Let's get going on our stuff

Sorry about this being a title that sat with no other info. I didn't know that was going to happen like that.
Well, I have finally done it. After much urging from my wife about how I should make some paper surveys and send them around to people I have finally completed some.
There are two versions, one with just OTC painkillers - by far the most popular survey I have done to date - and one with my personal interest, neuro meds. I have called a local Neurologists office to send out some feelers and see if they are interested in taking a look at the surveys and letting their patients fill them out for me.

Hopefully this will bring good things. I have no doubt that the OTC surveys will bring up some numbers. Especially because I can pass those out in some of my classes and get people to fill them out right there and then collect them at the door. That is my advice of the day, make some paper surveys and pass them out.

Just waiting for approval from my wife and from the directors of the internship. Hopefully I have these bad boys hot off the presses by tomorrow.

Time for me to get some lunch!

Sorry, we don't allow any B.L.T.s

In addition to seeing traumatic injury and neurological dysfunction we also work with patients that need orthopedic care. One of the most common surgeries that we see, at least post-operatively, is a spinal fusion.
If any one has had contact with this, or any, type of spinal surgery then you know it is a very invasive, complicated and painful surgery. For some reason the orthopedic surgeons usually choose to do spinal fusions on adolescents. This is good for the patient for several reasons, but usually translates into difficult care because of how these patients react to the surgery.
Pain Service - the folks that administer and track the use of pain medicines, usually the hard-core narcotic stuff - used to just place a single epidural, basically a needle is placed in the spinal nerves were pain medication is administered, this often resulted in a lot of pain for both the patient and the care staff.
Recently, however, they have started placing two epidurals and that has resulted in much lower pain levels which eases anxiety and increases the patients ability to recover. http://www.or-live.com/distributors/NLM/rnh.cfm?id=321 - this link is to a real surgery video for a spinal-fusion on an adolescent. It was interesting and informative to watch, but it is not for everyone for obvious reasons.

After thinking about this situation I decided to look into what it is that is being administered to the patient through the epidural line. Often the medication of choice is known as Fentanyl. Often Fentanyl is paired with another analgesic known as Bipuvacaine, but we can only focus on one drug due to my time and length restrictions. With these ideas in mind, this weeks 'DotW' feature is going to be about Fentanyl.
Let us begin, as always, with the organic molecule:


Fentanyl has gotten a lot of press lately due to the fact that several deaths have resulted from overdose in the past little while.

Fentanyl is an analgesic of high potency, approximately 300 times that of morphine...The first CsA (case of abuse) of fentanyl came to the attention of law enforcement in late 1979 but was not identified until 1981. In the next three years a procession of new fentanyl CsA's appeared in the illicit drug market. The abuse of fentanyl CsA's peaked in 1985 and has since decreased dramatically, a phenomena which was the result of DEA successfully terminating the operation of the responsible laboratories. However, the ripple effect is still being felt as international and national meetings have been held to discuss the problems presented by CsA's.
(http://designer-drug.com/synth/index.html)

Fentanyl is used illegally for a feeling of intense happiness that is provided by narcotics such as fentanyl. However this feeling is often followed by some of the negative side effects listed below. Another reason that fentanyl is bad to use illegally is because it is highly addictive. Since it is taken most often using a shot, when used illegally some of the transmitted diseases such as AIDS and hepatitis can be transmitted as well.

Fentanyl falls under the category of narcotic analgesics, this means basically that it is a pain reliever that relieves pain without the patient losing consciousness. Another narcotic analgesics include morphine and oxycontin. Fentanyl is used in two major ways: by taking orally or by using a patch.
(http://web1.caryacademy.org/chemistry/rushin/StudentProjects/CompoundWebSites/2004/fentanyl/Uses.htm)

Shortly after its discovery in 1960, another form of fentanyl was discovered that is widely used today and that is fentanyl citrate. Fentanyl citrate allows for patients to have fast pain relief, up to 80 times that of morphine, by simply sucking on a "lollipop". This lollipop however is supposed to be bitter.
(http://web1.caryacademy.org/chemistry/rushin/StudentProjects/CompoundWebSites/2004/fentanyl/History.htm)

It is also possible to snort or smoke Fentanyl for the desired effect. Fentanyl is a dangerous drug in the wrong hands because it is similar to the drug heroine in its uses and in its addictiveness.

