A few years ago I attended the funeral of a man whom I have known since he was ten years old. I knew him and his family, parents, and siblings. He had a rich life until about 4 years ago when he was in his mid-fifties. He was gainfully employed and enjoyed his profession, the fruits of which were recognized by his students and co-workers. He did everything a normal human does, had a family, friends and hobbies, was very intellectual, athletic, very talented linguistically, and above all smart. Four years ago he developed severe depression. He tried everything to get help, doctors, psychotherapy, medications, even electro-shock treatments. Nothing helped! He sank deeper and deeper. He self-medicated with alcohol and drugs to beat his profound sadness. His first attempt to end it all was with that. He almost succeeded, but with heroic medical intervention, he survived. A new treatment for the dying brain was utilized by cooling his brain, and him down to a temperature of around 33̊ C, and then slowly bringing it up to normal, near 37˚ C, over a couple of days. I have been impressed by how well this works under the right circumstances and saw another dramatic success of this in one of my employees who had a cardiac arrest for over an hour caused by a heart attack. With CPR he got to the emergency room with a still viable brain. He too survived and is back to work with all his marbles.
My friend resolved to beat this horrible illness but alas nothing worked. He decided since he suffered terrible pain and had no help, he could not live like this, especially since his previous life, prior to the dark curtain of depression descended on him, was so rich and enjoyable. On New Year’s Eve 2019, he laid down on the railroad tracks of Amtrack near La Conchita and ended it.
At first, I was devastated. What a waste I thought. At the service, multiple speakers came up to tell us what a wonderful person he was. So many people were influenced in a positive way by him. He was truly outstanding and a good human being.
How can a wonderful person do such a horrible and hostile thing? Suicide is a gruesome final act from which there is no recovery. It is definitely definite! One thing his brother said at his memorial service struck a chord with me. “I am not mad at you! You did a good job all your life and you deserve to be remembered as that person who brought enlightenment, joy, and laughter to so many.”
Depression is a dreadful illness, for which we still do not have all the answers. “Killing oneself is, anyway, a misnomer. We don’t kill ourselves. We are simply defeated by the long, hard struggle to stay alive.” (as quoted from Sally Brampton in Shoot the Damn Dog: A Memoir of Depression.) When a person dies who has endured cancer and finally is relieved of his suffering, we praise him for his prolonged torture and say he fought so hard and he is finally released. Suicide is often not judged along those lines. “He just gave up!” We did not recognize nor appreciate the long-suffering that was relentless and not seen by us. People who end it all do not make that decision lightly. It is a conclusion they come to after much desperate thought, as there is no other answer to their pain and distress, and there are no other choices that they have not already tried and failed.
Ultimately it is our failure. The failure to recognize the agony and pain of the depressed person, the failure of trying all the remedies we have at our disposal, the failure of the medications that just don’t live up to the promises they hand out in the television ads. The failure of the society to understand the depressed person, the failure of medical science to recognize and treat this cancer of the mind, this illness without a proper diagnosis, without a precise explanation, and above all too often without effective treatment.
Painting by Marianne Stokes “Death and the Maiden” (Maiden photoshopped out) d’Orsay, Paris
Most of you will not be familiar with the name. He influenced the course of health care, medicine, science, anthropology, biology, and politics. He was a personality of immense intellect and achievements who deserves our knowing who he was.
|Rudolf Virchow © Photos.com/Jupiterimages|
He was born on October 13, 1821, as Rudolf Ludwig Carl Virchow in Schivelbein, Prussia, now Poland. His parents were farmers. Rudolf was a brilliant student. In gymnasium (equivalent to high school) he became fluent in German, Latin, Greek, Hebrew, English, Arabic, French, Italian, and Dutch. He was headed for a position in the clergy, but his uncertainty about God and his self-assessment that he had a weak voice made that an untenable career. He chose medicine instead. He studied at the University of Berlin. After graduation, he did an internship at Charité Hospital, the most prestigious hospital in Berlin. He introduced the use of the microscope to study diseases and developed a method for discovering the cause of death, the autopsy. Forensic medicine was another one of his creations, and he was often called as an expert witness in criminal cases.
In 1847 the Prussian government sent him to study a typhus epidemic in Silesia. It was there that he came upon the principles of public health for Germany and, eventually, the rest of the world. His theory was that medicine is the study of disease, and the enlightened government is nothing more than medicine expanded to the population. Because of his political activism, he lost his position at Charité. He left Berlin to be the chair of pathology at the University of Würzburg in Bavaria, the first such position in Germany. Eventually, he was invited to return to Berlin to become Charité’s director of pathology for the next 20 years.
He realized that all cells come from other cells (Omnis cellula e cellula). From this sprang his theory of cancer origin and how it spread. He discovered blood cancers that he was the first to call Leukemia, coining that word and many more, such as spina bifida, embolism, thrombosis, and others. The “Node of Virchow” is now recognized as a swelling in the left side of the neck that is the harbinger of the lethal spread of a gastrointestinal malignancy. “Virchow’s Triad” details the causes of blood clots in vessels due to one of three causes, stasis of blood, injury of the vessel’s inner lining, and blood that is hypercoagulable.
