John T. Rowe, MD

The Human Skeleton

Bones By the Number

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          Did you know that infants have approximately three hundred bones at birth, but adults have only 206?  This is because as we grow, some of the bones fuse together.  Of those 206 bones, more than half, or 106, are located in the hands and feet.  There are 14 bones in the face and 8 in the cranium, surrounding the brain.  The largest and longest bone in the human body is the femur (thigh bone) and the smallest is the stapes which is one of the three small bones in the ear that help us hear.  Bones are living tissue with their own nerves and blood vessels.  In the average adult, bones account for about 30 to 40% of our body weight and contain about 25% water.

          The skeletal system helps protect and support the rest of the body.  The bones of the skull form a protective helmet around the brain and the 24 ribs and sternum (breast bone) protect the heart and lungs.  The rest of the skeletal system prevents us from being a gelatinous blob by providing support, yet with enough flexibility to enable us to move.  If that wasn’t a big enough job, bones also make red and white blood cells in the marrow, store fat and regulate the amount of phosphorous and calcium in the body.

         A broken bone is called a fracture and takes about 6 to 8 weeks on average to heal.  Depending on the location and severity of the fracture and the age of the individual, healing time can range from 3 weeks (toe) to 10+ weeks (femur).  To maintain healthy bones, it is important to stay active and maintain a proper diet with an adequate amount of calcium.  Protecting the bones is also important.  Wearing a helmet while bike riding and using the proper protective equipment while participating in other sports is essential.  The skeletal system is truly an amazing part of the human body.  No bones about it!

The Human Skeleton
The Human Skeleton

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The Importance of Immersing Children in the Arts

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          Much to the detriment of childhood education, the art curriculum in public schools has taken a double hit in recent years.  It is slowly being squeezed out due to budget mismanagement at the state level and it has increasingly been supplanted by newly mandated subjects with political overtones.  This makes it all the more important to find ways to expose children to the arts at home and to take advantage of other opportunities that are available after school hours.  How else will you know if your child got the ‘music gene’ or has the potential to become a talented painter or sculptor or perhaps has the creativity to write the great American novel?  

          Learning to draw or play a musical instrument is a creative endeavor that can not only bring self-satisfaction and promote self esteem, but provides an alternative to the many other unsavory distractions that tempt today’s youth.  Such activities can awaken the creative potential in a child’s mind that might otherwise remain dormant, suppressed by the massive amounts of passive screen time many children engage in today.  Participating in music and other forms of art promote the development of interests and activities that can last a lifetime, long after physically taxing activities are no longer possible.  It can also contribute to social development, as for example playing an instrument in a band, which can teach the same principles of teamwork as playing on a ball team. 

          A child who discovers the joy of listening to classical music, opera or big band music is less likely to fall victim to the thankfully short-lived productions that are cranked out today, thereby reducing exposure to their harmful messages promoting sex, drugs and violence.  I am constantly amazed at how popular the ‘Oldies but Goodies’ are with teenagers today, an indication that many of them do have good taste in music and have the self-confidence to resist peer pressure.  Developing an appreciation for good music can bring entertainment and pleasure to teens who might otherwise be tempted to seek it in unhealthy ways. 

          I am fortunate to have had a wonderful family with wise, caring parents who exposed me to music at an early age.  They sacrificed to get me started with piano lessons at age seven and I still enjoy playing piano and organ to this day.  We went as a family to the great musical productions of the time, including Gigi and South Pacific, and attended youth concerts that were held at the local high school on a regular basis.  I remember how my Dad used to purchase a classical record every so often when they were offered as part of a series in a sales promotion at the Safeway grocery store.  That was my very first exposure to the likes of Scheherazade by Nikolai Rimsky-Korsakov.  My Dad taught me how to recognize all the different musical instruments in the orchestra as we listened together. 

