Medtronic Concerto Investigation Update

I called Dave Steinhaus, MD, Vice President and Medical Director of the Cardiac Rhythm Management Division at Medtronic yesterday regarding the Concerto allegation and he returned my call about 45 minutes ago. In summary, it seems there were a number of engineering concerns that their former engineer, Christopher Fuller, had regarding the wireless platform that Medtronic implemented for the Concerto device (and also pertains to their Virtuoso ICD). Some of these concerns were addressed, he said, but others were not felt to be of concern to whom he raised issue with at Medtronic. He confirmed that Mr. Fuller then chose to report his concerns to the FDA and a Minnesota senator. Dr. Steinhaus referred me to this news release from Reuters, claiming the FDA investigation is closed.

In essence, their stand at present is that this is a disgruntled employee, and that there has been no failures or complaints of any of their Concerto or Virtuoso implants to date, and they stand by its safety.

-Wes

Addendum: 1 Feb 2007 1845PM - Regarding the above claim from the Reuters press release that states: "Medtronic said it has had no reports of patient safety issues related to the wireless features of the device." I have checked and found one patient injury reported on the FDA Maude database from the Concerto device dated August 1, 2006 resulting in a patient injury. It can be viewed here. I was unable to see if other reports occurred in 2007. In no way should be construed as being related to Mr. Fuller's allegations, nor related to significant engineering issues with the device.

This one device malfunction in an estimated 11,000 implants is well below the prior reported average of 20.7 device malfunctions in 1000 implants noted by the prior report of the Heart Rhythm Society's Task Force of Device Performance Policies and Guidelines. - Wes

Pregnant Mom Gets Her Wish

Jennifer Gordon, the very pregnant mom who wanted to trade her belly for ad space in exchange for Super Bowl tickets, got her wish today. She earned two tickets from uBid.com on the 50-yard line in exchange for showing her belly before, during, and after the game.

Funny thing will be if she delivers before then. Will her shrunken belly then have the contracture, "U'bom?"

Best of luck to her and her husband... and Go Bears!

War Zone

A very moving front-line assessment of the war in Iraq can be found over at The Thoughts of Artemis. It makes my rants seem trivial.

-Wes

The Irony

The irony of cigarettes:

“Wall Street loves money. And cigarettes are money. You are clearly earning huge returns at the expense of people’s lives.”
-Michael D. Hausfeld, a lawyer in a pending class-action lawsuit against tobacco companies

* * *

“At times, as a tobacco investor or a tobacco analyst, it seems like an unending stream of negative news,” Mr. Adelman of Morgan Stanley said. “You hear about smoking bans, a new piece of legislation. You hear about criticism from the World Health Organization.

“And then lo and behold, manufacturers release their results,” he said. “And they are good.”

It's enough to make you sick.

-Wes

09:54 CST - Addendum: Sadly, Altria's Board just approved the spin-off of Kraft. Wall Street will be even happier...

East vs. West

I wonder if I should turn my office into a spa.

It seems spas are now incorporating acupuncture, an age-old therapy from the Far East, and billing $90-150 for one "therapist" to place little needles in peoples' forehead and allowing them to relax. People are flocking to these places.

In Western medicine, we too sometimes place needles in people, but at slightly different places.

But according to the Medicare 2007 fee schedule for an established patient office visit (codes 99213, 99214, or 99215), we can only collect (on average) between $45 and $130 and have a lot more paperwork.

No wonder doctors are thinking more and more about spas...

... they're stressed.

- Wes

Grand Rounds 3.19 Is Up

Check out Medical Bloggers' Grand Rounds 3.19 over at Envisioning 2.0. The topic this week: Consumer-Driven Health Care. A very worthwhile read, indeed.

Next week, Grand Rounds will be hosted by Dr. Couz over at Tales from the Emergency Room and Beyond.

-Wes

Medtronic 's Wireless ICD Scrutinized

This morning the WSJ reported that allegations were raised by a former Medtronic engineer, Christopher Fuller, regarding their Concerto biventricular implantable defibrillator:

Mr. Fuller, an engineer who had worked on the Concerto device, said he resigned from Medtronic in protest over what he terms "serious issues" regarding "how Medtronic evaluated the Concerto."

Last year, Mr. Fuller contacted the FDA and the offices of the U.S. senators from Minnesota. In one letter to Republican Sen. Norm Coleman, Mr. Fuller wrote that the Concerto device's long-distance telemetry "exhibited instabilities in testing" and that Medtronic "has chosen to ignore the problem."

Medtronic spokesman Rob Clark said the company believes the frequency band used by doctors to monitor patients with the Concerto "is dedicated for these uses and we believe it's extremely stable. We have had no adverse events reported due to the wireless telemetry features of the devices."

Mr. Fuller contends that this instability can "prevent other circuits from behaving properly" and can lead to "excessive" battery depletion or can "burn up" other circuitry in the devices.

We have implanted some of these devices and are unaware of issues to date with the exception of the wireless telemetery having interference issues with surgical xenon headlamps, but await a formal response from Medtronic and the FDA's evaluation.

Boy, this gives a new meaning to Medtronic's ICD ad campaign, "What's Inside?"

-Wes

Reference: WSJ (subscription required)

Acceleration/Deceleration Injury...

...might be what one gets if they try this crazy hillbilly slingshot routine:



-Wes

via Conservative Grapevine

An Intravascular Implantable Defibrillator

Just received word via a press release that InnerPulse, Inc has received funding to begin preparation for eventual clinical trials of a fully intravascular cardiac defibrillator. The implications for the patient will be an invisible implant, placed probably by a transvenous route from a femoral approach (in the leg). The company was founded in 2003 and has just won significant financial backing from many of the "biggies" in the defibrillator market (Medtronic, Boston Scientific, and Greatbach, but also has signficant investor interest from Johnson and Johnson). Sketchy details about the device are provided by their website, but the concept is VERY interesting and can extend to conventional pacing as well. Whether the device might increase the risk for deep venous thrombosis remains to be seen. Look for more on this in upcoming electrophysiology and interventional cardiology meetings.

-Wes

Stretching Ethical Boundaries

Today's Chicago Tribune described an Israeli mother's desire to preserve her son's lineage:

More than four years after her 20-year-old son was killed in action in the Gaza Strip, Rachel Cohen is hoping for a grandchild after winning a court case to have a woman inseminated with the dead soldier's sperm.

The case, decided this month by a court near Tel Aviv, is the first in the world in which a court permitted a woman to be inseminated from a known, dead sperm donor who was not her partner, according to the lawyer who argued the case, Irit Rosenblum.

The circumstances of the case have significant implications:

Rosenblum, who heads New Family, an Israeli family rights group, said the ruling meant that family lines could continue years after death through a person unknown to the deceased.

"We've created a victory over nature," Rosenblum said. "This is an unprecedented human drama."

