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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Friday, December 13, 2019

Should journals always report fragility index on a clinical trial.

Interesting article in December 2019 Circulation.(See here.) that discusses the "robustness" of a number of cardiovascular disease trials.

A  purported measure of robustness is the Fragility Index (FI) which is the number needed to move from the non-event group to the event group to turn a statistically significant finding into a non-significant event. A FI of 1 would mean that if one subject was moved from the event to the non event group there would no longer be a significant  difference.

A related concept is  the comparison of the FI to the number of subjects lost to follow up. The trial's results would be considered less robust if the number lost is greater than the FI.

Ridgeon et published a review of 56 RCTs in critical care treatment topics.The median FI was 2 and slightly greater that 40% of trials had a FI of one or less.So does that suggest that clinical guidelines based entirely or in part on those low FI studies are built on shifting sands?


But wait, listen to this criticism of the concept of FI by Dr. F.Perry Wilson before rushing to trash a RCT simply because the FI is too low. Wilson shifts the problem to one of having too much reliance on the p value in the first place.



1)Ridgean EE et al Crit. Care Med 2016,vol 44 ,1278

Thursday, December 05, 2019

What could possibly go wrong when legislators think they know how to practice medicine

Here is another item from the file labelled "I'm so glad I don't practice medicine any longer"

A proposed bill from the Ohio legislature breaks new ground in the land of the  ignorant and absurd.

It would require a physician to transplant an embryo from the fallopian tubes to the uterus of the mother or face a charge of capital "abortion murder".See here

Friday, November 29, 2019

State legislatures act to increase collateral damage in the opioid epidemic war


This Thanksgiving I am particularly thankful that I am not a practicing physician any longer and
no one in my family suffers from chronic pain.

Several state legislatures have passed legislation that mandate chronic pain patients sign adhesion "contracts" and agree to periodic urine tests and a drug test prior to obtaining their first prescription for an opioid .I do not know if there are any penalties for physicians who do not comply with the law.

Here are details of the Pennsylvania law known as Opioid patients Prescription Agreement Act.It requires in order for a patient to get a prescription for an opioid for chronic pain they must sign an agreement  and consent to an initial urine drug test and then periodic tests.Credit is due to
the Pennsylvania Medical Society for their opposition to this ill advised law

Treating patients like criminals or potential criminals will do little to stem the opioid epidemic but is bad news of physicians,patients,dentists and pharmacists.

This recently enacted,effective immediately, Pennsylvania law is a poster child for an act of legislation that will make chronic pain patients lives even more miserable,doctor's practices more difficult and will decrease the number of opioid deaths not at all. To force patients to do periodic urine drug tests is to not even pretend to act for the welfare of the patient sacrificing it to some nebulous, hypothetical goal of decreasing the diversion of unused prescription drugs.(the idea here apparently being that if the patients tests negative for drugs that they may well be selling their medications) .

In an earlier era physicians would likely be pleased when their patient with chronic pain used less pain medicine- now they are expected and perhaps legally obliged to consider their patient might be involved in criminal activity.

 That is so different from the comment,traditionally attributed to
Maimonides

"May I never see in the patients anything but a fellow creature in pain"



What does a physician do if a chronic pain patient tests negative which raises the possibility of the patients diverting the pills.Is the physician obligated to investigate or call the police or the DEA? What if he doesn't?

Probably it is best to not have chest surgery or shoulder surgery or a Pacemaker implantation in Kentucky, Tenn. or Fla. as the legislatures in those states have mandated that a initial opioid prescription be limited to a 3 or 4 days supply.(1) Who would know better how to practice medicine  than the democratically elected officials ?Managing chronic medical conditions must be thought to be too important to be left in the hands of the patients and their physicians.


Dr.Jeffery A. Singer,surgeon and Cato fellow, has been studying and speaking out about  the harm done by the war on drugs for years and is worth quoting:

"Evidence continues to mount that curtailing prescription opioid use serves divert nonprescription use to heroin....most opioid users initiate drug use for non medical reason."

In short, the opioid problem is not because of the way physicians treat pain and limiting the access of patients with pain to pain relief will only make the "epidemic" worse.We have the wrong diagnosis and the wrong treatment.

1)National Conference of State Legislators. Prescribing Policies: States Confront Opioid Overdose Epidemic. NCSL website. http://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx. Published October 31, 2018

Saturday, November 16, 2019

is Google being a "business associate" of Ascension Health Care something to worry about

In you are or  have been a patent of Ascension health care system your names,diagnosis, date of birth may be accessible to employees of Google according to recent news reports on various sites.The information is reported as including names and date of birth and you do not have to give permission.

