Tendinitis is often used incorrectly as a generic term for overuse tendon injuries. The term that should be used is tendinopathy. Tendinitis and tendinosis both refer to microscopic changes that are seen on biopsy. Even spelled as “tendonitis”, it is still incorrect. The current view is that long term overuse tendon injuries display little to no inflammation. While the original meaning of the word inflamation refers to something feeling like it is “on fire”, the medical term refers to histopathology and microscopic examination. While it may still hurt and in a sense feel as bad as if it were on fire, we need to start calling the injury tendinopathy. Of course the biggest problem is that when a doctor tells you that your problem is “tendinopathy” it will take a 20 minutes of discussion to define what is meant by that.

The running injuries website has been updated to include an overview on the science of tendinopathy. We’ll update this page as new information and research appears.

Science, Numbers, Journalism and Critical Thinking

I believe it was on a Merlin Mann podcast, where someone jokingly mentioned the concept of an iColon website which in typical Web 2.0 fashion people could share the images and films of their colonoscopy procedures. This week the New York Times managed to demonstrate where their heads were at regarding simple mathematics and statistics. An article by one of their most popular reporters reviewed a new study that showed that colonoscopies were not all they were cracked up to be as far as picking up colon cancer and in their ability to prevent future cancers from developing from detection and removal of polyps.

The American Cancer Society still strongly recommends the colonoscopy as a useful  screening procedure. and the physicians I know who both perform this procedure and recommend it all strongly feel that it is one procedure that can actually save lives. We will however take a quick and simple look at the use of math and see a lack of simple math skills and the failure of editorial checking at the New York Times.

The NY Times reported on a study that demonstrated that colonoscopy missed virtually all polyps on the right side of the colon. The  article stated that 40% of all cancers and polyps originated on this side. Of those on the left side of the colon up to 30% of those were missed. The article then went on to quote and conclude that rather than preventing up to 90% of colon cancer from devleloping it might only be useful in preventing 60% to 70%. Now, this seems to be a fairly simple math problem. And a quick glance by anyone even one with only minimal math skills just looks and sounds wrong on the surface of it all.

If 40% of the lesions occur on the left side but are undetectable, than you have remaining 60% of the lesions to deal with that you can find. If 1/3 of these ones are not found, by splitting them into 3 equal parts of 20% 20% and 20%, and you remove 1/3 you are then left with 40% of the lesions that you would be able to find.
Hence, it is clear that it is not 60%-70% number of lesions that you’ll expect to find, but a number significantly less than 50% and which clearly looks to be 40%. The physician interviewed in the New York Times encourages people to have the colonoscopy as a screening procedure, but to not necessarily expect to be safe for the next 10 years. It is strongly recommnended that you follow the colon cleaning procedures prescribed prior to undergoing the procedure.

There will be more studies in the future and likely ones that will be quite positive on colonoscopy. Techniques will likely be modified that also result in improved detection of right sided lesions. Until then, we now and always will need clear heads to do the math and keep evidence based medicine, based on evidence and not on an easily obtained quote.

Up soon we may dissect an article published within the last few months that looked at the longevity of runners and non-runners. If you know the study, here’s a hint: check out the disparate population groups studied and see if it looked like a well designed and controlled study.

New Math From the New York Times:

“In the new study, the test missed just about every cancer in the right side of the colon, where cancers are harder to detect but about 40 percent arise. And it also missed roughly a third of cancers in the left side of the colon.

Instead of preventing 90 percent of cancers, as some doctors have told patients, colonoscopies might actually prevent more like 60 percent to 70 percent.”

The stress fracture article at Dr. Pribut’s Running Injuries site has been updated. The article discusses the concept of stress fractures as repetitive stress injury of bone.

Stress Fracture: A Common Running Injury – repetitive stress injury of bone

George Sheehan’s book “Running & Being” is one that every dedicated runner should read. George, a cardiologist, and one of the early, great running philosophers and gurus has been an inspiration to all old school runners.

Many years back, some people, Jim Fixx included, thought that running marathons would give an immunity to fatal heart disease. While running is certainly excellent for cardiovascular health, this has been found to not be so. The most recent studies seem to demonstrate that long distance running reduces your overall risk from dying from cardiovascular disease but that during running itself your risk is higher than while at rest. I still believe that this is a reason to run and not to avoid running. The overall benefit to reduced risk of cardiovascular disease, high blood pressure, depression, body weight, and many more benefits clearly and strongly outweigh the statistically somewhat increased risk of exercising.

