Tag Archives: Dr. C’s Journal

Dr. C's Journal, Medicine, Opinion, Reviews, Women's Health

Medicine: A Historical Look At Breast Cancer

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Breast cancer is best looked at from the historical perspective, as did Lindsay Fitzharris in the December 3, 2022 issue of the Wall Street Journal.

Can you imagine having breast cancer in the mid 1800s before the germ theory was developed? 50% of all surgeries died of severe infection at that time.  Before the development of anesthesia, of course, cancer removal was extremely painful as well. Even if the patient escaped dying from infection, the one size fits all  often meant removal of some chest wall muscles, leading a gaping wound.

Today, prophylactic breast imaging (mammography) often discovers the cancer at a very early and treatable stage.

Searching the cancer cells for rogue genes and surface markers often shows the way to better treatment; no longer does one size fit all.

Sometimes the breast lump is removed with minimal surgery and radiation is used, often yielding better results than the old time radical mastectomy.

Surgery itself is often aided by tissue biopsy, and now, with “intelligent” knives, gases from the surgical cut, using mass spectrophotometry, can tell the surgeon whether the tissue being cut is cancerous or normal.

Immunization methods are in development which will help your immune system to conquer any residual cancer, and “smart” T cells can be used to attack cancer cells directly.

Breast cancer Is still the most common cause of cancer deaths in women, even with all of the modern developments. Early detection is very beneficial, as with Breast self-examination and regular mammograms as prescribed by your doctor.

Extra care should be taken in families with certain genetic markers like like the BRCA gene.

—Dr. C.

Dr. C's Journal, Medicine

Dr. C’s Journal: What Is Hereditary Hemorrhagic Telangiectasia (HHT)

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HHT is a rare hereditary condition with abnormal connections between the arteries and the veins. it’s most obvious sign is little spidery blood vessels, which increase with age, most apparently on the lips, but more importantly in the nose, where they lead to the most common problematic symptom, recurrent nosebleeds.

The abnormal connections between arteries and veins, called arteriovenous malformations, most commonly affect the nose, lungs, brain, and liver.

The AVMs in the lung can short-circuit the blood circulation and lead to shortness of breath, as can iron deficiency anemia caused by the frequent nosebleeds, and bleeding from the G.I. tract. Liver nodules, detected by imaging techniques such as CT and ultrasound, can be helpful in confirming the presence of the disease.

The AVMs in the brain can cause headaches and seizures.

The diagnosis is often delayed, unless it is known to run in the family. HHT is often called the great masquerader because of the variety of problems it can cause.

Children of proven HHT should have genetic testing, since the symptoms and telangiectasia are often not present in childhood. There are also other genetic abnormalities linked to HHT that can produce such disparate things as colonic polyps.

If I had this problem, I would invest in a device to monitor my hemoglobin level so as not to slip silently into debilitating anemia. I might also invest 15 or $20 In a fingertip oximeter. If I were short of breath, and not anemic, I might have a pulmonary AVM which bypasses the lung and produces a decrease in the Oxygen saturation.

With respect to Nose bleeds, it is important to maintain an adequate hemoglobin, preferably above 12g, using oral iron on a daily basis, and if necessary supplemented by intravenous iron. It  is also important to avoid medication and foods which cause increased bleeding. This includes the NSAIDs, fish oil, ginkgo, and St. John’s wort. News to me is the possible contribution to nosebleeds of blueberries, red wine, dark chocolate, spicy fruit and spicy foods. It may well be advisable to keep a food diary that that also records when nosebleeds occur. Perhaps you are eating something that affects coagulation that is not on the common lists. Take it with you to your doctor visit.

This is a rare condition, and should be evaluated in a medical center specialized to treat HHT.

CureHHT has some interesting information. My alma mater, UCSF, specializes in this condition.

Mayo clinic and the Cleveland clinic, as well as Wikipedia, have broader, more organized articles on HHT. A link to the former will be attached, and the latter is the most detailed.

—Dr. C.

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Dr. C's Journal, Infographics, Medicine

Dr. C’s Journal: What Is Achilles Tendinitis?

