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Worcester Medicine
Editorial
Sports Medicine
Elbow Injuries in the Throwing Athlete: Diagnosis, Treatment and Prevention
Sports-related Eye Injuries; Protection is Prevention
Performance Enhancing
Aids and the Athlete
Driven to Perfection; Eating Disorders in the Adolescent Athlete
Pre-participation Cardiac Screening for Sports in Childhood Literature & Medicine MassMedLine Update Legal Consult Financial Advice for
Physicians Science Corner Off Call Correspondence President's Message:
Sports Medicine It is my opinion that every physician must have some awareness of the nature of sports injuries as well as the proper means to initially treat such injuries. Physicians are faced with sports injuries in their practice setting, in several adult recreational venues, in their neighborhoods, and at schools where their children compete. As an emergency physician, I have treated injuries involving a spectrum from professional athletes to sandbox wrestlers. Despite my emergency department experience, I have often felt “out matched” when called onto the field doing field hockey games, gymnastic meets, or basketball matches when a competitor has been “knocked out,” “cannot walk,” or is “crying because of neck pain.” While most of these findings and complaints turn out to be minor or transient, my mind invariably races through a list of all the horrible injuries that could be present and made worse if I make the wrong decision when the coach asks, “Can he/she go back to compete?” Sports medicine is not just about injuries. Issues such as proper training and conditioning, maintaining a proper diet, and the athlete’s mental preparedness for victory or defeat must also be considered when dealing with teams of competitors. Despite the risks associated with competition and physical exertion, for most individuals the benefits from such activities outweigh the associated risks for injury. It is up to the health care provider to determine if a pre-existing condition precludes athletic activity and to make sure that the individual is aware of both safe techniques and the fact that each sport is associated with certain injuries or ailments that will require medical input to achieve an acceptable outcome. Editorial: The Athlete and
the Role of Sports Medicine It seems that the number of Americans participating in sport continues to grow as fast as the new activities that are considered sport. We range from the traditionally recognized sports such as skiing, football, baseball, soccer and gymnastics ~ to name but a few ~ to all the new extreme sports such as skateboarding, half-pipe snowboarding, and mountain climbing. Also, the age of the participants is expanding, with people initially engaging in sport at a younger age and then continuing to participate well beyond middle-age. All of these individuals are also in various states of physical condition. Thus, it is then not unreasonable to see an increase in the number and types of sports injuries. The increase in athletic activity also has increased the number of individuals, of all ages, who are participating in sport in a competitive atmosphere. In those sports where competition is keen and has potential economic benefits, there are those who will utilize various methods to enhance performance. The methods chosen to enhance performance are not always legal, nor are they supported by scientific evidence and fact. The individuals who opt to utilize untried and untested methods of performance enhancement are at risk of causing themselves physical harm. This may necessitate their seeking treatment and advice from physicians and other healthcare professionals. This issue will highlight some of the common and more salient aspects confronting healthcare professionals who interact with patients who participate in various athletic activities. What is presented is not meant to be all inclusive, but we hope that it sparks in the healthcare community a greater awareness and interest of the issues surrounding athletes of all levels.
Performance-Enhancing Drugs: A Review In an era of extremely competitive sports, more athletes are using performance enhancing drugs to help their quest in achieving the gold. Athletes are inundated with these drugs’ claims of improved body definition, strength and performance but don’t necessarily realize the potential harmful consequences to their health and careers. Some of these agents ~ strychnine, cocaine, heroin and ethyl alcohol ~ were used often but then superseded by other agents such as anabolic steroids1. The purpose of this article is to review the most common performance enhancing drugs used in a variety of sports. Anabolic androgenic steroids (AAS) including testosterone and dihydrotestosterone (DHT) enhance athletic performance by increasing lean body mass. AAS increase muscle mass and strength as well as promote bone growth and remodeling, which consequently increase the production of red blood cells. Due to the injectable route of administration of these products, an oral testosterone precursor, androstenedione, has become increasingly popular1. However, studies have shown that androstenedione does not increase testosterone levels but rather estrogen levels, which contribute to gynecomastia and increased cardiovascular event risk2. Side effects of AAS include hypertension, hepatotoxicity and alterations in left ventricular morphology3. While the beta2- adrenergic agonists, albuterol and clenbuterol, are not considered AAS, they exhibit similar effects on lean body mass when taken orally and have shown to enhance aerobic performance in non asthmatic consumers. Side effects of clenbuterol include tremor and tachycardia1,4. Insulin is an anabolic hormone that is often used in conjunction with anabolic steroids as it promotes anabolic processes. Insulin also inhibits catabolism in liver, muscle, and adipose tissue by increasing the synthesis of glycogen, fatty acids, and proteins, as well as by promoting the entry of glucose and amino acids into the muscle and fat cells5. Reports of hypoglycemia are associated with insulin use; therefore, insulin is only permissible in athletes with insulin dependent diabetes mellitus1. Athletes may also take growth hormone (GH), which stimulates cell growth and reproduction, in conjunction with anabolic steroids to further increase muscle strength and mass while decreasing body fat. GH is mainly used by bodybuilders and can cause acromegaly, arthralgia and edema1. Erythropoietin, a glycoprotein hormone responsible for the regulation of red blood cell production, has replaced transfusions for blood doping to enhance athletic performance. Blood doping, which enhances performance by allowing more oxygen delivery to muscles via increasing red blood cell mass, can be achieved with three weekly injections of erythropoietin for six weeks. Side effects of erythropoietin include increased blood viscosity which may lead to thrombosis1. Creatine, a nonessential amino acid synthesized predominantly in the liver, serves as an ATP source within skeletal muscle when aerobic energy production is inadequate. This is particularly important during short periods of intense exercise where creatine has shown to improve muscular force or power output. Although the side effect profile of creatine includes hepatic dysfunction and altered glomerular filtration rate, it is considered one of the most widely used drugs among athletes2. Ephedra, also known as ma-huang, is another agent that is widely used among athletes. Ephedra is structurally related to a drug class known as amphetamines and contains