Gastrointestinal truths

I have female patients who try to convince me that they don’t pass gas.  I tell them, “Well I know you pass gas every day, and I know how much you pass every day!”

– GI Pathophysiology prof

For the record: 7-8 times a day.  Males do it twice as much.

Gems from First Aid

There’s a study book to use for the Step 1 called First Aid, and you’ll see pretty much every med student on campus (and on any campus) carrying it around wherever they go.

Here are some of the gems it has:

How to remember that the nipple is at the level of the T4 dermatome?  T4 for the teat pore.

How to remember that Gardnerella vaginalis is one of the bacteria causing bacterial vaginosis, which produces discharge with a fishy smell and white blood cells covered in bacteria (clue cells)?  I have no clue why there’s a fishy smell in my vagina garden.

Whoamygosh. Or, how I became a Glimpse Correspondent

The first time, I was in Thailand and my PayPal account was going to put me behind the deadline.  Sitting in an uncomfortable internet cafe in Bangkok, feeling the patience of my brother running down, I was clicking away at my computer, editing my writing sample while in other windows I was working on setting up a PayPal account to pay the application fee.  It was an old fiction piece I had written for my high school senior English class about the last days of your mother’s life, and letting go.  All interspersed with lyrics from “Across the Universe”.  I loved it back in high school.  When I reopened it years later, I was shocked at how bad it was.

That was after my MSc, when I was in that strange funk of excitement to explore the world, with simultaneous fear and disappointment of not knowing what I was doing with my life.

Now, three years or so years later, I’m in Grenada, sitting in Taylor, a chilly study hall on my medical school campus.  I’ve heard it described as a “freezer full of angry medical students” but when I opened the email from Glimpse it had at least one speechless one.  I shook Frond, and we headed outside where I could properly freak out, dance and yell unintelligibly in peace.  “The extensor surface of my arms are tingling!  My radial nerves are flipping out!”  I am such a nerd sometimes.

I am so fortunate.  Really.  To have finished my MSc then decided not to continue in the same field, so I had time to explore other options and stumble across the Glimpse Correspondent program.  To move to Grenada after having been rejected by all the North American medical schools I applied to, after two rounds and thousands of dollars in application fees, and just as many tears.  To have had Frond to help look over my application writing sample and tell me not to try so hard, to just tell the story and not tell people what to think or feel.

I have so much more to learn about writing!  I’m so excited.  I really want to become a great communicator; to tell stories that make people think and feel, and to use this when I keep going on, to help people around the world learn about each other, and to connect them.  Maybe along the way I’ll learn how to stop using commas so much too.

My extensor surfaces are still tingling, my schoolwork has gone totally untouched, and a mosquito is having the time of it’s life with my knee.  But that’s all great.  Somehow, sometimes, when you really put yourself out there, the stars align and you get that email.

Here’s what I submitted to Glimpse as my writing sample.  It might seem a bit familiar as it has pieces taken from other blog entries.

New In Town.

Rumbling down a dusty unpaved road in Shervin’s jeep, we whipped around a leafy green blur and came to a clearing.  There were two small buildings, surrounded by knee-high kids in twos and threes, running here to there, stopping, then taking off again in a new direction.  They were each monochromatically dressed in either green, red, or yellow.  It was a multicoloured ant hill.  On the other side were older kids dressed in long navy blue pleated skirts, white collared short-sleeved blouses and red ties or navy pants and white dress shirts.  These kids were leaning over the railing of the second floor, many yelling, some throwing food onto the yard, most just gazing about coolly.

We had come to talk to the principal about a new pilot program we were starting.  In light of the diabetes and obesity epidemic on the island, we were proposing to help teach some life skills and healthy food choices on the backdrop of fun physical activities.  Healthy Grenada, we called it.

