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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, September 29, 2017

Will the real Phidippides Syndrome (if there is one ) please stand up

The legendary Greek courier who ran back and forth in the days surrounding the big battle between the Greek and the Persians in the fifth century BC was named Phidippides. The story goes that he first ran from Athens to Sparta carrying a request of the Athenians to the Spartans for aid and then ran back to Athens with the bad news that Sparta could not help, something about a religious holiday not allowing them to fight,running a total of 280 mile  round trip which took about 36 hours each way. That is about 3.8 mph or a 15.7 minute per mile pace- more of a brisk walk but the course was hilly. Then after the Athenians upset the Persians he ran from the site of the battle, the plains of marathon, to Athens to warn the city that the Persians  fled Marathon and were hoping to rush to Athens  by sea and attack again. This time Phidippdes was in a more of a  hurry and ran the 26 miles distance in about 3 hours or about a 7 minute per mile pace and died on arrival.

At least three different  clinical presentation have been deemed to be Phidippdes Syndrome (P syndrome)

James O' Keefe commented on the death of a legendary trail runner, Micah True AKA Caballo Blanco, who died on a run and at autopsy was said to have a dilated cardiomyopathy saying that this was an obvious case of P syndrome  if there were no other causes of a dilated cardiomyopathy and that P syndrome has some diagnostic,generally agreed upon differentiating features.

Dr. Justin Tivaxx reported a case of a 50 year old  half  marathon  runner who collapsed with and was resuscitated from ventricular fibrillation some 12 hours after a running workout. His MR showed a focal area of late gadolinium enhancement in the basal anterior septal said to not be a coronary artery distribution. This was suggested to be the focus of the previous ventricular fibrillation episode. Dr. Tivaxx presented in his paper an "hypothesis" concerning pathophysiology relevant to endurance exercise cardiac dysfunction and also said "considerable research is needed for to mature into an accepted understanding in clinical practice." Amen, yet some investigators write as if P. Syndrome is an accepted entity and that the general medical audience knows what it is.At the point I don't see how.

A third condition sometimes refers to as P syndrome is the putative clinical entity of exercise induced ARVD.At least two group of researchers  have presented some evidence that such an entity exists.

So what is P syndrome, a dilated cardiomyopathy in a endurance athlete, a runner with an area of delayed gadolinium uptake or  a person with ARVD who exercises.?

Tuesday, September 26, 2017

Does long time aerobic exercise mitigate age related heart stiffness by altering titin isoforms?

Well, with a topic title like that, I expect an overload of hits.

In 1977 Maruyama described a muscle protein that he named connectin, now more commonly referred to as titin.

Titin is responsible for the passive elasticity of muscles and to prevent muscle over stretching. It is the largest protein in nature and is appropriately  encoded by the largest human gene,  the TTN gene. The titin molecule is the length of the sarcomere stretching from the Z line to the M band in the sarcomere.

Lalande et al (1) describe the link between exercise and titin's properties, specifically passive stiffness.The are a number of titin isoforms, some are long and thin associated with less stiff muscles , while others seem more likely to be related to stiffer muscles.. The authors present animal experiment data  that suggest titin stiffness  can by modified by such post translational mechanisms such as  phosphorylation.

They suggest that "cardiac passive stiffness (k )may be a unifying mechanism "that links the benefits of long time aerobic exercise and the negative cardiovascular effect of sedentary lifestyles.

They review the work of the Dallas group (2) that demonstrated long time endurance athletes have ventricular stiffness similar to that of young sedentary subjects and their meta-analysis (3) that suggested that exercise levels above the US guidelines ( which is 150 minutes of moderate level exercise per week, or 500 Met minutes per week) significantly reduced the risk of diastolic heart failure presumably by mitigating the age and inactivity related increase in cardiac stiffness,

They review animal models that demonstrated exercise induced changes in cardiac passive stiffness that may be related to alterations in titin. To date there are no human data demonstrating that relationship but perhaps post translational alterations in titin offers a mechanism by which endurance exercise maintains cardiac compliance.Anyway it is nice to think so.

