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What We Talk AboutWhen We TalkWith Medical Students
MJ JoynerN Charkoudian
TB Curry
JH EisenachEA WehrweinMayo Clinic
Rochester, MN
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Raymond Carver
Cover of novel:What We Talk
About When We
Talk About Love
Photo of Raymond Carverfrom WikipediaFreely available at
http://en.wikipedia.org/wiki/Raymond_Carver
http://en.wikipedia.org/wiki/Raymond_Carverhttp://en.wikipedia.org/wiki/Raymond_Carverhttp://en.wikipedia.org/wiki/Raymond_Carverhttp://en.wikipedia.org/wiki/Raymond_Carver8/4/2019 Cardio Physio
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Haruki Murakami
Cover of novel:What I Talk
About When I
Talk AboutRunning
Photo of Haruki MurakamiFreely available athttp://en.wikipedia.org/wiki/
Haruki_Murakami
http://en.wikipedia.org/wiki/Haruki_Murakamihttp://en.wikipedia.org/wiki/Haruki_Murakamihttp://en.wikipedia.org/wiki/Haruki_Murakamihttp://en.wikipedia.org/wiki/Haruki_Murakami8/4/2019 Cardio Physio
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Med Students: FAQ
Can you post the slides on the web?
Can you post the answers to the quiz on theweb?
Will this be on the test?
Why do we have to know X when my clinicalpreceptor tells me its not relevant to medicalpractice?
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Information Smoothie
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Information Smoothie: FAQ
Can you post the slides on the web?
Can you post the answers to the quiz on theweb?
Will this be on the test?
Why do we have to know X when my clinicalpreceptor tells me its not relevant to medicalpractice?
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Can We Go Home?
Gary Larson Far Side cartoon of
teacher in front of class. A studentis asking Mr. Osborne, may I be
excused? My brain is full.
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20 Questions AboutExercise & Respiratory Physiology
for Medical Students
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# 1What is the Fick equation
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#4Can Avogadro explain why each
gm of hemoglobin (HGB) can bind~1.35 mls of O2?
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#17Is the main cause of increasedlactic acid production during
exercise hypoxia in the exercisingmuscles?
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#182-3DPG (2,3- disphosphoglycerate)causes a right shift in the O2-HGB
dissociation curve.Why then is the curve shifted to theleft at extreme altitude?
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#19You are 70% saturated while
mountain climbing in the
Himalayas.Why are you becoming apneic atnight?
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#20What feature of the Avian lung
permits birds to fly over Mt.Everest?
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Advantages of Questions
They are different
No hiding in comfort zones
Focus on ideas
How much of what we are currently teaching iswrong?
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We Made Too ManyWrong Mistakes
Nitric oxide
Acute respiratory distress syndrome &ventilators
-blockers and congestive heart failure
Viagra
Vascular endothelial growth factor
Yogi Says
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Questions: The Internet is YourFriend?
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Readers Digest Version
http://www.merck.com
Regulating Blood Pressure:The Renin-Angiotensin-Aldosterone System
From Merck
Freely available athttp://www.merck.com/mmhe/sec03/ch022/ch022a.html
http://www.merck.com/mmhe/sec03/ch022/ch022a.htmlhttp://www.merck.com/mmhe/sec03/ch022/ch022a.html8/4/2019 Cardio Physio
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Lab Based Demonstrations in the MayoClinical Research Unit (CRU/CTSA)
Mental stress
white purple pink
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Chart Window
HeartRatebpm(
V)
-2
-1
0
1
2
MS
MSRecovery
ArtPressuremmH
g(mmHg)
50
100
150
200
:50 11:40 12:30 13:20 14:10 15:00 15:50 16:402 3 4 5
8/28/2006 2:15:34.725 PM
ECG
Art.
Line
Stroop Colored Word Test
59 129 74
128/67 167/92 157/80
Instr. Stress Blood
draw
Recovery
From Joyner (unpublished data)
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Cardiac output during handgrip
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Intermediate Phenotype
Figure 1.From Eisenach, J.H., and Wittwer, E.D.
