Shouldering Up

“He will order an MRI, recommend PT, and then set you up for surgery.”

That was Barb’s prediction when I finally succumbed to chronic shoulder pain and scheduled a visit with the orthopedic surgeon that my internist had recommended. A few months of retirement with its excessive tennis, pickleball, bowling, golf, and biking had done what 45 years of twiddling a microscope fine focus knob had not and sent me off to a specialist.

I was barely able to raise my right arm without pain — I could forget about trying to serve a tennis ball. During our Germany journey, it was rough getting our carry-on bags into the overhead compartments on our many flights. And Cooper’s tugging at his leash during our long walks sent shock waves through my right arm.

The orthopod and his Physician’s Assistant followed Barb’s prediction to a tee. After they completed a quick examination and asked me a few questions, they told me I had some rotator cuff damage. Their prescription: get an MRI, get some physical therapy, and then get back to us for future plans.

As expected, the MRI showed a bit of structural wear and tear in my shoulder, but nothing excessively dramatic. So off I went to a small private physical therapy office recommended by a friend, located across the street from my internist.

I have spent the last month going to PT twice a week. The first visit consisted of lots of assessment of arm movements and levels of pain. Since then, therapy has consisted of lots of shoulder and neck massage, strengthening exercises, and a home workout regimen.

And none of it was working. My shoulder didn’t feel any better, and my neck and arm started to feel worse. I was about to tell the therapist that I was not going to schedule any further sessions when out of the blue, he said “Let’s try a few things we haven’t done yet.” It was “Hail, Mary” time.

He began with a technique called scraping, running a dull-edged blade against my upper shoulder. It was pleasant but didn’t feel therapeutic. My shoulder felt the same. But then came the coup de grâce–dry needling. While I quaked in my shoes, my PT inserted a needle into the tender points in my shoulder twiddling it around, looking for muscle twitches.

He found them. As he repeated the needle insertion in three different spots, I could feel my muscles jerking, sometimes painfully. My right hand began trembling uncontrollably. And when it was done, I felt…better.

That was three days ago. I feel some soreness as a result of the needling. I have a bit of residual tightness, which a remarkable device called the Thera Cane is helping resolve. But my shoulder is almost pain-free and I can literally reach for the sky.

I will schedule follow-ups with the PT and the orthopedic surgeon. But right now the sun is shining and it is a beautiful day.

Tennis, anyone?

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It’s Not TOO Medical–A Salute to An Outstanding Professional

“I want something medical, but not too medical.” Those were the words that launched a high school senior on a more than 40-year love affair.

The words were a response to a career question from Barb’s high school counselor. The counselor had a friend, or perhaps a friend of a friend, named Jan. Jan was an Occupational Therapist, an “OT.” While Barb had never heard of the field, she agreed to spend a day shadowing the woman in the hospital where she practiced her craft. Jan was a little dynamo, and Barb was hooked. She applied to and was admitted into the Occupational Therapy program at the University of Illinois for the following year.

Three years of a general curriculum at Champaign-Urbana were followed by 18 months of specialized OT training at U of I’s west side Chicago medical center campus. This included clinical rotations around Chicagoland–and also included meeting me, a medical student and a co-resident in the med center dorm.

We picked out an engagement ring while Barb was taking her clinical exams. I married my OTR (registered Occupational Therapist) a few months after her graduation. By then she was working full-time at the first of her positions, as a therapist at one of Rush University’s facilities.

As she gained experience, Barb’s career path took her to the Rehabilitation Institute of Chicago, and with some prodding from a good friend to Lutheran General Hospital in the northern suburbs. While working as a general therapist at LGH Barb discovered her true calling.

It wasn’t in the pediatrics clinic, where Barb helped out often enough to be exposed to and catch a bad case of chicken pox. It wasn’t with stroke patients needing the standard OT “assistance with daily living” therapy. What Barb was drawn to, and made into her career, was hand therapy–assisting patients, who either following disease, injury, or surgery, required precise and specialized care and instruction to improve the utilization of their hand and arm.

