ArizonaRoom

Government is not a business

2011-07-27T00:29:00.000-07:00

Those who compare government to a business have it all wrong. Business exists for the purpose of “making” money. Sometimes it actually does, sometimes it loses money, but the very definition of business is the spending of money for the intended purpose of making more.

Government does not exist for the purpose of making money. The purpose of government is to provide services. Traditionally, governments provide currency, transportation routes, water and sewer services, civil law and order, and military forces. Governments provide whatever services the sovereign power decrees. In the United States, only seventeen sovereign powers are vested in the Congress, whereas most traditional sovereign power is vested in the States. Most of the services provided by government cannot be provided for a profit, and many businesses that have tried to provide these services have gone bankrupt instead.

Government finance is quite unlike business finance. In business, a group of hopefuls plan to make money, then raise capital, spend what it takes to carry out the plan, and, if they run out of money before they make any profits, go broke. The government, unlike a business, has the power to compel income via the collection of taxes, and thus the ability to be assured of some income no matter what. Businesses operate using existing currency. National governments have the power to create money and declare its value. A bankrupt business goes away, its employees go away, its assets are sold off, and it is gone. A bankrupt government may change its leaders, but still remains the sovereign power in its jurisdiction, and still has the power to tax and the responsibility to provide for the common defense and promote the general welfare. Bankrupt government does not go away, although it may be replaced by another, which may become solvent by the expedient of declaring the debt of the preceding government void.

Businesses and governments both borrow money at interest in order to make payments greater than net cash on hand. Business debt requires collateral, but sovereign debt is backed by the tax base of the borrower country alone. Business creditors can seize property, but creditors holding sovereign debt cannot, nor even sue for payment without government consent. Commercial debt has a credit limit, the maximum amount of credit that the lender will extend to the borrower. Sovereign debt has no formal limit, merely the authority of the government to go borrow as enacted. In a monarchy, the King does not need parliamentary permission to take out new loans. In the United States, the Constitution grants Congress the power to take out loans, but Congress has neither staff nor bureaucrats to do the paperwork, so we have the Treasury telling Congress it needs more money with which to pay enacted disbursements, and Congress telling Treasury to go sell more bonds to raise the cash. This borrowing authorization up to a specified amount is called the “debt ceiling” by the media, a fairly inaccurate label. It limits the authority of the Treasury to sell US bonds, but does not limit the power of Congress to incur debt by enacting spending that revenue does not cover.

When currency is made of precious metal, it has inherent value as a commodity. All ancestral media of exchange had inherent value as commodities, but a government is able to create currency whose value is its word, the coins and paper having only symbolic rather than actual value. It has been the practice for major trading nations to issue fiat currency like this worldwide since about 1850, and there is now too little gold or silver in the world for the US economy to go back to precious coinage at any price. Just to even up the amount of currency with the amount of metal at current prices would require a tremendous devaluation of the currency (i.e., a tremendous price increase for the commodity.) The value of fiat currency is not tied to commodities at all, but is tied to the word of the issuing sovereignty – if a government with fiat currency and bonds goes back on its word, its currency loses value and its credit costs go up.

When a nation issues sovereign debt, the only value it has is the expectation of future solvency of that nation, with tax revenues to pay off with. As a nation approaches insolvency, buyers sell its debt in trade for that of more solvent or wealthier nations. The distance from insolvency of a nation can be measured in part, by the demand for its debt outside its own borders. The nation least likely to go broke soon is the one whose debt is most widely held, whose currency is the standard in world trade. Since 1945, world trade has been conducted in US dollars, and demand for US sovereign debt is still higher than that for any other nation. As long as the United States keeps its financial word, US dollars and US bonds will be considered “as good as gold”, even though their value is entirely promissory.

As of this writing, the United States is in the 27^th month of slow recovery from a multi-trillion dollar capital crash in the fall of 2008 (full recovery from capital crashes takes three to four years.) Unemployment is at historically high but not unprecedented levels. Revenues, based on taxable incomes, are the lowest as a proportion of GDP since the 1950s, while spending exceeds revenues by 44 cents of every dollar spent. The Congress more than doubled the national debt during the W Bush Administration, lowering taxes at the top while increasing both budgeted and off-budget spending, including two hugely expensive Asian wars funded as “supplementary” spending, together exceeding the amount of entire budget itself, which was in deficit even without them. The capital crash blew away over a trillion dollars in book value, capping eight years of declining employment with a burst of even greater unemployment. It is not good to have to borrow another two trillion dollars just to keep the economy barely afloat for two more years, but that is the present circumstance.

John Maynard Keynes proved that national economies, unlike businesses or households, do not actually have to break even, as long as their credit lasts. He showed that spending was the basis for modern western economies, that both government and private sectors stimulate the economy by spending, and that government spending on sovereign credit can keep GDP up during a collapse in private spending. While business is advised to follow the business cycle, expanding during a boom and contracting during a bust, government cannot do the same and meet its obligation to promote the general welfare. Keynes theory has been demonstrated to be correct – if the government grows during busts and shrinks during booms, opposite to business, the general welfare can be sustained while sovereign credit is sustained too. If government contracts when business and households contract, the economy enters a deflationary spiral and a depression ensues. The government must raise taxes during good times to retire the debt incurred during bad times, the opposite of sound business management. It works because the government is not, after all, a business, nor enough alike to one to be run as if it were. Keynes called this phenomenon the “paradox of thrift”, because the same thrift that businesses practice to their benefit during an economic slump is disastrous for the economy as a whole when practiced by the government. Counter-intuitively, unlike a business, a government actually can spend the economy into recovery on borrowed money!

The next time you hear someone say that the government has to operate more like a business or a household, tell them that they do not know what they are talking about. They don’t.

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2011-05-10T23:49:00.000-07:00

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Probiotics: Has enthusiasm outpaced the evidence?

2011-05-10T16:19:00.000-07:00

As a Internal Medicine clinician I see a large portion of patients who present with acute onset diarrhea. Viral etiologies are the most likely cause accounting for nearly 90% . Other causes include antibiotic associated diarrhea, known as Clostridium Dificille (C. diff) or pseudomembranous colitis, because of the way the bacteria create a layer (membrane) along the colonic border. Less comon causes could be contributed to toxin mediated (food poisoning) and others could be from Hepatitis A, E coli and or travelers diarrhea. Giarida (from drinking the water in Mexico) is something we always ask about especially here in Tucson, Arizona.

I have been asked before, and have thought about the use of Probiotics as an adjunctive treatment for acute diarrhea. Is there good evidence to support there use? Are there any negative consequences as you are introducing bacteria and live cultures to the "normal" gut flora. I decided to investigate. Below are some quotations from various studies. See for yourself and decide. I will end with a brief discussion and reccomendation.

1. 2010 Nov 10;(11):CD003048. Cocharane databse systematic review.

Probiotics for treating acute infectious diarrhea:

This was a review of 63 studies from a medical journal database search.
No adverse events were reported. They concluded that probiotics decreased the duration of diarrhea although the size of the effect varied considerably between studies.

"Used alongside rehydration therapy, probiotics appear to be safe and have clear beneficial effects in shortening the duration and reducing stool frequency in acute infectious diarrhoea. However, more research is needed to guide the use of particular probiotic regimens in specific patient groups."

