Category Archives: Dr. C’s Journal

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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DR. C’S JOURNAL: WHAT IS AUTOIMMUNE DISEASE?

Our immune system contains cells that are part of us, and they evolved to protect us. They generally do a good job of this, as witnessed by our survival in a sea of viruses, microbes, and parasites.

However, just like our police force, occasionally the protective function goes awry and damage is done to our own body, in the protective act. For many years I was a practicing allergist, and observed this protective function misfiring. In allergic rhinitis and allergic asthma, tiny harmless particles in the air are interpreted by the body as a threat. The TH2 immune system, initially evolved to fight parasites, is activated, and causes considerable disease and misery.

Some of the antigenic determinants on the surface of the pollen, animal dander or dust particles are interpreted as being dangerous by the immune system, which causes chronic inflammation with acute allergy attacks.

Autoimmunity is a similar misreading, in which our own cells are deemed dangerous. In this case the immune agency is the more powerful Th-1 system, which often causes crippling or even fatal results.  

Millions of people are sickened by an immune system that is supposed to defend them.

An article in the September 2021 issue of the Scientific American lists 76 of these disorders, and classifies them as to frequency, patient gender and age of onset. It is worth reviewing, at least for the listing on page 32 and 33.

Auto immunity must be considered as a possible cause in any illness that is not easily diagnosed, common, and well known to your doctor. Many patients have to be their own advocates, and persist in trying to get themselves diagnosed.

Celiac disease, Lupus, and Addison’s disease come to mind as tricky customers. Although “autoimmune disease” in toto is common, many of the individual diseases occur in less than one in 1000 patients, and are not high on the diagnostic list of most doctors.

The skin, nervous system, endocrine system, and digestive system are the most common areas involved. Recent advances in blood and antibody testing offers to give needed diagnostic help to the medical profession. These illnesses must be detected early to avoid functional loss in the tissues and organs affected.

Treatments are improving. In the past, immune suppressing cancer drugs and cortisone were the main drugs available. With increasing knowledge of the mechanisms of the separate diseases, treatment can be directed towards the specific causative antibody, receptor, or interleukin involved, hopefully with less side effects than the shotgun drugs previously available.

As with medicine in general, these modern treatments are excessively expensive as a rule, because much money and research went into their development. Prevention is obviously preferable. A healthy diet, with its attendant healthy microbiome comes to mind, as well as the avoidance of cigarette smoking and environmental toxins.

Proper sleep, exercise, and stress relief should also be helpful.

—Dr. C.

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DR. C’S JOURNAL: SOME TIPS FOR CARE OF THE FEET

When not walking barefoot at night or on the beach, my toes have been squeezed together most of my life. Closed-toe compression stockings for my varicose veins plus inadequate space at the front of my shoes have encouraged my big toe to “scissor” and to cross over the second toe. At that point I started wearing open-toe stockings, and tried to give my toes more room in larger shoes. I also used a spacer to push the big toe out.

Walking on the beach is a wonderful place to free up your toes. For a while, I walked in the deep sand at the top of the beach, trying to get more exercise. Periodically I would get some thorns in my feet, and go to podiatrist to get them out.

During one visit, the podiatrist told me that I was getting a hammer toe in the toe right next to my big toe, and I now use a little ring shaped cushion for that second toe, incorporated with a spacer.

It is amazing how little we use the musculature of our feet, and how surprisingly well they hold up. People that are really in good athletic shape stress flexibility as being very important, and athletes often do stretching exercises before they do their workout. Practically anything that will stretch a joint is helpful, such as flexing, extending, and spreading the toes, plus flexing and extending the foot.

You can overdo it, however, as I have learned to my discomfort. You must do any exercise within the limitations of your body, beginning slowly, and working up to your desired level.

My big toe has almost no flexibility, and the joint that attaches it to the foot is enlarged and pretty fixed. I am very careful how much range and pressure I use .Even something as simple as stretching the Achilles tendon can be a problem if you do too much of it all at once. Always work slowly into your exercises to make sure that you do no harm.

Ingrown toenails have also bothered me from time to time. I very carefully try to trim them back and avoid breaking the skin; the foot is easily infected, particularly among diabetics and older people. A podiatrist is very helpful if you let things go too far.

My toenails, particularly on my big toe, are getting white and thick with a nail fungus. This can be treated with an oral medication, dispensed by a doctor or a podiatrist. I have chosen to keep it in check with clotrimazole cream, and that seems to be working. I worry from time to time about creating a resistance factor in the fungus, but they are very slow growing, and not likely to develop a mutation.

If you would like further discussion on foot exercises, please check the following reference, one of many on the Internet.

—Dr. C.

