From the monthly archives:

March 2008

Beta-blockers are a class of drugs which decrease blood pressure and pulse and are used to treat high blood pressure, heart disease, and other medical problems. Beta-blockers also decrease the response of the body to fear or threat, known as the “fight or flight response.” This response usually causes anxiety, tremor, and increased pulse and blood pressure.

The fight or flight response can impair activities such as musical performance and competitive shooting which require concentration and precise movement. Even top musical performers may have performance anxiety or “stage fright,” a type of fight or flight response. Several studies have shown that beta-blockers improve musical performance, probably by reducing anxiety, tremor, and elevated pulse. Performance enhancement has been demonstrated with a variety of instruments, including strings, wind and brass, and piano.

Similarly, beta-blockers improve competitive shooting performance, an activity which requires intense concentration, precise muscle control, and suppression of anxiety and tremor. The International Olympic Committee has banned the use of beta-blockers by shooting sports competitors.

Jascha Heifetz, renowned violionist of the 20th century

Jascha Heifetz (1901-1987), the greatest violinist of the 20th century, did not need beta-blockers to perform.
Photo Courtesy of the Jascha Heifetz Society

Beta-blockers should only be used under medical supervision.

Beta Blockers used to enhance steady performance

Competitive shooting requires intense concentration, precise muscle control,
and suppression of anxiety and tremor.

Photo US Army.



by Brian Carty, MD, MSPH

Q: Doctor, before you performed the autopsy, did you check the pulse?
A: No.
Q: Did you check for breathing?
A: No.
Q: So, it is possible that the patient was alive when you began the autopsy?
A: Well, let me put it this way. The man’s brain was sitting in a jar on my desk. But I guess it’s possible he could have been alive and practicing law somewhere.


Are Ya Juicin’ It? - Anabolic-Androgenic Steroid Abuse

by Brian Carty, MD, MSPH

Irritable, angry, aggressive, but feeling strong and invincible, Mr. A, 32, a bodybuilder and prison guard, stopped at a convenience store to call his boss. Car trouble on the way to work.. He would be late.

Bodybuilder and enhanced performance
-With permission of Steve Michalik. Mr. Michalik, a former Mr. America and Mr. Universe, once used steroids and suffered as a result. He is now an energetic and outspoken opponent of steroid abuse.

Mr. A was taking his fifth cycle of anabolic-androgenic steroids (abbreviated in this article as “steroids”), and he was “stacking,” combining high doses of several different steroids, sometimes referred to by the slang term “juice.” The woman working at the convenience store noted his uniform and joked, “You officers use my phone so much, I ought to start charging for it.” Mr. A was strangely disturbed by this remark. He felt that the woman had criticized and demeaned him, and he was obsessed by the remark that afternoon and throughout the night. He slept poorly. His wife could not reassure him.

‘Roid Rage

Later, he said that he wanted to “scare the lady in return for that remark she made to me.” In the morning Mr. A drove back to the convenience store and forced the woman into his car. She fought back, biting his hand and grabbing his revolver which fired through the windshield. Although he subdued her and drove away, when the car stopped she bolted from the car. He shot her in the back as she fled, leaving her permanently paralyzed. Mr. A was later arrested, tried, and sentenced to twenty years in prison. After his arrest and withdrawal from steroids, he developed major depression which resolved in a month.

This case and several other cases of homicide or near-homicide by anabolic steroid abusers are presented in an article by Dr. Harrison Pope, Jr., and Dr. David Katz in the January 1990 Journal of Clinical Psychiatry. In another example, a 23 year old man, a bodybuilder, developed mood changes, aggressiveness, and explosive anger while taking anabolic steroids. To intimidate people, he began to bite chunks out of aluminum cans and rip phones off walls. He was later convicted of murder for beating a hitchhiker to death. A 24 year old man, also a bodybuilder, developed a similar syndrome while taking anabolic steroids and tried to kill his former fiancée.

