A Reverend and His Calling

The reverend in the picture writes movingly of his experience at the Port of Seattle. The link was forwarded to me by a member of his church. While I've never met the reverend, I have no reason to take his words at anything other than face value. Read his story with an open mind, as his words are very much worth reading.

Choosing a Medicare supplement

The open enrollment period to join or change a Medicare supplement plan is from 10/15 to 12/7 this year. Selecting the right plan for you does not have to be difficult. Seriously.

If you call an insurance broker to help you in this, you do want to sound very assured and informed about what expensive medications you take (if any) and what extent of coverage and monthly premiums you can afford. Otherwise, a broker is going to be unwilling to spend 1-2 hours with you without being able to sell you a plan.

The website for the Open Enrollment Center has gotten easier and easier to use since the start of the Part D (drug coverage) and Part C (Medicare Advantage) programs years ago.

First, click on the blue bar-shaped button called My Medicare Tools. (Sorry, Windows Vista is not easy to use for screenshots.) This goes to the Resource Locator page.

Next, click on the sidebar element called Drug and Health Plans. This will open the Medicare Plan Finder. Jackpot!

From here, you can use your Zip Code to look for available plans in your area. If you want, you can also do a more personalized search based on your Zip Code, and also your existing Medicare Number and demographic information.

Even using the general search just based on Zip Code alone, you still can indicate whether or not you are already on Medicare and whether or not you have any other help with prescription drug costs (such as Social Security, MediCal, SSI and so forth).

Continuing on the general search with regular Medicare alone, you get a chance to create a list of medicines you take by name. You do not have to do this, but it's useful if there are any medicines you get which seem to be unusually expensive. Usual examples of this would be inhalers for asthma or COPD, and pills for rheumatoid arthritis, chronic colitis, chronic pain and cancer. The vast majority of medicines for heart conditions and diabetes are generically available.

If you wish, you can bypass this by clicking "I don't take any drugs", or "I don't want to add drugs now".

The next screen then allows you to check off the pharmacy or pharmacies that you use. You can select as many from how ever many miles from where you live, or just skip ahead.

At this point, you get a Summary of plans in your area. This list will be limited to only ones that fit your selections if you made any specific selections. Here, you can go on to see an entire list of plans. You can also refine how the list is presented to you before you proceed. For example, you may want to show only Part D drug coverage plans because you already have Part A and Part B Medicare. Or, you may want it to show plans listed in order of monthly premium, or in order of annual deductibles, or ratings by consumers.

The last screen is titled Your Plan Results. This is a list of plans where you live, available to any pharmacies you may have chosen and any other specifics you may have made. You can still use the drop-down menu to change the list to show in order of cost, or ratings, or other choices. You can also check the box to the far left of any plans that interest you, and then click on the orange bar "Compare Plans" to show a head-to-head comparison of just the plans that interest you.

For what it's worth, looking for the most highly consumer-rated Part D plans in the Placerville area shows Medco, Blue Shield and AARP to be the best. Certainly, we've had no problems with any of these and patients do not complain about their coverage with them.

Otherwise, please please please DO NOT choose any plan that "takes over for Medicare" or makes Medicare your secondary insurance (this includes Part C Medicare Advantage plans). This will immediately result in a smaller pool of available specialists, more restrictions on medications, and long delays in getting authorization for any tests. If you don't like "the Canadian health care system", then don't pick any plan like this!

Be very suspicious of the nicely dressed, helpful young men and women with the tables set up at the grocery or drugstore. Plans they offer may be cheaper in the short run, but you will definitely be getting what you pay for here. Remember; if it's to good to be true, it is!

Emergency Contraception- the "Morning-After Pill"

"To err is human, to forgive is divine."

Despite best efforts, accidents can happen. In this case, we are talking about unprotected sexual intercourse and the possibility of undesired pregnancy. This could involve teens and young singles, and also married couples who do not yet want to have children or do not want to have more children.

Medication is available that can really lower the likelihood of pregnancy occurring in this event. Higher than normal doses of birth control pills can prevent a fertilized egg from becoming a fetus.

Specifically, these medications can keep an egg (or ovum) which has been fertilized by sperm from being able to implant (stick to) the inside of the uterus, and hence from eventually going on to become a fetus.

