Is the Annual Wellness Visit just a condescending waste of time or something worse?

 Is the Annual Wellness Visit (AWV) merely a demeaning waste of time or something actually harmful.? I have endured an AWV for the past 4 years, although it was only recently that I  realized what that irritating waste of time was called. For a friend of mine it may have been worse than just a waste of time and the money paid for parking at the large "not for profit" medical center where he PCP practiced.

I think the AWV should be considered potentially harmful to the extent it make take the place of the annual assessment by an internist, as assessment which by long standing tradition included a physical examination.Think opportunity cost/

Some internists , I have no way of knowing how many. have given up on the annual physical exam because the AWV pays better. Medicare does not pay for a routine physical exam. The traditional system review has been replaced by some version of a geriatric assessment exercise in the AWV.

 Annually  as part of his AWV BK an ,81 year old retired dentist, has  been asked about the frequency of falls, if he can prepare his  own foods and if he  can manage his  own finances. BK was asked to draw a clock and to remember three things for a few minutes.He was admonished about the value of the shingles shot,the pneumonia shot and the annual flu shot.He endured the AWV for three years..

No one noticed the mass in his thyroid which grew to the size of 5.5 cm X 3.5. X 3.5 before it was noticed on a CT exam of the cervical spine,ordered by a neurologist as part of a workup for a diagnosed peripheral neuropathy.

The tumor has been removed and the treatment was followed up by radioactive iodine treatment and currently there  is no  evidence of extra-glandular spread but you have to wonder whatever the prognosis is it surely would have been better if some time in the last  3 years the board certified internist who BK calls his primary care physician would have bothered  to  feel his  patient's thyroid gland . 

.Actually had he looked  up from his computer screen in year 3 exam he could have seen the bulge in the retired dentist's neck. The mass was large enough to deviate the trachea to the left. The first element of the physical exam about which he learned in medical school was Observation. It seems that at least some number of internists have given up on what used to be one of their " super powers"  the careful skilled physical examination to take part in the charade of the AWV.

The retired dentist's adventures in a large "non for profit" hospital system centered on how it took almost 6 months for the thyroid cancer to be diagnosed and treated and offers alarming insights into how corporate medicine and the electronic health record (EHR) have changed the practice of medicine and I plan to blog about details of all of  that which have been shared with me in  the near future.Warning spoiler alert -the internists,the radiologists and even the always with the final answer pathologists have little to be proud about.

Soluble serum transferrin receptor increases acutely after exercise but is not an " acute phase reactant" ?

 At least two research projects in runners and rowers have demonstrated elevation of the soluble serum transferrin receptor after strenuous exercise. and in one of the articles the soluble receptor had returned to normal in 24 hours.

The point to be made is that both reticulocyte hemoglobin content and the soluble serum transferrin receptor are generally said to not be acute phase reactants but technically that is not correct in regard to the Soluble serum transferrin receptor .It does rise acutely but would likely be back to baseline by the time an athlete would be evaluated for anemia. So for almost all practical situations it is not   an  acute phase reactant as the value is likely to be back to baseline by 24 hours.Of course if an endurance athlete does their early morning work out and then goes to lab  that day for a blood draw the serum transferrin receptor level could be elevated misleading the doctor into thinking the test indicated iron deficiency anemia.

So both iron deficiency and acute strenuous exercise can elevate the serum transferrin receptor.With the significant perturbations in certain measures of body iron caused by strenuous exercise two tests have become the go-to tests to differentiate iron deficiency anemia from anemia of inflammation: the reticulocyte hemoglobin concentration and the soluble serum transferrin receptor.The National Kidney Foundation recommends the reticulocyte hemoglobin as the preferred test to detect iron deficiency in renal failure patients.  

1.Auersperger,L The effect of eight weeks of strenuous exercise

2.Skarpansa-Stejnborn A Effect of intense physical exercise on hepcidin  

Addendum:   7/22/22

A 2010 article provides contradictory data. Sim et al (senior author is Peter Peeling) 

In subjects who exercised at 75% of 02 max for 90 minutes were shown to have a decreased soluble serum transferrin receptor at 3 hrs and again at 24 hours. ( The effects of carbohydrate ingestion during endurance running on post exercise inflammation and hepcidin levels. Eur J app Physio nov 2010.

Left bundle branch block- new paradigm brewing- echo plus ekg

 Left bundle branch block (LBB) has been defined by various EKG criteria. The pattern of inter ventricular and intraventricular desynchrony cannot be predicted nor the response to CRT based on the EKG..

A patient with a EKG  pattern of LBBB may have a conduction block or delay within the His Bundle system ( intra Hissian block) or distal to the His bundle or some version of a diffuse intra-ventricular conducting defect (s) .

Various criteria have been proposed by the EKG diagnosis of LBBB but no criteria offers 100% predictive value regarding response to cardiac resynchronization therapy  (CRT )but some appear better than others.

CRT is the treatment for heart failure refractory to the usual medical treatment in patients with LBBB. CRT in the form of bi-ventricular pacing is a "work around" essentially replacing one pattern of ventricular dyssynchrony with another less damaging form of non physiological pacing, while His bundle pacing is capable of correcting the abnormal conduction.

The physiological purity of His pacing is undeniable but there are problems which include technical difficulty in placing the electrode in the right place  (the His bundle is small and surrounded by fibrous tissue),  variably high capture thresholds and a certain percentage of cases which later on develop an undesirable high capture threshold.

 Incentivized by the recognition that  although His pacing was beautifully physiologic it had definite problems,  innovatively adventurous EP cardiologists discovered they could advance the catheter further towards the cardiac apex and screw the lead deeply into the interventricular septum and then could pace the left bundle branch thus fixing the LBBB with the apparently minor physiological cost of inducing a right bundle branch block. Further there appeared to be more likelihood of success   as precise localization into the His bundle was replaced by the much less technically demanding job of getting the catheter  in the left bundle branch area, There was the concern and occasional occurrence of pushing too far and placing the lead tip into the left ventricular cavity .If recognized during the procedure the lead could be safely withdrawn.Besides EP cardiologists penetrate the  atrial septum routinely  performing ablations so  poking a small whole in a septum did not appear to be a deal breaker and a some centers Left bundle branch area pacing hasr replaced His pacing.

