the history of Insulin

Dying alone in Japan

There is a bestselling manga in Japan called "stargazing dog" about a middle aged man who was fired from his job due to downsizing, had his wife and children leave him, and ended up dead of neglect in the middle of a field.

the author insists it was not a sad book.

A manga titled “Stargazing Dog” starts with the discovery of the skeletal remains of the protagonist who lost his job and family and died in an isolated field with his dog at his feet. However, Takashi Murakami, 54, author of the manga, said this is not a tragic story. “He was not unhappy at all,” Murakami said of the protagonist. Murakami objects to characterizations of people who die alone as sad “losers in life” who have not prepared for death. Of course, the author says, people who do not want to die alone should receive help and support. What he objects to is the classification that all isolated deaths indicate the person has lived an unhappy life.

most of those who die, die alone in their own homes, neglected by their families.

The author feels society has unfairly attached labels to those who die alone and those who die surrounded by loved ones.

WINNERS, LOSERS OF LIFE “The ‘winners’ might be the group of people who can disperse the risks and avoid living in isolation,” said Midori Kotani, 50, president of a research center for senior citizens who specializes in clinical thanatology.

Eight years ago, Kotani, who also teaches at Rikkyo Second Stage College in Tokyo, lost her husband. His death spurred Kotani to form a group to help people maintain their lifestyles after their partners die. “If you want to avoid isolation or a lonely death, it is important to connect to people other than family members who can be relied upon when you are still vigorous,” Kotani said.

Akihisa Kono, 50, who runs a surgical hospital in Sakai, Osaka Prefecture, saw many lonely death cases when he was a medical examiner in the prefecture. Kono said that Japan’s wealthy and convenient society helps to free us from the troubles of meeting people face-to-face.

But, he added, “The communication skills of people are worsening regardless of age, which widens the disconnect within a community and between generations and leads to isolation.” Since the first half of the 1990s, the number of “muen botoke,” people who die alone and go unnoticed, even by their children or relatives, has been rising in Yokosuka, Kanagawa Prefecture.

The number started surging after fiscal 2005. Alarmed by the trend, the city four years ago started supporting “Shukatsu” (preparing for death) for people who live alone and are financially strapped. Kazuyuki Kitami, a social worker at the welfare division of Yokosuka city, said changes in society are fueling the trend in lonely deaths. “It is not about losing bonds but rather the environment has made it easier to sever bonds,” Kitami said.

He said sharp social changes can be traced back to two time periods: in 1990, when the average family size shrank to three members or fewer, and the 2000s, when the use of cellphones spread. People now have fewer immediate relatives to connect with, and human relationships are maintained chiefly through smartphones.

Those who find themselves with few real-life connections may die alone, and their families or relatives might not care, he said. “What generates such an atmosphere that even relatives don’t receive the remains? I think we need to think about that question,” Kitami said.

and it's not just the eldely who disappear

Ebola, Measles and Diarrhea killing children.

StrategyPage writes about the Ebola epidemic in the DRC/Central Africa.

The good news:

international and Congolese health workers have a new weapon in their arsenal. Two days ago 11,000 doses of the new American Ad26-ZEBOV-GP vaccine arrived in North Kivu province. North Kivu, South Kivu and Ituri are the three provinces in the epidemic’s epicenter. Another 39,000 doses will arrive shortly. As of October 20, there were 3,243 Ebola virus cases and 2,185 deaths in Congo. Uganda has had four confirmed cases and three deaths. 

the bad news:

 Sadly, in 2019 measles has killed more people in Congo than Ebola. So far over 4,100 Congolese have died this year from measles. Estimates are that Congo had over 200,000 total measles cases in 2019. Over 140,000 of those cases were children under the age of five years. (Austin Bay) 

there was a push to eliminate measles from the world (similar to how smallpox was eradicated in the recent past).

This 2014 article discussed some of the problems of getting the vaccine into the chaotic DRC (Democratic Republic of the Congo).

So what are some of these bottlenecks? First, access to routine vaccination services is extremely limited. The population is spread over large geographic areas with very limited road and public transport networks. Second, in several provinces, health clinics perform poorly due to shortages of health staff, ill-equipped health structures, irregular supplies of vaccines and inadequate cold chain equipment for vaccine storage.8,9 Third, the logistics challenge of accessing children in distant areas is overwhelming.

the article goes into details about the logistical problems.
One problem with measles vaccine is that since it is a "live" attenuated virus, it needs refrigeration. So if it gets warm, it deteriorates and doesn't work. That alone is a major problem.

and when I read in the article that there are reports of a alot of measles despite the reports of a high rate of vaccinations.

