Happy New Year's Eve

Just a quick blog about the break - it has been a relaxing and refreshing time with family and friends. I have enjoyed it thoroughly, started paying back my sleep debt, and though I'd certainly appreciate another week, unfortunately, we don't have that luxury. I feel somewhat ready to get back to school. I didn't get much Boards studying done this break, but that's okay. It'll come when it does. I did get to work on several projects I have going, so it hasn't been entirely unproductive. Life at home feels different; it's a lot more stress-free and carefree, but the days go by quickly, and I wonder what I've accomplished each week. In any case, I go back to school tomorrow as we start on the second. I hope everyone celebrates a safe and happy New Year's.

Amusement

Dorsal Horn Concerto by The Amateur Transplants
There are also a few other amusing songs by them on YouTube.

Practice Questions for USMLE

More Practice Questions for USMLE

People Like That Are The Only People Here

I read Lorrie Moore's short story, "People Like That Are The Only People Here: Canonical Babbling in Peed Onk" from her collection Birds of America (originally published in The New Yorker). This is a fantastic short story about a mother's experience in pediatric oncology. The writing style is beautiful and witty ("The Mother knows her own face is a big white dumpling of worry." "Perhaps, she thinks, she is being punished [...] she had [...] on three occasions used the formula bottle as flower vases.") Lorrie Moore captures the range and dynamics of emotion that go through a mother's head when her child is diagnosed with cancer: disbelief, guilt, bargaining (she's willing to take a car crash at age 16 if her baby is miraculously cured). The tone has a lilting quality to it; it is furious, it is pitiful, it is humorous ("All of her nutso pals stop by - the two on Prozac, the one obsessed with the word 'penis' in the word 'happiness,' the one who recently had her hair foiled green."), it is philosophical. I think there's very little good medical fiction out there, and the best comes from writers, not doctors. Lorrie Moore is an enthralling writer, and I highly suggest reading this short story.

Image from amazon.com, shown under fair use.

Specialties List II

There are a bunch of ties here.

3. Emergency Medicine. Now this one is a surprise to me. I didn't come in with any draw to EM at all. But I have realized that diagnosis is extremely fun, and some of the best diagnosticians are emergency medicine physicians. There is a good mix of intellectual and procedural medicine; it can be exciting and fast paced. Although patient interaction is limited and you're nobody's "doctor," I'm not sure that would bother me too much. I like how anyone walking into an ED is treated, but there are issues with the finances of EDs. EM doctors do triage and stabilization; they are knowledgeable about much but masters of nothing, and I'm not sure I'd like that. Research possibilities are limited (it's mostly clinical). A lot of people praise the lifestyle; I'm not sure that's a big influence for me. I'm iffy on the patient population.

3. Internal Medicine -> Cardiology. I think cardiology is fascinating, and the sub-subspecialties really appeal to me (interventional, electrophysiology). It's highly competitive, well compensated, but mostly, the heart is just a great organ. The field also appeals to me as it is highly evidence-based.

4. Internal Medicine -> Hematology. This is entirely due to my classroom conception of heme; I really don't have a good idea of what hematologists do. I'm not sure I would want to do oncology, but I might end up doing the paired training anyway.

4. Pathology. I'm pretty unlikely to go this route as I love working with patients directly. However, the intellectual excitement of pathology is still quite tempting. It works well with research and teaching, two things I'm interested in. I'm no good with histology, and I'm iffy on anatomy, but I think I could find my niche somewhere (maybe ID or heme areas).

Specialties that are noticeably missing include pediatric and surgical fields. I think this is reflective of a lack of exposure to those fields; I'll figure more out later. I was originally pretty partial to opthalmology because it is fun, procedural, intellectual, well-compensated, and exportable, but I think it is too limited for me.

