Living Like It’s Shark Week!

Today is the start of this year’s Shark Week on the Discovery Channel.

shark (adapted image from Wikimedia Commons)

Dialog from NBC’s 30 Rock, Season 1, Episode 4 “Jack the Writer” (2006)*:

Tracy Jordan: But I want you to know something… You and me, it’s not gonna be a one-way street. Cos I don’t believe in one-way streets. Not between people, and not while I’m driving.

Kenneth: Oh, okay.

Tracy Jordan: So here’s some advice I wish I would have got when I was your age… Live every week, like it’s shark week.

(No further explanation is given. In the next scene the comedy writers take a one-minute dance break and then Jack provides an intro to GE’s six sigma program.)

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A Tapestry, and Double-Dose of Magic (on Carole King and James Taylor, Troubadour and Breaking Addiction)

My plan for today was to write on evidence-based medicine. But that can wait, at least until the morning comes.

I came upon the most wonderful recording of a concert by Carole King and James Taylor played in November, 2007 at LA’s Troubadour Club, a place I’ve never been. PBS aired the video, about an hour long in its fuller form, for its June fund-raising drive. I have tickets to see the pair at Madison Square Garden in a few weeks, and had seen yesterday morning a heartening review of the old friends’ joint concert tour.

Sweet Baby James (1970)

Even within the limits of our old TV and nothing approaching a Dolby sound system in our living room, the images – the sounds and smiles generated by Taylor and King, fixtures of my childhood – made me tremble with joy. It was lovely beyond verbal expression and I felt, among other things, glad.

Here’s the medical lesson – a surprise for me was Taylor’s astonishingly well appearance, in a born-in-1948-and-still-strumming sort of way. I’m speaking as a doctor now, as someone who’s used to eying people for signs of ill health. He looked fit, comfortable and happy in jeans and a button-down blue collared shirt. He grinned broadly while he sang, surely taking none of this for granted.

I couldn’t help but reflect on his past. He seems to have made it out of the woods. And how dark those were – to a teenager listening and watching him from afar, circa 1973, it seemed like he might not pull through. For purposes of this post, I’ll stick with the parts of Taylor’s health history that fell into the public domain long before the Internet entered our homes and minds.

Taylor, the son of a Harvard-trained physician, struggled with depression and serious drug use, including heroin addiction, for years. In 1969 a motorcycle accident broke his hands and feet.  In the same decade as he offered fabulous ballads – anthems like “Fire and Rain” and King’s “You’ve Got a Friend,” familiar even to my parents’ generation – he ravaged his body and then his marriage.

Tapestry (1971)

King’s personal story is less known to me, but the lyrics to Tapestry are deeply ingrained. I know them as I know the red carpet, flowered wallpaper and stodgy furniture of my old bedroom. She looks beautiful now. Older and gray, for sure, but natural, lovely, lively and playing strong.

The two together, even on TV, deliver a double-dose like magic. They’d performed together, in 1970, at the Troubadour and now were doing it once again, with grace. The genuineness of the friendship between them, manifest in King’s glances over the piano toward Taylor and what might have been a few tears, and his beaming toward her, could not have been staged. They’ve had some difficult times, for sure, but this was beautiful.

I’m afraid I’m gushing romantic, but as a doctor I’ve seen so many patients who’ve suffered through hard times alone, physical and mental illnesses without anyone to turn to. You have to wonder, to what extent did Taylor’s support system – his dad, who reportedly drove to retrieve him from some tough spots – and his enduring friendships and his family, old and new, help him to recover.

Not all drug abuse stories end like this one. Our government reports, based on a large 2003 survey (which may underestimate use of an illegal substance), that nearly 120,000 Americans said they used heroin in the month before the survey and 314,000 took it the year prior. From 1995 through 2002, there were approximately 150,000 new heroin uses per year in the U.S. Most were over 18, male and addicted. As for depression, the numbers are huge and deaths, very real.

What I’m thinking is this – how lucky Taylor is to have had the friends, family, financial resources and courage to get the help he needed. The message he conveys is that it is possible, at least for some, to get through it, to get better and to move on.

