Alzheimer's and Amyloid: How even a perfect aducanumab could help some and hurt others.

Representational drift, if validated, tells us that a memory is a set of relationships, not the specific neurons that embody those relationships. This sentence might be rendered in electrons or ink, but it has the same meaning.

Reading an article about this reminded me about an old concern with drugs that aim to treat Alzheimer's by reducing amyloid accumulation in neurons. Drugs like the recently approved (and seemingly minimally effective) monoclonal medication aducanumab. The root problem is that we don't know why neurons accumulate amyloid. There's been a growing suspicion over the past few years that amyloidization might in some way be helpful.

I wrote about one way this might play out in a twitter post which I've revised here:

Representational drift reminds me of a theoretical problem with aducanumab and amyloid therapy for Alzheimer’s dementia. It begins with recognizing that we don’t know why neurons accumulate amyloid. 

Many suspect amyloid has a physiological reason to appear in neurons. Suppose, for example, amyloid is the way old crappy neurons are "retired" from forming memory relationships. Amyloidization would then be the brain equivalent of marking a SSD region as unusable. 

A system like this would have 2 kinds of bugs. It might be too aggressive or not aggressive enough. 

If the retirement mechanism is too aggressive then neurons will be amyloidized prematurely. They could have still formed useful memories, but now they're dead. The brain can only produce so many neurons so it runs out prematurely. Early dementia develops. In this case a drug that cleared amyloid could help -- as long as it wasn't too aggressive. The balance may be fine and hard to get right. 

If the retirement mechanism is too permissive then a lot of flaky neurons accumulate without much amyloid. Dementia follows from this too -- but it might look clinically quite different. In this case a drug that cleared amyloid would make the dementia worse! Even more flaky neurons would accumulate. 

Even if the balance is just write we do run out of viable neurons. Even a very healthy centenarian has only a fraction of the cognition they once had. Again, in this case, an amyloid clearing drug would make the brain worse. 

If this was the way the brain worked then an amyloid reduction drug would make some dementia worse and some better. The net effect would be quite small -- even if the medication worked perfectly and was dosed correctly. 

All speculative. Come back in 5 years and see how it turned out.

Why did the patient's leg swell up?

I'm a physician. Ok, so it's a very part-time practice; I'm mostly a bureaucrat trying to keep civilization together. Still I have the degree and the board status and I listen to The Curbsiders religiously. So I was really annoyed when my left leg swelled up after a modest knee injury and I didn't know why. 

It wasn't just me; neither did my physician wife nor my colleagues nor the veteran ER doc I saw nor my CrossFit Physician colleagues. Nobody had an explanation. My rheumatologist had a story though, and I'll get to that one.

Legs swell for several reasons, but the textbook ones I know of are infection, bad veins, bad lymphatics and a backed up/overloaded drainage system (heart failure, kidney failure - usually both sides same). Less common causes are muscle damage (compression syndrome, rhabdomyolysis) and (rarely) tumors. Inactivity, esp sitting, makes most things worse.

My leg wasn't infected. I didn't think my veins had obstructed but I have a family history of clot [1] so I did get an ultrasound -- all good. My muscle, heart and kidneys are all reasonable for age. I didn't think my familial [1] "osteoarthritis" (better called mysterious arthritis) had messed up my lymphatics.

So I was mystified. Why had a knee tweak turned my left (below) leg* into a painless swollen ("edematous") bag with a good half-inch of tough pitting edema over my shin? True, I have an old somewhat arthritic cartilage-depleted knee ill-suited to 150 double-under badly executed rope jumps. True, after the jumps my knee had some kind of meniscal tear and a medial ligament strain. Still, it seemed disproportionate.

I bought a cheap Amazon compression sock that worked better than I expected and I did my usual careful injury care. Meaning I did a lot of mountain and road biking and whatever CrossFit my injured knee could handle. Sitting made the leg swell, sleep and exercise with the compression sock (esp. biking) made it better.

Over the course of about 3-4 weeks the knee improved and the leg swelling mostly resolved. I still didn't know what was going on though. For a while I wondered if I'd ruptured a Baker's cyst (an arthritis thing) doing a heavy squat, but my knee effusion didn't flatten out and the volume seemed too high and persistent.

So I asked my rheumatologist. He claimed I had "reflex sympathetic dystrophy"- see also fpnotebook's great summary. Textbook RSD (now more often called "complex regional pain syndrome") is a badly understood and ill-defined disorder with a dismal prognosis. Patients I've seen with it usually have debilitating chronic pain and often have mental health issues that predate the injury. 

