Vaccinate. Please. Prevent Death and Disease.

It continues to amaze me that there remains any debate over child vaccinations. I have posted about this issue before. Yet today I read that over 102 cases of Measles have been diagnosed this year, 2015, and it is only the beginning of February! In fact, as you may read below, that number accounts for the typical annual number of cases for past years.

Much misinformation and disinformation has been shared about vaccines. The truth is that vaccines help prevent disease and death by creating what is known as herd immunity. If 900 out of 1000 children are vaccinated with the MMR vaccine, over time, the group develops immunity and helps prevent disease in the rest of the group. The greater the number of individuals who are immune, the smaller the chance that a susceptible individual will contract the disease.

Review the readily available public information on the CDC website. You can find it here

The following is the excerpt from the AMA Morning Rounds. It contains interesting comments about this issue.

"CDC: Measles outbreak has grown to more than 100 cases.

The measles outbreak continues to generate an extensive amount of media coverage, with reporting divided between the growing outbreak and comments regarding vaccines made by politicians. The topics were discussed on two of last night’s national news broadcasts for a total of more than three-and-a-half minutes. Meanwhile, all major US newspapers and wires offered coverage. Many of the stories focusing on the outbreak quote Anne Schuchat, director of the CDC’s National Center for Immunization and Respiratory Diseases, or CDC Director Dr. Tom Frieden. NBC Nightly News (2/2, story 4, 2:25, Williams) reported, “New numbers out from the CDC” indicate that the measles “outbreak has grown to 102 cases in 14 states.” Additionally, “we’re seeing politicians entering the fray possibly at their peril over whether children should receive the measles vaccine that once eradicated the disease.”

        ABC World News (2/2, story 7, 1:10, Muir) reported that “the American Academy of Pediatrics” is “calling for parents to vaccinate their children.”

        The Washington Post (2/3, Berman) reports, “The large number of cases so far this year has already eclipsed the number typically reported each year, according to” Dr. Schuchat.

        TIME (2/3, Sifferlin) reports that in a press conference last week, Dr. Schuchat said, “It’s only January and we have already had a very large number of measles cases — as many cases as we have all year in typical years.” She added, “This worries me, and I want to do everything possible to prevent measles from getting a foothold in the United States and becoming endemic again.”

        The New York Times (2/3, Grady) “Well” blog reports that while “most infections are linked to” the “outbreak that began in Disneyland in December,” which was “almost certainly started by someone who brought the disease in from” outside of the US, “a ‘smattering’ of other imported cases have also occurred, according to” Dr. Schuchat.

        The Los Angeles Times (2/3, Mejia, Hamilton) reports that “of the confirmed measles cases in” California, “59 can be linked to visitors or employees at Disneyland or those who came in contact with them over the holidays.”

        Bloomberg News (2/3, Edney) reports that although “the anti-vaccination campaign seemed to reach a fever pitch in recent years with the help of celebrity endorsements, the movement goes back further, and it may be that the early wave of kids who never had their shots are the adults now at greatest risk.” Dr. Schuchat said last week, “Based on what we know now, we’re seeing more adults than we have seen in a typical outbreak.” According to Dr. Schuchat, “The majority of the adults and children that are reported to us for which we have information did not get vaccinated or don’t know whether they have been vaccinated.” She added, “This is not a problem with the measles vaccine not working; this is a problem of the measles vaccine not being used.”

        The Boston Globe (2/3) editorializes that “the cause” of the measles outbreak “is clear: parents who have refused to have their children vaccinated.” According to the Globe, “A parent’s concerns for his or her children is understandable, but the fears about vaccines are simply irrational.”

        The New York Times (2/3, Subscription Publication) editorializes that “it is bad enough that many misguided parents are endangering their own children by refusing to let them be vaccinated against measles and other contagious diseases.” However, according to the Times, “it is shockingly irresponsible of them to put other children and adults at risk of catching measles from their unvaccinated children.”

        Christie, Paul spark controversy with remarks on vaccinations. The AP (2/3, Colvin) reports New Jersey Gov. Chris Christie on Monday said that “parents should have some choice on whether to vaccinate their children.” While Christie has previously expressed that stance, Monday’s remarks “drew a new level of attention amid a U.S. measles outbreak and his recent moves toward” a potential White House run. Later Monday, Christie’s office said in a statement that “the governor believes ‘with a disease like measles there is no question kids should be vaccinated.’”

        Politico (2/2, Topaz) reported that Christie, who’s in the midst of a three-day visit to the UK, said that he and his wife “have had our children vaccinated, and we think that it’s an important part of being sure we protect their health and the public health.” Christie, added, however, “I also understand that parents need to have some measure of choice in things as well, so that’s the balance that the government has to decide.” Politico said that Christie’s comments “appeared to break with President Barack Obama and public health officials worried about a measles outbreak.”

        USA Today (2/2, Camia, Today) reports, “Christie said the ‘balance’ is necessary because of different diseases and vaccines, and he stressed that his comments are not meant to suggest that vaccinations are optional.”

        The Los Angeles Times (2/3, Lauter), in a report that focuses heavily on Christie’s remarks, says that Kentucky Sen. Rand Paul on Monday also “waded into the argument over childhood vaccinations,” saying “that he had heard of ‘many tragic cases’ of children suffering harm after receiving shots.” The Times says that the remarks by the two potential GOP presidential hopefuls, in tandem with Obama’s “defense of vaccinations over the weekend, injected an unexpectedly partisan element into a policy issue – how readily to give exemptions to parents who don’t want vaccines for their children – that until now had not shown much partisan division.” The Washington Times (2/3, Pompi, Sherfinski) reports that Paul, speaking on Monday with conservative radio host Laura Ingraham, “said that while he is not ‘anti-vaccine’ at all, he does think they should be voluntary.”

        On its front page, the Washington Post (2/3, A1, Rucker, Helderman) reports that Christie’s remarks and his office’s later clarification were “a sign of the sensitivity surrounding the vaccination debate” and served to underscore “the intense scrutiny already facing the broad field of likely” GOP presidential hopefuls. The Post also notes Paul’s comments on vaccinations.

        The New York Times (2/3, Peters, Pérez-Peña, Subscription Publication) also covers the story. In an editorial, the Wall Street Journal (2/3, Subscription Publication) criticizes Christie over his remarks on vaccinations."

When the benefits outweigh the risks...Treat.

There has been much press about people with terminal illnesses who choose to forego treatment and end their lives. These reports include such words as "dignity" and "peaceful."

But we must not lose sight of the risks and benefits in these types of discussions. If a particular disease is treatable, with a high cure rate, and a low risk of death and a low risk of significant, permanent side effects from the treatment, one would hopefully see that undergoing such treatment is a reasonable decision. To the contrary, if the risks of treatment far outweigh any potential benefit, then perhaps foregoing such treatment would be the reasonable choice.

There are many factors that must be considered when one weighs the risks and benefits of a disease and various potential forms of treatment. But let us not lose sight of the big picture when considering these aspects of one's illness.

The following email, from the AMA Morning Rounds, exemplifies what I am talking about: 

Connecticut Supreme Court to decide whether 17-year-old can be forced to undergo chemotherapy.

ABC News (1/6, Lupkin) reports on its website that “a court will determine whether a 17-year-old girl, under something called the ‘mature minor doctrine,’ can be forced to undergo chemotherapy after she refused treatment for her cancer.” The case is headed “to the Connecticut Supreme Court this week to determine whether the teen...has ‘the fundamental right to have a say about what goes on with your [her] body,’ attorney Michael Taylor, who represents the teen’s mother, told ABC News.”

        Fox News (1/6) reports on its website that “the family claims that, by allowing” Connecticut’s Department of Children and Families “to use their judgment over that of” the girl’s “family, without the finding of incompetence on their behalf, the forced treatment violates the family’s constitutional rights.”

        The Hartford (CT) Courant (1/6) reports, “The lawyer representing the cancer-stricken teenager battling the state over forced chemotherapy treatments said that doctors peg” the girl’s “chances of surviving her bout with Hodgkin’s lymphoma at 80 percent to 85 percent if she continues with the court-ordered treatments.”