The way in which I see Fentanyl administered is through an epidural line in the patient. It is often combined with another medication known as Bipuvacaine. When it is administered in this way it looks like a thick almost syrupy liquid. The Fentanyl is in small plastic bags - think of a small IV bag - and then placed in a device known as a PCA or Patient Controlled Analgesic. These are the pumps that allow the patient to press a button for a demand dose of pain control.
When only one epidural was placed the number of times the button was pressed was relatively high - there is a lockout function on these pumps so that the patient does not accidentally overdose on the pain med by pressing the button too many times. Now, with the advent of the double epidural I have seen little to no usage of the pain button, pain seems to be under control.

Stiff as a board

Hello once again. Well, time is winding down now. The scramble for me to get those last 70+ surveys is on. I have definitely learned a thing or two about public opinion based things. Additionally I have learned a thing or two about follow-up. It is not enough to trust that someone is doing what you asked them to do; you must follow-up and make sure that it has been done or is getting done. Also I need to stress the fact that multiple surveys are OK, in fact they are encouraged.
Overall though this has been a good experience, I am glad I did this thing.

So, on to the 'DotW' feature. Last night I sat with an adolescent male who needed constant attention - actually he was pretty stable, I sat and watched TV and studied organic chem for 12 hours - so that he would not yank out his g-tube. A g-tube or gastric tube is a tube that is placed in the stomach from the outside and held in it's location via an inflatable balloon. G-tubes are placed so that a patient who is not eating, or is at high risk for aspiration - putting fluid into your lungs by not swallowing properly - can still get the nutrition they need via a fortified liquid. Early yesterday it seems that he was able to completely yank the thing out on his own, that must HURT! It is also very surprising to me that he was able to pull the thing out because I have been on this watch assignment before, a lot in fact, and have yet to see one come all the way out despite the amount of times it gets yanked on.
Anyway, long story short, this kid was in the hospital this time for placement of a Baclofen pump.

This has got me thinking, and today's feature drug shall be: Baclofen!
Like always we will begin by looking at the organic molecule:

I think this is the first instance of where I have used the generic name first. The brand name of Baclofen is Lioresal. Baclofen is used to treat muscle spasticity and is basically a muscle relaxer. It is generally available as a white pill, but sometimes a pump is placed in the patient and a catheter is inserted into the spinal column, or intrathecal space.
(http://www.drugs.com/baclofen.html)

Personally I have seen both the oral dose and the pump version. The cool thing about the pump version is that because the drug is being delivered at the nerve site it can be administered in terms of micrograms instead of milligrams. The nurse who works in the clinic at my hospital is a friend of mine and she has explained all of this stuff to me. I have also held one of the pumps, they are solid metal - about the size and shape of a hockey puck - with a silicon part in the middle - sort of about where the hole of a donut might be - and one side there is a triangle shaped silicone piece that holds the catheter in place.
Here is a picture of one:
This webpage is full of interesting information about Baclofen pumps. They call them ITBs or intrathecal baclofen therapy.
Here is another picture showing the pump once inserted into a patient:
This particular picture is oriented so that the pump is slightly above the right hip of the patient.

