The Mighty Have Fallen

Crusading televangelist and father of the Christian Right, Jerry Falwell, has passed away.

CNN is reporting that Falwell was found unresponsive in his Liberty University office and despite aggressive resuscitative measures, could not be revived.

Falwell founded the Moral Majority in 1979 and is a nationally known voice for conservative Christian views.

The Associated Press reported that Dr. Carl Moore, Falwell's physician, said the evangelist had a heart rhythm abnormality. Most likely, this is atrial fibrillation for which Falwell probably took a blood thinner, i.e. warfarin (Coumadin).

While this may not have helped things, a-fib was almost certainly not the cause of death. Much more likely was the pastor’s history of coronary disease for which he had a stent placed in 2005.
When someone dies suddenly it is typically classified as a sudden cardiac death (SCD) and SCDs are usually the result of a very fast and unstable heart rhythm like ventricular tachycardia (VT) or ventricular fibrillation (VF).

Larry King Recovers from Cartoid Surgery

When it rains, it pours. And this week it was pouring 70-something talk show hosts with serious vascular issues. First Regis and now Larry King. Charles Grodin and Charlie Rose better pack a bag.

While Reege is hopefully thinking about discharge, the 73 yo King is fresh out of a carotid endarterectomy (CEA) and his camp says he'll be back by Monday to interview Sen. Barack Hussein Obama (that name is like a SNL joke - he couldn't have worse luck if his name was Stalin Bitler).

Larry King is no stranger to vasculopathy and has a history of 4-vessel CABG way back in 1987. Which also implies that he has probably had subsequent cardiac caths to open of some grafts or possibly even an ancient native vessel. King's propensity for vascular disease makes one wonder what risk factors he wields.

It is very likely he is hypertensive and most certainly takes a statin for high cholesterol. Is he diabetic, too? Probably not - all those years of poorly controlled blood pressure, cigarettes, drugs?, and booze is most certainly enough to give you the old coronary-carotid double feature.

Prior to surgery King definitely had a carotid ultrasound to assess the degree of stenosis. The question is, did symptoms prompt this vascular study or was it a smart doc who knew the talk show host's propensity for vascular atherosclerosis? Either way, he had enough of a lesion to dictate that medical therapy, compared with surgical revascularization, would be more likely to result in a stroke or even death.

What about his outcome? Well, all of the following characteristics have been associated with an increased risk of poor outcome (stroke, myocardial infarction, or death) at 30 days after CEA:

• Age 80 or older
• Severe heart disease
• Severe pulmonary dysfunction
• Renal insufficiency or failure
• Stroke as the indication for endarterectomy
• Anatomical issues including limited surgical access, prior cervical irradiation, prior ipsilateral CEA, and contralateral carotid occlusion

Surgical Methods

Carotid endarterectomy (CEA) is most often done through a neck incision either bordering the sternocleidomastoid muscle, or more esthetically, with a horizontal incision in a skin crease at the level of carotid bulb. Either way, the scar will be small and discrete enough to be covered by a good layer of pancake, so don't expect to see it on Monday unless King wants you to.

The underlying platysma (muscle) and sub-Q tissues are dissected and the carotid artery is isolated, from the common carotid to well beyond the bifurcation of its internal and external branches. After proximal and distal control of the artery is obtained, the patient is given anticoagulated. The internal, common, and external arteries are then clamped sequentially and a the artery is opened at the level of the bifurcation and extended proximally and distally. Some surgeons use a cerebral shunt which is inserted at this time.

The carotid plaque, consistently found at the carotid bifurcation and the origin of the internal carotid artery, is dissected out and removed through a dissection plane developed between the media and intima. Surgeons take great pains to create a smoothly tapered transition between the endarterectomized portion of the artery and its normal distal extent. This maneuver avoids intimal flaps which might lead to arterial dissection after flow is reestablished or perhaps become a nidus for platelet adhesion and thrombogenesis.

After careful inspection of the now clot-free surface, special attention is directed at repair. Some surgeons choose to repair primarily, while others patch the artery with saphenous vein or prosthetic material such as Dacron or polytetrafluoroethylene (PTFE).