But what would the son have thought about this:

"After he was killed, I picked up a picture of him that I had in the bedroom, broke the frame and started talking to him," Cohen said. "I told him: `You've been killed, all your dreams are gone, nothing is left of you.' Through his eyes he told me that it wasn't too late, and that there was still something to take from him.

"I didn't understand. I said, `You're about to be buried; what is left for me to take?' Then I realized it was his sperm," Cohen said. "I used to be a nurse and I knew from the newspapers that sperm can be frozen. I rushed to the local army office and asked that his sperm be removed and frozen. It was done the same day."

What bothers me about this case was the mother's statement, "...what is left for me to take?" I would have been more supportive if she had said, "what more could he give?" Organ donation should be pre-specified by the donor, not their loved one, and to violate this mandate crossed an important ethical boundary. As a physician, I would have a very hard time, indeed, granting the mother's wish to freeze her son's sperm unless he had requested organ donation before his death.

- Wes

The Supplication

“Dear God,
I bet it is very hard to love all of every body in the world. There are only 4 people in our family and I could never do it.”
– Nan

***

“Dear God,
Thank you for my baby brother but what I prayed for was a puppy.”
- Joyce

***

"Dear God,
Instead of letting people die and having to make new ones, why don't you just keep the ones you got now?"
- Jane

***


She was a 38 year-old mother of two kids with a warm personality and delightful smile. She had been plagued much her life with asthma but she had otherwise been fairly healthy. Her heart, she disclosed to her internist, had this nasty propensity to race when she became upset, exercised, or used her inhaler often. She complained about this to her doctor who ordered an exercise stress test and this is what it showed after 5 minutes of exercise:


For those not used to seeing an EKG, this one’s not normal. It demonstrates a rapid, wide-complex ventricular tachycardia (rapid heart rhythm arising in the lower chambers of the heart). The left bundle branch, inferior axis morphology suggested the ventricular tachycardia arose from the right ventricular outflow tract, just beneath the pulmonary valve. Although the cardiologist performing the exercise stress test usually gets a bit nervous when this rhythm starts during a treadmill test, the nice thing about this heart rhythm disturbance is it usually occurs in people with structurally normal hearts and is curable with catheter ablation (cauterizing the focus from where the arrhythmia arises). Alternative therapy with beta-blockers was not attempted because of the patient’s history of asthma.

So after carefully discussing the various therapy options with the patient, she chose catheter ablation.

“I’ll pray for you, Dr. Fisher.”

I didn’t know what to say initially, but thanked her and told her I’d see her on her surgical date.

***

Two weeks later, she arrived in our pre-op holding area with her hospital gown, IV, and surgical cap in place. Her friends and family surrounded her. She smiled contently as we prepped her for the procedure.

“Are you ready?”

“Yes I am.”

“Any last questions before we take you in the room?”

“No. You went over it pretty well during our visit.”

“Great, then we’ll get started…”

“Oh, Dr. Fisher?”

“Yes?”

“I had a dream last night. You see I prayed that your hands were guided to the exact spot of my fast heart beats. You’re going to do fine, you know.”

“Uh, sure, Ms. C. Thank you. I’ll see you in the room.”

I went to change into my scrubs and surgical attire. I entered the room and the staff were ready. I chose a simple approach using two catheters at first to make sure I could initiate the rhythm while she was sedated on our lab table. The catheters (wires) went in fine and I positioned one in the right ventricular apex and the other steerable ablation wire in the right atrium while we tried to start her rhythm in the lab.

At first we were not successful, but with the addition of a bit of Isuprel (an adrenaline-like medication we use to increase the heart rate), her tachycardia became easy to induce and was stable enough the permit careful mapping. I reached to the ablation catheter in the right atrium and placed it in the right ventricular outflow tract. The very first place I laid it appeared to be an excellent site for ablation. I couldn’t believe it. I asked my technician to pace from the ablation catheter tip. The paced EKG identically matched the spontaneous arrhythmia in all leads, even to the finest detail. The signal recorded from the ablation catheter tip preceded the surface electrocardiogram onset by 40 milliseconds (usually 30 milliseconds or so would suffice). Could it be? I dared not move the catheter.

I told my technician to prepare to perform the ablation. Once the energy settings and temperature adjustments were to my satisfaction, we applied radiofrequency energy to the tip of the ablation catheter. Her arrhythmia stopped three seconds after we started the lesion. Energy was continued for 47 seconds, then discontinued.

We tried and tried to re-initiate her heart rhythm disturbance and were no longer capable of re-starting the arrhythmia, even when she was given the Isuprel. We waited and kept trying to re-start the arrhythmia. Nothing happened. She was cured.

Total procedure time: 22 minutes.

Was it divine intervention? I have no idea. Frankly, it felt like pure blind luck. But to this day I have never had such a short, uncomplicated ablation procedure and I think back to her prediction and faith and I wonder...

-Wes

References: Kids Pray to God

Dragging My Heels in Healthcare

Intel’s Chairman Craig Barrett thinks I’ve been dragging my heels about using information technology in healthcare.

Hmmmm. Dragging my feet over something that represents hours of unpaid labor and exposure to litigation… What could I be thinking?

Yesterday in an interview by CNBC’s Maria Bartiromo at the World Economic Forum in Davos, Switzerland, Mr. Barrrett blamed the medical profession for lapses in implementing information technology in the healthcare arena in the area of chronic health management.

Bartiromo: Where else could technology enable better health care?

Barrett: Well if you look at it from a standard engineering analysis, about 80% of the cost in health care is in people who are chronically ill or old, and the real issue there is in fact, to keep them out of the hospital. That’s remote diagnostics and remote monitoring. Taking care of people who are chronically ill in their home. How do you do that? Information technology. Remote monitoring devices fire that information back to the doctors’ office let them keep track of the individual without having the individual have to go to the doctor’s office. Diabetes, congestive heart failure, all these things are amenable to information technology (and) diagnostics in the home.

Bartiromo: You could have all your information on a chip, I guess.

Barrett: Of course you could. I mean, we could have done this a long time ago if the medical profession would kind of get with it in this space. They’ve been kind of dragging their heels.

Whoa there Mr. Barrett! Are you suggesting that manufacturing of home monitoring devices containing Intel chips is the responsibility of the health profession? Have WE been dragging our feet or have YOU?

And Mr. Barrett, could there be an itsy bitsy reason that we have been dragging our feet? Could it be because no one is willing to compensate doctors for monitoring people using gizmos at home? Is this a trivial piece of information? I would suspect that you, “Mr. Swiss Alps,” don’t do much that isn’t going to compensate you, now do you? Or are you, “Mr. Six-Inches of Powder,” going to lead the charge at bridging this gap given your prescience on this issue?

