Noting Depression in Susan Glaspell’s 1917 Story: A Jury of Her Peers

Recently I read the short story, A Jury of Her Peers by Susan Glaspell, with a group of women in my community. The author, with whom I wasn’t previously familiar, first reported on the real 1901 trial of Margaret Hossack, as a journalist writing for the Des Moines Daily News. Later she adapted the story as a one-act drama, Trifles, and then in 1917 as a short narrative published in Everyweek, a long-defunct magazine of the Crowell Publishing Company.

Original performance of "Trifles," (from the Billy Rose Theatre Collection, New York Public Library at Lincoln Center)

There’s a lot you might take from this swift, rich read. It goes like this: A man and his son came upon a couple’s house in rural area. The man’s been killed, clearly; his wife sits in a chair, oddly, and can’t say what happened to her husband. The local authorities and a few neighbors step in. The home was not well-kempt; the wife is accused of murder. Two other women, whose words spin the tale, poke about the kitchen and make inferences about the jailed woman’s circumstances.

Some points are readily gleaned: on homemaking, and quilting – literally and metaphorically, in early 20th Century America. There are legal elements, and allusions to domestic violence and abuse. What intrigued me most, though, was the author’s indirect depiction of their neighbor’s isolation and apparent depression:

“A person gets discouraged–and loses heart,” one considers…

“I stayed away because it weren’t cheerful–and that’s why I ought to have come,” says the other.

The two women express sympathy for the accused wife’s plight; they regret that they didn’t visit or otherwise help her earlier on, before the situation took a catastrophic, violent turn. The women understood, without saying it exactly. Mental health wasn’t a topic of common discourse, then, but these characters – and so must have the author, clearly – got the drift.

I won’t tell the whole story here, but I do recommend the tightly-woven, knotted piece.

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Getting the Blood Tests Right at the Phlebotomy Center

Last week I had some blood tests taken before a doctor’s appointment. I went to a commercial lab facility, one of several dozen centers for collecting specimens have opened up in otherwise-unrented Manhattan office spaces lately.

I have to say I really like getting my blood work done at this place, if and when I need blood tests. And it’s gotten better over the past few years.

First, pretty much all they do in the lab center is draw blood and collect other samples based on a doctor’s orders. So the people who work there are practiced at phlebotomy, because it’s what they do most of the time. The guy who drew my blood last week did the same a year or two ago, and he was good at it back then. He used a butterfly needle and I didn’t feel a thing.

Second, they seem organized and careful about matching specimens to patients. The man who drew my blood didn’t just confirm my name and date of birth, but he had me sign a form, upon my inspecting the labels that he immediately applied to the tubes of blood he drew from my right arm, that those were indeed my samples and that I was the patient named Elaine Schattner with that date of birth and other particulars.

Sounds like a paperwork hassle for the phlebotomist? You might say this is time-costly for his employer and for me, the patient. Maybe, but I’d rather have my blood samples drawn in a place ordered like that, where it’s less likely that my tube of serum will be accidentally switched with another person’s, generating error, confusion, possible unnecessary worry, further hassle and costs.

I have a strong preference for not cutting corners when it comes to my health care. I’m glad there are more regulations of clinical laboratories, enforced mainly through CLIA. In a busy physician’s office or other medical facility where doctors and nurses and technicians are strapped for time, and too-often plainly tired, the more essential are these quality checks.

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The Trouble With Ginger

A short post for Friday:

The Times published a short piece on ginger this Tuesday, on whether or not it relieves morning sickness. The conclusion is that it’s less effective for nausea in pregnancy than in seasickness and chemotherapy treatment.

When I was getting chemo, I received a gift of ginger tea. It didn’t help at all. Now, if I even sniff that stuff, I want to throw up.

Curiously, I have no problems with ginger in food. I use the fresh ingredient all the time.

No explanation –

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Some Articles I Authored A While Ago

This post, on my research in cancer immunology, is strangely personal.

At one level, what follows is nothing more than a list, a narrative if you will, a sketch of a formative chunk of my career and personal history. I’ve wanted to put this out there (here) for quite a while, but couldn’t: It’s been hard for me, harder in some ways than was the breast cancer and spine surgery and all the other unpleasant illnesses I haven’t mentioned yet, to come to grips with my near-hit academic medial research career that stopped, which until today has been for the most part disconnected from this blog and my new on-line life.

