Hospitals & Asylums 








July 2013


By Anthony J. Sanders


There will be no moon eclipsing the peak of the Perseid meteor shower this August 11-13.  There is supposed to be a full moon party on the 22nd.  I hitched 30 miles and spent $50 to go to a concert and eat last full moon and I'll be damned if I'm going to spend another penny when there is a rave down the street to make peace with the neighbors.  The wildnerness has everything I need, wild carrots (yampa), onions, berries, herbal tea, reasonably priced two pound blocks of pepper jack cheese and friends to share with.  After dropping $250 on "rents" and a new digital camera last month I am hoping to save enough hiking the Pacific Crest Trail (PCT) to Crater Lake to buy some solar panels so that I can sit around my nearly finished 2 ½ ft. wide and 10 ft. long stick table until after fire season, and the earth oven isn't warm enough to type in a tarp shelter a half mile from the cross-country ski trail, anymore.  With the Internet more than 10 miles away and sister's 13 miles from wifi 1,000 miles away on vacation, I don't expect to run into any more writer's block as I cover my book in human skin and cancer this August-September. Dapsone a treatment for leprosy was proven effective in treating psoriasis and the skin diseases and burns of partially gassed Jews in concentration camps by Nazi Germany's last subsidized dermatologist, who I am loth to convict of war crimes, not to tempt physicians to test their moral fibre in totalitarian situations better understood by social workers, the medicine given torture victims is not always safe and effective.  Shaded from the ferocity of the 12-3 pm summer sun that will suddenly age the skin of 45 year olds, by the hiking trails of the PCT, I hope to walk 20 miles a day with a 65 pound pack my way from daily long distance running to five days a week of marathon running.  Having relaced my trail running shoes two days rest a week should be enough for my blisters to heal in the future.  The nearly daily ten mile run to charge the computer, each way, is a great routine - daybreak to 10-12 am workout, 10-12 to 3-5 pm typing, and 5-8 pm running hitchhike until I find the county trailhead off the Forest Service map, and run with a 10-20 pound pack, or hike in the shade with 65 pound pack and no inside job, 20+ miles a day, three to six days a week.      


Pulmonology HA-18-7-13


The respiratory system includes the nose, mouth, a pair of lungs, the tubes or airway to the lungs, chest bones and muscles.  Oxygen is pumped into the lungs by the respiratory muscles and is brought into close contact with blood, into which it passively diffuses, at the level of the pulmonary capillaries in the alveoli.  Carrier molecules in the blood, hemoglobin, bind the O2 to make blood, pumped by the heart, as efficient as the air in transporting O2.  Each cell in the body is equipped with a specialized furnace, the mitochondria, which burns carbohydrates with O2 to produce the high-energy ATP molecules that fuel the cells' functions, and ultimately maintain the life of the whole organism. O2 is transformed into water by this process and with carbon dioxide (CO2) is returned to the external environment where it is recycled by plants into O2 and carbohydrate by solar energy.  Humans can tolerate only 5 minutes of oxygen (O2) deprivation without irreversible damage and death.


The treatment of cough is successful in over 95% of cases.  All narcotic antitussives are effective cough suppressants. Dextromethorphan hydrobromide is the most common nonnarcotic cough suppressant, it is slightly less effective.  Around 2010 the FDA removed some 600 different types of flu remedies from the market.  The FDA has approved Allegra (Sanofi-Aventis) and Children's Allegra (fexofenadine) and Allegra-D (fexofenadine and pseudoephedrine) product lines to be marketed over-the-counter. The two prescription antivirals for the flu are Oseltamivir (Tamiflu) and Zanamivir (Relenza), for Haemophilus influenza the antiviral Amantadine (Symmetrel) and anbimicrobials ampicillin (Principen) or levofloxacin (Levaquin) are also used. Winter 2012-2013 the flu vaccine was reported to be only 8% effective.  Respiratory syncytial virus (RSV) infections are treated with NSAIDS such as acetaminophen or ibuprofen and corticosteroids may be administered if the pneumonia worsens.  Antibiotics should be administered if an ear infection (otitis media) or pneumonia develop.  For Severe Acute Respiratory Syndrome (SARS), a coronavirus, the treatment with no fatalities was to ventilate the patient and medicate with the antibiotic levofloxacin (Levaquin), and corticosteroids methylprednisolone IV and then prednisone.


