Antibiotic Resistance 101 — The Sad Case of Gonorrhea

Antibiotic Resistance

Calling all parents of young children! Have you ever dragged you sniffling little tot to the doctor’s office only to be told, and much to your chagrin, that your kiddo is sick with a virus and that the recommended treatment is to “take it easy for a few days” and to “drink plenty of fluids.” Seriously! You just paid doc all that money for him to tell you the same thing that your own mother told you back in the 1970s! “But doc, don’t you think he needs some amoxicillin!” — am I right!

Pink-amoxyl-meds[1]

If this situation is familiar to you rest assured, because your child has a good doctor and I’m going to explain to you why I’m so comfortable saying that. You see, every physician knows that refusing to give little Johnny antibiotics for his sniffles is going to tick off mamma bear, but the reality is that using antibiotics for viral illnesses does absolutely no good and can potentially can cause a whole lot of harm. Firstly, our bodies are naturally teeming with bacteria both inside and out, and most of these bacteria are actually beneficial to us because they make things for our bodies that we need but that can’t make ourselves (like vitamin K, for instance), and because they deny growing space to pathogenic (disease causing) bacteria. Antibiotics don’t just kill bad pathogenic bacteria, they also kill good beneficial bacteria, and if you have a viral illness then the only bacteria that will be getting killed are the good guys because antibiotics don’t do squat to viruses. Even more importantly, the injudicious use of antibiotics turns our bodies into mass production factories for drug resistant strains of bacteria, and that’s what we’re going to discuss today.

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The reason that yogurt can help with GI dysfunction is because it contains good bacteria. Taking supplements that contain good bacteria while you are one antibiotics has been shown to decrease some of the side-effects of antibiotic therapy, including the potential for antibiotic-associated diarrhea. One particular type of antibiotic-associated diarrhea, C. diff, is a common cause of mortality (death) and morbidity (sickness) in hospitalized patients. 

Antibiotics have a longer history than most of us realize. The Chinese, the Egyptians, and the Romans all used naturally derived antibiotics, albeit without knowing what they were really doing and in a mostly haphazard fashion. Modern medicine truly began in the 1860s when Louis Pasteur, the French scientist extraordinaire who also invented the process of Pasteurization of milk, and Robert Koch realized that our world was teeming with microscopic organisms and that some of these tiny microbes could cause infectious diseases. This intellectual breakthrough is now referred to as “The Germ Theory of Disease” and it wasn’t long before other scientists realized that it might be possible to design microscopic “magic bullets” to kill disease-causing microbes without simultaneously killing the person that the microbes were making sick – this last caveat is important because you can technically cure any infection with a blow torch or a steamroller, the person just happens to die at the same time as the bacteria!

320px-US_Navy_030910-N-7542D-164_Molten_steel,_recycled_from_the_World_Trade_Center,_glows_red_as_it_is_melted_in_a_cauldron_at_the_Amite_Foundry[1]

Jumping into this vat of molten steel is 100% guaranteed to cure your cancer, AIDS, pneumonia…

The first successful “magic bullet” was salvarsan. Introduced in 1910 to cure syphilis, salvarsan was a major advance in the treatment of this epidemic sexually-transmitted infection that previously was treated with mercury (which is toxic as hell), hence the old adage “a night with Venus, a lifetime with Mercury.” Salvarsan was soon followed by the sulfa antibiotics, drugs which are still used today in the form of Bactrim to treat urinary tract infections and some skin infections. Sulfa drugs work fairly well against a specific type of bacteria called “Gram Positive Aerobes,” but they are largely ineffective against many other serious bacterial pathogens. Penicillin first became widely available in the early 1940s, the first true broad-spectrum antibiotic, and when Papa Penicillin was first introduced it would treat just about any bacterial infection that humans could manage to contract – what a deal! Unfortunately penicillin was overused and then some, and today there are far more bacteria that are impervious to penicillin than those that it will actually still kill off. The downfall of penicillin is nothing more or less than evolution at work.

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Tertiary syphillis. Syphillis is a three stage disease. The primary phase consists of a small genital sore that is painless. In the secondary stage the syphillis bacteria spread throughout the body — in the secondary stage it is actually possible to catch syphillis from someone by shaking their hand because the corkscrew-shaped syphillis bacteria can actually migrate through skin. In the tertiary phase (like in the picture), syphillis is a deforming disease that also destroys the heart and the brain. Al Capone is one (in)famous victim of tertiary syphillis.

A great way to understand how bacteria become resistant to antibiotics is to examine the notorious pathogen, Neisseria gonorrhoeae. Neisseria gonorrhoeae, aka: gonococcus, causes (big surprise!) gonorrhea, a sexually-transmitted infection that causes painful urination and purulent discharge (pus) from the male penis or from the female urinary tract. Untreated gonorrhea can lead to irreversible scaring of the urogenital tract, irreversible infertility, joint infections that have to be surgically drained, urinary retention, and a public reputation as the wrong kind of girl/guy to get involved with. The vernacular term for gonorrhea, “the clap,” derives from the habit of gonorrhea-infected men in the pre-antibiotic age clapping their pus-clogged penises between their hands to dislodge the mucus plugs so that they could urinate. Ouch!

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Gonorrhea — The Clap.

The first successful treatment for gonorrhea was sulfa drugs and the second was penicillin. Getting gonorrhea was no big deal as recently as the 1970s – a little penicillin and you were good to resume free lovin’ all over again. Then in the 1980s gonorrhea started becoming resistant to penicillin. You see, there are naturally small numbers of bacteria floating around in the environment that are resistant to just about any antibiotic that humans can possibly dream up. The use, particularly the overuse, of antibiotics killed off all the gonorrhea that wasn’t penicillin resistant. Before we knew it the only gonorrhea in circulation was totally resistant to penicillin – Darwinian natural selection at work, only guided in this instance by the ill-advised hand of human intervention.

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Free lovin’ at Woodstock.

Fortunately, a completely new type of antibiotic, ciprofloxacin (aka: Cipro) was invented at the same time that gonorrhea was becoming totally resistant to penicillin. And during the 1980s and 1990s all was well – if you contracted gonorrhea your doctor simply prescribed a short course of ciprofloxacin and you were back in the game again in time for lady’s night at the local watering hole. Except the problem is that gonorrhea is now nearly entirely resistant to ciprofloxacin for the same reason that penicillin doesn’t work for it anymore – all of the gonorrhea that was sensitive to ciprofloxacin is dead and gone and we’ve naturally selected for the few strains that were ciprofloxacin resistant. The former minority of gonorrhea is now the majority and today neither penicillin or ciprofloxacin will cure your puss-clogged penis (of course you could use a condom and avoid this issue entirely…).

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Moving on to the modern era, the current treatment for gonorrhea is a combination of an injection of the antibiotic ceftriaxone and an oral course of a second antibiotic called azithromycin, members of two classes of antibacterials that didn’t exist a few decades ago. Disturbingly, strains of gonorrhea that are resistant to ceftriaxone have surfaced in both Japan and in Britain and it probably won’t be long before the current standard treatment for gonorrhea is as worthless for treating this infection as penicillin or ciprofloxacin. Worse yet, there is no accepted alternative treatment for ceftriaxone-resistant gonorrhea.

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Gonoccocal arthritis. Say bye-bye to your knees.

The problem of antibiotic resistance is greatly exacerbated by three bad habits that our society is presently addicted to: 1) The Overuse of Antibiotics, 2) Antibiotic Noncompliance, and 3) The Agricultural Use of Antibiotics. The overuse of antibiotics for viral infections does no good because antibiotics don’t kill viruses. Most sinus infections and the majority of cases of acute bronchitis, two very common ailments, are caused by viruses. Using antibiotics in these cases does nothing but inflict harm because it selects for antibiotic resistant bacteria even though bacteria are not causing the majority of sinus infections or cases of acute bronchitis. Remember that the human body is naturally home to billions of bacteria and that most of are not harmful. Using antibiotics kills these good bacteria and selects for bacteria that are antibiotic resistant. Even if the surviving antibiotic-resistant bacteria don’t cause disease themselves, they can still “swap” DNA with other bacteria (the exact mechanisms are beyond the scope of this article), some of which do cause disease, and make those bad bacteria antibiotic resistant.

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Antibiotic noncompliance, namely starting a course of antibiotics but not finishing it, is also a major problem. Some bacteria are partially resistant to antibiotics, but would be killed if they were exposed to a full course of these drugs — not finishing all of a prescribed course gives these bacteria a chance to become fully resistant. Again, the exact mechanism is a little too complicated to discuss today. Finally, the ungodly-massive overuse of antibiotics by farmers to improve the yield of meat from their farm herds is selecting for antibiotic resistance on a gargantuan scale. As we’ve discussed before, most infectious human diseases originated in domestic animals and overusing antibiotics in these animals means that future epidemic diseases may well be totally resistant to our best drugs!

Confined-animal-feeding-operation[1]

All on antibiotics.

What can we do?

1) Not prescribe antibiotics for infections that are likely viral in nature. 

2) If you are prescribed a course of antibiotics, finish it!

