Someone recently accused me of "threatening the livelihood" of the people employed at Suspended Animation, a company offering remote "standby, stabilization and transport" services, by limiting the number of new clients they might recruit. I believe that to be an extremely irrational accusation, based on the following information:
According to the CIA World Factbook, as of December 18, 2008, the United States currently has a mortality rate of approximately 8.27 deaths/1,000 population (0.827%). According to a document on Alcor's website, they estimate the annual number of cryonics cases to be approximately 41 per 5,000 prospective members, which is in agreement with the CIA statistics. Considering the relative youth and health consciousness of people interested in cryonics, I would guess their mortality rate to be significantly lower, but I will use the 0.827% figure, just to be generous.
There are currently only 1,240 people who have funded contracts for cryopreservation, (883 with Alcor, and 357 with Cryonics Institute). This would put the current expected number of cryopreservations at approximately ten cases per year. How many of those cases are likely to involve "standby, stabilization and transport"? One, or two?
SA charges $37,500 to transport a patient who dies before they get there, (which I am estimating would be 90% of the time), to CI. Let's just say they make a profit of $30K for those cases.
The cost of "standby, stabilization and transport" for patients who are alive when a team arrives, will vary from case-to-case, depending on a number of factors, with the most significant factors probably being the length of the standby and the location of the patient. Without many real numbers to go on, other than the costs that do not vary much, (such as the cost of the solutions, medication and disposables), I'll arbitrarily place the average cost of a remote "standby, stabilization and transport" at $30K per case. I believe SA charges $60K for such a case, so again SA is left with a $30K profit.
A company with an annual budget of approximately $1.4M per year, (an estimate of SA's annual budget, based on what it was, when I was there, and the "improvements" they have made), and an income of $30K per case, would have to do approximately 47 cases per year, to break even. Using the above numbers, this means Suspended Animation would require approximately 5,683 clients, (approximately 4.58 times the current number of members of Alcor and CI, combined), to break even.
Suspended Animation has only 74 clients that we know of. (SA's News Bulletin 13 of February 2008, states their 58th client signed up in January and News Bulletin 14 of December 2008 states they had a total of 17 new clients sign up, during 2008). Since they are about 5,609 clients short of breaking even, I doubt I could be held responsible if that company were to fail. Some people might want to blame me, if the LEF funding dries up, but shouldn't those who have set a long-standing pattern of fiscal irresponsibility, at SA, should be held responsible, if that happens? What I'm worried about is, what would happen to their clients who may not have made alternative arrangements, if SA was to close its doors.
Wednesday, March 18, 2009
Saturday, March 7, 2009
Michael "Mike Darwin" Federowicz
Below are my responses to some of Michael ("Mike Darwin") Federowicz' postings on the Cold Filter forum:
http://www.network54.com/Forum/291677/message/1234244535/On+Maxim%27s+Distotions+%26amp%3B+Cryonics+Expertise
Federowicz: Her position also denies the reality that cryonics once had both a professional perfusionist and a licensed hemodialysis technician (with extensive CPB experience) setting the standards and determining the technology used on cryopatients and that both these men used the medical model and, wherever possible, well vetted conventional medical equipment in delivering cryopatient care.
My position is that both these people have publicly claimed to have been "board-eligible perfusionists," when I don't believe either one ever was, and both of them seem to have engaged in other unethical behaviors and perhaps a few cryonics "cover-ups." As far as I know, neither Leaf or Federowicz ever attended an accredited school of perfusion and performed the 100 (live human) clinical cases required to sit for the boards. In "Mothermelters," Alan Kunzman claims Jerry Leaf, (the "professional perfusionist"), was never licensed to work with humans, (whether alive, or dead). Since I think it is unlikely someone would mistakenly think they have met the requirements to sit for the perfusion board exams, (and even more unlikely someone who has met the requirements would neglect to sit for the exams), I have to believe they lied, intentionally. This makes it impossible for me to put much faith in any information they have provided about their activities in cryonics, (or information on ANY topic, for that matter).
In addition, Federwicz publicly claims to have perfused "approximately 1,000 dogs." There is no evidence that many dogs have been subjected to cryonics experiments. My guess is, the number of dogs perfused in cryonics experiments is nowhere near that high. If Federowicz wants to maintain he has done 1,000 dog experiments, I'm sure PETA and other agencies would be interested in seeing the paperwork.
Federowicz: Perhaps most perniciously, her position denies the remarkable and successful research accomplishments attained during this period by these two men, and others working with them, using dogs in a survival model of CPB.
Where is the evidence of these "remarkable and successful research accomplishments"? Thus far, other than the write-ups published in "Cryonics," (Federowicz was an editor of that publication), I have only been able to locate ONE published paper on the cryonics dog experiments. If there have been 1,000 experiments, as Federowicz claims, they must not have been as "remarkable," or "successful," as he thinks.
Federowicz: In 1977 perfusionist and biomedical researcher at UCLA, Jerry D. Leaf, became involved in cryonics and began two organizations with the express mission to develop, validate, and standardize evidence-based procedures for every aspect of cryonics suspension using a medical model.
Former deputy coroner of Riverside, California, Alan Kunzman, publicly accused Jerry Leaf of ordering hundreds of thousands, if not millions, of dollars worth of medical equipment, on UCLA's tab, and having it delivered to Alcor. ***In the interest of fairness, I have revised this paragraph.*** Someone I trust has informed me that Alcor did purchase these items from UCLA surplus equipment, but they couldn't produce the receipts at the time because they had been confiscated by Kunzman's office. My informant states it is typical for the metal ID tags to remain on the equipment when it is sold, and I believe that is probably true.
Leaf was also involved in the cryopreservation of Dora Kent, whose death was somewhat suspicious. Allegedly, Saul Kent and Federowicz, (wearing white lab coats and driving a used ambulance with the ambulance company's name still on the side), picked Dora up and drove her to the Alcor facility, where she conveniently died and was cryopreserved, two days later. Leaf and Darwin, foolishly, declared her dead without a physician present and proceeded with a cryopreservation. (None of them had enough common sense to realize people were going to find these activities suspicious?)
According to Kunzman, Steve Harris MD admitted to signing not one, but three, death certificates. He said Alcor wrote up the death certificates and he "just signed them." Though Harris had already admitted to not being at Alcor, at the time of Dora's death, (and this was allegedly confirmed in Mike Perry's journal), Leaf later called the Coroner's office and provided them with a list of names of people who were, allegedly, present for Dora's death, and included Harris.
Federowicz: In short, Ms. Maxim is attacking the very people she says she feels are essential in cryonics while at the same time effectively denying that they once existed *and that a high standard of care (the same as a patient undergoing CPB in hospital at that time) was once the reality, at least in cryonics as practiced by Alcor at that time.*
I am "attacking the very people I feel are essential in cryonics"??? I am NOT. I don't believe people like Federwicz and Leaf, (people who seem to have thought they were above the law, and were willing to engage in some rather questionable activities), are "essential in cryonics," or that a "high standard of care (the same as a patient undergoing CPB in hospital at that time)," has ever been a "reality," in cryonics.
Federowicz: ...of understanding of how cryonics differs from conventional perfusion, and lack of understanding of the fairly large body of knowledge that has been accumulated which is unique to cryonics cases.
I'm quite familiar with the "large body of" speculation that has been accumulated, in regard to cryonics cases, I see more propaganda and narcissistic pride in unproven "accomplishments" than I see actual achievement.
In regard to my comments about flow probes:
Federowicz: Had Ms. Maxim established a dialogue with me this information would have undoubtedly been quickly passed along.
First of all, I do not respect Federowicz enough to seek out his advice, or opinions. Secondly, I didn't need Mike to tell me how electro-magnetic flow meters work. I wasn't sure of the exact composition of CI's solutions, but I was well aware the flow meters would very likely not function properly with those solutions. Regardless, I wanted to demonstrate the pump to Ben, because I felt it would add a margin of safety, for CI's patients. At the time, I believed it was more important for CI to avoid pumping air, and to learn to measure a more accurate patient pressure.
Federowicz: Why is knowing flow so important?...The history of scientific, evidence-based medicine is a testimony to the criticality of vigorously collecting data which is consistently and ACCURATELY collected. That means precision in quantification. Ms. Maxim seems not to grasp this.
Federwicz is in no position to state that I am not capable of understanding the importance of perfusion-related issues, even in cryonics. HE seems not to grasp the fact that he is calling for excellence from people who have little-to-no knowledge about basic perfusion. Does he really expect laymen, with little opportunity to develop clinical skills, to perform perfusion procedures with precision? Get them to stop pumping air to patients, and subjecting patients to inappropriate pressures, and THEN worry about accuracy.
Federowicz: 1) Knowing flows with precision and accuracy (indeed knowing them at all!) was critically important. It is absolutely essential in cryoprotective perfusion because flow rate is the primary perfusion parameter that determines cryoprotective agent equilibration in the patient. Flow is also the primary determinant of cooling rate (along with heat exchanger efficiency and the temperature of the wall water) during in-field CPB of cryopatients. Knowing when the patient will be cold enough to come off the pump is often really important since it can mean catching or missing a commercial flight. Roller pumps give a very consistent flow regardless of temperature, pressure, viscosity or perfusate composition. RPM can be converted directly into flow.