Specialties List I

I realized it would be cool to list the specialties I'm considering and watch how they change over time (unfortunately I didn't do it last year, and I have a feeling that my preferences have changed since then). With rotations coming up in a few months, it would be both interesting and important to document how I feel regarding different specialties and to see which stereotypes are reinforced or refuted. So here is my list right now.

1. Anesthesia -> Critical Care. I think I'd like to end up in critical care medicine because of the complexity of the cases and the emphasis on multiple organ systems and whole body physiology. That stuff excites me. I'm not entirely sure right now, but I may prefer intensive care of a patient for a limited period of time rather than a more longitudinal experience. I am okay with very sick patients who may die. I am interested in end-of-life ethics. So what about anesthesia? I think that anesthesia complements critical care well. They are both team-oriented hospital-based fields with vast possibilities of research. The procedures are similar, including hemodynamic monitoring and airway support. I like how anesthesia takes care of one person at a time, and the culture of anesthesiologists fits me well. It is an exportable specialty. Anesthesiologists work with adults, kids, pregnant women, and people in pain; it's a diverse field.

2. Internal Medicine -> Critical Care +/- Infectious Disease, Cardiology, or Pulmonary. While most people opt for a Pulmonary/Critical Care fellowship, I'm not certain that's what I'd want to do. Pulmonology doesn't excite me that much. I could consider doing infectious diseases or cardiology first. These aren't ideal pathways. ID might make sense if I'm interested in ID research or infection control (big problem in ICUs). I think it'd be a useful but not essential background. Cardiology is an iffy proposition; there was the advent of coronary care units (CCUs) but it remains to be seen whether cardiology-trained intensivists are required to run those (it may just be sufficient to have either cardiology or critical care, not both). Furthermore, I would enjoy doing a further fellowship in interventional cardiology, and to do critical care after interventional cardiology would be a significant loss in compensation (it's unlikely that I'd really care though).

The thing about critical care is that you need something else to balance it out; it's too easy to burn out doing 100% ICU medicine (if I wanted to do that, I would consider being a hospitalist). Anesthesia (well-controlled environments, one patient at a time), cardiac caths (procedural, fun, high reimbursement), pulmonary clinic (straightforward, longitudinal continuity), ID consults or infection control all provide a venue to destress. It remains to be seen what I end up choosing.

Happy Holidays

Happy holidays to you and yours from me and mine.

Overdosed America

It's been a while since I wrote a book review. I had read Overdosed America by John Abramson before, but rereading it after cancer block has made it more salient. Directed at laypeople, this book argues that Americans are taking too many medications and doctors are prescribing too much because of undue influence by the pharmaceutical companies on medicine without proper independent regulatory agencies. He gives very specific examples like the often cited Vioxx/Celebrex (rofecoxib/celecoxib) drama and HRT. He does a decent job of explaining the construction and presentation of clinical studies to demonstrate how interpretation of data can be skewed to favor pharmaceutical companies (ie. using relative risk instead of absolute risk reduction). It actually made a lot of sense with epidemiology background. And I became pretty convinced that bias does creep into major studies published in journals like JAMA and NEJM. The book itself is okay. It's not groundbreaking or exceptionally written or anything. It does make a decent case, and it's pretty opinionated. But it might be worth looking at, if you're interested in the intersection between big pharma, academic medicine, and governmental regulation. It's stuff that all doctors should know, but a lot of it is presented in medical school anyway.

Academic vs Community Medicine

One interesting thing about medical school is that the majority of our exposure is to academic medicine. We're taught by professors doing cutting-edge research in facilities with the most advanced equipment treating patients in a tertiary care center (meaning that we get referred cases that are too complicated for other centers). Most doctors, on the other hand, are community physicians who treat "bread-and-butter" cases, worrying more about allocation of limited resources rather than active research. As a result, medical students get a skewed view of the field.

