text:
Since the 1970s, Goa has become a popular tourist destination in India. There are beautiful beaches, excellent south Indian food and the cost is relatively affordable. One can find adequate beach huts for as little as ₹1000/night (or about $15/night). Which is a fantastic deal for the traveller. And for the Goan economy, tourism has crept up to about 30% of total GDP.
Which makes it more curious that, until very recently, all shacks and huts had to be dismantled each year! In September of each year, entrepreneurs via for licenses allowing them to build beach huts. And then they construct temporary huts each year for the tourist season, which lasts until May. In May, as the tropical environment scorches the terrain, tourist season is low and these entrepreneurs have to deconstruct their huts. They wait through the monsoon season of June through August and re-apply the following year.
Some questions naturally follow from this policy:
Since the beaches are a natural, communal resources, it seems that the licenses should be allocated by lottery - for longer than a year! - and that the licensees should be taxed heavily for the use of these resources. The Goan community seems to have already started down this road with licenses now for 3 years with the added benefit that they do not have to be torn down each year.
This still leaves many econo-environmental issues. For example, how to solve the rentier problem as a consequence of license lotteries - in which the winners charge exorbitant sums from current hut operators who did not win a license. Or how to balance capital influx from outsiders without losing the Goan flavor? And, of course, how to protect this natural resource from the rising sea levels?
These are the questions that Goans and Indians will have to answer to keep this paradise intact.
The simple, selfish answer is no. I landed in Delhi airport on 14Nov2016 - 6 days after PM Narendra Modi unveiled his surprise plan to remove all existing ₹500 and ₹1000 notes. (₹ is the symbol for the Indian Rupee - which was trading at $1=₹62 before this announcement.) So...having just landed from South Sudan where there is no place to buy Rupees, I planned on either retrieving Rupees from the ATM or exchanging Dollars for Rupees. Unfortunately, both those options were halted by Modi's demonitization. Removal of the ₹500 and ₹1000 notes meant that 86% of India's currency value had just been eliminated without proper replacement. The ATMs had already been drained empty and the currency exchangers limited Rupee buying to only $100 - with disbursement only in ₹2000 bills.
But of course, India being a cash based economy and taxis not accepting credit cards, having a ₹2000 note when a taxi ride to the hotel was only ₹200 wasn't very helpful given that no one had ₹500 and ₹1000 notes to give change! So for me personally, demonitization was more hassle than worthwhile.
But, of course, the question must be asked to the larger goals of Modi - will demonitization decrease corruption, tax avoidance and smuggling? The answer is a 'one-time' yes. Black market transactors and hoarders of the high value currency (hawala traders, smugglers, counterfeiters, terrorists and criminals) will lose all value of cash that they currently hold.
But the actionable word in that last sentence is 'currently'. They'll just replace their currency grease with the ₹2000 notes and eventually with the new ₹500 and ₹1000 notes. But even that overestimates the impact as much of the hoarding and transacting isn't done through currency, but through illegal buying of homes (benami transactions), gold hoarding, swiss bank accounts and other cash-less money laundering.
So maybe Modi has future proposals to curb all these activities. But for the present, the answer to this post's question is 'absolutely no' for the general population. Demonitization has resulted in punishment for non-digitized Indians. Those with credit cards and digital cash (e.g. paytm) can get through this. But as 97% of Indian transactions are cash based, all those rickshaw drivers, farmers, street vendors and simple traders who aren't engaging in illegal activity, but simply subsisting on current monetary rules are screwed.
Adam Carolla once commented that mis-estimation of an activity's duration can be blamed on the Mike Tyson Principle: 3 minutes in a ring with Iron Mike can seem a lot longer than it really is. (note: Carolla used a much funnier, sexual joke, of course). Crassly seguing to humanitarian emergencies, there are frequent mis-estimations of the severity of a crises in the middle of one. Yet, the estimation of how many people are suffering is a crucial criteria for intervention. Heudtlass et al push the principles underlying Bayesian statistics to solve this problem - but they get the answer only half right.
To start with, Bayesian statistics uses 'pre-test' probability to get to a 'post-test' probability. It implies that just knowing the answer of a test isn't sufficient, that it has to be read in context. Many Bayesian proponents use the breast cancer analogy, but I'll use a slightly different one to help explain the concept. Imagine 3 patients with similar chest pain that come to your office:
For which patient(s) is heart disease the problem? After first ensuring that the patient isn't currently having a heart attack and stabilizing the patient, the next 'test' that should be done is a 'stress' test. The classical and intuitive way to interpret stress test results would be to say that if the test is positive, then it's the heart that's causing the pain and if it's negative, it's not the heart. But Bayesian stats would argue that you have to take the prior probability of heart disease into account. In this way, if the 22 year old had a 'positive' stress test - it's most likely an error (false positive) and he probably doesn't have heart disease. Similarly, if the 80 year old had a 'negative' test, that shouldn't be believed either as it's probably a 'false negative'. Realistically then, in clinical terms, you shouldn't do a stress test for either of these patients because your pre-test probability is already so high that no matter what the test result, it won't change what you would do for this patient: you'd still likely send the 22 year old home and hospitalize the 80 year old. Where the stress test really helps is in the 50 year old when you're not really sure.
Heudtlass shows how these concepts can improve emergency evaluations. He first uses the Doctors Without Border's survey showing an extraordinary high mortality in Yida, South Sudan in 2012. He argues that they should have argued a prior probability to come up with a more reasonable 'post-test' probability and in this way, would speak with more credibility. I agree with him. Just giving the result of a test isn't always informative, like the stress test examples before. Test results need to be put in statistical perspective and compared to the pre-test probability. But he then eschews Bayesian principles making two crucial mistakes.
The first mistake he makes is to use the general sub-Saharan African mortality rates as his prior probability. But he neglects to follow evidence which suggests that mortality increases during conflicts, from both direct war causes and non-war causes (e.g. epidemics, malnutrition, etc.). And second, Bayesian statistics are iterative. Once you have a new post-test probability, that becomes 'testable' again until it either converges to fit a hypothesis...or it you'll have to restart your thinking. In this case, it's hard to say that the MSF estimates were proper or not without further testing the hypothesis. Were there post-emergency surveys? Did malnutrition rates concord with the mortality survey? What about vaccination rates or vaccine-preventable disease outbreaks - were they consistent with such a high mortality rate? Heudtlass doesn't know because he doesn't follow up on the question.
He's right that we should move past frequentist stats and promote humanitarian thinking in a probabilistic sense. Especially in emergencies where situation knowledge is frequently opaque, probabilistic and iterative thinking should be prioritized. Unfortunately, in his examples, he chooses the appropriate pre-test probability and fails to follow the evidence to understand if it converges onto a narrower confidence interval.
Full disclosures: a. I've worked with MSF in the past and b. I don't have the technical chops to hang with his math - i'm writing more about his concepts.
Matt Yglesias rightly scolds Democrats for focusing solely on Hilary versus the Republican mess while ignoring the vast majority of government outside the Federal Executive Branch. Democrats don't really have a plan in the US Congress nor one at the State levels. One exception may be in Louisiana, where Democrat John Bel Edwards may have a chance to beat Republican David Witter for the right to reverse Bobby Jindal's destructive policies in the November 21 run-off.
At the very least, the stakes are crucial for access to health care. Edwards will accept the Medicaid expansion provision of the Affordable Care Act, which will instantly provide basic insurance to thousands of Louisianians at NO EXTRA COST. The taxes are already being paid to the federal government, but we're refusing the benefits - straightforward insanity brought upon solely by the crass ambition of Jindal. In addition, Edwards wants to support the safety net charity systems which have been gutted over the past decade.
Of course, Louisiana Democrats aren't made like coastal Democrats. Edwards has strong ratings from anti-abortion groups and from the NRA, per Vote Smart, and has separately said he'd oppose legalizing marijuana. These are his political indiscretions. Indiscretions by his opponent, on the other hand, include undying allegiance to the three pillars of modern American conservative movement: anti-Obamaism, cutting taxes for the rich, gutting social safety networks.
The difference in health care alone should be decisive in choosing Edwards over Vitter. But to return to the meta-discussion on American politics, quality of life won't improve simply by electing Hillary. She'll still have to deal with the obstinacy of the likely Republican Congress she'll inherit. It will only improve one-city-at-a-time and one-state-at-a-time. And in Louisiana, this means focusing on electing John Bel Edwards over David Vitter.
Liberia suffered immensely with Ebola in 2014. But the tide started turning towards the end of the year and by early 2015, Liberia was well on it's way to being declared Ebola free. There were fewer new cases each week AND the probability that every new person who became diagnosed with Ebola came from the 'contact list'. This mattered since if there was a 100% concordance between new patients with ebola and those on the contact list - then epidemiologists had found ALL the transmission chains. Eventually, by May 2015, every 'contact' had gone through the 21 day waiting period (incubation time of Ebola) and Liberia was declared Ebola free!
Sadly, Ebola re-reared it's ugly head in Liberia a week ago. There has already been 1 death and 2 other confirmed cases - all about an hour outside of the capital city of Monrovia. The first priority should be to treat these two living confirmed cases, find all the contacts and follow them for 21 days (it's not necessary to 'isolate them'). But after these initial steps, we're left with two equally scary propositions: a) we either didn't have a good enough understanding of the transmission chains or b) there's a different mode of transmission.
