Deer are a major road hazard around here. One of the local body shops apparently sees the results of a number of car vs deer incidents. They have an ad that plays out a scenario complete  with *crash* bang* smash* noises.

It ends with: “And remember, venison goes best with a nice baked potato.”

For my local radio station.

Like your mother always said, if you play with your knob too much, it’ll fall off.

The local tradition, with baby boys, is to have them circumcised. I don’t have strong feelings about this one way or the other: I know what the research says about HIV and STI rates, and I think this research is very flawed, and is being conducted by people who have a political agenda. I know about the people who want their foreskins back and equate it to female genital mutilation, and I think these people are missing something other than a small piece of skin.

There are likely a few reasons for the local preference:

Local penile hygeine is possibly suspect (here we have a group of people who have casual and dress-up sweatpants, and for whom underwear is optional), so women may have had a few bad experiences with unkempt foreskins.

Families are often split, so mothers don’t necessarily know how to care for a foreskin.

The father is often circumcised and “I just want him to look like his dad.”

And obviously there is the odd horror story about infected foreskins, but I think may of these are urban legends.

At any rate, it’s commonly done. When asked about it, I provide all the information and a referral to someone who performs this procedure. I explain both sides and I try to give a balanced view.

Mothers for some reason like to ask me: will it hurt?

At which point I say, Of course it will hurt.

Here’s what happens:

A baby boy is strapped into a little harness on his back. His diaper is opened and his penis is cleaned. He is given a pacifier soaked in sucrose (table sugar- which has been shown to somehow provide pain relief in infants).

The attachment of the foreskin to the tip of the glans is broken and a small metal bell is placed to protect the glans. The foreskin is rolled forward over the bell and is sliced through using a scalpel.

Usually the baby is screaming by now, regardless of the sucrose.

Usually there is not much bleeding.

A non-stick dressing is placed on the penis. It will take about a week of vaseline in the diaper (to prevent the penis from sticking to the diaper) to heal.

Complications are unusual, though there is the occasional infection.

I do not describe this procedure to parents, because usually they do not want to know. I also don’t offer my opinion on what they should do.

Personally, I think if it was my baby, I would let it grow in and he could make his own decision.

My county got its first case of swine flu.

The public health unit panicked and sent “Outbreak Kits” with gowns, hand sanitiser, and blue masks to all the doctors’ offices.

People forget sometimes that “pandemic” doesn’t mean “killer bug,” it means “worldwide distribution.”

Yes, we’re heading for a pandemic.

It’s the same freaking disease everyone refuses to get their shots for every year, only this time you don’t get to choose because there isn’t a vaccine. I’m allowed to get upset, I get my flu shot every year.

If you don’t, why get up in arms now?

This game predates the swine-flu scare.

It lets you design your own pandemic, where you get to be the virus. Fun in a mildly paranoia-inducing sort of way.

You win if you wipe out mankind. Yeeps.

When I was a microbiology student many years ago, I had a virology professor who studied measles and influenza. He was convinced that these two viruses were going to become more and more important over the coming years.

He used to talk about the potential for an influenza pandemic. His students saw him as the bearded guy with the pamplets and sandwich board saying “The End Is Near!” and giggled behind our hands.

Hmm.

———

The current outbreak of influenza in Mexico has the experts up in arms for a number of reasons.

We are overdue for a flu pandemic. Flu epidemics are cyclical, with new strains becoming prevalent every year due to genetic drift, or slow mutation of currently circulating viruses. Because these are closely related to viruses we have encountered in the past, we have partial immunity, either from infection or from vaccination in previous years.

Once every 60 or so years over the past few centuries, there is evidence of a genetic shift associated with a lack of immunity in the population.

The 1918 pandemic which killed an estimated 60 million people worldwide is an example of what happens with a shift.

——–

The influenza virus is an unusual virus in that is has eight distinct “chromosomes.” These are segments of RNA which each encode a different functional protein. They are in separate pieces.

