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Dr. John Ryan

“Cases from the Mountains”, Medical Grand Rounds with Dr. John Ryan

Nolan Breault, MSc Candidate (TMED)

A hallmark of early-stage disease is the presence of any number of undifferentiated symptoms. Depending on the illness, these can include headaches, coughing, and other forms of discomfort. While such symptoms are oftentimes little cause for concern, their persistence may signal that something more serious is at play. For pulmonary hypertension patients, one of the defining early symptoms is dyspnea, a shortness of breath that reduces one’s ability to engage in everyday aerobic activities.

 

Last Thursday’s Medical Grand Rounds was delivered by Dr. John Ryan, an internationally-renowned physician-scientist from the University of Utah who runs a dyspnea clinic dedicated to early diagnosis and treatment of pulmonary hypertension (PH). Dr. Ryan’s clinic is one of few that specializes in both cardiovascular and pulmonary diagnostics, seeking to shorten the delay between symptom onset and treatment that so often worsens long-term outcomes (1). Indeed, for Dr. Ryan, “no dyspnea is good dyspnea”.

 

Rounds consisted of an exploration of noteworthy referrals from Dr. Ryan’s practice. This included an example of Eisenmenger’s syndrome, which is a severe form of PH associated with congenital heart disease and large unrepaired shunts, a case of central cyanosis stemming from dietary silver intake, and an instance of unresolved patent ductus arteriosus (2). In each of these cases, Dr. Ryan discussed the diagnostic criteria and techniques employed to accurately assess his patients. These frequently consist of echocardiography and right heart catheterization, allowing for precise observation of the structure and function of the heart. In advanced cases of PH, echocardiography readily reveals an enlargement of the heart’s right ventricle, indicating increased strain on the tissue that later culminates in right-sided heart failure and death. Right heart catheterization serves as an invasive but critical tool for assessing hemodynamics to aid in PH diagnosis.

 

Outside of his clinical time, Dr. Ryan has written extensively about the physiology, genetics, and biochemistry of PH. Recent, high-impact publications revolve around the role of mitochondrial dynamics in the disease’s pathogenesis, particularly with respect to the activities of dynamin-related protein 1 (DRP1) and mitofusin-2. Dr. Ryan has assisted in showing that DRP1 activity is enhanced in PH and allows for a dysregulation in cell division of vascular smooth muscle cells, leading to an obstruction of blood flow and an increase in pressure (3,4). Further, a downregulation in the activity of mitofusin-2, which counteracts DRP1’s role in cell division, has also been implicated in the onset of disease (5). These findings have formed the basis of a new direction for PH therapeutics that function through disease regression as opposed to symptom management.

 

Following the conclusion of Dr. Ryan’s presentation, he engaged the class in an enthusiastic discussion of issues in modern healthcare accessibility and lay media representation, as well as how he navigated critical junctures in his career thus far. For the former, Dr. Ryan identified that many of his referrals came from rural communities, where historically a multitude of barriers such as poor coverage by health insurance, geographic distance, and distrust of medical institutions often leads patients to avoiding care. Dr. Ryan cited a few key areas of improvement in recent years that are supporting the delivery of healthcare to such communities, such as increasingly portable diagnostic tools like echocardiograms and growing amounts of medical information online. He elaborated by saying that patient empowerment, in this instance provided by the ability to educate oneself, is a key step towards improving accessibility but must be guided to ensure the accuracy of information. This theme was further highlighted by a discussion of the recent rise in popularity of electronic cigarettes, or “vapes”, which are marketed as a healthier alternative to traditional cigarettes but present a new public health concern by way of industrial evolution that exceeds the rate of research (6). In closing, Dr. Ryan transitioned to give the career advice of pursuing what one is most skilled at and recognizing that success most often comes from opportunity and meeting the right people at the right time, with the caveat that it takes hard work to be given such opportunities and to be placed next to “the right people”.

 

For the members of TMED 801, Rounds with Dr. Ryan provided insight into the clinical complexities that can arise out of undifferentiated symptoms such as dyspnea. Our later discussion came with perspective on contemporary healthcare issues and professional decision-making. On behalf of the class, I’d like to thank Dr. Ryan for sharing with us his time, expertise, and enthusiasm for work that extends the bounds of clinical knowledge.

