March 31, 2014

Where Can You Go for Lawful Assisted Suicide?

That question came up at my Parkinson's support group meeting last Friday. I said I thought Switzerland was the only jurisdiction with an assisted suicide law that permitted non-residents to use it. I checked over the weekend, and that's still the case.

Assisted Suicide Laws in U.S. 
Three states -- Oregon, Vermont and Washington -- have legalized physician assisted-suicide laws by legislation. One -- Montana -- has done so by court ruling. Thirty-nine states have laws prohibiting assisted suicide. 

All four of the states permitting physician-assisted suicide make it available only to residents of the state. The three that do so by law require that the patient be diagnosed with a terminal illness that is expected to lead to death within six months. The laws also require that the patient be capable of making healthcare decisions for herself.

For more information on these laws, see the state-by-state comparison charts at

Assisted Suicide Laws in Europe
European countries that permit assisted suicide include Belgium, Luxembourg, the Netherlands and Switzerland, Only Switzerland allows non-residents to travel to the the country for an assisted suicide.

Assisted Suicide, Not Euthanasia
Commentators and journalists often claim that euthanasia is allowed in these jurisdictions but that's not true. Only assisted suicide is permitted. Euthanasia involves the killing of a person who has a terminally illness -- the Dr. Kevorkian scenario. 

Assisted Suicide in Switzerland
Switzerland has permitted assisted suicide since the 1930s, but only in recent years has that country become a magnet for foreigners who want to commit suicide.

March 28, 2014

The First Day Under My Taxi-Not-Car Rule Damn Near Killed Me!

A bit of hyperbole, but nevertheless not a day I want to repeat. This past week, after a lot of thought -- and talks with housemates Nimesh and Bhawana -- I decided to cut out virtually all my driving -- a decision I discussed in a post on Tuesday. Among my new guidelines, I resolved to travel to and from engagements in downtown DC via cab, and not by driving myself to the nearest Metro station to catch the subway.

The next day, Wednesday, I had a chance to apply that guideline. I have lunch downtown once or twice a month with a good friend whom I've known since our college days in the early 1950s. We'll call him Newt (everybody will immediately think Gingrich which will annoy my pal). On Wednesday, we were scheduled to have lunch at 12:30.

Taxi to Lunch and Almost to Emergency Room
Not wanting to break my brand new taxi-not-car resolution, I called a cab. I'll use entries from my blood pressure log to tell the rest of the story. Here goes:

March 27, 2014

Vitamin D and Parkinson's: Importance of Early Intervention

I’ve written before about the association that studies have suggested between Parkinson’s disease and low vitamin D levels.

A new study that investigated the levels of vitamin D in PWPs (people with Parkinson’s) suggests that early intervention with the vitamin might delay or even prevent the onset of cognitive impairment and depression. This new analysis -- published in a recent issue of the Journal of Parkinson’s Disease – is the result of an “add-on” to an ongoing longitudinal study of PWPs.

All 286 PWPs in the study were given a battery of tests measuring global cognitive function, verbal memory, semantic verbal fluency, executive function, and depression. That same day, researchers also measured the subjects’ serum 25-hydroxyvitamin D levels.

The cognition tests revealed that 61 of the 286 patients were considered demented, based on the Diagnostic and Statistical Manual of the American Psychiatric Association (4th edition). The other 225 were not.

For Undemented Subject, Better Cognition with more Vitamin D
For all subjects, scientists found significant associations between vitamin D levels and disease severity (measured by the Hoehn and Yahr Scale and the United Parkinson's Disease Rating Scale motor section). The undemented participants showed slightly higher vitamin D3 levels. (D3 is the active form of vitamin D produced by skin.)

Data for the entire group also showed association between vitamin D3 levels and greater fluency for naming vegetables and animals and immediate and delayed recall on a verbal learning test. More interestingly, for the undemented subjects only, there was significant correlation between D3 levels on the one hand and fluency and verbal learning on the other.

March 26, 2014

Pause for Reflection, #2: To Drive or Not To Drive?

It's time to revisit this perennial issue. I last posted my thoughts in September 2011, after totaling my car the previous month. At that time, I created a list of things I could do to make the roads safer for me and others. I've been pretty good about sticking to those recommendations, but it's time for review.

