Sociable

Monday, June 28, 2010

Unfaithful?

I have a confession.I have been seeking satisfaction elsewhere.

No, nothing like that.

See, for a variety of reasons, I started another blog. It can be accessed from my website, pascalelane.net, or via pascalelane.wordpress.com. Stream of Thought, as I’m calling it, will focus on professional material such as healthcare and diseases. A lot of posts will be geared toward parents and children with kidney disease. See links to my current posts below:

The Biomedical Fair

From Orlando: Improving Your Child’s Future Health

Golden Thoughts will remain for another audience. Humor, wardrobe advice, and other topics near and dear to my heart will have this venue for discussion.

For a few days I will be spending time with my family and not posting at either location. Don’t worry- I’m not fooling around with a third blog.

Saturday, June 26, 2010

Tee-Hee-Hee: Bp Edition

NonSeqHad to crop it to fit my layout, but the essentials remain. Click the image for the full strip.

Thursday, June 24, 2010

Up, Up, and Away

ADA2010
Today I venture to Orlando for the annual Diabetes Meetings. For the next few days communication will be erratic as one thing or another catches my fancy.
Today involves multiple airports. Rest assured that I am efficiently packed with an exquisite collection of appropriate warm-weather meeting clothes. And lovely shoes.
I wonder what Mickey’s background strain could be? C57 Black?

Wednesday, June 23, 2010

Things You Can Learn Online: TSA Edition

Tomorrow I fly again, through the hot muggy skies of Omaha to the hot muggy world of Orlando. As I wait for my flip video camera to upload, I trolled through the TSA site. Omaha’s airport now has one of those fancy imagers. I don’t think it’s on the set of gates I use, but it could be.

So here are potential images from these machines as stolen acquired from TSA:

Images above used backscatter technology; the ones below were generated with millimeter wave:

The images cannot be seen at the screening checkpoint, only at a remote site.

I also learned that my netbook may be screened in its case:

Electronics: Electronics the size of a standard laptop or larger, such as game consoles and full-size DVD players, and video cameras that use video cassettes must be removed from their carrying cases and submitted separately for X-ray screening. Smaller electronics such as e-readers, netbooks and iPads typically do not need to be removed from carry-on baggage for screening.

I have always removed my netbook from the case for screening, but not my Kindle, phone, or iPod. I’m not really clear on why a netbook or iPad can be screened through a layer of neoprene, but a 13” laptop cannot.

My download is almost complete. That’s my cue to go home and pack!

Tuesday, June 22, 2010

Goodbye, Johnny! You Will Be Missed.

CWS

Help! Fearsome Frogs have invaded Omaha!

Once again it is College World Series, Omaha’s annual block party. Last night I saw the TCU Horned Frogs succumb to the Bruins of UCLA. Once the sun set, the evening breeze cooled us in a pleasant way. The evening was lovely, yet bittersweet.

This was the final CWS game that I will see in Rosenblatt Stadium.

The Johnny, as locals call it, hosts its 61st and final CWS this year. The facility is showing its age (aren’t we all?), and it would be nice to see the field of play from the concession area, as in most modern ballparks.

Johnny Rosenblatt was an athlete and local businessman and political figure who brought the CWS to Omaha:

Johnny Rosenblatt (1907-1979) whose name graces this ballpark, played amateur, semipro, and professional baseball before entering a life of public service. He located this hilltop site and pushed for its construction. It opened in 1948, and two years later, attracted the NCAA College World Series. Rosenblatt Stadium has won the hearts of those who have attended the College World Series.
Johnny, ebullient and upbeat, served as mayor of Omaha from 1954 to 1961, but was stricken with Parkinson's Disease in the prime of life. Omaha's Rosenblatt Stadium, also home to the Omaha Royals, has carried his name since 1964. Thanks to the dedication of the city of Omaha and countless benefactors, the stadium has evolved into a representation of what college baseball is all about -- teamwork, dedication and camaraderie.

More about the stadium and its history can be found on the CWS website.

