Medical Investigations into the Occult

My journey through medical school has been crazy , since I am given an incredible amount of freedom to pursue my own interests with little time to spare for the occasional lecture or two. I love lectures; I always attend them (though I have been known to sleep through a whole bunch as an undergrad rousing myself to take notes whenever I hear something new.)

Med school is all about learning new things -- but not all of these new things are all that interesting. If more lecturers paid attention to the times, maybe people would tune in more.

In a constant quest for case-relevance, I tune in to the hubbub that surrounds me... Halloween! I got the idea from Dr. Charles' elf entry and from Yahoo story about a paper entitled "Ghosts, Zombies and Vampires - Cinema fiction versus Physics Reality" by Costas Efthhimiou. They've got some great stories and I wanted to add a bit more. It might not be PC, it might not even wholly accurate, but gosh darnit, I hope it's educational and dare I say it?!? I hope it's amusing as well.

To start things off in my investigation into occult medical "mythdiagnoses", I turn to the classic Halloween monster of them all:

Vampires!

Vampires are photophobes and hemophiles, fearing sunlight but loving blood. This makes them the perfect candidates for porphyria! (wikipedia, lifespan) Porphyria is a group of genetic defects in heme synthesis. Accumulation of various intermediate products give rise to various symptoms like tea or wine-colored urine, neurological problems and photosensitivity.

My biochem professor speculated that King (correction: George) the III had a few bouts of acute intermittent porphyria and as a result, Britain lost in the American Revolution. People with other types of porphyria with buildups of tetrapyrrole get itchy or burning sensations in their skin in bright light. This can lead to hair loss, loosening of nail beds and retraction of gum lines (which is probably less disconcerting around Halloween.)

In all fairness, I have a link for the skeptics (straight dope.)

Vampires are said to have a strong aversion to garlic and with a little research, I learned that garlic does have an effect on blood. Ancient Babylonia and China used garlic for medicinal purposes and it is now believed that allicin is the active ingredient. Raw crushed garlic has the highest concentration of antiplatelet (platelet aggregation occurs before a fibrin clot forms and coagulates) and fibrinolytic properties.

Werewolves

A few types of porphyria (variegate and cutanea tarda) can cause hypertrichosis (wikipedia) or excessive hair growth... so these might have contributed to werewolf legends as well.

Since the phenotype is so readily apparent, it was much easier to find information about people with hypertrichosis vs porphyria. Hirsutism (wikipedia) is another type of excessive hair growth usually referring to women with high androgen production.

Familial hypertrichosis is not a myth. People with these X-linked conditions are often male, performing in circus shows. ABC news did a story on one such man a few months ago, entitled "Real-Life Werewolves," about a Mr. Gomez who is a 5th generation wolfman! Chuy the wolfboy also has an interview online and oddly enough, they are both men in mexican circus shows. They have interesting stories to tell.

It doesn't seem like they have any predisposition to howl at the moon or turn violent, but animals do bite more during a full moon. (BMJ, 2000.)

Is there a basis for killing werewolves with a silver bullet? None that I could find. Perhaps it is a Type I contact allergy to silver... copper or nickel is more common (I think.) Perhaps it has to do with the antimicrobial activity of something like silver nitrate...

Zombies

The Efthimiou paper I mention earlier has a compelling argument about the basis of zombie legends. Basically, Haitian voodoo priests use pufferfish tetradotoxin to paralyze victims and make them appear to be dead. When(If!) the toxin wears off, the subject awakens as if from the dead.

This is all well and good, but it doesn't quite match up to today's image of zombies as hungry, mindless monsters with rotting flesh. People suffering from lepromatous leprosy (WHO) match the physical description surprisingly well. They have an infection of Mycobacterium leprae and their immune systems have taken the wrong approach to getting rid of it. Leprosy affects the skin and nerves.

Peripheral neuropathy in places like the sural nerve (in the shin of the leg) causes the foot to drag on the ground, making them lift their legs higher to compensate. Damage to the radial nerve (though rare in leprosy patients) causes wrist drop.

Decreased sensation of these floppy feet and numb hands means that damage to them goes unnoticed. Toe and finger stubbing can lead to necrosis, as these tissues literally rot and fall off their body.

Zombies are not as much of a threat to medieval peasants as werewolves and vampires were, so I can't really think of any myths about how to kill them (other than decapitation, but that's not very subtle.) Oh! Mycobacterium are acid-fast bacteria. Holy water... acid... ok, it's a stretch.

