Prostate Cancer: A Roller Coaster of a Ride

Prostate cancer is the most frequently diagnosed type of cancer in American men. According to the American Cancer Society, “about 1 man in 6 will be diagnosed with prostate cancer during his lifetime.” Out of every 36 American men, one will actually die from prostate cancer.

Although that is an unpleasant statistic, there are at least two million American men who have been diagnosed with prostate cancer that are still alive today, thanks to ongoing advancements in cancer treatments.

Prostate cancer is exactly what it sounds like: it’s cancer of the prostate (the male reproductive gland found in the urethra that secretes semen). Slowly over time cells located in the prostate glands begin to mutate into cancerous cells. In some cases, the cancer spreads quickly, but in most cases it spreads slowly over time. In fact, most men live their entire lives without exhibiting symptoms of prostate cancer.

Stanley M. Redwood, M.D. FACS, Chief of the Department of Urology at Sinai Hospital, gave an enthusiastic Grand Rounds presentation last week that addressed prostate cancer, its risk factors and its various methods of treatment titled “The Prostate Cancer: A Roller Coaster.” For those who aren't familiar with the disease, some of the symptoms include:

• Frequent urination
• Burning during urination
• Painful ejaculation
• Inability to have an erection
• Blood in the urine and semen

If left untreated, advanced prostate cancer can spread to other parts of the body such as the pelvis, ribs and spine. It can also lead to bone pain and tenderness.

Although prostate cancer causes many physical problems in men, Dr. Redwood explained that it can also be a major cause of male insecurity. Since women naturally go through menstruation, society is more accepting that they need to buy items such as feminine pads. But for a man with prostate cancer who can’t control his bladder, it’s almost always humiliating to walk down an isle in a store to buy male sanitary napkins.

Dr. Redwood also explained the different risk factors for prostate cancer. These include:
• Genetics – Occurs in 5-10 percent of males.
• Diet – A diet higher in fat leads to an increased risk of prostate cancer. Soy products are a great way to reduce the risk of prostate cancer.
• Hormones – Using anabolic steroids increases the risk of prostate cancer.
• Race - African American males have a much higher risk for prostate cancer than Caucasian males. In fact, darker pigmented males (such as those of native African descent) are at an even higher risk of getting prostate cancer.

Here is an age-related breakdown of prostate cancer cases found in African American men:

AGE	RISK
0-39	1 in 10149
40-59	1 in 38
60-69	1 in 14
70-79	1 in 7
80-Death	1 in 6

Treatment options for prostate cancer include:

• Anti-Androgen Hormone Therapy – Using hormones to block certain cell receptors.
• Taxotere (Docetaxel Injection) – Used with other medications to stop the spread of cancer cells.
• Brachytherapy – Implanting radioactive “seeds” into the cancerous tissue.
• CyberKnife® – A non-invasive robotic surgery that uses beams of radiation, available at Sinai Hospital.
• Taxotere Chemotherapy – Intravenous chemotherapy.
• Radical Robotic Prostatectomy – Surgery performed remotely using a robot.
• Intensity-Modulate Radiation Therapy - Small radiation beams are aimed at a tumor from different angles.
• Da Vinci Surgical System – Surgeons control a robotic platform with their hands, available at LifeBridge Health.

Even though it’s rare for men to get prostate cancer before they are 40 years old, it is still wise for men in their 20s and 30s to get an exam every few years. Once they hit 45, they should get one every year.

To learn more about prostate cancer and other cancer-related conditions visit the Alvin & Lois Lapidus Cancer Institute.

You can also read these previous blog posts about prostate cancer:
• Prostate Cancer Screening at Northwest Hospital
• Guidelines for Prostate Cancer Screening Revised

-Trish Smith

Another Reason to Stop Smoking

While Chronic Obstructive Pulmonary Disease is not fully reversible, patients and physicians can take action to minimize the disease's progression, a pulmonary expert said last week.