So here goes, a partial list of my publications, selected from ~30:

On a novel mechanism for B-cell death, my first first-author article based on my research in lymphoma immunology, in The Journal of Experimental Medicine, 1995:

CD40 ligation induces Apo-1/Fas expression on human B lymphocytes and facilitates apoptosis through the Apo-1/Fas pathway

On how “helper” T cells can kill some forms of malignant B cells, in Blood, 1996:

CD4+ T-cell induction of Fas-mediated apoptosis in Burkitt’s lymphoma B cells

A solicited review of my early labwork, completed with my research mentor, in Immunologic Research, 1996:

Fas expression and apoptosis in human B cells

My first paper on CD40L and autoimmunity, in CLL, in Blood, 1998:

Chronic Lymphocytic Leukemia B Cells Can Express CD40 Ligand and Demonstrate T-Cell Type Costimulatory Capacity

A case report (as my lab and non-physical stature grew I became senior author), in the British Journal of Haemotology, 1998:

Novel association of haemophagocytic syndrome with Kaposi’s sarcoma-associated herpesvirus-related primary effusion lymphoma

On some experiments with mantle cell lymphoma cells, in Leukemia, 2000:

Proliferative response of mantle cell lymphoma cells stimulated by CD40 ligation and IL-4

Work accomplished with colleagues-now-friends, in Blood, 2000:

Inhibition of NF-kB induces apoptosis of KSHV-infected primary effusion lymphoma cells

The first major paper from my NIH-funded lab, in The Journal of Immunology, 2000:

Modulation of NF-kB Activity and Apoptosis in Chronic Lymphocytic Leukemia B Cells

We sent this one to Science. They declined. So did a bunch of other journals. Eventually it came out in Blood, 2001:

Survival of leukemic B cells promoted by engagement of the antigen receptor

A nearly life-eating chapter that took up way too much of my time but was probably worthwhile nonetheless, on immunology, for a Neoplastic Hematopathology textbook, in 2001:

Immune System: Structure and Function

An interesting story, we thought, in Autoimmunity, 2002:

Inhibition of Fas-mediated apoptosis by antigen: implications for lymphomagenesis

A monograph I wrote around the time I got sick, on how malignant lymphocytes die, somewhat theoretical, in Cancer Investigation, 2002:

Apoptosis in Lymphocytic Leukemias and Lymphomas

For there record, there’s earlier and later stuff too, by me alone and with others, and (sadly) reams of unpublished data, mainly from 1997 – 2002. These are the published papers I consider most my own.

Looking back, I’m pretty sure we were right, at least on most of these findings.

(Is there an opposite-of-decline effect?)

I’ve often wondered how differently things might have turned out if there’d been blogs and open-access journals with real-time comments when we in my lab were trying to get our work published in top, grant-renewing, tenure-securing journals.

Didn’t happen…

Well, now that this is done, I can keep moving forward!

With gratitude to my colleagues who collaborated, and especially to those who worked with me in the lab,

ES

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Dr. Greenfield is Human

A few days ago I read that Dr. Lazar Greenfield, Professor Emeritus at the University of Michigan, resigned as the president-elect of the American College of Surgeons over flak for authoring a Valentine’s Day-pegged, tacky, tasteless and sexist piece in Surgery News. The February issue is mysteriously absent in the pdf-ied archives. According to the Times coverage: “The editorial cited research that found that female college students who had had unprotected sex were less depressed than those whose partners used condoms.

From Pauline Chen, also in the Times:

It begins with a reference to the mating behaviors of fruit flies, then goes on to discuss studies on the menstrual cycles of heterosexual and lesbian women who live together. Citing the research of evolutionary psychologists at the State University of New York, it describes how female college students who had been exposed to semen were less depressed than their peers who had not, concluding: “So there’s a deeper bond between men and women than St. Valentine would have suspected, and now we know there’s a better gift for that day than chocolates.”

Not that I’m OK with any of this, as I’ve known the ickiness of older male physicians who don’t even realize when they’re being inappropriate.

But this morning I learned from Orac that Dr. Greenfield is the Dr. Greenfield, the one that invented the Greenfield filter. This threw me a bit, because I admire Dr. Greenfield for his work. He’s saved a lot of lives, perhaps tens of thousands. (I’m guessing on this number; it could be more, the point is – a Tsunami’s worth of lives.)

