AllianceMD

Bill Clinton Hospitalization for Angina Not Unexpected

Nom de Plume, M.D. — Tue, 07 Sep 2010 12:40:03 +0000

Former President Bill Clinton was admitted Thursday to a New York City hospital after experiencing mild angina (chest pain) for several days. He underwent an interventional procedure to have a clogged coronary (heart) artery unblocked by the placement of a stent (a mechanical “tube” to prop the clogged vessel open). As a Cardiologist myself and loosely familiar with his condition, I can say that this was not unexpected. After all, the 63-year-old Clinton underwent quadruple cardiac bypass graft (CABG) surgery six years ago (where “virgin” blood vessels from elsewhere in his body are grafted to restore or “bypass” the inadequate blood flow through the existing “blocked” coronary arteries). However, it’s a known fact that bypass grafts – despite cholesterol lowering medications and exercise – become blocked after a number of years. In fact, tests on Clinton revealed that one of those bypass grafts had become completely occluded, prompting the placement of two stents into the blocked graft vessel to open up and restore blood flow to his heart muscle. After CABG, on an average, vein grafts last about seven years and arterial grafts last about eleven years before occluding and at which point patients start developing angina symptoms. Since Clinton received mostly vein grafts, one can expect a redo CABG operation in the near future. It’s just a matter of time. Importantly, however, Clinton did not suffer a heart attack – and his heart pumping capacity is still good – so I foresee his prognosis as being very good. Of course, it’s important that he be followed closely by his Cardiologist with periodic stress testing to assess the status of his coronary blood perfusion (flow) so that preemptive interventions can me made early – rather than at the time of symptoms. After all, Mr. Clinton’s busy schedule certainly includes being on long flights across the Atlantic without quick access to medical attention, which could be dangerous if his heart health is not closely monitored.

Jeremy Shockey Pushoff to His Left Side Impaired in Super Bowl?

Nom de Plume, M.D. — Tue, 07 Sep 2010 12:39:20 +0000

New Orleans Saints coach Sean Payton indicated that Jeremy Shockey received good news on consulting with an orthopedic surgeon for his sore right knee. What this tells me from the medical perspective is that x-rays failed to reveal any fractures and that the MRI failed to reveal any structural damage to tendons or ligaments of the knee. What Shockey has is a bone bruise that is causing all the soreness that has limited him in New Orleans’ two playoff games. The effected area is the tip of the femur (thigh bone) where it connects to the knee. A “bruised bone” typically refers to bleeding that occurs under the tough fibrous covering of the bone called the periosteum. The bleeding causes significant pain in the area of the bone until the blood is eventually reabsorbed just like a bruise of the skin. While the recovery time for a knee bone bruise ranges from days to weeks, the most painful bruises can sometimes take months to heal. These two weeks off before the Super Bowl have certainly allowed some healing. I’m sure the Saints training staff have been aggressively treating Shockey with techniques such as microcurrent therapy to treat the pain, break up adhesions (scar tissue), or stimulate healing. Depending on the level of pain Shockey experiences, the medical staff may very well give him an injection of a powerful pain medication (Toradol) before the game to minimize the pain that could otherwise limit his right knee pushoff. I believe Shockey will be able to play at about 90 percent of full capacity. The Indianapolis Colts defense should certainly key in on any limitation in Shockey’s pushoff to his left side, which could be affected, and use this in their strategy and techniques in guarding him.

