This week in a short respite after a doozy of exams

The severity of a neoplasm is partly determined by it's characteristics in differentiation - a general rule, though not always applicable to all tumors that develop, is that the more well-differentiated a neoplastic tissue is, the less likely it will progress to a state of malignancy. A tumor can be either well-differentiated, and hence shows characteristics of a terminally differentiated cell, such as smooth muscle, skin, etc., or poorly differentiated. This lack of differentiation is given a name - anaplasia.

The Greek roots are "ana" (ἀνά), meaning "ascent" and "plasis" (πλάσις), meaning "formation." So, in a direct translation, anaplasia ought to mean "a formation which proceeds in an ascending fashion." The direct translation is quite close to its true medical definition, which is an undifferentiated growth, or a growth which progressed backwards, back up its developmental tree towards some anomaly that only Nature herself can explain. Many genetic and molecular cogs play a role in the entire anaplastic machine, but I won't dwell on that here.

I recognized the word anaplasia not through a brief read of Robbins' Pathology, but from my days as an ROTC cadet. One of the classes I took as a recommendation at BU was "Warfare in Antiquity." One of the books assigned for the course was "Anabasis Alexandri", by the Greek-born, Latin writer and historian Arrian. The title can be interpreted as "the walking up of Alexander", but its true contents depicts the campaigns of Alexander the Great of Asia. It was titled "Anabasis" because it was a "walking away or up" from the coast of the Mediterranean Sea and inland towards Central Asia and India.

Aside from the various descriptions of battles, cultures, and schemes of Alexander, one of the most striking was the mic-drop he gave to Darius after defeating him at the famously accounted, Hollywood dramatized, Battle of Gaugamela, with the routing of the Persian army and Darius fleeing the field. Of course, no Hollywood production can equate to the portrayal of the protagonist's personality and wit as well as the written work:

"Your ancestors invaded Macedonia and Greece and caused havoc in our country, though we had done nothing to provoke them. As supreme commander of all Greece I invaded Asia because I wished to punish Persia for this act – an act which must be laid wholly to your charge. You sent aid to the people of Perinthus in their rebellion against my father; Ochus sent an army into Thrace, which was a part of our dominions; my father was killed by assassins whom, as you openly boasted in your letters, you yourselves hired to commit the crime; having murdered Arses with Bagoas’ help, you unjustly and illegally seized the throne, thereby committing a crime against your country; you sent the Greeks false information about me in the hope of making them my enemies; you attempted to supply the Greeks with money – which only the Lacedaemonians were willing to accept; your agents corrupted my friends and tried to wreck the peace which I had established in Greece – then it was that I took the field against you; but it was you who began the quarrel. First I defeated in battle your generals and satraps; now I have defeated yourself and the army you led. By God’s help I am master of your country, and I have made myself responsible for the survivors of your army who fled to me for refuge: far from being detained by force, they are serving of their own free will under my command.

Come to me, therefore, as you would come to the lord of the continent of Asia. Should you fear to suffer any indignity at my hands, then send some of your friends and I will give them the proper guarantees. Come, then, and ask me for your mother, your wife, and your children and anything else you please; for you shall have them, and whatever besides you can persuade me to give you.

And in the future let any communication you wish to make with me be addressed to the King of all Asia. Do not write to me as to an equal. Everything you possess is now mine; so, if you should want anything, let me know in the proper terms, or I shall take steps to deal with you as a criminal. If, on the other hand, you wish to dispute your throne, stand and fight for it and do not run away. Wherever you may hide yourself, be sure I shall seek you out." -- Anabasis Alexandri Book 2.

This week in exam cram galore

This will be short, as I have way too much to study.

http://youtu.be/nuja52KosN4

Back in philosophy class (I almost typed physiology instead of philosophy), we discussed Socrates' "Euthyphro" and his debate with Euthyphro about piety. The scene is Socrates bumping into Euthyphro in the center of town; Euthyphro is going to report on his father for terribly mistreating a slave, causing the death of a human being. Though noble, Socrates pursues Euthyphro's reasoning for going against his father and whether reporting is truly justified. In the debate, Socrates famously asks the question, and present's Euthyphro with a dilemna - "Is the pious loved by the gods because it is pious? Or is it pious because it is loved by the gods (10a)?" In other words, is what is morally good commanded by Divinity because it is morally good, or is it morally good because it is commanded by Divinity? Is there a moral good, which exists a priori to Divinity, or does Divinity dictate what is morally good?

