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Category Archives: Children’s Health

Rohypnol: What You Should Know About the Date Rape Drug

August 8, 2011 Dr. Pullen

Rohypnol, or roofies, is the name for what is more commonly called the date rape drug. Rohypnol has become notorious because of its potent amnestic and hypnotic effects which can lead a person given a dose of Rohypnol to have short term amnesia. This has led to its popularity as a “Club Drug” along with Ketamine, MDMA (Ecstasy) and GHB. Rohypnol has not been approved for use by the U.S. FDA and is considered an illegal drug in the U.S. Rohypnol is in the benzodiazepine class of medications along with more well known and commonly used drugs like diazepam: read diazepam side effects (Valium), alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonapin) and many others.

Rohypnol (chemical name flunitrazepam) is the most potent of the benzodiazepines on a mg-for-mg basis and is very fast acting, making it potentially useful in severe refractory insomnia, mostly in patients in the hospital. For the same reasons it is notorious for its abuse as a date rape drug. Rape by someone well known to the victim, often date rape, is unfortunately very common. Rohypnol has been found to be involved in a very small percentage of date rape, probably less than 1% of cases, but it undeniably is abused for that purpose. The much more common drug involved in date rape is simply ethanol, the alcohol in all alcoholic beverages which can also lead to blackouts, amnesia and vulnerability to sexual abuse.

This said, how should a woman avoid becoming a victim of date rape associated with Rohypnol? Probably the key is to avoid situations where heavy drinking and drug use is expected. In addition trying not to leave a drink unattended and then picking it back up to drink may be considered. Still if going to a dance club and drinking while there, if you dance you are likely to want to put your drink down. This issue makes nearly eveyone at a dance club who drinks alcohol at some risk for having their drink spiked with Rohypnol. This means other than completely avoiding dance clubs and drinking we need to depend on our friends to watch out for each other. That said the real issue is with the societal issues that lead to use of drugs like this in the first place.

That issue is with the perpetrator of the crime giving the drug to the victim. As a society we need to watch out for each other. We need to teach our sons and daughters that if they even suspect this type of behavior may be happening or going to happen that they take action to avoid being involved and if possible to stop the perpetrator of the crime. It is far too easy to explain away the odd behavior of a friend as just having had too much to drink, or to not want to interfere or embarrass their friend or themselves by taking action to intervene. We need to have the courage to step up and take actions to intervene when suspicious behavior is noted. Given that alcohol is probably the most frequent drug involved in date rape and other mishaps of intoxication thinking that behavior may be “just alcohol” is flawed thinking.

One helpful thing may be to recognize the effects of Rohypnol on someone around you. If a friend starts to look odd, dazed or confused we should take measures to protect them. Typical symptoms of ingestion of Rohypnol include confusion, uncoordination and sedation. These effects can come on quite quickly, and may look much like alcohol intoxication. Alcohol does in fact clearly increase the sedative and central nervous system depressant effects of all benzodiazepines. All told the best way to reduce the chances of being given Rohypnol is to avoid situations where heavy drinking and drug use is prevalent.

Rohypnol is also used recreationally, especially in conjunction with stimulants and heroin. Stimulants like cocaine and methamphetamine lead to severe insomnia and Rohypnol is sometimes used to “soften” the so-called crash from these stimulants. It is also used to achieve profound intoxication, and when combined with alcohol this can lead to fatal overdoses. Rohypnol has many street names including roofies, forget-me-pill, Mexican Valium, and many others.

Rohypnol has also been documented in Europe as an adjunct to robbery, with victims given Rohypnol and then robbed. This is a type of abuse of Rohyphol that also takes advantage of the potent amnesia that those who are under the influence of Rohypnol experience. In Europe where Rohypnol is available as a prescription drug the potential for misuse is certainly higher than in the U.S.

Rohypnol has no legitimate role in U.S. medicine, and is a drug of abuse. Rohypnol in the U.S. is imported from abroad where its use is apparently even more widespread. I pray that you as a parent or as a young person never have any first hand experiences with this drug, and that the word Rohypnol is something you only read about in places like this.

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What do Dogs and Dr. Pullen Have in Common? We Dislike July 4th Fireworks!

