They are so cool!

Here is a picture of a cedar leaf in cross section, using polarized light.

And here’s a marine worm using a technique called confocal photography (which is explained in detail on the site, for you photomicrography bugs.

This one is the seed of the small-flowered willowherb (Epilobium parviflorum).

And this lovely scene is some rat hippocampal neurons being attacked by Alzheimer’s related neurotoxins>

I don’t know that these images demonstrate the beauty of nature, so much as the beauty of photographic images that depict nature in clear lines and bright, nifty colors.

Still, they’re great to look at.

How he heard about Tregellys Fiber Farm in Hawley, I do not know. What he failed to tell us when we met up at the Creamery in Cummington is that is is a forty-five minute drive into the middle of nowhere.

He and my mom cruised on ahead, no doubt listening to classical music on the radio, chatting and enjoying the scenery.

In our car, Rebecca immediately starts on a migraine. The kids occupy themselves by making as much noise as possible: scatological screeching, punctuated by repeated demands for various things that cannot be procured on a small country road in Ashfield.

On and on we drive. We’ve been going for miles on a single-lane dirt road through a pine and beech forest. It’s been fifteen miles since we passed even a house.

Jane starts to feel carsick. Poor Rebecca is sitting silently with her eyes closed looking tense. I am thinking how much I would rather be almost anywhere than in this car on a beautiful fall day, and about the hydrocarbons we’re emitting, and global warming, and wondering what on earth my father was thinking; and also trying to concentrate on my out-breaths and relax into the moment, which is not working. I am not relaxing.

Then, suddenly, we come into a clearing and we’re in…

Tibet.

This farm is set on a steep, rocky hillside overlooking a forested valley. Just beyond the farmhouse, the ground falls away steeply and you can barely see to the bottom of the ravine, where another mountain rises just as severely, filling up the horizon.

Okay, it’s not the Himalayas, but it’s an incredibly beautiful, secluded corner of western Massachusetts. The hill above the road is figured with large stone terraces. At the edge of the rise stands a tall stupa (Tibetan prayer shrine).

In large wire pens, or roaming about free, are animals such as Bactrian camels, Royal Pinto Yaks and Icelandic sheep and rams. Plus pigs, sheep and chickens, and a pet duck who swims around in a spectacular hand-laid slate fountain the size of a small pond.

The kids, of course, had a great time running up and down the terraces and petting the animals. No, they had not, previously, seen Bactrian camels (native to the steppes of eastern Asia and domesticated around 2500 B.C.E., we learned).

Apparently Ed Cothey and Pamela Steward bought the land thirteen years ago and raised conventional animals there. They got a story in the local paper when they bought a llama. This attracted some visitors from Tibet, nostalgic for home. One thing led to another, and soon they had several Tibetan families living with them.

Then they started to import Asian animals. One of their guests contributed the terracing and the stupa; and stayed to open a Tibetan stonework business based on the farm.

Ed is an accomplished weaver, and Pamela is quite a good poet. She has a book with the University of Chicago Press.

Such a place, in the hills of Western Massachusetts. Who knew?

Plus they told us about Tibet Fest 2007, in Goshen, Connecticut. So we have next weekend planned already.

Here’s one from the American Heart Journal, Progression of paroxysmal atrial fibrillation to persistent atrial fibrillation in patients with bradyarrhythmias.

We know that some patients can have paroxysmal atrial fibrillation for decades, and others progress gradually to persistent atrial fibrillation.

The authors studied recordings from implantable devices for a bit over a year, looking at the “cumulative daily AT/AF burden.” The findings:

Seventy-eight patients (24%) progressed to persistent AT/AF during the follow-up period with a mean interval of 147 ± 149 days. Mean AT/AF burden increased progressively (slope 14 s/d, P < .001) over 500 days after implant, and median AT/AF burden also increased (P < .01) in this subgroup of patients. This increase was highly correlated with the presence of structural heart disease (P < .001).

In the discussion, the authors note that, first of all, implantable devices are useful for following the progression of atrial tachyarrhythmias. In terms of the pathophysiology of atrial fibrillation:

We observed that a proportion of patients progressed to persistent AF. In this population, this was 24% at a mean follow-up duration of 5 months. This is a more rapid transition than previously suspected and may be related to the more sensitive recording method. The mean AT/AF burden has remained relatively constant over time in the patients remaining in paroxysmal AF, whereas it steadily increased in those transitioning to persistent AF…

We were able to obtain unique insights into the period around transition from paroxysmal to persistent AF. Interestingly, this transition is rather sudden and discrete in most patients rather than gradual as previously hypothesized. There is no substantial AF burden surge immediately before the transition point, suggesting that the persistent AF event is triggered by a single or very low density triggering arrhythmia and may be maintained by a remodeled substrate.