This may seem impressive to laymen, but it's absurd, to me. Cryoprotective agent (CPA) uptake is going to rely on a number of factors, and vary from patient-to-patient. You need a way to accurately measure the actual concentration of the CPA, not try to calculate it by flow rate, which will need to be adjusted, depending on patient pressures. As for the washout procedure, the flow rate, (and, therefore, the cooling rate), is going to be largely dependent on the pressure. It doesn't matter what time the next flight is. Yes, "roller pumps give a very consistent flow regardless of temperature, pressure, viscosity or perfusate composition," (even if the perfusate is AIR)...herein lie the fundamental problems with amateurs using these pumps.
2) It is possible to design TBW systems so that no macro air can be perfused using roller pumps. This was done with the ATP.
Nothing could be further from the truth. I believe the "ATP" at SA, when I first went to work there, was virtually identical to the circuit Federowicz designed, for Alcor, and there was NOTHING on the "ATP" that would have prevented the pumping of macro air.
3) The notion that centrifugal pumps cannot cause physiologically devastating over-pressure injury is incorrect. While centrifugals cannot generate an infinite head of pressure under occluded conditions as can roller pumps, the static pressure of most medical centrifugals under no-flow (occluded arterial or venous line) conditions varies from ~500 to well over 700 mm Hg. Such pressures will NOT rupture the extracorporeal circuit (i.e., explode oxygenators, filters, or blow apart circuit connections) but they can cause tremendous damage to patients.
More distraction. The reality is that, unlike a roller pump, a centrifugal pump will decrease flow in response to increased outlet pressure. If I am perfusing a patient at 60mmHg at 2,000RPM and 3L of flow per minute, and the pressure increases, the flow is going to go down without any adjustment of RPM's and a "low flow" alarm is going to go off, well before the pressures Federwicz mentions are ever reached. A person would have to be TRYING to reach those pressures and ignoring the pump alarms, when using a centrifugal pump. Also, if the people in cryonics wouldn't slide the tubing over every available barb on the connectors, and double-band the connections, I believe the circuit would blow apart, before those pressures were reached.
Federowicz: 4) No cryonics patient, to my knowledge, has ever been air embolized during in-field TBW due to a roller pump or due to pumping the venous reservoir dry.
How many in-field total body washouts has Federowicz been present for? I have a very hard time believing no cryonics patients have been subjected to air embolization in the field, where the conditions are certainly not as good as those at the cryonics organizations, where we know air-embolization of patients is a blunder that occurs with an alarming frequency.
Federowicz: 7) Centrifugal pumps are not acceptable for CPA perfusion and personnel MUST learn how to reliably and safely use roller or other occlusive positive displacement pumps.
I'm not sure this is true. Ben Best and I ran a centrifugal pump with CI's most viscous solution, at temperatures near zero C, without any problem other than those associated with the flow probe, and there are alternatives to using that flow probe to measure flow.
Federowicz:The solution is to have *only properly trained/skilled personnel perform TBW*. Clinical perfusionists are the ideal (with additional training)...
Agreed, but "properly trained" personnel shouldn't be trained by people of questionable capabilities. The "additional training," in regard to the washout procedure, would be minimal and could be carried out using a bucket of water as a "patient." I'm sure the SA staff feels good about themselves for "playing doctor" with a pig, but it was unnecessary.
Federowicz:...but the fact is that any intelligent, motivated person with the right temperament and reflexes can be trained to operate an open circuit TBW system (with the proper safeguards) with a high degree of safety.
Nonsense. There's not enough proper training available, in cryonics, where there is little opportunity for clinical experience.
Federowicz: There was a time when that was done both safely and effectively (if you count me as a non-perfusionist).
Federowicz is a "non-perfusionist." People don't become perfusionists by qualifying for such in their own minds.
Federowicz: I refused to provide CI with a more complex circuit absent extensive training to a level where I was satisfied that the personnel using the system would be reasonably safe.
I have no idea how Federowicz ever convinced himself, much less others, that he is one of the world's leading perfusion experts. (Actually, I do have an idea, judging by the number of times he writes "I did this...I did that...I...I...I..." As I recall, he began his review of SA by comparing himself to some misunderstood mythological god. I only read Kunzman's book, last week, and he had the same opinion as I, regarding Federowicz self-absorption.
Federwicz: Countless CPB cases have been pumped worldwide with roller pumps with a microscopic incidence of air embolism due to the presence of the roller pump, per se; and with excellent outcomes.
As I've written before, ALL CPB cases have introduced microscopic air to the patients, regardless of the type of pump being used. It's absurd for anyone in cryonics to be concerned with the elimination of microbubbles in perfusion circuits, when they haven't even mastered basic perfusion with a level of competency that was achieved in conventional medicine, DECADES ago.
Federowicz: Outside of cryonics, in the world of clinical medicine, I have almost no doubt that centrifugal pumps will become the standard of care...
If this were true, it would have probably happened nearly two decades ago. There are two main reasons why this is unlikely to happen:
1. The cost of a small length of tubing for a roller pump is only a few cents, while the least expensive centrifugal head runs about $80. (They were closer to $150, a decade ago, but I doubt they'll ever be as cheap as a piece of tubing.) With managed healthcare, this will continue to be a factor in the choice of pumps.
2. Occlusive pumps in conventional medicine are components of computerized heart-lung machines that provide automatic flow adjustment in response to changing pressure, and complete shutdown with automatic line clamping in the presence of dangerous pressures or air in the lines, making the safety of the less expensive occlusive systems comparable to that of the significantly more costly centrifugal systems.
Federowicz (in response to me asking why he demanded to know if the SA flow probes worked with their washout solution, and then suggested Mathew Sullivan test the probes with water): I suggested tap water because it is cheap and readily available. If the flowmeter reads tap water flows accurately then it is worth proceeding to test it with perfusate (really expensive) under real-world conditions. I suggested tap water for the same reason you used it in training circuits: it is a cheap liquid which you can pump and which behaves enough like blood for the purpose at hand. If the SCPC flowmeter gives an invalid number for tap water, particularly if it is misleadingly close to a believable flow, then you should proceed with real caution if you proceed at all.
Why do we need to use "a cheap liquid which you can pump which behaves enough like blood for the purpose at hand"? The question wasn't whether the probe would work with blood, (and I assure everyone it would), but if it would work with SA's washout solution. Federowicz' argument for the flow probe to be tested with water was just a foolish waste of time and money (Mathew's time and salary). It should be tested with SA's washout solution.
Federowicz: I'm glad SA has such a fine perfusionist. But, no matter how good this man is, he will almost certainly not have expertise unique to and essential to proper extracorporeal management of cryopatients.
I believe SA claims to have NINE "fine perfusionists," who I am sure have a knowledge base and experience that far exceeds Federowicz'. Regardless, how could ANYONE have "expertise unique to and essential to proper extracorporeal management of cryopatients"? Other than Leaf, cryonics has a long history of reliance on amateurs who seem to think they know a lot more than they really do, a history of pumping air and subjecting patients to inappropriate pressures, and no outcomes to determine if what has been done has been of any benefit, whatsoever.
Federowicz: No patient presenting for clinical CPB even approximates the average cryopatient presenting for TBW and/or asanguineous ECMO. Even within perfusion there are areas of specialization that require additional knowledge and training: extended ECMO, emergency fem-fem CPB, nenonatal and paediatric CPB, and normothermic CPB, to name a few. What is so extraordinary about the idea that cryonics should be the same?
What is "extraordinary," here, is the degree of the "god complex" Federowicz has, and the number of people who have been buying into his alleged expertise, if you ask me.
Federowicz: As just one small example, Ms Maxim had no idea how or why conventional CPB flowmeters worked, or that they would not work in cryonics.
Federwicz assumes I didn't understand how the flowmeters worked. What I wasn't sure of, was the composition of CI's solutions. I knew it was highly likely the flowmeters wouldn't work with CI's solutions but, again, I felt the safety features were worth exploring alternate methods of measuring flow. This exploration cost ME a lot more time and money than it cost CI, and I would do it again, in a heartbeat. I still think the safety of the centrifugal pump would be of benefit in cryonics procedures, especially if amateurs are sitting behind the pump.
There was a time when I held some degree of respect for Federowicz, but that was before I read his narcissistic ramblings and complaints about medical professionals on another forum, before I started studying the dog experiments, before he lied about having been a "board-eligible perfusionist," and before I read Kunzman's book. If you ask me, it's people like Federowicz who give cryonics a bad name.
http://www.network54.com/Forum/291677/message/1234244535/On+Maxim%27s+Distotions+%26amp%3B+Cryonics+Expertise
Federowicz: Her position also denies the reality that cryonics once had both a professional perfusionist and a licensed hemodialysis technician (with extensive CPB experience) setting the standards and determining the technology used on cryopatients and that both these men used the medical model and, wherever possible, well vetted conventional medical equipment in delivering cryopatient care.
My position is that both these people have publicly claimed to have been "board-eligible perfusionists," when I don't believe either one ever was, and both of them seem to have engaged in other unethical behaviors and perhaps a few cryonics "cover-ups." As far as I know, neither Leaf or Federowicz ever attended an accredited school of perfusion and performed the 100 (live human) clinical cases required to sit for the boards. In "Mothermelters," Alan Kunzman claims Jerry Leaf, (the "professional perfusionist"), was never licensed to work with humans, (whether alive, or dead). Since I think it is unlikely someone would mistakenly think they have met the requirements to sit for the perfusion board exams, (and even more unlikely someone who has met the requirements would neglect to sit for the exams), I have to believe they lied, intentionally. This makes it impossible for me to put much faith in any information they have provided about their activities in cryonics, (or information on ANY topic, for that matter).
