Friday, October 7, 2011

Happy Birthday, Grader Boob!

J'ai passé une nuit blanche.  No surprise there.  The good news is that I completed all the forms necessary for my continued receipt of the big monies.  No, that stretched and screaming envelope has NOT been mailed or otherwise transferred from my sticky fingers to my insurer's cold claw.  I plan to weasel my way into Fred's Good Graces so that it gets dropped into the appropriate mail box -- as soon as The Fredster wakes up.

[He did NOT pass a white night, sleepless.  He did, however, only wish me a good evening at 4 am, before stumbling in the direction of the closest uninhabited Guest Wing.  Sometimes we sleep where the Manor tells us to -- She murmurs "Gargoyle Alley," and off we go -- She suggests the Paisley Pavilion, and you grab your favorite pillow, because those suites were meant more for play than rest, and the Brother Monks like to make semi-permanent forts out of bolsters and piled mattresses (with Abbot Truffatore carefully packed in their centers).]

Despite lacking the clarity that comes from sleeping, I was pretty darned focused. I think I ate every 10-15 minutes, following a free-wheeling menu ranging from scorched Kettle Korn, apples, a peach, yogurt, and cauliflower to rye toast.

I had a fit of laughter when I spotted a carefully dated frozen washcloth that I'd folded inside a plastic bag to serve as a cold compress for my future aching head.  Fred had placed it on a plate inside the fridge -- to defrost, I guess -- and had affixed this query:  What *is* this?  Clearly, he thought something fuzzy, green, and out-of-date had no place inside his freezer.

Anyway, due to a resultant blood sugar in the one bazillion range, my vision is a mess.  That'll clear up once I take my 9 million units of insulin.

The way the story goes, I don't "really" have diabetes.  Oh, no.  That would be too simple.  I have "steroid-induced hyperglycemia," or, as the nurses in the hospital deigned to call it:  Diabetes.  The "steroid" part is only important when NOT being formulaic about insulin -- for example, on a day where my steroid consumption will be decreased.  In that case, it's important that I not be loaded up with the usual dose of long-acting insulin, since my blood sugars will be lower in the absence of prednisone or hydrocortisone, or whatever.  Given that infection also causes blood sugars to rise, no one is convinced that I have the dread diabetes, but I still end up testing 3-4 times a day and injecting insulin or scarfing down glucose, depending on the results.  It's crazy.  MDVIP Go-To-Guy is more fearful of me dying via hypoglycemia than he is concerned about the myriad symptoms caused by high blood sugars... try explaining that to a classically trained nurse-type person.

I have a point, and that point is that I started jonesing for cake, sometime after the yogurt and before the peach.

Cake made me think of birthdays, and that reminded me that today belongs to Grader Boob:  Happy Birthday, Grader Boob!

When last we heard from our intrepid Educating Hero, a mere two days ago, he was whining:

Have 84 papers -- Rogerian arguments all -- to grade in preparation for conferences next week. Papers and conferences -- I truly am in Hell! They get a week off from class and have to see me for a 10-minute period, while I get to say the same thing 84 times.But that's why we earn the big bucks.
I hope his students know about the "no contact" rule on birthdays.

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Thursday, October 6, 2011

Never, Disambiguated

I am cutting it close!

If ever you've wondered how Fred and I are able to afford such a luxurious lifestyle, here's our secret:  We live on 60% of my salary (frozen at its lofty 2001 level with nary an adjustment for pesky details like "costs of living in A Manor") and have expenses that exceed that amount by 127% (excluding some medical debt that would be economically lethal to consider as actual money owed).

We've saved beaucoup bucks thanks to our dedicated squatting here at Marlinspike Hall, an endeavor that was envisioned as a convenient feet-propped-on-a-plush-leather-ottoman kind of thing but that turned out, as my dedicated readership knows, to be more of a trompe l'oeil affair, in which lazy leisure is the trick.

To push the edge of the tattered brown envelope, our anxious virtuosity is less Magritte's crisp "lucid dreaming," being infinitely more in keeping with his "alleged" forgeries.