Barb studied hard to learn her craft. Acceptance into the American Society of Hand Therapists was a year-long slog. Barb found a study group to join, and a hand surgeon to sponsor her. We spent many weekends at my Evanston Hospital Laboratory Office, writing up case histories on a first-of-its-kind machine, a word processor. It all paid off, as Barb was one of the few candidates nationwide to pass the difficult ASHT certification exam on their first try.

Barb’s career flourished as a well-liked and well-respected hand therapist throughout the Chicago area. She loved her patients and became involved in their life stories as their professional therapist and personal confidant. She greatly enjoyed being a mentor training a multitude of young professionals, a gaggle we call the “Barbettes.”

Officially, Barb stopped working a few years ago. Of course, that hasn’t stopped her interest in the field. If she has seen you on the street or in a grocery store with your hand in a splint, you can bet she has asked you what your injury was and how it was being treated–and maybe even offered a suggestion or two.

Just yesterday, Barb received a letter from the National Board for Certification in Occupational Therapy, informing her that she had not renewed her membership and was no longer entitled to use the letters OTR, a registered trademark of the Board.

I am not sure if Barb shed a physical tear, but I know there was a mental one. Her illustrious career has truly drawn to a close. But Barb, on behalf of the patients you helped, the surgeons you worked so closely with, and the young professionals you trained so well, I say thank you for a job well done!

Hey! Can you do me a favor? If you are a subscriber and enjoy my blogs, please email them to friends and contacts. And if you read my blogs on Facebook, please share them! We are always looking for new readers.

You can always get a hold of me at chidoc@post.com Look forward to hearing from you.

This White Powder Isn’t Cocaine. Alum Is Better!

I’ve been dipping into a white powder recently. I rub it all over my mouth: on my gums, on my lips, and under my tongue. As long as I am careful, none of it goes up my nose. And while it may give my mouth a tingle, it sure doesn’t get me high. No, the white powder isn’t cocaine or any other drug. But it is something that I hope will improve my quality of life. a humble spice that I hadn’t heard mentioned in 50 years.

A few years ago I wrote about my canker sore malady and my dashed hopes in the Kiwi Fruit cure. Even after that disappointment, I have never stopped looking for a minor miracle, something that would put canker sores in my rearview mirror. And maybe I have found it!

Last weekend former neighbors Nancy and John were at our house for dinner and conversation. I was in the midst of a pretty bad canker sore outbreak making both chewing and conversing a challenge.

Halfway through the salad course, a piece of pear lodged in my throat and I excused myself from the table. I returned to discover that in my absence my mouth had become the topic of discussion and John had the answer to my prayers.

“Alum,” John told me. “Just rub some on and the sores will all go away.”

Alum? If you are like me, you don’t know much about alum. I remember in high school, the school pool was closed for a week while alum was added to disinfect it. But other than that, I knew nothing.

Some research reveals that alum is the chemical aluminum potassium sulfate. It is a fine white powder that is used in pickling foods, purifying water, and fireproofing textiles. Deeper research suggests that alum MAY have some value in lessening inflammation and decreasing the length and severity of canker sore attacks.

So why not give it a try? What did I have to lose? On our next weekly visit to Woodman’s Market Barb and I scrutinized the spice aisle looking for a jar of my potential savior. The McCormick spice rack–no alum. The Spice Island rack–no alum. Spice Supreme rack–no alum. I was about to give up hope when Barb found a tiny 1.3 oz canister of Tone’s Alum.

I could barely wait until bedtime to self-treat the half-dozen lesions I had in my mouth. I opened the small vial, sprinkled the white powder on my index finger, and began to dab at each sore.

My mouth began to tingle as it filled with a peculiar acrid taste. Smoke poured out my ears and I began to speak in tongues (ok, maybe it just seemed that way.) I said a “shehecheyanu” and went to bed.

I awoke the next morning and heard the angels sing in heaven. Instead of the mouth pain, the nasal congestion, and the achy muscles that had been my companions for the last several days, I felt — 90% fine! A look in the mirror revealed my mouth ulcers had shrunk and were no longer surrounded by fiery red, swollen, gums.

It has been a few days now. I rub in a sprinkle of alum every day, and every day there has been an improvement. And no new lesions have cropped up.

A big thank you to John. I am hopeful that alum, unlike Kiwi Fruit, will be my ongoing magic bullet. This pickling spice has made me a happy gherkin!

