Omakase

Monday, December 12, 2011

More great quotes…..

“A man must be big enough to admit his mistakes, smart enough to profit from them, and strong enough to correct them.” - John Maxwell


“You’ll seldom experience regret for anything that you’ve done. It is what you haven’t done that will torment you. The message, therefore, is clear. Do it! Develop an appreciation for the present moment. Seize every second of your life and savor it” - Unknown


“There are three qualities a leader must exemplify to build trust: competence, connection, and character.” - John Maxwell


A lot more great leadership & motivational quotes here: http://sourcesofinsight.com/john-maxwell-quotes/


And, as a bonus, a clever take on the Euro financial crisis, courtesy of Tyler Cowen's Marginal Revolution.

Monday, November 28, 2011

Myhrvold: Subsidies Stymie Wind, Solar Innovation - Bloomberg

For the first time that I've seen so cogently explained, Nathan Myrvold (former Microsoft CTO) lists the flaws and conflicts inherent in our current energy policy. He points out a more efficient and effective way to both develop new energy technologies and balance energy production between existing and alternative technologies.

It's a short article and worth a read.

http://www.bloomberg.com/news/2011-11-27/energy-subsidies-stymie-wind-solar-innovation-nathan-myhrvold.html

Sunday, November 27, 2011

Burn Fat Faster with Vitamin D

Saving a link for myself that might be helpful to you: vitamin D has a broad and deep impact on health, and vitamin D daily recommendations for people like me (40+ and overweight) are multiples greater than previously thought (3,000 IUs daily vs 600.) I Ned to check the content of my daily multi-vitamin and perhaps supplement with vit D tabs. Also: this is one more good reason to start the day with milk & cereal.




Monday, November 21, 2011

Quote worth sharing

"The secret of success is to understand the point of view of others." - Henry Ford

Thursday, November 17, 2011

Carticel recovery @ four months

I reached my four month anniversary two weeks ago, and to celebrate, I decided to absolutely abuse my new knee.

(The decision was more like "I've got some business travel to do in Europe. What if I used my spare time to do a walking tour of wherever I happen to be, and count on only needing regular sleep to recover?")

Before further explanation, let me catch up on the last two months: I transitioned from my full-length leg brace (ankle to thigh) to a much smaller unloader brace which I wear only when awake. The smaller brace allows complete freedom of movement, and as I learned, is firstly for protection, not recuperation. (In other words, it is designed to keep you from doing anything stupid, whether intentional or accidental.)

Along with the new brace, I have graduated from mentored physical therapy to a self-guided physical therapy program, also graduating from increasing range of motion to increasing strength. My typical routine is a 5-10 minute cardio warm-up followed by a series of lifts - leg extensions, leg press, hamstring  lifts, and thigh abduction/adduction, finished with a cardio session of 20-30 minutes either stationary cycle or elliptical. (Though typically shorter intervals with the elliptical.)

I alternated every day between the above lifting routine, and aquatic sessions - 15-20 minutes of chest-deep movement exercises and up to a mile of lap swimming. I highly, highly recommend having an aquatic component, btw.

I thought I had a complete approach, but I was reminded at my four-month check in that I need to continue the leg lifts with ankle weights in addition to the gym & pool work.

For the last month or so it has been very exciting to see increases in leg strength. The progress has been obvious just looking at my weight lifts, and by my speed and strength in the pool. Also, by and large, I have been pain-free even during my most aggressive workouts, though plenty of times I have rapidly fallen asleep on my couch following a good workout.

I have also weened myself off of the pain meds, including ibuprofen (Advil), which I'll take 1-2 times per week.

On to my 4-month update:

So, at four months, my doc, Dr. Zaslav, was very happy with my status. No problems, good flexibility and good strength. I won't see him for another 4 months, and in the interim I am allowed to wind down my use of the unloader knee brace, and wind up outdoor cycling - though only on flat ground, and without standing up on the pedals. (I need to wear the brace while cycling or working out any way except swimming.)

The only item of interest at my 4-month check-in is a minor discoloration (bruise-like) on the inside of my knee, roughly corresponding to the site where the carticel was implanted. The discoloration ebbs in intensity, seemingly depending on how intense my use of the knee was that day. The doc didn't know what this might be - he'd never seen this phenomenon before, so we didn't take any action or curtail my workouts. Has anybody else had this discoloration?

Your host @ the Arc de Triomphe in Paris, November, 2011. Can you guess which leg has the brace on?

To celebrate, I flew off to France, Scotland, and London. (OK, it wasn't a celebration so much as a necessary work trip.) I did manage to spend time walking around some of these great places (and I'll post some picture highlights in a subsequent post).

I was fully mindful of my knee health, and always intend to let my knee determine the duration and pace of touring. However, I completely forgot the advice I received post-surgery: always stay ahead of the pain.

I would set off from my hotel with the intention of stopping mid-walk for a stop at a cafe or Starbucks no more than every hour or so. I was pretty faithful to this approach, but inevitably, I'd get tired before I found a cafe, or have to walk a bit further than expected. In retrospect, I should have had the intention of stopping every 45 minutes, but be prepared to go an hour (if it takes 15 more minutes to find a cafe), instead going an hour, and sometimes struggling to an hour and 15 minutes.

I found myself being able to go less and less far between breaks, but typically didn't realize it until my limits were only 10 minutes or three blocks between rests. (At one point, I was down to resting between blocks.)