The term "true LBBB" has been used to indicate the conduction defect that responds well to CRT ( either Bi V or conducting system pacing ( His pacing or left bundle branch area  pacing). Further True LBBB is associated with right to left activation of the interventricular septum  and a  echocardiographic finding referred to as "septal flash"

An important question is which of the several EKG criteria of LBBB best predicts who has a true LBBB and therefore a greater likelihood of benefit from CRT

Calle et al compared the new,more stringent ESC criteria ( 2021) with the older 2013 ESC criteria.They suggest that certain other criteria should be considered;delayed R wave peak time,a septal flash,apcial rocking and a specific septal strain pattern.

Calle has published several papers on this general topic and seems to consider that the echo cardiographic finding of septal flash defines the " true electromechanical LBBB substrate and is predictive of complete reversible re-modeling.

1) Calle,S Defining left bundle branch block according to the new 2021 European Society of Cardiology Criteria.Neth Heart J. 03 May 2022  in their "point of view" section

The coivid pandemic and one million U.S.deaths have waned my anti progressive,public health antibodies just a bit

 Many decades of reading libertarian and classical  liberal literature and at least semi serious reading of Austrian school economics mixed with mainline Econ101 had for the most fixed my thinking and planted some priors that seemed unlikely to be refuted.

I was disturbed by the movement in medical discourse toward something called population medicine and blogged about traditional medical ethics with a backbone of a fiduciary duty of the doctor to the patient was being challenged by a  mushy, vague admonition for the physician to be responsible not only to the patient but somehow also to be charged with a co-duty that including being responsible for the group.Some how the physician needed to treat his/her patient but to somehow work to heal the village.

Although I  once displayed a certificate of board certification in preventive medicine- a field that includes public health,I had never felt aligned either by experience or philosophical leaning to be a member of the public health tribe. Noticing that it had become an often repeated mindless expression that Disease X,Y or r Z is a public health problem  I blogged that would make nearly everything a public health problem.I do not believe that everything is a public health problem; However, if there is spread of a potentially fatal respiratory illness than is spread by the small aerosol particle routes at times by asymptomatic persons and whose spread can significantly be mitigated by wearing masks then that is a public health problem if there ever was one and covid is one for the ages.

Claims by politicians that wearing masks is just  a personal decision because it only affects the wearer's health is clearly wrong,scientifically wrong and even wrong,IMO,from a libertarian point of view.Hat tip to Nassim Taleb who pointed out the obvious that the fundamental principle of libertarianism is the non-aggression axiom, ie. one does not have to right to initiate force against another human being. The fact that the CDC echoed the pretend conservative-libertarian thought that only the wearer is affected does not make it so and may have been the most shockingly  un public health advice even issued by a public health organization .The CDC began their battle against covid with a egregious technical error in test production and 2 years later topped that with a shape shifting moral error.

All of which brings me to admitting that I have convinced myself that not just out of a survival instinct that mandating masks and vaccines is necessary much as many abrogations of individual freedoms are necessary for a civilized society,

Mandatory vaccination and mandated masing have catalyzed a definite division in libertarian circles .One academic libertarian, Jessica Flanigan Phd has written a lengthy and I think persuasive commentary supporting the idea that mandatory vaccination  is consistent with basic libertarian views .My simplistic view of her argument is that she relies mainly on the nonaggression axiom without explicitly using those words.(Her essay can be found on the HEC forum, online, August 2013 edition. )

Reason is,and ought only to be, the slave of the passions.David Hume 

Hemolysis is part of strenuous exercise - it is not a disease

 The intravascular destruction of red blood cells (rbcs) is a normal part of strenuous exercise.It is a feature not a bug of strenuous exercise.A recent review by Lippi and Sanchis-Gomar describes hemolysis as being common place in running and characterizes the intravascular hemolysis as "paraphysiological"  and is "typically mild" with average variations of hemolysis  biomarkers( serum free hemoglobin and haptoglobin) perturbated    between 1.2 and 1.8 times and "self limiting"resolving within 24 to 8 hours.

All types of repeated  strenuous exercise are associated with hemolysis but  more notably so with running usually attributed to foot strike but non contact activities including rowing,swimming and cycling are all known to cause hemolysis.

Foot strike is thought to be a major contributor in running related hemolysis as was demonstrated in an excellent cross over study of hemolysis  in  running and cycling by Telford in 2003. Tri athletes ran and  cycled at 75% of their measured 02 max and serum free hemoglobin was elevated during both activities but  there was significant drop in haptoglobin only after the running session. Methemoglobin , an indicator of oxidative stress, was elevated to the same degree after each exercise.

Red blood cell survival is significantly shorter in runners versus sedentary controls. Chromium labelled RBCs survival is 74 days in runners  versus 115  days in a sedentary control group..

This shortened life span increases need for  RBC production with an associated increase in iron utilization. The 1 to 2 mg of iron absorption per day  normally is balanced against the normal 1-2 mg of iron loss. Endurance athletes will need a larger iron intake.Iron deficiency and iron deficiency anemia have been described not only in runners but cyclists,swimmers and rowers as well is in rugby,tennis and soccer players.

A possible mechanism for increased iron loss secondary to strenuous  exercise induced hemolysis (SEIH) is the following.Hepcidin is stimulated by the increased iron in the blood.Hepcidin decreases the release of iron from duodenal cells into the blood, trapping iron in the enterocytes. These cells live only about 3 days and then shed off which is probably one mechanism by which there increased GI blood loss in runners. Hepcidin also limits iron egress from macrophages and liver cells limiting the supply of iron to the bone marrow at a time when more iron is needed. The more running,the more hepcidin release ,the more iron tapped in the duodenal enterocytes the more iron loss in the stool. So runners and other endurance athletes  loose more iron and need more iron to increase RBC production and need a higher iron intake than a sedentary person.