This “Pause for Reflection” series was prompted by my turning 85 in two months, the setbacks I experienced on my recent "Trip from Hell,” and my skin cancer surgery. All those factors play into my new thoughts about driving.

I got back from the Valparaiso-to-Buenos Aires cruise on a Saturday, rested on Sunday, and drove on Monday to my regularly scheduled bridge game at the local senior center. Back in 2011, I decided it was OK for me to make that short 15-minutes drive. The senior center is also where my weekly Parkinson’s support group meets. In addition, I'd often drive to that same neighborhood -- and park -- to catch the Metro.

Driving to the recent bridge game, I felt post-trip fatigue. I felt much worse on the trip home. I later realized I’d forgotten to take my noon Parkinson’s med. So, I decided to take the less-traveled side streets, which I thought were safer than the faster, more direct four-lane route.

As I drove down a quiet residential street, I saw a little girl, maybe six years old, come out of her house and walk toward the sidewalk and road. I slowed way down and was relieved to see her stop before reaching the road.

But later, I kept thinking; "What if she had suddenly run into the road? Would my reaction time have been good enough to stop the car quickly?" I wasn't sure.

March 25, 2014

Overeating and Inactivity Bring Negative Physiological AND Genetic Changes

Health is so often a simple matter of diet and exercise: a “mantra” on this blog. Now, there’s another reason to believe.

This particular study – conducted by scientists at the University of Bath, England – concerned “energy surplus,” the technical term for consuming more calories than we burn. We already know what happens when an energy surplus continues unchecked: among other poor health outcomes like obesity, it contributes to insulin resistance, the first step toward diabetes.

In particular, the team at Bath wanted to determine if exercise had effects beyond simply reducing the energy surplus by burning calories. How would they establish a methodology to find out?

The researchers corralled 26 health young men. None of them were obese, and they all exercised regularly. During baseline health assessments – which included biopsies of their fat tissue – they all showed normal metabolisms and blood sugar control. None showed any symptoms of early diabetes.

Eat a Lot More, Move a Lot Less
These healthy men were randomly assigned to one of two groups. The first ran briskly on a treadmill for 45 minutes every day; the second didn’t exercise. To more accurately assess the effects of the treadmill exercise, the men in both groups were told to otherwise reduce their movements every day, limiting their steps -- tracked by pedometers -- to about 4,000 paces.

In addition, both groups were instructed to substantially overeat, increasing everyone’s energy surplus. 

March 24, 2014

Pause for Reflection, #1: The Computer and Me -- I Need Less PC, More Kindle

I made many mistakes planning my recent cruise from Valparaiso to Buenos Aires. But packing my Kindle -- which I'd just pre-loaded with John Adams, the biography by David McCulloch -- was probably my best planning decision.

Books and Me
I thought I'd spend lots of time at sea listening to several mysteries I had loaded onto my Nano. The cruise seemed a perfect opportunity to give audiobooks a try. But I picked up the Kindle first, and -- after just a few pages -- I was totally hooked on the Adams biography. 

OK, I confess: I'm only about 1/4 of the way through the book. But at least I'm reading it. I've had the paperback version on my bookshelf for years, but its size -- 750 pages of small type -- always intimidated me. There was no such effect with the Kindle.

My book reading has typically consisted of 15-30 minutes before my afternoon nap and again before bedtime. Frequently, I'd read magazines during those times, not books. 

The Adams biography reminds me how much I've enjoyed reading books, especially biographies and memoirs. I wish I had more time for reading.

But the big problem is . . .

March 21, 2014

My Energy Bank Balance Looks Worse, But I Look Better

Adding Tuesday's four-stage surgery for the skin cancer to the earlier energy drain from my "trip from hell" left my energy bank near bankruptcy. I staggered from couch to chair to bed yesterday. Today, I'm beginning to feel the energy dribble back in.

But my mood got a big boost this morning when I removed the outer bandage and saw that the inner bandage -- which I'll be wearing for at least two months -- is much less gross than I'd expected. It almost matches the color of my hair. But look closely and you'll see the beginning of what my doctor predicted: I may be sporting two black eyes as I walk down the aisle at my granddaughter's wedding a week from Saturday.

An Apology to Others
I feel uncomfortable making this big a deal about a procedure that was a walk in the park compared to the health challenges several of my friends -- and legions of others -- are facing.  But this blog is intended to tell my story as I deal with my health issues. I'll surely have occasion to talk (I hope) about more serious challenges later.