July 4, 2011 Dr. Pullen

July 4^thFireworks just aren’t my thing. I enjoy a good professionally done show at a distance, but the consumer fireworks to me are just a loud, smelly, and dangerous distraction. Our

Say Yes to the Pros

dog Simon died last year as some of you may recall from my article on physician assisted suicide, but while he was with us Simon didn’t do well on Independence Day each year. Actually one year he lost his independence as he uncharacteristically escaped our back yard, and spent the night at the dog pound. I don’t think I’ll end up incarcerated because of my dislike of July 4^th fireworks, but I do feel like a spoil-sport sometimes.

Intellectually I am confident that I’m right to have deprived my children of this thrill. My son thinks I just see the dangerous side of things because I’m a family doctor, and that I don’t see the fun and excitement of blowing up firecrackers, shooting off bottle rockets, and swirling sparklers.

Say No to Your Kids

Actually I just don’t find them very exciting, mostly too loud, smelling really bad, and yes I do think their dangers far outweigh their entertainment value.

As a family physician I tend to think about the human injuries related to July 4^th fireworks. The last year we have good statistics for is 2008, when there were:

7000 Emergency Room visits for fireworks related injuries. (2/3 of these were in the perid from June 2- and July 20) 7 people died. There were 1400 hand and finger injuries, 1000 eye injuries, and 900 leg injuries.
Over 40% of injuries were in children under 15 years old, and 58% in persons under 20 years old.

This didn’t surprise me but I hadn’t thought about the vast amount of property damage from fires related to consumer fireworks. In 2008 there were 22,500 fires and 1400 total structure fires. Imagine 1400 families burned out of their homes due to fireworks related fires. In the United States there are far more fires on July 4^th than on any other day of the year. The estimated property damage from fireworks related fires in 2008 we $42 million.

I know it is easy to think that you are more responsible than the contributors to these statistics. Your children are better supervised. You only buy approved fireworks. (5 out of every 6 of the injuries in 2008 were related to approved fireworks). I feel like I live in a community with pretty responsible, reasonable, and typical U. S. parents. Still I see young children roaming the neighborhood every Independence Day with fireworks alone and in small peer groups without any apparent adult supervision. This is just a culture we have come to accept in America. July 4^th fireworks is as American as any tradition we have, and I don’t expect it to change anytime soon. Still even after Simon’s passing I don’t expect to like July 4^th fireworks any more than I did when I sat in and held my trembling dog on Simon’s last July 4th while my family went to the beach to watch the fireworks.

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How Young Can You Go: Contact Lenses for Children

June 17, 2011 Dr. Pullen

Contact lenses for children is a topic my family went through having a myopic child. I appreciate this guest post by Brett Olivera to put out helpful information on this topic for readers. Enjoy.

Contact Lenses for Children

by Brett Olivera

When it comes to a child’s eyesight, parents often assume their child only has the option to wear glasses until they’ve reached their teenage years. Although many parents choose to transition their children to wearing contact lenses when they are a bit older, the delay in switching eyewear isn’t due to the child’s eye health. It really depends on the eye care needs and overall disposition of the child.

Some infants can be safely fitted with contact lenses to manage various vision complications that may have existed since birth. Although controversial, some eye doctors argue that young children can wear contact lenses to actively slow the progression of Myopia, or nearsightedness. Otherwise, the most popular age for children to transition from glasses to contact lenses is around 8-12 years old.

Since contact lenses are safe for children of all ages, the decision to switch really depends on the sense of responsibility your child has. If your child tends to be independently responsible when it comes to schoolwork, daily chores, and taking care of their pets, he or she may be ready to handle the responsibility of wearing and caring for contact lenses. Your child’s eye doctor will prescribe a specific wearing schedule, and explain how to clean and care for your child’s contact lenses. In general, when children take well to the responsibility aspect of wearing contact lenses, children are perfect candidates to wear them.

Playing sports and participating in other outdoor activities can be difficult with bulky glasses. Contact lenses can improve your child’s vision and focus, while eliminating the barriers of frames or goggles in his or her peripheral vision. Kids are less likely to have problems with dry eye, and studies show that children often adapt to the routine of contact lens care better than most adults, therefore are less likely to over-wear them or neglect to clean them.

Many children and teenagers prefer to wear contact lenses over regular glasses simply because contact lenses boost their self-esteem, motivate them to participate more, and make them feel more confident with their overall appearance.

