Rhabdomyolysis at the University of Iowa

The University of Iowa football team’s workouts may be too tough, or at least poorly designed.

13 football players were hospitalized with extreme soreness and discolored urine from rhabdomyolysis. Rhabdomyolysis is the breakdown of muscle cells after intense workouts, crush injuries or other trauma. After rigorous workouts, especially with workouts that involve squats, rhabdomyolysis is fairly common. The jail population sometimes forces new inmates to do ‘burpies’, or exercises that require jumping in the air from a push up position, until the signature tea colored urine appears. Rhabdomyolysis treatment if provide early is hydration and sometimes bicarbonate. Kidney failure requiring dialysis will set in without treatment.

IOWA CITY, Iowa (AP)—The University of Iowa said Wednesday that 13 football players had to be hospitalized this week with a muscle disorder following grueling offseason workouts that left them with extreme soreness and discolored urine.

The players have rhabdomyolysis, a stress-induced syndrome that can damage cells and cause kidney damage and even failure in severe cases, school spokesman Tom Moore said at a news conference two days after players were hospitalized at the University of Iowa Hospitals and Clinics in Iowa City.

School officials said the players, whom they would not identify, were in stable condition and responding well to treatment, which includes bed rest and the administration of hydrating fluids. Moore said he did not know when the players would be discharged.

Director of football operations Paul Federici said the players participated in workouts that started last Thursday after they returned from winter break. Some of them complained to medical staff after a workout on Monday and symptoms included soreness throughout the body and tea-colored urine, and other players were told they should receive treatment if they had similar problems, he said.

A former athletic trainer, Federici said he’s never seen the syndrome among student-athletes at Iowa before. He said he was still looking into the details of the workouts but said they were no different than those from previous years during what he called a critical seven-week stretch of training.

“It is strenuous. It is ambitious. The student athletes know that,” he said. “This is an anomaly. We just haven’t seen this type of response before.”

He said the players range from freshmen to upperclassmen and include a range of positions.

One of those hospitalized is freshman linebacker Jim Poggi of Towson, Md., whose father, Biff Poggi, said his son complained to trainers on Monday after several days of soreness. He said his son’s pain started last Thursday with a lower-body workout that involved performing 100 squats in a certain amount of time and pulling a sled 100 yards. It got worse Friday after an upper-body workout, and Monday’s workout “didn’t go well.” His urine was discolored, and the team’s medical staff sent him for treatment.

Iowa coach Kirk Ferentz, athletic director Gary Barta and team doctor Ned Amendola were all out of town on business and not at the press conference. Chris Doyle, the team’s strength and conditioning coach who has worked under Ferentz all 12 years of his tenure, and other strength coaches who oversaw the workouts were not made available to reporters.

Doyle is nationally known as a leader in player development, turning sometimes scrawny freshmen into physical specimens by the time they graduate. Ferentz has said that is a key part of his program’s success.

Biff Poggi, a high school football coach in Baltimore, said he was concerned about the situation but also confident his son would recover and rejoin the team. He said the hospitalized players are disappointed and eager to resume practice.

University of Iowa doctor John Stokes, a kidney specialist who is not involved in the players’ treatment, said the common denominator is they had all participated in strenuous exercise, which commonly brings on the disorder in otherwise healthy young people. He said the symptom is common among military recruits in boot camp and treatment usually focuses on trying to limit kidney damage.

“I’ve been at UI for 32 years and I don’t think I’ve seen 13 people get rhabdomyolysis,” he said. “It’s a fairly common diagnosis .This cluster would be unusual.”

Athletes routinely recover from the disorder and go back to playing, but they may change their exercise routines and ensure better hydration, he said.

Associate athletics director Fred Mims said school officials would take steps to “ensure it doesn’t happen again.” Mims, who is in charge of the department’s compliance with NCAA rules, said the matter did not need to be reported since the workouts were allowed and routine.

He said the case is a “good lesson” for why university officials should ask players about how they are feeling after strenuous workouts. He said Iowa will also try to avoid problems after players return from school breaks and might not have kept up with fitness routines by making sure expectations are clear.

