Monday, October 22, 2012

Mid-October Cyclocross

Official cyclocross racing season runs from September through December in this country. Although now it is a bit longer because beginning last year, the national championships was moved from mid-December too early January. Further, the Master's world championships is in the US for 2012 and 2013 and this year (well, actually early Feb 2013), the elite World Championships is going to be in the US. So now you can race in the US from September through early February. That get's to be a pretty long season, and similar to baseball, different riders (teams) ratchet things up at different times.

This past weekend was an exciting one for cyclocross fans because the American hero of our sport, Jeremy Powers, got his best ever finish in a world cup...which bodes extremely well for the rest of his season and the possibility to see him on the podium at the world championships.

Locally, there was a big race weekend down in Tulsa, OK, which originally looked extremely attractive. But seeing that the friday and saturday races started at 9:30pm, I decided that I'm too much of an old man, and that it'd be better too stay in Missouri.

This is a point in the season where you can still build some high-end fitness too last through the winter, so I've been hitting it pretty hard during the week and also on Saturday's. So, like all self-centered cyclists, I'm trying to rationalize why my legs didn't feel super hot on race day this past Sunday. One of my favorite racers in cyclocross wrote a great blog piece about those days/times when you're legs don't show up to a race:
"Dear legs,

I regret having to send this letter, but enough is enough. Maybe you never got the memo. Or maybe you just forgot because it doesn't feel like autumn yet and in your defense, it has been quite a while. So let me take this opportunity to remind you that we are supposed to be a bike racer now. Actually, it was supposed to be a week ago and due to your absense, beard and hands were hung out to dry. I have to wonder how you failed to notice how hands were out practicing for bike driving and beard was filling out in preparation for the coming season. What have you been doing? I have supplied you with all the tools you should need to succeed. Hard training, long rest, but you don't seem to take the hint. Well, moving forward, we have a long job ahead of us and it's going to be much longer if you continue to fail at your part of the bargain. Unfortunately I have to put you on the spot. If you don't get it together I am going to have to reconsider your involvement at this facility.

Sincerely your's
Bike Racer Dan"

I think Josh must have sent a similar memo to his legs after last week, because he brought some heat and put me into a serious pain cave yesterday. It was like old times and honestly, really fun to suffer at the hands of the butthead. Well, let me re-phrase, it was really fun too race off the front with Josh from laps 4-10 yesterday. We traded leading and thus, attacking each other and had a solid dual. Which lasted until the finish line and concluded in pats-on-the-back and my comment to him, "thank you sir, may I have another". 

As far as the race report, I've been pretty bad at writing these lately and need to get my day started...but, Kenda/Felt pro-mountain biker and super nice dude, Drew Edsall recently moved to St Louis. He was there and put in a blistering 2nd lap...which almost shattered all of us. Devin Clark was also riding really strong and at one point, it seemed like he and I were going to repeat the shenanigans of Hermann. However, an untimely miscalculated corner would prevent that from being the case. 

Next up for me...well, it's Monday. Time to go cut some cancer cells with a laser (cancer research is awesome). 

Bike-stuff-wise: I really want to go to a few bigger races this year. Originally the plan was Jingle cross and then try really hard to do well at the master's 30-34 race at nationals. Jingle is a logical choice because it's only 5ish hours from my house, the race supports a good cause (always important to justify our self-centered-ness with pseudo-concern for others), and it's a mid-west thing. But last week I got the urge to travel out to Boulder for the Boulder Cup and the Colorado Cross cup this coming weekend. The family situation will allow for that too happen, but right now an examination of our bank account may prevent that from happening. Which is a shame, because it looks like it is going to snow in Boulder on Friday! I guess it's always good to think about goals in these situations, the reality is that money is the biggest limiting factor in being able to travel for a bike race and the 1500mile round trip to Boulder probably isn't compatible with the cost-benefit equation. 

post-script: I was talking to a friend about favorite CX racers and have established this list:
1. Adam Craig
2. Jeremy Powers
3. Tim Johnson
4. Dan Timmerman
5. Stybar
6. Tie between Tristan Schouten and Brian Matter
7. Zac McDonald
8. Barry Wicks
9. Sven Nys
10. Francis Mourey

Thursday, October 11, 2012

Performance enhancing drugs

"So, I have a question for all my cycling coach, exercise physiologist, fitness expert friends out there. If one took performance-enhancing drugs and improved their VO2 Max and LT, but then stop taking drugs is it safe to say they may still reap some benefits of the enhanced physiological adaptation brought on by the drugs, even years later?"- Brandon Dwight, of Boulder Cycle Sport.

