Shingles Recurrence: Can The Vaccine Help?

This montha??s Harvard Health Letter has an article about getting shingles a second or even a third time.??(Click here to read the full article.) The bottom line is that recurrence is a) certainly possible and b) if some recent research is??correct,??much more common than previously thought and about as likely as getting shingles in the first place if youa??re age 60 or older.

I talked to Barbara Yawn, M.D., director of research at the Olmsted Medical Center in Rochester, Minn., for the article and??mentioned??results??that she??and her colleagues??first presented at??a conference several years ago.

Yawn reported a more complete version of those results in last montha??s issue of the Mayo Clinic Proceedings (a favorite journal of mine). Full text of the study isna??t available unless you have a subscription to the journal, but here’s a summary (in medical publishing, such summaries are called abstracts.)

Melinda Beck, a health columnist for the Wall Street Journal, ??had a column??about shingles last week and this??how she??neatly summed up Yawna??s research:

For the new study on shingles recurrence, researchers at the Olmsted Medical Center in Rochester, Minn., examined medical records of nearly 1,700 patients who had a documented case of shingles between 1996 and 2001. They found that more than 5% of them were treated for a second episode within an average of eight yearsa??about the same rate as would typically experience a first case.

And here is a link to the Journal Watch item of the??study and a short comment by the Journal Watch editor. Journal Watch is a monthly newsletter published by the Massachusetts Medical Society that summarizes and comments on recently published research.

In the Mayo Clinic Proceedings paper, Yawn and her colleagues report that 95 of the 1,669 people with an a??indexa?? case of shingles got shingles again over the course of a follow-up period that averaged 7.3 years, which??works out to about 5.6 percent??of the shingles sufferers.??Six??people had two recurrences and two had three! The timing of recurrence varied from 96 days to 10 years after the initial episode. In??45 percent of those who got shingles again, the site of the recurrence was in a different region of the body than the site of the first case. They also noted that the single biggest risk factor for having a second case of shingles was having pain that lasted 30 days or longer during the first case.

Other studies have shown the recurrence rate to be much lower. Yawn and her colleagues said a longer follow-up period is one explanation for their results:

Studies that include 1 to 2 years of follow-up may underestimate the average yearly recurrence rates over a lifetime. A reliable estimate of HZ [HZ stands for herpes zoster, the more formal medical term for shingles]??requires several years of follow-up. In our study, few recurrences occurred in the first 12 to 18 months after the index case, except in those who were immunocompromised. Our two-year recurrence rate (2.0%) is similar to that reported by Donahue et al but is poorly predictive of the eight-year recurrence rate.

They also said their study probably did a better job than most at capturing all the shingles cases:

Unlike other studies, our cohort came from a community-based population with a well-established infrastructure to report administrative diagnoses and allow access to medical records for in-depth review. The ability to obtain follow-up information across all health care facilities within the county is likely to have ensured a high degree of completeness of recurrence identification.

There is a vaccine against shingles. It’s called Zostavax and it’s made by Merck (Merck funded Yawna??s research, along with the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institute on Aging). Zostavax isna??t guaranteed protection against shingles. But in the large clinical trial that led to its approval by the FDA, the vaccine??did cut the risk of getting shingles in half and the risk of pain that lingers after the signature shingles rash is gone, called postherpetic neuralgia, by even more.

So should people who have had shingles get the vaccine to lower their??chances of getting it again?

Thata??s what the March 2011 Health Letter article is about, and youa??ll find more details there (click here for full-text access to the article.) Factors to consider are cost (Medicare coverage is funky), side effects (it seems from a study published last year that you dona??t need to worry about major side effects), and, yes — the chance that youa??ll get shingles a second or even third time (the risk is??real enough, if Yawna??s research is to be believed, and perhaps especially so if your first bout of shingles included a long period of lingering pain).

But quickly, a key point: Zostavax may very well protect against shingles recurrence, but thata??s an??assumption at this point. No studies have been done that show that to be the case. When I asked Merck officials about this, I was told??via email that no such study is planned.

- Peter Wehrwein, Editor, Harvard Health Letter

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Asymptomatic Strep Throat: Should We Treat It?

Occasionally, I see patients who have received throat swabs for strep that have come back positive… even if they have no signs or symptoms of pharyngitis.

In this situation, there are 2 main actions a physician may take (I am biased towards one):

1) Prescribe antibiotics until throat cultures are normal

2) Do nothing

Personally, if a patient is without throat symptoms and has no history of rheumatic fever or kidney damage, I would not have even bothered obtaining a strep test. What for???

Also, a person can be a carrier for strep without suffering any health problems. As such, even if the strep test is positive, but if the patient has no symptoms, I do not recommend treatment. (Which again begs the question of why bother getting a strep test if no treatment will be recommended regardless of the test result.)

I would go so far even to say follow-up cultures are NOT necessary after antibiotic treatment for strep throat if a patient does not have any more symptoms and exam is normal.