He discovered that many animal diseases could be transmitted to humans, from which he coined the term “zoonosis.” Coronavirus is a zoonosis that is said to have originated from bats. Virchow was ahead of his time. He found the cause of Trichinosis, the tiny parasitic larval form of worms, trichinella spiralis, that resided in the muscles of pigs and by eating insufficiently cooked pork, could infect humans. Introducing meat inspections in Berlin eventually wiped out that disease in Germany. The sewer system and water supply of Berlin were designed by him. Virchow managed to get himself elected to the German Reichstag (the Parliament) from 1880 to 1893, and often championed better sanitation, support for the poor, improvement of health care, and other issues that concerned the public good. The Chancellor, Otto von Bismarck, who acted as the head of state, often did not see eye to eye with Virchow, especially on excessive military spending. He irritated Bismarck to such an extent that Bismarck challenged Virchow to a duel. The rules of such a potentially lethal encounter required that the one who was challenged gets to choose the weapons. Virchow cleverly chose Kielbasa, Polish sausage, filled with trichinella spiralis worms. Bismark refused to do battle with him based on it being undignified as well as too dangerous!
History, anthropology, and paleontology were his passionate avocations. He accompanied Heinrich Schliemann to the site in Turkey, where he believed the city of Troy was formerly located, to help in the excavations there. Furthermore, Virchow was convinced that no Aryan race existed, by studying over 6,000,000 school children, concluding that the people of Europe belonged to a mixture of races that could not be sufficiently identified to be separated, much less considering any group as being superior. He is often mentioned as an opponent of Charles Darwin’s theory of evolution, but that is not entirely accurate. Virchow was just not convinced that it should be considered fully proven, but a hypothesis.
He was offered an aristocratic title but declined this as a privilege he deemed too snooty. He did, however, subsequently accept the title Geheimrat (Privy Councillor), a distinguished title of the highest advising official or high ranking academic professor who made outstanding contributions to science. Having published over 2,000 papers and books, he certainly qualified for the title.
Early in 1902, Virchow jumped from a streetcar and broke his thighbone. He never recovered from that accident and died later that year at age 80. For his liberal ideas, champion of freedom, and proponent of elected representational government by the German people, and his pronouncement that there was no such thing as a superior Arian race, his non-scientific books were burned by the Nazis, even though he had died decades before.
I confess I am a relentless optimist. The joke of the two boys, one an optimist and the other a pessimist, portrays the difference quite well. The pessimist got a pony for his birthday. He sat looking at his new pony with large tears running down his cheeks. “Why so sad?” he was asked. “All ponies eventually die!” he blurted out between the tears. The optimist was given a room full of manure. He was happily throwing the manure up into the air, giddy with joy. “Why so happy?” he was asked. “With all this horse poop around, there has to be a pony somewhere!”
Despite all the pessimism we are steeped in, I am optimistic. One of our biggest fears is fear itself, as said so well by one of the icons of our nation, Franklin Delano Roosevelt, who uttered those words during another crisis our country faced, different but yet similar in terms of even greater risk to life, lifestyle, the economy, and need for regulation of its citizens. A lot of damage has been done by the panic of the coronavirus, which I feel has been whipped up by the media and a lot of craziness in the social media. The rumors that the virus was created by the Chinese, the Russians, the Martians, the Jews, or the US military, with one of their weaponizing projects gone rogue, is just insane. First of all, we are not that sophisticated to create viruses (yet), although the Martians might be if they existed. And this would be a totally new way of terrorism that has never been accomplished by humans before. The global stock markets have shed 6 trillion dollars, while the US markets own 2/3 of that loss i.e., 4 trillion. This seems like another over-reaction in my view. Coronavirus (COVID-19) is nowhere near the aggressiveness of other pandemics we have had. The mortality is going to settle out at less than 1%, and the older population, especially the ones with comorbidities, are at greatest risk. The 1918 Spanish flu, which was the H1N1 swine flu killed 100,000,000. Both MERS and SARS were more aggressive, but peaked out before widespread epidemics. China has peaked out and is on the other side of the curve both in terms of the disease and in terms of its economy. Even their domestic air travel is showing signs of recovery. South Korea is close behind in beating the epidemic. The warm weather is coming. All previous viral epidemics showed an amelioration when the temperature went up, and this will likely do the same with this epidemic (something good that can be said about global warming).
I do have concerns about the wisdom of shutting down the whole country with its obvious detrimental consequences to the economy, when isolating the likely susceptible at risk are the only ones that really need to be. The rest of the healthy younger population could be getting herd immunity. But all the smarter people than me with a lot of data from other countries that have gone through this seem to think that the social distancing, the school closures, limiting the number of people gathering at no more than ten, and working from home, etc. are what is necessary. In the meantime, there are at least ten vaccine candidates out there with Moderna, Inc (Nasdaq: MRNA) in Phase 1 trials that have started today. Several anti-viral drugs that are already available have proven some efficacy against the coronavirus, as does serum from recovered coronavirus patients. Our President and Chief of Optimism thinks by July this will be contained. I do believe that everything that can be done is being done, and a lot of very smart people are involved. There are reasons to be optimistic. There really are no other choices.
My last two essays were, you guessed it, on COVID-19. That is all you hear on the radio or TV these days. In keeping with the trend, I am continuing to stir the pot. It has gone viral. Coronavirus, true to its name, is a virus that has gone viral!