I'm not here to answer this question, as this bit of ancient Greek philosophy is so ahead of its time, it is almost anachronistically so: Immanuel Kant is the next philosopher that truly tackles this concept in the late 18th century, almost two millenia after it was first inquired.

Rather, I'd like to draw attention to some linguistic feature of Euthyphro's dilemna. In Greek, the phrase "the pious" is written as τὸ ὅσιον, or in phonetic Latin, tò hosia. This is interesting, as it shows a great connection between the ancient, Hellenistic culture and our modern culture. The extent of the influence of the Greeks after the reign of Alexander the Great is incredible - so vastly did he spread Greek culture that the New Testament of the bible was written in Greek.

And this is where we have our modern Christian phrase of "Hosanna in the highest". "To hosia" was a biblical phrase (biblical in the sense that it was religious) whose Greek roots were not influenced in any way throughout the history of cultures. The Latin word for piety is pietas, but you don't hear Sunday services exclaiming "Pietas in the highest!"

And in music, we see the Hellenistic influence on sacred works, such as Bach's "Osanna in Excelsis," translated "Hosanna in the highest."

So, when studying the plasmin-bradykinin-coagulation love triangle this week, ask yourself - "Is inflammation occurring in the body because it is inflamed? Or is the body inflamed because the body makes it so?"

Thus far, I have not read any ancient Greek scripts that would indicate, either or - I shall name it the De La Garza dilemna

This week in remembrance of an friend.

Dear Claire,

It has been a serious while since we have last spoke. I believe the last time we met was in Boston, when you had just received word of your acceptance to medical schools, at a restaurant on the corner of Kilmarnock and Peterborough, Fenway, Boston. You were so happy with your friends, and I figured a casual "Hello", a handshake, and a short exchange of pleasantries would have sufficed. At that time, I had thought that we would meet again, once we were physicians - it is, after all, a small world within the medical profession.

I am deeply saddened that such a fantasy will never be physically manifested.

The first place we had met was in the BU Chamber Ensemble. You played the clarinet, Tamsin, the oboe, and I, the piano. I hope you remember what we tried to play -

http://youtu.be/GFuMQWd1o5A

If you don't recall, it was a disaster! We called it off as we couldn't find enough time to practice the technicalities for the concert. Perhaps another day, we had thought.

Then we had left for the summer. No one had heard from you, but it was mainly because no one had the motive to keep in touch. Upon returning, we met again in chamber ensemble. It was then that you had stated you developed some form of skin cancer, and spent the entire summer sleeping because the therapy was so draining. I did not ask anything further as I could only imagine how draining and difficult it was to tell the story so many times over again. Tamsin said, "Well, you do have very fair skin." That was as far as we spoke about that. You had looked revitalized, but there was a lingering lethargy through your eyes and smile. But I did not ask anything further.

Afterwards, we went our separate ways. I had stayed in Boston to work, while you had another year for your undergraduate time at BU. Finally, the inevitable congratulations and status updates on Facebook made it easy to deduce that you had gotten into medical school. You were headed to Northwestern's Feinberg, as I was headed to New York Medical College. I had missed an invitation to your going-away party last year, as I had already moved out of Boston and was planning my trip to Europe before I started my medical school career. In hindsight, I deeply regret not making the drive to Boston to see a future colleague and friend.

I do not think I have the correct medium to express the loss that I and those who have known you currently feel. But know that you have made an impression on many people. With me, it was through your musicality. I have heard you play, I have played with you, and I have been privileged to take part in your musical pursuits at Boston University. In addition, I knew you through our common interest in medicine, our fascination with the human body and spirit, and our motivation to become physicians. These are two very weighted testaments of your incredible spirit and your extraordinary person; the impression you have left me will be deeply imbedded on my person as well.

So, Claire, you will be in my thoughts as I progress through my career in medicine. In addition, you will be in my thoughts when I play the piano. But most importantly, you will not be forgotten because of the impressions you've made in so many more individuals, including myself. We all celebrate you as the incredible person that you were. We lament your passing.

With the utmost respect, deepest warmth, longing nostalgia of times past, and many more thoughts of you in the future.

Henry

This week in my life in Manhattan

After spending a few weeks at home, I found myself in the upper west side of Manhattan, on Riverside Drive. I am here for a one-month long clinical fellowship in psychiatry at Metropolitan Hospital. You might be wondering to yourself, "Why are you living cross-town?" Well, my little sister is here doing an internship at Columbia University Medical Center, and we figured it would be more convenient for her, as this is her first time living in the city.