Doctors, including non-surgeons like me, would sometimes advise insertion of Greenfield filters in patients with blood clots and a contraindication to blood thinning. One example of countless I recall in my own experience as an oncologist: an elderly patient with pancreatic cancer and limited mobility who had a DVT in the leg and a brain met. We wouldn’t want to give the patient a standard blood thinner, like heparin or coumadin, because the tumor in the brain might bleed with catastrophic effect.

The common teaching was that a Greenfield filter, inserted through a large thigh vein up to the inferior vena cava, would prevent a blood clot from spreading from a patient’s leg up to the heart’s right chamber and into the lung’s circulation, where it might lodge in the form of a pulmonary embolus, a serious and sometimes lethal condition.

As a patient, I once had a newer-model Greenfield placed on a temporary basis. Because I’d had a major DVT while immobilized after spine surgery for scoliosis as a teenager, and then I had breast cancer – another risk factor for DVT – when I needed spinal repair as an adult in 2003, my orthopedist and hematologist were concerned that my risk for developing another major clot was great. Because they couldn’t put me on an anticoagulant for days after such a big operation, they advised prophylactic insertion of a temporary Greenfield device. I accepted the plan, hesitatingly, as reasonable.

So from both my professional doctor’s and my patient’s perspective, I’ve perceived value in Dr. Greenfield’s contribution and possibly benefited from his work. Then again, a 2000 review in Blood suggests more evidence is needed to support the filters’ widespread use. I agree.

The clearest take, maybe, is that some powerfully driven, innovative and brilliant people make personal mistakes.

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Passover Preparations, and Good Housekeeping

There’s so much medical stuff I’d like to write on today. The thing is, it’s almost Passover. I’ve just got a few hours to finish readying our home for the holiday.

And so this will be the topic for today’s ML, on home-making:

Part of the Passover preparation is, in my mind, like spring cleaning: we scrub surfaces in the kitchen, pantry and elsewhere; we shake out all the rugs and vacuum or sweep extra carefully; we go through old foods and decide what’s worth keeping or should be discarded. We remove all bits of bread, and then set a minor flame (I use a match) to, symbolically and really, burn the last crumb.

I’m reminded of the spring of 1987, when I spent the second half of Passover in a small apartment in Cochabamba, Bolivia, where I followed an endocrinologist in his rounds and learned about so-called tropical diseases: malaria, Chagas, amoeba and other parasites I hadn’t seen first-hand before. There was running water for only 4 hours early each day in the place where I stayed; I learned to gather, boil it and apply iodine to sterilize it before washing my few dishes. There I ate matzah I’d stashed in my suitcase. (Later on in my journey, its well-known constipating effects proved beneficial.)

The main public hospital in Cochabamba held patients in old-fashioned, long rectangular rooms with 15 or 20 beds along each side. Ventilation came by breezes through the open windows, and patients’ families were responsible for giving them food. Nurses – nuns, really – kept the place clean; they swept under each bed daily. No blankets or sheets touched the floor; it was immaculate.

I know there are people out there who think a sterile home breeds diseases – like asthma and peanut allergies and maybe even Hodgkin’s; the notion is that somehow it’s good to get our immune systems exposed at an early age to lots of bacteria and other organisms, so they won’t respond too vigorously to nature’s tiniest offerings. While there may be a germ of truth in some of these arguments (for the record, I don’t agree with most, and am fearful of the harmful bugs and parasites that can be lethal if ingested), I do think that for the most part, we could do a better job on the hygiene front.

At the AHCJ meeting I attended a session on food safety. There was a lot of discussion of how the FDA, USDA and other agencies are and aren’t tracing sources of contamination in the food supply, from large and small (excluded from some regulations) growers and manufacturers, and what to do about imported foods, which are screened now for radioactivity as well as for unwanted germs.

The way I see it is this: We’re responsible for our health to the extent that our behavior can reduce our risk of illness. Keeping a clean home, and washing food thoroughly, and cooking it carefully, are things we can do to reduce the odds of getting sick. Nothing’s full-proof, and I don’t mean to suggest that if someone develops hemolytic uremic syndrome from eating contaminated spinach or bad ground beef that it’s their fault.

But maybe we’ve become lazy as a culture, or just too rushed: we buy prepared food and pre-“washed” salad. We grow accustomed to the dust behind a bed-board or bookcase that’s hard to move; we don’t flip the couch cushions periodically and clean what’s under there, as perhaps our grandmothers would have, should they have been sufficiently fortunate to have upholstered furniture.

