PSYCHIATRIC SKIN DISORDERS — Delusional Parasitosis and Friends.

“Neurodermatitis” is a medical euphemism for psychiatric skin disorders — skin disorders caused by mental illness. This group of disorders includes delusional parasitosis, Morgellons disease, neurotic excoriations, trichotillomania, and dermatitis artefacta. These conditions are different, yet similar in many respects. All of them are diagnoses of exclusion — diagnoses that are only made after intrinsic skin disorders have been ruled out by the physician. Most of these disorders can be spotted for what they are (by physicians) based on the unique pattern and distribution of the lesions. The skin lesions generally only occur in places that the patient can readily reach and the lesions tend to look highly unusual to the trained eye. The history of the patient is also an important piece of diagnostic evidence in most cases — e.g. a patient with other psychiatric diseases who has been to half-a-dozen dermatologists and no one can figure out what the heck is wrong with them. A skin biopsy can also be useful in equivocal cases. All of these disorders are potentially debilitating, and they all tend to be expensive and sometimes impossible to treat.

475px-An_introduction_to_dermatology_(1905)_scabies

An artist’s illustration of the “gross” (as opposed to “microscopic”) appearance of scabies, definitely not a psychiatric disease. Sometimes when you feel like you have bugs crawling under your skin you really do! As with all conditions, remember that just because someone has a mental illness doesn’t mean that they don’t also get physically ill from time to time like everyone else.

523px-Sarcoptes_scabei_2

An electronmicrograph of the scabies mite. Scabies is usually treated with a drug called permethrin. Outbreaks are common in nursing homes and also sometimes occur in hospitals and daycare centers.

Dermatitis artefacta is a form of factitious disorder, an intentionally caused medical problem that is self-inflicted to fulfill a subconscious need to assume the “sick role.” Patients with this disorder don’t feel normal unless everyone thinks that they are sick. When you are sick people tend to be nice to you and to give you lots of attention, and this is what persons afflicted with factitious disorders crave. Sometimes people with factitious disorder intentionally cause medical problems in their children. Instead of craving the “sick role” for themselves, these individuals crave the role of “caregiver for the sick.” This is called Munchausens Disorder by Proxy and it is a form of child abuse, probably the worst form of child abuse given the amount of psychological damage that is done to the child victim, which is immense.

Factitious_dermatitis

Self-inflicted skin lesions in a patient with dermatitis artefacta.

Delusional Parasitosis, as the name implies, is a delusional disorder. A delusion is a fixed belief that a person continues to believe even in the face of overwhelming evidence to the contrary. In the case of delusional parasitosis, patients are convinced that they have bugs crawling under their skin when they don’t. Obviously someone with scabies does not have delusional parasitosis — they really do have bugs crawling under their skin! A similar condition to delusional parasitosis is substance-induced formication. That’s “formication,” not “fornication” — the term is derived from the chemical “formic acid” that causes ant bites to sting. People intoxicated with stimulants, such as cocaine and methamphetamine, and persons under-the-influence of hallucinogens, such as LSD and PCP, sometimes feel like they have bugs crawling all over them. This is different than delusional parasitosis because the sensation resolves once the drug is out of their system.

640px-Crack_street_dosage

Crack cocaine. A common cause of substance-induced formication.

Morgellons Disease is now considered by most physicians to be a subtype of delusional parasitosis. Instead of delusions of insects crawling under the skin, people with Morgellons suffer from a belief that painful or itchy fibers are erupting from their bodies. Some people with this condition believe that they are contagious, whereas others suspect that they have been inoculated with nanofibers (or microfibers) by the government or by space aliens. The following ABC Nightline clip (courtesy of YouTube) is an interview of the original Morgellons patient, who also is the person who coined the term “Morgellons” in the contemporary context.

I was highly reluctant to put the link to this YouTube video here for reasons that will be obvious after you watch it. I felt significantly less equivocal about it after I learned that the “founder” of this disease is running a website that sells purported “natural cures” for Morgellons, and a lot of other conditions that are of questionable medical veracity. Still, I wish that the kids weren’t in the video… With that said, the video is highly educational on several levels, and even more so in 20/20 hindsight, both for healthcare providers and for laypeople, which is why I have reluctantly decided to share the link.

This video was produced before a pivotal 2008 CDC study failed to reveal a medical (other than psychiatric) etiology of the Morgellons syndrome. The results were published in 2012 — see Reference #4 below. The CDC researchers scoured the medical records of 2.8 million Kaiser Permanente patients, Kaiser being an HMO that is known for good record keeping and that commands a large percentage of the healthcare market in Northern California, an area with a high concentration of possible Morgellons sufferers. The researchers identified 115 patients who met the criteria for possible Morgellons. Of these patients, 41 chose to participate in the study, which was designed to help determine if Morgellons was a new disease or not.

In summary, after an exhaustive study the CDC did not find evidence of a new disease entity. The fiber samples taken from patients with purported Morgellons disease were found to be mostly cotton fibers of the type found in clothing, etc. Most of the patients in the study also had comorbid psychiatric conditions and/or substance abuse problems. This study is a really good example of how the CDC investigates a potential new disease and it is an excellent read if you are into reading that kind of thing (and probably remarkably boring to you if you aren’t into reading medical studies!). Please note that this study absolutely does not say that folks with “Morgellons” symptoms do not have a disease. It just suggests (indirectly) that the condition that they suffer from is a subtype of delusional parasitosis, which is a highly disabling disorder that is potentially treatable with psychotherapy and with medications, particular with a drug called pimozide that is both an antipsychotic drug and a potent antipruritic (anti-itch) medication.

Finally, Neurogenic Excoriation Disorder is a form of Obsessive-Compulsive Disorder (OCD). It usually starts with a person who suffers from both acne and from OCD. People afflicted with OCD have obsessions — disturbing and recurring thoughts — that can be temporarily alleviated by performing a compulsive act, such as excessive hand washing or, in the case of neurogenic excoriation disorder, skin picking. The bad news is that OCD can be highly disabling. The good news is that it is highly treatable with a combination of counseling and psychiatric medication. The medication of choice is generally a member of the SSRI class of antidepressants, which are among the most commonly prescribed medications in the United States and which have an excellent safety profile. Trichotillomania is a related condition in which sufferers feel compelled to pull their hair out (and they do — see image below).

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An image of a person suffering from neurogenic excoriation disorder.

Trichotillomania_1

Trichotillomania.

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 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. Morgellons disease: Managing a mysterious skin condition. http://www.mayoclinic.org/morgellons-disease/art-20044996?pg=1.

2. Gupta, AK. Psychocutaneous Disorders. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Lippincott Williams & Wilkins, Philadelphia, PA. 2009.

3. CDC. Study of an Unexplained Dermopathy. http://www.cdc.gov/unexplaineddermopathy/

4. Michele Pearson, et al. Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0029908.  Published: January 25, 2012. DOI: 10.1371/journal.pone.0029908

5. Scabies Image: Walker, Norman Purvis () An introduction to dermatology (3rd ed.), William Wood and company Retrieved on 26 September 2010.

6. Scabies Mite (Electronmicrograph): Author: Kalumet. Date: 06.11.2004. http://commons.wikimedia.org/wiki/File:Sarcoptes_scabei_2.jpg.

7. Neurodermatitis, Wikipedia Image: “Factitious dermatitis” by Neeraj Varyani, Sunny Garg, Garima Gupta, Shivendra Singh, and Kamlakar Tripathi. – This image in Case Reports in Psychiatry Volume 2012 (2012), Article ID 674136, 3 pages doi:10.1155/2012/674136 Case Report Trichotillomania and Dermatitis Artefacta: A Rare Coexistence. Licensed under CC BY-SA 1.0 via Wikimedia Commons – http://commons.wikimedia.org/wiki/File:Factitious_dermatitis.jpg#/media/File:Factitious_dermatitis.jpg.

8. Excoriation Disorder: http://en.wikipedia.org/wiki/Excoriation_disorder#/media/File:Derma_me.JPG

9. Crack Cocaine: Uploaded: March 6, 2005 by David.Monniaux. http://en.wikipedia.org/wiki/Crack_cocaine#/media/File:Crack_street_dosage.jpg.

10. Alien Fibers: Morgellons Disease – ABC’s Nightline. Uploaded August 25, 2011. https://www.youtube.com/watch?v=xsiJpuARHcE.

