Netflix Channel Touch

Netflix, for all its wild movements over its existence, has followed a surprisingly steady ascending channel. The SlopeChart above contains the after-hours post-earnings surge (shown below). It’ll be interesting to see during tomorrow’s regular session if NFLX remains “contained” (to borrow a term from Mr. Bernanke years ago) or is so strong it breaks resistance.
Slope of Hope

Medical School 2020, Year 2, Week 6

From our anonymous insider…

One week before exams.

“We are going back to preschool,” said the young female dermatologist. “Dermatology is another language. We start with vocabulary.” She spoke in a monotone voice and enjoyed sadistic humor. “It helps if you know Latin. How many of you took Latin?” Two students raised their hands. She chuckled, “Well… that is too bad.” We went through several images, and described the lesion with the help of a handout with common terms: umbilicated nodule, erythematous maculopapular, scaly serpiginous plaque. The class was surprised to hear that erythroderma (diffuse erythema covering the body) is a “dermatological emergency”. This massive inflammatory response can cause a drop in blood volume and hypotension.

A dermatologic pathologist gave two hour-long lectures on skin histology (study of the microscopic structure of tissues) with slides of normal and diseased skin. I enjoyed seeing how certain skin issues manifested themselves so clearly on histology compared to other organ systems where the pathological manifestation is more subtle. He ended: “Gastroenterologists and dermatologists always argue with each other about what is the largest organ. There is a huge amount of blood flow to the skin. Inflammation frequently leads to skin changes. Think of the skin as a window into the body.”

“Dr. Joel”, a brilliant pedantic rheumatologist in his late 30s with a heavy Jamaican accent, discussed infectious diseases of the skin and immune disorders that manifest with skin symptoms. Roseola (“Sixth Disease” or “three-day fever”) is caused by human herpes virus 6 (HHV6). It is characterized by high fever, which can cause seizures in children, followed by a maculopapular (flat and raised erythematous dots) rash. Several of these childhood illnesses cause serious damage to a fetus if the mother becomes infected during pregnancy. A congenital rubella infection (German measles infection while pregnant) leads to the fetus having microcephaly and a patent ductus arteriosus (PDA). A male student commented, “Could you imagine living two hundred years ago before we understood the role of congenital infections? Your baby comes out as a dwarf or with microcephaly. Must be God’s will.”

These lectures should help us to answer multiple choice Board questions, but we are doubtful about being able to diagnose patients. Lanky Luke: “I feel much of medicine is getting the approval by society to witness disease. This ordained selection process entails paying it to the Man.” Luke thinks that more of our medical training should be an apprenticeship rather than lecture-based.

He got his wish when we went in for an afternoon to the dermatology clinic. Four-person groups crowded into each small examination room to spend 15 minutes with a patient volunteer and a dermatology attending or resident. My group first saw a 30-year-old female who has suffered from neurofibromatosis since she was a teenager. Only when the patient took her gown off did we see the copious neurofibromas (benign tumor of nerve sheaths) covering her body with the peculiar exception of her head and distal extremities (arms and legs). She could walk around in a long-sleeve shirts and slacks without anyone noticing. The patient allowed each of us to palpate her skin. Neurofibromas are thimble-sized fleshy cylindrical nodules with a dark brown color that sag from the skin. They feel mushy, almost like a fluid-filled vesicle. The attending noted, “A lot of patients first try to scratch them off. They return much worse.”

We rotated to the next room and a normal-appearing 50-year-old female. As we examined her more closely, we saw signs of scleroderma. She had sclerodactylyl (localized thickening of skin on fingers and toes) preventing full extension of her fingers. Her lips were permanently pursed with six or seven valley and ridges on the skin adjacent to her lips. “Before treatment with steroids, I could barely move any of my joints because the skin was so tight. I now live a normal life with my family.” Our patient did not have any of the life-threatening manifestations of scleroderma, which can include pulmonary hypertension and pulmonary fibrosis.

We then rotated through a case of eczema and psoriasis. Eczema, also known as dermatitis,  is characterized by pruritic (itchy), erythematous (redness that blanches with touch), oozing vesicles (fluid-filled sac) with edema (swelling) typically occurring on flexor surfaces. It is commonly caused by an over-reaction to an exposure such as poison ivy or the metal nickel (e.g., touching dime). Interestingly, eczema is more common in asthmatics. Psoriasis is an inflammatory condition without a known trigger characterized by acanthosis (keratinocyte hyperplasia; thickening of the skin) leading to scaly plaques on the extensor surfaces (e.g., the outside of the elbow). The attending confirmed the psoriasis diagnosis by eliciting the Auspitz sign, bleeding after a pinprick.

Our patient case: Fiona, a 42-year-old female elementary school teacher, presenting for bilateral stiffness and pain in her wrists, fingers, and knees that is worse in the morning. She had her thyroid gland removed (thyroidectomy) in her 20s after diagnosis of Graves’ disease: antibodies that bind to thyroid stimulation hormone receptor causing excessive thyroid hormone release. Her condition is now well-managed with synthroid.

