The Gossamer of Failth

The gathering storm looms over medicine. The clouds are turgid with the darkness of human thought. The winds of change are strong as they rattle the shutters while the windows grunt and the whole house of health shudders.

The vortex nearby touches down and in its finite warp captures the patient and the doctor and lifts them in its frenzy to spit them out in far away places. The anger of division meanwhile boils and bubbles. The distance between here and there is farther then the eye can see. The purpose is alienation.

“Doctor, what do you think I should do?” cries the patient. She is shielded only by the warmth of her family and friends, but now seeks shelter in the comforts of another being’s ability. She confides in his knowledge, his care, his desire to seek the ultimate help and his concern for another human’s distress. While he looks at the ravages of nature’s wrath upon a human being and thinks this could be him and captures every essence of what can be done and should be done to come to bear in helping this patient. He volunteers himself, his comfort, his knowledge, his waking moments and most times his resting moments to come up with a plan to thwart the disease that lurks.

“This is what I think we should do.” Replies the doctor after much thought, capturing in that moment all the knowledge that has come to fore on his shoulders to help his fellow human, live through the storm.

“But the insurance is denying this treatment.” She cries, the tears of anger and frustration welling up and threatening to cascade. Her cry seems to inquire, when did another party step into this decision making process? When did the “I think…” of the physician turn into a conspiracy of personal desire. Each individual is an entity that lives by the rule of his/her own double helix. Each is different and each merits an individual mandate of individuation. One size does not fit all, or so as we know from the fields of genetics, neuro-psychobiology, psychotherapy and nurtured life. Whereas for one a simple “no” can be considered a blow to the solar plexus while to another it is a challenge to be undertaken. The field of psychiatry has taken blows from the insurance industry, the latter expecting to cure age-old ailments of the mind in three to seven easy steps. Imagine undoing the riddles of the mature forty or fifty-year-old brain that has been seeded with strong neural pathways from overuse and expect to break from them with words such as, “that is not the way for you to think.” The psychotherapist has to gain the trust of the patient before the latter allows him or herself to be shown a different path. That takes time. Similarly the established bridge between a physician and patient has to happen before the full benefit of therapy can be reaped by both; that of a healthy being rid of the illness.

“So you really think this is the right path. Even the internet says that this treatment has less then a 50-50 chance to work.” She looks down not meeting his eyes.

“You are unique in your own individuality. My plan is based on what I know about you and about this tumor biology.” He answers trying to peer into her eyes. For fear and distrust leads to lack of faith and there he knows no medicine will be powerful enough to wash away this ordeal. It is the limbic connection he seeks that must exist between the physician and his or her patient where true healing resides. The trust feeds into the faith, which bleeds into the self-regenerating spirit. Someone is helping me help myself.

“But I won’t be able to pay for it!” She cries.

“We’ll work it out. There are options available to us. I’ll make some calls.” The doctor says, comforting her. The connection between the two remains firm and she lets go of her reservations. From those words and his eyes, she feels that he will take her to where she wants to go. He feels equally indebted to carry out his promise.

The bond of trust has been established. The faith of words has challenged. And the humanness of living will serve as guides for both.

The gulf that is now widening between the physician and the patient is still bridgeable if the dividers would leave medicine alone, any further and the bridges will not be able to span the divide. The cost of care is alarming in of itself mostly because of the third blind party that shells out the money. It deprives some, of quality care under the guise of unnecessary while it fills pockets of the overseers. It creates a wider gulf in the practice of medicine. It creates an environment whereby the patient distrusts the physician’s motive and in so doing hurts himself or herself due to the disconnect. The dance between the patient and physician follows in lockstep to the beat of a given therapeutic course suggested. Should they lose the rhythm and start stepping on each other’s toes with abandon, all form, grace and function is lost.

The physician is like the deep-sea diver, diving as an instructor with a student. If the oxygen mask accidentally gets disconnected and the student panics, the instructor is there to calm him and restore the continuity, even through all the arm-thrashing and panic. Without that one on one trust all hope and more often life is lost to the ravages of the stormy seas.

Medical care is a joint stewardship between the patient and the physician. It is akin to a mountain climber who anchored through his anchoring lines and pitons can help a slipping climber by lending a hand. If the connection between the two is weak, there is no impetus to support others for fear of self. On the other hand if the anchor of the one giving help is weak then lending support brings both of them down to certain doom. 

In medicine it is not the degrees in front of the name, or the number of articles written, or read or journals subscribed to. It is not in the pinstriped suit or the color of the tie that real care resides. It is not in the P4P, "bundling payments," EMRs, "Demonstration Projects" or other crafty words used as symbolisms, it is in the empathic connection for another human being in need. The luminescence of interpersonal resonance between doctor and patient is bright when not filtered through the veil of impersonal advocacy and imposition of a barrier.

Insurance carriers from any agency, government or private, have little impetus except to restrict, minimize, shrink the outlay of capital so the private companies can make more for their shareholders. For the government, so it can garner more support from the voting public. There is no love lost in individual care by either one, except the need to curb, curtail and crucify.

Personal responsibility on either side of the medical divide is the answer to the most efficient and cheap medical care. The free in freedom is for self-responsibility and not what can be had for free.

The most sacred of all things in caring for an individual or being cared for by another, is trust. We still live by that Gossamer of faith.

The Rise of the BORG (Bacterial and Viral Resistance)

"It is always wise to look ahead, but difficult to look further than you can see." ~Sir Winston Churchill

Resistance is Futile

Of all the things that convince me about the future, nothing is so stark, so definite, so telling, and so real than the human hubris. No don’t get me wrong; we live in an environment of self-proclaimed wizards, the same snake-oilmen, quasi-intellectuals who can charm the socks off of anyone. We are the experts that hail from the top of Mount Sinai and yet in that very expertise of existence there is this gnawing, irritating human trait called humanism, or more aptly describes as arrogance, the one that is seduced by the vapors of grandeur, by the deluding sense of perfection, by the lofty sense of perfect knowledge. Oh but I digress into the jungle of human existence.

We exist on this planet with billions of other species. And to be certain there are estimates derived from fossilized records that over a billion species have perished between life and now and that three species go extinct every hour. We are one of those species too but with a short lifespan overall thus far as we hasten towards self-annihilation. True we are the ones gifted with the bipedal motion, the extensions of arms and the dexterity of hands that has culminated in populating this planet with monoliths as high as the Stone Henge, Empire State Building, Khobar Towers and the like and made cities where once water and swamp reigned. Yes we are the quintessence of dust as Shakespeare called us, not because we are great or majestic, but because we have the power of reason and that sprinkle of pixie dust called hubris.