March 20, 2014

I'm Not Slow and Forgetful. I Just Know Too Much.

Results of an interesting study from Tübingen University in Germany make me feel better about my own forgetfulness.

The conclusions from that study suggest my brain isn’t necessarily in some process of increasing cognitive impairment; I just know a lot more than I used to, and it takes longer for my gray matter to process all the information it now stores.

I’m liking those findings, but I can't help thinking about amyloid plaques, neurofibrillary tangles, etc.

Computer Databases that Resemble Older Brains
Researchers trained computers to “read” a certain amount of new material every day. When a computer was exposed to a limited amount of information, it “performed” like a young adult on cognitive tests: pretty fast. When an identical computer was exposed to much more information – simulating the experience of a much older adult – its performance on the same cognitive test resembled, not surprisingly, an older adult’s: often more slowly.

The German scientists suggest that the brains of older adults – like the computers that approximated their greatly increased experience – work more slowly not because their ability to process data had declined, but because they have to sort through and manage so much more material.

As head researcher Dr. Michael Ramscar summed up: "The human brain works slower in old age, but only because we have stored more information over time."

Please Pass that Thingamajig

March 19, 2014

Will This Image Finally Persuade Me to Wear a Cap and Use Sunscreen?

This lovely photo was taken last night, after I spent most of the day undergoing surgery after surgery after surgery at a skin cancer center. I'll be sporting the huge bandage for at least two months, probably longer. 

Last weekend, I bought a new suit so that I'd look reasonably spiffy for my granddaughter's wedding a week from Saturday. I'm looking forward to participating in the ceremony; she asked me to escort her foster mother down the aisle. With my recent Parkinson's setback, I was thinking I might use my cane to be on the safe side. Now, with this latest development, I'm thinking maybe I should wear a Civil War soldier's uniform rather than a suit.

Here’s What Happened
Years ago, my internist recommended that I see a dermatologist regularly since I’m fair skinned and was spending lots of time outside on my bike. So, I started getting an annual skin checkup. About five years ago, he biopsied a spot on my cheek, found basal cell carcinoma, and removed the cancer. It was a quick, simple procedure, and the slight scar soon faded away.

A few months ago, when another biopsy showed a spot of skin cancer on my forehead near the hairline, I expected another quick and easy procedure. This time my dermatologist recommended that I see a doctor who performs Mohs surgery.

In this procedure, skin (including the carcinoma) is removed in very thin layers. Each layer is then viewed under a microscope for signs of cancer. The process continues until a layer shows no cancer. This approach allows the surgeon to remove the cancer while saving as much of the surrounding healthy skin as possible.

Ever the optimist, I arrived at the surgeon’s office at 10am, thinking I’d have one quick surgery and be home in time for lunch. Ha! I left his office at 4pm after four surgeries. Each time, they biopsy the surrounding skin for signs of cancer, and each biopsy takes about an hour.

March 18, 2014

More Bad News for Multivitamins

I’ve written periodically about the increasing evidence that multivitamins waste money, don’t really make a difference, and might even cause harm.

Now, results of three more studies – published in a recent edition of the journal Annals of Internal Medicine -- reinforce those conclusions.

No Benefit to Cognitive Health
First, Dr. Francine Grodstein from the Harvard School of Public Health, with colleagues, examined data from the Physicians Health Study II. Nearly 6,000 male doctors – all 65 or older – took either a Centrum Silver multivitamin or a placebo every day for twelve years. At intervals, researchers tested their subjects’ memory and cognitive function.

At the end of this study, researchers concluded: “In male physicians 65 years or older, long-term use of a daily multivitamin did not provide cognitive benefits.”

On the positive side, the data showed that risk of cancer dropped by 8 percent, and cataracts by 9 percent, for the men who took the multivitamin.

The report’s authors also noted that this particular study involved men only, and men who were generally in good health and well-nourished to begin with. It might be useful, the report suggested, to conduct the same exercise on a population not as well fed: 
This is of particular interest in an aging population because older persons are often at risk for nutritional deficiencies due to reduced micronutrient intake, altered absorption, and the metabolic requirements of vitamins.

March 17, 2014

What a beautiful St. Patrick's Day!

When I woke up this morning and looked out from my bedroom meditation chair, this is what I saw --

A good morning to get rid of some of the remaining firewood, assuming this is the last of the winter's many snowstorms.

