Thursday, March 22, 2012

Additional Sanctions Against Scott Reuben


Scott S. Reuben: Debarment Order




SUMMARY

The Food and Drug Administration (FDA) is issuing an order under the Federal Food, Drug, and Cosmetic Act permanently debarring Scott S. Reuben, M.D. from providing services in any capacity to a person that has an approved or pending drug product application. FDA bases this order on a finding that Dr. Reuben was convicted of a felony under Federal law for conduct relating to the regulation of a drug product under the Federal Food, Drug, and Cosmetic Act. Dr. Reuben was given notice of the proposed permanent debarment and an opportunity to request a hearing within the timeframe prescribed by regulation. Dr. Reuben failed to respond. Dr. Reuben's failure to respond constitutes a waiver of his right to a hearing concerning this action.Show citation box

The one where Buddy goes to the vet...

Shhhh!  I'm hiding out in the Computer Turret.  Buddy the Freakishly Large Kitten, who has the claws to match his moniker, needs rounding up for his first visit to the vet.  Not his actual first, of course -- it's his actual second visit, but the first happened without any muss or fuss, as he was not yet freakishly large, and was, in fact, very tiny, and lost in that peculiarly endearing stupidity of extreme-babyhood.

Buddy can con you in a New York minute.  And if his somewhat vacuous expression doesn't start you down the yellow brick road of his various diversions, he has those claws.

He exploits the "awwww..." factor like nobody's business.  Just yesterday, he sauntered up to me as I lay in my come hither pose, draped across my wheelchair, praying for death.  I wasn't feeling so hot.  Well, I was HOT, but, oh, never mind.

He doesn't so much meow as coo.  Maine Coons must be the mockingbirds of the feline community.  So he coos at me, and lifts an eyebrow.  I'm his bitch, and he knows it.

My shoulder hurts like hell.  It hurts worse since I discovered, yesterday morning, the Return of the Fistula (same one, same spot, same everything).  But no matter, I'm Buddy's bitch, and I know it.

Through a series of incisive questions, I determined that Buddy required that a certain ball, the soft, orange one, with the weird spikes, be retrieved for a rousing game of Fetch.  Odd, he usually reserves Fetch tournaments (he and Dobby are Fetch aficionados of the First Order) for the moment I enter REM sleep, which explains my dearth of dreams.

Ouch.  I am not sure that dearth can handle a personal possessive pronoun.

The ball in question turned out to be tucked under the edge of a Persian rug.  The Persian rug was under an antique console table.  Under the antique console table, also weighing down that expensive bit of carpet, was an oversized brass-studded leather Ottoman ottoman, filled with huge rocks.  Just kidding.  No rocks!  Oh, and on the console table?  Two huge celadon vases and an 800-pound concrete Laughing Buddha.

It's not your average graceful, eye-soothing console table.  Lovely turned, tapered legs, yes. But a loud, look-at-me marble top and a heavy, thick, very rectangular plinth that doesn't give the turn or the taper of the legs half a chance.

Yes, I have given that particular Haddock acquisition to the Manor a great deal of thought.  You would, too, if you had moved it, twice, while in a wheelchair and with only one functioning arm.  First, of course, I moved the Ottoman ottoman.  Those Turks and their darned footstools.  Actually, my extensive research shows that the word ottoman came into use as a designation for these bits of furniture because of the early 19th-century affinity for all things deemed oriental, and the act of reclining was considered, of course, oriental. [Don't look at me.  I just report these things.]

Proof that everything is political?  Even this ethnocentric perversion of simple furnishings turns out to be based on imperialist designs, in this instance, by one Napoléon Bonaparte, who molded the codification of orientalism in art with Description de l'Égypte, ou Recueil des observations et des recherches qui ont été faites en Égypte pendant l'expédition de l'armée française (English: Description of Egypt, or the collection of observations and research which was made in Egypt during the expedition of the French Army).


He was a great codifier, Napoléon!  Still, although his failed attempt to colonize Egypt and Syria inspired a wealth of artistic propaganda, napoleonic heavyhandedness was perpetuated by conflicts that continued throughout the century: first with the Greek War of Independence, then the French conquest of Algeria, and, in the 1850s, by the Crimean War.



I'm just saying.
For a completely different point of view, steeped in a more modern sense of the mercenary, read this.


As for the West and our affinity for glossing?  Well, Egypt, Turkey, Egypt, Turkey, who can tell them apart?  What matters is that all these [near] Eastern folk love to RECLINE.  

"What can Egypt be like?" wrote Eugène Delacroix, "Everyone is mad about it."

The Women of Algiers in Their Apartment, 1834
Eugene Delacroix

Right. So!
We're out of coffee, in case you were wondering.

Anyway, Buddy finagled the recovery of his orange spiky ball, and I got to take some extra pain medication, as a result.  In the process of checking out how The Wound had fared during my furniture-moving, vase-lifting exploits, what was kind of obvious was the Return of the Fistula.  Those of you who are detail-oriented may remember that The Fistula first came to my attention following a similar instance of exertion, after The Clearing of the Back Porch.

I crack myself up.  I knew that I'd regaled you, Dear Readers, with the Tale of the Back Porch but had no idea that there was a freaking Fistual Thread!  It appears I haven't consigned The Fistula to further literary recognition since November 7, 2011, when I noted, in my usual fashion, so devoid of drama:
These are the available choices:    
Either my head is going to explode or I am going to cry.
In June 2008, when I began elle est belle la seine la seine elle est belle, it was, mostly, a response to that same immense frustration, and my attempt to both restrain my tears and keep my head.  I thought that throwing fanciful and funny verbiage at my problems might release enough of the stultifying pressure for my lacrimal glands to dry up and -- should my head actually explode -- I wanted to have the documentation required by Guiness World Records.

I'm a Guinness junkie.  That's where I first read about SHR, Spontaneous Human Combustion.  One of the first things Fred shared with Abbot Truffatore and Father Anthony, over cocktails, was my firm belief in the reality of Spontaneous Human Combustion. He even requested some sort of ritualized intervention, as the three of them sat there, tying knots in cherry stems with their tongues.  Yes, Fred unwittingly polluted my chances with those Cistercian Power Brokers. I didn't get to see The Holy Foreskin, their most prized relic, until months after he did.

Does no one else see the hypocrisy?  I mean, so I believe in the ability of the human body to burst into flames without an outside agent or an inciting accelerant.  They believe a bit of shriveled foreskin is imbued with The Sacred.  Hello?


