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Nrupen Bhavsar, PhD

Assistant Professor in Medicine
Associate of the Duke Initiative for Science & Society

https://medicine.duke.edu/faculty/nrupen-bhavsar-phd

The reports and assessments provide organizations with comprehensive infection from bee sting discount tetracycline 250 mg overnight delivery, science-based information on common antibiotics for sinus infection mayo clinic buy cheap tetracycline 250 mg line, costly medical conditions and new health care technologies homemade antibiotics for sinus infection cheap tetracycline 500 mg with mastercard. Director Director best antibiotic for sinus infection cephalexin buy 250mg tetracycline visa, Center for Outcomes and Evidence Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality David C. Investigators thank Nathalie Lapierre, Gloria Baker, and Dorothey Ann Curran for their assistance with screening articles and helping with data abstraction; David Mackie and Mary Ocampo for helping with the evidence tables and appendices; and Tanya Horsley and Kasey Parker, both of whom helped to coordinate the process. Investigators would also like to thank Anne Marie Todkill, who assisted in the editing of the report. The records were screened for relevance, abstracted, and assessed for quality by two reviewers independently. Results: the evidence needed to ascertain the clinical utility of routine hormonal blood tests was limited in terms of the amount and interpretability. Patients treated with intracavernosal or subcutaneous injections experienced pain and priapism. This review outlined current gaps in knowledge that need to be addressed in future research. What is the Evidence of the Relative Clinical Benefits and Harms of Pharmaceutical Treatments (e. Successful Intercourse Attempts: Patients With Major Depressive Disorder in Remission………………………………………………………………………………………. Successful Intercourse Attempts: Patients With Hypertension on Antihypertensive Drugs…………………………………………………………………………………………... Any Adverse event (All causes): Patients With Hypertension on Antihypertensive Drugs…………………………………………………………………………………………... Headache (Treatment-related): Patients With Hypertension on Antihypertensive Drugs…................................................................... Dyspepsia (Treatment-related): Patients With Hypertension on Antihypertensive Drugs…................................................................... Flushing (Treatment-related): Patients With Hypertension on Antihypertensive Drugs…................................................................... It is defined as the persistent inability to achieve or maintain penile erection sufficient for satisfactory sexual performance. Reviews, editorials, commentaries and letters were excluded for all questions except Q3. Two independent reviewers performed full-text screening; discrepancies were resolved by consensus. Data Extraction and Assessment of Study and Reporting Quality Two reviewers independently abstracted relevant information from included studies using a data abstraction form. One reviewer completed the primary extraction, which was then verified by a second reviewer. We abstracted information on any and most frequently encountered specific adverse events, withdrawals due to adverse events, and serious adverse events. Synthesis of the Evidence the outcomes for each study were summarized qualitatively. The information pertaining to sample size and demographics, setting, funding source, treatment (dose and duration), comparator characteristics, study quality, and confounders was recorded and summarized in the text and summary tables. The decision to statistically pool results of individual studies was based on clinical and methodological judgement. The degree of statistical heterogeneity was 2 evaluated using a chi-square test and the I statistic. A series of subgroup analyses was also performed to explore the consistency of the results. This variation reflected differences in diagnostic criteria for hypogonadism, testosterone measurement methods (e. The prevalence of hypogonadism was higher in men ≥ 50 years versus men < 50 years of age. Results from four head-to-head trials comparing sildenafil, vardenafil, and tadalafil for improvements in erectile function were inconclusive. In all 4 trials, higher proportion of patients preferred tadalafil to sildenafil or vardenafil. The mean time (in hours) between dosing and sexual attempt was longer for tadalafil compared with sildenafil (5. In three trials, the use of intraurethral suppositories containing alprostadil was shown to be more effective than placebo. In only one of four small trials, the intramuscular injection of testosterone improved erectile function compared with placebo. Gel testosterone (50 mg and 100 mg doses) was found to have increased sexual intercourse frequency compared with placebo or patch testosterone. The use of both sildenafil and vardenafil was associated with an increased risk of headache, dyspepsia, or flushing compared with placebo. The differences in the incidence of any adverse events between treatment and placebo groups did not vary significantly among four head-to-head trials with patients treated with sildenafil, tadalafil, or vardenafil. Penile pain or priapism was more frequent in patients treated with alprostadil injections compared with those who received placebo. Patients who received a testosterone patch had a higher rate of skin reactions at the application site compared with those who received the placebo. One trial reported prostate cancer in two patients treated with a testosterone patch. The use of gel testosterone did not show a dose-related increase in adverse events. Prevalence of endocrinopathies, patient characteristics, diagnostic criteria, age distribution, laboratory methods (cut-off values, total, free, bioavailable hormonal levels), and/or study methodology varied widely. These measures are based on patient responses, and therefore are subjective in nature. Patients preferred tadalafil over sildenafil or vardenafil in four head-to-head trials in part due