Whether you are considering having your child wear contact lenses to possibly slow the progression of nearsightedness, or simply make playing sports and seeing the blackboard a bit easier, speak to your child’s eye doctor about all the options and aspects of eye care to see if contact lenses are right for your child.

Brett Oliveira works with BuyMoreContacts.com, where you can order contact lenses online at discount prices. BuyMoreContacts.com offers a variety of contact lenses, including lenses such as Proclear contact lenses, Biofinity Toric, and Air Optix Aqua contacts.

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Larsen Syndrome: A Rare Disorder I Saw in the Office

June 13, 2011 Dr. Pullen

This week in the office I had the pleasure of seeing a young woman with Larsen Syndrome. She started to see me in the office recently after her prior family doctor left the area, and I finally today made time to look at this rare but interesting syndrome. Larsen Syndrome is a rare autosomal dominant disorder with

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Molluscum Contagiosum: Common in Children and as an STD

June 3, 2011 Dr. Pullen

Despite the name which sounds like a terrible disease molluscum contagiosum is arguably the least serious and concerning of all warts and all STDs. Warts, STD’s, children, not serious? Has Dr. Pullen gone nuts? Hear me out. It all makes sense really if you read on.

Molluscum contagiosum is a viral skin infection that causes small, usually 2-5 mm size raised skin colored to pinkish bumps on the skin that usually have a small dimple in the center, so we call them umbilicated in appearance (like an umbilicus in the middle). They are almost always painless, and unless you scratch or dig at them they resolve without scarring usually. So what’s with the descriptive terms above:

Least Serious Warts: These are often called water warts, but are really not closely related to most other human warts. They are not in the human papilloma virus family with genital warts, plantar warts, flat warts, etc. but rather are caused by a member of the pox virus family. Molluscum lesions painless and almost always resolve on their own faster than most other types of viral warts. The typical total course of molluscum contagiosum in any one individual usually ranges from 6-18 months, although it can be longer in a small minority of people. Any one molluscum contagiosum lesion itself tends to go away sooner, often in 2-3 months. These lesions, unlike genital warts which are clearly associated with cervical, penile and tonsil cancer, are not felt to be associated with any serious or long term consequences.

Molluscum Contagiosum as an STD: Although in practice we mostly see molluscum contagiosum in children, they are also a sexually transmitted disease in older adolescents and adults. Molluscum contagiosum gets its name because it is fairly contagious. You tend to get the infection by skin-to-skin contact with another person with an infection, or contact with a fomite carrying the virus. A fomite is an inanimate object like a towel, clothing, toys, or any other object that has the virus attached to it. In sexually active persons the skin to skin contact tends to be on the genitalia, the torso and the proximal extremities. In children they are seen virtually anywhere except the palms and soles, although in my experience they are not common on the face.

Diagonsis: The diagnosis of molluscum contagiosum is usually easy for an experienced practitioner. The appearance is so typical we can often at a glance know with a high degree of certainty the diagnosis. If in doubt we can simply squeeze one of the lesions after using a small needle or scalpel blade to nick the roof of the lesion and express a cheesy whitish material that is very unique and confirms the diagnosis. In really odd appearing lesions a punch biopsy can be done to send for pathologic exam, but this is almost never necessary.

Treatment: In children I try to convince the parent to just wait out the course of the molluscum. Any treatments involve some sort of discomfort to the child, and unfortunately often even a thorough search for lesions and careful destruction of all the apparent lesions is fruitless as new lesions usually pop up shortly after the treatment requiring returning for another round or treatment. If I can convince Mom or Dad to just leave these alone, knowing they may get worse before they get better, they are happy to see them resolve after a few months or a year or two. In older children, adolescents or adults who really want to get rid of these they can be treated by many types of destructive therapy. Liquid nitrogen cryotherapy is effective. Simply unroofing each lesion and expressing the core works well. For this I use a larger needle, about 20 gauge, to nick the top, and gloved thumbs to pinch out the core between my thumbnails. Blistering agents can also be used.

Molluscum contagiosum in an adolescent or adult is a clue to discuss STDs, consider screening for other STDs, and if a severe case a reason to question immunity. In HIV patients or others with a suppressed immune system molluscum contagiosum can develop rapidly spreading and severe cases.