Which is why I find it surprising when children and adolescent patients receive multiple courses of antibiotics when they feel perfectly fine, but have received treatment just because a strep test came back positive.

Of course… that’s just my opinion as I do acknowledge that there’s another school of thought which supports antibiotic treatment of all strep positive cultures with follow-up cultures to ensure eradication.

Depending on the doctor you see, you will get different opinions. But it is good for patients to be aware of the varying views on this topic given how common sore throats are.

                       

What Makes A Good Therapist?

This is for Dr. D.

We were having lunch when Dr. D mentioned she wanted to write a book aimed at teaching residents how to do psychotherapy.  It would start with a section on What Makes a Good Therapist?   What does she thinks makes a good therapist?  Real life experiences which impart an ability to empathize.  Do we grow from our own difficulties?  More specifically, do we grow in to better therapists?  I asked another shrink this, and he said that people like to believe there is some meaning to their suffering, and perhaps it’s nice to believe that if you’ve been stuck suffering, then it makes you a better therapist, but he wasn’t so convinced it was true.  Me?  I don’t know, maybe.  Or maybe not.  Personally, I’m fine with the idea of not suffering, at all, ever again, so long as I live.

In residency, I was taught that warmth and empathy are important to being a good therapist. ??Empathy would speak to Dr. D’s theory.  These are hard things to teach— I don’t know how you make someone feel what they don’t feel and empathy is there or it isn’t.  I do think people can learn responses that get perceived as empathic, and that this is important.  When a patient talks about sadness around an issue and the shrink does not feel empathy, it’s still important to have a modulated response that acknowledges the patient’s feelings– this sounds terribly difficult….tell me more about how you are feeling…or kind, gentle, silence, but not, “Yeah, yeah, well I’m glad your old hag of a cousin died, she was never nice to you anyway.”

So what do I think makes a good therapist?  The ability to listen and hear what the patient is saying, even if the shrink doesn’t agree.  A non-judgmental stance, and this can be harder than it appears.  It seems obvious, but it can be hard when a patient talks about hard-to-hear things, such as a pro-racism viewpoint, or disliking people of the doctor’s religion or political party, or feeling happy that another person is person is suffering.

Non-dismissive is even better.  No one wants to hear that their feelings are stupid or unjustified.

Kind.  That’s important.

Probing in a way that brings up new information and insights.

Mostly, I think therapy is about pointing out to people their patterns of behaving and responding in a way that is not so painful that the patient becomes defensive, and lets the patient choose to make changes in these patterns.  Some patterns are harder to break than others, and the really entrenched one are often components of one’s personality.

I’m not doing so well here.  I Googled What Makes A Good Therapist, so you can check out these links:

http://www.therapist4me.com/what_makes_a_good_therapist.htm

http://www.therapists411.com/therapist-information/what-makes-a-good-therapist.html

http://askdrrobert.dr-robert.com/goodtherapist.html

http://www.goodtherapy.org/what-is-good-therapy.html

From here, I’ll leave it to you.  What makes a good therapist?—–

                       

When Patients Attack: Is Self-Defense Legally Dangerous?

Sideways Shrink posed a great question recently in a comment on my post “When A Thick Skin Helps.” The question was whether or not physicians are allowed to hit a patient who tries to assault them.

Certainly, physical assaults on patients are not the standard of practice in psychiatry or any other medical specialty. Psychiatrists do undergo some training about physical management of violent patients: I remember in residency we had to get trained in “take down” and restraint procedures. As a group we practiced applying pressure point joint locks on each other in order to make a patient break a grip on us, and to do two person restraints to hold someone immobile until security could arrive. None of this involved any “Crouching Tiger, Hidden Dragon”-type kung fu moves, there was no kicking or hitting or loud kiai karate yells. There was a lot of talk about the importance of being as least forceful as possible. Frankly, I’m not sure how much of that I would have remembered if I had ever been in a position to have to use it. The few times when I was actually assaulted by patients the incidents happened so fast there really wasn’t anything I could have done. (OK, so the little manic lady who hit me with a stuffed dog really couldn’t count as an assault, and she was already restrained in a geri-chair to begin with.)

But the real question is: will a doctor get into trouble for defending him or herself?

In situations like this it’s always best, as one of my friends and mentors regularly states, to think clinically before thinking legally. Safety first, then legalisms. Do what you must do to protect yourself. Learn the security procedures for your hospital or clinic or school or correctional facility, and know them so well you don’t have to even think to act on them. If no one orients you to security procedures on your new job, make a point of asking. (Free society employers are particularly bad about this, particularly in an outpatient setting.) Even when you follow the “right” procedures though, it takes some time to get help. By “time”, I mean several seconds to minutes, and in that short time a lot of damage can happen. Yes, doctors can and should defend themselves from attack.

What are the potential legal consequences? (Disclaimer: I’m not a lawyer, anything I say can and might be wrong from a legal standpoint, when in doubt call your hospital counsel or malpractice risk management office.)

