I’m applying right now and I was reminded about this hilarious video resume of this Yale student who is probably the most comical egocentric human being ever. I had to share quickly because I guess they are pulling this video offline!! Enjoy and laugh till you cry like I did.
http://www.sportpost.com/video/view/Impossible+Is+Nothing+video+rsum+Aleksey+Vayner
Here is Michael Cera’s spoof:
This week has been great because I have been working with this amazing dermatologist Dr. Eric Seiger. He is associated with the Pontiac/Botsford dermatology program for all you potential applicants! I know many of my readers are interested in their skin care and have been asking about cosmetic procedures like the mini-face lift. I have been working with Dr. Seiger and doing these mini face lifts EVERYDAY and I really wanted to share some information about them with you guys. You can also go directly to his website if you would like to learn about it on your own at : http://faceliftshalfprice.com
Dr. Seiger is a board certified dermatologist that in the past 15 years has done over 2500 successful procedures! Each mini face lift takes about 45 minutes to 1.5 hours under local anesthesia without even needing to go into the OR. Within three days, most patients can return back to their normal lives and the scars are hidden at your hairline. The procedures are currently half price because Dr. Seiger realizes that the economy is really not doing too well right now. Therefore, I urge you to check it out for either you or your mom, or grandma? Why should we look older than we feel…and that is Dr. Seiger’s mission to make you feel confident not only on the outside, but also on the inside.
Here are some before and afters:
This is CariDee English winner of the 7th season of of America’s Next Top Model in December 2006. 
Besides her career success, CariDee English is famous because she has become the new face for a skin conditon she suffers from called: Psoriasis.
Psoriasis is a chronic condition in which lesions are typically well-circumscribed erythematous plaques with thick silvery scale due to dermal inflammation and epidermal hyperplasia. It presents on the extensor surfaces of the elbows, scalp, lumbosarcarl region, and knees. The most common nail change is pitting of the nails and it can even cause it’s own form of arthritis called psoritic arthritis that is rhematoid factor negative, but HLA-B27 +. Psoriasis is common in white people with an onset in early adulthood. It exhibits a phenomenon called the Koebner’s Phenomenon in which local irritation or trauma makes the lesions worse/start. Psoriasis also shows an Auspitz sign in which after scale is scraped, pinpoint bleeding capillaries are revealed. Histologically, psoriais will demonstrate a thickened epidermis, without a granular layer, with sterile neutrophilic infiltrates known as Munro’s microabcesses. Some medications like Beta blockers, lithium, Ace-I can cause psoriasis, althought these medications are more critical to a patient’s health than the concern for psoriasis, it is something to tell primary care physicians in case they can modify their treatment options. Treatment is very diverse and includes steroids (although rebound phenomenon can occur), Vitamin D, UV light, lubricants, kerotolytics (tar, salicylic acid, anthralin). In refractotory cases, you can use biologics like remicade, humira, etanercept which all serve to block a factor called TNF Alpha. Psoriatic arthritis can be treated with NSAIDs first, then methotrexate. Although these treatments are very effective, it is critical to monitor for infusion reactions and to screen for diseases like TB.
CHALLENGE: Without the help of google what bacteria/virus/fungus caused this? Take your guesses, and I’ll tell you all about it shortly!
Time’s up! The answer is VIRUS. Who knew that a virus could cause a man to go from man to tree?
Yes, some of you got it, it is Human Papillomavirus (HPV), the same virus that causes cervical cancer, warts, genital condylomas! Thank you so much for taking the time to comment and I hope to hear from more of you guys, it’s nice to know that you are reading it and you spend your time to comment!
HPV Facts
* HPV is one of the most commonly sexually transmitted disease in the US! It is thought that most sexually active men and females will acquire some form in their lifetime.
* Gardasil is a vaccine we recommend to our patients below the age of 26 (because insurance covers it then) that protects against 4 strains of HPV: 16,18, 6, 11. The first 2 are the cervical cancer causing strains, while the last two are the genital warts causing strains.
* Cervical cancer is always caused by HPV and it is one of the most preventable cancers. It is preventable by getting a pap smear every two years. This used to be every year, but according to a new study by ACOG, it is now every two years.
* HPV 6,11 can cause respiratory papillomatosis where there are warts in the larynx (the voice box).
*HPV 1, 2 form the common warts (verrucous vulgaris). Vulgaris is a fancy word for common, not vulgar.
* HPV forms 6,11, 16, 18, 34, 35 are the sexually transmitted forms.
* Flat warts are caused by HPV 3.
