Takotsubo Cardiomyopathy, (A Broken Heart?)

 When I was a young lad eavesdropping on my parents and other adults I would sometimes hear them speak of people who  died from a 'broken heart'.  It may have been in reference to someone who lost a child, a spouse, a lover or almost anyone loved deeply.  Talk of a broken heart, in fact, was not that rare to the ears of a child whose comprehension was awakening in the disastrous years of WW2.  As one grew older and matured one came to realize that the term was metaphorical and  there was no such thing as a broken  heart.  Some people certainly die from stress and suffering, pain and depression and loss of  the will to live.  But a broken heart?

   Well, in  the 90's a cardiac condition was recognized in Japan and subsequently in the U.S. and has now wide recognition.  There were 300 journal articles published in 2010.

   Symptoms of heart failure with an ECG that is suggestive of a myocardial  infarction (heart attack) is a common presentation, so this is easily misdiagnosed.  Chest pain and shortness of breath may occur.  Stress, physical or emotional is considered to be the main factor.  Grief, as from the death of a  loved one, fear, anger are frequently included among the triggers.  

   The exact cause of the myopathy is unknown, but is thought to be associated with certain types of coronary artery spasms.  The heart muscle takes on an atypical ballooning effect.

   While unattended the condition can have serious consequences, most patients recover fully with supportive in-hospital care.

    Incidentally, the stressor can be an exceptionally happy event, like winning the lottery, so be careful!

    Shape assumed during contraction is supposed to resemble Japonese Octopus pots (Takotsubo) after which  the disease is named.

    So perhaps people have been dying of a broken heart since the beginning of time?

Reflections in the Swimming Pool.

   In addition to maintaining physical fitness, I really do believe that swimming contributes to mental fitness.  A certain equanimity results from swimming back and forth and as this metamorphoses into a not unpleasant boredom certain thoughts drift in and out of consciousness.   I call this the TAO of swimming.
   Many of the thoughts are philosophical on a grand scale e.g. the nature of the universe and just as many are trivial, but not, I believe, insignificant.  Many are related to medicine, an area to which I dedicated much of my life, perhaps too much, leaving other important things undealt with.  Despite the tremendous leaps of modern science, I fear for my profession as I reflect on some of the amazing physicians I was privileged to know and learn from.  For the most part their likes are gone and in this sad age I fear they would be more the objects of ridicule than of admiration.
   Unsummoned, embarrassing moments come back to haunt me.  Ridiculous, trivial incidents of little or no significance, that should have erased themselves from my memory half a century ago, still bring a metaphorical blush to my cheeks.  Some of the difficult decisions of the past raise their heads and either leave me with a feeling of satisfaction about how well I handled them, or a tinge of regret at how much better they could have been dealt with.  I often think of patients whom I was privileged to care for and admire their courage and attitude in dealing with the hands they were dealt.  I also remember some of the ones who had difficulty dealing with anything, who I could sometimes help.  I enjoyed a warm relationship with most of my patients and in fifty five years of practice never had a threat of a legal suit.  In fact, in my youthful naivety, I firmly believed that if one acted in the thoughtful best interests of one's patients, one was immune from legal suit.  No aspect of my practice of medicine was influenced by fear of legal suit until relatively recent years. It took me a long time to realize that was no longer the case, and that one had little option but to practice a self protective style of medicine in this adversarial atmosphere that our legal colleagues have bequeathed to us.  This is responsible for a very significant portion of the cost of modern medicine, without benefit to health care.
   And sometimes I am reminded of some of the things I don't want to be reminded of, and that's a whole other story.  
   It's all part of the Tao of swimming!
   

It's all in the genes!

   A short time ago I wrote a piece about speculation that genetic engineering of the Aedes Aegypti mosquito may have brought about a change in the Zika virus that is responsible for the virus's ability to cause microcephaly.  Speculation is just that, nevertheless the very fact that such changes are possible, makes consideration of the science fascinating.  CRISP-Cas9.  This allows scientists to snip a piece of DNA and replace it with a different piece.  This type of targeting is in its infancy but the technique is there and will become more precise very quickly. CRISPR stands for "clustered, regularly interspaced short palindromic repeats."  It is the quality of some bacterial DNA that enables them to create RNA, a single strand version of DNA, that seeks out DNA that matches its series of bases   The bacteria then sends a protein called 'Cas9' to attack the marked DNA.  The Cas9 can also be used to destroy and replace the targeted DNA with something better.
   The science is pretty difficult for folks without a science background and for some, like myself, who do.  A nice youtube diagrammatic explanation is worth looking at.    'CRISPR/Cas9 -how it works.'

