Marvel.Conceive.Advance (My Fresh, New Blog)

In the spirit of marvel and march, I created a new blog this autumn. It will be home to all further writing, research, and musings!

*http://www.meagangwhite.com/ *

Many thanks to the faithful reader who pointed out my need to redirect:)

Best,
MGW

Science is BeautyWords

Did you know that science is beauty?


This image illustrates evolving dynamical patterns formed during the spreading of a surface-active substance, or surfactant, over a thin liquid film on a silicon wafer. The usually slow spreading process was highly accelerated.


Never regard your study as a duty, but as the enviable opportunity to learn to know the liberating influence of beauty in the realm of the spirit for your own personal joy and to the profit of the community to which your later work belongs. * A Einsten *

.MGW.

The West is Burning

The West is Burning: Exploring AIR’s U.S. Wildfire Model



This summer, much of the western United States is in flames. Wildfires spurred by above-normal spring and summer temperatures and one of the worst droughts in decades have charred more than 4.5 million acres across the 11 western states. Between July 16th and 19th alone, 1000 new blazes ignited, prompting fire officials to raise the nation’s fire preparedness level to 5, its absolute highest.

The rise in singed acreage is largely due to bone-dry conditions, exacerbated by the Forest Service's policy of quickly halting fires that threaten residential areas. This policy permits accumulation of dry brush—perfect fire fuel. The most common cause of wildfires today, however, is human activity, including illegal campfires in heavily vegetated areas. The latter was the source of one of the summer’s most costly blazes, which occurred in late June near South Lake Tahoe, California. Dubbed the “Angora Fire,” the event destroyed 329 buildings and ravaged 3,100 acres. The U.S. Forest Service had initially hoped to contain it within a week, but what began as a small brushfire soon intensified into a full blown inferno. It raged for more than ten days, destroying nearly every structure in its path, before crews finally contained it. At the time, AIR estimated that total insured losses from the fire would likely exceed $150 million.





The Angora Fire highlights a worrisome trend: while the frequency of U.S. wildfires has remained relatively constant over the past several decades, wildfire-driven losses have significantly increased. Since 1980, wildfires in the U.S. have been responsible for insured property losses exceeding $10 billion.


This increase in losses is driven by the increase in the number and value of exposed properties in a high-risk construction area known as the wildland/urban interface (WUI)—a buffer zone where human development intersects dense woodland vegetation. Fire here can move readily between structural fuel and vegetation fuel, facilitating unusually rapid spread. Well over half of California wildfires occur in WUI zones.

Meanwhile, Americans continue to move in, building well-equipped first and second homes, particularly in the fire-prone West. Contractors in the WUI aren’t shirking from building opportunities either; between 1990 and 2000, the rate of construction on WUI-designated land exceeded that of non-WUI areas by a factor of three. The rush to build results in a convergence of risk factors: an unprecedented accumulation of fuels in areas of increasing population and property. This trend is similar to the one seen on coasts where Americans have an undaunted inclination to build vacation houses on hurricane-prone beaches.




Complicating risks for residents in fire-prone zones is the unpredictable nature of the wildfire peril; a sudden ignition can result in either a moderate blaze or a catastrophic event depending on atmospheric conditions, topography, and moisture content of local vegetation. Furthermore, fires can drive losses disproportionate to their size. For example, the 2003 Cedar fire was the largest in California history, destroying more than 270,000 acres. But it caused just $1.2 billion in insured losses, making it far less devastating than the $3.1 billion Oakland Hills fire in 1991, which scorched less than one percent of the acreage but ranks as the most expensive fire event in U.S. history.

According to the National Interagency Coordination Center (NICC), many tens of thousands of fires occur each year. And the risk of catastrophe property losses is increasing as population growth in the WUI continues apace. To help insurers more accurately quantify potential losses and support underwriting guidelines, AIR released its US wildfire model in 2006.


The AIR Wildfire Model for California




The AIR wildfire model utilizes a fire spread algorithm to simulate how a blaze will spread once it is ignited, as well as extensive maps outlining wildfire history to aid in predicting where fires will start. Historical data was pooled from, among others, two complementary sources: the California Department of Forestry and Fire Prevention (DCFFP) and the U.S. Forest Service (USFS).

In addition to historical information, the model is shaped by five key factors—the features governing wildfire frequency and severity. These are 1) ignition number and location, 2) vegetation, 3) weather conditions, 4) topography, and 5) fire suppression activities.

Ignition

Ignition can result from natural causes, like dry lightning—the source of most of this season’s wildfires—or human activity, such as the illegal campfire that spurred July’s Angora blaze. As previously mentioned, the vast majority of loss-causing wildfires occur in areas designated as WUI. WUI zones were originally designated as such by a 2001 U.S. Department of Agriculture and U.S. Department of the Interior report on communities at risk from fire. WUI boundaries are not well defined, however, and continue to change as the population disperses.

The maps below show the locations of historical California wildfires. The leftmost map shows California Department of Forestry and Fire Prevention (CDFFP) data overlaid on California WUI areas, shown in green. The CDFFP data consists of locations of fires larger than 300 acres from 1900 to the present, and fires larger than 20 acres from 1905. The center map adds the U.S. Forest Service (USFS) data for fires exceeding one acre, and the rightmost map shows all USFS-reported fires, regardless of size. The USFS data only covers fires reported from 1986-1995.


Vegetation (Fuel)

Fuel, another model parameter, is classified into different types of wildland vegetation, including coniferous trees, grass, and chaparral. Each burns at a unique rate and generates flames of different intensities. Grass, for example, does not hold moisture particularly well and can dry out even in a short drought, quickly transforming into ideal tinder through which flames can zoom.






In forests, fire spread rates are more complex. Forest fires may be fairly slow to spread depending on the undergrowth, but they can also be exceedingly difficult for fire-fighters to access and put out. Additionally, if forest fires manage to spread vertically into the canopy, they may become full-fledged crown fires, which move at incredible rates through treetops and can be virtually uncontrollable.

Weather Conditions

Wildfires in California are highly seasonal due to variation in temperature and precipitation within the year. During the six months from May through October, the average maximum temperature rises considerably. During the same time, little or no rain falls. This lack of precipitation removes moisture from vegetation until it reaches a very dry state, which in turn increases both the probability that wildfires will occur, and the rate at which they spread.




Seasonal winds represent another influential weather component. They can quickly revitalize a blaze, depending on their speed and direction. The Cedar fire of 2003 provides an excellent demonstration; its early growth was driven primarily by the presence of strong Santa Ana gusts—hot, dry easterly winds unique to California. Fortunately, Santa Anas are often short-lived. In the case of the Cedar fire, they were soon replaced with westerly winds from the Pacific Ocean, and this reversed the fire’s direction. The AIR U.S. wildfire model allows for such shifts. It incorporates historical data on average hourly wind speed and direction from NOAA Cooperative Observation Program (COOP) weather stations.

Scientists understand how fuel and weather affect a fire once it is ignited, but understanding just how it will spread so as to predict its final footprint is still a challenge. Fortunately, scientists have a considerable amount of data on fire size, location, and shape, as well less extensive data on wildfire duration and associated wind speeds. The model inputs these variables in the fire spread algorithm, which successively refines the initial approximation that on flat ground, and in uniform fuels, a fire will spread in an elliptical pattern. Wind speed and direction, along with local slope, are the major determinants of the ellipse’s shape. Vegetation factors in, too; as was noted above, fire spreads faster in some fuels than others, and if a sufficiently large region of non-fuels is encountered by a moving blaze, spread is halted accordingly.

Topography

Topography also affects how fire spreads. Fire travels upslope more readily than it does on level ground because flame advancing at an upward angle encounters a larger cross-sectional area of fuel than flame on level or downward sloping ground, feeding its growth. Additionally, trees and grasses immediately upslope from a smoldering fire are preheated by sweltering winds. These winds rob fuels of their moisture, turning them into perfect tinderboxes. The AIR model incorporates topographic data from the U.S. Geological Survey (USGS). These data are used to magnify fire spread when flames are traveling up-slope and to reduce it if a fire site is on level or downward sloping ground.