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The Achilles tendon, or “heel cord”, connects your calf muscle to the heel. Overuse can inflame the tendon, or even tear or rupture it, causing a lot of pain.

Sudden increases in intensity of exercise can be a cause. It is more common in men, and as you get older. Running a lot in the soft sand of the beach has caused problems in many of my friends. Achilles tendinitis can be caused by certain antibiotics, such as fluoroquinolones.

Varying your type of exercise, or cross training, distributes the strain you put on your body and decreases the likelihood of Achilles tendinitis. Swimming comes to mind with any disturbance of your lower extremities. The pool in which I swim three days a week is disparagingly called the “injured reserve pool” in my community  Stretching before exercising is always a good idea. Pick a routine and stick with it, particularly as you get older. If you have flat feet, getting a slight lift for the heel may help to take tension off the Heel cord, and orthotics may help. Getting expert advice is always advisable.

Prevention is always far better than treatment.

If a short period of rest doesn’t get rid of the pain, check with your Doctor, who might examine the tendon, take x-rays, or order ultrasounds to check the extent of the difficulty.

—Dr. C.

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Infographics, Medicine

Dr. C’s Journal: Flat Feet And Overpronation

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Flat feet will exempt you from the draft, but that is where are their benefit stops. This condition can be inherited, but the arch can also fail to develop during puberty.

The entire bottom of the foot will contact the ground when walking if you have flat feet.

Overpronation happens when the way you walk causes the arches of the feet to flatten even more, putting a strain on the muscles, tendons, and ligaments that support your arches. Overweight and running a lot on hard surfaces accentuates this problem, and pain in the ligaments in the arch of the foot is the result.

Overpronation may be indicated by excessive wear on the inside of the heels and soles of your shoes, and can cause all kinds of problems such as Achilles tendinitis, iliotibial band syndrome, plantar fasciitis, shin splints, and even knee, hip, or back pain. these things may  develop in compensation to overpronation while walking.

As an older person, I have pretty much given up tennis and running, and walk rapidly for long (for me) distances in order to get sufficient exercise. Without noticeably increasing my walking, I have recently developed tenderness in the arch of my left foot that made walking painful. Curling my toes, and walking on the outside of my feet seemed to alleviate the pain. This is an exercise that I remember from my childhood, and may have been shown me because of my moderately flat feet.

Swimming for Exercise, and decreasing the amount of walking seems to have corrected the condition at least temporarily, but I have also ordered some orthotic inserts for my shoes as an arch support, in case I need them going forward. I have been told that if this is insufficient I can go to a specialty store and order some special shoes that might help. I have not mentioned painkillers such as NSAIDs, because I try to avoid them

Please check with the accompanying references for more information about flat feet and over pronation.

—Dr. C.

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Dr. C's Journal, Infographics, Medicine

Dr. C’s Journal: Plantar Fasciitis And Foot Pain

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Our feet are subjected to such abuse that it is amazing we don’t have more problems with them. But problems there are, and I have been having some. I will be exploring the different types and causes of foot pain  beginning with this article on plantar fasciitis.

The plantar fascia is a triangular web of connective tissue on the bottom of the foot that begins at the heel and fans out to attach to the toes. With repeated stress, it can become torn or inflamed and caused pain.

The pain of plantar fasciitis is usually centered around the heel, on the bottom of the foot. It is often absent first thing in the morning, produces a stabbing pain on first walking, and goes away with activity; you can “walk it off”. Plantar fasciitis is usually slow to heal and may take several months

The doctor will usually make the diagnosis by your story(history), and the localization of the pain. X-rays, CT scans, and MRIs or necessary only if there’s a suspicion of a stress fracture.

Conservative treatment focuses upon stretching exercises and orthotics, but there are various types of injections, shockwave therapies, ultrasonic tissue repairs, and surgeries that some people need.

A particularly interesting treatment cited was the injection of platelet rich plasma from your own blood to promote healing. I recently read that this technique, in addition to a collagen scaffold  is currently used to treat rupture of the anterior cruciate ligament of the knee.

Of course, prevention is the ideal. Maintaining a healthy weight is important. Supportive shoes, with thick soles and good arch support will help. stretching exercises are also helpful as a preventative.