2. J Clin Gastroenterol. 2011 May 5.

A Randomized, Double-blind, Placebo-controlled Pilot Study of Lactobacillus reuteri ATCC 55730 for the Prevention of Antibiotic-associated Diarrhea in Hospitalized Adults.

This is a study just published last week where they conducted a double blinded placebo controlled initiative on patients who were recieving antibiotic therapy. The end point was diarrhea from any cause.
"Thirteen patients received L. reuteri and 10 received placebo. Patients treated with L. reuteri had a significantly lower frequency of diarrhea compared with placebo 50% in the placebo group vs. 7.7% in the probiotic group, P=0.02"

CONCLUSIONS:

"In this placebo-controlled, pilot study, L. reuteri twice daily for 4 weeks significantly decreased AAD among hospitalized adults. L. reuteri was safe and well tolerated."

3. J Nutr Health Aging. 2011 Mar;15(3):215-20.

Probiotics improve bowel movements in hospitalized elderly patients--the PROAGE study.

Daily probiotics were given to elderly patients in Geriatric Orthopedic Rehabilitation Department for 45 days.
"Throughout the 45 days of follow-up, the incidence of diarrhea was significantly lower among the study group (HR=0.42, p=0.04) with a more pronounced difference among participants aged ≥ 80 y (HR=0.32, p=0.026). "

CONCLUSION:

"We showed that probiotic supplements may have a positive effect on bowel movements among orthopedic rehabilitation elderly patients."

Lastly after reading UpToDate (an evidence based, peer reviewed information resource) they quote the following: "It is reasonable to recommend probiotics to adults and children with presumed infectious diarrheal illness with the hope of reducing the duration of symptoms by 17 to 30 hours."

Discussion:
Given the smattering of evidence as indicated above and the safety of probiotic regimens, I believe in acute infections diarrea, it is reasonable to administer lactobacillus within the first 48 hours of symptoms. There is no FDA approved treatment or amount. Until there are more definitive double blinded multicenter placebo controlled studies in specific patient populations and at specific doses we cannot reccomend more broad usage of these promising treatments.

What now in Afghanistan?

2011-05-03T16:02:00.000-07:00

As we view with pride the killing of Osama Bin Laden, we look across the border there to Afghanistan, where the 2011 fighting season is about to begin. If what we are looking at is body counts, we in Arizona are also looking south into Mexico where violent crime associated with the black market in drugs has filled mass graves. There are gun battles between law enforcement authorities and drug producers and distributors everywhere, there are huge numbers of minor drug dealers in prison, and there really is no appreciable drop in the frequency of overdose, accidents while driving under the influence, and family abuse consequent to drug addiction.

The analysis in the establishment press goes like this: see all the harm done in the war on drugs, so we must prosecute it all the harder. The question of relative costs and benefits is not asked. What if the violence is the result of, not the reason for, drug prohibition? What social benefit if any is achieved by current policy? Is there no alternative policy that would get better results for less cost?

What would happen if we no longer prohibited the prescribing of now wholly illegal drugs? What if we left it to the doctors to decide how much to give a patient, provided no doctor was their own patient? What if, instead of attacking drugs on the supply side, we focus all efforts on reducing demand? Demand is what drives any market, anyway, no matter what the statutes say and no matter what entrepreneurs do about supply. You can only sell what the buyers are willing to buy.

The United States once amended its Constitution to outlaw intoxicating alcoholic beverages. Thirteen years later, it was amended back, it being understood that Prohibition had failed. The end of Prohibition ended the gunfights over alcohol. It took the outlaw glamor away from "speak-easies", which became “night clubs”, their numbers shrinking even as their quality improved. Alcoholism became a medical problem, not a crime, eventually losing ground to the 12-step programs. Alcohol abuse is much less of a problem now that alcohol is a normal, licensed and taxed, commodity. Revenue agents only pursue unlicensed production on which taxes are not being paid. Moonshiners don’t have gunfights anymore. Advertising is the largest expense now in the effort to reduce alcohol abuse.

If the mission of United States forces in Afghanistan is to eliminate opium production there, it is quite unlikely to succeed. Afghanistan will remain, like Mexico, a battle field between US proxies and local drug producers. It is the law against them that makes these substances expensive enough to kill for. It is preposterous to think that there will ever be a more valuable crop than opium gum in some parts of Afghanistan, anyway, as there has not been since the dawn of local history. “Chinese” opium was made from Afghan gum balls before the time of Marco Polo, nine hundred years ago.

We can leave Afghanistan for good come summer, if we broker a settlement among the present native factions now that Bin Laden is gone. But we have to forget that drug thing.

Wasteful Government Spending

2011-04-13T14:34:00.000-07:00

The general public, in response to polling, shows that it has a false view of government spending, how it occurs, and how much of it is spent for what. Much blame is heaped upon the President. Government is represented as grossly inefficient simply because it is unprofitable. Bureaucrats are criticized for not doing more. Government regulation is depicted as both lax and oppressive. The man in street believes that "foreign aid" and support for arts and sciences are substantial fractions of the current deficit.

If you do the homework, check the data, and watch the boring hearings in Congress, you will find that the truth is something else. There are huge sums in past "war spending" not accounted for, but demonstrable waste, fraud and abuse together are a very small fraction of total expenditure. The biggest expenses at the Federal level are benefits checks and the biggest expenses at State and local levels are civil servant salaries. It is a proven fact that the number of bureaucrats assigned to audit is far too few to assure prevention of violations of law much less to assure apprehension and punishment of lawbreakers after the fact. The government is actually too small to keep a good watch on its own books

There are two kinds of "wasteful spending" by government. The first is buying things it does not need at prices it cannot afford. Secretary of Defense Bob Gates has identified $221 out of $700 billion spent by his department on programs for which "there is no mission." Every dollar of Defense spending must be spent on a mission if it is not to be wasted. These $221B can just be cut without any effect on "national security."

The other is the distribution of cash to those in no respect short of it, as an entitled benefit for membership in a statutory class. There are millions of Americans who depend for their food and shelter upon government checks. There are thousands who receive as much benefit without need because the statutes are written that way. The statutes are written by Congress. Statutes can be struck down in part or as a whole by courts, but the President is obligated to execute them as written. The President can merely propose, and then must either wholly accept or wholly reject what Congress sends him. Whatever wasteful spending the executive does is just exactly that which was enacted by the Congress.

The fact is that government revenues go up and down as the economy goes up and down. It is easy to collect taxes and give away money in a boom. It gets harder as private enterprise decreases. If private enterprise stops, and the government does nothing, the economy itself vanishes. The reason that governments are constituted to undertake debt is so that Defense and general welfare are not wholly at the mercy of the business cycle. The idea is to tax the booms and borrow the busts, the exact opposite of what households and businesses must do - spend the booms and contract in the busts. This is why all talk of running the government "like a business" is foolishness. Government is government, not business, and must be run like government if it is to run at all.

A national government has the power to create money and to survive in deficit as long as its credit is good. It is the critical need that the government act to strengthen, not weaken, its credit. Shutting down on reaching a statutory debt ceiling will certainly weaken, not strengthen, US credit. To strengthen credit you have to demonstrate the ability to collect revenue, by, for example, rescinding the Bush Tax Cuts for the rich! That, according to the math, is half or more of the deficit by itself.

The Real Deficit

2011-04-09T01:04:00.000-07:00

The real deficit is not a line on a balance sheet. It is the difference between what Congress spends and what Congress collects. Few if any participants in the political arena are prepared to really explain the stakes. The largest category of expenditures is entitlements. Any attempt to reduce expenditures enough to eliminate the deficit without reducing entitlements is doomed. There is just not enough else.