Exp. Physiol. 95(7): 757-764, 2010.Available for fee at
http://ep.physoc.org/content/95/7.toc
http://ep.physoc.org/content/95/7.tochttp://ep.physoc.org/content/95/7.toc8/4/2019 Cardio Physio
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HTN Risk & Responseto Acute Sympathoexcitation
Figure 1.From Matthews et al.Circulation110:74-78, 2004
Freely available athttp://circ.ahajournals.org/cgi/content/full/110/1/74
CARDIA study
BP responses tostress
Sympathoexcitation
Risk of future HTN
SNS involved in/riskfor hypertension?
BP, blood pressure; HTN, hypertension; SNS, sympathetic nervous system
http://circ.ahajournals.org/cgi/content/full/110/1/74http://circ.ahajournals.org/cgi/content/full/110/1/74http://circ.ahajournals.org/cgi/content/full/110/1/74http://circ.ahajournals.org/cgi/content/full/110/1/74http://circ.ahajournals.org/cgi/content/full/110/1/748/4/2019 Cardio Physio
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Building Highways vs.Providing a Road Map
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MAP=CO x TPR
Feedback control by Baroreflexes
CO, cardiac output; MAP, mean arterial pressure; TPR, total peripheral resistance
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Gore Diagram
EDV, end-diastolic volume; ESV, End-systolic volume.
From Gore, unpublished data.
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Using the Gore Diagram:Explain Why ~50% of Patients WithHypertension Fail Monotherapy
With Diuretics?
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Carotid Stimulation in Humans?
Figure 1.From Mohaupt , M.G., Schmidli, J., and Luft, F.C.Hypertension50: 825-828, 2007
Freely available athttp://hyper.ahajournals.org/cgi/content/full/50/5/825
http://hyper.ahajournals.org/cgi/content/full/50/5/825http://hyper.ahajournals.org/cgi/content/full/50/5/8258/4/2019 Cardio Physio
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Carotid Stimulation in Resistant HTN
Figure 2.From Mohaupt , M.G., Schmidli, J., and Luft, F.C.Hypertension50: 825-828, 2007
Freely available athttp://hyper.ahajournals.org/cgi/content/full/50/5/825
http://hyper.ahajournals.org/cgi/content/full/50/5/825http://hyper.ahajournals.org/cgi/content/full/50/5/8258/4/2019 Cardio Physio
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Figure 1a.From Epstein et al.Circulation40: 269-276, 1969
Freely available athttp://circ.ahajournals.org/cgi/reprint/40/3/269
This Was Tried In The 1960s!
http://circ.ahajournals.org/cgi/reprint/40/3/269http://circ.ahajournals.org/cgi/reprint/40/3/2698/4/2019 Cardio Physio
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Figure 1.From Schlaich, et al. Hypertension54: 1195-1201, 2009.
Available for fee athttp://hyper.ahajournals.org/cgi/content/extract/54/6/1195
Renal Sympathetic Interactions
http://hyper.ahajournals.org/cgi/content/extract/54/6/1195http://hyper.ahajournals.org/cgi/content/extract/54/6/11958/4/2019 Cardio Physio
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Renal Denervation Suppresses SystemicSympathetic Activation
Figure 1.From Schlaich, et al.
N. Engl. J. Med. 361: 932-934, 2009
Available for fee athttp://content.nejm.org/cgi/content/extract/361/9/932
http://content.nejm.org/cgi/content/extract/361/9/932http://content.nejm.org/cgi/content/extract/361/9/9328/4/2019 Cardio Physio
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Renal Denervation for ResistantHypertension
Figure 2.From Krum, et al.Lancet 373 : 1275-1281, 2009
Available for fee athttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltext
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltexthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960566-3/fulltext8/4/2019 Cardio Physio
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Questions & Medical Ignorance
Figure 1.From Witte et al.J. Investig. Med. 56(7): 897-901, 2008.
Available for fee athttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics
__in_Medical_and_Premedical_Education.4.aspx
C & th R t t
http://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspxhttp://journals.lww.com/jinvestigativemed/Abstract/2008/10000/_Ignoramics__in_Medical_and_Premedical_Education.4.aspx8/4/2019 Cardio Physio
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Comroe & the Retrospectoscope:How Did We Get to Heart Surgery?