Life is good!

A Week of Discoveries about My Heath, Including an Elixir

During my first week back after my "Trip from Hell," I focused more than usual on my heath, and made a few discoveries.

A Potion for My Ailments: Water
The malaise I’d felt on the trip continued when I returned. At week's end, I read something that made me wonder if my problem might be dehydration. Did it have something to do with coffee? For years, I've always had a cup (maybe two) at breakfast, and then more in the late afternoon after my nap. A large glass of water always accompanied the coffee.

Several months ago, I discovered a bottled iced tea I liked, which replaced the water at coffee time. I also started drinking the tea through the day. So, the diuretic coffee was now accompanied by the diuretic tea, and my water consumption went way down.

Googling “dehydration symptoms,” I found that the list included weakness and tiredness -- familiar to me on the trip and since -- and changes in blood pressure, both high and low. I've experienced significant bp spikes lately, too.

I’m now on Day Two of a new routine – a half-cup of coffee in the morning and late afternoon, no iced tea, and lots of water. It’s early in the game, but I’m already feeling better and the blood pressure readings are flattening out within the acceptable range. We’ll see.

It’s Official: I’m Overweight
Through the years, whenever I checked my Body Mass Index (BMI), I was always just below the "overweight" category (anything between 25.0 and 29.9). "Obesity" begins at 30.0. I liked seeing a "normal" BMI.

March 14, 2014

My Internist Agrees: The Cruise Left My Energy Bank Seriously Overdrawn

I’ve had Parkinson’s for at least five years. Until now, the progress of the disease has seemed slow and gradual. As a result, I was surprised by the setbacks I experienced on my recent trip to South America.

My Internist Weighs In
I returned home last Saturday, made an appointment with my internist on Monday, and saw her Wednesday. I had two issues:

1). The falls:  I had two major falls.  The first one  left me with pain in my sternum, but it only hurt when I coughed or took a deep breath. My internist said it was either a bruise or a fracture, and -- either way -- I just needed time for healing.

2). The fatigue, weakness, and increasing unsteadiness: These symptoms were trickier. But she agreed with me: it was foolish for an almost 85-year-old to undertake such an adventure on his own.

Last December, I started using two electronic gadgets to help reduce blood pressure and stress. Since they seemed to help, I stopped taking my bp meds . . . with my internist's reluctant agreement. On the cruise, I experienced some scary bp spikes. At our session Wednesday, my blood pressure reading in her office was something like 175/95 (150/90 is the new upper limit guideline for someone my age). I told her the readings I'd been getting at home since my return were usually below 150/90.

We debated whether I should return to the bp meds and agreed that I'll stay pill free for the next two weeks while continuing to carefully monitor my blood pressure and record the results in the log I keep. We'll revisit the issue when I see her again on March 25 and I'll bring my log with me.

My Energy Bank
I went to bed Wednesday evening feeling especially punk. When I awoke at 3am for my usual bathroom visit and “joy of quiet” time, I meditated longer than usual; 90 minutes sped by and ended with my having lots of thoughts about where I am and what I can do about it.

March 13, 2014

Is a Doctor Shortage Coming to Your Neighborhood?

Will you have trouble finding a new doctor in the years ahead? Will it become harder to make appointments with your current doctor? Will you spend less time talking with your doctor than before? Will your care be compromised? Two recent pieces in the New York Times suggest maybe... and probably not.

Sounding the Alarm
The Association of American Medical Colleges predicts that in ten years we’ll need 130,000 more doctors than medical schools are now producing. That shortfall sounds pretty scary.

Baby Boomers are graying. Today, 12.9 percent of all Americans are 65 and older. In 2030, that percentage will rise to 19. Seniors have more health issues than young people, and require more attention from doctors. 

Now that the website issues have apparently been mostly resolved, Obamacare is pouring new patients into doctors’ offices. By the end of this decade, about 30 million MORE Americans will have health insurance. Since we now have about 2.4 physicians for every 10,000 Americans, we’ll need about 90,000 additional doctors by 2020 just to maintain that ratio.

There’s no question: when you’ve got medical coverage, you’re much more likely to see a doctor.

Then There’s Medicaid
In California alone, there are now about 7 million Medicaid patients. Over the next two years – thanks in part to the Affordable Care Act – officials estimate an additional 2 million people will join the Medicaid rolls. That’s NINE million Medicaid recipients in one state alone.

