The Haversian Canal

I was reminded today while listening to NPR, of a new entrant in the pharma industry, NitroMed, which is pushing a patented formulation of two drugs that it calls BiDil. Even Dr Charles L Curry, an investigator in the clinical trials, and a paid member of the NitroMed speakers bureau, thinks the cost, six dollars a day, is high, especially with the two drugs, isosorbide dinitrate and hydralazine, which are available as generics at much lower cost.

There are 79000 children between 0 and 18 in Brazos County. The US Department of Education estimates 6.7% of children under 18 has an activity limitation. This is reasonably similar to independently gathered information indicating that 18% of US children have special needs, 51% of whom need OT. Autism occurs at a rate of 1 to 2 per 1000, based on population studies. Many other children, such as those with Asberger's syndrome, very low birth weight, and TBIs enjoy proven benefits from occupational therapy services.

Dan died on 22 November. I found out when I reviewed my site's statistics and noticed a spike of in-bound clicks from internet searches for his name.

Dan was one of the first midshipmen I recall learning about during my recent shore tour on staff at the Naval Academy. That tour started in January 2003 and I knew him by name by March. He had cancer even then. Congress says the Naval Academy program is four years. Due to the cancer, Dan wasn't going to graduate with his class in 2003, so the Superintendent and the Dean and the Commandant and the rest of the Academic Board had to review his case and decide what to do. I was the doorman. In reality there was more to the job than that, but when the Academic Board was actually in session, when the heavies were sitting at the big table in the dark room with a scared, I'm-about-to-get-kicked-out-for-whatever-I-did-or-didn't-do midshipman sitting on the other side, all I did was open the door and close the door. They kept Dan.

They kept him at the next five board meetings. He graduated, two years late, probably the only midshipman to graduate in six years. Once he had been in remission for almost a year when he got in trouble and had to go before the board. We literally notified him the afternoon before he had to appear, his doctor at NIH called him that evening to confirm that the cancer had metastasized, and he came before the board the next day.

The votes weren't perfunctory. Every time the situation was different, and I think it ended up being good for all involved to leave each session with that affirmation of support.

For some reason Dan had to come to my office one day after class, I told him about my plans for medical school and he ended up staying for two-and-a-half hours. Reflecting on his own experiences as a patient, he had written up some advice for those few of his classmates who would go on to be military physicians, and I asked for a copy of it, which he provided me. He also said I could post it on my site. If you google for him, it is now the top search return for him.

So does that mean anything? Is it just a statistical fluke? The two ships that passed in the night and bumped just enough to trade paint? Future military doctors won't find the essay, only people looking for Dan. Will it become a top search for pre-med midshipmen looking for advice? Do they look for advice? Who's searching for him?

From the New England Journal of Medicine's Image Challenge. It's not actually hairy, but it looks that way, because it's actually disordered overgrowth of filiform tastebuds, which normally look like this under a microscope.

While the cause is not exactly known, a good guess is that the relatively hot, chemically bizarre, cigar smoke has exposed the cells of the tongue's surface to so many thermodynamic insults and killed so many of them so many times (causing the survivors to reproduce more often, increasing the risk of genetic mutation), that the cell line evolved or may be stuck in some heat-shock like response, constantly protecting itself more and more with more and more layers, or structural protein. These would all be somatic: this wouldn't be passed on to offspring, the evolution is local to this cell population, which, in this case provided a thicker barrier to further insult. Different smokers realize different possible outcomes, each based on probabilities, which are all to complex, right now, to calculate based on the individual. We can only talk about the population. But some other smoker got tongue cancer. Another got emphysema; another got COPD and lost his vocal cords. Another died of the third heart attack. Etc, etc, etc.

Calcium pills may not be so helpful after all. Here's the New York Times summary of this recent finding of the Women's Health Initiative, a huge undertaking following almost 37,000 women since 1991. This is the same initiative that undermined a number of myths about hormone replacement therapy. So what helps keep bones strong? Well, I don't know all the factors involved, but I know the body remodels its bones in response to loading. For example, babies' legs don't straighten until they start walking. So weight-bearing exercise, if you can tolerate it (and most of us can), is probably the most sure-fire way to encourage the osteoblasts, bone-forming cells, to deposit more bone matrix, which, yes, happens to contain calcium.