1) Lalande, S et al  The link between exercise and titin passive stiffness.Exp Physiology 2017 p 1-12

2)Arbab-Zadeh, A Effect of aging and physical activity of left ventricular compliance. Circulation 110,1799

3)Pandey,A Dose-response relationship between physical activity and risk of heart failure: a meta-analysis. Circulation 132 ,1786

Will the new war on opioids make patients with pain collateral damage.

Warren Meyer who writes the blog Coyote got it right. He said in part in commenting on Arizona's governor Ducey's announcement of guidelines regarding opioid control:

"Consider that many legitimate users will need more than the legal maximum dosage to control their pain, and thus the issue becomes whether we want to essentially torture innocent sick people by forcing them to remain in excruciating pain in exchange for (possibly) reducing the number of accidental deaths from abusers of these drugs (I say possibly because over the last 40 years the government war on drugs has had such a super stellar track record in reducing narcotic usage)."

CVS Caremark in getting in the act as well with more of their nanny-style pharmacy practices.Their "opioid utilization management" plan includes in part:

 This program will include limiting to seven days (the Arizona guidelines mandate 5 days) the supply of opioids dispensed for certain acute prescriptions for patients who are new to therapy; limiting the daily dosage of opioids dispensed based on the strength of the opioid; and requiring the use of immediate-release formulations of opioids before extended-release opioids are dispensed.

Who would know better how much pain pill to prescribe and at what dosage than a large pharmacy-pharmacy management company aided by guidelines from the CDC , an organization in which one is unlikely  to find many folks who actually treat  patients for pain or anything else for that matter.

If the results of the decades of the war on drugs offer any forecast of the success  of this latest surge it may be well be that there will be significant collateral damage to the patients who most need pain control.

never should have made pain which is a symptom into a sign

Monday, September 25, 2017

Sadly we will not get to see how fast Ed Whitlock could run a marathon at age 90.

This year the legendary marathoner Ed Whitlock died at age 86  on March 13 2017 of prostate cancer.

Famous in the running world Whitlock at 72 was the first at age 70 or older to run a marathon is less than 3  hours . He ran a 2:5:10 in 2003. What I find perhaps most amazing was the fact that his running speed in marathons changed so little in the age range when typically  a person's  O2 max decreases rapidly.See  ref 2 below for description of how the decline in aerobic capacity accelerates with age which seems to contradict the literature than has shown a constant linear decline until about age 70 at which time a more rapid descent appears.

At age 70 he ran a 3:00. 23 marathon and at age 76 he ran 3:04.53 and at 80 he ran a 3:35 54.Over a six year period beginning at age 70 his marathon time decreased only about 4 minutes- a time difference easily attributable to varying weather-temperature and wind- and terrain differences over a 26.2 mile course or an extra bath room break.

Physiological testing was done on Whitlock at age 81 and his measured  02 Max was 54. This , as best I can find, is the highest recorded value for a man in his eighties.  Earlier, Karlsen (3) reported a value of 50 in an 80 years old Norwegian in 2015.

Trappe et al(1)studied nine  80 years old endurance athletes ( they had exercised regularly for fifty years) and found their O2 max to be from 34-42.

 The authors  reviewed data from the literature and reported that in a total of 195 non athletic  men   in their  eighties the measured  O2 max  ranged from 17 to 25.

One can speculate that Whitlock would have been able to run at least a sub 2:15 ( and probably better) marathon  in his late 20s or early 30's as his 02 max would have probably been in the 80s which is the range measured in the typical world class marathoner.

While speculation about what some folks who are far out on the normal curve of aerobic capacity are able to do is interesting but perhaps more importantly  what can the typical,healthy non-lifetime athlete in his/her eighties do physically. Here we are talking about people whose V02 max ranges from 17 to 25.