Whole grains are good...for longer life

We all know that we should eat foods that are healthy for us, that natural foods are better than artificial or processed foods, and that we should remember to eat and drink and exercise, basically everything, in moderation.

Now comes a nice little reminder and confirmation that whole grains are good for us and may lengthen our lives. Nice. 

From the AMA Morning Rounds email: 

Higher whole grain consumption may be linked to longer life.

The Huffington Post (1/6, Melnick) reports that research published online in JAMA Internal Medicine suggests that “eating whole grains improves health and may even help you live longer.”

        The Los Angeles Times (1/6, Bonar) “Daily Dish” blog reports that investigators “looked at data from more than 74,000 women from the Nurses’ Health Study and more than 43,000 men from the Health Professionals Follow-Up Study who filled out questionnaires about their diet every two or four years from the mid-1980s to 2010.”

        TIME (1/6, Oaklander) reports that the investigators “estimate that every 28 gram-per-day serving of whole grains was associated with a 9% lower rate of death from cardiovascular disease and a 5% lower rate of death from any cause.”

        The NBC News (1/6, Fox) website reports that the investigators “even looked at what kinds of whole grains people ate.” The study indicated that “it was definitely eating bran that seemed to keep people healthier...said” the researchers. Also covering the story are HealthDay (1/6, Thompson) and Reuters (1/6, Doyle).

Life Lessons --from Jonathan Tepper to his nephews

I wish I had written the following letter, but Jonathan Tepper did instead. Many introspective and self-aware adults with a bit of life experience could write similar thoughts down on paper. Here are a few short comments of my own:

1- Always try to do the right thing and you will never have to worry about the consequences of doing something wrong.

2- Learn something new everyday. 

3- Once you find your counterpart in life, settle down with him/her and stop looking for something better. 

4- Family comes first. All else is filler. 

I'll stop there for now but many thoughts start to come to the front of my brain. 

Here is the letter: 

"A year and a half ago, I was in a plane with very bad turbulence, and I worried that if the plane went down, many of the lessons I’ve learned in life would end up at the bottom of the ocean.  I wrote a letter to my nephews for them to read when they were older.  I hope they’ll find it useful.


Dear nephews,

I’m writing this on a plane. The reason I started writing this was that I feared the plane might go down, and if it went down, all the lessons I’ve learned in life would disappear with me. By writing this, I hope to pass on the few lessons I’ve learned.

The most important lesson is that the vast majority of things you worry about will not bother you the next day. A year later you will not even be able to remember them if you try. When you grow older, you will not worry about what grades you got. You won’t worry about games you lost.   You won’t worry about what other people thought about you. Most of the things you worry about will never happen. Even if the worst things that you worry about happen, life will still go on. Learn to enjoy every day, and try to enjoy it as if it is your last. It has taken me a long time to understand this, and I wish I had understood it sooner.

Happiness is not a destination but a journey. You will never be smart enough, rich enough, have a pretty enough girlfriend, boyfriend, husband or wife, or win enough prizes and awards. Whatever it is you want, there is always something better. Enjoy the journey of learning, working, and living. If you enjoy the journey, you’ll probably achieve a lot more than if you focused on goals.

Money can provide security, but once you have security, more money cannot buy you more happiness. If you show me someone who thinks money can buy happiness, I’ll show you someone who has never had a lot of money.

Things don’t make you happy, but memories will always stay with you. Whatever it is that you buy, you will soon get used to it. It will make you happy for a short while, but it will not make you happy forever. Experiences and memories can make you happy forever. I can’t even remember most of the toys I’ve had in my life, but I still think of my times with Timothy and your Grandmom with great happiness and fondness. I remember walking Timothy to school and how happy we were. I remember hugging your Gradmom when I came home for a weekend. Those memories will never go away. The happiest memories of my friends are my travels and dinners with them, not the things I’ve bought for myself. You’ll remember dinners and travels with friends and family more than any shiny things you’ll ever have.

Your family is the most important thing you have in life. Friends, boyfriends, girlfriends and co-workers come and go, but the only thing that you can always count on is your family. (If you find a friend who is always there for you, you’re extremely lucky. They exist, but they’re very rare.) One day, you will have your own family. You must love them and look after them. You will understand one day that just as your grandparents die, your parents will as well. Strive to be a good son and daughter. One day, you will be like your parents. Your parents are not perfect, and you will not be either. But you can be loving and be a good son and daughter. One day you can be a good parent.

Never stop learning, and always be ready to teach yourself things you don’t know. The only things you will remember are things you care about. You will forget about all the rest. You must teach yourself and care about what you learn. No one can teach you everything you need to know at school or university. You will also forget most of what you study, and that is fine. As Jacques Barzun said, “Civilization is all that remains after you have forgot all that you specifically set out to remember.”

Never live someone else’s life. Find your gifts and the things that give you pleasure, develop those gifts, and pursue them.   Do what makes you happy and be great at it. You have skills and gifts that no one will ever have or see again. If you’re a businessman, build businesses. If you’re a writer, write. If you’re a scientist, discover. If you do what you love and love what you do, you will work very hard, but you will enjoy every day.

One of the things that most influenced me was something Steve Jobs once said:

When you grow up, you tend to get told that the world is the way it is and your life is just to live your life inside the world, try not to bash into the walls too much, try to have a nice family life, have fun, save a little money. 

That’s a very limited life. Life can be much broader once you discover one simple fact, and that is that everything around you that you call life was made up by people that were no smarter than you. And you can change it, you can influence it, you can build your own things that other people can use. Once you learn that, you’ll never be the same again.

And the minute that you understand that you can poke life and actually something will, you know if you push in, something will pop out the other side, that you can change it, you can mold it. That’s maybe the most important thing. It’s to shake off this erroneous notion that life is there and you’re just going live in it, versus embrace it, change it, improve it, make your mark upon it.

I think that’s very important and however you learn that, once you learn it, you’ll want to change life and make it better, cause it’s kind of messed up, in a lot of ways. Once you learn that, you’ll never be the same again.

I hope that you will find what you love and you will change the world.

Life is full of struggle, and...bad things...happen....Many people suffer great tragedies and live full and happy lives. Remember the people you [have loved and lost] and mourn them. Accept that terrible things happen, and [these experiences may make you stronger.]

The best way to avoid anxiety, stress and unhappiness is to avoid internal contradiction. Don’t think that one thing is right and do the opposite. Listen to your conscience and obey it. Be a good person and live according to your convictions. You cannot answer for other people, but you can always answer for yourself. As long as you live according to your most basic beliefs, you will not have regrets or guilt. You will be able to die happily knowing that you looked after the poor and needy, that you were loving to those around you, and that you failed often but did your best. You will not lose a night of sleep if you always try to do your best.

I love you very much.

Much love,

Uncle Jonathan"

Concerned About Radiation? Don't Smoke!

Whaaaat?! Tobacco contains radioactive particles?! How is that even possible?

Well, as amazing as it sounds, it is true. Depending on the soil in which the tobacco is grown, scientists have discovered radioactive particles such as Lead-210 and Polonium-210 to be present on the tobacco leaves.

When you smoke cigarettes, not only do the filters only remove a "modest amount" of radioactive particles, but tar builds up in your lungs. We know this part. But what is now known is that the tar traps the radioactive particles, resulting in a huge radiation dose to your lungs over time. 

From the EPA:  

"Research indicates that lead-210 and polonium-210 are present in tobacco smoke as it passes into the lung. The concentration of lead-210 and polonium-210 in tobacco leaf is relatively low, however, this low concentration can accumulate into very high concentrations in the lungs of smokers.

