155612753Who knew that transplanting poop, otherwise known as fecal material, stool, gut microbiota and other less scientifically rigorous terms, could successfully treat at least one modern scourge, Clostridium difficile infection? Now Rick and I talk about frozen, encapsulated fecal microbiota transplant administered orally on this week's PodMed, and as reported in JAMA.  In spite of the substantial yuck factor, turns out the strategy works in the vast majority of patients.  Good news indeed for those with this increasingly common cause of fulminant diarrhea that may result in death.

Researchers with previous experience in fecal transplant to treat C. dif infection, as it is fondly abbreviated in medical circles, mused that while direct transplant either right into the large bowel or administered via a nasogastric tube worked well in the majority of patients, several limitations were apparent.  These included the need to transplant fresh material from a donor related to the patient, who has previously been screened for the organism, and placement of a infusion device to accomplish the transplant. They hit upon the idea that screened, frozen material could be used instead, and had used this in a previous study for infusion via a nasogastric tube.  It was a short leap to aliquoting transplant material into capsules and administering them orally.

The current study enrolled twenty patients ranging in age from 11 to 89 years, to receive the capsules. All of the subjects had had at least three previous episodes of mild to moderate C. dif infection and had failed treatment with the usual antibiotic therapy, or had been hospitalized at least twice with severe C. dif infection. The fact that one of the subjects was only 11 years old points to the disturbing recent increase in infections among the pediatric population. Each subject was given 15 capsules of fecal transplant material on two consecutive days by an investigator. Those who failed to respond were offered an additional course of treatment.

Here are the very impressive results as reported in the paper: No serious adverse events...were observed. Among 20 patients treated, 14 had clinical resolution of diarrhea after the first administration of FMT [fecal microbiota transplant] remained symptom free at 8 weeks. All 6 nonresponders were re-treated at a mean of 7 days after the first procedure. Of these 6, 5 patients had resolution of diarrhea after the second treatment. However, 1 patient relapsed within the predetermined 8-week follow-up after initial diarrhea resolution, resulting in an overall rate of diarrhea resolution of 90%. The only variable significantly associated with response to first treatment was overall health score prior to FMT. Patients who needed a second treatment to achieve resolution of diarrhea had lower pretreatment health scores (were more symptomatic) than patients who had diarrhea resolution after a single administration..  Wow.  That's pretty good.  So what about those capsules?

Fecal donors were healthy, non pregnant adults 18 to 50 years of age, taking no medications and having a normal body mass index.  Clearly no previous history of C. dif infection was necessary and all donors were screened for infectious disease according to blood bank procedures.  Previous to stool donation all donors were requested to avoid allergenic foods but otherwise to eat normally.  Their stool was frozen and stored for 4 weeks to allow rescreening of donors before their microbiota were transplanted.  All in all, sounds like a fairly innocuous procedure to me, and one that may also be readily expanded.  Rick and I agree that such a strategy sounds promising indeed to stem the tide of C.dif infection.

Other topics this week include a really cool use of stem cells to treat macular degeneration and dystrophy in the Lancet, an update on Ebola projections in NEJM, and exercise and depression in teenagers in JAMA Pediatrics.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

78751261Corneas, kidneys, lungs, hearts…now uteri (and yes, I checked it- that is the correct plural) can join the list of organs transplanted successfully and functionally into other humans.  That's as reported in the Lancet and as Rick and I discuss on PodMed this week.  What's the story?

Sometime in 2013 a 35 year old woman who lacked a uterus since birth, a condition known as Rokitansky syndrome, underwent transplantation of a uterus from her 61 year old, obviously postmenopausal friend, who had given birth to two children during her reproductive years.  Lack of a functional uterus is not uncommon; so-called 'absolute uterine factor infertility' can occur as a result of congenital absence of a uterus, hysterectomy, or a number of adhesions within the organ, and affects some 12,000 women in the UK alone.

As stated, the uterus was harvested from a live donor, who first took oral contraceptives for three months prior to organ retrieval to assure that bleeding would occur as predicted. The surgery spanned just over 10 hours due to extensive dissection relative to isolation and preservation of the vasculature supplying the organ. From my perspective, this is a mighty generous undertaking on the part of the donor!

