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8:30 AM EST, Tuesday, May 29: My daughter graduated and brought her beau to visit us over the long weekend. Nice. Weather was perfect. Got to play seven hours of tennis, got to rest and read a little. Most significant: a front page piece in the New York Times on strokes, the third biggest killer. Excerpts, with my emphasis:

Lost Chances for Survival, Before and After Stroke
Dr. Diana Fite, a 53-year-old emergency medicine specialist in Houston, knew her blood pressure readings had been dangerously high for five years. But she convinced herself that those measurements, about 200 over 120, did not reflect her actual blood pressure. Anyway, she was too young to take medication. She would worry about her blood pressure when she got older.

Then, at 9:30 the morning of June 7, Dr. Fite was driving, steering with her right hand, holding her cellphone in her left, when, for a split second, the right side of her body felt weak. “I said: ‘This is silly, it’s my imagination. I’ve been working too hard.’ ”

Suddenly, her car began to swerve.

“I realized I had no strength whatsoever in my right hand that was holding the wheel,” Dr. Fite said. “And my right foot was dead. I could not get it off the gas pedal.”

She dropped the cellphone, grabbed the steering wheel with her left hand, and steered the car into a parking lot. Then she used her left foot to pry her right foot off the accelerator. She pulled down the visor to look in the mirror. The right side of her face was paralyzed.

With great difficulty, Dr. Fite twisted her body and grasped her cellphone.

“I called 911, but nothing would come out of my mouth,” she said. Then she found that if she spoke very slowly, she could get out words. So, she recalled, “I said ‘stroke’ in this long, horrible voice.”

Dr. Fite is one of an estimated 700,000 Americans who had a stroke last year, but one of the very few who ended up at a hospital with the equipment and expertise to accurately diagnose and treat it.

Stroke is the third-leading cause of death in this country, behind heart disease and cancer, killing 150,000 Americans a year, leaving many more permanently disabled, and costing the nation $62.7 billion in direct and indirect costs, according to the American Stroke Association.

But from diagnosis to treatment to rehabilitation to preventing it altogether, a stroke is a litany of missed opportunities.

Many patients with stroke symptoms are examined by emergency room doctors who are uncomfortable deciding whether the patient is really having a stroke — a blockage or rupture of a blood vessel in the brain that injures or kills brain cells — or is suffering from another condition. Doctors are therefore reluctant to give the only drug shown to make a real difference, tPA, or tissue plasminogen activator.

Many hospitals say they cannot afford to have neurologists on call to diagnose strokes, and cannot afford to have M.R.I. scanners, the most accurate way to diagnose strokes, for the emergency room.

Although tPA was shown in 1996 to save lives and prevent brain damage, and although the drug could help half of all stroke patients, only 3 percent to 4 percent receive it. Most patients, denying or failing to appreciate their symptoms, wait too long to seek help — tPA must be given within three hours. And even when patients call 911 promptly, most hospitals, often uncertain about stroke diagnoses, do not provide the drug.

“I label this a national tragedy or a national embarrassment,” said Dr. Mark J. Alberts, a neurology professor at the Feinberg School of Medicine at Northwestern University. “I know of no disease that is as common or as serious as stroke and where you basically have one therapy and it’s only used in 3 to 4 percent of patients. That’s like saying you only treat 3 to 4 percent of patients with bacterial pneumonia with antibiotics.”

And the strokes in the statistics are only the beginning. For every stroke that doctors know about, there are 5 to 10 tiny, silent strokes, said Dr. Vladimir Hachinski, the editor of the journal Stroke and a neurologist at the London Health Sciences Centre in Ontario.

“They are only silent because we don’t ask questions,” Dr. Hachinski said. “They do not involve memory, but they involve judgment, planning ahead, shifting your attention from one thing to another. And they also may involve late-life depression.”

They are also warning signs that a much larger stroke may be on the way.

Most strokes would never happen if people took simple measures like controlling their blood pressure. Few do. Many say they forget to take medication; others, like Dr. Fite, decide not to. Some have no idea they need the drugs.