In addition, Federwicz publicly claims to have perfused "approximately 1,000 dogs." There is no evidence that many dogs have been subjected to cryonics experiments. My guess is, the number of dogs perfused in cryonics experiments is nowhere near that high. If Federowicz wants to maintain he has done 1,000 dog experiments, I'm sure PETA and other agencies would be interested in seeing the paperwork.
Federowicz: Perhaps most perniciously, her position denies the remarkable and successful research accomplishments attained during this period by these two men, and others working with them, using dogs in a survival model of CPB.
Where is the evidence of these "remarkable and successful research accomplishments"? Thus far, other than the write-ups published in "Cryonics," (Federowicz was an editor of that publication), I have only been able to locate ONE published paper on the cryonics dog experiments. If there have been 1,000 experiments, as Federowicz claims, they must not have been as "remarkable," or "successful," as he thinks.
Federowicz: In 1977 perfusionist and biomedical researcher at UCLA, Jerry D. Leaf, became involved in cryonics and began two organizations with the express mission to develop, validate, and standardize evidence-based procedures for every aspect of cryonics suspension using a medical model.
Former deputy coroner of Riverside, California, Alan Kunzman, publicly accused Jerry Leaf of ordering hundreds of thousands, if not millions, of dollars worth of medical equipment, on UCLA's tab, and having it delivered to Alcor. ***In the interest of fairness, I have revised this paragraph.*** Someone I trust has informed me that Alcor did purchase these items from UCLA surplus equipment, but they couldn't produce the receipts at the time because they had been confiscated by Kunzman's office. My informant states it is typical for the metal ID tags to remain on the equipment when it is sold, and I believe that is probably true.
Leaf was also involved in the cryopreservation of Dora Kent, whose death was somewhat suspicious. Allegedly, Saul Kent and Federowicz, (wearing white lab coats and driving a used ambulance with the ambulance company's name still on the side), picked Dora up and drove her to the Alcor facility, where she conveniently died and was cryopreserved, two days later. Leaf and Darwin, foolishly, declared her dead without a physician present and proceeded with a cryopreservation. (None of them had enough common sense to realize people were going to find these activities suspicious?)
According to Kunzman, Steve Harris MD admitted to signing not one, but three, death certificates. He said Alcor wrote up the death certificates and he "just signed them." Though Harris had already admitted to not being at Alcor, at the time of Dora's death, (and this was allegedly confirmed in Mike Perry's journal), Leaf later called the Coroner's office and provided them with a list of names of people who were, allegedly, present for Dora's death, and included Harris.
Federowicz: In short, Ms. Maxim is attacking the very people she says she feels are essential in cryonics while at the same time effectively denying that they once existed *and that a high standard of care (the same as a patient undergoing CPB in hospital at that time) was once the reality, at least in cryonics as practiced by Alcor at that time.*
I am "attacking the very people I feel are essential in cryonics"??? I am NOT. I don't believe people like Federwicz and Leaf, (people who seem to have thought they were above the law, and were willing to engage in some rather questionable activities), are "essential in cryonics," or that a "high standard of care (the same as a patient undergoing CPB in hospital at that time)," has ever been a "reality," in cryonics.
Federowicz: ...of understanding of how cryonics differs from conventional perfusion, and lack of understanding of the fairly large body of knowledge that has been accumulated which is unique to cryonics cases.
I'm quite familiar with the "large body of" speculation that has been accumulated, in regard to cryonics cases, I see more propaganda and narcissistic pride in unproven "accomplishments" than I see actual achievement.
In regard to my comments about flow probes:
Federowicz: Had Ms. Maxim established a dialogue with me this information would have undoubtedly been quickly passed along.
First of all, I do not respect Federowicz enough to seek out his advice, or opinions. Secondly, I didn't need Mike to tell me how electro-magnetic flow meters work. I wasn't sure of the exact composition of CI's solutions, but I was well aware the flow meters would very likely not function properly with those solutions. Regardless, I wanted to demonstrate the pump to Ben, because I felt it would add a margin of safety, for CI's patients. At the time, I believed it was more important for CI to avoid pumping air, and to learn to measure a more accurate patient pressure.
Federowicz: Why is knowing flow so important?...The history of scientific, evidence-based medicine is a testimony to the criticality of vigorously collecting data which is consistently and ACCURATELY collected. That means precision in quantification. Ms. Maxim seems not to grasp this.
Federwicz is in no position to state that I am not capable of understanding the importance of perfusion-related issues, even in cryonics. HE seems not to grasp the fact that he is calling for excellence from people who have little-to-no knowledge about basic perfusion. Does he really expect laymen, with little opportunity to develop clinical skills, to perform perfusion procedures with precision? Get them to stop pumping air to patients, and subjecting patients to inappropriate pressures, and THEN worry about accuracy.
Federowicz: 1) Knowing flows with precision and accuracy (indeed knowing them at all!) was critically important. It is absolutely essential in cryoprotective perfusion because flow rate is the primary perfusion parameter that determines cryoprotective agent equilibration in the patient. Flow is also the primary determinant of cooling rate (along with heat exchanger efficiency and the temperature of the wall water) during in-field CPB of cryopatients. Knowing when the patient will be cold enough to come off the pump is often really important since it can mean catching or missing a commercial flight. Roller pumps give a very consistent flow regardless of temperature, pressure, viscosity or perfusate composition. RPM can be converted directly into flow.
This may seem impressive to laymen, but it's absurd, to me. Cryoprotective agent (CPA) uptake is going to rely on a number of factors, and vary from patient-to-patient. You need a way to accurately measure the actual concentration of the CPA, not try to calculate it by flow rate, which will need to be adjusted, depending on patient pressures. As for the washout procedure, the flow rate, (and, therefore, the cooling rate), is going to be largely dependent on the pressure. It doesn't matter what time the next flight is. Yes, "roller pumps give a very consistent flow regardless of temperature, pressure, viscosity or perfusate composition," (even if the perfusate is AIR)...herein lie the fundamental problems with amateurs using these pumps.
2) It is possible to design TBW systems so that no macro air can be perfused using roller pumps. This was done with the ATP.
Nothing could be further from the truth. I believe the "ATP" at SA, when I first went to work there, was virtually identical to the circuit Federowicz designed, for Alcor, and there was NOTHING on the "ATP" that would have prevented the pumping of macro air.
3) The notion that centrifugal pumps cannot cause physiologically devastating over-pressure injury is incorrect. While centrifugals cannot generate an infinite head of pressure under occluded conditions as can roller pumps, the static pressure of most medical centrifugals under no-flow (occluded arterial or venous line) conditions varies from ~500 to well over 700 mm Hg. Such pressures will NOT rupture the extracorporeal circuit (i.e., explode oxygenators, filters, or blow apart circuit connections) but they can cause tremendous damage to patients.
More distraction. The reality is that, unlike a roller pump, a centrifugal pump will decrease flow in response to increased outlet pressure. If I am perfusing a patient at 60mmHg at 2,000RPM and 3L of flow per minute, and the pressure increases, the flow is going to go down without any adjustment of RPM's and a "low flow" alarm is going to go off, well before the pressures Federwicz mentions are ever reached. A person would have to be TRYING to reach those pressures and ignoring the pump alarms, when using a centrifugal pump. Also, if the people in cryonics wouldn't slide the tubing over every available barb on the connectors, and double-band the connections, I believe the circuit would blow apart, before those pressures were reached.
Federowicz: 4) No cryonics patient, to my knowledge, has ever been air embolized during in-field TBW due to a roller pump or due to pumping the venous reservoir dry.
How many in-field total body washouts has Federowicz been present for? I have a very hard time believing no cryonics patients have been subjected to air embolization in the field, where the conditions are certainly not as good as those at the cryonics organizations, where we know air-embolization of patients is a blunder that occurs with an alarming frequency.
Federowicz: 7) Centrifugal pumps are not acceptable for CPA perfusion and personnel MUST learn how to reliably and safely use roller or other occlusive positive displacement pumps.
I'm not sure this is true. Ben Best and I ran a centrifugal pump with CI's most viscous solution, at temperatures near zero C, without any problem other than those associated with the flow probe, and there are alternatives to using that flow probe to measure flow.
Federowicz:The solution is to have *only properly trained/skilled personnel perform TBW*. Clinical perfusionists are the ideal (with additional training)...
Agreed, but "properly trained" personnel shouldn't be trained by people of questionable capabilities. The "additional training," in regard to the washout procedure, would be minimal and could be carried out using a bucket of water as a "patient." I'm sure the SA staff feels good about themselves for "playing doctor" with a pig, but it was unnecessary.
Federowicz:...but the fact is that any intelligent, motivated person with the right temperament and reflexes can be trained to operate an open circuit TBW system (with the proper safeguards) with a high degree of safety.
Nonsense. There's not enough proper training available, in cryonics, where there is little opportunity for clinical experience.
Federowicz: There was a time when that was done both safely and effectively (if you count me as a non-perfusionist).
Federowicz is a "non-perfusionist." People don't become perfusionists by qualifying for such in their own minds.
Federowicz: I refused to provide CI with a more complex circuit absent extensive training to a level where I was satisfied that the personnel using the system would be reasonably safe.
I have no idea how Federowicz ever convinced himself, much less others, that he is one of the world's leading perfusion experts. (Actually, I do have an idea, judging by the number of times he writes "I did this...I did that...I...I...I..." As I recall, he began his review of SA by comparing himself to some misunderstood mythological god. I only read Kunzman's book, last week, and he had the same opinion as I, regarding Federowicz self-absorption.
