The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...
Monday, September 04, 2023
Tuesday, August 29, 2023
Saturday, July 08, 2023
A family member had an echo last year and again recently. Last year's prices was $1461 and this year $4715 plus an $ 69 interpretation charge . Pulmonary function test at the same well known facility was $ 3871. Charges for outpatient imaging procedures are much higher than in imaging centers and echos are magnitudes cheaper in cardiologist offices, Several web sites that monitorcharges reported echo fees in cardiologist offices magnitudes lower than in the hostials echo labs, i.e. in the order of less than $500 in the same city as my family members fee of close to five thousand dollars. Several years ago Anthem insurance company said they would no longer pay for imaging procedures for outpatients done in hospitals.
Friday, May 12, 2023
humans are pattern seeking story telling creatures.
Economics cannot provide the level of certitude that the experimental sciences provide.The best it can do is look for patterns and then tell stories.
What if physics were like economics From Jim Manzi Uncontrolled:The surprising payoff of trial-and-error for business, politics and Society.
And how those stories vary-eg Milton Friedman and there is no free lunch versus the better than a free lunch claim that fiscal stimulus in an economy which has less than full employment will give a free lunch and will generate stillmore free lunches.(This from the advice that arose fromthe work of Lerner and Hansen taking Keynes thought and turning them into just about the coolest tool a politician or elected official could have ever received.)
It began with Ayn Rand and may have ended up on life support with Covid19 and how humans have reacted
Thursday, May 11, 2023
Sunday, May 07, 2023
Monday, May 01, 2023
Monday, April 03, 2023
Those were pillars of medical ethics and of the medical culture.
However, in recent years we have seen a major effort ,with varying degree of success, by prominent medical organizations and foundations to change medical ethics and the culture of medicine.This is not just my interpretation of recent trends but direct quotes from leaders of several medical organizations say that is exactly what they wish to do.
While a number of organizations including foundations and think tanks have taken part in this effort my focus in this commentary is on two such organization-the American College of Physician (ACP) and the American Board of Internal Medicine (ABIM) and its affiliated foundation the ABIMF.
Basically the proposed change is the shift from the medicine of the individual wherein the physician acts in the interest of the patient ,that is as his fiduciary agent to the concern for the health of the population or the collective which is referred to by its advocates in the less emotionally charged term "population medicine".
ABIM and ACP have orchestrated two major initiatives; the Physician's charter and the Choosing Wisely Campaign. the later of which I believe which functions as a Trogen horse.
The 2002 publication of Medical Professionalism in the New Millennium: A Physician Charter played a major role in the movement toward the practice of population medicine .It was the result of a collaboration of the ABIM Foundation,the ACP Foundation and the European Federation of Internal Medicine. The Charter described three fundamental principle of medical professionalism.
Principle of primacy of patient welfare.
Principle of patient autonomy
Principle of social justice. Physicians must promote social justice in the health care system, including the fair distribution of health care resources.
Although the Charter said " physicians must reaffirm their active dedication to the principle of professionalism.".The third principle,social justice, had not been a feature of traditional medical ethics so it could hardly be reaffirmed. The authors gratuitously added a new principle to medical ethics and then in their concluding remarks pretend that physician must reaffirm a principle not previously part medical ethics .
The Charter also presented a "set of Professional Responsibilites", one of which was:
Since the Charter was proposing a sea change in medical ethics,voices were raised in opposition.
A particularly articulate critique was made by Dr. Richard Fogoros, who was blogging under the name DrRich on the blog The Covert Ratoning Blog . Quoting from his January 18,2010 blog commentary:
"The New Medical Ethics,...(Annals of Internal Medicine, February 5, 2002, vol. 136, pages 243-246), is deficient in the following ways:
- it undermines the foundation of the doctor-patient relationship,
- it threatens to fundamentally destroy medicine as a legitimate profession, and
- it places patients at grave personal risk whenever they encounter the healthcare system"
The second major initiative to change the medical culture began as what seemed to be a very reasonable and non controversial suggestion. Physicians and their patients were encouraged to have a dialogue and discuss various tests and treatments as they applied to a given patient in regard to the elimination or at least reduction in the number that were thought to be unnecessary,possibly dangerous and costly. This initiative is known as the choosing wisely campaingn.
This quote for Wikiipedia summarizes the relationship between the Charter and Choosing Wisely :
...The charter states that physicians have a responsibility to promote health equity when some health resources are scarce. As a practical way of achieving distributive justice, in 2010 physician Howard Brody recommended that medical specialty societies, being stewards of a field, ought to publish a list of five things which they would like changed in their field and publicize it to their members. In 2011, the National Physicians Alliance tested a project in which it organized the creation of some "top 5 lists". Analysis of the National Physician's Alliance project predicted that the health field could save more than US$5 billion by cutting waste."
So the basic principles are : physicians are stewards of medical resources and that they need to work for health equity and that by cutting waste and saving money distributive justice would be furthered.
Dr,Cassel in an August 2012 talk about Choosing wisely at Universality of California recalled that the CW program really begin a year earlier when she and others, including Dr. Berwick and leaders of the not for profit publication Consumer rRports met.
Consumer Reports,though purportedly non political supported Obamacare and the presidential appointment of Dr. Don Berwick to lead CMS.
Population Medicine as a form of utilitarianism based on on some nebulous impossible to quantify notion of utility or happiness based on the purportedly objective measure of QALY.
I did not go to medical school to work to maximize or optimize the overall health of some population based on some metric and some ultimately subjective value judgment of a planner but times have changed and my generation of physicians is retiring and dying off.The dogs barked and the caravan moved on.