Still, there is much more hope now, said Dr. Ralph L. Sacco, professor and chairman of neurology at the Miller School of Medicine at the University of Miami. Like most stroke neurologists, Dr. Sacco entered the field more than a decade ago, when little could be done for such patients.

Now, Dr. Sacco said, there is a device, an M.R.I. scanner, that greatly improves diagnosis, there is a treatment that works and there are others being tested. “Medical systems have to catch up to the research,” he said. ....

On average, said Dr. Brendan E. Conroy, medical director of the stroke recovery program at the National Rehabilitation Hospital, which is attached to the Washington Hospital Center, a third of the Washington hospital’s stroke patients die, a third go home and a third come to him.

Those whose balance is affected typically spend 20 days learning to deal with a walker or a cane; those who are partly blind or paralyzed must learn to care for themselves. Many functions return, Dr. Conroy said, but rehabilitation also means learning to live with a disability.

But what was perhaps saddest to the neurologists viewing the M.R.I. scans that morning was that tPA, which only recently appeared to be a triumph of medicine, had made not a whit of difference to these patients. They either had not arrived at the hospital in time or had been considered otherwise medically unsuitable to receive it.

Few would have predicted that fate for the drug. In 1995, after 40 years of trying to find something to break up blood clots in the brain, the cause of most strokes, researchers announced that tPA worked. A large federal study showed that, without it, about one patient in five escaped serious injury. With it, one in three escaped.

The drug had a serious side effect — it could cause potentially life-threatening bleeding in the brain in about 6 percent of patients. But the clinical trial demonstrated that the drug’s benefits outweighed its risks.

When the study’s results were announced, Dr. James Grotta of the University of Texas Medical School at Houston expressed the researchers’ elation. “Until today, stroke was an untreatable disease,” Dr. Grotta said.

But the expected sea change did not occur.

One problem was that patients showed up too late. Many had no choice. Strokes often occur in the morning when people are sleeping. They awake with terrifying symptoms, paralyzed on one side or unable to speak.

“That’s the challenge — we have to ask the patient” when the stroke began, said Dr. A. Gregory Sorensen, a co-director of the Athinoula A. Martinos Center for Biomedical Imaging at Massachusetts General Hospital. “If they don’t know or can’t talk, we’re out of luck.”

Another problem is deciding whether a patient is really having a stroke. A person who has trouble forming words could just be confused. Or what about someone whose arm or leg is weak?

“A lot of things can cause weakness,” Dr. Warach said. “A nerve injury can cause weakness; sometimes brain tumors can be suddenly symptomatic. Sometimes people have migraines that can completely mimic a stroke.”

In fact, he said, a quarter of emergency room patients with symptoms suggestive of a stroke are not actually having one.

Most get CT scans, which are useful mostly to rule out hemorrhagic strokes, the less common type that is caused by bleeding in the brain and should not be treated with tPA. Stroke specialists can usually then decide whether the patient is having a stroke caused by a blocked blood vessel and whether it can be treated with tPA.

But most stroke patients are handled by emergency room physicians who often say they are not sure of the diagnosis and therefore hesitate to give tPA.

Dr. Richard Burgess, a member of Dr. Warach’s stroke team, explained the situation: There is no particular penalty for not giving tPA. Doctors are unlikely to be sued if the patient dies or is left with brain damage that could have been avoided. But there is a penalty for giving tPA to someone who is not having a stroke. If that patient bleeds into the brain, the drug not only caused a tragic outcome but the doctor could also be sued. Few emergency room doctors want to take that chance.

There is a way to diagnose strokes more accurately — with a diffusion M.R.I., a type of scan that shows water moving in the brain. During a stroke, the flow of water slows to a crawl as dead and dying cells swell. In one recent study, diffusion M.R.I. scans found five times as many strokes as CT scans, with twice the accuracy.

A diffusion M.R.I. “answers the question 95 percent of the time," Dr. Sorensen said. It seemed the perfect solution, but it was not.

