John C Hagan III, MD, FACS, FAAO  
Kansas City, MO

Specialties: Ophthalmology

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Marathon Running Done Over Many Years Bad For Heart

May 21, 2015 - 77 comments

Marathon Running Harmful

Marathons: In the Long Run Not Heart Healthy
John C. Hagan III, MD & James H. O’Keefe, MD

As the June7, 2014 Hospital Hill Half-Marathon “run up” commences, disturbing research is accumulating about potential cardiovascular dangers of exercising at maximal levels for durations over an hour, especially after age 40.  While this type of ‘excessive endurance exercise’ can occur with cross-country skiing, long distance swimming, triathlons, and 100+ mile bike races, the prototype activity is marathon running.
The first marathon occurred about 2500 years ago by the messenger Pheidippides who ran the 26.2 miles from the plains of Marathon to Sparta there proclaiming the Greek victory over the Persians. History records his first words were, “Joy to you, we’ve won.” Less certain are his last words, perhaps “My feet are killing me” before dropping dead.
Incredibly many physicians and the public have misinterpreted Pheidippides’ fatal run as healthful. In 2014 there are 739 marathons scheduled in the United States and Canada. It is estimated that over a half million people will complete a marathon this year. 100 mile ultra-marathons are common and worldwide months long extreme-endurance races of over 3000 miles exist.

Research published in the April 2014 Missouri Medicine: The Journal of the Missouri State Medical Association, a peer-reviewed medical journal, found that long-distance running over decades of life may cause a greater than normal buildup of calcified “hard” plaque and the more dangerous fatty “soft” plaques in the vital coronary arteries that supply the heart muscle. Lead authors Robert S. Schwartz, MD, of the Minneapolis Heart Institute, and James H. O'Keefe, MD, Saint Luke's Mid America Heart Institute, Kansas City found that long-term participation in marathon training and racing is paradoxically associated with increased coronary plaque volume. Since most marathon runners believe their long hours exercising, sometimes logging over a hundred miles per week for years on end, creates a strong healthy heart, or at least does not damage this vital organ, this new information is perplexing and shocking. Nevertheless, daily and less strenuous exercise remains one of the most important facets of getting and staying healthy.
Regular exercise and high levels of physical fitness are linked to lower risks for cardiovascular diseases and improved life expectancy. Four decades ago Thomas Bassler, MD, an American physician, reasoned that if some exercise was good more had to be better, and famously hypothesized that marathon running confers immunity against coronary plaque buildup and heart attacks. In the current study, Bassler’s theory—long term marathon running protects against coronary atherosclerosis—was tested by quantitatively assessing coronary artery plaque using high resolution coronary computed tomographic angiography (CCTA) in veteran male marathon runners.
To qualify for the study the long distance runners had to have completed at least one marathon each year for 25 consecutive years. The control subjects were a group of apparently healthy men who had never been regular vigorous exercisers but who were similar to the marathoners in age and other general cardiovascular risk factors. The 50 male marathon runners, as compared to the 23 inactive male controls, had increased total heart artery plaque volume, calcified plaque volume and non-calcified plaque volume. Although other medical studies had indicated that marathon running can cause accumulation of the less dangerous “hard” plaque this was the first time “soft” plaque was also found to be elevated. Soft plaque rupture and clot formation is felt to be the most common cause of heart attacks and sudden cardiac death.
Additionally, a Missouri Medicine editorial overview of excessive endurance exercise by prominent cardiologists Peter McCullough, MD, of the Baylor Medical Center, and Carl Lavie, MD, of the John Ochsner Heart and Vascular Institute, conclude that in marathon runners the chronic stress of endurance training for long periods of time may stiffen the heart arteries predisposing them to hardening and becoming partially blocked. Unlike other sports because the heart is pumping 5-8 times as much blood as during rest, marathon runners while training and racing hold this heavy strain on the heart for a very long time without rest breaks.  When this happens, it may stretch the heart chambers and lead to scar formation in the cardiac muscle.  Scar tissue in the heart is the cause of lethal heart arrhythmias and cardiac arrest in some of the highly publicized cases of seemingly healthy marathoners who die during training or long-distance running events. These deaths include 57 year old ultra-marathoner Micah True, also known as Caballo Blanco featured in the best-selling book Born to Run and 52 year old Jim Fixx author of The Complete Book of Running. Both died while running. Boston Marathon winner Alberto Salazar at age 47 was luckier and was successfully resuscitated after sustaining a heart attack while running, collapsing unconscious and without a pulse for 14 minutes.  