11. John Y.M. Koo. Dermatitis Artefacta. http://emedicine.medscape.com/article/1121933-overview.

12. Trichotillomania Image: http://commons.wikimedia.org/wiki/File:Trichotillomania_1.jpg.

 

Tis the Season to be Jolly, Unless You’re a Heart!

Like many of you, the holidays are my favorite time of the year. Unfortunately, our hearts aren’t quite as keen on the occasion. So what with all the ballyhoo over Ebola — and not to worry, we’ll be back with scary infectious diseases with my next posting — let’s talk about something that might actually kill you or one of your loved ones this year. How’s that for the Christmas spirit!

The_Santa_Clause[1]SONY DSC
Popular culture — possibly part of the problem??? But oh so much fun!

The holiday season, especially the time between Christmas Day and New Year’s Day, carries with it an increase in cardiac death. The reasons for this are still somewhat debatable, but an interesting 2004 study published in Circulation attributed the effect at least in part to the duel threat of increased stress and a delay in people seeking medical care. This makes a lot of sense as we already know that the most common time of day for suffering a heart attack is in the morning due to levels of stress hormones, specifically corticosteroids, being highest at that time of the day. This increase in stress hormones increases strain on the heart and makes it more likely that a plaque in a coronary (heart-feeding) artery will rupture and cause the heart tissue that it feeds to die — a heart attack (myocardial infarction). Furthermore, hospital workers from coast-to-coast invariably will attest to the fact that the holidays are usually a slow period around the hospital. Since it’s safe to assume that this isn’t because Christmas and New Year’s Eve don’t magically make people less sick it logically follows that sick people must be putting off going to the hospital on these important family holidays. Unfortunately, ignoring a bad situation, especially a heart attack, is the one sure way to transform it into worse news, the take home message being that if grandpa is feeling sick at the Christmas party you should really put his butt into the car and drive him to the nearest ER for evaluation whether he likes it or not.

640px-The_Waltons_1974

I ain’t need no doctor. What I need is some a’ this bacon off a’ this ole hog!

Holiday Heart is another interesting holiday phenomena. Holiday Heart is an irregular heart rate that classically affects otherwise healthy young people after a drinking binge. The exact causation is unknown, but excessive alcohol (and it generally takes A LOT) consumption somehow screws with the conduction system of the heart and can push it into a pathologic rhythm called atrial fibrillation. Recall the normal conduction system of the heart, which is nicely reviewed in this diagram (don’t be lazy, it only takes 10 seconds to get it).
2018_Conduction_System_of_Heart[1]

The normal conduction system of the heart is illustrated by the yellow arrows. The electrical current flows from the SA node (the pacemaker of the heart) down the atria to the AV node and then to the ventricles. The electrical current causes the muscle cells of the heart to contract. This system allows the atria (top of the heart) to contract first, filling the ventricles, which then contract slightly later to pump blood to the rest of the body. Venous blood from the body flows into the right atrium (located on the upper left-side of the diagram — medical diagrams are drawn as if you were facing the patient) which then pumps blood to the right ventricle ,which then pumps blood to the lungs where it is oxygenated. Blood from the lungs flows back to the heart via the pulmonary veins, which empty into the left atrium (upper right hand corner of the diagram — again, imagine that you are facing the patient). The left atrium dumps its blood into the left ventricle which then contracts to pump blood to the entire rest of the body.

Heart_conduct_atrialfib[1]

In atrial fibrillation the electrical current in the atria goes totally screwy. Instead of moving in one direction, from the top of the atria to the AV node and then on to the ventricles, the electrical current in atrial fibrillation zips around the atria every which way. So instead of a nice regular current reaching the AV node (and then the ventricles) every second or so, the heartbeat in atrial fibrillation sometimes skips beats and sometimes goes really fast. The skipping beats is usually what scares people enough to go to the ER, but it’s actually the speeding up of the heart, which sometimes last just a few seconds but sometimes can last hours, that is really dangerous and that can even cause the heart to fail.

The good news about Holiday Heart is that it usually self-resolves (goes away on its own) within about 24 hours. The bad news is that if it doesn’t resolve within less than about 24-48 hours then the treatment is anticoagulation followed by electrical cardioversion. Electrical cardioversion is shocking the heart back into a normal rhythm with electrical pads, and you have to be anticoagulated first because the irregular rhythm of atrial fibrillation (if it persists) predisposes the body to forming blood clots in the heart. Shocking a heart with a big honking blood clot hanging out in the atria back into a regular rhythm is a bad idea because it can dislodge the clot and cause a massive stroke. This is the reason why most people (generally the elderly) who have chronic atrial fibrillation have to be on lifelong anticoagulation.

Warfarin_bottles_NIGMS
The most commonly prescribed anticoagulant for patients with chronic atrial fibrillation, Coumadin is both an extremely nasty drug and a drug that has prevented untold thousands of strokes. As with any medical intervention, it’s all about risks vs. benefits. Interestingly enough, Coumadin is also used in very high doses as rat poison. Rats are very intelligent creatures and it is difficult to design a poison that they don’t recognize and start avoiding after a few rats have died from eating it. Coumadin and its related compounds avoid this by slowly poisoning rats over time. The rats eventually bleed to death, but it takes way too long for the them to be able to identify the source of the poison. Coumadin works by inhibiting vitamin K, which is used by the liver to produce the clotting factors that exist in blood and that are activated when the body suffers damage that causes bleeding. One of the most common treatments for inadvertent Coumadin overdoses in humans is vitamin K, which is generally orally administered in present clinical usage.

Finally, I would be remiss not to briefly address heart failure exacerbations, which are extremely common around the holidays. Recall that blood from the body returns to the heart after delivering its oxygen through the veins. Heart failure occurs when the heart is unable to effectively pump the blood that is returning to it back to the body. Heart failure is failure of “the pump” and this causes fluid (blood and blood plasma) to back up into the lungs (left-sided heart failure), the body (right-sided heart failure), or both (combined heart failure). Patient’s with known heart failure are treated with medications that help the heart to fill with blood better, to pump blood more efficiently, and with diuretic drugs to decrease the amount of excess fluid and salt in the body (fluid follows salt in the body via the principle of osmosis; more salt retention = more fluid retention). The holiday cheer, with all of its salty foods and free-flowing goblets often results in a heart failure exacerbation for sufferers of this disorder who carelessly imbibe excessively.

Combinpedal

Pitting edema. A classic sign of a right-sided or combined heart failure exacerbation that is caused by the accumulation of excessive fluid and salt in the peripheral tissues. The most common cause of heart failure exacerbations is failure to adhere to salt and fluid dietary restrictions (medication noncompliance is a close runner-up).

Doc’s fiction and nonfiction books are on sale for the holidays. 99 cents on Kindle and sharply discounted in paperback as well. Click on the book covers and check them out! Thanks for reading!

The Life of a Colonial FugitiveIntrusive Memory E-Covershutterstock_97052615The Cannabinoid Hypothesis

 

Dr. Leonardo Noto

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. The Santa Clause: http://en.wikipedia.org/wiki/The_Santa_Clause#mediaviewer/File:The_Santa_Clause.jpg.

2. Milk and Cookies: English: This photo was taken by Evan-Amos as a part of Vanamo Media, which creates public domain works for educational purposes. Please visit my other galleries and projects for other free media. http://commons.wikimedia.org/wiki/File:Oreos-%26-Milk.jpg

3. The Waltons: http://en.wikipedia.org/wiki/Will_Geer

4. Philips, David et al. Cardiac Mortality Is Higher Around Christmas and New Year’s Than at Any Other Time. Circulation. 2004;110:25 3743.

5. Electrical Conduction System of the Heart: http://commons.wikimedia.org/wiki/File:2018_Conduction_System_of_Heart.jpg. Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.

6. Atrial Fibrillation Image: http://commons.wikimedia.org/wiki/File:Heart_conduct_atrialfib.gif. Content: Skizze Erregungsleitung im Herzen bei Vorhofflimmern
author: J. Heuser –~~~~ {{GFDL-self}} Category:Physiology Category:Heart

7. Coumadin: http://commons.wikimedia.org/wiki/File:Warfarin_bottles_NIGMS.jpg

8. Pitting Edema: James Heilman, MD. http://en.wikipedia.org/wiki/Acute_decompensated_heart_failure#mediaviewer/File:Combinpedal.jpg

 

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!