Mind you, if you feel or believe that preventing a fertilized egg from sticking to the inside of your uterus (womb) would be something that you feel wrong in doing then by all means do not do so. However, most people who feel strongly about "right to life" issues do not define this as abortion.

Plan B is the brand name of a medication you can buy over-the-counter, and use in case of emergency. It can cost about $45.

It is important to realize that time is of the essence in such a situation as missed birth control pills, condom rupture or unprotected sex. If Plan B is taken within 12 hours, it has a 95% chance of preventing undesired pregnancy. By 2 and 1/2 days later, the chance falls to 72%. Sooner is definitely better! It is probably best to simply buy some and have it ready to use if you ever need it. Twelve hours can go by very quickly when stores are closed on a weekend night.

Plan B was actually based on the known doses of birth control pills needed to prevent undesired pregnancy. It is simply packaged in a form that is easy to use.

This link from Princeton University provides useful guidance in how to use 19 different commonly used birth control pills as emergency contraception.

Life Line ultrasound screening- Meh.

I get asked about this test periodically, whenever Life Line scans come to town.

Do I recommend them? No.

Why doesn't my insurance cover them? Because they are proved not to be helpful.

The tests include ultrasound examinations of the carotid arteries which carry blood supply up to your brain, the abdominal aorta which carries blood supply to the abdomen, and also the circulation in your legs.

These are all standard diagnostic tests which can be ordered by doctors and are covered by insurances. The problem is, they are not useful as screening tests applied to patients who have no concerning symptoms. These tests have only been shown to be useful in preventing strokes, aneurysm rupture or worsening leg circulation in the presence of symptoms or abnormal physical exam findings.

In the absence of such, we find that applying these tests does not prevent these problems and simply exposes healthy people to further and riskier tests in the event of minor abnormalities being found.

Mind you, this is one of the reasons to be seen annually for wellness examinations or physicals. An important part of the exam is checking for findings that would suggest circulatory problems or aneurysms. Happily, the physical exam is quite sensitive in finding these problems and can guide further testing and treatment. When I am listening to your neck and abdomen and feeling pulses in your feet, that is exactly what I am doing!

Effectiveness of Prostate Cancer Screening

If you have been following the news in the last week, you will see that the United States Preventive Services Task Force (USPSTF) has recommended that doctors not routinely screen for prostate cancer in men. A separate and independent review panel agrees with this recommendation.

Mind you, both groups are composed of doctors and analysts who have no ties to government employment or drug companies. Also, their recommendations are based on how well screening and preventive efforts work without regard to their cost. In other words, recommendations are not made on the basis of cost to the system or rationing.

PSA blood testing and rectal examination have to some extent seemed to doctors to be tools that are not the "sharpest tools in the shed", but the only tools available. It was hoped that over time, their use in screening for prostate cancer would have a positive impact on outcomes; that is, keep men from dying of prostate cancer.

The problem here, is that these tests do not seem to end up saving lives. In fact, it may be that they cause more anxiety, suffering and painful and unnecessary tests and surgeries than benefits.

A major difficulty here is that prostate cancer is common, yet dying of it is not.

Cancer cells start to appear in a normal, healthy man's prostate gland as a pure correlate of aging. By the time you are 50 years old, the chance of having cancer cells in your prostate gland is 50%. At 65 years old, the chance is 60% and by 75 years old it is 75%.

Yet, out of 17 men with cancer cells in their prostate, only one will die. The other 16 will go on to die of natural causes or other conditions without any sign of prostate cancer.

The problem is, that we do not have a way of determining who is that 1 guy out of the 17, so we end up treating all of them as if they will go on to die of prostate cancer without treatment.I

In addition to this not very good statistic, the number of men every year who die of prostate cancer is staying the same over time. In other words, we are not saving lives by doing routine annual rectal exams and PSA blood tests.

Faced with this, it seems that it would be better if we simply stopped doing such routine screening until we can develop a way to determine who's prostate cancer should be aggressively treated, and who's can simply be watched.

Mind you, this does not apply where there are symptoms present that raise a concern of prostate cancer- that's not screening, it's diagnosis. It also may not apply to men with a concerning family history of prostate cancer in their fathers or brothers.

This is certainly a discussion that can be had face to face in the office. I just think patients should have all the information at hand to make decisions that they feel are right for them.

