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August 9, 2006

BehindTheMedspeak: Ketamine for depression?


Two days ago Dr. Carlos A. Zarate and his research group published a paper entitled "A Randomized Trial of an N-Methyl-D-Aspartate Antagonist in Treatment-Resistant Major Depression."

Sounds impenetrable, eh?

That's why you pay me the big bucks, to deconstruct these verbal firewalls and tell you about what's behind them in plain English.

Long story short: the scientists used ketamine, an anesthetic drug with a long, colorful and checkered history, to treat major depression.

The results: many of the patients improved, some in a matter of hours after receiving the drug.

Even more profound: they remained significantly better for one week following drug administration.

The importance of these findings, preliminary as they may be and in a group of only 18 individuals, cannot be overstated.

Depression kills.

Anything that can reverse it quickly — hours as opposed to the weeks or months required with current state-of-the-art antidepressants — marks a tremendous advance.

Zarate is chief of the mood disorders unit at the National Institute of Mental Health: this is no wacked-out guy trying something at Elsewhere General in a Third-World country.

Here's Shankar Vedantam's article about the study, from yesterday's Washington Post.

    Injection May Treat Depression Much Faster

    Government researchers announced yesterday that they have had striking success in treating depression in a matter of hours, using an experimental injectable drug that acts much more quickly than conventional antidepressants.

    The study, based on a small sample, is part of a push by researchers to develop treatments that can bring quick relief to patients with mental disorders. Patients and their doctors report that it often takes weeks or months for most available medications to improve symptoms.

    Much more work needs to be done before patients can see benefits from the breakthrough, the researchers said. Among the unanswered questions are whether patients will be able to tolerate the drug for long periods, and whether it will continue to be effective. Researchers said they hope the finding will prompt the pharmaceutical industry to develop similar compounds with fewer side effects that can then be tested on a large scale.

    "Psychiatrists have gotten used to the idea we have to wait weeks or months, but we can break the sound barrier and get an antidepressant effect within hours," said Carlos Zarate Jr., chief of the mood disorders research unit at the National Institute of Mental Health.

    Zarate and his colleagues published a paper about their findings in yesterday's issue of the Archives of General Psychiatry.

    In the study, 18 patients were injected with a drug called ketamine, which has been used for a long time as an anesthetic. Patients briefly experienced a well-known side effect of the drug -- a mild feeling of dissociation, where they felt disconnected or found it difficult to put thoughts into words.

    Ketamine is a controlled substance and can produce mild euphoria.

    But the dissociative symptoms disappeared within a couple of hours, and shortly afterward patients and physicians reported a dramatic improvement in mood. Half the patients had a 50 percent decline in depression symptoms after two hours, and by the end of the first day, 71 percent reported a similar improvement. More than a third continued to report such a benefit after seven days, and nearly a third reported a complete end of symptoms. Conventional antidepressants approach those kinds of numbers only after eight to 10 weeks of treatment.

    "We can truly raise the bar on what we can expect of antidepressant treatments," said Thomas Insel, director of the National Institute of Mental Health. "A modest response after six weeks is what we used to define as success. What I love about this project is it redefines success not in terms of weeks, but in terms of hours."

    Rather than go after the conventional targets of serotonin and norepinephrine, the new drug targets an entirely different neurotransmitter in the brain called glutamate.

    "This is not a subtle change," Insel added. "It is almost like rebooting a computer. It is a chemical reboot, and the striking thing is the effect lasts for about a week."


You want more?

How about the abstract of Zarate et al's paper?

It follows.

    A Randomized Trial of an N-methyl-D-aspartate Antagonist in Treatment-Resistant Major Depression

    Carlos A. Zarate, Jr, MD; Jaskaran B. Singh, MD; Paul J. Carlson, MD; Nancy E. Brutsche, MSN; Rezvan Ameli, PhD; David A. Luckenbaugh, MA; Dennis S. Charney, MD; Husseini K. Manji, MD, FRCPC

    Arch Gen Psychiatry. 2006;63:856-864.

    Context: Existing therapies for major depression have a lag of onset of action of several weeks, resulting in considerable morbidity. Exploring pharmacological strategies that have rapid onset of antidepressant effects within a few days and that are sustained would have an enormous impact on patient care. Converging lines of evidence suggest the role of the glutamatergic system in the pathophysiology and treatment of mood disorders.

    Objective: To determine whether a rapid antidepressant effect can be achieved with an antagonist at the N-methyl-D-aspartate receptor in subjects with major depression.