Polymicrogyria_arrows[1]

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!

Visible_Human_head_slice[1]

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.

 

blood-brain-barrier[1]

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.

Wikipedian_getting_a_lumbar_puncture_(2006)[1]

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.

Acral_gangrene_of_digits_-bubonic_plague[1]

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!

 Streptococcus_pneumoniae_meningitis,_gross_pathology_33_lores[1]

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.

Meningitis,_boy_of_eleven_1911-12[1]

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.

Steroids, EPO, and Other Performance Enhancing Drugs – On Creatine, Whey Protein, HMB, and Nitric Oxide Boosters. Part 3 of 3.

In the final installment of our series on performance enhancing drugs (PEDs) we’re going to shift our focus off of illicit PEDs and spend some time discussing legal PEDs, you know, the kind of PEDs that you see lining the shelves every time you stroll down the aisles of a Wal-Mart pharmacy.

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The Wal-Mart supplement aisle (a very small portion of it).

Whey Protein: Whey protein is one of the two major proteins that are found in cow’s milk. When milk is allowed to curdle the whey separates from the rest of the milk (the curds) and forms a watery layer on top. In short (I’m not an expert on cheese production!), whey protein is produced by pouring the whey off of the curds and then by drying it into a powder. Proteins, including whey protein, are digested in the human gastrointestinal tract into amino acids, which are then absorbed by the body and used to make new body proteins. Muscle is primarily composed of protein and water and dietary protein is essential if you want your muscles to get bigger and stronger.

 01_save_whey_3_P3120306md[1]

Separating the curds from the whey — like Little Miss Muffet.

Whey protein is prized by athletes for two reasons. First, it is easily digestible which means that whey protein goes from mouth, to stomach, to bloodstream, to muscles faster than just about any other protein on the market. This is really important because the muscles able to take up greater amounts of amino acids than they normally are during the first two hours after exercise. Athletes take advantage of this by drinking a protein shake within this time periods. Most of these protein shakes are also very sugary and the reason for the sugar is to cause an insulin spike. Insulin is a hormone that is naturally produced by your pancreas (an organ that is located near the stomach) and higher levels of insulin further increase the ability of muscles to gobble up amino acids to turn into bigger and stronger muscles.

 

Whey protein is generally safe for people who have normally functioning kidneys and for people who do not have an allergy to milk or to milk products. The idea that high protein intakes are toxic to the kidneys is probably a myth, although I guess enough of anything (including water) is toxic if you truly take ungodly amounts.  The whole “protein is harsh on the kidneys” urban myth stems from the fact that people with failing kidneys are unable to appropriately excrete the metabolic byproducts of protein and these byproducts can buildup to dangerous levels in these people (especially in people whose kidneys are so bad that they are on dialysis). I don’t know very many athletes with chronic or end-stage kidney disease and I think that it is safe to assume that whey protein is perfectly safe in most people. I have a bottle sitting in my cabinet right now! One quick caveat: if you’re lactose intolerant you can take whey protein but you’ll probably wish that you hadn’t (GI upset/severe flatulence) unless you take lactase with it. Lactase is an over-the-counter enzyme that breaks down the lactose (milk sugar) that people with lactose intolerance have trouble digesting. People with true milk allergies should never take whey protein and people with any food allergy should talk to their doctor before starting any nutritional supplement in general because you never know!

 Patient_receiving_dialysis[1]

A person with end-stage kidney disease receiving dialysis. Dialysis involves running a persons blood through a machine that is essentially an artificial kidney. The dialysis machine removes the waste products from the patient’s blood that their kidneys are no longer capable of processing. The procedure is rather miserable and has a high long-term mortality rate (due to immunosuppression, electrolyte imbalances, etc., etc., etc.).

Creatine: Is naturally found in muscle tissue in the form of creatine phosphate. Creatine phosphate is a backup fuel that your muscles use when they run out of their primary fuel, ATP, and it allows the muscles to contract for just a little bit longer than they normally would be able to when the body is really exerting itself. A good example of how the creatine phosphate backup system is useful in nature is to imagine two tigers fighting. If tiger “A” has plenty of creatine in his system and tiger “B” doesn’t then tiger “A” is able to keep fighting (or to run away) for 30 seconds or so longer than his opponent, an evolutionary safety mechanism that could understandably mean the difference between surviving a dangerous situation or becoming tiger food in the not very distant past!

 jacked[1]

Creatine may give you arms like this…if you combine it with ungodly amounts of anabolic steroids, growth hormone, exogenous insulin, cosmetic oil injections, etc. For the record, I think this dude looks clownishly terrible, but to each his own I guess…

In the early 90’s someone got the bright idea that packing your muscles full of more creatine than they naturally contain might improve athletic performance and, for sports that require short bursts of intense activity followed by periods of rest (e.g. American football and weightlifting) creatine does seem to provide some benefit. Creatine also appears to be anabolic, resulting in muscle growth, and this is possibly due to its osmotic effects — sucking greater quantities of water into muscles than would naturally be there, therefore making them bigger. The evidence is fairly robust in supporting that creatine both improves an athlete’s ability to perform a short burst activity (like lifting a heavy weight or pushing an opposing lineman) and causing muscles to become larger. Creatine is not useful in endurance activities and it is actually detrimental to endurance athletes because it predisposes them to dehydration.

4.1.1

Allowing yourself to get dehydrated during summer football camp is a good way to experience this firsthand.

Creatine appears to be safe for most athletes. Like protein, creatine should not be used by people with kidney problems because its metabolic byproduct, creatinine, can’t be excreted into the urine of people with chronic or end-stage (on dialysis) kidney disease at a high enough rate to prevent it from building up in the bloodstream. The idea that some doctors still promote that creatine is toxic to the kidneys stems from the fact that creatinine is used as a proxy for kidney damage by physicians. In order to assess how well the kidneys are working doctors draw blood and look for the level of creatinine that it contains. Creatinine is not known to be directly toxic to the body, it just happens to be a convenient marker of kidney function because we all naturally have creatine in our muscles that is naturally broken down to creatinine and then excreted into the urine at a fairly steady rate. If someone’s creatinine starts rising on their blood tests then doctors know that the kidneys aren’t working very well. The problem with creatine is that it screws up this test! The creatinine blood test is based on the assumption that you have a fairly steady amount of creatine in your muscles and that any increases in the blood levels of creatinine are due to your kidneys not excreting creatinine. Athletes throw a wrench into this whole equation by increasing the amount of creatine in their muscles which then results in elevated levels of creatinine that throw off the lab test!!!

c767d9a6[1]

Medical shorthand for a basic metabolic panel (BMP) and a complete blood count (CBC), two of the most common blood tests that doctors order. Creatinine, the metabolic byproduct of creatine, is found in the lower panel on the bottom row (third from the right).

There is no (good) evidence that supplemental creatine is toxic to the kidneys but common sense would tell you that people with kidney diseases or with other diseases that predispose them to developing kidney diseases (e.g. people with high blood pressure or diabetes) probably shouldn’t take something that is going to mess up the test that their doctors use to monitor their kidney function. With that said, as far as we know (remember, creatine has only been in widespread use for about 20 years) creatine is perfectly safe for most athletes.

Creatine is not without real side-effects and the most common of these are GI upset (it pulls water into the gut and can give you diarrhea) and dehydration (both from diarrhea and because creatine sucks water into the muscles). Anyone who has chosen to take creatine should be obsessive about staying well-hydrated, especially football players who practice for long hours under the summer sun.

Nitric Oxide Boosters: Are primarily marketed to men with erectile dysfunction and to athletes, which may seem a little bit counterintuitive since the erectile problem that most male athletes have is that they are excessively horny. Nitric oxide boosters are actually just the amino acid L-arginine, which is found in most proteins that you eat whether the protein is coming from milk, meat, beans, or whatever. In addition to being used by the body to make new proteins for your cells, the body also digests some L-arginine to make nitric oxide, a compound that causes your blood vessels to dilate (i.e. to relax and become wider). Since blood vessel dilation is what allows the penis to fill with blood to produce an erection, these supplements are often sold to men as an over-the-counter alternative to prescription erectile dysfunction drugs like Viagra (which also work via nitric oxide, FYI).

 enzyte-tshirt-swelling[1]

This is “Smiling Bob,” the notorious pitchman for a purported nitric oxide booster. The guys selling this product got into a lot of trouble with The Feds for refusing to let people cancel their recurring subscriptions without a doctors evaluation stating that the dietary supplement didn’t enhance their sexual performance!