          It is gratifying to see young families continuing this tradition with their children today.  Be sure to watch the video that follows which features a three year old who is destined to become the next Zubin Mehta.  Don’t tell anyone, but I also have a conductor’s baton that I like to swing as I stand in front of my stereo while playing something like Beethoven’s Fifth Piano Concerto (with all of the drapes closed, of course, as I sometimes really get into it!).  Thanks Dad and Mom for awakening my appreciation for good music at an early age.  It has provided me with many hours of pleasure over the years.

Check Out This Three Year Old Conductor!  You’ll Love It!

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Hearing Loss Increasing Among Teens

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          For anyone who has been observing the ‘plugged-in generation’ in recent years, it should come as no surprise that hearing loss is increasing among teenagers in the United States.  In a recent article appearing in JAMA, the Journal of the American Medical Association, J. Shargorodsky and colleagues reported that 20% of U.S. teens surveyed between 2005 and 2006 had some evidence of hearing loss, up from 15% in a group of teens surveyed between 1988 and 1994.  In both groups surveyed, it was more common for teens to have hearing loss in just one ear, rather than both and it was also more common to have high frequency, rather than low frequency hearing loss. 

          While the authors felt that the cause of this increase in hearing loss was unclear, it is known that high frequency hearing loss can be caused by exposure to noise.  Since hearing loss can affect many aspects of life, including learning and social skill development, it is important to moderate exposure to loud noise.  This should include monitoring the level of noise delivered to the ears through an ear piece as well as through ambient noise, such as that which would be experienced at a rock concert or noise from radios, stereos and televisions.  There is a natural trend towards waning hearing acuity with age.  With many of today’s teens expected to live to 100 years of age, it is all the more important for them to preserve this precious sensory organ for use in the years to come.

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Alcohol and Drug Induced Liver Disease

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          In the United States alone, two million people have alcohol induced liver disease.  Because it is the primary site where alcohol and other potential toxins, including drugs, are metabolized (processed and broken down) the liver is susceptible to damage from these agents.  Eighty percent of alcohol passes through the liver to be processed.  There are many factors that determine to what extent alcohol will affect the liver of each individual.  Genetics, malnutrition and poor diet, as well as the presence of other underlying liver disease such as chronic viral hepatitis B or C can each play a role in how alcohol affects this important organ.  While the reason is not clear, it is believed that women are more susceptible than men to the effects of alcohol on the liver.  In general, damage to the liver increases with increased quantity and duration of alcohol intake.  As damage progresses, the liver goes through three recognizable pathologic and clinical stages. 

Fatty Liver Disease 

          During this first stage of alcohol induced liver disease extra fat builds up inside the liver cells.  Most heavy drinkers will have fatty liver disease.  There may be no symptoms and this condition is generally reversible if alcohol intake ceases.  

Alcoholic Hepatitis 

          In the second stage in the progression of alcohol induced liver disease the liver swells and is damaged.  Between 10 and 35% of heavy drinkers will progress to alcoholic hepatitis.  Signs and symptoms may include loss of appetite, nausea, vomiting, abdominal pain and jaundice.  Mild cases can be reversed by abstinence from alcohol. 

Alcoholic Cirrhosis 

          Approximately 10 to 20% of individuals who drink heavily for eight to ten years will develop cirrhosis of the liver.  In this last stage in the progression of alcohol induced liver disease, normal liver tissue is destroyed and replaced with fibrous scar tissue.  While cirrhosis is generally not reversible, abstinence from alcohol can prevent further damage.  Some patients with cirrhosis will progress to liver failure.  In addition to a decline in the liver’s ability to perform its many important functions, complications of cirrhosis can include accumulation of fluid in the abdominal cavity, kidney failure, encephalopathy (confusion), and catastrophic bleeding from the veins in the esophagus.  Treatment is generally supportive and some patients may be candidates for liver transplantation. 

Drug Induced Liver Disease 

          There are a number of other agents that can be toxic to the liver cells, including both mainstream and alternative medications and, of course, certain species of mushrooms.  The most common cause of acute liver injury in the United States is ingestion of acetaminophen (Tylenol).  While the toxic affect of acetaminophen is dose dependent, individuals with malnutrition or who use alcohol may be susceptible to liver injury at lower doses.  Treatment of drug induced liver disease consists of supportive therapy and withholding the offending agent.  In the case of acetaminophen toxicity, patients may benefit from treatment with the antidote N-acetylcysteine.

