Category Archives: Dr. C’s Journal

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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DR. C’S JOURNAL: A WORD ABOUT DREAM THEORIES

Dreams are very egalitarian. I really believe that one person knows just about as much about dreams as another person, since almost all of us do a lot of it, and no two theories about dreaming are the same. However, I would like to give you some of what I have learned from my own dreams and readings about them. In addition, I have included a reference that discusses Scientific dreams studies in some detail.

When I was about 14 years of age, and burning up with a desire to learn more about medicine, I bought the only “medical” book I could find in Grass Valley, California: The interpretation of dreams, by Sigmund Freud. I vividly remember being amazed at how Freud could  figure out the symbolisms in the dream case studies he published. The interpretations were not at all clear to me, even after I was told the answer, and chewed on them a bit. I subsequently read the opinion that a lot of them were made up. The essence of Freuds theory of dreams is that they were wish fulfillments, which is patently not always true.

REM sleep was linked to dreams in 1953, a couple of years before I graduated from medical school. For years, dreams were studied in a unitary context of REM sleep, and in the opinion of some, this has slowed down progress on the knowledge of dreams immeasurably. We now know that dreams are not always linked to REM sleep. Dreaming can be neurologically interrupted, while REM sleep goes on. REM sleep can be eliminated while dreaming goes on.

So we go back to the starting block; what are dreams?

The Ancients put a lot of stock in dreams, such as Joseph’s dreams predicting a seven-year drought, which earned him a place on the pharaohs Staff. Martin Luther thought they were the work of the devil. My son Michael thinks they are a good thing, since when you dream you are sleeping, and sleep is a wonderful restorative.

My own theory is that they are random fragments of experience which are ordered and supplemented to form a story. These random fragments can either be from recent experiences, perhaps being consolidated in memory, or old experiences that are being pruned as unnecessary. These snippets are then aggregated under the influence of mood neurochemicals, and flow out in the dream narrative.

Sensations coming in from the environment can play a role. I will always remember the story of a sleep study patient, who was slapped on the back of his neck by a wet towel. He awakened immediately, and vividly remembered a dream about the French Revolution, in which he was guillotined. I read that dreams take 5 or10 minutes of time to develop, however.

I dream almost every night, and most are  forgotten rapidly. Some have enough detail and meaning for me too mull over before I get up. Some of my more common dreams are of flying, or getting lost. The pleasant dreams are definitely in the majority. Only rarely, a sinister one will wake me up.

The following reference details about 50 of the most common dreams that people experience. Much other pertinent information is contained. What is your theory on the causes and meaning of dreams? You probably have as good an idea as anybody else.

—Dr. C

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DR. C’S JOURNAL: CAUSES & SYMTPOMS OF INSOMNIA

Sleep has many functions, among which are clearing the body of toxins and consolidating memory. The exact amount we need is determined by age, and genetics among another things. From what I’ve read, eight hours is required, plus or minus an hour.

That being said, there are a few  among us who are super sleepers. Going back in history this probably included Mozart and Thomas Edison: They could live healthy, productive lives with as few as three or four hours of sleep. Genetic mutations, including changes to the Orexin Gene receptor account for true super-sleepers.

Familial fatal insomnia is a genetic disease operating through prion proteins, and does not illuminate the problem of insomnia. In most people  there are two major forces which determine the onset of sleep, the circadian rhythm, and sleep pressure.

The TIMING of the sleep varies from morning larks to night owls. These shifts in the circadian rhythm is also genetic, involving many genes, including PER and CRY. Diurnal rhythm can apparently be changed, But with difficulty.

The sleep pressure is caused by the gradual daily accumulation of adenosine in the system, apparently resulting from the stripping away of the phosphate groups from the energy currency, ATP.  This can be assuaged by caffeine containing drinks, such as tea or coffee. Caffeine temporally blocks the effect of adenosine, but when it wears off, you usually go right back to your fatigue state.

INSOMNIA occurs when you do not get as much sleep as you need, and are tired in the daytime. This is a major problem for a lot of people.

Insomnia has many causes. Stress will cause an increase in Cortisone in the bloodstream which interferes with sleep. Caffeinated drinks nicotine and other stimulants can cause you to have difficulty falling asleep, and alcohol will help you fall asleep but will often result in awakening in the middle of the night when the alcohol is metabolized.