Ghosts

I am not quite so convinced by Efthhimiou's arguments against vampires simply refuting it by demonstrating the implausability of exponential vampire growth assumes a 100% transmissibility rate which... ironically.... I find implausible! ;-) and ghosts, which he chalks up to temperature gradient differences and psychological expectations. Where's the weird phenomena in that explanation?

Well, I've stumbled across an excellent example for your reading pleasure!

Vic Tandy, an engineer, started working at a "haunted" lab in Coventry, England. Everyone had feelings of being watched and a lot of people were thoroughly creeped out. This engineer was working late one night and he saw a grey figure approach him at one point. "It would not be unreasonable to suggest that I was terrified," he says. The next day, he noticed that a fencing foil he was working on was vibrating. He was frightened at first, but after some investigation he found that his lab recently had installed an extractor fan.

This fan created a standing air wave projecting infrasound (wikipedia) at 19 Hz. This sound is not heard by human ears, but we can still perceive it as symptoms of uneasiness, dizziness and shortness of breath.

According to NASA, the human eyeball has a resonance of 18 Hz. In the standing airwave, the vibrating eyeball can cause a "smearing of vision". Hyperventilation is another symptom of whole body vibration. I've noticed that this sort of lightheadedness gives objects a special glow or aura afterward.

Interestingly, Tandy goes on to find 19 Hz infrasound again in a 14th century cellar in the Tourist Information Centre of Coventry.

So, never let it be said that the myths are all fictitious stories... there is a level of fact and fun can be had in finding it!

Happy Halloween!

Hobbits, Dwarves and Giants

Dr. Charles' entry on the genetic link to "elves" got me wondering about other mythical creatures.

Some 11-18 thousand years ago, a 3'6" tall tool-wielding "hobbit" roamed the island chain of Flores. Carl Zimmer of the Loom has a little timeline of what happened since their discovery and controversial claim to fame as a new species of humans. There is a big debate over whether or not the Homo floresiensis are pygmies, like those from Africa, or small children with microcephaly.

--

Shifting back to stories of fantasy, J.R.R. Tolkein's dwarves live in mountains where their short stature helps them survive the same way pygmies in the forest or on islands do. Dwarves have a fondness for ale, axes, beards, and gold.

People with dwarfism might not have the same predilictions, but the mythic dwarves are likely derived from the phenotypic characteristics of achondroplasia (Medline, OMIM entry). The autosomal dominant trait involves a genetic mutation of FGFR3, limiting bone formation from cartilage, particularly in the long limbs of the arms and legs. This results in short stature, disproportionately short limbs, a large skull and prominent forehead.

--

While little people have a problem forming bone, people with acromegaly (Mayo Clinic, OMIM) have a problem forming too much. Gigantism is caused by excessive secretion of growth hormone from the pituitary gland.

I remember reading a comic strip from Calvin and Hobbes referencing this... but people with gigantism don't grow to be skyscraper sized.

Andre the Giant is a famous example. He was a professional wrestler and he was in the Princess Bride. He was a very large man at 7' 2". This did not go without any consequences... his immense weight took a toll on his joints. His body grew too big for his heart and he died of congestive heart failure.

--

I'd like to add more, but I'm plumb out of ideas.

Stay tuned for the medical explanations of the occult, just in time for Halloween!

Avian Flu, What to Do? (III)

Do you live paycheck to paycheck? If you had to live at home, separated from the rest of the world (excluding your immediate family) for six months with little notice, would you be capable of this? Do you have enough emergency rations of food, water, batteries and toilet paper?

Neither do I. Even after the recent quake and subsequent blackout which left my family powerless, we haven't gone on a crazy rampage to stock up on our essentials. We had a gas-powered grill, but very little food to cook on it. We didn't want to open the fridge and freezer, instead opting to wait for the power to come back on. Seemingly inconsequential things suddenly became more important as I unconsciously flicked light switches on and off, attempted to put food into a non-responsive microwave and my stomach growled and grumbled the whole day. I quickly realized how powerless I am without electrical power. I learned how soft we've become in responding to unexpected events.

Now imagine a crisis in which everyone was ordered to stay at home. Public gatherings would be banned. Air travel would cease completely. Whole communities would be "socially distanced," exposed people would be quarantined for 10 days of monitoring and sick people would be swiftly isolated... hopefully waste disposal, food, medications and other necessities could be dropped off in some way.