To make matters worse, my overnight rest cycles were about the same as they had been at home. I should have budgeted an extra hour on touring days.

There was a mild knock-on effect - I found myself lagging in a few of my business meetings. One meeting - scheduled to go two hours - rant to almost 4 hours. I didn't realize it at the time, but I was absolutely pooped by the start of hour 3, and found myself getting a little bit silly in the meetings. Hopefully I didn't make the wrong impression.

The other negative is that once I made it home, I took three days off from my physical therapy routine. Not good, but definitely necessary.

A couple of observations/ideas/advice for Carticel patients:

-Very important: get a good seat on your flights. I scored an exit row seat with plenty of legroom for both long flights. I really didn't have any problems in-flight or post-flight as a result. If I hadn't scored, I probably would have been worse off, and being squeezed into a seat with less legroom would have certainly gotten in my head.

(Incidentally, my doc offered to write a prescription for business class seating, but as a consultant, the price of the trip came right out of my pocket, and I wasn't about to pay $3,500 more to make the trip.)

-Don't underestimate the walking mileage that you'll rack up in the airports. Always, always take the elevator if available - that walk to the gate or bus stop is always longer than you think.

-Consider taxi rides instead of subway/metro travel. I tended to get all-day passes for the metro/Underground, which certainly encouraged me to ride between tour destinations, instead of walking (which was smart), but eventually you'll have subway journeys with long walks to transfer, or plenty of stairs. The taxis are definitely more expensive but an investment in knee health.

-Dial down your touring ambitions and be smarter than me when it comes to knowing your limits. By the time I got back to my hotel room, all I could do was crash for the day or night. I lucked into hotels with good fitness facilities (including in one case a pool), but never did any PT as I was too pooped.

-Do NOT backpack - used wheeled suitcases! The last thing you need as a recovering patient is 25 or 35 more pounds of stress on your knee.

-I am extremely thankful that my trip wasn't a month earlier (month 3). I don't think I could have made it.


My final verdict on the trip will be determined by my strength tests tomorrow, when I'll learn if I grew stronger, or atrophied while traveling. For now, though, it is off to the gym for me!


I hope this update is helpful. As always, please feel free to ask me any questions in the comments section or via email.

Sunday, August 21, 2011

Tips and advice for Carticel patients to be


While Carticel and A.C.I. (autologous chondrocyte implantation) surgery is now ~15 years old, there is still a lack of non-Genzyme originated patient info out there. I've previously covered some of my experience online:


To anyone considering or just beginning their Carticel experience I’d offer the following points for consideration:

Tips & Insights

1)   1) Your most valuable item is your green, ring-bound rehabilitation guide. There’s a very good chance that your rehab center has never seen a Carticel patient. There’s a good chance as well that your therapist will see “A.C.I.” and think “ACL.” To combat this, share your green rehab guide guide, or better yet, get more than one copy so that you have one too.

2)   2)Get clarity on how your protocol changes with time and progress. Surprisingly, there’s not a ton of precision on when a patient progresses into a different protocol. Can you sleep without a brace at week 4 or is it week 5? Do you get off crutches at week 6 or 8?  It’s fluid – get firm, clear instruction from your doc/your doc’s physician’s assistant/physical therapist.

3)   3) Just like protocols were sometimes confusing, I sometimes got confusing and contradictory advice on simple things, like how to put my leg brace on. For instance, I was first told directly that the brace should be snapped in order from top (pelvis) to bottom (ankle). I found that the brace would tend to drift down my leg. Four weeks in, my physical therapist (my 4th different one) suggested a different order: when putting my leg brace on, it seemed that snapping the braces on in one particular order produced the best results. Mine has 4 ‘bands,’ which I’ll label from my ankle to my pelvis 1 through 4. I got the best results locking #2 first, followed by #1, #3, then finally #4.

4)   4) Since the Carticel cells are frozen once fully grown in anticipation of shipping for surgery, the scheduling of the implantation surgery is elective. I considered surgery during the winter holidays, or perhaps in the quietest part of winter, with the thought that these times were most conducive to sitting around, and basically doing nothing more demanding than rehab. I ultimately chose to operate immediately (July, after a late March harvesting of cells) mostly due to an interest in getting better sooner rather than later, but it had a benefit that I hadn’t anticipated: it was the time of the year to wear shorts. As I realized, long pants aren’t really a good option for the first month or so post-surgery, so consider having your surgery during a warm month.

5)   5) I’d suggest relying on a walker instead of crutches for the first month or so. Walkers are a bit slower and less mobile, but far more stable. I’d say that while on crutches, I’d have at least one “whoopsie” incident a day where I might have to apply significant (if momentary) pressure on my sore leg. Not fun. In contrast, walkers are very, very low risk. Also: you can drape a bag over an arm of the walker in order to carry books & gizmos with you.

6)  6) Get an iPad. You’ll be spending LOADS of time just sitting around recuperating. You’ll be in need of mindless distractions or entertainment.  I picked up a second-hand iPad for ~$225 and it was worth every penny during my recovery. I also used the iPad to gauge my health: I play backgammon and pre-surgery was beating the computer probably 3 out of 4 times on average. During the first ~3 weeks, my success rate against the computer was ~50/50, with some prolonged periods where I lost more than half my games against the computer, corresponding (on reflection) with the times where I was most exhausted or in pain. I’m happy to report that I’m back to normal, winning ~75% of my games.

