Fixing a painful wrist with high frequency weightlifting and wrist hyperextension. WTF.

In the spirit of my medical anecdotes, I present my left wrist.

Late Monday afternoon, while typing, I developed sharp pains in my left wrist. It hurt! I couldn’t type, though changing wrist position with a gel pad helped. Maybe, I thought, it was something with some recent mountain biking. Or maybe it was the high intensity CrossFit cleans I was doing. Whatever, it was obnoxious.

So I sort of splinted it with my weightlifting wrist wraps and then I waited to see what it would do.

It kept hurting, but another mountain bike ride didn't make it worse.

Maybe, I think, it’s an inflammatory arthritis of some kind. I’ve a family history and some intermittent personal history to worry about. Who knows.

I go to my morning CrossFit anyway. (Hmm. I wrote that one at 54. Now I’m 56…) Today the workout is muscle cleans and push press — about 180 of em. Great. That’s gonna hurt. I do the first 80-90 with a straight wrist, which is extra work. Then, between sets, I realize my wrist isn’t hurting any more. I do the next 90 with the usual wrist extension.

There’s some mild aching as the endorphins fade, but then nothing. Twelve hours later it’s slightly sore with unusual motions. [1]

If a patient came into my office with wrist pain back in the 90s I might have recommended ice, a splint at night, and some gentle range of motion exercises. Today somebody smarter might suggest something like the Dynaflex Pro. I don’t think anyone would recommend high intensity high repetition wrist extension weightlifting.

That’s what helped though.

I do not understand my increasingly aged body, and I don’t think I’m the only mystery. I suspect nobody really understands joints and backs. Once upon a time we recommended bed rest for sore backs, then we recommended activity and exercise;  I personally did well with relatively intense weight and flexibility training. More recently, mountain biking made my anterior knee syndrome slightly worse, but deep squats seemed to have no effect and conventional rehab seems to have helped. Today there’s the wrist.

Pity the poor physician who has to make a recommendation for someone’s sore wrist. It doesn’t work to say “I really have no idea”. It would be nice to know what’s going on though.

[1] I can make up a theory. I have reason to suspect I’m prone to dumping calcium into sore tendons and tissues — a counter-productive response that promotes inflammation. Bad genes I guess. Maybe the vigorous activity promoted clearance of some local calcium deposits. Maybe a stuck tendon sheath loosened up. Maybe the gods had mercy...

Update 5/1/2023: Almost 8 years later I can see this was probably the start of wrist involvement in my mixed-type arthritis. It became an on and off problem over the next 8 years. I'm on HCQ to slow progression and the symptoms seem to be dose responsive. It's annoying but not bad. When it's more bothersome I do "true pushups" or ring pushups or more reps at lower weights.

No, Apple News.app is not necessarily evil. Why do you ask?

[When first wrote this I chose an article, that, by chance, didn’t have a redirect to the original site. Which means I got things a wee bit wrong. Sirshannon gently corrected me. So now a bit of a rewrite …]

Viewing what I thought was a NYT article in News.app (turns out to be an Apple article that showed up on NYT page, which is kind of interesting) I can use Pinner.app 4.0 to create a Pinboard: Bookmark. That bookmark includes a URL like this:

https://apple.news/ABLDsKpUXSOafJmAr1FFtNg

From Pinboard app.net pourover and IFTTT (still around) share that link and my comment to app.net, twitter and my kateva.org/sh personal archive.

So far, so open. But what happens next?

If you access the particular link on an iOS device Apple launches News.app and you can view it there — both Safari.app and Chrome.app do the same thing.

If you access the link anywhere else you get this:

However, that’s not the end of the story (thought I thought it was). This link, opened in a web browser, redirects to a web page:

https://alpha.app.net/sirshannon/post/65149315#65148990

Apple does not redirect to the web version of the article. With NYT and other sources I chose one can open the News page in Safari.

This isn’t is surprising for two reasons. The first is that, even more than Google, Apple is all about Roach Motel class lock-in. The second is that, unlike the RSS of old, News.app has a viable ad-funded business model. Links to the open (perennially dying) web don’t fit that model.

So, despite my dire expectations, Apple, for now, is providing redirects to the web source. This doesn’t mean Apple will never interfere with the distribution of information that would hurt Apple’s business or offend its executives, and my confusion between NYT and Apple content is a bit weird (user error?), but for now News.app isn’t necessarily evil. I’ll be staying with Reeder and the lost mist-enshrouded all but forgotten Shangri La of RSS, Feedbin and Reeder until the last link dies  I’ll be experimenting with sharing News.app articles from it via RSS, Feedbin and Reeder ...

History: the printer has passed

First they came for the photo printer.

Then they came for the ink jet.

Now they’ve come for the rest.

Amazon return package label printing now includes ‘email to a friend’ and ‘request label by mail'

Yes, mail. Handled by people.

End an era, yes, but which era? 

Thirty years back — when we all had dot matrix printers?

One hundred and fifty years back, when typewriters became common?

Or do we go back to when paper became common in homes ...

Making of the modern pop song - fusion of the corporate and the anonymous individual

Bruce Springsteen and the E Street Band was the apex of my popular music connection. In a weird adventure of late childhood I attended Winterland's (San Francisco) last-but-one performance — featuring Springsteen.