The fastest growing expenditures under entitlements are for medical care. Projecting present trends forward, Medicare would become the bulk of all Federal expenditure. Medicare rules changes enacted under "Obamacare" may head that off, if implemented. The officially indeterminate savings could be anywhere from nothing to $3.6 trillion over the next 25 years, if the new rules are not blindly repealed. Every senior who refuses to die in ICU saves $500,000 in "health care" expenses and experiences a more comfortable and humane passing. When word gets out, who knows how many will repudiate life at any cost regardless of quality?

After Medicare, ahead of Social Security, is Defense. The United States spends about $700 billion annually on Defense. Some Congresses have over-appropriated for Defense so much that the civil service had to literally throw it away every year in order to not break the law. Current spending includes about $220 billion for which Secretary Bob Gates says "there is no mission." This is a substantial fraction of the present deficit. In effect, a 30% cut in "Defense" spending gives a 50% cut in the deficit. Given the statement about mission, any assertion that this cut would "weaken our Defense " is unsubstantiable.

Social Security is in a bit of a fiscal crisis, Congress having borrowed the trust funds and simply made transfer payments from collections since. Collections are now too small a fraction of benefits, and there is a risk that the current retiring generation cannot be supported by the current Social Security taxpayers. However, the maximum amount of income subject to Social Security taxation has not kept up with wage inflation and benefit inflation, and is now only 2/3 the value it was in real dollars the last time the cap was raised. The cap can easily be raised enough to keep the system solvent through the Baby Boom retirement, by separate Act of Congress.

As for taxes being too high. they are too high in the middle incomes because they are too low at the high incomes. At the time Ronald Reagan began the Republican policy of lowering the top tax rates, rates were between 70 and 90% of the marginal dollar in the highest bracket. An economist named Arthur Laffer published a paper describing the relationship of revenue and tax rates, with government revenue actually increasing as rates dropped from the 70s to the 50s of a a percent of marginal top dollars. However, as top marginal levies drop below half, government revenue declines, with lower taxes lowering revenues from there. The present 30% top marginal rate, the "Bush tax cuts", has always been projected as bankrupting the government eventually. That is the principal reason they were never made permanent. We actually have a law against permanent tax rates that calculate inevitably to bankruptcy when projected. The greatest likelihood is that setting top marginal income tax rates at 49% and requiring years instead of months for a gain to be considered a capital gain would actually stimulate the economy and job growth the way the "Bush tax cuts" were supposed to but actually did not.

If you are attracted to a flat tax as a "fair tax", you are chasing an impossible vision. All taxes are inherently "not fair" - they seize wealth from some members of the citizenry, by force if necessary. The power to levy taxes is the heaviest sovereign power, in that all are taxed somehow by some level of government. What matters about taxes is not how many dollars or how many percent of income you pay - it is what you have left after taxes that counts. Ten percent tax is a lot more to a thousand a month laborer, who then has $900 left, than to a million a month financial trader, who has $900,000 left. That is why "progressive" income taxes increase with income - the more you make, the more you actually can afford to pay! If there is no limit to incomes in the economy, someone somewhere is making so much money that if you did take 90% of the margin from there they would not notice its absence. How high is it fair to tax someone who is insensitive to taxes entirely due to the size of their wealth?

One can, instead of being fair, be efficient, and distribute the "deprivation" of wealth through taxes somewhat in proportion to the wealth remaining. Based on Laffer's calculations, the top marginal tax rate should be between 40 and 60% of every additional net income dollar - the peak in government revenue versus tax rate falls in this range. Above half can be considered confiscatory ethically anyhow - the government benefits more than the earner from the added value. At 49%, the earner is always two points up on the "tax man." If the 49% rate does not kick in until the second net million, or the tenth net million, or at some point where the earner no longer cares either, it becomes a mere nuisance rather than a burden to those who pay it but remains a cash cow to the Treasury. If a level of income is officially declared to be poverty, those who earn little or no more surely should pay no tax. Rates should scale up from zero to 49% as a first derivative of income greater than "poverty." You could calculate rates directly from the distribution of incomes itself. The Congress could still promote specific behaviors by declaring the profits or net income from specific activities tax free for a time.

There you have it. The government spends too much on Medicare because too many terminally ill patients spend their last days of life in intensive care. Almost 35% of the Defense budget has no defense justification. Social Security taxes on incomes are capped at much too low a level. Progressive income taxes now flatten out at too low a top marginal rate to sustain the government, which the Congress has been told, many times, by its own CBO. These are the big dollar facts. All of non-Defense discretionary spending is not even half the deficit. It is less than the $220 billion that Bob Gates says has no mission.

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2011-04-04T14:15:00.000-07:00

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Balancing the Budget

2011-04-04T13:51:00.000-07:00

The current political conflict over the American Federal deficit would be entertaining if the outcome was not critical to American wealth. The degree to which misconceptions and untruths dominate the discussion is overwhelming.

The Constitution requires the President to annually submit a budget for revenues and operations in the coming fiscal year. The House of Representatives must originate all tax and spending laws, but those must also pass the Senate and escape Presidential veto in order to go into effect. Congress is not required to pass the President's budget, nor pass any other, nor adhere to any budget it does pass. In effect, all Congressional debate and resolution about "budget" that is not an actual revenue measure or an actual spending measure is mere political theater of no importance in practice whatsoever. The Congress traditionally spends months on its own budget and then adopts a few omnibus appropriations bills that have no relationship whatsoever to that budget. The difference between revenue from taxes and spending via appropriations constitutes the deficit - the budget is wholly irrelevant.

While national deficits are not irrelevant, they are also not primary for the wealth of the economy and the body politic. The United States has run an annual deficit for about 200 of its 227 year history, and even repudiated some of its Revolutionary War debt. The United States is a wealthy country because of the agricultural, mineral, and manufactured products it produces, regardless of Federal taxes, Federal spending, Federal deficits and the national debt. Nations are not businesses - they can seize wealth and create currency, lawfully, neither of which even the largest private enterprise can do. Business credit depends on a business plan that will eventually produce a profit. Government credit depends on the prospect of its being able to raise enough in taxes to repay its long and short term bonds. The ability of a government to operate in deficit is limited only by the proportion of its revenue required to pay the interest on its debts. By such measures, US national debt is not yet half of the amount we could potentially sustain.

What is relevant is that deficits are the shortfall between taxes taken in and money spent. In a democratic republic, the tension exists between promising to lower taxes and promising to do more about something. More costs money. If taxes enough are not collected, on the average, the national debt eventually does get too big to be carried. If too much money is given away to the benefit of too few, more others will suffer. It does not take talk to balance revenues and spending, it takes math homework and prudent estimation.

Math shows that you get closer to solvent faster by making the greatest gains where the problems have the greatest size. Usually, 80% of the problem is due to 20% of the causes, and one or two among that 20% are half of that. The largest categories on the Federal books, save interest, are entitlement payments (any cash payments under any statute: farm subsidies, resource depletion allowances, pensions and insurance benefits) and Defense expenditures. Some entitlements are historical anachronisms whose justification is long past The Defense budget is alleged to have more than $200 billion out of $700 billion in spending for which it has no mission, and which should therefore not be spent. It turns out that failing to index the taxable income cap under Social Security while indexing benefits caused the alleged deficit crisis there. One does not need to drastically cut the smallest 12% of expenditures to make an acceptable dent in a 30% shortfall. If we could impose and sustain a 30% increase in revenues, we would balance the budget without cutting any expenditures at all!

