HeartSense

Follow the Money

Mary Knudson — Sat, 07 May 2011 15:37:00 GMT

by Mary Knudson

I’ve been working for a couple of months on an in-depth article on personal defibrillators that are implanted beneath the skin of a person’s chest to shock a heart that starts shaking, thereby restoring its normal beating and preventing sudden death. Discussing these defibrillators is extremely complex, which is why I am spending so much time on researching and writing the article intended to help patients and their families make an informed decision by learning the truth about the devices known as implantable cardioverter defibrillators (ICDs) -- the good and the bad, your life saved vs nothing happening or the accompanying risks and harm you may receive. So when I heard that a new study would be presented at the annual scientific meeting this week of the Heart Rhythm Society, a professional organization of cardiologists and electrophysiologists who use cardiac devices in their patients, I made sure to get an advance copy of what would be presented and interview the lead author.

Potentially such a study would be of interest to physicians and to patients considering getting an ICD because it looked at all shocks the defibrillators gave the heart in patients who took part in the clinical trial, including those sent for life-threatening rhythms and in error. For several reasons, I felt the study is not ready to report to the public. It is only an abstract. The full study has not yet been written, let alone published in a peer-reviewed journal or even accepted for publication. Patients with defibrillators who received shocks were matched to only one other patient who was not shocked, but the two patients were not matched for what other illnesses or poor quality of health they had. Yet they were matched to see who lived the longest and the study looked at death for all causes, not just heart-related. One critical question the study sought to answer was this: Do the shocks themselves cause a shortened life (even if they temporarily save it) or is a shortened life the result of the types of heart rhythms a person experiences?

But the thing that really slapped me in the face and gave me pause was the exchange of money. In all stories I write on drugs or medical devices, I have begun asking the sources I quote for any conflicts of interest they have with pharmaceutical companies that make these products and I list the conflicts within or at the end of the story.

This study was funded by Boston Scientific, a pharmaceutical company that makes defibrillators. And all eight authors of the study from different medical centers had financial ties to Boston Scientific. All of them?

Would I be surprised if the study found that it was not the defibrillator’s shock that shortened life? In the few write-ups that I’ve seen on this study presented Thursday, the lead author is quoted as saying that not the shock, but rather the type of rhythm is what was associated with shortened life. This study that was able to look at shocks sent for a variety of heart rhythms and for other reasons may be a valuable study. But I can’t help wonder, both as a journalist and as a potential patient, if the study would have been designed differently and reached any different conclusions if no money exchanged hands between a company that makes defibrillators and the eight physicians who designed the study and wrote its conclusions. I am not making any accusation here. I simply am saying that I am made to feel uncomfortable by the financial association of the doctors and big pharma. Why do doctors do this? Should organized medicine and university medical centers forbid doctors who have any financial ties to a company from participating in a clinical trial of a product that company makes? Especially if the company is funding the clinical trial? That would eliminate a lot of doctors. But the tide is changing and some financial arrangements once commonplace between doctors and industry are no longer allowed at some major university medical centers and everything is under more scrutiny than before. We were discussing this matter of conflicts of interest Tuesday in a university class I teach to doctors who want to write for the public.

Both doctors and journalists should be truth seekers, and seeking the truth is best done independently. Would the public be able to trust my long-researched piece on the truth about defibrillators if it turned out that I am being paid to write press releases for one or more of the companies that make these defibrillators? Or if I wrote speeches for executives of these companies? Or if I served as a consultant to the companies on public relations? As a journalist, I could not consider receiving money from groups I write about. Why should doctors be allowed to receive money from companies who make a product they are using on patients in a clinical trial that purports to provide answers to serious questions about the product?

As I was wrestling with this issue and whether to write about why I am not writing about that study, journalists with Pro Publica published several articles on their website and with USA Today on money ties between big pharma and the Heart Rhythm Society. See here , here, here and here.

When I first began attending various cardiology organizations’ scientific meetings I was taken aback by the numbers of physician speakers who would begin their talks with a conflict of interest slide that stayed visible only for what seemed like one second before the speaker clicked to the next slide, visible just long enough for the audience to see there was a long list of financial ties to industry, but not long enough to read what they were. The slides were there because the doctor organizations were requiring transparency. But what was happening was not transparent because nobody could read what was on those slides. How rare but heartening it was when a speaker began a talk by saying “I have no conflicts of interest.” That is changing and more doctors are able to say they have no conflicts. But much more needs to change.

I was also amazed to see the large numbers of “non-official” scientific sessions sponsored by individual pharmaceutical companies and listed in the official scientific programs -- with leading cardiologists as presenters and well attended by conference goers -- that preceded the official program at these major cardiology meetings. What portion of these presentations used company slides and drove home company messages? After seeing all this, I remember holding my breath as I asked the cardiologist I had invited to co-author a book with me about heart failure if he had any financial conflicts of interest with industry. I felt that if he did have, I could not write the book with him. How relieved I was when he said he did not.

Pharmaceutical industry financial relationships with individual doctors and with organizations of doctors are important to the public welfare because these relationships can influence judgment and decisions, can influence what is said and not said in writing about medical products and in speaking to and advising patients. And that is why these relationships are important to journalists who are servants of the public.