And for me, how lucky I am to have those tickets. I can’t wait to see them in concert later this month, in person, live.

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Nice Nerds Needed

In last weekend’s edition of NPR’s Wait Wait…Don’t Tell Me!, host Peter Sagal asked a panelist about a serious problem facing the Pentagon: There’s a shortage of nerds, a.k.a. geeks.

Space Shuttle Atlantis (NASA image, Wikimedia Commons)

Happily, Houston Chronicle deputy editor and blogger Kyrie O’Connor came to the right answer.

On the quiz show, Sagal reported that Regina Dugan, head of DARPA (the Pentagon’s research arm and developer of the early Internet), recently testified before the House Armed Services Committee about her concern for our country’s most famous five-sided structure’s looming intellectual deficit.

“The decline in science education in this country means fewer nerds are being produced, a fact which has serious national security implications,” Sagal said in summary.

“Nerds molt into tech geeks. Tech geeks grow into scientists and scientists maintain the United States technical superiority,” he explained. No worries, though –

Sagal suggests the current nerd shortage will self-correct based on the predictable laws of high-school ecosystems. (To listen to his short description of this evolutionary process, check the track for Panel Round 2, after minute 4:48.)

Wired covered, earlier, the same story on DARPA’s looming technogeek shortage and Dugan’s forward-thinking statement on the matter:

…outlined her vision for the future of the Pentagon’s blue-sky research arm, with everything from plant-based vaccines to biomimetics making the short list. But none of it’s possible, she told the panel, without more investment in American universities and industry to cultivate the techies of the future…

So we lack sufficient math and science education to support the Pentagon’s needs for cutting-edge technology. And we all know that American businesses are losing out for the same reasons.

My concern is health, that some turned-on science and math-oriented kids should grow up and become physician-scientists or even plain-old, well-trained doctors who are good at interpreting graphs and applying detailed, technical information to patients with complex medical conditions. Last week I wrote that better education would improve health and medical care delivery in the U.S. This seems like an obvious point, but the more common discussion strikes on the need for math and science education to support hard technology in industry.

We’re facing a shortage of primary care physicians, oncologists and other doctor-types. Lots of clever and curious young people are turning away from medicine. The hours are too long, the pay’s too low, and the pressure is too great. If we want doctors who know what they’re doing, we should invest in their education and training, starting early on and pushing well past their graduation from med school.

Sure, we like physicians who are kind and honest people and can talk to them in ways they understand. This is crucial, but only to a point – we still depend on doctors to know their stuff.

I like doctors who are nice nerds. We need more of those, too.

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News, Information, Facts and Fiction

This morning I was in the gym, half-watching CNN as I did my usual exercises. Mathew Chance, a senior international correspondent based in Moscow, recapped the horrific scene involving explosions at two metro stations at the peak of rush hour. Chance reported that the bombers were both women. Most of the other facts surrounding the tragedy remain uncertain, he said. John Roberts, one of the CNN hosts, asked about any claims of responsibility for the terrorist attacks.

“Well, in fact, we had some information earlier today,” Chance responded. “…there had been a claim of responsibility…But that information appears to be incorrect.”

Wow!  Now, there’s an AM Fix.

Can information be wrong? Of course it can, we all know. There’s good evidence for this in my medical textbooks, among other reliable sources.

Lately, and especially since I started this blog, I’ve been thinking a lot about the nature of information – how we define it, how and if it might be distinguished from data, and what separates information and opinion.

“Information is the lifeblood of modern medicine,” wrote Dr. David Blumenthal in a carefully-designated “perspective” piece in the February 4 issue of the New England Journal of Medicine. He continued:

Health information technology (HIT) is destined to be its circulatory system. Without that system, neither individual physicians nor health care institutions can perform at their best or deliver the highest-quality care, any more than an Olympian could excel with a failing heart…

OK, so information needs to get around. It’s kind-of like blood; we can’t thrive without it. We won’t win any gold medals in health-care delivery before implementing the Health Information Technology for Economic and Clinical Health (HITECH) Act.

