42 y/o M c EtOHism admitted for R femur fx d/t MVA, s/p ORIF POD#3, now complaining of AVH and c HTN + tachycardia on vitals.

Translation:

42 year old male with alcoholism (EtOHism) admitted to the hospital for a right (R) femur (thigh bone) fracture caused by (due to) a motor vehicle accident (MVA—a car crash), status post (s/p) open reduction, internal fixation (ORIF), post-operative day (POD) #3, now complaining of audio-visual hallucinations (AVH) and also has high blood pressure (HTN—hypertension) and tachycardia that was detected during a vital sign check.

In a Nutshell:

This alcoholic got into a car wreck and broke his right thigh bone. The orthopedic surgeon (bone surgeon) took him to the operating room and performed an open reduction, internal fixation – a surgery that requires cutting open the patient’s thigh and/or hip, repositioning the broken thigh bone, and then hammering a rod into the soft marrow cavity of the bone that will act as a support strut for the bone as it heals (see the X-ray below). It is now three days from the operation and the patient is going into alcohol withdrawal, a potentially fatal condition that can cause hallucinations, high blood pressure, tachycardia (fast heart rate), and seizures. This post-operative sequel could have been avoided by monitoring the patient for signs of withdrawal more closely and by treating him with benzodiazepines, a group of medications that include Xanax, Klonopin, and Ativan and which are similar to alcohol in some respects (both alcohol and the benzodiazepines activate GABA receptors in the brain) and which are useful in both preventing and in treating alcohol withdrawal.

18 y/o F c IDA, N/V/D, poor dentition, and amenorrhea x1yr. Pt BIBA to ED after parents found pt lying on the floor of the bathroom with AMS (mild) next to an empty bottle of MoM – suspect acute dehydration and underlying supratentorial etiology. BMI 18.

Translation:

18 year old female with iron deficiency anemia (IDA), nausea, vomiting, diarrhea (N/V/D), and one year of amenorrhea (lack of menstruation) who was brought in by ambulance (BIBA) to the emergency department after her parents found the patient (pt) lying on the floor of the bathroom next to a bottle of the laxative Milk of Magnesia (MoM). Apparently the patient was confused or acting strangely (mild AMS—altered mental status).  The doctor thinks that the patient is dehydrated due to her vomiting and diarrhea and that there is ultimately an underlying psychiatric etiology (cause) of her condition. The patient’s body mass index (BMI) is 18, which is very low (<20 = underweight; 20-25 is normal).

In a Nutshell:

This girl has an eating disorder. Her BMI of 18 suggests that she is anorexic (starves herself) while her purging behavior with laxatives suggests that she also has bulimic behavior (classically binging followed by purging, but sometimes just purging in anorexics who also have bulimic behavior). A lack of iron in the diet has caused this girl to develop iron deficiency anemia and her low BMI has resulted in hormonal abnormalities that have caused her to stop menstruating. Eating disorders are extremely serious and they are the psychiatric condition with the highest mortality. If you have an eating disorder your chance of dying from your disease if it is untreated is higher than the risk of death in even the most serious mood and psychotic disorders, e.g. bipolar disorder and schizophrenia. Unfortunately, some people with eating disorders consider this serious disease to be a “lifestyle choice”—shown below is a “Pro-Ana” bracelet in support of the anorexic lifestyle. It is common on pro-eating disorder websites for anorexia to be referred to as “my friend Ana” and for bulimia to be referred to as “my friend Mia.” Bulimics have a bracelet too by the way. Most people afflicted with eating disorders have both anorexic and bulimic behaviors, e.g. they usually have symptoms of both disorders.

21 y/o M with acute MDMA intox, admitted for GI pain 2/2 obstipation, now c BRBPR s/p self-removal of FB while being transported back from X-ray.

Translation:

21 year old male with acute MDMA (Ecstasy) intoxication, admitted for gastrointestinal (“stomach”) pain secondary to (2/2) obstipation (inability to pass gas or to have a bowel movement), now with bright red blood per rectum (BRBPR) status post (s/p) self-removal of a foreign body (FB) while being transported back from X-ray.

In a Nutshell:

This guy is high on ecstasy, stuck (or had stuck) a flashlight up his butt, and then had the great idea to yank it out while the poor ER staff was wheeling him back to his room after he got his X-ray. Now he’s bleeding and will probably need an exploratory surgery if the bleeding doesn’t stop on its own in the very near future. Rectal foreign bodies are very common in the emergency department—they are also a source of amusement for radiologists, who usually have a rather boring (albeit important) job. While rectal foreign bodies are embarrassing (don’t stick it up there, genius), they are also a serious medical problem and a potentially fatal cause of bowel obstruction and infection (due to disruption of the rectal /colon wall). If you ever have the misfortune of having this problem, go to the ER! Your doctor and the ER staff are required by law to keep their mouth shut about it and you can (and should) sue the heck out of them if they gossip (of course, the ideal way to prevent this problem is not to stick things up your butt).

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis –> (Click on the book covers on the right to check out my books!).

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

References:

Open Reduction, Internal Fixation. Courtesy of Wikipedia. www.wikipedia.org.

Rectal Foreign Body. Courtesy of Wikimedia Commons. http://commons.wikimedia.org.

Pro-Ana Bracelet. Courtesy of the Producer (Open Source Image).

The term “life support” has become so entrenched in the common jargon that people use it to refer to everything from the status of their failing relationship with a significant other to the condition of their old jalopy! Politicians fight over life support and whether or not we have the “right to die.” So what the heck is everyone, including probably you (even if you don’t know it), referring to when they utter those two dreadful words?

Let’s step back for a moment and briefly discuss breathing. You breathe for two reasons, to bring in oxygen so that the cells that make up your body can use it to “burn” fats and sugars for energy and to get rid of the toxic carbon dioxide that is produced as a by-product of this cellular metabolism (cellular “eating”). The diaphragm is a flat sheet of muscle that stretches across the bottom of your rib cage from front-to-back and that divides the abdominal cavity (“stomach”) from the chest cavity. The diaphragm is the primary muscle that powers breathing — when it moves down you inhale and when it relaxes and moves up you exhale.

Life support is more properly referred to as “mechanical ventilation” and a ventilator is simply a machine that breathes for someone who is unable to breathe for themselves. There are a lot of reasons why someone might not be able to breathe, and some of these reasons are temporary whereas others are permanent. People who overdose on narcotics often die because massive doses of narcotics depress your drive to breathe — once the narcotics are out of their system they start breathing again. A formerly common example of a reversible cause of respiratory failure (respiratory failure = you can’t breathe well-enough on your own to stay alive) was polio, a paralytic disease caused by the polio virus that has been eradicated from all of the world except Afghanistan, Pakistan, and Nigeria (due to anti-vaccination forces in those countries). Severe polio can weaken the body to such an extent that the polio victim stops breathing. Many lives were saved by the iron lung, the first mechanical ventilator (invented in the late 1800s and first widely used in the early to mid-1900s). These patient’s, most of whom were children, were kept alive by the iron lung for weeks-to-months until they finally recovered enough strength to breathe for themselves again, an amazing revolution in medicine because prior to the iron lung every single one of these people would have died!

