Iron: Too Little and Too Much

Poison is in everything, and no thing is without poison. The dosage makes it either a poison or a remedy.
Paracelsus. Swiss-German physician (1493-1541)

 

Iron is present in abundant quantities in the earth’s core and crust, in the sun, the stars and meteorites – and inside all living things. In humans, iron carries oxygen to all the body’s cells, carries carbon dioxide back to the lungs, enables many chemical reactions related to energy production, and binds oxygen inside for use in muscle cells. It is a vital nutrient – a substance that must be part of the diet, but also one which the body cannot excrete except by losing blood and skin cells. Both too little iron and too much iron present us with problems.

Where the body puts iron

Iron is absorbed from food in the upper part of the small intestine. Specialized proteins
carry it in the blood and store it in the liver and other organs. Ten percent of total body
iron is attached to myoglobin in muscles, 25 percent is stored in the liver and in specialized cells throughout the body, and the major portion, 65 percent, is bound to hemoglobin inside red blood cells. Hemoglobin-bound iron is constantly recycled as old red blood cells are destroyed and new ones are made.

Iron absorption from food – a tightly regulated process

Iron must be bound to proteins or it excites free radical damage in cells. When all of the protein binding sites for hemoglobin in the body are filled, the liver sends a signal to the small intestine to decrease the amount of iron taken in from food. This regulation of iron absorption is a very sensitive and tightly regulated process in which a message is sent to the intestines conveying how much iron is already in the body. That amount determines how much or how little iron is absorbed from food. This feedback loop is necessary because, beyond minor blood loss and regular shedding of skin and bowel cells, the body has no way to get rid of extra iron. Most health problems related to iron come from too little iron in the diet, from too much iron, delivered intravenously in the form of blood transfusions, or from genetic defects in the feedback loop that tells the intestines how much iron to take in.

Too Little Iron

Deficiency of iron in the body causes weakness, fatigue, and shortness of breath because of inability to carry enough oxygen in the blood and failure to produce required energy. Skin and nail beds are pale because mature red blood cell production is limited (iron deficiency anemia). Dizziness and fainting upon standing up can occur.
Iron deficiency comes about because dietary iron is insufficient to make up normal losses of iron through menstrual blood loss , or abnormal losses that might occur chronically, such as from an unsuspected stomach inflammation, an intestinal tumor or abnormally heavy menstrual bleeding.

Who becomes iron deficient?

Dietary iron deficiency is very common, especially in people who restrict calories, avoid meat or have poor diets.  Women of childbearing age, children and the elderly of both sexes are the most at risk. Dietary deficiency can also be aggravated by increased need for iron, as in pregnancy and childhood growth. While many foods contain iron, it is better absorbed from animal sources like beef, chicken liver, fish and mollusks than from plant based sources like spinach and beans. Iron absorption also requires an acid environment, which acid relieving drugs block.

Iron deficiency in post-menopausal women or in men of any age group always raises suspicion of low grade, unsuspected blood loss, which usually comes from the gastrointestinal tract. Causes are gastritis (often from use of anti-inflammatory drugs), ulcers, colitis, diverticulitis, tumors and rare vascular malformations are all causes. Black, tarry and metallic smelling stool is often a clue.

Replenishing iron stores

Treatment of iron deficiency requires improving diet and finding and correcting sources of blood loss. Iron is  better absorbed by the stomach from food than it is from pills. Red meat is the best source.  But iron supplements are necessary when iron deficiency has caused symptoms. Several different versions of iron supplements may have to be tried – ferrous sulfate is the most commonly prescribed, but can be hard on the stomach. Ferrous gluconate may cause less nausea and stomach upset. Ferrous fumarate contains more iron per pill. The addition of Vitamin C to the diet  helps absorption of iron supplements and iron can also be delivered by injection if dietary methods and oral suuplements fail.

Too Much Iron

Iron overload is called hemochromatosis and its symptoms come from damage to the cells in which iron is stored once the normal iron binding proteins can hold no more.  The damage is very slow and cumulative and the liver and the heart bear the brunt.  Testicles and thyroid gland are also storage sites. Skin storage may cause the patient to look inappropriately tanned, but weakness, lassitude, weight loss, shortness of with breath and abdominal pain typically bring the patient to the doctor.   

Transfusion-related iron overload

Hemochromatosis  can be caused by repetitive transfusions of blood. Transfusion related hemochromatosis afflicts patients with bone marrow diseases such as  myelofibrosis and multiple myeloma. Repeated transfusions are the treatment for severe anemia in these patients and each unit of packed red blood cells delivers enough iron for six months. Iron overload begins to develop quickly.

Hereditary hemochromatosis

Hemochromatosis can also be caused by a genetic problem in which too much iron is absorbed. This hereditary version of hemochromatosis occurs in about 5 in 1000 people in the US. Caucasians are more susceptible than other races. While men and women are affected equally, men typically develop symptoms in their 30s or 40s, a decade or two earlier than women, because women are able to shed iron on a monthly basis until menopause.

Hemochromatosis is treated by regular bleeding, performed in the same way that blood donations are collected. But bleeding is not suitable treatment for patients whose severe anemia is the problem that forces them to receive repeated blood transfusions. The only option for them is chelation of the iron with drugs that bind iron in the blood and carry it out of the body, a difficult and time consuming process, but one that lengthens survival time. A new oral drug may soon make the process easier. At this time in medical history though, using iron as a remedy is easier than treating iron as a poison.

