NIRVANA HEALTH?

Do you have a blender? Of course you do. Almost everyone does. Now take a few ingredients:

1.       Patient centered.

2.       Shared Responsibility

3.       Patient determined diagnostic tests

4.       Google

5.       Expert opinions

6.       Population Medicine

7.       Genetics

8.       Epigenetics

9.       Medical Apps

10.   Digital Electronic Medical (Health) Records

Put them in the blender and press the switch. And what do you get?

CHAOS!

Remember Mark Cuban’s self-monitoring regimen of serialdiagnostics?  Now add to that the new Arizona law that allows patient to seek diagnostic tests on demand, sponsored and perhaps lobbied, I believe by at least one private company Theranos, now defunct because of fraud, hubris and conceit. and then for good measure throw in the $1000 genome sequencer (available soon from MinION) and what will you have? I am all for low costs and freedom to violate the vein where truth flows, but shouldn't we also have the wherewithal to understand the information that elixir of life holds and its true meaning?

Otherwise we have, health-ism on steroids! Think Road Rage was a 2014 issue, think again. Wearables, forget them our sodium and potassium levels will be on TV just like the lady that walks smiling at everyone and finally levels with her co-conspirators in the ad that her cholesterol dropped by a few % points because of the pill. And what does that mean exactly for her health anyway? Now we find out…little. But that ad sold the pill to the tune of many billions of dollars and may reach $1 Trillion by 2020  .

Information is great if one can interpret it. Information is good if it can be assimilated and the individual can draw an understanding from it. (And there is no political correctness here about how smart the average person is) Even an above intelligent person, (reference to the average intelligent person cannot be found anywhere) with a science background but without the medical reasoning will be lost in the cold waters of the Atlantic Ocean just like Mr. DeCaprio in the Titanic or the warm waters in a pool in Hollywood, your call.

You see, and this is not a paternalistic statement, when fear envelops a person, reason is thrown to the wind. Everything becomes dark as fear and caution arrive at the doorstep. So yes Mark Cuban is a very smart business man and he has tens of interpreters of maladies available to him that assign risks as related to his medical tests. Do we all have that capacity? Yes you say, I have Google! Sure you do as does the rest of the world. But is the information in Google easily assimilated? For instance can you easily figure out what the following paragraph means? And then we circle back to is Mark Cuban correct in his interpretation?

“MIR-21 expression was demonstrated in 63 (79%) pancreatic cancers ( 1+ in 49, 2+ in 14 ) compared to one of 12 (8%, p < 0.0001) benign pancreas and 12/45 (27%, p < 0.0001) chronic pancreatitis. None of the benign tissues demonstrated strong miR-21 expression. Although miR-21 expression did not correlate with tumor size, differentiation, nodal status, or T stage, strong miR-21 expression was predictive of poorer outcome compared to absent or faint/focal miR-21 expression in patients with node negative disease (median 27.7 months vs. 15.2, p=0.037). Nodal status was also predictive of survival (p=0.029)”

Or for that matter, here in this article is the inverse of the loop-hole of expression, and benefits are told through the worm-hole of inhibition…

“This strategy was explored in the current study, where p53 downstream target miR-34 was restored in p53-mutant pancreatic cancer MiaPaCa2 cells with a high level of Bcl-2 and low levels of miR-34s, resulting in downregulation of Bcl-2 and Notch1-2, together with the inhibited clonogenic cell growth and invasion; increased apoptosis and G1 and G2/M arrest in cell cycle; and sensitization to chemotherapy and radiation. miR-34 restoration could thus re-build, at least in part, the p53 tumor suppressing signalling network in pancreatic cancer cells lacking functional p53. This multi-mode action of miR-34 provides a therapeutic advantage over the siRNA-based therapies in that miR-34 has multiple targets, can work on multiple cell signalling pathways at the same time, leading to synergistic effects which may translate into improved clinical efficacy for pancreatic cancer patients with p53 deficiency and advanced disease.”

Interpretation is filtered through the lens of one’s experience. Reasoning is based on critical evaluation that is derived from years of knowledge gathering and experience, sifting through what was evidence to what is evidence now and only through squeezing the fruits of your labor through the ethereal filter of the cognitive cloth, the nectar of reason appears. I doubt that Google searches can deliver that. Sergey might disagree.