The iron lung was an external respiratory and not very useful except for people with generally healthy lungs who couldn’t breathe temporarily because of some other cause, like the weakness caused by the polio virus or the temporary respiratory depression caused by narcotic overdosing. The iron lung was a negative pressure ventilator that created a vacuum around the patient. When the vacuum was turned up the patient’s chest rose and they sucked in air; when it was turned down the patient exhaled and then the cycle started over again. In the 1960s a truly revolutionary invention turned critical care medicine upside down and its head and back over again — positive pressure endotracheal intubation, the modern mechanical ventilator. Endotracheal ventilation involves sticking a breathing tube into a sedated or unconcious patient’s airway and then hooking it up to a machine that blows air into the patient’s lungs, a process that is roughly akin to using an airhose to inflate the tires on your car. The mechanical ventilator increases its air pressure to give the patient a breath and then decreases it to allow the patient to exhale (the chest is elastic and naturally exhales without really needing any assistance). This may not seem like a big deal, but look at the images of the iron lung versus endotracheal intubation and you can appreciate that it is possible to move (via a bed with wheels), operate on, and to examine a patient who is endotracheally ventilated — all of which are impractical or impossible in a patient who is being maintained on an iron lung. In addition, the superior and direct control of the airway pressures through the endotracheal ventilator allows the critical care doctor/pulmonologist to perform a lot of neat tricks (with pressures and mixes of inhaled gases) that can keep people with lousy lungs alive on the ventilator who would have died in the clunky old iron lung.

Image 1: A patient in an iron lung.

Image 2: A patient on a positive pressure ventilator being ventilated through an endotracheal tube.

Image 3: A diagram of endotracheal intubation. The tube is made of plastic and the balloon at the tip (“C”) seals the tube in place. Notice “D” — that is the esophagus, the tube that brings swallowed food into the stomach. It is a common and potentially deadly error to place an endotracheal tube in the esphagus instead of in the airway (the trachea).

***Factoid: If you’ve ever had general anesthesia for a surgical procedure you were intubated and kept alive on a mechanical ventilator! If you don’t remember it, well, that means that the anesthesia was working!!!***

An example of irreversible loss of the drive to breathe is a person who has suffered a massive head injuries — this unfortunate patient’s organs can often be kept alive with a mechanical ventilator, but since the brain is essentially destroyed and it is the brain that controls breathing, the minute you turn off the mechanical ventilator whatever tissues are still alive in the person’s body are going to die. The realization that you could keep a persons organs and tissues alive even when there was no chance of their brain recovering functioning (i.e. zero chance of them ever waking up) led to two important, albeit somewhat disturbing, changes in medicine. Before the invention of mechanical ventilation you died if you stopped breathing and your internal organs all died to within a few hours at most (some tissues die faster than other when they are cut off from oxygen — the brain and the heart die the fastest, within minutes, whereas skeletal muscle can take hours to complete the dying process). This led to the legal concept of brain death, which essentially is the determination that a person has suffered such a severe injury to their brain that they are unconscious and that they will never regain consciousness. Brain death is an important concept for two reasons, the first being that it doesn’t make any sense to keep everyone’s bodies alive after their brains are kaput — we’d have millions of people lying around on ventilators with zero chance of ever waking up if we did that and who would want that done to their body anyway, right. The second reason that brain death is important is that the overwhelming number of usable donor organs come from people who are brain dead — motorcycle accidents in people who aren’t wearing helmets are an especially common source of these organs because these accidents frequently kill the rider by destroying their brain and skull but leave the kidneys and liver intact and healthy enough to save another person’s life.

One Last Note: Patient’s in the ICU may also be treated with several other intensive therapies including powerful drugs to maintain their blood pressure, nutrition through a vein in patient’s who cannot eat for extended periods, and even with specialized pumps that are inserted into the aorta/heart to help it pump. But the cornerstone of critical care medicine is the mechanical ventilator and without mechanical ventilation modern critical care medicine would not be possible.

FYI: I’m having a promotional for the Kindle versions of all four of my books (click on the book covers) — all four books are $0.99 until May 15th!

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis –> (Click on the book covers on the right to check out my books!).

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

References:

Medscape Today:

http://www.medscape.com/viewarticle/552178_2. Accessed 10 MAY 2013.

Images courtesy of

http://www.wikipedia.org. Accessed 10 MAY 2013. PPV Image courtesy of Rcp.basheer. ETT diagram courtesy of PhilippN.

FYI: All four of my books are on sale (Kindle versions are 99 cents; paperbacks are also on sale), so go click on one of those fancy bookcovers over their to your right! —->

As we discussed last time, most illegal “narcotics” aren’t really narcotics (opium derivatives) at all! As promised, here is a rundown of other common substances of abuse and how/why they produce euphoria (a “high”). Each of these substances is deserving of a full blog post and I’ll be doing that at some point in the future. But for now, here’s the basics – enjoy!

Before we get started, let’s discuss an important general principle of neurobiology, i.e. how your brain works! The thinking part of your noodle is made up of “neurons” (nerve cells). Neurons talk to each other by releasing “neurotransmitters,” which float across the tiny fluid-filled gaps that separate neurons and then bind to a receptor on another neuron. If “Neuron A” wants to tell “Neuron B” something it releases a “message” in the form of a neurotransmitter which then binds to a receptor (the “mailbox”) on “Neuron B.” This causes electrical activity in “Neuron B” and the aggregate of all of this neurotransmitter messaging and electrical activity is what results in your “brain waves” and in all of your thoughts and emotions! The words that you are seeing on this blog right now are the result of light entering your eyes and causing a cascade of neurotransmitter messaging and electrical signals that when added together in aggregate in the massively powerful, neuron-computer called your brain are reconstructed into the words and thoughts that you are experiencing right now! Drugs screw with this process by affecting the distribution of neurotransmitters in your noggin and different drugs affect different neurotransmitters, which is why smoking a nicotine-containing cigarette feels different than downing a beer.

One other quick note: Even though most drugs of abuse are potentially addictive, this is not true of all of them and even highly addictive drugs generally have far more occasional, recreational users than true addicts. Most drugs of abuse have a ratio of users-to-addicts of 10:1 – for the most addictive drugs, like nicotine and heroin, this ratio can be as low as 3:1, but that still probably a lot lower than most people realize.

Alcohol – The active ingredient in alcoholic beverages is ethanol, a substance which is often abbreviated in the medical records as “EtOH.” If a doctor writes that you’re an EtOHic in your chart, that means “alcoholic” my friend. As we discussed, mind-altering drugs work by either enhancing or inhibiting naturally occurring substances in the body called neurotransmitters. Ethanol is no exception to this rule and whiskey, beer, and Toothless Joe’s moonshine it makes you feel relaxed by potentiating the activity of GABA receptors. GABA receptors are the same neuroreceptors that are activated by benzodiazepines (e.g. Xanax) and barbiturates (e.g. phenobarbital). GABA is an inhibitory neurotransmitter that “relaxes” the activity of other neurons in the brain—this is why excessive ethanol consumption makes you feel REALLY relaxed, i.e. it puts you to sleep! Ethanol also inhibits the action of NMDA receptors, which are important for memory consolidation. By blocking NMDA receptors ethanol causes both memory impairment (“blackouts”) and mild dissociation (feeling detached from reality). An example of a more powerful NMDA antagonist (“inhibitor”) is PCP, which causes severe dissociation from reality and vivid hallucinations. Generally 1-2 drinks per day for a non-pregnant adult is considered to be a reasonable level of alcohol consumption and alcohol in moderation is good for your heart and probably also for your brain; however, if you’re drinking more than this you may have a problem and you should talk to your doc about it to see if you need help. Alcohol depresses your drive to breathe and this effect can be fatal when it is consumed with other respiratory depressants, especially narcotics, benzodiazepines, and barbiturates.