Fire suppression

The fifth and final parameter contributing to the overall wildfire picture is fire suppression—the suite of tactical techniques used by firefighters to halt expanding flame. These include clearing underbrush, airdropping fire retardants, and building fire breaks, or gaps in vegetation.



Decisions regarding where and when to deploy firefighting resources are influenced by fuel conditions and weather forecasts. Officials review information on how a fire is developing, too, and where it is headed in order to identify potential locations at which to fight a particular blaze. In unpopulated areas, wildfires are often allowed to burn out. This eliminates fuel buildup. In areas closer to human habitation, however, fire policies are aimed at extinguishing fires as quickly as possible. AIR’s fire spread algorithm approximates human decision-making with respect to fire suppression based on such trends.

Damage Estimation



Using a synthesis of the factors outlined above, AIR scientists are able to simulate a wildfire’s perimeter—the area a fire could ultimately affect. A complementary analysis predicts the intensity with which the fire will impact points in the perimeter’s interior. Predictor variables (flame length, fire spread rate, heat per unit area, etc.) are computed using the USFS wildfire simulation program, FlamMap, as well as topographical and road access data provided by the ISO FireLine tool. Combinations of these variables are analyzed in order to determine how they compare to historical fire pictures described in damage reports. In this way, a point-intensity index with a value between zero and one can be derived.

This value is further refined using AIR damage functions, which produce estimates of fire-driven loss by incorporating the structural characteristics of specific properties, including vulnerability of different roofing and siding materials. Since people continue to populate fire-prone woodland spaces, engineers have identified construction materials that are fire-resistant. Unfortunately, many homes today still have wood siding and either wood or asphalt shingle roofs, both of which are highly susceptible to ignition.

In addition to building materials, AIR damage functions also account for set-back distances—cleared space separating a home from the surrounding vegetation. A post-disaster survey conducted by AIR investigators revealed that most of the fire-ravaged homes in the Angora blaze did not have these cleared spaces. Of the homes that did survive with minimal damage, complete or partial setbacks were in place.

Conclusion

The 2007 wildfire season is shaping up to be one of the most destructive in recent memory, threatening homes, power lines, and communication towers across the western U.S. The AIR wildfire model helps to quantify the risk driven by such catastrophic events.



.MGW.

YourVisionWords

Vision.

Mine's constantly evolving—always finding its sparkle-eye spirit in adventure, its muscle in mountain.

My vision for long life is inspired by short bursts of Milky Way bright on clear October nights and the sound of humans listening. It wears wonder. My vision plays hard and rarely comes in too soon. It sweats after newly-thought thoughts and lets their novelty grease its lining. It finds momentum in the pure, honest motion of running.

I want the freedom to learn for the rest of my life.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *


Recently, I prompted a dear friend to describe his vision. The prompt made its way to other friends—to mentors and dreaming minds.

Below: my humble prompt, and beyond, the beginnings of wonder in words I hope to continually capture.

Send me your vision: MeaganGWhite@gmail.com












*Prompt*


He'd learned a lot there in just two years, under crimson tides and Cambridge skies; Boston's yards had been good teachers. Its labs were informative, too, as was the every day company. And something else had been particularly edifying—something not at all crimson. It was a distant vision of superlative calm. He'd shaped it in still moments when energy was high, and when he had to describe this vision in words, he opted just to smile and say, I could best sum up this vision o' mine by describing a structure I'd build.

"It'd be a pretty sweet structure, too," he'd say, and then he'd proceed to describe it. People nearby couldn't wait to be captivated. The description went something like this:




A Corporate Structure


The description started metaphorically, with the bricks and mortar of biotech.

“We've only just begun to see what is possible in that realm,” he said. He was convinced that biotechnology could resolve a host of global issues—from energy crises to dilemmas in medicine. “I think it will change the world.”





The scholar depicted biotech’s impact in the form of a corporate structure. Part of the structure’s elegance was grounded in the assortment of builders; not only would his own immediate knowledge of science be utilized, but so would the savvy of eccentric thinkers in semi-distant fields. Leaders like Steve Jobs and Howard Hughes would be called upon to contribute.

Ultimately, his biotech construction would house innovative energy and medical solutions for the masses and more who entered its doors...



A Salmon Head in Gelatin


You start with the foundation: a six-inch thick slab of orange jello, with chunks of mandarin orange for structural stability. Any shape you wish. But just before the gelatin's gelafied, stick a thin layer of cotton balls over the top. Stretch out each ball before placing it in the gelatin, so small bits of orange show through the top.


Cuz calm, really, is all about aesthetic.

Last comes the garnish, the flourish: the fish. One, solitary saffron salmon head placed in the very center of the masterpiece.




"I don't do buildings"




I don't build buildings, but rather, construct dreams. Painstakingly, meticulously, in the vision of their creator. There is honor in continuing a dream a la Sagrada Familia, but it is perhaps more noble to think for oneself, reinventing mistakes and reveling in errors as though you were the first to commit them, and the last to learn from them.




A Tree House




This tree house would span dozens of the most majestic trees as they stood sentinel around a crystalline mountain lake, stashed away, inaccessible to those who wouldn't appreciate and float in it, thinking of bouncing bubbles and butterflies (a little Zarathustra for you).

The lower branches of the trees would be bare, supporting only our floating house. The canopy would strategically part, illuminating airborne epiphanies and squirrels as they resonated joy throughout the air. The branches would sway in the slow breeze and torrents of time, making bridges for friends to cross, and coves for family to sleep...

The summers would be green and gold under the foliage, the winters blue and white among the skeletal remains.

During the fall we would starve, as who could remember to eat with such color and awe-inspiring death enveloping us? And during the spring we would cry, overwhelmed at the beauty of budding leaves, and blinking infant-eyes.

The bedrooms would grow at our whims. Instead of a rug I would have thigh high ferns, which would part as I walked around contemplating life. A massive hardwood desk would arise with it's back to the lake, a mossy chair cushioning my ass. A leafy canopy would darken my bed at night, giving only slightly, letting the Milky Way float down as I watched it sleep.

In the morning shafts of light would use laser capture techniques to juggle specks of dust, and as we focused in on the thousand dust particles no doubt could reach us, and any feat would become probable.

This house would stand as an open invitation to those who will it. An open forum for life. No one would stay for long, because those who know how to love such things know that there is unfulfilled life outside this ring of trees, but the lake and its shade would be there, and I would prune its branches as needed. And fertilize it... with my poop.




A Simple Rowboat




The sweetness of the structure lies in its stark simplicity. A simple rowboat of light maple and soft pine, the lines of the wood merge swan-like at the bow. As she rests on the water, she hovers on each crest of the wave, never more than a quarter inch beneath the surface. The oars lie propped and parallel on the seat, big enough only for one.

Smooth and as elegant, almost more so than the boat herself, the oars beckon to be taken and pulled. Despite the wind that so often batters the sea, the vessel an image of complete and total serenity and the oars remain motionless.

To the uninformed, the structure is a well-crafted boat. She is measured flawlessly, varnished perfectly, designed brilliantly. She is indisputably seaworthy. To those who know, she is an oasis and an escape. Sleek, and alive, each stroke of the oars brings the owner of the boat further into the horizon.

The oars push the boat to unimaginable speeds driving away the careless thoughts that clutter the everyday mind. The product of a still moment with high energy, the small boat closes the distance to the vision of superlative calm, a vision of azure and navy with cool borders.




A Structure in Flux


it isn't the kind of structure one man could build, or the type of structure that you could understand by looking at it for a moment in time.

This was a building wrapped in it's own history. From the very first date when the location was chosen those first pioneers could never have imagined what it looks like on this day.

From humble beginings it was a dirt hut. It was a convenient central location for the intersection of two river and a view of the mountains; a natural crossroads. Travelers from many lands would cross paths there to echange ideas.




