As with all patients, those 13 to 64 years of age should get routine HIV tests. Unfortunately many hospitals and most physicians have been slow to counsel and test patients; if this were performed, many would not get HIV and would be found at an early stage. We still have people walking into the hospital half dead, not knowing they were HIV positive, and should have been treated years ago. Please help get the word out: get tested and wear condoms. Obviously and sadly heterosexuals pay less attention to routine testing than gays, but some gays are in denial and I have had many of them suffer much and/or die. I think gays have no excuse for not testing regularly, they are aware of the risks. I know this shocks you, but many gays participate in unsafe sex.

Evidently those over 50 should start therapy when the CD4 is less than 500, whereas this is optional for the younger and a little less optional for CD4s between 350 and 500. There are still some diseases where we should start medication with a very high CD4 count; the quantity of the immune system is good but the quality is not. Also, if someone insists on unsafe sex, then getting their viral load to undetectable will lower the risk of transmission greatly.

If the CD4 is greater than 500 then treatment is optional but it should be taken if the viral load is more than 50,000 or the CD4 is dropping fast, or they have risk factors for cardiovascular disease (heart attacks, strokes), such as smoking, family history of the same, high cholesterol, diabetes or high blood pressure. Smoking is the worst of all the risk factors and if you quit, you drop your risk dramatically. Risk takers, are you smoking, using drugs, and having unsafe sex? Come out of your fantasy and please accept reality, you’lll live longer and suffer less.

We should pay close attention to weight gain (common as we age), as it may lead to cardiovascular disease through causing some of the risk factors above.

To diagnose and monitor diabetes we use the hemoglobin A1C level, which tells us how the sugar has been the last 2-3 months. We usually like it below 6.5, but in elderly that can be raised to 8.

HIV patient s in general must have their laboratories monitored periodically, and this group is at higher risk for problems, so we must not postpone the blood tests and watch them closely.

We must be careful to monitor drug doses and interactions in the older patient since they cannot break down or excrete the drugss well as younger people. Mild kidney disease is common and we must adjust the dosages of medications. Older people are many times on multiple medications so we must be vigilant to check also for interactions. This can be very tricky. For example a lower cost generic for high cholesterol, simvastatin, the blood levels can go sky high and cause terrible side effects when combined with a family of antivirals. The HMOs love this medication since its cost is so low.

Hypertension is very common as we get older and we must pay close attention to diagnosing it and treating it. Avoiding too much salt, eating 5 portions of fruits and vegetables a day, and getting sweaty or breathing hard for 15-30 minutes a day is great prevention of hypertension and great for health overall.

Cancer of the rectum and anus is more common in HIV patients so a yearly rectal exam is recommended. Some are doing pap smears of the anus as we do in the cervix of women (they should have a pap smear once a year; we can’t let them rest for 3 years as we do with HIV negatives.) Remember that HPV, viral warts cause the cancer, may not be seen or felt by you, and transmit outside the condom protection area as does herpes and syphilis.

We should double check that the older patient is up to date on the recommended vaccines.
Safe sex (condoms) should be discussed at each visit as with the younger, but vaginal dryness and poor erections are common in the older patients and we have medications for these. If the vagina is dry, then it can be irritated during sex, causing better HIV transmission. We know that having an undetectable viral load lowers the risk of transmission and that a condom is a good backup since transmission is still possible. Likewise, we tell younger females that they need a condom and a backup method of birth control since there are failures of each method at times.

Osteoporosis (weakening bones) is more common in older patients and in HIV so a double risk is present. It is recommended to screen for this and check vitamin D levels.

The older we get, the closer to dying we are. It is inescapable. Younger people could have a tragedy so this applies to them too. Don’t avoid this. Please schedule a meeting soon with those whom you love this Valentine’s Day. This shows you love someone. It is a great favor to yourself and your loved ones to make out a:

A Will, so that all know where your valuables are going when you die.

A durable power of attorney for health care letter so that all know who the spokesperson is when you are unable to speak or think well, and with whom you have discussed your end-of-life issues and health goals with.

A living will: this has wording on the document that will help you express how you would want to be treated for severe problems. Of course it can’t predict all future events, but it helps your loved ones to know how aggressive you want to be, e.g. do you want to be a vegetable in a nursing home for years, with a diaper on and a feeding tube in your stomach, while you stare at the wall. This happens frequently since the patient put off the work needed to prevent it. Take a walk through a nursing home someday. Better yet, walk through one that has many people on breathing machines. Many of them didn’t do the paperwork and would rather not be there, but are now unable to express this.

Mental changes should be looked for whether it is from substance abuse, confusion, depression, or anxiety. Older people can slip into one of these and suffer more when it is unrecognized.
Well, that was pleasant! We must talk about this since it is unavoidable. Be mature, express that higher love.

Daniel Pearce, D.O., FACOI, AAHIVS
Associate Clinical Professor of Internal Medicine, Loma Linda University
HIV Specialist, Riverside County Public Health Department

What is the best diet to boost the immune system?
That would be a balanced diet with 5 portions/servings of fruits and vegetables a day to keep you at your best weight and limit empty calories (fast food). It is fascinating to me that the entrepreneurs pull nutrients out of food, put them in a pill and sell them to us at a high price. What is fascinating is that recent studies have shown in some groups that multivitamins or antioxidants did not help the patients as much as eating the food that contained the nutrients. It seems the interactions between the nutrients have a greater benefit than the individual nutrients by themselves. This makes sense since humans evolved eating whole grains, fruits, and vegetables. Those who were weak, died without children. Those who did well on this diet and exercise program lived to have children, and eventually….us. Studies have shown that a balanced diet helps the immune system but that effect is far less than killing the virus with effective medications.

Abuse of alcohol, tobacco, stimulants (meth and coke), and narcotics do bring the immune system down.