Benzodiazepines and Barbiturates: While we’re on the subject of GABA agonists (“agonist” = activates or enhances the effect of), let’s not forget barbiturates and benzodiazepines. Barbiturates are old drugs that were used for the treatment of anxiety back in the not-so-good old days when female doctors were still as rare as Texas steaks and when STDs were still treatable with penicillin. The problems with barbiturates are that they are addictive that it is really easy to fatally OD on them. Barbiturates are sometimes still used for people with severe seizure disorders and as a component of some powerful headache medications, but for the most part these dangerous drugs have been replaced by the benzodiazepines, a closely related class of GABA agonists that are much safer, albeit still addictive. The most famous benzodiazepines are Valium and Xanax, both of which are commonly used to treat anxiety disorders and which are commonly reported as the cause of fatal celebrity overdoses by the news media. While it is true that you can overdose on these medications, the reality is that overdosing on benzodiazepines alone is actually very hard to do and that the overwhelming majority of people who manage to kill themselves with benzos had also consumed another respiratory depressant (i.e. a drug that decreases your drive to breathe), usually alcohol, narcotics, or both. It just makes for a much better Nancy Grace or Fox News headline to say that “Pop Diva Z” overdosed on Xanax than to report that she overdosed on Bud Light, but the truth is usually both.

Nicotine: Smoking is the most common cause of preventable death in The United States and Marlboros, Camels, and Newports kill exponentially more Americans every year than all illegal drugs combined. Even alcohol, which wins the award for 1^st runner up (mostly due to drunk driving and other accidents), doesn’t come even close to killing as many people as King Tobacco. Nicotine activates (surprise!) nicotinic receptors in the brain and its effects are incredibly complicated, resulting in neuro-cascades that act through just about every damn neurotransmitter that you can think of (dopamine, norepinephrine, serotonin, GABA, and more!). You may have noticed that “nicotine” conveniently binds to “nicotinic” receptors. The naming isn’t a coincidence – most neurotransmitters and their receptors were discovered by scientists who trying to figure out how the drugs on this list work! Tobacco is incredibly bad for you, especially when it is smoked, but nicotine does have a few beneficial effects including enhancing memory.

Marijuana: Speaking of a drug leading scientific discoveries, marijuana is responsible for the research that discovered what is probably the most numerous class of neuroreceptors in the human brain! THC, the active ingredient in marijuana (aka: cannabis) works by mimicking the endocannabinoids like anandamide that are naturally present in the brain and body. Endocannadinoids (and THC) activate cannabinoid receptors which serve to temporarily “slow down” the activity of neurons in the brain and spinal cord. Cannabinoids affect appetite and pain and they are medically useful for the treatment of both wasting disorders and probably for some chronic pain conditions as well. Marijuana causing the munchies and decreased perception of pain, “duh,” you say! But this is actually another common theme in medicine—the side-effects of drugs, both the legal and the illegal one, often alert attentive physicians and researchers to new potential uses of the drug. Cannabinoids are also useful anti-emetics (anti-vomiting drugs), which since chemotherapy can cause severe vomiting can be a useful property of cannabinoids for cancer patients. Unfortunately, cannabinoids also affect the cardiovascular system and increase the risk of heart attacks and probably also worsen high blood pressure in recreational users. Generally speaking, there is no clinically significant withdrawal following cannabis use/abuse because THC and its relatives are highly fat soluble and naturally taper out of the body—this is also the reason why heavy users of cannabis can test positive on a urinalysis several weeks (or even months) after their last use. The quote/unquote “amotivational syndrome” that has been attributed to cannabis is probably a side-effect of heavy recreational drug use in general rather than of cannabis in particular. The long term effects of smoking cannabis on lung health (cancer risk, etc.) are controversial but commonsense would tell you that inhaling any form of hot smoke into your lungs probably isn’t the greatest health decision.

Cocaine and Methamphetamine: Both of these drugs are stimulants and stimulant drugs work by enhancing the activity of the dopamine and norepinephrine pathways. Cocaine is a reuptake inhibitor of these neurotransmitters whereas amphetamines (including meth-) cause dopaminergic and noradrenergic neurons to release greater quantities of dopamine and norepinephrine—in other words, cocaine and amphetamines essentially have the same effect, they just produce that effect by somewhat different mechanisms. Cocaine is an interesting drug for several few reasons. First, it is the root drug for most topical anesthetics. The lidoCAINE and marCAINE that your doctor uses to numb the skin before stitching closed a skin wound are both derivatives of cocaine and lidocaine is also a powerful cardiac (heart) drug when it is injected. Cocaine is also notable because a lot of the doctors who performed pioneering work with this extremely important drug, including Sigmund Freud (the psychiatrist) and William Halsted (possibly the greatest surgeon who ever lived), became addicted to it. Before cocaine was purified by Western chemists it was chewed in the form of coca leaves by Native Americans in the Andes Mountains to produce a mild stimulants effect that many describe as similar to drinking a cup of coffee.

Cocaine and other stimulants are known as “sympathomimetics” because they activate the “sympathetic” division of the nervous system. To keep a long story short, there are two opposing components of the nervous system that are known as the sympathetic and the parasympathetic divisions (there are a lot of other parts to the nervous system too, but I’m only one dude writing this blog and I have a day job too…jeesh!). The sympathetic division is responsible for the “fight or flight” response that you get when you’re being chased by an angry dog or having an episode of stage fright while the parasympathetic division is responsible for calming you down (in part) and for mundane functions like digesting your food and what not. The nasty effects of cocaine and its cousins mostly stem from there powerful sympathetic/stimulant effects. When you’re being chased by that angry dog your heart starts pounding and your blood pressure shoots through the roof, both good things (temporarily) if your life is truly in danger but very bad things if you are using cocaine for fun, especially if you are a chronic user—a chronically elevated heart rate and high blood pressure are setups for heart attacks and strokes! The concurrent use of ethanol and cocaine also forms a metabolite that is directly toxic to your heart – so using both concomitantly, as most cocaine users do, is a really, really bad idea.

LSD: Is a hallucinogen that primarily exerts its effects by enhancing the actions of serotonin in your brain. Serotonin is the same neurotransmitter that is affected by the most commonly used class of antidepressants, the selective serotonin reuptake inhibitors (“SSRIs”), which include Paxil, Prozac, and Zoloft. LSD can cause flashbacks in heavy users and it has been known to cause severely disturbing “bad trips” (unpleasant/frightening hallucinations) in some people. Overall, the negative health side-effects of LSD are surprisingly scant given how powerful this drug is; however, LSD is produced in black market laboratories and sometimes these garage-chemists screw up and produce a chemical that can seriously hurt people. I aware of at least one case-series in which a bad batch of LSD caused permanent neurological disability (Parkinson’s disease symptoms) in users.

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis –> (Click on the book covers on the right to check out my books!).

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The term “narcotics” is thrown about in daily speech, by the government, and by law enforcement professionals to refer to any illegal drug. In reality, most illegal drugs are not really narcotics and some of them, especially anabolic steroids, don’t even produce euphoria (euphoria = “high”). Let’s discuss the drugs the drugs that really are “narcotics” in the medical sense of the term – later this week I’ll touch base on other euphoria producing substances and that discussion will serve as a segue into a discussion of antidepressants next week.

