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.

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.

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

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.

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.

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.

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.

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?