I don't mean the kind of cleverness involved in faking one's own work ("to raise cash"), the assumptive motivation behind the existence of two Flavour of Tears:

Courtesy of Online Tate
No, I am referring to the outright, intentional theft of someone else's work, be the thievery clever or not.  Specifically, I citMarcel Mariën's claims to have sold numerous forged Picasso, Klee, Leger, De Chirico, and Renoir on Magritte's behalf in the 1940s -- none of which were "pipes," none of which were parody or illustrations of subversion.

Yeah.  Well.  My blurry vision informs me that Mariën’s pretension was culled from "La Reproduction Interdite: René Magritte and Forgery" by Patricia Allmer, a piece published in Papers of Surrealism, Issue 5 Spring 2007.  She is referencing, of course, Marcel Mariën’s autobiography, Le Radeau de la mémoire.

But we're not worms in the apple, Fred nor I, nor our entourage of Tintinistes, felines, and local-yokels:
We live in, and among, the Haddock family's ancestral home and holdings in Tête de Hergé (très décédé, d'ailleurs) but it is definitely luxury beyond what we cannot afford, so we tend and maintain it, following The Captain's orders and philosophies.

La Bonne et Belle Bianca Castafiore stays here under the same sort of understanding, though her opera career cuts back on the amount of damage she can inflict on Manor property.  She's proving, however, to be a reckoning force in the development of the Haddock's Detox and Rehab facilities, as well as their Best and Most Frequent Flyer.

It would be nice if we could get Bianca to understand the concept of "paying it forward," but we may forever be working on that slippery notion of "paying it back."  In the Fullness of That Which is The Castafiore, she has mal-adapted a behavior that covers both of these ideas, a cheerful, warbled version borrowed from Chapter Two of The Adventures of Tom Sawyer:

"Hi- yi ! You're up a stump, ain't you!"

No answer. Tom surveyed his last touch with the eye of an artist, then he gave his brush another gentle sweep and surveyed the result, as before. Ben ranged up alongside of him. Tom's mouth watered for the apple, but he stuck to his work. Ben said:

"Hello, old chap, you got to work, hey?"

Tom wheeled suddenly and said:

"Why, it's you, Ben! I warn't noticing."

"Say -- I'm going in a-swimming, I am. Don't you wish you could? But of course you'd druther work -- wouldn't you? Course you would!"

Tom contemplated the boy a bit, and said:

"What do you call work?"

"Why, ain't that work?"

Tom resumed his whitewashing, and answered carelessly:

"Well, maybe it is, and maybe it ain't. All I know, is, it suits Tom Sawyer."

"Oh come, now, you don't mean to let on that you like it?"

The brush continued to move.

"Like it? Well, I don't see why I oughtn't to like it. Does a boy get a chance to whitewash a fence every day?"

That put the thing in a new light. Ben stopped nibbling his apple. Tom swept his brush daintily back and forth -- stepped back to note the effect -- added a touch here and there -- criticised the effect again -- Ben watching every move and getting more and more interested, more and more absorbed. Presently he said:

"Say, Tom, let me whitewash a little."

Tom considered, was about to consent; but he altered his mind:

"No -- no -- I reckon it wouldn't hardly do, Ben. You see, Aunt Polly's awful particular about this fence -- right here on the street, you know -- but if it was the back fence I wouldn't mind and she wouldn't. Yes, she's awful particular about this fence; it's got to be done very careful; I reckon there ain't one boy in a thousand, maybe two thousand, that can do it the way it's got to be done."

"No -- is that so? Oh come, now -- lemme just try. Only just a little -- I'd let you , if you was me, Tom."

"Ben, I'd like to, honest injun; but Aunt Polly -- well, Jim wanted to do it, but she wouldn't let him; Sid wanted to do it, and she wouldn't let Sid. Now don't you see how I'm fixed? If you was to tackle this fence and anything was to happen to it -- "

"Oh, shucks, I'll be just as careful. Now lemme try. Say -- I'll give you the core of my apple."

