Dr. Andy

Reflections on medicine and biology among other things

Monday, October 31, 2005

Breast cancer and handedness

I have always been disappointed neither of my children is left-handed (I’m a southpaw). I guess now I’m glad, at least about my daughter. A recent article in the BMJ shows a more than 2 fold increased risk of premenopausal breast cancer in left-handed women.

There is also a plausible mechanism in that increased exposure to sex hormones in utero increases the chances of a fetus being left-handed and might also increase the risk of breast cancer. The mechanism of sex hormones effect on handedness seems to be via disruption of the typical pattern of “lateralization” of the sides of the brain. Most people are right-handed and that seems to be the default pathway of brain development. High levels of sex hormones (both the authors of the article and I are being deliberately vague here) disrupt this default pathway and make handedness more a 50-50 proposition.

As far as breast cancer, exposure to hormones, particularly estrogens help breast tissue proliferate and play a crucial role in the dysregulated proliferation of many breast cancers (Tamoxifen acts by inhibiting estrogen induced proliferation). Presumably prenatal exposure can influence breast tissue to make it more likely to turn cancerous in later life.

On the other hand, the reported increased risk of breast cancer has broad confidence intervals. The risk for all breast cancers was not significantly higher in the left-handed although it almost made it (lower limit of relative risk was 0.99). For premenopausal cancers the lower bound of the relative risk was 1.15 (meaning at the lower bound left handed women had only a 15% increased risk)

One could also imagine that handedness might be a marker for an unmeasured environmental risk that also predisposed to breast cancer, such as exposure to tobacco smoke in utero, although this doesn't seem to be the case (it is always hard to rule out unmeasured confounders in retrospective studies).

Happy Halloween

For those who complained about how ugly the pictures of my feet were, here are some more pleasing ones. This is Colin and Isabel in their Halloween costumes. Colin is Anakin Skywalker and Isabel is a snow princess. Business was slow here (I stayed home to give out candy and do work), just 5 total trick-or-treaters in 2 groups. I think our street is too busy and the houses too spread out to make it attractive to most kids and parents. Adrianne took the kids to a nearby area that has lots of closely spaced houses and said there was a lot of kids there. They each got about 5 pounds worth of candy. My best pediatrician advice on Halloween was gleaned from Gerald Haas, one of the all time best general pediatricians who practiced in Cambridge, Mass and at a health center, but also precepted part-time in the continuity clinic at Boston Children's Hospital, where I trained. He said let your kids all the candy they want on Halloween, then the day after eat some candy and then throw the rest out. By that point they'll be sick of it anyway and won't miss it too much

Here is Isabel at her 5th birthday party last weekend, along with her mom and dad

Finally, here are the kids finishing breakfast one morning. You can see a bit the view we have from our living room on the right (sorry about the caption and picture not matching up, I blame Blogger). I'm obviously not much of a photographer (actually I didn't take any of these) but my friend Jason is. Here is his blog, which has tons of great pictures and some tips on being a better photographer (and here are some more)

Cervical cancer vaccine

This is just stupid:

A new vaccine that protects against cervical cancer has set up a clash between health advocates who want to use the shots aggressively to prevent thousands of malignancies and social conservatives who say immunizing teenagers could encourage sexual activity.

Because the vaccine protects against a sexually transmitted virus, many conservatives oppose making it mandatory, citing fears that it could send a subtle message condoning sexual activity before marriage.

Have these conservatives ever actually dealt with a teenager? Do they remember being a teenager? Fear of cervical cancer is real high on their list of reasons for or against becoming sexually active.

3700 women a year die of cervical cancer in the US. Die. We have a vaccine that can prevent that, let's use it

UPDATE: I'm also in favor of over-the-counter availability of Plan B, post-exposure contraception (i.e. the "morning after" pill). But in that case, I can see why availability MIGHT increase frequency of premaritial sex, since fear of pregnancy seems very important, even, say to married couples. As I understand it, research suggests OTC availability of contraception doesn't lead to more or riskier sex, but I could see how it might. I'd be in favor anyway, figuring these decisions are best left up to individuals

Saturday, October 29, 2005

Ugly pictures of my feet

As those who read my race report know, I had lots of problems with my feet when I ran the the Arkansas Traveler 100 mile run. Here are some pictures in case you don't believe me. If you'd like to see some photos of me during the race, my second pacer Tom Watson has some on his blog.

UPDATE: Gruntdoc has a pretty nasty picture of another subungual hematoma

Friday, October 28, 2005

Un experto

“Con una influenza que nunca se ha visto antes, se está en riesgo mucho mayor de padecer una enfermedad severa, porque no se la reconoce”, dijo Andrew MacGinnitie, un inmunólogo del Centro Médico de la Universidad de Pittsburgh. . . .

Sin una oposición efectiva del sistema inmunológico, las células muertas se acumulan en los pulmones. Al mismo tiempo, el tejido lastimado de los pulmones empieza a filtrar fluidos.
“Hasta ahora, en los casos de las personas que se contagiaron del H5N1 de aves”, dijo MacGinnitie, “en un punto, los pulmones dejaron de funcionar y se murieron”.

My Spanish is really improving

Thursday, October 27, 2005

Who is who in the (Australian) hospital

This post from Barbados Butterfly does two good things

1. Clears up confusion as to what exactly consultant and registrar mean in the British (and in this case Austrailian) medical education system. I always read these articles in Lancet and BMJ and have no idea what these mean.
2. Makes you laugh

Wednesday, October 26, 2005

Modern Art

A Japanese artist has been paid £5,000 of taxpayers’ money to attempt to drink 48 cans of beer and then fall off a wooden beam.

