Well, the forecast was for a very windy day, more windy than we’d like. On the other hand, it was bearable on the Terry Trueblood Trail. However, the forecast is for high winds and hail and we’re not looking forward to that.
The highlight was seeing a leucistic Canadian Goose for the first time. They’re rare. It’s a color variation. The one we saw had a brownish head and white feathers on its body.
It was a great day for bird watching.
I’m just about fully recovered by a sudden case of shin splints and calf cramps in both legs this past Monday. I did no running, just walked for a little over 4 miles between our house and the shopping mall.
I thought I was doing pretty well until I got about a half mile from home. I had to cross a relatively busy street that doesn’t have a traffic light control, just a sign that suggests drivers slow down and stop for pedestrians in the crosswalk. Many drivers breeze through at around 30 mph and so I generally wait until there’s no traffic or when cars slow down enough that I can’t see the driver’s maniacal grin.
As a few cars waited, I began to cross the street and about halfway over, I started to trot and immediately both my calves cramped up. It was painful and I just managed to limp over to the sidewalk. As I leaned over and tried to ease the cramps by grabbing my toes and bending them toward my shins, I wondered why that happened.
Part of the reason was this was the first long walk of the spring after a winter of being relatively sedentary, other than some routine exercises including stationary bicycle, step box, and stretching routines.
I’m used to shin splints, which I noticed before the leg cramps. But I’ve never had both calves cramp like that. I’d gotten enough fluids, I wasn’t dehydrated, and I wasn’t low on electrolytes. Then, I got curious about the interplay of all those and found out there’s a fair amount of controversy about the causes of what I found out was called exercise-associated muscle cramps (EAMC)
Shin splints are a minor annoyance and could be due to me just being an old guy overdoing it and wearing not the greatest shoes on a concrete trail. Resting a while is the main way to get past it. But because of the double whammy of bilateral shin splints and calf cramps, I hunted on the internet for studies of the causes of EAMC, specifically calf cramps.
I’m sure most readers are familiar with web resources like the Cleveland clinic, which provide general guidance. They usually recommend avoiding dehydration and staying up to speed on electrolytes. Rest is the main suggestion. Meditating over an oleomargarine figurine of Elvis Presley is not recommended but has not been sufficiently studied.
Anyway, I found an interesting web site which challenges the usual guidance about the causes of EAMC. One of the authors of an article (“What Are the True Causes of Cramps While Running?” by Phattarapon Atimetin, MD; published May 15, 2019 on the website samitivejhospitals.com website) disputing the cause of EAMC being dehydration or mineral deficits pointed out that these are less likely than something called “altered neuromuscular control,” which appears to be advanced by a scientist named M.P. Schwellnus. However, the author didn’t cite any references, so I had to hunt them down. I think I found the right articles.
I found one the author didn’t mention, which was a comprehensive review (note the publication date, a few months after Dr. Atimen’s article):
Maughan RJ, Shirreffs SM. Muscle Cramping During Exercise: Causes, Solutions, and Questions Remaining. Sports Med. 2019 Dec;49(Suppl 2):115-124. doi: 10.1007/s40279-019-01162-1. PMID: 31696455; PMCID: PMC6901412.
The authors’ bottom line is:
Exercise-associated muscle cramp is a relatively common occurrence in a range of sport and exercise activities. Onset is generally unpredictable, and the intensity and duration of muscle spasms are highly variable. Spontaneous muscle cramping in occupational settings involving hard physical effort suggests that high ambient temperature and large sweat losses accompanied by the ingestion of large volumes of plain water may be risk factors, and there is some evidence that the risk is reduced by the addition of salt to ingested fluids. Laboratory models of cramp involve either voluntary or electrically-evoked activation of muscle held in a shortened position. These studies have produced mixed results regarding the effects of disturbances of water and salt balance on the risk of cramping; however, they do suggest that, at least in this model, sensory organs in the muscle invoke abnormal reflex activity that results in sustained motor drive to the afflicted muscles. There may be different mechanisms at work in different situations, and there is no conclusive support for any of the proposed mechanisms. Preventive and treatment strategies are not uniformly effective.
They mention M.P. Schewllnus, but they don’t endorse the altered neuromuscular control theory or any other as being explanatory in every case of EAMC. The review was supported by the Gatorade Sports Science Institute (GSSI), which makes me wonder about it a little.
I’m not certain but I think the references for the studies Dr. Atimen mentioned are below:
Schwellnus MP. Cause of exercise associated muscle cramps (EAMC)–altered neuromuscular control, dehydration or electrolyte depletion? Br J Sports Med. 2009 Jun;43(6):401-8. doi: 10.1136/bjsm.2008.050401. Epub 2008 Nov 3. PMID: 18981039.