Performance Enhancement by Steroids

Anabolic-androgenic steroids are derived from the male hormone testosterone. “Anabolic” refers to the muscle building effects of these drugs, and “androgenic” refers to the drugs’ enhancement of male sexual characteristics such as hair growth and deepening of the voice. Steroids increase muscle mass, strength, and athletic performance.

Adverse Effects

Steroids can cause serious adverse health effects. Side effects most often noted by abusers themselves are acne, increased sex drive, increased body hair, and aggressive behavior. There may be unfavorable changes in blood lipids which have the potential to damage the heart and blood vessels. High dose steroids usually cause temporary infertility. Some steroids may cause liver problems. Tendon rupture and gynecomastia (enlargement of the male breasts) may occur.

Females who abuse steroids may develop baldness, deepening of the voice, and enlargement of the clitoris, all of which may be permanent.

Steroid abusers have an increased risk of heart attacks and suicide. There have been many reports of a variety of other serious health problems associated with steroid abuse, but for many of these problems, it is difficult to know whether steroids are the direct cause.

Psychiatric Effects of Steroids

Psychiatric effects of steroids can include aggression, hostility, violence, mood disturbances such as depression or an abnormally elevated mood, and even psychosis. Psychosis is a serious mental disorder characterized by loss of contact with reality, often with disturbed behavior, hallucinations, paranoia, and other symptoms. Dependence on steroids can occur, and withdrawal symptoms may be seen in some abusers after they stop the drugs.

How Buff Can You Get Without Steroids?

There is a limit to the muscularity athletes can achieve without drugs. The degree of muscularity can be measured by the fat-free mass index (FFMI). In one study, researchers measured FFMI values in a group of athletes, some of whom used anabolic steroids (Kouri EM, Pope HG Jr, Katz DL, Oliva P, Clinical Journal of Sports Medicine 1995;5:223) Men who did not lift weights usually had an FFMI between 18 and 21. FFMI values were in the low 20s (range 21 to 25) in bodybuilders who did not use steroids. Steroid users had FFMI values in the upper 20s or even low 30s. Nonusers all had FFMI values less than 25.0, while many of the steroid users were well above this limit.

In the same study, FFMI values were estimated from photographs of Mr. America winners from the pre-steroid era, 1939 to 1959, and from photographs of a group of modern bodybuilders pictured between 1989 and 1994 in bodybuilding magazines. The Mr. America winners’ FFMI averaged 25.4, but the modern bodybuilders’ FFMI values were all higher than this.

Thus, fat-free mass index (FFMI) may help determine whether an athlete is using anabolic steroids. An FFMI over 25 is extremely likely to indicate anabolic steroid use, although a number of steroid users may have an FFMI below this value.

Steroid Abuser and Non-Abuser charteristics

Steroid User and Non-User - charteristics in pictures

Physical effects of anabolic steroid use. These photographs compare a “natural” bodybuilder who has never used anabolic steroids (left) with a man who has used large doses of anabolic steroids over several years (right). Both men are 67 in. tall and have 7 percent body fat. The man on the left weighs 170 lbs and represents approximately the maximum degree of muscularity obtainable without drugs. His fat-free mass index (FFMI) is 25.4. The man on the right weighs 213 lbs. and has a fat-free mass index (FFMI) of 31.7. Note that the muscle hypertrophy from steroid use is particularly marked in the upper body in the pectoralis, deltoid, trapezius, and biceps muscles. Any man significantly more muscular than the man on the left has almost certainly abused anabolic steroids.

-Kaplan & Sadock’s Psychiatry. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2005: p. 1323. courtesy of Dr. Harrison Pope and Lippincott Williams & Wilkins.

While the FFMI may represent a useful screening test for anabolic steroid abuse, the definitive test is the detection of steroids or their metabolic products in the blood or urine.

Why Would Anyone Abuse Such Dangerous Drugs?

The media report almost daily on the ongoing scandal of steroid abuse in professional sports. It’s easy to understand the reasons for steroid abuse by intensely competitive professional athletes. They are often willing to risk serious adverse health effects for an improved appearance or for increased strength and athletic performance. Some nonprofessional athletes abuse steroids for similar reasons.

