Seems I'm always asking for Purrs...

In article , "CatNipped"
wrote:

"Treeline" wrote in message
...

Now how good are you? I have been having a running battle with
cardiologists
and the machines for about 10 years now. They say the machines are
mis-interpreting the data. A big-time professor and researcher agreed
with
me
that the cardiologists were wrong and the machines were right.

If you are really, really good, how about I send you an EKG and you
tell
me if
it shows a past heart attack, to use the layman's term, or not?

Just an interesting aside here. My DH had WPW (Wolfe-Parkinson-White
syndrome) that was found *very* late (relatively) in his life at age 28.
Most people die of this in their teens without ever being diagnosed (who
thinks to perform an EKG on a teenager).

It's basically a birth defect and, to use a very lame analogy, it's like
the
heart is mis-wired. If you think of the heart as being electrically
wired
like a house would be to power its beating, then in this case it's like
there's a short circuit in the wiring. What happens is that the heart
will
start beating wildly out of control. Howard, Treeline(?), feel free to
jump
in with the correct physiological terminology/definition - this is just
from
one layman to other laymen to try to illustrate what when wrong.

In general, a flareup of WPW syndrome will cause a "supraventricular
paroxysmal tachycardia", of which there are several subtypes. This
affects the upper chambers of the heart, the atria, as opposed to the
most important pumping chambers, the ventricles, Atrial tachycardia
(rapid but regular beat) and even atrial fibrillation (irregular beat)
are still less dangerous than ventricular fibrillation. You can stop an
episode with drugs such as adenosine, or a much less violent electrical
shock than the typical television defibrillation.

It can sometimes be managed with drugs, often by a catheter procedure
into the heart, and sometimes needs full surgery.

It's very eerie (and fortunate) how it was found in DH. He had a
ganglion
on his wrist that was bothering him and he wanted to have it surgically
removed - an extremely minor surgical procedure. As is normal practice
with
any surgery using anesthesia, he needed pre-op testing, one of which was
an
EKG. The doctors saw something weird on the EKG and ordered a stress
test.
During the stress test DH's heart started beating wildly out of control
at
325 beats per minute.
..

The eerie thing about it all is that after his heart surgery, the
ganglion
just disappeared - as if it were no longer needed to alert everyone of
this
life-threatening condition. Had he not have had the ganglion to begin
with,
and not wanted to have surgery to remove it, there would have been no
reason
to perform the EKG (like most men, he never goes to a doctor for
"routine"
testing). It's most likely he would have had an attack and died within
the
next couple of years. Indeed, the doctors were genuinely amazed that he
had
live to age 28 with this.

This sort of random finding is more common than one might think. A
friend had the luckiest ulcer known, especially when ulcer surgery was
used more than it is today -- most stomach ulcers can be cured with
drugs. When his stomach was open, they found a very small but
potentially explosive cancer, which they were able to remove completely
-- but if he had gone a few months, it might have killed him.

On 2005-02-05, Treeline penned:

That's what I thought. But expert cardiologists often do not wish to do any
more analysis than they can get away with, make money, and not be sued, in
my experiences with expert cardiologists. I do not recall a single
cardiologist actually analyzing the ECG. They just blew it off saying even
if so it's not important. Not important to them. But to me? Knowing I had a
heart attack, at any time, is a non-trivial event.

Wow.

When my husband had some funky enzyme readings late last year, they called in
a cardiologist and his team late at night to do an angiogram and other fun
things. It turned out to (most likely) have been a virus that affected his
heart, and he was fine, but they kept him several days rather than risk that
they might have missed something important.

Given that DH was feeling great, it almost seemed like overkill. But it would
have been worse had they discharged him and he *then* had a problem.