"Look deep into nature, and then you will understand everything better." ~Albert Einstein

And then this:

We must rid mankind of all maladies!

Really?

I mean have we thought this one through at all. Have we reasoned? Have we spent an evening thinking about the entire collective life on this planet as a whole? Have we?

Tuberculosis

Take for example the TB conundrum. We started out with this scourge and found some medicines to combat it. And we were successful. A tincture of Streptomycin and the scourge was no more. Where previously sanatoriums had been constructed to isolate the infected and infirmed till their self-healing or death, now the magic of an injection arrested the continuum of that horrid vigil.

Soon better drugs reigned, like Ethambutol or EMB, Isoniazid or INH and Rifampin or RMP. Each garnered a better share of the TB bug. We all celebrated the onslaught against this vile bacterium that had cost so many lives and we had won. The flag of security had been flown atop the TB gravesite.

But then came the discovery of these clever critters finding little loopholes and infecting humans again. Mathematical Modeling revealed a stark but deafening verdict. TB was undergoing mutations and becoming resistant to our glorified, impenetrable lines of defenses. And that Mathematical Model was verified in real life!

“The rationale for using multiple drugs to treat TB is based on simple probability. The frequency of spontaneous mutations that confer resistance to an individual drug are well known: 1 in 107 for EMB, 1 in 108 for STM and INH, and 1 in 1010 for RMP.”

And not only that, but these little bacterial buggers were becoming more aggressive and thus more deadly in their behavior. What once was a relatively long survival, albeit in the sanatorium, to complete riddance of the TB bacterium now killed humans with impunity within a short span of days.

A study in Los Angeles found that about 6% of cases of MDR-TB were clustered. Multi-drug resistant tuberculosis (MDR-TB) is defined as TB that is resistant at least to INH and RMP. Isolates that are multi-resistant to any other combination of anti-TB drugs but not to INH and RMP are not classed as MDR-TB. Yet the MDR bug had climbed its way into the inner sanctums of inner city!

“There is currently an epidemic of XDR-TB South Africa. The outbreak was first reported as a cluster of 53 patients in a rural hospital in KwaZulu-Natal of whom 52 died. What was particularly worrying was that the mean survival from sputum specimen collection to death was only 16 days and that the majority of patients had never previously received treatment for tuberculosis.”

To be accurate about the Mathematical Model here is a short excerpt to understand the conundrum better:

“A patient with extensive pulmonary TB has approximately 1012 bacteria in his body, and therefore will probably be harboring approximately 105 EMB-resistant bacteria, 104 STM-resistant bacteria, 104 INH-resistant bacteria and 10² RMP-resistant bacteria. Resistance mutations appear spontaneously and independently, so the chances of him harboring a bacterium that is spontaneously resistant to both INH and RMP is 1 in 108 x 1 in 1010 = 1 in 1018, and the chances of him harboring a bacterium that is spontaneously resistant to all four drugs is 1 in 1033. This is, of course, an oversimplification, but it is a useful way of explaining combination therapy.”

So a new barrage of drugs are being crafted and drafted in the battle to circumvent this new abrogation in the paradigm of human thought; that we have control.

Hepatitis B Virus

Just so we don’t get too comfortable with the thought that this is only a single bug. Heck we can smash it in no time. Let me take you into the machinery of the HBV also known as the Hepatitis B Virus.

The gene that encodes the HBV polymerase overlaps with the gene that encodes the viral envelope, and so mutations in the overlapping reading frame can change both proteins.

The HBV is composed of 3400 base pairs and five genes. Each has a specific purpose.

The hepatitis B virus (HBV) is a DNA virus that replicates its genome via an RNA intermediate using reverse transcription. What is interesting is that for its replicative maneuvers, it converts itself into these CCCDNAs or Covalently Closed Circular DNA that is tightly wound together DNA machinery and is impervious to the drugs targeted against the HBV. 

Life Cycle within a human body

So while all viral particles floating around in the blood stream may be rid by the directed therapy, the CCCDNAs residing in the liver tissue by the billions laugh it off in comfort saying “We’ll get you in the end.” The CCCDNA survive to form a large reservoir for replication, reactivation and their own survival in the human body when the selective pressures of therapy are presented.

Hepatitis B Virus

It is important to note that the signs and symptoms from the HBV infection come not from the viral replication but from the Immune response initiated by the body to kill the virus itself. The genetic mutations occur at a glacial pace based on linear time. The rate is 1 nulceotide mutation per year (Mutation Rate = 5*10^-5).

The selection pressures allow the virus to mutate and create quasispecies to live within the liver: It is the constant destruction of the liver cells and the immune response mediated that determines the clinical behavior. “Mathematical modeling showed that the half-life of hepatocytes varies from 30 to 100 days, depending on individuals' immune response.”

The composition of the viral quasispecies evolves over time depending on the selective pressure including, vaccination and antiviral therapy and the host immune response. Escape mutants may then spread in the liver and become the dominant species depending on their fitness (i.e., their capacity to replicate and dominate wild-type strain in the presence of antiviral pressure) and the replication space available for their dissemination in the liver.

PCR Genotyping

The issues of genotyping plague a well-balanced assessment of the HBV quasispecies because of the many pitfalls in the process itself. Yet these are the known methods of determination at present and we have to make the most from them. The dilemma of study is compounded by the dilemma of the limitations of knowledge. Genotyping of the whole virus is tedious but remains the gold standard today. Yet studies continue to use partial genome analysis for reportage that hurts validity and confounds the truth in literature. Besides a single SNP or dual SNP cannot be ascertained by whole genome testing. It has to be done on a SNP by SNP basis with specific endonucleases... so there, now you have the most of it, if not all!

PCR Genotyping Methodology

“(Genotyping relies on either DNA sequencing or hybridization. Sequencing-based methods include standard population-based polymerase chain reaction (PCR), cloning of PCR products, and restriction fragment-length polymorphism analyses. Direct PCR-based DNA sequencing can detect a particular mutant only if it is present ≥20% of the total quasi species pool.61 Cloning can overcome this problem, but analysis of large numbers of clones is required. Viral mutants that constitute as little as 5% of the total population can be detected by restriction fragment-length polymorphism analyses, but separate sets of endonuclease reactions must be designed specifically for each (and known) mutant of interest. These methods are labor intensive, require highly skilled personnel, and are not suitable for high-throughput screening.)”