to the longer duration of the action of tadalafil compared with the other two agents. The evidence regarding the incidence of serious adverse events is not conclusive for several reasons, including poor reporting practices and the use of different definitions of serious adverse events. Some reports indicated only the most frequently encountered or treatment-related adverse events, the ascertainment of which may be prone to subjective judgment. In open label trials, patients or investigators may have over or underreported the incidence of adverse events because of their knowledge of the assigned treatment. The comparative evidence for the efficacy and harms associated with subcutaneous injections, sublingual, topical treatments, or intra-urethral suppositories was limited and inconsistent. One common limitation of the trials evaluating these therapies was that clinically relevant efficacy outcomes were not reported. Viewed in perspective, this report represents a striking example of a situation that reviewers of medical effectiveness research encounter often: a field of information in which one corner is intensively cultivated and other areas lie fallow. Erectile dysfunction can be treated at present by two main classes of drugs, phosphodiesterase type-5 inhibitors and/or androgens. In light of the growing popularity of androgen supplementation for a variety of indications in aging men, and in the context of complicated and controversial findings of the far more extensive studies of hormone replacement therapy in women, this gap in our research base is especially noteworthy. The effects observed in the controlled trials mostly denote differences of small magnitude in self-reported subjective judgments of function on a standardized questionnaire (e. Because of the randomization and the large number of subjects, the evidence is convincing that there is some therapeutic effect; the extent to which these real effects are great enough to be clinically meaningful is not as clear, and that is a separate question which this review does not address. The value of information might be enhanced by new sources of financial support for research and/or a change in regulatory requirements that would encourage broader comparisons and a longer time horizon. Conclusions the evidence comparing cause-specific therapies with symptomatic treatments (e. There is no universal consensus or agreed criteria as to how consistent the problem. A period of persistence over 3 months has been suggested as a 1,2 reasonable clinical guideline. Physiology of Erection Penile erection is a complex process involving interactions between neural, psychological, vascular, and hormonal factors. The pathway of normal sexual function in males consists of four stages: sexual desire.

Documenting why the encounter is taking place is important antimicrobial yeast infection generic tetracycline 250 mg free shipping, as the coder will assign a different code for a routine visit vs antibiotics sinus infection npr order 500mg tetracycline visa. If known infection 3 months after wisdom teeth extraction buy cheap tetracycline 500mg online, it is important to document whether or not patients are compliant with their medications antibiotic premedication for dental procedures purchase discount tetracycline on-line. When an issue with underdosing is noted, document if the matter is new or has been recurrent. Documentation indicates that lab results reveal a slight increase his baseline and possibly indicating early renal insuffciency. Guidelines allow the reporting of additional diagnosis to support the abnormal test result. If known, document whether or not the patients have the following: exposure to environmental tobacco smoke, history of tobacco use, occupational exposure to environmental tobacco smoke, tobacco dependence, and or tobacco use. The physician should examine the patient each year and compliantly document the status of all chronic and acute conditions. Patient states no palpitations, no tachycardia, and no blurred vision noticed prior to each episode1. He accomplished this by ingesting carbohydrates, minimal fuids, heavy exercise, and purging2. Dizziness, fatigue, and syncope likely secondary to hypotension, dehydration and hypovolemia. Since the etiologies for syncope and collapse scenarios are multifactorial, clear documentation is required to support your clinical thinking and judgment. Orthostatic hypotension should be supported in the record with specifc vital signs or measurements, and clinical manifestations whenever possible. This note provided clear documentation to support the orthostatic hypotension and the link with the patients initial dehydration and hypovolemia. Ideally, if the note is to stand alone, then more detail needs to be provided to document sinus tachycardia. Patient describes the pain as midsternal tight, squeezing and pressure in the epigastric region. Patient reports that the pain was accompanied by diaphoresis and lasted approximately 5-10 minutes before spontaneously resolving. Patient states she tried sitting up, walking, and taking some liquid antacid but experienced no relief with these measures. Angina, acute coronary syndrome and post-infarction angina are classifed under Ischemic Heart Disease. The subsection for angina disorders is now titled angina pectoris, the subsection for acute coronary syndrome is now classifed as other acute ischemic heart disease, and the subsection for post-infarctional angina is now categorized as certain current complications following myocardial infarction. This last selection would be used in conjunction with a code from the category of acute myocardial infarction or the category of subsequent myocardial infarction, if applicable. Angina without coronary atherosclerosis requires documentation regarding specifc characteristics such as stable, unstable, or the presence of spasm. In this example, angina pectoris, unspecifed is coded as the information in the medical record is insuffcient to assign a more specifc code. It is defned as essential (primary) and the concept of benign or malignant