Way to Drop the Ball, Florida

 Medicine, Politics  No Responses »
Jul 102012
 

Apparently the best time to shut down a TB hospital is during a TB outbreak. Stacey Singer at the Palm Beach Post has a superb article:

The CDC officer had a serious warning for Florida health officials in April: A tuberculosis outbreak in Jacksonville was one of the worst his group had investigated in 20 years. Linked to 13 deaths and 99 illnesses, including six children, it would require concerted action to stop.
That report had been penned on April 5, exactly nine days after Florida Gov. Rick Scott signed the bill that shrank the Department of Health and required the closure of the A.G. Holley State Hospital in Lantana, where tough tuberculosis cases have been treated for more than 60 years.

As health officials in Tallahassee turned their focus to restructuring, Dr. Robert Luo’s 25-page report describing Jacksonville’s outbreak — and the measures needed to contain it – went unseen by key decision makers around the state. At the health agency, an order went out that the TB hospital must be closed six months ahead of schedule.

Had they seen the letter, decision makers would have learned that 3,000 people in the past two years may have had close contact with contagious people at Jacksonville’s homeless shelters, an outpatient mental health clinic and area jails. Yet only 253 people had been found and evaluated for TB infection, meaning Florida’s outbreak was, and is, far from contained.

The public was not to learn anything until early June, even though the same strain was appearing in other parts of the state, including Miami.
Tuberculosis is a lung disease more associated with the 18th century than the 21st, referred to as “consumption” in Dickensian times because its victims would grow gaunt and wan as their lungs disintigrated and they slowly died. The CDC investigator described a similar fate for 10 of the 13 people who died in Jacksonville.

Cambodia Fresh!

 Culture, Quote of the Day  No Responses »
Mar 282012
 

A certain casualness about danger seems to be a legacy of the war: a few weeks earlier, a drunken farmer and three friends were killed when the rocket-propelled grenade he was using as a mock karaoke microphone exploded.

–Matthew Power, “Slipping Through the Net: Cambodia’s Border War Against Drug-resistant Malaria,” Harper’s Magazine, April 2012

Infection & Autoimmunity

 Biology, Medicine, Zoology  No Responses »
Nov 052011
 

There seems to be mounting evidence that infection and autoimmune disorders have an interesting–if frustrating–relationship: people exposed to more microbes are less likely to develop an autoimmune disorder. This American Life did a story (transcript / audio; skip to “Act Three”) on a fellow named Jasper Lawrence who had asthma super bad. One day he hears tell of the theory that most folks in developing countries don’t have asthma and that this is because they have hookworm.

So Jasper goes to Africa and spends a considerable amount of time literally going to remote villages and walking barefoot through the communal latrine while very confused villagers looked on. Not too long after, Jasper’s asthma pretty much disappears. (He then started selling hookworms on the Internet to other asthmatics but the Man shut him down.)

The whole idea behind this is something called the Hygiene Hypothesis (PBS video): the idea that excessive cleanliness prevents certain opportunities to acquire immunity and that this lack of immunity is related to the increasing incidence of autoimmune disease in industrialized countries and urban environments.


One of the players in the research is Dr. David Pritchard (NYT article):

While carrying out field work in Papua New Guinea in the late 1980s, he noticed that Papuans infected with the Necator americanus hookworm, a parasite that lives in the human gut, did not suffer much from an assortment of autoimmune-related illnesses, including hay fever and asthma. Over the years, Dr. Pritchard has developed a theory to explain the phenomenon.

“The allergic response evolved to help expel parasites, and we think the worms have found a way of switching off the immune system in order to survive,” he said. “That’s why infected people have fewer allergic symptoms.”

…

In the tropics, where it is common, hookworm kills 65,000 people a year and afflicts hundreds of thousands with anemia. In low numbers in adults in a controlled experiment, Dr. Pritchard said, the worms have not caused problems.

…

After Dr. Pritchard’s self-infection experiment, the National Health Services ethics committee let him conduct a study in 2006 with 30 participants, 15 of whom received 10 hookworms each. Tests showed that after six weeks, the T-cells of the 15 worm recipients began to produce lower levels of chemicals associated with inflammatory response, indicating that their immune systems were more suppressed than those of the 15 placebo recipients. Despite playing host to small numbers of parasites, worm recipients reported little discomfort.

Trial participants raved about their allergy symptoms disappearing.

So now it seems that H. pylori may also be protective against asthma.

Infection with the gastric bacterium Helicobacter pylori provides reliable protection against allergy-induced asthma, immunologists from the University of Zurich have demonstrated in an animal model together with allergy specialists from the University Medical Center of the Johannes Gutenberg University Mainz. Their results published in the Journal of Clinical Investigation confirm the hypothesis recently put forward that the dramatic increase in allergic diseases in industrial societies is linked to the rapid disappearance of specific micro-organisms that populate the human body.

The hygiene hypothesis reminds me of a computer science problem: memory and computation time are inversely related. It seems that in medicine–and most everything else, I guess–we run into a similar problem; we want to avoid harmful infection but we also want to avoid autoimmune disease.