--
monique, roommate of Oscar the (female) grouch
~~~~~~~~~~~~~~~~~~
Eros was adopted! Eros has a home now! *cheer!*

Howard Berkowitz wrote:

In article , "Treeline"
wrote:


"Howard Berkowitz" wrote in message
...



Man, I hope you two are friends, as I'd really hate to see you two in a
p*ss*ng contest.

Pam S. bemused

In article , "Monique Y.
Mudama" wrote:

On 2005-02-05, Treeline penned:

That's what I thought. But expert cardiologists often do not wish to do
any
more analysis than they can get away with, make money, and not be sued,
in
my experiences with expert cardiologists. I do not recall a single
cardiologist actually analyzing the ECG. They just blew it off saying
even
if so it's not important. Not important to them. But to me? Knowing I
had a
heart attack, at any time, is a non-trivial event.

Wow.

When my husband had some funky enzyme readings late last year, they
called in
a cardiologist and his team late at night to do an angiogram and other
fun
things. It turned out to (most likely) have been a virus that affected
his
heart, and he was fine, but they kept him several days rather than risk
that
they might have missed something important.

Well, remember that the enzymes detect destruction of cardiac tissue,
not necessarily the cause of the destruction. When a cardiac muscle
cell ruptures, it releases certain enzymes.

Most often, it ruptures because it's not getting oxygen. It could also
rupture due to an infection.

In these borderline cases, you look at things such as predisposing
factors (cholesterol and related levels), inflammatory substances in the
blood, etc. Eventually, you may have no choice other than to do some
kind of imaging. While I recognize the plural of anecdote is not data,
I never had significant ECG variations while quite a bit was going on.
This is not at all uncommon.

Given that DH was feeling great, it almost seemed like overkill. But it
would
have been worse had they discharged him and he *then* had a problem.


Exactly. There's a constant effort to reduce monitoring costs. Many ERs
now have attached "chest pain units" for 23 or so hours of monitoring,
so they don't incur the expense of an ICU admission. Even then, there
are alternatives to the ICU on an inpatient basis, ranging from Coronory
Special Care (or stepdown) units, or units with cardiac telemetry. In
general, the difference among these types is the range of monitoring
they can do. ECG, including wireless ECG from a walking patient, is
easy. Invasive measuring catheters and the like are not.

"Howard Berkowitz" wrote in message
...
In article , "Treeline"
wrote:

That hasn't been my personal experience with the cardiolgists I see --
now, maybe this is a special case since I can interpret to a reasonable
extent. We often discuss them together.

That's good. Did you hit textbooks on EKGs? They are amazingly expensive
although the info is old and old textbooks can be good enough.


The reality is that myocardial infarctions or even ischemia cannot
always be diagnosed with ECGs alone. In the emergency care situation,
you may get a higher confidence level with cardiac enzymes, troponins,
or C-reactive protein. In other words, there is a level at which
further refinements of the ECG alone may not provide much practical
benefit. A few cardiologists I know will occasionally put leads on the
back as well as the chest, but that's about the only variant I see even
among researchers.

My personal experience was that the first real evidence showed up on
thallium exercise SPECT scan, and needed coronary angiography to
confirm. On both exercise and physiologic stress, my ST segment stayed
isoelectric. Stress echocardiography did reveal reversible myocardial
akinesia.

How did you know it was reversible? Reversible by better echoes or they could
tell somehow? Akinesia is what some called hypomotility?


Later on, I had another angioplasty, and then bypass. About six months
after the bypass, I reoccluded two grafts, and my HMO refused to work
them up. Luckily, I was able to find and join an NIH Clinical Center
atypical chest pain protocol, and am now on long-term monitoring at NIH.
I'm occasionally a volunteer for new cardiac imaging, and typically
spend an inpatient week about every five years for extensive testing.
The good news is that much of my cardiac pathology has reversed with
aggressive medical management.

That's amazing. New cardiac imaging? Invasive, catheterization or noninvasive
such as Fast CT Scans or echoes?


I understand the concern. In general, I can get good cooperation from my
physicians, and we share and discuss all results and strategies. When I
run into a problem, as with the HMO not approving a workup, I know
academic and research medicine well enough to game the system into
providing adequate care.

Good for you. You have a lot of patience. I guess I could do that. But I am not
so sure I want another MRI ever, for example.

"Tanada" wrote in message
nk.net...
Howard Berkowitz wrote:

In article , "Treeline"
wrote:


"Howard Berkowitz" wrote in message
...



Man, I hope you two are friends, as I'd really hate to see you two in a
p*ss*ng contest.

Pam S. bemused

We have a friend in common, called truth. Try it, you'll like it

In article , "Treeline"
wrote:

"Howard Berkowitz" wrote in message
...
In article , "Treeline"
wrote:

