Archive for December, 2011

Meth Madness: Part 1

Wednesday, December 28th, 2011

Some people just pop pills

Recently our local paper, the Fort Collins Coloradoan, published a USA Today article titled "Missouri grapples with meth." I read about the nearly 7,000 law-enforcement seizures of laboratories and methamphetamine-related material in 2011 (through late November), saw that Colorado wasn't in the top ten states involved (at least in methamphetamine lab seizures) and wondered why Missouri, with 1,744 confiscations, was clearly the hot spot for this drug

A contentious issue is whether state law requires a  doctor's prescriptions for over-the-counter medications containing pseudoephedrine, a chemical also used for meth production. That's not true in Missouri where, at present the rules vary from county to county. Oregon and Mississippi have already passed such laws with impressive declines in meth seizures as a result. Fifteen other states have proposed similar legislation.

Then I found a series of articles that brought this issue squarely home to my state. In April 2011  the Denver Post published  two articles about proposed Colorado legislation that, if passed by the state Senate, would have made a number of pseudoephedrine-containing medications, used to treat the symptoms of colds and allergies, available only by prescription; eventually the potential new law went down to defeat by a 7 to 2 vote.

Yet the Colorado Meth Project, part of a much larger, multi-state prevention program whose focus is reducing the usage of this drug, said my home state ranked 7th in the U.S. in total number of "past-year meth users" aged 12 and up in a national survey on drug use during the 2006 to 2009 time frame. Did the "12 and up" catch your attention? This campaign, named the world's 3rd most effective charitable endeavour by a national magazine, was started in 2005 and works in three arenas: public service messages, public policy and community outreach.

It's been given credit for marked reduction of methamphetamine use in a number of states. As part of an ongoing CDC surveillance system, monitoring six types of health-risk behaviors that contribute to the leading causes of death and disability among youth and adults, the 2010 Youth Risk Behavior Survey saw a highly significant decline of teen meth use: 52% in Idaho, 63% in Montana and 65% in Arizona.

But we're not just speaking about teens. In late November of 2011, a 68-year-old former Colorado county sheriff was arrested; he allegedly was trading meth for gay sex. If proven guilty, he clearly wasn't alone in his drug-related activities.

Others inject their drug of choice

So returning to the question of why is this particular illegal substance so important? It's a highly addictive stimulant responsible for risky sexual behavior and extreme violence. The Centers for Disease Control and Prevention (CDC), published an extensive  2007 review on methamphetamine use and the risk for HIV/Aids. After discussing research indicating that meth-using gay men may increase their risk factors, they mentioned that heterosexual adults and adolescents who use meth may also engage in sexual practices that markedly increase their possibility of developing STDs including HIV.

That's by no means all that methamphetamine does to its users, but I'll write more concerning the chemistry and effects of the drug in my next post.






What else can a strep infection lead to?

Saturday, December 24th, 2011

tiny bacteria can lead to huge consequences

I wash my hands more frequently these days, not as a sign of OCD, but just from common sense. Familiar bacteria, ones that some of us carry and that our school-age kids may encounter several times a year, can rarely cause horrendous, life-threatening problems. WebMD has a short review of one of these diseases, one that physicians call necrotizing fasciitis (NF), but most non-medical folk know of as "Flesh-eating Strep."

I had read about this complication of the same bacteria that can cause strep throat, but prior to moving to Fort Collins in 1999, had never known of someone who developed it. Then, shortly after arriving here we joined the Newcomers Club. We met lots of people who came to the "Choice City" after retiring and heard of one who subsequently lost a spouse to the disease.

After that I paid a lot more attention to the entity. As I read considerably more about NF, I realized that streptococcal infections weren't its only cause, but I'll focus on strep today.

NF isn't the only major complication caused by Group A streptococci (GAS). There's a toxin-caused deadly illness called toxic shock syndrome. This has been around in the medical literature for about three decades. I became aware of it in December 1980 when the New England Journal of Medicine published an article describing 38 cases of this dire syndrome where patients, usually women who were menstruating and using tampons, developed high fever, low blood pressure and multi-organ failure, as well as sloughing off the skin of their palms and soles. The causative agent often was staph and blood cultures were often positive for staphylococci.

Yet half of the cases in a 2010 review did not involve menstruating women, in fact a quarter of the patents were men. Over the past thirty years, tampons have been improved so that the number of cases invoking their use has gone down markedly.

