A little internet history

Where did the internet come from?

On the NewMediaMedicine blog, there is a really interesting 30 minute video on the development of the ARPAnet, the precursor to our modern internet. These guys who put the thing together talk about really what can be described as the philosophy of the internet, and speculate about the future of computers. Almost everything they said in 1972 has turned out to be right on the money, and sounds surprisingly like how people in computers speak today!

Also entertaining are the 70s clothes and graphics.

Angioplasty rates ballooning?

This post starts out with some old news (from a blog perspective) -- news that is a week old.

At an AM conference at Evanston Hospital, the hospital at which I am currently rotating (by the way, thanks so much Dr. Wes for linking to my website and getting me started on a blogging addiction!), a New York Times article regarding off-the-charts rates of angioplasty in Elyira, OH was brought to my attention.

The numbers speak for themselves.


The rate of angioplasty in Elyria is almost double the next closest rate (I can see the people in Lafayette, LA getting nervous...) .

This sounds off the charts. But by another measure, it is half-way to Mars.

The distribution of angioplasty rates above follows the classic bell-shaped curve (in this case the bell is depicted as lying on it's side). Bell-shaped curves are found all over nature, and describe how randomly distributed variables tend to cluster around a mean (or average). Another important property of bell curves is the standard deviation, or a how "wide" the bell is.

A low standard deviation means most of the numbers fall close to the mean number, a high standard deviation means more of a spread. In fact, for an ideal bell-shaped curve, about 68% of the values fall within one standard deviation of the mean. About 95% fall within two. 99.7% fall within three. 999,999 out of a million fall within five. All but one in 384 billion fall within seven.

I just had to get in touch with my inner geek and crunch some numbers in Excel. All I had to work with was the above graph. I found that the mean rate of angioplasties in the country for Medicare enrollees is about 11/1000. I found that the standard deviation is about 3.9 angioplasties /1000 Medicare enrollees. This means that the catheterization rate in Elyria, Ohio is about (42-11)/3.9, or about 7.9 standard deviations above the mean!

This is really off the charts, and cannot be explained by chance.

Now it's interesting that in Elyria there is one dominant cardiology group. One explanation offered in the article is that angioplasty rates are so high because many patients that might get bypass surgery at other hospitals get angioplasties in Elyria. If that's true, then the bypass rate should be rock bottom, right? Right?

Someone also tipped me off to the Dartmouth Health Atlas, a free online database of loads of healthcare information. I queried the database for a graph of the different bypass rates of all the 306 hospital regions in the country in 2003. I got:

The red dot is Elyria, pretty much smack dab in the middle. There goes that argument.

Who knows what the inevitable Medicare investigation will show, but I think it will show fraud. What motivates this? Is it greed on the part of the doctors? Is it the fact that the doctors and the patients don't see the cost of their actions?

Is this something that is widespread? Or is it just a few bad apples that fall very very fall from the main trunk of the bell-shaped tree?

What got me to post on this was an email I got forwarded from a friend of a friend who has just finished Cardiology fellowship, and is about a month into his new job as a general cardiologist in private practice. I know this person to be an excellent physician and an all-around good person. The email addresses the "rules" he has learned so far in private practice. I will post a part of it:

"...Cath EVERYONE. 3 of my first 4 caths were normals on patients who had a negative MPI [editor's note: a type of stress test that is pretty good] within the previous week. My group appreciates this. Funny thing, so do the patients' primary care docs, and so do the patients! Insurance companies can be dealt with ..."

Now, in editorial fairness, at the end of the email, this person also says "...OK, so I'm exaggerating, but the rules are clearly different..."

But I am left with the distinct impression that over-testing may be a widespread thing in Cardiology, which disheartens me a bit. I'd be interested to hear other's thoughts.

On Destruction of Molecules and Men.

I had the privelege of attending Dr. Aaron Ciechanover's lecture yesterday at Northwestern University on his decades-long voyage of discovery regarding the ubiquitin system. For these endeavors, he won the Nobel Prize in Chemistry in 2004. His biography is a fascinating read.

What is the ubiquitin system? It is not one thing really. Rather, it is a family of proteins that Dr. Ciechanover estimates to comprise between 7-10% of the entire human genome. This makes it by far the largest family of proteins in the entire genome. These proteins work to specifically degrade other intracellular proteins, in order to end molecular signals within the cell, as well as to remove excess protein products. This, I discovered, is an incredibly important system of proteins that comprise an important set of targets for drug design.

This -- the removal of the old to make way for the new -- is good destruction.

What is bad destruction? Well, Dr. Ciechanover grew up in Haifa, Israel and has spent the majority of his professional career in that city at the Rappaport Family Institute for Research in the Medical Sciences at Technion - Israel Institute of Technology. For those of you who have been following the news over the past month in the Middle East, Haifa was the target of deadly rocket attacks from Hezbollah, in Lebanon. For that matter, Beirut, the capital of Lebanon, also suffered deadly civilian casualties as a result of Israeli Defense Force bombardment.

I don't care what your view is on the conflict between Israel and Hezbollah-- no matter where you fall, you definitely must lament the death of innocents on both sides.

This --the irrevocable rending of the fabric of human life -- is bad destruction.

The juxtaposition in Haifa of the discovery of the ubiquitin system (the good destruction by molecules of fellow molecules) and the rain of terrorist bombs (the bad destruction of men by fellow men) really brought home to me Sir Winston Churchill's quote:

"To build may have to be the slow and laborious task of years. To destroy can be the thoughtless act of a single day."