COPD, which causes difficulty breathing, is the No. 4 cause of death in the United States, with 12 million people diagnosed each year. Additionally, 24 million people are suspected to be undiagnosed. Thirty-five percent of smokers develop COPD, said Joshua Rubenfeld, M.D., a member of the Sinai Hospital Division of Pulmonary and Critical Care Medicine.

Dr. Rubenfeld presented a COPD update at Sinai Hospital Grand Rounds last Thursday. Other risk factors for developing the disease include drug use, an HIV diagnosis, a family history, or those with an occupation that exposes them to gas or fumes.

To make a diagnosis, a physician must do a spirometry test, which involves blowing out as hard as one can into a small machine that tests lung capacity, and use a bronchodilator at least one to evaluate the effect. Diseases that can mimic the symptoms of COPD include asthma, pulmonary edema, tuberculosis, or broncostaxis, which is why it's important to nail down a COPD diagnosis.

COPD is a 'global disease', says Rubenfeld, as it can cause skeletal muscle wasting, osteoporosis,
kidney disease and other tobacco-associated diseases like coronary or cerebrovascular problems.

If it sounds like a grim prognosis, there is a way for a patient to take control: stop smoking. This will allow lung function to improve the first year and then allow the lungs to decrease at a normal rate. Additionally, those with COPD benefit the most from oxygen therapy, and physicians will also often prescribe corticosteroids, bronchodilators, or antibiotics. Still, “everything is palliative except for the oxygen,” Rubenfeld said.

The bottom line is that quitting smoking before a COPD diagnosis offers the best chance to breathe easy, and those who are diagnosed should stick with the recommended medications. As Rubenfeld explained, “hospital admissions for COPD exacerbations portend a poor overall prognosis, surgical therapy is risky, bronchoscopic therapy is unproven, and medical therapy is the cornerstone for helping the disease.”

To learn more about Dr. Rubenfeld or Sinai Hospital, call 410-601-WELL (9355).
-Elizabeth Leis-Newman

Obesity Poses Challenges

This country faces many challenges and a big one – no pun intended – is obesity. “Obesity has become an epidemic,” says Lee Kaplan, M.D., Ph.D.

Dr. Kaplan, a visiting professor from Massachusetts General Hospital and director of the MGH Weight Center, presented a lecture on obesity during Grand Rounds at Sinai Hospital last week. The lecture was dedicated to the late Albert Mendeloff, M.D., who was a gastroenterologist, nutrition expert and former physician-in-chief at Sinai.

“It’s one of those disorders everyone knows about, but not enough about,” Dr. Kaplan says. “Severe obesity is getting worse. All you have to do is look at any playground.”

Make no mistake: Obesity has become a worldwide problem, he says.

“Since 2005, more people are obese in the world than malnourished. Yes, the U.S. leads the way but other countries are catching up,” Dr. Kaplan says.

Obesity is challenging because of its complexity and health risks. For example, not every obese person overeats and sometimes a thin person can habitually overeat and not become obese. But the consequences of obesity can lead to life threatening illnesses. In the U.S., 1,000 people a day die of complications of obesity, Dr. Kaplan says.

Doctors often do not mention concerns about obesity to their overweight patients. “It is not recognized by most physicians,” Dr. Kaplan says. He offers suggestions on how physicians can approach the topic with their patients.

• Respect the patient. Avoid pejorative language. “When most patients hear the word, ‘morbid,’ they think “disgusting,’” he says.
• Do not indulge in the “blame game.”
• Work to develop a therapeutic partnership and inform the patient that losing weight takes time. “There is no magic bullet," Kaplan says.
  
• Discuss the causes of obesity and treat any underlying disorders. Acknowledge that some drugs patients take can cause obesity, and find drugs that do not.
• Focus on a healthy diet, physical activity, stress reduction.
• Surgery is an option but it should be the “therapy of last resort,” Dr. Kaplan says.