These days my kids control the radio. So I hear a lot of country-pop and pop-pop. I assumed that music was made more or less the same way that Bruce did his work 30 years ago.

I couldn’t be more wrong. This month’s Atlantic Magazine included a short article that was the most surprising thing I’ve read in years [emphases mine]. It’s a review of John Seabrook’s book ‘The Song Machine’...

Karl Martin Sandberg, Mikkel Eriksen, Tor Hermansen and Other Songwriters Behind the Hits of Katy Perry and Taylor Swift - Nathaniel Rich, The Atlantic

The biggest pop star in America today is a man named Karl Martin Sandberg. The lead singer of an obscure ’80s glam-metal band, Sandberg grew up in a remote suburb of Stockholm and is now 44. Sandberg is the George Lucas, the LeBron James, the Serena Williams of American pop. He is responsible for more hits than Phil Spector, Michael Jackson, or the Beatles.

After Sandberg come the bald Norwegians, Mikkel Eriksen and Tor Hermansen, 43 and 44; Lukasz Gottwald, 42, a Sandberg protégé and collaborator who spent a decade languishing in Saturday Night Live’s house band; and another Sandberg collaborator named Esther Dean, 33, a former nurse’s aide from Oklahoma who was discovered in the audience of a Gap Band concert, singing along to “Oops Upside Your Head.” They use pseudonyms professionally, but most Americans wouldn’t recognize those, either: Max Martin, Stargate, Dr. Luke, and Ester Dean.

Most Americans will recognize their songs, however. As I write this, at the height of summer, the No. 1 position on the Billboard pop chart is occupied by a Max Martin creation, “Bad Blood” (performed by Taylor Swift featuring Kendrick Lamar). No. 3, “Hey Mama” (David Guetta featuring Nicki Minaj), is an Ester Dean production; No. 5, “Worth It” (Fifth Harmony featuring Kid Ink), was written by Stargate; No. 7, “Can’t Feel My Face” (The Weeknd), is Martin again; No. 16, “The Night Is Still Young” (Minaj), is Dr. Luke and Ester Dean….

… The illusion of creative control is maintained by the fig leaf of a songwriting credit. The performer’s name will often appear in the list of songwriters, even if his or her contribution is negligible. (There’s a saying for this in the music industry: “Change a word, get a third.”) But almost no pop celebrities write their own hits. Too much is on the line for that, and being a global celebrity is a full-time job. It would be like Will Smith writing the next Independence Day.

… We have come to expect this type of consolidation from our banking, oil-and-gas, and health-care industries. But the same practices they rely on—ruthless digitization, outsourcing, focus-group brand testing, brute-force marketing—have been applied with tremendous success in pop, creating such profitable multinationals as Rihanna, Katy Perry, and Taylor Swift...

.... “It’s not enough to have one hook anymore,” Jay Brown, a co-founder of Jay Z’s Roc Nation label, tells Seabrook. “You’ve got to have a hook in the intro, a hook in the pre, a hook in the chorus, and a hook in the bridge, too.”

Sonically, the template has remained remarkably consistent since the Backstreet Boys, whose sound was created by Max Martin and his mentor, Denniz PoP, at PoP’s Cheiron Studios, in Stockholm. It was at Cheiron in the late ’90s that they developed the modern hit formula, … Seabrook describes the pop sound this way: “ABBA’s pop chords and textures, Denniz PoP’s song structure and dynamics, ’80s arena rock’s big choruses, and early ’90s American R&B grooves.” ... music is manufactured to fill not headphones and home stereo systems but malls and football stadiums. … Session musicians have gone extinct, and studio mixing boards remain only as retro, semi-ironic furniture.

The songs are written industrially as well, often by committee and in bulk. Anything short of a likely hit is discarded. The constant iteration of tracks, all produced by the same formula, can result in accidental imitation—or, depending on the jury, purposeful replication….

… Hits are shopped like scripts in Hollywood, first to the A-list, then to the B-list, then to the aspirants. “. The most-successful songwriters, like Max Martin and Dr. Luke, occasionally employ a potentially more lucrative tactic: They prospect for unknowns whom they can turn into stars. This allows them to exert greater control over the recording of the songs and to take a bigger cut of royalties by securing production rights that a more established performer would not sign away...

… K-pop, a phenomenon that gives new meaning to the term song machine. Lee codified Pearlman’s tactics in a step-by-step manual that guides the creation of Asian pop groups, dictating “when to import foreign composers, producers, and choreographers; what chord progressions to use in particular countries; the precise color of eye shadow a performer should wear in different Asian regions, as well as the hand gestures he or she should make.”

In K-pop there is no pretension to creative independence. Performers unabashedly embrace the corporate strategy that stars in the United States are at great pains to disguise. Recruits are trained in label-run pop academies for as long as seven years before debuting in a new girl or boy group—though only one in 10 trainees makes it that far...

Of course it’s hardly surprising that pop songs have evolved to match the most common interests of the biggest audience. What fascinates here is the fusion of the modern corporate model with the peculiar talents of three Scandinavians and one American, and the purity of “star power” required of the modern pop performer.

I wonder when the nsAIs (non-sentient AIs) will displace those Scandinavians. Apple is famously vertical and AI-pop is the obvious next step after K-pop.

