Black Birds

Frozen Time

One of the first shots with my new camera.

Atrial fibrillation

Hockey is my winter sport. As a hockey fan I’ve recognized something this season other than the new NHL rules, but several players have had episodes of atrial fibrillation (a fib). Atrial fibrillation is a relatively common arrhythmia (irregular heart beat). The incidence of a fib is highest among elderly and those with structural heart disease. It is a rare condition in healthy young adults and children. The overall incidence of a fib was 1 percent. Seventy percent of that 1 percent were over 65 years old. It was slightly more common in men that woman, and whites than blacks.

Etiology:
A fib is almost always associated with structural heart disease of any nature. This heart disease is almost always associated with heart failure, atrial enlargement, and increased atrial pressure. One study was performed with a 24 hour heart monitor called a Holter monitor. It was found that patient’s with structurally normal heart that underwent paroxysmal a fib, the trigger was premature atrial contractions.

Other diseases associated with atrial fibrillation can be summed up in the pneumonic PASMITH:
• P- pulmonary etiology such as pulmonary embolism or pulmonary infection.
• A- Alcohol
• S- sleep apnea and COPD
• M- mitral valve disorder from rheumatic heart disease
• I- infraction (coronary artery disease and acute coronary syndrome), inflammation (i.e. pericarditis)
• T- Thyroid disorder (i.e. hyperthyroidism)
• H- hypertensive heart disease, heart failure, hypertrophy of the left ventricle.

Other conditions to consider: post coronary artery bypass surgery, medications such as theophylline or adenosine, and obesity.

Signs and Symptoms:
There are no specific signs of symptoms of a fib. Many patients are asymptomatic. Typical symptoms include palpitations, a sense of the heart racing, fatigue, lightheadedness, increased urination, or mild shortness of breath. More severe symptoms and signs include dyspnea, angina, hypotension, presyncope, or infrequently syncope (Uptodate.com)

Diagnosis:
• Blood work to check electrolytes, thyroid function,
• EKG,
• chest x ray,
• Holter monitoring,
• possible exercise stress testing.

Indications of hospitalization:
Any patient with a new onset a fib to rule out a myocardial infarction is my recommendation. Other factors to consider include:
• For the treatment of an associated medical problem, which is often the reason for the arrhythmia
• For elderly patients who are more safely treated for AF in hospital
• For patients with underlying heart disease who have hemodynamic consequences from the AF or who are at risk for a complication resulting from therapy of the arrhythmia (Uptodate.com)

Treatment: there are 4 approaches to treatment

1. Rhythm control- conversion to normal sinus rhythm
2. Rate control
3. Choosing between rate or rhythm control
4. Need for anticoagulation

As a student I have always had difficulty with the decision between rate control and rhythm control. From my research this is how I practice now. There was a study produced comparing the efficacy of the two options (the trials were AFFIRM and RACE). There were two conclusions.
1. Embolic events occur with equal frequency regardless of whether a rate control or rhythm control strategy is pursued, and occur most often after warfarin has been stopped or when the International Normalized Ratio (INR) is subtherapeutic (Uptodate.com)
2. Both studies showed an almost significant trend toward a lower incidence of the primary end point with rate control (hazard ratio 0.87 for mortality in AFFIRM and 0.73 for a composite end point in RACE) (show figure 8 and show figure 9). There was no difference in functional status or quality of life (Uptodate.com)

Based on these guidelines one concludes the following. First, you should attempt rate control. If the patient continues to have persistent severe symptoms (i.e. palpitations, dyspnea, lightheadedness, angina, presyncope, and heart failure), inability to control rate, or if the patient prefers, then carioversion with either DC or pharmacological methods are appropriate. If the condition occurs for more than 48 hours the patient should be placed on anticoagulation therapy with warfarin. The target INR is 2-3.

Rate control can be accomplished with Beta-blockers (Toprol XL, Lopressor, Atenolol, Coreg) or calcium channel blockers (diltiazem or verapamil). If the patient has heart failure digoxin may also be used. Rate control is defined as resting heart rate less than 80, 24 hour Holter monitor with average heart rate less than 100, and heart rate during 6 minute walk of less than 110.

Rhythm control is accomplished via DC cardioversion or pharmacologic medications such as amiodarone. Acute indications of cardioversion include: active ischemia, significant hypotension, severe manifestations of heart failure, and presence of a preexcitation syndrome. If there is time it may be beneficial to obtain a transesophageal ultrasound prior to the procedure to rule out a thrombus that could lead to a stroke or heart attack.

Anticoagulation should occur in patient’s with a fib greater than 48 hours, paroxysmal a fib, or while restoring normal sinus rhythm. Medications include warfarin therapy or aspirin. If the patient has contraindications to warfarin therapy then use aspirin. Otherwise warfarin was the recommended medication. The goal of treatment is an INR of 2-3.

Other treatments:
Blood pressure control with class of drugs called ACE inhibitors and Angiotension receptor blockers (ARBs).

So I wonder if these extremely healthy individuals are actually damaging their hearts? Based on the above information you be the judge.


References:
Uptodate.com

This sounds familiar!!!

Prufrockian (pru-FROK-i-uhn) adjective

Marked by timidity and indecisiveness, and beset by unfulfilled
aspirations.

Yet another intern!!