I had no pain that I noticed but he claimed this was not unusual in his experience. Reading the online references as a grumpy old seasoned physician I can confidently say we have no idea why things swell in RSD and that the handwaving talk about autonomic dysfunction and inflammation is mostly bullshit. I do believe there's a genetic component [1] and that the articles are correct to recommend exercise and compression. Once again my exercise addition led to a good outcome [2].

So, yeah, I'll go with RSD, which in this case translates as "it swells because you have a (somewhat rare) genetic malfunction in your injury response and the correct treatment is compression and exercise". It didn't show up in the differential of the textbooks I read, but I'll see if my friend Dr. Scott Moses will add it to his fpnotebook article on unilateral edema.

* technically and pedantically the leg is part of the lower limb below the knee but of course we use it to mean lower limb.

[1] All courtesy of my beloved mother who died age 87 of every possible medical condition (she lived on pure wilfullness). I inherited all her bad genes and, yes, she had bad leg edema. My father by contrast had only a bad back and post-90yo dementia but I inherited his back and probably the dementia disposition too. Happily my children are adopted.

[2] My back praises the Romanian deadlift.

Update 11/7/2021, wow, that's one ugly looking photo. I don't know what it was, or why it happened, but I guess I'll go with RSD plus some dubious lymphatics. My knee got better over 8-10 weeks and the edema resolved over 4 to 16 weeks. Sometimes I have trace pre-tibial edema but mostly nothing.

Update 4/12/2023: Never came back. So weird.

Mountain bikes have come a long way very quickly

My trail bike is a 2010 Cannondale Scalpel I bought used. It was a state-of-the-art racing machine in the 26" era and it's light and fun to ride.

Today I rode a friend's 2018 Trek Fuel EX alloy bike with 27.5" wheels. The Scalpel is lighter and has nicer brake levers -- but in every other way the $2,500 Fuel EX is a much better bike. Faster to climb, faster to descend, faster to cross country, better on the bumps, better shifting over a 1x range.

Huge price drop for better quality in 8 years. That's faster progress than my MacBook.

My prophylactic back exercise routine

I wrote the original of this post in the early COVID era. Since then I expanded the basement home gym with a way over-specced power lifting squat rack and a full Olympic spec weight set (what I could find, more than I wanted).  I also ran into some minor back strains, perhaps due to on/off COVID CrossFit and more of the age and arthritis annoyances. Between those two developments I've expanded my pre-lifting warmup. I still do the morning stretches and (on non-lifting days) the evening Roman chair, but if I'm lifting I have a more extensive warmup now:

• Roman Chair 10 reps
• Inchworm toe touch to push-up then Up/Down dog 5 reps
• Tuck 20 reps
• 1 arm lateral planks 40 sec each side followed by 5 lateral dips
• Touch toes with rounded back and slow roll-up
• Bar hang knee/hip rotation 40 reps (Hang from bar, trace figure 8 with knees while flex or extend hips.) 
• Tuck 20 reps
• Roman Chair 10 rep with two 15 lb dumbbells held in 90 degree reverse curl
• Romanian Deadlift (RDL) with 15lb dumbbells x 10
• Roman Chair 10 rep with two 25 lb dumbbells held in 90 degree reverse curl
• Romanian Deadlift (RDL) with 25lb dumbbells x 10
• RDL with 95 lb barbell x10
• Tucks
• RDL with 115 lb barbell x 10
• Tucks
• RDL with 135 lb barbell x 15
• Tucks
• RDL with 145 lb barbell x 10

[Update 11/11/2021: These days I take the RDLs off my rack and I go from 135 to 185 -- but I'm not sure there's much to gain for me above that. 

12/3/2022: My current routine does less roman chair, RDLs now 195, more hamstring stretches but otherwise pretty similar.]

 The Roman Chair is a 10yo StrengthTrainer ST45.

Then the workout. 

In the morning, for over 12 years I do these stretches every morning before I get out of bed, I got them from Physicians Neck and Back Clinic in Roseville MN (click for full size):

I don't bother with the wall lean stretch in morning (see below) and I combine the standing thigh stretch with a freestanding balance exercise of pivoting forward to stretch hamstring.

Editorial comments from 5/24/20 (rest of this article was updated more recently, the foot drop mentioned here went away about 1.5-2 years post onset)

My experience as a physician who treats people with back pain and as someone who has had some success with the problem is that nobody wants to hear that fitness is (almost!) the only fix. I get it, twenty years ago I also thought of this is an unfixable problem too, but at least since 2009 this has been common knowledge. The surprising bit is how much exercise it takes.