I’d love to read a Madonna essay on the topic, she seems now a bridge between the old world of Springsteen and the new world of Katy Perry. 

Vanguard voice biometric enrollment: the wrong way to do security

This showed up in my email. What’s wrong with it?

It tells me to click on a link to get started. How do I know this is really a Vanguard email? 

For something involving account security at this level it should give me instructions on how to proceed after I’ve logged in to my Vanguard account.

I believe this is a legitimate email, but I can’t trust it.

If you want to take a nonagenarian for a six hour flight to San Francisco...

If you want to take a mildly demented barely ambulatory nonagenarian out of his nursing home bed for a six hour flight to San Francisco you may be insane or murderous. Or perhaps your 93 yo WW II vet is in better shape than mine.

Or maybe you’re prepared.

I did this. Actually, my brother and I did this together, except for the plane flights where I went solo with Dad. We did it because my 93yo father had one request left in his life — to see his younger sister in San Francisco. And, thanks to an accident of Quebec’s healthcare and his disabled vet status, he had money to pay for the trip. 

Of course when I agreed to fulfill his wish he was 3 months younger than when we actually went — and significantly stronger. Old old age is like that.

Stil, we went. And because my brother joined us in San Francisco it went pretty well. Luck helped — we had perfect flights and transportation.

I don’t know anyone else who has done this, but I’m sure hundreds have. Somebody gets those old vets out for Normandy ceremonies.  On the other hand, I suspect those guys are in better shape than Dad (some of ‘em probably run foot races and jump hurdles).

If you want to do something like this, and before I dump all my trip memories (we aren’t doing this again), here’s what I learned:

• Airlines don’t make this super clear, but if you press a bit you can schedule wheelchair pickup from the front desk to the airplane seat. Do this. Do not do what I did, which was to make use of my father's transport wheelchair, walker, and my own strength. We might still be walking from the plane to the car rental office if a Montreal (YUL) security officer didn’t volunteer to push my father’s chair while i juggled luggage and walker. There’s no fee for checking a wheelchair or walker and you can also do plane side check with either. If you have the airlines doing wheelchair transport you’d check the transport chair and the walker in oversize baggage.
• During flights you want your 90+ yo in an aisle seat. They can’t necessarily get out of a window seat, especially when (in our case) the armrest divider was fixed. Inside passengers can typically squeeze buy ‘em - 90+ yo men tend to be small. Assume 2-3 bathroom trips a flight unless your guest has a catheter or is used to using a diaper. Bathroom trips require a physically strong companion — assuming your guest has some ambulatory ability. The seats need to be near the bathroom. We were in “business class seats” (not worth the money) and too far forward to use the assigned toilets, but the flight crew had us used first class which we could reach.
• You typically get to do special lines for customs and security. That helps. Carry food and snacks and water.
• You want two people for travel and care — at least one of whom should be strong (I’m strong, and my brother is stronger). At least one should be either a hospital or nursing home nurse (best) or a physician (not bad). If you’re using the airline wheelchair transport service you can make do with one person for that operation. Parenting experience is a plus.
• Get a “handicap” hotel room and an adjoining room with twin beds. My father needed an attendant for every bathroom visit — typically 2-5 a night. He slept in one of the twin beds and my brother and I took turns in the other. On our off night we slept in the handicapped room bed (king sized, one bed, which is weird hotel choice for a “handicapped” room but there you go). We used the handicapped bathroom with him.
• Whatever laxative routine is used at the care facility kick it up a notch. If warmed packed prunes are part of the routine bring those with you. Do not assume you’ll be able to buy them. Bring your dulcolax - both oral and suppository and glycerine suppository. Not ready to deal with poo? Don’t do the trip.
• Bring a waterproof bed sheet cover — as used with child travel.
• Wet wipes. Lots.
• Bibs - robust.
• Shirts: Purchase lightweight long sleeve travel shirts for summer travel. My father wears golf shirts at the Vets residence because he can take them on and off himself, but you need long sleeve shirts for sun protection and to reduce skin scrapes.
• Laundry: Assume you’ll do laundry 1-2 times, not least because you don’t want a lot of extra luggage. That still requires rolls of quarters at most hotels.
• If your nonagenarian uses pull-ups bring lots. If s/he doesn’t bring some.
• Assume most of the tourist stuff will be drive-by car touring. In our case I used Google and my own knowledge to construct a route made up of waypoints, then we used Google Maps on my iPhone to navigate from one waypoint to the next. Worked terribly well.  a handicapped parking card is a huge help (my aunt was with us and we could use hers) but with two people one can manage the 93yo and the other can drive around until pickup.
• Very limited alcohol - messes up sleep.
• Assume one social meal and 4 hours of drive by touring per day max. Every hour (at least) schedule a walkabout/transfer to keep bodies moving.
• Four days is a good visit length: one to travel/recover, one to prep/travel, two to visit and tour.
• Bring comfortable OTA headphones for your 90+ yo to listen to audio on long trips — something like Bose noise canceling headphones. But buy a set of the cheap airline phones in case he doesn’t like ‘em. (My Apple buds didn’t work with the airplane audio mini-jacks.)

There’s more but that’s enough for now — and probably the most I can remember since most of the traumatic memories are already fading. The good memories, because this trip actually, amazingly, worked, are getting stronger.