If you just won’t eat more than 3 servings of fruit and vegetables, then take a multivitamin with minerals. Prenatal vitamins are in this group; your pharmacist can recommend a good, cheap one. If you only have 1 serving or less, then take the vitamin twice a day, knowing it is a poor substitute for good nutrition, but better than your present intake.

Does having sex too often hurt the immune system?
No it doesn’t unless this is a sex addiction or the sex is unsafe so that diseases are transmitted. There are many psychological and physical benefits to good sex, that is sex with love involved. It can increase antibody levels, relieve pain, Burns calories (about 200, a normal size cookie).

What is the long-term effect of Atripla?
Most of this medication’s possible side effects are up front, during the first month: dreams, feeling intoxicated, rash. Many have no side effects at all. Your provider should watch the fats in the blood to see if there should be a dietary adjustment or another medication added, or a change in your antivirals. Also, watch the kidney blood test for early signs of poor function.

Can an HIV negative woman have a baby from an HIV positive man?
Yes, of course. The woman can turn positive and then she can pass it to the baby during the pregnancy, birthing process, or through breast feeding.

So we recommend condoms (or abstinence) until the time to get pregnant. The man should have his viral load below detection since it lowers the risk of transmission greatly. The mother should be tested for HIV after 2-3 months of pregnancy. If positive, then getting her viral load below detection will greatly reduce the risk of transmission to the baby. If the viral load is high, then a Caesarian section lowers the risk. With these strategies, only a very small number of HIV positive babies have been born in the USA.

Can a baby from an HIV positive mother be HIV negative? Yes, if no treatment is given to the mother, there is a 25% risk of being positive and if the mother and baby are treated, the risk is near zero. “There were no pediatric cases of HIV or AIDS reported in 2010”. (Riverside County Health Statistics). San Bernardino County also reports none for 2010 also. There certainly were pregnant HIV patients. It is routine to check for HIV when a woman is pregnant.

An HIV positive woman and her newborn were given AZT 14 months ago and the baby is HIV negative. Are there any side effects to the AZT we should expect? I know of no hidden, delayed side effects that a brief exposure to AZT will cause.

Many of these children have already reached their late teens and are without problems from the brief AZT exposure.

Can one take Complera and then develop resistance to Atripla? Yes. They share the same sensitive spots on their targets. So if their target changes from mutation, then both drugs won’t be able to jam the target. Missing pills is the main cause of resistance.

What are the treatments for lipodystrophy?
For the problem of gaining too much weight, there is a new drug, Egrifta, which may help, it is injected under the skin twice a day; it looks like you will gain the weight back if you stop. If the testosterone level is low in a male, then taking some may help.

To treat fat loss, there are expensive injections of fillers. We rarely use the antivirals most likely to cause these problems unless a patient has missed pills of the safer meds and now must take something more toxic to control the virus due to resistance developing.

When should you start medications?
This is based mainly on CD4 counts:
CD4>500 if you desire
<500 may help
<350 helpful
<200 life-saving
Of course treatment is needed if there is an AIDS-defining illness, a pregnancy, Hepatitis B needing treatment, or HIV-kidney disease. Treating early makes sense to kill the invader but there are possible complications of long term treatment such as resistance and fat changes mentioned above.

Why does an HIV positive person get Herpes?
For the same reason HIV negatives do. Having great immunity may not be enough protection. Humans get Herpes.

What is Growth Hormone for?
It is prescribed for wasting, poor muscle weight gain, and it can help with lipodeposition (gaining fat). It is very expensive and most insurances won’t pay for it without much paperwork.

What is the risk of my getting a super-infection from my partner if I and my partner have an undetectable viral load?
The risk is low, but present, so we still recommend condoms. At one moment the viral load was undetectable, maybe at another it is higher due to a cold coming on or other reasons. The semen, vaginal secretions, and rectal secretions do not have the same drug levels as the blood, and therefore may have more virus at times and this virus may be resistant. Studies have shown virus in these secretions when the blood shows none in some patients. Of course, sores or irritation promote transmission.

What is the difference among CD4 versus CD8 and why is important to keep track of those?
CD8 cells are Killer cells and kill opportunists. The Guidelines do not mention CD8 cells. Most HIV specialists do not act on them. The ratio of CD4/CD8 can give you an idea of how ill a person is, but does not change the treatment recommendations .

Send me your questions. Be safe and wise. Please send your medical questions to Adelante.

Daniel Pearce, D.O., FACOI, AAHIVS
Associate Clinical Professor of Internal Medicine, Loma Linda University
HIV Specialist, Riverside County Public Health Department

Testosterone is an anabolic (muscle builder) steroid; another is nandrolone (Deca-Durabolin). These and other medicines are controlled by law and are illegally sold to body builders to enhance their muscle mass and decrase their body fat. They typically look quite buff with very little body fat, causing pronounced definition of their muscles. Some of the models in this magazine may be using anabolic steroids.

Testosterone and the female hormones belong to the sex steroid class. There is another class of steroids, the anti-inflammatory steroids such as prednisone, dexamethosone, and methyl prednisolone. We give these for asthma and other inflammatory problems.

Testosterone is produced by cells in the testicles. Other cells there make sperm. A vasectomy stops sperm from going up the tube, but the testosterone is secreted into the blood, so it is not affected.

Testosterone helps change the fetus to a male and keeps it on track to become an adult male by influencing muscles, fat, bone growth, larynx growth, hair, genital growth and pigmentation, mood, behavior, strength, endurance, and body shape during puberty.

The testosterone level can be measured in the blood and it has a range of about 300 to 800. Some researchers feel that your testosterone level should be measured according to your age. The closer to puberty the higher; the closer to elderly, the lower. So having a level of 350 would be thought of as low in a person 40 years old, but not 80 years old.

