Category Archives: Dr. C’s Journal

Dr. C’s Journal: Care Of Hand Osteoarthritis

I started having hand pain about 20 years ago, and booked a visit with the rheumatologist in my medical building. He looked at my hands and immediately knew that I had osteoarthritis.

The thumb musculature (the thenar eminence) was angled with respect to the plane of the rest of my hand and wasn’t flat like normal. Some of my joints were slightly swollen and even warm to the touch, and many of my fingers were beginning to get crooked.

He ordered a rheumatoid panel, uric acid and inflammatory markers. The normal results confirmed his diagnosis of osteoarthritis.

The middle and index fingers have taken a lot of trauma over the years. They are also the crookedest, for the same reason. With the thinning of my skin or you can see the outline of my tendons  on the palm of my hand, and some are a little bit bumpy and irregular. I am unable to make a tight fist anymore, although my fingers will flex to some degree.

I practice exercises on my wrist, hands and fingers, such as rotating my wrist and thumb in a circular fashion, touching my thumb to the tips of my fingers in sequence, squeezing a rubber ball, and flattening out my hand against the back of my head. Recently, I have noticed a little resistance when I try to straighten out my ring fingers after flexing them, and worried about developing trigger finger. On further reading I found that trigger finger is not more common in people who have osteoarthritis.

I do a lot of swimming, and am worried that the irritative force of the water regularly acting up on my hand might be making the hand pain worse. But my hands seem to be a little bit better with the hand exercises. There seems to be less pain, although maybe I have the same amount of pain but tolerate it better since I’m doing something about it. One never knows about a preventative program, since you’re an experiment of one. You have to have faith that what you are doing is beneficial, and in harmony with medical studies. Perhaps my anti-inflammatory diet and turmeric, as well as my good sleep and aerobic exercise is also helping.

—Dr. C.

Dr. C’s Journal: Pain Without Treatable Cause

Pain is useful to survival, and therefore is evolutionarily conserved. There is a very rare syndrome with the congenital inability to experience pain that Is caused by mutations in the SCN9A gene, which codes for a sodium channel (Nav 1.7). Research on this channel has apparently produced some advances in pain medication, but not as much as expected.

Individuals with insensitivity to pain have many accidental injuries which can cause blindness, mutilations of the extremities, and other severe problems. Lack of ability to feel pain is serious handicap.

Pain is generally a useful red flag that warns us to stop the painful activity, or guides us into the doctors office; about half of all medical visits involve pain of some sort.

Considered as a symptom, pain helps guide the physician into the proper diagnosis and treatment. Normally the pain stops when the condition that produced it is corrected. Pain sometimes outlives it’s usefulness, however, and becomes a major problem on his own. The most obvious condition is “phantom limb pain”. Most people who have had an amputation will continue to experience pain in the extremity that is no longer present.

Back pain that has no valid surgical treatment will sometimes drive individuals to surgeons who will operate on them unsuccessfully. A second opinion, preferably by a medical doctor like a neurologist, is always a good idea with back pain without sciatica, numbness, or other localizing symptom to tell the doctor where to operate.

Neuropathic pain is another conundrum. I know of an individual who was bitten on the foot by a dog, and continued to have severe foot pain for many years after the original injury healed.

All pain is interpreted in the brain, and continuing circles of central nerve activation is the leading theory of phantom limb and neuropathic pain. Pain is not objectively measurable; there is no meter that you can attach to the patient and find how much pain they are actually having. The doctor must assume that the patient has the pain they are describing, and ask the patient to rate it on a 0 to 10 scale, describe its severity, time course, quality, and any factors that will make it better or worse. Most often this produces an avenue to treatment, but sometimes not.

A few decades ago, busy doctors would label the pain that they could not diagnose as “psychological”, and dismiss the patient to suffer in silence. Much of the pain, however, was very real to the patients, who joined in patient advocacy groups and produced a political backlash which induced doctors to overtreat the pain, often with opioids.