Obesity is a disease, he says. Complications from obesity can kill. “Obesity should be a global health priority,” Dr. Kaplan says.
-Sandra Crockett

Got the Urge? Incontinence and Women

When you “gotta go, gotta go,” all of the time, you probably should go straight to your doctor to determine the reasons why. It’s a problem facing many people. “Over 35 million people in America have bladder problems,” says Dee-Dee Shiller, D.O., the director of the Women’s Wellness Center at Northwest Hospital.

Dr. Shiller, presented a lecture on “urge incontinence” at Sinai Hospital’s Grand Rounds last week, where the focus was on women. “So many women deal with incontinence on a daily basis,” Dr. Shiller says. “The problem is, a lot of women don’t want to talk about it. They think it is part of the normal aging process.”

“Urge incontinence” is when a person leaks urine for no apparent reason after feeling the urge to urinate. It differs from “stress incontinence” which can happen after coughing, sneezing or exercising.

No one should suffer silently with bladder problems because good treatment options are available. Dr. Shiller advises her patients to urinate on a schedule, every two or three hours, instead of waiting until the situation gets dire. Also, her patients find that keeping a “bladder diary” is helpful.

The bladder diary can record the patients’ trips to the bathroom, what they drank, accidental urine leaks and what they were doing at the time. It can enlighten people to which bladder irritants may be causing the urge incontinence.

Bladder irritants can include caffeine, diet sweeteners, alcohol and tobacco. Dr. Shiller said that not everyone agrees with what can irritate the bladder. Also, losing excess weight, not drinking liquids three hours before bedtime, and doing Kegel exercises (contracting the muscles that form part of the pelvic floor for ten seconds and then relaxing) may help.

“Behavioral therapy does work,” Dr. Shiller says. However, there are medications that can also work although some can be costly.

The Women’s Wellness Center offers alternative therapies such as massage, yoga, meditation and acupuncture that can benefit women suffering from urge incontinence. “I would love it if Depends (adult diapers) were off the market,” Dr. Shiller says.

To learn more about the Women’s Wellness Center at Northwest Hospital, call 410-601-9355 (WELL).

A Primer on Gaucher's Disease

Are you or someone you love affected by Gaucher's disease?

A genetic disease, Gaucher's is caused by the deficiency of an enzyme that is the result of a genetic mutation. Without the enzyme, lipid (a fat) accumulates in the body and can cause symptoms that may appear any time.

Third year resident physician Malika Gupta, MBBS, presented at the Dr. Jennifer Ann Kierson Memorial Pediatric Grand Rounds at Sinai Hospital on Thursday, offering a primer on Gaucher’s disease.

Gaucher's disease symptoms can include, but are not limited to:
• easy bleeding and bruising
• excessive fatigue
• anemia
• weak bones
• enlarged liver and/or spleen causing a swollen stomach

There are three different types of Gaucher’s disease: Type 1, 2 and 3.

While Type 1 occurs throughout the world, it is most prevalent in descendants of Eastern European Jewish people. Within this population, Type 1 Gaucher Disease occurs at a rate of 1 in 450 live births, and is the most common genetically-based disease affecting Jewish people. The brain and spinal cord are not impacted in those with Type 1.

However, Types 2 and 3 are characterized by brain stem abnormalities. Type 2 is usually fatal during the first three years of life and occurs rarely; 1 in 100,000 live births. Type 3 Gaucher's disease is estimated to occur in 1 in 50,000 live births. The neurological symptoms of Type 3 Gaucher's disease are slowly progressive and appear later in childhood than the symptoms of Type 2 Gaucher's disease. Neurological symptoms of Type 3 Gaucher's disease include a lack of coordination, mental deterioration, and seizures.

Even if you do not have Gaucher's disease, you may be a carrier, as the National Gaucher Foundation estimates that, among Eastern European Jews, the carrier rate is around 1 in 15 people. Carrier status can be determined through a blood test. Talk to your physician about whether you might be a carrier.

If you suspect you or your child has Gaucher's disease, there are treatment options. To learn more about Sinai Hospital or to schedule an appointment, call 410-601-WELL (9355).