Chronic Fatigue Syndrome Gets Renamed

Imagine the way you felt the last time you had the flu. You were flattened, devoid of all energy. Staying upright to get dressed was more than you could handle. You slept – and slept – and slept – and still experienced none of the normal refreshment that a good night’s sleep provides. A fog descended on your mind and fuzzed up memory, destroyed drive and made your head ache. You could not concentrate on simple mental tasks like reading. Though you were doing nothing physical, your muscles ached. Then it all went away and you forgot about it.

But now imagine that it didn’t go away. The same misery persists and dramatically alters your life. You cannot work. You move from bed to couch and back to bed. You go to doctor after doctor and they find nothing wrong. Routine blood tests, X-ray and scan results are normal. Someone prescribes an antidepressant, confirming the suspicions of family, friends, and some doctors that your debilitating physical symptoms are “all in your head.” Eventually, you find your way to a doctor who makes a diagnosis. You have CFS which stands for chronic fatigue syndrome, and which, as of early 2015, has been renamed system exertion intolerance disease or, in our acronym-laden age, CFS/SEID.

A long history, with different names

CFS/SEID has probably been around for more than 200 years, making its appearance in the medical literature as “neurasthenia,” a term applied to patients who were lacking in physical, emotional and cognitive energy without any discernible disease to account for their malaise, without any improvement over time and without any progression that brought them to a worsened state. They were mostly ladies, whose frail constitutions prevented them from exerting themselves and who mysteriously took to their beds for weeks at a time.

The Yuppie flu

British doctors in the 1950s christened the symptom complex myalgic (painful muscles) encephalitis (inflammation of the brain), even though there was no evidence for inflammation to account for the headaches, difficulty concentrating and memory problems patients experienced. In the US in the 1980s, the syndrome was dubbed the Yuppie Flu because it seemed to follow viral infections like infectious mononucleosis and occurred in cities where young urban professionals (“yuppies”) congregated. When reported from other settings as well, the name was changed to chronic fatigue syndrome.

No apparent cause, but a real illness

Because no single infectious, hormonal or immunologic cause for CFS emerged from many attempts to identify its cause, because it was impossible to measure the subjective complaints constituting the syndrome, and because some improvements occurred when antidepressants were prescribed, CFS was, for decades, viewed as a psychological disorder. But this view became more and more untenable as it became clear that the illness hit people who had no history of depression or inability to cope with life. Many CFS patients continued to be very productive, learning how to manage their lives within the limitations of their fatigue and mental fog. Laura Hillenbrand, author of Seabiscuit and Unbroken is one outstanding example. Though no cause has yet been identified for the illness, the name change from chronic fatigue syndrome to systemic exertion intolerance disease signals that the illness is one rooted not in psychology but in an, as yet, unidentified physical cause.

Epidemiology and diagnostic criteria

It is estimated that there are about 1 million patients with CFS/ SEID in the US at any given time. There is no evidence that its incidence is increasing, but it is quite possible that some cases are hidden on among the legions of people who have been diagnosed only with depression. CFS/SEID is more common in women than in men. Sometimes it follows directly upon an acute flu-like illness, but at other times appears out of nowhere. The diagnostic criteria at this time include 6 months of unexplained, life-altering fatigue and orthostatic intolerance, which means the inability to stand for more than very short periods. Four of eight other symptoms are also required and these include disturbances in memory and concentration, persistent sore throat, tender lymph nodes, muscle pain, joint pain, headache, disturbed sleep patterns, and malaise following even minimal exertion. Additional symptoms may include increased sensitivity to tastes, odors, temperature and noise.

A relapsing illness

A small minority of CFS/SEID patients get completely better and never suffer a relapse. The majority suffer relapses for prolonged periods of time, perhaps the rest of their lives. Relapses are triggered by infections, surgery, temperature extremes and stressful events. Another minority are severely affected from the beginning of their illness and require support in the activities of daily living for the rest of their lives. Deterioration, though, is unusual and suggests the diagnosis of CFS is wrong and further attempts to find the correct diagnosis are indicated.

Problems in mitochondrial energy production?

While there is no identifiable single cause for CFS/SEID, poor energy production seems to be at the root of the many symptoms in this illness, which has focused some researchers’ attention on mitochondria – the powerhouses of all cells in the body. Mitochondria must continuously recycle the molecules they use to produce energy and there is some indication that this process is impaired in people with CFS/SEID. Perhaps this is why experience has taught many CFS/SEID patients to pace their lives, always allowing significant time for recovery from exertion.

Boosting energy production

In addition to pacing life to allow recovery time, lifestyle alterations that seem to help CFS/SEID patients minimize relapses also happen to be useful in maximizing mitochondrial function. These include avoidance of drugs and environmental toxins, avoidance of processed foods with high carbohydrate and sugar concentrations, addition of whole foods containing plenty of antioxidants and high quality protein, correction of hormonal problems, especially of the thyroid gland, and decreasing chronic inflammation associated with obesity and allergies. Gradual and graded programs of exercise, outdoors with some sun exposure help prevent the loss of muscle associated with inactivity and improve Vitamin D levels, with positive effects on immune function. Continued research will most likely show that CFS/SEID has many causes, all of which result in impaired mitochondrial function.

