Wednesday, July 31, 2013

Pig man?

Another cure for the fatal type of pulmonary hypertension is lung transplant, but they are lacking enough organs.

This article in Popular mechanics discusses a potential new source:
Pig human transplants...

The article discusses the "ethics", but in Catholic theology it is not a problem. Pig human chimera would be an ethical problem if a lot of genes are transplanted, but not if only a few genes are introduced. (if a lot of genes are tranplanted to make a chimera like the "underpeople" based on animals in the books of Cordwainer Smith, they would be considered human by the church, and the UKBishops even said chimeras with a lot of human genes should be adopted and raised as humans, not just culled and killed for convenience).

But the real danger is not ethics; it is infecion: there is a real  potential for causing epidemics. 

the existence of xenotropic endogenous retroviruses and the clinical evidence of long-lasting porcine cell microchimerism indicate the potential for xenogeneic infections. Thus, further trials should continue under regulatory oversight, with close clinical and laboratory monitoring for potential xenogeneic infections.

I am listening to a lecture on the population collapse of the Americas because the Europeans accidentally introduced a lot of diseases.

the missing clue to why this happened is the lack of domesticated animals in the Americas.
: in neolithic times, the close contact of humans and domestic animals resulted in a lot of viruses and bacteria migrating from animals to human beings. So there were local epidemics, and later, as trade routes expanded, (often via the silk road trade, the monsoon trade in the Indian Ocean, or the migration of the many steppe peoples such as the Huns, the scythians, the Samartans, the mongols, the turks, who tended to be able to move quickly between China and Iran and then Europe) the result was huge pandemics, but those who survived had more immunity...

So the "population collapses" in Eurasia happened, but they happened many times in pandemics, which often were followed by dark ages and recovery. But even the worse pandemics were one at a time, and the worst case scenerio was 50 percent population drop.

In the Americas, it was a twofold problem: One, everyone got sick at the same time, so there was literally not enough people who were well and able to care for the sick, and two: repeated epidemics of different diseases, so that the survivors of smallpox could then die of influenza or hepatitis B or measles in later epidemics.

Notice I said Measles? A big killer today in malnourished children. This is one of several diseases that are around all the time, but mainly kill children because the adults in the area are survivors of the disease. This means adults are still around to care for sick kids, and keep the civilization around.

But introduce measles into a new area, and it is a different disease.

Measles evolved from animal "rinderpest" about a thousand years ago. Many other diseases similarly are due to animal contact. HIV is probably from monkeys (from the custom of eating monkey meat in parts of Africa: the press didn't mention this part, so some people were under the impression the cause was a funny sexual perversion...of course, Americans think monkeys are nice cuddley animals too, but  most Africans and Asians know better.)

Pigs are a big problem here, because they carry a lot of diseases. Trichinosis gets the most attention, as does tapeworm, camplobacter, cryptosporidium, etc.but the main danger are the viruses that evolve into a human form, such as influenza.

The reason for "flu" epidemics is close contact of peasants with their pigs (and most bird flu cases were in those who raised chickens: wild fowl to free range chickens, which is why Jakarta banned people from raising fighting cocks in their back yards, but the real worry is if the bird flu mixes with pig flu and infects humans).

Note about chickens here in the Philippines: usually city folks buy chickens raised cheaply in chicken farms. Some do raise chickens for eggs, but you have to keep them caged, or they will hide the eggs in a nest.
Eating chickens can free roam, but are in danger of becoming dog food for feral dogs, or a meal for poor people who are hungry (one of our neighbors has some wandering around,  and I fear our dogs might attack them. However, those chickens are huge, and probably fighting cocks, not eating chickens.

Fighting cocks are ususally kept outdoors under a small shelter, with their leg tied to a post. That way they don't wander off, and they won't attack passing children. As for dogs, the cocks are vicious and can take care of themselves. But those who own and breed the chickens make friends with the chickens when they train them, so are at risk for contacting bird flu.

Just as an addendum: I didn't mention Ebola virus. Ebola Reston infects monkeys, and some of the monkeys were brought to the Philippines where they were kept and bred to sell to research places in the US...and some of the Ebola Reston spread to pigs, including local pigs.

Luckily, unlike monkeys, the pigs only got flu like symptoms, but in one local outbreak, a few humans felt ill, and several had blood tests showing they had caught and survived a mild case of the virus. Luckily it did not spread, which is saying a lot since in the Philippines, the sale of "double dead" meat and infected animals killed and sold instead of having their carcasses destroyed is a problem.

Tuesday, July 30, 2013

The sine wave EKG

Wired has a good story on germs resistant to modern antibiotics.

Lots of fake smoke, but also lots of real problem in the story to worry about.

Back to the good old days of dying from minor infections that ended up killing you...


Unrelated anecdote about paying attention to one problem and overlooking another.

When I was a medical, the problem was penicillin resistant staph.

So those with infections were put into an isolation ward, where they didn't spread it (but maybe where the care of other problems was lousy). The care was low level, sort of at a nursing home level, which was not good news if you got a really bad problem unrelated to your infection.

So when the nurses reported one patient was having symptoms, I was sent to the isolation ward to see a patient I didn't know and do an EKG...(I was a student, and didn't have much experience in EKG reading, but we were given "scut" work to do, so the hospital didn't have to hire a low level aide to do the work...).

So I got the EKG machine and found it was rarely used and no one ever fixed it. I could only get two leads to work, and got a strange sine wave pattern.

I showed it to the intern, a woman who hated me and the other female student, and she bawled me out and told me to find another machine.

So I searched around and found another machine, and redid the EKG, and voila, again it was a sine wave pattern.

so again, I took the EKG up to show to the intern, knowing I would again be bawled out in public for being incompetent. Luckily, she was talking to the Resident, who grabbed it out of my hand and said "Oh My GOD".

Her potassium was 8, a fatal level, but sometimes due to a "false positive" lab error if the blood hemolyzed. So the laboratory didn't call us with a "headsup", but the result was put into the "inbox" at the nurses station at 3 pm, which was about the time the resident took over and started treating her for diabetic related hyperkalemia.

