Science Fact - Pay Attention!

Elementary school was such a blast. You learn how to count and do basic math functions. You get to read fun children's books with great illustrations like the books by Robert Munsch. And you can do crafts for 3 hours a day and make cool stuff like turkeys out of a hand tracing.

I also remember that there were a few kids in my class who didn't seem to care about making crafts or learning about subtraction. They would be looking off into space, running around the room, and trying to get attention whenever they were bored (which was a lot). There was one kid who was known to jump up on his desk, pull down his pants, and pretend to play his twig & berries like a guitar. These (sometimes disturbing) images are my conception of ADHD.


ADHD, or attention deficit hyperactivity disorder, is a very common disorder that affects between 5-10% of kids. You see ADHD in more boys than girls (4:1 ratio), though it may not be identified as often in girls. It's characterized by 3 major symptoms:

1. Inattention


2. Hyperactivity


3. Impulsivity

There are different subtypes of ADHD, namely the inattentive type and the hyperactive/impulsive type. If you have a combination of the two types and show all 3 symptoms, then you would have the mixed type. This is the most common kind of ADHD.

You may say "Wait a minute, Hanni. Aren't most kids hyperactive? Why aren't more than 5-10% diagnosed with this disorder? And if most kids are hyper, then is ADHD a true disorder?" Very good questions, dear reader!! Well thought out. You're right that most kids are somewhat hyperactive. That's why the definition of ADHD required that there is functional impairment in more than one area in the kid's life. If kids are hyper and easily distracted, but aren't getting into excessive trouble at home and are keeping up in school, then it's not getting in the way of their functioning and therefore it's not a disorder like ADHD. If they only act out in class but not at home, they may have a learning disability instead of ADHD. Likewise, if they only act out at home there could be a lack of discipline or structure at home. Always remember that if the hyperactivity or inattention are not causing problems, then it's not a disorder.

Here are some common characteristics of ADHD to consider for each of the subtypes:

• Predominantly Inattentive Type
  
  
  Easily distracted
  
  
  Can't sustain attention on activities or conversations
  
  
  Makes careless mistakes
  
  
  Disorganized
  
  
  Loses things necessary for tasks or activities


• Predominantly Hyperactive/Impulsive Type
  
  
  Fidgets and squirms in their seat, leaves seat often
  
  
  Talks excessively
  
  
  Runs and climbs excessively
  
  
  Interrupts others
  
  
  Difficulty awaiting their turn


• Combined Type
  
  
  Combination of the above 2 types
  
  
  *Most children with ADHD have this type

If you are concerned that your child has ADHD, you can complete a take-home survey that will help you figure out the likelihood of a diagnosis of ADHD. If the test shows reason for concern, then it may be good to bring them to the doctor to see if they can make a formal diagnosis.

If children with ADHD go untreated, they are likely to have problems with many aspects of their lives. They may have academic problems, health issues, multiple injuries from their impulsive behaviour, substance abuse, increased risky sexual behaviour, problems with the law, and low self-esteem. When looking at that long list, it's easy to get disheartened and overwhelmed.

Well, one of the major realms of treatment that has shown a lot of benefit is medication known as psychostimulants. The most famous of them all is Ritalin (methylphenidate), but there are others such as Adderall and Dexedrine that are used as well. These are stimulants, but surprisingly they are able to calm down kids with ADHD and allow them to focus much better. Another medication that is not a stimulant is called atomoxetine. It works well but is often used as a second option if the stimulants don't work.

Medications have been shown to be most effective in treating ADHD, but there are several non-medicinal treatments that can show similar benefits, and are great when used in combination with meds. Some of these methods include individual or family therapy, exercise routines and extracurricular activities, social skills training, and classroom tutors.

Treating ADHD with the above methods will reduce the chances of running into the problems commonly faced by these children. Some people worry about the addictive potential of giving your kids stimulants, but it's actually been shown that these meds reduce the risk of substance abuse by 85% compared to untreated ADHD!!

Now for the downsides of medication. The major side effects are a loss of appetite and insomnia. It's important to make sure that they eat breakfast every day, even if they are not that hungry, and that you don't give meds in the late afternoon or evening for fear of causing insomnia (problems with sleep). Other side effects are seen at the beginning of treatment but disappear after a couple of weeks, such as headaches and fluctuating moods.

