This site is now one year old, and big enough to lose yourself in. I decided to try something new. How about walking tours? This is just that. I have organized a nice stroll through the site for just one topic: Kidney stones themselves. Not how to form them, or remove them, or prevent them, but just about them – their natures, their names, how they are put together, how we know what they are. You can start with me and sightsee, stop for a while, come back, abandon the tour as uninteresting. I mean it as a way of seeing a topic with a guide who knows something about the big rambling posts you find on this site, and … Continued


Doctor David Goldfarb is a recognized authority on medical prevention of kidney stones, and has played a very important international role as an expert and brilliantly informed advocate for high quality care of the millions of patients with this disease. The American College of Medicine, through its organ – The Annals of Internal Medicine – is known for publishing excellent guidelines that primary care physicians can use in their practices to achieve a reliable quality of outcomes. Here we have come upon a true conflict between experts like Dr. Goldfarb and the College of Medicine. He was chosen, by right of his expertise, as a peer reviewer of the defective guidelines the College promulgated last fall, improper and misleading guidelines for … Continued


Our Tasty Villain Salt, sodium chloride, part of our commons, our everyday, and central altogether in prevention of kidney stones. My recent article on the use of 24 hour urine collections was about stone risk: Supersaturation, and the key 24 hour urine components that affect supersaturation – volume, calcium, oxalate, citrate, and pH. Of these five components we think first about water when we treat patients to lower supersaturation: Fluid Prescription; Thirst for Variety; How to Drink Enough Water. But, if we are wise, we should think next about salt, and how to lower it, because in so many people it is a key to treatment success. It is key because sodium chloride strongly controls urine calcium and therefore the risk of kidney stones. Likewise, it is key … Continued

Why 24 Hour Urine: Supersaturation

My friends in the humanities are more popular than I am. At parties they can talk about poems, plays, novels, the modern and the ancient all with authority and considerable charm. Of course every doctor gets a share of medical questions. But when that brief flurry ends, and people ask what I do, a kind of pall falls over the table, or the little group at a cocktail party. What can I say besides that I prevent kidney stones? After a few curious people ask about how I do this, and others mention advice everyone seems to have heard somewhere, my moment passes. Even worse, if pushed for details, I am up against the unmentionable business of sampling body fluids. Which … Continued


A FIRST EXAMPLE OF WHAT I AM AFTER On the main page of Site Logic, I outlined my purposes. Science informs medicine, medicine uses science to alleviate illness. Among other matters I am in search of the paths between them. Said more exactly, I am after the mechanisms through which science arises from medicine and how the results of science inform practice. This one disease will suffice, I think, but only if we are willing to study individual examples from it. That is my purpose here. The picture gives away my general idea. The path is not a labyrinth but a maze. You walk the former pleasurably, there being one path to its center and another back without confusions. You walk the other for it’s wit … Continued

Citrate and the Ostwald Limit

Elder Joseph Brackett, a member of the Shaker community at Sabbathday Lake, wrote ‘Simple Gifts‘ in 1848. Although properly classified as a song (Shaker music was usually classified as anthem, hymn, or song), scholars believe it was a ‘dancing song’, or quick dance. Aaron Copeland offered it to the whole world in his ‘Appalachian Spring’ ballet and collection of ‘Old American Songs set for voice and piano’. He did not know its history, but his music reveals the powerful heartbeat of a dance inside the gentle melody of this beautiful Shaker song. The simple poetry celebrates the idea of a middle place, ‘the place just right’, which is the nature of a valley, a place of ‘love and delight’: A place between. Aristotle’s vision of the mean between extremes is perhaps … Continued

Potassium Citrate: The Contributions of Dr. Charles Pak

Even words themselves come and fade over time. See how, in English language books since 1800, science which once ranked no higher than poetry rose to ascendancy, while poetry itself dwindled below even medicine. The word is about 0.016% of all words in the books, meaning ‘science’ is used on average 16 times in every 10,000 words, poetry only 4 times. Surely there is some lesson here. Surely this graph says more than it shows. For reference, woman, man, love, God, war, all of these presently cluster around 0.02% to 0.05%. If you put in the names of Newton, Einstein, Planck, and Freud, the first of these has stayed constant for the 200 years at about 0.001%, about one half of the usage of the … Continued


If the lives of the Tudor nobility were luxurious, they were dangerous in equal proportions, for the King who bestowed their riches could in a moment wipe them, and those who possessed them, out. So intimacy with the person of the King and with the whole Royal Family was prized and feared. They lived, these powerful and dangerous people, in their Royal Palaces, to which you must go or have no influence. Even worse, King and Consorts made Royal Progresses, staying here and there as guests of the high nobility. Imagine that, the King as your houseguest. A person, like any other, and yet not at all like any other: glamorous, dangerous, and involved with high concerns. You could say this is a silly preface … Continued


The citrate molecule in urine not only binds calcium and therefore reduces supersaturation with respect to the calcium stone forming crystals but hinders the formation and growth of such crystals. Modern techniques permit scientists to visualize these effects of citrate, and other molecules, rather directly, and to quantify them. The reference I give above is outstanding as an exposition of the citrate and osteopontin effects of calcium oxalate, and therefore I have chosen it as my basis for this article. A wider ranging article is also outstanding, for those of us who love this topic. HOW CRYSTALS GROW Plates Being, as I am, a mere reader of the elaborate and rather abstruse field of crystal kinetics, I can say about crystal growth only … Continued


The citrate molecule in urine is thought to protect against formation of calcium stones. This thought began as reasoning from chemistry, and culminated in clinical trials which substantiate the idea. As a result manufacturers produce citrate products for medicinal use, and doctors prescribe the medicine. All this is a wonderful success story, a kind of perfection of the paradigm of translational science: From science to a treatment for patients that reduces illness from kidney stone disease. But what, exactly, is the science? Can scientists not enjoy the story of such a success, physicians derive from it a deeper understanding of the drug they so regularly dispense and patients the comfort that a perfected knowledge support the rightness of their prescribed treatment? Citrate The Molecule As … Continued