The virus exhibits the following drug resistant mutations referenced below in the Addendum: primary resistance mutations (rtM204I), secondary resistance mutations  (rtL180M with rtM204V) and compensatory mutations (rtV173L)

So after the facts and the implied human hubris, we are left with a rather sobering thought; species are coevolving and each species finds a niche to survive and progress. It is after all in the Darwin’s dictate that, “Survival of the Fittest.” Choosing to ignore such an important message based on aggregated evolutionary evidence is the hallmark of a callous disrespectful self-indulgent human mind. Say it ain’t so!

"All, everything that I understand, I understand only because I love." ~Leo Tolstoy

References:

David HL (November 1970). "Probability Distribution of Drug-Resistant Mutants in Unselected Populations of Mycobacterium tuberculosis". Applied Microbiology 20 (5): 810–14.

Sarah McGregor. "New TB strain could fuel South Africa AIDS toll". Reuters. Retrieved 2006-09-17

http://www.ihlpress.com/pdf%20files/hepdart09_presentations/emergence_prevention_vr/2_locarniniHepDart%20FINAL_SLocarnini_031209_REVISED.pdf

http://www.natap.org/2009/HBV/111109_01.htm

Addendum: (On HBV Drug Resistance)

The available agents currently in use against the HBV:

Interferon alfa-2b INTRON® A Merck/Schering 1991

Lamivudine EPIVIR-HBV® GlaxoSmithKline 1998

Adefovir dipivoxil HEPSERA ™ Gilead Sciences 2002

Entecavir BARACLUDE ™ Bristol-Myers Squibb 2005

Peginterferon alfa-2a PEGASYS® Genentech/Roche 2005

Telbivudine TYZEKA ™ Idenix/Novartis 2006

Tenofovir VIREAD ™ Gilead Sciences 2008

The viral mutations causing resistance over time to antiviral agents:

Interferon alfa-2a  (Intron A) Interferon 1991 None

Lamivudine  (Epivir-HBV) Nucleoside reverse

transcriptase inhibitor 1998 14 - 32% at Year 1;  60 - 70% at year 5

Adefovir (Hepsera) Nucleoside reverse

transcriptase inhibitor 2002 0% at year 1;  29% at year 5

Entecavir (Baraclude) Nucleoside reverse transcriptase inhibitor 2005

1.2% in treatment naïve at year 6;  57% in

lamivudine resistant at year 6

Peginterferon alfa-2a (Pegasys) Interferon 2005 None

Telbivudine (Tyzeka) Nucleoside reverse transcriptase inhibitor

2006 25% in HBeAg positive at year 2;  11% in HBeAg negative at year 2

Tenofovir (Viread) Nucleoside Reverse transcriptase inhibitor 2006

0% at year 2; adefovir resistant HBV should be treated with tenofovir and another HBV antiviral

Strange Melodies

They talk of changeable rhythms of the heart, the kind that go from lup-dup to brrrrrp causing untold misery to the patient. Similarly, humans give out signals of love and hate, of anger and peace, of vitriol and quiescence, of joy and despair. We are in a constant stream of rhythmic waves oscillating in the ether, all twisting, mixing and merging. And yet today we don’t see or hear them anymore. The isolation is deafening!

We are losing our sense of connection. Our eyes are forever locked onto the keyboards of ever-diminishing hand held screens. We smile or scowl at these mechanical devices while the world goes by, and Einstein's train slows down while time speeds up. The trees with their collection of birds, or the flowers with their assortment of bees and butterflies are now back in their own Pre-Cambrian domain isolated from the stare of the human eyes~ a colorful world viewed through grey lenses.

And then there is the human race isolating from itself as it devolves all thought and action into the world of glowing screens.

The seven-year old, texts her mother about her plans for the afternoon, while she is in the next room sending a text message to her neighbor. The boyfriend texts a love note to his girlfriend sitting next to him and she giggles in response. The wife texts about the young kids, embroiled in a fight and the father responds with a message to each with a reprimand. Meanwhile the toddler plays with the computer tablet and the infant looks intently to her older sibling, gathering information of what is to come.

What happened to looking into those beautiful baby blues or browns or blacks? What happened to looking through the dark mysterious pools into the soul and realizing the intent? 

Can a written word express the real meaning of what is felt? If not, then is the society losing its sense of feeling? Is this the reason why so many are bereft of emotions and qualify for a stake in the sand-box of the sociopath field? Are we losing our humanity?

There is a story in every eye that blinks, in every lip that curls and every fist that uncurls. There is a tale to be heard, like those camp fireside chats of hobgoblins, of dragons, of swords and archery, of love, of kindness and treachery. There is where we behold the delicious terror through the wide-eyed story-teller’s concocted emotions and display. A quick hand gesture after a moment of silence is enough to draw beaker-filled nerve stimulants into the nerve-endings to make every muscle twitch.  None of that can be simulated on the little screen that glows. Yet we are blinded by the rage of the tiny blinking screens. We are oblivious to each other’s nuanced emotions. If it isn’t seen on the screen maybe it does not exist. But it does. It does! The whole beautiful overarching canopy of wonderful sights and sounds, they exist. I promise you, they do! Just take the time to see them.

What will become of us? Ever think it through. Will we lose the sense of touch, and smell? Will we eventually become the animated robotic versions of our former selves? We have become the HALs of yesterday and are on target to become the WATSONs of tomorrow, with more unnecessary information loaded within, but without the essence of the deep knowledge and understanding to utilize it with deliberate efficiency. We seem to be moving into the realm of a society that augurs anger and laughter to the flash on the tiny screen. We seem to be losing the sense of touch and feel. Maybe, I plead to my inner sense of hope, that the pendulum has swung as far as it can go and now has nowhere to go, but come back to the center. Maybe? Just maybe?

We need to listen to the strange melodies of each other’s nature. We need to hear the sounds of our inner beings. We need to connect to the symphony of the human spirit. We need to connect with each other through the rhythm of our souls.

We need to talk to one another, see each other and hold together, for the world is a lonely place!

We need to talk!

"Hi there, Hows it going?"
"Great!"
"Any plans for the evening?"
"Yeah. I'm going to tell a story to the kids."
"Bravo! may I come?"
"Sure."

