another milestone

Last week, Terry and I were getting thai take out and the person in line behind me looked familiar. Because I'm a doofus (just ask my kids), I introduced myself and said "I know you; can't recall your name; I bet you're an Exeter doc." In fact, he was and we reminisced about Exeter when I was there, various events that had transpired, how things were different and the whole hep C story. We told him about our new house (which we bought from another former Exeter doc) and talked about the Manchester hospital scene. After we said our goodbyes, I realized that we had not discussed AML at all. It was a milestone: catching someone up to date on my recent life that did not include "I don't know if you heard; I had leukemia last year." Kind of a nice milestone to have, as though there is a possibility of having a life where leukemia is just a footnote.

The day described above is coming, just like the snow pictured here.

I am hopeful for more days where my leukemia is not relevant to the conversation and thankful that I have large stretches of time where it is not.

Day 173 - journal recs and more

What a lazy day today was! I read a couple of journals and did some weaving and that was about it! I've been planning this weaving project for ages; I think I bought the yarn a few years ago and just haven't felt like doing it. I'm not sure why because it sure is beautiful. It's a nubby silk/wool blend and the idea is to do a nice overshot sort of pattern with the same warp and weft. I'll show you the front tomorrow when there is enough done to see the pattern.

About half of the warp I'm working on now.

As for journals: The Dec 6, 2012 NEJM is completely lacking in interest for me except for an OK Clinical problem-solving article. The Dec 4, 2012 Annals, however, is packed with stuff I thought was worth a real look. The first article was on "Estimating Overdiagnosis in low-dose CT Screening for Lung Cancer" and was from Italy. They had a bunch of people who were getting low dose CTs every year and they had a complicated protocol where they didn't tell people about small nodules without scary features and just repeated the CT in a year. If a lung cancer appeared one year that wasn't there the previous year, they assumed it was there with a size of 2 mm (just below their detection limit) and calculated the cancer's doubling time. About 25% of people had slow growing or indolent (doubling time of 400-599 days or 600+ days). Their suggestion was that these were likely to be "overdiagnosis." People with fast growing tumors had a mortality of 9% and people with slow or indolent tumors had a mortality of 0.9% per year. Kind of interesting, but only works if the patient has regular lung CTs.

Next of interest was an article about "Interventions to Improve Adherence to Self-administered Medications for Chronic Disease in the US." Big surprise: reduced out of pocket expenses, case management and patient education with behavioral support are useful. I think I have read other studies that found case management not helpful--even one that found it made mortality worse for (I'm pretty sure) COPD'ers and I think I have also read one study that found surprisingly that the co-pay did not make a difference to compliance (in this one study). I've never read that patient education has had a negative effect on compliance. At the back is an "In the Clinic" article about hep C. I didn't read it in any detail because the way I manage hep C is to get a hepatology consult. I know how to diagnosis, vaccinate and put in the consult request. That has been a successful strategy for me so far.

The final article of interest in the Annals (see what I mean?) was a review of "Comparative Effectiveness of Warfarin and New Oral Anticoagulants for the Management of A Fib and Venous Thromboembolism." So, you may not know that Warfarin stands for Wisconsin Alumni Research Fund (arin added to the end). I did med school in Minnesota, you see. So, the New Oral Anticoagulants (NOAC) are in one of two classes: factor Xa inhibitors or direct thrombin antagonists. Thrombin antagonists' names end in -agatran and there is only one on the market right now, dabagatran. Ximelagatran was taken off the market due to liver toxicity. Factor Xa inhibitors' names end in -xaban. There are four, only two of which I had heard, apixaban, rivaroxaban, edoxaban and betrixaban. It's kind of easy to remember which is which because direct Thrombin inhibitors are the agaTrans and factor Xa inhibitors are the Xabans. The direct thrombin inhibitors may not be all that important to remember because the only one left is being evaluated by the FDA for reports of excessive bleeding especially in elderly and renally impaired patients. Anyway, for Afib, the conglomeration of the evidence slightly favors but with a bar crossing 1.0 NOACs (0.78 to 1.02), best estimate 0.89. For venous thrombo embolism, the range is 0.48 to 2.10 for the risk ratio, best estimate 1.0. For adverse effects of fatal bleeding and major bleeding, NOACs were superior. For GI bleeding, warfarin was superior. With respect to MIs, factor Xa inhibs appear to be about equivalent to warfarin and direct thrombin inhibitors appear to be associated with MIs. People on factor Xa inhibs were about as  likely to discontinue the med as people on warfarin due to side effects, but people on direct thrombin inhibitors were more likely. It looks like they are all about equivalent for LFTs greater than 3x the upper limit or normal. It also appears that the studies that showed bigger benefits for NOACs had worse control of the INR in the warfarin arm (not surprisingly).

As for news of the previously leukemic body, I was a little bit sore from yesterday's exertions so I decided to take today off from the gym. I am looking forward to Planet Fitness tomorrow. I also have my second opinion date: January 2. I may have mentioned that I have to see pulmonary too and am working on getting that set up (the reason is that my CT scan is still not normal. Every time we look, it's abnormal in a different way so I'm thinking none of it can be too bad. John thinks it is probably post-chemo stuff. I was very happy to see the nodules go away, speaking of screening for lung cancer).

I haven't barfed in 48 hours. My family is so proud of me.

Since this a a complete pot pourri entry, here is a nice video about kids who play instruments in Paraguay.

For me, I am hoping for a restorative night's sleep. For you, restorative sleep is not a bad thing either.

Day 55 TMI, d'oh! and Exeter

So, today I will eventually get around to talking about the Exeter hep C situation and why yesterday was a hard sort of day for me, but in order to get there, I will need to discuss a topic that for sure qualifies as Too Much Information. If you are worried that the payoff of hep C and what the doctor/patient discovers about her mood is not worth hearing about colons, then today might be a good day to skip out of the blog early. It's ok; if you change your mind, you can come back tomorrow; it'll still be here. I don't know why I can't get the jump to work now.