Monday, January 30, 2017

Forget Zika: The White Plague is back

The headlines in the US often are about exotic flashy but small epidemics like Zika and Ebola, not those that kill a lot more people, like Malaria or Measles.

Indeed, the traditional isolation techniques of Africa would have stopped Ebola's spread ( put the sick person in a hut, place food and water at the door, and when the hut starts smelling, burn it down.) This worked traditionally until Christian compassion made hospitals the norm.

But a potential epidemic that has been smouldering around for at least 30 years is now back in the news:

Drug resistant TB in South Africa, and is complicated by those who have HIV...

NYTIMES article reports they are finding cases, not just in those who had been treated in the past (often not completing treatment so the germs got resistant) but now it is spreading person to person.

XDR-TB has been reported in 117 countries, according to the World Health Organization. Most cases are isolated, but thousands of hidden cases are likely to exist because it takes multiple lab tests to detect each one.
The worst known outbreak is in South Africa, in the rural Zulu-dominated mountains behind Durban, where H.I.V. is also extremely common.
In 2006, researchers there reported an alarming finding: 52 out of 53 patients with both H.I.V. and XDR-TB had died, and half died within a month of getting a diagnosis.

to make things worse, few doctors in the US are able to recognize a case. Those of us who work with the AmerIndians are supposed to be aware we see "relapse" of cases, but X rays of TB scars make it hard to diagnose. I remember one case in New Mexico where I noted her scar edges seemed thicker... a bronchoscopy did reveal active TB, and the nurses were angry at me because it meant all of them had to be monitored for infection. Nowadays, PET CT scans etc. will make this easier for docs, but they are expensive in poor countries.

five to ten percent of inactive (and/or treated) TB cases will relapse: This is a problem if you were exposed as a kid and then developed Diabetes, cancer, HIV or immune problems. When I was in the IHS, we kept an eye on our diabetics, but debated whether or not to give prophylactic INH that lowers the risk but can cause liver damage.

The docs are debating how to treat it.

I suspect going back to the good old days of isolation and/or sanitariums is not a good idea. They closed most of the hospitals for this 50 years ago.

But other isolation might work... including masks, which is what we see here, not just on the street in flu season but when you go to some of the large clinics in Manila that treat TB etc. you see adults and kids walking around wearing surgical masks, to stop them from spreading infection. As in this photo of Jesus visiting the pediatric ward..
Joey Velasco

Friday, January 20, 2017

Take your pills dear

I remember years ago when the "experts" complained that pills with several ingredients inside were too rigid and too expensive, and that giving a patient the correct dosage which was nuanced for treatment was a better idea.

So instead of one blood pressure pill, you now took three. Some of them twice a day.

And people forgot.

So SciDaily says Hey, maybe fewer pills will lead to people remembering to take them.

"Fixed-dose combination pills appear to enhance adherence and persistence to anti-hypertensive medications among commercially insured patients starting treatment compared with single therapy," says Lauffenburger, in summarizing the findings. "For patients beginning anti-hypertensive treatment, clinicians may therefore want to consider starting patients on a fixed-dose combination pill rather than a single therapy."

yeah, like a lot of stuff in ivory towers, maybe they should have had a little imput by docs in the front lines.

Monday, January 16, 2017

Death by Nutella

There is a headline in the local paper about Nutella causing cancer, because it contains Palm oil.  which is really ironic, because only the rich and upper middle class can afford the spread (while the poor tend to use palm oil for cooking here because it is cheap and tasty).

So Nutella bad, palm oil used by the poor? Who cares?

Hm. The last palm oil scare was about popcorn in theatres that were cooked in palm oil. NYTiimes 2009 article from the wayback machine.

 The study, from the Center for Science in the Public Interest, looked at popcorn from three movie theater chains and detailed the contents of all portions offered.
A large tub of popcorn at Regal Cinemas, for example, holds 20 cups of popcorn and has 1,200 calories, 980 milligrams of sodium and 60 grams of saturated fat. Adding just a tablespoon of butter adds 130 calories. And do not forget that it comes with free refills.

They recommend you eat plain popcorn without any oil, which of course tastes like cardboard.

What is the problem with palm oil? it has saturated fatty acids, so was linked to heart disease.

Then they changed their mind and decided it was a health food.

Now again they are screaming: Cancer.

Yes, but only if you are a mouse who was injected with human cancer cells mixed with a certain compound that is supposed to be associated with palm oil.