My back isn't bulletproof. I've had several episodes of back pain over the past 12 years. The most worrisome was seven months ago and was probably an L5/S1 disc prolapse. That took 6 weeks to mostly heal with diligent exercise and 10 weeks before I could set new CrossFit personal weight lifting records. I think I have some residual left foot extensor weakness (had to switch from low support CrossFit shoes to real running shoes for runs). On the other hand I play ice hockey, do CrossFit Olympic lifts, and basically expect a lot out of a crummy old back.

Weird world example: "virtual cameras" for online videoconferencing

Somewhere in my twitter stream mention was made of the "virtual camera" and its advantages for videoconferencing especially as a replacement for screen sharing.

Sounded interesting, so I went looking for more information. I thought it would be an easy google search.

All I could find, in written form, was one quickly written blog post from 2019.

Twenty-five years ago a similar topic would have had a deep technical article in BYTE and a myriad of articles in PC Magazine, Mac User, and the like. Fifteen years ago there would have been hundreds of excellent blog posts. Google would have found them all.

Now Google finds almost nothing.

How is discovery happening in 2021? I'm ancient, so I'm quite ready to believe there are sources I don't know about (and Google, evidently, doesn't care about). What are they? What is the replacement for Google search?

Sapiens by Yuval Noah Harari - a brief review

I'm a fairly average sleeper for my age, but this morning I gave up a bit before 4am. With the unexpected time I finished Yuval Harari's 2015 book "Sapiens: A Brief History of Humankind". (The "finishing" part is a bit unusual, I too often lose interest 80% of the way through many books.)

Sapiens was, I've read, quite popular with the Silicon Valley set. So I was prepared to dislike it from the start. In truth, while I can see why the Captains of Industry were fans, it's not a bad book. I'd grade it as very good to excellent.

I didn't learn much new -- I have read many of the same things as Harari. I was reminded, though, of things I'd forgotten -- and he touched on many of my favorite themes. If I'd read this as a young person I might have found it astonishing.

What are the flaws? He has a weird definition of "The Liberal" and he really dislikes whatever he means by that. He has a thing about Hosni Mubarak -- a loathsome person, but an odd choice for chief villain. He is glib, but that's a necessity in a book like this.  The glibness is somewhat offset by his habit of critiquing his assumptions at the end of each chapter. He's weakest when he strays into the sciences, particularly biology. Since he wrote this book we’ve seen Trumpism, the rise of Xi, and the slow burn of the Left Behind — events that might cause reconsiderations.

I liked the repeated reminder that non-human animals have paid a terrible price for the rise of humanity. Most books of this kind don't consider them.

In a book of this sort one constantly tries to decipher the author's agenda. What does Harari truly think? He clearly admires Buddhism; I would be surprised if he were not a practitioner of the more intellectual forms of Buddhism. He has a love and admiration for capitalism that outshines his self-critique. On the current American spectrum of political ideology he'd be a techno-optimist libertarian to the right of Obama and me (his characterization of the British Empire is more than slightly incorrect.)

Most of the time the book affirmed my own beliefs and reminded me of things I'd forgotten. Sometimes it annoyed me, but in a way that forced me to examine my priors. It's aged well -- even if some of his 2014 near-future predictions look to be still a decade or two away. I recommend it.

Nordic skiing: Salomon SNS boot and binding compatibility - Profil vs Pilot

I usually share my blog posts to Pinboard, and from there some creaky old services create tweets and an archive on kateva.org/sh. Not this post though. This post is purely for the search engines. Here I will reveal knowledge lost to humanity. As far as Google can tell, it's not available anywhere but here.

I have been through 3-4 kinds of cross-country ski binding -- 3 pin, something with a post that went straight up (Salomon?) and then bindings I thought of as SNS (in fact they are all SNS Profil, the first version of SNS). I have SNS Profil bindings on 3 "classic" skis all between 25 and 38 years old. All work quite well and, given the limited present and worse future of Nordic skiing I've no reason to replace them. (I'd buy skate ski gear if Minnesota winter were not dying, but I invested in a Kona Wo fat bike instead.)

Which brings me to the point of this post. The bindings work, but after 40 years or so the boots have disintegrated. I needed to either replace the bindings on 3 skis (does anyone even do that on such old gear?) or find SNS boots. Problem is Salomon stopped making SNS boots sometime in the past decade. They are an obsolete proprietary system that was replaced by NNN (and probably more modern proprietary variants too). I might be able to find used boots, but that's a long slow process. Happily, in this one area, Google still works. I found a new pair of Salomon R/Pilot Combi (Combi because they are supposed to work for classic and skating) boots from Boulder Nordic Sport and had them shipped to my home in Minnesota. Despite being marked as US size 10 they were EU 44 -- really US 10.5. Even then they are bit on the generous side, but they fit me well enough. I think Solomon made biggish boots.