As for my long-researched piece on defibrillators, I have found more studies to read and a couple of new interviews to do. I believe that this examination of the truth about defibrillators that I am writing for a well known magazine’s website will be worth reading, and once it is published there, I will reprint it here.

What is Mitral Valve Regurgitation that led to Elizabeth Taylor’s Heart Failure?

Mary Knudson — Wed, 23 Mar 2011 23:19:00 GMT

by Mary Knudson

I am saddened that Elizabeth Taylor died today of heart failure. In his appreciation of her, film critic Roger Ebert said in the Chicago Sun-Times, “Of few deaths can it be said that they end an era, but hers does.”

She is a star that many of us felt we knew. She was a great actress and a woman of great beauty who was a hard working champion of people with AIDS and always seemed to be a determined person who knew herself. Yet she always had a vulnerable side. So many marriages, so many illnesses, so many, many surgeries, over 40, I’ve read. And then her heart problem developed. Which leads me to talk a little about that problem, mitral valve leakage.

The heart's mitral valve

The heart has four chambers and four valves that open to let blood through to the next chamber of the heart and on out to the body and back. The valves, acting as gates, then immediately close to prevent the blood from running back where it just came from. The mitral valve looks like a mouth with leaflets that look like lips that open and close. When I saw it in action on an echocardiogram, a test that uses sound waves to show moving pictures of the heart, I thought it looked like a very sensuous mouth. Each of the valves looks different. But because it looks like a mouth, the mitral valve stands out. Blood has just left the lungs carrying oxygen and arrives at the left atrium of the heart. The mitral valve’s mouth opens to let the blood pour through into the left ventricle. As the left ventricle contracts, the mitral valve closes and the aortic valve opens to allow blood to leave the heart and get out to the body.

A mitral valve can start to leak. This can range anywhere from a condition that is minor and does not need treatment to a serious problem that leads to a weakened heart and heart failure. In Elizabeth Taylor’s case, it led to heart failure and her symptoms must have included difficulty breathing and fatigue.

I asked Edward K. Kasper, M.D., director of clinical cardiology at Johns Hopkins Hospital, to talk a little about what can go wrong with a mitral valve. I should mention for disclosure that Ed is my cardiologist and co-authored with me the book Living Well with Heart Failure, the Misnamed, Misunderstood Condition:

A leaky mitral valve – mitral regurgitation, is common and has many causes. Most people tolerate a leaky valve well, but some need surgery to correct the leak. Repair is preferred to replacement. The MitraClip (which was used for Elizabeth Taylor) is a new technique to try and fix mitral regurgitation in the cath lab rather than in the operating room. There are no long-term comparison studies of this technique compared to standard OR repair – that I know of. Repair is currently the gold standard for those who have severe mitral regurgitation and symptoms of heart failure. Outcomes are better including improvement in symptoms and survival in patients with repair rather than replacement.

What takes a person from a leaking mitral valve to heart failure?

The leakage back into the left atrium increases the pressure in the left atrium. This increased pressure in the left atrium is passed back to the lungs, causing fluid to leak into the lungs, leading to heart failure. With time, the demands of severe mitral regurgitation on the left ventricle will lead to a weakened left ventricle, a dilated cardiomyopathy (disease of the heart muscle). We try to prevent this by operating before it gets to that point.

Mitral regurgitation can also be a consequence of a dilated cardiomyopathy - the orifice of the mitral valve enlarges as the left ventricle enlarges. The leaflets of the mitral valve do not enlarge. Therefore, they no longer close correctly, leading to mitral regurgitation.

It’s easy to see why anyone would want to opt for the Evalve MitraClip over open heart surgery. The MitraClip is little different from a common test known as an angiogram in which a catheter is passed through the femoral vein in the groin up to the heart. In this repair procedure, however, the catheter guides a clip to the mitral valve where the metal clip covered with polyester fabric is positioned over the leakage and brought down below the open flaps and back up, fastening the valve’s open leaflets together. The manufacturer, Abbott, shows in a video here how blood still is able to pass through on either side of the fastening.

Elizabeth Taylor got her MitraClip repair a year and a half ago, so it must have worked for awhile. Then about six weeks ago she was hospitalized with heart failure at Cedars-Sinai Medical Center in Los Angeles where she died with her family at her bedside. For more on mitral regurgitation, see this NIH site.

Heart failure has many other causes. High blood pressure can damage the lining of blood vessels leading to deposits of cholesterol. Coronary artery disease causes heart attacks. A heart attack kills part of the heart muscle, forcing the rest of the heart to work harder and in doing so, get large and weak. Only about half the people who develop heart failure have a weak heart. In another cause of heart failure, the left ventricle becomes stiff and the heart does not fill properly. And in some heart failure, the heart itself is normal but connecting blood vessels are not or a valve may be too narrow. In all of these cases, a person is said to have heart failure because the heart and vascular system are not able to provide the body with the blood and oxygen it needs.

