From the monthly archives:

June 2008

In the Hollywood mansion of a famous pop music star, a sign on a heavy oak door read “Super-Secret Playroom - Do Not Disturb.” A SWAT team agent pounded on the door as hard as he could without hurting himself. He called this “knocking for the last time.”

Dynamic entry

Without waiting, the SWAT team sprang into action. They were dressed in black from head to toe, their lower faces covered with fireproof Nomex masks. Only their eyes were visible through clear eye shields. Two men stood to each side of the door, holding Heckler & Koch MP5 submachine guns pointed straight up. A short stocky man who had been standing in the background suddenly kneeled in front of the door and jammed the muzzle of a 12-gauge shotgun against the keyhole of the lock.

There was an explosion. A few flecks of wood and brass fell on the floor in front of the door. A small puff of acrid grey smoke slowly wafted upward. Their shoulders slamming into the now freely swinging door, the men charged forward into the room.

What is a pedophile?

While the preceding account is fictional, it does convey the extreme seriousness with which society regards child molestation. The account also provides a useful springboard for a discussion of the medical technology available to diagnose pedophilia and attempt to reduce the frequency of child molestation.

Pedophiles, almost always males, are individuals who are sexually attracted primarily to prepubertal children. A child molester is an individual who has committed a sexual offense against a child. Pedophiles are not always child molesters, and child molesters are not always pedophiles. For example, Lewis Carroll, the author of Alice in Wonderland, was a pedophile but apparently never acted on his impulses.

Evaluation of pedophiles and child molesters

Every evaluation in medicine starts with a history or interview and a physical examination, followed by other more specialized tests as necessary. For the pedophile or sex offender, historical information is often obtained from arrest records, court reports, victim testimony, family members, and other sources.

“Billie Jean is not my lover”

Yeah, yeah, yeah. Isn’t that what they all say? This is why objective, specialized tests are often used in the evaluation of sex offenders. The tests rely to a great extent on reflexive, automatic responses which are often not under conscious control. The tests are thus useful in obtaining information about sexual interest or acts which individuals may deny. These tests include penile plethysmography or phallometry, polygraphy, and viewing time assessments.

Phallometry

Phallometry is a technique in which the erectile response is measured in response to neutral or sexually explicit audio or visual stimuli. After a moonwalk down the hall to the phallometry lab, a gauge is attached to the penis to measure changes in the circumference of the penis. Phallometry is the best method currently available to measure deviant sexual arousal. Phallometry can distinguish between pedophiles and non-pedophiles, and it is one of the most reliable predictors of repeat offending by child molesters.

Of course, phallometry cannot determine guilt or innocence, that is, whether a person has committed an offense or not. Also, the test is not absolutely reliable. Individuals can sometimes “fake” the test. The sensitivity of the test is at least 50%, so at least half of pedophiles will have a positive test. Polygraphy, the “lie detector test,” has also been used to evaluate sex offenders, usually to follow sex offenders on parole or probation.

Viewing time assessment

Another technique for assessing sexual interest and deviance is viewing time assessment. In this procedure, an individual views photographic slides depicting subject matter which is potentially sexually attractive to the individual. The individual being tested rates the sexual attractiveness of the slides, and the length of time the individual views each slide is measured. Longer viewing time has been found to indicate greater sexual interest.

Functional imaging

Another method for the evaluation of sexual deviance, still in the research stage, is brain imaging. Functional imaging, for example functional MRI (fMRI), gives information about the metabolic activity of different parts of the brain.

fMRI scans have been done on normal controls and pedophiles during the viewing of different types of sexually neutral or sexually explicit slides. Increased brain activity is seen during viewing of opposite sex adults by the normal controls. When pedophiles look at slides of children which they find to be a “Thriller,” they have similar increases in brain activity.

So, in summary, when dealing with pedophilia and child molestation, are you willing to accept lame excuses like “I just really love hanging out with children” and “Billie Jean is not my lover?” Hell no. Do a serious, take-no-prisoners assessment as outlined above.

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New Emergency Stroke Treatments

by Brian Carty, MD, MSPH
06-17-2008

In ancient Greece stroke was called apoplexy, which means “struck down by violence.” Stroke is a sudden and often catastrophic impairment of brain function. It is one of the most dreaded of all diseases, in part because many people fear a lifetime of disability even more than death.

Stroke symptoms

A stroke can cause a variety of symptoms, such as sudden weakness or numbness of the face, arm or leg, especially on one side of the body, sudden confusion, trouble speaking or understanding, or trouble seeing. Other symptoms are sudden difficulty walking, dizziness, loss of balance or coordination, and sudden severe headache.

New Treatments Are Available

Until just a few years ago medicine had little to offer a stroke patient except to let nature take its course and to provide supportive care such as oxygen, fluids, aspirin, and the like. But in the past 10 years, new and more effective emergency treatments have significantly improved outcomes for stroke patients.

Types of stroke

There are two main types of stroke: ischemic, caused by a clot in a brain artery, and hemorrhagic, caused by bleeding from a ruptured artery in the brain. In an ischemic stroke, the clot in the brain artery stops blood flow. When brain or any other tissue is deprived of blood flow, the tissue dies. Early restoration of blood flow decreases the amount of brain tissue lost.

The emergency stroke treatments discussed here are for ischemic stroke, not hemorrhagic stroke. Hemorrhagic stroke and other less common types of stroke will not be discussed further here. Hemorrhagic stroke will be covered in an upcoming Hot Medical News article.