Some Endocrinologists (hormone specialists) recommend morning testosterone levels only and measuring them a few times. That is difficult to do in a clinic where the patients have a hard time paying for transportation and must be at work every day to make money.

HIV patients have a higher incidence (20-50%) of low testosterone (hypogonadism) and these should receive supplementation. If I see a patient who is fatigued, depressed, not showing the average amount of muscle, has osteoporosis (weak bones), or having trouble with sexual desire or function, then I will check a testosterone level. A low level coupled with symptoms will result in a prescription for testosterone.

We use Marinol, medical marijuana, and megestrol to help with appetite in HIV, but these can lower the testosterone level. Chronic narcotic use for pain can also cause low testosterone levels.

In addition to HIV, men who are obese, have diabetes, or have high blood pressure are at risk for having low testosterone. Many of these men may attribute the symptoms of low testosterone to their other diseases, medications, or just getting old. They feel better when they receive supplementation. Some physicians feel it is too risky to give testosterone to elderly men. On the other hand, giving it may reduce their risk of a heart attack. One study estimates that 19% of men over 60 years of age have low testosterone levels.

Some men have a testosterone deficiency from birth. There is no evidence that testosterone levels vary from race to race.

The medication, if taken orally, is broken down by the liver so it must be given parenterally (outside of the gut), i.e. as an injection or on the skin. The injection is much lower priced than the patch or gel. The patch and gel are given daily and are better at mimicking the normal testosterone secretion pattern whereas the injection is an oil with testosterone mixed in and the drug leaks out of the oil over time.

Usually we give the injection every two weeks but if someone is finding great results the first few days and feels poor the last few days of the two week cycle, then we make the cycle every week at half the dose. Sometimes the insurance will pay for the gel or patch if the patient cannot inject himself and there is no one around to do it consistently and they cannot make it to the clinic frequently.

Hopefully the patient will experience improvement in the symptoms. If an HIV patient already has lipoatrophy (loss of fat in the face, arms, or legs) then this might get worse with testosterone therapy. The patient must weigh the risks and benefits of therapy.

If the symptoms are not better in a couple of months or they start looking like the Hulk, then I’ll recheck a level to make sure I am giving the proper dose. High levels have been associated with moodiness and increased aggression. Many need it for life; it is not a dependency like with narcotics, it is a deficiency that needs supplementation.

Testosterone doesn’t cause but can promote prostate cancer, so a check for this cancer periodically is a good idea.

When you get your sexual function back from testosterone or Viagra-like pills, don’t forget to put on a condom.

Body Builders take note: taking androgens, when not needed, can cause shrunken testicles, changes in the blood fats to make a heart attack or stroke more likely, kidney failure, infertility, breast development, accelerated baldness, blood clots in the legs and lungs, acne, enlarged forehead, separated teeth, ruptured tendons, mania, psychosis, hallucinations, delusions, roid rage, and liver cancer.

Some of this article uses MedScape and WebMd as a reference.
Please send your medical questions to Adelante.
Daniel Pearce, D.O., FACOI, AAHIVS
Associate Clinical Professor of Internal Medicine, Loma Linda University
HIV Specialist, Riverside County Public Health Department

By: Dr. Pearce

This is the parasite that is in cat feces. Rats eat that, it infects their brain, causing them to be attracted to the smell of cat urine in the same way they are attracted to a rat to mate with. They are not cautious and another cat, or the same cat eats them and the parasite completes its life cycle. Other animals, including humans, are exposed too and the parasite goes to their brain.

Toxoplasma have the ability to quickly migrate through the human intestines into the blood to many organs but preferentially will settle in the eye, brain and muscles. Humans ingest Toxoplasma through undercooked meat (mainly lamb and pork) or directly ingesting eggs in water, garden soil, children’s sandboxes or cat litter contaminated by infected cat feces, or it can cross the placenta. The congenital infection can cause severe neurological and eye problems. The eye problems usually become apparent when you are in your 20s or 30s. Antibodies keep the LT in check but it can be transformed to a more active infection when the immunity fails, as in AIDS or during immunosuppression from organ transplant or cancer treatment. It is the most common brain AIDS-related opportunistic infection in developed and developing countries.

In humans, latent toxoplasmosis (LT) has been shown to be associated with higher testosterone levels in men and lower levels in women. LT decreased testosterone levels in both female and male mice in comparison to uninfected controls. Interestingly, Hepatitis B and C viruses also alter sex hormone and increase the number of male babies. LT does this too: Up to 72% of babies born from LT mothers are male. Usually 51% of babies are male. Another virus that is latent in humans, CMV, can cause mothers to produce more daughters. So maybe one should get the second infection to even out the score!

Furthermore, a number of studies have now suggested LT as a risk factor for the development of schizophrenia, depression, and suicide in humans. Interestingly cytomegalovirus infection is also associated with schizophrenia. Are these effects due to direct invasion of tissues, products of the infection, or the immune response? LT reduces gray matter in schizophrenia but not in controls. Altered concentrations of dopamine via two toxoplasmosis genes coding for enzymes may be the mechanisms for these changes. LT damages a specific brain cell, astrocytes, and astrocyte damage has been associated with schizophrenia also. Some medications used to treat schizophrenia inhibit Toxoplasma growth.

LT, leads to longer reaction times in infected human subjects with a 2.65 times greater risk to have been involved in an automobile crash than the general population. In rats there is an increase in activity, less anxiety, decreased reaction speed, deficits in learning capacity and memory, decreased fear of novelty and predator vigilance.

Many studies have been performed to explain the differences in psychological profile of LT infected humans. This infection affects some of the key traits of human personality. Toxoplasma-positive subjects had lower Novelty seeking scores, including Impulsiveness and Disorderliness than the Toxoplasma-negative subjects. The infected subjects had also lower IQ and lower probability of achieving a higher education.