(she survived).

So I often complain about all those regulations we have to follow, but these regulations were put into place to prevent things like this: A lab result that was a dangerous level would now be required by law to be called to the doctor, the first EKG machine, (which was rarely used) would be checked ever month or so by someone that it worked...

----------------------------------- a version of this was cross posted to BNN.

Friday, July 26, 2013

Eugenics: it wasn't just Tuskegee

If you read a story about the gov't trying to get docs to talk to their patients about "end of life"  "choices", what they mean is to try to talk patients into not getting treated if they are too old or chronically ill.

And if you read that we need more such "outreach" to minorities, they mean we need to pressure more minorities to sign papers saying let them die.

don't believe me? Try this story about an ethicist who long denied she wanted to kill people, but now the NYTimes comes out with an admiring story on why she wants to do it. Apparently a person with a damaged brain, confused by drugs who pulls his breathing tube out needs their preferences followed?

I don't think so. 

The story is phrased as if he was dying, but the dirty little secret is that the docs did all they could because he had a chance to live. True, he might be left disabled, but that was not and should not have been part of their decisionmaking (if for no other reason that they are doctors, not fortune tellers, and no one can really predict such things).

But of course, a husband who is disabled is a pain in the neck, so of course confronting this made her think about legal killing, or letting him go.

Yes, must "educate" folks.

 The way Julianne Dickelman tells it, people make plans for their lives. They plan for a birth, marriage and retirement. But people aren't so good when it comes to their life's end.

 "We plan for everything in our lives except for this," she says. "We have birth plans, but we don't really have death plans."

 Dickelman is project manager for a new effort in Whatcom County called End-of-Life Choices Advance Care Planning Initiative. Its goal is to help county residents make clear what kind of end-of-life medical care they want, or don't want, via a written plan they make now, in case they can't communicate their wishes later.
notice they never want to educate folks that they might have a chance to live with treatment? Nah. Make them feel guilty that they will be a burden on their families if they live, and of course don't mention the gov't won't have to pay for their care.

At least that article is about a fairly affluent area in Washington state (where I suspect one of the subjects is how to kill  grandmom yourself).

the real problem are those minority patients who just won't stop treatment.

Washington Post article about the problem.
Those folks just won't let us kill them.

After lives in which they often struggle to get medical care, African Americans and other minorities are more likely than whites to want, and get, more aggressive care as death nears and are less likely to use hospice and palliative-care services to ease their suffering, according to a large body of research and leading experts.

 As a result, they are more likely to experience more medicalized deaths, dying more frequently in the hospital, in pain, on ventilators and with feeding tubes -- often after being resuscitated or getting extra rounds of chemotherapy, dialysis or other care, studies show.

 "I think we need to be very attentive to attending to suffering in our patients and do everything we can to help minimize and ameliorate it," said Richard Payne, who runs Duke University's Institute on Care at the End of Life. "African Americans and other minorities are at greater risk of not dying well."
notice it is not about the wishes of the patient, but that of the doctors, who see the treatment as suffering, not as a chance to live. There is a discussion of how people who see life even when suffering as meaningful for them, but then goes on to say ethics committees need to be part of the decision.

In other words, autonomy only means if you want to die, not want to live.

Also note that part about "coma". Too often this has been stretched (like in the case of Nelson Mandella) to "vegetative state" or those confused by delirium or medicines.

a typical example is this one which can be summarized in two words: Die sucker.
 On June 9, 2013, South Africa’s best-selling weekly newspaper, The Sunday Times, reported that Mandela’s long-time friend Andrew Mlangeni publicly stated: “You (Mandela) have been coming to the hospital too many times. Quite clearly you are not well and there is a possibility you might not be well again.”

Mandela’s long-time comrade recognized and verbalized the end-of-life equation whether the rest of the world wants to hear it or not. I applaud him.

The dirty little secret is that some of these folks go home and live longer, but never mind.

as this article admits: If you come home but continue to need care and/or are confused, you are a burden to others, so better you kill yourself.

Again, the "fortune telling" error of logic is here: because no one can tell if a person will live or not, if they will be disabled or not. But the real danger is assuming even if they live, they won't be productive citizens.

the phrase "useless eaters" comes to mind, but never mind.
 Nelson Mandella's recent illness is a good example. Guess what: he is still alive and recovering.

But this article  starts with the usual suspects, affluent white people who are activists in the "right to kill die movement": I had to help my mother to die. Not really. Your other choice was to give her food, but never mind. By cooperating with a depressed person who says they want to die, what you are doing is telling them their life is useless, so if they love you they should die.  Don't say: But mom we love you and you are not a burden. And never mind about alternatives, like decent pain control and hospice care.

as for Mandella: the article admits that Doctors said he was in permenant vegetative state, but he wasn't.

Go figure. Of course he wasn't: He was sedated, and you can't diagnose PVS for three months (I should add: 3 months without sedatives) and even then 40 percent are misdiagnosed.

so into the memory hole with all those who were cheerleading him to die:
From the UKGuardian 18 July:
Whereas the announcement in June that Mandela was in a critical condition brought sombre crowds to the Mediclinic heart hospital for what resembled a wake, on Thursday the mood was closer to a street party with bursts of song and jubilation. Members of the statesman's family visited him there and, according to his daughter Zindzi, gave him a collage of family photos as a present. "Tata (our father) is making this remarkable progress and we look forward to having him back home soon," she said....
 Bill Clinton, the former US president, told the meeting: "Although he is old and frail and fighting for his life and, as Hillary and Chelsea and I have seen in visiting Qunu over the last couple of years, he doesn't hear so well and he walks with the benefit of an elevated walker, what is in his heart still glows in his smile and lights up the room through his eyes." 
So what brought me to write all this?

Well Mrs Gay Caswell, a metis in Canada, remembers the time when her people were denied syphilis treatment in the name of experimentation, and other atrocities against her people by good socialists.

which is why such people end up suspicious of vaccines etc.