March 12, 2014

Where to Stay in Buenos Aires: Sheraton or Poetry?

Most of my fellow passengers on the Holland America Line (HAL) cruise from Valparaiso, Chile to Buenos Aires, Argentina were older couples. If they stay in hotels before or after their time at sea, they typically choose accommodations at the familiar big international chains, where they feel safer and more comfortable.

In fact, they may end up being less secure, as my recent experience showed. 

I've always preferred locally owned, boutique hotels to the same-old, same-old cookie-cutter places. My stay in Buenos Aires last week certainly showed the benefits of that option.

Like me, many passengers from the ship wanted to linger in Buenos Aires. HAL's crew offered ship-to-hotel transfers for people who chose to stay at the Sheraton Buenos Aires Hotel & Convention Center. As luck would have it, I had asked friends of mine -- former residents of the Argentine capital -- for a hotel recommendation. Their answer came right away: the Poetry Building. My friends had owned a unit in the lovely, renovated old apartment building, which now offered brief rentals, like hotels. I'm so glad I solicited their advice.

Here's the Sheraton in the downtown business district:

Here's the Poetry Building in Recoleta, an affluent residential neighborhood and a cultural center of Buenos Aires:

March 11, 2014

A Simple, Quiet End for Dying People: Too Much to Ask?

Consider the case of Robert Minton, 58.

When he was a teenager, rheumatic fever damaged his heart. Fifteen years ago, in complicated open-heart surgery, doctors replaced his failing aortic valve with pig tissue. His recovery from that procedure was brutal.

Now, the replacement valve is failing, and his heart pumps blood less and less efficiently. He could choose to undergo another complex, risky procedure, but he knows in his gut he would not survive it this time.

He wants to die -- on his own terms, in his own time, while he is still capable of making a clear, rational decision.

Minton lives in Denver, Colorado. If only he lived in one of the five states where “assisted suicide” -- or as advocates prefer to call it these days, “aid in dying” – is legal.

March 10, 2014

“So How Was Your Trip to South America?” Almost a Disaster!

During the three weeks I've been away, I posted a few general "touristy" updates on this blog. I refrained from reporting what was actually going on, not wanting to alarm my nearest and dearest. I got home around noon on Saturday. Now, Sunday evening, I can tell the real story.

So, what was going on?

I arrived at my initial stop -- Santiago, Chile -- absolutely wiped out. The usual jetlag was exacerbated by an 11-hour layover in Miami. During my 36 hours in Santiago before boarding the ship in Valparaiso, I ventured out of the hotel a few times, but I needed to stop and rest on benches during each brief walk.

On the ship, I developed a new problem that persisted through the trip. I’m addicted to the internet and this blog, so I’d brought along my Lenova ultrabook, which I knew from my trip to Europe last summer had problems. Those issues got worse on the ship. A computer geek onboard identified the problem: my Lenova has both a touchpad and a keyboard. The touchpad is highly sensitive to keyboard strokes, so the cursor kept jumping around. Unlike most machines, the Lenova doesn't have a way to deactivate the touchpad.

High Internet Charges AND Blood Pressure
That was bad enough. Holland America also charged 75 cents a minute for internet access. They did offer a discounted price if you bought 100 minutes or more, which I did. As I struggled with the computer and paid the hefty internet charges, my blood pressure readings began to rise above 150/90 -- considered the upper limit for someone my age. I'm sure that stress caused the bp spike, but the internet issues didn't help.

March 8, 2014

Around Cape Horn, #6: Punta Arenas to Buenos Aires

It’s Friday morning in Buenos Aires. I leave tonight on an overnight flight to Miami and fly Saturday morning to DC’s National Airport. I should be home by early afternoon.

I had planned to write a few more posts about the Valparaiso-Buenos Aires cruise, but I changed my mind. Instead, I'll do one quick photo recap. Then, assuming I get home safely, I'll tell the real story of this trip. Stay tuned.

Rounding Cape Horn
Probably every cruise that rounds the cape offers a similar memento:

March 7, 2014

FDA Approves Drug Northera to Treat Blood Pressure Crashes Upon Standing

On February 18, 2014, we learned that the Food and Drug Administration had approved the drug droxidopa (brand name Northera) to treat neurogenic orthostatic hypotension (NOH) – a sudden drop in blood pressure when standing up. That problem plagues many people with Parkinson’s, and is dangerous because it can cause light-headedness, dizziness, falls, and injury.