For me, though, I think I plan on staying in academic medicine. The disadvantages are clear. The compensation is lower yet the hours may be longer; part of the salary is grant-dependent and not guaranteed. The path to promotion (and tenure) is long and difficult. Nevertheless there are many advantages. What appeals to me is the greater flexibility; I can pursue research, education, administration, and clinical activities in a proportion that best fits me. I can pick research endeavors that interest me. I also like the high intensity environment of the academic center. I would enjoy the opportunity to teach students. The decreased compensation wouldn't really bother me.

Why We Do It

In high school, I worked with a nonprofit community based organization called Orange County On Track whose main component involved high school mentors working with elementary school children to act as good role models, promote healthy lifestyles such as resisting drugs and gangs, and improve scholastic achievement. I got a Christmas card from them with an insert of an essay from a 5th grader.

"A Time That Changed My Life"
By Dante

A time that changed my life was when I entered Orange County On Track. On Track is a program that helps you with your homework and how to behave better. Also On Track teaches you how to say no to drugs, gangs, and other bad things in the world. You get mentors too that help you with stuff.

When I first entered On Track, I was very shy because I was new and I didn't know what it was about. Then, I saw that my two friends, Edgar and Jefferson, were in On Track too...We went out to play kickball-basketball. We separated into teams and started playing...After that we went into the MPR and did a lesson about not doing drugs. I answered 10 questions because I wanted stickers so I could get a cool prize. After On Track was over at 6:30 I realized how cool it was and I wanted to stay in the program.

When I finished my first year of On Track I went in the second year of On Track because I knew how good they were to us kids and they want us to make the right decisions in the present and the future.

CBB Closure

Cancer: Bench to Bedside. In sum, it wasn't as satisfying a block as I had hoped for. In a way, I can understand why. It's sort of a hodgepodge block unified by the theme of cancer. We covered molecular and cellular biology, epidemiology and evidence based medicine, biostatistics, a few cancers, and hematology. A weird mix, and looking at it, I feel like maybe they did do a decent job. It's a catchup catch-all block, and it did feel like we were jumping around a bit. I think the most solid learning I did was in hematology, but certainly reviewing basic science and epi principles was reinforcing and helpful.

Personalized Medicine

Some of the pharmacology of cancer block focused on "targeted therapies" with drugs like imatinib which specifically targets the abnormal tyrosine kinase in chronic myelogenous leukemia (CML). Like monoclonal antibody therapies and other drugs specifically designed to inhibit a target, these drugs are highly efficacious with few side effects. Conventional cancer chemotherapy is a brute force approach, and its serious side effects are a result of its nonspecificity. The other aspect of personalized medicine is pharmacogenetics, where a person's genotype affects response to medication. For example, mutations in different enzymes can change the rate at which a person metabolizes specific drugs.

Anyway, I wanted to write a post about pharmacogenomics because it's often hailed as the next big thing in medicine. It's like testing the susceptibility of a microbe to antibiotics; you know which drugs will work best, maximizing efficacy and minimizing toxicity. I actually think this stuff is really cool and might be clinically feasible. Microarrays are a brilliant high-throughput technology, and the great hope with clinical microarrays is that we can quickly assay a patient's genotype or a cancer's profile to predict prognosis and direct treatment with more and more specificity. So although the lectures were pretty dry, I feel like this is a really cool and exciting budding field.

Consciousness

This is a great image from the cover of a 1969 New Yorker illustrating the stream of consciousness of someone as he appreciates a painting by Braque.

CAM II

I have to say, I am skeptical about CAM. The lecture has helped me become more receptive to such perspectives, though, which is good. I think my background, which has always been grounded in "Western" science, hypothesis-driven experiments, and critical thinking and reasoning, persuades me against easily accepting these other healing modalities. I am also wary about scams that take advantage of sick and vulnerable people. But more and more, randomized controlled trials and other "conventional Western" studies are verifying or refuting evidence regarding CAM. Thus, mainstream physicians are becoming more familiar with them and the patients who use them.

