Artificial pancreas could be 'holy grail' for Type 1 diabetics

Artificial pancreas could be 'holy grail' for Type 1 diabetics - CNN.com

By Saundra Young, CNN Medical Senior Producer
updated 8:31 AM EST, Sat November 26, 2011

A trial patient for the Juvenile Diabetes Research Foundation’s Artificial Pancreas Project tests the device.

(CNN) — Kerry Morgan was just 3 years old when she participated in her first clinical trial for type 1 diabetes prevention. She didn’t have the disease, but her 7-year old sister did and there was concern that she might develop it, too. During the trial she was given one shot of insulin a day in the hope that it would stave off the disease, but a year later, she was officially diagnosed.

“I remember a lot of things changed.” Morgan said. “I went from having juice every day and M&Ms to not having sugar at all. I remember getting shots every day, finger pricks, my parents had to hold me down.”

School, she says was difficult. “You had to let teachers know what was going on. You had a special relationship with the nurse because she had to check your blood sugar every day before going to lunch.”

At 14 she entered a second trial, this one at the University of Virginia, for a continuous glucose monitoring system called The Navigator. It was at UVA that she first learned about the artificial pancreas. A high school senior at 18 now, she has participated in four clinical trials and two have involved artificial pancreas systems.

“It was awesome. I’ve never done anything quite like it before. For the two days that I was on the artificial pancreas I experienced normalcy. I wasn’t checking myself every five seconds and giving myself insulin because it was doing it for me.”

In type 1 diabetics, the pancreas makes very little or no insulin, a hormone that controls glucose levels, or the amount of sugar in your blood. Patients must constantly check their levels throughout the day, determine how much insulin they need to lower their blood sugar and administer the proper amount using a pump or syringe. Drops or spikes in blood sugar can be extremely dangerous. If the level is too low — a condition called hypoglycemia — patients can experience shakiness, confusion, trouble speaking, seizures, even coma and death. A level that is too high — hyperglycemia — can cause excessive thirst, frequent urination and cardiac arrhythmia. Left untreated, hyperglycemia can lead to a number of serious complications including vision loss and nerve damage.

An artificial pancreas mimics the glucose regulating function of a healthy pancreas. The automated device features a sensor that’s placed under the skin that measures blood sugar. Information from this continuous glucose monitor is sent to a receiver and an insulin pump delivers insulin in controlled amounts. A glucose meter calibrates the sensor. Sophisticated software checks the blood sugar in the body and automatically provides the correct dose of insulin needed at the right time.

“When you have diabetes, every second you’re thinking about your blood sugar,” says Morgan. “You’re wondering if you’re high, if you’re low, if you’re OK, if you’re giving yourself enough insulin, if you’re not giving yourself enough insulin. With the artificial pancreas it takes that worry away because it’s doing it for you. It lets you know if something’s wrong. That way you’re not always worrying about your blood sugar.”

The device has not yet been approved by the U.S. Food and Drug Administration. In June the agency issued a draft guidance seeking input from the industry and researchers on an early version of the artificial pancreas, called the low glucose suspend system. It’s a backup for diabetics experiencing hypoglycemia. Patients still have to monitor their levels and give themselves insulin if necessary, but the low glucose suspend system temporarily reduces or stops the insulin flow in the event of an episode.

There are two types: A reactive low glucose suspend system that stops insulin infusion when a predetermined level has been reached, and a predictive low glucose suspend system that anticipates a hypoglycemic event based on the current blood sugar level and how fast those levels are falling.

Dr. Charles Zimliki chairs the FDA’s Artificial Pancreas Critical Path Initiative and he is a type 1 diabetic. Testifying before a Senate committee in June, he said the FDA is committed to seeing the device come to market but is proceeding with caution.

“While the potential benefits are enormous, an artificial pancreas system is considered a significant-risk device, meaning it presents a potential for serious risk to the health, safety or welfare of a patient. If not properly designed, use of an artificial pancreas device in an outpatient setting can place patients at significant risk, because the device controls the administration of insulin without the oversight of health care professionals.”

The FDA is expected to release new guidance for future generations of the artificial pancreas systems on December 1. The Juvenile Diabetes Research Foundation has been working closely with the FDA on the artificial pancreas. It says low glucose suspend systems have been in use in more than 40 countries for the last 2½ years and the process in the United States is taking much too long.