-Sandra Crockett

Thyroid Nodules Should Be Examined

Thyroid nodules – or abnormal growths on the thyroid gland – are quite common, with the rates of thyroid cancer growing, a leading expert told physicians last week.

Kenneth D. Burman, M.D., chief of the Endocrine Section at Washington Hospital Center and professor in the Department of Medicine at Georgetown University, presented at Sinai Hospital Grand Rounds on “Thyroid Nodules and Thyroid Cancer: Recent Advances.”

Dr. Burman cited an autopsy study in which it was discovered that 12 percent of the deceased had one nodule, 37 percent had multiple nodules and 2.1 percent even had thyroid cancer – even though they did not know it and died from other causes. Women are three to four times more likely to have thyroid nodules than men, and the nodules most commonly appear in women in their 30s and 40s.

While 90 to 95 percent of thyroid nodules are benign (such as adenomas, cysts or infections), it’s imperative that they are closely monitored by an endocrinologist to make sure they are not cancerous.

Two key diagnostic tools are ultrasound and fine needle aspiration. An ultrasound can tell a doctor if the nodule is solid, has blurred edges or calcifications, or has a lot of blood vessels feeding it – all of which are potential signs of cancer. If the nodule has any of these characteristics, a fine needle aspiration biopsy, or FNA, will be ordered. During an FNA, key portions of the nodule will be removed with a small needle so that they can be evaluated to see if they are cancerous.

According to Dr. Burman, 86 percent of thyroid FNA results come back as non-cancerous, while 4 percent are malignant and 10 percent are suspicious. However, when the FNA and biopsy are repeated 6 to 12 months later, 22 percent of nodules can be categorized as malignant or suspicious. (Sixty percent of suspicious FNA results are later found to be malignant.) Therefore it is important that the patient have another FNA about 6 months later and ultrasound be repeated every 6 to 12 months to recheck the size and characteristics of the nodule.

In terms of incidence, thyroid cancer is the fastest growing cancer, with a 5 to 6 percent increase in the number of cases diagnosed each year. Dr. Burman says that there has been a 2 to 3-fold increase in thyroid cancer in the past 20 or 30 years. The most common thyroid cancer – papillary cancer, which amounts for 80 percent of cases, has a fairly good prognosis, with 93 percent of papillary cancer survivors living 10 or more years after diagnosis.

However, anaplastic thyroid cancer, which accounts for 2 percent of all thyroid cancer diagnoses, is the deadliest of all known cancers, with a 14 percent survival rate of more than 10 years. As with all cancers, the earlier thyroid cancer can be detected, the better the chances are that a patient will make a full recovery.

As with all cancers, the earlier thyroid cancer can be detected, the better the chances are that a patient will make a full recovery.

Surgery and radioactive iodine therapy are used to treat thyroid cancer. Also, if a non-cancerous nodule is a causing cosmetic problems or compressing a patient’s esophagus, it can be surgically removed.

If you or a loved one has been discovered to have a thyroid nodule and you’d like to schedule an appointment with a LifeBridge Health endocrinologist, call 410-601-WELL (9355).

-Holly Hosler

Monitoring and Managing Diabetes and High Blood Pressure

People with diabetes should have their blood pressure monitored and managed aggressively, a leading nephrologist told a group of Sinai Hospital physicians last week.

George Bakris, M.D. presented on “Updates in Treatment Goals for the Diabetic Hypertensive” at Sinai Hospital’s Grand Rounds. Dr. Bakris is the Director of Hypertension Center and a professor at the University of Chicago Medical Center. The presentation was dedicated to the numerous accomplishments of longtime Sinai Hospital physician Leon Kassel, M.D.

There is a significant increase in mortality rates for patients in a hospital who have both diabetes and hypertension. Untreated high blood pressure increases the likelihood of a heart attack or stroke. That’s one of the reasons why physicians need to get patients’ blood pressure controlled, which can be accomplished through medication, Dr. Bakris says.