For option A - this means that there may have either been ongoing transmissions in Liberia with likely secret burials and obfuscation from the public health authorities OR people travelled to Guinea/Sierra Leone and the cross-border epidemiological links have not been made properly. This would show a persistent mistrust of the public health authorities and general fear among the population. This would indicate that we really don't have the epidemic under control in Liberia.
For option B - there are early theories about non-human-to-human transmission and consideration that these three 'new' cases got infected through sharing dog meat: "Dr Moses Massaquoi, case management team leader for Liberia's Ebola task force, said the three villagers who had tested positive for the disease "have a history of having had dog meat together." Dog meat is commonly eaten in Liberia. In spite of this huge epidemic in West Africa, fairly little is known about this dangerous disease. One of the unknowns is the animal reservoir - where does the virus stay when it's not infecting humans. Bats are the most likely reservoir - but maybe pigs and even dogs are also potential reservoirs? If this is true, however, what does this imply about how dangerous the future is for the population and for health workers in Liberia? How endemic will it become and will everyone who comes to a health center with fever need to be asked about dietary habits? In the end, it would likely mean that we can't have the epidemic under control in Liberia.
Either way, the bottom line is that these new cases of Ebola are a tragic recurrence in Liberia. The secondary question now is the quality (not the quantity) of this recurrence - is it due to the failings of the public health system or the emergence of new modes of transmission?
One of our recent blog posts talked about the ratcheted need for improved Infection Prevention and Control through lessons learned in the devastating West Africa Ebola outbreak. A key determinant involved mitigating the transmission of serious infections to health care workers who treat patients with unknown illnesses. Another new and ongoing outbreak only reinforces this need: MERS-CoV - Middle East Respiratory Syndrome (Corona Virus). To briefly review, this is a newly discovered virus first identified in the Middle East in 2012 and thought to have camels as the animal reservoir. Subsequently, human-to-human transmissions have been found...especially in health centers in South Korea.
The index patient in South Korea appears to have been an elderly South Korean man with respiratory symptoms who returned from the Middle East. Unsatisfied with his initial care, he ended up visiting 2 outpatient centers and two hospitals - creating a wake of exposed health care workers and neighboring patients, some of whom may have had exposure for as little as 5 minutes. Subsequently, 165 cases have been confirmed in South Korea (as of 19June15) with 24 deaths - some from the initial exposure by the index case and the rest by second order human-to-human transmissions.
And again, official recommendations have been to quarantine confirmed or probable patients (due to the likely airborne transmission) and for healthcare workers to protect themselves through proper IPC:
Droplet precautions should be added to standard precautions when providing care to all patients with symptoms of acute respiratory infection. Contact precautions and eye protection should be added when caring for suspected or confirmed cases of MERS‐CoV infection. Airborne precautions should be applied when performing aerosol‐generating procedures. (see here for definitions)
At this point in our history, where novel infectious diseases are emerging and the patient-clinician interface is a particularly high-risk encounter, this level of proper IPC seems to a necessary to even continue providing health care. As Liberia exemplified in the Ebola outbreak, when health care workers succumb to a disease, it puts the entire health care system at risk.
I remember being nervous about the exam.
The proctor called us all to attention for pre-test instructions then said,
"You may begin."
I cracked the seal on the exam book, opened to the first page and saw this...
D 約翰(John Lykouidis)成功以抗生素醫治自己的胃潰瘍。他於一個在 希臘舉行的會議上發表他的抗生素治療方法,但當時的醫療機構都 不理會他。
E 沃倫(Robin Warren)觀察到一些胃潰瘍病人的胃內,都有一種稱為 幽門螺旋桿菌的細菌。後來,馬歇爾(Barry Marshall)遇到沃倫,他 們共同提出一個有關胃潰瘍病的新假說,他們根據這個假說,成功 地以抗生素治癒胃潰瘍病人。
What the F*&^!!!
Why is the test in CHINESE!?!?
I looked around and saw all my classmate busy answering questions, writing on their scrap paper or turing pages to continue with their test - unphased while I sat there, stunned!
F*** it! I did the best I could do - answered "C" for all the questions and left passing to the Fates!
Afterwards, in the student lounge, everyone was talking about the test, the questions, their answers, other people's answers, figuring what they got right, what they got wrong, which questions they would challenge - and then I chimed in...
"Hey, did any of you guys noticed that test was like all in CHINESE?"
"Of course it was, idiot - it says in the syllabus that the final would be in Chinese. The professor said so in class the first day! HA HA HA"
"Oh, I must have missed that..."
A whole semester of med school ruined because I didn't know we'd also be expected to learn Chinese for that exam.
I'll never forget how painfully real that dream was. I even remember waking up thinking I need to get crakin' on that Chinese!
As a attending physician, (who's since learned Chinese, I might add) I no longer have anxiety dreams about med school exams in foreign languages.
Nowadays, it's recurring dreams where I'm struggling to remember all the things I leaned and need to remember...dreams about math.
Find all 6-digit numbers 685xyz that are divisible by 111
Oh, God! I know there's a formula for this, I remember learning it once...
...in med school.
Goodness gracious, me! If it isn't the Physician and Surgeon's Almanac of March 4th, 2015.
It's the birthday of Khaled Hosseini born in Kabul, Afghanistan, in 1965, his father was a diplomat in the Afghan Foreign Ministry and his mother taught Farsi and history at a high school. Following the Soviet invasion of their homeland, the Hosseinis fled to the United States as political refugees, where Hosseini graduated from high school on to the University of California, San Diego where he earned a medical degree in 1993.
While practicing as an internist, Hosseini published his first novel, The Kite Runner, that went on to become an international bestseller. It tells the story of Amir, a young boy, and his closest friend, Hassan, set against a backdrop of Soviet invasion, life in exile, and the rise of the Taliban. The story was later adapted to stage, film and a graphic novel.
In 2007, his second novel, A Thousand Splendid Suns, debuted and spent fifteen weeks as #1 on the New York Times bestseller list, remaining in that spot for and nearly an entire year on the bestseller list. The book focuses on the tumultuous lives and relationships of two Afghan women, separated by time and connected by marriage to the same husband.
No longer practicing medicine, Hosseini now lives in northern California and leads the Hosseini foundation, working to provide humanitarian assistance in Afghanistan.
Here's a poem by the poet and mother of the Afghan King, Mirwais Hotak...
Dew drops from an early dawn narcissus
as if tear drops from a melancholy eye,
O beauty, I asked, what makes you cry
life is too short for me, it answered
My beauty blooms and withers in a moment
as if smile comes and forever fades away
Proving you don't have to be a billionaire like Mark Zuckerberg to have your name put on a hospital these days, monastery founder and missionary mogul, St. Francis of Assisi, recently announced that his foundation is donating his name, and a small bird, to a county hospital that will be renamed St. Francis General Hospital and Trauma Center; bringing 40 to the number of hospital and medical centers in the US under the St. Francis name. The bird will be used on the hospital logo.
Zuckerberg, who has an estimated worth of $33.3 billion, gave a measly $75 million to have San Francisco General Hospital renamed after him. Salesforce.com founder Marc Benioff's name was added to UCSF's children's hospitals after donating $200 million, and venture capitalist Ron Conway's name was added to UCSF's Gateway Medical Center after his $40 million contribution. But neither come close to number of hospitals named after St. Francis, best known for having no money and a devotion to a life of poverty.
Neither Zuckerberg nor St. Francis would comment on the relatively small donation they both made, but in a statement St. Francis said, "Grant me the treasure of sublime poverty: permit the distinctive sign of our order to be that it does not possess anything of its own beneath the sun, for the glory of Your name, and that it have no other patrimony than begging."
Best known for saying absolutely, St. Joseph, with 81 US hospitals claiming his name, again, had no comment.
The Ministry of Information
"more power to the misinformed"
The realistic fear that Ebola envinces derives more from it's fatality rate than it's contagiousness. In fact,there are many infectious diseases that are far more 'contagious' than Ebola. This wonderful graph from the Information is Beautiful describes some common diseases based on how infectious they are (x-axis) and how deadly they are (y-axis).
Ebola is close to what HIV used to be before the advent of triple-therapy cocktails. In the 80s and 90s during pre-treatment era, HIV was actually a bit more contagious, as defined by it's 'basic reproduction ratio' - or the number of people any one person with a disease will infect. In the West Africa Ebola outbreak, the basic reproduction ratio is most likely less than 2. And that pre-treatment HIV virus was also a bit more deadly - though really there's not much good news between a fatality rate of 70% and 80%! And maybe we're looking back at that pre-treatment HIV era through the skewed optimistic lenses of today's good HIV medications, but it does seem that this current epidemic has people more afraid.
Perhaps this fear is due to the rapidity of death - HIV can take years before it destroys the immune system, leaving a long latent period. Or perhaps, it's because Ebola attacks the body so rapidly (less than 21 days!) and so savagely with many patients dying of visible hemorrhage. So as we tackle this current outbreak, it's also useful to remember how awful HIV was in the 80s and 90s how many people suffered. It took lots of activists and scientists to improve the care of HIV. It has and will take a similar effort to battle Ebola - only, much like the Ebola virus we're fighting, our pace has to be drastically accelerated.
Ebola kills victims at frightful pace, with some outbreaks having mortality rates over 90%. The current west Africa Ebola outbreak has killed over 70% of all known infected patients. To stop the contagion requires a very capable health system - from epidemiologists to water-sanitation officers to doctors and nurses. Yet these front-line Ebola fighters are themselves in harm's way, with almost 500 health-care workers killed by this current outbreak.
