MUSCLE DISEASES
Ed Friedlander, M.D., Pathologist
scalpel_blade@yahoo.com

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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at scalpel_blade@yahoo.com No texting or chat messages, please. Ordinary e-mails are welcome. Your confidentiality is completely respected.

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I'm still doing my best to answer everybody. Sometimes I get backlogged, sometimes my E-mail crashes, and sometimes my literature search software crashes. If you've not heard from me in a week, post me again. I send my most challenging questions to the medical student pathology interest group, minus the name, but with your E-mail where you can receive a reply.

Numbers in {curly braces} are from the magnificent Slice of Life videodisk. No medical student should be without access to this wonderful resource.

I am presently adding clickable links to images in these notes. Let me know about good online sources in addition to these:

Also:

pathology.org -- my cyberfriends, great for current news and browsing for the general public

EnjoyPath -- a great resource for everyone, from beginning medical students to pathologists with years of experience
Medmark Pathology -- massive listing of pathology sites
Estimating the Time of Death -- computer program right on a webpage
Pathology Field Guide -- recognizing anatomic lesions, no pictures


Freely have you received, freely give. -- Matthew 10:8. My site receives an enormous amount of traffic, and I'm still handling dozens of requests for information weekly, all as a public service.

Pathology's modern founder, Rudolf Virchow M.D., left a legacy of realism and social conscience for the discipline. I am a mainstream Christian, a man of science, and a proponent of common sense and common kindness. I am an outspoken enemy of all the make-believe and bunk that interfere with peoples' health, reasonable freedom, and happiness. I talk and write straight, and without apology.

Throughout these notes, I am speaking only for myself, and not for any employer, organization, or associate.

Special thanks to my friend and colleague, Charles Wheeler M.D., pathologist and former Kansas City mayor. Thanks also to the real Patch Adams M.D., who wrote me encouragement when we were both beginning our unusual medical careers.

If you're a private individual who's enjoyed this site, and want to say, "Thank you, Ed!", then what I'd like best is a contribution to the Episcopalian home for abandoned, neglected, and abused kids in Nevada:

I've spent time there and they are good. Write "Thanks Ed" on your check.

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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.

Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.

I cannot examine every claim that my correspondents share with me. Sometimes the independent thinkers prove to be correct, and paradigms shift as a result. You also know that extraordinary claims require extraordinary evidence. When a discovery proves to square with the observable world, scientists make reputations by confirming it, and corporations are soon making profits from it. When a decades-old claim by a "persecuted genius" finds no acceptance from mainstream science, it probably failed some basic experimental tests designed to eliminate self-deception. If you ask me about something like this, I will simply invite you to do some tests yourself, perhaps as a high-school science project. Who knows? Perhaps it'll be you who makes the next great discovery!

Our world is full of people who have found peace, fulfillment, and friendship by suspending their own reasoning and simply accepting a single authority that seems wise and good. I've learned that they leave the movements when, and only when, they discover they have been maliciously deceived. In the meantime, nothing that I can say or do will convince such people that I am a decent human being. I no longer answer my crank mail.

This site is my hobby, and I do not accept donations, though I appreciate those who have offered to help.

During the eighteen years my site has been online, it's proved to be one of the most popular of all internet sites for undergraduate physician and allied-health education. It is so well-known that I'm not worried about borrowers. I never refuse requests from colleagues for permission to adapt or duplicate it for their own courses... and many do. So, fellow-teachers, help yourselves. Don't sell it for a profit, don't use it for a bad purpose, and at some time in your course, mention me as author and KCUMB as my institution. Drop me a note about your successes. And special thanks to everyone who's helped and encouraged me, and especially the people at KCUMB for making it possible, and my teaching assistants over the years.

Whatever you're looking for on the web, I hope you find it, here or elsewhere. Health and friendship!

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More of Ed's Notes: Ed's Medical Terminology Page

Perspectives on Disease
Cell Injury and Death
Accumulations and Deposits
Inflammation
Fluids
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What is Cancer?
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Medical Dictionary

Courtesy of CancerWEB

Musculoskeletal
Taiwanese pathology site
Good place to go to practice

Brain, Nerve, Muscle
Photo Library of Pathology
U. of Tokushima

Musculoskeletal
Photos, explanations, and quiz
Indiana U.