I lived along for the first week, as my sister was still in school when my fellowship started. Immediately upon moving in, I heard a clarinet a few windows down, in another apartment. There were 2 voices, playing a trio sonata by JS Bach. [http://youtu.be/EuvsgPSLxM0]

I had recognized it because a few years ago, when I had developed an interest in organ music (DON'T JUDGE ME). The piece had been arranged for a reed trio and was very well played. It definitely gave some solace in such a busy city.

The fugue is difficult to execute by one person - usually, it is more interesting to listen to with 3 voices expressing a main fugal theme, interwoven throughout a piece of music. Bach's most interesting fugues are composed for ensemble play, not usually for a single instrument. The piano is event difficult to play an extended fugal motif. Hence, the organ, with two hands and the feet to play, allows for multiple voices to occur with only a single executor of the instrument. What results is the statement and development of a fugue theme with three voices.

The word "fugue" has another meaning to it, outside of music. A "fugue state", within the realm of psychiatry, is a mental state in which a person assumes another identity (or loses all identity) and travels impulsively, with no aim or direction; at the end of this fugue, they have no recollection of what had happened nor any clue as to why they had travelled to some other place, some times very distant from the place of origin. Common words derived from "fugue" include fugitive and refugee.

I recently admitted a patient to the inpatient psychiatry ward who had experienced a fugue-like state. He had stated that he had been wandering the streets for the past 2 weeks, with no recollection of where he was before he started, where he had been, or what he had done as far as food and shelter was concerned. He "woke up" from his wandering on the street, claiming that his mind was rushing, and called EMS who transported him the to the ER. He was extremely agitated and only stated that "I need my medication refilled." He was extremely paranoid on the floor and believed that the staff on the floor were there to perform mind experiments on him.

What is interesting and devastating to the scientific study of the mind is that it is perhaps the least organic and tangible entity of the human. When someone mentions "depression", "mania", "paranoia", or "mood", within the realm of psychiatry, these are words that have implications on the health of the mind. However, though these terms are use medically within healthcare, they do not yield anything that is tangible - there is no direct blood test, imaging test, or physical exam that can be utilized to properly diagnose any of these terms. What a clinician must rely on is the patient interview and language of communication in order to make a diagnosis.

Now imagine trying to interview a patient who is actively psychotic or so depressed that s/he does not even want to talk. What more can the physician elicit as far as diagnostic information in order to formulate a treatment plan? More often than not, I have found myself trying to make sense of a whole slew of pieces of a story. Organized chaos. But this is fun, and perhaps only scratching the surface for other medical specialties, such as internal medicine. Piecing together a story and making sense of all of the aspects of a patient excites those who love a challenging deduction.

As I stepped onto the 1 train for my morning commute, I recognized an old classmate from my undergraduate philosophy class. We had a small chat, asked how things were, and what she was doing in Manhattan. Before we knew it, it was the stop at 96th street. We both exited, not giving a formal good bye, disappearing individually into the meandering of the crowd, a fugue of individuals, all playing a voice in a grand ensemble of the city.

From the past: This week in shit to listen to while we memorize the cranial fossas

Dated 10/20/2013

http://youtu.be/EQIVWhKhwPA

I hope all of you are taking advantage of a short respite this week of insanity - after our ferocious powderpuff win (Facebook pictures for proof), the races I ran, and an (almost) free weekend (at least no test on Monday!), we are shuffled yet again into our next challenge - the NBME mini-board exams. I can assume that none of us have ever taken this exam before, and that we all have some anxiety for it.

The engagement of examination and studying is non-stop, and the number of unknowns is in itself unknown. Some of us don't even have a preceptor assigned yet. 

But in the end, we must keep calm and carry on. This is the essence of character captured in the second movement of Symphony 5 by Beethoven. All of you have probably heard the defining motif of the first movement, as Fate herself knocks on the front door! The second movement is far less ominously foreboding. The first few phrases in the major key give a sense of stoicism, as if one is marching forward with steadfast composure in the face of the most challenging of circumstances. 

I remember this coming onto the radio in Boston (WGBH 99.5) back in the summer of 2011. At this time, it was my first try at applying for medical school, with only a few interviews and no offers. I knew I should have waited, as I had a weird and jerky start to the first half of undergraduate career, but I decided to bite the bullet and give it a try. 