Braulick, K. W., Miller, K. C., Albrecht, J. M., Tucker, J. M., & Deal, J. E. (2013). Significant and serious dehydration does not affect skeletal muscle cramp threshold frequency. British Journal of Sports Medicine, 47(11), 710-714.
Hoffman MD, Stuempfle KJ. Muscle Cramping During a 161-km Ultramarathon: Comparison of Characteristics of Those With and Without Cramping. Sports Med Open. 2015;1(1):24. doi: 10.1186/s40798-015-0019-7. Epub 2015 May 21. PMID: 26284165; PMCID: PMC4532703.
The reference below is more recent and the authors’ bottom line is below:
Kevin C. Miller, Brendon P. McDermott, Susan W. Yeargin, Aidan Fiol, Martin P. Schwellnus; An Evidence-Based Review of the Pathophysiology, Treatment, and Prevention of Exercise-Associated Muscle Cramps. J Athl Train 1 January 2022; 57 (1): 5–15. doi: https://doi.org/10.4085/1062-6050-0696.20
Advances in our understanding of EAMC pathogenesis have emerged in the last 100 years and suggested that alterations in neuromuscular excitability and, to a much lesser extent, dehydration and electrolyte losses are the predominant factors in their pathogenesis. Strong evidence supports EAMC treatments that include exercise cessation (rest) and gentle stretching until abatement, followed by techniques to address the underlying precipitating factors. However, little patient-oriented evidence exists regarding the best methods for EAMC prevention. Therefore, rather than providing generalized advice, we recommend clinicians take a multifaceted and targeted approach that incorporates an individual’s unique EAMC risk factors when trying to prevent EAMCs.
The review was not supported by Gatorade. It turns out the best management is rest and gentle stretching. If that doesn’t work, the advice is to seek advanced medical care. There is no evidence that meditating over an oleomargarine figurine of Elvis Presley is effective in any way—although, again, it has not been studied that I know of.
I watched another episode of the Red Green Show last night called “Coup De Grass.” The one flaw in watching the episodes are commercials, which were rare when I started making my own YouTube videos years ago. Now they’re about as frequent as they are on TV.
The one good thing about commercials on YouTube is that I can click the “skip ad” button, which interrupts them.
Anyway, “Coup De Grass” was good for several chuckles, but I admit I scratched my head a little over the main sketch comedy skit. It was the what the title of the episode was about, and you might get what the parodic title means here.
The introduction opens with Red Green talking about the grass seed he accidentally spilled on the paint and chemical covered floor of his garage. It was a “horticultural breakthrough” because the grass grew only a couple of inches tall, which he though he could make a fortune on.
The next two segments I overthought and realized only later that the idea involved the mutant grass growing very tall and getting smelly and sticky—like the paint and toxic ooze in the garage it sprang from.
What confused me was that, after planting the grass outside the lodge, Red and the other cast members gradually developed abnormal walking with their feet sticking to the floor at every step. They also started to turn green. It reminded me a little of the Silly Walking episode on Monty Python’s Flying Circus.
Actually, the point of the silly walking is that they got contaminated by the grass, which quickly grew tall, sticky, and smelly.
So, who or what actually delivers the “coup de grass” or killing blow and who or what gets “killed?” I could take a stab at the answer, but that might be a spoiler.
This episode of Rounding@Iowa is about important medical advances in the treatment of pancreatic cancer. As you listen to Dr. Clancy interview Dr. Joseph Cullen about what’s new, you’ll hear a lot about high-dose intravenous Vitamin C. This can enhance treatment and improve response to chemotherapy and radiation therapy. Dr. Cullen’s most recent study about this technique showed the overall survival of patients with late-stage pancreatic cancer increased from 8 months to 16 months.
Reference:
Kellie L. Bodeker, Brian J. Smith, Daniel J. Berg, Chandrikha Chandrasekharan, Saima Sharif, Naomi Fei, Sandy Vollstedt, Heather Brown, Meghan Chandler, Amanda Lorack, Stacy McMichael, Jared Wulfekuhle, Brett A. Wagner, Garry R. Buettner, Bryan G. Allen, Joseph M. Caster, Barbara Dion, Mandana Kamgar, John M. Buatti, Joseph J. Cullen,
A randomized trial of pharmacological ascorbate, gemcitabine, and nab-paclitaxel for metastatic pancreatic cancer,
Redox Biology,
Volume 77,
2024,
103375,
ISSN 2213-2317,
(https://www.sciencedirect.com/science/article/pii/S2213231724003537)
Abstract: Background
Patients with metastatic pancreatic ductal adenocarcinoma (PDAC) have poor 5-year survival. Pharmacological ascorbate (P-AscH-, high dose, intravenous, vitamin C) has shown promise as an adjunct to chemotherapy. We hypothesized adding P-AscH- to gemcitabine and nab-paclitaxel would increase survival in patients with metastatic PDAC.