So even if a fantastic scientific outbreak occurs to furnish us with a high quality rapid diagnostic test for Ebola, it won't be 'perfect' enough to remove the higher bio-safety precautions necessary in clinics and hospitals. Rapid diagnostic tests can look like the do-it-at-home urine pregnancy tests sold all over, to simple gum swabbing tests that are now available for HIV or simple finger-prick tests that are commonly used by diabetic patients.
Whatever form this putative Ebola rapid diagnostic test takes, however, will not remove the need for high degrees of personal protection for health worker and high levels of suspicion. A pregnancy test that's only 90% sensitive is not ideal - but it's also not immediately life threatening (a repeat pregnancy test in couple of weeks should be more accurate as hormone levels increase). On the other hand, an Ebola test that's only 90% sensitive and used as a screening tool in a non-ebola treatment hospital may let slip in some patients with Ebola (i.e false negative tests). And the lack of proper personal protective equipment in these non-Ebola hospitals would endanger health workers slackened by bio-safety complacency.
So whatever new tools come down the pipeline, one thing that will remain is a high level of Infection Prevention and Control (IPC) in the medical world after this current Ebola outbreak ends (hopefully soon!). Much like the HIV outbreak taught us about universal precautions, instilling a disciplined approach to hand-washing, gloving and splash-protection, this Ebola outbreak should leave us with a much higher baseline protection for health workers.
But since it's not so easy to spend a whole day in these space suits, the other hammer that should drop should be innovations in personal protection equipment.
The contrast between old media versus new technology can be seen clearly in how maps are portrayed of the Ebola epidemic. For example, the World Health Organization epitomizes the 'old' media with it's very static portrayal of the dynamic timeline of Ebola's spread. Instead of a video or motioned map, it just presents a bunch of PDF maps in a downloadable series. One can't really see the evolution easily on one simple map - one would really need two monitors and put all the maps side-by-side to see them well.
Time improves on that a bit with a time-line super-imposed on top of a globe with red circles representing where ebola cases have occurred. But really, the map and the line have no relation and don't explain anything about each other. So...useless. But nice try.
Once we get to the new media, we can see better maps at the openstreetsmap project for Ebola which is an excellent crowd-sourced website using NGO, WHO and news accounts to layer on the map Ebola's incidence. And the other excellent new media is healthmap ebola timeline, an excellent chronogram of case incidences and separate modeling graph predicting the number of cases. Rather than crowdsourcing the data, the healthmap product comes from Harvard Medical School and the Boston Children's Hospital who culled WHO data.
One thing that's still missing, however, seems to be first person accounts - self-reporting by patients - or second person accounting - reports from community leaders/activists/religious groups/ngo organizations - that can give a richer accounting of the incidence and geo-time relationships. As usual however, it's left to Ushahidi to fill in this gap. Ushahidi has for years been trying to allow self-reporting or near-self-reporting of incidents, whether in terms of conflict or, in this case, in terms of an epidemic. And you can see from their website that anyone can report an incident of Ebola - good, bad or ugly - through their android/iphone phone, through email or through the web.
It's important for big media to get used these new innovations. They really explain the world in a much more nuanced way. More importantly, governmental organizations (WHO, ministries of health) and NGOs really need better capacity to both report and respond to this new layer of mapping - such that they can really improve the work for the people they intend to help.
The medical community seems in concordance that the next great challenge for the Ebola outbreak in West Africa is the discovery of a rapid diagnostic test for Ebola. Bill Frist, the former Republican head of the US Senate and also a cardiothoracic surgeon, puts it most succintly:
A very rapid test would be game-changing for Ebola. Let's look at triage in a clinic. Everyone comes in the front door together and waits together. Most people have a fever, but they aren't sure why. Most likely, it's another endemic infection like malaria, typhoid or shigella. An RDT could quickly identify patients needing quarantine from those who do not. The benefit here is threefold: fast and early quarantine to separate patients at risk for infecting others making the rest of the hospital safer; replacing fear and anticipation with knowledge; and a more efficient use of quarantine resources because they are saved for people with known Ebola infections.
And that's exactly the point. More than 2700 Liberians have died at the hands of this Ebola outbreak. That's fucking awful - it'll likely be more than the number of deaths from malaria this year in Liberia - estimated to be 2900 this year. And these tests need to have a high sensitivity (meaning very low false negatives - i.e. the person has Ebola but the test reads 'negative') and a high specificity (meaning very low false positive - i.e. the person does NOT have Ebola, but the test reads 'positive'). Having low levels of false positive and negative results that people aren't stigmatized unnecessarily and that infected people don't continue to spread the disease, respectively.
And here is the Physician and Surgeon's Almanac for January 20, 2014.
Today is the birthday of Leonard McCoy, M.D., born on this day in Georgia on the planet Earth, Stardate -95947.94, in the year 2227.
Son of David, McCoy graduated from the University of Mississippi then went on to Starfleet Academy School of Medicine.
A general physician, exobiologist and skilled
surgeon, in 2266, Lt. Commander "Bones" McCoy was assigned to the Federation
Starship USS Enterprise, under the command of Captain James T. Kirk, where he
served as chief medical officer on that historic ship's deep space exploration
missions where he became famous for his signature catchphrases, "I'm a
doctor, (Jim) not a(n)..." when asked to perform duties outside his role
as medical officer, and declaring, matter of factly, when someone or something
is clearly deceased, "He's dead, Jim."
McCoy's career and exploits are well known and have been widely documented on television, in print and in film. He created a cure for the life prolongation virus of the Onlines' homeworld, transported himself into Earth's past, creating a history without a Federation or Enterprise; he was the first xenophysician to treat the Horta silicon-based lifeform, the first to describe and find the cure for flying neural parasites, discovered the source and cure to the plague on Dramia II and synthesized a vaccine for Aquans syndrome among other notable medical accomplishments.
After leaving Starfleet in 2270, McCoy rejoined the Enterprise crew in 2273 and again served with distinction, most notably during the V'ger encounter of Stardate 7410, the famous Battle of the Mutara Nebula and the Space Probe incident of Stardate 8390.
His greatest accomplishment,however, is likely the generation of young people who chose careers in medicine inspired by portrayals of his character in live-action and animated television series and in film by the actors DeForest Kelley and Karl Urban and in books of the Star Trek science fiction franchise.
Admiral McCoy remained active in Starfleet until his retirement in 2364 at the age of 137.
Here is Sonnet #18 by Shakespeare, Shall I compare thee to a summer's day, in the original Klingon…
qaDelmeH bov tuj pem vIlo'choHQo'.
SoH 'IH 'ej belmoH law', 'oH belmoH puS.
jar vagh tIpuq DIHo'bogh Sang SuS ro'.
'ej ratlhtaHmeH bov tuj leSpoH luvuS.
rut tujqu' bochtaHvIS chal mIn Dun qu'.
rut DotlhDaj SuD wov HurghmoHmeH, HuvHa'.
'ej reH Hoch 'IHvo' Sab Hoch 'IH, net tu'.
'u' He choHmo', San jochmo' joq quvHa'.
'ach not wovHa'choH jubbogh bovlIj tuj,
'ej not ghomHa'choH Hochvetlh 'IH Daghajbogh,
'ej "QIbwIjDaq bIleng" not mIy Hegh nuj,
bovmey DaDontaHvIS, DojwI' nIHajbogh!
tlhuHlaH 'ej legh, wej 'e' lumevchugh nuv,
vaj yIntaH bomvam, 'ej DuyInmoH quv.
Translated by Nick Nedsetter, KLI, 1994
I remember learning all about Newtownian kinematics and gravity in high school. It seemed straightforward, though with some calculus needed to get a better understanding. Then in college, the profs taught us that our high school teachers had misrepresented physics to us - they had simplified the real world so that a bunch of teenagers could understand it. But, these college profs continued, to really understand the physical world, one needed to learn Einstein and his general theory of relativity. Gravity didn't really exist at all! It was just some distortion of the time-space continuum.
So when we fought wars with mortars and guns, Newton's laws worked well. But when we needed space ships and very precise GPS trackers, Newton's laws failed and one had to use Einstein's theories.
To pivot to the aid world, a growing number of researchers feel that the current paradigms of aid delivery and theory fall into this same simplicity trap. That we have looked at the world through a simple lens for expediency's sake. But that as we understand more and face bigger challenges, we have to rethink the basic equations of aid. Into this discussion steps, complexity theory: the idea that aid cannot be delivered through a linear model (e.g. give more food and hunger goes away), but that 'complex' forces need to be understood to both provide aid and evaluate it.
On Thursdays, we'll explore further the meanings and implications of complexity theory in aid - and flesh out whether and when it can be useful. But for now, let's use Ben Ramalingam's seminal 2008 paper to list the ten basic principles:
• Interconnected and interdependent elements and dimensions;
• Feedback processes promote and inhibit change within systems;
• System characteristics and behaviours emerge from simple rules of interaction;
• Nonlinearity;
• Sensitivity to initial conditions;
• Phase space – the 'space of the possible';
• Attractors, chaos and the 'edge of chaos';
• Adaptive agents;
• Self-organisation;
• Co-evolution.