Lots of traditions do not make the cut for the NCAA’s history. Every game, the general admission folks begin to chant “Right Field Sucks” and “Left Field Sucks.” Back and forth the verbal volleys fly, often for an entire inning. Contraband, highly illicit beach balls bounce throughout the stadium, although primarily in these outfield “cheap seats.” Last night, in addition to the occasional ball ponging about, left field got organized in this misdemeanor activity. They managed to keep about 40 inflated beach balls (and one inflated whale) hidden until the middle of the fifth inning. At that point zombie beach balls attacked. THEY WERE EVERYWHERE. Security and ushers rushed to remove errant balls from the field and delayed the game to expell at least two purported masterminds. Frankly, I found it delightful! To organize this crowd of strangers into an inflatable-toy flash mob required an impressive skill set, especially given the amount of beer some had consumer prior to entering the stadium.

A few years back, I bought tickets to the finals at a charity auction. My son, then in middle school, and I were in town without sister or father, daughter or husband. We attended every minute of the 3 game final series, including one which required 45 minutes huddling in the concourse during a thunderstorm. The temperature, about 95 when we entered the Johnny, dropped to 70. The souvenir shop sold out of sweatshirts in about 10 minutes. I did not rush to leave, even though I had to work the next morning. We stayed so he could see the victory dog-pile when the Oregon State Beavers claimed their title. My dedication to baseball during that series impressed my son, possibly more than anything I have else I have done. RoadtoOmaha

I understand the shortcomings of Rosenblatt. The CWS deserves a shiny new facility, although I wish it would still bear the name of the man who brought this event to Omaha, rather than the corporation who paid for naming rights. They can move the “Road to Omaha” statue there, but it won’t be the same.

Goodbye, Johnny. I’ll always love you.

Friday, June 18, 2010

From Sex and the City to Animal Farm: Voices of Women

This week brought aggravation. Not just the I’m-on-call-and-everybody-wants-a-piece-of-me-now stuff, but a lot of committee meetings. As I sat through these “events” I felt angry.
I am not opposed to what we were discussing; much of it makes a lot of sense. So why did I want to shout “No,” and do a Diva-stomp out of the room?
I finally figured it out. For several years I have wanted to make our section better, starting with another faculty member. A salary line received approval a few years back, but we were not allowed to recruit. Even when we confirmed increases in our patient volumes, we were told to wait, to be patient, to be team players. For years our opinions and desires have been ignored or minimized.
Now, a lot of other people are telling us what we must do. They don’t necessarily listen to our input, even when it might be in a patient’s best interest. They have their own agenda, and if we are in the way, well, too damn bad.
Animal Farm We have lost our voice. This theme recurred throughout Sex and the City 2: Miranda’s new boss, Carrie’s bad book review, and the veiled women of the middle east. All literally or symbolically suffered a blockade of their mouths.
I wonder if this could have anything to do with the composition of our section; after all, we are two women. Would a group of men be this disenfranchised? Ever?
In Animal Farm, society initially regulates itself by the Seven Commandments, summarized as all animals are equal. By the end of the book, the powers in charge have changed the most important commandment:
Yup, I know how they feel. My section, my specialty is definitely less equal these days.
And it’s damn irritating. Maybe I should practice my Diva-stomp.

Thursday, June 17, 2010

Sorry I Have Not Written

card deck 2

Change is the only constant.

The week proved more interesting than I hoped.  Anger and irritation dominated my thoughts the past couple of days, gnawing through my best intentions.

While such a situation can produce much blog fodder, a coherent post requires more self-indulgent rumination about, well, everything. I need a few days removed, a bit more perspective.

In other words, what I thought about writing… I’m not. At least not today.

My online life will be undergoing reorganization soon. Don’t worry; I will still spew Golden Thoughts.

So stay tuned; the best may be yet to come.

Image courtesy of PhotoXpress.

Tuesday, June 15, 2010

Ethical Doctor Blogging

PalMD (of the White Coat Underground) tweeted a link to a 2008 post calling for a code of ethics for MD blogging. A study under review showed:

17% of the blogs include enough information for patients to identify themselves or their physicians

I occasionally blog stuff inspired by my patients. I never worry that they will identify me- if they don’t, I would be really worried! I use my real name and image, after all.

Anonymous Most of the time I am blogging a condition, such as volume overload or neonatal hypertension. While these posts may have been inspired by one or more in my care, the posts reviewed the conditions; no patient data of any sort were shared!