Psychiatric Perspective on the Movie: The Lovely Bones

Nom de Plume, M.D. — Tue, 07 Sep 2010 12:38:41 +0000

In this movie, Jack Salmon as the father of a murdered young girl Susie Salmon will not let his daughter’s unsolved murder go – he is obsessed with finding the killer. As an accountant with a passion for building model ships in glass bottles, Jack Salmon has been set up well as possessing underlying obsessive compulsive traits. Jack also suffers classic posttraumatic stress disorder (commonly referred to as PTSD), a severe anxiety disorder that can develop after exposure to any event which results in psychological trauma. Characteristic diagnostic symptoms of PTSD that Jack is portrayed to suffer include increased arousal, such as difficulty falling or staying asleep, anger, and hypervigilance in particular. Hypervigilance is an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompanied by a state of increased anxiety which can cause exhaustion. Both OCD and PTSD are grouped in the family of anxiety disorders and there is some suggestion in studies of a link between trauma and later OCD, although not strongly shown. Additionally, Jack may be exhibiting characteristics of a trauma reaction in his search for the killer as a psychological defense mechanism to cope and have resiliency (of similar value to raising awareness or money for breast cancer after a family member dies from that). Finally, Jack’s behavior touches on the psychoanalyst concept of undoing and sublimation whereby searching for the killer diverts feelings/thoughts and has some sort of undoing her death. Actor Mark Wahlberg does an excellent job in his complex and realistic portrayal of Jack Salmon (with all of the psychological symptoms that suffers). The story as a whole unfolds extremely believably in the significant resulting social impairment of functioning (as primarily evidenced by Jack’s strained relationship with his wife). The story/movie as written and acted is extremely believable and true to life.

Likelihood of Nuclear Catastrophe in Manhattan Small

Nom de Plume, M.D. — Tue, 07 Sep 2010 12:38:36 +0000

The likelihood of a nuclear catastrophe in Manhattan is quite small. NYC has highly sensitive radiation detection devices at all imaginable access points into the city – bridges, tunnels, airports, and seaports. Additionally, there are unmarked vans with highly sensitive radiation detecting equipment that cruise the city streets. The only way a nuclear weapon could enter the city or be detonated in the city would be through an air strike. If this were to happen, the nuclear epicenter could be approximately 2 kilometers in circumference. Anyone in this epicenter will be instantly incinerated from the heat. Outside of this area, the shock wave will likely kill everyone through the massive physical destruction of the city infrastructure, but for those who survive the shock wave, there may have a chance. All radioactive fallout (exposure) must be avoided by moving “into the wind” such that the debris falls behind you – so it is essential to escape the city in the direction opposite to which the wind is blowing. Note that any exposure, however, to radiation, even if you survived, might result in radiation sickness affecting multiple organ systems within hours to weeks (depending on the amount of exposure) and would also result in some increased risk of cancer many years down the line. Contrary to popular belief, the advertised Potassium Iodide (KI) pills do not protect an individual from a major nuclear catastrophe as these pills are absorbed by the thyroid gland and prevent radioactive iodine-131 from being absorbed by the thyroid gland. I-131 is not a relevant part of a catastrophic nuclear device. It is more likely to be part of a “dirty bomb” – a radioactive “bomb” that someone could more likely bring into the city – but one that is most likely too ineffective to cause any significant harm. Rather, the media hysteria surrounding a dirty bomb is what will cause the most damage to the city – the “fear” factor – when in fact it is essentially harmless and clean up crews should be able to dispose of any dangerous elements in a relatively short period of time. Now if radiation or a biological agent gets into the water supply, then we have a more serious issue.

Dwight Freeney Ankle Injury a Ticking Time Bomb in Super Bowl

Nom de Plume, M.D. — Tue, 07 Sep 2010 12:38:04 +0000

Indianapolis Colts defensive end Dwight Freeney still hopes to play in the Super Bowl despite a torn ligament in his right ankle. Freeney relies on incredible speed, remarkable spins and leverage to attack opponents. Any ankle injury would impact how he pushes off the foot, either slowing him down or preventing him from making the spins, to pressure a quarterback. But what Freeney has is a third-degree low ankle sprain, which is the highest grade sprain with involved ligaments on the outside of the ankle actually torn. The problem with all the speculation regarding his injury improving with rest during the week preceding the Super Bowl is that while the inflammation and correspondent soreness and pain have been subsiding, this type of ankle injury takes weeks to heel completely – and when it is stressed in real playing conditions – even if it is stabilized with extensive taping – it will simply be a matter of time when it is either reinjured or exacerbated. He will certainly be medicated on pain medication (i.e. Toradol) to get him through as much as this game as possible. However, the idea that he will be healed enough after only a couple weeks of rest and aggressive medical treatment is ridiculous. Typically, this type and grade of injury requires 6 to 8 weeks to fully heal. Despite the fact that the team doctors will likely clear him to play – and if he does play (with serious ankle taping), he may be able to start the game well but I’d say by the second quarter, when the swelling starts to settle in, he will start to feel the pain and will lose his mobility. After a long halftime, I expect the injury to finally catch up to Freeney – he will be significantly limited in the second half of this game. So if I were the New Orleans Saints, I would prepare for this game knowing Dwight Freeney will only be a factor in the first half of the game.