Musculoskeletal
Utah cases for path students
Juliana Szakacs MD

Soft Tissue and Muscle
Iowa Virtual Microscopy
Have fun

Clinical Musculoskeletal Pathology
Go through IMC
You need to join first.
Pittsburgh Illustrated Case

"Why I Support Amateur Boxing"
Position paper by Ed
This is something about which
reasonable people can differ.

Muscle biopsy
Wash. U., St. Louis
Illustrated notes

Muscle Biopsy Quiz
Wash. U., St. Louis
Illustrated notes

Myopathies I
From Chile
In Spanish

Myopathies II
From Chile
In Spanish

Muscle Pathology
Good photos and text
Neuropathology Web

Muscle Pathology
Wash U., St. Louis
Best muscle path site

How to work up
a muscle biopsy
Oklahoma

KCUMB Students
"Big Robbins" -- Nerve / Muscle
Lectures follow Textbook

QUIZBANK Muscle & soft tissue (all except #'s 55-61)


Dino LaPorte
Former path TA

INTRODUCTION

{14614} skeletal muscle, histology
{20723} skeletal muscle, histology
{44101} skeletal muscle, ultrastructure
{44116} mitochondrion & sliding filaments
{44110} section of myofilaments
{18639}
{18643}
{18644}
{18665}

{14381} normal; NADH stain with type I fibers dark, type II fibers light
{14418} normal; ATPase stain with type I fibers dark, type II fibers light

Skeletal muscle
Cross-striations
KCUMB Team

Skeletal muscle
Cross-striations another way
KCUMB Team

REACTIONS OF MUSCLE CELLS

    Simple atrophy of muscle cells occurs when they are

    (1) deprived of its nerve supply ("neurogenic atrophy"), or

    (2) deprived of its blood supply ("ischemic atrophy"), or

    (3) not used ("disuse atrophy") or,

    (4) subjected to glucocorticoids (today, that's mostly "iatrogenic atrophy").

    * (5) vitamin D deficient (more common than you think? Arch. Int. Med. 160: 1199, 2000; update on the epidemic of vitamin D deficiency in young American women and its link to increased fat overall and specifically within muscle: J. Clin. Endo. Metab. 95: 1595, 2010; same finding on imaging in the vitamin D-deficient elderly AJR 194: 728, 2010)

type II muscle atrophy
Wash. U., St. Louis
Illustrated notes

{14430} disuse or glucocorticoid atrophy, type II fibers

{14414} degenerating fibers, early Duchenne's

Duchenne's muscular dystrophy
Autopsy view of calf
KU Collection

{14393} several target fibers

{14421} several angular fibers

Neurogenic atrophy
Tom Demark's Site

{25526} split fiber in early muscular dystrophy

MYASTHENIA GRAVIS

Other myasthenic syndromes: In addition to some genetic NMJ problems (Arch. Neuro. 56: 163, 1999), you need to remember the EATON-LAMBERT SYNDROME ("myasthenic myopathic syndrome"), a weakness syndrome typically seen with oat cell carcinoma of the lung, though sometimes alone. These patients make an autoantibody against calcium channels (NEJM 332: 1467, 1995 review) that blocks release of acetylcholine itself.

Myasthenia gravis
Wash. U., St. Louis
Illustrated notes

MUSCLE CHANGES IN PERIPHERAL NERVE DISEASE

    Denervation (i.e., lower motor neuron) changes in muscle occur only if the axon itself is damaged. (Contrast "demyelinating disease" of peripheral nerves, which leaves muscle unchanged.)

    Partially damaged nerve is the site of axonal sprouting, with axons from surviving neurons growing into the empty spaces once occupied by other axons. Since the current axon supplying a muscle cell determines whether it is a type I or a type II fiber, the redistribution of a diminished number of axons will result in type grouping of fibers, pathognomonic (in humans) of denervation-reinnervation.