Vaccines are the greatest achievement of modern preventive medicine.  Polio and smallpox have been eradicated and one more generation of vaccines will eliminate whooping cough, measles and mumps as threats to our children. Allergies have become more common since vaccines and GM crops saturated the market.  Antihistamines are sedative and 100 immunotherapy injections is a lot.  Herbal medicine is successful in the treatment of viral and allergic illnesses.  For allergic rhinitis the best treatment is the essential oils of fresh Lavender, Lemonbalm, and Peppermint in the nose, or as drops on the tongue or mix the oils in a ¼ cup of juice or water, swish 10-20 seconds in the mouth and swallow, relief should be instant, use must continue.  Eucalyptus oil kill dust mites, a common household allergen.  Take Vitamin C 200-1,000 mg daily to shorten duration of cold.  Oranges, echinacea and elderberry are high in vitamin C and very good at treating colds.


Initial therapy for acute asthma and chronic obstructive pulmonary disease (COPD) should include supplemental oxygen and inhaled beta-adrenergic drugs.  Corticosteroids are indicated if the initial response is insufficient or if the patient has had several recent asthma attacks.  There are two chief types of bronchodilator drugs: adrenergic agents (Ephedra aquisetina and E. sinica and synthetics) and those derived from theophylline (originally isolated from tea, Camellia sinensis) which act directly on the bronchial muscle to relieve obstructions, increase coronary blood flow and stimulate respiration centrally.  Tea as an oral treatment of 100 patients for 20 days proved effective in 93% of cases, of which 58% could be described as excellent.  During the course of treatment, sputum decreased in 91% of the cases, cough in 85% and asthmatic symptoms in 58.1%. 


Streptococcus pneumoniae is the most common bacterial cause of pneumonia.  Pneumococcus, Haemophilus influenzae, Legionella pnemonphila, Mycoplasma and viruses abound in the community and gram-negative bacteria and Staphylococcus species in hospitals.  Cystic fibrosis patients are frequently infected with Pseudomonas and Staphylococcus.  COPD patients are vulnerable to the typical community-acquired infections.  The bacterium Legionella pneumophila causes both Legionnare’s disease and Pontiac fever and is an occupational hazard contaminating air-conditioning units and water reservoirs. 


Empiric therapy for the majority of immune-compromised patients with a presumed pulmonary infection includes antibiotic coverage for both gram-positive and gram-negative organisms (usually a semi-synthetic penicillin or a cephalosporin plus an aminoglycoside.  Penicillin by mouth and corticosteroids by mouth or nebulizer may be effective in simple lung abscesses. Inpatient treatment of lung abscess, especially the putrid variety, should be 2 to 6 million U crystalline penicillin G intravenously daily; 600,000 U procaine penicillin G intramuscularly every 6 hours for 4 weeks may be sufficient in milder cases.  In the presence of serious penicillin hypersensitivity, clindamycin 600 mg 4 times daily, lincomycin 600 mg intramuscularly every 6 hours, or erythromycin 2 gm/day may also be used.  Some observers are in favor of adding streptomycin 1 gm intramuscularly daily for at least the first 7 to 10 days, or tetracycline 2 gm daily to 3 to 5 days, then 1 gm daily. 


If Staphylococcus aureus is found and believed to be a causative agent, intravenous methicillin, or an equivalent drug such as nafcillin, 8 to 16 gm daily, if penicillin resistant.  Vancomycin, 500 mg intravenously every 6 hours is an effective anti-staphylococcus drug but has significant toxicity, resistance and probably should seldom be used.  Antimicrobial treatment should be continued for at least 2 to 3 months, sometimes even longer.  Oral doxycycline 100 mg the once a day antibiotic, for the treatment of methicillin resistant S. aureus (MRSA), seems more ideal than hospital treatment for a hospital acquired infection. 


If Klebsiella organisms are found and are the causative agent, the initial therapy should include kanamycin, 15 mg/kg/day intramuscularly in 2 or 3 divided doses, the total dose being decreased if renal insufficiency is present or appears.  Metronidazole (Flagyl ER) is a safer and possibly more effective alternative but clinical trials are needed for the FDA to indicate its effectiveness against Klebsiella and E. coli.  When Pseudomonas is clearly the causative organisms, gentamycin or tobramycin should be used.  Metronidazole (Flagyl ER) is indicated for the treatment of Bacteroides spp. (e.g. B. fragilis).  Doxycycline, the once a day antibiotic, should be prescribed at hospital discharge to prevent hospital acquired staph infections. 


Although azithromycin (Zmax), the world's best-selling antibiotic, may be more a day or two more effective in most cases, pencillin or ampicillin (Principen) are the standard treatment for pneumonia, meningitis and upper respiratory infections, and erythromycin, a streptomycin like Zmax, is the traditional generic alternative for patients allergic to penicillin.  Metronidazole is a uniquely effective antibiotic at curing gastrointestinal infections without side-effects, that is also effective against bone and joint infections lower than the middle of the thorax. In 1989 ten drugs were used for the treatment of tuberculosis and non-tubercular mycobacteria (NTM), the four most important are isoniazid (INH), rifampin, pyrazinamide, and ethambutol with 95% cure rates in a 6 to 9 month short course of multiple drug chemotherapy. 