I've thought quite a bit about this question, and although I'm not credentialed in any of the ways he specifically addresses, I do understand medicine, physiology, pharmacology, and have a descent background in exercise phys. So this is all, from my humble opinion:
The bottom line is that performance enhancing drugs can't all be grouped into the same category. That is to say that Epo and blood transfusions are completely different than Clenbuterol, diuretics, anabolics, and things like growth hormone. 

The physical demands of a baseball player are so incredibly different than those of a stage-racer cyclist, which in-turn are pretty different than even mountain biking and especially track cycling. In baseball, cheaters want to get bigger, stronger, and faster. So their enhancing pharmacology with things like growth hormone, estrogen antagonists, and testosterone enhancers all reflect that. And those particular drug regimens definitely alter gene expression in such a way as to produce long-term, performance enhancing benefits. I would imagine that track cyclists, if interested in the benefits of pharmacology, would utilize similar cocktails. 

I'll never forget reading about some cat 2 cyclist from Houston who got busted taking a very advanced (medically speaking) estrogen antagonist and testosterone enhancing approach. He was on a bunch of breast cancer drugs (which as a cancer survivor, bike racer, and physician-scientist in training, really pissed me off). I'd predict that his ability to recover from training was enhanced and that he had a noticeable increase in short-duration power outputs on the bike. He probably won more sprints. But in terms of time trialing or a stage racing, there's a certain point where there would be diminishing returns and frankly null or even detrimental benefits with that particular pharmacologic approach. That's simply because the demands of endurance sports are so incredibly different than power sports. And size especially, but also to some extent the myofibril adaptations associated with high-power, is/are detrimental to type-I (endurance, skinniness) oxidative fibers. It's literally like comparing the white meat associated with a chicken with the red meat of a buffalo. They're metabolically incredibly different and everything from training to fuel-source are almost diametrically opposed. And this difference is mainly associated with the underlined, bolded term and has everything to do with oxidative phosphorylation, mitochondrial efficiency, and the physiology associated with getting hydrogen ions away from, and oxygen into working muscles. 

Oxygen delivery. That's the name of the game in endurance sports. Anabolic's and cortisol synthetics don't really affect it. Genetics are huge, and effect pulmonary/chest anatomy and physiology in such a way that it's probably the biggest difference between a pro-tour rider and the rest of us. But the genetics of erythropoiesis probably don't factor in much...which is to say that most people's bone marrow is on pretty similar playing fields. Unless of course, you alter the kinetics of hematopoeisis. And like most things in physiology, you can increase hematopoesis or decrease it, and these events can occur naturally (you get a bacterial infection, your bone marrow makes more white blood cells) or pharmacologically/iatrogenically (cancer patient get's radiation treatment which damages bone marrow stem cells, so they become deficient in various blood cells). Just to tie the point back to performance, it is the red blood cells which serve to help buffer hydrogen ions (which isn't always talked about but is a HUGE factor) and deliver oxygen from the lungs (genetically determined) to the working tissues.  Measurements of red blood cells often confuse medical students and physicians, so it isn't worth the effort to go through the meanings of Hct, Hgb, MCH, MCV, reticulocyte count, RPI, etc. But the key to discussing the answer to the question at the beginning of this post is that red blood cells hang out in the blood for around 4 months. So changing the kinetics of RBC production, like with EPO, or simple increasing circulating RBC mass, like with autotransfusions, have short-lived effects. 