as it relates to hypertension no longer exists. Multiple revascularization procedures done in staged manner due to chronic renal failure. In coding this scenario we assumed that the carotid stenosis is resolved as well as the renal artery stenosis, since this encounter is post revascularization procedure. Classifcations for nicotine dependence include: uncomplicated, in remission, with withdrawal, or present with other nicotine induced disorders. In this note, even though the patients health condition is complicated and he has multiple comorbid conditions, his nicotine dependence is classifed as uncomplicated as it does not meet the other classifcations since as he is not attempting to quit. The I11 category cannot be assumed between hypertension and heart disease unless the documentation supports a cause and effect relationship between the two such as a statement of hypertensive heart disease or heart disease due to hypertension. My right chest still hurts, though it is better, and I am still more short of breath than usual. Physical exam showed swollen R lower extremity which was painful and warm to the touch. If the prescription was correctly prescribed and correctly administered/taken then it would be an adverse effect. Tus, dentists are obligated to be familiar with these regulations and ensure compliance. Regulations require practitioners to provide physical access Outpatient surgery centers and in ofce general anesthesia may to an ofce (e. Parental and physician lack of awareness and knowledge discrimination on the basis of a disability. At a time hospitals, by imposing age restrictions, can create another agreed upon by the patient, parent, and pediatric dentist, the barrier to care for these patients. In cases where this is not possible or desired, the dental hospitals require dentists to be board certifed, thus making home can remain with the pediatric dentist and appropriate it difcult for general dentists to obtain hospital privileges. An accurate, comprehensive, and up-to nication with gestures and augmentive methods of commu date medical history is necessary for correct diagnosis and nication during the provision of dental care. Information regarding the chief does not communicate verbally may communicate in a variety complaint, history of present illness, medical conditions and/ of non-traditional ways. At times, a parent, family member, or or illnesses, medical care providers, hospitalizations/surgeries, caretaker may need to be present to facilitate communication anesthetic experiences, current medications, allergies/ and/or provide information that the patient cannot. If the patient/ Planning dental treatment parent is unable to provide accurate information, consulta The process of developing a dental treatment plan typically tion with the caregiver or with the patients physician may be progresses through several steps. Recent medical attention for illness or injury, newly behavioral, and dental histories must be gathered37 and clini diagnosed medical conditions, and changes in medications cal examination and any additional diagnostic procedures should be documented. Signifcant medical conditions should be identified in a conspicuous yet confidential manner in the Informed consent patients record. All patients must be able to provide signed informed consent Comprehensive head, neck, and oral examinations should for dental treatment or have someone present who legally can be completed on all patients. Informed consent should be well documented be applied periodically to assess changes in an individuals risk in the dental record through a signed and witnessed form. Tese behaviors can interfere with the safe delivery ommendations should be provided to the patient and parent/ of dental treatment. When appropriate, the patients other care providers patients with physical and mental disabilities can be managed (e. When appropriate, the physician general anesthesia is not feasible or effective, an out-patient should be consulted regarding medications, sedation, general surgical care facility might be necessary. Often, hygiene program that takes into account the unique disability information provided by a parent or caregiver prior to the of the patient. If a patients sensory issues cause the taste or texture of conditions fuoridated toothpaste to be intolerable, a fuoridated mouth The oral health care needs of patients with developmental or rinse may be applied with the toothbrush. Toothbrushes can acquired orofacial conditions necessitate special considerations. Electric toothbrushes and foss holders ments or advanced behavior guidance techniques commonly may improve patient compliance. Congenital oral conditions reduce the risk of caries in susceptible pits and fissures of may entail therapeutic intervention of a protracted nature, primary and permanent teeth. For patients who might swallow a rinse, a Patients with oral involvement of conditions such as osteo toothbrush can be used to apply the chlorhexidine. Patients genesis imperfecta, ectodermal dysplasia, and epidermolysis having severe dental disease may need to be seen every two to bullosa often present with unique fnancial barriers. Tose patients with the oral manifestations are intrinsic to the genetic and congen progressive periodontal disease should be referred to a perio ital disorders, medical health benefits often do not provide dontist for evaluation and treatment. This would include anticipatory the orofacial complex and those involving other parts of the guidance about risk of trauma (e. While local hospitals, public health facilities, and diminished oral health outcomes. Dentists have an obli rehabilitation services, or groups that advocate for those with gation to act in an ethical manner in the care of patients. Insurance coverage and fnan on lifetime oral health care for patients with special cial burden for families of children with special health needs. Continuity of health insurance health in America: A report of the Surgeon General. American Academy of Pediatrics, Committee on Child itation Standards for Dental Education Programs.

