Environmental discontinuity hypothesis: Buffer dysfunctions as a source of human disease

High Altitude Is an Independent Risk Factor for Developing a Pulmonary Embolism, but Not a Deep Vein Thrombosis Following a 1- to 2-Level Lumbar Fusion

STUDY DESIGN

Retrospective study.

OBJECTIVE

To identify if a 1- to 2-level posterior lumbar fusion at higher altitude is an independent risk factor for postoperative deep vein thrombosis (DVT) and pulmonary embolism (PE).

METHODS

A national Medicare database was queried for all patients undergoing 1- to 2-level lumbar fusions from 2005 to 2014. Those with a prior history of DVT, PE, coagulopathy, or peripheral vascular complications were excluded to better isolate altitude as the dependent variable. The groups were matched 1:1 based on age, gender, and comorbidities to limit potential cofounders. Using ZIP codes of the hospitals where the procedure occurred, we separated our patients into high (>4000 feet) and low (<100 feet) altitudes to investigate postoperative rates of DVTs and PEs at 90 days.

RESULTS

Compared with lumbar fusions performed at low-altitude centers, patients undergoing the same procedure at high altitude had significantly higher PE rates (P = .010) at 90 days postoperatively, and similar rates of 90-day postoperative DVTs (P = .078). There were no significant differences in age or comorbidities between these cohorts due to our strict matching process (P = 1.00).

CONCLUSION

Spinal fusions performed at altitudes >4000 feet incurred higher PE rates in the first 90 days compared with patients receiving the same surgery at <100 feet but did not incur higher rates of postoperative DVTs.

The hegemony of empiricism: The opportunity for theoretical science in medicine

Partly spurred by the rapid emergence of discovery tools, empirical science founded on experimental validation now dominates academic funding, publishing, and recognition while forums for theoretical science have been marginalized. Although this hegemony of empiricism instills useful discipline to the scientific process, it also limits the pace of science to sensor innovation and renders the ontogeny of scientific knowledge path-dependent, concealing potential discontinuities in intellectual trajectories. Theoretical science, founded on intuition, inspiration, and abstraction, can complement empirical science by creating disruptive paradigms that facilitate detection of spurious results and frame new hypotheses. For example, framing the compendium of human diseases as varying manifestations of buffer dysfunctions - insufficient or maladaptive responses to stress - portends new insights into disease mechanisms and treatments. As a specific incarnation of this theory, the "trauma hypothesis" suggests that the coordinated regulation of inflammation, coagulation, vasoconstriction, and fluid retention that evolved as a prehistoric adaptation to predatory stress and environmental injury conspires in modern times to produce acute coronary syndromes, heart failure, renal dysfunction, stroke, and pulmonary embolism. The theory also exposes the paradigmatic flaw behind the half-century detour perfecting balloon-deployed endovascular interventions. As the basis of buffer acquisition shifts from genetic to cognitive, phenoptosis - the theory that adaptive programmed death of organisms yields opportunity to successors - is rendered maladaptive, as an extended lifespan permits more efficient trait acquisition compared with life-death recycling. While forestalling death is a largely unfruitful medical game of "whack-a-mole" today, the recognition that aging and death may be programmed adaptations suggests they may also be amenable to systemic reprogramming. Epitomizing this opportunity are tumor cells, which reprogram themselves to escape their apoptotic fate and assume indefinite persistence. The prevalence and resilience of these cancer cells, and their ability to withstand the protean assaults of toxins, poisons, radiation, and host defenses, presage the potential robustness of life when appropriately programmed. Paradoxical medicine and dynamic range management may represent initial strategies to reprogram the neuroendocrine stress axes to modulate lifespan at the organism level, and many other strategies are anticipated. The key to theoretical science is original insight, but the prevailing pressure to conform to medicine's educational and practice standards dis-incentivizes independent thinking. A scientific future is envisioned when the commoditization of experimental science will enable its outsourcing, liberating health scientists from the tyranny of empiricism to engage in a more balanced process of discovery infused with theoretical considerations.

A new concept of melanocytic neoplasia pathogenesis based on the phenotype of common acquired nevi

Common melanocytic nevi are ubiquitous lesions which in some cases constitute a risk factor for the development of melanoma. To date, despite long term research there are no known molecular hallmarks for nevus development. We have observed that common acquired nevi excised from the same individual share remarkable similarity in their microscopic appearance and in the immunohistochemical expression of E-cadherin. Based on these observations, we hypothesize that all melanocytes are genetically similar in the same individual and changes predisposing to neoplasia are a global melanocytic event characteristic for each person and propose a microgenomics/proteomics approach to test this hypothesis.

Stress dysfunctions as a unifying paradigm for illness: repairing relationships instead of individuals as a new gateway for medicine

Stress has been implicated as a risk factor for most diseases, but a mechanistic explanation behind such associations remains elusive. As emergent responses to stress, adaptations range from acute responses where extant system capabilities mitigate current stress, to longer-term responses where system plasticity buffers against future stress. The long compendium of human ailments manifests through a much shorter set of symptoms that may operate through the stress axis. We propose a unifying ontology for human illnesses that classifies stress dysfunctions according to types of Darwinian dysfunction - inadequate response with adequate adaptation, inadequate adaptation, inappropriate adaptation, and epiphenomena of adaptation. Examples include cancer as a bystander effect of increased biologic plasticity in response to stress, and infectious illness as a manifestation of mutually escalating stress in an otherwise commensal relationship between hosts and microbes. We explore the contributing role of man-made stresses that have emerged as humans increasingly remodel their environment. Examples include biologic decompensation associated with reliance on technology to buffer stress, and behavioral stress caused by the dislocation of kin networks that promotes illegitimate signaling. Dysfunctional relationships engender stress not only among humans, but also among individual organs; heart failure, renal failure, and carotid stenosis may represent examples of such conditions. If stress dysfunction is the Occam's razor of human illnesses, and derangements in biologic relationships induce stress dysfunctions, then the study of relationships - an incarnation of systems biology - may represent a new gateway for medicine.