Federwicz: Countless CPB cases have been pumped worldwide with roller pumps with a microscopic incidence of air embolism due to the presence of the roller pump, per se; and with excellent outcomes.
As I've written before, ALL CPB cases have introduced microscopic air to the patients, regardless of the type of pump being used. It's absurd for anyone in cryonics to be concerned with the elimination of microbubbles in perfusion circuits, when they haven't even mastered basic perfusion with a level of competency that was achieved in conventional medicine, DECADES ago.
Federowicz: Outside of cryonics, in the world of clinical medicine, I have almost no doubt that centrifugal pumps will become the standard of care...
If this were true, it would have probably happened nearly two decades ago. There are two main reasons why this is unlikely to happen:
1. The cost of a small length of tubing for a roller pump is only a few cents, while the least expensive centrifugal head runs about $80. (They were closer to $150, a decade ago, but I doubt they'll ever be as cheap as a piece of tubing.) With managed healthcare, this will continue to be a factor in the choice of pumps.
2. Occlusive pumps in conventional medicine are components of computerized heart-lung machines that provide automatic flow adjustment in response to changing pressure, and complete shutdown with automatic line clamping in the presence of dangerous pressures or air in the lines, making the safety of the less expensive occlusive systems comparable to that of the significantly more costly centrifugal systems.
Federowicz (in response to me asking why he demanded to know if the SA flow probes worked with their washout solution, and then suggested Mathew Sullivan test the probes with water): I suggested tap water because it is cheap and readily available. If the flowmeter reads tap water flows accurately then it is worth proceeding to test it with perfusate (really expensive) under real-world conditions. I suggested tap water for the same reason you used it in training circuits: it is a cheap liquid which you can pump and which behaves enough like blood for the purpose at hand. If the SCPC flowmeter gives an invalid number for tap water, particularly if it is misleadingly close to a believable flow, then you should proceed with real caution if you proceed at all.
Why do we need to use "a cheap liquid which you can pump which behaves enough like blood for the purpose at hand"? The question wasn't whether the probe would work with blood, (and I assure everyone it would), but if it would work with SA's washout solution. Federowicz' argument for the flow probe to be tested with water was just a foolish waste of time and money (Mathew's time and salary). It should be tested with SA's washout solution.
Federowicz: I'm glad SA has such a fine perfusionist. But, no matter how good this man is, he will almost certainly not have expertise unique to and essential to proper extracorporeal management of cryopatients.
I believe SA claims to have NINE "fine perfusionists," who I am sure have a knowledge base and experience that far exceeds Federowicz'. Regardless, how could ANYONE have "expertise unique to and essential to proper extracorporeal management of cryopatients"? Other than Leaf, cryonics has a long history of reliance on amateurs who seem to think they know a lot more than they really do, a history of pumping air and subjecting patients to inappropriate pressures, and no outcomes to determine if what has been done has been of any benefit, whatsoever.
Federowicz: No patient presenting for clinical CPB even approximates the average cryopatient presenting for TBW and/or asanguineous ECMO. Even within perfusion there are areas of specialization that require additional knowledge and training: extended ECMO, emergency fem-fem CPB, nenonatal and paediatric CPB, and normothermic CPB, to name a few. What is so extraordinary about the idea that cryonics should be the same?
What is "extraordinary," here, is the degree of the "god complex" Federowicz has, and the number of people who have been buying into his alleged expertise, if you ask me.
Federowicz: As just one small example, Ms Maxim had no idea how or why conventional CPB flowmeters worked, or that they would not work in cryonics.
Federwicz assumes I didn't understand how the flowmeters worked. What I wasn't sure of, was the composition of CI's solutions. I knew it was highly likely the flowmeters wouldn't work with CI's solutions but, again, I felt the safety features were worth exploring alternate methods of measuring flow. This exploration cost ME a lot more time and money than it cost CI, and I would do it again, in a heartbeat. I still think the safety of the centrifugal pump would be of benefit in cryonics procedures, especially if amateurs are sitting behind the pump.
There was a time when I held some degree of respect for Federowicz, but that was before I read his narcissistic ramblings and complaints about medical professionals on another forum, before I started studying the dog experiments, before he lied about having been a "board-eligible perfusionist," and before I read Kunzman's book. If you ask me, it's people like Federowicz who give cryonics a bad name.
Tuesday, March 3, 2009
The "What About Microbubbles?" Syndrome / Cryo-Babble
There's a syndrome I'm well-familiar with, in cryonics. It's a tactic used by many cryo-employees and cryo-consultants, to make others think they know more than they really do, in regard to the conventional medical technologies related to cryonics. Since almost day one of my venture into cryonics, when discussing perfusion, (the technology used to sustain patients during open-heart surgery, and to deliver the washout and vitrification solutions in cryonics), I've been met with the question, "What about microbubbles?"
What about 'em? They're in every perfusion circuit, and there's not much we can do about it. It's highly debatable microbubbles are even worthy of discussion, in mainstream conventional medicine, and they certainly shouldn't be discussed in cryonics, where patients are still, frequently, being filled with massive amounts of air that can be seen with the naked eye. (Which reminds me, one of the world's leading cryo-experts recently wrote about "seeing" microbubbles in some tubing, but that's impossible, as they are "micro"scopic by definition.) Some of the world's leading research scientists have been addressing this issue, for decades, without resolution, so it's unlikely any of the great minds in cryonics is going to resolve it. Why are people who can't eliminate large visible amounts of air being pumped through their patients' vascular system concerned with microbubbles?
Perfusion circuits are dry, before they are primed, and thus far, it's been found to be humanly impossible to get rid of ALL the air. We can minimize the number of microbubbles, but we can't get rid of them, completely. Every patient who is put on a heart-lung machine is, no doubt, subjected to microbubbles. According to the American Heart Association, there were 694,000 open-heart procedures in the US, in 2006.
Given that only a very small percentage of patients qualify for "off-pump" procedures, probably more than 650,000 patients, in 2006 alone, were subjected to microbubbles. I believe the mortality rate in 2006 was probably three percent, or less, (and, keep in mind that the bulk of the patients who don't survive are the emergency cases, not the scheduled cases). Three percent of 694,000, is about 21,000. How many of the approximately 21,000 patients who died had their cause of death listed as being due to micro-air emboli? My guess would be "NONE." Yes, micro-air emboli are thought, by some, to cause neurological sequelae, most likely minor memory problems that resolve, on their own, over a short period of time.
"Air bubbles of less than 30 milliliters are thought to dissolve into the circulation harmlessly. Small volumes do not result in readily detectable symptoms, but ongoing studies hypothesize that these "micro-bubbles" may have some adverse effects." http://en.wikipedia.org/wiki/Intravenous_therapy
Even if they do have adverse effects, the fact remains that the discussion of microbubbles is irrelevant, in cryonics, where large amounts of visible air are said to have been introduced to a significant percentage of cryonics patients.
I think the "What About Microbubbles?" Syndrome is a concerted effort, on the part of certain individuals, to convince others, (and perhaps themselves), that they are more knowledgeable than they really are. For quite some time now, I have been attempting to get patient care providers in cryonics to avoid pumping gross amounts of air to their patients, and to quit subjecting their patients to inappropriate pressures, (whether too high, or too low). In response to some of my criticisms, I get back nonsense like this:
Michael "Mike Darwin" Federowicz:
"Ms. Maxim speaks of inappropriately high perfusion pressures in cryopatients. I concur, but would go further and ask these questions of her:
1) What are the safe and appropriate pressures to use in cryopatients during both blood washout and subsequent asanguineous recirculation? Please explain why you have chosen the value(s) you provide.
2) What are the absolute and relative medical contraindications to in-field TBW for cryopatients? 3) What are medical indications and contraindications for extended (> 1 hour) asanguineous extracorporeal support of cryopatients? What are the likely complications and how should they be managed?
4) What are the expected pressures (MAP & CVP) and flows in both acute TBW and ECMO treated cryopatients?
5) What colloids can be used in TBW/ECMO of cryopatients and for what reasons? What colloids are known to be contraindicated and on the basis of what evidence?
6) What FiO2 should be used during TBW and/or ECMO in cryopatients? Why?
Mike's questions fit one of those debate fallacies I can never remember the names of. Instead of addressing the issues at hand, he wants to take the discussion to a level the audience won't understand. No one with an ounce of common sense would expect cryonics organizations that can seldom do a washout or vitrification without pumping visible amounts of air, or subjecting the patient to inappropriate pressures, to address these issues. It's just more "smoke and mirrors." To discuss these issues with most of the people currently employed at organizations like Alcor and Suspended Animation would be rather like standing in the dark ages, trying to discuss rocket science with cavemen. (No offense, Geico.)
Could I discuss these issues with Mike, or others? Some of them, but I believe most of the answers are unknown, at this point in time. At any rate, it would be pointless to discuss this topic, (or other unresolved, complex issues), with an audience of laymen, when with most of the people working in cryonics don't even have the background required to address these issues. How about we just try to get the current cryonics care providers to quit pumping air that can be seen, and stop subjecting stroke patients to inappropriate perfusion pressures, for starters? Maybe we should precede that by eliminating "cryo-babble" which probably causes much more harm in cryonics, than microbubbles.
Of course, if Saul Kent would use the nearly three-quarters of a million dollars a year I estimate he is spending (LEF's money) on SA personnel and consultants, (mostly laymen with little-to-no medical education, or experience), to hire professionals who already know the basics, he wouldn't have to start from ground zero. Add the money he's throwing at CCR and Alcor, and we could have MANY competent standby teams spread out across the country. Instead, we have absurdities like Ms. Baldwin and her mostly under-qualified, inexperienced staff, riding around in the SA cryomobile, attempting to teach other laymen to perform medical procedures on pigs. When are cryonicists going to get tired of organizations like SA making them look like a bunch of fools?