Viruses grow exponentially (J-shaped growth curve), the fastest growth rate there is, the larger the growing population, the faster the growth, as long as the food holds out. When the food runs out, the curve then changes to a logistic curve (S-shaped growth curve). This curve shows a slowing down of growth. So what makes the curve slow down? There are only two things that make the curve slow down: #1 fewer in the susceptible herd are available (either through the susceptible making themselves less available or the process makes the susceptibles less available ). #2 the rate of growth slows down. This happens when it takes longer to infect the next person. This could be when people wash their hands more often, don’t go out to spread the virus, or at least sneeze into a napkin. Ultimately when the food supply runs out, both mechanisms are at work, reducing the susceptible and the rate of spread.
The number of new cases will slow down, guaranteed! But will we still be alive to talk about it? I think we will. There are several reasons I believe this. We are worried about it, in fact too worried! As evidenced by the stock market! The virus is not as dangerous as the news media tells us. The mortality rate is likely not 9% as SARS was, it is closer to 0.1% as the last flu outbreak was. The measures we are taking to reduce the number of people exposed, and the rate of spread will reduce the number of new cases. It is common sense not to go out and buy cruise trip tickets. It is common sense to limit your unnecessary exposure to large crowds. It is common sense to wash your hands often. It is common sense not to bring the virus close to the places the virus gains entry to your lungs, like your eyes, your nose, and mouth. The virus stays active for a couple of days on any surface, such as a door nob, so washing hands is not only hygienic but important.
I have been in the doctor business over two-thirds of my lifetime, and have washed my hands to the point that I have scrubbed off my fingerprints.
They always have trouble when I need to give a fingerprint for a passport or other ID, because I obliterated them off over the years. I first learned to scrub for surgery in my third year of medical school at UCLA from one of the icons of surgery. He put soot on our hands, then blindfolded us, gave us a brush and soap, and made us scrub our hands. You would be surprised how much soot stayed on our hands and the places that were most likely to remain black, the back of our hands, the webspace between the fingers, and the space between the wrist and the palm. For medical students, it was a minimum of ten minutes (first scrub of the day) to get our hands clean. But for our purposes, washing for 20 seconds is generally enough. I learned a nice little trick from my grandchildren’s primary school teacher, singing the “Happy Birthday” song twice (at regular speed) is precisely 20 seconds.
You get the virus from another person, either through direct contact or through a surface, the infected person has left some body fluids. Avoiding other people is one way to decrease contact. I believe that shaking hands was an ancient, rather strange custom. It goes back to the Middle Ages when you met someone in the forest. You extended your right hand, as did the other person, to show that they did not have a dagger in it. It was somewhat awkward standing there with both your and his hands extended, so grabbing and shaking seemed like the right thing to do. As we don’t carry daggers any more, this Middle Age custom has outlived its usefulness and needs to stop. I vote for the Mr. Spock handshake: right hand raised at your side with the index and middle finger spread form the ring and pinky finger in a V configuration. This is necessary because if you don’t spread your fingers, it looks like a “Heil Hitler.” And if you leave just your middle finger up, it changes the entire meaning.
Viruses, like white men, can’t jump. Therefore a yard distance between people should be enough although the CDC in an abundance of caution has now revised it to two yards unless they are coughing or sneezing. If they are, you need to get out of that room, because the sneeze generates particles that are as small as 5 microns in diameter that travel over 100 miles per hour, and can stay in the air indefinitely like any pollen sized or smaller particle.
Masks are not very helpful, except for the ill person who coughs and sneezes. It keeps the particles that are spewed out more confined. Regular masks, actually, are not very effective in preventing inhalation. For one thing, the sides allow fine airborne mist to enter the space behind the mask, which is inhaled. To be effective, it has to be a special mask fitted to the individual that allows only air that goes through the mask to get to the person using it. Those masks do not let fine mist or small particles to go through. These are called N95 masks.
Hugging is another one of those human customs that should go away. I won’t even discuss kissing. Hugging and kissing ought to go the way of arranged marriages and should be relegated to the XO on the written word.
Good Luck!! Gus Iwasiuk XOXO
Mark Twain by A.F.Bradley © Benjamin Disraeli Photos.com/Jupiterimages ©
“There are three kinds of lies: Lies, Damned Lies, and Statistics.” The phrase is often claimed to be one of Mark Twain’s quotes, who, in fact, attributed it to Benjamin Disraeli, who served Queen Victoria as Prime Minister of the United Kingdom. This quote is not found anywhere in Disraeli’s writings, although he may have said those words. Regardless of who said it, the sentence argues that statistics are often the worst kind of misinformation because they have the authority of numbers; the sources are hard to pinpoint and dispute and therefore are believed.
I fell into this trap recently and exposed my ignorance by quoting the Coronavirus mortality statistics, as given in large part, by the Chinese government. The clue to me should have been “Chinese government.” The number of deaths I saw in the news was 3,132 deaths of a total of 92,303 (the newest numbers 3,886 deaths and 111,650 total cases). Nevertheless, mortality rates remain close to 3.4%. The number of people that died is probably accurate. It is hard to fake death, and counting the dead is likely to be reasonably precise. If they don’t move, they are probably dead. The denominator has grown to 111,650 people that have the disease and are almost certain to be undercounted. Mild cases are frequently not diagnosed or reported. A runny nose is a runny nose, not COVID 19, in most people’s judgement, but then again, it could be. The denominator is likely a much larger number judging from statistical analysis of previous epidemics. This would significantly revise mortality downward.