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Habsah H antibiotic used for bladder infection purchase 250 mg tetracycline mastercard, Zeehaida M antibiotic 3 day discount 500 mg tetracycline fast delivery, Van Rostenberghe H antibiotics for uti first trimester 250mg tetracycline with amex, Noraida R antibiotics vs surgery appendicitis 500mg tetracycline mastercard, Wan Pauzi uncommon cause of monoarthritis. Case report: subacute synovitis of the knee afer a rose contaminated parenteral nutrition. A case of ventilator-associated pneumonia due to Pantoea periostitis associated with Enterobacter agglomerans infection. Pantoea agglomerans as a cause of septic arthritis afer palm tree thorn injury; case report septicemia in three newborn infants. Verdier-Metz I, Gagne G, Bornes S, Monsallier F, Veisseire P, Delbès Pantoea agglomerans sepsis afer rotavirus gastroenteritis. Lozo J, Berić T, Terzić-Vidojević A, Stanković S, Fira D, Stanisavljević World J 2012; 2012:156827, doi: 10. Pantoea peritonitis in a patient solitary beeOsmia cornuta(Hymenoptera: Megachilidae. Transmission of cotton seed and cause of peritonitis in peritoneal dialysis patients:Pantoea agglomerans. Fighting malaria with engineered symbiotic bacteria from vector Pacifc J Trop Med. A note: gut bacteria produce pneumonia outside of the hospital in a previously health patient. Annals of Agricultural and Environmental Medicine 2016, Vol 23, No 2 205 Jacek Dutkiewicz, Barbara Mackiewicz, Marta Kinga Lemieszek, Marcin Golec, Janusz Milanowski. Bacterial of the endotoxin produced by Gram-negative bacteria associated with spot of Chinese taro (Alocasia cucullata) in Brazil induced by Pantoea organic dusts. Moretti C, Cortese C, Passos da Silva D, Venturi V, Torelli E, Firrao causing leaf blight and vascular wilt in maize and sorghum in Mexico. Delétoile A, Decré D, Courant S, Passet V, Audo J, Grimont P, Arlet G, the gall-forming Pantoea agglomerans case. Polyphasic study of plant and and the Hrp regulon in relation to gall formation and epiphytic ftness clinic-associatedPantoea agglomeransstrains reveals indistinguishable of Pantoea agglomerans pv. Deleterious efects: Dust-borne endotoxins and allergens – focus on from Erwinia herbicola. Many of the words and phrases used by medical people are special to their work and may feel like another lan guage to us. We hope this booklet will help you when you read or talk to people about arthritis. Finally, at the end of this booklet, we leave space for new words, phrases and places you can call for more information. The people you live with and work with may have trouble understanding that you have a disease. Many people do not understand that some diseases are quiet for awhile and then can flare up for awhile. Your doctor may have to try a few medicines before finding the one which works for you. Managing a disease is hard work and we need to be sure that we have the support we need. This helps you build the strength and energy your body needs to deal with arthritis. It can be caused by aging, injury, being overweight, overusing a joint or from a poorly formed joint that you were born with. These libraries often have staff that can help you get the facts you need about lupus. Have a regular medical check-up Talk with your doctor When you manage a chronic disease like arthri tis, you will want to be sure to see your doctor on a regular basis—even when you are feeling well. Your doctor and others on your medical team can help you learn about arthritis and how to take care of yourself. Get support to help with the emotional side of illness A chronic disease like arthritis can be stressful and hard on your spirit and on your emotions. You might think that your friends, family and co-workers do not understand how you feel. You may feel unhappy because you cant do as much as you did before you had arthritis. Let them know that you want to be involved even though you may not be able to do everything. Spend your time on those important activities and with those people who mean the most to you. Counseling is help from a professional who will listen to you and help you develop a plan of action. You can help them understand that the disease sometimes flares up and causes problems. You can learn to change your exercise program depend ing on how you feel each day. This is very impor tant if you have osteoporisis, or take a lot of steroid medicine. A nutritionist can help you decide on a meal plan that fits your needs and is good for you. How to Say the Word You will see parenthesis that look like this () after each word. Carla walks on a treadmill indoors as an alternative to running outside in bad weather. Sonia always plans her annual breast exam the day after her birthday so she doesnt forget. The flu vaccine causes your body to make its own antibodies that will fight the flu. Mary finds it hard to pick things up when her arthritis is bad because of the pain and swelling in her hands. Robert controls his psoriatic arthritis