"Well, here -- No, Ben, now don't. I'm afeard -- "

"I'll give you all of it!"

Tom gave up the brush with reluctance in his face, but alacrity in his heart. And while the late steamer Big Missouri worked and sweated in the sun, the retired artist sat on a barrel in the shade close by, dangled his legs, munched his apple, and planned the slaughter of more innocents. There was no lack of material; boys happened along every little while; they came to jeer, but remained to whitewash. By the time Ben was fagged out, Tom had traded the next chance to Billy Fisher for a kite, in good repair; and when he played out, Johnny Miller bought in for a dead rat and a string to swing it with -- and so on, and so on, hour after hour. And when the middle of the afternoon came, from being a poor poverty-stricken boy in the morning, Tom was literally rolling in wealth. He had besides the things before mentioned, twelve marbles, part of a jews-harp, a piece of blue bottle-glass to look through, a spool cannon, a key that wouldn't unlock anything, a fragment of chalk, a glass stopper of a decanter, a tin soldier, a couple of tadpoles, six fire-crackers, a kitten with only one eye, a brass door-knob, a dog-collar -- but no dog -- the handle of a knife, four pieces of orange-peel, and a dilapidated old window sash.

He had had a nice, good, idle time all the while -- plenty of company -- and the fence had three coats of whitewash on it! If he hadn't run out of whitewash he would have bankrupted every boy in the village.
Yes, so some days Fred and I marvel along with a snickering Domestic Manor Staff as various visiting Baritones and Tenors, interspersed with the odd Contraltos, have taken up feather dusters or been seen hauling firewood or mucking out horse stalls -- each and every one with such an air of satisfaction that we've ceased to query The Castafiore on her methods.

Anyway, as I said at the outset, I am cutting it close.

The various formulas and barters that complicate life as a Working Squatter sometimes feel like more of a cognitive confusion than a rich system of interconnectivity.  I get turned around, disoriented.  And scared.  I mean, there's a good number of good people who depend on me and my attempts to preserve and extend the aforementioned 60% of a frozen salary.

Even though Captain Haddock has provided netting in the event of my total fiscal collapse, we have needs that escape the understanding of Tintinistes -- like insurance coverage, for instance.

I will explain -- AGAIN -- how it is that Fred and I are not immune to disease like the vast majority of Tête-de-Hergéens.  Simply put, because we entered the country in an unusual way -- via The Captain's miniature submarine, The Schvitz, with its patented Corkscrew Technology -- we were not subjected to the curative BioHasard Filter normally employed on immigrants.  Hence, we've needed to maintain our health insurance, even when doing so ate up 97+% of that famous aforementioned 60% of a frozen 2001 salary!

Since 2001, this private disability insurance has kept us afloat, although the occasional wave of tepid moat water does wash up my quivering nose.  And, with this private disability insurance, I purchase private health insurance, as I, the Resident Socialist, am not eligible for state-sponsored disability coverage.  That's right... I am totally and permanently disabled, but because the majority of my working life was spent in universities, few of which pay into the Social Security systems, I lack sufficient "work credits" to receive anything resembling state-administered disability income.

I know what you are thinking, Friend.  Something like:  "Well, then, they had to have paied into a pension plan on your behalf, so stop whining, Profderien!  Stop this mad shell game, Retired Educator!  'Fess up and show us the money!  I mean, didn't I read that she drives a 2008 Honda CR-V?  Equipped with a motorized wheelchair lift, too!"

Oh, chill.  Of course I tried to recoup the millions stashed in various pension plans under my illustrious name, thinking to create a dandy little Health Savings Account ("tax-advantaged"!)  because that would solve everything! 

{attempts::to::chuckle, failed}

Here's the punchline to that joke:  In order to get one's pension money, one must be vested, and usually one must be vested to the tune of five - seven years.