Friday, March 17, 2023
Willl longtime endurance exercise really preserve ( help preserve) a compliant left ventricle (LV) and mitigate the age related stiffening of the LV and the aorta?
Is the only solid evidence for that thesis the extensive work of Dr. Ben Levine and his coworkers at the Institute for Exercise and the Environment?
Some longitudinal studies have shown that active exercise achieve grater preservation of 02 max than do sedentary people but there are studies that contradict those findings.
Possible mechanisms by which long term exercise might preserve a compliant LV include:
animal work showing that rats with long time exercise develop elongated muscle fibers
improvement in calcium transport during relaxation 'increase in myocytes and improve fatty acid oxidation decreasing lipotoxicity Bhella , Impact of lifelong exercise dose on left ventricular compliance and distensibiity J Am Coll Cardio. 2014 vol 64 no 12
Saturday, February 18, 2023
As the years went by medical school, residency, fellowship all had their share of difficulty concepts to master and there was always something else to learn - always the perception that you needed to known all you could as you had people's health and lives in your hands.The rewards could be great but so were the challenges and the continuing obligation.
But then with the publication of the Physician Charter,the new medical professionalism,things seem to get even harder as a new daunting task appeared on the scene. Now doing your best for your patient to live up to your fiduciary duty was not enough, you also had to work for social justice and be a steward of society's finite medical resources.
Wow, that certainty didn't sound easy. In fact I had no clue as to how to live up to that new obligation nor understood exactly what these those terms even meant and was it not the case that sometime an individual's best interests conflicted with those of society assuming that the later interests could even be appropriately defined.
It was years later when I finally realized how I could live up to these new ethical obligations an exemplify the traits expected and demanded of a professional in the new milimeum and now it seems very easy.
It is easy because the medical progressives,the elite,the thought leaders , the hierarchy of various medical professional organizations will make it easy for the rank and file medical practitioners in the field. These leadesr will determine what is of value not only to the patients but to society. So based on what is high value guidelines will be forthcoming and the field docs will only have to adhere to them to do what is right for the patient which will also be what is in the best interests of society.
Any concern that I might have had about some conflict between the interests of the individual patient and society will vanish because as Victor Fuchs has told us what is good for the group will necessarily have to be good for your patient as well as he is a member of the group which is benefited. It gets better. The tests or procedures that you deny your patient is now understood to not be rationing at all. This is the case because some of the members of ACP elite has wisely redefined rationing as restricting the use of effective,high value care. So restricting lower value are is not by definition rationing at all.
This important role of determining what is high and what is not high value care is not the slam dunk that some members of the USPSTF task force said in regard to their pronouncement of no need to do any PSA screening. No this type analysis requires specialized expertise and training and is "typically performed by investigators", ( such as those writing the above referenced Annals article)
Wednesday, February 15, 2023
What seems to be a different view is that the following characterization of the MA by Dr.Steven Goodman who explains that a MA is basically an observational trial in which the subjects are themselves clinical trials. In the traditional hierarchic of clinical evidence observational trials are not considered the top of the pyramid.
so what is it-the highest order of evidence or merely a lowly observational study?
The ratio of the early velocity to the late velocity ( E/A ratio) is a simple measure of diastolic function.With aging early flow decreases ( generally thought to be due in early diastole to impaired relaxation and loss of elastic recoil) resulting in a lower E/A ratio. This is considered to be the earliest stage of diastolic dysfunction in which diastolic flow is decreased but cardiac filling pressures have not significantly increased. As ventricular filling become more impaired pressure builds in the left
But what to about echo reports that state impaired relaxation.Is it "normal for age" or a possible percursor to HFpEF.is there any role for aerobic exercise to lessen progression to HFpEF?
Pelegrino explains that the idea that the German war crimes perpetrated by physicians ( at least people with a medical degree) were the acts of only a handful was wrong. Many more physicians were involved in the what transpired under Nazi rule. He quotes historians who have demontrated how pervasive was the corruption and the degree to which German physicians "began to elevate service to the state above medical ethics"
Saturday, February 11, 2023
The value theory of value was promoted by David Ricardo and bought into and popularized by Karl Marx.
However, in the late 19th century three economists developed economic theory that became known as the marginal revolution. Value,they said was not something inherent in the object but value results from the subjective evaluation of the person and that evaluation is made at the margin. For example, if you have 20 apples you are likely to value the 21st apple less.
In this essay I will describe how the evaluation of a medical problem seems to work in at least one large not for profit big city hospital system and how that differs from how it used to be in a physician owned fairly large internal medicine practice in the same big city.
The basic events described are true but some non-essential details are altered in the following narrative to shield the identity of the innocent and the not so innocent.
William G,a retired 78 year old accountant has a routine annual visit with his primary care doctor who is a board certified ( and re certified ) internist.WG thought it was an annual exam but in reality, it was a modified Annual Wellness Visit (AWV) in which there was no physical touching involved between patient and physician. WG's red blood cell count was reduced from the previous year and the iron studies were done and they were consistent with ( but not diagnostic of) iron deficiency anemia. Based on his age a GI workup ( ie upper and low GI endoscopy) was in order and WG set off to get an appointment with a GI doctor in the same hospital system who had done a coloscopy for WG three years earlier. Although he was an established patient it was 3 week before an office visit could be scheduled and the another 5 weeks before the endoscopy procedure could be scheduled, a frustrating 2 month delay.
When I was in internal medicine practice in the 1970s in a physician owned group the time from one partner having a patient needing a GI endoscopy to seeing one of the GI docs in the group would have been one or two days at the most and the procedure would have been scheduled in another one to three days at most.
