A must see video guide for "Lost" fans


I was talking to someone the other day who had just discovered ABC's TV series "Lost". The storyline and mythology of that great show is formidable and can be overwhelming to most casual fans as it is extremely self referential to earlier episodes and full of allegory and oblique symbols. There is NO way for most people to decipher this show and catch all that the creators are "burying" on screen.

To the rescue come's "Seanie B" on Youtube. This guy takes each episode and breaks them down in detail, pointing out things you'd never have picked up. It really takes watching the show to a new level. Sean's "channel" on Youtube can be found here.

Below is a clip from Season 1


Rob

I just noticed, but last week was the best week in 34 years for the S&P US stock index, up 19%!

I've written before how much of a believe I am in all things Bogle (see last July's "Bogleheads of the World Unite!" (John Bogle being the father of passive index investing). Bogle's advice on staying the course and relying on age appropriate asset allocation offer some comfort at times like these.

In the words of investment guru Larry Swedroe "while it is almost 100% certain that the economic news will get worse (with unemployment certainly headed much higher) stock markets are FORWARD looking, leading indicators, something most investors either don't know or forget.". While we're still in choppy waters and lower earnings in early 2009 can erase this progress, history suggests we may be nearing the bottom of a 40% decline in the market's value.

If you don't stay invested and contribute during this period, you're going to miss out on historically low equity prices. When you look at a decade or more's worth of behavior of the market, there are only a few trading days where the growth of the market index value for an entire bull market is largely established. Last week was likely a clump of these days. Stay the course!

Rob

Happy Turkey Day 2008



Happy Thanksgiving from Plastic Surgery 101!

I've got lots of posts kind of half-finished so expect fairly regular output here in the next few weeks.

Rob

Plastic Surgery 101's winter music recs - Samples, Samples Everywhere!


Someone wrote me the other day asking if I'd do another post on music after stumbling across my last group of recs in May (see here). I've gotten interested in how some artists are incorporating sampled guitar/rhythm loops into their acts, especially in live performances, so I think I'll point to some of my favorites!

Master of the sampled loop, Imogene Heap in "Just for Now". How the heck she can keep track of all these samples during this performance I have no idea. Absolutely jaw dropping! I also suggest the beautiful "Hide and Seek" which is introduced by NBC's "Scrubs" star, actor Zach Braff BTW.


KT Tunstall's "Black Horse and the Cherry Tree" live on the Today Show in 2006. This performance single handedly launched her career in the United States.


Yoav's creepy acoustic "Club Thing". His song "Beautiful Lie" is also really neat with the samples


The Kills industrial-tinged "Getting Down". There's a great feature on them on the Sundance channels' Live from Abbey Road series. Must see TV!


The Yeah Yeah Yeah's "Maps". This is an a great acoustic version. For the an extreme electrified live version go here


Please feel free to leave any suggestions in the comments for interesting music! I'm always looking for new stuff.

Rob

There's a paper this week in the Archives of Internal Medicine discussing the phenomena of some breast cancers possibly going away without treatment. As I do a lot of breast cancer related surgery, I know I'm going to get asked about this by a patient one of these days.

The paper is titled "The Natural History of Invasive Breast Cancers Detected by Screening Mammography" and can be read online here.

It opens with the observation that

...screening mammography has been associated with increased breast cancer incidence among women of screening age. If all of these newly detected cancers were destined to progress and become clinically evident as women age, a fall in incidence among older women should soon follow. The fact that this decrease is not evident raises the question: What is the natural history of these additional screen-detected cancers?

From autopsy studies of the elderly, we know we find many breast and prostate tumors which are clinically silent and that the patients died with rather then from. In an idealized world we could understand tumor biology enough that we could safely say some breast cancers could be watched, just as we already do with some prostate cancer.

This idea of "benign neglect" (no pun intended) for malignancies in regards to current standard treatments of surgery, chemotherapy, and radiation could potentially spare people significant morbidity and save the health system a great deal of money. One example of this would be the emerging idea that the drugs that block estrogen hormone metabolism (Arimidex) or estrogen receptors (Tamoxifen) may be just as effective as chemotherapy in post-menopausal women with estrogen receptor positive (ER+) tumors.

Now the study in question is taking some BIG leaps in logic making their conclusion. Much like financial analysts use "back casting" to test stock/bond buying strategies in the rear view mirror, these type of retrospective ideas can suffer from the fallacy of taking a result and looking back to make the data fit. This idea of watching these tumors would need to be done prospectively with very close followup. It would never be possible to do this trial in the United States due to internal review boards (IRB) and medical malpractice issues, but such an experiment might be possible in other countries (In the New York Times write up, Mexico is suggested for instance as a candidate. Gracias muchacho!)

Something to think about!