Lyme Disease: A Whodunit Tale

Some medical advances begin with old-fashioned detective work. Lyme disease, which was unknown in this country prior to 1975 is a good example.  That fall, two mothers from Old Lyme, Connecticut convinced the state Department of Public Health and Yale University to explore a mysterious outbreak of cases of inflammatory arthritis among the town’s children, because they were unsatisfied with the explanations they had been given for the cause. The investigation that winter centered on thirty-nine children and twelve adults from Old Lyme, all of whom had developed painful swelling of one or more joints between June and September.

Clues in clinical histories

Although blood tests and physical exams of the affected people had not previously revealed any known cause for the painful, swollen joints, investigators noted that there were striking similarities in the patients’ histories. Especially notable was a peculiar spreading rash that appeared about a month prior to the development of the arthritis and resembled an archer’s bull’s eye target. The affected people also lived close to one another, all in heavily wooded areas. The researchers concluded that the area where the cases clustered and the time of year in which they occurred were both crucial clues to the mystery. They believed that the illness could be an unknown type of infection but would have to await the next disease “season” for confirmation of this theory.

More clues in old European medical literature

In the meantime, investigators began combing through European medical literature, where they discovered similar descriptions of rashes going back to 1909. Over time, the Europeans had named the skin lesion erythema migrans and associated it with an illness that was similar to the one being reported in Connecticut, although without the arthritis. Some European reports mentioned tick bites in conjunction with the rashes, as well as successful treatment with antibiotics. Back in Connecticut, the next summer produced thirty more cases of what was by then being called “Lyme arthritis,” which investigators now believed was some kind of infection transmitted during outdoor activity.

Figuring out the tick relationship

The next pieces of evidence came from field studies of ticks. The distribution of a particular type of tick called Ixodes scapularis (variously known as the blacklegged tick, deer tick, or bear tick) near Old Lyme matched the distribution of local arthritis cases. Tick autopsies conducted in New York on Shelter Island, another hot spot for this mystery arthritis, showed that most of the ticks carried a spiral-shaped bacterium called Borrelia burgdorferi. Blood tests on affected individuals for antibodies to this organism tied it to the clinical cases of arthritis. Over the next two decades, the explosion of the deer population carrying the tick made the disease more common and widely known.As knowledge about and experience with the new disease accumulated, Lyme arthritis was renamed Lyme disease.

Early  Lyme disease symptoms

Lyme disease symptoms include an early stage of fatigue, muscle and joint pains, swollen glands, and headaches and fever that begin days to weeks after the infected tick bite. These symptoms represent the immune system’s response to the bacterial invasion. If a bull’s eye rash at the site of a former tick bite is present, diagnosis is easy. If not, diagnosis depends on a clear history of a tick bite and on the development of antibodies to the organism, which usually occurs later than the first few weeks of the illness.

Later symptoms

Left untreated, some, but not all infected patients develop symptoms within the next few weeks to months after the infected tick bite. Symptoms include arthritis, nerve pains, facial nerve paralysis, heart palpitations, shortness of breath, and chest pains. An even less common late phase that can occur up to two years after an infected tick bite might include migrating joint pains, muscle aches, abnormal muscle movements, weakness, heart arrhythmias, and cognitive complaints such as memory problems. These symptoms are not well understood and may represent a combination of the body’s ongoing fight against persistent bacteria and an autoimmune response that they trigger.

Treatment

Treatment of Lyme disease with oral antibiotics, either doxycycline or amoxicillin, is usually curative. If an infected tick is attached for more than thirty-six hours (the least amount of time it takes for transmission of the infection) and was encountered in an area where more than 20 percent of the deer tick population carries Borrelia burgdorferi, most patients are given a prophylactic one-time dose of doxycycline. Otherwise, treatment with antibiotics for two to four weeks begins as soon as the diagnosis of Lyme disease is made. The earlier the treatment, the faster the disease responds and symptoms subside. Late-phase treatment of neurological, cardiac, or arthritic symptoms may require intravenous delivery of antibiotics over longer periods. Although rare cases of persistent symptoms after treatment exist, no study has yet shown enough benefit from very long-term antibiotic use to justify the potential adverse effects of such a treatment.

Prevention of tick bites

Prevention of Lyme disease is the best way to deal with the illness, and there are things you can do to protect yourself. In the states where most cases occur (the New England states and New York, New Jersey, Maryland, Virginia, Wisconsin, and Minnesota), be aware that ticks tend to cling to high grasses and shrubbery in areas where deer roam. By hiking in the center of paths, away from tall grasses and shrubs, and wearing protective clothing, such as long sleeves and pants, you can reduce the chances of a tick bite. Shirt tails should be kept tucked in at the waist, sleeves should be kept closed at the wrists, and pants cuffs should be kept tucked into socks at the ankles. Additionally, spraying with insect repellent containing 20 to 30 percent DEET can help.

Self-examination is very important after potential tick exposure

The type of tick that transmits Lyme disease is Ixodes scapularis. It may be either a six-legged, immature tick nymph the size of a poppy seed or the slightly larger, eight-legged mature tick. Both forms excrete an anesthetic in their saliva that prevents you from feeling their bite, so close examination of your body is necessary after potential exposure. Bathe within two hours of coming inside and do a full body exam, with the aid of a mirror, paying close attention to areas covered with hair. Inspect all gear, clothing, and pets for ticks, and tumble clothing in a dryer at high heat to kill any hidden ticks.

