Considering the Coverage of the Earthquake, Tsunami and Nuclear Reactor Breakdowns

Listening to and watching the news, last night and this morning, I’ve heard all kinds of stuff – mainly from reporters who don’t seem to know very much about physics or radiation. (Personal kudos to Anderson Cooper, who seems to have a broader command of the terms and handle on the situation than some of CNN’s designated experts.)

image via multiple sources, originally on NHK world news (link)

In general, my take on the English media coverage so far is that the New York Times is doing a good job with the physics and the unfolding events in themselves (with the exception of an irrelevant, essentially absurd three paragraphs in a strange piece with quotes from a former astronaut on why we should worry about asteroids hitting the earth that fell into the Sunday Week in Review; don’t know how that got through the editor’s non-panic button); Scientific American has some strong coverage on the matter; Slate has its streaming, distinct slant

Here in the U.S., yesterday (and perhaps earlier) some people started worrying how this might affect us, here. Some friends have asked me what I think they should do. Supposedly all companies that manufacture potassium iodide pills have sold out. I don’t offer public health advice here, and I won’t comment on the confusing and contradictory published recommendations and doses for potassium iodide which has, if anything, a limited potential to protect people from thyroid cancer.

The sites below are unfortunately limited in the information they provide, and outdated as I considered last weekend, but the sources are comparatively reliable:

Union of Concerned Scientists

U.S. Nuclear Regulatory Commission

CDC on Radiation Emergencies

EPA on What You Can Do

FEMA on Nuclear Power Plant Emergency

Radiation Effects Research Foundation (a joint project of the Japanese and U.S. Governments; hat tip to Merrill Goozner for cluing me into this agency’s existence)

The bottom line is that there’s no easy fix, or ready protection from most forms of radioactivity. My personal opinion is that the risks here are low, essentially negligible, and that the reason to watch all of this is to learn how we (in the big sense, including them) can build better, safer energy sources in the future.

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Still Thinking About the Earthquake in Japan, and How to Help

Here is a partial list of agencies helping to provide assistance and relief to the people of Japan during this emergency:

Save the Children

Doctors Without Borders

The American Red Cross*

United Jewish Appeal Japan Earthquake Relief Fund

You may have your own favorite charity, which of course may be the best way for you to help.

And then I found Lady Gaga on-line late this evening; she’s lending a hand with proceeds from special Japan prayer bracelets that she’s designed. Based on her website links, it appears the money she raises, promoted via Twitter, will go to the Citizen Effect Japan Earthquake Relief Fund.  Whatever works –

Addendum, 3/16/11 – I read in today’s NY Times that the Japanese Red Cross is not accepting help from the American Red Cross, or from many other (unspecified) charities and international agencies. I cannot verify the goodness or efficiency of any particular charities, except to say that in general it seems from the pictures that the people in northeast Japan need food and clean water, among other things.

I don’t know which are the “best” ways to help, if you can and want to do so, except that money that can be used as needed is generally considered more effective than sending, say, hundreds of thousands of used shoes and blankets and canned vegetables. Or maybe not.

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Live-Blogging a Book, and the Earthquake

I don’t know if makes sense to blog on a book by a woman who’s dead, who wrote about photographs and the news. But new media allows us to try new things, unedited. Here goes:

In Regarding the Pain of Others, which I began, unknowingly, on the evening before the recent quake and tsunami, Sontag begins Chapter 2:

Being a spectator of calamities taking place in another country is a quintessential modern experience <she refers mainly to war photography>…’If it bleeds, it leads’ runs the venerable guideline of tabloids and twenty-four-hour headline news shows – to which the response is compassion, or indignation, or titillation, or approval, as each misery heaves into view.

This observation, published in 2003, would account for CNN’s sending so much of its lead staff – Anderson Cooper, Dr. Sanjay Gupta, Soledad O’Brien and others – to northeastern Japan now. Some of us are drawn to the images of devastation, and these do sell.

(AP Photo/Asahi Shimbun, Toshiyuki Tsunenari)

The author continues, later:

…But there is shame as well as shock at looking at the close-up of a real horror. Perhaps the only people with the right to look at images of suffering of this extreme order are those who could do something about it – say, the surgeons at the military hospital…or those who could learn from it. The rest of us are voyeurs, whether or not we mean to be…

So maybe (as she sees it, in Chapter 2) it’s OK to look at the images if there’s a good reason to do so – for examining how others cope with a catastrophe by distributing food in limited amounts in orderly lines in order to learn, for example; or for demonstrating which structures withstood the quake and flood, which breezed over the seawall; or for planning the location and cooling protocols for nuclear reactors elsewhere…Also, quite plainly, the images may serve to raise money and needed support for the devastated region.