3) Limit the use of antibiotics in farm animals to animals that are actually sick. Most agricultural use of antibiotics is prophylactic, e.g. used to prevent potential illness before the animals actually get sick, and to promote weight gain (for reasons that aren’t fully understood animals on antibiotics gain weight faster than those that aren’t).

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis. Amazon Link to Doc’s Writing:  http://www.amazon.com/Leonardo-Noto/e/B00ATVOMCW/ref=ntt_dp_epwbk_0

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your e-reader at http://www.smashwords.com/books/view/215272 and on Amazon at http://www.amazon.com/Life-Colonial-Fugitive-Leonardo-Noto-ebook/dp/B006ZD0EYI/ref=tmm_kin_swatch_0?_encoding=UTF8&sr=&qid=    

Thanks for reading!

The Life of a Colonial Fugitive

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 16-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 opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

 

 

 

References:

1.       Aminov, RI. A Brief History of the Antibiotic Era: Lessons Learned and Challenges for the Future. Front Microbiol. 2010; 1: 134.

2.       Julian Davies and Dorothy Davies. Origins and Evolution of Antibiotic Resistance. Microbiol. Mol. Biol. Rev. 2010, 74(3):417. DOI:10.1128/MMBR.00016-10.

3.       Germ Theory of Disease. http://www.sciencemuseum.org.uk/broughttolife/techniques/germtheory.aspx

4.       The History of Salvarsan. http://protomag.com/assets/paul-ehrlich-and-the-salvarsan-wars

5.       Sexually Transmitted Diseases. http://www.cdc.gov/StD/Gonorrhea/arg/default.htm

6.       Cephalosporin-Resistant Gonorrhea. http://www.medicinenet.com/script/mai/art.asp?articlekey=154633

7.        Amoxicillin Image: www.diefooddye.com

8.        Yogurt: www.flickr.com

9.        Molten Steel: www.commons.wikimedia.org

10.      Tertiary Syphillis: www.flickr.com

11.      Gonorrhea/The Clap: hardinmd.lib.uiowa.edu

12.       Hippies/FreeLove: www.commons.wikimedia.org

13.       Condom: www.commons.wikimedia.org

14.       Penicillin Ad: en.wikipedia.org

15.       Gonococcal Arthritis: hardinmd.lib.uiowa.edu

16.       Agricultural Antibiotics: en.wikipedia.org

 

What is Meningitis? Meningitis 101.

The brain is the pilot of the incredibly complicated system that we refer to as a person. The brain is responsible for controlling just about everything we do, whether it’s done consciously, like kicking a soccer ball, or unconsciously, like digesting a meal. Because the brain is so important, it should come as no surprise that the body goes to great extents to protect it, just like an army goes out of its way to protect its general or The United States bends heads-over-heels to protect our President. The skull is an incredibly tough vault that encapsulates the brain in solid bone. However, the skull wouldn’t be worth a whole lot if the brain was allowed to bounce around inside of it. Think about it. If you hit your head and your brain was free to move around inside the skull then it would smack itself back and forth against the skull bones, quite possibly doing more damage than conking your noodle outright in the first place!

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This is a dissection of a human brain from the front (“the coronal axis” for you fancy medical folks out there). Essentially, this cadaver had its face cut off and this is a view of the brain along the same plane that you see every day when you look someone in the eyes — this is just a little bit deeper in the old noggin. The outermost layer is the scalp and the skull bones are right underneath. The sponge-looking thing in the middle is your brain, the organ that is processing and making sense out of these words for you as you read my medical blog!

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This is another cadaveric dissection, except this time we’re looking down on the cadaver at the top of their noggin (which obviously has been removed). The flappy layer on the outside is the scalp. Underneath that is the bone. The white bone is tough cortex while the darker colored stuff in the middle is bone marrow. The brain is white and brownish colored in this preparation and it is sitting inside the skull.

The body prevents this dangerous scenario from occurring (in most instances) by stabilizing the brain inside the skull with fibrous “support ropes” that are called “the meninges.” The rope analogy is actually fairly accurate, by the way. In a cadaver the consistency of the meninges feels very much like rubbing a thin piece of wet hemp rope, albeit without the rope splinters! In addition to its meningeal “support rack,” the brain is surrounded and filled internally with a fluid called CSF that cushions the brain and acts as a biological shock absorber. Overall, the human brain is very well protected indeed.

 

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This is an MRI of the head and brain. You can see the meninges if you know what you’re looking at, but what I really want you to notice here is the CSF. See that black stuff in the middle of the brain (in the lateral, third, and fourth ventricles to be precise)? That’s CSF. The layer of black directly around the brain and the spinal cord (located underneath the brain) is also CSF.

 

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Okay, here’s a good picture of the meninges. In this illustration, which was based on an actual cadaveric dissection, everything inside the skull vault except the meninges has been removed. See that big fibrous band? That’s the meninges! The blue structures are “dural venous sinuses,” large veins that run inside the meningeal layers and that return blood from the brain back to the heart.

The defenses of the human brain don’t end with the mechanical protections of the CSF and the meninges. The brain is also garrisoned against bacteria and viruses by specialized adaptations of the blood vessels that provide it was oxygen and nutrition. Unlike the relatively “leaky” blood vessels in the rest of the body, that allow cells and nutrients from the blood to freely pass back and forth between the blood and the body tissues, the blood vessels in the brain are tightly lined with a “blood-brain barrier” that specifically regulates what can and cannot pass into and out of the brain via the bloodstream. As formidable as the blood-brain barrier is, every once in a while the blood-brain barrier is infiltrated by a bacteria or a virus and the result is meningitis, encephalitis, or both.

 

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This is an illustration of the blood-brain barrier. Don’t perseverate over this complicated cartoon! The point is that nothing is supposed to get into the brain from the bloodstream that the body doesn’t want there — and most of the time the blood-brain barrier keeps things that way.

Meningitis is an infection of the meninges and it is frequently accompanied by encephalitis, an infection of the brain proper. Meningitis causes a high fever, a severe headache with light sensitivity, confusion, nausea and vomiting (often projectile), and sometimes seizures that can be fatal. On physical examination patients with meningitis often have an extremely stiff neck and this is called “nuchal rigidity.” Meningitis can only be definitively diagnosed with a lumbar puncture, the dreaded “spinal tap” procedure that is so often portrayed in the movies and on television. A lumbar puncture is performed by placing the patient on their side with their legs flexed and then inserting a long needle through the layers of the lower back and into the meningeal layers that line the spinal cord [the brain + the spinal cord = the “central nervous system (CNS)” and both parts of the CNS are surrounded by supporting meningeal layers). The point of a lumbar puncture is to obtain CSF so that this special fluid can be analyzed in a laboratory. The reason that CSF is so important is that meningitis can be caused by several very different types of pathogens, all of which require a different type of treatment by the medical team.

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A lumbar puncture…good times are not waiting. In reality it’s not as bad as it looks, but I still wouldn’t volunteer to let someone practice a lumbar puncture on me (I let folks stick my veins for practice all the time).

Most cases of meningitis are caused by viruses and these infections, while they make you feel really lousy for a week or two, are usually fought off by the body on its own with no residual effects. One specific type of viral meningitis is herpetic viral meningitis and it is treatable with an antiviral drug called acyclovir. CSF evaluation is pretty good at showing whether a case of meningitis is caused by a virus, but really lousy at determining which specific virus is the guilty party. Because of this many physicians treat all patients who have viral meningitis with acyclovir just in case they happen to have herpetic meningitis, which is a fairly common disease because the herpes viruses (there are lots) are much more prevalent than most folks realized. Remember that herpes viruses don’t only cause the notorious genital disease, the also cause cold sores, which most of us have from time-to-time.

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An electron micrograph of one of the many, many, many types of herpes viruses that are floating around in our environment.

The biggest concern that a doctor has when they are confronted with someone who has meningitis is to determine if the meningitis is cause by bacteria. Bacterial meningitis is bad news because it is fatal about 10% of the time and responsible for brain damage or limb amputations in up to 20% (that’s 1-in-5) of the survivors. Limb amputations? Yep, I said that right. Bacterial meningitis frequently causes shock and DIC, two deadly conditions in which the whole body more or less shuts down in response to an infection. When this occurs the body tries to shunt its blood supply to its most important organs, namely the heart and the brain, and this comes at the expense of the limbs in particular. Because the limbs no longer are being supplied with an adequate amount of blood they die and the treatment for a necrotic limb is to amputate it before it becomes infected because otherwise the infection of the dead limb is likely to spread to the rest of the body and result in death.

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Gangrene. What doctors are trying to prevent when they amputate a dead limb, hopefully before it becomes infected.