That, however, is not the essential source of misleading information. To accurately estimate disease mortality, raw numbers give the wrong impression. In the seasonal flu mortality, we see every year, and the numbers are more accurately reported remaining under 1% because:
- We are in the USA
- Our health reporting is mandated by governmental agencies (not necessarily a strong point)
- We try to be scientifically as honest as we can with checks and balances that report dishonesty or ulterior motives for inflating or deflating numbers
- The people in charge of reporting don’t have quite the hidden motives or pressures as an autocracy generates, who initially punished reporting physicians
- Our system has multiple sources of input that act as an automatic control mechanism
- Our math adds the mild cases and estimates of asymptomatic people to the calculations (although this has to be retrospective)
Almost all comorbidities affect mortality rates: heart disease, chronic lung disease, renal failure, liver failure, obesity, neurologic disease, diabetes, cancer, immune deficiency, pregnancy, age, etc.
Without knowing the demographics of the population under discussion, raw data mortality rates are almost meaningless. In the 2017-2018 flu season, which was one of the most severe epidemics in the last decade, if you were a healthy person, not pregnant, under 65 years of age, your risk of death was under 1%, but if you had a heart problem and were over 65 your mortality was over 10%.
How can we interpolate all this to the Coronavirus? The 3.4% mortality rate is a raw number for many (but not all affected people); the mild ones didn’t even get counted. I hate to use the term “fake news” because of its political overtones, but I think it is justified here. The news media has “hyped up” this issue with inflated numbers for reasons that are suspicious to me. To sell more newspapers? To be ahead in reporting doom and gloom? (which seems to be a habit of the news media culture). Or is it to affect elections? To create panic? To develop financial uncertainty? To…? A recently published editorial in the most prestigious medical journal in the world, The New England Journal of Medicine written by Anthony S. Fauci (the nation’s leading expert on infectious diseases), H. Clifford Lane, and Robert R. Redfield, https://www.nejm.org/doi/full/10.1056/NEJMe2002387 has stated, and I quote, “the case fatality rate (of Covid 19) may be considerably less than 1% (the bold letters are mine). This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%).” So take everything with a grain of salt!
Ludwig Boltzmann was probably the most important scientist of the 19th century. He was an Austrian physicist who introduced the concept of atoms. He was ridiculed and harassed to the extent that he eventually committed suicide in a desperate depression of what he saw as a rejection of him and his life’s work. The most prominent scientists of the time stood up during his lectures to declare that atoms are just an imaginary construct to explain mathematical formulations, not reality. Scientific journals did not even allow him to use the term, “atom,” as it was just not scientific. Besides who has ever seen an atom? He traveled to the attend the World’s Fair in St. Louis in 1904, also to Berkeley and Stanford, where he lectured and discussed his atomic theories with colleagues, but failed to realize that proof of his concepts and theories was just around the corner, and he would be vindicated. But it was not to be. In 1906, while vacationing in Italy he hanged himself while his family was out swimming in the Adriatic.
The picture above is his gravesite in the Zentralfriehof (Central cemetery) of Vienna. The inscription above his bust, S=k.log W is a formula that sums up his interpretation of the second law of thermodynamics. S is entropy (the level of disorganization), k is the Boltzmann constant, and W is all the possible molecular states. In 1906 there were four known states of matter: solid, liquid, gas, and plasma.
But there is a fifth possible molecular state, the Bose-Einstein condensate (BEC) that both men had theorized but was not created until 1995, long after Bose and Einstein had joined the immortals. Satyendra Nath Bose, born in Calcutta India, became a theoretical physicist. While studying a particular molecular relationship of gases under various thermal environments, called the Maxwell-Boltzmann distribution, he theorized that under very cold conditions, the molecules would not behave as the Maxwell-Boltzmann statistics predicted. He presented his thoughts to Albert Einstein who agreed and helped Bose publish his theory. During extremely low temperatures, he showed that atoms lose their individual structure and fuse together into one super-atom at the balmy warm temperature of one billionth of a degree above absolute 0. Matter does not behave the same in this state. Electrons can sneak through the maze of now motionless fused together atoms, without any loss of heat, it now has become a superconductor. That super cool matter can even explode like a supernova, fondly called “a bosenova.” I never got past college freshman physics, so my level of physics competency would not be able to tell you if Bose-Einstein condensates would also act differently than Boltzmann’s formula on entropy would predict.
The first law of thermodynamics states that energy is constant in the universe. It can neither be created nor destroyed, although it can transform from one state to another. For example, fire can heat water which will produce steam which will drive a piston up and down to turn a wheel. Heat is transformed into mechanical energy.
The second law was the focus of Boltzmann’s attention. Entropy, the level of disorganization, increases with time. He realized that the disorder in the universe must always get more disorganized. Even if you think you are organizing your house, sweeping, washing, making the beds, straightening the table cloth etc. etc., you are breathing, moving muscles, moving the broom. In aggregate, you are using up energy, disbursing heat, excreting CO2, using up O2, burning up sugar and degrading the body’s tissues. You are increasing entropy. Just as burning a log in the fireplace making a pile of ashes from an organized piece of wood, with bark, fibers, and nutrients that used to course through its tubules. Entropy is increasing, as it must. Just as the energy of heat must flow from a higher level of heat to a lower level (colder) and can never be in the opposite direction, things are constantly getting worse. But as it does so, it peels off energy. Without this energy nothing would work, nothing could grow, nothing could exist. It is this energy we use to live and thrive. In driving a car it burns a very organized, symmetrical, aromatic six carbon organic chemical, that derives from ancient life through complex processes. As it combusts, it winds up as CO2 and H2O. But it generates the energy to get us from point A to point B. Without this inevitable process called entropy, we would not be able to survive. Eventually, entropy will reach a level of equilibrium where no further disorganization can happen, where entropy will cease to increase. This will happen when no more energy is readily available, and the universe will be a dark, empty, and cold place. But don’t worry, this will take billions upon trillions of years. We can still celebrate a few more birthdays.