For those of you who still think HIPAA is   all about your medical privacy , think again This is said to be perfectly legal under HIPAA as Google is a "business associate" of Ascension Health Care and the data is available to Google without permission of the patients or their physicians and apparently without the need to even notify patients about it.

A detailed explanation is found in a recent article in WIRED. See here.Actually after the story was published on multiple sources both Google and Ascension made  press releases assuring all concerned that there is absolutely nothing wrong and this arrangement is nothing to worry about and that everything is perfectly compliant with HIPAA

We are told that the arrangement and Google's help is " to optimize health and wellness of the individual and the community"

The story goes that what happens in Vegas stays in Vegas but what you tell your physician in the Ascension Health system goes to the Google  cloud.

With all the errors and fabrications I have personally noted on the EHR medical records of two patients and the very big risk of the  GIGO phenomenon  Google will likely devise some interesting optimizations.

Examples of those errors:

1.One erroneous diagnosis of atrial fibrillation
2.One erroneous diagnosis of hyperthyroidism
3.a diagnosis of osteoporosis which had no basis
4.two complete physical exams "documented in the chart" that never happened
5.one designation of an orthopedic abnormality in the wrong extremity
6.one designation of a  "my"primary care physician who I had never heard of

If the number of errors noted in just two patients is extrapolated to even a small percentage of medical records , you have to  be skeptical about how accurate or  useful would Google mega data magic be?.With a significant amount of garbage in won't we expect a bit of garbage out?

So with the privacy issue and the questionable reliability of HCRs ,the business associate relationship between Google and Ascension has a number of people concerned.

Sunday, November 10, 2019

Could government mandated "quality" programs be bad for your health.

Dr. Paul Hsieh explains how exactly that has happened in his recent commentary in Forbes.
He explains how the Hospital Readmission Reduction Program (HRRP) has backfired and likely caused harm. Another example is the "Never"programs in hospitals.

Certain mishaps including patient fall are deemed "never events" and hospitals are penalized for Medicare patient's falls. This apparently has lead to some hospitals and nurses taking various measures to keep patients in bed to prevent falls.Bed rest in the elderly can quickly lead to weakness and a greater tendency to fall.

This reminds one of the famous 4-hour pneumonia rule,which is a great real life example of  Goodhart's law , i.e. when a measure become a target it looses its value as a measure. The folks at CMS appeared to learn nothing from that debacle.

What may even be worse is that physicians may be intimidated by some thing called the disruptive physician concept into not saying the obvious and calling the emperor naked. I quote from an earlier blog entry:


"The mandatory and quasi mandatory nature of guidelines or quality indicators as wielded by the CMS mandarins and other institutional elites become even more dangerous with the spreading use of the "disruptive physician" doctrine. Not only must you go by the rules you can't complain about them without incurring the wrath of the hospital's disruptive physician committee.This doctrine is a brilliant control mechanism.If you challenge the disruptive physician concept you are by definition disruptive. "






Thursday, November 07, 2019

The developing Vison of Primary Care in the Big Rock candy Mountain

Probably the primary care physicians in training who authored a  commentary in the NEJM describing their view of what primary care should be may will have to google the candy mountain reference in the title or just look here.

KA Barnes,J. Kroening-Roche and BW Comfort wrote a perspective piece in the Sept 6 201212 issue of the NEJM.

In it they describe their vision of primary medical care in the U.S. I will not quote their description of what they hope primary care will be but I will quote a sentence that is the essence of what I believe to be a bogus concept.

"Primary care cannot be primary without the recognition that it is communities that experience health and sickness."

Their description of a typical day a primary care practice can be dismissed as idealistic and naive or wishful thinking as in lemon aid springs of the Big Rock Candy Mountain ( at least to an increasingly curmudgeonly old retired doc) but the quoted sentence expresses a conceptual error.

No, communities do not experience anything;nor do they choose anything nor do they suffer or rejoice. Only sentient beings can do any of those things and communities are an abstraction . Similar terms ( society,the country, etc) can sometimes be useful summary ways of thinking and talking- a useful short hand. To say that a community is ill or well is a figure of speech;to say that Mr. Brown is sick is an empirical fact. Mr.Brown can regret his earlier excessive use of alcohol, but to say the community regrets anything is a category error.

This is not to deny that there are economic factors and social factors that might impact someone's health but to the degree that such things happen they impact the health of individual, real life people not society and not a community.Government programs can improve the health of individuals, with such things as immunization campaigns and providing health care to the indigent.But it is not the community whose health improves it is the individuals who can benefit.

Society or communities are not some super being or entity apart from the individuals who comprise it. To consider that they are or to reify this abstraction lays the foundation for consideration of weighing the value of the individual against this mythical creature and presto we have the new medical ethics.