They also fit my bindings. They came with a tiny manual that actually describes what ancient discontinued Salomon boot fits which binding types. This is information that can be found nowhere else  -- but even this obscure manual is misleading. So here is an enhanced version:

SNS PROFIL boots with 1 bar at toe -> SNS PROFIL bindings

SNS PILOT boots (1 bar at toe, 1 under ball of foot) -> SNS PROFIL bindings and SNS PILOT bindings (in other words, all SNS)

PROLINK boots -> PROLINK or NNN bindings

NNN boots -> PROLINK or NNN bindings

The Salomon's site for my R/Pilot Combi boots says they have 1 rail, but in fact they have two rails. Which fits their name. They do seem to fit my old Profil bindings, just as this old web page says (emphases mine):

... Some of the boots that use the Salomon SNS Profil binding include Salomon, Atomic and Hartjes... 

... Salomon also makes SNS Pilot bindings, and while Pilot boots can be used with a normal Profil binding, normal Profil boots cannot be used with Pilot bindings. There’s an extra hinge thingie on the Pilot bindings that attaches to the center of the Pilot boots and there’s no attachment point on the Profil boots...

In short, if you have SNS bindings, the "Pilot" boots should fit them.

PS. More on these old obsolete gear from the "binding confusion" page:

There are two main versions of the SNS Series, the Profil and the Profil Pilot ...  the black, extra hinge attachment plate in the middle of the Pilot binding.

... There’s only one cross bar on the SNS Profile and two cross bars on the Pilot. The Pilot system was intended to help stabilize the boot for skaters but I like it better for classic style striding as well.

There is both a manual and automatic version of the SNS Profil. The difference between the two versions is you physically have to open the manual styles by lifting up on the toe piece of the binding and the automatics you can simply step in to attach and use your ski pole to push down the release button on the toe piece to step out of them.... 

... Salomon also has the Propulse binding, which promises greater kick, but as far as I can tell, it accepts all SNS Profil boots...

Biden's essential task is to help the Left Behind

This is the last in a short series of post that began on Nov 11, 2020, shortly after Biden won the presidency for the first time. Back then it looked like McConnell would hold the Senate. 

In the decades since that post Trump became more insane than usual, a deranged mob of Trump cultists invaded the Capitol building, the Dems took the Senate, and Biden won the presidency for the third or fiftieth time depending how one counts. Truly, I need to finish this series while we still have electricity.

In the first post I wrote about how I think about the Trump voter (and America). I divided the Trump voter up into the religious fundamentalist (sometimes Trump cultist), the despicables (ex: Hawley, Cruz, the WSJ reader), and the Left Behind. The NYT profiled a Left Behind on 11/7/2020 (emphases mine):

... Nick [a] 26-year-old hair stylist ... spent the past few months campaigning for President Trump, taking special satisfaction in offending Biden supporters...

... He did not go to college and prides himself on his independent thinking; he puts himself in the category of street smart, not book smart...

... He had never bothered to register to vote until 2016, when he first heard Mr. Trump debate on television, and saw a political figure who reminded him of himself....

... When Fox News began reporting polls showing Mr. Biden in the lead, Ms. Rocco tried tuning into One America News, the right-wing cable network, which predicted a convincing victory for the president. The Roccos got news from a variety of sources — TikTok, QAnon, the pro-Trump comedian Terrence K. Williams, the YouTube mystic Clif High. “I’m a conspiracy theorist, I guess, if you want to call it that,” Ms. Rocco said...

...  he reminded himself what kept him out there all these months: People had disrespected him. The Facebook group manager who had kicked him off. The neighbor who took his yard sign. Teachers who responded to his daughter’s enthusiasm about Mr. Trump with awkward silence.

“People who don’t like Trump, I honestly think they are very soft people,” he said. “That is why the world is becoming so sensitive today. Back in the day, you could throw a snowball at someone at school and everything was fine. Nowadays, a letter gets sent home: Your child is being mean.”

... His older brother, who he describes as the brainy one, took the other path, winning a scholarship to college. (He is the Biden voter.) But Mr. Rocco’s aspirations were staunchly blue-collar; he chose trade school and went to work at 17...

It's unlikely Nick would have done well at a four year college or succeeded as a knowledge worker. He could marry well, or find an inheritance, or show unusual entrepreneurial talent -- but more likely he's going to be the disrespected Left Behind. In today's America if you aren't a knowledge worker you're probably not going to make over $30/hr, and you're not going to make it into the middle class as an individual [2]. Even in countries with effectively free college this non-knowledge worker cohort is about half the population [2].

America can't survive as a democracy with half its citizens Left Behind. We'll have a January 6 every year -- only the mobs will be larger and have better weapons. Of all the threats we face, this is our greatest near term challenge. Even CO2 driven climate change is a lesser threat.