Could my patients identify themselves from my posts? A number of parents of hypertensive neonates probably believe their child inspired me to put fingertips to keyboard, but they cannot tell from that post. Only one post comes to mind in which the patient concerned would know for sure it came about because of him: the post on Page kidneys. Given the date of the post, the few vague items presented, and the fact that this patient knows he has the honor of being the first and only patient I have treated for this condition, he would figure it out.

I do not feel this post is unethical. Only someone who knows this person’s diagnosis and that I am his doctor can identify the patient. If they already know that much about him, they will learn nothing new from the post! The pathophysiology of Page kidneys, not the patient, remains the focus of the blog.

I would never try not to moan about inappropriate or inconvenient patients in a public forum. All physicians have “war stories” that we share; this blog is not the time or place. Occasionally I write about colleagues when either (1)I do not care if they read it and know it is about them; or (2) I have no clue who it is. Either way, no ethical issues apply. These situations are like complaining about jerks in traffic.

I have to go see a patient now. I am not going to say who, where, or what, though. And this kid will never know s/he inspired my closing today!

Image above is my daughter about 20 years ago. No patients were compromised in the creation of this post.

Monday, June 14, 2010

Saturday Night at the Movies

Over the weekend I finally saw Sex and the City II. Clearly, this flickSATC2 targets me, a huge fan of the original show. The movie also touched on issues discussed in the blogosphere last week.
Charlotte, at the end of the first movie, held her newborn daughter. Rose has now moved into the “terrible twos,” and Charlotte is overwhelmed, even with a full-time nanny. The nanny, a young hot Irish woman, eschews certain items of lingerie; she becomes “Erin Go Braless,” as a result. When first we meet Ms. Erin, Samantha suggests Charlotte should keep an eye on her husband around the nanny.
Crying
Between Rose, who cries and fusses constantly, and Lily, her adopted daughter, Charlotte has her hands full (although why she tries to ice cupcakes in a cream-colored vintage Valentino pencil skirt is beyond my understanding). After the action moves to a luxury resort in the middle east, Charlotte and Miranda, the other mother in the group, commiserate about raising kids. Charlotte’s big confession? When Samantha said something about her husband and the nanny, her first thought was, “Oh my god, we can’t lose the nanny!” Remember, Charlotte stays at home with the children and has full-time help.
These mothers have not forgotten that they are wealthy and have excellent support. Their assets do not keep them from feeling overwhelmed by caring for their offspring! They cannot figure out how women do it without their resources – and finally they drink a toast to those moms.
Miranda finds herself “between jobs” at this point in the  movie. She makes another confession in this scene. Although she loves her son more than anything in the whole world, she misses working. She is a lawyer, and she wants to retain her sense of herself. Motherhood and her career are both parts of her, and neither should be excluded from her life.
I remember when my son was born; he also fussed a lot, and he slept no more than 2 hours at a stretch for the first 3 months of his life. I sent his older sister to daycare (we had to pay for it to keep her spot), even though I was on leave. I do not know how all of us would have survived if I had her at home, waking me up every time I finally got Tim to doze.
Later that night, I toasted all those moms who raise kids without my resources- I don't know how they do it!
My 22-year-old daughter accompanied me to the movie; she turned to me as the lights came up and said that it was worth every minute and every penny we spent on it. “And I know you have blog ideas for the next week or so.”
Yup. Stay tuned.
Click on photos to see on original sites.

Saturday, June 12, 2010

Guess This Lesson Didn’t Stick

My friend, Dr. Isis, raised some hell over on ScienceBlogs last night, suggesting that – gasp – men may need to should do their fair share of the housework! It may be Mr. Clean, but we can tell who really uses those products-MrClean I know that this concept is still a a pipe dream for most women; I am, after all, the person who arranges the home appliance repairs, the housekeeper, the veterinarian, and the sports physicals (even, sometimes, when I am in a different time zone from my spouse).
The post did tickle some synapses and bring a poem from Free to Be You and Me to mind. Below, I present Housework, originally read by Carol Channing. Lyrics here were shamelessly cut and pasted from LyricsZoo.