In the private practice group the clinic administrator worked for the doctors and in the large big hosptial system to some degree it is the other way around.The staff who do the scheduling are hired by the hospital and work for the hospital
Do the arguments of Kenneth Arrow and William Baumol forclose Market solution provison of health care
In regard to Baumol's disease, it is far from the case that his formulation is unchallenged. Baumol makes a number of simplifying assumptions and aggregations in his model most of which have been seriously critiqued. For example see here for an excellent detailed economic analysis of his assumptions and his logic and analysis. But as usual the headlines are on page one and the clarifications and retraction are found buried much deeper in the paper in smaller type .
Clinical trials are concerned with efficacy and safety. There are statistical tricks and methodologic manuevers than can be used to either give the illusion of safety when that has not been proven by the data and/or likewise give the appearance of efficacy or equivalence with a comparison drug when the data does not really allow for that conclusion. Some of these methods are intuitively obvious-once they have been pointed out-others are more subtle and require a degree of sophistication not typically possessed by the average physician and at a level not likely to be taught to most medical students.
Here are some of the simple ones :
use a dose of the comparison drug that is too low(or too high) depending it you are trying to show equivalence or superiority or comparing side effects
in a comparison trials -keep the power low by have a relatively small trial
measure multiple endpoints but report only those that are favorable
use sub-group analysis to find a set of patients in whom there appears to be efficacy
arrange multi-center trials reporting those results from centers in which the right answer is found
cherry pick the subjects to minimize likelihood of side effects
report composite end point results when demonstration of efficacy is the aim and report individual safety outcomes when safety demonstration is the aim
In the days when I trained as an internist and for another 20 years or so after that medical folks talked about the doctor's doctor. This referred to an internist known for his meticulous history taking skills and performing a very complete physical exam that would at least sometimes find something others has missed, He (and it was not always a he) was the physician to whom other doctors would refer to when they or their family member had a serious or mysterious medical condition or maybe just for reassurance.
However, as time went on the monetary compensation of the internists shrunk to a point (where for example they make only slightly more than a CRNA) and there was no time to take the time the oldtimey internist took because they could not afford to.Less compensation per patient lead to more patients per hour needed to be seen.
Recently I learned of an encounter a relative living in France had with his internist.At least there is one internist in France who seems much like that idealized internist that my fellow internal medicine residents and I hoped we could become.
My relative had been the victim of a missed acute appendicitis and was now several weeks post percutaneous drainage of several abscesses secondary to a ruptured appendix and was awaiting a follow up appendectomy
The internist took very detailed history and examined him and agreed with the need for follow up appendectomy and gave him the names and backgrounds of several surgeons.
Senior internists in France earn about $21200 per year only slightly less than US general internists but graduate from medical school without significant debt and have low malpractice premiums and are largely free of the major hassles of insurance approval for testing.Perhaps their practice styles allow them more time to be more like the stylized internist model of the past in the U.S.Alternately perhaps my relative's internist was an aberration.
"Determining" the risk of a heart attack for an individual patient was routine.Determining is in quotes because that seems to be a verb to use to magnify or exagerate the imporance or validity of what may be an educated or partially educated guess or even something less valid than that i.e. something you just make up.
do endurance athletes live longer beause of voluminous exercise or because their genes predispose them to high 02 oxygen uptake in later years?
If data show that endurance athletes live longer than non endurance athletes is it so because of the life prolonging effects of endurance exercise performed over many years or is it the case that the endurance athletes genetic inheritance allows them to not only run long and fast but to survive longer. By survive longer I mean in part that for example an octogenarian with an 02 maX of 30 is more likely to withstand the physiological trauma of septsis or major trauma better than an age cohort with an 02 max of 19.
A person',s maximal oxygen uptake(v02Max) is a strong predictor of life expectancy. A major part of frailty in the elderly is a low 02 max.
Tuesday, February 07, 2023
Late gadolinium enhancement (LGE) in long time endurance athletes may not mean scar tissue (in the sense of replacement scar tissue ) and may represent a "benign" finding.All LGE may not mean the same type of tissue alteration.That particularly applies to LGE at the insertion points of the right ventricle (RVIP).
See Grogoratos,c clinical importance of late gadolinium enhancement at right ventricular insertion point Int J cardiovascular imaging 2020 .
and Shambhag SM et al https://academic.oup.com/eurheartj/article/40/6/529/5185127
"... LGE at the RVIP ( right ventricular insertion points) has been proposed to represent focal plexiform fibrosis (associated with myocardial disarray rather than replacement fibrosis" Bravo, PC, Late gadolinium enhancement confirmed to the right ventricular insertion points in hypertrophic cardiomyopathy an intermediate stage phenotype, European heart journal cardiovascular imaging, 2016 Mar 17(3) 293 /// this article references the following as the source of the plexiform fibrosis pattern
One key question is does plexiform fibrosis pose the risk of inciting an arrythmia that does replacement fibrosis.
See also Moor, JC, The histological basis of late gadolinium enhancement in cardiovascular magnetic resonance imaging in hypertrophic cardiomyopathy. Amer Coll cardio 2004 43 2260
Paroxsymal atrial fibrillation (APF) is currently defined a a spontaneous remitting episode of atrial fibrillation (AFIB) lasting less than seven days and resolving without intervention. Current U.S. guidelines recommend oral anticoagulation therapy (OAC) for patients with all types of afib based on the stroke risk estimate using CHA2DS2-Vasc score.