Future research is needed to find who is susceptible to having this happen, why, and how can we best train and exercise and enjoy the benefits without taking on life-threatening risks. One such test is a Heart CT Scan.  This relatively quick and painless examination can measure calcium deposits in the heart arteries. These calcium deposits are indicative of plaques in the coronary arteries. A normal value is zero but numbers over a 100 are associated with increasing risks of heart disease including angina, heart attacks and cardiac death. St. Luke’s Hospital offers Heart CT tests for $50 which is usually not covered by insurance. Tests can be scheduled by calling XXXXXX. No physician referral is required.
Exercise might be best understood as a drug with powerful benefits, especially for cardiovascular health. As with any potent drug, establishing the safe and effective dose range is critically important—an inadequately low dose may not confer full benefits, whereas an excessive dose might produce harmful effects that outweigh its benefits. Running marathons for decades is an excessive amount of exercise, predisposing to an increased coronary artery plaque buildup despite favorably altering many risk factors such as weight, blood pressure and risk of diabetes. A more moderate dose of exercise is a better strategy for promoting long-term cardiovascular health and durability.
An example of a sensible and time efficient ‘exercise prescription’ is shown in figure 1. Before starting or increasing exercise programs have a physical examination and discuss your exercise prescription with your personal physician.
Nothing in this new research invalidates that the most important and under-utilized “wonder drugs” for health maintenance are regular moderate exercise, a good diet, body weight vigilance, avoidance of all nicotine use, for those that drink alcohol no more than 2 drinks per day-ideally red wine, drive carefully and always fasten the seatbelt, get plenty of sleep, develop a social network of friends, have a pet─preferably a dog to walk─ and a satisfying spiritual-religious belief system.



About the authors:
John C. Hagan III, MD is the Editor of Missouri Medicine and a Discover Vision Centers-Northland ophthalmologist. He is a former marathon runner and current daily walker-swimmer.

James H. O’Keefe, MD is a nationally known preventive cardiologist with the Mid-America Heart Institute at St. Luke’s Hospital, Kansas City. He is a daily moderate exercising runner. He and his dietician wife Joan authored “Let Me Tell You a Story: Inspirational Stories for Health, Happiness and a Sexy Waist” (McNeel Publishing, 2013)

New Article on Multifocal IOL vs "Mini-monofocal" 2015

May 21, 2015 - 35 comments

Mini-monovision Versus Multifocal Intraocular Lens Implantation

Labiris G, Giarmoukakis A, Patsiamanidi M, Papadopoulos Z, Kozobolis VP

J Cataract Refract Surg. 2015;41:53-57

Study Summary

This study was performed by a team of investigators from Alexandroupolis, Greece, who compared levels of spectacle independence and visual symptoms in cataract surgical patients.

Two groups of age-matched patients with no ocular abnormality underwent cataract surgery performed by the same surgeon. One group received a refractive multifocal IOL (Isert PY60MV; Hoya Surgical Optics, Inc.) with both eyes targeted for plano, whereas the other comparative mini-monovision group received a monofocal aspheric IOL (SN60WF; Alcon Laboratories, Inc.) targeted for -0.50 D in the dominant eye and for -1.25 D in the other eye.

Pre- and postoperative evaluations were obtained with the Visual Function Index-14 (VF-14) to determine visual symptoms and general visual functionality. Uncorrected binocular near and distance vision were assessed, as well as the proportion of patients who were spectacle-dependent for near and distance vision.

Both the multifocal and mini-monovision groups achieved good binocular uncorrected distance vision. The multifocal lens provided better overall near vision than the -1.25 D target for mini-monovision. There were no differences between the two groups in contrast sensitivity, stereopsis, or VF-14 items pertaining to distance or near vision.

Approximately twice as many multifocal patients (66%) reported being spectacle free compared with mini-monovision patients (34%). However, dysphotopsia (shadows and glare) occurred much more frequently in multifocal patients than in mini-monovision patients.

COMMENTS: William Cuthbertson MD
Although two thirds of the multifocal group was "spectacle-free" in this study, spectacles are not expected to provide relief from dysphotopsias in multifocal emmetropic patients; therefore, patients would be "spectacle-free" no matter what their visual function.

An additional question that could be posed in these studies comparing multifocal IOLs with monovision would be, "Is your vision adequate to do everything that you want to do with ease, including if you wore glasses when you need to?" If the occasional need to wear glasses is included, the excellent vision without dysphotopsias afforded by monofocal monovision would reflect a very high level of visual satisfaction in virtually all patients.

In conclusion, although the term "mini-monovision" could be better defined for study purposes, the concept of providing proximal-range, convenient, and usually spectacle-free vision with simple monofocal IOLs is very appealing. It maintains justifiable advantages over more expensive, and sometimes problematic, multifocal IOLs.