A soldier carries an elderly man on his back to a shelter in Natori city, Miyagi prefecture on March 12, 2011. (Photo credit: STR/AFP/Getty Images, via Flickr, as permitted)

Back to medicine – today, people are quite familiar with images of sick people. There are open, on-line communities of people sharing heartache and complications, sometimes with wrenching images. TV and the movies familiarize us with catastrophes to such a degree they may seem ordinary or unimportant. We’re desensitized, I fear, in which case the news audience’s attention is strangely reassuring.

"Japan Earthquake: Watching the Terrible News on TV" (flickr by LuisJouJR)

Maybe the people who are looking at the pictures are doing so because they really care about the people in northeast Japan. Or maybe it’s because they’re wondering – could this happen to me, all of a sudden, in the middle of an ordinary day, i.e. do I need to worry about this? Or both.

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Searching for Information in Case of a Nuclear Disaster

I find it hard to think much about anything besides the earthquake and devastation in northeast Japan. It’s a place I’ve never been. I don’t speak the language.

In trying to learn something from this, it makes sense to review what to do in case of a nuclear disaster, the kind of thing that should never happen. Today millions of people on the planet are concerned about the radioactivity and what’s happening to the power plants without electricity and the usual cooling systems, with failed backup generators and tons of uncertainty.

Yesterday evening CNN had Bill Nye, the science guy, on TV telling us about nuclear plant meltdowns. This reminded me of my children when they were children and watched his good show. Not helpful, now. (Sorry, Bill.)

The problem is the dearth of reliable information on what to do about nuclear reactors that are or were or are intermittently releasing radiation into the atmosphere. The Times says the Danger Posed by Radioactivity in Japan is Hard to Assess. Scientific American offers expert details on reactors, instructive on the physics but not exactly useful for people wondering what they ought to do in an emergency.

Here is what I could find in the way of practical links in English:

CDC on radiation emergencies and potassium iodide (and Prussian blue, not recommended without a doctor’s supervision; of historical interest to hematologists, for reasons of iron staining in bone marrow specimens, and others);

EPA on Responding to Radiological Emergencies (with subpages, mainly on how the EPA and officials would work) and What You Can Do (clear info on reporting a problem; little advice on what to do in case one happens);

FDA on potassium iodide (w/ info on doses);

FEMA on Nuclear Power Plant Emergency. This site seems to have the most practical advice on what to do during a nuclear event;

Health Physics Society doesn’t seem to cover this topic (please correct me if I’m wrong);

Nuclear Regulatory Commission (NRC) on Preparing for and Responding to a Radiological Emergency (recommendations to check radio or TV for updates seem outdated as they would be problematic in case of widespread power failures).

To be thorough, I searched what some would call the blogosphere –  medical and physics – for updates on this, and found essentially nothing. Weekend effect?

My main observation is that publicly-available information on this topic is woefully inadequate. Surely, health officials around the world are taking notes.

The other main point, as is explained on the CDC’s site, is that potassium iodide (KI) can protect from absorption of radioactive iodine in the thyroid gland. This would reduce the risk of thyroid cancer developing later on, but doesn’t protect from harmful effects of other isotopes.

My thoughts and prayers are with the people of northeastern Japan.

all links accessed 3/13/11

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Contemplating Empathy, Early This Morning After the Earthquake

Last night I began reading a long essay, Regarding the Pain of Others, by Susan Sontag. The work dates to 1993, and centers on the power of photographs of war. She considers Virginia Woolf’s earlier reflections on horrific images from the Spanish Civil War, in Three Guineas.

Sontag writes: “Not to be pained by these pictures, not to recoil from them, not to strive to abolish what causes this havoc…for Woolf, would be the reactions of a moral monster… Our failure is one of imagination, of empathy: we have failed to hold this reality in mind.”

This morning I awoke early and saw video of an earthquake rattling portions of Japan and a tsunami destroying broad swaths of land in a country where I’ve never been. I’m distracted by those images and while I’m trying to work on another subject, my mind flips back to what’s going on there, along the Pacific.

Japanese Tsunami Victims

(from Flickr: Japanese Tsunami Victims, by Logan)

So it seems like the right day to review some basics on empathy. I hope my readers won’t mind if this part is too simple. It’s just that the word is thrown around so often lately, in places like Twitter and Time Magazine, on doctors and compassionate health care; I should remind myself if no one else exactly what empathy is supposed to be.

First, a distinction: Sympathy usually refers to feelings elicited upon a mutual or shared experience; empathy involves understanding another’s experience.