So yes, the world is agog with patient centricity but rational decisions can be irrational in times of stress. Take for example the rate of the C-Difficile infection rate differencesbetween the Northeast, 

where everyone seems to know everything, the C-Diff rate is 8/1000 hospital patients. In the South the rate is 5/1000 hospitalized patients. Here the prodigious use of antibiotics is the culprit- a problem both at the consumer demand level and the physician care-delivery level. Judicious use of therapy is equally as important as the reasoned use of diagnostics.

Speaking of Genetics, now there is where real information will flow; and lots of it. But will anyone be able to accurately decipher it. Probably not well. Even geneticists have problems merging the science of DNA (easy) with miRNA (not so easy) and that to translatable proteonomics (even more difficult). Our thinking that one gene defect equates to one disease is unfortunately archaic. Now we have come to realize that even mutations within the BRCA 1 gene segment have varying consequences on health.

From there we have come to the “BRCAness of breast cancer disease process.” Things do go bump during a lifetime with the jumping genes or transposons as Barbara McClintock called them; mating, fusing, halving at will, to always create the “fittest” model of human being.“The progeny of two (such) sister cells are not alike with respect to the types of gene alteration that will occur. Differential mitoses also produce the alterations that allow particular genes to be reactive. Other genes, although present, may remain inactive. This inactivity or suppression is considered to occur because the genes are ‘covered' by other non-genic chromatin materials. Gene activity may be possible only when a physical change in this covering material allows the reactive components of the gene to be ‘exposed' and thus capable of functioning." -- Barbara McClintock”

BRCA 1 & 2 Gene Segments

Such inner experiments by the DNA are not uncommon. So it is better to realize the shades of meanings before we start touting the virtues of genomic diagnostics. We could end up ruining lives and for their “forever,” live in a state of fear of a hazard that never materializes, like a benign nodule in the lung on X-Ray. Yet the fear throws them into the caves of depression and enforces consumption of fifteen different pharmaceutical agents via televised broadcasts of longevity and that, my dear friends in some cases becomes the norm.

Just before we go drinking that “milkshake of nirvana health” from the blender, let us consider the consequences of such a drink. Shall we?

Above all do no HARM!

A G36 CROSS-COUNTRY TO REMEMBER

It is quite compelling when with a guilty sense of the “rush,” you fly closer to the ground and watch it slipping by at a quickened pace. When your heartbeat matches the tick of the clock in the rhythmic resonance and you proclaim, “Ah Life!”

Now mind you, it has happened before but nothing like this. I’ve flown different aircraft for many years and my favorite one had been the laminar flow version with a turbocharge attached. I started flying the low to mid-teen dry-hypoxia inducing air with a nasal cannula stuck in my nostrils. It was good, looking at the GPS winding down the time and winding up the speed. It was good. But something was missing…

Then came the day when I and a friend picked up a 2007 G36 from Nevada. I had to bring this gorgeous beast all the way to the East Coast. But, there was a caveat; A new 0-timed engine that had to be treated with gloved hands and the travails of an October month. Gloved hand care, we gave it but the October sun was complicit in our delights only for half the way.

So, we, my Bonanza flying friend with close to 5000 hours in a three engine TBO-ed V-tail, decided that 7500 feet would be the best-case scenario to keep the 75% power schedule at 20 degrees Rich of Peak across the hills for ring seating and cylinder smoothened cross-hatching mechanism. And that, was what we did! Ever run a mile in 20 seconds? Well that is how it feels as your heart races and the body is comfortably seated held up in the air by a set of powerful wings!

The late-afternoon departure from Carson City, NV was ordinary with my first shot behind the yoke and a G-1000. We navigated close to Victor 6 Airway as possible, so we could have communication with the Air Traffic Control, playing the valleys as we went along. “We’ll turn left around that outcrop and then right around that one.” The G-1000 showed the outcroppings as elevated terrain in yellows and reds. The Red color were peaks above our flight altitude. Soon, the dry bed turned into drier bed of arid land with outcropping of mountains at 9000 and 10,000 feet poking their tops around us. An endless desert of possibilities. The G-1000 at times not happy with the GPWS proximity alerts piped in with “Terrain, Pull Up, Pull Up” warnings. Happily, it was VFR with scattered layers above and the big blue above and a nifty steady 10-knot tailwind of a 23 knot crosswind along the way. In reasonable smooth air, we gave the peaks a wide berth, swinging through the flatter valleys. Ever ride a motorbike on a winding road? It feels like that at a much slower but more thrilling pace. After all we were not in a kerosine burner tied to our backs like the Jetman. 