The consequences could be civil or criminal. An assault or battery charge could be filed by a patient, or a general tort (injury) civil suit could be filed against a physician. A malpractice claim could be made (I doubt anyone could claim that a physician assault against a patient would be a standard part of psychiatric treatment!) however in states that allow contributory negligence (a limitation on damages when an injury is caused in part by patient behavior) the physician’s liability would be limited. Finally, the patient could file a board complaint against the physician. So even in the absence of a criminal or civil case the physician could end up on the wrong end of a long, drawn out and painful licensure investigation.

There are factors that could lead to a greater risk of legal consequences if they suggest that more force was used than necessary: if the patient dies or has a serious permanent injury, or if the physician has a chance to escape but chooses to stay and fight instead. And yes, gender discrimination may play a role. If the physician is a young twenty-something, male, six foot four inch tall physician weighing 200 pounds and the patient-attacker is a five foot, 125 pound grey-haired old lady, you could be in trouble.

Off the top of my head I’m not aware of any cases where this has been an issue, and in the heat (or rather terror) of the moment I doubt any doctor is going to stop and weigh out all the potential consequences. And even when the doctor has a legitimate need to defend himself there could still be legal consequences, which are not fun even if the doctor ends up cleared of all allegations.

If I come across any relevant cases or references I’ll put them up, but that’s what I think off the top of my head.

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Insect-Killing Fungus May Provide Basis For New Multiple Sclerosis Treatment

A very well-written review of an orally-active drug for multiple sclerosis has just appeared in the April 25th issue of the Journal of Natural Products, a joint publication of the American Chemical Society and the American Society of Pharmacognosy.

The review, Fingolimod (FTY720): A Recently Approved Multiple Sclerosis Drug Based on a Fungal Secondary Metabolite, is co-authored by Cherilyn R. Strader, Cedric J. Pearce, and Nicholas H. Oberlies. In the interest of full disclosure, the latter two gentlemen are research collaborators of mine from Mycosynthetix, Inc. (Hillsborough, NC) and the University of North Carolina at Greensboro. My esteemed colleague and senior author, Dr. Oberlies, modestly deflected my request to blog about the publication of this review.

So, I am instead writing this post to promote the excellent work of his student and first author, Cherilyn Strader. As of [Wednesday] morning, this review article is first on the list of most-read articles in the Journal. This status is noteworthy because the review has moved ahead of even the famed David Newman and Gordon Cragg review of natural product-sourced drugs of the last 25 years, the JNP equivalent of Pink Floyda??s The Dark Side of the Moon (the album known for its record 14-year stay on the Billboard music charts.).

Reproduced from Strader et al., J. Nat. Prod. 2011, 74, 900a??907.

The story of fingolimod is a fascinating journey from early 1970s work on fungal-derived immunosuppressants in Japan to synthetic organic synthesis by Tetsuro Fujita at Kyoto University in 1992 that has led to a non-injectable option for patients with multiple sclerosis. Some of these fungi are ones that infect insects and their fruiting bodies have been used in traditional Chinese medicine as elixirs.

From the review:

Isaria sinclairii is native to Asia, mainly China, Korea, and Japan, and is classified as an entomopathogenic fungus. It is the imperfect stage of Cordyceps sinclairii (Clavicipitaceae) and is closely related to Cordyceps sinensis Sacc., whose Chinese name, Dong Chong Xia Cao, means a??winter worm, summer grassa??; this species was reclassified recently to Ophiocordyceps sinensis. Fungal spores infect the larvae of suitable insect hosts, including members of the order Hymenoptera and Lepidoptera; the fungus is parasitic, growing within the host and resulting in death of the insect. The fungus completely colonizes the insect cadaver, and in the spring and summer white fruiting bodies appear as stalks up to 6 cm in height. Fungi at this stage of development are regarded as mysterious and mystical in some Asian cultures and have been used for thousands of years in traditional Chinese medicine, as they are believed to impart eternal youth.

From a biology standpoint, Ms. Strader very nicely describes the in vitro and in vivo assays used to identify the natural product progenitor from Isaria sinclairii, myriocin (ISP-1), as an immunosuppressant agent. A clever mixed lymphocyte assay was used by Fujita and colleagues to detect inhibition of T-cell proliferation when splenocytes from two strains of mice were co-cultured in the presence of alloantigen. To confirm activity in vivo, the investigators then used rat skin transplant model where tissue would normally be rejected when transplanted from one rat strain to another. Active compounds were scored based on their ability to prolong the viability of the transplant. This work from the Journal of Antibiotics is available here as free full text.

In both the in vitro and in vivo assays, ISP-1 exhibited activity superior to that of the immunosuppressant, cyclosporin A. But as with many natural products, the compound has some toxicity and solubility issues. Several groups went on to synthesize over 50 analogs of the ISP compounds and Ms. Strader details the reaction schemes and strategies, again pointing out that the two biological assays were crucial to evaluating the structure-activity relationships.