psuedoephedrine and ephedrine which stimulate the adrenergic receptors, thereby increasing myocardial contractility and enhancing athletic performance. Ephedra also produces a surge of energy, decreases fatigue and appetite, and causes serious cardiac adverse effects including arrhythmias, myocardial infarction, and cardiac arrest2. Many athletes use protein and amino acid supplements which claim to stimulate and maintain muscle growth, promote efficient utilization of energy, and fuel the release of GH2. It is well documented that infusions of specific chain amino acids postoperatively will decrease protein breakdown, and thus b-hydroxy-b methylbutyrate (HMB) has been utilized by athletes for that purpose. Of note, HMB is not banned by the International Olympic Committee (IOC) and is currently widely used by athletes in various sports1. Protein supplements such as Power Bars and Slimfast bars are widely used by non athletes as well and can contribute to liver and renal damage if excessive amounts are consumed2. Diuretics have been used to enhance athletic performance either directly or indirectly. In sports like weightlifting, wrestling, and gymnastics, diuretics are used due to their ability to affect weight and thus eligibility in these sports. Diuretics can also enhance performance by altering drug testing as they reduce the urinary concentration and expedite the clearance of other drugs4. Diuretics are associated with many adverse events including hypotension and electrolyte disturbances which may predispose patients to serious cardiac conditions. Despite all the reports and media coverage on the detrimental side effects of performance enhancing drugs, some athletes, whether on a national or international level, will still choose to consume them as winning the game is their primary focus and goal. The challenging aspect to all of this information is the increasing number of adolescents and children that are using these drugs and the ease by which they can obtain these unregulated agents. References:
Elbow Injuries in the Throwing Athlete: Diagnosis, Treatment and
Prevention Twenty years ago, I saw relatively few injuries to the elbow secondary to throwing activities. Now I see hundreds a year and operate on about 30. Is this just coincident to my gray hair, or does it suggest an epidemic of sorts? After discussion with my colleagues, I believe that it does indeed demonstrate a growing physical problem confronting the young athletes whom we all treat. Why is this occurring, and what can we do as health care providers to stop it? First we will define the problems and their treatment, and then address processes to alter their occurrence. The Problems Flexor-Pronator Tendonopathy Throwing athletes frequently overstress the origin of the pronator teres and the flexor tendons, including the flexor carpi ulnaris. This will present as pain at and just anterior to the medial epicondyle. It will occur during the acceleration phase of throwing (ref. 1) and will usually not cause a decrease in velocity. The diagnosis is based upon noting pain to palpate the medial epicondyle and the area just anterior to it (the pronator teres). There will usually be pain to resisted pronation of the forearm. In skeletally immature athletes, avulsion of the medial epicondyle apophysis must be considered and substantiated by x-rays. In subtle cases, the call should be made by clinical exam or by bone scan. The treatment is rest (not throwing or performing heavy lifting), NSAID’s, splinting, and physical therapy for stretch and strengthening exercise. Steroid iontophoresis or phonophoresis may be helpful. In some skeletally mature individuals, one corticosteroid injection may be indicated. This is followed by a throwing program of short toss, long toss and a structured progressive program of throwing off the mound. In very rare instances, surgery may be indicated to repair the flexor-pronator origin. Ulna Neuropathy Problems with the ulna nerve at the elbow are very common. The athlete will present with pain at the cubital tunnel or at Osbourne’s fascia (the origin of the flexor carpi ulnaris). The athlete will have a positive elbow hyperflexion test (pain and dysethesias in the ulna nerve distribution with elbow flexion). I believe that this is due more to a neurodesis effect (loss of nerve excursion) than a compressive neuropathy. The diagnosis should be based upon clinical examination and not upon diagnostic studies. Nerve conduction studies will (hopefully) be negative and rarely will there be “distal” symptoms (loss of sensation and motor power in the hand). If this has occurred, it is usually too late in that return to normal function is poor. At times, MRI may be helpful by demonstrating bulbous and edematious changes of the ulna nerve at the cubital tunnel. None the less, one must have a high index of suspicion with the athlete who has recalcitrant medial elbow pain and negative objective findings. The treatment is the use of a potent anti-inflammatory (I use Prednisone), and the prevention of elbow flexion. I use a “cubital tunnel” splint at night to prevent elbow flexion. If this fails, the athlete will in all likelihood require surgical decompression. This would be either a subcutaneous transposition with a faciocutaneous sling, or a submuscular transfer. Rupture of the Anterior Oblique Ligament of the Medial Collateral Complex This problem completes the “Medial Triad” of injuries to the medial elbow in the throwing athlete. One diagnosis does not exclude the others, and frequently they occur together (for example, a ligament tear with ulna neuropathy). Ruptures of the anterior oblique ligament (AOL) may present as a sudden “pop” or a note of pain and decreasing velocity on the pitch. Pain on examination will usually be at the coronoid process. I have found the mini c-arm to be very helpful in the diagnostic process. With the arm in 30 degrees of flexion (to relax the anterior capsule), the elbow is stressed in valgus. If the medial joint line opens greater than 4 mm, this demonstrates instability of the medial collateral ligament. This can be substantiated by a MRI/arthrogram to demonstrate detachment of the ligament and leakage of dye at the medial elbow. Treatment is dictated by the severity of the injury. Grade 1 and 2 ruptures (partial) will usually respond to a well-structured rehab program of the elbow and the shoulder. Grade 3 ruptures (complete) require surgical reconstruction. This is followed by a full year of rehabilitation. The athlete and his/her family need to be informed that this extensive amount of surgery and rehab is only indicated if they wish to continue with hard throwing. If the athlete were to discontinue the sport, he or she would not require this extensive treatment. Epidemiology of the problem Medial elbow problems in the throwing athlete have become epidemic. Is this due to improved diagnostic techniques or to a preponderance of injury? I feel it is a combination of the two. Twenty years ago, the athlete would be diagnosed with a “dead arm” and sent home. Now we are able to define the injury and usually treat it effectively. That is not to say that the rate of injury is not increasing…it is. Kids today are overthrown. That is the problem. If you are a child in a small community and you are a good athlete (pitcher), you will be overthrown. The school and community leagues want to win, therefore the good pitcher will be utilized with little or no regard to pitch counts. They will usually do well until late high school or college when the stress will accumulate and take its toll, being manifested by one to the above reviewed entities. The potential (financial and other) incentives are too great. There is too many dads living vicariously through their kids. There is a lack of education of the coaching staff. There is poor training and ultimately a poor understanding of the genetics of the individual. There is a reason why Nolan Ryan has persisted and Roger Clemens has persisted: genetics, training, coaching and prevention, (i.e., pitch counts) Little League Baseball recommends the following:
Added to this, it is my belief that skeletally immature children should not throw a curve ball (until approximately age 15). The slider should wait until age 18. Our Role as Health Care Providers We need to educate our patients (athletes), parents, coaches and colleagues as to the stress imparted by athletic activity. We should never condemn this activity, but instead be realistic about expectations and how to successfully attain “the dream” without injury. We need to be involved with our children and our community to provide this education. This is as important to our children as the messages of smokeless tobacco and steroids. Armed with the knowledge, we can provide a framework within which our patients and children can enjoy athletics while minimizing injury.
Sports-related Eye Injuries: Protection is Prevention Estimates vary, but some forty thousand to one hundred thousand eye injuries occur each year due to sports- related activities. The most vulnerable populations for sports injuries are children and young adults. Males are more likely to participate in higher risk sports and are more frequently victims of accidental injury. The overwhelming majority of these injuries are preventable through the use of protective equipment. The increasing popularity of projectile sports such as paintball has become a cause for concern as significant injuries continue to occur despite the nearly universal use of face protection. Appropriate supervision, enforcement of use of protective equipment and maturity-appropriate participation are key elements of prevention. Engineering of safer play equipment also plays a role in reducing the human cost of sports-related injury. High risk sports include those involving high velocity small projectiles such as air rifles, BB guns and paintball. Larger hard projectiles and “stick” sports contribute to the high risk status of baseball/softball, field and ice hockey, squash, cricket, lacrosse, racquetball and fencing. Racquet sports are the leading cause of eye injuries in the 25-64 year old age group. High impact contact and intentional injury raise basketball, boxing and martial arts to the high risk category. Moderate risk sports include tennis, badminton, soccer, volley ball, water polo, football, fishing and golf. Low risk sports are swimming, diving, snow and water skiing, non-contact martial arts, wrestling and bicycling. (1) Individuals who are functionally monocular face an additional risk of significant handicap if the well-sighted eye is injured. Polycarbonate lenses are recommended in daily use glasses and sport-specific eye protection is strongly recommended. Numerous sport-specific standards are in place to provide a high level of protection from eye and other injuries. Protective equipment, when properly fitted, is highly effective in reducing the risk of injury. The introduction of full-face protective devises for amateur hockey in Canada reduced the annual number of injuries from 257 to zero in the course of nine years. (2) Individuals charged with supervising sports activities should be familiar with the protective gear available and should play an active role in requiring the use of this equipment during practices and competitive play. It is important to remember that fashion eyewear and “safety glasses” for OSHA needs are not adequate for sports eye protection. Contact lenses do not offer any protection and in some injuries present additional risk. Specific recommendations for eye protection are available from a joint policy statement of the American Academy of Pediatrics and American Academy of Ophthalmology. (1) It is vital to educate parents on the importance of sports safety. Most paintball injuries, for example, occur when the required eye protection is not in place. Most organized venues for paintball go to great lengths to enforce protection. It is the impromptu backyard “demonstration” or unsupervised play by children that results in injury. Some sports such as baseball demonstrate a relationship between injury and players’ level of maturity and experience. This argues for age-appropriate activity. The use of safer play equipment can contribute to reducing the degree of trauma from a sporting accident. As an example, a softer baseball can reduce the extent of injury and can still be engineered to feel like a regulation ball. Sport sanctioning organizations need to recognize this avenue to reducing injury. (3) Penetrating injuries of projectiles and sharp objects, such as a fish hook, eyeglass fragments or a fingernail, can create devastating eye trauma including globe rupture, vitreous hemorrhage, retinal detachment, optic nerve avulsion and corneal injury. Delayed consequences include a risk for retinal detachment, cataract formation and secondary glaucomas. Injuries from blunt trauma can include trauma to the globe, but can also include fractures to the orbit, as well as facial and intracranial trauma. Orbit fracture may result in CSF leakage, infection, and entrapment of extraocular muscles resulting in diplopia. When an injury occurs it is important to protect the eye from further injury and to seek professional help. While the evaluation and management of sport-related eye trauma is beyond the scope of this article, an excellent review is presented by the American Academy of Family Practice. (4) Needless to say, an ounce of prevention is clearly worth more than a pound of cure. References:
Performance Enhancing
Aids and the Athlete Performance enhancing drugs have existed in sports for many years. In the 1970s, the Olympics were notoriously suspect as eastern bloc nations sent athletes who by today’s standards would have failed tests for steroids. The cycling world has been rocked by scandal a number of times since the 1980s, with this year’s Tour de France rising as another example of the ongoing allure of performance enhancing drugs. Certainly professional sports are not without scandal as both baseball and football have been affected by similar scandals. A number of supplements (both legal and illegal) have been used and will continue to challenge the diagnostic and investigative abilities of those who govern sports. Many athletes, in the hope of gaining a competitive advantage, will purchase supplements to improve performance; from protein powder to creatine, they are available in stores and on the web. Many claims touted on packaging cannot be substantiated and often the physician is confronted with a patient asking advice on the myriad of preparations available and about whether the purported benefits really exist. However, there are supplements that are safe and have evidence to support their use. Deciphering the variety of preparations is challenging, but the following agents have some evidence backing the claims and can have a beneficial effect on the athlete. Creatine is a legal supplement that has had widespread use. Studies have reported up to one half of all high school and 70% of Division I college football players have used creatine1. Creatine is a nitrogenous amino acid produced by the liver and used by muscles for ATP resynthesis. It has been shown not only to improve performance for short duration exercise but also to increase lean muscle mass1. It has not been well studied among children and adolescents, leading the American College of Sports Medicine to recommend limiting usage to athletes over age 18. 