It's interesting that from a philosophy standpoint, such studies may not be suitable for studying these alternative healing modalities. CAM involves a different paradigm of medicine than conventional Western science. Their view of the world and internal rules for coherence are fundamentally different than that of Western medicine. Instead of talking about enzyme kinetics and cell biology, CAM might deal with harmonizing the soul and aligning different life forces. Philosophers such as Thomas Kuhn (The Structure of Scientific Revolutions) would argue that evaluating CAM by Western standards is absurd; you can't judge a completely different system of thought with the rules of your system of thought. It's like evaluating quantum mechanics by the rules and criteria of Newtonian physics: you will get wrong answers even if it is a valid way of looking at the world. The two types of medicine are so different that they cannot be compared head-to-head.

Now to very Western thinkers, this is a ridiculous claim. Traditional science, they might say, uses objective criteria. Especially in evidence-based medicine, outcomes such as death or length of survival or recurrence of cancer are studied. These benchmarks can be used for any paradigm of health and illness. But a true Kuhnian would not be convinced. Perhaps the strength of traditional Chinese medicine is in the subjective experience of acupuncture; perhaps what's important is not the release of endorphins or the decrease in nausea and vomiting. Those are just the benefits that Western science evaluates. Unless you see the world from that paradigm, you can't predetermine how that paradigm should be evaluated. Of course, this leads to the big Kuhnian problem (which he acknowledges) that paradigms cannot be evaluated. They can only be analyzed for internal coherence, but never extrapolated to determining how close they model the world (also a very Kantian view). So it may very well be the case that both Western medicine and CAM operate to improve someone's health even though the former acts by modulating vascular reactivity to prolong survival while the latter optimizes meridians to improve the flow of Qi.

CAM I

Complementary, Alternative, and Integrative Medicine (CAM) refers to a "broad range of healing philosophies, approaches, and therapies" that don't fall into standard Western medicine. CAM encompasses herbs, acupuncture, homeopathic medicines, Tai Chi, mind-body medicine. It's especially big in San Francisco (UCSF has a special "Osher Center for Integrative Medicine"). We were introduced to CAM in cancer block because it's commonly used in addition to conventional chemoradiation.

It's interesting. I didn't realize this was a billion dollar industry or that it has higher use in more educated populations. I learned a lot about different herbs (St. John's wort that causes major drug-drug interactions), and surprisingly (or perhaps not), many herbs that have been studied are as efficacious as traditional pharmacology in treating diseases (St. John's wort for mild-moderate depression, Kava for anxiety). We also talked about some traditional Chinese medicine (and two of our classmates had acupuncture done on them in front of the class), things I know about but never had formalized instruction in. I was especially interested to learn that in some Chinese medicine practices, the doctor is paid insofar as the patient remains healthy; only when the patient gets sick is medical attention free. It makes so much sense (the purpose of a doctor is to keep someone healthy) yet it's completely the opposite of the Western perspective. It has a much stronger orientation to preventative medicine and the whole body.

Dean Kessler

Over the last 24 hours, there has been a flurry of talk about Dean Kessler. David Kessler is a remarkable figure. A pediatrician, lawyer, and administrator, he was FDA Commissioner for an impressive seven year tenure. He pushed for stronger regulation of big tobacco and food labels, cut the time needed to approve AIDS drugs, and increased the agency's efficiency. He then became the Dean of the Yale School of Medicine before coming to UCSF as Dean of Medicine.

His appointment as Dean of Medicine and Vice-Chancellor was terminated by the Chancellor J. Michael Bishop, an equally remarkable figure. I almost see this as a clash of two giants, an FDA commissioner and a Nobel Prize winner. The circumstances around this termination remain obscure and a source of rumor and gossip. Indeed, the Wikipedia page for David Kessler was updated with this news just hours after he sent out an email to the students. The situation seems to involve whistle-blowing and financial irregularities, but it's fairly complex; not only did Kessler initiate an allegation of inadequate financial controls, but an anonymous letter initiated an allegation that Kessler himself was involved in irresponsible spending. After investigation by the University auditor, neither of those allegations were substantiated.

