End of Basic Sciences is Near

It's November of my 2nd medical school year, and I'm close to the end of the part of medical school called "Basic Sciences"or "Pre-Clinical Curriculum." The view from here is quite different from when I started medical school. In a way I feel a lot better. I'm used to my new life, which is about to change again. The big change from basic sciences to clinics is one thing I remember from all the speeches from medical students when I was a pre-med. Right now I have a lot of freedom (I can work out, help drive my kids to swimming in the middle of the day, etc.) and soon I will have a more rigorous schedule that is much less flexible, especially in services such as surgery. In any case, I certainly feel like I have learned a lot and continue to build up my basic medical knowledge. I know the symptoms of many ordinary afflictions that physicians encounter every day and some not-so-common ones. My physical exam skills are still pretty poor (I'm very slow), but I will work on that so that I can do well on my upcoming OSCE exam. I have a lot of studying and test-taking to do between now and the end of the year. In another way, I'm somewhat burned out. I don't get as much sleep as I would like to (maybe 5 hours a night on a typical day). Mostly that's being a father. When I come home, I help out with my kids and a lot of times it is late when I finally sit down to study. At school, I miss the everyday interaction I had with people when I was working. While there are plenty of friendly students I like to talk to, studying is something that is more or less a personal activity. Although you can study with others, everyone needs to memorize the same material and there is no division of labor, where people are assigned to those things that they do best (at this point anyway). I understand the logic of laying a foundation of medical knowledge, but I still miss the teamwork I had at work anyway. Speaking of studying, I'm going to get back to that now.

Nephrolithiasis (Kidney Stones -- Very treatable)

Let's be clear: I am not a medical doctor and I am not licensed to provide medical treatment. However, I can give informal / general health suggestions that you may wish talk over with your physician (nephrologist) who is licensed to help you.

This is just a quick post concerning the fun fun fun topic of Kidney Stones. I have had some mild ones, but many people that have had some that hurt as much as childbirth. For mine, I just drank some Crystal Light which has potassium citrate (and water, of course) and it cleared up after a few days of that ... obviously the potassium citrate in Crystal Light might not have done anything for me (and the stones just went away on their own, more or less) or what works for me may not work for anyone else, and so don't do something just because it worked for me. However, the point of me writing this is to encourage those who do have a problem with these kidney stones is that I'm encouraging you to prevent and treat them non-invasively, if possible. According to a nephrologist I spoke with (check this out yourself ... don't just take my word for it), essentially 100% of them can be prevented. I had a roomate in my undergraduate years who had a kidney stone disease (Cystinuria) that quite possibly has killed him by now. The thought that something preventable (by taking a few pills and drinking a bunch of water ... really not hard) kills people disturbs me. As long as the problem goes away and never comes back (and doesn't cost you a fortune and tons of pain to treat), you will be happy.

Those devils can get caught and sometimes even need to be removed by a urologists. In fact, many urologists remove kidney stones all the time ... it's a lot of work for these physicians. If thes stones are preventable, why are so many people suffering from them? I'm not really sure. However, if you or anyone you know suffers from kidney stones, you really should see a nephrologist who is skilled in treating and preventing kidney stones.  If you have one, your chances of getting another one are quite good. Why anyone would want to have an expensive invasive procedure instead of getting an oral ("pill") treatment is beyond me. Anyway, if this is an issue for you or someone you care about, here is a little information you can take to your doctor and ask them more about it. Doctors often *hate it* when patients bring them information from the "Internet." However, it's your health, so be persistent.

Although I have access to official medical sources, I cannot quote them here for obvious copyright restrictions. Thus, I'm going to cite some information from wikipedia which is not a realiable medical source, but it's free ... so unless you have a subscription to a medical information provider or medical journals (both of which are copyrighted), you would have a hard time finding more accurate information among all the treatments that don't work.