As the three of us were standing under the sun discussing how we would run the first session, a pair of girls in their pleated dresses walked up to stand behind me and giggled when I glanced at them.  After a few minutes we were ready to leave, and we started back towards the jeep.  The two girls, still giggling, followed us a few steps behind and in the instant just before we pulled away, I heard one say: “I want to be white too”.

—

Two months earlier, I was on a bench under a tent in the Carenage in a concrete room with two walls and no roof.  It felt like an old construction site, perhaps abandoned after Hurricane Ivan in 2004.  There were about 70 Grenadians patiently standing in line to sit beside me, ranging from middle aged to elderly.  I was helping out at a school health fair, a student-organized event where students and our physician clinical tutors come out to screen the community for high blood pressure and diabetes.  My job was to take blood pressure and ask a few questions before they went on to see the physician.  Beside me was Helen, a well dressed lady in her 50s or 60s in silver rimmed glasses and a white blouse.  I asked her how she was doing, and she said, “Fine, just a little warm but that’s okay”, with a smile.  It was humid and hot, with an occasional spattering of rain, but typical of Grenadians, the participants were patient and without complaints.   I apologized for the lack of set up early on.  There was a miscommunication with the organizers and although the volunteers and participants arrived on time, the equipment, tables, chairs, and tent was about an hour late.  “That’s fine”, Helen said “we make do.”

I wrapped my blood pressure cuff around her arm and began to pump it up.  The crowd around our small table leaned in slightly, watching the process.  160/90; it was high.

“Have you ever been checked for blood pressure?” I asked.

She had.

“What kinds of things are you doing to manage it?”

Helen looked at me and said, “Well I have a prescription.  But the pharmacy is out so I haven’t had it.”

“Do they know when they’d be restocked?”

“They’re not sure.”

“Since when have they been out?”

“Three weeks.”

“How often are you supposed to take the medication?”

“Every day, morning and afternoon.”.

The next woman eased onto the bench beside me and I pulled the table closer for her to rest her arm.  It was hard to tell her age, but she was young, perhaps in her 30s.  She was well obese and had come during her break-time from work, as clear from her green uniform shirt and baseball hat for a local grocery store.  I introduced myself and asked her name.  “Angel”, she said.  As I unwrapped and wrapped the cuff around her arm I noticed the Diet section of her questionnaire hadn’t been filled out.

“Can I ask, how many meals a day do you have, typically?”  I asked.

“One or two.  Usually one.” she answered.

“Do you get to eat regularly?  Or do you find yourself skipping meals here and there?”  I started.

“I skip meals, maybe every other day.  When things get busy.”

“And what’s your typical meal like?” I asked Angel.

“Juice, bread” She trailed off, still looking around.

“Any vegetables or leafy greens?”

She looked directly at me for the first time since sitting down.  She had hazel eyes but was wearing no make-up, unlike many of the young women who had previously come by.  “I eat what I can find.  When you have no money, you eat what you can find.”

I thought back to the brief training we had done for the health fair. “Offer a bit of counselling,” the coordinators advised us. “It’s easy, basic nutrition and healthy eating – balanced meals, being active however you can.  You guys will do great.”

—

We walked up the long road toward the school with a group of volunteers and a folder full of quizzes, worksheets, and activities we had planned for our first session of Healthy Grenada.  Alongside us were a group of young boys, about 9 years old, in burgundy pants and white polo shirts, laughing and running about.  One of the boys had a long thin stick and was playfully swinging it about and making growling noises.  They told us they were playing a game they made up called Daddy.  “It’s a different culture,” Shervin said to me, “let it go.”