Arguing against the role of hepcidin  in runner's anemia is the following: Although hepcidin is definitely elevated acutely several studies have demonstrated that after a period  of time ( 1-2 weeks) the hepcidin levels return to their baseline values.So hepcidin is only transiently elevated  and other studies have demonstrated that hepcidin levels are only elevated in those persons whose ferritin levels are above 30 suggesting that the red blood cell production imperative overrides the hemolysis induced hepcidin increase and any significant exercise related cytokine increase, 

Add to that metabolic supply chain issue a vegan diet in some athletes and menstrual  blood and there is no surprise that there is  iron deficiency and iron deficiency anemia is athletes who take part in repetitive strenuous exercise 

Hemoglobinemia and hemoglobinuria were first described medically in the early 1940s with studies of cross country runners and marathoners describing march hemoglobinuria  although observation of dark urine associated with strenuous exercise was described in the 1880s.

Iron deficiency in athletes is now so well recognized that athletes themselves and coaches and sport Medine doctors all utilize the measurement of blood ferritin levels to monitor iron levels. The 2019 Olympia Committe on Physical examination for athletes including measurement of iron status .One recent study reported that 70% of professional cyclists and competitive rowers had iron deficiency by the end of their seasons. 

"Runners anemia" is the prototype  of an iron deficiency anemia brought about by  the hemolysis associated with  multiple bouts of  strenuous exercise in an individual whose iron intake does not match the increased iron needed for the increased red blood cell production needed to compensate for the shortened average life span  and GI iron loss. Runner's anemia might be more  accurately described as the anemia of repeated strenuous exercise induced hemolysis in the face of inadequate iron intake to compensate for the associated increased iron needs. Or much simply-exertional hemolysis in a person with an iron poor diet. 

                                  

Epidemiologists are finding those thrown under the "we've had it with covid" bus

 

The strange transition of the CDC from a public health authority to a public voice of pseudo- libertarian thought was predicted to have consequences. Their abandonment of their long standing advocacy of protect the vulnerable was predicted to obviously have consequences on the vulnerable who in the context of covid are the  elderly and the immunocompromised and children under five years of age ( the later at least until a covid vaccine is approved for use in that group).

To be clear- the notion that mask wearing protects both the wearer and others was discarded in favor of the advice that mask wearing was an individual choice regarding the individual's assessment of his/her risk, This is strange advice indeed from a public health agency concerning a potentially fatal respiratory illness that may have asymptomatic spread and is spread by aerosol. 

There are now data indicating that some of the vulnerable (elderly even with boosters) are a increasing number of the deaths from omicron  making it not just a pandemic of the unvaccinated. Elderly vaccinated and boosted persons are not well advised to go maskless if they "consider their risk to be low". 

(14) Eric Topol on Twitter: "The headline: "Covid deaths no longer overwhelmingly among unvaccinated as toll on elderly grows" The reason: "The bulk of vaccinated deaths are among people who did not get a booster shot" https://t.co/6VEXi2eWgf by @FenitN @dtkeating" / Twitter

note the Washington Post article above is behind a pay wall so I cannot present the actual numbers.

Hepcidin is the major player in anemia of chronic disease but probably not so much in runner's anemia

 Dr. Thomas Ganz,in whose lab hepcidin and later a counter regulatory hormone erythroferrone were discovered,said in a commentary (1) written ten years after hepacin's discovery) that hepcidin maybe an important contributor in runner's anemia.

While at the time that seemed reasonable  based on the knowledge of the function of hepcidin and the finding of elevated hepcidin in runners, subsequently data has been published making hepcidin's role in runners anemia less ikely to be a key determinant 

The purposes of this posting are to  

1)present data showing that while early on perhaps in the first several weeks of an endurance exercise program hepcidin  is increased  after that initial period hepcidin returns to its the level present before initiation of the program. 

and

 2) to consider how mechanistically chronic hepcidin excess would not result in the iron profile pattern of runner's anemia but rather the iron profile  of the anemia of chronic inflammation.

First the stage needs to be set as regards 1) the hematologic physiology of prolonged strenuous exercise with running  as the prototype 2)the actions of hepcidin and 3) how iron travels into, out  of and through the body.

 1) Intravascular hemolysis,the breakdown of red blood cells within the blood circulation, has been repeatedly described in detail by numerous investigators  in runs of various distances and durations.This hemolysis is easily detected by measurement of serum free hemoglobin ( hemoglobulin not contained within  the red cells) and by the protein haptoglobin level which decreases in proportion to the red cell destruction. This is not a new observation , a study in 1943 from Boston demonstrated hemolysis and hemoglobinemia and hemoglobinuria in runners providing some scientific validation of observations made in the 19th century of dark urine following long marches.

 Hemolysis is commonplace in prolonged strenuous exercise of various types and has been well documented in running, cycling,distance swimming,rowing ,rigorous military training and in soccer,tennis and basketball players and in resistance exercise  and should be considered physiologic and a feature not a bug in the wisdom of the body's programming. Culling the older, less flexible and less well hemoglobinized RBCs should facilitate the increased need for more oxygen delivery during strenuous exertion.

Repeated episodes of this brief,self limited and relatively mild hemolysis results in  average life span  of RBC s in runner of about 74 days versus that of the sedentary subject which is 115-120 days. This increased turnover of RBCs requires an increase in iron supply and over time in a person with low oral iron intake can result in iron deficiency and ultimately iron deficiency anemia.Runner's anemia can be explained that simply.