It’s not about just getting the data to the doctor. That, sir, is NOT healthcare. Instead, it’s about differentiating signal from noise. With a data dump to doctor’s offices, who will sift through the mountains of data (pun intended) to determine which data represent a problem in a particular patient versus a significant change? Data can change in expected ways when certain drugs are administered: like the elevation of a white blood count after steroids are administered. Will your little data processor be capable of making higher-order decisions? Unlikely.

More importantly, if a data point exceeds a pre-defined parameter and a doctor like me is notified by an e-mail using your handy-dandy device, who will follow-up to make sure I received and acted upon the notification? E-mailing data this way, without personal contact, is like planting a sinister bomb on my desk that is waiting to explode in my face. If I don't happen to check my e-mail that week because I am inundated by the scores of aged entering their twilight years, will you take the liability heat, or will I?

Pompous, arrogant sound bites do little to address these critical issues regarding information technology’s application in health care.

I'm sure there's plenty of doctors who'd like to have a weekend in Switzerland to discuss our "economic" thoughts, too, Mr. Barrett. Just ask.

-Wes

Addendum: Dr. Helen has more discussion and interesting commentary on this post.

Caffeine-Laced Donuts

This should be filed under "why didn't I think of this?"

With all the popularity of energy drinks, coffee stands, and Dunkin Donuts - these will sell like, er, hotcakes.

Hey, maybe I can add caffeine to hotcakes... or ice cream.... or ....

-Wes

Venture Philanthropists

In a sign of the ever-growing frustration with academic medical centers to produce translational research - that is, research that can move lab-based experiments from cell to bedside, large non-profits are beginning to turn to for-profit companies to leap the seemingly insurmountable FDA hurdle:

It's a sign of desperation. One reason there have been so few drug breakthroughs lately is that the profit motive actually works against the development of new pharmaceuticals. Drug companies suffer from blockbuster-itis, the belief that only billion-dollar almost-sure things need apply for development. As a result, even the most brilliant discovery may not be translated into a drug unless it has 10-figure sales potential. Also, short time horizons on the part of venture capitalists, who generally want to see their biotech bets pay off in three years, don't mesh well with the lengthy drug-development process.

But the complicated business of moving a drug to market involves clinical trials as well. Perhaps nowhere else is the glacial pace of development slowed further than in academic medical centers, where highly-regulated Investigational Review Boards with over 20 members need to approve clinical trials before a research project can commence. While the well-meaning intent of such IRB's is for patient protection, more and more companies are moving away from academic centers in favor of busy clinical practices whose investigational oversight is less stringent, and approval process can takes weeks rather than months.

Academic medical centers desiring to participate in such trials need to appreciate the competitive disadvantage that they, too, are missing in the high-stakes world of clinical research. Maybe they, too, would then be privy to some of the "venture philanthropy" that exists in the marketplace.

-Wes

Reference: WSJ 26 Jan 2007, Section B1, "Why Non-Profits Fund For-profit Companies Doing Drug Research."

Pregnant Bellys as Ad Space

Now here's a new use for the pregnant belly:

Jennifer Gordon wants to sell her body. Not the whole thing, just her pregnant stomach.

Gordon, a lifelong "die-hard Bears fan," already has airfare booked and a place to stay in Miami -- but no Super Bowl tickets.

She's hoping to remedy that by auctioning off ad space on her nearly nine-months-pregnant belly to the highest bidder -- or someone with really, really good seats. It's a last-ditch attempt by a season-ticket holder who lost out in the Bears lottery.

Heh. You gotta love those Bears fans.

-Wes

Cholesterol Guidelines - Evidence Based?

The controversy over the appropriateness of using HMG CoA reductase inhibitors or "statin" drugs (e.g., atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin and simvastatin) to treat high blood cholesterol levels in hopes of to preventing the development of heart and vascular disease just heated up.

Drs J Abrahmson and JM Wright published an interesting article in The Lancet on their evaluation of guidelines for the treatment of hyperlipidemia:

For adults aged between 30 and 80 years old who already have occlusive vascular disease, statins confer a total and cardiovascular mortality benefit and are not controversial.

The controversy involves this question: which people without evident occlusive vascular disease (true primary prevention) should be offered statins? With about three-quarters of those taking statins in this category, the answer has huge economic and health implications. In formulating recommendations for primary prevention, why do authors of guidelines not rely on the data that already exist from the primary prevention trials?

The authors argue that current guidelines are an extrapolation of secondary prevention trials, or data combined from secondary and primary prevention trials, and not based on randomized trials of just primary prevention in the hyperlipidemia literature. To establish a basis for their concerns, they performed a retrospective analysis of the data from primary prevention trials (which they admit were not perfect because some of the patients had known vascular disease) and discovered the following:

We used two outcomes to estimate overall benefit (benefit minus harm): total mortality and total serious adverse events (SAEs). Total mortality was not reduced by statins (relative risk 0·95, 95% CI 0·89–1·01). In the two trials that reported total SAEs, such events were not reduced by statins (1·01, 0·97–1·05) (data on SAEs from the other trials were not reported). The frequency of cardiovascular events, a less encompassing outcome, was reduced by statins (relative risk 0·82, 0·77–0·87). However, the absolute risk reduction of 1·5% is small and means that 67 people have to be treated for 5 years to prevent one such event. Further analysis revealed that the benefit might be limited to high-risk men aged 30–69 years. Statins did not reduce total coronary heart disease events in 10,990 women in these primary prevention trials (relative risk 0·98, 0·85–1·12). Similarly, in 3239 men and women older than 69 years, statins did not reduce total cardiovascular events (relative risk 0·94, 0·77–1·15).

There has already been interesting commentary on this subject, unfortunately it is by an individual who also wants to sell his book. Nonetheless, there is a large monetary incentive for the pharmaceutical industry to promote statins to the general population. One is left wondering if there could be a subgroup of asymptomatic individuals who really don’t need primary prevention treatment of hyperlipidemia, or if there are individuals in whom the risks of drug side effects exceeds the reward of primary prevention therapy.

With studies like this, there is no question that patients can become confused. Should I stop my statin drug? What drug is best?

The answer here is simple: ask your doctor. This article is not justification for discontinuation of statins, especially since it, too, is flawed by the retrospective nature of their data. Rather, the authors' point appears to expose an area that should be studied further to assure our ounce of prevention is not worse than a pound of the disease.

-Wes

Reference: J Abramson and JM Wright ,”Are lipid-lowering guidelines evidence-based?” Lancet, 20-26 Jan 2007, Vol 369, Issue 9557, pp 168-169.

More on Medtronic's DTC Campaign

As published in this morning's Chicago Tribune.

-Wes

Medical Grand Rounds 3.18 is Up

Check it out over at Signout. I think he got it right when chosing TBTAM the Magnificent's post if the "Best of" category. Check it out.

-Wes

Totally Artificial Heart

Cool video (albeit a bit fast) of the implant of a totally artificial heart is online at the National Geographic website.