I don't think I can hide out up here much longer.  There's too much to do and it really stinks of cowardice.

It's a great little perch, the Computer Turret. I can see Fred down there, all red-faced and sweaty, struggling to strap the oversized pet carrier into the front passenger seat.

Oh, my God, there's a Buddy paw clawing its way out, talons extended... Run, Fred, run!

POSTSCRIPT [visual]:

Buddy, back from the vet... and healthy as a horse...





Wednesday, March 21, 2012

Scott Reuben "MD": His Unmitigated Gall

Twenty-six thousand patients die each year in the US from NSAID induced complications. Paul White, an A & A Editor, has estimated that billions of dollars of Cox-2’s were sold based on Dr. Reuben’s papers and he adds,  “For now, at least, neither the drug companies nor Reuben’s co-authors are officially sharing in the blame, but that’s expected to change."

“There’s a lot of responsibility to pass around,” White says. “It’s all being focused on Scott Reuben, but the reality is there are many other responsible parties." We will never know how many patients received NSAIDs during a very stressful and high risk time and how many may have been injured or died from Cox-2 related complications.

-- "Welcome to the Fraudosphere," PainPoints

The Affordable Care Act contains some interesting, little known provisions, among them a strengthening of the preexisting federal False Claims Act.  As one article put it, "experts warn that doctors need to be ready." Guffaw!


It was this expansion of liability that resulted in GlaxoSmithKline's $750 million in penalties for having sold "mixed-up products, diabetes drugs with too much or too little of the clinically effective ingredient," and for manufacturing drugs in "a nonsterile area of the facility that was used to make injectable drugs and [using] a water system contaminated with microorganisms."

In 2009, the Health Care Fraud Prevention and Enforcement Action Team (HEAT) in the first six months of operation recouped almost $3 billion in penalty payments.  The ACA provides $350 million over the course of a decade for the work of the HEAT Task Force.  That's a pretty decent return.

All of that reading and talk of fraud made me wonder what the inimitable Scott Reuben, MD might be up to these days, now that he's out of prison and all.

By the evidence, he is no closer to renouncing the self-serving tendencies that got him to the Big House of Correction to begin with.  He continues to offer the transparent excuse that he was out-of-control due to undiagnosed bipolar disease.  Undiagnosed (and unremarked upon) for well over a decade!  Even his wife, a psychiatrist, failed to pick up on it during all those years that he spent assiduously committing one of the worst known cases of medical and academic fraud.

I guess we should file the following document under "Unmitigated Gall," next to my previous ten posts about Scott Reuben, the Medical Madoff.


Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Civil Remedies Division


Scott S. Reuben, M.D.,
(O.I. File No.: 1-09-40105-9),
Petitioner,

v.

The Inspector General.
Docket No. C-11-664
Decision No. CR2481
Date:  January 6, 2012

DECISION


Petitioner, Scott S. Reuben, M.D., asks review of the Inspector General’s (I.G.’s)
determination to exclude him for five years from participation in the Medicare, Medicaid,
and all federal health care programs under section 1128(a)(3) of the Social Security Act
(Act).  For the reasons discussed below, I find that the I.G. is authorized to exclude
Petitioner and that the statute mandates a minimum five-year exclusion.

Discussion 
The sole issue before me is whether the I.G. has a basis for excluding Petitioner from
program participation.  Because an exclusion under section 1128(a)(3) of the Act must be
for a minimum period of five years, the reasonableness of the length of the exclusion is
not an issue.  Act § 1128(c)(3)(B); 42 C.F.R. § 1001.2007(a)(2).

The parties have submitted their written arguments (I.G. Br.; P. Br.), and the I.G. filed a
reply.  With his brief, the I.G. submitted four exhibits (I.G. Exs. 1-4).  In the absence of
any objections, I admit into evidence I.G. Exs. 1-4.


I directed the parties to indicate in their briefs whether an in-person hearing would be
necessary and, if so, to describe the testimony it wishes to present, the names of the
witnesses it would call, and a summary of each witnesses’ proposed testimony.  I
specifically directed the parties to explain why the testimony would be relevant.  Order
and Schedule for Filing Briefs and Documentary Evidence, Attachment 1 (Informal Brief
of Petitioner ¶ III) and Attachment 2 (Informal Brief of I.G. ¶ III) (Sept. 9, 2011).  The
I.G. indicates that an in-person hearing is not necessary.  Although Petitioner does not
directly respond to the question, he does not contend that an in-person hearing is
necessary and lists no potential witnesses.  I therefore conclude that an in-person hearing
is not required.

Petitioner must be excluded for five years because he was 
convicted of felony fraud in connection with the delivery of 
a healthcare item or service. 1

I make this one finding of fact/conclusion of law


Petitioner was a Massachusetts anesthesiologist who contracted with the drug
manufacturer, Pfizer, Inc., to conduct clinical studies on patients to determine the efficacy
of a certain drug in treating post-operative pain.  Pfizer paid for the studies.  Petitioner
subsequently claimed to have conducted the studies, administering the tested drug to 100
post-surgical patients and a placebo to another 100 post-surgical patients.  He published
papers in a scientific journal claiming to have achieved success with the tested drug.  In
fact, he had not enrolled any patients in any study, and he fabricated the “results.”  I.G.
Ex. 3 at 12-16.

On June 24, 2010, Petitioner pled guilty in federal district court for the District of
Massachusetts to one count of felony health care fraud, 18 U.S.C. § 1347.  Under that
provision, a person commits health care fraud if, “in connection with the delivery of or
payment for health care benefits, items, or services,” he “knowingly and willfully
executes, or attempts to execute” a scheme 1) to defraud a health benefit program or 2) to
obtain, “by means of false or fraudulent pretenses, representations, or promises,” money
or property owned by a health benefit program.

The court accepted Petitioner’s plea and entered judgment against him. I.G. Exs. 2, 4.
In a letter dated June 30, 2011, the I.G. advised Petitioner that, because he had been
convicted of a felony offense related to fraud, theft, embezzlement, breach of fiduciary
responsibility or other financial misconduct in connection with the delivery of a
healthcare item or service, the I.G. was excluding him from participation in Medicare,
Medicaid, and all federal health care programs for a period of five years.  I.G. Ex. 1.