by taking medicines and following his treatment plan. Some signs are weight gain around the face, as well as the upper back and very thin skin. Santos told Linda that her face looked a bit larger because her medicine caused cushingoid symptoms. Gene had to buy larger gloves because his arthritis caused some deformity of his hands. The arthritis in Tonys knees has gotten worse over the years because of a degenerative disease called osteoarthritis. Guzman was able to diagnose Marys rheumatoid arthritis after seeing more symptoms over time. Healy gave Joe a diagnosis of rheumatoid arthritis after a check-up, some tests and hearing Joes story. Roberts health care team taught him to manage his psoriatic arthritis with medicine, exercise and good planning. You should not drive when you take a narcotic because you may fall asleep at the wheel. Mary occasionally forgets to take her medicine but she remembers most of the time. The occupational therapist taught Carla how to set up her kitchen and office space to lessen the stress on her hands. Healy told him that he had osteonecrosis because he had taken steroids for many years. Janet had a persistent cough for two months and went to the doctor to find out why. This person makes sure you get the right kind and amount of medicine that your doctor ordered. The physical therapist taught Carla how to change her exercise program when her arthritis was in flare. Marys visits to the psychiatrist helped her to cope with her arthritis and to feel better. The radiologist looked at the x-ray of Carlas hip and told her that she had osteoporosis.

Meeting his obligation to me meant adding one more thing to his to-do list: an embarrassing phone call with his boss antibiotic xifaxan cost buy tetracycline with visa, revealing his error music infection purchase generic tetracycline on line. And along with shift work comes a kind of shiftiness antibiotic resistance explained simply discount tetracycline online american express, a subtle undercutting of responsibility antibiotics for acne nausea buy 250 mg tetracycline free shipping. If he could just push it off for a few more hours, I would become somebody elses problem. She wished me a speedy recovery and apologized for the fact that she was heading out of town for a week. Part of my soft palate and pharynx died from dehydration and peeled out of my mouth. I was in pain, floating through varying levels of consciousness, while a pantheon of specialists was brought together to help: medical intensivists, nephrologists, gastroenterologists, endocrinologists, infectious disease specialists, neurosurgeons, general oncologists, thoracic oncologists, otolaryngologists. During lucid moments, I was acutely aware that with this many voices, cacophony results. I felt the responsibility of my care: during bouts of consciousness, I typed out the sequential details of my current illness and, with Lucys help, tried to corral all the doctors to keep the facts and interpretations straight. Later, while half asleep, I could dimly hear my father and Lucy discussing my condition with each team of doctors. We suspected that the main plan should just be to treat me with fluids until the effects of the chemotherapy wore off. But each group of specialists had to allow for more esoteric possibilities and advocate tests and treatments for them, some of which seemed unnecessary and ill-advised. Samples were taken, scans were ordered, medications were given; I began losing track of events and time. I requested that these plans be explained to me, but sentences would become slippery, voices would dampen and muffle, and darkness would descend in the midst of doctors speeches as I wobbled in and out of coherence. Ive been reading science and literature trying to find the right perspective, but I havent found it. Emma was now the captain of the ship, lending a sense of calm to the chaos of this hospitalization. Eliot sprang to mind: Damyata: the boat responded Gaily, to the hand expert with sail and oar the sea was calm, your heart would have responded Gaily, when invited, beating obedient To controlling hands I leaned back in my hospital bed and closed my eyes. I weighed as much as I had in eighth grade, though my hair had considerably thinned since those days, mostly in the past month. But on the day by-day, Im ready to get back to physical therapy and start recovering. I needed that oracle to scry again, to gather secrets from birds or star charts, from mutant genes or Kaplan-Meier graphs. She pronounced it, but without the authoritative tone of an oracle, without the confidence of a true believer. Like she was not so much speaking to me as pleading, a mere human, with whatever forces and fates truly control these things. There we were, doctor and patient, in a relationship that sometimes carries a magisterial air and other times, like now, was no more, and no less, than two people huddled together, as one faces the abyss. I lay down on a cot in the delivery room, heat packs