Thursday, December 21, 2006

Suggestions for sterner FDA warnings for acetaminophen

"FDA Wants Sterner Pain Reliever Warnings" - AP, 12/20/06

1. Extended use of this product will make your face stay that way.
2. Use as directed or you'll shoot your eye out.
3. Converting this package into a bong is prohibited by federal law.
4. For internal use only; do not insert product into ear or nose.
5. This product is not approved for use by squirrels.

Wednesday, December 20, 2006

Vitamin D may lower MS risk

A study published in JAMA says that white people with the highest blood levels of vitamin D are less likely to develop multiple sclerosis than people with low levels. The study looked at blood samples from 7 million members of the US military. Here's a link to a short piece in the WaPo.

I've been taking a daily vitamin D supplement for maybe a year, in part because I know I don't drink enough milk to get my RDA that way, but also because of some vague half-baked notion that it might help with MS. I know there's no evidence that it could work that way, i.e., that someone who already has MS could be helped by getting more vitamin D. Perhaps this reflects a little sparkle of optimism, some kernel of hope, from a place deep in the brain that is unburdened by logic.

It's easy to let the logical parts of the brain shout down that little sparkle. It's easy to sigh disapprovingly at bee venom, amalgam replacement, laetrile, and any other "therapy" for which there is no proof of effectiveness. It's really, really hard, though, to let yourself believe that things will get better, or even that they might get better.

Tuesday, December 19, 2006

What's in my grocery cart?

3 boxes (family size) Post Raisin Bran
3 boxes Quaker Corn Bran
4 bags Sunsweet Pitted Prunes
1 16 oz. bag golden raisins
1 8-pack Activia Yogurt (strawberry/blueberry)
2 5-lb. bags King Arthur Bread Flour
1 cucumber (Euro-type)
6 apples (Pink Lady)
3 liter bottles Naleczowianka mineral water (bubbly)
3 Freschetta frozen pizzas (cheese, pepperoni, supreme)
1/2 gal. skim milk (organic)
1 pint half and half (organic)
1 bottle chipotle/cheddar salad dressing
1 4-pack Sioux City birch beer

Friday, December 15, 2006

What's right with our relationship

We've been to see our therapist for a couple of joint sessions, and the really surprising thing is that it's helped us to see how good our relationship is, how our occasional fights really are occasional, and how most of the time, each of us feels great respect for the other and wants to look out for the other. In fact, I was thinking that much of the substance of our next meeting would be devoted to receiving instruction in meditation and mindfulness. I was thinking that until yesterday afternoon, when my wife called me to report that she'd been laid off.

It wasn't a total shock; there had been pretty painful warning signs over the last month, but it still made me want to inflict some sort of awful harm on the people responsible. Fortunately, we'll be fine in terms of finances and health insurance coverage. Some of my wife's colleagues will have a much harder time.

So we may end up spending some time with the therapist trying to sort this out. But it has been somehow comforting to notice how strongly each of us empathizes with the other, how deeply each of us feels the other's hurt, even though research suggests that this kind of empathy is less important to a relationship than our ability to genuinely share our partner's joy.

Wednesday, December 06, 2006

Crusty nirvana

I spend a lot of time in the kitchen, especially when the weather is cooler and invites warm, savory comfort food (braises, soups, stews, etc.) that pairs well with wine. I've dabbled with bread on and off, with mixed results, but for the last couple years I've been content to buy crusty bread when I had a hankering for it. But a few weeks ago, Mark Bittman's Minimalist column in the NYT offered a simple recipe for satisfying bread with no kneading, relying on a long, slow rise to develop gluten and baking partially inside a heavy pot to produce a hearty crust.

In the last few weeks, I've made maybe a half a dozen loaves of the stuff, and I love it: dense, chewy, with big irregular holes inside and a crisp, thick crust. Today, Bittman's column has some ideas for further refinements, additions, and substitutions. I'm anxious to try a rye version (up to 20% rye flour, plus caraway seeds) and maybe a baguette shape, if I can figure out what to put it in.

Bittman reports that he prefers to bake in a smaller cast iron pot, maybe 3 or 4 quarts. I started out using an old Magnalite aluminum dutch oven of about that size, but have since decided I prefer to use my big (8-qt?) Calphalon soup pot. I found that in the smaller pot, the bread wouldn't develop much color at all until I took the cover off, and by the time it was finished it wasn't yet that beautiful dark mahogany that I associate with great artisanal bread (I've got a picture of my first loaf, which I'll post when Blogger cooperates). With the bigger pot, the larger volume decreases the concentration of steam that the bread is exposed to for the first half hour.

My favorite thing about the bread is that it's just as good toasted a few days after baking as it was right out of the oven.

Tuesday, December 05, 2006

What's a defect?

Today's NYT has a short essay on a journal article on parents using preimplantation genetics to ensure that their offspring, like them, express genetic traits like deafness or dwarfism. Usually, the technique is used to prevent the transmission of diseases like CF and Huntington's, but a survey of 190 fertility clinics indicated that 3% had used the technique to select for a disability. Snip:
In other words, some parents had the painful and expensive fertility procedure for the express purpose of having children with a defective gene. It turns out that some mothers and fathers don’t view certain genetic conditions as disabilities but as a way to enter into a rich, shared culture.

It’s tempting to see this practice as an alarming trend; for example, the online magazine Slate called it “the deliberate crippling of children.” Dr. Robert J. Stillman of the Shady Grove Fertility Center in Rockville, Md., has denied requests to use the process for selecting deafness and dwarfism. “In general, one of the prime dictates of parenting is to make a better world for our children,” he said in an interview. “Dwarfism and deafness are not the norm.” Dr. Yury Verlinsky of the Reproductive Genetics Institute in Chicago, who also refuses these requests, said, “If we make a diagnostic tool, the purpose is to avoid disease.” But both doctors said they would not oppose sending families to other doctors who might consent.

This really seems to cut to the heart of what it means to be disabled. In the case of deafness and dwarfism, there seems to be a culture that comes along with the physical difference such that those who have access to that culture (and perhaps not to elements of the larger culture that are available to the able) desire to share the culture with offspring.

It seems pretty obvious that MS lacks a culture of its own. Our physical differences are often undetectable, and move among the larger culture even though we may be able to take part in it fully. Given the prevalence of MS, we may encounter others with the same illness without even knowing it. If there is an MS culture, it probably exists only on the net; that's the only place where we're likely to encounter each other as members of the same gimpy tribe.

Monday, December 04, 2006

An investment of a sort

Tonight, she and I will be returning for a dual session with the therapist. We have, more than a few times, buried the hatchet in whatever conflict happened to make one or both of us furious and sworn that we really ought to see someone, i.e., marriage counselor, but we never really got anywhere until recently. The problem is that our insurance doesn't pay for family issues, so the question was: If we're going to pay out of pocket, who do we want to see? She managed to get a recommendation from a coworker for a guy who has some experience with MS couples, so we went last Monday for a session.

Of course, the first session doesn't really go anywhere, mostly just getting-to-know-you-and-your-marital-issues. I think C. even surprised herself when she was in tears after the first question, to wit: "So what do you hope to get out of counseling?" She went first, saying something about some suggestions for managing conflict, which went fine, but then I said something about how I wasn't really expecting to get advice, but just an opportunity to talk thru some things, especially since I really don't have many (any?) close relationships in which I'd feel comfortable bringing up marital stuff. And that was enough.

See, my wife has this extraordinary capacity for empathy, and what I said was enough to make her feel, all at once, all of the sudden, the isolation and loneliness that I've often felt not just with MS but even before as a guy who perceives himself to lack great social skills. And I sorta sat there for a while thinking about how it felt to feel her feel my pain. (The therapist seems to like to interact with one person at a time, leaving the other to listen and think.) Anyway, it seemed like we were done pretty quickly, and just that brief experience I think gave us enough empathy to have a week in which we really enjoyed each other's company.

But there is the small matter of the fee: $120 for an hour, which ain't exactly pocket change. For a couple days afterward, we talked about whether we felt like it was worth $120 an hour to go back for more sessions in the future. As an avowed cheapskate, I felt like maybe we could have found someone better, even though we'd only been to see this guy once. C. agreed that $120 would multiply rapidly, especially if it turned out that we wanted to keep coming back. So I called and left the therapist a message saying that we liked him but we didn't feel like we could afford his services, that we'd probably try to see therapists covered by our insurance on an individual basis, etc., etc. I was a little surprised when he called me back to so that he could offer us a discount, that he thought we would really benefit from couples work, etc., etc.

So we're going back tonite.

Friday, December 01, 2006

Is there a place for carrots and/or sticks in Medicaid?

Interesting piece in NYT on a West Virginia pilot program that will reward Medicaid beneficiaries who are "responsible patients" and deny some services to those who do not join weight-loss or antismoking programs, or who miss too many appointments. Snip:
Those signing and abiding by the agreement (or their children, who account for a majority of Medicaid patients here) will receive “enhanced benefits” including mental health counseling, long-term diabetes management and cardiac rehabilitation, and prescription drugs and home health visits as needed, as well as antismoking and antiobesity classes. Those who do not sign will get federally required basic services but be limited to four prescriptions a month, for example, and will not receive the other enhanced benefits.
No one questions that West Virginia, more than most other states, needs more healthful lifestyles and better primary and preventive care. But the new plan has stirred national debate about its fairness and medical ethics. A stinging editorial in The New England Journal of Medicine on Aug. 24 said it could punish patients for factors beyond their control, like lack of transportation; would penalize children for errors of their parents; would hold Medicaid patients to standards of compliance that are often not met by middle-class people; and would put doctors in untenable positions as enforcers.