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Viral Hepatitis

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          In our previous articles we discussed how hepatitis is a general term for inflammation of the liver.  It can be caused by a number of conditions, including autoimmune diseases, drugs, and alcohol.  There are also several viruses that specifically attack the liver.  In this article we will discuss the three most common viruses which cause hepatitis A, hepatitis B and hepatitis C, respectively.

Hepatitis A 

          Hepatitis A was formerly called infectious hepatitis and accounts for approximately half of the cases of acute hepatitis in the United States.  It is transmitted through ingestion of food or water that has been contaminated by feces containing the virus (fecal-oral route).  It can also spread through a household by contact with oral secretions resulting from intimate kissing or contact with stool due to poor hand washing.  Children in day care centers and customers at restaurants lacking sanitary precautions such as hand washing are also at risk of contracting hepatitis A.  Hepatitis A is endemic in some parts of the world and travelers to those areas are at increased risk. 

          Signs and symptoms include malaise, jaundice, nausea and poor appetite which develop two to three weeks after contact with the virus.  Some patients will develop dark, coca cola colored urine and light stools.  A blood test for an antibody to the virus confirms the disease.  Hepatitis A does not become chronic and patients develop immunity after having the infection.  There is a vaccine to prevent Hepatitis A which consists of two injections given 6 months apart. 

Hepatitis B 

          Hepatitis B was formerly called serum hepatitis before it was known that it could be spread a number of ways, including by sexual contact, sharing of contaminated needles by drug users, accidental needle sticks and blood transfusions, as well as from mother to newborn.  Many young people today are not aware that hepatitis B (and hepatitis C) can be spread by tattoos, body piercing and by sharing razors and toothbrushes.  Approximately one quarter million individuals in the United States develop hepatitis B each year. 

          Approximately one to four months after exposure, patients develop symptoms similar to those noted above for hepatitis A.  Diagnosis is confirmed through blood tests for antibodies to the virus, but interpretation of these tests can be complicated.  For most patients, the infection clears by six months, but approximately 10% will develop chronic infection lasting beyond six months.  These patients are at risk of cirrhosis, liver failure and liver cancer and remain infectious as long as they have the virus in their blood.  It is estimated that 200 to 300 million individuals throughout the world have chronic hepatitis B.  

          Management of hepatitis B consists of close monitoring, treatment of complications, antiviral therapy and liver transplantation, when necessary.  Hepatitis can now be prevented by vaccine, which is recommended for all newborns, as well as children and adolescents who did not receive it previously, and others at risk for contracting hepatitis B. 

Hepatitis C 

          Most individuals with hepatitis C are not even aware that they have it.  It is thought that two thirds of those in the United States with the disease are baby boomers who shared contaminated needles while using drugs twenty to thirty years earlier.  Some individuals with this infection may have only used IV drugs on one occasion many years previously.  During the ensuing years after initial exposure, the virus slowly and steadily damages the liver.  Hepatitis C is now the most common blood borne infection in the United States with nearly four million individuals infected and 170 million worldwide.  

          Most individuals infected with this virus have no symptoms, even though they do not clear the virus from their bloodstream.  Approximately 85% will develop chronic infection and can pass the infection on to others.  Of these, approximately 25% will develop cirrhosis over the next twenty years.  Approximately 5% of these patients will develop liver cancer each year.  

          Hepatitis C used to be called non-A, non B hepatitis before the hepatitis C virus was identified.  An antibody test now confirms the diagnosis and is used for screening those at risk for the infection.  In addition to anyone who has ever injected illegal drugs, others at risk include health care workers who have sustained accidental needle sticks, those on hemodialysis, those who received blood transfusions before 1992 when the screening test became available and babies born to infected mothers.  Transmission through sexual contact is thought to be rare.  Young people with tattoos and body piercing are at higher risk of having hepatitis C. 