Housework

You know, there are times when we happen to be
Just sitting there, quietly watching TV,
When the program we're watching will stop for a while
And suddenly someone appears with a smile,
And starts to show us how terribly urgent
It is to buy some brand of detergent,
Or soap or cleanser or cleaner or powder or paste or wax or bleach,
To help with the housework.
Now, most of the time it's a lady we see,
Who's doing the housework on TV.
She's cheerfully scouring a skillet or two,
Or she's polishing pots till they gleam like new,
Or she's scrubbing the tub or she's mopping the floors,
Or she's wiping the stains from the walls and the doors,
Or she's washing the windows, the dishes, the clothes,
Or waxing the furniture till it just glows,
Or cleaning the fridge or the stove or the sink,
With a light-hearted smile, and a friendly wink,
And she's doing her best to make us think
The her soap, or detergent or cleanser or cleaner or powder or paste or wax or bleach,
Is the best kind of soap, or detergent or cleanser or cleaner or powder or paste or wax or bleach,
That there is in the whole wide world.
And, maybe it is, and maybe it isn't,
And maybe it does what they say it will do,
But I'll tell you one thing I know is true.
The lady we see when we're watching TV,
The lady who smiles as she scours or scrubs or rubs or washes or wipes or mops or dusts or cleans,
Or whatever she does on our TV screens,
That lady is smiling because she's an actress,
And she's earning money for learning those speeches
That mention those wonderful soaps and detergents and cleansers and cleaners and powders and pastes and waxes and bleaches.
So, the very next time you happen to be
Just sitting there quietly watching TV,
And you see some nice lady who smiles
As she scours or scrubs or rubs or washes or wipes or mops or dusts or cleans,
Remember, nobody smiles doing housework but those ladies you see on TV.
Your mommy hates housework,
Your daddy hates housework,
I hate housework too.
And when you grow up, so will you.
Because even if the soap or cleanser or cleaner or powder or paste or wax or bleach
That you use is the very best one,
Housework is just no fun.
Children, when you have a house of your own,
Make sure, when there's house work to do,
That you don't have to do it alone.
Little boys, little girls, when you're big husbands and wives,
If you want all the days of your lives
To seem sunny as summer weather,
Make sure, when there's housework to do,
That you do it together!
Free to Be You and Me now has a 35th anniversary edition in print. I guess some many of its lessons didn’t get learned.

Friday, June 11, 2010

Have A Good Weekend

Abstract 3D HourglassI will be on call the next couple of days and may not take time to blog. After back-to-back business trips, a few piles of laundry call out for my attention as well. Oh, yeah, I have to work at a baseball game tonight and perform parental duties.

If you haven’t seen it yet, head on over to The Scholarly Kitchen for a 10 minute video on the power of time perspectives. The real-time drawing is cool on its own; the information presented raises the cool factor to ice!

What are you waiting for? Click the link already!

Image courtesy of PhotoXpress.

Thursday, June 10, 2010

Why I Read Non Sequitur

NonSeq10June

NonSeq10June Can’t add much to this one. I certainly have no desire to return to the days when, as a woman, I was less than a person.

I just wish “non sequitur” were easier for me to spell!

Tuesday, June 8, 2010

From Cowboys to Equity: Children in Clinical Trials

Today’s post presents the challenge of writing when beach and ocean lie just across a boulevard. Yours truly sat in a subterranean conference room all day, learning about a clinical trial protocol, while the paradise that is beachfront Fort Lauderdale beckoned. The group of kids playingtribulations I endure for my patients!
Events such as this were distinctly uncommon in years past. Today we will stroll through a brief history of pediatric clinical trials in the United States. After this walk in the woods of regulatory affairs, you will agree that my current endeavor amazes!