I not only wonder if the vaccine had been kept cold and had been given properly, but if the health care workers just faked the data to get paid.

and that doesn't even mention little things like roaming gangs who steal medical equipment, rob health care workers, and terrorize locals, or that many people are fleeing the war between insurgencies and government troops.

nor does it mention the propaganda war against vaccinations. This has been notorious with both polio and measles, usually in Muslim countries where the Mullahs take a half baked anti vax conspiracy theory from the web and tell their people not to get their kids vaccinated.

But these rumors are also complicating the ability to control the ebola epidemic. (something mentioned in the SP article)

The government and medical aid organizations are battling rumors that Ebola is a hoax. ... Many locals refuse to believe Ebola is what local and foreign doctors say it is. Traditional healers and the few Islamic terror groups in the area also oppose efforts to use modern medicine to treat Ebola. The traditional healers see it as a threat to their livelihoods while the Islamic terrorists believe Western medicine is really an infidel (non-Moslem) plot to poison Moslems or Africans in general.

Opponents to Ebola treatment encourage violence against those providing this treatment and that has led to some deaths and a considerable amount of violence.

Then we have this complaint: the upsurge in measles cases might have been partly because health resources have switched from vaccinating for Ebola rather than routine childhood vaccinations.

A combination of factors – increased violence, growing mistrust towards medical teams in the wake of the Ebola outbreak as well as the diversion of resources to deal with Ebola – have resulted in reduced vaccination coverage in general.

....Community mistrust towards the outbreak response team has been cited as one of the challenges. Another is the high levels of insecurity due to battles between the army and armed groups. This has affected access to health services by communities.

you don't say.

and from my experience, a lot of the "measles" deaths won't be reported: often the children would die of croup, pneumonia a week or two after the measles rash disappeared.

And then there is the problem of tuberculosis: Measles causes "anergy", meaning your resistance against tuberculosis goes down, and then you can die of TB. TB also is seen when the immune system is weakened by malnutrition, HIV, malaria, or other infectious diseases. 

and yes, malaria remains a major killer of children and adults in the area.

and don't forget that one of the major killers of young children is various forms of gastroenteritis, or diarrhea disease, usually viral, which usually is because of lack of clean water.

Sigh.

There are ways to fight all these diseases (been there, done that: baby clinics, digging wells, village health workers with WHO rehydration fluid, supplying chickens and cheap protein supplements and nutrition villages), but when there is a war and the roads are not safe, when clinics are robbed or medical personnel are killed, then the plan collapses.

been there, done that too. 

Sigh.

cross posted from my main blog

Military suicide

strategyPage has a long essay on PTSS, suicide, and the military, and how the military is trying to control the epidemic.

LINK

Military epidemiologists (experts on medical statistics) have long sought to convince people outside the military that the rise in suicide rates within the military has little to do with the stress of combat and mostly to do with the stresses of military life during wartime or peacetime. In other words, the increased suicides were not concentrated among the combat veterans, who make up less than 15 percent of those in the military but are more evenly distributed among all service personnel.

For example, during the last decade over 75 percent of suicides were among troops who had never gone overseas. The military, especially the army, has long documented all deaths and the Department of Defense in 2013 released a study of all suicides since 2001, when more troops saw combat, to 2008, when the heavy fighting in Iraq ended.

A similar study for 2009-2012 suicides found little change. The researchers also point out that the reasons for suicides in the military are quite similar to those for civilian suicides, especially when victims are of the same age, education, and other factors as their military counterparts. In other words, periods of intense combat for the military have little impact on the overall suicide rate because so few troops are exposed to combat.

These revelations were not well received by the mass media which makes much of the rising suicide rate in the military but pays less attention to rising suicide rates among civilians of the same age and education. That was 9 per 100,000 in 2001 but had risen to 17.5 in 2013 and by 2016 was 26 per 100,000 men aged 25-44, which is the age of most men in the military.