Overall molluscum contagiosum is usually an easy diagnosis where in children the biggest task is to assure the parents have realistic expectations and ideally the patience to just wait out the course. Unless there is undue anxiety or parental concern, this is a reassuring diagnosis to many parents if presented calmly and with confident reassurance. At least it’s usually easy to be confident of the diagnosis.

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Enterobius Vermicularis and the Scotch Tape Test

April 20, 2011 Dr. Pullen

The scotch tape test for Enterobius vermicularis, the common pinworm, is one of the really simple, inexpensive and just plain cool tests used in primary care. In addition the life cycle of the pinworm is well understood and is quite unique (not to mention disgusting) in that it depends completely on humans eating feces repeatedly.

To understand why the scotch tape test work works we need to first review the interesting life cycle of the pinworm. Enterobius vermicularis is known as the pinworm because it is about the size of a common pin. It lives in the human small intestine and proximal colon. After living a few weeks the female worm migrates down the colon, exits the anus and lays its eggs on the skin of the perianal area at night. The female dies after laying her eggs. The worm and the eggs seem to lead to itching, which initiates scratching which helps facilitate the eggs getting on the fingers and then reingested. The infection is most common in children who have less concern about putting their hands in their mouth after scratching or touching their anal area, and self-inoculate themselves. The ingested eggs then hatch in the duodenum, the males and females mate, the male dies and the female moves to the distal small bowel after molting twice as she passes through the bowel, and the process is repeated.

This sounds disgusting but the fecal-oral route of spread is a common way that infections are spread. The unique thing about the pinworm is that it’s probably the only common human infestation that depends on people perpetuating and sustaining the infestation by repeatedly ingesting more eggs over and over. If no eggs were reingested the infestation would die out as the worms die after laying their eggs.

All this sounds terrible, but there are a few good things about pinworms. The first is that the infection is almost harmless. Infection tends to either be asymptomatic, or just cause perianal itching. In girls it can sometimes cause a vaginal itch if the organisms inadvertently crawl into the vagina instead of the rectum after coming out to lay their eggs.

The second good thing is that pinworms are easily diagnosed. When I see a child I suspect of having pinworms I have their parent wake them about 2-3 AM and look at their anus with a flashlight. Often the worms can be seen on the outside. Sometimes they are also seen in the diaper or the toilet after a bowel movement. If not seen the scotch tape test is done by taking a piece of scotch tape, applying the sticky side to the child’s anus on awakening in the morning, and sticking the piece of tape to a microscope slide. I just give a few microscope slides to the parent to collect the specimens at home on two or three mornings, and have them bring the slides in for me to examine. The pinworm eggs are easy to see under the microscope, and a diagnosis is made if eggs are noted.

The third good thing about pinworms is that treatment is very easy and effective. A single dose of mebendazole, a 100 mg chewable tablet, is effective in most cases. We do routinely treat the whole family at once to eradicate the organism from any unsuspecting family members and increase the chance of long term cure.

Unfortunately reinfection is common, especially in children in daycare or when they originally contacted the organism from another child who remains undiagnosed. If your child contacts pinworms, don’t be overly concerned. It’s common, easily treated and not at all serious.

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Strep Throat is Only Modestly Contagious

March 25, 2011 Dr. Pullen

Strep throat is contagious, but surprisingly far less contagious than many other common illnesses, including influenza, chicken pox and the common cold. Strep throat can be passed from one person to another by droplets from a cough or sneeze, by sharing eating or drinking utensils or kissing, and by hand-to-hand contact. Surprisingly strep throat can even be passed from a pet to a person in unusual cases. Still, often even with household exposure you may not get strep throat. In the office I often see one child in a family with strep throat and the parent wonders why her other children have not contacted the illness. Your chances of getting strep are higher if you are a child than if you are an adult.

Strep throat is caused by Group A Streptococcus pyogenes, a bacteria in the same family as the common pneumonia bacteria Streptococcus pneumoniae . This is also the same bacteria that causes skin infections like erysipelas, some cases of impetigo, and the dreaded flesh-eating streptococcal tissue infections that make the news from time to time.

