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Archive for the ‘Fiction and medicine’ Category


That is the question…

Anyone who follows healthcare news, as I do , cannot help being impressed with the number of scientific and non-scientific items that mention the applicability of Magnetic Resonance Imaging (‘MRI’) to medical procedures.

A very important aspect that is worthwhile noting is that the promise MRI bears to improve patients’ screening – pre-clinical diagnosis, better treatment choice, treatment guidance and outcome follow-up – is based on new techniques that enables MRI-based tissue characterisation.

Magnetic resonance imaging (MRI) is an imaging device that relies on the well-known physical phenomena named “Nuclear Magnetic Resonance”. It so happens that, due to its short relaxation time, the 1H isotope (spin ½ nucleus) has a very distinctive response to changes in the surrounding magnetic field. This serves MRI imaging of the human body well as, basically, we are 90% water. The MRI device makes use of strong magnetic fields changing at radio frequency to produce cross-sectional images of organs and internal structures in the body. Because the signal detected by an MRI machine varies depending on the water content and local magnetic properties of a particular area of the body, different tissues or substances can be distinguished from one another in the scan’s resulting image.

The main advantages of MRI in comparison to X-ray-based devices such as CT scanners and mammography systems are that the energy it uses is non-ionizing and it can differentiate soft tissues very well based on differences in their water content.

In the last decade, the basic imaging capabilities of MRI have been augmented for the purpose of cancer patient management, by using magnetically active materials (called contrast agents) and adding functional measurements such as tissue temperature to show internal structures or abnormalities more clearly.

 

In order to increase the specificity and sensitivity of MRI imaging in cancer detection, various imaging strategies have been developed. The most discussed in MRI related literature are:

  • T2 weighted imaging: The measured response of the 1H isotope in a resolution cell of a T2-weighted image is related to the extent of random tumbling and the rotational motion of the water molecules within that resolution cell. The faster the rotation of the water molecule, the higher the measured value of the T2 weighted response in that resolution cell. For example, prostate cancer is characterized by a low T2 response relative to the values typical to normal prostatic tissue [5].

T2 MRI pelvis with Endo Rectal Coil ( DATA of Dr. Lance Mynders, MAYO Clinic)

  • Dynamic Contrast Enhanced (DCE) MRI involves a series of rapid MRI scans in the presence of a contrast agent. In the case of scanning the prostate, the most commonly used material is gadolinium [4].

Axial MRI  Lava DCE with Endo Rectal ( DATA of Dr. Lance Mynders, MAYO Clinic)

  • Diffusion weighted (DW) imaging: Provides an image intensity that is related to the microscopic motion of water molecules [5].

DW image of the left parietal glioblastoma multiforme (WHO grade IV) in a 59-year-old woman, Al-Okaili R N et al. Radiographics 2006;26:S173-S189

  • Multifunctional MRI: MRI image overlaid with combined information from T2-weighted scans, dynamic contrast-enhancement (DCE), and diffusion weighting (DW) [5].

Source AJR: http://www.ajronline.org/content/196/6/W715/F3

  • Blood oxygen level-dependent (BOLD) MRI: Assessing tissue oxygenation. Tumors are characterized by a higher density of micro blood vessels. The images that are acquired follow changes in the concentration of paramagnetic deoxyhaemoglobin [5].

In the last couple of years, medical opinion leaders are offering to use MRI to solve almost every weakness of the cancer patients’ pathway. Such proposals are not always supported by any evidence of feasibility. For example, a couple of weeks ago, the British Medical Journal published a study [1] concluding that women carrying a mutation in the BRCA1 or BRCA2 genes who have undergone a mammogram or chest x-ray before the age of 30 are more likely to develop breast cancer than those who carry the gene mutation but who have not been exposed to mammography. What is published over the internet and media to patients and lay medical practitioners is: “The results of this study support the use of non-ionising radiation imaging techniques (such as magnetic resonance imaging) as the main tool for surveillance in young women with BRCA1/2 mutations.”.