The “performance”, which took place at the Chapter arts centre in Cardiff, has outraged members of the local council and caused bafflement among the public, many of whom do exactly that without getting paid every Friday and Saturday night

Nice writing, though.

(via Scott Burgess)

Southern blots

Edwin Southern showed that DNA could be separated by size on an agarose gel and then transferred to a nitrocellulose membrane where sequences of interest could be identified by hybirdizing with a radioactive probe. This advance was published in 1975 and the technique almost immediately was termed "Southern blots" (blots because you use a lot of paper towels to draw a solution through the gel onto the membrane, carrying the DNA with it) or just "Southerns". Eventually, a similar approach was applied to RNA and then proteins, which were called "Northerns" and "Westerns."

Southern received the Lasker prize this year for his contributions to early molecular genetics, but we learn from co-recipient Alec Jeffreys that Southern hasn't let success go to his head:
The problem was how to monitor purification. The answer was provided by Ed Southern and his blots (incidentally, and with typical modesty, Ed never calls them Southerns but generally DNA transfers), which we showed, much to our surprise, were capable of detecting single-copy genes in complex genomes. This led to the first physical map of a mammalian gene and one of the first descriptions of introns.

Free investment advice

Whether physicians should sell their time to advise investment firms is currently quite controversial. Despite the high valuation of my blog, said firms are not exactly knocking down my door bidding for my time, so I decided to offer this advice for free to my readers. Here are some of the products in the allergy/asthma marketplace and how I see them.

Important caveats
1. I don't know which companies make which meds, so you'll have to figure that out yourselves.
2. I also serve as a consultant for Genentech which makes Xolair so keep that in mind.
3. I don't invest in individual stocks myself, so I don't have any particular interest in seeing one or the other do well
4. In general, you get what you pay for

Asthma Drugs

Inhaled steroids.

Flovent (fluticasone) dominates this market. I have heard that fluticasone is now off patent, but so far there is no generic form. If I were a generic drug maker I'd be pushing to get generic fluticasone to market. Once they do, I think most insurance plans will make that the preferred inhaled steroid, and push everything else to a higher copay.

Pulmicort (budesonide) comes in two forms. The respules, for use in a nebulizer, are the only approved inhaled steroid up to age 5 and therefore a goldmine. The concept that asthma is an inflammatory disease and needs regular anti-inflammatory treatment has made it out into the primary care community, so the respules are and will continue to be widely used with no competitor in site.

The Turbuhaler delivery device is okay. Good product but my sense is that almost everyone uses Flovent as the default. The drug reps are pushing value, which is good (200 doses/device with most patients using 2-4 doses/day) but not enough.

Aztra Zeneca (I had to look it up) is getting killed because they don't have a delivery device that can be used by kids ready to transition off the respules. By 3 or 4 most kids won't sit still for the respules (which take about 8 minutes via neb) and get switched to Flovent using a mask and spacer because they aren't ready for the Turbuhaler. If there were, say, a Pulmicort MDI (metered dose inhaler) all those kids would go to that, but there isn't. So sad. I guess the Astra-Zeneca CEO will have to console himself with only $50million this year, could have been a 100.

Qvar (beclamethasone) Good product, but late to market, so rarely used. Some data on better penetration of small airways, but more something people talk about than act on.

Asmanex (mometasone) dead on arrival. Yawn. I could use an alternative to Adviar; I don't need another inhaled steroid. Device is no better than Turbuhaler and we use other inhaled steroids once a day so indication for once daily dosing is no big deal

Ciclesonide (not yet approved) see Asmanex

Other drugs

Advair (fluticasone/salmetereol). Black box warning hurts, but this is enormous drug. Patients like it, doctors like it because salmeterol makes patients feel better and therefore take it more regularly. Expensive, but worth it. Not surprisingly, deemphasizing Flovent to push this for more and more patients. I'm seeing tons of patients for whom this is prescribed by PCPs. Jerome Bettis ads and asthma control test are good way to push more people onto this. I think there is a lot of undertreated asthma out there, and Advair will help a lot of it.
No competition until Symbicort (budesonide/fomoterol) comes, but the AZ reps are saying at least a year

Xolair (Omalizumab) Works great, but outrageously expensive (10-20K/yr roughly). Use will continue to increase as allergists/pulmonologists get more comfortable with it, but insurance companies starting to toughen standards. Doubt will ever be widely used for food allergy.

Singulair (montelukast) Decent product, good prospects. Recently published PREVIA trial shows effectiveness in kids with wheezing only with URIs, which is huge market and plays into parents steroid-phobia. In adults, NEJM studyallegedly showing no difference in control of mild persistent asthmatics with use of daily inhaled steroids is being pushed by reps, who say Singulair should be equal alternative in treatment of these patients. Chutzpah given that this trial incuded another leukotriene antagonist (zafirlukast) which showed absolutely NO benefit (vs. steroids which improved control on some measures). Effective marketing. Also useful in some patients with refractory urticaria, but market apparently too small to pursue this as indication.

Symbicort (budesonide/fomoterol) Studies look great, so why is it taking so long to get approved? Since fomoterol (unlike salmeterol) has rapid onset and long-acting beta-agonist properties, potential use as a "single inhaler" used both as daily controller and prn reliever is appealing (though scary to asthma specialists!). Wonder if, like Qvar and Azmacort, it will be a day late and a dollar short.

