Friday, September 28, 2012

Joey Keller, Lego King of the World, Needs You RIGHT NOW

Hi all.  I went to bed worried about Joey, one of the four (okay, four "or so") pediatric cancer patients that I follow via the wonderful site CaringBridge.  You can go directly to his by clicking HERE.

His cancer, like every cancer, is a terrible one.

No, that's not true.  The first line of his "story" reads:  "Joey Keller is fighting multiple relapse medulloblastoma.."

He has one of the worst, but he has the biggest hunk of faith and derring-do that clearly comes from a slightly hyper father and a stalwart mom.  And his own joyful, humble little self, of course.  I forget sometimes how unique and -- sometimes for good -- alone these kids can be, despite the hurricane of activity whirling around them.  In their aloneness, they often develop god-sight and world-sight that puts adult vision to shame.

Such is Joey, Lego Kind of the World.

Last night, while his Dad was helping him take a bath, he suffered perhaps a stroke, perhaps a seizure, and became unresponsive.  At the hospital, he remained unresponsive, although he did begin to speak some, though what he was saying was incoherent.  He's in there, though, and that's the point.

They did a CT but really need an MRI.  He just had one recently, with fairly positive results in a very negative situation.  He has tumors of the brain and, almost more scarily, up and down his spine.

His Dad is in the allied health field (that's my impression) and is an avid amateur minister, investigator of God's promises, a tough friend to the deity.  He wears me out, frankly, and bless him for the drive to keep his Lord on his or her toes.  His Mom... she is balance, and I am sure she is sick of it.

I don't think anyone believes Joey is going to survive this cancer, and I hope his Mom and Dad won't reach through my computer screen with a wicked bitch slap.  But goodness, goodness, goodness, he deserves a conscious, peaceful death.  He deserves, they deserve, to feel connected to God, to feel that nothing has been left unsaid.

His Dad wrote, at some point during the night:  "He looks around a lot and seems like he wants to talk. We feel so bad for him. He's looking at me now, the light from hallway shining on our faces. I keep thinking my alarm clock's gonna go off, and ill wake up. or like less than 2 yrs ago, he'd walk up to the side of the bed and put his hand on our shoulders and gently rub our backs Till we woke up. This can't be real-"

So please, dearest readers, do what you do, so well, on Joey's behalf, and do it now.



UPDATE, 2 PM, 9/26/2012:  From Joey's Dad:  "Quick update. The meds needed to control Joey's seizures were stopping him from breathing. Very labored, and episodes where he would stop altogether. They moved us to ICU and intubated him for many reasons. They're gonna throw kitchen sink at stopping these seizures and on a ventilator they can't stop his breathing. Priority #1. We actually don't know if labored breathing is from the meds or the seizures. So gotta stop seizures. You know, I can't keep thoughts straight. Thx for prayers. As I get more info, I'll pass on so we all can be on same page with prayers. Thank you."

UPDATE, NOON, 9/29/2012:  "We just met with the lead ICU team, and wanted to get an update out on where we are at medically. I’ll try to remember all the details. She wanted to emphasize that the Joey we knew, with almost 100% certainty, will not be the Joey we see in the future. And without getting into all of the medical specifics, his brain has suffered so much trauma and injury, they think he won’t be at the “baseline” he was before the initial seizure in the tub. I want to mention too though, that the CT scan and EEG data don’t really show anything. They are going by the “posturing” we saw and some of the neurological deficits they see now. ALTHOUGH, they said in the first 24 hours (after incident or trauma) they always see patients getting worse. After that, we have about 4-6 days to see improvement (no guarantees of any improvement, or could see dramatic recovery, they really don’t know, medically.) They think after the first seizure, his sodium crashed and flushed fluid out of his brain, thus the posturing (and potential for brain damage/death.) This is really concerning. I was standing over him, alone, praying actually, when he went into that modeling pose and to think I was watching the fluid being flushed out of his brain, and possible assault to his brain makes me sick. SO, the fact that the CT scan and the EEG don’t show anything huge (like massive brain bleed) is a positive thing. Also, he pulls away from pain, pupils respond to light, he has been stretching, sometimes will open his eyes, heart rate goes up every time I talk to him, all are really good things. On the other hand, while the drugs he’s on are sedating, we found out, not so much that he couldn’t be waking up (over time, don’t know how much, but slightly concerned it hasn’t happened yet) pulling at the vent, irritated, etc. concerns them. But it could be too early to tell. She really didn’t know much, and we told her appreciated her saying that, other than he won’t be the same Joey we knew…but didn’t say what that would look like etc. Physically? Mentally? Or to what extent we would see those deficits."


Wednesday, September 26, 2012

I'm pretty sure I don't have cerebral palsy, YAY!