Strader discusses how the molecular mechanism of action of the lead, fingolimod, was then picked up by the group at Novartis, the company that licensed the compound. In this currently-free paywalled article in the a??Case Historiesa?? section of Nature Reviews Drug Discovery, Brinkmann et al. detail how fingolimod is actually a prodrug, requiring phosphorylation by sphingosine 2-kinase (SPHK2) to inhibit a series of G-protein-coupled receptors in the sphingosine 1-phosphate (S1P) family. These receptors that bind sphingosine lipids mediate actions of T-cells and endothelial cells that lead to the neuroinflammation of multiple sclerosis.

Most relevant from a drug discovery standpoint is that this mechanism of action is distinct from other immunosuppressants such as FK506 and cyclosporin A which act upstream in this pathway to inhibit serine palmitoyltransferase. This observation is a central theme in natural products pharmacology: naturally-occurring compounds often revealed novel mechanisms of therapeutic action. A far more detailed description of these investigations can be found in this cited review.

Strader then continues in her JNP review to discuss the clinical pharmacology and pharmacokinetics of fingolimod and the other potential uses of the compound, specifically in organ transplantation and cancer therapy. Her review is a lovely example of a comprehensive story that spans from traditional Chinese medicine a?? where fungi have been used for centuries a?? to modern drug development.

Why do I single out this review?

As a biologist and pharmacology instructor, I appreciated learning about the chemistry of the drug and the painstaking dissection of its mechanism of action, all directed by a clever battery of bioassays to probe some excellent synthetic work.

Moreover, Stradera??s review demonstrates that fungal natural products, while part of our history, remain today a robust source of leads for drug discovery. When studied using solid, science-based techniques, even something as bizarre as an insect fungus can give rise to useful therapeutic agents. In particular, this work demonstrates that drug companies are indeed interested in natural products and can generate new intellectual property and patents: the chemical modifications to ISP-1 created the new composition of matter claim for fingolimod.

Finally, I believe that this published review originated as a graduate class assignment by Cherilyna??s instructor. Ms. Strader seized upon the encouragement of her professor to further develop this story, expanding and refining it to the quality and breadth required to be considered for publication. Cherilyn could have just stopped and gotten an A for the original assignment. Instead, she took on this additional effort under the guidance of my colleagues. She is deserving of congratulations on achieving this milestone. It certainly doesna??t hurt onea??s career development prospects to have a review paper among the most highly-read articles in an official journal of the ACS and American Society of Pharmacognosy.

Regular readers know that I am driven to use this blog as a mechanism to recognize the efforts of the next generation of chemists and pharmacologists a?? students, postdocs, and early-career scientists. As such, please feel free to recommend to me other cases of such publications and interesting backstories that are deserving of this less traditional mode of dissemination.

While this review is currently behind the ACS paywall, many of you should be able to access it via institutional or personal subscriptions.

Reference: Strader, C., Pearce, C., & Oberlies, N. (2011). Fingolimod (FTY720): A Recently Approved Multiple Sclerosis Drug Based on a Fungal Secondary Metabolite Journal of Natural Products, 74 (4), 900-907 DOI: 10.1021/np2000528

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How To Take Back Control Of Your Google Searches

Eli Pariser talks at TED about how wea??re losing the internet to algorithmic gatekeepers at Google, Yahoo, Facebook and even our news sites, which tailor search results to what they think we want to see. Which is why I often start exploring my search results on page 10 instead of page 1. But what if some search results dona??t even make it onto my queue?

The side by side comparison of two different usersa?? internet search on the term a??Egypta?? during the crisis there is a stunning example of how computerized gatekeepers choose for us what we see (and dona??t see) when we log on.

You cana??t have a functioning democracy if citizens dona??t have a free flow of information.

I encourage you to watch the entire video, and hope the big mahoffs??of the internet sitting in the TED audience heard Pariser when he told them this ??-

We really need for you to make sure that these algorthms have encoded into them a sense of the public life, a sense of civic responsibility. We need you to make sure that theya??re transparent enough that we can see what the rules are that determines what gets through our filters. And we need you to give us some controls so that we can decide what gets through and what doesna??t.

Because I think we really need the internet to be that thing that brings us all together. We need it to introduce us to new things, and new ideas, new people and different perspectives.

And ita??s not going to do that if it leaves us all isolated in a web of one.

In the meantime, Pariser tells us ten things you can do now to get back onto the internet you fell in love with. ??Here is his list of what to do a?? head to his site to learn how.

1. Burn your cookies.

2. Erase your web history.

3. Tell Facebook to keep your data private.

4. Ita??s your birthday, and you can hide it if you want to.

5. Turn off targeted ads, and tell the stalking sneakers to buzz off.

6. Go incognito.

7. Or better yet, go anonymous.

8. Depersonalize your browser.

9. Tell Google and Facebook to make it easier to see and control your filters.

10. Tell Congress you care.

                       

MyPlate: Spiffy New Nutritional Guidelines For Americans

The crumbling Food Pyramid and its hip successor (MyPyramid) fell into oblivion yesterday, eroded by the stinging winds of science. Their replacement? A quartered plate calleda??wait for ita??MyPlate that was designed to visually convey the elements of healthy eating to Americans of all ages.