    Design: A randomized, placebo-controlled, double-blind crossover study from November 2004 to September 2005.

    Setting: Mood Disorders Research Unit at the National Institute of Mental Health.

    Patients: Eighteen subjects with DSM-IV major depression (treatment resistant).

    Interventions: After a 2-week drug-free period, subjects were given an intravenous infusion of either ketamine hydrochloride (0.5 mg/kg) or placebo on 2 test days, a week apart. Subjects were rated at baseline and at 40, 80, 110, and 230 minutes and 1, 2, 3, and 7 days postinfusion.

    Main Outcome Measure: Changes in scores on the primary efficacy measure, the 21-item Hamilton Depression Rating Scale.

    Results: Subjects receiving ketamine showed significant improvement in depression compared with subjects receiving placebo within 110 minutes after injection, which remained significant throughout the following week. The effect size for the drug difference was very large (d = 1.46 [95% confidence interval, 0.91-2.01]) after 24 hours and moderate to large (d = 0.68 [95% confidence interval, 0.13-1.23]) after 1 week. Of the 17 subjects treated with ketamine, 71% met response and 29% met remission criteria the day following ketamine infusion. Thirty-five percent of subjects maintained response for at least 1 week.

    Conclusions: Robust and rapid antidepressant effects resulted from a single intravenous dose of an N-methyl-D-aspartate antagonist; onset occurred within 2 hours postinfusion and continued to remain significant for 1 week.

    Trial Registration clinicaltrials.gov Identifier: NCT00088699.

    Author Affiliations: Mood and Anxiety Disorders Program, National Institute of Mental Health, National Institutes of Health, and Department of Health and Human Services, Bethesda, Md.


Now you're really intrigued, huh?

I mean, you made it this far: you should get something for your trouble, if there's any justice in the world.

OK, then: how about the details of the NIH clinical trial?

They follow.

    Rapid Antidepressant Effects of Ketamine

    This study is currently recruiting patients.

    Verified by National Institutes of Health Clinical Center (CC) May 2006

    Sponsored by: National Institute of Mental Health (NIMH)

    Information provided by: National Institutes of Health Clinical Center (CC)

    ClinicalTrials.gov Identifier: NCT00088699


    This study will test whether a single dose of ketamine - a drug that blocks a brain receptor called NMDA - can cause a rapid (next day) antidepressant effect in patients with major depression. Several medications are effective for treating depression; however, they take weeks or months to achieve their full effects. A more rapidly acting antidepressant would have a significant impact on the treatment of depression. In a previous study, ketamine produced a rapid antidepressant effect within hours, but the effect lasted less than 1 week. Understanding how ketamine works may lead to a better understanding of the causes of depression and the design of a longer lasting rapidly acting antidepressant.

    Patients between 18 and 65 years of age who are currently experiencing an episode of major depression of at least 4 weeks duration and have not responded to two treatment trials may be eligible for this study. Candidates are screened with a medical and psychiatric history, physical examination, and blood and urine tests.

    Participants undergo the following tests and procedures:

    • Medication tapering: Patients who are taking medications for depression are tapered off the drugs over a 1- to 2-week period.

    • Ketamine/placebo trial: Patients are given a single dose of either ketamine or placebo (an inactive substance), administered intravenously (through a vein) over 40 minutes. After 7 days, patients are given another dose of study drug in crossover fashion; that is, those who previously took ketamine are switched to receive placebo, and those who took placebo are switched to ketamine. Oximetry (measurement of blood oxygen), pulse, and blood pressure are measured continuously for 1 hour before and 4 hours after each ketamine or placebo dose to monitor safety.

    • Interviews and rating scales: Patients complete a series of psychiatric rating scales to assess the effects of the study drug on mood and thinking. The rating scales are repeated up to 18 times during the study, with each time taking about 15 to 20 minutes.
    Physical examination and laboratory tests: Patients have a physical examination, blood tests, weight measure, and electrocardiogram (ECG) at the beginning and end of the study.