{14429} denervation-reinnervation pattern with type grouping; compare normal
{14418}

Tetanus with denervation

Yutaka Tsutsumi MD

Type grouping
Tom Demark's Site

{14353} neurogenic atrophy

Neuropathic changes
Photomicrographs and essay
UCSF

{14372} Werdnig-Hoffman disease
{14375} Werdnig-Hoffman disease
{14403} Werdnig-Hoffman disease

{14380} Kugelberg-Welander disease (note poor muscular development)
{14377} Kugelberg-Welander disease (Gower's sign like in Duchenne's; see below)

{14413} Charcot-Marie-Tooth disease, adult
{14407} Charcot-Marie-Tooth disease, kid
{14429} type grouping, this was a case of Charcot- Marie-Tooth disease

MUSCULAR DYSTROPHY

Muscular dystrophy
Photomicrographs and essay
UCSF

DUCHENNE'S MUSCULAR DYSTROPHY ("Jerry Lewis's kids")

{14443} Duchenne's, kid
{14446} Duchenne's, kid
{14449} Duchenne's; Gower's sign
{14408} Duchenne's, early, dark-staining fibers are dying
{14411} Duchenne's, classic histopathology
{09036} Duchenne's, biopsy; trichrome stain (i.e., muscle red, fibrosis blue)

Duchenne's
Autopsy muscle
Personal gallery

Duchenne muscular dystrophy
H&E
Wikimedia Commons

{14473} Becker's (I think; pseudohypertrophy of calves)
{14467} Becker's (I think; pseudohypertrophy)
{14470} Becker's (I think; pseudohypertrophy)

Becker's
Heart

Becker's
Wash U, St. Louis

{27271} Emery-Dreifuss
{27274} Emery-Dreifuss
{27277} Emery-Dreifuss
{27280} Emery-Dreifuss
{27283} Emery-Dreifuss
{27352} Emery-Dreifuss

Emery-Dreifuss
Wash U, St. Louis

{53755} myotonic dystrophy
{14485} myotonic dystrophy
{14488} myotonic dystrophy
{14491} myotonic dystrophy

{14515} facioscapulohumeral dystrophy, patient

Facioscapulohumeral dystrophy
Wash U, St. Louis

{14521} limb-girdle dystrophy, patient
{14385} limb-girdle dystrophy, histology

OTHER HEREDITARY MUSCLE DISEASES ("the other congenital myopathies"; floppy babies or kids who do especially poorly in gym-class). This group does NOT show the histopathology suggesting muscular dystrophy.

Acid maltase deficiency, child
Wash U, St. Louis

Acid maltase deficiency, adult
Wash U, St. Louis

Acid maltase deficiency, child
Wash U, St. Louis

Glycogen
Wash. U., St. Louis
Illustrated notes

{15334} teen with mild acid maltase deficiency; looks okay but tires easily at sports

McArdle's
Pittsburgh Pathology Cases

McArdle's Disease
Pittsburgh Illustrated Case

McArdle's Glycogenosis
Brazil Pathology Cases
In Portuguese

AZT myopathy
Ragged red fibers
Great photo from NEJM

{14435} mitochondrial myopathy; mitochondrial clusters are dark purple
{14436} mitochondrial myopathy; mitochondrial clusters are dark b;ie

Mitochondrial myopathy
Wash U, St. Louis

{14376} rod body ("nemaline") myopathy
{14378} rod body ("nemaline") myopathy
{14379} rod body ("nemaline") myopathy, Gomori trichrome stain

Nemaline myopathy
Electron micrograph
Children's

Nemaline myopathy
Wash U, St. Louis

THE OTHER HEREDITARY ONES

Tubular aggregates
Wash. U., St. Louis
Illustrated notes

Central Core Disease
Wash U, St. Louis

{27319} central core disease; patient (no really diagnostic features visible)
{27331} central core disease; patient (no really diagnostic features visible)
{27352} central core disease; patient (no really diagnostic features visible)
{27325} central core disease, patient

INCLUSION BODY MYOSITIS ("distal myopathy with rimmed vaculoes"; Am. J. Path. 156: 1835, 2000; Am. J. Path. 164: 1, 2004):

RHABDOMYOLYSIS

{27349} myositis ossificans; bumps are bone

Myositis ossificans
Pittsburgh Pathology Cases

INVOLVEMENT OF MUSCLE IN SYSTEMIC DISEASE

Ipecac myopathy

Pittsburgh Pathology Cases

{46215} pus in necrotic muscle infected with bacteria; this is unusual
{08215} trichinosis
{08288} trichinosis
{15750} trichinosis
{24498} trichinosis

