5 March 2001

1. ? Fake Fainting
2. Sonar to Zap Cancer?
3. Dermatologist to Diagnose Rash
4. A Variation of Normal is Normal
5. Coral Injuries
6. L-Glutamine Supplementation
7. Disclaimer

• Read Questions & Answers in Another Column

? Fake Fainting

I have only one question, which I cannot find an answer for anywhere. I have read many articles on fainting.

I believe I have a "fake" fainting going on and I need to know. When he fainted, he was laying on his stomach, and his eyes were wide open, staring straight ahead. The eyes didn't twitch, blink, flutter or anything. He looked "dead". His breathing was very quiet and still-like. I have seen, and have fainted before..and the eyes always close, or roll back etc... If you could please let me know, so I know what I am dealing with (could be an attention getter), I would appreciate this very much.

Thank you

-TO

Dear TO: Whether or not a patient's eyes are open or closed cannot be used as a criterion to determine if he is conscious, has fainted, or had a seizure. If the patient has multiple fainting episodes where he always falls flat on his stomach and yet never injures himself, you certainly could be suspicious. Add to your suspicion if the child appears to be delighted about these spells rather than upset.

Your query does not have enough details such as the frequency of these episodes, how long they last, the child's response to the episodes, how alert he is afterward, the circumstances under which these spells occur, whether or not the child tends to seek attention or is hypochondriacal, etc. for me to be sure. I would have to suggest the child at least have an evaluation by his pediatrician since multiple fainting episodes could be serious and you can't be sure the boy is faking it.

Sincerely,
Dr. Warren

Sincerely,
-KT

Dear KT: I hadn't heard anything about dolphins zapping cancer cells in other dolphins using sonar. My first question, if it's true, is how do the dolphin's know where to zap if the cancer isn't visible? If your information is correct, I'm sure medical scientists are already working on finding answers to that question and learning how to mimic the dolphin's cancer zapping ability.

In answer to your question, getting a stone to disintegrate requires a different kind of energy. The solid, non-flexible nature of the stone makes it more fragile than a cell. If you get hit in the head with a rubber ball, it causes you less injury than if you get hit by a china plate, but if you drop them both on the ground, the plate shatters and the ball is not harmed at all. These differences are a result of the differences in the material the two items are made of. Vibrating a stone with just the right frequency of sound wave can make it crack without damaging the tissue around it. On the other hand, even though cancer cells are different from normal cells, they are not so different that you could reach them with sound waves intense enough to destroy them without damaging healthy tissue. Although some degree of damage to healthy tissue would be acceptable in the management of cancer (since chemotherapy and radiation certainly damage healthy tissue), damaging cells with sound waves is not as easy as dissolving a stone because the stone is more fragile even though (and probably as a result of the fact that) it is harder than a cell.

If the growth plates on your long bones have fused you cannot grow anymore. If you haven't grown for a few years and your body is fully mature, chances are your growth plates are fused. If there is any question about that, x-rays can determine if your growth plates are fused, or if you have any more growth potential (which is unlikely since you haven't grown in 3 years).

Even though your weight is in the normal range for a 16 year old, it is at the lowest end of the normal range. With your height below the 5th percentile, this could be too much weight for you, but if you are muscular and/or have a large bones structure, your weight may be fine. You are certainly not obese, so the best question is how do you look? If you don't look overweight, as long as you're not gaining weight (you shouldn't gain if you're not growing) your weight is fine.

Sincerely,
Dr. Warren

-ST

Dear ST: As you know from reading other letters about rashes, it can be very difficult to make a diagnosis without seeing the rash. Given that other physicians who have seen the rash haven't given you an answer, I doubt I could do better without seeing it. Without a diagnosis, I can't recommend treatment. One thought comes to mind. If your trip to Children's Medical Center brought you to an emergency room, you may have seen some of the best doctors for dealing with a crisis, but they may also have been some of the least experienced doctors with non-urgent diagnostic problems. Your son should see a pediatric dermatologist.

Sincerely,
Dr. Warren

-W

Dear W: The routine blood work which suggested your friend's daughter had been fighting an infection was also reported as normal. The prior blood work was about a year ago. But if it was also considered normal, the suggestion that it indicated she might have been battling an infection can't be taken as meaning anything since it may be the child's norm. I could explain in more detail only if I had the actual results of the blood work to review. If there is any question about the significance of the blood work, follow up testing can help clarify the issue.