The ground rolled by faster than the TAS at 174 knots by a few knots as we got closer to Salt Lake City and then the wonders of nature just usurped the entire thoughtfulness, leaving me speechless. The purple Salt Lake, the mountain range and the causeway splitting the purple salt bed from the blue water, all merged to create a dreamscape one sees conjured up by movie directors and CGI experts.

The Salt Lake Approach (KSLC) was unlike the high-powered-rat-a-tat East Coast ATC.

Quiet, discerning and very helpful. Near Ogden (KOGD) we climbed to 9,500 feet at the gentle urging of the controller and soon the blotches of red turned into pinpoint red peaks to negotiate again and terrain clearance was safe and legal.

Finally, we arrived late in the evening at a plateau hosting a 10,000-foot runway aptly named Rock Springs (KRKS). 

The next morning at sun up and after a thorough preflight evaluation of the IO-550B and its confines, which remained speck-less, we departed into the smooth air of the rising sun. Gorgeous is all I can say. The G36 revved up to its broadcast 174 knots at 7,500 feet again and off we went looking for Don Quixote leaning against the Wind Farm silos that floated by. The terrain after Cheyenne, Wyoming started to fall a bit and we entered into some crosswind with a small headwind component. The cloud deck below went from scattered to a solid undercast and the only way into Des Moines was via Instrument Rules.

A bit about the G-1000 and its integrated Autopilot. It is like an airliner. Nary a twitch, the magenta line and the approach all beautifully choreographed in a seamless dance. The barometric pressure changes, you input the data and the “George” or “Jeeves” does your knob-bidding. Use the FLC and a touch of reduced power and it claims the new lower altitude preselected at the cruise speed. Ah the wonders of gizmos and the ease of flying never cease. Essentially, after a fuel stop at Sydney, Nebraska (KSYD) we filed Instruments to KDSM (Des Moines, Iowa), we had to go down to the DH (Decision Height) at 200 feet above ground to go below the clouds, on the ILS approach into KDSM. After breaking out, I took over the controls from "George" and made a soft 15 knot right crosswind landing on Runway 5. “Man,” I thought, “this G36 makes a pilot look good!”

Departing KDSM was a blur of clouds and in-between layers. The autopilot negotiated the magenta line with expertise, any master aviator would be envious. A little rain here and there, but mostly clouds and minor turbulence, the rest was all grey. There is isn’t much poetry in those next 5 and ½ hours that ensued, except ATC making our straight magenta line into a warped crooked one to get to our destination around some busy airspaces. Arrival was a non-event in 800-foot ceiling, light rain and 7-mile visibility and we were back to sea level residency.

The story of this travel was the G36. Comfortable, OMG as one would say, Awesome! Humming all the way for 13+ hours with less than half a quart of oil. Now that is what I call a machine’s machine. if you ever happen to encounter this kind of possibility, take it! You will thank me for it.

Loved it. What a wonderful adventure, attributable to the folks who made this beautiful flying machine; Beechcraft Bonanza G36.

Hats off to them!!

A G1000 PRIMER

“I've got gadgets and gizmos a-plenty
I've got whozits and whatzits galore” – Ariel

Of all the advances in aviation science, besides the jet engine that is, there is little that beats the G-1000 suite or its forerunners. From the steam gauges to the “Glass” is a short hop into nirvana. Imagine if you could…disregard that, we need to get there and I have to help get you there.

G1000

Turning On:

After the battery is turned on and the Reversionary Mode has been successfully viewed, turning the Avionics Master Switch does the trick. The G1000 goes through its system check and then wants you to accept its status with an ENT button.

PFD:

Displays the 6 steam gauges on a single screen and many more. The Speed and Altitude on an Up/Down Ribbon as well as the VSI adjacent to the Altitude. There are small magenta ribbons that tell you the projected speeds and altitude if one stays on the trend trajectory. An embarrassment of riches awaits you to get yourself involved inside the cockpit, but don’t. Learn to scan the relevant information and then scan the horizon for others, even with an ADSB virtuoso installed. Remembering flying is an art and not a video game. That having been said, let us go filtering through the catacombs of this brilliantly crafted machine.