***Note: The two posts immediately prior to this one have been updated.
What about 'em? They're in every perfusion circuit, and there's not much we can do about it. It's highly debatable microbubbles are even worthy of discussion, in mainstream conventional medicine, and they certainly shouldn't be discussed in cryonics, where patients are still, frequently, being filled with massive amounts of air that can be seen with the naked eye. (Which reminds me, one of the world's leading cryo-experts recently wrote about "seeing" microbubbles in some tubing, but that's impossible, as they are "micro"scopic by definition.) Some of the world's leading research scientists have been addressing this issue, for decades, without resolution, so it's unlikely any of the great minds in cryonics is going to resolve it. Why are people who can't eliminate large visible amounts of air being pumped through their patients' vascular system concerned with microbubbles?
Perfusion circuits are dry, before they are primed, and thus far, it's been found to be humanly impossible to get rid of ALL the air. We can minimize the number of microbubbles, but we can't get rid of them, completely. Every patient who is put on a heart-lung machine is, no doubt, subjected to microbubbles. According to the American Heart Association, there were 694,000 open-heart procedures in the US, in 2006.
Given that only a very small percentage of patients qualify for "off-pump" procedures, probably more than 650,000 patients, in 2006 alone, were subjected to microbubbles. I believe the mortality rate in 2006 was probably three percent, or less, (and, keep in mind that the bulk of the patients who don't survive are the emergency cases, not the scheduled cases). Three percent of 694,000, is about 21,000. How many of the approximately 21,000 patients who died had their cause of death listed as being due to micro-air emboli? My guess would be "NONE." Yes, micro-air emboli are thought, by some, to cause neurological sequelae, most likely minor memory problems that resolve, on their own, over a short period of time.
"Air bubbles of less than 30 milliliters are thought to dissolve into the circulation harmlessly. Small volumes do not result in readily detectable symptoms, but ongoing studies hypothesize that these "micro-bubbles" may have some adverse effects." http://en.wikipedia.org/wiki/Intravenous_therapy
Even if they do have adverse effects, the fact remains that the discussion of microbubbles is irrelevant, in cryonics, where large amounts of visible air are said to have been introduced to a significant percentage of cryonics patients.
I think the "What About Microbubbles?" Syndrome is a concerted effort, on the part of certain individuals, to convince others, (and perhaps themselves), that they are more knowledgeable than they really are. For quite some time now, I have been attempting to get patient care providers in cryonics to avoid pumping gross amounts of air to their patients, and to quit subjecting their patients to inappropriate pressures, (whether too high, or too low). In response to some of my criticisms, I get back nonsense like this:
Michael "Mike Darwin" Federowicz:
"Ms. Maxim speaks of inappropriately high perfusion pressures in cryopatients. I concur, but would go further and ask these questions of her:
1) What are the safe and appropriate pressures to use in cryopatients during both blood washout and subsequent asanguineous recirculation? Please explain why you have chosen the value(s) you provide.
2) What are the absolute and relative medical contraindications to in-field TBW for cryopatients? 3) What are medical indications and contraindications for extended (> 1 hour) asanguineous extracorporeal support of cryopatients? What are the likely complications and how should they be managed?
4) What are the expected pressures (MAP & CVP) and flows in both acute TBW and ECMO treated cryopatients?
5) What colloids can be used in TBW/ECMO of cryopatients and for what reasons? What colloids are known to be contraindicated and on the basis of what evidence?
6) What FiO2 should be used during TBW and/or ECMO in cryopatients? Why?
Mike's questions fit one of those debate fallacies I can never remember the names of. Instead of addressing the issues at hand, he wants to take the discussion to a level the audience won't understand. No one with an ounce of common sense would expect cryonics organizations that can seldom do a washout or vitrification without pumping visible amounts of air, or subjecting the patient to inappropriate pressures, to address these issues. It's just more "smoke and mirrors." To discuss these issues with most of the people currently employed at organizations like Alcor and Suspended Animation would be rather like standing in the dark ages, trying to discuss rocket science with cavemen. (No offense, Geico.)
Could I discuss these issues with Mike, or others? Some of them, but I believe most of the answers are unknown, at this point in time. At any rate, it would be pointless to discuss this topic, (or other unresolved, complex issues), with an audience of laymen, when with most of the people working in cryonics don't even have the background required to address these issues. How about we just try to get the current cryonics care providers to quit pumping air that can be seen, and stop subjecting stroke patients to inappropriate perfusion pressures, for starters? Maybe we should precede that by eliminating "cryo-babble" which probably causes much more harm in cryonics, than microbubbles.
Of course, if Saul Kent would use the nearly three-quarters of a million dollars a year I estimate he is spending (LEF's money) on SA personnel and consultants, (mostly laymen with little-to-no medical education, or experience), to hire professionals who already know the basics, he wouldn't have to start from ground zero. Add the money he's throwing at CCR and Alcor, and we could have MANY competent standby teams spread out across the country. Instead, we have absurdities like Ms. Baldwin and her mostly under-qualified, inexperienced staff, riding around in the SA cryomobile, attempting to teach other laymen to perform medical procedures on pigs. When are cryonicists going to get tired of organizations like SA making them look like a bunch of fools?
***Note: The two posts immediately prior to this one have been updated.
Sunday, March 1, 2009
Critical Care Research Inc.'s (CCR's) Dogs
Here are some numbers on CCR's dog experiments:
Year:............A:............B:
2007...........33............10
2006...........43............19
2005...........47..............6
2004...........46..............5
2003...........34............26
2002...........28............21
2001...........35..............6
TOTAL:.......................93
A = "Number of animals being bred, conditioned, or held for use in teaching, testing, experiments, research, or surgery, but not yet used for such purposes." (Column A not totalled as same dogs were probably included in multiple years.)
B = "Number of animals upon which experiments, teaching, research, surgery, or tests were conducted involving pain or distress to the animals and for which appropriate anesthetic, analgesic, or tranquilizing drugs were used."
Numbers and definitions from: http://www.aphis.usda.gov/animal_welfare/efoia/7023_AL-CT.shtml
93 dogs subjected to "pain and distress," over the course of seven years, for what?
What are CCR's accomplishments? Have they contributed anything to medical science, or the science of cryonics? Have the dog experiments in cryonics really accomplished anything that even begins to compare with what was accomplished, decades ago, in conventional medicine? Or, has their greatest accomplishment been to impress the wallets, and potential clients, in cryonics? (More "feel good" psychology?)
How many dogs were subjected to cryonics experiments, before 2001?
Where are CCR's, Alcors' and Michael "Mike Darwin" Federowicz' studies published? Mike claims to have 1,000 under his belt, where are they?
I've heard and read, many times, about the dogs subjected to an extended period of ischemia, (?17 minutes?), but where is the proof of this?
Was this study ever published? What are the details of this experiment? I was given a mass of information to study, when I was at SA. As I recall, there was a study on dogs included, but I can't remember the details. I DO remember someone mentioning that one of the dog experiments had two variables. As I recall, it had something to do with one dog (or group of dogs) undergoing cardiac arrest at normal temperatures but being provided with flow (via a perfusion circuit), with the other group being cooled and having no flow. Again, my memory fails me, but I'm certain about being told there were two variables. Even my eighth-grader knows an experiment should only have one variable. I'm looking for this document, (and any other documents related to animal experiments in cryonics), if anyone has them, please forward them to me.
***I think a lot of people in cryonics have been overly impressed by reports of dogs being cooled and recovering. This is reflected on CI's "FAQ" page 2-13, where Tim Freeman answers a question regarding hypothermic dog experiments. He writes about Dixie being cooled to 4C, and being perfused with a "synthetic solution." My guess, based on my experience in human circulatory arrest cases, is that Dixie might have fared much the same, without the synthetic solution. Mr. Freeman states that Dixie "made a total recovery," but that's not what I've heard. Maybe, after all those grand mal seizures and horrific suffering, she was eventually able to walk and eat again, but it's difficult to measure neurological damage in a dog. Many human patients have been cooled and arrested for periods exceeding one hour, and have recovered with personality and memory intact. (Note: "Dixie" was an Alcor experiment, but the major players involved in the dog experiments overlap with the other cryonics organizations.)
Where do CCR's dogs come from?
I'm informed CCR breeds dogs for their experiments, and on at least one occasion had to euthanize dogs because they had too many. I believe it is legal to breed animals for research, but I find this practice to be offensive. If you ask me, there's something rather sick about raising puppies, playing with them, naming them (as CCR does), and then subjecting them to pain and suffering, and/or death, (or, worse yet, allowing them to live after they have suffered extreme neurological insult). Why not use dogs that are already scheduled to be euthanized? If these experiments are necessary, (and I have my doubts), why not put the dog out of its misery at the end of the experiment?
How are they kept? (In small kennels? Do they have a place to run and play?)
I have, from a reliable source, that CCR has large clean climate controlled indoor facilities and an outdoor dog run for exercise.
How long are they kept?
Are any of the dogs operated on more than once? (I believe that would be illegal.)
I'm told, from an outside source, the dogs are not subjected to multiple experiments.
What happens to the dogs after the experiments? (Are neurologically damaged dogs being kept as "trophies"?)