Before the artery is closed, the internal carotid artery (ICA) is unclamped distally and flushed free of debris in a retrograde fashion. This vessel is then reclamped and the common and external arteries are opened. This way, all the left over aretreial "gunk" is jettisoned via the external carotid artery prior to restarting antegrade flow, i.e. that blood which goes to the brain. This technique is based on prior experience showing that patients were coming out of surgery with new neurologic events despite the best efforts of the surgeons to remove all the plaque adhered to the wall of the artery. [Interestingly, when carotid stenoses are done percuatneously, i.e. by catheter, interventionalists use a distal occlusion device to prevent embolic events. However, the interventional community is having a tough time showing benefit, or even equivalence to CEA.]

Once hemostasis is achieved, a Jackson Pratt drain is left in the wound to minimize neck hematomas and the muscle and skin are closed. when King was waking from his anesthesia, a neuro check was performed and repeated probably every 10 mins for the first hour and then every hour during recovery to make sure the talking head wasn't slurring as a result of the arterial manipulation.

Below is a sweet slide presentation we found that provides a step-by-step approach to carotid surgery.

http://www.pvss.org/Cases/CartEnd/car3.htm

Deep Chene Thrombosis

Add another item to Dick Cheney's long list of medical issues. In addition to his 4 heart attacks (first being at a sprite 37 yrs of age), 2 bypass surgeries, multiple coronary interventions, popliteal aneurysms, ischemic cardiomyopathy, and subsequent implantation of a cardiac defibrillator - the vasculopath has staved off death yet again.

The cat-like veep has amazing luck or a ridiculously attentive medical staff. Following an around-the-world trip which included more than 60 hrs of air travel, Cheney complained of slight calf pain which elucidated the DVT.

Cheney visited his doc at George Washington University hospital and a duplex revealed the clot, prompting his MD to start him on warfarin. In a statement today, Mr. Cheney’s office said he would be treated with “blood thinning medication for several months.”

We can only assume that Cheney is already on standard anti-platelet therapy, aspirin and Plavix, considering his multiple stent history. Throw in some warfarin for this latest diagnosis and his blood will be "thinner" than Nicole Richie. Speaking of "thin blood", why do we use this euphemism and who came up with it? The blood's viscosity does not change at all. Is it really that hard to explain or understand that platelets help clots to form and these medications prevent the bonding of platelets to each other? It is due time that the media and PR flack start speaking of medical treatments in real terms rather than 3rd grade metaphors. If advertisors can advertise directly to consumers than consumers should understand medical terminology rather than psedo-scientific analogies.

Back to Cheney's hard-to-believe medical history, Dr. Cameron Akbari, a senior vascular surgeon at Washington Hospital Center in the District of Columbia, said Mr. Cheney’s history of heart disease puts him at only “a very slightly increased risk” of developing a deep venous thrombosis.

“Reasons No. 1, 2, 3, 4 and 5 why he developed this are he was on a very long plane ride,” Dr. Akbari said.

Ok. But why does he keep clotting every portion of his vascular bed. I am quite sure that Cheney has had the over-ordered hypercoagulable work-up, but he should also be tested for aspirin and clopidogrel resistance.

To clarify, it is unlikely that the clot lodged in Cheney's left leg is actually sitting in his calf. The vast majority of these thrombi sit in the larger, more proximal venous system. And lastly, Coumadin or Warfarin, will prevent further propagation of this clot but will not dissolve the clot - so the risk of PE is still there all you anti-Chenites.

One more interesting historical note: Warfarin was named in honor of the Wisconsin Alumni Research Foundation who discovered that coumarin, a byproduct of moldy silage, was a potent anticoagulant and the cause of bleeding cows. Warfarin was first registered for use as a rodenticide in the US in 1952, but its true mechanism of action, the inhibtion of vitamin K-dependent cofactors was not elucidated until 1978.

Hepatitis A Scare for Beyonce's Party

An unlucky employee of Wolfgang Puck Catering diagnosed with hepatitis A may have donated his virus to guests at several high-profile functions, including Sports Illustrated's swimsuit issue party attended by Beyonce Knowles and other pseudo-celebs, officials said.