Most hospitals say they cannot provide such scans to stroke patients. They would need both an M.R.I. technician and an expert to interpret the scans around the clock. They would need an M.R.I. machine near the emergency room. Most hospitals have the huge machines elsewhere, steadily booked far in advance for other patients.

It is simply not practical to demand the scans at every hospital or even every stroke center, said Dr. Edward C. Jauch, an emergency medicine doctor at the University of Cincinnati and a member of the Greater Cincinnati/Northern Kentucky Stroke Team.

“If you made M.R.I. the standard of care before giving tPA, most centers would not be able to comply,” Dr. Jauch said. And if it takes more time to get a scan — as it often does — it might be better to forgo it and give tPA immediately if the patient’s symptoms seem unambiguous.

Doctors do not need an M.R.I. to diagnose and treat stroke, said Dr. Lee H. Schwamm, vice chairman of the department of neurology at Massachusetts General Hospital. But, Dr. Schwamm added, if the question is whether it helps, there is one reply: “By all means.”

It has still not been shown, though, that M.R.I. scans actually improve outcomes. It might depend on the circumstances and the hospital, said Dr. Walter J. Koroshetz, deputy director of the National Institute of Neurological Disorders and Stroke.

But some who use M.R.I. scans, and who have studied them in research, say the system has to change. They say enough is known about the scans to advocate having them at every major medical center that will treat stroke patients. ...

In those awful moments when she realized she had had a stroke, Dr. Fite, unlike most patients, knew what to do. She told the ambulance crew to take her to Memorial Hermann Hospital, even though it was about an hour away. She knew that it was one of the Houston stroke centers, that Dr. Grotta worked there, and that its doctors had experience diagnosing strokes and giving tPA.

When she arrived, Dr. Grotta asked if she was sure she wanted the drug. Did she want to risk bleeding in the brain? Dr. Fite did not hesitate. The stroke, she said, “was just so devastating that I would rather die of a hemorrhage in the brain than be left completely paralyzed in my right side.”

“In my horrible voice, I said, ‘Yes, I want the tPA,’ ” Dr. Fite said.

Within 10 to 15 minutes, the drug started to dissolve the clot.

“I had weird spasms as nerves started to work again,” Dr. Fite said. “An arm would draw up real quick, a leg would tighten up. It hurt so bad I was crying because of the pain. But it was movement, and I knew something was going on.”

Now, she looks back with dismay on her cavalier attitude toward high blood pressure. She knew very well how to prevent a stroke but, like many patients and despite her medical training, she found it all too easy to deny her own risk.

Researchers have known for years the conditions that predispose a person to stroke — smoking, diabetes, high cholesterol and an irregular heartbeat known as atrial fibrillation. But the major one is high blood pressure.

“Of all the modifiable risk factors, high blood pressure leads the list,” Dr. Sacco said. “With heart disease, you think more of cholesterol; with stroke you think of high blood pressure.”

The reason, Dr. Sacco said, is that with high blood pressure, the tiny blood vessels in the brain clamp down so much and so hard to protect the brain that they can become rigid. Then they get blocked. The result is a stroke. ...

Even when people do try to control their pressure, doctors may not prescribe enough drugs or high enough doses.

“They’re on a couple of drugs, and the doctor doesn’t want to push it,” said Dr. Jeffrey A. Cutler, a consultant to the National Heart, Lung and Blood Institute and a retired director of its clinical applications and prevention program.

The result is that no more than half the people with high blood pressure have it under control, Dr. Cutler said. He estimated that half of all strokes could be prevented if people kept their blood pressure within the recommended range.

Another lost opportunity to prevent strokes is the undertreatment of atrial fibrillation, in which the two upper chambers of the heart quiver. Blood can pool in the heart and clot, and those clots can be swept into the brain, lodge in a small blood vessel and cause a stroke.