Here is the information you may want to ask your physician about:

http://en.wikipedia.org/wiki/Kidney_stone#Treatment
[edit] Prevention
Preventive strategies include dietary modifications and sometimes also taking drugs with the goal of reducing excretory load on the kidneys:[31][21]
Drinking enough water to make 2 to 2.5 liters of urine per day.
A diet low in protein, nitrogen and sodium intake.
Restriction of oxalate-rich foods, such as chocolate, nuts, soybeans,[32] rhubarb and spinach, plus maintenance of an adequate intake of dietary calcium. There is equivocal evidence that calcium supplements increase the risk of stone formation, though calcium citrate appears to carry the lowest, if any, risk.
Taking drugs such as thiazides, potassium citrate, magnesium citrate and allopurinol, depending on the cause of stone formation.
Some fruit juices, such as orange, blackcurrant, and cranberry, may be useful for lowering the risk factors for specific types of stones.[33][34]
Avoidance of cola beverages.[35][36]
Avoiding large doses of vitamin C.[37]
For those patients interested in optimizing their kidney stone prevention options, it's essential to have a 24 hour urine test performed. This should be done with the patient on his or her regular diet and activities. The results can then be analyzed for abnormalities and appropriate treatment given.
[edit] Diuretics
Although it has been claimed that the diuretic effects of alcohol can result in dehydration, which is important for kidney stone sufferers to avoid, there are no conclusive data demonstrating any cause and effect regarding kidney stones. However, some have theorized that frequent and binge drinkers create situations that set up dehydration: alcohol consumption, hangovers, and poor sleep and stress habits. In this view, it is not the alcohol that creates a kidney stone but it is the alcohol drinker's associated behavior that sets it up.[39]
One of the recognized medical therapies for prevention of stones is thiazides, a class of drugs usually thought of as diuretics. These drugs prevent stones through an effect independent of their diuretic properties: they reduce urinary calcium excretion. Nonetheless, their diuretic property does not preclude their efficacy as stone preventive. Sodium restriction is necessary for clinical effect of thiazides, as sodium excess promotes calcium excretion. Though some have said that the effect probably fades after two years or so of therapy (tachyphylaxis), in fact it is only randomized controlled trials lasting 2 years or more that show the effect; there is really no good evidence from studies of calcium metabolism that the thiazide effect does not last indefinitely. Thiazides are the medical therapy of choice for most cases of hypercalciuria (excessive urinary calcium) but may not be suitable for all calcium stone formers; just those with high urinary calcium levels.

[edit] Allopurinol
Allopurinol (Zyloprim) is another drug with proven benefits in some calcium kidney stone formers. Allopurinol interferes with the liver's production of uric acid. Hyperuricosuria, too much uric acid in the urine, is a risk factor for calcium stones. Allopurinol reduces calcium stone formation in such patients. The drug is also used in patients with gout or hyperuricemia, but the latter is not the critical feature of uric acid stones.[40] Uric acid stones are more often caused by low urine pH. Even relatively high uric acid excretion will not be associated with uric acid stone formation if the urine pH is alkaline. Therefore prevention of uric acid stones relies on alkalinization of the urine with citrate.
Allopurinol is reserved for patients in whom alkalinization is difficult. For patients with increased uric acid levels and calcium stones, allopurinol is one of the few treatments that has been shown in double-blinded placebo controlled studies to actually reduce kidney stone recurrences. Dosage is adjusted to maintain a reduced urinary excretion of uric acid. Serum uric acid level at or below 6 mg/dL is often the goal of the drug's use in patients with gout or hyperuricemia.

[edit] Decreased protein diet
A high protein diet might be partially to blame. Protein from meat and other animal products is broken down into acids, including uric acid. The most available alkaline base to balance the acid from protein is calcium phosphate (hydroxyapatite) from the bones (buffering). The kidney filters the liberated calcium which may then form insoluble crystals (i.e., stones) in urine with available oxalate (partly from metabolic processes, partly from diet) or phosphate ions, depending on conditions. High protein intake is therefore associated with decreased bone density as well as stones. The acid load is associated with decreased urinary citrate excretion; citrate competes with oxalate for calcium and can thereby prevent stones.
In addition to increased fluid intake, one of the simplest fixes is to moderate animal protein consumption. However, despite epidemiologic data showing that greater protein intake is associated with more stones, randomized controlled trials of protein restriction have not shown reduced stone prevalence. In this regard, it is not just dietary calcium per se that may cause stone formation, but rather the leaching of bone calcium. Some diseases (e.g., distal renal tubular acidosis) which cause a chronically acidic state also decrease urinary citrate levels; since citrates are normally present as potent inhibitors of stone formation, these patients are prone to frequent stone formation.