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Sudden Death in Young Athletes

Mary Knudson — Sun, 06 Mar 2011 20:58:00 GMT

by Mary Knudson

John Mandrola MD is a cardiac electrophysiologist practicing in Louisville, Ky who blogs as Dr. John M. Below is his insightful discussion about why cardiac screening may not be possible to prevent sudden death in young athletes. Yet it is so distressing each time a young athlete falls dead during or after a game because he and his family did not know that he had a serious heart problem that could have been identified in a test. For some heart defects, if only the family were aware of the defect, it would be appropriate for the young athlete to wear an implanted defibrillator that would save his life either through extra pacing as the disturbance began or through electric shocks if his heart suddenly went into a wild shaking known as ventricular fibrillation.

I understand John’s concern about the high cost of making electrocardiograms and echocardiograms, heart tests that could pick up significant heart defects, a required part of a sports physical in schools and colleges. Aside from the cost is the important issue that screening can pick up false positives and “shadows and innocent blips” that lead to further invasive testing. Yet, I could see parents springing for these cardiac exams themselves, but then being very cautious about doing any further testing.

It is unforgivable not to have an automatic external defibrillator at all sporting events, close to the court or the field, and more than one athletic staff member trained to use it. Every minute counts when a person’s heart stops working. Realizing what has happened, then calling an ambulance and waiting for the paramedics to arrive, may take up too much time to save a young athlete’s life. When an athlete falls to the ground and is not moving, the trainer or other staffer should immediately have the defibrillator or crash cart ready so that the shocks could be applied to the athlete’s heart within one to two minutes.

Reprinted from the blog Dr. John M.

A five-minute cardiac screen for athletes?

by John Mandrola MD

MARCH 5, 2011

It’s heart-wrenching when young athletes die of sudden cardiac death (SCD). This week, the death of Wes Leonard, a Michigan high school star athlete, was especially poignant since he collapsed right after hitting the game-winning shot. This sort of tragedy occurs about one hundred times each year in America. That’s a lot of sadness.

The obvious question is: Could these deaths be prevented?

Let’s start with what actually happens.

Most cases of sudden death in young people occur as a result of either hypertrophic cardiomyopathy (HCM), an abnormal thickening of heart muscle, or long QT-Syndrome, a mostly inherited disease of the heart’s electrical system. Both HCM and Long-QT syndrome predispose the heart to ventricular fibrillation–electrical chaos of the pumping chamber of the heart. The adrenaline surges of athletic competition increase the odds of this chaos. Unfortunately, like heart disease often does, both these ailments can strike without warning.

Sudden death is sad enough by itself, but what makes it even worse for doctors (and patients) is that both these ailments are mostly detectable with two simple painless tests: the ECG and Echocardiogram (heart ultrasound).

Let’s get these kids ECGs and Echos then. Git-r-done, you might say.

On the surface the solution seems simple: implement universal cardiac screening of all young athletes. And you wouldn’t be alone in thinking this way. You could even boast the support of Dr Manny Alvarez of Fox News, and the entire country of Italy–where all athletes get ECGs and Echos before competing.

But America is not Italy and things aren’t as simple as Fox News likes to suggest.

There are three major flaws with Dr Manny’s simplistic proclamation that all (American) athletes should have pre-participation ECGs and Echocardiograms.

The Economic:

The estimated cost–in our current health care system–for adding an ECG and Echo to the sport’s exam is about $1000. That’s a bunch more than $19.99–the advertised price of the sports physical at my local grocery store’s walk-in clinic. Parents may be amendable to charging $19.99 to their credit card, but even when the safety of their teen is at stake, few can afford the current-day costs of ECGs and Echos.

Now, you could make the argument that 1000$ is ridiculously high. And you would own a valid point. But that argument goes to the heart of the healthcare debate.

Let’s consider this notion for a moment: I could listen to your teen’s heart, look at their ECG, place a hand-held ultrasound probe on their chest, and in a matter of five minutes I could clear them for competition. The ECG would exclude long-QT syndrome, and the Echo would exclude excessive thickening of the heart muscle. The reason why I could do this are threefold:

My entire medical career revolves around understanding ECGs.
I look at Echos nearly every day, and was schooled by one of its pioneers, Dr Harvey Feigenbaum.
In general, I waffle a lot less than the average reader of subjective cardiac tests. (That trait might not be valuable at the Mayo Clinic, but it would be good for screening thousands of young people, who are normal 99.999% of the time.)

Ah, but that’s not how things work in our present health care model. Obviously.

You can’t just deliver quality care that easy. There’s got to be a certified technician and machine to do the studies–portable Echos will not work. Calling an Echo normal these days is totally insufficient, fraudulent even. There has to be a three page report documenting each section of the heart. And of course, I can’t officially read an Echo because I am not board-certified in Echocardiography, I am just board-certified in Cardiology and Electrophysiology.

It’s not just the high costs that make screening athletes problematic.

It’s the Math:

Why don’t the numbers support widespread cardiac screening of athletes?

Again, it isn’t as simple as Dr Manny suggests. He portrays ECGs and Echos as black and white, yes or no, high or low kinds of tests. That’s not even close to accurate. They are both highly subjective tests that require mastery of nuance, including the ability guts to call something “normal.” When a young person’s life is at stake, shadows and innocent blips look much more sinister. Before guaranteeing the invincibility of a young athlete, doctors often see things on ECGs and Echos that “might be something.” Radiologists sometimes call these shadows “incidentalomas.”