Short Stick in the Arm

 Medicine  No Responses »
Oct 052011
 

Lots of drug shortages recently. We are all out of morphine–that stolid workhorse of analgesia–at work. My prescription had to be dispensed in different dosages from different manufacturers because the DEA put a limit on Adderall production. NPR sez:

Drug shortages mean a growing number of Americans aren’t getting the medications they need. That’s causing drug companies and doctors to ration available medications in some cases.

“We’re now at 213 shortages for this year,” says Erin Fox of the University of Utah, who tracks national drug shortages. “That surpasses last year’s total of 211. And it doesn’t seem like there’s an end in sight.”

The shortages involve a wide range of medications: cancer chemotherapy agents, anesthetics, antibiotics, electrolytes needed for nutrient solutions, and dozens more. One drug currently in short supply is used in critically ill patients to bring down soaring blood pressure.

So far, 15 people have died and whole lot more are being rationed. Kevin Zakhar is a kid with no small intestines who survives on TPN, an ingredient of which is calcium gluconate:

One reason that Kevin Zakhar hasn’t been able to get the calcium solution he needs is that hospitals have been reserving it for patients who need it even more desperately than he does.

Kathy Gura, a pharmacist at Children’s Hospital in Boston, points to one of those patients, a tiny infant born only 23 weeks past conception, as premature as a baby can be and still survive. And he wouldn’t have survived without the same kind of IV feeding that Kevin Zahkar gets.

Gura and caregivers at other hospitals say they have had to divert scarce electrolytes from other children and adults to save the lives of fragile preemies. Gura calls it “robbing Peter to pay Paul.”

This is stupid. First of all, calcium gluconate is generic. Second, it doesn’t take a rocket scientist to make it. Third, it’s kind of important. Fourth, let the preemie die. It sounds brutal, but it makes sense. Kevin is already a part of our society, has deeper roots, and is healthier than the preemie.

Dr. Taylor Thompson, medical director of the Mass General’s medical ICU, calls it rationing – something most people think happens only in socialized medical systems or developing nations, not in America. But experts say the problem has been building over the past decade, and has accelerated since 2006.

“It’s really no way to run an integrated health care delivery system, to take cornerstone drugs and have to do without and find alternatives monthly,” Thompson says.

An integrated healthcare system would be nice. Too bad we don’t have one.

For what it’s worth, my psychiatrist got paid shit tons of money by Eli Lilly ($100,383), and he told me Strattera sucks after I brought it up as an option.

Where From Other Than Inside?

 Medicine  No Responses »
Aug 262011
 

Addiction is often misunderstood and stigmatised by the public and doctors alike, and, as a result, is often undertreated. This situation might stem in part from the long-running debate between addiction experts over how to explain the disorder. Some researchers favour a moral model of addiction in which the disorder is largely viewed as a behavioural problem, whereas others prefer a neurobiological explanation.

Last week, the American Society of Addiction Medicine (ASAM) released a definition of addiction that supports the latter model, which states that: “…addiction is a chronic brain disorder and not simply a behavioural problem involving too much alcohol, drugs, gambling or sex.”

Although this definition could help to destigmatise addiction, increase patients’ willingness to engage in medical treatment, reduce punitive approaches towards drug use, boost investment into addiction research, and increase access to treatment, there could be a downside to overmedicalisation of addiction. Such an approach might in fact stigmatise addiction, lead to fatalism among patients, and prevent governments from addressing the social environments that increase the risk of addiction—eg, poverty. Some researchers have also argued that if addiction is viewed as a medical problem affecting a few people, it could reduce public health measures to control substance misuse in the wider public (eg, higher taxes and restrictions on sale and access to legal but addictive substances).

In truth, many factors—genetic, neurobiological, and social—affect addiction. The new ASAM definition also describes addiction as a primary disease (not merely the result of emotional or psychiatric problems) and a chronic disease needing treatment over a lifetime. These more useful points to emphasise about the nature of addiction should help to increase and improve treatment.

A multifaceted approach to treatment is needed that could involve not only pharmacological treatment, but also psychosocial approaches and social support to minimise risk, and motivate addicted individuals to make healthy lifestyle changes. Doctors should treat addiction as a complex disorder, and with the compassion that has been lacking in the past.

–The Lancet, Volume 378, Issue 9793, Page 742, 27 August 2011

Some researchers favour a moral model of addiction in which the disorder is largely viewed as a behavioural problem, whereas others prefer a neurobiological explanation.

A maladaptive behavior does not necessitate a moral failure. How else do you explain behavior than by neurobiology? There is no Devil to compel evil from you or angels to guide you through the narrow gate. Where else would behavior immediately originate from other than the brain?

A multifaceted approach to treatment is needed that could involve not only pharmacological treatment, but also psychosocial approaches and social support to minimise risk, and motivate addicted individuals to make healthy lifestyle changes.

Well, duh. Pharmacological options for alcohol suck–Antabuse (disulfuram) requires the patient to actually take the pill daily to provide the violent reaction against alcohol which is supposed to prevent the patient from drinking (and not from taking the pill). Obviously, compliance is a problem. Suboxone (buprenorphine) is a narcotic in and of itself and, like methadone, doesn’t solve anything other than surface problems like arrest, endocarditis, etc. So of course you need to use other approaches!

Does this all seem painfully obvious to anyone else?