Modern pacemakers (PM) can now record tracings continuously and store them for long periods of time. Several studies have analyzed these tracings and we have learned that commonly PM patients have short runs of Afib,( or more accurately atrial high rate episodesAHRE-some of which are in fact not AF) varying greatly in duration and frequency .
It does not make sense to assume we should have the same prognostic concerns and therapeutic recommendations to someone with a episode of afib lasting one minute as to someone with afib lasting five days without good data validating that position.
Several studies have attempted to correlate these runs of afib with stroke rate. With one exception data (see footnote 1) have not been analyzed if these episodes last less than 5 or 6 minutes.These studies have shown that there is a coarse grain dose response relationship between duration or "burden" of afib and stroke risk. Attempts have been made to determine an afib burden level above which there is a significant increase in risk worth of initiating anticoagulation and no consensus has been reached.
Various investigations have yielded different burden levels .
The ASSERT trial is widely quoted as showing a two fold increase in stroke risk for episodes of afib last over 6 minutes. See footnote 2 for a discussion of the surprisingly and diametrically different ways these results were described in medical publications.
Yet another article discussing ASSERT claims that a fib greater than 24 hours does have increased risk of stroke but for shorter episodes no statistically significant relationship was shown.
1. The Rate Registry study reported no increase risk of stroke for afib duration episodes less than 10-20 seconds.But what about those episodes between 20 seconds and six minutes?
2. Chin-Scarabellit et al including senior author K. Ellenbogen describe the ASSERT trial simply as showing an increased hazard ratio (HR) even though it was not statistically significant while Conn et al say "surprisingly,no correlation was found in the ASSERT between AHRE (atrial high rate episodes) and a history of stroke" and speculated that this might have resulted from the fact that the sampling period was only the first 3 months after PM implantation. A third spin on the ARREST was offered by Dr B P Knight (EPLab Digest March 2012) who said that only the highest quartile of duration ( more than 18 hours) was statistically significant.He did not discuss the problems involving in relying on subgroup analysis to reach a conclusion regarding outcome validity less alone making therapeutic decisions on that basis. Data is often hard to obtain but sometimes the real difficulty is in finding agreement as to what the data signify.
We used to complain abaout the Friday afternoon late call about from Dr. Brown who asked if could transfer Mrs Jone to your hospital. We were specialists and in an earlier era we were called diagnosticians .
Thee once was a organization called the Metropolitan Society of Internal Medicine. In its day there were several hundred members and monthly meeting were very well attended, often approaching 100 attendees. Membership was not open to anyone who called himself an Internist, you had to be Board Certified or Eligible to apply and there was a membership committee who oversaw the approval process.
I remember the last meeting I attended whee the members and guests were seated a one long table seating about 15 people. Today there is no such society.
I recently scanned the County medical society bulletin and say many other societies listing their dates for meetings.The internists society was no longer listed.
Libertarians and egalitarians both favor equality of opportunity but have different concepts of opportunity
Their view of opportunity includes the following consideration. If someone is ill,or poor or has some disability then they cannot enjoy equality of opportunity. A chronically debilitated,poor person does not have the same opportunity to obtain employment or get health care insurance or buy nutritious good or decent housing. Just as the modern day liberals ( progressives) have co-opted the term liberalism from the use of the word as in classical liberalism (now libertarianism), they seem to have co-opted equality of opportunity to mean much more than equality under the law which is typically the sense in which libertarians and conservatives use the term.
The egalitarian ethic is not just an abstract principle but an imperative to do something about the inequality of opportunity. Charity would be one method of mitigation of inequality but while many sincere progressives and egalitarians volunteer and contribute to charities their broader solution is government enforced redistribution of resources to lessen whatever inequality that is of particular concern at that time.
Here , of course, is the area in which conservative and libertarians and progressives part company and it becomes clear that the opposing groups do not seek the same rules of society.They both may favor equality of opportunity but mean different things by the word.
Now what about the term social justice?
To the progressives social justice means taking action to mitigate instances in which there is unequal access or unequal opportunity that is brought about by many societal factors , such as poverty and poor public schools.
The classical liberal concept of justice is the securing to individuals a domain in which they are protected from interference from others and from agencies of the state while Rawls et al maintain that limited view of justice does not recognize "that distributive shares ..are often determined by factors that are "arbitrary" from a moral point of view,eg the inheritance of certain factors, intelligence ,strength ,social advantage,wealth that are just the luck of the draw and the recipients are not deserving of those advantages. even if they work hard and use those advantages well those accomplishments are still arbitrary from a moral point of view.As Hayek said, the term justice does not need a modifier.
Wednesday, February 01, 2023
The unexpected relationships between both high dose statins and high level endurance exercise and coronary calcification
The jury has been back for a quite a while. Statins decrease the risk of coronary artery events. The curvilinear relationship between exercise and coronary artery events is also apparently beyond debate.
So one would not predict that both statins and exercise could be too much of a good thing in regard to coronary artery disease. Remember coronary calcification is, by defintion,coronary artery disease.
There are ample data demonstrating that long time and high dose statin use may increase the development of coronary calcification.In addition,there are reports of increased coronary calcification in long time marathon runners and endurance athletes.
So,how does this work? Exercise at least up to some level (that level has yet to be defined) decreases CAD risk but at some level increases coronary artery calcification which is a marker of CAD. Is the calcification different in endurance athletes? There is evidence that in endurance athletes who have coronary calcification that there are more of the dense variety and less of the mixed type which is thought to be more likely to thrombosis.
I have sampled four internists , two in active practice two retired more than 10 years earlier.Perhaps we can excuse the ignorance in the retirees.