Depression, Parkinson’s, chronic pain, gastroesophageal reflux and any other medical conditions can interfere with sleep. Sleep apnea, often associated with overweight and heavy snoring, is a special problem that sometimes needs the help of a sleep specialist.

Some poor habits such as reading in bed, doing work in bed, eating at bedtime, and heavy exercise just before bed can also be a problem.
A regular routine of Preparing for sleep, such as brushing and flossing and taking a warm shower are also helpful; you can get more details by looking up “sleep hygiene”.

A lot of people take a nap, but this can cause some difficulty in going to sleep. Among things you can do to prevent insomnia include living an active life, making your bedroom comfortable for sleep, and using your bedroom ONLY for sex and sleep.

Please refer to the accompanying Mayo clinic article for more organized information.

—Dr. C.

Mayo Clinic articlehttps://www.mayoclinic.org/diseases-conditions/insomnia/symptoms-causes/syc-20355167


Dr. C’s Journal: Risks & Symptoms Of Heatstroke

We humans, in common with all mammals and birds, are homeothermic; we defend a body temperature of approximately 98.6 F.. When we are cold, we shiver to warm up. If we get too cold, such as being in 50° water temperature for 50 minutes, we have a 50% chance of dying. When we are warm, we sweat . When we get too warm, and our core body temperature rises above a critical point, approximately 105°, we may die.
This article is about HEAT EXHAUSTION, which is very topical, considering the season and the recent “heat dome” in the Pacific Northwest, not to mention global warming.

Our main defense against heat is to sweat. The water in sweat has a very high heat capacity. Changing sweat into water vapor requires a lot of heat, which is gratefully donated by the person who is too hot. Too much water vapor in the air, a high relative humidity, decreases the rate of evaporation, and therefore of Cooling. The critical measurement to warn us of Environmental overheating danger is the WET-BULB THERMOMETER,  which is used in tandem with the regular, dry bulb thermometer to calculate the relative humidity.

To give perspective, the wet bulb thermometer reached 77° And the dry bulb thermometer read 116° in the pacific northwest, associated with 118 fatalities. In 2003, when Europe was hit by a heat wave, the wet bulb thermometer reached 82.4°, associated with 30,000 deaths.
When it Feels hot (check the heat index), which is related to both the temperature and the relative humidity, you should start to worry. You should drink extra fluids, wear loose fitting clothes, stay out of the direct sun, avoid sunburn, exercise in the cool of the morning and night, not during the heat of the day, avoid closed vehicles, especially for children, and don’t get sunburned, which decreases the ability of the skin to produce sweat.

Certain groups have more risk, such as very young or old age, the obese, and  diabetics. Certain drugs, such as Alcohol, diuretics and beta blockers are factors.

Some typical symptoms are heavy sweating, faintness, dizziness, fatigue, muscle cramps, nausea, and headache. If you are hot, and think you might be experiencing heat exhaustion, you should stop all activity, move to a colder shaded place, and drink cool water or sports drinks.

If you’re caring for somebody, you should worry about confusion, agitation, and other central nervous system symptoms; the brain, together with the heart, kidneys and muscles are very susceptible to overheating.

Rectal temperature is the most reliable, and if it gets to 104°, immediate cooling is necessary, even packing in ice. Don’t bother to use aspirin, since it does not work with heat exhaustion. If coma or seizures develop, and the patient is diagnosed with a heat stroke, the fatality rate and long-term neurological complications are grave.

Please read the excellent article by Joe Craven McGinty in the July 10 Wall Street Journal, or the accompanying mayo clinic article. And stay Cool!

—Dr. C.

Heatstroke article in WSJ

DR. C’S JOURNAL: YEASTS – CANDIDA ALBICANS

Candida albicans is a ubiquitous yeast that has evolved the ability to stick to mucocutaneous linings, e.g. mucous membranes and  skin. When present  in the mouth it is called thrush, and on the skin intertrigo, or diaper rash among other names.