Here I sit, stuck.  Playing Taylor's "It's enough to be moving on..." in alternation with "Pancho and Lefty" by my dear, dear Townes Van Zandt.  I confess to an interlude by one of Dylan's worst.  Nope, not gonna admit which one.  Take a guess, why doncha?

Blue?  Clinically depressed?  I can tell you that in the second case, one gives a royal damn about the label.

Yesterday was spent freaking out a nurse practitioner who then called in my least favorite physician in the world, so that they could "upcode" my visit, I'm sure, to some ungodly ka-ching ka-ching cost that my Obamacare-inspired PCIP insurance coverage will pay without blinking a governmental eye.

He creeped up behind me, addressed me, as a vet might announce himself to a mildly feral kitten -- which is when I was able to add something to my list of why I don't like him:  He sounds like a girl pretending to be a boy who is sensitive and therefore, in his coiffed world, immediately likeable.

All he wants to do, he girl-whispers, is listen to my lungs and heart.  Ten seconds, tops.  The NP feels better,  now that he is of the opinion that I am not dying on the premises.  The entire ten seconds, he has his free hand pushing down on my left shoulder.  Wait! Isn't there something wrong in my presentation?  Right!  Now I remember!  I don't have a freaking left shoulder anymore, so that ten seconds was excruciating and I used it to explain my heart rate of 124.

"Oh, I am so sorry," s/he almost lisps, as s/he pats me on the freaking same spot.  He doesn't know that I know that he wears what must be a very elaborate hair piece.  I'm saving that for the day I really need it.

He's the PainManagement Dood, last highlighted in this blog, I believe, with this post, "The Cash Cow Blues."

You unsympathetic types out there are sniffing, muttering, "Well, why don't you just change doctors?" Well, welcome to the War on Drugs.  I am at the stage of CRPS (and, I reckon, chronic osteomyelitis) where pharmacological management is all that's left.  "Quality of life is what matters now," is how the NP neatly put it yesterday.

I found two great pain management practices and neither would take me on because I was solely managed by medication and would not require (nor allow) "procedures."  That's code word, usually, for sympathetic block upon sympathetic block, which I have done, and done, and done, to no avail.  So it's chichi toupéed pain management dood or no one.

But I like this new NP.  She thinks I'm reasonable.

Did I tell you that they drug tested me last visit?  And ushered me into a non-accessible to the wheelchaired-in-extreme-pain restroom for the Big Pee?  It was a riot.  I dropped the cup several times on the floor, praying that no one had sprinkled their cocaine on those questionable spots.

Great news:  "We found nothing in your tox screen except what we expected to find." Yay!  She reminds me that they do this every three months.  I tell her that's interesting, because that was my first drug test in 10 years.  She said, "I wondered how you were going to get along in that bathroom." I cracked my crack joke and she did not smile.

Anyway, we took one drug away, and added another that is very similar but less likely to make me suddenly bleed out, and, as I said, we established that using these more dangerous drugs is okay because everyone and their third cousins are in agreement that I have no more treatment options and that the goal, now, as approved by all the half-step-siblings, is "quality of life."  Unbelievably, these people actually shorten it to QOL.  Seems like an obscenity.

The reason the NP thought I was dying in her office?  Hypoglycemia.  Another side effect of the drug we eliminated.  Also possibly due to taking insulin and forgetting to eat.  So Fred was running down to the pharmacy to buy candy and I was raiding the treat jar they keep at the office check-out counter.  I couldn't explain myself, so I am sure the new employee on the other side of the desk thought me, at least, ill-mannered, as I grabbed one piece of hard candy after another.  Then she watches as Fred lopes in, breathless, and throws a chocolate bar at me and lobs over an orange juice.  She did great.  Smiled politely, as if being blitzkrieged by sugar fanatics was all in a day's work.  As soon as I could speak, I mumbled "blood sugar," and she added a nod to her smile.

Of course, now I realize that she was on the phone the whole time, having an earpiece 'n all.

I have treated myself to two things, even though I am also doing a Practice Lent.  I broke my café presse several weeks ago and have been living on coffee dripdripdripped through a Melitta filter.  Here's my thinking.  I am wasting coffee, as I require it very strong and the drip method needs a hunka-hunka coffee to make that happen.  So... ha!  Discover Card had its way with me.  They've made it possible to link your Bonus Points/$ to Amazon.  And that amount paid for my new La Cafetière café presse.  The goal now is not to break this one.

The second thing?  Nothing spectacular -- but we've found a brand of muesli that we like a lot, that is sold in bulk at Amazon, on the cheap, and is delivered to the front door.

Carbon footprint?  What carbon footprint?

If you knew me, if you knew me NOW, you'd be asking, "Hey, prof, what has got you so nervous that you're mired in all this minutia?" Well, smarty-panted Reader, I am to see the neurologist tomorrow, the famed hawaiin-shirted, always-sandled neurologist, who sometimes cries.  If he cries tomorrow, I am going to slug him right in the nose.