Thursday, August 18, 2011

Carticel patient status update


Today I am celebrating the 6-week anniversary of my A.C.I. surgery. I am currently mobile via crutches and walker. I am wearing a brace during the day, but sleeping without one. I attend physical therapy 3X/week, and exercise at home on the off days according to plans made by my therapist.

There is very little pain, and at this point, very little need for painkillers. I pop 2-3 ibuproferen tabs 2-3X per day, and that’s it. I also ice my knee a few times a day.

My biggest problem to date has been sore muscles in my “good” leg. Twice I’ve pulled calf muscles when hopping – once climbing stairs, and once hopping without crutches. The second time I pulled the calf muscle was accompanied by an audible “pop.” I’ve talked to my PT about it, and she says that the soreness is temporary, and that I ought to stretch daily and before relying on a cold muscle.

The current expectation is that I’ll be off crutches permanently in ~4 weeks, with initial crutch-free re-training beginning in 2 weeks.

Unfortunately, this means I lost a race with my 1-year old niece to see who would walk first. I challenged her in early July, and just this week she took her first repeated steps.

Other than that, things have been good.

Please feel free to send me any questions about my Carticel experience via email here

Saturday, July 30, 2011

Carticel patient experience

One of the highest traffic pages on my blog has been my posts detailing my 2011 knee surgery(s) and recovery. Since those postings in March and April, respectively, I have had a second surgery on my knee to implant Carticel chondrocytes (in other words, to plant new knee cartilage like planting new grass sod.) 


By popular demand, then, here's the continuation of my experience and some tips/thoughts for anyone about to have or considering this surgery.


As a refresher/background: I'm an early 40's semi-athletic male who began experiencing frequent and serious knee pain in my left knee in the summer of 2010, most pronounced when distance running. My initial diagnosis was a torn meniscus, and I underwent directed physical therapy to strengthen surrounding muscles to compensate. 


Fast forward six months, and during arthroscopic surgery to debride the meniscus, my doc realized the true nature of my knee problem: a large amount of articular cartilage damage on my left knee. More details and pictures are here.




During the March 2011 (first) surgery, my orthopedic surgeon harvested some of my knee cartilage for a second procedure: implantation of new cartilage grown up in a lab from the cartilage harvested in March. This surgery for me took place in July, 2011 and I am now in the midst of recovering and following the Carticel post-op protocols.


My Carticel story begins just after my March surgery. My local orthopedist (Dr. Grant, of Charlottesville, VA) and his office and surgical teams were absolutely top-notch through my first surgery and recovery, but Dr. Grant suggested that my condition would benefit from seeing a specialist in Richmond, VA, Dr. Kenneth Zaslav.


I was lucky to find good care and treatment from Dr. Grant & team. My luck continued with the introduction to Dr. Zaslav: he's a rockstar in his area. He was one of the first physicians in America to perform the implantation surgery, so he's one of the most experienced, and he was the lead author of the defining academic study of such procedures (a study of ~150 Carticel patients over four years.)


Dr. Zaslav confirmed Dr. Grant's prognosis and suggested two possible courses of action:


1) periodic injections of Synvisc - a fluid that provides knee lubrication - though only for about six months before dissipating and thus requiring another shot. Oh, and the regular synvisc shots are fairly expensive and very serious, nasty shots.


2) implantation of Carticel tissue. (I'll use the terms 'tissue' and 'cartilage' in lieu of the more accurate term "autologous chondrocytes." Technically, what's implanted is a mish-mash of cells that by 9-12 months takes root and form cartilage.) 


Carticel has the advantage of a high permanent success rate (~80%), but is high-cost, and has a long and demanding rehab protocol.


I had already done plenty of research and was already leaning towards Carticel, and speaking with Zaslav increased my confidence in Carticel. Within days of the meeting, I had made my decision and set the wheels in motion. A tentative surgical date was set for early July (~8 weeks from my meeting with Zaslav). The next order of business was to get approval from my insurance company to cover a large portion of the therapy. Upon approval, word would be sent to Genzyme to begin growing my cells for implantation - a 4-6 week process.


Zaslav's staff is used to wrestling with insurance companies, and they took the lead on gaining approval from Anthem Insurance. Also heavily involved in this process is Genzyme. 


Unfortunately, this process - expected to take 10-15 business days - took ~5 weeks. (Apparently due to a paperwork snafu.) 


My biggest complaint from my entire Carticel expereince is from this period. The process and progress is not transparent at all. While I heard from my doctor's office through the process that approval was imminent and that there was no reason to change my impending surgery date, after the first ~3 weeks of waiting, I had little confidence in such a positive outcome. Not only did I worry about payment and surgical plans in flux, but I was very, very worried that my cells being grown by Genzyme could be hurt hurt in some way by a hasty growth cycle, impacting my ability to make a good recovery.


After all approvals were garnered, a rush of paperwork occurred. I think I paid full attention to the details, permissioning, etc., but the haste of the paperwork, the legalese, and the lack of hand-holding was a shock.


But, ultimately, we went forward on the original surgery date, with no restrictions. My cells were ready, and I was ready.


In my next post, I'll detail what came next. 

