is-trying-to-start-a-new-company

This post would not be complete without mentioning one of my favorite bloggers, a cardiologist Dr. Westby Fisher @Doctorwes who has exposed the many virtue-signaling harms committed by the ABIM and ABMS against the physicians. And these organizations have amassed many millions of dollars in all the fine places for their “Annual and semi-annual Retreats,” all at the altar of “Public Good.” These organizations have never been able to show benefit of their quasi-knowledge tests undertaken under the strict scrutiny of “physical and virtual guards,” in confined spaces. Meanwhile by extracting large sums of money from the physicians they have their lobbyists, lobby the government to mandate their scheme to gain a universal order of such money extraction in perpetuity. So, please extend your kudos to him and Charles Kroll CPA @CharlesPKroll. As the war against these self-appointed middlemen wages on, the outcome is eagerly awaited by most of the physicians whose main concern remains; delivering good patient care.

http://www.changeboardrecert.com/anti-moc.html
https://www.policymed.com/2017/06/anti-moc-laws-picking-up-steam-across-the-united-states.html
https://practicingphysician.org/moc/
https://www.medscape.com/viewarticle/881274

These organizations ABIM, ABMS are fighting back with their “representativeness heuristics” to cobble together estimates of dubious harm and probability outcomes couched in their falsified estimates. It is important to remember that the incidental, anecdotal, irrelevant perceptions and other such haphazard cognitions can and do effect judgment and behavior of those at the higher echelons of power with “No Skin In The Game” (SITG). To the power-hungry crowd only money bags matter. So stay alert at the next signal that repeats the words, ”FOR THE PUBLIC GOOD.”

But as Shakespeare once said, “Mischief, thou art swift.”

Where did we go wrong?
When did we refuse to follow the path of “Above All do No Harm?”
How did we come to this?

We forget the patients, whose misadventured piteous overthrows in finding a sanctuary against illness do with their death, bury the GPOs and PBMs and other hidden bureaucrats between the money-sheets racketeering schemes to keep from visible light. Thus they remain alive and with their viper poisonous tongues and sharp fangs, clot the blood of all civility, confuse the mind’s messages and normal human discourse.

It seems that when the many who rushed to acquire MBA degrees from prestigious universities and got hired at institutions rolling with cheap and free printed paper money, these new hires were expected to come up with their “algorithms” to determine the best mechanism of monetary extraction from the tax payer funded largesse. An endeavor that was quickly replicated across the private industry. There were others as well, especially those educated in the “Streetonomics” of how to get rich schemes, duly exploited the loop-holes in the framework of morality and deceit was writ large. The damage these few have unleashed on the framework of this Great Nation is telling in where we are in our daily dialog. Anger and distrust breeds with equal fervor in our society today.

We have turned into a country of Lobbyists and other large “money baggers.” The bigger the pot, the more “say.” The more the say, the more regulations. The more the Regulations, the more stifling of the “Free Market.” The more stifling of the Free Market, the more the horns of the Socialism dilemma grow. The more of that and we are no different that Venezuela, Cuba and the rest of the totalitarian regimes across the globe. Give that a moment to sink in.

All beings emanating from the Mitochondrial Eve must face the same Common End!! 

So...

For now, ”Live Long and Prosper.” -Spock

Saturday, July 21, 2018

Aircraft LANDINGS Made Easy

Let us talk about landing an aircraft, shall we?



Apparently from what I seem to find when flying with another person and even with another pilot, nothing seems so satisfying as greasing the landing. The rest of the flight blurs and is captured into this singularity called landing. You might have dodged a thunderstorm, you might have experienced a wind shear, you might even have encountered a gusty crosswind, but if, and that is the biggest if, if you didn’t chirp the landing, well then, you just displayed your incompetence.

In fact, several weeks ago, I was a passenger in seat 29A in a B737 on a very gusty day, landing at KEWR. The pilot up ahead behind the bolted doors must have been very good, he touched down smoothly without a lurch. Hmm… I thought, I had fallen into the same trap? Actually no. You see most of the flight on this large aluminum tube was on the triple redundant autopilot, but the landing was definitely the pilot’s, so he gets the award.