I should add that the Hepatitis A vaccine was experimentally given on one of the Sioux reservations in South Dakota, to see if it would work on children. Never mind that hepatitis A wasn't a big problem: we rarely saw any cases in children or adults, most of the liver problems being from alcohol.

and then there was the Red Lake streptococcus experiment: the first epidemic was wiped out by surveying the population and treating every case of impetigo, because there was a strain of strep that caused kidney failure. (Indians develop severe ecsema from sun allergy, which easily gets it is not purely a hygiene lack problem, which is what a lot of folks imply).

But when it returned, the docs decided only to treat those who came to the hospital. So six folks developed kidney disease (two of them on dialysis when I worked there were from this experiment). and that was by the University of Minnesota.

a lot of Americans see death as preferable to not being productive and independent, or preferable to suffering. So some are eager to give out death, especially to others, and are morally blind that this translates to killing the most vulnerable in society, instead of trying to help them.

But in poor areas, where suffering, disability, and other woes are common, it is a part of life, to be borne with stoicism. My Indian patients saw it as a road given to them by the Creator that they had to travel.

When we had a lady with frontal lobe syndrome and inability to swallow, we asked a neurologist the best medicine to control her overemotional reactions, and he spent the entire visit telling the family that they should stop feeding her. The family, being Indian, meaning they are polite and don't open up to strangers, kept quiet, but at the end of the meeting, one cousin turned to him and told him off: that's the difference between we Indians and you white folks. We take care of our elders, not kill them.

Thursday, July 25, 2013

the "WAGD" story of the day

From the UKMail:
A bioterrorism attack could spread to several continents before it is even detected, according to a startling new scientific study. 
The study found that if a small group of terrorists infected themselves with a disease such as smallpox and walked around London, then the pathogens could spread to up to four nations before doctors managed to diagnose it. 
'A deliberate smallpox release is likely to assume an international dimension even before the epidemic is identified,' the researchers wrote in the  study, which was published in this month's Scientific Reports, a trade publication. 

Read more:
Follow us: @MailOnline on Twitter | DailyMail on Facebook

Reality check: you wouldn't need terrorists to spread it in London.

The "Dark winter" scenerio was smallpox released at a truck stop in Oklahoma city.
A Tom Clancy novel had it released at the Olympics.

But the reality is blowback: the country that sponsored the bioterror attack would itself end up with a lot more casualties than the US or advanced countries in Europe or Asia.

That would defer most countries, except maybe the eco terror types who were behind the attack in the Clancy novel. Indeed, I loved how he "punished" them: He dropped them in the middle of the Amazon jungle sans supplies, so they could enjoy a nice green lifestyle.

When 911 happened, we actually were given instructions on what to do if smallpox was released. You isolate/encircle the outbreaks and vaccinate everyone (hoping that the vaccine would induce immunity before the virus worked). It told you how to set up a clinic in the local schools, and all the little details on how to get everyone vaccinated.

If you remember, the scare back then was anthrax: ordinary anthrax, not the resistant kind, but it had been treated not to clump, so it could stayed small enough to enter the lungs easily and kill. Why anthrax? Well, no blowback: it will kill or infect those breathing the treated spores, but will not spread from one person to another.

Wednesday, July 24, 2013

Cat allergy? There is hope

BBC reports the cause of cat allergies has been found.

De Plague De Plague

Most of the history of the plague acts as if it occurred only in western Europe.
medievalists also links to an article on the plagues in Egypt.

also at medievalistsnet: The plague in India.
and a list of stuff on the black death.

Defoe's book on the London plague is a classic, but is fiction, and he was not an eye witness.

Grescham college has a bunch of neat lectures on disease in British history, including this one about the plauge.

The ten plagues of history...note that some minor plagues were included because they occurred in Europe.

 But they do note the smallpox etc. that decimated the Americas, and the 3rd plague pandemic:

“Third Pandemic” is the name given to a major plague pandemic that began in the Yunnan province (pictured above) in China in 1855. This episode of bubonic plague spread to all inhabited continents, and ultimately killed more than 12 million people in India and China alone

But the Antoinine plague, (that killed Marcus Aurelius, not his son) depopulated the Roman empire and weakened says a lot about Rome that the empire didn't collapse then.

This plague, along with the plague of Cyprian, not only weakened Rome but contributed to the collapse of the Han empire of China...

article about McNeill's book on plagues in history. 

In 1976 McNeill forged that path with a sweeping book that took a new approach to disease history. Plagues and Peoples (Anchor Press/Doubleday) focused a biological lens on the ebb and flow of human civilization, from prehistory into the 20th century, and the picture that emerged showed a pattern of what he calls "fateful encounters" between infectious disease and world events: China's ancient Han Dynasty, like the Roman Empire, was brought down in part by epidemic illness, McNeill argues, and during the 14th century the Black Death proved a similarly "shattering experience" for the Mongol Empire. Only by taking disease into account can one explain Athens's failure to defeat Sparta during the Peloponnesian War, a conflict that transformed the ancient Greek world. Greek historian Thucydides described a sudden, devastating plague that struck in 431 BC, wiping out a quarter of Athens's land army and inflicting "a blow on Athenian society," McNeill writes, "from which it never entirely recovered." The historian also brought disease to bear on such diverse phenomena as the rise of Christianity and Buddhism, the caste system in India, and the expansion of the British Empire.

the debate is if these were "measles" (which can easily kill those who have never been exposed to it) or smallpox, or pestis, but the problem is that plagues evolve over time: the classic example being syphilis, which originally killed people quickly...

DNA studies are the final decider: And so the black plague was indeed Y.Pestis, and the plague of Athens typhoid, and the Spanish Flu a type of bird flu...

and it doesn't take an epidemic to think "what if"...for example, Stalin survived smallpox, FDR survived polio, and Churchill survived being hit by a car...

Camus' book The Plague is about a fictional outbreak in Algeria. The book is an allegory on the spread of fascism, Nazi takeovers in particular, and the theme is that it is important for people to decide to fight it. PDF HERE>

Saturday, July 20, 2013

Iris scanners?

TeaAtTrianon has links to an article on using Iris scanners to check if your kids are getting on the right school bus.