That’s the rub with screening that Dr Manny omits. For every life saved by the screening test, there will be hundreds (perhaps thousands) of patients sent for more (and often highly invasive) testing. Doctors are not going to be wrong about sudden death in a young person. No way. No how. There will be more tests, not just because of defensive medicine, but also in the name of quality.

To the numbers: Rare diseases like HCM and Long-QT kill athletes at a frequency of about 0.01%. That’s the left side of the equation. On the right side of the equation are the risks of all the cardiac caths, electrophysiology (EP) studies and dye-requiring CT scans ordered as a result of the screening tests. Though an individual cardiac cath, EP-study or CT are low-risk, the cumulative risk of doing these on thousands of normal people surely approach the 0.01% chance of sudden death in an athlete. Said more simply, with made up numbers to make my point, if screening saves 50 of the 100 teens who die each year, but 50 die from complications that occur from chasing down incidentalomas, than it’s an expensive statistical wash.

The Reality of the Athletic Ethos:

The third major flaw with the idea that mandated cardiac screening will save lives is that making the diagnosis of heart disease doesn’t always equate to preventing sudden death. The athlete has to accept the treatment, which for them, like it was for Boston Celtic great Reggie Lewis, is often untenable.

Gosh, I wish we could save all the young athletes that die suddenly.

But the paradox of our present health care system is that awash in all its fury of available technology (the MRIs, the robots, the GPS-navigational-systems) is our inability to do simple things for the many.

That’s too bad.

JMM

P.S.: One thing that Dr Manny was spot on about was that more AEDs (Automatic External Defibrillator) in athletic arenas are surely a good thing. In the case of AEDs, there exists strong science to show that increasing their availability saves lives.

Baseball and Heart Health

Mary Knudson — Wed, 02 Mar 2011 15:06:00 GMT

Engaging in a sport as a player or as a robust fan is surely good for your heart health. My favorite way to blow stress away and soar on summertime cottony cloud puffs of happiness is to watch a baseball game.

I share my passion for baseball in this Guest Blog post at PLoS Blogs.

An Open Letter to Bora Zivkovic on Baseball

By Mary Knudson

Posted: March 1, 2011

Dear Bora,

You said on Twitter that you have lived in the United States for 20 years and have never seen a baseball game and don’t know what the point of the game is. With the 2011 spring training games now underway, I must respond.

I love baseball. It seems as natural a part of my life as eating and writing. Baseball makes me happy. My team is the New York Yankees. You notice I said MY team. That’s how baseball fans feel about their teams. The relationship is very personal. I love the glorious remarkable history of the Yankees. Lou Gehrig, Babe Ruth, Mickey Mantle, Yogi Berra, Whitey Ford, Casey Stengel, Catfish Hunter, Reggie Jackson, Thurman Munson. I wish those names meant something to you. Each player was a legend and together with the owner, managers, trainers and coaches, they built a legacy. The Yankees have had streaks of carrying on that legacy with modern players, winning championships and world series. Baseball needs new heroes now who do amazing things, not for the huge salaries, but out of hard work for the love of the game.

Fans respect the giants of baseball for what they gave to the game and some of them we love for who they were as men. On the wall of my exercise room is a large reproduction of a famous photograph of Lou Gehrig making his last appearance in Yankee Stadium after he learned he had the fatal paralyzing disease amyotrophic lateral sclerosis (ALS) that would later bear his name. In his famous short speech to his fans who had packed the stadium, with his teammates lined up nearby on the field, knowing his fate, he still said: “Fans, for the past two weeks you have been reading about the bad break I got. Yet today I consider myself the luckiest man on the face of this earth.”

Gehrig was the first “iron man”, playing 2,130 consecutive games over a span of 15 seasons between 1925 and 1939. How many people go to work every work day over 15 years, never staying home sick? During that time Gehrig had 17 hand fractures, back pain, and several different illnesses, but he played through it all. His streak ended only because he developed ALS. But his record was so strong it lasted 56 years before

Photo: Michael O’Neill, SI

Cal Ripken, Jr., shortstop and third baseman for the Baltimore Orioles, another true “iron man” with an unyielding work ethic, broke it in 1995. Cal Ripken brought a special joy not just to Baltimore, but to all baseball fans, and won back their respect for baseball after the bitter 1994 strike. I will always remember the standing ovations fans gave him in city after city his final year as a player, 2001. These were cities that belonged to the opposing teams the Orioles had come to play. But the other teams’ fans showed their respect for Cal.

You never know when you watch a baseball game if you will be witnessing history. Lou Gehrig was one of 15 players who have hit four home runs in one game! Can you imagine the thrill of watching that happen? A home run comes when a batter lays the bat just right on the ball, just right, on the “sweet spot” of the bat, sending the ball rocketing out of the ballpark. What ecstasy to watch in disbelief the fourth time a batter does that in the same game! How can you have any stresses in your own life on a day that happens? Bobby Lowe of the Boston Beaneaters was the first to do it in 1894 and Carlos Delgado of the Toronto Blue Jays the last on September 25, 2003. Maybe it will happen again this year. You always hope to see something great in each game you watch.

