Anorexia nervosa-another brain-heart-bone-axis at the pivoting point according to Dr Watson

Life can be wonderful at times like what happened last night in  our temporary quarters in the Irving Ludmer Building at the top of Peel Street on McGill’s campus.

I was sitting in my little corner section when I noticed from the corner of my vision this pretty girl come into our lab with a real beautiful smile announcing,”There’s a Christmas party downstairs for the building-free food and drinks-come on down to room 138 to celebrate!” So we did.

It was one of those informal affairs with a bunch of people who work around us in offices but we don’t know each other. We are in dental/bone/heart/brain research plus we are here temporarily as a new sprinkler system gets finished in our old building- the former library of medicine at the Strathcona Anatomy Dentistry Building. Back when they constructed this building over a century ago they didn’t know that asbestos, which they added to every single brick in the building as a binding agent, was so dangerous. So when any work involving the structure is involved, like installing a new fire suppression water sprinkler system, they have to isolate the work with full contamination protocols. So basically we were kicked out of our offices 3 months ago-hence our imposed exodus to Ludmer.

I walk up to this petite lady dressed in black to thank her for the Christmas party invitation. I start talking shop to her, explaining what we are trying to do with opening a different dialogue with concussions. Then she introduces herself as Mimi Israel, she explains she studies anorexia. I gulped. Many years ago for a few months I was real heavy into anorexia reading about the topic for a few months. In a previous blog I had described my encounter with Dr Duncan Stewart using anorexia as a way to view heart changes with dietary suppression. I mentioned Dr Stewart after she had said some key words like: osteoporosis, heart pacing anomalies, brain control. Then she mentioned she knew Dr Stewart, “He’s my era.”  ‘Wow,’ I said to myself, ‘ we’re on common ground here, it’s the neurocardiac bone axis of control.’ So I told her I had a great new German EKG test to evaluate cardiac changes maybe with her anorexic patients that I had only unraveled in the previous week. Would she like to collaborate with us perhaps with Dr Chris Andersen and his awesome GE bone density scanner? Certainly looks like a potential joint project could be hatched. Dr. Andersen studies bariatric surgery patients. These are very, very big people like 400 pounds big. The stresses on their body with such a massive weight gain is huge, their hearts  have to absorb this swirling abundant load, their bones have to carry the weight, it’s a very serious problem. Dr Andersen scans their entire bodies as they lose over relatively short time periods, sometimes over a hundred, sometimes as much as two hundred pounds. This is a significant change to their bone structure-hence his acute interest. Dr Ross Andersen has a Canada Chair to study this disease, he’s a very capable clinical researcher.

Then it dawned on me.’Mon Dieux! These two patient groups, anorexic and bariatric are almost identical, they both lose a ton of weight. ‘ They both have heart arrhythmias, they both are osteoporotic, they must be experiencing the same pivoting decoupling in their brains, and our little group in dentistry knows where to look ! ‘It’s the brain-heart-bone axis dilemma.’ When I mentioned this term to Dr Israel she looked at me, her eyes sparkling, ” I like how you describe that, where did you get that term?” “It’s mine it’s what we do too, we’re on the same boat – we have to talk,” I blurted out.

So lets talk a little about anorexia, again…..with a different spin- with Taku Tsubo cardiomyopathy from Dr Watson’s point of view. Please bear with me!

This image is sourced from the journal The Netherlands Journal of Medicine   :CASE REPORT Taku Tsubo cardiomyopathy, presenting with cardiogenic shock in a 24-year-old patient with anorexia nervosa authored by M.N.M. Volman, R.W. ten Kate,and R. Tukkie

Check one of my previous blogs on Taku Tsubo, if you will recall the little drawing in the middle of this ultrasound image is the outline of an octopus trap, which is takutsubo in Japanese. So the image is with the upper portion (apical in medical lingo) that is as if the heart is squeezed, that’s the LV or left ventricle on the right. LA is the left atrium, by the way the image is oriented upside down to our usual frame of viewing the heart.

Taku Tsubo usually affects postmenopausal women with presentation to an emergency room as acute myocardial infarction complaining of chest pain. Upon EKG examination- ST elevation and/or T-wave inversion plus a rise in cardiac enzymes (troponin)  is the usual reports from the literature. The Sherlock Holmes puzzler is: no coronary event is found. So who or what done it?

If I were to role-play as Watson here’s my answer, ” Holmes, surely changing the overall shape of the heart has something to do with this girl’s condition, I mean after all her heart looks like a round-bottomed narrow-necked Japanese pot used for octopus fishing for heavens sake!”

The extreme risk and acute symptoms of Taku Tsubo can become very severe, cascading into cardiogenic shock, involving ventricular arrhythmia’s precipitating to death. However, prognosis is usually quite favorable with a full recovery of left ventricular function in most cases.

The authors have speculated: ‘ that hormonal changes seen in young women toward sensitizing them toward Taku Tsubo cardiomyopathy, altering endothelial function (lining of blood vessels) and microcirculatory vasomoter reactivity in response to sympathetic-mediated (my emphasis) myocardial stunning.’

Watson slips forward, canting his chair onto two legs, “My dear Holmes that recent report of sympathetic/parasympathetic pivoting point by that McHugh fellow surely must have tipped completely over.  I mean the poor women’s heart is stunned, why didn’t they measure her acceraction capacity-deceration capacity, surely this cardio-brain ratio could given them some good clue as to why her heart has so radically changed character to have changed shape the way it did.”

Holmes settled into his favorite chair, the ring of pipe smoke parked, slowly spiraling over his head. For a few minutes he sat there, allowing his grey matter to dwell, a familiar pattern spinning inside of his head. Always looking where no one looked. He broke his self imposed silence.

“Dr Watson I read the McHugh report, it’s really very elemental. It’s not just the heart as everybody is so worried about- it’s the brain too, that’s where the traffic causing the Taku Tsubo to take shape comes from. What did McHugh call it?-Oh yes- the brain vortex. All that endothelial disregulation, the pivoting point surge from a sympathetic bath in the central control zone, the brain pacing simply decouples from parasympathetic. Everybody is dazzled by the fireworks of the heart-it’s the brain zone -Watson- that’s where it started! But here’s the clincher, it’s her also bone density, they are all critical, its all of the above Watson ! It’s about bone, it’s about brain and it’s about heart !”

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Montreal Grandmother, Agnes Kent was saved by Raul Wallenberg from certain death, when he provided papers for her and her Mom to escape away from the Nazis. Today when asked what that escape meant, she replied,"Remind people, that while statesmen and whole countries remained silent and did nothing, a single individual chose to act, with ramifications that proved enormous. Similar choices confront us today. Write that simple truth she said, it can never be repeated often enough because the world keeps forgetting it."
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