The idea behind marketing nitric oxide boosters to athletes is two-fold. First, taking a nitric oxide booster before lifting weights can allow a greater muscle “pump” and the greater stretch on your muscle cells when a muscle is gorged full of blood is thought to provide a stimulus for growth, partly via the stretch and partly because greater blood flow to a muscle also means that more oxygen and nutrients are getting to the said muscle. Second, taking nitric oxide boosters after exercise is hypothesized to allow nutrients (i.e. the nutrients from the post-workout protein shake) to reach the muscles because all of these nutrients ultimately get to the muscles via the bloodstream.

Nitric oxide boosters are relatively new on the market (in widespread use for about 10 years) and their efficacy for both erectile dysfunction and for athletes who are trying to build muscle is highly debatable and needs more study. With that said, I think that it is quite reasonable for anyone with issues with blood pressure in general and low blood pressure in particular to avoid potentially vasodilating nutritional supplements, like nitric oxide boosters, like the plague. The same also goes for people with heart conditions. I also think that taking these supplements before a workout with heavy weights is probably not the greatest idea because passing out from having a low blood pressure with a 425lb weight on your back doesn’t sound like a very good day to me—SPLAT!!! It is a really bad idea to combine one vasodilating substance with another one, e.g. combining a nitric oxide booster with alcohol or with your blood pressure medications. In short, if you’re not perfectly healthy I wouldn’t even consider taking one of these supplements without talking to your physician first, and even if you are in great health it’s still probably a good idea to run it by your doc.

 0[1]

A severe weightlifting accident that occurred during the Beijing Olympics (I sincerely hope that he was okay) and a poignant reminder that putting a huge amount of weight on your back can be really dangerous!

HMB: Is a derivative of the amino acid leucine that is naturally found in most of the proteins in your body and in most of the proteins in your diet (which is where your body gets it from in the first place!) HMB appears to be anti-catabolic to muscle tissue and possibly anabolic as well. There are two main metabolic processes at play in your muscle tissues at all times, anabolism and catabolism. Anabolism is, in simplified terms, muscle growth and catabolism is muscle breakdown. The balance between anabolism and catabolism determines whether your muscles are getting bigger (anabolism > catabolism), staying the same (anabolism = catabolism), or shrinking (anabolism < catabolism). Both processes are essential because your proteins contain lots and lots (millions upon millions) of individual proteins and old proteins are constantly wearing out, requiring them to be digested (catabolism) and replaced with new proteins (anabolism). HMB seems to slow the rate of muscle breakdown and to possibly enhance the rate of muscle protein buildup as well.

Currently it looks like HMB probably works, although the effect isn’t massive or super quick like some of the illicit PEDs (the same is true of creatine, which has a modest effect when compared to anabolic steroids). There are no known side-effects of HMB at present. However, unlike creatine, which has been used by millions of people, HMB is a more esoteric supplement due to its rather hefty price. Please see my “word to the wise” below before considering using any of the nutritional supplements described in this article and please also consult with your physician before use.

A Word to the Wise: These four “nutritional supplements” (read: “legal PEDs”) are the main four that are currently available that actually work. There are a ton of others out there, mostly of questionable safety and efficacy. One final word on nutritional supplements that anyone who takes them should be well aware of: nutritional supplements are categorized as such because they are not regulated by The Food and Drug Administration (FDA). This means that none of these supplements are required to go through the safety and efficacy trials (studies to prove that the drug is safe and that it works) that substances that are officially categorized as drugs have to go through. Anyone can stick a label on a bottle of “substance X” and claim that it “may promote muscle growth,” or whatever. As long as “substance X” is found in nature and has not already been claimed by a drug company this is perfectly legal. Let’s just remember that poison ivy, tobacco, and cobra venom are all found in nature so buyer beware!  Let’s also remember that a lot of these supplements are produced in developing countries with questionable food safety practices—although it is rare, there have been cases of people getting seriously ill and even dying from contaminated nutritional supplements and even from nutritional supplements that were at one time perfectly legal to sell over-the-counter!!!

Mozambique-spitting-cobra-spitting-venom-at-scientist[1]

An image of a naturally-occurring substance, spitting cobra venom, and an example of the kind of person who necessitates me having a huge disclaimer at the end of every blog post (the stupidity of some people is truly amazing).

MY BOOKS!

The Life of a Colonial FugitiveIntrusive MemoryMedical School 101The Cannabinoid Hypothesis

 

REFERENCES:

Note: The first two links are to The National Institutes of Health’s excellent website, which provides an overview of the efficacy and side-effects of the most popular medications and nutritional supplements. The list is extensive but, due to the huge numbers of drugs and nutritional supplements, nonetheless incomplete. HMB is notably missing. The third link/reference is to an excellent academic review of the evidence regarding the efficacy and safety of HMB.

http://www.nlm.nih.gov/medlineplus/druginfo/natural/873.html

http://www.nlm.nih.gov/medlineplus/druginfo/herb_All.html

Wilson MJ, Wilson JM, and Anssi Manninen. Effects of beta-hydroxy-beta-methylbutyrate (HMB) on exercise performance and body composition across varying levels of age, sex, and training experience: A review. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2245953/  Nutr Metab (Lond). 2008; 5: 1.

Wal-Mart Supplement Aisle Image: http://www.flickr.com/photos/cleanwalmart/419584946/

Image of Separating the Curds from the Whey: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fbiology.clc.uc.edu%2Ffankhauser%2Fcheese%2FRicotta%2Fricotta_00.htm&h=0&w=0&sz=1&tbnid=WW6_E2hTfajyhM&tbnh=207&tbnw=244&prev=%2Fsearch%3Fq%3DWhey%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=Whey&docid=9yut4RCaXIMX0M&hl=en&ei=6kfjUcLsA4HoqgHYroFo&ved=0CAEQsCU

Person Receiving Dialysis: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fcommons.wikimedia.org%2Fwiki%2FFile%3APatient_receiving_dialysis.jpg&h=0&w=0&sz=1&tbnid=x_sU-AGSpaF2MM&tbnh=194&tbnw=259&prev=%2Fsearch%3Fq%3DDialysis%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=Dialysis&docid=xN-zOG-pqhyzUM&hl=en&ei=5knjUYv5F8usqAGOnoHIDg&ved=0CAEQsCU

Guy With The Really Bad Looking Arms/Creatine Joke: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fforum.bodybuilding.com%2Fshowthread.php%3Ft%3D144515111%26page%3D1&h=0&w=0&sz=1&tbnid=ym1n2WkA2QocvM&tbnh=212&tbnw=237&prev=%2Fsearch%3Fq%3DCreatine%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=Creatine&docid=jKDZvehaYMDchM&hl=en&ei=9krjUaHNDIHHrgHSyYGwDw&ved=0CAYQsCU

Ambulance Image: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fwww.nationmaster.com%2Fencyclopedia%2FStretcher&h=0&w=0&sz=1&tbnid=oAnQGPZLcM33lM&tbnh=218&tbnw=144&prev=%2Fsearch%3Fq%3Dambulance%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=ambulance&docid=IlLQQDQd1aASrM&hl=en&ei=Y0zjUdnjF5OCrQGtuYHwDg&ved=0CAQQsCU

Basic Metabolic Panel and CBC Image: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fwilliamchaseallen.com%2F&h=0&w=0&sz=1&tbnid=aS5JweRqFQ3QiM&tbnh=181&tbnw=278&prev=%2Fsearch%3Fq%3Dbasic%2Bmetabolic%2Bpanel%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=basic%20metabolic%20panel&docid=xrdDjx1BccjosM&hl=en&ei=G03jUf7IG7ObyAGJ54HIDQ&ved=0CAQQsCU#imgdii=_

Smiling Bob: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Foddculture.com%2Fweird-news-stories%2Fsmiling-bob-whistles-all-the-way-to-jail%2F&h=0&w=0&sz=1&tbnid=fg4jXqZDYd6bzM&tbnh=116&tbnw=116&prev=%2Fsearch%3Fq%3DSmiling%2BBob%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=Smiling%20Bob&docid=WBqPtBZ4eP64KM&hl=en&ei=QU7jUcOACorqrAGj-oDQAw&ved=0CAIQsCU

Weightlifting Accident: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DuI0Zl-tMRf4&h=0&w=0&sz=1&tbnid=EYPK1KbCnXbh4M&tbnh=194&tbnw=259&prev=%2Fsearch%3Fq%3Dsquatting%2Baccident%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=squatting%20accident&docid=_1etUQQ9VbUCjM&hl=en&ei=bk_jUa0oiNHLAfregbAH&ved=0CAEQsCU

Spitting Cobra Image: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fwww.arkive.org%2Fmozambique-spitting-cobra%2Fnaja-mossambica%2Fimage-G90055.html&h=0&w=0&sz=1&tbnid=XXGemoMN1jCX1M&tbnh=184&tbnw=275&prev=%2Fsearch%3Fq%3DSpitting%2Bcobra%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=Spitting%20cobra&docid=PkXecPFnBpwWzM&hl=en&ei=I1DjUYO6OsKcqgHQvYCgBA&ved=0CAUQsCU

Dr. Leonardo Noto

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

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 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 necessarily 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.