Trichinosis

Yutaka Tsutsumi MD

{29501} polymyositis, histology
{05780} polymyositis, histology
{09039} polymyositis, histology
{14352} polymyositis, histology
{14356} polymyositis, histology; obvious perifascicular atrophy
{14358} polymyositis, histology; obvious perifascicular atrophy
{14433} polymyositis, really bad inflammation
{29504} polymyositis, histology, showing regeneration

POLYMYALGIA RHEUMATICA (Lancet 381: 28, 2013; BMJ 336: 765, 2008)

CRITICAL ILLNESS MYOPATHY ("acute quadriplegic myopathy" was the original name for the group of illnesses; there are now many other names, first major review; Crit. Care Med. 27: 2544, 1999; updates Muscle and Nerve 23: 1785, 2000; Muscle Nerve 32: 140, 2005); Chest 131: 1541, 2007

THE MUSCLE MEMBRANE DISEASES: Electrical troubles! Old review: NEJM 328: 482, 1993. The chloride channel itself: Neurology 54: 937, 2000. Reliable stain Neurology 79: 2194, 2012.

{14500} myotonia congenita with hypertrophy
{14503} myotonia congenita, older patient with atrophy
{14506} myotonia congenita, older patient with atrophy

OTHER MUSCLE PROBLEMS

{24748} rhabdomyosarcoma (striations)
{09006} alveolar rhabdomyosarcoma; very undifferentiated tumor
{25305} sarcoma botryoides with cambium layer

Alveolar Rhabdomyosarcoma
Tom Demark's Site

Rhabdomyosarcoma
WebPath Photo

Rhabdomyosarcoma
WebPath Photo


Action hero -- 1950's
Kirk Douglas as "Spartacus"

Action hero -- 1980's

ATHLETICS

Sports do not build character. They reveal it.

{18664} "pumped"

Johnny Weissmuller as Tarzan
BEFORE working out became popular
Weissmuller was also a real athlete.

Mel Gibson, ~ age 50
Cast as an ordinary guy, AFTER
working out became popular

Douglas Fairbanks
Cast as an action hero BEFORE
working out became popular

Bruce Willis
Cast as a psychologist AFTER
working out became popular

Eroll Flynn
Cast as an action hero BEFORE
working out became popular

Kirk Douglas
Cast as a an action hero BEFORE
working out became popular

Ronald Reagan, Johnny Davis, and John Payne
Hollywood studs BEFORE
working out became popular

Harrison Ford, age 58
Cast as a college professor
AFTER working out became popular

      The traditional wisdom in "exercise and the heart" was to emphasize the health-benefits of aerobic training, and to dismiss the idea that strength training has benefits beyond sports. This all changed in the 1990's.

        Strength training helps old folks walk farther (Ann. Int. Med. 124: 568, 1996), re-muscles the elderly so they can do more ("reversing sarcopenia", Geriatrics 51: 46, 1996), strengthens rheumatoid arthritis patients and causes them to report less pain and less fatigue (Arth. Rheum. 39: 415, 1996), reduces (!) osteoarthritis activity in the knee (Nsg. Res. 45: 68, 1996), lowers diastolic blood pressure in older folks (Arch. Int. Med. 165: 756, 2005), "tells a counterstory of aging that resists the narrative of decline" (i.e., lets the world know you're not going to just give up, get old and die; J. Geront. 66: 628, 2011), etc., etc. Even the fibromyalgia patients benefit significantly (Arth. Rheum. 47: 22, 2002).

        Reports on strength training and lipids are mixed, but in 2007, the American Heart Association gave a reasoned, very extensive endorsement to resistance training for people both with and without heart diseases (Circulation 116: 572, 2007).

        Weightlifting builds and strengthens older folks (60+). J. Ger. Mar. 1995; Am. J. Phys. Med. Rehab. 81(S-11): S3, 2002). Older diabetics: J. Ger. 58: 740, 2003. Both resistance training and aerobic training reduce HgbA1c in diabetics (JAMA 305: 1790, 2011).

        The academicians finally got around to seeing whether having post-polio patients pump some light iron helped, and of course it did (Am. J. Phys. Med. Rehab. 75: 50, 1996).

        * Weightlifting seems neither to help nor hurt myotonic dystrophy patients, while it apparently helps some neuropathy patients (Arch. Phys. Med. Rehab. 76: 612, 1995).

      Hopefully to no one's surprise, resistance strength training was very helpful for folks who have trouble walking because of peripheral vascular disease -- probably by improving the availability of the muscle.