Rhinitis meds

Intranasal steroids Not much difference one to another. Flonase has best insurance coverage, at least in Pennsylvania, and I like using same med for nose and lungs. Nasonex has advantage of being approved down to 2, Rhinocort and Nasacort are widely felt to be best tolerated. Insurance coverage is key driver of use

Antihistamines Insurance dictates everyone try loratadine (now generic, was Claritin) first. Some will pay for Allegra (fexofenadine) or Zyrtec (ceterizine) or even Clarinex (desloratadine) if loratadine fails, but increasingly only for severe pathology (hives, anaphylaxis) not for run of the mill nasal allergies.

Incredibly, Singulair is starting to be covered by some insurances for allergies, despite data that it is marginally effective at all and less potent than loratadine.

Astelin (azelastine) Not effective, too many sprays, no one likes the taste.

Apparently, they are working on a nasal form of olopatadine (Patanol when used for eyes, maybe Patanasal? for nose) which might be big if effective as it would apparently have rapid onset, which steroids don't, and appeal to all the patients/parents who get palpitations whenever someone says "steroids."

Eye meds

Patanol (olopatadine) dominates this field. When I ask opthamologists what to use on tough patients awaiting optho visit for ocular steroids, they all say they use Patanol, despite some data other drops may be better

All the rest Hard to get market share. Occasional insurances will make others (e.g. Zaditor) front line but patients are all already on Patanol and don't want to switch


is the value of this blog, according to this site. Valuation is apparently based on the number of links to a blog via Technorati and the AOL payed for Weblogs. This is obviously a medical, not a finance blog, but I feel safe in saying the quoted number seems high.

Any interested buyers can contact me off line.

My friend Jason's blog is worth about 3 times mine, while Ollie's has no value

Tuesday, October 25, 2005

Medical response to Katrina

The October 13th NEJM has a number of articles about the medical response to Katrina, all from people involved. They are all free full text

One point made by two articles is that public heatlth measures come first. All the docs like me who imagine making a difference by taking care of patients one-by-one are not really needed, at least early in the process:
In the immediate aftermath of a disaster involving large, displaced populations, doctors, as difficult as it might be to accept, are one of the least useful commodities. The first priorities, standards in the developing world, are security and safety for the population, then water, sanitation, food, and shelter. Once the humanitarian-aid staff is safe from danger, the most effective way to save lives is to ensure the availability of clean water, secure a place for bodily wastes away from the water supply, and then vaccinate every child younger than 15 against measles. Only after these needs have been addressed can curative care become operational.

Unfortunately, the skill set for such a response was not on the curriculum vitae of any of the health care workers who had shown up to volunteer. All the eager, superbly trained doctors and nurses who told me "I'm here to help" almost always meant that they were ready to deliver care in the same way they did at home. But the burden of the initial emergency response is on logistics, not on the provision of direct care. Indeed, attempts to provide direct care in a setting with no coordination or infrastructure can distract from the urgent mission of establishing basic human security and meeting immediate needs.
Apparently some of the doctors who stayed in hospitals in New Orleans didn't get the memo about how there wasn't any looting or violence:
My husband was exposed to sniper fire twice while helping to evacuate the emergency-room dock. People with guns shut down an entire hospital evacuation for many hours. The real Katrina disaster was not created by the elements but by a society whose fabric had been torn asunder by inequality, lack of education, and the inexplicable conviction that we should all have access to weapons that kill.
Of course doctors can be as vulnerable to hype as anyone else. Another doc, who went to help at the convention center, found himself welcome if impotent:
We found that a physician in scrubs with a stethoscope and a kind but forceful police officer were immediately welcomed into the crowd. . . .

One elderly, obese, diabetic, wheelchair-bound woman said she thought she had something wrong with her legs. I lifted her housecoat to reveal multiple bilateral deep epidermal ulcerations on her tibia and feet, as well as a few gangrenous toes. I told her that I couldn't do anything for her right now but that I'd get help as quickly as I could. She said, "That's OK, honey, I'm old, they don't hurt that bad, and there are some sick babies here — you go worry about them."

Grand rounds 2.05


Sunday, October 23, 2005

"Your lungs stop working and you die"

or how I became an expert on avian flu.

I don't have any particular expertise on influenza, avian or otherwise, a year ago. As time went on, I blogged more about it, read more about it, and learned more about it; this lead be to blog more about it, although I haven't been in any sense comprehensive about the subject.

I did write one post I was particularly proud of about how all the recriminations about the Katrina response might be better addressed toward improving the response to the coming bird flu pandemic (which was even referenced by instapundit).

Anyway, earlier this week I got a call from our PR department asking if I'd be willing to talk to a reporter about the immune response to the avian flu. Sure I said, but that's not really my area of expertise. Turns out the reporter had seen my blog and knew I was interested in the issue

So I guess now the old media is following the new. The reporter, Jeff Nesmith, was very well prepared and very knowledgable, having read several of the NEJM articles I had. I think what he needed most was someone knowledgable to walk through the immune response to infection, which I was happy to do.

I'm thinking about blogging an introduction to avian flu, but for now this free full text article from the NEJM is good, but maybe a bit tough for beginners, and this one sets the stage for how bad it could be.