Game Theory “Prisoner’s Dilemma” View on Amanda Knox Trial

Nom de Plume, M.D. — Tue, 07 Sep 2010 12:37:00 +0000

This is an absolutely fascinating case that touches on two potentially relevant psychiatric phenomena: sadism or sadomasochism – and the “prisoner’s dilemma.” Sadism is pleasure in the infliction of pain or humiliation upon another person, while masochism refers to pleasure from receiving the pain. These practices are often related and are collectively known as sadomasochism and may be used clinically, in psychotherapy, to describe mental illnesses, psychopathology or counterproductive coping mechanisms – and additionally may describe consensual sexual practices. What’s even more interesting to the Amanda Knox trial is that the 3 primary suspects have not incriminated each other despite seemingly overwhelming evidence that they may be guilty. Interestingly, what’s been termed the “prisoner’s dilemma” is a social phenomena fundamental problem in game theory that demonstrates why two people might not cooperate even if it is in both their best interests to do so. Two suspects are arrested by the police. The police have insufficient evidence for a conviction, and, having separated both prisoners, visit each of them to offer the same deal. If one testifies (defects from the other) for the prosecution against the other and the other remains silent (cooperates with the other), the betrayer receives a lesser sentence and the silent accomplice receives the full sentence. If both remain silent, both prisoners may be found innocent – but they certainly risk being found guilty and receiving the maximum sentence. Each prisoner must choose to betray the other or to remain silent. In the classic experiments, each one is assured that the other would not know about the betrayal before the end of the investigation. How should the prisoners act? Experiments have shown that 40% of the time, both prisoners will not betray each other. What makes this case even more interesting is that there are 3 prisoners involved, so the probability based on studies that no one will betray another is less likely – approximately 20% – so the likelihood of at least one of the suspects in the Amanda Knox case betraying the others would be 80% (assuming that they are indeed guilty accomplices). One would assume that rational prisoners would care only about minimizing his/her own time in jail – but perhaps in this case, they feel that they will all be found not guilty – or perhaps there is something even more sinister to this case that they all feel must not come to light…

Celebrity Toxicology Delays Explained – Not Always Like TV

Nom de Plume, M.D. — Tue, 07 Sep 2010 12:36:46 +0000

With daily injections of TV shows like CSI into our living rooms, we need a reminder that real life isn’t like television or the movies. Nowhere do the worlds of fantasy and reality contrast more sharply than in the case of a celebrity autopsy when media speculation comes to a screeching halt with the phrase, “Toxicology tests will not be available for several weeks.” How could anyone be treated in E.R. if medics had to wait weeks for test results before treating a possible overdose? Of course, in an E.R., clinical toxicology is rapid as it only involves testing blood for a narrow range of legal or illegal drugs as a guide to life-saving treatment. Testing performed after death (aka forensic toxicology) forms the basis for a possible criminal investigation and is included in a legal document requiring exact, valid, reliable detail that is defensible in a court of law. Forensic toxicology ultimately aims to determine the exact cause of death. It includes samples of blood, urine and tissue taken from various different parts of the body. Testing goes beyond simple identification of toxic substances. A whole slew of sophisticated procedures very specifically measure quantities of drugs and interactions with other substances. And unlike a TV show, where a large team of specialists is on call day or night to put a vast range of sophisticated equipment into use, most forensic teams are smaller and often poorly equipped – and nationally there is a huge backlog of cases. Often specimens must be sent to specialized facilities. Further, testing often must be repeated as more evidence is uncovered. Although toxicologists may have a preliminary results and a pretty clear idea of the cause of death within a couple of days, a official report may be months in the making because a certified cause of death requires that every last piece of investigation be finalized. And if a crime is suspected, the autopsy report may be held up indefinitely.