The third law of thermodynamics deals with when entropy reaches that equilibrium. Entropy will reach a steady-state, when it is so cold it will be the theoretically lowest temperature that it can get, 0 Kelvin. If heat is molecular motion, there will be absolutely no motion. In Centigrade that would be – 273.5 ̊C which happens to be absolute zero, calculated correctly by William Thomson, which earned him the title of Lord Kelvin.
At that temperature, the state of matter would all transform into the Bose-Einstein condensate, one super-atom of the universe. And if S=k.logW does not apply to this form of matter, it would set up for the release of all the nuclear forces, another “Big Bang” or in this case a “Bosenova” as so eloquently stated by Yogi Berra, “It’s déjà vu all over again!”
I do not intend to be condescending, but I do believe that most people are ignorant of the dangers of this killer. I have spent a half-century grappling with most of the variations of this disease and have some idea how underhanded, furtive, and devastating it can be.
Unfortunately, even fellow physicians have ignored patients presenting with symptoms that demand investigation, such as blood in the stool. But because the patient was too young, too old, just worked up a year ago and not found to have a problem, etc. it was ignored. As astonishing as it sounds, there are 26-year-old people that get colon cancer too. Familial adenomatous polyposis, a hereditary condition, patients can develop cancer quite early and need to start screening as young as age 10. Almost 100% of patients that have presented with colon cancer to me self-diagnose as bleeding from hemorrhoids. The patients, or sometimes their primary physician, has treated the hemorrhoids for months for this benign disease while ignoring the tell-tale signs of the monster waiting to be discovered just beyond the finger. Furthermore having hemorrhoids does not preclude also having cancer.
The colon is one organ that does not inspire glamour. Politically the colon does not garner the publicity, the fundraising capability, or the interest as, for example, breast cancer. It is after all the transporter of the end of digestion back to nature. Its contents are often used as a four-letter word to curse or denounce a person, thing, or event, a word that is recognized in all languages as one of extreme displeasure. Even our closest cousins, the chimpanzee, share in this. When they want to show their extreme unhappiness, they throw “it” at you.
There is a story of how the actual word originated. I don’t know if it is true or not. It is said that during our Civil War, wood and coal became a commodity that was increasingly difficult to obtain because the war consumed all possible sources of energy. Cattle feedlots produced large amounts of cow dung that, when dry, burned quite well. It was packed and shipped to parts of the country that needed it most. Some lethal accidents occurred when the cow dung got wet in a closed area, such as the hold of a ship. Methane gas was released. When someone with a lit lantern went down below deck an explosion ensued. From that experience, cow dung had to be shipped above deck. The shipping containers were inscribed with warning signs, “SHIP HIGH IN TRANSIT” abbreviating it into its acronym created SHIT.
1 in 20 Americans will be afflicted with colon cancer during their lifetime. This year 53,200 people will die from it, the second leading cause of cancer deaths of both men and women combined. The lung is still number one. Happily, we are making an impact as the death rate (deaths per 100,000) in colon cancer is dropping, except in the population under 55, where it has increased 2% per year since 2007. This has prompted the American Cancer Society to revise its screening guidelines to age 45 for people at average risk, that includes those people that do not have a family or personal history of colon cancer or polyps, hereditary colon cancer syndromes, or a personal history of inflammatory bowel disease.
Most colon cancer starts as a polyp. There is a condition called Hereditary Non-Polyposis Colorectal Cancer (HNPCC) that skips the polyp phase and goes straight to cancer but is not very common (1 in 400 people have it). But nevertheless, nearly all cancers start as a polyp. There are different types of polyps, some more dangerous than others. In order of increasing risk inflammatory polyps are the lowest risk, then hyperplastic polyps, of which the serrated kind are more dangerous, and then the adenomatous polyp, and finally the highest risk are the villous polyps. Size also plays a role, the larger the more serious. The question often comes up, “When should I have my next colonoscopy?” It is a statistical answer that depends on age, family history, how many, what kind, and how big the polyps found were (about a third of the people I have examined I have found have had one or more polyps) I would often enlist the patient’s input before I would give a semi-definitive answer. Even the low-risk hyperplastic polyps, that are supposedly benign and offer no increased risk, but if there are lots of them, especially on the left side of the colon or have elements of being a serrated polyp on microscopic exam worry me, and I would see these people back in 1 to 3 years.
Additionally, many pathologists are not yet attuned to the serrated polyp designation that makes them a notch more dangerous. I always reviewed the pathology slides myself with the pathologist and recall seeing a polyp that was half hyperplastic and half villous which is just a step away from cancer, and raised my threshold of concern for the supposedly harmless hyperplastic polyp. Recently the ACS guidelines state you do not need a colonoscopy after age 85. But if you are healthy and likely will live another 10 years, why not? Death from untreated colon cancer is quite unpleasant with colostomies and painful swollen bellies at the end.
