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tag:blogger.com,1999:blog-110342292016-09-26T08:10:09.057-07:00retired doc's thoughtsjames gaultehttp://firstname.lastname@example.com:blogger.com,1999:blog-11034229.post-24079212002574205502016-09-07T05:46:00.002-07:002016-09-12T08:00:43.878-07:00Endurance exercise athletes heart works differently from the untrained but how much is training and how much genetic?The exercise physiology party line had been for years-probably fifty or more- that as one increases his level of exercise, both heart rate and stroke volume (SV) increase together up to a point. That point is around a heart rate of around 120 or a work load of about 40% of 02Max at which time the SV levels off. The thinking was that at higher heart rates diastolic filling time will become so limited that SV would flatten out at a relatively low heart rate More recent data indicate that while that pattern is what happens when the untrained person exercises a different pattern has been observed in ( at least some) well trained endurance athletes and this difference may be due in part to impressive diastolic function .

The endurance athlete continues to increase the SV to levels higher than the text book limit of a heart rate of 120 and several authors including Gledhill et al ( ref 1 below) showed no plateau to the SV in heart rates up to 200 beat per minute in trained endurance athletes. Their ability to continually increase stroke volume was attributed to not only enhanced ventricular emptying but to a even greater increase in ventricular filling.The left ventricular ejection time was longer and the diastolic or filling time was shorter. Not only could they push blood out better they could suck blood into the ventricle even better.

This enhanced ventricular filling make the endurance trained group better able to use the Frank Starling mechanism. ( Shifting the curve up and to the left) Further the greater blood volume seen in endurance athletes helps maintain adequate filling pressure and end diastolic volume given the shortened filling times that occur with heart approaching 200 bets per minutes. The greater ability to empty out the ventricle leads to a greater recoil from a lower end systolic volume with a greater suction effect enabling better filling.

The athletes were able to , for example, refill the ventricle with each 188 ml stroke volume in 0.1 sec.

Levine and co workers have shown similar patterns of enhanced diastolic function in older endurance athletes. (ref 2)

 Gledhill compared young ( average age 22) untrained subjects with a 02 max of about 40 with a trained group with 02 max of 60 plus. ( Group average for the untrained was 44 versus 68). So the trained group has 02 max values typically associated with folks who can run a sub-three hour marathon. A trained person with a baseline of 44 V02 max would be expected to be able to run a marathon in under 4.5 hours. (Estimates are from data of Davies and Thompson as depicted in table 2.3 in Noakes' Lore of Running, 3rd edition.) Obviously Gledhill's endurance trained group were rather far out on the curve of ability to exercise and though they trained hard you have to wonder how high was their 02 max before training.

The authors of this and several similar articles hoped to study how fitness levels modify the heart and vascular system response to exercise. However the authors realized that this type of cross-sectional study cannot tease out the effect of training from the effect of genetic endowment,

Quoting Gledhill:

"It is not possible to state with certainty ,based on these findings, that the difference in cardiac function between endurance trained athletes and normally active individuals is an adaptation to endurance training,a consequence of genetics or a combination of these influences."

 So far all of this seems little more than inside baseball physiology talk but could there be a broader significance ?

A optimistic " maybe" seems to be the view of Dr. Benjamin Levine of Southwestern Medical School (see reference number 3).

Levine's et al showed that there was some preservation of diastolic function-i.e ventricular compliance as measured by echocardiography (E/a ratio etc) as a function of the amount of long standing aerobic exercise and it seemed proportional to the amount of exercise. Long term exercisers had better compliance ( aka measure of ventricular stiffness) while measurements of "relaxation" decreased in the exercisers to about the same degree as the sedentary group-this was measured by the relaxation time (IVRT) of the left ventricle.

On the other hand Hirofumi Tanaka et al from Colorado (see reference 4) concluded that the compliance was not preserved in the long term exercisers ( though some of his data was consistent with that hypothesis) while there was a beneficial modulation of the age associated stiffness in the large elastic arteries ( as measured by the aortic pulse wave velocity)

 Levine ( reference 5) has suggested that the long term endurance exercise ( maybe as "little" as 2-3 hours per per week) can prevent the decrease in left ventricular compliance associated with aging and/or inactivity and perhaps have important implication for prevention of cardiovascular disease ( ie. diastolic heart failure). While, in my opinion,the evidence for this is a something less than overwhelmingly convincing this is a reasonable possibility and it would be very nice to think so, particularly to someone who has done a lot of running over the years.

A mechanism by which exercise may help to maintain ventricular compliance has been outlined by Hyo-Bum Kwak ( ref 6) on the basis of rat research into apoptosis or programmed cell death and exercise. Myocytes decrease in the aging heart and this is in part thought be due to a mitochondrial-mediated apoptotic pathways. Kwak has shown that exercise training decreased these apoptotic pathways .

 "Reason is, and ought to be, the slave of the passions and can never pretend to any other office than to serve and obey them." David Hume

references:

 1.Gledhill, N. et al Endurance athlete's stroke volume does not plateau:major advantage in diastolic function.Medicine and Science in Sports and exercise,26, pp 1116-1121, 1994

2.Levine, BD et al. Left ventricular pressure volume and Frank-Starling relations in endurance athletes.Circulation 84:1016-1023.1991

3.Prasad,A The Effects of Aging and Physical Activity on Doppler measurements of diastolic function. Am J Cardiol 2007, 99, 1629

4.Tanaka, H Endurance exercise performance in Master's athletes age-associated changes and underlying physiological mechanisms. J Physiol 586, 2008, 555-58

5.Bhella, P Impact of Lifelong exercise "dose"on left ventricular compliance and distensibility
JACC 641257-1266,2014

6. Kwak,H , Effects of aging and exercise training on apoptosis in the heart. J exer Rehabil 2013 apr 212-219

james gaultehttp://firstname.lastname@example.com:blogger.com,1999:blog-11034229.post-21385882967675507992016-09-02T11:34:00.001-07:002016-09-26T08:10:09.073-07:00Health care with other people's money- what could be wrong with that?

Paying for health care with other people's money-what could possibly go wrong?

Dr. Paul Hsieh answers the question posed in the title in a commentary in Forbes. See here.

He outlines four important ominous consequences of basing health care on spending other people's money.

 This excellent article should be read in its entirety but let me briefly comment on the first in the list.

"Doctors will be increasingly expected to save money for the system ."

This is already happening.Various medical professional organizations are re-writing traditional medical ethics, pushing the fiduciary duty of the physician to the patients into the memory hole and substituting the bogus concept of the physician as a steward of society's medical resources which at least one physician's organization (the ABIM Foundation) has strangely linked to social justice. I have ranted about this before but the caravan rolls on and increasingly the rhetoric in various medical forums emphasizes saving money for the system. It seems that the medical professional elite would have us believe that the road to social justice is for physicians to follow guidelines, which may not be designed for patient benefit alone but also for cost containment for the third party payers.

The medicine of the collective is replacing the medicine of the individual. This is being promoted in part by what I have called the progressive medical elite who, to a frightening degree, seem to occupy the leadership positions in many influential medical organizations . Their unspoken mantra is that medical care is too complex and too important to be left to the individual patient and his physician. Wise leaders with ideas need to be in charge. Of course, it is promoted by the third party payers, private and public who may well consider the medical professional elite in this ethical paradigm shift as useful idiots.

 The third party payers and the professional medical elite have attempted to turn traditional medical ethics around so that the fiduciary duty to the patient is somehow replaced by an ethical duty to save money and the whole flim-flam activity is sprinkled with non sequiturs about social justice. Social justice is typically taken to mean redistribution and if cost to the system is reduced it is difficult to see wherein the redistribution lies if everyone gets less.Everyone, of course, except the third party payers.

 In regard to private property the owners have the incentive to be a "good steward" of theirresources.You have to ask what is the incentive of physicians to act as stewards of a mythical collectively owned resource?

The notion of "the system" [in regard to medical care] while a rhetorically useful notion for a certain agenda, is basically fallaciously aggregating elements that do not belong together. In short, there is no system for health care just as there is no car delivery system or a home building system. It makes no sense to speak of the situation in which someone buys a new car as a cost to the car supply system or a person buying a home as a cost to the home supply system.All of these are transactions in which there are buyers and sellers and exchanges take place.Mr Jones gets a CT of the abdomen.. This is not a cost to any system. It is a cost to Jones and/or his insurance company while to the providers of care it is a payment. One person's cost is another person's income.To call this a cost to a system is nonsense.Unless all the health care is provided, operated and owned by a single entity, usually the government., then the services provided could be considered a cost to the system.

Who gains from acceptance of this bogus notion of physicians as stewards of some mythical collectively owned medical resources? The third party payers for whom the gain is obvious and the medical elite progressives who stand to gain from their position of prestige as experts and rule makers and the rest of us,physicians and patients, lose.