“What if everyone at a major corporation were told they would lose benefits if they didn’t lose weight or drink less?” said a co-author of the editorial, Dr. Gene Bishop, a physician at Pennsylvania Hospital in Philadelphia.

I don't know if I like this or not. On one hand, I'm sympathetic to the NEJ's concerns about denying medical services on the basis of something that's beyond their reasonable control. On the other hand, there's John Johnson. Snip:
Speaking from the easy chair where he spends his days in a small wooden house near this small Appalachian town, his left trouser leg folded by a safety pin where a limb was lost to diabetes, he lighted another cigarette. Mr. Johnson, 61 and a former garbage collector, takes insulin and goes to a clinic once a month for diabetes checkups. Taxpayers foot the bill through Medicaid, the federal-state health coverage program for the poor. But when doctors urged him to mind his diet, “I told them I eat what I want to eat and the hell with them. I’ve been smoking for 50 years — why should I stop now?” he added for good measure. “This is supposed to be a free world.”

We're all paying for John Johnsons, both in Medicaid and in our HMOs and other insurance pools. And sure it's galling to have to pay for health services for a guy who doesn't care enough about his health to change obviously unhealthy behaviors. But I'm uncomfortable with giving the government a stick in this situation. It's not clear from the article to what extent the program involves the stick approach, but from a structural perspectice, the use of a stick requires a lot more due process protection to ensure only those who are truly stick-worthy get stuck. I'm much more comfortable with a carrot approach: if a beaurocracy makes a mistake in handing out carrots, nobody gets hurt. People might not get a carrot they're entitled to, but nobody gets hurt. And from a behavior-modification standpoint, doesn't science teach us that carrots reinforce good behavior much more effectively than sticks prevent bad behavior?

Thursday, November 30, 2006

North Korea: Puzzling, fascinating

I'm probably not the only person who's curious about North Korea. Not just because of the news, but also because the gradual Wal-Martification of the rest of the world has made North Korea seem that much weirder. I recently read Guy Delisle's nifty Pyongyang, a graphic novel recounting the author's experiences working there, and today, Slate's "Today's Pictures" has a few tantalizing shots from North Korea. If you search on "Pyongyang" at Flickr, you can see some more glimpses into this frighteningly odd society.

Consumer-directed health plans: early reviews mixed

WaPo has an article about a study of people enrolled in so-called consumer-directed health plans. Basically, we're talking about people who are enrolled in high-deductible, low-premium health insurance plans and who pay their share of health costs with pre-tax money from health savings accounts.

According to the study, these folks are indeed paying more attention to their cost of care, just as advocates for such plans predicted. On the other hand, they tend to be healthier, whiter, and richer than those who in traditional plans, just as critics predicted. Bottom line: half of those in consumer-directed plans would switch to a traditional plan if they could; about a third of those in traditional plans say they would switch to consumer-directed plans. Snip:
In contrast with other plans that typically require $15 or $20 co-payments for visits to the doctor, the new plans can require consumers to shell out hundreds or thousands of dollars of their own money for medications, physicians' services and hospital care before most coverage kicks in. The plans have high annual deductibles, but their premiums tend to be lower.
"It's a cultural shift," said Devon Herrick, a health economist at the National Center for Policy Analysis in Dallas. "When you go to Wal-Mart you don't have to ask about price -- it's right there next to the good or service you are buying. Health care is not there yet, but it's getting that way. This is the early stages. We have the incentives to get people more responsible and asking about price."


Tuesday, November 28, 2006

Young man, don't sit up straight

Interesting item in the ChiTrib today about sitting and posture. Turns out that sitting up straight, with your back at a 90-degree angle to the floor, is more likely to lead to back pain than leaning back. Specifically, a 135-degree angle is ideal. In fact, that big-ass recliner in front of the TV would be perfect, if you could get it into your cubicle. Snip:
"Really the best position is what you get in a La-Z-Boy, although that wouldn't work well for someone using a computer," said Dr. Waseem Amir Bashir, who led a study conducted at Woodend Hospital in Aberdeen, Scotland.

Bashir's findings, which confirm what experts in ergonomics have believed, were presented at the McCormick Place meeting of the Radiological Society of North America. His conclusions come from getting a different view of the spine, using a newly designed magnetic resonance imaging machine that allows for a full view of the back while sitting.
Assuming any position for a long period is a bad practice, said Judy Lesse, an ergonomics consultant for Herman Miller. "We design our chairs so that people can change positions regularly," she said. "You may find it difficult to lean back while using a computer, but you can lean back while talking on the phone."

Dave Trippany, corporate ergonomist for Steelcase Inc., a Grand Rapids, Mich., maker of office furniture, said that "flexibility is the key. People should move around to increase circulation. Reclining is part of that."


Monday, November 27, 2006

Anti-inflammatory plant stuff

This morning's WaPo has a gee-whiz article about research into the anti-inflammtory properties of a plant from the ginger family called Afromomum melagueta. In the wild, gorillas have apparently long been savvy to this stuff's benefits, but unfortunately lacked the marketing skills to properly exploit its commercial potential. Thank goodness Avon got ahold of some; it plans to market skin-care products containing Afromomum. Others speculate about its use as a substitute for anti-inflammatory pharmaceuticals like Vioxx and Bextra. Snip:
A clear vial filled with amber fluid rests on scientist Ilya Raskin's desk, glinting in the autumn sunlight streaming through his office window. The container, a small glass bottle with a plain white screw-top, contains a substance Raskin calls 006. "Double-zero-six" is potentially more precious than the rarest topaz.

Raskin is a biochemist at Rutgers University's Biotechnology Center. The golden liquid on his desk may prove to be one of the most powerful anti-inflammatory substances ever discovered. "It contains a derivative of a plant known as grains of paradise, or Aframomum melegueta, a member of the ginger family," said Raskin. The compound works in a similar way to the well-known anti-inflammatory drugs Vioxx, Celebrex and Bextra but, it is hoped, without their side effects, said Raskin and other scientists.


Wednesday, November 22, 2006

Stupid brain tricks

As a person whose brain is kinda, well, broken, I sometimes lose sight of what a wacky gizmo the brain is. Frinstance, there's a little article in the NYT about a rare condition called lexical-gustatory synaesthesia, in which the brain tastes words. Snip:
One subject, Dr. Simner said, hates driving, because the road signs flood his mouth with everything from pistachio ice cream to ear wax. And Dr. Simner has yet to figure out any logical pattern. For example, the word “mince” makes one subject taste mincemeat, but so do rhymes like “prince.” Words with a soft “g,” as in “roger” or “edge,” make him taste sausage. But another subject, hearing “castanets,” tastes tuna fish. Another can taste only proper names: John is his cornbread, William his potatoes.

So let's give thanks for brains, even broken brains, for connecting us with the world. Hold the ear wax.

Thursday, November 16, 2006

Is this anything? I don't think so.

I've seen a few articles on this particular "story" since Monday or so: the nation's leasing health insurance trade group has come out with a "plan" for covering the millions of Americans who lack health insurance. Snip from a Chicago Trib article:
The organization called on the federal government to spend an additional $300 billion over 10 years to expand public health programs for poor Americans, offer subsidies to working families to buy medical coverage, and support state health reform efforts. But there are no specifics on how the proposals would be financed or provisions for taming rapidly escalating costs.

The first priority should be providing insurance protection to almost all of the nation's children in three years, Ignagni said. Then the focus should turn to programs that will aid adults, including new tax-advantaged accounts for people who purchase insurance on their own.

With the Democrats taking charge of Congress after last week's elections, the industry plan helps set the stage for action on health reform. Democrats have long considered health care a priority and signaled a keen interest in expanding medical coverage.

Is it just me, or is everything in the insurance industry's courageous proposal completely consistent with the industry's interests? It's kinda like the auto industry calling for all Americans to have access to a car.

The articles I've seen characterize the industry's release as a sharp counterpoint to the Harry-and-Louise ads that tanked the Clinton plan a dozen years ago. I could never figure out why it was that the industry opposed the Clinton plan. If I remember right, the plan would have essentially pushed for more employers to offer coverage to their employees, meaning it would have pushed more customers into the waiting arms of the insurance industry.

The only thing that seems not obviously in the industry's interest is the expansion of Medicare and Medicaid. But even there, the industry stands to reap a substantial benefit: more sick people get access to care before they get so sick that they end up in the ER. Right now, the compulsory ER "charity care" is paid for by jacking up the charges to those who have coverage. If you can stop or at least slow down the stampede of poor people through the ER, you can slow down the growth in premiums that's led so many employers (and some employees) to drop their health coverage.

Wake me up when the insurance industry puts out the press release explaining how to pay for the expansion in coverage.

Wednesday, November 15, 2006

How dry I am

A week and a half into my latest med change, I'm feeling slightly improved but dry as a Mormon barbecue. Since last Friday, I'm taking (for the pain-sleeping-peeing stuff) 40 mg Cymbalta in the morning, then 20 mg amitriptylene, 250 mg Serzone, and 0.8 mg Flomax at night. I think the pain might be a little better: yesterday, I was able to wear a pair of woolly trousers to work with only minimal itching. Sleeping has improved, too: I haven't had the foot-twitching clonus in bed for a few days, and I think I only got up to pee twice last nite. And I actually went two nights without waking up in a puddle.