It is important though to note and keep track of your own personal risks. Be aware of your lipid profile, your total cholesterol, your HDLs, LDLs, Triglycerides, and what you must to do make it as good as can be done for you. Be aware of your personal and family history of cardiovascular illness. Have your blood pressure checked, and as you get older have it checked more often. High blood pressure is a serious and by many an underrated, and undetected but major contributor to severe cardiovascular illness. Do not underestimate it or think you may be immune to it because you did not have it for the first 25, 35 or 40 years of your life.

Jim Fixx, author of one of the early and earth shaking popular books on running, died from heart disease while running. Today, Ryan Shay, a promising American runner died in the U.S. Olympic Marathon trials. At this time the cause of death has not been established. It was a very sad thing to learn. He is believed to be the first american elite runner to die during a running event. Earlier this year Alberto Salazar had a severe heart attack and was without a self-sustaining heartbeat for more than 5 minutes. Amby Burfoot recently wrote a great article about Alberto’s heart attack in Runner’s World, in which his personal risk factors were discussed. One of his grandfather’s died at 52 from a heart attack and the other at age 70. He reported that his father had had more than one heart attack. If I recall correctly Alberto was being treated for high blood pressure and an abnormal lipid profile. His lab tests and blood pressure were considered fine while under treatment. Serious heart disease ran in his family. This was pointed out as a risk factor that you can not alter. A few weeks ago I came across another article about Alberto Salazar in a section of the New York Times written by John Brant, an author who has written a book on the famous Salazar – Beardsley Boston Marathon race. Salazar related to Amby Burfoot that his doctor recommended an echocardiogram which would not have demonstrated cardiovascular disease. In the New York Times article something jumped out at me. Alberto, according to this article, had had significant neck and back pain that made him go to visit his physician. Normally, he endures pain stoically. His doctor did a resting electrocardiogram and some lab tests and it seemed normal. He was then given an appointment for some weeks later to have stress electrocardiogram.

“…in Indianapolis, Salazar was unable to sleep, had little appetite and felt perpetually tired. Stabs of pain rose from his neck and back, which he attributed to sitting awkwardly on the plane. As soon as he returned to Portland, his primary-care physician prescribed some tests, which were inconclusive, and referred Salazar to a cardiologist. An EKG stress test was scheduled for early July.”

Unfortunately, before he had that he had his near fatal heart attack. Or as some called it a fatal one that he survived. (Since he lived, even though his heart stopped, I do not call it fatal.). This is another extremely important item for runner’s to note. Do not ignore chest pain, neck pain, left side of the jaw pain, upper back pain and any other pain that makes you think something could be wrong. If you have risk factors or if a possible coronary atherosclerosis is suspected, you don’t need your stress test and or thallium blood flow study next month, you need it now. You should have that test as soon as possible. Salazar had serious signs of heart disease that were perhaps taken a tad less seriously and attended to a little slower than they should have been. His test should have been the following week and not the following month. Another, not quite as good a runner, David Letterman, did get tested early, and had a quintuple bypass. Salazar, was lucky to only need a stent. Happily, both have recovered and are running again.

The Runner’s World article by Amby was excellently written and gripping. Alberto is thoroughly quoted within the article. In trying to figure out why there was a difference in how he related his symptoms before his heart attack to the two authors I was at a bit of a loss. In a close reading though, Alberto clearly wanted to emphasize his spirtual beliefs in both, and perhaps even more so in the earlier interview with Amby. He viewed his heart attack as part of God’s master plan for him. I don’t know why he didn’t mention the symptoms he had. I’d suggest if you do hear a bit of knocking at the door in the form of unusual discomfort, pain, fatigue or dizziness you pay attention quickly.

Since most of you runners are doing all that you can to be healthy, let’s make sure you don’t ignore signs that you need just a little help to keep that ticker working. And don’t put off the stress test, if you need it.