Steroid abuse by athletes should remind us of similar choices made by nonathletes to sell their souls or well-being for money, power, sex, fame, professional achievement, or other goods. Hopefully, better information about the adverse health effects of anabolic-androgenic steroids will convince more people to forgo this dangerous form of drug abuse.


Wrinkles Treated More Quickly Than Skin Cancer

by Brian Carty, MD, MSPH

A study in the December 2007 Journal of the American Academy of Dermatology showed that the average waiting time to see a dermatologist was 38 days for a changing mole (a lesion which is suspicious for skin cancer), but only 16 days for Botox treatment of wrinkles. In the study, sham patients called over 800 US dermatologists’ offices to request appointments for one of these two problems.

Obviously, waiting time should be shorter for a potentially more serious condition. Although the study did not examine the reasons for the difference in waiting times, it seems likely that the difference is due to the way physicians are paid. Fees for wrinkle treatments are not covered by insurance plans or Medicare, are paid out of pocket by the patient, and are set by supply and demand. Fees for evaluation of a possible skin cancer are usually set by government programs or by insurance companies. The fee for the Botox injection may be several hundred dollars, but for the mole examination the dermatologist will have to wait for $50 or $75 from Medicare or an insurance company.

It would be wonderful if dermatologists acted without regard to how they are paid or how much they are paid, but the laws of human nature and economics are not going to be repealed. We ignore them at our peril. Price controls always fail and always produce the same results: decreased quality, shortages, and black markets.


Anal Cancer Rates on the Rise

by Brian Carty, MD, MSPH

Anal cancer is a very serious disease. In the past 30 years incidence rates have roughly doubled in males and increased by about 50% in women. Changes in sexual practices have almost certainly caused most of the increase.

A few facts about anal cancer

Anal cancer is not common. Approximately 5000 cases are predicted to occur in 2008 in the US. Five year survival rates are 70% to 80%. Although chemotherapy and radiation are the main treatments, surgery may be necessary.

Risk factors

Risk factors for anal cancer include smoking, sexually transmitted human papillomavirus (HPV) infections, and suppression of the immune system. Anal cancer is more common in patients with immune suppression caused by HIV infection, but the risk is also increased by suppression of the immune system caused by drugs given after organ transplants.

Risks from sexual activity

Risk factors for anal cancer include a greater number of lifetime sexual partners and a history of receptive anal sex. Both the average number of lifetime sexual partners and the number of people having anal sex seem to have increased in the last 30 years.

Janet Daling, Ph.D. is one of the authors of a study published in 2004 in Cancer which examined the factors responsible for the rising rates of anal cancer. She believes that HPV infection is required in virtually all cases of anal cancer, and that the “increased incidence of anal intercourse among both men and women is most likely to be the primary cause behind the rise in anal cancer.”

Similarities between cervical and anal cancer

The high risk (cancer-causing) HPV types which seem to play a role in anal cancer are chiefly types 16 and 18, the HPV types responsible for most cervical cancers in women. In fact, just as the Pap smear is used to screen women for cancer of the cervix, anal Pap smears are used to screen for anal cancer in some people at increased risk of the disease. The anal Pap smear is essentially the same test used to screen for cervical cancer. The area to be tested is scraped to remove cells which are then examined under a microscope to look for early signs of cancer.

Who should get anal Pap smears?

Some experts recommend yearly screening of all HIV infected men and women with anal Pap smears. Some centers also do anal Pap smears on all women with HPV-associated precancerous lesions of the genitals and cervix. It is suggested that male homosexuals who are not HIV positive should have an anal Pap test every two to three years.

Future trends

It will be interesting to see if the new HPV vaccine (also known as the “cervical cancer vaccine”) will reduce anal cancer rates. Although only females are being vaccinated at present, the HPV vaccine is being tested for possible use in male homosexuals.


Medical Image of the Month March 2008

by Brian Carty, MD, MSPH

click image for complete text and photos

Transfer of a toe to the hand.

- Photo courtesy of New England Journal of Medicine.