“Here in the U.S. we’re now almost three years behind and the first study to test these systems is just going to launch in the next month, which means it’s going to be another year or so before patients even have access,” said Aaron Kowalski, assistant vice president of treatment therapies for the foundation. “What JDRF is advocating for is to ensure that people here in the U.S. have access to these tools in a timely manner.”

The FDA says other countries have different regulatory systems in place that do not require the same safety and effectiveness data for a product of this level of risk.

Tom Brobson, a 51-year-old Christmas tree farmer and the national director for donor relations at JDRF was diagnosed eight years ago with type 1 diabetes. “I think they’re getting hung up on better when good enough can do the job. You can’t get better until it’s out there being used. We know that technology isn’t perfect, but what we’re talking about are significant improvements and enhancements over what we have today that can significantly reduce the daily burden of living with this disease, improve quality of lives and save lives.”

Brobson has been participating in artificial pancreas clinical trials at UVA since 2007. “It’s been awesome, fantastic, frankly everything I could ever imagine it to be and then some,” he says. “The open question for me was could a computer system using off-the-shelf technologies do a better job of controlling my blood sugar than I was already doing for myself and the answer turned out to be overwhelmingly yes.”

Without it, Brobson says he has to spend every minute managing his diabetes. “I have to be my own pancreas 24 hours a day. Last thing at night, first thing in the morning and often in the middle of the night. When the artificial pancreas took over, that was a real power moment. It kept me perfect from 8 p.m. to 8 a.m. When the artificial pancreas took over moment to moment when it was actively assisting me in the management of my disease, it was a life changing moment and it was life changing because I didn’t have to think about my diabetes every moment of the day.”

Dr. Michelle Magee is an endocrinologist and director of the MedStar Diabetes Institute at Washington Hospital Center in Washington, D.C. “The data from other countries showed that the system could be used safely and effectively. It’s been somewhat disappointing that it has taken so long to get approval here.”

She says the long awaited system offers hope to patients. “For people with type 1 diabetes, the artificial pancreas has been kind of the holy grail of technology to support self management of diabetes. It’s not going to cure it, but it’s going to be a huge step in the right direction. Once it’s approved and can be used it will be fantastic.”

According to the Juvenile Diabetes Research Foundation, about 80 people a day are diagnosed with type 1 diabetes. Approximately 3 million Americans are living with the disease. Most of them only have healthy blood sugars 30% of the day. The foundation says it has spent $1.5 billion on diabetes research, $40 million of that on research on artificial pancreas systems.

“Our goal is to drive the development of artificial pancreas systems,” Kowalski said. “This could not only improve tremendously glucose control, and help reduce the risk of these terrible diabetes complications, it could also help people with diabetes live easier. The bottom line is diabetes is a 24 hour a day, 7 day a week, 365 day a year job and if we can make some of that easier that would be a huge step forward.”

Morgan agrees. “I think it’s superimportant, I think next to having a cure for diabetes it’s the big thing. Because it’s such an instrumental piece of equipment it can allow you to live closer to what we consider normal than anything that we have now.”



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How about a wireless pacemaker?

Next-Gen Cardiac Care Includes Wireless Pacemakers:
scientificamerican.com





WiCS: In the new pacemaker called the Wireless Cardiac Stimulation (WiCS) system, a wireless electrode replaces one or more leads. A conventional pacemaker is implanted just below the collarbone in the left side of the chest and sends out a signal through a lead running into the heart’s right side. The WiCS unit, implanted near the heart, wirelessly senses the pacemaker’s pulse via this lead; it then sends an ultrasonic signal to the wireless electrode on the left side, which converts the sonic energy into electrical energy to pace the left ventricle synchronously with the right. Image: Courtesy of Cambridge Consultants

Millions of pacemakers have been successfully implanted in the past half century to regulate erratic heartbeats, but the electrical leads, which connect the device to the heart, complicate the surgery and increase infection risks. The heart’s continuous and vigorous beating also creates strain on the leads and can damage them over time.