The Cubs didn’t last past the first 3 games of the baseball playoffs and the Chicago Marathon only lasted 3.5 hours until it was called. Running in the heat is extremely dangerous. There is precedence for closing a race early. The Madison, Wisconsin Marathon in 2006 was closed app0ximately 2 hours early for reasons of temperature. I’m not sure the authorities had any other reasonable choice. One person died, approximately 49 were hospitalized and about 250 people were treated online for presumably primarily heat related illness. Here in Washington, D.C. one person died in the Army 10 Miler. The latest news states that the runner who died in Chicago, Chad Schieber, had Mitral valve prolapse and that was the cause of death. Mild mitral valve prolapse is a fairly common condition and is not usually considered to be a reason to not exercise. Exercise induced mitral valve regurgitation, however, is a reason to not exercise. The condition is thought to occur in 4-7% of the population. Those with Mitral Valve Prolapse usually will need antibiotic prophylaxis for procedures as ordinary as dental tooth cleaning and scaling. If you have this condition, you’ll need to check with your internist or cardiologist on what exercise is safe and suitable for you.

There was advance notice of the ensuing heat. Should there be terms placed in marathon literature detailing under what circumstances the race will be canceled? Should other arrangements have been made? Were all of the runners properly evaluated including those with suspected heat illness with rectal temperatures? What recommendations and guidelines should marathons have for the future? Should the Chicago Marathon be shifted later in October?

Ralph Paffenbarger, was one of the first epidemiologists to study and provide evidence for the significance of exercise in lowering the risk of cardiovascular mortality (heart disease, etc.). His earliest studies showed that the risk of being sendentary (for example: sitting on your behind and playing computers games in todays parlance) was twice as great as exercising and burning up 2,000+ calories per week.

Ralph himself became a marathoner and ultra-marathoner.

His studies were significant and have had an enormous impact on health and understanding necessary components to living in a healthy manner. Between dietary changes, treatment of lipid and cholesterol abnormalities, blood pressure evaluation, and improvement in exercise routines, heart disease can be significantly reduced. The incidence of heart disease in the United States has decreased incredibly over the past 30 years.

Dr. Paffenbarger’s obituary may be viewed at the New York Times.

Evidence Based Medicine vs. Sensationalism
The New York Times, today, in a fairly sensational manner, discusses Non-Hodgkins Lymphoma and medications in vogue in reference to two medicines, including Zevalin, which at this time is used in cases of failure of other therapies. The accusastion being made is that physicians are not using Zevalin, a radioactive drug, that can only be administered in a hospital using a complex protocol, because of incentives to use more established and well studied protocols including Rituxan in conjunction with “CHOP”.

They highlight the essentially anecdotal evidence of 3 patients who have done well after failing other protocols. That is both the manner in which Bexxar and Zevalin are to be used and the manner in which they have been studied so far. While studies that will indicate if survival time is increased should be complete soon, there is no study that by the principles of Evidence Based Medicine (EBM) do this yet. EBM requires evidence of a high order in well conducted studies that effectively, objectively and statistically demonstrate the utility of a treatment.

This is a higher standard than media generated sensationalism or pharmaceutical company based marketing offer. The studies must stand on their own merit. So far the medications are being used as studied and demonstrated. They are used after failure of other treatment. They are complicated and difficult to administer. They should be used though where needed. Hopefully, the studies that will reportedly be completed soon will demonstrate their superiority, effectiveness, and utility for Non-Hodgkins Lymphoma. Knowledge is increasing fast in this area, but of course not fast enough.

A sensational article like this one, discussing treatment, witholding of treatment, and implying decicsion making is arbitrary and even selfish without even the mention of what EBM is, is not responsible.

You can do your own literature search at PUBMED for more information.

U.S. Clinical Trials – searchable database. You may find active studies using Zevalin or other products here.

Selected Literature Search ResultsExpert Rev Anticancer Ther. 2002 Oct;2(5):485-93
The current indications are: low-grade or follicular lymphoma refractory to rituximab, and relapsed or refractory, low-grade, follicular or transformed lymphoma. Additional studies have been initiated to further define the role of this new therapy in the treatment of patients with B-cell non-hodgkin’s lymphoma.

Semin Oncol. 2003 Dec;30(6 Suppl 17):17-22.
Gregory, SA. Selecting patients for treatment with 90Y ibritumomab tiuxetan (Zevalin).