Later that night I slipped quickly out the door, trying to leave faster than the mosquitoes could enter.  It must have looked pretty comical, like Kramer from Seinfeld as I opened and closed the door in one movement, manoeuvring my gym bag out of the way.  I glanced around to see if anyone saw my awkward exit.  There was no one, but a silhouette of two little boys, maybe 10 or 12, drinking cartons and rummaging through the trash bins outside the apartment.  Neither had looked up.  Not wanting to embarrass them, or perhaps embarrassed myself, I started walking towards school as if I hadn’t just seen two kids looking for food in my trash bin.  About two minutes later I passed the security gate of the school, and as I approached the student center, I passed a group of students chatting and holding takeout containers full of food.  I walked past students playing basketball on the lit-up court, filled up my bottle at the water fountain, and ran on the treadmill for a half hour.

Blind mole rats and my first citation

I published part of my MSc research last April. It was my first and only paper, and had taken about an extra year or two after my MSc finished to wrap up all the revisions, run new experiments, write and revise again. I remember being in a hotel room in China during my time on a cleft-lip surgical mission, writing scripts and starting programs on Brian’s computers back at Mac. It passed through three rounds of reviewing and on the final round, one of the reviewers still didn’t agree that the findings made sense but s/he also didn’t seem to understand the experiments. Thankfully, the editor of the journal stepped in and told us it was accepted anyway. It’s tough writing about population genetics and computational biology. It’s like explaining math without using numbers.

So once in a while, I like to look at how many times the paper has been downloaded. Ya, nerdy and kind of self-absorbed, but you’d do it too. After all, many people google themselves (I do that too, but thanks to a Singaporean pop star it doesn’t satisfy my ego), and many others start personal blogs (ahem). Good thing there’s such a fuss about stopping internet censorship because how else would we find out so much stuff about ourselves?

Instead of studying Pharm, I checked on my paper’s views again. And my paper has been cited! The paper citing me is called “Is Evolution of Blind Mole Rats Determined by Climate Oscillations?”. Oh academia. Bonus points for it being a paper about climate change (my paper had nothing to do with climate change).

Medical verbal diarrhea

Since coming home I can’t help but bring things I’ve learned into every-day conversations.  I’m starting to realize that not everyone is necessarily always interested in being counseled.

Par example:

At a baby shower for my close friend.  It’s my first time getting to catch up with friends from home, and I go get the attention of M, who has a strange skin rash that hasn’t gone away in weeks.  Since we didn’t cover Skin in Pathology, I tell her what I heard from my brother (a doctor) about rashes: that generally speaking if it’s itchy it’s not life-threatening, that if it’s been hanging around for a long time it’s not life-threatening, and that often they don’t bother finding out exactly what it is, but they will prescribe first a steroid and then if that doesn’t work, an anti-fungal.  At least the last part is helpful for M, who thought the doctor was just humoring her by prescribing an anti-fungal when they still weren’t sure what it was exactly.

Later in the shower, Ktown, M and I are talking about high blood pressure.  M is worried because she has had a couple slightly high readings in the past few times.  Eager to ease her worries, Ktown suggests she shouldn’t have to worry because her eyes aren’t bloodshot.  M agrees; her eyes are not puffy like her father’s – he has high BP – and so she probably doesn’t need to worry so much. Later in the day I realize I never made it clear to them that hypertension is typically totally silent and doing it’s damage over the long term while the person is totally unaware until it’s well advanced.  I write a message to both M and Ktown clarifying this and saying that maybe it’s something she can talk to her doctor about.  Ktown responds thanking me for clearing it up and letting M know she probably doesn’t have much to worry about, but later cheerfully tells me that she was kind of perplexed why I sent the message that would likely just make M worry more.

Another conversation Ktown is telling me about, a silly one, about circumcised and uncircumcised penises.  She’s recounting this conversation, laughing at the awkwardness, where basically it comes up that a couple people we know are uncircumcised.  I can’t just laugh at this, but I have to bring up how circumcision isn’t just a matter of religion, there are also health benefits such as avoiding phimosis and paraphimoses, preventing HIV transmission, and decreasing the chances of smegma buildup which would lead to squamous cell carcinoma of the penis (the latter is something I didn’t quite understand until a fellow student kindly explained the whole concept of foreskin and the gunk that gets stuck under it – smegma – to me using his arm, his t-shirt sleeve, and the appropriate theatrics).