The Blinkspot scanner syncs with a mobile app that parents can use to see where their child is. Every time a child boards or exits the bus, his parent gets an email or text with the child's photograph, a Google map where they boarded or exited the bus, as well as the time and date.


so what could go wrong?

well, professional criminals will use contact lenses and other means to get around these things, and of  course, they could merely hack the database and change the information.

and what no one wants to check: If repeated infrared scanning will lead to premature development of cataracts.

one of the ironies of the Philippines is that everyone wears badges: even kids in schools.

I find it ridiculous: politicians steal millions of pesos but they are worried about identifying who is in school.

update PDF about infrared light and eye damage.

says stuff about LED lights too.. for further reading...

Tuesday, July 16, 2013

Dementia estimates were exaggerated

More recent surveys suggest the huge epidemic of dementia might never happen.

NYTimes story here.

key finding:
The studies assessed dementia, which includes Alzheimer’s disease but also other conditions that can make mental functioning deteriorate. Richard Suzman, the director of the division of behavioral and social research at the National Institute on Aging, said it was not possible to know from the new studies whether Alzheimer’s was becoming more or less prevalent.

"dementia" is a syndrome (a collection of symptoms) not a disease, and has many causes.

One cause is "multi infarct dementia" caused by repeated ministrokes.

Treating high blood pressure and lowering cholesterol (which forms plaques that block the arteries) will decrease the rate of dementia.

And these medicines to lower blood pressure
have been available starting in the 1970's and for cholesterol in the 1990's....

so what about Alzheimer's disease?

That too might have several causes, and until they figure out the cause, treating it might not help.

Two factoids here: A lot of studies stress checking for "dementia" ignore the non alzheimer's causes, since we only check for symptoms, not pathology (cell changes).

Two: People with Down's syndrome (aka Mongolism, aka Trisomy 23) develop Alzheimer's disease in their 40's...they also are more prone to have certain forms of leukemia and hypo thyroidism (low thyroid function).

I remember when they transferred a Down's syndrome client to the "baby" (mainly bed ridden) ward where I was the doc when I worked in an ICF/MR (intermediate care institution/mental retardation).

When reviewing the chart, I saw a weight gain, and one nurse noted that he used to be a "terror" but now just sat around. Sure enough, his thyroid was almost zero...but the symptoms had come on so slowly that no one thought to check...(this was before the association was well known).

Viagra uses

Viagra, or the "little blue pill" is best known for it's use to help men in their sexual lives.

But it actually is a vaso-dilator, making the blood vessels open up. When there was a study if it would work with men having heart disease, the men sheepishly told their docs that they were now able to have intercourse.

(Physiology lesson: the blood vessels open up, fill the spongy area of the penis with blood, and voila, it gets hard. After orgasm, it drains out. If it doesn't drain out, it ends up clotting and the person can lose it's function: this is a side effect of some major tranquillizers).

So the UKMail has a report that they are doing a study using for pregnant women who have small babies, to see if it improves the blood flow to the kids in late pregnancy, from blood vesesle to the placenta that spasm up from pre eclampsia.

The drug has been used to save the lives of both babies and adults suffering from a condition called pulmonary arterial hypertension, which affects around 4,000 people in the UK.
Blood pressure becomes dangerously high in the pulmonary artery, which carries blood from the right side of the heart to the small arteries in the lungs.
But a Viagra-based drug, called Revatio, is extending the lives of some sufferers by boosting blood flow to the lungs, reducing the workload on the heart.
The drug has also shown potential as a treatment for everything from breast cancer and diabetes to cold hands and heart attacks.

Monday, July 15, 2013

Killing grandmom take two

UKTelegraph articles on the scandal:

Financial incentives for NHS staff who place patients on the pathway are expected to be described as “totally unacceptable”.
The care pathway was originally developed at the Royal Liverpool University Hospital and the city’s Marie Curie hospice to ease suffering by setting out principles for how the dying should be treated.
It has since been introduced in the majority of NHS hospitals and involves the withdrawal of treatment and even fluids from patients assessed to approaching the end of life.
NHS protocols state that the patient, if possible, and their families should be consulted before someone is placed on the pathway.
But the system has been mired in controversy amid claims that it has been used actively to hasten death. In some cases, family members were not consulted before food and fluids were withheld from patients.
Some patients have even gone on to recover after being placed on the pathway supposedly because they were on the brink of death.
Lady Neuberger is a rabbi who has written on caring for the dying and was appointed to provide a “faith perspective” to the review.
Her team has held a series of meetings with families of those placed on the pathway who raised concerns about its operation.
Every year 130,000 patients are placed on the LCP, which usually involves heavy sedation with morphine or similar drugs. 

NHS executives could also face discipline.

the irony is that the sedation at end of life IS a compassionate way to treat those in pain.

But it also can be used to kill people, and the background of this is a country where shoddy care and overworked staff find it easier to just sedate than to care for terminally ill people, and of course the background is a "medical ethics" that has been undermined by the pro death folks who see the unproductive as useless eaters who should want to die, so let's help them along.

Let's kill grandmom (and save money)

The "Liverpool pathway" was supposed to be about pain control in those dying of cancer, but quickly morphed into a quick and legal way for medical personnel to kill patients (often against the wishes of the patient and their families). UKMail report here.
It emerged late last year that as many as 60,000 of the patients placed on the scheme were never asked for their consent, or their families were not asked. Many found out by accident, and others recovered fully after relatives found out and got their loved ones taken off the pathway.
 and yes, there is a money connection:
We also revealed how some hospitals were being paid six-figure ‘bribes’ to meet targets about the numbers of patients on the LCP – leading to fears that doctors were put under pressure to use the pathway.

Saturday, July 13, 2013

Interview with Oliver Sachs.


Homicide as a public health issue

The dirty little secret is that Homicide deaths are down in the USA, and that they are concentrated in certain politically correct subgroups.

But there are ways to counteract the toxic environment that make such deaths inevitable.