All were woefully ignorant about the basics of the most common cause of anemia in the world,Iron deficiency anemia (IDA).
Case in point. A 78 year old man is noted to have a decrease of more than one gram in his hemoglobin from the previous annual "wellness meeting" which should not be confused with the annual physical exam which at least for some perhaps many Medicare patients is a thing of the past.Medicare will pay for an annual wellness visit but not a real hands on physical exam. The internist who practiced in a practice group associated with a large "not for profit" hospital system recommend he take ferrous sulfate three times a day,
Note- there was not at the time a recommendation for the patient to have a GI tract evaluation, not even a stool Guiac was mentioned. In 2019 a influential often quoted article by Ganz and Weiss included a flow sheet indicating that older patients ( over fifty) undergo a upper and lower endoscopy to rule out a source of bleeding if their initial blood tests has a pattern consistent with ( but not necessarily diagnostic of ) iron deficiency anemiaThe patient 's blood test fit that pattern. This pattern was low serum iron and percent saturation and a ferritin less than 100. Possible iron defeciency anemia in a man over fifty certainty warrants an evaluation for GI tract bleeding.
As the case evolved the GI doc's ignorance re IDA was revealed when he commented that a subsequent increase in the patient's ferritin reflected increasing iron stores. These two internists apparently knew little or nothing about the iron regulating hormone,hepcidin, If they did they would know how to administer oral iron and how to use the ferritin ( and other tests suh as the Ferritin index )to help differentiate between IDA and anemia of chronic inflammation and their combination.
For the past five years I have taken part in a version of the Medicare Wellness Visit with the addition of a series of blood tests.During that time a thyroid cancer grew to the size of a very large egg ( 5.5 cmX 3.5X 3.5) before it was finally detected from a cervical spine CT. Medicare Wellness exam is reimbursed by Medicare reasonably well but Medicare does not pay for physical exams
My medical " care " during a nine month period during which I was ostensibly being evaluated for a mild anemia is notable for the following:
1.The entry of a number of errors in my medical chart ( which is recorded in a widely used electronic health record (EHR) My diagnosis included atrial fibrillation and diabetes neither of which do I have.The EHR continues to admonish me that my diabetic eye exam and diabetic foot exam are overdue.
2.The ignorance of my primary care doctor and a GI specialist in regard to the diagnosis and treatment of the most common anemia in the world namely iron deficiency anemia was not reassuring. Both of their knowledge gaps could have been quickly corrected by spending a few minutes accessing Up T0 Date on their electronic device.
3.The alarmingly long time lag between various elements of my diagnostic workup which took place in a nationally known and highly ranked medical care system AKA hospital system. For example from the time my thyroid cancer was diagnosed by a fine needle aspiration (FNA) until the day of surgery was 43 days.
4.Entries in my record of several "phantom" medical exams. By phantom I mean description of exams that were in fact not done but still attested to by the physician's electronic signature. Why do some many physicians put their signature to a cut and paste exam that was not performed? Do they know what they will say if asked at a future deposition 'Doctor, did you actually do a exam on Mr.Jones on such and such date? Do you routinely lie on the medical record? .During a nine month period I was seen in the office by physicians 8 times and none of them apparently even looked at my neck let alone felt my thyroid gland though on several occasions a normal thyroid exam was recorded in the chart ( ie. the phantom exam).
5.My bone marrow aspiration and biopsy was done by a NP who told me she had been taught the procedure by a hematologist only some several months earlier. A noteworthy thing about the BM exam was the price charged ($ 23,000 ) by the hospital.
6.The thyroid mass was detected by a CT of the cervical spine ordered by a neurologist who never did notify me of the abnormality. Fortunately I was able to access the report and read of the finding myself. An earlier chest CT report did not mention a thyroid mass although it was clearly visible.
7.Astonishingy an ENT specialist who did a fiberoptic office exam of my throat for evaluation of a cricopharyngeal bar recorded a normal neck exam including the comment that the thyroid was free of nodules did not perform an exam of the thyroid at all. One week later the cervical CT showed a thyroid mass 5.5 cm in its largest dimension. I had to wait 6 weeks for that ENT appointment.
8.The pathology report of the surgical specimen of the thyroid tumor has a number of syntactical and transcription errors,likely representing inconsequential errors but IMO reflecting an alarming lack of proofing and professionalism.
(9 The attending surgeon and the consulting endocrinologist both either misread the pathology report or did not understand the significance of the reported findings and both told me that it was a very low risk variation but after the case was presented to the tumor board both amended their evaluation and recommendations accordingly based on the microscopic findings.
Iron deficiency is common in strenuous exercise i.e in endurance athletes.
In runners "GI iron loss"is frequently mentioned as a possible cause of the iron deficiency frequently observed in runners but those publications rarely describe or explain exactly what they mean by GI iron loss.
Do they mean that the incidence of well recognized causes of GI bleeding (colon cancer,polyps,peptic ulcer etc) are common in runners. I find little evidence of that.Perhaps the reference is to some type micro bleeds. Or do they mean there is some physiological mechanism by which there is GI iron loss without gross GI bleeding namely occult GI bleeding ( ie. normal stool color with a positive hemoccult test).
Actually there are data indicating occult GI iron loss with at least one study with positive guaiac tests post marathons and another pre and post marathon upper endoscopy study showed some small lesions in the stomach that could possibly cause small amount of blood loss.
