Category Archives: Dr. C’s Journal

Dr. C's Journal, Infographics, Medicine

Dr. C’s Journal: Sexually Transmitted Disease (STDs)

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Sexually transmitted diseases are so common they deserve their own acronym, STDs. Down through the ages, Sexual activity with multiple partners has been so popular that the ever-resourceful bacteria, fungi, and viruses all compete for this ever present ecosystem. It is not uncommon to have multiple STDs at the same time.

Since STDs have many symptoms and physical findings in common, it is essential to go to the doctor for a diagnosis; certainly the treatments very widely.

Until the mid 20th century, treatments were very unsatisfactory, and the infection of the vagina would often lead to deeper infections of the uterus and abdominal cavity; pelvic inflammatory disease (PID)was fairly common then, and still occurs in people foolish enough to postpone getting their problem treated properly.

The common STDs include bacterial vaginosis, chlamydia, gonorrhea, genital herpes, human papilloma virus infection(HPV), Syphillis  and Trichomoniasis. These are sufficiently different in their symptoms and treatment as to deserve their own discussion among the 101 common disorders. Now we have a new kid on the block, Monkeypox, that is helping out AIDS as a plague to the homosexual community.

I have a dear friend who is a physician for a student health department at a major university. STDs, depression, and other psychiatric problems are among the more common things that she sees in her practice.

—Dr. C.

Dr. C's Journal, Medicine, Research

Cancer Treatments: CAR-T Cell “Smart” Therapy

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In war, we are familiar with “smart bombs” that home in on a laser-marked target, or a heat source. The same thing is happening in our battle with cancer. Everybody has had friends or relatives given chemotherapy, which affects all cells, but  cancer cells, since they are dividing more rapidly, suffer the most. However, the entire body is affected with weight loss, hair loss, anemia, leukopenia and other severe symptoms.

The two developments I would like to address here, are smart chemotherapy using ADCs, and smart immunotherapy using CAR-T cells.

In smart chemotherapy, a poisonous package is linked to an antibody which homes in on cancer cells having a specific membrane marker on their surface. For instance, many cancers, not just those of the breast, express HER-2 receptors. Antibodies specific for this receptor are attached to such drugs as doxorubicin, in a therapy called ADC. The coupled pair then home in on the cancer cell and kill it, sparing  the rest of the body most of the exposure to this toxic chemical. This is really a form of immunotherapy, since it uses antibodies.

Smart cell therapy with CAR-T cells, uses T lymphocytes which normally have surface ligands that attach to various cells marked for killing. These T-cells have their targets genetically modified, with antibody receptors, to be specific for such things as CD 19 and BCMA on the surface of cancer cells. When infused, the T-cells latch on to the specified cancer cells and punch holes in them. The treatment can have some side effects, but they are usually much less severe than  regular chemotherapy.

CAR-T cell therapy has been very successful for blood cancers like leukemia, Lymphoma, and multiple myeloma. It can produce flu-like symptoms from the recruitment of lymphokines, and occasionally neurologic symptoms. It is currently successful in about a third of the cases, used as a second line therapy, and is very expensive.

It used to be that a cancer was classified according to its anatomic location, e.g. breast cancer, colon cancer, skin cancer. With increased knowledge, it is now becoming more important to know the surface markers of the cancer than the organ of origin.

—Dr. C.

JAMA Oncology Article

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Dr. C's Journal, Medicine

Dr. C’s Journal: Types Of Cancer Screening Tests

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There are a number of recommended screening tests for cancer.

Mammography has been shown quite effective in reducing deaths from breast cancer, it is recommended for women ages 40 to 74.

HPV and PAP tests are recommended for cervical cancer screening in women. Testing should begin at age 21 and end at age 65.

Colonoscopy is recommended for colorectal cancer screening for both men and women ages 45 through 75.

HCT, a type of CT, is recommended for heavy smokers at ages 15 to 80.

Where the risks are high, there are other tests not generally recommended for everybody. Tests are available for liver cancer, prostate cancer, skin cancer, and ovarian cancer where are the risk is high. In women with BRCA1 And BRCA2  mutations, breast MRIs are recommended.

