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!