On this day of Small Anecdote, another one to bolster your faith in the medical system:  The nurse who called me this morning about tomorrow's neuro appointment said the good doctor needed to know if I thought my spasming was due to my cerebral palsy.

So my greatest joy thus far, and which shall buoy me through every suicidal moment of this day, was my immediate and assertive (not aggressive) response:  "I'm pretty sure I don't have cerebral palsy!"

Yay, me!

(Please excuse me, all of you who DO have cerebral palsy.  I'm classless, tasteless.)

She called back about 5 minutes later to apologize profusely, emphasizing that the doctor did, indeed, know whom I was as well as my "disease processes."  Her voice sounded all red and insecure.  I felt like saying they could diagnose me with leprosy, I don't care, so long as they treat the CRPS dystonia along the way.

"It's enough to be movin' on..."  Muesli, anyone?  How about a cuppa joe?






  

Monday, September 24, 2012

more reasons to hang on to a good doctor



i've been meaning to write but things have been extraordinarily rough.  this morning, i forced myself to take care of some business, financial, medical, and the spots on the kitchen floor.  that kind of thing.

also, chasing one buddy the freakishly large kitten who had what we politely call a "cling-on," a game that he found hilarious, but which induced need of a nap in me.  the expedition was a success, i am glad to say, and buddy is now allowed back on the bed...  where his twitching, dreaming self suggests that he is reliving the fun of ridding his derrrière of stray matter.  his huge paws are twitching...

there have been many mentions in this blog of my MDVIP go-to-guy.  at my most destitute, i came up with the money to keep him as the center of my medical "team." he's just that good.  you can read about MDVIP HERE.  i cannot vouch for anyone save my guy, of course.  there are some things about the system that i still don't understand, but that's about average for me, and probably won't be an issue for smarty-panted old you, dear reader.

but i ask you, how many of you have doctors that would field an email such as this one, that i just fired off?  he's told me that he lacks time for extra research into biofilm infections and -- like everyone -- is stymied by my extensive CRPS.  that said, he's asked me to forward to him references and my "takes" on journal articles that my astute judgment deem possible sources of actual action.

gracious?  the man is gracious -- even if it is mostly the epitome of a polite and sympathetic blow-off.

this morning's email:


need order for annual echo + med adjustment + consideration for more medication adventures

 profderien@gmail.com
2:15 PM (18 minutes ago)





to X, X  bcc: me

hi,

since insurance is at 100% coverage, i thought i would try to knock off any annual testing before the end of 2012.

  • the most important thing to me is the annual echo. i called dr. w's office and they require dr. MDVIP's referral/order.  would you please ask them to call me to schedule the appointment? 

i also just pre-ordered most of my meds for the rest of the year, some rx have expired or need renewal, so i apologize in advance for the flurry of faxes that will be coming your way.  

  • through experimentation, i've come to believe that taking two 200 mg generic plaquenil helps with bone pain better than just one.  if it is okay with you (and please pardon the experimentation), could the rx be changed to that dose amount?  i have never tried MORE than 400/day... ?  anyway, this is the rx# atmedco.com.  if you want me to stick to 200 mg/day, i surely will, in which case no changes are required at medco.   200MG  Rx# X



things are pretty miserable around here, mostly due to pain, spasm, fever, sweats, no sleep or too much -- otherwise known as "the usual"!  

  • before the end of the year, i'd like to have my blood rechecked, if that makes sense, including sed rate and c-reactive protein.  i won't be returning to infectious disease dood who usually does the blood work as a matter of course.  would/could you order through quest, as there is one near our manor.

a piece of confidential health care cost gossip?  infectious disease dood's office has garnered over $275,000 since JANUARY.  can you say "wretched excess"? i know the drugs are expensive... but, please...

i am trying to do the groundwork on biofilm infections but have trouble concentrating and most of the info stresses the wonders of prevention, and the best ways to identify bugs from implanted devices (once removed) -- which is all irritating to someone who is on the other side of the thing.

  • i am very interested in trying "drugs that work through TNF-alpha blockade" -- as there are many abstracts out there pushing for more studies of these biologics in CRPS -- going after the inflammation, i guess.  i am ready to skip the studies and go right to giving something an "off-label" try.  or maybe something like enbrel/remicade/humira wouldn't even need to be "off-label"?  how's about thalidomide?  i am wondering if my insurance would be suitably impressed just by a history of my c-reactive protein scores as justification... that'd knock their insurance socks off!
  • i am also wondering if it is worth restarting "bisphosphonate-type compounds such as calcitonin, clodronate, and alendronate" -- which we stopped because i had been on them so long. i've been off of them for well over a year now.  if yes, and they're all pretty much the same, my preference is for the cheapest! i'm doing my best not to bankrupt the country, though clearly, it is too late.
  • if we scratch off methadone and ketamine, there are still some NMDA receptor antagonists i haven't ingested, namely amantadine, memantine, dextromethorphan (did you suggest this to me once?).  the discussions (anecdotal patient message boards) i've seen for dextromethorphan have a huge range of doses, but all recommend "compounded" versions rather than OTC which has alcohol in it.  amantadine seems to be used for neuropathic pain pretty frequently...  memantine's best study included a huge cohort of three patients, so i dunno... you gotta love the investment big pharma is making into CRPS.

