Lynchburg Family Medicine

Ultra-endurance competitions are defined as events that exceed 6 h.1 These long and gruelling athletic endeavours to most of us are of herculean proportions. For example, ultra-distance running is defined as an activity covering distances greater than a marathon. These include events of 50 km to 100 miles and beyond. Last year in the USA, it was estimated that 10 000 individuals competed in ultra-distance events.2 So what is the problem with ultra-endurance athletes? The problem is that we, as healthcare providers, do not understand these athletes and they do not understand us. Frequently they come to our office seeking care and advice for an injury that occurred at mile 87 of a 100-mile event, our answer is “Do not do that again”. In doing so we fail to recognise that, specifically for ultra-endurance athletes, the mental fortitude and commitment to their sports is immense and that these athletes …

Every morning, I look forward to receiving a poem in my e-mail inbox from The Writer's Almanac with Garrison Keillor. Not too long ago, I received Alicia Suskin Ostriker's “The Surgeon.” I was not previously familiar with Ostriker, but I liked the poem so much that I purchased her collection of poems, The Book of Seventy (“Seventy” refers to the book's page length but, more important, also to the author's age). I later learned that the book won the National Jewish Book Award for Poetry in 2009. The poems in the collection explore themes of aging, sickness, love, and death. The first poem in the book, “Approaching Seventy,”1 offers the first of many dazzling metaphors: Sit and watch the memory disappear Romance disappear the probability Of new adventures disappear Well isn't it beautiful When the sun goes down Don't we all want to be where we can watch it Redden Sink to a spark disappear The wistful speaker in Ostriker's “The Surgeon” is also in the sunset of his life. Imagine a surgeon approaching seventy, a distinguished professor emeritus at State, with white hair or no hair, grandfatherly, leaning back in his chair, sipping on his second glass of wine, offering wisdom and soothing words to a surgical intern who has come to him for solace after a surgical mishap. It's late in the meal, a time for meaningful conversation, and a time when alcohol and good food bring down emotional guards. On the other hand, would the surgeon wait until the end of a meal to offer consolation to a distraught intern? That kind of serious conversation usually occurs without much preliminary chit-chat, and in the privacy of an office, not a restaurant. Perhaps his audience is the entire surgery class during orientation, sitting around a large table in a comfortable dining room or dark restaurant, listening intently to the surgeon, sipping glasses of wine. Early in the evening, the surgeon relates the satisfactions and joys of a career in surgery; then, words about the pain, the mistakes and the deaths they will inevitably experience. Then, he offers the unsettling, personal anecdote. Or maybe the surgeon never intends to share his personal story, but during the meal, he drifts away from the conversation of the group, slipping into reverie. He looks across the table and sees young, eager faces. Who knows? Maybe one of them is a young, red-headed woman! Then he recalls the red-headed woman on the operating table, the woman who made him shake like a car with a broken axle. The woman who looks like his sister. The momentary flashback wakes him, and he addresses the group. The fact is, we do not know where the conversation occurs, nor do we know to whom the surgeon is speaking. What we do know is that he has never forgotten the death of a young, red-headed woman. Even more puzzling is why he refers to the woman as “It,” as though he still cannot personalize the woman or the painful experience. As physicians we all have experiences that never really leave us. I remember pushing chemotherapy into the arm of a young woman with leukemia during my oncology rotation. The patient didn't look like my sister, she looked like me— a chilling reminder of my own vulnerability. I will never forget another patient who died shortly after I performed a routine paracentesis. I remember shaking inside and out, feeling and hearing the broken axle harshly pounding down the road to my heart. And what about Ostriker's surgeon's words—Did his mentor get it right? Do you literally have to fill a graveyard “before you know this business”? Or are these words an exaggeration, a metaphor meant to make young surgeons feel better about losing patients? Or words the mentor used to make himself feel better? Internists, of course, have their own ways to fill graveyards. Missed diagnoses. Dosing errors. The surgeon in this poem could just as easily have been an aging internist talking about unexpected deaths and tragic mistakes. Physicians who practice medicine long enough too often experience the feeling of unexpectedly losing a patient. Ostriker's remarkable poem articulates that feeling, brings it from the inside out onto the page, where it can be shared and offered as solace to those of us who were not present at the surgeon's dinner table. Dean Gianakos, MD