Tick removal

Should you find an attached tick on your body, to remove it place the tip of a clean, fine-tipped tweezer as close to the skin as possible and pull gently, in a straight line. Dispose of all ticks in a toilet or drown them in alcohol and then seal them in a plastic bag for disposal. Clean bites with alcohol or iodine. Because the transmission of an infection from a tick to a human requires thirty-six to forty-eight hours of attachment, ridding yourself of ticks in the first twenty-four hours is effective prevention. Longer attachments that occur in high-risk parts of the country merit a single dose of doxycycline within seventy-two hours of a bite. Otherwise, be alert for symptoms or a rash, and seek treatment as soon as possible if they occur.

Research continues

The detective work surrounding the unraveling of the Lyme disease mystery continues today in the laboratory. Now researchers tend to focus on the rare people who, despite receiving adequate antibiotic treatment after contracting Lyme disease, experience persistent, unexplained, or recurring symptoms. These people remain almost as much of a mystery to researchers today as the initial thirty-nine children and twelve adult with arthritis were to researchers in the mid-1970s.

From Heartburn to GERD

At my Grandmother’s house, there was little for children to do after dinner but play games and eavesdrop on the grownups who sat around the table for hours after the end of the meal. Back then, the adults seldom talked about “diseases,” but they did seem to think that bodies, like cars, had parts that could be relied upon to malfunction with age and abuse. Dining room table wisdom held that “heartburn” was the expected result of overindulgence in rich food, alcohol, coffee and cigarettes, and that Alka Seltzer was the best remedy. I can still recall the fizz of the tablets dissolving in water.

Renaming a symptom

Heartburn is a vivid word image for the most common gastric complaint – distressing, burning pain just beneath the breastbone. With time, technology, and advertising, heartburn has been replaced by the anatomically correct term gastro-esophageal reflux (GER), which accurately describes the source of the symptom: acid splashing up into the esophagus from the stomach. However, renaming a symptom, heartburn, with its cause, reflux, does not make it a disease, no matter how many TV commercials advertising drugs for GERD (gastro-esophageal reflux disease) say otherwise. Diseases are sometimes associated with GER, but they are diseases that promote reflux, diseases treated with medications that promote reflux, or diseases that result from stomach acid eating away the sensitive lining of the esophagus.

How the esophagus works

Stomach acid is potent stuff, necessary to break down food and to kill off the bacteria that come along with it. Acid also helps with the absorption of vital substances like calcium, iron and Vitamin B12. The stomach lining produces acid and is remarkably resistant to its corrosive effects, unlike the lining of the esophagus above. The job of the esophagus, a muscular tube, is to assist gravity in getting food from the mouth to the stomach via a series of coordinated contractions. In its lowest portion, the esophageal muscle works like a valve. It opens to let food into the stomach and closes to hold it there as digestion begins. The esophagus can also reverse its normal action, opening the valve and emptying the stomach in a hurry, propelling its contents back out the mouth. This very unpleasant action, called vomiting, is perceived mainly as a squeezing, muscular sensation rather than a burning pain, because the exposure of the esophagus to the upward rushing acid is short-lived.

Reflux is backwards, upward flow of stomach contents to the esophagus

Reflux is a more leisurely affair. The muscular valve at the junction of the esophagus and the stomach is not a tight one, and it is subject to the effects of foods and drugs, and diseases that limit its responsiveness (see sidebar). Reflux is more common in people with hiatal hernias – upward slippage of the stomach top into the chest through a weak spot in the diaphragm (muscle between the abdomen and chest). With a stomach full of actively digesting food, reflux can occur simply with lying down or bending over, positions that limit gravity’s help in holding stomach contents down. And held down they must be, for at least awhile, because the stomach is a reservoir where the initial breakdown of food occurs.

The abdomen is a crowded space

The reservoir sits like a pool behind a dam, awaiting opening of the pyloric valve between the stomach and small intestine. The stomach shares close quarters with the liver, spleen, pancreas, small intestine and colon – and with fat tucked around all these organs. The more fat -and the tighter belts and pants are – the less the space available. The upper valve, between the esophagus and the stomach, is the weak link when pressure rises; it gives way while the pyloric valve holds fast, and stomach contents flow into the esophagus. The upper valve also yields in pure overeating (e.g. hot-dog eating contests), when the stomach fills faster than digestion can proceed.

Acid in the wrong location causes trouble

Chronic exposure to stomach acid inflames the lining of the esophagus, and then diseases appear – shallow erosions, deeper ulcers, and scars that interfere with swallowing. Risk of esophageal cancer rises. Acid reflux can go as high as the mouth and erode the enamel of the teeth, add to gum disease, and produce mysterious sore throats and hoarseness. Lung problems and asthma are more frequent in people with chronic reflux.