As it passes into the lungs, the smoke impacts the branches of the lung passages, called bronchioles, where the branches split. Tar from tobacco smoke builds up there, and traps lead-210 and polonium-210 against the sensitive tissues of the bronchioles. Studies show filters on ordinary commercial cigarette remove only a modest amount of radioactivity from the smoke inhaled into the lungs of smokers. Most of what is deposited is lead-210, but polonium-210 (whose half life is about 138 days) quickly grows in as the lead-210 (half life = 22.3 years) decays and becomes the dominant radionuclide. Over time, the concentration of polonium-210 directly on tissues of the bronchioles grows very high, and intense localized radiation doses can occur at the bronchioles."

If you have ever questioned the amount of radiation you might receive from airport scanners, dental x-rays, mammograms, a chest x-ray or CT scan remember that, once again, cigarette smoking can kill you. And second-hand smoke can kill your loved ones and friends.

So please stop smoking. 


Greek Society of IR Wins Supreme Court Appeal!

I am stunned that the Greece Society of Vascular Surgery actually had the gall to sue the Greek Society of Interventional Radiology, stating that IRs do not have the "skills to manage patients before, during and after procedures, and that this could pose a significant public health threat."


The Greek Supreme Court upheld a lower court ruling that upheld Interventional Radiology as a true subspecialty.

"The Supreme Court decision acknowledged that our clinical training is adequate for the purpose of pre- and post-procedural care. It also valued the fact that the ministry's decision stated that interventional radiologists will practice in the context of multidisciplinary medical decision-making," Elias Brountzos, Professor, Second Department of Radiology, Attikon University Hospital, Athens Greece told "Interventional News."

Dr Scott Gottlieb's Accurate WSJ OpEd on the ACA

ObamaCare’s Threat to Private Practice

The payment system is forcing doctors to sell out to hospitals. The trend, and the law, will be unstoppable without reform.



Dec. 7, 2014 5:12 p.m. ET


Here’s a dirty little secret about recent attempts to fix ObamaCare. The “reforms,” approved by Senate and House leaders this summer and set to advance in the next Congress, adopt many of the Medicare payment reforms already in the Affordable Care Act. Both favor the consolidation of previously independent doctors into salaried roles inside larger institutions, usually tied to a central hospital, in effect ending independent medical practices.

Republicans must embrace a different vision to this forced reorganization of how medicine is practiced in America if they want to offer an alternative to ObamaCare. The law’s defenders view this consolidation as a necessary step to enable payment provisions that shift the financial risk of delivering medical care onto providers and away from government programs like Medicare. The law’s architects believe that doctors, to better bear financial risk, need to be part of larger, and presumably better-capitalized institutions. Indeed, the law has already gone a long way in achieving that outcome.

A recent Physicians Foundation survey of some 20,000 U.S. doctors found that 35% described themselves as independent, down from 49% in 2012 and 62% in 2008. Once independent doctors become the exception rather than the rule, the continued advance of the ObamaCare agenda will become virtually unstoppable. 

Local competition between providers, who vie to contract with health plans, is largely eliminated by these consolidated health systems. Since all health care is local, the lack of competition will soon make it much harder to implement a market-based alternative to ObamaCare. The resulting medical monopolies will make more regulation the most obvious solution to the inevitable cost and quality problems.

A true legislative alternative to ObamaCare would support physician ownership of independent medical practices, and preserve local competition between doctors and choice for patients.

First, Congress should remove the pervasive biases in ObamaCare that favor hospital ownership of medical practices. Payment reforms that create incentives for the coordinated delivery of medical care (like Accountable Care Organizations and payment “bundles”) all turn on arrangements where a single institution owns the doctors. They’re biased against less centralized engagements where independent doctors enter into contractual relationships among themselves.

These ObamaCare payment reforms are fashioned after 1990s-style health maintenance organizations, or HMOs, in which entities like hospitals would get a lump sum of money from Medicare (or now, ObamaCare) for taking on the risk of caring for a large pool of patients. But right now all of these payment schemes are tilted far in favor of having hospitals pool that risk, and not looser networks of doctors.

For one thing, providers who want to participate in the “reformed” physician payment plan must control their own IT infrastructure to comply, as opposed to collaborating freely across space rented in the cloud. This practical need can require IT infrastructure that costs millions of dollars. It makes participation absurdly expensive for anyone but a hospital that already has its own server hub.

Also, waivers of certain anti-kickback provisions (that prevent doctors from forming needed business partnerships) only apply when providers qualify as an Accountable Care Organization. Not surprisingly, ACA qualification is largely dependent on requirements that create the same need for physical infrastructure and bureaucratic overhead that is hard to replicate outside the hospital setting.

To implement real reform, Congress must give independent, private-practice doctors an equal footing. One legislative proposal would let a new class of “independent risk managers” act as third parties to help individual doctors analyze and share the risk of caring for these patient pools. This would make it possible for independent medical offices to band together and bid against hospitals for a pool of patients. Private companies specializing in analyzing and pricing medical risk could serve as brokers and help the doctors know what they’re getting into. But ObamaCare deliberately crowds out this sort of market innovation in favor of hospitals and their existing networks.

Individual, provider-owned medical practices also deserve equal footing when it comes to reimbursement. Right now, Medicare is paying much more for many procedures when performed in a hospital outpatient clinic rather than an independently owned medical office. Things as common as heart scans ($749 versus $503), colonoscopies ($876 versus $402) and even a 15-minute doctor visit ($124 versus $70) all pay more when done by a hospital-based doctor than a privately owned medical office. Obama officials know that hospitals are buying doctor practices to take advantage of this difference. But they favor hospital ownership of doctors and see it as a small cost to pay to drive that migration.

When I talk to physician colleagues, Republican or Democrat, a frequent refrain is that their professional strain would be the same regardless of what happens to ObamaCare. They are wrong. ObamaCare has accelerated many of the detrimental trends doctors see in their profession, and introduced new ones.

Reformers in Washington need to do a better job of explaining how market-based alternatives to ObamaCare are a better outcome for the structure and delivery of health care. And how they intend to preserve the entrepreneurship, autonomy and physician ownership that have long been the hallmark of American medicine.

Dr. Gottlieb, a physician and resident fellow at the American Enterprise Institute, is a member of the Health IT Policy Committee that advises the Department of Health and Human Services. He also invests in and advises health-care companies.

ACA - A Good Start?

I have attempted to look at the Affordable Care Act objectively, something that is almost impossible to do in today's world. But, as proponents point out, there are some good aspects to the Affordable Care Act. The inability to be denied coverage due to a pre-existing condition, and the ability of "children" up to age 26 to stay on their parents plans are two positives that come to mind.

Unfortunately, there are also negative aspects that need reworking and adjustment.

A glaring "loophole" is commented upon below - the lack of inpatient coverage for many ACA-approved plans. 

What I want to know is how did these plans ever get approved?

How could there possibly have been such a loophole?

Whose idea was it to include such a glaring lack of coverage for the recipients of such plans?

Is there any accountability for poorly written plans/acts/bills/laws?  

There doesn't seem to be. 

In my opinion, these types of loopholes and errors and oversights are exactly why there remains controversy over the entire Affordable Care Act.

We could have done better if politics didn't get in the way. Let's hope that improvements can be made before people are harmed.

Press compilation from the AMA:

HHS moves to close hospital coverage loophole.

The Hill (11/25, Viebeck) reports that Federal officials “are moving to stop some employers from cutting hospital coverage in the health insurance they provide under ObamaCare.” The Centers for Medicare and Medicaid Services issued proposed regulations on Friday to require companies with 50 or more employees to offer hospital benefits as part of their health plans. CMS stated, “A plan that excludes substantial coverage for inpatient hospital and physician services is not a health plan in any meaningful sense.” According to The Hill, the agency offered the clarification after an online “minimum value” calculator provided by HHS “approved plans that did not include hospital benefits.”

        Kaiser Health News (11/25) reports that HHS “also proposed granting temporary relief to employers that have already committed to calculator-approved plans without hospital coverage for 2015.” For 2016, however, no large-employer plan will meet the minimum-value threshold without inpatient benefits, the agency said. According to the article, “calculator-tested” plans lacking inpatient coverage “have drawn strong interest from large retailers, restaurant chains, staffing companies and other lower-wage employers seeking to control costs.”