The over-prescribing  doctors, and unscrupulous drug companies led to the flooding of the market with opioid medication, leading to the opioid crisis that is now being addressed. There is difficulty in making scientific progress on an adversary that cannot be measured properly.

Some doctors, usually anesthesiologists, specialize in treating the chronic, severe pain that standard medical practice has been unable to diagnose or alleviate.

They may use nerve blocks, antidepressants and combinations of different pain medication. Judicious propofol has been used also not only for chronic undiagnosed pain, but also depression.

My wife had a pain problem which responded to a combination of two simple medications, motrin and acetaminophen. The suggested overall approach is to get the best medical care available to diagnose the cause of the pain, and ask for a pain management referral if a solution is not found.

More information can be found in the appended Wikipedia article.

—Dr. C.

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DR. C’S JOURNAL: VITILIGO

Vitiligo is the loss of skin color in patches. Most often it is widespread. It tends to occur on the hands, or around the mouth, and can start where there are irritations or injuries to the skin, such as with tattoos. This generalized Vitteligo begins in middle age, but a more localized, or segmental Vitelligo can start earlier, and affect one area or side of the body.

Well-tanned skin, and skin with a darker color make the vitiligo stand out more prominently and give more trouble.

When I was a kid, I had a sort of reverse vitiligo, namely freckles. With freckles, the pigment gathers into small spotty areas, and leaves the rest of the skin without sunburn protection. I can attest to the fact that ANY kind of skin difference will lead to social problems; the main suffering  with vitiligo is social.

Vitiligo is considered an autoimmune condition, and carries with it an increased likelihood of other autoimmune conditions, primarily thyroid and other endocrine.

Mimicking vitelligo, skin pigment can also disappear in areas of irritation or surface infection, such as in tinea versacolor and pityriasis alba. There is often a “halo” around a pigmented negus.

There are various treatments which aim to lighten up the surrounding skin area, or Increase pigmentation of the affected area. Such techniques use ultraviolet light, in combination with various various creams and medicines. Even surgery is sometimes used, so great it is the suffering of affected individuals.

Please refer to the accompanying article for more information.

—Dr. C.

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DR. C’S JOUNRAL: STEM CELL TREATMENT UPDATES

The stem cell dream has been present for years, but so far the dream has outpaced reality. Only A handful of stem therapies are actually useful treatments at present.

A Japanese researcher has succeeded in making iSC into eggs, and discovered that you needed supporting ovarian tissues to make the system work in mice.

Some stem cell treatments deemed  successful may have actually been due to dead cells or immunity-stimulating debris causing increased functionality, particularly in the heart.

Interestingly, as stem cells slowly differentiate into heart cells, there is a stage of cardio myocyte that beats on its own. This leads to arrhythmias if there is insufficient differentiation in stem cell treatment. Only later in differentiation does the myocyte stop beating on its own and rely upon a signal to contract, as the adult heart does.

A 3-D model of pluripotent heart stem cells has been seen to self organize. Mostly researchers have focused on building tissue around a scaffold to re-create the heart chambers structure, but a heart organoid, known as a cardioid, has been created by adding six signaling factors.

Stem cells in culture mutate about 840 times faster, creating problems. I have a friend who has his own iSC dopaminergic stem cells injected into his brain,  but the tissue culture media worryingly shows a teratoma, a type of tumor with all three embryonic tissue lines.

Stem cells had previously been classified as naïve or prime. An intermediate stage is now been discovered called  the rosette stage. The developing organism must be sure before it goes ahead.

Whether to make pluripotent stem cells from a persons own tissue, and use it for replacement therapy in that single individual, or to take a cell line that has been vetted, and use it in everybody, accepting the necessity of immunosuppression, is currently being worked out. The Japanese groups are generally going with this latter “allogenic” package and working to match histocompatibility sites.

Parkinson’s treatment is unlikely to be a cure, since the transplanted cells may eventually become diseased themselves. Stem cell treatment can improve symptoms potentially, but can’t alter the course of the disease.