Lets Listen... For you never know what you might hear and learn...

Medicine and the Nash Equilibrium

Sand-pile Experiment

Stability of a system relies heavily on risk mitigation strategies; these evanescent little fingers that plug the holes of a universal breakdown are but band-aids of sorts, because risk mitigation strategies are based on observable risks only. The Bak–Tang–Wiesenfeld sandpile model is a dynamic system that displays self-organized self-criticality. The system is one sand particle away from a collapse.

Therein lies the problem.

Medicine has gone through its own risk mitigation for a long time. Every hole in the human behavior that potentially could lead to the fall of man is being plugged, band-aided or in some cases spackled over. Medicine has survived many upheavals in the past and it has done so by the artful, careful, considerate and thoughtful understanding by the doctor scientists of the past. Simmelweis utilized the art of hand washing to prevent obstetrical deaths. John Snow an Englishman was the first to show water contamination as the cause of Cholera that was causing 3 million deaths per year in the 1800s. Sabin and Salk used the vaccine to prevent further Poliomyelitis catastrophes in 1952. These are examples of the risk mitigation strategies that have heaped significant rewards for humanity.

As medicine improved humanity’s lot, a desire to help everyone ensued. The grand cathedral of safety was built to help elderly retirees. Medicare was created, as a safety net for the elderly in 1965. It was a monumental success. The price to get the benefit from the system was to pay into the safety net via taxes while a person was employed in the work force, deriving an income and then when a “fixed income” status was reached upon retirement, that money would help defray the cost of their care. On paper, it seemed, a laudable and a well-choreographed scheme. It was designed as a “Pay now Reap Later” concept. Another large gaping hole had been plugged for the senior citizens of the U.S. and many nations who promulgated the same policy. It was a tactical approach to a practical matter.

However over the years as all powerful and wealthy nations with a declining birth rate experience, the U.S. also fell into this trap, the number of workers started to recede in comparison to the numbers receiving the subsidy. Unfortunately this occurrence seemed to happen at the same time that the FICA paying individuals retirees come of age and started receiving Social Security benefits. The debacle that is, brought light to the fact that the government had been using the FICA tax to build bridges to nowhere and stuff the burgeoning public sector “business” with unnecessary expensive “schemes.” The flow of money was so great, free and limitless, that there was no urgency to keep the funds tied up for future retirees. More and more was promised by the politicians running for their congressional seats and the Senate seats in the United States. They brought federal tax payer capital to their states building large behemoth railway stations named after themselves and grand buildings in various municipalities that still lie vacant collecting dust, accruing cracks for the weeds to take hold. Out of guilt or desire for votes, more and more was promised, with less and less available to keep those promises. A picket fence American dream for all was in site and “cheap” money was bandied about so that a $30,000 earning individual was promised a half a million dollar home on cheap mortgage. While that was going on, some used it as an excuse to speculate and house jump reaping rewards for incurring their risks. But then as all bubbling brooks run out of water, credit froze because of the unraveling of the financial engineering and securitizations. Banks stopped taking the “empty” letters of credit and the whole Ponzi scheme came to a screeching halt taking down millions if not billions of people who were left looking through a dark tunnel. The final grain of sand had fallen on the tip of the sand-pile and the cascading landslide created a devastation that we all behold today.

The Landslide

What did that have to do with Medicine? Well, everything, I think. You see fingers of instability have been sewed into the medical system too. Medicine has become more about money then about care. The unstable probes that have been launched onto the medical landscape over time are about to test the fingers of instability. The, this and that was encouraging doctors to accept Medicare payments in part – up to 80% of total. While the money flow was unrestricted more physicians accepted assignments and patient felt they could and did fill the waiting rooms and Emergency Rooms because they did not have to resolve to pay out of their own pockets. Every cough and sniffle found its way into the halls of the hospitals. Each visit cost thousands (read thousands) of dollars. The physicians in the meantime inundated with the burgeoning rolls of patients added to their practices; managing scheduling, billing and other sundry things to handle the large volume of care delivery. Meanwhile insurance feeling the rising cost, limited bonuses and steady profits started raising the premiums and started a “pre-approval practice” forcing doctors to hire more staff to manage approvals and denials of reimbursements. Medicare and the other Insurance Companies initiated an automatic 10-12% denial policy. If the doctor’s office was not prudent in keeping an eye on fiscal matters or on top of their game in billing strategies, then it was too bad for them. They suffered the financial harm to their own detriment and to the thriving bottom line for the insurers.

Medicare feeling the pinch from the rising costs of healthcare due to the planting of miniature “time-bombs” of regulatory fiat, started the nationwide advertising of “fraud and abuse” and started training elderly Medicare recipients and turning them into “whistleblowers” against people perpetuating such fraud. Soon the multi-trillion dollar industry had it tattooed on the populace’s mind that the entire system of healthcare was a fraud being committed in perpetuity. The doctors were vilified and demonized for ordering too many diagnostics and those expensive therapies that “experts” believed should not be used were vilified in the press. The system devolved to the point that the “well-meaning” politicians decided that if they could show their magnanimity by instituting healthcare for all then they would be the grand designers for the future of humanity. But as all schemes done in anonymity are prone to ride slowly to the top of the mountain with banners, they also come down with an express spirit too. That scheme has approached the peak and the sand pile has collapsed. And that is where we are today.

While these ingredients are on a boil in the cauldron and the steam is rising, the detractors pinch and pull the curtains to keep reality from being visible to the masses. “Ah, this is this and that is that,” they say (in Flounder speak) and all the while the bubbles form and burst and the vile mixture is about to burst and splatter over the landscape.

"John Nash" in the movie "A Beautiful Mind"

John Nash the author of “Nash Equilibrium,” is the subject of “A Beautiful Mind” who suggested that as long as strategies are not changed in midstream the equilibrium of mutual benefit is expected.

Well as we have seen that the experts have continued to apply band-aids to the fingers of instability and now have decided to change strategies midstream for all the people - akin to burrowing a hole on the side of the sand-pile. This one-sided change of strategy has disenfranchised the entire population. The “Mutual benefit” is hardly mutual. If you ask the 270 million people who have borne the rising tide of insurance premiums and those that were supposed to be protected find themselves not being able to find good, or, for that manner any care, the entire system is wrought with something unpalatable. Additionally they, the patients, face rising scrutiny for the physician proposed therapies based not on need but on expense. The turgid torque of this volcano is about to expel an undigested reality and it will smell horrid.