 

References

1. Brown, L., M., Chen, H., Halpern, S., Taichman, D., McGoon, M. D., Farber, H. W., et al. Delay in Recognition of Pulmonary Arterial Hypertension. https://doi.org/10.1378/chest.10-1166 Chest [Internet]. 2011 Mar 10 [cited 2021 Oct 17];140(1):19-26. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3198486/

 

2. Wood, P. The Eisenmenger syndrome or pulmonary hypertension with reversed central shunt. https://doi.org/10.1136/bmj.2.5099.755 Br Med J[Internet] 1958 Sept 27 [cited 2021 Oct 17]; 2:755. Available from: https://www.bmj.com/content/2/5099/755

 

3. Marsboom, G., Toth, P., Ryan, J. J., Hong, Z., Wu, X., Fang, Y., et al. Dynamin-Related Protein 1-Mediated Mitochondrial Fission Permits Hyperproliferation of Vascular Smooth Muscle Cells and Offers a Novel Therapeutic Target in Pulmonary Hypertension. https://doi.org/10.1161/CIRCRESAHA.111.263848 Circ Res [Internet] 2012 Apr 17 [cited 2021 Oct 17];110:1484-1497. Available from: https://www.ahajournals.org/doi/full/10.1161/CIRCRESAHA.111.263848

 

4. Sharp, W., Fang, Y., Han, M., Zhang, H. J., Hong, Z., Banathy, A., et al. Dynamin-related protein 1 (Drp1)-mediated diastolic dysfunction in myocardial ischemia-reperfusion injury: therapeutic benefits of Drp1 inhibition to reduce mitochondrial fission. https://doi.org/10.1096/fj.12-226225 FASEB J [Internet] 2013 Sept 27 [cited 2021 Oct 17];28:316-326. Available from: https://faseb.onlinelibrary.wiley.com/doi/full/10.1096/fj.12-226225

 

5. Ryan, J. J., Marsboom, G., Fang, Y., Toth, P., Morrow, E., Luo, N., et al. PGC1α-mediated mitofusin-2 deficiency in female rats and humans with pulmonary arterial hypertension. https://doi.org/10.1164/rccm.201209-1687OC American Journal of Respiratory and Critical Care Medicine [Internet] 2013 Feb 1 [cited 2021 Oct 17];187:865-878. Available from: https://www.atsjournals.org/doi/full/10.1164/rccm.201209-1687OC

 

6. Morris, P., Ference, B., Jahangir, E., Feldman, D., Ryan, J. J., Bahraml, et al. Cardiovascular Effects of Exposure to Cigarette Smoke and Electronic Cigarettes: Clinical Perspectives From the Prevention of Cardiovascular Disease Section Leadership Council and Early Career Councils of the American College of Cardiology. JACC [Internet] 2015 Sept 22 [cited 2021 Oct 17];66(12):1378-1391. Available from: https://www.jacc.org/doi/abs/10.1016/j.jacc.2015.07.037

 

Comments

Name
Kiera Liblik

Mon, 10/18/2021 - 09:57

Hello Nolan,
Thank you for your thoughtful summary and response to Dr. Ryan's presentation. I appreciate your identification of the unique nature of Dr. Ryan's dyspnea clinic. It will be interesting to see in coming years if we move away from an 'organ-based' or 'disease-based' approach to medicine with an increased focus on common clinical presentations.
Furthermore, the cases that Dr. Ryan demonstrated that a whole organism evaluation instead of a system-based approach can help diagnose even the most perplexing or uncommon cases. Sometimes it truly does take a village to figure out what is causing a patient to be short of breath (or blue!). Although, in practice, the combination of a strained healthcare system, patient barriers to accessing care, and wait times do act as hurdles to developing new types of clinics involving multiple specialists/consultants.
Nolan, I wonder after reflecting on Dr. Ryan's presentation and our discussion if you think that in a post-COVID era we will start to see the development of permanent virtual clinics to expedite care?
Cheers,
Kiera

Name
Kiera Liblik

Hi Kiera,
Thanks for the response; I thought you asked some very nuanced questions that helped make for an engaging discussion! I think it'll be interesting to see how the prevalence of specialized clinics like Dr. Ryan's changes in the coming years, as they would help to establish the practice of personalized medicine. This is especially important in the world of progressive diseases like pulmonary hypertension, where patients often go 1.5 - 2 years before being formally diagnosed. Without the vasodilatory effect of modern therapies, pressure overload on the right heart is allowed to go unchecked and contributes to the low (~62%) 5-year survival rate (1).

