Death panels won't die

Death panels are back...

...if they ever existed in the first place. But the concept lives on in the minds of Obamacare's political opponents.

Here is the latest incarnation of this dubious claim: the government directs cancer physicians refuse cancer treatment to terminally sick cancer patients who are covered by the Obamacare. It is alleged that if a patient, in the opinion of a physician, is unlikely to achieve the remission, why spend more money on this patent's treatment. In other words, a death panel would chose not to continue to treat this patient since nothing would prolong the patient's life.

On other hand, the same people who cry foul on the Obamacare are busy making the access to health care harder or impossible for millions of low-income Americans. Does not take a genius to realize that someone without medical insurance is unable to get the recommended cancer screening to prevent cancer to begin with.

Some opponents of the Obamacare I spoke with readily admit that they protect the principle that everyone is entitled to chemotherapy to prolong life if they so choose regardless of how futile it may be; it's a right to be given a drug (and thus have the government pay for it). How tricky such an argument is when it is applied by the opponent of the Obamacare. If they claim it is such a right, then how conceptually different is the right to be seen by a physician or have the access to a contraceptive medication?

The opponents of the Obamacare appear less certain on the subject of whether such a cancer treatment at any stage of the disease is in best interest of a patient. It is probably true that majority of opponents of Obamacare have not seen severely sick dying cancer patients with falling blood counts left helpless in face of deadly infections or confined to intensive care units wrapped in tubes and pumps, or bleeding, puking, incontinent, and half-out because of high-dose pain meds. Would anyone want to get a drug that will kill? Those opponents of the Obamacare who would still think that those who suggest to stop the torture belong to death panels are clearly not in the know regarding palliative medicine.

It is far easier to stir a controversy to equate futile treatment with rationing than help people get access to health care to maximize quality of life for many Americans. So please, the political opponents of the Obamacare, wise up, for one day some of you will be in that ICU bed wrapped in tubes begging to end prolonging death.

Russian Blues

Had to go to Russian consulate in New York, and have some observations.

The crowd, anywhere from 5 to 40 people, waits outside. It is pleasant in May, but was bitterly cold in December.

There are lot of elderly folks, and most of them usually attempt to inch in front of the line, to ask a question. Not unusual to see a Russian citizen to inch in front of a line to "ask a question." In Russia questions were usually something like "how much these potatoes cost?" or "any fish left?" One cannot find the answers to these questions from the back of the line.

Since the line is outside, there is no number to take, no seat to occupy, no customer service to inquire. All wait in the same line, asking each other on details of paperwork and procedural details, which clearly nobody knows. Every 5-10 minutes a clerk unlocks the main door from inside, and steps out to let a group of people out and another group in. This is a window of opportunity for elderly emigres to ask a question. The clerk's job is to deflect all questions and get inside as quickly as possible. Some elderly citizens clearly don't know it, and scream the questions, all at the same time. The clerk randomly answers one question, and it is always a variation of a "No," as in "you are wrong, we don't do that, go home," or "your question requires an answer from the Consul, but he is not in today." This latter response clearly is designed to baffle the questioner; if the consul is not in, there is clearly nobody to answer any questions. Another popular question is to request an affidavit of some sort. According to the clerk, such an (or any?) affidavit was ceased to exist 4 years ago. This answer utterly confuses the elderly because the clerk does not offer anything in its place.

Having derailed the attempts to gain the access with questions, the clerk shouts names of those who are allowed in. Actually he does not allow them in right away. He asks why they are there. Clever elderly citizens know this, and stand in line to ask a question. The clerk deflects their questions as well. It appears that some elderly citizens learned that they won't win this game, and have a paperwork that they shove to the clerk. This invariably makes the clerk cease calling names and review the paperwork. I am surprised at that since paperwork is just a fancy way of asking a question. Sometimes if deflects it, but sometimes he allows the person in.

Immediately inside is a narrow hallway framed by a metal detector. I am convinced it is for show. It beeps randomly and did not detect car keys and a phone in pockets. Bags that are passed on the outside of the frame are not examined either. Works for me. There are several chairs in the foyer; several people are waiting there. The clerk ushers me in the next room, "wait for your name is called." People are sitting on two sofas and lean against a large table with "Russian-American" newsletter scattered on it. Someone's name is called to one of the officer's windows. Each window looks exactly like that of customer care booth on the Grand Station Terminal in New York. It has a round microphone/speaker assembly cut in the middle. Under the thick glass, there is a metal box that looks exactly like the one on gas stations where you would put cash, and the register clerk would pull it in, and then will push back the change.

So, someone's name was called. The entire dialog is heard with all personal details including names, addresses, the number and names of children, marital status, the reason for being there. Wild.