Clin J Pain. 2006 Jun;22(5):425-9.
Pharmacologic management of complex regional pain syndrome.
Rowbotham MC.
UCSF Pain Clinical Research Center, Departments of Neurology and Anesthesia, University of California, San Francisco, School of Medicine, USA. mcrwind@itsa.ucsf.edu


Few randomized controlled trials of oral pharmacotherapy have been performed in patients with complex regional pain syndrome (CRPS). The prevalence of CRPS is uncertain. Severe and advanced cases of CRPS are easily recognized but difficult to treat and constitute a minority compared with those who meet minimum criteria for the diagnosis. Unsettled disability or liability claims limit pharmaceutical industry interest in the disorder. Many studies are small or anecdotal, or are reported on only via posters at meetings. Targeting the process of bone resorption with bisphosphonate-type compounds such as calcitonin, clodronate, and alendronate has shown efficacy in three published randomized controlled trials. Intravenous phentolamine has been studied both alone and in comparison to intravenous regional blockade or stellate ganglion block. Steroids continue to be administered by multiple routes without large-scale placebo-controlled trials. Topical medications have received little attention. There has been considerable interest in the use of thalidomide and TNF-alpha blockers for CRPS, but no published controlled trials as of yet. Numerous other oral drugs, including muscle relaxants, benzodiazepines, antidepressants, anticonvulsants, and opioids, have been reported on anecdotally. Some therapies have been the subject of early controlled studies, without subsequent follow-up (eg, ketanserin) or without an analogous well-tolerated and equally effective oral treatment (eg, intravenous ketamine). Gabapentin, tricyclic antidepressants, and opioids have been proven effective for chronic pain in disorders other than CRPS. Each has shown a broad enough spectrum of analgesic activity to be cautiously recommended for treatment of CRPS until adequate randomized controlled trials settle the issue. The relative benefit of oral medications compared with the widely used treatments of intensive physical therapy, nerve blocks, sympathectomy, intraspinally administered drugs, and neuromodulatory therapies (eg, spinal cord stimulation) remains uncertain. In summary, treatment of CRPS has received insufficient study and remains largely empirical.





your natural reaction will be that some specialist somewhere should look into all this and do any prescribing.  excuse me while i giggle, because there just aren't any brave souls lining up to help.  i am going to try to make an appointment with the hawaiian-shirted neuro-guy , but am pretty sure he no longer wants to deal with me, either. this may seem an odd complaint, but he tends to over-medicate me...

sorry to cram so much into one email.  please take your time responding, there is no rush (except for scheduling the echo and correcting the plaquenil, if that's okay).  and if you ever want to charge me for an office visit as part of dealing with such an email, i'm good with that, you brave, brave doctor man.

take care,
profderien

Friday, September 21, 2012

Big Tall Bob Used To Reek Geek




He's a giant of a man.  When I first met him, seven years ago, he reeked "geek." He's still shy, but now he's buff, tan, wears the coolest clothes, and his spirit seems to have grown into his height, and beyond it, hovering as icy blue aura, or just making the air shimmer..  He seems to move with grace, even in clunky exam rooms overcrowded with rolling stools and tables full of tape and bandages, and those cotton swabs that top only one end of long, thin wooden sticks.

He's never been paid for his part as "assistant surgeon" in any of the eleven or twelve operations in which he has helped.  The insurance companies write that my surgeries should not require extra assistance.  If I can, and that's a huge "if," I'm going to try and leave him some money in my will.  He would die of Extreme Blushing and Embarrassment were I to do it while alive -- and I love his anti-geekness too much to put him in danger of a return to stammering and crooked glasses.

That makes an elegant segue for my tale of yesterday's appointment with Bob, Brilliant ShoulderMan's Physician's Assistant.  Unfortunately, I need to take a break, grab some frozen strawberries, cover them with fake sugar, and splashes of milk.  This concoction has comforted me several times a day over the last few weeks.  I don't know why -- except that it does cool me down, and I'm starting today's fever.  So I'll be back.  It's also a chance to give Buddy -- who is looking after me this morning -- his favorite treat of bonito flakes, fresh from the one-pound package in the freezer.  (We got the "okay" from the vet to give him as much as he wants, and he wants, and wants, and wants...)