2)Hepcidin is made by the liver and functions as a regulator of iron transport in the body. Hepcidin shuts down or at least slows down the delivery of iron to the bone marrow by blocking iron exit from the duodenal lining cells and from the macrophages, who routinely scavage iron from the hemoglobin of  the aged RBCs,and from the liver cells where iron is stored as feritin.Increased iron levels and inflammatory cytokines stimulate hepcidin release and anemia , hypoxia and increased red cell production decrease its production as do testosterone,increased RBC production ,Epo low iron levels and  the marrow derived hormone, erythroferrone.

3)Iron is absorbed in the duodenum and from there either released into the blood or stored briefly in these enterocytes  only to be sloughed off into the fecal matter as these cells survive only for 3 days.Iron absorption is limited to a few milligrams' per day which balance the daily loss and there is no mechanism by which excess body iron can be eliminated.

The anemia of chronic disease is thought to be a hepcidin excess conditions Inflammatory cytokines,mainly IL6, stimulate hepcidin production. Hepcidin  acting by disabling the ferroportin channels blocks down or markedly slows down the iron highway within the body.The iron egress is blocked from the duodenal cells,the macrophages and the liver cells restricting iron access to bone marrow. The anemia is characterized by low serum iron but elevated ferritin levels making it an anemia of iron restriction rather than iron deficiency. There is more than ample iron overall (the macrophages and liver cells have plenty) but the bone marrow is lacking.

Quoting Larsuphrom 2011 extensive review (2) " Judging from the prevailing evidence acute exercise seem to promote post exercise hepcidin elevation while long term exercise training might attenuate exercise induced increased hepcidin." If you measure urine or blood hepcidin after a long run hepcidin will be elevated. However, if you measure hepcidin on a runner several weeks into a training program the initial elevation of hepcidin returns to pre exercise levels. Research from Auersperger and from Moretti ( see reference no 2 for citations) indicate that hepcidin levels are not chronically elevated in endurance athletes. The baseline ferritin may be a key factor in the hepcidin respond to strenuous exercise. Peeling ( see ref 45 in my ref 2) found that increased hepcidin only occurs  in subjects whose baseline ferritin levels were greater than 30. This suggests that the biological systems that favor red blood cell  production may trump the hepcidin imperative to conserve iron .

An outliner to the above is the study authored by Dzerzej  et al  (4) in 2016 in which they presented data from hepcidin blood levels in professional basketball players before and then 2 days after a competitive season which showed levels were elevated at the end of the season implying a chronic elevation              of hepcidin.

Runner's anemia ( better named exertional anemia ) results from increased iron requirements due in  part ,( perhaps mainly to hemolysis) in a subject whose iron intake does not meet the increased need that occurs with prolonged and repeated strenuous exercise.It can be mechanistically explained without invoking a key role for hepcidin while admittedly the acute increase in hepcidin  (stimulated both by ILa 6 release during exercise and the hemolysis release of iron into the blood) and its effect to slow down release of absorbed iron into the blood could be contributory.See below for possible exceptions to tht generalization.

Incidence of iron deficiency is said to 30 to50% in endurance athletes.

Note- there is another runner's anemia also called pseudo anemia. This condition is a decreased hematocrit due to an increased plasma volume which is a regular adaptation to endurance exercise in excess of the overall increase in blood volume secondary to endurance exercise.It is typically associated with an increased MCV (mean red cell volume) likely due to an increased number of younger larger RBCS.

Serum iron levels, typically clinically measured as serum ferritin, is often the first thing an endurance athlete  or the coach or a sports medicine specialist  think about when exercise performance  does not meet expectations.

There is a subset of the anemia of repetitive strenuous exercise (ARSE) in which hepcidin may actually be contributory. If a person exercises repeatedly at a high  level of intensity with inadequate calorie intake to maintain body weight there may be chronic elevation of hepcidin,There is strong evidence that glycogen depletion stimulates hepcidin production and that subjects in this calorie deficient high exercise state may also poorly absorb iron.Recent extensive research by S R Hennigar and others on military personnel in simulated military maneuvers provides an example illustrating this concept.see ref 3). 

Also  James P McClung et al reported elevated hepcidin in military personnel after a 7 day training  event. The level of exercise and the reported food intake strongly suggested they were caolrie defecit and likely glycogen depleted. 

Further a report of chronically elevated hepcidin in runners who had twice a day workouts (I have misplaced the article but will add it evidence later)

1) Ganz,T Hepcidin and iron regulation 10 years later.Blood 2011 Aug 28 117 4425-4433

2)Larsuphrom,P Association of serum hepcidin levels with aerobic and resistance exercise.Nutrients 2021 jan 27 393

3)Hennigar,SR et al Energy deficit increases hepcidin and exacerbates  decline in dietary iron absorption Nutrition 113, Feb 20211 

4)Dzedej,A The effect of a competitive season inProfessional basketball on inflammation and iron metabolism. Biol of Sport 2016 May online

addendum . July 6 2022  The last paragraph added after learning about Hennigar's and similar

 publications.

Europe is surging again so will the U.S. "wall of immunity" prevent another spring surge.

 As of early March 2022 cases and hospitalization are increasing in several European countries.

Data from Great Britain indicate increases in cases in all age groups and in all parts of the country.See Eric Topol's wonderful twitter feed for detailed data on the European uptick in cases,etc

The hope of many is that in the US the "wall of immunity" is sufficiently robust to prevent further surges.The wall is built on immune protection from vaccines,boosters and infection which, it must be said are known to wane over time. The elderly were a group who received the vaccination and the boosters fairly early so now in England there is a plan for the 4th shot, not so for the US so far.

The US's waves of  alpha,delta,omercron were preceded by waves  in GB and Europe . Maybe now this is different but I struggle to find a reason why. The surges seem to be attributed to some combination of increase in the BA 2 variant,cessation of masking,etc and the waning of immunity all factors seemingly applicable to the US. Actually in one regard GB 's "wall" may be stronger since  90 % of their elderly has been triply vaxed versus 65  % in US.