So, in summary there is no medical care system to which a cost is charged with every medical care transaction and secondly the physician as steward concept is completely contradictory to the traditional role of the physician as the fiduciary agent of the patient .

james gaultehttp://firstname.lastname@example.com:blogger.com,1999:blog-11034229.post-37646293476809045672016-09-01T06:54:00.003-07:002016-09-01T07:21:50.816-07:00What is going on with the price of the Epipen? Scott Alexander on his blog Slate Star Codex offers this insightful explanation of what is going on with the price of the Epipen and why are there not cheaper substitutes available in the US. Actually Alexander tells us this is one.See here.

John Goodman tells a similar story here.

Disclaimer:
 I have never actually used an Epipen but in an ill planned effort to dispose of an out of date pen I managed to drive the needle through my thumb.

james gaultehttp://email@example.com:blogger.com,1999:blog-11034229.post-33082869602286302902016-08-03T06:21:00.001-07:002016-08-03T07:41:25.272-07:00New high school football season advice-don't let your babies grow up to be defensive backs Extracted from an article  from AANS regarding traumatic brain injury (TBI) data from 2012:

Defensive backs in American football are at the greatest risk for both fatal head injury and serous cervical spine injury.:

"The majority of catastrophic injuries occur while playing defensive football. In 2012, two players were on defense and one was in a weight lifting session. Since 1977, 228 players with permanent cervical cord injuries were on the defensive side of the ball and 55 were on the offensive side with 44 unknown. Defensive backs were involved with 34.6 percent of the permanent cervical cord injuries followed by member of the kick-off team at 9.2 percent and linebackers at 9.5 percent."

Spending even a small amount of time watching high school,college and professional football on TV makes it seem obvious that the vast majority of high impact collisions occur in the defensive zone involving defensive backs and either runners or receivers and on kickoffs.Quarterbacks receive many hits with the helmets impacting the ground and have a significant risk of concussion but apparently have lower risk of fatal injury or injury leading to permanent disability.Offensive and defensive linemen may receive more sub-concussive head blows over a game or a season and whatever the long term consequences of that may be seem less likely to regularly be involved in high impact collisions and therefore less at risk for serious brain or cervical spine injury. There is a reason for ambulances to be parked near the playing field of high school football games attesting to the cognitive dissonance of some of the parents cheering them on.The EMTs are not on site to help manage sprained ankles.

Don't let your babies grow up to be defensive backs.

Notice: This is a lightly edited and altered version of an earlier commentary on this blog. As I see high school kids on the practice field in early August in Texas with heat indices pushing 105 my antipathy to high school and youth football flares again.

james gaultehttp://email@example.com:blogger.com,1999:blog-11034229.post-3894647030804435522016-08-01T08:23:00.000-07:002016-08-01T08:23:39.284-07:00Another football season begins, what do we know about sports related head traumaWhat do we know about head trauma in high school and college football?

Mild Traumatic Brain Injury ( mTBI) encompasses the clinical entity of concussion. Concussion is defined as a trauma induced alteration of mental status with or without loss of consciousness.

Considerable research has been published regarding concussion and recently research has been published about the multiple blows to the head that occur in all levels of football in the absence of a recognized concussion. These "sub-concussive blows" have become the target for various types of brain imaging and cognitive function testing and the results have raised concern about the long term effects on the brains of highs school and college players.

 Some of what we know is :

1.While conventional MRIs and CTs in concussed high school and college football players are normal , Diffusion Tensor Imaging (DTI) and functional MRI have shown abnormal findings some of which may persist for weeks or months. Additionally subtle impairments of verbal memory and other cognitive tests have been reported in concussion cases persisting past the time during which the player has any symptoms.The long term significance of these finding is not known.

2.Similar imaging findings and cognitive testing results are being reported in high school and college players after a season of participation in football even thought the players had no reported concussive event.

3.We know that football helmets do not prevent concussions.

4.We know that at least some college level contact sport athletes decades later show abnormal white matter by Diffusion tensor imaging and lowered test results on cognitive testing but again we don't know if these changes are a predictor of later symptoms of CTE.

 Some of what we don't know is :

1.We do not know what pathological changes underlie the imaging findings. Do the scan results indicate transient damage and tissue repair without likely long term sequelae? Is there a recognizable subset of these players with these findings who if they continue to be exposed to multiple head blows over many years will develop Chronic Traumatic encephalopathy (CTE)? How can those who may be destined to develop CTE be distinguished from the vast majority of players who never will have those problems

From the wide range of head hit exposures in those NFL players who have been diagnosed with CTE the obvious implication is that there must be a fairly wide range of thresholds. There are reports of NFL players with as little as five years of play showing typical pathological findings at autopsy. Further there has been at least one case of a college player diagnosed with CTE.

2.the long term cognitive changing on various tests and brain imaging abnormalities have been demonstrated in contact sport athletes in college and high school who did not experience a concussion.

 After the last high school football season ending there were reports of 13 fatalities. This is about average for the years following the meaningful changes made in the rules and the instruction of techniques of blocking and less dangerous ways to tackle. Better helmets probably prevent skull fractures but not concussions.Can you imagine the outcry if high school boys were forced to take part in an activity that results in deaths each year?

See here for details of some of those deaths. Tragically it seems that two were due to heat stroke, all were not due to head injury.In reading over the cases it seems reasonable to designate two of the deaths to the second hit syndrome.

You see the same parents who carefully made sure their kids did not ride tricycles without wearing helmets are some of the same ones watching and yelling at Friday night football games and probably do not see the irony of common practice of there being an ambulance at the stadium. If their son is the victim of the second hit syndrome, probably an ambulance won't help.

Note: Much of this posting is a rewrite of another commentary from last year which I shamelessly re-post now with only a few additions because this topic is one I obviously feel strongly about .I used to really enjoy watching professional and college football on tv now I only occasionally watch just to sample the action to notice obvious head trauma. Professional players increasingly are able to make some effort at an informed decision to play with considerations of the risk to their brains, high school kids and younger much less so.

james gaultehttp://firstname.lastname@example.com:blogger.com,1999:blog-11034229.post-15752283106750469002016-07-11T08:10:00.001-07:002016-07-11T08:10:52.110-07:00Is the new professionalism and ACP's new ethics really just about following guidelines?The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of the physician and the patients but presumed to define what the relationship of the physician should be to society. The physician was to strive for social justice and was to act as the "steward of society's " finite medical resources.

Implicit in the stewardship of resources notion is the egalitarian concept of the collectivization of privately owned resources i.e all of the assets and individual skills that constitute the medical resources. This is the view that resources as a whole should be considered as the common asset of everyone with each to have a right to their share or that the resources are "owned" by everyone. This notion is antithetical of the notion of private property and seemingly ignoring the key role of private property concepts as the basis for civilization, At least that is what David Hume,Adam Smith, John Locke and founding fathers thought about the importance of private property.

Owned is in scare quotes because the concept of ownership in a free society with rule of law entails the right of the owner to use his property,to exclude others from use of his property and the right to dispose of the property.If everyone owns the resource then no one owns it and no one could be excluded from use of the property.

All of the medical resources of the United States cannot in any real sense or legal sense be owned by everyone. So the common ownership rhetoric must be metaphorical and physicians as stewards of the resources must be rhetorical as well. It is a poetic way of saying the physicians should rein in the ever increasing cost of medical care. Further they can do that by ordering fewer tests and procedures and treatments,that they should abide by recommendations based on studies of cost effectiveness of various medical options, that they should not let their concern and duty to the individual patient override the collective good which will be brought about by doing what is best for the group and what will be best will be determined by the progressive medical elite.Just follow the guidelines,Doc.

james gaultehttp://email@example.com:blogger.com,1999:blog-11034229.post-3038398454036269662016-07-05T10:43:00.002-07:002016-08-18T07:31:36.034-07:00The 4th of July, Pride and "How Can I help you/"This blog is for the most part about medicine and the practice of medicine so quoting extensively from a economist's blog might seem off track and one may wonder what if any is the link to medicine. This recent posting by George Mason University's professor, Don Boudreaux is so congruent with my core beliefs and he expresses them so well that I have to quote him.

Broudreaux's topic is why, on the 240 th anniversary of the United States, we should be proud to be an American. See here for the entire essay.

Quoting from his blog, Cafe Hayek:

"...I'm proud of the peaceful manner in which most Americans conduct their private affairs. I'm proud of the widespread respect for private property that continues to govern people's personal, private relations. I'm proud of the entrepreneurial spirit that continues to exist among many of my fellow denizens of these United States. I'm proud of – and deeply grateful for – the innovativeness and entrepreneurial creativity of many of my fellow Americans. I'm proud that America continues to be a destination for people seeking better, freer lives. I'm proud that many Americans continue to believe that the most ethical course in life is for each individual to be self-responsible, self-supporting, hard-working, honest, and upright.

I'm proud, in short, of America's bourgeoisness. It's this bourgeoisness that has made America great. This greatness comes not from bellowing politicians, not from well-weaponed armies, not from arrogant judges, not from meddling bureaucrats, not from pompous Washington and New York and San Francisco pundits; it comes not from anything but the hundreds of millions of ordinary Americans who daily work hard, honor their contracts and other people's property, cherish their families, friends, and neighbors, and think it perfectly natural to ask strangers in commercial settings "How can I help you?" "

 It has always seemed natural for a physician to ask that same question upon seeing a patient. In fact I recently saw an orthopedics for pain in my calf who asked that exact question.