The City of Bell’s Robert Rizzo has a successor…David Carmany hired in Manhattan Beach

Ahh, Robert Rizzo, the city of Bell administrator who earned $800,000 a year with 20 weeks of vacation/ sick leave who claims to have done nothing wrong while serving community service as a parking lot attendant for his DUI.

Nationwide, unethical behavior is rampant in public officials. Most get away with transgressions that are unlikely to receive attention. Check out your local gang of idiots. David Carmany, for instance, just received the city manager position at Manhattan Beach. He immediately negotiated a city supported housing purchase with the city picking up $540,000 as well as $65,000 in renovations (link at the end). This pilfering of the Manhattan Beach city coffers comes in the face of heavy criticism for increasing his own salary at his last job, ala “mini Bell”. (See below)

What is the solution, less government, more volunteers....mindless blogging???

http://www.sunnews.org/politics/seal-beach-council-reviews-city-manager-s-salary/

Seal Beach City Manager David Carmany’s salary was on the agenda Monday night, Aug. 9. District 4 Councilman Gary Miller had requested a report on Carmany’s salary on July 12.

His current salary comes to about $217,000 a year.

After a lengthy discussion, the council voted 3-2 to receive and file a report on salary increase Carmany had received under his contract since he was appointed on April 23, 2007.

Miller and District 1 Councilman Charles Antos voted no. Mayor David Sloan said there was no finding of impropriety in the report.

Miller said Carmany took an 8 percent pay raise meant for former Seal Beach City Manager John Bahorski just 27 days after Carmany was hired.

“Contractually, that appears to be possible,” Miller said. However, he questioned the ethics of Carmany accepting the pay raise.

According to the staff report by Director of Administrative Services Robbeyn Bird, section 4.B (13) of Carmany’s contract gave him the option of converting $7,500 in deferred compensation into salary.

In October 2008, Carmany took that option.

Miller pointed out that Carmany increased the number of days he can take administrative leave, which Miller said gave him an additional $7,000 in value.

Bird’s report to the council said that Section 4.B (15) of Carmany’s contract allows the city manager to receive all benefits and adjustments received by management employees.

Under that provision of the contract, Seal Beach received a monthly salary increase to $15,750 a month on July 1, 2007 under the executive and mid-management terms/conditions of employment that the council unanimously adopted on July 24, 2006.

The city increased Carmany’s monthly salary to $16,333 on July 1, 2008.

Miller also pointed out that under his contract, Carmany automatically benefits from any pay raise given to management staff. Yet Carmany negotiates with mid-management on behalf of the city. Miller called this a conflict of interest.

Miller said salary and benefits should only be increased by the City Council.

Miller wasn’t the only person to object to Carmany’s salary. During the public comment segment of the council meeting, College Park East resident Patti Campbell complained that Carmany had given himself pay raises. “He has no business giving himself any kind of raises,” she said.

Campbell, a long-time critic of Carmany, said he had demonstrated that he was not honest by giving an architectural contract for the design of Fire Station 48 to a friend without disclosing his relationship with the architect to the council.

Joyce Parque, of Old Town, also criticized Carmany’s salary.

“When he’s negotiating with the police chief, he automatically gets a raise,” Parque said.

“He’s up to $217,000,” she said.

Parque asked if Carmany would get a 90 percent pension if he left next year following the election of a new City Council.

“This is a mini-Bell that’s getting ready to explode,” Parque said.

She criticized the council for not doing its job.

“You’re not representing the taxpayers,” she said.

Parque asked if Carmany had a credit card from the city.

“This is like the city of Bell,” she said. “Make it transparent.”

Miller proposed removing sections 4.B (13) and (15) from the contract. Miller also proposed reducing Carmany’s pay by 8 percent.

City Attorney Quinn Barrow said that because the contract is an agreement, Carmany would have to agree to the changes. He said the City Council could not unilaterally change the agreement.

Miller disagreed. Later in the meeting, he said the council could make the changes. It would be up to Carmany to sign the agreement.

“There’s no reason not to modify the city manager’s contract,” Miller said.

District 5 Councilman Michael Levitt agreed there was a conflict of interest in having Carmany negotiate with the city’s management group.

Barrow said that issue could be “cured” without changing the city manager’s contract. He said the city attorney used to negotiate with city employees, but city employees didn’t want lawyers involved.