[edit] Other modifications
Potassium citrate is also used in kidney stone prevention. This is available as both a tablet and liquid preparation. The medication increases urinary pH (makes it more alkaline), as well as increases the urinary citrate level, which helps reduce calcium oxalate crystal aggregation. Optimal 24 hour urine levels of citrate are thought to be over 320 mg/liter of urine or over 600 mg per day. There are urinary dipsticks available that allow patients to monitor and measure urinary pH so patients can optimize their urinary citrate level.
Though caffeine does acutely increase urinary calcium excretion, several independent epidemiologic studies have shown that coffee intake overall is protective against the formation of stones.[41]
Measurements of food oxalate content have been difficult and issues remain about the proportion of oxalate that is bio-available, versus a proportion that is not absorbed by the intestine. Oxalate-rich foods are usually restricted to some degree, particularly in patients with high urinary oxalate levels, but no randomized controlled trial of oxalate restriction has been performed to test that hypothesis.

[edit] Calgranulin
Crystallization of calcium oxalate (CaOx) appears to be reduced by molecules in the urine that retard the formation, growth, aggregation, and renal cell adherence of calcium oxalate. By purifying urine using salt precipitation, preparative isoelectric focusing, and sizing chromatography, some researchers have found that the molecule calgranulin is able to inhibit calcium oxalate crystal growth.[42] Calgranulin is a protein formed in the kidney. Given the large amounts of calcium oxalate in the urine, and considering its potency, calgranulin could become an important contribution to the normal urinary inhibition of crystal growth and aggregation. If so, it will be an important tool in the renal defense against kidney stones.

http://en.wikipedia.org/wiki/Cystinuria
Cystinuria
Cystinuria is an inherited autosomal recessive disorder and is characterized by the formation of cystine stones in the kidneys, ureter, and bladder.

[edit] Causes
Cystinuria is characterized by the inadequate reabsorption of cystine during the filtering process in the kidneys, thus resulting in an excessive concentration of this amino acid. Cystine may precipitate out of the urine, if the urine is neutral or acidic, and form crystals or stones in the kidneys, ureters, or bladder.
Mutations in the SLC3A1 and SLC7A9 genes cause cystinuria. The SLC3A1 and SLC7A9 genes provide instructions for producing the two parts of a transporter protein that is made primarily in the kidneys. These defects prevent proper reabsorption of basic, or positively charged amino acids such as histidine, lysine, ornithine, arginine and cystine.[1] Normally this protein allows certain amino acids, including cystine, to be reabsorbed into the blood from the filtered fluid that will become urine. Mutations in either of these genes disrupt the ability of this transporter protein to reabsorb these amino acids, allowing them to become concentrated in the urine. As the levels of cystine in the urine increase, the crystals typical of cystinuria are able to form, resulting in kidney stones. Cystine crystals form hexagonal-shaped crystals which can be viewed upon microscopic analysis of the urine. The other amino acids that are not reabsorbed do not create crystals in urine. The disorder affects 1 in 7,000 people, making it one of the most common inherited diseases, and the most common genetic error of amino acid transport. Cystinuria is inherited in an autosomal recessive pattern.

How can it be treated (this is something we learned in class ... again ask your doctor). Here are aspects of treatment your physician may consider:
* High fluid intake > 3L per day
* Potassium citrate
* D-penicillamine
* beta-mercaatoproprionyl-glycine

But, please don't just have the stones removed by invasive procedures. Work with your physician to try to prevent them.

Again, let's be clear: I am not a medical doctor and I am not licensed to provide medical treatment. However, I can give informal / general health suggestions that you may wish to talk over with your physician (nephrologist) who is licensed to help you.

Handheld computers for medicine

Someone asked me a few questions about my Palm computer, so I thought I would share the answers here in case anyone else is interested:

Question: (A medical student asks) I am interested in using a Palm TX handheld computer (to use on my rotations). Did it ever crash on you? did it ever work strangely? ? The Palm techs say that third-party software is sometimes incompatible and is a major source of tx breaks, so careful of what you download! Do you have any other medical software on your tx that havent caused resets?

Answer: I use the Palm TX for Epocrates only. It works well for that. I have a Blackberry Curve for messaging and Tablet PC (Lenovo X61) for taking notes in clinics.

The Palm has occasionally “crashed” (frozen up and needs to be reset). However, for the most part, it has worked very well, especially with Epocrates, which is a very stable application. Some of the other applications (such as the PowerPoint emulator) can get overwhelmed with large documents.

