Friday, November 14, 2014

Eight high school football deaths from head or neck injury in 2014 equaling the number in 2013.

The Annual Survey of Football Injuries 1931-2013 (first author Kristen Kucera)l was published in March 2014.See here for the full report.

The report distinguishes between direct death (basically brain or neck injury) and indirect death which includes a cardiac cause or heat stroke among others.

In 2013, there was 8 directs deaths ,all in high school, and nine indirect deaths seven of which were related to high school football. Of the direct deaths 6 were from brain injury and 2 were from neck injuries.There are approximately 1.1 million participants in high school football. So there were 16 death related to football in 2013 in that population.News report indicate that there have been 8 apparent direct deaths from high school football in 2014 .

Of the 8 direct deaths in 2013, 3 occurred in running backs, 2 in defensive backs and one  in wide receiver and one in line backer and the position of the eight player was not known.

In 1976, a major football  rule change was put into place and review of the deaths tabulated by year indicates it was an important contributor to overall fewer deaths from head and neck injury but has certainty not eliminated them There were further rule changes in 2005 and 2007 designed to eliminate the use of the helmet as a weapon.. In 1976 it became illegal to make initial contact with head and face while blocking or tackling (so called "spearing").The decrease in cervical spine injuries is greater than that seen in fatal head trauma following that rule change and the increased emphasis of not hitting with the helmet.Still from 2003 through 2013, 23 high school players died from head or neck injuries and 103 died from indirect causes ( largely heat stroke and cardiac causes).

 What is thought to be the mechanism(s) involved in  the football related. fatal brain injuries . The likely candidates  are 1)acute subdural hematoma and 2)and those  of the second hit syndrome. See here for Dr. Robert Cantu's description of ten cases of the second hit  syndrome.The second hit syndrome is thought to be at least in part a disorder of cerebral blood flow auto regulation occurring acutely after a second blow to the head in a player who is still symptomatic from an earlier (perhaps unrecognized) concussion and may result in fatal herniation and brain stem compression which can occur within a few minutes of the second  head blow.

Better helmets,greater awareness of concussion and the efforts to restrict play for a concussed athlete and rule changes since 1976 are thought to have decreased fatal had  and neck injuries. Things did look like they have gotten better. From 1968 through 1971, 44 high school players died from head and neck injuries and 12 died in sandlot type football  and 12 died playing college ball and 2 died in pro and semi pro leagues.In that 4 year  time frame 70 people died from playing football .

 The reports states that data from the decade 1985 - 1994 showed reduction in those injuries.However, the data from 1995-2004 show an increase in brain fatalities over that in 1985-1994 ,namely 11 more deaths during 1995-2004 representing a 33% increase.In the latest nine year period  analyzed (2005-2013) 25 brain deaths have been recorded in high school players.

Football continues to be a sport in which there are high impact collisions which place the head and neck at a non trivial risk. It may be that the mitigating factors mentioned above (rule changes etc) have done what they can do but a very troublesome residual exists and young athletes continue to die while cheerleaders and family members gather on Friday nights to celebrate the rituals of high school football. Judo has been made mandatory part of  high school education in Japan and a number of athletes die every year as a result of head trauma associated with that sport. Understandably parents in Japan have raised  justified protests.Just imagine what protests would be raised if high school football were a mandatory part of high school education.It has become common ( mandatory?) for an ambulance to be on hand at high school football games.I wonder if their presence is reassuring to parents or a troublesome reminder that medical tragedies continue to occur in spite of the considerable effort that has been made to avoid them.





Monday, November 10, 2014

The Great Health Information Technology Flim-Flam explained in plain english

Margalit Gur-Arie has hit another out of the park on her blog "Health Care Technology". Everyone should read her recent entry entitled "Technology for Onesies-Twosies". See Here.

Her comments are aimed at the almost one half of U.S. physicians who are still in private practice, most of which are in medium or smaller groups.The topic the government program to "help"private docs obtain and use electronic health records (EHRs) and its "Meaningful Use" Program which is a carrot and stick approach to get  recalcitrant physicians on the program.

Quote:

"Case in point: Meaningful Use is a voluntary program. The maximum incentive per Medicare physician is equivalent to seeing one more patient per week. The maximum penalty for a typical Medicare physician can be recuperated by seeing one more patient per week. The cost of using a Meaningful Use EHR, in both cash and physician time, far exceeds one weekly visit. Can someone please enlighten me on why there is no market (and trust me, there isn’t) for non-government sanctioned technology that is purposely built to serve doctors? Remember, you own more than half the market."

Bottom line- signing on to the government subsidy EHR program is not just a bad idea it is much worse than that. Note, the computer programs that are government sanctioned are for the most part not meant to help the physician practice medicine nor to help the patient receive better care.Read her entire article and find out who really benefits.Spoiler- it ain't the patients and physicians.