Now researchers seek to go wireless. In a new pacemaker called the Wireless Cardiac Stimulation (WiCS) system, a wireless electrode replaces one or more leads. California start-up EBR Systems, working with English technology-development firm Cambridge Consultants, recently announced their system was successfully implanted in 100 patients needing cardiac resynchronization therapy (CRT) during a series of human clinical trials in Europe. (Wireless signaling is not entirely new to pacemakers—doctors have for the past few years been able to communicate with them via the Internet or even smart phones.) CRT patients suffer from a type of chronic heart failure requiring both the left and right ventricles to be paced. Normally, such devices require the implantation of three leads, the trickiest of which is threaded through a complex route running from the right atrium, into the coronary sinus on the outside surface of the heart, and then to the left ventricle. In the new device, a small electrode inserted in the left side of the heart replaces one or more of the leads. In the system, a conventional pacemaker, implanted just below the collarbone in the left side of the chest, sends out a signal through a lead running into the heart’s right side. The WiCS unit, implanted near the heart, wirelessly senses the pacemaker’s pulse via this lead; it then sends an ultrasonic signal to the wireless electrode on the left side, which converts the sonic energy into electrical energy to pace the left ventricle synchronously with the right. Advances in low-power microelectronics and improved digital signal processing at high speed and low power enabled the system, says Andrew Diston, Cambridge’s director of global medical technology. The ultimate goal is to eliminate all wire leads, making the pacemaker easier to implant. Another goal is to integrate the functions of the conventional pacemaker and the WiCS into a single device. Wireless technology is notoriously tough on battery life. Diston says that most of the pacemaker’s battery—generally lasting seven or eight years before needing to be replaced—is still dedicated to monitoring the heart and deciding when to pace. The WiCS system has its own battery, and no modification to existing pacemakers is required, he added. Diston is hesitant to set a time frame for the system’s availability to the general public. WiCS continues to be tested in human clinical trials in Europe and will first be available there. Before it is made available in the U.S., it will need successful clinical trials here and approval from the U.S. Food and Drug Administration.

WiCS is potentially a disruptive technology, says Bruce Wilkoff, director of cardiac pacing and tachyarrhythmia devices at the Cleveland Clinic, who was not involved with the research. It is still immature, he adds, because it requires other components to coordinate the stimulation. Given that wireless technology is typically not as reliable as its wired counterpart, the largest concern involves the signal—whether the ultrasound will penetrate the heart muscle consistently and efficiently transfer energy to the wireless lead, Wilkoff says. Still, he adds, “I don’t think that there is any concern about safety.”

Pacemakers in general require patients to take certain safety precautions, such as not placing cell phones directly against the chest and avoiding strong electric or magnetic fields. Whereas some newer pacemakers are not affected by magnetic resonance imaging (MRI) scans, patients should consult their physicians before undergoing such tests. The addition of wireless to a pacemaker does not change the need to take these precautions.

Some experiments to “hack” into pacemakers capable of communicating wirelessly with computers and smart phones have been demonstrated by security researchers, but there have been no reported incidents of wireless pacemaker data being tampered with to the detriment of a patient. Still, researchers from the Massachusetts Institute of Technology and the University of Massachusetts Amherst say they are developing a jamming device that could be used to shield pacemakers from cyber attackers.

EBR and Cambridge are not only ones working on wireless pacemakers. Minneapolis-based Medtronic, Inc., last year introduced plans for a small, self-contained and fully leadless pacemaker the company hopes to market within three or four years. The Medtronic titanium-encased device will have a circuit board, an oscillator to generate current, a capacitor to store and rapidly dispense charge, memory to store data, and a telemetry system to wirelessly transfer that data to a computer or smart phone.

Unlike WiCS, however, Medtronic’s bullet-shaped pacemaker, about the size of an antibiotic pill, would be delivered directly into a patient’s right ventricle through a catheter, without surgery. Unfortunately, as currently designed, the Medtronic device could not be repositioned or retrieved from the heart after its seven-year battery failed. It would remain in the heart to be replaced by a new miniature pacemaker.


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How about getting an EKG with your iPhone?

From Red Ferret


It seems that almost every day I’m amazed by what smartphones can do. Sure, making calls, sending emails and checking the weather are cool, but some companies are really making the most of these devices. Take, for instance, this iPhone ECG that is currently being developed.