In Memory of Lin Brehmer and Dr. Rebecca Blank. After Every Loss We Must Fight For More Wins. Please Read To The End.

Last July, my post was centered around the newly public cancer diagnoses of Lin Brehmer and Rebecca Blank. As everyone in Chicagoland knows, Lin, our local WXRT radio legend, succumbed to prostate cancer last month. This week, we learned that Dr. Blank, the incoming President of Northwestern University, has passed away from her “aggressive” cancer, which I have seen classified as pancreatic cancer.

Sadly, my campaign for a moment of radio silence in honor of Lin fell on deaf ears. Too many readers let me know that “dead air” was the last thing a radio pro like Brehmer would have wanted. My next request will be for NU’s men’s basketball Wildcats to win a few games in the NCAA March Madness Tournament to honor the University President who never got to be. Go Cats!

Prostatic cancer and pancreatic cancer are the two diseases that took my father and my sister. Each year tens of thousands of other Americans die of these two scourges. A thimbleful of DNA gone wrong, a pinpoint of genetic material led astray, and a person’s life and sometimes lifespan is indelibly altered.

I am not an eternal pessimist. All cancer news is not negative. Progress is being made in the multi-faceted battle against the disease. The very genes whose alterations begin the malignant process are now targets for therapies that can halt or reverse the course of the disease. Surgery and radiation treatments have become more focused in an attempt to minimize patient side effects and avoid damage to surrounding tissues. In fact, better treatment along with earlier diagnoses and a decrease in smoking rates have given us a remarkable 33% drop in cancer death rates over the last 30 years.

My friends with cancer histories are fighting strong and proud. This week I bowled with a prostate cancer survivor and played tennis with a kidney cancer warrior. I aspire to play half as well and be half as optimistic as either one of them. And my dear wife is 11 years past her melanoma diagnosis and treatment. I look forward to a day when all cancer patients can celebrate the same successes.

Those of you who know me well are aware that for many years I have been involved in the SEA Blue/Zero Prostate Cancer Walk and Run for Prostate Cancer Awareness. My involvement continues this year. If you are thinking of Lin or someone in your family who has been affected by prostate cancer and want to help prostate cancer patients please support our cause by clicking this link. (Please be aware the donation process currently only works from mobile phones. It does not work on desktop computers or tablets.) Any and all donations are appreciated.

And if you are a Northwestern alum and want to recognize Dr. Blank, a memorial fund exists at the University of Wisconsin, where she served as Chancellor for nine years.

The fight goes on!

Mr. Lindt and My BLCQR: Going Heavy Metal

“Maybe you should say goodbye to Mr. Lindt.”

With that pronouncement four years ago, a registered dietician named Meg pointed me toward improved eating habits and better weight control.

Why did Meg give me that particular bit of advice? I had just described my current diet to her, a regime filled with sweet indulgences. Half of a large Lindt Dark Chocolate Bar was an almost daily afternoon treat.

I mostly followed meg’s recommendation, substituting some string cheese and a piece of fruit for my 2:00 pm snack. But I didn’t give Mr. Lindt a total heave-ho. Instead, I limited my consumption to one square piece from the bar each day, taking 10 days to daintily consume what I had previously devoured in two. I found a way to have my chocolate and eat it, too.

The health reputation of dark chocolate pogos, first up and then down. Are the flavanols it contains heart healthy, or is this counterbalanced by the deleterious effects of the sugar and fats the chocolate contains? Does dark chocolate trigger migraines? Every “pro” has its “con.”

Today I was hit with more chocolatey bad news. If the sugar doesn’t get you, the metal will. An article in today’s New York Times reports on studies indicating that dark chocolate may contain high levels of lead and cadmium.

“So what?” you say. Well, lead and cadmium aren’t particularly healthy, especially for young kids, pregnant women, and nursing moms. Lots of organs can be targets, including bones, kidneys, and the nervous system.

So I got a little nervous. Even though I am not a kid, am not pregnant, and am not nursing, had those years of heavy Lindt consumption done some internal damage? Was my one square a day just adding to my BLCQR (body-lead-cadmium-quantification-ratio)? Was my nervous system going to degenerate before (or behind) my very eyes?