There are plenty more HPV specifics, but let’s get back to our patient.
Why did this indonesian man become like a tree? Well this virus mixed with the fact that he was immuncompromised led to a condition called Epidermodysplasia verruciformis.
EDV/ Epidermodysplasia Verruciformis is also known as Lewandowsky-Lutz dysplasia or Lutz-Lewandowsky epidermodysplasia verruciformis. It is an extremely rare autosomal recessive condition which is highly associated with malignancy of the skin. According to wiki, it is associated with EVER1 or EVER2 genes, which are located adjacent to one another on chromosome 17. The sad news is that there aren’t that many good treatment modalities, because we still haven’t found a way to kill the virus itself. Therefore, we symptomatically break down the lesions with Retinoids, Interferon therapy, Vitamin D (in the same way we treat psoriasis). Other modalities include using liquid nitrogen, surgery, etc.
1. Leprosy causes your limbs to fall off! – No it does not, it may cause the nerves to be infiltrated, leading to sensory loss and injury. It may also lead to bone resorbtion, but this does not constitute falling limbs!
2. Leprosy is a sexually transmitted disease. No, it is transmitted primarily through respiratory secretions and at one point it was mistaken for Syphilis and that is why it was thought to be an STD.
3. Leprosy is a disease that cannot be cured. No, leprosy is an infectious, bacterial disease that can be cured with multi-drug therapy. There are issues of resistance that can result; however, 15 million people have been cured over the last 20 years!
4. Leprosy can only affect humans. No, leprosy can affect humans and 9-banded armadillos.
5. Leprosy has been around since biblical times. Yes, it was first reported in th 6th century BC in India, China, Egypt.
6. Leprosy affects children and elderly more than middle-age adults. No, it’s the opposite. Usually young adults are the most commonly affected with men 2-3 times more likely than women to be affected.
Alopecia is another term for hair loss. When a patient comes in with this problem, there are certain steps we can take as physicians to ensure that this issue is properly addressed.
What questions should a dermatologist ask his patient? What questions should you ask yourself as a patient?
Daily Counts: Patients can collect hair lost in combing, showers and count them. These hairs will be checked for whether they are in the anagen/telogen phase.
History: We should inquire about drugs, diet, vitamin A supplementation, thyroid symptoms. Determine time of onset and duration because if it is more abrupt telogen efflubian it may be related to a certain event, gradual losses are more complicated invoving a shortened anogen (androgenic alopecia, alopecia areata, scarring alopecias).
Physical: Examine the scalp surface and hair shaft, microscopically as well. Hair density has to be reduced by 50% before you even notice that it is thinner. That is why you cannot rely on mere observation. Is there scarring or non-scarring? Is it localized or generalized? Is it inflammatory v. noninflammatory? Are there skin diseases in taht area or others?
Hair Tests:
Hair Pull Test: Get about 20-40 hairs around the ear and pull it with the thumb and index finger with slow, constant traction. There should be less than 6 club hairs that come off. Then you can study these hair bulbs.
Part Width: Create coronal parts and measure the part width over the vertex. Hair is less dense in the vertex in both genders and thinning increases with age.
Clip Tests: You can actually cut the hair close to the scalp and check for abnormalities such as pili torti (hair is twisted on its axis).
Hair growth window: in an area where hair doesn’t grow and you suspect trichotillomania occlude the aiea anin a week, and if you see growth, then it may likely be trichotillomania.
Hair Pluck-Trichogram: This is painful! You extract hairs with a rubber-tipped needle holderand float them on a slide. Telogen hairs are small unpigmented withotu an internal root sheath. Anagaen, are pigmented elongated with internal root sheath.
Other tests include: hormone studies, scalp biopsy, KOH examination for Fungi!
If you are like most people, you may think there are no dermatological emergencies… Well, there are a few, and one of them is called Steven-Johnson’s Syndrome. Unfortunately, it can be lethal. In fact, just today, June 19th, a Sudanese basketball Player named Manute Bol died at the age of 47 from complications of Stevens-Johnson Syndrome. Manute Bol was a 7′7” basketball player that played for the Warriors and also participated in numerous charities in Sudan. He will be missed by many.