In contrast, the recipient's operation took just less than five hours but that, of course, is where the easy part ended.  Immunosuppression was initiated and many and frequent examinations of the transplanted uterus ensued. Menses appeared spontaneously 43 days after the transplant, and continued at regular intervals thereafter.  Two minor rejection episodes were managed successfully and one year after uterine transplantation, the patient underwent embryo transfer with she and her partner's embryos, previously conceived via IVF. Pregnancy commenced and continued normally for 31 weeks, when the patient developed pre-eclampsia.  The baby, a girl, was delivered by Cesarean section at 31 weeks and 5 days gestation, and had normal Apgar scores and other measures of health.  Thus far, both mother and baby seem to be doing well.

The authors coin a term, "ephemeral transplant," to describe the fact that after one or two pregnancies, the transplanted uterus can and likely should be removed to allow the recipient to cease immunosuppression. Such removal should not take place immediately following birth as both the health of the infant and a period of recovery for the mother should be assured, but they say this successful management of infertility provides proof of concept that such a strategy is possible for women with absolute uterine factor infertility. Hmmm.  Rick and I are both in awe of so many aspects of this report, perhaps mostly because who knew that recycled uteri could still be so clearly functional? As those bumper stickers extolling the virtues of organ donation state, "Don't take your organs with you to heaven, we need them right here," I wonder how much pressure potential donors might be under if such a practice becomes widespread?  Somehow that harvesting operation doesn't appeal; I think there would have to be some pretty persuasive reasons to participate.  For now, yet one more miraculous medical intervention to ponder.

Other topics this week include a pan on transfusions for yet another group of people: those with septic shock, in NEJM, another in the Lancet on quality of life for teenagers with cerebral palsy, and in JAMA Internal Medicine, a look at decision fatigue and the prescription of antibiotics among physicians.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

dv708017 When I think of teenage women this photograph conjures up an adage I largely agree with that 'girls just want to have fun.' Perhaps that accounts at least in part for the rather astonishing prevalence of adolescent pregnancy in the US: more than 600,000 each year, for an overall rate of 3 in 10 teenage women becoming pregnant before age 20. On this week's PodMed, Rick and I talk about a study in the New England Journal of Medicine that assesses a multipronged approach to intervention, with stellar results.

The study enrolled just over 1400 adolescents 15 to 19 years of age at any time during the study period. They were part of a larger study known as the  'Contraceptive CHOICE Project.' This project employed long acting reversible contraceptives (LARC) as the method of choice to reduce unwanted pregnancy among almost 10,000 women 14 to 45 years of age living in the St. Louis area. Participants in the study were provided with education regarding reversible contraceptive methods, identified from most to least effective.  Side effects, risks and benefits of each method were also identified. Women were provided with their chosen method free of charge the same day they attended an education session. Women were offered same day insertion of their method of choice among the LARCs, either intrauterine devices or implants, and they could obtain another shorter acting method if they were ineligible for same day insertion until their chosen method became available to them.

Telephone interviews were conducted by study staff at 3 and 6 months after employment of the chosen contraceptive method, then every 6 months thereafter up to 2 or 3 years, depending on enrollment date. Subjects received a $10 gift card at completion of each survey, which gathered data on satisfaction with the method, sexual behavior and pregnancy.  Pregnancy outcomes were recorded for those subjects who became pregnant.

The study states that the "majority of teens in both age groups chose LARC methods, but teens 14 to 17 years of age were more likely than older teens to do so (77.5% vs. 68.4%,). The implant was the most common contraceptive choice for participants 14 to 17 years of age, whereas an IUD was most commonly chosen by older teens." Here's what the conclusions are: " During the 2008–2013 period, the mean annual rates of pregnancy, birth, and abortion among CHOICE participants were 34.0, 19.4, and 9.7 per 1000 teens, respectively. In comparison, rates of pregnancy, birth, and abortion among sexually experienced U.S. teens in 2008 were 158.5, 94.0, and 41.5 per 1000, respectively."  Wow!  Those are some very impressive results, and suggest, at least to Rick and me, that provision of both information and free contraceptive methods can have a huge impact on this persistent problem.