 

All about white males

For a long time, medical care and clinical experimentation had no regulation! Children were subjected to experimentation without consent or assent during this time, as were adults. The best history of the evolution of clinical research regulation can be found in The Immortal Life of Henrietta Lacks (which I previously reviewed). Over the years, the public demanded better protection for human research subjects; vulnerable populations, including women, children, prisoners, and the mentally incapacitated, presented special problems for enrollment. Women could become pregnant, resulting in an “adverse event” with a fetus, perhaps yielding death or life-long disability, a risk not many drug companies are willing to bear. Most children enjoy good health, so marketing chronic medications to them provides little financial benefit to a drug company (certainly not enough to justify study as required by regulatory bodies). Thus, through the 1970s, women and children had few studies performed, aside from drugs directed specifically to their group.
Ethnic and racial minorities presented other challenges (once again, see the HeLa book for more discussions; I can't imagine why you haven't read it yet, really). Investigators often excluded minorities because a large enough population could not be recruited in any study to make the confounding variables worth examination. So most clinical trials included only white men.
In 1983, the NIH adopted a policy requiring inclusion of women and minorities in clinical research, particularly phase III clinical trials, a policy made law in 1993. You could still exclude women or minorities (for example, you would not include women in a prostate study), but you had to have a really good reason if you wanted federal funding. As a study section participant for the Veteran's Administration, I know many of their studies exclude women and children because they simply are not available in the VA population. Participating in research was redefined as an opportunity that could not be denied at the whim or convenience of an investigator.

What about kids?

Children took more time, in part because a paternalistic attitude seemed more appropriate to offspring. In the 1990s, some patent extensions became available for testing in pediatric age groups. The Pediatric Pharmacology Research Units (PPRU), 13 sites coordinated by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), proved that children could participate in pharmacologic research. Based on success with the PPRU, the NICHHD gained additional powers with the Best Pharmaceuticals for Children Act (BPCA), initially signed into law in 2002. Almost 2 years later, the Pediatric Research Equity Act became law, requiring pharmaceutical companies to provide timelines for pediatric testing or request a waiver or deferral if appropriate. [Note: if you search for PREA on Google, at least the first 2 pages of results are various Prudential Realty groups or the Prison Rape Elimination Act; spell it out if you search to learn more] Children could no longer be ignored because their market was small; pediatric use had to be considered by companies preparing new agents.
Congress amended the BPCA in 2007 to increase the scope of NICHD’s responsibilities. Specifically, the institute was granted power to identify gaps and needs in the pediatric therapeutic armamentarium and to target studies to those areas.
A flurry of studies in the 1990s (of drugs we already used) has proceeded to prospective planning of pediatric clinical trials, thus, my presence near the sandy shores of Fort Lauderdale.

How did we test drugs before?

About 1500 children develop chronic kidney disease in the US each year; obviously, this number does not provide a viable market for most drug companies to develop and test an agent. How did we get agents to treat these children before the present day?
  1. A new drug would be approved for adults.
  2. The pediatric nephrology “cowboys” would try it in bigger patients (you know- those early adapters who will try anything); if nothing bad happened, they would use it in smaller kids, especially if the pharmacy could cook up a liquid formulation.
  3. Those of us with a bit more caution would have a patient where we really needed to use the drug; we would contact our “cowboy” friends to see what they had learned about dosing.
  4. Eventually, enough of us would use it that it was generally accepted; someone might even publish dosing guidelines based on their empirical use.
We generally got away with this approach. Of course, a lot was learned through trial and error rather than really scientific study. Many drugs used once daily in adults must be given twice daily in kids. We don’t really know if this reflects less absorption, faster metabolism, or some of each, because we have no pharmacokinetic/pharmacodynamic data, just our clinical observations.

Testing now

The drug in the present study, aliskiren, directly inhibits the enzyme renin. It is the first drug in its class, and the pediatric studies have been prospectively planned. We used to believe that angiotensin II (AngII) was the only active component of the renin-angiotensin-aldosterone system. As shown below, we were wrong!
NotYourMamasRAASVarious components of the system have their own receptors that may induce beneficial or detrimental effects. Our present agents inhibit ACE, preventing AngII formation, or block the AngII type 1 receptor. Both of these approaches increase renin via a feedback loop. We now know it has its own receptor, and elevated renin could produce fibrosis and hypertrophy, both detrimental to the kidney and other organs.
Aliskiren reduces renin and AngII. The current trial will examine its efficacy and safety in children with hypertension, but I foresee a role for this drug  in many chronic kidney disease situations. It also cheers me to know that we are testing children with this agent as we should, even though the studies required are complex and expensive.
I’m sure some of my “cowboy” friends have already used this drug in their patients. I am happy to help provide data to do these studies the right way. Yes, a PHARMA company will make some bucks off of this effort; but we will have a novel therapeutic agent for children.
Image of children courtesy of PhotoXpress.com.
Image of renin-angiotensin system courtesy of Pamela Carmines, PhD.