This ECG is a case that will attach to your iPhone, and provide you with an accurate ECG reading, with nothing more than a phone. It can be used either in your hands, or against the chest to take a reading. The results can be stored both locally, and uploaded elsewhere via WiFi. You can perform breathing exercises for relaxation, and use the ECG to see how your heartbeat corresponds to the relaxation. The device is still awaiting approval by the government as a proven medical instrument, so it may still be a little while before we see these on the market. There is also an Android version in the works.

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Lab created blood used in transfusion

For the First Time, Lab-Grown Blood Is Pumped Into a Human's Veins | Popular Science popsci.com
By Sean Kane Posted 11.11.2011 at 2:57 pm






Artificial blood may become a common reality, thanks to the first successful transfusion of lab-grown blood into a human. Luc Douay, of Pierre and Marie Curie University, Paris, extracted hematopoietic stem cells from a volunteer’s bone marrow, and encouraged these cells to grow into red blood cells with a cocktail of growth factors. Douay’s team labeled these cultured cells for tracing, and injected 10 billion of them (equalling 2 milliliters of blood) back into the marrow donor’s body.

After five days, 94 to 100 percent of the blood cells remained circulating in the body. After 26 days, 41 to 63 percent remained, which is a normal survival rate for naturally produced blood cells. The cells functioned just like normal blood cells, effectively carrying oxygen around the body. “He showed that these cells do not have two tails or three horns and survive normally in the body,” said Anna Rita Migliaccio of Mount Sinai Medical Center in New York.

This is great news for international health care. “The results show promise that an unlimited blood reserve is within reach,” says Douay. The world is in dire need of a blood reserve, even with the rising donor numbers in the developed world. This need is even higher in parts of the world with high HIV infection rates, which have even lower reserves of donor-worthy blood.

Other attempts to synthesize blood have focused on creating an artificial blood substitute, rather than growing natural blood with artificial means. For example, Chris Cooper of the University of Essex in Colchester, UK, is working on a hemoglobin-based blood substitute that is less toxic than the protein in its unbound state. Artificial blood substitutes present a solution for transfusions after natural disasters and in remote areas. The artificial substitutes do not require refrigeration, unlike fresh and stem cell-grown blood.

The stem cell method has its own pros, though. “The advantage of stem cell technology is that the product will much more closely resemble a red cell transfusion, alleviating some of the safety concerns that continue around the use of the current generations of artificial products,” says Cooper.

While Douay’s results, published in the medical journal Blood, are a major step forward, mass-produced artificial blood is still a long way away. A patient in need of a blood transfusion would require 200 times the 10 billion cells that Douay and his colleagues used in the test. Robert Lanza, one of the first people to grow red blood cells in a lab on a large scale, suggests using embryonic stem cells, which could generate 10 times the amount grown by Douay.


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$0.99 iPad 2 app does vital signs

App Measures Vital Signs Using iPad Camera | Gadget Lab | Wired.com
Wired | by Charlie Sorrel on November 17, 2011




Doctor iPad is in the house

Amazingly, it’s possible to count your heart rate just by observing tiny changes in the color of your skin, caused by the movement of blood through the body. Even more amazingly, it’s possible to detect these changes using the terrible camera in the iPad 2.

The app that performs this double-rainbow of technological magic is Philips Vital Signs Camera. It uses the front-facing camera of the iPad to both track the rising and falling of your chest to determine breathing rate, and the small changes in skin color to track heart rate.

Incredibly, it actually seems to work.

I downloaded the app and tried it out. You need to sit still in a well-lit area and make sure your face and chest are in the correct parts of the screen (there are colored rectangular guides to help). That’s it. The default settings stop when a measurement has been determined, and you can just read them or inflict them on your friends via Facebook or Twitter.

It’s certainly no replacement for a proper doctor, but as a technological demonstration, it’s surprisingly impressive. The app is available now, for $1.
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A New Small Cardiac Assist Device

Devices - The Future of Medicine



Cardiac Assist Device

Let’s consider some other devices that can be helpful for patients with heart problems, in particular, patients with heart failure. I will illustrate with the story of Ron Caspian, a fifty-nine-year-old analyst with one of the think tanks that surround Washington, DC. In the fall of 2002, he developed some chest discomfort one Saturday morning. His wife and daughter were out shopping, so he drove himself to the nearby emergency room where it was quickly confirmed that he was having a heart attack.