But the syndrome is still around and other bacteria, especially GAS, have been involved. Many of the patents who developed strep-associated toxic shock syndrome (STSS) had underlying chronic diseases (e.g., diabetes, cancer or alcoholism) or had recent surgical procedures. Some researchers have implicated a specific toxin in strep TSS.

When GAS bacteria find their way into areas where they are rarely seen, they can cause diseases much more severe than the usual strep throat or skin infections. These illnesses are called "invasive group A streptococcal disease."

It's estimated that an average of 10,000 cases of invasive GAS disease with a mortality rate over 10% happen in our country every year. Necrotizing fasciitis and STTS are even more likely to be lethal. A fifth to a quarter of those who develop NF die and half of those who have STTS.

Remember most of the millions of cases of strep infections that occur yearly here are relatively mild, but even those are nothing to be ignored. Good hand washing technique is crucial and I've provided you a link to the Mayo Clinic's article on thus subject.

The CDC article stresses that anyone who develops an infected wound, particularly if they also have a fever, should see a physician immediately. You may save your life if you do so.


The PANDAS controversies

Thursday, December 22nd, 2011

We're not talking about this kind of Panda

The more I read about the relatively new syndrome PANDAS, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus, the more I realize how complex the issues are that surround it. We appear to be entering a new field of medicine, one that holds enormous potential for unlocking the root causes of baffling problems in neurology and psychiatry

The story starts in the mid 1990s when Dr. Susan Swedo, now Chief of the National Institute of Mental Health's (NIMH)  Pediatrics & Developmental Neuroscience Branch , reported that childhood obsessive-compulsive disorder (OCD) may sometimes be triggered by a strep infection.  OCD may involve compulsive handwashing, twenty or thirty times a day; it can manifest itself as a need to have things "just so" in order to relieve anxiety, repeating and checking behavior, counting and arranging objects or clothing, hoarding, praying, reading a section of a story over and over again.

Some of these youngsters also have tics, involuntary movement disorders. Another subset just has tics, but no OCD.

A moving portrait of a child who fits this profile was published in the Los Angeles Times early this month. The boy involved wa a normal eleven-year-old sixth grader until he developed a strep throat. Then his behavior altered to the point where daily life seemed totally changed; he became obsessed with being clean  and afraid of germs to the point where he was unable to go back to school.

Increasingly these diseases and perhaps others are being linked by some eminent researchers to strep infections. A senior immunologist at the University of Oklahoma College of Medicine thinks the mechanism of PANDAS involves antibodies, released in response to a strep infection, that can bind to brain cells and cause the release of dopamine, a brain chemical which in excess, may be linked to OCD and tics. The diagnosis, at the moment, is strictly clinical; there is no lab test to confirm that a child has PANDAS.

One form of OCD involves repetitive handwashing

Many youngsters with OCD and/or tics don't appear to have this strep-related syndrome and some equally prominent academic physicians feel kids can have a mental health/neurological disorder first and just have it exacerbated by strep throat or other infections. Others want to treat the most severely affected of these children with antibiotics even if they don't have an active strep infection.

The NIMH makes the point that these children, as opposed to others with OCD and/or tics, have an abrupt worsening of their symptoms when they have a strep infection. They then will have a slowly improving course after a few weeks or months.

The guidelines are admittedly vague; NIMH says PANDAS can be "identified after two or three episodes of OCD or tics that occur in conjunction with strep infection."

A senior Harvard professor of psychiatry who is the head of the International OCD Foundation's scientific advisory board has been quoted as saying the portion of OCD linked to PANDAS is "exceedingly common."

Is this the tip of an iceberg of neuropsychiatric problems linked to infections? Only time and lots of research will tell.

Don't you need a disaster preparedness plan?

Saturday, December 17th, 2011

Trouble coming this way

When my wife and I were active duty Air Force medical officers we participated in disaster exercises and when I became one of the senior staff at various places I helped plan some of those drills. After we retired our only effort along those lines was accumulating a small supply of food and a few jugs of water. That was ten years ago and obviously the stock needed to be rotated or used on a regular basis, but it hasn't been.

From 1988 to 1991 I commanded a 150-bed Air Force hospital in Wichita Falls, Texas. We met with the local civilian disaster planning group for their yearly event. They were even better prepared than those of us in the military and, when I asked why, told me of the triple tornado that had merged and ripped though their city ten years before, an April 1978 event called Terrible Tuesday.

We lived on Keesler Air Force base in Biloxi, Mississippi next and I was the commander of a 325-bed medical center. During our two years there three hurricanes headed our way. Two turned away well out in the Gulf; one didn't until six hours away. By then I had called in Air Force planes and evacuated my patients.