The actual "firing" is fairly interesting. Apparently, the position of dean of the medical school is an "at-will appointment, meaning Dr. Kessler held the appointment at the pleasure of the chancellor" (UCSF Today). Evidently, this position is not protected from whistleblowing. It seems that he was offered a chance to resign and he declined, thus escalating into this termination.

I've heard Dr. Kessler speak on several occasions. He strikes me as a person who fights to the end for his principles, and will not back down until his ethical standards are met. I can't really say who is in the right here (or whether such a thing can be said), but in the capacity of dean, he has been great to us medical students, and I wish him the best of luck whatever happens next.

Metablogging

Recently, an orthopedic surgeon published a TIME article that was lambasted by the blogging community. His article complained about the "Googling" patient (who researches everything and challenges the doctor on every issue), and many advocates for patient rights found his article distasteful. Similarly, I read the blog of an emergency medicine doctor whose readers find him so offensive they've threatened to sue; yet, he trudges on with a growing fan base and growing opposition. You love him or you hate him. I realized that writing and blogging really puts yourself out there. It's a risk; people will disagree with your opinions, think you're absurd, argue with your ideas. Blogging is not easy, and I really respect the courage of my friends who are able to put themselves out there in this faceless and public world.

Collaboration

For the end of this block, we had to put together two presentations in small groups (4 people) on designing a research study (which was a lot harder than I originally anticipated; a lot of thought has to go into inclusion and exclusion criteria, assessing outcomes, confounders, etc.) and on a basic sciences journal article. Anyway, we're putting stuff together with Google Documents, and it's really cool. I've used Google Docs before, but never for anything formal or important (I've used it for a list of movies I want to watch and philosophy texts I'm willing to lend). It's awesome to see multiple people updating different slides at once, checking recent revisions, and talking to each other, all with increased efficiency. For a gadget-y person, it's really fun.

Boards II

I am ambivalent about Boards. On the one hand, I think it is actually a useful and (dare I say it?) rewarding experience to reflect on the 18 months of the first and second year. We covered a lot of material, and I want and need to integrate all the blocks into an overarching uniting theme. When I see a patient, I won't have the luxury of knowing which block his disease falls in. With something like acute abdominal pain, the differential could involve something from any block: appendicitis (Prologue), AAA (cardiac), lower lobe pneumonia (pulmonary), pyelonephritis (renal), GERD (GI), gastroenteritis (I3), colon cancer, ruptured ovarian cyst (life cycles). I was trying to think of a BMB one: maybe Munchausen's (that's a stretch) or acute angle closure glaucoma (which we didn't technically learn in BMB, but we did do the eye). I think I'd actually really enjoy the experience of looking at things I learned last year with the perspective I have now.

But the USMLE is also a standardized test, which I strongly dislike. I think they distort people's attitudes toward learning (learning for a test rather than for knowledge or patients). Boards don't predict how good of a doctor someone will be, but they are used by residencies to assess applicants. They don't adequately reflect the skill or knowledge base we are taught in medical school nor the skill or knowledge base a doctor needs. Of course, I recognize the limitations; there needs to be a licensing standard, and a multiple choice exam is one of the few ways that is actually feasible. It's a necessary evil.

Over this winter break, I should start studying. I have decent test taking skills, but the way I prepare is not efficient compared to many of my classmates. I strongly dislike review books, and I oppose the ridiculous commericalism surrounding standardized tests. I studied for the MCAT on my own with textbooks. But I recognize that it's hardly the best way of approaching these things.

Boards I

The USMLE Step 1 is the first part of a three part licensing examination for physicians. It covers basic science applied to clinical concepts and is an eight hour computer-based test with 350 questions, 72 seconds per question. It's tough, and depending on residency, its importance in applications ranges. We have to take it by early April.