WHAT IS A NARCOTIC? Narcotics are derived from opium poppies that originally grew in the wilds of Eurasian and which are now primarily cultivated for the production of heroin in Afghanistan and Myanmar. Narcotics include morphine, codeine, heroin, methadone, dilaudid, norco, percocet, and demerol – marijuana, methamphetamine, cocaine, LSD, and most of the other illegal drugs commonly listed as “narcotics” by the government are quite simply not! True narcotics function by mimicking naturally present neurotransmitters called endorphins that are important regulators of pain in the normal functioning of the human brain and body. Endorphins probably evolved, at least in part, to enable humans to function under duress without being crippled by pain — as an historical example, it would be a bad idea to stop running from the lion that was trying to eat you just because your sprained ankle started hurting really badly. A more modern example of endorphins in action can be appreciated when you watch UFC fighters kick each other in the head and then shake it off and go back to fighting without missing a beat — it’s because their brains are releasing tons of natural endorphins so that they won’t be distracted by pain and can continue fighting. Natural endorphins are also the reason why Jon Jones (UFC 205lb champion) didn’t notice that his foot was broken until someone pointed it out to him after he had won his championship fight last night if you were watching like I was! Endorphins are responsible for the runner’s high that you get after your daily jog and they are also involved in the brain’s rewards pathway, the set of neurons in your noodle that makes doing evolutionarily beneficial activities like sex feel good. The rewards pathway is very important because humans without a powerful sex drive wouldn’t be around very long! After all, what man or woman would put up with their significant other if it wasn’t for the carrot-and-stick catch-22 of sex!  Another common activity that causes you to experience the power of endorphins is being in the sun. Sun exposure was evolutionarily important because your body makes vitamin D in a reaction that requires sunlight and that occurs in the skin. No vitamin D à broken bones à early death (for a caveman) à no babies à no more humans!

Thai Boxing: Courtesy of Wikimedia. Sorry, Jon Jones broken toe image is copyrighted (as is most UFC stuff, but you get the picture).

HOW DO NARCOTICS WORK? Endorphins work by binding to opiate receptors in the brain and it is the activation of opiate receptors that causes the effects (diminished perception of pain and euphoria) of these powerful neurotransmitters. Naturally occurring opiates from plants (morphine and codeine) and synthetic opioids like dilaudid, demerol, heroin, percocet, and norco are designed to chemically mimic endorphins. You can think of endorphins as being analogous to a key that fits into the opiate receptor “door” and “unlocks it,” allowing the brain to decrease the amount of pain you’re feeling and to start buzzing with euphoria. Morphine, heroin, hydrocodone, and friends all mimic the shape of the natural endorphins at the molecular level and they function to “unlock” (activate) the brain’s opiate receptors, activating these receptors to a degree that the body naturally wouldn’t have. Opiate receptors are also found in the digestive tract were they function to slow everything down. Loperamide (aka: Immodium) is a synthetic opioid that is sold over-the-counter to treat diarrhea. You can’t get high off of loperamide because unlike most other opiates/opioids it doesn’t cross the blood-brain barrier.

Heroin: Courtesy of Wikipedia.

THE HISTORY OF NARCOTICS: The extract of the opium poppy has been used for pain-control for thousands of years. By the time of the Roman Empire the medical use of opiates was already old news, which I’m sure that legionnaires who had been gravely wounded in battle greatly appreciated! The abuse of opium is probably equally ancient and many a war has been fought by a supplier nation taking offense when a weaker consumer nation decided to ban the importation of this medically important but socially destructive drug. Opium addiction most famously caused The Opium Wars between Britain and China and the scourge of narcotic addiction also scarred the early United States when a wave of morphine addiction swept the country after The Civil War, an epidemic that was partly due to wounded soldiers returning addicted to these medications and partly due to war widows becoming addicted to a drug that was less socially ostracized at the time than alcohol, the other primary chemical escape of the era. But narcotic addiction didn’t really take off until the late 1800s, when chemists synthesized heroin, a synthetic opioid that is far more potent than the naturally occurring morphine and codeine.

The Opium Poppy: Courtesy of Wikipedia.

THE USE AND ABUSE OF NARCOTICS TODAY: The wave of narcotic addiction at the beginning of the 20^th century had a rather nasty, unintended consequence. Physicians began refusing to prescribe these medications even to people who clearly needed them, like patients who were lying on their death bed with metastatic bone cancer (extremely painful!) and to burn victims. Even when narcotics were prescribed, they were usually under-prescribed and many a severe burn victim from the era has publically stated that the pain was so bad that they wish that they had died, even after recovery! These horror stories led to the passage of laws that essentially forced physicians to ask patients about their level of pain and to treat them with pain medications, including narcotics, until that pain was adequately controlled. These laws have made life much more pleasant for people who are dying from terminal diseases and for those with painful injuries; however, they have also resulted in prescription drugs becoming the #1 cause of accidental drug overdose (as opposed to intentional suicidal overdose) in the United States. There are currently 100,000-200,000 heroin addicts in the U.S., and 2 MILLION prescription opioid addicts!!! Just about all of these addicts obtain their drugs legally and through their physician; indeed, opioids are the #1 prescribed class of drugs in the U.S., prescribed more often than antibiotics, antidepressants, acid reflux pills, etc. Every physician deals with at least one prescription opioid addict per day, most of whom (at least in my experience) shouldn’t be on these medications. The problem is that under the current laws there isn’t a whole lot the physicians can do about this problem—if you don’t treat someone’s reported pain you’re setting yourself up for harassment (in the form of complaints) and possibly for litigation (malpractice lawsuits).

NARCOTIC WITHDRAWAL AND OVERDOSE: Narcotic overdose kills you by depressing your respiratory drive, i.e. you quite breathing. If prompt medical assistance is available there are drugs that can reverse the effects of narcotics (naloxone, naltrexone) and mechanical ventilation can also keep the overdosed person alive until the narcotics wear off. Most people who OD on narcotics are also under the influence of another respiratory depressant, usually either alcohol or a benzodiazepine (e.g. Xanax—we’ll talk more about benzos next time). This is the reason why people who pop a few percocet and then wash them back with Budweiser are asking for an early trip to the grave. Narcotic withdrawal is unpleasant and the terms “going cold turkey” and “kicking the habit” both derive from the symptoms of morphine withdrawal that were described 100 years ago. People withdrawing from narcs become very restless, especially in their legs, and get goose bumps and chills. They also suffer from severe diarrhea, insomnia, pain, and agitation — basically withdrawing from narcotics produces the exact opposite symptoms that taking them produces. Instead of euphoric, people withdrawing from narcs feel miserable (dysphoric). The good news is that even though narcotic withdrawal might make you feel like you want to die, it won’t actually kill you. This isn’t true with alcohol withdrawal, which actually can kill serious alcoholics who suddenly quit drinking. Of course the caveat to this discussion is that many narcotic addicts are addicted to multiple drugs of abuse including alcohol — please seek medical advice from your doctor prior to making any major medical changes in your life and for assistance with rehabilitation if you happen to be addicted to narcs and contemplating quitting (and good for you if so!!!).

