Pradaxa, A New Drug, Be Careful

Drug ads are now filling commercial time on most television programs. On the evening news the other night,  I watched an ad for a new drug, Pradaxa, which is supposed to "sometimes" take the place of Coumadin for people with chronic atrial fibrillation. Sounds like a real advance, mainly because Coumadin is a "terrible" drug. It requires constant (monthly) monitoring to avoid serious complications, and it interacts with just about everything we consume, including other drugs. Frankly, it's dangerous, and I have personally witnessed complications in patients. So Pradaxa may, I say MAY, be the answer to replace Coumadin. We must just wait and see.  Unfortunately, we need to wait until a multitude of patients use it to really see what it does.

There is an expression in the medical field that applies to Pradaxa, “Be sure to use the new drugs early while they still work.” This might sound strange, but there are real reasons for this insightful statement.

Do you remember Fen-Phen? It was introduced in the mid 90s as a weight loss drug, and many flocked to its promise, because we are almost all overweight. Turns out, that by 2004, the FDA pulled it off the market. Further experience with it revealed that it caused pulmonary hypertension, and heart valve problems. Legal damages have amounted to $13 billion, and Wyeth—the unfortunate pharmaceutical company that marketed it—has allegedly put away another $21 billion for other potential legal problems.

How about Vioxx ,which had 80 million users at one time. This drug was introduced in the 1990s as a Cox 2 inhibitor that helps with chronic pain syndromes. This drug was withdrawn in 2004 because it apparently significantly increased the incidence of myocardial infarction and strokes in patients. As of March, 2006, there had been 10,000 lawsuits, and 190 class action law suits filed against Merck.  Are we beginning to see a pattern?

Another drug that deserves mention is  Avandia a relatively “new” diabetes drug. In September 2010, the NY Times reported that this drug was “banned in two European countries.” One study reported that from 1999-2009, claimed 47,000 people needlessly suffered heart attacks because of this drug. Apparently, the use of this drug has now been highly restricted.

I guess this history of unintended side effects makes me uncomfortable when I see TV adds for new drugs. Pradaxa may eventually work well, but the fact is we just don’t know.

"Using the new drugs early..." makes sense, because once millions begin to use them, side effects may become evident that were not discovered in the clinical trials, and some of those “effects” can be serious.

The human body is complex and delicate, and putting chemicals into it, and into the cell, can have effects that don’t become evident for a time. If we imagine the complexity of the cell, with its multiple interrelated chemical reactions, and the delicate balance of these reactions, we can begin to understand why there might be some untoward side effects when we “tamper” with this chemistry. My guess is that we only measure a few of the effects of medicines, and that there are possibly other effects that we don’t completely understand or know about. Those “side effects”  are the ones that show up over time when enough people begin to use a “new” drug.

As a physician, I have great respect for the pharmaceutical industry. It has brilliant scientists working for it, and it has given us many life saving drugs that have stood the test of time. There have been some pit falls along the way, but name an industry that has not had them.

Pradaxa may turn out to be just what we are looking for to replace the unpredictable and precarious Coumadin drug we are currently using. I hope it is. But it is a “new” drug, and even if I needed it, I might stick to the old stand-by, and wait and see what Pradaxa really does to our bodies.

Instant Play Review in Baseball? No Way!

I went to a AAA baseball game last night and enjoyed a close 1-0 victory for the

Durham Bulls. They are doing well again this year, and all Durhamites have hopes for another "World Series" victory. But as I was enjoying the atmosphere of classic baseball and watching these excellent players apply their skills, I couldn't but think about the tempo of the game and its accurate reflection of what all of us experience every day in our lives. The tempo of life.

You see, baseball has a unique tempo, that no other sport has,  that reflects everyday living. I'm convinced that this is one reason that it is the National Pastime because we sense this familiar rhythm when we attend a game  During a basketball game, we have to keep our eyes glued to the court, otherwise we might miss a critical moment of the action. Basketball is  almost ALL action, but life isn't, and either is baseball.