But it's definitely starting to be the time of year for dry, itchy skin and hangnails, especially after spending some time in the pool. I'm moisturizing my hands twice a day, using only Cetaphil bar soap in the shower, and drinking as much water as I can choke down, but I'm still feeling shriveled. Also, I seem to have regressed back into chronic constipation, so back on the glycolax, I guess. This sucks, because the last time I got the glycolax filled, it was from a different generic manufacturer. The stuff tastes bitter and yucky and never seems to dissolve fully, unlike the last two batches I had. Yuck.

Monday, November 13, 2006

Making a case

Last Friday, I got a visit from a friend. T's not somebody I feel I know well, mostly because he lives elsewhere, but a guy who's a little older and a little smarter than me, the kind of guy I wish I knew more of. Anyway, T came over Friday evening and we had a lovely meal with some really nice wines he brought with him, and a couple neighbors popped in for a glass, and it was really great. I made a squash bisque and roasted a couple chickens and we had a little fancy chocolate tasting after the meal. Nice.

T. spent the night, and we were both up and about at 7:30 or so the next morning, and we got into this kinda long conversation about me and MS. T's a lawyer, too, has a fabulous analytical mind and a very easy-going manner, and he started out with an open-ended question like "So how's your health?" or something like that. I gave him the sort of autopilot answer that I give without thinking, something like, "Oh, not too bad, I guess" or something like that. I don't remember exactly how it went from there, but he just started to ask a few more questions that made it clear that he really wanted to know how things were going.

T wasn't so much interested in any of the history, but really seemed interested in a pretty deep account of where I'm at are now. It's been a long time since I had a conversation like that. I don't have a very large social circle, just a few close friends and assorted medical professionals; these people either know the whole story, because they've participated in it, or they don't, because they haven't asked or because I'm kinda tight-lipped.

Anyway, the theme, I guess, was coping: How do you do it? Why do you do it? What makes some people able to do it, but not others? T's got a pretty close friend with MS (also a lawyer) and he talked about his admiration for those of us who manage to retain some level of control over our situations and his dismay at his inability to understand others who seem unable to cope, particularly a couple of members of his family who've lost or are losing battles with alcoholism.

I don't remember much about what we said, although we went on for an hour or so. But I remember feeling strangely satisfied that I'd stated my case, that I'd been called on to give an account of my experience of my illness--how it feels, and how I live with it--and had been judged worthy. I guess I like to think of myself as a person who doesn't like to feel like he owes anyone. I want to make do for myself, meet life on my terms, but I know that I often feel a contradictory urge to prove that independence. Saturday morning, I had the feeling that I'd made a persuasive argument.

Tuesday, November 07, 2006

Booze news you can use

Whatever your political leanings, tonight will almost certainly be cause for celebration or lamentation. Champagne glasses will be raised in triumph, and bourbon will be slugged in bitter defeat. According to the NYT, if you're gonna be drinking tonight, you might feel better in the morning if you nix the cheap brandy in favor of some high quality vodka. Snip:
Experts say that the type of alcohol you drink does make a difference, but for various reasons. Among the most important is the amount of congeners (pronounced CON-juh-nurz) — complex organic molecules, like methanol — in a particular drink. Impurities in poorly refined spirits like cheap vodka can also play a role, but congeners, which are common in darker liquors, seem to have the greatest effect.

According to one report in The British Medical Journal, which looked at the effects of different types of alcohol, the drink that produced the most hangover symptoms was brandy, followed by red wine, rum, whiskey, white wine, gin and vodka. Another study showed that bourbon was twice as likely to cause sickness as the same amount of vodka.

I voted this morning and hope to find some way to forget the whole deal until tomorrow morning. As a moderate lib, I'd like to see control of the House shift, but I've got no illusions about what little impact that would have on the issues that matter to me. It just means that we return to being a country where it's hard to change the law, which is how it ought to be.

Friday, November 03, 2006

About time

A week and a half after my last visit, the pain clinic finally called with my new med instructions. Apparently, they'd been playing phone tag with another of my posse of health professionals. I was pretty sure that was the problem, but I resent that nobody saw fit to tell me that. I called them a half a dozen times, but couldn't get a status report until just this morning. In my profession, if I told a client I was going to take a specific course of action, but failed to do so and failed to explain that to the client, I would be subject to professional discipline.

Anyway, the plan is this: 1) stay on 40 mg Cymbalta, but try taking in the morning instead of bedtime; 2) add 10 mg of amitriptyline at bedtime, increasing by 10 mg/week up to 30 mg; and 3) decrease to 300 mg of Serzone now, then drop by 50 mg per week until I get down to 200 mg. This is all to get me better-quality sleep at night (the amitriptyline is supposed to help with bladder stuff) and to ensure that I don't develop serotonin syndrome. If it goes well, then we can talk about increasing the Cymbalta to further reduce the pain.

Initially, I thought, Wait, this plan looks like gives more weight to helping me sleep than it does to actual pain relief. But then I remembered how last nite I got up to pee 8 times and how, when the alarm went off a 6:15, I just about cried. So I think maybe it's just fine if we're focusing on sleep first. It certainly seems at this point like it might be the easier problem to solve.

Monday, October 30, 2006

Less miffed, less grumpy

Last Friday, I was feeling miffed and grumpy because the pain clinic wasn't getting back to me about the med changes we discussed at my appointment last Tuesday. I'd felt really positive about the appointment: the nurse practitioner had listened very carefully to me, and talked about some med changes and physical therapy stuff, and I thought I would be adjusting my meds that nite after dropping in at Walgreen's. I think it was something like cutting the Cymbalta down to 30mg/day to reduce my need to get up and pee half a dozen times every night, and add a little bit of amitryptaline to help me sleep. There was, however, a question about whether I would be getting too much serotonin, whether I'd have to change my dose of Serzone, and they'd need to get in touch with the psychiatrist who prescribes the Serzone.

When I went to the pharmacy, though, they said they didn't get a call from the pain clinic. So I called, and they said they hadn't gotten ahold of the psychiatrist. That was Wednesday. By Friday, I still hadn't heard, so I called and got the same repsonse. And while it seemed completely plausible that they were having trouble reaching the psychiatrist (who is only part-time at my HMO), I really felt like I needed to be doing something different.

When I got home on Friday, there was our friend L., who has lymphoma that hasn't responded to treatment (2 autologous stem-cell transplants and god knows what else). She'd been at the hospital that day getting fluids, because her gut wasn't working properly, and needed to have somebody look after her. She was pretty miserable, rushed to the bathroom every 15 minutes, and winced whenever she sat down. She ended up back at the hospital yesterday (getting fluids topped off), and my wife spent the day there with her.

Today, I'd really like to hear from the pain clinic. But I'm feeling a lot less miffed and grumpy, even though I had another night of intermittent, unsatisfying sleep.

Wednesday, October 25, 2006

Are democrats exploiting Michael J. Fox?

You've probably seen or heard about the ads: Michael J. Fox bobs and weaves while talking about a republican candidate's opposition to stem cell research. I guess there's one running in my state, now, too. Initially, Rush Limbaugh claimed Fox was gimping it up in the ads, either by skipping his meds or by simply faking up his Parkinson's symptoms. Later, apparently, he "apologized," but charged that "Michael J. Fox is allowing his illness to be exploited and in the process is shilling for a Democrat politician." Now, a hastily-produced response ad featuring some B-list celebrities is responding, urging that Missouri reject a ballot initiative on stem cell research (main points: initiative creates constitutional protection for stem cell research, poor women will be trapped into donating eggs for money, usable stem cell treatments still 15 years away).

I think the Fox ad is extremely effective, in a way that can't be neutralized by trotting out some pro-life athlete or actor. See, the public has already decided this one: whether they understand the science, whether they understand the work that remains to be done, they're in favor of helping sick people, and just as with in vitro fertilization, they're not as concerned with what happens to the embryos are they are with what happens to Michael J. Fox, because they are not of equal moral worth. And the ad just reminds them of this, in a memorable way. It's silly to think that they only feel this way because Michael J. Fox told them to.

But is Rush right? Is he being exploited? No. I doubt very much that Fox believes that he will benefit from stem cell research. I doubt he's getting paid scale. I doubt he's being held in the chair against his will until he finishes shooting a dozen spots. Is he a shill? Well, no more than anybody else who lends their name and image to endorse a product/service/cause/candidate.

Look, I know there a thousands of sick people who would be happy stand in for Fox; we'd love to tell the folks out there in TV-land about our illnesses, how our lives have changed as a result, and to talk about why it's so important that the government not squelch this research by closing the federal purse. I'm happy, though, that Fox is doing it, because everyone knows who he is, or was; because everybody knows his story; and because he's so darned cute.

And if Fox was exaggerating his symptoms, if he was gimping it up? Fine. I hereby grant to Michael J. Fox the right to supplement his symptoms with my symptoms: he's free to add a couple stutters, wobbles, and tremors, and, if he wants, he should feel free to wet his pants on my behalf, too, because nobody asked me to appear in an ad. If that's the worst distortion or deception that happens in a political ad this season, we can all rejoice.

Link to short NYT piece about the Fox ads.

Tuesday, October 24, 2006

What does Alzheimer's look like?

NYT has a riveting article and slide show about an American artist in London named William Utermohlen. Utermohlen learned he had Alzheimer's in 1995; the Times shows some of his self-portraits from 1995 through 2000. Now 73, he lives in a nursing home and no longer paints. Snip:
The paintings starkly reveal the artist’s descent into dementia, as his world began to tilt, perspectives flattened and details melted away. His wife and his doctors said he seemed aware at times that technical flaws had crept into his work, but he could not figure out how to correct them.