FIGURE 1. Firearm and nonfirearm homicide rates among persons aged 10–24 years — United States, 1981–2010
The figure shows firearm and non-firearm homicide rates among persons aged 10-24 years in the United States during 1981-2010. The overall homicide rate among persons aged 10-24 years varied substantially during the 30-year study period. Rates rose sharply from 1985 to 1993, increasing 83% from 8.7 per 100,000 in 1985 to 15.9 in 1993. From 1994 to 1999, the overall rate declined 41%, from 15.2 per 100,000 in 1994 to 8.9 in 1999. Alternate Text: The figure above shows firearm and non-firearm homicide rates among persons aged 10-24 years in the United States during 1981-2010. The overall homicide rate among persons aged 10-24 years varied substantially during the 30-year study period. Rates rose sharply from 1985 to 1993, increasing 83% from 8.7 per 100,000 in 1985 to 15.9 in 1993. From 1994 to 1999, the overall rate declined 41%, from 15.2 per 100,000 in 1994 to 8.9 in 1999.

FIGURE 2. Homicide rates among persons aged 10–24 years, by sex and age group — United States, 1981–2010
The figure shows homicide rates among persons aged 10-24 years, by sex and age group, in the United States during 1981-2010. Homicide rates for males remained substantially higher than rates for females during 2000-2010. When homicide rates were examined by age group, rates for persons aged 20-24 years remained highest, and rates for persons aged 10-14 years remained lowest. Alternate Text: The figure above shows homicide rates among persons aged 10-24 years, by sex and age group, in the United States during 1981-2010. Homicide rates for males remained substantially higher than rates for females during 2000-2010. When homicide rates were examined by age group, rates for persons aged 20-24 years remained highest, and rates for persons aged 10-14 years remained lowest.

FIGURE 3. Homicide rates among persons aged 10–24 years, by race/ethnicity — United States, 1990–2010
The figure shows homicide rates among persons aged 10-24 years, by race/ethnicity, in the United States during 1990-2010. During 2000-2010, rates for blacks aged 10-24 years remained the highest and rates for whites in this age group remained the lowest. Alternate Text: The figure above shows homicide rates among persons aged 10-24 years, by race/ethnicity, in the United States during 1990-2010. During 2000-2010, rates for blacks aged 10-24 years remained the highest and rates for whites in this age group remained the lowest.

graphs are from this CDC report:

Although law enforcement responses to violence and focused attention on high crime areas and perpetrators help to reduce the continuation of violence, they do not stop violence from happening in the first place. Research on youth violence demonstrates the importance of implementing primary prevention approaches that begin in childhood to disrupt the developmental pathways to serious violence in adolescence and adulthood and can be diffused across large populations (6,7). A number of primary prevention strategies are scientifically proven to reduce the risk for and occurrence of youth violence and provide critical complements to law enforcement approaches (6,7). Examples of primary prevention strategies include 1) school-based programs that build the communication skills of youths to nonviolently solve problems; 2) family approaches that help caregivers set age-appropriate rules and effectively monitor children's activities and relationships; and 3) policy, environmental, and structural approaches that enhance safety and increase opportunities for positive social interaction.

the preventive medicine approaches can be found HERE.

the irony is that as Mexican gangs spread into the heartland, the idea of "black on black" violence may soon be replaced by fear of Hispanics.

But just as it isn't PC to mention that some black neighborhoods are toxic to children, similarly it isn't PC to mention that the open borders of the US is also meaning that their narcoterrorism might spread north.

Ironically, Colombia has pretty well clamped down on their narco terrorism, so the thugs moved north, but Mexico is still in the midst of the fight.  I have to laugh when StrategyPage notes that Mexico is a failed state that hasn't fallen apart because ten percent of their population has migrated north to the USA.

In all of this, my sons, who are Hispanic, are at risk; ironically, drug users are looked down upon in Colombia, and those who got involved in growing drugs (because of poverty) often are seen as asking for bad luck...

Wednesday, July 10, 2013

Medical stuff: BPA or disease?

So my AMA wire links to a USAToday/PLOS article to tells me that BPA,  a plastic related chemical, might be causing obesity in young girls.

But they place this fact on the "women physician" part of their newsletter, presumably because only women docs treat girls.

I don't belong to the AMA for 20 years since their "ethics" committee said it was okay to take organs from living babies with brain defects, but never mind (they "Changed their mind" after a huge public outcry, but it shows how their experts are isolated from normal humanity).

And I never belonged to their "women physician" part, partly because I was a physician period, not a "woman physician" (I graduated before feminism...and then the pro death feminists took over the "women physician" group so I refused to join them).

Yet BPA is a universal health hazard. A good way to monitor the world wide cause of obesity is to monitor Asia: Our farmers are thin but the middle class children are gaining weight. Is it BPA? (everything here comes in "sachets", small plastic packetts, not bottles, which no one can afford). I suspect it might be more from less hard work: even our school kids now rent a tricycle/taxi to go to and from school (20 pesos for five kids)...

related item behind a wall: Obesity as a disease.

one third of Americans are overweight and one third are obese. That is the reality. If we say that obesity is not a disease, that is a call to inaction. It means that we can blame it on gluttony, slothfulness, and a lack of willpower, and I don't think our patients in the clinic need to hear that one more time. What they do need to hear is that their physicians care about them as people, that we understand what they are dealing with in terms of their weight and how they struggle not only with the cosmetic or societal issues, but also the health consequences of obesity.
and what they aren't saying: The "cure rate" for obesity is less than ten percent...
but having it as a "disease" means we can "bill" the gov/t insurance companies for it, while the big pharm will make oodles of money because their pills will be paid for too.

And I am not alone in this cynical take if you read the comments by physicians. What is interesting is the "others" who comment tend to go along with the AMA/ PC part, but not the docs...indeed, very few docs seem to be commenting at all, which tells you a lot about those who have time on their hands.

When  obesity to becomes a disease, what does that do to the overall cost of health care in the US? A third of the people are suddenly eligible for massive health expenditures. I am not trying to state it is not a disease and rob people of access to health care, I am trying to ask whether we are being fiscally responsible. If a child is declared obese and a large number of children are, does that mean they have an automatic ticket to subsidized health care for the rest of their life. When followed to one, two and five years only about 6% manage to keep their weight off even in the best wieght management control programs. 