No Caffeine Under Age 18

Treat caffeinated beverages as you would cigarettes. Children under 18 should not drink caffeine.

This simple rule of thumb hopefully will help readers understand that, in young people, caffeine is not healthy, and may be harmful.

Our children should have more than enough energy from daily intake of foods and non-caffeinated beverages. I know that not all children are fed healthy diets but that is the best way to safely increase one's energy levels.

When I read the excerpted quotes below, it just makes me sad. Educate your children. Stay informed. 

AMA excerpt as follows:

Energy drinks may cause seizures, heart problems in young kids.

NBC Nightly News (11/16, story 7, 1:40, Holt) reported, “We’re back now with a new warning about the popular energy drinks and the potential danger they present when they get into the hands of young children.” NBC News medical contributor Natalie Azar, MD, explained, “Researchers looked at records from 55 poison control centers over a three-year period and found more than 5,000 cases of energy drink exposure,” nearly all of which were unintentional. Additionally, more “than 40 percent involved children under the age of six.”

        Bloomberg News (11/17, Cortez) reports that some of the children who drank energy drinks ended up “suffering seizures and heart problems.” Individuals “of all ages with underlying health conditions should be vigilant about the heavily caffeinated beverages...said” Steven Lipshultz, MD, chairman of pediatrics at Wayne State University in Detroit, MI. The study data were presented over the weekend at the American Heart Association conference.

        HealthDay (11/17, Doheny) reports, “Some energy drinks have up to 400 milligrams (mg) of caffeine per serving, Lipshultz said, compared to about 100 mg or 150 mg in” the average cup of coffee.

Eye Health From A Radiologist's View

Notwithstanding the obvious pun, which surely garnered groans, your eye health is paramount. It has been said (by many authors, apparently) that the eyes are the "windows to the soul."

According to the CDC, tens of thousands if eye infections occur annually related to contact lens use and people who sleep with their contacts in have a 20-fold higher chance of infection!

As you might imagine, as a radiologist, I care deeply about eye health. Thankfully, though the day is fast approaching, I do not yet require corrective lenses. But you can be sure that I intend to use the highest degree of cleanliness when I do need lenses.

Care for your lenses. Your eyes will thank you.

AMA excerpt follows:

CDC: Poor contact lens care tied to hundreds of thousands of eye infections.

The AP (11/14, Stobbe) reports that a report released yesterday by the Centers for Disease Control and Prevention in its Morbidity and Mortality Weekly Report claims that “sloppy care of contact lenses is a main reason for hundreds of thousands of eye infections” annually. The CDC “estimates that there are nearly one million patient visits to doctor’s offices, clinics and hospitals for treatment of an infection of the cornea called keratitis.”

        The Washington Post (11/14, Phillip) “To Your Health” blog quotes medical epidemiologist Jennifer Cope, MD, MPH, of the CDC, who said, “People who wear contact lenses over night are more than 20 times more likely to get keratitis.” She added, “Wearing contacts and not taking care of them properly is the single biggest risk factor for keratitis.”

        The Boston Globe (11/14, Kotz) “Daily Dose” blog reports that the CDC report pointed out that “$175 million annually” is spent “in medical costs for diagnostic exams and treatments for keratitis.” Most of the time, “keratitis can be easily treated with prescription antimicrobial eye drops or creams,” but severe, untreated infections may lead to corneal scarring and even blindness.

        HealthDay (11/14, Reinberg) reports that “for the report, CDC researchers analyzed three national databases of outpatient care centers and emergency” departments. Investigators then “estimated that each year there are some 930,000 visits to doctors’ offices and outpatient clinics and 58,000 emergency room visits for eye infections.” HealthDay also provides a list of commonsense contact lens care tips.

        Medscape (11/14, Brooks) reports that the report’s results were published “ahead of the first annual Contact Lens Health Week, which runs from November 17 to 21.” The NPR (11/14, Shute) “Shots” blog and the NBC News(11/14, Fox) website also cover the story.

Are You Truly Allergic To Penicillin?

An allergy is a serious thing. If you are allergic to a medication, typically that means one of two things:

1- You break out in hives, of varying severity, with varying degrees of itching. Hives are self-limited and can be readily treated with oral or IV Benadryl. 


2- You develop difficulty breathing with swelling of the throat and other symptoms can develop including complete circulatory collapse, also called anaphylaxis. 

Unless you demonstrate one of the above constellations of symptoms, you do not have a true "allergy." What you may have instead is called a side effect. While side effects can be unpleasant, they are not life-threatening. To consider penicillin an allergy, you limit the kinds of medications you may receive during an illness. This is no small matter. Check with your doctor before labeling yourself as having an allerkgy. Make sure that you are clear on the symptoms you have experienced. 


Excerpt from AMA Daily Email:  

Studies: Most people who think they are allergic to penicillin are not.

NBC Nightly News (11/8, story 8, 1:50, Williams) reported that “the nation’s top allergists are saying most of those” who believe they are allergic to penicillin are not.

        On its website, NBC News (11/7, Silverman) reported that in one study presented at the at the American College of Allergy, Asthma and Immunology meeting, investigators “tested 384 people who said they were allergic to penicillin. “

        ABC News (11/8) reported on its website that the investigators “found the overwhelming majority – 94 percent – of test subjects showed no allergy to penicillin.”

        HealthDay (11/8, Preidt) reported that “in the second study,” also presented at the ACAAI meeting, “penicillin skin testing was performed on 38 people who believed they were allergic to the antibiotic, and all of them tested negative for such an allergy.” Also covering the story are Medical Daily (11/10), and the Syracuse (NY) Post-Standard (11/8, Canedo).

        Survey: Many physicians may have misconceptions about allergies. HealthDay (11/8, Norton) reported that research presented at the American College of Allergy, Asthma and Immunology’s annual meeting suggests that “many primary care doctors may not be up to speed on the causes and best treatments for allergies.” Investigators who surveyed more than “400 internists and pediatricians...found that misconceptions about allergies were fairly common – particularly when it came to food allergies.” Among other things, the survey found that “one-third of all doctors, and half of internists, did not know” that “the go-to treatment for a person who develops hives and vomiting after eating a known food allergen” is an epinephrine injection.

Cervical Cancer Is Preventable/Curable, So Why Are Women NOT Getting Screened?

Cervical cancer is preventable through regular screening. So it comes as a shock that 8,000,000 women in the US did not undergo screening during the past five years. Why not? The recession? Are your finances more important than your health? How much does a visit to the gynecologist for preventative health screening cost? I'll give you a hint; it costs less than the cost of cervical cancer treatment. It costs less than lost time at work. And it costs much less than the loss of a woman's life to her family.

Get screened now. Everything else are empty excuses. 

AMA excerpt:

CDC: Eight million women in the US have skipped cervical cancer screening in the past five years.

NBC Nightly News (11/5, story 8, 1:55, Williams) reported, “A startling number out tonight from the CDC reporting that eight million women in” the US “have skipped the screening test for cervical cancer in just the past five years.”

        On its website, NBC News (11/6, Fox) reports that Ileana Arias, the CDC’s deputy director, said, “Every visit to a provider can be an opportunity to prevent cervical cancer by making sure women are referred for screening appropriately.” Arias added, “We must increase our efforts to make sure that all women understand the importance of getting screened for cervical cancer. No woman should die from cervical cancer.”

        The Augusta (GA) Chronicle (11/6, Corwin) reports that approximately “12,000 women are diagnosed each year with cervical cancer and about 4,000 die from it, Arias said.” The Chronicle adds, “Lack of screening, cervical cancer cases and cervical cancer deaths are particularly high for the South, she said.”

        The Oregonian (11/6, Terry) reports that “in 2012 alone,” the CDC “found that more than 11 percent of the women surveyed were not been screened.” The survey indicated that “the percentages were much higher for those without health insurance – 23 percent – and even higher for women who did not have a regular health care provider – nearly 26 percent.” Also covering the story are HealthDay (11/6, Preidt) and Medscape (11/6, Brooks).