“The spatial sense kept slipping, and I think he knew,” [his wife] said. A psychoanalyst wrote that the paintings depicted sadness, anxiety, resignation and feelings of feebleness and shame.

I wonder what a portrait of multiple sclerosis would look like. I used to dabble in art, but it gradually stopped being fun: I found I no longer had the energy required for the creative enterprise. Maybe that's what my portrait of MS would look like--a blank canvas, an unmarked sheet of paper, an instrument unplayed.

Saturday, October 21, 2006

Living Legends Department: Saxophone Colossus

NYT has a lovely profile of legendary tenor sax player Sonny Rollins, who will be releasing his first studio album in about 10 years. I'm ashamed to admit that I thought he was no longer living; I assumed (and I suspect I'm not the only one) that everybody as good as Rollins was dead. Can't wait to hear the record. Snip:
Until recently, Sonny Rollins practiced his tenor saxophone in a cottage studio a short, loping distance from his house here, on the rustic property he and his wife, Lucille, bought nearly 35 years ago. Mr. Rollins, who has long been lionized, partly for his intense, solitary practicing — or woodshedding, in jazz argot — would often work in the cottage past nightfall. At the house, his wife would turn on the porch light so he could find his way back through the dark.

Lucille Rollins died not quite two years ago, and Mr. Rollins initially turned to his regimen for solace. “So I came out here a few times,” he said in his studio one recent afternoon, “and then I looked, and there was no light on the porch. It just kind of highlighted that, well, there’s nobody there now.” These days, he practices in the house.


Friday, October 20, 2006

Update on Wal-Mart generics

I seem to be getting a lot of thru-traffic looking for the list of generics included in Wal-Mart's $4 deal, so here's an update: Wal-Mart's expanding the list of drugs included and expanding the states where it will be offering the deal. Snip from WaPo:
The company's plan covers a month's supply of 314 prescription drugs. That number is made up of 143 drugs in a variety of dosages and solid or liquid forms. The program was launched in the Tampa area two months ago, as part of what the company called an effort to save working Americans money on health care.

The program was expanded to the rest of Florida two weeks ago, and yesterday it was extended to Alaska, Arkansas, Arizona, Delaware, Illinois, Indiana, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Texas and Vermont.
Health-care experts said any price competition is welcome, but noted that generics are less of a burden to consumers than higher-priced brand-name drugs that remain under patent. Critics, including rival non-chain pharmacies, said the plan covers only a fraction of a prescription drug market that includes about 8,700 FDA-approved generics. "This is a public relations stunt meant to drive foot traffic. Most people will find their prescriptions do not fall under the $4 plan," said Charlie Sewell, senior vice president of government affairs at the National Community Pharmacists Association, which represents about 24,000 non-chain pharmacies.

Here's a link to an updated list of covered drugs, which now includes lovastatin.

I'm still not impressed, and I think it's downright goofy to tout this as some kind of market-based solution to the problem of access to health care. This is a teeny slice of the whole list of generic drugs out there. And let's don't forget that you still need to see a doctor to get these drugs, so you're still on your own for the most expensive part of the transaction.

That said, I think it's brilliant marketing on Wal-Mart's part. It'll get gazillions of people through the doors, at least until they find out their drugs aren't on the list, and it buys some badly-needed good press for Wal-Mart. I'm not a rabid WM-hater, but even if this included one of the drugs I'm on, it wouldn't get me to drive all the way out to Wal-Mart when Walgreen's is just few minutes away.

Thursday, October 19, 2006

A gift and a slow start

It's fall for sure, now. On my way home from work last night, about a block from my house, I spied a suspiciously lumpy little pile of leave under a small oak tree in a neighbor's front yard, and pulled a quick U-turn. A closer look confirmed a delicious find: a mushroom known as the hen of the woods. Big, too: about the size (and weight) of a ten-pound sack of potatoes.

My interest in mushrooms goes back to occasional tramps in the woods with my dad in search of morels when I was a kid. Since then, I seem always to keep an eye out for one of the "safe six" that I feel confident enough to eat (shaggy mane, sulfur shelf, oyster, morel, hen of the woods, and giant puffball). I got out of the car, trudged through the drizzle. and knocked on the door. No answer, so I turned and scooped up the big shroom and put it on a towel in the car. I spent about an hour pulling off some nice clean pieces and cutting them into thumb sized-pieces for drying. Hen of the woods makes a lovely creamy soup or stroganoff-type ragout.

Had a bad night and morning, though, and I'm dragging ass pretty badly today. Went something like this:

10:15 Rebif, pills, and bed. Mmmmm, cozy.
11:39 Wake up, pee. Back to bed.
1:24 Wake up. Hip and shoulders sore (swimming?). Sigh. Pee. Back to bed.
3:42 Wake up. Sore, again, hip and calves. Sigh. Gotta pee, but don't wanna get out of bed. Sigh. Pee.
5:15 Wake up. Sore. Fan making annoying little rattle. Sigh. Roll over.
5:38 Wake up. Gotta pee. Sigh. No, maybe not. Well, actually, yeah. Sigh. Pee.
6:05 Alarm goes off. Wake up, sigh. Dawn simulator has bedroom light up to 25% or so. Listen to NPR, doze back to sleep again.
6:30 Wake up. Dawn simulator has bedroom light up all the way. Listen to annoying clip from Rahm Emanual interview. Sigh. Wife opens door, dog stands up and comes over to sniff my hair. Out of bed, into sweats and bathrobe.
6:37 Let dogs out. Rub eyes. Sigh. Feet hurt. Too much standing up to pee in bare feet? Let dogs back in.
6:46 Coffee. Mmmmm. Sit down and stretch a little. Still sore.
6:52 Feed dogs. Sit on recliner to make sure alpha dog doesn't interfere with yellow dog's breakfast. Sigh.
7:01 Shower. Brr. Yellow dog barks, has to poop right after breakfast. Wish I could do that. Hurry out of shower. Let dogs out again.
7:11 Stand in front of closet. What to wear? Only clean trousers are itchy wool ones. Dang.
7:22 Stalled after sitting down to tie shoes. Am I really gonna go to work? Yes, I am going to work, because today is not yet The Day. Sigh. Am I sure it's not The Day? Yes, I'm sure.
7:37 NPR says somebody in the state won $15M lottery jackpot last night. Bastard. Bet he or she isn't going to work today.
7:43 Stalled again, this time on futon. Think about looming home improvement project and hail-damaged roof. Sigh.
7:49 No milk left for cereal. Dang. Sigh. Brush teeth. Sit down at computer, check email. Goofy joke message from kid sister. She's a funny kid. Wait, am I stalled again? Dang. Sigh.
8:08 What can I take for lunch? Gaze into fridge, sigh. Grab apple and bag of prunes. Sneeze.
8:16 Final approach. Where's the phone? Charging. Where's the iPod? Charging. Locate car keys and wallet, unplug phone and iPod. Sigh.
8:21 I'm late. Yellow dog knows I'm leaving for real now, and follows me into bathroom. Pee. Glance in mirror, check for sleep drool, boogers. Clear for take-off.
8:25 Finally in car. Sigh.

Wednesday, October 18, 2006

Pool at noon

I've been trying to get to the pool to swim a few laps at least twice a week. Up until a couple weeks ago, I was doing pretty well, but two busy weekends kinda got me off track. Fortunately, the pool (at the high school near where I live) is open for lap swimming from 11:30-1:30. Today, I ditched work at 11:40 and met my wife at the pool. I got to school promptly at noon, swam half a dozen laps, showered, and got back to my desk at 1:00. Pretty slick, and at $1.50 a visit, deeply satisfying to my inner cheapskate. I hope I can keep it up through the winter, because a 20-25 minute swim really feels good without leaving me legless for the rest of the day.

Monday, October 16, 2006

Aquaman: "Shyeah."

So it's Monday, and I had a nice weekend goofin' around with some old friends who know me from way back when I was a strapping young man fresh out of law school, and thinking about how times change and people change and we got to hang onto each other because we could all, like, vaporize or melt or disappear without warning at any time onnacounta any little freaky midget head-of-state can get his/her hands on a nukular bomb, when I stumbled over this piece at McSweeney's by Glen Weldon. It's Aquaman, see, and he's pissed about all the snickering about him and his not-so-cool powers, because it's a bigger deal than you understand to be able to control sea life. Snip:
If I want, you know, a pod of Burmeister's porpoise to ram the hell out of Black Manta's Manta Sub, that shit gets done. If I totally want, like, a southern minke whale to go hump a giant squid (its most hated enemy, by the way), I just go doodoodoodoodoodoo and it's like Show World down there. Not that I would, because, you know, gross, but I'm just saying: I don't ask. I'm not going to be all, If you wouldn't mind terribly much, please, Mr. Southern Minke Whale, go get your nasty freak on with that giant squid.

Just, you know, FYI.

It's part of a serious of short imagined monologues, it's laced with profanity, and it's a great Monday read. Link.

Friday, October 13, 2006

MS, depression, and the future

I read an abstract this morning about MS and depression. Like depressed folks generally, MS patients who are depressed tend to have trouble anticipating future positive experieces; it's not so much about anticipated future negative experiences.

That fits. My own frequent visits to the blue side find me not so much dreading the future as struggling to find something to look forward to along with the dread. Of late, I've found myself thinking about my job, and how it's getting harder for me just to sit still at my desk, much less get anything done, and how the seemingly inevitable end of my career will no doubt be much, much worse: increasing difficulty precipitates crisis and confrontation, inevitable struggle with insurance company and SSDI, followed by years of financial woes.