      What's more, resistance training bulks the heart (Cardiology 90: 145, 1998) as aerobic exercise does. This was so politically incorrect that at first all the big-hearted bodybuilders in the study were wrongly accused just on this evidence of taking anabolic steroids. Science is now winning out over politics, at least here.

    Lifting is safe, even for younger kids if you supervise them properly (Sports Med. 15: 389, 1993); I'd be concerned about using heavy weights that might cause premature closure of the epiphyses. It's safe for the emphysema folks (it makes them feel better! Thorax 47: 70, 1992), and the coronary-disease guys (Am. J. Card. 71: 287, 1993; Am. J. Card. 67: 939, 1991). The skeletal muscle mass of a distance runner is around 38% of body weight; for a bodybuilder, it's around 59% (J. Sports Sci. 11: 3, 1993).

      Bodybuilders will ask you for your opinions about various nutritional supplements to enhance their performance. Despite the advertisements, the ones that got tested during the 1990's were all total flops (animo acids: Int. J. Sport. Nutr. 3: 290, 298 & 306, 1993; boron: Int. J. Sport. Nutr. 3: 140, 1993; chromium picolinate Int. J. Sport. Nutr. 2: 343, 1992; growth hormone J. Appl. Phys. 74: 3073, 1993; I could only get these as abstracts).

      So what works? The value of both creatine (J. Fam. Pract. 51: 945, 2002; Am. J. Clin. Nutr. 72(S2): 607-S, 2000) and post-exercise intake of protein or carbohydrate are now established (Can. J. Appl. Phys. 25: 254, 2000.) More than 20&ngsp;grams of protein after working out is a waste (Am. J. Clin. Nutr. 89: 161, 2009). Creatine evidently makes the satellite cells divide (Int. J. Sports Med. 21: 13, 2000). Early concerns about creatine producing rhabdomyolysis seem to have come to nothing. Creatine is now being used to prevent muscle wasting during, and restore muscle mass after, immobilization (Diabetes 50: 18, 2001). No offense to anybody, but eating meat (rather than just other animal or vegetable proteins) helps too (Am. J. Clin. Nutr. 70: 1032, 1999).

    While lifting weights, it's best to keep your glottis open, and not Valsalva. The more elaborate instructions about "when to breathe in, when to breathe out" are of course designed to make lifters keep their glottis open.

      * In one study, the blood pressure in a bodybuilder lifting his maximum with a closed glottis was reported to rise to an average of 311/284, and one muscle guy got it as high as 370/360. (I wonder about the measurement techniques... Arch. Phys. Med. Rehab. 76: 457, 1995).

    SYNTHETIC ANABOLIC STEROIDS: ("breakfast of champions", etc.; review J. Clin. Endo. Metab. 95: 1533, 2010; South. Med. J. 98: 550, 2005 explains what "stacking" and "pyramiding" are; Lancet 371: 1872, 2008 emphasizes the major public health problem, especially the violence)

      Around one million Americans will take human-made anabolic steroids illicitly to bulk their muscles this year (see references below), often in doses up to 40 times what is recommended for therapeutic use (reversing negative nitrogen balance, preventing angioedema).

        * The unfortunate man who didn't know what was really in his "protein health drink" prepared specially at the gym: Br. Med. J. 313: 100, 1996.

        * Today, senior bodybuilders are much sought-after as supposedly possessing arcane knowledge about anabolic steroids, and there is a huge underground literature, much of which strikes me as dubious. Review (finally) in Sports Med. 32: 285, 2002, by the psychiatrists at Western Missouri.

        Weightlifting and 'roids for the men with AIDS wasting (wasting can proceed even if you are on HAART): JAMA 281: 1282, 1999. 'Roids help the man on dialysis stay well-muscled and well-functioning: JAMA 281: 1275, 1999. For the women: Arch. Int. Med. 165: 578, 2005 (seems safe and effective).

      They work. Men (South. Med. J. 84: 552, 1991, and also women; see Am. J. Ob. Gyn. 165: 1385, 1991) can and do develop spectacular muscles using steroids, and the drugs also improve mood and increase aggressiveness (JAMA 269: 2760, 1993 for the first placebo-controlled study; one guy in the subject group went crazy).