Alcohol Is More Harmful Than Heroin, Crack: Lancet Study

I am home for the holidays!  Ah, what a feeling.  There are lots of festivities planned in the next few days, and so this article is pretty timely.  Thanks Frond for sending it to me.  Be safe with your merry-making, everyone!

In the present study, Dr. Nutt and colleagues undertook a review of drug harms using the multicriteria decision analysis approach, a special approach that has been shown to be useful to help decision makers who face particularly complex issues with many conflicting objectives.

The multicriteria decision analysis (MCDA) model assessed 20 drugs most commonly used in the United Kingdom for their potential to cause 16 harms, as listed below:

• Drug-specific mortality;
• Drug-related mortality;
• Drug-specific damage;
• Drug-related damage;
• Dependence;
• Drug-specific impairment of mental functioning;
• Drug-related impairment of mental functioning;
• Loss of tangibles (job, housing, income, etc);
• Loss of relationships;
• Injury;
• Crime;
• Environmental damage;
• Family adversities (eg, family breakdown, child neglect, etc);
• International damage;
• Economic cost; and
• Community.

Drugs were scored on a points scale of 100, with 100 being the most harmful drug and zero being something that caused no harm at all.

The study found that overall, according to the new MCDA model, alcohol was the most harmful drug, with an overall harm score of 72. Heroin came second, with a harm score of 55, and crack, with a harm score of 54, came third.

Heroin, crack, and crystal meth (harm score, 33) were the most harmful drugs to the individual, whereas alcohol, heroin, and crack were the most harmful to others.

[…]

They conclude, “It is intriguing to note that the two legal drugs assessed — alcohol and tobacco —score in the upper segment of the ranking scale, indicating that legal drugs cause at least as much harm as do illegal substances.”

[…]

In the MCDA model used in the study, alcohol did the most harm largely because of the harm it causes to others, he added. “If you just looked at the harm to users, alcohol would actually fall behind heroin, crack, methamphetamine, and cocaine, but because of the ubiquity of its use and because of a lot of things that can happen during intoxication, alcohol ends up doing a lot of damage to other people.”

Rickets in sunny places

© 2011 Nucleus Medical Media, Inc.

A few weeks ago, I wrote about seeing kids here with Rickets, and wondered why they’d have this condition that’s classically linked to low vitamin D, which is a vitamin produced by exposure to sunlight.

Well I wrote my Nutrition final this morning, and we covered it a little more.  So-called African Rickets is common in developing countries, despite the sunniness.  Bone health is a complicated thing that’s not just Vitamin D.  It could be a lack of calcium in the diet, which would increase the release of calcium from bones, weakening them over time.  This makes sense since calcium’s involved in a lot of really important functions, some which are more important than bone strength (e.g. nerve and heart function).  So the bones go in order for more important things to continue to function.

Cow’s milk isn’t too expensive at supermarkets here (at least, not the strange long-shelf-life kind that is imported from Europe and will likely be on this island longer than I am), but the fact that cow’s milk has to be imported from Europe suggests how important it is in the Caribbean diet.

Another thing could be fruits and vegetables.  Surprisingly, they also impact bone health.  Fruits and veggies have a lot of potassium which helps to decrease the acidity of your body.  Without the fruits and veggies, the acidity goes up and bones will tend to “de-mineralize” (i.e. dissolve).  Not sure why there’d be a lack of fruits and veggies in the Caribbean diet.  Maybe it’s just individual kids personal preferences not to eat them, or maybe it’s a greater emphasis on starchy foods when kids are weaning off breast milk.

And that’s that!

Stories from the Female Reproductive Tract

Heard in class:

“Last week I realized how little I know about the female vagina.”

“You really had to specify that it was female, huh.”