Bacterial meningitis is treated with potent antibiotics, antiepileptic drugs to prevent seizures, and with powerful anti-inflammatory drugs to decrease damage to the brain. With that said, the best treatment for bacterial meningitis is to prevent it in the first place and the medical establishment is actually pretty good at this if people will vaccinate their kids! Pneumococcus and Haemophilus influenza type b were formerly very common causes of very serious cases of bacterial meningitis in young children. The incidence of meningitis caused by these two nasty bugs has greatly decreased due to the Conjugated Pneumococcal Vaccine (PCV7) and the Hib Vaccine, both of which are routinely given to young children with the first dose of Hib being given at the age of 2 months. In addition, the most notorious cause of meningitis in teenagers and young adults is Meningococcus and we have a pretty good vaccine that covers most strains of this nasty killer and that is now routinely given to children at age 12 (with a booster at age 16), thus saving many otherwise young healthy lives. The take home message is to please vaccinate your children!

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Pneumococcal meningitis. The band of tissue being held back by the metal forceps is the meninges. That yellow stuff underneath the meninges, but on top of the brain, is puss. There is a vaccine that covers the most common strains of pneumococcus, which is also a common cause of (big surprise) pneumonia, a disease that is still one of the leading causes of death in America today.

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An 11-year-old boy with meningitis being held down by his physicians as he suffers a violent seizure. This photograph was taken in the pre-antibiotic era.

There are two other uncommon, but exceedingly nasty, other types of organisms that are potential causes of meningitis: fungi and parasites. Fungal meningitis most commonly afflicts people who are immunocompromised, e.g. people with AIDS and people suffering from cancer. Though usually uncommon in healthy persons, there was an outbreak in 2012 that was spread by contaminated corticosteroid injections (often used for joint injections in people with arthritis) that unnecessarily killed a lot of people. An even more scary cause of meningitis is the parasite Naegleria fowleri, an ameba that can swim up the nose of people who are swimming in warm fresh water and that causes a form of meningitis that has a 95% mortality (death) rate! Fortunately Naegleria meningitis is rare; unfortunately, when it does strike it is usually in young healthy teenagers because this is the age group that most commonly swims in warm lakes and rivers.

Naegleria_fowleri_lifecycle_stages[1]

Naegleria. On the left is the cyst form. When inhaled through the nose the cyst transforms into the nasty buggers seen on the right. The Naegleria ameba literally eats your brain.

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis. Amazon Link to Doc’s Writing:  http://www.amazon.com/Leonardo-Noto/e/B00ATVOMCW/ref=ntt_dp_epwbk_0

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your e-reader at http://www.smashwords.com/books/view/215272. Thanks for reading!

Amazon

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 16-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 opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

References:

  1. http://www.mayoclinic.com/health/meningitis/DS00118
  2. http://www.nvic.org/vaccines-and-diseases/Meningitis.aspx
  3. http://www.cdc.gov/meningitis/parasitic.html
  4. http://www.cnn.com/2011/HEALTH/08/17/amoeba.kids.deaths/
  5. www.flickr.com Courtesy of Liz Henry.
  6. www.wikipedia.org. Brain Dissections.
  7. www.ilearnttoday.com507 × 444Search by image. Blood-Brain Barrier Illustration.
  8. www.wikipedia.org. Lumbar Puncture.
  9. www.flickr.com. Herpes Virus.
  10. www.wikipedia.org. Gangrene.
  11. www.wikipedia.org. Pneumococcal Meningitis.
  12. www.wikipedia.org. Boy with Meningitis.
  13. www.wikipedia.org. Naegleria.

Let’s Talk About Fluids — Intravenous Hydration 101

Hydration may seem like a mundane topic at first, but I assure you that it’s not. When I first entered medical school I was fascinated, and a little bit disappointed, about how much time we spent talking about how to pump salt water through some guys veins. Hell, it was all half of the doctors lecturing us wanted to talk about, especially the emergency medicine attendings! With all of the flashbang drugs we have, and all of the fancy mechanical interventions like respirators, why were these guys so hung up on IV fluids???

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A man dying of cholera.

Well, it turns out that these “doctors” actually DID know what they were talking about and that “little med student me” was really the one who was clueless. Got cholera? Guess what, it’s the fluid loss from the profuse diarrhea that kills you, not the bacteria, which your body will eventually fight off on its own if you don’t die from the dehydration first. Done got shot or blowed up with an IED? Guess what, the reason that the blood loss kills you (primarily) is due to the loss of hydrostatic (fluid) pressure in your blood vessels resulting in circulatory collaspe — replacing that fluid pressure can keep your heart pumping while the docs work to stop the bleeding. So as you can see, fluids are quite important indeed.

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Let’s go back to the basics before we talk about the fancy stuff. We normally replenish our body fluids by drinking water and by eating food and the reason that we need to replace a portion our body fluids every day by drinking is that we are constantly loosing fluid through two processes: 1) sensible fluid loss and 2) insensible fluid loss. Now the “sensible” and “insensible” terms in this case aren’t being thrown around in the way that we use them in the vernacular. For instance, we aren’t talking about it being sensible to lose fluid during a water balloon fight and insensible to lose it by throwing a bottle of water out of a speeding car while school children are skipping on the side of the road. Rather, “sensible” fluid losses are fluid losses that you can see/feel while “insensible” fluid losses are imperceptible. Sensible fluid losses include urination and defecation whilst insensible losses occur in small amounts with every breath that you take and with sweating, which is usually unnoticable unless you’re overheated.

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A urinal. A device invented so that men would stop urinating (a form of sensible fluid loss) onto the toilet seat. The urinal has met with mixed success.

Hydration isn’t just about water, it’s also about electrolytes, especially sodium and chloride. Sodium chloride (NaCl) is table salt and when you dissolve table salt into water the NaCl crystals breakdown into positively charged Na ions and negatively charged Cl ions. These ions are essential to keeping your body running properly. When you lose fluid you lose both water and NaCl and many disease processes wreak their havoc on the body (at least in part) by accelerating this fluid loss. Diarrhea = excessive water and electrolyte loss in the stool. Burns cause excessive fluid loss through the body surface areas that are no longer covered by intact skin. Gunshot wounds cause fluid loss via bleeding. Fevers cause increased fluid loss via sweating and through the lungs. See a common theme here!!!

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Table salt that hasn’t been ground into the fine powder that most Americans are habituated to.

Hang in there, we’re almost to the good stuff, but before we start talking about poking folks with IVs and central lines let’s address one more basic question: how is it possible to die of thrist in the middle of the ocean? Everyone knows that you can’t drink salt water because it will make you sick, but why is that? I mean, the oceans hold over 90% of the Earth’s water! The reason that drinking salt water makes you sick is that ocean water contains 3.5% NaCl whereas human body fluids only contain 0.6% NaCl. The way that your body gets rid of excess electrolytes (including NaCl) and waste products is to flush them out via the kidneys in the form of urine and this process requires water. The concentration of NaCl is so high in sea water that getting rid of the excess salt actually requires more water than the amount that you gain by drinking it. In other words, drinking out of the ocean actually makes you lose more body water in the urine than you have gained by drinking it, the net effect being to dehydrate you faster than if you hadn’t sipped on the sea water in the first place. While some NaCl in the blood is essential for the body to function properly, too much causes bad things like seizures and comas.

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The primary way that doctors replace body fluids is with crystalloid solutions, and the most commonly used crystalloid solution is normal saline. “Crystalloid” sounds like a fancy term but all it really means is water with an electrolyte dissolved in it. Normal saline is water with salt (Salt is a crystal before it is dissolved, right. Salt crystals anyone!) dissolved in it at approximately the same concentration as the levels of salt that are found in your blood. Actually, human blood is 0.6% NaCl whereas normal saline is 0.9% NaCl; but normal saline still is approximately equivalent to human blood plasma (the liquid component of blood) because human blood has other electrolytes in it, albeit in much lower concentrations than NaCl. It’s usually just fine to use normal saline to replace a few liters of fluid but if you have to give more than that sometimes doc will have to add some potassium, magnesium, or phosphorous to the solution to keep your electrolytes balanced. There are also other crystalloid solutions that come prepackaged with physiologic doses of electrolytes but now we’re getting way beyond the scope of my little blog!

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A bag of normal saline. Normal saline usually comes in 1 liter bags but they do make smaller and larger bags for specialized purposes.

Human blood is composed of approximately 55% plasma (essentially salt water) and 45% blood cells, primarily oxygen carrying red blood cells. Since all healthy people walk around with way more red blood cells than they actually need (not necessarily true in anemic or chronically ill people), most dehydrated people do pretty well when their plasma volume is replaced with crystalloid solution. People who have suffered massive blood loss or who are anemic to begin with may need a blood transfusion. But it takes time to match blood products and the loss of hydrostatic presssure in the blood vessels is what kills you in the shortrun anyway, so volume replacement with fluids is pretty much the first step for any severely dehydrated or bleeding patient (yes I am aware of the military’s tenets of hypotensive resuscitation — that’s for another blog post!). 

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So how do physicians get all of this lifesaving salt water into their patients, you ask. Well, the tried and true method that works 90%+ of the time is the peripheral IV, a needle with a plastic sheath over it that is inserted into a vein in one of your extremities. When the needle is removed, wallah, you have a nice plastic tube inside of a big fat vein just ready to receive fluid. Now IV’s have a few rather large downsides, the first being that even the big ones are actually somewhat wimpy with regards to the amount of fluid that they can carry in a given amount of time. If you really need to dump fluid into someone who is actively dying in front of you an IV just isn’t going to cut it! The second major issue with IV’s is that some people are really hard “sticks.” Got really dark skin and rolling veins? You’re a hard stick. Severely dehydrated or massively bleeding? Your veins are all collapsed and you’re a hard stick. Are you a former chemotherapy patient, an IV drug abuser, or a dialysis patient. You’re a really hard stick!