Almost everybody is infested by candida in low amounts, as indicated by the common incidence of a whitish membrane (thrush)  in the mouth of people who regularly use inhaled corticosteroids for asthma. The Cortisone lowers the resistance, enabling the fungus to grow more profusely. The use of broad-spectrum antibiotics also facilitates the growth of Canada by killing off the competition.

Diabetes is a risk factor that commonly increases difficulties that people have in controlling candida growth in their oral and genital areas. Certainly anything that affects the immune system such as very young or very old age, viral infections especially AIDS, organ transplants, and chemotherapy will increase the incidence of Canada.

Due to it’s widespread presence in the body, Candida albicans is the fourth most common cause of bloodstream infections among hospitalized patients, where it grows on indwelling catheters and other in certain devices, which act as avenues for the yeast to invade the bloodstream.

Candida Auris  is a member of the same genus, Candida,that has developed some gain of function mutations to allow it to infect the body much more readily. It is very hard to get rid of, and at least one emergency room has been shut down because of a Candida Auris infestation. Another little trick that  it has evolved is resistance to most antifungal agents; The mortality rate of systemically infected people is very high.

The combination of greater infectivity and resistance to treatment makes it formidable indeed, but still it is mainly a problem for immuno suppressed individuals. C. Auris is not  as widespread as Candida albicans, and the number of cases is currently nowhere near as great. But if you get it, watch out!

As with so many other problems, it is better not see them. In other words, stay healthy with sleep, diet and exercise.

–Dr. C

DR. C’S JOURNAL: COPD -CHRONIC OBSTRUCTIVE PULMONARY DISEASE

COPD is the brother of asthma. Both can cause shortness of breath and wheezing. Asthma is the more Treatable of the two, and is due to muscle spasm around the airways which narrow those airways making it more difficult to breathe in and especially out.

COPD comes in 2 general forms,  Chronic bronchitis and emphysema.
Chronic bronchitis is an inflammation of the airways, which differs from the usual allergic asthmatic TH2 type of inflammation. The inflammation of chronic bronchitis is the more common TH1 inflammation that comes from the likes of bacteria and viruses.

The second type of COPD is usually caused by cigarette smoke or other fumes which lead to the destruction of the air sacs and associated elastic tissue, allowing a check valve type of obstruction to occur on breathing out.

COPD is rarely a pure type of chronic bronchitis or emphysema, and is usually an admixture of the two. In fact there can be an “asthmatic element” mixed into COPD, which allows for a better response to the myriads of medication that we now have for asthma.

The symptoms of COPD include shortness of breath, wheezing, chest tightness and chronic cough with production of sputum. Coughing up a significant volume of phlegm from your chest suggests chronic bronchitis rather than emphysema.

The symptoms of COPD come on rather slowly and are usually not noticed until the problem is severe. After all, the cigarette smoker is EXPECTED to cough isn’t he?

As COPD becomes very advanced, fatigue, lack of energy, and unintended weight loss may occur. Swelling of the legs may be a problem and could indicate involvement of a heart; with COPD the right side of the heart has a hard time moving blood through the diseased lungs.

We’ve all seen people pushing around a cart with an oxygen tank. These people most often are smokers who developed COPD. One particularly disgusting advertisement against cigarette smoking showed a person with a hole in the windpipe (tracheostomy) through which he was smoking his cigarette.

Pulmonary function testing it’s often helpful in diagnosing asthma and COPD. In pulmonary function testing, the amount of air in the lungs  and the rapidity with which it can be expelled from the Lungs is measured and graphed. it is the rate of flow on exhalation that is diminished in COPD and asthma, the slower the rate the worse the blockage.

In the case of asthma the test is repeated after a bronchodilating adrenaline type medication has been given. The REVERSIBILITY of the airway obstruction is shown by comparing the airway function before and after treatment  With no improvement, usually COPD is usually the culprit.

In both asthma and COPD, respiratory infection is a big problem. The compromised lung is usually very vulnerable to these inflammatory reactions. There are a score of medications  that are commonly used in asthma which also benefit COPD to a certain degree. Doctors have a large armamentarium for respiratory disease these days.
As mentioned, asthma is more treatable. However if it is poorly treated or neglected, a condition known as REMODELING can occur which will render treatment less effectual.

Please check with the Mayo clinic article on COPD for more information.

—Dr. C.

