Sunday, April 30, 2017

Beethoven and Ancient Rome and lead

There is actually a Wikipedia site on Beethoven's death, that includes his autopsy findings..

The autopsy revealed a severely cirrhotic and shrunken liver, of which ascites is a common consequence. Scholars disagree over whether Beethoven's liver damage was the result of heavy alcohol consumption, hepatic infection, or both.
Yup. I've treated lots of these folks. Mainly in heavy drinkers. He also had evidence of a shrunken pancreas, suggesting pancreatitis.

but at the end of the article they insist he died of lead poisoning.

In 2010, Dr. Andrew C. Todd, of the Mount Sinai School of Medicine in New York City tested two pieces of Beethoven's skull for lead, and determined that the concentration of lead was no greater than would be expected for a normal man of 56 at that time.[16]
The leading cause of death still remains lead poisoning however. M. H. Stevens and his team have concluded that high levels of lead deep in the bone sampled from Beethoven's skull suggest repeated exposure over a long period of time rather than limited exposure prior to the time of death. Among other evidence, the finding of shrunken cochlear nerves at his autopsy is consistent with axonal degeneration due to heavy metals such as lead. Chronic low-level lead exposure causes a slowly progressive hearing loss with sensory and autonomic findings, rather than the classic wrist drop due to motor neuropathy from sub-acute poisoning. Beethoven's physicians thought that he had alcohol dependence

So where did he get lead? Yes, it was used as a medicine, but one overlooked reason for lead is that it was used as a sweetener in cheap wine.
Wikipedia article here on how this was done.
They were made by boiling down grape juice or must (freshly squeezed grapes) in large kettles until it had been reduced to two-thirds the original volume, carenum; half the original volume, defrutum; and one-third, sapa. The main culinary use of defrutum was to help preserve and sweeten wine, but it was also added to fruit and meat dishes as a sweetening and souring agent and even given to food animals such as suckling pig and duck to improve the taste of their flesh

Smithsonian article discusses.

Lead acetate, also known as sugar of lead, is a salt that (ironically) has a sweet flavor—a fairly unusual quality in poisons, which are more likely to taste bitter, signaling to the taster that they are unsafe for consumption. The ancient Romans used the compound—which they called sapa—to sweeten wine, and the aristocratic segments of the population could toss back as much as two liters a day (about three bottles’ worth, although wine was usually diluted with water). There is debate as to whether the wine alone could have produced the traditional physiological effects of lead poisoning, such as organ failure, infertility and dementia—the little things that help facilitate the fall of an empire. 
this article discusses lead in Roman times. It was recognized as a poison, since those working with lead tended to get sick.

The irony of lead pipes is not that they could cause lead poisoning, but that hard water deposited calcium on top of the lead. This means all those stories of lead poison from their pipes might be exaggerated: The lead was covered... except when they cleaned them out..

deposits of calcium carbonate in pipes and aqueducts protected against corrosion and insulated against the introduction of lead. With no taps to shut off, water flowed continuously and so would not have been in prolonged contact with the metal. Most water brought to Rome by its aqueducts was used, in any event, to supply its public baths.
but wine was sweetened by boiling it down... in lead vessels. And some used lead pots.

Like modern folks who have gotten acute lead poisoning from drinking acidic wine in pewter or ceramics with high lead content, the lead could cause problem.  The article gets into discussing lead vs copper vessels, and then calculates the dosage... or not. Long technical discussion there.

Science magazine discussion of lead poisoning and Rome. Yes, there was lead, but not enough to cause problems.

The researchers compared the lead isotopes in their sediment samples with those found in preserved Roman piping to create a historical record of lead pollution flowing from the Roman capital. Tap water from ancient Rome likely contained up to 100 times more lead than local spring water, the team reports online today in the Proceedings of the National Academy of Sciences. While the lead contamination was measureable, the team says the levels were unlikely high enough to be harmful, ruling out tap water as a major culprit in Rome's demise.
so what about the skeletal evidence? 

As far as I know, the first and only study to actually measure levels of lead in skeletons from Rome is the one that involved my samples from the two cemeteries of Casal Bertone and Castellaccio Europarco (1st-3rd c AD).... 

