Gordon is Bi

So, I was watching Prime Minister's Questions yesterday and the new PM, Gordon Brown was emphasizing the need for bipartisanship. Now, I may be an ignorant Yank, but everyone knows that Britain has three major parties. Perhaps one of the Lib dems should mention it at question time:

"Mr. Speaker, is the prime minister aware of the liberal democrats? Because if he isn't the electorate certainly is."

Recently Asked Questions

Q1: When did you take the boards?*
A1: June 1st.

Q2: What was it like?
A2: 6 hours of sheer boredom, followed by an hour of boredom on the 6 bus that was, if anything, even sheerer.

Q3: How did you do?
IF (Q'er = Jose Quintans)
A3a: You tell me. (Unless you file papers to not have your score reported, your medical school and administrators will receive your score 4 to infinity days before you, as they get it electronically and yours is sent via US mail, hence the chance of infinity. You can file to report to them nothing, or merely that you took the test, unfortunately, those papers have to be filed 2 weeks prior to the exam, which I didn't realize until 3 days before the exam.)

Q3a1: Why can't they send you your score some other way?
A3a1: See answer 9

ELSE
A3b: No idea The score haven't come back yet.

Q4: When will you get your scores?
A4: They said it usually takes 3-4 weeks.

Q5: Why does it take so long to grade a computerized multiple choice test?
A5: Because everyone takes a different test they curve how you did versus people who did the same questions 3 weeks before and after your exam.**

Q6: Why can't they compare you to test takers from the previous 6 weeks?
A6: See Answer 9

Q7: It's been more than 4 weeks, why don't you know?
A7: Since June is a peak test taking month it may take them 6-8 weeks to process your score.

Q8: But you just said that normally they have to wait for enough data before sending your score out. If more people are taking the test, shouldn't you get it back faster?
A8: See answer 9.

Q9: WTF is going on?
A9: Either the National Board of Medical Examiners, or you, are a moron. Since the NBME, with their opaque boards and their monopolistic match control my fate for the next 20 or so years, I'm going to go with you. You are the moron.

Q10: Why am I a moron?
A10: Because you asked questions. And this is medical school.



*: Step 1 of the US Medical Licensing Exam

**: I'm actually kind of grateful that they don't have the scores right away simply because then I wasn't even more tempted to rush through the final test blocks.

So what, Ubuntu

About a month ago, I got a new laptop*, which came with Windows Vista. Being one of those people that said, "Oh, I'll never use that pile of kludge," I installed Linux on it. As it happens, there is no single Linux in the same way that there is a single OS X or Windows. Instead, there is a universe of distributions each of which is a collected set of all the bits that make up a functional operating system. I could, if I had wanted to, hand selected and tuned each piece of the operating system and assembled my own 'distro' from scratch... yeah right.**

Eventually I settled on Ubuntu 7.04 x86. Why: 1) Ubuntu 7.04 was the first distro that detected my sound card and my wireless right off the bat. 2) Have to use x86 or you cant run Flash (i.e. no YouTube et al.). 3) Ubuntu is the most popular distro, so I assume it will be decently well taken care of.

Since I'm the first person in my med school class (I think) and the first person in my family to be running Linux, I've been showing off for the past month, and the response I get is "Oh, it's a computer, it works." Having been deprived of the ego satisfaction, I've gotten to feel the same way. After all, what I've got is a rather boring laptop running a collection of programs that are slightly ugly looking knockoffs of the Windows equivalents.

Don't get me wrong, I appreciate that OpenOffice.org can export PDF's at the touch of a button, but it's best feature is that it can edit Word files without screwing up the formatting. Firefox is exactly the same, GIMP is $300 cheaper than Photoshop, if a little underpowered*** I use all of these pieces of software on my Windows computer, and I appreciate them...

But there's no killer app. The closest Ubuntu comes in my experience is apt-get, a program that lets you find and easily install, yes, more free knockoffs of Windows programs.