Regarding the post-COVID clinical landscape, I think it's difficult to argue against the possibility of extensive telehealth and virtual service adoption, at least in the context of primary care and consultations. This is due of course to the convenience of being able to access a physician almost anywhere (especially important for patients who may not be able to easily take time off work & commute to a clinic, as well as those with mobility issues), but potentially also because of the resilience of the delivery method to changes in public health protocols (as we've seen during the pandemic). In the case of Dr. Ryan's clinic, this mode of care may be used to perform follow-ups with patients after beginning a course of treatment and to facilitate the presence of multiple care providers, if need be. Dedicated virtual clinics, optimistically, might also have unique modes of billing in the event that overhead is reduced, potentially passing savings on to patients and further improving accessibility.

We're certainly reaching a very exciting and transformative junction in healthcare delivery as we approach what is hopefully the tail-end of the pandemic.

Thanks again for your response, Kiera!

Nolan

References
1. Badesch, D. B., Raskob, G. E., Elliot, C. G., et al. Pulmonary arterial hypertension: baseline characteristics from the REVEAL Registry. (2010) Chest 137: 376-387.

Name
Nolan Breault

Hi Kiera,
Great comment about the organ-based and disease-based approach versus the clinical symptom-based approach. As we have experienced from our TMED 800 observer ships we often see that patients that are referred to specialists based on their chief complaint such as shortness of breath or because of an event that happened such as heart attack. Dr. Ryan’s talked showed us that this clinical model can be successful, especially when integrated with a multidisciplinary clinical model, which helps to foster collaboration and problem-solving in complex cases and limits the number of separate visits a patient may have to commute to. Multidisciplinary care clinics have become popular in many conditions, including diabetes, cancer, and PCOS [1–3] . Of course, limitations do exist (costs, resources, physicians being housed at larger institutions etc.), and multidisciplinary clinics won’t meet all patient needs. I think the access to telehealth medicine will continue to have great utility in a post-COVID-19 world [4]; however, this must be in conjunction with in-person visits so that adequate physical and diagnostic testing can be done. Recently Dr. Kieran Moore, the Ministry of Health and the College of Physicians and Surgeons of Ontario, urged physicians to resume in-person care citing concerns for the backlog of people who will not have had their lungs and heart listened to, blood test, blood pressure checked, and cancer screenings are done which are all critical to holistic and preventative care [5].
Looking forward to hearing your and others thoughts,
Alyssa

1. Multidisciplinary clinics reduce treatment costs and improve patient outcomes in diabetic foot disease - ScienceDirect. https://www.sciencedirect.com/science/article/pii/S0741521419300679. Accessed 18 Oct 2021
2. Multidisciplinary Clinics in Lung Cancer Care: A Systematic Review - ScienceDirect. https://www.sciencedirect.com/science/article/pii/S1525730418300202?cas…. Accessed 18 Oct 2021
3. JCM | Free Full-Text | The Current Description and Future Need for Multidisciplinary PCOS Clinics. https://www.mdpi.com/2077-0383/7/11/395. Accessed 18 Oct 2021
4. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19) - Anthony C Smith, Emma Thomas, Centaine L Snoswell, Helen Haydon, Ateev Mehrotra, Jane Clemensen, Liam J Caffery, 2020. https://journals.sagepub.com/doi/10.1177/1357633X20916567?url_ver=Z39.8…. Accessed 18 Oct 2021
5. (2021) Ontario’s top doctor urges physicians resume in-person care, reduce virtual appointments. In: Toronto. https://toronto.ctvnews.ca/ontario-s-top-doctor-urges-physicians-resume…. Accessed 18 Oct 2021

Name
Alyssa Burrows

Hello Alyssa,
I absolutely agree with you - a virtual consult is by no means a replacement for vital physical examination maneuvers such as auscultation. In regards to bloodwork, many tests can still be ordered (as they are often not conducted at the clinic but rather centers like LifeLabs). I wonder if then, perhaps, vital signs (such as blood pressure readings) could also be collected during appointments for collecting blood work, urine samples, etc. I believe that we will see a hybrid approach take over but not without growing pains in finding the right balance between 'in-person' and remote appointments.
Cheers,
Kiera

Name
Kiera Liblik

Name
Lubnaa Hossenbaccus

Mon, 10/18/2021 - 10:30

Hi Nolan,

I really enjoyed your summary of Dr. Ryan’s Grand Rounds talk! The point that dyspnea is never a good thing stood out to me.