Friday, October 24, 2014

Does much of the blame for sarcopenia rest on the satellite cells of the fast twitch muscle fibers?

Well, at least some of the blame anyway.

Dr. LB Verdijk and coworkers at the Masstricht University in The Netherlands have published several articles contributing insights into at least some of what goes on with the age related loss of muscle size and strength.See here and here.

Their work deals with satellite cells (SC), so called because in their resting form they hang out on the periphery of skeletal muscle cells, wedged between the basement membrane and the sarcolemma.They are the muscle's stem cells. They are poised to multiply and to differentiate into myofibers when signaled by damage such as occurs with strenuous exercise.

Their 2007 publication  gives a good summary in the article's title, "Satellite cell content is specifically reduced in type II skeletal muscle fibers in the elderly" The authors did muscle biopsies in the lateral thigh in 80 elderly subjects (age 76 +/- 1 yr) and 80 twenty year olds. The proportion and mean cross-sectional area of type II fibers was reduced in the elderly  as were  the number of satellite cells per fiber .A similar pattern was not noted in the slow twitch (type I) fibers.The type II fibers were smaller and fewer in number and contained fewer satellite cells per fiber .

Now for the sorta  good news.

A more recent article from the same  research group in the Netherlands reported that a 12 week program of resistance exercise training significantly increased both muscle fibers size and satellite cell count in type II fibers in elderly subjects. This was part of a more comprehensive study which examined muscle fiber type and satellite cell content in 165 subjects in various age ranges. 49 of which were 70-86 years of age.Also a subset of elderly subjects took part in a 12 week resistance exercise program .Muscle biopsies after the training program demonstrated increased type II fiber size and satellite cell content.

It seems plausible that the satellite cell awakening induced by resistance exercise was instrumental in muscle cell growth.There are , of course, many other factors in the muscle loss of aging including loss of sex hormones,increase in inflammatory cytokines,inactivity,poor nutrition and loss of anterior horn cells,among others. Resistance exercise in the setting of adequate protein intake  is not the fountain of muscle youth but so far it seems the best we've got.

A final word.writing as someone who has run more ( much more ) than can be justified  based on reasonable  concerns of improving health .Running will not prevent sarcopenia. While running on level ground the quadriceps does little more than stabilizes the patella. I suppose running up and down hills may activate some type II fibers but basic jogging will not prevent the age related loss of muscle size and strength.That requires resistance exercise and adequate protein intake.



Tuesday, September 30, 2014

Can long standing endurance exercise training mitigate the loss of age related compliance of left ventricle?

With more evidence available to generate legitimate concern about an increased risk of atrial fibrillation with  many years of endurance exercise and papers about long time endurance athletes and the  much less likely risk of developing arrhymogenic right ventricular dysplasia (ARVD), some good news for the crazy, old long distance runners was very welcome.

Here is a link to summary of the paper by Dr. Paul Bhella et al. entitled "Impact of Lifelong Exercise "dose" on Left Ventricular Compliance and Distensibility"

Here is the authors'conclusion :

" Low doses of casual, lifelong exercise do not prevent the decreased compliance and distensibility observed with healthy, sedentary aging. In contrast, 4 to 5 exercise sessions/week throughout adulthood prevent most of these age-related changes. As LV stiffening has been implicated in the pathophysiology of many cardiovascular conditions affecting the elderly, this "dose" of exercise training may have important implications for prevention of cardiovascular disease."

Is there an age related decrease in left ventricular compliance.  According to a 1984 article by Rodeheffet et al the aging heart may be able to maintain cardiac output in the face of an age associated decrease in maximal heart rate by increasing stroke volume. See here for link. The older person relies more on an increase in end diastolic volume and riding the beneficial part of the Starling curve, but if the left ventricle become less compliant, which it is claimed it does as a function of age that adaptation would only work for a while.

Is the decrease in LV compliance due to just getting old or might it be due to lack of vigorous physical exercise. Dr. Armin-Zaeh and coworkers at the Dallas Based Institute for exercise and environment medicine  believe  it is the latter. See here.  My personal bias is obviously to agree with them. Here are the conclusions from the above linked article.


"In conclusion, a sedentary lifestyle is associated with a decline of ventricular compliance, leading to higher cardiac filling pressures and lower stroke volumes for a given filling volume compared with age-matched athletes or young individuals. Prolonged, sustained endurance training preserves ventricular compliance with aging and may be an important approach to reduce the probability of heart failure with aging."