The fact is, the economy would not tolerate either a 30% tax increase nor the complete elimination of non-Defense discretionary spending. It probably could not tolerate a zero-deficit year, at least until private spending picks up again, without it precipitating another recession. Government can actually stimulate private spending by imposing confiscatory taxes with just the right "loopholes." It also can raise the general standard of living by assuming debt to cover it, but clever tax policy is more sustainable.

First you must accept realities. Then you do your math homework. Then you use every trick to sell the sound policy, mere truth being inadequate for the purpose. Then you work the Constitutional process to deliver the benefits named in its Preamble. You cut benefits to the few, raise taxes on the wealthiest, and convert health care from illness treatment to health maintenance and prevention. That's how to balance the "budget."

On Libya

2011-04-04T12:43:00.000-07:00

The first thing to keep in mind when making American foreign policy about other nations is that they are not our countries - as much as Americans have resented and fought foreign influence here, so will the most nationalist elements in any other country resent and fight American influence there. In some countries America has a lot of influence, in some it has little, but in no country besides our own are we in a position to dictate anything.

The second thing to keep in mind is that most countries in Europe, Africa and Asia have local civilizations much older than ours. Local politics is heavily influenced by local history, and local politics sets a limit on what policies can actually be put into effect and carried out. The only way for outside influences to have a beneficial effect is for those influences to respect local history and customs and work with popular forces rather than against them. Help unwanted and unasked for is almost universally seen as interference. Ultimately, the governed must consent to their own government regardless of the interests and wishes of all other nations.

Libya is a synthetic country, put together by treaty among European powers from pieces left from the defeat of the Ottoman Empire in World War I. There has been a nation-State headquartered in Tripoli since Roman times, but for much of the subsequent two thousand years there was a separate nation-State headquartered in Benghazi. For five hundred years under the Ottomans these two entities were governed as separate provinces. Traditional political organization was tribal, and tribal affiliations and conflicts continue to dominate Libya. Between the World Wars Libya was in the Italian sphere of influence - as a victorious WWI ally, Italy gained control of several former Ottoman provinces. Italy undertook a war of conquest to subjugate the Libyan tribes, but the outcome was inconclusive. The tribes had the choice of submitting to Italy or resisting and making common cause with Britain, during the Second World War, and the landscape became the principal battlefield for German/British tank battles. Libya entered the UN after the war as a monarchy. In traditional Ottoman style, government was corrupt, inefficient and undemocratic. When a military coup led by Colonel Muammar Gaddafi removed King Idriss, it was, at first, wildly popular, but after 40 years of equally corrupt, less democratic, and even insane government by Gaddafi, the regime is supported now only by those who are somehow paid to do so.

Gaddafi is crazy but not stupid. The populations of the east have revolted against rule from Tripoli many times in the past. Accordingly, government troops headquartered at Benghazi had less and lighter weaponry and less training than the more reliable loyal troops in the west. As was proven by Franco in the Spanish Civil War, the winners are the ones with the bigger and better army, given equal enthusiasm. If the present civil war in Libya is fought only by the Libyans only with current arsenals, Gaddafi will win, and if he runs true to prior form, he will then massacre civilians and execute any rebels he captures.

The surrounding political community is even more fed-up with Gaddafi than the Benghazis. No one in the world outside his family, his tribe, his mercenaries and his tribal allies wants to see him defeat this uprising in the usual brutal manner. However, sovereign powers retain the legal right to suppress insurrection within their borders, if they refrain from the kind of butchery of civilians now classified by international treaty as war crimes. The stated objective of the UN and Arab League resolutions is to prevent such butchery, not to explicitly remove Gaddafi. Nations must respect international law even when dealing with "outlaw" nations, in order to protect their own prerogatives if and when the shoe is on the other foot.

The United States government has good reason to want Gaddafi removed but cannot lawfully remove him. The Libyan rebels do not have the weaponry and training to defeat Gaddafi, even with allied air cover protecting them, even with allied air power destroying Gaddafi's punitive expeditions. It will require an unofficial and covert effort to arm and train the rebels - rich nations and individuals need to send weapons and mercenaries to Libya to defeat Gaddafi, but not as nations and not as overt foreign policy, in order for Gaddafi to be defeated.

It was a similar covert and unofficial program to arm the Israeli Yishuv that allowed the new State of Israel to survive its war with the Arab League. It was the lack of such an effort that allowed Francisco Franco and his Fascist allies to defeat the forces of democracy in Spain. The outcome in Libya hangs in the balance, beyond the scope of UN, US, and NATO authority.

Frank Zappa 1969

2011-04-01T20:19:00.000-07:00

Frank Zappa 1969
Central Park New York City
Mothers of Invention

Stangy gallery new pics

2011-03-27T21:42:00.001-07:00

Stangy Photos

2011-03-27T12:53:00.000-07:00

"Baby Egrets"
Ion Swamp SC

Kissing Birds

2011-03-25T17:11:00.000-07:00

"Kissing Babies"
Common Egrets

Wisconsin: budgets versus unions

2011-03-17T11:10:00.000-07:00

The Governor or Wisconsin has claimed that his State needs to restrict or eliminate public employee unions in order to balance its budget and keep it there. There may be some truth to the assertion that unfunded liabilities under current union contracts pose a danger of fiscal insolvency. However, the failure to save up to pay for pensions and the failure to deal responsibly with the rising cost of health care have nothing to do with unions, collective bargaining, or future union negotiations. The technical term for the arguments used by the Governor is sophistry - fancy argument that really has no bearing on the issues. You may also, if you wish, call them bullsh*t!

Point One - unfunded pensions costs are the result of promises made but not kept by prior management, whether public or private. When management agrees to provide future retirement for current workers, it also agrees to save and invest between the present and that future in order finance those costs. It is irresponsible management that ignores this obligation and then complains later that they cannot pay as promised. Those retirement plans that invested in the blind CDOs that collapsed were just being stupid - any blind "investment" is not an investment no matter how highly it is rated by Moody's - like Warren Buffet says, "never invest in anything you do not understand!"

Point Two - rising health care costs are overwhelmingly due to the practice of providing intensive care for the terminally ill. Not only is such care futile (these patients cannot possibly recover), it is unaffordably expensive (five times the cost of comfort care) and seriously inhumane. A few weeks of mere life itself, without any quality of life, is not worth 80% of your lifetime medical costs, especially when that amount is $600,000 per patient. This has absolutely nothing to do with unions.

Point Three - In Wisconsin, as under the Federal government as a whole, so called conservatives have pushed through a tax relief program for the rich that is uneconomical, unaffordable, and based on wholly false ideas about taxation and the economy. Giving money back to the rich as tax relief does not promote real investment, does not add to consumer spending, and makes no contribution to real economic growth. While it is true that top marginal income tax rates were too high during the 1950s (90% at the top), the real situation is that there is a bell shaped curve of government revenue versus top marginal income tax rates, so the best revenue and economic growth is achieved by setting income tax rates for the rich at the peak of the bell, between 40% and 60% of the last dollar, and then declining with declining income, so that the lowest economic class pays no taxes on income at all. Current tax rates are in fact much too low at the top (and a bit too high in the middle.) To continue to hold on to the idea that we must cut taxes to grow the economy when government revenue shortfall is one of the greatest threats to the economy is just plain stupid. Wisconsin faces a $140M deficit now, but that is mostly due to the $117M tax cut that the present Republican majority put through first.