-Wes

Taking Issue with Antiviral Tissues

Do we care that Kimberley-Clark (KMB) has no idea if their anti-viral Kleenex tissues are in fact anti-viral? Is it ethical for them to place advertisements with claims regarding their products without substantiating evidence?

This morning I read the Wall Street Journal's article on the carefully-contructed marketing campaign to "re-brand" Kleenex facial tissues - using an anti-viral "pesticide" in its middle layer that claims to kill 99% of viruses when activated by moisture within 15 minutes. But I was particularly struck by the fact that there were never any tests to prove their effectiveness:

"After a year-long review, the EPA approved the product in 2003, with certain caveats. The agency, for example, required that Kleenex state on its label that the product hadn’t been tested against bacteria, fungi, or viruses.”

But what is this "pesticide?" According to their website (and confirmed by their material data safety sheet on their "virucide"), nothing but citric acid and sodium laurel sulfate (a sudsing agent). They claim that citric acid kills 99.9% of viruses on contact after 15 minutes. Really? Could spreading orange juice on our skin prevent the bird flu pandemic? Am I drinking a "pesticide" each morning? Aaaauuugghhh! Quick, Marge, to the Emergency Room!

So what then, does the term “anti-viral” mean? Does it mean “we really think it’s anti-viral? Does it mean, their "pesticide" combo is so bad that we dare not test this stuff? Is it really, as their ad says, a “Ruthless Killer” of viruses, bacteria and fungi?

For its ads, Kleenex considered a bold approach, showing a little girl blowing her nose and a message that punched up the tissue's tough side. After focus groups didn't seem to mind, the brand started running the print ads in 2005. The tagline: "Ruthless Killer."

And just to show their compassion to a schools in Texas and Michigan:

When flu outbreaks closed schools in Texas and Michigan in 2005, Kimberly-Clark shipped them dozens of free boxes of antiviral tissues. The Lovelady Independent School District in Lovelady, Texas, put two boxes in every classroom.

Remarkable that claims like theirs can be placed on products without proof – but then, it’s all about marketing, isn’t it?

Citric acid a "pesticide" - shheesh!

-Wes

10:20 AM - One more thing: these "antiviral" tissues cost 40% more than regular ones. You might want to save your money.

Reference: WSJ (subscription)

A Knitted GI System

Too funny, but anatomically correct.

-Wes

Source: Crafster.org via Boing Boing.

One Lucky Paramedic

He must have done a good job instructing.

But then again, sometimes you're just lucky.

-Wes

Miami Bound!

Saints 14, Bears 39!

The defense (and snow) was awesome!

-Wes

Its Show Time!

Go Bears!

Er, perhaps I should say "Its Snow Time!"

Snow, 30 degrees, winds 15 MPH from the ESE: perfect weather!

-Wes

Photo credit

Coronary Calcium Screening by CT Scan

New guidelines by the American Heart Association and the American College of Cardiology were issued earlier this week supporting the use of coronary calcium scans to assess risk of future heart attack.

Coronary calcium scans, also known as heart scans, provide pictures of the calcium deposits in coronary arteries that might herald the existence of a significant blockage. Depending on the amount of calcium detected, the result of this test is often called a coronary calcium score. Scores range from 0 to over 1000, with the lowest numbers suggesting lower risk and higher numbers suggesting a higher risk of future heart attack. Heart scans and coronary calcium scoring may indicate if someone is at a higher risk of a heart attack or other problems well before they have any outward symptoms of disease.

The new guidelines represent a reversal of the AHA/ACC recommendations from 2000 when there were insufficient data to formalize recommendations regarding coronary artery calcium (CAC) screening to the general public.

But the new recommendations, published online 12 Jan 2007 in the online version of the Journal of the American College of Cardiology, are made with some qualifications. CAC screening is only recommended for patients at moderate risk of developing coronary artery disease while very high and low risk patients are still not recommended to have CAC screening.

So what justifies a moderate-risked individual in whom the CAC screening is recommended?

People referred for CAC screening should not have evidence of other vascular disease or be at high risk of developing such disease (like diabetics or those with known coronary artery disease). If a person has a greater than 10% risk of cardiovascular death in 10 years as determined by having two or more of the following cardiovascular risk factors: cigarette smoking, hypertension exceeding 139/89 or those being treated for hypertension, high cholesterol or low HDL (< 40 mg/dl), a family history of premature coronary heart disease (male first-degree relative < 55 years or a female first-degree relative < 65 years) and age (men >45 and women >55), then they might be candidates for screening.

You can estimate your own risk by using this special calculator from the National Heart, Lung, and Blood Institute.

People with 0 to 1 of the cardiovascular risk factors above should not undergo screening, according to the guidelines.

The controversies and limitations of this test are nicely outlined here. Realize, too, that this report does not cover the appropriateness of newer, 64-slice CT scanners for evaluation of coronary artery disease screening. (Medicare still considers these "experimental").

So look for more CT scanners to come to a mall near you - but only get it if you really need it.

-Wes

Living Donor Transplantation

"However this turns out, I have no regrets. I love [my parents] both more than I could have ever admitted to myself. So the million-dollar question is: What does unconditional love mean to me? Everything. Worth suffering for, worth dying for, but most importantly worth living for. I have given everything I am, and everything I ever hope to be, into this decision. It was easy to make but tough to live with. This surgery may not save my father's life, but it has already saved mine."

So begins Mark Foster's decision to donate two-thirds of his liver to his father. The complex medical, social and personal decisions to proceed with live liver transplantation to his father dying of cirrhosis inflicted by Hepatitis C and alcohol are outlined in this morning's Wall Street Journal:

For decades, almost all organs used in transplants came from deceased donors. But as the operations have become more routine, the number of available organs is falling far short of demand. As a result, living donations have tripled in the past decade to about 7,000 a year, according to the United Network for Organ Sharing, which oversees transplants in the U.S.

Liver donations make up more than 300 of that number, with a close relative the typical beneficiary. Most of the rest are kidney donations. If all goes well, the two pieces of the divided liver each grow large enough to do the work of a complete organ. Yet more than a third of liver procedures have complications. Since the operation was first performed in the late 1980s, more than a dozen donors are known to have died world-wide, including three in the U.S.

The decision to surrender a piece of a liver can be an affirmation of love and selflessness. As Mark Foster and his parents discovered, it also can be an agonizing choice for the donor and recipient, one that forces families to confront tensions they might have preferred remain dormant.

And so, after significant soul-searching, Mark decides to proceed with the surgery:

Mark didn't like talking about the surgery -- people considered him either heroic or foolish. At a party, a friend's father, an anesthesiologist, reminded him of the dangers. The doctor said John had lived a long-enough life and told Mark "your life is not his." Warned he would have a significant scar, Mark gave his stock answer: "Chicks dig scars."