It could have gone quite badly though. This isn’t for the faint of heart.

American economy 2015: Ta-Nehisi Coates and Donald Trump lead to the same conclusion.

Donald Trump as the voice of the non-college 50%. TNC on the mass (black) incarceration society - and reparations. Hundreds of colleges produce no earnings boost (but lots of debt).

There is a common thread. America needs 40 million non-college jobs that pay $30 an hour.

That is our 21st century “Manhattan project” class challenge.

Get creative.

Google Trends: Across my interests some confirmation and some big surprises.

I knew Google Trends was “a thing”, but it had fallen off my radar. Until I wondered if Craigslist was going the way of Rich Text Format. That’s when I started playing with the 10 year trend lines.

I began with Craigslist and Wikipedia...

• Craigslist is looking post-peak
• Wikipedia looks ill, but given how embedded it is in iOS I wonder if that’s misleading.

Then I started looking at topics of special relevance to my life or interests. First I created a set of baselines to correct for decliniing interest in web search. I didn’t see any decline

• Cancer: rock steady, slight dip in 2009, slight trend since, may reflect demographics
• Angina: downward trend, but slight. This could reflect lessening interest in search, but it may also reflect recent data on lipid lowering agents and heart disease.
• Exercise: pretty steady
• Uber: just to show what something hot looks like. (Another: Bernie Sanders)

Things look pretty steady over the past 10 years, so I decided I could assume a flat baseline for my favorite topics.That’s when it got fascinating. 

• Inline skating (I do this) is dead and so is skateboarding
• Microsoft Excel is stable, but Google Sheets is way way up. Apple Numbers is doing a lot better than I expected.
• Special Needs has a slight downwards trend but Downs Syndrome has plummeted - perhaps due to America's eugenics program. I wonder if the fading of Downs syndrome is responsible for the modest decline in special needs searches.
• Cycling for exercise is somewhat down, with a nice seasonal spike pattern. Mountain biking has declined significantly.
• Cross Country Skiing varies (bet it’s snow depth) but seems constant at a low level
• CrossFit has probably peaked but is still popular.
• AI (artificial intelligence), much to my surprise, is way down.
• Growing use of searches on “Apple Quality” — probably not in a happy way (I’m betting this is Apple corp, not Apple fruit).
• Dementia is a slowly growing concern
• Backpacking is in a gentle decline
• Google seems to have flatlined and even Android is trending down, but Facebook has fallen off a cliff (hard to interpret, it’s so ubiquitous), Apple has slow growth but iPhone is only holding steady. Weirdly, Twitter looks rather like Facebook - not healthy at all.
• RSS. Sob.
• Health Informatics, my professional discipline, has had a big decline since 2004. It feels that way. SNOMED CT is in a lesser decline. On the other hand, family medicine is pretty stable (one weird 2011 peak) even as Geriatrics is in decline (WTF?)
• Carbon tax is off the radar and interest in global warming is way down. Be afraid.
• eBooks are post-peak - a failure to takeoff (I blame the DRM).

Some of these findings line up with my own expectations, but there were quite a few surprises. It’s illuminating to compare Excel to Google Sheets. The Downs Syndrome collapse is a marker for a dramatic social change — the world’s biggest eugenics program — that has gotten very little public comment. I didn’t think interest in AI would be in decline, and the Facebook/Twitter curves are quite surprising.

Suddenly I feel like Hari Seldon.

I’ll be back ...

See also:

• Research the past 200 years of memetic propagation: Google Books ngram viewer 12/2010

Repairing a 2010 RockShox Monarch RT3 - good luck getting parts

My 2010 RockShox Monarch RT3 rear shock is on its deathbed. It needs a rebuild or replacement (much more expensive), but it’s hard to know if parts are available. It’s easy to find parts for the 2012 model — but are they compatible?

The net was little help — until now. Buried in a footnote in the 2012 Rockshox spare parts manual: "2011-2012 Monarch parts are not compatible with pre-2011 Monarch rear shocks."

Tick bite causing meat allergy? (alpha-gal oligosaccharide allergy)

When Emily saw repeated comments online about a tick bite causing allergies to red meat we first assumed it was a mass medical delusion.

Turns out the belief comes from a Vanderbilt University allergy researchers claims and a 2009 WaPo article.

… Scott Commins, an assistant professor of medicine and lead author of the U-Va. study published in the Journal of Allergy and Clinical Immunology, said that in susceptible people such as Newell, a tick bite that causes a significant skin reaction seems to trigger the production of an antibody that binds to a sugar present on meat called alpha-galactosidase, also known as alpha-gal. When a person who has the antibody eats meat, it triggers the release of histamine, which causes the allergic symptoms: hives, itching and, in the worst case, anaphylaxis.

But many questions remain unanswered, said Platts-Mills, whose research is continuing. His lab has collected data on more than 300 patients from across the country and abroad.

"We're sure ticks can do this," he said. "We're not sure they're the only cause." Nor do researchers know why anaphylaxis is so delayed or why only some people develop a problem after tick bites. They do know that the allergic reaction is dose-related: Eating a tiny amount of meat probably won't cause a serious reaction. A large steak will….