Mechanical Ventilation: Courtesy of Wikipedia. Property of Calleamanecer. Note: This is a highly photogenic ICU patient. Most of them have secretions, etc. dripping around the edges of their mouths and do not have their hair-combed like this attractively ventilated patient! I’m pretty sure this is a “Hollywood” version of the ICU, but it will suffice for our purposes!

A WORD ON COMBINATION PILLS: A quick word on combination pills, e.g. norco, percocet, vicodin, tylenol 3, and friends. All of these medications contain both a synthetic narcotic and acetaminophen (aka: tylenol). A common cause of unintentional overdose with combination pills is the consumption of tylenol with these medications. Acetaminophen/tylenol is toxic to the liver in doses greater than 3-4 grams per day, less in those who already have liver disease and in drinkers (and many people who abuse prescription meds are also drinkers). As an example, let’s say that you’re taking 2 pills of “generic combo pill 5-500” four times per day for your chronic back pain. The first number in the 5-500 is the narc, the second number (500) is the amount of acetaminophen in every pill of “generic combo pill 5-500.” Since you’re taking eight of them per day, that equals 4,000mg (4 grams) of acetaminophen per day—already at nearly the toxic level. Now add a few drinks or a few extra-strength tylenol on top of that and you can see why these pills are your liver’s greatest enemy. Something to think about, please!

The Abdomen of a Patient with Hepatic (Liver)Failure: Image Courtesy of Wikipedia. Propery of James Heilman, MD.

References:

The National Institute on Drug Abuse. http://www.drugabuse.gov/publications/topics-in-brief/prescription-drug-abuse. Accessed 28 APR 2013.

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis.

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

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The United States Government announced today that it has evidence that strongly suggests that the Syrian army has used chemical weapons, namely sarin gas, against the rebels that are revolting against the Syrian dictator, Bashar Al-Assad — http://www.cnn.com/2013/04/25/world/meast/syria-civil-war/index.html?hpt=hp_t3. Chemical weapons have been used since antiquity, mostly in the form of noxious smokes that were used to encourage defenders to evacuate castles and the like. The Byzantine Empire successfully employed  an ancient form of napalm called “Greek Fire” that they used to dominate the Mediterranean Sea during the age of galley warfare, a concoction which I suppose might technically fit into the category of chemical warfare agents. However, chemical warfare as we generally think of it today – deadly gases that are released into crowds of people – didn’t take off until World War I. The German army was the first to use chemical weapons in the form of chlorine gas in 1915, but the Allies soon followed suit and before long both sides were blasting each other with gases that had the nasty habit of blowing back onto their own troops whenever the prevailing winds shifted, which was a common occurrence. Adolf Hitler was one of the unlucky grunts who was gassed in the trenches of “The War to End all Wars” (a poor choice of monikers in retrospect, huh!) and this experience kept his trembling hand off of the chemical weapons trigger during World War II, this despite the fact that Nazi Germany possessed ungodly quantities of chemical bombs and artillery shells. The Soviets and the Allies responded in kind and chemical warfare has been a global taboo ever since. Saddam Hussein was one of the few leaders of a modern state to defy the world’s antipathy towards chemical weapons when he used them against revolutionary Iran during the 1980s. The Iranians responded in kind – later Mr. Hussein would stoop to a new low when he used chemical weapons to gas Kurdish citizens of his own country.

There are four main types of chemical weapons. I have listed the categories and a stereotypical agent of that category below. Also explained are the effects of exposure to these horrible weapons and the antidotes/treatments for people who have been exposed. Remember that the gases that are used in chemical weapons are generally heavier than air and that they settle as a result – in other words, moving to a higher place during a chemical weapons attack is usually a better idea than crouching to the ground or moving to an area of lower elevation like a basement. Also, the first step of treating exposure to just about any chemical agent is to remove the victims clothing (tell them to do it so that you don’t expose yourself), to wash them down with soap and water and lots of it (a hose works well so that you don’t touch the exposed person and contaminate yourself), and to seek immediate medical assistance. All of these treatments, even the basic stuff, should be performed by trained personnel if those personnel are available because it is very easy to fatally contaminate yourself while trying to help someone who has been exposed to chemical agents, particularly nerve agents, and that doesn’t do anyone any good. By the way, I’ve never had to deal with a chemical weapons attack in “real life” (thank god), but I know a lot about the subject because I trained in medical decontamination drills when I was in the military on multiple occasions.

1. Pulmonary Irritants — Chlorine gas. Chlorine gas is widely available because it is used in all sorts of industrial processes. Other agents in this class are similarly easy to get, ammonia for instance, which is used as an industrial cleaning agent and in some refrigeration processes. Irritant agents are directly toxic to the tissues that they come in contact with, especially moist tissues like the eyes and the lungs, both of which suffer searing injuries when chlorine is aerosolized and dispersed by the bad guys. Chlorine causes blindness and acute lung injury – the acute lung injury is what kills the victim and it can sometimes be treated with a combination of bronchodilators (e.g. medications like the albuterol that is used in your kid’s asthma inhaler), corticosteroids (e.g. prednisone), and mechanical ventilation (“life support”).

2. Blood Toxic Agents – Cyanide. Your body consists of an interconnected lump of cells that work in concert to make the being known as “you” and every cell in your body is a tiny little chemical power plant. Your body cells stay alive and functioning by taking up glucose and free fatty acids from the food you eat and then “burning” it via a reaction with the oxygen that you breathe to form energy to power the cells activities. Cyanide works by poisoning one of the essential enzymes in the biological chemical reaction that turns food + oxygen into energy. Thus cyanide causes your body to essentially suffocate and to starve to death simultaneously. Yes, a victim of cyanide poisoning still has plenty of glucose, fat, and oxygen, just like they did before they were exposed to the cyanide. But they can’t use any of it because of the cyanide so the net effect is basically the same as being starved for a few months and then tying a plastic bag over your head and around your neck. The treatment for cyanide poisoning is with 100% oxygen (the stuff you’re breathing right now is 21%, unless you’re on top of a mountain in which case it is less) and with specialized drugs called sodium nitrite and sodium thiosulfate (hydroxycobalamin, a form of vitamin B12, also works) that help your body get rid of the cyanide. You may remember that some nasty people in Chile during the 1980s poisoned apples bound for America with cyanide – what you may not know is that cyanide is readily available in every city and town in America because it is used by jewelers and other professionals as a cleaning agent. Cyanide smells like almonds because, big surprise, almonds contain cyanide. By the way, never eat wild almonds because they contain enough cyanide to make you very ill–the grocery store kind were selected by humans over the centuries and have thus evolved into the nontoxic kind that I’m eating while I write this blog post!

3. Blistering Agents – Mustard Gases. These miserable creations—and yes, there are several different types of mustard gases—cause severe blistering and, like the irritant agents, are especially fond of causing respiratory failure by blistering your lungs and blindness by destroying your eyes. Mustard gases have nothing in common with the mustard that you eat on your yummy, greasy, mystery meat hotdog. Rather, “mustard” in this case refers to a specific type of organic chemistry reaction that I’m not going to explain because I forgot that crap a decade ago! It is interesting that several chemotherapy drugs are related to the mustard gases. One of these drugs is cyclophosphamide, a miserable chemo drug that is used to treat a plethora of cancers including leukemias and lymphomas. Cyclophosphamide can cause you to urinate frank blood and it can also knock out your bone marrow and set you up for a catastrophic infection (recall that white blood cells fight off the bacteria, fungi, and parasites that are constantly trying to eat your body—including right now!). Mustard gases also destroy your bone marrow, so if they don’t kill you right away by destroying your lungs they may get you a few weeks later by knocking out your bone marrow. If you are unfortunate enough to be exposed to a large dose of aerosolized mustard gases you will also likely be blind; good times! Dimercaprol is a chelating agent–a drug that is used to bind heavy poisons and it can be used to treat mustard gas exposure. Dimercaprol is also used to treat arsenic, mercury, and (sometimes) lead poisoning. The good news is that mustard gases are highly unstable and that it is difficult to transport them, qualities that make mustard gases a less than ideal weapon for terrorists.