I agree on the essentialness of information in medical practice and decision-making. But that brings us back to the crucial issue of its nature – how people, doctors, scientists, news reporters or anyone, literate or otherwise, can tell if something’s true or untrue.

Last year in journalism school at Columbia University I took a course called “Evidence and Inference.” We went as far back as Plato’s cave, and as far forward as the New York Times’ 2002 reporting on possible evidence for weapons of mass destruction in Iraq. The point of the exercise, in sum, was that it’s sometimes hard, even for inquisitive journalists, scholars and scientists, to tell fact from fiction.

(Rest assured, I didn’t need a graduate course at Columbia to learn that much, although I did enjoy going back to school.)

Last week’s cover story in the Economist, on “Spin, Science and Climate Change,” drew my attention to some parallels between the Climategate controversy and distrust regarding other areas of scientific and medical knowledge. In a briefing within, the author or authors write:

…In any complex scientific picture of the world there will be gaps, misperceptions and mistakes. Whether your impression is dominated by the whole or the holes will depend on your attitude to the project at hand. You might say that some see a jigsaw where others see a house of cards. Jigsaw types have in mind an overall picture and are open to bits being taken out, moved around or abandoned should they not fit. Those who see houses of cards think that if any piece is removed, the whole lot falls down. When it comes to climate, academic scientists are jigsaw types, dissenters from their view house-of-cards-ists.

The authors go on to consider some ramifications of a consensus effect. (There’s an interesting discussion on this, which relates to a herding effect, in a recent post by Respectful Insolence).  Meanwhile, house-of-card-ists, dubbed doubters, emphasize errors from confirmational bias, or the tendency of some people to select evidence that agrees with their outlook.

There’s far more to consider on this subject – how we perceive and represent information – than I might possibly include in today’s post. So let’s just call this the start of a long conversation.

Getting back to medical lessons – the problem is that most of us can’t possibly know what’s really right. (Yes, I mean doctors too.) Few know enough of the relevant and current facts, or even the necessary terms, to make decisions about, say, which therapy is best for Ewing’s sarcoma in a four-year-old child or whether a new drug for Parkinson’s is worth a try in your dad’s case. Even for those of us who know something about statistics, it’s tricky.

Ultimately, I think it comes down to a matter of trust in the people who provide us information. It’s about knowing your source, whether that’s Deep Throat, a person reporting from the street in Moscow early this morning, or your personal physician.

Well, it’s a holiday for me over the next few days. I’ll read some history first, and then some fiction.

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A New Nurse Jackie in Preview

Nurse Jackie’s back on TV tonight. I know this because when I logged on to the New York Times this morning her ad flashed right at me, front page and right center. She’s displayed prominently on Huff Po, vanishingly on Dictionary.com. With just a quick search I can’t find her anywhere in the Wall Street Journal. At the LA Times she takes over the screen.

Poster for Nurse Jackie, Season 2

(As an aside, on the shifting nature of medical information, most future readers of this post will not know for sure if what I’ve described about the present on-line positioning of these commercials for TV is true. The same happens in practicing medicine, when clear signs of disease – like abnormal crackles on a lung exam – can be fleeting, leaving no digital or even a film imprint, yet very real. So you’ll have to trust me, or take no value from this depiction.)

For the “facts” on Nurse Jackie you can find her on Showtime’s original website. There, the program promises to continue “its look deep inside the complicated heart and soul of a functioning addict, a loving wife, mother, and a first-class nurse.” I’m curious but must admit that last year I watched only part of one episode and didn’t return.

Back then I was turned off preemptively by the image of Edie Falco looking harsh, white-coated and unsmiling. The syringe and needle in her raised, gloved hand suggested a third finger, or at least that’s how it seemed as we drove past her image, repeatedly, on a giant billboard. That poster was enough for me. I’d spent too much time in hospitals in trust of innumerable nurses to want to see that side of health care delivery.

Also, I liked Edie as Carmela Soprano so much, then fresh in my memory. Why ruin it?