An x-ray which shows a variation of normal is a normal x-ray and does not tell anything about what is causing the child's limp. I might be able to clarify this more if I knew what "variation" was seen.

The bottom line is that a persistent limp needs further evaluation. The child should see an orthopedist.

Sincerely,
Dr. Warren

-EBC

Dear EBC: Until I received your question about coral puncture wounds, it never occurred to me that there was anything special about them. In twenty years as a pediatrician I have not had the occasion to see any kids who were injured during deep sea diving. Since I know nothing about them, to answer your question I found the following information in Rakel: Conn's Current Therapy 1998, 50th ed., Copyright © 1998 W. B. Saunders Company in the Chapter written by PAUL S. AUERBACH M.D., M.S. from Stanford University School of Medicine Stanford, California in an article about HAZARDOUS MARINE ANIMALS:

STONY CORALS

True (stony) corals exist in colonies that possess calcareous outer skeletons with pointed horns and/or razor-sharp edges. Snorkelers and divers frequently handle or brush against these living reefs, inflicting superficial cuts and abrasions on the extremities. Coral cuts are probably the most common injuries sustained under water. The initial reaction to a coral cut is stinging pain, erythema, and pruritus, most commonly on the forearms, elbows, and knees. Divers without gloves frequently receive cuts to the hands. A break in the skin may be surrounded within minutes by an erythematous wheal that fades in 1 to 2 hours. "Coral poisoning" describes these red, raised welts and local pruritus. Low-grade fever may be present and does not necessarily indicate an infection. With or without prompt treatment, this may progress to cellulitis with ulceration and tissue sloughing. These wounds heal slowly (3 to 6 weeks) and result in prolonged morbidity. In an extreme case, the victim develops cellulitis with lymphangitis, reactive bursitis, local ulceration, and wound necrosis.

Coral cuts should be promptly and vigorously scrubbed with soap and water, then irrigated copiously with a forceful stream of freshwater or normal saline to remove all foreign particles. It is occasionally helpful to use hydrogen peroxide to bubble out "coral dust." Any fragments that remain can become embedded and increase the risk for an indolent infection or foreign body granuloma. If stinging is a major symptom, there may be an element of envenomation by nematocysts. A brief rinse with diluted acetic acid (vinegar) or isopropyl alcohol 20% may diminish the discomfort (after the initial pain from contact with the open wound). If a coral-induced laceration is severe, it should be closed with adhesive strips rather than sutures if possible; preferably, it should be debrided for 3 to 4 days and closed in a delayed fashion.

There are a number of approaches to take with regard to wound care. The first (preferred) is to apply twice-daily sterile wet-to-dry dressings, using saline or a dilute antiseptic (povidone-iodine solution, 1 to 5%). Alternatively, a nontoxic topical antibiotic ointment (bacitracin or polymyxin B-bacitracin-neomycin [Neosporin]) may be used sparingly, the wound covered with a nonadherent dressing (Telfa), and secondary infections dealt with as they arise. A less often utilized approach is to apply a full-strength antiseptic solution, followed by a powdered topical antibiotic, such as tetracycline powder. No method has been supported by a prospective trial.

Despite best efforts, the wound may heal slowly, with moderate to severe soft tissue inflammation and ulcer formation. All devitalized tissue should be debrided regularly using sharp dissection. This should be continued until a bed of healthy granulation tissue is formed. Wounds that appear infected should be cultured and treated with antibiotics as previously discussed.

The patient who demonstrates malaise, nausea, and low-grade fever may be suffering from a systemic form of coral poisoning or be manifesting early signs of a wound infection. It is prudent at this point to search for a localized infection, procure a wound culture(s) or biopsy as indicated, and initiate antibiotic therapy pending confirmation of the organisms. If the patient is started with antibiotic therapy and does not respond, a supplemental trial of systemic corticosteroids (prednisone 60 mg tapered over 2 weeks) is not unreasonable. In the absence of an overt infection, the natural course of the affliction is spontaneous improvement during a 4- to 12-week period.

Sincerely,
Dr. Warren

I was wondering if you could answer a question about marine infections and secondary post infections? If you had embedded coral sutured in wound, would this be the cause of developing a marine infection (Cellulitis & nectrotic tissue..gangrene)? Would this also cause secondary infections? This article is about Strep... which can cause Cellulitis and can lead to kidney infections and other secondary infections... Just wondering if this is why I am so sick right now.............