Transient Ischemic Attack (TIA)

A note about transient ischemic attack (TIA), a neurologic deficit such as paralysis or speech disturbance which resolves in a few minutes or hours. A TIA often precedes a full blown stroke. Recent research shows that most patients with TIAs should be immediately admitted to the hospital for a rapid evaluation and treatment. This approach markedly reduces the risk of a disabling stroke.

IV-tPA

tPA is drug which dissoves blood clots. Intravenous tPA (IV-tPA), has been shown to improve the outcome from ischemic stroke when given within 3 hours of stroke onset. The time since the onset of the stroke is the time elapsed since the patient was last seen to be normal. For example, if the patient went to bed and was normal at 10 PM and woke at 2 AM paralyzed on one side, for treatment purposes, the time since the onset of the stroke is 4 hours.

Before IV-tPA is given, bleeding in the brain must be ruled out with a CT scan, and other conditions must be met. Intravenous tPA for stroke should be available in most community hospitals.

The MERCI device and IA-tPA

View Video

An animated video of the use of the MERCI device for removing a clot which has caused an ischemic stroke.
-with permission Concentric Medical

In these two treatments, a catheter is inserted into a peripheral artery and then threaded directly into the artery which is blocked by a clot which has caused the stroke. The MERCI clot retriever device is then used to grasp and remove the blood clot (see video). This device must be used within 8 hours.

Intra-arterial tPA (IA–tPA) involves injecting the clot-busting drug tPA directly into the clot to attempt to dissolve it. IA-tPA must be given within 6 hours. Usually the MERCI device is used first. If the MERCI device is unsuccessful or only partially successful in removing the clot, then IA-tPA is used. The MERCI device and IA-tPA are usually available only at large stroke centers with an interventional neuroradiologist. For example, in California, the MERCI device and IA-tPA are available only in Los Angeles, Sacramento, and in the San Francisco area.

Treatment summary

Here is a summary of the emergency treatments for stroke and the times since stroke onset within which they must be given:

    0 to 3 hr – intravenous tissue plasminogen activator (IV-tPA)
    0 to 6 hr – intra-arterial tPA (IA-tPA)
    0 to 8 hr – MERCI device

Summary

A stroke is a medical emergency, and every minute counts. Call 911 immediately if anyone has stroke symptoms. “Time lost is brain lost.” The sooner treatment is given the better the outcome. For a thrombotic stroke, after an emergency CT scan has ruled out bleeding and after other conditions have been met, IV-tPA within 3 hours is standard therapy. At a major stroke center with an interventional neuroradiologist, the MERCI device and/or IA-tPA may be even more effective.

 

 

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Hollister T-shirts
click image to enlarge

Colostomy Bag

Do you wear a baseball cap backwards? Probably not. Reading medical websites is more of a middle-aged or older activity. How many 50 year olds have you seen wearing a baseball cap backwards?

Which brings us to a question. Will the “Hollister” t-shirt, which you see everywhere, surpass the backwards baseball cap as the cardinal emblem of the surly teenager, the “slacker?” A company named Hollister makes the t-shirts, but anyone with a bit of medical knowledge knows that a different Hollister company, Hollister Inc., is a leading manufacturer of ostomy products: bags and pouches for people with ostomies.

An ostomy is an opening between a body cavity, usually one of the gastrointestinal organs, and the exterior of the body. A common example is a colostomy, a surgically created opening in the large intestine to allow feces to drain out of an opening in the abdominal wall into a pouch or other collection device.

So the next time you see someone wearing a “Hollister” t-shirt, at least you can enjoy a smug sense of superiority in knowing that the nitwit is inadvertently advertising ostomy products. That’s worth something, isn’t it?

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A little tired and bleary-eyed, the waitress said with a faint smile, “May I take your order?” The six college students sitting at the table in front of her, all with bloodshot eyes, simultaneously burst out laughing. After a few seconds the waitress said “I’ll come back in a few minutes.”

Diagnosis? Cannabis sativa with secondary hyperphagia. In other words, the college kids were stoned and had the “munchies,” a craving for food associated with marijuana use.

It must have occurred to someone long ago that if marijuana makes people hungry, maybe there is an “antimarijuana,” a substance that opposes the appetite-stimulating effects of marijuana, causes weight loss and thus effectively treats obesity.

Hence, the drug rimonabant, a cannabinoid receptor blocker. The cannabinoid receptor is a molecule in the brain which, when stimulated by the active ingredient in marijuana, THC, causes the typical effects of marijuana: euphoria (the “high”), antinausea effects, and appetite stimulation. Rimonabant produces the opposite effects by blocking this receptor and is effective for weight loss. In a recent study in the April 2 Journal of the American Medical Association, patients given rimonabant had a ten pound weight loss.

The problem is that rimonabant also causes high rates of nausea, depression, and anxiety. Rimonabant has been associated with a 2-fold increase in the risk of suicide.

Although rimonabant is available in Europe and Mexico, the US Food and Drug Administration’s Endocrine and Metabolic Drugs Advisory Committee unanimously recommended against approval of the drug in 2007.

There are a number of appetite suppressants available in the US, but these drugs at best produce modest weight loss. The drugs must be taken continually to maintain this weight loss. Furthermore, many obese people need to lose far more than the 10 pounds seen in the rimonabant study cited above. So the search for a safe and effective appetite suppressant continues. The drug companies and the research community are hard at it, but as yet have had no success.

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Medical Image of the Month June 2008

by Brian Carty, MD, MSPH
06-01-2008

Lime Disease at site of tick bite
click image to enlarge

On a woman’s posterior right upper arm, the “bulls-eye” rash of early Lyme disease at the site of a tick bite.
Photo: Centers for Disease Control.

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