New Cannabis Article from NORTH Magazine July/Aug 2014

Jul 20, 2014 - 10 comments


At one time asbestos used in school construction, doctors recommending cigarettes to soothe sore throats and putting cocaine in soft drinks seemed like good ideas. Now we can only wonder, “What were they thinking?”  Perhaps we can forgive our forebears because scientific evidence of the cancer causing properties of asbestos and tobacco and the addicting and health destroying nature of cocaine was not in existence at the time. That is not the case with marijuana.
Its unlikely future generations will absolve us of responsibility if the recreational and medical use of marijuana becomes national. The number of states permitting medical marijuana (23) and recreational cannabis for adults (Washington and Colorado) continues to increase. Short summary—bad idea!  As research physicians we present the known adverse health implications of marijuana use.
While generally mellow, marijuana users only seem to become angry and agitated when any suggestion is made that their pot use might have adverse consequences. When we wrote on this subject in the Kansas City Star, they had to shut down The Star website discussion because of all the abusive and vulgar postings. It’s obvious that stoners would rather get mad than carefully consider any contrary evidence to their mental construct that chronic marijuana use is harmless fun.
The high growing cannabis plant has been used commercially in the United States since colonial times when it was imported from Caribbean countries. It was refined or spun into cloth, ropes, wax, resins, paper, fuel, pulp and other useful products.  The Caribbean natives were aware of the psychoactive effects of smoked hemp which they called “ganja”. Presently smoked cannabis plant is also known by many monikers most commonly:  pot, weed, Mary Jane, reefers, roach, buds, joint, green, and back to its original roots—hemp and rope.  
The potency of present day marijuana is from 5 to 20 times stronger that the hippie “grass” used in the 1960’s. That increases the habituating and addicting properties of tetrahydrocannabinol (THC) the major cannabis psychoactive ingredient. This accounts for the rising annual number of emergency room visits (400,000+) for panic attacks, acute psychosis and toxicity.  A review of medical and mental damaging effects of marijuana can be found in Missouri Medicine 2012. Suffice here to say that THC is especially dangerous to children under age 15 and increases the incidence of mental health problems, in some cases the risk of Schizophrenia is increased 10 fold compared to the general population. Ambition and drive is blunted, memory impaired and IQ may be reduced permanently by as much as 8 points. Driving and working while using marijuana dramatically increases the chance of accidents and injuries.
The rapidly expanding commercial marijuana industry e.g. the profitable California based Medbox Corporation, has already produced cannabis food (marijuana laced brownies to be sold in vending machines) and candy like cannabis concoctions with names like “Pot Tarts” and “Kif Kat Bars” that  appeal to youngsters.  Deaths have occurred in children who overdosed on ‘cannabis candy.”
As we reported in Missouri Medicine, “Proponents of cannabis use argue that smoking cannabis provides relaxation and pleasure, enhances the sense of well-being, contributes to stress relief, and helps to deal with hard reality. Of course any enhancement of well-being in a mentally healthy person through use of a psychoactive substance is in some sense an oxymoron. Furthermore, cannabis use alters cortical dopamine, which plays a major role in higher cognitive functions, working memory, executive function, etc. Hence, the “relaxed” feeling most cannabis users report as a desirable acute effect, in all likelihood reflects cognitive dulling (non- or a-motivated syndrome) caused by altered cortical dopamine balance. In other words the weight of evidence indicates that cannabis creates cognitive dulling rather than reduction in anxiety, indifference rather than relaxation, and amotivation rather than inner peace, all closer to psychopathology than well-being.”
Numerous medical studies have shown that chronic marijuana use can permanently impair memory, intelligence, coordination, driving ability, impulse control, damage the heart, lungs, immune system, liver and increase the risk of certain types of cancers. The younger the user and the more frequent the use of marijuana the more potential for serious health problems.  Australian psychiatrist David Castle, MD filled a 252 page text (Marijuana and Madness, 2nd Ed, Cambridge Press) with carefully referenced studies on physical and mental disease caused by marijuana. There were 49 respected contributing scientists from all over the world.
Already over 400 chemicals have been identified in marijuana including carbon monoxide, hydrogen cyanide and ammonia. “Hey man, you want a drag of cyanide and ammonia?” might not find as many takers among the tokers when the roach makes the rounds at parties.
The FDA and physicians rightfully consider cannabis a drug and subject to federally stipulated rigorous study protocols. The legislative route being used to introduce medical and recreational marijuana illegally and dangerously circumvents this FDA drug testing process. Federal law also mandates that marijuana use and possession is illegal but Presidents and the Justice Department have chosen to ignore the laws they swore to defend.
Legitimate FDA type research has been done on purified cannabis and useful products for cancer chemotherapy such as Marinol® and Cesamet® are available. These drugs do not produce psychoactive effects. The use of marijuana products such as “Charlotte’s Web” for childhood seizures and other illnesses is unproven, anecdotal and potentially harmful. Cannabis use for glaucoma treatment is never needed. Medical marijuana “cards” are widely abused. Searching on Google “How to fake needing a medical marijuana card” offers 871,000 helpful suggestions. The most frank and succinct being, “Like man you tell them you got pain. Every dude has pain. Pain work every time!”  
Although dependence and addiction to alcohol and nicotine are among Missouri’s biggest social and health problems, the legal use of booze and cigarettes are cited by marijuana activists as reasons to legalize pot. Less than 8% of Americans smoke marijuana while 52% use alcohol and 27% smoke nicotine cigarettes. Missouri has over 10,000 tobacco related deaths per year. Addiction and abuse of legal medications are more of a problem than illegal drugs.  Deaths from legal drug overdose exceed the number of deaths from automobile accidents and surpass all types of illegal drug deaths combined.  It is catastrophically illogical to introduce another public health problem and source of habituation and addiction to our already overwhelmed health and social welfare systems.
How should one account for nanny-state social planners and big city politicians demonizing sugar, banning trans-fats and large size soft drinks while giving marijuana a pass? Why does the bent-out-of-shape crowd  rail at ‘Big Tobacco, Big Food and Big Pharma” while ignoring “Big Weed” (e.g. CannabisInvestments.com) gearing up to make stores peddling smoked and eaten marijuana as ubiquitous as Starbucks and Subways?  Revenue from taxing marijuana has failed to achieve projections.
As physicians we regard recreational and sham-medical marijuana as a looming public health problem with adverse consequences that could eventually rival those of tobacco use and alcohol addiction.
Washington and Colorado are now conducting de facto social and scientific experiments on the problems of   widely available medical and recreational marijuana. Let’s wait at least five years to assess their results. Let’s stay off the “high” way.
Svrakic DM, Lustman PJ et al. Legalization, Decriminalization & Medicinal Use of Cannabis: A Scientific and Public Health Perspective. Missouri Medicine 2012; 109(2)90-98