The new icon consists of a white plate divided into four segments: green for vegetables, red for fruits, orange for grains, and purple for protein. Dairy has a prominent place, sitting where a glass of water should be. The hope is that the plate will nudge Americans away from meals dominated by meat and starch and towards meals made up mostly of plant-based foods.

The original Food Guide Pyramid debuted in 1992. It was built on shaky scientific ground. Over the next few years, research from around the world chipped away at the healthy eating message in the pyramida??s base (refined carbohydrates), the middle (meat and milk), and the tip (fats).

The Pyramid got an extreme makeover in 2005. To create MyPyramid, it was flipped on its side (so no food type was on the bottom, and perceived as a??worsea??), painted rainbow colors, was given a stick figure sprinting up its side, and stripped of any useful information. The million-dollar makeover was a step backward.

MyPlate, by comparison, is a good move. It offers information on portion sizes and sends the message that a balanced meal should be at least half vegetables and fruits.

a??Clearly MyPlate will be better than MyPyramid,a?? nutrition expert Walter ??C. Willett told The Nutrition Source. a??But the most important issues are in the details that are not captured by the icon. What type of grain? What sources of proteins? What fats are used to prepare the vegetables and the grains?a?? Willett, who chairs the department of nutrition at the Harvard School of Public Health, has been a long-time critic of the Food Pyramid. His best-selling book, Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating, details how and why the old pyramids actually contribute to unhealthy eating. (Full disclosurea??I co-wrote the book.) Willetta??s Healthy Eating Pyramid is based on up-to-date nutrition science.

MyPlate doesna??t show that whole grains are better for you than refined, rapidly digested grains, or that Fish-in-Water-Belt-Buckle-246.html' target='_blank'>fish and beans are better protein choices than red meat. It doesna??t give any guidance that eating more unsaturated and omega-3 fats is good for health, as is cutting back on saturated fats from meat and dairy.

One thing missing from the place mat is a garbage or compost can for the sugary baked goods, breakfast cereals, and drinks, and the salty processed foods and snacks, that make up a big chunk of the average Americana??s daily caloric intake.

Although the USDA is trying to make MyPlate sound new. It isna??t. The New American Plate, which the American Institute for Cancer Research developed in 1999, uses an almost identical plate icon to encourage people to eat more vegetables, fruits, and whole grains. In the United Kingdom, the Eatwell Plate has served as a pictorial guide to healthy eating.

In spite of their shortcomings, the latest Dietary Guidelines for Americans and MyPlate are better than their prior versions. MyPlate is worth teaching in schools and printing on cereal boxes. Whether this will help stem Americansa?? frightful eating habits is anyonea??s guess.

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Human Breast Milk For Sale Without FDA Regulation

The June issue of Wired carries a feature on the Booming Market for Human Breast Milk. You can read about the under-the-counter and over-the-Internet sale of a??liquid golda?? with a typical asking price in the range of $1 to $2.50 an ounce.

Herea??s a taste, from the article:

a?|a??rich,  creamy breast milk!a?? a??fresh and fatty!a??a?| Some ship coolers of  frozen  milk packed in dry ice. Others deal locally, meeting in caf??s to  exchange cash for commoditya?|

Late last year, the FDA issued a warning about feeding your child human milk from strangers. Still, the stuffa??s barely regulated.

milk containers, Wired Magazine, June 2011

As much as I think ita??s a good idea for women to breast feed their babies as best they can, I was  pretty shocked to learn about this unregulated industry.?? Mainly because  if a woman who donates milk is infected with a virus, like HIV or HTLV-1,  the milk often contains the virus. The infant can absorb the virus and  become infected. Feeding human breast milk from an unknown donor is kind  of like giving a child a blood transfusion from a stranger, unchecked  by any blood bank.

Ia??m not sure why Wired ran this story, which is admittedly  interesting. Maybe ita??ll push the FDA to take a more aggressive stance  on this matter, as it should.

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Excess Sun Exposure Can Trigger Mole Development

Do you ever wish you didna??t have so many moles? It might be too late for you, but it doesna??t have to be for your kids. By reducing their sun exposure, you can reduce the number of moles (also called nevi) they develop.

Sunburns and excess sun exposure are triggers for moles to develop. Having lots of moles can be unsightly and increases their risk of developing melanoma later in life. Reducing excess sun will limit the number of moles they have and reduce their risk for melanoma many years from now.

Protect against sun to reduce moles.

Many of us grew up without good sunscreens (baby oil and iodine anyone?), but you can do so much more for your children:

• Apply a water-resistant sunscreen with SPF 30 (preferably one with zinc or titanium).


• Reapply every two hours.