I admit that I’m very imperfect in all of this, that my home is far from absolutely clean, and that I sometimes eat salad in restaurants where I doubt it’s been quite so-well washed as I’d like or want to know. There is surely some dust on this laptop, and I fear now there may be a crumb of bread that’s escaped the feather’s final sweep.

But I’ll do my best, and sign off now, and enjoy the holiday with my family.

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Hot Wasabi, and a Continuing Radiation Crisis

a poem for Wednesday:

I was touched by this headline in yesterday’s news: Japan nuclear crisis may have a silver lining for radiation health research. Yeah, and cancer is a gift.

The wasabi is too hot,

NPR shared yesterday, and I agree.

This radiation story has a long half-life, whether we write on it or not.

Sketch of a wasabi (Japanese horseradish) plant, from an 1828 in botanical encyclopedia, by Iwasaki Kanen (Wiki Commons)

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A Nutritional Tidbit, on Quinoa

I first heard about quinoa a few years ago, when food-sellers started marketing the stuff as a cereal-like, cholesterol-lowering nutritious substance.

Chenopodium Quinoa (Wiki Commons)

It’s from the Andes, I knew, and comes in some varieties. If you purchase the raw stuff or receive a gift, say, from a Peruvian person who knows her quinoa, you’ll find quickly that you have to rinse it a few times with water before cooking it with whatever seasoning you choose, such as cilantro or just a pinch of salt, or with some olive oil and ground pepper, cinnamon or curry, because the starch has to be rinsed of its saponin (soapy) coating.

What I learned yesterday, beginning with an informative feature in the Times, is that quinoa is not a grain but a seed. According to that article and Wikispecies (a fabulous web-find, in itself), quinoa belongs to the chenopod family or subfamily of plants which includes the likes of beets and spinach. The word chenopod stems from the Greek roots: <chen> (goose) and pod (foot), as in goosefoot. These are said to be flowering plants that lack petals.

The U.S. MyFoodPedia site is devoid of information on quinoa, as is the USDA’s Nutrient Database, as of this morning. Sellers say it’s rich in fiber, protein and minerals. A research study published by agricultural scientists based in Santiago, Chile, found an ideal balance of amino acids and minerals mixed in the starch, along with omega-6 oils and vitamin E.

In my fourth year of medical school, I spent most of two months in Bolivia studying infectious and other diseases in Cochabamba. But I don’t think I ever tried quinoa. And it’s definitely not something I learned about in class.

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Change the Channel?

The situation in Japan remains grim. I can’t reasonably report on this, except to say what’s evident by the photographs, videos and usually-reliable sources: a second reactor may have ruptured. There’s been another burst of radioactivity into the air.

Flickr, Official U.S. Air Force photo stream

Meanwhile, thousands of bodies are being discovered in the post-Tsunami landscape along the northeast coast. The Emperor’s speech adds a feeling of gravity, essentially unfathomable to those who are not there, and maybe even to those who didn’t live, first, through the atomic bombings in that country 75 years ago.

people in a shelter, as shown on NHK world TV

Working my/our way* through The Pain of Others, Sontag writes:

What to do with such knowledge as photographs bring of faraway suffering? …For all the voyeuristic lure – and the possible satisfaction of knowing, This is not happening to me, I’m not ill, I’m not dying, I’m not trapped in a war – it seems normal for people to fend off thinking about the ordeals of others…

People can turn off not just because a steady diet of images of violence has made them indifferent but because they are afraid…

She considers the role of TV, and the CNN effect regarding images from the war in Sarajevo, and says now (in the book):

The question turns on a view of the principal medium of the news, television…Images shown on television are by definition images of which, sooner or later, one tires. What looks like callousness has its origin in the instability of attention that television is organized to arouse and to satiate…The whole point of television is that one can switch channels, that it is normal to switch channels….

*in reality, her book-essay – on war imagery – grips with relevance, I sped through.

Probably by now, my dear readers are wishing I’d write on something else, and somewhere else, which indeed I am doing with most of my time now. But I think the real-time contemplation of the images – and why we look at them, or don’t – is valuable in itself.

And also, maybe it would help the people of Japan, there, to know that people are thinking about their plight.

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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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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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Opening Up a Dialogue on the R-Word

Today a short article in the NY Times, New Kidney Transplant Policy Would Favor Younger Patients, draws my attention to a very basic problem in medical ethics: rationing.