Tuesday, July 9, 2013

Malaria kills, but doesn't get into the headlines

Science Daily reports: Recently researchers in Boston and in Portugal have come up with a possible new family of medicines to kill malaria:

In work published online today in the journal PNAS, researchers at the Instituto de Medicina Molecular (IMM), in Lisbon, Portugal, have discovered a new class of highly potent antimalarial compounds. These compounds, referred to as Torins, were originally developed by researchers in the Boston, MA to inhibit a key human protein involved in cell growth, mTOR, and have been shown to be effective anticancer agents in rodent models. In research perdormed by Dr. Kirsten Hanson in the laboratory of Dr. Maria Mota, the IMM team and their collaborators have discovered that Torins are extremely effective multistage antimalarials; Torins appear to have a novel activity against the Plasmodium parasites themselves, distinct from both currently used malaria therapeutics and from their ability to target human mTOR.

but this is the part no one wants to notice:

. An estimated 220 million people are infected each year by malaria-causing Plasmodium parasites, which are transmitted by the bite of an infected mosquito. This enormous infection burden leads to some 660,000 lives lost to malaria each year, the majority of these young children in sub-Saharan Africa. While a vaccine to prevent malaria remains elusive, we depend on antimalarial compounds both to treat infections and prevent disease.
the good news? Bill Gates is on it.


The bad news? His wife has been busy diverting his money to fund abortion in poorer countries.

and the other bad news: Thanks to Carson and the greenies, DDT was banned, resulting in millions of deaths, to save a few birds.

Monday, July 8, 2013

Going Blind? We don't care

Newest "expert" panel of the US Gov't says that there is no proof to say screening for glaucoma helps, nor is there proof to say early treatment improves the 'outcome".

This ignores Rumsfeld's rule: The absence of evidence is not the evidence of absense.

I mean, when there is a treatment for a disease that causes blindness, are you going to be part of the "double blind" study that doesn't treat you?

Glaucoma is increased pressure inside the eye. With time, the pressure destroys the nerves you see with: it starts with a decrease in peripheral vision.

this is from Dr. Higgon's webpage:

see that "early glaucoma" part? you probably wouldn't notice it. As it gets worse, you might first "notice" you've lost your side vision when you don't see a car or a pedestrian in your peripheral vision (as did my uncle, whose car was hit from the side).

However, there is "inadequate evidence" that treatment for people without symptoms can prevent more serious vision loss and blindness, the panel wrote Monday in the Annals of Internal Medicine.
That doesn't make sense. The NIH says you need screening.

Early symptoms are mild: Which is why so many folks end up with tunnel vision without treatment....and remember: the "symptoms" mean you have lost your vision already.

"It's clear that the treatment can improve the disease," Moyer told Reuters Health. "It's not crystal clear that the treatment of disease before it's noticeable improves the outcome."
It's not "crystal clear". It's probable, it makes sense that treatment would stop the damage, but never mind. 

What's more, most glaucoma tests available in primary care offices aren't very accurate,

It's hard to do the measurement with the old fashioned "pressure" gauge during the yearly physical exam.

I used to use the Shultz tonometer. This is called "direct tonography": you numb the eyeball with drops, and then place a measuring device on the eye, and check your pressure directly.

This is the old fashioned one we used:

You lowered it to the eye, until the outer part hit the eyeball, and the middle part measured how much pressure difference there was.

Problem? If the person moved, they might end up with a scratched eyeball (abrasion of the cornea).

But the newer version is more expensive (usually only specialists have it) and easier.

Dr. Singh has a nice video here:

there is now a "puff" test that is quicker and easier to do, however it's not as accurate. 

We didn't do a lot of the tests because most of our older patients already we seeing eye doctors who had done the test...and so we only did a few a year and sort of forgot to check about it...the dirty little secret is if you don't do a test a few times a month, you are probably going to do it wrong.

Even if we came  up with a "positive" test, we just sent them to the eye docs for a second opinion...

there is a "third" way to test for glaucoma: Look into the eye with an opthalmoscope. But the dirty little secret is that it's a subtle change (and most of us can only see major problems, since few primary care practitioners "dilate" the eye before the do a proper examination, you need to put in those drops that make your iris open wide, and make your eyes sensitive to light and hard to drive home from the office, before you do the examination).

So the first part, saying the test isn't accurate by primary care docs/practitioners is correct.

The problem is the last part of the sentence.
What's more, most glaucoma tests available in primary care offices aren't very accurate, according to the USPSTF, and can't discern when vision problems are likely to get worse. That could lead some people who never would have developed advanced glaucoma to be diagnosed and treated unnecessarily.

Translation: Well, the drops might stop you from going blind, but hey, we don't know, because few docs who pick up the disease on the screening test are willing to let you maybe go blind (and sue them) by not treating you when they diagnose it.

But that means a lot of money for you to spend (or your insurance company to spend) on eyedrops and repeat examinations of your vision. But now the government is paying for it, and man, it costs money.

So let's just not screen you. 

I don't have the US pricetag, but this "NICE" article (NICE is the health care rationing board in the UK) breaks down the costs to 100L a year (about $150) and less than a million pounds (or about a million and a half dollars) to treat 70 percent of those who need it (the 70 percent is the estimate of how many people actually will use their medicine).

Ironically, the NICE is willing to pay for screening and treatment, which tells you something since they are tightwads.

But what about that part you might not need treatment?

The cornerstone of pushing the new "health care" bill was that it would pay for yearly screening examinations on everyone. Supposedly, diseases would be caught early and either cured or treated early, so the patient would end up healthier and cost less money in the long run.

And since the health care bill was  passed, we see one report after another about how such screening tests are "not cost effective" or should only be used in a few patients.

That's because we were told to do them (and sued if we didn't do them), but most people don't go to docs for yearly exams, so no problem.

But now, if they all come in, the cost of screening everyone, mainly low risk people to pick up a few isolated cases, is too high.