A partial,apparent  counterpoint to the  above studies can be found here in this 2003 article by  P E Gates and co-authors whose analysis and summary minimized the importance of one of their own findings  ( namely that a standard measure of diastolic function (the A/e ratio) was higher in endurance trained subjects) and instead emphasized the value of the decreased arterial stiffness noted in long term exercisers.Either way it seems good news to long term endurance exercisers.

addendum: 10/1/14 Correction made on title, "Stiffness" changed to "Compliance"


Friday, September 26, 2014

Another chapter in "were you wrong then doctor, or are you wrong now?" this time regarding stenting of non culprit lesions.

The American College of Cardiology recently retracted one of its magic five "Choosing Wisely" recommendations.In 2012 ACC had advised that in the setting of an acute coronary event one should only revascularize the "culprit artery".This is the artery thought to be responsible for the event and if other obstructions are detected the ACC said that there was evidence that the fix everything approach might be harmful.This advice was based on non randomized trials. Here is ACC's official statement.

Now apparently two randomized trials  suggest one should fix the other obstructions. Here is quote from ACC:

 “over the last two years, new science has emerged showing potential improvements for some patients in their overall outcomes as a result of complete revascularization.”

Larry Husten,prolific medical journalist whose Forbes article on this subject is linked above, really nailed it , quote:

" It seems to me that the medical organizations that produce guidelines should freely admit this lack of evidence for most recommendations. Then, instead of getting their panties all in a bunch trying to defend the indefensible– as we saw recently with the salt guideline– they could advocate for better evidence...So if they want to make the case for more data they will have to first acknowledge their ignorance.

Acknowledging ignorance seems the last thing  likely to emerge from the guidelines generating organizations.

In 1728, the three verdict system arose in Scottish Criminal cases.The accused could be found guilty,not guilty or not proven. So guilty, not guilty or admitting their ignorance and admitting we just can't say.


Being  a guideline author seems to confer immunity for having to say you are sorry.  The individual physician strives to do what is the right thing for his patient and hopes that what he does is right, the quality rule makers are able to summon up sufficient hubris to  presume to know what is good for everyone. Of course they frequently do not. Remember the beta blocker fiasco.



 


Friday, September 19, 2014

Are pediatric football concussions different from high school and college head trauma?

It would be nice to think so and a 2012 study by Maugans et al provides some data ( see here for full text) which suggests it may be the case. Eight young football players  (in a study of 12 athletes ) were studied early post concussion and at two subsequent times.The football players ages were : two 12 year olds,one thirteen year old,three 14 years olds and 2 aged 15.

Multiple Imaging techniques were used . The diffusion tensor imaging (TDI) tests were normal  as were conventional MRIs,and proton magnetic resonance spectroscopy.

 This is in contrast to two studies in college and two studies in high school football players, none of whom experienced a concussion ,which showed decreased fractional anisotropy (FA) in certain white matter tracts and/or functional MR  abnormality in the dorso-lateral frontal cortex.See here for Talavage's article regarding functional MR changes in high school players.

.Further ,one study (Bazarian,  (see here for full text)) showed persistence of the TDI changes six months after the college football  season ended. Here is the authors' summary:

" we have demonstrated that a single football season of RHIs  [ repeated head impacts]without clinically evident concussion resulted in WM changes on DTI. These DTI changes correlated with multiple helmet impact measures and persisted despite 6 months of no-contact rest. This lack of WM recovery could potentially contribute to progressive, cumulative WM damage with subsequent RHI exposures. If this relationship is confirmed in longitudinal studies, efforts to limit the development of RHI-related WM changes by monitoring helmet impact measures, and further elucidation of modifiable factors that may influence WM recovery, could mitigate the long-term risk of CTE [chronic traumatic encephalopathy]."

Maugan's group did demonstrate decrease in  cerebral blood flow ( CBF) in the concussed subjects which tended to return to normal over a few weeks.The authors' conclusion;

"Pediatric SRC [sports related concussion] is primarily a physiologic injury, affecting CBF significantly without evidence of measurable structural, metabolic neuronal or axonal injury.(I am still trying to figure out what a "physiologic injury means.)
 
What might account for the apparent differences in brain scan results in the college and high school players and the younger athletes studied by Maugan?

Possibly the younger players have a  threshold for CNS symptoms given a head blow  that is lower that the  threshold for whatever tissue changes take place that are reflected in DTI findings.There are contradictory data regarding the question of whether younger brain are more or less susceptible to damage for head trauma.

While it has been shown that  some head  impact levels ( as measured by accelerometers in helmets) in  youth football may approach those demonstrated in high school and college they are on average lower.(see here for full text of article by Cobb, 2013 for detailed data of head impact forces ) Further, the total number of impacts in a season of high school or college practice and game time may be considerably more than in a season of youth football and it may be the cumulative effects is what drives the DTI changes and whatever underlying tissue changes that may occur.Also as the years pile up, youth football and then high school and then college and then for a few professional football the total  number of head impacts grows and it may be the long term cumulative effect of multiple sub-concussive plus the occasional concussive blow that  leads to CTE in a minority of football participants.A definitive link between the imaging findings on active players and the pathological changes seen in chronic traumatic encephalopathy has yet to be established.