The University of Virginia’s Thomas Platts-Mills is pushing the tick theory — though a recent abstract (article is $40) equivocates (emphasis mine) ...

The alpha-gal story: Lessons learned from connecting the dots

Our recent work has identified a novel IgE antibody response to a mammalian oligosaccharide epitope, galactose-alpha-1,3-galactose (alpha-gal). IgE to alpha-gal has been associated with 2 distinct forms of anaphylaxis: (1) immediate-onset anaphylaxis during first exposure to intravenous cetuximab and (2) delayed-onset anaphylaxis 3 to 6 hours after ingestion of mammalian food products (eg, beef and pork). Results of our studies and those of others strongly suggest that tick bites are a cause, if not the only significant cause, of IgE antibody responses to alpha-gal in the southern, eastern, and central United States; Europe; Australia; and parts of Asia. 

So the belief that a tick bite is causing a meat allergy has a basis in at least newspaper reporting and at least one team’s publications.

From my literature search it’s not clear anyone but Plats-Mills and his collaborators are making the strong connection to tick bites, much less to the Lone Star tick. I’d file this one under “suspect”. Of course that means that if Plats-Mills is right about the tick connection he will be well rewarded.

I’d bet he isn’t.

On knee pain and the state of medical knowledge (updated)

One of the interesting things about being old (45+, sorry to tell you that) and active and is that we develop conditions that we then get to read about.

That's typical. But if you're old and active and a physician there’s a twist. You get to compare the medical textbooks (and web references to your personal experience, and because of the old-part this reading is further informed by a finely tuned bullshit detector.

The bullshit detector is first developed in medical school. No, it’s not when we learn that following the exam preparation advice of professors is suicide — that’s the betrayal and pit-of-knives detector. For me it was the illuminating moment when I realized my 1986 renal physiology professors really had no idea how the kidney really worked. In their hearts they knew this, but there were exams to write and textbooks to teach to — so they faked it.

Later we run into seemingly erudite residents and medical students who we sooner or later realize are just spinning during medical rounds. Attendings varied in their response, I think some were hapless while others found it amusing. Or not amusing.

Much later, sometime after the first few years of practice, we realize that most journal articles are rather like those residents. (More recently reproducibility studies have made this rather more apparent.) We begin to spot the handwaving in textbooks — and to treasure the few that are relatively honest about ignorance.

Which brings me to my the pain below my left patella (knee cap). It could be related to the patellar tendon, to the “fluid-filled sacs” (bursa) that are usually said to be [1] under and around various tendons and neighboring bones, or the knee joint (cartilage/arthritis).

The cause is important to treatment. There’s nothing much to do for arthritis except rest and general muscle strengthening. Patellar tendonosis is treated with knee extension exercise starting at 90 degrees, but something (I’ll get to that) called “patellar-femoral syndrome” is treated with knee extension exercise starting close to full extension. So it’s good to differentiate those two.

The differentiation turns out to be relatively simple. If pain hurts coming down stairs (down > up) it’s likely “patella-femoral syndrome”; you won’t be able to do resisted extension at 90 degrees of flexion but you’ll be fine doing it at at 10 degrees of flexion. Also, “patello-femoral syndrome” is much more common than patellar tendonpathy. A related characteristic is that discomfort is maximal between 15 and 35 degrees (stair descent) — so I have no discomfort extended or in a deep squat.

The medical knowledge/bullshit detector bit comes with reading about "patello-femoral syndrome”. As far back as 1990 one of our texts, “Practical Orthopedics” by Lonnie Mercier, refreshingly admitted that this might as well be called something like “sore knee syndrome”. It’s probably a bunch of things involving some degree of irritation of the bursae and tendons (patellar, iliotibial) beneath and below the patella along the course of the patellar tendon. We used to think it had something to do with the cartilage below the patella, but as far back as 1990 Mercier’s text suggested that “chondromalacia patellae" was relatively infrequent, not clearly related to symptoms, and ought to be carved out as a separate diagnosis.

Reviewing a 2007 AAFP article it looks like nothing fundamental has changed [2]. So points to Mercier.

I wasn’t able to find a persuasive evidence-based treatment program for “sore knee syndrome”; I liked Dr Lee Cohen’s PDF for its guide to resuming exercise [3]. Basically I’m avoiding what hurts (flexing knee on stair descent), doing what doesn’t hurt (high rep, low pressure cycling and swimming), doing near-full-extension quad cybex-style weight. I'll increase extension range as the knee improves, and I’ll try some of Dr. Cohen’s routines. I don’t like NSAIDs because of repeated studies showing they delay tendon healing, so not doing those.

Once I can do squats with 50 lbs or so (very light) and run a mile or so without discomfort I’ll go back to CrossFit...

- fn -

[1] human anatomy is more variable than the diagrams suggests

[2] I don’t particularly recommend that article btw. It reminded me a bit of 1986 renal physiology.

[3] Low intensity mountain and road biking feels fine, so I’m doing that. I’m “on leave” from CrossFit until I can do squats without pain or swelling — one of the great things about contract-free CrossFit at our gym is they’ll stop fees if we’re out for 2 weeks or more.

Update 9/12/2015: Occurred to me that I should change to flats on my mountain bike until the knee is done healing (it’s improving well). Normally SPD cleats allow a lot of lateral mention, but sometimes my mountain pedals get jammed with sand. That’s a formula for worsening my knee problem. So flats for now (which, these days, work pretty well anyway).