Dr. Ryan mentioned the testing of B-type natriuretic peptide (BNP) levels as a preliminary marker of heart strain. It is released from cardiomyocytes of the heart’s ventricles, stimulated by the stretching of cells due to changing blood volumes (1). Increased BNP levels can be associated with pulmonary hypertension and heart failure, hinting at potential underlying cardiac concerns in patients experiencing dyspnea (2). However, Dr. Ryan explained that BNP levels may naturally vary, and as such, a patient’s clinical history and the context of their symptoms also needs to be considered.

What do you think are the benefits of early assessment of BNP in patients with dyspnea, and do you think there may also be challenges or pitfalls?

Looking forward to hearing your thoughts,

Lubnaa

(1) https://www.ahajournals.org/doi/10.1161/01.cir.0000100687.99687.ce
(2) https://www.hkmj.org/abstracts/v14n3/216.htm

Name
Lubnaa Hossenbaccus

Name
Nolan Breault

Mon, 10/18/2021 - 20:22

In reply to by Anonymous (not verified)

Hi Lubnaa,

Thanks for the response! I think the essence of the usefulness of BNP as a diagnostic tool lies in a patient's general story, as previously discussed. A pulmonary hypertension diagnosis bears a number of hemodynamic values that require invasive techniques, like right heart catheterization as discussed in the post. BNP should be evaluated as an upstream tool and then related to a patient's medical and family history while being complemented by echocardiography to assess heart structure.

The power of a clinic like Dr. Ryan's is its ability to thoroughly explore a chief symptom of complaint from multiple perspectives. This allows for high continuity of care and likely a superior diagnostic timeline relative to what might be seen when a patient passes between a primary care provider and a specialist at separate clinics. It's also possible that neither of said providers has the full range of equipment to precisely explore the ins-and-outs of the symptom, potentially leading to off-target diagnoses and even further delays.

Ultimately, I think having dedicated clinics like Dr. Ryan's is an excellent idea for early diagnosis, but their popularity will likely be determined by the financials of having a very narrow scope of practice.

Cheers,

Nolan

Name
Nolan Breault

Name
Sophia

Mon, 10/18/2021 - 10:36

Great job, Nolan!

I'd be curious if you could summarize Dr. Ryan's career path and what you learned most from this portion of our discussion.

I'd also be curious to hear everyone else's main takeaways.

Sophia

Name
Sophia

Hi Nolan and Sophia,

Thank you Nolan for your excellent summary of Dr. Ryan’s talk. One of my biggest takeaways from this particular rounds was the idea that Dr. Ryan enjoyed basic science research and was good at it, but as he explained, he didn’t enjoy it enough and wasn’t good enough to continue to make it a priority in his life. I think this is pertinent for many TMED students as we begin to explore whether we want to pursue careers that are strictly clinical, strictly research, or a combination of both. Working as a clinician scientist means you will always be balancing two roles - and as we've discussed in previous rounds, unless you have protected time for research this can become difficult. There are pros and cons to any career path, and the more responsibility one takes on, the more one must be willing to sacrifice in other areas.

I am curious to hear if anyone else has thoughts on this!

Best,

Trinity

Name
Trinity Vey

Name
Katie Lindale

Wed, 10/20/2021 - 17:15

In reply to by Trinity Vey (not verified)

Great discussion, Nolan! Thank you so much to Dr. Ryan for the insightful and energetic conversation following such an intriguing presentation of cases. One of the things that jumped out at me during the conversation with Dr. Ryan was the theme of patient empowerment. As Trinity mentioned, Dr. Ryan made the decision to follow the clinical route. Through these experiences, especially working in such a huge variety of populations such as athletes and patients who had never engaged in public healthcare previously, he shows us how patient empowerment can be an interesting and critical factor in health outcomes. An interesting example that he used was discussing the empowered patients who have vaccine hesitancy, and how the empowerment can come from untrustworthy sources but still lead to empowerment. I found his reflections on the nuances and sources of empowerment to be a fascinating new way to look at health decisions and patient-clinician interactions.