But today she beckons, half-smiling, an aura of pills and syringes above her head. Maybe she’s happy about the health care reform bill’s passage last night, but I don’t think she could have known about that when the photo was taken, or in her TV unreality world, that legislation matters. What’s clear is that Nurse Jackie looks warmer, tired maybe from her work. She’s appears ready to help someone, a stethoscope slung over her neck. Her right arm is raised, like in last year’s pose, but gentler, calmer. It’s no accident the poster heralds a “Holy Shift.”

Back to reality –

This morning I was listening to WNYC while reading the newspaper and eating my healthy breakfast. As I recall, according to a reporter assigned to assess the public’s and health care workers’ response to the health care reform bill among people on the street near Lenox Hill Hospital, in my neighborhood, one individual said she doesn’t really know what to expect from the changes because she gets most of her news from TV. I didn’t catch any more details – if she meant CNN, for example, or Fox or The View – and exactly how and why she found the source limiting.

One thing I did note in the Times, and also on the Kaiser Health News website, both of which provide excellent summaries of the hopefully-real health care changes to come, is that reform won’t even start to happen for the most part until 2014. Meanwhile grows an authentic addiction to the Internet, TV, radio and even some blurry advertisements for information on medicine that people can’t or don’t get elsewhere.

So I’m thinking I should watch Nurse Jackie tonight. Give it another try. Maybe I’ll learn something. And whatever did happen to the House of God?

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Peter Sings Colonoscopy

Hi Readers,

This new form of medical information outreach outweighed any other contenders for today’s post:

“When I had my colonoscopy I had a question on my mind.

Do we all look the same when the doctor sees us from behind?

Then I had the answer…

Peter Yarrow, starting The Colonoscopy Song

Am I pro- or con- colonoscopy for routine screening, you might wonder. Well, that depends.

Am I pro- or con- famous singers and other celebrities extolling the benefits of particular medical interventions? Well, that depends, too.

But I’m sure I prefer “Puff the Magic Dragon.” Also “Leaving on a Jet Plane” fills me with imperfect memories of 6th grade. (I don’t know much about the history of this song, but there is an older, grainier and harder-to-hear version on YouTube dating to March, 2008.)

Thanks Peter, for this unique verbalization of what some doctors might otherwise convey. Glad to see you singing, aging, smiling about something.

The CDC confirms that March is national colorectal cancer awareness month (NCCAM).

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New Boss on The Office is a Breast Cancer Survivor

Jo's mock-biography (NBC, The Office)

There’s a new survivor on TV and she means business.

In the latest episode of The Office, Kathy Bates walked into the Scranton branch of Dundler Mifflen and onto my living room TV screen as Jo Bennett, CEO of Sabre, a fictitious Tallahassee-based company. An assistant and two large canines accompany her as she meets the crew. She’s firm, graying and very much-in-charge.

When the camera gets her alone, in focus, here’s what she has to say:

“I’m Jolene Bennett, Jo for short.

I’m a breast cancer survivor, close personal friends with Nancy Pelosi, and Truman Capote and I slept with three of the same guys. When I was a little girl I was terrified to fly, and now I have my own pilot’s license.

I am CEO of Sabre International and I sell the best damn printers and all-in-one machines Korea can make.

Pleased to meet ya.”

(from The Office, Season 6, Episode 16, “A Manager and a Salesman”)

—–

Jo’s words are clear, delivered with eyes straight at you. It’s hard not to wonder what’s the significance of her being a breast cancer survivor, on the show and to her audience, and why she lists this alongside her other achievements in a highly-accomplished, fabricated life.

Kathy Bates is not the first actress to portray a woman who’s had breast cancer, and Jo Bennett is hardly the first TV character who’s had treatment. But this introduction seems like a perfect, even targeted strategy to revisit the topic:

What’s the significance of being a breast cancer survivor in 2010?

Maybe Jo’s a warrior, veteran-like, hardened after battle. Or perhaps wounded, deeply, now guarded by the dogs and a fierce resume.

Does she feel entitled? Bitter? Seek pity? Bates doesn’t play it in any of these ways, at least not in this first airing.

There’s no Misery here. Rather she appears large, strong, smiling broadly.