Feeling Sick?...You Do Not Have Ebola

You developed a fever today or last night.

You may have nausea and vomiting.

You may have diarrhea.

You may have a cough.

You may have stomach pains.

I have news for you.

Unless you have recently traveled to or returned from countries or regions affected by the Ebola do not have Ebola.

Unless you live with someone, who has recently traveled to or returned from countries or regions affected by the Ebola outbreak and had direct, prolonged contact with them, AND they have the symptoms listed do not have Ebola.

AMA Morning Rounds excerpt follows:

Misinformed patients with Ebola-like symptoms can take up time, resources in busy EDs.

The AP (10/30, Tanner) reported that patients with symptoms are more likely to have the flu than Ebola. The article added that “misinformed patients with Ebola-like symptoms can take up time and resources in busy emergency rooms, and doctors fear the problem may worsen when flu season ramps up.” Dr. Kristi Koenig said during a break at the American College of Emergency Physicians’ annual meeting, “The whole system gets bogged down, even if it’s a false alarm.”

        Louisiana medical conference impacted by Ebola fears. The AP (10/31, Marchione, McConnaughey) reports, “Louisiana state health officials told thousands of doctors planning to attend a tropical diseases meeting this weekend in New Orleans to stay away if they have been to certain African countries or have had contact with an Ebola patient in the last 21 days.” Because of the order, “several doctors, including some from the World Health Organization and the Centers for Disease Control and Prevention, now may not be able to attend or present studies at the meeting, which runs Sunday through Wednesday.” Meanwhile, “in contrast to the Louisiana situation, there were no such restrictions placed on doctors attending the American College of Emergency Physicians’ annual meeting in Chicago this week.” NPR (10/31, Beaubien) also covers the story in its “Shots” blog and on its “All Things Considered” program.

        Nurse, Maine governor square off over Ebola quarantine. Kaci Hickox, who left involuntary quarantine in New Jersey earlier this week, returned to Maine in a firestorm of controversy over her quarantine status, which she vehemently opposes. On Thursday, Hickox left her home for a bike ride, an event covered by several news outlets. Don Dahler of the CBS Evening News (10/30, story 2, 2:35, Pelley) reported that Hickox went out for an hour-long bike ride on Thursday, defying quarantine for the second time. Dahler also reported that Main Gov. Paul LePage “is threatening legal action.” LePage said in an announcement on Thursday that Hickox is “pushing my patience.” ABC World News (10/30, story 3, 1:55, Muir) added that a state trooper followed Hickox’s bike ride. ABC also covered LePage’s announcement in which he reportedly said the town she lives in is “scared to death.” NBC Nightly News(10/30, story 2, 2:55, Williams) also reported the event, covering LePage saying, “As long as she is not touching other people or, you know, staying a distance from other people, then I don’t see the harm.”

        The AP (10/31, Bukaty) adds that the bike ride was taken “on a dirt path to avoid coming into contact with people.” The AP quotes her boyfriend as saying, “We’re not trying to push any limits here. We’re members of this community, too, and we want to make people comfortable.”

        The Washington Post (10/31, Berman, Dennis) reports the event, writing that efforts to come to a compromise between Hickox’s lawyers and state officials “had broken down.” The Post also reported a statement from Maine Gov. Paul LePage that said he intends to pursue the matter in court because Hickox “has been unwilling to follow the protocols.”

        In “Post Nation,” the Washington Post (10/30, Berman) calls Hickox the “central figure in an ongoing debate over how the government will deal with healthcare workers who return to the United States after working in the Ebola-ravaged part of West Africa.”

        The New York Times (10/31, Bidgood, Zernike, Subscription Publication) reports that LePage said his attempts to reach an agreement with Hickox included a provision that she would be allowed to leave her house as long as she stayed three feet away from others and agreed to monitoring by health officials. The American Nursing Association said on Thursday in a statement that it supports Hickox and does not agree that she should be quarantined.

        The Wall Street Journal (10/31, Levitz, Subscription Publication) adds that though LePage has threatened legal action, he has not detailed how he would get the courts involved.

        Military preps hospitals for Ebola. USA Today (10/31, Zoroya) reports that Joint Chiefs of Staff chairman Gen. Martin Dempsey’s spokesman, Col. Edward Thomas, said that the military is preparing its US hospitals, including Walter Reed, to handle Ebola cases. Thomas said a team with members from the Joint Chiefs of Staff, the office of the Secretary of Defense, and the Defense Health Agency are determining the number of beds needed to treat potential Ebola cases.

        USA Today (10/30, Brook) reports that Defense Secretary Chuck Hagel defended his decision to quarantine military personnel returning from the Ebola zone on Thursday. Dempsey explained the measure was wise because troops are in the region for a much longer than most healthcare workers. The AP (10/31, Kuhnhenn, Burns) also reports the statements.

        Professors: Military will not spread Ebola. The Wall Street Journal (10/31, Subscription Publication) publishes an op-ed by Jonathan D. Moreno, professor of medical ethics and health policy at the University of Pennsylvania, and Stephen N. Xenakis, adjunct professor at the Uniformed Services University of the Health Sciences. The two professors, supporting the military’s presence in the Ebola zone, argue that the fear that military personnel will catch Ebola is not unusual, as all missions carry some degree of danger. The professors also state that the public should not fear that the military will bring the disease back to the US because of its strict monitoring policy.

        Visit the AMA Ebola Resource Center (10/30) for expert resources for physicians and the public.

Ebola: Quarantines Are For Public Safety

Some states recently instituted 21-day quarantines for healthcare workers returning from Ebola virus-stricken countries. I believe this decision is prudent. After the New York physician, Dr. Craig Spencer, self-quarantined and was subsequently diagnosed with the virus, it became apparent that his measures were inadequate. Because of his incomplete self-quarantine, a cab driver and his fiancée are now also quarantined, but hopefully not infected.

Ebola infection has a high death rate, otherwise this discussion would be ludicrous. But instituting quarantines for workers who have had close contact, despite being "properly" protected, is a judicious public safety maneuver.

That the White House and the ACLU have now put pressure (see excerpted quotes below) on the governors of the states of New Jersey and New York is a testament to just how poorly understood this issue remains.

In my opinion, a 21-day in-home quarantine, for workers or people who have had documented close contact with Ebola sufferers, is not too much to ask to ensure the public safety.

I hope that politics will not overcome good science and reasonable and temporary restrictions on behavior. 

Excerpts from the AMA Daily Email below:



Cuomo, Christie revise Ebola quarantine rules introduced late last week.

After receiving harsh criticism for strict mandatory quarantines, the Governors of New York and New Jersey qualified their policies on Sunday night. The New York Times (10/27, A1, Flegenheimer, Shear, Barbaro, Subscription Publication) reports that on Sunday night, New York Gov. Andrew Cuomo, “facing fierce resistance from the White House and medical experts,” announced that “people quarantined in New York who do not show symptoms...would be allowed to remain at home and would receive compensation for lost income.” According to the Times, “The announcement...seemed intended to draw a sharp the policy’s implementation in New Jersey.”

        Shortly after Cuomo’s announcement, the Wall Street Journal (10/27, Dawsey, Orden, Gay, Subscription Publication) reports that New Jersey Gov. Chris Christie also announced that quarantines could be done at home, saying this was always the plan.

        In a front-page article, the Wall Street Journal (10/27, A1, Nelson, West, McKay, Subscription Publication) reports that Cuomo claimed that he had received no pressure from the White House to revise the quarantine rules he imposed last week and emphasized that New York’s precautions still go beyond what Federal officials have deemed appropriate. Cuomo is quoted as saying, “My personal practice is to err on the side of caution.”

        The AP (10/27, Eltman) notes that on Sunday night, Cuomo, who “had criticized Dr. Craig Spencer” last week “for not obeying a 21-day voluntary quarantine,” referred to medical workers in West Africa as “heroes” and “encourage[d] more medical workers to volunteer to fight Ebola.”

