Featured Post

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 ...

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,but not under all conditions including Left bundle branch block.

 See here for the full text article.

Basically the exercise program which was mainly endurance training with some resistance exercise which was 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.

 The other site of improvement in exercise capacity resulting from an exercise program is improvement in the A-V 02 difference and several studies have indicated that it is that aspect of physiology that improves in HF patients who benefit from endurance exercise.This is the first paper I have seen that suggests that the heart  benefits as well.

.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 long training runs don't work out as well is  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 to further  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 to 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."

Monday, May 04, 2015

endurance exercise and the right ventricle-some thoughts

The issue of the effect(s) of endurance exercise on the right ventricle bothers me from time to time and I have blogged about it before.(see here)

A number of studies have shown that endurance exercise, marathons,triathlons, etc,  may result in transient changes in right ventricular function  (increased volume , decreased ejection fraction), while such changes in the left ventricle are typically not the case although some transient changes have been documented..But an important question is- do repeated episodes of prolonged exercise lead to some deleterious changes in the right  ventricle  which could include a predisposition to ventricular tachycardia or worse.Is there an exercise induced clinical picture of ARVD in someone who does not have the recognized genetic profile for ARVD?(see below).After thinking about it again and reading more about it,I think maybe but it does not seem to happen very often.

J. Ector and co workers studied right ventricular  (RV) function  in a group of  22 endurance athletes who had experienced episodes  of ventricular arrhythmias and concluded "Endurance athletes with arrhythmias have a high prevalence of right ventricular structural and/or arrhythmic involvement." ,the implication being the repeated endurance events predisposed to the rhythm problems (Eur Heart J. 2007, Feb 28 (3),345-53)

LaGerche studied 39 endurance athletes, see here, immediately after an endurance event,and one week later with echocardiography and Magnetic resonance Imaging. with gadolinium. Transient RV function changes noted immediately after  the event resolved by one week but 5/39 demonstrated  late deposition of gadolinium (delayed gadolenium enhancement or DGE) in the interventricular septum.The authors seemed to assume that the MR findings were fibrotic lesions and were causally related  to multiple bouts of endurance exercise but the actual cause of the late deposition of gadolinium has not been determined but it is true that  in some contexts ( maybe most) the histologic basis of the delayed gadolenium uptake is fibrosis.

Arrhymogenic right ventricular dysplasia (ARVD)-also called Arrhymogenic right ventricular cardiomyopathy) is an inherited condition primarily involving the right ventricle with replacement of cardiac muscle with fibrous tissue and fat, leading to decreased  right ventricular function and predisposition to arrhythmias including ventricular tachycardia and ventricular fibrillation.. Typically it is inherited as an autosomal dominant and involves several mutations in the genes that code for the desomsomal adhesive proteins which function to help bind muscle cells together.

ARVC is much more common in Italy and naturally there is more awareness in Italy and more more published research. The most common cause of sudden cardiac  death in the young in Italy is ARVC accounting for 22% of deaths versus 7 % from hypertrophic cardiomyopathy (HCM) in contrast to  HCM being the most common congenital problem found in sudden deaths in young athletes in the United states.See here for details of the long standing cardiac screening program in Italy.

While it seem reasonable to conjecture that a person with one of the ARVD gene patterns might hasten the clinical manifestations of ARVD by endurance exercise , is it possible/likely that a person could bring about an  ARVD-like clinical picture by repeated endurance training and endurance events in the absence of the Italian or other recognized  genetic patterns ?

Earlier work in 2009  by Breuckmann et al ( see here ) also demonstrated some marathoners with delayed gadolenium enhancement (DGE) but in a different distribution that seen in LaGerche's subjects. Of 102 marathon runners age 50-72 who had run at least five marathons in the preceding 3 years,12 showed a DGE .Of those, 5 had a "coronary artery disease" pattern along the distribution of the left anterior descending coronary artery while 7 showed a "predominantly midmyocardial patchy pattern".Could these midmyocardial patches of presumed fibrosis be the earliest lesions of a endurance athlete's cardiomyopathy, which to my knowledge, except for arguably ARVC , has not been reported. Have autopsies been done on Tarahumara runners?