So if you think your kid has ADHD (or if you think you may have it) the first thing to do is figure out whether or not they actually have it. Talk to your doctor and find out if there could be a formal diagnosis of ADHD. The next thing to do is consider all of the treatment options. Remember that if this is left untreated it can cause a lot of problems in their life, and that it's better to get professional treatment (medication, therapy, or support) than it is to self-medicate with cigarettes, alcohol, and harder drugs.




*BONUS! Here is an article that discusses whether it's right to treat kids with ADHD differently than others, namely by letting them skip line-ups at amusement parks because they have trouble waiting. Which side do you think is right?

Band/Album Names (Pt 25)

It's time once again for the ever-popular band/album names!! These ones were mostly brainstormed in Montreal last weekend when I visited my bro and the Maritime crew (Jack, Danny, et al). Prepare to be blown away:

• Hardcore Scenery


• Heavens No


• Bear The Honey


• Say Goodbye To The Germans


• Query Latvian Festival

And the best one of the bunch (especially for those of us who grew up watching Canadian TV):

• Hinterland's Hoo-Hoo

Science Fact - Contraception and the Amazing Mirena IUD

During my time working in obstetrics and gynecology, I learned a lot about having babies. It was fantastic for me to interact with first-time mothers, watch their progress and deliver their little bundle of (messy) joy. But I also learned a lot about NOT having babies during my rotation, in terms of both contraception and infertility. For those who don't know, contraception means countering conception, or birth control. I always love words that have "contra" in it because it reminds me of the Konami code, but I digress. After dealing with women for several weeks, I came to fully appreciate one of the methods available to women for contraception: the Mirena IUD.

You may be asking me why I admire this little device so much. You may also be asking what the heck an IUD is, let alone a Mirena IUD. We will explore these FAQs and hopefully at the end of this entry you may be just as infatuated with them as I am.



There are several general methods of birth control. Let's go through each one and discuss how they work:

Barrier Method (condoms, diaphragm)

As the name suggests, they act as barriers to prevent the sperm and the egg from meeting. They work well when you remember to use them, and use them properly. An added bonus is that condoms can protect against many sexually transmitted infections (STIs).

Spermicides (spermicidal jelly, sponges)

The purpose of this stuff is to kill the sperm before they can reach the egg. It's common to see spermicides teamed up with barrier methods. Also, the Seinfeld-famous sponges are often soaked in spermicide to trap and kill sperm before they enter the uterus.

Hormonal Contraception ("The Pill", depo-provera injections, patch, vaginal ring)

The birth control pill, or oral contraceptive pill, is one of the most common forms of birth control. All pills contain progestin (a synthetic progesterone that prevents ovulation), and many (but not all) contain varying amounts of estrogen as well. They work very well, up to 99.9% effective, but only when the woman remembers to take it every day. The other hormonal options are also based on progestin and work in similar ways. In some women they have the added benefit of making your periods lighter and more regular.

Intrauterine Devices aka IUDs (Mirena, copper)

IUDs are physical devices that are placed inside the uterus in order to irritate the uterus lining and prevent the egg from implanting.

Permanent contraception (tubal ligation, vasectomy)

These methods are for people who are sure they no longer want biological children and don't want to deal with any of the other methods. They are quite effective, but are difficult to reverse if something changes in your life such as a remarriage.

Abstinence

Always remember that you can't get pregnant if you don't have sex. Abstinence is 100% effective. But if you are going to have sex, then that percentage goes down quite a bit.

Now that you know about the major categories, let me elaborate on IUDs. The first IUDs were made of copper and worked by irritating the lining of the uterus, thereby preventing the egg from implanting into the lining and beginning to grow. This worked relatively well (99%) but it caused a lot of cramping and heavier periods. Not fun for any woman...