Personally, I get a yearly PSA test, mainly because a good friend, a physician, died within 3 years of prostate cancer when he stopped taking the test.

I also get a skin examination by a dermatologist every six months, because I have a very fair skin, probably caused by the freckle variant of the MC1R gene.

There are a number of symptoms and signs that suggest cancer,  particularly when they don’t go away, such as fatigue, weight loss or gain for no apparent reason; trouble swallowing, nausea, or abdominal pain; swelling or lumps anywhere in the body; cough or hoarseness; unusual bleeding; change in bowel habits; fevers or night sweats; bleeding areas in the mouth. Protracted headaches or vision problems can be worrisome.

In short, any distressing or unusual symptom that doesn’t improve on its own should be watched very carefully, and reported to your doctor; but it is far better to pick them up early with a test or a doctors routine examination than to wait for symptoms to develop.

—Dr. C.

Dr. C's Journal, Medicine

Dr. C’s Journal: Recent Gains In Cancer Care

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Recent medical advances in the treatment of cancer you have been amazing. Many of these advances have taken advantage of our own immune system‘s and fighting the cancer. If you or a loved one have had the recent diagnosis of cancer, there are several general things that you should know.

MVU MHA 2021 Q4 Infographic_ Advances, Breakthroughs, and Innovations in Cancer Treatment

The amazing technological advances in medicine have a come with a price tag, more than just the astronomical cost.

Preventative medicine it is given little attention in the medical profession these days, it wasn’t that great in the past either. The reason? Doctors don’t get paid to prevent disease; they get paid for treating it, and doctors are merely human beings like the rest of us and have a fondness for making money. Besides, the individual patient never knows whether he would’ve gotten the disease, had he not tried to prevent it. It takes a large number of people in a planned study to discern that.

Sleep, diet and exercise have all been casualties.

If you have established cancer, your tendency will be to give up on any exercise that you have been doing. This is an error. Depression is very common in patients with cancer, and inactivity makes it worse. Exercise is the one of the best things you can do for depression, and it may well  benefit cancer itself. To be sure to ask your doctor directly about this.

Diet is also extremely important. Many Cancers produce substances that kill the appetite. Weight loss in cancer is one of the hallmarks of the disease. It becomes very important to maintain a good diet.

Sleep is also very important. Just a day or two with poor sleep can harm the Immune cells, and with immune system damage, cancer can only worsen.

Drug studies improve medical care. They also deliver care free of charge, except for your time in taking part in the study. The usual Cancer study compares the new drug with established treatment. There is minimal worry that you are going to be getting a sham treatment.

Certain medical centers are known to specialize in certain areas of cancer treatment. For instance, in Southern California, the University of San Diego is known to be a Center that treats pancreatic cancer. The city of Hope in Los Angeles is known to be a center specializing in CAR-T cell treatment, A promising if expensive treatment for pancreatic cancer. 

It is very definitely worth your while to check into the availability of specialized care centers and drug studies in your area.

One of my friends developed melanoma and was told by his doctor to get his affairs in order. This absurd statement was made by a cancer doctor in one of the best hospitals in our area. In checking with an oncologist of my acquaintance, I found that a mere 30 miles away was a center specialized in the treatment of Malignant Melanoma. He went to the center for treatment, and was given a drug called a checkpoint inhibitor. He was virtually asymptomatic in a year. Unfortunately, patients can rarely expect such dramatic results.

In the history of the world, it has never been easier to learn about your disease, in this case cancer, and participate in its treatment. Especially in medicine, the best is none too good; it pays to do your homework, or at least find a medical advocate who will pursue your cause.

—Dr. C.

Dr. C's Journal, Infographics, Medicine

Dr. C’s Journal: Care Of Hand Osteoarthritis

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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, Medicine, Resources

Dr. C’s Journal: Pain Without Treatable Cause

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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, Medicine, Resources

DR. C’S JOURNAL: VITILIGO

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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 Journal, Medicine, Research

DR. C’S JOUNRAL: STEM CELL TREATMENT UPDATES

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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, Medicine, Opinion, Resources

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

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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, Medicine, Resources

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

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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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