I have used this particular Palm TX for about 9 months. In the past I used Palm computers all the time. Right now I prefer tablet computers and only use the Palm if I don’t have internet (e.g., many hospitals and clinics) and need to figure out a DDx or look up a drug. I may activate cellular internet service for my tablet so that I can access internet, but even cellular service does not work in many hospitals. I would like to get away from the Palm TX because I really want all my stuff on one machine (like my tablet) and the Palm TX is really not powerful enough for me. However, my Palm TX is very nice for DDx and looking up drug when I’m being pimped, need a DDx, or need drug information. Epocrates has a ton of information and you can also take word documents, small powerpoint files (don’t even try to put a 50 MB powerpoint file on this). Also, most doctors don’t have an engineering background like me and would really rather not carry around a tablet computer (they like the more compact Palm or a phone better). I also have the free Epocrates on my Blackberry.

Yes, there are some applications that are not compatible, but many of them are. The bigger issue in my mind is that Palm is phasing out the handheld Palm like in favor of their Palm Treo and Palm Smartphone line. Really the Palm TX is not a bad machine. It’s a little slow and it’s not going to work with our VPN or super-secure wireless network. It does go wireless on most public and home gateways (mine anyway).

I have several medical applications on it (IV dosing and the like). Epocrates also comes with a ton of BMI, CME, and other software. Again, I prefer to use my tablet computer but unfortunately Epocrates is not available for it. There are many more applications available for the PC than for the Palm. However there are many Palm medical applications. So far I haven’t really run across something that is anywhere close to Epocrates.

Starting MS2

I heard a lot about the second medical school year when I was a first year student.  It was supposed to be more difficult and more interesting at the same time.  I would say that's pretty much how it looks right now.  The pace is a little faster in the Hematology / Oncology course, but I think that the tail end of MS1 prepared us well for this increased pace.  I'm enjoying both Cardiology and Heme / Onc so far.  It is a little sad sometimes to see what I have already forgotten from 1st year.  We took a pre-test in a pharmacology elective and I couldn't remember the antibiotics very well at all.  We will review them in that elective, and I'm really happy that my school is offering this pharamacology course that also covers a lot of review.

Death of a Legend

Yesterday Dr. DeBakey died at age 99 leaving a larger than life legacy.  Our medical school class was the last to have Dr. DeBakey welcome it to Baylor College of Medicine (BCM) about a year ago. He gave rather strong admonition for us to study hard and excel in our chosen profession.  More recently, he also gave an interesting presentation on key accomplishments in his career this past Spring at our BCM research symposium.   It was amazing to have a 98 year-old physician lecture with such energy, passion, and dignity.  He told us how he became interested in sewing from watching his mother sew.  He also learned how to sew and appreciate good fabric.  This skill was obviously useful in preparing him in his career as a vascular and heart surgeon.  His innovative use of Dacron in aortic repairs was a major invention that he cherished to the end of his life.

How I did not want to spend my summer or How high efficiency and poor parts and construction create increase the actual cost of air conditioning

Well, it's nice to be off a little while in the summer to relax and take care of things that I don't have much time for during the year.  I have been spending most of my time with family and on pet research projects that are kind of like my hobbies now that I'm in medical school.  Unfortunately our fairly new home is having some problems that need attention as well.  Thank you Pulte (http://www.pulte.com/), for using "builder grade" junk to construct our home.   Pulte seems to use a lot of parts (faucets, A/C's, etc.) that fail in only a few years (we just replaced our main sink faucet ... we are not going to replace the inadqueate duct work, which would cost $8000).  I hope their "cutting corners" reputation / using parts that fail in 5 years catches up with them.   To their credit, our furnace is nice, as shown in the picture above left.  The air conditioning portion lacks an expansion valve and instead relies on an orifice.