Monday, June 7, 2010

Finally: Homeopathy for the Kidney!

I am seriously considering a homeopathy web start-up.

See, a bunch of my friends have recently “passed” kidney stones. Really, “passed” is too gentle a term for what these small but mighty gravel bits inflict on their hosts.

Now, based on the composition of the stone and/or analysis of what a person excretes in their urine, we have a number of therapeutic options to prevent stone recurrence. But the mainstay of all therapy remains water. Lots and lots of water. The more water is in the urine, the less likely other molecules are to come together and rock on.

So, you take a stone (or, if you can’t get it when it passes, substitute a garden rock) and put it in your drinking water. The teensiest bit of it will then be in the water. Drink 3 or more quarts of this liquid each day, and your stone formation will decrease dramatically.

When I searched kidney stones and homeopathy earlier today, Google found more than 3 million sites. Most of these would love to separate you from your hard-earned cash. I have just given you an excellent, nephrologist-certified homeopathic kidney stone preventative FOR FREE.

If this tonic fails to prevent stones, please see your doctor. You may have a more serious disorder requiring different treatments. Don’t worry- they will continue to encourage this “natural” remedy (albeit without the stone or rock).

Image from Wikipedia Commons.

Friday, June 4, 2010

I Heart Word Clouds

As a visual person, I love both written words and images. Books-on-CD will never cut it for me. Word Clouds make me smile. Wordle, my favorite word cloud site, will let you create clouds from any web site with an RSS feed.

Today’s image comes from the wisdom of Dr. Isis:IsisWordCloudI really thought other synonyms would trump “penis,” if nothing else from their inclusion in “cockweaseldouchemonkey,” athough that appears to be a single word. Enjoy!

Thursday, June 3, 2010

Serving with Pride

VA

Once again I write my update from the Omaha Airport. Today I fly to Washington, DC, for a study section for the Veteran’s Administration research program. Physicians and scientists with appointments to a VA hospital can apply for grants to support research that betters the lives of veterans. Since veterans are generally people, much of this work will benefit everyone.

The process began several months ago with an email. I had finished a regular term on this study section last May, but they needed me again for the session tomorrow. Over the next couple of months I signed agreements about confidentiality, ethical conduct, and travel reimbursement. I then received a spreadsheet with information about who submitted a proposal and what it was about. Based on that information, I could declare a conflict if I had collaborated with someone on the grant. I could also indicate applications I really wanted to review and those that I did not wish to consider. About 2 months ago I received my assignments and the current scoring guidelines.

I generally read all of my applications through once for a general feel about them; you might be surprised how well this first impression correlates with the final score generated by the group! Then I read each in more detail and evaluate each of the following areas:

  • Significance: Does the study address an important problem? If not, then why should limited resources go to it?
  • Approach: Will the proposed experiments address the problem? Are they the best way to address the problem?
  • Innovation: Are the studies novel, or do they merely replicate earlier work?
  • Investigators: Are the investigators well-trained and capable of performing the experiments based on their prior accomplishments?
  • Environment: Does the VA Hospital and associated university have the facilities necessary to perform the studies?
  • Feasibility: Can this be done? Photoxpress_2973759
  • Overall Evaluation: Will the proposal lead to important new knowledge? Do its significance and strengths outweigh any identified weaknesses?
  • Ethical/Safety Issues: Could anyone be harmed by these studies? Have appropriate institutional oversight procedures been followed?

After writing up each of my assignments, I then assigned them a score from 1-5 using defined criteria. Three of us reviewed each proposal and posted our scores and critiques on line. On some of them, all three of us gave nearly the same score; others have a bit of spread that will have to be resolved when we discuss them face-to-face tomorrow.

Study sections can be inefficient and unfair, but thus far they are the best system we have for doling out limited funds. I am proud to participate.

I hope the people reviewing my current proposal today and/or tomorrow feel as positive as I do right now.

Piggybank image courtesy of PhotoXpress.