Recently four friends told me of incidents where they or their  adult children were without power for four to nine days. One lived in Chicago, and having three young children wanted to be ready for a contingency. She put a grill in her fireplace for roasting marshmallows...or anything else. When a Midwestern snow storm took down power lines, leaving her without electricity for six days, she was prepared.

this could be the start of your emergency supply kit

After reflecting on these episodes, I dug out the old disaster file I once had used, found the Emergency Food in a Nutshell book a writer friend had given me, and started compiling a list of things we'd need. I've already purchased a few, high-priority items and stored them. I emailed a letter on the subject to nearly fifty friends; ten have already replied with suggestions.

Then I talked with another writer who suggested  I send a request out for my blog readers to cogitate on what they'd think of accumulating/buying.

Do we stay or leave?

When I have input from a variety of of you, I'll add items to my own list, send a copy of the updated version to each person who has contributed and then, hopefully,  publish an article with the list included.

Depending on where you live, you may face the potential threat of an earthquake, tornado, flood or hurricane. In 2003 great swatches of the Northeast portion of the United States lost electrical power. Potentially a disaster could be man-made. You may be evacuated to safety or you could be stuck in your home for weeks or even longer.

So let me know, if you want to join in this endeavor, what you'd want to have for a "very rainy day" or week or month.

Now we have PANDAS in the United States...unfortunately

Wednesday, December 14th, 2011

Those nodes are swollen

Until today I thought Pandas were black and white bears found in zoos or in small numbers in parts of China. Then I read a Wall Street Journal article titled "Does Strep Throat Trigger Serious Ills?" The concept being discussed was that of PANDAS or Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus. I subsequently found a National Institutue of Mental Health (NIMH), article online about this unfamiliar, relatively new and bizarre condition in which children get neurological problems caused or flared by a streptococcal infection.

Let's begin this two-post discussion with an overview of strep throat, a bacterial infection most commonly seen in children between the ages of 5 and 15. Younger kids can certainly get this disease as can adults, but the typical kid in school has strep throat several times a year. It's important to realize that most (75-80%) sore throats in children aren't bacterial in origin, but if they are caused by streptococcal infection they can lead to severe consequences.

Among those are rheumatic fever with its attendant heart valve consequences and, less frequently, a significant kidney sequela, post-streptococcal glomerulonephritis (inflammation of the tiny filtering blood vessels in the kidneys). Both of these are seen worldwide with considerable frequency, but are much less common in the United States than in years past.

Why is that? Well, most of us who have healthcare (and I know that's far from all of us), would take our children to the pediatrician/family practice physician promptly if they had sudden onset of fever with a severe sore and red throat,  swollen lymph nodes in the neck and trouble swallowing (or even some of those). The doc would do a rapid strep test using a swab similar to that done for a throat culture and if that were positive prescribe antibiotics. If it was negative (it can be in about 5% of cases of strep throat, AKA strep pharyngitis), but the presentation and/or exam was suspicious, the physician would do a throat culture.

Those complications I mentioned are relatively rare. When they do occur they're due to an autoimmune reaction; that means the antibodies we produce to help fight the streptococcus can also, in some instances, attack our own tissues.. The theory behind that is called "molecular mimicry," a fancy way to say our heart valve, kidney, joint or brain tissue may have proteins that somehow resemble those of the bacterial cell wall.

after this you get a lollipop

There a PubMed Health review on treating strep throat, at least that caused by the bad kind of streptococcal bacteria. Their scientific name is group A beta-hemolytic strep sometimes termed GABHS. PubMed, by the way, comes from the National Institutes of Health's (NIH) National Library of Medicine and prints very solid material that I think you can rely on.

They looked at a series of articles on how best to treat strep throat, 17 trials with over 5,300 subjects, and concluded that good old-fashioned penicillin should be the first choice. It's cheap and no antibiotic resistance in GABHS has ever been documented. So unless you or your child have had an allergic reaction to penicillin, that's the drug your doc will likely use.

We'll get back to PANDAS next post.

What's worse than TBI?

Friday, December 9th, 2011

play today, pay tomorrow?

In my last post I wrote about the immediate risk to our youngsters, that of traumatic brain injury (TBI). Now I'd like to move on to an even grimmer issue, much more severe and long-lasting brain damage that's also trauma-associated. We've heard of professional football players developing personality changes, then more severe neurological problems; most recently I read of a professional hockey player who had similar issues.