Antos said it would be appropriate for the city manager to come out with a report when he negotiated with city employee groups and to have the report signed by the mayor or the mayor pro tem. Antos said he saw it as informing the council of those provisions of the city manager’s contract.

Sloan said that after reviewing the report, he found no impropriety and moved to receive and file the report.

Miller said he wanted to make additional comments.

Sloan called for a motion. The motion was made and seconded.

Miller said: “I want to divorce myself of anything unethical and I consider this unethical.”

(more here about David Carmany's housing purchase here)

http://www.mbconfidential.com/2011/01/pricey-perk-on-pacific.html

(the latest here about Robert Rizzo)

http://www.latimes.com/news/local/la-me-0113-lopez-20110113,0,1294355.column

Jacob Trette Remarkable Rescue at Mavericks: Raw Footage

This link shows Mr. Trette’s dramatic rescue.

http://www.ktvu.com/video/26584105/index.html

Determining his prognosis is difficult although it appears a hypothermia protocol is underway suggesting significant underlying ischemic brain injury.

"As of last evening Jacob was moving his arms and legs and his pupils are dilating. They're lowering his body temp so he doesn't use as much oxygen and keeping him heavily sedated. He has an anoxic brain injury do to lack of oxygen to the brain. To early to tell how much damage has been done if any. Sending our prayers to him and his family."

More here

http://www.grindtv.com/surf/blog/23806/law-breaking+photographer+saves+the+life+of+mavericks+surfer/

Dr. Lawrence Saks sentenced Tuesday to three years behind bars and ordered to pay nearly $486,000

Medical professionals frequently behave otherwise. Dr. Saks apparently has a long history of misdeeds including 6 months in prison for tax evasion in 1990, a $1.1 million dollar fine, multiple license suspensions including one for the death of a liposuction patient at which time Dr. Saks admitted to improperly assessing the high-risk patient before embarking on the surgery, and failing to adequately monitor her after the operation.

His most recent fraud for billing both patients and insurance companies will land him in prison for three years.

Here is a character assessment from a cousin of Dr. Saks: "I'm not a psychologist. I don't know why people who have everything sometimes do stupid things," said Moshe Reiss, a cousin in Montreal. "I'm sure that you will find somebody who will say bad things about even the best plastic surgeons. These guys work with people who want to take imperfect and make it into perfect, and obviously not everybody is happy with the results."

And for kicks he sued, and lost, Charity Mission Baptist Church for fraud.

Tread carefully....

All of the previous references, and more, can be found at the following links:

http://articles.latimes.com/1990-12-13/local/me-8556_1_income-tax-evasion

http://articles.latimes.com/1991-12-22/local/me-1305_1_free-services

http://implants.webs.com/apps/blog/show/2531867-depressed-10-year-olds-have-plastic-surgery-in-mind-

http://www.dailybreeze.com/news/ci_17130672

http://www.insidesocal.com/crime&courts/cases/saks/

http://www.metnews.com/articles/saks0725.htm

Steve Jobs: Cancer Recurrence after Liver Transplant

Steve Jobs in 2004 had a pancreatic neuroendocrine tumor resected by a ‘Whipple’ or resection of the head of the pancreas, duodenum and part of the biliary tree. Resection is the only cure for this tumor.

In 2009 Job required liver transplant for undisclosed reasons although the likely scenario was the primary neuroendorine tumor advanced to his liver. Mortality is very high unless the metastases are removed.

One aggressive treatment for primary cancers of the liver, such as hepatocellular carcinoma, is a liver transplant. With liver metastasis from a neuroendocrine tumor that started in the pancreas, transplant is highly experimental as immunosuppressants are necessary to prevent the body from rejecting the liver. The risk of the immunosuppressants is that if cancer remains, it is highly aggressive.

I suspect cancer recurrence after liver transplant is the current scenario.

Steve Jobs addressed Stanford graduates in 2005, this is an uplifting piece worth a look.

http://www.ted.com/talks/steve_jobs_how_to_live_before_you_die.html

Here is the lastest from AP

Apple CEO Steve Jobs takes another medical leave

AP

SEATTLE – Steve Jobs, the CEO who transformed Apple Inc. from niche computer maker into the most-envied consumer-electronics brand today, is taking a medical leave of absence for the second time in two years.