According to the Washington Post coverage, the proposal comes from the United Network for Organ Sharing, a Richmond-based private non-profit group the federal government contracts for allocation of donated organs. From the Times piece:

Under the proposal, patients and kidneys would each be graded, and the healthiest and youngest 20 percent of patients and kidneys would be segregated into a separate pool so that the best kidneys would be given to patients with the longest life expectancies.

This all follows last week’s front-page business story on the monetary value of life.

I have to admit, I’m glad to see these stories in the media. Any reasoned discussion of policy and reform requires frank talk on health care resources which, even in the best of economic times, are limited.

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A Vitamin Chart From the National Women’s Health Information Center

Lately I’ve been worrying about Kevin’s refusal to eat broccoli, and wondering what exactly is so good about those green bunches of roughage. In browsing the Web for more detailed information on the matter, I found a helpful vitamin chart.

This table comes from the HHS-sponsored National Women’s Health Information Center – a good spot to know of if you’re a woman looking on-line for reliable sources. It’s a bit simple for my taste. In the intro, we’re told there are 13 essential vitamins our bodies need. After some basics on Vitamin A – good for the eyes and skin, as you probably knew already – the chart picks up with a quick review of the essential B vitamins 1,2,3,5,6, 9 and 12 (my favorite), followed by a rundown on Vitamins C, D, E, H (that would be biotin) and K:

Vitamins, Some of their Actions, and Good Food Sources
Vitamin Actions Sources
A
  • Needed for vision
  • Helps your body fight infections
  • Helps keep your skin healthy
Kale, broccoli, spinach, carrots, squash, sweet potatoes, liver, eggs, whole milk, cream, and cheese.
B1
  • Helps your body use carbohydrates for energy
  • Good for your nervous system
Yeasts, ham and other types of pork, liver, peanuts, whole-grain and fortified cereals and breads, and milk.
B2
  • Helps your body use proteins, carbohydrates, and fats
  • Helps keep your skin healthy
Liver, eggs, cheese, milk, leafy green vegetables, peas, navy beans, lima beans, and whole-grain breads.
B3
  • Helps your body use proteins, carbohydrates, and fats
  • Good for your nervous system and skin
Liver, yeast, bran, peanuts, lean red meats, fish, and poultry.
B5
  • Helps your body use carbohydrates and fats
  • Helps your body make red blood cells
Beef, chicken, lobster, milk, eggs, peanuts, peas, beans, lentils, broccoli, yeast, and whole grains.
B6
  • Helps your body use proteins and fats
  • Good for your nervous system
  • Helps your blood carry oxygen
Liver, whole grains, egg yolk, peanuts, bananas, carrots, and yeast.
B9 (folic acid or folate)
  • Helps your body make and maintain new cells
  • Prevents some birth defects
Green leafy vegetables, liver, yeast, beans, peas, oranges, and fortified cereals and grain products.
B12
  • Helps your body make red blood cells
  • Good for your nervous system
Milk, eggs, liver, poultry, clams, sardines, flounder, herring, eggs, blue cheese, cereals, nutritional yeast, and foods fortified with vitamin B12, including cereals, soy-based beverages, and veggie burgers.
C
  • Needed for healthy bones, blood vessels, and skin
Broccoli, green and red peppers, spinach, brussels sprouts, oranges, grapefruits, tomatoes, potatoes, papayas, strawberries, and cabbage.
D
  • Needed for healthy bones
Fish liver oil, milk and cereals fortified with vitamin D. Your body may make enough vitamin D if you are exposed to sunlight for about 5 to 30 minutes at least twice a week.
E
  • Helps prevent cell damage
  • Helps blood flow
  • Helps repair body tissues
Wheat germ oil, fortified cereals, egg yolk, beef liver, fish, milk, vegetable oils, nuts, fruits, peas, beans, broccoli, and spinach.
H (biotin)
  • Helps your body use carbohydrates and fats
  • Needed for growth of many cells
Liver, egg yolk, soy flour, cereals, yeast, peas, beans, nuts, tomatoes, nuts, green leafy vegetables, and milk.
K
  • Helps in blood clotting
  • Helps form bones
Alfalfa, spinach, cabbage, cheese, spinach, broccoli, brussels sprouts, kale, cabbage, tomatoes, plant oils. Your body usually makes all the vitamin K you need.