Gehrig still holds the record for the most grand slams: 23. A grand slam is a fan favorite. Especially when it wins a game. One by one your team’s players hit the ball without it being caught by the other team and they get on base. In a grand slam the batter stands in the batter’s box (it’s not really a box, Bora) and his teammates are out there on all three of the bases: first base, second base, third base. If the batter hits a home run, he and all three of his teammates get to run home for a grand slam, a total of 4 runs. Pretty spectacular to hear the crack of the bat, see the ball ascend over the heads of the outfielders, you suck in your breath, praying please, please, and then shriek as the ball sails out of the ballpark. “See ya!”, one announcer always punctuates a homer. Lots of high fives at home plate and in the dugout. If you’re at home watching, you’re on your feet whooping and hollering, doing high fives with your dog. You don’t hold back. There is no holding back in baseball. Not for fans. How good you feel, Bora! This is real happiness.

The point of the game? The point of the game is to win. To get more runs than the other team. To do that your pitcher needs to be better than the other team’s pitcher so that the other team doesn’t hit balls that turn into runs. A pitcher can be so skilled and so powerful in the way he unleashes the ball, sending it hurtling sometimes 94, 95, 97 mph at the batter as a fastball, a slider, a curveball, a cutter, a changeup, that batter after batter can not get his bat on the ball. And in some types of pitches it’s more the finesse with which the ball leaves the pitcher’s fingers than the speed that matters. A battle of wits goes on between the pitcher and the batter, as the pitcher tries to stare down the batter and the catcher crouches behind the batter trying to influence what kind of pitch the pitcher throws. You’ll see the pitcher shake his head back and forth if a pitch the catcher is signaling is not what he wants to throw or nod yes if he agrees with it. The pitch is everything. A team wins if its batters find a way to hit what the pitcher throws.

And those men in the infield and outfield who chase balls and lurch and dive for them are very important. Some of the spectacular plays of baseball come from outfielders who leap higher than you think possible and snare a ball about to fly out of the ballpark or throw themselves horizontally after a ball, clutching it in one glove as their body slams brusingly to the ground. Derek Jeter, Yankees shortstop and captain, has a signature twisting leap that always astonishes when he catches and then wheels in mid air and throws to first or second base for an out. Infielders often try for a double play, forcing runners out at both first and second base.

One of the grandest events in baseball is when a pitcher pitches a no-hitter. Through nine innings, not a single man on the opposing team can get a hit. Either the batters are unable to connect the bat to ball or, if they do hit the ball, someone on the other team catches it. No hits throughout an entire game of some three hours. An amazing feat! If you are lucky enough to see one, Bora, it is an experience of a lifetime. It is the glory of baseball.

Fans feel baseball. We are part of the game. And we like to help manage the team. In this pre-season time of year we worry about whether our team will be ready for the season. I worry about what the starting lineup of pitchers will be for the Yankees who will add some new faces this year from youngsters coming up from the minor leagues. I hope so much that A.J. Burnett who had a terrible season last year will make us proud as a starting pitcher. I want to get to know the new pitching coach Larry Rothschild and feel content that I agree with his plan of action. I feel the pain of distinguished veteran catcher Jorge Posada who will be 40 in August and learned that, barring some emergency, he will never again catch for the Yankees. “I think I can still catch,” I heard him say in an interview. He instead will be their designated hitter, a less involved role. For all the emphasis on team and winning, a team nevertheless is made up of individual men who have feelings and pride, and it is hard to get older in baseball and relinquish leading roles. A catcher helps direct a pitcher’s throws. A DH just goes out and takes his turn at bat.

The Yankees will face outstanding competition in the American League East this season. The Boston Red Sox who were held to low expectations by injuries last year could be a dangerous opponent this spring and the Phillies who snared Cliff Lee, a star pitcher the Yankees badly wanted, now have a starting lineup of pitchers that may be the best in baseball. The Baltimore Orioles, under new leadership, were showing big improvement the end of last season and might surprise everybody. There are great expectations for an exciting, suspenseful competitive season.

A baseball game squeezes many intense, anxious moments out of us. You experience the game individually, willingly allowing what you see and hear and hope for to penetrate your senses and govern your soul. Watching baseball is a take-no-prisoners commitment. And yet it is also a spring and summertime and fall layback, informal, take-the-family group event where you eat and chat and join with thousands of others as you root for your team. You can also enjoy baseball about as much by watching a good game on TV. In fact, @Hudsonette recommends doing that before you go to your first game in person because you learn a lot by listening to savvy announcers call the game and explain what’s happening.

