Wednesday, June 17, 2015

There are some amazing octogenarians out there

Some  know-it-all-officious-busybodies   medical progressive elite presume to know when various medical procedures should be limited on the basis of age. Some even presume to know how long someone will live as in recommendations regarding limiting of medical procedures for those deemed to have less than ten years life expectancy or using 75 as a cut off date for certain type of screening tests.My pathology professor in medical school was fond of saying when you tell someone how long he has to live they may piss on your grave.Spock's "live long and prosper" butts up against Dr.Zeke's proposed forgoing of preventive measures for those 75 and older, well at least for him, or so he claims now.

Two recent journal articles shed some physiological light on  some  folks in their 80s,folks about whom some of the progressive elite would desire to limit medical care.

Trine Karlsen et al described a remarkable 80 year old Norwegian.The authors believe that the subject of their study may have a world record for maximal oxygen uptake (VO2max). for his age,50 ml/kilo/min.Accordingly to the authors this value is compatible of a normal, active, non endurance trained 35 year old Norwegian man.(How to be 80 year old and have a V02max of a 35 year old, Case Reports in Medicine, Vol 2015, article id 909561). The "how " seems to be to have great genes and to be very physically active.

 To put V02 max  in some perspective; It is a measure of the highest rate at which oxygen can be utilized by the body during intense exercise.It is a function of how much blood the heart can deliver to the muscle ( cardiac output) and how  much oxygen the muscles can take up measured by the a-v oxygen difference.

It is generally believed to peak somewhere between age 25 and 35 and decreases afterwards. Various estimates of the rate of decline have been made. A stylized version is that the decrement is of the order of 5-10 % per decade until about age 70 and then V02 max declines more rapidly.For those who continue to do endurance exercise training the decrease is in the 5% per decade range.Some data indicate that endurance athletes' VO2 max actually decreases more per decade in absolute terms ( ml/minute/kilogram) but since they begin the decline with a higher absolute value their percentage decline is about half of that of the non trained healthy person. In that regard as in most things there are some conflicting data and considerable individual variation. Karlsen's subject has his 02 max measured at at 45 so that the calculated decrease in his 02 max  from age 45 to age 80 was a remarkable 2.3 ml/min/kilo per decade while previous reports suggested the average decrease is 5.4 ml/min/kilo per decade. At age 25 he was measured at 75 ml,min/kilo.

World class endurance athletes typically have values in the 70s and 80's. The value of 90 is often quoted as the highest record, this in a 24 year old cross country skier while other publications quote the recording of 95 . The value of 17.5 ml/kilo/min ( 5 mets)  has has been labelled the aerobic frailty level, the value below which a person is by one  imprecise definition, frail, and would find the activities of every day life consuming such a high percentage of their O2 max that fatigue would greatly limit function.A value of 7 ml oxygen /kilo is said to be the lowest level compatible with life.Endurance exercise training program typically increase 02 max by 10-15% ( with the occasional outlier of more than 30%) but those folks in the 70 plus range can thank their parents ( at least one of them) for their exercise capacity.The sled dogs who race have 02 max values in the range of 240!

Scott Trappe and co authors in an earlier article in the Journal of Applied Physiology ( see here) published detailed physiological data including results of muscle biopsies and muscle enzyme studies on 15 active healthy octogenarians (one actually was 91).Nine were long time endurance athletes and 6 were age matched healthy untrained men without serious medical conditions and who were fit enough to do the exercise testing. Not only had the athletic group been competitive cross country skiers in their youth, they had continued with vigorous programs and all had trained  on average 8 hours a week for the last fifty years. ( Fifty years is not a typo).The endurance athletes had 02 max values between 34 and 42 while the healthy non endurance folks had on average a 21.

And then there is Ed Whitlock.See here for details of his setting the marathon time record for a 82 year old human . He finished at 3:41:58 which is nine minutes 49 second per mile.Whitlock is also noted for being the only man to run a sub three hour marathon at age 70 or older.Estimating his V02 max using table 2.3 from Tim Noakes's Lore of Running ( which is derived from data of Davies and Thompson) gives a value of about 48 ml/kilo/min, which is close to Karlsen's subject's measured value..


Tuesday, June 16, 2015

do you need a physician to order your blood tests?

There are a number of folks who want to eliminate at least one aspect of  gate-keeper role of the physician  or at least allow people  to order blood tests without getting a physician's order.

To name a few: Dr Eric Topol,Elizabeth Homes,and apparently the governor of Arizona.

Elizabeth Holmes is founder and CEO of a company named Theranos,which has developed a technology to enable a very large number of blood tests to be done from a few drops of blood,less than the tube drawn on a standard veni- puncture.

In April 2015 , the governor of Arizona signed a statute "allowing" clinical labs to perform blood tests without a physician's health care provider's order.