Reification refers to the treating of an abstraction as if it were a concrete real thing or an actual physical entity.In short turning an idea into a thing and treating it as if the idea posses the attributes of an actual being.

It is the public health paradigm taking over clinical medicine. I hope that when I get older and ill that the physician I consult will realize that I am her patient and not the community in which I reside or the HMO to which I belong.

Sunday, November 03, 2019

More long time followup on his bundle pacing

Dr. Francesco Zanon of Italy and Dr. Pugashendhi  Vijayaramen of the Geisinger Clinic in Pennsylvania report on the long term performance and safety of 884 patients implanted between 2004 and 2016.

The first 368 were implanted using a deflectable delivery system while for  the next 476 patients a fixed curve delivery system was used.There was a significant difference in both the capture threshold and in the complication rate between  the two groups,with the data strongly favoring the fixed curve system.

Complications  were fewer in the fixed curve group (11.9 % and 4.2%) and the capture threshold was lower (2.4 volts versus 1.7 volts)The complication rate difference could at least in part been due to  the learning curve as the fixed curve system was used later.

1) Zanon, F, Long term performance and safety of His Bundle pacing:A multicenter experience.
J.of Cardiovascular Electrophysiology, 2019, July 16







Friday, October 25, 2019

Does your doctor really work for a venture capital firm

Some of the docs who see you in the ER,or read your imaging study, or give you Propofol for an endoscopy may well be the employees of a company that is owned by venture capital companies such as KKR.And if you have been hit by a big surprise medical bill because the ER doc for example is not part of the network your insurance covers it is even more likely .Apparently at least some  medical staffing companies owned by venture capital companies are accused of being heavily into balance billing.The names  Envision and EmCare come to mind.

Dr.Roy Poses had published an excellent report entitled "Who advocates for surprise medical billing?" on this topic on his blog, Health Care Renewal.See here for some eye-opening information.

Emergency room physicians are often supplied by physician staffing firms, such as Envision and EMcare.

 According to the HCR blog commentary these two are said to be  owned by  the global investment firm KKR.However the entry on Wikepedia on EmCare gives a different description of the various buyout and mergers surrounding EMcare not mentioning KKR.In any event we are talking about the corporate practice of medicine which is still not legal (although various states have exemptions of the rule) in some states. EmCare operates in 42 states.Envision, however, was acquired by KKR in 2018 for 9.9 billion.It is more complicated than that as Em Care through a series of buyouts  may have actually become Envison.Whatever may be the history of these company's buyout name changes, the point is that  venture capital companies own corporate entities that in turn supply physicians in various roles- i.e.ER docs,anesthesia services and even ICU doctors.So in the interest of transparency those doctors could have white coats with the logo of KKR.

The wide spread operations of companies such as these does not mean that laws restricting the corporate practice of medicine are no longer enforced  even  though their control of medical practice have greatly decreased..For recent examples of medical practices and non physicians owners getting caught by corporate practice law see here.

The basis of the corporate practice doctrine is usually said to be the conflict between the fiduciary obligation of the corporation to its shareholders to maximize profit  and the fiduciary role of the physician to the patients.

It does not take much imagination to think of situations in which what is good for the corporate bottom line does not correspond to what is good for the patients.






Thursday, October 10, 2019

Aristotle trial,bad data from China,but apixaban probably still better than warfarin

In 2011, the Aristotle trial was published in the NEJM.It demonstrated aprixaban's superiority over warfarin in the treatment of non-valvular atrial fibrillation (AF)- fewer strokes, less bleeding and apparently a decreased over all death rate. But wait. The  FDA did not quickly approve apixaban.

One major problem was questionable  data from a China trial site which included mixed up medication distribution and some possibility of fraudulent data. Critics also noted that  there was no mortality benefit noted in the European cohort and that 35% of the warfarin group did not achieve a therapeutic INR.

After considerable back and forth between the drug companies and the FDA apixaban ( Eliquis) was approved for  treatment of non-valvular AF but not the claim that the overall mortality was reduced.

That should have been the end of it but recently an analysis of a number of meta analyses revealed that the original  Aristotle data ( including  the tainted China  cohort) was included.A number of these MAs claimed a benefit for Apixaban that is said to have  vanished when the questionable data were excluded.

Even with the flawed trial apixaban is preferable to warfarin for non-valvular AF.In the treatment arm, there were fewer strokes driven mainly by fewer hemorrhagic strokes there being only a slight advantage to apixaban in regard to ischemic strokes.Apixaban is safer and dietary and medications interactions much less of a problem than with warfarin and no needed for frequent follow up blood tests.

After Homer quit his job at the Kwik E mart,Abu said:

"He slept,he stole,he was rude to customers.Still there goes the best damned employee a convenience store ever had."




