Category: Uncategorized

The Force of Nature

tree man

As we just witnessed on a macro-level with Hurricane Harvey, nature can act with overwhelming force. But what’s often lost in the shuffle is that nature can operate just as devastatingly on a micro-level too.

The above picture is of a man’s hand overrun with human papillomavirus (HPV) that turned into “tree man” disease, so-called because the tumors can resemble wood or bark. Fortunately, according to the NPR story, surgeons at a Jerusalem hospital were able to restore his hand to near normal, though the growths will probably return necessitating more surgery.

The story serves as a vivid reminder that when we hear vague phrases such as “pathogen-infested swamp,” referring to the aftermath of Harvey floodwaters; or that “millions of pounds of toxic chemicals” are pouring from damaged Houston area petrochemical plants — that these invisible-to-the-naked-eye substances will also have real-world consequences, every bit as much as the viral-induced growth seen on the hand.

The difference, however, is that with Harvey so many more people will be affected.

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After the Hurricane: Harvey Floodwaters are Loaded with Pathogens

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As we reported last week, “Infectious diseases could sweep across Texas as Harvey floods Houston … turning entire neighborhoods into contaminated and potentially toxic rivers … [and] the city into a sprawling, pathogen-infested swamp.”

Now the details are starting to come in and the news isn’t good. CNN is reporting that “unfortunately the numbers are stunningly high … especially bacteria, especially fecal bacteria.” For example, the number of viable E. coli cells in public water should be zero, yet CNN found as many as 8,600 such cells (colony forming units) in their small-sized samples – and they’ll continue to multiply, exponentially.

And because the pathogen count in general is so high there’s “the potential for sewer plant malfunction or sewer plant continuing to discharge untreated or partially treated waste.”

What you should therefore do: “take a bath or shower … as soon as possible after coming out of that water … [and] get rid of the clothes you had on because just washing them will not destroy the harmful bacteria.”

How to Raise a Child Without Antibiotics

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Since this Atlantic article was tweeted by @BradSpellberg you know it’s worth a careful read. It’s the unusual case of a 14-year old boy who, though he had been sick, had never been given an antibiotic. That’s because his parents understood the foundational rule: That antibiotics only work on bacterial-driven infections not viral-driven ones. Thus, for example, when you have the cold or flu antibiotics are not for you.

But this can be hard to follow in practice especially when facing your sick child. The article nicely explains why:

 Take a cold, for example, or bronchitis. Our friends know on one level that these are usually caused by viruses, but after a week or two of yuck and snot they’ve had it — so they call the pediatrician for an antibiotic. The harried doctor knows it’s likely viral but doesn’t want to fight with yet another parent about antibiotics — so out comes a prescription. “Just in case this thing’s bacterial, let’s cover our bases,” the doctor says, and moves on to the next patient. The child takes the antibiotic, and around the same time the cold would run its course anyway, the child gets better. Everyone is happy, right? No harm done. Except there’s lots of harm done.

 

So to avoid falling into this trap, there’s 5 refrigerator-door rules to know & follow:

  • Antibiotics are unnecessary for colds or bronchitis, even when they last longer than two weeks. Colds and bronchitis often take more than two weeks to resolve, so if there are no signs of pneumonia, then antibiotics can be withheld safely.
  • Green sinus discharge and green sputum does not mean you require antibiotics. Sinus discharge, sputum, and phlegm all turn various colors as the body fights infection, and many studies have shown that green sputum is as likely to be viral as bacterial.
  • Ear and sinus infections don’t always require antibiotics. Medical guidelines for sinus and (hot off the presses) ear infections suggest that patients without red flag symptoms can be observed without antibiotics; your doctor can help ensure this is safe.
  • If your child gets a prescription for antibiotics, ask your doctor to explain why.
  • The diagnosis of pneumonia — a legitimate indication for antibiotics — can not be made without a chest X-ray. Since the symptoms and physical examination can be the same in bronchitis (which is usually caused by a virus) and pneumonia (often bacterial), a chest X-ray is needed to determine if the diagnosis is really pneumonia, and therefore if antibiotics are needed. Don’t accept a prescription for antibiotics for pneumonia without a chest x-ray.