Maybe in some fields (web servers? security? mathematics?) the programs that everyone wants are written for Linux, but I suspect that you won't see large scale migration at the consumer level until such an app exists for non-computer professional users. Even if Linux programs looked and ran so well that Windows programs looked like the cheap knockoffs, I think people feel more comfortable with something that you buy.

So if any Linux techies are reading this (unlikely) stop chasing the taillights and do your own damned thing.



*: Acer blah blah blah. Basically I wanted a combination of small, cheap, and AMD. I should note that I didn't pick a computer based on
**: Incomplete list of distros I tried: Xubuntu, SimplyMEPIS, Freespire, Fedora Core, Kubuntu, Debian. Note that all of them installed perfectly on the first try from a LiveCD without needing to be told more than what time it was, which is pretty good. Please please don't tell me why each and every one of these is better. I give my reasons above and I'm sticking to them (for the time being).
***: Yes, I've heard of Krita, but as my computer broke down crying when I tried to run Kubuntu, I don't think it's such a hot idea to try out.

Going to take a toilet bowl cruise...

As you may know, I'm taking the USMLE Step 1 tomorrow. Briefly - it's an eight hour computerized test covering the first two years of med school. Oh, and it's $400 to register for it. Here's a nice bit of the rules:

Your entire testing session is scheduled for a fixed amount of time. The computer keeps track of your overall time and the time allocated for each block of the test. At the start of the testing session, you have a total of 45 minutes of break time. This allotment of time is used for authorized breaks between blocks and is also used to make transitions between items and blocks.

I like the bit about my break time being used for transitions. That means I get charged a nickel every time I answer a question, a dime if the computer decides to be slow. It reminds me of the Dilbert* where the Pointy Haired Boss tells the employees that they're banking too much vacation time, so therefore they will be charged vacation time while they're in the bathroom, hence my title, which is a paraphrase of Wally's reaction.


*: Can't find it, otherwise would post, also don't have time, must sleep. An hour of sleep is like an hour of studying, or something.

A Procedural Marriage

Q: Who would marry a surgeon?
A: Another surgeon.

Q: What would the marriage be like?
A: Surgery is a procedural specialty, so I suppose they would have a procedural marriage...

- Marital procedures would commence promptly at 7:00 a.m.
- It might take all day
- There would be a minimum of post-op follow-up
- A third person might be present to administer anesthetics

There would be some problems, of course...

- Each partner would only specialize in a few procedures
- It would be impossible to "go big or go home"* because most procedures would already be home




* The surgeon's motto.
** You might wonder why I did not include my usual throat clearing explanation of why I was thinking about this. Well, I realized such things are rather dull and also there could be professional conflicts.

No, no, I live in...

I have a friend that lives in the west loop. Well, not actually the west loop. He lives west of the west loop, in what one might call the United Center Zone. However, one can't say that one lives in the United Center Zone because to those in the know, it is the equivalent of saying, "I live in a free fire zone."

This is the problem with the neighborhood system in Chicago. The only semi-official demarcation dates back to 1920, with the obvious problems that come from never getting updated. Thus, developers rename areas of gentrification to make them sound like the areas they want them to be, and not like the areas that they are.

I have decided to do the same thing for Hyde Park,* so, with no further throat clearing:

GENTRIFICATION NAMES FOR HYDE PARK:

Academic Village - obvious
Rockefeller Park - after the university's first benefactor
Forefront Beach - after the hospital's ridiculable slogan
Exposition Park- after the 1893 Columbian exhibition
Suchi and Nuchi - Southern and Northern University of Chicago in the fashion of Tribeca
Olympia - in hopes of netting the 2016 games


We'd just have to do something about the food, the groceries, the public transit, the entertainment and we'd do just fine.

GENTRIFICATION NAME FOR THE UofC: Northwestern.



*: Note that, according to the old system, I live in Woodlawn, which is considered even less desirable, but would be contained within my rubric(s).
**: Rejected names: Columbia Park (columbia is always a 'not-nice' part of town), Harpersville (lame), University anything (see columbia) Ferris Pont (weird), Midway anything (association with previously sketchy airport, though I now note that Midway is quite clean and nice looking, also convenient for moi).