The clinical implications? In patients with devices, we may be able to predict the likelihood of progression, with yet-to-be-defined algorithms. And, with regard to directions for therapeutic research:

The focus of many AF therapies has been to reduce trigger mechanisms. This new understanding from device data logs strongly promotes interventions directed at the substrate. Atrial-specific antiarrhythmic drugs, multisite atrial stimulation for electrical resynchronization, and linear ablation/isolation for ablative approaches are more likely to favorably affect the substrate. Drugs such as angiotensin converting enzyme inhibitors and other therapies such as dual-site atrial pacing may improve hemodynamics, potentially slowing the progress of substrate decay.

Finally, quantifying cumulative time and and out of fibrillation may help us to estimate thrombotic risk more precisely in individual patients and better direct anti-thrombotic therapy.

Yesterday was Rosh Hashanah, the beginning of the Jewish New Year, which ends eight days from now with Yom Kippur. Between the two holidays, we focus our thoughts on repentance, and on returning to God.

An interesting thing about Judaism is that many of its essential themes were forged at a time of defeat and loss. The notion of a Covenant with a protective God certainly predated the sack of Jerusalem by the Babylonians in 586 B.C.E. In fact, the idea of a patron God who resided in a temple and protected the kingdom was commonplace in the Bronze Age. I think the Judeans and Israelites endowed this with a bit more of a Utopian character than their neighbors, but the basic theology was not terribly different.

It was not until the destruction of Solomon’s temple Jerusalem and the exile of most Judeans to Babylonia that Judaism took on its distinctive character.

One must imagine people who had faced the individual fear, deprivation and loss of a long siege, had seen their agricultural land laid waste, their cities razed, and their God desecrated. Then they were shipped off to exile in Babylonia.

There, for some reason, rather than adopting the gods and customs of the Babylonians, they reconstructed their religion. Now, however, they had no place to carry out animal sacrifices and other rituals, no physical space for worship – no temple in which their God could live among them. They were forced to think about the non-ritual aspects of their religion.

More importantly, their experience challenged the fundamental concept of an inviolable sanctuary protected by an all-powerful deity who would provide eternal protection to the descendants of Abraham.

The religious thinkers of the Judeans reconciled the dilemma this way: They maintained the belief in an omnipotent God, but they incorporated the new idea of a people who could sin. The people could turn away from God, could incur God’s anger and punishment. By turning back to God, they could also earn God’s forgiveness.

The Prophetic writings, which most directly address the exilic situation, are full of expressions of this relationship between God and Israel. God is presented (in patriarchal fashion) as a jealous husband who punishes an unfaithful wife; as a farmer pruning away diseased vines; as a merchant sorting the good fruit from the bad.

In the process, and almost by accident, the nature of God’s existence is re-conceptualized. He is not just the most powerful among a pantheon of deities associated with various nations. Rather, he has power over all nations: he sends an army from afar to punish his unfaithful people. By the same construct, God can be present for the Judeans in Babylonia even though there is no temple. The temple in Jerusalem is thus proposed to have housed God’s Name – not God Himself, who is omnipresent and cannot reside in a physical structure.

In this way, I think, the notion of sin and redemption was forged. It has been of central importance to Judaism and to the religions derived from it, Christianity and Islam.

I will write a bit more in a future post about the resonance this has for me, especially in relation to biology and the medical arts.

In this Lancet article, the researchers tried putting all patients on a fixed dose combination of ACE inhibitor and diuretic.

Traditional strategies set arbitrary blood pressure levels at which treatment is initiated and arbitrary goals against which treatment should be titrated. This strategy neglects those diabetic patients without what is typically defined as hypertension, and yet for whom blood pressure remains an important determinant of their risk of vascular disease. Additionally, this strategy is usually resource-intensive, needing multiple patient visits, careful monitoring of both blood pressure and side-effects, and the coordination of complex drug regimens. Perhaps partly as a consequence of such complexity, surveys of blood pressure control indicate that few patients receiving antihypertensive drugs achieve recommended goals for blood pressure.

The findings:

The relative risk of death from cardiovascular disease was reduced by 18%… and death from any cause was reduced by 14% … Although the confidence limits were wide, the results suggest that over 5 years, one death due to any cause would be averted among every 79 patients assigned active therapy.

We know that ACE inhibitors slow the progression of diabetic nephropathy. So they’re indicated for that, they’re indicated for hypertension - why not just put all diabetics on them?

I’m all for keeping things simple. All my type II diabetics can go on lisinopril, hydrochlorothiazide, metformin and simvastatin right off the bat - a sort of diabetic cocktail. This would save me an awful lot of monitoring and decision-making on each visit.

Of course, patients don’t like taking a lot of pills. Maybe we could just put them all in one big combination pill?

In all seriousness, I do think the next movement in diabetes care management may be toward simplification - i.e. rather than basing treatment decisions on separate pieces of patient data that need to be collected at various intervals (blood pressure, glycohemoglobin, microalbumin, LDL, etc.), base them on overall goals of reducing macrovascular and microvascular disease .