4. Nerve Agents – Sarin. Sarin, tabun, and VX gases are probably the worst-of-the-worst when it comes to chemical warfare, and they are what Mr. Al-Assad is accused of recently using against his people. All of these agents are colorless, odorless, and deadly in microscopic doses. They also kill in a horrific fashion, thus making the nerve agents excellent weapons from the terrorists’ point of view. Nerve gases work by inhibiting an enzyme in your body called acetylcholinesterase. Acetylcholinesterase breaks down acetylcholine, a neurotransmitter that controls the contractions of the muscles of your body, that controls “housekeeping” functions like defecation and urination, and that regulates the secretion of body fluids. So how do nerve agents work??? Blocking acetylcholinesterase results in increased levels of acetylcholine because it prevents the body from recycling the acetylcholine that it has already released. Normally, acetylcholine is released by a nerve cell, passes on its message to a muscle or gland cell, and then it is rapidly recycled–nerve agents block the recycling of this potent neurotransmitter causes acetylcholine to build up to dangerous levels in the body. Increased acetylcholine makes your eyes tear like after a teenage breakup, makes you salivate so profusely that you choke on your own saliva, and causes you to urinate, vomit, and defecate uncontrollably just for good measure. But it gets worse. Acetylcholine also controls the contractions of skeletal muscles and, paradoxically, when too much acetylcholine is present for too long the skeletal muscles first spasm uncontrollably and then become paralyzed. Since the muscles that control breathing– namely the diaphragm and the intercostal muscles between your ribs–are skeletal muscles you stop breathing and die. Luckily many of the effects of nerve agents can be blocked and sometimes even reversed by the prompt administration of atropine and 2-PAM. These drugs are administered intramuscularly just like a tetanus shot—the “inject it into your heart” technique that is seen in the movies is Hollywood drama and a really terrible idea! Mechanical ventilation may also be necessary in victims of nerve agents, the downside being that in a major nerve agent attack on a large population center there probably wouldn’t be nearly enough ventilators to save everyone. Poisoning with nerve agents (aka: organophosphates) can also occur accidentally because farmers use relatives of these deadly weapons as pesticides. An isolated incidental exposure is usually easy to spot because terrorists are unlikely to target a couple of farmers in North Dakota and because organophosphate pesticides are unlikely to normally be present in the subway system in a major metropolitan area.

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis.

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

References:

Beary JF and Arkadi Chines. Chemical terrorism: Diagnosis and treatment of exposure to chemical weapons. In: UpToDate.com. Accessed 25 APR 2013.

http://www.cnn.com/2013/04/25/world/meast/syria-civil-war/index.html?hpt=hp_t3. In: CNN.com. Accessed 25 APR 2013.

The short answer is “yes.” Excessive exercise can stress your muscles to the point that they actually begin to die and this serious medical condition is called rhabdomyolysis. Rhabdomyolysis is a scary looking word, so let’s break it down. “Rhabdo” means “striped” and “myo” means “muscle.” Myocytes are muscle cells and the type of muscle cells that are found in your skeletal muscles—the muscles that you use to move around and to pick things up during daily activities—appeared striped (“striated”) when viewed under a microscope, unlike the muscle that is found in your gut, which appears “smooth” under magnification. So “Rhabdomyo” = striped muscle cells. “Lysis” means cell death so “rhabdomyolysis” = the death of striped muscle cells, Whewww!!!

Rhabdomyolysis most commonly occurs when previously sedentary people suddenly decide to take up an intensive exercise program, like the obese computer guy who puts down his bag of double-salted pork rinds, waddles out of the house, and decides to train in the kickboxing gym across the street for five hours straight because he has a crush on the instructor chick—total setup for rhabdomyolysis, man (but good for you for at least trying!—let’s just try smarter next time). On a serious note, rhabdomyolysis is common in young military recruits, especially when they first join the military, and it kills young people who wear the uniform every year. My first scenario also wasn’t entirely unrealistic because weekend warriors are at high risk for rhabdomyolysis because they tend to overdo it and to overdo it severely. Athletes who are returning from a long vacation during which they haven’t been training are also at risk for developing this condition. Another powerful factor, perhaps the most powerful factor, that predisposes to the development of rhabdomyolysis (no matter how great shape you are in) is dehydration—always stay well hydrated when exercising!

Rhabdomyolysis is such a deadly serious problem because muscle cells (myocytes) become leaky when they die, leaking huge amounts of potassium and myoglobin into the bloodstream. When there is too much potassium in the bloodstream it screws with the electrical conduction system of the heart—the heart’s pacemaker system that keeps it ticking and keeping you alive in the process. Rhabdomyolysis can cause blood potassium levels to rise to such an extreme level that it can actually cause the heart to stop beating entirely! If you’re thinking that you might have heard something about this blood-potassium-heart-thing you’re right—an injection of potassium chloride is the “lethal” part of the lethal injections that are used in most states that still have the death penalty.

To make matters worse, rhabdomyolysis releases ungodly amounts of a large and sticky protein called myoglobin into the blood. The kidneys are the body’s blood filtration system and they work overtime to get rid of all that myoglobin. Unfortunately, flushing huge quantities of myoglobin through the kidneys’ tiny filtration system, the nephrons, is like trying to drain your bathtub after you’ve given a Siberian Huskie a bath! Just like long dog hair, the myoglobin all clumps together, clogging the kidneys and leading to potentially fatal kidney failure (aka: renal failure). Worse yet, the kidneys are also the organs that are responsible for getting rid of excess potassium, a vicious cycle that ends in death from asystole (“heart stopping”) in severe rhabdomyolysis without prompt medical attention.

The treatment of rhabdomyolysis is with aggressive intravenous hydration to both dilute the elevated blood potassium levels and to flush the myoglobin clumps out of the kidneys. In the acute stages when the heart is at risk of sudden cardiac arrest, agents that make the heart less susceptible to the effects of potassium are administered (calcium gluconate) along with drugs that cause the body to excrete large amounts of potassium through the gut by causing diarrhea (good times, huh!). Rhabdomyolysis isn’t just caused by excessive exercise in untrained or dehydrated individuals. Other causes include crush injuries, certain medications (the common cholesterol-lowering statins are a potential cause), and illegal drugs like PCP.

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis.

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

It’s almost hard to believe, but yet another study demonstrating NO link between autism and vaccinations has managed to make the headlines, including the front page of CNN.com — http://thechart.blogs.cnn.com/2013/03/29/vaccine-autism-connection-debunked-again/?hpt=hp_bn13. “Hard to believe, why?” you say. And my answer is that this is the oldest news on the block to physicians, akin to learning the gossip about the prettiest girl in school shacking up with the class computer nerd ten years after they’re happily married with two kids and a third one on the way.