Using fetal cells has proven very problematic, since a given procedure for Parkinson’s may require 4 to 12 fetuses per patient, and you have ethical problems besides.

Spinal cord injury is plagued by inter-species architectural differences, and knowing exactly how severe the injury actually is. Researchers also have to be sure they are not going to make the situation worse.

Chimeras are developing as a research bonanza. The idea is to take a lower species, block the development of a given organ, then inject a higher species stem cells which are more likely to fill the niche if they don’t have domestic competition. Many efforts are directed towards developing human organs in subhuman species. When using primates as the sub species, however, an additional step, blocking the possibility of stem cells becoming neurons is advisable. There’s a lot of ethics in this area.

The pancreas is the area of greatest work at the present time. Keeping an embryo alive in a dish is very important, but difficult. The “14-day rule” is being extended.

The suffix “oid” is getting very popular. We have organoids, spheroids, blastoids, and assembloids. I was a bit surprised to hear how self organizing these tissues are, and also how important are the accessory, helper cells: the ovarian support tissues, the astrocytes in the brain, the pigmented epithelial layer of the eye, the pericytes in blood vessels.

Jeanne Loring is trying to save the white rhinoceros. Just cloning the rhinoceros is not good enough. Some mutations in the germ-lines are needed to make different individuals. This also requires going from Induced stem cell retrograde over to sperm cells; the only two white rhinos still alive or both females.

Currently it requires great technique to take a somatic cell back to induced stem cell. These talented people are called “cell whisperers”.
Mention is made of the Chinese hamster ovaries cells that are commonly used to produce therapeutic proteins. They tend to float in the reactor as single cells. Pluripotent  stem cells are more fragile, and need to grow in aggregates. You must form sheets of the stem cells in order to get them to take  in the eye, for instance, in order to get them to form retinal pigmented  epithelial cells, photo receptors, horizontal cells, bipolar cells, amacrine cells, and ganglion cells. “We transplant 10-20,000 cells per eye. To recover vision you probably need hundreds of thousands of cells. Most people appreciate even a slight improvement in vision, however”.

“ All models are wrong, some are useful“ is the guiding principle of leading edge stem cell Whisperers.

—Dr. C.

DR. C’S JOURNAL: IT PAYS TO BE KIND TO YOUR STOMACH

This whipping boy of humanity is regularly insulted by all sorts of concoctions dictated by our taste buds and psyche, not to mention the many drugs required to treat our poor health. It is amazing how much abuse it can absorb with minimal complaint.

The stomach has evolved as a “fiery pit” of high acid content to intercept various bacterial invaders. Fortunately a few escaped to populate our intestinal tracts, where they are mostly beneficial. One bacterium in particular evolved to tolerate the high acidic conditions of the stomach, like extremophile bacteria tolerate the “smoking vents” underneath the sea. This is the famous helicobacterium pylori, which caused most gastric ulcers in the early days of my medical career. Ulcers were then treated by an ongoing special diet. Now they are treated by a simple course of antibiotics.

The stomach evolved a special lining to tolerate the acid, and a valve to keep it in place. Over time this valve may weaken, allowing the acid to reflux back into the swallowing tube, the esophagus. This produces the familiar heartburn that most of us have experienced, and if chronic, can produce inflammation and the condition called Barrett’s esophagus, which frequently leads to gastric cancer.

Gastric cancer comprises only about 1.5% of cancers in the United States, but in Korea it is the most common cancer. This may be because of the Korean diet, Which often finds nitrites in close proximity to proteins, which donate an amine group to form the carcinogen nitrosamine.

I have begun a time restricted eating program, where I eat my entire days food within a six hour window. My stomach has seemed to tolerate this, but I have noticed that when I eat a lot of fat late in the day (I like half-and-half on my oatmeal) my stomach will object. Alcohol does the same thing, and when I was in medical school we used to give a dose of alcohol to stimulate stomach acid production, as a test.

If you have a lot of pain in the area of the stomach (the epigastrium), chronic heartburn or trouble swallowing chunks of meat, you may well need to see a gastroenterologist, who will look into the esophagus and stomach to check for problems.