In the last decade, Jobs, 55, has survived a rare but curable form of pancreatic cancer and undergone a liver transplant. The news that he will again step back from his day-to-day role raises serious questions about the CEO's health.

But analysts believe the company Jobs shepherded from garage startup to a $65 billion technology trendsetter is in good hands with the current slate of talented executives — even as Apple, now the Silicon Valley player to beat, faces increasing competition from Google Inc. and others.

It is not yet clear investors in the U.S. will share analysts' confidence. The news was delivered Monday when markets were closed for the Martin Luther King Jr. holiday. Investors sent Apple's shares down $15.48, or 4.4 percent, to $333 in Tuesday morning trading.

Investors have pinned much of their faith in the company on Jobs himself, sending shares tumbling on every bit of news or rumor of his ailing health. That's because Jobs is an industry oracle of sorts, inventing new products he knows consumers will want even before they realize it. He is also known as a demanding and hands-on leader who is involved in even the smallest details of product development.

In a note to employees, Jobs said he will continue as CEO and will be involved in major decisions. Chief Operating Officer Tim Cook will be responsible for all day-to-day operations.

For now, very little is known about Jobs' current condition. Apple did not provide any information beyond the six-sentence note announcing his leave, leaving unanswered questions about whether the CEO is acutely ill, whether the leave is related to his 2009 liver transplant or whether he is at home or in a hospital.

Unlike Jobs' 2009 leave of absence, when he vowed to return to work in less than six months, Jobs did not say in the note made public Monday how long he would be on leave this time.

"I love Apple so much and hope to be back as soon as I can," Jobs wrote. "In the meantime, my family and I would deeply appreciate respect for our privacy."

Although some analysts expect Apple shares to sink Tuesday in the U.S., many believe the company can function successfully even without Jobs in the corner office full-time — and with Apple at the forefront of a new revolution in personal computing.

In 2010, investors seemingly grew accustomed to Jobs' extreme thinness, focusing instead on the early success of the iPad with consumers. Shares increased 53 percent last year to top $300. With Apple no doubt polishing the second version of the iPad and competition among tablet makers expected to heat up this year and next, some stockholders may fear that without Jobs, Apple could lose its lead to tablets running Google's Android software or Microsoft Corp.'s Windows.

Analysts believe Apple has plans for several years' worth of products in the pipeline. And Cook, who is seen as a logical eventual successor to Jobs, is no stranger to investors. He ran the Cupertino, Calif.-based company for two months in 2004 while Jobs battled pancreatic cancer, and again in 2009 during Jobs' most recent medical leave. Apple chugged along smoothly then, releasing a new version of the iPhone and updated laptops on schedule.

Since Cook, 50, began with Apple in 1998, he has been credited with tuning Apple's manufacturing process to solve chronic product delays and supply problems.

"Steve is clearly still the visionary behind Apple," said Tim Bajarin of Creative Strategies, who has been covering Apple for decades.

But, Bajarin said, Cook "understands the way Steve thinks, how Steve manages. He understands Steve's vision and probably more important than anything else, he understands Apple. And I don't see any changes in direction or vision or execution even though Steve's not day-to-day."

Apple's products can command a premium in part because of their design and materials, choices made by Jonathan Ive, Apple's top design executive, and his team. Ive has been with Apple since 1996 and has overseen the industrial design of the iPod, the aluminum-body Macbook laptops, the iPhone and the iPad.

"He's responsible for the look and feel of the stores, the products, the software. And no slight to Tim (Cook), but we think he's the most important person in the company," said Shaw Wu, an analyst for Kaufman Bros.

Without more information about Jobs' medical condition, it's impossible to say when the CEO might be able to return to work — if at all. Apple has a history of extreme secrecy when it comes to the iconic CEO's health, disclosing major illnesses only after the fact.

The company waited until after Jobs underwent surgery in 2004 to treat a very rare form of pancreatic cancer — an islet cell neuroendocrine tumor — before alerting investors. That type of cancer can be cured if diagnosed early, unlike the deadlier and more common adenocarcinoma.