This was a time of great uncertainty for me, as medical school rejections compounded with job application rejections. On top of that, I was studying, yet again, for the MCATs. One can no doubt imagine the depressive and pitiful state that I was in. On some days, getting up in the morning was the most difficult thing to do. And I remember very vividly, in the middle of June, with my iTunes alarm set at 7 AM to play WGBH, I was awakened by Laura Carlo's announcement of Beethoven's 5th. The first movement was certainly a good wake up call, but I stayed in bed, not moving for the duration. It wasn't until the second movement that forced my volition to get up and say to myself, "I got shit to do." 

Fate, if you believe in it for philosophical or religious reasons, has already completed her duty as our pathfinder. Fate knocks on the door, we open it, and invite her in for a hot beverage and Minnesotan hotdish. And the idea conveyed in the second movement is the idea that regardless of what path Fate has assigned to us, it is up to us to make the best of it; to let ourselves divulge into pouting, saying that "Fate is unfair", or something to that liking, does not help our condition in any means. Sometimes, events transpire even when we have no control over them. If one believes in the just nature of Fate, one must grit their teeth, smile, accept the fact that any outcome is the best of all possible outcomes, and tackle her challenges head on, like Val did during the powderpuff game.

But that branch of philosophical discourse is not what I am thinking of. What I think of when I am miserable in the library is how Fate has brought us together. You will make it through this, just like you did with the MCATs, the SATs, the middle school chess competition (I'm a nerd, I know); an added factor is that you will be amongst all of us (FOR THE NEXT FOUR YEARS WOW THAT'S SO MANY WEEKS OF CLASSICAL MUSIC I BETTER START WRITING AHEAD OF TIME). 

And that is an encouraging thought... that we are with each other, not the spam email I send to you every week... but still, I hope you enjoy them!

See you all on the dark side.

This week in summer vacation

It is about one year ago that I had visited Munich for the second consecutive summer. For some reason, the Bavarian city contains an allure that is hard to resist... or because there was a business conference that required my presence.

But truly, Munich in my opinion is a city in which one can settle. It has the ambience of Boston - considered a city due to its wealth in culture, education and pleasures, yet much less hectic than Manhattan. Its history and culture is rich as well, with the Pinakothek's, Kirchen, und Residenz. Even more attractive is its location at the heart of Bavaria; a few minutes on der Deutsche Bahn will place you on the Bavarian countryside, with magnificent views of the foothills of the Alps.

http://youtu.be/BMf314Ougus

The glass armonica was invented by Benjamin Franklin, and one was on display in the Deutsches Museum in Munich (taken by me.. yes, another Halperin moment). Franklin in the 1760s first worked with a private glass blower in London to create a mechanized "glass harp" (or, from Greek history, referred to as hydrodaktulopsychicharmonica, or "harmonica to produce music for the soul by fingers dipped in water"). It was in London, while traveling with his father Leopold Mozart, that W.A. Mozart was first heard the instrument. It wasn't until the last year of his life that W.A. Mozart composed for the instrument in Vienna. 

Around the same time, a philosopher by the name of Immanuel Kant was at the peak of his engagement with the intellectual spheres of Europe. His often-quoted essay on "What is Enlightenment" (1784) details the overall sentiment of the European Enlightenment, the rebirth of knowledge, rationality, and logic within the budding scholarly and scientific initiative in modern Europe at the time. To spare you reading Gothic German font, enlightenment is the progress of the human being to use his or her reasoning unfettered by religious censorship or authoritarian duress. "Habe Mut, dich deines eigenen Verstandes zu bedienen!"; "Sapere aude!"; Have the audacity to utilize your own reasoning!; Dare to know!

Having finished our first year in medical school, we ought to be amazed at our mental capacity. The brain and mind's plasticity under high levels of stress, torrents of information, and all the meanwhile preserving whatever is left of our ability to socialize, is truly something of a miracle. In the past year, we have gone through clinical anatomy, histology, the entire physical exam, physiology, biochemistry, biostatistics, neuroscience, and behavioral science/basic psychiatry, and we are ready for more to come! I doubt that anyone had known the amount of material that was to be thrown at us prior to starting medical school.

And this is the spirit of Enlightenment (note the capitalization). We dare to know, to learn about everything there is to know about the normal human, and in the near future, the human under duress of illness. Due to this sentiment of epistemology, this theory of acquiring as much knowledge about medicine as possible, and along with the shear breath of this type of knowledge, we are set apart from the rest of the world who rely on us to one day need doctoring. 

But herein lies an internal conflict - if we are so set apart from the rest of society in such a unique and necessary set of knowledge, how can we possibly collaborate with others of society, who know so much less, and perhaps due to their ignorance, may not have any of what we tell them?