Some cool people on Twitter love baseball and send you some sage reasons why, if you give it a try, Bora, you will love it, too:

From @Hudsonette

1st Amendment lawyer, blogger

If you’re unfamiliar with baseball, it helps to watch a game while listening to great announcers, such as Vin Scully of the L.A. Dodgers, or Ken Singleton with the Yankees. They will not only explain what just happened, which can be baffling because often several things are happening at once, but also the strategic choices and the moment to moment tension of competing interests involved in each pitch and each play. It’s intricate, complex, dependent on individual skill choreographed with other teammates while battling the sun, wind, physical injuries, mental lapses, and the opponents’ own hidden stratagems. It’s a game of statistics coupled with human grace. There’s not much more beautiful than watching the great relief pitcher Mariano Rivera strike out a batter with his cut fastball, or the sound of a ball hit perfectly on the sweet spot of the wood, or the shortstop Derek Jeter appearing out of nowhere to make an intricate play that saves the game. There’s no greater anguish than being a Cubs fan. But above all, it’s fun to go to a game, even a minor league game, sit in the sunshine, eat what you want, say what you want very loudly, and get away completely from the troubles of the world.

Note: There is an unwritten code to baseball that does not tolerate disrespect towards the other team such as public displays of exuberance (by the players, not the fans) if your team is way ahead. See the Ten Unwritten Baseball Rules. Some great baseball books: Moneyball, Veeck As in Wreck, Sadaharu Oh: A Zen Way of Baseball.

From @DeliaCabe

Writer, professor of magazine writing, blogger

My love affair with baseball starts with my grandfather, who came to this country from Puerto Rico because he wanted to be a bat boy for “los Yankees”. He watched the Yankees all his life. He never did become a bat boy, but his love for the game became mine.

I don’t watch other sports. Baseball is different. No sport is as literary as baseball is. It’s a slow, evolving story that takes place over nine innings–no timers, no buzzers, no masks. The game begins with two protagonists, two pitchers, and goes from there.

Bora should see the Durham Bulls, since he lives near there! (He could also watch the movie. Here’s Susan Sarandon talking about making the movie movie.

From @garyschwitzer

Publisher, HealthNewsReview and blog

I can’t top George Carlin .

From @Joe_Wallace

Author, Diamond Ruby, baseball-related historical novel

The historian Jacques Barzun once said, “Whoever wants to know the heart and mind of America had better learn baseball.” I don’t know if that’s true, but I definitely believe that the game–and, especially, its remarkable history–provides a window into the U.S.’s own past. From the Civil War (when baseball was used to knit the fractured nation) onward, every controversy, every struggle, has been reflected by the game. Race relations, women’s rights, political upheavals, cultural changes–they’re all here.

Baseball itself is a beautifully constructed cat-and-mouse game, filled with endlessly debatable strategy and tactics. In our noisy, fast-paced world, it can seem slow (and it’s certainly not for every taste), but like a great novel both the game and the long, unfolding season reward patience and close attention. Once you begin to understand, it can make you laugh out loud with pleasure…even when you’re past fifty, as I am, and not ten.

From @ivanoransky

Ivan Oransky, MD

Executive editor, Reuters Health

Embargo Watch

Retraction Watch

I fell in love with baseball as a five-year-old watching Reggie Jackson be the “straw that stirs the drink” and then hit three home runs in a single World Series game.

I love baseball enough that even though my wife has banished it to a sunroom, I have my very own bleacher seat from the old Yankee Stadium. Even she agrees, however, that spring training in Arizona is a perfect couples’ vacation: A spa, hiking, and a baseball game every day.

I love baseball because when I’m at a conference in Tampa and have nothing to do, I can go see someone hit the second of two majestic back-to-back walk-off home runs.

I love baseball because it has inspired a whole literary genre. And what other sport has inspired a book, Michael Lewis’ Moneyball, about the controversial genius of Bill James’ and Billy Beane’s data-mining?

Baseball is hardly perfect. It’s a deeply human enterprise. But the fact that it’s a long season every year means there’s a narrative that builds on itself and actually goes somewhere. Sort of like science.

——

Bora, if you still have any doubts about getting involved with baseball, feel the intense emotions immortalized in this poem that fans experience during a game. Baseball is such a slice of life. Sometimes you win, sometimes you lose. But as long as you believe they are trying, always you are one with your team. You are a fan.

Mary

Casey at the Bat

BY ERNEST LAWRENCE THAYER

A Ballad of the Republic, Sung in the Year 1888

The outlook wasn’t brilliant for the Mudville nine that day;
The score stood four to two with but one inning more to play.
And then when Cooney died at first, and Barrows did the same,
A sickly silence fell upon the patrons of the game.

A straggling few got up to go in deep despair. The rest
Clung to that hope which springs eternal in the human breast;
They thought if only Casey could but get a whack at that—
We’d put up even money now with Casey at the bat.

But Flynn preceded Casey, as did also Jimmy Blake,
And the former was a lulu and the latter was a cake;
So upon that stricken multitude grim melancholy sat,
For there seemed but little chance of Casey’s getting to the bat.

But Flynn let drive a single, to the wonderment of all,
And Blake, the much despised, tore the cover off the ball;
And when the dust had lifted, and men saw what had occurred,
There was Jimmy safe at second and Flynn a-hugging third.

Then from 5,000 throats and more there rose a lusty yell;
It rumbled through the valley, it rattled in the dell;
It knocked upon the mountain and recoiled upon the flat,
For Casey, mighty Casey, was advancing to the bat.