Wednesday, June 08, 2011

Something I've been thinking about....(gov't consolidation)

Today's WSJ has an interesting article about how the governor of Michigan is pushing Michigan municipalities to consolidate. His point is that his state doesn't need 1,800 different units of government in the state. He isn't trying to consolidate the power in his office, but rather just trying to reduce the cost of government. (How many accounting departments are needed in Michigan, for example.)

(here comes a rant)

I've been thinking about this same thing since hearing that here in Virginia, county lines were originally drawn in the 1600's based on how far one could ride on a horse in one day. This makes for counties with ginormous populations (Fairfax, with 1.1M people) and tiny populations (Highland County, with just 2,510 people, which is adjacent to a county with only 4,500 people.) Now that we've drive cars instead of horses, shouldn't we reinvent the definition of a county?

I see the potential efficiencies, but it turns out they are overstated or illusory. (See the financial detail in the WSJ article.)

Local governance is always best, and highly appreciated by most, as the WSJ article describes that only 27 of 105 consolidation ballot initiatives have passed in the last 100 years.

I mention this issue as I think there's a lot of lessons for us to apply in other policy areas. In this era of progressivism, there are a never ending stream of new top-level (often Federal) policies, plans, or departments to instigate a desired change propelled by the efficiency argument. Two quick examples - among many - are the Obamacare iniitative and the entire Department of Education.

In both cases, local control is being subsumed by progressive programs, with the sponsors saying not only do they know what's best for you, but they can apply their brilliance more inexpensively than the local solution. Unfortunately, as the consolidation example illustrates, the reality is that the plans are rarely better, and seldom economicaly beneficial. Think about that the next time someone in a faraway place comes along with a plan to cure whatever ill is on the front page of the papers.

(rant over)

Wednesday, May 25, 2011

Study: Politicians Are Abnormally Good Stock Pickers. Hmmmm....

House representatives are up +6% annually over the market in a study of 16,000 trades over 16 years. Senators were even better.

+6%/yr is ludicrous performance. How can it be that people who can't balance the budget can pick winning stocks?

Hmmmm........is it that they're trading on insider info, steering federal spending towards their favorite stocks, or getting 'hot tips' whispered in their ear?

Thursday, May 19, 2011

Another picture show n' tell

Here's one of my favorite shots from my frequent trips into the Blue Ridge mountains. This particular shot is a view southeast from Calvary Rocks in the Shenandoah National Park. (Click to enlarge)

Even today, I can't tell definitively how many ridges are in this picture. Infinity might not be inaccurate.


The view is accessed from the Riprap Trail - one of my favorites having done it at least 3 times (including at least 1 full 10 mile circuit where I saw 6 different black bears, getting to within ~50 feet of a family of bears, as you can see in this pic:

Thursday, April 21, 2011

Picture time!

Here's another of my semi-regular postings of interesting pictures. As always, you can click on the picture for a larger view.

Today's pictures are from Stockholm, Sweden, and they show how incredibly photographic the city is.

With so much of the city surrounded by water, the locals must have been tempted to use some of it for public art, such as this scene in front of the legislature in 2005. It's a brilliant way to spice up an otherwise boring lagoon.

Earlier in the day I was on a hill overlooking a schoolyard. Most every exposed flat area in the schoolyard was painted with a short phrase in English, which I thought was very weird to see in Sweden, especially since there was no commonality shared by the phrases.

I thought the phrase shown in this picture was a very interesting and perhaps educational choice. One other was "Wish you were here," which I assume was inspired by a Pink Floyd song.



Finally, here's one of my favorite images from my trip to Stockholm. It is practically impossible to take a bad picture in Stockholm.

Friday, April 15, 2011

Obama: incendiary rhetoric bad for you, good for me

This is worth re-blogging. From ABC News White House correspondent Jake Tapper's blog:

President Obama at the GOP House retreat, January 2010:

“We're not going to be able to do anything about any of these entitlements if what we do is characterize whatever proposals are put out there as, ‘Well, you know, that's -- the other party's being irresponsible. The other party is trying to hurt our senior citizens. That the other party is doing X, Y, Z.”

President Obama today (4/13, while introducing his budget proposal):

 “One vision has been championed by Republicans in the House of Representatives and embraced by several of their party’s presidential candidates…This is a vision that says up to 50 million Americans have to lose their health insurance in order for us to reduce the deficit. And who are those 50 million Americans? Many are someone’s grandparents who wouldn’t be able afford nursing home care without Medicaid. Many are poor children. Some are middle-class families who have children with autism or Down’s syndrome. Some are kids with disabilities so severe that they require 24-hour care. These are the Americans we’d be telling to fend for themselves.”

I don't begrudge politicians for posturing, exaggeration (50 million Americans?)  or even for talking out of both sides of their mouth, but the blatantly provacative and exploitative use of Down's syndrome kids and autistic kids is disgusting, as is the attempt to smear the R's as insensitive to these causes. So much for the notion that Obama was a uniter and not a divider.

Tuesday, April 12, 2011

Knee surgery update

“When was your accident?”

I was in my 2-week post-surgical follow-up with my doctor (Dr. Grant)’s ace PA (physician assistant) Vince. He was reviewing pictures from my knee surgery, which was the first time that we had seen real images of my damaged knee.

“Accident? Huh?” I answered.