The second image is an animation of how the pump is positioned in the body

There is a bump - once again about the size of a hockey puck - that is visible under the skin of the patient. Clicking on the color picture will show the curious person the actual procedural pictures of a spinal fusion and insertion of a baclofen pump. I think it's pretty cool, but the more squeamish should be spared my medical curiosity.
Baclofen is a very effective medication at treating spasticity or spasms. After severe head trauma or when a person has decreased neurological function is when I have typically seen these inserted. The reason why spasticity is an issue after trauma or with decreased function was explained to me this way; the muscles in the body want to be contracted all of the time; the brain basically blocks out those signals and filters them so they can be controlled for autonomous muscle use. When the brain is impaired it no longer is able to filter out those signals like it once did. Baclofen therapy is also useful for persons who are suffering from MS. My wife's cousin is suffering from complications of MS and is really hoping to get a pump inserted to help with her spasticity and spasm issues.

According to: http://www.southshoreneurologic.com/clinical/itb/itb-results1.html there is a statistical significance in the amount of persons on baclofen and a decrease in their spasticity and spasm levels. On one of the tables they state that 168 patients were included in the study and spasticity was abolished 97% of the time; muscle spasms were abolished 98% of the time; bladder function was restored or improved 78% of the time and overall function was improved 70% of the time.


In addition to it's use as a muscle relaxer it seems that baclofen can be used to block the addictive effects of cocaine usage; at least in female rat populations. This is interesting though because it might have future benefit in therapy as an agent to help individuals who are struggling with addiction. (http://www.drugabuse.gov/NIDA_notes/NNVol17N6/Animal.html)

I am sorry for the brevity of this post. Once again I have bit off a bit more than I can chew with this feature drug. I would love to discuss all of the information I have found and the incredible resources I have by knowing the staff who maintain and install these devices, but time is forever against me. If you are interested in learning more any of the links provided should be more than sufficient.
Personally I think this drug is unbelievably helpful in the lives of people who are dealing with anything from complications of severe head trauma to MS.

The Intractables

Today I am unsure what to talk about. I have honestly not thought much about my blog this week. In weeks past I have attempted to blog several times during the week, but because I am now in the last few weeks of my semester at school time has been a bit of a luxury.

Surveys seem to be going well. I have posted a large amount of fliers on the second half of my school's campus and there seems to be a good response. The best way I have found to make sure surveys get done is to talk to people directly. If you are there with a computer they are a lot less likely to say they will do surveys and then never quite get around to it. Also I need to talk to my neighbors in my apartment complex. Direct communication there will also be helpful for making sure that surveys are being completed.

Like always a lot of thought has gone into picking the 'DotW' feature for this post. In the last few weeks at work we have had a large amount of kids who are sick with RSV or Bronchiolitis. Now it seems that those numbers are decreasing as the season for those illnesses is passing and we are getting our regular kids again.
Along with getting our regular patient load we have gotten patients who have severe headaches. One of the most common treatments that I have seen for intractable headaches is administration of a medication known as D.H.E. 45

So, this weeks feature shall be: D.H.E. 45, or dihydroergotamine mesylate
The organic molecule is:
Yes, that is a rather complicated molecule; lots of sights of possible action. For example the empirical formula, the most simple way of writing this thing down, is: C33H37N5O5·CH4O3S.

Needless to say the mechanism is a little complex. I would need about two years more neurological biology to fully understand it myself. There are two proposed ways in which this medication molecule functions to calm down headaches, or migraines - I know that migraines are different from normal headaches because I have suffered from them, but for the purposes of this blog we will just say they are the same as intractable headaches. The first is by neurological vaso-constriction - making the blood vessels in your brain smaller - and the second is by inhibiting the release of an inflammatory substance known as neuropeptide. D.H.E. 45 is administered through IV or through subcutaneous injections. There have been some heart complications and there have been no studies to determine what, if any, other long term effects this medication has on the body. For additional, and more complicated, explanations of this drug visit: http://www.drugs.com/pro/d-h-e-45.html

Personally, due to my experience with migraine headaches, I believe that this medication acts as a vaso-constrictor. Not for any medical reason, but because when I have taken drugs that act on that end of fixing the problem I have gotten better. Typically when I have seen D.H.E. 45 administered the child is in the hospital for about a week and they are kept in a dark quiet room over the length of their stay. Sometimes this is very successful, and sometimes it is not successful at all. Seems to be rather hit and miss in my opinion.