As I talked to the reporter, I said I thought people might be overstating how many people might die, that it wouldn't be 10% of the population. He pointed out that even if it killed 0.5% that would still be 1.5 million people in the US alone.

Saturday, October 22, 2005

Inside the Nigerian email schemes

Stephen Kovacsics of American Citizen Services, an office of the U.S. Consulate, spoke to a victim who had lost $200,000.

Kovacsics says he is awakened several nights a week by Americans pleading for help with an emergency, such as a fiancee (whom they have only met in an online chat room) locked up in a Nigerian jail. He has to tell them that there is probably no fiancee, no emergency.
Not much new, but interesting. I don't feel very sorry for them either.

UPDATE: This is probably the kind of thing my friend Ollie thinks the government needs to protect us from

Friday, October 21, 2005

More innumeracy

From an article about rich young doctors at the mag Medical Economics
"To have $1.5 million in a retirement plan by 65, a 35-year-old physician would have to consistently fund $42,000 each year," says Sherman L. Doll, a CPA and financial adviser from Walnut Creek, CA.
Either that or Mr. Doll expects really bad returns from the market over the next 30 years. Think about it, if you contributed $42K/year for 30 years, your principal (and it is principal, not principle) would equal 1.26 million. According to my Excel based calculations (I don't have a calculator with logarithmic functions around) you'd need a whopping annual return of a bit under 1.2% to make it to 1.5 million. That is well under the real return of inflation-indexed treasury bonds.

It doesn't even matter if the market goes to hell in the first few years since you have plenty of time to earn it back. Even if the market went to zero at year 5 (that is you lost all you'd invested up till then) a modest 3% yearly return would get you to 1.5M. Hopefully, Mr. Doll was misquoted, otherwise I don't think I'd want him as my CPA.

Capitalism and medicine

I am a capatilist at heart. Self-interested actors leading unwittingly to the overall good, the invisible hand et al. I'm a believer. But there seem to be instances in which everyone acting in their own interest doesn't benefit patients. In yesterday's NYT is an article about failures in a particular brand of defibrillators which are implanted into the hearts of patients at high risks of arrythmias (abnormalities of the hearts rhythym) such as our vice-president, Dick Chaney, and Joshua Oukrop, a young man with a congenital defect, hypertrophic cardiomyopathy, that caused his heart muscle to grow too thick. Unfortunately, his defibirllator shorted out and he died, an apparently frequent occurence with this specific model of Guidant defibrillator.
Two months after Mr. Oukrop's death, the Guidant Corporation, the country's second-biggest maker of heart defibrillators, acknowledged that it had not told doctors for three years that one model had short-circuited in about two dozen cases, including the one involving him.
The article is good, read it all. The hard thing is you can understand why Guidant didn't want to step forward earlier, all the incentives were to do nothing. Same thing with Merck and Vioxx.

I don't know the answer to this, but I do know a more rationally designed health care system will have to take these kinds of things into account.

I suppose the other side of the coin is that maybe the system is okay: many more people would have died if it had taken even longer for these things to come out. Maybe some combination of lawsuits, doctors who want to be whistleblowers and regulation is actually pretty good at picking up these sort of dangers, just not perfect, and we are focusing too much on the failures.

One thing that is clearly misguided is allowing the companies themselves to be in charge of post-marketing surveillance:

Guidant executives like Mr. McCoy have insisted that their decisions about when to disclose product defects were not affected by financial factors, like the pending Johnson & Johnson deal. Guidant said that as with the Prizm 2 DR, the rate of failure of the Contak Renewal was not high enough to meet the company's criteria for notifying doctors.

"At this company, the quality culture is absolutely apparent," Mr. McCoy said in his July interview with the Minneapolis Star Tribune.

Others are skeptical. "I think J.& J. colored things," said Dr. Hauser of Minneapolis.

Whether the company was influenced by financial concerns or not, it surely appears they would be. Some sort of independent board monitoring adverse effects would be free of those pressures.

The rat race

A single Norway rat released on to a rat-free island was not caught for more than four months, despite intensive efforts to trap it. The rat first explored the 9.5-hectare island and then swam 400 metres across open water to another rat-free island, evading capture for 18 weeks until an aggressive combination of detection and trapping methods were deployed simultaneously.
Apparently, it is quite hard to clear islands of rats and once they are cleared they often get reinfested. Now we know why. Above is part of the abstract of and article from this week's Nature (not free access)

An extended account is here:

Despite being weighed down by a tiny radio transmitter collar, Razza eluded intensive efforts to trap him during his 10-week sojourn on New Zealand's uninhabited and forested Motuhoropapa Island.

During that time, the rat evaded an arsenal of traps and poisoned baits that included peanut butter. He even continued to stay one step ahead of sniffer dogs sent in to track him down.

Then he disappeared only to turn up on neighboring Otata Island after his dip, apparently motivated by primordial urges during the spring-summer mating season

Only a cynic would note that by not catching the rat they got a paper in Nature, and wonder how hard they really tried.

Thursday, October 20, 2005

Too stupid for words


Hyponatremia in marathon runners

The word is getting out that overdrinking is more of a risk than underdrinking for endurance athletes. Too much water leads to low levels of sodium (aka hyponatremia) and can be very bad news.

I can't believe this statistic is true, however
Last year, one percent of the more than 35,000 New York City marathoners were hospitalized with hyponatremia, Maharam said, and although that is a smaller toll than in other cities' marathons, doctors say every one of those life-threatening medical emergencies could have been avoided.
That would mean 350 hospitalized runners with hyponatremia. I just can't see that.