Wednesday, October 02, 2019

RPU-responsible physician unit-possible replacement by "systems"


The following is a re-do of an essay I wrote 14 years ago.


In the March 1, 2005 Annals of Internal Medicine the "Improving Patient Care"section deals with a case in the discussion about which the author emphases the problems associated with lack of follow up by and "hand offs" to physicians.

 A 70 year old man with a history of alcoholism presents with cough and weight loss.His chest xray showed "RUL pneumonia with a dense infiltrate with extensive fibronodular disease and upper lobe volume loss. No tb studies were done and the patient was discharged on antibiotic therapy.Through a series of lapses it is some 2 months later and after the patient was sent to and then sent back from a nursing home before the diagnosis of tb was finally made and treatment started, but apparently too late. He died of respiratory failure shortly thereafter.

The author discusses various methods to ensure followup . He does not mention, however, a well established method of obtaining follow up of lab tests. It is the RPU. This stands for responsible physician unit. The physician caring for the patient is responsible for finding out what were the results of the tests 

The clinical picture and chest film shouted r/o tb ( rule out TB). The narrative of sequential foul-ups is disturbing and the author's comments about the important of systems to ensure that reports are seen by doctors are appropriate. However, the original "fumble" occurred because of the apparent ignorance of the medicine resident ( I assume they were medical residents). While the subsequent events are alarming-and may be mitigated or eliminated by appropriate systems and safeguards- the lack of basic clinical knowledge demonstrated in this case is astonishing.

I cannot believe even a first year resident would not think "rule out tb" when he encounters an alcoholic with cough, weight loss and a upper lobe infiltrate. (the initial radiologist's report displays a equally high level of cluelessness also by not mentioning tb as a diagnostic possibility) Even if the resident was ignorant about tb,where was the attending?Not doing tb tests in this type case is comparable to not doing biomarkers for heart damage in er patients with chest pain.

At the county hospital where I trained that patient's arrival would have lead to the intern, resident and medical student spending the next few hours getting sputum samples and doing AFB stains. Even if the smears were negative the patient would have likely been hospitalized in a contagion unit to rule out tb given the very high "pre-test" probability of tb.

The author speaks of algorithms for this and algorithms for that. What is the nature of the algorithm to prevent house officers from harming patients based on their ignorance? In a earlier - less politically correct era- in regard to the first house office who saw the patient- we would have asked where did he go to med school.

Monday, September 30, 2019

Why have price controls on hospitals not caused a shortage

Arnold Kling has said that economists do not save the useful economic thoughts and insights for graduate level courses but teach the good stuff in econ 101.

One of the pearls in econ 101 is that wage and price controls typically have some very predictable consequences.These are shortages,decrease in quality of the good or service, mis-allocation of resources and black markets.

The Center for Medicare and Medicaid services,CMS, has placed price controls on hospital care in the form of something called DRGs.

A patient admitted to the hospital with pneumonia is classified under the DRG system. A given DRG determines the maximal amount that CMS will pay for hospital care for a patient with that diagnosis.If the patient remains in hospital too long then the hospital costs will be greater than the allowed charges. This seems to be one important reason for the rise of the hospitalist movement in which physicians hired by the hospital can strive to get the patient home soon.

However, the governmental control over hospital care is not that simple.

Anyone who has been in a hospital or examined a relative's hospital bill will be struck with the fact that the amount charged is greater ( often markedly greater ) that the "allowed charge" ( the amount medicare or a private carrier will pay). So why is the bill configured that way?

See here for some information about the complicated details of the DRG system.

The difference between the allowed charge and the amount charged is considered to be "uncompensated care". The federal government gives a rebate to the hospital for some fraction of this uncompensated care for Medicare patients.

This rebate is not a secret but my guess is very few people know about this.In the strange world of government control ,this perhaps makes some sense in a non traditional sense of the word "sense",but to the non policy work it seems odd to impose price controls with one hand and the with the other institute a program to mitigate the effect of the control.

Friday, September 27, 2019

Will hospital adverse internists loose their critical care skills

In the waning years of my professional medical life I witnessed a bifurcation of internists into  three groups, the hospitalists and those who only saw patients in their office ( officists) with a third small group who soldiered on trying to do both, swimming against the strong economic tides.

It occurred to me that perhaps if a physician who trained to be able to care for complex, very sick patients in the hospital no longer did that type care that his critical care skills would atrophy. Further, since he now longer needed to know about the advances in the care of various types of very ill patient his incentive to keep up in those areas would decrease and the periodic testing for recertification would become even more of a contrived, farcical   exercise benefitting the ABIM.

Thursday, September 26, 2019

The endless demand for excelence - a burden too great?