Dengue Fever may sound like some awful fictional disease dreamt up from the progeny of Laurie Garret and Stephen King, but it is real and has spread rapidly over the past few decades. This steady climb in incidence can be seen in the graph to the right, while the post-1960 ubiquity can be seen in the map below. The disease is everywhere, with reported cases even in Florida in 2012. It affects millions of people a year, with a mortality rate of 2.5%.
The Aedes aegypti mosquito transmits the virus which causes the disease and, as per the map, disproportionally affects people in the tropical and sub-tropical regions of the world. Once infected, many people get symptoms which we in the US might consider 'flu-like' - fevers, muscle pain, joint aches and so forth. Specific to Dengue fever, however, is pain behind the eyes (retro-orbital) and a rash.
In many people, the symptoms self-resolve, but in some people, it advances to cause severe hemorrhage and shock, which is called Dengue Hemorrhagic Fever (DHF) or Dengue Shock Syndrome (DSS). Once this happens, the victim suffers from catastrophic bleeding and liver failure and without appropriate supportive care, can die rapidly.
We don't yet have a vaccine to prevent Dengue Fever and our best method to reduce incidence resides in vector control (i.e. kill the mosquitoes!). And sadly, we don't have a cure - so unlike, say Influenza, where we can use medicines like Tamiflu if diagnosed early enough, once we diagnose Dengue fever, the best we can do is to ensure that with proper hydration and blood product replacement, a patient won't die.
But given that at the least we can prevent some deaths, surely we would like to make a clinical diagnosis of Dengue fever in a patient as quickly as possible. Unfortunately, clinicians don't have much in their field laboratory arsenal to make the diagnosis. They are forced to use clinical signs and symptoms, including one ridiculous antiquated modality, the tourniquet test, which is actually incorporated into the WHO diagnostic guidelines. It consists of inflating a blood pressure cuff for 5 minutes and then counting the number of red spots on the arm (petechiae). WTF? It doesn't work! A disease that affects millions of people worldwide in 2013 and this is one of the ways the WHO recommends for us to diagnose the disease in the field? It would be hard to find a better example of the failure of the larger US medical community to respond globally rather than parochially.
As we get further into the gaming world, the surgical field has developed laparoscopic simulators that allow trainees to understand the dynamics of this type of surgery before performing them on actual patients. In a further twist on gaming, this study out of Rome tested whether the simple act of playing on a Wii for a few weeks could improve performance on the surgical simulator. The investigators randomized 40 residents: 1/2 used the Wii for a month, while the other 1/2 did not. At the end, the investigators re-checked each resident's performance on the surgical simulator. Voila! the residents who had played on the Wii significantly improved scores with the surgical simulator.
So that's great. Residents can play on the Wii and improve service for their patients. But let's think about the opposite way for a second. There are a lot of surgeries happening in this world where laparoscopic surgical equipment does not exist: war surgery in Syria, emergency surgeries in the Central African Republic, etc. And soon, a growing problem with humanitarian surgeons (especially expatriate surgeons) will be that many will be competent in laparoscopic surgeries, but NOT in open surgeries. Especially as the benefits, safety and ease of laparoscopic surgeries far outweigh that of open surgeries, fewer and fewer surgeons are comfortable with open surgeries. This helps those patients in the developed world, but when these surgeons arrive for humanitarian missions that don't have laparoscopic equipment, they may need a steep learning curve - at the cost of patient safety.
One easy way to circumvent this problem would be for humanitarian organizations to recruit more competent surgeons from developing countries - where the pool of those qualified to do open surgeries can be vast. Humanitarian organizations should do this! The other option would be to have surgical simulators that mimic 'open surgeries'. There's probably not a market for this in the developed world, but as a training module for surgeons, it could prolong the queue of competent 'western' surgeons until a Utopian time when even in war-ravaged or isolated surgeries can be performed laparoscopically.
Often neglected, but never forgotten, the Physician and Surgeon's Almanac for November 27, 2013.
It's the birthday of Fe del Mundo, M.D., born on this day in 1911 in Intramuros, Manila.
When her older sister died of appendicitis at the age of 11, del Mondo decided that when she grew up she wanted to become a doctor to the poor.
She graduated from the University of the Philippines in 1926, was class valedictorian from medical school in 1933 and placed third among students qualifying for the medical boards that year.
When the President of the Philippines offered her a scholarship to complete her training at any university in the world, the chose to study pediatrics Harvard and in 1936 she was accepted to the Harvard Medical School.
Unknown to Harvard officials they had admitted the first woman and first Asian to their all-male student body. Nine years later, Harvard began to routinely accept female students in 1945.
Del Mundo went on to practice pediatric medicine and became
a leader in public health in her native Philippines, establishing the first
pediatric hospital in the country, writing medical textbooks and she was also a pioneer in the field of infectious disease.
She practiced well into her 90's, making daily rounds at the Dr. Fe del Mundo Children's Medical Center until her death at the age of 99.
Here's a Tagalog song by Justin Morgan...
May date ako
sa Mindanao
Pupunta ako
sa Mindanao
azul na langit
- at ikaw!
Pupunta ako
sa Mindanao!
(I have a date
in Mindanao
I'm going to
The sky is blue
- and so are you!
I'm going to
Over the past few years of traveling in and out of the US, I lost touch with some of the wonderful work done in New Orleans for free and low-cost health care. The camaraderie and solidarity post-Katrina really showed some of the innovations and successes that could be done under difficult situations. Maybe I'm too far removed from health care system in NOLA feels disjointed nowadays. Here's an initial cyber-effort to re-engage with these clinics - and hopefully be inspired by the work being done by awesome people in this city.
Way back in the day, in the 1990s, one of the best health medical record system belonged to the Veterans Administration. That once creaky, decrepit institution where veterans feared they'd exit a hospital stay missing one or more limbs, had miraculously re-invented itself as a leader of comprehensive health care with the best medical record system around. More than 60% of US physicians trained at least partially at a VA and uniformly boasted about the VISTA computer record system for patients. Sitting at a terminal, any nurse, respiratory tech, lab tech, or physician could see all the notes, x-rays, EKGs, lab results and put in new orders.
Flash forward to the 2010s and we see now an incredibly complex system of electronic medical records (EMRs) available to all private and public hospitals - and even to the VA. Since I don't currently work at a VA hospital, a google search of the current EMRs in use at the VA and throughout the Military Health System (MHS) reveals the following programs: AHLTA, Clinicomp/Essentris, along with the original VISTA. And then there's the failed $150 million VA patient scheduling system along with the possibility that ALTHA, implemented in 2004, could also be soon declared a failure.
WTF? How did we get from the early successes to these failures? And does this portend doom for the Obamacare website, which completely failed its premier? Yes - if the current development models continue to be used. Hiring different companies and using off-the-shelf tools will lead to failure. One of the reasons the VA health system worked is because there was no top-down model. Individual pharmacists, nurses and doctors took it upon themselves to write open-source code in guerrila style:
VistA was not developed as an "approved" project. It was developed as a kind of rebellion against the backward software that was available at the time and a rebellion against the backward ideas held by VA bureaucracy. This rebellion was called the "underground railroad" among VistA insiders.
In fact, when it finally did become top-down, it started to rot and gave us the hot mess we have now:
Once the VA approved the project and started managing the software development using top-down practices, everything slowed to a crawl.
So going back to its guerrilla-like roots and to open-source should drastically improve the overall function of the VA EMRs. In the same vein, 'guerrilla-like' websites like thehealthsherpa.com give a way forward to the Obamacare people. Give out parcels of the project, make it open-source code and give the crowd a way to make it work. Working in a top-down or closed environment, with off-the-shelf products will lead to further failure. Doing the opposite will give the website a glimmer of hope.
Cervical cancer kills women. Lots of women. In the 1940s, it was amongst the leading cause of cancer deaths in women in the US. Yet since the invention of the Pap Smear and its use as a screening tool, the incidence and mortality from cervical cancer dropped precipitously (see graph on right). Unfortunately, over 4000 women in the US still die from cervical cancer each year - either because of they lack access to routine screening or because of an aggressive cancer.
Meanwhile, as per the graph, rates around the world are still way too high. Public health authorities estimate that 275,000 women worldwide still die each year from cervical cancer, many in developing countries. There are lots of efforts to reduce this.
The Gates Foundation did a landmark study of over 100,000 women in rural India using different modalities of screening (Pap smears, cytology, and vinegar - a common tool in the developing world) - with then appropriate treatment for at-risk lesions.
Others have pushed vaccines, including Gardasil and Cervarix. Since the 1980s, when we found that young women with a high number of sexual partners had a higher risk of cervical cancer (the same goes for young men with anal-receptive intercourse), we postulated that a sexually transmitted organism might be the proximate cause. We've subsequently identified a virus called Human Papilloma Virus (HPV) - specifically HPV-16 and HPV-18 - that cause about 70% of cervical cancers. These viruses can be transmitted sexually. So voila! - we've found a cause of cervical cancer.
And after painstaking work, we found vaccines that work against these viruses (Gardasil and Cervarix). They reduce the incidence of pre-cancerous and cancerous lesions in women not previously exposed to HPV-16 and HPV-18. Yes - they have some side effects. And these need to be carefully watched. But, no - there's no real evidence that they cause death. In a study between 2006-2008 32 women died after they received a anti-HPV vaccine. But let's not so quickly confuse 'correlation' with 'causation'. On autopsy, these unfortunate women were found to have died of another cause - "diabetes, viral illness, illicit drug use, and heart failure."