To confirm the essential role of CD36 in cancer spread, they added it to non-metastatic cancer cells which then caused the cells to become metastatic.
so did they feed the mice palm oil? no. And no, CD36 is not present in palm oil

CD36 sits in the cell membrane where its job is to move fatty acids from outside of the cell into the middle.  The researchers therefore wondered how a high fat diet would impact on cancer spread, given the key role of CD36.
Interestingly, a high-fat diet, or direct stimulation of these cells with a saturated fatty acid called palmitic acid (the main component of palm oil) increased their ability to spread.
But they didn't cite where that last part, but I googled this article via Scidaily:

The researchers next looked at the role of fat intake on cancer spread. They provided mice with a high fat diet then injected them with a type of human oral cancer. The high fat diet caused 50% more mice to have larger and more frequent metastases.

so if you are a mouse who a scientist injected with human cancer don't eat nutella.

Ironically, the really important part of the research is hidden deep within the article:

Using mice with human oral cancer, the researchers were next able to show that blocking CD36 completely prevented metastasis. 

 Did I read this right?There is a drug that blocks CD36 and prevents metastases?

 LATimes article about this. 

The work of identifying those human antibodies, and of beginning to test them in humans, is expected to take up to 10 years, Benitah said. However, with a few lucky breaks, antibodies capable of knocking out CD36 in human cells could be found in just three or four years, he said.
a monoconal antibody to stop metatases. Faster, please.

It has long been known that obesity is associated with Cancer, but then you have a problem: Is it because chubby women have more estrogen, which causes breast/uterine cancer? Is it because the chronically ill are skinny? Is it genetic? Or is obesity a marker for poverty, and lead and chemical pollution is more common in poor areas (e.g.Flint Michigan)?

Is it palm oil, or is it only when you use it to fry foods, causing high temperature chemical changes? But nutella doesn't fry the oil. So why point fingers at Nutella?

maybe it's because the SJW types hate the Nutella company: lot of articles on the company websites defending their labor practices which suggest the activists have been after them.

This german paper gasps: It's sweetness is addictive!

well, duh. everything is addictive today: Anthony Weiner call your office.

So why are they after palm oil (again)? maybe because the real aim is to demonize Palm oil, to save the orangutans.
or maybe the rain forest.

Yup. Keep the environment pristine, the orangutans happy, and the local farmers dirt poor.

This article in the UKIndependent is a good debunker of all the scare stories you are reading.

What makes a good health scare?
Three essential ingredients. 
 First, there has to be something mundane that lots of ordinary people do, and preferably enjoy doing.
 Second, there has to be a nasty disease, or a frightening health condition.
Third, the word “causes” must appear.
A big scare last week concerned Nutella, with reports that the processed palm oil used in the production of the hazelnut spread might be carcinogenic. ...

 The problem with such stories is not the underlying science, but that the fact that they generally do a terrible job of conveying a clear sense of the scale of the risk to the typical reader.
The palm oil research is at too early a stage for any kind of quantitative headline about risks to health.
 they then go on to parse statistics: A huge number might only mean a slight increase in actual personal risk.

This was apparent during the 2015 bacon scare, when reports of an 18 per cent increase in the risk of contracting bowel cancer from consuming two rashers of bacon a day were widely interpreted as suggesting an almost one in five chance of getting it.
In fact, the lifetime risk for regular bacon eaters of developing bowel cancer is 7 per cent, up from 6 per cent for those who don’t eat it.

ah Bacon!

so enjoy:

cross posted from my main blog.

Saturday, January 14, 2017

knitting post of the week

When a blood vessel or your broncheal tube is blocked, you open it and put in stent to keep it open. Usually a stent is a sping or basket weave, and they are left in place. But what about if they are in places where they could cause scar tissue and should be rmoved?

Mattsson evaluated and tried several different methods, but he found the ultimate solution in a pair of old socks. Mattsson's stent is knitted, and like a sock can be unraveled after it has been used. This allows the stent to be removed when it is not needed anymore.

Fetal Alcohol syndrome

Worldwide, an estimated 119,000 children are born with fetal alcohol syndrome (FAS) each year, a new study shows. The study provides the first-ever estimates of the proportion of women who drink during pregnancy, as well as estimates of FAS by country, World Health Organization region and worldwide.

I suspect this might be an estimate of the severe full syndrome, but like a lot of things, it is a continuum, and if you include all babies with some damage it is probably ten times that much.