Point Four - creating a crisis in order to drive some other change is conflation of issues. It is easier to resolve a political deadlock by lumping things together in one piece of legislation, but it is also easy to ram through some piece of junk by piggy-backing it on top of some crucial bill that must pass. The issue of union rights is regulatory, not budgetary. Using a fiscal crisis, whether real or manufactured, to make changes in non-fiscal law is trickery.

Let us be clear. The numbers do not respond to our hopes, our fears, or our theories. If you have not actually done all the math homework, you do not know what you are talking about!

"Life is Beautiful" or is it? Movies I reviewed this week

2011-03-15T18:12:00.000-07:00

Adjustment Bureau- I Saw this in the theater on Sunday. I liked it, didn't love it like a lot of people did. Tried to hard to hammer home the theme, too many scenes with a guy from the Adjustment Bureau explaining everything to Matt Damon (got a little repetitive).

Altered States- Didn't really like this too much either. Film was written by the great Paddy Chayefsky (Network). A lot of great ideas but poorly executed. Paddy didn't like it either, so much, he fought to get his name taken off the movie. Easy to see why. Maybe he should of just directed the thing himself, I mean he did write the novel it was based on.

Network
Adamus G Approved
Written by Paddy Chayefsky and Directed by Sidney Lumet. Hilarious movie about a T.V station's desperate need for ratings and what they are willing to do to get them. Faye Dunaway, Peter Finch, Beatrice Straight won Academy Awards for acting and Paddy Chayefsky won for Screenplay, however, it lost out to Rocky for Best Picture.

Life is Beautiful
Adamus G Approved
Written, Directed and Starring Roberto Benigni. Benigni won the oscar for best foreign film and best lead actor. It's a comedy/drama about a father and son trying to survive a concentration camp during World War II. I definitely recommend this movie.

Short Cuts- A three hour movie involving people's quest to find love, happiness, and redemption. Directed by Robert Altman, starring a whole slew of people that I don't feel like naming. I also liked this movie but didn't love it.

If you want to see a three hour movie about the same thing, I suggest you watch the greatest movie of all time, Magnolia, written and directed by my favorite director Paul Thomas Anderson (Boogie Nights, Punch Drunk Love, There Will Be Blood).

ADAMUS G

Top 10 guiding principles for better SLEEP

2011-03-14T18:06:00.000-07:00

1. Go to bed at the same time every night and wake up at the same time every morning (including the weekends).

2. Use your bed for Sleep and Sex ONLY

3. Avoid Caffeine in the afternoon (Caffeine has a half life, time it takes for half of the drug to be eliminated by the body, of approximately 5 hours)

4. Exercise regularly; preferably 4 hours or more before sleep

5. Avoid Alcohol and Cigarettes near bedtime (alcohol causes disordered sleep specifically decreasing REM sleep and cigarettes lead to stimulation)

6. Maintain a comfortable environment in your bedroom; cooler temperatures (ideally a consistent 68 degrees), minimal noise and darkness are key.

7. Make a list of your most pressing concerns or issues before bed and deal with these in the morning.

8. Avoid naps during the day or keep the naps to short “power naps” such as 30 minutes only

9. If you cannot fall asleep in approximately 20 minutes get out of bed and relax on the couch either read a book or listen to soothing music (do not watch TV balance your checkbook or study as these reward sleeplessness)

10. Natural remedies such as melatonin 3-5mg taken 30 minutes prior to bed, or chamomile tea with valerian root are great ways of aiding with sleep without the typical side effects of prescription drugs.

Hope this helps Anna, thanks for the question : )

The five scariest words you could hear on your first call

2011-03-09T20:39:00.000-08:00

Here it was July 3^rd; I have been a doctor for a total of 3 days. Today was the day I have been in fear of probably since medical school began. Today was my first call. Just like your first day of school as a kindergartner or the first Junior High dance (I can remember being terrified of holding hands with my girlfriend Michele) this was a day that has been burned into my memory banks.

The day started off fine, I knew I was going to be working in the hospital for 30 hours straight and brought all the essentials. I had my Diet Cokes, my moms home made bran muffins, enough food to feed a small army, my EKG book, antibiotic book, my internal medicine pocket handbook, and lastly my advance cardiac life support step-by-step guide. Although I just had my advanced CPR training course, this is what scared me the most. What if there was a code arrest. Someone is on the verge of death and I; a 26-year-old freshly minted doctor of less then 72 hours, is expected to save that poor soul.

The day went well, no major hang ups, I had someone present with cough, fever, chest x-ray shows Pneumonia, simple, antibiotics some intravenous fluids no problem. Another patient came with a foot infection; no problem, obtain a sample of the pus for culture, antibiotics, and supportive care. We had a homeless man come in drunk who was there really to sober up, he was sleeping for most of my examination and I would check on him again once he was awake. The day went on like this, busy but manageable, nothing overwhelming, nothing I couldn’t handle.

As night fell I began to realize, I never took a break, not to pee, not to eat (I had only been snacking on those bran muffins), not even to second-guess all those earlier medical decisions. I decided now was the time, my pager hadn’t gone off in at least 5 minutes and I was famished. I sat in the team room, had the most amazing can of Diet Coke, and wonderful turkey sandwich. After eating, looking up some blood work, and catching up on paperwork, I started to feel the twinges of something cooking in the pit of my bowels. All those nerves and bran muffins from earlier must have gotten to me, I had to poop.

I went to the closest bathroom and began to take care of business. Browsing on my blackberry and contemplating, how uneventful things had gone thus far, I counted my lucky stars. I had such good fortune and to top it off no codes. Then like god himself came down and pulled the lever the alarm on my pager beeps. This beep was different though, louder, continuous, and then a voice “We have a Code Blue on the 3^rd floor”, I thought literally oh SHIT!! I “chopped the log”, pulled up my pants washed my hands, looked at myself in the mirror and said Gorlitsky you can do this, besides there is no chance in hell I will be the first or only doctor there.

I ran down the hall and saw the commotion at the last room on the left. Tons of people I thought, what a relief, I’m late I can just observe. When I walked into the room, the Nurse said the five scariest words I could have imagined “Thank god the doctors’ here”. I thought where? Not only was I the first, but I was the only doctor in the room. …

Axioms for the modern age

2011-03-03T23:32:00.000-08:00

A man named Pythagorus developed geometry for flat surfaces (plane geometry) using "axioms", statements so obviously true as to require no proof. For example, the shortest distance between two points (on a plane) is a straight line. Here are a few new ones, which I have made up or collected:

1. Practice makes better; perfect is impossible.

2. Cleanliness is next to impossible, for the whole world is made of dirt.

3. Everyone is entitled to their own opinion, but there is only one set of facts (thanks to Daniel Patrick Moynihan)

4. Political advertising is not required to contain even a grain of truth; often it does not.

5. Politics is not war. No political defeat or victory is ever total or permanent. Winners are always stuck with having to deal with an opposition.

