Frayed Leads

I’ve been following this story for quite a while.

Doctors and the company are now trying to understand the scope of the problem, but experts say it is extremely distressing because the wires are particularly dangerous to remove and also may pose dangers if they are left in.

Luckily for me, my leads aren’t St. Jude’s and I only have a dual-lead pacer, not an ICD. Still, I count on my leads to do the job they are supposed to, so when I hear about issues with pacemaker leads, my ears really perk up. While a pacemaker is easily replaced every seven years or so, the leads are not.  When a pacemaker is put in, the ends of the leads are embedded in the heart.   It takes several weeks for the heart to seal over the ends of the leads with scar tissue, but once that has happened, the leads should be good to go for a long, long time. Removing defective leads is a big deal, and in fact, if leads need to be replaced, more often than not, the old leads are just left in place to avoid damage to the heart where they are embedded.

 

Gentleman in a Fedora

I may have mentioned before that my lighting instructor is an award-winning photographer. His bread and butter is commercial photography, but his photography goes far beyond. On the first day of class he showed us some of his work, and later we learned more of the back story to many of his shots through this program, The Work of Art, produced by KNPB. I highly recommend watching it and it will give you a great idea of who Jeff Ross is as an artist and a human being.

I had a routine visit with my cardiologist today. Actually, it wasn’t that routine as my regular EP, Dr. Dhir, has left the practice and I was seeing a “new” doctor today: Dr. Letitia Anderson.  The last time I’d seen Dr. Anderson was in November 2009 when I was in the emergency room at Renown prior to being admitted for four days of observation. I liked her then, and today’s visit confirmed that I made the right choice in requesting her after Dr. Dhir’s departure.

Yes…there is a connection here. Patience!

Dr. Anderson wanted me to get my pacemaker read and as I was heading into the waiting area I saw an elderly black man checking in with the receptionist. I immediately recognized him as the gentleman in this photo.  A super-sized version of this photo hangs in Jeff’s studio in Reno and it moves me very much.

And there he was, looking just as he did in the photograph. Same hat, same expression, same demeanor.

At first I wasn’t going to say anything to Mr. Marks, but I felt drawn to him. I wanted him to know I knew who he was, and so I walked up to him and said, “I know you from your photograph.”  We chatted briefly; I told him how much I loved Jeff’s photograph of him. He remembered Jeff and the photo.  I touched the sleeve of his trench coat with my left hand, and he reached for my right hand to hold it.  I told him that I would tell Jeff tonight that I’d seen him. We said good-bye.

And then he smiled at me and kissed my hand.

Cross-posted at The Neophyte Photographer

Well, well, well

At this point, one would have to ask, why is this drug still on the market? It’s not as effective as the one it is supposed to replace, and for others it appears to be deadly.  This is the same drug I took three (3) doses of in November 2009 and reacted so badly to that I stopped it immediately.  I discovered in my own research that my kind of heart rhythm issues did not make me a candidate for this medication so one has to wonder what my cardiologist was thinking when he prescribed it.

The zipper club

My “zipper” is hidden a bit, due to the way my surgery was done, but this article describes the vibe at the ACHA conference very well.

The entire conference, I was blown away by the collaboration of the physicians. Not just with each other, but with their patients.

Doctors, cardiologists in particular, can have an unbelievably large ego, but there is something unique about cardiologists who specialize in congenital heart disease. Honesty, partnership, openness and honest to goodness caring make these physicians the caviar of the medical community. They have devoted their life to advocating, advancing and improving care for individuals affected by congenital heart disease.

We met experts in the field; leaders who are directing the way we approach health care for aging survivors of a “pediatric” disease. But all of them felt more like a best friend who just wants the best for you, and each of their devotion to our cause was palpable. We broke bread, we drank wine, and we danced together.

The conference went by too fast and I learned a lot about myself, my emotional life journey, and met others just like me.

On a side note, where the hell did Callie’s heart surgery scar go? Way to go Grey’s Anatomy! (not!)

The national debt as public utility

While Maven is spiffing up her new digs, she’s been emailing links to interesting articles. Her latest is to this Truthout article about our national debt and deficit.  Cheney was right, national deficits don’t matter. Neither does national debt if it is incurred properly.

Keep in mind that the government is not like a family or a private business. Neither of those entities can issue their own money. Every time I hear some politician say that the goverment, like a family, has to live within its means (and that includes President Obama), I want to scream. No family can “create” its own “means.” The government can.

Read on.