One of the things needing attention is our central air conditioner, which is being replaced at a very young and tender 6 years of age.  Ours had some kind of leak or other problem that was causing it to freeze and fail about every 3 months, making us hot at the most inopportune times (usually a Holiday, like 4th of July when you can't find a A/C repair person).  We have had a Carrier 3.5 ton Model CK3BXA042021AAAA / 38BRC042330 (R-22 Refrigerant, which is being phased out) (see picture at left).  Needless to say, the Carrier central A/C should not be failing so soon and it really makes me think that Carrier parts quality is very poor (along with the Pulte unwise selection of parts and home construction of that unit).  Apparently I'm not the only one who thinks so (see another Carrier complaint).  The complaints.com link also allows searching by brand and "Carrier Air" turns up about 96 complaints compaired to 12 for Lennox and about 12 for Pulte.  Every A/C company is likely to get some complaints, but Carrier really stands out and Pulte does not reflect well on themselves for choosing that brand.  If Carrier wanted to improve, they might start with paint that doesn't fall off after a few years (note the Carrier label that is falling off the top of the unit in an attempt to hide the guilty).   However, that's what came with the house, so it wasn't really something we could do a lot about other than replace certain critical components, which is what we are doing.  I noticed our neighbors also had theirs serviced recently as well, and so I don't think the problem is limited to our home.   We are replacing the central A/C system with a 4 ton Lennox Ch23-41 / XC14048 (new R-410A refrigerant) unit for about $6400 from Central City Air here in Houston.  

We had a Lennox central A/C in one of our previous other homes, and it lasted 18 years, which is how long these air conditioners should be lasting.  We nursed that previous 18 year-old Lennox unit along near the end and found out that it's better to replace a failing unit early on after we had sunk a couple of thousand in repairs into it.  A few $200 bills here, and another $400 bill there, and pretty soon, you could have paid for a new unit.  Our outside condenser system just plain looks bad for its age and corroded and our A/C repair man raised a number of concerns about the construction and working parts of that system as well.  Our home is one of those "high efficiency" homes, which uses more insulation and an undersized heating and cooling system.  High efficiency with an undersized A/C also means that the air conditioner will work harder and longer to begin with; add poor parts quality from Carrier and poor construction from Pulte and you wind up with a problem in only a few years that we had to address.  Despite these little annoyances we have been enjoying living in the Houston area, however.  There is a lot to do for our children (local parks, beach, entertainment, etc.), traffic moves pretty well, and the cost of living here (including gas prices) is low compared to national averages ... we save money overall living here and it's quite nice.  I even like our neighborhood; it's attractive, safe, and people are friendly.  I should not complain too much.  However, I wasn't able to find a lot of information concerning the actual quality of air conditioning units on the web, so I thought I would write this up.

Firefox 2 and 3 freeze-ups

Internet Explorer has not serving me very well (it's slow, it sometimes doesn't close, etc.).  Internet Explorer is functional, but leaves some things to be desired.   So, I decided to use Firefox a few months ago (until now) until I was forced to confront the 100th encounter with an interesting feature of Firefox somehow freezing my entire Windows XP systems from time to time.  We are talking about the mouse no longer moving and no keyboard recognition; it happens on multiple systems with many different users.  It seems to be a common problem (check out this search:  http://support.mozilla.com/tiki-searchindex.php?words=firefox+system+freeze+Windows+XP&sa= ) .  It might be an issue with Windows XP but we see similar issues on Vista as well.  It might be the way that Firefox does business.  I have no idea exactly, but it seems to affect both Firefox 2 & 3.   Anyway, the "party line" from the Mozilla folks is that it can't possibly by Firefox and they send users chasing their tails with suggestions to update/change drivers, firewalls, and all that.  Nevermind that there is no other application that does this and that the problem only occurs with Firefox and is reproducible across numerous machines and users.  Even if it is something else, Firefox has the unique distinction of activating this terrible bug, so there should be a bit more sympathy, but no.  Anyway, I loaded Opera (www.opera.com) on three of my machines and my Blackberry (http://www.opera.com/products/mobile/) and I'll see how it goes.  Hopefully it doesn't freeze up the entire Windows XP system like Firefox did ... not even Internet Explorer had that problem.  Opera also seems to be faster as well.  Anyway, I hope it will be an uneventful permanent switch.

First year (MS1) is done

Wow, it's hard to believe I'm at this point.  I'm done with my first year of medical school and it feels great.  Ok, I realize this is supposed to be the easiest year, but, in any case, I feel a certain sense of accomplishment or at least relief that I have time to do something other than my medical school assignments.  We have gone swimming, to an amusement park, and I get to play with computers as much as I want.  I am also working on a couple of research projects including one that I'm writing an MS Access database for right now (I actually find that fun).