As I read commentaries about the MACRA proposal and the nearly 1000 pages it takes to describe the process I wonder how long as the bureaucratic interference levels continues to increase and impede medical practice will it be before that question will be merely perfunctory as more and more time and effort will be drained away in an effort to go by the rules of " quality care" and properly document them so the reimbursement will be 3 or 4 % more or less ( see here) and less available to do what is needed to help the patient.

Addendum; For an excellent review of how MACRO will change just the "Meaningful Use" program (and there is much more to it than that) see here.

 h/t to Margalit Gur-Arie on her blog "On Heath Care Technology"

james gaultehttp://firstname.lastname@example.com:blogger.com,1999:blog-11034229.post-88376663384537276682016-06-22T15:25:00.002-07:002016-09-05T12:35:45.528-07:00The last refuge arguments for central planning find a home in health care discourseThe economist and historian Dierdre McCloskey put it this way ( my paraphrasing). If some one glanced at what happened in the twentieth century and still believed in the value of central planning, they were not paying attention.

The Marxian dreams and even the subsequent efforts of the market socialists such as Oscar Lange ended badly or sometimes never really got off the ground. Things ended badly in the case of the USSR and Communist China wherein the promises of greater prosperity and equality ended in mass starvation and mass murder.The 1917-1991 gigantic social experiment was a failure.

 The contrast between East and West Germany and North and South Korea could not be more striking and devastating to the devotees of socialist planning and their advocates had to find arguments not based on economic success.

The economist Anthony de Jasay in his book Political Economy,Concisely discusses what he considers to be the two last refuges of the socialist central planner;the plea for social justice and the doctrine of unequal exchange.

We can find versions of both in the rhetoric of the defenders of the Affordable Care Act (ACA) and in the pronouncements of the medical progressives whose major premise is that medical care is too important and complex to be left to the individual physician and patient and that we must have wise leaders with ideas to replace the traditional "dyad" of the patient and physician as the deciders of medical care .

."The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design." FA Hayek from The Fatal Conceit

james gaultehttp://firstname.lastname@example.com:blogger.com,1999:blog-11034229.post-57031414237388031442016-06-21T09:20:00.003-07:002016-06-21T09:20:53.549-07:00Exercise associated collapseThe term exercise-Associated Collapse (EAC) as used by Dr. Tim Noakes of Cape Town South Africa refers to athletes collapsing after completing a marathon or longer event, though the term more generally could refer to anyone collapsing during or after an endurance event.

Noakes writing specifically about the endurance race event collapse is describing a runner who typically finishes the event and then feels lightheaded, possible nauseated and may indicate that he feels like he will faint. The blood pressure is low in the 100 to 110 range with a mild tachycardia in the 110 range. Noakes emphasizes that the appropriate intervention is to elevate the legs or low the head below leg level. This maneuver, in his vast experience will bring about recovery fairly quickly without the use of IV fluids. This approach received some documented support from a small randomized trial recently published by Noakes and co workers. See here for abstract.

Although the runner will be to varying degrees dehydrated, or volume depleted, Noakes indicates that the faint is not due to the volume status per se. Rather the mechanisms he postulates is as follows:

The post exercise collapse ( as opposed to the collapse that may occur while exercising which brings to mind a number of other more serious possible causes ) is due to postural hypotension related to several factors.

With exercise in the heat there is increased blood flow to vessels near the skin leading to a redistribution of blood to the peripheral veins ,more so as the ambient temperature increases.

Next the action of the calf muscles, while exercise continues, will reduce the volume of blood stored in the lower limbs and maintains an adequate venous return to the heart. When exercise stops, the calf muscle mechanism for venous return decreases and blood accumulates in the dilated venous system leading to decreased venous return and hypotension in the upright position.He also suggests that in the trained athlete there is a blunted compensatory increase in heart rate in response to a lowered blood pressure further increasing the likelihood of faint or near fainting.

So the treatment is the standard treatment for what used to be called vaso-vagal faint namely the Trendellenberg position. He believes that dehydration is not the cause and volume repletion is not the treatment, although obviously volume replacement is appropriate but can be done orally.

Noakes in his book ,Lore of Running, 4th edition, says that approach has worked well in his vast experience in the medical tent after the Comrades ultramarathon in South Africa.

Key information to management of the collapsed athlete is the following;

Location of collapse (i.e. while running versus after the race)
Level of consciousness and cognition (altered states suggest something more ominous that benign post exercise hypotension-particularly exercise associated hyponatremia )
Rectal temperature greater than 40C ( 104 F) means heat stroke.

Noakes and others have emphasized the importance of prompt measurement of serum sodium and blood sugar. Serum sodium less than 120 plus altered mental status should lead to administration of 3 % NaCl.

james gaultehttp://email@example.com:blogger.com,1999:blog-11034229.post-89935502322061635042016-06-17T11:17:00.002-07:002016-06-17T11:17:35.067-07:00This preventive medicine stuff is not easyCase in point is in regard to hormone replacement therapy (HRT) for menopausal women.It has not been easy to get that right.

The stylized facts of the history of that effort briefly are:

Use HRT widely as heart disease will be prevented plus the usual listing of such things as better skin,lessened hot flashes,improved mentation and all of the advantages of being younger rather than older.

Give HRT to almost no one as actually it increases not decreases incidence of heart disease.Yeah we got the sign wrong.And then there was the issue of increased blood clots and cancer risk.

Then a study demonstrates decreases incidence of clinical heart disease if the HRT is given early after the onset of menopause.The earlier data that demonstrated increased heart disease was derived from a study of older women who received HRT later after the onset of menopause. This suggests that a major determinant of outcome is timing.

See here for the more recent study on HRT in which women received HRT soon after the onset of menopause which demonstrated a decrease in the incidence of clinical heart disease.

Preventive medicine is not rocket science. The rocket scientists know with impressive accuracy where the rocket will come down as the law of physics applicable to that application are pretty well worked out. Preventive medicine is much harder.james gaultehttp://firstname.lastname@example.com:blogger.com,1999:blog-11034229.post-1124984892833607632016-06-17T06:48:00.000-07:002016-06-17T06:48:42.551-07:00Information voltage drop-not just a hospitalist issueI recently read that hospitalists have a term for one type of failure to communicate namely "information voltage drop"

This refers to the information relevant to the patients discharged from the hospital not reaching the outpatient "health care entities", eg the nurses at the nursing home and/or the doctors who don't go to hospitals doctors doing the primary care. This would obviously was a problem if the physician in the hospital and the physician in the office were the same person as it was typically in the heyday of the general internist.

It is , of course, a multi-two way street, information from the primary care docs do not always get to the hospitalists in a complete accurate form. reports from tests in the hospital may not get to the chart in time for discharge, etc etc.

 A google search yielded 131,000 hits for that term in quotes. The blog "notes form dr.rw" recently discussed the important issue of the drop of key information from the hospital setting to the post hospital care. I has seen it repeatedly in my mother-in-law as she veered from nursing home to the ER and then hospitalization..One one occasion her Remeron was not given for weeks in the nursing home due to nursing oversight and then started back in the hospital at the dose the docs thought she was taken resulting in near coma and a neuro consult.

Voltage drops can occurs in very short times and distances. I informed at least 6 different medical personnel prior to a invasive cardiac procedure , one not fifteen feet and four minutes before an IV bag was hung containing the same mediation regarding which I had repeatedly mentioned a personal allergy.Fortunately the dose of Versed I had received was low and I could protect myself. james gaultehttp://firstname.lastname@example.com:blogger.com,1999:blog-11034229.post-47693971530175869562016-06-06T04:17:00.000-07:002016-06-06T04:17:55.956-07:00Does the Conflict of Interest statement in medical journal articles really mean anything? I am beginning to think that the answer to the question in the heading is no.Thinking about a article in the NEJM published at the time of the run up to the passage of Obamacare and who the authors are probably shaped my opinion.

In the August 1,2013 NEJM a special report is published entitled "Prescription for Patient-Centered Care and Cost Containment" The authors are Thomas Daschle, Pete Domenici,William Frist and Alice Rivlin.The article predictably is in favor of the Accountable Care Organization and opposes fee for service in medicine. The article is not remarkable for its content.That could have been predicted from the names of the authors. What I find remarkable- but not unusual or atypical- is that one of the authors who is a principle in a venture capital firm that invests in health care businesses states that he has no conflicts of interest and that his business interest would not even possibly be conceived as such.

Dr. Frist's credentials are well known as he is an accomplished cardiac and transplant surgeon and former US Senator.His family's association with Hospital Corporation of America is also well known and Dr. Frist is not now associated with that organization. A few minutes of effort on the web yields considerable information about his current business interests at the time of the article's publication.

He is a partner in a venture capital firm, Cressey and Company,which specializes in health care related investments.These following are listed under partnerships on their website: 1)equity partnership in US Renal Care,a large private dialysis enterprise,2)Encompass Home Health,a provider of hospice and home health care with over 100 locations in 12 states 3)Jazz Pharmaceuticals 4)Select Medical which owns rehab and long care facilities, 5) Spine Wave Inc 6)Strategic Heath Care Program 7) Wound Care Specialists.