Yesterday, when they announced the winner of the Nobel for literature--a Turk--I thought about how I used to fantasize about traveling to Turkey, and adventurous travel in general, and I thought, Well, I can't imagine going to Turkey in my present condition. Even three days at the cabin over the weekend was about a day and a half more than I found myself capable of enjoying (Jeez, I sure miss my own bed and big ugly recliner, etc.).

I'm sure that part of the solution is to carpe the diem and create things to look forward to, schedule and plan for things that feel good; that way, not only do you have stuff to look forward to, but you're doing something in the present. But how do you plan when you find yourself struggling to enjoy the stuff you know you enjoyed in the past?

Link to abstract.

Wednesday, October 11, 2006

First snow!

Right now, the first snow of the year is falling outside my office. For some reason, it still thrills me to see the first few flakes, just like it did when I was a kid. Of course, it will be weeks before this stuff stays frozen after it hits the ground.

Seems maybe just a wee bit early--usually we hafta wait until at least Halloween. I bought a little electric snowblower this year, and I can't freakin' wait to plug it in and throw some snow around!

Wednesday, October 04, 2006

Feds OK 90 days of Canadian meds

Hurrah for cranky old and sick people! The federal government will no longer seize prescription meds imported from Canada for personal use. Snip from WaPo:

Customs spokeswoman Lynn Hollinger confirmed the policy change Tuesday, saying the agency would no longer intercept the drugs or issue letters to postal carriers indicating it is illegal to import prescription medications. She said the policy change was due to political pressure from lawmakers and people who complained they were no longer receiving their medicine.

[Sen. Bill] Nelson said that the new policy will allow Americans to import small amounts of prescription drugs - roughly a 90-day supply.

"It's a great victory, particularly for the senior citizens who are having difficulty making financial ends meet in a time in which, sadly, some senior citizens have to make a decision between buying their prescription drugs and buying their groceries," Nelson said.

The change means that the U.S. Food and Drug Administration will resume oversight of the importation of prescription drugs. Before Customs took over enforcement the FDA largely ignored the importation of small amounts of prescription drugs. It is still illegal to import prescription drugs from abroad, but Nelson said he received assurances from the FDA that the agency will not act on small drug shipments for individuals.


I presume you will still need to import your 90-day supply of pot from BC in the trunk of your car.

Tuesday, October 03, 2006

When pooper-scoopers attack!

A woman with a history of alcohol abuse and drug use was sentenced Monday to two years in prison for attacking a Waukesha couple she didn't know with a metal pooper scooper and scissors in a bizarre middle-of-the-night assault. Snip about the incident in June:
It took five police officers, three hits with a Taser gun, leg straps and a spit bag to subdue a 5-foot tall, 105-pound woman who entered a Waukesha home and attacked a couple she didn't know with a metal pooper scooper and scissors, authorities said. Still kicking after being strapped and handcuffed, the woman was carried by police out of the home in a bag, and she looked "like a sack of potatoes," the homeowner said.
Waukesha residents John and Linda Dormer said they do not know [attacker Leisa] Reed and kept telling her she was in the wrong house, John Dormer said Monday. Reed kept saying that someone was going to kill her and threatened to kill the Dormers, he said. "I tried to reason with her," he said. She then hit him with the pooper scooper and armed herself with two scissors, he said. He said he feared for his life and the lives of his family. Two of the couple's children, 12 and 13, also witnessed the attack. The Dormers are OK but still shaken up, he said. They credit their dog, rescued from a shelter in Oshkosh, with alerting them to the intruder and saving their lives.

Reed told authorities she doesn't remember being in the Dormer's home. She told police that a friend picked her up at her apartment in Milwaukee on Saturday evening and took her to her friend's apartment in Waukesha. Reed's husband, Matt, was also there, the criminal complaint says. Reed said she drank a 12-ounce can of beer and purchased $40 in crack cocaine, which she smoked at her friend's apartment in Waukesha, the complaint says.



A gorgeous fall weekend: unnaturally blue sky, cool air so dry and crisp it crackled in your nose, the ash tree dumping the first load of spent leaves onto the yard and into the gutters. This is what the weather is supposed to be like when my birthday comes around. We cancelled our reservation at the fancy restaurant and roasted weenies over a fire in the back yard instead. But when the beer wore off the next morning, I was miserable.

I'd bumped up to 40 mg Cymbalta on Thursday, which also meant cutting my daily dose of Lyrica to just 150 mg. Most of my body was either aching or burning, and I hadn't been able to sleep most of the night. I was also having more trouble walking. The day before, my legs seemed to have gotten twice as heavy, especially the left one, and I seemed to be using my trunk muscles to help hoist myself around.

At 10:00 am (on a Saturday!), my neurologist called to say that my head MRI from Wednesday looked pretty good: some characteristic MS lesions, sure, but the burden of disease on my brain looked quite light considering I developed MS more than a dozen years ago. We'll do a C-spine MRI sometime soon, but things look good up there. "No excuses now; you'll have to win every case," he joked. I could feel myself getting prickly, and reminded him that I no longer worked in court, but forced myself to say something like "That's great news."

I didn't really think it was great news, though. I think I'd been secretly hoping that my MRI would show that my brain had turned into butterscotch pudding, that it was a miracle I was able to tie my own shoes, that it was only by virtue of my miraculous determination and strength of character that I still managed to function as well as I do.

For whatever reason, I spent most of my birthday weekend in a funk, watching birds at the feeder from my recliner or staring at the TV or the computer. Yesterday, I did more or less the same thing at work, thinking about the impending end of my working life and the great unpleasantness that will no doubt happen as it starts to become apparent to my supervisors and coworkers that I'm not carrying my own weight. Today, like yesterday, I'm walking slowly and stiffly, coasting on this morning's caffeine buzz, wondering if my bowels are still doing their job, thinking about the impending up-tick in my workload, thinking about home improvement projects that have stalled, thinking about the new strain MS is throwing into my marriage, thinking about a planned weekend at the cabin that could be spoiled by my inability to haul my sorry ass down the hill to the lake to watch the wobbly, noisy V's of geese on their way to somewhere else.

Thursday, September 28, 2006

Journal: One week on

It's been a week since my latest go-round with Cymbalta. As of tonight, I'll be down to just 150 mg of Lyrica and up to 40 mg of Cymbalta. So far, so good, I guess. I can definitely tell that I haven't had a serving of Lyrica this morning: thighs are on fire, so I'm slouched way down in my chair to keep my weight on my back and butt and off of my thighs. But over the last seven days, I only wet the bed once, which is within usual limits. We'll see how things go when the dose goes up tonight.

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Wednesday, September 27, 2006

In the news: What health care crisis?

In the news lately, there's been lots of ink spilled about the 7.7% rise in the cost of health coverage over the past year. But the first thing I read after my MRI this morning was a piece in the NYT by David Leonhardt arguing that the increased cost isn't really a problem, because most of the increase is attributable to the deployment of new technologies that have extended and improved life. According to Leonhardt, there may be some waste in the system, but the only way to achieve real savings is to limit care. While he acknowledges that the current trend is unsustainable, Leonhardt argues we should, as a society, acknowledge that better care is worth paying for. Interesting read. Snip:
Somehow, going to the mall to buy clothes has come to be seen as a vaguely patriotic way to keep the economy humming, and taking out a risky mortgage is considered to be an investment in one's future. But medical care? That's just a cost.

It's easy to be against high costs, and it will no doubt be hard to come up with a broad health care solution. But the way to start is by acknowledging that an affluent society should devote an ever-growing share of its resources to the health of its citizens. "We have enough of the basics in life," Mr. Cutler, the economist and author, points out. "What we really want are the time and the quality of life to enjoy them."
Link. And see this post about the future health care economy.

Monday, September 25, 2006

Research: Nabilone for spasticity pain

Some promising results in a test of a synthetic cannabinoid for spasticity-related MS pain:
J Neurol. 2006 Sep 20; [Epub ahead of print]
Low dose treatment with the synthetic cannabinoid Nabilone significantly reduces spasticity-related pain : A double-blind placebo-controlled cross-over trial. Wissel J, Haydn T, Muller J, Brenneis C, Berger T, Poewe W, Schelosky LD.

About 30% of patients with chronic upper motor neuron syndrome (UMNS) suffer from disabling spasticity-related pain not sufficiently correctable by conventional treatment. Delta9-tetrahydrocannabinol (Delta(9)-THC) was reported to add benefit in the treatment of pain in patients with multiple sclerosis (MS). The question arose whether synthetic cannabinoids with lower potential for psychotropic side effects could be effective as well. To evaluate the safety and efficacy of low dose treatment with the synthetic cannabinoid Nabilone (1 mg per day) on spasticity-related pain a placebo-controlled double-blind crossover trial was performed.11 out of 13 included patients completed the study. The 11-Point-Box-Test showed a significant decrease of pain under Nabilone (p < 0.05), while spasticity, motor function and activities of daily living did not change. 5 patients reported side effects: one moderate transient weakness of the lower limbs (Nabilone phase, drop out), three mild drowsiness (two Nabilone, one placebo) and one mild dysphagia (placebo). One patient was excluded from the study due to an acute relapse of multiple sclerosis (Nabilone phase, drop out).Nabilone 1 mg per day proved to be a safe and easily applicable option in the care of patients with chronic UMNS and spasticity-related pain otherwise not controllable.