Two aspects of this issue remain concerning for me.  One is that while 2 in 10 white teenagers will experience pregnancy before age 20, the number is twice that for blacks and Hispanics, so cultural sensitivity must play a role in such interventions.  Of even greater concern is the fact that none of these methods protect against STIs, some of which are livelong and even life threatening.  Rick and I agree with the American Academy of Pediatrics which also issued recommendations this week, citing first abstinence as the most effective contraceptive, but also advocating for condom use in addition to other methods for everyone's protection.

Other topics this week include early gluten introduction and celiac disease, also in NEJM, and two from JAMA: acupuncture for knee pain and heart valves in middle-aged adults.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 5.0/5 (1 vote cast)
No Comments

166132487If you’re a woman, pretend for a moment that you’re pregnant.  If you’re a man, imagine you’re a woman who’s pregnant.  Then address the question, would you chose to undergo prenatal testing?  If the answer is yes, which type of testing would you chose?  Finally, what would you do based on the results? As Rick and I discuss on PodMed this week, a JAMA study elegantly demonstrates that pregnant women can be educated and informed regarding prenatal testing using a computer-based tool, and that when they are so-informed, even when prenatal testing of all types is offered free of charge, they chose to undergo such testing only half of the time a control group choses it.  Our conclusion is that development and utilization of such educational tools is practical and should likely be expanded to a host of complex healthcare decisions, particularly as people are being called upon more and more to engage in ‘shared decision making’ with their healthcare providers.  Let’s take a look at the study.

Researchers recruited from prenatal clinics in a variety of healthcare settings in the San Francisco area, representative of many economic and educational strata as well as ethnicity. All women were less than or equal to 20 weeks of gestation with no history of previous prenatal testing in the current pregnancy. A total of 710 women were recruited, 357 of whom were randomized to a computerized interactive decision support guide conducted in their choice of either English or Spanish, along with remission of fees for any prenatal testing they chose that was not covered by their insurance, or the remainder to routine care.

The computerized guide was administered at an interview site and took 45 to 60 minutes to complete.  The guide utilizes video, text, audio and graphics and a bilingual female narrator to describe prenatal testing options and their potential risks and benefits. The program emphasizes that the range of choices available are all reasonable and personal and optional additional detail is provided.  Outcomes for the study included whether and which prenatal testing options were chosen by the women, verified by medical records, and an assessment by telephone of subject regret later in pregnancy on which choices were made. As I’ve
already foreshadowed, invasive prenatal testing was selected about half of the time among those who were administered the computer guide as those who received usual care.  Moreover, those women who saw the guide were very happy with their decision later in pregnancy, as was the control group.

What this study tells Rick and me is it's very practical to offer this kind of guide to people making complex medical decisions, especially since it requires no additional time of any provider. So many decisions remind me of this!  Should you have arthroscopic knee surgery? cardiac stenting? carotid endarterctomy? the list seems endless.  If such an educational strategy were undertaken I believe it would empower people much more to feel responsible for their own health, and that's all to the good. Here, here!

Other topics this week include new Ebola estimates in MMWR, varicose vein treatment in NEJM, and PET scanning for lung cancer diagnosis in JAMA.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

512984219Trying to understand what it might actually be like to be in an African nation stricken by Ebola virus infection running rampant is mere speculation for most of us.  On PodMed this week, with an eye toward promoting better understanding of the human dimension of this global health crisis, Rick and I depart from peer-reviewed studies to feature a perspective piece in the New England Journal of Medicine: Face to Face with Ebola — An Emergency Care Center in Sierra Leone. Our thanks and kudos to the author, Anja Wolz, R.N., who has been working in this center in Sierra Leone with the international aid organization Médecins sans Frontières, or Doctors Without Borders, for the last seven weeks. What she describes provides a window into the daily ordeal of attempting to stem the tide of this infection. Slideshow recommended.