Section 5 of the ICMJE form , which authors of articles are obliged to complete and which can be accessed for all of the authors on the NEJM website states:

"Are there other relationships or activities that readers could perceive to have influenced or that give the impression of potential influencing what you write in the submitted paper?" (my underlining)

Dr. Frist and the others all answered no to each of the questions.

At the very slight risk of appearing cynical I suggest that his relationship with Cressey just might " give the impression of potential influencing" to some readers. The words potential and impression seems to make that question one that would be hard to answer in the negative if someone were involved in just about any aspect of health care.

 I wonder how many readers might consider the article in a different light if following the article there was a statement that Dr. Frist was a partner in a firm whose income stream is dependent on various health care entities. I'll bet more than a few readers might just think about the potential of influencing even though Dr. Frist is not on the actual boards of the companies in which he invests nor is he likely to be involved in anyway with the day to day operations of these businesses.Is the ICMJE form and the manner if which the form is answered really provide any useful information to journal readers ? Do the editors of medical journals need to have any oversight over the ICMJE form answers?Does the COI statements appearing regularly in medical journal mean anything at all?

I am not suggesting that Dr.Frist's views on the various topics covered in the NEJM article were determined or even influenced by considerations of what the author's recommendations would have on the income streams of the various health care business entities in which he is invested.But it is certainty possible that readers of the article just might get the impression of potential influence if they were informed about them in the COI statement.

james gaultehttp://firstname.lastname@example.com:blogger.com,1999:blog-11034229.post-1159039203289364212016-06-06T04:08:00.002-07:002016-08-16T08:06:14.174-07:00Managed Care and "learned helplessness" and medical professionalismHealth Care Renewal in the Sept.22,2006 posting referenced comments by the editor of The British Medical Journal,Leona Godlee, suggesting that physicians in the British NHS may have been so beaten down by their increasingly dysfunctional system that they seem unable to stand up and fight back as their medical professionalism demands. Roy Poses then links their behavior and some he has witnessed in physician's seeming inability to push back at the administrative forces that are squeezing the life out of American medical case to the concept of "learned helplessness."

From that reference and Google I learned that "Learned helplessness" is a term born in the 1960 psychology experiments in which animals "learned" that they had no control over a given experimental situation. Later, when the animals were placed in a different situation in which they had control, they remained passive and were unable to act . Actually only about 2/3 of the animals learned helplessness in that way, the others were able to solve a simple problem to escape a electric shock.(About 5 % of animals seemed to be rather helpless even before the conditioning.) That work by Martin Seligman lead to a theory of depression.

I have written before about some of the ways that Managed Care has damaged medical professionalism in this country. Examples abound. No longer are consultations routinely arranged by physicians based on their personal knowledge of the clinical expertise of the consultant but rather to someone on the patient's insurance plan. Medications sometimes are chosen more on the basis on the insurance company's pharmacy management's arm formulary than on the basis of the physician's judgment. Time pressures directly or indirectly shaped by HMO and Managed Care have placed physicians in the untenable situation of not having time to deal with the patient's problem(s). Approval for testing and procedures have to be pleaded for.More and more time is wasted checking off boxes purported to capture the "quality" of care that the health care professional delivers that is the future will be more determinative of the physician's compensation.

In an earlier posting, I considered the notion that not only have the practices of managed care-which would not have occurred if we had not agreed to go along with them-seriously eroded the physician-patient relationship but also the relationship between physicians.

Dr. Godlee's editorial was aimed at the British physicians but are U.S. physicians far behind in the areas of learned helplessness and diminishing professionalism? To not speak out against the practices and structures of managed care that clearly are detrimental to patient care, and to go along to get along would be about as antithetical to medical professionalism as anything I can think of. Some of the current behavior of physicians may well be characterized as learned helplessness but in the early days of managed care our failure to act must have had other origins as we had not yet had time to learn to be helpless Moreover the new Professionalism, as envisioned by the ACP and the ABIM and the Robert Wood Johnson Foundation meshes neatly with the learned helplessness . By following guidelines physicians can work for the common good and further social justice all the while not feeling helpless at all.

Note: Obviously the reference to the BMJ article is not breaking news. In reviewing drafts of earlier blog commentaries I realized I had neglected to post this one. james gaultehttp://firstname.lastname@example.com:blogger.com,1999:blog-11034229.post-76302128975646664472016-06-05T04:04:00.001-07:002016-06-17T11:14:42.777-07:00Worried about your health care?Do not fear, the Medical Platonic guardians are gearing upPlato envisioned a utopian society ruled by philosopher kings,leaders with ideas. Brilliant and knowledgeable, logical and devoted to the good of the crowd. Even back then the question was raised, "who will guard the guardians?" or "Quis custodiet ipsos custodes?"

The platonic ideal has persisted through the years since Plato pontificated.Currently those whose world view echos Plato are called progressives or [modern day]liberals as opposed to the classical liberals who hold the opposite view.Also, from what I've read the neo-conservative Leo Straus was a bit enamored with some of Plato views on government.

A apparent modern Plato fan is H.J.Aaron who has had three commentaries in the Perspective sections of the NEJM in the last year. He seems to be their go-to guy for his Platonic mindset and particular for IPAB issues.Here is a link to a sample of his views.

He praises Congress for their willingness to "abstain from meddling in matters they are poorly equipped to handle." ( Well, that would be a first) He seems to be aware of Public Choice theory (he has a PhD in Economics from Harvard) when he talks about the temptation of Congress to spend money for political ends but seems to have missed the point when he apparently assumes that the IPAB panelists would be immune to lobbying efforts.Clearly, he believes it is a good and desirable thing for Congress to delegate its powers to agencies and other bodies- a view somewhat in opposition to what James Madison envisioned but a major feature of the administrative state.

He likens the creation of IPAB to the creation of the Fed Reserve which was to be an entity not subject to congressional control set up a governmental entities largely not controlled by Congress.

IPAB is not much in the news currently as the legislative trigger for its activation has not been pulled but be aware it is still on the books and is available to be the mechanism by which selfless, wise leaders will direct health care miraculously immune to pressure from lobbyists representing interests that Madison referred to as factions.

james gaultehttp://firstname.lastname@example.com:blogger.com,1999:blog-11034229.post-12493258401690398422016-06-03T04:45:00.000-07:002016-09-06T07:30:08.713-07:00Politicalization of medical ethics-you have to ask why and by whom The politicization of medicine is cogently discussed by Dr. Thomas Huddle. See here for an abstract of his article.

First, with the publication of the Charter, Professionalism in the New Millennium in 2002 the notion of social justice was injected into the listing of attributes and behaviors that physicians should exhibit to act professionally.Rather than a well reasoned and documented argument for such action being presented by the authors, we saw a series of gratuitous assertions.

Subsequently a commitment to social justice was declared to be an ethical imperative in the American College of Physicians' (ACP) ethics manual. Other professional organizations followed suit pledging at least rhetorical support of the inclusion of social justice into their ethical propositions.

 Dr Huddle, who teaches at University of Alabama Medical School at Birmingham, says in part:

1) civic virtues are outside the professional realm, (2) even if civic virtues were professionally obligatory, it is unclear that civic participation is necessary for such virtue, and (3) the profession of medicine ought not to require any particular political stance of its members.

"Advocacy on behalf of societal goals... is inevitably political".

" civil virtues are outside of the professional realm" and " the profession of medicine ought not to require any political stance".

Requiring a commitment to social justice is clearly political and requires physicians to take a particular political stance and a particular philosophical position..Advocacy for social justice is one feature of the modern liberal or progressive political stance.Such advocacy is not typically part of the conservative political viewpoint or the libertarian ( aka classical liberal) position.

The notion of justice upon which which the country was founded was that of the justice embodied in the rule of law,i.e. treating everyone equally under the law. The foundational notion of the social justice line of thinking is essentially that treating folks who are unequal equally is unfair and unjust and therefor there must be societal ( i.e governmental) effort to mitigate inequality by redistributional and other coercive efforts of the state.

The physicians who authored the Charter and the ACP's new ethics would appear to be of the progressive persuasion while there are many physicians in the country who are not. A small group of what I have labeled as the "medical progressive elite" have seemingly captured the conversation and are attempting to profoundly alter traditional medical ethics.To the extent that they and similar minded individuals set the agenda of major medical professional organizations and medical students education they may have succeed. but I wonder how many practicing physicians are even aware of the views that they pretend to be a settled issue.

Why would such an effort be launched and well funded ? Who gains from efforts to bring about a sea change in traditional medical ethics? The answer to that may be found in the plan that the elite medical progressives later introduced to enable practicing physicians to on a day by day basis practice social justice.Simple they just had to follow guidelines .In that way there would be an alleged greater benefit to the collective -although sometimes as the expense of the individual patient-and presto we have a utilitarian form of social justice with the collective and of course third party payers benefiting.Is this the "why"?