They should be able to finish Stage 1 on the Bruce protocol treadmill tests as this is thought to require a 17.5 02 uptake and be roughly comparable to a 15 minute per mile walk. Some would be able to actually finish Stage 2 which corresponds to a 15 minute per mile run.  (It requires only 70% as much 02 uptake to walk a fifteen minute mile as it does to fun a mile in fifteen minutes.)According to the data from the CDC and ASM ,walking at less than 5 mph , golfing and ball room dancing would  well be in the range of activities easily done by folks in this aerobic capacity range as well as light house work and all activities of daily care.

1)Trappe,S et al New records in aerobic power among octogenarians lifelong athletes. J.A. P 2013, 114 3-10

2) Fleg,Jl Accelerated longitudinal decline of aerobic capacity in healthy older adults. Circ.2005;112;674-682

3) Karlsen T. How to be 80 years old and have a v02 max of a 35 year old.Case reports in Medicine vol. 2015. id no 909561

1/17/18 addendum Several corrections made.

Wednesday, September 20, 2017

Bone Marrow lesions- not "bone marrow edema"

In 1995 in a misguided effort to increase my exercise program I developed severe groin pain that was shown to be hip adductor muscle tears by MR. The MR also demonstrated 2 area interpreted as "bone marrow edema" and the radiologist recommended I see my internist to evaluate with one concern being  possible myeloma. A normal protein electrophoresis allayed my concern and I decided to learn what bone marrow edema was all about.

The term "bone marrow edema" (BME) was introduced in 1988 in a radiology journal article which described the MRI findings in a group of patients with severe pain and osteoarthritis (OA) of the hip and knee.  Areas of  increased signal intensity on T2 weighted images were described  in  the femoral head and condyles. Followup examinations showed that the lesions were transient and described by the authors as a  "bone marrow edema- like" imaging pattern. Since then in spite of histological evidence that the pattern is not really marrow edema,that imaging pattern is often called BME or bone marrow edema

In 2000 a pathological examination of the resected bone in 16 patients with OA  who underwent total knee arthroplasy  (TKA) demonstrated that the bone in these BME area were in fact not edematous at all but showed varying degrees  mainly normal bone and degrees of fibrosis,necrosis,bleeding and abnormal trabeculae. The BE areas demonstrated no more edema than surrounding bone.

The term "bone marrow lesions" ( BML) is now preferable to the pathologically incorrect BME, though BME is still frequently found on MR reports.
It is now recognized that patients with knee osteoarthritis (OA) frequently have these lesions in the femoral condyles and are often but not always associated with exacerbations of pain and that these lesions may be transient and may increase or decrease in size over time  and the literature is conflicting regarding how well these BML correlate with the pain. Yet the association with pain is sufficiently strong to apparent warrant various strategies to treat BME. It seems from my sampling of  web activity that OA patients  regularly are searching for some effective treatment for BME and different operative and non operative approaches have been tried with there being no strong evidence that any approach is very effective.

BML are seen in a variety of settings.

1) Athletes in certain setting have been shown to have BMLs. For example about a third of college basketball players during their active season reported in one paper had lesions in the knee that were asymptomatic and not associated with an other findings on the MRIs. In another study 3/22 marathon runners were shown to have BMLs in the femur after a marathon.

2) trauma

3)Spontaneous osteonecrosis (ON) of the knee (SONK or SPONK)

First described by Ahlbach in 1968 the currently popular etiopathophysiology concept is that the entity is really a subchondral insufficiency fracture (SCIF).The SCIF is thought to sometimes heals  in some cases while in others is  progressive  wherein  there is  bone necrosis and subsequent impaction of subchondral bone and deleterious change in the contour of the articular surface which facilitates the progression of osteoarthritis.

4) post knee procedure ON. The typical case is a older age female with a medial  meniscus tear involving the posterior horn who undergoes an arthroscopy and a partial meniscectomy with or without a chondroplasty on an area of cartilage loss on the medial femoral condyle.