Anja begins her shifts at the 80 bed Ebola case management center at 6am. The place is staffed 24 hours a day every day of the week in three rotating shifts.  In relating a typical day Anja comments that those who work there are thankful when it rains, because the personal protective equipment (PPE) isn't as hot as it is when the sun is shining. Even so, personnel are limited to 40 minutes of wearing the full regalia because it simply becomes unbearable, yet it is easy to lose track of time with so many tasks to complete in the isolation area. Donning the PPE takes fully five minutes to perform, in the company of a designated dresser, whose task it is to make sure no skin area, however minute, is exposed.  Overalls, aprons, double gloves, two masks, boots; some of these will be sterilized and reused, but the majority are burned after use. Before PPE can be removed those who've been in the isolation areas are sprayed down with a chlorine solution, and removing the garb is as elaborate a ritual as putting it on.

The organization of the care areas speaks to the knowledge of the staff in containing infection. The center is divided into two areas designated low- and high-risk regarding contagion.  Low risk areas include the pharmacy, laundry, laboratory, water chlorination area, dressing area and staff meeting area, while high-risk or isolation areas are those where patients are housed.  These last are organized into suspected, probable and confirmed Ebola cases, and the staff proceed through them systematically beginning with the suspected case area. Patients become sicker in successive tents, and they are also warned about the possibility of cross-contamination amongst themselves.

This points up one of the most poignant aspects of Anja's narrative:  the total lack of human touch between staff and patients, or between patients, even when the patients are children.  She relates the death of two young children in her recent charge, and rues the fact that she cannot touch them. She notes the fear apparent among patients as they learn the results of PCR tests to confirm infection and their subsequent advance to the next tent. Fear, Rick and I note, is just so prominent in this crisis; today the news outlets reported the stoning death of 8 community outreach workers in Guinea because people thought they were conveying Ebola infection.  Even here in the educated and informed US, fear is prominent, although some might argue not prominent enough as we have been rather slow to respond to this crisis.  Hopefully global efforts are underway now.

Other topics this week include generic versus brand name statins in Annals of Internal Medicine, and spinal manipulation and sciatica in the same journal, plus CT versus ultrasound for diagnosis of kidney stones in the ED in NEJM.  Until next week, y'all live well.

 

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

481552311Whatever your feelings on the rapid decriminalization of marijuana nationally as well as its meteoric rise as a cash crop, a study in this week's Lancet Psychiatry raises some red flags with regard to the use of this drug by adolescents.  As Rick and I discuss on PodMed this week, we second concerns as well as recommendations made by the authors of this study that for this group of vulnerable people, strict limits should be employed to reduce long term sequelae of marijuana use.

Investigators did a meta analysis of three longitudinal studies taking place in New Zealand and Australia, together comprising several thousand subjects followed from 13 to 30 years of age. Multiple assessments were made during the study period, but for the purposes of this analysis the relevant ones included cannabis use before the age of 17 years, with categories of never, less than monthly, monthly or more, weekly or more, or daily. Developmental outcomes to the age of 30 years included attainment of a high school degree, attainment of a university degree, dependence on cannabis, use of other illicit drugs, suicide attempt(s), depression, and welfare dependence.

The studies attempted to correct for a multitude of variables and confounders that may have impacted marijuana use and outcomes.  Here's what the paper states, "We included 53 covariate factors from the three studies in the analysis. These covariates spanned individual background and functioning, and measures of parental and peer factors... After adjustment, the associations for depression and welfare dependence were both non-significant and negligible in size. For all other outcomes the associations remained significant. The estimates for adjusted ORs [odds ratios] suggested that individuals who were daily users before age 17 years had odds of high-school completion and degree attainment that were 63% and 62% lower, respectively, than those who had never used cannabis; furthermore, daily users had odds of later cannabis dependence that were 18 times higher, odds of use of other illicit drugs that were eight times higher, and odds of suicide attempt that were seven times higher. Wow.  No matter how you spin that data, it's pretty powerful.  Moreover, the analysis identified a clear dose-response between deleterious outcomes and frequency of marijuana use.