For my part, being a man over 50 with no history of prostate cancer in my family, I do not intend to have prostate cancer screening tests done as part of my annual physicals.

Advance Directives- Pre-Hospital DNR, or AND

The idea around decisions or orders to Allow Natural Death (AND), or Do Not Resuscitate (DNR) is to address your preferences or personal wishes in the event of a sudden and immediately life-threatening loss of heartbeat and/or ability to breathe.

In previous posts, we discussed directives you can make which speak to your wishes on matters affecting your medical care.

This post specifically discusses sudden, unexpected and potentially immediately fatal events occurring outside the setting of a hospital or ER, and your wishes in such an event. More particularly, this pertains to a sudden loss of heartbeat and ability to breathe such as might occur in a massive heart attack.

This may be ultimately expected in a terminal illness such as advanced cancer, or may be entirely unexpected.

Doctors generally ask about your preferences since we do not wish to withhold care from you that you want, but we also do not wish to perform heroic or even desperate procedures on you that you actually do not want.

Certainly, you should realize that a decision by you to allow a natural death or not to resuscitate does not affect your care in other matters such as your cancer, pneumonia or hip fracture. As our nursing colleagues rightly point out, "no resuscitation does not mean no care"!

Something to be mindful of in your decision-making is what is occurring during a loss of breathing and pulse and during CPR.

A sudden loss of breathing and pulse can occur for a variety of reasons, but while it is occurring, there is a significant loss of oxygen supply and blood flow to your brain. CPR is an attempt to maintain circulation of blood to the brain while awaiting definitive attempts to restore normal heart rhythm by delivering an electrical shock. This is known as defibrillation (or "shock paddles", as seen on TV). Medicines given if this occurs in a hospital are largely given in order to maximize blood flow to the brain. It is ultimately timely defibrillation that can restore normal heart rhythm with intact brain function.

Note the emphasis on the intact brain function part.

The tricky part here is that your brain can only go for 5 minutes without good blood supply before permanent brain damage starts to occur. Past this limit, the longer the duration of sub-optimal blood flow the more extensive the damage. For a worst-case scenario, think Terri Schiavo.

Even in the best of circumstances where this occurs in a hospital, the odds of going home alive and with an intact brain are about 15%.

If this occurs outside a hospital (such as at home, a friend's house, a movie, a restaurant, etc.) the lack of immediate access to a defibrillator makes an enormous difference.

If you survive long enough to make it to an ER, and survive long enough to actually be admitted to the hospital, your odds of eventually going home alive and with an intact brain are only 2-8%. This is because your valuable 5 minute window of opportunity is already gone by the time paramedics can arrive even if someone has immediately called 911.

Once paramedics arrive, they are legally required to initiate CPR and resuscitative efforts. If, given the aforementioned discussion, you would wish for them to do so, you do not need to take any action at all.

On the other hand, if you would NOT want them to do so, you need a signed order from a doctor instructing them not to start resuscitative efforts.

This handout and sample form can be used if you feel that you would not want paramedics to start resuscitation for such an event in your home. It only requires your signature (or your caregiver's) and your doctor's signature.

(Paramedics will still come to your home and provide the usual help in all other matters! Signing this does not mean that they will not come to your home, or help you if you have fallen down or have a medical problem.)

Advance Directives- POLST

In 2009, a new sort of advance directive became available. It is called Physician Orders for Life-Sustaining Treatment (POLST). It is not meant to replace an Advance Directive for Health Care, but rather to amplify on it in a clear and easily read manner. Also, it can be used even if there is no formal Advance Directive.

Additionally, the POLST form takes the form of a physician order and does not require notarization or witness co-signatures as does the Advance Directive. It addresses your wishes around heroic resuscitation or cardio-pulmonary resuscitation (CPR), as well as your preferences in terms of how intense or aggressive you wish your medical care to be in the event of a serious medical problem.

This is a very helpful list of frequently asked questions from the California Hospice Foundation.

This .pdf document is the actual POLST form itself for your use.

Advance Directives- An Introduction

Advance Directives are important legal documents, but are sometimes misunderstood. Generally speaking, advance directives designate another person or persons to make decisions or take actions on your behalf should you be unable to do so for yourself. They can also be designed to state your own wishes and preferences.

Many people have such directives around legal and/or financial matters. For example, they may have a will or a living trust or they may have a document authorizing their spouse to gain access to financial accounts or pay bills or sell assets if they were to become unable to do so themselves or jointly.