So in short, anabolics can have potentially long term performance enhancing effects. Drugs and transfusions to affect oxygen delivery almost certainly don't. But, since doping leads to enhanced performance, which can lead to winning races...then (to quote Adam Myerson) 'It can make the ability to return to that higher level easier than it would have if it was done cleanly, and incrementally. But more importantly, the access to better teams, better races, better support, and better money, all lead to an ability to do better preparation, and reach a higher level still. So, not exactly the question you asked, but an example of how it can indirectly continue to benefit the level of fitness reached after doping.'

To me, the use of EPO in endurance sports is a medical travesty and if you want too seriously talk about long term effects of EPO use, I think you're getting into the realm of oncology and cancer biology. Synthetic EPO saves lives; mostly for cancer patients and renal failure patients. And like any drug that is ingested or injected, there are effects beyond those associated with the therapeutic benefit. I was taught in medical school that there is no such thing as drug 'side-effects'. Biology doesn't work that way, there are only effects. For EPO, it's a mitogenic agent, or something that induces/promotes the cell cycle. Anything that does that, has the potential to facilitate conditions that lead to cancer. So in a sense, a cancer patient or former cancer patient that takes EPO is putting themselves at risk for more cancer. And in another, more abstract sense, spitting in the face of the patients for whom EPO was originally intended. 

Personally, I've received enough radiation over the years that my bone marrow has taken a hit. When you measure my white blood cells and red blood cells, you can see that deficiency. Also, I ride and race bikes with active, living tumors in my vertebrae and in my lungs (although those in my lungs are only 5-10mm). I'm clearly not a world class athlete and could never be one, but my point in saying that is that these things effect oxygen delivery in my body, but I'm clearly still capable of having a descent power output at LT and VO2. My own conclusion based on understanding my own physiology, is that training can trump anatomy, but only to a certain point. 

Wednesday, October 3, 2012

Medicine and the election

It's been a little while since I've posted anything besides bike racing stuff.

I hesitated to post links to the following on facebook, so will therefore post them here and then link to facebook!

Lot's is at stake in this election coming up in November. In terms of healthcare, you should read the following links and think about them no matter where you are on the ideological/political spectrum:
The conservative case fo Obama care

Also, both presidential candidates wrote pieces for the most important journal in medicine.
Replacing Obamacare with real reform- Romney
Securing the future of American Healthcare- Obama

I'm not sure if there's anything more important in my life (besides my family) than being a physician. I have not yet completed my training, but will in the next couple of years. For me there is no higher calling, nothing more meaningful, interesting, exciting, or engaging than the art and science of medicine. I won't go on a rant about what I believe as far as national health care, but suffice to say that having had cancer as a 20-something made it undeniably clear that our healthcare system has been broken. This article by Atul Gawande, a Harvard Suregon essentially summarizes my opinion.

As an aside, in terms of those two articles from each candidate in the New England Journal, I speak essentially 3 languages: English, spanish, and medical. And honestly, even though I read it with an open mind, I have no idea what Mitt Romney is saying in some sections of his piece.

There are a bunch of comments following each piece. My own view is summarized by the following:
"We Need to Go Deeper Than Glossy Rhetoric
We will never have a smart, cost-effective healthcare system in this country until we address the way we pay for health care. Our third party payer system - private as well as government-funded - supports the health industrial complex, not health care. It provides all the wrong incentives for specialist care, overmedicalization and procedures, and shapes the way a doctor practices at least as much as medical science does. To think that an unregulated free market system will put less emphasis on profit and put patients' interests first is to be stuck in a 1950's mentality: as long as clean cut white men in suits are in charge, we are all in good hands.
The Affordable Care Act, as well as its earlier version, Romneycare, moves us towards providing incentives for quality outcomes and cost-effectiveness rather than for productivity. We the people, in the form of a democratic government, need to continue to work towards this critical goal, keeping special interests at arms length. Private business has very different goals, ones that are often directly at odds with patient's best interests."
-RANDY KOZEL, MD | Physician | Disclosure: None