Is it humane to subject a dog to experiments that result in neurological deficits and then keep that dog alive? (Question based Federowicz' "Bring Dixie Back" diary entry and Kunzman's remarks on the dogs at CCR.)
Were any of the ten dogs reported in 2007 used to teach perfusion to SA's staff members? (We know the staff members were at CCR for perfusion training. Again, it was insane for anyone to think the staff members of SA could go for a weekend training session, followed by videotaped refresher courses, and could competently perform perfusion. My guess is, CCR/Harris made a lot of money for providing the training session, Platt made a lot of money for the videotaping, and the SA team members got a free trip to California. Just guessing.)
Given that CCR only performed 93 experiments over the course of seven years, I'm still wondering where Michael "Mike Darwin" Federowicz did the approximately "1,000" dog perfusion he claims to have performed. He would have had to do an average of one dog per week, for more than 19 years, to get to 1,000. I think this is extremely unlikely. If he did, I'm sure the animal welfare people would love to see documentation of those experiments.
In searching for CCR's numbers, I stumbled across a 2007 report for 21CM that shows they experimented on 351 rabbits. What were the results of those experiments?
I'm often curious about 21CM, due to the lack of information and the connections between 21CM, CCR and SA. I'm told Kent/LEF provides less than half of 21CM's funding and that they receive substantial government grants for their research, (for conventional medicine purposes, not cryonics, I assume). I'm also told Fahy of 21CM publishes most, if not all, of his work.
Year:............A:............B:
2007...........33............10
2006...........43............19
2005...........47..............6
2004...........46..............5
2003...........34............26
2002...........28............21
2001...........35..............6
TOTAL:.......................93
A = "Number of animals being bred, conditioned, or held for use in teaching, testing, experiments, research, or surgery, but not yet used for such purposes." (Column A not totalled as same dogs were probably included in multiple years.)
B = "Number of animals upon which experiments, teaching, research, surgery, or tests were conducted involving pain or distress to the animals and for which appropriate anesthetic, analgesic, or tranquilizing drugs were used."
Numbers and definitions from: http://www.aphis.usda.gov/animal_welfare/efoia/7023_AL-CT.shtml
93 dogs subjected to "pain and distress," over the course of seven years, for what?
What are CCR's accomplishments? Have they contributed anything to medical science, or the science of cryonics? Have the dog experiments in cryonics really accomplished anything that even begins to compare with what was accomplished, decades ago, in conventional medicine? Or, has their greatest accomplishment been to impress the wallets, and potential clients, in cryonics? (More "feel good" psychology?)
How many dogs were subjected to cryonics experiments, before 2001?
Where are CCR's, Alcors' and Michael "Mike Darwin" Federowicz' studies published? Mike claims to have 1,000 under his belt, where are they?
I've heard and read, many times, about the dogs subjected to an extended period of ischemia, (?17 minutes?), but where is the proof of this?
Was this study ever published? What are the details of this experiment? I was given a mass of information to study, when I was at SA. As I recall, there was a study on dogs included, but I can't remember the details. I DO remember someone mentioning that one of the dog experiments had two variables. As I recall, it had something to do with one dog (or group of dogs) undergoing cardiac arrest at normal temperatures but being provided with flow (via a perfusion circuit), with the other group being cooled and having no flow. Again, my memory fails me, but I'm certain about being told there were two variables. Even my eighth-grader knows an experiment should only have one variable. I'm looking for this document, (and any other documents related to animal experiments in cryonics), if anyone has them, please forward them to me.
***I think a lot of people in cryonics have been overly impressed by reports of dogs being cooled and recovering. This is reflected on CI's "FAQ" page 2-13, where Tim Freeman answers a question regarding hypothermic dog experiments. He writes about Dixie being cooled to 4C, and being perfused with a "synthetic solution." My guess, based on my experience in human circulatory arrest cases, is that Dixie might have fared much the same, without the synthetic solution. Mr. Freeman states that Dixie "made a total recovery," but that's not what I've heard. Maybe, after all those grand mal seizures and horrific suffering, she was eventually able to walk and eat again, but it's difficult to measure neurological damage in a dog. Many human patients have been cooled and arrested for periods exceeding one hour, and have recovered with personality and memory intact. (Note: "Dixie" was an Alcor experiment, but the major players involved in the dog experiments overlap with the other cryonics organizations.)
Where do CCR's dogs come from?
I'm informed CCR breeds dogs for their experiments, and on at least one occasion had to euthanize dogs because they had too many. I believe it is legal to breed animals for research, but I find this practice to be offensive. If you ask me, there's something rather sick about raising puppies, playing with them, naming them (as CCR does), and then subjecting them to pain and suffering, and/or death, (or, worse yet, allowing them to live after they have suffered extreme neurological insult). Why not use dogs that are already scheduled to be euthanized? If these experiments are necessary, (and I have my doubts), why not put the dog out of its misery at the end of the experiment?
How are they kept? (In small kennels? Do they have a place to run and play?)
I have, from a reliable source, that CCR has large clean climate controlled indoor facilities and an outdoor dog run for exercise.
How long are they kept?
Are any of the dogs operated on more than once? (I believe that would be illegal.)
I'm told, from an outside source, the dogs are not subjected to multiple experiments.
What happens to the dogs after the experiments? (Are neurologically damaged dogs being kept as "trophies"?)
Is it humane to subject a dog to experiments that result in neurological deficits and then keep that dog alive? (Question based Federowicz' "Bring Dixie Back" diary entry and Kunzman's remarks on the dogs at CCR.)
Were any of the ten dogs reported in 2007 used to teach perfusion to SA's staff members? (We know the staff members were at CCR for perfusion training. Again, it was insane for anyone to think the staff members of SA could go for a weekend training session, followed by videotaped refresher courses, and could competently perform perfusion. My guess is, CCR/Harris made a lot of money for providing the training session, Platt made a lot of money for the videotaping, and the SA team members got a free trip to California. Just guessing.)
Given that CCR only performed 93 experiments over the course of seven years, I'm still wondering where Michael "Mike Darwin" Federowicz did the approximately "1,000" dog perfusion he claims to have performed. He would have had to do an average of one dog per week, for more than 19 years, to get to 1,000. I think this is extremely unlikely. If he did, I'm sure the animal welfare people would love to see documentation of those experiments.
In searching for CCR's numbers, I stumbled across a 2007 report for 21CM that shows they experimented on 351 rabbits. What were the results of those experiments?
I'm often curious about 21CM, due to the lack of information and the connections between 21CM, CCR and SA. I'm told Kent/LEF provides less than half of 21CM's funding and that they receive substantial government grants for their research, (for conventional medicine purposes, not cryonics, I assume). I'm also told Fahy of 21CM publishes most, if not all, of his work.
Suspended Animation Inc's (SA's) Recent Use of Animals
I need some help, here. I don't have time to research the rules and regulations for animal experimentation, or to find all the existing reports of animal experiments that have taken place in cryonics. I am going to be posting what I can find, with questions. If anyone has copies of reports on animal experimentation in cryonics, or the answers to any of my questions, please email me. Thanks.
Let's start with the most recent cryonics animal experiments I am aware of:
From SA's News Bulletin, Number 14:
"NEW STANDBY TEAM TRAINING Last December, Suspended Animation began developing a pig cadaver training model for cryonics procedures. Throughout 2008, SA worked with a USDA-certified facility and a large animal veterinarian to refine that model and the training protocol to create a realistic, hands-on experience using SA’s equipment and stabilization procedures. SA is now ready to begin rotating our extended network of standby team members through this new training that covers all procedures from pronouncement through washout and perfusion with organ preservation solution." http://www.suspendedinc.com/newsbulletins.html
From SA's News Bulletin, Number 13:
"NEW TRAINING AND SIMULATION DEVELOPMENT In December, Suspended Animation began developing a porcine cadaver training model for cryonics procedures. The first step toward developing the model was to test it using the human protocol. The SA staff and three consultants used SA’s E450 transport vehicle to perform a 27-hour standby, stabilization and transport exercise about 400 miles from the SA facility. After an overnight standby, “the patient” was pronounced in the late morning. He was then cooled with ice, intubated and ventilated, medications were administered through an IV line, chest compressions were provided by the AutoPulse, and the femoral artery and vein were cut-down and cannulated, followed by blood washout using the ATP. Total procedural time before washout and transport could begin was 45 minutes. With more practice, we hope to reduce that time significantly. A few hitches and glitches revealed that some different sized instruments and cannulae will be necessary to make the model practical to use. Overall, working on a cadaver provides a more realistic, and therefore more valuable, training experience. We are looking forward to our next test run in the first Quarter of 2008." http://www.suspendedinc.com/newsbulletins13.html
In Bulletin Number 14, they mention use of a "USDA-certified facility, but in Number 13 they only mention their vehicle. Where were they doing the experiments in Number 13?
Is it legal to perform animal experiments in SA's vehicle?
Is it legal to use animals for the sole purpose of training laymen to perform medical procedures on cadavers?
The events described in SA's News Bulletins aren't really "experiments." I believe they are training sessions intended to teach surgical skills, paramedic skills and perfusion skills to people without the proper educations.