Name
Katie Lindale

Hey Nolan,

Thank you for your summary regarding medical grand rounds with Dr. Ryan.

I just wanted to build off of Sophia's latest question. With the majority of this year's incoming Translational Medicine Graduate class being interested in a career as a physician-scientist, what is a notable lesson that we can all take away from Dr. Ryan's MGR career path? How does this lesson directly apply to successfully support our efforts in conducting our research while keeping in mind the translational aspect of the patients that we hope will benefit?

Emmanuel

Name
Emmanuel Fagbola

Name
Dilakshan Srikanthan

Tue, 10/19/2021 - 14:49

In reply to by Emmanuel Fagbola (not verified)

Dear Nolan and Emmanuel,

Thank you so much for your summary and perspectives on Dr. Ryan's talk and career path. One of the things I took away from Dr. Ryan's career pathway is that a clinician-scientist's research program is and can be very flexible. I think that one of the things that stood out to me was that regardless of your research program, whether it is in basic sciences, clinical research, computing etc., the most important aspect is that your research program is aimed at improving human health. Through their study of patients and human subjects, clinician-scientists can make substantial discoveries in disease mechanisms, pathogenesis, novel interventions and policies. While historically clinician-scientists typically had a basic sciences research program, it is now widely appreciated that contributions and discoveries from other modalities of research are just as a impactful to human health. I believe that this opens up the clinician scientist pathway to more people as they will be able to do what they enjoy with regards to their research program.

Name
Dilakshan Srikanthan

Name
Nolan Breault

Wed, 10/20/2021 - 13:26

In reply to by Emmanuel Fagbola (not verified)

Hey Emmanuel,

Thanks for commenting; something I thought that was a key takeaway from Dr. Ryan's career path was that he always seems to have paid attention to where his strengths are. He acknowledged and listened to recommendations about becoming a cardiologist when beginning his time in the US and is now pivoting to focus on patient care, which I think will serve him quite well due to the upbeat and personable air that he has about him.

As for our work, this is applicable in that it calls us to critically evaluate how we perform with different tasks. There's an argument to be made for developing different skills and branching out, but it's also important to recognize where our natural abilities are and foster those (ideally bringing us greater success and allowing us to answer important questions). If we're able to better comprehend and gain comfort with our research area, we'll likely be able to deliver the material to audiences as well and help build the translational aspect of our work. This also plays into which area of medicine we might want to pursue. I myself very much enjoy getting to really know the people I talk to and am not particularly great with my hands. This suggests I might be more successful in primary care as opposed to a procedure/surgery-heavy discipline.

Thanks again for joining the conversation!

Nolan

Name
Nolan Breault

Hi Sophia,

Sure thing! Dr. Ryan did his early schooling in Tipperary, Ireland and showed outstanding academic ability throughout, earning the Ceannt Medal for ranking first in Ireland's National high school exit exam (1). He then completed his undergraduate medical studies at University College Cork and received multiple awards for attaining the status of the highest-ranking medical graduate in the country.

The newly-minted Dr. Ryan then completed postgraduate training in Medicine and Surgery at Cork University Hospital before moving to the United States to pursue an Internal Medicine residency at Boston University. During our discussion, he remarked that there's an air of expectation in Ireland that those in medicine will leave for greater opportunity elsewhere and potentially return after honing their skills.

After completing his work in Internal Medicine, Dr. Ryan moved to practice at the University of Chicago. Here, he was appointed Chief Cardiology Fellow and began cultivating his expertise in pulmonary hypertension research alongside Dr. Archer. Today, Dr. Ryan is an Associate Professor at the University of Utah and acts as the director for the local pulmonary hypertension center.

What was clear to me throughout his story is that Dr. Ryan is excellent at playing to and pursuing his strengths. Despite his career advice of working in what one is good at as opposed to what one loves, he struck me as having a very energetic and friendly demeanor, potentially hinting that what he's good at has also brought him fulfillment.