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A beautifully done IV, almost certainly placed by a nurse rather than a doctor! Don’t ever let a doctor poke you with an IV unless the doctor is an anesthetist or you’re dying and there no one else is around to do it! The nurses are the pros at this one folks.

Fortunately both of these issues, the low flow of IV’s and the difficulty of starting an IV on a “hard stick,” are readily solved with a central line. A central line is a really big needle + plastic tube that is inserted into a really big vein, a vein so big that it essentially never collapses and that can be located on anyone. There are three of these veins: 1) the femoral vein in the groin, 2) the subclavian vein underneath your clavicles (collar bones), and 3) the internal jugular vein in your neck. Now having a massive central line sticking out of your neck, chest, or groin obviously isn’t pleasant, but the chances are that if you need one of these you’re dying so the central line is the least of your worries, okay!

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An internal jugular vein (“IJ”) central line in a patient’s neck. Doctors usually use an ultrasound to guide placement these days, but in the past there was sometimes a bit of “fishing” involved in the procedure!

Central lines can take a while to insert and in some instances, like in a bouncing ambulance or in a Blackhawk helicopter, trying to place a central line borders on lunancy. And that’s when you go to the admittedly unappealing, but nonetheless lifesaving, intraosseous line (IO). An IO is basically a short central line that is drilled into either your tibia (calf bone) or your sternum (breast bone). Yes, I said drilled! The way that you place an IO is to either hand drill or electrically drill (with a medical drill, but it’s still a drill) the catheter into the bone until you hear a gut-wrenching “POP.” Then you flush the line and start to dump fluid into the patient to your heart’s desire.

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IO drills. Usually the tibia (the big bone in your calf) is the preferred site for an IO. However, in people who have lost their legs in accidents, to IED’s, etc. a sternal (breast bone) IO can be used. Using an excessively long IO needle for a sternal insertion is a really bad idea for obvious reasons! People have been known to make this mistake since tibial IOs are longer than sternal IOs.

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis. Amazon Link to Doc’s Writing:  http://www.amazon.com/Leonardo-Noto/e/B00ATVOMCW/ref=ntt_dp_epwbk_0

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your ereader at http://www.smashwords.com/books/view/215272. Thanks for reading!

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 16-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 opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

References

1) Myburgh, JA and Mythen, MG. Resuscitation Fluids. The New England Journal of Medicine. September 26, 2013.

2) Somers, MJ. Maintenance Fluid Therapy in Children. In: UpToDate. Accessed September 30, 2013.

3) Dehydrated Man: http://en.wikipedia.org/wiki/File:Adult_cholera_patient.jpg

4) Man Dying of Massive Hemorrhage: http://www.flickr.com/photos/rafahkid/3155998947/

5) Urinal: http://www.flickr.com/photos/pointnshoot/261555819/

6) Table Salt: http://en.wikipedia.org/wiki/File:Himalaya-Salz-1.jpg

7) Cats on Raft: http://www.flickr.com/photos/31333486@N00/2441671268/

8) Normal Saline: http://en.wikipedia.org/wiki/Saline_(medicine)

9) Fractionated Blood: http://en.wikipedia.org/wiki/File:Blood-centrifugation-scheme.png

10) Peripheral IV: http://en.wikipedia.org/wiki/File:Intravenous_therapy_2007-SEP-13-Singapore.JPG

11) Central Line: http://en.wikipedia.org/wiki/File:Triple-Lumen.jpg

12) IO Line: http://en.wikipedia.org/wiki/File:Vidacare3productsystems.jpg

What is Brain Death?

Death occurs when a living organism (a person for example) can no longer independently maintain the essential body functions (breathing, a beating heart, etc.) that are necessary to keep the person as a whole alive. As a general rule, death occurs when the body can no longer supply its vital organs, like the heart, the lungs, and the kidneys, with enough oxygen to keep these organs going. This lack of oxygen, termed hypoxia in medicalese, can occur for multiple, multiple different reasons. For example, a person with severe lung disease might die from hypoxia because they can’t effectively breath whereas a person who has suffered a massive heart attack is at risk of dying because their heart can’t circulate oxygen (from the lungs) through the blood to reach the other vital organs –different mechanisms causing organ hypoxia, but with the same end result. 

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An Egyptian mummy. If only it were always so obvious when people are dead my job would be much easier…

The reason that oxygen is important to the body is because it is used to “burn” the biological fuels that we all obtain by eating to produce the energy that body tissues need to stay alive — no energy, no life. Different organs die at different rates when they don’t get enough oxygen. For instance, the brain begins to die after about 4 minutes of oxygen deprivation whereas skeletal muscle (your biceps muscles for example) can last for up to 4 hours without an adequate oxygen supply — a really big difference!

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An image of human cells growing in a laboratory. These are HeLa cells, cells which were taken from Henrietta Lacks’ fatal tumor before her death in 1951 (without her consent) and have since become the standard human laboratory cell for study. No one objects to disposing of old HeLa cells, but the individual cells are very much alive, another excellent demonstration of why the distinction between life and death isn’t quite as obvious as most would think. 

Okay, hang in there because I’m going somewhere important with all of this. The concept of brain death didn’t exist until the advent of mechanical ventilation, aka: life support. Since the brain controls breathing, the blood pressure, and (indirectly) the heart, before the invention of life support a person with a nonfunctioning brain rapidly progressed to a state in which none of their other organs (lungs, heart, etc.) were working either — they were either obviously dead or they weren’t. Mechanical ventilation and other advanced intensive care techniques changed all of this by enabling physicians to artificially keep a persons heart and lungs working even if the brain was damaged beyond repair. This is because the brain is the first tissue to die when a person’s body has an inadequate supply of oxygen and sometimes physicians are able to treat people only after their brain has been irreparably damaged, but before their heart, lungs, kidneys, and other vital organs have begun the irreversible dying process. This scenario is really important for several reasons and more common than you might think.

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A mechanically intubated American serviceman injured overseas and being prepared for brain surgery. The tube coming out of his mouth continues down his trachea (the airway) and is attached at the other end to a mechanical ventilator. The black device on his head is used during neurosurgery to precisely localize portions of the brain in the operating room.

Because keeping a person’s body breathing on a ventilator when their brain is irreversibly destroyed makes absolutely no sense, physicians began contemplating the need for a diagnosis (that did not exist at the time) to convey to patient’s families the irreversible nature of the damage to their loved one so that they wouldn’t suffer from delusions of false hope and so that limited Intensive Care Unit beds wouldn’t be taken up by patients with no chance of recovery (and therefore possibly denied to other patients who might recover due to lack of beds). The answer to this conundrum was the development of the concept of “brain death” by the medical community, a concept that met great resistance from some quarters and which was highly controversial outside of the world of medicine until at least the mid-1970s, nearly three decades after mechanical ventilation became a common place treatment in intensive care units.

In 1954 the world’s first successful internal organ transplantation occurred (it was a kidney transplant that was performed in The United Kingdom) and over the next three decades organ transplantation became widespread, saving thousands upon thousands of lives that otherwise would have ended prematurely. Because brain dead patient’s often have little wrong with their other vital organs, at least in the first few hours-to-days, people who have suffered brain death are the source a very large proportion of donor organs. This is because many cases of brain death are caused by head trauma and many head trauma victims are young people with otherwise extremely healthy organs (you wouldn’t want a kidney transplant from a dead elderly person whose kidney’s had been damaged over the years from diabetes and high blood pressure, right!). The fact that brain dead patient’s have no chance of recovery, coupled with the fact that their internal organs can potentially save the lives of many others, led the Federal Government in The United States to finally get off its butt and propose national standards for the determination of brain death, standards which were approved in 1980 and soon thereafter adopted by an overwhelming majority of the 50 States.

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The fluid-filled abdomen of a man with end-stage cirrhosis. A liver transplant would likely save his life. Not all cirrhosis is caused by alcohol, by the way. Genetic diseases, drug reactions, and autoimmune diseases can all destroy the liver as well.

Before we delve deeper, let’s briefly look at the 5 categories of Altered Levels of Consciousness: Confusion, Delirium, Obtundation, Stupor, and Coma. A confused person is mildly disoriented while a delirious person is completely disoriented and also may have both hallucinations (e.g. hearing voices or seeing things that do not exists) and delusions (e.g. thinking that the nursing staff is trying to kill them). An obtunded person is sleeping but you can wake them, at least for a little whle, by talking to them or with other gentle stimuli, for instance by nudging their shoulder. Patients in a stupor can only be aroused by causing pain and a very common way to do this in the hospital is to forcefully rub the patient’s breastbone with your knuckles or to press down hard onto one of their fingernails with pen or with the metal shaft of a reflex hammer. A person who is absolutely unable to be awakened is in a coma.