Steroids, EPO, and Other Performance Enhancing Drugs – On Lance Armstrong, Barry Bonds, and American Culture. Part 2 of 3.

Okay, I’m back. Wow, it’s been nuts around the hospital but life is good. Doc made a diagnosis that was missed by one of the top hospitals in the world during his absence (tooting own horn — TOOT!!!!), so I haven’t been entirely slacking. Anyway, let’s knock out Part 2 of our series on performance enhancing drugs so that we can roll on to other subjects before I’m old enough to star in Viagra commercials.

EPO: Erythropoietin (EPO) is perhaps the most notorious performance enhancing drug on the market today, and for good reason. EPO is a naturally occurring hormone that is produced by the kidneys and that causes the bone marrow to make more red blood cells. Red blood cells are essentially sacks full of the protein hemoglobin, an iron-containing protein that carries oxygen from your lungs to the rest of your body including your muscles. Not surprisingly, EPO is abused by endurance athletes (e.g. Lance Armstrong) to increase their aerobic capacity: more red blood cells –> greater oxygen reaching the muscles –> increased ability to run a marathon or to pedal away in the Tour de France.

iyer-fig2[1]

This is a popular brand of synthetic erythropoietin.

The downside of this is that red blood cells are also the primary determinants of the blood’s viscosity, e.g. how thick it is. Syrup drips more slowly than water because it is more viscous and thicker blood behaves according to similar principles. Slower moving blood is more likely to clot so people who abuse EPO are setting themselves up for a stroke or a pulmonary embolism — conditions that are (most commonly) caused by blood clots in the brain or the lungs, respectively.

saddleembolus[1]

This is a particularly nasty type of pulmonary embolus (blood clot in the lungs) called a “saddle embolus” seen at autopsy in the lungs of a deceased person that it killed. A saddle pulmonary embolus usually forms in the large veins of the legs or pelvis, breaks loose, travels through the heart, and then becomes stuck in the junction of the pulmonary arteries. The pulmonary arteries carry blood from the right-side of the heart to the lungs where the blood becomes oxygenated, travels back to the left-side of the heart, and is then pumped to the rest of the body. Saddle emboli block blood flow to the lungs and often result in sudden death.

One quick factoid about red blood cells and hemoglobin: iron turns reddish when it is bound to oxygen. Hemoglobin is an iron containing protein (the reason why low iron causes anemia) and the binding of oxygen to hemoglobin is the reason that blood is red. This principle is also the reason why rust is red colored — rust is iron that has bound to oxygen!

images[11]Blood_Smear_Texture_by_Thestrange87[1]

An image of a car covered by a thin layer of rust next to an image of a thin blood smear. Interestingly, oxidized iron in the soil is also the reason why the planet Mars is red!

 

By the way, a legal way that athletes increase their red blood cell mass is by training at high altitude for weeks to months before a competition. The low oxygen concentrations at altitude cause the concentration of oxygen that reaches the kidneys through the bloodstream to go decrease. The kidneys respond by pumping out EPO and this causes the bone marrow to naturally produce more red blood cells, red blood cells that stick around in the circulation for up to 120 days (on average) after they are produced.

The type of EPO that is abused by Lance and friends is a synthetic hormone that was designed for medical uses. Synthetic EPO has important medical uses in patients with severe kidney disease (dying kidneys can’t produce EPO) and in patients with failing bone marrows (it makes the marrow that is still viable work harder). Even in patients who absolutely need EPO it still increases the risk of blood clots, stroke, and pulmonary emboli so EPO is used much more cautiously in the hospital these days than it was in the past.

Since EPO is detectable on the specialized drug screens that are used by big name competitions like The Olympics and The Tour de France, this has led to an ingenious and medically horrifying (to doctors) alternative method of  increasing red blood cell mass by some athletes. These geniuses actually draw out some of their own blood weeks or months in advance of a competition and then store it in a freezer (usually with the help of a crooked doc). This time lag gives their body plenty of time to naturally replace the blood that is now sitting in the freezer. Come competition week the blood is unfrozen and given back to the athlete as a transfusion, a remarkably dangerous medical procedure to perform without medical supervision because improperly stored blood breaks down (partially) and releases all sorts of cytokines (chemical messengers) and electrolytes — including potentially fatal high concentration of potassium that can cause the heart to stop via the same principle that potassium chloride injections (when given quickly and in a high dose) cause cardiac arrest in felons condemned to the death penalty! And that’s on top of the risk of blood clots that go along with having too many red blood cells floating around, not even to mention the risk of infection from an improperly performed transfusion, or the risk of death from a transfusion reaction if the athlete accidentally gives themselves their buddy’s blood that happens to be of a different blood type.

article-1299787-0A8D0A22000005DC-317_468x345[1]

Preparing for a blood transfusion in the hospital, a potentially dangerous medical intervention even under the best circumstances.

Well that’s it for today, guys and gals. “Medical School 101” is free for Kindle right now (until Sunday 14 JUL 2013) so tell your college kid to go grab a copy while the getting is good!

Doc’s Books!

Medical School 101The Life of a Colonial FugitiveIntrusive Memory E-CoverThe Cannabinoid Hypothesis

 

Dr. Leonardo Noto

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

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

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

The opinions voiced on this medical blog are solely the author’s own and they do not necessarily 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.

Images:

Procrit: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fwww.jyi.org%2Fvolumes%2Fvolume11%2Fissue6%2Ffeatures%2Fiyer.php&h=0&w=0&sz=1&tbnid=bYJj98B-P97w1M&tbnh=195&tbnw=259&prev=%2Fsearch%3Fq%3DEPO%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=EPO&docid=YKPULwSlZdXU_M&hl=en&ei=G-viUYa_DIarqgGOu4HQDg&ved=0CAQQsCU

Saddle Pulmonary Embolus: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fcmspath.edu%2Frfc%2Fassign%2Fhemodynamic-1112.htm&h=0&w=0&sz=1&tbnid=VBuomKoweNkvaM&tbnh=275&tbnw=184&prev=%2Fsearch%3Fq%3Dpulmonary%2Bembolism%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=pulmonary%20embolism&docid=SQ5AK4M0CEuDWM&hl=en&ei=DuziUdKpHZOCrQGtuYHwDg&ved=0CAcQsCU

Rusted Car: http://www.google.com/imgres?imgurl=&imgrefurl=http://zaoxinwei.com/effective-ways-to-lessen-the-effects-of-car-rust.html&h=0&w=0&sz=1&tbnid=ws6c0VGkofyvRM&tbnh=183&tbnw=276&prev=/search%3Fq%3Drust%26tbm%3Disch%26tbs%3Dsur:fc%26tbo%3Du&zoom=1&q=rust&docid=1kicy65rc4aWbM&hl=en

Blood Smear: http://thestrange87.deviantart.com/art/Texture-Blood-Smear-126563713

Blood Transfusion: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fwww.bioedge.org%2Findex.php%2Fbioethics%2Fbioethics_article%2F10117&h=0&w=0&sz=1&tbnid=5QUUQQTMZReRnM&tbnh=193&tbnw=262&prev=%2Fsearch%3Fq%3Dblood%2Btransfusion%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=blood%20transfusion&docid=eA8WQ4vWAQrlkM&hl=en&ei=RO_iUYOpEIadrgHnzIDYDg&ved=0CAgQsCU

 

Steroids, EPO, and Other Performance Enhancing Drugs – On Lance Armstrong, Barry Bonds, and American Culture. Part 1 of 3.