Exit is not free. The door is locked, and gets unlocked every few minutes to exchange the visitors. The cycle repeats, questions, deflections, affidavits, paperwork. Some bent universe.

Maps of Us

A fantastic collection of maps showing a tremendous spectrum of our lives. Play here.

Here is how to cure HIV.

HIV depletes the number of CD4⁺ T cells, and causes AIDS by essentially erasing the immune system. To enter a T cell an HIV viral particle must have correct keys to a door on the surface of a T cell. The door opens only when an HIV viral particle "touches down" and attaches to two receptors on the surface of a CD4⁺ T cell, CD4 and CCR5. While an HIV viral particle always binds to the CD4 receptor, in a small number of people, especially of European Caucasian descent, CCR5 receptor could be mutated, and the "key" on the surface of the HIV virus does not "fit" the receptor on the surface of the T cell. In this case, CD4⁺ T cells stay HIV free.

This is what happened in the case of "Berlin patient" Timothy Ray Brown. He has been living with HIV since 1995 controlling it with anti-retroviral drugs. In 2007 he was diagnosed with leukemia. As a part of treatment for leukemia he underwent a hematopoetic stem cell transplant (HSCT, A.K.A. bone marrow transplant,) from an unrelated donor, who actually had a mutation in the genetic code of the CCR5 receptor. As a result of such a transplantation, Timothy's new T cells are impervious to HIV. Whatever HIV he had in his own T cells was presumably wiped out with his entire own immune system in preparation for the transplant. He remains HIV free since 2008.

It did not require a giant intellectual leap to propose blocking CCR5 receptors to make CD4⁺ T cells resistant to HIV. In this case the door on the surface of T cells stays locked, and a person, HIV free. Based on this premise so called entry inhibitors were developed that prevented an HIV virus touching CCR5 receptor. At the same time, those who already have HIV will likely benefit as well. Those T cells infected with HIV make and release new viral particles. But HIV-free T cells with blocked CCR5 receptors are protected from the viral entry. CD4⁺ T cells already infected with HIV die, while those with blocked CCR5 receptors remain uninfected. Over time, at least in theory, all HIV infected cells will die, including those that harbor so called "HIV reservoir," that remains dormant on anti-viral medications. The end result, complete HIV cure.

One of problems with this approach is that CCR5 blocking is not 100% efficient, and the virus gets through. How to make this fence impenetrable?

Well, a new study published in NEJM reported building such a fence by editing CCR5 gene in CD4⁺ T cells. HIV-positive patients with undetectable viral loads and sufficiently high levels of CD4 T-cells had some of their CD4⁺ T cells removed, genetically edited to introduce a specific mutation into the gene coding for CCR5 receptor, and infused back. Following the transfusion, six out of 12 study participants went off anti-viral treatment for 3 months. In these patients the load of HIV increased, but the decline in modified CD4⁺ T cells was significantly lower than in those unmodified ones.

This is a very encouraging results, to say the least. If the number of CCR5-modified CD4⁺ T cells could stay the same or even increase, over time infected CD4⁺ T cells will die leaving the patient HIV-free. The reason why the number of CCR5-modified cells also decreased is the following. Each cell has two copies of the same gene, one from each parent. Thus one needs to edit both copies in each CD4⁺ T cells. The gene editing method proposed in the study did not "edit" each copy of the CCR5 gene, resulting in reduced but existing susceptibility to HIV entry.

There was, however, one patient who inherited one copy of CCR5-mutated gene from one of parents. His CD4⁺ T cells, as all his cells, had one of two copies of CCR5 genes already mutated but it was not enough to protect him from contracting HIV. But he only needed to have one copy of CCR5 gene edited in CD4⁺ T cells. Therefore for him, effectiveness of gene editing was much much higher, and his viral load remained undetectable after he received the infusion of gene-edited CD4⁺ T cells and went off anti-viral therapy.

This is a remarkable study shows the proof in principle and safety of the gene-editing approach. It seems to be only a matter of time, and probably not too distant, when someone will effectively edit both copies of the CCR5 gene to make them insensitive to HIV. HIV will become history then.

Reflection on House of Cards I

If you were like me snowed a bit this past President's weekend, you might have found yourself drawn to the second season of "House of Cards."  The major event that comes in the middle of the first episode is Frank (Kevin Spacey) throwing Zoe (Kate Mara) under the train. He then leaves and seemingly without a trail. At least a trail detective in the second episode cannot find. Lucas (Sebastian Arcelus) examines the surveillance video with one of detectives at the District police department. The detective says there were two witnesses, and both are duds. So Frank washes hands in the first episode, and becomes a president in the last.