Methods
Patients diagnosed with stage IV pancreatic cancer randomized 1:1 to gemcitabine and nab-paclitaxel only (SOC, control) or to SOC with concomitant P-AscH−, 75 g three times weekly (ASC, investigational). The primary outcome was overall survival with secondary objectives of determining progression-free survival and adverse event incidence. Quality of life and patient reported outcomes for common oncologic symptoms were captured as an exploratory objective. Thirty-six participants were randomized; of this 34 received their assigned study treatment. All analyses were based on data frozen on December 11, 2023.
Results
Intravenous P-AscH- increased serum ascorbate levels from micromolar to millimolar levels. P-AscH- added to the gemcitabine + nab-paclitaxel (ASC) increased overall survival to 16 months compared to 8.3 months with gemcitabine + nab-paclitaxel (SOC) (HR = 0.46; 90 % CI 0.23, 0.92; p = 0.030). Median progression free survival was 6.2 (ASC) vs. 3.9 months (SOC) (HR = 0.43; 90 % CI 0.20, 0.92; p = 0.029). Adding P-AscH- did not negatively impact quality of life or increase the frequency or severity of adverse events.
Conclusions
P-AscH− infusions of 75 g three times weekly in patients with metastatic pancreatic cancer prolongs overall and progression free survival without detriment to quality of life or added toxicity (ClinicalTrials.gov number NCT02905578).
Keywords: Pancreatic neoplasms; Ascorbic acid; Controlled clinical trial; Gemcitabine; Nab-paclitaxel
Dr. Cullen mentions that patients contact him not infrequently to ask if taking high-dose oral Vitamin C will help them achieve similar results. Unfortunately, it will not. Giving it intravenously facilitates giving much higher doses. The study had a relatively small number of participants, which limited ascertainment of quality of life.
On the psychological side, there are ways to bolster the mental health challenges of those with pancreatic cancer, which typically has a grim outcome in terms of survival:
Spiegel D. Mind matters in cancer survival. Psychooncology. 2012 Jun;21(6):588-93. doi: 10.1002/pon.3067. Epub 2012 Mar 21. PMID: 22438289; PMCID: PMC3370072.
Further, Dr. William Breitbart, MD, Chair of the Department of Psychiatry and Behavioral Sciences at Memorial Sloan Kettering Cancer Center was interviewed in 2021 and emphasized the need for bolstering mental health for those diagnosed with pancreatic cancer. According to Breitbart, “Pancreatic cancer triggers an inflammatory response in the body, which can lead to mood disorders,” Breitbart explains. Psychiatrists can prescribe certain antidepressant medications that directly target that inflammatory response.”
I was clicking through the web the other day and came across something that triggered a distant memory—The Red Green Show. It was a Canadian sketch comedy TV program that ran between 1991 and 2006.
I used to watch it and now I can’t see how I ever found the time to do that. I was in medical school between 1988-1992, and was in residency between 1992-1996. After that, I was on staff in the psychiatry department at University of Iowa Health Care.
The Red Green Show was on in the evening and it caught my attention like a couple others: Monty Python’s Flying Circus and Red Dwarf (a really quirky outer space show), which came on just before the Red Green Show. I’ve always been big on comedy, but I just don’t know how I ever found time for it. I was usually pretty tired or up all night on call.
Anyway, there’s this Red Green web site where you can watch all the episodes over the 15 years it was on—for free. The big star was Steve Smith, who played Red Green. The web site marketing all the old shows and T-shirts and whatnot is based in Overland Park in Kansas City, Kansas. Figure that one out, a Canadian TV show now selling souvenirs and Possum Lodge membership cards in Kansas City.
The show won a Canadian Gemini Award (similar to the Academy Emmy Award in America) for comedy in 1998.
If you watch one of the episodes, it’ll make you scratch your head about the notion of making Canada the 51st state, but I won’t get into it.
