Peter G. Tuteur

Transient Right but Not Left Ventricular Dysfunction After Strenuous Exercise at High Altitude

OBJECTIVES We sought to evaluate whether prolonged exercise in ultramarathon runners results in left ventricular (LV) damage. BACKGROUND Strenuous exercise has been reported to cause LV damage. METHODS Fourteen runners who completed an ultramarathon at high altitude underwent echocardiography, finger-tip oximetry and blood measurements of cardiac troponin I (cTnI) and creatine kinase, MB fraction (CK-MB) levels before, immediately after and 1 day after the race. RESULTS At baseline, the echocardiograms showed normal LV and right ventricular (RV) size and function in all subjects, as well as mild tricuspid regurgitation in nine subjects, with normal estimated pulmonary artery systolic pressure (mean 28 mm Hg). At baseline, all oxymetric readings and CK-MB measurements were normal, and cTnI was undetectable. Immediately after the race, the echocardiograms showed the expected augmentation of global and segmental LV function in all subjects. Although the RV was normal in nine subjects, five developed marked RV dilation and hypokinesia, paradoxic septal motion, pulmonary hypertension and wheezing. CK-MB values were elevated in all subjects. In all but one subject cTnI was undetectable. In that subject there was a small elevation in cTnI accompanied by severe RV dysfunction and pulmonary hypertension. At the 1-day follow-up study, the echocardiographic measurements had normalized in all subjects. CONCLUSIONS In trained athletes, strenuous exercise at high altitude did not result in LV damage. However, wheezing, reversible pulmonary hypertension and RV dysfunction occurred in a third of those completing the race. The incidence and pathogenesis of these findings remain to be determined.

Strategies for improving and expanding the application of health status measures in clinical settings: General audience discussion

imprecise, because whether a physician says the tumor is the size of a peanut or a lemon or a grapefruit is usually based on some external examination, and it [the description] is sometimes tantamount to a guess. Now, a physician may see the tumor on surgery and actually measure its size, but that is not usually the way tumor size is measured when the physician is monitoring the patients progress and tracking the progression of a disease. So there is a lot of acceptance of measures that are relatively imprecise but are, in fact, quite useful. I would further contend that the physician, even one who does not know every-

Searching Eyes: Privacy, the State, and Disease Surveillance in America (review)

Perspectives in Biology and Medicine economy and to fairness (equity), along with long-term environmental security. Brown emphasizes sustainable development: better living with less impact for the indefinite future. If you have always been a skeptic about environmental concerns such as global warming, this book will challenge your beliefs with facts. (You may already be aware that the business community, governments of industrialized nations other than the United States, and many U.S. municipal governments and corporations are currently revamping their energy policies and planning toward the mitigation of global warming with the expectation of coming out ahead financially.) If you are green to the core, here is fresh ammunition and inspiration. If you are undecided and open-minded, or just don’t know how to broach this vast topic, there can be no better guide than Lester Brown. Not through rhetoric, hyperbole, ideology, inspirational messages, or attacks on detractors, but rather, through an avalanche of facts, concepts and insights. Little idealism; much realism; urgent optimism. The subtext to this book seems to say: our forebears worked hard to give us material well-being.Our generation must similarly work hard to create and hand down environmental sustainability. To promote his clarion call, the Earth Policy Institute (of which Brown is president) andW.W. Norton offer this book at an impressively low price. (And, of course, it is printed on recycled paper.)The charge is further reduced for bulk purchases. Furthermore, the book can be downloaded, chapter by chapter and free of charge, from the Institute website: http://www.earth-policy.org/Books/ PB3/

Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (review)

“Producing good doctors is a responsibility shared between society and medical [school] faculties.” From this starting point, author Kenneth Ludmerer carefully, critically, and fairly leads the reader through a century of American medical education. He stresses how medical education was influenced by society’s volatile relationship with its doctors, medical school faculties, teaching hospitals, and—more recently—the academic health centers. In a beautifully written narrative, Ludmerer depicts how the changing intensity of acceptance of this covenant, both by medical school leaders and by society, was influenced by multiple forces: the intellectual revolution championed by Flexner as the century began, the advancement of quality research and its generous public funding, and the augmented role medical professors accepted for the direct and indirect provision of clinical care. For me, a senior faculty member, this history is an insightful “déjà vu all over again.”1 For junior colleagues, it is perspective developing. For our students, it is a mustread: it nourishes professional identification and develops an understanding of the past leading to acquisition of the tools of leadership. As Ludmerer guides us through an interpretative history of this century’s American medical education, he prepares the reader well for the last two and most challenging chapters. They could have been entitled “You Are Here” and “Now Be a Leader.” Nevertheless, the more formal appellations disguise neither his meaning, nor his spirit. He presents his argument in a scholarly, thoughtful, and sensitive manner. The author’s approach is illustrated by the open, well-documented, and free-flowing discussion of how, in the last two decades, academic health centers under stress have dealt with the process of student admissions. In an almost tongue-in-cheek fashion, Ludmerer documents, with annotated references, how some insightful faculty members recognized that “medicine’s popularity during the Viet Nam war . . . related primarily to the changing attractiveness of other careers rather than to the perceptions college students held about medicine.” He traces how the annual number of medical school applicants changed over time in a manner parallel to the perception of future financial remuneration. He speaks of admission committees’ dilemma of which qualified applicants to accept, how much weight to place on GPAs and MCAT scores, and whether it was proper to attempt to select from “two

Review of Problem Solving in Clinical Medicine

Excerpt To the editor: In his recent review of Paul Culters text,Problem Solving in Clinical Medicine(1), Dr. Barondess (2) seems to have missed the point. Cutler expands the implications of the b...