The much talked about objective of "protect the vulnerable" has largely faded away but the numbers of the vulnerable have not.There are 100 million not vaccinated,seven million with various immunocompromised conditions and millions of kids currently too young for vaccination and the US lags behind Europe in the percent of the elderly who have received the booster shots. What could possibly go wrong?

EKG criteria for differentiation of non-selective His pacing from RV septal capture

 Dr. Marek Jastrzebski has written extensively on the differential diagnosis of  non selective His Bundle pacing (Ns HBP)  versus myocardial only capture.

In Ns HBP  not only is the His bundle captured but also  is a segment of the myocardium in the IV septum.The ORS morphology is influenced by the signal from the captured segment of myocardium  and the electricity traveling along the His Bundle  resulting in  a fusion beat.

His diagnostic algorithm is:

is there QRS notching in lead I v5 or v6 if yes then there is myocardial pacing

If no ,, then ask is the v6RWPT greater than 100 msec if yes then there is myocardial pacing.

However, there are false positives in the use of the notching rule wherein there may be QRS notching in cases of confirmed His Capture. particularly in cases of LBBB. A non corrected intra-hisian conduction defect resulting  in a prolonged HV interval may occasionally result in Lateral lead QRS notching.

 

1)Jastrzebski M, ECG Pacing criteria for differentiating conduction system pacing from myocardial pacing.Arrhythmia and Electrophysiology Review June 2021 p 172

So how did Federalism work out for you during a pandemic

 By December 2021 almost 800,000 American had died due to Covid 19 and by March 2022 the death toll was approaching one million. The IMHE in a recent Lancet article estimated that by the end of 2021 18 million deaths occurred because of covid.

 The proportion of deaths per capita was not uniform throughout the fifty states with the  proportion of deaths being greater in states that voted for a particular presidential candidate. If there is a causal relationship, what mechanisms could be responsible for such a strange circumstance?

Could it be the some characteristics of voters who favored one particular candidate predisposed them to acquiring and dying from Sars co V 2? Could certain actions of political leaders in some states been such that they lead to more or fewer citizens contracting the disease? Certain risk factors have been linked to greater mortality from covid 19 including obesity,diabetes  and hypertension. Are these and possibly other risk factors found to a greater degree in voters who choose one candidate?

Is it true, as Thom Hartman claims that the Trump administration changed its focus regarding covid mitigation on April 7 2020, when the CDC reported that there were disproportionally more deaths among  black  and brown people and soon after Fox commentators began to downplay the seriousness of covid .

Governors in Texas and Florida have through executive action and by encouraging legislative action limited the ability of businesses to set the terms of their business and to determine with whom they will do business.  This limitation was specifically in regard to so called vaccine passports and requiring their employees to get covid vaccinations. Mask mandates by school districts in those states have been prohibited by either executive order or legislation or both. So much for the venerable old conservative support for the notion expressed by " no shoes,no shirt, no service".Shopkeepers and business men can set the terms regarding who they do business with unless they cross the line and dare to claim they will only serve those who are masked and/or vaccinated for covid.

Of course correlation is not causation and other factors must also  be in play but the vector's direction seems obvious  but the magnitudes are more difficult to determine. 

Advocates of federalism talk about  the states as "Laboratories of democracy" where state governments act as social laboratories  creating and testing policies and legislation in way similar to aspects of the scientific method.What experiments did the red states do and what experiments did the blue states do? What, if anything,was learned?

.

The Government's new covid plan 2-Public Health 0

 Gregg Gonsalves writing in The Nation claims that the Biden administration has turned its back on the pandemic and that the perceived public desire for normalcy has lead to an "organized abandonment". 

It is as if the "I've had it with covid" mentality was transformed into a U.S. national policy. 

It would be wonderful if the covid virus would mutate itself into another common cold coronavirus but hope is not usually much of a plan for a respiratory virus than so far had killed almost one million Americans. 

Meanwhile back at the real world covid ranch there are signals that there may be the beginnings of a surge in several countries who have declared masks and other NPI measures are no longer necessary namely  Great Britain, Denmark and more recently Canada.The vulnerables are left with one way masking and so far inadequate supplies of sotrovimab and Paxlavid.The CDC should have emphasized the importance of use of N 95 masks particularly in the context of one way masking since people are no longer admonished to wear masks to protect others.

The apparent nascent recent surge in omicron cases must be due to some combination of increase in the BNA2 variant,cessation of basic mitigation procedures and immunity whether induced by vaccine or disease waning .  

For an amazingly detailed and comprehensive daily update of most things covid you cannot do better than Eric Topol's twitter feed. For detailed  and nuanced discussion of many aspects of covid I highly recommend the writings of Dr. Katelyn Jetilina who writes under the title of "Your Local Epidemiologist"

Thoughts on CDC's new low for community spread

 The CDC revised its covid guidelines.  

The new low would have been "substantial spread "according to the old definition new low is 20 times the old low. 

Remember the pro masker's rallying cry "my mask protects you, your mask protects me" and contrast that with the CDC latest package of guidelines that say in part  that mask wearing  is "a personal preference informed by personal level of risk". "Personal preference" and "personal level of risk" sounds more like libertarian or perhaps more accurately faux libertarian thinking than  standard public health which tends to trump personal choice with measurable or at least purported collective good.

I never thought that CDC would make a recommendation so out of resonance with basic health dogma as mask wearing is a " personal preference informed by personal level of risk". This seem little different from the medically ignorance claim that "I harm no one by not wearing a mask" because if covid is spread by aerosol and if there is asymptomatic spread then by not wearing a mask you may well harm others.

 Libertarian thought and fundamental public health recommendations are strange bed fellows. The vulnerable might now well think  that  I need a mask to protect me because not even the CDC is telling people to wear mask to protect me  and the other vulnerables nor to protect the healthy and not so healthy  folks whose jobs put them at high exposures levels by their daily person to person contact.

Beside the elderly who have varying degree of age related diminution in immune responsiveness there are 7 million immunocompromised individuals in the US  and 19 million kids less than five year of age for whom as of March 2022 there is  no available vaccine.