There is a physiologic mechanism by which runners ( and other endurance athletes) loose blood in the GI tract.The mechanism is the sloughing off of iron loaded duodenal luminal lining cells (aka enterocytes) Actually this is a physiologic process that happens in everyone but is believed to be significantly increased in endurance athletes particularly runners because they may have more exercise induced hemolysis which in turn leads to more iron loss due to duodenal cell sloughing which is intensified by hepcidin release for exercise which traps the iron in the duodenal cells and the macrophages. Enteroyctes have short ( about 3 day) life span.
Here is an "as if" story of how that might work. Strenuous exercise leads to the release of IL6 which in turn stimulates the release of hepcidin, the hepatic hormone that is the master regulator of iron absorption and transfer and storage. (The putative release of hepcidin by IL6 is not crucial to the story it is the release of hepcidin that is important ).Hepcidin blocks the release of iron from the enterocytes and from macrophages slowing down the transfer of recycled iron to the bone marrow.
The Assocation of iron deficiency and running is well discussed in the sports medicine literature and in the lay runners press but much less so the hematology journals.
Tuesday, January 31, 2023
Are the Strauss criteria for LBBB diagnosis best suited to predict favorable outcome for CRT ?
Jastrzebsi et al have published data suggesting that the answer to that question is yes. The authors compared four EKG criteria for the diagnosis for LBBB and then compared the outcomes of CRT of patients defined as having LBBB by the various criteria. Patients with Strauss defined LBBB did better than the patients with LBBB defined by other criteria.
This study supports the notion that LBBB defined by Strauss detects so called "true LBBB" with delayed activation of the lateral left ventricular wall and the abnormal inter-ventricular septum motion which can be detected by the "septal flash" on cardiac echo exam. In other words the Strauss EG patterns seems to detect patients whose conduction defect(s) is most likely to be corrected by CRT differentiating it from various "non-specific intraventricular conduction defects".
Jastrzebski,M et al Comparison of fojr LBBB definitions for predicting morality in patients receiving cardiac resynchronization therapy. Ann Noninvasive Electro 2018 23 (c) e 12563
My pace maker battery life is on the downslope of available electrons.This week I had an in office PM interrogation and the company tech took the opportunity to promote their new option ( for some units) namely an app for a smart phone to replace the bed side transmission unit I have now.
I personally believe the patient should have full access to all of the information typically displayed on the interrogation reports.What Medtronic seems to offer to the smart app holder is the battery voltage reading and the expected battery lifetime and the daily activity. You will need to use your app to send in the interrogation to the Medtronic mother ship from which your physician or the third partly interrogation report reader company can access the report.
So now it seems that gathering the data from your Pace Maker and transmitting it to Medtronic falls upon the patient and his internet connection and his modem/router. while previously all of that was done by the hardware and software supplied by the pace maker company. You did not need an internet connection or even a phone line which in the past was a means of sending in data to the company/
My thinking is that the current bed side system works well and I see no reason for me to take on the responsibility of the care and feeding of the electronic mechanisms and hardware to transmit the interrogation.When and if the bed side unit fails or wears out Medtronc will send you another without charge.When your smart phone dies you will replace it .
In 2013 the Heart Rhythm Society published a position paper on the issue of remote interrogations (RI) and remote monitoring (RM) of CIEDs ( cardiac implantable electronic devices). As pointed out in the HRS paper, RI and RM are often used interchangeably with RM being used " colloquially for both"
Robert A Levy of the Cato Institute discusses some aspects of the recently announced covid 19 mandates on the Septembers 1 Bob Harden Show podcast.
Interestingly Levy did not specifically use the term which is the so called prime directive of libertarianism. The non aggression axiom. If one believes that the world is in the throes of a pandemic involving a respiratory virus that spreads by aerosol transmission and that this disease is very contagious and that vaccinated and of course unvaccinated can spread the disease and that masks mitigate the risk and that vaccination mitigate the risk then not wearing a mask in public in an area in which the disease is spreading should be considered an aggressive act.Therefore not wearing a mask under those conditions is about as un libertarian a thing as there be.
Governors Abbott and DeSantis have through their executive actions and/or legislation they sponsored acted to limit the private property rights of business owners in their states. Business owners have the right to set the terms and conditions of their employees and the terms of business arrangements of their customers. Both governors have prohibited businesses from utilizing a de facto vaccine mandate regarding their customers. Conservatives have long favored a " no shirt,no shoes no service" business approach. which they now discard in an effort to what they seemingly believe to gain approval of a minority of Republicans who are perceived to be strongly anti mask and anti covid vaccination under the faux banner of preserving freedom while actually abrogating the property rights of business owners.
Saturday, January 28, 2023
In October 2015 I was implanted with a pace maker which used a His Bundle (HB) lead.Every thing it seems now is thought of or written about as a journey so I tell my journey.
Since I developed a high grade second degree heart bock that was precipitated by exercise and a left bundle branch block (LBBB) also,I was a candidate for a pacemaker (PM) and cardiac resynchronization therapy (CRT) which at the time was synonymous with bi-ventricular pacing (BI-V) .
BiV has been accomplished by atrial pacing,right ventricular pacing and left ventricular pacing which was done by inserting a pacing lead into a vein of the epicardial surface of the left ventricule (LV) .which was accessed by placing a catheter into the coronary sinus in the right atrium and threading it into a LV epicardial vein.
My EP cardiologist had a different approach. He implanted a lead in the right atrium and placed the ventricular lead near the bundle of His in the interventricular septumThe third lead was placed in a vein on the surface on the left ventricle.This bi-V approach is done in cases of heart failure (HF) in which there is significant desynchrony of the left ventricle (LV) which reduces cardiac output and leading to significant deleterious cardiac remodeling.