Mayo Clinic article

DR. C’S JOURNAL: ASTHMA – DIAGNOSIS & TREATMENT

Asthma is a lung condition with narrowing of the airways, especially on exhalation, or breathing out. This narrowing leads to the musical sound on breathing the air out of the lungs that I heard so often with  my stethoscope and over the phone, when I was in active allergy practice. With an asthma attack, the blockage to airflow can become severe enough to dangerously raise the carbon dioxide concentration in the blood stream, and lower the oxygen content.

Many attacks occurred at night .Over the phone, I had older kids and adults take a deep breath, and count from 1 to 30 as rapidly as they could. If they could count out loud to 30 with one breath, at least the obstruction and attendant blood gas changes were not usually serious at that moment in time. That helped me decide whether or not I had to see them in the emergency room.

Asthma is an inflammatory condition of the lining of the airway that stimulates the smooth muscle surrounding the airway to constrict and obstruct flow of air, particularly on exhalation. Early on in my medical practice the main pathology was thought to be overactive airway muscles, and the main effort was to relax those muscles so that breathing could be easier. This was typically done with adrenaline injections, or the inhalation of adrenaline-like agents such as albuterol.

More sustained opening the airway was accomplished by oral theophylline. As time went on, it became  known that its effectiveness required a certain blood level. We had an HPLC machine in the office to measure this. 5 to 10 µg per milliliter was required for relief, and anything over 20 µg per milliliter was dangerous. Many cases of convulsions have been recorded in people with excessive blood levels.

We were always aware of the fact that cortisone medications would relieve asthma, but regular use of these drugs caused worrisome side effects such as interference with growth in children, osteoporosis, weight gain and loss of sleep or other problems. Most worrisome was the possibility of adrenal insufficiency and sudden death. We used Cortisone only as a last resort.

There was a group of young children especially 1 to 6 years of age that developed extreme asthma a few days after they developed a common cold. I found that giving prednisolone for two or three days at the start of a runny nose would block the advent of this asthma, without suppressing the adrenal gland. Three days of prednisone was also used to blunt severe attacks.

The excellence of Cortisone in the treatment of asthma should’ve told us that inflammation was a particularly important factor. It is now known that Asthma is not a disease of airway smooth muscle sensitivity per se, but rather a chronic inflammation of the airways that causes the muscles to be irritable.

Asthma is more common in allergic individuals, particularly when they are young. For this reason, the allergies are treated by avoidance of exposure to such things as cats, dogs, house dust and pollen.  Allergy injections to the skin test positive items is also useful.
Currently,  asthma is treated by inhaling special cortisone  preparations and long acting bronchodilators.

The chain of chemical reactions that cause asthmatic airway inflammation has become apparent over the years. Drugs to block these are available, and include special antibodies can be exceptionally expensive; but very effective.

The youngest of my former partners is still practicing Allergy, and almost never has to deal with acute severe asthma.
The beast has been tamed, if not conquered.

—Dr. C.

Mayo Clinic Article

Dr. C’s Journal: Rib Fractures & Cracks

Broken ribs are fairly common, and if you’ve ever had one, you don’t want another. A rib fracture causes lots of pain, which is worse when you take a deep breath, press on the area, or twist your body.

The pain on taking a deep breath creates a catch 22, because taking a deep breath every few minutes is a good idea, if not essential to keep your lungs open and functioning, yet you don’t want to do it because it hurts a lot.

A rib fracture is usually caused buy a direct trauma to the chest from a fall, automobile accident, or sport.

Repetitive minor injury can also cause rib fractures. This can occur when you escalate your exercise to rapidly and stress a bone, like in the foot, or when you have a chronic cough that’s violent and continuous, which could cause a stress rib fracture.

Interestingly, children age 10-12 can stress their chests enough with a heavy backpack to cause a problem where are the ribs meet the breastbone, called the costochondral junction.

Any severe chest pain raises concern for heart disease, and the fact that it is worsened by pressure on a certain area, or by taking a deep breath can be reassuring. The doctor should be contacted depending on the severity of the pain and how certain you are it is related to trauma.