    At my stage in the game, my interest is more philosophical than scientific.  I have no doubt that the science will be mastered, that's only a matter of time.  The potential for good is as limitless as the potential for disaster.  The very nature of the human race may be radically altered.  Genetic interference may have outcomes that we cannot as yet imagine.   There will be major ethical issues to deal with in the use of these techniques to breed super humans with perceived advantageous traits.  Both physical and mental advantages may be for sale in the future.  In any event and for many reasons, we all need to  be informed about what is going on in the area of genetics.   A new semi-human species may be just around the corner.

Let me know if you think it's time to engineer a new human race! 

  

Curmudgeons at the Pool and health care!

   As I changed into my swimming togs at the 'Player's Club' in Hilton Head, I couldn't help noticing that the mean age of the 'athletes' must have been about 75.  Not all of them were going for a leisurely swim as I was.  Many of them were working out on a variety of machines that would have looked in place in a medieval torture chamber.  I watched some of them for a while and although some were obviously in great shape, others were not.  Indeed, a couple of them looked as though they could fall down at any moment.    I had noticed a few in the changing room who's scars indicated that they belong to the same cardiac club as I do.  Of course these morbid thoughts were induced by my erstwhile profession and if asked I would certainly have recommended that they continue their activity. This started me thinking about the "good old days", when anyone who had any cardiac symptoms, no matter how mild was confined and restricted in a manner which would be inconceivable today.  As I swam my laps in the pool, I speculated on the skills,resources and expense involved in maintaining the last few years of life. Now all of us 'old guys' want to live forever as long as we have our faculties (or think we have!), but the truth of the matter is that because of the very success of medicine it will not be possible to offer everything to everyone for much longer.  Costs are climbing exponentially and with every advance in medicine will continue to grow rapidly.  Understandably, patients will expect and demand all that is available, regardless of their age, and at each election, politicians of all stripes will make promises that they can't possibly keep, because the country will not be able to afford them  Once elected they will have to appear to at least be attempting to keep some of their promises and that will involve increasing taxes on the shrinking working age segment of the population which will of course be very unpopular and not a vote winner.  Their only other way of making more available will be to squeeze the health care system itself and they will do this ruthlessly.  Bullying physicians, nurses and other health care workers to do more for less by the government will initially be met with indifference or general approval from most of the population not directly involved with health care at the time.  Of course, as time goes by the general deterioration of  health care will become more apparent to the recipients of the services.   Unfortunately, politicians, unlike all other segments of the population bear no personal responsibility or liability beyond their term of office.  The worst that can happen to them is that they don't get re-elected. 
   The physicians of Ontario are already the victims of such systemic bullying.  Most of the population don't know about it and don't care.  Eventually they will.
   

Zika Pt 3- or we really don't know!

"Brazilian state suspends larvicide used to combat Zika virus"

This article published a week ago in a Brazilian newspaper reports that the Brazilian state of Rio Grande do Sul suspended the use of a larvicide used to eliminate mosquitoes, particularly aimed at Zika virus control.   The larvicide in question is Pyriproxyfen.  The measure was taken was taken after an Argentinian based Physicians group, specialists in crop spraying questioned whether the larvicide rather than the Zika virus might be the cause of the microcephaly.  As with Zika, no causative relationship has been established, so we are still at the hypothesizing (or guessing) stage.  The product has been approved by the World Health Organization since 2004 and by the U.S. Environmental Protection Agency since 2001.  This clearly indicates the need for further precise and definitive research.  The funds would be available if only we could learn to redirect resources from the many 'mickey mouse'* research projects we are wasting money on today.  

*Apologies to Mickey Mouse.

Aid in the Air.

       Aid in the Air.      

           "Is there a physician aboard the aircraft?" The Captain's voice rang out over the intercom system of the 747.

            I lingered in my seat, as long as my conscience would allow me, hoping there was another physician on board, who would come forward before I did.  This was the first holiday Irene and I had managed in two and a half years, and our first trip to Hawaii. I knew I'd been too preoccupied with work for too long, and I hoped this holiday would just give us some time together.  I pushed myself reluctantly out of my seat and identified myself to the stewardess.

            "We have him up in first class, doctor, there's more room there. He's having a fit," She said.

            I rapidly moved up to the front of the aircraft, beyond the curtained partition, into the comfortable, spacious, first class area.  A disheveled, heavy-set man was convulsing on the floor.  A stewardess kneeled beside him, trying to push a wooden tongue depressor between his teeth. White foam escaped from his mouth as amidst the seizuring he attempted to turn his head away.

            "What sort of medications do you have on board?" I asked the stewardess as I knelt down beside the patient, and taking the tongue depressor in one hand, I firmly grasped the man's chin with the other, forcing his jaws apart sufficiently to insert the wooden stick between his teeth.