The risk of illness was 'quite low,' but anyone who ate raw food at the magazine's Feb. 14 party was urged to receive a preventive shot by Wednesday, the LA County Department of Public Health said Tuesday.

The affected employee was placed on medical leave, said Carl Schuster, president of Wolfgang Puck Catering.

'We immediately worked to take every precaution to further safeguard our patrons and other employees,' Schuster said in a statement.

Sports Illustrated said in a statement that it was taking the situation very seriously and was working directly with county health authorities.

'We are alerting our guests and staff as quickly as possible to ensure they receive the relevant health warnings,' the statement said.

Hep A (HAV) is usually spread via the fecal-oral route, i.e. infected people share the yellowing virus through food and water that they handle – after touching their ass. It is more prevalent in low socioeconomic areas in which a lack of adequate sanitation and poor hygienic practices facilitate spread of the infection.

To get technical on your ass, (and for those of you prepping for Boards) Hepatitis A is a 27 nm, nonenveloped, icosahedral, positive-stranded RNA virus classified in the Heparnavirus genus of the Picornaviridae. But you knew that.

According to our favorite medical resource, UpToDate.com, community outbreaks due to contaminated water or food have also been described, shellfish being the most popular offender. However, several outbreaks related to consumption of “contaminated” green onions have been reported in the literature.

HAV infection usually results in an acute, self-limited illness and only rarely leads to fulminant hepatic failure.

The two most common physical examination findings are jaundice and hepatomegaly, which occur in 70% and 80% of symptomatic patients, respectively. Less common findings include splenomegaly, cervical lymphadenopathy, evanescent rash, arthritis, and, rarely, a leukocytoclastic vasculitis.

Laboratory findings in symptomatic patients are notable for marked elevations of LFTs (usually >1000 IU/dL), serum total and direct bili, and alk phos. Typically, ALT is higher than the AST and bilirubin levels above 10 mg/dL are not uncommon.

The diagnosis of acute HAV infection is made by the detection of anti-HAV antibodies in a patient with the typical clinical presentation. Serum IgM anti-HAV is the gold standard for the detection of acute illness.

Because the disease is usually self-limited, the treatment is supportive.

But believe us, it would be a lot more than supportive if one of the celebs turned yellow.

Top 5 Differential Diagnoses for Britney's Break

Despite the appearance of physical health - at least, until she shaved her head - Britney is not well. To enlighten our writers and readers we decided to enlist the help of an Ivy League-trained clincal psychologist for this special edition of Celebrity Illness. Enjoy.

1. Substance Abuse Disorder - Addiction. That’s right, you guessed it. Like we said about so many young celebs in this article: if it smells like drugs, and looks like drugs.... it’s drugs! Coke, Meth, Crack, X, Alcohol…whatever. That’s my call.

2. Borderline Personality with Psychotic Features - Altogether likely. Given the labile mood, strange and extreme behavior and chronic emptiness coupled and with pre-morbid narcissism, pattern of unstable relationships and shallow affect, BPD with psychotic features is definitely a contender for the diagnosis. It is almost a requirement for to be a Hollywood/performer type.

3. Psychotic Disorder NOS - Purely based on strange behavior and poor judgment, we don’t actually know if she has lost touch with reality (like hearing voices, seeing and/or smelling things, delusions). Unlikely since she is a bit old for a psychotic break..though still within the age range for women.

4. Postpartum Depression with Psychotic features - Britney did just have a child within the past six months so we can’t totally remove it from the differential; it is unlikely because this diagnosis is usually diagnosed within the first 6 weeks postpartum…and it is kind of like she doesn’t have any children at all…so what is she depressed about? Hormones.

5. Bipolar Disorder - High on the differential because it is so hot and hip these days with the famous set. Britney’s impulsive behavior..partying (i.e. self-medicating), flying all over the country, checking in and out of rehab within a day, hyper -sexuality, shopping, irritability. True bipolar will generally see an approx 3 months manic period followed by deep depressive period for approx 9 months. So, we could be in the downward spiral anytime.