Seemingly unstoppable Frank, who was denied the post of Secretary of State in the first episode of the first season frees himself from all allegiances, and with his wife Clair (Robin Wright) presses ahead through power plays and schemes screwing people lives until he becomes a president via vice presidency (thus you may guess requiring a resignation of the elected president in the process). No one seems a worthy opponent who can crack Frank's intentions and bring him down. Several have tried in vain. Journalists investigating the suspicious suicide of the Congressman Russo (Corey Stoll), businessman Raymond Tusk (Gerald McRaney) who in the end sells out President Walker,  the president Walker (Michael Gill) himself briefly gets a whiff of Frank's malfeasance as his (Walker's) political demise nears, but then lets his guard dissipate again in the face of obvious clues of Franks' treason. 

There were lots of chances to make Frank's life more difficult and, in my humble opinion, show more thrilling. But the writers seemed to be so preoccupied with fitting the process from Frank's becoming the VP to his presidency in 13 episodes that many story-lines felt sloppy, underdeveloped, and frankly did not hold water for how clearly unrealistic they were.

In this regard, the story-line that bothers me is the one with Zoe's death. Zoe comes to meet Frank disguised in a fedora and thick-rimed glasses at the train station and ends up under the train; he pushes here onto the tracks after a dialog. He then leaves seemingly incognito, while walking in the direction opposite everyone is running to see what happened, and uncaptured on surveillance tapes. No evidence to suspect or prove a foul play. I am sure everyone watching thought, "Oh c'mon, seriously!" Perhaps the writers wanted to avoid the whole "what if he is captured on the surveillance" story, but we don't need a CSI-style investigation to claim an unrealism of this line of thinking. With cameras watching every corner, Frank (or at least a figure leaving the station) would have been seen and exposed. In fact, the right of the surveillance video Lucas is watching with the detective  (the lower picture) shows where Frank exited after having pushed Zoe. There is certainly the evidence of foul play. So go from there, detective.

This is not to say the Frank should have been exposed and accused of murdering Zoe, but I would have liked to see this plot developed rather than pushing Lucas into deep web and locking him up for cyber terrorism (what a doozy subplot).

Bloody mess

My biggest fear is for the code pager to go off while I am in the restroom.

It did go off angrily followed by the overhead PA system announcement the code location. The unit to which I was instructed was located a hike away from where I was standing watch, but it's all hands on deck at nights. By the time I get there, running overpasses across the hospital and climbing stairs avoiding slow elevators, the code team localized to that section of the hospital is firmly in control. Anesthesia team is intubating, intensive care unit crew is assessing and making the transfer arrangements. Seeing the order coming out of chaos, I sign off and head back to my tower. One of the intesivists wishes me a good night, "See you at the next code," he says.


Back to my hematology unit, where I am watching over thirty-four patients trusted to me by the day teams, my spectralink house phone goes off incessantly.

"Ms. B. has a fever of 100.8. She _is_ neutropenic; do you want to culture her and start antibiotics?" "Sure, I'll put the orders."

"Ms. M's platelets are 4."
"Yes, I know. I need to speak with the blood bank since she needs special platelets. Is she bleeding anywhere?"

"Ms. L.'s heart rate is 150, and blood pressure in the low hundreds."
"Please do an ECG, and I will be right there."

"Mr. F. has a temp of 103, his rigoring and breathing at 30. He is going to hospice tomorrow morning. What would you want to do, doctor?"
"I will be right there"

"Ms. C. has soft blood pressures, heart rate in 120, and she has not had made urine since the beginning of the shift"
"Give her a liter of normal saline bolus. I will be right there."

"Hi, is this heme service?"
"Yes."
"You have an admission from the emergency room. He just arrived on the floor."
"Oh. What is he here for?"
"I will be right there..."

I look at my spectralink that says "Bloody Mess" where it should be "Hello, World." The code on my floor is just a matter of time. No time for a restroom break.

Code pager goes off again. _Not_ my floor. Where? East Pavilion. Stairs down, bridges, stairs up. Running through the mental checklist of what to do when I get there. Same intensivist joins me on the run, "Get me there the shortest way." "No problem boss, hang on to your badge."

The day team starts to trickle in. Interns first. Early. Hair is still wet. Time to sign out the service back to day teams.

"OK, so Ms. M. got her matched platelets. She is fine."
"Ms. B. had a small temp, cultures sent, broad-spectrum antibiotics. She is fine."
"Ms. L. was in atrial fibrillation, there were no telemetry beds, so I managed her on the floor. She converted back to sinus. Blood pressures stable. But watch her closely today. She will need a cardiology consult."
"Mr. F... had a fever and rigors, but better with morphine"
"Mr. C...needed some fluids."
"Oh, and you have three new admissions."
"But nobody coded."