Do I look bloated to you?

Hello. This past week has been an interesting one. I have not really done any homework since I got back from Spring Break. The laziness has been nice, but it has certainly increased my stress level.

This week I would like to make a departure once more. This past Tuesday I attended a funeral for my wife's grandfather. He died of natural causes after a long fight with heart failure. This forum is not appropriate to discuss the nature of my beliefs about the soul of man, but I do not believe that he is gone forever. When I too die I will no doubt be reunited with those who have preceded me to the next stage of existence. That is all I have to say about that.

Due to this experience I have chosen to focus on a medication that is often administered for the person who is enduring the complication of heart failure. This is especially relevant as I did a survey for this medication just yesterday as I spoke with a co-worker.
This weeks 'DotW' feature will be: Lasix, or Furosemide.
Here is a molecule of Lasix, also known as Furosemide. Using my limited understanding of chemistry, even though that is going to be my minor, I can see several sites where a possible reaction could occur. This molecule looks rather reactive.

Lasix is a form of Diruetic. Basically what this means is that it causes your body to loose fluid.
According to www.rateadrug.com:

Furosemide

Furosemide (INN) or frusemide (former BAN) is a loop diuretic used in the treatment of congestive heart failure and edema. It is most commonly marketed by Sanofi-Aventis under the brand name Lasix. It has also been used to prevent thoroughbred race horses from bleeding through the nose during races.Along with some other diuretics, furosemide is also included on the World Anti-Doping Agency's banned drug list due to its alleged use as a masking agent for other drugs.

That is a rather succinct summation of what Lasix is. Now, however, we must look at what a loop diuretic is.
This a graphic that explains the mechanism of absorption and action through which Lasix acts.

As you look through the mechanism you can see that Furosemide is labeled in the fifth group of actions going from left to right. There are a lot of ways that your body can have a diruetic agent act upon it.
Each type of medication works in a different part of the Nephron. The Nephron is the functional structure and basic unit of the Kydney (http://en.wikipedia.org/wiki/Nephron). The above picture is a simplified version of a Nephron.

Each class of diuretics has a distinct site of action in the nephron...Furosemide (Lasix), bumetanide (Bumex), ethacrynic acid (Edecrine) and torsemide (Demadex) work in the loop of Henle. (http://www.cmellc.com/geriatrictimes/g010327.html)

With the help of www.drugs.com we learn that a loop diruetic is essentially a 'water pill' that does not allow your body to absorb salt and instead passes that salt through your urine.

Diuretics are actually compounds that increase the urinary salt excretion, and water just happens to come along...Chemically, diuretics are organic anionic compounds.
-Christian W. Mende M.D. (http://www.cmellc.com/geriatrictimes/g010327.html)

Like most medications there are a number of cases in which it may be prescribed. I have chosen to discuss Lasix as they are used in the treatment of the heart failure patient, but the list of possible doses is, but is not limited to: congestive heart failure, kydney disorder, hypertension and liver disease (http://www.drugs.com/lasix.html). Additionally there are cases in which a medication such as Lasix is used to treat the symptoms of a different drug therapy. No specific instances come to mind, but a chain of drugs meant to relieve the symptoms of a first medication is not at all uncommon.

Now we have reached the end of our discussion on Lasix. Thank you for coming. As I ponder on the current status of medicine and pharmacology I find myself thinking that we have come a long way. The fact that my wife's grandfather was able to live as long as he did after he had his first surgery was nothing short of miraculous. That is due to prayers on his behalf and due to the advances in modern medicine that we all take for granted.
There is much more work to be done though.
I wish the best of luck to those who are working even now to improve the absorption pathways and better understand the human anatomy.