Like it or not, each and every one of us, only taking into our account of knowledge that we possess, are outsiders, an existential entity that transcends the normal currents of society in thought, knowledge and skill. And this is dangerous: with our knowledge, we have the potential to do great justice, but just as likely to do great evil. In the clinical setting, in a person's weakest and most vulnerable state, we will have the capacity to give beneficial or malevolent advice for the organic vessel that contains their mind. All human action is guided by motives, upfront and ulterior, and this is dangerous. 

Outside of the clinic, our knowledge is very minimally required or even needed. We may even be considered outcasts of society, one which contains a majority of people who do not know what sort of environment we work in or care for the knowledge that we possess. We are set apart in our knowledge and the element in which we transcend all others. How, then, are we to integrate ourselves into society, as we are human, too?!

We participate in the humanities. At our recent Convocation Of Thanks, I had witnessed just the tip of the iceberg of what makes us truly exemplary human beings. Knowledge is one side of humanity, with rationality being the other. It is our ability to express emotion, through art and culture in whatever way, that makes us not only highly knowledgeable individuals, but also highly rational human beings. And it is through our rationality, a part of which exists as our expression of our human, that jettisons us back into society as its members. It is rationality that levels us and other in society, such that what is truly at stake in society are our dignities, vulnerable, exposed, and equal across all human beings. There is no derealization of our rationality (irrational thought, as expressed in the epistolary novel La Nausee by Sartre) along with no disillusion about the amount of knowledge we possess, will possess, or will never possess as far as medicine is concerned.

So, it is our practice of the humanities, such as music, art, writing, etc. that connects us back into society. This is why I love and practice music, write, and converse (even though most people hate it when I do). The exercise of our rationality keeps us human, and the expansion and utilization of our knowledge allows us to transcend and help our fellow humans in the appropriate setting. Because of our rationality, our human dignity is as exposed as all other in society. And in anticipation of our second year of medical school, I can only give you the advice of sapere aude, but listen to classical music and read my blog.

This week as we try and stay sane as we learn everything there is about insanity

It's been a while since last we spoke OMG I MISSED YOU ALL SO MUUUUUCH.

http://youtu.be/DAyUzxDB9eE

If you were to diagnose a psychotic person described by the piece, what would your diagnosis be?

I recently visited Boston many times in an effort to help my little sister visit colleges. In doing so, I visited a philosophy/sociology professor at Boston University (who will be making a debut this coming autumn at NYMC). I dropped in on one of her seminars, which analyzes the culture of the mind through the lens of modernity, being all things during and after the European Enlightenment. When I took her class back in 2009, we looked at functional mental illnesses through the scope of modernistic thinking.

During this session, we discussed the influence of music on the culture of our mind. In discussion, neuroscience came into the picture (OH NOOOOOOOOOO).

When we perceive our external world, when we intake stimulus with our sensory apparatus, most of the sensations must be turned into an electronic signal that can be projected into our brain for interpretation. In other words, there is a translation that must occur - a true "green" from our outside world is turned into an electrical impulse by our retinal cells. In addition, smell, touch, sense of the self, warmth, and cold are all interpreted through an altered electrical stimuli and not an unmolested conception from our external universe. It is through these electrical stimuli that we fabricate a wondrous stage of a play that is our environment. Through such orchestration, I am able to appreciate and interact with this universe. 

In essence, we are confined within a box, into which electrical impulses seemingly tell us what is being done and influencing us on what ought to be done. We have no true concept of what is "green" or "sand" or "air" strictly because we are only interpreting them second-handedly, through an electrical impulse. And this is only one of millions of existential crises I have every time I walk from my dorm to the MEC.

We are in a box

We are in a box

But there is hope. There is one stimulus which proceeds unadulterated through the box and into our self. That is sound. As you may recall from lecture, our cochlear nuclei are comprised of multiple specialized cells that make the effort to remain as faithful as possible to an external sound stimulus. Through globular, pyramidal, spherical bushy, octopus, et al. cells, an electrical interpretation of a sound wave is created, but in such a way that almost directly copies the pressure wave stimulus from the external world. 

From here, the stimulus goes to our upper brain, where it is fed along frequency-specific areas of the brain (Brodman's 41st). It is this high fidelity to sound stimulus and frequency that is unique about our sense of sound. 

What implications does this have on the culture of our mind? Some things quite profound! Sound, from the above explanation of neuroscience (though much more complicated), is the most purest form of sense of our external world. If a person were born blind, anosmic, ageusic, and physically numb, how would he or she describe the world with only audition?