Under our current monetary scheme, debt and deficits not only don’t matter but are actually necessary in order to maintain a stable money supply. The reason was explained by Marriner Eccles, governor of the Federal Reserve Board, in hearings before the House Committee on Banking and Currency in 1941. Wright Patman asked Eccles how the Federal Reserve got the money to buy government bonds.

“We created it,” Eccles replied.

“Out of what?”

“Out of the right to issue credit money.”

“And there is nothing behind it, is there, except our government’s credit?”

“That is what our money system is,” Eccles replied.“If there were no debts in our money system, there wouldn’t be any money.”

That could explain why the US debt hasn’t been paid off since 1835. It has just continued to grow and the economy has grown and flourished along with it. A debt that is never paid off isn’t really a debt. Financial planner Mark Pash calls it aNational Monetization Account. Government bonds (or debt) are “monetized” (or turned into money). Government bonds and dollar bills are the yin and yang of the money supply, the negative and positive sides of the national balance sheet. To have a plus-1 on one side of the balance sheet, a minus-1 needs to be created on the other.

Except for coins, all of the money in the US money supply now gets into circulation as a debt to a bank (including the Federal Reserve, the central bank). But private loans zero out when they are repaid. In order to keep the money supply fairly constant, some major player has to incur debt that never gets paid back; and this role is played by the federal government.

But the deficit! The debt! We’re going to go belly up!

Um. Nope. Not if we borrow from ourselves. Check out Japan.

Japan’s economy remains viable, although its debt-to-GDP ratio is nearly four times that of the United States, because the money does not leave the country to pay off foreign creditors. Rather, it is recycled into the Japanese economy. As economist Hazel Henderson points out, Japan’s debt is twice its GDP only because of an anomaly in how GDP is calculated: it omits government-provided services. If they were included, Japan’s GDP would be much higher and its debt-to-GDP ratio would be more in line with other countries.’ Investments in education, health care and Social Security may not count as “sales,” but they improve both the standard of living of the people and national productivity. Businesses that don’t have to pay for health care can be more profitable and competitive internationally. Families that don’t have to save hundreds of thousands of dollars to put their children through college can spend on better housing, more vacations, and other consumer items.

Locke calls the Japanese model “a capitalist economy with socialized capital markets.” The national debt has been “monetized” – turned into the national money supply. The credit of the nation has been turned into a public utility. 

Thomas Hoenig, president of the Kansas City Federal Reserve, maintains that the largest US banks should be put in that category as well. At the National Association of Attorneys General conference on April 12, he said that the 2008 bank bailouts and other implicit guarantees effectively make the too-big-to-fail banks government-guaranteed enterprises, like mortgage finance companies Fannie Mae and Freddie Mac. He said they should be restricted to commercial banking and barred from investment banking.

“You’re a public utility, for crying out loud,” he said.

The direct way for the government to fund its budget would have been to simply print the money debt-free. Wright Patman, chairman of the House Banking and Currency Committee in the 1960s, wrote:

“When our Federal Government, that has the exclusive power to create money, creates that money and then goes into the open market and borrows it and pays interest for the use of its own money, it occurs to me that that is going too far…. [I]t is absolutely wrong for the Government to issue interest-bearing obligations…. It is absolutely unnecessary.”

But that is the system that we have. Deficits don’t matter in this scheme, but the interest does. If we want to keep the interest tab very low, we need to follow the Japanese and borrow the money from ourselves through our own government-owned banks, essentially interest-free. “The full faith and credit of the United States” needs to be recognized and dispensed as a public utility.

Back in 2009 I wrote this post on state-owned banks.

My friend sent me a link to this article by Ellen Brown wherein she outlines how states can remedy their insolvency crises by chartering state-owned banks.  She cites the example of cash-rich North Dakota, which has had a state-owned bank since 1919, explains how it works, and then examines the bigger picture.

Some experts insist that we must tighten our belts and start saving again, in order to rebuild the “capital” necessary for functioning markets; but our markets actually functioned quite well so long as the credit system was working. We have the same real assets (raw materials, oil, technical knowledge, productive capacity, labor force, etc.) that we had before the crisis began. Our workers and factories are sitting idle because the private credit system has failed. A system of public credit could put them back to work again. The notion that “money” is something that has to be “saved” before it can be “borrowed” misconstrues the nature of money and credit. Credit is merely a legal agreement, a “monetization” of future proceeds, a promise to pay later from the fruits of the advance.

Furthermore, money that is now paid to Wall Street and private financial institutions in the form of interest goes right back to the state, rather than bonuses, perks and gargantuan salaries of those “irreplaceable” CEOs. Even better, the state would not be at the mercy of private financial institutions when it comes to interest rates either. The state bank can charge whatever rate it wants, allowing for very low cost financing of especially worthy projects.