    Official Title: Investigation of the Rapid (Next Day) Antidepressant Effects of an NMDA Antagonist

    Total Enrollment: 101

    Study start: July 2004

    Last follow-up: May 2006

    Data entry closure: May 2006

    Bipolar affective disorder (manic-depressive illness) and unipolar depression are common, severe, chronic and often life-threatening illnesses. Impairment in physical and social functioning resulting from depression can be just as severe as other chronic medical illnesses. Recent preclinical and clinical studies suggest that the glutamatergic system is involved in the mechanism of action of antidepressants. In two separate trials, we tested riluzole (an inhibitor of glutamate release) and found it to have antidepressant properties in patients with unipolar and bipolar depression (Zarate et al. 2004, 2005). In another study, we found that the non-competitive NMDA antagonist (ketamine) was effective in treatment-resistant major depression. Ketamine resulted in rapid, robust and relatively sustained antidepressant effects. Response with ketamine occurred within 2 hours and last approximately 1 week (Zarate et al in press). The current protocol consists of 3 studies designed to address 3 major questions:

    Study 1 (Rapid improvement research in unipolar depression):

    Does the NMDA antagonist ketamine produce rapid antidepressant effects in patients with treatment-resistant major depression? Patients, ages 18 to 65 years with treatment-resistant major (unipolar) depression will in a double-blind crossover study receive either intravenous ketamine or saline solution.

    Study 2 (Rapid improvement research in bipolar depression):

    Does the NMDA antagonist ketamine produce rapid antidepressant effects in patients with treatment-resistant bipolar depression? Patients, ages 18 to 65 years with treatment-resistant bipolar depression will in a double-blind crossover study receive either intravenous ketamine or saline solution added to a mood stabilizer (lithium or valproate).

    Study 3 (Rapid and sustained improvement research in unipolar depression):

    Does riluzole (an inhibitor of glutamate release) prevent relapse in patients with treatment-resistant major depression who have rapidly responded to a single intravenous dose of ketamine? Patients, ages 18 to 65 years, with treatment-resistant major (unipolar) depression who have rapidly responded to a single intravenous dose of ketamine will in a double-blind study receive either riluzole or placebo to determine if the rapid response obtained can be sustained.

    Our primary hypotheses for these studies are: 1) rapid response (same or next day) can be achieved in patients with treatment-resistant major (unipolar) depression, 2) rapid response (same or next day) can be achieved in patients with treatment-resistant bipolar depression, and 3) rapid response (same or next day) can be sustained in patients with treatment-resistant unipolar depression.


    Ages Eligible for Study: 18 Years-65 Years; Genders Eligible for Study: Both


    1. Male or female subjects, 18 to 65 years of age.
    2. Female subjects of childbearing potential must be using a medically accepted means of contraception.
    3. Each subject must have a level of understanding sufficient to agree to all required tests and examinations and sign an informed consent document.
    4. Subjects must fulfill DSM-IV criteria for Major Depression (296.3) without psychotic features, based on clinical assessment and confirmed by a structured diagnostic interview, SCID-P.
    5. Subjects must have an initial score of at least 22 on the MADRS at screen and at baseline of study phase I.
    6. Subjects with a greater than a 25% decrease in the MADRS total scores between screen and baseline of study phase I will be dropped from the study.
    7. Current or past history of lack of response to two adequate antidepressant trials (may be from the same chemical class) operationally defined using the Antidepressant Treatment History Form (ATHF).
    8. Current major depressive episode of at least 4 weeks duration.


    9. Presence of psychotic features or a diagnosis of Schizophrenia or any other psychotic disorder as defined in the DSM-IV.
    10. Subjects with a history of DSM-IV drug or alcohol dependency or abuse (excluding nicotine or caffeine) within the preceding 3 months.
    11. Female subjects who are either pregnant or nursing.
    12. Serious, unstable illnesses including hepatic, renal, gastroenterologic, respiratory, cardiovascular (including ischemic heart disease), endocrinologic, neurologic, immunologic, or hematologic disease.
    13. Subjects with uncorrected hypothyroidism or hyperthyroidism.
    14. Subjects with one or more seizures without a clear and resolved etiology.
    15. Previous treatment with riluzole or hypersensitivity to it or to amantadine.
    16. Previous lack of response to ketamine for depression.
    17. Treatment with a reversible MAOI within 2 weeks prior to study phase I.
    18. Treatment with fluoxetine within 5 weeks prior to study phase I.
    19. Treatment with any other concomitant medication not allowed 14 days prior to study phase I.
    20. No structured psychotherapy will be permitted during the study.

    Please refer to this study by ClinicalTrials.gov identifier NCT00088699


    National Institute of Mental Health (NIMH), Bethesda, Maryland, 20892, United States of America


I daresay I know as much about using ketamine in people as anyone on the planet.


Because even after ketamine was essentially abandoned as an anesthetic due to side effects like hallucinations, flashbacks and in rare cases respiratory obstruction and death, I kept it in the back of my drug drawer "just in case."