Paris Hilton's Nipples

Fiddle: What do you think is the greatest crisis facing the survival of humanity today?
long silence
I: Well, it's not terrorism. On a personal scale, global terrorism is like waking up in the morning and realizing you can't have a bagel because you're out of cream cheese.
Fiddle: I've thought of terrorism as being like Paris Hilton.
I: And Osama bin Laden is Paris Hilton's nipples - popping in and out of view and always garnering far more publicity than they deserve.



All conversations approximate.

Brief Defence of the FDA

I was at the doctor's office today, and for no apparent reason they have The Wall Street Journal. The editorial page is sort of like watching Prime Minister's Questions - a bunch of people who appear to speak the same language look at the an issue in this country and come at it from a completely perverse direction.

Witness Arcoxia! (etorcicoxib)! that ASTOUNDING wonder drug from Merck. The WSJ Op-Ed guys are in a snit because the FDA won't allow the drug to be marketed. Brief summary:

The FDA explained that it didn't see the need for another drug like this. Robert Meyer, director of the FDA's Office of Drug Evaluation II, told reporters that, "simply having another drug on the market" wasn't "sufficient reason to approve the product unless there was a unique role defined." The FDA is supposed to judge whether a drug is safe and efficacious and that's all.

OK. The authors then rip apart the FDA based on this quote. I say the quote is irrelevant.* The question is, is the drug safe and effective for its stated purpose? Answer: Define "Safe and Effective." Some percentage of people taking warfarin will suffer a fatal bleed into their brain. On the other hand warfarin may prevent them from developing fatal clots. There's a balance depending on the purpose. One is more willing to tolerate side effects from potentially lifesaving treatments from those that merely make life more comfortable.**

So, what does etorcicoxib do? Well, it merely makes life more comfortable (who didn't see that coming?). Etorcicoxib is, for civilian purposes, a pain killer. More specifically, as the 'coxib suffix implies, a COX-2 inhibitor. You may remember the COX-2 inhibitors from such debacles as VIOXX!!!

"Wait," Cara said, "didn't Merck also make Vioxx and get sued for a bunch of money."
"Indeed," said I.
"What a bunch of morons," she noted, then dozed off.

To give you the 60 second caricature, when you pop an Aspirin, or Tylenol, or ibuprofen, or Aleve, the drug inhibits two enzymes, COX-1 and COX-2 which are involved in synthesizing a lot of different molecules called prostaglandins that have different effects in different parts of the body. This broad distribution explains the broad effects of the so-called Non-Steroidal Anti Inflammatory Drugs or NSAIDS - a baby Aspirin thins the blood preventing heart attacks and strokes. Tylenol reduces fevers and relieves pain. Step back a moment andc onsider how odd it is that those effects are linked.

Unfortunately, NSAIDS are also a leading cause of gastric ulcers. This effect is presumably because they block COX-1 in the gut, which results in less secretion of protective mucus (mmmm, protective mucus). Also, the anti-coagulating effect is also due to COX-1, perhaps making the ulcers more difficult to heal. Thus were born, THE COX-2 INHIBITORS!!!. Unfortunately, COX-2 inhibitors kill. All of them. And the degree of killing is related to the degree of COX-2 inhibition. It's late, and I'm studying for boards, so I'm just going to have to take what my pharm professors said and whack you over the head with it. I'm sorry. PubMed will work for you as well as me, and is non-essential to my continuing points. Also, the COX-2 inhibitors don't really prevent ulcers, if you look beyond 6 months of use.

Even before the whole Vioxx thing, I was a big hater of the COX-2 inhibitors, because the things were like, three bucks a pill, and I said, "heck, for three bucks a pill, you could take a truckload of Tums." New, older and wiser, I say, "heck for three bucks a pill, you could buy a cratefull of Prilosec OTC" (unsurprisingly this works).