Please check the following Mayo clinic articles for more information.

—Dr. C.

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DR. C’S JOURNAL: SIGNS OF A SILENT HEART ATTACK

Heart attacks are something that most people know about; the sudden severe chest pain, radiating into the jaw or left arm,  associated with shortness of breath, nausea, and the like. However there’s a lot of confusion also; not all heart attacks have typical symptoms (silent heart attacks). Some significant chest pain is not due to a heart attack, and some significant cardiac disease is something different from a heart attack.

I will cover these three scenarios one at a time, beginning with the most dangerous, the silent heart attack.

The silent heart attack has the same effect as the more typical variety, and is caused by blockage in the coronary arteries,  which interferes with oxygen and glucose delivery, and causes death of heart muscle. It occurs under physically or emotionally stressful circumstances, particularly in the cold. It may be more common in women, and accounts for at least half of all heart attacks.

Risk factors are identical to those of a regular heart attack, and include being overweight, diabetic, not exercising regularly, having high blood pressure, high cholesterol or smoking cigarettes.

The symptoms may be Flu like, fatigue, indigestion, and perhaps a soreness in the chest, upper back, arms or jaw. My mother-in-law died in my house after a stressful incident, and was heard to be vomiting in the middle of the night. My father had inordinate fatigue and paleness, which caused my mother to take him to the doctor, who sent him by ambulance for a bypass operation.

Many silent heart attacks are discovered when the doctor takes an electrocardiogram in the course of an  examination. This is a good argument for the regular physical examination, since having a silent heart attack increases the likelihood that you will have another.

The frequency and seriousness of heart attacks is of course an excellent argument for proper sleep, diet, exercise, and other good preventative habits.

—Dr. C.

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DR. C’S JOURNAL: SIGNS & SYMPTOMS OF NARCOLEPSY

Narcolepsy is a sleep disorder with daytime drowsiness, sudden episodes of falling asleep, sometimes sudden loss of muscle control, and occasionally hallucinations.

If this sounds like the bad, overbearing, uncontrolled brother of REM sleep, that is because it is. The features of REM sleep are there; sleepiness, muscle paralysis(cataplexy) and Hallucinations(dreams). This combination of symptoms can often disrupt jobs, and can be dangerous, leading to accidents.

The cause of narcolepsy is unknown, but there is an association with decreased blood levels of the neurochemical hypocretin. The disease starts in youth, and sometimes occurs and families. The patients are often overweight, and can have sleep apnea in addition.

The Diagnosis is usually made in specialist sleep centers, which find an unusually rapid entrance  into sleep, beginning in the REM stage. Normally REM sleep occurs later in the 90-minute sleep cycle.

There are a lot of different stimulants and some sleep-restoring and paralysis-reducing medications used to treat narcolepsy. This and other information may be found on the accompanying Mayo clinic article.

—Dr. C.

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DR. C’S JOURNAL: SIGNS AND SYMPTOMS OF APPENDICITIS

The appendix is a finger like projections at the origin of the colon in the right lower part of your abdomen. It may become inflamed, especially if there is a blockage. Appendicitis is best considered a medical emergency, since it may rupture and infect the entire abdominal cavity.

When I was a practicing pediatrician, appendicitis was one of the two conditions I refused to allow myself to overlook; the other one was meningitis, which is now mostly prevented by immunization.

Pain in the abdomen is almost invariably present as the main symptom of appendicitis. This pain often begins around the belly button and then migrates to the right lower part of the abdomen. The patient should try to notice whether jarring the abdomen by walking makes the pain worse; if so, this finding would favor an inflammatory condition like appendicitis.

A similar condition, diverticulitis, may cause similar symptoms in the left lower part of the abdomen, and other conditions may cause confusion. The doctor checks to see if it is more painful in the right lower belly area, and she may pull her hand away suddenly. If the pain intensifies, there may be inflammation around the appendix. Sometimes a vaginal examination or rectal examination will be needed to help with the diagnosis; the appendix is close to these areas.