Friday, September 22, 2006

In the news: Wal-Mart's $4 generics list

Here's a link to a list of drugs included in Wal-Mart's $4 generics menu. I see only one that I'm currently taking on the list: baclofen. Also on the list are an assortment of tricyclic antidepressants, antibiotics, and generic Prozac. Seems pretty underwhelming.

In the news: Cladribine on FDA's fast track

Snip from CBS news:
Swiss biotech firm Serono SA, which earlier Thursday agreed to sell a majority stake in the company to German drugmaker Merck KGaA for $13.31 billion, said its oral cladribine treatment for multiple sclerosis has received 'fast-track' status from the U.S. Food and Drug Administration. This designation covers patients with relapsing forms of multiple sclerosis.

Serono's oral form of cladribine is currently being evaluated in a multi-center, multi-national Phase III study called CLARITY. It is a two-year, double-blind, placebo-controlled study involving more than 1,200 patients. Patient enrollment is planned to be completed by the end of 2006.

This kind of news used to get me all excited, but not so much anymore. I'm not sure, but I think I'm probably more secondary-progressive than relapsing-remitting. (Is this something I need to know, what form of MS I've got?) It's been years since I had a recognizeable exacerbation. These days, I'm more interested in finding pain relief than in reducing the number of enhancing lesions or whatever clinical measure is used to tout the latest MS drug.

Not that I'm complaining about the way things have turned out for me: I'm about 14 years out from my initial MS symptoms, 13 years past diagnosis, and I'm still mostly upright. On Wednesday, my neurologist told me that at this stage in the game, most MS patients aren't doing quite as well. Neurologically, my grades are pretty good, I guess, except the pain.

Last night, I started Cymbalta again. Third time's the charm? We'll see. The urologist says double up on the Flomax to counteract Cymbalta's retention effect. For the last couple days, I've left the office at 4-ish, because the burning and squirming left me completely unable to get anything done. Here's hoping Cymbalta will improve things, because my work load is steadily ramping up.

Link to CBS story.

Wednesday, September 20, 2006

Journal: Neurologist visit, and Segseat

Yesterday morning, I woke up, threw on some clothes, and raced over to the clinic. I'd forgotten to set an alarm, and it's been a long time since I managed to get out of the house so quickly (no shower, no shave, no coffee, no stretching, no letting out and feeding dogs, etc.). I made it with a couple minutes to spare, so in the waiting room I opened up an issue of the MS Society's magazine Inside MS. I think there was a time when I got it in the mail, but at the time I was put off by the images of smiling people in wheelchairs. "Soon, you'll be one of us," they seemed to be saying, cheerfully. "We're saving a little red scooter just for you." This time, though, I found myself flipping through the little ads near the back for MS-related products and services: cooling vests, lap pools, lifts, etc. One caught my eye: a seat for use with the Segway.

Back when the Segway was introduced, it seemed to have a lot of potential as a mobility aid. At the time, walking was getting more difficult for me, and I imagined rolling around on a Segway as a way to extend my range. But as it got difficult just to stand in one place for any length of time, the Segway seemed a lot less appealing, and it drifted out of my daydreams. Seeing the ad for the Segseat has it back in again.

The Segseat is a nifty little gizmo that allows you to sit on a little bike-type seat while operating your Segway. It seems pretty well designed: it mounts on the post that the 'handlebars' are attached to, and it slides back and forth so as you change the angle of the Segway, your butt remains in approximately the same position. You can flip it up and out of the way if it's not in use. It's a little hard to describe, but there's a video at the web site. Problem is, it adds another 750 clams to the $5,000 price tag of a Segway, so it's unlikely to appear outside my
daydreams any time soon. But it would really be lovely to go for a 'walk' that takes me more than a few hundred yards from home base. Here's the fantasy: heading out to a state park with wife and dogs on a crisp October day, and wandering into the woods (on a very well-groomed trail) a mile away from the parking lot. That would be dreamy, almost like the good old days.

Not much new at the neuro: let's not try Novantrone yet, let's see if we can find a way to get good pain relief and get a brain MRI just to see if there are any active lesions. Observed by a young intern who sat quietly through the whole visit until neuro mentioned something to do with fMRI, and which point she lit up and starting talking about this research and that research, prompting the neuro to get a little exasperated and cut her off. It was somehow very appealing to see someone have a little geek-gasm about neuroscience. Makes one a little more hopeful about the prospects for a cure someday.

Tuesday, September 19, 2006

Journal: Tough luck

In the NYT today, an essay about medicine and luck (or chance, or what you will). The gist: medical science may have improved your chances of a positive outcome, but there's still plenty of room for failure, and the occasional lucky break. Snip:
Luck seems to have become particularly anathema in an era of evidence-based medicine, in which physicians and patients are encouraged to learn the latest relevant data to guide decisions. Dr. Peter A. Ubel, a University of Michigan internist and author of "You're Stronger Than You Think," believes that his patients prefer biological explanations of why they are sick, rather than hearing that they have bad genes or bad luck. But given the biological variability within given diseases, like cancer, and the fact that variable genetic makeup leads different individuals to respond differently to diseases and therapies, even better scientific knowledge will not eliminate the role played by luck. Chance, the British physician R. J. Epstein wrote in the Quarterly Journal of Medicine, ensures different outcomes within given sick populations.

I would guess that MS patients, as a group, probably understand this idea better than others. It starts with that consult with the neurologist where he show you some blurry little patches on the MRI, and tells you that you might have MS, or you might be fine, but it's impossible to say at that point. It continues with every new tingle, tremor, tic, every new symptom or disability. And every new drug you get: studies indicate that subjects who took the drug were 30% less likely to have new exacerbations/were 25% more likely to remember where they put the car keys/were 12% less likely to punch the bus driver/were 66% groovier/were 72% more likely to fit into their jeans/were 17% less likely to miss a mortgage payment/were 59% less likely to chew off their own feet.

Then there's the subset of those of us with pain. We are exquisitely conscious of our rising and (mostly) falling fortunes. We fill shoeboxes with drugs that didn't work, or stopped working, or that we tried because our insurance companies wouldn't pay for the drug the doctor prescribed until we tried the half-dozen cheaper alternatives. Anyone need Neurontin? I have buckets of the stuff, plus a bunch of pills with names that end in -amine, and some Lyrica that will probably be left over when I switch back to one of the losers to give it another try.

Nobody needs to explain to us that medicine is partly science and partly art. We are the canvas upon which medicine doodles: Drug not working for you? Try playing around with the dose. If that doesn't work, we'll try something else, something we're studying, something off-label, and feel free to play around with that, too. If that doesn't work, put all your meds into a blender with some yogurt, some orange juice, a banana, and some honey, and make a smoothie. Feel free to play around with that.

When it still hurts, the artsy side of medicine -- the side that we haven't had good luck with -- looks to us like Jackson Pollack, or de Kooning. Art? we scoff to ourselves. Shit, a four-year-old could have come up with that.

Monday, September 18, 2006

Shoutout: Hail, BrainTalk 2

Learned yesterday that there's a site serving as a sort of interim BrainTalk forum (thanks, Anonymous!). I can't quite figure out what the deal is with BT 1, but BT 2 is up and running. You'll need to register as a new user, and it's unclear what will happen with either BT in the future. Pass it on.

Thursday, September 14, 2006

Journal: Ironman?

As I walked in, using a cane, the lifeguard recognized me. I hadn't taken the cane to the pool before, but figured it might reduce the chance of me losing my balance and spilling the contents of my skull onto the pool deck.

She mugged a look of concern and said, "Are you okay? Did you do the Iron Man [triathlon held in town over the weekend]?"

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Wednesday, September 13, 2006

Research: Another angle on neutralizing antibodies

So we all know that lots of us who take interferon-beta have developed antibodies to the stuff, which might be reducing the effectiveness of the stuff. If I understand this abstract correctly, the antibodies might also be messing with the interferon-beta your body is producing on its own. Is that a problem?
Arch Neurol. 2006 Sep;63(9):1296-9.
Potential for interferon Beta-induced serum antibodies in multiple sclerosis to inhibit endogenous interferon-regulated chemokine/cytokine responses within the central nervous system.
Shapiro AM, Jack CS, Lapierre Y, Arbour N, Bar-Or A, Antel JP.

BACKGROUND: A proportion of patients with multiple sclerosis (MS) receiving systemic interferon beta therapy will develop serum neutralizing antibodies (NAbs) that can reduce the activity of the drug. Interferon-beta (IFN-beta) is produced by glial cells within the central nervous system. Although systemic interferon beta does not access the central nervous system, titers of serum NAbs may be sufficient that some will access the central nervous system. OBJECTIVE: To address whether serum samples that contain high titers of NAbs could inhibit glial cell production of chemokines and cytokines that are regulated by endogenous IFN-beta. DESIGN: We used an in vitro assay involving toll-like receptor 3 ligand (polyinosinic-polycytidylic acid) signaling to assess the effect of serum samples containing high titers of NAbs (1800-20 000 U) on production of the chemokine CXCL10 and the cytokine interleukin 6 by human astrocytes. RESULTS: Serum samples positive for NAbs significantly inhibited polyinosinic-polycytidylic acid-induced CXCL10 and IL-6 production by astrocytes. CONCLUSION: High-titer NAbs to interferon beta may block endogenous IFN-beta function and alter the chemokine/cytokine microenvironment within the central nervous system, thereby modulating the profile and course of the local inflammatory response.