As feat trod in and out so did hands help to expand the walls and support the roof. Over time the meeting place grew with every new idea brought in. At certain times individuals sheaperded renovating activities and at other times groups placed their stamp.

But each generation left their own improvements. New materials enabled further increases in architectural capability, but the core utility remained the same. It was a house of ideas built to incubate and hatch eggs of thought, and itself a reflection of the ever improving capability if it's inhabitants.

Truly a structure in flux. Though solid - always changing identity. A building not of brick and mortar, but supported by the cumulative thoughts and voices of those who had found shelter there. It was a forum for expression not just inside, but by it's very existence- symbol and example, standing for free expression within and without.

So when you see the high vaulted ceilings, know that the mural pays tribute to the great minds that once looked to that same point in wonder. See the cascading wall of water and reflect in the pool at it's base- though the fountain remains itself, there is never a moment when it is at rest.

Recognize that the green roof is an homage to the original mud hut and a testimony to the cyclical nature of thought; when ancient technology finds its way to the cutting edge. From the solar/geothermal internal temperature control system recognize that this building is connected to the earth, finding it's own equilibrium from natural ebb and flow. This is not just a structure build on the earth, but out of it and into it.

A house of innovation for innovation and built by it. A monument of human achievement but gracious through and through for the gifts of the natural world. A secular house of god, and shrine to aspirations of wisdom.




A bookshelf

It would be a bookshelf full of favorites and all the world's time to read. Beside the bookshelf, a hammock, and below the hammock, the wildest wildflowers reaching up to a slow, gold sunset.

No talking.























to be continued...and many thanks to those who have contributed :)

Predicting Hurricanes In a Warming World Words

Predicting Hurricane Risk in a Warming World

*This article highlights one catastrophe modeling firm's approach to predicting hurricane risk in the face of global warming.*

In recent years, devastating hurricane events like Andrew and Katrina have increased media attention on higher hurricane activity due to climatological factors, including global warming. The catastrophe modeling community is aware of the buzz, and while some among it question the influence of climate change, others believe the warming trend signals a new regime—one that calls for similarly radical changes to hurricane modeling methodology.

From AIR’s perspective, the debate is not whether climate factors have an influence on hurricanes; scientists tend to concede that they do. If there is any debate at all, it is on how to provide insurance companies concerned with deriving reliable results from catastrophe models with the latest science, particularly that of the influence of elevated sea-surface temperatures (SSTs) in the Atlantic.

The Atlantic basin has been in an active phase since 1995. This phase is characterized by above long-term average hurricane activity. Some scientists, like those at the National Oceanic and Atmospheric Administration, associate this with the warm phase of the Atlantic Multidecadal Oscillation (AMO), a climate signal measuring the change in North Atlantic SSTs. The AMO is just one of several measures of Atlantic sea-surface temperature anomalies, but other measures indicate warming trends now, too.

At AIR, climate scientists have been monitoring the relationship between global warming and Atlantic hurricane frequency since the early 1990s. They stay abreast of the latest scientific literature on the AMO and other climate signals, evaluate related findings, and conduct research of their own. In 2005, AIR meteorologists undertook new and extensive analyses of the link between elevated SSTs in the Atlantic and landfall frequency and location—a research effort that is still ongoing. The result was a near-term hurricane catalog released in April 2006.

Unlike AIR’s standard catalog, based on over a century’s worth of hurricane data and more than 20 years of research and development, the near-term version relies solely on hurricane statistics from 2004 and 2005—seasons of notable Atlantic intensity. But despite general consensus as to the impact of warming seas in these years, standard use of a near-term catalog inspired by recent storm trends remains controversial. That’s largely because researchers have not yet translated their finding regarding a jump in Atlantic hurricane intensity into information useful to insurance companies—a percentage increase in foreseeable insured hurricane losses on land.

To date, the primary focus of investigation has been on basinwide storms, leaving landfall trends unexplored. If hurricane risk is to be assessed with a high degree of confidence, however, the relationship between hurricane activity in the Atlantic, landfall activity, and regional insured losses will require significant additional investigation. AIR meteorological teams are making great strides on this front.

Meanwhile, in the face of uncertainty around the near-term view—the methodology of which is currently undergoing rigorous review by peers—AIR maintains that a short-term model offers a valuable perspective from which to manage hurricane risk. The issue then becomes how to offer this untested model to insurance companies.

When it was first released in 2006, AIR made the scientific judgment to keep the near-term catalog separate from its standard version. By doing so, it did not impose a new model with high uncertainty on its clients, but instead allowed them to choose for themselves just how they wanted to use the model’s new information in their decision making processes.

This year, AIR will make the same provision—offering the near-term catalog as a supplement to its long-term model, rather than a replacement. Interestingly enough, the long-term model is scrutinized, too. It has occasionally been characterized as “backward looking” because it incorporates data from 100+ years, but this judgment requires inspection. The purpose of using historical data is not to reproduce the past, but to better estimate what may happen in the future. Along those lines, AIR’s standard catalog provides clients with scenarios that could happen in upcoming storm seasons even though they have not happened before—scenarios that include both more intense storms and years with more landfalls than have been historically seen. Ideally, nothing should happen that the model does not account for, and the AIR model for U.S. hurricanes has performed very well in this regard.

.MGW.

9/11 Animation EngineeringWords

Most Americans think they know what brought down the World Trade Center on September 11, 2001, but civil engineers aren't so sure. They're still seeking answers--answers that could save lives in future attacks--and the search continues with the help of a state-of-the-art animated visualization created by researchers at Purdue University.

Investigators at Purdue's Rosen Center for Advanced Computing have created an animation they say reveals more information than could be conveyed through a scientific simulation alone.

While a scientific simulation shows details essential to an engineer--the structural damage caused by a plane tearing through several stories of the World Trade Center within a half-second--it doesn't deliver details useful to a layperson, such as flames and smoke. In the animation, these details are clearly rendered, and that's important.

A damage picture that lacks them is scientifically inaccurate.

When a plane hits a building, it moves through the structure like flaming lava; the kinetic energy of the fuel associated with the moving aircraft causes a significant portion of damage. Thorough examination of the 9/11 attack on the World Trade Center revealed that the weight of the 10,000 gallons of fuel--more than the impact of the crash--caused the building's collapse. In fact, if it hadn't been for the fuel-driven fire, the structural damage to the WTC's north tower might haven been much less, comparable to that seen had the crashing aircraft been filled with water.

Purdue's animation detailing the impact of fire is the latest in a series of post-9/11 projects by the university team. The team's goal is to identify the structural damage that occurs when an airplane collides with a building, and ultimately, to prepare builders to design structures that will stand up to anything--even terror.

.MGW.

View o' the Charles

Charles River


.MGW.

Tides Need Moon Words

--Tides Need Moon--

Tides need moon for motion,
Waves want wind to be.
Politicians make decisions;
They need currency.

Shoots need sun to shoot up.
Roots reach but need earth.
Laissez-faire needs freedom,
As do I--for mirth!

I call for salty looseness
Of Gibraltar gales and hues,
And repartee, and severance
From small and tiny views.

.MGW.

Chinese Typhoon Words

Modeling Typhoon Risk in China




Nowhere else in the world are typhoons more frequent than off China’s coast, in the Northwest Pacific basin.

The word typhoon stems from the Chinese JuFeng which originated in 5th century Chinese literature to mean “scary wind.” While typhoons in China certainly cause significant wind damage, the torrential rainfalls that accompany many typhoons also cause considerable damage from flooding. At work these days, I'm writing articles that provide an overview of China’s typhoon hazard, as well as the vulnerability of the Chinese building stock to typhoon-induced wind and flood.


.MGW.

Old Complications Rising Words

Old Complications on the Rise:
Anesthesiologists, Are we as good as we think?