Although parents may feel some reassurance from Maugan's research, there is little to be reassured about in  the brain imaging studies of high school and college football players following a concussion free season as well as those studies on players with concussions.There is certainly little reassurance offered in this lengthy and detailed  article from Rolling Stone.There is an increasing about of research on the effects of football related head trauma ( as well as ice hockey) .One pundit, a retired football  player,commented  that it is the parents who really need their heads examined.

Addendum : Minor alterations in syntax and spelling and grammar done on 9.24.14.The original, unfinished version was published on 9/19/14 by mistake .

Thursday, September 18, 2014

Is the "triple aim of health care" analogous to the dual mandate of the Federal Reserve

Well, it can be argued that they are both unachievable and the execution of their aims and goals will require wise men such as the "Men of system" discussed by Adam Smith.

In 1977,  Congress, having accepted at least part of the theory of Keynesian economics, amended The Federal Reserve Act, with the passage of the Humphrey-Hawkins Act, stating the monetary policy objectives of the Federal Reserve as:

"The Board of Governors of the Federal Reserve System and the Federal Open Market Committee shall maintain long run growth of the monetary and credit aggregates commensurate with the economy's long run potential to increase production, so as to promote effectively the goals of maximum employment, stable prices and moderate long-term interest rates."

In other words, the Federal Reserve System is tasked by law to control inflation and maximize employment in spite of the fact, given the tools to which the system has access, that the two mandates might be incompatible.

Dr Don Berwick speaks of medicine's "triple aim"  ( as envisioned by the Institute for Health Care Improvement)  : Population health,the patient's experience and the per capita cost.The collective medicinal "we" should strive  to improve population health,the individual patient's experience and reduce the per capita cost.

I am reminded of a series of  articles in JAMA in 199 4by Dr. David Eddy ( "Rationing resources while improving quality" ) in which he promised to provide a means to improve quality of medical care and reduce costs. This was to be done by utilizing a utilitarian cost calculus.The idea was to do what was best for the group,the health care collective statistically, even though he admitted that in such a system there would be winners and losers but the utility to the former would out way the dis utility to the minority. Of course in this scheme quality had to be defined or redefined as  what is better for the aggregate. At least Eddy was candid about there being losers,in Berwick's utopian visions in the picture he paints there seem only to be winners.The population will do better, the individual patient's experience will improve and "we" will spend less money per patient. Everyone will do better and it will even cost less.What could possibly be wrong with that?

I believe that IHI's policy recommendations are basically Eddy's prescription adorned with a layer or two of management-speak verbiage dumped on the top to obfuscate what is really happening. When you improve population health care or outcome and simultaneously  decrease per capital costs, you essentially are doing a cost effectiveness analysis based on a statistical benefit to some group ( e.g. those covered lives in an ACO or HMO) regardless of what determent might befall some other  individuals in the group making the third aim of improving the  patient's experience little more than a fraudulent claim. This is population medicine dressed up in polite euphemisms designed to flimflam the members of the health care collective.

Both Dr. Robert Berenson and Dr. Harold Sox,former president of the American College of Physicians, are  perhaps more candid about about their visions for medical care in the country.

Berenson writing in 1998 in the Annals of Internal Medicine said.

"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible.

Berenson makes it clear that the individual's interest shoudl be trumped by the group's interest.


Dr Harold Sox, former president of the American College of Physicians, in his commentary regarding "population medicine"  made it clear that in shifting funds from managing one disease to another would involve for at least a few generations results in some not receiving treatment so others might enjoy some type of preventive measures. That would be quite an "experience" for those who might have to forgo some treatment.

Quoting Sox's  November 12, 2013 JAMA commentary:

 "Planning to optimize population health will mean determining the frequency,causes and consequences of he common medical conditions in a population and devising strategies for dealing with them over a lifetime. "...
resources must be allocated across program to prevent,detect and treat disease and its risk factors. "...One reasonable principle to move resources from groups of patients less likely to benefit to groups more likely to benefit...

With the application of this utilitarian calculus there will be winners and losers which Sox seems to admit implicitly the following paragraph.

"It will take several generations to realize the benefit of investments in disease prevention.In the short run, these investments may draw resources away from the tests and treatment of some sick people.In the long run, diseased prevention and better low-cost technology could reduce the outlay for treatment."

If Berwick's, triple aim is something other than  the utilitarian approach of Eddy,Berenson and Sox I wish someone would explain. It is the old wine in newly labeled bottles, this time labeled "enhanced patient experience" and the platitudinous "patient centered care" when really it is the greatest good for the greatest number as judged by cost effectiveness calculation and the real winners are the third party payers and their fellow travelers. .