Biden needs to work out a solution for the Left Behind problem. The good news is that for this problem survival and politics align. The Left Behind are the core of Trump's base and the modern GOP, it's tricky for the GOP to block policies to bring the Left Behind into the middle class. And, after Jan 6, 2021, there's intense awareness of the danger posed by the Left Behind (though that will be quickly forgotten). 

Most importantly the Left Behind are not only white, they are also Black [3], Hispanic, Asian and any slice you like (though more men than women). Helping the Left Behind crosses political boundaries, unlike reducing college debt.

What policies can be put in place so that most non-knowledge workers can earn over $30 an hour? I've written of a few over the years, here's a partial list:

1. A $15/hour minimum wage. Put pressure at the base.
2. Subsidize employment directly, or provide direct cash support (family allowance and the like), or do a mixture of both [4].
3. Learn from Germany and from Quebec's manufacturing sector.
4. Reduce corporate scale, favor smaller companies that employ more blue collar workers [5]
5. Get creative about small business generation - including a national small business generator.
6. Do public works and infrastructure that generate employment. I've been told the pharaohs built pyramids so laborers had work between flooding of the Nile. (The US military is one model for non-college public works employment.)
7. Review all our tax, accounting, finance and labor policies and revise to favor non-college employment.

This is what Biden needs to focus on.

- fn -

[1] One trade worker and one service worker couple can squeak in it as long as they don't have child care expenses and as long as they stay together.

[2] See also my pre-catastrophe 2015 post on why I was a "fan" (heavy irony) of Trump or a recent post/pre catastrophe retrospective. I've been on this topic for a long time though my thoughts have evolved quite a bit over 17 years.

[3] Deep and pervasive structural racism means there's great potential for increasing four year college participation in Black America. I don't think there's anywhere near that potential for White America.

[4] I think subsidized work has significant political, cultural, economic, psychological, and social advantages over direct cash subsidies -- but I'm not adverse to experimenting. 

[5] "Blue collar" is a historic synonym for Left Behind.

My 2015 post on why Trump was a sign of a healthy democracy

I'm on the way to writing about what I think should be Biden's #2 priority (#1 is undoing Trump's executive orders). Three previous in this series include: 

1. How I think about the Trump voter (and America)
2. What is middle class and why can't half of American voters get there?
3. Biden's lost agenda

This fourth post is about something I wrote in 2015. Back then I thought Trump was a bad joke. I thought that American politics was a compromise between corporations, powerful (wealthy) individuals, and the voting masses. Clearly corporations and the wealthy would prefer many GOP candidates over Trump, and the masses alone would not be enough.

Yay masses.

Now, amidst the smoldering wreckage, I'm going to quote from that old misguided post (emphases added): 

Donald Trump is a sign of a healthy democracy. Really.

... I’m a fan because Trump appears to be channeling the most important cohort in the modern world — people who are not going to complete the advanced academic track we call college. Canada has the world’s highest “college” graduation rate at 55.8%, but that number is heavily biased by programs that can resemble the senior year of American High School (in Quebec, CEGEP, like mine). If we adjust for that bias, and recognizing that nobody does better than Canada, it’s plausible, even likely, that no more than half of the population of the industrialized world is going to complete the minimum requirements for the “knowledge work” and “creative work” that dominates the modern economy.

... This [never-college] cohort, about 40% of the human race, has experienced at least 40 years of declining income and shrinking employment opportunities. We no longer employ millions of clerks to file papers, or harvest crops, or dig ditches, or fill gas tanks or even assemble cars. That work has gone, some to other countries but most to automation. Those jobs aren’t coming back.

The future for about half of all Americans, and all humans, looks grim. When Trump talks to his white audience about immigrants taking jobs and betrayal by the elite he is starting a conversation we need to have. 

It doesn’t matter that Trump is a buffoon, or that restricting immigration won’t make any difference. It matters that the conversation is starting. After all, how far do you think anyone would get telling 40% of America that there is no place for them in current order because they’re not “smart” enough?

Yeah, not very far at all.

This is how democracy deals with hard conversations. It begins with yelling and ranting and blowhards. Eventually the conversation mutates. Painful thoughts become less painful. Facts are slowly accepted. Solutions begin to emerge.

Donald Trump is good for democracy, good for America, and good for the world.

"Good for democracy" except, of course, the white non-college masses spoke clearly back in 2016. An actual "President Trump" was unthinkable, but it happened. I do not underestimate him now.

So that part of the post did not hold up so well. But I stand by the part about making the never-college 40-50% of Americans a political focus. More on that when I write the fifth post in this series.