Then along came the Mirena IUD. Instead of copper, this new device uses a synthetic core that releases progestin (namely levonorgestrel) slowly over time. It prevents pregnancy in several ways now: (1) it irritates the lining of the uterus, (2) the progestins keep the uterine lining thin and less suitable for egg implantation, (3) the progestin also may prevent ovulation, or at the very least slows the progression of the egg through the fallopian tubes so that fertilization is less likely, and (4) it thickens the mucous plug in the cervix that sperm need to travel through in order to reach the uterus. With all that protection, the Mirena provides 99.9% protection (meaning 1 in 1000 women who have sex regularly for 1 year will get pregnant). This is as good as the pill, but you leave the IUD in for up to 7 years so you never have to worry about remembering to take a pill every day!! You also get lighter periods over time where there's a 20% chance of having no period at all after 1 year of using the Mirena IUD (bonus!!). Not only that, your fertility will return to normal 1-2 months after you decide to remove it. It's even cheaper than the pill if you keep it in for over 3 years. What's not to love?



Ok, it's time for the downsides, because all options have downsides and this info would seem too biased without them. Most of the worries occur during the first month of using the IUD. Your uterus may be upset with having something inside it and cause cramping. The other common side effect is having irregular spotting for the first few months. Both of these will settle down over time. Another worry is if your uterus "spits it out", so to speak (expulsion). You can't replace it after that because it may be contaminated, so you'd lose out on the money you spent. More rare but more serious side effects would be if the doctor accidentally punctures your uterus and places the IUD inside your belly, where it would hang out around your intestines for a while until it's discovered. Finally, the Mirena IUD doesn't increase your risk of infections or STIs, but if you get an STI you have a higher chance of the bacteria spreading to your uterus and fallopian tubes. This can cause serious damage to your health and permanent infertility. So if you're in the sex industry and are at higher risk for STIs, you may want to use some other form of birth control.

If you can handle the relatively rare risks of IUD insertion, and you are looking for a more stable form of birth control, I would recommend considering the Mirena IUD. If I was a woman looking for 3-7 years of contraception I would totally do it. No need for memory, light (or absent) periods, cheap, and the most effective on the market today. What else do you need?


***

Let me put a bit of a disclaimer at the end of this topic, since it can be a bit controversial. Some people don't believe in contraception, and I respect that. I feel that everybody has the right to an opinion and should follow their beliefs. But this includes those that believe in contraception. These are my opinions, and you can disagree all you want, but there's no need to be upset with people just because they have different beliefs or principles, especially if they're not trying to change yours.

Band/Album Names (Pt 24)

Once again it's time for epic band and album names from yours truly. Let the party begin! And for those of who with any band or album names of your own, feel free to share them with us!

• Vagrants Galore


• Anti The Yearbook


• As Far As The 90's


• Aren't You The Jeweler?

And my favourite of the bunch:

• But First

Science Fact - The Sweet Smell of Liver Failure

I just started a 2 week medical elective in my home province of Nova Scotia. I've been away for so long that I thought I could easily deal with living abroad (read: Ontario) without feeling like I'm missing out on the Maritimes. But now that I'm here I feel like I have been trapped in the Maritime tractor beam and am being slowly pulled back to my heritage. Or at least one of my heritages. The strange thing is that I became most drawn toward Nova Scotia again because of the smell of Downtown Halifax. It's not necessarily the cleanest smell, as the famous Halifax harbour contributes to the overall scent, but it's intriguing nonetheless. It smells like home to me.

Speaking of smells, I had an interesting encounter today in clinic. I am learning about liver disease and liver failure from one of the leading hepatologists in the Maritimes, and we were assessing patients to see if they qualified to get a brand new (or technically second-hand) liver. In the middle of one assessment, my preceptor casually told me to smell the breath of the patient.

Now I don't know what the proper etiquette is on assessing the odour of a patient's breath. Do you ask them to blow in your face? Do you use 2 fingers to waft their breath toward your nose, like smelling a fine wine or a dangerous chemical? Do you put your nose a few inches away from their face? After you smell their breath, do you nod approvingly or keep stone-faced throughout it? So many questions...

The interesting thing was that I could smell something peculiar. Something I had smelled in the hospital before with very sick patients. It's difficult to pinpoint that exact smell, but the closest description would be sweet, flowery feces. It sounds gross, and it really is, but that only dawns on you after a few whiffs. At first you think to yourself "What is that smell? Is it good or bad? Where is it coming from?" Once you get the words "sweet shit" in your mind, it's hard to feel the same curious enjoyment from the smell coming out of someone's mouth.

The technical term for this aromatic breath is fetor hepaticus, otherwise known as the breath of the dead. It's caused by liver disease that is progressing or has already reached the status of liver failure. In fact, it's the most sensitive sign of liver failure out of all the possible signs (such as spider nevi, gynecomastia, ascites).