        The Washington Post (10/27, Kang) reports that earlier on Sunday, Christie and Cuomo “defended their policies, saying the potential threat was too great to leave to self-monitoring by returning aid workers.” On Fox News Sunday (10/26, Wallace), Christie said, “I don’t believe when you’re dealing with something as serious as this that we can count on a voluntary system.” Politico (10/26, Gass) noted that Christie predicted that the precautions he has put in place “will become a national policy sooner rather than later.”

        On ABC World News (10/26, story 2, 1:00, Vega), Dr. Richard Besser, ABC News’s Chief Health and Medical editor, said he is opposed to mandatory quarantines, but predicted “the middle ground is coming this week.” According to Besser, “They are moving away from self-monitoring of fever and now every healthcare worker who returns will be monitored by a health department.”

        The Wall Street Journal (10/27, West, Subscription Publication), the Los Angeles Times (10/27, Susman), Bloomberg News (10/27, Deprez, Klopott), the AP (10/27, Eltman), the AP (10/27, Eltman), Reuters (10/27, Wulfhorst, Mcgurty), Fox News (10/27), CNN (10/26), and the AP(10/27), cover the story.

        White House developing guidelines for returning healthcare workers. On ABC World News (10/26, lead story, 3:00, Vega), correspondent Linsey Davis reported that the White House “is sharing its concerns with the Governors and working on guidelines for healthcare workers returning from Africa.” The Daily Caller (10/26, Hunter) reports that President Obama convened a meeting to discuss national guidelines on returning healthcare workers from West Africa on Sunday. Twenty-four people attended, including Ebola Response Coordinator Ron Klain and Secretary of Health and Human Services Sylvia Burwell, as well as Vice President Joe Biden and CDC Director Thomas Frieden remotely.

        The Los Angeles Times (10/27, Serrano) reports that an anonymous “senior official” said the Administration “was working on new guidelines for returning healthcare workers.” The Hill (10/27, Balluck) adds that President Obama said of the guidelines, they “must recognize that healthcare workers are an indispensable element of our effort to lead the international community to contain and ultimately end this outbreak at its source, and should be crafted so as not to unnecessarily discourage those workers from serving.”

        Bloomberg News (10/25, Gilblom, Klopott, Chappatta) reports that Fauci said of the guidelines, “That is something that is right now under very active discussion, and you’ll be hearing shortly about what the guidelines will be.”

        USA Today (10/27, Madhani, Jackson), Bloomberg News (10/26, Lauerman, Armstrong), Reuters (10/24, Rampton), CNN (10/24, Botelho), also report the new guidelines.

        FDA fast-tracks Ebola diagnostic platform. The Wall Street Journal (10/25, Burton, Subscription Publication) reports that the Food and Drug Administration on Saturday declared it would allow two new tests for Ebola that promise to halve the time in which the disease can be detected in possible patients from four hours down to two. Both tests are manufactured by the company BioFire Defense, one is for hospital use and one for lab use. The FDA used its public health emergency power to issue an emergency use authorization. The company announced the news in a press release (10/27).

        The Salt Lake (UT) Tribune (10/27) reports that 300 hospitals in the United States already use BioFire’s system for identifying other diseases. The Tribune explains how the system works in greater detail: “In about an hour, the polymerase chain reaction, or PCR, diagnostic tool can analyze human blood, saliva or other bodily fluid at the molecular level, find genetic markers for various diseases and post the result on a laptop computer.”

        Ebola infections surpass 10,000. The AP (10/26, Dilorenzo) reports that the World Health Organization warned that the figures “are likely an many people in the hardest hit countries have been unable or too frightened to seek medical care.” Reuters (10/25, Nebehay) noted that the death toll from these reported cases of Ebola has reached 4,922.

        “All but 27 of the infections and all but three of the deaths” were in Guinea, Liberia, and Sierra Leone, the New York Times (10/26, Cumming-Bruce, Subscription Publication) reports, noting that one of the deaths was that of a 2-year-old child in Mali Friday, leading to the isolation of “43 people, including 10 health care workers.” Authorities have warned that the child was symptomatic “when he rode hundreds of miles by public bus,” presenting “multiple opportunities for exposures — including high-risk exposures — involving many people.”

        Reuters (10/25, Diarra, Diagana) reports that Mauritanian officials said Saturday that the country has closed its border with Mali over concern about the case.

        The CBS Evening News (10/25, 5:43 p.m. EDT) reported that in rural Liberia, mandatory cremation practices are “being met with strong resistance,” as it runs contrary to “ancient burial traditions which involves touching and washing the dead,” making it difficult to contain the outbreak in rural areas.

        The Los Angeles Times (10/25, Dixon) noted that, in addition to unsafe burial practices, “the WHO has expressed concern that cases in Liberia are being underreported, which would mean that people are resisting treatment and keeping sick people at home.” Liberia reported its highest number of Ebola casualties for a month this past week.

        The Wall Street Journal (10/25, Morse, Subscription Publication) and The Hill (10/25, Byrnes) also report on this story.

Dear Bill (Gates): Fund This! ...Eradicate TB!

Much effort and money has been spent to fight Ebola of late. This is a scary, deadly virus that has, however, affected a remarkable few compared with the millions that die every year from such diseases as tuberculosis. Below is a short excerpt from an email I receive daily. Tuberculosis is an insidious disease that kills readily. It should be eradicated. It requires a concerted worldwide effort and billions of dollars to do so.

WHO: Nine million people developed TB in 2013.

CNN (10/23, Wilson) reports, “On Wednesday, the World Health Organization released its 2014 Global Tuberculosis Report, which shows that 9 million people developed tuberculosis in 2013 and 1.5 million died, making it one of the world’s deadliest communicable diseases.”

        TIME (10/23, Frizell) adds that, of the nine million cases, TB’s death toll was “1.5 million people in 2013, including 360,000 people who were HIV positive.”

        NBC News (10/23, Fox) reports that despite the high prevalence of the infectious disease, “companies and countries alike are actually cutting their investments in TB.” The WHO says “$8 billion is needed each year to find and treat patients and to invest in better drugs and work on a vaccine,” but each year there is a $2 billion shortfall in funding. Dr. Mario Raviglione, director of the global TB program at WHO, told reporters “the pharmaceutical industry is less interested in developing countries, where the potential gains are limited.”

        US News & World Report (10/23, Leonard), Reuters (10/23, Kelland), and Medscape (10/23, Brooks) also report on the story.

NO, Ebola is NOT a Biological Weapon

Stratfor publishes erudite fact-based information and this article is no exception. I have not seen any significant discussion about Ebola as a biological weapon, but hopefully this article (quoted below) will put that suggestion to rest.

Evaluating Ebola as a Biological Weapon

By Scott Stewart

Over the past few weeks, I've had people at speaking engagements ask me if I thought the Islamic State or some other militant group is using Ebola as a biological weapon, or if such a group could do so in the future. Such questions and concerns are not surprising given the intense media hype that surrounds the disease, even though only one person has died from Ebola out of the three confirmed cases in the United States. The media hype about the threat posed by the Islamic State to the United States and the West is almost as bad. Both subjects of all this hype were combined into a tidy package on Oct. 20, when the Washington Post published an editorial by columnist Mark Thiessen, in which he claimed it would be easy for a group such as the Islamic State to use Ebola in a terrorist attack. Despite Thiessen's claims, using Ebola as a biological warfare agent is much more difficult than might appear at first blush.
In the past, there have been several outbreaks of Ebola in Africa. Countries included Sudan, Uganda, the Republic of the Congo and the Democratic Republic of the Congo, and several comparatively small outbreaks occurred in Gabon as well. In most cases, people who handled or ate animals infected with the disease started the outbreaks. "Bushmeat," or portions of roasted meat from a variety of wild animals, is considered by many to be a delicacy in Africa, and in a continent where hunger is widespread, it is also a necessity for many hungry people. After several months of medical investigations, epidemiologists believe the current outbreak most likely began when a two-year-old child in Guinea touched or perhaps ate part of an infected animal such as a bat or monkey.