Note: An shorter version of this essay had been published previously. I redo it now because sadly a version of social justice seems to be firmly appended to medical ethics,on paper if not in practice and few voices are heard in opposition.I find physicians believing that they should work for the good of the group or the collective or society a very frightening notion one with a slippery slope as evidenced by what went on in collectivist societies in the last century. james gaultehttp://email@example.com:blogger.com,1999:blog-11034229.post-25785567338729377212016-06-02T03:59:00.000-07:002016-07-22T12:44:18.998-07:00Presidential Election 2016-the wisdom to choose.
Thomas Sowell laments the choice that we are likely to have in the upcoming presidential election.In a recent commentary entitled "Grim Choice" ,he writes that the November election will offer a choice between a "thoroughly corrupt liar and an utterly irresponsible egomaniac"."

"More than any other time in history, mankind faces a crossroads. One path leads to despair and utter hopelessness. The other, to total extinction. Let us pray we have the wisdom to choose correctly."

 Woody Allen
james gaultehttp://email@example.com:blogger.com,1999:blog-11034229.post-70294179657370842912016-06-02T03:46:00.000-07:002016-06-29T09:24:51.775-07:00More thoughts on correction of severe hyponatremiaIn adults electrolyte issues have traditionally been the arena in which internists ( and I guess now mainly hospitalists) earn their fees. Here is an interesting take on the correction of severe hyponatremia.

Severe ( often defined as less than 120) hyponatremia is typically considered as an medical emergency. Discussions regarding it usually consider acute hyponatremia ( as in runner's hyponatremia) and chronic. In the former some urgency exists in regard to treatment as the concern is brain swelling and catastrophic brain herniation. In chronic, too rapid correction runs the risk of osmotic demyelination.

Beer potomania is part of the differential diagnosis of hyponatremia. This article provides gives data on alcoholic patients with hyponatremia and explains several mechanisms for the low sodium other than what is usually thought to occur in beer potomania syndrome.

james gaultehttp://email@example.com:blogger.com,1999:blog-11034229.post-87201146385420750172016-05-30T12:11:00.000-07:002016-05-31T04:11:04.494-07:00At least one labor union fails to recognize the social justice of ObamacareApparently the roofers union believed the administration's claim that if you like your health care insurance plan you can keep it. Now they finally seem to have realize the bogus nature of that pre ACA passage ploy.

See here for the union leaders statement asking for repeal of at least some of ACA.

" I am therefore calling for repeal or complete reform of the Affordable Care Act to protect our employers, our industry, and our most important asset: our members and their families."

addendum: My apology. This post clearly is old news .In reviewing my store of unfinished drafts of posting I must have hit the publish button my mistake.5/31/16james gaultehttp://email@example.com:blogger.com,1999:blog-11034229.post-49767620370151762832016-05-30T04:38:00.000-07:002016-06-04T04:53:01.715-07:00The determinates of the stiff aging heart and what if anything can be doneDiastolic heart failure had been for the most part a diagnosis of exclusion.Symptoms and physical signs of heart failure (Hf) and an elevated natriuretic hormone level in the face of a normal ejection fraction (EF) as determined by echocardiography or gated myocardial perfusion imaging are the elements of the diagnosis.More recently echo studies of flow through the mitral valve opening have allowed a diagnosis of inclusion based on various indicators of diastolic flow and ventricular filling but evidence of diastolic dysfunction is not sufficient to make the diagnosis of diastolic heart failure with preserved systolic function abbreviated as HFpEF.

In the classic physiology text book's 70 kilogram man the stroke volume is 70 ml and the volume of blood poised in the left ventricle at the end of diastole is 120 ml, and the volume at the end of systole is 50 ml giving a EF of 0.58 ( 58%)) where EF = EDV-ESV/EDV, Clinicians like to use the term pre load. Pre load is the end diastolic volume.

But the percentage ejected per beat is not even close to whole story of cardiac pump function because first the ventricle has to fill and it has become apparent than at least as many patients have filling problems as have lower ejection fractions. The HF from filling problems is known as diastolic failure or in the jargon HFpEF ( heart failure with preserved ejection fraction) as opposed to HFrEF (heart failure with reduced ejection fraction)

Of course all patients with HFrEF also have diastolic dysfunction., i.e.failure of normal filling of the ventricles.

Echocardiography has become the major tool to diagnose diastolic dysfunction. Doppler techniques measure blood flow early and late in diastole.In the healthy compliant heart most the flow occurs early and that phase is is designated the A phase and the second phase is the E phase and the E.A ratio has become a useful indicator of diastolic dysfunction. As the ventricle become more stiff , for whatever reasons,the ratio of E to A decreases and diastolic filling relies more on the atrial kick phase.

A model or stylized working hypothesis concerning the heart stiffness has been proposed in which two major elements. are considered: 1) reduced compliance which is defined a change in volume/change in pressure in the left ventricle The relevant pressure is the difference between the left atrial and left ventricular pressure and 2) ventricular muscle relaxation.

Compliance is assessed to some degree and imperfectly by the E and A and E/A ratio and the E/E prime ratio while the relaxation is measured by the isovolumic relaxation time of the left ventricle (IVRT) This is the period after the closing of the aortic value and before the opening of the mitral valve.An increased value denotes poor relaxation.The E/A ratio can be deceptive because as diastolic function decreases,the left atrial pressure may rise to help push the blood into the ventricle which tends to increase the E/A ratio that may have become depressed in an earlier phase of filling problems resulting in a "pseudo-normal" pattern.

To help sort out normal and pseudo normal ratios, tissue Doppler Imaging (TDI) can be helpful. TDI measures the movement of the mitral annulus as it move upwards as the ventricle fills and is designated as E prime.

It has been recognized that the e/a ratio decreases with aging and some cardiologists recommend using an age adjusted set of value to determine if a value is abnormal just as values for lung function test indices are age adjusted. So is it normal or is it the case that everyone get a bit of diastolic failure as they get older or for that matter a little bit of lung impairment.It has been suggested than the aging lung is a bit like early COPD.

Several groups of researchers have taken the optimistic view that regular endurance type exercise over the years can help prevent at least some of the age related stiffness of the heart. There are data that suggest that is the case as at least some groups of older long time endurance athletes have better e/a ratios than their otherwise apparently healthy more sedentary cohorts. However the IVRT does not differ between the two groups, so the impaired relaxation of the myocardium that accompanies aging does not seem to be mitigated by regular endurance exercise.

The putative underlying cellular mechanisms for increased stiffness and the sluggish myocardial relaxation are topics for another day.Basically the narrative is that myocardial cells die with aging (apoptosis) and the surviving cells hypertrophy plus subendocardial fibrosis develops.

addendum:5/30/16 Hitting the wrong key lead to publishing a uncorrected version. I think I fixed most of the typos ,etc now .
. james gaultehttp://email@example.com:blogger.com,1999:blog-11034229.post-47833991266193445132016-05-27T04:42:00.001-07:002016-05-27T06:12:07.148-07:00Has medical care reached a near Fubar condition because of the Answering machine?I argue it may have.

Being a physician and knowing what I know about physicians , the good and the less good, I absolutely hate to go to a doctor. For most of my life I have not had to -now that I have to. I am past being appalled at the near impossibility of having meaningful or for that matter any communication other than face to face in the office.Some of this failure to communicate is due to the answering machine.

An illustrative real life case.

After the implantation of a pacemaker I experience several somewhat uncommon complications. One week post procedure my heart rate suddenly jumped to 150 . My pacemaker came with a bedside device that enabled me to send data to the PM center at the hospital .I sent a signal, called the number and was informed by the tech that it looked like I had atrial flutter. Calls to my EP doctor office were answered by a machine and the only relevant choice was to leave a message for his nurse. No call back in one or two hours and heart rate continues at 150, a value that exceeded the number that was sent to the PM center earlier. Knowing that atrial flutter is not a real call 911 situation did not keep my anxiety level from mounting.

Finally , knowing this was my ep doctor's clinic day my wife and I decided to go to the office and insist on seeing the physician . As it turned out the flutter has stopped by the time I saw the doctor.

The answering machine has turned into a situation in which the patient is given two options-leave a message and hope that you will get a reply sooner than the next or call 911 (or head directly to the ER on your own) .

james gaultehttp://email@example.com:blogger.com,1999:blog-11034229.post-7096715359004247272016-05-27T04:29:00.000-07:002016-05-27T04:29:55.811-07:00Medicine and the first rule of economics and the first rule of polticsThomas Sowell tells us that the first rule of economics is:

We live in a universe of scarcity and there will be trade-offs. and

The first rule of politics is to ignore the first rule of economics.

In this column by Thomas Sowell we see examples of how the economic rule is ignored by offers of pie . I suggest there are offers of pie in the sky in regard to medical care and financing.

Can we have decreased medical cost and increased quality? No problem- all we need in a governmental single payer.(Interestingly the Medical Home advocates sometimes make that same promise although recent analysis from the Congressional Budget Office concludes they really can't tell if it will cost more or less.) Also more recently we are told if were pay for value not volume the same miracle will occur.