Why is ultrasound not mentioned as a potential “non-ionising radiation imaging technique”?

Another illustration is the following advert:

An MRI scan takes between 30 to 45 minutes to perform (not including the time of waiting for the interpretation by the radiologist). It requires the support of around 4 well-trained team members. It costs between $400 and $3500 (depending on the scan).

The important question, therefore, is: Are there, in the USA, enough MRI  systems to meet the demand of 40 million scans a year addressing women with radiographically dense  breasts? Toda there are approximately 10,000 MRI systems in the USA. Only a small percentage (~2%) of the examinations are related to breast cancer. A

A rough calculation reveals that around 10000 additional MRI centers would need to be financed and operated to meet that demand alone.

References

  1. Exposure to diagnostic radiation and risk of breast cancer among carriers of BRCA1/2 mutations: retrospective cohort study (GENE-RAD-RISK), BMJ 2012; 345 doi: 10.1136/bmj.e5660 (Published 6 September 2012), Cite this as: BMJ 2012;345:e5660 – http://www.bmj.com/content/345/bmj.e5660
  1. http://www.auntminnieeurope.com/index.aspx?sec=sup&sub=wom&pag=dis&itemId=607075
  1. Ahmed HU, Kirkham A, Arya M, Illing R, Freeman A, Allen C, Emberton M. Is it time to consider a role for MRI before prostate biopsy? Nat Rev Clin Oncol. 2009;6(4):197-206.
  1. Puech P, Potiron E, Lemaitre L, Leroy X, Haber GP, Crouzet S, Kamoi K, Villers A. Dynamic contrast-enhanced-magnetic resonance imaging evaluation of intraprostatic prostate cancer: correlation with radical prostatectomy specimens. Urology. 2009;74(5):1094-9.
  1. Advanced MR Imaging Techniques in the Diagnosis of Intraaxial Brain Tumors in Adults, Al-Okaili R N et al. Radiographics 2006;26:S173-S189 ,

http://radiographics.rsna.org/content/26/suppl_1/S173.full

  1. Ahmed HU. The Index Lesion and the Origin of Prostate Cancer. N Engl J Med. 2009 Oct; 361(17): 1704-6
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Is Patient Engagement with Medicine different than World View?

Curator: Larry H. Bernstein, MD, FCAP

 

In Mark Twain’s later years he had personal and financial losses.  I think that was when he wrote “why do we laugh at a birth and cry at a funeral? It is because it is not I!”

The first Chairman of Medicine at John Hopkins Medical School was William Osler.  He taught that a physician must be broadly knowledgeable about the arts and culture in order to make a difference in engaging the patient.  This has come into play in the republican primaries for the first time, regardless of other requirements.

When I was a freshman medical student we had a special course on Inborn Errors of Metabolism.  I think it was a first, given a new and energetic Chairman of Biochemistry from Harvard.  Nevertheless, over the next decade, the influence of “Oslerism” was fading, to be replaced by the concept of a British physician, Archibald Garrod (1857–1936), in the early 20th century (1908). He is known for work that prefigured the “one gene-one enzyme” hypothesis, based on his studies on the nature and inheritance of alkaptonuria. His seminal text, Inborn Errors of Metabolism was published in 1923.[1] Some years later I learned that the selection of students entering was weighted in success with organic chemistry.

 

Type of inborn error Incidence
Disease involving amino acids (e.g. PKU), organic acids,
primary lactic acidosis, galactosemia, or a urea cycle disease
24 per 100 000 births[3] 1 in 4,200[3]
Lysosomal storage disease 8 per 100 000 births[3] 1 in 12,500[3]
Peroxisomal disorder ~3 to 4 per 100 000 of births[3] ~1 in 30,000[3]
Respiratory chain-based mitochondrial disease ~3 per 100 000 births[3] 1 in 33,000[3]
Glycogen storage disease 2.3 per 100 000 births[3] 1 in 43,000[3]

 

  1.  http://www.esp.org/books/garrod/inborn-errors/facsimile/
  2. Jump up^ Vernon, Hilary (Jun 2015). “Inborn Errors of Metabolism: Advances in Diagnosis and Therapy”. JAMA Pediatrics.
  3. Jump up to:a b c d e f g h i j k l Applegarth DA, Toone JR, Lowry RB (January 2000). “Incidence of inborn errors of metabolism in British Columbia, 1969-1996”. Pediatrics 105 (1): e10. doi:10.1542/peds.105.1.e10PMID 10617747.