Rob

The FDA's got dermal fillers "under their skin"

This past week the FDA had some hearings to discuss the issues of dermal fillers (like the popular Juvederm, Restylane, Sculptura, & Radiess) and BOTOX. The use of such products has exploded in recent years and we've seen some real complications reported. The majority of such problems are usually minor and transient as most of these products degrade or wear off. However, there are some products whose effects are permanent (like some of the micro-silicone injectables which aren't used in the US) or last up to several years (like Radiess or Sculptura).

The FDA presented data on over 800 patients who suffered reactions after injection with dermal fillers between 2003-2008. There have been no deaths reported to the FDA, but almost 80% of the patients required follow-up treatment of some sort. Most of these were minor swelling and redness (which isn't really a complication, but expected IMO). However, the FDA also received reports of "serious and unexpected" problems, including facial, lip and eye paralysis, disfigurement, vision complications and some severe allergic reactions.

Most troublesome complications of these fillers are those injected around the eye to fill the hollow "tear trough" that develops under the lower lid with aging. Injections in that area offer a solution that cannot be reliably fixed surgically as the changes are produced from a combination of atrophy of the cheek bone (malar complex), deflation of the fatty tissue of the orbit/cheek, and thinning of the skin rather then something descending and producing loose skin. The thin skin of the lower lid is unforgiving for imprecise injection of dermal fillers as it shows each and every irregularity. In addition, inadvertent injection into a blood vessel in this area has been associated with embolic phenomena to the eye which can produce blindness. Natasha Singer, the NY Times go to girl for cosmetic surgery articles wrote a nice summary up last week (see here).

Not directly addressed at this hearing was the hornet's nest of exactly who is actually doing these procedures, particularly those indications that are still "off label" for the injectable. (Natasha, if you're reading this BTW that subject is screaming for an feature by you....Rob) To this point, states have been reluctant to engage the issues about qualifications and credentialing for doctors performing aesthetic medicine or surgeries. It strains common sense to allow people who are un or undertrained to perform these types of procedures. IMO, if you're not trained in lower eyelid surgery (a la an opthomologist, plastic surgeon, or ENT surgeon) you don't have much business pushing injectables or fat grafting that area - it's that finicky! In many other states, physicians are not even required to do these procedures themselves but are free to delegate them to low level providers or nurses.

Rob

The death of the bull market in cosmetic medicine (?)


Sorry for the extended break!

Lots going on with the practice and the increasingly complex undertaking of building out a new office and surgery center while the country is treading water with the financial markets. There's lots of anxiety in Plastic Surgery these days as people's disposable income is drying up for cosmetic surgery, injectables (like BOTOX & Juvederm), and noninvasive laser treatments (IPL, hair removal etc..).

A number of medispa outfits have gone bankrupt, stock prices for major players in cosmetic medicine like Allergan & Mentor have fallen faster then other stocks of similar market cap size, and practices across the country are reporting flat or negative growth for 2008. Just today I heard that Rhytec, maker of the innovative Portrait Plasma laser resurfacing system is shutting down, potentially leaving owners SOL for replacing the disposable treatment tips on their expensive laser machines.

I've been obsessed reading a number of books about financial history, market theory, and asset allocation. I can't recommend enough the classic book by Dr. William Bernstein (who is a practicing Neurologist of all things BTW), "The Four Pillars of Investing" which lays out a very compelling lens thru which to view the ebb & flow of investment going back hundreds of years. Everything we're enduring now has happened in some form or another somewhere in history, and about once a generation we should expect the world markets to go crazy. It's ironic that if you're early in your adult life, the current events may make the best time to invest heavily in equities that you will ever see during your lifetime (in the "buy low, sell high" sense).

I'm thinking of this as I'm reading an article by Michael Lewis in today's Portfolio magazine "The End of Wall Street's Boom". Lewis is the author of the classic baseball book "Moneyball" and the 1980's wall street classic expose "Liar's Poker". This article revists the same territory of "Liar's Poker" and is a fascinating look at the insanity/stupidity of the Wall Street culture in priming the pump for our current problems. It really dovetails nicely with Bernstein's book at exposing what fools we mortals be!

Rob
Ok, I bit on the headline of some new "revolutionary" (their words) breast cancer technique written up on the UK's Daily Mail..... the "keyhole technique"


The article describes an endoscopic (lighted camera) assisted mastectomy done to preserve the nipple during surgery in breast cancer cases. As nipple sparing mastectomies have been done by plastic surgeons (and more recently breast oncologists) for about 50 years, officially color me skeptical that this technique adds anything other then complexity and or time.


For instance, in the last 2 weeks I did 2 nipple sparing mastectomies thru 3 cm incisions (one for male breast enlargement - gynecomastia, and one prophylactic for a woman with a history of breast cancer) sans endoscope in well under 45 minutes


Rob
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