Hope for people with Locked-in Syndrome or ALS?

One of the worst things that can happen to a person is something called "Locked-In Syndrome" (see http://en.wikipedia.org/wiki/Locked-In_syndrome). The reason this is so bad is that the person can still think and is conscious but is unable to communicate with the outside world because that part of the nervous system has been destroyed. In a sense, the person is "buried alive" inside their own body. This might happen as a result of a stroke that takes out a significant part of the left hemisphere or part of the brainstem in the pons, for example. People with ALS suffer a similar fate in that they lose the ability to move their muscles and eventually even lose the ability to breathe or keep their airway open and suffocate.

One of the technologies that might offer some hope is something called a Brain-Computer Interface (http://en.wikipedia.org/wiki/Brain_computer_interface). Using such a tool, it might be possible for a person to manipulate a robot arm or computer interface to communicate or otherwise interact with the outside world. It sounds a little science fiction, but recently scientists were able to get a monkey to feed itself using a robot arm that interfaced with the monkey's brain (http://www.nytimes.com/2008/05/29/science/29brain.html). Obviously there must be some limits to this technology and it has not been tried in humans yet. However the monkey and human brain have many similarities that make trying this technology in humans seems very close and I'm sure it is being tried to some extent already using EEGs and fMRI interfaces.

Back from a Holiday weekend

I always like to talk to my classmates after a Holiday weekend (like this past Memorial day 3 day weekend). Everyone is so rested and happy. Even our lecturers seem to have a little extra spring in their step. Soon we will be in exam study mode and year 1 will be over and then we will get a 1 month break. One thing that is clearly helping me is daily workouts. It's been tough working that into my schedule for really no valid reason, but I'm there and I love it. We have learned time and time again how working out helps cardiovascular health, and, most recently, that it has actually been proven to be equivalent to a natural antidepressant and an inducer of brain cell growth development! How about that for motivation to work out. I need every brain cell I can get with all the memorization we need to do.

Neulaw Conference Summary

http://neuro.bcm.edu/eagleman/neurolaw/Home.html

" Baylor College of Medicine’s Initiative on Neuroscience and Law addresses how new discoveries in neuroscience should navigate the way we make laws, punish criminals, and develop rehabilitation. The project brings together a unique collaboration of neurobiologists, legal scholars, ethicists, medical humanists, and policy makers, with the goal of running experiments that will result in modern, evidence-based policy."

Dr. Eagleman in his introduction of Neuroscience and law gave a broad overview of the many ways that neuroscience can explain criminal and other legally interesting behavior. Dr. Eagleman focused mostly on results from science as he explained how Charles Whitman and Phineas Gage were not consciously able to influence their behavior. He gave the example of a man who became interested in sex with children as a result of a tumor and was treated twice and with each surgery was able to regain normal sexuality.

After this, Dr. Hays explained key rulings and issues related to the admissibility of expert testimony (FRE 702. He showed that expert testimony related to neuroscience could be admitted in court if it met a four part test outlined in Daubert v. Merrell Dow 509 U.S.579 if the technique / theory was tested, peer review and published, had a known error rate, and had widespread acceptance within the relevant scientific community. He indicated that actually polygraph tests did very well in determining whether subject were being dishonest and that traditional juries are not well characterized in terms of their ability to assess truthfulness.

Dr. McGuire is very interested in the implications of neuroscience on ethics and law as in the case of participation in imaging research study leading to unexpected discovery of a large tumor by scientists who are not clinicians. She highlighted the many ways in which neuroscience is giving beneficial insights but that results can have uncomfortable implications for patients and research subjects. For example, some of the questions we would really like answers to cannot really be funded for ethical reasons. During the panel discussion she elaborated on this point by explaining that if we studied predictive factors for future criminal behavior based on fMRI imaging of school children, one would be worried about the stigma for children with these predictive factors for criminal behavior and this would outweigh the benefits of perhaps early intervention.

As a neurologist, Dr. Kass was able to go into more detail about how neuroscience can be used to assess individuals. He spoke about how differences in human frontal lobes lead to differences in emotional regulation such as the processing of risk, reward, and ambiguity as well as individual information thresholds for decision making. He spoke about variability in human self-regulatory styles; for example, some people are driven by gain and this leads to eagerness. Others are driven by loss prevention, and this leads to vigilance.