6. Absolutes can accept no compromise. Governing requires compromise. Therefore, absolutes have no place in governing.

7. Change is inevitable, so the conservative opposition to all change is, ultimately, futile.

8. If it first you don't succeed, it figures! Beginner's luck is exactly that.

9. Anything that did not work before is unlikely to work when tried again under similar circumstances.

10. The ends cannot justify the means because the ends may never be reached. The means must justify themselves.

11. Of course the rich must pay most of the taxes; they have most of the money.

12. The public interest is not the same as the sum of all the interests of all its members.

13. Policy based on falsehoods must fail.

14. If you have not done the homework, you do not know what you are talking about.

What are the five biggest risk factors for pulmonary embolism?

2011-03-03T18:11:00.000-08:00

With the news being dominated by so many things including Libya, Wisconsin, the infamous Charlie Sheen diaries, and Justin Beibers' hair, floating somewhere in the abyss is the story of the 29 year old 13 time grand slam champion tennis star Serena Williams. She was hospitalized with a Pulmonary Embolism last week and a lot of people are questioning why, or how? How does someone with such athletic prowess end up in the hospital with a blood clot in the lungs. At this point it would be speculation as to what led to this unlikely turn of events.

As a physician we see numerous cases of PE (pulmonary embolism) and are familiar with the risk factors and the diagnostic criteria. Some risk factors that could be implicated in a young female would be: a family history of blood clots, oral contraceptive medications, smoking, or immobilization due to injury. At this point its all speculation. Below are the top five risk factors, with odds ratio, based on the JAMA article titled "Does this Patient have a Pulmonary Embolism" in the Rational Clinical Exam series.

(The odds ratio provides a measure of the strength of relationship between two variables, the higher the number the stronger the link, with 1 being no relationship)

5. Neurological Disease with lower leg paralysis (odds ratio 3.0)

4. Cancer with chemotherapy (odds ratio 6.5) Cancer without chemotherapy (odds ratio 4.1)

3. Immobility (odds ratio 8.0)

2. Trauma (odds ratio 12.7)

AND THE NUMBER 1 RISK FACTOR IN DEVELOPING PULMONARY EMBOLISM IS...

1. Surgery (odds ratio 21)

Further details below...

For my colleagues and others who are interested

The Wells Criteria was looked at in this study
Clinical Symptoms of DVT (3 points)
Other diagnosis less likely then PE (3)
Heart Rate >100 (1.5)
Immobilization or surgery in past month (1.5)
Previous DVT/PE (1.5)
Hemoptysis (1)
Malignancy (1)

High probability >6 points

Moderate 2-6 points

Low <2 points

In one study using the Wells Criteria
the prevalence of PE in the subgroups were as follows
Low 1.3%
Moderate 16.2%
High 40.6%

This demonstrates that our pretest probability is fairly accurate when it comes to diagnosing PE. Given this along with some basic labs and imaging (D-Dimer approximately 90% sensitive, but 40-50% specific) we can make well informed clinical decisions regarding further testing and the need for anticoagulation.

Fact, Opinion, Belief

2011-03-02T11:46:00.000-08:00

There is a lot of malarkey in the media about a lot of things. How is a person to know what is real and what is not?

In order to make sense of life, you have to be able to tell the difference between what is really true, what is presented as probably true by an expert, and what is unknown to be true but is believed on faith.

There is no doubt that facts exist. If they did not, there would be no science. If there were no science, there would be no technology. If there were no technology, humans would still be living in caves as they did at Lascaux, France, 250,000 years ago.

A fact is a real world event that is not dependent upon who observes it, if anyone. Facts are the result of the properties of objective reality - physics, chemistry, biology and mathematics. Facts are about the past - an event is not real until it actually occurs, and the present is only an instant. By the time one notices a fact, it is past. Nothing predicted about the future is a fact. An estimate is not a fact. The outcome of predictive modeling is not a fact. Only those things that actually happen are facts. Who reports a fact does not affect its reality. A statement of fact is either true, because it happened, or false, because it did not, not matter who says it, no matter why they said it, and no matter what benefit or cost comes from accepting or rejecting it.

Unfortunately, there are limits to what can be known, even about the past. Expert opinion is an educated conclusion, based on some but not enough facts, plus an understanding of the underlying behavior of the subject. A valid medical opinion requires years of medical training, a valid legal opinion requires years of law school, a valid political opinion requires long study of political science. If you are not a learned expert on a particular subject, your opinion about it is of no value. Expertise does not transfer - a doctor is qualified to have an expert medical opinion, but not an expert legal opinion, unless also a lawyer. An expert opinion is not a fact - but it is sometimes all you can get! Unlike facts, expert opinion can be about the future - most often, the non-expert is asking the expert to predict it!

Furthermore, there are matters about which there are neither facts nor experts. The question, "what is the meaning of life?", has neither a factual nor an expert answer. Questions about God, beauty, love, and intangible value not only have no correct answers, they can have none. Each person must find answers for themselves and choose what to believe. These are matters for faith - there is no proof, and there can be no proof, that a given belief is valid, nor does a lifetime of study improve one's chances of getting it right. On a daily basis, humans live by their beliefs, planning for an uncertain future they may never see. Faith in something is essential in order to survive the vicissitudes of life. Group faith is stronger than individual faith, which is why humans form congregations of shared belief.

However, the objective realities are not subject to what one believes. The majority does not get to vote on which statements of fact are true; reality "bites', and it occasionally bites back very hard. One has limited power to act, limited ability to anticipate, limited ability to know, and life, liberty and property are at stake. Facts, where they exist, must overrule contrary expert opinion or faith. Expert opinion can carry through where facts are inadequate but a history of accrued knowledge does exist. Where there is neither, one must choose what to believe in order to know how to act. In all cases, one must be able to tell the difference - what can be known to be true, what is believed to true by expert opinion, and that which must be taken on faith.

Charlie "The Masheen!"

2011-03-02T08:47:00.001-08:00

"Yea, I'm on a drug, It's called Charlie Sheen!"

Is it sad that the majority of the country, including myself, care more about watching this guy's self destruction on national T.V than what's going on in the rest of the world? Maybe the world is coming to an end.

Bring back THE MASHEEN!

http://www.youtube.com/watch?v=7ulUX5iy6vY

2011-03-01T19:43:00.000-08:00

Is juicing a good way to get my fruit and vegetable servings or is it just going to make me fat?

As I was reading the back of a juice box, I saw the designation “2 serving of fruit in an 8 oz glass”. I thought wow I’m always telling my patients I want to see them eat 6-8 servings of fruit and vegetables dally, maybe this would be a great way to encourage it! Then I thought more about it and remembered the calories and the glycemic index (a numerical method of determining how much a given carbohydrate will raise the blood sugar compared to a piece of white bread). We have a choice a caloric heavy 100% fruit juice vs. the dreaded sugar content it comprises. Now I had a conundrum what should I tell my patients? I decided to investigate.

The average glass of 8oz juice has approximately 120 calories and 27 grams of sugar. This would compare to an 8oz Dr. Pepper, which has 100 calories and the same 27 grams of sugar. So your telling me juice and soda have similar nutrition facts? Obviously not, soda has almost no nutritional value, whereas juice has your fruits and vegetables, which include plenty of antioxidants, vitamins, and minerals.

Some evidence based medicine:

Does juice make me gain weight?