Guess who was enjoying a life of living-here::living-there, studying with this Famous Person on the West Coast, struggling under these Over-Inflated Egos of the Eastern Seaboard?  The idea that I needed to stick with any one university long enough to be able to access my pension just did not register in my conscious mind.  

"Employers use this strategy to promote loyalty.  Employees do not want to leave free money on the table, so they may not want to leave the employer." {guffaw}

So, yes, there are two large, well-known universities that owe a small measure of their financial health to having bilked me of my benefits.

You can see that the aforementioned 60% of a frozen 2001 salary assumes more and more importance in our world.

Cutting it close: I believe I've mentioned that tendency of mine before.  Okay, so perhaps I tend to project the blame for all procrastination onto Sweet Fred, since he suffers from ADHD, and I, well... I do not.

Except when it comes to filling out the paperwork from my private disability insurer in order to update them about my progress as a completely useless, worn-out, debilitated, and totally gimpified person.

They cram this stuff down my throat every THREE years or so!  I mean, Jeez, give a person a chance to breathe, would 'ya?

The paperwork to be completed arrived six weeks ago.  It is due tomorrow.  Technically, I can turn it in whenever, but they did make the terroristic threat that failure to get it in by tomorrow might result in an interruption of my benefits.  Harrumph.

The most important part has been done, and was done within a week of the request:  the Attending Physicians Disability Status Update.  I was thinking that my MDVIP Go-To-Guy Doctor would need time for reflection and careful consultation of his notes, so Fred and I zipped it out to him right away.

He filled it out in front of me.  At one point, he giggled.  As I began to explain where he could fax the completed forms, he handed them back to me, in triplicate, notarized -- all done.

The remaining sections contain such thrilling morsels as medication lists, hospital admission dates, specialists' names and addresses, and my sworn testimony that I am not on anyone's payroll.

I've kept Go-To-Guy's portion carefully tucked away in a crisp, white envelope.  I was hoping to stave off curiosity and just toss it into the final mix when my sections were finished.  I mean, what could he say that would be news to me, anyway, y' know?

So here I am, febrile again, dripping all over the laptop, headache raging, bones screaming, facing a deadline that can no longer be avoided.  And, of course, instead of dedicating myself to the 15 minutes worth of writing required to finish this task, the only thing worth doing, suddenly, is perusing the Physician's Status Update.

The first thing I notice is that he's knocked off a good 20 pounds on my weight.  What a nice man!  The second thing that jumps off the page is that, next to my diagnosis, he has written "Severe," with an exclamation mark.  Underlined.

I figure that his giggling episodes must have been triggered by the Functional Capacity, because this Fool of a Medico went crazy with notations and equivocations.  I have a 1-33% ability to push/pull with my dominant hand but 0% ("Never") in the other, for instance.

I have 0% ("None") ability to CLIMB but a confusing 1-33% ability to TWIST/BEND/STOOP.  Even more disconcerting, though, is that my twisting/bending/stooping is matched by my 1-33% ability to OPERATE HEAVY MACHINERY.  What the heck?

The very next line asks about current restrictions, which he begins to answer by writing: "Do not operate heavy machinery..."!

Okay, so I was finally laughing along.

Then, as I was checking that he spelled his own name correctly, my eyes fell on the last nugget of information they needed.

Q:  "When do you expect improvement in the patient's functional capacity?"
A:  "Never."

Except that it looked more like "Neve." The final R is there, but it looks as if his pen might have fallen out of his hand, or slipped on the page, somehow.

If they cut off my benefits or some other nasty deed, it's gonna be because of his bad penmanship, not because I didn't rush to make sure they knew I was such a diamond in the rough.

Wikipedia has the following disambiguation information for the word neve:

  • Neve (band), American pop rock group, 1997-2001
  • Neve (titular see), former Roman Catholic diocese in Arabia
  • Neve, Hebrew word for oasis, first word in the name of several settlements in Israel
  • Névé, young, granular type of snow which has been partially melted, refrozen and compacted

Wednesday, October 5, 2011

From Case Reports to Disinhibition: CRPS Odds and Ends

It's been a day of music and a kind of leisure.  It seems appropriate to top the hours off with a bit of light housekeeping:  Here are a few of the research article abstracts that are piling up around here. [I would say that the waste of redundant hard copies gather dust in the corners... but I can't fool you.  You know that Computer Turrets don't have corners!]