Encyclopedia of Bodybuilding
Lots of helpful terminology
Courtesy link

Mr. Universe Contest, 1953 (pre-steroids)
Probably about the limit for "natural".
Sean Connery is 4th from left

      Users are willing to take the risks, which include:

      • Short-stature for life (if used before natural closure of epiphyses; JAMA 261: 1856, 1989)
      • Accelerated male pattern baldness
      • Testicular atrophy and infertility (you're making no gonadotropin while on steroids; the sperms come back after cessation; Fert. Ster. 52: 1041, 1989; J. Urol. 153: 1628, 1995 for the guy who roasted his pituitary....)
      • Increased LDL cholesterol, xanthomas, coronary and stroke risk (well, allegedly; Arch. Path. Lab. Med. 125: 253, 2001 describes sudden death in two 'roided-up bodybuilders but the only pathology seems to be an MI in one and normal decomposition in the other; even the cardiologists now say that the arteries are not impaired by 'roiding-up J. Am. Card. 37: 224, 2001);
      • Gynecomastia (infamously irreversible when due to anabolic steroid use; some bodybuilders use tamoxifen or surgery to remove their "b-tches' t-tties", and surgery is now routine, be sure you get all the breast tissue: Plastic & Rec. Surg. 107: 240, 2001)
      • Altered libido (up and/or down) and impotence
      • Crazy aggressive behavior (Am. J. Psych. 145: 487, 1988; demented murders J. Clin. Psychiat. 51: 28, 1990; anabolic steroid use runs with tobacco, drugs, and aggressive behavior JAMA 270: 1217, 1993; NEJM 328: 922, 1993; J. Fam. Pract. 35: 401, 1992; Arch. Gen. Psych. 51: 375, 1994; this behavior by "steroid monsters" is by now well-known and gives gym types, who are mostly okay guys, an undeserved bad name)
      • Withdrawal syndrome, characterized by severe depression (Am. J. Psych. 147: 510, 1990; suicide Am. J. Psych. 146: 1075, 1989; series of suicides Ann. Clin. Psych. 11: 223, 1999; DSM-III criteria for addiction met J. Clin. Psychiat. 50: 31, 1989, but gee whiz, coffee does too)
      • It was once claimed that 'roids make tendons stiff and brittle (not good if you plan to lift heavy weights: J. Bone Joint. Surg. 74: 411, 1992; a bodybuilder doesn't need a ruptured biceps tendon); ultrastructural studies failed to confirm this (Injury 29: 769, 1998);
      • "Peliosis hepatis"; dilatation of hepatic sinusoids ("blood cysts") that occasionally hemorrhage
      • Hepatocellular carcinomas (rare; see Clin. Pharm 6: 687, 1987 for this and other physical risks; the newer literature reports hepatocellular adenomas instead, which are prone to bleed)
      • prostatitis (? your prostate getting its architecture scrambled and its fluid getting all crusty? JAMA 276: 257, 1996)
      • thromboemboli (Am. Heart J. 125: 367, 1993), well maybe
      • focal-segmental glomerulosclerosis (maybe; Am. Soc. Nephro. 21: 163, 2010)

      The first six are common. In addition, women are likely to grow thick hair on their faces and other un-feminine places, and smell as bad as we men do because of the hypertrophy-hyperplasia of the apocrine glands. Pee-yoo! You have been warned.