Advance Directives for Medical Care (so-called "Living Wills") make your wishes known about medical care and designate people to make medical decisions for you if you become unable to state them for yourself. For example, you will typically be asked to state a preference around organ donation and around prolonging life in the event that you are in a coma or persistent vegetative state ("brain dead") or some terminally ill condition.

Please be aware that your wishes around artificially prolonging your life only become applicable when you are already brain dead or in a coma or terminal condition. Advance Directives generally do not address your preferences or wishes around scenarios that could lead up to being terminally ill or brain dead.

For example, you may have strong feelings about the roles of interventions or procedures such as dialysis or emergency brain surgery in dire emergencies where you are already so sick that cannot discuss them for yourself. It is okay to add these wishes to your Advance Directive.

Advance Directives allow extra space for the addition of any further statements that you may care to make. In California, they do not require an attorney to draft. They simply require your signature and either a notary public or the signatures of two persons who know who you are.

However, you may wish to enlist the aid of an attorney if such a directive seems complicated or unclear.

This site has state-specific free downloads of Advance Directive forms.

Five Wishes (produced by the non-profit Aging With Dignity) is an advance directive that more fully addresses your feelings around comfort and is a bit more specific around examples of life-sustaining interventions or procedures and allows you to address them as you see fit. The document costs $5, but can be previewed for free as a .pdf document.

This form from the Attorney General's office of the State of California is also freely available.

We also have a handout on this subject and sample forms from the California Hospital Association for your use. Feel free to ask for one next time you are in the office!

Pharmacokinetics: What happens to the medicines I take?

Folks often ask questions about their medicines (whether over-the-counter or prescription) that have to do with how long they last, or how long it will be before they take effect, or how long until side-effects may go away or for the medicine to be out of circulation.

A handy principle or "rule of thumb" has to do with what happens to medicines after you take them; this is known as pharmacokinetics. (On the other hand, what they do after you take them is called pharmacodynamics.) Mind you, this rule of thumb only applies when a medicine is being taken regularly and as directed. This means that it is being taken in the instructed amount and frequency and not "as needed" or "now and again". However, this rule of thumb applies to nearly any medicine by any route (swallowed, injected, i.v., etc.).

How much of a medicine (dosage) and how often it needs to be taken (frequency) has to do with how quickly your body metabolizes or breaks it down, and then how quickly it is excreted out of your body. For the vast majority of medicines, the liver breaks them down, and then they are excreted in your urine.

When taken at the directed dose and frequency, a medicine does not stay at a fairly constant and effective level in your blood stream until after the 4th dose. This is called steady state.

For example, if today you start taking a pill for pain that is supposed to be taken three times every day, then a steady and pain-relieving amount will start to be maintained in your system by later tomorrow. On the other hand, if you start one that is a once a day pain pill, it will not reach a steady level until five days from now.

Similarly, if you are taking a medicine regularly and feel that it is causing troublesome side effects it will not be entirely gone until after the fourth missed dose.

FDA Concerns About Zocor/simvastatin in the 80 mg dose

The Food and Drug Administration (FDA) announced concerns yesterday about the risk of muscle injury specifically around Zocor or generic simvastatin in the 80 mg dose.

Statins have been widely used since the 1980's for reduction of cholesterol and reduction in the occurrence of sudden deaths from cardiac arrest, heart attacks and strokes. Muscle injury is known to be an uncommon side-effect of the statins and is proportional to the potency ("strength") and dosage ("size") of the particular statin.

Simvastatin is the most potent of the generically available statins, and the 80 mg dose is the highest dose made for it.

The FDA is concerned (this link is technically worded) that the risk of muscle injury with 80 mg a day of simvastatin is higher than for comparable doses of other statins. Specifically, they are recommending that doctors not start patients on this dose, or increase patients already on lower doses to this dose.

This concern is based on a recently completed medical study comparing the effects of simvastatin in 20 mg and 80 mg doses with and without supplemental Vitamin B12 and folic acid after heart attack.

One of the findings from this study was that the risk of muscle injury with the 80 mg dose was 0.9%, and 0.02% with the 20 mg dose. Prior to this test, the risk with the 80 mg dose had been reported as 0.53%. Hence, the warning.