What is it that makes marijuana use especially problematic for adolescents?  Evidence has been abundant for some time that adolescents undergo a period of neuronal sprouting and subsequent pruning that may account for their oft-observed impulsive behavior, and that seems to give way to a greater degree of sense as individuals age into their twenties and beyond. Perhaps the presence of metabolites of cannibis in the central nervous system hinders this process somehow.  Another explanation is that there is already some proclivity among those prone to choose cannibis use that accounts for the apparent sequelae.  In any case here's what we know:  there won't be a prospective trial anytime soon enrolling lots of teenagers and randomizing them to various frequencies of cannabis use or not, then looking at outcomes.  For now, we agree with the authors of the paper that both efforts to limit the availability of marijuana to teenagers as well as screening efforts should be employed, as we are all vested in the outcome.

Other topics this week include new hip and knee prostheses in BMJ, questionable medication use in people with profound dementia in JAMA Internal Medicine, and aspirin to prevent preeclampsia in Annals of Internal Medicine.  Until next week, y'all live well.

 

 

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

492027539ZMapp is the name of a treatment that's been tested in our close cousins, monkeys, that's offering the only hope so far that we may be able to make some headway against Ebola virus (EBOV) infection, Rick and I discuss on PodMed this week. And while we almost never feature studies limited to non-human primates, or things published in Nature, in this case the public health import is so great we've made an exception. Thank you, monkeys!

Previous research on treatments for Ebola virus infection identified two combinations of monoclonal antibodies that looked promising:  the monoclonal antibody cocktail MB-003, consisting of human or human–mouse chimeric antibodies, and ZMAb, consisting of mouse antibodies. When these were administered after Ebola virus infection more than 24 hours previously, they still demonstrated substantial benefit. The current paper aimed to optimize the combination of these two cocktails and determine what the authors call the "therapeutic limit."

The mouse antibodies were humanized, multiple combinations of antibodies were screened in guinea pigs and Rhesus monkeys, with the animals challenged with the virus and survival noted. The optimal combination was administered to monkeys up to five days post-infection with the Guinean variant of the virus, the one currently in circulation in Africa. Eleven of twelve monkeys had both fever and detectable virus in their blood, indicating that the antibody cocktail was therapeutic rather than prophylactic. ZMapp was able to reverse severe EBOV disease as indicated by elevated liver enzymes, mucosal haemorrhages and rash in a few animals.

This is of course, the self-same cocktail of antibodies that was administered to two American workers who were infected and became quite ill with EBOV, both of whom survived. The authors note that such antibody cocktails, (and I bow here to colleagues who've vociferously corrected me on the use of 'cocktail,' implying as it does fun times and socializing, which couldn't be further from the truth with regard to infections associated with a high degree of mortality), are much less problematic clinically than antibody purified from convalescent humans, easier to scale up, and useful across the age spectrum.  In view of the patent fact that so far, containment efforts underway in Africa have sadly failed, with CDC and WHO folks predicting somewhere between 20,000 and 100,000 new infections before things damp down, seems the most compassionate strategy to get large-scale manufacturing underway as soon as possible. Rick predicts that ZMapp will likely have a role in the armamentarium even as a vaccine is developed, since there will always be a population in whom the vaccine fails to elicit a protective immune response. Having been to sub-Saharan Africa myself, it also seems likely that even highly publicized vaccination efforts are likely to miss quite a few people who would then remain susceptible to infection.  But thank God at least that vaccine development, as announced by the NIH this week, is also underway.

Other topics this week include two from NEJM: a novel agent in the management of congestive heart failure and the usefulness of flu vaccination in pregnant women, both HIV positive and HIV negative, and in the Lancet, beta blockers in people with congestive heart failure and atrial fibrillation.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

178897619_medWho knew that depression in teenagers was such a common problem, leading to things like self-harm, obesity, and risk-taking behavior? And that one in five adolescents experience at least one episode of major depression by age 18?  Rick and I both admit to being unaware of the magnitude of the problem on PodMed this week , and were heartened to see results of a study in JAMA showing that a collaborative care model employed in primary care practices is quite beneficial.