[Will post in full after published in Anesthesiology News]

Despite vast improvements in surgical and anesthetic practice, a new trio of studies makes it appear that anesthesiology may have a ways to go. Advances in technology have seemingly contributed to increases in old anesthesia-related complications. At least, that's what these findings—highlighted by three abstracts presented in March at the International Anesthesia Research Society's (IARS) 81rst Congress—would initially suggest.

The abstracts, each based on a database of more than 37,000,000 patients assembled by the Agency for Healthcare Research and Quality (AHRQ), discussed rising trends in three areas: postoperative respiratory failure (PORF), anesthetic complications, and postoperative septic shock (POSS). The first complication, PORF, actually doubled from 1994 to 2003, increasing from two to four percent.

“We would not have anticipated an increase in PORF, let alone one so pronounced,” said this study’s lead author, Mark Nunnally, MD, an anesthesiologist at The University of Chicago, where all three studies were based. “Our effort now is directed at uncovering as much as we can about why this finding exists in a database this size.”

Recent investigations have associated increased PORF with age; patients over 45 are more susceptible. Other contributing factors have included patient incomes below $25,000, care from non-metropolitan hospitals, and use of Medicare or Medicaid versus private insurance.

As anesthesiologists consider why PORF and other old complications are getting worse, one point seems clear: surgical and anesthetic techniques are not to blame...


.MGW.

26.2 Words

In your element
you can be
as fierce
and as fast
as your will can see...

.mgw.

Wrinkles in TimeWords

Wrinkles in Time in the OR:
A Call for Synchronized Clocks



Wrinkles in timekeeping can cost hospitals big bucks. Lawsuits and compliance issues are just two problems stemming from imprecise timestamps—a consequence of nurses, anesthesiologists, and other healthcare providers recording times from unsynchronized clocks.

“I’ve been in many medical institutions where all the clocks are different,” said anesthesiologist Michael Jopling, MD, Chairman of Anesthesiology at Mount Carmel St. Ann's Hospital in Columbus, Ohio, and President of the Society of Technology in Anesthesia (STA). “This is very frustrating. It creates a big problem for record keeping.”

But even synchronization of clocks—including those in computers and physiological monitors, as well as clocks on walls—wouldn’t iron every last wrinkle in the hospital timekeeping dilemma. There’s yet another fold.

This March, thanks to the Energy Policy Act of 2005, Daylight Saving Time (DST) will begin three weeks early—a move meant to reduce energy consumption. Unfortunately, the time change has unintended consequences. Devices with clocks not programmed to make the DST transition could supply incorrect timestamps for weeks.

Now, specialists at Geisinger Medical Center in Danville, Pennsylvania are teaming up to tackle both problems—starting with synchronization. Anesthesiologist Mark Poler, MD, is spearheading the movement. He has been instrumental in encouraging Geisinger to replace independent time pieces with those that are specially synchronized.

The devices, known as Primex radio-synchronized clocks, have base stations that acquire time from Global Positioning System (GPS) satellites in orbit. The base stations are positioned throughout the hospital and use a radio transmission on a licensed frequency to rebroadcast time to clocks equipped with special receivers.

Dr. Poler’s interest in bringing Primex clocks to Geisinger was spurred by troublesome trends he’s noticed in the operating room (OR). “People keep time by their wrist watches,” he said. “Others take times from clocks on the walls that don’t run at the same speed because nobody’s bothered to set them.”

This lack of synchronization means that a patient leaving the OR at 10:12 in the morning could magically arrive in the recovery room at 10:05am—a mysterious step back in time.

To further confuse matters, Dr. Poler explained that computers used to record the duration of medical procedures have clocks in them which may or may not be synchronized to each other either, let alone to clocks on the wall. This is also the case for physiological monitors that measure heart rate and blood pressure and .often do not have network ports or software to facilitate synchronization to a reference standard.

But what really got him thinking about the synchronization problem was a financial concern: the realization risk that Geisinger was overcharging Medicare due to erroneous calculations of elapsed time from unsynchronized clocks.

Determination of elapsed time in the OR affects billing; errors can have major financial consequences. In particular, underestimating time results in less time billed and lost hospital revenue, and overestimating chargeable time is a compliance issue punishable as fraud. All medical institutions walk a fine line between justifying charges based on time of rendered services versus taking great care not to overcharge.
.
While reviewing the record books at Geisinger, Dr. Poler observed that certain short procedures occurring over midnight and lasting only 15 minutes were instead logged at 15 45 minutes and 23 hours. This happened because timekeeping operating room management software was unable to handle the transition to a new date at midnight. Subsequently, checks and procedures had to be put in place for the billing process.

Meanwhile, mistakes like these—which are due in part to lack of clock synching—could lead to billing thousands of additional dollars in one hospital.

“When hospitals bill time to Medicare or insurance companies, they do not want to bill for time that didn’t actually occur,” said Dr. Jopling. “This is a compliance issue, and it’s grounds for huge penalties.” Mistakes in timekeeping have lead to thousands of additional dollars being billed in one hospital.


Needless to say, compliance with medical regulations is a critical motivation, which Geisinger has actively pursued, for synchronizing clocks. A second major impetus is avoiding lawsuits.

“It’s interesting—the clock rarely causes problems for the actual patient, but discrepancies in timekeeping can provide a field day for lawyers who misinterpret records,” said Michael O’Reilly, MD, an anesthesiologist at The University of Michigan Health System in Ann Arbor.

Dr. O’Reilly explained that healthcare workers trying to reconstruct an operating room event for the medical record book write a timeline. “When the timeline reflects gaps or inconsistencies,” he said, “people can be sued.”

Random elements in timekeeping can be misconstrued as incompetence on the part of the physician. “If you’re talking about delivering a baby by emergency C-section,” said Dr. Poler, “and the delivery actually happened in 5 minutes, but according to the clocks it was 13, and then the baby isn’t born perfectly, the attorney could say the surgeons were slow and inept.” In fact, the procedure actually happened efficiently and there was nothing the surgeons could have done to make that baby’s outcome good.

Dr. Poler believes the cost of synchronizing clocks at hospitals could be trivial compared to the money hospitals save in lawsuits.

Meanwhile, it’s possible that the money Congress hoped to save in oil consumption by initiating the Energy of Act of 2005 could be paid to technology specialists called to update timekeeping devices, including devices at hospitals.

“The change in the dates for Daylight Saving Time is extremely sticky and has the potential to deliver some of the chaos that was predicted for Y2K,” said Robert Murcek, Director of Network Infrastructure and Support at Geisinger.

Employees unaware of the new legislation might not know the correct weekend to make the time change. In hospitals, this means that lab computers could be updated while OR clocks are forgotten, or vice versa. Time stamps could be misplaced by an hour on blood pressures and heart rates. Billing departments could charge for an extra hour of operating room care. The list goes on and on.

“The real consequence of the time change,” said Dr. Poler, “is that people must be aware that it will occur and that the clocks they have are either going to handle it correctly or not at all—and they probably all won’t do the same thing.” At the last Daylight Saving Time change, most Primex clocks made the expected adjustment. However some did not “fall back,” demonstrating that the system is not foolproof. Dr. Poler said that pairs of analog clocks within a foot of each other have been reported to show a one hour time difference. Meanwhile, digital clocks that lose the synchronization signal at a time change simply start to display dashes.

He is hopeful that the Primex clocks will handle the transition to the early DST, as the clock makers have promised.

Dave Thewlis, Executive Director of Calconnect—an IT consortium of calendaring and scheduling systems, vendors, and customers which is working towards interoperability between different systems—says the time change doesn’t have to be a headache if people prepare.

Most software vendors are publishing notices telling their customers whether or not there’s a problem with their individual programs. “My advice is to check with your software vendor about updates,” said Thewlis. “If an update has to happen, make sure it happens prior to March 11th—the first day of the new Daylight Saving Time. If a program doesn’t need an update, get it in writing. The last thing you’d want to do is have someone say you don’t have anything to worry about when you really do need to update the software, especially in the medical profession.”