When I entered my third year of medical school, I had a huge awakening. I was now engaged with patients at Detroit Receiving Hospital.  It was not unlike Cook County, LA County, Charity Hospital, King County or Belleview Hospital.  This was a year before the Detroit riots.  Receiving Hospital (later Detroit General) had a large population of indigent patients and was a trauma center located adjacent to skid row.  There were students who looked down on the patients, many on welfare, and who took a taxi to the hospital.
Most of my colleagues did not have that view.  However, I would guess that my view was transcended some time later when I recall students concerned about “racial balancing” for entry to colleges.

I saw the victims of gun, knife and other violence in the Emergency Room (ER).  On one occasion, the entire surgery staff was called out of the weekly Grand Rounds to attend to 3 cases with massive bleeding in the ER. One of the cases was presented the following week with a discussion of whether the patient should have been taken to the operating room instead of handling the emergent case in the ER.

I also recall a woman who might have been 45 years old who was extremely anxious and had had 5 divorces. Nobody came to visit her.  We were taking her blood pressure when it spiked very high.  My classmate might well have said holy smoke and ran to the library to check things out.  She had a very rare occurrence of pheochromocytoma, a tumor of the adrenal medulla that secretes adrenaline.  It was probably also a factor in her social history.  It was the first such case to be seen by the Chairman of Surgery.

I don’t know that preparation in the great city hospitals has changed.  It is an important experience.  I did see some anger expressed by patients in the ER, mainly related to the life experiences of the patient.  In my 20 years at Bridgeport Hospital, there was a large admission population from “Father Panic Village”.  I recall vividly a patient saying to me, when he learned my last name is Bernstein, get away from me.

Over the years, not that much has changed.  There is a much larger uneducated, unemployed, and ignorant population that has no hope of a future.  It is most disconcerting at this time because they are bereft of a dream, and they don’t participate in our society.  Moreover, large disparities influence voting patterns and also the use of tight public resources.

It would be difficult for me to consider this to be unrelated to an emerging world crisis that we are observing today.  There is an increased downward pressure on the lower class with a vanished middle class.  The entering well prepared medical staff is inundated, but more skilled at the inadequate medical information systems they have to use.  There has been emigration to the UD for decades, but now we have more openly advocated do not come unless you have value to provide.  We are in the midst of a Middle East crisis, and despite economic recovery since the Wall Street collapse, there is a “doomsday” chronicle.  Emma Lazarus wrote “Give me your poor, … and your huddled masses yearning to be free”.

TS Elliott wrote “The Hollow Men” in 1925, post WWI . We remember “This is the way the world ends. This is the way the world ends. Not with a bang, but a whimper.  I hope that it hasn’t come to that.

 

 

 

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Research in the Raw

Larry H Bernstein, MD, FCAP, Curator

LPBI

 

Wild Researchers: Scientists in their Element

Suzanne Tracy, Editor-in-Chief, Scientific Computing and HPC Source
http://www.scientificcomputing.com/blogs/2015/11/wild-researchers-scientists-their-element

In a unique collaboration, University of New South Wales (UNSW), Sydney, and Australian photographer Tamara Dean set out to “show our knowledge seekers in a different light, in their environment. Not in a way the public normally sees them and their work.” They had the ingenious idea to “help take our research out into the world” to showcase scientists working in the elements to address problems like climate change, endangered species, toxic industrial sites and marine pollution.