Strokes from atrial fibrillation can largely be prevented with anticlotting drugs like warfarin. Yet many who have the condition do not know it and many who know they have it were never given or do not take an anticlotting drug.

Some strokes can also be prevented by procedures to open obstructed arteries in the neck that supply blood to the brain.

As for Dr. Fite, she completely recovered. And she has changed her ways.

She was sobered by the cost of her treatment and brief hospital stay — $96,000, most of which was paid by her insurance company. But she was even more sobered by how close she came to catastrophe.

Now, Dr. Fite takes three blood pressure pills, a drug to prevent blood clots and a cholesterol-lowering drug. She plans to take those drugs every day for the rest of her life.

“I was so stupid,” she said. “Boy, when you go through this, you never want to go through it again.”

“I have been given that precious second chance,” she said. “I was so blessed.”

Google desktop search. Don't waste your time. The software is meant to index your computer's a hard desk, letting you easily and quickly find files and things inside files. It doesn't work well. It will sometimes find the file your search item is in. But it won't highlight them in your file. You're left to search the file on your own, which is a pain. The only decent desktop search tool is dtSearch.

You can pick up a free 30-evaluation. A single user version will cost you $199. It's worth its weight in gold if you're constantly searching your PC for things -- "the letter I sent to Joe," "the proposal to ABC Corp." "the photo of Aunt Jane,:" etc. The only downside to dtSearch (and all other desktop search engines) is that they spend some time indexing your hard disk and the resulting large file indexing file takes up space. Still, it works. It's lightning fast and it highlights what it's found. It also has a spider which will index your favorite web sites -- like Google does. For a free download, pick dtSearchEval741.exe Someone has spent much time figuring how to reach a human on all those 800 and other toll-free "service" numbers. Here is a useful, though not comprehensive list.

Sadness at the cemetery
Isaac was a very successful marketing director. Sadly, his wife Rifka dies. At the cemetery, Isaac's friends and family are appalled to see that the headstone reads: -"Here lies Rifka, wife of Isaac Levy, MCIM, Post Graduate Diploma in Marketing and Marketing Director of Quality Marketing Services Ltd."

Isaac was standing in front of Rifka's grave reading the headstone when he suddenly burst into tears.

His brother says to him, "I'm not at all surprised that you find this distasteful. It's right that you should cry, pulling a cheap stunt like this on our Rifka's headstone."

Through his tears, Isaac sobs, "You don't understand. They left out the web address."

The helping hand
Maurice came home from the Reform synagogue one Saturday with a black eye.

“Maurice, what ever happened?” asked his wife Becky.

“Well,” said Maurice, “it was like this. During the service, we had to stand several times and on one occasion I noticed that Mrs Levy, who was sitting in front of me, had her dress stuck in the crease of her bottom, so I leaned forward and pulled it out. But Mrs Levy didn’t like this at all - she turned around and hit me full in the face with her prayer book.”

The following week, Maurice comes back from synagogue with the other eye blackened.

“And what happened this time, Maurice?” asked Becky.

“Well,” says Maurice, “it was like this. Once again Mrs Levy had her dress trapped, but this time my friend Issy saw it. He leaned over and carefully pulled out the dress. But I know that Mrs Levy doesn't like this - so I tucked it back in again!”

This column is about my personal search for the perfect investment. I don't give investment advice. For that you have to be registered with regulatory authorities, which I am not. I am a reporter and an investor. I make my daily column -- Monday through Friday -- freely available for three reasons: Writing is good for sorting things out in my brain. Second, the column is research for a book I'm writing called "In Search of the Perfect Investment." Third, I encourage my readers to send me their ideas, concerns and experiences. That way we can all learn together. My email address is . You can't click on my email address. You have to re-type it . This protects me from software scanning the Internet for email addresses to spam. I have no role in choosing the Google ads. Thus I cannot endorse any, though some look mighty interesting. If you click on a link, Google may send me money. Please note I'm not suggesting you do. That money, if there is any, may help pay Claire's law school tuition. Read more about Google AdSense, click here and here.
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