***This post is a "work in progress," and will be updated in the very near future.
Let's start with the most recent cryonics animal experiments I am aware of:
From SA's News Bulletin, Number 14:
"NEW STANDBY TEAM TRAINING Last December, Suspended Animation began developing a pig cadaver training model for cryonics procedures. Throughout 2008, SA worked with a USDA-certified facility and a large animal veterinarian to refine that model and the training protocol to create a realistic, hands-on experience using SA’s equipment and stabilization procedures. SA is now ready to begin rotating our extended network of standby team members through this new training that covers all procedures from pronouncement through washout and perfusion with organ preservation solution." http://www.suspendedinc.com/newsbulletins.html
From SA's News Bulletin, Number 13:
"NEW TRAINING AND SIMULATION DEVELOPMENT In December, Suspended Animation began developing a porcine cadaver training model for cryonics procedures. The first step toward developing the model was to test it using the human protocol. The SA staff and three consultants used SA’s E450 transport vehicle to perform a 27-hour standby, stabilization and transport exercise about 400 miles from the SA facility. After an overnight standby, “the patient” was pronounced in the late morning. He was then cooled with ice, intubated and ventilated, medications were administered through an IV line, chest compressions were provided by the AutoPulse, and the femoral artery and vein were cut-down and cannulated, followed by blood washout using the ATP. Total procedural time before washout and transport could begin was 45 minutes. With more practice, we hope to reduce that time significantly. A few hitches and glitches revealed that some different sized instruments and cannulae will be necessary to make the model practical to use. Overall, working on a cadaver provides a more realistic, and therefore more valuable, training experience. We are looking forward to our next test run in the first Quarter of 2008." http://www.suspendedinc.com/newsbulletins13.html
In Bulletin Number 14, they mention use of a "USDA-certified facility, but in Number 13 they only mention their vehicle. Where were they doing the experiments in Number 13?
Is it legal to perform animal experiments in SA's vehicle?
Is it legal to use animals for the sole purpose of training laymen to perform medical procedures on cadavers?
The events described in SA's News Bulletins aren't really "experiments." I believe they are training sessions intended to teach surgical skills, paramedic skills and perfusion skills to people without the proper educations.
***This post is a "work in progress," and will be updated in the very near future.
Thursday, February 19, 2009
"Feel Good Words Like 'Transparency'"
Recently, I was listening to CNBC, and a commentator mentioned "feel good words, like 'transparency.'" (I'm not sure who made the comment, or I'd give him credit.) "Transparency" is certainly a "feel good" word that gets tossed around a lot, in cryonics.
Transparency is a great thing, but only when someone is capable of interpreting what they see. SA consultants Charles Platt and Aschwin de Wolf may have written the most "transparent" cryonics case report, ever, for SA's involvement in the CI-81 case. The problem was, even THEY couldn't "see" what they had written, because they didn't have the appropriate educations, or clinical backgrounds. They didn't have a clue as to how medical professionals with a background in perfusion technology, (the method used to deliver SA's washout solution), would interpret that report. When I, (a perfusionist), pointed out the obvious, SA published an addendum that only supported my accusations. (Why were a science fiction writer and someone with an education in political science, who were not even present for the CI-81 case, be writing the case report, anyway?)
Indeed, cryonics organizations could not be much more "transparent," but what is the result? Them standing around patting themselves on the back, for being "transparent"? When a medical professional points out that the introduction of massive air emboli and the improper pressurization of patients were virtually eliminated in conventional medicine, decades ago, all that comes back is "We're doing the best we can?" and more back-patting for being "transparent"?
I've been chastised on the Cold Filter forum, for running off cryonicists willing to post under their real names. Whom have I run off? A science fiction writer/wannabe engineer who I believe has wasted enormous amounts of money on building makeshift equipment, sometimes when there was existing medical equipment available at a reasonable price? Someone who is publicly, and regulary, called a "liar" even by cryonicists? A physician on the LEF payroll who is willing to publish blatant lies about a fellow medical professional he doesn't even know, and who wouldn't tell laymen to give a patient heparin, unless they knew to ask? People who engage in animal experimentation of questionable merit? A mostly self-taught, self-proclaimed "cryo-expert" who wants to carry on highly-technical discussions the audience won't understand, (not because they are unintelligent, but because they don't have the appropriate background.)
The readers on Cold Filter have frequently remarked that they don't understand Michael ("Mike Darwin") Federowicz' posts, but they still revere him and think he should be employed at one of the cryonics organizations. Do they know why Mr. Federowicz isn't welcome, as an employee, at any cryonics organizations? I believe I do, but it would be "hearsay," at this point in time.
Mr. Federowicz' ramblings are extremely transparent, but few, (if any), in cryonics, see through them. They get blinded by the medical terminology and scientific formulas he throws out. They read "iatrogenic" and Poiseuille's Equation, and then sit around oooohing and aaaahhhhing, thinking they are in the presence of a medical expert.
There are at least several published accounts of Federowicz' career in cryonics, from the time he was a teenager, but I've yet to find one that mentions him attending perfusion school, or working in open-heart surgery. In order to have been "board-eligible," as he claims, Federowicz would have had to graduated from an accredited school of perfusion technology and participated in a minimum of 100 clinical cases, (and I don't believe dogs, or "legally dead" patients count). Eleven days ago, on the Cold Filter Forum, I asked Mr. Federowicz two very simple questions: "Which accredited perfusion program did he attend?" and "Where did he perform the 100 clinical cases required to sit for the boards?" Mr. Federowicz has yet to respond to these simple questions, which don't require in-depth technical discussions, terminology, or scientific equations the audience wouldn't understand. Has he neglected to answer because no amount of "smoke and mirrors," (technical jargon and scientific formulas thrown out to an audience comprised mostly of laymen), can cloud this issue? Did he disappear from the forum due to what the moderator has called my "cheap unimaginative shots," or did he disappear because I asked a valid question he doesn't want to answer?
The way transparency is supposed to work is; someone who can see through the fog points out the obvious, and something gets done about it. When a qualified professional complains, (for nearly two years), that laymen are being paid two-to-four times what their qualified counterparts would be paid, to perform well-established medical procedures, (the tasks of paramedics and perfusionists), someone does something about it. (And, "doing something about it" should not include slandering and libeling the critic.)
Edit on March 2, 2009:
Someone writes to me that the "powers that be" in cryonics "want to be told pleasant lies, all while having the form of brutal honesty." I believe this fits right in with my "Feel Good Words like Transparency" theory.
Transparency is a great thing, but only when someone is capable of interpreting what they see. SA consultants Charles Platt and Aschwin de Wolf may have written the most "transparent" cryonics case report, ever, for SA's involvement in the CI-81 case. The problem was, even THEY couldn't "see" what they had written, because they didn't have the appropriate educations, or clinical backgrounds. They didn't have a clue as to how medical professionals with a background in perfusion technology, (the method used to deliver SA's washout solution), would interpret that report. When I, (a perfusionist), pointed out the obvious, SA published an addendum that only supported my accusations. (Why were a science fiction writer and someone with an education in political science, who were not even present for the CI-81 case, be writing the case report, anyway?)
Indeed, cryonics organizations could not be much more "transparent," but what is the result? Them standing around patting themselves on the back, for being "transparent"? When a medical professional points out that the introduction of massive air emboli and the improper pressurization of patients were virtually eliminated in conventional medicine, decades ago, all that comes back is "We're doing the best we can?" and more back-patting for being "transparent"?
I've been chastised on the Cold Filter forum, for running off cryonicists willing to post under their real names. Whom have I run off? A science fiction writer/wannabe engineer who I believe has wasted enormous amounts of money on building makeshift equipment, sometimes when there was existing medical equipment available at a reasonable price? Someone who is publicly, and regulary, called a "liar" even by cryonicists? A physician on the LEF payroll who is willing to publish blatant lies about a fellow medical professional he doesn't even know, and who wouldn't tell laymen to give a patient heparin, unless they knew to ask? People who engage in animal experimentation of questionable merit? A mostly self-taught, self-proclaimed "cryo-expert" who wants to carry on highly-technical discussions the audience won't understand, (not because they are unintelligent, but because they don't have the appropriate background.)
The readers on Cold Filter have frequently remarked that they don't understand Michael ("Mike Darwin") Federowicz' posts, but they still revere him and think he should be employed at one of the cryonics organizations. Do they know why Mr. Federowicz isn't welcome, as an employee, at any cryonics organizations? I believe I do, but it would be "hearsay," at this point in time.
Mr. Federowicz' ramblings are extremely transparent, but few, (if any), in cryonics, see through them. They get blinded by the medical terminology and scientific formulas he throws out. They read "iatrogenic" and Poiseuille's Equation, and then sit around oooohing and aaaahhhhing, thinking they are in the presence of a medical expert.
There are at least several published accounts of Federowicz' career in cryonics, from the time he was a teenager, but I've yet to find one that mentions him attending perfusion school, or working in open-heart surgery. In order to have been "board-eligible," as he claims, Federowicz would have had to graduated from an accredited school of perfusion technology and participated in a minimum of 100 clinical cases, (and I don't believe dogs, or "legally dead" patients count). Eleven days ago, on the Cold Filter Forum, I asked Mr. Federowicz two very simple questions: "Which accredited perfusion program did he attend?" and "Where did he perform the 100 clinical cases required to sit for the boards?" Mr. Federowicz has yet to respond to these simple questions, which don't require in-depth technical discussions, terminology, or scientific equations the audience wouldn't understand. Has he neglected to answer because no amount of "smoke and mirrors," (technical jargon and scientific formulas thrown out to an audience comprised mostly of laymen), can cloud this issue? Did he disappear from the forum due to what the moderator has called my "cheap unimaginative shots," or did he disappear because I asked a valid question he doesn't want to answer?