According to the American Heart Association, 77 percent of first-time stroke victims have a blood pressure of over 140/90. The recommendations for blood pressure levels in those with diabetes and chronic kidney disease (without proteinuria) should be less than 140/90, Dr. Bakris says.

“If your patient doesn’t have proteinuria, treat the blood pressure and lipids with the simplest medications and get it below 140/90,” he says.

Diabetes and high blood pressure are risk factors for kidney disease. Those with diabetes should be monitored for microalbuminuria, or small amounts of a protein called albumin in the urine, although physicians should be careful to not jump to conclusions.

“Microalbuminuria does not by itself indicase kidney disease,” Dr. Bakris says. “It is a risk marker, not a risk factor. If you take care of the heart and the brain the kidneys will come along for the ride.”

Both patients and health care providers also need to remember to take blood pressure accurately.

“The patients’ back should be support with both feet on the floor,” Dr. Bakris reminded the physicians. He’s a believer in letting patients use home blood pressure kits.

“Taking blood pressure at home empowers the patient with information,” he says.

To learn more about assessing your high blood pressure, visit the American Heart Association's High Blood Pressure Health Risk Calculator. You can also visit Know Your Health Baltimore to do a heart assessment test.

Vitamin D: Are You Getting Enough?

By Holly Hosler

Ever since I went to Sinai Hospital Grand Rounds last week, which featured a talk on vitamin D by John Hopkins Bayview Hospital endocrinologist Suzanne M. Jan de Beur, M.D., I’ve been tempted to spend a little time outdoors during my lunch break. That’s because I learned a mere 15 minutes outside (without sunscreen) between 10 a.m. and 2 p.m. can cause the body to produce 3,000 IUs of vitamin D. This is necessary for bone mineralization and the prevention of fractures and osteoporosis, and potentially important for staving off conditions such as breast, prostate and colon cancers; diabetes; and cardiovascular disease.

Experts recommend that we get 800 to 2,000 IUs of vitamin D per day. (Levels up to 10,000 IUs per day on a continued basis are even safe, suggests a study cited by Jan de Beur.)

Unfortunately, it is believed that up to half of us have too little vitamin D in our bodies. The consequences of vitamin D deficiency include osteoporosis, osteomalacia (in adults)/rickets (in children), thyroid problems, muscle pain and weakness, and an increased risk for breast, prostate and colon cancers, as evidenced by epidemiological data. Those who are elderly, obese, spend most of their time inside, have dark skin, live in northern climates or have certain health conditions are particularly susceptible to low levels of vitamin D.

Jan de Beur explained that barring supplemental vitamins, ninety percent (90%) of our vitamin D comes from sun exposure, while the remainder comes from food sources such as sun-dried shiitake mushrooms, salmon and cod liver oil, and a slight amount from fortified products such as milk. She showed a graph illustrating that young people naturally produce more vitamin D from the sun than older folks. Of course, the elderly are at higher risk for falls and fractures, so it is critical that they receive enough vitamin D to help their bones absorb calcium.

Ironically, the UVB rays necessary for vitamin D production are the very same rays that cause skin cancer, so I decided to scrap my idea to eat lunch outside. Plus, in Maryland, the sun only helps us produce vitamin D between March and November. Therefore, Jan de Beur recommends that vitamin D be obtained through dietary supplements, as there is no evidence that this supplementary vitamin D is inferior to the vitamin D our bodies produce from the sun. She says that most people require vitamin D supplements to get the amount that they need for good health.

Do you suffer from insufficient vitamin D? Symptoms include bone pain and muscle weakness, but sometimes the signs aren’t very pronounced. Talk with your doctor if you have concerns, especially if you are not already taking a supplement with at least 800 IUs of vitamin D.

The Evolution of Liver Transplantation

End-stage liver disease is best treated by a liver transplant, a renowned gastroenterologist said at yesterday's Sinai Hospital Department of Medicine Grand Rounds.

Paul Y. Kwo, M.D., is an associate professor of medicine and the medical director of liver transplantation in the Division of Gastroenterology and Hepatology at Indiana University. His talk at Sinai was made possible by the Ellen Wasserman Lectureship.