I first read about the notion of increasing quality while decreasing cost or at least containing cost in medical care in a series of article in JAMA by Dr. DM Eddy over ten years ago. The bait and switch trick here was for Eddy to redefine quality as the greatest good for the greatest number. Eddy's series of articles seemed mainly to deal with the topic of decision analysis, an area that Eddy had apparently specialized in after foregoing a surgical career but his major thesis was/is that the goal of a health care system should be to maximize the health of the group and individual physician's concern about individual patients is misplaced.Eddy seemed to claim there would be no trade off , we would have both higher quality and lower cost., by simply redefining quality.Of course he is suggesting a system with its own major dangerous trade-off, namely the nebulous,loose and ambiguous good of the collective ( which will be in the eye of the elite in charge of the medical enterprise) over the much more easily discerned good of the individual.

Enter the decision analyst who can determine what is maximal health and how best to allocate or cost shift to achieve the maximal health of the group. He spoke of health care as a closed system and that it was a "zero-sum"game where for the good of the collective some patients may well be worse off, but although regrettable that is necessary for the greater good the details of which will be worked out by competent decision analysts.

This was an early proposal by the progressive medical elite for a overt rationing of care that self identified very smart people would be able to devise for the greater good of the herd. Eddy may well deserve a role in that group of smart people. The rationing that is part of the Independent Advisory Board ( IPAB) which was part of PPAC but not yet activated would be, I think, more of the covert rationing variety wherein there would be no explicit announcement of a utilitarian mandate but the board would rather simply say what was effective and ultimately what would be paid for by the third party- government and that would be leaped upon also by the third party private insurers. DrRich ( in a no longer active blog ) had a lot to say about that , see here.

Eddy's polemic is now more than ten years old and rarely read but others have forged ahead in his footstep. Enter the folks and ABIM , ACP and ABIMF and their program to change medical ethics ,make physicians be considered stewards of a collectively owned medical resource base and nudge and if necessary coerce physicians to dutifully follow guidelines that should boost the bottom line of the third party payers .

james gaultehttp://email@example.com:blogger.com,1999:blog-11034229.post-42538601067751364952016-05-27T04:22:00.002-07:002016-06-09T12:30:15.071-07:00Some of the reasons why (at least some) older runners have decreased heat toleranceStimulated by my own frustrating inability in recent years to run as far on my weekend "long runs" as I could just 3 or 4 years earlier I began to search for some physiological reasons. For years I would run a slow 18-20 miles on Saturday or Sunday throughout the years but in last 2 years I have basically crashed around 14-15 miles and was generally wiped out the rest of the day loosing weight from a pre run of 160 to a post run of 152 to 154 in warm to hot weather conditions and having a postural BP decrease indicative of volume depletion.

So far I have found evidence in the literature that at least 4 factors might play a role

1.A age related decreased in nocturnal ADH ( Arginine vasopressin) may cause a nocturnal polyuria.

2.Increased rate of glycogen utilization in older runners.

3.Lower levels of body water in older people.

So that my body water in the morning was lower to begin with as more water lost in the evening preceding the run and my glycogen stores were more rapidly depleted even after some efforts at glycogen loading leading to some limiting level of dehydration and glycogen depletion.The relatively meager liver glycogen stores are used during sleep.

4.Decreased V02 max with aging. the carbohydrate (CHO)/fat mixture changes as a person exercises harder and at some percentage of 02 max ( often quoted as about 60%) fuel source shirts to mainly CHO and little fat so that CHO stores ( glycogen) are more quickly depleted).So maybe in a misguided effort to run a bit faster than I should be,I get glycogen depleted quicker, i.e. after fewer miles have been run. So lower V02 quicker glycogen depletion.

 Dehydration in the older runner likely leads to to lower blood pressures post long hot run as the stiffer ventricle and central arteries respond to decreasing blood volume with exaggerated blood pressure changes- sort of a Starling curve thing. This of course is an effect and not a cause of volume depletion. james gaultehttp://email@example.com:blogger.com,1999:blog-11034229.post-53691121182106292012016-05-12T04:57:00.000-07:002016-05-14T05:29:31.453-07:00Snake oil salesmen and politiciansWhen Chinese railroad laborers in the 19th century used snake oil they consider it a legitimate and p useful product. The story goes that the laborers brought over with them oil from the Chinese water snake which they believed to be useful to relieve muscle and joint aches and pain from long hard days laying track on he US railroads making their way to the west coast.History provides us no record of randomized clinical trials.

A business man named Clark Stanley began to peddle what he purported to be rattlesnake oil said to have marvelous medical purposes. Following the passage of the 1906 Federal Food and Drug act a suite was brought against Mr. Stanley for "misbranding", as the ointment did not actually contain any snake oil. Whether it had any therapeutic value was apparently not at issue. So originally the term snake oil had no negative connotation but later became another word for con job or flim flam or mildly put -deceptive advertising.

Dr. Roy Poses of the blog Health Care Renewal expounds on the exploits of a modern , until now, unsuccessful politician currently leading the Republican race for president which involved a multi level market scheme for selling vitamin tablets that were purportedly customized to the individual customer based on a urine test. Ultimately the higher links in the multi level apparently could not pay their bills and the Trump Network's contract with the vitamin company lapsed and the Trump Marketing engine moved on to better pickings.

(the article that apparently was first on this story was the NY magazine in 2011)

The term snake oil salesmen morphed into a synonym for hucksters or con men or film-flame artist -terms that are not uncommonly used to describe politicians.

If a politician found he had cannibals among his constituents, he would promise them missionaries for dinner. H. L. Men
Read more at: http://www.brainyquote.com/quotes/authors/h/h_l_mencken_2.html

If a politician found he had cannibals among his constituents, he would promise them missionaries for dinner. H. L. Men
Read more at: http://www.brainyquote.com/quotes/authors/h/h_l_mencken_2.html

If a politician found he had cannibals among his constituents, he would promise them missionaries for dinner.  H.L. Mencken

james gaultehttp://firstname.lastname@example.com:blogger.com,1999:blog-11034229.post-1045145030925783512016-05-02T12:39:00.000-07:002016-05-02T14:17:03.710-07:00Retired doc celebrates 1000 + commentaries with some self referential rehases. Happy anniversary to self.

About ten years and now slightly over one thousand blog commentaries have passed by since I started a blog about the same time I retired .

Here are some of my favorites topics , a few of which have had a few thousand hits which is a lot for a backwater blog with minimal general interest and too much inside baseball talk.

1)I have written about so called "high value" medical care more than once. Here is my favorite in which I suggest that while modern mainstream economic thought is very diverse and has many areas in which there is marked disagreement, most agree that demand curves slope downwards and value is subjective. The now widely talked about notion of high value medical care seems to contradict that second principle.Simply put- the question is high value according to whom.

Another commentary on a related issue is here . Value=quality/cost as a pseudo-equation used to pretend that cost containment is really all about quality and has nothing to do with third party payers enhancing their profits by lowering costs, i.e. paying less for medical care.

2)Meta Analysis is a topic I have written about for ten years with my basic grip being that meta analysis should not be enshrined at the tip top of the evidence based medicine pyramid.See here .
I quote from from an important essay by Dr. Steve Goodwin .

3)The issue of how to apply population data , as in for example a randomized clinical trial, to a real life individual patient, is a topic I wrote about in 2005 quoting heavily from an important paper by Kravitz,Duran and Braslow in one of a series of blog entries that were facetiously labeled suggestions for a medical school curriculum. (Facetious because I had no role whatsoever in curriculum planning)

4) Another "curriculum suggestion" dealt with education about the transformation of Nazi physicians to Nazi killers.This quoted liberally from a book ( The Nazi Doctors) by Robert J Lifton,M.D. Lifton said - That according to the Nazi medical credo the physician was to be concerned with the health of the Volk and was to overcome the old individualistic principle of the right to one's own body and the embrace the duty to be healthy and the physician duty was to the collectivity.( a paraphrase not a direct quote). Scary ideology that did not die out with the end of World War II and what happened and how it happened in Germany is an important thing for current physicians to know about.

5)A theme I have hammered away on perhaps too much is that of the progressive medical elite,the medical arm of the progressive mindset who believe that ordinary citizens are just not qualified to mind their own business and that the elite must mind it for them , ideally by persuasion but if necessary through coercive means.Here is a sample. Some might use the term" medical clerisy" to refer to this group.

6) Little seems to be written now about the  Complete Lives System promoted by Dr. Zeke Emanuel that caused a bit of a controversy in 2009 . My critical commentary received more hits than most of my efforts as well a number of supporting letter echoing the concern I had.Here I suggest what Hayek might have said in regard to the complete lives system.

7) Physicians, like all humans, deal a lot with uncertainty One framework that can be used to consider uncertainty divides it into two types- stochastic or random and epistemic i.e. one based on lack of knowledge. Dr. Steve Goodwin offered a useful metaphor or story about the difference between random or stochastic versus deterministic. I wrote about that here.

8)Hoodwinking the medical profession ( and the public) to further the boondoggle that medical practice is becoming was the topic of a blog for which I borrowed heavily from a very insightful commentary by another blogger , Dr. Michale Accad. The Baptist and Bootlegger metaphor is applicable here as well.