The way transparency is supposed to work is; someone who can see through the fog points out the obvious, and something gets done about it. When a qualified professional complains, (for nearly two years), that laymen are being paid two-to-four times what their qualified counterparts would be paid, to perform well-established medical procedures, (the tasks of paramedics and perfusionists), someone does something about it. (And, "doing something about it" should not include slandering and libeling the critic.)
Edit on March 2, 2009:
Someone writes to me that the "powers that be" in cryonics "want to be told pleasant lies, all while having the form of brutal honesty." I believe this fits right in with my "Feel Good Words like Transparency" theory.
Tuesday, February 17, 2009
"Experts" and Animal Experimentation in Cryonics
I've been thinking about animal experimentation, in cryonics, for quite some time, now. I've made comments on this blog, and on the Cold Filter forum, indicating I thought some of the experiments were unnecessary, and I've questioned the amount of suffering that has been inflicted, during cryonics dog experiments. I've never been involved in animal experimentation, in cryonics, so my concerns arise from what I have read, and what I've been told, by others. I've recently stepped up my exploration of animal experimentation, in cryonics, and I don't like what I am finding. (More on that in future posts...for now, I'll just leave you with this: http://www.alcor.org/Library/html/bringingdixieback.html)
Cryonics organizations have a history of sending laymen to do their patient procedures, so I find it quite difficult to believe the quality of their animal experimentation to be much better. (If it is, isn't there something wrong with providing quality care for animal experimentation and sending laymen, sometimes with no medical experience whatsoever, to care for human patients?)
I spent the last 30 minutes searching for references to the dog experiments that have been performed at the cryonics organizations, and so far, the only information I have found is that published by the organizations, or people tied to them. In other words, the only people who seem to hold any regard for these experiments, are people tied to the cryonics organizations. The same can be said for the "cryonics experts" who carry out these experiments. As far as I can tell, their work has had little recognition outside the very small community of cryonics.
One of the people mentioned most often, in connection with the dog experiments in cryonics, is Michael ("Mike Darwin") Federowicz. Mr. Federowicz claims to have, at one time, been a "board eligible" perfusionist. I can find no record of him attending an accredited perfusion school, and thus far, he has not responded to my inquiries on this matter. Indeed, I can find no information regarding a post-secondary education, of any kind, for Mr. Federowicz. He was, at one time, a dialysis technician. Though many people in cryonics seem to have been led to believe dialysis is similar to cardiovascular perfusion, those occupations are only very distant "cousins." Dialysis technicians are often "OJT's," working in hospitals, under the supervision of RN's. Dialysis is a relatively simple process, and some patients perform their own (peritoneal) dialysis at home, by themselves. This is hardly a comparison to supporting a patient with a heart-lung machine.
There seems to be a group of "intellectuals" in cryonics who stick their noses in a lot of books and come out thinking they are medical "experts" capable of teaching laymen to perform cutting-edge medical procedures. I've been told Mr. Federowicz is a self-taught man who has become some sort of "leading expert in emergency medicine." Being a "respected contributor" to a "critical care medicine Internet discussion group," and writing a couple of articles hardly qualifies one as a "leading medical expert." (http://en.wikipedia.org/wiki/Mike_Darwin) I have a serious problem with laymen who dress themselves up in surgical garb, or white labcoats, and think they are the peers of medical professionals and qualified research scientists.
I have spent nearly two years posting on the Cold Filter cryonics forums, and blogging, about what I believe to be an extreme degree of incompetence and unethical behavior within the cryonics community, particularly within the Life Extension Foundation (LEF) funded organizations, which I believe can now be extended to include Alcor. There are some specific individuals I have targeted, for various reasons. Some of those individuals responded to my criticism by posting blatant lies about me, lies which led to one of them hiring an attorney who advised him to retract and apologize.
There is another medical professional, Larry Johnson, who seems to have received much the same treatment as I did, in cryonics. Mr. Johnson is a paramedic who was an employee of Alcor Life Extension Foundation, at the time of the Ted Williams cryopreservation scandal. After Mr. Johnson complained about the activities of Alcor, he was accused of stealing a non-disclosure form that insiders at Alcor have told me he said never existed. Interestingly, the exact same lie was told about me, and I believe that lie was told by the same person.
I first heard of Larry Johnson, when I was working at Suspended Animation, Inc., in Boynton Beach, Florida. I was told he was a liar, and an opportunist just out to "make a buck" on the Ted Williams scandal. Being new to cryonics, and thinking the people I was dealing with were honest and sincere, I took them at their word. Until news of his upcoming book, "Shiver: A Whistleblower's Chilling Expose of Cryonics and the Truth Behind What Happened to Ted Williams," I thought Mr. Johnson was dead, having been told he died in some sort of mysterious motorcycle accident.
Based on stories I have heard, from my friends in cryonics, (or, perhaps, I should say my "former friends"), I have the suspicion that Mr. Johnson is going to make certain accusations against some of the very individuals I, (without even knowing Mr. Johnson was alive), have been accusing of imcompetence and unethical behavior. If Mr. Johnson does name the same individuals I've been criticizing, will the cryonics community finally sit up and take notice, or will they simply vilify Mr. Johnson, and me, and continue to believe in the "experts" who have brought them nothing much more than a very bad public image?
It's fun to believe Santa leaves the presents under the tree, David Copperfield can make an airplane disappear, or that Bernie Madoff is earning high rates of interest on one's money, but sometimes we have to just admit the "wool is being pulled over our eyes."
Larry Johnson's "FreeTed" website.
Cryonics organizations have a history of sending laymen to do their patient procedures, so I find it quite difficult to believe the quality of their animal experimentation to be much better. (If it is, isn't there something wrong with providing quality care for animal experimentation and sending laymen, sometimes with no medical experience whatsoever, to care for human patients?)
I spent the last 30 minutes searching for references to the dog experiments that have been performed at the cryonics organizations, and so far, the only information I have found is that published by the organizations, or people tied to them. In other words, the only people who seem to hold any regard for these experiments, are people tied to the cryonics organizations. The same can be said for the "cryonics experts" who carry out these experiments. As far as I can tell, their work has had little recognition outside the very small community of cryonics.
One of the people mentioned most often, in connection with the dog experiments in cryonics, is Michael ("Mike Darwin") Federowicz. Mr. Federowicz claims to have, at one time, been a "board eligible" perfusionist. I can find no record of him attending an accredited perfusion school, and thus far, he has not responded to my inquiries on this matter. Indeed, I can find no information regarding a post-secondary education, of any kind, for Mr. Federowicz. He was, at one time, a dialysis technician. Though many people in cryonics seem to have been led to believe dialysis is similar to cardiovascular perfusion, those occupations are only very distant "cousins." Dialysis technicians are often "OJT's," working in hospitals, under the supervision of RN's. Dialysis is a relatively simple process, and some patients perform their own (peritoneal) dialysis at home, by themselves. This is hardly a comparison to supporting a patient with a heart-lung machine.
There seems to be a group of "intellectuals" in cryonics who stick their noses in a lot of books and come out thinking they are medical "experts" capable of teaching laymen to perform cutting-edge medical procedures. I've been told Mr. Federowicz is a self-taught man who has become some sort of "leading expert in emergency medicine." Being a "respected contributor" to a "critical care medicine Internet discussion group," and writing a couple of articles hardly qualifies one as a "leading medical expert." (http://en.wikipedia.org/wiki/Mike_Darwin) I have a serious problem with laymen who dress themselves up in surgical garb, or white labcoats, and think they are the peers of medical professionals and qualified research scientists.
I have spent nearly two years posting on the Cold Filter cryonics forums, and blogging, about what I believe to be an extreme degree of incompetence and unethical behavior within the cryonics community, particularly within the Life Extension Foundation (LEF) funded organizations, which I believe can now be extended to include Alcor. There are some specific individuals I have targeted, for various reasons. Some of those individuals responded to my criticism by posting blatant lies about me, lies which led to one of them hiring an attorney who advised him to retract and apologize.
There is another medical professional, Larry Johnson, who seems to have received much the same treatment as I did, in cryonics. Mr. Johnson is a paramedic who was an employee of Alcor Life Extension Foundation, at the time of the Ted Williams cryopreservation scandal. After Mr. Johnson complained about the activities of Alcor, he was accused of stealing a non-disclosure form that insiders at Alcor have told me he said never existed. Interestingly, the exact same lie was told about me, and I believe that lie was told by the same person.
I first heard of Larry Johnson, when I was working at Suspended Animation, Inc., in Boynton Beach, Florida. I was told he was a liar, and an opportunist just out to "make a buck" on the Ted Williams scandal. Being new to cryonics, and thinking the people I was dealing with were honest and sincere, I took them at their word. Until news of his upcoming book, "Shiver: A Whistleblower's Chilling Expose of Cryonics and the Truth Behind What Happened to Ted Williams," I thought Mr. Johnson was dead, having been told he died in some sort of mysterious motorcycle accident.
Based on stories I have heard, from my friends in cryonics, (or, perhaps, I should say my "former friends"), I have the suspicion that Mr. Johnson is going to make certain accusations against some of the very individuals I, (without even knowing Mr. Johnson was alive), have been accusing of imcompetence and unethical behavior. If Mr. Johnson does name the same individuals I've been criticizing, will the cryonics community finally sit up and take notice, or will they simply vilify Mr. Johnson, and me, and continue to believe in the "experts" who have brought them nothing much more than a very bad public image?
It's fun to believe Santa leaves the presents under the tree, David Copperfield can make an airplane disappear, or that Bernie Madoff is earning high rates of interest on one's money, but sometimes we have to just admit the "wool is being pulled over our eyes."
Larry Johnson's "FreeTed" website.
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