She has been to her doctor several times over the past few years for joint pain in her hands. “I was originally diagnosed with arthritis. I got frustrated with my doctor. He would take an x-ray, prescribe physical therapy, and never follow up.” Over the last two months she has been unable to do several daily activities at work and the pain has begun to interfere with her sex life with her husband. Her proximal interphalangeal joints (proximal knuckle) and wrists are swollen and warm to the touch.

Fiona has rheumatoid arthritis (RA) defined by synovitis (inflammation of the synovium or fluid within joint capsule). The pathogenesis of rheumatoid arthritis is unknown, but some people are predisposed genetically and there are environmental risk factors, e.g., smoking, which increases the risk of RA up to 40 times in individuals with Shared Epitopes (SE) gene variants of MHC proteins.

Fiona never smoked, although she had the positive ACP titer (measure of antibody concentration in serum) that is typical of smoking-induced RA. She also had other hallmarks of chronic inflammation such as elevated C-reactive peptide (protein produced by liver suggestive of systemic inflammation). The Rheumatologist explained, “The ACP is helpful to know what kind of rheumatoid arthritis I am dealing with. However, once it is present I no longer care about it — think of ACP as a pregnancy test. You can’t get more pregnant once you test positive. Instead, I listen to Fiona’s symptoms and follow her C-reactive peptide levels.”

She was initially prescribed naproxen (nonsteroidal anti-inflammatory marketed as “Aleve”; similar to Advil) without any symptom relief. She currently takes methotrexate, a folate synthesis inhibitor used to treat several cancers and inflammatory conditions. “I will still get flare-ups if I over-exert myself, but I am able to be active. I even exercise three times a week on the elliptical.”

Describe the pain before your treatment? “My joint pain was unbearable before I was referred to Dr. Joel. Our family goes to the beach once a year… my one break from teaching. We always have a crab leg feast. I had to stop eating the crabs because my pain would be terrible for several days afterwards. I was bedridden. Perhaps it is punishment for the gluttony.”

Does anyone else in your family have immune disorders? “I know my mother had joint problems. She was never diagnosed with rheumatoid arthritis though.”

How does RA affect your family? “I’ve learned my limits now and my husband and kids are truly great about understanding. In the beginning they were a little confused. I still sometimes hear my kids half joke, ‘Oh, Mom isn’t cooking dinner? She is so lazy.’ Even with treatment I still have to be careful how much strain I put on my joints. Scrubbing or cutting too much will cause a bad flare-up that lasts for a few days.”

Dr. Stein, an internist who has been in practice for over 40 years, followed up on the “Motivational Interviewing: Eliciting Patients’ Own Arguments for Change” lecture from two weeks ago. “There are 5 stages of change: precontemplation, contemplation, preparation, action, and maintenance. We also no longer use the word compliance to describe the degree of a patient following prescriptions and medical advice. We now use the term adherence because it suggests an active role and collaboration of the patient with the doctor and treatment process.” 

After one hour and fifteen minutes of theory, Dr. Stein brought in one of his longstanding patients, an overweight female in her late 40s who quit smoking six months ago. She began smoking a pack a day when she was 14. “Smoking was a part of my life. I felt that I would not know what to do if I did not smoke. It helped keep peace in the house. It kept me calm during work.” She described how Dr. Stein would bring up smoking “every single time” she went in. “He said all the right things, but I was just not ready up in the head. The key was I felt comfortable with Dr. Stein. He was not judging me, pointing a finger. When I finally was ready, Dr. Stein leveraged this motivation to help me.” What made you quit smoking? “If you have a big enough why, you will figure out how to quit. I hated seeing my children grow up with me smoking. My father recently had a heart attack — I am sure smoking all his life did not help. I had these two drivers in my mind and I just went cold turkey.” We congratulated her for her smoke-free six months.

Afterwards we divided into four-person groups to present a patient from our clinical shadowing experience. We were fortunate to be presenting to Dr. Stein. Our goal was to practice how to present patients to attendings for Rounds next year and how to write a medical note. The general format of a note: chief complaint in the patient’s own words, History of Present Illness (HPI), Past Medical History (PMH), Medications, Family History, Social History, Review of Systems (RoS), Physical Exam (PE), Assessment, and Plan. The transgender wave has reached daily Rounds: “Don’t use male or female in HPI anymore,” said Dr. Stein. “It’s frowned upon.” After Dr. Stein revealed his fondness for “complementary medicine” (accupuncture, yoga, etc.), Gigolo Giorgio said that Dr. Stein reminded him of someone who had a “midlife crisis and suddenly turned Zen.”

We wrapped up the week by reflecting on a three-week prescription simulation. Students were divided into two groups: diabetics and HIV patients. The faculty gave us pill bottles filled with M&Ms. Our class president sent periodic GroupMe messages about various simulated issues. Example: “Update: your throat is burning and your chest is on fire! wait an additional 35 minutes after taking your pills before eating.” Some students ate all the M&Ms the first day. Some abandoned the simulation. Everyone forgot to take at least one pill.