            "I'll get the medications bag," the stewardess said, moving quickly into the storage area in the front of the cabin.

            I loosened the man's collar and tie, and then took the black medications bag that was handed to me.  I quickly rooted through its untidy contents, then emptied it on the seat beside me.  I found a small cardboard container of ampoule of Phenobarbital, and a syringe and sucked up the contents of two of them into the syringe. 

            "Need any help?" one of the few passengers who had been watching apprehensively, asked.

            "If you can give us a hand to get his jacket off, I'll be able to inject this right into the vein and get this seizuring stopped," I said.

            With the help of the man and the stewardess, we got the patient's jacket off and I managed with difficulty to get the needle into the vein of the still seizuring man.  I injected the Phenobarbital.  A short time later the seizures had diminished, and the man slipped into an uneasy sleep. 

           

     "Has this man anyone with him?" I asked the stewardess.

            "No," said the stewardess, "he's on his own."

            "I think he'll be okay now, but he should be checked over by the airport physician when we land.  We'll need to find out about his previous history, and if he's on any medications in order to decide what needs to be done next. How long will it be before we land?"

            "About two hours, we'll radio ahead to make sure the airport physician is available to look after things".

            "Well, I'll go back and join my wife, you can come and get me if you need me," I said.

            "Would you give us your name and address, doctor, so we can account for the drugs we have used?"

            I gave them my name and address, and went back to join my wife.

            "No rest for the wicked," I grumbled.

            "The least they might have done is moved us up to first class for the rest of the flight," she said.

            About three months after the Hawaiian holiday, I had to attend a meeting in Toronto. The professional association to which I belonged and served on the executive, met several times annually, usually in Toronto.

            Earlier in the day, the chairman, Don Watson had suggested that after the meeting the group go out to dinner in a nearby restaurant that had recently opened.

            "Great," said Rick, "I hear this place is really good, although I haven't actually eaten there yet."

            "Everything," Don said, "Will I make reservations for about seven?"

            Everyone agreed that this would be a good idea, and a few minutes after seven o'clock, when I walked into the Magnolia Grill, everyone else was already working on their first drink.  Several members of the party saw me enter the restaurant and waved to me.

            "I'm with the Watson party over there," I indicated to the hostess who greeted me."

            She waved me on, and I made my way through the noisy restaurant over to the group of seven physicians sitting in an alcove that slightly muffled the ambient sounds. I took the empty seat next to Marie Levesque, one of the two women in the group.  Marie was a lively attractive thirty two year old physician from Quebec.

            "Half the department heads in family medicine are so busy with their administrative work that they only see patients one or two half days a week.  No one can maintain either their credibility or competence with that limited amount of practice," Ian Robbins was saying." "Hi Steve," he called to me as I came in,

            "I hope you guys aren't going to talk shop all night. Haven't you had enough all day?"

            "Dr. Smith wants some scintillating conversation," Marie Levesque sarcastically."

            "Well, I wouldn't actually expect that from this group," said I facetiously.  At the same time I thought to himself I wouldn't actually expect much from this group."

            "I just had an interesting experience on my way back from Moscow," Don Watson's timely interjection defused the developing tension.  "I got the Moscow - London fight, and we were barely in the air, when the Captain wanted to know whether there was a doctor on board.  Well, I sat for a moment, hoping some eager young physician would rush forward and leave me sipping my scotch, but of course no one did, and I reported for duty to the stewardess.

            'Just up there in first class, Doctor' she said'

            I went upstairs into a very fancy looking lounge, and found a perfectly healthy looking young woman, who had some pain in her left shoulder and had read somewhere that this can be the first sign of a heart attack, which very obviously it wasn't.  So I gave her the appropriate reassurance and was heading back to our rather modest seats in the back of the aircraft, when the stewardess said, 'we'd like you and your wife to enjoy the first-class facilities for the rest of the trip, Doctor.'  So Ann and I came forward and go the royal treatment for the rest of the trip."

            A chorus of "lucky so and so " went around the table.

            Then I said, apropos of our Hawaai trip, ""I guess that wasn't Air Canada, then.  Let me tell you what happened to me"and I recounted my story of a few months earlier, finishing with, "and I didn't even get a thank you note.""

            "What you want, they kiss your ass?" Marie said, her French Canadian accent coming to the fore.

            "No," said I, a little taken aback at the strength of her reaction, and the obvious resentment in her voice, "all I wanted was a little common courtesy."

            Marie pulled a cigarette out of the packet sitting on the table beside her, put it in her mouth and lit it herself, and then rummaged around her bag, finally pulling out a pen.  She then fixed her angry gaze on me.

            "What flight was this supposed to be on?" she quizzed me.