She has a mock-biography, Take a Good Look, I’d like to read. From the pseudo-Sabre website:

“A trailblazer in the world of electronic office equipment, Jolene Bennett serves as the President and Chief Executive Officer of the Sabre Corporation…Mrs. Bennett has received awards and recognitions, including being named one of Enterprising Women‘s Magazine 25 Most Influential Executives of 2007 and being named as a finalist for Tallahassian of the Year by the editors of Tallahassee Magazine in 2005.

Mrs. Bennett, a former Southern beauty queen, knows the importance of giving back. She has also received numerous awards for her philanthropic efforts with, among others, the Negro College Fund, The Florida Great Dane Rescue Society, and the American Breast Cancer Foundation. As a breast cancer survivor herself, Mrs. Bennett is especially passionate about helping other strong women beat cancer the way she did…

Jo’s company’s name is pointed. A sabre is a sword of sorts, usually curved, thick and sometimes lethal. My mind wanders to saber-toothed tigers, ferocious and extinct. And then, of course, to the Sabra, a native Israeli like a prickly pear – sharp on the outside, sweet beneath the rough skin.

I have no idea where The Office is headed with this theme, nearly ten years since Barbara Ehrenreich’s “Welcome to Cancerland” and roughly five since Elizabeth Edwards started her first chemo sessions.

I’m struck by how little talk there’s been of Jo’s mission since the episode’s debut. I’ve read dozens of blogs, TV reviews, there’s nothing. The Great Danes get mentioned, but not the breast cancer. Are we inured to the subject?

This isn’t about big Pink and ribbons. I’m talking about real patients who get tumors and need treatments. Some get depressed. Some die. Stuff happens.

As an oncologist, I saw women respond distinctly to their surgeries, radiation, chemotherapy and other treatments. Besides, the tumors vary in themselves – responding, sometimes lingering, killing too often. Some people need lots of medical care, others skate through.

There’s no right answer here, no one size fits all.

Regardless, I can’t wait to see the show’s next episode. Pam’s having a baby, life goes on.

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You’re Sick and I’m Not, Too Bad

“The insurance market as it works today basically slices and dices the population. It says, well you people with medical conditions, over here, and you people without them, over here…

– Jonathan Cohn, Editor of The New Republic, speaking on The Brian Lehrer Show, February 16, 2010*

There’s a popular, partly true, sometimes useful and very dangerous notion that we can control our health. Maybe even fend off cancer.

I like the idea that we can make smart choices, eat sensible amounts of whole foods and not the wrong foods, exercise, not smoke, maintain balance (whatever that means in 2010) and in doing so, be responsible for our health. Check, plus.

It’s an attractive concept, really, that we can determine our medical circumstances by informed decisions and a vital lifestyle. It appeals to the well – that we’re OK, on the other side, doing something right.

There is order in the world. God exists. etc.

Very appealing. There’s utility in this outlook, besides. To the extent that we can influence our well-being and lessen the likelihood of some diseases, of course we can!  and should adjust our lack-of-dieting, drinking, smoking, arms firing, boxing and whatever else damaging it is that we do to ourselves.

I’m all for people adjusting their behavior and knowing they’re accountable for the consequences. And I’m not keen on a victim’s mentality for those who are ill.

So far so good –

Last summer former Whole Foods CEO John Mackey offered an unsympathetic op-ed in The Wall Street Journal on the subject of health care reform. He provides the “correct” i.e. unedited version in the CEO’s blog:

“Many promoters of health care reform believe that people have an intrinsic ethical right to health care… While all of us can empathize with those who are sick, how can we say that all people have any more of an intrinsic right to health care than they have an intrinsic right to food, clothing, owning their own homes, a car or a personal computer? …

“Rather than increase governmental spending and control, what we need to do is address the root causes of disease and poor health.  This begins with the realization that every American adult is responsible for their own health.  Unfortunately many of our health care problems are self-inflicted…

Now, here’s the rub. While all of us can empathize, not everyone does. And few citizens go to medical school. Some, uneducated or misinformed, might sincerely believe that illnesses are deserved.