Laboratory Corporation of American has recently announced that they will perform lab tests on folks without requiring a doctor's order. See here for article.

According to the Bloomberg article linked above some twenty states already allow blood tests to be done without a physician's order.However according to this chart more states than that allow what is call "direct access testing". (This table is from a website called Longevity Testing.Com and I cannot attest to its accuracy as there are no links to supporting data.)

LabCorp and Quest and other large commercial labs have seen decrease in fees from CMS cuts and also from fewer referrals from independent physician's office as more doctors move to large groups or are being bought out by hospitals,who have their own labs. So they obviously welcome more direct assess customers.

In some instances a person's copay for a visit to a doctor to get a hall pass for a blood test may be more than the fee for service going the direct access route plus you do not have to wait in the doc;s office to see him and then wait for his office to send you your results.Of course,this assumes that the quality and resource conservation guidelines that he is "encouraged"   to follow will "allow" you to have the test.As you know the American College of Physicians and the American Board of Internal Medicine have declared that physicians are the "stewards" of the allegedly collectively owned national medical resources

Direct access testing fits in nicely with Dr. Topol's latest book The Patient will see you now in which he argues that smart phone based technology will go a long way to the democratization of medicine and the continuing stamping out of the lingering paternalism that was a regular feature of medicine for centuries.

Tuesday, June 09, 2015

Bad news for pediatricians-good news for ABMS and the hegemony of the progressive medical elite

See this blog posting regarding the unfortunate situation regarding board certification for pediatricians and how, at least so far, the  monopoly of ABMS is preserved.

If possible the MOC situation regarding peds is even worse that that regarding internists and their board, the ABIM.

One major insurer has refused to recognize certification from anything other than a ABMS recognized board.

Quoting Dr. Med Edison in her blog:

 " After months of speculation about insurer acceptance of anything other than ABMS certification, Blue Cross Blue Shield of Michigan is on record refusing certification through the National Board of Physicians and Surgeons. To my knowledge, they are the first to do so.
This is actually a big deal for pediatricians in Michigan. For our internist friends, the ABIM has slowed down implementation of MOC. But the American Board of Pediatrics refuses to listen to pediatricians, and instead instructs insurers to “check” our certificates yearly."

From the narrative related by Dr. Edison the folks at ABIM seem like avuncular colleagues compared to the even more hard nosed folks at the pediatrics board.

It may be too early to say  but it looks like we might see another situation in which the dogs bark and the caravan moves on. If other insurance companies refuse to accept NBPAS certification the viability  of that organization is in doubt.

Tuesday, May 26, 2015

Who elected the ACP as the"conscience" of medicine?

In a embarrassing display of  self congratulatory praise , in this  commentary Bob Doherty ,senior vice president of the American College of Physicians office of government affairs and public policy, makes the assertion that internists and particularly  the ACP are the "conscience of medicine".

How does he support that claim? First, he cites the advocacy that ACP has provided for universal health care and for other causes..He also quotes from a commentary from Lancet which declared that internists and ACP were the conscience of medicine.Further, he makes the claim that the ACP has always put the patient first even if some aspect of their advocacy might not be in the best interests of internists,while other professional organizations lobby in Washington  for their parochial interests. In his view apparently ACP (or at least its leadership) knows what it is best for the public good and selflessly strives to achieve those goals.

Conscience can be defined as the complex of ethical and moral principles that controls or inhibits the actions or thoughts of an individual or an inner sense impelling one toward right action.

Does Mr. Doherty believe that the ACP has acted in some way or ways that distinguish it from other medical professional groups  in regard to this alleged role as medicine's conscience?

What about pediatricians and their professional organization,the American Academy of Pediatricians, (AAP). If advocacy in regard to certain positions for various social issues is one criterion for being medicine's conscience,one could argue that the AAP has "out-advocated" ACP or at least earned a tie.Maybe ACP and AAP could be the co-conscience of medicine.

For example AAP has taken stands on measures to decrease firearms deaths,supported the Affordable Care Act,increased funding for the Children's health Insurance Program (CHIP) to name a few of their efforts.Since its founding  AAP has  advocated for the "health of all children", so ACP has no monopoly in putting "the patient first" and to claim that it is only internists that put patients first is without foundation and seems more like self serving rhetoric .

The American Psychiatric Association says its mission is in part to promote the highest quality care for individuals. That sounds like they put patients first too. The APA is more modest , however, in that their claim is that APA is the "voice and conscience of modern psychiatry".So maybe ACP should soften its claim and say they are the "conscience of medicine except for psychiatric issues".

In light of the most recent Newsweek revelation regarding executive pay and booking keeping practices and other alleged improprieties  at ABIM in regard to its maintenance of certification program (MOC), perhaps ACP could flex its conscience muscles and actually make a comment about ABIM's behavior.