The difficult thing is figuring out if you're the right sort of sick or not. Hospital doors would be barred with police and perhaps even National Guard protecting its borders to prevent desperate people from barging in... hopefully real emergencies would grant them access. People would be evaluated for their exposure and if they met the criteria, they would be taken to the hospital. They would develop an extreme shortness of breath, like that seen in SARS, and many people would need to be put on ventilators just to keep breathing.

Typical drugs to fight this disease would not work. Everyone would want to stock up on the presumed magic bullet but governments might have to ban private stockpiling. It would be given ineffectually by inexperienced (and scared!) users who might inadvertently increase the diseases' resistance instead of fighting it off.

There is not enough of this "magic bullet" to even protect the healthcare workers who would be treating sick people. Vaccines would not be made against the outbreak... the soonest they could be made would be 5-6 months and those would be shots in the dark. There is not enough ventilators to treat all of the sick people and many people would have to be taken off (and left to die) in a desperate triage situation to save someone else's life.

This would be the reality of the Avian Flu Pandemic.

The H5N1 virus replicates and sheds more virus silently for 12-24 hours before the host starts to feel ill with headaches, fevers, chills, sweating (diaphoresis), and difficulty breathing. Strangely, the bird flu is a lower respiratory infection (rather than an upper respiratory one like other flu viruses) so there is often no runny nose or sore throat... but stranger still, there might be diarrhea. After 4 days of feeling ill, the host's breathing would become so labored that he/she would have to go to the hospital. There, the host would get oseltamivir (Tamiflu) and be placed on a respirator. If they are lucky, they will live. If not, death would come after 9 days of illness.


This is a very scary and serious disease. A flu outbreak could break our nation, killing potentially millions of citizens despite our best efforts to contain the flu, cripple our economy when millions of people are suddenly banned from working or even seeing each other... we wouldn't even be able to have funerals for lost loved ones.

What can we do?
How can we prepare ourselves?
How can I help?

I don't mean to scare or alarm anyone; just tell the facts as they are right now. I certainly don't have all the answers, but I'll try to address a few points of each of these questions as I learned about them during a Bioevents conference.

I will focus on the specific response of Medical Students during a Avian Flu Pandemic in my next post.

Fey folk: Myth or Reality?

I was reading Dr. Charles' ScienceBlog today and I learned that a deletion of the elastin gene makes you an elf!

[edit: 9/26/07]I'm removing this cute pic of a kid with Williams because it is doing something funky with my pagecounts.

People with Williams syndrome "usually have a small upturned nose, long philtrum (upper lip length), wide mouth, full lips, small chin, puffiness around the eyes, and a prominent "starburst" or white lacy pattern on the iris of the eyes."

"Children with WS are more sensitive to music. Upon listening they become more emotionally involved, more attentive, with happy and sad feelings persisting much longer than normal and with greater intensity. This affinity for music, if fostered, can help many overcome developmental problems. Some children with WS can barely write, sign their own names, or navigate a stairway, yet can they learn to execute the slight hand movements needed to play the piano or drums."

I think it's pretty amazing how our myths are based on truth... stay tuned for the next episode in which we explore the scientific basis for vampires! :)


[addendum]
For the more technically inclined, here's a link to the Online Inheritance in Man (OMIM) information on the elastin gene and condition of WS.

Avian Flu, What to Do? (II)

I had a dream recently that I went to Indonesia for my summer preceptorship
experience. It wasn't quite what I expected... much more free time than
clinic time (which was nice, but difficult trying to get around not
knowing the language)... challenging to learn what was going on in the
hospital but I got a lot of cool procedural experience out of it... but
when I picked Indonesia, I figured that I'd get to be in the tropics,
working with colorful cultures and exotic microorganisms.

And indeed I did. When I went back home, I started to develop a dry cough.
Then I got a headache and sore joints. I was sick with the flu for a
few days and I would have dismissed it, I got diarrhea. My chest
started to close up and I found myself gasping for air. Fluid was
pouring into my lungs and out of my pores. In my dream, I contracted
the Avian Flu. Then, my family started getting the same symptoms...

For precisely this reason, I'm sure that there is absolutely NO WAY I could
go to Indonesia this summer, as much as I would want to. My Medical
School just wouldn't allow it with the terrorism, the lawsuit
liabilities and the health risk of contracting the Avian flu and
becoming Patient 0... as beautiful and exciting as Indonesia would be
as a vacation/learning opportunity. ;)

The Avian Flu Pandemic is a big worry in the health community but I feel that it is blown off by the general public. What's the big deal? It's just the flu; I've gotten that before.