Living at home with no job and few friends took its toll. Ever since leaving college, Mark's life had been on hold. He had $100,000 in student loans, which he deferred; he can defer them only one more time before facing default. He still owes his college $3,000 and can't get his diploma until he pays the bill.

Mark chronicled his ordeal in his blog that contains videos of his ordeal. And yes, he's using his brief moment of fame from the article to help repay those loans. Given the national spotlight he's made for living donor transplantation, seems like the least the blog-o-sphere can do for this young man.

So spread the word.

-Wes

References:
Donate Life America
WSJ Article (subscription)

Spiders on Drugs

A review of the effects of various drugs (LSD, caffeine, THC [the active ingredient in marijuana], alcohol, and crack cocaine) on wood spiders. A bit of Maple Leaf magic ...

NHS Doctor Blog Wins Awards

Congrats to Dr. John Crippen at NHS Blog Doctor for winning three of the MedGadget Medical Blog Awards 2006: Best Medical Blog, Best Literary Medical Blog, and Best Health Policies/Ethics Blog.

The other winners can be found here.

-Wes

What is "Wellness?"

Today I read with interest the Jan/Feb 2007 issue of WebMD magazine that was sent as a “Complimentary Waiting Room Copy” to my office. I find these “journals” of particular interest because it is what our patients peruse as sources of higher medical knowledge.

In this issue, I was particularly struck by the sensationalist article under the “Wellness” section entitled “Germ Warefare” by Heather Hatfield, a WebMD health contributing writer and edited by Michael W. Smith, MD, Chief Medical Editor for WebMD. Insurers love the concept of “wellness.” No doubt they give funds to WebMD so our patients can understand this better.

As a former US Navy guy, in response to the title “Germ Warefare” I anticipated a cool article on anthrax or smallpox, but instead I found an invaluable article on how to avoid a cold or the flu this winter and how “innocent objects could be your greatest health threat!” The article offers a sobering look at what the media are teaching our patients. Here’s what they recommend to avoid the flu and a cold this winter (my comments are in italics):

Sternutation (sneezing): cover your mouth when you “achoo” – very reasonable – please make every effort to do this in my waiting room.

Grocery carts: Don’t use them. It seems “half of American children put their mouths on the handle!” Oh, and don’t put your veggies in the grocery cart seat! Diaper-aged kids sit in them! Yikes! So go without those infected carts and stuff your groceries in your pockets.

Elevator buttons: avoid the first floor elevator button – it’s loaded with germs (since everyone pushes it). Solution? Take the stairs.

Do not use the sponge, dishcloths, kitchen sink, cutting boards, toilet seat, bathroom counter, or bathroom floor – they're loaded with contagion! “This is where fecal bacteria hide, and when we find fecal bacteria, we usually find viruses that cause colds and flu.” Solution: grill outdoors all year and don’t cut the chicken up on the toilet seat.

Do not touch the escalator rail at the mall – “we find mucous, saliva, blood – they tend to be pretty grody.” Solution: fall down the escalators instead, then sue the Mall of America and get rich – at least you won’t get the flu.

Don’t work at a desk: it has “400 times more bacteria on it than a toilet seat” and “don’t use the computer keyboard or the phone – they’re the germiest,” Solution: don’t work, get fired and stay home so you can join the masses without health insurance.

Stay away from the middle toilet in public restrooms – it’s used the most often and a great place to catch the flu – “go for the first stall.” Solution: Better yet, just hold it.

“Kissing can prevent cavities; it stimulates the flow of saliva, but it can also make you sick” Solution: total abstinence.

Don’t shake hands with colleagues – you’ll catch something! Solution: be a jerk and look away when they say “hi” – at least you’ll be safe!

“Don’t use airplanes: if someone is sick on the plane, everyone within three feet is at risk!” Here's what it'll get you. Solution: drive to your destination in complete isolation, irrespective of location.

Tell your doctor to not wear a tie because “half of the neckties worn by doctors were swarming with disease-causing germs” and “doctor’s ties were found to be eight times as likely to harbor germs as those of security personnel, who apparently have an undeserved reputation for being slovenly.” Solution: have security personnel round on patients.

Is this really “wellness” or idiocy?

-Wes

Getting Stuck with the Bill

Death or liver transplant costing $450,000? In Canada, a patient decided and was stuck with the bill:

"This week's ruling was a blow for the 57-year-old retired high school teacher, who contracted hepatitis C from a tainted blood transfusion and was diagnosed with liver cancer in 1999. He spent $450,000 for a transplant in England after being denied the life-saving help in Ontario.

The court argued Flora's Charter rights were not violated when he was forced to choose between death or costly overseas treatment. The ruling, by a panel of three judges, also quashed his appeal of an earlier decision that refused to order the province to reimburse him.

The implications of this decision are far-reaching and can affect many throughout the province in life-threatening situations, said Flora's lawyer, Mark Freiman.

"It restricts the government's obligations in terms of providing heath care, especially life-saving health care," said Freiman, a former Deputy Attorney General of Ontario and expert on the Charter. "If the decision is upheld, it's not likely that people in a similar situation can require the government to assist them with providing life saving medical treatment.

"When government takes it upon itself to monopolize the provision of necessary medical care it has the responsibility to provide life-saving medical treatment."

With the political-correctness of providing health care to the uninsured, it will be interesting to see if similar precedents are forthcoming in the US.

-Wes

Art Buchwald Dies at 81

Illness clouds one's thoughts with all things medical.

I have seen this in my own father's struggles with his multiple medical conditions. They are all-consuming illnesses which chronic issues: diabetes, arthritis, renal insufficiency, and the like. None of them simple, all of them difficult to manage as individual problems, but even more complex when they occur together. Management issues seem to come before relationships when things get so complicated. So I continue to struggle to get my father to look up from his life, even for a moment.

So the coming of Art Buchwald's book, Too Soon to Say Goodbye could not have been better timed. The similarities of his illnesses with my father's were uncanny: renal failure, needing an amputation, struggling with the issues of dialysis or not, and deciding not to proceed that way. So I bought the book and gave it to him.

At first it went ignored. But time passed. He opened it and read the first chapter, and was hooked. He even laughed out loud. Art Buchwald managed to capture his attention better than I ever could have, and told a story that resonated deeply with another similarly afflicted man.

Mr Buchwald's ability to capture the humor in his last weeks, while making hospice care a reasonable option, was unique. He shared his wit and wisdom with sensitivity and pupose while managing to touch many of those he will never know along the way.

Thanks, Art. We'll miss you.

-Wes

When Doctors Get Their Hand Caught in the MRI Cookie Jar

...bad things can happen.

-Wes

Parasitic Symbiosis as Therapy?

My mother always had a sense of humor and loved this poster. It was framed in our bathroom and was displayed prominently for all to see - I just couldn't imagine all of those little critters in my colon to keep me thin.