Update 11/24/2015: I learned a few more things, which really ought to be in a textbook. 

My own knee did get better after a few weeks of CrossFit abstention, a bit less mountain biking (week off), and quad strengthening. Subsequently, however, I found CrossFit didn’t bother it much at all, but heavy mountain biking could be annoying. Since mountain biking season ended I have been mostly doing CrossFit and ice hockey — and it is now better. I ended up thinking the mountain biking was probably the greater aggravating factor.

Ahh, but there’s a twist as well. I have since learned that what mountain biking and stairway descent have in common is 15 degrees of flexion, which is when the patella is most in contact with the femur. At greater degrees of flexion strong quadriceps pull the patellar undersurface away from the femur — which is why my strong quadriceps limited the pain. Alas, the clinical presentation cannot distinguish inflammatory arthritis (idiopathic, as in OA involving primarily the synovium), from psoriatic arthritis (less idiopathic, with tendon involvement). In my case other clinical findings point to more chronic conditions - psoriatic arthritis or idiopathic inflammatory arthritis (aka, erosive osteoarthritis). So I’ll write a bit more about that sort of thing over time.

Family medicine board examination 2015: One last time.

I’m taking my family medicine board exams one last time. This is not entirely sensible. It’s been 21 years since I did family medicine, and 17 since I last saw a patient. I’m unlikely to practice again. The exam will be difficult; my brain is old and cruddy. (Long ago I did rather well on these, but it does help to actually practice medicine.)

Still, for one reason or another, I’m committed to doing the exam this November. I’ve slogged my way through the ABFM’s intricate preparations, including, for the non-practicing candidate, 6 self-assessment modules (SAMs) and one “alternative” module (which was quite awful and may have been since withdrawn). I even managed to meet the under-documented CME requirements [1]. The expensive Self-Assessment Modules varied from quite good to rather poor; alas the simulations are not worth continued investment [2].

When I’m done I’ll revise this post with what I end up with. By far the best guide I’ve found for someone like me was something written in 2008 (*cough*). I’m basically following my old recommendations (including ignoring audio CME/podcasts). For example:

• ABFM | Exam Preparation: look for the tiny links at bottom to Study Tips and 2-week checklist. Some of this advice is wrong for me - and probably for most people. Still worth a read.
• ABFM | Exam Content: this page hard for me to find - maybe my problem. I focus on topics with 5% and above.
• I have old online medical notes written back when we thought HTML would be a good format for knowledge sharing and documentation. How naive we were! My medical notes started out in pen, moved to Symantec MORE 3.1, then FrontPage/HTML and now they’re back to an outliner (OmniOutliner 3). I have to write to learn. When I’m done I’ll attach a version of my notes here, but they’re really only going to be useful for me.
• SAM Module Review: The SAM modules were a mixed bag, but the question explanations are superb summaries of current/expected knowledge. I’m mining those for my notes.
• ABFM in training exam: The ABFM provides 3 years of teams. I’m studying these in depth, identifying any areas of strength, guiding my study, and generally awakening old memories.
• Online references: this has changed, and not for the better. There’s much less available for “free” online than there was in 2008 [3]. Only Scott Moses’ self-funded hobby/obsession remains - the FP Notebook. So I’m buying selected paper references [4] like the venerable Washington Manual and Sanford Antimicrobial therapy. Some of my old textbooks (EKG interpretation) still work.
• AAFP Board Review prep: skip over the expensive and inefficient modules and find the free (38 credit!) Board Review Questions. I think this is what the ABFM “exam prep” document was warning against. Needless to say, I’ll be sampling these, though Emily recollects they’re less useful than the ABFM in training exam materials.
• Monthly Prescribing Reference (print version): still evil (drug money funded), still remarkably useful. Trick is to know what drugs are actually used vs. what are legacy — would be nice to have a version filtered by popularity.

I’m alternating topical work (reviewing Sanford, relearning EKG interpretation) with review designed to rebuild old memories. My medical knowledge network is frayed and fragmented, but there’s a lot of it. Much of my preparation is really resurrection. I've brute memorization ahead - reading, closing eyes, regurgitating. Then exam-guided note review and expansion.

It will be interesting to see how it all goes. Failure is certainly an option.

- fn - 

[1] Dear ABFM: Please note the current cycle progress tracker omits CME requirements but the future cycle includes CME requirements. Could be fixed.

[2] In the late 80s through early 90s we used to get 360K floppy disks each month with a unique DOS based medical simulation. I cannot, just now, remember what medical publisher did them (something Cardinal?). I remember them as quite excellent, I featured them in our residency computer-based training program.  Several clinicians, likely retired now, did some serious work on those. There really is no modern equivalent. Which is a kind of interesting.

[3] UpToDate is by far the dominant online resource for medical information — and it’s very expensive. (Priced for organizations.)

[4] See [2]. Also the movie Groundhog Day.

Update 11/22/2015

I don’t know my exam results yet, but it went more or less as expected. The test environment worked well — though it took me a while to realize I had to select text then click a secondary highlight icon that floated nearby to get highlighted text for review. My foot pulled a power cord out, but when our proctor fixed it everything worked. For most modules and sections there was ample time. We do get markers and writing material, I didn’t see that mentioned in the ABFM exam descriptions.