I’m not seeing the down side of this.  It would certainly help here in Nevada.

Or for our country either.

On a personal note, I’m off to southern California for a week to attend the ACHA conference, spend some time with my parents, and take another trip to Disneyland with daughter. Posting may be lighter than usual. Sweetie is holding down the fort at home. Have I mentioned what a great guy he is?

PS – It appears I put my seedlings in the ground too soon, and with the exception of the green beans, the snow peas, and perhaps the carrots, I will likely need to do start a new set of seeds when I get back. Hey, live and learn, right?

It’s not like it’s a vital organ or anything

This is just infuriating. First of all, wouldn’t you like to know  that the cath lab (and the persons operating it) where you got your angiogram, or your pacemaker or your stents passed a minimal certification?  Wouldn’t you want to know that the work being done on you was completely necessary? That’s what I thought. And so does the Society for Cardiovascular Angiography and Interventions as well as the Maryland chapter of the American College of Cardiology.

Barring that, it would seem at least prudent and cost efficient to at least study the possibility of maybe, perhaps requiring cath lab certification.

Nope. Not in Maryland. (HeartWire)

Maryland house nixes cath lab oversight plan

April 12, 2011 | Reed Miller

Annapolis, MD – At the eleventh hour before the end of its spring session, Maryland state legislature elected not to require the formation of a study group to evaluate the merits of requiring the state’s PCI programs to be accredited.

As reported by heartwire, the Society for Cardiovascular Angiography and Interventions (SCAI) and the Maryland chapter of the American College of Cardiology (ACC) lobbied both the Maryland House and Senate to pass the Maryland Cardiovascular Patient Safety Act, which included several measures intended to improve oversight of cath labs in the state and prevent centers or physicians from performing inappropriate PCIs to increase revenue.

Last week, when it became apparent that the bill that included a mandate for cath-lab certification would not pass the Maryland House, the sponsors withdrew the bill, while the act’s supporters in the Senate attached amendments to House Bill 1182 to require the Maryland Health Care Commission (MHCC) to create a multidisciplinary working group that would study the possibility of requiring cath-lab accreditation in the future.

Like I said, the least they could do. At least investigate the possibility fercrissake. 

The Senate passed its version of the bill with those amendments, but late April 11, the last day of the legislative session, the Maryland House voted behind closed-doors not to “concur” with those amendments, according to president-elect of the Maryland chapter of the ACC, Dr Mark Turco (Washington Adventist Hospital, Takoma Park, MD) . The Senate then agreed to pass the bill without the amendments, so the bill will now go to the governor without the provisions for a study group. The ACC and SCAI have not found out which members of the House killed the amendments.

Maryland doesn’t have an Open Meeting law? Seriously? How can they do this?

“It’s like watching your favorite team go up a run in the top of the ninth inning but then lose the game in the bottom of the ninth with a walk-off home run,” Turco told heartwire. Turco said he was especially “saddened by the amount of external influence in the legislative process” but hopes that physician societies, hospitals, and legislators both in Maryland and around the country “can move forward as a united body, keeping patients as our number-one priority.”

However, the MHCC may still decide to study ways to improve data coordination and oversight of cath labs in Maryland, Turco said. The chair of the Senate finance committee, Sen Mac Middleton (D-Charles County), has offered to write a letter to the MHCC commissioner in support of forming a study group to investigate how Maryland can more efficiently collect outcomes, cost, and safety data from cath labs, improve the peer-review process, and possibly implement accreditation requirements for PCI programs.

ACHD – Adult Congenital Heart Defect – the gift that keeps on giving

I almost unsubscribed to HeartWire, and then I got today’s email. Regular readers know of my cardiac history, so this was quite an interesting read for me.  The article mentions ACHA (Adult Congenital Heart Association) and I am actually going to be attending their annual conference at the end of this month. I’m really looking forward to it.

This is a long article, and it does require registration to read it, but if you or someone you know is affected by a congenital heart defect, this is a very informative read.

Lost in transition: The looming epidemic of grown-up congenital heart disease (April 12, 2011 | Lisa Nainggolan)

 . . . Congenital HD is the most common congenital disorder in newborns, affecting almost 1% of infants worldwide. In countries where children have access to cardiac surgery, 90% of those affected now survive to adulthood. But although many of these patients will continue to suffer complications—heart failure and arrhythmias being the most common—most of them stop having annual cardiac checkups when they reach 18. In most countries, this is the time when they would transition to adult care but, for numerous reasons, the majority simply stops attending the clinic; when they do see a doctor, it is likely to be a primary-care practitioner who knows next to nothing about congenital heart disease.