Before we get started, let’s begin by defining a few basic terms to make sure that we understand them before we dig any deeper. Oh, as an aside, “The Cannabinoid Hypothesis” is free on Kindle from 19 JUN 2013 to 23 JUN 2013 so grab a copy if you like dark medical fiction!

Hormone – A long-acting chemical messenger. A hormone is like a biochemical “office memo” that is produced by an organ somewhere in the body, travels through the bloodstream to reach the “mailbox” of a distantly located target organ, and then tells the target organ what to do. For instance, the biochemical messenger thyroid stimulating hormone is produced by the pituitary gland (a pea-sized gland in your brain), travels through the bloodstream to the thyroid gland (located in your lower neck), and then tells the thyroid gland to produce thyroid hormone – a hormone that has a plethora of effects including regulating your metabolism.

Hormonal Cascades – You’ll notice that both thyroid stimulating hormone (TSH) and thyroid hormone are hormones (thanks genius, right?). Thyroid hormone travels from the thyroid gland through the bloodstream and then acts on just about every other organ in the entire frickin’ body. This is a common and important theme. Most hormones act in cascades (hormone A effects the production of hormone B, hormone B effects the production of hormone C, etc.) and some of these cascades can be really long and complicated – don’t worry, this is a blog not a textbook and we’re going to stick with the meat and skip the potatoes! Knowing what a hormone is and what a hormonal cascade does is important because most of the performance-enhancing drugs (PEDs) that we’re going to discuss today are hormones.

One final comment/disclosure: I strongly believe that criminally prosecuting (persecuting?) the average Joe for using PEDs is a gross violation of personal liberties and, frankly, an irrational policy. I absolutely do not advocate the recreational use of any of these substances and I DO believe that athletes who surreptitiously use PEDs to gain an unfair advantage over their competitors should be severely punished for the same reason that a baseball player who corks his bat should be punished – it’s cheating. With that said, putting Moe the College Kid in jail for using steroids to get bigger biceps doesn’t make a lot of sense in my book – he’s not hurting anyone except for himself, and even that is debatable. And yet American society has no problem with Susie having a major elective surgery to enlarge her breasts and to reduce her nose, no problem with selling cigarettes at gas stations, and no issue with glamourizing boozing on national television during family programming like the Super Bowl…

Anabolic-Androgenic Steroids

Anabolic-androgenic steroids (AAS) cause muscle growth (“anabolism” roughly means “growth”) and also result in the development and accentuation of male sex characteristics (the androgenic effects—growing a beard, etc.). The term “steroid” simply refers to a common chemical structure/backbone that is shared by glucocorticoids, mineralocorticoids, and sex hormones – all of which are produced from choleSTEROL.  In other words, not all steroids are AAS – actually most aren’t. When your kid was prescribed steroids for his asthma exacerbation he was prescribed cortiocosteroids (aka: glucocorticoids), which are anti-inflammatory stress hormones that actually are catabolic (catabolic roughly means “causes tissues to shrink”). Mineralocorticoids are extremely important regulators of sodium, potassium, and blood volume while estrogens and progesterones are the female sex hormones.

So returning to AAS, these drugs are all derivatives of the major male sex hormones, DHT and testosterone. Because both DHT and testosterone are highly androgenic — causing acne, hair growth in generally unwanted places, and deepening of the voice (etc.) — drug companies in the early half of the 20th century tried to develop derivatives that would retain the anabolic properties of the natural male sex hormones minus the undesirable androgenic side-effects. Dozens of derivatives were produced and here is a listing of some of them (these are all injectable drugs; we’ll talk about oral AAS in a moment):

Nandrolone Decanoate (aka: Deca) – The closest that the drug companies have yet to come to a purely anabolic steroid that is void of androgenic properties. This drug was formerly very popular among athletes but it has lost favor because its metabolites are detectable in the body for up to 18 months. Unlike most AAS, nandrolone isn’t metabolized to estrogen. The reason that AAS abusers get bloated is because most AAS are converted to estrogens before they are eliminated from the body and, as every woman knows, estrogens cause bloating.

DECA_QV_300[1]

This is an image of a bottle of Mexican veterinary nandrolone decanoate (aka: Deca). The “300” on the label means that it contains 300mg of nandrolone decanoate per milliliter of the oil solvent. Nandrolone is injected intramuscularly.

Testosterone Cypionate and Enanthate – These drugs are simply testosterone that has been conjugated (chemically linked) to a fatty ester. The fatty ester makes the testosterone less soluble in body fluids for the same reason that a drop of fatty oil floats on the top of a glass of water. This slows the active testosterone’s release into the bloodstream. Testosterone that isn’t linked to a fatty ester needs to be injected every day because it is rapidly absorbed into the body after being injected. In contrast, testosterone esters are released over the course of 3 days to several months, depending on the size of the fatty ester, allowing them to be administered much less frequently than straight testosterone. Sustanon is a well-known form of testosterone that is a mixture of four different types of esterified testosterones – one of the esters is released rapidly (testosterone propionate – released over the course of 3 days or so), two of the esters hang around in the body for a few weeks, and the final ester has a half-life of 4-6 weeks (testosterone undecanoate).

These are just a few examples of the plethora of anabolic hormones that the pharmaceutical industry has developed over the decades, but they all have one major drawback, they must be injected and nobody likes to get a shot. The reason that you can’t take testosterone cypionate or nandrolone decanoate orally (at least not if you want it to work) is that these drugs are broken down by the liver before they make it into systemic circulation — in other words, before they reach the rest of the body. The drug companies solved this dilemma by chemically modifying testosterone derivatives via a process called 17-alpha-alkylation. What this means in English is that the testosterone derivative has been chemically modified to make it much harder for the liver to break it down – the downside of this is that 17-alpha-alylated drugs are toxic to the liver. A few examples of orally-active 17-alpha-alkylated AAS are D-bol (aka: dianabol), Anadrol, and Anavar. All of these drugs have the potential to seriously damage the liver.

 3956372_f260[1]

This is dianabol (D-bol) produced in Thailand — often referred to as “Thai pinks.” D-bol is a oral 17-alpha-alkylated anabolic steroid that is toxic to the liver. It also has a particularly high affinity for aromatase, the enzyme that converts some anabolic steroids to estrogen (but not all of them), resulting in the classic “moon face” and bloating of anabolic steroid users.

The medical uses of AAS include: 1. hormone replacement in men with disorders of the endocrine (hormone producing) system; 2. for a rare disease called hereditary angioedema; 3. to enhance healing in some surgical patients (especially severely burned patients); 4. and to encourage weight gain in people with wasting diseases like cancer and AIDS. AAS are generally pretty safe when used under a physician’s supervision, even when they are used for years and years without respite. Common side-effects include increased acne, increasing the rate of the benign enlargement of the prostate that naturally happens over time in all men, increasing the rate of hair loss on the scalp in men who are genetically predisposed to male pattern baldness, increased male pattern hair growth in places where most people don’t want it (the back, the shoulders, etc.), and a decrease in good cholesterol (HDL) with a simultaneous increase in bad cholesterol (LDL). These cholesterol abnormalities can increase the risk of heart disease if a person chronically uses AAS (we’re talking years to decades of use in most cases).

 hairy_back[1]

A bit of humor. While steroid use dose cause hair growth in undesirable places, including the back, this gentleman clearly has a genetic disorder of some sort (a bit of dark medical humor). Female users of anabolic steroids (yes, they do exist) can become masculinized and grow beards, an enlarged clitoris, etc.

Recreational users of oral AAS can cause liver cysts and these cysts can, albeit extremely rarely, rupture and bleed. On rare occasions this can be fatal, but the same side-effect can also occur (again, rarely) with birth control pills – orally-active female hormones. Oral AAS are toxic to the liver and prolonged abuse can absolutely cause liver damage. The biggest dangers of injectable AAS are infection due to poor injection technique, sharing needles (yes, I am aware that this is really uncommon among steroid users), and due to contaminated drugs straight from the factory – something that can occur with medications produced by reputable pharmaceutical companies but which is particularly a risk for illicit AAS users because many of the drugs that they use are actually veterinary drugs produced in shady factories in Mexico. Long term use of AAS causes the body to quit producing its own androgenic hormones. Since the testicles produce androgens in males, long term use (and/or abuse) of AAS causes your nuts to shrink! The common belief that AAS shrink the penis is not true, by the way.