This 'correlation/causation' mistake would be like me banging my head against a brick wall after reading some anti-vaccine article which totally misquotes a researcher and then uess false statistics to promote clearly ideologic message - and then blaming my brain bleed on that article's author. Wait - actually this causation is far closer than that attributed to vaccines!
Anyway - the point is that cervical cancer kills. Pap smears have shown to save women from this terrible cancer. And now, we have another arsenal with new vaccines against the most common cause of cervical cancer. So yes, we need further data, like we do with every new drug/vaccine. And the price of these vaccines should be much lower. And women still need to get Pap smears.
But the message that vaccines like Gardasil kill and are some conspiracy against the population itself is a dangerous one. Ask anyone who recently suffered from the resurgence of Whooping Cough in the US. Or died from Measles in Africa. Or now suffers from Polio in Syria - where the two year civil war has precluded large number of children from getting appropriately vaccinated!
First, if you haven't already, go see 12 Years a Slave. It might even be better to see it alone, so you have unencumbered viewing and time to process. You'll need it.
Second, the movie reminds me again that there are so many stories about New Orleans that escape casual conversation. Discussions that focus only around the revelry of Bourbon Street or punctuate in the punchline of calling the city 'Nawlins' (no one who lives in NOLA speaks like that) do the city and its history a disservice. Whether it's the forgotten story of Homer Plessy (and the 1896 Supreme Court case which codified 'seperate but equal') to the story of Solomon Northup told in 12 Years a Slave, New Orleans history always amazes the detailed listener with its tapestry.
And so here we arrive at a seemingly incongruous little scene in 12 Years a Slave where as they return from the working fields, a group of black slaves meets some American Indians. These American Indians have just caught some prey on a hunting trip and the scene initially portrays a potential standoff between the two groups. But instead, the American Indians share a barbecue with the slaves along with some merry dancing.
This connection between the American Indians and the slaves increased over time, with more and more gracious acts of kindness by the Indians. And each Mardi Gras, African-Americans in New Orleans pay homage to these Indians by dressing up as Mardi Gras Indians. As usual, the customs, complexity and styles of these Mardi Gras Indians have taken a fantastic New Orleans flavor, but the basic premise still honors the service of the American Indians during and after the time of slavery.
If you ever get the chance to visit New Orleans, stay away from Bourbon street and try to find some Mardi Gras Indians. Or visit the Back Street Museum to learn more about them.
But first, go see 12 Years a Slave.
1. Education.
2. Human resources capacity.
3. Communication networks.
4. Emergency drug stocks and "washout medications".
5. Secure drug storage.
6. Decentralisation of care.
7. Cooperation with HIV treatment facilities in neighbouring regions.
8. Treatment information cards and duplicate medical records.
9. Integration with other services.
Here's the Physician and Surgeon's Almanac for May 25, 2013.
Today is the birthday of Armand Hammer, the son of Russian, Jewish immigrants. His father, a physician, ran a general medicine practice and drug stores in New York City.
Although Hammer went to work in the family drug store and soon graduated from Columbia with a degree in medicine in 1921, it was the world of business, not medicine, where he distinguished himself.
Although Hammer owned a considerable share of stock and served on the board of directors, the Church & Dwight Company's brand name, Arm & Hammer, originates more than 30 years before Armand Hammer was born.
Energy, not baking soda, was the business Dr. Armand Hammer was best known. After successfully leading the family drug store and other business ventures, Dr, Hammer acquired control of the California-based oil exploration and production company Occidental Petroleum, a company he ran for decades. In 1986, Forbes Magazine estimated his net worth at $200 million.
A philanthropist and collector of fine art, his personal acquisitions form the core of the permanent collection of the UCLA Hammer Museum, located next to the Occidental Petroleum headquarters building in Los Angeles.
Hammer was also a political activist, donating to Republican candidates and helping the son of his close friend, Al Gore, Sr., win an election to the US Senate. Hammer also worked throughout the Cold War to improve US-Soviet relations and to improve the lives of those in communist countries. He was nominated several times for the Nobel Peace Prize, but never won.
He married several times and had one son. His great-grandson and actor, Armand Douglas "Armie" Hammer became known for his portrayal of the Winklevoss twins in the 2010 film The Social Network, and will play the title character in the 2013 film Lone Ranger.
In 1990, Hammer lost his life to bone marrow cancer at the age of 92. He was buried in Westwood Village Memorial Park Cemetery, across the street from the Occidental Petroluem building and the Armand Hammer Museum.
We've seen before in the Games in Medicine (Tuesdays) posts that there are some early failures in the value of gaming in health. A Cochrane Review didn't find any significant evidence that using the virtual world of Wii provided any beneficial 'arm function' or 'ADL [activities of daily living] function' in the elderly over conventional therapy. In other studies, the value of Wii gaming could easily be offset by the anti-bucolic, seasonally-affective-disorder-producing monotony of indoor activity relative to the fun of playing outdoors.
But there are obvious success also. Foldit, the addictive game of 3D spacial modeling developed at the University of Washington, found success when its crowd-sourced solution to a long-standing conundrum took only 10 days to solve. For 15 years, researchers were unable to model the correct configuration of the Mason-Pfizer retrovirus - a simian virus causing a disease similar to HIV. But within 10 days, the Foldit community was able to figure out the right answer, giving hope that similar exercises can find the right targets or compounds for faster development of antibiotics/antivirals/biologicals against difficult or neglected diseases.
In clinical medicine, we find that gaming itself can improve adherence to chemotherapy medications in adolescents. HopeLab developed an action game called Re-Mission, simulating the destruction of cancer cells by chemotherapy and the control of side effects (e.g. nausea, vomiting). Subjected to a randomized-control trial of adolescents with cancers, active participation with the game had both functional (as measured by functional-MRI) and outcome (medication adherence, self-efficacy and knowledge) improvements in the treatment wing relative to the control group.
One further cool aspect of the Foldit model that the HopeLab idea could co-opt is the team-mentality. In the Foldit world, there are scores of teams, with names like Anthropic Dream, Contenders, Void Crushers, and so forth. It would be fantastic to see Re-Mission be a multi-player game, with the participants cooperative instead of competitive. The power of crowd-sourcing added to the benefits of gamification could potentially augment the value of gaming in the Chronic Care Model.
Fast Company has a curious story about an external 'thermometer' for the iphone. The thermometer's developers had originally written a weather app and then added an external button which plugged into the head-phone jack - serving as a (fake) thermometer. Once users figured out that the external button was sham, they wrote all kinds of 1-star reviews on itunes. So this company decided to make an actual thermometer, which would still plug into the headphone jack - only this time, it was a real thermometer. Fast Company jokingly teases this 'app' a bit when they ask "why would you use this thing?"
No one, is the answer to the rhetorical question. Except everyone wanting to know the temperature of a baby. And then wanting to directly download that information to that patient's medical record. In advanced hospitals, this is exactly what's done. Rolling 'vital sign' machines check the temperature, heart rate, blood pressure and other important patient data and then uplink this information to a central server. But in remote field settings, having this bulky equipment may not be so handy. What would be quite helpful is the micro-sizing of this equipment a
nd then linking it to an iphone like device.
Right now, temperature, pulse oximetry, and simple blood tests (like hemoglobin or glucose levels) can possibly be done through a simple iphone interface. But we still can't tell blood pressure without a sphygmomanometer, malnutrition levels without weight scales, or infection causes without sizable laboratories. And while these are concepts two steps removed from current reality, ten years ago, would we have imagined that our mobile phone could order us pizza, trade stocks, pay bills at a local store...or take a room's temperature?
Knee pain is a common ailment and increases in prevalence with age. Some people just tough it out. Others try glucosamine or natural remedies. Still others try over-the-counter medications or exercise. A few get a prescription for an exercise or weight-reduction program from their doctor. But unfortunately, there are many who get sent for a referral for a knee arthroscope.
And yet study after study shows that arthroscopy (a camera guided 'cleaning' of the knee) is no better than placebo. In the (in)famous study published in 2002 in the New England Journal of Medicine, it was shown that for patients with knee arthritis, actually doing arthroscopy on their knees in an operating room was just as effective as taking patients into the operating room, sedating them, nicking their knee and then doing absolutely nothing else. Further studies have reproduced this finding.
So while the number of arthroscopies for knee arthritis have decreased, perhaps it's been replaced in the surgical field with just knee replacement. In this procedure, the whole knee is replaced with a prosthesis. In 2009, knee replacements were the 13th most common procedure in the US - after such 'procedures' as cardiac angiographies, CAT scans and diagnostic ultrasounds. Over 676,000 knee replacements are done each year.
But again, there don't seem to be real good studies showing the benefit. Meanwhile, there are lots of harm and risk. Every surgery has a risk of bleeding and infection. Years down the line, any hardware inserted into the body can fail and break, necessitating repair. And the anesthesia associated with any surgery carries an independent risk of complications. For what benefit? We've found that 'washing' out a knee is of low utility. So where are the studies that show that 'replacing' it are better? Sure, we can always find anecdotal evidence that this or that person felt better after a knee repair. But have we shown this systematically? (To be fair, the whole ethics of a placebo-controlled surgical trial is murky.)
And though the wages of those producing and inserting the knee replacements may be high, what are the expenses to the patient and society?
And here is the Physician and Surgeon's Almanac for February 17, 2013.