All patients had baseline creatinine greater than 1.2. Two hundred and sixty-four patients were randomized to receive, for six hours before and six hours after angioplasty, either:

• One hundred cc/hour of saline,
• 154 mL of 1000-mEq/L sodium bicarbonate added to 846 mL of 5% dextrose in water, or
• Saline plus Mucormist 600 mg twice daily

The findings:

When we head-to-head compared each treatment group, the incidence of contrast induced nephropathy was significantly lower in the sodium bicarbonate group (4.5%) compared with the sodium chloride group (13.6%, P = .036) and tended to be lower than in the NAC group (12.5%, P = .059)

This is a common and difficult situation - a patient with renal insufficiency who needs cardiac catheterization. You try to avoid doing the cath, because you don’t want to land the patient on dialysis by damaging the kidnies further with a big dose of contrast dye. When you have no choice (working kidnies won’t help the patient much if she dies of a massive heart attack), you would at least like a regimen to minimize the renal damage.

The convention at our hospital has been saline and Mucomist. Perhaps we should consider sodium bicarbonate instead.

Comparison of three regimens to prevent contrast-induced nephropathy

The authors studied 9,949 patients who had undergone weight loss surgery, and compared them to a control group of 9,628 severely obese individuals who did not have the surgery.

The findings:

• Overall mortality decreased by 40% in the patients who had surgery.
• There were 56% fewer deaths due to coronary disease,
• 96% fewer deaths due to diabetes
• and 60% fewer deaths due to cancer.

Long Term Mortality After Gastric Bypass Surgery.pdf

The accompanying editorial warns:

The lowest surgical mortality is seen among surgeons who have performed more than 50 operations and preferably more than 100 operations.

We know that obesity is an increasing epidemic in this country, and we know it’s killing people. The lives saved by obesity surgery is one measure of the mortality attributable to obesity.

Clinically, I would have to say that this study shows bariatric surgery is a good option for morbidly and perhaps even moderately obese individuals. An article in the Voice of San Diego observes that the study:

…should put to rest uncertainties about the benefits and risks of weight-loss surgery and may cause governments and insurers to rethink who should qualify for the procedure, some doctors said.

“It’s going to dispel the notion that bariatric surgery is cosmetic surgery and support the notion that it saves lives,” said Dr. Philip Schauer, director of bariatric surgery at the Cleveland Clinic in Ohio, who had no role in the research.

On a broader level, though, this is a social problem and a preventive health issue. We are grossly overfed in this country. Food processing, distribution and marketing has made food overabundant, cheap, and highly gratifying to consume. We have learned to eat for pleasure rather than for nourishment.

I try to counsel my patients to change their attitudes toward food. We need far less to run our bodies than what we actually eat.

I have started giving as much attention to dietary counseling as I do to tobacco cessation. Obesity causes as many deaths now as smoking.

One good online resource for patients looking for info on healthy eating and weight loss is the National Heart, Lung and Blood Institute Obesity Initiative. You can calculate your body mass index and your risk of weight-related diseases. The site also has information on diet plans, menus and exercise.

If you really want to get serious about healthy eating, you could buy Mark Hyman’s book, “Ultra-metabolism”. Another terrific resource for understanding and shedding the habit of over-consumption is “Hooked! Buddhist writings on greed, desire and the urge to consume”, by Stephanie Kaza.

In the Berkshires, if you are interested in the possibility of weight loss surgery, the guy to see is Andrew Lederman. The program is relatively new, but the patients I’ve sent to him so far are satisfied.

The article is available in PLOS Medicine, an open access journal published by the Public Library of Science.

In the 1918 Spanish Flu pandemic, blood (actually, plasma, which is the portion of the blood that contains antibodies) from survivors was administered to newly infected patients and cut the death rate in half.

Now the method is more sophisticated. Instead of transfusing plasma, we can isolate the antibody that is effective, produce it in cell culture, and administer it in purified form. This is called a monoclonal antibody, and that’s what the mice in the Vietnamese study received.

This is much safer than a plasma transfusion. Also, monoclonal antibodies can be mass produced.

For those who have not been following the Bird Flu topic - H5N1 is a new strain of influenza that is spreading among birds, and to a limited extent from birds to humans. The human population has no immunity to this strain, so it has the potential to cause a worldwide epidemic (a pandemic) with fairly high mortality.

At present, bird flu cannot cause a pandemic because it is not yet transmitted from person to person. Based on the history of other flu viruses, however, this is expected to happen eventually. Scientists are watching bird flu very closely for any signs of mutation to a more transmissible form.

If bird flu does mutate and cause a pandemic, monoclonal antibodies may be a form of early, lifesaving treatment for those infected.

Our first few days were complete chaos. They moved the furniture in on Thursday morning and we opened Thursday afternoon, with unpacked boxes in the hallways, no equipment, no printer, copier or office supplies.

A sensible person would surely have waited until Monday, but the truth is I had a lot of patients who really needed to be seen and I did not want to put them off another four days… (more…)

I use Firefox as my browser, and if you have not checked it out, I recommend it. It’s free, it’s extremely easy to download and install (just click the button and it installs). It’s perfectly safe - in fact, better virus-protection than Internet Explorer.

And stuff just looks better.

You can download Firefox here if you like.

But I promise I will fix the site for IE.