The result is a compelling photography series that presents a powerful challenge to the stereotype of nerdy researchers working in a lab coats. From studying heat stress on beach sand dunes in Sydney to combining seafaring with mathematical modeling, and from mathematical analysis of colossal fire tornadoes to subterranean sleuthing, the Wild Researchers exhibition transports viewers outside into the landscapes where researchers work. It gives a glimpse of scientists as they really are, in the real-world environments where they acquire data, collect samples and ponder scientific mysteries and discoveries.

“Imagination: it’s not the first word usually associated with research — with science itself — but it’s a vital one,” writes journalist and science writer Ashley Hay in an essay included in the exhibition catalog.

The exhibition’s 12 images showcase university researchers in the field. Most of the 17 researchers featured are working in scientific areas — from mathematics and astronomy to climate change and biotechnology — along with a landscape architect and a philosopher.

Dean’s body of work “powerfully explores the relationship humans have with the natural world,” and she discusses her inspiration for Wild Researchers and how the project brings together her two loves — nature and art making — in a four-minute video. The exhibition was developed and commissioned in 2014 as part of Dean’s UNSW Artist-in-Residency. Her multi-sensory art installation, Here and Now, premiered to critical acclaim at Studio One in February 2015, assisted by the University’s Creative Practice Lab.

The Australian Museum in Sydney is hosting Wild Researchers from November 4 through December 13, 2015. The exhibition also can be viewed on the University of New South Wales (UNSW) Web site at www.wildresearchers.unsw.edu.au.

“I am thrilled that journalist and author Ashley Hay took up our commission of an essay for the exhibition. Just as Tamara has so evocatively conjured up these images, Ashley has worked a different kind of magic. Her essay is a gorgeous meditation on photography, place and science and I commend it to you,” said Denise Knight, Director of Media at UNSW Australia.

Hay observes: “If I could have any piece of knowledge I would ask what these subjects thought about as they sat still — pinned, pressed — as Tamara Dean fixed these richly made images.” Her companion essay is titled “The Fieldwork of Looking and Seeing.”

The exhibit catalog can be downloaded at http://www.wildresearchers.unsw.edu.au/download

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Gregory House, MD

Curator: Larry H Bernstein, MD, FCAP

Gregory House M.D. (2004–2012)

http://www.imdb.com/title/tt0412142/

This long-running medical drama follows the professional and personal life of Gregory House- a witty, arrogant, rule-breaking, self-destructive, pain-pill addicted but genius diagnostician at the fictional Princeton-Plainsboro Teaching Hospital in New Jersey. House and his team of doctors work against the clock to diagnose and treat patients when other doctors can’t seem to figure out what’s wrong with them, often resorting to unorthodox methods based on House’s hunches on the patients, their families, or his own personal experiences.

– Written by Hunter Logan

 

Creator:

David Shore

Stars:

Hugh LaurieOmar EppsRobert Sean Leonard |

Hugh Laurie  Dr. Gregory House (176 episodes, 2004-2012)
Omar Epps  Dr. Eric Foreman (174 episodes, 2004-2012)
Robert Sean Leonard  Dr. James Wilson (174 episodes, 2004-2012)
Jesse Spencer  Dr. Robert Chase (171 episodes, 2004-2012)
Lisa Edelstein  Dr. Lisa Cuddy (153 episodes, 2004-2011)

During Hugh Laurie’s audition, producer David Shore told how Bryan Singer, one of the executive producers, said, “See, this is what I want; an American guy.” Singer was completely unaware of the fact that Hugh Laurie is British.

Dr. Gregory House was based on Sherlock Holmes… but Holmes, in turn, was based on a Doctor that Sir Arthur Conan Doyle knew while studying medicine, Dr. Joseph Bell, whose specialty was diagnosis. The reference is pushed further when, In episode 11 of the fifth season, Wilson presents House with Joseph Bell’s Manual Of the Operations of Surgery as a Christmas gift. When House’s staff begin to wonder why he would throw away the expensive gift, an amused Wilson begins making up a story about House having a closeted infatuation with a patient named Irene Adler whom he will always consider to be “the one who got away”. Irene Adler is a romantic interest of Sherlock Holmes.