We just finished the female reproductive system in Pathology and I have to say it has got some freaky stuff going on.  It’s hard to conceptualize for many (I’ve heard a lot of guys complain that they just don’t get it because they don’t have ovaries, tubes, uterus, etc.. but it’s not like it’s something women can just open up and look at on themselves), but it’s really cool when you step back from it.  The whole process of ovulation and menstruation is so messy (Eggs rupturing out of the ovary!  Layers of the placenta breaking down and falling out!) and the pathologies you see in the female tract are so different from anywhere else because of the cells that are there ready to develop into a new person.

Mature teratomas

A cancer of the (unfertilized) egg where it starts to grow random bits of body like hair, skin, teeth, even brain.  Although it’s a cancer it’s totally benign and won’t spread or cause any trouble.  What might though is the skin that develops from it, which can sometimes turn into a skin cancer inside your ovary.

Endometriosis

The endometrium, the part of the uterus that is sloughed off every month in your period, is a sneaky bugger.  Sometimes it can start to develop outside the uterus, in places like the ovary, the fallopian tubes, even the lungs and in bone or in scars of previous surgeries (laprotomies and C-sections).  Even though it’s in an unusual place, it keeps functioning like normal every month i.e. bleeding in time with your period.

Partial Hydatidiform Mole

This is a kind of abnormal placental growth that’s caused by abnormal fertilization where a normal egg is fertilized by two sperm at the same time.  The embryo ends up with one and a half times the normal number of genes, which doesn’t stop it from developing at least a little bit, but then dies.  The woman will think she’s pregnant but after 3 or 4 months, she might be wondering why her tummy isn’t getting bigger anymore, and may go to a clinic when she notices she’s passing out tiny grape-like structures.  Instead of a developing baby, she has some normal placental parts, plus some abnormal grapey placental parts, and some embryo parts as well.

Increased in-hospital infections with increased temperatures

Knitted bacteria by loxosceles

An 8-year study of infection data from 132 hospitals finds that as outside temperatures rise, in-hospital infections with some of the most problematic pathogens rise also. – Wired.com

What just happened? The researchers looked at blood-samples from 132 US  hospitals (they admit that New England was somewhat lacking in representation) for 8 years, tracking the number of infections diagnosed as due to different kinds of bacteria.  It’s never normal to find bacteria in your blood, even normal flora of our bodies like E.Coli.

What were they looking for? They wanted to see whether the number of bacterial infections changed depending on the temperature outside (i.e. the season).

What’d they find? Well…

Independent of season, monthly humidity, monthly precipitation, and long-term trends, each 5.6°C (10°F) rise in mean monthly temperature corresponded to increases in Gram-negative bacterial BSI frequencies ranging between 3.5% for E. coli (95% CI 2.1–4.9) to 10.8% for Acinetobacter (95% CI 6.9–14.7). The same rise in mean monthly temperature corresponded to an increase of 2.2% in S. aureus BSI frequency (95% CI 1.3–3.2) but no significant change in Enterococcus BSI frequency. – Eber et. al (2011)

For every 5.6°C rise in monthly temperature, they increases in some bacterial infections and not others.

The ones they saw increases for are the Gram-negatives:

– E.Coli, which can cause a range of infections, from meningitis in young people to moderate diarrhea and dehydration, to extreme bloody diarrhea and widespread internal bleeding around your body.

– “Acinetobacter” or Actinobacter, which can cause pneumonia, or pus-filled cavities (abscesses) around your body if it gets systemic (i.e. into your blood).

Both of these bacteria are normally found on or in healthy people.  The trouble starts when it gets to where it shouldn’t get, and/or change so that they are more disease-causing.  That’s called “acquiring increased virulence” and it happens a lot in hospitals where you have lots of sick people and people who are always around sick people, and lots of antibiotic use.  Since there’s so much antibiotic use, bacteria in hospitals can more quickly develop antibiotic resistance which is something they can pass on to other bacteria.  Along with sharing antibiotic resistance, bacteria can share other virulence factors.