The AAFP board review questions and the ABFM provided residency training exam questions were a good guide. The AAFP questions generated CME credit, but I liked going back and forth. Whenever the questions exposed an unfamiliar topic I went off and did guided studying. There’s an AAFP board preparation page that provides USPSTF screening guidelines that’s quite useful.

FP Notebook was, and is, outstanding. I wouldn’t make many changes to my studying, but I’d have stared using FPN intensively sooner than I did. It is a perfect way to bring old knowledge on board, to identify obsolete knowledge, and to extend the sample exam question critiques. It’s also a great way to review medication information. Beyond FPN I mostly used American Family Physician articles and a handful of textbooks.

My key book references were The Washington Manual, Sanford antimicrobial therapy, MPR Prescribing Monthly, Emily’s ACLS “cards” and my venerable med school EKG primer. That’s similar to 2008, but since then my presbyopia has not improved. This year I found the app versions more readable than the paper versions; the Sanford and Washington Manual print text seemed microscopic. The Sanford app is a $40/year subscription, but Emily uses it too (we share same AppleID for purchases). My paper Washington Manual came with a free code for the electronic version, hosted by inkling.app (iOS). I barely looked at the paper manual, but I used the inkling version often.

The ABFM Maintenance of Certification examinations (I had to do 6!) were not particularly useful preparation for the board exam. I don’t think the maintenance exams a useful guide to real world practice either — they are much too esoteric. I regret the time and money I spent on those, but of course we don’t get a choice.

Even though most physicians would have key references like Sanford, Up To Date and drug information at their fingertips our board exams still rely on brute memorization. I suppose they’d be too easy otherwise. Given the years since I’d done family medicine (1994), and the years all by themselves, memorization was not particularly easy. I had to interact with information. I took handwritten notes on exam questions that I knew I’d never look at — but the writing process was important. I created my own spreadsheets of drug information for antimicrobials, antidepressants, anticoagulants, and, above all, oral diabetes meds (mercifully lipid therapy has gotten much simpler!). In each case I created my own groupings (med classifications), frequently reorganizing them. It helped to organize medications but their modern use, rather than by the sequence in which I encountered them. For the oral diabetes meds I would attempt to recreate my classifications by memory, then see where I got them wrong, then repeat… At about 30-40min of painful memory work a day it took 3 days to learn them.

I moved my old notes into OmniOutliner Pro 3 — itself an old piece of software. This was a ‘back to the future’ moment as my notes started out decades ago in a similar product - Symantec’s MORE 3.1. After a couple of weeks of study I could recognize what was worth keeping, what needed to be rewritten, and what should be deleted (much of lipid therapy!). I updated my old references with FP Notebook on a separate screen; this process helped tie old knowledge to new knowledge. 

The old knowledge was important — during the exam I found myself dredging things up from 25 years ago. I was surprised I could get anything from that far back, but really most of my medical base is from that era. For this exam I was largely refreshing and resurfacing it.

I’ll find out some weeks from now whether I need to do it again in a few months, or years, or perhaps never again.

Update 1/25/2015

I passed the exam by a substantial margin. If the maximal score represents percentile I scored about the 75th. That’s much lower than my score when doing academic practice, but it’s not bad for 20 years without patient care.

I did well in all the areas I studied. I didn’t do as well in obstetrics and gynecology, but I strategically omitted them.

My studying approach worked quite well for me.

Pectus Excavatum complications - beware neck strike during barbell Clean

I am deformed …

Current Management of Pectus Excavatum [jf: depressed sternum associated upper chest]

Pectus excavatum (PE) is one of the most common anomalies of childhood. It occurs in approximately 1 in every 400 births, with males afflicted 5 times more often than females. PE is usually recognized in infancy, becomes much more severe during adolescent growth years, and remains constant throughout adult life. Symptoms are infrequent during early childhood, but become increasingly severe during adolescent years with easy fatigability, dyspnea with mild exertion, decreased endurance, pain in the anterior chest, and tachycardia. The heart is deviated into the left chest to varying degrees causing reduction in stroke volume and cardiac output. Pulmonary expansion is confined, causing a restrictive defect.

Repair is recommended for patients who are symptomatic and who have a markedly elevated pectus severity index as determined by chest X-ray or computed tomography scan…. Operation rarely takes more than 3 hours, and hospitalization rarely exceeds 3 days. Pain is mild and complications are rare, with 97% of patients experiencing a good to excellent result. The new minimally invasive Nuss repair avoids cartilage resection and takes less operating time, but is associated with more severe pain, longer hospitalization and a higher complication rate, with the bar remaining for 2 or more years…

My chest wall deformity is moderately severe, not as impressive as the wikipedia photo. A correction attempt was made at age 15 or so, but without the reinforcing “bar” used now. The post-operative pain then was not “mild”, it was exquisite — at least during breathing. The collapsed lung or two probably didn’t help. (I suspect my surgeon was pleased I survived). The deformity recurred, but my operative experience cured my psychic distress. I decided having an “ant’s swimming pool” wasn’t so bad after all.