The source of the disease means it is highly unlikely that some malevolent actor intentionally caused the latest outbreak. Besides the fact that the current outbreak's cause has been identified as a natural one, even if a transnational militant group such as the Islamic State was able to somehow develop an Ebola weapon, it would have chosen to deploy the weapon against a far more desirable target than a small village in Guinea. We would have seen the militants use their weapon in a location such as New York, Paris or London, or against their local enemies in Syria and Iraq.

As far as intent goes, there is very little doubt that such a group would employ a biological weapon. As we noted last month when there was increased talk about the Islamic State possibly weaponizing plague for a biological attack, terrorist attacks are intended to have a psychological impact that outweighs the physical damage they cause. The Islamic State itself has a long history of conducting brutal actions to foster panic.

In 2006 and 2007, the Islamic State's predecessor, al Qaeda in Iraq, included large quantities of chlorine in vehicle bombs deployed against U.S. and Iraqi troops in an attempt to produce mass casualties. The explosives in the vehicle bombs killed more people than the chlorine did, and after several unsuccessful attempts, al Qaeda in Iraq gave up on its chlorine bombings because the results were not worth the effort. Al Qaeda in Iraq also included chemical artillery rounds in improvised explosive devices used in attacks against American troops in Iraq on several occasions. Again, these attacks failed to produce mass casualties. Finally, according to human rights organizations, the Islamic State appears to have recently used some artillery rounds containing mustard gas against its enemies in Syria; the group presumably recovered the rounds from a former Saddam-era chemical weapons facility in Iraq or from Syrian stockpiles.

The problem, then, lies not with the Islamic State's intent but instead with its capability to obtain and weaponize the Ebola virus. Creating a biological weapon is far more difficult than using a chemical such as chlorine or manufactured chemical munitions. Contrary to how the media frequently portrays them, biological weapons are not easy to obtain, they are not easy to deploy effectively and they do not always cause mass casualties.

The Difficulty of Weaponization

Ebola and terrorism are not new. Nor is the possibility of terrorist groups using the Ebola virus in an attack. As we have previously noted, the Japanese cult Aum Shinrikyo attempted to obtain the Ebola virus as part of its biological warfare program. The group sent a medical team to Africa under the pretext of being aid workers with the intent of obtaining samples of the virus. It failed in that mission, but even if it had succeeded, the group would have faced the challenge of getting the sample back to its biological warfare laboratory in Japan. The Ebola virus is relatively fragile. Its lifetime on dry surfaces outside of a host is only a couple of hours, and while some studies have shown that the virus can survive on surfaces for days when still in bodily fluids, this requires ideal conditions that would be difficult to replicate during transport. 

If the group had been able to get the virus back to its laboratory, it would have then faced the challenge of reproducing the Ebola virus with enough volume to be used in a large-scale biological warfare attack, similar to its failed attacks on Tokyo and other Japanese cities in which the group sprayed thousands of gallons of botulinum toxin and Anthrax spores. Reproducing the Ebola virus would present additional challenges because it is an extremely dangerous virus to work with. It has infected researchers, even when they were working in laboratories with advanced biosafety measures in place. Although Aum Shinrikyo had a large staff of trained scientists and a state-of-the-art biological weapons laboratory, it was still unable to effectively weaponize the virus.

The challenges Aum Shinrikyo's biological weapons program faced would be multiplied for the Islamic State. Aum Shinrikyo operatives were given a great deal of operational freedom until their plans were discovered after the 1995 sarin attacks on the Tokyo subway. (The group's previous biological weapons attacks were so unsuccessful that nobody knew they had been carried out until after its members were arrested and its chemical and biological weapons factories were raided.) Unlike the Japanese cult, the Islamic State's every move is under heavy scrutiny by most of the world's intelligence and security agencies. This means jihadist operatives would have far more difficulty assembling the personnel and equipment needed to construct a biological weapons laboratory. Since randomly encountering an infected Ebola patient would be unreliable, the group would have to travel to a country impacted by the outbreak. This would be a difficult task for the group to complete without drawing attention to itself. Furthermore, once group members reached the infected countries, they would have to enter quarantined areas of medical facilities, retrieve the samples and then escape the country unnoticed, since they could not count on randomly encountering an infected Ebola patient.

Even if Islamic State operatives were somehow able to accomplish all of this -- without killing themselves in the process -- Ebola is not an ideal biological warfare vector. The virus is hard to pass from person to person. In fact, on average, its basic reproductive rate (the average amount of people that are infected by an Ebola patient) is only between one and two people. There are far more infectious diseases such as measles, which has a basic reproductive rate of 12-18, or smallpox, which has a basic reproductive rate of five to seven. Even HIV, which is only passed via sexual contact or intravenous blood transmission, has a basic reproductive rate of two to five. 

Ebola's Weakness as a Weapon

The Ebola disease is also somewhat slow to take effect, and infected individuals do not become symptomatic and contagious for an average of 8-10 days. The disease's full incubation period can last anywhere from two to 21 days. As a comparison, influenza, which can be transmitted as quickly as three days after being contracted, can be spread before symptoms begin showing. This means that an Ebola attack would take longer to spread and would be easier to contain because infected people would be easier to identify.

Besides the fact that Ebola can only be passed through the bodily fluids of a person showing symptoms at the time, the virus in those bodily fluids must also somehow bypass the protection of a person's skin. The infectious fluid must enter the body through a cut or abrasion, or come into contact with the mucus membranes in the eyes, nose or mouth. This is different from more contagious viruses like measles and smallpox, which are airborne viruses and do not require any direct contact or transfer of bodily fluids. Additionally, the Ebola virus is quite fragile and sensitive to light, heat and low-humidity environments, and bleach and other common disinfectants can kill it. This means it is difficult to spread the virus by contaminating surfaces with it. The only way to infect a large amount of people with Ebola would be to spray them with a fluid containing the virus, something that would be difficult to do and easily detectable.

Thiessen's piece suggested that the Islamic State might implement an attack strategy of infecting suicide operatives with Ebola and then having them blow themselves up in a crowded place, spraying people with infected bodily fluids. One problem with this scenario is that it would be extremely difficult to get an infected operative from the group's laboratory to the United States without being detected. As we have discussed elsewhere, jihadist groups have struggled to get operatives to the West to conduct conventional terrorist attacks using guns and bombs, a constraint that would also affect their ability to deploy a biological weapon.

Even if a hostile group did mange to get an operative in place, it would still face several important obstacles. By the time Ebola patients are highly contagious, they are normally very ill and bedridden with high fever, fatigue, vomiting and diarrhea, meaning they are not strong enough to walk into a crowded area. The heat and shock of the suicide device's explosion would likely kill most of the virus. Anyone close enough to be exposed to the virus would also likely be injured by the blast and taken to a hospital, where they would then be quarantined and treated for the virus.

Biological weapons look great in the movies, but they are difficult and expensive to develop in real life. That is why we have rarely seen them used in terrorist attacks. As we have noted for a decade now, jihadists can kill far more people with far less expense and effort by utilizing traditional terrorist tactics, which makes the threat of a successful attack using the Ebola virus extremely unlikely.

Read more:  Evaluating Ebola as a Biological Weapon | Stratfor 
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Ebola: Facts, Not Hyperbole (Thank You Johns Hopkins!)

Johns Hopkins, my undergraduate alma mater, has always held a special place in my heart and mind. It is one of the greatest institutions of "higher" learning and the people who attend and work there are exposed to a ridiculous wealth of knowledge. Now, as usual, Johns Hopkins has put together a special forum to discuss and explain Ebola from all angles, including the history, epidemiology, current and past outbreaks, and treatment solutions. Please take some time to review the videos they published on YouTube. In particular, Dr Trish Perl's talk (Part 2) is highly informative and educational. She puts into perspective the other past outbreaks of the Ebola and similar viruses.