See also

• Unemployment and the new American economy - with some fixes (Jan 2011)
• Rubio, Sanders and the President Gordon agenda (Mar 2016)

Monitoring the patient with chronic kidney disease -- my ABFM QI project criteria

Every three years I have to do a quality improvement project to maintain my family medicine board status.  This year I decided to focus on my patients with moderate chronic kidney disease. I have access to a report that identifies the patients of interest so all I need to do for the project is upgrade their care.

To do that I had to put together a list of things to do by reading the short "pocket card" version of the VA/DoD care guidelines (I'm too lazy to read the entire long thing). I then ran it past a friend who is a leading research nephrologist to comment on which of the guideline actions were really valuable.

I liked the result so much I'll share it here. The numbered items are what I took from the guidelines, the comments in () are his corrections, the comments in [] are my later thoughts. I think it's most interesting to read with both, I added emphases: 

As of Dec 2020:

1.       Measure urine alb/cr ratio yearly (sure in people with diabetes not on ace/arb)

2.       Measure Cr yearly (ok- not great evidence) [U/A, micro albumin, Iron]

3.       ACE/ARB for all but not both (if htn and/or microalbuminuria – or chf) [so implies measure for microalbuminuria along with yearly Cr]

4.       Oral iron therapy (if iron deficient, or starting epo) [so, contra guideline, not routinely, but implies check iron yearly?]

5.       If Hgb < 10 consult for erythropoietin (I’d wait till < 9 – no evidence for greater)

6.       DM

a.       Evaluate metform if CrCl < 40 (ok)

b.       SGLT-2 (empagiflozin, etc) inhibitor if stage 1-3 and DM (can go down to egfr of 30)

c.       GPL-1 agonist (liraglutide)  (no good evidence beyond sglt2) [contra guideline]

7.       If GFR < 60 then BP < 140/90 (I think this would be for most people)

8.       Do cystatin-C GFR one time (never unless paraplegic or loss of muscle mass – amputation) [contra guideline]

9.       If not Diabetic need at least one renal imaging study [I made this one up, but seemed to follow] (sure)

10.   Apply Kidney Failure Risk Calculator (Navdeep Tangri, MDCalc) (sure)

11.   Stage 3 and above: dietary consult

a.       Bicarbonate supplementation if metabolic acidosis (if bicarb < 18)

b.       Dietary sodium restrictions (yes – for all those with htn)

c.       Protein 0.6-0.8 g/kg/day (skip this one – good evidence – hard to do) [Curbsiders had recent podcast saying same]

12.   Stage 3 and above need a PTH measured (never measure pth in ckd unless hypercalcemia) [contra pocket card guideline so many a mistake in that] 

Biden's lost agenda

In the Fall of 2020 the American people decided to dump Trump. Americans didn't agree on much else; voters rejected significant change. Overall the result did not surprise me, especially given the summer riots and the "defund the police" movement.

Biden's agenda is mostly history. Except for the most important part. I'm going to get to that in a future post (it's not student loan forgiveness!), but first I want to reference the future America rejected. I'll use George Packer's summary in the Oct issue of The Atlantic (emphases mine):

America’s Plastic Hour Is Upon Us

... The scale of Biden’s agenda is breathtaking. At its center is a huge jobs program. A Biden administration would invest $2 trillion in infrastructure and clean energy. He proposes creating 3 million jobs in early education, child care, and elderly care—sectors usually regarded as “soft” and neglected by presidential candidates—while raising their pay and status. “This economic crisis has hit women the hardest,” Sullivan said. “These care jobs are primarily jobs filled by women—and disproportionately women of color and immigrant women—but they don’t pay a fair wage, and the opportunities to advance aren’t there. This is a big, ambitious, bold proposal—not an afterthought, but at the core.” Another $700 billion would go to stimulating demand and innovation in domestic manufacturing for a range of essential industries such as medical supplies, microelectronics, and artificial intelligence. Some $30 billion would go to minority-owned businesses as part of a larger effort to reduce the racial wealth gap.

Biden is proposing industrial policy—massive, targeted investment to restructure production for national goals—something that no president has openly embraced since the 1940s. His agenda would also give workers more power, with paid family and medical leave, paid sick days, a public option for health care, and an easier path to organizing and joining unions. It would more than double the federal minimum wage, to $15 an hour ...

Ok, that's the agenda that was. Wave good-bye to it, but don't give up entirely. There's something in there that can be saved.

What is middle class and what percentage of American voters can't get there?

What would make someone "middle class" in 2020?