Research: Buried alive in your own skull

Today at, William Saletan has a piece about an account of a young woman in England who appeared to be in a persistent vegetative state following a car crash. Snip of what happened next:
Then, scientists put her in a Functional Magnetic Resonance Imaging scanner, which tracks blood flow to different parts of the brain. They asked her to imagine playing tennis and walking through her home. The scan lit up with telltale patterns of language, movement, and navigation indistinguishable from the brains of healthy people. Something was awake inside that woman's skull. Without the scanner, no one but her would have known.
Now scientists are debating what goes on in the English patient's head. Some call her performance a "decision"; others dismiss it as a mere "response." They ask why her body doesn't move, since her motor pathways appear to be preserved. The analysis in Science concludes that she has a "rich mental life" but may not be "conscious." What in God's name does that mean? Would you pull the plug on a 24-year-old relative with a rich and responsive but unconscious mental life? Go ahead, raise your hand. Or just think about raising it, and we'll record your vote by brain scan.

Saletan gives the obligatory comparison to Terry Schiavo (starved of oxygen for years, her brain had "liquefied") and raises the issue that "the reality of your mental life" may depend on which tests you or your insurer can pay for, which hospital you're taken to.

This kind of stuff scares the shit out of me, though I know it's unlikely that MS could put me in a similar situation. But in darker moments, when I've been out in the sun too long and lost my ability to walk and peed my pants and been reduced to a lurching, mumbling pile of meat and bones, I feel utterly disconnected from the corporeal existence that I used to know. Increasingly, I find myself drifting in and out of this disconnected state; the discombobulated state sometimes feels more ordinary than the flares of physical and mental vitality.

Tuesday, September 05, 2006

Journal: Bits

Off to the east coast for a conference this week, so just bits and pieces:

1. Boat-related discombobulation last weekend...still too hot, I guess...both my wife and sister-in-law in attendance...afterward, wife asked if she should try backing up the trailer...actually thought for a couple second before saying "Nope."

2. Wife found a giant puffball mushroom the size of a Hyundai growing in the neighbor's'd think they'd be a lot tastier than that.

3. DHEA supplements consigned to shoebox full of other non-miraculous cures.

4. Hockey tape looks really cool on the handle of my cane.

5. Finally bought small electric snowblower, guarranteeing dramatic accelleration in global warming.

6. Pain hurts.
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Thursday, August 31, 2006

Law stuff: SCOTUS prefers vanilla

Dahlia Lithwick at Slate is one of my favorite law-related pundits. Today, she writes on the decline in the number of women selected for super-prestigious short-term gigs as judicial clerks for Supreme Court justices (yesterday, NYT ran a story on the subject by Linda Greenhouse). Snip from Dahlia:
The real problem here, of course, is that there is just no way to measure what makes for "better" clerks. What makes for a good clerk is that her boss likes her. And assuming that they aren't drinking and cite-checking at the same time, most clerks thus do just fine. But evidently some older male judges still feel uncomfortable with young women. Or their wives do. Some just prefer to hang out with those who share their political or ideological views. Many judges have quirky personal preferences (for tennis players or history buffs). Others just don't think there's any benefit to diversity in their chambers. And so, not unlike the guys at the Sigma Chi house, some judges just go with their instinct, and in some cases that means their choices are overwhelmingly male. That has little to do with personal politics, by the way. If Clarence Thomas has one of the court's best records for diverse hiring, liberal icon William Brennan had one of the worst.

As usual, Dahlia's got it right. As a former (non-SCOTUS) clerk, I know that there are loads of qualified candidates for every spot, so a judge has the luxury of making a hire based on a hunch that the candidate will be a good "fit," a person the judge will feel comfortable with. So why don't some of the justices feel comfortable working with women (or other people who aren't white men)?

In the news: Medical practices organized around faith

WaPo has a piece about the growing number of medical practices that provide care according to the faiths of the practitioners. Mostly, this plays out in the context of family planning. Snip:
[The practices] tailor the care they provide to the religious beliefs of their doctors, shunning birth-control and morning-after pills, IUDs and other contraceptive devices, sterilizations, and abortions, as well as in vitro fertilization. Instead, doctors offer "natural family planning" -- teaching couples to monitor a woman's temperature and other bodily signals to time intercourse.

Proponents say the practices allow doctors to avoid conflicts with patients who want services the practitioners find objectionable, as well as to provide care that conforms with many patients' own values. The approach, they say, provides an alternative to mainstream medicine's reliance on drugs and devices that, they argue, carry side effects and negatively affect couples' relationships. 'I want to practice my faith,' said John T. Bruchalski, the obstetrician-gynecologist who started Tepeyac. 'I'm not interested in pushing it on other people. But this allows me to practice medicine without having to do something that I wouldn't see as positive or healthy.'

Critics, however, worry that the practices are segregating medicine along religious lines and may be providing inadequate care by failing to fully inform patients about their options. The critics are especially alarmed about the consequences in poor or rural areas with few alternatives.

Hypothetically, if a patient knew exactly what she was forgoing by going to one of these practices, then fine, I guess. But is it possible to get a patient's informed consent in advance to all of the choices the doctor has already made about what is appropriate for that patient?

Wednesday, August 30, 2006

Shout out: BrainTalk progress?

I was a frequent visitor to the BrainTalk MS forum, and its recent server outage has been frustrating. For a couple months, the only sign of life has been an ASCII message promising to have the server up as soon as possible. Now, there are signs that BrainTalk may be on the mend:
UPDATE 08.24.06 It has taken me much longer than expected to at least get the front page here and chatrooms running. I ran into the need to update the operating system, which caused more problems (the OS is broken to the point where I cannot run incremental updates). I'm waiting for the latest full version of OSX Server on CDs so I can do a full wipe of the drives and reinstall everything from scratch. Disks should arrive in the mail on Sept 5th the latest. Once that's here, I'll install the newest version of vBulletin and recover as much of the data from backups as I possibly can. I'm so sorry the system has been down for as long as it has. Every step forward I've taken to try and restore things seems to knock me 2 steps back, plus I have been travelling for work a great deal the past month. But I think I see the light at the end of the tunnel. Thanks for hanging in there. To get to the BrainTalk chatrooms, please visit:

My recollection is that BrainTalk was run on a shoestring budget funded by donations from users. When the forums come back, I think I'll make a contribution; I've missed them, and maybe more money will help keep the lights on.

Tuesday, August 29, 2006

In the news: Cooling products, better late than never

Just in time for the dog days of, um, autumn, WaPo brings us a comparison of several products intended to keep the body cool. Doesn't sound like any of these products is a slam-dunk solution, but I might look into the evaporative-cool vest, though not as a part of the Village People ensemble pictured here.

Something like the vest might have come in handy this past Sunday. I went for a paddle with my dad and my brother on a crisp, cloudless day, and got warm enough that by the end up the trip I was partially discombobulated, wobbly, and ready for bed. Snip:
We pulled the canvas-colored vest ($34.99, on sale from $69) out of its bag and couldn't figure up from down. The hook-and-loop straps took a little untangling (and still we didn't know which way was inside out). It looked like it might inflate into a raft; instead, it expanded into something a nattily attired highway flagman might wear.

After soaking the garment in cold water (the greedy polymers in the lining lapped it up), we strapped it on. It felt cool but not wet; the added pound of weight was hardly noticeable. The cool effect lasted more than 50 minutes, or else we just got numb.


Thursday, August 24, 2006

In the news: Rational opposition to new technique?

Well, early signs are that taking one-eighth of a blastomere for use in stem-cell research will not pass the moral objections of the president or congressional science foes. Snip from NYT:
With the approach of midterm elections, in which some candidates are already making the research a central theme, some scientists speculated that President Bush might embrace the new method as meeting his principal objection to the research and showing that he had been right all along to wait for a better technique to turn up.

But Emily Lawrimore, a White House spokeswoman, suggested that the new procedure would not satisfy the objections of Mr. Bush, who vetoed legislation in July that would have expanded federally financed embryonic stem cell research. Though Ms. Lawrimore called it encouraging that scientists were moving away from destroying embryos, she said: “Any use of human embryos for research purposes raises serious ethical questions. This technique does not resolve those concerns.”
Congressional Republicans who led the resistance to the embryonic stem cell legislation that had bipartisan support in the House and Senate also said the new technique did not ease their opposition. Brian Hart, a spokesman for Senator Sam Brownback, Republican of Kansas and a prominent opponent of federal financing for embryonic stem cell research, said Mr. Brownback's moral objection remained.
"You are creating a twin and then killing that twin," Mr. Hart said.

Really, this smacks of the same kind of thinking that opposes birth control methods that prevent the implantation of a fertilized egg in the uterus on the ground that a fertilized egg is a teeny tiny person, a microscopic Haley Joel Osment swimming around in the mysterious human hot tub that is the female reproductive system. On the other hand, it's hard to be surprised by Sam Brownback's weirdness, after the whole snowflake thing.

Link to NYT.

Wednesday, August 23, 2006

Research: Embryo-friendly embryonic stem cells?

Interesting article in the NYT on a new method for obtaining embryonic stem cells. Snip:
The new technique would be performed on an embryo when it is two days old, after the fertilized egg has divided into eight cells, known as blastomeres. In fertility clinics, where the embryo is available outside the mother in the normal course of in-vitro fertilization, one of these blastomeres can be removed for diagnostic tests, such as for Down’s syndrome, and the embryo, now with seven cells, can be implanted in the mother if no defect is found. Many such embryos have grown into apparently healthy babies over the ten years or so the diagnostic tests have been used.