There is, of course, one other factor – luck. As the author points out: “Granted, we have been very lucky. Our son has never been in a major accident, needed surgery, or contracted any major illnesses. He was born healthy, he was breastfed, and he got his vaccines. He’s had his fair share of colds and a particularly scary case of flu, but never, not even once, required antibiotics.”

 

 

 

Frontline Re-Airs “Hunting the Nightmare Bacteria” Tonight

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In case you missed it the first time round, be sure to watch Frontline’s re-airing tonight of their exceptional report on the rising plague of antibiotic resistance. As they put it:

Has the age of antibiotics come to an end? From a young girl thrust onto life support in Arizona to an uncontrollable outbreak at one of the nation’s most prestigious hospitals, FRONTLINE investigates the alarming rise of a deadly type of bacteria that our modern antibiotics can’t stop.

Infectious disease specialist Brad Spellberg, MD, who runs the Los Angeles County-University of Southern California Medical Center, calls their report a “phenomenal story.”

Here’s the trailer:

Health Care Watch: From Robin Hood to Robbing the Hood

Since 2004 the US health care system has consistently ranked last among high income countries, according to a report in The New England Journal of Medicine. For example, “its population is sicker and has higher mortality than those of other high-income countries” and “the rate of death from conditions that can be managed and treated effectively is far higher than in other high-income countries.”

Three reasons are given: Too many people simply can’t afford US health care; there’s too much bureaucratic “hassle” for those that can afford it, and; the system marginalizes the poor, the less-educated, and those of a certain “race or ethnic background” (read: African-Americans & Hispanics). The common thread is “these three features disproportionately affect the quality of care for populations with higher health risks due to lower income, lower educational level, or minority status.”

 

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Yet the Journal goes on to argue optimistically that the “United States could achieve the best-performing health care system in the world by undertaking coordinated efforts that address each of these challenges.” And we should begin, the Journal says, by expanding the Affordable Care Act and Medicaid eligibility.

But the government has a better idea: repeal the ACA and thus eliminate Medicaid expansion. Which would, according to the Congressional Budget Office (1) increase the number of uninsured by 18 million in the first year of the repeal (2) increase that number to 32 million by 2026 (3) immediately hike insurance premiums by 20 – 25% for those able to afford private coverage, and (4) further raise those premiums by 50% by 2026.

Hmm, that seems like a strange way to move the US from the bottom right on the graph to the top left, as the Journal says we’re quite capable of doing. Oh, wait a minute, what was it President Obama (and pretty much everyone else) said about the real reason for the repeal?

The Senate bill, unveiled today, is not a health care bill. It’s a massive transfer of wealth from middle-class and poor families to the richest people in America. It hands enormous tax cuts to the rich and to the drug and insurance industries, paid for by cutting health care for everybody else. … Simply put, if there’s a chance you might get sick, get old, or start a family—this bill will do you harm.

 

MRSA Goes to Hollywood

 

BEVERLY HILLS, CA: MRSA, traditionally a hospital bug, is on the move. Increasingly it’s being found in the community, especially where people gather: athletic facilities, schools & daycares, military barracks, and downwind of industrialized food animal farms. And now, a California lawsuit reveals, it’s hanging out on Wilshire Blvd at the Beverly Hilton Hotel – home of the Daytime Emmy and Golden Globe Awards.

Texas businessman, reality show developer, & now plaintiff, Larry Poe, went for a facial at the Hilton Hotel spa just as he has 100 times before. But this time was different. Poe says the spa aesthetician poked him with a pair of tweezers in an attempt to remove a hair from his upper lip, and this caused a small wound to open. The tech applied a cream to try and sooth it but it was too late – MRSA had either already slipped in, or was contained in the cream and entered the wound upon application. Either way, his lip soon began to swell and after 3 days of unrelenting pain & swelling Poe finally went to the ER where he was diagnosed with MRSA. He was immediately quarantined and needed 4 days of hospital care to get well again.