Administrators at Geisinger are already checking with software vendors, according to Mr. Murcek, to ensure that applications receive necessary updates.

Meanwhile, all this watching of the clock is a headache for physicians. “We spend a lot of time doing clerical timekeeping work and we want to reduce that,” said Dr. Jopling. “We’d rather be engaged with the patient.”

This may be possible someday. There is talk of employing a tracking device that would instantaneously record everything from when a patient receives a drug to when he enters the recovery room. Until then, though, each tick of the clock must be carefully recorded.

“We’re really coming into a transition period right now,” said Dr. Jopling. “Some hospitals have a computerized, paperless process and others are more paper-based, but as we start to move forward, one thing’s for sure: we need all of our medical devices to be synchronized.”

.MGW.

CoverWords

Bottom left cover of February's "Anesthesiology News": Surge in Coated Stents Raising Issues For Anesthesiologists.

(that's me...wheee!)

.MGW.

Weaker than EuclideanWords

I'm helping a grad student at UCSB draft a letter to "Nature" that will highlight exciting elements of 3 years of research he undertook in the Virtual Reality Lab while an undergrad at Brown University. His research seeks to understand the geometry underlying cognitive maps. In other words, he wants to know what kind of math humans use to navigate the world.

Previous studies say it's standard metric geometry, but he's not so sure...

Introduction only:

To understand how we as humans navigate our surroundings—to find detours, for example, or simply to walk next door—many researchers have first tried to understand how we represent the world mentally, in our heads. Researchers have sought to do this since 1948, when the term “cognitive map” was first introduced.

To date, every study assumes that humans impose a metric structure on mental representations of space. In other words, in order to navigate, we depend on knowledge of distances and directions between learned places along a one-dimensional route or in a two-dimensional environment. This outwardly logical assumption advocating metric structure is grounded in a series of experiments which shaped the constraints of cognitive maps, starting with visual tests performed by Shephard & Metzler in 1971.

Shephard and Metzler asked individuals to look at two shapes and decide as quickly as possible whether the two were the same. If the shapes were in the same view point, participants could identify matches within a second. When shapes were rotated at different angles, however, participants took noticeably longer to identify sameness.

A similar experiment by Bundensen, Larsen, & Farrel in 1981 using rectangles sized at different ratios gave concurring results; participants took longer to identify sameness the greater the scale adjustment—up or down—of the rectangle.

Together, these two studies seemed to imply that when we perceive an object in the world, we do it so accurately that we then have an almost physical copy, or map, in our brains. This was further affirmed by Kosslyn, Ball, & Reiser in 1978. They found that participants asked to memorize a map and then mentally scan from different target locations took longer to scan from objects the further apart they had been.

In 1976, Chedru localized where in the brain spatial maps exist by studying patients with spatial neglect—a condition in which an individual’s visual field is bisected by a vertical line. Chedru concluded that perception of space is dependent on location in the visual field, further laying the groundwork for our understanding of constraints on a cognitive map. His findings also indicated that processes related to spatial perception occur in the parietal lobe.

Studies by Taylor & Tversky in 1992 revealed that humans can learn a new environment equally well independent of their method of learning. The researchers taught participants the layout of a park using one of two methods—verbal description of a route navigation, or verbal description of a survey view. Participants then had to say whether statements about the layout of the park were true or false and they had uniform success despite different learning methods.

Learning our surroundings does seem to benefit from some physical input. Presson and Montello (1994) and Resier (1989) asked participants to imagine walking from home to point A, and then to point B. They then had to indicate the direction from point B back to home again, and they were consistently incorrect.

In a different experiment, when participants actually walked the route—from home to A, and A to B—the physical action of walking greatly improved their ability to indicate the direction from B to home.

The researchers doing this experiment concluded that we live in a physical world such that without physical inputs, we cannot construct an accurate mental representation of space (Klatzky, Loomis, Beall, Chance & Golledge).

Despite the number of studies pointing to metric structure as the basis of wayfinding ability, it is possible that cognitive maps are based on a less stringent geometry and in turn, have a less defined shape. The apparently metric behavior associated with navigation could in fact be accounted for by adaptive strategies based on topological geometry, which relies not on knowledge of distances and directions between learned places but on knowledge of environmental features—places, junctions, and landmarks.

This latter notion dissociates spatial knowledge from Euclidean geometry and opens the forum to progressively weaker geometries, which preserve fewer of the properties that remain invariant in metric structure. A cognitive map based on constraints of such geometries might only preserve ordinal structure, such as the adjacency relationships among neighborhoods, or relationships between places based on interlinking paths. Shortcuts and detours could be derived from knowledge of the connectivity or neighborhood structure together with visible landmarks.

The recent development of ambulatory virtual environments makes it possible to study the spatial knowledge used during actual navigation and in particular, to analyze the hypothesis that a geometry other than Euclidean facilitates human wayfinding...

.MGW.

CancerStemCellNicheWords

--Sacking the Cancer Stem Cell Neighborhood--

[This article was posted on "Science Magazine's" website today, to coincide with the embargoed release of a paper from "Cancer Cell."]

Scientists have found the Achilles heel of a special class of cells that jump starts tumor growth. According to a new study, targeting the niche where they live is the key to destroying these previously invincible cells. This insight paves the way for more effective cancer therapy.

Until recently, researchers believed that all cells in a tumor were pretty much the same. But in the early 1990s, a team at the University of Toronto found some interesting characters hanging out in a population of leukemia cells: instead of rapidly dividing like their companions, about one in every million leukemia cells was capable of maintaining itself in a culture dish without differentiating and then initiating tumor growth when transplanted. These were indications that the cell was likely a stem cell.

Since then, researchers have discovered similar stem cells—including those behind acute myeloma leukemia, two brain cancers, and breast cancer—but no drug to date has successfully eliminated CSCs, which infinitely renew themselves and generate cells to replenish the tumor even after the bulk of it has been eliminated by chemotherapy or radiation. CSCs can do this in part because they grow at a sluggish rate, rendering them insensitive to conventional therapies designed to target rapidly dividing cells.

Now, researchers lead by neurobiologist Richard Gilbertson at St. Jude Children's Research Hospital in Memphis, Tennessee, have found a way to target cancer stem cells independently from the bulk of the tumor. They did so by looking for similarities between these stem cells and non-cancerous neural stem cells. Neural stem cells—immature cell masses that give rise to more specialized cells that form nerve tissue—are concentrated in blood vessel-rich regions called "vascular niches." These regions are lined with endothelial cells, which secrete chemical signals that promote stem cell survival. Gilbertson's team inferred that cancer stem cells might require a similar niche.

Sure enough, after examining a large cohort of human brain tumors, the researchers found that cancer stem cells were frequently located close to capillaries—the body's tiniest blood vessels. When the researchers injected human brain tumor cells called medulloblastomas together with endothelial cells in mice, the animals sprouted larger tumors than mice receiving tumor cells alone, the team reports today in Cancer Cell. This experiment further supports the role of endothelial cells and the vascular niche in providing signals that promote tumor growth.

Additionally, in tumor-bearing mice, drugs used to deplete blood vessels caused a significant drop in CSCs and subsequently inhibited tumor growth. The same vessel-killing drugs hardly effected the survival of cells in rest of the tumor, confirming that CSCs require a vascular niche.

"This study is an excellent example of bringing stem cell insight to cancer," says Richard Wechsler-Reya, a cancer biologist at Duke University Medical Center in Durham, North Carolina. "I think this is going to be the beginning of a really popular approach to treating cancer stem cells."

.MGW.

Gotta See About a MountainWords

[Fiction]

Manhattan smelled of snow the morning I decided to leave it---not for eternity though, just for the weekend. The weather was right for skiing.

And without thinking about the work I'd miss or the stories needing my time, I threw my warmest fleece in a backpack, grabbed the pod, and sat down at my MAC: "Dear Editor and colleagues, I'll talk to you next week. Gotta see about a mountain, Meagan."