Section 1128(a)(3) provides that an individual or entity convicted of felony fraud, theft,
embezzlement, breach of fiduciary responsibility, or other financial misconduct in
connection with the delivery of a health care item or service must be excluded from
participation in federal health care programs for a minimum of five years.  See 42 C.F.R.
1001.101(c).  Because Petitioner was convicted of felony health care fraud, he is subject
to exclusion.

Petitioner does not deny that he was convicted of felony fraud in connection with the
delivery of a health care item or service.  Instead, he attributes his misconduct to mental
illness, points out that his practice as a clinician is unblemished, argues that he has paid
his debt to society, and maintains that he is ready to resume his medical career.  These are
simply not bases for overturning a mandatory exclusion.

Conclusion
For these reasons, I conclude that the I.G. properly excluded Petitioner from participation
in Medicare, Medicaid and all federal health care programs, and I sustain the five-year
exclusion.


Carolyn Cozad Hughes
/s/
Administrative Law Judge



Photo credit:  Details

Four Days Post Rotationplasty: Go, Hannah, Go!


Hannah's Mom updated her progress again today.  From home! My admiration grows with every communication detailing this young girl's courageous journey.  I've copied below the section that I find most inspiring, as it details some of the intricacies of adjusting after rotationplasty -- an orthopedic surgery I'd never heard of before being referred to Hannah's CaringBridge Journal.

[In case you were wondering how I "pick" the four kids I follow, I don't -- not in over two years, anyway.  I wait for the day when one child's journal entry asks for intercessory prayer on behalf of another child.  I'm all about referentiality, "degrees of separation."]

If you decide to follow Hannah, please be a faithful cheerleader.  In the days and years ahead, there are going to be some rough times of inertia to offset the many good times of clear and positive progress. But be real... I think this kid is equipped, not just with a "new" leg, but with all kinds of radar!

This amazing child, only 4 days past her rotationplasty, was able to leave the hospital and go home. Now that her body has changed so dramatically, we are all in a bit of a learning curve as to how to navigate the logistics of everyday "normal" life. I will never again take getting in and out of a chair for granted. The amazing thing is that this girl is able to get in and out of her wheelchair on her own, with only the help of another person to balance her. I've taken a few videos that I'm going to try to upload to YouTube so you can see just how determined and strong she is. The only physical difficulties she is facing at this point is the splint on her "new" leg-which must stay on at least 2 weeks-maybe longer. She's wrapped from her rotated foot all the way up to around her hip and waist. That makes navigation challenging at best. Also, the thigh muscles are having to be retrained b/c they aren't really thigh muscles--they're actually calf muscles. We're having to train them to go in the opposite direction than normal. This is a challenging and painful process but she's doing exercises to help with this. Once the splint is off, she'll then have to train her ankle muscles to go the opposite direction as well. 

Tuesday, March 20, 2012

the thing with feathers

I had a heck of a time using Blogger last night and hope the issues have been resolved.

Other hopes for today?  That GOOG will shoot up to 700 or so.  That URBN will at least reach that point where I can comfortably bail.  That Marmy Fluffy Butt's left eye ceases to seep, so she can have some relief from her allergies.  That I successfully capture on video the behavior that inspired Dobby the Runt's nickname of "Butt Boy." [And that the video be appropriate for a G-audience.]  That Fred stop racing toward the drawbridge  in his sleep [He keeps hearing knocks and "yoohoo"s in his dreams.  Twice already this morning, he's gone flying by, knees pumping, chest out, yelling, "I'm coming, I'm coming!" My reassurances that there's been nary a knock and not even one "yoohoo," were met with drowsy disbelief.]

Let's see, what else?  I hope that My Hero, Ms. Hannah, gets to go home from the hospital today, after her successful rotationplasty last Friday. Her Mom summed things up yesterday this way, on her CaringBridge site:

I could not hold back my tears of joy as I watched Hannah--my "miracle baby"--do her physical therapy session. She did almost everything on her own. She only had help from physical therapist for balance. Hannah did not flinch or pout or complain or cry. She said it didn't hurt at all and was no big deal. She stood up on her own for a 5-count then sat back down and did that 5 times in a row. Every day I am more amazed by this kid. I'm so proud of her!

I know there are more hopes percolating inside my head and heart.  Dare I give them voice?

I hope that the two-inch nugget glimpsed under the bed (from whence I was retrieving my grabber -- using my cane!) is not what I think it is.  This is the Poo-Free Zone of The Manor.

I hope that federal officials can charge George Zimmerman in the murder of Trayvon Martin, as well as investigate any malfeasance on the part of the Sanford police.  There are several reports that seem credible of officers attempting to "mold" witness statements into a form friendly to Zimmerman's twisted version of the crime.

I hope that yesterday's despair doesn't taint today's progress.  The return of fever, sweats, and that particular pain of the bone infection really got to me, for some reason.  As if another couple of far-from-routine surgeries, $250,000+ in hospital and LTAC bills, intravenous vanco and Cubicin, oral Bactrim, and the wound vac experience were not enough to make me realize that I'm in the midst of another failed attempt at a cure, it took my inability to pop the top off of a can of Progresso soup to have it all sink in.  [The soup?  Tortilla y pollo, doctored for more heat.]



Other fantasies?  That I could spend this Persian New Year with  my former best friend, the Wild Iranian Lesbian, admiring the beautiful table, the flowering hyacinth, the optimistic gold fish.  My hope, of course, is for her year to be a wonderful trip around the sun.


I dare to hope that the Ellerbecks have a measure of comfort, somehow, today.  


I wish Captain Haddock would just go ahead and surface in the moat, in his jaunty little pink submarine -- the threat of a Domestic Inspection is so much worse than the actual wielding of The White Glove.  [Fred found The Castafiore waxing the steps of Buonarroti's Spiral Staircase again, and spritzing the Old Masters with household cleaner laced with ammonia.]


Given what I can glimpse outside this casement window, newly installed in the upgraded Computer Turret, I hope to "play in the dirt again" sometime very soon, if not this day.  The sky is blue and so is the sea... Drat. Why is I Am a Child playing in my head? I fear it is the impact of thinking about the Trayvon Martin travesty down in Florida.

At least my brain picked the Buffalo Springfield version.