There I go, tarring etorcicoxib with that rofecoxib brush. Why don't we just see how it stands up on its own? As the WSJ says, there was a trial of over 37,000 people that showed that etorcicoxib was safe. I think they're referring to this trial (PubMed ID 17113426 if that doesn't work), which shows that etorcicoxib is about as safe as the NSAID diclofenac, and had fewer ulcers. Diclofenac? Yes, it's a real drug. I'd never heard of it either 'til I came to med school. In my limited exposure, I have yet to meet anyone taking it. Why the comparison with diclofenac, then? It's a stacked deck.*** As the Wikipedia article linked above indicates, diclofenac has 10:1 inhibition of COX-2 versus COX-1, i.e. it is, essentially, a COX-2 inhibitor (note that even the classic COX-2 inhibitors like rofecoxib, celecoxib, and etorcioxib have some COX-1 inhibitory effect). 'Classic NSAID' indeed.

How does etorcicoxib stack up against stuff that people actually take? Well, there's no significant difference there either. Wait, let's actually read a bit of the abstract:

The RRs for thrombotic events were 1.11 (95%CI: 0.32, 3.81) for etoricoxib (N = 2818) versus placebo (N = 1767);

Let me try and translate this: People taking etorcicoxib were somewhere between one third as likely and three times as likely to get a clot as people taking sugar pills. In other news, I weigh somewhere between an Oxford English dictionary and a Honda Accord. My intelligence is somewhere between a ground squirrel and Da Vinci. George Bush's approval ratings are somewhere between 7 and 70%.

Here's the real "money quote."

1.70 (95%CI: 0.91, 3.18) for etoricoxib (N = 1960) versus naproxen (N = 1497).

Translation number 1: The risk of developing a clot was somewhere between a little less than 1 and 3 times as likely in people taking etorcicoxib versus Aleve. Translation number 2: If the study had gone on 3 months more, we would have succinctly demonstrated that our drug kills people.

So, if I'm the FDA, I bounce the drug, not because there's not a marketing niche, but because it's not safe and effective for purpose. On the other hand, I suppose the study has demonstrated a "unique role" for the drug - expensive AND deadly, woo-hoo.

It's past my bedtime, so I'm going to take a final parting broadside at the WSJ, specifically this anecdote:

One patient, Kathleen Slocum, said that her life without Vioxx or other COX-2 inhibitors was "misery." She also pointed out that while over-the-counter analgesics work well for pain relief, the main problem she has had with her severe arthritis is joint swelling and stiffness; OTC analgesics haven't helped her with these problems. Ms. Slocum knows more about her specific needs than the FDA does. Isn't it possible that at least some segments of the population would find that Arcoxia addresses their needs? And remember that the people choosing are self-interested patients and their highly educated and trained physicians.

I should note that 'over the counter analgesics,' with the exception of Tylenol, will take out COX-2 as effectively as any 'coxib, so from a pathophysiologic standpoint, her argument is meaningless. I also note that 'joint swelling and stiffness' are rather vague terms that would be quite susceptible to placebo effect. Perhaps if naproxen were prescription only and 5$ a pill it would be more effective for her. Finally, there's the dodge about knowledgeable patients and highly educated physicians. I would argue that patients don't know what they need, hence they go to doctors and request drugs they saw advertised on TV.**** And I would argue that physicians, my future self included, are vulnerable to the claims of leggy drug detailers, and busy enough that we won't do the legwork that could save out patients. We will assume that if it's FDA approved, it's benefit essentially outweighs its risk in the intended use. So that's what FDA approval had better mean.

*: Key difference between science (or scientistic fields like medicine) and journalism. In journalism, it's all about getting different authorities to give quotes and bash them against each other. Medicine is supposed to be about the evidence.

**: Look, you can argue this, you can say, "But Jeff, isn't there some pain so bad that it makes life not worth living?" And I would say yes, and then I would say, "If you're so concerned about the pain, why not go for narcotics? Or something to address the underlying problem like joint replacement (for osteoarthritis) or REAL immunosupressants (e.g. steroids, methotrexate, cytoxan... for rheumatoid arthritis)?"