I had a book written by Steve Smith a long time ago but I can’t remember which one it was. I think it had a red cover. Maybe it was “How to Do Everything.” It’s a guide for do-it-yourself and self-help. That’s a hoot because I can barely tie my shoes, much less fix anything. On the other hand, neither could Red Green.
I watched the first YouTube episode from 1991 and it made me chuckle. I admit that one of the Red Green quotes, the Man’s Prayer, fits me like a fishing vest (I don’t fish!):
“I’m a man, but I can change, if I have to…I guess.” Red Green.
Today’s post connects weirdly with the one I wrote yesterday entitled “The Zamboni Effect,” in which I mistakenly believed I had invented the term “Zamboni Effect” based on my observation of what an ice resurfacing machine did to an ice rink in a local mall. It clarified the ice and also metaphorically, by extension, clarified relationships from the past viewed in the present—sort of.
As a reminder, the ice resurfacing machine was first invented in 1949 by a guy named Frank Zamboni. A lot of companies with different names make them nowadays but people still tend to call them all Zambonis.
Just for fun, I looked up the “Zamboni Effect” on the web today and it returned a few surprising results. Among the different meanings of the Zamboni Effect:
And for all I know, there may be other meanings for the Zamboni Effect that just never made it to the internet.
I was walking around the mall today doing ordinary old guy things: watching the Zamboni machine resurface the ice rink, which I’ve never seen before, by the way. The surface was pretty dull before the Zamboni team started. There were two kids in the seat, one young lady driving and the other young man pointing out spots she missed. They went around and around getting the thin layer of water on the whole rink while eager skaters waited to get out there. They rejuvenated the rink, got it shining like crystal and skaters spun, twirled, and had a great time. It was the Zamboni Effect.
After that, I got up and did my usual thing, looked at books in Barnes & Noble, got a bite to eat, wondered why the mall security guy was walking by the bench so often where I was sitting. After his third pass, I got up and did my best to look like a solid citizen who is aware that loitering might look sinister to some mall security guys.
And when I wandered back to the tables next to the ice rink, I sat down again because the mall security guy was nowhere in sight. While I was just zoning out watching people pass by, one of them stopped and made a funny face at me. For a half-second, he didn’t register in my memory and then he called me by name. I suddenly recognized him as a former resident in the Medical-Psychiatry training program at University of Iowa Health Care (UIHC). It was Ravneet, one of the best trainees I have ever had the pleasure to work with.
It was kind of a shock. He had left for a great position with a health care organization out in Arizona many years ago and is very successful. He and his wife and daughter were on vacation and were walking through the mall. His son is also a high-level performer in science but he was not with them today. Ravneet takes time out every so often to travel like that. I’m sure it helps rejuvenate him—kind of like how the Zamboni machine rejuvenates the ice rink–the Zamboni Effect.
We exchanged pleasantries, he took a selfie with me, and I forgot to ask him to send me a copy, probably because I was so flabbergasted at running into him at the mall. It really brightened my day. Again—the Zamboni Effect. I really felt rejuvenated.
Every now and then, we all need the Zamboni Effect. Maybe it could even help the mall security guy.
The thing about this movie we saw last night on the Svengoolie show, “The Thing That Couldn’t Die,” is that it heads in the wrong direction from the start—with a woman who douses for treasure. Dousing or witching for water or other things employs a special stick or rods to find objects buried underground. I actually saw this many years ago when I worked as a land survey crew member and watched an old guy use dousing rods to find buried water tile lines in a field. I remember one guy in my crew mentioned under his breath that the guy was probably old enough to remember where the tile line was originally buried.
Anyway, this film was released in 1958 and the general idea is that a sorcerer named Gideon Drew was beheaded by Sir Francis Drake 400 years ago. The head was buried in a box and the rest of the body was buried somewhere else. This would ensure that Gideon would suffer for all eternity—as long as nobody used his head to figure out that if you reconnected Drew’s body and his head, he could again commit mayhem.
Jessica is a seemingly empty-headed woman who is really able to find important objects by dousing. She finds the box containing Gideon’s head and a special charm necklace that protects her (at first) from Gideon’s ability to get inside your head.
Gideon possesses the deadhead character Mike because he’s the one who first opens the box. He then kills his controlling buddy, Boyd, who yells his head off, waking up Peggy’s Aunt Flavia, the owner of the land on which the box was found. Aunt Flavia has a head for figures because she runs the dude ranch where all the characters are and realizes that the box contained something valuable, learning later that she could get $5,000 for it from an archaeologist.
Mike drags Boyd’s body around in the woods by the head for a while, eventually dropping it into the hole where the box was originally found, but then gets killed off early in the movie. The actor, Charles Horvath, was ticked off about it and later went on to form the well-known rock band, the Ungrateful Head.