The Real John Nash

Plugging small holes in the dam is a euphemism of thought in risk management without an eye towards the bigger picture. And the bigger picture is a calamity of proportions yet to play out. No, this is not a doom and gloom story, it is an unfortunate series of historical events.

Risk mitigation with an eye towards the bigger picture causes a more stable scenario. Piling on sand on sand-piles, eventually, will initiate instability that is sure to end in a calumny.

Collapsing the Degrees of Separation

Digital Pen-Pals

"Those friends thou hast, and their adoption tried,

Grapple them unto thy soul with hoops of steel.." ~Hamlet

Adopting the internet carries a reward unlike any other. It brings people into your life that you would have never met nor would you ever have the chance of meeting. A surprising pause in this reflection bleeds into your thought process, just then, “Huh really?” followed by “I never thought of that before.” And neither have the ones who have not intrigued themselves with the idea of forging this connection.

The ancient oak of reason spreads its roots into the bedrock of communication; it grows loftier in the air while its roots slide and anchor onto more rocks for greater support. It is in the art of communication through which humans find comfort and connection.

Business, Marketing and Advertising lend themselves readily to any format to extend reach. If I can get to your eyeballs and through them into your mind, well then, I’ve got you for that moment. The connection is made through words and it is akin to “You had me at hello!” How so? And is it all about eyeballs and sales?

An interesting question at first glance. No! there is more to the "need for this speed" of communication. One makes “digital pen-pals.” Remember in the old days when you sat down and wrote in scripted format, a letter to another living in far away land, expressing and describing what was around you and what was happening to you, sharing stories embellished with adjectives? Yup I do! The letter was a veritable postcard of your life and your imagined life. Upon receiving a reply and filled with equal measure of the same, you imagined the other side in daylight and in moonlight, through your own rose-colored glasses of how the trees glistened in the sun and how the moon colored the moisture soaked flowers in its silvery embrace. Oh yes, you did, because, I remember sending those letters to you and receiving them from you.

The anticipation was always so electric. The 6-degrees of separation had been rooted firmly through that contact. The landmasses had congealed back into the Pangaea of existence.

But now we are collapsing that 6-degrees into even smaller-degrees. We have the Internet.

What about Medicine in the age of the Internet, you might ask?

Medicine lives on a loftier plane. It does, I know. The pace is furious, the time is short, the distractions are plenty and the meaning of each word is incalculable. In each wink a life is saved and in every other, one is lost. Why then should the doctor consider this medium for interaction? Is it another distraction and a waste of time?

Medicine has some implanted fears. These fears are the regulatory bias of seeming control and yet so many loopholes exist to allow communication to happen between unknown “Business Partners” that the only person whose life, liberty and profession is jeopardized by the turn of the screw, is the physician. You know of course the grand design of the HIPAA law. So then why should the doctor use the Internet for communication?

Communicating with patients directly is a wonderful ancient art of healing. Eye to eye, hand on shoulder, heart to heart. But sometimes in the dead of despair a word or two help. A genuine word of comfort gives solace to the tortured soul. However using digital words that can seep into the “clouds” of unencrypted or even encrypted data by collapsing this degree of separation may initiate the juggernaut crying, “felon,” “miscreant,” and all such relevant forms of vilification against the physician. How best not to traverse that minefield?

There is a way. Write and educate.

Doctors can disseminate information via the digital word, the video format and all sorts of moving art available in the digital world. There are several very intelligent and prolific writers in the field like @Jordangrumet, @DoctorWes, @SkepticalScalpel, @Doctor_V of 33 Charts @GregSmithMD @drjohnm and @hjluks amongst other notables. On the patient advocate side there are other remarkable communicators like @jodyms @jackiefox12 @BCsisterhood that come to mind. These and others like them communicate but do not make it the morphine of distraction! 

So let us collapse the degrees of separation, write and enlighten each other, express our thoughts, understand the other’s, interpret through the lens of our own values, see the world through naked eyes and learn from each other, all without identifying specifics of our maladies or of our life and person. It is after all not about the singular person, it is about enriching life!

Yes doctors as well as patients can both benefit from this digital revolution. No, it is not earth-shattering, it is not the greatest of all things for humanity, it is just two minds communicating via a new format. And the more that find each other in this vast jungle of a 7-billion-humanity, life becomes intelligent, innovative thoughts seize reflective moments and the world transforms.

Remember the jingle: “Reach out and touch someone?”

"To mingle friendship far is mingling bloods" ~ Leontis (A Winter's Tale)

CTCs ( CIRCULATING TUMOR CELLS )

Some years ago sitting in on a cancer conference just barely keeping my eyes at half mast, the discussion was circumnavigating chemotherapy and the cell cycle. The genetics were being discussed but in a oh so "we do not know what this does yet?" sort of a way, that one could barely perceive the many shades of reality and fiction that mixed in the soup of the unknown. As the conference was winding down an older gentleman, a retired physician, happen to raise his hand and inquire whether it was possible to prevent metastasis by placing patients with cancer on anticoagulants? It was for that time a bold queation. But the only response it was able to garner was a few hrrmphs and a couple of snickers. I don’t quite remember the official answer the speaker rendered but suffice it is to say, it was wanting.

It was a plausible question. In fact it was a well-thought through question. Aside from the dearth of data availability he had questioned the very nature of vascular metastasis.

There were several interesting studies that kept raising the bar of this thought in years to come. The CALGB (Cancer and Leukemia Group B) study done in Stage 1 Lung cancer suggested that when the pleural (lining of the lung) was washed with sterile water and the fluid analyzed, the results showed that 40% of the patients had viable lung cancer cells in the fluid, even though the primary cancer was deep in the lung tissue (parenchyma). Stage I Lung cancer has a 60+% 5-year survival. And  then as in now the question asked, is why should 40% of people with such early resected cancer fall victim to their disease? Or another way to put it; why after all, is it considered stage I and a full, in-toto, resection of the cancer done and yet the patient has only a 60+% chance of survival? One would have to hazard a guess that the resection did not quite reach the R0 state. Something remained rotten in the state. Something surreptitiously ethereal and famously wicked continued to haunt the neighborhood of survival. Something that is in the form of a cancer cell!

Interestingly a Japanese study of Breast Cancer patients showed that almost 40% of the patients in early stage cancer had cancer cells in their bone marrow! These findings gave credence to the fact that even early stage cancers of different origins are already outside of their initial site, meaning they had spread, or more technically speaking "Metastasized."