Bob listens to me, and hears me, too.  When I'm stupid, he ignores the babbling.  When I'm glossing over something difficult, he gets very still, a hard thing for a big man to pull off.  He has crystal aquamarine eyes.

We talk cats sometimes.

There have been late-afternoon appointments, over the years, where he and Brilliant ShoulderMan's nurse would both sort of collapse onto chairs or rolling stools, even putting their heads down on the exam table.  I was like a fixture, I guess, and attuned to their fatigue.  These are some hard-working people. Once, I think we all three dozed off.  I remember the nurse shaking herself awake, handing me some pre-op paperwork to sign.  She started to go over each document, then said, "Oh, you know the drill..."  Informed consent at its best!

In the hospital, it is Bob who rounds more than anyone else, so he was the one who got to witness most of my CRPS misery.  He'd drop by between 5 and 6 AM, and I'd be doing well.  Between operations, say around 11 AM, he'd pop in to find me writhing, jerking, cussing.  He heard it all, he heard me say I was giving up, he heard me full of bravado, he saw me when I could not even speak.

When they take me into the surgery suites, I'm always lost.  I cannot see, so I tend not to speak to anyone, whereas they all feel like we're old friends, and come up and crack jokes, say sweet things, explain what is going on.  ShoulderMan and Bob usually aren't in there then, they come swooping in as I am put to sleep, I guess.  But this last time, in June (has it been that long?), there was this unmistakably tall figure moving about the surgical suite, emitting a reverberating voice.

Moving from the pre-op gurney to the operating table is always difficult.  Normally, the surgical staff would help, and the patient would be grateful.  Me?  They knew me so well that should some Newbie reach for a leg to help guide me onto the table, a whole chorus of "Don't Touch Her Legs, Let Her Do It!" rang out.  (Why the nurses up on the floor couldn't grasp the concept, I dunno!)

But this time, my legs were seizing and out of my control, mostly. My left shoulder was shot, hurt horribly with any movement (we shall not intimate that the regional block FAILED miserably!), and that left my right arm as the only available appendage to see to this transfer from gurney to operating table.  Had there been a trapeze, I might have been able to just drag myself over with that one arm, but you can imagine how incredibly crowded it already was in that area... machine after machine, lights, tables full of instruments, and people, lots of people.

I had already led some of the nurses in a sing-a-long during the trip there, and even as we all pondered how this transfer was gonna take place, we were still humming.

Finally Bob's masked face came down to about an inch from my nose.  "Hi Bob," I called out.  I think he laughed.

"We're going to pick you up and move you, and we're going to be quick and gentle."  Before I could bitch and hem and haw, it was done, but not without Bob's face coming back into the one-inch-from-my-nose range.  "Are you alright?"

It would have been one of the easiest entrances into surgery for me ever had not the anesthesiologist screwed up.  I always ask that they please give me good warning before putting me to sleep, as I like to say "thank you" to everyone in the room first.  (Tevye: "Tradition!")  I asked the guy, he said "okie-dokie."

I am difficult to intubate, so much so that they have had to break my teeth in desperation.  I guess that is what he was thinking about.  Anyway, the bleepety-bleep-bleep gave me the paralytic and then couldn't get the tube in, and I was wide awake, unable to suck air for myself, having thanked no one, and was about to come off the table in panic.

Move along, prof, move along.  I am avoiding getting to yesterday.

So... yesterday.  I had an appointment with Bob, one of the interminable "follow-ups." He asked, first thing, how it had gone with World Famous Hip Guy, who was supposed to have done an ultrasound and/or fluoroscope-guided aspiration of my hips, tracking down that wily Propionibacterium acnes.  The journey that led to me losing a shoulder was to begin with my hips.

I picked a spot on the wall behind Bob's right ear.  I told him that World Famous Hip Guy refused to operate on "someone like me" and wasn't eager, therefore, to do the diagnostics.  I told him we were kind of like oil and water.

Then I told him that I was giving up, and relayed the info from the biofilms expert, paraphrasing his "first there is a wound, then they lose a toe, a foot, a leg, and then they die." He did some fast blinking, as did I, and I risked looking at him.  He made it easy:

"So we're going to concentrate on pain control, then?"  blinkblinkblink

"Yeah, I think that is what makes the most sense..."

I was proud of Bob and proud of myself, in that I did not do that awful thing of asking:  "What do you think I should do?"

Somehow, we started cracking bad jokes, the best kind.  And we talked about the carbon footprint of sending a power wheelchair I am trying like hell to donate to someone in Haiti -- where my orthopedic team does mission work twice a year.  There is a local agency that could use it but they won't get their act together and come pick it up and we cannot deliver it for lack of a stabilizing bar for the lift.  BlahBlahBlah.