Up to now, human embryonic stem cells have been derived at a later stage of development when the embryo consists of about 150 cells. Harvesting these cells destroys the embryo. Last year, Dr. Lanza reported that embryonic stem cell cultures could be derived from the blastomeres of mice, a finding others have confirmed. He now says the same can be done with human blastomeres.

If this works, then it would seem to overcome the ethical objections to research that would result in the destruction of discarded human embryos, right? Well, almost. See, the technique still requires the fertilization of human egg by human sperm outside the darkened confines of a marital bedroom, and there are still some people out there with moral objections to in vitro fertilization. Snip:
Catholic bishops, in particular, oppose both in-vitro fertilization and P.G.D. testing, and therefore still object to the research, even though the cells would be derived from an embryo that is brought to term.

Richard Doerflinger, deputy director for pro-life activities at the United States Conference of Catholic Bishops, said the church opposed in-vitro fertilization because of the high death rate of embryos in fertility clinics and because separating procreation from the act of love made the embryo seem “more a product of manufacture than a gift.” Asked if he meant the parents of an in-vitro child would love it less, Mr. Doerflinger said he was referring to the clinic staff. “The technician does not love this child, has no personal connection with the child, and with every I.V.F. procedure he or she may get more and more used to the idea of the child as manufacture,” he said.

So there are some people for whom this slope is so perilously slippery that they really would prefer that you didn't even shower after sex. One hopes that someone--perhaps one of the gazillion frustrated childless couples giving up vacations and cars in order to pay for IVF--will be able to adequately explain to our President that IVF does not cross his moral line in the sand, that this kind of research must be funded.
New Stem Cell Method Avoids Destroying Embryos - New York Times

Research: Extensive remyelination?

Autopsies indicate that some 20% of MS patients have been busy remyelinating their lesion areas. I'd just like to say cheers to the specimens who, um, participated in this research. First, kudos to you for remyelinating. I wish I knew how to do that. Second, thanks for your generous foresight in donating your recently-vacated corporeal forms. Here's a snip from the abstract:
The extent of remyelination was variable between cases. In 20% of the patients, the extent of remyelination was extensive with 60-96% of the global lesion area remyelinated. Extensive remyelination was found not only in patients with relapsing multiple sclerosis, but also in a subset of patients with progressive disease. Older age at death and longer disease duration were associated with significantly more remyelinated lesions or lesion areas. No correlation was found between the extent of remyelination and either gender or age at disease onset. These results suggest that the variable and patient-dependent extent of remyelination must be considered in the design of future clinical trials aimed at promoting CNS repair.


Tuesday, August 22, 2006

In the news: The future health care economy

For those who are interested in big-picture trends, the NYT has a story about the predicted growth of the share of GDP spent on health care. It's gonna get a lot bigger, and maybe that's not a bad thing, economically speaking. Snip:
By 2030, predicts Robert W. Fogel, a Nobel laureate at the University of Chicago Graduate School of Business, about 25 percent of the G.D.P. will be spent on health care, making it the driving force in the economy, just as railroads drove the economy at the start of the 20th century.

Unless the current system is changed, most health care costs will continue to be paid by insurance, especially Medicare, which means that the taxpayers will foot the bill. But Dr. Fogel says he is not alarmed. Americans can afford it, he says, because the nation is so rich. "It takes so little of household income to satisfy expenditures on food, clothing and shelter," he explains. "At the end of the 19th century, food, clothing and shelter accounted for 80 percent of the family budget. Today it's about a third."
Still, Victor R. Fuchs, also an economist at Stanford, notes that buying health care is fundamentally different from buying a television or a car. “Most of it involves transfers from the young to the old,” he said. “Down the road, most medical care will be for people over age 65, and most of the payments will be from taxes on younger people.” Dr. Fuchs calls it the restaurant check problem. “You go out to a restaurant with a bunch of friends and you sort of understand that you will split the check,” he said. “The waiter comes along and says, ‘The lobster looks very good, and how about a soufflĂ© for dessert?’ The restaurant check balloons, but you are not so careful because you figure everyone is splitting it. “That’s the way medical care gets paid for,” he said.

To me, this is interesting stuff, but the more important question has to do with efficiency. How much of the money we spend buying health care is wasted? In our current system, there are commercial interests influencing spending. What additional value do we get from our market-centric approach?

Friday, August 18, 2006

Journal: Assigning homework

I went out for tacos the other day. Mom lives on the other side of town, but we don't see a whole lot of each other, and this is a source of worry and insecurity for Mom.

My relationship with Mom has been dodgy since I was 12 or so, and getting MS hasn't helped. I know she's worried about me and genuinely want to help, but the time I spend with her exhausts and frustrates me. We seem to spend our time together either talking about how I'm feeling or about our dysfunctional relationship.

Here's the gist of our conversation at the taco place:

Mom: Mmmm. This is really good, isn't it?
Me: Yeah, the smoked pork is wonderful.
Mom (making exaggerated eye contact, with great sympathy): So how have you been feeling lately?
Me (hoping to get this part over quickly): I've been feeling pretty tired and weak, but that comes with the territory.
Mom (eyes moistening): So what does your neurologist say when you tell him that? Is there anything he can do for you?

At this point, I begin a short lecture about the various drugs I'm taking, about treatments that affect the natural history of the disease versus treatments aimed at symptom management, etc. And I sound a little exasperated, and my eyes wander over the old album covers that decorate the walls, and then I excuse myself to use the restroom. Where I have a rather good idea.

On the way home, I tell Mom that when she gets back from her trip to Budapest, I'm going to give her a book about MS, and I think she needs to read it, because I feel like she still doesn't understand the basics about MS, and it's a little frustrating to me that 13 years into my illness she hasn't taken the time to learn that stuff. And I tell her that when I was first diagnosed, I read absolutely everything I could about MS, that it was a minor obsession, that it was empowering to learn as much as I could because there was so much uncertainty involved in the disease itself.

Mom says that she thinks it is a fine idea, and that for the first five years after I got sick, she couldn't bear to read anything about MS, which is hard for me to understand, but okay, whatever.

I wonder what book I should give her.

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Wednesday, August 16, 2006

In the news: Talking to your doc

Interesting little piece in the NYT about doctor-patient communication, with some good suggestions. The best one, I think, comes last. Snip:
Doctors don't like confrontation any more than patients do; they may give in to a patient's request if it is made in an assertive manner. In a study under review for publication, Dr. Bylund found that patients who persistently asked for a specific treatment or test, based on Internet research, were more likely to get it than patients who came in with a vague list of symptoms, or who were more deferential to the doctor.

But be careful, she warned. Anyone who treats a doctor as a dispensary instead of a trusted medical guide loses the advantages of the physician's experience. Negotiating to win, in this case, may get you what you want, but not what you need.


Monday, August 14, 2006

Research: MS fatigue linked to DHEA levels

God help me, I'm thinking of going down to Walgreen's this afternoon to buy some DHEA and conduct my own N=1 study of DHEA supplementation. For the last couple weeks, my legs (especially the left one) have felt like a couple of oversized rubber chickens attached to my hips.

Mult Scler. 2006 Aug;12(4):487-94.
Fatigue in progressive multiple sclerosis is associated with low levels of dehydroepiandrosterone.Tellez N, Comabella M, Julia E, Rio J, Tintore M, Brieva L, Nos C, Montalban X.
Unitat de Neuroimmunologia Clinica, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain.
BACKGROUND AND OBJECTIVE: Fatigue is one of the most limiting symptoms in multiple sclerosis (MS) and the mechanisms underlying its origin are poorly understood. Our aim was to test whether fatigue in MS is associated with endocrine markers. METHODS: We longitudinally studied 73 progressive MS patients. Fatigue was assessed at baseline and at 3, 6, 12 and 24 months using the Fatigue Severity Scale (FSS). Given the longitudinal design of our study, patients were labelled as sustained fatigued when FSS scores were >5.0 at all time points, and as non-fatigued when FSS scores were < or = 5.0 at all time points. Serum levels of dehydroepiandrosterone (DHEA), its sulphated conjugate (DHEAS) and cortisol were measured at each time point. RESULTS: Twenty-nine patients scored >5.0 in the FSS at all time points, and 9 patients (12.3%) scored 5.0 at all time points. Mean baseline levels of DHEAS and DHEA were lower in MS patients with sustained fatigue when compared to patients without fatigue (P = 0.01 and P = 0.03 respectively). Analysis of DHEAS and DHEA over time showed significantly lower hormone levels in patients with fatigue [F(1,31) = 6.14, P=0.019 for DHEAS; F(1,32) = 6.63, P=0.015 for DHEA]. CONCLUSIONS: Fatigue in progressive MS could be related to low serum levels of DHEA and DHEAS. Our results suggest that these hormones should be considered as biological markers of fatigue in MS patients and that hormone replacement may thus be tested as an option to treat fatigue in MS patients.

Research: Stress and MS

A couple new studies look at the relationship between stress and MS. The gist:
The number rather than severity of stressors was most important in relation to MS relapse risk, along with coping responses that utilized social support, suggesting that MS patients should avoid situations that are likely to generate multiple stressors or which provide few avenues for social support. Link.

Life-event stress impacts to a small degree on MS relapse. The number and not the severity of acute stressors are most important; chronic stressors do not predict later relapse. Males and those with early stage disease are also at greater risk of relapse. MS patients should be encouraged to reduce acute stressors during times of high stress, and feel reassured that disease-related chronic stressors do not increase their relapse risk. Link.