The example used in the article is a runner who became hyponatremic at the 2004 Boston marathon. He was basically turned away at the medical tent after the race because he looked too well. I ran that race and it was horrible. After a cold spring it got close to 90 on race day. I remember finishing (about 4 hours elapsed time, 4:20 clock time) and seeing a line of wheelchairs waiting to get into the medical tent!

Wednesday, October 19, 2005

Why health care is so expensive

This excellent article from Sunday's NYT magazine shows how the profit motive can lead to medicalization of natural variation and overspending on "health care." It details Eli Lilly's succesful campaign to have its version of human growth hormone approved to treat "idopathic short stature" which is just a fancy way of saying shortness. The drug is expensive ($20K/year x 4-5 years) and minimally effective (final increased height in the range of 1-2 inches). And new research shows being short doesn't lead to any major psych issues.
You would think the clinical virtues of a $2 billion drug would be readily apparent, but just last month, an editorial in a medical journal acknowledged that "uncertainties" about the psychological benefits "may well dampen enthusiasm" among doctors for increasing use.
So while lots of people can't afford insurance, the health care system is paying $50-100K per inch to make kids taller. In a more rational system, where people actually cared about medical costs, either the drug would be a lot cheaper, or used a lot less.

I should note that growth hormone does have a legitimate role in patients with truly medical conditions resulting in short stature like actual deficiency of growth hormone.

And another thing, the summers are too hot

Gov. Jeb Bush, like millions of Floridians, expressed amazement that another hurricane is headed toward the state, which has been hit an unprecedented six times in the past two years, including hurricanes Charley, Frances, Ivan and Jeanne in 2004 and Dennis and Katrina this year.

"Why us? How could it be a storm would take a sharp, 90-degree turn to the east? It's something that we're going to have to live with and prepare for," he said Tuesday.
Why us? I don't mean to be rude, but your state is a peninsula that sticks out directly at the epicenter of Atlantic Ocean tropical storm creation. What the hell do you expect? You are going to get some hurricanes there.

Organ donation ethics

Is it permissable to donate your organs based on race? Does it matter if it is to a specific person instead?

Such are the quandries in organ transplantation, detailed in this article in the NEJM (I know it is old, I've been meaning to blog on this, but been busy).

In the first case, a man's family stipulated that, based on his racist beliefs, only whites could receive his organs. The organ allocation system complied, but it caused such an uproar that the state, Florida, passed a law banning the practice.

In the second case, a Jewish man decided to donate one of his kidneys to a Jewish child who needed a transplant, despite the fact that he did not know her. He apparently would not have donated his organ if she had not been Jewish.

Is Florida right to ban the practice of discrimination. Should the Jewish man's kidney have been accepted?

I think the second case is easy: while I find the man's insistence on only donating to a Jewish recipient unseemly, I can't see rejecting the organ. While the recipient will get the organ because she is Jewish, I don't see anyone else who is harmed. Everyone else waiting for a kidney is still on the list and someone else may get a transplant that would have gone to the girl since she is off the list. Additionally, as long as directed donation is acceptable banning donation based on race/ethnicity/religion will just encourage people not to disclose why they chose a given recipient. In addition, it seems like a bit of a slippery slope. Say this man knew the girl who needed the transplant because they went to the same synagogue, would that be unfair (since a Christian girl wouldn't have the same opportunity?).

I should note that there is some controversy about the whole idea of living people deciding to donate their organs to specific non-relatives: the procedure is not risk free and favors patients who can effectively appeal for donation to a large audience. This gives an advantage to the well-off, who are disproportionately white. My feeling is that we can accept some unfairness to minorities for the overall greater good that living related donation to non-relatives allows. Indeed, some minorities may get kidneys by virtue of others already having organs via living related donation. I don't think anyone seriously opposes the donation of kidneys among relatives on ethical grounds.

The first case is a bit tougher, but I think Florida is right to ban racially directed donation. One big difference is that living donors can direct their organs as they choose, whereas cadaveric donor's (i.e. dead ones) are allocated based on a complex system that takes into account genetic matching, acuity of need and length of waiting. Is this difference fair? Maybe, maybe not but it makes sense. Alive, I'd give a kidney for my child or sibling without a second thought, but haven't given one to a stranger as of yet. I will, though, happily donate to whoever needs it once I'm dead (if appropriate). If living donors (at least those who weren't related or even know the recipient personally) couldn't specify who their organs went to, we'd probably see a big drop in donations, although I suspect the number of living donations to strangers is low. Of course, one could argue that the inability to direct donation by race may keep racists from being (cadaveric) organ donors (ed- perhaps we could have a new donation campaign directed at racists "Donate 'em now while they'll still go to another whitey").

In addition, stipulating his organs can only go to white recipients does affirmatively discriminate against non-white patients who would have otherwise gotten the organs.

I also think the state of Florida and society need to strongly oppose outright racism, which is what donating only to another white person is. I'd feel the same way if the man had specificied only a Jewish/Catholic/born-again/etc. recipient. Of course, the living donor case comes perilously close to this line.

One other interesting thing in the article is the following
With directed donation to loved ones or friends, worries arise about the intense pressure that can be put on people to donate, leadingthose who are reluctant to do so to feel coerced. In these cases, transplantation programs are typically willing to identify a plausible medical excuse, so that the person can bow out gracefully

So if your brother "couldn't" donate a kidney to you, maybe he just didn't wan't to.