Voila: One "screening test" after another is being discarded.

OK. You want to take the chance?

Dr. Angelo Tanna, a glaucoma researcher from the Northwestern University Feinberg School of Medicine in Chicago, said screening can still be useful when performed by an ophthalmologist.

ah, but most of us see optometrists, not opthalmologists.

So the end result should be the government paying for the test for older folks and to pay for a visit to the optometrist every two years or so.

That's what I do...

Thursday, July 4, 2013

Maurice King

since in a previous post I mentioned Maurice King, I decided to google him.

We used his very nicely practical books when I worked in Africa, but when I came back to the US didn't know where I could buy a copy of my own (this was years before Amazon, and yes they are now available there)

Apparently he is alive and well, and still has a sense of humor:

Maurice Henry King, MD, FRCP, FRCS

What do letters mean anyway?

       At 85 (this figure is 2003!), and still in 2012 very hard at work, I am an Honorary Research Fellow of the University of Leeds, busily engaged in trying to lift the taboo on demographic entrapment by every means in my power.

       I 'left my placenta in Ceylon and my heart in Africa' I was educated in England at Cambridge and St Thomas', and spent 20 years as a doctor in Africa, in Northern Rhodesia, Uganda, Zambia and Kenya - five years in each, with a five-year spell in Indonesia meanwhile. I started in Africa as pathologist in 1957, and moved into public health in 1963, and from then on became a writer of books for the health workers of the developing world. I have now written ten, of which Primary Surgery (two volumes) has, among others, been widely acclaimed as the standard work.

his website is here.

includes this nice illustration of the problem of population in developing countries.

sounds about right.
yes, I have talked against things like the RH bill here in the Philippines, but that is because it ignored the women delivering with untrained hilots and made birth control a policy to be pushed in our clinics (something that led to human ri: I suggested a better way to do this would be the pill ladies used by Bengladesh or in Zimbabwe, where a woman to woman talk would  be private and uncoerced by government.

Bikini wax to the rescue

The Daily Mail has an article suggesting that the Bikini was, made popular by "sex and the city", is one reason we see a lot fewer cases of public lice.

unlike ordinary head lice, these suckers look like tiny crabs

more HERE, including this photo.

Drug abuse and pain

The headlines might cry about a "300percent increase in drug deaths" from opiods, but the picture is actually quite different.

CDC report on the problem:

Results: In 2010, a total of 15,323 deaths among women were attributed to drug overdose, a rate of 9.8 per 100,000 population. Deaths from opioid pain relievers (OPRs) increased fivefold between 1999 and 2010 for women; OPR deaths among men increased 3.6 times. In 2010, there were 943,365 ED visits by women for drug misuse or abuse. The highest ED visit rates were for cocaine or heroin (147.2 per 100,000 population), benzodiazepines (134.6), and OPR (129.6). ED visits related to misuse or abuse of OPR among women more than doubled between 2004 and 2010.

when there are almost a million Emergency room visits for drug abuse, there is a problem.

But the increase in percentage is high, yet the numbers are not:

In 2010, a total of 15,323 deaths among women were attributed to drug overdose, a rate of 9.8 per 100,000 population. Among these, a drug was specified in 10,922 (71.3%) deaths. One or more prescription drugs were involved in 9,292 (85%) of the drug-specified deaths among women, and OPRs were involved in 6,631 (71.3%) of the prescription drug overdose deaths. These numbers represent substantial increases from 1999 (5,591 drug overdose deaths among women and 1,287 OPR overdose deaths). The percentage increase in number of OPR overdose deaths was 415% for women and 265% for men.
 so the numbers involved are in the thousands, yet given the large population we are talking about (280 million Americans, or even from the 1 million overdose problems seen in the ER) the actual numbers are not that high.

But how many of these were from accidental drug overdose? Or from suicide? or from taking them to get high?

The article admits they don't know.

information on the motivation for use might be incomplete; some ED visits might have resulted from suicide attempts. Finally, distinguishing between drugs taken for nonmedical and medical reasons is not always possible, especially when multiple drugs are involved. 

The long acting medicines are especially prone to overdose, since they take awhile to work, and then may accumulate their effects after the person takes a second dose. Those with other problems are also vulnerable: I've had two women with COPD (chronic lung problems) who had to be "rescued" after their fentenyl patches slowed their respirations, even though they had tolerated the same patch dosage for a couple weeks for chronic pain.

But then I had a druggie overdose on some MSContin she stole from her relative dying of cancer. Again, she didn't get high so took a few too many.

So how many of these pills were "diverted" or stolen? Our reservation's casino had an ongoing market for Tylenol with codiene. (usual price was only 5 dollars a pill, much less than if you bought it on the street in the nearby town)....

Our old ladies would sell a few if they were short of  money, but they also knew that they could buy a few if they hurt too much and didn't want to sit in the emergency room for a couple of hours. Go figure.

Then there was the teenager "offered" a swig of another teen's grandmom's morphine syrup (grandmom had died, but the teen found a small bottle in the glove compartment of the car, for breakthrough pain).

Then there was the druggie with lupus. She'd come in with red swollen joints barely able to move, yet was unreliable in taking her medicine... We finally "solved" her problem with a strict pain contract that would only give her pills if she took her methotrexate dose in the clinic, after we had done her blood tests. That worked, but she had withdrawal symptoms when she developed pneumonia (a problem since her immune system was a mess). So what should we have done about her? Let her suffer? 


so what is the alternative for those with chronic pain?

NSAIDS? (motrin/ibuprofen, alleve, aspirin?)

the dirty little secret is that we see more problems from them than narcotics (usually bleeding ulcers, but also kidney problems)

LINK emedicine

Both acute and chronic poisoning with NSAIDs results in significant morbidity and mortality. The Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) system has estimated that more than 100,000 hospitalizations and more than 16,000 deaths in the United States each year are due to NSAID-related complications with costs greater than $2 billion. Gastrointestinal (GI), renal, central nervous system (CNS), hematologic, and dermatologic symptoms may ensue (see Complications).

that has led some to tell old ladies to take tylenol instead for their pain.