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An obtunded cat, greatly in need of a referral to Alcoholics Anonymous. Let’s all pray for him tonight…

Okay, returning to brain death. All brain dead people are in a coma but not all people in a coma are brain dead. Coma’s have multiple causes and some are reversible while others are not. The first thing that a physician does when they evaluate a person who is potentially brain dead is to look for a known cause (e.g. a motorcycle/”donor cycle” accident in a person who wasn’t wearing a helmet). The next step is to rule out any potentially reversible, i.e. “fixable,” conditions that might be contributing to the patient being in a coma, especially drugs/alcohol, electrolyte abnormalities, and hypothermia — “you’re not dead until you’re warm and dead” — as the ER maxim goes.

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As with all maxims, there are probably some reasonable exceptions to “you’re not dead until you’re warm and dead.” This is a frozen juvenile wholly mammoth fossil.

In order to be declared brain dead in The United States a person must undergo a thorough examination by at least two physicians. Both of these physicians perform an extensive neurological examination. Brain dead patient’s are unresponsive to painful or noxious stimuli above the neck, have unresponsive dilation of the pupils, no gag reflex, and do not breath spontaneously (as determined by a specialized “apnea test”). If all of these findings are consistent with the diagnosis of brain death on both physicians’ separate physical examinations then the patient can be declared dead.

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A spinal reflex — no brain required.

Interestingly, brain dead patient’s often do have a response to painful stimuli below the neck and they can even move in response to it (e.g. moving an arm when it is stimulated). This is because the reflexes below the neck are controlled via the spinal cord and sometimes the spinal cord takes longer to die than the brain. Another interesting category of patients is people who have obviously suffered a brain injury that is so severe that they are in an irreversible, permanent coma but who don’t meet the full criteria for brain death. These people are in a “vegetative state.” Vegetative states have a poor prognosis and people who have been in a vegetative state for greater then one year (like in the Terri Schiavo case) essentially have a zero percent chance of recovery. 

The first take home message is to please treat your brain gently and wear a helmet, seatbelt, and other commonsense safety equipment when engaging in activities that can result in head injury such as skateboarding, riding a bicycle, and driving an automobile. The second take home message is to please consider signing an advance directive with your family and physician so that your wishes are known as to the extent of treatment that you would desire if you were to suffer a severe brain injury (would you want to be an organ donor and potentially save someone’s life?). We all live in a dangerous world full of automobiles driven by distracted drivers — think ahead and spare your family the agony of having to make difficult decisions for you without knowing what your wishes would have been.

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Three people on a motorcycle without helmets, a fantastic example of a really bad idea!

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis. Amazon Link to Doc’s Writing:  http://www.amazon.com/Leonardo-Noto/e/B00ATVOMCW/ref=ntt_dp_epwbk_0

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your ereader at http://www.smashwords.com/books/view/215272. Thanks for reading!

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 16-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 opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

References

Reynolds, NC. Special Issues in Medicolegal Neurology. In emedicine. http://emedicine.medscape.com. Sept. 16, 2009.

Young, BG. Diagnosis of Brain Death. In UpToDate. http://www.uptodate.com. May 17, 2012.

Determination of Death Act Summary. Uniform Law Commission. http://www.uniformlaws.org. 2013.

Loss of Consciousness. In PDR Health. http://www.pdrhealth.com/diseases/loss-of-consciousness.

First Successful Kidney Transplant Performed in 1954. In: A Science Odyssey — People and Discoveries. http://www.pbs.org.

The Multi-Society Task Force on PVS. Medical Aspects of the Persistent Vegetative State.  N Engl J Med 1994;  330:1572-1579.

Egyptian Mummy: http://commons.wikimedia.org/wiki/File:Mummy-UpperClassEgyptianMale-SaitePeriod_RosicrucianMuseum.png

HeLa (Henrietta Lacks) Cells: http://en.wikipedia.org/wiki/File:HeLa_Cells_Image_3709-PH.jpg

Ventilated Head Trauma Patient: http://en.wikipedia.org/wiki/File:US_Navy_040723-N-8977L-008_Navy_Hospital_Corpsmen_and_Medical_Officers_assess_the_treatment_and_prognosis_of_a_patient_with_a_gunshot_wound.jpg

Hepatic Cirrhosis: http://en.wikipedia.org/wiki/File:Hepaticfailure.jpg

Burns, M. Cat with a Drinking Problem: http://www.flickr.com/photos/mike-burns/35538355/sizes/m/in/photostream/

Frozen Wholly Mammoth: http://en.wikipedia.org/wiki/File:Mamut_enano-Beringia_rusa-NOAA.jpg

Patellar Reflex: http://www.google.com/imgres?imgurl=&imgrefurl=http%3A%2F%2Fmeded.ucsd.edu%2Fclinicalmed%2Fneuro3.htm&h=0&w=0&sz=1&tbnid=TbeJEv9WUMdqNM&tbnh=259&tbnw=194&zoom=1&docid=pBB_SrdVm0_2QM&hl=en&ei=Rhs1Usm1GZPEqQGP4oH4CA&ved=0CAEQsCU

Donor Cycle: http://en.wikipedia.org/wiki/File:Family_transport_in_Tehran.jpg

Biological Weapons of Mass Destruction

Unless you’re living in a cave, or perhaps a man-cave with your eyes glued to ESPN College Football, then you undoubtedly know that The United States is currently contemplating an attack against Syria in retaliation for the Assad regime’s use of chemical weapons against civilians. Since I already authored a recent article on chemical weapons of mass destruction, today I would like to discuss biological weapons of mass destruction, weapons which are even scarier than sarin or mustard gas. As always, the best way to understand complicated issues today, including the use of weapons of mass destruction, is to examine (briefly in our case) the history of these weapons.

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This is a photograph from WWI of blinded soldiers being led in a line away from a chemical weapons attack, the winds mercifully having changed directions and now blowing the deadly gas away from these victims. Many biological agents can be dispersed in a similar fashion, although the amounts needed to cause massive damage would be much, much smaller.

Biological weapons primarily consist of three categories of substances: bacteria, bacterial toxins, and viruses. Historically, the biggest killer on the battlefield wasn’t swords, bows, guns, or artillery — it was germs, especially typhus, which is caused by a bacteria that is carried by the human body louse (a rare parasite today thanks to modern hygiene, but very common up until at least World War I). The intentional use of biological weapons dates back to at least feudal times, when enemy armies would catapult the victims of plague (a bacteria), smallpox (a virus), and other nastiness over the walls of enemy cities. During World War II the Japanese extensively used both chemical and biological weapons against the Chinese, including the dropping of “plague bombs” from their aircraft into Chinese cities — essentially cannisters that were full of fleas carrying the bacteria Yersina pestis that causes bubonic plague (aka: “The Black Death”).

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This is Shiro Ishii, the microbiologist and general who led Japan’s infamous Unit 731 during WWII. Unit 731 was responsible for Japan’s biological weapons program and also participated in dissections of living human beings and other horrific medical experiments that were performed on living, unanesthetized humans. Dr. Shiro Ishii was not punished for his crimes.

As terrible as these examples are, the greatest biological attacks in history have actually been unintentional. Nonetheless, these unintended “attacks” show us how potentially devasting an intentional biological attack might be — a scary prospect given that manufacturing biological weapons is actually pretty easy to do (anthrax probably lives in soil your backyard!!!). While “The Black Death” of Europe is probably the most infamous example of a massive pandemic decimating a population, having killed at least one person in three in 14th century Europe due to the inadvertent transmission of Yersina pestis infected rats/fleas aboard trading ships, the most poignant example of (mostly) inadvertent biological catastrophy actually occurred in the Americas and it is largely responsible for the cultural makeup of North and South America today.

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Florid smallpox afflicting a child.

Unlike Europeans, Africans, and Asians, who had lived in contact with one another and with one another farm animals (the initial source of many human pathogens), Native Americans had no innate resistance to smallpox, measles, and a host of other diseases that Europeans brought with them after Columbus’ monumental voyage of 1492. Although hard numbers are difficult to come by, it is likely that in many areas up to 90% of the native population died from these diseases in a very short period of time, ultimately making their conquest by Europeans much easier than it otherwise would have been. A particularly good example is The Pilgrims, who landed in Cape Cod to find fertile lands that were devoid of inhabitants and that just so happened to also be filled with lots of recently emptied villages. This was not a coincidence! European traders had visited the area shortly before The Pilgrims arrival and the bustling native population was ravaged by the diseases that they brought with them. Had the Pilgrims landed at any other time they would have certainly been driven off. However, the remaining Native Americans decided to put up with The Pilgrims because they thought that they might be useful allies against their adversary tribes, who had not (yet) been affected by European diseases — it seemed like a good idea at the time! By the way, if you want to read more on the topic of the European/Native American first encounters I highly recommend these two books, both of which I strongly based this paragraph upon — Mann, C.C. 1491: New Revelations of the Americas Before Columbus by Charles Mann and Guns, Germs, and Steel by Jared Diamond.

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The evolution of the wound/scar that forms after smallpox vaccination.