287569669_0670f4d966_o[1]

Despite the widespread conviction in The United States that AAS abuse can cause cancer and “roid rage,” the scientific literature doesn’t confirm this and it probably isn’t true*. A very common “side-effect” of AAS abuse is muscle growth – anyone who tells you that they don’t work is either lying to you or has never opened the pages of a bodybuilding magazine while killing time in the checkout aisle at the grocery store. This muscle growth can actually be a problem in serious abusers of AAS because their muscles often grow faster than their tendons (the connective tissues that attach muscles to bones), predisposing steroid abusers to tendon ruptures – a potentially serious type of injury that can sometimes result in permanent disability. Other problems with walking around weighing 50 or 100lbs more than your body is naturally supposed to weight included an elevated blood pressure, strain on the heart, and premature joint damage that can lead to arthritis.

 Bicepstendon10[1]

A ruptured right biceps tendon — notice the balling of the right biceps compared to the left biceps.

As I said before, using prescription drugs without a physician’s supervision is a really bad idea. With that said, the common notion the AAS are deadly drugs that ruin lives is also largely a fiction. Used medically, AAS are very safe medications and even gross abuse rarely causes major health problems. Can abuse of AAS cause health problems? Absolutely! I’m just saying that most people who abuse these drugs most commonly suffer from rather minor side-effects at most and that the stereotypical portrayal of deadly “steroids” doesn’t have a very sound basis in scientific reality. If a patient came into my office and said, “Doc, I use steroids, I smoke (a legal poison), and I frequently drive around town with a blood alcohol level of 0.07 (very dangerous, but also legal) – which should I quit first for my health?” I’d tell him that quitting smoking was priority #1, quitting impaired driving was priority #2, and quitting AAS abuse was a distant third.

West_Coast_Daddy_Re_Morph_by_BigTeenBodybuilder[1]

In case you were wondering, yes, both of the bodybuilder images have been enhanced to make them look even more ridiculous — to each his/her own!

Okay, so that’s anabolic-androgenic steroids. Next time we’ll cover EPO (erythropoietin) and in Part #3 we’ll cover legal performance enhancing supplements including creatine, HMB, nitric oxide boosters, and whey protein. Hope to see you there!

*There have been a few studies that demonstrated increased emotional lability in AAS abusers. However, these studies suffered from small sample sizes and from numerous other flaws. One of the major problems with studying the mood effects of AAS abuse is that it’s safe to assume that most people who want to look like a bodybuilder in the first place have pre-existing psychiatric issues. Studying the emotional effects of AAS abuse in this patient population is sort of like studying the psychiatric effects of dieting using a sample of anorexics – you’d undoubtedly conclude that dieting causes severe psychiatric disturbances because everyone in your sample is already disturbed! AAS probably have some psychiatric side-effects; in fact, it would be rather shocking if they didn’t since people with high levels of male hormones (men) tend to be different psychologically than people with lower levels of these hormones (women). However, the psychotic “roid rage” syndrome is completely unproven and, in my experience, almost certainly a myth. There are over 1 million current and former abusers of AAS in The United States alone and “roid rage” attacks, while a convenient legal defense strategy in the courtroom, are about as common as Big Foot sightings – when is the last time that a legitimate one happened in your town, because I guarantee you that your town has steroid abusers living in it…

References:

Deca Image: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=bodybuilder&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=TpTDUczbCNPL0gG4v4HoCA#as_st=y&hl=en&tbs=sur:fc&tbm=isch&sa=1&q=nandrolone&oq=nandrolone&gs_l=img.3..0l10.70421.72422.0.72589.10.10.0.0.0.0.71.472.10.10.0.eqrwrth..0.0…1.1.17.img.ut8Pss9tOno&bav=on.2,or.r_qf.&bvm=bv.48175248,d.dmQ&fp=13dc04e8b48effa6&biw=922&bih=531&facrc=_&imgdii=_&imgrc=dL1dULNpDGqX7M%3A%3BO6GuoanSUrNvYM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252Fc%252Fc5%252FDECA_QV_300.jpg%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253ADECA_QV_300.jpg%3B405%3B586

Guy with Ridiculously Large Lats Image: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=bodybuilder&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=TpTDUczbCNPL0gG4v4HoCA#facrc=_&imgdii=_&imgrc=hZsOCJchxdDYYM%3A%3BBYZg-6aMeou4eM%3Bhttp%253A%252F%252Ffarm1.staticflickr.com%252F104%252F287569669_0670f4d966_o.jpg%3Bhttp%253A%252F%252Fwww.flickr.com%252Fphotos%252Fmawkroy%252F287569669%252F%3B550%3B367

Guy with Hairy Back Image: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Funiqueblogofawesome.blogspot.com%2F2012%2F07%2Fyou-crazy-little-coconuts.html&h=0&w=0&sz=1&tbnid=fqWDyLcy9RC-TM&tbnh=192&tbnw=256&prev=%2Fsearch%3Fq%3Dhairy%2Bback%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=hairy%20back&docid=jidzrZkryZisOM&hl=en&ei=8pPDUYHbMYbo8wS55ICACA&ved=0CAEQsCU

D-bol Image: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fhubpages.com%2Fhub%2FDianabol-Side-Effects&h=0&w=0&sz=1&tbnid=UEOCRGyduzQErM&tbnh=173&tbnw=208&prev=%2Fsearch%3Fq%3Dd-bol%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=d-bol&docid=hLK3uWlhS1cQPM&hl=en&ei=tpTDUZLCO4bs8wSyuoD4Cw&ved=0CAEQsCU

Bicep Tendon Rupture: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=bodybuilder&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1600&bih=752&sei=TpTDUczbCNPL0gG4v4HoCA#as_st=y&hl=en&tbs=sur:fc&tbm=isch&sa=1&q=tendon+rupture&oq=tendon+rupture&gs_l=img.3..0l9j0i5.2096.4771.2.4923.17.16.1.0.0.0.103.917.15j1.16.0.eqrwrth..0.0…1.1.17.img.3kvqHsEqgqA&bav=on.2,or.r_qf.&fp=13dc04e8b48effa6&biw=1600&bih=752&facrc=_&imgdii=_&imgrc=kOrcm-fbmFMy-M%3A%3B1Z0qBbmEyEePWM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F8%252F8d%252FBicepstendon10.JPG%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253ABicepstendon10.JPG%3B2970%3B2183

Guy with Ridiculous Pecs Image: http://bigteenbodybuilder.deviantart.com/art/West-Coast-Daddy-Re-Morph-164856324

 

Dr. Leonardo Noto

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

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

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

The opinions voiced on this medical blog are solely the author’s own and they do not necessarily 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.

Doc’s Books!

The Life of a Colonial FugitiveIntrusive Memory E-CoverMedical School 101The Cannabinoid Hypothesis

Screening Smokers and Former Smokers for Lung Cancer – Hot off the Press!

Note: The United States Preventative Services Taskforce recently decided to recommend screening smokers and former smokers as described in this article. The final guidelines are still being formulated, but a consensus has been reached and this is going to happen in the near future. Remember, you heard it here first!

Lung cancer is the #1 cause of death from cancer in the world and this lovely disease was exceedingly rare before cigarette smoking became widespread in the 19th century. If you are a smoker, a former smoker, or a person who has had prolonged exposure to secondhand smoke (e.g. bartenders, etc.) then you are at risk of developing and dying of lung cancer, a really terrible and often painful way to go. Even former smokers are at risk of this disease – as a general rule your risk of dying of lung cancer returns to “about” the level of a lifelong nonsmoker 20 years after you smoke your last cigarette, but it never actually returns to zero, with zero actually being pretty close to the chance of developing lung cancer in a person who has never smoked and who didn’t live or work in a smoky environment.