On the other hand in our tinier aluminum or composite bodied transportation devices, we can and do use “George” at cruise and sometime through descent but once in the 5-mile vicinity of the airport, it is all on the left seat driver. To put it gently, “You’re it!”

Consider approaching the 45-degree entry for the downwind. It is important to scan traffic and look at the departure end of the runway for traffic and potential landing zones if on a later flight the engine decides to pull a fast one. (VSO specified in this example as 60 kts – adjust Vso and tailor the advice to your specific aircraft accordingly). So on 45-degree approach to runway, Speed Vso * 1.6 (in most cases 95-100kts). Stabilized with the appropriate power settings. Left downwind stabilized at 1000 feet (midfield) above the runway threshold keep the speed to VSo *1.5 (In most cases 90-92 kts). Turning Base reduce to Vso * 1.4 (in most cases between 82-85 kts). Turning final reduce power for Vso *1.3 (in most cases 78 kts). The last 500 feet on final are a matter of experience and practice. In short field approaches reduce speed to Vso *1.2 ( in most cases 72 kts).



Ok, ok, I realize the above rhetoric looks kind of pedantic, but now here is the key to the puzzle. Let’s say you are in a Cessna 172 or Archer aircraft where the power settings are by means of the RPM only. The trick is to set the power setting to the most appropriate setting (Maybe 1600-1700 RPM) and then use the flap settings to realize the speed reductions. This is easily done at altitude on level flights. Go out there in the wild blue and practice this to figure out at LEVEL ALTITUDE say around 1000-2000 feet and see what the aircraft delivers. Start with 2000 RPM and reduce your way to 1500 RPM with increasing flap settings to realize the speeds the aircraft delivers, to figure out what works for the aircraft you are commanding. Once the appropriate speed is determined. Write the power settings and configurations down and voila you have a winning strategy. In the Arrow , Mooney, Bonanza and other Manifold (MP) yielding complex aircraft the idea is similar but slightly different. Establish the power setting with a 17 MP and a 2400 RPM (should get you to gear speed) Put the gear down and trim for level flight and then use the flaps for future speed reductions. Further reduction in power starts at 500 feet on final. Hmm…QED.



Flaps are a great addition to the wings; they provide drag and 30 degree flaps essentially are like barn doors that decrease air speeds and allow us to fly deeper descents to the field without increasing the air-speed. Pretty smart thinking by Edward F. Zaparka in 1932. They also by virtue of the increased camber of the airfoil (wing) help reduce the stall speed. A double advantaged whammy, so to speak. Lower Airspeeds, Lower Stall speeds and viola you can hover down to a chirper landings...most of the time. Except that one time when the Airbus 321 pilot decided to flair 10 feet above the runway and darn near took my teeth out. I can still some days hear that chatter.



Nuance: In gusty winds add HALF the gust (say 320 10G20) or 5 kts to your speed by adjusting upwards the MP or RPM as the case maybe.

Another nuance: The Dreaded, sweaty and bile eating last 500 feet. How do we address that? Simple. My dear Watson!



The power is in your hand. Get your aircraft visually aligned with the runway. Put the nose of the aircraft right on the approach end of the runway and KEEP it there (as if you are in a shallow dive), now adjust the power (MP or RPM) to maintain the Vso *1.3 till you know you have the runway made (which means in case of complete loss of power at that altitude, you can glide to a safe landing on to the runway). But please make sure if this format is different than your instructor’s advice, practice what your instructor says and if any of the above is helpful to your thought process, incorporate while he or she is stuck in the right seat.



As always… Safety is no accident, so FLY SAFE!

Ahhhh...

A short video of 7 Landings in 7 minutes for your viewing pleasure...

https://youtu.be/ozrowvQYv_M



Monday, July 9, 2018

"PERMITS, LICENSES & CERTIFICATIONS"

Humans have a neural substrate of imagined sounds. In music sometime anticipation is used. At times, the musician will withhold a much-anticipated note to increase the desire to hear it by the listener. In fact, our mind predicts such imminent structural pauses as whetting the desires of the potential future. Ringo Starr of the Beatles did that masterfully in his drumbeats. But what happens when that note fails to materialize? It simply jars the mind. 

