What happened to Damar Hamlin?

The media have been focused on the tragic collapse of Damar Hamlin, a professional football player, during a televised game last Monday. Hopefully it will bring more attention to this huge problem: some 350,000 sudden deaths occur annually in the United States, though it is rare for it to happen in a fit athlete.

Some terminology:

This was not a “heart attack,” the lay term for what health professionals call an acute myocardial infarction. An acute MI typically happens to an older person who has (sometimes unknown!) narrowing of the coronary arteries and is generally felt as chest tightness rather than sudden collapse, though this can occur. It would be very rare for a fit young athlete to have coronary disease. While possible, this is unlikely to have happened to Damar.

Nor was it “heart failure,” a condition in which the heart, because of weakened muscle, cannot adequately pump blood and which usually comes on very gradually and whose cardinal symptoms are tiredness and shortness of breath due to fluid backing up in the lungs.

This was a sudden cardiac arrest, in which the coordinated electrical activity that regulates the heart becomes totally uncoordinated. The ventricles, the main pumping chambers of the heart, no longer contract rhythmically. Instead, they quiver in a totally uncoordinated manner, and there is NO effective pumping of blood. This is called VF: ventricular fibrillation. The first organ to feel the lack of blood is the brain, and hence the sudden collapse.

While the commonest cause of this in the general population is coronary disease, in young people there are commoner causes. Bostonians with a long memory will recall the tragic death of Reggie Lewis, star player with the Boston Celtics, who collapsed and died during a practice in 1993.

One possible cause of VF in a healthy person is a blow to the chest which happens to occur at just the wrong time in the heart’s electrical cycle. This is called Commotio Cordis. It tends to be more common in younger males, possibly because their chests are less muscular and a blow is more easily transmitted to the heart. It has been seen in lacrosse or hockey players getting a stick in the chest and baseball players struck in the chest by a ball. This could have caused Damar's collapse.

Another cause is a cardiomyopathy, an abnormality, often congenital, of the heart muscle. If this is very localized, the athlete may be able to perform at a high level but still be prone to VF.

A specific form of cardiomyopathy, that may have been the cause of Reggie Lewis’ sudden death, is hypertrophic cardiomyopathy: the heart is too thick and during exertion there may be severe obstruction of blood flow out of the left ventricle.

The good news is that Damar appears to have been successfully resuscitated and with luck will come out of this tragedy with minimal damage. If so, he will owe his life to the prompt recognition of what had happened, prompt administration of CPR and prompt use of an AED: automatic external defibrillator. This last is a device that allows the general public to give a life-saving electric shock to stop VF without having to wait for medical personnel to arrive on the scene.

Time is critical: the brain suffers irreversible damage if resuscitation is delayed, even if heart function can be restored.

Learn CPR. If you have any influence, see that any place where groups gather has an AED and personnel trained in its use.

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Curing Alzheimer's? Lies, damn lies and statistics

If you flip a coin three times and all three times it shows heads, you would not be shocked. If you flipped it 50 times and it came up heads every time you would ask for a new coin! Statisticians have ways of describing the odds that something happens by chance, and this type of calculation is broadly used in medical trials.

When treatment A gives a different outcome than treatment B, this is generally accompanied by a “P value,” which expresses the likelihood that the difference was purely by chance. The commonly accepted metric that there is a real difference between two arms of a trial is a P value less than 0.05. If P<0.05, this says there is less than a 1 in 20 chance the results were not really different. The lower the P value, the greater the chance the results were not coincidental.

While many researchers worship at the altar of P<0.05, I urge caution. If you include very large numbers of patients, even small differences in outcome can be “statistically significant,” when the difference is meaningless to patient outcomes.

Let’s say you treat 10 patients with an aggressive cancer with A and 10 with B. After 3 years, all the patients given A are dead and 9 of those given B are alive. You don’t need a statistician to choose your treatment.

Instead, let us say you treat 1000 patients with A or B, and the average lifespan for those given A is 2 years and two months, while those given B live an average of 2 years and a month. Because of the large number of patients in the trial, it is reported that A is statistically better than B. Yes, but… Those given A were twice as likely to have to stop treatment for a time due to serious side effects, and spent several weeks more in hospital. Choice depends on individual values.

There is often a serious difference between statistical significance and clinical significance.

This brings me to lecanemab, the newest “wonder drug” for Alzheimer’s disease. Like several others released or in testing, this monoclonal antibody targets amyloid-beta, a protein that accumulates in the brain of patients with Alzheimer’s. I must note that experts are still not agreed on whether amyloid causes Alzheimer’s or is simply a marker of the disease.

The trial of lecanemab involved 1795 patients, half getting an infusion of the drug every two weeks and half getting a placebo. The results, touted loudly by the drug’s manufacturer showed a highly statistically significant difference (P<0.001) in favor of the drug.

When you dig deeper, the results are less impressive. Patients in both arms showed steady deterioration in mental acuity, though the decline was less for those on the drug. The absolute difference after 18 months was 0.45 on an 18-point scale, a difference, but a modest one.