That morning, as New York highways turned into New Hampshire roads, the wintery sky above my car was as resistant to categorization as any sunrise scene I'd ever known. Gray clouds--fat and stoic--formed castles in the air, while whiter, wispy things lingered oddly outside their gates. Together these fat and small clouds barely veiled a pink sun, and I looked at it often and in spurts--a routine I kept up all the way to New Hampshire.

The cloud castle gates had closed on the sun when my car finally stopped. I wasn't in a parking lot though. And I wasn't at a ski resort. I had stopped at a footpath leading to a mountain named by no map. Just a mountain somewhere. I'd seen it from a distance once and thought it might want to be visited by someone willing to climb.

Snow made my climb especially quiet that dark afternoon; no sounds but my own deep breaths and the occasional hawk. The hawks were watching me but I was watching the view, and the way the mountain slope was slipping into a misty depth with my each upward step.

It was a steep mountain, that's for certain, but I hoped it would slip steeper still on the opposite face. When I got there and threw down my pack, I was glad to see just that. It was peace enough for the moment--hunting and finding a great decline. So I enjoyed it, but not by skiing down on the skis I'd brought. Instead, I opened my backpack and took out a book.

Like the mountaintop, this book had no name. Its pages weren't filled and there was no preface. There was no author either--not until the pink sun peeked out from cloud castle gates and blinded all wild eyes on the mountaintop. That's when I was moved to pen something--fast and strong--on those very blank pages. I authored the book, writing something so raw and true it might have been just like a hawk's pulse in flight.

I felt easy...

Before too long, I grabbed the book and my pack and flew down the mountain on a slope skiied only by wintering deer. And perhaps it was the wind's kiss or the birds closely watching, but I had never felt so alive.

.MGW.

Scientist As RebelWords

Freeman Dyson may be short in stature--or so he seemed when I met him last year--but his accomplishments are undeniably tall. A former member of England's Royal Air Force, a longtime physics professor at Princeton, and a distinguished scientist with a bent for elegant mathematics, this Brit also has a way with words; he is lovely writer.

In Dyson's newest book, The Scientist as Rebel, the seasoned physicist speaks to the nature of scientists throughout the ages. "From Galileo to today's amateur astronomers, scientists have been rebels," he writes. They are free spirits, like artists and poets, casting off the restrictions their cultures impose. In their hunt for Nature's truths, they are guided as much by imagination as by reason, and their brightest theories have the uniqueness and beauty of great works of art.

Dyson affirms that the best way to understand science is by understanding those who practice it. He tells stories of scientists at work, and looks with a skeptical eye at fashionable scientific trends.

Dyson also reflects on broader philosophical issues--the limits of reductionism, the morality of nuclear bombing, the preservation of the environment...

This charming scientist offers a fresh and eloquent perspective on today's topics of scientific debate, as well as a narrative that highlights the finer linings of some of the greatest minds of all time.

.MGW.

InterestAndStrengthWords

“Love many things, for therein lies the true strength, and whosoever loves much performs much, and can accomplish much, and what is done in love is done well.” --Vincent Van Gogh

"A large volume of adventures may be grasped within this little span of life, by him who interests his heart in everything." --Laurence Sterne

I aspire.

.MGW.

WildernessWords

Caledonia-my home sweet home






"In wilderness lies the preservation of the world." HD Thoreau

Anti-CancerWords

In the pipeline...

Researchers at Hopkins have created a hybrid molecule that causes cancer cells to self-destruct. The recipe: a sugar + a fatty acid called butyrate.

Butyrate slows the spread ofcancer cells, which scientists have known for 20 years. Unfortunately, attempts to use this molecule as a general drug for tumors haven't worked well because of the need for exceedingly high doses.

To get around the dosage problem, scientists have tried to make butyrate more potent by modifying it or joining it to other compounds. Results have been disappointing though; there are toxic side effects associated with partner molecules.

Now, Gopalan Sampathkumar, a postdoctoral fellow in JHU's Department of Biomedical Engineering, has found that when butyrate is matched with just the right sugar, the resultant hybrid molecule acts like a cancer-killing weapon, wiping out every cancer cell in its immediate path within about 15 days.

This is not the first time scientists have tried combining butyrate with sugars, but the sugars used previously just eased the delivery process, helping the hybrid molecule get into the cancer cell. Sampathkumar was more selective. He chose a sugar called cetyl-D-mannosamine, or ManNAc, which acts like ammunition in the cancer-killing process. It helps enzymes to resume the normal assembly of sugar molecules, which often goes awry when cancer occurs.

Meanwhile, the butyrate half of the hybrid molecule corrects aberrant gene expression. The result is a double attack, triggering just what the doctors ordered: cancer cell suicide.

More to come after I talk with the docs. This hasn't yet been tested in humans or animals and I'd like to know what the prospects are for this cancer-killing strategy in our generation.

.MGW.

Arcos De La FronteraWords

-Arcos de La Frontera: Red Puppet in a White City-


[This is an archived piece. I wrote it after a particularly lively trip during my travels in Spain.]

I had never ridden a mule, and the man had no teeth. I think that’s what made it so easy; we were both unsure. But he smiled at me, a visitor, as I mounted that mule, and I thought I could not soon be higher than this—on a mule’s back on a hilltop whose skirts were sheer rock.

This hilltop, a fine point of defense, had drawn Moors to Arcos, but it had not drawn me. I had come to Spain’s most dramatically perched pueblo—a pueblo blanco—because I wanted to walk narrow streets of a town too old to wake up. I wanted to see its cobblestones and its whitewashed homes, and know who lived inside.

This toothless man did not, though I was lucky to meet him. He lived below, where sheer rock plunged to dirt. The dirt, like the hilltop, had tempted the Moors; it was fertile and rich, and I could tell from one green glimpse that it was the dirt’s fruit that had fattened the mule.

He was most certainly fat, and I was uncomfortable. But I smiled despite it, with all of my teeth, and held tight as the man pulled his beast through the streets. In Arcos, the streets are strikingly narrow. Lined with small elegant homes and wrought ironed gates, they are not meant for creatures so fat.

As my feet brushed white plaster, I wondered why nobleman had not wanted streets sufficiently wide for grand carts and carriages. Perhaps they’d been happy to walk.

Men like the man who pulled me that day could have walked four by four; unlike his mule, he was thin as the gates. I watched him amble—lovely, light steps—and the only sound in the town was mule hoof on street.

Now he didn’t know me and I didn’t know him but my backpack probably explained a lot, and my eagerness, too. And I’m certain my Spanish—blunt and not sweet—had helped earn me free passage that day. But I was content to be thought a traveler. Afterall, I was just that, and maybe, I thought, maybe he knew who lived behind these white walls, where I could sit and bite olives.

Olives are Arcos and oranges are, too. Their scents haunt the air; I couldn’t stop smelling. But I stopped when he stopped. The man pulling me stopped in the middle of town and reached into a bag on his old leather belt. He pulled out a thing which I would not think men tote—a puppet, tiny and brown, but a little bit red. Red where someone had painted his shirt.

And then, as bulls do, the children came out. They came out of white doors to see that red puppet. The square held them there; a square lined with benches and guarded by trees, but not olive trees. These were orange trees. But not the oranges you eat. These oranges were stored in barrels on ships and then made into marmalade, and they were also good for tossing. My senora had explained that. And I guessed that these children tossed them often and happily, and probably off of the hilltop.

The oranges were pale though, compared to the puppet. The children knew what he could do, and they watched the thin man and I watched him, too, as he made his puppet walk. He hadn’t bothered to tie up his mule, and I sat on its back—fat and heaving—and wondered if the man was a farmer or just a minstrel that made children laugh.

I laughed, but not too much, because my eyes looked away. I looked at the children and their bronzed skin. Their simple eyes wide and bright, very bright. I thought they must play hard and sleep well at night. Most of them were thin, like the man, though their laughter was fat. It echoed off white walls ‘til one mother called: que te vengas!

It was six o’clock.