Vince explained that he was wondering what had happened to so colossally mess-up my knee. I realized what he meant because I had been asked it before. Nobody 40 years old should have this level of cartilage damage without being in some sort of accident.

“Oh, I wasn’t in an accident. But I played catcher for 30 years.”

Vince was startled, but managed to say “Really? That might do it.”


Vince did the 2-week post-op review, and I was lucky to receive rave reviews* – little swelling, good range of motion, and no infections or other complications. There is very little scaring and I’m allowed to resume normal activities “as tolerated,” except I must avoid high impact activities like running.

Though the surgery was a success, the reason for avoiding impact activities can be seen in some of the surgical pictures as seen through the arthroscope during surgery.

Originally, we thought that I had a simple meniscus tear prompting a couple of months of physical therapy to strengthen the surrounding muscles. A few months later, an MRI indicated a slight degradation of my articular cartilage. The pictures, though, showed twice as many areas of cartilage degradation, each many times larger than reported on my MRI.



 A little bit on articular cartilage, or chondyle: it’s the very slippery material on the front of the femur at the knee joint that allows smooth and easy bending of knees. How slippery? Cartilage on cartilage rubbing is 10X more slippery than ice rubbing on ice. The articular cartilage is ~4mm thick, and mine had worn to the bone, resulting in arthritis. Yes, I’m a 40 year old with arthritis, but hopefully not for long.

Knee parts: 
Copied from http://www.orthspec.com/articular_cartilage_injury.htm

Side view of a cartilage “divot:" (Click on any picture for a larger view).


 (Each white area is cartilage, each tan area is bone.)

To repair the “divots” in my knee cartilage, I’ll be going in for another knee surgery (autologous cartilage implantation) in a few months to have new cartilage laid into the gaps – like laying sod or filling a pothole. Just like after laying sod, I’m not allowed any movement for 6-7 weeks post-surgery that could rip up the newly laid cartilage.

Because the replacement cartilage will be frozen for shipment to Virginia, I can choose the schedule for the implantation surgery, so as to schedule when 6-7 weeks of downtime might be convenient. My two thoughts here are to either proceed as soon as possible (likely early June implantation, back on my feet by late July) or to delay until next winter, when I wouldn’t mind being couch-bound and unathletic for 2 months. What would you do?



* For the great 2-week review I have to thank my parents for taking care of me post-surgery and Move Better physical therapy for the post-op rehab.

Tuesday, April 05, 2011

Sharing some photos

Since I enjoy photography and have now enabled some graphics-intense ways to view this blog, I'll be posting some of my most favorite or most fun pictures from time to time.



Today's entry was shot in a parking garage in Luebeck, Germany in 2007. I was zipping around Germany with my buddy Kevin when we decided to visit the Christmas Market in the small but very cool Baltic city of Luebeck in north central Germany. The Aldstadt (Old City) is an island in the middle of a river and pedestrian only, so we parked on the outskirts, where we witnessed the locals' sense of humor.

Saturday, April 02, 2011

Libya: zero to quagmire in under 30 days.

I just finished reading an excellent article on the politics of the Libya intervention (erm, kinetic action), by Victor Davis Hanson ("President Obama’s Ten Libyan Paradoxes"
here.) Hanson - a historian and classicist does a great job of illustrating the pickle that we (the US & NATO) are now in.

There aren't many favorable possible outcomes, and the likelihood of them occurring are very small. Consider the top-level possible outcomes:

1. MQ (Moammar Quadaffi) is deposed. A democratic secular government results.
2. MQ is deposed. An Islamic theocracy results.
3. MQ stays in power across all of Libya.
4. Libya splits - MQ continues to rule western Libya.
5. Total chaos.

The fact that only one outcome is truly favorable isn't what bothers me - these scenarios are not easy to control, nor is it easy to define a win. What bothers me is that Obama's strategy has left us exposed to all possible outcomes while pulling off the rare feat of both dirtying our hands with the military action and tying our hands beyond it.

I just can't see many (any) scenarios where we don't escalate anti-MQ activities in the event that MQ hangs on.

I'm also bothered by the context and precedent of the US intervention. Is Obama saying that we should have intervened during the Prague Spring in 1968 (a popular uprising against a dictator who used a modern military on protesters)? If Obama were the King or PM of the UK in 1861, would he have declared a "no sail zone" around the Union states at the beginning of the Civil War? (i.e. aid rebels by neutering the technological & military advantage of the status quo government.)

As for the context, the Obama rationale is to act in Libya to avoid a Rwanda-level genocide. This is of course plausible, but reacting in response to the worst case scenario rather than the most likely or most desired outcome is very poor governance.

Libya itself is small potatoes in the geopolitical world, so what happens on the ground there isn't something to stress about until US actions reach the level of Iraq (boots on the ground.) However, we SHOULD be worried about how other global powers might play this situation. What if China, in a bid to undermine US credibility, negotiated a peace agreement in Libya whereby the rebels get the east of Libya, while MQ gets Tripoli and the west?

This would of course stop (or postpone) the bloodshed, but would leave an enormous amount of egg on Obama's face as the outcome would deliver the necessary peace but directly in contrast to Obama's assertion that MQ "has to go" in order for peace. What happens the next time Obama (or any future US president) asserts that a regime or nation must change behavior?