A quarter of those given the drug had serious reactions to the infusion, and one in eight had brain swelling. There were two deaths in the active treatment group that remain unexplained. Potentially useful? Maybe. A game-changer? No.

Existing drugs like the cholinesterase-inhibitors (Aricept et al) also slow the decline but do not cure the disease. There is also recent evidence that this class of drugs prolongs life.

In the meantime, do things proven to help that are low cost and safe: do not drink to excess; every drink over 1/day progressively shrinks your gray matter. Eat less processed and more unprocessed food. Be sure your Vitamin D levels are in the normal range; if you do not live in the tropics, taking a daily supplement is advised. Be sure your blood pressure is below 140/80.

My bias is that chasing amyloid is chasing down a blind alley. Time will tell, but be cautious about “statistically proven” treatments of marginal clinical benefit.

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Doctor: would you mind saying that again, but in English?

It will come as no surprise to most of you that what doctors think they say and what patients hear are frequently not the same.

Every field has its own jargon, understood by the practitioners but not “outsiders.” Be honest: if you bring your car in for service and the service advisor says you have a bad solenoid, would you understand what this means? [engineers excepted]

A recent study published in JAMA Network Open described what researchers found when they asked a group of adults attending the Minnesota State Fair last year their understanding of common medical expressions used by doctors talking to patients.

Despite the fact that this was an educated group (90% had at least an associate degree and 65% a bachelor’s degree or higher), less than 10% correctly understood the question “Have you been febrile?” and 2% understood the statement “I am concerned the patient has an occult infection.” 11% knew what it meant when they were told “You will need to be NPO at 8 AM.”

A common cause of confusion is the frequent difference between common usage and medical meaning. In most circumstances, “positive” has a good connotation, but in “your lymph nodes were positive,” the opposite is true. Being told “your performance on the test was impressive” would make a student happy, but if your doctor says “your Xray findings were very impressive,” you had better worry.

Even doctors may miscommunicate if an abbreviation is used out of context. If one doctor says to another “the patient has MS,” does this mean they have multiple sclerosis or mitral stenosis? If it is one neurologist talking to another, the meaning will usually be clear, but if the neurologist is talking to a cardiologist, all bets are off.

How should this affect your behavior?

A good medical interaction should end with the doctor asking the patient to tell the doctor what they understood of the conversation, but this rarely happens in today’s frantic environment. You should take the initiative and tell the doctor what you believe they just told you. Do not be surprised if they say “no, that is not what I intended to tell you.” You can then hopefully get a clarification.

Remember: the only dumb question is the one you should have asked but did not. Do not leave a medical visit without being sure you know what you were told and understand all its implications.

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Out from the valley of the shadow of death

It has been a while since I last wrote, but there was good reason. On Sept 23, I went in to one of the country's "top ten" hospitals for a “minor procedure” that was supposed to let me out in 3-4 days. My surgeon was very well-respected. On the second post-op day I told the staff there was a problem but was reassured my recovery was normal. Late on the third day my blood pressure disappeared, a fever developed and I was rushed back to the operating room, where 2 quarts of blood were found in the abdomen, indicating a post-operative hemorrhage, and then I was admitted to the ICU in “guarded condition.” [Translation: may not make it.]

After 10 days in the ICU, I went to the surgical floor for a week and then a rehab hospital where I could not get out of bed without help. Two weeks of rehab, followed by home PT for a month and I am well on the way to recovery.

What lessons should you take from this experience?

First, let me remind you of my definition of “minor surgery:” surgery done on someone else. Something can always go wrong, so be very sure there are not non-surgical alternatives before agreeing to an operation.

Second, be your own advocate or have someone close assume that role. I was probably not insistent enough that studies were needed the day before everything went sour.

Third, be sure you have a written health care proxy and have reviewed it with your surrogate. Do you want to be on a ventilator? In what circumstances? This should be made explicit.

Fortunately, my tale has a happy ending, but that was far from guaranteed.

On another note, the newest Alzheimer’s drug has been reported to great fanfare, but I urge caution. As is all-too-often true with new drugs, the benefit was "statistically significant" but I was not impressed with the clinical benefit, and the two deaths in the trial remain to be explained. More when I have a chance to read the full paper.

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The new Covid boosters

As you must be aware, the U.S. FDA recently approved (on August 31) a new booster shot against Covid-19, The bivalent vaccines, which are updated boosters, contain two messenger RNA (mRNA) components of the virus: one of the original strain of SARS-CoV-2 and the other, one that is common between the BA.4 and BA.5 lineages of the omicron variant of SARS-CoV-2, the most recent strains of the virus that are circulating.

Should you get one? Some facts:

The first is that the mRNA vaccines have been remarkably effective. While they do not necessarily mean you will not catch the virus, they dramatically reduce your chances of getting very sick or dying from it. Hospitalization rates were over 10 times commoner in unvaccinated people. Vaccinated people who are sick enough to require hospital care are overwhelmingly the elderly and those with multiple other medical illnesses.