Suddenly, Bob blew it.  "You're a very special person."  Aw, damn. I, who know me, cannot let that stand, it feels like acid poured on my soul.

I made a rote denial and then managed a "Thank you, Bob, and thank you for everything you have done for me."

More blinking, and that was it.  He made some recommendations for drugs that won't make my stomach bleed, made me promise to come back in 3 months, and blinkblink, I woke the sleeping Fred in the waiting room, where people seemed to be guarding his snoring frame from disturbances.

"Awww." murmured the people, the Greek Chorus, as Fred struggled back to consciousness, cute as the dickens.

We did not speak of the appointment during the long ride home, and I was able to pretend to be bothered by the sun in my eyes.

Thursday, September 20, 2012

CRPS and Vaccines

Complex regional pain syndrome following immunization

  1. Nigel W Crawford1,4,6
-Author Affiliations
  1. 1SAEFVIC, Department of General Medicine, Royal Children's Hospital (RCH), Melbourne, Victoria, Australia
  2. 2Department of Anaesthetics and Pain Management, Royal Children's Hospital, Melbourne, Victoria, Australia
  3. 3Department of Paediatrics, West Suffolk Hospital NHS Trust, Suffolk, UK
  4. 4Murdoch Children's Research Institute (MCRI), Melbourne, Victoria, Australia
  5. 5Paediatric Infectious Diseases Unit, Department of Paediatrics, Monash Children's Hospital, Southern Health, Monash University, Melbourne, Victoria, Australia
  6. 6Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
  1. Correspondence toDr Nigel W Crawford, SAEFVIC Immunisation Safety Service, Department of General Medicine, Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia; nigel.crawford@rch.org.au
  • Accepted 26 June 2012
  • Published Online First 1 August 2012

Abstract

Complex regional pain syndrome type 1 (CRPS-1) is a clinical syndrome that affects one or more extremities and is characterised by persistent pain disproportionate to any inciting event, and at least one sign of autonomic dysfunction in the affected limb(s). The pathogenesis of this syndrome is poorly understood, but its onset is often precipitated by a physical injury, such as minor trauma, fracture, infection or a surgical procedure. In the literature, there are reports of CRPS-1 following immunization with rubella and hepatitis B vaccines. Here we present a case series of CRPS-1 following immunisation in adolescents, with either diphtheria-tetanus-acellular pertussis (1 case), or human papillomavirus vaccines (4 cases). Enhanced awareness of this syndrome and its potential to occur following immunization in the paediatric population is vital to the prompt and effective management of this condition.

Okay, not the most enlightening of abstracts.  A little research, however, disclosed this 2004 case study available in its entirety in the European Journal of Pain 9 (2005) 517-521:  Complex Regional Pain Syndrome Type-1 After Rubella Vaccine.  It's available through RSDS.org and its impressive library of free research.

Wednesday, September 19, 2012

It's enough to be on your way...


 Uploaded by Astralionica on Dec 27, 2009

Notes:
JT on Sony.com:

My brother Alex died in '93 on (not for) my birthday. We all went down to Florida to say goodbye. The day after we flew home (the day after his cremation) a giant mother hurricane followed us north through the Carolinas; trashing everything in its path and finally raining record rains on Martha's Vineyard (home).

In Paris, a year later I changed his character to a hippie chick named Alice and the location to Santa Fe; but my soulful older brother is still all over this song like a cheap suit.

Almost Fuck-free. 




The sun shines on this funeral
The same as on a birth
The way it shines on everything
That happens here on Earth
It rolls across the western sky
And back into the sea
And spends the day's last rays
Upon this fucked-up family
So long old pal

The last time I saw Alice
She was leaving Santa Fe
With a bunch of round-eyed Buddhists
In a killer Chevrolet
Said they turned her out of Texas
Yeah she burned 'em down back home
Now she's wild with expectation
On the edge of the unknown



Oh it's enough to be on your way


It's enough just to cover ground
It's enough to be moving on
Home, build it behind your eyes
Carry it in your heart
Safe among your own

They brought her back on a Friday night
Same day I was born
We sent her up the smoke stack
And back into the storm
She blew up over the San Juan mountains
And spent herself at last
The threat of heavy weather
That was what she knew the best




Oh it's enough to be on your way
It's enough just to cover ground
It's enough to be moving on
Home, build it behind your eyes
Carry it in your heart
Safe among your own



It woke me up on a Sunday
An hour before the sun
It had me watching the headlights
Out on highway 591
'Til I stepped into my trousers
'Til I pulled my big boots on
I walked out on the Mesa
And I stumbled on this song



Oh it's enough to be on your way
It's enough just to cover ground
It's enough to be moving on
Home, build it behind your eyes
Carry it in your heart
Safe among your own



\

Uploaded by LivingLegendsMusic on Apr 15, 2008
An exclusive series of Living Legends Music interviews with Livingston Taylor. Part 4 of 10. Recorded on January 12th, 2008 in Vero Beach, FL.