The LV lead was to be a back up lead and in the first five years was not needed as during implantation the Right ventricular catheter recorded a His Bundle signal which captured the Purkinje System and provided a narrow QRS complex replacing the LBBB. The HB pacing was considered to be "non-select" HB pacing as both the His Bundle and a portion of myocardium was stimulated giving an EKG with a delta wave resembling the EKG of an anteroseptal preexcitation pattern.
Non select HBP is thought to be as effective as select HBP ( in which there is only capture of the His Bundle and the EKG has an isoelectric interval between the stimulus and ventricular capture signal) in terms of cardiac output.
HBP typically has requested a higher capture voltage than does right ventricular apical capture and has a greater incidence of need for lead replacement and may have a lower r wave. HBP has also required a longer implantation time and higher incidence of failure to capture rate. All of those issues have become much less of an issue as operator experience has increased and better catheters have become available with procedure times being shortened, capture threshold lower, and fewer cases of that require a lead replacement.
The post implantation period was not without drama. The first night the chest pain was severe and frightening and I felt lightheaded. I had been NPO from midnight of the day preceding the procedure day and although the procedure was scheduled for 7 am , because of an intervening emergency it was after one pm before I went into the cath lab by which time I was likely moderately volume depleted.
This lead to a situation in which I had chest pain and a low blood pressure.My wife also a physician were able to convince, badger and intimidate the rookie nurse to run in more fluid.The fluid and a shot of morphine relieved the pain and volume depletion correction alleviated the weakness.
3 days later I developed left sided pleuritic chest pain,a heart rate of 150 (shown to be atrial flutter on EKG) and an emergency Pulmonary CT angio was interpreted as showing several pulmonary emboli in the left lung and a peripheral pulmonary infiltrate in the same area.
Symptomatic Pulmonary emboli after pacemaker implantation are uncommon.One study using V/Q lung scans demonstrated probable emboli in 15% of a small number of asymptomatic casesI had a repeat pulmonary CT scan following 3 months of apixaban which was normal .
Six years later my pacemaker battery was nearly end of service and I had a pacemaker replacement. No post op complications occurred this time.
In 2006 ,Rafael Barba-Pichardo et al from Spain published a series of cases of HBP which included a single case of using the His Bundle to pace a patient with heart failure in whom a LV vein could be assessed. This appears to be first case report of HB paced CRT/
In 2010 DL Lustgarten et al accomplished direct His pacing in 10 patients who were candidates for Biv pacing. ( Lustgarten Dl Electrical resynchronization induced by direct his bundle pacing ..Heart Rhythm 7 , 2010 p 15
In 2017 Rodney Tung from Chicago and Kalyanam Shivkumar from UCLAA (2) reported a series of 21 patients in a study the purpose of which to assess the feasibility of a His-bundle lead for CRT in place of the coronary sinus lead.
1)Barba-Pichardo, R et al , Permanent His Bundle Pacing in patients with infra-Hisian atrioventricular block. Revista Espanola de cardiologia, vol 59m553-558
2)Ajijola,OA et al Permanent HIs-Bundle pacing for cardiac resynchronization :initial feasibility study in lieu of left ventricular lead.Heart Rhythm2017,sept 14 (9) 1353-1361
Thursday, January 19, 2023
Six years ago after I had recovered from my pacemaker implantation and the subsequent complications (pulmonary emboli and pocket hematoma) I mentioned to my EP cardiologist that I believed that I could run a half marathon. I had abandoned thoughts of completing a full marathon because for the proceeding two years I had barely finished in under six hour which was the cut off time to be officially counted as a finisher. for the full marathon.
The EP doc said that is not a good idea and when asked why he mentioned the risk of atrial fibrillation. I thought he was wrong but let the mater drop. I did not doubt that there is a relationship between running and AF but felt sure that the level of exercise sufficient to train for a half marathon was not in the range where there would be worry about AF.
The irony of recently seeing the EP doc's picture posted by him on a social medium site showing him with the half marathon medal along with his finishing time did not go unnoticed.
This is a good time to review the current recommendation for exercise to reduce cardiovascular risk,at what level of exercise does it becomes too much or a good thing,and at what level does there appear to be an increased risk of atrial fibrillation.
Currently the widely accepted view and the WHO recommendation is that as a minimum one should exercise at a level of 8 met hours per week.This is equivalent to 1/2 hr of moderate exercise for five days a week. Moderate is defined at a 3-6 Met level.8 met hours per week can also be achieved by vigorous exercise ( defined at greater then 7 mets) for 1.25 hours per day for five days per week.
8 met hours per week is good but it is widely believed that at least a bit more is better, for example exercise at twice the minimum level would be better in term of cardiovascular risk reduction.This would be exercising at a moderate intensity for one hour a day for five days a week.
So it seems in terms of cardiovascular risk reduction more is better but there must be limits to that.Is there a level of exercise beyond which there is no further improvement in risk reduction?
Eisvogel's data analysis suggest that that level is around 41 met hours per week. That is five times the minimum or 2.5 hours of moderate exercise per day five times a week . Interestingly the risk reduction exercise volume curve flattens out at a much lower level for vigorous exercise, at 11 Met hrs per week according to Eisjvogels analysis data from Wen and from Aren.
At what level of exercise can we expect an increased risk of atrial fibrillation?
Data from Ricci 2018 suggests that level may be about 55 met hours per week or 7 times the minimum recommended dose which would be 3.5 hr moderate exercise per day five times a week
The level of exercise sufficient to train for a half marathon is definitely less than the estimated threshold for increased risk of atrial fibrillation. Check out any of the numerous half marathon training program and you will see the volume suggested is much less than 7 times the minimal WHO recommended exercise level.