By 2008, Jobs had lost a noticeable amount of weight, but Apple attributed his gaunt appearance to a "common bug." In January 2009, Jobs issued a statement saying the weight loss was caused by a hormone imbalance, and that the treatment was simple. He backtracked less than two weeks later, however, announcing a six-month medical leave. During that time, he received a liver transplant that came to light two months after it was performed.

Methodist University Hospital Transplant Institute in Memphis, which performed Jobs' 2009 transplant, said Monday that he is not a patient. It declined to comment on his current condition.

Medical experts who do not treat Jobs can make some educated guesses.

Dr. Michael Poryako, medical director of liver transplantation at Vanderbilt University Medical Center in Nashville, listed a slew of conditions that might be affecting Jobs, including jaundice and kidney and vascular problems — not to mention side effects from the immunosuppressant drugs patients take following an organ transplant.

However, he said it's unlikely Jobs' body is rejecting his liver two years after the transplant.

"If the liver is functioning appropriately, people tend to return to normal muscle mass and normal physiologic functioning, which makes them feel better and look better," he said.

Dr. Roderich Schwarz, director of surgical oncology at the University of Texas Southwest Medical Center, said it is possible cancer has invaded Jobs' new liver.

Schwarz, who also has not treated Jobs, said it's possible the CEO is also having problems linked to his initial surgery targeting the pancreas, which controls key digestive enzymes.

Apple's board members approved Jobs' request for medical leave. Most did not immediately return messages seeking comment.

Arthur Levinson, chairman of Genentech Inc., declined to comment. Millard Drexler, CEO of J. Crew Group, was unavailable for comment, according to a spokeswoman. Former U.S. Vice President Al Gore referred a reporter to Apple's press office.

___

AP Technology Writers Dana Wollman in New York and Rachel Metz in San Francisco and AP Business Writer Sandy Shore in Denver contributed to this report.

Prognosis for Gabrielle Giffords

Here is the latest updated from the Associated Press about Gabrielle Giffords.

Although Gabrielle Giffords recovery from the gun shot wound to her head is impressive this far, the need for a tracheostomy and gastric tube suggests her hospital course will be long and complicated.

When the conversation changed from extubate and feed to tracheostomy and percutaneous gastric tube, questions regarding her ability to protect her airway and swallow secretions arise.

Keep Ms Giffords in your prayers!

Doctors remove bone chips from Rep. Gabrielle Giffords eye socket

AMANDA LEE MYERS and BOB CHRISTIE, Associated Press Amanda Lee Myers And Bob Christie, Associated Press

TUCSON, Ariz. – The husband of Rep. Gabrielle Giffords has told doctors and an interviewer that his wife has improved so much that she has been able to smile and give him a back rub from her hospital bed.

The encounters with astronaut Mark Kelly are new signs of Giffords' impressive progress in recovering from a gunshot wound to the head at a political event nine days ago.

"She knows that he's there, and from what we can tell from the fixation of her eyes, she is interacting with him," said Lynn Polanski.

By fixation, Polanski meant that Giffords' eyes were focusing, although it's not clear how much she can see and doctors won't know that until they talk to her. Giffords still cannot speak, because of a tube in her throat that is helping her breathe.

"She cannot vocalize, but she certainly can mouth words when she's ready to do that," said Dr. Randall Friese.

Kelly also told doctors he saw Giffords smile. Sometimes people see what they want to see, but that "if he says she's smiling, I buy it," Friese said.

Besides the tracheotomy for breathing, Giffords also had a feeding tube inserted Saturday.

And doctors successfully performed a surgery on Giffords' eye socket to remove bone fragments to relieve pressure on her eye. There were no complications from the surgery, said Dr. Michael Lemole.

Kelly told Diane Sawyer of ABC News in an interview to air Tuesday that his wife is now able to move around well enough that she gave him a back rub from her hospital bed.

"(It is) so typical of her. She's in the ICU. You know, gone through this traumatic injury. And she spent 10 minutes giving me a neck massage," Kelly explained. "I keep tellin' her. I'm like, 'Gabby, you're in the ICU. You know, you don't need — you know, you don't need to be doin' this.' But it's so typical of her that no matter how bad the situation might be for her, you know, she's lookin' out for other people."

The gesture seemed to comfort Giffords and shows that his wife is improving and that her spirit and their personal bond remain strong, he said.