Noted investigator atPENN and UCSF
Developed CVRI
Focused on integration
Concept of theRetrospectoscope
Comroe and Dripps (Circ.Res. 35: 661-669, 1975)
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Breakthroughs are Incremental& Take Luck
1 giant leap tothe pinnacle?
Or climb thesteps up theback of themountain?
Adapted from Comroe and Dripps (Circ. Res. 35: 661-669, 1975)
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Comroe & the Retrospectoscope:How Did We Get to Heart Surgery?
About 50 of 100 key discoveries had amajor luck component
Many of the targeted discoveries were
targeted towards other thingsMost traced to a fundamental discovery
X-rays are a typical example
One of the only truly comprehensiveassessments of how medical advanceshappen
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Why the Retrospectoscope?
Non-linear nature of progress Warn the students about the nature of future
change
Undermine the Central Administration and theireffort to manage research.
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We Made Too ManyWrong Mistakes
Nitric oxide
Acute respiratory distress syndrome &ventilators
-blockers and congestive heart failure
Viagra Vascular endothelial growth factor
Yogi Says
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Physiology as Narrative
Oxygen supply vs. demand and coronaryartery disease
Kinder gentler ventilation in acute
respiratory distress syndromeSurfactant
Nitric oxide
Reductionism is rarely the answer!
Coronary Artery Disease vs Cancer:
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Coronary Artery Disease vs. Cancer:Oxygen Supply vs. Demand as Narrative
Figure 6. From Heron et al. Deaths: Final Data from2006. National Vital Statistical Reports 57 (14), 2009.
R d Di t V i
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Readers Digest Version
http://www.merck.com
Regulating Blood Pressure:The Renin-Angiotensin-Aldosterone System
From Merck
Freely available athttp://www.merck.com/mmhe/sec03/ch022/ch022a.html
http://www.merck.com/mmhe/sec03/ch022/ch022a.htmlhttp://www.merck.com/mmhe/sec03/ch022/ch022a.html8/4/2019 Cardio Physio
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Why Not a Traditional Presentation?
We are members of the SNS vs. renal camp We wanted to make this talk about approaching
the unknown vs. reiterating the known
Consistency is the Hobgoblin of small minds--
Emerson
H D Y St d SNS S t f BP?
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How Do You Study SNS Support of BP?
Ganglionicblocking drugs
Sympathetic ¶sympathetic
ganglia
How much does BP
drop after ganglionicblockade?
Change in MAP With Ganglionic Blockade
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Figure 4.From Jones, et al.Circulation104:2424-2429, 2001
Freely available athttp://circ.ahajournals.org/cgi/content/full/104/20/2424
Change in MAP With Ganglionic Blockadevs Sympathetic Tone
CP1311815-44
http://circ.ahajournals.org/cgi/content/full/104/20/2424http://circ.ahajournals.org/cgi/content/full/104/20/24248/4/2019 Cardio Physio
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SNS Activity and TPR
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Total Peripheral Resistance & MSNA
5
10
15
20
25
30
10 20 30 40 50 60 70 80
MSNA (bursts/100 hb)
TPR(mmHg/L/min)
r2 = 0.37r = 0.61
From Joyner, unpublished data
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Not So Fast!
Do These Relationships Hold in Women?
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Do These Relationships Hold in Women?
Figure 2.From Hart, et al.Hypertension53: 571-576, 2009
Freely available athttp://hyper.ahajournals.org/cgi/content/full/53/3/571
http://hyper.ahajournals.org/cgi/content/full/53/3/571http://hyper.ahajournals.org/cgi/content/full/53/3/5718/4/2019 Cardio Physio
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Old Irish Saying:Is This a Private Fight
or Can Anyone Join?
Can We Go Home?
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Can We Go Home?
Gary Larson Far Side cartoon of
teacher in front of class. A studentis asking Mr. Osborne, may I be
excused? My brain is full.
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