Other symptoms and signs may be a low-grade fever, vomiting, add an elevated white blood cell count. In the modern medical era, ultrasound, CT scans, and MRIs are sometimes used to visualize the appendix to evaluate its size and possible inflammation.

Treatment used to consist only of surgery, but with imaging techniques available to prevent disaster, the condition can be treated with antibiotics. 30 to 50% of those so treated will still eventually require surgery. Removal of the appendix is now sometimes performed through a fiberoptic scope, leading to more rapid recovery.

A dilemma is present for individuals who go to the south pole to live for several months, and where weather may prevent them from getting proper medical help. Such  people may have their appendix removed as a preventative. Of course they also can take antibiotics if appendicitis develops, but it’s really scary to use medical treatment only, without the aid of modern imaging techniques.

Please consult the following Mayo clinic article for more information.

—Dr. C.

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DR. C’S JOURNAL: WOMEN AND AUTOIMMUNE DISEASE

Almost 80% of autoimmune diseases occur in women. Why should this be?

From the evolutionarily standpoint, perhaps up regulation of immunity conferred a survival advantage. Women spent a much greater percentage of the time pregnant in Hunter gatherer days than they do at the present time, and an active immune system may have been an advantage in getting both you and your child’s genes through the many ancient environmental hurdles.

Women differ from men in the prominence of the X chromosome, the female sex hormones, estrogen and progesterone, and, surprisingly, in their microbiome. All three areas may play a role in autoimmunity.

The X chromosome contains many genes directly tied to Autoimmune diseases. One of these is a gene for TLR-7, which is important in the innate immune response, and is linked to disorders such as lupus and scleroderma. Another Gene, TASL, increases the production of interferon, a common inflammatory factor.

Many autoimmune diseases are driven by estrogen. For instance, estrogen attaches to, and turns on the gene that codes for interferon gamma. It activates B cells which produce antibodies. Progesterone, another female hormone is elevated in pregnancy, and tends to switch on the TH-2 response, which produces more antibodies. AIRE, the immune regulator itself, is partially influenced by the sex hormones.

A severe asthmatic I was treating became pregnant, and her asthma marvelously improved. I had always thought that pregnancy turned OFF her asthma-linked TH-2 response, going against one of the observations above.

At the present stage of knowledge, individuals may respond in perplexing ways to interleukins, treatments and pregnancy. Cellular interactions are complex indeed.

The microbiome in the male tends to increase testosterone, which tends to down regulate the immune system. The reverse is true for the female microbiome.

The fact that identical twins may be discordant with autoimmune disease favors environmental factors, such as the microbiome and other extrinsics such as smoking, diet, stress and chemicals. Some of the males who get autoimmune diseases tend to be feminized, such as in the Klinefelter syndrome, which has an extra extra X chromosome, and an XXY genotype.

The use of the estrogen or progesterone in the form of contraceptives tends to increase the likelihood of autoimmune diseases. The observation that women are more susceptible to autoimmune diseases goes along with many of these genetic, hormonal, and environmental observations.

Please consult for Scientific American, September, 2021, P 40 for more information.

—Dr. C.

DR. C’S JOURNAL: AMBLYOPIA

Amblyopia is an example of how the body suppresses or gets rid of activity that is not used. Amblyopia “ex anopsia” is the leading cause of poor vision in children, and the most common reason is a “lazy eye”. If the eyes do not work together for binocular vision, the weaker of the two eyes has suppressed development and eventually eyesight is lost.

I have a friend who was going in the pilot training, it was found to lack good depth perception, and could not proceed. He now complains occasionally of double vision, and may be an example of the suppressed eye with lack of binocular vision.

I have a muscle in balance which causes a rotation of my eye so that it’s hard to fuse on a horizontal linear object. I was probably able to fuse  when I was younger and avoid this loss of vision in the weaker eye.

So be on the alert for a squint, or wandering eye in children. Get them in early for treatment, the earlier the better, and it must take place before age 5 to 7.

—Dr. C.

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