          Treatment consists of interferon and ribavirin which clears the infection in about 40% of cases depending on the genotype, but not without significant side effects.  Hepatitis C is the leading cause for the need of liver transplantation.  Recently, several new drugs have shown promise in the treatment of hepatitis C.  Patients with the infection should avoid alcohol and other agents that can damage the liver.  If you fall into one of the categories for those at risk of harboring this insidious infection, check with you personal physician to discuss whether you should be screened with the antibody blood test for hepatitis C.

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Liver Disease

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Overview 

          In the previous article we reviewed some of the important functions that the liver performs and now have a better understanding of why the liver is considered a vital organ.  It makes sense that because the liver does so many things, there are many things that can go wrong.  Hepatitis is a general term essentially meaning inflammation of the liver and indicates some type of liver injury.  Often the first indication of liver injury will be elevation of the liver enzymes on routine blood testing, as discussed in the previous article.  Further testing would then be required to determine if the problem is due to liver cell injury (hepatocellular injury) or due to a problem with bile flow (cholestatic injury).  If the liver disorder has been present for less than six months it is considered acute hepatitis and if longer than six months it would be considered chronic hepatitis.  Signs and symptoms of liver disease can include general malaise, weight loss, fatigue, nausea, jaundice and pain in the right upper quadrant.  Some of the less common liver disorders include: 

Autoimmune Hepatitis         

          Autoimmune hepatitis is a rare condition occurring mostly in females and is caused by the immune cells attacking normal liver cells.  It is often associated with other autoimmune diseases like thyroiditis and can lead to cirrhosis.  Most patients are asymptomatic, but some may have malaise, rash or arthralgias (joint pains).  Severe cases are treated with prednisone. 

Metabolic Liver Disease

          Fatty Liver Disease describes a condition where fat accumulates in the liver, accompanied by inflammation and fibrosis.  This condition has increased in frequency to the point where it is becoming one of the more common forms of liver inflammation.  It is more common in individuals with obesity, insulin resistance, hypertension and hyperlipidemia.  Treatment consists of controlling these factors.

          Wilson Disease is a rare condition characterized by accumulation of copper in the liver.  This genetic disorder results in decreased excretion of copper into the bile.  Copper accumulates in the liver and also in other tissues such as the brain and the eye, which can lead to neuropsychiatric symptoms.  Treatment is based on reducing copper overload.  Relatives of patients with Wilson Disease should be screened for this disorder so that intervention can begin before the disease progresses.

          Hereditary Hemochromatosis is a fairly common genetic disorder occurring in Caucasians which results in accumulation of iron in the liver, heart, pancreas and other organs.  It can lead to cirrhosis, heart disease and diabetes.  Treatment is by frequent phlebotomies (withdrawing blood) to remove excess iron. 

Cholestatic Liver Disease

          Primary Biliary Cirrhosis is another autoimmune disease affecting mostly women.  The most common presenting symptoms are fatigue and pruritis (itching).  It is a slowing progressing disorder that can lead to malabsorption of vitamins, hyperlipidemia and osteoporosis.  While some new medications have been tried, management consists mostly of symptomatic treatment.  Some patients may eventually require liver transplantation.

          Primary Sclerosing Cholangitis is characterized by bile duct inflammation and eventually destruction of the bile ducts leading to cirrhosis.  It is more common in men and occurs in the fourth or fifth decade of life.  There is a strong association with ulcerative colitis, which is present in 80% of patients with this disease.  Signs and symptoms include fatigue, pruritis and eventually jaundice.  This condition can also lead to malabsorption of vitamins.  There is no specific treatment and the disease often progresses to cirrhosis.  Patients who undergo liver transplantation usually do well. 

Coming Next 

          In the upcoming articles in our series on the liver, we will look at the more common liver diseases, including viral hepatitis and alcohol or toxin induced liver disease and, finally, we’ll review some of the complications of liver disease and take a look at liver transplantation as a treatment for advanced liver disease.

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