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DR. C’S JOURNAL: STEM CELLS

The ultimate stem cell is the fertilized egg from which we came. This omnipotent stem cell divides countless times, “differentiates”, and forms more and more specialized tissues, and our body is the eventual result. All of our tissues contain some stem cells, which grow increasingly rare as we age.

Regenerative medicine takes advantage of stem cells derived from diverse sources. An embryo, an umbilical  cord, or your bone marrow contains stem cells. Even one of your mature connective tissue cells that has been dedifferentiated, or sent back along the pathway that originated from the single cell from which you came, can be induced to form a stem cell (iSC).

If the stem cell originates from your own tissues, it is  accepted by your body, as one of its own.

I have an wealthy acquaintance whose Parkinson’s disease is being treated by one of his own cells induced to form a dopamine containing neuronal stem cell.

The article posted previously regarding rotator cuff surgery apparently used stem cells to shorten the recovery time.

I have heard about the use of stem cells in heart failure, osteoarthritis, and other joint problems, and I’m sure we will hear about this increasingly as time passes. However, there are hurdles to be overcome, moral, legal and medical. The possibility (small) of induced stem cells to evolve into cancer is one medical hurdle, and if the Stem Sell originates from another individual, immunosuppressive treatment must be used in the recipient to allow the stem cells to work. Also, the use of the other individual’s stem cells may involve some moral, legal and possibly religious objections.

Please refer to the following Mayo clinic article for more information.

–Dr. C

DR. C’S JOURNAL: PAIN FOLLOWING TOTAL KNEE REPLACEMENT SURGERY


Total knee replacement(arthroplasty) is one of the most successful orthopedic operations. Satisfaction rate varies between 75 and 90%. Even so, almost 10% of operated individuals will have anterior knee pain, the most common complication, 1 year after TKR.

I had an even greater appreciation of the knee after reading the following article, which explain the causes of knee pain more adequately than I can, and would be good to read.

With knee replacement surgery, a great deal depends on the technical expertise and precision of the operating surgeon. A rotational error more than a degree or two can be critical, so important is proper tracking of the kneecap in the trochlea, or groove in the leg bone(femur). An imbalance in the pull  of muscles, or a knock knee, (Valgus) angulation of the knee, hip rotation, spinal problems, all can be important in generating pain as you get older.

There are psychological factors too. The knee pain after TKR average is only 1/3 of that suffered before the operation, on average. However if you expect that discomfort will disappear completely, or if your pain threshold is low, or if you have anxiety or depression, you may have more postoperative pain, and  be disappointed with the surgery.

My immediate reason to write this article was the anterior knee pain developing in a friend of mine, 15 years after surgery, at the age of 89. She had polio in childhood, and her right leg was severely affected. This caused her to overuse her left leg, resulting in a TKR 15 years ago. Just recently, she started developing anterior knee pain in the left knee. A thallium scan showed a lot of signal on the inside of the kneecap, most likely indicative of inflammation. She is not enthused about having another operation because of her age., and wondered about other things she might do.

An orthopedic friend of mine suggested that injections of a viscous lubricant might help, if the initial operation did not include resurfacing of the kneecap (patella). I would imagine that eventually the resurfacing of the patella with advanced materials, or perhaps stem cells might help.
I also thought of a special brace with a motor assist for her right leg, but the orthopedist said that this did not work very well in polio patients, who have a weak nerve signal.

Although my friends polio made her TKR almost inevitable, there are things that you can do, or avoid doing, that could help avoid TKR. Activities to reduce include squatting, deep lunging, running (particularly in deep sand), high impact sports, repetitive jumping, and running up stairs. Basketball, football, and volleyball come to mind as regular sports that are risky. Maintaining a healthy weight, controlling blood sugar, stoppage of smoking, avoidance of injury, and regular exercise, particularly walking and swimming ,are things that might help.

Remember that your knees are your wheels and are jewels to protect as you get older.

–Dr. C

DR. C’S JOURNAL: PROTEIN-BASED MEDICATIONS

Proteins, the very structure of life itself, are currently being understood with increasing precision. This will undoubtedly lead to a new generation of medications useful in treating a wide variety of diseases. Such proteins could be coded by DNA or RNA, and churned out by veritable protein factories, yeasts.

This could drastically lower the cost of such medications, which are more stable than RNA, allowing easier distribution and storage. DNA and RNA advances are currently getting all the press, with CRSPR  advances in manipulating their structure. Indeed, the RNA vaccines by Moderna and Pfizer have been a rapidly deployed life saver with the COVID-19 epidemic. Correction of genetic disease is also possible in rare instances, if only one gene causes the disease.

PROTEINS, the result of DNA and RNA activity, form the basis of a vast array of signaling molecules, offering many possible treatments of disease.