Cheers,

Nolan

References
1. Patient, U. U. U of U Health. healthcare.utah.edu. [online] https://healthcare.utah.edu/fad/mddetail.php?physicianID=u0874835&n… (Accessed October 19, 2021)

Name
Nolan Breault

Name
Alyssa Burrows

Mon, 10/18/2021 - 13:25

CW: Mentions of sudden death and suicide
*citations added*

Dr. Ryan is also the Sports Cardiology consultant for the US Olympic Committee, the International Olympic Committee, the National Basketball Association, Major League Soccer and NCAA. Sudden cardiac arrest in Athletes has been frequently reported in the media, with a more recent case involving Christian Erikson, a European soccer player collapsing on the field.[1] The incidence of sudden cardiac death (SCD) is 1 in 40,000- 80,000 athletes a year. For athletes under 35, inherited cardiac conditions, mainly hypertrophic cardiomyopathy (HCM) and anomalous origin coronary artery disease, are the most common cause in the US. Leading up to the SCD event ~30% of athletes report symptoms of chest pain, shortness of breath, performance decline, palpitations and syncope [2]. Although SCD is devastating, Dr. Ryan provided nuanced context on this issue, highlighting that the prevalence of SCD is rare, but the media reports on it, and it may be somewhat paternalistic to bar certain athletes from participating in sports. In contrast, in consultation with their physician(s), athletes should make an informed decision on their risks of participating in sport. Dr. Ryan then highlighted other issues facing athletes such as mental illness, suicide, substance use & abuse, and other accidental deaths [3, 4]. Athletes like Simon Biles and Carey Price have been leaders of change in speaking out about mental health struggles within elite athletes [5]. This conversation leads me to question why there is such a narrow focus on athletes' hearts and if sports medicine is evolving to focus on the athlete as a whole person.

Looking forward to hearing your thoughts,

Alyssa
1. Why do super-fit, young athletes suffer sudden cardiac arrest? - National | Globalnews.ca. In: Global News. https://globalnews.ca/news/7981266/athletes-cardiac-arrest-euro-christi…. Accessed 18 Oct 2021
2. Wasfy MM, Hutter AM, Weiner RB (2016) Sudden Cardiac Death in Athletes. Methodist Debakey Cardiovasc J 12:76–80
3. Castaldelli-Maia JM, Gallinaro JG de M e, Falcão RS, Gouttebarge V, Hitchcock ME, Hainline B, Reardon CL, Stull T (2019) Mental health symptoms and disorders in elite athletes: a systematic review on cultural influencers and barriers to athletes seeking treatment. Br J Sports Med 53:707–721
4. Anchuri K, Davoren AK, Shanahan A, Torres M, Wilcox HC (2020) Nonsuicidal self-injury, suicidal ideation, and suicide attempt among collegiate athletes: Findings from the National College Health Assessment. Journal of American College Health 68:815–823
5. Bogart N, Writer Ctvn ca, Contact F| (2021) From Carey Price to Simone Biles: Evolving attitudes help athletes address mental health. In: CTVNews. https://www.ctvnews.ca/sports/from-carey-price-to-simone-biles-evolving…. Accessed 18 Oct 2021

Name
Alyssa Burrows

Alyssa,

You brought up some very interesting points. It was certainly insightful to get Dr. Ryan’s “insider” view of paternalism in professional sports and how cardiac events only make up around 10% of cases.

You mentioned that Biles and Price have been driving forces behind the conversation of professional athletes mental health, and it appears that officials and researchers have taken notice. In 2019, the International Olympic Committee (IOC) released a consensus statement on “Mental Health in Elite Athletes”, making efforts to “advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes” (1). In early 2021, the IOC published a piece in the British Journal of Sports Medicine outlining preliminary evaluations of two mental health assessment tools: the “Sport Mental Health Assessment Tool 1” (SMHAT-1) and the “Sport Mental Health Recognition Tool 1” (SMHRT-1) (2). They suggested that the SMHAT-1 and SMHRT-1 may facilitate earlier recognition of mental health symptoms and disorders and allow athletes to receive the proper support and treatments. It appears to be a hopeful start, though seems like much work is still needed.