Strep throat is most common in children, although it does occur in adults too. Typical symptoms include a sudden onset of quite severe sore throat, usually associated with fever, chills, swollen nodes in the neck, and sometimes a rash. Typically strep throat is not associated with a runny nose, cough or congestion. In the office we now have rapid strep tests, where a throat swab is done to test for strep bacteria in the throat. This test has largely replaced the throat culture that is the gold standard test for diagnosis of strep throat because of its convenience and ease of use. The big problem with the rapid strep test is its lack of sensitivity, with only about 70-85% of culture positive patients having a positive rapid strep test.

Strep throat is most common in the fall and winter months, but is seen sporadically throughout the year. As a family physician I can plan on seeing a number of children with strep throat in the office just a few days after school starts in the fall.

Clinical signs of strep throat are variable, and on physical exam strep throat can be difficult to diagnose with any degree of confidence based only on history and exam. The findings of strep throat are also different at different ages. The chances of a patient with a sore throat having strep throat at the doctor’s office decrease with age. It’s estimated that at the time of an office visit about 30% of children under 10 years old, 15-20% of older children and adolescents, and less than 10% of adults with sore throat have strep throat.

Treatment of strep throat is usually with penicillin or amoxicillin unless the patient is penicillin allergic. Penicillin can be given orally or by injection as LA bicillin, with both methods approximately equally effective.
Look at this page on amoxicillin side effects if you are prescribed this medication. In my experience it is difficult to diagnose strep throat in patients post tonsillectomy because their throat may look fairly unimpressive and lack the usual enlarged tonsils and patchy exudate. Tonsillectomy is effective at reducing the frequency of strep throat in patients with large tonsils and frequent episodes of streptococcal tonsillitis, but it is certainly possible to get strep throat after tonsillectomy.

The most helpful physical findings in suspecting strep throat are petechiae of the palate, a sandpaper-like texture reddish rash of the torso often called a scarletina rash, and tender enlarged anterior cervical lymph nodes along with fever.

Infectious mono can mimic strep throat, although the lymph nodes with mono are often larger and less tender, and the white on the tonsils with mono tends to be a more confluent white than the shaggy white-yellow exudate typical of strep throat. I often see patients worried about white patches on the throat that are just epithelial pearls, buildup of shed epithelial cells in the crypts of the tonsils.

Overall strep throat is contagious but only moderately.

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A Stuttering Oscar Winner

February 27, 2011 Dr. Pullen

Hollywood has a long history of making great movies about special people with medical conditions. This year a stuttering king, but from Rain Man about Autism

to The Elephant Man about neurofibramatosis

Oscar nominated films are often about medical conditions. As I watched the Academy Awards last night and remembered how much I enjoyed watching The King’s Speech I was prompted to review a good overview in AFP from 2008 that reviewed stuttering. The issues in the movie are those addressed by a child and then an adult, who happens to become the king of England, with a major stuttering disorder. Review of the article was helpful to put the things I saw in the movie into perspective. In summary stuttering is fairly common in young people and tends to improve by adulthood. Here are a few of the key points on the review article:

1.4% of children under 10 years old stutter.
80% of children who stutter are male.
80% of children with developmental stuttering resolve by adulthood.
Over to 80% of stuttering is classified as developmental and over 75% of preschoolers who stutter spontaneously recover within 4 years.
Some developmental stutterers develop associated tics or other physical movements

The AFP article goes over the differentiation between normal speech fluency dysfluency, mild stuttering and severe stuttering. It’s a good review for parents or physicians faced with questions about speech fluency questions.

Stuttering: An Overview

JANE E. PRASSE, MA, CCC-SLP, Stamford Hospital, Stamford, Connecticut

GEORGE E. KIKANO, MD, Case Western Reserve University, University Hospitals of Cleveland, Cleveland, Ohio

Am Fam Physician. 2008 May ;77(9):1271-1276.

Leave a comment about your favorite movie with a medical topic. I love The Pride of the Yankees, One Flew Over the Cuckoo’s Nest, and Iris.

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Research Fraud

January 7, 2011 Dr. Pullen

Physicians have known for years that the original 1998 BMJ article that started the fear of an autism relationship with the MMR vaccine was bad research, but the BMJ has now come out and bluntly called the research intentional fraud. The authors had a consulting relationship with trial attorneys seeking clients and settlements for this relationship, and the publication was just a crime. It’s too little-too late, but nice to see the truth finally come out. It will be interesting to follow the three part article planned in BMJ. Here is Part 1.