Friday, April 01, 2011

Introducing new blog formats

Blogger has enabled new blogging formats perfect for reading via devices with non-traditional form factors (tablets, phones.) CogentPassion can you be viewed using these alternate feeds:

Timeslide
Flipcard (my favorite style, and a great way to get a concise view of many posts. Also perfect if you use Flipboard for the iPad, I expect.)
Mosaic
Sidebar
Snapshot

4 of these 5 styles are very graphic-oriented, which will probably make me want to increase the graphic content of this blog.

Let me know if you have a favorite among these new styles.

Monday, March 28, 2011

MJH Outpatient Surgery & Dr. Grant: two thumbs up!

Last week I had arthroscopic surgery performed on my left knee by Dr. Grant of Albemarle Orthopaedics at the Martha Jefferson Outpatient Surgery Center. I am now 5 days post-surgery and stunned at the ease and quality of the surgery, care, and facilities.

I first went to Dr. Grant in early fall 2010, though the injury was noticeable months before (I stupidly ran three triathlons on it before giving in to the pain.) I found Dr. Grant's practice through blind luck: I had been calling for an appointment at UVA's Sports Medicine practice, but after three days without a callback to schedule an appointment, I did a search online for local orthopaedists and stumbled onto Dr. Grant's web site.

My initial diagnosis last fall was a torn meniscus - a straighforward injury with non-surgical therapy - and was prescribed a cortisone shot and physical therapy at Move Better Physical Therapy in order to strengthen muscles near the meniscus to compensate.

The knee pain continued and a January cortisone shot had almost no effect. This lead to an MRI for my knee, and the finding that I had a chondral displacement, specifically that I had a roughly 10mm x 10mm area of my chondral cartilage completely missing, with significant deterioration of the remaining cartilage. This injury is typical only in the elderly - it's an accumulated injury. At one point, I was asked if I had an injury that precipitated this, as I was very, very young for this diagnosis. I answered no, but that I had played catcher in baseball for approximately 30 years. The response: "That'll do it."

So I had an osteoarthritic condition which would only get worse with time, severely limiting my mobility, fitness, and quality of life. (No more running or biking for me.) Treatment options were 1) treatment with euflexxa (an injectable acid) to artificially lubricate my knee, 2) simple chondral debridement (arthroscopic clean-up of the messy cartilage. No  permanent improvement resulting, but likely less pain and greater mobility), 3) surgical procedures to regrow/replace cartilage (more on this later), or 4) full knee replacement.

I immediately ruled out the full knee replacement, and began researching option#1. Euflexxa was appealing, but had 2 problems: it only treated the symptoms (i.e. the knee problem never went away - it would just hurt less frequently), and each injection provided benefit for only 2-4 months at a time, meaning that I would become a Euflexxa junkie - also bad because Euflexxa is expensive.

So surgery was the answer. The options, were simple clean-up (chondral debridement - a clear preference, though it's long term benefits are debatable), micro-fracture surgery to encourage growth of new cartilage, the "OATS Procedure" (another, more intense way to encourage cartilage growth), or
autologous chondrocyte implantation (ACI).

ACI is an amazing surgery - a portion of the injured cartilage is collected then sent to a lab in Boston to be grown into a larger piece of cartilage for re-implantation. This procedure is still new and quite expensive, but ideal for "young, healthy patients with medium to large sized damage to cartilage."


An indication of my extreme interest in my knee health is that even though ACI and the other knee procedures are expensive, I never blinked an eye at the financial commitment. (ACI alone is $20-35,000k. I'm pretty sure that I'll end up paying 20% of the final bill, but it is definitely worth it.)

The unnerving thing about surgery is that the most effective treatment option can't be determined until the surgeon sees the injury up close - in surgery. Surgery involves general anesthesia, so I could not participate in choosing the treatment while Dr. Grant was operating on my knee. I was more freaked out by this than the notion of undergoing surgery (with all of its' risks) or being knocked out. I guess I like to be in control.

The day of surgery came, and while I was nervous, it was a fantastic experience from start to finish.

To begin with, I was instructed to mark which knee was NOT to be operated on - a low tech, but effective step. I also had to go 12 hours without food or water, which was darn hard.

Martha Jefferson's outpatient facility is just a few years old and modern in every way. Given the lobby receptionist, my intake felt more like was visiting someone's business offices than I was about to undergo a medical procedure.

The day unfolded as I had been told to expect - except where MJH and the team exceeded expectations. For example, I had been told that the recovery from anesthesia would take 2-3 hours. However, I was conscious and eating animal crackers 45 minutes post-surgery. Dr. Don Mathes - my anesthetist - was an absolute maestro - verbally walking me thru the procedure, then delivering me on the other side quickly and with absolutely no nausea or side effects.

Dr. Grant was fantastic (as expected) on the day of surgery, and received high marks from someone who would know - my Mom.

My Mom just retired from a 40+ year career as an OR nurse in an outpatient surgery center very similar to MJH and was able to appraise the MJH facility and team (excellent), and got her peer's appraisal of Dr. Grant prior to my surgery. (From one nurse to another, my Mom was pulled aside and told that Dr. Grant was excellent. (You'd be surprised how often the nurse appraisal is "that Doc isn't very good," or "Dr. ______ is the one you want to see." A nurse's appraisal is worth any 100 other reviews.)

I have nothing but high praise for everyone else who worked on me that day. I wish I had a full list of the team that worked on me, but unfortunately I can only go by memory (hazy, due to the anesthesia). The two additional names that standout are Maggie Lebo (who prepped me for surgery), and Judy, an R.N. who screened me and walked me through the procedures.