Gender differences have been shown in the psychological profile of LT infected humans also. Men with LT disregarded rules and were more expedient, more suspicious, jealous, and dogmatic; whereas women with LT were more warm-hearted, outgoing, and were less trusting, accepting, and tolerant. The longer the infection, the more pronounced these factors were. An evolutionary reason for these changes might be for the male animal to pass the agent on to the cat by taking risks, and the female stays alive long enough to pass it on to her fetuses (which then become cat prey). The Toxoplasmosis is programmed to go to our brains and it doesn’t know we are not cat food.

Besides Hepatitis B and C and cytomegalovirus influencing behavior change, there are other models of infection causing similar effects to complete their complicated life cycle. Parasites cause an ant’s abdomen to turn bright red to make it look like a tasty berry to a predator or making the tentacles of snails pulsate with light to make them look like caterpillars. Rabies changes animal behavior to promote biting with more viruses in the increased saliva. Certain infected caterpillars, as they get sicker, stay in the trees and die high up and then there are other genes in the virus that then make the caterpillar melt and millions of virus particles drop onto leaves for the same animals to consume.

In addition to a high rate of Toxoplasmosis infections, HIV patients also have a high incidence of low testosterone levels. The normal decrease of testosterone levels with age, confound the picture. Modern antiretroviral therapies and strategies have caused the aging of HIV patients to progress so they have the opportunity to acquire more of the diseases the negatives have.

How much can we blame on LT: car crashes, mental illness, more risk taking, the fact you were born a male? Treatment of LT hasn’t been tried to reverse these changes since it is not clear there will be a benefit. Of course we treat anyone with low CD4s and a brain lesion of Toxoplasmosis, or prevent it with antibiotics when the CD4 is less than 100. We also ask HIV patients with low CD4s and pregnant women to avoid cat litter.

Adelante readers may be at risk. No, there are not Toxoplasmosis parasites in the magazine… that I know of. But I have noticed that there is a higher incidence of LT in my non-Anglo HIV patients; we routinely test for it when a patient first comes to the HIV clinic, so they got it before they got HIV.

You may ask your provider if you have been infected with Toxoplasmosis, but unless you have cancer or HIV, it won’t be necessary since there is nothing we can do about it. Weird, huh?!
Please send your medical questions to Adelante (readelante@aol.com).

Daniel Pearce, D.O., FACOI, AAHIVMS
Associate Clinical Professor of Internal Medicine, Loma Linda University and Western University
HIV Specialist, Riverside County Public Health Department

Telaprevir (Incivek®) and boceprevir (Victrelis®) have been approved but only in combination with the older medications which are hard to take—so no break yet from the old regimen! These new medications offer hope for those resistant to the main treatment. Possibly, they also offer pieces of future regimens that will be only oral and be more tolerable.

Here is a summary of important presentations at July’s International AIDS Conference in Rome. I used the summary from Clinical Care Options website for HIV specialists as the main source.

Prevention by treatment of the positive partner. This was a study in 5 regions and 4 continents followed for 1.7 years. 1763 couples entered, where the focus was on the positive partner with treating immediately with a higher CD4 or waiting for a lower CD4 to begin treatment. 97% were heterosexual couples. Of course they were encouraged to use safe sex so both groups had very low transmission rates. The early treatment group had 1/3% transmissions/year and the late treatment group had 2.2%, so there was a 96% reduction in likelihood of HIV transmission among serodiscordant couples if the positive partner was treated immediately. These transmissions are the result of unsafe sex. So treating the positive partner reduces risk of transmission to the negative partner.

Prevention by treating the negative partners of 4,747 couples. The Partners Pre-exposure prophylaxis study showed that taking tenofovir (Viread®) daily decreased risk by 62%. The pills worked well in women and men. This study was randomized (you could not predict which pills you were going to take (active medication or placebo) and double blinded (neither the clinic staff, nor the patient knew which they were taking). It was performed similarly to the study above with encouraging safe sex which is great in preventing transmission, but about 1% of the women became pregnant, and 1/3 had sex outside of the relationship (safe sex advice was not followed in some).
There were some promising medications discussed: Lersivirine (both similar in strength to Efavirenz), Dolutegravir and Elvitegravir (similar in strength to Raltegravir).

Very early treatment of HIV: Treating for a year, as close to the moment the infection starts, has these benefits: having a lower viral load maximum (set point), CD4 later will go down slower and can rise better, but there was no difference when you consider the time on therapy, i.e. when those not treated at the beginning were finally treated, they could make up this drop. Early treatment did not cause resistance to emerge. Treating the same types of patients for only 12 weeks had no such benefits. Based on this study some might want to get treatment for at least a year as soon as they know they are infected.

Osteoporosis and fractures. The risks for these are: higher age, being Anglo, smoking, having diabetes, being too thin, chronic kidney disease, and having hepatitis C. This study seemed to implicate tenofovir (Viread®), using boosted protease inhibitors, or being on lopinavir (Kaletra®). This risk was not associated with the other Nucs such as abacavir (Ziagen®) or other protease inhibitors. Please note that to find these small differences, they looked at over 56,000 Veterans Administration patients and only 2% had fractures over the 10 years of data looked at.

Tenofovir (Viread®) seemed to be correlated with chronic kidney disease more than other medications. This report is a confirmation of past research. Chronic kidney disease is associated with diabetes, older age, high fats in blood, being female, and having a low CD4. This was an incidence of about 1%/year chance of having this condition in this study of 2,693 patients followed for 3.4 years. Remember that tenofovir is also in Atripla® and Truvada®. Ask about your kidneys if you are on these medications even though this problem is uncommon.