2 Off the shelf usage predominantly begins in the high school age range, however2. There have been no consistent long term side effects from creatine although theoretical concerns about GFR and liver toxicity exist. Adverse effects include weight gain (may be desired effect for some high school athletes) and an increased risk for compartment syndrome. Muscle cramping has been reported as well. Typical regimens include a loading dose of 20 g/day divided in four doses for 5-7 days followed by a maintenance dose of 5g/day thereafter3. Not all athletes can necessarily benefit from creatine supplementation, hence the term “responders.” 2, 4 Those who respond to creatine tend to have lower amounts of protein in their diet prior to instituting creatine supplementation. Another agent receiving press that has become popular among athletes is branched chain amino acids (BCAA). BCAA have been shown to reduce muscle damage from exercise and may help minimize protein degradation during intense exercise1, 6, 7. They may also increase lean muscle mass. They do not directly improve performance and/or change body composition with resistance exercise. Side effects include gastrointestinal upset and diarrhea. Supplementation has been recommended at 5-10 g/day and may benefit endurance athletes5, 8. There is theoretical concern that they may deplete thiamine and additional supplementation with that vitamin may be necessary5. Glutamine has been purported to increase lean muscle mass as well but no convincing studies prove this statement.1 It has been shown to help prevent upper respiratory infections in athletes performing prolonged exercise.8 Arginine alpha-ketoglutarate (Nitric Oxide products) may help boost nitric oxide. Nitric oxide causes vasodilatation that may help boost blood flow to muscles.1,6 This claim has not been substantiated by rigorous review. As long as there are competitive sports there will be athletes attempting to gain a competitive advantage through dietary means. No mention of anabolic steroids was made in particular, as they are clearly illegal and are banned by all of the major sports governing bodies. Supplementation certainly does not supplant a well designed conditioning and training program but may benefit the athlete under specific conditions and with recovery. Guiding the athlete with over-the-counter supplements can prove difficult, but spending the time may be rewarding in deciphering the conflicting results in the literature about supplementation. References and suggested reading:
Driven to Perfection: Eating Disorders in the Adolescent Athlete The desire to excel is strong in many adolescents, especially during the high school years. Competition becomes fierce as students strive to become the best candidates for college admission and scholarship money. These goals are behind many students who are on the way to becoming “elite athletes” in their chosen sport. But achieving these goals may come with a high price on their health. Eating disorders are a problem for some adolescents. While more common in females, the disorder can also afflict males. In what is referred to as “weight sensitive sports” like cheerleading, distance running, wrestling, rowing, swimming, gymnastics, diving and figure skating, weight control is perceived to be an advantage. Sometimes adolescents resort to unhealthy weight control practices and the physician needs to be alert and ask the right questions when doing those sports physicals. While many athletes are very aware of healthy dietary practices, some will do things which can be harmful to them. Restricting food intake is the most common method, but more dangerous methods include vomiting, voluntary dehydration, over exercising, and using medications such as stimulants, insulin, laxatives and diuretics. The physician caring for these young athletes must address these practices and emphasize their dangers during the office visit. Athletes who are doing some form of weight control may do this during their sports season or all year long. Significant weight restriction methods can impair performance, increase injury risk and lead to medical complications such as anorexia, bulimia, delayed growth (or permanent growth impairment), amenorrhea (lack of menstruation), oligomenorrhea (very light periods) or any major organ system malfunction. Depression is also significantly higher in this population. In female athletes, there is a triad of symptoms of disordered eating, menstrual dysfunction and loss of bone mineral density. It is called, reasonably enough, “female athlete triad” and is more or less a cascade effect of too few calories leading to menstrual irregularity leading to loss of bone density. Let’s briefly discuss each of these components. An energy deficit occurs when you don’t eat enough for the activity you are doing. Disordered eating takes this deficit to extremes. The restriction can be minimal to severe, obviously with more dire health consequences as the disorder becomes more serious. Students who participate in those sports where leanness is emphasized or seen as improving performance are at a greater risk for developing disordered eating. As mentioned above, these sports include distance running, figure skating, cross-country skiing, diving, gymnastics and ballet. Other sports that use weight classifications, such as martial arts and rowing, can also place the athlete at an increased risk. Menstrual dysfunction is more common in athletes than in the general population. Girls who participate in sports before they start their periods may have delayed onset of menstruation. In girls who are already menstruating, periods may become erratic or very light if disordered eating is present. This abnormal cycling of menses can lead to the third part of the triad, loss of bone density or osteoporosis. This bone loss may be irreversible despite estrogen and/or calcium replacement or the return of periods, and can cause an increase in injuries and long term health problems. The causes of eating disorders are multiple. Social and environmental factors can influence a teenager. The media has a profound effect on this age group with the mantra of “You can never be too rich or too thin” shaping their lives. Psychological traits can play a role, too. Many adolescents with an eating disorder also have depression, anxiety, perfectionism, and low self esteem. Genetic causes are now being recognized as a possible cause, too. There is an increased incidence of these disorders when there is a family history of the same. As physicians, we must address nutritional issues at every visit ~ and don’t forget to ask the parents about eating habits in themselves and their children. Take advantage of the sports physical to discuss eating habits. Try to reinforce how participating in sports can be a wonderful experience and can lead to a very healthy lifestyle. Mention eating disorders and the dangers of this condition to all adolescent patients so they are well aware of this problem. Caution parents to be on the lookout for changes in eating behaviors or apparent weight loss in their children, especially those children who participate in the “weight sensitive” sports. Perhaps our awareness of the problem will help us to identify those adolescents who begin to have difficulty before they reach a critical point in their health status.