There seems to be a lot of controversy surrounding this. In multiple epidemiological studies this seems to be true, however other studies dispel this rumor. The so-called meal replacement shake such as Slim Fast, are touted to aid with weight loss. The evidence born out from multiple studies is actually very good, suggesting this to be the case. It is noted that a significant amount of calories in these shakes are high fructose corn syrup. The sugar content is on the order of 25-35 grams per drink. It is postulated that the protein content, as high as 9 grams, and the fiber, usually around 5 grams, aid in satiety and therefore weight loss. (It is worthy of note the money to purchase the shakes and bars were provided to the patients in most of these studies)

On further investigation I saw the sugar content of soda, fruit punch, 100% furit juice, and meal replacement shakes all are around 12 grams per 100g. All the same! What we forget is the difference in cost. A 120z can of soda costs about 50 cents, a 100% fruit juice box is well over one dollar and those meal replacement shakes are much more. Even though the sugar content of all these drinks are similar, it is the low cost soda that have been most heavily linked to weight gain. Why is that?

It seems that regular intake of sugared drinks need not be immediately linked to weight gain. In fact meal replacement shakes, which are chalk full of sugar have been shown to induce weight loss. Given these facts we find consumption of sugar beverages linked to weight gain as well as weight loss, therefore it seems likely coupled to other confounders’, namely dietary behavior. Most sugar-sweetened drinks are consumed with a meal; meal replacement shakes are instead of a meal. Given this, it appears that the most important issue is not sugar metabolism but how the user takes in the sugar. Studies show that the likely link to obesity and sugared beverages has more to do with cost then satiety or glycemic index.

So what will I tell my patients?

I will recommend the usual cutting of calories and exercise as the stalwart for true weight loss, with a real emphasis on lifestyle change. I would advocate putting down that sugared soda with dinner. I will continue to recommend 2 liters of water a day (unless your doctor specifically tells you otherwise) and finally in regards to 100% Juice I say drink up, in moderation of course.

Forget January and February, March is here.

2011-03-01T16:24:00.000-08:00

The month of March is more than merely the third month of the year. March offers an array of marvelous gifts.
Just when you begin to tire of the cold weather and you come to terms with the fact that without Fantasy Football your Sunday's no longer offer the same prominence, the weather changes for the better and the days begin to get longer. Especially out here in the southwest, people begin to trade their sweaters, pants and shoes for t-shirts, shorts and sandals. And the moment you think that March has risen your spirits like the sun on an early spring morning and nothing can possibly get any better you realize a few things: a) Spring Training has just started, sparking eight months of baseball, b) the NBA is past the halfway point and leads way for the climax, the Playoffs, and more importantly c) March Madness.
For most the phrase March Madness needs no explanation, but just for fun let us journey further more into the "Madness".
This is the first year in which we get to witness the most recent extended format of the tournament. The NCAA has extended the field from 64 to 68, and most believe that future tournaments will have up to 96 teams. Also added to the tournament is a first and second round with every game televised. With all the new founded anticipation one need not to overlook the importance of filling out the 26 different brackets in order to win your office or local pub's pool. And with a new number one ranked team falling on a weekly basis this years tournament looks to open to whichever team gets hot heading in to the ladder part of March.
So when the NFL and it's overblown, over-covered, and over-hyped Draft Combine and the bleak future of a 2011 season has you down and out. Or you have become so frustrated with collegiate athletics, thanks to abomination which is NCAA football. Or just the reality of another new year not going your way and another list of resolutions unfulfilled, just remember that March has begun and along with the temperature, every one's spirits may rise.

2011-02-28T09:19:00.000-08:00

Mark Twain is reported to have said that the biggest trouble comes, not from the things we don't know, but from the things we do know that just ain't so!

Here are some examples:

1. The biggest problem facing the government of the United States is the Federal deficit.

In fact, the government of the United States has run a deficit for most of its 225 years. When actual expenditures are greater than revenues, the Treasury sells bonds and notes to get the cash to make up the difference. As long as the United States makes its interest payments, US bonds and notes will remain the most sought after financial instruments in the world, as they are today, and there will be no difficulty financing both the current national debt and any additional debt taken on to manage economic growth.

2. The government of the United States is too big.

In fact, in a nation 3000 miles wide, 15oo miles deep, populated by 308 million people, a Federal civil service of 2.1 million, less than one percent of the population, is actually too small. Even if you count the approximately 19 million State and local government employees, we still have smaller government payrolls as a percentage of population than any of the other G0-20 (the 20 wealthiest developed countries.) There are not enough auditors to prevent fraud, not enough inspectors to ensure the safety of our food supply and mines, not enough border agents to even wholly monitor much less secure our borders, and just too few personnel altogether to properly execute all the laws our Congress has enacted to protect public health and safety.

3. Huge sums of money, enough to balance the books, are given away by the United States in foreign aid.

The entire foreign aid appropriation is a few tenths of a percent of total Federal expenditures. While the absolute amount is tens of billions, as a percentage of either the total budget or the total economy it is a much smaller fraction than the amount given in aid by more than a dozen European countries which are less wealthy than we are.

4. The Social Security program is responsible for a major part of the deficit and debt

In actual fact, not only is Social Security not in debt, the United States Treasury owes the program more than enough money for it to last for another century. Current payments are made out of current collections, and can continue for the next seventeen years if nothing at all is changed. All that the program requires for continued program solvency is to raise the ceiling on income taxable for Social Security by the same percentage that benefits have increased in the past two decades - 48%, from $108K to $160K. This "tax increase" is 7% of up to $52K on those whose income falls between 108 and 160 - $5207 per year, each, maximum.

5. Republican Administrations are historically more fiscally responsible.

In fact, no Republican President has actually balanced the Federal books since Herbert Hoover. Republicans talk about balancing the budget and achieving a surplus, but they have not actually done it. The last President to submit a balanced budget was Bill Clinton. Ronald Reagan never did.

6. Taxes are too high.

Nobody actually likes paying taxes, but nobody ever objects to receiving US Treasury checks. The economist Arthur Laffer plotted Federal revenue in relation to top marginal income tax rates, and this is what he found - when you increase the tax rates above a certain level, total government income goes down, but when you lower taxes below a certain level, government income also goes down. The tax rate at which taxes collect the most is between 40 and 60 percent - therefore, right now, with taxes at the top pegged at 30% of marginal regular income and 15% of income gained from the sale of short term investments, Federal income taxes, at least on the largest incomes, are much too low.

7. Benefits to the families and individuals with the highest incomes stimulate the economy.

In actual fact, spending stimulates the economy. Investment only takes place when future sales are expected to be up. The people at the top of the economy make more money than they can spend, so reducing their tax burden does nothing to increase their spending. The same applies to taxable corporate income - corporations can adjust their strategy to actually pay no taxes regardless of the official rates. People at the very bottom of the economy, in contrast, spend every penny they get. People in the middle spend and save, spending more when they feel wealthier. Reducing middle class taxes can increase both spending and saving, but only by those who have money left at the end of the month. The surest way to increase commerce is to take money from the rich and give it to the poor to spend, which they will.

II

The real biggest problem with Federal accounts is that Federal spending is too high in proportion to revenue. The program that is really in the most trouble is health care - Medicare and Medicaid. It was the insolvency of these programs that was the target of the so-called "Obamacare" health insurance reform. If the Congressional Budget Office projections are valid, the reforms enacted will decrease net federal outlays for health care by over a trillion dollars over ten years. There are no projections from any source which are either more reliable or more accurate.

In order of magnitude, the biggest cost drivers in health care are end-of life terminal care, non-emergency care rendered in emergency rooms, medical information errors, and defensive medicine and malpractice insurance.