A post on KevinMD by Barbara Ficarra, a few months back, led me to a 2003 academic review on empathy in clinical medicine, by Jodi Halpern, MD, PhD, who writes:

…Outside the field of medicine, empathy is an essentially affective mode of understanding. Empathy involves being moved by another’s experiences. In contrast, a leading group from the Society for General Internal Medicine defines empathy as “the act of correctly acknowledging the emotional state of another without experiencing that state oneself.”3

Halpern explains the difference between empathy and sympathy, with a distinction I was taught in a rudimentary ethics class in medical school:

This recent definition is consistent with the medical literature of the twentieth century, which defines a special professional empathy as purely cognitive, contrasting it with sympathy. Sympathetic physicians risk over-identifying with patients…

Th open-text article in the Journal of General Internal Medicine (18: 670–674, 2003) is well-worth the full read.

Meanwhile I’ve discovered measurable criteria for physicians’ empathy, the so-called Jefferson Scale of Empathy. From the Science Daily (via the Tweet, above) on a report in the journal Academic Medicine:

Researchers used the Jefferson Scale of Empathy (JSE) — developed in 2001 as an instrument to measure empathy in the context of medical education and patient care. This validated instrument relies on the definition of empathy in the context of patient care as a predominately cognitive attribute that involves an understanding and an intention to help. The scale includes 20 items answered on a seven-point Likert-type scale (strongly agree = 7, strongly disagree = 1)…

This sort of empathy rating system seems strange to me, even alienating; it’s plainly too numerical.

I’d rather stick with my feelings, and stare at today’s photographs and videos, and finish reading Sontag’s notes on The Pain of Others, this evening.

Monster Quake Hits Japan (the Australian.com, March 11, 2011)

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Benlysta, A New Treatment for Lupus

Lupus, an autoimmune disease, turned up on the front page, right side of today’s Wall Street Journal. It cropped up, also, on the first page of the New York Times business section, and elsewhere. Scientific American published a nice on-line review, just now. The reason is that yesterday the FDA approved a new, monoclonal antibody for treatment of this condition.

The drug, Benlysta (belimumab), targets a molecule called BlyS (B-lymphocyte Stimulator). The newspapers uniformly emphasize that this drug marks some sort of triumph for Human Genome Sciences, a biotech company that first reported on BlyS in the journal Science way back in 1999. BlyS triggers B cells to produce antibodies that, in patients with lupus tend to bind and destroy their own cells’ needed machinery, causing various joint, lung, liver, kidney, brain, blood vessel and other sometimes life-threatening problems. So if and when Benlysta works, it probably does so by blocking aberrant, autoimmune B cell activity.

micrographs of lupus pathology in the kidney, Nephrol Dial Transplant, 25: 153-159 (2010)

The papers don’t give a lot of details on the drug’s effectiveness, except that it appears to help roughly 1 in 11 patients and the main benefit may be that some lupus patients on Benlysta can reduce their use of steroids, which have long-term and toxic effects on many organs. The most recent, major medical publication on a trial on the drug came out in the Lancet, two weeks ago.

Some reported caveats are that the drug has not been adequately tested or approved for patients with severe kidney or neurological manifestations of the disease, and that its activity, marginal as it is, appears to be less in patients of African heritage based on trials completed thus far. Additional trials are in the works.

The drug is expensive, to the updated tune of $35,000 per year. According to the WSJ: “Estimates of how many Americans are affected range from 161,000 to 1.5 million.” (How’s that for a wide ballpark figure? – likely a function of how hard it is to define and establish diagnosis for this disease, which anticipates how hard it will be to measure this drug’s effects, see below.) The same Journal piece says analysts expect the drug to become a blockbuster, with annual sales eventually topping $1 billion.

I’ve been intrigued by lupus ever since I was a second-year medical student, studying pathology before BlyS was discovered and monoclonal antibodies could be bulk-manufactured and tested in clinical trials. The disease’s name – from the Latin term for wolf, refers to the appearance of a facial rash that some patients develop.

Lupus can be scary to treat. One of my clearest late-night memories of my residency was when a 23 year old woman with lupus “rolled in,” as we would say, to the E.R. around 5:30 AM, as I was nearing the end of my then nearly-unrestricted shift. “We’ve got a sickie,” a nurse said as she roused me from my work on a hand-written note about someone else. The patient was dehydrated and gasping for air, and I remember having trouble getting her IV in, but somehow I did and she made it at least to the ICU.

From an immunologist’s perspective, it’s a fascinating condition because it flares and quiets – sometimes on its own – and affects different organs in distinct patterns among patients. The causes of lupus are likely varied. It may be that shutting down BlyS with an antibody is just a fancy and possibly more-targeted, less-toxic way of doing what steroids, like prednisone, do to B lymphocytes.