Corticosteroids, sporanox (itraconazole) oral and amphotericin B are the only medicines indicated for Aspergillus spp (i.e. A. niger sold to academic laboratories) which causes invasive pulmonary aspergillosis, and releases a most highly carcinogenic aflotoxin, as well as the other fungi also treated by ketoconazole Coccidiodes immitis, Cryptococcus neoformans, Candida organisms, Histoplasma capsulatum, and Blastomyces dermatitidis. Hypoxemia can be effectively corrected by using controlled oxygen enrichment by double nasal cannula or Venturi masks.  Expectorants and mucolytics such as guafenesin or the herb mullein help liquefy secretions and allow one to cough up mucus more easily.  One of the best expectorants is water.  Drinking an adequate amount of water, about one quart per day, will make clearing phlegm easier, which may lead to improved breathing. 


Any change in pH, whether produced by respiratory or metabolic changes, alters O2 affinity.  Under pathologic conditions, blood pH can deviate markedly from pH 7.4 and have profound implications in oxygen delivery.  Low pH may hamper oxygen uptake in the lung.  Addition of CO2 to blood causes pH to fall by 0.03 to 0.05 units.  Sputum has a pH of 7.0 and must be removed through daily naso-bronchial hygiene.  Ascent to high altitudes produces both hypoxemia and respiratory alkalosis.  Alkalinity can be prevented by administration of acetazolamide.  Acidosis is often corrected by hyperventilating through pursed lips and its cure is dependent on the excretion of acid by the kidneys.  Bicarbonate therapy is most effective when plasma bicarbonate is low and there is little be gained when the initial (HCO3- ) is above 20 to 1 mEq/liter.


Lung cancer has a 10-15% five year survival rate.  The probability of contracting lung cancer is 12 times higher in smokers and 50 times higher in smokers who have been exposed to asbestos, a fiber that only causes cancer in smokers.  The most active single antineoplastic agents are methotrexate and cisplatin.  Each produces response rate of approximately 30% (mostly partial responses) of 4 to 6 months' duration.  Cisplatin responses usually occur more promptly.  Cisplatin is an effective drug whose major route of excretion is renal, and its use should be limited to patents with a creatinine clearance that is more than 50 ml/minute.  The standard dose is 100 mg/m2 every 3 weeks. Methotrexate is generally given at 40 mg/m2 intravenously weekly.  Methotrexate 2.5 mg, once a week, might be more effective with fewer side-effects, exposure to community and hospital acquired infections and carcinogens and at 70 cents a pill, lower cost.  Don't lose weight, extra rations for physical labor, pregnancy and respiratory disease.


Book 2 Attorney General Ethics (AGE)


To amend Chapter 2 Soldier’s and Airmen’s Home §41-70.  The American Legal System has failed, lawyers are either behind bars or drunk on power. In 2001, the majority of the 93 million judicial cases filed, were processed by 15,555 state trial courts operating under the supervision of the county; 13,515 of limited jurisdiction and 2,040 of general jurisdiction, operated by 29,266 judges.  There were 55.7 million traffic cases filed, 15.8 million cases were filed with the civil division, 14.1 million Criminal cases, Domestic Relations processed 5.3 million cases, 2 million criminal cases were filed in Juvenile Courts and 276,408 cases were filed with the Appellate Courts.  A civil law system must be instituted by lowering law school entrance to high school graduates and the bar exam to BA and terminate the licenses of all lawyers who are elected or appointed to public, commercial or social office, a Civil-law Amendment III to the Annotated United States Constitution calls for 4 year terms for elected federal judges, with a two term limit for justices, and one year term for chief justice, to repeal the constitutional right to bear arms and quartering of troops in people’s homes, to change the name of prosecutor to district attorney, elect licensed social workers to adjudicate traffic, divorce, mental illness, substance abuse, tenant-landlord and small claims, and funeral directors to avoid Probate, to abolish the death penalty, to change the name of the Drug Enforcement Agency (DEA) to Drug Evaluation Agency (DEA) and transfer to the Food and Drug Administration (FDA), to change the name of the Court of International Trade of the United States (CoITUS) to Customs Court (CC), to change the name of the Office of Violence Against Women to Office of Women’s Rights and transfer to Social Work Administration (SWA) when established, to ratify Optional Human Rights Protocols, to appoint a new Attorney General, to transfer the Justice Assistance Grant (JAG) and other extra-jurisdictional finance entirely to halfway house programs, primarily financed by up to 7.7% of the Supplemental Security Income (SSI) program for poor people on probation and parole, to safely reduce the jail and prison population to less than 250 per 100,000 residents legal limit within a decade, to separate the lawyers who are behind bards from those who are drunk on power; Quiz…218