Fortunately, the NYT article included a link to a chart from an organization called As You Sow. The chart lists the amounts of cadmium and lead found in over 450 chocolate concoctions.

I did a search for my favorite Lindt Dark Chocolate with A Touch of Sea Salt bars. My mood was sweetened by the results of my search. The chart indicated that the amount of toxic metal within each serving of my fav was lower than the California Maximum Allowable Dose Level.

Does this mean my present consumption is safe? I’m not sure. I just know that I am going to continue to enjoy my Lindt and forget about the risk of transmuting my kidney, bones, etc. into heavy metal toxic dump sites.

I’m sorry Meg. You were a well-meaning dietician, but I’ll never say goodbye to Mr. Lindt–at least until the next negative article comes along.

Was it COVID Brain Fog or Writers Block?

It’s time to let the creative juices flow once more!

It's been a while since I have done it.
Put words to the page and then I've spun it.
Sending to readers a timely missive.
Hoping my followers aren't too dismissive.

I'm not sure of precise causation
That caused two weeks of blog cessation.
What was it kept my fingers napping
Instead of on the keyboard tapping.

It started when two lines appeared
On the COVID test I'd commandeered.
The first line meant the test was working.
The second confirmed the virus's lurking.

Two Moderna shots then double boosted.
Yet still in my nose the microbe roosted.
With coughs and sneezes and feeling sickly.
Into quarnatine I disappeared quickly.

So empty moments were now my friend.
Hours  of leisure I thought I'd spend.
Writing blogs 'bout things that were popping.
I might have been sick but the world was not stopping.

My mind was all foggy, could not concentrate at
The things going on that I'd want to debate at.
But now it's much better and I'm seeing clearly
Here are some things I missed most severly.

There were hearings in DC that were causing a ruckus
They told how Trump and his friends were trying to f*ck us.
Thanks to Adam, Elaine and of course Ms Liz Cheney.
We were sure mesmerized learning about how insane he.

The planet is hotter, it's like a fire pit glowing
Who knows just what to our kids we're bestowing.
Heat waves, deadly storms, and still the President's action
Was blocked by refrains from coal's friend Hot Joe Manchin.

But up in the cosmos there was such delight
As the Webb telescope provided a sight.
Of the universe edges as they were at formation
I say it's Big Bang, some say God's creation.

Those topics I missed while my brain it was snoozing
So my silence for weeks I hope your excusing.
I'll do what I can to get back up to snuff.
For reading this verse, I can't thank you enough.

_________________________________

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A Prostate Pathologist Pencil Pusher. Making a Better Diagnosis.

Using a pencil in the laboratory? Absolutely verboten. If you write down something in the lab, make sure it’s in indelible ink, magic marker, or perhaps blood. Something, anything, that can’t be erased.

Does a tech need to make a change in what they see on an instrument printout? Our accreditation regulations (courtesy of the College of American Pathologists) are pretty strict:

Original (erroneous) entries must be visible (ie, erasures and correction fluid or tape are unacceptable) or accessible (eg, audit trail for electronic records).
Corrected data, including the identity of the person changing the record and when the record was changed, must be accessible to audit.

In layman’s terms, that means carefully drawing a line through your mistake, initialing, and then dating your correction.

So what am I doing wearing pencil after pencil down to its nub? I am making sure I am the best pathologist I can be.

Through this part of my career, looking at multitudes of prostate biopsies, I have developed, inaugurated, and continuously improved a printed, unofficial worksheet that I use for every prostate case. At the top of each sheet our laboratory information system prints the patient’s name, age, medical record number, and pathology case number. I then search the medical record and add in relevant clinical history, such as previous biopsy findings, PSA values, and results from imaging studies.

The sheet then contains a row for every biopsy location. After looking at each slide I can quickly pencil in whether I think the biopsy is benign or malignant, what the Gleason Grade is, the extent of tumor, and any special studies I want to perform. It is really a very efficient way for me to work.

And I do it in pencil. Why? Because diagnostic pathology is not all ink–it is an art as well as a science. Cancer cells don’t actually have a big “C” on them under the microscope. Malignant changes can be striking, but they can also be subtle, and first impressions can sometimes be misleading.