The drug’s manufacturer – Chelsea Therapeutics in North Carolina -- reported that the drug should become available in the second half of this year.

Although droxidopa has been used to treat NOH in Japan since 1989, its path toward approval in the U.S. has been trickier. As recently as March, 2012, the FDA denied approval of the drug, questioning its efficacy after a week of use. People taking a placebo had results that appeared to be statistically no different from study subjects taking Northera.

The FDA: “More Data, Please”
Nonetheless -- particularly since no other effective treatment exists for NOH -- the FDA left the door open, challenging Chelsea Therapeutics to produce additional efficacy data from an ongoing clinical trial. And this time, the agency gave Northera the green light.

March 6, 2014

Good News for Caregivers, Finally

Several months ago, I was asked to participate as a blogger on Aging Care, a site dedicated to helping caregivers for the elderly. No, I’m not really a caregiver – and don’t yet receive the kind attention of a caregiver – but, nearing my 85th birthday, I'm sure to need caregiving support as my Parkinson's disease progresses. I've been very impressed with care being given to members of my PD support group by both spouses and professional caregivers.
In the March 2014 edition of the University of California’s Berkeley Wellness Letter, I was intrigued  by a report titled “Good News for Caregivers.” It was based on a National Institutes of Health (NIH) study – published recently in the American Journal of Epidemiology -- that tracked 3,500 family caregivers (average age: 63) over six years. Researchers drew two particularly interesting conclusions:
  1. The caregivers experienced 18% lower mortality than their matched, non-caregiving equivalents in the control group,
  2. The greatest survival benefit affected those caregivers who were helping an elderly parent (a subgroup that represented about a third of all caregivers involved in the study).
More often, we hear about the giant burden caregivers bear, how their stresses carry severe negative consequences for their physical and mental health, how the accumulating pressures and strains can even shorten caregivers’ lives.

March 5, 2014

Prescription Drugs: It Pays to Shop Around

I’ve written periodically about prescription drug costs. It’s a subject of interest for almost everyone I know.

The February 2014 edition of the Harvard Health Letter featured an article – “Save Money on Your Prescription Medications” – with several helpful suggestions, and a few we’ve heard before. I thought they were worth sharing.

Comparison Shop
Especially if you have no insurance – or Rx insurance with a high deductible – it makes sense to shop around. Prices for the same drug can vary sharply from one pharmacy to another, since some drugstores get their supplies directly from manufacturers, while others use “middle-man” wholesalers.

Call a few local pharmacies before dropping off your prescriptions. Some of them may say “Sorry, we can’t check prices without first entering a prescription into the computer.” Others may give you helpful answers. Calling might very well pay off.

Use Big Box Stores
That’s another suggestion we’ve seen before, since some of them regularly offer among the lowest prices. Retailers like Walmart, Kmart, Target – and grocery chains like Kroger and Publix -- offer many generics for as little as $4 and $10 for 30- and 90-day supplies. The pharmacists there can supply a list of these drugs. Since they may not offer the information on their own, it pays to ask.

March 4, 2014

Around Cape Horn, #5: South Along Chile's Patagonian Coast

If you are in a hurry, you are wasting time.
--Patagonian saying

One of the things I liked about this trip was the scheduling of days at sea vs. days touring. After I bungled my flight schedules -- which resulted in my being completely wiped out during a brief stay in Santiago -- it was great to start the cruise with a relaxing day at sea. The next few days exploring the pristine beauty of Patagonia -- the sparsely populated part of southern Chile -- were also peaceful.

Here are the stops we made heading south down the coast toward Cape Horn.

Puerto Montt
Our first tour began with a cruise feature I like least. Usually the ship must anchor offshore and take passengers to the dock in small tenders. I'm impatient in queues -- and I was always eager to get on the little boats -- so that Patagonian saying above was meant for me.

We were told to report to the main lounge at 9:45am, and we didn't board our bus at the pier until after 11 o'clock.

The next stop was Puerto Varas, the “City of Roses.” It’s a nice town on a lake by the snow-capped Osorno Volcano:

We stopped here to shop and snack. These "shop-overs" have driven me nuts on other tours, particularly in Asia. I was pleased that Holland America kept them brief.