Eighty percent of individual life time medical costs are incurred after a terminal diagnosis. The money is spent on intensive care to prolong life by a matter of days or weeks. Private insurance covers up to a million dollars of lifetime costs, so end of life costs, on the average, $800,000. Of this, the patient will be billed for 20%, $160,000, which the surviving relatives will be asked to pay. On Medicare, federal coverage is 75%, so the average cost of terminal care to the taxpayer is $600,000 per patient. This is the real problem with the Federal budget, because there are 60 million Baby Boomers who will die in the next 25 years, which will cost, under present rules, $3.6 trillion dollars.

Current medial ethics require intensive care of the terminally ill unless the patient has left clear instructions otherwise. Every possible treatment is given despite a realistic assessment that the patient cannot survive no matter what. The dying patient will be resuscitated, over and over again, in the absence of firm instructions to not do so. In each State, family law grants some nearest living relative the authority to refuse care, but no one has such authority for an unconscious indigent with no known relatives. The simple mandate that all Medicare recipients must execute a "living will" will save the Treasury $500,000 on each patient who elects to die in palliative instead of intensive care. There is no formal estimate of how much this Obamacare provision will save of the $3.6 trillion estimated spending without it; the $1 trillion savings CBO projects from Obamacare is for provisions of the law that reduce non-emergency use of ER and decrease medical information errors.

So - anyone who claims that they will balance the budget and save the economy by lowering taxes on the rich, by lowering benefits for the middle class and the poor, by cutting out foreign aid and support for the arts and sciences, and by repealing Obamacare simply has all their facts wrong and does not know what they are talking about.

The Combine trial for alcohol dependence treatment

2011-02-27T01:10:00.000-08:00

About 8 million individuals in the United States currently meet diagnostic criteria for alcohol dependence. I reviewed the COMBINE trial Combined Pharmacotherapies and Behavioral Interventions (COMBINE). This trial compared pharmacotherapy naltrexone and or acamprosate with or without cognitive behavioral psychotherapy, to elucidate which combination would be most efficacious.

Positive and comparable outcomes were produced by cognitive behavioral intervention alone, naltrexone alone, and the combination of CBI and naltrexone, if provided in the context of medical management

All combinations increased the patients percentage of days abstinent, number of days before a heavy drink, and increased good clinical outcomes.

Examples include achieving 80% of days abstinent with naltrexone and medical management, something a primary care doc could accomplish. The dose. Was 25mg days 1-4, 50mg days 5-7, and 100 mg days 8-112.

So there is a lot of hope out there and good medical evidence to back that up.

An abstract of the study may he found at: http://jama.ama-assn.org/content/295/17/2003.abstract

Will Charlie Sheen's downward spiral continue? - USATODAY.com

2011-02-27T00:35:00.000-08:00

Will Charlie Sheen's downward spiral continue? - USATODAY.com

2011-02-26T20:10:00.001-08:00

Another new author

2011-02-26T19:43:00.000-08:00

We also have a new contributor to the publication, David P a PhD offering insight pertaining to the modern era.

New Author

2011-02-26T17:42:00.000-08:00

We are pleased to have a new author for the blog. His name is Justin Ryden, he will be offering personal insight on the pursuit of happiness.

2010-12-28T18:16:00.000-08:00

Dietary

Approaches to

Stop

Hypertension

“Diets will allow you to lose weight in the

short run only, usually leading to moderate weight loss followed

by weight gain, due to inability to maintain such restrictions e.g.:

(NO Carbohydrates, 500 calorie/day etc…) It is my philosophy

that Lifestyle change is the only way to lose weight healthily and

keep it off, set a good example for those around you, and make

your Doctor happy”

-Barry Gorlitsky MD

1. LIMIT UNHEALTHY FATS AND CHOLESTEROL

FATS TO CHOOSE:

• Olive oil

• Canola oil

• Margarine that's free of trans fats

• Cholesterol-lowering margarine, such as Benecol, Promise active or

Smart Balance

FATS TO LIMIT:

• Butter

• Lard

• Bacon fat

• Gravy

• Cream sauce

• Nondairy creamers

• Hydrogenated margarine and shortening

• Cocoa butter, found in chocolate

• Coconut, palm, cottonseed and palm-kernel oils

2. CHOOSE LOW-FAT PROTEIN SOURCES

PROTEINS TO CHOOSE:

• Skim or low-fat (1 percent) milk

• Fat-free or low-fat dairy products, such as yogurt and cheese

• Egg whites or egg substitutes

• Fish, especially fatty, cold-water ﬁsh, such as salmon

• Skinless poultry

• Legumes

• Soybeans and soy products, for example, soy burgers, tofu or

edamame

• Lean ground meats

PROTEINS TO AVOID:

• Full-fat milk and other dairy products

• Organ meats, such as liver

• Egg yolks

• Fatty and marbled meats

• Spareribs

• Cold cuts

• Frankfurters, hot dogs and sausages

• Bacon

• Fried or breaded meats

3. EAT MORE VEGETABLES AND FRUIT

FRUITS AND VEGETABLE TO CHOOSE:

• Fresh is Best

• frozen vegetables and fruits

• Low-sodium canned vegetables

• Canned fruit packed in water

FRUITS AND VEGETABLES TO AVOID:

• Coconut

• Vegetables with creamy sauces

• Fried or breaded vegetables

• Canned fruit packed in heavy syrup

• Frozen fruit with sugar added

4. SELECT WHOLE GRAINS

GRAIN PRODUCTS TO CHOOSE:

• Whole-wheat ﬂour

• Whole-grain bread, preferably 100 percent whole-wheat or 100

percent whole-grain bread

• High-ﬁber cereal with 5 or more grams of ﬁber a serving

• Whole grains such as brown rice, barley and buckwheat (kasha)

• Whole-grain pasta

• Oatmeal (steel-cut or regular)

• Ground ﬂaxseed

GRAIN PRODUCTS TO AVOID:

• White, reﬁned ﬂour

• White bread

• Bagels

• Mufﬁns

• Frozen wafﬂes

• Corn bread

• Doughnuts

• Biscuits

• Quick breads

• Granola bars

• Cakes

• Pies

• Egg noodles

• Buttered popcorn

• High-fat snack crackers

• 5. REDUCE THE SALT IN YOUR FOODS (1500 mg

or less)

LOW-SALT ITEMS TO CHOOSE:

• Herbs and spices

• Salt substitutes (no salt)

• Reduced-salt canned soups or prepared meals

• Reduced-salt versions of condiments, such as reduced-salt soy sauce

and reduced-salt ketchup

HIGH-SALT ITEMS TO AVOID:

• Table salt

• Canned soups and prepared foods, such as frozen dinners

• Tomato juice

• Soy sauce

6. CONTROL YOUR PORTION SIZE (the best “diet” is a

calorie restricted diet)

7. PLAN AHEAD: CREATE DAILY MENUS

8. ALLOW YOURSELF AN OCCASIONAL TREAT

9. LIMIT ALCOHOL INTAKE

10. DON’T FORGET WATER INTAKE 6-8 8oz cups

daily (for heart failure patients <2 Liters/Day is appropriate

and weigh yourself daily)

11. SOME GREAT SNACKS:

Edmame dry roasted, wasabi, or fresh steamed

Nuts such as peanuts, almonds, cashews, walnuts

Greek Yogurt with low fat granola on top