I think I got lucky that day; I dismounted my mule and received an invite to eat olives inside white doors. I don’t think I’ve ever known olives so good—an old taste that lingers. Old like Arcos and fat like the mule. And full like the children, who laughed at the table and questioned my speech. I told them everything about my home. They wanted to know this, for they’d never seen it. I will never forget seeing theirs.








.MGW.

FDA PanelWords

--Drug-Eluting Stents Not Safe for All...Yet--

[This piece is a continuation of an investigation I'm doing for Anesthesiology News in light of the FDA panel that convened earlier this month.]

A man who underwent hip surgery seven weeks after receiving a drug-eluting stent experienced a heart attack within 12 hours of his hip procedure, according to a study published last month in the Journal of Clinical Anesthesia.

Presumably, the heart attack was a result of discontinuing Plavix®—the anti-clotting medication required after placement of a drug-eluting stent.

Providing adequate surgical care for patients with drug-eluting stents is a big issue,” said the study’s lead author, Mayo Clinic anesthesiologist Michael Brown.

This issue surfaces amidst general controversy over drug-eluting stents. Earlier this month, the FDA convened a two-day panel in Gaithersburg, Maryland, to evaluate the safety of these devices, which now prop open the arteries of 3 million Americans.

Unlike conventional stents, drug-eluting stents ooze chemicals designed to battle restenosis, or renarrowing. But the chemicals they spew not only prevent the growth of artery-clogging cells, they also inhibit cells that would naturally fight clotting.

This means that patients with drug-eluting stents suffer suppressed anti-clotting systems and should stay on medications like Plavix for several months to a year.

According to Roger Moore, vice president of the American Association of Anesthesiologists, people on anti-clotting medication present unique challenges for anesthesiologists. That’s because anti-clotting drugs reduce the tendency to clot at the expense of bleeding—a risk inherently high during surgery. As such, patients on medications like Plavix are often recommended to discontinue their regimens before surgery.

But without Plavix, clotting risks skyrocket, and clotting—unlike restenosis—is linked to heart attacks, and even death.

The FDA panel in Gaithersburg sought to determine how likely drug-eluting stents are to cause long-term blood clots, and what should be done. While the American Heart Association recommends at least 3 to 6 months of Plavix treatment following drug-eluting stent placement, the optimal duration of this medication has not yet been established. The Gaithersburg panel meeting marked the first time the FDA sought the help of anesthesiologists and surgeons to inform such guidelines.

During the trial, presentations by doctors and stent manufacturers and data from numerous studies verified that drug-eluting stents increase clotting—both for approved patients, as well as for those who are “off-label.” Despite clotting risks, however, the panel concluded that drug-eluting stents are safe, as long as they’re used in conjunction with anti-clotting medication and in the intended population.

But—as evidenced by Michael Brown’s study—drug-coated stents cause problems even within the FDA-approved group when people who have them undergo surgery.

“The fact of the matter is that more and more people will be getting drug-eluting stents,” said Richard Shemin, a cardiac surgeon who was present on the FDA panel, “and surgeons and anesthesiologists are going to have to learn how to take care of people who have them.”

The most obvious strategy, according to Dr. Moore, is to postpone surgical procedures during the 6 month window directly after stenting.”

If surgery is emergent, however, a preoperative cardiology consultation is the next best approach.

“Communication between the surgical team and the cardiologist who placed the stent is vital,” said Sanjay Kaul, Director of the Vascular Physiology and Thrombosis Research Laboratory at Cedars-Sinai Medical Center in Los Angeles. His medical center has formed a Plavix Taskforce Committee to encourage interdisciplinary discussion.

“The problem now is that too often these conversations don’t take place,”
said Thomas Slater, an interventional cardiologist at NYU’s Tisch Hospital in Manhattan. He emphasized the need for anesthesiologists to consult with a patient’s cardiologist to understand the trade-off between the risk of stent thrombosis, or clotting, versus the risk of surgical bleeding.

“Anesthesiologists should learn why and when the stent was placed, how big it was, and how long the patient has been on anti-clotting medication,” said Dr. Slater. The risk of stent thrombosis is contingent upon these factors, as well as others such as presentation of the initial acute coronary syndrome, vessel lesions, bifurcation stenting, and an underdeployed stent.

In patients for whom the clotting risk is low, discontinuing Plavix to avoid excessive bleeding is less of a concern. For patients at an increased risk, however, remaining on anti-clotting medication during surgery should be a definite consideration.

And there are other ways anesthesiologists and surgeons can make the operating room safer for patients with drug-eluting stents.

For example, while stenting may have successfully opened significant obstructions in a patient’s major coronary arteries, obstructions could still exist in coronary arteries in the periphery. “This needs to be considered in approaches to anesthetic management,” said Dr. Moore.

He said that anesthesiologists operating on patients with drug-eluting stents should also avoid anesthetic techniques that could increase bleeding in areas already sensitized to it by Plavix. Additionally, anesthesiologists should monitor a patient’s cardiac status since any patient with a stent has previously had cardiac disease, which the stent may not have cured.

Finally, a study published this month in the Canadian Journal of Anesthesia discusses the potential for new anti-clotting medications—drugs with predictably short onsets and offsets of anti-clotting action. A patient on such a drug could stop the long-acting antiplatelet agent and switch to the short-acting, reversible one before surgery, to minimize bleeding. The short-acting agent could even be continued throughout the surgical procedure if the bleeding incurred was not excessive.

“Ultimately, drug-eluting stents are still great devices as long as patients who have them are well-managed in a surgical setting,” said Dr. Shemin. “With time and experience, as well as the willingness of specialists to communicate, we’ll know better how to do that.”


.MGW.

Making "Safe" Stents SaferWords

--The key to making “safe” drug-eluting stents safer--

When it comes to tackling matters of the diseased heart, like clogged arteries, drug-eluting stents have rapidly become standard procedure. After hitting the market in 2003, these medical devices now prop open the arteries of 3 million Americans.

Earlier this month, however, the FDA convened a panel to evaluate their safety. These metal tubes—which ooze tissue-killing chemicals into arteries—do an extraordinary job of fighting the re-clogging associated with conventional stents, but they have also been linked to clotting, a phenomenon that can lead to heart attacks, and even death.

Clotting occurs more readily with drug-eluting stents because chemicals in the stent coating are nonselective; they inhibit the growth of harmful artery-clogging cells, as well as growth of cells that would fight clotting naturally.

Despite ties to clotting, the FDA panel concluded on December 8th that drug-eluting stents are safe, as long as they’re used in conjunction with anti-clotting medication, and in the intended population. But risks still loom; even within this approved group, drug-coated stents are causing quite a stir for a particular set of people—those who undergo noncardiac surgeries shortly after stenting.

“Surgery appears to carry a greater risk for these patients than we saw in patients with bare metal stents,” said Deepak Bhatt, Director of the Interventional Cardiology Fellowship at the Cleveland Clinic in Ohio.

That’s because Plavix—the anti-clotting medication required after drug-eluting stent placement—increases bleeding. And since the risk for bleeding is naturally higher during surgery, patients on Plavix should stop taking it before an operation. Without this medication though, the likelihood of harmful clotting skyrockets.

Herein lies the trade-off for people with drug-eluting stents who undergo surgery: stay on Plavix and bleed, or discontinue it, and clot.

According to Richard Shemin, a cardiac surgeon present on this month’s FDA panel, “the fact of the matter remains that more and more patients are getting drug-eluting stents, so surgeons and anesthesiologists are going to have learn how to take care of [complications in] people who have them.”

This becomes especially apparent in light of studies like one published last month in The Journal of Clinical Anesthesia, which reports that a man who underwent hip surgery seven weeks after receiving a drug-eluting stent experienced a heart attack within 12 hours of his hip procedure, presumably due to the clots that formed as a result of discontinuing Plavix.