Pre-participation Cardiac Screening for Sports in Childhood Sudden death in young athletes has gotten much press and is always a tragedy. Put in perspective, it is indeed a rare occurrence, but may be preventable. Pre-participation screening of athletes for cardiac conditions in children and adolescents is generally the responsibility of the primary care provider. A focused history, family history and physical exam are often sufficient to identify individuals who require cardiac referral. Patients with known congenital heart disease should be counseled about sports participation by their treating pediatric cardiologist. There are detailed published guidelines and they will not be discussed in depth here. Cardiac conditions that have been associated with sudden death include congenital heart disease, cardiomyopathies, conduction abnormalities and congenital coronary anomalies. The history is important to screen for symptoms of circulatory insufficiency including exertional lightheadedness, dizziness, and syncope. Exertional chest pain is worrisome, although most likely is secondary to bronchospasm. Family history of sudden death in young adults may be secondary to familial hypertrophic cardiomyopathy or long-QT syndrome. These conditions are most often autosomal dominant. Affected first degree relatives ~ parents or siblings ~ should prompt screening of the entire family. Long QT syndrome can be ruled out with an ECG. Hypertrophic cardiomyopathy may also be associated with an abnormal ECG but should be ruled out with an echocardiogram. The cardiac exam is important to detect murmurs suggesting structural heart disease, specifically valvar aortic stenosis and hypertrophic obstructive cardiomyopathy ~ the two conditions most commonly associated with sudden death in athletes. This is confounded by the high incidence of innocent murmurs in children and adolescence of 25-33% in many studies. Severe valvar aortic stenosis is associated with a loud, harsh systolic murmur with a thrill in the suprasternal notch. Hypertrophic cardiomyopathy (previously known as IHSS ~ idiopathic hypertrophic subaortic stenosis) may be more subtle. While innocent murmurs are generally softer when going from supine to sitting, the murmur of hypertrophic cardiomyopahty is often louder in the sitting or standing positions and decreased after squatting. Other problematic cardiac conditions include dilated aortic root/aneurysms, which again may be familial and often have stigmata of Marfan Syndrome. This requires an echo as well as Clinical Genetics evaluation to assess for multi-system involvement with associated skeletal or ophthalmologic abnormalities in a coordinated fashion. In the 21st century, genetic markers are being developed for many of these disorders such as familial hypertrophic cardiomyopathy, Marfan Syndrome and long QT syndrome. Currently, the testing is restricted to specific academic laboratories. Finally, commodio cordis is circulatory collapse caused by ventricular arrhythmia induced by sudden impact of a projectile object ~ such as a baseball or hockey puck ~ against the chest wall, inducing a ventricular arrhythmia. Recent studies have shown that a chest protector is not sufficient to protect children. References:
Literature &
Medicine In the last issue of Worcester Medicine, the final stanzas of “A Winter Visit,” excerpted from Dannie Abse’s White Coat, Purple Coat: Collected Poems, 1948-1988, were regrettably omitted. We apologize for the error and any inconvenience it caused. Below are the excerpt and the accompanying piece in their entirety. Joseph Cady, Ph.D., formerly the literature and medicine professor at the University of Rochester Medical School, taught the Massachusetts Foundation for the Humanities seminar “Literature and Medicine: Humanities at the Heart of Health Care” at UMass Memorial Medical Center in 2006. He can be reached at joscady@aol.com. Emotion pervades the worlds of doctors and patients. Physicians can spend entire days seeing patients in distress, and for patients a diagnosis of serious illness is not just a biologic event but a wrenching personal experience. Medical education generally does not prepare students for the emotional labor of medicine and the problem persists in later practice, where frankness about feelings is largely taboo among colleagues. Though some medical schools still teach biopsychosocial issues, under pressure for outside funding most have turned to an even more “hard science” emphasis, and the most many physicians-in-training can hope for is a lucky encounter with a sympathetic mentor who can model emotional intelligence for them by his/her clinical example. Literature about medicine characteristically “speaks” the issues that the traditional medical model leaves unspoken, and one of the most compelling chroniclers of the “science-emotion split” in medicine has been the Welsh-born, British-trained, physician-poet Dannie Abse (b. 1923). From a family of doctors (one brother, two uncles, and four cousins are also physicians), Abse worked as a pulmonary specialist at a London clinic while also producing a formidable body of literary work that earned him a reputation as one of the major British poets of the post World War II period (at last count, he had published ten books of poems, three books of plays, three novels, 3 autobiographical volumes, and one book on the English medical profession). In the two accompanying poems, Abse vividly documents the high price traditional medicine pays for ignoring the emotional dimension of its work. In “A Winter Visit,” he finds himself helpless ~ and substantially speechless ~ before his frail, exhausted ninety-year-old mother who asks him not for help in dying, but for simple validation of her suffering. But so conditioned is Abse by his profession’s code of emotional constraint ~ symbolized here by the doctor’s “white coat” which he does not just wear but “inhabits” ~ that he cannot discard its straitjacket even in this most private of moments to express basic compassion and sorrow (Abse’s phrase “…am not qualified to weep” is multiply resonant ~ in Britain a licensed physician is described as “qualified” to practice). At the end he can only circle the subject, “…speak[ing] of small approximate things.” In “Lunch with a Pathologist,” the title figure is the “white coat” casualty but, unlike Abse in the previous poem, he lacks any awareness of his