Today is the birthday of René Théophile Hyacinthe Laënnec born on this day in 1781 in Quimper, France in the province of Brittany.
After his mother died from tuberculosis and his father proved incapable of caring for him and his brother, at the age of twelve, Laënnec went to live with his uncle, the dean of medicine at the University of Nates. In 1800 Laënnec went on to Paris to studying anatomy and dissection with famous physicians such as Guillaume Dupuytren, Gaspard Laurent Bayle, and Jean-Nicolas Corvisart des Marets and after graduating in 1804, Laënnec continued his research as a faculty member of the Society of the School of Medicine in Paris and was appointed personal physician to the half-brother of the French Emperor, Napoleon I.
In 1816, Laënnec was appointed as physician at the Necker Hospital in Paris, where he invented the stethoscope. His new device replaced the long established practice of "immediate auscultation", in which the physician laid his or her ear directly on the patient to listen to chest sounds. Laënnec's simple stethoscope design consisted of a hollow tube of wood that transmitted sounds from the patient's heart and lungs to one ear.
Use of the stethoscope became known as "mediate" auscultation and in 1819 Laënnec published De l'auscultation médiate ("On Mediate Auscultation"), the first work describing heart and lung sounds heard through the stethoscope. Physicians from throughout Europe came to Paris to learn auscultation from Laënnec and the use of his new diagnostic tool. Laënnec wrote the first stethoscope descriptions of pneumonia, bronchiectasis, pleurisy, emphysema, and pneumothorax. A brilliant researcher, beyond auscultation, Laënnec's was the first to describe micronodular growths on the liver as cirrhosis. In 1804 he used the Greek word melanose, meaning "black", to describe melanoma, being the first to recognize that melanotic lesions were the result of cancer cells from the original tumor that had spread to other places in the body.
Laënnec was appointed chair and professor of medicine at the College of France, appointed to the French Academy of Medicine and in 1824 he married was made a chevalier of the Legion of Honor. Two years later, at the age of 45 Laënnec, using his stethoscope, diagnosed himself and understand that he was dying from the same disease that killed his mother.
Laënnec's stethoscope has evolved into the model we use today and became the principal diagnostic tool in medicine and the stethoscope technique revolutionized the diagnosis of cardiac and lung disease.
Here's a poem by physician and poet Oliver Wendell Holmes, Jr., M.D.
The Stethoscope Song
There was a young man in Boston town,
He bought him a stethoscope nice and new,
All mounted and finished and polished down,
With an ivory cap and a stopper too.
It happened a spider within did crawl,
And spun him a web of ample size,
Wherein there chanced one day to fall
A couple of very imprudent flies.
The first was a bottle-fly, big and blue,
The second was smaller, and thin and long;
So there was a concert between the two,
Like an octave flute and a tavern gong.
Now being from Paris but recently,
This fine young man would show his skill;
And so they gave him, his hand to try,
A hospital patient extremely ill.
Some said that his liver was short of bile,
And some that his heart was over size,
While some kept arguing, all the while,
He was crammed with tubercles up to his eyes.
This fine young man then up stepped he,
And all the doctors made a pause;
Said he, The man must die, you see,
By the fifty-seventh of Louis's laws.
But since the case is a desperate one,
To explore his chest it may be well;
For if he should die and it were not done,
You know the autopsy would not tell.
Then out his stethoscope he took,
And on it placed his curious ear;
Mon Dieu! said he, with a knowing look,
Why, here is a sound that 's mighty queer.
The bourdonnement is very clear,--
Amphoric buzzing, as I'm alive
Five doctors took their turn to hear;
Amphoric buzzing, said all the five.
There's empyema beyond a doubt;
We'll plunge a trocar in his side.
The diagnosis was made out,--
They tapped the patient; so he died.
Now such as hate new-fashioned toys
Began to look extremely glum;
They said that rattles were made for boys,
And vowed that his buzzing was all a hum.
There was an old lady had long been sick,
And what was the matter none did know
Her pulse was slow, though her tongue was quick;
To her this knowing youth must go.
So there the nice old lady sat,
With phials and boxes all in a row;
She asked the young doctor what he was at,
To thump her and tumble her ruffles so.
Now, when the stethoscope came out,
The flies began to buzz and whiz
Oh ho! the matter is clear, no doubt;
An aneurism there plainly is.
The bruit de rape and the bruit de scie
And the bruit de diable are all combined;
How happy Bouillaud would be,
If he a case like this could find!
Now, when the neighboring doctors found
A case so rare had been descried,
They every day her ribs did pound
In squads of twenty; so she died.
Then six young damsels, slight and frail,
Received this kind young doctor's cares;
They all were getting slim and pale,
And short of breath on mounting stairs.
They all made rhymes with "sighs" and "skies,"
And loathed their puddings and buttered rolls,
And dieted, much to their friends' surprise,
On pickles and pencils and chalk and coals.
So fast their little hearts did bound,
The frightened insects buzzed the more;
So over all their chests he found
The rale sifflant and the rale sonore.
He shook his head. There's grave disease,--
I greatly fear you all must die;
A slight post-mortem, if you please,
Surviving friends would gratify.
The six young damsels wept aloud,
Which so prevailed on six young men
That each his honest love avowed,
Whereat they all got well again.
This poor young man was all aghast;
The price of stethoscopes came down;
And so he was reduced at last
To practise in a country town.
The doctors being very sore,
A stethoscope they did devise
That had a rammer to clear the bore,
With a knob at the end to kill the flies.
Now use your ears, all you that can,
But don't forget to mind your eyes,
Or you may be cheated, like this young man,
By a couple of silly, abnormal flies.
And now for something completely different... the Physician and Surgeon's Almanac for January 8th, 2013.
Today's the birthday of Graham Chapman, M.D., born on this day in Leicester, England in 1941.
Educated at Melton Mowbray Grammar School , Graham studied medicine at St Bartholomew's Medical College and later graduated as a physician from Emmanuel College at Cambridge. He did not go on to pursue a career in medicine, but comedy writing and acting as one of the founding members of a landmark BBC television comedy series...
A fan of radio comedies as an early age, Chapman stated "from about the age of seven or eight I used to be an avid listener of a radio program called The Goon Show. In fact, at that stage I wanted to be a Goon".
During the 1960s, Chapman distinguished himself a comedy writer for the BBC, contributing to sketch comedy television and radio shows like I'm Sorry, I'll Read That Again, The Frost Report, At Last the 1948 Show and Doctor in the House.
With success at comedy writing and as cast members for programs like The Frost Report and At Last The 1948 Show, the BBC offered Chapman and his writing partner, John Cleese, the opportunity to develop their own comedy program.
In 1969, Chapman and Cleese, joined Terry Gilliam, Eric Idle, Terry Jones and Michael Palin to create the Monty Python's Flying Circus television series.
The show was a collaborative effort, with different Python members responsible for elements of the creative process. Graham was best known for writing in partnership with Cleese, playing authoritarian characters, helping other writers decide which skits were funny or not and introducing absurd ideas to make the sketches of others funnier; including a sketch in which a man tries to return a defective toaster to a store. Graham suggested instead that the customer attempts to return a dead bird which later became famously known as "the Dead Parrot Sketch".
Among the many characters Chapman is best remembered for are the lead roles in Monty Python films, Holy Grail, as King Arthur, and Life of Brian, as Brian Cohen, the accidental Messiah.
Graham Chapman was one of the first celebrities to openly acknowledge his homosexuality, often alluding to his sexual orientation while playing comic characters and supporting gay rights activities in Britain. His alcoholism, however, was not as well tolerable by his Monty Python co-creators. His drunkeness often affected his ability to remember lines, and alcohol withdrawl limited his ability to perform.
Graham Chapman died of spinal and throat cancer on October 4, 1989, with his partner, his brother, sister-in-law, John Cleese and Michael Palin at his bedside.
In his eulogy to Chapman, John Cleese remaked …
"Graham Chapman, co-author of the "Parrot Sketch", is no more. He has ceased to be. Bereft of life, he rests in peace. He's kicked the bucket, hopped the twig, bit the dust, snuffed it, breathed his last, and gone to meet the great Head of Light Entertainment in the sky. And I guess that we're all thinking how sad it is that a man of such talent, of such capability for kindness, of such unusual intelligence, should now so suddenly be spirited away at the age of only forty-eight, before he'd achieved many of the things of which he was capable, and before he'd had enough fun.
Well, I feel that I should say: nonsense. Good riddance to him, the freeloading bastard, I hope he fries. And the reason I feel I should say this is he would never forgive me if I didn't, if I threw away this glorious opportunity to shock you all on his behalf. Anything for him, but mindless good taste…"
Here we have the Physician and Surgeon's Almanac for December 31, 2012.
It's the birthday of Andreas Vesalius, M.D., born Andries van Wesel on this day in Brussels, Belgium in the year 1514. Descendent of a line of royal court physicians, he was the son of Anders van Wesel, court-apothecary to the Emperor Charles V of the Holy Roman Empire.
In Padua, in 1537, he became a doctor of medicine and, in his short career as an anatomist, he introduced the Renaissance to medicine, dispelled over a thousand years of accepted medical beliefs and convince us to look at our bodies with our own eyes.