Mr. Dan Goldberg provided an important legal perspective by warning about how application of neuroimaging and related science can be used to mislead juries. In addition to Daubert 509, lawyers can sometimes apply Federal Evidence Rule 403 to neuroimaging because the value of such evidence may not be sufficient compared to the potential undue prejudice that can be caused. For example, in studies, juries that were given a fallacious narrative backed up with a brain imaging study overlooked the errors in the story whereas juries that did not have imaging studies as part of the presentation saw the problems.

Dr. Amir Halevy gave an engaging presentation of the factors in determining brain death and explained that dying is not an event, but rather a process in which a body becomes a corpse. He walked the audience through the history of how death is determined and explained how the coincidental development of technology such as ventilators and organ transplant capabilities led to ethical worries that organ donation might precede death, if not in actual fact, then possibly in a legal sense. He carefully outlined important considerations such as whether the body was at normal body temperature when a determination of death was made as one example to ensure that every appropriate attempt had been made to resuscitate the patient.

Finally Dr. Winslade wrapped up the formal presentation portion of the conference with a careful analysis of voluntary surgical castration for three sex offenders under Texas Law, as for certain non-violent pedophiles . It is important to recognize that this castration procedure is part of a comprehensive therapy that includes intensive counseling and education. Dr. Winslade discussed three cases that showed that it is possible to treat pedophiles so that they can have better control over their impulsivity and other behavior problems even if there is no proven cure for pedophilia.

Neurophysiology and Criminal Behavior

We are gradually wrapping up several weeks of intensive study of neuroanatomy among other things, such as infectious disease. In a few weeks we'll start a round of tests and then we will be out for the summer. A lot of my classmates are feeling pretty burned out. Personally, I have a renewed sense of energy and purpose. I like what I'm studying even if I don't master it fully or forget important points. The information is really very interesting in and of itself. For me neuroanatomy has been a real eye-opener to the mind and brain. It's just amazing how scientists are now able to trace depression to physiological changes in the brain and are beginning to track down the development of Alzheimer's disease for current and future treatment.

One of the more remarkable aspects of this is an effort to trace issues such as criminal behavior to neurophysiology. It has been known for a long time, as in the study of the case of Phinease Gage (http://en.wikipedia.org/wiki/Phineas_Gage) that damage to the frontal lobes can cause behavior that is at best not moral and can evidently become criminal. On Friday many students in our class will be attending a conference on neuroscience and law here at Baylor CM (www.neulaw.org). We hear of considerations from psychiatry and neuroscience in criminal and other aspects of law; here will be our chance to learn about some of the recent developments and their implications. We are still quite far away from being able to implant, say, a chip in the brain of a pedophile to change such a person's thoughts, but we can perhaps learn more about various ways that people can lose judgment and what that means in the legal context.

Professors who make you look forward to practicing medicine

There is a lot to learn and medical school professors are an important part of the equation in the learning process. A good professor presents the material clearly ... but a great one inspires you with their passion for their work. Today we had Dr. Sargent talk about pediatric mental health. I'll say right off, that while this field is interesting, it isn't my passion currently; but that's not important. What's important is that this professor like several other key professors here at BCM have more than semantic information to provide. Specifically Dr. Sargent has a vision for dramatically improving life for many children in our community, which, of course, means that he has a vision for a better future for our community. Here are some specific things that he mentioned:

* Multiystemic therapy uses dollars that are already being spent to keep juveniles in detention and incarceration to provide treatment for kids with various mental. Here is one of several links that can be readily found on this topic: http://www.colorado.edu/cspv/blueprints/model/programs/MST.html

Key reference: Family preservation using multisystemic therapy: An effective alternative to incarcerating serious juvenile offenders.

Henggeler, Scott W.; Melton, Gary B.; Smith, Linda A.

Journal of Consulting and Clinical Psychology. 1992 Dec Vol 60(6) 953-961

* Systems of Hope. This is the organization that Dr. Sargent is involved with. Here is
http://www.systemsofhope.org/

Here is a little bit about the organization that Dr. Sargent is involved with:

Systems of Hope meet the needs of Harris County children and youth with serious mental health needs and their families by creating a collaborative network of community-based services and supports using the systems of care framework. A plan of care is created for each family focusing on their strengths. Systems of Care is more than a program — it is a philosophy of how care should be delivered. It is an approach to services that recognizes the importance of family, school and community, and seeks to promote the full potential of every child and youth by addressing their physical, emotional, intellectual, cultural and social needs.