Reducing stomach acid works, but may cause other problems

Heartburn sometimes requires medical evaluation (see sidebar), but is often responsive to simple antacids like Maalox that temporarily lower stomach acidity. Powerful, safe and effective drugs called proton-pump inhibitors (Prilosec, Nexium, etc.) block the last step of acid production in the stomach. Reflux goes on, but stomach contents are no longer corrosive. But no drugs are free of unintended consequences. Without acid, food digestion is slower. Risks of pneumonia and gastrointestinal infections in long-term users rise, suggesting that in an acid-free environment, bacteria survive in the gut and spill upward into the respiratory tract. Some researchers believe that proton-pump inhibitors also turn acid production off in osteoclasts, cells that build bone, resulting in an increased rate of hip fractures in long-term users.  One very worrisome statistic in the age of altering stomach acidity is a rise in rates of esophageal cancer, though the cause of the rise is not fully understood. Lack of stomach acid, however,  has long been known to be a risk factor for the development of stomach cancer.

New generations have replaced my grandparents and TV and social media outdraw after-dinner talk, but heartburn, though renamed, is still just a symptom of a mechanical problem – acid reflux. Blunting the effects of acid with over-the-counter or prescription drugs is a temporary solution that does nothing for the inciting problem – the reflux. Weight loss, smoking cessation, elevation of the head of the bed (on 6-9” blocks), avoidance of large meals and offending foods and drugs, and allowing several hours to elapse between meals and bedtime are the keys to taming reflux and keeping GER from becoming GERD.
______________________________________________________________________________

 

Common Factors in Patients with Heartburn:
• Obesity, the most common factor.
• Diabetes (delays stomach emptying)
• Pregnancy (space shortage + hormone effects)
• Medications: antihistamines, antidepressants, narcotics, calcium channel blockers for high blood pressure and heart disease, progesterone, anticholinergics (bladder control drugs), some sedatives and tranquilizers
• Foods: fried foods, chocolate, alcohol, caffeine and others.
• Smoking(stimulates stomach acid)
• Asthma and anti-asthmatic medications
• Hiatal hernia
• Stomach outlet obstruction by ulcer or tumor

Seek a Medical Evaluation for Heartburn that:
• Wakes you up at night
• Happens regularly, more than once a week
• Is unresponsive to simple antacids like Maalox or Rolaids
• Recurs promptly after antacids or drugs wear off
• Has associated symptoms: nausea, vomiting, abdominal pain, difficulty swallowing, increasing abdominal girth, or blood in the stool

 

Over the Counter Pain Relief

Pain stayed so long, I said to him today

“I will not have you with me any more.”
I stamped my foot and said, “Be on your way,”
And paused there,
Startled at the look he wore.
“I, who have been your friend,” he said to me.
“I, who have been your teacher,
All you know of understanding love,
Of sympathy and patience I have taught you.
Shall I go?”   

Author unknown

Pain is a friendly messenger, carrying news from the frontiers of the body to the command center of the brain. Like the messages traveling across telephone wires, pain is just a series of electrical impulses traveling up nerves. The brain sorts the electrical impulses and presents them to you, the conscious mind inside, as a coherent story about what’s going on down below. Sometimes the message triggers an immediate reflex action, like pulling a hand away from a hot stove, even before your mind grasps the problem.

How is pain relieved?

Relief from pain depends on stopping the electrical impulses carrying the pain message or on altering the way the brain puts the message together. Every drug or procedure used in pain treatment works on either the simple electrical message, or on its complex interpretation by the brain. Ultimate relief comes when the conscious mind disappears into sleep, which is of course the great achievement of general anesthesia. Consciousness is the barrier to complete relief of severe pain.

Most pain, however, is not the severe unremitting variety that requires treading the fine line between consciousness and oblivion. Most pain comes in an acute form that gets us to the doctor for treatment of a sudden illness, or in a chronic form related to our heads or our skeletons. Thousands of years ago Cicero made the distinction: “All pain is either severe or slight; if slight, it is easily endured; if severe, it will without doubt be brief.”

Willow bark – the first pain medicine

Time and chemistry have given us surgery, anesthetics, antibiotics and narcotics – life-savers for diseases heralded by severe pain. They have also given us lesser drugs for lesser pains, a long process beginning in the 5th century BC when Hippocrates recommended chewing the bark of the willow tree to relieve pain and reduce fever. A long line of chemical derivatives of the willow bark’s salicilin culminated in a stable powder patented and marketed in 1899 as aspirin, the world’s first synthetic drug. Aspirin launched the world’s pharmaceutical industries.

Anti-inflammation and pain

Inflammation causes pain and the purpose of the pain is to get you to attend to whatever is causing the inflammation. Pain relief from aspirin is best understood in terms of its anti-inflammatory effects, but the drug has multiple other biochemical properties, many still being discovered. One effect, on an enzyme involved in the production of chemicals that produce inflammation, led to the development of ibuprofen and its cousin naproxen. These newer drugs, non-steroidal anti-inflammatory drugs (NSAIDS), are mainstays in the treatment of the aches and pains of daily life.  Anti-inflammatory steroids like prednisone are far more potent and used only when their risks are balanced by the seriousness of the problem under treatment.

Tylenol is not an anti-inflammatory drug

Tylenol, or acetaminophen, is commonly thought to be just like aspirin, but it is chemically unrelated, has no anti-inflammatory effects, produces no gastric upset and doesn’t affect blood clotting. It reduces fever by a direct action on the brain, but no one knows how it reduces pain. The pain-relieving properties of aspirin and the NSAIDS, apart from their anti-inflammatory effects, are also poorly understood. It is possible that they decrease pain perception in the mind, but if so, no one understands how.  They are most effective after an acute injury, after simple surgical procedures, or with infrequent headaches (relief here is also of unknown mechanism).