I think that this day of choice is dawning for humanity. Will we today thoughtlessly destroy the world? Or will we take up the slow laborious task of years? Are we poised today on the brink of a golden age of discovery? Or instead are we unleashing a dark period of decay?

There are those who want to make the world better. And there are those who literally want to unmake the world. I hope that the thoughtful prevail.

But right now, the score in Haifa is 1-1.

Internal Medicine Board Exams

I just took my Internal Medicine board exams, and now am sitting in the lobby of the silly testing center in Matteson, Illinois, waiting for my friend Raj to finish so we can sit in inbound rush hour traffic on 57 and the Dan Ryan (did I mention that it's under construction?) before downing a few well-deserved beers at Jake Melnick's.

The test I thought was fair. After a year of cardiology, I realized a lot of my Internal Medicine knowledge has atrophied. I'm pretty sure I knew enough to pass. The scores come put in November.

Out of all the standardized exams I've ever taken in my life (PSAT, SAT, MCAT, USMLE I, II, III, and now this) this is definitely the one I've studied the least compulsively for. I'm pretty sure it's a combination of 1. There's no reason to do anything more than pass 2. Mild test-taking burnout 3. Hubris 4. No one who did internal medicine at Northwestern has failed in the past few years.

Also, I figure, what possible bearing does memorization of the workup of glomerulonephritis have on my future career as an academic Cardiologist? Without any exaggeration, knowing how many licks it takes to get to the Tootsie center of a Tootsie pop is more germaine (in that it may allow for the more accurate estimation of the carbohydrate intake of my patients.)

So now with this test out of the way (hopefully), I can move on to other things, like Cardiology boards (2 years away), echo boards (if I decide to take them, also two years away), and the Internal medicine recertification exam (if all goes well, 3650 days away)!

Cardiovascular disease in the developing world

A fascinating article in the Lancet's most recent issue (many will not be able to access the full-text of the article unless they have access to medical journals). I first became aware of it through theheart.org It addresses treating cardiovascular disease in developing nations. Many of us are aware of the impact that HIV is having on developing nations. In some countries, it is literally wiping out an entire generation. Most of us, I think, are less aware of the impact cardiovascular disease (like heart attacks, heart failure, and strokes) has on developing nations. I certainly wasn't aware, and I'm a cardiology fellow!

Turns out that most of the global cardiovascular disease burden is in developing nations. This is not just a function of the fact that most people live in developing nations: apparently the number one killer in the developing world (with the exception of sub-Saharan Africa) is cardiovascular disease.

The idea behind this article is that there are cheap drugs that we know help prevent heart trouble. Aspirin. Statins (a class of cholesterol-lowering drugs that includes lovastatin, pravastatin, simvastatin, atorvastatin, rosuvastatin, and others). Ace-inhibitors (these definitely help people who have already had a heart attack--what is less clear is whether these help stave off heart attacks.) Beta-blockers (help people who have had heart attacks).

What is also known is that lowering blood pressure cuts down your risk of a heart attack.

So these investigators took a bunch of people in the developing world at risk of having a heart attack as predicted by the Framingham risk score (developed from a population of people in the 1950s and 1960s from Framingham, MA), gave them cheap generic medications, and compared them to a group of people who did not get medications. Then they waited and counted who had heart problems, and who didn't.

The results are very interesting. You can predict that the people who got treatment did better. What is fascinating, though, is how little money it cost to save lives. For just a dollar a day...

No, seriously.

For just a dollar a day (about $350 a year), treating people who have had a heart attack already will end up saving a year of life. This figure compares very favorably to the cost of treating HIV in the developing world.

And it beats the pants off the cost-effectiveness of therapies delivered in the West. By way of comparison, mammography costs something like $10,000-$20,000 for every year of life saved.

Woo Hoo!

the internet is a wonderful thing! I can't believe I got the email thing to work on my first try.

email test

This is a test of whether or not I have successfully configured posting from my treo. Not very interesting, I'm afraid.

My picture

This post is just so I can get my picture up on the profile. The picture was taken in Keystone, Colorado, during the American Heart Association basic science conference this year. How dorky, but actually it was a very cool experience!

Palm Medical Stuff

I have had a palm-based PDA ever since March of 1997 when my dad gave me a PalmPilot Pro (or something like that) that he did bought but did not use because it was too hard to pick up Grafitti. Then I got a Palm Vx for graduation from college. That was a really good device. I still see plenty of people using them around the hospital, actually. Then one day in the middle of my third year of medical school, my Palm stopped working. I then got a Sony Clie. That was pretty worthless because the screen was so sucky, but the good thing to it was that it was one of the first 320x320 resolution displays available.

Now I am on my Treo 650, and have had it since December, 2004. I love it. BUT, I still am working on upgrading it with stuff to make it more useful to me.

Recently, I have become enamored with the amount of free wisdom available on Project Gutenberg. There are currently 18,000 free titles available there. The problem is that no one really wants to sit in front of a computer screen and read Milton. Well, maybe the problem is that one doesn't want to read Milton in any form whatsoever, but that's not what I'm getting at.

I think it would be nice if there was a way for me to be able to read these things on my Treo. That way when I am on call or moonlighting, and have nothing to do, I can read. Reading philosophy or literature in the hospital is a challenging thing to do, because such endeavors require an amount of concentration that buzzing ICU alarms preclude, but it can be done.

So I am in the middle of setting up iSilo on my Palm, with the idea that I can convert Project Gutenberg plain text files into iSilo documents. We'll see how it goes...