The mid-20th century marked a period of bustling research into weapons of mass destruction and biological weapons of mass destruction were no exception. At one point both The United States and The Soviet Union measured their biological weapons stockpiles in tons. The average car weighs 1-2 tons — a useful “yardstick” to wrap your head around how much of this stuff their was (is?) in the world not very long ago. The good news is that both The United States and the former Soviet Union, aka: Russia, began officially destroying their stockpiles of biological weapons during the 1990s. The only countries today with likely stockpiles of biological weapons that also publically have stated that they would consider using them in war are North Korea and Syria, the bad news being (for American readers) that we have officially been at war with North Korea since the 1950s and we are probably about to march off for a little adventure in Syria due to the regime’s recent blatant use of chemical weapons (probably sarin gas) against civilians. Before we look at specific types of biological weapons, here’s a list of countries that have or had biological weapons at one point in the not too distant past (courtesy of The Arms Control Association): Russia, The United States, China, Syria, North Korea, and Libya. Other countries which may possess or may have possessed biological weapons are: Egypt, India, Iran, and Israel.

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Bashar Al-Assad, the dictator of Syria, who is also an ophthalmologist by training (a medical doctor who specializes in eye surgery). The deathtoll is much higher now, by the way.

Types of Biological Weapons:

1. Smallpox: The only disease ever eradicated by the actions of mankind, smallpox was declared extinct by The World Health Organization in 1980 after a decades-long global vaccination effort. Smallpox was capable of killing in excess of 1/3 of its victims and of incapacitating most of the rest for periods of weeks to months. Those who recovered were often maimed for life with deep pockmarks over their faces and bodies Smallpox vaccination with a related bovine virus, cowpox, actually began long before Edward Jenner popularized the technique in 1796; indeed, after witnessing the effects of smallpox firsthand (he bore facial scars for the rest of his life), General George Washington began the practice of compulsory smallpox vaccination in the American (Continental) Army in 1777 that continues to this day. While an effective vaccine does exist for smallpox, there is no effective cure once you have the disease. Smallpox is an inviting biological weapon for both armies and for terrorists because the perpetrators of the attack could protect themselves before hand by being vaccinated. Most people, including most people in The United States, are no longer vaccinated against this terrible virus, which continues to live on in select laboratories in The United States and in Russia (other countries too?).

Smallpox_virus[1]

An electronmicrograph of the smallpox virus.

2. Bubonic Plague: Bubonic plague is most commonly spread from infected rats (and other critters) to humans via fleas but it can also be spread through the air, both intentionally in the case of a biological weapons attack or simply by coughing from a person with pneumonic plague — bubonic plague that has spread to the lungs. Bubonic plague results in the massive enlargement of lymph nodes to form pus filled sacks under the armpits, in the groin, and in the neck of persons afflicted with this deadly disease, which kills up to 90% of untreated victims. Antibiotics can cure bubonic plague if the infected person gets them quickly and if there are still enough antibiotics to go around, a rather important caveat if a large city or cities were to be infected simultaneously with this horrible pathogen. Victims of the bubonic plague often turn black due to disseminated intravascular coagulation (DIC), a coagulation disorder that can be triggered by an overwhelming infection. In DIC the body forms excessive blood clots, runs out of the clotting proteins that are necessary to form blood clots, and then bleeds internally. Again, bubonic plague is an inviting weapon for modern militaries and terrorist organizations because soldiers can be pre-treated with antibiotics before plague is unleashed.

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A man dying from bubonic plague, aka The Black Death.

3. Anthrax: The bacterium Bacillus anthracis is a ubiquitious soil organism that, as I stated above, probably lives in the soil in your backyard. This organism rarely naturally infects humans and when it does it usually presents as a nasty skin infection that afflicts persons who work with dirty animals (cutaneous/skin anthrax is also known as “wool-sorters disease”). The problem with anthrax is that it is easy to make and that when this bacterium is aerosolized in the form of a concentrated powder it rapidly produces a fatal pulmonary (lung) infection. Anthrax can be treated with antibiotics but, frankly, unless you get them into your system quickly even these modern drugs don’t work very well for someone with fullblown pulmonary anthrax. There is also an effective vaccine and all American soldiers, myself included back when I was still wearing the uniform, are vaccinated against this disease before they deploy overseas. The combination of anthrax being preventable with vaccination and with the preventative early use of antibiotics again make this a “good” candidate for use as a biological weapon. We all know that there have already been several lonewolf anthrax attacks in The United States, first after the Sept. 11th attacks (perpetrator likely deceased) and again in April 2013 (the targets were President Obama and US Senator Roger Wicker of Mississippi — perpetrator still at large). It is both easy to make for someone with Bachelor’s degree level microbiology training and deadly…

youcannotstopusanthdasch[1]

One of the Sept. 11th anthrax letters, this one having been sent to Senator Tom Daschle (the Senate Majority Leader at the time).

4. Ricin: This biological poison exists in a gray area between biological and chemical weapons. Ricin is a naturally occuring toxin that is produced by castro beans and that can be distilled from them using fairly rudimentary chemistry techniques. Ricin has been used in assasinations, the most famous of which was the assasination of a Soviet dissendent in London during the 1970s via ricin that was administered by poking him with an umbrella with a concealed hypodermic needle in its tip. This powerful poison can also be disseminated through the air and their is no curative treatment for the havoc that it unleashes inside the bodies of its victims. Ricin works by shutting down the production of proteins inside the body’s cells and this rapidly causes tissues such as the lungs, the liver, the kidneys, and the gastrointestinal tract to stop working (to put it simply), with death as the result.

Castor_beans1[1]

Castor beans, the source of ricin.

5. Viral Hemorrhagic Fevers: Include the feared Ebola virus, which kills up to 90% of exposed people in a particularly gruesome way — by causing them to bleed both internally and externally, with blood oozing from every bodily orifice as the victim’s life slips away. These horrible viruses are found in nature and they have no effective preventative vaccination or postexposure cure. This likely gives viral hemorrhagic fevers too many potential unintended consequences for any sane military to consider their use — the risk of the virus circling back and infecting your own people would likely be too great (unless there is a vaccine or effective antiviral treatment that no one else knows about…). These same properties likely make viral hemorrhagic fevers a tempting weapon for terrorists who don’t mind losing their own lives in the process, especially for terrorists who hail from places that are unlikely to be reinfected via routine global transit — like terrorists who live in prehistoric villages in Afghanistan, the tribal regions of Pakistan, or the nether regions of Yeman for example.

flickr-2340497389-hd[1]

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis. Amazon Link to Doc’s Writing:  http://www.amazon.com/Leonardo-Noto/e/B00ATVOMCW/ref=ntt_dp_epwbk_0

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your ereader at http://www.smashwords.com/books/view/215272. Thanks for reading!

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 16-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 opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

References:

1. Emergency War Surgery: Third United States Revision. Department of Defense, United States of America. 2004.

2. Pickover, C.A. The Medical Book: From Witch Doctors to Robot Surgeons, 250 Milestones in the History of Medicine. Sterling Publishing, New York, New York. 2012.

3. Arms Control Association. http://www.armscontrol.org/factsheets/cbwprolif

4. Mann, C.C. 1491: New Revelations of the Americas Before Columbus.Knopf. 2005.

5. Riedel, S. Edward Jenner and the History of Smallpox and Vaccination. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1200696/

6. CDC: Facts About Ricin. http://www.bt.cdc.gov/agent/ricin/facts.asp

7. Poison Gas Attack: Courtesy of Wikipedia. http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=biological+weapons&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=728&sei=WFMlUu2RGMTlygHtsoCAAQ#as_st=y&hl=en&q=biological+weapons&tbm=isch&tbs=sur:fc&facrc=_&imgdii=_&imgrc=AUS5I1VchAloMM%3A%3Brz0CWPBHJlp6eM%3Bhttps%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F0%252F09%252FPoison_gas_attack.jpg%3Bhttp%253A%252F%252Fen.wikipedia.org%252Fwiki%252FChemical_weapons_in_World_War_I%3B713%3B262

8. Shiro Ishii/Unit 731: Courtesy of The Government of Japan and Wikipedia. http://en.wikipedia.org/wiki/File:Shiro-ishii.jpg. http://en.wikipedia.org/wiki/Shiro_Ishii.