            "It was January 17th. Air Canada. I don't remember the number, but how many flights can there be from Toronto to Honolulu in any given time."

            "Yes, we can find that out" Marie replied, noting the date that II had given her.

            "Why are you so interested in this?" asked'.

            "Because my husband is the Head of public relations for Air Canada."

            I couldn't suppress a chuckle. “I see," I said.

            She scribbled furiously on the back of her cigarette package, her crescendoing anger becoming increasingly evident.

            "Air Canada routinely sends out a letter of appreciation all passengers who come to the aid of others." Implying I didn't mention I had received one.

            "I certainly didn't get one."

            "If you didn't, we'll check it out and send you one."

            "Thanks"

            She continued scribbling on the back of her cigarette package.

            "I will give this information to my husband and you will hear from him, if you didn't get a letter."" she said sourly.

            "Don't worry about it," said I casually.

            The evening wound down uneasily, and at about 11.30pm the group stood up and started their goodbyes.

            "See you in the morning," said Don Watson, "We should have our business completed by noon, so those of you with early fights should have no problem."

            The gathering broke up, with those with cars making sure that everyone had a ride back to their hotels.  

            Following the meeting I took a limousine out to the airport to catch the mid afternoon flight back to Saskatchewan.  I was glad to get back at a reasonable hour for a change and have a little time to spend with the kids before bedtime, and a pleasant long evening with Irene.

            Eight O'Clock monday morning Iwas at Family Medicine Rounds.  The rounds, usually over by nine am dragged on until nine thirty.  As soon as they were over I slipped away to my office to check the mail as I had been away for several days.  It was the usual rubbish, advertising literature which had slipped past my secretary, and usually not much did, some teaching activities from other departments that I wasn’t much interested in, a complimentary copy of a book in which I had written a chapter and some notifications of upcoming events.  A pretty boring assortment, all in all.  I was getting ready to go over to the clinic, when the phone began to ring insistently.

            "Hello," said I.

            "Hi Stan," said Peter Graham, executive director of the Association of Family Physicians, "I'm afraid I have some very bad news for you.  Marie Levesque was pulling out of the hospiyal parking lot, leaving after making her hospital this morning, when she slumped unconscious over the wheel of her car.  By the time they got her into the emergency department, she was dead from a brain hemorrhage."

            "Oh my God, how awfull,"" I said feeling inadequate for not having anything more meaningfil to say.

I reflected on their recent animated controversy.

            "We are going to send regrets from the executive, and suggest that we would like to establish a scholarship in her name  As an executive member would you be supportive of setting up such a fund?" asked Peter.

            "Definitely," said I, trying to brush aside my unreasonable feelings of guilt.

           

True story, only some names have been changed.

           

           

           

                            

Tastebud or Toxins?

I have always felt that that much of the charm of eating out was the camaraderie, the ambiance, and the relaxation, more than the food.  even the best restaurants are unable to match my wife's culinary skills... Nevertheless, a major part of any holiday has always been the adventure of eating out, of trying different ethnic foods which were not as universally available as they now are, of trying things that were too difficult or too messy to make at home.  Perhaps most of all was the delight of sitting sipping a glass of wine with one's spouse, while someone waited upon us.  We ate at some great restaurants both at home an abroad.  Often, the best restaurants were not the most expensive .Innovation and excellence were not confined to expensive restaurants and we had many esculent meals in modest eating places.
   Eating out while vacationing in America was often an adventure, both in the expensive and in the economic range. Quantities were absurdly extravagant and quality could range from mediocre to excellent.  Driving across America, one often found  small off-highway Mom and Pop restaurants that were surprisingly good.   And if one was anywhere near the coast, one was virtually guaranteed fish so fresh that it looked as though it might be just about ready to jump right off your plate!  Those were the days before the big restaurant chains ran everything.  It's hard to find a restaurant these days that isn't part of a chain.  Now, the preoccupation is more with uniformity than with excellence  They want to be just good enough to compete, no better.
   So, when my wife and I went to one of our favourite fish restaurants in Hilton Head, South Carolina for one of our favourite dishes, whole fried flounder on the bone, we knew exactly what we expected.  A big crispy beautiful looking seared fried flounder, so big that it's edges draped over the side of the plate.  Despite looking as good as it always did, it somehow lacked that exotic, ocean fresh flavour that I remembered. And was the consistency just a little different?   I was just beginning to think that maybe my aging taste buds were beginning to let me down when my wife said,"not quite as good as it used to be!" 
   Later that night as I read The Economist's predictions for 2016, I was reminded that the oceans have become dumps for huge mountains  of plastics.  It transpires that the plastic breaks up into micro-particles and these particles are ingested by the fish along with plankton and other micro-particles of food.
   Maybe we were just eating a little plastic with our flounder?