9 )The New Professionalism as envisioned by a subset of folks at the American Board of Internal Medicine and the American College of Physicians with editorial and financial assistance from the Robert Wood Johnson Foundation represents an effort to reformulate traditional medical ethics from which in which the physician has a primary fiduciary duty to his patients to one in which a nebulous duty to be a steward of society's medical resources assumes a major role and social justice is appended to the traditional medical ethical precepts.Here I comment on the relationship between social justice and the rule of law and here I write about Thomas Sowell's Conflict of Visions
as related to the old and the new medical ethics.

Enough for one posting-maybe I reminisce about some others latter. james gaultehttp://email@example.com:blogger.com,1999:blog-11034229.post-26348119336515609152016-04-30T05:32:00.001-07:002016-04-30T05:32:55.882-07:00Transformation from "layperson" to physicianIn the ten years since I began blogging much of what has been written about medical professionalism, I find alarming. The New Professionalism as promulgated by the American College of Physicians and the ABIM attempts to transform the basic medical obligation of the physician to the patient to a nebulous,operational vague co-duty to serve society by conserving resources and furthering social justice.

The following is taken from an earlier blog entry with light editing and additions.

Dr. Lawrence G.Smith, writing in the April 3, 2005 issue of the American Journal of Medicine speaks of this transformation. from lay person to physician. Professionalism has been written about extensively as it relates to doctors. Smith maintains the core of professionalism is the "personal transformation of self that takes place in stages during the early years of medical training and practice" When transformed the person now interacts with society in a new and different manner ).Dr. Smith was not speaking of professionalism in terms of being a steward of collectively owned resources,that distortion of basic medical ethics was not then widely written about.

I have no doubt that transition happened to me. I can still remember comments made by teachers now over 50 years ago which were part of that process. I remember the attitude of respect and seriousness that was passed to me from the professors of gross anatomy as it related to behavior to the cadavers and behavior in the lab. I remember the pathology professor who told us that when we saw patients at night in the hospital how important it was for us to look and behave like physicians.I remember the chief of surgery who insisted that his residents wear shirts and ties in the hospital and clean coats and that his definition of a surgeon was a physician who knew how to operate.I remember how the clinical faculty typically treated the patients in the county hospital always with courtesy and respect, even though at times residents might have not.

 Soon after I completed residency and fellowship training I was doing a locum tenens and had the occasional to call the chief of medicine, with whom I had trained, to see a private patient at 3 am. She had end stage lupus and he had seen her several years before and her parents insisted that he see them. I called him at home and he arrived soon after .. He was well shaven and well dressed in a suit and tie.. He spent over a hour with the patient and family,taking a detailed history and ding a physical examination , completed a page and half note and spent another 10 minutes with me.The family was greatly relieved that all that could be done was being done. I was greatly relieved and felt that the chief had taught me another lesson;how a physician can do things the way that should be done in the real world.

These are just a few snap shots of the many events and attitudes that lead to my transition from a college kid who really had no idea what to expect in med school or beyond to a person who felt he was trained to do serious, often difficult, important work and that it all was a privilege and a great obligation and that doing the right thing for the patient was what it was all about. Much of what my high school friends had done while I was in training, I had missed and in the years of training much of transpired in the world I had also missed. And much of the everyday concerns of relatives seemed to be so much less important.I believe part of that transformation process is the isolation from the daily events of the world that seems required by the intense study and training lasting for years past the usual time an adult joins the work force. Part of that transformation occurs because most of your waking hours are spent with other physicians and professionals doing what doctors do and talking about things doctors talk about.Role models are everywhere.

I might add my classmates and I made that transition with the "benefit" of the trophies- for- everyone -before- the- game white coat ceremony.

As Dr. Smith said, once the transformation occurs you cannot think of being a physician as just a job.And it is difficult to think of yourself as any thing but a physician.

And because of that transformation it becomes very hard for a physician to retire or to be forced to leave practice because of illness. Are you transformed back into a lay person or are you still a physician who ...?james gaultehttp://firstname.lastname@example.com


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Re: Freshstart
I would treat this user like I treat my 11 y.o. 1.Ignore the bad behavior and it will probably change or 2. go away completely.
Big selling was internal not individual investors
panic. Besides most people know what Syy does and I find
the report hard to be held responsible for 2 pts. I
think planned sells were a lot more than expected and
the market lost a lot this week. Syy not the only
great stock to lose over 1pt in 24 hr. It will rebound
very soon always does. Also, this probably due to
concerns over chapter 11
protection to the large
healthcare chain that Syy was servicing and Wendy's deal
seems to have been rumored to have problems. SYGMA
closing Atlanta branch that serviced only
Wendy's and
a steakhouse chain. Rumored loss of Wendy's
business don't know who let who go or even if it is
entirely true. Do know steakhouse chain was told they were
more than likely losing Wendy's and could not service
then and the account went to a competitor USFS or PYA.
I think USFS.
There was a map of locations for Freshpoint & Sysco pinted in the July 17,2000 "The Packer" newspaper. There seems to be pretty coverage of East & West coast sites so immediate benefits look good.
cnbc listed syy with hmo's.
Anyone hear any rumors about PYA/Monarch dealing with someone else in Foodservise Distribution??
food and healthcare supplies; i.e., SYSMED -- who's the idiod (sic) now?!?
cnbc reported syy was a health care co, they showed 4 true health care co that had dropped in recent days and also posted syy. those idiods, syy supplies food to hospitals not drugs.
Any real info on this Freshpoint purchase? I'm curious to know if it is dead or not and how the decisions will affect stocks?
Spell Check, then I will relax.....
Someone just wanted to cash out. Probably a
senior executive who cashed in some options.
seen this before. Itll spring back within a few days.
A 19% increase in profits and 10% increase in sales
is strong. This baby will be in the mid forties
before you can say
anytrhing. Why anybody would sell
afte these kind of numbers is beyond me unless they
needed some cash. Im not at all worried.
I realize $2 is nothing, but SYY rarely moves
more than that, and volume was above average. Was it
because of earnings yesterday? I thought they were pretty
impressive. Is it because of the FRES deal?