But now researchers in Argentina have reported in the Annals of Neurology that intestinal parasites may help remit bouts of multiple sclerosis:

(BBC) The scientists said it was possible that the parasites were able to influence the production of T-cells - cells which "dampen down" immune reactions within the body, both ensuring their success, and reducing "autoimmune" illnesses such as MS.

"To the best of our knowledge, this is the first study to report chronic exposure to parasites as an environmental factor altering the course of MS in humans," they wrote.

How is it thought to work? By changes in the immune system thought to be induced by the presence of the parasites:

Myelin basic protein-specific T cells cloned from infected subjects were characterized by the absence of IL-2 and IL-4 production, but high IL-10 and/or TGF-(beta) secretion, showing a cytokine profile similar to the T-cell subsets Tr1 and Th3.

Any parent who has had a child with pinworms knows that this therapy will never fly long-term, but perhaps a better understanding of how these worms manipulate the immune system will lend a jumpstart to understanding this disease.

-Wes

MedTees Contributions 2006

As you may know, our t-shirt website, Medtees.com, sells health-related t-shirts and contributes a portion of its proceeds to charities based on sales from the preceeding year. We are pleased to announce our contributions for 2006 in descending order of amount:

Heart Rhythm Foundation - $172.28
American Cancer Society - $137.81
Juvenile Diabete Research Foundation - $82.70
Am. Academy of Orthotists and Prosthetists Project Quantum Leap - $46.79
American Organ Transplantation Association - $43.10
Children and Adults with Attention Deficit/Hyperactivity Disorder - $35.34
Obsessive Compulsive Foundation - $30.02
Sponditilis Association of America - $20.50
American Lung Association - $14.58
Epilespy Foundation - $14.50
National Multiple Sclerosis Society - $13.20
Crohns and Colitis Foundation of America - $10.89
Hadley School for the Blind - $9.90
Arthritis Foundation - $7.10
Plus other, smaller, donations...

Total Contributions for 2006 - $646.91 !!!

Thanks to all who contributed ideas and to those who have purchased shirts supporting these organizations!

-Wes

First Glimpse: Medtronic's DTC Defibrillator Ad Campaign

The first public glimpse of Medtronic's direct-to-consumer ad campaign dubbed "What's Inside" made its debut yesterday. Electrophysiologists are wary about this tactic (Star Tribune):

“There was a lot of angst a decade or so ago when the pharmaceutical industry started advertising that it may not be entirely appropriate,” said Dr. Stephen Hustead, an electrophysiologist who implants ICDs with Metropolitan Cardiology Consultants in Coon Rapids. “But if this raises awareness about [sudden cardiac arrest], then it could be very positive. It depends on how it’s done.”

I still have a lot of angst now: if I thought this was genuinely for the good of patients instead of stockholders, I'd be more enthusiastic.

-Wes

23:45 PM Addendum: Sid Schwab at Surgeonsblog adds his thoughts.

17 Jan 2006 2300: A link to the Medtronic commercial. - hat tip: TBTAM the Magnificent

Combined Carotid and Coronary Bypass - Safe?

"Dad needs a bypass."

"Are you kidding?"

"No, really, all of the major blood vessels to his heart are critically blocked and the doctors think it's best to proceed with bypass soon."

"So what's the hang up?"

"It seems they found he has a 95% narrowing of his carotid artery on the right, too. They're worried he might have a stroke if the put him of the heart bypass machine."

There aren't too many more complicated issues for recommending a patient with severe coronary disease for bypass when there's a critical narrowing of a carotid artery. It is incredibly harrowing to fight the battle of coronary artery revascularization, only to lose the war when a patient wakes with an expressive aphasia (inability to speak) or the ability to move one side of their body after suffering a major stroke during bypass. This is not minor issue.

So today's article in Neurology with gushing claims from the lay press tries to shed a bit of light on the issue, claiming a 40% increased risk of stroke exists if a carotid endarterectomy is performed in conjunction with a heart bypass procedure, rather than as separate procedures.

But caution must be exercised when interpreting these researchers' findings. There is a clue to the problems with this trial: why was such a "cardiovascularly-related" article found in the journal Neurology? Could it be that the data are suffering from a homonymous hemianopsia?

In evaluating this work, the reader and lay press would be well-advised to review the methodology of this study. It used retrospective chart review of computer-coded data, albeit in large numbers of charts, in an attempt to glean a flicker of data with which to draw a glimmer of a trend - NOT a conclusion. To attempt to make any sweeping treatment recommendations (e.g. there is a higher risk of stroke with combined bypass and endarterecy) without knowing the severity of carotid narrowing, or even if stroke victims had both carotid arteries narrowed as opposed to one, quickly demonstrates the flaws in such a retrospective analysis. Teasing out the validity of data requires "retrospective" analysis that can be subject to bias as well - many of which cannot be anticipated by the reviewer - like coding bias - wich may have been performed to improve reimbursement by the hospital. Another bias might be changes in operators or surgical technique that occurred over the time period studied. Can the authors prove this did NOT happen with their retrospective evaluation? Of course not.

But the most damning of the findings of the study were the admission of the investigators themselves:

"The limitations to the use of administrative data sets include both inaccuracies and inadequacies of available data. Diagnostic coding errors are common, though improving over time. We have tried to eliminate as many miscoded cases as possible by narrowing the data set."

Translation: "We know the data are poor and we fixed them a bit to clean them up and erased some data, but don't worry about that."

What can be said is that there were alot of computer-generated codes flying through a microprocessor and a statistics package that suggested a trend in increased risk might exist. To say much more with this study is meaningless.

A better source is the data from the 2004 ACC/AHA Guidelines for Coronary Artery Bypass Surgery:

Hemodynamically significant carotid stenoses are thought to be responsible for up to 30% of early postoperative strokes. The trend for coronary surgery to be performed in an increasingly elderly population and the increasing prevalence of carotid disease in this same group of patients underscore the importance of this issue. Perioperative stroke risk is thought to be <2% when carotid stenoses are <50%, 10% when stenoses are 50% to 80%, and 11% to 19% in patients with stenoses >80%. Patients with untreated, bilateral, high-grade stenoses and/or occlusions have a 20% chance of stroke. Carotid endarterectomy for patients with high-grade stenosis is generally done preceding or coincident with coronary bypass surgery and, with proper teamwork in high-volume centers, is associated with a low risk for both short- and long-term neurological sequelae. Carotid endarterectomy performed in this fashion carries a low mortality (3.5%) and reduces early postoperative stroke risk to <4%, with a concomitant 5-year freedom from stroke of 88% to 96%.

'nough said.