Go to this post by Dr. Jeffrey Parks who blogs under the name "Buckeye Surgeon".

He write about the endless demand for excellence and quotes Cicero who said:
"For the better he is at his job, the more frightened he feels about the difficulty... about its uncertain fate... about what the audience expects of him."

Back though the years perhaps  there was a time of the "complete internist", before the economic hegemony of the third party medical payers divided internists into officists and hospitalists,when the general internist shared similar frightening challenges that the surgeon from Ohio writes about so well. This was time when the internist was not a competitor of the NP , PA and family doctor. (no, I do not equate the family physician with the two categories of "physician extender"). The challenge of the complex, critically ill patient was parallel to the challenge that the general surgeon faced with a "tough case". So today far fewer general internists do that sort of thing as they are relegated to the office and juggle guidelines for routine management of standardized problems and inquire about seat belt use,and flossing and offer wellness to the worried well in the form of various preventive measures .

I began to sense the endless demand for excellence in medical school in the clinical years.You could never know too much.Something you did not learn or did not do could result in a catastrophic for someone entrusted to your care. There seemed to be endless demands. It seeemed like too much was expected.

Monday, September 23, 2019

Is it valid to compare numbers needed to treat (NNT)

Scattered throughout medical literature is the metric known as number needed to treat or NNT.

It has been claimed that in trials in which there are varying follow up times the simple NNT measure can be misleading - see here for a statistical discussion of that point from the NEJM commentary that suggests Kaplan Meier approach be used to account for varying followup time.

NNT is typically presented without a confidence interval or an error term.but apparently there are at least two methods for determining the CI of a NNT ( see here ) but according to this critique the two methods can yield markedly different results which I believe leads to the conclusion that one cannot compare NNT from one trial with a NNT from another trial.

It seems that one of the factors taken into account in the PHSTFP recommendations was the difference in the NNT from women 40-49 versus women over 50 in regard to mammograms.

Sunday, September 22, 2019

Can high school football players develop Traumatic brain injury without a concussion


note:This a reposting of a commentary posted five years ago. So few people saw the post I am offering it again as High School Football season is underway and subconcussive head blows occur every Friday night. 


Traumatic brain injury (TBI) is classified as mild,moderate and severe based on mental status change and duration of loss of consciousness (LOC). Mild TBI  involves LOC less than 30 minutes and corresponds to  a Glascow Coma Scale rating of 13-15. For example, a football player who appears stunned and confused with only brief of no loss of consciousness would have a Glascow score of 14.

A major element of TBI is diffuse axonal injury thought to be caused by rotational and linear acceleration of the brain. Conventional MR imaging and CT images do not detect that type of changes. However, diffusion tensor imaging (DTI) can detect changes in fiber tracts reflecting changes in diffusion of water into nerve tissues.A DTI based measurement ,fractional anisotropy (FA) ,reflects water movement along the axons.In normal tissue FA is high ( approaches 1)

DTI abnormalities have been demonstrated in concussive cases of  mild TBI and the degree of abnormality correlates with the severity of post trauma symptoms.(see here). Typically FA increases acutely in TBI and later on values are decreased (see here ), although there is some inconsistency about the direction of change in this measurement  in the literature and there are case reports in which acutely FA decreases.

Football players  college,high school and professional, who have sustained concussions,have been shown to have abnormal DTIs.

There are  several publications  (1. Davenport et al,2.Talavage,3.Barzarian  4.McAllister )describing research involving college and high school football players that have shown similar DTI changes in athletes who did not have clinical concussions,These imaging changes seem related to multiple sub-concussive head blows.Some studies-but not all- have also shown that these DTI findings correlate with decrements in memory test results over the course of one season.Generally these DTI abnormalities correlate with measurements of acceleration forces of the skull detected by in- helmet accelerometers.

 1)EM Davenport and her colleagues from Wake Forest studied the cumulative effects of head impacts in a single high school football season in players without a recognized concussion.(Abnormal white matter integrity related to head impact exposure in a season of high school varsity football" J of Neurotrauma 2014 Jul 14, published ahead of print).

The authors' summary:

"We show that a single season of football can produce MRI measurable brain changes that have been previously associated with mTBI (mild TBI) .Finally, we demonstrate that these impact related changes in the brain have a strong association with postseason change in cognitive function." The cognitive function was noted in a verbal memory composite score which correlated with the magnitude of the MR findings.

 2) TM Talavage and coworkers studied 11 high school players with functional MRs (fMR),measures of head impact events and neurocognitive function testing. "Functionally detected cognitive impairments in high school football players without clinically diagnosed concussion." J of Neurotrauma. 31:327-338,Feb 2014)

 Unlike most of imaging studies of TBI this group found abnormalities in the frontal lobe with functional MR.DTI was not done.