Please note that if you already are on simvastatin at 80 mg a day for a year or more and not having side effects (such as persistent muscle or joint pain, or weakness), there is no need of concern.

News announcements suggest switching to other medicines that are as effective as 80 mg of simvastatin. The problem with this is that the only medicines that are equally effective are Lipitor 40 mg and Crestor 20 mg. Neither of these is generic, so they are often much more expensive.

If you would like us to switch you to one of these, let us know. Please check your insurance formulary to see which of these you would prefer so you can let us know which one to switch you to.

Can I split this pill?

We often get asked whether it's okay to split or crush a pill. This might come up because of a need to reduce the dose, or because of difficulty swallowing the pill whole (think sulfa antibiotic or potassium replacement).

Generally, pills that have a score or line imprinted into them are intended by the manufacturer to be safely and easily splittable. Also, pharmacies will put an easily visible sticker on the bottle telling you not to crush or split the medication if this is an issue.

Pill splitting devices are easily and cheaply obtained at supermarkets, drug stores and pharmacies and are much easier to use than using a kitchen knife on the counter-tops!

If it interests you to know why some pills should not be crushed or split, there are a number of reasons (h/t Art Gonzalez, Pharm.D., Marshall Hospital Pharmacy Department):

• Crushing pills meant to dissolve under the tongue (sub-lingual) such as nitroglycerin for chest pain or angina can cause them not to work.
• Extended-release formulations of medicines often are designed to have an outer coating that allows the medicine inside to be slowly absorbed into your bloodstream over a long period of time. Spitting or crushing these can allow 12-24 hours worth of that medicine to get into you in a few hours: this would not be good. Often, these medicines have abbreviations after their names such as CR, LA, SR, XL, XR, CD, etc.
• Crushing or splitting pills with potential to be cancer-causing (carcinogenic) or birth-defect causing (teratogenic) can cause the medicine to be released into the air and can be positively dangerous to patients and their family members. Examples would include chemotherapy pills and hormonal pills.
• Sometimes the pill bottle will be labelled not to crush or split the pills because they are fragile, taste bitter, or might stain your teeth or irritate your throat.
  

Is there a link between cell phone use and cancer (v. 2.0)?

I posted on this topic a few months back, and noted that there was no compelling evidence to suggest that cell phone use was linked to brain cancers. Certainly, the occurrence of the types of brain cancer in question (gliomas and acoustic neuromas) has remained pretty much the same over the last decade or two, even though cell phone use has escalated very rapidly.

The World Health Organization (WHO) announced concerns of a potential risk in heavy cell phone use for developing gliomas and acoustic neuromas.

If you've been looking for a good excuse to stop answering your cell phone or to spend money on hands-free headsets, then now's the time!

However, if you are wondering how safe or unsafe cell phone use may be from the standpoint of brain cancer risk it's worth noting that the WHO's findings are far from conclusive.

• The level of risk is not new compared to earlier studies, and is assigned a level of 2B. This means a possible risk of cancer in humans, but with very limited evidence.
  
• Note that other possible carcinogens in the 2B category include carpentry, coffee and pickles.
• Even if this finding is taken at full face value, we are still talking about an uncommon form of cancer which means that the risk in any individual of developing a brain cancer from using a cell phone regularly is still very low.

To me, this is also interesting as telecom industry studies show that cell phone users are using there phones less for actual voice phone calls and more for texting, email and data transmission such as smart phone apps.

Until I am convinced otherwise I plan to continue to use my cell phone, start off my day with a mug of coffee, and eat pickles or kim-chee when the mood strikes me. However, I will continue to defer carpentry to my wife since she is far better at it than me!

Travel Preparations

Summer is fast approaching, and we often get questions about travel abroad.

The idea here is to have a great time, but also be able to avoid or deal with health-related problems that may arise.

First, don't forget the basics.

• Bring things you already use such as spare glasses or contact lenses, sunglasses and prescription medicines you normally take. I suggest you bring controlled substances such as sedatives and pain-killers in the original pharmacy-issued containers. You might also want to make sure that such medicines are legal to possess on entering the countries in which you will be traveling.
• Bring normal first aid supplies such as lip balm, insect repellent, eye drops, band-aids, athlete's foot cream, Neosporin, and Tylenol or Advil.
• Pack for the kind of activities you will be doing. Rick Steves has a lot of great advice on this!