Autism is a cluster of developmental disorders that cause impaired socialization, impaired communication, and behavioral abnormalities. Whether “autism” is a single disease entity or a convenient grouping of disorders that happen to have similar symptoms is debatable—with that said, the difference between having full-blown autism (classic autism) and mild autism (Asperger syndrome) is like the difference between night and day. Patients with severe autism-spectrum disorders are essentially disabled due to their disease and a great example of a severe case of autism is Dustin Hoffman’s character in the movie Rain Man—just remember that Mr. Hoffman is portraying an extreme case and that most people with autism-spectrum dysfunction have milder symptoms, although some people with this sad disorder really are as impaired as the character in that excellent (and very sad) movie. Patients with Asperger syndrome are often entirely functional, with mild social impairment that may not even be noticeable to most other people.

People with autism can be totally noncommunicative, may engage in repetitive speech, or may suffer from echolalia (“echoing” words spoken by others). Some autistic people are mentally retarded, some have a normal IQ, and a rare few are savants—people who are incredibly skilled in one small area, like memorizing the square roots of thousands of numbers, for instance. Autism-spectrum disorders are diagnosed by neuropsychiatric testing that is performed by a specialist. The prevalence of autism is rising, currently about 1:90 in the U.S., but this may or may not be due to better detection of milder cases of autism spectrum disorders by physicians rather than due to a true increase—the prevalence is also rising in the rest of the world. The etiology of this sad disease is unknown, but the best evidence currently points a multifactorial (more than one gene) genetic cause of autism with a possible unknown environmental contribution (something in the environment may be involved in activating the preexisting genetic disorder). The fact that autism tends to run in families and that boys are affected 4x more often than girls are both strongly point to a genetic causation—in general, boys are much more likely to suffer from genetic diseases because they only have one copy of the X chromosome whereas girls have two.

The debate over the purported link between autism and vaccination started in 1998 when a flawed—and since publically retracted, including by all of the authors save for one—study was published in The Lancet, Britain’s most prestigious medical journal (Read the details of why this study was garbage here: http://thechart.blogs.cnn.com/2013/03/29/vaccine-autism-connection-debunked-again/?hpt=hp_bn13). Since 1998, study after study have failed to corroborate the findings of the investigators in the 1998 Lancet publication and that study is now regarded by the mainstream medical and scientific community as one of the greatest examples of lousy research in the history of modern medicine. Unfortunately, this hasn’t prevented the growth of a small (but growing) anti-vaccination movement that has resulted in outbreaks of measles, mumps, and rubella throughout the country, diseases that were previously more-or-less eradicated in The United States but which are now rearing their ugly heads and infecting both children and adults. It is true that vaccines are not without risks, but the risks of the diseases that they prevent are MUCH higher, something that is easy to forget because most adults of childbearing age in The United States haven’t been alive long enough to know people who have had their lives ravaged by polio (causes paralysis and/or death), measles (can be mild, fatal, cause mental retardation, or paralysis), rubella (severe birth defects), Hib (airway edema—killed George Washington), and diphtheria (death due to suffocation)—and that is to name just a few. Remember, there are multiple areas of the world in which people are militantly (as in chasing vaccination workers off with guns) against vaccination—northern Nigeria and the Afghanistan/Pakistan border are the most notorious—and it only takes one person arriving at the airport in your city to start an outbreak of a disease that was previously eradicated in the West!!!

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis.

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.comis intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

Do you have medical problems? Don’t feel bad, because we all do and history’s most famous people are no different in this respect from the rest of us! Here’s a brief rundown of some of the more notable historical figures and their afflictions.

Leonardo Da Vinci and Michelangelo both suffered from bipolar disorder and produced most of their famous works while they were manic. People with bipolar disorder, particularly untreated bipolar disorder like both of these geniuses, alternate between severe depression and an equally severe elevation of mood that is called mania. Mania closely approximates how people feel and behave when they are under the influence of powerful stimulants like cocaine and methamphetamine (“meth”) and both of these guys were described as working feverishly on their masterpieces for days (and nights) at a time and then crashing into depression, not getting anything done until their next bout of mania. Michelangelo is mostly known for his jaw-dropping paintings, including the roof of the Sistine Chapel, while Da Vinci was a painter, a scientist, an architect, and too many other things to mention. Both men were also homosexuals at a time when being gay was punishable by death. Da Vinci nearly learned this the hard way when he was caught with a male prostitute, but a powerful ally saved his butt and he moved to France. The King of France was present at his side when Da Vinci died of old age years later.

George Washington probably had Klinefelter’s Syndrome, a genetic disorder in which a man has two X chromosomes instead of the usual one, resulting in an XXY male instead of the XY pattern that most men have. This results in a tall and lanky frame, a narrow chest and big butt (look at some of his portraits), a lack of facial hair and small testicles, and infertility. George Washington died of a “sore throat,” probably epiglottis—the swelling of that dangling thing in the back of your throat that you can see when you look in the mirror and say “ahhh.” People with epiglottitis are at risk of suffocation because the epiglottis can swell to such a great size that it blocks the airway. Fortunately, this condition is now rare due to childhood vaccination against H. influenzae (Hib shot), the bacteria that was historically responsible for most cases of epiglottis. George Washington’s death was probably accelerated by his physician, who didn’t do old George any favors by repeatedly performed bloodletting while he was on his deathbed.

King George III most likely suffered from acute intermittent porphyria, a rare metabolic disorder in which environmental triggers cause the buildup of toxic metabolites in the body, resulting in discolored urine (brown or even blue) and insanity. The most common triggers today are alcohol and certain medications, especially barbiturates (drugs that are sometimes used for epilepsy)—King George III apparently had an exceptionally rare trigger, pears. George III gets a bad name for both his intermittent bouts of insanity and his gross mishandling of the American Revolution, which is really a shame because he actually was an enlightened despot—as far as despots go, anyhow—and a pretty decent guy. I highly recommend the movie, The Madness of King George, if you’re interested in learning the full story. The acting is impeccable.

Queen Victoria lived in an era when the royal families of Europe still intermarried as a way of cementing alliances. Unfortunately, the queen (who was quite reproductively prolific) developed a mutation in her reproductive cells that causes hemophilia and she passed this disease to most of the royal families of Europe. Hemophilia is a severe bleeding disorder that, at the time, had no treatment. Queen Victoria’s mutation did its most evil work in Russia, where the heir to the throne during the early 20^th century inherited the disease. His distraught family sought the advice of a shady physician and overall conman named Rasputin, who became a powerful advisor to the court and likely contributed to the Bolshevik Revolution due to his malignant influence on the royal family.

John D. Rockefeller had a rough childhood due to his sociopathic father, who was a child abuser, polygamist, womanizer, and conman. Rockefeller was ashamed of his father and he usually lied about him later in life, claiming that his pop’s was a hard worker who passed on his work ethic to his children. In reality, Rockefeller senior stole from his children, routinely beat them, and was secretly married to several women at the same time. His son went on to found the greatest monopoly in American history, Standard Oil. John D. Rockefeller may have been the richest man in the world at the time of his death and he was also a great philanthropist during the later stages of his life.

Theodore Roosevelt was a sickly child and he was also extremely nearsighted. Unable to play sports as a child due to his constitutional weakness, Teddy Roosevelt spent much of his adulthood engaging in outdoors activities (including warfare and big game hunting). He even spent time as a rancher in Montana, a childhood dream that he had developed while reading about the American West while bedbound with various illnesses. As President, Teddy Roosevelt led the anti-monopoly campaign that so greatly enraged Rockefeller and the other fat cats of the era.