I should also note that Dr. Truog, author of the article, was head of the ICU at Boston Children's when I was there and while I didn't work with him much, made a very good impression. Unlike some "medical ethicists" who just go to meetings and listen to each other pontificate, he really takes care of patients and cares about real-life ethical issues.

UPDATE: much more on organ donation, here, from Galen's Log, someone actually involved

Sunday, October 16, 2005

The big four-oh

"I won't last forever, but I'm damn well going to know that I was here!"
- George Sheehan

Well, I turned 40 today. Roughly halfway in the ultra of life.

Unlike an ultra, however, life seems to speed up as you go, whereas the second half of an ultra seems to take forever.

I have a lot I'm proud of (education, being a good doctor, husband and father, etc.) The regrets I have are minor (e.g. not developing a taste for wine earlier). If it were to end tomorrow the things I'd feel remorse over are unavoidable (not seeing my kids grow into adults) not anything I have or haven't done. I also don't think too many of us can say we weigh less at 40 than we did at 18, at least not 20lbs less.

Latest sign

that the apocalypse is upon us:

This months Wine Spectator has a feature on Jeff Gordon, NASCAR driver and wine enthusiast. I knew there was a reason he fared so poorly this year.

What to feed your kid

Turns out most of what you hear from your pediatrician is probably wrong, or at least without any real basis:
bring on the spices. Science is catching up with the folklore that babies in the womb and those who are breast-fed taste -- and develop a taste for -- whatever Mom eats. So experts say if Mom enjoys loads of oregano, baby might, too.
My kids for the most part are adventerous eaters and enjoy spicy food. I remember once eating with my son and my parents and asking him if he'd like calamari. He asked what it was and when I replied "basically fried squid" he responded "sounds good" much to his grandparents amazement.

Wearing my allergist hat, I do have to caution against early introduction of foods like peanuts and shellfish in kids at high risk of food allergies, although the data for this intervention is weak.

Thursday, October 13, 2005

Power, sex, suicide

Not the title you'd expect for a book about mitochondria but it sounds great
Mitochondria are truly fascinating beasts. While many of us find it difficult to become excited about vesicles, ribosomes, endoplasmic reticulum, or even the Golgi apparatus, it is difficult not to become entranced by the tiny organelles that fuel our existence. As with so many objects of admiration, it is difficult to be precise about what we find so enthralling. Is it that they posses their own DNA? That gram for gram they generate more energy than the sun? Or that they may have once been free-living organisms? Perhaps they fulfil a deep-rooted Oedipal complex; the only part of us that is all of our mother, with no paternal influence to dilute the relationship.
Review from BMJ (not free, I don't think). I have to admit I completely share the reviewer's fascination with mitochodria. This book is definitely on my Xmass list.

For those who don't know, it is believed that mitochondria evolved from free living organisms. Evidence for this includes the fact that they have their own DNA and a "double" membrane such as might be formed by one organism being engulfed by another (i.e. inner membrane that is from the mitochondria and outer membrane is from the plasma membrane of the engulfing cell).

I admit I am a nerd.

Wednesday, October 12, 2005

Life without e-mail

Somehow, the IT geniuses have mananged to delete my e-mail account. My computer knowledge is tenuous at best, but as I understand it, we are moving to a new server for our e-mail accounts. I got an e-mail at my old account Friday afternoon saying I was being migrated and the only difference would be the web address to use browser based e-mail.

All weekend I tried to log into the new site without success. I called our help(less) desk on Monday morning and talked to a nice young man who initially denied I had ever had an account. "But Andy, I can't find your account anywhere." He finally located my mainframe accoutn which convinced him I could conceivably once had an e-mail account under the same ID. As if physicians today have nothing better to do than call up computer techs pretending they have accounts that don't exist.

Well, once I'd convinced him their might be a problem, he announced he'd have to refer this to the "migration team." No word, no progress and no response to several messages. Aaargh.
I hope no one is emailing me any critical info, because I'm not getting it. One of my colleagues asked me yesterday what I'd thought of his email.

In a strange way it is sort of liberating, but in the sense that I feel free, but know that a brick may fall on my head at any time.

First post-Arkansas run

I did my first run post-Arkansas this am, 7 easy miles.

Heres a puzzler for you. What is the worst time of year for me as far as dealing with darkness on my runs?

You might think either around Dec 21st (shortest days) or just before the end of daylight savings times, since I am running the longest before sunrise (I typically finish my weekday runs about 6:30 so I can shower before getting the kids up, dressed and to school).

In fact August/Septemeber and April/May seem to be the worst. Why? As the amount of vegeatation decreases, I get a lot more ambient light and can see the trails I run on better. I noticed today that despite finishing my run an hour prior to sunrise I could see pretty well even without my flashlight.

I wonder how much this varies for runners outside cities. I run in Schenley park which is smack dab in the middle of Pittsburgh and has lots of streetlights, etc. I'd suspect for more isolated trail the phase of the moon and how cloudy it is would play bigger roles.

Here is a website where you can check on sunrise and sunset times for your location and date

Blame it all on global warming

Everything from heatwaves to hurricane Katrina, from West Nile to hantavirus is the fault of climate change according to this article in the NEJM.