limitation, blithely reciting at lunch “…the morbid verse of [the body’s] facts” with no apparent recognition that those organs once belonged to actual people. Note that the poem does not heroicize Abse, however. Sharp enough to sense the pitiless animalism behind the pathologist’s nonchalance (“…picked shredded meat from his canines”), Abse still can only come up with a sardonic, fanciful reply that goes completely over the pathologist’s head. And, symbolizing the continuing power he sees “the white coat” wielding over his profession, Abse the author gives the pathologist the last word over Abse the character, branding him as the “peculiar fellow” he undoubtedly would seem to be from a traditionalist medical perspective. Abse chiefly works in a discomfiting realist mode, devoting his texts to the presentation of a problem (sometimes using himself as the prime example) rather than dramatizing a consoling solution. This does not mean, however, that he actually sees no solution, only that he prefers his readers to reach it themselves by jarring them to oppose negative examples of the issue in his text. It is in the words of an earlier British physician-poet that we find one of the plainest and most moving statements of Abse’s underlying point in these two poems. Robert Bridges (1844-1930) practiced medicine in London until 1881, then turned to a full-time writing career that culminated in his appointment as Poet Laureate in 1913. In a 1922 lecture to University of Michigan medical students, Bridges praised the “fellow feeling” of a former colleague, Thomas Barlow, who “…of all the doctors I ever knew was the one who had the most intimate personal sympathy with his patients.” In an unintended irony, Bridges’s portrait of Barlow implies that the “science-emotion split” in medicine is ultimately unscientific (i.e., unempirical): “It is not only somewhat dangerous for a physician to allow feelings full play ~ they may disturb his scientific judgment. But to bestow a genuine fellow feeling on all your patients daily is a burden it needs almost superhuman effort to assume ~ to say nothing of the difficulty of sustaining it. But Barlow’s fellow feeling was inexhaustible and unwearied. So far was it from injuring his judgment that it led him often to a sounder and clearer insight into his cases ~ and while it strengthened his own hopefulness and determination it also helped his patients toward recovery by evoking their confidence.” Dannie Abse (b. 1923), from White Coat, Purple Coat: Collected Poems, 1948-1988 (1989) A Winter Visit Now she’s ninety I walk through the local park Dare I affirm to her, so aged and so frail, I do. But she like the sibyl says, “I would die;” Yet must not (although only Nothing keeps) So I speak of small approximate things, Lunch with a Pathologist My colleague knows by heart the morbid verse At lunch he recited unforgettably, “Yes,” I said, “at dawn I’ve seen silhouettes Partial to women they’ve stripped women bare My colleague wiped his mouth with a napkin, MassMedLine Update:
Medicare Part D - A Synopsis for 2007 In 2006, the Medicare Prescription Drug Plan was unveiled and Massachusetts seniors had 44 different stand-alone prescription drug plans from which to choose. For the 2007 benefit year, every one of the plans has changed. Some plans have left the area while others have been engulfed by other insurance companies. Five new companies have entered the market and other plans have new offerings, bringing the total number of plans for 2007 to 51. In other words, seniors in Massachusetts now have 51 stand-alone prescription drug plans to choose from through the Medicare program. The standard benefit for 2007, as required by the Medicare Modernization Act, has accounted for increased drug costs. The deductible is now $265, up from $250. The coverage gap now beings at $2400, not $2250, and the catastrophic coverage begins once an individual spends $3850 in out-of-pocket expenses, up from $3600 in 2006. Every year, plans can change their benefit design, monthly premium, deductible amounts, coinsurance, formulary, drug prices, and service area. In 2007, however, some plans have taken their changes to the extreme. For a premium of $55.08, the Humana organization offered a complete plan in 2006 where individuals would not experience a gap in coverage. During the gap in the standard benefit design, individuals in the Humana Complete plan would continue to be offered both their generic and brand name medicines for a co-payment price. However, in 2007 they will drop their coverage of brand name medications in the coverage gap and increase their monthly premium to $87.40. Overall, the average premium of a plan has dropped by $5 to $27.35. None of the plan offerings in the new benefit year will offer coverage for both generics and brand name medicines in the coverage gap, but there are 15 plans that will help with generics during this benefit period. There are 15 basic plans that are under the benchmark, allowing some individuals who are eligible for MassHealth, Extra Help through the Social Security Administration, or who have our State Pharmacy Assistance Program, Prescription Advantage, to choose plans where they will not have to pay a monthly premium. With so many variables to consider, it is highly recommended that every Medicare beneficiary re-evaluate the options for 2007. Even beneficiaries who may be happy with their current plan should see if anything has changed for the new benefit year. Medicare suggests that seniors evaluate the cost and the coverage of their plan as well as other areas that might be of concern such as the customer service provided by the company. As always, beneficiaries can call MassMedLine, the toll-free information and referral line at the Massachusetts College of Pharmacy and Health Sciences (1-866-633-1617), for assistance. The MassMedLine program was created to fulfill the vision of President Charles F. Monahan, Jr. to provide a free safety-net service for individuals with questions regarding drug information and healthcare access issues. Other community, state and federal programs are also available for assistance in choosing a Medicare Drug Benefit Plan. These include Medicare (1-800-633-4227) and SHINE (Serving the Health Information Needs of Elders) (1-800-243-4636, option 2). It is important that beneficiaries with questions seek assistance to obtain the best options for cost, convenience, and coverage. Legal Consult: Flying