***: I'm as pro-pharma (probably more pro) as the next guy. If you look at a pharma trial, you will find that it has been conducted superbly. However, a trial is only as good as the question is asks. Too often, the comparison is against older drugs with known side effects, or they will test higher doses of the company drug versus lower doses of a competitor drug. This isn't always the case, but it's worth looking out for. It also gives me an excuse to stick to reading the abstracts.

****: This makes me think about all the adds Apple keeps putting out for iPods. It's like, everyone that was going to buy one already has one, but they need to keep advertising so people still think that what they bought is cool. I wonder if you could do a study about some drug in a placebo-ey category like anti-depressants and see if it's apparent efficacy waxes and wanes with the amount of advertising surrounding it.

The problem with Watson-Crick base pairing

Is that W and C don't base-pair. You know what works? Goldstein-Crick base pairing.

(Why this should be funny but probably isn't to you: In addition to the A, T, G, and C of normal DNA sequences, other letters of the alphabet are used to designate possiblities, e.g. W = weak, which could be either A or T, so named because they make only 2 hydrogen bonds, as compared to the Strong G-C base pairs which are held together by 3 bonds.)

Psychiatry

We get conflicting accounts of medicine in popular media, in undergraduate biology, and in more research oriented basic science lectures. But it's always good to get the single consensus answer. In CPP this comes from the mouths of practicing physicians specializing in the disease being discussed. Their answer has the advantage of having survived contact with reality, and being relatively accepted by a lot of other medical types you might talk to.

Psychiatry is an area where the gap between popular accounts and practice appears to be the widest. Civilians* throw around diagnoses, or sub-diagnoses or outdated diagnoses with great freedom, assigning fairly serious conditions to (say) celebrities they have never met. As described in psychiatry, life is more complicated. Diagnosis consists of large lists of criteria that patients have to fulfil, e.g. in order for you to be depressed, from this list:

Depressed mood
Energy loss
Anhedonia (lack of pleasure)
Death thoughts
Sleep changes
Worthlessness
Appetite
Mentation changes
Psychomotor

You must have depressed mood or anhedonia and five of the others for most of the day every day for two weeks to qualify those weeks as a depressive episode. This sort of formal rigor is much more appealing than saying, "Hey, this guy is sad, let's give 'im some Prozac."

One of the best parts of this section was that in lab, instead of only reading cases, we had actual patients come in to talk to the class so we could see what it was like. And that's where the nice neat system vanishes. Our bipolar patient was being treated for anxiety, our obsessive-compulsive disorder patient had depression. Our schizophrenic patients seemed to have well behaved disorders, but our recovering alcoholic physician had his ADHD misdiagnosed as anxiety, and got addicted to his Xanax. And if depression was such a difficult diagnosis to meet, antidepressants would not be among the top-selling drugs.

They do teach some things that are pretty easy for me to swallow:
Psychodynamic psychotherapy ("And how does that make you feel?") is reserved for those with lots of time and money.
Cognitive behavioral therapy is pushed, especially for certain disorders where medication is not helpful.

It seems to me that the reliance on medication is partially about efficacy and partially about cost. Consider that you can get a month's supply generic prozac or paxil (fluoxetine and paroxetine) for $4 from Wal-Mart, but that a month's supply of cognitive therapy is $400.




* I realize that this is my first use of this potentially derogatory term to describe non-medicos and another step on my long journey to becoming and asshole physician. Further I recognize that this blog began as an attempt to stymie said journey, and has instead served as a record of it.

More Veiled Conceit*

Peruse this wedding announcement:

"Unknown to Ms. Luft, her skirt had somehow become tucked into her pantyhose. When the elevator door opened, she realized there was a problem. 'I only noticed when everyone in the elevator was staring at my backside,'"

Obviously, this woman is very enamored of her sweet, tight buns or she wouldn't have related this tidbit to the whole planet. Or at least she was enamored of her 16 year old buns. Let's see what Wechter has to say about it:

''I was very attracted to Sara when I first met her... She's got a very engaging personality. I thought about her all the way home.''