Galen anatomy (left) Vesalius anatomy (right)
In the past, physicians studied and taught anatomy by reading the classical texts on the subject written Galen or Mundino while a barber-surgeons dissected cadavers. Few in medicine questioned the accuracy of these centuries old authoritative works. Vesalius, on the other hand, chose a radical course...
When he was named head of anatomy at the University of Padua, he decided do his own dissections and would teach based on the anatomy as he observed it, not as others had observed and asked him to accept. Eventually, this led him to uncover many errors in accepted anatomic teaching. His dissected humans did not match what was written in the standard textbooks. He began to believe that Mundino de Lucci probably dissected few human specimens and Claudius Galenus had probably never dissected a human body at all.
In 1538 he published his own anatomy book based on his dissections the "Tabulae anatomicae" followed by "De humani corporis fabrica" in 1540 which masterfully presented drawings and paintings describing the human anatomy in realistic detail, with his skeletons and muscle men posing for the reader as if alive with action.
Beyond being just artistically expressive, Vesalius' work openly questioned traditional teaching and promoted the scientific method in anatomical study, which was too much for some.
In his writings Vesalius went against the medical community and rejected teaching Galen. He pointed out that Galen human anatomy was based on Galenus' study of apes and he introduced his own drawings and dissections of human as a source of knowledge and encouraged others to embrace the scientific method in theorizing how the human body functioned rather than blindly following what they were told or read in books.
Vesalius described the mandible being one bone, not two as Galen had described it. Vesalius' illustration of the heart at first confirmed Galen's description of right ventricle supplying blood to the lower organs, the left ventricle supplying blood to the higher organ and holes between the cardiac ventricles allowing for the flow of blood (below), but when Vesalius failed to observe such pores between the ventricles in dissection after dissection he shocked many in 1555 by openly questioning Galen when he wrote,
"Not long ago I would not have dared to turn even a hair's breadth from Galen. But it seems to me that the septum of the heart is as thick, dense and compact as the rest of the heart. I do not see, therefore, how even the smallest particle can be transferred from the right to the left ventricle through the septum."
Like Galileo stating that the Earth revolved around the sun and not the other way around, all hell broke loose when Vesalius said what no one dared to say - Galen's ventricle pores did not fit what was consistently being observed. By questioning Galen and demonstrating contrary evidence based on his own, repeated observations, Vesalius encouraged independent questioning and investigation by others, too.
Vesalius later described the connection between the arteries, veins, atria and ventricles of the heart, giving the mitral valve its name. He also went against the accepted church and medical belief by demostrating that men did not have one less rib than women…
With over a thousand years of unquestioned ideas now being turned on their heads, believers in Galen's description of human anatomy and defenders of tradition even went so far as to argue that Galen was not wrong but that, over the centuries, it was the human body that changed!
Despite his detractors, in 1544 was appointed court physician to Holy Roman Emperor Charles V and then to King Philip II of Spain, the Emperor's son.
Because of his radical ideas, based on scientific investigation and evidence in a medical community that clung to biblical teachings and tradition, he continued to gain enemies and some say the attention of the Spanish Inquisition.
In a popular story about the life of Vesalius, he was said to have dissected a man whose heart was still beating, leading to his being charged with murder. In hopes of the most severe punishment, the deceased's family also accused him of atheism before the Inquisition. With the aide of King Philip II, he avoided the death penalty, and was sent on pilgrimage to Jerusalem, from which he never returned.
Whether escaping the Inquisition was his reason for going to the Holy Land, upon his return, Vesalius was shipwrecked on a Greek island and died at the age of 49.
Although he died poor, his legacy was a new word of medical knowledge based on hypotheses, investigation, observation, theorizing and facts about the form and function of the human body.
Here's a bit of a popular melody written by African-American author and songwriter James Weldon Johnson called Dem Bones…
The toe bone connected to the heel bone,
The heel bone connected to the foot bone,
The foot bone connected to the leg bone,
The leg bone connected to the knee bone,
The knee bone connected to the thigh bone,
The thigh bone connected to the back bone,
The back bone connected to the neck bone,
The neck bone connected to the head bone,
Oh, hear the word of the Lord!


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These guys are not afraid of a bold outfit.
The NBA has notably been home to some very intense fashion as of late. The players' pre-game walk has turned into a runway, and NBA red carpets have become full-on playgrounds. We'd never fault someone for taking a style risk, so long as it has purpose. And the risks taken at this year's NBA awards red carpet were big and purposeful. The results? Mixed. But they were certainly entertaining! Take a look at the boldest, the weirdest, and the actually stylish outfits right here.
In ASOS.

subset: commoncrawl


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The love I have for you will never go away. These are the words that flood my mind, as the day of my oldest brothers' birthday approaches. It has been almost seven years, since we lost him.
My heart is peaceful, but there is still a hole, due the absence of his physical presence. Yet there is also relief, in knowing, that there will be a reunion in heaven. My eyes are flooded as I remember our talks, your laugh, and your gentle-kindness. Joy and sorrow are sometimes not so distant cousins, and untamed emotions can be distorted by the grief of the heart. I find solace in the following scripture:
1 Thessalonians 4:13
And now, dear brothers and sisters, we want you to know what will happen to the believers who have died so you will not grieve like people who have no hope.
When I consider the deterioration of your frail form, my heart it is at ease knowing that your pain has ceased, and in a way healing has taken place. There is no more suffering for you to face, no need to watch you agonize in pain. There is now some relief, in knowing that despair in death may be misplaced. Death in itself has liberated you unto a better place, where tears dissipate and laughter is full of joy and grace. Yet, there is still a hole in my heart, because of your missing presence.
Quietly you transitioned in peace; you embraced your journey to a place of rest. You are loved brother, and so dearly missed. Every day, I rejoice in the memories we shared, and go on knowing that God has you wrapped in the bosom of his arms. We shall meet again, for my heart alone understands there is eternal hope. It's irrefutable this hope, this assurance, this peace in my heart. I can see you dancing in the sun, the light you've shown will never fade.
With courage you answered the call, and without struggle fall asleep in the father's arms. Its irrefutable this eternal hope that gives peace, in the face of loss, despair, and grief. Each day, I hope and rejoice in the memories imprinted on my heart. Brother, I will see you again!
Remembering you with joy and laughter is a choice to celebrate you, instead of living a life confounded by hopelessness.


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Julie Vaughn Group
86 Retreat Village
St. Simons Island, GA 31522
(912) 434-9964
(912) 434-9078 (fax)
Monday through Friday 10am to 5pm. Saturday & Sunday - By appointments
Julie Vaughn Group
For almost two decades I have served the Jacksonville Beaches/ Ponte Vedra Beach, and now St. Simons Island and Golden Isles real estate markets. From residential real estate to commercial, buying a home or managing a rental property, investing in real estate or developing a large-scale projects.
In the heart of St. Simons @ the round about in the Winn Dixie shopping Center


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Homes on Web are delighted to announce to the market this extended four bedroom detached property situated in the sought after town of Newport Pagnell. With its close proximity to local shops and amenities and within a sought after school catchment, this property really does tick all of the boxes you would want for a family home. In brief the property comprises; Entrance hall, lounge, kitchen, dining room, cloakroom. On the first floor there are four bedrooms and a family bathroom. Outside there is a rear garden perfect for entertaining and a driveway providing off road parking leading to a garage. This property really does need to be top of your viewing list to fully appreciate the accommodation on offer.
ENTRANCE HALLDouble glazed front door and window. Doors leading to cloakroom, kitchen and lounge. With stairs rising to the first floorCLOAKROOMFitted in a two piece suite comprising; Low level WC and wash hand basin. Double glazed frosted window to side.LOUNGE - 16'11" (5.16m) Max x 12'6" (3.81m) MaxDouble glazed window to front. Doors leading to dining area. TV points. Radiator. Fire placeDINING ROOM - 14'0" (4.27m) Max x 11'7" (3.53m) MaxDouble glazed window to sliding doors to rear. Radiator. Serving hatchKITCHEN - 18'5" (5.61m) Max x 13'0" (3.96m) MaxDouble glazed window to side. Double glazed sliding doors to rear. Fitted in a range of wall and base units with complementary work surfaces. One and a half bowl stainless steel sink and drainer with mixer tap. Space for cooker with extractor over. Space for fridge freezer. Plumbing for washing machine and dishwasher Radiator. Tiled to splashback areas.FIRST FLOOR LANDINGDoors leading to first floor accommodation and bathroom. Double glazed window to side.BEDROOM ONE - 11'6" (3.51m) Max x 10'9" (3.28m) MaxDouble glazed window to front. Radiator.BEDROOM TWO - 11'4" (3.45m) Max x 8'0" (2.44m) MaxDouble glazed window to rear. Radiator.BEDROOM THREE - 10'8" (3.25m) Max x 7'4" (2.24m) MaxDouble glazed window to front. Radiator.BEDROOM FOUR - 8'7" (2.62m) Max x 6'11" (2.11m) MaxDouble glazed window to rear. Radiator.FAMILY BATHROOMFitted in a three piece suite comprising; Low level WC, wash hand basin and panelled bath with shower over. Tiled to splashback areas.REAR GARDENMainly laid to lawn. Mature shrubs. Patio area. Access to the driveway and garage.GARAGEUp & over garage doorNoticePlease note we have not tested any apparatus, fixtures, fittings, or services. Interested parties must undertake their own enquiries into the working order of these items. All measurements are approximate and photographs provided for guidance only.