Franklin Delano Roosevelt was a distant cousin of Teddy Roosevelt. Though healthy as a young man (and a bit of a womanizer), FDR was struck with a paralytic disease in mid-adulthood that cost him the use of his legs. It is somewhat debatable whether FDR suffered from polio, a viral illness that is now rare due to vaccination, or from Guillian-Barre Syndrome, an autoimmune disease that causes ascending paralysis. Polio was the most common cause of paralysis at the time but the disease primarily affected children, often resulting in suffocation due to weakness of the respiratory (breathing) muscles and leaving many of the survivors crippled for life. Vaccination has eradicated the polio virus from all of the world except Afghanistan, Pakistan, and Nigeria. It is unfortunate that militant groups in these regions are actively engaged in spreading anti-vaccination propaganda, claiming that vaccination is a Western conspiracy to sterilize the population. The United States did not help the vaccination effort when it used a physician posing as a vaccination worker to collect blood samples as part of the effort to identify Osama bin Laden in Pakistan—several vaccination organizations have since been expelled from the country.

Richard Nixon suffered from hyperhidrosis, a disorder that caused him to sweat profusely. Check out the video of Nixon’s debate against Kennedy in his first (unsuccessful) run for President and you see him frequently wiping the sweat off of his brow and his hands. Nixon was probably also a sociopath.

Stephen Hawking is the world’s most prominent living physicist and he has contributed to theories about particle physics, black holes, and time—all from his wheelchair. Dr. Hawking suffers from  Amyotrophic Lateral Sclerosis (ALS), a disease that destroys the nerves that control the muscles of the body. This disease not only affects the muscles that you use to move around, but also affects the muscles that are used for breathing and swallowing—a truly horrible disease. The cause of ALS is unknown, although a small minority of cases are known to be inherited. Dr. Hawking accomplishments would be amazing for an able-bodied person and the fact that he has achieved so much while suffering from one of the worst diseases known to man is truly remarkable.

Ronald Regan suffered, and ultimately died from, Alzheimer’s disease. Alzheimer’s disease is the most common cause of dementia—severe cognitive decline—and it presents with memory loss that progresses to a complete inability to function. In many ways, persons with Alzheimer’s disease revert to an infantile state at the late stages of their disease and they become utterly unable to care for themselves or to function in even the most basic aspects of daily life. A few cases of Alzheimer’s disease are known to be inherited, but the cause of most cases is unknown.

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis.

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.comis intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The most widely accepted screening guidelines state that healthy men >35-years-old and healthy women >45-years-old should being having their cholesterol checked (if you have certain medical problems the age to start screening can be much younger for you). The reason that cholesterol screening is important is because high cholesterol is a silent killer—silent until it smacks you on your butt with a giant wooden paddle that is known as a heart attack! The Western diet is loaded with saturated fats and other nasty substances (trans-fat is especially bad) that raise the level of cholesterol in your blood. Making matters worse, your liver also produces cholesterol and many people produce much more than their body could ever need. High cholesterol is bad because that extra cholesterol slowly builds up in the walls of your arteries, essentially forming fatty “zits” that grow and grow over the years until one of them finally pops. When a cholesterol plaque ruptures special cells in your blood called platelets are activated and they form a blood clot (essentially a scab) inside the artery on top of the ruptured plaque. This blood clot blocks the artery so that blood can no longer get to the tissues that the artery feeds. No blood = no oxygen = dead tissue. If this occurs in one of the arteries that feeds your heart muscle then you have a heart attack; if it happens in an artery in your brain then you have a stroke. Atherosclerotic (cholesterol plaque) heart disease is the #1 killer in The United States—and that’s not even including all of the people who die or are disabled by strokes caused by atherosclerosis!

When your doctor checks your “cholesterol” they are really checking the following:

LDL: This is your bad cholesterol, the kind that builds up in the walls of your arteries. An LDL >160 is always bad, but for people who already have heart disease any number >100 is too much and <70 is ideal. Regularly eating foods high in saturated fat (e.g. red meat) is a sure way to elevate your bad cholesterol into the danger zone.

HDL: This is your good cholesterol, your arteries bestfriend because HDL removes some of the cholesterol that LDL dumps into the walls of your arteries and takes it back to the liver. The liver then converts excess cholesterol into bile, which is excreted in the feces (it’s what makes your stool brown or black). HDL >40 in men and >50 in women is generally considered healthy—but higher is better when it comes to HDL. HDL can be raised by exercise and by moderate alcohol consumption.

Triglycerides (TGs): Technically not a type of cholesterol, triglycerides are the way that your body moves fat around in the bloodstream that it plans to use for energy. Unfortunately, high TGs predispose you to both heart disease and to pancreatitis. Generally <150 is considered to be a healthy number for TGs. Regular consumption of fish oil is one way to lower TGs (but talk to your doc about it 1st).

Why do we have cholesterol? Cholesterol is used by the cells in your body as an essential part of their cell membranes—a layer of fat that surrounds every cell in your body, keeping stuff that is supposed to stay in the cell inside it, and junk that isn’t supposed to get into the cell outside of it. In many ways the cell membrane is to a cell as the skin is to your entire body—a barrier between your insides and the rest of the world. Cholesterol is also used to make hormones (chemical messengers), especially the sex hormones (testosterone and estrogen) and the essential salt-retaining hormone, aldosterone. The take home message is that some cholesterol is essential, but too much of a good thing is very, very bad.

Pop Quiz: “What American President had a deficiency of aldosterone?” See below for the answer.

I have high cholesterol! What can I do about it?

Healthy people who have high cholesterol are initially treated with a trial of diet and exercise. People who can’t get their cholesterol down with diet and exercise, and people with another medical condition that requires a big reduction in cholesterol (e.g. heart attack and stroke victims, diabetics) are treated with medications. There are a slew of medications on the market that lower cholesterol, but only one group of these medications has been shown to decrease the risk of dying from atherosclerosis and its sequelae—the statins. Statins lower cholesterol by decreasing the production of cholesterol by your liver. Basically, cholesterol is produced on an “assembly line” in the liver that consists of a “line” of “workers” called enzymes. Statins disrupt one of these enzymes and thereby disrupt the entire cholesterol assembly line in the same way that one broken machine in an automotive factory blocks production of the cars even if all of the other machines on that line are in fine working order. Statins also stabilize preexisting cholesterol plaques and make them less likely to rupture–recall that it is the rupture of these plaques that causes a blood clot to form and that it is the blood clot that actually blocks the artery. Finally, statins have been proven to actually shrink cholesterol plaques that are already in the walls of the arteries! These drugs are easy to recognize because their generic names all end in, guess what?, -statin. For example, the generic name of Lipitor is atorvastatin—too easy, right! Statins are well-tolerated by most people; however, they can be hard on the liver and can also cause muscle pains and even muscle breakdown.

Well, I could rant on about cholesterol for hours but Doc has a dog to feed and some sleeping to do before clinic tomorrow. I hope that you learned something and had fun doing it!

Pop Quiz Answer: John F. Kennedy had Addison’s disease, a salt-wasting disorder in which the body is unable to produce adequate quantities of aldosterone.

FYI: All four of my books are currently on sale for $0.99 (Kindle version only)–thanks for reading!!!

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis.

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.comis intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!