Uploaded by  on Jan 21, 2011

I hope, as does everyone in vicinity to moi, that I can overcome my fear of falling and take a shower today, the first since the morning of January 23, 2012.  Somewhere in this blog, in another of my awesomely introspective and well-organized posts, I detail how to maintain a pristine state without benefit of getting in the bathtub.  It's not so easy these days, and more than anything, I actually long for the feel of water on my skin.  [In my case, due to CRPS, running water feels an attack of tiny needle sticks -- tolerable, but sometimes just barely tolerable.]  My legs, especially, need a soak.

I hope, too, that I can pull off a shower without that being my pinnacle achievement for the day!

Because I also crave and want and expect and yearn for... a day put to good use.  You know, when you don't just fill the pets' bowls with food, but take careful time to sanitize the bowls first.  Did you know that eating from plastic bowls can cause pimples to sprout around a cat's mouth?  I didn't think so!  Only one of our bowls is plastic, and we use it because Marmy Fluffy Butt (aka I-choose-to-leave-my-poo-beside-the-litter-box-for-your-maximum-pleasure) will not eat out of anything else.  That reminds me.  I absolutely pine, fancy, and crave the services of an animal psychologist.

This day, cast useful, should include other bits of spot-cleaning.  The disgusting coffee apparatus that Fred uses -- and that Bianca's frequent overnighter, Sven Feingold, adores -- hasn't been washed since... well, since I last had a shower!  In between hospitalizations, while I was insane with fever and dehydration, I made several inspired online purchases, the best of which proved to be a new Bodum French press, so I am brewing my coffee separate from Fred, Bianca (and Sven).  I tell you, it was like Christmas (finally!) for a few days, in spite of the definite Lenten attitude exhibited by our UPS driver.  I had no recollection of my purchases but fortunately, some innate good sense prevailed and I only ordered household items according to an apparent "upgrade" theme.  Frilly stuff like a new dish drainer, and magnetized tools (miniature grabbers, really).  Even the more wasteful orders are not so wasteful, after all.  Not if you squint and stare into the direct sun.  For instance, even though we now have enough bonito flakes to make dashi for all of Japan, I have faith that my Buddy the Freakishly Large Kitten will eat his way through them by the end of the year.

How did the shelter staff not know that he was a Maine Coon?!

Other expectations, faith, and fancies for today?  That we can figure out the idiosyncrasies of this new wheelchair before hosting the "Wheelchair Tech" tomorrow.  It seems like such a small matter, hardly worth someone making the long journey from Tête de Herge's only Full Service Gimp Supply Store.  Still, it is not a good thing to suddenly lose power in the midst of crossing the street.  There's also the whiplash factor!  Fred, stubbornly sticking to scientific method, has debunked each of my theses about the cause of this behavior, citing "coincidence" as the underpinning for my observations.  I much desire equanimity should we tackle the problem again this afternoon.

I'd positively love to do some cooking and baking, but cannot wield a knife.  That's not true.  I just cannot safely wield a knife or expect that my knife skills won't result in personal tragedy.  Hence, the adventures with soup cans and many microwave meals.  Fred is a great cook but he's kind of in recovery right now, himself, you know.  Bianca?  Puh-leeze!  Sven can concoct some amazing comfort food dishes but I can feel my blood vessels begin to clog after the first few bites.  And it turns out that asking for help from the genetically indentured Domestic Staff can result in charges of Abuse of Power.  Who knew?  Damn those corporate flow charts.

Well, if I don't end this, and then finish revising the post that Blogger was blocking last night, I'll never get to my extensive Wish List.  Hmm, how to close, how to close?

As if you weren't expecting it!

Hope

Hope is the thing with feathers
That perches in the soul,
And sings the tune--without the words,
And never stops at all,

And sweetest in the gale is heard;
And sore must be the storm
That could abash the little bird
That kept so many warm.

I've heard it in the chillest land,
And on the strangest sea;
Yet, never, in extremity,
It asked a crumb of me.

-- Emily Dickinson

Repost: Spring Cleaning at Marlinspike Hall

originally posted 3/22/2009

I repost this annually, as much for my benefit as for the New Reader who may have wandered in by mistake. To what end? Well, to remind myself that the tasks necessary to keep order in our little corner of The Manor are mere trifles compared to what we face in the rest of Marlinspike Hall. If you are new to elle est belle la seine la seine elle est belle, this also may help you better visualize Captain Haddock's family home.  And who knows?  Thinking about spring, even if it's spring cleaning, might brighten your day.

I'd best get back to it. Medieval tapestries don't whack themselves clean, you know.




***** ***** ***** ***** ***** ***** ***** ***** ***** *****


Here, deep deep in the Tête de Hergé, it's the time of year when we tenants of Marlinspike Hall clean and straighten, rake and trim, sweep and scrub. Sometimes in matching outfits. Spring might herald a visit from The Captain to his ancestral home, and he expects to find a tight ship.

What is involved in keeping The Manor neat as a new pin? It's not terribly complicated and probably is very much like what you might do in your own home.

The Old Masters must be dusted and straight. Simple enough.

Before I made the acquaintance of The Biddington, I had to use whole bowls full of emulsion cleaner, varnish remover, and even a few drops of Domestic Industrial Strength Environmental Neutralizer for the dingiest of chef-d'oeuvres. Mrs. Biddington -- known in the industry as The Bo-Bizzle of Blue Ball Biddies -- influenced me to try cleaning our oils with various breads and doughs, even the occasional muffin and non-alcoholic fruitcake. Now I only violate EPA guidelines when working on some of the more obscure works stashed in the odd uninhabited corners of The Manor, and I wile away the winter snows by tending to them, one at a time, slowly. Cotton swab by cotton swab, corrosive compound by corrosive compound. Why such diligence? Captain Haddock likes to circulate his distinguished family's art holdings from year-to-year, so you never know when that smoky and yellowed Rembrandt self-portrait is going to see the light of day. (O! There are an annoying quantity of Rembrandt self-portraits to deal with. I keep advocating that they all should be hung in the creepy and destabilizing carny Mirror Room.)

I will never forget the Spring day, several years ago, when my dear friend La Bonne et Belle Bianca Castafiore decided that she wanted to pitch in.

I cocked an eyebrow.
Fred produced a paroxysm of belabored coughing.
Marmy issued a subtle "*ack*-*ack*-*ack*" as she puffed her mighty fluffy butt and stalked off.
I don't know where the boys were.