Yttrium 90 ibritumomab tiuxetan (Zevalin; Biogen Idec Inc, Cambridge, MA) was the first radioimmunotherapeutic agent approved by the US Food and Drug Administration. It is indicated for treating patients with relapsed or refractory low-grade, follicular, or transformed B-cell non-Hodgkin’s lymphoma, including patients with rituximab-refractory follicular non-Hodgkin’s lymphoma. Proper patient selection is essential for optimizing the efficacy and safety of treatment with (90)Y ibritumomab tiuxetan. It may be advisable to use (90)Y ibritumomab tiuxetan relatively early in a patient’s course of treatment because overall and complete response rates, and the estimated median duration of response, are higher among patients who have had fewer median prior antineoplastic regimens than among those who have had a greater median number of such regimens. Furthermore, the myeloablative effect of multiple courses of chemotherapy can preclude the later use of (90)Y ibritumomab tiuxetan. In contrast, other therapies, including chemotherapy and rituximab, can be used safely and successfully after (90)Y ibritumomab tiuxetan without concerns about increased hematologic toxicity from the previous radioimmunotherapy. The main adverse event associated with (90)Y ibritumomab tiuxetan therapy is hematologic toxicity and, as a result, only patients with adequate bone marrow reserves and less than 25% lymphoma marrow involvement should currently be considered for clinical therapy.

Cancer Biother Radiopharm. 2005 Apr;20(2):185-8.

Yttrium-90 (90Y) ibritumomab tiuxetan (Zevalin) induces long-term durable responses in patients with relapsed or refractory B-Cell non-Hodgkin’s lymphoma.
Wiseman GA, Witzig TE.
Mayo Clinic, Rochester, MN, USA. gwiseman@mayo.edu

AIM: Yttrium-90 ((90)Y) ibritumomab tiuxetan (Zevalin) radioimmunotherapy is an effective treatment for relapsed or refractory B-cell non-Hodgkin’s lymphoma (NHL), with overall response rates ranging from 74% to 82%. This retrospective analysis was conducted to determine the number of patients achieving long-term durable responses with (90)Y ibritumomab tiuxetan treatment. MATERIALS AND METHODS: The medical records of patients (n = 211) with relapsed, refractory, or transformed indolent CD20+ B-cell NHL who were treated with 90Y ibritumomab tiuxetan were reviewed. Time to progression (TTP) of > or =12 months was noted in 78 patients (37%), who were identified as long-term responders and were further characterized. RESULTS: Median age of the long-term responders was 58 years (range, 24-80 years) with 44% over 60 years, and 55% were male. Notably, 59% of patients had received > or =2 prior regimens, 33% had received > or =3 prior regimens, and 37% had failed to respond to immediate prior therapy. Median response duration was 28.1 months (range, 10.5-80.3+ months). Median TTP was 29.3 months (range, 12.1-81.5+ months). In patients with ongoing response, median TTP was 53.9 months (range, 49-82+ months). CONCLUSIONS: (90)Y ibritumomab tiuxetan produces durable long-term responses in patients with relapsed/refractory B-cell NHL. Failure to respond to prior therapy does not preclude achieving a long-term response with 90Y ibritumomab tiuxetan.

Dos And Donts For Summertime Running

1. Do wear socks made of synthetic fibers that wick moisture away from your skin to help prevent blisters and athlete’s foot.

2. Do fit your running shoes or other sports shoes with the type of sock you intend to wear them with.

3. Don’t wear sandals or flip-flops when playing sports.

4. Don’t go barefoot outside, cuts and bee stings are not fun on your feet.

5. Do wear sport specific running shoes. Running shoes do not have the lateral support needed for tennis. Help yourself avoid ankle sprains and other injuries.

6. Do wear protective shoes or sandals at pools and in locker room showers. This will help you avoid warts and athlete’s foot.

7. Do replace your running shoes often, at least every 350 – 450 miles run.

8. Do break in new sport shoes before racing or using them for a long run or workout.

9. Do use sunscreen to prevent solar injury to your skin and sunglasses for UV protection for your eyes. Make sure your sunscreen protects you for both UVA and UVB.

10. Do be careful in the heat. Don’t forget proper and regular fluid replacement. Most recommendations call for about 8 oz. every 20 minutes. Try to avoid running in the middle of the day. Remember that running outside on Code Red Bad Air Days does not improve your health.