The main reason I am concerned about my health is that I was diagnosed with Congenital Hydronephrosis (chronic UPJ obstructions) which required 4 alternative surgeries that did not work, and I ended up having an operation (Pyeloplasty) done last year. Post surgery said I have 39% vs 61% use of my kidneys........ while being treated for necrotic cellulitis, I had another renal scan, which basically said I have not changed since my post surgery scan... I still only have 39% vs 61% use of kidneys..... And after recovering from the necrotic Cellulitis, I have developed 2 kidney infections... and also been diagnosied with IBS (irratible bowel syndrom). I am wondering if these infections are somehow inter related, and that is why I am so sick right now. I was on Flagyl for the IBS, but they wern't working becuz of the kidney infection, so my urologist put me back on Cipro.... in the meantime, next week I have to have an IVP test done to find out why I am in such pain and what is going on with my kidneys...

I am really concerned about my health because of my kidney problems, and was just wondering if all these infections are inter related to having cellulitis and gangrene.

Thanks !

-EBC

Dear EBC: From reading your current inquiry, I'm not sure if it was sent before or after I replied to your previous inquiry. As stated in my response, which I trust you have received by now, I have no first hand knowledge of coral injuries. The information I sent you is what I could find.

The article suggested closing lacerations with adhesive rather than suturing and provided information on wound care. Any foreign body closed into a wound could potentially increase the risk of infection although, if the material is inert and the wound clean, the risk is small. The problem is that coral is a living organism (not just the dry shell most people are familiar with). The coral produces toxins and the reaction to organisms causes tissue damage. The tissue damage caused by coral significantly increases the risk of infection.

Strep is certainly a potential cause of cellulitis from any injury including coral, but it is not the only one. Glomerulonephritis is a specific complication of strep which causes blood in the urine (it usually looks like cola) and a temporary decrease in kidney function with high blood pressure and edema. Glomerulonephritis is NOT a kidney infection.

Unless you were septic (bacteria in your blood stream) from a coral infection, I cannot see how it would contribute to kidney infections, although a persistent cellulitis could conceivably periodically seed the blood stream with bacteria which, on being filtered through the kidneys might cause an infection. Since the article did not address the issue of any effects on the kidneys, I can't state with certainty whether your complaints are related. There was no specific mention of IBS in the article, and I'm not aware of any relationship with coral injuries.

Major illnesses tend to have an adverse effect on the immune system and sometimes on other organ systems. During recovery patients often find that they have a higher incidence of other, unrelated illnesses than usual; however, most patients eventually return to their prior pre-illness state.

Sincerely,
Dr. Warren

-Billy

Dear Billy: L-Glutamine is marketed as a nutritional supplement, not as a drug. As such, it is subject to less scrutiny from the FDA with regards to its claims of possible benefits. It does have to meet certain safety standards in order to be marketed.

I'm trying to be objective in providing you with information, but I do have a bias. It is my belief that the best nutrition for athletes comes from a healthy diet. There are lots of articles written by the sales staff for these supplements. You can even find them on the Web. The articles are full of hype about these special sports supplements. Their glossy pamphlets are full of testimonials, but these don't constitute proof. Nobody questions whether or not your body requires some of the ingredients in these supplements, but where is the evidence that these concoctions provide any benefit over getting the same ingredients from a healthy diet.

I am including the abstracts of three articles below. If you find the abstracts difficult to follow, don't worry. I have included a summary and commentary after each.

1. Nutrition 1997 Jul;13(7-8):738-742 The effects of oral glutamine supplementation on athletes after prolonged, exhaustive exercise. Castell LM, Newsholme EA University Department of Biochemistry, Oxford, United Kingdom.

   Athletes undergoing intense, prolonged training or participating in endurance races suffer an increased risk of infection due to apparent immunosuppression. Glutamine is an important fuel for some cells of the immune system and may have specific immunostimulatory effects. The plasma glutamine concentration is lower after prolonged, exhaustive exercise: this may contribute to impairment of the immune system at a time when the athlete may be exposed to opportunistic infections. The effects of feeding glutamine was investigated both at rest in sedentary controls and after exhaustive exercise in middle-distance, marathon and ultra-marathon runners, and elite rowers, in training and competition. Questionnaires established the incidence of infection for 7 d after exercise: infection levels were highest in marathon and ultra-marathon runners, and in elite male rowers after intensive training. Plasma glutamine levels were decreased by approximately 20% 1 h after marathon running. A marked increase in numbers of white blood cells occurred immediately after exhaustive exercise, followed by a decrease in the numbers of lymphocytes. The provision of oral glutamine after exercise appeared to have a beneficial effect on the level of subsequent infections. In addition, the ratio of T-helper/T-suppressor cells appeared to be increased in samples from those who received glutamine, compared with placebo.