In one smooth arcing movement, Bianca spritzed Aqua-CitraSolve Natural Household Cleaner and Degreaser on The Conversion of Saint Paul and The Crucifixion of Saint Peter by that murderous, kinda baroque-y, sorta manneristic imp-of-a-guy, Michelangelo Merisi da Caravaggio. I can't get the straight poop from Haddock as to how his family put its hands on the pair -- both once graced the Cerasi Chapel of Santa Maria del Popolo -- until Cardinal Tiberio Cerasi, a flighty guy, himself, and Treasurer to Pope Urban the SumpthingSumpthing, couldn't make up his flighty-guy mind about whether he wanted them or whether he wanted to commission another attempt at the religious subject matter. Those Haddocks sure were lucky.

I cannot count the hours I have spent cleaning all that lucky plunder.


I don't like to complain overly much -- but as you can see from the photo at left (taken in the Cozy Breakfast Nook behind The Spit Kitchen in the Western Wing), just getting to these suckers to wield a tentative and gentle feather-dusting requires those ladder skills you learned in high school and never thought you'd use!

Back to that Spring Day of the Spritz. This was the same day Bianca waxed the reclaimed antique oak of the risers on the biggest spiral staircase in our wing of Marlinspike Hall. "Reclaimed antique oak risers"? That's what I said. Wait while I consult the History of The Manor. Yes, here it is! The wood was original to the medieval castle of Vol-le-Bois -- and Lord knows there isn't much built of wood that usually survives that era free of worm holes and degrees of rot. Il s'agit là d'une récolte très sage des produits forestiers. Really, it seems insufficient to describe what The Castafiore did as mere "waxing." She lovingly burnished each step with as much Lemon Oil as she could force the old wood to accept (if not exactly *absorb*), and then polished it all off with liberal applications of thick and gooey Creamed Lemon Wax.

Later, in the Salle d'Urgence, she would claim an unexpected and preventable "slip-and-fall." When Fred called The Captain, Haddock's perennial fear of La Bonne et Belle Bianca kicked in and he offered her a healthy settlement. Their relationship is truly one of a twisted pretzel -- the big, soft kind that street vendors sell. Hmm. Well, the ones here, in Tête de Hergé country, are a nice combination of a Philly soft pretzel, but shaped like, and as tasty as, a New York pretzel --sprinkled with a liberal amount of Kosher Sea Salt and dipped in a good pungent mustard.

But I digress.

Back to Castafiore and Caravaggio: Did you know that one of the theories about why oils can be such pains in collecting dust and crap -- is that oil paint never dries? That's why spritzing the damned paintings was such an ill-advised approach to the maintenance of Old Masters. Bianca adores the fresh scent of Aqua-CitraSolve Natural Household Cleaner and Degreaser. "Ah! C'est fabriqué avec de véritables oranges!" she crows. And crows.

[It smells not unlike harvest time in the Florida groves when The Castafiore exits her bath in mid-morning. Bourbon French Orange Blossom, for a mere $45 an ounce -- it wafts, it clogs the nares, it is unmistakeable. She sought the same cloying scent on behalf of the saintly pair of Caravaggios.]

No doubt, too, that she wants to make everything all shiny, like that bleepety-bleep miroir. It's mindboggling, but even with her troupe being out of work due to the Global Opera Crisis, she persists on belting out, à la Ethel Merman, je ris de me voir si belle en ce miroir! I mean, really! They may very well want to mount something besides that tiresome Faust after Socialism takes over everything, including the theatre arts. Oh, what a happy day that will be! Art for all! Health care for all! No more inequality of resource allocation!

Anyway. Cough. The only reason those two priceless works were salvaged was because she did her spritzing right in front of me. In a reaction fueled by a burst of outraged adrenaline, I turned the wheelchair on Super-ZoomFast, a setting only to be used in the event of a true emergency. It requires an immediate administrator's authorization and key code. The first time I used it, both the chair and I ended up on our sides, not unlike Arte Johnson and his toppled tricycle on Laugh-In.

True Confession: I have been hording all the Velasquez works in the cool, dry nooks of the upper story of the Knoppenburg Manor Replica Stables. Sometimes, I lean back against wooden slats and think, "mine, all mine."

Wow. I haven't even begun to explain how we spruce up our digs every Spring. Maybe because it truly is a year long process. It never stops.

Keeping the antique Blue Jasper Wedgwood plaques free of cat fuzz. Maintaining the lawns -- replete with a scale replica of Wimbledon courts 1-19 plus Centre Court -- deeply green and trim. Oh, and the neverending battle to keep the black algae out of the moat... daily brushings and constant correction of chlorine requirements -- not too much, the eel and koi are kind of sensitive.

Like I said, it's simple enough. Sure, this year we may have to pay to have others do certain things -- Fred refuses to serve as chimney sweep, for example, and I am having a difficult time beating all the tapestries clean, plus I get a terrible crick in my neck trying to stop the stupid Persian rug borders from unraveling. There is a fix for the problem -- but weaving wool through all the fringe ends and warp threads -- it's called "cashmere and overcasting" -- followed by lots of fine needle work -- and my sore neck, back, and pinpricked hands are going on strike.

I am not gonna do it anymore.

Outsourcing. That's the ticket.

And La Bonne et Belle Bianca Castafiore? What is she doing this Spring Cleaning? We've put her in charge of morale.

Monday, March 19, 2012

CRPS Research: QST Profiling and Central Motor Processing

For weeks there is nothing in the research news about CRPS, then, bam!  Today I received notice of the following two items, as well as a bit of a education being given by the RSDSA Scientific Board in an exchange of letters over a proposed redefinition of neuropathic pain. [For that discussion, check out the Letters to the Editor in PAIN.]


QST = Quantitative Sensory Testing


Sensory signs in complex regional pain syndrome and peripheral nerve injury
PAIN Volume 153, Issue 4, Pages 765-774 , April 2012

Janne Gierthmühlen, Christoph Maier, Ralf Baron, Thomas Tölle, Rolf-Detlef Treede, Niels Birbaumer, Volker Huge, Jana Koroschetz, Elena K. Krumova, Meike Lauchart, Christian Maihöfner, Helmut Richter, Andrea Westermann, the German Research Network on Neuropathic Pain (DFNS) study group

Janne Gierthmuhlen is the corresponding author. Address: Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Strasse 3, Haus 41, Kiel 24105, Germany. Tel.: +49 431 597 8510; fax: +49 431 597 8530.

Received 7 March 2011; received in revised form 1 October 2011; accepted 7 November 2011. published online 12 December 2011.