So let’s set some facts straight on real illness and would-be uninsurable people like me:

Most people who are sick – with leukemia, diabetes, osteogenesis imperfecta, heart disease, multiple sclerosis, scoliosis, glycogen storage disease Type II, depression, Lou Gehrig’s disease, sickle cell anemia, rheumatoid arthritis or what have you – are not ill by choice. They didn’t make bad decisions or do anything worse, on average, than people who are healthy.

Rather, they became ill. Just like that.

The idea of an insurance pool is that when everyone in the community participates, whoever ends up with large medical expenses is covered, explained Jonathan Cohn. When contributions come in from all, including those who are healthy, funds are sufficient to provide for the sick among us.

As things stand, the insurance industry divides us into likely profitable and unprofitable segments. “So you know if you’re one of the people born with diabetes, you have cancer, you had an injury that requires lengthy rehabilitation, tough luck, you’re going to end up in that pool of unhealthy people,” Cohn said.

Insurance is no cure-all, to be sure. It won’t take away my cousin’s cancer or fix Bill Clinton’s heart. That would require research and better medicines.

Depriving insurance, or care, to those who need it most is inconceivable to a society as ours was intended. It’s uncivil.

*as heard on The Brian Lehrer Show 2/16/10: Rates on the Rise

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On Precious

This is my first film review, if it is that.

I was tempted to write about Ethan Hawke, hematologist among vampires in Daybreakers, but gore’s not my favorite genre. A mainstream choice would have been Harrison Ford solving the enzyme deficiency of Pompe disease in Extraordinary Measures, but I didn’t get sucked in. I chose Precious, instead.

Poster for Precious, the film based on the novel “Push,” by Sapphire

This luminous movie relates to the practice of medicine everyday, big-time. Directed by Lee Daniels and based on the novel Push by Sapphire (Ramona Lofton), the film follows a very obese Harlem teenager who’s pregnant with a second child by her abusive father. She’s humiliated daily by her welfare-dependant mother who forces her to cook greasy food and perform sexual acts all-the-while telling her she’s worthless. She’s 17 years old and can’t read. Things can get worse, and do.

What’s relevant to medical lessons?

For doctors –

The message of Precious, that every human life has value, should be obvious to every person employed in the health care system. But I know too well that’s not true.

When I was a medical student in 1985, working with a team of surgery residents, we cared for an obese young woman from Harlem who came in with a life-threatening case of pancreatitis. Her internal insulin-manufacturing organ was so inflamed that her entire gigantic abdominal cavity was tender and bloody. During what seemed like an endless operation in the middle of the night I stood and held firmly a retractor as best I could. The next morning and thereafter, when we made rounds, the residents called her “the whale.”

I learned a lot about pancreatitis and surgery that month. But I couldn’t understand how she, my patient, tolerated the team’s attitude. She didn’t seem to mind, perhaps because we saved her life and the care we provided was free. In retrospect, I wonder if maybe, like Precious, she was too-accustomed to disrespect.

Of course, this is an extreme example from 25 years ago. And I know from my experience working for years in a hospital, and in my years as a patient, that most doctors treat most patients with appropriate dignity. But those residents I worked with then are senior practicing physicians now, likely some on the faculty of medical schools. The disposition to disparage patients, more often subtly – in keeping them waiting without good reason, in dismissing their long lists of real concerns, in somehow putting ourselves above them and even, still, occasionally expressing frank contempt for some unfortunate souls still permeates the hospital culture.

For patients –

When Precious is abused, her mind runs elsewhere. She imagines herself, huge body and all, cast glamorously among television stars or dancing with popular singers. She pretends that she’s all right even when she’s not, really. Finally she speaks up for herself, telling a social worker about her predicament.

Ultimately that’s what makes the difference – her confidence in the value of her own bruised life. She recognizes that, despite everything, she’s a full-fledged human deserving better and has the guts to ask for help. By insisting, by knowing, that her life matters, she pushes herself out, if only partly, from the bleakest of circumstances.

If you’re disabled, hurt, wounded, damaged – ask for help when you need it. Respect yourself, as Precious did. That sends a signal to doctors that you value your life, and they should treat you accordingly.