   Essentially, this article says that their is some benefit to the immune system in taking L-Glutamine. There is a concern that heavy exercise depletes L-Glutamine putting athletes at greater risk for infection after vigorous training or competition. The article does not say that L-Glutamine enhances exercise or endurance or increases muscle mass.

2. Am J Physiol 1997 Jul;273(1 Pt 1):E122-E129 An abundant supply of amino acids enhances the metabolic effect of exercise on muscle protein. Biolo G, Tipton KD, Klein S, Wolfe RR Department of Metabolism, Shriners Burns Institute, Galveston, Texas, USA.

   Six normal untrained men were studied during the intravenous infusion of a balanced amino acid mixture (approximately 0.15 g.kg-1.h-1 for 3 h) at rest and after a leg resistance exercise routine to test the influence of exercise on the regulation of muscle protein kinetics by hyperaminoacidemia. Leg muscle protein kinetics and transport of selected amino acids (alanine, phenylalanine, leucine, and lysine) were isotopically determined using a model based on arteriovenous blood samples and muscle biopsy. The intravenous amino acid infusion resulted in comparable increases in arterial amino acid concentrations at rest and after exercise, whereas leg blood flow was 64 +/- 5% greater after exercise than at rest. During hyperaminoacidemia, the increases in amino acid transport above basal were 30-100% greater after exercise than at rest. Increases in muscle protein synthesis were also greater after exercise than at rest (291 +/- 42% vs. 141 +/- 45%). Muscle protein breakdown was not significantly affected by hyperminoacidemia either at rest or after exercise. We conclude that the stimulatory effect of exogenous amino acids on muscle protein synthesis is enhanced by prior exercise, perhaps in part because of enhanced blood flow. Our results imply that protein intake immediately after exercise may be more anabolic than when ingested at some later time.

   This article addresses intake of all proteins, not just the amino acid L-Glutamine. It essentially says that protein stimulates muscle protein synthesis (and presumably growth) and that it does it better if taken immediately after exercise. The article does not state anything about increasing endurance if taken before exercise.

3. Sports Med 1996 Feb;21(2):80-97 The emerging role of glutamine as an indicator of exercise stress and overtraining. Rowbottom DG, Keast D, Morton AR Department of Microbiology, University of Western Australia, Perth.

   Glutamine is an amino acid essential for many important homeostatic functions and for the optimal functioning of a number of tissues in the body, particularly the immune system and the gut. However, during various catabolic states, such as infection, surgery, trauma and acidosis, glutamine homeostasis is placed under stress, and glutamine reserves, particularly in the skeletal muscle, are depleted. With regard to glutamine metabolism, exercise stress may be viewed in a similar light to other catabolic stresses. Plasma glutamine responses to both prolonged and high intensity exercise are characterised by increased levels during exercise followed by significant decreases during the post-exercise recovery period, with several hours of recovery required for restoration of pre-exercise levels, depending on the intensity and duration of exercise. If recovery between exercise bouts is inadequate, the acute effects of exercise on plasma glutamine level may be cumulative, since overload training has been shown to result in low plasma glutamine levels requiring prolonged recovery. Athletes suffering from the overtraining syndrome (OTS) appear to maintain low plasma glutamine levels for months or years. All these observations have important implications for organ functions in these athletes, particularly with regard to the gut and the cells of the immune system, which may be adversely affected. In conclusion, if methodological issues are carefully considered, plasma glutamine level may be useful as an indicator of an overtrained state.

   This article basically states that over-exercise depletes glutamine and therefore measuring glutamine levels can be used to as an indicator of exercise stress and overtraining. The article states that glutamine is important to many bodily functions and that glutamine levels may remain low in athletes for prolonged periods after overtraining. The article does not state that this can be reversed by glutamine supplementation, although, in combination with the other articles, that is implied. Nonetheless, the article does not indicate anything even in combination with the other articles which would prove that glutamine enhances training.

Sincerely,
Dr. Warren

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