Straight-Shooter Sally recounted the awkward conversation after her new roommates, a nursing student and college-educated bartender, accidentally read a message: “You forgot to take your HIV antiretrovirals for today. Double up.”

Mischievous Mary, a smart, petite jewish girl who dyed her hair pink last year because “it was the last time I could do something stupid before we start clerkships — unlike a tattoo, this is reversible.” She began school aspiring to follow in her father’s footsteps as an internist, but is now determined to become a heart surgeon. Mary responded to Sally’s story: “I realized this weekend that I have lost all sense of decency. I was in this quaint coffeeshop by my apartment studying STDs looking at pictures of penises on my computer, easily seen by the other patrons.” Jane added, “I was walking with Giorgio on the Greenway. We somehow got on the topic of syphilis. It took us several minutes to understand why people were looking at us strangely.”

Statistics for the week… Study: 20 hours. Sleep: 8 hours/night; Fun: none (one week before exams).

More: http://fifthchance.com/MedicalSchool2020

Philip Greenspun’s Weblog

What could President Trump name after Apple Computer?

Now that Apple is going to pay some Federal income tax (previous post), what would cost $ 38 billion that President Trump could name in honor of the company? Here are some ideas:

  • The Apple Computer Border Wall (estimated cost $ 21.6 billion, so it wouldn’t consume this one-time payment)
  • The Tim Cook nuclear-powered aircraft carrier (complete with fighter jets and rescue helicopters)
  • rename Interstate 280 to the “Android is No Good at All National Highway” (what has Junipero Serra done for anyone lately?)

Readers: any good ideas? Why not show some love to what I assume will be the nation’s biggest taxpayer in 2018?

Philip Greenspun’s Weblog

Hey, That’s SWELL!

My life revolves about SlopeCharts (both as a user and as a developer), and I don’t think I’ve ever been so excited to announce something new in this product. I call it SWELL (Slopecharts Worldwide Economic Library Lists), and it provides access to an ungodly amount of economic data (literally hundreds of thousands of items)  […]
Slope of Hope

Weekly Market Recap Jan 21, 2017

Investors suffered through two whole days of losses in a shortened week – but the indexes still gained on the week! Boo yah! Even a sharp reversal Tuesday (gap up, close at the lows) – which is usually negative short term – couldn’t stop the freight train. Earnings season kicked off in earnest. The government shutdown put absolutely zero fear into markets.
“I would characterize a shutdown…

Read the full article at StockTradingToGo.com


Stock Trading To Go

Sapiens

For Christmas, my son bought me a copy of the book Sapiens which I thoroughly enjoyed. I’ll once again be a lazy bum and share with you Amazon’s own description: “One hundred thousand years ago, at least six different species of humans inhabited Earth. Yet today there is only one—homo sapiens. What happened to the […]
Slope of Hope

This Is Finally Decent

As a child of the 80s, I have a great fondness for the music of that era (most particularly around 1982-1987). There was one song, however, I detested, and it was the Mick Jagger/David Bowie “Dancing in the Street”. However, a YouTuber, God bless him, made it actually enjoyable by removing the music. Check out […]
Slope of Hope

5 Trade Ideas for Monday: Cadence Design Systems, Cincinnati Financial, Encompass Health, Schneider National & Weyerhaeuser

Written By: DragonFly Capital

5 Trade ideas excerpted from the detailed analysis and plan for premium subscribers: Cadence Design Systems, Ticker: $ CDNS Cadence Design Systems, $ CDNS, jumped in February […]
Dragonfly Capital

“The Future is Female”: Women’s March in Boston 2018

I happened to be driving by the Cambridge Common on Saturday just as a “women’s march” was officially starting. Attendance was limited, with crowd covering only about one third of the Common (so the local media used a tight shot to make it look like it was jammed; see boston.com for example). I assumed that there was a big march over in Boston proper (on the vastly larger Boston Common) and that this was just a local march for people insufficiently outraged to ride a few stops on the Red Line. But it turned out that Cambridge was the official location for anyone #Resisting in the Boston area.

The boston.com story is interesting because it says that a top state official, Maura Healey, “wore a T-shirt that read The Future is Female.’” I understand that the majority of voters are women, but I wonder what would happen if a politician anywhere in the U.S. had worn a T-shirt reading “The Future is Male.”

[Separately, Healey “referenced the many lawsuits her office has filed against the Republican president’s administration over the past year.” (no mention that Massachusetts taxpayers get to pay for legal fees on both sides of any such lawsuit!).]

Here’s an image from a Facebook friend in Manhattan. It seems that marchers in New York were more cash-oriented…

[She posted a photo of herself in front of a cardboard sign painted “RESIST!” and the comments from her friends were kind of interesting. 3 out of 4 of the female-named commenters (of course I can’t know their true gender IDs!) mentioned her appearance, e.g., “Too cute!”, “You are beautiful.”, “super cute”. Isn’t one of the complaints that #Resisting women have voiced that they don’t want to be judged based on their physical appearance?]

Readers: What did you see in terms of a Women’s March in your area?

Related:

Philip Greenspun’s Weblog