Steven Johnson’s syndrome is a life-threatening disease that is considered to be a hypersensitivity reaction in which immune complexes are deposited to affect the skin and mucosa. It is considered to be an extreme form of erythema multiforme in which cell death cause the top layer of the skin/epidermis separates and peels off from the dermis/second layer of the skin. It is often talked about in conjunction with a similar disease called toxic epidermolysis syndrome (TEN). Steven Johnson’s Syndrome (SJS) may be precipitated by viral illness, drugs (especially cocaine), malignancies. In Bol’s case, it was most likely due to his medications for his kidney disease. Bol also suffered from kidney failure requiring dialysis and it was thought that the medications he received may have caused the SJS. What is interesting about this case, is most cases of SJS tend to involve Caucasians, but like our cas with men twice more likely than women to be affected. This disease can affect any age group, even infants, but clusters in teh 2nd-4th decade of life. Death like that Bol suffered is similar to death by burning, you are losing your skin and you are losing fluids. Therefore, death is likely through dehydration. However, also because the skin has lost its functional ability to act as an innate barrier against infection, infection and consequent sepsis may arise as well and lead to death.
(Above is a patient with SJS- notice the sloughing of the skin)
According to emedicine, “Mortality is determined primarily by the extent of skin sloughing. When body surface area (BSA) sloughing is less than 10%, the mortality rate is approximately 1-5%. However, when more than 30% BSA sloughing is present, the mortality rate is between 25% and 35%, and may be as high as 50%.”
Treatment is geared at replacing fluids and electrolytes and securing the ABCDEs. The offending agent must be addressed and if it is a drug, it should be discontinued. It is unfortuante these efforts were not enough to save Manute Bol.
Humans start out with 5 million hair follicles at birth. During the embryo stage the hair follicle starts out as a club-shaped epidermal down growth that invaginates to contain a papilla of the hair follicle. The central cells of the down growth form the hair matrix. The hair matrix forms all the cells of the hair shaft and surrounding structures. The matrix is within the subcutaneous fat.
The mature follice contains a hair shaft, 2 sheaths, and a germative bulb. It is divided in three regions: infundibulum, isthmus, and inferior segment(that exists only in the growth anagen phase). The infundibulum extends from the surface to the sebaceous gland duct, isthmus goes from the duct to the erector muscle, and inferior segment goes from the erector muscle to the base of the matrix.
The matrix has the highest mitotic rate of ANY organ! Many of the cells in the matrix are undifferentiated and differentiate as they move up the bulb. The mitotic activity of the matrix is influenced by stress/disease.
The hair shaft is composed of dead protein/compact cells with a cuticle thats made of platelike scales. The living cells of the matrix push up into the follicular canal and dehydrate to form the hair shaft (keratinized cell mass). The hair shart has an outer ucticle, cortex, and inner medula- all made of dead protein. The growing shaft has an outer root sheath that is static and continuous with the epidermis, an inner root sheath (Henle and Huxlye layers, and cuticle) which is the gelatinous mass that you see when you pluck your hair. It doesn’t make it to the top of the infundibulum.
Split ends occur when the cuticle is damaged because of brushing/chemicals.
Types of Hair: terminal hairs are thick, dark hairs on the beard/axillary/pubic areas influenced by androgens. Androgens are responsible for making the bitemporal hair thin and these other areas thick. Lanugo hairs are fine peach fuzz hairs on the fetus, whereas in adults this is called vellus hair.
The average scalp has more than 100,000 hairs!!! Scalp hair grows approximately 6 inches a year. Humans have a mosaic growth pattern where hair loss is continuous. Hair follicles go through three stages: catagen (transitional), telogen (resting), and anagen (growing). 90 to 95% of hairs are in anagen phase, with 5-10% in telogen phase. Everyday, about 100 telogen hairs are lost and even double, if the hair is shampooed! Hair follicles in different areas of the body prdouce different hair lengths. The longer the hair, the more likely it stayed longer in the anagen phase. Some dogs, have continuous anagen phases: poodles. They never shed hair! Catagen is the process of involution that occurs with cell death in the follicular kerotinocytes, it is the end of the anagen phase…but less than 1% of the scalp hairs are in the 2-3 week transitional stage. The catagen phase ends withthe formation of the “club” hair. Telogens hairs are also called club hairs/resting hairs which conginue in this stage for 100 days. Once the matrix cell division stops, the catagen/anagen phase begins.
Again, Anagen hairs grow for about 1000 days, catagen phase last 2 weeks on average, telogen hairs grow for about 100 days. Contrary to popular belief, shaving and menstruation do not affect hair growth!!