The problem I’d anticipate with the trials – carried out by my ever-patient, expert rheumatology colleagues – is that it’s sometimes hard to measure disease activity and responsiveness in lupus, apart from the kidney, because so many of the symptoms are subjective. And because the disease can affect so many organs, it’ll be hard to appreciate the drug’s toxicity, as apart from disease in itself.

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New Data for Avastin (Bevacizumab)

A new report was published on-line this afternoon by the Journal of Clinical Oncology (JCO). It covers a Phase III (randomized) clinical trial of Avastin (Bevacizumab) in women with metastatic BC. Over 1200 patients were included in the analysis, all with Her2 negative disease.

The design of the randomized study protocol was a bit unusual, in that the treating physicians could choose among a few, standard chemo options to give their patients – the so-called “backbone” for treatment for each cohort in the trial, along with hormonal treatment and the study drug: Avastin or a placebo. Avastin is a monoclonal antibody that binds to the vascular endothelial growth factor (VEGF). It’s manufactured by Roche and is quite costly.

What the investigators report, now, is that women who received Avastin and any of the chemo regimens did better – in terms of what’s called progression free survival – than did those who received the same chemo and placebo treatment. The difference was a matter of a few months, on average, and there were no measurable change in overall survival. What this means is that in some women with metastatic breast cancer, Avastin appears to help keep the disease in check.

The study is called RIBBON-1, which I learned this evening would be for the first study of Regimens in Bevacizumab for Breast Oncology. Sounds lame, I know, but believe me – it’s hard for oncologists to keep trials straight without acronyms. Even with the acronyms.

It happens I know some women with triple negative BC who have benefited from Avastin. These women may be outliers on the curve, but they are real and they exist and I know them personally, in what should be the middle of their lives.

Maybe we, and the FDA, shouldn’t give up so fast on Avastin.

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The Flip Side of Unrealistic Optimism

Last week, Pauline Chen wrote on medical ethics and clinical trials. She reflects on her training at a cancer research hospital, where some cancer patients go with unrealistic optimism.

Like Dr. Chen, I spent part of my training at a famous cancer center where I worked as a resident and fellow on rotations. And yes, some patients were unreasonably optimistic and some – perhaps even most, it seemed – didn’t fully “get” the purpose of their trial, which in Phase I studies were not designed to help them. This is a real dilemma for treating oncologists.

The problem of patients’ false expectations might arise from a Lake Wobegon effect, suggests Dr. Daniel Sulmasy in the Times piece: “If you have more than 50 percent of patients saying their chances are better than average of avoiding some harm or obtaining some benefit, they are being unrealistically optimistic because you can’t say that most people are above average.”

I share Chen’s concern about ethics in clinical trials. Besides that patients don’t always (read: often) don’t understand the study, and that they may be coerced – usually subtly – into signing on, and that they may, ultimately, be simply used as objects in a researcher’s career-advancing investigation, clinical research sometimes does help humans, and progress occasionally happens in medicine. Take the woman with metastatic melanoma she recalls in the story: There might be effective drugs for her condition now, or next year.

The flip side of the Wobegon effect in medical ethics of clinical trials is that some patients (and their doctors) might have undue pessimism. These are the “50 percent” of patients who won’t show up at research centers, which could, potentially, help them to get well or at least feel better.

I think one of the biggest challenges for patients with serious conditions and their doctors is discerning what’s worth trying, and what’s snake oil in an academic outfit. Hard to know before the trial’s done –
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Portrait of a Peculiar Relationship at the End of Life

Last weekend I went to see a strange, slightly unnerving play, The Milk Train Doesn’t Stop Here Anymore by Tennessee Williams. It’s a sad take on the end of life, and desperation in some lonely characters.

Olympia Dukakis plays an aging, vain, older woman who’s dying of an unnamed condition. She takes morphine injections help her “neuralgia,” and uses liquor to entertain guests and, without success, to blunt her emotional pain. A handsome young man, presenting himself as a poet and sculptor of mobiles, climbs up the hill on which rests her Italian villa.

She’s no fool and quickly learns of his moniker, “the angel of death.” It’s said he has a particular fondness for terminal, moneyed women. Still he is impoverished; he shows up essentially starving and with nearly nothing in his sack; he has not exactly benefited from his exploits.

Darren Pettie and Olympia Dukakis

Dying alone is scary, unbearable. So she lets him in; her fear outweighs the final compromise of being used, and touched, by a stranger seeking something in exchange.