That hasn't been my personal experience with the cardiolgists I see --
now, maybe this is a special case since I can interpret to a reasonable
extent. We often discuss them together.

That's good. Did you hit textbooks on EKGs? They are amazingly expensive
although the info is old and old textbooks can be good enough.

I have several. Also, the major cardiology textbooks like Hurst have
extensive chapters.


The reality is that myocardial infarctions or even ischemia cannot
always be diagnosed with ECGs alone. In the emergency care situation,
you may get a higher confidence level with cardiac enzymes, troponins,
or C-reactive protein. In other words, there is a level at which
further refinements of the ECG alone may not provide much practical
benefit. A few cardiologists I know will occasionally put leads on the
back as well as the chest, but that's about the only variant I see even
among researchers.

My personal experience was that the first real evidence showed up on
thallium exercise SPECT scan, and needed coronary angiography to
confirm. On both exercise and physiologic stress, my ST segment stayed
isoelectric. Stress echocardiography did reveal reversible myocardial
akinesia.

How did you know it was reversible? Reversible by better echoes or they
could
tell somehow? Akinesia is what some called hypomotility?

In basic testing, reversibility is defined by having normal perfusion
(SPECT) or visible movement (echocardiography) before the stress (by
drugs or exercise), and no perfusion/movement afterwards.


Later on, I had another angioplasty, and then bypass. About six months
after the bypass, I reoccluded two grafts, and my HMO refused to work
them up. Luckily, I was able to find and join an NIH Clinical Center
atypical chest pain protocol, and am now on long-term monitoring at
NIH.
I'm occasionally a volunteer for new cardiac imaging, and typically
spend an inpatient week about every five years for extensive testing.
The good news is that much of my cardiac pathology has reversed with
aggressive medical management.

That's amazing. New cardiac imaging? Invasive, catheterization or
noninvasive
such as Fast CT Scans or echoes?

An assortment. Transthoracic (against the chest) and transesophageal
(down the throat) echocardiography, with drug-induced stress, and an
assortment of imaging enhancements including several different acoustic
contrast media and additional computer processing for three-dimensional
visualization. SPECT using different isotope protocols. Radionucleide
angiography (also called multiple gated ucquisition (MUGA) or
radionucleide ventriculography). MRI before the pacemaker.
Catheterization/angiography, including a new technique called Biosense,
and an assortment of intracardiac drug stimuli.

Biosense has a couple of elements. First, and most generally, the tip of
the catheter has a small attached magnet, and the patient is surrounded
by coils, so the catheter tip can be precisely located in
three-dimensional space -- you can only estimate the third dimension in
convention fluoroscopic angiography. Second, in this protocol, they
administered electrical stimulation to various parts of the heart
muscle, to differentiate between true scar tissue and "stunned"
myocardium that would recover with new blood supply.

During that last procedure, the cardiology fellow, who was English, and
I engaged in a bit of dialogue that delighted half the team and utterly
confused the rest. When he would find scar tissue after finding stunned
myocardiun, I'd respond "'es not dead! 'es merely resting!"

"It only stays there because it's nailed to the rest of the heart! It's
gone off and joined the choir eternal! THIS IS EX-MYOCARDIUM!"

It was probably revenge for the chief of invasive cardiology, an
Iranian-American, demanding really bad country and western as procedure
background music.


I understand the concern. In general, I can get good cooperation from
my
physicians, and we share and discuss all results and strategies. When I
run into a problem, as with the HMO not approving a workup, I know
academic and research medicine well enough to game the system into
providing adequate care.

Good for you. You have a lot of patience. I guess I could do that. But I
am not
so sure I want another MRI ever, for example.

"Howard Berkowitz" wrote in message
...

I have several. Also, the major cardiology textbooks like Hurst have
extensive chapters.

Thanks for the tip. They sure are heavy, around $300 by now?

In basic testing, reversibility is defined by having normal perfusion
(SPECT) or visible movement (echocardiography) before the stress (by
drugs or exercise), and no perfusion/movement afterwards.

An assortment. Transthoracic (against the chest) and transesophageal
(down the throat) echocardiography, with drug-induced stress, and an
assortment of imaging enhancements including several different acoustic
contrast media and additional computer processing for three-dimensional
visualization. SPECT using different isotope protocols. Radionucleide
angiography (also called multiple gated ucquisition (MUGA) or
radionucleide ventriculography). MRI before the pacemaker.
Catheterization/angiography, including a new technique called Biosense,
and an assortment of intracardiac drug stimuli.

That's great. My mitral valve is a big problem here. Everyone says it's a
judgment call. You say tomato I say tomatoe. Whether a T-E-E or regular, the