Larry Poe is just one of the more than 80,000 people a year in the US who suffer a serious MRSA infection. Thankfully, he was not one of the more than 11,000 people who die from it. But he’s paying a price: on top of his pain, anxiety over treatment outcome, and missed work, he’s left with a permanent scar (troubling because he’s a public speaker), tens of thousands of dollars in medical bills, and the travails of pursuing a civil suit against a well-resourced corporation.

 

 

Antibiotics and unintended harm

Here’s a great infographic by ID specialist Michael Edmond, MD, on the unintended harm caused by antibiotics. It nicely summarizes the JAMA paper published last week that we ran a brief report on here.

Notice the figure at the bottom left that says “19% of antibiotic regimens not clinically indicated.” Meaning 19% of the antibiotics prescribed shouldn’t have been, and as the JAMA paper points out these prescriptions also harmed 1 in 5 patients. And this is Johns Hopkins, ranked as one of the best hospitals in the US. Across the country that number is much higher. A report in Medscape says “… up to 50% of antibiotic prescriptions in the United States continue to be unnecessary or inappropriate.”

 

Collateral Dmg

A gorilla walks into the operating room …

An emerging concept in medicine is the One Health movement that says human health is inextricably linked to the health of animals & the environment. And that human & veterinary medicine will unite as one discipline. For example, it’s been shown that MRSA travels back & forth between owner & pet.

The following story illustrates the idea. But that’s not really why we’re running it. It’s because it’s so darn heartwarming. And in this time of politically-driven pathology we need stories that remind us of our common humanity. In addition to the video, there’s a neat backgrounder piece – it’s brief – in the Atlantic about the surgeon who delivered the baby gorilla & her day at “the office.” Be sure to read it to the end where there’s a nice surprise waiting.

Johns Hopkins study: 1 in 5 patients harmed by antibiotics

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Question: What is the likelihood of developing an antibiotic-associated adverse drug event (ADE) for a hospitalized patient receiving antibiotic therapy?

Answer: 1 in 5 patients experienced at least one antibiotic-associated ADE.

Researchers looked at the medical records of 1488 adult inpatients at Johns Hopkins Hospital & found a total of 324 ADEs overall. The most common one’s were gastrointestinal, renal, and hematologic abnormalities, accounting for 78 (42%), 45 (24%), and 28 (15%) 30-day ADEs, respectively. Of those, 186 (57%) happened within 30 days, and 138 occurred within 90 days. Of the 138 ADEs occurring within 90 days, 54 (39%) were cases of the life-threatening Clostridium Difficile Infection, and 84 (61%) were Multi-Drug Resistant Organism infections, such as MRSA.

The researchers suggest the 1 in 5 figure is probably an underestimate because the study did not include patients seeking out-of-network care or those receiving prolonged or inappropriately broad antibiotic therapy.

The authors didn’t say this, but keep in mind that the study was done at Johns Hopkins – perennially ranked as one of the best hospitals on the planet.

Conclusion: “Although antibiotics may play a critical role when used appropriately, our findings underscore the importance of judicious antibiotic prescribing to reduce the harm that can result from antibiotic-associated ADEs,” said one researcher.

Decrease the Demand Please

Here’s a helpful video on antibiotic-resistant infections from Time. The key message is that we’re misusing antibiotics in 2 ways:

(1) We use them for the flu which isn’t affected by these drugs. And according to the CDC, antibiotics can’t cure the common cold or viral pneumonia, are almost never needed for bronchitis, are not recommended to treat many ear infections, and are typically not needed to treat a sinus infection (sinusitis).

(2) 80% of antibiotics are used in our food animals to keep infections at bay (i.e. they’re used on the animals when they aren’t even sick), and as a way to encourage chickens, pigs, cattle, turkeys, and (farmed) fish, to grow larger and produce more meat.

The upshot is that with so many antibiotics circulating in people and in animals, bacteria mutate to find ever more clever ways of becoming resistant to the drugs. The answer is to put the brakes on how we use antibiotics: we need to decrease the demand. Treat them more as a drug of last resort & limit their use in industrial farming to the treatment of sick animals.

 

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