This was declared to be a health emergency, and to a certain degree, it was. What was missed in all the discussion was that the higher suicide rate in the military is usually below the rate for civilians of military age.

Pain pills and trauma care

People rarely die of prescription opioid medications they are prescribed. 
Well, duh. Sounds about right.

even those on high doses for chronic pain don't get "addicted": They might need to be withdrawn slowly from the medicine, but the psychological problems of addiction are not there (i.e. they take it to get rid of the pain not to get high).

The opioid crisis got bad after I left practicing medicine and moved here, but I know of two deaths in people who stole narcotic medications from cancer patients and died of an overdose. One was a known druggie, but another was a 13 year old girl at a party who was told to "drink this" and did. She was unpopular so obeyed the girl who gave it to her (probably as a joke). The source of the narcotic was the girl's grandmother, who kept liquid morphine for break through pain in her purse. Sigh.

but the dirty little secret is that the little old ladies often sell or borrow pain pills from each other because... arthritis pain.

A lot of older people just use a single mild opioid tablet at bedtime so they can sleep.


Yes, NSAIDs are just as good: indeed, for a lot of pain they are better, because they relieve inflammation: but in the elderly they have the risk of bleeding ulcer and kidney damage, so may kill more people than prescription opioids. So which are safer? It's hard to do a "clean" study, since the abuse cases and suicides confuse the statistics LINK

as for the suggestion to use Paracetamol (Tylenol), sorry: it just doesn't work as well, and it only lasts for 4 hours so you have to take a lot of pills to stay comfortable and again they do not relieve inflammation (which causes pain).

Drug abuse is a societal problem.

But of course, if you acknowledge it is Chinese fake percocet/ oxycontin /Fentanyl being smuggled in via Mexican drug cartels, you might have people actually saying yes build that wall to keep out drugs.

and my question: Where are the churches here? Isn't this a moral weakness to use drugs to get high? And how many take drugs because they were in despair, and no one was there to comfort them?

Ah, but PC churches have different priorities: Too busy worshipping Pachamama and changing Wikipedia pages for their enemies I guess...
--------------------------------------------------------------------------------

The Good news: from StrategyPage: Freeze dried plasma will save lives.

you give it to people suffering from blood loss. Plasma has been used since World War II (one of my professors was in charge of the blood bank using this to treat D Day casualties) but the new version is portable and doesn't require refrigeration.

The bad news: The French have been using it since 1994, and the US military has been using the French version since 2010 but is still trying to get the paperwork done to make it for the USA.

Article on the history of treatment of shock with plasma and blood transfusions and with IV fluid. LINK

A black physician, Dr. Charles Drew, developed the logistics of providing blood to the injured used in World War II.

His pioneering research and systematic developments in the use and preservation of blood plasma during World War II not only saved thousands of lives, but innovated the nation’s blood banking process and standardized procedures for long-term blood preservation and storage techniques adapted by the American Red Cross.

The Strategypage article notes other lifesaving methods devised for the military and now used in civilian life, such as hemecon and woundstat, used to stop bleeding and the abdominal belt to stop internal bleeding from the aorta.

not mentioned: Don't forget the helicopters.

The opening scene of MASH shows the helicopters bringing in the wounded, but in the last 30 years, helicopter transfer for civilians is becoming more common: Indeed, when possible they will land at your car accident site or near by (e.g. in parking lots) to take you to the Emergency room in some isolated rural communities.


the bad news: Consumer reports laments often they are used when alternative transport is available, leaving the person with a huge bill. But the problem is that when you call the ambulance, you don't often know how serious is the injury, or if the patient might die at the less equipped local hospital, or deteriorate during the long ambulance ride (when I worked in Northern Minnesota, it was 6 hours to Minneapolis and three hours to Fargo by ambulance... and in rural Pennsylvania a trip that is ten miles by map might take an hour and 30 miles by the mountain roads).

This article about a central Pennsylvania auto accident discusses how people are rescued and transported by medivac helicopter. 

I know the area.

Boalsburg is 30 minute drive to state StateCollege and another one hour or more drive to Altoona and in this case, the helicopter landed in a nearby parking lot.

the maps insist it is only a 45 minute drive to drive the 49 miles, but that is not true: that assumes the car accident happened near the interstate highway, that there is perfect weather, and that you can break the speed limit... 
And the dirty little secret is that it is hard to care for a critical patient in a noisy moving ambulance or in a fixed wing transport...