Please check with the Mayo Clinic article for more information.

—Dr. C.

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Dr. C's Journal, Infographics, Medicine

Dr. C’s Journal: What Are Symptoms Of Gonorrhea?

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Gonorrhea been present since the earliest times. The United States has one of the highest incidences, and it was very common in colonial America, where it was called “clap”. Adolescents, with their increased sexual activity, have the highest incidence, and girls are somewhat more likely to have it than boys.

The symptoms have to do with infection and inflammation of the urethra. Burning on urination is almost universal, and purulent discharge and presence of pus in the urine is frequent. The infection is mostly a nuisance, but it can travel up the genito-urinary tract, and into the spermatic ducts in the male or the fallopian tubes in the female, and it is a common cause of sterility and pelvic inflammatory disease, or PID.

With its high frequency in young females, bacterial ointments are routinely applied to the eyes of newborn babies to prevent severe infection and possible blindness.

When I was practicing medicine, the diagnosis was made by culturing for the bacterium neisseria gonorrhea. Now the NAAT, the nucleic acid  amplification test, is the gold standard.

In my practicing  days, penicillin was the magic bullet, but resistance he has developed so that a cephalosporin and azithromycin combination is currently used.

STDs, sexually transmitted diseases, are one of the commonest conditions encountered in student health, according  to a good friend.

Please refer to the attached Mayo Clinic article for more information.

—Dr. C.

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Dr. C's Journal, Medicine, Prevention

Dr. C’s Journal: Bee Sting Allergies And Reactions

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Almost everybody experiences a bee sting sometime in their life, although only a few people have more than a mild reaction to the stings. Adults react more commonly than children, and old people more seriously than young.

Anaphylaxis, which is potentially fatal, is the main worry about bee stings, although if you get stung in your throat, or by 10 or more insects there is risk of problems from the venom alone.

The usual reaction to a bee sting is sudden pain, a small swelling that lessens later in the day, after which there is recovery. A large local reaction can occur where the swelling increases over a 2-3 day period and can last for 7 – 10 days. This is called a large local reaction, and considered to be an allergy, but carries no increased likelihood for anaphylaxis.

A bee sting with hives developing on the skin but no other symptoms usually requires nothing more than an antihistamine. Interestingly, I had a bee sting on my foot after walking on the beach, became itchy all over and developed hives, received desensitization, and had no more trouble with the several stings I had later.

Anaphylaxis is defined as a reaction distant to the site of the bee sting that involves more than one organ system. For instance you might have hives and wheezing, hives and dizziness, or any number of other combination of organ involvements or sickness.

If anaphylaxis results from the sting, it is best to be referred to an allergist.

Interestingly, bee sting allergy is NOT more common with allergic individuals, even though they may have more severe reactions. Apparently, the sting reactions are dependent upon an excess number of a cell called the mast cell, and this is determined by a serum test for tryptase.

The allergist usually performs skin or blood tests to determine whether there is sensitivity to insect stings; in addition to the Honeybee, yellow jackets and to a lesser degree other stinging insects called Hymenoptera can produce analyphaxis.

Desensitization is the only curative treatment for anaphylactic reactions to stinging insects. In addition, rapidly administered epinephrine or adrenalin, such as an EpiPen, as well as antihistamines, are usually kept on hand for use in case of a bee sting.

When I first started practice, we made our own extracts using the whole bee. Unfortunately, the digestive tract enzymes in the bee destroyed the protein of the venom so that our materials were not sufficiently active. Even after pure venom extracts became available, we also would give injections to individuals who developed hives as the only reaction other than the pain and swelling of the sting. A large study showed that  desensitization for a large local reactions, or hives only, was not warranted.

Medical science continues to advance, and you are well advised to go to the best-trained specialist you can find for bee sting anaphylaxis. Your life may depend on it.

—Dr. C.

Dr. C's Journal, Infographics, Medicine

Bacteria: The Risks Of Pseudomonas Aeruginosa

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Bacteria have long been classified according to how they are stained by the chemical dye called the Gram stain. Pseudomonas aeruginosa is Gram-negative, compared to the Staph aureus which is gram-positive.