It might also be in order to make a statement regarding ACP's educational products sold to internists that are promoted  as helpful for ABIM recertification.There are  numbers of internists out there who, rightly or wrongly,suspect there has been a very cozy and cahoots relationship between ABIM and ACP and their foundations with a revolving door type situation regarding the leadership ranks of those not for profit organizations . Surely, the voice of the conscience of  medicine should have something to say about that.

 Does advocacy for certain solutions to perceived social ills or problems constitute evidence for someone or something acting out of conscience?  It might but would it not be more correct to characterize ACP's advocacy for certain solutions as simply expressing views consistent with mainstream progressive thought which is in  some if not most  instances  contrary to mainstream conservative or libertarian thinking.While it may be possible that a majority of internists (I am not aware of a head count) consider themselves progressive, there are doubtlessly many libertarian and conservative internists who find ACP's views on a number of topics not an expression of their conscience.

Tuesday, May 19, 2015

Can a regular exercise program improve cardiac function in asymptomatic diastolic dysfunction with and without heart failure?

 Well ,at least one recent research paper answered that question in the affirmative.

 Dr. Nole and colleagues  (see below for reference) did a detailed study on the effects of endurance and resistance exercise on a small group of patients, some of who only had diastolic dysfunction (DD) and others who in addition had heart failure (HF) with preserved ejection fraction.

 For purposes of the study normal diastolic function was defined as having: the following echocardiographic findings 1) E/A greater than one,2)E/e prime less than  10 and 3) preserved E/A greater than one during the valsalva maneuver.The E/A ratio is the ratio of early diastolic filling of the ventricle to the late filling (aka atrial kick).The E/e prime ratio is the ratio of velocity of early diastolic filling to the movement of the mitral value annulus as determined by tissue Doppler  and is thought to be a reasonable estimate of the pulmonary capillary pressure.

 See here for the full text article.

Basically the exercise program which was mainly endurance training with some resistance exercise added later in the program lead to improvement in symptoms in those who were symptomatic and in indices of diastolic function as determined by cardiac echos.

Other studies have also demonstrated that exercise training can improve diastolic function.I have commented before about the effects of long time endurance exercise and the possible mitigation of age related diastolic dysfunction.

.WNolte K., Schwarz S., Gelbrich G., Mensching S., Siegmund F., Wachter R., Hasenfuss G., D√ľngen H.-D., Herrmann-Lingen C., Halle M., Pieske B., and Edelmann F. (2014) Effects of long-term endurance and resistance training on diastolic function, exercise capacity, and quality of life in asymptomatic diastolic dysfunction vs. heart failure with preserved ejection fraction, ESC Heart Failure, 1, pages 5974, doi: 10.1002/ehf2.12007


Wednesday, May 13, 2015

Summertime running in the south, quicker glygogen depletion and possible value of ice slurries

You don't have to be an exercise physiologists to know you cannot run as fast or as long in the summer.

One of the reasons that long training runs don't work out as well is the mater of glycogen depletion occurring sooner in hot weather. .This seems to be a fairly well demonstrated physiological fact.See here. Of course volume depletion is a more dominant limiting factor.

 First a brief taste of stylized "glycogenology". The classical 70 kilogram person of physiology textbook lore carries around about 100 grams of glycogen in the liver and about 500 grams in muscles.Liver glycogen can be broken down and released into the blood as glucose while muscle glycogen can only be directly used locally to fuel muscle action,getting ATP to the myosin heads.After a 24 hour fast some 50-60% of liver glycogen is depleted to supply glucose for resting metabolic activities. Indirectly, muscle glycogen can function as a blood sugar source by producing lactate which can be transported to the liver and converted back to glucose (Cori Cycle).Glycogen depletion is a major factor in endurance exercise adventures and this can be mitigated a bit by glycogen loading,ingesting carbohydrates during the event,repleting liver glycogen before the event and by lots of training which hopefully shifts the fuel mix somewhat to fat utilization delaying the time of glycogen depletion.When that occurs you slow down appreciably as muscles fuled mainly by free fatty acids cannot contract as rapidly. 

 So, maybe if you can keep cooler you can delay glycogen depletion.

One thing  you can do to keep cooler seems to be to drink ice slurries.

I quote from an article in the Scandinavian Journal of Medicine and Science in Sports By authors Tan and Lee from the National University of Singapore.See here for abstract.

"The ingestion of ice slurry during exercise is a practical and an effective strategy that greatest the greatest heat sink because of the additional energy required to effect a phase change from solid ice to liquid water.A smaller volume of ice slurrry ( as compared with that of cold drinks is required to achieve similar reductions in body core temperature and improvements in endurance performance."