Just in case I had a patient coming to the OR bleeding out, for example: ketamine acts like adrenaline, increasing blood pressure and heart rate and supporting a bottoming-out circulatory system.

That's because its mechanism of action peripherally involves the release of epinephrine.

Oh, and did I mention that it improves airway function and respiratory status?

So why isn't it used more?

Because given in large doses without ancillary drugs, it can cause all manner of unpleasant psychiatric side effects.

For example, patients under ketamine anesthesia may start talking or yelling or singing.

Sometimes it's so bizarre or off-color that nurses and surgeons beg me to give the patient something to make them stop.

If they ask nicely I comply.

But I digress.

The dose used by the psychiatrists in their study (0.5 mg/kg IV) isn't enough to provide surgical anesthesia.

I use an initial dose of 1-2 mg/kg IV to induce a patient, with subsequent doses of 0.5-1.0 mg/kg as needed (about every 20-30 minutes in most cases).

I add IV fentanyl, propofol, Versed or other drugs as needed.

Perhaps I should add a surcharge for psychotherapy for those of my patients receiving ketamine.

Ya think?

August 9, 2006 at 04:01 PM | Permalink | Comments (8) | TrackBack

'World's smallest and most comfortable self-contained cordless headset phone'


Seven of Nine, call the holodeck: your phone is in.

From the website:

    Xact Cordless Headset Phone

    It’s got style.

    It’s got beauty.

    It’s got brains... it’s got hands-free comfort fit.

    What more could you ask for in a cordless headset phone?

    They say if it’s got the looks — it doesn’t have the brawn.

    Not true.

    You can have both.

    Our exclusive Xact Cordless Comfort-Fit Headset Phone is so sleek and so fabulously designed in contemporary chic — and did we mention it’s the most comfortable and tiniest compact phone system around?

    And here’s the brains:

    • 2.4 GHz digital spread spectrum 77 channel auto-hop, digital security code, and Commander Circuitry-filtered sound system gives you crisp, static-free sound quality and keeps your conversations private.

    • Fully-featured with speed dial memory, digital security code, volume control, hearing aid compatible, out-of-range indicator, auto stand-by, flash, tone/pulse switch, and hi/lo/off ringer control.

    • Measures 3¾"L x ¾"H



Price break: originally $129.95, now reduced nearly 40% to $79.30.

It just occurred to me that you could have great fun doing your own phone mashups: just put this device on one ear and a Bluetooth headset on the other, make calls on both simultaneously and enjoy the confusion.

'Course, I can do that around here without any phones at all but that's a whole other story.

August 9, 2006 at 03:01 PM | Permalink | Comments (0) | TrackBack

Al Christensen on 'The End of Willpower'


Al just contributed a comment on yesterday's final post.

It's far better than the dreck I routinely fill this space with so I'm putting it here, front and center under the big top, instead of just leaving it on the outside looking in.

    Al Christensen on 'The End of Willpower'

    I don't know about willpower but I know about making choices. Do I eat that pie for the short-term gratification or do I skip it for the sake of a long-term goal? Do I buy crap at the market and then fight the urge to eat it, or do I not buy the crap so it's not in the house calling to me to have just a teeny bit?

    On the other hand, I know our minds and bodies hate deprivation. It's so boring, so bleak. Why live longer if it just means going longer without the things you enjoy?

    Well, one answer smacked me up side the head a couple of months ago. All sorts of very annoying but non-lethal things started happening to my body. See, I had imagined I would just drop dead someday from a heart atack or stroke — nice, short, clean ending. Adios, it's been fun. I hadn't thought much about being plagued with all sorts of nasty health problems that would kill me very slowly. Oh, that. So I went to the doctor for the first time in 15 years. He confirmed what I suspected: diabetes.

    So now I'm back to the choices. Every minute of every day I have to decide whether to do the smart thing or the self-destructive thing.

    That leads me to a tangential theory. Perhaps when we sense the environment has become too crowded or stressed, some genetic switch flips in some of us that overrides our self-preservation instinct. It's like the code is telling us, "Look, it's time to cull the herd and your particular contribution to the preservation of the species is no longer needed. How about checking out early?"

    And so we drift into self-destructive behaviors — behaviors our minds and bodies resist changing. Maybe I eat the bacon cheeseburger with a side of chili fries and a huge chocolate shake not because I lack "willpower" but because my genetic code is trying to kill me off.


A few more commenters like Al and I'll be able to take early retirement.