Surfer’s Sinusitis

Fast Times at Ridgemont High was required viewing for the 80’s surfer. Sean Penn’s depiction of Jeff Spicoli set the high (or low) watermark for countless dawn patrollers of the decade. Both surfing and Sean Penn progressed but the 1982 movie offers an example of a current surf disease. Remember Spicoli’s high nasal voice, “No shirt, no shoes, no dice!”? This is a sign of the medical condition, ‘Surfer’s Sinusitis’.

Surfer’s Sinusitis is inadequately described in the medical literature. Your complaints of frontal sinus pressure, post nasal drip, productive coughs, and a Jeff Spicoli’s nasal voice may puzzle your land-locked doc. One recent question posed by a reader to the surf magazine Carve tearfully described how his physician told him to stop surfing because of his recurrent sinusitis. The magazine editor recommended referral to an Ear, Nose and Throat specialist, which is excellent advice. Maybe this column can save you the trip.

Do you have Surfer’s Sinusitis? To some degree all wave riders do. The Paranasal sinuses are air filled spaces within the bones of your skull that communicate with your nasal cavity. When you duck dive or face plant, salt water enters your nose and then your Paranasal sinuses. Perhaps you remember the enormous amount of water draining from your nose at those inopportune times: the

meeting with the boss, while sitting in class, the cusp of romance? Thank your nasal sinuses for accumulating a little ocean with each wave. That river from your nose is embarrassing enough but there are a number of other health concerns, especially when you consider the high levels of pollution in the water. Do you have a low grade, frontal pressure that can turn into a headache as the day progresses? Your Paranasal sinuses are filled with salt water. Has that productive cough lasted for weeks? When you sleep, instead of draining out your nose the ocean water will drain back down your throat and into your lungs. This drainage can lead to bronchitis and even pneumonia.

There is a more serious health concern related to Surfer’s Sinusitis, which is the entry of bacteria into your body. In January of 2001 a patient presented to my hospital with mental status changes. His pregnant wife stated he was acting strangely and when I examined him he could barely answer my questions. This patient complained of a severe headache, nausea, vomiting and a fever. During the exam he lapsed into a coma. I remember him well in part because his brother told me he surfed the frequently polluted waters of Malibu everyday. A CT of the head noted a large frontal mass consistent with a cerebral infection. His situation could have required emergent removal of his skull to decompress the pressure on his brain. Long story short he responded well to the antibiotics and after months of rehab, surfed another day. You may have heard about the surfer, Timmy Turner. His many successes include the 2004 Surfer Magazine Video of the Year. Mr. Turner acquired a Staphylococcus infection, which led to a CNS infection and cerebral swelling. The infection nearly took Mr. Turner’s life, although after multiple surgeries and a long recovery he recently presented at the 2006 Surfer Award ceremony. My understanding of his case is that the route of entry for the Staphylococcus infection was uncertain; the Paranasal sinuses could be the source.

So what can you do? Make friends with your doctor, maybe print this article out and ask her if your symptoms fit Surfer’s Sinusitis. Maybe ask for a referral to an Ear, Nose, and Throat specialist. You can also try a few of my tricks. The first is to be aware of the previous symptoms and after a day filled with a face plants or a number of duck dives take generic, over-the-counter Sudafed 10mg as directed (which is up to every 4 hours). Twice a day works for me. Ibuprofen 600mg will help with the headache. There are a couple more tricks for surfers who are miserable because of Surfer’s Sinusitis. Their sinusitis is more severe and frequently requires antibiotics. If this is you, discuss with your doctor your recurrent sinusitis and request a few refills of antibiotics so you can initiate treatment at the onset of your symptoms. This way you can shorten the infection and avoid the complications. And lastly, you could also wear a nose clip. Yep I wear one of these ‘Kook clips’. They are officially called by swimmers ‘competition nose clips’. I bought mine for $3.00 at swimthings.com but shop around and find the cheapest site. Purchase a few because the shipping will cost as much as the clip. Tie down the clip to your rash guard or wet suit with 6lb test fishing line. Without question wearing a nose clip decrease the episodes of Surfer’s Sinusitis. We will discuss how to deal with the taunts in another column.

Surf Safe!
Dr. Jude