In several episodes, House is shown at home and his apartment number is 221B, a tribute to Sherlock Holmes famous London address, 221B Baker Street.

Hugh Laurie’s own father was a doctor, and he feels a twinge of guilt at “being paid more to become a fake version of my own father.”

After receiving his honorary doctorate in fine arts, TV satirist Stephen Colbert placed several pictures of other famous TV doctors who inspired him on the mantle-piece of his show’s set. One of these is of Hugh Laurie as Dr. Gregory House. The others are Bill Cosby as Dr. Cliff Huxtable and Noah Drake from General Hospital.

One of the movie posters on Wilson’s office is Orson Welles’ Touch of Evil (1958), where Orson Welles plays a detective with a gimp leg, who solves crimes purely on his intuition. Clearly one of the influences for the character of Dr. House.

Top-Rated Episodes

S4.E15

House’s Head

A bus that House was riding crashes. House claims there’s a victim on the bus that’s dying, but not from the bus accident. He stops at nothing to figure out who the patient is and what is ailing them.

S5.E24

Both Sides Now

House and his team treat a patient who had his brain split in half, now it seems like one side of his brain is causing some health/behavioral issues. House plays games with Cuddy over the night he …

S6.E1

Broken

House fights his doctors, the staff and his fellow patients when he’s forced to stay in the psychiatric hospital under threat of permanently losing his medical license.

Sherlock (2010– )

http://www.imdb.com/title/tt1475582/

A modern update finds the famous sleuth and his doctor partner solving crime in 21st century London.

Creators:

Mark GatissSteven Moffat

Stars:

Benedict CumberbatchMartin FreemanRupert Graves

Top-Rated Episodes

S2.E1

A Scandal in Belgravia

Sherlock must confiscate something of importance from a mysterious woman named Irene Adler.

S2.E3

The Reichenbach Fall

Jim Moriarty hatches a mad scheme to turn the whole city against Sherlock.

S3.E3

His Last Vow

Sherlock goes up against the notorious blackmailer Charles Augustus Magnussen.

The Secrets of Sherlock’s Mind Palace

The BBC/Masterpiece sleuth employs a memory technique invented by the ancient Greeks

http://www.smithsonianmag.com/arts-culture/secrets-sherlocks-mind-palace-180949567/#rRR6xgt1hfGeMOQT.99

Sherlock Holmes, in any incarnation, packs a lot of information into his head, and he has to be ready to draw out those details as he makes his deductions and solves the most mysterious of mysteries. The Holmes of Sherlock, the BBC/Masterpiece program that aired its season finale Sunday night on PBS, is no exception. This time, though, his creators have gifted him with a talent for a mnemonic device straight out of ancient Greece—the mind palace. Of course, this being Holmes (and television), his version was somewhat more advanced than that of the average rememberer.

According to myth, the Greek poet Simonides of Ceos invented the technique after attending a banquet gone wrong. Simonides stepped outside to meet with two young men. But when he arrived outside, the young men were not there and the hall was collapsing behind him. Though his fellow banqueters were too badly crushed by the collapse for their remains to be identified, Simonides was supposedly able to put a name with each body based on where they had been sitting in the hall. That ability to remember based on location became the method of loci, also known as memory theater, the art of memory, the memory palace and mind palace.

On May 22, 1859, Arthur Conan Doyle was born in Edinburgh, Scotland. In 1890 his novel, A Study in Scarlet, introduced the character of Detective Sherlock Holmes. Doyle would go on to write 60 stories about Sherlock Holmes.

http://www.biography.com/people/arthur-conan-doyle-9278600#synopsis

Sherlock Holmes – Seven Percent Solution (TV-14; 1:44) Legal at the time, herion and cocaine allow Holmes to relax and fuels him to complete his legendary caseload.