One of the more well known potentially antibiotic resistant bacteria, S.aureus, was also found to have increased numbers of infections as outdoor temperatures went up.  S. aureus resistance is pretty common now in both hospitals and out in the communities.  There are still treatments for most, but there are also strains of antibiotic S. aureus that don’t currently have any antibiotic that will consistently work.

No increase was observed for Enterococcus, which are bacteria that can cause GI problems like diarrhea, but can also cause troubles elsewhere once they get into the blood.

The bottom line? Bacteria become more dangerous as temperatures outside go up.  We’ve already seen that as temperatures go up, there are more infections.  The last paragraph of the paper sums the whole thing up (as they always do!):

In conclusion, we reported substantial increases in the frequencies of bloodstream infections due to clinically important Gram-negative organisms in summer months. These increases, as well as variations in infection frequencies within seasons, appear to be associated with elevated monthly outdoor temperatures. The seasonal trends reported may be used to inform infection prevention and should be considered in the design and evaluation of longitudinal quasi-experimental studies of infection prevention interventions. Furthermore, if the underlying mechanisms of the temperature associations are identified, these findings could inform the global climate change debate.

Emphasis mine.  Interesting!

Special sumo fat

Non sumos. (Annie Leibovitz)

Have you ever noticed that sumo wrestlers don’t look exactly like regular fat people?

We recently learned that the kind of fat sumo wrestlers put on is different from the kind of fat us regular folks may put on.  While our fat (giving the classic pear or apple shape) puts us at risk of heart disease and stroke, the kind of fat a sumo wrestler has doesn’t.  The difference is that they are able to train so that they can put on as much fat as possible but in such a way that the fat doesn’t deposit around their organs like it would for us.  Sumo wrestlers actually have rippling jacked bods, but you just can’t tell because just atop their amazing muscles and just under their skin is all that fat.

Sumos do this by tricking their body into thinking they are starving.  Wha-at?  According to the very academic violent hero powerlifting dot com, as sumos sleep, their body uses up all their body’s energy stores (same as us).  But as soon as they get up they skip breakfast and train all morning.  By the time they get to eat in the afternoon, their body is in starvation mode and stores as much energy as it can as subcutaneous fat.  I read that they also eat in big social groups because people tend to eat more when they are socializing at the same time.  I can attest to that last point.  Sometimes I’ll be studying with Frond and he’ll ask me if I’m hungry.  I’ll say no, but then if he replies that he’s actually feeling a bit hungry, I’ll start to feel hungry too.

Fine specimens (Robb Kendrick)

I remember in Biochem that after about 12 hours of not eating your glycogen stores are used up.  I think glycogen is what people in violentpowerlifting.com are talking about when they say “energy stores”.  Once glycogen is used up your body starts to use up muscle then fat stores.   When you eat a massive amount, like what the sumos do, your body first uses the glucose from the food that is absorbed and floating in your blood.  But if there’s more glucose floating around than that your body can use at that moment, you start to store it as glycogen and then fat.  So this is what happens to anyone who eats more than their body is using.  For people who don’t exercise, the fat can deposit around their organs such that someone who looks thin but doesn’t exercise might actually have a lot of fat deeper inside but not the subcutaneous type of fat that sumos are aiming for.  This type of fat, the type that surrounds your organs, is the type of fat that causes all the obesity-related problems.  Since sumos are exercising so much, they don’t accumulate the fat around their organs, but since they consume crazy high amounts of calories all at once, they are still storing fat, but without the obesity-related problems.  That is, sumos don’t have a higher risk for heart disease, nor diabetes, or stroke.  Even the fattest ones!

This is the second time sumo wrestling has come up this week.  What can I say, I loves me some sumos.

Photo1: Annie Leibovitz for vanityfair.com

Photo2: Robb Kendrick for National Geographic