The Attitude Indicator is based on the AHRS and has no vacuum pumps to worry about. The Display is centered with the Speed and Altitude Ribbons on both sides (arrows). The Speed Ribbon on the bottom also gives the Calculated TAS enabled through the Air Data AIRNC.

Normal Mode of PFD and MFD depicted below…

The Attitude Indicator is the entire horizon depicted across the screen, so you cannot escape the Blue over the Brown/green (right side up analogy). There is a command bar on top that tells you what operating mode is on display. If the Integrated Autopilot is on it will tell you AP + GPS (Magenta Line Navigation) + ALT + XXXfeet + NAV or HDG. IF either the ALT or NAV are disabled by pressing twice on those buttons then ROL for NAV and PIT for Altitude become operative. The Desired Track, ETE and DTK and Track are also up there. For most $200 hamburger flyers, there is a DIRECT TO button that gives the shortest magenta route to that burger. And if you should care to now what Airports are nearby, just press the NRST button and a range is presented in the MFD. The information about these Airports can be readily available by pressing the FMS button and outer knob to navigate to desired airport and getting all the data upfront. If you have flown a 530 or 430, the G1000 is like them on steroids; awesome. The Multipage Flow Diagrams for some of the SOFT KEY Functions are detailed below...

The Soft Keys below the screen have different functions when the First level, second level or other level pages are used. For instance, in the First level page if the ENGINE soft button is keyed, it will display LEAN/ASSIST modes which when pressed will take you to those pages.

On Second level page for example, if WIND is pressed it gives you options for Wind Direction, Crosswind, Headwind and Tailwind components. It is logically hierarchical.

The HSI can be configured to give the Compass rose of 360 or ARC HIS.

AUDIO PANEL:

The Audio Panel has many Superior qualities. It can isolate the Pilot/ Pilot + Crew. It can allow the Pilot and Co-Pilot to monitor different Frequencies. And the Red Button below is for the Manual Reversionary mode if One screen goes blank then the other takes over as the PFD. Some of the functions may be disabled depending on the aircraft model.

An INSET button on the Soft Keys on the PFD will plant a miniaturized MFD data on the left lower corner of the PFD in reversionary mode, so one does not have to swivel the head too often.

MFD:

Simply a huge map that can be zoomed in and out with the Range button. A Flight Plan (FLT) to insert inputs. (Garmin Pilot App interfaces with the latest version of G1000 software and uploads the Flight Plan via special hardware insert)

Below the MFD MAP there are Functions that can be entered by turning the FMS Knob on the Right lower corner of the MFD Display. Each of those Functions have multiple Page displays that can be entered by using the small FMS Knob. You can turn to the AUX page and review the GPS data, Current Software and more such goodies on those pages.

On Start:

The System Engine Page always ON, on the MFD gives you read outs on the MP (if there) or the RPM. Fuel Flow, Oil temp, Oil PSI, Gal Remain, Gal Used, Endurance, Range in nautical Miles and Electrical Information. Engine LEAN can be used to lean the engine at altitude to desired temps and there is an ASSIST button to help pick out the peak (with a hollow blue rectangle on top) on the Cylinder number to use as a guide for lean of Peak or Rich of Peak aircraft performance.

If a Flight Plan is ACTIVATED then the Integrated Autopilot will fly the magenta line, anticipate the turns on the proposed plan and give distances and times to the next Waypoint. If there are various Altitudes that the specific Waypoints require to be flown at then the FLIGHT PLAN screen box can be made to set those Altitudes manually and the GFC700 Autopilot will fly them accordingly. A real nifty little feature is the VS (Vertical Speed) Toggle that button and then punch in the Up or down button (for each push up or down the VS climb and descent of +100 feet/ minute is activated). On the other hand if one presses the FLC button with a Hard Altitude set on the Altitude box and the power is diminished 500 RPm or 5 Inches on the MP, the GFC700 will command the aircraft to descend at the specific IAS to that specified Altitude, when the Throttle can be advanced again.

Okay this article is getting long on the tooth. So, let me sign out. More next time, if you like this one, let me know. 

Next time perhaps an IFR flight on the G1000?