The concept of Circulating Cells is not a new one. In 1869, yes, we are talking back in the late 19^th Century when Thomas Ashworth observed circulating tumor cells in the blood of a man with metastatic cancer. He surmised that the presence of these cells that looked identical to the ones in the original cancer may “throw some light upon the origins upon the mode of origin of multiple tumours existing in the same person…“One thing is certain, that if they [CTC] came from an existing cancer structure, they must have passed through the greater part of the circulatory system to have arrived at the internal saphena vein of the sound leg.”

Sage musings of a scientific mind, don't you think?

Now comes an even more substantial progression of this thought. Lately and notably there has been a significant impetus in “Circulating Tumor Cells.” These CTCs as they are called are found wading in the blood stream of both early stage and late stage cancers. The early stages have fewer then 5 CTCs in a given quantity (7.5ccs) versus the late stage cancers. But what is interesting is the fact that now we have the capability of detection at a very early level.  In a large multi institutional double-blind prospective clinical trial of breast cancer patients Swaby et al. state; "One hundred and seventy-seven patients with measurable disease had CTCs tested prior to beginning a new palliative treatment regimen for progressive disease, followed by repeat assessment at first follow-up visit approximately 4 weeks later. This landmark trial prospectively identified a CTC cut-off level of ≥5 cells per 7.5 ml of blood to be a reliable identifier of patients at higher risk for disease progression and decreased survival from metastatic breast cancer. Regardless of histology, hormone receptor and HER2/neu status, or whether the patient had recurrent or de novo metastatic disease, those with less than 5 CTCs at baseline, and more importantly, at first follow-up after beginning a new treatment regimen, had superior progression free (PFS) and overall survival (OS) (7 vs 2.1 months [p < 0.001] and 10.1 vs more than 18 months, [p < 0.001], respectively).

These CTCs present an attractive surrogate phenotypic and genotypic markers for disease status in a more dynamic and real-time basis.

Several new studies have been undertaken to be able to decipher their presence and use them as predictor of metastasis and survival. Powell et.al reported:

Patients in a training set with levels of circulating tumor cells equal to or higher than 5 per 7.5 ml of whole blood, as compared with the group with fewer than 5 circulating tumor cells per 7.5 ml, had a shorter median progression-free survival (2.7 months vs. 7.0 months, P<0 .001=".001">

Other related studies have demonstrated with equal aplomb the benefits of CTCs as predictors of response much before radiological data becomes confirmatory, eg. CT scan findings lag behind the drop in the CTCs in the peripheral blood samples.

Left bank shows viable CTC cells, Central bank shows damaged CTCs, Right bank shows sheared cells.

The problems and there are always more then one, are how to confirm that the cells being viewed are indeed cancer cells and if they are cancer cells are they effete (apoptotic) or viable? If they were viable did they have the capability to establish an anchor on to the blood vessels and thence spread into far away organs? If they did have the capability did they have the efficient mode of the EMT (Epithelial Mesenchymal Transition) ability to be able to harness the biochemical powers needed to broach the basement membrane? Additional problems that confound have a molecular basis to them and we will address those by the by.

Circulating Tumor Cells morphologically are distinguishable by their appearance in a majority of cases. Tumor cells have a distinct nuclear/cytoplasmic dys-synchrony, meaning that the nucleus of the cells is a large polyploidal, angry-looking-mushroomy globular structure and the cytoplasm (the surrounding fluid) is small and sometimes negligibly invisible. This is in stark contrast to a normal cell, which has a small well delineated nucleus and a large volume of cytoplasm.

Breast Cancer CTCs

Present State:

Our current modus-operandi is to be able to evaluate the presence of the CTCs. Having done that and shown the presence of such CTCs at a certain limit signifies a poorer prognosis in survival. As Powell et al. and others have shown that there is value in such determinations. Built into this simplicity one still has to undo the large conspiracy of “Is it or is it Not? In other words where the dilemma keeps haunting the researchers, is the ability to accurately decipher that the cell they earmark as a cancer cell in circulation is truly a cancer cell and functional at that!

Colon Cancer CTCs:

(Bonus) Here is one method of isolating the cancer cells from the blood sample (CTCs)

http://www.jove.com/video/4248/rapid-isolation-viable-circulating-tumor-cells-from-patient-blood

Several roads lead to this land of promise; from morphologically deciphering via visual inspection (thus based only on reliance of the observer) to using immuno-histochemical means where chemicals added to the cells can make them more prominent, to using molecular means are all different methodologies currently in vogue.

1.   Since the white cells are the ones that confabulate the issue of recognition between them and the cancer cells. The problem arises when you force the blood through shearing stressors of mechanical corralling in a machine for identification and is related to forces of fluid dynamics. The cellular distortion causes the nucleus to appear as all kinds of monsters even in normal cells and gives the nucleus a "naked" distorted appearance resembling a cancer cell. Thus attempts to verify a good cell from a bad cell has taken many a turn and twist. Using Flourescein labeled antibodies to CD45,  an antigenic determinant for the white cells and also utilizing EP-CAM or Epithelial-Cell adhesion molecules with antibody coated magnetic bead for cancer cells that express Cytokeratin is one way of differentiating between the two: “The procedure enriches the sample for cells expressing the epithelial-cell adhesion molecule with antibody-coated magnetic beads, and it labels the cells with the fluorescent nucleic acid dye 4,2-diamidino-2-phenylindole dihydrochloride. Fluorescently labeled monoclonal antibodies specific for leukocytes (CD45allophycocyan) and epithelial cells (cytokeratin 8,18,19phycoerythrin) are used to distinguish epithelial cells from leukocytes. The identification and enumeration of circulating tumor cells were performed with the use of the CellSpotter Analyzer, a semiautomated fluorescence-based microscopy system that permits computer-generated reconstruction of cellular images. Circulating tumor cells were defined as nucleated cells lacking CD45 and expressing cytokeratin.”