leaking cannot be quantified or really known for sure. Great. So I do not know
if I have a grade of F for miserable severe Failure or just D for depressing
moderately severe because the jet is "eccentric" like me It's great you get
good data and somewhat reliable results. Everything for me is mostly judgment
calls and when I call the shots, I improve. I sure wish I could trust the
doctors as you do so superbly. You must have great social and communication
skills. I don't have any - must be another defect with the "connective tissue,"
this time in the corpus callosum.


Biosense has a couple of elements. First, and most generally, the tip of
the catheter has a small attached magnet, and the patient is surrounded
by coils, so the catheter tip can be precisely located in
three-dimensional space -- you can only estimate the third dimension in
convention fluoroscopic angiography. Second, in this protocol, they
administered electrical stimulation to various parts of the heart
muscle, to differentiate between true scar tissue and "stunned"
myocardium that would recover with new blood supply.

Thanks for the "tip." I "sense" that. Love puns, sometimes.


During that last procedure, the cardiology fellow, who was English, and
I engaged in a bit of dialogue that delighted half the team and utterly
confused the rest. When he would find scar tissue after finding stunned
myocardiun, I'd respond "'es not dead! 'es merely resting!"

That's really funny.


"It only stays there because it's nailed to the rest of the heart! It's
gone off and joined the choir eternal! THIS IS EX-MYOCARDIUM!"

It was probably revenge for the chief of invasive cardiology, an
Iranian-American, demanding really bad country and western as procedure
background music.

I never did this, with or without music. Bad decision on my part, very, very
bad. Now it does not really matter, too late. Well, I am hoping that
researchers in Scotland come up with a nice, bionic valve and I can afford it.
I went to the best in the USA, Cleveland Clinic, what a dump, poorest city in
the USA in 2004, cannot afford a good infrastructure, bad nursing, bad
supporting doctors, regardless of reputation where the "mistakes" are buried
in the ground or in the high numbers so it's not obvious they screw up
big-time. Can't sue in Ohio unless dead or paralyzed, then it's easy,
especially if you are dead. I'll stop before I start ranting.

What is your ejection fraction before I forget? Around 55%?

In article , "Treeline"
wrote:

"Howard Berkowitz" wrote in message
...

I have several. Also, the major cardiology textbooks like Hurst have
extensive chapters.

Thanks for the tip. They sure are heavy, around $300 by now?

Check the used listings on Amazon -- I saved about $100 for one in
like-new condition, from an overstock company.


In basic testing, reversibility is defined by having normal perfusion
(SPECT) or visible movement (echocardiography) before the stress (by
drugs or exercise), and no perfusion/movement afterwards.

An assortment. Transthoracic (against the chest) and transesophageal
(down the throat) echocardiography, with drug-induced stress, and an
assortment of imaging enhancements including several different acoustic
contrast media and additional computer processing for three-dimensional
visualization. SPECT using different isotope protocols. Radionucleide
angiography (also called multiple gated ucquisition (MUGA) or
radionucleide ventriculography). MRI before the pacemaker.
Catheterization/angiography, including a new technique called Biosense,
and an assortment of intracardiac drug stimuli.

That's great. My mitral valve is a big problem here. Everyone says it's a
judgment call. You say tomato I say tomatoe. Whether a T-E-E or regular,
the
leaking cannot be quantified or really known for sure. Great. So I do not
know
if I have a grade of F for miserable severe Failure or just D for
depressing
moderately severe because the jet is "eccentric" like me It's great
you get
good data and somewhat reliable results. Everything for me is mostly
judgment
calls and when I call the shots, I improve. I sure wish I could trust the
doctors as you do so superbly. You must have great social and
communication
skills. I don't have any - must be another defect with the "connective
tissue,"
this time in the corpus callosum.

One of the things that has helped me is that in developing expert
systems that interact with physicians, the system dialogue and report
must sound as if a physician wrote it. This required me to study, in
detail, how clinicians talk to one another.

It's emphatically not a matter of vocabulary, but learning the
tremendous amount of contextual assumptions under which the
connversation happens. For example, physician X may ask the result of a
particular blood test. Physician Y understands that X is less concerned
with the actual test than of a certain implied diagnosis. Y responds
with the result of a urine test that rules out the diagnosis.

This makes perfect sense to the physician, but will sound like gibberish
to anyone who doesn't know the context. I have found that when I make
one or two contextual leaps like that in context, the other person may
reflexively start calling me "doctor".

There are other speech patterns that have this sort of effect --
discussing "the differential" and possibly identifying things that you