 What you can see is that there are fairly low levels of lead in the pre-Roman periods in Britain (Neolithic, Bronze Age, Iron Age) and the levels are lower in the post-fall of the Roman Empire (after 5th c AD).
... no one in the pre-Roman period is getting poisoned. The Imperial period is pretty special - we've got a person with lead levels over 20 mg/kg, which is 20 times higher than modern recommendations! In fact, this level is two times higher than the level the WHO considers "very severe lead poisoning."
the problem? Sample bias. It is not known if the sample was evidence of lead poisoning in the entire population.

water supply contamination continues to be a problem: in 2004, high lead levels were found in some neighborhoods of WashingtonDC.

find your state here if you want to know if there is a problem.

we still see kids with lead poisoning from old paint: The peeling paint chips are sweet and eaten by toddlers who place everything in their mouths. Since these paints now are forbidden, such cases are much less common, except in older buildings.

of course, nowadays one doubts anyone is using lead acetate to sweeten anything.

But back in 2008, there were a couple dozen acute cases in Germany from smoking marijuana: Some dealers added lead powder to their stash to make it seem heavier than it actually was to make a bigger profit.

Lead acetate has to make meth:

Acute lead poisoning is another potential risk for methamphetamine abusers. A common method of illegal methamphetamine production uses lead acetate as a reagent. Production errors may therefore result in methamphetamine contaminated with lead. There have been documented cases of acute lead poisoning in intravenous methamphetamine abusers.

But lead as a sweetener is not something used nowadays, because there are a lot of other cheap artificial sweeteners that can be used instead.

we get reports of fake sweeteners all the time here, but it is usually cyclamate, which is not very toxic.

However, the real worry is if old fashioned anti freeze is used.

Luckily for folks, the Austrian wine scandal using this chemical was detected by the Germans quickly.

Not all such contamination has been found easily, nowever.

here have been quite a few deaths from Chinese medicines that used Antifreeze to sweeten them.

NYTimes 2007 article about that scandal

Agatha Christie, call your office.

Saturday, April 29, 2017

Sugar baby

Freakonomics has a podcast on the evils of sugar.

KAHN: The next one is something called temporality. In other words, is there association in time between sugar consumption and obesity? That held pretty true from about 1985 to the year 2000. Where obesity levels went up, sugar consumption went up. But thereafter starting in the year 2000, even to today, sugar consumption has declined somewhere around 15 to 20 percent, whereas obesity rates continue to rise. We don’t see that at all with smoking, the analogous situation. Cigarette smoking rises, cancer rises. Cigarette smoking declines, cancer declines.

Cross posting: Fetal alcohol syndrome.

Long blog post on my other blog about Fetal alcohol syndrome.

We saw a lot of this on the reservation when I worked in the IHS.
many have ADHD and intellectual difficultiies.

aand young folks now are smoking marijuana instead, as "safe" but the "studies" are out of date: The drug was much less potent 40 years ago when the studies were done, and like alcohol the damage is dose related.

So studies asking "have you ever" often are nonsense.
A little wine probably does nothing, but a heavy drinking bout or heavy daily alcohol use is not the same thing. I mean, not all kids had FAS in the good old days when beer and wine were used all the time (because water was dangerous and full of germs, ergo "drink a little wine in your water for your stomach's sake"...( something that tea and coffee drinking put a stop to).

 One puff, or a heavy habit.

Cross posting: Suicide chic, Yellow jack

From my other blog: Two articles on suicide chic in a hit TV chick flick series aimed at female teenyboopers..

and link to a CDC technical article on why they have a yellow fever vaccine shortage.

essentially only one company makes it, and they had to throw out a lot of vaccine because of technical difficulties. Now they want to manufacture a new version but they have to do extensive testing.

And I have written in the past about the YF outbreaks on Africa and now in Brazil, that has used up a lot of the world's stock of vaccine even though they give partial doses to some folks.

Friday, April 21, 2017

Hashish in medieval Egypt

when the naive drug pushers were trying to push Massachusetts to legalize marijuana as harmless and non addicting years ago, an Egyptian doc who had worked in the slums of Cairo testified about the severe social problems from the drug's use, and the idea was stopped.

