Presidential Pathology

In honor of election season, let’s review some pearls and boards material surrounding our nation’s presidents!

Woodrow Wilson – Influenza, Stroke

1918: There is some suspicion that President Wilson caught the famous virus from the 1918 flu pandemic. He later suffered a TIA and a massive stroke (L hemiplegia) – his staff hid the severity of his stroke while his wife supervised his duties.

Influenza:

·      Antigenic drift = small mutations that create different seasonal flus

·      Antigenic shift = switches species

·      Tamiflu = all hospitalized & high risk patients ASAP, low risk patients within 48hrs

o   Tamiflu debate, click here

Stroke:

·      Highest risk of stroke after TIA = 48hrs

·      Blood pressure goals:

o   Ischemic stroke, TPA eligible = Keep below 185/110

o   Ischemic stroke, no TPA = 220/120

·      TPA to be given within 4.5 hours

FDR – Polio

1933-1945: Photographers avoided taking pictures of FDR while he was in his wheelchair as it was viewed as a sign of weakness. Photos of him were deliberately taken only while the president was in a car or behind a desk.

Polio

·      The WHO anticipated eradicating polio from the planet by 2023. However, President Trump’s withdrawal from the organization had led to a severe decrease in funding and that may need to be reconsidered. Check out this clip from Sunday’s Last Week Tonight With John Oliver to learn more.

Eisenhower – MI, Crohn’s Disease

1955: He stayed in Fitzsimons Army Hospital in Colorado for 7 weeks after his heart attack, but I couldn’t find how they treated it. Just a few months later, six months prior to his next election, he was diagnosed with Crohn’s Disease and required surgery. He went on to win the election.

MI: Lysis vs Cath

·      Lysis if PCI cannot be performed in the “appropriate timeframes” below

·      PCI timeframes:

o   AMI within 2hrs = PCI in 60 minutes

o   AMI within 2-3hrs = PCI in 60-120 minutes

o   AMI within 3-12hrs = PCI in 120 minutes

Crohn’s Disease

·      Typically 2nd/3rd decade of life, male, hx of IBD in the family

·      Any part of the digestive tract from mouth to anus

·      Skip lesions

·      Full thickness inflammation (unlike UC = epithelial layer only)

Jed Bartlet – Multiple Sclerosis

2000: Widely acclaimed as the greatest president of our time, the Bartlet Whitehouse was rocked by scandal and outrage when it was revealed that the president and members of his administration had willfully omitted knowledge of the president’s devastating demyelinating disease. Despite the controversy, Americans saw past this lapse of judgement and reelected President Bartlet for a second term.

MS

·      Autoimmune, more in females, connected to psoriasis and thyroid disease

·      Internuclear ophthalmoplegia = difficulty adducting eye = pathognomonic

·      LP = Oligoclonal bands & IgG in the CSF

·      MRI = optic nerve lesions, juxtacortical lesions, and Dawson Fingers

·      Steroids for flares (inpt or outpt)

George W. Bush – Colonoscopy

2002, 2007: Colonoscopies aren’t that interesting but Bush did, indeed, hand over the power of the presidency to Dick Cheney on two occasions, each lasting just over 2hrs while he had routine colonoscopies.

Colonoscopy

·      Q10yrs, starting at age 50 (unless family hx, familial adenomatous polyposis, etc.)

·      Complications:

o   Pyogenic liver abscess

o   Infection

o   Bleeding (post-polypectomy, 1 week after procedure)

o   Perforation

o   Post-polypectomy syndrome: peritonitis without perforation after a transmural burn in the colon

Kennedy – Addison’s Disease

1961-1963: It looks like JFK suffered from quite a number of medical problems: chronic back pain, colitis, UTI, abscess, possibly malaria, and apparently was on a brief course of antipsychotics after a change in mood when he started some antihistamines. The most famous of these maladies was his Addison’s Disease, for which he was on daily steroids.

Interestingly, Kennedy was wearing his back brace on the day he was assassinated, which kept his posture fully upright in the limousine prior to getting shot.

Addison’s Disease:

·      Chronic adrenal insufficiency, autoimmune – patient’s on chronic steroids

·      Hyperpigmentation

·      Must be distinguished from acute adrenal insufficiency:

o   Look for hyponatremia and hyperkalemia (low aldosterone)

o   Hypoglycemia

o   Refractory hypotension

o   Hydrocortisone 100mg IV

REFERENCES:

https://www.cnn.com/2020/10/07/health/us-presidents-health-problems-wellness/index.html

https://www.healthline.com/health/diseases-of-presidents

https://www.ahajournals.org/doi/10.1161/STR.0000000000000211

https://text-message.blogs.archives.gov/2016/09/22/heart-attack-strikes-ike-president-eisenhowers-1955-medical-emergency-in-colorado/

http://www.emdocs.net/multiple-sclerosis-ed-pearls-pitfalls/

https://www.businessinsider.com/25th-amendment-colon-trump-reagan-bush-unfit-president-2017-10

http://www.emdocs.net/post-colonoscopy-complications/

peerix.acep.org

"Six Feet"

Six feet.