Friday, September 15, 2017

The new "medical professionalism"-the dogs bark and the carvan moves on

Five years ago a push- back to the new medical professionalism was a frequent topic on the medical blogs.Now I hear or read little about it. On several levels it seems to be a fait accompli as least in academic writings and in appropriate politically correct speech. How practicing  physicians think about it  may be another matter.

I was reminded of one of my earlier blog postings by a letter from  CVS CAREMARK who wanted to be sure that I was still taking my BP meds as their records indicated that I had not refilled my prescription on time.

The origin(s) of the phrase " The dogs bark but the caravan moves on " is unclear, but the point is that the barking did not significantly impede the caravan on its journey. I suspect our barking did little.

I repeat a lighted edited version of a posting I offered 5 years ago in the hope that interest may be rekindled and to not let folks forget about the chilling  philosophy expressed the book "New Rules".  Some of the links may well be broken by now.

Kudos to Doug Peredina  at the blog roadtohellth with this commentary on medical nannies,the activities of CVS Caremark alone those lines and the broader topic of the problems with the new medical professionalism, also known as the "new ethics", a topic of considerable concern to me and one about which I have ranted repeatedly.See here and here.

Dr. Peredina discusses a lawsuit filed against CVS . Dr. Troyen Brennan is the CMO and executive vice-president of CVS Caremark. The following is a quote from the book "New Rules" which was written by Dr. Brennan and the current head of CMS Dr. Donald Berwick. They are discussing the physician patient relationship and say the following:

"Today, this isolated relationship is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making.”

In 2007,Dr. Brennan,then the executive vice president of Aetna cowrote an article in JAMA entitled "Managing Medical Resources. A return to the medical commons" which I blogged about ( see here) and I said in part:

"They speak of an abstract hypothetical " medical commons" and how the current emphasis by the physician on the welfare of the individual patient will spoil the commons much as the farmer who selfishly grazes his cattle on public land without regard for depleting the resource will destroy the resource.Physicians are implored to "reconstitute the medical commons" and think in terms of resource conservation and allocation so at the end the greatest medical good can be done for the greatest number of patients.They admit there is not currently such a commons. There never has been so I am unsure how a return is possible."

With this increasing constraint of decentralized individualized decision ( translation-individual docs advising individual patients about a course of action) someone else must make those decisions. Do you think the folks at insurance companies and pharmacy management companies might enjoy that role? Isn't it interesting that the head of CMS and the vice-president of a pharmacy management company share the same view of the "proper"role of the physician?

Also kudos to DrRich at his blog, which sadly is no longer active, Covert Rationing Blog with this thoughtful and important criticism of the new medical ethics, in which the traditional physician patient relationship with its fiduciary duty of the physician is being replaced with a nebulous duty to society . Also DrRich-in his real life persona of Dr. Richard Fogoros- hosted a discussion on Sermo which from my vantage point was well received and he did an admirable job in fielding a variety of questions. It is instructive and worrisome that a number of the physicians writing in had not even heard about the New Professionalism. If you have not, go here to read about it in the original.

Also kudos to Dr. Beth Haynes at the blog Blackribbonproject for this entry concerning various aspects of the attack on the traditional physician-patient relationship.

This important topic deserves all the attention it can get.

Saturday, September 02, 2017

ESPN football commentator quits-Football too dangerous

I have blogged aabout head injury and football several times. What a former player and now former TV football analyst,Ed Cunningham had to say has much more limbic valence.

I refer to what he wanted to say to some football coaches after one of the more meaningless post season Bowl games after watching one the QBs being repeatedly pummeled.

Paraphrased - Dudes, what are  you doing- these are just kids.



addendum 9/4/17 Another quote I had to add. This from a George Will column regarding NFL football. He quotes college football coach Jim Harbaugh who said [football]" is the last bastion in America for toughness in men". Will added ..that thought must amuse Marines patrolling Afghanistan's  Helmand province.