Squirrels and Liability for Sports Injuries Under Massachusetts law, liability for personal
injuries arising out of an athletic event requires not mere negligence, but
a reckless disregard for safety. The leading Massachusetts decision in this
area of the law ruled that when a Worcester State College hockey player
suffered severe injuries when he was “butt-ended” during a game by the
hockey stick wielded by an opposing player from Nichols College in violation
of hockey’s safety rules, since the Nichols College player did not act with
reckless misconduct, that player was found not liable. More recently, the
rule requiring recklessness was not applied in the A “flying squir The judge in the UMass cheerleader In the UMass It appears then, that the rule in Massachusetts is that
a higher showing of recklessness is required to find liability for sports
injuries suffered during competition, but only a lower showing of ordinary
negligence is required where the injury occurs during preparation for
competition. Is the vigor of athletic competition unduly chilled by this
distinction? When an athlete practices, isn’t he or she engaged in a
sporting activity, with the attendant tacit agreement to undergo otherwise
unacceptable physi The legal rationale for the higher standard of reckless
disregard for safety is not limited in its appli It is not obvious why a rule intended to have the eff Financial
Advice for Physicians: Planning Needed - College Costs Are Real In the ancient world, the most unappreciated workers were the water slaves. These unfortunates endlessly carried water jugs from deep within massive cisterns to satisfy the community’s thirst. Our modern equivalent is the tuition slave, who is successful enough to pay retail for his child’s education. Doctors make great tuition slaves. As the father of seven ~ 3 college graduates, 2 in college, and 2 preparing ~ I am very experienced in the tuition wars. I have learned that a successful doctor should not expect to qualify for any financial aid. In fact, you will be the one funding the aid. You need to realize that the outrageous predictions on the cost of college are accurate. My advice is to treat education expenses as known obligations for which you should plan. Don’t ignore these expenses because they are in the distant future. Don’t procrastinate, thinking that you can always “pay as you go” or borrow when your prodigy enters the university. There is a better way, a 529 College Saving Plan, which I wish had been available when my children were young. Today’s private colleges cost $42,000 annually, while public colleges cost about $18,000. By factoring in a 5.5% inflation adjustment, we can estimate that your baby will need $415,000 for a private college or $178,000 for a public one, your 6 year old will need $325,000 or $140,000, and your 12 year old will need $242,000 or $104,000. The 529 Plan provides tax free college saving growth. The higher your tax bracket, the better this program. Like a Roth, the growth and withdrawals from these accounts are income tax free both federally and in Massachusetts. Unlike Roth 401(k)s, you can liberally fund these plans up to $24,000 per child annually to a maximum of $250,000. The sooner you start funding your 529 Plan, the better. 529 Plan funding for your 6 year old’s private college, assuming 8% returns, will require $1,300 per month v. $1,550 without the 529 tax savings. This $250 monthly tax savings is real and can be realized for each of your children. A 6 year old’s education savings for public college should be about $570 per month, which saves about $100 per month from the taxable alternative. Do yourself and your children a favor by opening a 529 Plan through PIAM or your financial advisor and begin aggressively funding for the college years. Science Corner:
Physical Exertion and Sudden Cardiac Death in Adolescents and Young Adults Sudden cardiac death (SCD) is rare before age 35 years, yet unfailingly has dramatic impact and places intense pressure on caregivers to identify those at risk and implement preventive measures. Strenuous physical exertion is a frequent precipitant of these deaths, whether related to formal competitive athletics, recreational or sporadic activities, or employment. Population-based studies report young SCD incidents ranging from one in 100,000 to one in 300,000 individuals.(1,2,3) There is a consistent male predominance, and most often a functional or structural cardiac abnormality which prompts a fatal arrhythmia. Although there are numerous causes of SCD at young ages, (1) a consistent few entities account for the very large majority of occurrences. These must be kept in mind by physicians when advising individuals regarding sports participation or strenuous physical exertion. Most common are cardiomyopathies, whether hypertrophic (with or without obstruction) or dilated and arrhythmogenic right ventricular dysplasia (ARVD) (2, 3). Their presence should trigger family screening and restriction from strenuous exertion. Myocarditis is an often overlooked, yet common, cause of exertional SCD. It is frequently preceded by febrile illness. Precocious atherosclerothic coronary artery disease (CAD) is infrequent below 30 years of age but is an increasingly common cause of SCD thereafter. Congenital coronary artery anomalies are noteworthy causes of exertion related symptoms, ventricular tachyrhythmia, and SCD and require suspicion and targeted cardiac ultrasound for diagnosis (5). Structural congenital heart disease, whether previously operated upon or not, may still remain a cause for SCD, notably with strenuous exertion (1). Highest risk lesions include some with tetralogy of Fallot, transposition of the great arteries, aortic valve and root abnormality, and any patient with Eisenmenger’s syndrome. Reassessment of the current clinical status of these patients and cardiology consultation to formulate appropriate advice regarding level of exertion are warranted. A number of excellent consensus guidelines address specific exertion recommendations for these individuals (6, 7, 8). At first glance, these deaths appear to be sudden, unheralded and unexpected; in fact, however, in most instances they are none of the above. For the majority at highest risk, both prior identification and prevention are possible and well within reach of present medical practice (2, 3, 4). The majority