Katherin J. Wu Ph.D. writing in the March 3 2022 on line issue of The Atlantic notes that last week Cook County Illinois was at a high level of transmission  but now according to CDC's redefining of risk levels is at a comfortable low level and masks may be removed. She continued saying that  country wide with the old criteria nearly everyone needed to mask now only 37 % need to.

The new CDC guidelines focus now  more on hospital burden rather than local disease transmission  level to determine what levels of mitigation measures need be implemented even though hospital rates are a lagging indication suggesting that by the time hospitals and filling up the horse is well gone from the barn. 

Somehow by pretending that disease levels are less dangerous by re-defining risk categories we will "control covid rather than covid controlling us" It seems that much of the heavy lifting in that control seems to fall on the elderly and the immunocompromised as others will be wearing masks much less often .

Quoting Dr. Eric Topol " When states and counties proclaim we just need to live with the virus and end all restrictions many people interpret that message [to mean] that the pandemic is over"

My retired epidemiologist friend believes the CDC basically declared the US is now in an endemic phase of covid 19 and by proclamation covid will be considered like the flu and as long as hospitals do not reach some stipulated level of threat of being overwhelmed we will "just live with it". 

It has not gone unnoticed by some pundits that the new covid status is in place  well before the upcoming mid term elections and that the doing away with masks and vaccine mandates might be thought to  deprive reublicans from a major talking point. 

Pacemakers generate electricity and tons of data , who monitors the data

 Recently I had my pacemaker replaced.This process is often erroneously refered to as  getting a new battery when in fact it is replacement of the IPG (implantable pulse generator). The IPG consists of the battery,the software  and connectors to the leads. The process takes about 1 to 2 hours and generally the recovery process is quicker than the implantation itself of the pacemaker as arm movement does not have to be as restricted.

Typically, every three months a "remote interrogation" is done. Data is downloaded from the pacemaker and then transmitted to in my case to the Medtronic computer  system and from there to either my physicians office or again in my case to  a third party organization who  then sends an interpretation of the data to my doctor's office.It appears that both the third party company and my EP doc's office can earn a fee approved by Medicare for the report review.

The third party interrogation monitoring company typically sends me a copy by secure Google email of the interrogation. For several reasons which I have written about before I find it important to actually  see my report as opposed to receive a message that " every thing is OK" Or " if you don't here from us everything is OK". The Cures Act now mandates that physicians and hospitals must give the patients copies of lab work and even clinical notes in  a "timely" manner or face hefty fines. Patients no longer have to accept the " we will call if something is not OK" from their doctor. 

The reports themselves are not that difficult to understand as least in regard to a pacemaker versus a ICD (defibrillator). some of the important values to review are: capture voltage,lead impedence ( resistance,)arrhythmias and battery life estimation. The pertinent data can be reviewed quickly .

While the basic data seem to be  well monitored I am less sanguine about the regular occurrence of a review of the  optimal settings for such things as pulse amplitude and pulse duration  and review of arrhythmias flagged by the unit's algorithms. In my case my interrogation report indicated several episodes of AF (atrial fibrillation). This finding lead to a fair amount of concern about having runs of AF but I learned later that the  unit's algorithm misidentified  "far field sensing" as AF. Far field sensing refers to the atrial lead sensing activity from the ventricular lead and double counting of atrial signals. 

Phantom physical exam reports continue to proliferate in the strange world of the electronic health record

 Recently,I learned that nurse practitioners as well as physicians are authorized to post  the results of physical exams that were not done in the medical record (EHR) 

The narrative of the encounter  I had with NP was accurate and fairly detailed and I actually learned a lot about how the thousands of remote device interrogation are reviewed in their department.

 Although one of the reasons for the visit was to check the surgical wound (I had a pacemaker replacement one week before) there was no mention of that in the EHR report of the encounter although the NP did glance at the surgical site.  I was described as having no edema and having normal pulses but those findings were fictional. A similar fictional physical exam was detailed in the pre op visit one week earlier with the EP cardiologist. (Actually I do have a trace of ankle edema at the end of the day and my posterior tibial artery is very hard to palpate.)

When I attended medical school in an earlier century my teachers emphasized the importance of transcribing a physical exam and other clinical findings as accurately as possible and that the medical record was a legal record and could be subpoenaed. The medical record is the basic legal document in medical malpractice litigation. 

Why would a bogus physical exam description be routinely inserted into the EHR as that occurrence appears to be the case. If it is done to be able to "upcode" the record why would the practice not be fraud?

Other than an intent to defraud, what else could explain the profusion of bogus system reviews and physical exams. Simply put it may be a unintended consequence of the EHR and the quality movement, Standard boiler plate material is generated by the EHR to fill the need to comply with the increased demand for documentation of "quality "clinical work. The alleged intent was to have clinicians edit out activities not performed.However,that has not been the outcome as through inattention or in some cases perhaps intent the fictitious exams remain displayed in medical records awaiting a plaintiff lawyer to ask Dr. Did you perform a physical exam on a certain date?

addendum: 3-15-2022 I learned from someone knowable in current Medicare charges and EHR vagaries that Medicare no longer pays more if a physical exam is performed and charges are earned based on time spent and case complexity. So there would be no monetary advantage to charting a physical exam or system review but the phantom exams seem to still be appearing in EHRs.

Status report Covid 19 in Texas at end of 2021

 From my vantage point in Houston everything I see here validates my decision to urge a relative not to travel here  from Paris for Christmas. 

Cases soar and  emergency rooms are packed,Drug stores have sold out of the home antigen tests and the state is out of (or almost out of ) the only antibody treatment that is effective for Omicron (sotrovimab). Houston's county health agency urges people to not go to the ERs to get a covid tests and to use masks in congregate settings.

The Texas Medical Center reported for the week of December 20th a positivity rate of 15.4 % versus  6.2% for the previous week and  201 Covid admission versus 101 the previous week. 