But the dirty little secret is that you have to take a lot of them, and yes, you can also run into problems with tylenol. ( Acetaminophen, paracetamol).

The main dirty little secret is that if you overdose on it, you don't die right away: You die a few days later when your liver shuts down. Yes, it can be treated if a doc knows about it and gives you the antidote, but often the suicidal person might not present to the ER.

Luckily, such deaths are rare:
Analysis of national databases show that acetaminophen-associated overdoses account for about 56,000 emergency room visits and 26,000 hospitalizations yearly. Analysis of national mortality files shows 458 deaths occur each year from acetaminophen-associated overdoses; 100 of these are unintentional. The poison surveillance database showed near-doubling in the number of fatalities associated with acetaminophen from 98 in 1997 to 173 in 2001. AERS data describe a number of possible causes for unintentional acetaminophen-associated overdoses.
 All the textbooks assure us that tylenol works "as good" as other medicines. well, that's true: but the half life means you have to take it every four to six hours. Me, I prefer to take one naprosyn which lasts 24 hours, and pop an omeprazole if it causes heartburn.

I remember one doc who gave an impassioned plea about not using ibuprofen (another "NSAID") for pain, after he had discussed the increase in kidney transplants for "analgesic nephropathy". 
at the end of the talk, when someone pointed out that tylenol just doesn't work as well as Motrin(ibuprofen) and asked him what he took for pain, he admitted he too ibuprofen, but tried not to take it often.

So should we just sit and hurt?

That can cause depression, obesity, and suicide.

No, I don't have an answer for this, but I'm not a good one to ask: I don't get high on oxycodone, and I get better pain relief with NSAIDS than codiene.

as for studies on what works for pain and what doesn't: The placebo effect is huge here.

in experiments, the only pain medicine that "statistically" is better than placebo is...injected morphine.

Wednesday, July 3, 2013

Childbirth in the good old days

Medievalist web has an article on maternal death in Anglo Saxon days.

full article HERE.

Oakington is the site of an early Anglo-Saxon cemetery in Cambridgeshire (AD 450–700). Excavated in June 2011, grave 57 contained a woman with a descended foetus across her pelvic cavity, a position unlikely to result from post-mortem extrusion. She was aged between 25 and 30, had congenitally absent teeth and occupational wear on her hands and feet. She was buried supine in full dress with a cruciform brooch and two small long brooches. The foetus lay low and transverse across her pelvis, which was probably the cause of this double fatality (. Even today transverse lie pregnancy is a dangerous malpresentation for both mother and foetus, almost always resulting in Caesarean section.
 yes, transverse lie means the kid is sideways. Usually this is found in women with a weak uterus (a woman who has had many pregnancies) although it can also occur in the second twin, where after the first one delivers, the second twin flops sideways in the now roomier uterus.
the relationship of the long axis of the fetus to that of the mother; see also presentation.
longitudinal lie a situation in which the long axis of the fetus is parallel to that of the mother; in presentation, either the head or breech presents first.

The only way to get the baby to deliver is to rotate it first, or do a Caesarian section.

If the uterus is soft, you might be able to rotate it externally, by using pressure to change the baby to head down (or buttock down).  Th.e baby will then deliver normally

An alternative is to put your hand inside and rotate the baby around, then either let him deliver normally or grab his leg and pull him out as a breech birth.

Sometimes you first recognize the transverse lie with the kid's hand pops out.

I wrote about this at Xanga: a story told by one of our old Sisters in Africa. She was a teacher who did first aid, and was called to the village because there was a problem with a woman in labor, and the women there didn't know what to do.

The woman quickly relaxed when she saw sister, and went on to deliver a nice girl baby, but then a hand popped out. Sister Gervasia, a farmer's daughter, knew that this meant trouble but wasn't sure what to do. So she told the family: We sisters have to pray now, but I'll be back in a little while after our prayers.  So she rushed home, got the first aid book out, read up on the problem, and returned to the village. She managed to push the hand back and externally rotate the baby, and voila, a baby boy.

The mother was lucky: You can rupture the uterus turning a child, and sometimes the uterus is lax after the delivery and mom dies of post partum hemorrhage (usually we give ergotrate for this, although nowadays we use pitocin).

I doubt many US docs have seen the problem, unless mom has an abnormal uterus, but it is still seen in Africa, as this journal article shows.
Eighty percent of the women were delivered abdominally; and 63.33% of these were cesarean deliveries. Vaginal
delivery was achieved in 13.33% of the women, vaginal route destructive operations and delivery in conduplicatio corpore on two occasions each
 If you want the gory examples of that last part, check here (Not safe for work or kids or for those with a queezy stomach). it's from a book by Maurice King, who has written other practical books for docs working in really isolated hospitals in Africa. King's stuff tends to be very pragmatic, and if you are a survivalist, you might want to download the book.

Again, these things are very very dangerous to mom, so don't try them at home. 

another resource would be Hesperian.

home birth types in the US need to watch the BBC series "call the midwife" to see all the stuff that can go wrong in even low risk "home births"...I don't recommend it, even though 80 percent of women could give birth without problems...

Back to early England.

There is the possibility of other women who died in Childbirth:

There are other examples of women with in situ foetuses from Anglo-Saxon cemeteries. However, in archaeology the dominant interpretation for extruded and partially extruded foetuses is currently a phenomenon known as coffin birth: the post-mortem extrusion of a foetus into the grave
 A couple years back, a gruesome murder case of a pregnant woman was verified when the baby was found on the beach near to where the husband had buried his pregnant wife whose body had been weighted down...why these deliveries? It's the gas...(don't ask).

There are also stories of children being taken from mom's womb when she died, (MacDuff was from his mother's womb untimely ripped"), the idea being that maybe the kid would live, and also to baptize the kid.

One suspects such cases are rare, since usually the baby dies of exhaustion before mom dies of exhaustion, but in cases of amniotic fluid embolism or heart attack in a mom with a damaged heart, it could happen.

Moving my xanga blog here

testing one two three