Baseball is a slow, and sometimes routine, and one might even say boring for some. Pitch the ball, catch the ball, throw the ball back. Pitch the ball, catch the ball, throw the ball back. Pitch the ball, catch the ball, pitch the ball, hit the ball to the second baseman, and throw him out. Pitch the ball, etc. It goes on. Get up, go to work, come home, watch the news, and go to bed. Get up, go to work, come home, watch the news, and go to bed. Get up, need I belabor the point? I don't think so.

In life as in baseball, every once in a while something happens, and all hell breaks loose. Can I mention 911, Pearl Harbor, 1929 crash? I could go on. In baseball it's the line drive over the shortstop's head with a man on second. When this happens everyone on the field must react to the incident, and figure out how to get out of it. Baseball is a slow, relentless unfolding of events marked by "short" bursts of real "action." When I played high school baseball, I started out in left field, but  was so bored, I moved to first base. Just the right amount of action.

You can sit with a friend at a baseball game, and, during the game,  have a nice in-depth conversation  about multiple topics, but you can't to that at a basketball game, or a soccer match, because there is too much "action." In this sense, compared to life, all this action is artificial. If life had this much action, we would end up in the hospital.

This tempo I am talking about is something that we should not tamper with. If we do,  it will take away one of baseball's treasures: a familiar tempo we can all "dance to" as we sit and feel a baseball story develop during an afternoon's game.

One clearly developing threat to this tempo and this national game is the instant replay of questionable calls by the referee. It is going on in most sports now, and has begun to creep into baseball with the review of questionable home runs. That's enough, and let's not go any further with this in baseball. Imagine the first base calls, or the slides into home, or even the individual pitch that isn't certain, should we stop the game and review that "call"? What will "instant replay"  do the rhythm of the game but ruin it.

Life isn't certain, and, the vast majority of the times,  we don't get to review or  change  decisions  we make in life either. Uncertainty is something we live with every day, and trying to eliminate it from baseball will surely cripple one of it's major appeals: that touch of uncertainty that adds the spice of surprise to the play.

This drive to "review" calls is another example of questioning of authority, isn't it?  Unfortunately, with the exposed nature of many of our authority figures today, I guess we should question it. But with baseball, leaving that element of uncertainty there adds that dollop of the unknown that pervades all of our earthly travels: some good, some not so good. It just makes the experience of the game more real.

I guess there are some who want to know the "truth" of each encounter on the ball field. I think the enjoyment of the game is more important, and stopping the game to review a questionable call will remove one of baseball's appeal to all of us: a familiar tempo we can dance to. Finally, is it THAT important anyway? To most of us it really isn't, and if it is I suggest you "get a life."

Rolling Thunder XXIV: A Perfect Memorial Day

Oh, just like all of us, I have thought a little about Memorial Day each year it comes along. I have thought about the wars, and the sacrifice, and the hurt to all the families of America and other countries. But I have never had as deep an appreciation of the sacrifice of many until I went to Washington, D.C. last weekend and rode in  "Rolling Thunder."

This is the 24th year of this happening, when motorcyclists come to Washington from all over this nation to publicize the POW/MIA issue. Many don't know it, but Americans have been left behind after a war either as "missing in action" or "killed in action" and "RT" began in 1987 to show concern for this issue. Today, although that cause remains central to its ideals, it has grown to include the idea of paying respect to all those who have sacrificed their time, devotion, and all too often their lives for our freedom.

The folks who made this trip to Washington came from all corners of our country, and I personally met people from Massachusetts, Oklahoma, Florida, Illinois, and North Carolina. I had never been to Rolling Thunder, but decided, since I had the time, I had to give it a go. It could not have been a better decision. Just being with all those "freedom loving people" filled me with an intense  pride in our country. Let's face it, motorcyclists have chosen "freedom" just by their decision to ride. It is risky, but exhilarating, and it draws those who love freedom. It draws patriots! Why? Because freedom is the American Spirit, and there were at least 450,000 of them who came Sunday and rode to honor our troops, past and present.