On May 22, 1859, Arthur Conan Doyle was born to an affluent, strict Irish-Catholic family in Edinburgh, Scotland. Although Doyle’s family was well-respected in the art world, his father, Charles, who was a life-long alcoholic, had few accomplishments to speak of. Doyle’s mother, Mary, was a lively and well-educated woman who loved to read. She particularly delighted in telling her young son outlandish stories. Her great enthusiasm and animation while spinning wild tales sparked the child’s imagination. As Doyle would later recall in his biography, “In my early childhood, as far as I can remember anything at all, the vivid stories she would tell me stand out so clearly that they obscure the real facts of my life.”At the age of 9, Doyle bid a tearful goodbye to his parents and was shipped off to England, where he would attend Hodder Place, Stonyhurst—a Jesuit preparatory school—from 1868 to 1870. Doyle then went on to study at Stonyhurst College for the next five years. For Doyle, the boarding-school experience was brutal: many of his classmates bullied him, and the school practiced ruthless corporal punishment against its students. Over time, Doyle found solace in his flair for storytelling, and developed an eager audience of younger students.
When Doyle graduated from Stonyhurst College in 1876, his parents expected that he would follow in his family’s footsteps and study art, so they were surprised when he decided to pursue a medical degree at the University of Edinburgh instead. At med school, Doyle met his mentor, Professor Dr. Joseph Bell, whose keen powers of observation would later inspire Doyle to create his famed fictional detective character, Sherlock Holmes. At the University of Edinburgh, Doyle also had the good fortune to meet classmates and future fellow authors James Barrie and Robert Louis Stevenson. While a medical student, Doyle took his own first stab at writing, with a short story called The Mystery of Sasassa Valley. That was followed by a second story,The American Tale, which was published in London Society.During Doyle’s third year of medical school, he took a ship surgeon’s post on a whaling ship sailing for the Arctic Circle. The voyage awakened Doyle’s sense of adventure, a feeling that he incorporated into a story, Captain of the Pole Star.
http://www.medscape.com/features/slideshow/public/best-books-by-physicians#14
10 medically-trained authors whose books all doctors should read
Sir William Osler, the great physician and bibliophile, recommended that his students should have a non-medical bedside library that could be dipped in and out of profitably to create the well rounded physician.

The History of Radiology

by Arpan K. Banerjee

http://blog.oup.com/2014/12/author-doctor-reading-list/#sthash.udqLFwHo.dpuf
Jerome GroopmanJerome Groopman, a staff writer since 1998, writes primarily about medicine and biology. He holds the Dina and Raphael Recanati Chair of Medicine at the Harvard Medical School and is the chief of experimental medicine at the Beth Israel Deaconess Medical Center. His research has focussed on the basic mechanisms of cancer and AIDS. He has been a major participant in the development of many AIDS-related therapies, including protease inhibitors, and he is active in regional and national education activities in AIDS and cancer medicine, as well as in the training and education of young scientists in these fields. Recently, he has extended the research infrastructure in genetics and cell biology to studies in lymphoma, myelodysplasia, and leukemia. He is a member of the American Academy of Arts and Sciences and the Institute of Medicine of the National Academies. He has served on many scientific editorial boards and has published more than a hundred and eighty research articles; his editorials on policy issues have appeared in the Times, The New York Review of Books, and the Wall Street Journal. Among his books are “How Doctors Think” and “Your Medical Mind,” written with Dr. Pamela Hartzband.
Robert Brian “Robin” Cook
an American physician and novelist who writes about medicine and topics affecting public health. He is best known for combining medical writing with the thriller genre. Wikipedia
Physician Authors and Editors

UpToDate is an evidence-based clinical decision support resource that is authored and peer-reviewed exclusively by physicians who are recognized experts in their medical specialties.