August 9, 2006 at 02:01 PM | Permalink | Comments (0) | TrackBack

Wash-A-Way Power Mower Blade Washer


From a catalog and website:

    Wash-A-Way™ Mower Washer

    Wash-A-Way makes for a clean machine!

    Cleaning the underside of your mower deck will make your machine last longer and give you a cleaner cut, too.

    Wash grass clippings and more off the underside of your gasoline-powered mower with this specially designed new sprayer.

    Simply screw the Mower Wash-A-Way to your garden hose and slide it under the edge of your mower deck — it stops when it's in the right position.

    You don't need to tilt the mower up for access and you don't need to get your hands anywhere near sharp surfaces.

    Then turn on both the water and mower and let centrifugal force do the work.

    The whirling action of the cutting blades acts as a power washer, deep cleaning every part of the deck, even the corners, in a flash.

    Works with side-discharge and mulching push mowers as well as ride-on mowers: not for use with electric models.

    Made from durable heavy-gauge plastic.

    12" x 9.5" x 2".


Guaranteed to result in some very unpleasant visits to the ER.

Wash a working power mower's blades?

Heck, why stop there?

Why not clean out a jet engine's turbines while it's powered up?

At first I though this was a prank product but it appears legit.

Bad, bad idea.

Perhaps the worst one so far this year.

But if you're the type of person who enjoys living on the edge — as it were — then by all means go right ahead.


August 9, 2006 at 01:01 PM | Permalink | Comments (6) | TrackBack

LiveMarks — Real time tags


I don't understand what's going on here but you don't have to be a weather man to know which way the wind blows, do you?

"LiveMarks is a project to show del.icio.us and other services' bookmarks live."

It's a creation of SWiK.

I do know this: I found a lot of interesting things there and you will too if you noodle around for a while.

August 9, 2006 at 12:01 PM | Permalink | Comments (0) | TrackBack

BehindTheMedspeak: Miniaturized personal pulse oximeter/heart rate monitor


It's a miracle.

There is no other way to describe the device pictured above and below, which gives you an quick readout of your arterial blood oxygen saturation and heart rate.

In the O.R. I use a machine that performs these functions.

It costs about $5,000 and is about the size of a small toaster oven.

It requires a wire running from the thingie on your finger to the box.

From the website:

    Check Mate

    New medical mini-marvel lets you easily measure your pulse and oxygen level with remarkable accuracy

    It just got easier — and about three times more affordable — to measure your blood oxygen saturation levels and heart rate instantly and non-invasively.

    Just place the Check Mate on your finger and press the “On” button and within seconds, the unit will display accurate readings of your arterial blood oxygne saturation (SaO2) and heart rate in large, easy-to-read LCD numbers.

    The larger version of this device, utilizing the same breakthrough technology, is already in use at thousands of hospitals; the compact Check Mate is ideal for personal use and homecare-related applications where fast measurement of vital signs is required.

    It’s also great for gym workouts and joggers!

    It is highly energy efficient, eliminating the need for frequent battery replacement, and can be used outdoors in many conditions, including at high altitudes, high and low temperatures and even in the dark.

    • Signal Indicators: Sensor Off, Weak Signal, and Battery Power

    • Measures Blood Oxygen Saturation from 40 to 99% ± 2%

    • Measures Heart Rate from 40 to 250 bpm ± 3%

    • Pocket-sized (3” x 1.6” x 1.6”)

    • Weighs only 1.8 oz.


The version featured here — a miracle of miniaturization, computerization and industrial design — costs $199.95.


Easily the most impressive piece of technology I've seen this year.

August 9, 2006 at 11:01 AM | Permalink | Comments (1) | TrackBack

BehindTheMedspeak: Why your 'great doctor' might be a quack


Abigail Zuger, M.D., wrote an August 1 New York Times Science section essay entitled "Dr. Good Has Left the Building," lamenting the exodus of excellent clinicians to careers in administration and research.


I weighed in with a letter to the Times which was published yesterday and appears above and (far) below.

    In the Examination Room

    To the Editor:

    Re “Dr. Good Has Left the Building”: The writer quoted a famous doctor as saying to her that “any idiot can make a patient feel better” to illustrate why she wouldn’t want to work for someone so cynical.

    The doctor was 100 percent correct. Why do you think many of the doctors consistently at the top of best-doctor lists are known to peers to be barely competent?

    Because they’ve learned to compensate for their lack of medical knowledge with tremendous interpersonal skills that invariably “make a patient feel better.” Be careful is all I’m saying.

    Joseph A. Stirt, M.D.
    Charlottesville, Va.