Feel free to see us if you have further questions or concerns. Also, we can help you with specific medical needs such as:

• Hepatitis shots
• prescription medicines to prevent malaria
  
• Tetanus shots
• prescription medicines in case of travelers' diarrhea
• prescription medicines for "jet lag"
• prescription medicines for flying-related panic attacks

Travel Med is a good resource for those unusual immunizations that doctor offices and public health departments do not carry, such as yellow fever vaccine. They have a Sacramento location at:
4250 H Street, Suite 4
Sacramento, CA 95819
916/254-2100

The Centers for Disease Control (CDC) have a lot of information for travelers, including specific concerns about your destination.

Also, don't forget to check the U.S. Department of State for information on travel such as passport requirements and crisis situations in your destination.

Bon Voyage!

Preventing Kidney Stones

Kidney stones are a relatively common problem, and a very painful one to have.

Lifetime risk of ever having one in both men and women is 5%. Fortunately, the risk isn't higher since passing a stone can be more painful than childbirth (or so every female patient who has had both has told me).

80% of stones contain calcium. Out of these, 80% are made of a chemical called calcium oxalate.

Happily, these kinds of stones may be prevented by some dietary suggestions:

• avoid high protein, high salt diets
• avoid Pepsi, Coca-Cola, tea and iced tea
• avoid excessive cheese and dairy products in your diet
• drink lemonade regularly (or, 8-10 ounces of lemon juice in 64 ounces of water)
• drink "reverse osmosis" water such as Aquafina, Dasari, or Alhambra instead of tap or well water
• if you take calcium supplements, use the ones that contain calcium citrate and not calcium carbonate (such as TUMS, RolAids or "natural" calcium)

(h/t Dr. Kash Desai, a local urologist)

Discount Prescription Drug Program

While the rest of California is participating in the economic recovery (jobs, home prices; that sort of thing), unfortunately the Sacramento area is not.

A patient recommended this website for a California discount drug card. He tells me it's pretty much as billed: no application or registration, and accepted in many local pharmacies.

Check it out if you'd like to pay less for prescription medications.

Do Cell Phones Cause Cancer? (No, not likely.)

Certainly, holding an emitter of electromagnetic radiation close to your head frequently should raise some question as to whether this could be harmful. However, cancers that could be caused by such EMR are occurring less frequently even as cell phone use is becoming more and more common. The best medical studies to date do not show a link, either.

This article (h/t New York Times) does an elegant job of bringing together the concerns and the most reliable information to date. For those avoiding the NYT paywall, this article (h/t BoingBoing) summarizes it quite nicely.

A Couple of Interesting Notes

Are lucky people really lucky, or just more flexible and open to opportunity? (h/t to Lifehacker)

It's pretty shocking to put the recommended evacuation areas around the Fukushima reactor near Tokyo into perspective. Gizmodo provides some maps of the same sized zones around reactors in L.A. (and also New York and Chicago). Ouch.

A Few Interesting Reads

• From Wired magazine, an interesting re-do on the famous Milgram experiments from back in the day. If asked, do you think you would deliver electrical shocks to a stranger for money? If actually offered money and provided with a real person, would you still?
• In Vanity Fair, a famous economist writes on the effects on our country of having 40% of the country's wealth in the control of 1% of its people.
• Ted Rall's cartoon: Terrorist Plots We Could Really Use.
  

Why did some pills suddenly get so expensive?

Well, I had been wondering that myself.

It appears that the FDA is trying to eliminate very old drugs that are widely used in conditions for which they were actually never proved to be safe and effective.

This in itself is not a bad idea. For example, a look into whether childrens' over-the-counter cough and cold formulas really help or not has shown not only that they don't help to relieve cold symptoms in children, they can also cause serious side-effects such as seizures. This has led to efforts by family doctors and pediatricians to let parents know this and to use more supportive home treatment than over-the-counter medicines.

On the other hand, this has led drug companies to respond in unfortunately predictable ways. This story explains why colchicine (used for decades to relieve or prevent severe gout pain) went suddenly from 10 cents/pill to $5/pill.

It is also probably why you can't get quinine pills for leg cramps anymore. It was never actually tested for any condition but malaria. My guess is that the companies that make it don't want to go through the trouble and expense of testing it for leg cramps and simply withdrew it.