Frequent analgesic use can increase pain problems

But what about pain of chronic conditions like osteoarthritis and frequent “tension” headaches, in which inflammation plays a lesser role? Much arthritic pain is from tightness and muscle imbalance. Gradual activity warms up joints and removes some of the discomfort. Exercise, heat, ice, massage, weight loss, stretching, Pilates, and yoga help minimize drug use in these chronic conditions. Frequent use of analgesics for headaches (more than once a week) actually lowers the threshold for headache triggers (like lack of sleep, alcohol, lack of exercise, stress, etc.)  and for pain perception, and often leads to a cycle of increasing drug use producing increasing numbers of headaches. This phenomenon is known as rebound headache and it highlights the importance of other methods of headache prevention and relief (adequate sleep, stress management, attention to diet and exercise, etc.).

Selling pain relief like candy

Since 1915, when aspirin became available without a doctor’s prescription, the sale of over-the-counter (OTC) pain relief has achieved the heights late Merck chief Henry Gadsden aspired to when he wished aloud 30 years ago that he could sell drugs to healthy people just like Wrigley’s sells candy and gum. These days, OTC pain medicines are so readily available that they seem as harmless as the candy next to them on the shelf.

Side effects

Unlike candy, OTC pain relievers have to be processed by the liver and kidneys. Chronic use can produce liver and kidney impairment, even failure of these organs. Chronic analgesic use damages hearing. Aspirin and other NSAIDS may erode the stomach lining; all but Tylenol impair blood clotting. Recent statistical studies resulted in withdrawal of two newer NSAIDS from the market because people taking them had more heart attacks than those on placebos. The problem also appears in statistical analysis of those on high doses of the older NSAIDS.

Don’t kill the messenger – heed it

Because no drugs are risk-free and pain is just messenger telling you about a problem, try to reserve the pill option for pain that interferes with sleep or truly inhibits you from carrying out the activities that are important to you. Attend to the causes of the message in as many non-pharmaceutical ways as possible. And remember that an analgesic “virgin” or infrequent user gets more out of a painkiller than an analgesic veteran.

Stem Cell Treatments: Hope and Hype

In the early 1920s, John Romulus Brinkley, an entrepreneurial Kansas physician with dubious professional credentials, ran a lucrative business implanting goat testicles under the skin or in the scrotum or abdomen of patients who sought his help for any one of twenty-seven ailments, including flatulence. He was one of many medical hucksters who took advantage of an unregulated medical world in the United States at that time and made fantastic claims for their medical treatments, potions, and elixirs. Eventually, Brinkley’s medical license was revoked by the state of Kansas, and he moved south to Texas, where he advertised his services via a folksy radio station broadcasting from just over the border in Mexico. His station’s powerful antenna beamed his ads and promises all the way to the Canadian border, drawing patients south for his “treatments.” In the end, Brinkley is said to have made millions of dollars before a federal grand jury indicted him in 1941 for postal fraud. He died, bankrupt, in 1942, before he ever stood trial.
Fast-forward to a well-regulated medical world in December 2014. A famous ex-hockey player suffers a stroke and travels to Mexico for stem cell treatments. His family claims great results, and his therapists corroborate the reports, leaving many who read the story to wonder whether their brain-damaged relatives could also benefit from this therapy and why they would have to travel to Mexico to get it. Is this the same type of treatment being offered, without FDA approval, at the new stem cell clinics popping up in many American cities? And why is stem cell treatment not FDA approved? The answers require some understanding of stem cell research, clinical trials of new therapies, and the reasons why the FDA exercises caution when approving novel therapies.

What are stem cells?

Stem cells begin in a fertilized human egg, which splits into two cells, then again into four, and again into eight, and on and on. The first few dozen cells have the potential to become any type of cell in the body and are called embryonic stem cells. As the fetus develops, cells begin committing themselves to different roles, shaping a human body with all its complex organs. Some cells in each organ, however, retain enough of their primitive character to serve as a reservoir of cells for the repair and growth of the organ. These cells are called adult stem cells. The term “stem cell treatment” might refer to procedures involving either type of stem cell, but the stem cell therapies being offered commercially are adult cells.

The hope of stem cell therapy

The promise of adult stem cell therapy is based on the hope that stem cells can be harnessed to perform on demand and develop into mature cells to replace aging or damaged cells. In an ideal world stem cells could be coerced to act like the stem cells residing in bone marrow do naturally and regularly. Marrow stem cells make new blood components continuously – red blood cells, white blood cells, and platelets. They must do so because blood cells have life spans of only a few weeks.
Bone marrow transplants were the first stem cell treatments. They were used successfully in treating blood cancers and worked by replacing the patient’s bone marrow with that of a healthy donor. Bone marrow contains many types of blood and immune cells, but it is the stem cell component that repopulates the patient’s diseased marrow after it has been wiped out by chemotherapy. Originally, drugs were needed to keep the body of a recipient of a bone marrow transplant from rejecting the foreign cells, but advances in doctors’ ability to separate healthy stem cells from all the other bone marrow components now make it possible for physicians to give the patient his or her own cells, making antirejection drugs unnecessary.
The discovery that stem cells existed in many different tissues widened research horizons and raised hopes that stem cells could be used to repair and regenerate more tissues than just bone marrow. A wide variety of stem cell experiments aimed at treating a number of diseases, including multiple sclerosis and heart disease, are now being conducted. Ongoing clinical trials at academic medical centers are enrolling patients under strict protocols. Such trials are the only objective way to establish the safety and efficacy of stem cell treatments compared to standard care and to placebos. But so far, these trials are still ongoing, and the FDA has only approved marrow and umbilical cord blood stem cell use for the treatment of blood diseases like leukemia and lymphoma.
The hype: what are stem cell clinics selling?