Tuesday, September 18, 2012

Respite from Romney: Peace is tenacious



Published on Sep 12, 2012 by 
Produced by News Channel 9 WSYR (Syracuse, NY) and Jim Dessauer.

From Gratefulness.org:  [In the "Fear and Peace" section]  This documentary by Jim Dessauer of Interfaith Works of Central New York honors five people from The Syracuse Area Middle East Dialogue Group who - for 30 years - have been building bridges of understanding that affirm the dignity of all people and all faith traditions.

InterFaith Works of Central New York, through education, service and dialogue, affirms the dignity of each person and every faith community and works to create relationships and understanding among us.



Medical Biofilms, Detection, Prevention and Control: free docstoc ebook download

Medical Biofilms, Detection, Prevention and Control


Edited by:

JANA JASS
Department of Microbiology and Immunology,
The University of Western Ontario, and
The Lawson Health Research Institute,
London, ON, Canada

SUSANNE SURMAN
London Food, Water & Environmental Microbiology Laboratory,
CPHL, London, UK

JAMES WALKER
CAMR, Porton Down, Salisbury, UK

Preface

Biofilms are a complex heterogeneous consortium of microorganisms associated with surfaces and interfaces and have been shown to play an important role both in causing disease and for maintaining health.

Microorganisms growing in biofilms may cause or prolong infections through, colonisation of implants or prosthetic devices and problems resulting from dental plaque formation. Modern medical practices and implant technology have alerted clinicians to the implications of biofilmassociated infections due to their persistence and resistance to antimicrobial treatment. Biofilms are also shown to be important in maintaining health by supporting commensal microflora that may assist in preventing pathogen infectivity.

This book is the first to deal specifically with biofilms associated with different medical areas including: the contamination of medical devices such as catheters, orthopaedic prostheses, renal dialysis, shunts, pacemakers and drug delivery systems; infection of tissue surfaces as in the lungs of cystic fibrosis patients, on damaged tissue surfaces (i.e. burns and surgery), bone (osteomyelitis), cardiac tissue (endocarditis) and genitourinary tract; and dental plaque, the cause of caries and periodontal disease.

For each of these topics the book provides an overview of current research in medical biofilms focusing on detection and monitoring the problems associated with biofilm and current strategies for control and eradication. To fully understand infectious biofilms, a current summary of the basic concepts in biofilm research and future prospects are included.

The editors intend that the book be used as an aid in teaching and research. Persons with an interest in medical diseases will find this book fascinating to read and the format is aimed at complimenting many hospital teaching courses for clinicians as well as medical and dentistry students.

The publication came about due to the increased awareness of the importance of adherent microbial populations in human health and disease, yet lacking a comprehensive text on information and research investigating the problems of medical biofilms, how to detect them and ultimately how to control their presence. Industrial environments have been ahead of the medical profession on their understanding and research progress on biofilms and biofouling of surfaces by microorganisms. The companion volume ‘‘Industrial Biofouling’’ (2000) discusses biofilms as a persistent problem and how to control them in potable water systems, industrial water systems and the food industry.

Dowload the PDF book here:
http://www.docstoc.com/docs/16424965...on-and-Control



Romney, "raw and unplugged": Thank you, David Corn



SECRET VIDEO: Romney Tells Millionaire Donors What He REALLY Thinks of Obama Voters

When he doesn't know a camera's rolling, the GOP candidate shows his disdain for half of America.
—By David Corn | Mon Sep. 17, 2012 1:00 PM PDT

During a private fundraiser earlier this year, Republican presidential candidate Mitt Romney told a small group of wealthy contributors what he truly thinks of all the voters who support President Barack Obama. He dismissed these Americans as freeloaders who pay no taxes, who don't assume responsibility for their lives, and who think government should take care of them. Fielding a question from a donor about how he could triumph in November, Romney replied:

There are 47 percent of the people who will vote for the president no matter what. All right, there are 47 percent who are with him, who are dependent upon government, who believe that they are victims, who believe the government has a responsibility to care for them, who believe that they are entitled to health care, to food, to housing, to you-name-it. That that's an entitlement. And the government should give it to them. And they will vote for this president no matter what…These are people who pay no income tax.

Romney went on: "[M]y job is is not to worry about those people. I'll never convince them they should take personal responsibility and care for their lives."

Mother Jones has obtained video of Romney at this intimate fundraiser—where he candidly discussed his campaign strategy and foreign policy ideas in stark terms he does not use in public—and has confirmed its authenticity. To protect the confidential source who provided the video, we have blurred some of the image, and we will not identify the date or location of the event, which occurred after Romney had clinched the Republican presidential nomination. [UPDATE: We can now report that this fundraiser was held at the Boca Raton home of controversial private equity manager Marc Leder on May 17 and we've removed the blurring from the video. See the original blurred videos here.]

