Nephrogenic Systemic Fibrosis

February 28, 2008

As if the world weren’t dangerous enough new diseases keeping popping up like, well new diseases. Over the past few years nephrologists have recognized a new skin disease that was previously called nephrogenic fibrosing dermopathy, but which has been rechristened Nephrogenic Systemic Fibrosis. The current issue of the NEJM describes another patient with this disorder.

The disorder is only seen in patients with renal disease – typically in patients with renal failure on dialysis. The skin becomes tight and can so limit mobility that contractures develop. Fibrosis of internal organs has also been described. Recently an association with the use of gadolinium has been reported. Gadolinium is used as a contrast agent to enhance the images obtained with MRIs. How gadolinium might cause nephrogenic systemic fibrosis is not known. Most nephrologists currently avoid using the agent in patients with impaired renal function. While radiologists have set a glomerular filtration rate of 30 ml/min as the cut-off below which gadolinium should only be used for the most urgent problem, there’s no way right now of knowing exactly how decreased renal function must be for this potentially lethal disorder to occur. The disease is progressive and the mortality rate high. The best strategy is to prevent it.

Of course never at a loss for a business opportunity trial lawyers are advertising like trial lawyers to recruit patients who’ve developed nephrogenic systemic fibrosis after gadolinium exposure even though the association of the disease and the contrast agent was only first made in 2006. Put the disease into Google and the first listings will be paid ads by trial lawyers soliciting new plaintiffs.

After the lawyers comes The International Center for Nephrogenic Fibrosing Dermopathy Research. A support group inevitably will follow. Good intentions and profit seem inextricably linked.

Right now there’s no treatment for the disorder. Also unknown is how common it will turn out to be and what its range of severity will be. The best advice for patients with renal disease is to avoid gadolinium unless there is extraordinary need for it. How tight the association of this disease with the contrast agent is also uncertain.


Joseph Calleja Revisited

February 26, 2008

More than three years ago I reviewed tenor Joseph Calleja’s first recital CD. Though it received many favorable notices,I wasn’t all that impressed. I heard the broadcast of his Met debut as the Duke in Verdi’s Rigoletto and still wasn’t impressed. What annoyed me the most was his fast vibrato (or bleat if you’re inclined to be harsh). I wrote that given time it might spontaneously abate. I thought it would take a few years to go away. The tenor is still quite young; he just turned 30 last month

I have yet to hear this singer in the house so my opinion rests on shaky ground. But several You Tube postings seem to indicate that he’s getting better at a rapid rate. His singing of Federico’s Lament from Cilea’s L’arlesiana shows that the excessive vibrato is just about gone. His forward vocal placement and bright tone is reminiscent of Björling. I don’t want to push that comparison too far, Björling sets the bar awfully high. But just for fun here’s the great Swede singing the same aria in a 1947 recording(Federico’s Lament).

Calleja seems to have gained more control over his voice with maturation. His high note are produced with greater ease and they are focused. He came to prominence at such a young age that his vocal growth has happened in plain sight. His tone also seems sweeter than it initially was and he sings softly with greater ease.

Also from the same July 2007 recital is a performance of Nessun Dorma complete with chorus. It too is quite good. Calleja’s only scheduled performances at the Met this season are three appearances as Macduff in Macbeth in May. This is essentially a one aria role, though the aria is a really good one. Since outstanding lyric tenors are as rare as common sense let’s hope that Calleja continues to improve and has as splendid a future as many have already predicted for him.


Southern Society for Clinical Investigation

February 18, 2008

New Orleans
Saturday February 23, 2008
Powerpoint Presentation will be posted later

2:25
State-of-the-Art Speaker
CURRENT CONCEPTS AND CONTROVERSIES IN TREATMENT OF METABOLIC ACIDOSIS.
Neil A. Kurtzman, Texas Tech University Health Sciences Center


Manon Lescaut in HD – Feb 16, 2008

February 16, 2008

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I imagine that the Met’s almost 30 year old production of Puccini’s Manon Lescaut was brought back as a vehicle for one of the company’s star sopranos, Karita Mattila. If so it was a mistake. Prior to this run the Finnish singer had only performed one Puccini role at the Met – Musetta in six performances of La Boheme back in 1996.

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She doesn’t have the right vocal style for Puccini. There’s a break in her register when she goes from middle voice to high notes. Her top doesn’t have the ring one associates with Puccini’s sopranos. Mattila’s high notes in this performance seemed to have been imported from a Strauss opera. Worse, her acting was bumptious. In the first act she seemed to on her way to a convent fresh from a barnyard. In the second act she was a Rockette direct from The Radio City Music Hall. She concluded her dancing lesson with a split. She’s obviously very proud of this ability as she did two of them before an astounded Renee Fleming during the first intermission feature. Fleming, in passing, is a very good TV interviewer and looks better than she has for quite some time.