Here's the science behind the unique smell. The liver is a major organ that's responsible for several things. (1) It detoxifies the blood, metabolizes drugs and removes harmful compounds. (2) It can store glucose in a handy easy-to-use molecule called glycogen. (3) It helps your blood to clot by making hormones that promote the production of platelets, and by making vitamin K which promotes the production of clotting factors. (4) It makes albumin, a very common yet important protein that holds fluid in your blood vessels and helps to transport molecules throughout the bloodstream.

The breath of the dead has to do with the first reason (detoxification). In people with liver disease for some reason or another, they can develop cirrhosis. Cirrhosis of the liver means that the liver has been damaged, and instead of being replaced by normal liver cells it gets filled in by fibrotic tissue. The tough, structural, and nonfunctioning fibrotic tissue "takes over" the liver, so that the overall liver function is greatly reduced. All of your blood passes through your liver in the "portal system", but if your liver is tough and fibrotic can't filter the blood very well. This causes the blood to back up. After a while, the blood gets pissed off and tries to find other ways around the liver to complete the circuit back to the heart. The blood travels through smaller veins that pass along the esophagus, and then end up in the heart and lungs. But by bypassing the liver, the blood is now full of toxins and weird chemicals. Some of these chemicals are aromatic so they get excreted into your lungs, and you breath them out. Thus, the strange smell. It's sensitive for liver disease because only people with bad livers who have developed alternative blood pathways will get this.

The bad news is that these toxins can enter your brain and cause may problems. This is known as encephalopathy. Many people who develop encephalopathy (without proper treatment) have a poor prognosis and will die rather quickly. That's why that smell is known as the breath of the dead.

So the next time you smell sweet excrement, think fetor hepaticus.

Science Fact - Strep Club

Have you ever had a nasty sore throat for a couple of days where drinking orange juice felt the same as swallowing shards of glass? It's a horrible experience. But what's even more horrible is when you go to see your family doctor or a walk-in clinic and wait for 2 hours, only to be told to go home and rest. It made no sense to me why they would dismiss you that easily, sometimes without even taking a swab of the back of your throat. A few doctors will still blindly prescribe antibiotics to anyone with a pulse, but the majority these days will hold onto those magical drugs as if they were precious gems. So I wondered: Do doctors ever do anything for people with sore throats?


Since I have completed several hospital rotations, I've had the chance to be on the other side of the situation. Now that I understand the reasons for treating vs not treating, I can more properly take care of patients. And I'm a better patient myself whenever I have a sore throat. Let's walk through some of the science behind sore throats and then explore what doctors consider before sending you on your way.

The bacteria that we worry about the most with sore throats is Streptococcus pyogenes, aka Group A Strep. Why do we worry? It's not because the throat infection is particularly bad, or that you cannot recover from the infection on your own. The reason is that throat infections with Group A Strep ("strep throat") can spread from the throat to other areas and cause worse infections. There is a chance that the bacteria can enter the bloodstream and travel to the heart, brain, and joints. This is called acute rheumatic fever. People with rheumatic fever often have a fever and joint pain beginning 1-3 weeks after getting strep throat. The biggest concern from a medical point of view is that the bacteria can infect the heart tissue and cause major problems. You can end up with permanent damage to your heart muscle or valves.

So with all of this scary information about strep throats, why don't we treat every sore throat with antibiotics to prevent rheumatic fever? First of all, sore throats can be caused by viruses as well as bacteria. In fact, most sore throats are viral in nature. The common culprits are adenovirus and the common cold viruses (rhinovirus, coronavirus, parainfluenza). Antibiotics would have absolutely no effect in this case. Secondly, if the sore throat is bacterial, it may not be strep that's causing it. There are a few other bacteria that could be the responsible organism. To be fair, though, Group A Strep is the most common bacteria that causes sore throats.