Nowadays, the Open society (Soros money) is pushing it via the stalking horse of medical marijuana, alas. and those who see the problems won't be allowed to testify on the neighborhoods and Indian reservations destroyed by drug use.

But none of this is new: Medieval net has an article on hashish use in medieval Egypt.

While medieval physicians knew about the health benefits of cannabis – it was used as diuretic for instance – they often also warned people about the bad effects of hashish. A 14th-century Egyptian, az-Zarkashi, gives a complete list of all the problems the drug caused:
It destroys the mind, cuts short the reproductive capacity, produces elephantiasis, passes on leprosy, attracts disease, produces tremulousness, makes the mouth smell foul, dries up the semen, causes the hair of the eyebrows to fall out, burns the blood, causes cavities in the teeth, brings forth the hidden disease, harms the intestines, makes the limbs inactive, causes a shortage of breath, generates strong illusions, diminishes the powers of the soul, reduces modesty, makes the complexion yellow, blackens the teeth, riddles the liver with holes, inflames the stomach, and leaves in its wake a bad odor in the mouth as well as a film and diminished vision in the eye and increased pensiveness in the imagination. It belongs to blameworthy characteristics of hashish that it generates in those who eat it laziness and sluggishness. It turns a lion into a beetle and makes a proud man humble and a healthy man sick. If he eats, he cannot get enough. If he is spoken to, he does not listen. It makes the well-spoken person dumb, and the sound person stupid. It takes away every manly virtue and puts an end to youthful prowess. Furthermore, it destroys the mind, stunts all natural talent, and blunts the sharpness of the mental endowment.
nothing much has changed.

Ironically, he problem of intoxication was why the Prophet forbad his followers from using Alcohol (similar to how the Baptists and Methodists, seeing the probem of alcoholism in the poor, insisted on not using alcohol.)

Wednesday, April 12, 2017


cross posted from my main blog: Why do shoelaces untie?

The scientists expected that the knots would come undone slowly. But their slow-motion footage — focused on the shoelaces of a runner on a treadmill — showed that the knots rapidly failed within one or two strides. To figure out why, O’Reilly and his colleagues used an accelerometer on the tongue of a shoe to measure the forces acting on a knot. They found that when walking, the combined impact and acceleration on a shoelace totals a whopping 7 gs — about as much as an Apollo spacecraft on reentry to Earth’s atmosphere.

this sounds more frivilous than it actually is: Because if an elderly person trips on an untied shoelace, they can break an arm or a hip.

This is also a problem in surgery: Braided silk usually doesn't untie easily, nor does Chromic catgut. We usually do three or four knots (square knots not grannie knots) and no problem.

But newer unifilament nylon does tend to untie itself.

And if it unties before the wound is healed, you end up with the wound falling apart.

Although I found that nylon skin sutures, even with six or eight knots usually don't start to unravel until the wound swelling goes down and the tension on the knot allows it to unravel.

but if a person is malnourished (i.e. low protein diet, diabetes, cancer) the wound could take longer than usual to heal.

when we were in Africa, we used monofilament fish line to sew the skin because the pre packed nylon or silk was too expensive and often poor quality.

The real problem was the catgut and newer absorb able suture: If the catgut (regular or chromic) was old, it could lead to internal bleeding. Not a big problem for under the skin, but for C Sections it could lead to bleeding or other complications (a uterus that would rupture in a later pregnancy, a dangerous complication). We would usually use the modern versions donated to us by German or American hospitals.

and no, catgut is not made from cats: It is made from sheep guts, or as Wikipedia explains:

Catgut suture is made by twisting together strands of purified collagen taken from the serosal or submucosal layer of the small intestine of healthy ruminants (cattlesheepgoats) or from beef tendon.[1] The natural plain thread is precision ground in order to achieve a monofilament character and treated with a glycerol-containing solution
but it is not used as much nowadays, especially in Europe, because of mad cow disease worries and because there is an alternative.

Thursday, April 6, 2017

STD increase in MSM

the old STD syphillis has increased in MSM...