HIV dementia still occurs even though we have great medications to control the HIV. Some medications do not prevent it or treat it well. One investigator has studied which medications will do a better job penetrating the brain cells, treating the dementia, or preventing it. He came up with scores for the medication. Sadly, these scores, when applied to patients do not seem to make a difference in the study presented.

IRIS is Immune Reconstitution Inflammatory Syndrome which begins when a person has a low grade infection (maybe they don’t even feel it) and flares up then they start antivirals. The powerful antivirals causes their bone marrow to recover very well and white cells attack the low grade infection causing swelling and inflammation suddenly. This can happen in the eyes, brain, lungs, and other places. The risk is highest when the CD4 is less than 100.

A recent study showed that if you start antivirals sooner when you are also just starting TB treatment, then you may get a large flare of the TB. About 4% died from the flare. On the other hand, if you don’t treat the HIV early enough, then the patient can die from AIDS-related causes. Starting antivirals after 8 weeks of TB treatment caused fewer problems than at 4 weeks.

Another study showed that early antiviral treatment of HIV at 4 weeks had more IRIS cases than waiting till the intensive phase of TB treatment was over (usually 8-12 weeks depending on the patient’s response) and that this last method had the same number of IRIS cases as treating HIV after the year or so of TB treatment was finished.
Safe sex or no sex is best. Get tested regularly. Don’t miss medications. See your doctor regularly.

NEW*NEW*NEW
Daniel Pearce, D.O., FACOI, AAHIVMS
HIV Specialist Physician, Riverside County Public Health Department
HIV Specialist Physician, AIDS Healthcare Foundation, and Desert AIDS Project
Associate Clinical Professor of Internal Medicine, Assistant Director of Medical Affairs, Center for Advancement of Drug Research and Evaluation (CADRE) Western University, College of Osteopathic Medicine of the Pacific

When we eat, nutrients are absorbed through the intestines. The liver processes the nutrients to make energy and parts for cells to repair themselves or grow. The parts (chemicals) left over are waste and the two places the waste goes are the kidneys and gall bladder. If the waste can be made to dissolve in water then it goes through the kidney tubes which act to filter out the waste into the urine and keep the chemicals we need inside the blood. The chemicals that can’t be dissolved are put in the gall bladder since that is where the oily chemicals go. Eventually that liquid (bile) goes into the intestine to help dissolve fats like soap would, so they can be absorbed.

Just like an automobile, the body has many parts and each is important for the entire machine to work well. The kidney parts can have several problems; the most common is infection. Usually it is from bacteria from the poop or from sex, travelling up the urine tube (urethra). In men this is in the penis so it is longer than in the female. The short urethra in the female makes it easier for the bacteria to climb into the bladder; they have more urine infections than men. The infection can be in the bladder or make its way up into the kidney and then into the blood. If the infection is just in the bladder, then having to pee small amounts frequently and some burning may be all you feel. If it goes higher then there are sometimes back pain, sweats, and chills and one could die if left untreated. Antibiotics are the best treatment. Cranberry juice has a little benefit. Perhaps drinking or eating sweets makes the bacteria grow more easily in the sweet urine. Diabetics, if sugars are high, will have sweet urine too. Drinking lots of water to flush out your bladder is a good prevention.

Taking a long trip and holding your urine too long or having a common prostate problem (in men over 40 or so) causes the bladder to not empty completely—poor flushing.

If we don’t drink enough water and drink too much milk or chew too many calcium antacids, then the calcium can build up in our kidneys causing a painful stone. Sometimes the stone can be infected and make the infection hard to treat since the antibiotics cannot reach inside the stone well (it is not connected to our circulation). Sometimes a stone can block one of the tubes and a specialist must put a tube through the skin in the back to collect the urine in a bag in order to keep that kidney from total, permanent failure. Other times they can go up the urethra (don’t think about it–you will be asleep and it is totally necessary) and thread up a thin plastic tube (stent) to help urine get past the blockage. They take out the stent and the blockage after the inflammation has calmed down; otherwise surgery might make a hole in the soft, inflamed tubes, causing even more problems.

From sex or the same mechanism as getting a urine infection, the bacteria can swim to the ovaries in females or the testicles or prostate in males. These are important infections. Usually there is pelvic pain involved. The female may lose her ability to pass the egg to the uterus in the future, causing the sperm to have to swim farther to fertilize and then the fetus grows in her tube. That can be very painful and emergency surgery is the best plan. They would wish they had used condoms more to prevent the initial infection and pregnancy.

Poorly controlled diabetes, hypertension, or frequent infections can lead to kidney failure, slowly heading for dialysis. Kidney failure is painless. The leftover toxins that should go into the urine, stay in the blood, causing accelerated aging, hardening of the arteries (think strokes and heart attacks), and fatigue (like you are little poisoned). We use dialysis machines to pull the blood out, filter it, and then put it back. Usually a vein and an artery in the arm are connected by a surgeon so that the dialysis nurse can stick the needles in there. Before that, usually we put in a thick tube (catheter) under the collar bone that has 2 tubes combined, one for the blood to come out, the other for the blood to go back. Frequently these catheters cause a blood infection (because the barrier—the skin—has a hole in it now, and a hospital stay of a week or so may be needed to clear up the infection and remove and replace the tube.

Being low on fluids or having a blocked outlet can lead to acute renal failure. We can put a catheter in the urine tube to get past the blockage usually (happens more in men from enlarged prostates) and then give medications or perform surgery to open up the outlet. People who don’t take enough water on a desert hike, or people who have severe vomiting and/or diarrhea may need a lot of fluids to help flush out the toxins and get their kidneys working correctly again. It is amazing the boost of energy a liter of fluid will give such a person. Usually when it gets hot in July, we see people fainting and having dark urine, signs of not enough water taken in to make up for the loss of increased sweating and breathing. Dark urine usually means you need more water.