Here's a few facts about the flu.

Influenza di freddo means "influence of the cold (winter)" in Italian.
Unlike some other microorganisms, the flu virus lies dormant during the summer
months and becomes active. Some speculate that it has to do with the
temperature or the humidity change or the fact that everyone crowds up
indoors -- but we don't really know why this happens. Subtle changes in
the virus' single-strand of RNA alters its envelope and capsule
proteins so each year, we are susceptible to the same viral infection. Hemagglutinin and neuramidase (of H5N1 fame) are the major antigens on the surface of the viral package. This process is called antigenic drift.

Our bodies develop immunity to the flu if you catch it naturally, but it is to past bugs, not present ones. If you get the flu shot, you are getting a vaccine granting you immunity to the Top 3 predicted modified viruses for this year by Top scientists. It's not full protection (washing your hands and having good hygiene also help) but it's better than getting sick.

The regular flu season comes around November or so and peaks in February.
Every 2.4 years, we get a flu epidemic. This means that we have more
cases of the flu than the expected endemic proportions and this
"outbreak" lasts from 6-8 weeks. Since 1580, we have had numerous flu
epidemics recurring about every 14 years. The last epidemic we had was 38 years ago, but the "Spanish Flu" is the most memorable one.

The "Spanish Flu" outbreak of 1918 killed between 50-100 million people in the course of a few months -- that's more than the 38 million casualties of World War I. That's about a third of our current U.S. population wiped out. That's how deadly the flu can be. When the flu virus undergoes antigenic shift, we are completely susceptible to it and our bodies react with disastrous consequences. The Spanish Flu probably came from Kansas where to different strains of the flu combined.


That's enough for today. You can visit the Flu Wiki if you are interested in learning more @
http://www.fluwikie.com/

My next post will compare the regular flu season to the H5N1 flu pandemic that we are so worried about.

Avian Flu, What to Do? (I)

I just finished with my first round of tests of medical school. I tried to keep up with my posting by putting up a few mnemonics that I thought were useful and good to know... many of them were invented by my good friend Knewton.

Now that I'm out of that study grind, I wanted to move on to something else. This week, I will feature different aspects of the Avian Bird Flu and what the role of medical students would be in the case of a pandemic outbreak.

In case you didn't know, last week was "Pandemic Flu Awareness Week!" My Medical School put on a Bioevents conference for the med students in which we suspended regular classes for a day long seminar on different aspects of the Avian flu: introduction to the flu, the microbio and clinical aspects, a public health response, a medical response, mental health implications and case studies.

Regrettably, the majority of my class dug out after lunch to study for our exams... and in my opinion, this was a mistake. First off, it was disrespectful to the speakers who came to talk with us and second, you're blowing off what might become the most critical service we will provide?!? (We're not sure when the Avian Flu will become a pandemic outbreak, but we know it WILL happen...) I'm very passionate about these sorts of public health situations.

That's why I wanted to disseminate the information I've gathered to share with you. It is important that everyone knows what is expected of them during a disaster situation. As Sunday's earthquake and subsequent blackout attests... My State isn't quite ready to handle the sheer enormity of this task without the full cooperation and understanding from our citizens.


Sorry, I know this is a big teaser, but stay tuned as I introduce you to the flu as we know it!

cut and PASTE risky behaviors away

Mnemonic for helping adolescents give up risky behaviors

PASTE

Problem - define the problem
Alternatives - list possible alternative solutions and list pros and cons
Select an alternative
Try it
Evaluate the choice and modify it if needed

Cancer MALADIES

Mnemonic for the 8 characteristics that a cell can acquire to become cancerous!

MALADIES

Metastasis/invasion
Angiogenesis
Limitless replicative potential
Apoptotic signal resistance
Defect in DNA repair
Inhibitory growth signal resistance
Evasion of immune surveillance
Self-sufficiency for growth

Testicular lump: OVA+TESTES=HATCH

Here's a quick and dirty mnemonic for the differential diagnosis of testicular lumps:

Orchitis
Variocele
Autoimmune orchitis

Tumor
Epidermal cyst
Spermatocele
Torsion
Epididymitis
Scrotal trauma

Hydrocele
Abscess
Testicular microlithiasis
Cryptorchidism
Hernia

Losing your ADLs is like falling down the DEATHSHAFT

A mnemonic for Activities of Daily Living (DEATH) and Instrumental Activities of Daily Living (SHAFT)

Dressing
Eating
Ambulation
Toilet
Hygiene

Shopping
Housekeeping
Accounting
Food preparation
Telephone/Transportation

Differential Diagnosis: A VITAMIN C/I VINDICATE AIDS

Mnemonics for recalling the various arenas of the differential diagnosis when presented with a problem case.