“This is a big issue,” said the study’s lead author, Mayo Clinic anesthesiologist Michael Brown. “People outside the cardiology realm don't really appreciate the difference between a conventional bare-metal stent and a drug-eluting one, let alone the problems associated with a drug-eluting stent during an operation.”

The good news for patients with drug-eluting stents is that there are ways for physicians to improve safety in the operating room.

“The most obvious strategy,” said Richard Moore, Vice President of the American Society of Anesthesiologists, “is to postpone surgical procedures during the 6 month window directly after stenting. That’s when the patient is undergoing the most intense anti-clotting therapy.”

If surgery is emergent, however, a preoperative cardiology consultation is the next best approach.

“Communication between the surgical team and the cardiologist who placed the stent is vital,” said Sanjay Kaul, Director of the Vascular Physiology and Thrombosis Research Laboratory at Cedars-Sinai Medical Center in Los Angeles. “The problem now is that too often, these conversations don’t take place.”

Dr. Kaul says that anesthesiologists need to consult cardiologists before stopping Plavix.

“They should confer with the cardiologist to understand why the stent was placed, when it was placed, how big it was, and how long the patient has been on anti-clotting medication.” This information helps determine a patient’s clotting risk. For some, it’s relatively low. For others, it’s higher, and remaining on anti-clotting medication during surgery should be a definite consideration, despite chances of bleeding.

Dr. Moore says that anesthesiologists operating on patients with drug-eluting stents should also avoid techniques that could increase bleeding in areas already sensitized to it by Plavix. Additionally, anesthesiologists should monitor a patient’s cardiac status since any patient with a stent has previously had cardiac disease, which the stent may not have cured.

“Ultimately, drug-eluting stents are still good devices as long as patients who have them are well-managed in a surgical setting,” said Dr. Shemin. “With time and experience, as well as the willingness of specialists to communicate, we’ll know better how to do that.”

.MGW.

Drug-Eluting StentWords

--Drug-Eluting Stent Controversy: No Clear-Cut Answer--

Drug-eluting stents, called by some the biggest breakthrough for interventional cardiology in 25 years, have been the source of recent controversy. These devices appear to pose a higher risk of blood clots, which can lead to heart attacks, than conventional bare-metal stents. An FDA panel convened last week in Gaithersburg, Maryland, to evaluate this risk.

Drug-eluting stents ooze medicine that prevents arteries from growing scar tissue and ultimately, from renarrowing--a problem commonly associated with conventional stents. When drug-eluting stents hit the market in 2003, they were highly endorsed by cardiologists and have been widely used ever since, inhabiting the arteries of 3 million Americans.

Now, it seems these drug-spewing stents are more likely to cause blood clots--a risk considered more severe than the renarrowing associated with stents of old. This risk can be minimized, however, when patients remain on anti-clotting medications, like Plavix and aspirin. But this medication is very expensive and induces bleeding during prolonged use.

And there is yet another problem associated with drug-eluting stents; patients who have them and later undergo surgery must be taken off of their anti-clotting medication so as to minimize chances of perioperative bleeding. But discontinuing anti-clotting medication invites risk of late stent thrombosis (clotting).

Thus, the trade-off: patients with drug-eluting stents who undergo surgery can either stay on their anti-clotting meds and endure complications associated with bleeding, or discontiue them entirely, risking clot formation that could lead to heart attacks.

I'm speaking with cardiologists across the nation, and anasthesiologists, too, to see how they will resolve the issue of drug-eluting stent safety. More to come. And it will start with George Vetrovec in Virginia.

.MGW.

Pièce de résistance Words

--Pièce de résistance--

Ages and days have passed since I've updated this blog, but I have been writing, and writing more than ever. Unfortunately, my best energy is devoted to work I can't blog: the science of Joan Massaguè, Marcel van den Brink, Michel Sadelain, and beyond. These physician-scientists are making strong strides on all fronts--performing allogeneic bone marrow transplants, identifying the genes that underly metastasis, engineering red blood cells to deliver proteins...

You can read more about their work in journals like Nature and Cell, but not here! And they're doing this fabulous work in MSK's new research building (pictured above). It's an Upper East Side gem--23 floors of the best kept scientific secrets in the world.

In other news, I've been working on some longer pieces. They cover topics ranging from Basques to beauty, and they light me up and extract my deepest parts. Meanwhile, travel writing has captivated me, too; I like to recall Spain and write about its rhythm. (I am no Michener, but I aspire.)

So I'll post these pieces soon, and other ones, too. There could be a pièce de résistance among them! If one strikes you as such, please read it twice:-)

Happy writing!

.MGW.

TwoWildWords

--Two Wild--

Grace,
man-i-fest in the midnight,
Seals stares of ravens who
spot
Slits between your skin and my skin
Recede as the cold night turns hot.

Strength,
ev-i-dent in the morning,
Feeds hunt of hungered who
sense
Muscle and sinew in man flesh
Exposed at companion’s expense.


Poise,
vis-i-ble in the daylight,
Locks stance of hunters who
know
Union of two wild creatures
Shall never shatter by bow.


Light,
obv-i-ous still in sundown,
Lingers on watering
pools
And fires the innermost lining
Of twilight’s most auspicious fools.

.MGW.

GammaRayWords

Explosions in Space

Gamma-ray bursts don't loiter, and neither can the people who hunt them. That's why astronomer Andy Fruchter has set his cell phone to ring every time one of these massive explosions - packed with the energy of a trillion suns - occurs in outer space. Since the 1960s, when scientists scanning the sky for elicit nuclear tests first witnessed these powerful explosions and misconstrued them for Russian bombs, the origin of gamma-ray bursts (GRBs) has been a mystery. But Fruchter's recent attention to cosmic detail has filled in one of the gaps: he and his team have identified the types of galaxies where these bursts occur in a study published in Nature on May 10.

A GRB, best-described as a flash of very high-energy radiation, can be triggered by the collapse of a massive star. It is always accompanied by a supernova - another type of explosion resulting from the death of a star - and a GRB will be followed by a supernova instants later in a powerful succession of blows. However, although one might expect the two events to form in similar environments, images from the Hubble Telescope collected by Fruchter and other astronomers from the Space Telescope Science Institute in Baltimore show that they don't. In fact, the presence of a supernova doesn't always indicate that a GRB has occurred.

This is where it gets tricky. Although a GRB is a lot brighter than a supernova, and is observed first, it is actually produced by the supernova, which is typically of much higher energy. Sometimes the collapse of a star will only result in a supernova: for a GRB to occur as well requires the right conditions.

Fruchter observed long-duration GRBs (those lasting more than 2 seconds) and noticed that if a supernova occurred in a massive - and older - galaxy, this supernova would not have an associated GRB. He attributes this to the high metallicity characteristic of older galaxies, where metal ions have had years to accumulate, and suggests that GRBs can only be produced by supernovae in galaxies with low metal levels.

Metallicity inhibits GRBS in two ways. First, metal ions in the atmosphere absorb emissions, or the gas jets, constituting a GRB, and this smothers the burst. Second, the magnetic field generated by the metal ions opposes and slows the rapid spin needed to generate a GRB. "Some supernovae would like to produce GRBs," explains Fruchter, "but they can't."

Luckily, these are the supernovae seen in massive, metal-rich, evolved galaxies, like ours. If a GRB were to occur in our Milky Way galaxy, it could destroy the ozone, start fires on Earth, cause mutations and even mass extinctions. So Fruchter says that one of the results of this study is: "Relax!" It is very unlikely that our galaxy will host such an explosion and the closest star where one could occur is about 150,000 light years away.

This reassuring conclusion has been reached after painstakingly capturing images of GRBs with the Hubble Telescope for the past 10 years. "There are well over 3000 gamma- ray bursts known," Fruchter explains, "but only 40 or so for which we have a good image." But the next time an image is captured, the astronomers won't be so much wondering if it's close to home. Instead, they will be using it to study star formation in the early universe. Since GRBs are very bright, they are visible in areas where stars have formed, whereas these areas are normally not observable using telescopes available today.

.MGW.