Sweet, tight, engaging.

Couples write their own wedding announcements, so one can only wonder why the couple chose to write it this way. Do they want us to read between the lines? Do they figure they have a better shot of getting in if they have a bit of salacious summer camp gossip?

Doing an O&P (That's occupations and parents) we find that their jobs are investment/portfolio types, as are their parents, so, they're standard fare for the NYTWCA. They live in New Jersey, he works in Greenwich, and she works in New York. How miserable. Each of them spends at least 3 hours a day in the car or in transit.

Other than the meeting story, this couple is so aggressively boring that they would normally fly under the VC radar, except for the bride's heavily aftershadowed closing line, '''It was Josh, making sure I got home safely from my flight,'' she said. 'That was when we were 16 years old, and we've pretty much stayed together since.'''


pretty much [prit-ee muhch] adv. 1. After dating for two years dating long distance, they agreed to 'see other people at college.' His banana face

doomed him to four years of sucking face at closing time at the Copabanana. (Slogan: Where ugly girls go to cop banana faces.


I just realized that this icon is probably for an establishment where ugly girls go to cop other sorts of bananas, but I think the point is made). His bitterness increased when in a desperate, drunk dialing rage he called her voice mail and got: "Hi, this is Sar, please leave a message after the tone. If you're calling because you saw my name above the urinal at Tongue and Groove (click for awesome music), please send a head and a body shot to luftballoon@emory.edu. I'm totally stoked to hear from you, bye-ee." His sobbing description of a strange sore on his penis drew out her compassion, and she agreed to get back together... after the penicillin kicked in.

2. He demanded that they stay together through college, but then one day that girl in his Management 318 class showed up with her skirt tucked in her pantyhose. She flew in unexpectedly to surprise him, and found the pantyhose draped over his doornob. "Wechter?" He said over the phone, "I hardly knew 'er." Six years, 14 breakups, and numerous heartfelt conversations later, they give up on dating other people and show the whole world their orthodontic work on the NYTWCA.

3. In order to stay together in college, they lived in Rocky Mount, VA (exactly halfway between University City and Atlanta) and commuted 6 hours in either direction, which makes their current 3 hour commute look like crossing the street. Once she got really sleepy and stayed in a rest stop in North Carolina, so they spent the night apart.

Which do you think is most likely?



*Veiled Conceit is the original idea of 'Zach' at Veiled Conceit
With special help from Cara.

A Little Veiled Conceit*

Veiled Conceit: A glimpse into that haven of superficial, pretentious, pseudo-aristocratic vanity: The NY Times' Wedding & Celebration Announcements

Before we begin this week's edition of Veiled Conceit, I'd like to give small public service announcement:

Do not, under any circumstances let your picture look like this:











Seriously. She's either ridiculously smug, or giving every pretentious male in the U.S. a 'come-hither' look. Maybe both. She was in the Peace Corps. I would say that ex-Peace Corps folk are usually highly pretentious about it, but the one's I know are actually quite nice. damn. She used to fight child trafficking in Nepal, but then she started working for Planned Parenthood, and you know what inappropriate trafficking joke goes here. As for the groom, Bob, he's totally oblivious, although his gaze is oddly mesmerizing.

Update: I just noticed the bride is 35. I swear officer. I know she looks 17, but at least she's old enough to know to lie, right?


Let's go to this week's vows couple, fine art photographer Alex Heilner and his bride to be Amy Scott. Let's look at some of his work, eh? I immediately went for the collection called 'microbes.' The best I can say is that the landscape photos are much better.


a colony of Penicillin Resistant E. statebuilding

It seems that Mr. H is known for his alphabetizing ability, and his annual scavenger hunt. He's also known for his list of desired girlfriend qualities, "An abridged version" said the Sunday Stylez Crew, "would include: brainy, creative, humble, funny, confident and energetic enough to go out every night. And one more thing: 'Hot. That was important.'" Translation: Hot. Re-translation: Hot, and willing to always put Queen II in front of Queen on Fire: Live at the Bowl because I comes before O, or U.