March is colorectal cancer awareness month. So here are some fun facts from Cathy Eng, assistant professor of medical oncology at MD Anderson Cancer Center in Houston. Dr Eng is currently recruiting patients for a study and chairing the first annual 5k Sprint for Life on 26 March.
Colorectal cancer is the third-leading cause of cancer. It is highly preventable. It takes 7 years, on average, for a polyp to convert to a malignancy. 75% of cases are spontaneous, not related to family history. Here are some risk factors you can control:
Red meat: increased risk to distal colon and rectum.
Physical activy: occupational activity has no benefit to women. Vigorous activity is good.
BMI is directly proportional to colorectal cancer risk.
Alcohol is a moderate risk factor, most of the others in this list are bigger.
Tobacco contributes to a host of cancers, but rectal cancer is particularly increased, at least among various colorectal cancers.
Fiber: the academics are conflicted about whether or not fiber prevents cancer but there's more than one reason to eat salad.
Turmeric (curcumin): an ingredient in common Indian curry spice may reduce the risk. Studies are currently underway.
Colonoscopy is the gold standard for screening. 36% of colorectal cancers start in the cecum, the part of the colon furthest from the lower end. Gotta use the long scope to find 'em. Colonoscopy is recommended for everyone over fifty. People with normai findings should have another colonoscopy every ten years. Sigmoidoscopy (a shorter scope that doesn't see everything) is recommended at the five year midpoint.

Sunday march 26th 8 am.

Cathy Eng

Here's the NOVA article I referred to earlier about the Tulane medical student, Andy Martin, who had sinonasal undifferentiated carcinoma. Whoever keeps hitting my site following search strings like sinonasal undifferentiated carcinoma hope and sinonasal undifferentiated carcinoma longest living survivor, e-mail me.

Michael Brownlee wrote an excellent review article in Nature in 2001 (414:813-820), Biochemistry and Molecular Cell Biology of Diabetic Complications. It talks about AGEs, sorbitol and the polyol pathway, reactive oxygen species, glutathione and free radicals, the hexosamine pathway, protein kinase C (PKC), and offers that a high mitochondrial membrane potential might play a central role in all of these. The excess glucose raises the mitochondrial membrane potential, but this is converted to heat by thermogenin (uncoupling protein-1), until thermogenin is overwhelmed. Brownlee argues that it is only when thermogenin is overwhelmed that the glucose becomes so great that it starts backing up into these other pathways (polyols, hexosamines, AGEs, and PKC activation). Just gotta get over the British spelling of hyperglycaemia.

What the others do:

Polyol pathway: increases sorbitol, causing damage.
AGEs: inhibit proper protein function, particularly among structural proteins.
Hexosamine pathway: creates glycoproteins
PKCs: activate lots of processes involved with making new vessels and laying down fibrous proteins, but also inhibits nitric oxide synthesis in capillaries and kidney glomeruli, so these vessels don't dialate. Also causes increased vessel permeability via VEGF.

And I really hate it when I make additions to the Wikipedia but forget to sign in before they're recorded.

It is not likely that I will come up with the classic rules for any subject, not like Strunk and White, Maxwell (of Maxwell's equations), Edward Tufte, or Major Roberts (of Robert's Rules of Parliamentary Procedure). I am, however, interested in the rules. Dr Robert Johnson told me yesterday about Bach Theory, which intrigues me. What is it? Here are some links:

Wikipedia's entry on the Well-Tempered Clavier
Yo Tomita, a internationally known scholar who has posted MIDI files of the Well-Tempered Clavier.
Tim Smith and David Korevaar's site

A message from Dr Gary Field and Lori Koonce of the American Diabetes Association:

Dear Colleagues,

As you may well know Camp Victory (formerly known as ADA Louisiana Lions Camp) is a very unique program to the children with diabetes in Louisiana. Over the past 30+ years the American Diabetes Association has been able to offer this great camping opportunity to Louisiana children FREE of charge. Camp Victory is located in Leesville, LA at the Louisiana Lions Camp and consists to two one-week sessions from July 16-22 (ages 6-10 & CITs age 15) and July 23-29 (ages 11-14). The American Diabetes Association takes great pride in this camp and hopes that we can fill the camp to capacity which is 220 kids.