Note the embedded homage to my head crack team researcher in the final sentence: it's one of her favorite tropes.

And no — when a trope goes missing it doesn't mean you dislike people.

But I digress.

Here is Dr. Zuger's column in its entirety, so you have a level playing field, as it were, on which to judge the merits or lack therein of my response.

    Dr. Good Has Left the Building

    When people ask me to recommend a doctor for them, half a dozen spring to mind immediately.

    They are all intelligent, kind and committed, intellectually imposing but down to earth, practical but visionary, and leavened with a good sense of humor. You couldn’t ask for a better person to oversee your health than one of them.

    There’s only one problem: not one of them sees patients anymore.

    No, they haven’t retired. They have simply moved onward and upward into the medical stratosphere. They have arrived at positions of power and influence; they do groundbreaking research, set policy, write guidelines and generally shape the health of the planet.

    As for figuring out why you can’t stop coughing, forget it. They don’t do that kind of thing anymore.

    Doctors without patients: can such creatures really exist? Or do they automatically negate themselves into some other sphere of existence, a cloudy existential plane where teachers without students and merchants without customers all wander around in search of a new identity?

    It is a purely rhetorical question, because not only do doctors without patients exist, they thrive. They top most heaps: they are the administrators, the professors, the chairmen, the directors and the chief executives.

    In fact, if truth be told, little baby doctors often go to bed at night thinking, I want to be just like them.

    In the memoir “Teacher Man,” Frank McCourt described “the situation in the public schools of America: the farther you travel from the classroom, the greater your financial and professional rewards.”

    The situation in the health care arenas of America may not be identical, but there are certainly parallels. Like the blackboard, the examining table is where the grunt work is done. Brilliant career paths often lead in the opposite direction.

    Some medical movers and shakers head off without a backward look: they never liked that “say ahhh; where does it hurt?” business to begin with.

    Some wax nostalgic: “If I only had the time,” they say, gesturing at the toppling piles of papers on their desks. “I miss patient care.”

    But they never quite make it back to that buffer-free zone of the examining room, to that lonely hot seat where the decisions are all theirs, and the fallout is too.

    Instead, their horizons expand, and in some sense, so do their patient loads. After all, to write an article establishing that one treatment is better than another is effectively to participate in the health care of millions. So is taking a new chemotherapy from test tube to pharmacy, or configuring an insurance company’s preferred drug formulary. And should something go wrong, the seat still gets plenty hot.

    But the work is not quite the same. Most of medicine these days is based on the big picture — trends set by thousands of research subjects (or hospital admissions or insured lives) moving in synchronies visible only to high-speed computers. The patterns can look very different writ small.

    In other words, a giant study may show that two pain relievers work about the same. But if only one helps Mrs. Jones (the gallant, delightful, terminally ill and utterly impoverished Mrs. Jones) and her insurer pays only for the other one, Mrs. Jones’s physician will quickly come to realize that they are not the same after all.

    Doctors who never get to know Mrs. Jones seldom learn this lesson. In fact, after enough years away from the examining table, it is easy to forget that people like Mrs. Jones exist at all.

    Some say that’s for the best. Many years ago, a famous professor and researcher interviewing me for a job remarked, in the tones of one imparting a secret of the universe, “Any idiot can make a patient feel better.”

    Research was the key to medicine, he continued, to really making a difference. Otherwise, wishes and hopes and idiosyncrasies, both yours and those of your patients, would tangle you up so completely that you would never break free.

    At least, I think that’s what he was trying to say. I actually never saw him again, deciding to take a job elsewhere, with a somewhat less famous man who still saw his own patients, one of the few graying heads in a sea of young medical grunts.

    “Keeps you honest,” he said.


It may or may not be good news to you that bookofjoe has burst the bounds of virtuality and now grabs a toehold in the old media space.

We are everywhere.


To paraphrase Joyce Kilmer:

Letters are written by fools like me,
So that you can go, 'hee hee'

August 9, 2006 at 10:01 AM | Permalink | Comments (2) | TrackBack

Mutant Dishrack


From the website:

    Half-Sink Dish Drainer

    Compact dish drainer rests over half the sink and leaves the other half free for washing or soaking!

    Holds up to 10 plates, cups, glasses and pots and drains directly into the sink.

    Fits 18" to 21-1/4" length sink; 8-1/4" wide.

    Great if you have limited counter space!

    Coated metal won't mar surfaces.

    Can also stand freely in sink.


August 9, 2006 at 09:01 AM | Permalink | Comments (1) | TrackBack

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