Melanoma is an extremely dangerous skin cancer that has the potential to spread systemically and result in lethal consequences. Of the three major types of skin cancer -basal cell carcinoma, squamous cell carcinoma, melanoma- it is the worst. Often it begins as a nevus/mole that changed or was not completely uniform in appearance. We use the ABCDEs to help differentiate a normal nevus from a dysplastic one and hope to catch the dysplastic ones before they are considered to be melanomas. If melanoma metastasizes to other organ systems, the prognosis is extremely poor. We use Clark and Breslow’s depths to provide us with more information on how to classify the mortality rates. According to the Seattle Times “Last year in the United States, there were about 68,720 new cases and 8,650 deaths from the disease. Worldwide, more than 50,000 people die of melanoma each year”. Until now, there has been very little we can do to improve survival. However, this past week, there has been clinical trials to demonstrate that a drug called Ipilimumab may provide some hope!
Ipilimumab (MDX-010 or MDX-101) is a human monoclonal antibody that is in the process of being created by Bristol-Myers Squibb and Medarex. It works by stimulating the immune system. Ipilimumab is undergoing clinical trials for the treatment of melanoma, non small cell lung cancer, and small cell lung cancer, and prostate cancer. The FDA is currently reviewing this drug and if approved, it could be released by the end of the year. In a double-blind placebo controlled clinical trial that included 676 people who suffer from inoperable, stage 4 metastatic melanoma. The patients were given one of three treatments: ipilimumab alone, another immune-stimulating drug alone, or ipiliumumb and the other drug together. After two years, 24% of those given the drug alone or in combination were alive compared with 14 % of patients given the immune-stimulating treatment alone. Additionally, the study showed that an improvment of median survival from 6 months to 10 in patients with advanced melanomas. These results came out with the American Society of Clinical Oncology (ASCO) in Chicago — and were published simultaneously in the New England Journal of Medicine.
As stated earlier, Ipilimumab is a human antibody that binds to CTLA-4(cytotoxic T lymphocyte-associated antigen 4), a molecule on T-cells that is believed to play an important role in negativetly regulating T cell activity against tumor cells. Ipilimumab is designed to block the activity of CTLA-4, in order to sustain an active immune response against melanoma tumor cells. This drug refered to as “ipi” does not cause nausea and GI upset as readily as other chemodrugs, but can stimulate autoimmune diseases such as rheumatoid arthritis. These are considered to be IRAE- immune related adverse effects.
You can read about the actual clincial trial at : http://clinicaltrials.gov/ct2/show/NCT00495066
Another interesting article that talks about ipi is at : http://theoncologist.alphamedpress.org/cgi/content/full/12/7/864
On NPR recently, they were talking about the study of Albert Einstein’s brain in order to discover the difference between his brain and the brain of people who didn’t discover E= MC squared. Apparently, it wasn’t the number of neurons/brain cells, it was the number of supportive cells called glial cells. There is an interesting story about how they got his brain and exactly where those glial cells were found, but the overall message is that to make a champion or a genius, it isn’s just about the brain cells, arguably, it is even more about the supportive cells. In this case, I would like to talk about UCLA, one of the greatest athletic institutions ever (in addition to academic), that owes a lot of its success not just to its athletes, but to the coaches that inspired them.
Specifically, Coach John Wooden.
UCLA has a rich history of basketball, in addition to the fact that they were the first university ever to reach 100 NCAA Championship Titles. 11 of these titles occurred in men’s basketball, and 10 of the 11 titles occurred because of John Wooden. However, that is not the only accomplishment Coach Wooden achieved for UCLA; on the contrary, he continues to inspire UCLA students and athletes around the world for his supportive words, positive attitude, faith, and his ability to continue to attend every UCLA basketball home game. On a side note, if you have ever lived in the LA area, it takes guts at the age of 99 to battle the traffic, climb up and down those massive stairs at Pauly Pavillion, and sign 100s of autographs just to attend a single game! Therefore, like the glial cells in Einstein’s brains, Coach Wooden has served as the additional glial cells that support so many of us on a daily basis. Unfortunately, today he is critically ill in no less UCLA Hospital, fighting for his life and therefore, I dedicate this post to him! I believe that in order for me to achieve my goal of one day becoming a dermatolgist, or for any of you to attain your ambitions, inspirational words (even if you are a USC fan) are always valuable.
“Do not let what you cannot do interfere with what you can do.”
John Wooden
“It isn’t what you do, but how you do it.” For dermatology, I believe this means…even though you aren’t doing CPR or surgery, doesn’t mean what you are doing is meaningless…on the contrary, it too can save lives!
John Wooden
“Success is peace of mind which is a direct result of self-satisfaction in knowing you did your best to become the best you are capable of becoming.”
John Wooden
He has so many quotes that have given me the hope through all the hard times of medical school and before, and even life in general and I hope he can help you!