Reading the above description it seems I can blame my unimpressive athletic career on my chest wall. Come to think of it, I did feel quite tired this morning on the fourth round of 400 meter sprints and as-many-reps-as-possible box-jump-over burpees. [1]

All of which is a prequel to new knowledge. I’ve figured out why I’m the only person at CrossFit who tends to hit their neck when doing a barbell “Clean”. With most people, even with poor technique, the upper chest pushes the bar away from the throat. With me it directs the bar towards my throat.

So there you go. For all the other persistent Pectusoids out there, if you are doing a barbell Clean pay attention to hitting your mid-body target and work on your technique — your pectorals will not save you.

[1] Sarcasm here should hint that this abstract’s disability description is debatable. In reality it is unclear how much cardiopulmonary compromise there is, and whether surgery really helps. Some articles suggest it helps cardiac function but worsens pulmonary function. There are big nocebo (deformity) and placebo (surgery) effects that make outcome evaluation difficult.

Update 8/31/2015: After writing this I realized I have a genuine CrossFit disability. I can’t do an “Rx” pushup, because I can’t touch my upper chest to to the ground (lower chest gets in way, not to mention my shoulders and head). During WODs I use an Ab Mat as a target, but I couldn’t do that in competition.

Mountain biking: A good sport for heavy kids?

I help out with a High School mountain biking team; it’s a team #1 rode with last year. (He might be first special needs student to compete in a NICA high school race, though I wonder about the Utah league.) It’s a sweet deal — I do adult things, carry the first aid kit, and help with team communications; in turn I get to ride with a great group of adults and kids while I get quality coaching by listening and practicing with our riders. #1 helps too, I’ve made it part of his post-high school “transition” training.

One of the things I've heard from the coaches is that heavy kids tend to do well with mountain biking. The bike takes a lot of weight off knees and hips and, by necessity, these kids have powerful legs. Weight isn’t a big disadvantage on the downhills. Being heavy does make climbs harder, but that work boosts conditioning. Heavy kids who go to practice lose fat and gain muscle, so they improve faster than slimmer riders. That rapid improvement is a powerful reinforcer. If they persist they keep the powerful leg muscles and lose fat — and become quite competitive.

I see the logic. It would be interesting to get some data, but I couldn’t find any studies in the medical literature. It could be a fun research topic. 

[1] He may be the only special needs student, so far, to compete in high school mountain bike races.

Amazon reviews show a Shimano SPD pedal has a safety defect. Do Amazon and Shimano have a duty to report under US law?

I’ve sent two sets of Amazon purchased SPD pedals to Shimano for warranty replacement in the past month. I’d used each set for 2-3 months when they developed bearing clicks.

That could be bad luck, or it could be Shimano has lost control of its Chinese manufacturing pipeline. I’m just too small a sample to know.

But that’s not what I’m curious about.

I’m curious about Shimano’s apparent disinterest in the Amazon reviews of the Shimano PD-A530 SPD Dual Platform Bike Pedal. Many reviewers, over several years, have described the same safety issue I ran into. These pedals have two sides, a flat side for shoes and a “cleat” (confusingly these are called “clipless pedals") side that locks onto metal tabs attached to bicycle shoes. The clip lock setting is far too tight, at the default setting it’s quite difficult to remove a shoe from the pedal. Maybe the spring is the wrong tension, maybe there’s some other design error, but this is dangerous. Reviewers report falling over in traffic due to excessively tight clips.

The workaround is to set the adjustment bolt to its minimum setting (though the bolt is more cheaply made than other SPD pedals, so you have to work it a bit to make sure the nut slides down). On every other SPD pedal I’ve worn over about 15-20 years this would be too slack, but on these pedals it’s about right. Of course a lot of cyclists won’t know to do this, or won’t immediately recognize that the pedals are miscalibrated. It’s a persistent safety defect.

Under US law both Shimano and Amazon have a duty to report safety defects...

Duty to Report to CPSC: Rights and Responsibilities of Businesses | CPSC.gov

If you are a manufacturer, importer, distributor, and/or retailer of consumer products, you have a legal obligation to immediately report the following types of information to the CPSC:

… A defective product that could create a substantial risk of injury to consumers...

… Failure to fully and immediately report this information may lead to substantial civil or criminal penalties.  CPSC staff’s advice is "when in doubt, report.” ...

… 

What if I receive information that reasonably suggests my product could create a safety or health hazard but no reports have been received alleging that actual harm or injury has been suffered?

You must immediately report the information about the product. The law does not require injury or harm to have occurred….

It’s clear these pedals have a defect, though a defense lawyer would argue about “substantial risk of injury”. After all, it’s the nature of clipless pedals to reduce foot-to-ground time, and a lawyer would argue that only knowledgeable people should buy a clipless pedal, and thus know how to adjust them.

It would be unwise, however, to rely on the kindness of US courts. I suspect if Shimano’s lawyers read the Amazon reviews they’d recommend doing a (confidential) CPSC report and fixing the darned pedals. Judging by the age of the reviews, however, they haven’t done the latter.

Which is interesting. Why doesn’t Shimano read Amazon reviews of its products? And what are Amazon’s obligations as a distributor or retailer?

Great questions for a law school class ...

Update 8/5/2016: Shimano sent me a replacement for the clicking PD-AF530 pedal. After less than 10 months of light use it developed a severe creak/click. Trash.