There are several screening exams that have their own risks, accuracy, costs, difficulty, and inconvenience. The simple test for blood in the stool has no risk, although a little unpleasant. It is hower not all that accurate. Only one-third of cancers will show a positive test, not a very good track record. A more accurate test is the Cologuard stool test, although it is not a certainty that if positive you have cancer and if negative that you don’t. 13% of the time it is positive and the patient does not have cancer (false positive) and 8% of the time the test is negative when indeed the patient has cancer (false negative). It has no real risks and is easy to do. Just collect a stool sample in the privacy of your home and send it off to the lab in the provided container. It screens for DNA that is related to cancer or pre-cancer, such as a polyp. Many insurances pay part or all of the cost of $649.
Colonoscopy is the gold standard, but also the most expensive, unpleasant, and risky. The radiologists have expanded on the old fashioned barium enema, or more sophisticated double contrast study, both of which are screening exams for colon cancer, but they too can miss cancer. The newer version is the CT colonography. By offering this exam the patient avoids the unpleasantness of a colonoscopy, but not the prep for it. The patient must still have a pristine colon. Otherwise small bits of stool will be interpreted as a polyp, which will then prompt a colonoscopic exam. The CT colonography often raises more questions than it answers and has not been the answer to how to avoid the formal colonoscopy.
Colonoscopy is a direct visual inspection of the entire colon and therefore is the most accurate. But it too is not 100%. The colon has many twists, turns, and folds where small cancers or polyps can hide, but if done correctly it is extremely unlikely that anything will be missed. It will surprise you that doing a colonoscopy too fast is actually a measure of poor quality. At some centers, nurses actually time your withdrawal time and if you come out in less than 6 minutes you are “timed out” so to speak.
The big risk is a perforation, followed by bleeding, a partial burn injury from polyp removal, infection, adverse anesthetic problems, complications from the prep especially in older individuals getting fluid overload, or sometimes dehydration, and cardiovascular problems. Still, perforation remains the most feared of the complications. The literature quotes a rate of 0.016% to 0.2% risk. But therapeutic colonoscopies and large polypectomies have a perforation rate as high as 5%. My own perforation rate in 40 years was 2 in about 15,000 colonoscopies (.013%), but I do remember both vividly, and both survived.
A word about the prep. Having had several colonoscopies myself in my now 77 years of life, I must say that for science to have landed us on the moon, being able to transplant hearts, livers, lungs, we are woefully lacking sophistication in cleaning out the colon. To say it was unpleasant is an understatement, and the most often prescribed prep, Go-LYTELY, is a misnomer in my book. Newer preps are available that make it a bit easier but at rather exorbitant prices. The old 1.5 oz. of Fleets Phosphosoda taken two times was still the easiest, quickest, and least unpleasant. Unfortunately, it killed a few people and was removed from the market.
The vote is in, 52 to 48 for acquittal of Donald Trump on the abuse of power charge and 53 to 47 on the obstruction of Congress charge. There are several possible interpretations.
1. 52 Republicans believed that the charge of abuse of power did not occur and 45 Democrats 1 Republican and 2 Independents thought that it did. On the obstruction of Congress, 47 thought that it happened and 53 did not. The No’s have it.
2. 52.5 Republicans believed, that although Trump did not act properly, that it did not constitute what has been described as high crimes and misdemeanors, and therefore did not justify removal from office. Conversely, 47.5 Senators believed that it did constitute high crimes and misdemeanors and therefore requires removal from office. Of course, 47.5 votes lack being the two-thirds majority (66) it would need to be anyway. Again, the No’s have it.
3. 52.5 Republicans ignored what the House presented and voted against what they knew to be the truth only to support the Republican in office, regardless of what the truth is. Conversely, the Democrats held their noses and voted with their party to get rid of Trump, knowing that his actions did not reach the level of high crimes and misdemeanors. As they say, the end justifies the means.
4. 47 Democrats want to get rid of the man they have been trying to get rid of ever since he got elected, and saw this as one of the fourth or fifth reason to do so (1. the Stormy Daniels’ affair, 2. the Muller investigation, 3. The Putin link, and of course 4. the Zelensky phone call. There must be a few others I don’t recall).
5. A combination and permutation of the above four!
One has to assume that if #1 or #2 are not the correct interpretations, the other possibilities, #3, #4, and #5 require dishonesty, deceit, unethical, or criminal behavior ( or all of the foregoing) on both sides.
The House and Senate are all elected officials with long track records, all with a sworn testament to uphold the truth, most of them being lawyers. It would seem that if they stoop to lying, corruption, and criminality they would have shown evidence of that behavior at other times, but none of that is evident or provable beyond a doubt. If there were such provable evidence, they would likely not be walking free at this time. Their political opponents would have seen to it.
Senator Kamala Harris called the results “a travesty of justice.” It is precisely the opposite. It is what was created by our Constitution and 19 prior impeachments of presidents, judges and various federal officials that have been conducted since1798 on. The rules are there, but nothing is set in stone that cannot be changed by 51 votes. The rules were followed, even about the part for no witnesses, and if you don’t like the result, your issue is with the Constitution of the United States, the framers and the rules that have evolved since inception. Name-calling is not helpful nor the way to voice your concerns. It exposes ignorance of history and adds to the disrespect for a system that has worked quite well for over two centuries, and furthermore falls into the same type of behavior we witnessed for showing lack of decorum in the legislative chamber that belongs to the people of the United States.