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Ecoresort Le Sirenè, Gallipoli
- Free breakfast, free WiFi, and free parking
Main amenities
- 120 guestrooms
- On the beach
- 2 restaurants and 2 bars/lounges
- Outdoor pool
- Outdoor tennis court
- Beach umbrellas
- Conference center
- Airport shuttle
- Childcare
- Terrace
- 24-hour front desk
- Coffee/tea in a common area
For families
- Cribs/infant beds available
- Supervised childcare/activities
- Children's pool
- Children's club
- Playground on site
- Babysitting or childcare (surcharge)
What's around
- On the beach
- Tip of the Swine Beach (1.2 mi / 2 km)
- Baia Verde Beach (1.3 mi / 2.1 km)
- Green Bay Beach (1.3 mi / 2.1 km)
- Parco Gondar (2 mi / 3.2 km)
- Gallipoli Greek Fountain (3.7 mi / 6 km)
- Brindisi (BDS-Papola Casale) 60-min drive; 55 miles/88.5 km
- Free self parking
- Free valet parking
- Free extended parking
- Airport shuttle (surcharge)
- Area shuttle (surcharge)
- Train station pick-up (surcharge)
Ecoresort Le Sirenè, Gallipoli
Hotel Info: 01 65 69 441from €53
- Standard Triple Room
- Standard Double Room
- Standard Single Room
- Family Room
- Standard Room
- Deluxe Quadruple Room, Sea View
- Standard Quadruple Room
- Standard Duplex, View
- Economy Quadruple Room
- Economy Double or Twin Room
More great choices
At a glance
Key facts
Hotel size
- This hotel has 120 rooms
- This hotel is arranged over 4 floors
- Check-in time starts at 5 PM
- Check-out time is 10 AM
- Express check-in/out
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
Travelling with others
- Babysitting/childcare *
- Children's club *
- Pets allowed *
- Free WiFi in public areas
- Free WiFi in rooms
- Airport shuttle (available on request) *
- Train station pickup *
- Free valet parking
- Area shuttle within 3 km *
Nearby Three Star Gallipoli hotels
In the hotel
- Children's club (surcharge)
- Supervised childcare/activities (surcharge)
- Free breakfast daily
- 2 restaurants
- 2 bars/lounges
- 2 coffee shops/cafés
- Snack bar/deli
- Poolside bar
- Room service (during limited hours)
- Coffee/tea in a common area
- Beach sun loungers
- Beach umbrellas
- Outdoor seasonal pool
- Outdoor pool
- Outdoor tennis court
- Children's pool
- Tennis on site
- Pool sun loungers
- Pool umbrellas
- Billiards or pool table
- Business center
- Conference space
- Meeting rooms 2
- Conference center
- 24-hour front desk
- Concierge services
- Tours/ticket assistance
- Dry cleaning/laundry service
- Laundry facilities
- Hair salon
- Luggage storage
- Wedding services
- Multilingual staff
- Number of buildings/towers - 1
- Year Built 1970
- Elevator/lift
- Safe-deposit box at front desk
- Garden
- Picnic area
- Terrace
- Television in common areas
- Accessible bathroom
- In-room accessibility
In the room
- Air conditioning
- Minibar
- Private bathroom
- Shower/tub combination
- Free toiletries
- Hair dryer
- Free WiFi
- Phone
- Daily housekeeping
- In-room safe
Top Gallipoli hotels
Recently reviewed hotels in Gallipoli
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"We had an amazing stay at the centrally located Palazzo Belli B&B. Our rooms were exactly as advertised , extremely clean, spacious, beauifully decorated, artistic with even a…"Sep 20, 2016
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"We arrived early, the owner giovanni met me in a local square and allowed us check in early. The apartment is quiet, clean and has everything you need. Giovanni and his wife are…"Jul 19, 2016
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"This is a super hotel for value - we had an excellent experience here. Hotel is ideally located on the water front, and close to any number of great places to eat."Jun 15, 2016
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"Really lovely B&B with great hosts who were very friendly and helpful. The location is great and within five minute walk of the centre of town. Our room was very bright and…"Apr 8, 2016
Recommended hotels
Special features
DiningLe Tamerici - Overlooking the pool, this restaurant serves breakfast, lunch, and dinner. Guests can enjoy drinks at the bar. A children's menu is available. Reservations are required.
On Site
- Outdoor tennis court
- Tennis on site
- Bicycle rentals on site
- Ecotours on site
- Fishing on site
- Miniature golf on site
- Helicopter/airplane tours on site
- Kayaking on site
- Motor boating on site
- Mountain biking on site
- Playground on site
- Rowing or canoeing on site
- Sailing on site
- Scuba diving on site
- Snorkeling on site
- Tennis lessons on site
- Windsurfing on site
- Hiking/biking trails nearby
- Scooter/moped rentals nearby
- Surfing/boogie boarding nearby
- Water skiing nearby
Ecoresort Le Sirenè, Gallipoli's small print
Also known as
- Ecoresort Le Sirene Gallipoli
- Ecoresort Le Sirene Hotel Gallipoli
- Ecoresort Sirenè
- Ecoresort Sirenè Gallipoli
- Ecoresort Sirenè Hotel
- Ecoresort Sirenè Hotel Gallipoli
All guests, including children, must be present at check-in and show their government-issued photo ID card or passport.
Cash transactions at this property cannot exceed EUR 2999.99, due to national regulations. For further details, please contact the property using information in the booking confirmation.
For transfers, guests must contact the property 72 hours prior to arrival at the number on the booking confirmation.
Mandatory fees
You'll be asked to pay the following charges at check in or check out:
- A tax is imposed by the city: EUR 1.50 per person, per night, up to 7 nights. This tax does not apply to children under 16 years of age.
Optional extras
Cribs/Infant beds are available for an extra charge
Children's club access is available for an extra charge
Babysitting/childcare is available for an extra charge
Pets are allowed for an extra charge of EUR 30 per accommodation, per week, plus a one-time cleaning fee of EUR 30
Airport shuttle service is offered for an extra charge of EUR 110 per person (roundtrip)
Train station pick-up service is offered for an extra charge
Area shuttle service is offered for an extra charge
We have included all charges provided to us by this hotel. However, charges can vary, for example, based on length of stay or the room you book.
Is the description of this hotel not correct? Tell us


text:
Three candidates are to contest the election for new vice-president of the Institute of Chartered Accountants in England and Wales (ICAEW), it has been announced.
The three are: Dennis Cox, chief executive officer of Risk Reward Limited, Martin Hagen, non-executive director of Oxonica plc and Hilary Lindsay, business lecturer and e-learning consultant.
In his candidate statement, Cox drew on his experience as CEO of several SMEs. "I know the problems faced by our members at first hand, the problems of rules, regulation and capital raising," he said. "I also have the business flexibility to take a greater role within our Institute."
Hagen added that the key opportunities he would focus on as vice-president would include seeking consolidation options and developing plans to exploit market oppor...


text:
|Reviews for The Master of Hallowed Time
| fastreader12 chapter 5 . 7/8/2015
I'm curious to see where the story will go... Please update soon! :)
| GarnetMonsoon chapter 5 . 12/30/2012
Aw dude, I can't wait to see more of this! Though, I kind of think they'd tell Ron about it. They couldn't keep something so big from him, maybe it would be too hard, you know?
But if you can work it out, cool!
I can't wait to see more! This is one of the more original and interesting ones I've seen.
| Guest chapter 5 . 12/4/2012
| Guest chapter 5 . 12/1/2012
Please update
| Cassandra30 chapter 5 . 11/29/2012
Good stuff! Quick thinking Hermione!
| Cassandra30 chapter 4 . 11/29/2012
I agree with Harry. It needs to be done right away. But I do understand Hermione's concerns.
| Cassandra30 chapter 3 . 11/21/2012
| Cassandra30 chapter 2 . 11/21/2012
| Cassandra30 chapter 1 . 11/21/2012
Terrific start.
| Guest chapter 1 . 11/7/2012
Pplease update
| A great fan chapter 5 . 10/27/2012
Please update really soon please
| Guest chapter 5 . 10/24/2012
Pl ease update
| Guest chapter 5 . 10/15/2012
Rawr rawr raawwrr...that means brill in dinosaur ;)
| witowsmp chapter 5 . 10/15/2012
His only mistake was talking to the Horcrux. He should've simply grabbed it and took it to the Chamber of Secrets, which, by the way, I've always believed must actually contain secrets - not just be a basilisk cage. It never got fully explored in the books.
I'm sure Hermione will enjoy hearing about Bertha Jorkins' death, along with Frank Bryce's, while she plots.
| witowsmp chapter 3 . 10/15/2012
The Trace is a lie. Dumbledore told Harry that in book 6. The Ministry only tracks locations where underaged wizards who live with muggles live (mostly muggle-born, except for Harry, who's muggle-raised). That's why Dobby could fool the Ministry into thinking that Harry had cast a spell in book 2. They tracked the magic, not the person. The Ministry lies about it to the public, and that's why Hermione, etc, believed in the Trace. I don't know why Harry didn't remember that fact in DH. I suppose he still doesn't remember that fact in this story, which is consistant with the amnesiac Harry became in the beginning of Deathly Hallows.


text:
This looks craaaaazyyyyy. Word has it, this game is fan-made and Capcom is backing it. Oh look, fuck a rumor. The official word:
…this is a true collaboration between Capcom and its fans. Singapore superfan Seow Zong Hui (maybe you've seen his Dhalsim skills?) approached our own Christian Svensson back at EVO 2012 with the skeleton of SFxMM running on a laptop. Seeing the potential and serendipitous opportunity, Sven shared it with GregaMan and I a week later. We evaluated (aka played to death) it and said uh yeah, this is pretty damn cool. Then it all started coming together.
Look out for the FREE PC download on December 17, 2012 (Mega Man's official 25th birthday!!) at capcom-unity.com.
[via capcomunity]


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CHICAGO – It's 3am on Saturday night/Sunday morning on August 20th, and you're just not ready to quit. How about indulging in the 2016 "Abbie Hoffman Died for Our Sins" Theater Festival? The three-day theater marathon is in its 28th edition, and will be sponsored for the final time by the Mary-Arrchie Theatre Company, and hosted by the "Godfather of Storefront Theater," Rich Cotovsky. It all takes place at the Den Theatre, 1333 N. Milwaukee in Chicago (details below).
Adrian Hodges
TV Review: Great Cast Nearly Rescues Deeply Flawed 'Survivors'Submitted by BrianTT on February 11, 2010 - 7:42pm
CHICAGO – Who knew the end of the world would be so dull? BBC America makes a rare misstep this weekend with the debut of "Survivors," an ensemble show with a strong cast and timely concept but self-serious writing that rarely clicks into anything entertaining in its premiere.


text:
New York, NY, August 23, 2006 … The Anti-Defamation League (ADL) today slammed the human rights group Amnesty International for its report on the Israeli-Hezbollah war, calling it "bigoted, biased, and borderline anti-Semitic."
Abraham H. Foxman, ADL National Director called the Amnesty International report, "bigoted, biased, and borderline anti-Semitic." Currently in Israel visiting devastated areas in the north, Mr. Foxman said, "I see deliberate destruction of Israeli homes, hospitals, and other institutions."
He added that, "Amnesty International has a longstanding pattern of rushing to judgment to stigmatize Israel. They chose to ignore the fact that, after Hezbollah's unprovoked attack on Israeli soil, Israel did not deliberately strike civilian centers, while Hezbollah did, killing and maiming Israeli Jews and Israeli Arabs and destroying their homes and businesses."
Mr. Foxman went on to say that, "One would have hoped that Amnesty International would have started with the victim, Israel, and conducted their study here first reporting on violations of international law and war crimes committed by Hezbollah. When it comes to Israel, Amnesty International has an anti-Israel bias."
The Anti-Defamation League, founded in 1913, is the world's leading organization fighting anti-Semitism through programs and services that counteract hatred, prejudice and bigotry.
© 2006 Anti-Defamation League