I think the evidence indicates that human activity is causing climate change, specifically warming, but this is the kind of truly hysterical article that makes me skeptical. I am opened to reasoned arguments about the effects of climate change on human health and disease, but this article starts with the premise that climate change is all bad and goes on to attribute just about every new disease or spreading illness to it, with little if any evidence.

Mix that with a liberal dose of punitive environmentalism
All in all, it would appear that we may be underestimating the breadth of biologic responses to changes in climate. Treating climate-related ills will require preparation, and early-warning systems forecasting extreme weather can help to reduce casualties and curtail the spread of disease. But primary prevention would require halting the extraction, mining, transport, refining, and combustion of fossil fuels — a transformation that many experts believe would have innumerable health and environmental benefits and would help to stabilize the climate.
Note the false understatement (no one would accuse this author of underestimating the biologica response to climate change. It is my general sense that creative solutions to climate change are likely to be more succesfull than attempts to get the development genie back in the bottle. Others obviously disagree, but can anyone seriously propose a halt to use of fossil fuels?

Thursday, October 06, 2005

Pacer report

Tom Watson, my crew and pacer at AT100, has posted a report of his experiences. He is far to kind about how cranky I was, but it is impressive how bad he was feeling, yet how he hid that from me so I could focus on my goal of finishing as quickly as possible.

Tuesday, October 04, 2005

Arkansas Traveller Race Report

"In ultrarunning, the pain is inevitable, but the suffering is optional" -Al Bogenhuber

Prologue: I had tried this race in 1997 as my first 100. I trashed an ankle and maybe even fractured my fibula on a rock about mile 20 and had to drop out. I’d gone on to finish 3 other 100s but wanted to come back and finish this one. I didn’t make the Western States lottery so decided to do this AT.

I trained well, hitting about 480 miles in the 10 weeks of training before my 3 week taper, which is almost certainly a record for me. Strained my hamstring doing 800m repeats during my last hard workout, 22 days before race day. Didn’t run much during the taper, but the hamstring seemed better. Until Sunday, 6 days out when it hurt all the way during my final, easy 12.5 mile run. I was worried all week but it didn’t bother me one bit during the race

Flew to Little Rock, weighed in at 191 lbs dressed, met Tom Watson, my crew and pacer for the last 32 miles, ate at the spaghetti dinner, etc. Tom and I camped with other runners just over 1/2 a mile down the road from the start/finish/headquarters My non-ultrarunning friend Jonathan was planning to drive down Saturday from St. Louis to pace the 19 miles from 48 to 57.

Race Day: The switch to Central Time Zone and relatively late start meant I got a fair amount of sleep. The race starts on some downhill road and I was worried about my hamstring so held back just a little, but it was fine. Then on some good dirt road and I’m moving well, trying to hold back. There is a decent, but not steep climb up to where you start on the Ouachita trail which is fairly rocky single track. The whole race takes place in the Ouachita National Forest. I’m not sure but think Ouachita is a Native American word that means “abundant rocks of all shapes and sizes.”

I ran well here, passing some people who were obviously not very good trail runners (since they were slower than me!). With my ankles having troubled me in other trail runs I spent a lot of time doing ankle strengthening exercises and working on balance and propiroception using a balance board. This really paid off as I ran better and even when I stepped funny or rolled an ankle I pulled out of it quickly with no lasting effects.

I ate 6 pieces of bacon on my way through the Brown’s Creek Aid station at 11.9 miles. Yumm. I skipped a Succeed electrolyte tab figuring I got enough sodium for that hour from the bacon. A few miles later, I briefly passed a woman who was running very well when she stopped to tighten her shoe laces. Since I knew Chrissy Ferguson, who often wins the woman’s race, was behind me, I figured this woman was really doing well. A few minutes later she passed me back when I stopped to pee. It would be the last time I was passed for 80 miles (more on that later).

I got into Lake Sylvia at 16.4 miles in like 3:10 and headed off. The woman, Tracy Thomas was just ahead of me. I thought now that the trail part was done we’d have easy dirt roads (I should have remembered from 8 years ago that are lots of very rocky “roads” (they have little resemblance to anything I’d consider driving on). I noticed it was warming up, but wasn’t too worried yet. I made it down 132C where I’d hurt my ankle last time, and the climb up to Electric Tower. I was able to run down to Rocky Gap, despite all the rocks and passed one guy moving slowly. I wasn’t sure if he’d gotten hurt or was just being careful. Then I ran a long way alone, which is unusual for me.

The course alternates between some pretty rocky stuff and decent dirt road, but there are lots and lots of rocks. I had decided to wear road shoes, but would probably do trail shoes if/when I do it again. The rocks weren’t big and the footing wasn’t horrible, but the cumulative effect just got to me. Coming down Smith mountain I pondered the amount of potential energy converted into kinetic energy and then lost to friction by runners kicking rocks.

I felt a couple of hot spots on my feet (L heel rubbing my shoe and small stone in bottom of R shoe) but, stupidly, didn’t want to waste time stopping. I couldn’t find my gaiters when packing so I went without

When I got to Chicken Gap at mile 46.1, they told me the leader had already gotten to the Turnaround at mile 58 and dropped. Wow, I though, he must have been flying.

I got to Powerline apparently just minutes after Jonathan arrived, having driven all the way from St. Louis. Would have sucked if he’d missed me. The woman who’d passed me 30 miles ago was just leaving as I got in. This section is where I really started to struggle with the heat. Even though I’d lost some weight for the race, I am still big (6’2” and ~190) and just don’t handle the heat very well. It took a while until we saw the leader, who didn’t look great. The woman was flying as she was way in front of me. I passed a couple people near the turn around and figured I was close to the top 10, but didn’t pay enough attention to know exactly where I was (I’m not that into my place which is generally somewhere in the middle).