An international team of authors like no other

At the heart of UpToDate is a global community consisting of thousands of physician authors and editors who share a singular passion: writing and editing evidence-based information that helps clinicians everywhere practice the best medicine. Although these physicians serve on the faculty of prestigious medical schools, practice medicine, and in some cases conduct groundbreaking research, they repeatedly carve time from their demanding schedules to contribute to UpToDate. Drawing on their extensive experience, our physician authors and editors begin with a structured clinical question, placing the latest evidence about the topic in context with the larger body of available evidence. Next, they synthesize that evidence into recommendations clinicians can use to diagnose and treat their patients, even when the evidence is thin or no consensus exists.

http://www.uptodate.com/home/physician-authors-and-editors

Sherwin B. Nuland,

the surgeon and man of letters who unshrouded death in “How We Die,” a best-selling volume that received the National Book Award and became a classic of medical literature, died March 3 at his home in Hamden, Conn. He was 83.

Oliver Wendell Holmes (1809-1894), American author, poet, physician, and teacher wrote The Guardian Angel (1867).

A man of contrasts and contradictions, Holmes lived his life between the poetic and the realistic. A celebrated poet-doctor, he spent the greater part of his life as physician and professor at Harvard University teaching anatomy and physiology. He published many essays and journal articles on travel, epidemiology, psychology, and literature, and hundreds of short stories both humorous and critical. Along with his good friend James Russell Lowell, he was one of the founding editors of the journal Atlantic Monthly in 1857

W. Somerset Maugham

William Somerset Maugham was born in Paris in 1874. He spoke French even before he spoke a word of English, a fact to which some critics attribute the purity of his style.

His parents died early and, after an unhappy boyhood, which he recorded poignantly in ‘Of Human Bondage’ , Maugham became a qualified physician. But writing was his true vocation. For ten years before his first success, he almost literally starved while pouring out novels and plays.

During World War I, Maugham worked for the British Secret Service . He travelled all over the world, and made many visits to America. After World War II, Maugham made his home in south of France and continued to move between England and Nice till his death in 1965.

William Carlos Williams

On September 17, 1883, William Carlos Williams was born in Rutherford, New Jersey. He began writing poetry while a student at Horace Mann High School, at which time he made the decision to become both a writer and a doctor. He received his MD from the University of Pennsylvania, where he met and befriended Ezra Pound.

Pound became a great influence on his writing, and in 1913 arranged for the London publication of Williams’s second collection, The Tempers. Returning to Rutherford, where he sustained his medical practice throughout his life, Williams began publishing in small magazines and embarked on a prolific career as a poet, novelist, essayist, and playwright.

Following Pound, he was one of the principal poets of the Imagist movement, though as time went on, he began to increasingly disagree with the values put forth in the work of Pound and especially Eliot, who he felt were too attached to European culture and traditions. Continuing to experiment with new techniques of meter and lineation, Williams sought to invent an entirely fresh—and singularly American—poetic, whose subject matter was centered on the everyday circumstances of life and the lives of common people.

ErnestoCheGuevara

an Argentine Marxist revolutionary, physician, author, guerrilla leader, diplomat, and military theorist. A major figure of the Cuban Revolution, his stylized visage has become a ubiquitouscountercultural symbol of rebellion and global insignia in popular culture.[5]

As a young medical student, Guevara traveled throughout South America and was radicalized by the poverty, hunger, and disease he witnessed.[6] His burgeoning desire to help overturn what he saw as the capitalist exploitation of Latin America by the United States prompted his involvement in Guatemala‘s social reforms under President Jacobo Árbenz, whose eventual CIA-assisted overthrow at the behest of the United Fruit Company solidified Guevara’s political ideology.[6] Later, in Mexico City, he met Raúl and Fidel Castro, joined their 26th of July Movement, and sailed to Cuba aboard the yacht, Granma, with the intention of overthrowing U.S.-backed Cuban dictator Fulgencio Batista.[7] Guevara soon rose to prominence among the insurgents, was promoted to second-in-command, and played a pivotal role in the victorious two-year guerrilla campaign that deposed the Batista regime.[8]