But what about the stem cell clinics in the United States that offer treatments for a wide range of diseases related to aging, including diseases such as Parkinson’s disease, Alzheimer’s disease, chronic lung disease, and cardiac disease? These clinics are entrepreneurial ventures that operate without FDA approval. Stem cells are not considered drugs because they are harvested from the patients own body for re-injection into it; therefore, the FDA has no jurisdiction over the hundreds of stem cell clinics operating in the United States. If trouble occurs in these clinics (and it has, including death) then state medical boards are responsible for policing the people providing services until some kind of FDA regulation is put in place.

Fat is the usual stem cell source

Today’s stem cell clinics appeared after the discovery that fat was one of the richest sources of adult stem cells. With the purchase of a cell separator and participation in a weekend seminar, any doctor can open a stem cell clinic. During stem cell treatments, fat is harvested from each patient through a version of the liposuction process. The stem cells that reside deep in the fat, near blood vessels, are concentrated in the cell separator and mixed with the patient’s plasma to cause the stem cells to begin to divide and grow. Some clinics also obtain marrow stem cells through a large needle inserted into the bone of the hip, and, in some clinics, lasers are used to activate the stem cells and raise them from a dormant state to a reproductive one. Treated cells are then injected back into the patient, into the bloodstream, under the skin, into a joint, or into the spinal fluid. In theory, these cells find their way to the targeted, ailing tissues, turn into the desired cell type – such as knee cartilage – and heal the problem. Some practitioners, however, believe that the stem cells may not propagate themselves but only stimulate the body’s natural repair processes.

Risks 

Stem cell clinic literature often gives the impression that these procedures are risk free, but, in fact, all invasive medical procedures carry some risks, like infection and adverse effects such as dizziness. Recently several patients became blind after stem cell injections aimed at curing threating the macular degeneration in their retinas. Risks and side effects should be disclosed to every patient, even if their rates of occurrence are low.

No long-term follow-up studies available

Stem cell treatment is so new that there have been no long-term follow-­up studies done on large numbers of patients, the type of studies that are used to uncover unexpected trouble with new procedures. Since stem cells are meant to reproduce and grow and since manipulating them outside their natural environments and injecting them into patients presents a risk of changing the programming that keeps their reproduction under control, long-term follow­ up studies over many years are essential. While some stem cell clinics purport to do studies on patient outcomes, they demand that their patients pay for their treatments, and no legitimate study would require payment for the patients to be involved. Furthermore, the studies done in these clinics do not include control cases to assess placebo response or control groups to compare results with standard treatment.

Over-regulation or protection against charlatans?

With advertising claims being made that stem cell therapy rejuvenates aging body parts, with many people suffering from painful joints and other ravages of life, and with the FDA restricting stem cell treatment approval to specific blood conditions, what is the interested potential patient to think? That in the last one hundred years we have overreacted to charlatans and are using regulatory agencies to unnecessarily restrict useful medical therapies? Or that the injection of stem cells into the body with the expectation that these cells will reach the correct destination and perform just the repairs needed is a bit like trusting the promises John Brinkley once made about his goat testicle therapy? Desperation may drive some people to try what is easily available (though very expensive), but the safest course at this time is to stick to FDA­ sponsored stem cell studies for any attempted treatment. And to remember that placebo effect of any medical treatment, even antibiotics, accounts for 30% or more of the positive  responses in studies of efficacy. Glowing reports from friends and relatives don’t necessarily mean that demonstrable changes occurred in their bodies.  Research on stem cell treatments continues, but there is still a very long way to go.

Skin Cancer: Common and Commonly Curable

Babies arrive in the world with soft, smooth, and usually flawless skin. Old men and women leave the world wrinkled, mottled, spotted, and scarred. In between, the skin replaces itself many hundreds of times and in the process accumulates enough DNA damage to make skin cancer the most common of all cancers, with more than 2 million cases occurring in the United States each year. Fortunately, most skin cancers stay put in the locations where they start. They don’t invade nearby tissues and don’t spread through the base of the skin to travel to other parts of the body. Skin cancer is largely curable by removal alone.

Different skin cells and different skin cancer names

The three most common types of skin cancer arise from cells that grow in the epidermis, or outermost layer of the skin. The inner layer of the epidermis is made up of basal cells. Basal cells regularly reproduce themselves in order to make squamous cells, which are replacement skin cells and form a middle epidermal layer. This layer also contains cells called melanocytes. Melanocytes produce melanin, the pigment that gives skin its color. The outer layer of the epidermis consists of dead skin cells that are constantly being shed. The most common skin cancers come from these three types of skin cells: basal cells, squamous cells, and melanocytes. All three types of cancer are more common in fair-skinned, light-haired, light-eyed people. All three are also related to lifetime sun exposure.