Sure, they might smoke too much, and sometimes have tattoos over much of their bodies, and may be dirty looking (riding on the road does kick up a lot of dirt), but that's the essential expression of the spirit that takes its energy into battle against those forces that would ruin our way of liberty for all!

I have never been in the military, but the focus of this weekend and the intensity of the company made me feel ever more deeply the sacrifice of our Armed Forces. I don't think I will ever have another Memorial Day without those feelings. I visited the wall and looked up the remote names of those I personally met and knew (Wilson Halley from Indiana, and Roger Innes from Chicago) who did not make it back from Vietnam. Roger's body was not "discovered" for over 25 years after his death. What sacrifice and sorrow.

I knew Roger in high school and we both served as acolytes at St. Margaret's church on the south side of Chicago. He was a pilot, and was apparently shot down in Nam. Wilson was a promising junior from Indiana who I met at a Harvard recruiting meeting my junior year in high school. I believe he went into the Navy after college, and was killed in 1968. So many years ago, years that you and I have had because of their sacrifice.  

I actually had some people tell me not to ride in Rolling Thunder because you have to arrive at 7am, and wait for 5 hours before the actual parade begins. Then you ride with "strangers" and it can be dangerous if they don't know what they are doing. But I rode anyway. I figured if the troops can sacrifice all they have for me, I can wait for one day in the sun, and ride to show my respect for what they all have given. Damn, what a good decision.

Whether we realize it or not, the troops mean a lot to all of us. Give them your support. When traveling, if you see a military person in an airport, go up, shake his/her hand, and thank them for their service. It's a small thing, but I'm certain their road is not easy, and "thanks" means a lot.  Most important, when Memorial Day comes around again, do something. Go to the parade in your area, go to a Federal Cemetery and place some flags on the graves, or just take some moments to think about them--about those who have given all they could give.

Summing Up A Trip Down the Rhine and Danube

Home now, but what a trip. We spent 16 days on these rivers visiting towns all along the way. The inconsistent availability of the internet, and my general business on the tour prevented me from recording all the towns and cities we visited. I felt it best to summarize the last few places on the trip.

We spent a couple of days in Budapest, and it was, again, an old and impressive city. It was in Budapest (two cities across the Danube from each other, Buda and Pest!!),

that I saw my most poignant image of WWII. It was a touching memorial to Jews executed on the  bank of the Danube river. . They apparently were told to take off their shoes, and were then summarily shot and dumped in the Danube. The memorial is a "statue" of the shoes of these helpless victims. For some reason, this site aroused more emotion in me than all the other memorials on the trip. Notice the
little shoes in the picture. Those are the ones that really hurt!

Budapest has beautiful buildings with many, many statues all over those structures.

I can't show you all of them, but will include a few. I don't have space to mention Slovakia. It was part of Czechoslovakia until about the 1990s when they had a velvet revolution, and separated. Now they are big hockey rivals, and indeed, the world championship is just going on, and the Czech Republic  won the game. I'm certain it was exciting. Isn't that a better way of using up aggressive energy? You betcha.
That night picture is a bridge in Budapest. They light up much of the town at night.

Next, it was a bus ride to Prague for three days. Prague also, is a beautiful. It

has it's famous castle (from around 700ce). It also has a tumultuous history that represents most of eastern Europe. Taken over in WWII by the Germans, then by the Russians in 1946. It has changed hands with the tides of political power. The Communists left in 1989, and they had their first free elections in 1990. They are about 80% non communist and 10% communist government representatives now. Our guide hated the communists. She said that the communist government is for "stupid and lazy people." It seems that they had a large weight lifted off their backs when the commies left.

Some general thoughts about the trip as an experience.
First, traveling on a boat is the best. No packing and unpacking. Just leave it in the room and the cities come to you. I don't think there is a better way to travel.
Next, one cannot travel to those areas of Europe without thinking about the war. Each city you wait to hear what happened there during the war? How much of it was destroyed, and how much was rebuilt? What happened to the people in the town during the war? I guess we are too close the that experience (65 years), and it will take a few generations for those questions to fade away.