Radiation Exposure

While I trust that the fax from Grandpa's Pharmacy offering to sell me and my office staff much-sought-after potassium iodide at the bargain rate of $60 is well intended, I doubt that it will be necessary. Apparently, there's been a run on the supply in the US, especially on the West Coast.

Potassium iodide can help to displace radioactive iodine from being taken up by the thyroid gland in the event of exposure to it, but would have to be taken at least 6 hours before exposure. Even given the US NRC recommending US citizens in Japan evacuate from within 50 miles of the troubled reactor, the exposure levels on the US mainland over 5,000 miles away is going to be just about nil. Overall, the smart money in avoiding exposure to radioactive iodine will be avoiding drinking milk from northeast Japan.

Some interesting reading on the subject:

• ProPublica has a nice reading list from a variety of news sources covering basic background, up-to-the-minute liveblogs and twitter feeds, and the public health aspects of radiation exposure.
• MSNBC (h/t to Boing Boing) shows a ranking of US nuclear power plants at risk for quake damage causing a core meltdown. (Hint: the most at-risk are not in California)
• For those concerned about TEOTWAWKI (the end of the world as we know it), Medscape has a very technical discussion of nuclear and radiologic decontamination including a discussion of potassium iodide. Who knew Mylanta and Maalox can help to reduce absorption of strontium and radium? (Dose: 100cc by mouth ASAP upon exposure)
  
• For an interesting and lighter side note, Slate discusses why there is so little looting going on in Japan right now.
  

Interesting conversation over breakfast with my daughter this morning about how to decide on your livelihood. She is a high school freshman who wants to contribute to the world, have a comfortable salary, have a family, travel and enjoy what she does for a living. Indeed, don't we all?

Interesting she should ask (and believe me, I'm glad she's asking), since there have been some interesting reads in the news on this very subject.

This article in the Harvard Business Review questions the practice of "business as usual" and re-frames the question for the future as "Does what you do have a point- one that matters to people, society, nature and the future?"

The next people to be displaced by computerization (not so much by off-shoring) are attorneys. Wow. Just wow.

Staying cool under pressure is somewhat genetic, but more so environmental. And the good news is, it can be taught!

Here's a handy way to estimate portion sizes.

For those who struggle with trying to visualize diet recommendations such as "1 cup of pasta",

• 3 ounces of meat is the size of a deck of cards
• 1 and 1/2 ounces of cheese is the size of 4 dice
• 1 cup of cooked cereal or pasta is the size of a baseball.

(h/t to Consumer Reports magazine!)

A Clinician's Perspective on the Question of Violent Language in the Public Media

I agree with the author of this article (a practicing psychiatrist) that the link between violent acts and violent language used on TV and in talk radio cannot be so easily dismissed.

This is much discussed in the setting of the shootings in Tuscon by Jared Loughner; it is reasonable to suppose that Mr. Loughner did not get the idea to shoot Representative Giffords simply because he follows Sarah Palin's website. However, I'd say that it's hasty to say that no connection exists between his actions and the general tone of Ms. Palin and others like her. "Don't retreat: Reload" is not a peaceful or reasoned exhortation.

An Alternative to Coumadin (warfarin)

As many of you already seem to be aware, the FDA approved a medicine called Pradaxa in late October, 2010.

Currently, it is for use in patients who have a very common arrhythmia called atrial fibrillation (AFib) without any heart valve disease along with it. The purpose of the medication is to act as a "blood thinner" to prevent stroke due to the AFib.

Up until this time, the only way to do this was with a pill called Coumadin (warfarin). Aside from the 2% per year risk of serious bleeding due to the medication, it also requires frequent lab testing to be sure that the dose is adjusted correctly. Dose adjustments are common because many, many common foods and medicines can interfere with the metabolism of Coumadin.

The deal with Pradaxa, is that it works just as well as Coumadin in preventing AFib-related stroke, and is about the same in terms of side-effects and bleeding risks. However, the dose is largely the same for all patients, and does not require lab testing. Pradaxa can be used as a first medication, or as a change from Coumadin.

Currently, the cost of this medicine is about $200/month since no insurance plans cover it (the exception to this is the military's TriCARE insurance which covers all but a $20/month co-payment). Depending on you financial state of affairs and the value you place on your time and co-pays for lab testing, you may still find this worthwhile.