Lastly, and this is a big point, most of the strep infections will be successfully eradicated by your own body. It's often the case where people with throat infections do not get medical treatment. Their sore throat resolves after several days and they move on with their lives. The reliance on antibiotics has been a recent development in our history, and we did quite well without them, especially with minor infections. It is NOT true that strep throat will always cause rheumatic fever if untreated. The prevalence of rheumatic fever is very low, and is even lower in developed countries like ours. In fact, some countries like England don't bother to test people for Group A Strep because they don't give antibiotics to patients with sore throats unless their mouth is about to implode. You can bet that there are numerous times when patients have strep throat and are not treated, but the amount of rheumatic fever in England is as low as it is here in Canada. This shows how rare it is these days to develop complications from strep throat.

This brings us to how we in Canada treat sore throats (known as acute pharyngitis in the medical community). There is no mystery behind it at all. There are 4 criteria that we look for which may indicate if strep is the culprit. Here they are:

• 1. Fever (Temp >38°C or >100.4°F)


• 2. No cough


• 3. Swollen tonsils with exudate/pus


• 4. Tender lymph node enlargement in the neck

If you have all 4 of these criteria, then you are about 40-60% likely to have strep throat. In this case, the doctor will prescribe penicillin to you right away, and likely get a throat swab to confirm the diagnosis. If, on the other hand, you have a sore throat with a runny nose and cough, no fever, no white stuff coming out of your tonsils, and no swollen lymph nodes, then your infection is almost certainly viral. In this case you would definitely be told to go home and rest. Even if you had one of these criteria, you'd still be sent home sans prescription.

If you have either 2 or 3 of the criteria above, the doctor will likely swab your throat and culture the goop to see if Streptococcus pyogenes will grow. This usually takes 2 days, and often by then the sore throat has resolved. If it hasn't and the culture is positive for strep, then the doctor will prescribe anitbiotics.

So what does this all mean for you, the patient? The next time you get a sore throat and are debating whether to go see a doctor, think about these 4 criteria. If you score a 2 or higher, you may want to go in and get swabbed, or antibiotics if you're lucky enough to get 4 points. But if you score a 0 or 1, stay home and get some chicken soup into you. Wait until tomorrow to see if you get better on your own, or if your score goes up. This may prevent an unnecessary doctor's visit. And more importantly, it will save you from an annoyingly long wait in the waiting room surrounded by other sick people and copies of outdated Readers Digest magazines.



* Click here for an online version of the criteria that you can fill out on your own and find out what to do!

Band/Album Names (Pt 23)

It only feels right to start off my posting with the 23rd set of band and album names. I truly hope that some of you will use these for your up-&-coming garage band, or at the very least for a mixed CD that you make for a friend (or your special lady). Here they are!

• The Kitchen Skivvies


• Largely in my Undies


• Dirty Servant


• Second Winter Burning


• Nuts & Gum


• Oh Hey Hey

And my favourite of the bunch:

• Double Whammy

A New Hope

This is it! The glorious return of Off The Contrary after over a year of being lazy/studying medicine/traveling. I was originally going to title this entry "Return of the Jedi", but I thought that was far too pretentious as I am a Padawan learner at best. The chosen title is more humble, and is far more fitting for a story that has taken a lengthy hiatus and now sets out on the second (and final?) saga.

In the coming weeks you can expect some medical tidbits, some random thoughts, possibly some answers to questions that you (my beloved reader) would like to ask me. And, of course, band and album names galore.

Oh, and before I forget, I have to give a shout-out to those who have stumbled upon my blog over the past year and have left me very interesting (and sometimes inappropriate) comments. I was even mentioned by other blogs like Broke-Ass Stuart's website, which blew me away because it actually looks like an established site! Well, at least it's way more professional than this one.

Stay tuned for the second coming of Off The Contrary!!

Band/Album Names (Pt 22)

I know I haven't been writing much in terms of scientific education and hilarity, but after my crazy exams this week I'll be sure to write down the plethora of ideas that I've had while studying. In the meantime, I'll share with you a special installment of band/album names. Each one is medically themed and is a set of band & 1st album. Enjoy!!

• Fat Legs and the Crackles     -     Hyper Trophy


• Bolus     -     Push It


• Pertussion     -     Whoop Dreams


• Melena     -     Poop Out


• Anal Tone     -     Sounds Like The End


• Failure To Thrive     -     Small For Dates


• XXY     -     Congenitalia

It's A Trap!!!

What's better than a short clip featuring an obscure Star Wars character? A short clip featuring an obscure Star Wars character AND a new breakfast cereal!! Check it out:



Or, if you don't like embedded videos, you can click here