Summary
QST revealed more similarities than differences between CRPS-I, CRPS-II, and PNI: sensory loss occurred in 63% of CRPS-I and sensory gain in 81% of PNI patients.

Abstract
This study determined patterns of sensory signs in complex regional pain syndrome (CRPS) type I and II and peripheral nerve injury (PNI). Patients with upper-limb CRPS-I (n=298), CRPS-II (n=46), and PNI (n=72) were examined with quantitative sensory testing according to the protocol of the German Research Network on Neuropathic Pain. The majority of patients (66%–69%) exhibited a combination of sensory loss and gain. Patients with CRPS-I had more sensory gain (heat and pressure pain) and less sensory loss than patients with PNI (thermal and mechanical detection, hypoalgesia to heat or pinprick). CRPS-II patients shared features of CRPS-I and PNI. CRPS-I and CRPS-II had almost identical somatosensory profiles, with the exception of a stronger loss of mechanical detection in CRPS-II. In CRPS-I and -II, cold hyperalgesia/allodynia (28%–31%) and dynamic mechanical allodynia (24%–28%) were less frequent than heat or pressure hyperalgesia (36%–44%, 67%–73%), and mechanical hypoesthesia (31%–55%) was more frequent than thermal hypoesthesia (30%–44%). About 82% of PNI patients had at least one type of sensory gain. QST demonstrates more sensory loss in CRPS-I than hitherto considered, suggesting either minimal nerve injury or central inhibition. Sensory profiles suggest that CRPS-I and CRPS-II may represent one disease continuum. However, in contrast to recent suggestions, small fiber deficits were less frequent than large fiber deficits. Sensory gain is highly prevalent in PNI, indicating a better similarity of animal models to human patients than previously thought. These sensory profiles should help prioritize approaches for translation between animal and human research.

Keywords: Complex regional pain syndrome, CRPS, Peripheral nerve injury, Quantitative sensory testing, Somatosensory, Pain

REFERENCES


********************************************************************************

Kinematic parameters of running stride

Motor control in complex regional pain syndrome: A kinematic analysis
PAIN Volume 153, Issue 4, Pages 805-812, April 2012

J.C.M. Schilder, A.C. Schouten, R.S.G.M. Perez, F.J.P.M. Huygen, A. Dahan, L.P.J.J. Noldus, J.J. van Hilten, J. Marinus

Schilder is the corresponding author. Address: Department of Neurology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands. Tel.: +31 71 5262895; fax: +31 71 5248253.

Received 16 August 2011; received in revised form 9 November 2011; accepted 23 December 2011. published online 15 February 2012.

TOC Summary
CRPS patients perform repetitive finger movements slower and with more hesitations with both the affected hand and the unaffected hand, pointing at impaired central motor processing.

Abstract
This study evaluated movement velocity, frequency, and amplitude, as well as the number of arrests in three different subject groups, by kinematic analysis of repetitive movements during a finger tapping (FT) task. The most affected hands of 80 patients with complex regional pain syndrome (CRPS) were compared with the most affected hands of 60 patients with Parkinson disease (PD) as well as the nondominant hands of 75 healthy control (HC) subjects. Fifteen seconds of FT with thumb and index finger were recorded by a 60-Hz camera, which allowed the whole movement cycle to be evaluated and the above mentioned movement parameters to be calculated. We found that CRPS patients were slower and tapped with more arrests than the two other groups. Moreover, in comparison with the hands of the HC subjects, the unaffected hands of the CRPS patients were also impaired in these domains. Impairment was not related to pain. Dystonic CRPS patients performed less well than CRPS patients without dystonia. In conclusion, this study shows that voluntary motor control in CRPS patients is impaired at both the affected as well as the unaffected side, pointing at involvement of central motor processing circuits.

Keywords: Bradykinesia, Central motor processing, CRPS, Kinematic analysis, Motor control

REFERENCES

SXSW 2012: Springsteen's Keynote Address

Copies of this speech are being yanked off YT, so I don't know how long this one will remain viable... posted to UStream by sanctified4one -- Thank you!




There You Go!



Man, I've had it.  There is this crazy woman in Dallas who is a Dr. Phil fanatic, and apparently, delusional as all get out.

She tweets nonstop about her need for a brain-to-ass makeover, including cosmetic dentistry (but never, you will notice, for the psychiatric services she needs most), all the while denigrating people who make sensible use of the entitlement systems that are in place for... you know, people who need those services!  No... she would rather tweet the cast of the Dr. Phil Show, any partial blood relative of his, any entertainment spinoffs, like The Doctors.

She tells these poor people about her "10/10" pain in her ribs, how she thinks she is on the verge of actual, physical death.  In a tweet.

Never mind that a 10/10 pain wouldn't allow for the formulation  of one tweet, much less the million she can produce over a single somatic symptom.

Never mind the complete assification exhibited by using Twitter as your private 911 line.

Never mind that you become a fascinating creature to watch, in terms of all sorts of anthropological data collection.

But recently, she began to sound a little...  grounded.  She was tossing around terms like "responsibility," and this morning, even compared herself to Thoreau.  I had a ridiculous moment of hope on her behalf.  Stupid me, I thought, "Hey, she's finally hit on the miracle of self-reliance!" [Yes, I often confuse Emerson for Thoreau.]

Intransigeant, ridiculously rigid , yes, I can see the reasoning in her referencing Thoreau.

Aw hell.  You know what she tweets about as much as anything else?  Her personal Paradise Lost.  Her rape.  The battering that caused the dental problems she now wants a celebrity to fix, for free.  The same dozen memories, from something she thinks people said at one of her failed childhood birthday celebrations to  verbatim quotes from 1996, when one doctor decided not to take her as a patient because she did not have health insurance.

She reminds me, God damn it all, of my Father.

Not that my father would ever tweet, I mean, at all.  Much less, tweet his personal problems in the hopes that a male power figure would swoop down into his life and alleviate all need for force of will.  No, how they are alike is in this scary affinity for backhanded "Nyah, nyah, I told you so"s.

Once, when my brother Grader Boob was all of 16, he had a rare emotional meltdown that resulted, if memory serves me correctly, from having had the distance between the end of his sideburns and the tip of his ear lobe measured with a ruler.  In order to understand this scenario, I guess you either have to be from a military family (of a certain era) or you had to be there.  Let's just say that the teenager felt oppressed, judged, harassed.  It was late in the evening, too, so add "tired."

And out of his teen-aged mouth came this:  "I wish you would stay out of my life."