Sometimes looking at the 7th core in a patient’s biopsy series can affect how I view what I saw on the 3rd biopsy. Sometimes special stains are going to nudge me to call a biopsy malignant that I had originally noodled in as “atypical.” Sometimes viewing a core the next morning will clarify my thinking, or a word from my associates will lead me in a better direction. When any of those things happen I grab my worksheet and out comes my pencil, eraser end first. And I mark down my new, improved, diagnosis.

Eventually, the worksheets get turned into our administrative team, entered into a digital pathology report, and following my electronic signature, become very official. Corrections can still be made, but only through a very regimented procedure, with documentation of every step. No more pencils, no more erasers.

But rest assured, the next morning I will be at the sharpener, getting my favorite diagnostic tool ready for another busy day.

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Pearls for the People From a Prostate Pathologist

A tray of prostate biopsy slides is ready for microscopic review.

As my career in pathology heads toward the home stretch, some pearls I have picked up along the way, particularly during the last 17 years as a prostate pathologist.

I Can Name That Surgeon in 3 Cores

You all know that no two people have the same exact fingerprints or DNA. I can tell you that no two surgeons send the same exact prostate biopsies.

I can look at a case and know right away who the urologist is. Fourteen cores? That tells me this case is from Dr. B. A ten-pack? Got to be Dr. M. Lots and lots of cores from every location in the prostate? Dr. Y must be the urologist of the day. Long, thick cores come from Doc A, while Doc B sends more fragmented specimens. Sixty different urologists, sixty different biopsy “fingerprints.”

It’s Not Over Until the …

I sometimes get a bit exasperated looking at 15 or twenty prostate biopsy cores from a patient, all of which look perfectly normal; well-formed acini with lots of basal cells, bland stroma, nice even spacing.

But today I got a reminder why I need to look carefully at each and every one of those cores, all the way to the end. In two consecutive cases, I found nothing, nothing, nothing, until the final core in each case demonstrated prostate cancer. And not the potentially insignificant Gleason 3+3 kind, but high-grade cancers that will require treatment to preserve the patient’s health and hopefully prevent a cancer death. It’s humbling to realize that the 12th biopsy found what the first 11 didn’t.

Statistically, Things Tend To Return To The Mean

There is a saying in baseball that a ballplayer’s batting average is going to match the numbers on the back of his baseball card. A .250 hitter might go on a hot streak, but eventually, he is going to go back to being a .250 hitter.

It’s like that in the lab, too. Some days every prostate I look at will be malignant and I feel like Dr. Death. Other times, every case is benign, and while that is great for the patients, I worry that I am missing things, that I have forgotten what prostate cancer looks like under the microscope. But over time, it all evens out. From month to month, the percentage of cases I diagnose as cancer is the same. The diagnostic peaks and valleys cancel each other out. Statistics just don’t lie.

Whatever Remains…

Sherlock Holmes once said, “Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth.” Over a long career, I have realized that a pathologist’s most valuable skill is recognizing the many faces of non-cancer. While scanning prostate tissue, my brain automatically eliminates the benign, the inflamed, the reactive.

Whatever remains is where my concentration needs to be focused. Those areas might not be malignant, but I need to look at them carefully to make sure they aren’t. When in doubt, a second look the next morning, or a special stain, or a consultation with my colleagues will guide me to the truth. The Holmesian method of diagnostics.

I am sure I have learned a few other things, but I will save them for another snowy day.

This blog is the opinion of the author and not UroPartners LLC.

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I Know What’s In The Vaccine. It Is Hundreds Of Years of Progress.

Dr. Edward Jenner performing his first vaccination against smallpox on James Phipps, May 14, 1796, oil on canvas by Ernest Board.Credit…DEA Picture Library/Getty Images

There is a lengthy meme circulating on Facebook that begins “I’m vaccinated and, no, I don’t know what’s in it.” I’m vaccinated as well, and I want to tell you that I do know what is in the COVID-19 vaccines, be it Moderna, or Pfizer, or even poor old Johnson & Johnson.

Have I read the list of ingredients? Have I checked for additives, preservatives, or carcinogens? No, because the vaccine contents that I know about won’t be listed on any label. The ingredients I speak of are the men and women, the giants of science, on whose shoulders the current tier of scientists and researchers stand.