 Quoting from the authors summary:

"Additionally, we observed players in a previously undiscovered third category, who exhibited no clinically-observed symptoms associated with concussion, but who demonstrated measurable neurocognitive (primarily visual working memory) and neurophysiological (altered activation in the dorsolateral prefrontal cortex [DLPFC])."

3 JJ Bazarian  studied 10 college football players over the course of one season. ( "Persistent Long Term cerebral White Matter Changes after Sports related Repetitive Head Impacts. Plos one 9(4),e94737)

 Head impacts were recorded and measured by helmet accelerometers and DTI was done preseason, immediately post season and six months after the end of the season.

 DTI abnormalities in white matter were noted in these players none of whom sustained a clinically evident concussion. The changes in most players,but not all, were also seen in the six month followup images. .. There was a positive  correlation between number of head impacts and DTI findings. The DTI changes were not correlated with changes in cognitive testing or tests of balance.

4)  TW McAllister's study involved 80 college football and hockey players ( "Effect of head impact of diffusivity measures in a cohort of collegiate contact sports athletes", Neurol. 10:1212/01Dec 11 2013.)
Quoting the authors:
"The magnitude of  [TDI] change in corpus callosum MD (mean diffusivity) was associated with poorer performance on a measure of verbal learning and memory."  Again these findings occurred in players with no recognized concussions.

The risk of concussion is greater in certain positions such as quarterback and wide receivers. Lineman , on the other hand have fewer concussions but most experience multiple head impacts during each game and each full contact practice session.See here for a detailed study on impact forces on various player positions.


Maugans and coworkers studied athletes younger than typical varsity high school players.These players were 12 to 15 years of age and DTI scans done fairly soon after the concussion did not show abnormalities in diffusion indicators including fractional anisotropy.

Dementia Pugilistica as a clinical condition in professional boxers was described as a clinical entity in a JAMA article in 1928.In 1973 the pathological findings were published. In 2005,Omalu et al published the results of an autopsy on an National Football League  player, Pittsburgh Steeler center,Mike Webster, on whom Dr. Omalu had performed an autopsy 3 yearns earlier.This was the first report of Chronic Traumatic Encephalopathy in a football player.

Zhang et al provided some data regarding brain changes in boxers who were symptoms free and who had a normal neurological exam. 47 professional boxers ( age 30 +/-4.5 years ) underwent conventional MRIs and DTIs.In 42 the conventional MRI was normal while 7 demonstrated some focal non specific white matter changes. The 42 demonstrated abnormal DTIs, with decreased fractional anisotropy in regions of the corpus callosum and internal capsule.Boxers have been the canaries in a coal mine.Their experience has made it clear that repeated blows to head can cause permanent progressive brain damage that is not immediately apparent but develops over a  variably long period of time.The question is to what extent does this apply to football in which the players wear helmets.For years it was believed that helmets were adequately protective but now that view is increasingly less plausible.

By 2013 the NFL agreed to settle a class action law suit brought about by former NFL players and their families  but the judge did not agree to the amount offered..Now the NFL has seemingly admitted that as many as one third of players will develop some sort of cognitive impairment and that they will have funds available to cover the agreement.

The distinction between a concussive and a sub-concussive head blow is on the margin indeterminate.  A player may experience a blow to the head and feel slightly dizzy or dazed and not report those symptoms to the coach or trainer. There may be social or peer pressures on players to not report symptoms as they would be benched and not allowed to play until they complete whatever concussion protocol is in place.So the distinction between a group of players with a concussion and a group with no history of reported concussion is  not one based on clear cut objective criteria,often relying on the voluntary reporting of subjective symptoms.So it should not be surprising that cognitive tests and brain imaging studies show similar findings in football players with and without a concussion history.

So in reply to the title question, yes I believe there is convincing evidence, But there has not yet been established a clear linage between the changes in cognitive tests and brain imaging studies  seen after a season of high school or college football  and the development of  chronic traumatic encephalopathy .



 


Saturday, September 21, 2019

How does the elite endurance athlete's heart differ from normal people and the non-elite

The cardiovascular system of the trained endurance athlete differs in a number of ways from the untrained person.These include:
1.increased red blood cell mass and blood volume
2.increased numbers of mitochondria and capillaries in leg muscles.
3.lower peripheral arterial resistance
4.lower systolic and diastolic blood pressure during exercise.

Those and likely other factors I have neglected to mention will be found in both the elite and the non endurance athletes. What distinguishes the elite endurance  athlete is the capacity of left ventricle to fill with blood quickly without significant increase in the ventricular pressure. The elite have much better diastolic function.While endurance training and high intensity training may somewhat improve diastolic function , they do not seem capable of developing the super compliant left ventricles of the world class endurance athletes.Genetics provide the substrate for the marathon winner,training finishes the process.