9. Child with Smallpox: Courtesy of Wikipedia. http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=biological+weapons&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=728&sei=WFMlUu2RGMTlygHtsoCAAQ#as_st=y&hl=en&q=small+pox&tbm=isch&tbs=sur:fc&facrc=_&imgdii=_&imgrc=kK0fifoo49WX2M%3A%3BiNBHHMAvHy4RzM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F6%252F66%252FChild_with_Smallpox_Bangladesh.jpg%3Bhttp%253A%252F%252Fen.wikipedia.org%252Fwiki%252FFile%253AChild_with_Smallpox_Bangladesh.jpg%3B1995%3B3040

10. CDC: Evolution of Smallpox Vaccine Scar: www.bt.cdc.gov.

11. Gasmask: www.photopedia.com. http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=biological+weapons&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=728&sei=WFMlUu2RGMTlygHtsoCAAQ#as_st=y&hl=en&q=biological+weapons+&tbm=isch&tbs=sur:fc&facrc=_&imgdii=_&imgrc=IjTK3e2PVBxQeM%3A%3BBsUcnXtQGfx59M%3Bhttp%253A%252F%252Fimages.cdn.fotopedia.com%252Fflickr-2340497389-hd.jpg%3Bhttp%253A%252F%252Fwww.fotopedia.com%252Fitems%252Fflickr-2340497389%3B1620%3B1080

12. Smallpox Virus: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=biological+weapons&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=728&sei=WFMlUu2RGMTlygHtsoCAAQ#as_st=y&hl=en&q=smallpox+virus&tbm=isch&tbs=sur:fc&facrc=_&imgdii=_&imgrc=t2MLkYzo_s_P1M%3A%3BWb1fAUxORmoNmM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252Fd%252Fd4%252FSmallpox_virus.jpg%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253ASmallpox_virus.jpg%3B700%3B529

13. The Black Death: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=biological+weapons&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=728&sei=WFMlUu2RGMTlygHtsoCAAQ#as_st=y&hl=en&q=bubonic+plague&tbm=isch&tbs=sur:fc&facrc=_&imgdii=_&imgrc=vbas0_EVeECZMM%3A%3B4BQtgg5Tgf9DOM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F0%252F0a%252FAcral_necrosis_due_to_bubonic_plague.jpg%3Bhttp%253A%252F%252Fen.m.wikipedia.org%252Fwiki%252FFile%253AAcral_necrosis_due_to_bubonic_plague.jpg%3B331%3B504

14. Anthrax Letter: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fanthraxmuseum.tripod.com%2Ftheanthraxmysterymuseumtm%2F&h=0&w=0&sz=1&tbnid=wHMn548pTuUnWM&tbnh=194&tbnw=259&prev=%2Fsearch%3Fq%3Danthrax%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=anthrax&docid=4oNxDVLII1jjHM&hl=en&ei=dVwlUt3nGcq7qAGX2IHQBQ&ved=0CAUQsCU

15. Castor Beans: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=biological+weapons&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=728&sei=WFMlUu2RGMTlygHtsoCAAQ#as_st=y&hl=en&q=castor+beans&tbm=isch&tbs=sur:fc&facrc=_&imgdii=_&imgrc=V8B0kVUzGBJvcM%3A%3B_71waOagMkhaPM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F3%252F3d%252FCastor_beans1.jpg%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253ACastor_beans1.jpg%3B1234%3B1195

16. Bashar Al-Assad. www.flickr.com.

Skin Cancer — Recognizing Skin Cancer and Preventing it in the First Place!

Tis the season for excessive sun exposure and excessive sun exposure = risk for skin cancer. Yes, that’s right, that sun exposure that gives you your sexy tan is also the #1 preventable risk factor for all three of the main types of skin cancer. Dermatologists (doctors who specialize in the skin) uniformly recommend protecting your skin when you are outdoors with a sunblock of at least SPF 30 and hopefully that is old news to you, especially if you are a parent, because sunburns when you are young (i.e. in your kids) are an even greater risk factor for skin cancer than they are once you are a crusty old bastard like me. Another good tip is to wear dark clothing and a good broad-brimmed hat when you’re outside and to limit your sun exposure between the hours of 10:00am and 4:00pm, which is the time of day that the sun is most directly overhead in the temperate latitudes (like the U.S. and the U.K.), most intense, and most damaging. Remember that UV light doesn’t only damage your skin, it also damages your eyes and can cause cataracts (commonly) and potentially fatal intraocular melanoma (cancer inside the eye) — wear sunglasses! The CDC has an excellent, and short, webpage on sunprotection here: http://www.cdc.gov/cancer/skin/basic_info/prevention.htm

800px-UV_and_Vis_Sunscreen[1]

Sunlight is composed of a broad spectrum of lightwaves (hang with me here) including the visible light that you can see and ultraviolet light (UV) that you can’t. UV light is further composed of UVA and UVB and both of these types of UV light are damaging to your skin, causing it to look old and wrinkled, and potentially can cause skin cancer in people with excessive sun exposure. The SPF of a sunscreen is a measure of how much UVB light the sunscreen blocks under laboratory conditions. Under laboratory conditions an SPF 30 sunblock blocks out approximately 97% of damaging UVB light — the take home message being that if you really want the level of protection that the sunscreen is supposed to provide you better follow the instructions on the bottle. If you think that you’re doing your skin any favors by applying a light coat of SPF 30 sunblock in the morning and then spending 10 hours in the sun without reapplying it every two hours (or whatever the bottle says) you should think again! Remember that SPF only is a rating of protection against UVB light, but UVA is damaging too! Look for a sunscreen that specificially says that it protects against UVA + UVB and don’t settle for anything less.

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This is good sunscreen because it has UVA and UVB coverage and it clearly states this on the label. Whether or not an SPF of greater than 30 actually provides greater protection is debatable, but use at least SPF 30 to be safe.

All of this talk about SPF (that’s Sun Protective Factor) immediately begs the question, at least in my mind, as to what the SPF of your skin naturally is and whether the SPF 30 sunscreen recommendation holds for dark skinned people as well as for those of us with lighter complexions. It surprised me to learn that a tanned persons skin only has an SPF of about 4 and an extremely dark skinned person (a black person with very dark skin) still only naturally carries an SPF of about 13 naturally! That’s right, even if you’re as dark as they come you still need to wear sunblock when your outside in the sun or you’re placing yourself at risk of getting skin cancer. While it is true that very light skinned people, especially redheads, are at higher risk for developing a skin cancer (approximately 7x higher risk) than the rest of us, everyone is at risk for this disease and dark skin people tend to be diagnosed later (and with more advanced cancers) because they don’t realize that they can get skin cancer too!

Skin_tanning[2]

How much protection does this guy’s nice dark tan provide against the sun? Only about SPF 4 — better than nothing, but still pretty darn mediocre.

The Major Types of Skin Cancer

1. Basal Cell Carcinoma: If you absolutely must have a cancer, this is the one to have because it virtually never metastasizes (spreads throughout the body) and it is the metastases that generally make cancers deadly. The downside is that basal cell carcinoma loves to grow in places that are highly visible, like your nose and cheek for instance (notice that these are also highly sun exposed areas!!!), and they can be extremely disfiguring. The only way to get rid of a basal cell carcinoma is to have it surgically cut of your body — and they only get bigger with time, not smaller!

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There probably won’t be much of a nose left after this is resected. Keep the plastic surgeon’s in business anyhow…

2. Squamous Cell Carcinoma: Unlike the classic raised and pearly appearing lesion of a basal cell carcinoma, squamous cell carcinoma of the skin likes to form ulcerations. This cancer does metastasize but it is generally slow growing and tends to be curable unless people choose to ignore the large ulceration on their face — which happens more often than you would think (??!!!??!!!??).

Squamous_Cell_Carcinoma[1]

Ditto.

3. Melanoma: The granddaddy of all skin cancers and one of the worst cancers that you can possibly get, period. Melanoma loves to spread through the body with a rapidity that is difficult to imagine, being especially fond of migrating to the bone (extremely painful) and the brain (causes delirium, seizures, etc.). This cancer is CURABLE if caught early and surgically resected. There has been some medical progress in the past few years for treating metastatic melanoma but once this cancer migrates out of the skin it remains a death sentence.

800px-NodularMelanomaEvolution[1]

Given the size of this unfortunate fellow’s melanoma it is unlikely that it hadn’t metastasized by the time the second photo was taken. Given that the second photo was taken in 2009, it is also unlikely that he is still alive. Melanoma is a devasting disease.

4. Actinic Keratosis and Xeroderma pigmentosa: The girl in the picture below has a genetic condition called xeroderma pigmentosa, or “XP” for short. Everytime you step outside into the sun the sun’s powerful UV rays damage your skin, causing genetic mutations (changes in your skin cells’ DNA). Most of the time your body is pretty good about repairing these mutations, the problem being that every once in a while one slips through the natural repair mechanisms and sticks around inside your skin cells, which then pass it on to new skin cells. Over a lifetime of sun exposure these mutations buildup, just like mutations slowly accumlate in the lungs of long time smokers, and skin cancer (or lung cancer in the case of the smoker) is often the result.

Child_suffering_from_Xeroderma_Pigmentosa_(_Rukum_Nepal)[1]

People with the genetic disease xeroderma pigmentosa are born with a defective DNA repair mechanism in their skin and all of that sun damage rapidly results in mutations that, unlike in a healthy person (most of the time, anyhow), don’t get fixed. The result in skin cancer in childhood. People with this disease also suffer from early cataracts, which is why the girl in the picture has cloudy appearing eyes. This unfortunate girl is a potent example of what sun damage does to your skin over time if you don’t take care of yourself — it just happened to her a lot sooner! By the way, the crusted appearing skin lesions on this girl’s face are actinic keratoses, precancerous lesions that each have a 10% chance (in a healthy person) of developing into a skin cancer.