Indeed, his heart rapidly began to fail, and he was rushed to the cardiac catheterization laboratory where an angioplasty was performed. This opened up the major blocked artery, but his heart muscle was dangerously weak. His cardiologist telephoned a cardiac surgeon at the hospital where I worked and asked if he could transfer the patient while adding, “But I’m not sure you’ll be willing to accept him.”

The surgeon, never one to give up easily, asked, “Why not?” “Well, because despite the angioplasty, his pulse is very rapid, his blood pressure is zip, his kidneys are not making much urine, and his blood flow is so limited he is semi-comatose.” “Send him quick,” said the surgeon, who geared up to insert a cardiac assist device. The idea is to let the heart rest while a mechanical device does much of the pumping for the heart. It is hoped that after a few days the heart may regain some of its function and be able to carry on its role once again.

So Mr. Caspian was transferred, and the cardiac assist device was installed. It is about the size of your fist and fits around a portion of the heart and through a pneumatic system helps the heart pump blood to the body. The large pneumatic driver that powers the assist device is housed in a small suitcase-like affair that the patient must keep next to him all the time.

I saw this gentleman when I came to work on Monday morning, and he certainly did not look well-although the surgeon was quite pleased. By Wednesday, Mr. Caspian was sitting up and really looking pretty good. This was remarkable because there is no question he would have died on Saturday afternoon if not for the quick work of the cardiologist in doing an emergency angioplasty and the cardiac surgeon in implanting the cardiac assist device.

After a few more days, however, it became evident that Mr. Caspian’s heart was just not going to recoup and that he would need a heart transplant to survive. But a heart for transplantation becomes available only every so often, and in fact, most patients die before a heart is ever available.

What to do? The cardiac surgeon decided-with the advice and consent of both the patient and his wife-to try a new device. It is about the size of a D battery, like the one you use in your flashlight, with a little electric turbine inside; yet it can move blood, not quite in the amounts that a normal heart can pump, but still enough to keep the body functioning at a fair level of activity.

The surgeons tell me it is quite easy-for a skilled surgeon-to insert, but the description I am about to give you may not sound all that simple. First, the chest is opened, and then the tip end (apex) of the heart is opened, and this battery-sized device is inserted and sewn into place. Coming out from the heart is a tube about an inch in diameter, which goes to the aorta, that large artery that sends blood to the rest of the body. Also a wire from the little turbine comes out through the chest and hooks onto a battery about the size of a cell phone that can be hooked to your belt. The chest is sewn up. Using electricity from the battery, the turbine moves the blood from the heart out through the tube up to the aorta and into the body.

This device is much smaller than the larger assist device that Mr. Caspian first had installed; it can be left in place for quite some time, and it runs on batteries. Indeed, some even think that this may prove to be a long-term alternative to a heart transplant, a “destination” device if you will. This was placed into Mr. Caspian’s chest, and he did great. He was shortly up and about and after a time went home.

Then about three months later, a heart became available and he had a cardiac transplant. I saw him one day in the hospital coffee shop, and he said that he was going to retire. “I’ve been eligible for three years now and frequently thought about it, but after 9-11 there was so much work to be done at our organization that I just couldn’t leave. But now I know I need to avoid the stress and take care of myself. I have a new lease on life, and I want to make good use of it.”

That all sounded pretty logical to me, but when I saw him again six months later he said, “Well, I just started back to work. They made me an offer I couldn’t refuse. I really need to get out of the house and do some constructive things. But I will be careful. I feel really good, but I do know I need to not get overstressed.”


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How Steve Jobs mentored a physician and changed health care

How Steve Jobs mentored a physician and changed health care



Published on October 6th, 2011kevinmd.com
How Steve Jobs mentored a physician and changed health care

I’ve been reading A Game Plan for Life: The Power of Mentoring written by famed UCLA basketball coach John Wooden. Wooden spends half of his book thanking the people who had a powerful influence on his life, coaching, philosophy, and outlook on life. Important people included his father, coaches, President Abraham Lincoln, and Mother Theresa.