How the Case against the MMR vaccine was fixed

Brian Deer, journalist

In the first part of a special BMJ series, Brian Deer exposes the bogus data behind claims that launched a worldwide scare over the measles, mumps, and rubella vaccine, and reveals how the appearance of a link with autism was manufactured at a London medical school read the full article here

(Published 5 January 2011) in BMJ Online.

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How Contagious is Mono

December 20, 2010 Dr. Pullen

How contagious is mono you ask? The short answer is only moderately contagious. Unlike many common illnesses infectious mononucleosis (mono) is spread by ingesting the causative Epstein Barr Virus (EBV) shed in another person’s saliva, hence the “kissing disease” nickname. Other than kissing you can spread mono by sharing eating or drinking utensils or by touching something contaminated by mono and then putting your hand in your mouth. Also limiting spread is the fact that many infants and young children contact mono as an asymptomatic minor illness and so already have immunity. This lends a degree of “herd immunity” to the population and holds down rapid spread of the disease.

The Epstein-Barr Virus is a member of the Herpes family of viruses. The typical presentation of mono is in a teenager who develops a severe sore throat and fever. Keep in mind that the usual office blood test for mono, the “mono spot” test, is often negative until up to 10 days of symptoms. The presentation can be clinically indistinguishable from strep throat initially, and up to 50% of patients with mono have positive throat cultures or rapid strep tests. Pair this with the 20-30% false negative rates of the office rapid strep tests, and the initial diagnosis is often not made until a second or third office visit when it becomes apparent that the child is not responding to treatment for strep throat and the mono test becomes positive. If treated with amoxicillin a patient with mono will often develop a reddish macular rash all over, and this can be mistaken as a penicillin allergy; see amoxicillin side effects for a nice resource. Still the classic thick white exudate on the tonsils of a child or teen with mono can be very suspicious to an experienced examiner, and if paired with really big 3-5 cm anterior or posterior cervical lymph nodes or an enlarged spleen we can often suspect the diagnosis on the initial visit even if it’s too early to confirm the diagnosis with lab tests.

Because of the wide variety of symptoms that mono can cause, and the wide variety of severity of illness, it is the disease that comes to my mind first when I hear the old med school adage, “Uncommon manifestations of common problems are much more common than common manifestations of uncommon problems.” Despite its peak incidence in children and young adults, mono is seen at all ages. Presentation in young children is often quite subtle, and not diagnosed. In older adults it often presents with sore throat, enlarged tonsils with a thick white exudate, and swollen cervical nodes like in teens, but can also present with florid hepatitis, simple fatigue, or abdominal pain from hepatosplenomegaly. Rare presentations include aseptic meningitis and leukocytosis found on a routine CBC.

One of the frustrating aspects of mono is the long duration of fatigue some patients get. This can be very debilitating, and mono is one of the few diagnoses where rest is especially important. Listening to your body and not trying to push yourself to your limit and allow the symptoms to resolve more quickly than if you try to push yourself to exhaustion every day. Half days of school, with naps and focus on the key subjects can allow students to stay on course throughout the course of the illness. Antiviral medications are not helpful in mono. In severe acute presentations a short course of prednisone can quickly shrink the tonsils and allow the patient to eat and drink enough to stay hydrated and nourished. Fever can persist for several weeks in some cases. (See prednisone side effects)

The relationship between EBV and chronic fatigue syndrome is not clear, and although I believe chronic fatigue syndrome is a real condition, I don’t believe it has been shown to be related to EBV. Some recent research suggests a virus called XMRV as a cause of chronic fatigue syndrome, although this is very controversial. Most patients with EBV can get back to school or work within a few weeks. Management of athletes in contact sports has been better defined in recent years. Most sports medicine experts allow participation in contact sports after the fatigue has resolved if absence of hepatosplenomegaly can be documented with ultrasound. In past years we insisted on at least 8 weeks time after diagnosis prior to contact sports. The newer approach seems more appropriate, and allows both individualization of advice, and gives confidence to the physician who does need to keep a young athlete out of competition.

For a graphic look at a goofy teen with mono and a flashlight see this video. Note the very white exudate on the very large tonsils. Thanks kid.

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