• Cover them up with clothing (which is great for the beach when even the best sunscreens wash off in the surf).

Many of my patients wish they didna??t have so many moles. By insisting that your kids protect themselves now, youa??ll prevent them from being one of those patients later.

Photo: Atiretoo, Flickr

                       

What You Need To Know About Snakebites

Eastern coral snake, photo courtesy of Norman Benton, CC-BY-SA 3.0

The Wilderness Medical Society held its annual meeting at  Snowmass last summer July 23-28, 2010. There were numerous terrific educational  sessions. In a series of posts, I am going to highlight some of what we learned  from the presenters.

Jonathan Allen gave a presentation on venomous snakebite  management. Here are some facts to remember:

Snakebite Statistics

Approximately 15 percent of the 3,000 snake species  worldwide are dangerous to humans. There are annually 400,000 to 2,000,000  envenomations from snakebite worldwide, with 20,000 to 100,000 deaths. In the  U.S., there is at least one species of venomous snake in every state except  Alaska, Maine, and Hawaii. There are  approximately 20 venomous species, including pit vipers and coral snakes, and  an estimated 6,000 to 7,000 venomous snakebites each year, including six to 10  deaths. Perhaps only 20 percent of bites are reported.

Deaths from snakebites typically occur in elder victims, in victims  who do not receive antivenom or in victims who receive inadequate amounts of  antivenom. Ninety-eight percent of bites are on the victima??s limbs, usually the  arms or hands.

Coral Snakebites

Venomous coral snakes in North America can be recognized by  the pattern of red bands bordered by yellow bands. a??Red on yellow, kill a  fellow; red on black, venom lack.a?? The venom of the Texas coral snake is  generally less toxic than that of the Eastern coral snake (pictured above). The Sonoran coral  snake is small; the limited volume of venom it can deliver makes its bite  relatively insignificant.

Because a significant coral snake envenomation can have  serious symptoms that are delayed or gradual in onset, anyone who has a  suspected coral snake bite should be transported to appropriate medical care  (typically, an emergency department) even if no signs or symptoms are present.  If a person has been bitten by an Eastern coral snake and has any sign of  neurotoxicity, antivenom should be administered as soon as possible. North  American Coral Snake Antivenom (NACSA) is produced by Wyeth; production ceased  in 2006, so very little of this product is available. A Mexican product, Coralmyn,  which is effective against both the Eastern and Texas coral snakes, is not  available in the U.S. Antivenom is usually not needed for most bites from the  less toxic Texas coral snake, and supportive care alone without antivenom is  the appropriate therapy for Sonoran coral snake bite.

Crotalid Snakebites

Western diamondback (a type of crotalid), photo courtesy of Clinton & Charles Robertson, CC-BY-SA 2.0

Crotalid snakes (such as rattlesnakes) have fangs with a  deep groove through which venom flows. The fangs can be folded into the snakea??s  mouth, or hyperextended up to 180 degrees. The fangs move independent of each  other, and the snake can control whether or not to inject venom and how much to  inject. The venom of crotalids varies between species, can vary within a  species, and is very stable to temperature changes and drying.

One quarter of all pit viper bites are a??drya?? and do not  result in envenomation. When envenomation does occur, youa??ll notice pain,  redness and swelling near the bite site occurring within 30 to 60 minutes. Over  several hours, blisters (often bloody) occur, sometimes with inflammation in  the lymphatic system. In three to six hours, there can be extensive bruising.

What to Do if Someone  is Bitten by a Snake

When someone is bitten by a crotalid snake, one should limit  motion of the bitten part (such as by using a splint), try to limit walking,  remove jewelry and constrictive clothing that might cut off circulation if  swelling were to occur, and use acetaminophen for pain. The next step is to transport  the victim to the emergency department. Useless and potentially harmful first  aid maneuvers include tight tourniquets, incision and suction, venom extraction  devices, electric shock, immersion into crushed or cubed ice or ice water, and  application of papain or meat tenderizer.

A severe allergic reaction may occur following a snakebite.  This is treated in standard fashion with drugs such as epinephrine,  antihistamines, and steroids.

Exotic Snakes

Exotic snakes imported into the U.S. can certainly bite  victims. The symptoms of envenomation are often different than those from North  American venomous snakes, and include flaccid (a??floppya??) paralysis, muscle  tissue breakdown, severe bleeding disorder, kidney failure, tissue death at the  bite site, infection or abscess at the bite site, and allergic reactions.

                       
                       

This post, What You Need To Know About Snakebites, was originally published on
                        Healthine.com by Paul Auerbach, M.D..

Survivorship Planning May Be The Key To Beating Cancer

I am a poster child for why everyone who has had cancer needs to work with their doctor(s) to develop and implement a survivorship plan.

Two of my four cancer-related diagnoses were found during routine screenings.?? Two of my cancer-related diagnoses and one serious heart condition were almost certainly due to late effects of cancer treatment when I was young.