The good news, according to Dr. Kwo, is that the increased use of the Model for End-Stage Liver Disease (MELD) gives more weight to disease severity than the patient's time on the wait list. At Indiana University, the median wait time for a liver transplant is 1.6 months versus 11.3 months nationwide, and the adult survival rate for the organ recipients is at 90.04 percent. Physicians are "inching our way" toward transplants for HIV-positive patients, and there's increasing evidence that age doesn't impact the success of a liver transplant.

Plus, transplantation in patients with severe obesity is "feasible," Dr. Kwo said. "The one-year survival rate is no different," he said.

Now for the bad news.

The demand for livers, along with other critical organs, continue to exceed what's available. Liver cancer (hepatocellular carcinoma) is the most rapidly increasing cancer in the United States. Hepatitis C is the most common indicator for liver disease; between 3 to 4 million people are infected in the United States; and half a million people have Hepatitis C-related cirrhosis. Cirrhosis is the slow degeneration of the liver, and while it's most commonly associated with alcohol, it can also result from hepatitis B, C or D or other diseases. Finally, while the death rate from liver disease has fallen overall, it is still highest in the African-American population.

What does this mean for you? Protect your liver by avoiding excessive alcohol consumption and eschewing drugs. Maintain a healthy diet and weight, and stop smoking.

Finally, remember that National Donate Life Month is around the corner. Talk to your family members about becoming an organ donor and sign up with your state registry.

Physician and Author Discusses Cultural Challenges

by Holly Hosler

During grand rounds at Sinai Hospital yesterday, scores of LifeBridge Health doctors and residents heard physician and writer Danielle Ofri, M.D., speak about the cultural challenges presented when meeting with patients.

Dr. Ofri’s talk, titled “Journeys with our patients: multiculturalism in a two-person canoe,” opened with a passage from her book Incidental Findings: Lessons from My Patients in the Art of Medicine. She read about her patient, Mrs. Uddin, a 35-year-old Bangladeshi and observant Muslim, who always complained of pain. “Why so much pain? Why, doctor, why?” the patient would moan in broken English.

Mrs. Uddin’s test results showed she was physically healthy; rather, her pain was a psychosomatic result of depression. Unfortunately, Mrs. Uddin continually resisted Dr. Ofri’s advice to see a psychiatrist and take medication that would alleviate her depression. Yet Mrs. Uddin frequented the doctor’s office month after month for eight years, and Dr. Ofri grew to despise her and everything about her – religious veil included – simply because there was nothing she could do to help or get through to her patient.

Dr. Ofri also documented this saga in a piece in the New England Journal of Medicine called “Torment.” She says she published it to “face up to the parts of me that I’m not proud of” and to expose areas in which doctors need to learn to be more sensitive to their patients’ cultural differences. Later in the lecture, Dr. Ofri revealed that when she openly asked Mrs. Uddin and her daughter about their Muslim veils – why they wore them and why they were of different styles – her patients warmed to her in ways previously unimaginable. Instead of being offended by her questions about their cultural practices, they were eager to discuss these parts of their lives. For the first time in her presence, says Dr. Ofri, Mrs. Uddin became “delighted” and “buoyant.”

“All the multicultural education we receive … seems so limited,” says Dr. Ofri.

Generalizations about different cultural groups – e.g., Hispanics are religious and value family and camaraderie – feel so “awkward” and “pitiable,” she says. On the other hand, when doctors practice cultural neutrality, patients perceive it as coldness and indifference. As a solution, Dr. Ofri suggests that doctors take “journeys” with their patients and coworkers from different cultural backgrounds by asking questions and gaining insights into their different perspectives. And she also warned us to be careful not to stereotype against ourselves, which she learned after failing to notice a key symptom in one of her patients whom she perceived to be like her – “white, female and neurotic.”

“Being a good doctor is so much harder than knowing all your medicine,” Dr. Ofri observed. By getting to know one’s patients, doctors will often find that their initial assumptions about their patients and the patients’ realities will be vastly different.