-Wes

Stem Cells Create Beating Heart Muscle

Although it is too early to tell how this might be incorporated into an actual human heart, the implications of this work for heart failure patients are staggering:

The researchers, whose study appears in the on-line edition of the prestigious journal Circulation Research, created the heart tissue in their lab by sorting human embryonic stem cells that turned into heart muscle cells and growing them together with endothelial cells and embryonic fibroplasts. The culture was carried out in three dimensions on a scaffold made of self-destructing sponge material that the researchers also created in their lab. In the future, they will look into the possibility of implanting the engineered cardiac tissue, with the blood vessels improving the implantation of the new tissue and its connection to the blood system.

The technique is aimed eventually at helping patients who have cardiac insufficiency due to heart attacks.

Not only are beating cells produced, but the blood supply to nurture them. The cells used were "pluripotent human embryonic stem cells of the H9.2 clone (passage 30-60) that were grown in the undifferentiated state on top of mouse embryonic fibroblast feeder layer."

Of mice and men...Steinbeck would have been proud.

-Wes

Go Bears!

Seattle Seahawks (10-7) at Chicago Bears (13-3) today.
Go Bears!

-Wes

15:30 Addendum: Squeeked by 27 - 24 in overtime. Whew!

Medtronic's Death Ads Go Direct to Consumer

From the Wall Street Journal:

Starting this coming week, television viewers will be treated to smiling faces, soothing narration and cheerful melodies in ads about ... sudden cardiac arrest.

...brought to you by Medtronic, Inc., the world's largest manufacturer of implantable cardiac defibrillators (ICDs) - those devices that treat rapid, potentially life-threatening heart rhythm abnormalities in people with weakened hearts from prior heart attacks or other causes. $100 million in ads. With this initiative, Medtronic is talking a card from the pharmaceutical industry: betting that direct-to-consumer advertising can boost sales of their devices. The feel-good nature of these devices that have the potential to treat arrhythmias painlessly with pacing protocols or deliver a powerful 800-volt shock to the heart to restore someone's heart rhythm back to normal will be awe-inspiring:

"10,000 more kisses...200 more football wins...An ICD could give you many more bedtime stories, tons of hugs, and one more thing -- peace of mind."

But in reality, these devices are surgically implanted and are a big deal for the recipient to receive. Certainly they can mean peace of mind in some folks, but the variable psychologic impact of these devices should not be underestimated. I would say the majority of patients I have implanted with these devices are genuinely happy they have one. But there are also patients who have had unfortunate experiences with these devices: from their implant to their follow-up after recurrent shocks from the device. Sugar-coating the implications of a device implant with sexy TV spots might win people's initial acceptance, but a dose of reality and the implications for continued follow-up and management of these devices should also be reviewed carefully with the implanting physician.

One of my teaching aides regarding the "Top 15 Questions" about automatic defibrillators can be found here. It's a no-nonsense way to learn about the real issues regarding defibrillators, the surgery, and even pictures of what the chest looks like after one is implanted.

I know, I know: I should be happy ad campaign is taking place. After all, it means I'll have more business, right? But the "direct to consumer" nature of these ads removes the doctor-patient interaction in favor of the medical device industry-to-patient interaction. I find this objectionable for it limits my opportunity for an objective, unbiased discussion with my patients at an emotionally-charged period in their life. How will these ads effect my discussions with the family of a loved one who really doesn't qualify for such a device, even though their heart is weak? Will the family object to losing those "10,000 more kisses?"

I'd be interested in hearing what patients and doctors think about this upcoming ad campaign. I am reluctant to act as a drug rep for the device industry on this one - but I'll stand behind the data that these devices can save lives in patients with heart disease from certain congenital heart abnormalities and in patients with markedly weakened heart muscles - irrespective of cause - and will be the first to implant them when medically indicated.

-Wes

Smokers' Hand Gel Fix

Smokers rejoice! Your answer to the proliferation of local smoking bans in now at "hand." Now you can put down those nasty cigarettes and matches and reach for Nicogel, the nicotine-containing hand gel! No, don't stop smoking - get a hand job fix, instead!

In response to local smoking bans, it seems smokers now can get their nicotine fix by smearing this rapidly absorbed nicotine-containing gel on their hands. Made by privately-held Blue Whale Worldwide Inc., this gel is marketed to quell the smoker's craving when in tobacco-free zones and will be available soon at your local Walgreens drug store:

Nicogel, which is already sold in 40 other countries including the United Kingdom, France and Germany, could generate $200 million in U.S. sales this year, Whalen said, predicting that sales will reach $1 billion by the end of 2008.

Smoking bans, which have cleared some air in places such as New York, Washington D.C., Louisiana, and Philadelphia, are helping to make cigarette alternatives, like smokeless tobacco, the fastest-growing segment of the industry, according to Charles Norton, portfolio manager of the Vice Fund, which has $75 million under management.

The U.S. moist smokeless tobacco category, which is dominated by Skoal and Copenhagen maker UST Inc., is one-tenth the size of the cigarette market, but is seeing unit volumes grow 8 percent to 9 percent a year, Norton said. By contrast, U.S. annual consumption of cigarettes is falling 1 percent to 2 percent.

What is concerning about this gel, is that it is not an antidote to quit smoking, but rather a cigarette substitute. Nicotine's addictive potential exceeds that of heroin and cocaine. The rapid absorption of the compound through the skin with this gel is marketed as similar to the bolus of the drug one gets with inhalation. And now it'll be available in your local Walgreens drug store.

Amazing. I can't get a Sudafed tablet in Walgreens for my cold without an international investigatory tribunal approving the purchase, but a Nicogel tobacco-fix? It will be easily purchased for about 60 cents a fix - much less than a frappachino at Starbucks!

On the bright side, this new craze might make the caffeine-laden energy drinks passé.

I wonder how long it will be before "Nicogel bars" come to a neighborhood near you. They might be modeled after the latest smoking fad near many college campuses: hookah lounges.

-Wes

BlueCompare Doesn't Dare

In a follow-up to my earlier post regarding insurers rating doctors, I seems the launch of BlueCompare in Texas was delayed after Texas Medical Association voiced concerns.

-Wes

Hat tip: Kevin, MD

Quitting Smoking

He was referred to me for an evaluation of atrial fibrillation, a chaotic beating of the upper chambers of his heart which caused him to become markedly short of breath when climbing stairs.

When I first saw him, I learned that he had been a smoker all his life - at least two packs a day for 48 years. His clothes had smelled like smoke, his fingers where stained that familiar yellowish stain from holding his filterless cigarettes, and his dentition was poor. Remarkably, his lung function had never been tested. I was concerned that his rapid heart rhythm was secondary to an as yet undiscovered lung disease, and referred him (after an appropriate cardiovascular evaluation) for pulmonary function tests. I also eventually prescribed a heart rate controlling medication and the blood thinner, warfarin, for him. Most of our visit was spent discussing the issues about smoking at length. He thanked me and felt renewed to try to stop smoking again.

He seemed appreciative and left after our first visit to return to his world. I was not overly optimistic that much would change.