Why I bring that up is simply to explain the nuances in our current state of society that have subverted the naturally occurring structural pauses into dead ends. Permits and licenses and certifications are everywhere! The pedigree of these chaotically semi-predictable meanderings has long been passed down as pedogogical constructs. We expect them. We know them to happen as the laws of Nature and civility.



Imagine if you will, a 9-year old sitting on a bare-bone furniture of chair beside a table with the following set of artifacts. A Pitcher filled with Lemonade, some plastic cups and a sign “50c Lemonade.” People come and go in front some with a glance and a smile and others willing to partake in the offering. Soon the child has accumulated $8.00 as her revenue and starts on the second pitcher when a blaze of blue and red lights filter across the horizon and stop in front of her lawn. By then, the child is in tears and the parents are answering legal questions to protect their child and themselves. Far-fetched imagination, you think? Nope. It happens in most of the “ultra-intellectual” states of the United States today.

In fact, the other day there was woman aptly termed “Permit Patti” who upon seeing a 8-year old selling water called the police. Ah yes, she was the whistleblower against the 8-year old child. Permit Patti was looking to put an end to the child’s entrepreneurial spirit and dashing all hopes of an innovative mind of the future. A shame!

Yes, we as a society of the “developed and civilized” world have become the most developed “permit, license, certification needs” hungry society of all times. The legion of Rent-seekers are burgeoning to fill the void where common sense once prevailed. A pity! You want to cut a tree down, get a permit. you want to put up a fence, get a permit. You want to add plumbing to your house, get a permit. In fact, you want to have a garage sale, get a permit. Our lives revolve around the “Permit Alleys” of the Municipal buildings and other such Regulatory bodies daily. Still, I haven’t yet seen a permit for practicing witchcraft yet. But I have seen one for landscapers, pest catchers, pet groomers and all other sort of occupations. It appears, the authorities are at the threshold of every mode of work one can do, collecting fees.

via Charles P Kroll CPA


Case in point, once again; Medicine. You need a license to practice medicine governed by a small cadre of physicians and others called the Board of Medical Examiners (BME) (Hmm... The others include; lawyers, lay people, nurses, insurance liaisons and others sought fit to deem if the physician is fit to practice medicine). Each State in the United States has one. (Then there is a Federation of the Board of Medical Examiners a quasi-non-governmental organization that seeks to rent-seek at the National level and recently tried to acquire a large multi-million dollar building in Washington DC near the seat of power to exact some for itself, but failed). Well okay then, that is the law of the land. And away we go to the proverbial “paddy-fields.”

Next, we get to some off-the shelf, quasi-self-appointed-governing body that has coopted some of the BME power over the physicians by crafting a net over the entire nation and wishes to exact its authority and the physician's financial resources around the globe as the global authority in physician knowledge testing. It is a not for profit organization. Using their “(esoteric-)knowledge-based examination certifying that the physician had achieved a level of knowledge above the rest of his or her peers, they claimed, was a badge of excellence, . No support for this excellence in patient benefit or physician benefit has EVER been found. Yet the drum beat goes on. That examination, initially, was voluntary and would cost around $2000.00. But as time went on and conflicted Authors from that Board wrote self-serving papers trying to prove the validity of the need for that examination as a corollary to a physician’ s competence in caring for the patients, the cost now seems well in advance of $10,000.00-$15,000.00 (if you factor in all associated costs). Soon ABIM/ABMS were awash with money, enough to lobby and win the governmental seal of approval. The Certification Examination being a very expensively generated and with proprietary set of statistical modelling tools, was held in “prison-like environment to prevent physicians from copying the questions. See Dr. Westby Fisher’s podcast. 