An Important Note: All forms of skin cancer can present in atypical forms, some of which look nothing like the lesions demonstrated above (especially certain types of melanomas). If you have any skin mark/lesion/mole/etc. that is or might be changing, or that is or might be suspicious, get it checked out by your physician!!!

As an aside, the CDC has an excellent webpage detailing the risk factors for skin cancer here: http://www.cdc.gov/cancer/skin/basic_info/risk_factors.htm

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis. Amazon Link to Doc’s Writing:  http://www.amazon.com/Leonardo-Noto/e/B00ATVOMCW/ref=ntt_dp_epwbk_0

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your ereader at http://www.smashwords.com/books/view/215272. Thanks for reading!

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 16-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 opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

References:

1. Sunscreen SPF: http://www.skincancer.org/skin-cancer-information/ask-the-experts/does-a-higher-spf-sunscreen-always-protect-your-skin-better

2. SPF of Black Skin: http://news.bbc.co.uk/2/hi/health/5219752.stm

3. With Sunscreen, Without Sunscreen: http://commons.wikimedia.org/wiki/File:UV_and_Vis_Sunscreen.jpg

4. UVA/UVB Protection Sunblock: http://www.google.com/imgres?imgurl=&imgrefurl=http%3A%2F%2Fwww.walmart.com%2Fip%2FCoppertone-Sport-High-Performance-Ultra-Sweatproof-Sunscreen-SPF-100-4-oz%2F17619676&h=0&w=0&sz=1&tbnid=B65Fwr6SBHb5iM&tbnh=225&tbnw=225&zoom=1&docid=ul9nyaTgmWXhEM&hl=en&ei=yhEdUtzQMYa4qQG7q4DACQ&ved=0CAEQsCU

5. Darkly Tanned Skin: http://en.wikipedia.org/wiki/Human_skin_color

6. Basal Cell Carcinoma: http://en.m.wikipedia.org/wiki/File:BCC_Nodular_type.jpg

7. Squamous Cell Carcinoma: http://commons.wikimedia.org/wiki/File:Squamous_Cell_Carcinoma.jpg

8. Melanoma: http://commons.wikimedia.org/wiki/File:NodularMelanomaEvolution.jpg

9. Xeroderma Pigmentosa: http://commons.wikimedia.org/wiki/File:Child_suffering_from_Xeroderma_Pigmentosa_(_Rukum_Nepal).jpg

Are Genetic Diseases Evolutionarily Beneficial?

Are genetic diseases evolutionarily beneficial? It sounds like a crazy question, but the answer is “yes, some are.” In my blog post, “Why are Black People Black and White People White,” we discussed how sickle cell trait (primarily in people of African descent) and thalassemia (a group of diseases that is mostly found in Southern Europeans and in Asians) are both protective against malaria. Inherit one copy of the sickle cell gene and you gain substantial and lifelong protection against malaria, historically one of the most deadly diseases to afflict mankind, the downside being that the rare person who inherits two copies of the sickle cell gene ends up dying from a horrible genetic disease. The genetics of thalassemia follow this concept, although the actual inheritance patterns are more complicated and not something that I’m going to bore you with. The take home message is that on a population level, at least historically, having the sickle cell gene and the thalassemia genes floating around in the population did a lot more good than harm (on a net basis) and that this is the reason why these genes are still with us today!

The impetus for my writing “Why are Black People Black and White People White” was the excellent book The World Until Yesterday, by Jared Diamond (he’s also the author of Guns, Germs, and Steel — another exceptionally great read), which reminded me of some things that I’d learned years ago in medical school, found fascinating, and just never gotten around to blogging about. Following on this theme, I thought that it would be interesting to briefly explore some additional genetic diseases that are present today because they were evolutionarily beneficial, at least on the population level, to people in the past. Most of these diseases work in the same basic way — lots of people inherit one copy of the defective gene and gain protection against something in the environment with little downside. Unfortunately, a few people inherit two copies of the defective gene and end up suffering from a full blown genetic disease.

Cystic Fibrosis: The mutation that causes cystic fibrosis causes your body to retain salt from the gut. Inheriting one copy of the mutated gene provides protection against cholera, a bacteria that is contracted by drinking contaminated water and that causes your gastrointestinal system to waste salt which results in profuse diarrhea. Cholera killed millions upon millions of people in Europe during the 19th century and this terrible disease recently reared its ugly head in the Western Hemisphere when Nepalese U.N. Peacekeepers inadvertently carried cholera with them to Haiti during their earthquake relief mission, unfortunately causing a deadly epidemic in the worst possible place at the worst possible time. While having one copy of the cystic fibrosis gene protects against “King Cholera” at little cost to the carrier of the defective gene by making the carrier resistant to loss of salt through the gastrointestinal tract, inheriting two copies of this defective gene causes cystic fibrosis, a terrible disease. Patients with cystic fibrosis cannot excrete adequate amounts of salt into their bowels or their airways and, since water follows salt, this results in the accumulation of thick and dry mucus that clogs up the airways and the gut and that causes all sorts of really awful problems, eventually resulting in early death in most cases (although this outlook is slowly improving with advances in medical science).

imagesCA9SQH23

This is a cholera clinic in India with patients lined on “cholera cots (cots coated with easily cleanable plastic).” Notice the white buckets below each cot — those are for diarrhea. Cholera is caused by a bacterium that causes profuse diarrhea. Cholera kills its victims by dehydration. This deadly pathogen has been largely eradicated in the developed world due to effective water sanitation efforts.

imagesCAQ9L30H

A diagram of the effects of cystic fibrosis. Mucus plugs in the lungs provide an excellent habitat for difficult to eradicate bacterial infections, especially by the pathogen Pseudomonas aeruginosa, a bacterium that is notoriously resistant to antibiotics. Patient’s with cystic fibrosis also suffer from mucus plugging in the gastrointestinal tract and this causes a range of complications including potentially fatal pancreatitis.

HIV Resistance: CCR5 is the name of a gene on a group of your white blood cells called CD4+ T cells, and these are the cells that the HIV virus loves to work its mischief inside. Approximately 10% of people of European descent have inherited one mutated copy of the CCR5 gene and these lucky people are resistant to the HIV virus, and thus resistant to getting AIDS even if they are exposed to HIV. People with two copies of the mutated CCR5 gene — about 1% of Europeans — are immune to HIV (as far as we know) and apparently can’t get AIDS even if they are exposed to HIV. The CCR5 mutation is not found in non-European peoples and it is thought that this mutation was selected for hundreds of years ago because it provided some protection against either bubonic plague (“The Black Death”) or smallpox, both of which were major killers in medieval Europe. Since people with the CCR5 mutation were less likely to die from the above said diseases, the gene eventually became widespread in Europe because people dying from smallpox or from bubonic plague (people without the mutation) are a heck of a lot less likely to have children than healthy people for obvious reasons! The downside of having the CCR5 mutation is that it probably weakens immunity to some other infectious diseases, including the West Nile Virus, which is an avian (bird) virus that causes meningoencephalitis (an infection of the brain and its supporting tissues, the meninges) in humans.

imagesCAS5UYQ2

A man dying from AIDS. In and of itself HIV does not typically directly kill its victims. Rather, the HIV virus destroys the immune system and leaves its victim vulnerable to environmental pathogens that people with intact immune systems are able to easily ward off.

So that’s a few more examples of predominantly genetic diseases/mutations that are, at least at times, beneficial on the population level, which is why they are still floating around in our gene pool. While a few select genetic diseases fit into this category, most are simply bad diseases and we’ll discuss the “hows and whys” of these afflictions next time (in English!) — hope that you join us!

Doc’s Fiction!

The Life of a Colonial FugitiveThe Cannabinoid Hypothesis

 

Dr. Leonardo Noto

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

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your ereader at http://www.smashwords.com/books/view/215272. Thanks for reading!

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 16-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 opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

References:

1. HIV Resistance Via CCR5 Mutation. Stanford at the Tech: http://genetics.thetech.org/original_news/news13

2. Cholera Clinic. Flickr.com. https://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=cholera&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1366&bih=622&sei=JlUSUt2DKYro2QX-noHYCw#facrc=_&imgdii=_&imgrc=8PiUOA3RqTPBIM%3A%3BZvgjzhUR9-GmxM%3Bhttp%253A%252F%252Ffarm1.staticflickr.com%252F32%252F66832397_c3d1224de7_o.jpg%3Bhttp%253A%252F%252Fwww.flickr.com%252Fphotos%252Fknobil%252F66832397%252F%3B800%3B600

3. Cystic Fibrosis. Children’s Hospital.org. http://www.google.com/imgres?imgurl=&imgrefurl=http%3A%2F%2Fwww.childrenshospital.org%2Faz%2FSite2934%2FmainpageS2934P0.html&h=0&w=0&sz=1&tbnid=ijQWsIiGnCSJJM&tbnh=225&tbnw=225&zoom=1&docid=PRJDSxdx5tiO8M&hl=en&ei=l1USUsL_E-2yygHEyoFQ&ved=0CAEQsCU

4. AIDS Patient. www.gsdmc.com.