There is nothing earth-shattering, just the train-train quotidien of progress.  So long as we have that dull, repetitive noise as a lazy day soundtrack, we're okay.

For today's lazy day, that's fine.  Come tomorrow?  Maybe we can step it up a bit, eh, you scientist types?

Tease a little more information from those short fibers (Destined for Ganglia!)!

Add the Ketamine to the Propofol, whaddaya get?  Ketofol!

[Will my insurance cover Deep Brain Stimulation, do you think?  The At Home version?  I've had about enough of this tw-tw-twitching... Shouldn't be that hard to sink a few carelessly modified TENS leads into the old gray matter, then hook those babies to the ramped-up three-phase step-down transformers that Fred mounted between the two utility poles in back of the barn...  Don't worry, we'll carefully document our results and protocols.  The ABSTRACT ought to be ready to go by the weekend, pending publication in the October DIY CRPS Revue.]

Efficacy of Outpatient Ketamine Infusions in Refractory Chronic Pain Syndromes: A 5-Year Retrospective Analysis

Patil, S. and Anitescu, M. 
(2011), Pain Medicine. doi: 10.1111/j.1526-4637.2011.01241.x

Objective.  We evaluated whether outpatient intravenous ketamine infusions were satisfactory for pain relief in patients suffering from various chronic intractable pain syndromes.
Design.  Retrospective chart review.
Setting and Patients.  Following Institutional Review Board approval, we retrospectively analyzed our database for all ketamine infusions administered over 5 years from 2004 to 2009.
Outcome Measures.  Data reviewed included doses of intravenous ketamine, infusion duration, pain scores on visual analog scale (VAS) pre- and post-procedure, long-term pain relief, previous interventions, and side effects. All patients were pretreated with midazolam and ondansetron.
Results.  We identified 49 patients undergoing 369 outpatient ketamine infusions through retrospective analysis. We excluded 36 infusions because of missing data. Among our patients, 18 (37%) had a diagnosis of complex regional pain syndrome (CRPS). Of the remaining 31 (63%) patients, eight had refractory headaches and seven had severe back pain. All patients reported significant reduction in VAS score of 5.9 (standard error [SE] 0.35). For patients with CRPS, reduction in VAS score was 7.2 (SE 0.51, P < 0.001); for the others, the reduction was 5.1 (SE 0.40, P < 0.001). The difference of 2.1 between groups was statistically significant (SE 0.64, P = 0.002). In 29 patients, we recorded the duration of pain relief. Using the Bernoulli model, we found (90% confidence interval) that the probability of lasting pain relief in patients with refractory pain states was 59–85% (23–51% relief over 3 weeks).
Conclusions.  We conclude that in patients with severe refractory pain of multiple etiologies, subanesthetic ketamine infusions may improve VAS scores. In half of our patients, relief lasted for up to 3 weeks with minimal side effects.
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Complex regional pain syndrome with associated chest wall dystonia: a case report

David J Irwin and Robert J Schwartzman

Journal of Brachial Plexus and Peripheral Nerve Injury 2011, 6:6
Published: 26 September 2011

Patients with complex regional pain syndrome (CRPS) often suffer from an array of associated movement disorders, including dystonia of an affected limb. We present a case of a patient with long standing CRPS after a brachial plexus injury, who after displaying several features of the movement disorder previously, developed painful dystonia of chest wall musculature. Detailed neurologic examination found palpable sustained contractions of the pectoral and intercostal muscles in addition to surface allodynia. Needle electromyography of the intercostal and paraspinal muscles supported the diagnosis of dystonia. In addition, pulmonary function testing showed both restrictive and obstructive features in the absence of a clear cardiopulmonary etiology. Treatment was initiated with intrathecal baclofen and the patient had symptomatic relief and improvement of dystonia. This case illustrates a novel form of the movement disorder associated with CRPS with response to intrathecal baclofen treatment.