Following the Cuban Revolution, Guevara performed a number of key roles in the new government. These included reviewing the appeals and firing squads for those convicted as war criminals during the revolutionary tribunals,[9] instituting agrarian land reform as minister of industries, helping spearhead a successful nationwideliteracy campaign, serving as both national bank president and instructional director for Cuba’s armed forces, and traversing the globe as a diplomat on behalf of Cuban socialism. Such positions also allowed him to play a central role in training the militia forces who repelled the Bay of Pigs Invasion[10] and bringing the Soviet nuclear-armed ballistic missiles to Cuba which precipitated the 1962 Cuban Missile Crisis.[11] Additionally, he was a prolific writer and diarist, composing a seminal manual onguerrilla warfare, along with a best-selling memoir about his youthful continental motorcycle journey. His experiences and studying of Marxism–Leninism led him to posit that the Third World‘s underdevelopment and dependence was an intrinsic result of imperialism, neocolonialism, and monopoly capitalism, with the only remedy beingproletarian internationalism and world revolution.[12][13] Guevara left Cuba in 1965 to foment revolution abroad, first unsuccessfully in Congo-Kinshasa and later in Bolivia, where he was captured by CIA-assisted Bolivian forces and summarily executed.[14]

John Keats (1795–1821)

John Keats, who died at the age of twenty-five, had perhaps the most remarkable career of any English poet. He published only fifty-four poems, in three slim volumes and a few magazines. But at each point in his development he took on the challenges of a wide range of poetic forms from the sonnet, to the Spenserian romance, to the Miltonic epic, defining anew their possibilities with his own distinctive fusion of earnest energy, control of conflicting perspectives and forces, poetic self-consciousness, and, occasionally, dry ironic wit. In the case of the English ode he brought its form, in the five great odes of 1819, to its most perfect definition.

In his own lifetime John Keats would not have been associated with other major Romantic poets, and he himself was often uneasy among them. Outside his friendLeigh Hunt‘s circle of liberal intellectuals, the generally conservative reviewers of the day attacked his work, with malicious zeal, as mawkish and bad-mannered, as the work of an upstart “vulgar Cockney poetaster” (John Gibson Lockhart), and as consisting of “the most incongruous ideas in the most uncouth language” (John Wilson Croker). Although Keats had a liberal education in the boy’s academy at Enfield and trained at Guy’s Hospital to become a surgeon, he had no formal literary education. Yet Keats today is seen as one of the canniest readers, interpreters, questioners, of the “modern” poetic project-which he saw as beginning with William Wordsworth—to create poetry in a world devoid of mythic grandeur, poetry that sought its wonder in the desires and sufferings of the human heart. Beyond his precise sense of the difficulties presented him in his own literary-historical moment, he developed with unparalleled rapidity, in a relative handful of extraordinary poems, a rich, powerful, and exactly controlled poetic style that ranks Keats, with the William Shakespeare of the sonnets, as one of the greatest lyric poets in English.

Anton Chekhov (1860-1904),
Russian physician, renowned short story author and playwright wrote Uncle Vanya (1899);

We must live our lives. Yes, we shall live, Uncle Vanya. We shall live through the long procession of days before us, and through the long evenings; we shall patiently bear the trials that fate imposes on us; we shall work for others without rest, both now and when we are old; and when our last hour comes we shall meet it humbly, and there, beyond the grave, we shall say that we have suffered and wept, that our life was bitter, and God will have pity on us. Ah, then dear, dear Uncle, we shall see that bright and beautiful life; we shall rejoice and look back upon our sorrow here; a tender smile–and–we shall rest. I have faith, Uncle, fervent, passionate faith. We shall rest. We shall hear the angels. We shall see heaven shining like a jewel. We shall see all evil and all our pain sink away in the great compassion that shall enfold the world. Our life will be as peaceful and tender and sweet as a caress. I have faith; I have faith.–Sonia, Act I

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