More specific running injury advise at the running injuries page.

Sunscreens are helpful in reducing exposure to the harmful effects of UVA and UVB. These types of solar radiation contribute to the development of premature skin aging, wrinkling and both malignant and non-malignant skin cancer. Basal Cell Cancer and Melanoma, among other types of skin cancer has an increased incidence in sun exposed individuals. Some have estimated that only about 20% of melanomas are related to skin cancer. Other disfiguring cancers, including basal cell though seem to have a very high correlation with sun exposure.

Melanoma has multiple risk factors which include fair complexion, blonde or red hair color, blue, blue/green eye color (skin phototypes I/II), total sun exposure and a history of blistering sun burns. Genetics, or inherited risks may include genetically linked disorders such as the dysplastic nevus syndrome. The overall risk has increased dramatically over the last 50 years or so. In 1935 the lifetime risk for developing melanoma was 1:1500 in 1935 and grew to 1:74 in 2000. It is estimated that it will grow to 1:50 in 2010. It is estimated that over 53,000 new cases of melanoma are diagnosed now each year. A good number of these are diagnosed at an early stage.

Today’s New York Times implicitly criticizes Neutrogenia for a campaign in which they imply that not using sunscreen and their products is akin to suicide. It includes a clip in which a woman holds up a photo and says “My sister killed herself. She died of skin cancer.” Since melanoma can occur in people with little sun exposure and the majority of it may, this is in bad taste. There isn’t even a campaign that strong for lung cancer sponsored by Nicorette.

US regulatory agencies, including the FDA delayed for many years the approval of UVA protecting agents which had been widely used in Europe for many years. Mexoryl (Terephythalylidene Dicamphor Sulfonic Acid) in particular was long delayed. First approved in Europe around 1991, it only came to the US within the last year. Avobenzone, another compound with a broad UV coverage, degrades in certain conditions with sun exposure. In general you may look for the following compounds to obtain at least some UVA protection: avobenzone, octocrylene and oxybenzone. UVA protection does not have a defined measurement such as SPF.

Is it true that 80% of your sun exposure is obtained by the time you are 18? In this day of middle aged marathoners, ultra-marathoners, skiiers, and tria-athletes and young video gamers? Unlikely! Carl Bialik blogging at the WSJ notes that a more recent study purports that only 25% of lifetime sun exposure is obtained in the years before becoming an adult. Dianne Godar, writing as lead author of a paper in 2003 noted exposure measures approximately “23% of their lifetime UV dose by the age of 18. They get about 46% by the age of 40, and 74% by the age of 59” the rest comes over the remaining course of an individuals lifetime.

The first line of prevention though, is avoidance of mid-day sun exposure. The next is covering yourself up in the manner of Zorro. Dark, absorbant clothes and a broad brim hat. And, since no one will do this, cover yourself well with sunscreen, before you go out the door, and then repeat periodically, particularly after getting wet. There really is no such thing as a waterproof sunscreen. Don’t forget your eye protection. UV protecting sunglasses can help prevent glaucoma, cataracts, macular degeneration and other eye problems.

Remember, if you don’t use protection in the sun, you could end up looking like Mick Jagger, and not have the same access to Botox.

1. Godar, D.E., Urbach, F., Gasparro F.P., and van der Leun, J.C. “UV Doses of Young Adults.” Photochemistry and Photobiology, 2003, 77 (4): 453–57.

The title comes from as a riff on a Joe Cocker album “Mad Dogs and Englishmen”, which derives from a song by Noel Coward entitled “Mad Dogs and Englishmen”. Coward lampooned British Colonialism and may be heard singing the chorus (wav). Joe Cocker seemed to be a bit of both a mad dog and an englishman.

With summertime here, it is time to review how to handle the Heat and Humidity. Check out Heat and Solar Related Illness and out Top Ten Tips For Summertime Running . Updated material on sunscreens and solar protection is on the way, and some of it is already available.

In tropical climes there are certain times of day
When all the citizens retire to tear their clothes off and perspire.
It’s one of the rules that the greatest fools obey,
Because the sun is much too sultry And one must avoid its ultry-violet ray

* Noel Coward (1932)