Each was a complete surprise to me, and while there is evidence that predicts most of these occurrences, not one of my doctors used this literature to shape a plan for my post-treatment care.

I was on my own.?? My fear of yet another recurrence led me over time to cobble together a motley collection of oncologists (one for each body part) and other specialists (cardiologist, dermatologist, endocrinologist, and so forth) to watch over me.?? I thought I was lucky that this has worked so far.

But since I have become a patient at Memorial Sloan-Ketteringa??s Adult Long-Term Follow-Up program two years ago and I now have a formal survivorship plan, I know I was lucky. The success of my haphazard plan was most likely due to its a??even a stopped clock is right twice a daya?? approach a?? an extraordinarily bad use of time and resources, mine and my insurera??s.?? Now that I am working with a knowledgeable physician, I can see how rudimentary and inadequate my efforts were.

Anyone who has experienced (or witnessed) the impact of a cancer diagnosis and the disruption a??physical, emotional and social a?? of treatment knows that the experience of cancer doesna??t end with that final appointment in the chemotherapy suite.

I am not alone in my lack of a survivorship plan.?? Most people who complete the initial intense part of treatment for cancer do not have a formal plan for their ongoing care once that phase is over.?? The aim of care after active treatment is to return the person to health and functioning, prevent a recurrence or detect it early, minimize long-term side effects and treat conditions that result from the toxic effects of chemotherapy, surgery or radiation.

Raising the priority and value of (and insurance coverage for) survivorship care has been the focus of the Office of Cancer Survivorship at the National Cancer Institute, which has funded research to identify the long-term effects of treatment and CDCa??s Cancer Survivorship efforts to implement those findings. The National Coalition for Cancer Survivorship has worked with the Institute of Medicinea??s Cancer Policy Forum and Congress to define what constitutes survivorship care and eliminate the barriers to its delivery.?? The American Society of Clinical Oncology has implemented standards for treatment summaries for survivorship care.?? And the Lance Armstrong Foundation has, in recent years, added on-the-ground muscle to these aims.

Nevertheless, progress toward implementing a personalized survivorship plan for each person treated for cancer in the US seems stalled. There are many reasons for this, most related to the organization and incentives of health care delivery, the knowledge, interest and proclivities of various health professionals and the twin demands of cost control and evidence-based care.

And where does this leave those of us who have completed the first intensive phase of cancer treatment?

Mostly on our own, looking for a knowledgeable oncologist or primary care clinician who is willing to stay on top of the emerging evidence to help us match our risks and needs to the tests and services that will keep us as healthy as possible.

On Monday, March 14, I gave a talk that spells out in detail what we patients (and our loved ones) currently have to do to develop and implement a good, solid survivorship care plan at the Survivorship Planning in an Era of Cost Consciousness meeting sponsored by the National Cancer Institute.

Our role is not a a??piece oa?? cake,a?? thata??s for sure.?? Take a look.

The conclusion:

I have learned two lessons about survivorship from my experiences as a person living with cancer:

First: regardless of the excellence of the data, the promise of reimbursement and the skill of the physician, if I dona??t show up, discuss my risks and my options and then follow through on the decisions I make with my clinician, I will get no benefit from survivorship planning, nor from the tests and technologies that can be used to improve the quality and extend the length of my life.

These are the things only I can do.

And second: I know with complete certainty that regardless of how much expertise, experience, connections and energy I invest in developing and implementing a survivorship plan, I cannot do this alone.

An effective survivorship plan requires an active partnership between the patient and his or her provider.

                       

Elizabeth Taylor And Understanding Heart Failure

The condition that took Elizabeth Taylora??s life affects millions of Americans.

Reports of Elizabeth Taylora??s death focused, as they should, on her life, not on her death from heart failure. But given how common this condition isa??the American Heart Association says nearly 6 million Americans are living with heart failure and it kills about 300,000 each yeara??a little attention to it might be a good idea.

What is heart failure?

The term a??heart failurea?? is a scary one, conjuring up images of a heart that is suddenly unable to work. In truth, it represents a gradual decline in the hearta??s ability to pump enough blood to meet the bodya??s needs. As the heart weakens, all parts of the body suffer the consequences.

The main signs and symptoms of the hearta??s reduced ability to supply the body with oxygen-rich blood are shortness of breath with exertion or lying down; fatigue and weakness; swelling in the legs, ankles, and feet; and reduced ability to exercise.

What causes heart failure?

In most people, heart failure is caused by damage to the heart muscle. Scar tissue from a heart attack can make the heart pump less efficiently. Years of slow damage from high blood pressure or cholesterol-clogged arteries can cause the condition. Damage to a heart valve, or diabetes, can contribute to heart failure. Sometimes it is caused by a mechanical defect of the heart muscle that can be present from birth or brought on by disease or infection later in life.

Are there other names for heart failure?

Once known as dropsy, this condition was more recently referred to as  congestive heart failure because it often caused congestion in the  lungs. Experts are trying to drop the a??congestivea?? and just call it  heart failure.