I'm now 5 days post-surgery and feeling great. I used crutches and pain killers for the first 4 days post-surgery, but I am fully ambulatory (though tender) and have already had 2 physical therapy sessions.

I am under orders to take it easy for the next month. (I haven't even tried to climb a flight of stairs yet) and won't be allowed to bike or swim for about three weeks. In about 10 days I will see Dr. Grant for the post-surgery analysis. My hope is that the chondral debridement (clean-up) will be enough to get me back to pre-injury health, but it is probably 75% certain that I will undergo an additional surgery in 2-3 months to re-implant the replacement cartilage (ACI.) Unfortunately this is going to mess with my cycling and baseball goals this spring/summer, but I know that I will appreciate my improved knee health in the long term.

I'll also increase my appreciation for the US health care system. Politicians keep creating one-size fits all healthcare solutions, but my improved knee health (and overall experience) is only possible (and available at a reasonable price) through specialization. Instead of an expensive hospital stay, I was in and out in ~2 hours, and was able to benefit from the expertise of an orthopedics specialist.

Political solutions like Obamacare are firmly aligned against specialist practices. For example, there are all kinds of regulations against physician-ownership of outpatient facilities, and intense regulation of outpatient competition through things like "certificate of need" legislation. (In Florida, for example, you can not open a new hospital or surgical facility unless the nearby hospitals sign-off that there is a need for additional surgical capacity. In practice, this squishes competition.)

This most often takes the form of a big hospital lobbying to stop the permitting of a specialized center, such as for heart surgery. Heart surgery is fairly profitable for a large hospital, but a specialized (focused) center will deliver better results at a lower price. The big hospital fears that eventually the focused heart center will take customers away, raising the fixed price of all of the healthcare they deliver (e.g. still paying for the costs of establishing their heart center.)

In much the same spirit, my therapy was only possible due to R&D incented by the American healthcare system and profit motive. Only ~10,000 patients have had my surgery so far, and this would not be possible without clinicians mindful of adopting new, advanced procedures (due to the pressure of market competition, rather than the status quo of nationalized healthcare), and my ACI therapy would not be possible without the R&D and regulatory effort by Genzyme (an American biotech company.)

The regulatory pressures (as from Obamacare) combine to make our healthcare more expensive and less effective as possible. There are additional dimensions to the US system that I experienced that will make for another post (for example, I was ~3 weeks from decision to surgery. In Canada or the UK, I'd be lucky to experience 3 months from decision to surgery), but suffice to say, I had an excellent experience with Dr. Grant, his team, MJH, and the US healthcare system.

Monday, March 14, 2011

Two different tsunami stories of huge magnitude

Something about the Japan tsunami and quake that blew me away: as reported by CNN, the quake moved the main island of Japan 8 feet and moved the Earth's axis 4 inches. This was caused by the 18-meter (~59 foot) movement of two tectonic plates off of Japan. Unbelievable, as is this picture:

(My guess is that the airbase didn't have enough pilots on duty to move the plane in advance of the tsunami.)

and.....

Apparently, researchers believe that Atlantis has been found (in Spain), and that Atlantis was the victim of.....you guessed it, a tsunami

Thursday, February 24, 2011

Things to ponder......

-Col. Qadaffi, Libya's ruler, has been in power for 41 years. Why is he still a Colonel?

You'd think that dictators can promote themselves to any position that they want. Does he not think his performance has been promotion worthy in 41 years?

Monday, February 21, 2011

Launching two new blogs.....

I've launched two new blogs just for fun:

Apple B.S. - business-oriented commentary on Apple. I've been a hard-core Apple fan for a decade, and enjoy playing along with the company's product and strategy development.

Molecular Future - biotech and more specifically genomics commentary from a guy in the business. A successor to my Xcovery biotech business blog of 5 years ago that still generates consistent traffic.

Please check 'em out and forward any hints/tips/ideas to improve my blogs. Oh, and click on an ad too!

Saturday, February 12, 2011

No way I'm missing the next revolution.

Congratulations, Egypt! You've done something amazing and wonderful and we all look forward to your future as a vibrant democracy. (Not so sure about the vibrant part. Per capita GDP is ~ $2,700, and the government employs 39% of the workforce. Can a young democracy make the hard changes in spending required to grow?)

Egypt has also served to reinvigorate our appreciation of liberty.


Liberty lacks in appreciation for many reasons, but happily the overall international trend is very positive. We can add Egypt to the list of "color" revolutions just in this last decade, joining the Ukraine, Yugoslavia (Serbia), Georgia, Lebanon, and Tunisia in regime change. Iraq (purple) and Iran (green) are also cited as color revolutions. I don't think this long term trend has been considered much in the US.

What these countries also have in common - along with the former Eastern Bloc in the late '80's/early '90s - is that they are revolutions that I only saw on TV.

I was in college when the Berlin Wall fell (Oct 1989?). I remember a fellow student @ W&L who, realizing the monumental importance of the event (and the fun of partying with reuniting Germans), quickly booked a plane ticket to Germany, and witnessed history for a few days before returning back to campus.