Hopefully they’ll be paying attention.

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Henrietta’s Cells Speak

“One of the ways that I gained the trust of the family is that I gave them information.”

(R. Skloot, a journalist, speaking about her interactions with Henrietta Lacks’ family, Columbia University, Feb 2, 2010)

This week I had the opportunity to hear a terrific talk by Rebecca Skloot, author of a new, flying-off-the-shelves book –The Immortal Life of Henrietta Lacks.

Mrs. Henrietta Lacks died of metastatic cervical cancer in the colored ward at Johns Hopkins Hospital in Baltimore, MD in September 1951. She lived no more than 31 years and left behind a husband, five children and an infinite supply of self-replicating cancer cells for research scientists to study in years to come.

HeLa cells with fluorescent nuclear stain (Wikimedia Commons)

Like many doctors, I first encountered HeLa cells in a research laboratory. Investigators use these famous cells to study how cancer cells grow, divide and respond to treatments. I learned about Mrs. Lacks, patient and mother, just the other day.

Skloot chronicles her short life in fascinating detail. She contrasts the long-lasting fate and productivity of her cells with that of the woman who bore them. She connects those, and her human descendants’ unfortunate financial disposition, to current controversies in bioethics.

In the years following their mother’s death, scientists repeatedly approached her husband and asked her young children for blood samples to check the genetic material, to see if their DNA matched that of cell batches, or clones, growing in research labs.

The issue is this: her husband had but a third-grade education. The children didn’t know what is a “cell,” “HLA-testing” or “clone.”

The family had essentially no idea what the doctors who’d taken, manipulated and cloned their mothers’ cells were talking about, Skloot recounts. They thought the doctors were testing them for cancer.

Years later, when they learned that their mother’s cells were bought, sold and used at research institutions throughout the world, they became angry and distrustful. The problem was essentially one of poor communication, she considered.

“Even a basic education in science would have helped,” Skloot said. “Patients, they want to be asked, and they want to be told what’s going on.”

Well said!

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Blood Matters

January, the coldest season in my vicinity, turns out to be National Blood Donor Month. This designation, a legacy of the Nixon administration (see Proclamation 3952 of December 31, 1969), I learned last week.

Besides, blood’s hot.

HBO’s True Blood received an invigorating, early renewal notice last summer; a third season will come out in June. And on film 2009 witnessed a quick, hungry revisit from Twilight, among others vampire flicks. Just this month, Ethan Hawke revealed himself in Daybreakers as Hollywood’s first hematologist-protagonist.

So it seems that now’s the perfect time to talk about it –

Blood, always my favorite Aristotelian humor, comprises two elements – plasma (a hazy yellowish fluid) and cells. The plasma bathes the blood cells in a mixture of salts and proteins as they travel within the walls of blood vessels throughout the body (the circulation) and in the chambers of the heart. Plasma proteins include some hormones, enzymes, clotting factors and antibodies.

Let’s start with some basics on the cellular components of blood: white blood cells, red blood cells and platelets:

neutrophil as seen in a peripheral blood smear, Wikimedia Commons (WC)

White Blood Cells

White blood cells (WBCs), physically larger than the rest, serve as warriors against infection. These include a cast of various types, each with a distinct role in battling germs. The most familiar white cells in the “peripheral blood” – as doctors refer to fluid passing through arteries and veins – are neutrophils, lymphocytes and monocytes. Two other forms, eosinophils and basophils, emerge from the bone marrow and typically travel in lesser numbers.

scanning micrograph, red blood cells, WC, adapted NIH image

Red Blood Cells

Red blood cells (RBCs), the most abundant and usually uniform blood cells, carry and deliver oxygen throughout the body. Mature, circulating red cells are disc-like in shape, indented on each side, and lack nuclei. They’re loaded with hemoglobin, a complex, iron-laden molecule that binds oxygen and turns blood red.

When someone receives a transfusion, that’s usually a unit of packed red blood cells, concentrated red cells from which most of the donor’s white cells, platelets and plasma have been removed.