Lubnaa

(1) https://pubmed.ncbi.nlm.nih.gov/31097450/
(2) https://pubmed.ncbi.nlm.nih.gov/32948518/

Name
Lubnaa Hossenbaccus

Hi Lubnaa and Alyssa,

Thank you both for bringing up the important topic of mental health in sport. This is one aspect of our discussion with Dr. Ryan that really stood out to me. Dr. Ryan shared with us that suicide is a very real issue in athletes, especially following the Olympics. I can understand the identity struggles elite athletes must face once the goal they committed their life to is complete. The absence of the pressure to succeed and attention for its high-profile nature can leave athletes searching for another motivation to live once their career ends.

He shared with us that all NCAA athletes are screened for the possibility of sudden cardiac death but there is no screening for mental illnesses. Suicide is the fourth leading cause of death for college athletes (Rao et al., 2015), so why are we not taking every measure possible to prevent deaths in these exceptional young people? One thought I have is related to the controversial “out of sight, out of mind”. Athletes can die from sudden cardiac death while performing in front of thousands of people whereas suicides go relatively unnoticed. Consider the occurrence last year of soccer star Christian Erikson collapsing on the field in front of an entire stadium and during live broadcasting of the event. Now consider Jeret Peterson, an American Olympian who committed suicide in a remote canyon between Salt Lake City and Park City Utah. I’m sure many of you have heard of Christian Erikson and his sudden cardiac arrest but has anyone heard of Jeret Peterson? We screen for sudden cardiac arrest to protect the athletes but perhaps it has more to do with protecting the audience watching them. After all, if it were truly to protect the athletes, screening for mental illnesses and other diseases that are unlikely to occur during performance would also be a priority. Does anyone agree or have other thoughts on this?

Best,
Bethany

Rao, A. L., Asif, I. M., Drezner, J. A., Toresdahl, B. G., & Harmon, K. G. (2015). Suicide in National Collegiate Athletic Association (NCAA) athletes: a 9-year analysis of the NCAA resolutions database. Sports health, 7(5), 452-457.

Name
Bethany Wilken

Name
John Ryan

Mon, 10/18/2021 - 16:44

What a great group of people! Such a pleasure to spend time with them on Thursday morning. I could have stayed all day - and a great summary by Nolan. An additional area of discussion was talking about sudden cardiac death, as well as mental heath, and how to handle these tragic diseases in college students. Witnessing this groups empathy, and self-awareness reinforced my believe that our future is in good hands

Name
John Ryan

Name
Pierce Colpman

Tue, 10/19/2021 - 11:06

Hi Nolan, thanks so much for your insightful post. I think you did an excellent job of summarizing the key points which Dr. Ryan wanted to get across to the class. Thank you! I also wanted to commend you for the style in which you facilitated the question period, I think it was very engaging and it was obvious you put much thought into it!

My question stems from a quote which you included from Dr. Ryan. “No dyspnea is good dyspnea”. Dr. Ryan emphasized that all dyspnea is bad, however based on my understanding of the topic dyspnea can occur simply due to strenuous exercise which is not a bad thing by any means. Adding high intensity more strenuous exercise to your fitness routine has been shown to have positive effects on individual health. In fact, in a 2012 study by Rognmo et al., it was shown that exercise performed at higher relative intensities elicits a greater increase in aerobic capacity and greater cardioprotective effects than exercise at moderate intensities (1). It seems to me that pushing yourself until you experience shortness of breath, or dyspnea, is a good thing for cardiovascular and lung health when induced through exercise. Also, from my personal experience as well as I’m sure your own as a triathlete, I am attest that high intensity exercise has positive long term effects on mood, energy, and a general physical feeling of wellbeing. Do you think that the dyspnea involved in vigorous exercise is potentially a bad thing despite its cardioprotective effects? Or do you think Dr. Ryan would agree that not all dyspnea is in fact bad. Thank you again for you great post and facilitation.