The two prescription medications approved by the FDA for out patient treatment of Covid 19 are yet to arrive in the state . A number of eateries have closed due to the lack of staff and New Year's Eve is approaching and from what I see mask wearing is not prevalent, The Christmas church services  whose live streams I sampled did not seem to require masking in spite of the recommendation of the CDC and county health authorities. By contrast the Pope's Christmas mass had everyone wearing a mask. 

On a positive note, a number of centers have been designated to administer Evusheld, This is an antibody cocktail to be given IM every six months to prevent infection in immunocompromised patients which received an EUA in early December.

President Biden has just said there is not a "federal solution" to the developing crisis and defers to the state Governors. Residents of Texas may find little comfort in that as Govenor Abbott has by executive action and legislation taken steps to minimize masks use by schools and vaccine mandates by state schools and by businesses. I hope  I am wrong but Texans are not likely to see Covid mitigation actions coming from Austin. By contrast the govenor of Connecticut  has ordered the national guard to  distribute N 95 masks and antigen test kits.

Apparently both the Delta strain and the Omicron variant are circulating, one being much more contagious and the other more virulent  and physicians have no quick way of distinguishing between the two. 

All we can do is pull up the draw bridge and hope to not have a medical emergency and not deplete too much psychic energy lamenting and asking the question how  could the richest country in the world end up where we are now. 

Addendum 12/31/21.As of 12/31/21 Walmart and Sam's Club Pharmacies in Texas have both Paxlovid and Molnupiravir available with prescription from physician. 

Without durable individual immunity you cannot even talk about herd immunity

 In the early days of the covid 19 pandemic there was much speculation about what percent of the population would have to be vaccinated in order to achieve herd immunity )(HI). It seemed to be a matter of not if but when HI would be accomplished.

Writers made analogies to  measles and smallpox for which vaccination programs achieved herd immunity and in the case of smallpox, eradication. If HI could be achieved  for a  very infectious disease such as measles spread by aerosols, why not covid 19?

Theoretical considerations regarding HI center on the basic reproduction number (R naught or Ro which is the average number of people that one infected person will infect.  The number of people needed to be immunized in order to reach HI is 1-1/Ro.For example-if the Ro is 2 then 50% would have to become immune (either through vaccination or infection) for a Ro 0f 3 we see 1-1/3 equals 2 thirds or 67% 

Several simplifying assumptions underlie the formula for HI including that all individuals have an equal opportunity to become infected. Epidemiologists disagree as to what exactly HI is and as to what the necessary assumptions are in estimating a HI vaccination level.

However the key-typically implicit- assumption is that being vaccinated ( or recovering from an infection) results in long lasting immunity.(1)

We now know that this major assumption does  not conform with reality. We now know that fully immunized individuals can become infected and can transmit the disease and also  that recovery from covid 19 infection does not preclude becoming infected again. 

The idea underlying HI is that as individuals become vaccinated ( or recover from infection) they are removed from the susceptible pool. With covid vaccination or infection  both groups seem to be removed from that pool only for a time , perhaps as short a time as 6-8 months. While infection blocking immunity (nasal mucosal immunity) wanes quickly the disease reducing immunity seems to be more durable.

When cases of abreakthrough infection became recognized as a real thing,some in the public health sector  said  " well, the vaccine was only intended to prevent serious disease and death".But if that were the case why was there so much  talk about achieving herd immunity a concept that IMO only makes sense if the vaccine prevents spread.

Dr Jennie S Levine has been quoted that she and her colleagues talk about transient herd immunity.

My thought on that is perhaps we are seeing a transient HI for example now In Louisiana and Texas .Both states had a major Delta surge with a surge of cases and hospitalization and death and now the surge seems to have abated.Possibly as more and more people were vaccinated and more infection plus mandatory NPIs (in Louisiana ) the number of susceptible individual decreases to reach some level of transient herd immunity like condition. However, as immunity wanes again in states with a large number of unvaccinated individuals serving as a covid reservoir some level of spread could occur again  for another round of surges . Are we likely to continue to see regional whack a mole events .

A much more optimistic scenario is that the booster shots will bring about a sufficiently long period of immunity so that more than a transient herd immunity could be achieved. In other words- the covid 19 mRNA vaccine should have been a three shot vaccination  program all along.  

1)Core Concept: Herd immunity is an important—and often misunderstood—public health phenomenon | PNAS

How big will the US covid winter surge be?

The epidemiology  predictors at IMHE made their prediction for the 2021 winter on a tweet published November 5.

Based on three factors they predicted there will be a winter surge but, of course its magnitude is unknown.

The factors are : 1) seasonality 2) waning vaccination immunity 3)less caution by the public,We think we know the direction of these vectors but what about their magnitudes?

As time goes on not only vaccine immunity will fade but so will the immunity of previous covid 19 infection  both of which seem to fade in about six months.   Countering that direction is the number of people receiving the booster shots.Countering that is the relentless barage from right wing media claiming that the vaccines are either dangerous or worthless.

Meanwhile in France and Germany a new surge seems underway and travel restrictions to to the US have been lifted. What could possibly go wrong?

Dr. Michael Osterholm is quoted: "Any effort to predict future course beyond 30 days relies on pixie dust for its basis" and we all remember what Yogi said about predictions particularly for the future.

Cardiac fibrosis in endurance athletes

 There have been a number of reports of cardiac fibrosis in endurance athletes. It turns out that these reports pertain to areas of late gadolinium enhancement in right ventricular insertion points.Some explanation is required . To begin with-all forms of fibrosis are not the same.