There was ease in Casey’s manner as he stepped into his place;
There was pride in Casey’s bearing and a smile on Casey’s face.
And when, responding to the cheers, he lightly doffed his hat,
No stranger in the crowd could doubt ’twas Casey at the bat.

Ten thousand eyes were on him as he rubbed his hands with dirt;
Five thousand tongues applauded when he wiped them on his shirt.
Then while the writhing pitcher ground the ball into his hip,
Defiance gleamed in Casey’s eye, a sneer curled Casey’s lip.

And now the leather-covered sphere came hurtling through the air,
And Casey stood a-watching it in haughty grandeur there.
Close by the sturdy batsman the ball unheeded sped—
“That ain’t my style,” said Casey. “Strike one,” the umpire said.

From the benches, black with people, there went up a muffled roar,
Like the beating of the storm-waves on a stern and distant shore.
“Kill him! Kill the umpire!” shouted some one on the stand;
And it’s likely they’d have killed him had not Casey raised his hand.

With a smile of Christian charity great Casey’s visage shone;
He stilled the rising tumult; he bade the game go on;
He signaled to the pitcher, and once more the spheroid flew;
But Casey still ignored it, and the umpire said, “Strike two.”

“Fraud!” cried the maddened thousands, and echo answered fraud;
But one scornful look from Casey and the audience was awed.
They saw his face grow stern and cold, they saw his muscles strain,
And they knew that Casey wouldn’t let that ball go by again.

The sneer is gone from Casey’s lip, his teeth are clinched in hate;
He pounds with cruel violence his bat upon the plate.
And now the pitcher holds the ball, and now he lets it go,
And now the air is shattered by the force of Casey’s blow.

Oh, somewhere in this favored land the sun is shining bright;
The band is playing somewhere, and somewhere hearts are light,
And somewhere men are laughing, and somewhere children shout;
But there is no joy in Mudville—mighty Casey has struck out.

– Poetry Foundation

Guest Blogger Profile: MARY KNUDSON is the co-author of “Living Well with Heart Failure, the Misnamed, Misunderstood Condition”, a health blogger at HeartSense Blog, teaches writing at Johns Hopkins, loves books, baseball, and critters. She can be found on Twitter as @maryknudson

17 Responses to An Open Letter to Bora Zivkovic on Baseball

Coturnix says:
March 1, 2011 at 7:06 am
Wow! Thank you so much! Anton promised to take me to a game in Durham very soon!

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Ivan Oransky says:
March 1, 2011 at 7:56 am
And let me make Anton’s offer for when you’re in New York during the season, Bora. My bleacher season tickets at Yankee Stadium are right up your alley.

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Jeanne Garbarino says:
March 1, 2011 at 9:03 am
Hi Bora – Since you are in NYC quite often, you should see a Yankee game. The experience is truly second to none!

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Krystal D'Costa says:
March 1, 2011 at 7:48 am
Mary – This is a beautifully written post that captures the essence of the game perfectly–and I say this even though we are actually cross town rivals! Certainly an apt introduction for Bora or anyone else who wonders what this sport can mean to people.
Baseball to me marks the coming of spring. I look forward to Spring Training every year, and every year–despite the previous season (many of which have admittedly hurt in recent years)–it represents a new beginning: a time to meet and try again, and tell a new story.
The Mets recently moved to a new home, and I’m sharing a letter that Shea, our former home, wrote to the new stadium because I think it captures the sense of tradition and history that the game represents: http://newyork.mets.mlb.com/news/article.jsp?ymd=20090907&content_id=6839464&vkey=news_nym&fext=.jsp&c_id=nym

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Mary Knudson says:
March 1, 2011 at 9:28 am
I was both a Yankees fan and a Mets fan for years (how can that be, you ask?) but I felt like I knew both teams and really liked members of the Mets. But then the players I cared about and manager Bobby Valentine all left and I didn’t feel like I knew anyone at the Mets anymore and I quit caring about them. Glad you liked the baseball story and glad to have you share the letter! Thanks, Mary

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Franc says:
March 1, 2011 at 8:32 am
Dear Mary,
I’m sure Bora was not writing his Twitter notice in disrespect of baseball or of any of the baseball’s fans. He is much to kind a person he would do that. But for somebody who was born in the Soccerland Europe, being myself from there, I can see how difficult is to understand the baseball idea and philosophy. And we from Europe are very curious why e. g. soccer is not so popular in America as it is in Europe?