We recently had a talk about the Boards (and attendance doubled that of a normal lecture). I didn't find it particularly useful and got mixed messages. Some people emphasized that we're already well prepared and there is no need to start reviewing until after winter break. Others suggested that we should already have started thinking about it. The general message seemed to be that we shouldn't worry, but it is a big deal and we can't put it off either. Everything was vague, and I think it caused general anxiety.

We take Step 1 earlier than other schools, and although at this point, it feels like a disadvantage, apparently it gives us an extra elective rotation before residency applications which helps. There are rumors that UCSF "soft plays" the Boards, de-emphasizing it and that the curriculum is not geared towards the standardized test (for example, we only have lectures on five cancers: breast, cervical, lung, prostate, and skin, but the USMLE certainly expects more than that). I'm not really sure how to take all of it, but the right attitude is that here is where I am, I know what I need to do, and I have confidence I will get there come the test.

Hematology

Surprisingly, I found benign hematology to be really fun. I wasn't expecting to; I never really thought about hematology much at all. But something to do with the intellectual aspect of it draws me. I like the differential diagnosis involved; from a blood smear (spherocytes shown above) or a few numbers like the MCV and retic count, you can get a decent impression of what might be going on (autoimmune hemolytic anemia or hereditary spherocytosis). There is a very organized way of thinking about the differential and the tests that need to be ordered. Even the coagulation cascade, which I never got for a long time, has become a little more manageable. There are just so many diseases that can involve blood, and I really enjoy thinking through them.

Image shown under fair use, from the University of Virginia website.

Another Opera

Oddly enough I saw another Puccini opera tonight - Madama Butterfly at the San Francisco Opera. It was really lovely; I think it's good for me (being fairly ignorant of such matters) to see more famous operas. Knowing the plot helped a lot. The orchestral score and singing were really beautiful, and the whole thing was very heartfelt and touching. I really enjoyed it. But now, back to studying.

Image is in the public domain.

Words

Some people really emphasize the words in medicine, and to some extent, it's true. Dysplasia, aplastic, hypergammaglobulinemia, thrombocytopenia - the meanings of these words can be inferred from knowing the etymology of its component parts. I do happen to enjoy words a lot; I'm not sure what that means, but I like learning new nifty words. One thing that fascinates me is how disease names evolve over time. Tuberculosis has been called consumption, phthisis, scrofula, tabes mesenterica, and TB. Congestive heart failure used to be called dropsy (technically, dropsy could be edema). It's fascinating to read Victorian literature and come across these diseases. And yet there are other names that aren't changed even though the names are terrible. For example, lupus anticoagulant is a ridiculous misnomer. Not all patients with lupus have lupus anticoagulant; not all patients with lupus anticoagulant have lupus. Even more importantly, it's not an anticoagulant; it's actually a procoagulant. Ah, medicine.

Peds Preceptorships Again

I wrote about my pediatric preceptorship several weeks ago, but we just had our last session. As a whole, I really enjoyed it; over my four sessions, I worked with two attendings with different approaches to teaching (one had us see as many cases as we could; the other had us see only one case but follow it from start to finish). I had a great experience; the last two sessions, I saw cases of a thyroglossal cyst, an intervertebral disc calcification, a suspected Kawasaki's. I had a chance to talk to families, examine children, order labs and tests, and review those tests with the patient. It was pretty fun. Unlike most preceptorships, mine was in the ER so we didn't have any well-child check-up visits. I guess I didn't learn as much about general pediatric health visits and growth charts and preventative care. But that's okay. I think I'm much more interested in diseases and therapies rather than annual physicals. Though obviously the latter is incredibly important and comprises a bulk of pediatric medicine.