He returned the other day, a bit to my surprise, for follow-up and review of his test results. He had shaved but was wearing dark glasses. He again smelled of smoke and there were his hard-pack of Marlboro cigarettes in his front pocket. He acknowledged that he had not been successful at quitting his smoking habit, but had been given some Zyban by his internist.

"I can walk better upstairs," he told me. "My heart doesn't race as much. I started an exercise regimen and don't get so short of breath."

"I'm glad to hear you're feeling better," I said, but he sensed by disappointment.

"I've always wondered what you doctors' think when a patient fails to do what you want them to do," he said. "You must get really pissed off."

I paused and was surpised by his statement. And then I thought about it.

"I used to," I told him. "When I was younger and more idealistic, I used to get upset at my patients. I'd lecture them for countless hours about how they were poisoning their bodies with countless known poisons, radioactive substances, and heavy metals known lethal to the human body. I'd tell them about the physiologic effects of smoking, review the costs involved, and even offer then $100 (I even showed them the money!) if they could name ONE thing (besides social acceptance) that smoking does that's good for you. No one ever came up with anything. I was always right. Pompous, pompous, pompous. But you know what? It never worked."

"So why don't you do that now?"

"Because I'm older and a bit wiser to the bigger world out there. I realize that this 45-minute visit means little in your overall life experience. I cannot begin to understand all of the forces that have led you to this addiction of smoking. I cannot control all of the minute triggers that you associate smoking with - like lighting up while driving, or having a cigarette while reading the paper with your coffee each morning. Those are POWERFUL relationships and habits that I cannot begin to break. But I can do one thing for you."

"What's that?" he asked.

"I can be your advisor. I can suggest some things. I can show you the effects of your smoking as it relates to these tests and translate what these tests MEAN so you can understand them. But YOU, my friend, have to quit. YOU have to decide this is important enough in your life. YOU have to understand that I believe your heart rhythm disturbance was directly a result of your bad lungs. YOU have to believe you can quit. I just don't want to sit here and watch you decline on the inexorable course you're surely going to have if you don't. Before long, at your current rate of decline, I'm concerned you'll need continuous oxygen."

"My Dad needed oxygen. He had bad emphysema." His eyes welled up with tears as he looked away.

"It's not too late to quit," I said.

"Thanks for not giving up on me."

"I'll see you in a month."

-Wes

Back from Vacation - And Tagged

Boy, a real vacation. Wonderful. Too bad it had to end. But we did get a brief reprieve after our flight was cancelled out of Great Falls, Montana on Friday, permitting an extra day in Montana. Seems the weather in Denver was bad again on Friday.

Great Falls was interesting, to say the least. It gets its name from the series of falls and cascades of the Missouri River, around which the Lewis and Clark expedition had to spend some time portaging. But unfortunately I never saw any falls, instead our family counted 30 casino's in a 5.2 mile stretch of Tenth Street (their main drag through town) - a mini Las Vegas without the glitz and much of the blight - with pawn shops and places to trade in your car title for a little extra cash. It was easy to see how casinos had turned into the major industry out there. Sad really. Gone are the farms and the cattle ranches - at least most of 'em. I guess this is how the rural West has been "won."

Anyhoo, I got back in town and discovered that I had been tagged by the ever-loving and affable Moof about 5 things that most people don't know about me. So, in the spirit of cooperation and sportsmanship, here they are:


(1) I like to sail catamarans on Lake Michigan with the family.


(2) My favorite sports are racquet sports - but my all-time favorite is Platform Tennis, or some call it "paddle tennis." For those of you not familiar with this sport - it is typically played in the WINTER, OUTDOORS - rain, snow, or shine. You see beneath the "platform" are heaters with blowers that melt snow and ice that might accumulate on the very rough scaled-down tennis court-like surface. It is typically played as a "doubles" tennis would be played (with a partner), and the difference between it and tennis is that you only get one serve with each serve and you can play the ball off the chicken-wire screens that surround the court. It's a huge growing sport here in the Chicago metro area. Players are typically ranked from levels 1 (pro) to 15 (beginner). I'm a 7. But my favorite part is the "apres paddle" time where guys can socialize and share a beverage together.


(3) I like to cook and, after salt and pepper, my favorite spice is rosemary.


(4) I used to raise chickens (our township would only allow you to have hens -- roosters were too noisy). Our favorite hen was a bardrock variety shown above. Its amazing how much of life can be shared with the kids in raising these animals. They are certifiably the least intelligent animal with which I have interacted, but also some of the most entertaining. The egg-a-day produced by the hens was the envy of the neighborhood - egg shells really ARE harder from free-range birds. But the funniest realization of all was how many people think that the rooster has to be present for the hens to lay eggs...

(5) I'm a morning person, just bring on the coffee...

-Wes

Obesity Report Cards

In an attempt to bring the childhood obesity epidemic home, state legislatures and school boards have adopted a policy recently of sending body mass index scores home with children's grades from school. As reported in the New York Times today, it seems schools have time to insist children step on a scale and measure their height, but are unable to offer counseling, food choices, guidance, or programs to counteract the epidemic.

Is this constructive?

It reminds me of people who sit in meetings and gripe about problems at work, but offer no tenable solutions to the problems at hand. While there is value at bringing up these issues to bring them to the conciousness of the workforce, the REAL help is when someone can propose a solution.

As mentioned by Marlene Schwartz, director of research and school programs at the Rudd Center for Food Policy and Obesity at Yale:

The practice of reporting body mass index scores in schools has gone from pilot program to mass weigh-in despite “no solid research” on either its physical or psychological impact, and “no controlled randomized trial,” said Ms. Schwartz of Yale. “Entire states are adopting a policy that has not been tested.

And to suggest that the problem is only with the children is just as flawed. Many, many of the obese children I see in my practice have parents who would set new records on the BMI score.

The childhood obesity epidemic begins at home, not at school. While notifying those who are overweight might be a seemingly noble goal, until the deleterious effects of such notification to those who are of normal weight or underweight are evaluated, such untested mass notifications that carry no real solution to the problem are merely window dressing to the real problems that have yet to be addressed by state legislatures and school boards.

-Wes

Happy New Year

There is no way to describe the value in a vacation. Although there has been quite a hiatus since my last post, it has been time well-spent. We spent one day in Yellowstone National Park with friends. Touring the park in winter, without the crush of cars and crowds, was magical.

We chose to travel through the park was on one of these "Snow Coaches:"


They seat about 10 people to a car and permit you to delve deep in to the park. THe only other way to tour it this time of year is my snowmobile.

There is an incredible amount of wildlife in the park, and for those of us city folk, it was quite a thrill to see such sights:





The vistas across these geologic wonders are breathtaking:




And what would a stop be at Yellowstone, without watching Old Faithful geyser shoot its incredible steam blast hundreds of feet in the air!


Hope you have a wonderful and healthy New Year!

(I'm just glad this trip isn't over yet!)

-Wes