1. Rognmo, Ø., Moholdt, T., Bakken, H., Hole, T., Mølstad, P., Myhr, N. E., Grimsmo, J., & Wisløff,
U. (2012). Cardiovascular risk of high- versus moderate-intensity aerobic exercise in
coronary heart disease patients. Circulation, 126(12), 1436–1440.
https://doi.org/10.1161/circulationaha.112.123117

Name
Pierce Colpman

Hi Pierce,

Thanks for the question! I think it could be reasonably argued that there is a dividing line between maybe..."allowable" dyspnea and something that should be investigated. The American Thoracic Society defines dyspnea as "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity" (1). Determining whether, in the event one has symptoms which match this description, there is a need for medical attention, I think should be dependent on whether it impedes functioning in a distressful manner. For example, someone who had no issue running around a soccer field for 90 minutes at a time is suddenly having difficulty getting up a flight of stairs would certainly have "bad dyspnea", whereas the exhaustion one feels after an effort that they know pushes their normal limits wouldn't be cause for concern. It would never hurt to get examined, but as to whether one should be anxious about dyspnea requires placing what is "normal" for them into context, their family history, and how long the dyspnea is lasting.

Cheers,

Nolan

References
1. Parshall, M., Schwartzstein, R., Adams, L., Banzett, R., Manning, H., Bourbeau, et al. (2012) An Official American Thoracic Society Statement: Update on the Mechanisms, Assessment, and Management of Dyspnea. Am. J. Respir. Crit. Care. Med. 185(4): 435-452.

Name
Nolan Breault

Name
Kyla

Tue, 10/19/2021 - 17:47

I want to start off by saying thank you to both Dr. Ryan and Nolan for this week’s medical ground rounds. We are so lucky to have had Dr. Ryan, a fellow student of Dr. Archers, share fascinating clinical cases in pulmonary and cardiovascular hypertension. Nolan, you did an incredible job summarizing not only Dr. Ryan’s achievements but also the impact he has made on the scientific community. The most interesting clinical case, that will forever stick with me, is the argyria condition from silver dosing. It’s amazing to see the vast range of case Dr. Ryan sees and the process him, and his team take, to find a diagnosis.

Something I wondered which is along the same lines as Kiera, what will the impacts of COVID-19 look like for clinical access to pulmonary and cardiovascular care? There are so many unknowns in terms of the impacts of COVID-19 but also the long-term effects of infection. It will be interesting to see how this is accommodated and if a virtual clinic, as Kiera had discussed, will be the “new normal” for care.

Thank you so much Dr. Ryan for sharing your journey and expertise in the field. And thank you Nolan, for an excellent recap.

Kyla

Name
Kyla

Name
Cassie Brand

Tue, 10/19/2021 - 22:18

Nolan, what a great recap of the fascinating discussion we had last week!
Like a couple classmates commented on, BNP can be used as a diagnostic marker of heart strain to help with early diagnosis. Additionally, in our discussion after GMR we talked about careful screening of athletes for cardiac abnormalities. One comment Dr. Ryan made pertaining to this was that this almost made it seem like the lives of athletes were more valuable for others. This peculiar idea makes me wonder if BNP tests should be performed regularly in the adult population? Or, perhaps if not everyone, then patients who may be more susceptible such as those with certain occupations, age ranges or family history. These tests are cheap and produce rapid results, so why not use them more if there truly is a benefit to identifying hidden issues earlier? One downside is that even by using these markers, there is no certainty that a deadly cardiac event will occur, and the patient as a whole still needs to be taken into consideration. I would love to hear if anyone else has any thoughts on this. Would the benefits outweigh the harm the patient may experience from knowing?

Name
Cassie Brand

Name
Samantha Ables

Wed, 10/20/2021 - 20:43

Hi Nolan,

Thank you for a fantastic summary of last week’s grand rounds!

In this grand rounds, what really stood out to me was the example of the patient who, due to her parents’ distrust of the health care system, developed severe symptoms because of a disorder which is usually cured at birth. I immediately thought of how many people today disagree with COVID-19 public health measures and vaccines, which is creating distrust of the medical field. While we didn’t discuss these topics directly during the question period, Dr. Ryan mentioned that sometimes, individuals will come across misinformation in their search for understanding their own medical condition or a disease. I think misinformation and mistrust in the medical field is a growing concern, and I wonder if you have any ideas about how we, as translational medicine students who participate in both the clinical and research aspects of medicine, can work to counter misinformation? Or how healthcare professionals more broadly can help the public avoid misinformation?

I look forward to hearing your thoughts!

Thanks,

Samantha

Name
Samantha Ables

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