Making time for fun

Medical school takes a lot of time for the typical person (including me). Sometimes when I'm goofing off doing something fun with the family I wonder if I'm taking too much time away from my studies. Yes, balance is important but if you get behind in keeping up with the material it can be hard to catch up and that creates stress ... thus there is an incentive to work hard all along, at least for me. Yesterday we had a class picnic and I never thought about studying -- probably because there was a lot going on in terms of physical activity. Because of the parking situation I hauled a 40 lb bar-b-que gill about half mile or so and go a pretty good workout even before the picnic really started for me. We ran a lot, played frisbee, volleyball and the like. Usually when I work out, I'm back studying after about an hour. This was a multi-hour deal and that was probably key to unwinding. I was always under the impression that is better to spend time throughout the week to work out or goof off. That usually means its going to be fairly short. The picnic showed me that sometimes you need several hours to completely get your mind off things and refreshed.

Wasting time with marginal software

In a nutshell: The Nero 7.0 Essentials is a timewaster that may or may not work (probably does, but be prepared to spend a long time working with it, especially if you have a lot of data (e.g., 6 GB+) that you want to offload onto DVD).

There are plenty of ways to waste time, and one that I'll cover here in this brief note is dealing with software / computer issues. I bought a new DVD burner because my tablet computer did not have a DVD drive and I needed to install some software. I wanted to also take advantage of the burner to offload some files. The burner comes with the piece-of-junk Nero 7.0 essentials software. I don't normally develop negative feelings toward software, but Nero is an exception, as I have wasted countless hours either attempting to get this software to do its job or to install some "feature" that was breaking the rest of the system in the not too distant past. My memory of this software is a combination of lockups and application crashes. Don't get me wrong ... the software often worked, but it wasn't reliable.

Today was no exception. I went to install the software and it took forever for some reason. It isn't just possible to install a simple burner. It installs all this junk that I don't want but it is what it is. Then it attempts to associate itself with every imaginable media file type -- NO, THANKS. However, the installation was basically a smooth process. It did require a reboot, but that wasn't too bad. After that, I wanted to burn my data to DVD. By default, the software chose a CD-ROM drive insead of the DVD burner ... not a huge issue until I tried to cancel to switch to the correct drive. The program of course locked up and had to be forced to end. After that it wasn't possible to start the Nero software again. I had to reboot my system to start the Nero software once again.

The second time around I was much more careful about setting the drive to use because I knew I would not get a second chance to correct this. I added the directory I wanted to burn and it went fairly smoothly. Then there is a message about "Please wait..." without any explanation of what the software is doing. Who knows if I will ever get that directory burned. With this software it's difficult to tell if its locked up or doing something. Keeping the user informed is apparently an occasional task that Nero may or may not perform. When it does give a message, be prepared for indications such as no progress with no improvement (are we locked up?) or 100% complete but "please wait" (so what exactly does 100% complete mean?). Well, I need to get back to studying. I'll let this software keep try to do its thing in the background.

Pace picking up / It was fun listening to Feigin today

Well, I'm past the mid-point of the first year and things are picking up. We move through material quickly and the expectations of what we are supposed to remember increase in terms of level of detail. All the while, my lectures are mostly empty now (few students go). Most students just watch the lectures on recorded video, which is not a bad idea, actually. I still go to lecture, mostly because I enjoy it. I can tell my memory is getting better with all this practice I'm getting remembering tons of important medical facts.

Today I attended a lecture by Dr. Ralph Feigin. He strongly promoted pediatrics and challenged us to excel in our education. He was very energetic as you would expect of someone with his reputation.

Half way through 1st year

Well, I'm half way through my first year and I'm having a good time. We just finished our Block 4 exams and it feels great. The immunology test was certainly the most challenging one, but that was no surprise. Classes keep me busy because there is a lot to learn. I spend time on research and my family. I'm surprised it all works out.

I know that at some point I'll be in the clinics and I'll see my family less, but right now I'm enjoying the flexibility of a first year medical student schedule at Baylor CM. I have found a few research projects that I'm keeping up with. They are only a few hours a week, but I enjoy them, and I'm surprised how often I'll know the answer to a test question because I studied that topic in my research.