[ . . . ]

Dr Barbara Mulder (Academic Medical Center, Amsterdam, the Netherlands), another leading light in the adult congenital HD (ACHD) movement, concurs. “In the early days of surgery, physicians thought patients were cured. It was never expected that adults would have so many residual defects and that they would develop new problems and have long-term complications,” she explains.

Now Gatzoulis, Mulder, and other thought leaders in the field, along with patient advocacy groups [1,2,3] and national organizations, are stressing the importance of treating congenital heart disease as a lifelong illness. Crucial to this aim is the successful transitioning of these children—beginning in adolescence or even earlier—from pediatric care into the hands of specialists in ACHD. Over half (55%) of affected patients will require long-term care under an ACHD specialist, while the remainder should at least be seen by a regular cardiologist. And the latter should still be assessed at least once in a tertiary ACHD center, to reassure the patient and family and to decide on a path of care, say Gatzoulis and Mulder.

[ . . . ]

But, as ever, funding and staffing issues are a huge problem. Even in the countries that perform best in the world for taking care of adults with congenital heart disease, there is a big shortage of medical staff specially trained in this field and a struggle to find enough resources to treat these patients properly. The Netherlands currently leads the way in the care of adults with congenital HD, while the UK, Canada, and some other European countries perform reasonably well. The US, by contrast, lags behind for numerous reasons.

Before surgery for congenital heart disease became the norm in industrialized countries, only around 40% of children born with congenital HD survived, and even just 15 to 20 years ago, survival was, depending on complexity of disease, in the range of 70%. Now almost all children survive in developed countries, and this represents a huge future burden of care.

“This is a looming epidemic,” says Dr Peter Varga (University of Chicago, IL), who works in a mid-sized ACHD unit in Chicago. “In the US alone, there are a million adults living with congenital heart disease, and they have now exceeded the number of children with congenital HD. But existing resources come nowhere near to catering for the vast majority of these adult patients, which means that 90% are either receiving no care or receiving care in a very haphazard way in clinics or primary-care offices that are woefully unfamiliar with these very complex issues.”

[ . . . ]

Also key to the disparities between these two North American countries is the nature of funding for healthcare in each place, says Webb. “In the US, business considerations drive everything, and ACHD is near the bottom of the business ladder for cardiology. Things are more organized in Canada. Cardiologists there are more likely to encourage their patients to be followed at adult clinics, whereas American cardiologists will typically be reluctant to allow an ACHD clinic to see their patients—again, business considerations.”

In the US, business considerations drive everything, and ACHD is near the bottom of the business ladder for cardiology.

And Varga explains how the insurance-based healthcare system in the US creates yet another major barrier to the care of adults with congenital HD. “Children here are generally covered up to age 18, either by private or governmental insurance programs, although we do have some pediatric patients who are underinsured or have a hard time availing themselves of care.” But then, at age 18, “All of a sudden they are out the door and they have absolutely nowhere to go: transition time. This has a major impact and is one of the reasons why 90% of the adult congenital HD population falls through the cracks: the fear of not being adequately covered and the reality of not being adequately covered. There are many factors that play a role in this issue, but there is no doubt that insurance is a major one.”

Varga says that patient advocates are working hard to focus attention on this issue, in particular the ACHA. “There is a congressional proposal slowly percolating through the House of Representatives to dedicate resources and attention to adult congenital HD because of the growing impact on the healthcare system in general, but that’s going to take a few years.”

He is cautiously optimistic that healthcare reform may come to the rescue beforehand: “I’m hoping the limited healthcare reform that has been passed in the US is going to have a major impact, because it has a provision about not precluding insurability based on existing disease. And of course all of these people, by definition, fall into this category.

“Ultimately everything boils down to money,” Varga adds. “If Congress dedicated funds to support this effort, I think it would have teeth, it could make an impact. The population of a million adults in the US is growing, because survival is almost approaching 100% into adulthood, and most of these folks are gainfully employed and have a reasonable quality of life, by their own assessment. So outwardly, they are no different than you and me, even with complex heart disease.”

Much, much more at the link.

Advil Queen No More

I just tossed the bottle in my purse. I’ve been hearing rumblings of this for a while, but this latest meta-analysis has given me pause.