So I found the Boston Center for the Study of Traumatic Encephalopathy (that term translates as "disease, damage or malfunction of the brain."), and read one of their major publications on what is called Chronic Traumatic Encephalopathy   (CTE). Trust me, most of the medical jargon it uses is tough even for a Internal Medicine subspecialist. It was published in a journal I've never heard of, J Neuropathol Exp Neurol, but is very well written and, in addition to detailing the brain changes in 48 cases of CTE, provides an excellent background discussion of the entity. Ninety percent of the neuropathological confirmed cases of CTE were in athletes.

I remembered a story in 2009 of a 26 year old Cincinnati Bengals receiver who had died after falling out of a pickup truck during a domestic quarrel, reviewed the recent New York Times piece on a 260+ pound NHL "enforcer" who died of a combined alcohol and painkiller overdose and found another Times article, this one from May of 2011, about a former Chicago Bears defensive back who had committed suicide and donated his brain to the Boston research center. All three had CTE.

That article said about two dozen retired NFL players were eventually found to have this disease; the research article mentions that over one-sixth of those having repetitive brain injuries called concussion or mild TBI eventually will go on to have CTE .

But we're not just speaking of football players or hockey players. Professional wrestlers, soccer players, domestic abuse victims, military veterans, horseback riders, seizure victims, head bangers as well as boxers and hard-form martial arts participants may well have similar recurring brain trauma and potentially could go on to CTE.

It's time to study their brains, hopefully before it's too late.

The NFL donated $1 million in 2010 to CSTE, the Boston University research group; researchers at the center have lined up 100 former players  to try to find ways to diagnose the condition during life and more than 250 active and retired NFL players have agreed to donate their brains and spinal cords to the CSTE.

Nearly 100 are suing the league over the issue of player safety, saying the NFL has down-played the concussion problem to give fans more action. A knowledgeable friend told me the NHL allows bare-fisted fights between its enforcers and others to go on for roughly fifteen seconds; he said the audience loves the brutality.

Bread and circuses were a way to keep the Roman populace from revolting. Why are we emulating them?



It goes far beyond football, boxing and hockey

Wednesday, December 7th, 2011

The brain is vulnerable to trauma

I feel like I've opened the proverbial can of worms, finding, in this case, a topic that keeps expanding. I started with reading an article in The New York Times about the death of a professional hockey player, but I quickly delved into the medical literature.

I've spent much of the day reading article after article on traumatic brain injury  (TBI), which can be mild or severe, and another entity called chronic traumatic encephalopathy or CTE, one that's frequently been in the news over the last two years. Let's start with TBI. I'll be writing about teens and younger kids. I'll deal with CTE in another post focused on adults.

A Center for Disease Control and Prevention (CDC)  report in the most recent edition of the Journal of the American Medical Association reviewed nonfatal TBI related to either sports or recreational activities in kids age 19  or younger. The numbers involved were staggering, nearly 175,000 per year being seen in Emergency Departments (EDs).

A large majority of those sports and recreation-related TBI ED visits were by boys and the annual total of those ED trips increased markedly during that nine-year time frame. They were injured biking, playing football, soccer, basketball or while engaging in miscellaneous playground activities. They went to the ED in smaller numbers for injuries suffered in many other activities, including horseback riding, ice skating, ATV riding, tobogganing and even golfing (here the injuries included those related to golf carts). Surprisingly, skateboarding accounted for only a fourth of the ED visits for biking and football accidents and TBI was less frequently seen.

A helmet is a good start

As my wife and I drive around town, we often see college students riding their bikes at night while helmet-less and light-less. I fear for their brains.

There's another, less well-accepted entity, so-called "Second Impact Syndrome." I read an article about this in a February 2009 article by two authors on the faculty of the University of California, Irvine School of Medicine. In this scenario athletes who've had a TBI then have a second brain injury when they go back to playing their sport far too quickly. The initial injury may have been relatively mild; the recurrent trauma may kill them in a matter of minutes.

Another review of this  syndrome said 94 catastrophic head injuries had been reported in American high school and college football players in a 13-year time frame, 92 in high schoolers.  Seven of ten had a prior concussion in the same football season; over a third played with continuing symptoms.

This speaks to the crucial question of when an athlete (or a bike or horseback rider) who has suffered TBI should return to their sport/activity. Last night I called a younger friend who had been bucked off his spooked mare and suffered a concussion eight days ago. He was still having headaches and agreed with me that it was far too soon to get back on his horse.

A new CDC program called Heads Up offers TBI guidelines for coaches, parents and physicians.