Whether you have acute or chronic renal failure and your kidneys can possibly improve we avoid all metformin, aspirin, ibuprofen, naproxen and other arthritis medications, since they can worsen the kidney damage.

Of course any organ can be hit by cancer and the kidneys are no exception.
Be nice to your kidneys, drink water till your urine is clear like water. Condoms are good too!

by Dr. Pearce

Just think, all that food is broken down into tiny nutrients. Instead of letting it go straight to the main blood circuit, it goes through a special vein to the liver to be processed and released into the body in a controlled fashion over hours rather than minutes. The liver holds onto sugar and releases it slowly, as needed. It does the same to fat and protein. It manufactures many of our important chemicals from these basic food building blocks; there are too many chemicals to name and explain here.

The older red blood cells are removed from circulation and broken down. The byproducts of hemoglobin (red) become bile (green) and bile helps form a soap-like substance around the oils you eat to help break them up into tiny particles to be absorbed. Bile is stored in the gall bladder and hormones signal the gall bladder when to squeeze a little bile into the intestine to help digest the fat coming down the intestine. This is recycling at its best; very little waste!

The liver is damaged by viruses, chemicals or gallstones. Gallstones form in the gall bladder for complex reasons. They are more common in those who are overweight, females (especially those who have had several pregnancies, and in those over 40. The stone can just sit there and not cause a problem, so surgery is not always necessary. It can block the exit from the gallbladder or the end of the tube (bile duct) as it joins the small intestine. When there is blockage, nerves send out signals of pain. Blood tests show high chemicals, especially the bile backed up in the blood; this is why we turn yellow and our urine can turn brown during liver disease. The stool is not as dark since there is less pigment coming down. This can happen more when a fatty meal causes a strong signal for more bile to be sent down. The pain can be severe. The gall bladder can become inflamed; surgery is needed then. An ultrasound ( and less so, a CAT) scan is quite helpful at diagnosing gall stones.

Hepatitis can be from germs or chemicals. We are all familiar that more than 2 shots or drinks or beers a day for a female, and 3 for a male can damage the liver. The liver is funny in that it may not show the damage that has taken place until the reserves run out years later. Do not doubt that the liver takes a hit when these numbers are exceeded. The more and sooner you drink alcohol, the sooner the reserves will run out and the liver will fail. Overdoses of Tylenol can hurt the liver also, but suffering is much quicker.

Viral hepatitis is quite common. Hepatitis A is transmitted from people not washing their hands well after pooping and then preparing food for others. Hepatitis B and C are mainly transmitted from needle sharing, and some from sex. Hepatitis A rarely leads to long-term problems. If B doesn’t get cured naturally, as it does in the majority, then it needs treatment. Very few C patients are cured naturally.

Treating A is usually with rest. B uses drugs similar to anti-HIV medications which are quite tolerable. C needs an injection weekly and pills daily for usually a year. If the lab tests are not improving then treatment should be stopped since it is not working. Hepatitis C is curable for some. The Hepatitis C medications can sometimes make you quite ill. But it is usually better than having cirrhosis which is replacement of most of the liver by scar tissue, so very little of the liver is working. We have vaccines for A and B and all are encouraged to get them.

Cirrhosis has multiple complications. Since there is so much liver scar tissue, the blood from the intestines and spleen back up, causing a large, sometimes painful spleen. Platelets, the blood clotting cell pieces, get trapped in the large spleen so there may be dangerous bleeding. Fluid leaks from the intestinal lining since there is so much back pressure; and this causes swelling of the abdomen. The liver doesn’t make its regular products so there are problems with low levels of blood protein (causing swelling in the legs and scrotum–the sac holding the testicles) and blood clotting factors (causing bruising and bleeding). This back pressure causes hemorrhoids and esophageal varices (like hemorrhoids but in the bottom of the food pipe). The varices can break open any time and cause massive bleeding which goes down the intestines (painless and hidden) or out the mouth (vomiting). A person can bleed to death from hidden sites without waking up.

Being obese can cause fat to infiltrate the liver causing liver failure also.
So keep an eye on your weight, keep your daily alcohol intake down, get vaccinated, wash after pooping, don’t use needles, wear condoms, and see your doctor regularly. Thank God for your liver!

Heartburn. This is usually caused by too much acid or having a weak lower valve. The excess acid can be from cigarettes, caffeine, chocolate, peppermint, or alcohol. You usually feel a burning in your lower chest or stomach, especially when lying down. There are multiple medications which lower the acid or push the food on down so that the stomach isn’t so full for too long. A hiatal hernia is when the stomach is pushed into the chest a little bit so that the valve between the stomach and food pipe (the esophagus), the lower valve, doesn’t work well and the food can’t pass down easily, therefore it sloshes into the esophagus. The upper valve is in your neck to keep stomach and esophageal secretions from coming into your mouth or lungs. Usually they work well.

Trouble Swallowing. The acid sloshes up from the stomach and repeatedly burns the esophagus causing a narrowing by creating a scar. This can be relieved by having a scope passed down and then inflating a balloon to dilate the narrowed zone.

Gastritis is an inflammation of the stomach lining, again caused by too much acid. You may have a sour taste in your mouth, or belch more than normal with any of these acid problems. The pain is usually worse with eating. This is also treated by the acid reducer medications and avoiding the causes.

Gastroenteritis is from an infection causing nausea, vomiting, and/or diarrhea. This is very common and usually comes from contamination of the food from an unclean restaurant, food packager, or poor practices at home. You can avoid street vendors and low-rated restaurants. At home the most common cause is cutting meat and then vegetables served raw in a salad, but not cleaning the cutting board thoroughly between the meat and the vegetables. The bacteria or viruses on the meat will be killed with cooking, but live on the raw vegetables and then inside of you. There are a huge number of cases of gastroenteritis in the USA. Almost everyone has one or two per year. You have heard of E. Coli and Salmonella being in meat and vegetables and the recall of these items.