      Between 5% (Am. J. Dis. Child. 144: 99, 1990) and 11% (Pediatrics 83: 921, 1989) of high school athletes have used anabolic steroids. One older study cites 7.6% of high-school males and 1.5% of high-school females (!; Am. J. Dis. Child. 14: 823, 1992). Parents request them for their skinny, non-athletic sons (Pediatrics 84: 940, 1989). More recent self-reports (now that there's more of a stigma), it's only 1.5% of all teens but with no change between 1999 and 2004 (Pediatrics 119: 476, 2007); or 2.7% of twelfth-graders (Am. J. Phys. Med. Rehab. 88: 192, 2009 -- the retrospective study retired football players -- there are obviously lots of confounding variables; the 'roid users had more ligament injuries but not tendon injuries -- any ideas why?). We won't talk about college, Olympic, or professional athletes. In amateur boxing, which is primarily about speed and smarts rather than strength, and where keeping one's weight down is critical, there is probably little anabolic steroid use. In a switch from complete condemnation, the pediatricians (Pediatrics 99: 904, 1997) now talk about moderate steroid use as a personal choice for the young athlete (though of course it's probably illegal and immoral). Today's common-sensical doctor is invited to review the risks and remind Junior that the social benefits of jocking it up (i.e., excelling on team sports and looking a lot better than most other boys nowadays) can be obtained about as easily without using steroids. Common sense triumphant. More common-sensical advice for realist-physicians: Ped. Clin. N.A. 54: 771, 2007. The "official" statement from the American Academy of Pediatrics of course still condemns the use of all performance-enhancing substances (Pediatrics 115: 1103, 2005), and I think this is the moral thing to do. However, I'd much rather have my own son express an interest in trying steroids under supervision than telling me he has a favorite brand of beer, smoking tobacco, or getting a motorcycle. The politics of anabolic steroid use, and attempts at control: NEJM 321: 1042, 1989; the latter have historically been a joke (older review NEJM 322: 775, 1990; Olympics Nature 407: 124, 2000). Only six athletes were disqualified on screening for the 2008 Beijing olympics because of banned substances; six athletes were caught during the games. The Olympics folks now freeze blood samples for eight years, in the hopes that future technology will detect what we can't today. Truth be told, I have known a few gym guys who have tried anabolic steroids, and all regretted it in the long run. And in my unscientific series, most women prefer a naturally-muscled man.


Brevity
Despite the anecdotal evidence, there are no good studies correlating dosage, drug type, and effect. Physicians are now sometimes supplementing older men with synthetic androgens, just as we've supplementing older women with estrogens for decades to relieve menopausal problems and control osteoporosis (Sci. Am. 272(2): 76, Feb. 1995 -- it's now routine for older men who are losing muscle mass, and the biochemical pathways are coming to be known Endocrinology 151: 628, 2010). The "horror stories" seem to be mostly from people who took very high doses of these potent substances (Psych. Clin. N.A. 21: 829, 1998.) Today's pediatrician knows that Junior will be offered anabolic steroids and supplements, and it maybe good to remind him that these are much-hyped, expensive, somewhat hazardous to mind and body, and are really more for extreme bodybuilders than for ordinary teenaged athletes (Ped. Clin. N.A. 57: 729, 2010). Life's a matter of weighing benefits (to yourself and those around you) against risks (to yourself and those around you). It's your body and your mind.

At present, speaking as a physician, your instructor recommends AGAINST you or your patients taking anabolic steroids to "stud up".

* By the time you are in practice, "gene doping", genetically modifying one's genome by viral vectors, or gene products like myostatin through inhibitory nucleic acid sequences, may become commonplace. Perhaps the sports underworld will make faster progress with "gene therapy" than those seeking to treat disease. What may come: Ped. Clin. N.A. 54: 807, 2007.

* SLICE OF LIFE REVIEW

{14612} skeletal muscle, normal
{14613} skeletal muscle, normal
{14614} skeletal muscle, normal
{14615} skeletal muscle (high power), normal
{14616} skeletal muscle cross section, normal
{14617} skeletal muscle cross section, normal
{14618} smooth muscle, longitudinal section
{14619} smooth muscle, longitudinal section
{14620} smooth muscle, normal
{14621} smooth muscle (cross & longitudinal section)longitudinal and cross sections
{14622} cardiac muscle, normal
{14623} cardiac muscle, normal
{14624} cardiac muscle intercalated disks
{14625} cardiac muscle intercalated disks
{14955} tropomyosin, cell biology
{14956} tropomyosin, cell biology
{14957} myosin actin, cell biology
{14958} myosin actin, cell biology
{15110} muscle, cardiac
{15226} tongue, skeletal muscle
{15240} esophagus, skeletal muscle
{15263} duodenum, muscle
{15296} trachea, trachealis muscle
{20722} muscle, skeletal
{20723} muscle, skeletal
{20724} muscle, skeletal
{20725} muscle, skeletal
{20726} muscle, smooth
{20727} muscle, smooth
{20728} muscle, cardiac
{20729} muscle, cardiac
{20905} trachea, trachealis muscle
{20906} trachea, trachealis muscle
{21890} ocular muscle, NADH stain - normal
{35951} muscle spindle, normal

BIBLIOGRAPHY / FURTHER READING

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