Friday, September 20, 2019

High Intensity interval training and atrial fibrillation

Does high intensity interval training increase the risk of atrial fibrillation (AF) or does it mitigate the AF burden in patients with non permanent AF or both?

An article from Brazil with a 3 year followup suggest that HIIT increases the risk of AF and increases atrial size when compared with moderate exercise in hypertensive patients with chronic renal failure (1). But what about normotensive folks with no renal disease?

A short term trial (2) from Norway comparing HIIT with no exercise in patients with non permanent AF demonstrated less AF burden in the HIIT group.



1)Kiuchi,MG The effects of different activities on atrial fibrillation in patients with hypertension and renal failure. Kidney Research and Clnical Practice. 2017, spet 36 (3) 264

2)Malmo,  Aerobic interval training reduces the burden of atrial fibrillation in the short term  Circ 2016,133 466-473

Physicians as Guardians of Society's Resources-


In the early part of the second half of the 20th century when I received by medical education,physicians were taught they had a fiduciary duty to their patients. There was for the most part no third party obligations. There were  no  major presence of HMOs at that time.Richard Nixon changed that.

As medical care costs and expenditures increased, third party payers including the growing HMOs and  large corporations who provided health insurance  (some were self-insured) took measures to control costs. There were larger deductibles and co-payments and more scrutiny by insurance companies on what exactly they would pay for. There were guidelines and pre approval rules for testing. These counter measures probably helped somewhat but costs continued to rise and continue they would as basically this was folks spending someone else's money and the fingers on the cost gun were in the hands of hundred of thousands of physicians.

The problem was how to control the activities on these physicians who had been schooled  for many decades with the ethical imperative of do what is right for the patient. For physicians trained in that ethical environment, cost to the " system", be it United Health Care,Exon, or Medicare,was not a major priority in their value  system or decision making calculus.

So various variations of carrots and sticks were employed by the third party payers.Pay for performance grew up as a type of bribe to docs to follow the cost cutting guidelines which went by the wink,wink,nudge, nudge name of quality guidelines.

Although carrot and stick techniques have a proven history of changing behaviors to some degree,what is even better is to have as the triggers of medical cost initiation i.e physicians (or some alternative "health care provider, eg NP, PA)) folks  who  really believe their duty lies at least to a significant operational degree in cost saving.Clearly to the third party payers physicians had their priorities all mixed up.

Enter the concept of physicians as stewards of society's resources.

I have not devolped a detailed chronology of that part of the literature which deals with medical policy matters to be able to date with any precision when and how this concept arose. I have written before on some of the earlier papers in the mainstream medical literature.


In 1988 Hall and Berenson writing in the Annals of Internal Medicine said that "the traditional ideal" [the prime duty to the patient ] was "not compatible with the role that existing insurance contracts and manged care arrangements define for physicians." Their comments were not subtle when they 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.

Note-now we are talking about a benefit to a specific HMO or PPO and  not in the benefit of some abstract "society" yet often the arguments for the new ethics is framed in terms of benefits to society.

Note:Berenson glibly justifies that sea change because the role that insurance contract define for the physicians. Here we might pause and remember that one of the defining characteristics of a profession is that members are bound by a ethical code that is largely self defined.Now it seems that medical ethics should be defined by insurance company interests.

Over the next 20 years far from that proposal being dismissed out of hand as medical ethical heresy which is how many of us at the time would have characterized it, it has become part of the generally accepted medical ethical package nestled in professionalism statements by most medical organizations and has become or is becoming part of medical education .

The fiduciary duty to the patients seem to have been demolished ( or at least made secondary) without much more that the occasional outcry by physicians of the old school. Various attempts to resist this over turning of traditional medical ethics have not prevailed. The dogs bark and the caravan moves on.

We have traveled a long way since the Berenson article.Now we read of a suggestion that "cost-consiousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a a new seventh general competency." In other words, residents should be schooled and graded on their mastery of the skill set necessary to be good stewards of [society's] resources. ( reference, The Idea and Opinions Section, Annals of Internal Medicine,20 Sept 2011,Vol.155 no.6, by Dr. Steven E. Weinberger,of the American College of Physicians.




Wednesday, September 18, 2019

Cardiac pacemaker interrogation reports-who does it and how well?


This is a revision  of an earlier posting on this subject, redone and reposted because I believe this is an important topic about which very little seems to be said. 