Yes, President Abraham Lincoln and Mother Theresa.

Though clearly he could have never met the former and didn’t have the opportunity to meet the latter, Wooden correctly points out that as individuals we can be mentored by the writings, words, and thoughts of people we have never and will likely never meet.

Which seems like the most opportune time to thank one of my mentors, founder and former CEO of Apple, Steve Jobs.

Now, I have never met nor will I ever meet Steve Jobs. Lest you think I’m a devoted Apple fan, I never bought anything from Apple until the spring of 2010. Their products though beautifully designed were always too expensive. I’m just a little too frugal. I know technology well enough that people mistaken me for actually knowing what to do when a computer freezes or crashes. Yet, the value proposition was never compelling enough until the release of the first generation iPad. Then the iPhone 4. Finally the Macbook Air last Christmas.

No, thanking Steve Jobs isn’t about the amazing magical products that have changed my life as well as millions of others. It’s more than that. What he has mentored me on is vision, perspective, persistence, and leadership. Nowhere is this more important than the world I operate in, the world of medicine. Increasingly health care is fragmented, confusing, and frustrating for patients. As Dr. Atul Gawande noted in his commencement to Harvard Medical School:

Everyone has just a piece of patient care. We’re all specialists now—even primary-care doctors. A structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care.

We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It’s like no one’s in charge—because no one is. The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people.

We don’t have an actual system of care. A majority of doctors still use paper charts and prescription pads which can be difficult to access or decipher (doctors have poor penmanship?) and communicate with colleagues via letters, faxes, and phone calls. In an industry which is information driven, this seems too antiquated to be true. Hospitals each have their own unique system of care and their is little standardization which means both patients and doctors need to learn new rules with each new hospital. Patients cannot invest in long term relationships with their doctors because they change jobs, their company or their doctors dropped their previous insurance plan.

What we have is a potpourri of doctors, hospitals, pharmacies, and health insurers cobbled together to form a “health care system”. For a patient, the number of combinations is staggering. Each experience varies depending on who they see, what insurance coverage they have, and the type of (or lack of) information technology their doctors have. Many doctors today still bristle at the possibility that they actually need to email their patients and as a result don’t offer that as a way of communication or education.

In the end, what patients and doctors really want sits at the intersection of humanity and technology. Patients want doctors who know them as individuals, use medical technology thoughtfully, and a system that is highly reliable, safe, and focused on them to stay well or get them better. Doctors want patients who are partners in their care, technology that enables them to get the accurate information they need real-time, and a system that is streamlined to allow doctors to be healers.

In other words, we need a better health care system for both parties.

As a practicing primary care doctor, his words inspire me to help work towards creating a system which “simply works” for both doctors and patients. Some of the most important quotes that has shaped my thinking include:

“Innovation has nothing to do with how many R&D dollars you have. When Apple came up with the Mac, IBM was spending at least 100 times more on R&D. It’s not about money. It’s about the people you have, how you’re led, and how much you get it.”
— Fortune, Nov. 9, 1998

“It’s really hard to design products by focus groups. A lot of times, people don’t know what they want until you show it to them.”
— BusinessWeek, May 25 1998

“It comes from saying no to 1,000 things to make sure we don’t get on the wrong track or try to do too much.”
— BusinessWeek Online, Oct. 12, 2004

“Do you want to spend the rest of your life selling sugared water or do you want a chance to change the world?”
— The line he used to lure John Sculley as Apple’s CEO, according toOdyssey: Pepsi to Apple, by John Sculley and John Byrne

“So you can’t go out and ask people, you know, what the next big [thing.] There’s a great quote by Henry Ford, right? He said, ‘If I’d have asked my customers what they wanted, they would have told me “A faster horse.” ‘ ” – CNN / Money

“My job is to not be easy on people. My job is to make them better. My job is to pull things together from different parts of the company and clear the ways and get the resources for the key projects. And to take these great people we have and to push them and make them even better, coming up with more aggressive visions of how it could be.” – CNN / Money

“Your time is limited, so don’t waste it living someone else’s life. Don’t be trapped by dogma — which is living with the results of other people’s thinking. Don’t let the noise of others’ opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.” – Stanford 2005 commencement address


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