I like to think of this in terms of what a "middle class" 30 yo adult should have or be able to do without inherited wealth [1]:

• basic health, life, dental, and disability insurance.
• enough savings to live without income for 3 months.
• at least two weeks of vacation a year plus holiday
• ability to take the family on a local or auto based holiday
• cover the basics: food, utilities, broadband, mobile phone, automobile, two laptops, a game console, netflix, a bicycle
• together with a partner
• enough income to cover a 15 year mortgage on an average American non-urban home with good-enough public school services
• enough income to raise up to two children to adulthood (but not pay for their college -- that's upper class)
• a second car

That's not a comprehensive list, but I think it's not hard to fill in the rest. Things that are often beyond middle class include:

• international travel
• paying for children's college education
• a short commute
• weekly restaurant meals
• multiple bicycles
• substantial savings esp. retirement savings
• routinely buying work lunch
• multiple streaming services, cable TV
• a subscription to the New York Times digital services (this is a problem)

How much compensation, including income and benefits, does it take to be middle class today?

In the absence of good data my impression is that a new teacher is at the very bottom of middle class (compensation increases over time). Salary.com says the range for all teachers is $50K-$74 plus. Add on benefits that are worth at least $10K and the entry to middle class America in 2020 is probably $60K for an individual. 

A 2014 Pew report article on "middle income" estimated that "a three-person household would have to earn between $42,000 and $126,000. I believe that number omits benefits so it supports my $60K compensation number as a good reference. 

For a 50 week year at 40 hours a week a $60K/year compensation works out to about $30/hour or twice peak minimum wage. Google tells me the hourly wage for a plumber or electrician is about $25/hour, enlisted American soldiers get $20/hour but with benefits and allowances for food, housing, etc they may be in the $25 range. In 2000 motor vehicle manufacturing workers made a similar $20 hour, with benefits that might get compensation up to $22/hour. In US government a GS-7 level is about as high as one can get without a college degree and it maxes out at about $50K/year -- just barely middle class given benefits.

All of these are below my "middle class" threshold though federal employment comes closest.

It's hard to make it into the American middle class range without a college degree or some degree of business ownership [2]. Since no country on earth has gotten much more than 50% of young adults through college this means a middle-class-or-better life, which still comes with quite a bit of economic stress and uncertainty, is only available to about half of Americans.

Half of US voters unable to attain the basics of the bottom of the middle-class is not a politically viable situation. More on that in a post that updates this one.

- fn -

[1] If you live in American for a while it eventually dawns on one that a lot of white folk inherit a substantial amount of money. I'm excluding that from this definition but it does explain some unusual consumption patterns.

[2] Bruce Springsteen, Bill Gates, Steve Jobs, Wayne Gretzky, yada yada ya. Don't make me come down and bop you.

How I think about the Trump voter and America

A few days ago I listed about 25 reasons that Donald Trump should not be President. Any one of them is sufficient by itself.

There are lots of lists like that. Every science and reality oriented publication in America had its own list. All opposed Trump. All recognized that beyond his venality and incompetence democracy was also at stake.

And yet ...  he almost won reelection. The GOP held the Senate. Dems lost some House seats. The polls were wrong again (I blame the iPhone for the polls - ask me why).

So what do I think about America in general and the Trump voter in particular?

America is what it has always been. Some decades it does better, some worse, but in general it's a rough neighborhood. We were born from slavery and genocide, we fight lots of wars, we don't have universal healthcare, we tolerate mass shootings of children, we have large majorities that support torture of prisoners, we fund public education with local taxation and college through massive debt, we tolerate systemic anti-Black racism, we allow suppression of Black voting, we reelected GWB despite his torture program and the misdirected conquest of Iraq. We did well with higher education and science for a while, but the GOP attacks on science have done grave damage.

We aren't the worst of nations. China, Russia, North Korea, Germany in the early 21st century ... there are lots worse than us. We aren't the best of nations. Canada, the Nordics, South Korea, most of Europe, Japan are all better. Among post-industrial nations we are probably somewhere in the bottom third, but I could maybe argue for being average. Which makes sense -- we are made of humans and we're big and diverse enough to have a representative sample. Our Presidential system and electoral college and our history drive us down a notch or two.

That's America. What about the Trump voter?

I divide the Trump voters into slices. The biggest and most important are the "White* Left Behind". They are a diverse group, but in general they do not have the cognitive traits to be a "knowledge worker". They did not attend college and college would have been a poor use of their time and money. They don't read newspapers, they don't reason out their vote, they vote based on tribe and emotion. They are more or less anti-Black racist but they don't think they are being unfair. They are desperate to work but there are few good jobs for them. Living in an increasingly high tech and complex world they are every day reminded that they can't keep up. They live on the edge.

Trump's genius was exploiting the WLB while showing them that they have real political power. I don't blame the WLB for voting Trump. They are as much victim as they are aggressor.