An earlier paper by J Dugas compared running times in the heat ingesting slurries with cold water and found his subjects could run further before exhaustion with the slurry. See here.

A similar study from Australia   by Siegel and co authors also showed a increase in running duration ( about 20%) in the heat when cold water ingestion was compared with ingestion of ice slurry.See here.

The ice slurry function as a Heat Sink, a concept well known to folks who fiddle around inside computers.The small ice particles have a high surface area to volume ratio which facilitates heat transfer.

If you like snow cones you might give it a try on a hot summer days. I find the  slurries refreshing and fun to eat whether my endurance is enhanced on not. 

Thursday, May 07, 2015

The U.S. medical care boondoggle depends on hookwinking the physicians

The terms hoodwink and boondoggle are so appropriate. My comments here were inspired in large measure by Dr Michel Accad's Jan 2009 insightful  blog entry from which I quote:

'... beyond ignoring the obvious tension between the individual and the group,hoodwinking physicians into practicing "population medicine" is of course the essential  means to confuse practitioners into thoughtlessly carrying out sweeping intervention whose primary benefit is the profit of third parties."

 to this I add and the profit-not necessarily in monetary terms-of the academics whose writings give a scholarly veneer to this monumental hoodwinking enterprise.

See here for Dr. Accad's entire essay,

In this regard several terms and concepts are important:  population medicine, physicians as stewards of finite resources,cost  effectiveness research and  high value care. The key idea is to establish the notion that medical resources is a collectively owned resource and all are entitled to it by virtue of their existence. From this follows that the  utility of the aggregate matters and not that of the individual and that  some one has to manage this collectively owned resource and the elite medical progressives are the self nominated candidates for that job.

The medical  progressive's claim  to being egalitarian advocates of social justice is contradicted by their advocacy for a utilitarian approach to the allocation of these finite resources. Utilitarianism is not a subset of egalitarianism.A leading egalitarian, John Rawls accurately characterizes utilitarianism as being inattentive to the separateness of individuals and treating people merely as means for the achievement of some aggregate or social end. The medical progressives claim to promote social justice in the abstract but operationally sponsor utilitarian calculus in which some individuals may suffer from some alleged statistical benefit to the collective. The progressives play the social justice card frequently in their polemics profiting from this polymorphic notion's lack of generally agreed upon specificity - the term social justice is loose , vague and indeterminate.

The medical progressives causally dismiss the notion of rationing by their unilateral re-definition  which excludes the limiting of "low value" care from their universe  of rationing. Rationing according to this formulation means only limiting high value care and they presume they will be the arbiters of what value is high and what value is low. 

Another linguistic trap is to speak of a given medical expenditure as a "cost to the system" rather than an exchange.  So when someone goes to the ER with chest pain or severe headache that is considered to be a cost to the system or even more ridiculously a drain of resources rather than providing a service for a fee and the transfer of funds as part of various exchanges that are part of the ER medical encounters.

 When someone goes to a car repair shop to replace a radiator or visits a barber for a haircut why do we not speak of draining the car care industry's resources or depleting the finite hair care resources?It is because to a large degree we are paying for the medical care with someone else's money It is the third party payers and their academic facilitators that have accomplished a monumental hoodwinking of the public and most of the medical profession by distorting the language of medical care and shifted the emphasis from a long standing  oath based imperative to care for the patient to one of limiting care the effect of which is to benefit the third party payers

 The language of medicine has been transformed into the language of medical collectivism and the third party payers owe a large debt to the efforts of the collectivists in medical academia and in some of those individuals in influential leadership positions of certain professional medical associations.

In support of the claim that many physicians have been hoodwinked is the amazing amount of support  from professionals medical organizations for the passage of the so-called "doc-fix" or MACRA which mainly replaced one centrally planned system of price controls with another such system , one that placed even more control of medical care in the hands of federal planners and administrators and some "thought leaders" who have arisen from the leadership of various national medical organizations with important input from the lobbyists from the "Bigs" (big pharma,big hospital, big insurance,etc)

In closing I quote Dr. Accad again with this masterful summary:

" But beyond ignoring the obvious tension between the individual and the group, hoodwinking physicians into practicing “population medicine” is of course the essential means to confuse practitioners into thoughtlessly carrying out sweeping interventions whose primary benefit is the profit of third parties.  Only clever sophistry can claim to reconcile the needs of patients with the profit margin of insurance companies, the bottom line of hospital administrators, the end-of-the-month income of practitioners, the annual reports of employers, the promises of legislators, the zeal of government regulators, the self-importance of academics, the confused intentions of voters, and the pocketbooks of taxpayers.  The term “society” simply conceals the myriad of interest groups that partake in the boondoggle we call the health care system."