While any vaccination helps, the best protection is offered by having the original two shots plus 1 or 2 boosters.

If you have not had your 3rd or 4th shot, the new vaccines will now be the only ones offered.

While the new vaccines have been shown in mice to produce good antibodies against the current Omicron strains, their effectiveness at preventing disease in humans has not been fully studied.

My take: if you have been fully vaccinated – 4 shots – I would be in no rush and would wait for more human studies to be reported. If you have not yet had your boosters, get one!

Also: everything we know tells us that this winter is likely to be a bad flu season. There was severe influenza in the southern hemisphere during their just-finishing winter and that is often an early warning about what we will experience.

The much-discussed mask wearing of last winter had a spin-off benefit: much less respiratory illness in general, including influenza. As people have begun to stop wearing masks, this extra layer of protection will be gone.

Get your flu vaccine before the end of October.

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Foods as medicine

As you know from reading earlier posts, the effects of different foods on health can be difficult to interpret. Rarely do studies get to compare people who are exactly alike except for their consumption of the substance of interest. Avocados may be good for your heart, or it may simply be that people who eat avocados eat a healthier diet overall. Hence the often contradictory headlines - coffee is good for you/coffee is bad for you – that populate the press.

I have thus been very interested to find several recent studies with robust data behind the health claims.

First bananas. A British group treated almost 1000 people with a hereditary tendency to colon cancer (Lynch syndrome) with a “resistant starch” powder made from bananas or a placebo for 4 years and followed them for at least 10 years. The supplement group had a similar rate of colon cancer but dramatically fewer cancers of the pancreas and upper GI organs: 5 vs. 21.

Another study looked at the value of cocoa-based chocolate compared to white chocolate and placebo in elderly patients with advanced cancer in palliative care. After 4 weeks, the group given dark chocolate had better calorie and protein intake and overall better nutritional status than either the white chocolate or no chocolate groups. They also had improved functional status.

Finally: prunes. Prunes are known to contain large amounts of antioxidant compounds. Researchers at Penn State gave post-menopausal women 55 to 75 either 6 prunes/day, 12 prunes/day or no prunes for 12 months. All 3 groups were given daily calcium and Vitamin D. Not surprisingly, the group assigned to 12 prunes/day had a high (41%) drop-out rate, presumably because of excess bowel movements, but only 10% of the 6-prune group and 15% of the no-prunes group left the study.

After a year, the groups taking prunes had much lower levels of inflammatory markers in their blood. More important to the women in the study, the placebo group had a significant fall in their bone mineral density while the group who took 6 prunes/day had no drop.

So, good data showing that bananas, dark chocolate and prunes have proven health benefits. Enjoy!

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Do I really need that test?

A 2019 study estimated that overtreatment and “low value” testing costs the U.S. between $75 and $100 Billion annually. Why should you care? You should care because this means that the cost of your health insurance and your out-of-pocket costs go up to pay for this unnecessary treatment and testing.

We will leave treatment to another post and focus on over-testing. Unnecessary or low-value tests are those which are very unlikely to make you live longer or feel better.

Such over-testing is ubiquitous, but one area is “routine” pre-operative testing. Clearly if you have evidence of bad heart or lungs and are being asked to have a risky surgery, your doctor may need tests to determine if you can safely undergo surgery. That, however, accounts for only a tiny fraction of pre-op testing.

The vast majority of pre-operative testing is done on relatively healthy people who are about to have low-risk surgery such as hernia repairs or cataract extractions. Decades ago, the American College of Cardiology and the American Heart Association, in conjunction with the anesthesiology societies, published guidelines recommending against pre-op stress testing for most patients, and even advised against routine ECGs. While some hospitals have tried to reduce such testing, the overall impact of these recommendations has been minor.

In many cases, asking a few questions, such as “can you walk up 2 flights of stairs without problems” will avoid the need for most heart and lung testing before surgery.

Why do so many unnecessary tests continue to be ordered? Some of the incentive is financial. Doctors and hospitals are paid more when they do more. As long as this perverse incentive continues, there will be pressure to do more. Research has demonstrated that doctors who own MRI machines order many more MRI studies. If I were paid by the word to write, you can bet this post would be much longer.

The other factor is cultural. Doctors have been conditioned to believe that “It cannot hurt to get more information.” While an occasional extra blood test may not cost much or harm you, some invasive tests carry risk, and the added cost and inconvenience of any test is not trivial if you take off time from work or drive a distance. Another under-appreciated factor is that many “routine” tests turn up unexpected minor abnormalities that are not significant, but which require other tests to prove this.

What can you do? Before agreeing to any test, ask how the results will change your treatment.

For anything but blood tests or plain X-rays, ask if there is any risk to the test.

Ask if there are simpler alternatives.

Ask if there is any harm in waiting a bit. Many illnesses are self-limited, and the doctor will often be certain you have nothing serious but orders tests “to be sure.”

If the recommended test is invasive, such as cardiac catheterization, consider asking for a second opinion before you agree to have it.

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