The segments of interest to us are the hemagglutinin (H) and neuraminidase (N) segments. These segments encode the proteins on the outside of the virus, the proteins that our immune systems can therefore recognise.

These are the proteins used to design vaccines. There are sixteen known distinct versions of H and nine of N. Usually only one or two of each are circulating in any given year, and there are only a few at any one time known to infect humans.

H and N proteins change a little from year-to-year, and so the flu shot one gets one year may not give full protection the next year.

——–

Influenza infects two other types of animals: birds and pigs. The flu virus that infects other animals usually is only slightly able to infect people, because the six other proteins are different between human and animal flu. They are specific to the host they infect: avian flu best spreads in birds, swine flu best spreads in pigs.

A person who is highly exposed to one of these animal viruses could get infected, but usually cannot pass it on to another person, because these six other proteins just don’t work as well in humans.

The tricky bit is this: sometimes a person who already is infected with human influenza may get infected with animal influenza. This is a very unlucky soul indeed.

If the two viruses mix around, sometimes a new virus is produced which has an animal version of H and N, and a human version of the other six pieces.

This is trouble.

This virus is what is called a shift. It is not anything like the other flu viruses in the human population, because its entire outside has only been in either birds or pigs in the past. Our immune systems cannot recognise it. Our vaccines are not ready for it.

But it has all the machinery to spread in humans.

This has been the fear with avian flu, but so far human outbreaks have been limited: there has been no virus which has picked up both avian hemagglutinin and neuraminidase, and all six human functional proteins. We may not be as lucky, I fear, with the Mexican outbreak. Human-to-human transmission is happening.

Looks like my prof was right.

——

H1N1 cases confirmed in Nova Scotia, in kids just back from a school trip to Mexico. The kids are doing fine, with relatively mild cases.

Colon Cancer Canada:

“We’re behind your behind.”

Two thirds of the consults in geriatrics:

This old person is in hospital with an acute infection. We put him on antibiotics, bunged an IV in his arm and catheter in his willy, doped him to the gills with painkillers and sleeping pills, and we can’t figure out why he doesn’t know the date and keeps calling us his kids’ names.

*sigh*

We docs are very good at helping sick people get well, but we sometimes forget that this stuff has a tendency to mess with the brain.

Working with old folks can be fun and frustrating.

It’s always a shocker when the cute little old lady in the pink floral pinny and the tight white perm (who incidentally has dementia with frontal release) starts hitting on the male resident.

I find myself yelling at everyone. It can be embarrassing, particularly when the old guy says: “I’m not deaf, don’t shout at me!” Not to mention when you go to the cafeteria and find yourself bellowing at the servers.

And then there’s the forgetfulness. “Yes, Mrs. Enderby, we talked about your sore knee and you are going for an X-ray…” I for one find myself wondering if it might be a good thing to get going on the Aricept right now, in the hopes of heading it off.

I saw a case not too long ago that upset me terribly. The patient was a young lady, in her late 30’s, with biopsy-confirmed espohageal cancer.

Here’s the catch: the biopsy was of a lymph node in her neck. Which made her stage IV at diagnosis. Her cancer was too far advanced to be treated by surgery.

She kept asking the oncologist, directly, What are my chances? Am I going to die of this? Is this going to kill me?

The oncologist hemmed and coughed and looked at his watch and evaded her question.

Now, I’m a family medicine resident and certainly no expert in oncology. But I know a few things. Esophageal cancer is a miserable illness, usually found late, as this lady’s was, and notoriously resistant to most chemotherapy. Surgical resection has a cure rate, but chemotherapeutic gains are generally measured in months and quality-of-life

Breaking bad news is not easy. It’s difficult to find the balance that conveys the truth without taking away hope.

I don’t know how this best would be handled. Should such questions be saved for a later date, after the diagnosis itself -cancer with a capital C-has been digested? Would she lose hope knowing immediately the full extent of what she was facing? Or did she deserve to know the whole picture as it stood on that day?