You can see the problem in this description:

Globally, nearly 10 per cent of women drink alcohol during pregnancy, with wide variations by country and WHO region. In some countries, more than 45 per cent of women consume alcohol during pregnancy. In Canada, which has clinical guidelines advising abstinence during pregnancy, an estimated 10 per cent of pregnant women still drink, which is close to the estimated world average.
wait a second: If you include countries who routinely drink wine (or beer) with their meals, you get a huge number of drinkers, but not a lot of FAS. Whereas in Canada, I suspect their "First Nation" doctors see a lot of it, because drinking there is hard drunkeness although not necessrily daily alcohol.

Both exaggerated (no, one drink won't affect your kid) and much.

more from the article:

Nearly 15 per 10,000 people around the world are estimated to have FAS, the most severe form of Fetal Alcohol Spectrum Disorder (FASD). FAS is characterized by mental, behavioural and learning problems, as well as physical disabilities. 

In Canada, the estimate is 10.5 cases of FAS per 10,000 people.
 Not every woman who drinks while pregnant will have a child with FAS. "We estimated that one in 67 mothers who drink during pregnancy will deliver a child with FAS," says lead author Dr. Svetlana Popova, Senior Scientist in CAMH's Institute for Mental Health Policy Research. 

 She notes that this figure is very conservative and does not include other types of FASD that may occur from alcohol consumption during pregnancy, including partial FAS (pFAS) and Alcohol-related Neurodevelopmental Disorders (ARND). Although it's well established that alcohol can damage any organ or system in the developing fetus, particularly the brain, it's still not known exactly what makes a fetus most susceptible, in terms of the amount or frequency of alcohol use, or timing of drinking during pregnancy. Other factors, such as the genetics, stress, smoking and nutrition also contribute to the risk of developing FASD.

Good news: Decrease in kidney failure in American Indians

CDC has a report that the intensive treatment of diabetics has decreased the rate of end stage kidney disease in American Indians.

We had a very aggressive prevention, intervention, and treatment program for our diabetics and it seems to be working.

In the United States, diabetes is the leading cause of end-stage renal disease (ESRD), which is kidney failure treated with dialysis or transplantation (1).

The prevalence of diabetes among American Indians/Alaska Natives (AI/AN) in the United States in 2012 (15.9%) was higher than that among non-Hispanic blacks (blacks) (13.2%), Hispanics (12.8%) or non-Hispanic whites (whites) (7.6%) during 2010–2012 (2).
Diabetes accounts for 44% of new cases of ESRD (diabetes-associated ESRD [ESRD-D]) in the overall U.S. population and for 69% among AI/AN (1).
Prevention or delay of ESRD-D involves control of blood pressure and blood glucose, early identification and monitoring of kidney disease, and use of angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARB) in patients with albuminuria (3,4).
This report presents trends in ESRD-D incidence for AI/AN compared with other racial/ethnic groups, and discusses the probable factors that influenced the improvements observed in this population during 1996–2013.
Read the details at the link.

I should also note that we also had a "limb preservation" program that cut our rate of diabetic related amputations down.

However some of our end stage kidney disease was from Collagen diseases (e.g. Lupus), Glomerulonephritis or from IgA nephropathy.

a lot of the "preventive medicine" stuff is about fancy expensive testing, including some that have limited results. but treating diabetes and high blood pressure and cholesterol saves lives.

The problem is you need the personal touch for these patients: No, a computer won't work as well (except to help them monitor themselves at home). Visits don't just check the patien't sugar, but their home situation.

One advantage of the IHS is that medicines were free, and we had tribal health workers who could check up on them at home, not to mention extended families so we could call their cousin or other relative to see how they are doing (sometimes they didn't have phones or phone lines, although Obamaphones and cellphones have probably improved things in the last 15 years since I retired).

For example, one of our problems in Minnesota was that the elderly couldn't exercize much during the cold winters, and didn't dare jog a lot outside in summer for fear of being attacked by bears. So the tribe started an indoor exercize program for the elders.

And we had a podiatry (including special shoes) program, an aggressive optometry program to treat diabetic retinopathy, and a surgeon who flew up to supervise our aggressive wound treatment program to stop ulcers from ending up with amputations.

In these diseases, frequent visits with a good general physician (Family doc) or even a nurse practitioner or physician assistant who know them personally and know their family and how they live could do the work.

and you need a culture friendly practitioner: the best would  be a local member of the tribe, but a person from another tribe, or a non Indian could fit in if they got along with the culture.

The IHS had tribal preference for this.

when I read about the problem of inner city black people (and immigrants), well, there are or used to be clinics that had similar outreaches.

But a similar approach can be and is used (to a lesser extent) for chronic diseases in these areas.