Investigators randomized 101 adolescents who screened positive for depression in a primary care setting to either usual care as self-referral to mental health care after receiving a letter from their primary care physician with their screening results or to a 12 month intervention employing follow-up by a master's level clinician with a special interest in depression, so-called 'depression care managers.' The depression care manager was empowered to assess the patient and provide brief cognitive behavioral therapy, medications, or both, after consultation with both the patient and the parents.

Outcomes included changes in a clinician-administered questionnaire on depressive symptoms and another on impairment at baseline and 12 months, and remission. As the paper states, "At 12 months, intervention youth were more likely than control youth to achieve depression response (67.6% vs 38.6%, OR = 3.3, 95% CI, 1.4-8.2; P = .009) and remission (50.4% vs 20.7%, OR = 3.9, 95% CI, 1.5-10.6; P = .007)."  Yikes.  These are really big intervention effects. It's worth noting that the outcomes reflect the hands on approach taken by the depression care managers.  Following their initial consult the DCMs followed up every one to two weeks, escalated interventions if the teenager wasn't responding, and changed medications if necessary, all at a cost of about $1400 per patient.

Issues of concern emerged from this study:  the majority of adolescents did not complete the screening assessment, and a large percentage of parents declined consent for their adolescent to participate.  In Rick's opinion, these outcomes underpin a persistent factor underpinning undertreatment of depression: stigma.  Parents did not want to admit that depression might be a problem for their teenager.  Juxtapose that against the fact that the study authors credit participatory parents as a major support in providing good outcomes in their intervention group, and the need for some strategy to overcome bias is apparent. Of course stigma relative to depression is not limited to an adolescent population, but couple that with black box warnings about use of certain antidepressant medications in this age group, resulting in reluctance on the part of primary care docs to even attempt to manage the condition, and things seem dire indeed.  Rick and I agree that the depression care manager model is one well worth exploring and implementing further, and perhaps expanding to other populations in whom depression is common.

Other topics this week include MERS contagiousness in household contacts in NEJM, cardiovascular events in low, middle and high income countries in the same journal, and self-management of high blood pressure in JAMA.  Until next week, y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments

79393642_sqIf you're a woman of a certain age, read that 'teenager,' you're probably almost inexpressibly tired of hearing about the benefits of exercise. Well, as Rick and I discuss on PodMed this week, we're giving you fodder for taking an opposing view with a study identifying at least one risk of exercise for adolescent girls.  At least if you're an elite athlete playing soccer, a study in JAMA Pediatrics demonstrates a real risk for concussion. Add this to the growing body of evidence on long term health consequences relative to concussion, and the necessity to develop interventions seems imminent. It's also a timely message as school is either just about to begin or has begun in much of the US, and sports-related injuries are likely to rise.

The study followed four 'elite' girls' soccer teams comprised of 351 female players from 11 to 14 years of age. The players were followed from March 2008 through May 2012, with over 92% completing the study. Almost 44,000 hours of athletic exposure for the players accumulated over that time period.

The study employed a validated injury surveillance system consisting of a once-weekly email sent to the player's parent with a web link to a survey querying the occurrence of head injury with concussive symptoms. Such symptoms included memory loss, difficulty concentrating, confusion or disorientation, dizziness, drowsiness, headache, more emotional than usual, irritability, losing consciousness, nausea, ringing in the ears, sensitivity to light or blurry vision, and sensitivity to noise, as identified by the 3rd International Conference on Concussion in Sport.

If concussive symptoms occurred the player received a phone call from study personnel, who queried the nature of the injury, whether the player continued to play after sustaining the injury, whether she was seen by a qualified health care professional, and whether a diagnosis of concussion was made.