CDC report:

In 2015, the rate of reported primary and secondary syphilis in the United States was 7.5 cases per 100,000 population, nearly four times the previous lowest documented rate of 2.1 in 2000 (1). In 2015, 81.7% of male primary and secondary syphilis cases with information on the sex of the sex partner were among gay, bisexual, and other men who have sex with men (collectively referred to as MSM) (1)...
...The overall rate of primary and secondary syphilis among MSM was 106.0 times the rate among men who have sex with women only and 167.5 times the rate among women.*

ironically, most of the increase was in the south:

Rates of primary and secondary syphilis among MSM varied by U.S. Census region and by state, with the highest rates in the South and West. Four of the five states with the highest primary and secondary syphilis rates among MSM were southern states (Louisiana, Mississippi, North Carolina, and South Carolina) (Table 2). Among states with the 10 highest rates of primary and secondary syphilis in the United States in 2015 (1), five states (Arizona, Louisiana, Mississippi, Nevada, and North Carolina) also ranked among the top 10 states with the highest rates of primary and secondary syphilis among MSM (Table 2).

 meaning they were less likely to be screened and treated? the talk of "secondary" syphillis makes one worry about not being diagnosed early.

On the other hand, the rates might be a reporting error:

Second, the denominators used in calculating the rates of primary and secondary syphilis were estimates of the number of MSM in each state, based on the reporting of same-sex households in the American Community Survey; underreporting of same-sex households could result in an underestimation of the MSM population and an overestimation of primary and secondary syphilis rates.
one also wonders if the rate is local, i.e. in cities. Often due to the stigma, MSM travel to bars away from home and manage to catch STD's but don't tell their local docs (yes, patient privacy... in the good old days we knew this was nonsense so didn't put it into the record, or used code words. Now the Feds want to have everything there, all nice and written out on the computerized files for the Russian/chinese hackers or your ex wife to find it).

Monday, April 3, 2017

Bangungot: Sleep death in young men

The Inquirer article on young men who die in their sleep.

The identification of young males—aged 25 to 44, presumably healthy, without any known cardiac illness—as at-risk individuals is also consistent with international scientific reports on the Brugada Syndrome. Southeast Asian males seem to have an increased predisposition to it. Similar cases are also seen in Pacific Rim countries and Polynesian populations where Southeast Asians have migrated. 
a sudden arrhythmia?

Some medicines like good old quinidine have been shown to be effective in preventing life-threatening arrhythmias, but for those who can afford it, an implantable cardiac defibrillator (ICD), similar to an artificial pacemaker battery, is surgically implanted just beneath the skin layer on the chest. It’s hooked to the heart and gives it a mild “shock” (defibrillate) whenever it goes into a life-threatening heartbeat.


A young man in his 20's just died of this in our barangy... our cook's son probably died of it also, but he was dizzy and went to the doctors and collapsed. This happened before, and he recovered, but this time it took to long to transfer him so he died. Sigh.  

this runs in our family also: Lolo's brother and nephew both had sudden cardiac deaths. (His father also died young, but we think it was from TB..)

Wikipedia article here.

The cause of sudden death in Brugada syndrome is ventricular fibrillation (VF). The average age of death is 41. According to clinical reports, sudden death in people with Brugada syndrome most often happens during sleep. The episodes of syncope (fainting) and sudden death (aborted or not) are caused by fast polymorphic ventricular tachycardias or ventricular fibrillation. These arrhythmias appear with no warning. 
There are several syndromes that cause this, and some genetic testing, and an EKG might be a good way to screen.

But the treatment, an implantable defibrillator, is too expensive for ordinary folks, and alas there is no push to screen for the problem.

this first came to light in US medical journals when some Cambodian refugee men dropped dead. The anti war folks blamed it on Russian "yellow rain"..., but anyone with Asian relatives would be aware of the syndrome... 

More HERE. on what drugs to avoid if you have the syndrome.

HealthMatrix discusses the folk lore behind the syndrome.