(from womenshealth.gov, table accessed 2/19/2011)

Overall I’d say the chart is useful, a good place to start if you want to know, say, what’s a good, non-citrus source of Vitamin C. It could be improved by provision of more details, like the precise amount of Vitamin B2 per cupful of Swiss chard, and how preparing foods in distinct ways – like roasting, sautéing, boiling, or serving them raw – affects the nutritional value.

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May I Call You ‘Doctor’?

Last week I considered the relationship between the Prince Albert and his speech therapist in The King’s Speech. One aspect I wanted to explore further is why the future king initially insisted on calling the practitioner “doctor.”

In real life, now, patient-doctor relationships can be topsy-turvy. This change comes partly a function of a greater emphasis on patient autonomy, empowerment and, basically, the newfangled idea that the people work “together, with” their physicians to make informed decisions about their health. It’s also a function of modern culture; we’re less formal than we were a century ago.

Patients enter the office with their own set of information and ideas about what they need. The recent Too-Informed Patient video highlighted this issue, effectively.

Doctors are human, we are painfully aware in 2011. They make mistakes and they sometimes need to have dinner with their families. They may even let us down.

When I was a young physician, my patients almost universally called me

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Quote of the Day, on Health and Discrimination in Hiring

From an article in today’s New York Times on hiring discrimination against people who smoke:

“There is nothing unique about smoking,” said Lewis Maltby, president of the Workrights Institute, who has lobbied vigorously against the practice. “The number of things that we all do privately that have negative impact on our health is endless. If it’s not smoking, it’s beer. If it’s not beer, it’s cheeseburgers. And what about your sex life?”

I think he’s right, more or less, in a slippery-slope sort of way, seriously –

Lots to think about this weekend!

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Contemplating Diet and Nutrition: A First Look at the USDA’s New Guidelines

On Sunday afternoons I tend to think about food for my family. Sometimes that’s because we’re having a few more than usual at the dinner table. Also, it’s a time when I order the bulk of fish, meat, produce and other ingredients for the week ahead.

Since I had cancer, I’ve paid much more attention to the food I serve in our home than before. While a balanced diet is no fail-safe for avoiding disease, I do think it’s prudent to be aware of the variety and quantity of food we eat. In medical school we learned surprisingly little about nutrition. Most of what I know I’ve learned from reading books – like Michael Pollen’s In Defense of Food – and reading through detailed reports like the USDA’s new Dietary Guidelines for Americans (7th Edition) issued a few days ago.

From the press USDA and HHS joint press release:

Because more than one-third of children and more than two-thirds of adults in the United States are overweight or obese, the 7th edition of Dietary Guidelines for Americans places stronger emphasis on reducing calorie consumption and increasing physical activity.

The Times summed up the new guidelines nicely in its headline: Government’s Dietary Advice: Eat Less.

But it’s not a trivial report. Rather, it’s a hefty-if-printed (I didn’t) 112-page pdf with some fluff (even blank pages for notes) and some excellent, hard-to-find-elsewhere details on nutrients. Some highlights include Figure 5-1, which demonstrates with abundant clarity that we don’t eat sufficient fruits, vegetables, whole grains or most other recommended foods:

I’m still digesting (sorry, I can’t help myself) detailed chapters and tables in the full report. There’s a lot of useful information to take in. For example, Appendix 11, on p. 85, charts the “Estimated EPA and DHA and Mercury Content in 4 Ounces of Selected Seafood Varieties” – handy if you serve fish for dinner at least twice per week, and like me, figure it’s best to hedge on potential toxic effects by serving a variety of fish.

More from the press release, on tips that will be provided to help consumers translate the Dietary Guidelines into their everyday lives:

• Enjoy your food, but eat less.

• Avoid oversized portions.

• Make half your plate fruits and vegetables.

• Switch to fat-free or low-fat (1%) milk.

• Compare sodium in foods like soup, bread, and frozen meals – and choose the foods with lower numbers.

• Drink water instead of sugary drinks.

All of these seem wise, but obvious. Still, it’s clear that most of us aren’t following the guidelines, or even common sense.

Setting guidelines should help, so teachers in schools and cafeteria-caterers can know what to tell and feed kids, so they develop good eating habits. But really I think that most of the information, if you can call it that – what constitute our dietary habits begun in childhood – has to be cultivated in our homes, the popular culture and community at large. So my plan is to delve further into the USDA report, and elsewhere, and once each week (maybe) post a nutritional ML. I hope it won’t be too simple or boring.

Like a diet, we’ll see how this goes –

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