Compounding Mattila’s problems was video director Brian Large’s in your face closeups which made one think that Mattila and Nancy Pelosi share the same plastic surgeon. Mattila’s acting and singing did improve in the 4th act. There she was not required to be coquettish or coy. Her performance of “Sola, perduta, abbondonatta” was moving. But on balance I don’t think the soprano will be glad that this performances is preserved for all time and that it’s also on the way to the stars and beyond.

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Marcello Giordani, on the other hand, was the right tenor in the right role. His voice is now a fully formed spinto. His Des Grieux was the best I’ve encountered since Richard Tucker. It was the late tenor’s favorite role. Having heard Giordani in the house I’m confident that what I heard from the satellite was authentic. His tone was round and burnished. All the high notes were ringing. Des Grieux is a great part for an Italian spinto and Giordani got everything out of it. His acting was conventional Italian tenor, but with the way he sang that was plenty. In an age of super specialization, when a baseball pitcher is expected to only play half a game, Giordani voice was stronger and more vibrant at the opera’s end than at its start.

Dwayne Croft seems to have settled into a career as a second banana. He was fine as Lescaut. Sean Panikkar made a good impression in the first act as Edmondo.

Once again James Levine’s conducting was outstanding. He seems like a new maestro. The sound engineers had the volume turned too high on the orchestra making it out of balance with the singers. Nevertheless Levine’s whip-like intensity was palpable. The Met Orchestra responded with their best playing which is just about as good as it gets. The three decade old production held up well enough though it appears its age.

So the Met revived the opera for the wrong soprano only to be bailed out by a great performance by a tenor who seems to have become the house’s all purpose leading man. A masterly job by Levine also didn’t hurt. Two out of three in the theater is pretty good. If Giordani continues to sing like this perhaps the Met will mount a production for him. If so, I hope Levine conducts.

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Money Squawks

February 12, 2008

The February issue of The ACP Internist contains an article Adding cosmetic procedures lifts internists’ sagging incomes that defines the decline in morale of our country’s most important profession. Click on the link and you can read the whole sad story and make up your mind about what’s happening to medicine.

The article reflects a reality that few wish to confront directly – people don’t want to pay for medical care. They are willing to pay whatever it takes to look better. When they get sick and must have care they expect someone else to pay for that care. They are a mess of tangled contradictions. They want affordable care that is readily available. They want to be able to pick and change their doctors. They want portable health insurance that doesn’t cost too much. Half of them want the government to stay out of paying for the 50% or so of medical care they don’t already pay for, while the other half wants the government to take over the whole kit and caboodle.

The public doesn’t mind spending a lot of money on veterinary care for their dogs and cats, but resents having to pay for medical care for their children. They don’t want to pay for management of their diabetes or hypertension, but will pay cash for Botox or cosmetic laser surgery or skin peels. These types of cosmetic overhauls seems to be spreading to all layers of the socio-economic pie.

The New England Journal of Medicine published two papers in back to back issues of the journal which illustrate how conflicted we are. In the February 7th issue they published a piece by Robert Kuttner: Market-Based Failure — A Second Opinion on U.S. Health Care Costs. Asking Robert Kuttner to write about health care is like asking me to critique the design of the latest atomic reactor. He’s never met a problem (outside of the Pentagon) that he doesn’t think requires a government solution. Of course he thinks that market driven mechanisms to provide medical care have failed (how he knows is mysterious since we’ve never had a market driven system) and that a national single payer health care system is the only civilized solution to our medical woes. What he thinks is predictable before he writes anything. If you want a contrary opinion ask Thomas Sowell. What’s interesting is that the NEJM asked Kuttner for the piece since even a first year medical student could have told you exactly what he would say. I’ve already mentioned in a previous post that the NEJM wants national health insurance.

“Great health improvements can be achieved through basic public health measures and a population based approach to wellness and medical care. But entrepreneurs do not prosper by providing these services, and those who need them are the least likely to have insurance. Innumerable studies have shown that consistent application of standard protocols for conditions such as diabetes, asthma, and elevated cholesterol levels, use of clinically proven screenings such as annual mammograms, provision of childhood immunizations, and changes to diet can improve health and improve outlays later on.”

To begin with, that statement is not necessarily true. Second people don’t want to pay for preventative maintenance out of their pockets especially if it comes to choosing between “wellness” and good looks. Behavior modification is harder than diamonds. Yes millions have stopped smoking, but health insurance wasn’t the reason. Regular medical care seems more palatable if we can get someone else to pay for it. To muddy the waters more the February 14th issue of the NEJM has a paper Does Preventative Care Save Money? The answer – maybe, sometimes, other times no. And we’re not really sure which is which. The paper’s revolutionary conclusion – get more evidence before making recommendations about how to restructure the medical system.