A Vitamin CDE

Acquired
Vascular
Inflammatory
Trauma/Toxin
Autoimmune
Metabolic/Medication
Infection
Neoplastic
Congenital
Degenerative
Endocrine/Electrical

I Vindicate AIDS

Inflammatory
Vascular
Infectious
Neoplastic
Degenerative
Idiopathic
Congenital
Autoimmune
Trauma
Endocrine/Metabolic
Allergic
Iatrogenic
Drugs
Social

*I bolded the ones that are special additions for the longer mnemonic... I'd recommend just starting off with a shorter one and tossing in the later considerations as needed.

THE STAPH CELL

Mnemonics to help you remember the various virulence factors in S. aureus.

THE STAPH CELL
TSST
Hemolysin
Enterotoxin
Staphylokinase
Teichoic acid
A (Protein A)
Penicillinase
Catalase/coagulase
Exofoliatin
Leukocidin
Lipase

And to remember what category these S. aureus factors belong to...
"Disabling" factors
Handi-Capped Parking Lessens Ambulation
Hemolysin
Coagulase
Leukocidin
A (Protein A)

"Invasive" factors
Hungry Staph Likes To Pigout!
Hyaluronidase
Staphylokinase
Lipase
Teichoic acid
Protease

"Military" factors
At Ease (2Es)
Assault proteins:
TSST
Enterotoxin
Exofoliatin

My scars make me unique.

Perhaps when I smile, your eyes are not drawn to my dazzling pearly whites. You might notice the half-moon shaped scar that crinkles like a dimple when I smirk. Or maybe the scar slashing across my upper lip. I might be tilting my head just so and you'd also see the scars underneath my chin and the flattened red keloid on my cheek.

Such scars seem like the beginning of some great story and many people might be hesitant to ask me about it. Was I attacked by rabid dogs at a young age? Did I get into a knife fight trying to save an old lady from a group of gangbangers? Was I the sole survivor of an Unforgivable Curse (tm) like Mr. Harry Potter?

No, my dear friends, it was a mere speed bump at the bottom of a great hill that did this hero in. I was always a clumsy kid. I have scars on my forehead from a thump on the corner of my uncle's bed during my third Thanksgiving dinner. I seem to have a thing for holiday accidents.

It was a chill and eerie Halloween morning that I went bike riding with my dad. I was groggy and I was riding on a new bike I'd never rode on before with very sensitive front brakes. I closed my eyes as I raced down a hill in the quiet botanical garden a few blocks away from my house... and at some point I lost consciousness for about 10 seconds because I found myself on the ground with about 10' of street gravel rubbed into my face. (It's rather strange how my story seems so silly and similar to Dr. Charles.)

My parents took me to the ER and I had a few rocks the size of quarters taken out of my cheek.


A few weeks later when the itching was subsiding and the keloid was injected with steroids to make it sink down, I was asked if I wanted cosmetic surgery.

"Nope!" I'm proud of my scars. While they might be reminders of my idiocy, they give my face character. They make me a unique person. If I were ever cloned in a laboratory and someone tried to replace me with my identical double, people who know my face would know which one is me.

And that makes me smile even more.

Pop Culture Education: Brains and Balls

Pinky and the Brain educate the masses on the Anatomy of the Brain. I'll definitely be using this when we get into the neuro unit! :)

---------------------

And a more risque video... Rachel Gets Fruity for Testicular Cancer!
The music makes it seem as though it is not safe for work or school. I showed it to my group while doing a presentation on testicular self-exams (TSEs) and I justified it by saying "just thought you would rather hear about the exam from someone else." It is provocative in the thinking sense. ;)

The only catch is that the U.S. Preventative Service Task Force actually advises against the teaching of TSEs, because the cancer is uncommon and when detected early by the doctor, they have a good outcome. This seems a bit bizarre to me. If people are worried about their testicles, they should be told by their doctors what is unusual and when they should be checked by a professional.


I think it is a great thing to have these sorts of pop culture education moments. Let me know if you've seen any good ones too!