I believe that the majority of Senators, whether they voted Yea or Nay, acted on their convictions and true conscience. I believe that those who voted to convict felt justified to do so, and those that voted against conviction truly felt this was uncalled for. Even though the vote was almost down the party line, as most of us know who are not naïve, most votes tend to be down party lines because each Senator brings with him, or her, their own set of internal rules that define him/her as a liberal or conservative. The one Senator who split his vote, is in my opinion, more evidence that Senators voted their conscience. Both sides have been spewing their views, clearly and succinctly, from the argument that “the evidence is incontrovertible” from the left to the right’s question, “Where is the crime? Abuse of power to benefit one’s electability is not on any list of impeachable offenses! In fact, if it were, no one could get elected.” As stated by Alan Dershowitz, a recognized constitutional law scholar. Furthermore, precedence in history proves it to be so.
House members who are so intent on conviction for abuse of power have not read the history of Jefferson and Adams. Jefferson, as Adams’ vice president, was so horrified at Adams for what he considered abuse of presidential power that he walked out on Adams and left Washington for Monticello to plot his revenge. The Alien and Sedition Acts gave Adams unprecedented powers to imprison people. Jefferson came back three years later, in an unbelievably bitter campaign, to win the Presidency. Both sides used deceit and slander that makes today’s politics pale in comparison. Jefferson accusing Adams of being a “hideous hermaphroditic criminal character” while it became public knowledge that Jefferson supposedly had lecherous dalliances with slave women at Monticello, something that haunted him the rest of his life. Nevertheless, Jefferson prevailed, he took office March 4, 1801. Had today’s standards for abuse of power prevailed, Adams would have been impeached and convicted. And furthermore, Jefferson would have gone to jail for slander.
Today, neither the Republicans nor Democrats buy each other’s arguments, despite that both sides are very earnest in their beliefs. To get consensus, you would have to have at least some compromise on each other’s arguments. That is just not happening. You would have to be a super cynic or a die-hard fan of Game of Thrones to believe that the majority of the Senators on both sides committed perjury by this vote. Jefferson and Adams were bitter enemies for 12 years but eventually reconciled, remaining friends until they died 5 hours apart on July 4, 1826, a history lesson our Congress should emulate which our country desperately needs and from which it would greatly benefit.
My interpretation of the vote points to the first two possibilities being the only viable and likely explantation. A patriotic American of either party would have to believe that our legislators are by and large honest people of principle even if some of them have drunk too much of the blue or red Kool-Aid, but they are not a bunch of conspiratory Mafioso. We now must accept the results and let it go if we believe in the process of our democratic form of government.
If we continue to wallow in this muddy, swampy bog, we risk harming our form of government, our economy, and our way of life. The OMB (Office of Management and Budget) said that holding up funds for Ukraine was illegal. That assertion has not been tested in the courts. We could run that question all the way up to SCOTUS (Supreme Court of the United States). Or, better yet, let’s review the Muller Report one more time that refused to call the abuse of power question in the first place and maybe (or not) give us the answer. The DOJ (Department of Justice) calculated the cost of the Russia probe to be $32 million so far. That could be doubled and in another 2 years, we could (or not) get the final answer. The DO-NOTHING CONGRESS could do nothing quite a bit longer yet. I know, let’s call Bolton to testify. He could read his book for the Congressional Record. That would be a great way to continue to do nothing, especially since the content of the book is already known, but it would be better than getting an Oprah endorsement. How about a re-impeachment?
Have we not had enough? In just a few months, we have the opportunity to elect a president. This will be the time to exercise our rights as citizens and make a decision that we then must abide by, and start acting like reasoning adults instead of spoiled children who will not shake hands or tear up each other’s papers which by the way were historic documents belonging to us, We the People.
The Missing Link
It has become clear that we, homo sapiens, have DNA from other ancient hominids and not so hominids. It seems that neat stick drawings of evolutionary trees are not a realistic picture of where we came from. Europeans have 2-4% Neanderthal DNA, while South Asians and people from Oceana have at least 5% Denisovan DNA. There are other as yet unidentified DNA sequences from at least two “Ghost” subspecies, now extinct, that have had dalliances with homo sapiens in the last 50,000 years. These have been temporarily named with the placeholder designations of EH1 and EH2. There were a lot more eligible bachelors and bachelorettes available then, that would have made for much more exciting TV shows than what we are forced to watch now. The EH1 group has disbursed its DNA within 2.6 to 3.4 percent of Asian and native Australian populations. While the EH2 hominids are limited to Indonesia, specifically the Island of Flores where the skeletal remains of a small hominid named H. floresiensis were found. Because of its size, it is given the nickname of “the hobbit.” Although this name is currently under legal challenge by the Tolkien estate which claims it is the copyrighted property of the author J.R.R. Tolkien who wrote the book, The Hobbit.
When I was in high school, I recall in biology class the enigma we were all taught about, our link to monkeys was just not there. “The missing link” was proof positive that Darwinian evolution was all godless bunk. As it turns out, multiple missing links have been dug up in various sites of the Rift Valley, especially at the Olduvai Gorge in Tanzania by the Leaky’s and others. It was Louis Leaky who gave Jane Goodall her start in studying the daily life of chimpanzees, which led her to slay many of the sacred cows of what supposedly defines our species as human, such as using tools, communicating with each other, and social behavior.