For example, we were given a talk about one program to check for hypertension in the black community (which often is not found or is not treated aggressively) was done through the black churches.

The churches are trusted, whereas outside doctors and big hospitals with clinics might not be.

Friday, January 6, 2017

Racism and/or sickle cell disease?

PhysEd article about racism in health care. Yes I know: it just points out the white/black disparity in heath care in the US but it comes down to the talking point memo: racism.

Uh, things are not so simple.

First of all, which black population are you discussing? Inner city blacks who have to go to clinics where they barely know the docs and nurses there? But  among these hard working folks a lot of individuals whose lives are full of social pathology. (not to mention high lead levels if you live in Flint Michigan or Washington DC, but that is another cause for ADHD/impulsivity etc).

And yes there is a lot of prejudice against blacks, especially among the foreign medical graduates from Muslim countries, who look down on them for cultural reasons (Arab and Egyptian disdain of Africans has a long history). But also among white upper class types who lean over backwards not to be prejudiced.

But one of the undiscussed demographic changes in the USA is the decrease in "social pathology" among the black community in recent decades.

One is because of the civil rights movement, that allowed many blacks to move into decent housing (leaving behind, alas, those who are less successful and have more social pathology. This is not new, but see in immigrant groups in the past).

 but also TWO: immigration. West Indians, Africans, and Somalis. They have fewer pathological problems because they stress family values and don't carry the luggage of slavery.

So are these health care disparities seen in other inner city populations: Somalis, Hmong, poor ethnics? West Indian blacks? They also face a similar barrier to local medical care (often using Emergency rooms since the clinic means sitting in a large building for impersonal care).

But there are other factors. Hispanics often have extended families, but on the other hand, so do a lot of inner city Blacks (these families are just invisible to outsiders).

But some are genetic. Is the high infant mortality from teenagers having babies? Or is it from Pre Eclampsia? Or because drug/alcohol use causes sick babies?

Compare and contrast the statistics to Hispanics, or maybe more pertainent, Amerindians, whose substance abuse problems are a major problem.

And then there is diabetes/ hypertension. Again genetic..

AmerIndians have a lot more diabetes, but hypertension is common in Afro Americans, even at a young age, and is a killer. You have to take expensive medicine every day, and often it is a "silent killer" because it is not diagnosed early.

so yes, racism, but there are also genetic factors in this.

And the elephant in the living room is actually none of the above.

It is sickle cell disease.

  • People of African descent, including African-Americans (among whom 1 in 12 carries a sickle cell gene)
  • Hispanic-Americans from Central and South America
  • People of Middle Eastern, Asian, Indian, and Mediterranean descent
Because sickle cell anemia symptoms can begin by four months of age, early diagnosis is critical. All newborns in the United States are now tested for the disease. Sickle cell anemia can be identified before birth by testing a sample of amniotic fluid or tissue from the placenta. People who carry the sickle cell gene can seek genetic counseling before pregnancy to discuss options.

yup Abort the kid and voila, no  problem?

Imagine if 100 thousand white people lived with a devesating, painful disease?
There would be marathons and all sorts of stuff out there to educate patients.

and with aggressive treatment, the deaths can be limited:

hydroxyurea helps, as does giving pneumonia vaccine and daily penicillin prophylaxis (one common cause of death is pneumococcal pneumonia/sepsis, mainly because the sickle cells destroy the spleen that produces immunity to fight off this germ).

 In the last 50 years, survival has improved dramatically for people with SCD in the United States. Their average life expectancy in the 1970s was <20 years of age. By the early 1990s, the Cooperative Study of Sickle Cell Disease estimated a median life expectancy of those with sickle cell anemia, the most severe form of the disease, of 42 years of age for males and 48 years of age for females.
The red blood cells sickle/become a crescent shape when oxygen is low, and this clogs tiny blood vessels, causing pain etc.

One way to stop them from sickling is blood transfusions of normal blood cells, but alas HIV, the shortage and price of blood, and long term iron overload make that a difficult option.

and presumably a complete bone marrow transplant would work also: But again, very expensive and possibly fatal, so not used for a disease that might not kill ou for 30 years.

The reason that babies don't get symptoms, is that babies have Fetal Hemoglobin (wth a slightly different oxygen dissociation level) but this turns off after birth.

So could stopping this help? If you had maybe 20 to 30 percent of your cells as fetal hemoglobin, could you stop sickling crisis?

or why not just give them a gene that produces normal hemoglobin?

SicentificAmerican article on genetic treatments (2016)

read the whole thing.