In the English-speaking world, we talk about the Night Hag and similar apparitions (see pp38–40). These terrifying beings are glimpsed in the darkness of nightmare, pressing down on their victims and preventing them from breathing. Their attacks, though scary, are generally harmless, whereas the nightmare demons of the Far East can be lethal. In Japan, this type of death is known as pok-kuri; the Filipinos call it bangungot or batibat; and the Hmong people of Vietnam and Laos call it tsob tsuang. In Thailand, the being to fear is the phi am or ‘widow ghost’ who comes to steal away the souls of young men. Some men defend themselves from phi am by wearing lipstick at night, so that the ghost mistakes them for women and leaves them alone.
Although he discovered references to the condition in Filipino medical literature as far back as 1917, Dr Aponte could draw no conclusions about the nightmare deaths. The same condition was later documented among refugees from South-East Asia, and in 1981 some 38 victims had been recorded in the US, most of them Hmong. The term Nightmare Death Syndrome was coined, which was later changed to Sudden Unexplained Nocturnal Death (SUND) or Sudden Unexplained Death Syndrome (SUDS) (see FT48:25, 55:15). The immediate cause of death was cardiac arrest. But why had the men’s hearts failed when there was seemingly nothing wrong with them?
In folklore, a “mare” or “nightmare” is not an awful dream, but rather a supernatural being that crushes a sleeper’s body by sitting on it. Another related term is hag-riding which implies a frightening feeling of being held immobile in bed, often as if by a heavy weight pressing on one’s stomach or chest and it is said that it might be accompanied by the sense of an alien presence, and by visual hallucinations. In folklore, it was thought of as a magical attack, whether it was a demonic incubus, ghost, harmful fairy, or witch depending on culture and time period.

if you have heard the folk advice not to wake someone up suddenly when they are asleep, this syndrome is the reason.

Saturday, April 1, 2017

Yellow fever update

tw articles from the CDC:

one is a report about  last year's the epidemic in the Congo 

and this one is about "adverse effects of the vaccine". in that country:

during May 25–June 7, 2016, the DRC Ministry of Health administered approximately 240,000 doses of yellow fever vaccine to all persons aged ≥9 months during a mass vaccination campaign in Matadi, ....

a small number of people were followed and a few problems were found
Overall, 15 AEFIs were identified by active surveillance among approximately 2,800 patient records reviewed at the two targeted referral hospitals, including eight AEFIs previously reported during the immunization campaign (Table).

Two AEFIs were classified as serious and 13 as nonserious. The serious AEFIs comprised a spontaneous abortion that occurred after inadvertent administration of yellow vaccine early during an unrecognized pregnancy and a nonspecific gastrointestinal syndrome, both resulting in prolonged hospitalizations. Nonserious AEFIs included cutaneous allergic reactions, itching, fever, and injection site erythema. The incidences were 6.2 per 100,000 vaccine doses administered for all identified AEFIs and 0.8 for serious AEFIs.

Previous studies in African settings have found an expected AEFI rate of 8.2 per 100,000 yellow fever vaccine doses administered for all reported AEFIs and 0.4 for any serious AEFI (4).

there is a worry about the vaccine affecting the growing fetus causing defects butt

the cdc page on Yellow fever notes

Yellow fever vaccination has not been known to cause any birth defects when given to pregnant women. Yellow fever vaccine has been given to many pregnant women without any apparent adverse effects on the fetus. However, since yellow fever vaccine is a live virus vaccine, it poses a theoretical risk. While a two week delay between yellow fever vaccination and conception is probably adequate, a one month delay has been advocated as a more conservative approach. If a woman is inadvertently or of necessity vaccinated during pregnancy, she is unlikely to have any problems from the vaccine and her baby is very likely to be born healthy.

Pubmed has this abstract of a study on the risk of anomalies from the vaccine.

Seventy-four cases were analyzed, 58 with a completed follow-up. Pregnancies ended in 46 births, five voluntary abortions and seven spontaneous abortions. Three newborns had minor anomalies and two had major defects (ureteral stenosis and triphalangeal hallux). Although the sample is too small to rule out a moderate increased risk of adverse reproductive effect of YFV, it gives no argument for such an effect and should lead to reassure pregnant women who might be inadvertently vaccinated.

the rate of abnormalities is about the same as baseline.