The Energy-Efficiency Rating is a measure of a home's overall efficiency. The higher the rating, the more energy-efficient the home is, and the lower the fuel bills are likely to be.
The Environmental Impact Rating is a measure of a home's impact on the environment in terms of carbon dioxide (C02) emissions - the higher the rating, the less impact it has on the environment.
Property ID: 801


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Posts Tagged 'lapse'
Time Lapse HD Video CameraBy CTTBO | Geek, Technology
This HD video camera can make time lapse photography really simple, yet still flexible with its optional lenses and custom program time intervals! BUY on Amazon in your country! BUY on Amazon.com Note: The product may not be available on every Amazon websites. When it's the case, you hit a search results page.


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|» Products
|» Commercial R.O Plant
Commercial R.O Plant
We would like to introduce ourselves as a Delhi based eminent manufacturer and exporter of technically advanced Commercial R.O. Plant. The offered item consists of energy efficient water pump for providing pressure to its activated carbon filter, quartz sand filter for eradication of organic and colloidal matters, activated carbon filter for trouble free removal of organic matter, free chloride and color, micron filter for removing bacteria and virus present in water, advanced RO membrane and multi stage pump. Low energy consumption capacity, smooth functioning, compact design and stable performance are the unique features of this Commercial R.O. Plant.


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Product Introduction
Totally free of any fragrances or dyes, it packs all the funk-fighting power with none of the extra fluff, with guaranteed TidyLock technology that uses activated charcoal to absorb and lock away odors.
Strong deodorizing formula, zero dust, let you no longer have trouble.
Latest News:
Farewell cat litter scoop! Time-saving and clean cat litter box


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Basic Pistol Course
This class is for the first time handgun owner with limited or no experience, also for those who wish to cover the basics as a refresher.
Subjects covered: Firearms Safety, Field stripping and disassembly and re-assembly of the semi-auto handgun. Cleaning and maintenance, Action types and Firing Cycle. Demonstration and practice (dry-fire) of grip, stance, sight alignment, sight picture, follow through, loading and unloading.
Second half of the class will consist of live fire, with drills to ground the student in the Fundamentals of Marksmanship.
Equipment required: Eye and Ear Protection, your semi-automatic or revolver with at least two magazines or speed loaders, suitable ammunition for that firearm (150 rounds), magazine/speed loader pouch, rigid belt and rigid holster for that handgun.
*limited quantity of rental handguns
New to North End Gun Club?
Ask us about membership!
Copyright 2018 © Gunpowder & Lead, LLC


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Welcome to the Super 8 High Level, conveniently located on the corner of Hwy 35 North and 58 West. We are 10 km from the High Level Airport and 5km to the Fox Haven Golf Course. Stay in town while you enjoy our Annual Winterfest which is held every February or our Annual Tradeshow in September. Super 8 High Level rooms offer the conveniences of free high speed internet, in-room coffee, refrigerator, microwave, iron and board, and hair dryers. We also offer an indoor pool, waterslide, hot tub,meeting room, fitness room, and a SuperStart breakfast to send you on your way in the morning. Pets accepted – 25 CAD charge. Our pool is closed for maintenance until further notice. We apologize for any inconvenience.
If you are the owner of a Pet Sitting or a Dog Walking business in High Level, Alberta and wish to add your business listing free of charge to this city please submit your info here.


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08 May 2013
Serene Silhouettes
10 comments:
VERY pretty!ReplyDelete
I love all the different looks from the same stamp! This set is one of my favorites!ReplyDelete
Love all of them:-) Favorite is number three :-) Very fun to see all of the different looks.ReplyDelete
what tehcnique did you for those beautiful backgrounds? they are T-rific. i didnt even realize they were the same stamp. the backgrounds themselves caught my attention first . wonderful versatilityReplyDelete
Pretty cards. I love taking the same basic design and coming up with a variety. Hugs!ReplyDelete
hi vickieReplyDelete
just dropping by to say hi and ask if they have discontinued the xmas stocking stamps? i dont remember the name but I wanted to get a set this year . i didnt make up my mind until it was already closed out for the year . i know terrific timing .i hope i can still get one
These are all so gorgeous. I'm so happy to see you doing some crafting!ReplyDelete
Stopping by to say hello:-)ReplyDelete
Happy Saturday!ReplyDelete
hi vikki jo . hope your new job is bringing you happiness along with a paycheck . after all a girl has to be able to shopReplyDelete


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Terra Casserole by Jansen+co
The use of terracotta has a long history as a means to cool down or heat up products. The versatility of the material makes it a very interesting product to work with.
The Terra collection, a combination of an earthy and rustic look with bold colours is a real eye-catcher for every table. The perfect balance between design and the choice of materials give this collection a distinct character.
The collection consists of a casserole, dishes, oven dishes and wine coolers. The clay is extracted from the clay pits of Portugal and manufactured by true craftsmen.
Stock Items
Stock items are typically our popular small to medium sized items held in our warehouse for a quick dispatch. Customers based in the United Kingdom will receive their items approximately 1-2 working days from when the order is placed, depending on the service you choose. For UK orders under £50 a delivery charge will be applied, orders over this amount are sent free of charge. Items that fit within DPD's maximum parcel dimensions will be sent on a Next Day service. Our customer order information is sent to our warehouse at exactly 12:00 Midday, if you need an item the next day, please ensure the order is placed before this time. Please email us if you need any more information or read our full delivery details here.
International orders have different shipping pricing structures depending on your location. Orders sent within the EU are mostly sent by road whereas customers further afield will have their items sent by airfreight. A range of speed and cost options can be provided on the first page of our checkout, simply add any products to your shopping cart and enter your country and postcode. If no pricing is provided please get in touch for a bespoke quote.
'Made To Order' items
Larger items or items available in a wide variety of finishes are offered on a 'Made To Order' basis - Really Well Made purchases these items from the manufacturer specifically on the customer's request. The 'Delivery Time' as stated above is guidance provided by the manufacturer and is only an estimate. Really Well Made will advise on current production timeframes at the time of the order being placed.
Made To Order items are generally only refundable in the case of a fault, not on customer preferences. Please place orders for these items with care and ask any appropriate questions you may have regarding the item or delivery before placing an order.
Please refer to our full Terms & Conditions for more information


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Do you know what to do if you're involved in a car or truck accident? Even as a victim, you have some responsibilities to uphold. Of course, the first thing you should do is to seek out medical attention, but following treatment, you need to take steps to obtain the ...Read More
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Accidental deaths include many kinds of deaths, from those involving auto accidents as a result of a person's distraction to slipping and falling on ...View More
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Being safe around animals can save children from suffering major injuries. In fact, many dog bite incidents are completely preventable. How can you ...View More
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Chief: Michael Winn
Deputy: Byron Eldridge
EMS Officer: Lt. Jason Davern
Fire Prevention Officers: Martin MacNeely and Michael Grossman
Captains: Sean Greene, Richard Sargent, T. J. Burchell and Brian Morrison
Lieutenants: Roger Aalto, Eric Bengston, Christopher Adams, Thomas Miskiv, Thomas Goodearl, Eric Sabatinelli, Daniel Osgood, Matt Dillon, Enrique Arrascue, Mike Miskiv, Louis Sassone, Jason Davern and Patrick Hill.
Firefighters: Robert O'Melia, Michael Simmons, Charles Schneckloth, Andrew Reed, R.W. Henson, Daniel Carpenter, David Ferola, Shawn Lehane, Gordon Williams, Thomas Long, Richard Sahl, Michael Carney, Edward Dalbec, Thomas DeGraan, Michael Rogers, David Gelinas, Charles Riley, Christopher Rogers, Matthew Malone, Zachary Hunter, Bradley Smith, Scott Mullin, Steven Coombs, Jason Travis, Rich Anderson, Jack McGonigle, Kathleen Denneen, Michael Perry, Patrick Cox, Adam Travers and Ryan Scott.
Dispatchers: Jeff Gifford, Laurie Motte, William Monroe, Richard Pierce and Amy Brouillette
Mechanic: David Scott
Administration: Louise O'Neil, Sandra Mackey and Kathleen Thut
Custodian: Joe Desrosiers
News & Updates
Open burn season is Jan. 15 – May 1st only. You must check daily to ensure atmospheric conditions are allowing burning. View current status on Open Burning page or on recorded phone line 508-771-2089
The following Commissioners will be running for re-election:
David Lawler
Scott Crosby
Ed Riley


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Dear Martial Arts Enthusiast, Welcome to the second edition of the Chosun e-newsletter. The Chosun Taekwondo Academy wants to extend and invitation to you and your family to attend our:
13th Annual Awards Banquet
& Dinner Dance
Saturday December 11th, 2010 6:30 - 11:00 pm
Black Bear Golf Club, 138 Route 23 North, Franklin, NJ 07416
Guest of honor Grandmaster Richard Chun, DJ and dancing, cash bar, awards presentation, and a visit from Santa!
Adults: $49 / Children:$39 / under 4 years: FREE Make checks payable to Chosun Taekwondo Academy. Remit to Chosun Taekwondo Academy PO Box 721 Warwick, NY 10990 Reserved seating available: contact Chosun at firstname.lastname@example.com
Kamsahamnida, Patty Cook, Editor
Celebrate the season and your dedication to the traditional martial art of Taekwondo. Happy Thanksgiving!
Read the entire newsletter