Here is Romney expressing his disdain for Americans who back the president:




At the dinner, Romney often stuck to familiar talking points. But there were moments when he went beyond the familiar campaign lines. Describing his family background, he quipped about his father, "Had he been born of Mexican parents, I'd have a better shot of winning this." Contending that he is a self-made millionaire who earned his own fortune, Romney insisted, "I have inherited nothing." He remarked, "There is a perception, 'Oh, we were born with a silver spoon, he never had to earn anything and so forth.' Frankly, I was born with a silver spoon, which is the greatest gift you can have: which is to get born in America."

Romney told the contributors that "women are open to supporting me," but that "we are having a much harder time with Hispanic voters, and if the Hispanic voting bloc becomes as committed to the Democrats as the African American voting block has in the past, why, we're in trouble as a party and, I think, as a nation." When one attendee asked how this group could help Romney sell himself to others, he answered, "Frankly, what I need you to do is to raise millions of dollars." He added, "The fact that I'm either tied or close to the president…that's very interesting."

Asked why he wouldn't go full-throttle and assail Obama as corrupt, Romney explained the internal thinking of his campaign and revealed that he and his aides, in response to focus-group studies conducted by his consultants, were hesitant to hammer the president too hard out of fear of alienating independents who voted for Obama in 2008:




We speak with voters across the country about their perceptions. Those people I told you—the 5 to 6 or 7 percent that we have to bring onto our side—they all voted for Barack Obama four years ago. So, and by the way, when you say to them, "Do you think Barack Obama is a failure?" they overwhelmingly say no. They like him. But when you say, "Are you disappointed that his policies haven't worked?" they say yes. And because they voted for him, they don't want to be told that they were wrong, that he's a bad guy, that he did bad things, that he's corrupt. Those people that we have to get, they want to believe they did the right thing, but he just wasn't up to the task. They love the phrase that he's "over his head." But if we're—but we, but you see, you and I, we spend our day with Republicans. We spend our days with people who agree with us. And these people are people who voted for him and don't agree with us. And so the things that animate us are not the things that animate them. And the best success I have at speaking with those people is saying, you know, the president has been a disappointment. He told you he'd keep unemployment below 8 percent. Hasn't been below eight percent since. Fifty percent of kids coming out of school can't get a job. Fifty percent. Fifty percent of the kids in high school in our 50 largest cities won't graduate from high school. What're they gonna do? These are the kinds of things that I can say to that audience that they nod their head and say, "Yeah, I think you're right." What he's going to do, by the way, is try and vilify me as someone who's been successful, or who's, you know, closed businesses or laid people off, and is an evil bad guy. And that may work.

(Note: Obama did not promise his policies would keep unemployment under 8 percent, and 50 percent of college graduates are not unemployed.)

[....]

READ THE REST OF DAVID CORN'S FIRST PIECE ON THIS VIDEO FROM THE BOCA RATON FUNDRAISER HERE.

More from the secret Romney video. (Romney tells his donors he doesn't believe in a two-state solution for the Israeli-Palestinian conflict, that resolving this conflict is "almost unthinkable," and that he would merely "kick the ball down the field."): SECRET VIDEO: On Israel, Romney Trashes Two-State Solution 

Here is a surprising and shocking teaser to that second Corn piece:  "Palestinians have no interest whatsoever in establishing peace."  I confess that I am still not over the shock of Romney's remarks made at the end of July, during his Gaffe World Tour:

"As you come here and you see the GDP [gross domestic product] per capita, for instance, in Israel which is about $21,000, and compare that with the GDP per capita just across the areas managed by the Palestinian Authority, which is more like $10,000 per capita, you notice such a dramatically stark difference in economic vitality." Mr. Romney told a group of donors gathered at the King David Hotel in Jerusalem. He added: "And that is also between other countries that are near or next to each other: Chile and Ecuador, Mexico and the United States."  He went on to explain that the marked décalage between the GDP in Israel versus the downright pitiful laziness exhibited in the GDP of Palestine was due to "culture."   I don't understand how the Earth continued to turn on its appointed axis after that statement, but that's just me...

As for Romney's response to the release of the Boca Raton videos [that underscore what everyone already knew, but were striking in the ease and familiarity of tone the Good Guvnor exhibited], the Christian Science Monitor reports:


At an impromptu news conference Monday, Romney offered no apologies, conceding the comments were not "elegantly stated" and were spoken "off the cuff." The Republican presidential nominee said the remarks showed a contrast between President Barack Obama's "government-centered society" and his belief in a "free-market approach." 
"Of course, I want to help all Americans, all Americans, have a bright and prosperous future," Romney told reporters.



Zofran, anyone?