Craig Venter's Genome

J Craig Venter became famous by founding Celera Genomics which competed against the government in sequencing the human genome. The race to sequence the human genome is quite an interesting story; Celera was a for-profit business firm that wanted to license out the sequence, while the government wanted to make it open source. Venter designed several novel and brilliant ways of speeding up the sequencing. Interestingly, his DNA was one of the samples that they sequenced. He recently published his genome in PLoS Biology. I wanted to write a few thoughts about that.

This is pretty unique. His genome is the first genome of a single identifiable individual to be published. He makes public a lot of information about himself. Indeed, people have already identified that he has a higher risk of earwax, antisocial behavior, Alzheimer's, and cardiovascular disease. His life is now an open book, and scientists are using his data to find out more about his biology. What is it like, I wonder, to find out you have a polymorphism that predisposes you to some disease? What is it like for it to be public knowledge? It's also one of those things where people find only bad things; the majority of people are looking for SNPs for disease and not ones for good hair or memory or intelligence. This seems like a very risky thing. It's really a novel and strange ethical issue.

The Gates

The Gates
Rachel Hadas

No wonder we so love the dead. The living
are brittle, easily wounded,
petty, distracted by shadows,
ungrateful, obsessive, persistent,
needy, greedy, vain,
impulsive, wrapped in day's opacity.

Better at resisting
wishes, the dead are patient,
peaceable, deliberate.
Having skipped the jaws of appetite
as blithely as the pilot
who slipped the bonds of earth,

they glide across the hours.
But that I see the dead
in peaceful places, in unhurried silence
doesn't mean they're never
desperate presences
hammering at the gates.

Image is Rodin's "The Gates of Hell," Musee Rodin; from Wikipedia, GNU Free Documentation License.

Stem Cells

Stem cells are a fascinating topic. Scientifically, they hold a lot of promise in better understanding development and perhaps someday, in treating a multitude of diseases (bone marrow transplants are already used to treat leukemias). The issue, however, is fraught with ethical dilemmas and political controversy. I just wanted to write about two sides of stem cells that I find interesting. The first is really unfortunate. There are a lot of stem cell scams out there (usually in other countries). I've seen websites with foreign doctors advertising that they can inject stem cells into patients to cure a variety of diseases. There's absolutely no evidence supporting these claims, and indeed, they may rely heavily on the placebo effect. These scams target scientifically naive people with lots of money, taking advantage of the popular media reporting on stem cells.

The second interesting thing is the recent two articles on induced embryonic stem cells. The problem with embryonic stem cells is that the isolation is ethically controversial. In these papers, two groups (including one associated with UCSF) report a new method of generating embryonic stem cells. A differentiated adult somatic cell is transfected with a retrovirus that encodes master transcriptional regulators. These induce the differentiated cell to become undifferentiated. I took a quick look at the papers and they're very cool. The cells resemble embryonic stem cells in all the ways tested. I think this breakthrough merits further investigation, but I caution those who pay attention only to the popular press that treatments for diseases like Parkinson's or Alzheimer's are still a long way away.

La Rondine

A few friends from college and I caught the closing performance of Puccini's La Rondine by the San Francisco Opera at the War Memorial Opera House downtown. I discovered something marvelous - standing tickets, purchased the day of, are only $10. That's remarkable! Being poor students with strong backs, we opted for the standing tickets which was very reminiscent of an old Shakespearean theater. The venue is really really gorgeous; I think it's one of the most beautiful buildings I've seen in San Francisco (even nicer than the Carnelian room).

Even though I know very little about opera (and went with devout aficionados), I had a great time. The singing was beautiful; I was really awed by the versatility of the human voice. It was very interesting for me to realize how beauty can be expressed in a language I don't understand. I enjoyed the costuming, stage, dancing, and general ambiance. The story was easy to follow with the subtitles, but the plot was a little iffy to me (it's one of Puccini's lesser known operas). However, it was the debut of soprano Angela Gheorghiu and she was incredible. One of my friends even went to see her in Italy. I highly recommend the experience even if you're non-opera.

Image is in the public domain.