and blankets keeping my skeletal body from shivering. For the next two hours, I watched Lucy and the nurse go through the ritual of labor. As a contraction built up, the nurse counted off the pushing: And a one two three four five six seven eight nine and a ten! Feeling her weight in one arm, and gripping Lucys hand with the other, the possibilities of life emanated before us. Looking out over the expanse ahead I saw not an empty wasteland but something simpler: a blank page on which I would go on. Day to day, week to week, Cady blossoms: a first grasp, a first smile, a first laugh. Her pediatrician regularly records her growth on charts, tick marks indicating her progress over time. As she sits in my lap smiling, enthralled by my tuneless singing, an incandescence lights the room. Time for me is now double-edged: every day brings me further from the low of my last relapse but closer to the next recurrence—and, ikindlebooks. The most obvious might be an impulse to frantic activity: to live life to its fullest, to travel, to dine, to achieve a host of neglected ambitions. Part of the cruelty of cancer, though, is not only that it limits your time; it also limits your energy, vastly reducing the amount you can squeeze into a day. If time dilates when one moves at high speeds, does it contract when one moves barely at all? In English, we use the word time in different ways: The time is two forty-five versus Im going through a tough time. Medical training is relentlessly future-oriented, all about delayed gratification; youre always thinking about what youll be doing five years down the line. And so its not all that useful to spend time thinking about the future—that is, beyond lunch. Which is correct: I am a neurosurgeon, I was a neurosurgeon, or I had been a neurosurgeon before and will be again ? A few months ago, I celebrated my fifteenth college reunion at Stanford and stood out on the quad, drinking a whiskey as a pink sun dipped below the horizon; when old friends called out parting promises— Well see you at the twenty-fifth! Most ambitions are either achieved or abandoned; either way, they belong to the past. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described hold so little interest: a chasing after wind, indeed. I dont know what this girl will be like when she is fifteen; I dont even know if shell take to the nickname weve given her. There is perhaps only one thing to say to this infant, who is all future, overlapping briefly with me, whose life, barring the improbable, is all but past. That message is simple: When you come to one of the many moments in life where you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying mans days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. Between Cadys birth and Pauls death, if youd seen us sucking on ribs at our local barbecue restaurant and smiling over a shared beer, a dark haired baby with long eyelashes napping in her stroller beside us, youd never have guessed that Paul likely had less than a year to live, nor that we understood that. It was around Cadys first Christmas, when she was five months old, that Pauls cancer began to resist the third-line drugs recommended after Tarceva and then chemotherapy had stopped working. Cady tried her first solid food during that holiday season, snug in candy-cane striped pajamas, gumming mashed yams as family gathered at Pauls childhood home in Kingman, Arizona, the house aglow with candles and chatter. His strength waned over the following months, but we continued to experience joyful moments, even in the midst of our sorrow. And, of course, Paul wrote, reclining in his armchair, wrapped in a warm fleece blanket. As winter turned to spring, the saucer magnolias in our neighborhood bloomed large and pink, but Pauls health was declining rapidly. By late February, he needed supplemental oxygen to keep his breathing comfortable. I was adding his untouched lunch to the trash can atop his untouched breakfast, and a few hours later Id add an untouched dinner to the pile. He used to love my breakfast sandwiches—egg, sausage, and cheese on a roll—but with his waning appetite wed changed to eggs and toast, then just eggs, until even those became intolerable. Even his favorite smoothies, the glasses I filled with a steady stream of calories, were unappetizing. Bedtime crept earlier, Pauls voice slurred intermittently, and his nausea became unremitting. Although Paul accepted his limited life expectancy, neurologic decline was a new devastation, the prospect of losing meaning and agency agonizing. We strategized with Pauls oncologist about his top priority: preserving mental acuity as long as possible. We arranged entry into a clinical trial, consultation with a neuro-oncology specialist, and a visit with his palliative-care team to discuss hospice options, all in service of maximizing the quality of his remaining time. My heart swelled even as I steeled myself, anticipating his suffering, worrying that he had only ikindlebooks.