Let's look at the man himself...

Objects in mirror are closer than they appear.

Any middle class pig can photograph himself in the bathroom mirror. But, the car mirror! Genius. Every car commercial every written satirized in a single, digital moment! Couldn't we get a better head-shot, you ask? Well, no. He's a small, Beetle-like figure in wedding picture A, and an out of focus cheek in wedding picture B.


He's definitely "small enough to fit in a guitar case"

According to the article, the couple married themselves, as is legal under Colorado law. What sort of pretentious yuppie Napoleon bullshit is this?



Napoleon: Also small enough to fit in a guitar case.




Buyers Remorse

As always, the real story is in the background...

He and Alex gaze at the same thing far to the right. Is it the open bar? The air conditioner? Or the next item on Alex's scavenger hunt of love? Only time will tell, but statistics say...



Finally, I'm going to try to convince Cara to help me out with a video, which may get updated in below.
Update:


*Veiled Conceit is the original idea of 'Zach' at Veiled Conceit

Top residency choices this week:

1 allergy & immunology 46
2 hematology 44
3 radiology 44
4 aerospace med 43
5 dermatology 43
6 neurosurgery 43
7 neurology 42
8 emergency med 42
9 general surgery 42
10 pediatrics 42

The 3PPS Test

How to do it: Visual examination of the proximal phalanx of the third "ring" finger of the left ("sinister") hand.

Possible findings - documentation:
1. Nil.
2. Ring - describe ring.
3. Ring callus - note.


The upshot is that my frequent failure to perform this simple task has resulted in mockery from my physical diagnosis comrades,

Tofu Cube... OF DEATH!!!

I had a charming case of food poisoning last quarter, which I was able to (thanks to Medical Micro) identify as heat stable staph toxin. I don't want to go into it now, but at the time, I asked my friends who had been at the same restaurant if anyone had the same symptoms, and a friend wrote back that she can't get food poisoning since she doesn't eat any meat.

Contra that, today I noticed a report in the CDC's Morbidity and Mortality Weekly Reports, and they talk about this Chinese couple that got botulism from their fermented tofu.

Anyway, I have extracted below the recipe for TOFU OF DOOM.

The tofu was a commercially packaged product purchased at a retail market. In the home, the tofu was boiled, towel dried, and cut into cubes. The cubes were placed in a bowl, covered with plastic wrap, and stored at room temperature for 10--15 days. The tofu was then transferred to glass jars with chili powder, salt, white cooking wine, vegetable oil, and chicken bouillon to marinate at room temperature for 2--3 more days. Finally, the fermented tofu was stored and eaten at room temperature.


*
Note that I cite MMWR below.

After I dressed this morning...

C: You look like you're going clubbing.
I: Not so much, but I am going to go study clubbing.

The image to the side is of clubbing - bony expansion of the tips of the fingers caused by long-term lack of oxygen, e.g. that caused by smoking or other lung damage.

AIDS drugs cause AIDS I

Yesterday, I was puttering through the hospital when I came across a J, pathologist friend of mine. Whenever I see a pathologist, I always ask to see whatever slide they're working on, which usually results in an interesting story.

J told me about a case from his residency in 1994. A 20 year old man presented to the morgue with multiple Kaposi's Sarcomas in his GI tract. KS is a cancer of an unknown, probably blood vessel cell which is caused by the Kaposi's Sarcoma Herpes Virus (KSHV, HHV8). Prior to 1981, the stereotypical patient with KS was an 85 year old Italian male.

In '94 the stereotypical patient was this patient, a young gay man. Since the cancer was in his digestive tract instead of the skin, he didn't have a chance to get treatment.

Not that there was much treatment.

J kind of breaks off and says, "We don't really see cases like that anymore, not since '96."