A straight read of the play might make you think it’s the story of a man who flatters older women in exchange for shelter and food. Another take might consider the man’s need or desire to comfort, to reduce another’s pain, which might be genuine while pathologic, and the pleasure he might feel in doing so.

Hard to know what was Williams’ intention in this 1963 work. I found it intriguing.

A medical lesson?

Yes, I’d say it is, especially now as doctors may become as robots. I can’t help but think of a patient who somehow and for whatever reasons alone in the hospital at the end of life, who cannot be helped by a machine. One role of the oncologist or other familiar physician, some might say, is to be there – even if paid, “on duty” if you insist – to hold the patient’s hand when the end comes.

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Tennis News and Why a Healthy Young Woman Might Get a Pulmonary Embolism

Yesterday I learned that Serena Williams, the tennis pro, has been treated for a pulmonary embolus. My husband found out this morning upon reading the newspaper. He wondered why this would happen to a strong, young, athletic woman.

Without delving into the private or specific aspects of her case:

A pulmonary embolism, or PE in doctor-speak, happens when a blood clot enters or forms in the blood supply to the lungs. It’s a serious condition, because when blood vessels in the lungs are compromised, the lung cells can’t deliver fresh oxygen to hemoglobin that would normally pass through in red blood cells. Symptoms sometimes but not always include shortness of breath, pain in the chest that’s sharp in quality, and fatigue. Usually the diagnosis is made by a scan, such as a VQ or a special kind of (spiral) CT.

tennis racket and ball (Wikimedia Commons)

Treatment includes a blood-thinner, usually for a period of months. At first, and depending on the severity of the circumstances, patients may benefit from oxygen treatment through a light face mask or by nasal prongs. In general, doctors monitor patients for a short time in a hospital, to make sure the clot doesn’t get worse and that they don’t need additional oxygen support, and that the anti-coagulant is working.

When patients get blood clots it’s usually because they have a genetic tendency combined with some situation that aggravates that disposition. For example, if someone is born with a deficiency in a protein – of which there are quite a few – that normally dissolves clots, they might feel fine throughout life and be unaware of their hypercoaguable state. But after a big surgery, or if they were immobilized and dehydrated on a long plane ride, that might lead to a clot formation.

Sometimes surgery or inflammation in an extremity, such as a leg, can dispose to clot formation. When a clot forms there, it’s called a deep venous thrombosis (DVT) and that can, especially if untreated, break off and move through the large veins, to the right side of the heart, and then enter the pulmonary artery and smaller vessel or vessels in the lung. In that case it’s a PE.

Pregnancy, in itself and especially in women with underlying clotting disorders, can dispose young women to a DVT or PE. The same is true for estrogen-containing medications including birth control. Smoking, too –

A short personal perspective is that I once cared for a woman who had a PE who was young and attractive. She had been on a long, international flight a few days before she came to the E.R. It took hours for her to get past triage, and I suspect that was because she looked so healthy. It turned out she had a huge clot in her lungs, and a complex clotting disorder.

If a person with a DVT or PE turns out to have a genetic disposition, it doesn’t mean they need life-long treatment with a blood thinner. Depending on the location, severity of the clot and the circumstances, treatment is given for weeks or months. But it can be helpful to know if you have a clotting disorder. Some patients take prophylactic, low-doses of blood thinners when they travel or after immobilizing surgery, like a hip replacement.

Here are some useful websites that provide information on blood clots:

The American Society of Hematology (which confirms that March is DVT Awareness Month)

PreventDVT.org

Medline Plus

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Learning About the Cancer Genome Atlas

A tweet from a former research colleague reminded me about the Cancer Genome Atlas, which I’d been meaning to check out. This website covers a project jointly funded by two NIH institutes: the NCI and the National Human Genome Research Institute (NHGRI). The project is about documenting cancer genetics for many, many human tumors.

Cancer Genome Atlas image

Some basics –

We all have genetic sequences we’re born with: our personal genomes. If you were to get your genome sequenced by a company, like 23andMe, they’d get some DNA from any of your cells or body fluid, and sequence your “somatic” or cellular genome. They would identify variants and mutations that you carry in the DNA of all or most of the cells in your body.

Cancer cells often contain genetic mutations that are not present in the patient’s healthy cells. So an individual’s breast cancer genome, for example, might differ from her baseline, inherited genome.

The purpose of the cancer genome project is to sequence DNA present in tumors samples so that researchers can identify specific, genetically distinct cancer forms and, eventually, develop smarter drugs that take aim at those tumor-specific mutations.

The site offers some cool, public-domain pathology and genetics images through a multimedia library. Good to know –

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