Internists have turned to Botox because “wellness” doesn’t pay much. This is so irrespective of insurance status. In fact those most likely to benefit from “wellness” programs are those least interested in it with or without insurance. How do I know? Fifty years of personal observation, which is 50 years more than Kuttner has. Sure I could be wrong, but we didn’t become the fattest nation in the known universe because we were in love with “wellness.”


British Men Prefer TV to Sex – Androgen Deficiency Suspected

February 9, 2008

A new survey finds that almost 50% of British men would forgo sex for six months in return for a 50″ plasma TV. Only a third of British women would make the trade. Remember this from a country that only has about four channels and which imposes a yearly tax on each television set.

Britain went through a lot in the 20th century and a delayed result seems to be a 21st century epidemic of androgen deficiency. At least that’s my interpretation of the data. This problem seems to have affected not only the general male population, but male politicians to an even greater degree. Regardless of the accuracy of the latter statement, Margaret Thatcher did not suffer from this endocinopathy.

How can Americans help their cousins across the ocean? Well, as a short term fix we could ask the American firm Solvay Pharmaceuticals Inc to pressure its supplier Laboratoires Besins International, a French company and thus like the UK an EU member, to donate a free one year supply of its topical testosterone, Androgel, to the about 10 million British men apparently suffering from hypogonadism.

A long term solution requires a different approach. We are talking about a serious problem. The fertility rate in the UK is 1.66 children per woman. This is far below the 2.1 needed just to replace the population. (As an aside, why is the CIA keeping tabs on this?) The obvious culprit here is TV addiction which suppresses androgen release – at least in men..

My best clinical advice is that the BMA recommend desensitization therapy to the National Health Service. This would require a multi-pronged approach. First the tax on television sets should be repealed. This would result in more television sets bought in the UK and, at first, more time spent watching TV. To further encourage this behavior cheap access to satellite TV programs should be provided. The NHS should pay the tab. After about six months of watching 250 to 500 channels the allure of the plasma TV will fade. This is when part two kicks in. Fifty million copies of the Victoria’s Secret Catalog will be mailed to every household and office in the UK. A plain brown wrapped edition will be sent to sensitive portions of the British population.

Next, all sex education classes will be permanently disbanded. Britons everywhere will be told to cleanse their minds of impure thoughts and to forgo sex unless procreation is the intention. In other words clever and devious reverse psychology will be insinuated into the British psyche. Before long the Brits will be copulating like gerbils and the birth rate will soar because accidents always happen. Who knows, the price of plasma TVs may fall and they can have their cake and eat it too.


Luck, Not Ripeness, Is All

February 4, 2008

As almost everyone knows the New York Giants upset the New England Patriots to win the 42nd iteration of the Super Bowl. The Giants won the game with a touchdown with only 35 seconds left to play. But the critical play happened moments earlier. David Tyree a mostly invisible player made once in a century catch on a pass that never should have been thrown. Eli Manning, the Giant’s quarterback, should have been tackled ending the play, but miraculously he got away from a pack of defenders and heaved the ball in the general direction of Tyree. The rest is now myth.

The point here is that the universe is ordered by chance. Manning could repeat the great play over and over again like Sisyphus and the rock and never make the completion, but on the one time he had to he did. Somebody wins the lottery no matter how steep the odds. Without the almost, note almost, impossible play everything is different. Manning is not the Most Valuable Player. the Giant’s coach is not a genius rather just another coach, the Patriots have a perfect season. The Giants have a great season, the Patriots a failed one all because of a sport. Forget about luck being the residue of design. Sometimes it’s just random, blind, dumb luck

The strangeness of reality caused the ancients to invoke divine intervention in the affairs of men. Modern scientists have come up with chaos or complexity theory. The universe is built on a palace of chance. Everything appears predictable, logical, and orderly after it’s happened. Before the event we deal in probabilities only. If you anticipate the event early enough any outcome is improbable. Yet there will be an outcome. Our lives are improbable.

Artists have wrestled with this problem in varying ways. Tolstoy’s famous theory of history posited a logic to history. The logic of cause and effect, not the toss of the dice that troubled Einstein so famously. Woody Allen (I blush to mention Allen in the same paragraph with Tolstoy and Einstein but I need to make a point) made a movie about how life turns on chance.

Pasteur decreed that fortune favors the prepared mind. And it often does. But sometimes the quarterback gets away and a spear carrier saves the day. Of all the good things to be in life lucky is the best. Just don’t award too much credit when luck turns the day. Luck has a way of turning around.