Gadolinium is the contrast agent  used in MRIs.It accumulates in the extracellular space and lights up on a cardiac MR and is called Late Gadolinium Enhancement (LGE)

LGE is seen in myocardial infarctions in necrotic areas with scars consisting of replacement fibrosis.LGE has also been reported in hypertrophic cardiomyopathy (HCM) ,pulmonary hypertension and more recently in a number of long time highly trained endurance athletes.In these three conditions the underlying pathology is not replacement fibrosis  (as is seen in a myocardial infarction scar) but rather plexiform fibrosis and myocardial fiber disarray and is typically seen at the insertion points or hinge points where the right ventricular wall inserts on the interventricular septum. 

Sato et al (1) proposed  that paradoxical motion of the interventricular septum is a primary mechanism for late gadolinium enhancement (LGE) at the ventricular insertion or hinge points.

LGE at ventricular insertion points has been described in pulmonary hypertension and in a number of highly trained endurance athletes .It is unlikely that paradoxical septal movement explains the LGE at hinge points in these athletes although it may be  true in the cases described by Sato.

DeBosscher et al (2) found LGE at the hinge points in young and older highly trained endurance athletes but found no evidence that LGE was associated with any structural,functional or electrical problem with LGE at the insertion points which they found  28% of the 233 athletes studied.

LGE was first described in  older endurance athletes   but now this data demonstrates that younger runners may also have that finding and that it is not a uncommon findings in highly trained runners and its long term significance remains to be determined. I suppose the fact that the LGE does not represent replacement fibrosis  with its associated risk of reentrant ventricular tachycardia  is good news.However,data is lacking as to the long term consequences (if ANY) of LGE at the RV insertion points in long time endurance athletes regarding reentrant rhythms or other clinical problems. 

1) Sato,t et al Paradoxical motion of the interventricuar septum as a primary mechanism of ate gadolinium enhancement at ventricular insertion points. Int J Cariol 2012;158 (1) 156-7 

2)De Bosscher, R et al Hinge point fibrosis in athletes is not associated with structural, functional or electrical consequences;a comparison between young and middle aged elite endurance athletes. Euro Heart Journal, 41,supp 2, Nov 2020 

What is the threshold for exercise induced cardiac remodeling (EICR)

 It has been known for over 100 years that physical exercise  may cause heart enlargement.A study of Harvard rowing team members described cardiac enlargement in an 1899 issue of the Boston Medical Surgical Journal.  

There have been numerous cross sectional and longitudinal studies documenting the structural changes in the heart associated with high levels of aerobic exercise.These  are enlargement of all four chambers and mild to moderate increase in the left ventricular wall thickness and an increase in left ventricular mass index- a condition referred to as eccentric hypertrophy to be distinguished from the concentric hypertrophy characteristic of strength building exercise. 

How much exercise is required to bring about that remodeling? Is  eccentric remodeling observed in runners whose activity  level is far less that that required  to be competitive in a full triathlon ?

Dawes and associates  (1) have provided some answers.They performed cardiac mri s on 1096 volunteers and linked  the mr results with their self reported exercise habits over the previous 12 months. They divided the exercise histories into four categories with category 1 being essentially no regular aerobic exercise and category 11 defined as less than or equal to 3 hours per week. They found that there was no statistical difference between category I and category 11 in regard to cardiac MR findings/

So one 'take- home" from their study might be  that exercise less than 3 hours per week is not likely to be associated with any exercise related structural cardiac changes. 

Moreover they found that increasing activity levels were significantly associated with increased ventricular end-diastolic volumes and left ventricular mass index

However, minutes exercised is not the only variable related to EICR which is likely related to some summation or interaction between intensity, frequency and duration. One could speculate that someone doing 3 hours of high intensity interval training per week  might well induce a bit of EICR and that someone doing 8 hours of slow walking in the park per week may probably would not

1) Dawes TJW Moderate physical activity in healthy adults is associated with cardiac remodeling.Circ Cardiovascular imaging 2016  se004712  

Has the conservative- libertarian "fusion" been severed by Trumpian authoritarianism ?

 Aaron Ross Powell from Cato Institute writes about the  always fragile "fusion" of conservatives and libertarians becoming increasingly severed. He refers  back to Robert Nozik's observation that  " Liberty disrupts patterns" as at least a partial explanation. 

Conservative- preferred social patterns are disrupted by liberty  So to maintain those patterns conservatives turn to authoritarian means , if not they loose their conservative values. 

What are these conservative values? They generally include family values which mean a man-woman stable relationship,opposition to gay unions,opposition to abortion and a tending to endorse traditional female roles in society, allegedly based in and supported by biblical principles. Additionally conservatives  endorsed  a society that is  largely managed and controlled by white anglo saxon men with opposition to encroachment by black and brown immigrants, preferring things as they once were or  were thought to be at some vaguely defined prior time.

Progressive big government with its ever growing body of liberty limiting regulations is a common foe for conservative and libertarians with conservatives bristling  at bureaucratic rules antithetical  to conservative's preferred social norms and libertarian obviously promoting liberty.

Decisions once made by families and local governments have been shifted to state and then federal government as the locus of decision making, a development well described and critiqued by Thomas Sowell in his book "Knowledge and Decisions ". This central decision making  shift is another common foe for conservatives and libertarians.

Arnold Kling offered a framework for considering the differences between the languages used by progressives,conservatives and libertarians Progressives tend to frame things as there being a battle between the oppressed and the oppressors, while conservatives see things as between civilization and barbarism while libertarians view matters as between liberty and coercion.

In answer to the title question-No Trumpian authoritarianism   did not break the conservative-libertarian fusion as it was a fragile union to begin though arguably useful regarding  certain issues   but his rhetoric may have provided a effective rallying cry (MAGA) and gave the nativists' core of conservatism a person around whom  to rally.

I believe the key insight in Powell essay is that liberty disrupts patterns and conservatives hold certain societal patterns to be important which are put at risk by liberty so conservatives have to jettison liberty to protect their values. In the terminology of Kling the issue  framed for conservatives is barbarism versus civilization and sometimes liberty must be sacrificed to fight off barbarism.Quoting Powell " conservatives have to restrict liberty to retain their social and economic patterns.".