The religious fundamentalist is another slice. A complicated slice. For some religion is a shallow facade they may assume or discard as needed. Others have a deep conviction that to me shades into delusion -- but I respect delusion. The universe is a vast and terrible place dominated by violence and entropy -- we all need some delusion. If you believe that every terminated ovum is a murder, and you know Trump will suppress abortion, then that outweighs all his other crimes. You might even decide to worship him. 

I don't much blame the religious fundamentalist for voting Trump. They may be rationally choosing based on their fixed belief.

That leaves those who are not dominated by religious belief and who won enough of the cognitive lottery to be able to read newspapers, to remember what happened weeks or months or even years ago, and to make an informed decision.  They may feel that democracy is hopeless, that authoritarian rule is inevitable, and they want to be on the side of the winner. They may care only about their wealth and privilege and feel Trump will best defend them. They may be fully racist -- generally anti-Black racist rather than pan-racist. (Anti-Black racism is far from a White-only thing.) They may enjoy living in an authoritarian society where they are commanded by superiors and able to command the inferior.

They are the elite Trump voter. I blame them. They have chosen a wrong path. They can redeem themselves in future, but for now I cannot be their friend.

* As of 2020 American "White" may include Latino/Hispanic. That boundary has long been fluid.

The Trump I remember

It's Nov 6, 2020 and I believe Trump's presidency is ending. I look forward to forgetting him, but one day I'll be asked what all the fuss was about.

For that day, to remind me, here is what I know of him know:

1. The crimes for which he was impeached -- extorting a foreign power to attack a political opponent.
2. The crimes for which he was not impeached -- the collusion with Russia against HRC.
3. The obstruction of justice.
4. The personal corruption.
5. The corruption of government and of industry, including running a protection racket against businesses.
6. The casual racism.
7. The people who worked for him.
8. The anti-science -- from CO2 to COVID to the environment and beyond.
9. Inserting Christian fundamentalism into American government.
10. The constant lying. (He was paradoxically transparent however. An accusation was invariably a confession.)
11. His mockery of persons with disabilities.
12. The threats and the cruelty. Not least the separation of migrant children and parents.
13. The stupidity. He really didn't seem to know very much about anything beyond corruption and real estate.
14. The propaganda.
15. The destruction of the ACA without a replacement.
16. The complete disinterest in art, culture, and the humanities.
17. The destruction of government agencies.
18. A complete lack of honor, compassion, or decency.
19. COVID mismanagement.
20. QAnon.
21. The authoritarianism.
22. The pardons. (Remember Al Kinani)
23. The post-election conduct.
24. The record-breaking federal executions.
25. The Gallagher war crime pardon
26. The illegal destruction of government records. 

As of Nov 2020 McSweeney's has a list, NYT Magazine did an interactive summary, The Atlantic had many articles summarized in their Biden endorsement:

...he has divided our people; he has pitted race against race; he has corrupted our democracy; he has shown contempt for American ideals; he has made cruelty a sacrament; he has provided comfort to propagators of hate; he has abandoned America’s allies; he has aligned himself with dictators; he has encouraged terrorism and mob violence; he has undermined the agencies and departments of government; he has despoiled the environment; he has opposed free speech; he has lied frenetically and evangelized for conspiracism; he has stolen children from their parents; he has made himself an advocate of a hostile foreign power; and he has failed to protect America from a ravaging virus"

Was there anything he did that was good?

1. Accepting North Korea as a nuclear power. It was the only viable choice, but I'm not sure HRC could have taken it (esp. with a GOP Congress).
2. He understood the Left Behind -- the majority of Americans who will never be knowledge workers. I don't think my team gets this. He didn't know what to do for them, but he knew what they wanted.

Update 1/18/21 - adding Unthinkable from The Atlantic.

What I would add to the standard blog model

The combination of RSS and the basic blog post is almost perfect. There are, however, a few things that would make them even better as a way to share information in most organizations.

1. Provide an email summary option that is generated on post, daily, or weekly. (SharePoint does this for some list types.)
2. Add a Publication Date in addition to the Last Modified date and make the Publication Date both the primary sort field and make it user editable without changing the URL. That way a publisher can choose to easily replace a topical post with a newer version and optionally republish it as new. (For organizational use the historical record is unimportant.)
3. Author control of notification generation. There's no need to generate a fresh RSS entry or email update for the correction of a few typos or other minor changes.
4. Easy sharing of articles by email and other 'send' modalities.
5. Tags with tag specific rss and views (many blogs do this).
6. Editing tags should not generate notifications.

That's all. No comments -- in practice I think these can occur elsewhere.

PS. It looks like Blogger has broken tags/labels as of today! So this post has none.