Please be careful when handling pets or their excrement, to wash your hands thoroughly so you don’t spread the bacteria to the food for you and others.

Staph infection is also common and can be spread by those with sores on their hands. We routinely ask them to not prepare food until the sore is closed and not red.

Another way to spread bacteria is to not wash your hands after having a bowel movement and then preparing food.

Restaurants are rated in LA County by the Health Department and the closer to grade A the better and probably cleaner the processing. I have eaten in B and C restaurants without problems, but I was aware that they had deficiencies on their latest inspection.

Irritable Bowel Syndrome. This is a condition where you might experience bloating, diarrhea, or constipation or all of these, especially when under stress. Both conditions produce misery. There are medicines that can help.

Constipation. This condition is very common. The bowels need enough fluid and fiber to process the food properly. Fiber is in vegetables and fruits (remember we discussed eating 5 or more servings per day). 8 glasses of liquid is generally recommended per day, but as long as your urine looks clear to light yellow, you know you are getting enough fluids. When we say fluids, we mean those without caffeine or alcohol since these cause you to urinate more than normally and lose some of the fluid you drank unnaturally. If you want to lose weight, then drink water. If you start drinking water more, your body will start to crave it and it is satisfying and low cost. Filtered water in bottles has been proven to be no more safe or nutritious than tap water that is filtered. I think charcoal filtering is superior.

When you are constipated, your stools are hard, causing gas, bloating, and maybe hemorrhoids or tearing of the anus which results in bleeding. Hemorrhoids are varicose veins that have enlarged due to being blocked from the hard stool; they expand and stretch the lining over them in the anal-rectal region. There are two zones for the veins. When the lower zone near the anus stretches, it results in itching and burning, with painful bowel movements. The upper zone in the rectum doesn’t usually have pain receptors so they usually are discovered by bleeding or being pushed down by stool so that you feel something strange is in your anus; there is. Feel free to squat over a mirror with a flashlight to see what is going on. Preparation H or its generic form can be quite helpful.

Diverticulitis. When there is not enough fiber and fluid you get constipation but you might also get small pockets/bubbles/aneurysms of the bowel lining pushed out from the high pressure which was needed to move the tiny, hard stool balls along. Later these can be blocked by a small piece of stool and cause inflammation, pain, and can burst, causing an infection. The prevention and treatment for the stage before blockage is (duh!) fiber and fluids. Eating only meat and potatoes is a bad idea for many, many reasons!
Bleeding from above or below is important to mention to your provider. It is an emergency when more than just a little blood comes out; call your provider or the nearest emergency room for advice. One can die from this quickly. Black stool is produced when you bleed in the stomach and the acid turns the blood black (and I mean black).

Eat healthy, exercise, take care of your bodies. An ounce of prevention is worth a pound of cure.

Timing: When the weather is changing, so do the plants. They put out pollens based on weather triggers such as warming up, cooling down, wetness, and dryness. In addition the Santa Ana winds blow dry air full of pollen from the deserts into the valleys of Southern California. Also, when it is hot or there isn’t much of a wind, the allergic reactions from smog are worse.

General symptoms: Usually there are no swollen lymph nodes/glands in the neck, fever, chills, or sweats with an allergy. The appetite and energy level are unaffected unless you have lost sleep from not being able to breathe well, or coughing. The symptoms of allergies are in each section below.

Skin is typically itchy in the winter due to dryness. Colder air holds less moisture and when we heat it at home, at work, or in public places, it is very dry. That causes the skin to dry out and become itchy. A good method to treat this is to dry yourself, not to thoroughly, after bathing and apply a thin layer of petroleum jelly, such as Vaseline over the itchy areas. This will trap in the moisture and protect you from further drying out. This is not a true allergy but since it itches and happens this time of year, I thought I would include it.

Itchy eyes: The lids and the eyes can become itchy and red with this weather. The lids may need an antihistamine pill, but the eye may need topical treatment, starting with the easiest to the most expensive: washing with water and using artificial tears are good ways to help without using medication. Decongestants (like Sudafed pills, but in drops) like Visine or Murine, are over the counter. You need a prescription for Patanol which is an antihistamine and helps prevent the continuing cascade of the allergic reaction. Naphcon-A can has the benefits of both classes of medications.

Itchy throat: The throat can also feel like something is there, it feels itchy or swollen in a certain part, or just plain hurts. An antihistamine or decongestant can help. I explain these later. If the pain is bad, then you may need a topical treatment which doesn’t really treat the causes as the pills do. Cough drops help soothe the area as does lemon and honey. Chloraseptic spray can be directed right to the sore area and swallowed. I have some next to my bed so I can get some sleep when I have a sore, allergic throat. Unlike the liquids, lozenge, or troche, the spray avoids the tongue so you can taste food.

Itchy or runny nose: Usually the mucus is clear. Phlegm or nasal mucus can be colored in the morning due to the lack of coughing at night and all the dust we breathe in. Providers don’t pay much attention to this unless the color is green, yellow, brown, or gray after the morning mucus and clearing. Nasal steroid sprays can help. Be careful with over-the-counter sprays since the nose can become dependent on the medication and you will have to use the medication daily for years due to this dependence. I recommend Afrin spray sometimes for very congested noses but just for 3-4 days at a time to avoid dependence.