Wednesday, January 18, 2023
The thresholds for capture of the ventricular muscle may change over time with changes in the myocardial excitability which may be related to disease progression , electrolyte variation ,exercise,temperaturre etc.
With the development and proven effectiveness and safety of automatic threshold determinations pacemakers were able to have longer battery lives and there was more assurance of ventricular capture than was possible with in office threshold determination every 3 or six months as was the practice. Automatic capture management (ACM) s have clearly been a useful development in PM technology.Patients' threshold levels could be measured daily.
Various pacemaker manufacturers have developed their own automatic capture management systems and have become commonplace..
However since the increasing use of conduction system pacing in the form of His Bundle pacing,problems have become evident with ACM algorithms.
Journal articles by Haran Burri and P. Vijayaraman have described the problems with HBP and ACMs. In regards to ACM issue details vary with what port on the PM is the His lead attached and whether there is selective or non-selective His pacing.
The story of left bundle branch block from interesting anomaly to a electrophysiologic fixable condition
As time went on it was realized that the pattern represented a "block" or conduction delay in the left branch of the Bundle of His and became established as a reliable sign of heart disease, it being often associated with ischemic heart disease,hypertensive heart disease and various cardiomyopathies.
Recognition of the role of a prolonged QRS and decreased cardiac function and the role of ventricular dyssynchrony in HF lead to idea of cardiac resynchronization therapy (CRT) in which there was pacing of both the right ventricle and the left ventricle( with a pacing lead in a coronary vein accessed via the coronary sinus) in an effort to restore synchrony between the septum and the ventricular free wall.
From 2001 through 2009 there were several randomized clinical trials that demonstrated the efficacy of CRT in improving cardiac function, lessening symptoms and in reducing mortality in heart failure patients.
Sunday, January 15, 2023
In out ancestral, tribal- based behavior maybe there is some DNA driving us to seek out and follow leaders, strong wise individuals who can shepherd us through tough times- societal and even personal as in health care matters.
Knowing as much as I know about doctors and medicine and clinical trials and fragile and contradictory guidelines and the utter impossibility of being able to keep up with every thing even in your own subspeciality and the temporal fragility of medical advice I think I have largely lost the capability to benefit from the placebo- witch doctor -effect when -I absolutely have to see a
The question I am raising here is will HCPs without MD degrees pack the same placebo power as physicians for those who are not as skeptical as I am of the physician's ability.
At least some of what occurs behind the anesthesiologist drapes stays there not being completely captured by the surgeons op note. This is the case because the surgeon does not know what goes on in real time focused as he should be on the details of the procedure.
I have a pacemaker, a dual chamber in DDD mode with the right ventricular lead placed in close proximity to the Bundle of His.Typically this is referred to as non select His Bundle pacing, I was to have surgical procedure with the operative field to be within a few centimeters of the pacemaker .
It is common practice to deactivate the sensing function of the PM since the cautery typically used in surgery can emit electromagnetic energy ( electromagnetic interference (EMI )) that can damage the PM or change its function with variable clinical consequences.
The sensing function of the PM can be disabled by the application of a magnet over the PM.This converts a PM in DDD mode to one in D00 mode in which the atrium and ventricle are paced typically at a rate of 85. This is called asynchronous pacing and referred to as magnet mode .
This eliminates the risk of EMI but at the cost of limiting the heart ability to increase cardiac output and poses the risk of ventricular tachycardia or ventricular fibrillation if a pacing spike should occur at the vulnerable phase of repolarization. If the patient has a functioning sinus node and intact electrical transmission there will be two competing rhythms .
The operative record include a series of Blood pressure recordings all of which in my case were normal.Yet the medication record includes levophed which would have only been used if the blood pressure has decreased significantly. So that fact must have stayed behind the drapes.
Could the presumed blood pressure drop be due to the magnet mode not allowing an intrinsic increase in cardiac output assuming there was a valid reason for the use of levophed?
Thursday, January 12, 2023
An important study with data from the Cooper Clinic in Dallas provides some information on that question.
Defina et al (1) presented data from a large cohort of men ( 21,758) with ten years of more of followup. In the group there were 432 men with an exercise history of equal to or greater than 3000 met-min per week .This is approximately equivalent to one hour of vigorous activity per day ( at a level greater than 7 Mets which is the oxygen uptake required to finish Stage 2 on the Bruce protocol).This is a level of exercise about 6 times the minimal level of vigorous ( greater than 7 Mets) exercise per week recommended by the 2018 guidelines.
Men in this group had a greater risk of having a coronary calcium score of 100 or greater but their risk for cardiovascular mortality (CVD) and all cause mortality was not greater than men exercising at lower levels and was lower than the least active men in that cohort. This was the case even though they had higher CAC scores which generally predicts a higher cardiovascular risk.
Franklin and co-authors (2) said this about the DeFina study:
" These finding refute the notion that high-volume endurance activity ( greater than one hour/day) increases mortality regardless of CAC level"
The issue in the De Fina article was the signficance of increased CAC in long time endurance exercisers on cardiovascular mortality but it also provides some information regarding the title question .
1)DeFina,LF et al Association of all-cause and cardiovascular mortality with high levels of physical activity and concurrent artery calcification. JAMA Cardiology 2019 42 (2) 174
2)Franklin, BA Exercise related acute cardiovascular events and potentially deleterious adaptations
following long term exercise training. Placing the risks into perspective-An update A scientific statement from the American Heart Association. Circ 2020 Feb 26 PMID 32100573