Boards question:
A 37 year old male heroin user has noticed multiple 0.5- to 1.2-cm plaque-like, reddish-purple, skin lesions on his face, trunk, and extremeties. Some of the larger lesions appear to be nodular. These lesions have appeared over the past 6 months and have slowly enlarged. The most effective treatment for his condition is:

A. Vincristine, irinotecan, and cisplatin.
B. Valcyclovir, gancyclovir, and foscarnet.
C. Indapamide, metoprolol, and prazosin
D. Zidovudine, lamivudine, and efavirenz.
E. Ticarcillin, clavulanate, and gentimicin.


Tick
Tick
Tick


Correct answer: D. The common thread in all of this is the Human Immunodeficiency Virus, and the cocktail indicated is an ideal treatment. The release of protease inhibitors in 1996 meant that the number of patients with full blown AIDS and AIDS defining illnesses cratered, hence the dearth of KS biopsies.

This brought to mind a story on badscience.net about South Africa's stand against providing AIDS drugs to AIDS patients. For instance at an international HIV/AIDS conference, the South African booth featured that infamous reverse transcriptase inhibitor, the African Potato. Anyway, part of the South African government's argument is that, as the title of my piece indicates, AIDS drugs cause AIDS.

How can we reconcile J's observations with this claim?

Prior to 1987, there were no AIDS drugs in general circulation. One can only conclude that gay men, injection drug users, and hemophilliacs were secretly stealing AZT and snorting it starting in the mid 1970s. Of course the world's known supply was sitting on some lab shelf in Research Triangle Park. The only reasonable explanation is therefore that the Columbian cartels must have stolen the structure and synthesized a bunch of the stuff, and used it to cut the blow.

Explaining the sudden drop of KS after 1996 is relatively trivial. As it turns out, AZT causes AIDS, but the 3TC and Efavirenz are actually antidotes, so as long as people take them as a cocktail, nothing too horrible happens.

Essential resources:
AIDS reappraisal - Wikipedia (it's almost painful how hard they worked to keep this article neutral)
A little piece of history. Check the date.
Hopefully I'll get to address other aspects of the 'reappraisal' in a later piece.

Among my many flaws:

I: I seem to be missing the gene that makes you want to go to a bar, have one drink, and say, "Hey, let's go to a different bar!

She: SRY?

A problem possibly solved

Yesterday we started anemia, particularly the iron, B12, and folate deficiencies. It reminded me of a patient I saw last year who had a very confusing constellation of symptoms, but which I now realize were all anemia caused by a rash that had appeared on his chest 3 years earlier. The rash contained, presumably, rapidly proliferating skin cells and immune cells, which would suck of the folate and B12, both of which are involved in DNA synthesis. This was compounded by the patient's poor eating habit. Now if I could just figure out what the autoimmune condition was.

Something sort of similar is maybe in this paper.

Problem Solving Skills Dos

We're doing CPP&T this quarter, which is the part of medical school where they actually teach medicine. Each lecture takes the following format: "Here's a disease, here's how you get it, here's how you recognize it, here's how you treat it." Then we have lab twice a day, which is a series of cases where patients have the illness and we have to establish differentials and suggest labs and such.

We're also taking Physical Diagnosis, part of which is to run around the hospital, interviewing patients and doing as much of the physical we have learned, then trying to do diagnosis and present them to an attending physician.

It occurred to me today that medicine is very much like school problem solving - you are presented a patient/problem, you attempt to solve it in a stereotyped way based on practice problems of a similar appearance. You either get it right or wrong, but either way, you quickly move on to the next problem. If you do a good or bad job overall, it will definitely matter, but success on one problem, or even one type of problem is not necessary.

This is unlike other areas of work, which I can't think of right now, where either you can't move on, or all your problems are interrelated in ways that are simply impossible to entangle.

Anyway, that makes medicine comparatively comfortable, as opposed to, say, research, where you may be stuck on a problem for years, never knowing if you have the right answer.