A Neti Pot can be very helpful for allergic noses, colds and sinusitis. It looks like a small teapot with a narrow spout that fits into your nostril which you can buy online. You put warm water in it and a little salt and irrigate your nose and sinuses. The method is a little tricky but it really gets rid of the mucus for an hour or more. Too much or too little salt can cause burning and more swelling of the tissues. My nose is used to snorting up warm water without salt. These methods also get rid of the dusts and pollens we have breathed in during the night that may still bother us.

Cough: Usually this is from a tickle, a “dry” area, a swelling, or an irritation in the throat or from the lungs. The irrigation above, lozenges, honey and lemon, or cough drops can help. But occasionally a cough medication is needed. The most famous cough syrup, Robitussin, has a main ingredient that isn’t well-proven to be of benefit. The other ingredients in all the Robitussin syrups have activity, especially Dextromethorphan (DM). A prescription is needed for the other cough suppressants: codeine (also in Tylenol #3) and hydrocodone (also in Vicodin). Another suppressant, not commonly used but effective, is Tessalon, in a pill form. I’ve found it effective for patients when the others don’t work well. It is non-narcotic and has less side effects that the codeine and hydrocodone.

Asthma is an allergy in the lungs and we have discussed this before.

Medications: The medications for allergies, viral infections, and bacterial infections of this area are usually one or a combination of the following:

Antihistamines: These attack the actual chemical reaction in the body that releases histamine that causes the swelling and mucus. The ones that cause less drowsiness are: Claritin, Zyrtec, and Allegra. The older ones that cause somewhat less are: chlorpheniramine and brompheniramine. The ones that cause more drowsiness are Benadryl, Atarax, and Phenergan. Some get no drowsiness from these.

Decongestants: The main one is Sudafed, but also phenylpropanolamine and phenylephrine are in some preparations. There are restrictions on Sudafed since you can make crystal methamphetamine from it.

When to seek a medical provider: If you have poor appetite or energy, or have fevers, chills, or sweats or are concerned about your condition, then consider seeing a provider. You may notice that antibiotics are not listed since they do not help allergies or for that matter, viral infections.

We have over 300 million tiny air sacs in our lungs! Each of them is a membrane for these two gasses to pass from blood to air and vice versa. The membranes together would form a surface area of 160 square meters or 40 x 40 meters (a meter is slightly longer than a yard). That’s a ginormous membrane.

Let’s talk about lung problems.

Altitude
So you are in Denver or Mexico City, a mile higher than sea level, and you are more short of breath climbing stairs. If you are in Machu Picchu, about a half mile higher, you would really feel it. There is less pressure so high up, so the oxygen has more trouble being pushed into your blood across the membrane. You have to breathe faster to get the same amount of oxygen that you need than you would at sea level.

Pneumonia
This is an infection of the lung. Viruses and Pneumocystis (a fungus that attacks HIV patients) cause an inflammation of the membranes in many of the sacs so one gets short of breath since the gasses have trouble crossing that thickened membrane. Bacteria cause a little pus, or inflammation of more than just the membrane but usually in a certain zone of the lungs rather than all over so that knocks out the function of that part of the lung.

Asthma
This is an inflammation of the tubes, airways so that there is more mucus and swelling of the lining of the tubes, in addition to the muscles in the tubes become hyperactive and squeeze them down. That results in air having trouble getting out of the lungs, resulting in wheezing. This is usually from allergies to pollens, smog, other fine chemicals or particles that we inhale. An albuterol inhaler opens up the muscles and a steroid inhaler decreases the inflammation and secretions.

Smoke Damage
Whether from cigarettes, cigars, or smoke from fires, the ashes get trapped in the lungs and cause inflammation and increased mucus like in asthma. It can also cause loss of lung tissue; the air sacs are destroyed so that you have less area to exchange gas. Many people walking around with an oxygen tank and tubes up their noses have this from chronic smoking. Most of them at this stage stay home, needing oxygen to walk to the bathroom or the kitchen. Many of them die very early in life. Dying from not being able to get oxygen is horrible. Even a couple cigarettes a day cause this type of damage.

Heart Failure
When the heart is weak, for example, from pumping against untreated high blood pressure for years, the blood might back up in the lungs. The liquid may leak into the membrane so that you have a similar problem like viral pneumonia.

Diagnosis
Asking questions, examining the patient, performing lab tests and a chest X-ray is helpful to diagnose lung problems.

Ventilators
When the person tires out and can’t exchange enough gasses, they will die unless assisted by a machine. Usually we put a tube into their main airway (after making them drowsy of course) and have a machine push in oxygen and let it out. The types of pressure, volumes, and flow are scientifically matched to the disease. We usually give 100% oxygen at first and then taper down since being on that high of oxygen can be toxic to the lung—strange! Most of the time we have to sedate the patient to keep them on the ventilator since it is uncomfortable. Their hands must be tied down so they don’t rip the tube out or the deep IV lines or other catheters or devices. Also, they usually must be fed through a tube passing through the nose into the stomach.

This is acceptable to most who feel they will live through this and recover. Those who don’t have a good chance should think about this ahead of time. I have told my wife and son to not let me be a vegetable if there is poor chance of recovery to a meaningful life. I define a vegetable as one who can’t receive or give love and they are just existing, having very little pleasure in life. They are usually fed by a tube that goes through the abdominal wall and into the intestines. They must have diapers changed and be turned frequently to avoid bed sores.

If a ventilator tube is left in more than 10-14 days, then sores might result from the irritation in the throat. So we perform a tracheostomy, which is a hole in the neck that the tubing can go through. After the person is more alert there are devices that allow them to speak in spite of the unnatural way the air is routed.

Prevention
Well, this has been a happy subject! To prevent these problems, get your flu shot, don’t smoke, take care of your asthma, talk with your next of kin about what you would and wouldn’t want done if you were not thinking clearly. A car crash could happen any time and it is very frustrating for all concerned when family members say, “I don’t know what he would want in this situation.”