This year we are faced with a challenge of enormous proportions. Due to the relocation of many of our previous medical staff personnel, we may experience a shortage of medical staff which could severely limit the number of children we can accept to attend Camp Victory.

I would like to encourage each of you to consider this noble and rewarding experience not only for your patients and the other children with diabetes in Louisiana, but also as a physician. Please remember that it is not required that you attend the entire week, however it is recommended and appreciated that you attend as many days as your schedule will allow. There are a few who have committed to volunteer this year but the need is still great. RNs, LPNs, PAs, NPs, and MAs are also welcome.

As an added bonus, this year we are offering 11.7 CEUs to all nursing staff who attend the pre-camp orientation as well as the professional development periods during camp time. With this in mind, we encourage you to share this gratifying opportunity with the members of your nursing staff.

See you at camp!!

Gary Field, MD, Committee Chair

Lori Koonce, Camp Coordinator
Associate Manager, Programs
American Diabetes Association
2644 S. Sherwood Forest Blvd., Suite 122
Baton Rouge, LA 70816
225-216-3980 x6079

Covenant House's New Orleans site has opened a free health clinic, thanks in no small part to the vigorous efforts of Dr Karen DeSalvo. A group of Tulane med students got together and decided to pitch in with the hopes of keeping the clinic open on Saturdays. Led by Dr DeSalvo (woman front and center in red t-shirt) and Ben Rieff (upper right, beard and ball cap), a number of us painted the clinic from Friday, June 2nd, through Sunday. And late Sunday, let me tell you. Waiting to get in on Sunday morning, Dr DeSalvo told us that she'd been to a funder's conference the night before, and reported that the charities are experiencing Katrina fatigue. This, however, is not a Katrina issue. Covenant House's mission is long-term. They focus on taking in homeless children.

I wish I had come up with Medviews: The Fix. But Dr Stuart Henochowicz did, and bravo to him. In brief, the top five priorities for fixing the American healthcare system:

1. Enacting compulsory health insurance.
2. Promote primary care
3. Fund the National Health Information Network
4. Encourage consumerism
5. Encourage physician involvement and leadership in health care policy.

Judge Posner takes on, and Professor Becker responds, to the Professor David Cutler, et al's, article in the New England Journal of Medicine, The Value of Medical Spending in the Unites States, 1960-2000. The context of the whole debate is framed by
Paul Starr's book The
Social Transfomation of American Medicine.

Doctor Leon Weisberg, neurologist and author of the first book on CT scanning of the human brain, seven other books and over 150 articles, is dead. I interviewed Dr Weisberg in Houston after Katrina. Here is the second interview, the essay that came out of those interviews, and, reprinted here, my note at the end of the essay.

Essay (pdf)
Interview (mp3)

As Allan Cormack was amazed to find no one had solved the CT problem, I was somewhat amazed when I looked for background information on Dr Weisberg and found nothing but his own scientific reports. I strongly encourage future History of Medicine Society writers to consider writing about the great doctors in New Orleans. It is more satisfying, more enjoyable, and more important than synthesizing secondary sources. I have found it immensely satisfying to learn about this man, his career, and his family. The personal interviews were far more interesting than library research, and library research was far more interesting when I knew some of the stories behind the writing. There is so much more to write and there are so many more questions to ask. I restricted myself to a brief overview and only addressed one aspect of Dr Weisberg's work. More importantly though, if we do not take the opportunity to learn about and write about the heroes among us, I am afraid their legacies may get short shrift. Our commercialized pop culture has made every effort to usurp our hero metaphor and tries to convince us heroes are actors who jump out of flaming helicopter props, save storyboard civilizations, and have a ready supply of snarky one-liners. The hero metaphor, however, was surely born in villages, communities of families knit tight to protect each other in an all too dangerous world. Their heroes were good people, people who demanded excellence of themselves, and were thus ready when challenges arose. In the cacophony of pop culture it may be only through our own efforts that we learn about the great doctors we see in the halls.

The family has asked that, in lieu of flowers, donations be sent to the Louisiana Stroke Association or the Louisiana SPCA.

Dr Cusick is collecting rememberences from past students if you would e-mail them to her at cusick*at*tulane*dot*edu.

5-8 January, MAA—AMS joint National meeting! Oh, I so totally want to go. And I was just browsing the R L Moore Legacy Project.