via Charles P Kroll CPA

The ABIM/ABMS revenue stream was increasing at a geometric scale but not as fast as the salaries of these “esteemed” board member individuals and their lucrative pension plans. They decided that the initial examination was not enough to sustain their avarice and thus the new dictum came down; “all physicians needed to take the recertification examination every 10 years.” There was another revenue spike to the delight of these few. Soon the Cayman island resorts and associated “free-from the prying jurisdiction of the IRS,” banks were frequented for annual, semi-annual and quarterly “Retreats.” A nice multimillion dollar condo in Philly fully furnished with a Mercedes Limousine and Tax-exempt cash stored offshore for safe-keeping became a “brilliant scheme” away from the prying eyes of physicians and others, didn’t it? Or so they thought, till it was brought to light. They concocted the scheme to have a continuous “Maintenance of Certification” operation inflicted upon the physicians, because, well, physicians, they implied, seem to lose their grasp of medicine pretty quickly and their care could not be trusted, because, well, jumbo jets filled with physician mistakes were crashing and causing a high mortality...see the Susannah Fox piece  virtual patient-loaded-jumbo-jets crashing every week. 

Meanwhile the MOC as it was named generated oodles of money to the tune of $160+ million for the so called Not for Profit organization, yet the handsome salaries, bonuses and pension liabilities of these few, continue to exceed the revenue streams. “What to do?” they must have thought? More pseudo-scientific papers were written to convince the need for the maintenance of certification (MOC). Those with vested interests and no SITG (Skin in the Game) http://www.medtees.com/content/MedicareBilling.pdf sang praises as they lined their pockets,while, in the meantime the physician force was getting despondent, depressed and with the burdens imposed upon it from this organization and other governmental Regulatory initiatives, there was a rash of physician suicides. “No, don’t look there!” they implied, “Look here, where we are doing so much “public good,” by testing the competency of the physicians constantly.” But the gig seems to be up!

A few physicians have seen the charade and the façade behind the whole scheme. More are learning daily. And, the dollar-lined walls of these organizations are starting to show deep cracks. 

“Permits,” it’s all about permits and licenses and certificates Oh My!

A society so constrained from achieving its potential will ultimately die from starved ideas. The bureaucratic hold on innovation and entrepreneurship always destroys the desire of the few lurching towards the “Next Frontier.” Only the few crooked ones make out fortunes for a while until the hammer comes down on them: Theranos and her Holmes face, to name one. Where exactly were the permit-granters, allowing $9 billion investor money and hundreds if not thousands of patient harmed based on inexact diagnostic report generation. Where were these “expert permit granting authorities?” Nowhere close because Elizabeth was smart enough to fill her Board seats with well-known politcos and power-brokers so no one dared, until John Carreyrou, a recalcitrant health-care reporter from The Wall Street Journal did. 

So you see dear reader, this charade of “Permits, Licenses and Certifications” is a game for the thrones. Decrees to pay up and shut up. Who thrives is known. Who gripes, who cares?

By the way, I forgot to mention the Medical Organization… It is the American Board of Internal Medicine (ABIM) and American Board of Medical Specialties (ABMS). Other agencies and organizations usurping physician’s abilities to give good care to their patients also include the now famous American Medical Association with 12% membership and most (Almost $200 million) revenues coming from the CPT coding needed for the Electronic Medical Records and Billing… @CharlesPKroll (twitter) a stalwart researcher CPA, adds these miniature bites to inform us:

AMA Membership Dues vs CPT Royalties 2008 - 2016
☐Total Dues: $362.3 million ☐Total Royalties: $673.9 million
☐2016 Dues Down $5.0 million (-11.3%) from 2008
☐2016 Royalties Up $53.5 million (+97.1%) from 2008
☐2017 Dues Down Another $2.5 million

 The American College of Physicians and other specialties with the word “American” before it, all appear in cahoots with raising their revenues thru these quasi-ponzi authoritarian schemes without concern about the harm to patients.

The "note" of humaneness and harmony is missing and there is grave dissonance in the society these days. Maybe it will pass and maybe it won’t. But it won’t be for the want of telling the truth.

Because Dear Reader, remember, if you harm the physician, you also harm the patient! 

I wonder how they (the rent seekers) can live with that?

https://www.vanityfair.com/news/2016/09/elizabeth-holmes-theranos-exclusive