However there is another twist in this particular fate; Aggressive cancer cells lose the ability to project the Ep-CAM on their surface, hence looking for CTC just on the basis of the CD45 and Ep-CAM may falsely eliminate cancer cells and that is exactly what happens in the real world scenarios. For example in the aggressive Inflammatory Breast Cancer or IBC patients the CTC detection based on the two immuno-histochemical technique fails miserably for that specific reason. Maryam B. Lustberg, M.D., MPH, study investigator and assistant professor of internal medicine at The Ohio State University College of Medicine, explains: "Some of the most aggressive forms of cancer, including triple negative breast cancer (TNBC), downregulate EpCAM and have high numbers of EpCAM negative CTCs, cells that would be missed by the most commonly utilized technologies. The results of this study support the theory that there is a heterogeneous population of circulating cells in the blood of cancer patients which may hold clues regarding the metastatic process."

Lung Cancer CTCs:

2. Facing diminishing returns, the incorporation of the genomic makeup of the cancer cell is a more predictable one and is based on mutated genes from the primary source. This has been applied to eliminate the false negativity related to antibody mediated histochemical determinations. Although this may appear to be the answer to the conundrum, it is far from it. Powel et al. again make the following references; “the MagSweeper - a cell purification technology, which gently isolates rare CTCs with high specificity. availed recent advances in microfluidics, isolation protocol does not impact viability and RNA integrity of isolated cells nor gene expression, and as evident here by consistent detection of multiple reference gene transcripts, comprehensive genomic studies on robust subpopulations of cells is greatly facilitated. gene expression profiling of primary tumors and its application in the molecular subtyping of breast cancer has provided a biological framework for defining the clinical heterogeneity of this disease. addressing the issue of how to eliminate the contributions of potentially large numbers of contaminating WBCs to overall gene expression profiles when measuring genes common to both 63% of MagSweeper-captured cells showed robust, non-degraded reference gene expression: of cells with non-degraded reference RNA, 60% were defined as CTCs and 21% expressed the CD45 WBC marker.” So here lies another minor issue; the commonality of genes between normal cells and the cancer cells has also to be taken into consideration. The puzzle pieces thus proliferate from the simple to the very complex. Then one has to address the mutated genes and the lack of commonality of the mutated genes between different metastatic site CTCs. Oh what a web nature weaves!

3. While we are involved in this complicated issue (as it exists – Remember I am just the messenger), here is another dollop of mischief that the cancer cells have in store. The Primary cancer at its initial site has a completely different set of genetic mutations as compared to the cancer that is spreading or one that has already spread but circulating its wealth around. Within the circulating cancer cells there may be a large numbers of populations of metastatic cancer cells from different sites that have different genetic determinants. To elaborate that further; CTCs from the primary cancer cell and others from various metastatic sites (eg. lung, liver, bone etc) all will have differing degrees of mutated genes. So even though we can with clarity state that the cells we are looking at are cancer they will have differing sense of  behavior and create a much different sense of foreboding for the molecular geneticists. “Intriguingly, high levels of PTEN expression in 83% of the CTCs were observed despite the known inverse association between this gene and TGFβ expression. It is possible that repression of this gene by TGFβ requires receptor tyrosine kinase signaling (such as EGFR). which might be compromised as indicated by undetectable EGFR expression in the CTCs in our study.. Consistent with the acquisition of invasive and migratory characteristics is the absence of the cell adhesion protein, CDH1, in migrating cells such as CTCs, as illustrated by our expression data. Ostensibly, systematic implementation of single cell CTC profiling will shed new light on the dynamics of migratory tumor cell biology during metastatic dissemination.”

 Image (Heatmap of single cell gene expression of 87 genes within seven individual cells isolated from three primary tumor-derived (pink: CCdl054, orange: CCdl672, gold: CCdl675), and four metastatic effusion-derived (red: MDA-231 plum: SKBR3, dark green: MCF7, and bright green: T47D) breast cancer cell lines. Yellow indicates high gene expression; gray is median expression; blue indicates low expression; and black represents undetectable expression. All cells showed expected expression patterns. The breast cancer cell lines used represent a spectrum of cell differentiation, e.g., from less differentiated and more mesenchymal/stem cell-like ER-negative (basal-like) cells (MDA-231 and SKBR3) to more differentiated ER-positive (luminal-like) cells represented)

Additional data which should come as no surprise is that CTCs seem to be in abundance in patients with bone metastases and are underrepresented in non-bone metastatic patients. The conjecture here is that bone metastases occur via vascular spread and the marrow of the bone that carry the blood-vessels to and from called vaso-vasorum bring in and take out the CTCs from circulation. Hence the discrepancy of finding CTCs in various forms of stage IV cancers.

Future of CTCs

Okay we seem to be getting better at determining what the CTCs are, how they look like, what their chemical characteristics are and what makes their genetic makeup tick. Looking at how we can possibly manipulate this information to better serve humanity, we will focus on the probabilities ahead.

1. The epitope (antigenic) expression of the cancer cells can be used to target these cancer cells both in the blood stream, metastatic and ultimately also at the primary site  Knowing the cell surface antigens of the various gene-expressions can result in utilizing a targeted set of antibodies directed at these epitopes to neutralize their action in thus suppressing the proliferating cancer cell. For example if gene “A” causes an antigen “X” to be expressed then an antibody “Xa” directed at the antigen “X” will prevent the cells from receiving the signal for growth. That will cut short the cell survival and ultimately put the cancer into a remission. However here too there are some relevant issues that have to be addressed before we  arrive at the Utopian paradise. The cancer cell being visualized may lose some of these expressive antigens and thus their pathways of signal transduction by merely undergoing the shearing stresses mentioned previously. Thus available data may be compromised for relevance. For example Powel et al explain;  “Therapy that targets only one CTC population might not ablate other subpopulations, which may continue to spread and grow.” They also go on to explain that, “Our expression profiling analyses demonstrated that CTC populations are relatively quiescent. Transcript levels of growth factors and their receptors, such as VEGFA, MET, ESR1, EGFR, and HER2 were relatively undetectable in CTCs compared to cancer cell lines. Consequently, expression of downstream effectors involved in cell cycle progression and proliferation such as MYC, ATF3, TERT, RAC1, FOXA1, RRM1, CCNB1, and BIRC5 were significantly diminished in CTCs in contrast to breast cancer cell lines. On the other hand, we found that some CTCs maintained the expression of genes associated with the PI3K-AKT-mTOR cell survival pathway.”

CTC understanding has taken on a whole different meaning since the days of Thomas Ashworth. Oh what a path we have taken, full of glorious achievements and the agony of new found hurdles. Yet each hurdle is a challenge to accept and surpass. Therein lies the wonders of Science and human ingenuity.