Provisional PDF of the complete article is available HERE.

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Rheumatology (2011) 50 (10):1739-1750.

doi: 10.1093/rheumatology/ker202
Complex regional pain syndrome (CRPS) is a highly painful, limb-confined condition, which arises usually after trauma. It is associated with a particularly poor quality of life, and large health-care and societal costs. The causes of CRPS remain unknown. The condition's distinct combination of abnormalities includes limb-confined inflammation and tissue hypoxia, sympathetic dysregulation, small fibre damage, serum autoantibodies, central sensitization and cortical reorganization. These features place CRPS at a crossroads of interests of several disciplines including rheumatology, pain medicine and neurology. Significant scientific and clinical advances over the past 10 years hold promise both for an improved understanding of the causes of CRPS, and for more effective treatments. This review summarizes current concepts of our understanding of CRPS in adults. Based on the results from systematic reviews, treatment approaches are discussed within the context of these concepts. The treatment of CRPS is multidisciplinary and aims to educate about the condition, sustain or restore limb function, reduce pain and provide psychological intervention. Results from recent randomized controlled trials suggest that it is possible that some patients whose condition was considered refractory in the past can now be effectively treated, but confirmatory trials are required. The review concludes with a discussion of the need for additional research.

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The 'disinhibited' brain

New findings on CRPS -- a disease characterized by severe pain

The Complex Regional Pain Syndrome (CRPS), also known as Morbus Sudeck, is characterised by "disinhibition" of various sensory and motor areas in the brain. A multidisciplinary Bochum-based research group, led by Prof. Dr. Martin Tegenthoff (Bergmannsheil Neurology Department) and Prof. Dr. Christoph Maier (Bergmannsheil Department of Pain Therapy), has now demonstrated for the first time that with unilateral CRPS excitability increases not only in the brain area processing the sense of touch of the affected hand. In addition, the brain region representing the healthy hand is simultaneously "disinhibited". The group has been performing research on and treatment of CRPS for a number of years. The researchers are reporting the new findings in the renowned journal Neurology. The study was supported by the Research Funds of the Deutsche Gesetzliche Unfallversicherung (DGUV).

Contact: Dr. Martin Tegenthoff
Ruhr-University Bochum 

The rest of this press release can be read HERE.

This is the ABSTRACT for the much-hyped research itself:

Bilateral somatosensory cortex disinhibition in complex regional pain syndrome, type 1 

Neurology September 13, 2011 vol. 77 no. 11 1096-1101

  1. M. Lenz
  2. O. Höffken, MD
  3. P. Stude, MD
  4. S. Lissek, PhD
  5. P. Schwenkreis, MD
  6. A. Reinersmann
  7. J. Frettlöh, PhD
  8. H. Richter
  9. M. Tegenthoff, MD and 
  10. C. Maier, MD

Objective: In a previous study, we found bilateral disinhibition in the motor cortex of patients with complex regional pain syndrome (CRPS). This finding suggests a complex dysfunction of central motor-sensory circuits. The aim of our present study was to assess possible bilateral excitability changes in the somatosensory system of patients with CRPS.
Methods: We measured paired-pulse suppression of somatosensory evoked potentials in 21 patients with unilateral CRPS I involving the hand. Eleven patients with upper limb pain of non-neuropathic origin and 21 healthy subjects served as controls. Innocuous paired-pulse stimulation of the median nerve was either performed at the affected and the unaffected hand, or at the dominant hand of healthy controls, respectively.
Results: We found a significant reduction of paired-pulse suppression in both sides of patients with CRPS, compared with control patients and healthy control subjects.
Conclusion: These findings resemble our findings in the motor system and strongly support the hypothesis of a bilateral complex impairment of central motor-sensory circuits in CRPS I.

Data Supplement: Three tables; Three Microsoft Excel documents