Further down the Rift Valley in Ethiopia, “Lucy” was found. She was a 3.7 million-year-old Australopithecus hominid who walked upright and appeared after the split into two families, Pongidae (monkeys) and Hominidae (hominids). It is all very complicated with crosslinks and the ancient species leapfrogging into our species, leaving tell-tale bits of DNA behind. That all elusive “missing link” is not missing anymore. Not only did fossil evidence spring out of the ground, but DNA from test tubes leaked into the evidence pool to become even stronger proof of our origins.
The discovery of Denisovans, an entirely new species of Homo, was based on DNA obtained from the tip of a 50,000-year-old phalanx bone of a child found in Denisova Cave in the Altai Mountains of Siberia, and subsequently confirmed from the DNA isolated from an adult’s molar tooth.
It is no longer possible to deny that we are a melting pot of organisms with ancient DNA residing in our cells and floating in our bodily fluids. It is time we own up to our origins and our relationship to the rest of the miracle of life.
There are a variety of afflictions from which we suffer that are remnants of ancient genes floating around in our DNA. Migraine headaches, for example, were once genetically selected when the saber-tooth tiger was prowling around. If you were an Australopith that had migraines, you would be hiding in a cave much of the time because light really bothered you, making your eyes tear and your head split. All your brothers and sisters that did not have this affliction were out hunting small game and gathering roots and berries. They became saber-tooth tiger food while you survived in your cave. But you got the benefit of reproducing; however, your offspring also suffered from migraines, but nevertheless escaped the tiger. The migraine gene was preferentially selected. Now we don’t have the tiger to worry about anymore but have more humans with the migraine gene.
A large study done at Vanderbilt University of 28,000 people, in conjunction with records from Kaiser Permanente, studied people with depression. Interestingly the population who had a large percentage of Neanderthal genes in their genome was more likely also to have depression and had much more difficulty in quitting cigarette smoking. Homo Neanderthal is the closest extinct relative of Homo sapiens, us. The first Neanderthal was found in the Neander Valley, a small town near Düsseldorf, Germany. No Neanderthal has been seen for 25,000 years since our last ice age. Why they disappeared remains a mystery. Did H. sapiens outbreed them; were they unable to tailor warm fur clothing, or did we just absorb them? The latter has some merit as much of 4% of Neanderthal DNA can be found in our DNA, suggesting there was more than casual contact. The Neander Valley is known for its Octoberfest beer, and I suspect that had much to do with the higher genetic content of their DNA in us. Too much beer interferes with good judgment and as they say, “shit happens!”
Neanderthal had a whole host of other questionable traits that would have made any H. sapiens’ (meaning wise) mother warn their sons to stay away from the Neanderthal ladies. For example, they were prone, not only to depression, but to eating disorders resulting in malnutrition.
Furthermore, the Vanderbilt study found other undesirable traits such as skin cancer was more common amongst them, as well as an increased risk for blood to clot, which would be useful in case of an injury but could also lead to a pulmonary embolism. They were prone to carry the known cancer-causing virus, Ebstein Bar. Altogether, not great genetics! But Neanderthals were pretty spectacular artists.
Unfortunately, our genes are the most important factor in what we look like, what diseases we are prone to, what our body weight is likely to be, our eye and hair color, how long we will live, and pretty much everything else. Whatever environmental changes we have at our disposal, whatever medicines or surgical treatment we undergo cannot change the genes. Just choosing different parents would do it. Of course, that would take a time machine or a wormhole in the fabric of space-time. There is nevertheless some hope for the future. GMO (Genetically Modified Organisms) have been around for a few decades. Regrettably, there is not much public support for it. Stories of genetically modified foods bring up visions of horror shows with the modified genes taking over our bodies with new diseases, and furthermore, the wild genes creating mutations that are then passed on to our offspring. Movies showing fly heads implanted on human bodies and other monstrous assaults on our delicate biochemical structures have frightened us. But that is mostly hype of people who read too much Sci-Fi and trust the environment and nature more than it deserves to be trusted. GMO’s, on the contrary, have done a lot of good, from providing better yield in growing produce, to animals that are healthier, make more milk, and provide more meat. The entire dog population is GMO created. We would not do very well having a wolf sleeping with us at night. But with just a few modified genes, we get cute, friendly, puppies that grow into the best friend man (or woman) can have.
T-cells are a special lymphocyte in the blood that are central in formulating the body’s immune defenses. It has become possible to snip out parts of a DNA sequence that is harmful or inactive in a T-cell and replace it with a beneficial sequence. Diseases that were incurable are now nearer to a cure than ever with gene therapy. Certain malignancies and Multiple Sclerosis can be controlled by harvesting your T-cells in the blood, getting a virus that has been pre-programmed to carry a beneficial DNA snippet that infects your T-cells, thus inserting the good DNA into them. Now your T-cells are ready to take on the fight against whatever malady with which you are afflicted. It sounds impossible, but it is here and now.
Buckminster Fuller, the architect, inventor, and futurist who discovered that the rate of new knowledge increases with ever-accelerating speed, and now our fund of knowledge doubles every 12 months. It took us 3 million years to get from the Rift Valley in Kenya to Kitty Hawk, North Carolina, and about another 69 years to reach the Sea of Tranquility on the moon. We are starting a new decade; it will be astounding*!
*Line was stolen from Walt Adair, former Chief of Police of Santa Paula, CA.