Here's the data from the study:  "Soccer players experienced 59 concussions, 51 incident and 8 repeat. Among concussed players, 72.9% had 1 and 27.1% had 2 concussions. Mean (SD) length of symptoms was 9.4 (13.2) days (median, 4.0 days), with 11.9% lasting less than 1 day; 52.5% lasting 1 to 7 days; 11.9% lasting 8 to 14 days; 15.3% lasting 15 to 21 days; and 8.4% lasting more than 21 days. Most concussions occurred during a game (86.4%) involving contact with another person (54.3%), the ball (29.8%), or the playing surface (15.9%). Players were heading the ball (30.5%), goaltending (11.9%), chasing a loose ball (10.1%), or getting the ball from an opponent (10.1%) when concussed. Fouls were called in 15.2% of the concussions."

Hmmmm.  As Rick and I discuss in the podcast, this data seems to suggest that helmets might be a good idea for those playing soccer, just as they've been adopted in other sports where head injury is common and problematic.  I'm certain the 'cool factor' could be overcome if the rules simply mandated helmet use.  Another practice that perhaps should be examined is heading the ball, as almost a third of the concussions occurred as a result of this practice.  Finally, Rick and I agree that early and repeated concussion may represent more of a long term health problem for girls as previous research has shown that girls are more susceptible to sports-related concussion than boys.  The significant health benefits of regular physical activity are well-known; let's make it safer if we can.

Other topics this week include a new drug for multi drug resistant TB in NEJM, cancer screening in the elderly in JAMA Internal Medicine and smoking cessation post-hospitalization, in JAMA.  Until next week,y'all live well.

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
1 Comment

185479646What with all the coverage of Ebola virus infection taking first place in news outlets, you may have missed another viral infection that's likely to be much more impactful here in the US, also originally an African import: Chikungunya.  As Rick and I discuss on PodMed this week and featured in an online first release in JAMA, the first two cases of local transmission of Chikungunya have occurred here in Florida, so it's official: Chikungunya has arrived on mainland USA.  And it's not cause for celebration.

As the report notes, since late last year the number of cases of Chikungunya has been increasing worldwide, with some 400,000 or so cases reported by the Pan American Health Organization.  The virus has been wreaking havoc in the Caribbean this summer, with tens of thousands of infections spread over much of the region. Until now, most cases in the United States have been the result of people traveling to the Caribbean islands and becoming infected there, then returning home.

Now, however, the typical pattern of infection has taken place in Florida, where an infected mosquito bites someone who is infected, then transmits that infection to the next person it bites.  The mosquito is merely the vector for the virus to pass from one person to another.  The virus has mutated such that it can now infect two species of mosquito:  Aedes aegypti and Aedes albopictus.  Aedes aegypti is the preferred and longstanding host, but acquisition of a single point mutation by the virus now allows it to be transmitted by A.albopictus as well.

So what about these mosquitos? A.aegypti makes its home in the southeastern US and parts of the southwest, while A.albopictus also forays further north to the mid-Atlantic and lower Midwest regions.  It's worth pointing out that in contrast to many of their peers, these two species of mosquito feed during daytime hours so wisdom regarding bite avoidance at twilight is sketchy at best.  In view of the fact that the infection mimics the flu except for joint pain many describe as 'excruciating' and 'disabling,' and can last as long as six months post-acutely, we all would like to avoid infection, so what should we do? Rick emphasizes that mosquito control is the best strategy, primarily by eliminating areas of standing water, such as flower pots, kiddie pools and the like.  Use of insect repellants and clothing is also helpful.  He points out to healthcare providers that Chikungunya is a reportable disease, so samples should be sent to local health authority or CDC labs for confirmation.

Good news has emerged also with release of data from a very early study on a vaccine candidate for Chikungunya reported in the Lancet.  In this small trial using a virus-like particle approach, volunteers did mount neutralizing antibodies to the virus and few side effects of vaccination.  Stay tuned.

Other topics this week include a number of studies examining the role of salt with hypertension and cardiovascular disease in NEJM, flexible sigmoidoscopy benefits in JAMA, and BMI and cancer in the Lancet.  Until next week, y'all live well.

 

VN:F [1.9.17_1161]
Rating: 0.0/5 (0 votes cast)
No Comments