Are there different types?

There are two basic types of heart failure. In systolic heart failure, the heart muscle becomes stretchy and weak. Diastolic heart failure stems from the opposite problema??the heart muscle becomes too stiff and cana??t relax enough to completely fill with blood. The end result in both is a reduction in the amount of blood that each heartbeat pumps into circulation.

Can heart failure be cured?

Heart failure is manageable, but so far it usually isna??t curable.

How is it treated?

Managing heart failure initially involves a combination of lifestyle changes and medications. A healthy diet, minimizing salt intake, controlling fluid intake, and regular exercise all help keep heart failure under control. Treating an underlying cause, such as a faulty heart valve or diabetes, can help. Medications such as diuretics (water pills), ACE inhibitors, and beta blockers are commonly used. Sometimes a special pacemaker called a biventricular pacemaker is used to help both lower chambers of the heart beat in unison; an implantable cardioverter-defibrillator (ICD) may also be needed.

Advanced heart failure requires more intense medical therapy. Sometimes a heart transplant is needed. When this isna??t possible, a left-ventricular assist device can take over the pumping job of the left ventricle

More information on heart failure is available from the National Heart, Lung, and Blood Institute.

                       

Homeopathy: Why is Fraud Legal?

Imagine hearing a commercial on the radio:

Send us money, and we wona??t send you anything in return.

No one would do that, right? How about this:

Send us your money and wea??ll send you an empty box.

Better? Not much. Now how is that different from:

Send us money and wea??ll send you stuff wea??ll call medicine that we claim will help you, but therea??s no actual active ingredients in it at all.

I dona??t think therea??s one bit of difference. Wouldna??t you agree that that commercial is fraud, pure and simple? The problem is that the general public doesna??t understand that the word a??homeopathica?? means a??diluted beyond the point where it contains any active ingredients.a??

Ia??ve recently heard commercials for homeopathic vertigo treatments, eye drops for allergies, irritable bowel, and spider veins on legs. Ia??m tempted to contact the radio station and complain, but stopped short realizing that their first question is going to be, a??But is it legal?a??

Thata??s the problem: it is. So what I want to know is, why?

I understand the structural reasons: therea??s lots of money to be made defrauding naive consumers, and those who rake it in by exploiting ignorance have convinced gullible legislators, both state and federal, to make it legal. But that doesna??t make it right.

Seeing packages of homeopathic remedies sit next to actual, active chemical medicines on pharmacy shelves makes my blood boil. Who in their right mind would pay nearly $10.00 for sugar pills? Someone who doesna??t realize that a??homeopathica?? means diluted out of existence, ie, the vast majority of the general public.

Someone ought to do something. Because homeopathy is fraud; and fraud shouldna??t be legal.

                       

FluPhone Tracks “Super Spreaders” Of Disease

“Are you a super-spreader?” That’s the catchphrase for a new study out of the University of Cambridge. However, if you answered “yes”, you may want to stay home and cover your mouth, because the study was designed to track the spread of influenza using cellular phone technology.

The study (and accompanying app) is called FluPhone, and it uses cell phones to collect information on social encounters within the study sample of participants in Cambridge. A phone’s Bluetooth antenna detects encounters with other participants and also records the proximity to each other. The built-in GPS chip tracks each user’s location, but this feature was disabled due to recent ethical concerns. Finally, the phone’s 3G/GPRS antenna sends all the proximity data automatically back to researchers for analysis. Other features include the ability to program a specific disease model by introducing a virtual “pathogen” which can be transmitted via Bluetooth when at least two users are near each other.

In addition to revealing useful data about the spread of disease and how to minimize its effects, the study could also be helpful for creating more effective public health messages.

More from the University of Cambridge: FluPhone: disease tracking by app…

Research project page…

FluPhone participant website…

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How To Tell If Your Doctor Is Talented At Endoscopy

I have noticed that??we all think??we are the best endoscopist around (in my case, that is indeed true!). However, we really never measured colonoscopy skill as a a??patient-centereda?? metric and instead often use speed, efficiency, sedation needs, etc. when judging our colleagues. What is more important than these measures, however,??is whether we find and remove adenomas, thereby preventing colon cancer downstream in our patients.

A number of surrogate markers for quality colonoscopy and polyp detection have been used in the past, including scope-withdrawal time from the cecum. But the one measure that has been the best predictor of quality is an endoscopista??s ADR (adenoma detection rate). In fact, this is the most reliable quality measure yet determined, and it may become the basis for being paid for these procedures in the not so distant future.

So I need to ask you:

1)?????????? Do you know your ADR?

2)?????????? Do you or does your group compare your ADR to other endoscopists within your endoscopy unit or practice?

3)?????????? Is there a program to increase ADR in low performers in your endoscopy unit?

4)?????????? Do you use your ADR as a marketing tool?

5)?????????? What is your take on the ADR as a quality measure?

I look forward to hearing from you on this topic!

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