(I have no experience in the helicopters but these medevacs are well equipped, with experienced personnel, so things are less primitive than when I used to make ambulance runs in ambulances or in the fixed wing Cessna owned by the local undertaker that we used to borrow in the 1980s to transport people 150 miles to Rapid City from the Reservation).

My son in law is a Medevac pilot, Keep him in your prayers. 

----------------------------------------

In World War I, those suffering mental problem from combat were said to be suffering from "Shell shock".

And the SP article cited above notes that yes, post traumatic stress syndrome is more common in those who had mild brain concussions from IED explosions.

While largely the result of being exposed to a lot of combat, it was, by the late 1990s, realized that head trauma, usually from being too close to a lot of explosions, played a part as well. Work on PTSD continues, especially now that more methods have been developed, including medicines...

more HERE. 

however PTSD also occurs in civilians who had traumatic experiences. WEBMD discusses diagnosis and treatment.

Joe Kenda (of Homicide Hunter) discusses:

Kenda knows he suffers from post-traumatic stress disorder similar to what military veterans experience, and the show is a way for him to release some of the pent-up stress that still eats away at him to this day.

“It doesn’t go away,” says Kenda, who worked his way up to commander of the Major Crimes Unit. “You can’t un-see those things, you can’t not think about them, and you can’t forget them, even though you want to...

There are certain events that will trigger a memory, and it’s startling. Imagine having a nightmare while you’re awake. That’s what it can be sometimes.”

Sigh. Been there, done that. We docs see a lot of horrors too, cases of suffering we couldn't stop, or abuse cases or accidents, or of treatment that didn't work,  and you keep busy so just put the memory in a box and carry on. But after retirement, the memories pop back suddenly, and all I can do it give the problem to the Lord...

sigh.

(cross posted from my regular blog.)

CDC in the news

CDC: most violent deaths are... suicides.

by white males, young or old, or AmerIndian/Innuits.

homicides are more likely among Black non Hispanic teenage males.

Less than 1 percent are death by law enforcement.

----------------------------------

CDC reports one third of those with Lupus (SLE) take opioids for pain, and the experts are not happy about it.

Quick: What's wrong with this statement.

The widespread and long-term use of prescription opioids among this cohort of patients with SLE was striking given lack of evidence regarding safety and efficacy of opioids for treating chronic pain associated with rheumatic disease (1,7).

translation: we don't have scientific studies that opioids work for this type of pain (just ignore the experience of thousands of physicians who find it's the only thing that keeps their patients comfortable enough to function)

Particularly concerning is that some of the less appreciated medical risks associated with long-term opioid use, such as myocardial infarction, immunosuppression, and osteoporosis (8), are potentially compounded in persons with SLE, whose baseline risks for these comorbidities are elevated because of the underlying disease and adverse effects of immunosuppressive and glucocorticoid therapies.

translation: opioid use is associated with these things, but hey, the disease of the patient cause them too.

Further, recent preliminary data suggest that opioids are associated with increased mortality in lupus.¶

so is it from the opioids, or because we give opioids to the patients whose lupus is worse?

The study about increased mortality is, of course, a "metanalysis" meaning it took a bunch of studies and averaged the results.

so what does this mean?

A qualitative review was performed because the number of articles pertaining to specific adverse effects of opioids was typically small, and the diversity of adverse effects across systems precluded a quantitative analysis.

hmm.. in other words, not a lot of data out there so the analysis might not be accurate.

Through a variety of mechanisms, opioids cause adverse events in several organ systems. Evidence shows that chronic opioid therapy is associated with constipation, sleep-disordered breathing, fractures, hypothalamic-pituitary-adrenal dysregulation, and overdose.

True. Constipation in cancer patients on opioids is a big problem no one wants to talk about. You get respiratory depression, and I've seen this in the elderly, who are doing well on their opioid dosage until they pneumonia... a Overdoses might be accidental or deliberate (not just suicide but from taking extra dosese because you hurt and take a second or third dose before the first dose starts to work).

However, significant gaps remain regarding the spectrum of potentially opioid-related adverse effects. Opioid-related adverse effects can cause significant declines in health-related quality of life and increased health care costs.

or maybe they increase the quality of life when taken. That part is not addressed.