at risk can be identified by screening family history of primary relatives with SCD at a young age or by screening for high risk lesions including cardiomyopathy, ARVD, Marfan’s syndrome and precocious atherosclerothic coronary artery disease. A personal history of typical or atypical chest pain, particularly with exertion and particularly when associated with palpitation and altered consciousness or frank syncopa, or a history of recent febrile illness and myocardltis antedates SCD in a new majority. Others at risk may have a history of congenital heart disease, hypertension, severe anorexia, Eisenmernger’s or prolonged QT syndromes. An abnormal ECG showing STT inversion in anterolateral leads, right or left ventricular hypertrophy, Wolff-Parkinson-White, prolonged QTC or ventricular tachyarrhythmia also flag individuals at potential risk. Only a minority with more occult entities eludes dedicated primary care screening and requires further cardiac testing for diagnosis (3). When potential high-risk SCD individual is suspected or identified, a definitive diagnosis and recommendation regarding physical exertion and sports participation must be determined. Cardiology input and sometimes more subspecialized assessment and management are needed. Recommendations must be shared with patients and family in a frank, patient, and compassionate manner and consistently reinforced in follow-up visits. Covering what activities are prohibited, as well as those which are acceptable, is important. Beginning these discussions as early in life as possible is helpful. It is important to leave the patient with a positive attitude but patient and family must understand the potential risks involved. A recent review of the Northern Italian experience with pre-participation screening of high school and college athletes cited a reduction in SCD occurrence from one in 27,000 athletes prior to screening to one in 250,000 athletes after screening and exclusion from participation, when indicated (3). In summary, although challenging, the task of identifying most young individuals at risk and markedly reducing the incidence of SCD is attainable and can be achieved in large part at the primary care level. Bibliography:
Off Call: After the Race Last year, at age 55, I decided to train for a triathlon to help me get into and stay in shape. I am an energetic woman, just under 5’3” tall and plump! I have always enjoyed hiking, biking, kayaking and swimming, but at a comfortable pace. I felt that if I had a definite goal, I would work harder and more consistently at being fit. The Danskin Women’s Triathlon is an annual event that takes place all over the country and locally in Webster, MA. I was excited at the idea of participating in an all female event. The “culture” of this race is supportive and feminist; one is expected to help and be encouraging to other participants. Commitment seemed a good idea, so I had already registered for the race by the time the informational meeting in the spring rolled around. Leader Sally Edwards (Iron Man athlete) was inspiring and funny. I listened to her stories and looked at the women around me ~ and was both scared and excited. I had never participated in any competitive sport since archery as a Camp Fire Girl! My goal was just to finish, and to finish in less than 3 hours. I started doing the “Heart Zones” training program, which had me biking and speed walking. When race day arrived, I found I was feeling quite confident. I had my gear ready. I was reassured that I had followed the training program and when I had doubts, reminded myself to “trust” that the training would take me through the event. The swim was first. I have never been in the water with so many people! I felt like a fish in a school and the rest of the school was going faster than I was! We slogged out of the water and jumped on our bikes. I was pumped to see that I’d finished the swim in 3 minutes less than I had planned! The bike portion was fun though hilly. I even stopped to help another woman put the chain back on her gears ~ a lucky stop on a steep hill that gave me a chance to catch my breath. I saw one woman give her water bottle to another who had lost hers and was having a hard time. I constantly heard “You look great,” “You go girl,” and “Good job” throughout the events. The run was the hardest ~ it was hot, I was tired and grimy and just wanted to finish. One my colleagues who’d done a relay met me and ran with me part of the distance. It was such a gift to have her support; it helped me “put on the speed” for the finish. I was able to run across the finish line and whoop as my arms flew up in the air! What a feeling! My daughters and son-in-law met me with hugs and flowers. The crowd was hooting and hollering! The music was playing! I had a medal placed around my neck just like a real athlete...and I thought, “Now “I AM a real athlete!” Over 2000 women of all ages participated in this event! For those other “round” women out there, I should add that while I am much more aerobically fit than I was when I started the training, I am still quite plump. Don’t let it stop you! It really is true that the woman who finishes the race is a different woman than the one who starts the race. No turning back now! I enjoyed it so much, I did it again this year! November 27, 2006 Worcester District Medical Society Dear Medical Society Members: I am very pleased to announce that Spectrum Health Systems was awarded a contract by the Massachusetts Tobacco Control Program to implement a “Community Smoking Intervention Demonstration Project” in Worcester! We are one of five pilot sites in the state. I can’t thank you enough for your support throughout this competitive procurement process. Thank you! Communities chosen to receive funding for this project had to demonstrate community support for smoking intervention and the capacity to address identified tobacco issues. Receipt of this grant speaks highly of the work that is already being done in Worcester around a host of health issues, as well as of the ability to address future identified health issues. Due to these combined efforts, Worcester is well positioned to implement the smoking intervention project. I am pleased to have been able, in a small way, to bring these resources to Worcester and I look forward to working with you on future tobacco projects. Sincerely, Barb Grimes-Smith Barb Grimes-Smith, Director |