One day in not too distant a future, Real-Time analysis will better monitor cancer responses to targeted and non-targeted therapy. These therapeutic responses will be able to predict survival data and in so doing add to the armamentarium of cancer therapy. The resultant decrease in the CTCs will open the door for more selective therapy attacking the unaffected (resistant) cells with specifically directed treatment towards them. Thus with the new bag of tricks we will come ever so close to the ultimate aim of "cure."

Oh and that elderly physician who raised the question about using anticoagulants to prevent or delay metastases, after all may not have been too far off course in his thinking. New data suggests that Heparin interferes with metastasis by mechanisms other than direct interference:  "the anti-metastatic effect of heparin is not a result of its anticoagulant activity but rather its ability to inhibit the interactions between some oligosaccharides present on tumor cells and P-selectin on platelets."

So all in all, the gentleman was correct in his thinking and in his musings too.

Here's to all the thinkers!
Here's to all the doers!

Here’s to human intelligence!

Here’s to human perseverance!

And to all of us; Keep Searching for the Truth!

Circulating Tumor Cells: a Window Into Cancer Metastasis by Daniel Haber - Harvard Medical School/MGH:

http://mit.tv/zh4TXd

References:

Ashworth, T. R (1869). "A case of cancer in which cells similar to those in the tumours were seen in the blood after death". Australian Medical Journal 14: 146–7

Kagan M, Howard D, Bendele T, et al. A sample preparation and analysis system for identification of circulating tumor cells. J Clin Ligand Assay 2002;25:104-10.

Kagan M, Howard D, Bendele T, et al. Circulating tumor cells as cancer markers: a sample preparation and analysis system. In: Diamandis EP, Fritsche HA, Lilja H, Chan DW, Schwartz M, eds. Tumor markers: physiology, pathobiology, technology, and clinical applications. Washington, D.C.: AACC Press, 2002:495-8.

Guller U, Zajac P, Schnider A, et al. Disseminated single tumor cells as detected by real-time quantitative polymerase chain reaction represent a prognostic factor in patients undergoing surgery for colorectal cancer. Ann Surg 2002;236:768-776.

Terstappen LW, Rao C, Gross S, Weiss AJ. Peripheral blood tumor cell load reflects the clinical activity of the disease in patients with carcinoma of the breast. Int J Oncol 2000;17:573-578.

Fehm T, Sagalowsky A, Clifford E, et al. Cytogenetic evidence that circulating epithelial cells in patients with carcinoma are malignant. Clin Cancer Res 2002;8:2073-2084.

Cristofanilli M, Budd GT, Ellis MJ, Stopeck A, Matera J, Miller MC, Reuben JM, Doyle GV, Allard WJ, Terstappen LWMM, Hayes DF: Circulating tumor cells, disease progression, and survival in metastatic breast cancer. N Engl J Med 2004, 351:781-789

Smirnov DA, Zweitzig DR, Foulk BW, Miller MC, Doyle GV, et al. (2005) Global gene expression profiling of circulating tumor cells. Cancer Research 65: 4993–4997

Sieuwerts AM, Kraan J, Bolt-de Vries J, van der Spoel P, Mostert B, et al. (2009) Molecular characterization of circulating tumor cells in large quantities of contaminating leukocytes by a multiplex real-time PCR. Breast Cancer Res Treat 118: 455–468

Talasaz AH, Powell AA, Huber DE, Berbee JG, Roh KH, et al. (2009) Isolating highly enriched populations of circulating epithelial cells and other rare cells from blood using a magnetic sweeper device. Proc Natl Acad Sci U S A 106: 3970–3975.

Kalisky T, Quake SR (2011) Single-cell genomics. Nat Methods 8: 311–314.

Thiery JP (2002) Epithelial-mesenchymal transitions in tumour progression. Nat Rev Cancer 2: 442–454.

Chow JY, Dong H, Quach KT, Van Nguyen PN, Chen K, et al. (2008) TGF-beta mediates PTEN suppression and cell motility through calcium-dependent PKC-alpha activation in pancreatic cancer cells. Am J Physiol Gastrointest Liver Physiol 294: G899–905.

Chow JY, Quach KT, Cabrera BL, Cabral JA, Beck SE, et al. (2007) RAS/ERK modulates TGFbeta-regulated PTEN expression in human pancreatic adenocarcinoma cells. Carcinogenesis 28: 2321–2327.

Courtney KD, Corcoran RB, Engelman JA (2010) The PI3K pathway as drug target in human cancer. J Clin Oncol 28: 1075–1083.

Habib AA, Chatterjee S, Park SK, Ratan RR, Lefebvre S, et al. (2001) The epidermal growth factor receptor engages receptor interacting protein and nuclear factor-kappa B (NF-kappa B)-inducing kinase to activate NF-kappa B. Identification of a novel receptor-tyrosine kinase signalosome. J Biol Chem 276: 8865–8874.

A Tunable Cancer Cell Filter Using Magnetic Beads: Cellular And Fuid Dynamic Simulations. ariv.org/abs/1110.0995

Akl EA, et al.: Parenteral anticoagulation for prolonging survival in patients with cancer who have no other indication for anticoagulation.

Cochrane Database Syst Rev; CD006652 2007.

Zielinski CC, Hejna M: Warfarin for cancer prevention.

N Engl J Med 2000, 342:1991-1993.

Fuster MM, Brown JR, Wang L, Esko JD: A disaccharide precursor of sialyl Lewis X inhibits metastatic potential of tumor cells.

Cancer Res 2003, 63:2775-2781.

Giordano A, Giuliano M, Jackson S, Reuben JM, De Laurentiis M, Handy BC, Ueno NT, Andreopoulou E, Alvarez RH, Valero V, De Placido S, Horotobagyi GN, Cristofanilli M: Circulating tumor cells (CTCs) in metastatic breast cancer: Prognosis, molecular subtypes and metastatic sites.

2011,

Cristofanilli M, Budd GT, Ellis MJ, Stopeck A, Matera J, Miller MC, Reuben JM, Doyle GV, Allard WJ, Terstappen LWMM, Hayes DF: Circulating tumor cells, disease progression, and survival in metastatic breast cancer.

N Engl J Med 2004, 351:781-789

Ashley A. Powell Single Cell Profiling of Circulating Tumor Cells: Transcriptional Heterogeneity and Diversity from Breast Cancer Cell Lines PLoS ONE 7(5): e33788. doi:10.1371/journal.pone.0033788