Next, I got the feeling of eastern Europeans as being conquered by the "power of the month" and it would get awful tiring for someone new to come into town and change everyone and everything. That's why many of them came to the United States. They were just tired of that history.

Finally, I find it hard to believe how cruel and nasty people can be to each other. We worked ourselves up into a frenzy during those years so that we could drop bombs on each other whilc the citizens were just trying to have a nice quite evening and enjoy life. It's good that this history does not die. We need to remember. By the way, it's against the law to make a Nazi salute in Germany. You can be put in jail.

Vienna, Austria

Vienna is everything you have ever heard about it. It is an old city with a Roman history, but it begins it's prominence in 955 when Otto I began his rule. He established boarders for Austria, and Vienna became the capital in 1156. The Habsburg
dynasty began it's reign in 1273, and it lasted for six hundred years. This dynasty expanded the borders of Austria into the Austro-Hungarian empire to include Austria, Hungary, the Czech Republic, Slovakia, Slovenia, Croatia, Bosnia-Herzegovina, and parts of Poland, Italy, and Romania (all those countries that I never understood or thought about in high school). The assassination of Archduke Franz Ferdinand, heir to the Habsburg throne, began WWI when he was killed in Sarajevo. This empire ended in 1918 at the conclusion of the war. Austria was engulfed by Germany in WWII, but after the war, in 1955, Austria declared its neutrality, and reestablished its territorial sovereignty.

Vienna, the capitol of Austria is the City of Music. It is beautiful. Its history is speckled with the likes of Mozart, Beethoven, Hayden, and Strauss. Both Mozart and Beethoven are buried there. With it's serene atmosphere of art and architecture,  it's understandable that such great music could have been conceived in this magnificent city. Look anywhere, at any building, and one sees statues to historic generals, battles, gods, ideas, and almost anything. Vienna is one of those cities that puts American architecture to shame, but them, they have had many, many more years to develop it, haven't they. Rumor has it the Beethoven moved over 60 times when he lived here. I guess he was a difficult neighbor.

During Mozart's time, in the eighteenth century, it was the coffee houses that functioned as the Internet of the day. People gathered to read the newspapers, talk over the issues of the day, and relax. Coffee houses are still prevalent there, and we visited the Sacher Cafe' famous for its tortes, and coffee.These delicious torts have been served since 1840s, and with some whipped cream, and coffee (with a slug of liquor) it can't be surpassed for comfort and relaxation.

Johann Strauss was the rock star of the nineteenth century. He was engaged 13 times, and married 3 times. He died in 1899. His third marriage was the best. She apparently knew how to care for him, and allowed him to blossom as a composer.

The evening of our visit to Vienna, we went to a concert given by a small orchestra in Vienna. They played Mozart, and Strauss with opera singers, and ballet dancers.

It was pleasant and entertaining. I have been here for only one day, but believe I have tasted a bit of the delicious flavor of Austria and Vienna. It would be good to come back and explore more of this special city.

Passau a Bavarian City on Three Rivers

We visited a peaceful, beautiful city yesterday--Passau. It is situated on three rivers, the Danube, Ilz, and the Inn rivers. It forms a peninsula because of this geography, and becomes an old quaint European city of charm.

The city is at least 2,000 years old, and was founded as much was in ancient Germany, by the Romans. The Celts were here for 4-500 years, and left in 100 B.C. No one knows why--possibly the economy? The Romans left in 480, as Rome was disintegrating, and the outpost was no longer viable.

The current town has a population of about 50,000, and a University with another 10,000 students. The University was founded in the 1960s. The largest industry here is a factory that makes gears for John Deere tractors. It employs about 3000 workers.