In the first 4 years of living with a cardiac  pacemaker (PM) implanted, the following instances of misinformation,lack of proper oversight,delayed reports and/or  misdiagnosis occurred.I did not need that stress after having a titanium foreign body containing a 3 V battery  crammed under my left chest wall muscle attached to wires going to various parts of my heart  which was quite enough to ramp up my anxiety level to at least sub-panic attack levels.

1)In October 2015 I had a pacemaker implanted- one  which is designed for bi-ventricular pacing  the most common form of CRT (cardiac resynchronization therapy).This has 3 leads, right atrium,right ventricle (actually mine is in the His Bundle position) and a Left ventricular lead (in a vein along the wall of the left ventricle)

 2)The technician who assisted and provided technical advice to the EP cardiologist at the time of the implantation told me on the following day that my home -bedside PM communication device  would send a recording every night to the manufacturer's web site  and then to the hospital PM center.

Only 6 months later was I informed by him , in reply to a question from me, that no -that was not true and that arrangement was only for devices with a defibrillator  which I did not have.  So for six months I made a effort  to be near  near by communication device device each night that in fact did nothing at all.

2.In October of 2016 my device recorded several episodes designed as AF/AT  (atrial fibrillation/atrial tachycardia) Episodes of AF are thought to be common  ( at least 30% by three years in patients with a PM- according to one data base).This lead to to my fairly extensive literature review of the issue of AHRE ( atria high rate episode). I learned that the topic is controversial and opinion varies as to what if any threshold there is for "signficiant volume of AF" to justify anticoagulation. (There are 2 randomized clinical trials underway that are designed to try and answer that question)

Also, All AHREs so designated by the PM's algorithms are  not in fact AF. The phenomenon of far field r wave sensing and  and a less common and more obscure PM rhythm disturbance known as  recurrent, non reentrant ventricular atrial synchrony (RNRVAS)  are capable of mimicking AF.The technician at the hospital PM center  who is tasked with screening the remote interrogation report had not recognized that the rhythm was FFA and apparently did not feel that the issue required calling the matter to the attention of the EP cardiologist.

I send an email to my EP cardiologist  and I was  told  the issue of short episodes of possible AF are very controversial and I  did not need to come any sooner or consider taking anticoagulants. He apparently did not address the possible issue of FFS or RNRVAS) or actually review my interrogation report until months later even though I has asked in my email if the data really indicated AF.

 However three months later, at routine office followup a  Medtronic technician said  that the earlier interrogation did not actually show AF but rather FFS  the reoccurrence of which he intended to prevent  by increasing the sensitivity threshold(i.e making detection less sensitive) on the atrial lead. The EP cardiologist  agreed, and I later leaned that FFS is not an uncommon cause of AHREs particularly so in the type of lead placement that I have. (Placement in the Bundle of His which in my case is higher up in the ventricle than the standard apical placement of the RV lead-sometimes the His Bundle Lead is in the atrium)


3)At an August 2018 in office PM interrogation, the technician and I entered into a conversation about battery life estimation  and she wondered if the estimate of battery life was disproportionately shorter than what may have  been expected on the basis of the settings .She forwarded the data to the home office and the engineers found nothing to do to improve the settings.Her concern and interest was appreciated but ..

In talking to her I quoted the section of  the device manual in regard to the device powering down a bit with several settings once three months has passed after the recommended replacement time ( RRT date). She said no that was not the case with my particular model However, I contacted the pacemaker company  technical support and they confirmed the manual's description was correct. 

4)Issue of high left ventricular (LV)  threshold occurring on multiple of the every three month reports.It was not until October 2017 (2 years after implantation ) that the left ventricular management system was switched to "monitor". I can only speculate as to the degree to which battery life was shortened by  what seems to be the less than prompt attention to that issue. 

The interrogation report is fairly long and reviewing it requires considerable technical knowledge about  cardiology,PMs in general as well as certain details regarding the specific brand,various programmable settings and particular model and various lead placement configurations and at least a little knowledge about electricity .

 The device clinic technicians review reports from  various pace maker brands and also the more involved and complicated reports from ICDs (cardiac defibrillators) .Being a retired physician I have had the time and interest to spend a fairly large amount of time and effort into learning about PM lore and in particular the interrogation reports. My  shaken confidence in the folks monitoring  how well the wires  in my heart are performing has certainly provided incentive to learn how  to read the basics of device interrogation reports. 

5)By the summer of 4th year following implantation the   device clinic  services  had deteriorated to the point that I wrote the head of the EP section.They no longer directly  answered the phone and the messages left were only replied to days later and my complaints to them was met by curt replies that they were too busy. Reports that were typically available the same day took a week or more and required multiple phone calls . The section head  said  those issues were being addressed and apparently they hired a company that does device monitoring and were now also available 24/7 while their own in-house clinic also did some or all of their review work.How well that arrangement works remains to be seen.