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Mary Knudson says:
March 1, 2011 at 9:35 am
Dear Franc,
Of course Bora meant no disrespect for baseball! Everybody who knows Bora knows how incredibly helpful and kind he is. He is our leader in science blogging. I am grateful to know Bora and occasionally write for him and will be honored to be on a panel with him in April. He was having fun with our Twitter comments about baseball. But his comment gave me the idea for this story about why we love baseball and Brian Mossop graciously printed it.
I fully understand how difficult it is to follow a game when you don’t know the rules. I find it boring to watch soccer or hockey because I don’t have any understanding of those games. I’ve had to learn about baseball over the years. And I keep learning.
My letter to Bora was to encourage him to get to know baseball and was a vehicle for me to express some of the passion I am once again feeling as the 2011 season hovers. I love Bora. We all do. He is an incredible gem!
Mary

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Franc says:
March 1, 2011 at 11:55 am
Dear Mary,
I know that Bora doesn’t need an advocate, I only used the opportunity to enter the discussion on your really excellent and inspiring blog entry. And it’s my personal intention, when I go the next time to the States, that my American son-in-law will have to take me to watch a baseball game and I’ll do my best to try to enjoy it . Another friend of mine, who also lived some 12 years in the States, actually agrees with Bora in not understanding the game. He describes the game as a bunch of middle aged, beer-bellied men who mostly just stand around, often scratch their crotches , throw things around, seem to threaten each other and the umpire with a big stick, all the time spitting disgusting goo on the ground, argue with the umpire and from time to time madly dash around like they stepped on a fireanthill. Please understand, these are my friends words and he is not known to mince words a lot! He likes, however, to quote Yogi Berra, and wishes to soften these here words with one of his quotes: »Little League baseball is a good thing because it keeps the parents off the streets and the kids out of the house«.

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Mary Knudson says:
March 1, 2011 at 12:18 pm
Franc,
One thing I agree with your friend on is the spitting. I have considered writing an article on why do baseball players spit. I know some of them spit because they chew tobacco, a habit that is not only nasty to some, but also poses a risk of cancer. But I think that is now a minority of the spitters. Spitting somehow became part of baseball culture. Basketball player don’t spit. Football players don’t spit. Why do baseball players need to spit? I would think they would be concerned about sliding into base with their hand or diving for a ball and encountering the spitted product on the turf. How often, just as the camera goes in for a closeup of a player, he spits. Etiquette, please! There should be No Spitting in Baseball!!!

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David Dobbs says:
March 1, 2011 at 8:53 am
Bora at a baseball game. I REALLY WANT TO SEE IT. In fact, I’d like to be there.
But just in case I don’t make that particular game, here’s my Foreigner-Goes-To-First-Baseball-Game joke.
A Scot visits a friend in the States. Friend takes the Scot to a baseball game. Tries to explain the game as it goes along — how the batter tries to hit the ball, and if it he does, runs as fast as he can to get to first so he won’t be tagged or thrown out.
Scot gets into it. He’s cheering, yelling the hitters down to first. It’s going pretty well when a batter in the second inning draws a walk. Batter drops the bat and starts to trot slowly to first base.
The Scot, panicking, stands up and yells. “Run, mon, run! They’re going to tag you out!”
“No, no, it’s okay,” says this American host, reassuring him. “He’s got four balls, so he gets to just walk.”
The Scot looks thinks about this a minute, absorbs it, and yells, “Walk with pride, mon! Walk with pride!”
One month to Opening Day.
David Dobbs
P, SS, 1B
Montpelier Monties

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Joe Wallace says:
March 1, 2011 at 9:13 am
Thanks for asking me to contribute a “guest perspective” to this terrific post, Mary.
I remember, when I was researching my first baseball-history book, walking into the Baseball Hall of Fame Library and thinking, “I’m being paid to do this!” What a pleasure to be surrounded by the game and its unforgettable figures.

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Steve Mirsky says:
March 1, 2011 at 9:15 am
Fav baseball joke. Elderly former Cy Young winner in nursing home is visited by an angel. Says to angel, is there baseball in heaven? Angel says, I have good news and bad news. Guy says, what’s good news? Angel says, there IS baseball in heaven, beautiful field, great players, terrific equipment. Guy says, what’s the bad news? Angel says, you’re pitching tomorrow.

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Mary Knudson says:
March 1, 2011 at 9:41 am
Thanks David Dobbs and Steve Mirsky for spicing up this baseball package with your baseball jokes! Anyone else have a baseball joke to contribute?

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Steve Mirsky says:
March 1, 2011 at 10:38 am
Mickey Mantle used to tell a joke on himself. He said that he had a dream that he died and got to the Pearly Gates and St. Peter said, “Mick, I’m afraid that you led such a sinful life that you didn’t make it in. But before you go, could you sign these six dozen baseballs?”

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James says:
March 1, 2011 at 3:06 pm
I have played baseball up until the last two years in Australia. I was a pitcher and first baseman (could never hit unfortunately) and played in the top division in South Australia as well as representing my state twice. As an Australian I think its easily one of the best sports, much better than dreary cricket, and can’t understand how you haven’t got into it already Bora!!!
I loved this piece too, reminded me of why love the game so much. It’s just a shame there was so much Yankee love. You really want to go for a good team instead Bora, like the Red Sox

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Mary Knudson says:
March 1, 2011 at 9:13 pm
Thank you, James. Comments from Red Sox fans are welcome. I could never love the Red Sox. It would go against my DNA. But what we all have in common is our love of baseball! I am so psyched for the long season to unfold. And I admit I’m curious to see how good the Sox are this season. We both need to worry about those Phillies.

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James says:
March 1, 2011 at 10:09 pm
I know. A postdoc who has recently returned to the lab has come back a Phillies fan. It’s so very depressing…