Let’s start with the microbe hunters, who first identified and clarified the concept that there was a world of tiny organisms and that these might cause disease. Names like Antonie van Leeuwenhoek, Louis Pasteur, Robert Koch, and Ignaz Semmelweis. There is an essence of all of them in the vaccine.

Rosalind Franklin, James Watson, Francis Crick–the best known, but not the only, scientists whose work led to the understanding of the structure of DNA. Francisco Mojica, who added CRISPR to our lexicon as a way of manipulating DNA. There is plenty of them in today’s mRNA vaccines.

You must have heard of Edward Jenner, Jonas Salk, and Albert Sabin. Shall we call them the great-grandfather, the grandfather, and the father of vaccines? And what about all the scientists who have been striving for 30 years to create a vaccine against the Human Immunodeficiency Virus, the author of AIDS? Surely the blood, the sweat, and the brain cells of all these investigators are part of every “jab.”

That is how science grows. We take the knowledge of our ancestors and add on to it. We test new ideas, accept the ones that seem to work, discard the ones that don’t.

Accepted science changes! New data forces us to challenge each other, to consider new answers to old questions. And on top of that, nature is not constant. So while Newton’s Laws of Motion have stood the test of almost 350 years, the SARS-CoV-2 virus, with us for less than two years, mutates. It is not because the science is “bad” that recommendations about the vaccine and other matters related to COVID-19 need to be updated on a regular basis. It is because life, science, and the virus evolve.

So I will continue to put my faith in science–in the men and women who have made tremendous advances in our knowledge of the world around us. The vaccines aren’t perfect, but we have them because, as Isaac Newton himself said, we have been standing on the shoulders of all those giants.

Please forward or share on Facebook. If we can each convince one person to vaccinate…

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“Friends” Don’t Let Friends Skip Their Prostate-Specific Antigen (PSA) Test

There has been plenty of talk about the reunion of the Friends cast earlier this month. Maybe you were a fan of the show during its original run and wanted to see how the actors had aged, or maybe you discovered it online and wanted to see something new. In any case, it was good to see your friends hale and hearty.

But then news broke this week that James Michael Tyler has advanced (Stage 4) prostate cancer. You may remember that Mr. Tyler played Gunther, the Central Perk manager who appeared in more episodes of Friends than anyone other than the Big Six. Call him The Magnificent Seventh.

So as I do anytime the chance arises, I remind you, or your partner, or your father, brother, uncle, our second-cousin-twice-removed to please get screened for prostate cancer (PCa). PCa is by far the most common cancer diagnosed in men in the USA, and the second leading cause of male cancer death.

The Prostate Specific Antigen blood test is still the most common test used in prostate cancer screening. It isn’t perfect, there are false positives and false negatives, but it is inexpensive, readily available, and when used intelligently to guide the patient-physician relationship it is useful in alerting to the possibility of prostate cancer. And there are lots of other associated lab tests such as Free PSA and Prostate Health Index (PHI) that can help make blood testing more specific.

Suppose you and your doctor decide a diagnostic biopsy is needed. There are techniques now that greatly reduce post-biopsy infection, once the biggest risk of the biopsy procedure. MRI studies can increase accuracy by pointing out suspicious areas to sample. And pathologists are great at making the correct diagnosis.

And if you wind up told you have prostate cancer? Treatment options abound – including no treatment in certain situations. And as in other cancers, the ability to test your DNA for abnormalities in both your cancer cells and in your non-cancer cells have lead to new treatment paradigms as well as assessment of the risk of prostate cancer in other family members.

If you are Black, your risk for prostate cancer death is even higher. US Too, the Chicago-based organization fighting prostate cancer (I am on the Board of Directors) has launched The Black Men’s Prostate Cancer Initiative. Check it out.

To all my friends with prostate cancer (and there are many) keep fighting the good fight. To the rest of you, black, white, or brown, with a family history of prostate cancer or without one, get screened.

Mr. Tyler, thank you for this opportunity for me to speak out once again. I wish you the best, and know that you have lots and lots of Friends!

The above is the opinion of the author and not necessarily UroPartners LLC or US Too.

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