This disease is mainly seen in West Africans, so yes, you see it in London and Europe.

If you have sickle cell trait, usually you don't have many problems. This is where the good gene makes most of the cells but you have some sickling genes: rarely a problem unless you are a paratrooper exposed to high altitude.

But the theory is that the trait helps protect you against malaria (malaria parasites grow inside red blood cells). A similar theory explains why you seen the various thalessemias in Greeks and other Mediterranean immigrants.

So i f you live in West Africa, the baby with sickle cell disease will die, but the ones with just the trait are more likely to live. Voila. Population drift to more people with sickle cell disease.
mediInteresting factoid: We didn't see sickle cell anemia in the Mashona of Zimbabwe.

They descended from the high veldt tribes where there was no malaria. Indeed, I saw exactly one case in the three years I worked there: And that mother was a local prostitute who worked at a local mine. She (and most of the miners) were from Mozambique or Malawi.

Monday, January 2, 2017

cdc on Zika, Goats and Chronic fatigue


not much new except they go into the guideline stuff for docs and public health folk.

And yes, spraying should help.

Successful control of Aedes aegypti, the primary mosquito vector of Zika virus, has proven extremely difficult using existing control methods. CDC’s technical assistance during the Zika response has therefore included support for improved mosquito control infrastructure, novel mosquito control techniques, and integrated vector management that uses existing control methods. During the Zika virus outbreak in the Wynwood neighborhood of Miami-Dade County, Florida, aggressive ground-based integrated vector management was supplemented by sequential aerial applications of adulticide and larvicide, which rapidly reduced adult mosquito counts in surveillance traps by approximately 90% and helped to end this local outbreak (36). A similar approach in Miami Beach, Florida, using aerial applications of adulticide and ground-based applications of larvicide, also substantially reduced adult mosquito counts. Recent advances in aerial insecticide application methods, and the fact that, in the continental United States, Aedes aegypti lives primarily outdoors, likely contributed to the success of the aerial approach in Miami-Dade County. Public opposition to aerial pesticide application in Puerto Rico precluded a similar approach there; instead, lethal mosquito traps have been deployed as part of large community trials that aim to evaluate this method of preventing future outbreaks of mosquito-borne disease on the island (37).

unless you are pregnant, the disease only is minor (yes, Guillian Barre, but that is rare). I had to groan at a yuppie who wrote an essay on one of the left wing magazine type sites bragging they got and survived Zika, and used this to brag you don't really need to use precautions like DEET or insect repellant when traveling in third world countries.


but never mind. Dengue is not a big thing: Only Zika, which can be hyped to push contraception, or Ebola, which is really bad, are in the news.


a bad strain of EColi causing bloody diarrhea has been linked to a goat farm...


Chronic fatigue syndrome discussion here.

The cause or causes of ME/CFS remain unknown. Patients often report an acute onset after a flu-like illness that does not go away, and some patients have a history of frequent infections before their illness. This suggests that an infection can trigger the illness, though it is less clear that the ongoing chronic illness is perpetuated by an infection. Investigators have looked for, and failed to find, a single etiologic agent. However, chronic fatiguing illnesses have long been described in the medical literature following infection with several different agents. For example, a syndrome with similarities to ME/CFS occurs in approximately 10% of patients with a variety of viral and nonviral pathogens, such as Epstein-Barr Virus, Ross River Virus, Coxiella burnetti (Q fever), or Giardia (12). The severity of the acute infection was most predictive of subsequent illness, and there is no evidence of unusual persistence of infections in those who remain ill; baseline psychological profile and socioeconomic status did not predict who would become chronically ill (12). Other studies have found that, compared with healthy controls, persons with ME/CFS have had exposure to significantly more stressors (trauma and other adverse life events) and are more likely to have metabolic syndrome, as well as higher physiologic measures of neuroendocrine response to stress (allostatic load) (13). These associations are not specific to ME/CFS, because stress is a factor in many chronic illnesses.
I have found patients with this who tested positive for Mononucleosis/EBV infection, post viral pneumonia (PPLO/Mycoplasm) and various forms of hepatitis. Often "tincture of time", and reassurance will work. Some were depressed, and counseling with a decent diet/exercize program will help, but the real puzzling cases are when you have a person who just loses their ability to work due to fatigue, and they don't fit into any of these boxes.

So it is a syndrome (a combination of symptoms): whether or not it has one cause is not certain.

But it is not "all in your head", and like fibromyalgia and other vague syndromes, the approach is to try to keep the patient functioning rather than a magic shot to cure it.