Being Gram negative, Pseudomonas has an extra membrane, the outer membrane, and a shell of a nasty material called Lipo polysaccharide. These extra structures act as a barrier to entrance of antibiotics. In addition, the Pseudomonas has many more genes than the average bacterium and uses these genes for adaptation. For instance, it is good at forming a raft of mutually supporting cells called a biofilm, which enables it to become particularly entrenched. In a condition of the lung called cystic fibrosis, this biofilm contains specialized cells, one of which is called the Persister cell. When Pseudomonas senses that a critical number of bacteria is present, called quorum sensing, the persister cell multiplies to become around 10% of the bacterial population, and slows down their metabolism massively, becoming a sort of “zombie cell”. These cells are very hard to kill and persist through an antibiotic treatment that kills other Pseudomonas cells, only to rev up their metabolism and become active again once treatment is withdrawn.

In addition, Pseudomonas has all of the other resistant talents mentioned in the previous article on Staphylococcus aureus, such  as plasmid acceptance, ability to destroy penicillin, efflux pumps, and rerouting of metabolism.

In trying to control Pseudomonas, techniques other than antibiotics are being tried out of desperation, including interference with a quorum sensing, use of bacteriophages and chemical  elements such as Gallium which masquerades as the iron this bacterium requires.

Pseudomonas is not as actively pathogenic as Staphylococcus aureus, but it has made a great niche for itself in the respiratory tract, especially in people with a compromised immune system, or pulmonary abnormality such as cystic fibrosis. Ventilation tubes and other hospital equipment can become contaminated and spread the infection, unless thoroughly cleansed of Pseudomonas; it is very sensitive to acidic solutions, and those who need nasal CPAP for sleep apnea may recall that they have to rinse their equipment in vinegar, or acetic acid. Swimmers can get an external ear infection with this organism, and the drops for swimmers ear often contains acetic acid.

The next rogue to consider is a frightful yeast called Candida auris.

—Dr. C.

Dr. C's Journal, Infographics, Medicine

Dr. C’s Journal: The Rise Of Antimicrobial Resistance

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We are immersed in a vast sea of tiny organisms, microbes, most of which are either helpful or neutral. There are a few bad actors that can harm people and are responsible for plagues of the past, such as the black death, cholera and influenza epidemics.

This whole picture changed in the late 30s with the advent of Sulfonamides, and especially Penicillin, the “magic bullet”. I was practicing medicine early in the days when antibiotics eliminated almost all infections.

In fact, at one time infections were thought to be a problem of the past. Unfortunately, overusage, chronic multiple infections, surgically implanted devices, immune suppression for cancer and autoimmune diseases have allowed bacteria, fungi and viruses to evolve resistance mechanisms.

At the present time there are a number of bacteria, such as staphylococci, actino bacteria, enterococci, and candida that are essentially untreatable. Even if they are somewhat treatable, second and third level antibiotics are so toxic that they can cause problems with the kidney, liver, or heart.

In later postings, I plan to consider specific organisms and the situations in which they operate. I will also eventually talk about efforts to create new antibiotics by harvesting genetic material from unusual places, even our oceans.

—Dr. C.

Dr. C's Journal, Medicine

Dr. C’s Journal: Signs & Symptoms Of Prostatitis

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Prostatitis seems to be a catchall diagnosis varying anywhere from clear cut acute bacterial infection of the prostate gland with burning on urination, fever, positive cultures, and response to antibiotics, through recurrent nagging symptoms that can include pain on urination, urine flow obstruction, sexual dysfunction, blood in the urine, and chronic pain syndromes affecting the pelvic region.

Prostatitis constitutes perhaps 10% of urology practice, and is often frustrating to patients and physicians alike.

Symptoms are shared with BPH and prostate cancer, which are more clear-cut entities with standard diagnosis and treatment.

Prostate and bladder stones can give similar symptoms on rare occasions. STDs can be a diagnostic consideration in people with multiple sexual partners, and with international travel, we mustn’t forget parasitic infections.

From the patient’s standpoint, the important thing is to find a good urologist who can sort out the symptoms and find a proper diagnosis and treatment plan.

Please refer to the following Cleveland clinic article for a more orderly discussion.

—Dr. C.

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