My father could not quote this son, verbatim or even approaching such accuracy, on any topic of import to that son.  No knowledge of his core beliefs, no knowledge of his heartbreaks, not an inkling of how generous and kind a child he'd produced.  But -- should anyone ever suggest, say, that he throw the kid a life preserver, as he appeared to be drowning in the deep end of the pool, my Dad, without fail, would say, "You know, on X day in 1970-something, Grader Boob told me to stay out of his life. And I have, and I will continue to do so."

I can't reproduce the tone.  The tone is the clincher.  You'll just have to use your imagination.

Anyway, this Dr. Phil-crazed woman is the same way.  Someone, somewhere does something once within her sphere of knowing, and it is as if all of humanity acted in tandem, and not for an instant, but for a really boring eternity.

But like I said, I saw signs of hope.  She paid for a checkup, for example.  That may sound weird, but that was a huge step.  She needed a checkup.  She spent, I dunno, about 16 years needing one.  When she got "connected" to the world through computers, she started a campaign to guilt-out Nice People Of Means into providing her with what she wanted and needed.  All of that intelligence and creativity, wasted in needling, wheedling, whining -- like an overgrown, over-the-hill Shirley Temple, dressed all in crinoline that barely covered her ass, graying hair in shellacked ringlets.

And yes, damn it., I know perfectly well that the adult Ambassador Shirley Temple Black was a woman to be admired.

That's the only teeth-grinding allusion that will come to mind, somehow.

Hope, I was talking about hope.

Out of the blue, this woman began to say stuff about how maybe it is a good thing to do things for one's self... and we here at Marlinspike Hall burst into fits of cheering and expectations of feats of derring-do.  Not that we are a completely independent people, no, far from it.  In fact, we are about as intertwined and joined at the hip as it gets.  But should there be a pressing need for X in our world?  We get X.  We buy it, rent it, borrow it.  We finance it, we replicate it, we steal it.

Just checking to see if you're paying attention.  No, we don't steal X!  C'mon!  Captain Haddock would make of us a finely minced tartare...

This morning, I made my once a week perusal of the Dr. Phil Crazy Lady tweets -- and saw that she was back to her old habits and, well, I lost it.  I tweeted her a link to PCIP -- one of the wonderful provisions created in the Affordable Care Act.  It is the Pre-Existing Condition Insurance Program., and if you read this blog regularly, you know that it has probably saved my life.  It still is too much of a secret, so I try to spread the word however I can.

Admittedly, suggesting to someone living in Fantasy Land that she be proactive and use some of the money she spends on television and computing to buy herself some health insurance was not my most reasoned thought of late.  Particularly when she assumes that people who contact her via Twitter -- but whom she is not "following" -- are HACKING into her account!

I'd roll my eyes but I have a headache.

Basically, if I write anything at Dr. Phil's website (which usually results in a nasty, itchy, red contact dermatitis) or on Twitter, she considers herself hacked.

I imagine that if you look at her sideways, she screams that you're inflicting a bloody murder upon her person.
I've seen her be ingratiatingly cruel to people she considers beneath her -- moments when your own quick intake of breath registers the real mettle of a person.

She does not respect women, though she'd go all purple in contradiction.  She doesn't respect herself.  That's what needs to change.  There's no need to whitewash or otherwise disguise the violent episodes of her life, but there is no need to continue to proffer them as the only real examples of having lived.

Okay.  She's a lot like me, in some ways.  I know that my days would be much happier if, every time I felt the urge to launch into a litany of woes through the vehicle of an anecdote, I would stop... just stop... and explore how saying nothing feels.

The armchair psychologist in me wants to diagnose rampant anxiety as the stultifying culprit in such matters --when we with ourselves too much discuss.  But clearly there is also PTSD, and that needs treating, too.

I was at the Pain Management Dude's Place this morning, being "pharmacologically managed." In my curly head, on the way, I regaled Fred with all the witty things I planned to say to the PA -- most all of which stemmed from the fact that they failed to help me and Go-To-Guy in an hour of true need.

She came in the exam room, smiled, and said, "It's been a while.  Where have you been?"

Well, that took a while to answer.  The last time we'd communicated, she'd emailed me that Go-To-Guy should manage the Baclofen issues, and that I needed to make an appointment and come in if I needed further help.  Of course, within 48 hours, we had called 911 ("Tante Louise!") twice and I ended up in ICU, making my surgeon stomp his little foot and yell, "You almost died!"

By the time I got to signing out AMA from the LTAC, and the details about the second surgery, and the wound vac...  her brown eyes were bugging out.

I was -- and this is the absolute truth -- restrained in the manner of my telling.  Instead of making a single insinuation of dissatisfaction over their response to the whole spaz-spaz-spaz crisis?  I stated, simply, that their  failure to respond in a meaningful or helpful way had shaken my faith in them.

Her response was not what I expected.

She said, "What email?  What are you talking about?"

Oh the blows to ego!  Aren't they wonderful?  It's like someone pushing your reset button.

In the moment, I knew I could either go ballistic, as in "What the hell do you mean, 'What email?' The one where I begged you to help us find a way to treat the dystonia without overdosing on Baclofen!" -- or, I could do what I did, which was to laugh, look her in the eye, and say:

"Well.  There you go!"

It's an improvement for me, I think, don't you?

A laugh.
A look in the eye.
"Well.  There you go!" (with a lilt, mind you)

Best of luck to you, crazy Dr. Phil Lady!  There you go!


Sunday, March 18, 2012

in::dire::need

I've been in dire need of pain medication for six hours now.  Yes, I have the medication.  No, no one has told me not to take it.  Some of it is scheduled, meaning that I take it at certain times, whether my pain is stable or out of control.

I have been doing very well with it, truth be told, and even plan one of my unauthorized periods of abstention in early April.

It's something of a game, what I am doing.  How long can I go?  How bad is the pain, really, hmm*?

[*Question:  Why is "hmmm" a misspelling?]

Okay, well, this is ridiculous.  I pried open the stiff lid of this irritating laptop in order to create a pithy, amusing verbal snapshot of my Sunday morning.  Complete with cats, Fred, Bianca (and Sven).  Rounded out by The Story of Our Unwieldy Trash.  I also wanted to bemoan more medical bills, particularly the $26,000+ being paid to Doctor Ewwy-Gooey Infectious Disease Guy's office.