I’ve said it. You’ve said it. Fauci has said it. But why are we saying it?

Doesn’t that seem a bit… I don’t know, arbitrary? Random? Other synonyms?

Did you know that the World Health Organization actually recommends one meter?

Can’t germs travel seven feet? Or ten? What about the butterfly effect – if a butterfly sneezes in Taiwan, can’t it infect someone in Madagascar? (Something like that.)

Where did this number come from… (ominous ellipses)

Back in 1942, someone took a “high-speed camera” and photographed respiratory droplets to see if they could travel six feet. They found that most of the droplets fell within 3 feet, which became the party line for social distancing for decades. That’s right – we based social distancing on images from a 1940s camera that photographed spittle drops. 3 feet.

To try and further suss it out, a few bold (?crazy) scientists in the UK opened up the Common Cold Research Unit in 1946. They offered volunteers a 10-day getaway in Salisbury, UK, under one condition… volunteers agreed to be inoculated with the common cold. They suggested in 1947 that the safest distance was 30 feet, though the podcast referenced later here suggests 3ft for large droplets (again). Check out this original publication:

https://journals.sagepub.com/doi/pdf/10.1177/003591574704001104

And a video of their unit from the 50s: https://www.youtube.com/watch?v=SJfBU_MUpI0&feature=emb_logo

In the 1980s through the 2000s, more data (from studies and other outbreaks) came out to suggest not one, but two meters would likely be more effective. So that's where we've stayed...

Fast forward to this year, a systematic review that respiratory droplets often went farther than two meters – like, much farther. Like, 8 meters.

Not only that, but some suggest COVID stays in the air for 16hours! (Though the prevalence and infectivity of these particles is debatable.)

Lots of factors can increase the distance of droplet/particle transmission and it seems that 6 feet may be a bit of an outdated blanket statement. Consider maintaining as much distance as reasonably attainable in your various social situations. Wash your hands, wear a mask, and wear eye protection.

For all you auditory learners, check out this 20min podcast by Radiolab: https://www.wnycstudios.org/podcasts/radiolab/articles/dispatch-4-six-feet

For all you visual learners, below are some fascinating shots of simulated “violent respiratory events” with and without masks, from AIP Physics of Fluids.

(For all you kinesthetic learners, just wear a mask.) 

References:

WHO: who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-publi

CEBM: https://www.cebm.net/covid-19/what-is-the-evidence-to-support-the-2-metre-social-distancing-rule-to-reduce-covid-19-transmission/

Visualizing the Effectiveness of Face Masks in Obstructing Respiratoory Jets: https://aip.scitation.org/doi/10.1063/5.0016018

Radiolab: https://www.wnycstudios.org/podcasts/radiolab/articles/dispatch-4-six-feet

Other references embedded in the the above email

POTD: TPA in PE

POTD: TPA in PE

• Massive PE can lead to hemodynamic instability and death

• Smaller but clinically significant PEs can lead to pulmonary hypertension, RV dysfunction and subsequently poor quality of life (decreased exercise tolerance and even dyspnea at rest)

• TPA in PE is surrounded by controversy with various opinions on the matter

AHA:

• Massive: hemodynamic instability defined as SBP<90 (or 40 point drop from baseline) for >15 minutes=

• Thrombolysis indicated unless there are contraindications

• Sub-massive: hemodynamically stable but with signs of RV strain (elevated troponin/BNP, echo findings of RV dysfunction) = Thrombolysis may be considered (level IIb/C)

ACEP:

• Hemodynamically unstable patients: Thrombolysis indicated if benefits outweigh risks of bleeding

• Level B recommendation

• Hemodynamically stable patients: insufficient evidence to do thrombolysis

MOPETT (Moderate Pulmonary Embolism Treated with Thrombolysis):

If

• Symptomatic moderate defined as ≥2 signs/symptoms (7 total in inclusion criteria) in addition to CTPA involvement of >70% involvement of thrombus in ≥2 lobar, or left or right main pulmonary arteries

• Ventilation/perfusion scan showing mismatch in ≥2 lobes

• SBP<95 excluded

Then

• enoxaparin/heparin only vs enoxaparin/heparin + half dose tPA (10mg bolus then 40mg over 2 hours)

• primary end point: pulmonary HTN at 28 months

• rates in treatment group=16%, control group=57%

• combined end point: pulmonary HTN at 28 months + recurrent PE

• treatment group=16%, control group=63%

• no patients in either group bled

Conclusion:

• Studies suggest that half-dose thrombolysis is safe/effective in the treatment of moderate PE, with a significant immediate reduction in pulmonary artery pressure that was maintained at 28 months

• ”Thrombolytics have demonstrated faster improvements in RV function and pulmonary perfusion, but these benefits have not translated to improvements in mortality.”

• So the measured outcome is of questionable significance as opposed to actual measurements of quality-of-life

• Perhaps consider in your young patient in whom potential improvement in exercise tolerance in remaining lifetime may be more relevant than in older, immobile patients

Stay well,

TR Adam