The authors performed a meta-analysis of randomised trials of NSAIDs with at least 100 person years of follow-up in the studied arms. They used a potentially powerful technique known as network meta-analysis,10 which, when certain assumptions are met, can extract more information from the available data than traditional methods. For example, the analysis was able to compare etoricoxib versus placebo despite there being no large placebo controlled trials. This is because etoricoxib has been compared with diclofenac, which in turn has been compared with both rofecoxib and celecoxib, which themselves have been compared with placebo. From this chain of direct comparisons, the effect of etoricoxib relative to placebo is estimated through an indirect comparison.

This example illustrates both the strengths and weaknesses of network meta-analysis. It uses all of the data, but certain assumptions about homogeneity are necessary for valid estimates of indirect comparisons. Although in theory these assumptions can be checked and uncertainty incorporated into the estimates, this may be difficult in practice with a limited number of comparisons. The usefulness of this technique is limited for NSAIDs because too few adequately powered clinical trials exist. For this reason, the estimates from the meta-analysis that primarily rely on indirect comparisons—such as those for the comparison of etoricoxib with placebo—should be interpreted with caution.

What does this all mean when prescribing NSAIDs for patients at high risk of cardiovascular disease? Current data suggest that selective cyclo-oxygenase-2 inhibitors, particularly in higher doses, should be avoided. With regard to traditional NSAIDs, the most extensive data are available for diclofenac, ibuprofen, and naproxen. Meta-analyses of clinical trials and observational studies have found greater cardiovascular risk for diclofenac,78 which suggests that it should be avoided in high risk patients. Ibuprofen may attenuate the antiplatelet effects of aspirin, an important consideration in patients with a high risk of cardiovascular disease.11 In contrast, currently available evidence indicates that naproxen has the best cardiovascular safety. Although the ongoing PRECISION (Prospective Randomised Evaluation of Celecoxib Integrated Safety versus Ibuprofen Or Naproxen) trial will eventually provide more information on the relative cardiovascular safety of naproxen, celecoxib, and ibuprofen, until these results become available, naproxen seems to be the best choice with regard to cardiovascular safety.

My cardiologist has recommended that I take a small daily dose of aspirin specifically for its antiplatelet effect. Given my arrhytmias and cardiac history, I understand that I am at greater risk of stroke, therefore the prophylactic aspirin seems a reasonable precaution. It would be silly to negate that with ibuprofen, wouldn’t it?

I’d rather err on the side of caution and stick to aspirin.

Dodged a bullet? UPDATE

I was prescribed this back when my pacemaker went in, but I had such a bad reaction to it, I stopped after three doses. After a lot of research, I realized that I made a very good choice to stop taking it. First of all I wasn’t comfortable with what I read about the research. Second, I don’t have, and never have had, atrial fibrillation.  I should never have been considered a candidate.

Sanofi-Aventis To Inform Doctors About Liver Transplants in 2 Patients Taking Multaq (Dronedarone)

Sanofi-Aventis is about to send a “Dear Doctor” letter to physicians informing them of two cases of fulminant hepatic failure/necrosis resulting in liver transplanation in two patients taking Multaq (dronedarone), CardioBrief has learned. The two patients were women in their 70′s with no other apparent causes of liver injury or known elevations of liver function tests (LFTs) prior to the acute liver failure. Liver failure developed after the women were taking dronedarone for four to six months.

Wow…

The FDA originally rejected Multaq in 2006, but then approved it in July 2009.

UPDATE: The FDA has issued a safety communication regarding liver damage associated with Multaq. Honestly, the closer you look, the worse it seems to get. It would be nice if this means the drug gets pulled, but it doesn’t appear to be the recommendation at this point.  From the link above Larry Husten quotes Steve Nissen:

Steve Nissen provided the following comment to CardioExchange about Multaq:

I have significant concerns about the safety, efficacy and tolerability of dronedarone.  Although liver toxicity was not anticipated, other safety issues have been apparent even prior to launch. The increased risk of death in heart failure patients represented a particularly concerning finding in pre-approval studies.  The drug is substantially less efficacious compared with amiodarone and the GI tolerability is poor. Despite these warning signs, the drug has been aggressively promoted, often through industry-sponsored CME offered by professional medical societies. Over-promotion of a risky drug during its initial launch period has been a historically important harbinger of serious safety concerns. Dronedarone may be headed for trouble.

Worried

For a couple of reasons.

1. That my previous post will make me appear to be a heartless monster.
2. Cardiac episode last night at 6 p.m. – calling doctor this morning.

I guess #2 proves I do have a heart.

And I hope the content of this blog does as well.