With such lofty intention, why am I writing about that amber bottle, one-third full of salmon-pink tablets, one of which fits precisely within the dimensions of an eye's vacant pupil?

Because I HATE this PAIN.  And yet, I don't often face it, not really.  I don't stare at it, I don't assess it purely on the basis of what it is, how it is.  I don't do the ontology of pain.  I don't have much respect for it, in spite of the accumulated evidence of its power and importance.

If I am suddenly so keen to interrogate pain, and to probe it with my dull and rusty knife, why not keep to my plan and wait for the organizational advantage of my scheduled withdrawal next month? It wouldn't feel so much like sport, like a pickup basketball game on a blacktop court without a backboard, a hoop without a net.

Okay, so basketball is in the air here at Marlinspike Hall, permeating everything.  I hate to say it, but I am still disappointed in Duke -- and I'm sure Coach K and the players wish I would lift the heavy burden of my dead and dashed hope from their shoulders.

This is an absolute marvel: A site dedicated to connecting players to pick-up basketball games.  I am finally convinced of the usefulness of the world wide web!


About InfiniteHoops

Founded in 2003, InfiniteHoops is a Seattle-based service for finding basketball games and players worldwide. Our mission is to make it easy for basketball players to connect and organize pick-up games with players of similar ability and skill.
InfiniteHoops was the first site in our pick-up sports network. It was followed by sites dedicated to soccer, softball, football and hockey - InfiniteSoftball, InfiniteFootball and InfiniteHockey.
In 2010, we incorporated our sites into InfiniteSports LLC. Soon after, we partnered with CALLE to buildUnderground, a site for pick-up soccer.
The service was founded and developed by Tosh Meston. Contact him on LinkedIn.

The trick I just demonstrated was so subtle and sophisticated that maybe you missed it.  See, I can use writing, and even looking up seemingly silly things, as a means of distraction, and as anyone experienced in pain will tell you, distraction is the best painkiller of all.

It doesn't make for a cohesive blog, unfortunately, but I make no apologies.  I have a manor to run, detoxing carnies to supervise, a festival to organize, an odd, craggy, rich old sailor to appease, and a moat full of algae.

Besides, I took the breakthrough pain medication about five minutes ago.  The placebo effect is very real, even if its reference is to ephemera.  I get almost instant psychological relief from knowing that in 20-30 minutes, some actual help may arrive.  Will arrive.  Usually arrives.  Please, arrive!
Good God, Zimmerman, that deluded, self-important fool, clearly executed young Trayvon Martin. Sorry -- various 911 calls have been released to the media -- and you can hear, on some of the recordings, and you can hear it clearly, Martin calling for help.  I read somewhere [a detestable phrase!] that Zimmerman, a 28-year-old Hispanic man, has claimed to be the one calling for help.  One of his neighbors offered a heartbreaking deconstruction of that lie.  She explained that, first, it clearly was the 17-year-old "crying," but if one wished to dispute that fact, one would have to wonder why the calls for help came to a sudden mid-word halt when Zimmerman pulled the trigger.
Oh, out with it.  I fear that the infection is already back!  How?  After two "washouts" of the joint, removal of the tainted prosthesis, replacement with an antibiotic-laced spacer, a few weeks of intravenous vancomycin, six weeks of intravenous Cubicin (the "new" antibiotic of last resort), and now eleven days [out of a planned thirty] of a large dose of Bactrim DS?  Really?  How the heck can this be?

And yet, I am ridiculously informed as to what my body, mind, and soul experiences when the infection takes hold.  I say "the" infection because my mind refuses to wrap around considerations of "new" or "different" problems.

Acting out of habit, I emailed my MDVIP Go-To-Guy late last week, as I had several favors to beg, and included in my list a lamentation of the fever, nausea, and malaise that was once again plaguing me.  A new order was needed to the outpatient oncology clinic that kindly flushes my implanted port every four-to-six weeks.  Blood work was requested by Doctor Ewwy-Gooey Infectious Disease Guy's PA.  And, oh, by the way, I am again running hot, again feel invaded, again, again, still, still.


Go-To-Guy replied with what most of you are probably saying to your monitor right now: "What is your major malfunction, numbnuts? Don't tell me, tell the Ewwy-Gooey Infectious Disease Guy!"  Who knew he was a Full Metal Jacket junkie, and channeling Gunnery Sergeant Hartman?

Of course, I got that message at 4 pm on Friday, not the time to bother the ID people with a problem of several days' duration.  "If it continues through the weekend," I said to myself, "I'll call them first thing Monday."

Here it is, Sunday, and I am already waffling.  Mostly because I don't want to hear what I am going to hear.  Also because I forgot that tomorrow is largely dedicated to an appointment chez Pain Management Dude, who currently heads my Shit List.

I imagine that the ID crowd will huddle up, confer, and then change antibiotics.  They may want testing first, which means a trip we dread, mostly due to the parking difficulties (and cost!) as well as the physical layout of the place, which recently moved into one of the hospital doctors' buildings, reachable only by a bridge and three elevator rides.  Or maybe that's just a smokescreen of an excuse.

I never ever feel "sicker" than when I am in that office.  Everyone is clearly ill, and seriously.  The doctors and PAs are candid and compassionate, and to see such able folk nonplussed can be upsetting.  Still, in the spirit of the place, I adopt the same abstracted, bland, blah expression as my infected mates.  We're a desperate group, pretending that nothing matters anymore.  We are, sadly, cool.


You must be really regretting the pithy and amusing account of my Sunday morning that this post was meant to be!

I did visit briefly with the three felines, as they are strangely separated today.  Marmy has coopted a comfy chair, and looks like she will never budge again.  Dobby is sulking, but sticking close to me, as is his wont, lately. And young Buddy is prowling about, vocalizing, and begging for food.  He sleeps as much as the other two but hasn't yet learned to anticipate his naps.  He just sort of collapses wherever he happens to be when fatigue hits him.

Believing that homey cat videos can salvage even the most disparate of blog posts, I present to you Buddy the Freakishly Large Kitten (enjoying some bonito tuna flakes and growing in front of my eyes) , Marmy Fluffy Butt (the embodiment of aloof), and Dobby the Runt (trying to remember why he's pissed at me).

Unfortunately, I didn't spot "triumverate" until the movie was made, and, well, I'm hoping you'll forgive me.

I'm freezing and gonna crawl back under the covers.  Me and Dobby, Dobby and me, forever....

Thanks for the distraction!