The reason why advances in protein chemistry has been slow, is that protein is a very large molecule that exercises its effects by its three dimensional structure.This is formed by the loops,foldings, twists, and bunchings of its amino acid string. A molecule’s three-dimensional structure is very expensive to determine at the present time,

Encouraging scientists to attempt predicting  the structure by knowing  the  electric charges and other sticky characteristics of different parts of that amino acid string. Recently, artificial intelligence has come to the rescue, and the field is advancing rapidly.

Novel vaccines are being developed, using small protein pieces of the COVID-19 antibody combining site. Pieces of proteins are being designed that can stick to that antibody combining side and prevent it from attaching. Novel signaling blockers, or even agonists,  are looking increasingly possible.

I thought you would like to know about this little island of optimism in the midst of all the gloom. My interest in PROTEINOMICS was fueled by an excellent article in the Scientific American July 2021 issue, by science journalist Rowan Jacobson, who presents the story in a very interesting fashion. I would very much recommend the reading of this article.

–Dr. C

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DR. C’S JOURNAL: WHAT IS VALVULAR HEART DISEASE?

I continue to be amazed by-and grateful for -the astounding collection of miracles that is the human body. Each element is durable if properly maintained and potentially provides us with a long and healthy life. The heart Valves are a part this wonderful orchestra, opening and closing about 2 billion times in a full lifetime.

It is possible to visually appreciate our heart and it’s valves, but millions of other microscopic-nanoscopic-little protein machines are also opening, closing, twisting and folding anonymously, allowing us to live and move.

Now is a particularly good time to talk about the heart valves because imaging devices are available to detect, and surgical techniques are at hand to treat, the common problems that develop in the course of optimally guiding our blood through the heart, into 2 separate circuits, the pulmonary, and the systemic. Life can be defined as an island of order in a sea of chaos. Energy is required to allow this island to fend off dissolution. The energy is used to continually maintain the integrity of our cells, the island in this metaphor, and keep entropy at bay.  Myriads of biochemical mechanisms direct this repair. Sleep, diet, and exercise aid in the mending.

We use our bodies in the daytime, and at night switch to a cleansing and repairing function, sleep.  Diet, and our resident microbiome, provide the materials for this restoration. Exercise helps utilize excessive nutrients, and directs our metabolism towards regeneration and repair.

Some valvular problems are present at birth because of defective development. Bicuspid aortic valves and mitral prolapse are examples. Hypertension places a strain on the entire system. Type two diabetes can cause inflammation and abnormal deposits in the valves. A variety of biochemical pathways active during the formation of the heart can go awry and fail to maintain the neatly layered deposits of collagen, proteoglycans and elastic tissue that forms the basis of the valves, and the endothelial cells that line them.

Tobacco smoke, which harms in so many other ways, can also damage the heart valves, as can infections, which sometimes grow on the heart valves themselves. Symptoms of heart valve disease include abnormal sounds that your doctor can hear, or the the presence of fatigue, shortness of breath, swelling of the ankles, and dizziness, which are common symptoms of cardiac malfunction. Unusual chest pains, particularly with mitral prolapse, and irregular heartbeat can also be present.

Replacement of some valves via a catheter inserted in an artery is one of the recent advances in treatment of Valvular heart disease.

Ultrasound is particularly useful in diagnosing valvular heart disease, but a whole cafeteria of diagnostic tests are available to doctors these days.
Please refer to the following Mayo clinic article for more information.

—Dr. C

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DR. C’S JOURNAL: WHAT IS PNEUMOCYSTIS PNEUMONIA?

Pneumocystis is found in the respiratory tract of most mammals and Man. Pneumonia from this organism was extremely rare or unknown before the advent of AIDS.

When the lymphocyte count of a person with AIDS drops below 500, or especially 200, pneumocystis pneumonia is a frequent complication. Symptoms include cough, fever, rapid breathing, and shortness of breath.. The chest x-ray typically shows a “ground glass” appearance, caused by fluid inside the air sacs and throughout the lung. Treatment is usually with trimethoprim sulfa.

Immunosuppressive therapy is often given for organ transplants and auto immune diseases these days. Patients and doctors should be on the lookout for pneumocystis symptoms in this situation. Even long-term corticosteroids can produce enough immunosuppression to allow pneumocystis to invade the body.

Pneumocystis Jeroveci is the causative organism, and used to be called pneumocystis Carini. Doctors suspect this disease when an immuno-suppressed patient, especially AIDS , has a dry cough, with pneumonia and  a very low oxygen concentration, more severe than expected.  Fluid taken from the lung shows several  organisms in little sacks or cysts.

Treatment is with sulfonamids, if they are tolerated. Cortisone must be given not the same time to prevent a severe reaction from absorption of the dead organisms. Pneumocystis is a yeast-like fungus and is also discussed under opportunistic fungal infections.

The following article will give you more information.

—Dr. C.

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