The narrow streets house many different high and low end stores, and the shopping is excellent. There is a church here, Saint Stephan's, that was originally built in

850, but it burned twice (1662, 1680) and was rebuilt after that in the baroque style. It is magnificent, and I have included a few photos of it. The interior has elaborate sculpture, and painting that cannot be shown in this limited description. The alter itself depicts the martyrdom of Saint Stephen and graphically, but tastefully shows his stoning. One cannot look at any point in this church without seeing some form of artistic expression of the Christian message. It is awesome! It was mentioned that this town was not heavily bombed in the war, and the Cathedral was only hit by six of seven shells.

Ironically, supporting churches this size takes many Euros, and a tax instituted by (yours truly) Adolf Hitler, helps with this issue. He instituted a "church tax" in

an effort to stop church attendance. It still exists, and is about 8% of your total income tax. It has helped to keep the beautiful churches viable and repaired.

Anne and I found a beautiful local restaurant for lunch, and ate some local bratwurst (lamb and pork), sauerkraut, and a liter (4.5% alcohol) of a local beer. It made the walk back to the ship easier. It was local, as the waitress had a difficult time getting our order. It was worth it!

It should be mentioned that Napoleon stopped by in 1803, and removed all the church rulers and monarchs. He made Passau part of Bavaria. That's why we were drinking so much beer there.   

Nurenberg and The War Crimes Trials

Visited Nuremberg on Saturday. It turned out to be a wonderful visit mainly because it supplied much information about WWII. I have always wondered how the German people could have gone down the Hitler road, and a visit to the Documentation Center supplied many answers to this question. This museum is a place of learning as many Germans go there. Just as important, German soldiers go there to learn their history. It surprised me that the whole episode is laid out clearly in this museum: the politics, the brain washing techniques, the concentration camps, the loses at the end of the war. Importantly, they do go into the failings of the Weimar Republic, as contributing to the rise of Hitler and the Nazi party.

This Documentation Center is built in the amphitheater that Albert Speer designed to help spread the propaganda of the Nazi party. It was huge and designed based on architecture of the Roman Coliseum. Built to sit 50,000 people; it had no electricity. It was to have a glass ceiling to let light in over the podium from which Hitler was to speak.(All the focus was to be on him.) It was never finished because of the War. Near by, in the Zepplin Field Hitler held many of his massive rallies. All of this architecture was designed to make the individual feel insignificant, and to gain strength from the massive crowds. It was essentially and "architecture of intimidation." Intimidation of the individual, forcing him to become part of a massive movement.

Hitler was presenting himself as the savior of Germany. It was an incredible propaganda machine that he wanted to present through the architecture and history of Nurenberg-- his favorite city. On January 1-2, 1945, 90% of the old walled city was destroyed by RAF incendiary bombing.

Hitler was a reaction to the Weimar Republic. He gave the people hope to grow out of their economic depression (there was 30% unemployment then), and to become a great nation again.

Very near this proposed amphitheater was the was a massive parade ground. In some movies, the  massive swastika on the  roof of this field was destroyed by the allies at the termination of the War. Another significant place in Nurenberg is the court house. This is the place where the war crime trials were held at the end of WWII.

Apparently, it was the opinion of the U.S. legal team, that these trials should establish principles for the future of international was crimes. Our tour leader told us that the Russians wanted to hang all of the 31 defendants, but the U.S. felt that that would undercut the credibility of the proceedings. In the end, three of the defendants were let go, and many were hanged or received life in prison. Goebbles, a prominent Nazi leader, committed suicide just prior to his hanging. No one knows how he got the cyanide, and it may or may not be a coincidence, but the guard of his prison cell ended up with his watch! It was humbling to stand in the very court room where this famous trial was held, and it appears that the U.S. team's ideas prevailed and have been perpetuated in such trials held at The Hague.

The rest of the day, we walked around the city. It's special. Beautiful square, and

churches. Had a lunch in a local restaurant of bratwurst, sauerkraut, and beer (bad for the arteries, but tasty). We sat with a couple of German's and one of them suggested a desert shop that we must visit. That topped off  our lunch with a scrumptious desert.