------------------------------
remember all the hysteria about the Zika virus causing mental retardation among infants whose moms were exposed to it?

well the dirty little secret is that Rubella does this too:

but thanks to vaccine, (MMR means Measles Mumps Rubella) it has gone down world wide.

CDC report:

Progress toward rubella elimination has resulted in 168 (87%) of 194 countries protecting infants with RCV and 81 (42%) eliminating rubella transmission. Equity between countries using rubella-containing vaccine has increased as lower-income countries have introduced rubella-containing vaccine.

this paper notes the decrease in cases from 2000 to 2016 

In 2016, 22,361 rubella cases were reported to WHO, a 97% decrease from 670,894 cases reported in 2000, and a 76% decrease from 94,277 cases reported in 2012 

there is a big worry that the increase in refusing "measles" shots (actually MMR shots) will increase the rate of fetal rubella syndrome: 

but one might not see this until these unvaccinated kids grow up and get pregnant.

and in some poorer countries, only measles vaccine was given, not the MMR combination which is usually used in the USA.

CDC Measles outbreak

Measles outbreak summary: 

most were isolated cases, some were from immigrants who didn't get shots (or maybe whose shots didn't work: in my experience the vaccine is unstable and doesn't work if not given properly).

herd immunity probably kept the disease from spreading to most unvaccinated kids, but the outbreak among Orthodox Jews in the NYCity area was an exception.

I know why the antivax idiots refuse the shot: Because Hollywood types spread the message that the vaccine causes autism.

And I know why the Muslims in some areas refuse the shots: Because the Imans read the hysterical anti vax stuff in the British papers and told their people it was a plan to destroy Islam.

And I know why the Philippines has an outbreak: The Denguevax scandal, where some kids who got the vaccine (but shouldn't have) got a fatal cases of Dengue, so some parents now refuse all vaccines (we also have polio and at least one case of diphtheria here).

But why Orthodox Jews, who usually are sophisticated? Maybe because an anti vax type group targeted them:

NYTimes article:

“The Vaccine Safety Handbook” appears innocuous, a slick magazine for parents who want to raise healthy children. But tucked inside its 40 pages are false warnings that vaccines cause autism and contain cells from aborted human fetuses.

“It is our belief that there is no greater threat to public health than vaccines,” the publication concludes, contradicting the scientific consensus that vaccines are generally safe and highly effective.

The handbook, created by a group called Parents Educating and Advocating for Children’s Health, or Peach, is targeted at ultra-Orthodox Jews, whose expanding and insular communities are at the epicenter of one of the largest measles outbreaks in the United States in decades.

or maybe because they were told the vaccine contained forbidden substances (similar to the ubercatholic trads who refuse vaccines because they were made from stem cell lines from aborted fetuses, despite the Vatican saying it was okay if the alternative vaccines weren't available).

WaPost notes it's not just NYCity, but Israel who has an epidemic;

The reason, health officials say, has nothing to do with religion and everything to do with the ultra-Orthodox way of life, as well as public health services that don’t meet the needs of large families. “Most rabbis encourage vaccination based on the Torah commandment to protect one’s life,” said Rabbi Yuval Cherlow, founder and head of the ethics department of the Tzohar Rabbinical Organization in Israel. “In Judaism, the majority has the right to dictate what takes place in the public space to ward off danger.” Still, “there is no pope in Judaism, and no one can force you to vaccinate,” Cherlow said. In 2018, Israel’s Health Ministry reported 4,000 cases of measles, compared with 30 the year before. In the United States this year, 387 cases have been reported through March, compared with 372 during all of 2018, according to the Centers for Disease Control and Prevention.

why?

no, it's not religion, but anti vax beliefs about autism.

maybe because they don't trust the government.

and maybe because it is spread from other countries in Europe including the Ukraine, where immigrants come from.

Or maybe, the article says, because they have so many children they don't get around to getting the kids all their shots.

Ironically a lot of the cases are in kids under one year of age: Usually we don't give the vaccine to these kids since it doesn't work well (due to immunity inherited from mom). In Africa, we did give it to kids over 6 months but repeated it at 18 months, because partial immunity was better than none, and most of the kids who had partial immunity who got measles survived.

This is where "herd immunity" is important: If enough people are immune, the disease is less likely to spread to the entire community, and means most infants would never be exposed to it.