To see if Dr. Ofri is speaking in your city, click here.

Medical Mystery Behind Beethoven

by Holly Hosler

It’s not every day that Sinai Hospital Grand Rounds begins with the opening strains of a live rendition of “Romance No. 1 in G major.” But that’s exactly what happened yesterday morning in the Zamoiski Auditorium, where Phillip A. Mackowiak, M.D., gave a historical clinicopathologic presentation on Beethoven’s health problems. (Yes, that’s “Beethoven” as in Ludwig van.)

Before and after the presentation, Netanel Draiblate, Ph.D. candidate in violin performance at the University of Maryland College Park, wowed the audience of physicians with a couple of the extraordinary composer’s masterpieces.

University of Maryland School of Medicine’s Dr. Mackowiak, author of Post Mortem: Solving History’s Great Medical Mysteries, is an expert in using the historical record to shed light on the ailments suffered by luminaries such as Alexander the Great and Joan of Arc. He started the presentation by painting a picture of late 18th century Viennese life, a time of the Enlightenment and revolution, the Napoleonic Wars, high infant mortality and pre-Pasteurian medicine. Beethoven had been raised by an upright mother and an abusive, alcoholic father, who paraded him around courtly society to show off his talent.

Beethoven’s health problems began to show up in earnest when he was in his 20s. He suffered first from diarrhea and abdominal pain, which were to be a lifelong issue for him. (Beethoven himself revealed that the 4th movement of his 2nd symphony is a musical description of the rumblings of his bowels.)

However, Beethoven’s most famous malady is his loss of hearing. He began to notice the problem at the age of 26 and by age 32, he accepted that he would eventually become completely deaf. This plunged him into a deep depression; he was embarrassed that even though he was a composer, he would lose his auditory sense. Beethoven tried to compensate for his loss through the use of headphones, but he never again heard a sound after the age of 50. (Even so, he went on to write his 9th and final symphony, also known as "Ode to Joy", which is lauded by many as the greatest symphony ever composed.)

The great composer had a litany of other health problems: migraine headaches, rheumatism, bronchitis, jaundice, painful eye inflammation and nosebleeds, to name a few. His final illness was a combination of diarrhea, jaundice and pneumonia, among other things, and he died in a delirium at age 56. Among the abnormalities revealed by Beethoven’s autopsy were cerebral atrophy (brain), macronodular cirrhosis (liver) and renal papillary necrosis (kidneys).

Scholars are at odds as to whether Beethoven had one disease, such as syphilis, or several that accounted for his poor health. Diagnostic solutions to Beethoven’s medical mysteries have included typhus, Paget’s Disease and lead intoxication. A couple members of the Grand Rounds audience even suggested that tuberculosis may have contributed to Beethoven’s problems – certainly a possibility, as the disease was widespread at the time and had claimed the life of Beethoven’s mother.

However, syphilis remains the strongest candidate to explain the physical sufferings that Beethoven endured. Though the man came of age alongside actors and actresses (infamous in those days for their promiscuity) and was known to have had affairs with married women, Dr. Mackowiak believes that it was congenital syphilis – probably passed down from his father – that was the source of Beethoven’s ill health. Congenital syphilis does not usually affect its victims until they are in their 20s, which is consistent with when Beethoven started noticing his hearing problems.

In fact, with the exception of his kidney problems, syphilis could explain all of Beethoven’s various ailments. However, even his kidney problems have a plausible explanation: Beethoven’s brother, who was an apothecary, had provided him with analgesics for most of his life. These drugs could have very easily caused analgesic nephropathy leading to the renal papillary necrosis. (In other words, too many painkillers killed his kidneys.)

While a definitive diagnosis is impossible with the limited physical evidence we have left (the temporal bones of Beethoven’s skull were saved, but were lost in the decade or two after his death), today’s Grand Rounds reflects why it's so important to have teaching hospitals like Sinai. The lectures illustrate the fascinating art of diagnosing patients – even long after they are dead.