Platelets

Platelets are tiny, blood clotting cells. Like red cells, these cells circulate without nuclei, but they’re irregular in shape and sticky, loaded inside with plug-forming proteins and on their surfaces with adhesive receptors, ready to clump at the nick of a chin or a pinprick.

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Both cancer and its treatments can affect the bone marrow, where blood cells are formed. Some tumors, like leukemia and lymphoma, arise from blood cells. Other medical conditions cause blood cell problems, too. For example, chronic kidney disease causes anemia, and HIV infection leads to reduced T-lymphocyte counts.

For all these reasons, I think it’s helpful for everyone to have some understanding of blood and blood cells – any discussion of stem cells, bone marrow and transplantation presupposes some knowledge of these basics.

More to follow!

Meanwhile, if you’re searching for more blood info on the Web, I suggest these sites:

American Society of Hematology – Blood: the Vital Connection

America’s Blood Centers – What is Blood?

American Society of Clinical Oncology (Cancer.Net) – Understanding Blood Test Results

MedlinePlus – Blood and Blood Disorders

National Heart Lung and Blood Institute – Blood Diseases and Resources Information

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On Juno and Screening Test Stats

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“Well, well” says the convenience store clerk. “Back for another test?”

“I think the first one was defective. The plus sign looks more like a division symbol, so I remain unconvinced,” states Juno the pregnant teenager.

“Third test today, mama-bear,” notes the clerk.

Juno recluses herself and uses a do-it-yourself pregnancy test in the restroom, on film.

“What’s the prognosis … minus or plus?” asks the clerk.

…”There it is. The little pink plus sign is so unholy,” Juno responds.

She’s pregnant, clearly, and she knows she is.

(from Juno the movie*)
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Juno\’s pregnancy test
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Think of how a statistician might consider Juno’s predicament – when a testing device is useful but sometimes gives an unclear or wrong signal.

Scientists use two terms – sensitivity and specificity – among others, to assess the accuracy of diagnostic tests. In general, these terms work best for tests that provide binary sorts of outcomes – “yes” or “no” type situations. Sensitivity refers to how well a screening tool detects a condition that’s really present (pregnancy, in the teenager’s case). Specificity, by contrast, measures how well a test reports results that are truly negative.**

Juno’s readout is relatively straightforward – a pink plus sign or, not; the possibilities regarding her true condition are few.

Still, even the simplest of diagnostic tests can go wrong. Errors can arise from mistakes in the procedure (a cluttered, dirty store is hardly an ideal lab environment), from flawed reagents (the package might be old, with paper that doesn’t turn vividly pink in case of pregnancy) or from misreading results (perhaps Juno needs glasses).

Why does this matter, now?

The medical and political news are dense with statistics on mammograms; getting a handle on the costs of cancer screening requires more information than most of us have at our disposal.

Of course, breast cancer is not like pregnancy. Among other distinguishing features, it’s not a binary condition; you can’t be a little bit pregnant.  (Both are complicated, I know.)

To get to the bottom of the screening issue, we’ll have to delve deeper, still.

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*Thanks Juno, Dwight and everyone else involved in the 2007 film; details listed on IMBD.

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**I was surprised to find few accessible on-line resources on stats. For those who’d like to understand more on the matter of sensitivity and specificity, I recommend starting with a 2003 article by Tze-Wey Loong in the British Medical Journal. This journal, with a stated mission to “help doctors to make better decisions” provides open, free access to anyone who registers on-line.

I’ll offer an example here, too:

To measure the accuracy of Juno’s kit, a statistician might visit a community of 100 possibly pregnant women who used the same type of device. If 20 of the women are indeed pregnant (as confirmed by another test, like a sonogram), but only 16 of those see the pink plus sign, the sensitivity of the test would be 16/20, or 80 percent. And if, among the 80 women who aren’t due, 76 get negative results, the specificity would be 76/80, or 95 percent.

False negatives: among the 20 pregnant women 4 find negative results; the false negative rate (FN) is 4/20, or 20 percent.

False positives: among the 80 women who aren’t pregnant 4 see misleading traces of pink; the false positive (FP) rate is 4/80, or 5 percent.

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