When hemodialysis first started in the United States in the 1960s, a large percentage of patients performed their treatments at home. However, because of reimbursement issues, home hemodialysis (HHD) gradually succumbed to an in-center approach and eventually a mindset. Since the introduction of nightly HHD by Uldall and Pierratos in 1993, there has been a resurgence of interest in HHD. This paper describes the different types of home hemodialysis being performed as of December 31, 2007 in this country. Because neither the United States Renal Data System (USRDS) nor the End Stage Renal Disease (ESRD) Networks break down home dialysis into the different modalities, a provider questionnaire was sent out to 2 major providers, a number of mid-level providers and other providers known to do HHD. In addition, a questionnaire was sent out to 3 machine providers to obtain the number of patients using their machine for HHD as of December 31, 2007. The results showed that 91.7% of patients are dialyzing in-center, 7.3% are doing peritoneal dialysis, and 0.7% are doing HHD. Currently about 1% of ESRD patients in the United States are doing home hemodialysis. NxStage, however, has started 1000 patients in the past year on short-daily home hemodialysis. Patients are beginning to understand that there are better options than 3 times a week in-center dialysis. And as a result of the "HEMO Study," nephrologists now believe that longer and more frequent dialysis is a better therapy for ESRD patients. Therefore, promotion of HHD should become a priority for the renal community in the future.

What constitutes adequate dialysis has been debated in the nephrology literature over the past eight years. The mortality rate of patients on dialysis in the United States is about 20% per year. We believed that short and infrequent dialysis sessions contributed to poor outcomes. To improve the results, Lynchburg Nephrology started the nightly home hemodialysis (NHHD) program in September 1997. Ten patients were trained in the first 15 months of the program. Patients dialyzed 7 - 9 hours, 6 nights/week, using the Fresenius 2008H machine. A standard dialysis solution with 2.0 mEq/L potassium, calcium concentration of 3.0 - 3.5 mEq/L was used. Dialysis solution flow rates were 200 - 300 mL/min. Serum phosphate levels were maintained above 2.5 mg/dL by adding 0 - 45 mL Fleet's Phosphosoda to the bicarbonate bath. Patients had marked improvement in quality of life as measured with the SF-36. Blood pressure was better controlled with fewer medications. All phosphate binders were eliminated. Caloric intake and protein intake increased to normal levels as measured by three-day dietary histories pre-NHHD, and at 3, 6, and 12 months on NHHD. Epoetin alfa dosages were reduced by about 50%. Nightly home hemodialysis should be considered as a valuable modality option for end-stage renal disease patients; it is potentially superior to conventional thrice-weekly hemodialysis.

Report of an 18-year-old black girl successfully treated for congenital dislocation of the hips and knees is presented. Progress from date of birth, methods of treatment, and results are given. It is concluded that the condition is unusual, that dysplasia and intrauterine forces are the cause, that early treatment gives excellent results without surgery, and that follow-up through the entire growth period is essential.

SERUM alkaline phosphatase activity was markedly elevated in a young man without an apparent underlying disorder. The unexpected finding of an elevated alkaline phosphatase level in the patient's father prompted an investigation of other family members.Subjects and MethodsA 15-year-old boy, 160 cm tall and weighing 41 kg, complained of abdominal pain. The results of physical examination and laboratory studies, including complete blood count, urinalysis and analysis of blood components, were normal, except for a serum alkaline phosphatase level greater than 1050 units per liter (normal, 30 to 85) (Bessey-Lowry-Brock method1).Subsequent evaluation revealed normal values for liver . . .