Basal cell skin cancer

Basal cell cancer is the most common type of skin cancer, accounting for 80 to 90 percent of reported skin cancer cases. It is also the most benign skin cancer. Basal cell cancers begin with errors in a cell’s DNA, which serves as instructions for building squamous cells from basal cells. The abnormal cells that are created by this damaged DNA form a tiny area of skin that is different from surrounding normal skin. Typically, it looks like a little dome, with a waxy, pale appearance. Over time it may develop tiny blood vessels around it. It might bleed easily or develop a sunken center or a crusted top. Sometimes the color may be a little darker or rosier than that of the surrounding skin.

Basal cell cancers grow slowly and very rarely travel to other parts of the body. That said, they can invade nearby tissues, and the earlier they are removed, the less likely they are to recur (and the smaller the scar caused by their removal will be). Basal cell cancers occur most commonly on areas of the body exposed to the sun, especially the scalp, forehead, and corner of the nose. They are also more common in people who have been intermittently exposed to the sun without protection. Basal cell cancers take many years to develop, and by age sixty-five, about 50 percent of the population will have developed at least one such cancer. Within five years of treatment of one basal cell cancer, one-half of patients will develop a second one. Because of the popularity of tanning, both indoors and out, basal cell cancers are now appearing in some people before middle age.

Squamous cell skin cancer

Squamous cell cancers can occur in areas of the body that are not generally exposed to the sun, like the mouth and the genital region. However, when squamous cell cancers appear on the skin, they typically develop in areas that show other signs of sun damage—wrinkling, freckling, mottling, thinning, and sagging. They may also evolve from solar, or actinic, keratoses, which are considered precancerous markers of sun damage. Usually appearing as small red spots (under a quarter of an inch in diameter), solar keratoses have some white scaling on their surfaces. Some are sore and tender, and thickening with increased tenderness can indicate a progression to a skin cancer. Squamous cell cancers can be flat and scaly patches of skin or firm, red nodules or non-healing sores. Unlike basal cell cancers, squamous cell cancers, particularly those on the lip, can penetrate deeper layers of skin and travel to other parts of the body by way of the lymphatic system, though this spread is uncommon. If many precancerous lesions are present, treatment with chemotherapeutic creams helps prevent cancer development.

Melanomas

Like basal cell and squamous cell cancers, melanocyte cancers, which are known as melanomas and appear similar to moles, more commonly occur in fair-skinned people and are also related to sun exposure. It is no coincidence that the highest rates of melanoma in the world are in Australia and South Africa, two highly sunny areas colonized by fair-skinned people who are genetically better suited to the gray skies of northern climates.

Melanomas must be distinguished from normal moles, which develop in virtually all people. The average adult has twenty-five moles with varying degrees of pigmentation. Many “rules” exist for helping physicians decide whether a mole might be cancerous. For example, moles that are asymmetrical in shape and color, have irregular margins, and are larger than a pencil eraser are often considered suspect. However, none of these “rules” is a reliable way to tell if a mole is cancerous. More reliable suspicions are generally based on observations concerning mole development. The development of a new mole, particularly on the back or the legs, that grows over a number of years is definitely something that should be discussed with a physician.

A full 70 percent of melanomas are what are termed superficial spreading melanomas and are curable if caught when they are less than 1mm thick. Another 7 to 10 percent of melanomas, those that are deep blue-black or purple nodules, tend to spread more readily to other parts of the body. Rarer yet are melanomas in odd locations like the eye, under a nail, on the palm of the hand, or on the sole of the foot. These, too, are more dangerous.

Like basal cell and squamous cell cancers, the treatment for a melanoma is removal. There are a variety of different ways to remove skin cancers, ranging from scraping and cauterizing to a surgical excision with microscopic monitoring to find the edges of the tumor. Cure rates are high—in the 98 percent range, particularly when the tumors are small. If a tumor does spread to nearby tissues, it can still be cured, though with more surgical scarring. Metastatic melanomas do not respond well to conventional cancer treatments as a rule but may react differently to newly developing targeted immunological treatments.

Screening for skin cancer: no controversy 

In contrast to the confusion surrounding screening tests for some other types of cancer, clarity is the mark of medical advice about skin cancer. It helps if you know what to look for and to seek a medical opinion about any suspicious skin spots. Most often, doctors will recommend biopsy of a suspicious lesion as the surest way to make a diagnosis, and patients can expect that removal will be part of the cure for any cancers that are found. You won’t ever regain the skin of a newborn, but you do not need to have skin cancer.

 

Your role in skin cancer prevention

• Beginning early in life, protect your skin, particularly the skin on your face, scalp, ears, lips, back , arms, and hands. Use hats, shirts, and sunscreen (at least 30 SPF) to help block the harmful rays of the sun.
• Avoid prolonged sun exposure when the sun is high in the sky.
• At least once in middle age, have a professional examination of all your skin. If you are fair-skinned, and/or have sun damaged skin, heed your physician’s advice if he suggests more regular checkups. The American Academy of Dermatology sponsors free screening exams every May.
• Keep an eye on your skin and have new, enlarging, color-changing, non-healing or bleeding spots checked by a professional.

No more posts.