 3564450933_99daed43b2_o[1]

Like most cancers, catching lung cancer early greatly increases the chance that it will be curable, usually by surgical removal of the tumor, something that is essentially impossible in late stage lung cancers because by then the cancer has metastasized (spread) all over the body from its initial site. In order to treat an early stage cancer you have to be able to find it and that has been a major problem in lung cancer because the lungs aren’t exactly a part of the body that you can easily see in the mirror and early stage lung cancers are usually too small to cause any symptoms. By the time lung cancer is large enough to cause symptoms (weight loss, breathing difficulties, coughing up blood, etc.) it’s usually too late for physicians to do anything about it other than to treat the person with palliative support – i.e. to make them as comfortable as we can and to perhaps moderately prolong the inevitable.

 fatal-lung-cancer[1]

Screening tests are always a double-edged sword. If we wheeled every former smoker to the operating room and cracked their chest, examined their lungs from the outside, and then stuck a bronchoscope down the patient’s throat to examine the inner aspects of the lungs we probably could diagnose most lung cancers in the early stage. Obviously this is a bad idea because the risk of routinely doing this hypothetical screening procedure would outweigh the potential benefit – we’d detect a lot of early stage lung cancers but more people would probably die as a result of the screening procedure than we would save from cancer (not to mention that this method of “screening” would completely bankrupt our healthcare system and leave no money for interventions that actually make sense)!!! As such, the key to developing a good screening test to detect early stage cancers while they are still potentially curable requires that we develop a test in which the harms of the test are greatly outweighed by the benefits of performing the screening protocol. It also helps to develop a test that is affordable because the reality of life is that both money and medical resources are finite commodities – anyone who doesn’t think that rationing of healthcare isn’t both a reality of our current system and an essential aspect of it is truly a fool (everything in life is rationed except air, and even that isn’t true on submarines!).

The May 23, 2013 issue of the prestigious medical journal, The New England Journal of Medicine, reported the results of The National Lung Screening Trial which studied low dose CT scan as a screening method for lung cancer in smokers and former smokers. A CT scan (aka: CAT scan) is a machine that zaps your body with a bunch of X-rays from lots of different angles and then feeds the information from these X-rays into a computer which reconstructs them into a 3D image of, in this instance, your chest and lungs. In this 10 year study, which involved over 50,000 participants, low dose CT was compared to chest X-ray (a single X-ray instead of dozens) as a method of screening smokers and former smokers who were in their mid-50s to mid-70s for lung cancer – since chest X-ray had already proven to be a lousy way of screening for lung cancer they researchers were in effect measuring low dose CT screening vs. not screening for lung cancer.

 

The key to determining whether a screening test is worth its salt is determining whether the test provides a reduction in mortality (risk of dying). Chest X-ray had already proven not to reduce mortality so it should liven every smokers and former smokers day to learn that in this impressive clinical trial screening with low dose CT decreased mortality from lung cancer by 20%! That’s great news but don’t rush out and beg for a low dose CT scan quite yet because the ultimate verdict on using this diagnostic test for lung cancer screening is still out for several reasons. First, low dose CT scan detected most, but not all, of the lung cancers in the patients who were screened – 6% of lung cancers were missed by the screening test but that’s still pretty darn good. Second, even though “low dose” CT uses less radiation than full dose CT the procedure still zaps your body with a substantial amount of radiation which could conceivably induce a new cancer down the line. Since the people who were screened in this study were mostly older folks this is less of an issue than if low dose CT was being used for screening in younger people; nonetheless, it’s definitely a valid consideration because you never want a CT scan for any reason (because of the radiation) unless you really need one. Third, even though most of the lung cancers in the screening cohort were detected this detection came at the expense of picking up a ton of false positives. For every potential lung cancer that was detected only 6% of them actually turned out to really be cancer! The other 94% of the detected “scary lesions” turned out to be benign but many of these people still underwent lung biopsy (sticking a needle through the chest and into the lungs) and/or bronchoscopy (shoving a scope down your throat and into your lungs while you are sedated) and both of these confirmatory procedures can result in some really nasty side-effects, like a collapsed lung or a nasty case of pneumonia. Finally, there is the issue of whether screening for lung cancer with low dose CT is cost-effective because no matter how great a test is if we can’t afford it as a society it isn’t a good screening test.

 Ct-scan[1]

A CT Scanner. The table moved back and forth through the “donut,” which spins around the patient and takes a bunch of X-rays from different angles.

imagesCAY2SCD8

A Normal CT Scan of the Chest: 1. Right Lung, 4. Aortic Arch, 5. Left Lung (you’re viewing it from the aspect of the patient’s feet while they’re lying down), 7. A Vertebra of the Spinal Column (“backbone”), 8. A Rib.

In a nutshell, screening smokers and former smokers for lung cancer with low dose CT is looking very promising but more studies need to be done before it becomes a routine part of medicine. Remember, if you smoke the #1 thing that you can do to improve your health is to quit smoking! In addition to lung cancer, smoking predisposes you to heart attacks, high blood pressure, strokes, bladder and kidney cancer, mouth and throat cancer, COPD (formerly known as emphysema – a terrible disease to live with), bone loss, and a litany of other badness that is avoidable by quitting! I know that it’s hard to quit, that’s why the tobacco companies are so wealthy, but if you smoke please think long and hard about it because it really is very very very important! Your doctor has lots of medications that can assist smokers in quitting and many of them help more than you would think. But that doesn’t change the fact that if you aren’t truly committed to quitting smoking you won’t – finding the will to change your life always has been and always will be both the most difficult and the most important medical decision.

 

References

1.       The National Lung Screening Trial Research Team. Results of Initial Low-Dose Computed Tomographic Screening for Lung Cancer. The New England Journal of Medicine. 23 MAY 2013.

2.       http://www.cancer.gov/newscenter/newsfromnci/2011/NLSTprimaryNEJM.

3.       Rigotti NA, Rennard SI, and Daughton DM. Benefits and Risks of Smoking Cessation. In: UpToDate. Accessed 14 APR 2013.

4.       Image 1: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=marlboro+man&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1366&bih=622&sei=dN20UZnmLanHywHy1oHICw#facrc=_&imgrc=KhBna-iUrhIK_M%3A%3BKTd40oBkDDDcsM%3Bhttp%253A%252F%252Ffarm3.staticflickr.com%252F2470%252F3564450933_99daed43b2_o.jpg%3Bhttp%253A%252F%252Fwww.flickr.com%252Fphotos%252Fbeaumontpete%252F3564450933%252F%3B1200%3B900

5.       Image 2: http://www.google.com/imgres?imgurl&imgrefurl=http%3A%2F%2Fourawesomeessay.wikispaces.com%2FHow%2Bsmoking%2Baffects%2Bhealth&h=0&w=0&sz=1&tbnid=UFDO02mpgYV3rM&tbnh=201&tbnw=251&prev=%2Fsearch%3Fq%3Dlung%2Bcancer%2Bfrom%2Bsmoking%26tbm%3Disch%26tbs%3Dsur%3Afc%26tbo%3Du&zoom=1&q=lung%20cancer%20from%20smoking&docid=D3JE6-ovyd9paM&hl=en&ei=Gd60UZ-QEoONrAGSwYDgCw&ved=0CAEQsCU

6.       Image 3: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=marlboro+man&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1366&bih=622&sei=dN20UZnmLanHywHy1oHICw#as_st=y&hl=en&tbs=sur:fc&tbm=isch&sa=1&q=CT+scanner&oq=CT+scanner&gs_l=img.3..0l10.62728.64210.2.64374.10.10.0.0.0.0.162.1080.5j5.10.0.crnk_timepromotionb..0.0…1.1.16.img.rTEBuId2TYA&bav=on.2,or.r_qf.&fp=dceb5884aff80566&biw=713&bih=486&facrc=_&imgrc=fY-O8OH8T9VcVM%3A%3BkT6sJ6Oy56F4CM%3Bhttp%253A%252F%252Fupload.wikimedia.org%252Fwikipedia%252Fcommons%252F3%252F35%252FCt-scan.jpg%3Bhttp%253A%252F%252Fcommons.wikimedia.org%252Fwiki%252FFile%253ACt-scan.jpg%3B901%3B605

7.      Image 4: http://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=marlboro+man&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc&biw=1366&bih=622&sei=dN20UZnmLanHywHy1oHICw#as_st=y&hl=en&tbs=sur:fc&tbm=isch&sa=1&q=chest+CT&oq=chest+CT&gs_l=img.12…0.0.0.4004.0.0.0.0.0.0.0.0..0.0.crnk_timepromotionb..0.0…1..16.img.g02h2J4EtVE&bav=on.2,or.r_qf.&fp=dceb5884aff80566&biw=1366&bih=622&facrc=0%3Bchest%20ct%20aortic%20arch&imgrc=_

Dr. Leonardo Noto

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

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

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

The Life of a Colonial FugitiveIntrusive MemoryMedical School 101The Cannabinoid Hypothesis