Of course, if the pain in the middle of the chest, feels like pressure or radiates, You would be foolish not to go to emergency room. The treatment for a rib fracture no longer includes taping the chest, but rather continuing to take occasional deep breaths and use medication if needed for pain.

Of course you need a doctor’s diagnosis in order to continue doing this. If the Fracture was due to a fall, you should definitely educate yourself on how to avoid falls in the future. In July 2020, I posted an article on falls that you could access by typing “falls” into the question box.

There are a variety of things you can do to prevent falling: remove clutter in the house, strengthen your muscles, check your eyesight, hearing, proprioception, and balance. There are even programs for teaching the elderly HOW to fall.

Please refer to the mayo clinic article on broken ribs for more detail.

—Dr. C.

Mayo Clinic Article

Dr. C’s Journal: What Is Huntington’s Disease?

Degenerative neurological diseases are particularly horrible. They affect the brain, the very essence of our humanity. Moreover, almost all of  these conditions have no satisfactory treatment. Alzheimer’s, Parkinson’s, and Huntington’s disease come to mind.

Much more is known about the genetics of Huntington’s  than any other aspect of the disease. The problem is due to CAG repeats, which either crowd out or distort the function of the Htt protein.

If a child of a Huntington family anticipates having children, intervention to prevent transmission, such as artificial insemination and eliminating any zygotes containing the Huntington Gene will prevent the children from inheriting the disease.

Huntington’s is considered to be inherited by a somatic dominant Gene. This gene codes for a number of CAG repeats in excess of the normal number, less than 35. However the number of CAG repeats tends to increase with each generation, and it is possible for parents with somewhat less than 35 repeats eventually to produce the disease in their offspring.

As in any degenerative brain disease, the focus of medical treatment is on neurotransmitters. This is because neurotransmitters can be studied and used as the basis of medical treatment that lessens the effects of the disease. In the case of Huntington’s, dopamine, glutamate and acetylcholine  have all been implicated, although transmitter balance is probably more important, and changes with time.

Neural malfunction, however, is where the true pathology lies, and all neurons, especially those of the Corpus stratum and Cerebral Cortex contain Htt and are eventually involved, Leaving a shrunken brain that loses much of its substance and function.

The symptoms begin as a movement disorder, and initially was called Huntington Chorea, because of the abnormal “Dance-like”  movements of affected individuals . Eventually, psychiatric, intellectual and other symptoms occur which  span all areas of the brain.

Today, after swimming, I encountered a man whose brother has Huntington’s disease. So far he has been spared. He is part of a study of Huntington’s Disease Families. He denies knowing anything about his genetics, and indeed does not want to know, Nor would I in his situation, since nothing can be done to affect the basic progress of the disease.

Please refer to the accompanying meal clinic article for more information about Huntington‘s disease.

—Dr. C.

Mayo Clinic Article

DR. C’S JOURNAL: TIMING IN HEALTH AND MEDICINE

Timing is important in everything we do, and of course is important to health and how our bodies function.  It is a vast subject, and the only thing I can do here is to give you some ideas that might be helpful.

Your body will perform best for you if you have a daily routine; waking up at the same time every morning, and going to bed at the same time every evening keeps your circadian rhythm from getting confused. Of course, getting a good nights sleep is excessively important to your health. If you have trouble going to sleep at night or staying asleep, you can get all kinds of information over the Internet on “sleep hygiene”.

If you are an international traveler, jet lag is very important because the circadian rhythm is disrupted when you change time zones. The Internet is a rich source of information on how you might or rapidly get back into your routines. Timing of bright light and melatonin are involved.

Your metabolism also has a routine, and drugs work by targeting certain receptors, which cycle, depending on when their function is needed. “ Chronopharmacology” is a slowly developing science that will someday-if doctors, perhaps with electronic help, can ever get enough time to properly take care of the patients- be very important. As an example, certain cancer therapies vary significantly in their effects, depending upon the time of day they are given.

When I was a practicing Allergist, I took care of many Asthma patients. In the 60s and 70s there were few drugs to treat asthma, which is predominantly a nighttime disease. Giving medications, such as Theophylline, at the right time was therefore very important.

Finally, if you have any choice, you might arrange for your surgery during the first half of the day. Surgeons make less errors in the morning, when their minds are well rested.

—Dr. C.