Meanwhile, Linda, who earlier invited Jessica to a square dance who declined because she preferred head banger music, gets hypnotized by Gideon. Linda then puts Gideon in a hatbox, which she gifts to Jessica after Jessica’s wannabe boyfriend, Gordon, takes the charm away from her to get it cleaned up. When Jessica opens the hatbox, Gideon zaps her, causing her to become a bad girl. Linda slaps her boyfriend Hank in the head a couple of times, which leads him to head back to their cabin to tear up his painting of her portrait and get his head bad by drinking whiskey.
Linda, Jessica, and Hank all get pretty drunk, and eventually Jessica decides to witch for the body of Gideon Drew, which she finds and the action starts coming to a head—Gideon’s head that is.
Jessica replaces Gideon’s head on his body. He integrates into the consistency of grayish head cheese and his vocal cords start working. The gang’s all there and Gideon threatens everybody and starts to bully them. Gordon tries to shoot him but bullets don’t work, and he then gets his head on straight, remembering he has the charm necklace. Gordon points it at Gideon, who reacts like Dracula does to a crucifix and almost immediately jumps back into the coffin his body was buried in, where he disintegrates.
Gideon’s spell is broken and a good time was had by all with nothing left to suffer but a mild headache from the whiskey hangover.
The moral of the film’s story is lost in all the interpersonal drama, but it might be that if you’re having trouble with water witching for drain tile lines, you should not lose your head because you can probably find a map of tile line locations in the city engineer’s office.
This week was what the Iowa Legislature calls funnel week. Today determined what bills stay alive and which one die.
The bills opposing vaccines died for this legislative session:
“mRNA vaccines: Senate File 360 proposed a ban on health care providers administering gene-based vaccines, like the COVID-19 vaccines developed by Pfizer and Moderna. Under the proposal, health care providers who administered vaccines that use nucleic acids like messenger RNA (mRNA) would face punishments of a misdemeanor charge and a fine of $500 for each violation.”
“Vaccine manufacturer immunity: House File 712 proposed requiring vaccine manufacturers waive their immunity from lawsuits over injuries that result from a “design defect” in a vaccine in order to distribute or administer the vaccine in Iowa. Under the 1986 National Childhood Vaccine Injury Act, there is a National Vaccine Injury Compensation Program providing no-fault compensation to individuals and families injured by childhood vaccines. While supporters of the bill said the current compensation program has problems, medical practitioners and advocates said allowing for lawsuits to be filed against manufacturers would prevent vaccines from being available in Iowa.”
Story published in Iowa Capital Dispatch, “Funnel week 2025: What bills are alive, dead at Iowa Statehouse after first deadline” by Robin Opsahl. March 7, 2025.
Beats me. Sorry, just kidding. I’m just a little bleary from looking at the web sites about the definition of “design defect” related to vaccines as it applies to the Iowa bill to make vaccine manufacturers waive their immunity from lawsuits about vaccine related injuries.
I am sympathetic to anyone who in fact has suffered a vaccine related injury.
That term “design defect” has been bugging me for days now and I just found out that this has been the subject of states vs federal legal wrangling for years. I’m not up to explaining all the legalese but there is a really tangled trail of cases in Georgia and Pennsylvania roughly around 15 years ago that ultimately led to a U.S. Supreme Court decision saying, essentially, the Vaccine Injury Compensation Program and the federal Childhood Vaccine Injury Act of the 1980s preempts all state level vaccine design defect claims.
I think that explains why the Iowa bill says that vaccine manufacturers have to waive their immunity from suits if they want Iowans to get their vaccines.
I can hear the groans and shouts of dissent even as I write this. Hey, you can’t make this up. Talk to your legislator or lawyer about it.
I’m not sure why Iowa would want to repeat the grind that Georgia and Pennsylvania went through which led to the conclusion that you can file vaccine design defect claims at the state level and not have to repeat history which would likely lead to any decisions made there being reversed in federal court.
And I’m not sure why any vaccine manufacturer would want to fight that battle in Iowa either. They might just steer around us and take their vaccines elsewhere.
The beginning of the Georgia story.
The end of the Georgia story.
The beginning and the end of the Pennsylvania story.
Vaccines aren’t perfect. They are neither 100% safe nor 100% effective. However, I support having vaccines available to help keep us healthy and the right to choose getting a vaccine. That’s why I don’t support a bill that I believe would make them less accessible.
Go Retire Psychiatrist 