would rule out, etc. Unfortunately, there's no simple way to get this
across. You have to be reasonably familiar with some of the textbooks
and current journals they look at.



Biosense has a couple of elements. First, and most generally, the tip
of
the catheter has a small attached magnet, and the patient is surrounded
by coils, so the catheter tip can be precisely located in
three-dimensional space -- you can only estimate the third dimension in
convention fluoroscopic angiography. Second, in this protocol, they
administered electrical stimulation to various parts of the heart
muscle, to differentiate between true scar tissue and "stunned"
myocardium that would recover with new blood supply.

Thanks for the "tip." I "sense" that. Love puns, sometimes.


During that last procedure, the cardiology fellow, who was English, and
I engaged in a bit of dialogue that delighted half the team and utterly
confused the rest. When he would find scar tissue after finding
stunned
myocardiun, I'd respond "'es not dead! 'es merely resting!"

That's really funny.


"It only stays there because it's nailed to the rest of the heart! It's
gone off and joined the choir eternal! THIS IS EX-MYOCARDIUM!"

It was probably revenge for the chief of invasive cardiology, an
Iranian-American, demanding really bad country and western as procedure
background music.

I never did this, with or without music. Bad decision on my part, very,
very
bad. Now it does not really matter, too late. Well, I am hoping that
researchers in Scotland come up with a nice, bionic valve and I can
afford it.
I went to the best in the USA, Cleveland Clinic, what a dump, poorest
city in
the USA in 2004, cannot afford a good infrastructure, bad nursing, bad
supporting doctors, regardless of reputation where the "mistakes" are
buried
in the ground or in the high numbers so it's not obvious they screw up
big-time. Can't sue in Ohio unless dead or paralyzed, then it's easy,
especially if you are dead. I'll stop before I start ranting.

I'm surprised. I've been on the fringes of some clinical automation with
them, and they sounded very good. My surgery was at Georgetown, the
cardiac surgery department of which has consolidated at the Washington
Hospital Center. It still doesn't hurt the traditions that Hufnagel
introduced valve surgery there.

What is your ejection fraction before I forget? Around 55%?

Around that, conservatively -- some studies give 60%. When I had my
first episode of angina, it was 65%. After reocclusion after bypass, it
was down to about 35%, but has steadily been coming back up under
aggressive medical management.

"Howard Berkowitz" wrote in message
...

One of the things that has helped me is that in developing expert
systems that interact with physicians, the system dialogue and report
must sound as if a physician wrote it. This required me to study, in
detail, how clinicians talk to one another.

Jargon is critical when dealing with an "in" group. I have noticed that nuclear
physicists do not have to rely on jargon but then, they are relying on reality.
In other words, I can attend a lecture on advanced nuclear physics and follow
most of it, even the equations to a degree, without any advanced knowledge -
aside from knowing a little math and how the universe is set up with particles
and what not. I cannot do that in medicine, not because the concepts are
difficult. Most of them are at the idiot savante or baby level. Because the
jargon is not defined for the lay people, on purpose and laziness, I always
have to ask, when you said Vancomycin was reserved for Grand Rounds, did that
mean...

It's emphatically not a matter of vocabulary, but learning the
tremendous amount of contextual assumptions under which the
connversation happens. For example, physician X may ask the result of a
particular blood test. Physician Y understands that X is less concerned
with the actual test than of a certain implied diagnosis. Y responds
with the result of a urine test that rules out the diagnosis.

This makes perfect sense to the physician, but will sound like gibberish
to anyone who doesn't know the context. I have found that when I make
one or two contextual leaps like that in context, the other person may
reflexively start calling me "doctor".

That happens to me. But when I say I am not a doctor then they get all
discombobulated that I may know more than they do. I may not actually know
"more" but my bias is less, hence my sphere of knowledge increases, to twist
Blaise Pascal, just a bit. [As the diameter, or radius if you prefer, of my
knowledge grows, so does the ignornace displayed by the circumference of the
circle.]

There are other speech patterns that have this sort of effect --
discussing "the differential" and possibly identifying things that you
would rule out, etc. Unfortunately, there's no simple way to get this
across. You have to be reasonably familiar with some of the textbooks
and current journals they look at.

That's hard to do when my hands are shaking but you're right.

What is your ejection fraction before I forget? Around 55%?

Around that, conservatively -- some studies give 60%. When I had my
first episode of angina, it was 65%. After reocclusion after bypass, it
was down to about 35%, but has steadily been coming back up under
aggressive medical management.

An amazing success story.