Jonathan, who had been itching to run at the start, started to tire on the way back to Powerline, even having trouble keeping up with me a bit. He is a road runner and not used to the hills and rocks (although this is one of the gentler parts of the course). He didn’t have a light so I waited a bit for him, but to be honest I didn’t mind as I was struggling a bit too and appreciated the rest. I was amazed to see runners still heading out, calculating they had little chance to finish under the 30 hour limit.

Soon enough we were back to Powerline where Jonathan got some needed fluids and fuel and Tom Watson and I took off. It was dark by now, but hadn’t cooled off like I hoped. We made pretty good pace to Chicken Gap and ran some coming down Smith Mountain. I missed out on some of the famous food by not being in the mood for soup or stew at the right aid station (I never did hear about any burritos) but enjoyed the pimento cheese sandwiches that Mickey Rollins had. I had 1/2 a sandwich on the way out and a whole one coming back.

I started to fade and couldn’t run much of the descent into Winona. I’d expected people to be streaming by me by now, but no one did, not yet. We passed someone else moving very slowly up from Winona and made it to Rocky Gap. The climb out of there went on forever and it seemed there were more rocks than on the way down (maybe the volunteers used the interval between the slower runners on the way out and the leaders coming back to spread out a few more?).

I was, to put it mildly, very cranky from here on in and appreciate Tom putting up with it. By feet were hurting, as were my quads and I was starting to chafe. In addition, I started needing to make frequent pit stops. I’ve never had more than two bowel movements in a 100 miler so this was a new experience. I violated the “no-muling” rule to borrow wipes from Tom once I ran out of toilet paper (you may criticize me as you wish). I stopped maybe 6 or 7 times total, then went about 4 or 5 times Sunday after I was done. Not sure why. I was also very tired despite taking cola at most aid staions (and a “Monster energy drink” or frappacino at each major staion). I’d often close my eyes for 2 or 3 strides at a time to get a rest. The resulting kicked rocks didn’t help my feet feel any better.

We trudged on. I had read you could run the whole way from Electronic Tower at mile 91.4, but I couldn’t run much even on the descent into Pumpkin Patch, and had no taste for pumpkin pie there (although I did have a piece on the way out). 132C is flat to gently downhill, but I just walked on. Now the people started coming by with 4 runners passing me in the last 5 miles. A lot was bothering me now but most of all my breathing really bothered me when I ran. In retrospect I wonder if all the dust from the trucks and SUVs, and the dirt roads in general gave me respiratory problems. I thought I heard some wheezing when I was falling asleep after the race, but didn’t have my stethoscope so hard to say. On Sunday, I noticed I had a cough productive of a bit of yellow phlegm.

I couldn’t even really run the last mile or 2 of gentle downhill on good dirt road once we got off 132C. We hit the pavement, then Lake Sylvia, then power walked the last hill up to Camp Oauchita and the finish. I finally ran the last 50 yards or so to finish in 22:48:50.

Post-race: Tom told me I’d finished 9th, which I could hardly believe, but the heat had gotten to a lot of the faster runners. We drove back to our campground (after I walked right past my rental car, assuring Tom it wasn’t mine) and Tom showered while I wiped off with diaper wipes. We both slept a couple hours before getting up, me showering and heading to the awesome breakfast provided by the race (hotcakes, eggs, many varieties of breakfast meat and grits, a personal favorite). Then we picked up Tom’s car and I went to get my buckle at the awards ceremony (a civilized 30 minutes).

The trip home was okay, but I wondered what people thought about a (relatively) young guy like me walking so gingerly through the airports. Now on Tuesday night, I’m feeling a lot better. I got a massage from my wife last night, which really seemed to help. My feet are pretty ugly, but I’m sure they’ll get better. The big one on my heel is oozing a ton of fluid so I’m having to change gauze all the time. I ate about 5000 calories today including a chocolate croissant in the afternoon and chocolate chip cookie dough ice cream for dinner at desert. I tell myself I need all the calories to recover.

I’m disappointed to not have run faster, or at least finished better, but everyone I know is congratulating me on how well I did. I guess finishing 9th impresses them, but that is probably more reflective of the field than my performance. On the other hand the course was much tougher than I’d expected (tons of rocks); I’m a strong climber but not so good with rocks, so I think it is not a course that plays to my strengths. I’m also a poor hot weather runner, so that hurt me too.

As far as the future, I think I need to recover for a few weeks before I consider what I want to do next. The thing that has me down is that I didn’t really enjoy myself the last 1/3 of the race. I don’t really see the point of going through that again, but in my previous 100s that hasn’t been the case. I guess we’ll just see how I feel in a few weeks.

My understanding is that I’ve qualified for both the 2006 and 2007 Western States (the qualifying period for 2007 started 10/1, conveniently). Since I didn’t make the lottery this year, if I don’t make it for 2006 I’m guaranteed entry in 2007. But before I enter I want to make sure I’m willing to commit to all the training it will entail.

Monday, October 03, 2005

Arkansas Traveller

I finished! 22:48:50. 9th overall out of 75 finishers and 120 starters. It was a tougher course than I expected and I was and am glad to be done.

I'll write more later