I've recently acquired a fascination for politics. My commutes have been filled with the rhetoric of Rush Limbaugh and Hannity. Although, I cannot agree with everything they speak,I still find them entertaining at least. Rush recently discussed the 2008 Presidential race. He was commenting on a Clinton vs. Condi race.

I was struck by this thought, a thought one should not contemplate while driving 15 miles per hour over the speed limit on a perfect race track two lane road.

Let's, for entertainment sake, say Hillarious Clinton is elected to the Oval Office. If I'm not mistaking that would make Hill Billy Clinton the "First Gentlemen." With this comes many responsibilities, such as:

1. hosting during receptions at the Presidential residence;
2. advocating on behalf of public causes and charities;
3. accompanying their spouse in official travel abroad;
4. State functions and other like duties.

Will the "First Gentleman" have an intern to assist in his affairs (no pun intended)? Will it be Monica Lewinsky? Will the new President allow such an assistant for her adulterous husband? Will there be new legislation passed down by the White House?

Then it raises the question, what will occupy Hill Billy while his wife negotiates nuclear treaties with Russia? Will he have tea and vodka with Putin's significant other? Will he have sexual relations with Putin's significant other?

For the conspiracy theorist's, will he use this as a way to acquire a third term in the office legally? Or better yet, will this be Hillarious' third term? Time will only tell. Until then, Da sveedaneeya!! Pratty

An actual response from a reader!!!

When creating this blog, I never dreamed I would actually receive comments to m worthless thoughts. Today I thought, what the hell, I'll check and see if anyone has responded to these worthless entries.

The first entry, no response. The second entry, no response. Then like a breath of fresh air, at the bottom of a quote I'm fond of, a comment. My pulse increased, I became tachypneic, the anticipation surged. I struggled to move my cursor to the link.

I clicked on the link, my computer slowly crunched the information. To my amazement there was actually a comment. I began to read-

"Great blog. If there is anything I can do to help let me know...."

Then the kicker. The remaining portion of the comment an ad for Banners. I was dumbfounded. My first comment, spam in a can. My anger and frustration soon disappeared and I was back to contemplating how to get my steering wheel to heat up like the seats in my car. Cheers!!!

Transportation with a Gieger counter

I've often contemplated nuclear power plant operations. As an advid science enthusiast I've wonder how they removed the toxic waste. Now this is hostile operations! A train transports nuclear waste to Germany from France.

Food for thought

The day began more than 14 hours ago. An odyssey marked with me waking up on cheap Berber carpet with an extremely low thread count in an abandoned apartment situated in the depths of redneck country and northern Mexico. Unfortunately, I was not drunk or wasted; I was in perfect sanity as I made the transformation from white trash living to upper lower class accommodations.

For months now my significant other and I have parked our $40,000 vehicles underneath a falling maple tree and next door to a schizophrenic methamphetamine pusher. The picturesque white trash living; a $15,000-$20,000 shanty with a stray cat in a cat cage on the front porch, and a hot pink "No trespassing" sign in the front window, compliments of the previous tenants that caught the kitchen on fire attempting to brew some homemade ice. A combination that wreaks catastrophe; fire and crank. Hunter S. Thompson would be proud or probably a part of the action.

When the $6,000 couch was placed in its new home I discovered on the floor a penny heads up. I made my wish- the standard "a flight in an Extra 300 s with Charlize Theron as my co-pilot"-and proceeded with my duties for the afternoon. I jumped in the Rambler I borrowed from my mother to move the furniture and started cruising south, the pedal to the metal, only producing a meager 55 mph quit literally. On the way, my Polo khaki shorts ruined because of the Duck tape on the bench that keeps the springs from poking through.

I step back into my shanty for only a few more hours and the contents of my pocket traverse to the considerably low thread count Berber carpet that covers the floorboards. At this moment my curiosity was ignited. In the contents of my pocket- what a wonderful song title- I discover 2 dimes and 5 pennies, 2 of which are heads up. This was my revelation.

IF YOU DROP A PENNY AND IT LANDS HEADS UP, WILL THAT BRING YOU GOOD LUCK AS WELL???????????????

Or does it have to be dropped by some other creature and later discover by yet another creature????

Hypothesis: If you discover a penny heads up you will only acquire good luck if that penny is novel to you. Being a theoretical physicist at heart, I've begun contemplating the many fascinating experiments to test my hypothesis. The first involves a character such as myself- handsome, debonair, intelligent, and ripped like the Governor of California- walking about downtown New York dropping pennies and then monitoring each individual that picks up a heads up penny to visualize the wonderful luck created in their life. Now before I begin there is only one conundrum to this scenario. There is no way to monitor each individual simultaneously. So I must adapt and move to a more logical experiment.

And here it is; I myself will walk around and drop a penny from my own pocket. Then only pick up the ones that land heads up. I estimate that would have to occur approximately 10,000 times in order to have an adequate sample size. The cost of the experiment is minimal; only one cent. I have estimated I will only need one penny for the experiment. My results will be entered into my work computer. The electricity will be acquired from work. The rewards to me from this experiment will be improvement in lower extremity and lower back muscle tone; increase in cardiovascular stamina; and the exercise will help keep my bowels regular. If my hypothesis is not disproved, I may even become the next Power Ball winner.

Once I'm finally settled into my humble abode, I will proceed with this experiment. For the details on how your can increase your chance of winning the lottery with a mile walk each day and picking up heads up pennies as you go, keep checking back. As for now, Da svidaniya -- Pratti!