I didn't have then the means, the appreciation or even the passport to do something similar, but the idea of doing so has stuck with me through all of the revolutions since. When the protests started in Egypt, I realized that I had the resources to just hop on a plane to go experience history, but made too many excuses not to go. ("What, take a week off? I can't.....)

How cool would it be to be in Cairo right now? After seeing the events unfold in Egypt, I'm more motivated than ever to witness the next revolution in person. When the next one breaks, I'm going!*

(If you're a friend who might be interested in joining me when the time comes, let's talk. I also want to hear from any friends who might have already witnessed history in this way. (Tom D?))

Only an expensive plane ticket and skipping out on some ongoing US obligations (like a job or family) are remotely good excuses not to go.

As for the plane ticket, I've got >200,000 frequent flyer miles, and even if I have to spend some cash, what good is it for if not to partake in events like a revolution?

As for obligations, I think we all overstate the importance of our day-to-day obligations. There aren't too many jobs that can't do without you for a week, and we all have too many events or connections that we overvalue. (I think I could safely skip a UVa football or basketball home game.)

So, I'm going to the next one. Hold me to it.

Here's my short list of exciting possibilities for the location of the next 'color revolution':

Belarus
Burma
China
Cuba
Iran
Russia
Syria
Venezuela
and a couple of piddly African (Zimbabwe?) and Middle Eastern countries.

My guess is that I'll be traveling to Minsk, Belarus next. (Which is exciting because it is already on my "wanna go there list.") Unfortunately, I don't see the big ones (China, Russia, or Cuba) revolting soon. But we can hope.

* I reserve the right to skip piddly revolutions (Yemen?) and revolutions in sparsely populated, uninteresting countries (Algeria?)


Just to stir the pot a bit: besides the Egyptians themselves (winners) and other Middle East regimes (losers), who are the other winners and losers:

Winners:

George W. Bush - I'm still not a fan, but maybe he was on to something in the Middle East.

Israel - they are rightfully nervous with the change as Mubarak - in spite of his other faults - represented stability in a region short on it. I still think that over the long term, Israel will be safer with a democracy as a neighbor that a dictator.


The west's security/war on Jihad - what if - sensing domestic opportunity - the jihadists shift their attention from the Great Satan (us) to their local monarchs, dictators, and oppressors? Could (for example) al qaieda shift effort from trying to strike at the west (London bombings, etc.) to trying to dethrone the House of Saud?

Losers:

Obama foreign policy - I thought the Obama administration struck the right tone during the 18 days of protests in Egypt, but Egypt still represents a faulty policy, and underscores the failure of supporting the Iranians in revolt in 2009.

Remember, Obama chose Egypt as the place to deliver his initial entreaties to Islam just after taking office in 2009. His message - as I recall - was basically "We're not as bad as the last 8 years have made you think, and I want to work with you." Noble thoughts, but they can't begin to compare with more directed foreign policies by prior American leaders. (Think Reagan's "Mr. Gorbachev, tear down this wall.") (Sure, Obama's Cairo speech wasn't the setting to crank up the rhetoric, but Obama's accomodative speech and his policy in the Middle East over the last 2 years are similar.)

Obama missed a chance when the Iranian people protested in 2009. The administration took a position of non-interference in order to establish a new relationship with the crazy people running Iran. I definitely believe that a full-blown revolution in Iran faltered in 2009 because of a lack of public support by the USA due to intentional diplomatic insouciance. (Not the first time that this has happened - GW Bush left the Iraqi Kurds hanging when they tried to revolt against Saddam Hussein following the first Gulf War.)

The lesson here is that when we identify 100% bad regimes (such as Iran, or the Soviet Union), public accommodation in any form is to dilute our foreign policy goals and diminish US values. (In essence, we tacitly support and play down to the level of the regime.)


Along those lines: The US' ability to learn lessons and adapt foreign policies. We have a really bad habit of tolerating anti-democratic allies. While the outcome in Egypt in 2011 is far more positive than Iran in 1979 (much more like Ferdinand Marcos & the Philippines in the late '80's), we still made the same mistake: holding our nose and backing a bad guy because of short-term geopolitical considerations.

Sometimes this makes sense when small progress can be seen over time, as in South Korea, where the US backed a military-led government, as the country "matured" into the vibrant democracy it is today. However, Mubarak never liberalized at all over 30 years. (He kept emergency laws in place all 30 years.)

The good news is that there aren't too many other current examples of the US tolerating local dictators in order to support US geopolitical interests. All I can think of are the countries neighboring Afghanistan - the former Soviet "-stans," and Pakistan. (Where the government is less dictatorial than dysfunctional.)

With my new friends on the Great Wall of China

With my new friends on the Great Wall of China
Click to go to my online photography

World sun clock

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Uncommon Man's Creed

"I do not choose to be a common man. It is my right to be uncommon -- if I can. I seek opportunity -- not security. I do not wish to be a kept citizen, humbled and dulled by having the state look after me. I wish to take the calculated risk; to dream and to build, to fail and to succeed. I refuse to barter incentive for a dole, I prefer the challenges of life to the guaranteed existence; the thrill of fulfillment to the stale calm of utopia. I will not trade freedom for beneficence, nor my dignity for a handout. I will never cower before any master, nor bend to any threat. It is my heritage to stand erect, proud, and unafraid, to think and act for myself, to enjoy the benefit of my creations, and to face the world boldly and say, "this I have done." All this is what it means to be an American." -- Anonymous