Dec 04, 2013 - 47 comments

Posted on Tue, Dec. 03, 2013

By Ravikumar Chockalingam MD and Dragan Svrakic MD
Special to The Kansas City Star

Imagine the public outrage if a toxic drug was approved without any regulation for “recreational” use in adults and children that suppresses the immune system, causes schizophrenia, mental illness, brain and lung disease including cancer and death. Also, many long-term and frequent users of this toxic drug have lowered IQs, impaired memory, poor judgment and diminished driving ability.

Finally, suppose this toxic drug is sold “for medical use” to treat diseases for which safer medications are available and at the same time puts them at greater risk of addiction to other substances. Public outrage would be unprecedented; the FDA would be severely and rightly criticized for not subjecting this toxic drug to study. Trial lawyers would be everywhere soliciting lawsuits against the manufacturer.

The toxic drug is marijuana (cannabis) and this nightmare health scenario has occurred in other states. It might occur in Missouri or Kansas if ill-informed and misleading groups like John Payne’s Show-Me Cannabis (As I See It, 10/20/2013) have their way. There is already a considerable amount of medical research showing marijuana to be harmful that is never mentioned by advocates of legal marijuana.

Sadly, this research is largely ignored or underreported by the media. When properly viewed, as a drug subject to FDA study, marijuana would be declared not safe, not effective and not approved based on studies already published in medical journals.

As physicians we attest that the dangers of “medical marijuana” far exceed any therapeutic usefulness, particularly in the context of safer and more evidence-based alternate treatment. Legal cannabis is a bad drug trip the public should avoid.

Like deadly asbestos fibers, the long-term adverse medical consequences may take decades to appear.

The National Survey on Drug Use and Health reported that 55 percent of marijuana users are between 12 and 18 years old. They frequently go on to use more dangerous drugs. Marijuana users have higher “driving while intoxicated” convictions than alcohol users. In 2004, during the five years following legalization of cannabis in California, marijuana-related fatal motor vehicle accidents increased. Marijuana use on the job is common and more problematic than alcohol use.

Cannabis users have slower reaction times, impaired thinking, reduced levels of alertness and poor memory compared to non-users. This leads to higher on the job accident rates and defective or dangerous workmanship.

With 2.5 million new users of marijuana in 2012 age 12 and older (6,800 new users per day) legalizing marijuana will dramatically increase these numbers. Marijuana use in elementary, middle and high school will become common. Parents and educators should be dismayed that long-term marijuana use has been associated with an irreversible eight-point drop in IQ. No wonder cannabis has long been known as “dope.”

Marijuana is a noxious drug with proven medical side effects that trump any reason to legalize its use. Our understanding of this drug and its consequences negates all reasoning to make this readily accessible to public.

Ravikumar Chockalingam of St. Louis is a psychiatry resident at Barnes Jewish Hospital-Washington University School of Medicine. Dragan Svrakic of St. Louis is an associate professor of psychiatry at the Washington University School of Medicine and the St. Louis Veterans Affairs Medical Center.

This appeared in the "As I See It" Editorial, Kansas City Star  December 4, 2013