Ebola: USA Laser-Focused on Containment

Although there were missteps related to the delayed diagnosis of the first Dallas Ebola patient, Mr Duncan, and subsequent infections occurred in two nurses which might have been prevented with better protocols, these issues appear to have been remedied. I am very encouraged by the recent decisions to transfer infected individuals to appropriately equipped and readied hospitals. I think that is an excellent move. It is a sign that the nation's efforts are coming up to speed. Hopefully therefore, this thing will be contained and eliminated in short order. Might we see more infections occur in the USA? Perhaps. But awareness and vigilance, not panic and fear, are of key importance moving forward.

Please visit my site and click on the "Ebola" tab for more educational resources. 

From the AMA daily email: 

Frieden testifies at congressional hearing on Ebola.

The CBS Evening News (10/16, story 3, 2:30, Axelrod) reported, “Federal health officials were on Capitol Hill today. They came under fire for the handling of the Ebola situation.” CBS Congressional Correspondent Nancy Cordes added, “Under oath the CDC director went head to head with Republicans, who want a ban on travelers from West Africa.” Tom Frieden, CDC Director argued against such a ban, saying, “If passengers are now allowed to come directly, there is a high likelihood that they will find another way to get here, and we won’t be able to track them.” Cordes added that Dr. Daniel Varga, the head of Texas Presbyterian Hospital in Dallas, “testified by videophone.” Dr. Varga said, “Unfortunately in our initial treatment of” Thomas Eric Duncan, “despite our best intentions and a highly skilled medical team, we made mistakes. We did not correctly diagnose his symptoms as those of Ebola. and we are deeply sorry.”

        Bloomberg News (10/17, Wayne, Hunter) reports that “in written testimony submitted before he appeared before a panel of the House Energy and Commerce Committee,” Frieden said, “We remain confident that Ebola is not a significant public health threat to the United States.” He added, “We know Ebola can be stopped with rapid diagnosis, appropriate triage and meticulous infection-control practices in American hospitals.”

        Meanwhile, in a 1,200-word story titled “Transfer Of Ebola Patients Reflects A Tacit Shift In Strategy,” the Los Angeles Times (10/17, Levey) reports, “The federal government effectively began to restrict the care of Ebola patients to hospitals with special bio-containment units” yesterday, “and the Obama administration labored to reassure jittery Americans and increasingly skeptical lawmakers that public health authorities can prevent a widespread Ebola outbreak” in the US. This “tacit shift in policy came amid growing concerns about mistakes at Texas Health Presbyterian Hospital in Dallas, where two nurses who treated Thomas Eric Duncan of Liberia have since come down with the disease.” One of those “nurses is being treated at Emory University Hospital in Atlanta,” while “the other” will be treated at “a specialized treatment center at the National Institutes of Health.”

        Obama considers appointing an “Ebola czar.” In an 1,100-word article titled “White House takes drop everything approach to respond to public health crisis,” the New York Times (10/17, Shear, Subscription Publication) reports, “President Obama remained at the White House on Thursday to focus on the government’s response to Ebola, canceling a second day of election-season travel as the administration concentrated on what is already turning into a political as well as a public health crisis.” According to the Times, “Aides said there was no sudden shift in the president’s thinking and described his new, more aggressive public posture on Ebola as the natural response to a ‘dynamic situation.’”

        According to the Washington Post (10/17, Eilperin), the President’s effort to show he is focused on the Ebola outbreak “has done little reassure a jittery America public that the danger is contained or to stanch the political fallout, some of it from lawmakers in his own party.” The Post says the White House “is now engulfed in a crisis that has resurrected questions about the president’s governing style.” White House senior adviser Dan Pfeiffer is quoted as saying, “We need to try to calm people because many people are fanning the flames here now in a way that’s deeply irresponsible, but we also understand that there is real concern, and we’re trying to be sensitive to that.”

        In an 1,800-word front-page story, the New York Times (10/17, A1, Healy, Tavernise, Goodnough, Subscription Publication) reports, “President Obama raised the possibility on Thursday that he might appoint an ‘Ebola czar’ to manage the government’s response to the deadly virus as anxiety grew over the air travel of an infected nurse.”

        The AP (10/16, Kuhnhenn) reports that the President “said his team of Ebola advisers is doing ‘an outstanding job.’” But, he said, “It may make sense for us to have one person ... so that after this initial surge of activity we can have a more regular process just to make sure we are crossing all the Ts and dotting all the Is.”

        Calls for travel ban mount. The AP (10/17, Werner, Daly) reports that on Thursday, “House Republicans demanded a travel ban...calling it the only sure way to protect Americans,” but, according to the AP, the White House continues to insist that a ban is “not under consideration” and “could actually make things worse.” Although some Democrats are among those urging the implementation of travel restrictions, most reports cast the debate in partisan terms.

        On CNN’s AC 360 (10/16), Anderson Cooper reported that President Obama had just announced that he “didn’t rule out appointing a so-called ‘Ebola czar’ if need be, and also talked about growing calls to restrict travel from West Africa.” President Obama was shown saying, “I don’t have a philosophical objection necessarily to a travel ban if that is the thing that is going to keep the American people safe. The problem is, is that in all the discussions I’ve had thus far with experts in the field, experts in infectious disease, is that a travel ban is less effective than the measures that we are currently instituting.”

        The Washington Times (10/17, Wolfgang) notes that CDC officials “argue that if a ban is instituted, travelers who have visited affected countries — primarily Sierra Leone, Guinea and Liberia — may lie about where they’ve been in order to get into the US,” which “would complicate efforts to track the virus and determine who may have been infected.”

        Visit the AMA Ebola Resource Center (10/16) for expert resources for physicians and the public

A Rare Vascular Cause of Left Arm Pain and Numbness In A 30 Year-Old

A 30 year-old woman with three weeks of numbness and tingling in her left arm underwent an arterial ultrasound that showed recent thrombosis/occlusion of the radial and ulnar arteries. She described blanching of her raised hand, which occurred while washing her hair. Interestingly, she also had a longer-standing history of several years of neck pain and left arm pain, numbness and tingling.

A vascular surgeon then performed surgery (open embolectomy) to remove the blood clots in her arteries and restore blood flow to her hand. A CT scan of the neck and upper chest was also obtained which showed a cervical rib, an aneurysm of the left subclavian artery, and a false joint (or pseudarthrosis) of the C7 rib where it meets with the 1st thoracic rib.

The course of events and clinical and anatomic findings may seem straightforward as I’ve described them. But the long-standing symptoms may have contributed to the length of time that the underlying anatomic abnormalities went undiagnosed by creating a difficulty for the physicians who had previously seen her. They had evaluated her for musculoskeletal or nerve-related abnormalities. Those diagnostic evaluations were unsuccessful in yielding the true nature of her ailment until the arterial ultrasound was performed and interpreted by this vascular radiologist. She will still need definitive therapy, constituting surgical resection of the abnormal rib to remove the extrinsic compression on the subclavian artery and eliminate the potential for further vascular problems.

3-D CT rendering of a left C7 cervical rib

3-D CT rendering of a left C7 cervical rib

Cervical rib depicted as anatomical cartoons, also demonstrating the relationships to adjacent nerves and the subclavian artery, which are displaced anteriorly.

Cervical rib depicted as anatomical cartoons, also demonstrating the relationships to adjacent nerves and the subclavian artery, which are displaced anteriorly.

From Wikipedia:

“A cervical rib is a rare congenital abnormality where a rib arises from the seventh cervical vertebra. A cervical rib is estimated to occur in 0.5% of the population, 66% are bilateral, and are twice as common in females as in males.

Most cases of cervical ribs are not clinically relevant and do not have symptoms; cervical ribs are generally discovered incidentally. However, they may cause problems such as brachial plexopathy or thoracic outlet syndrome, because of pressure on the nerves or subclavian artery, respectively.

A cervical rib represents a persistent ossification of the C7 lateral costal element. During early development, this ossified costal element typically becomes re-absorbed. Failure of this process results in a variably elongated transverse process or complete rib that can be anteriorly fused with the T1 first rib below.

The presence of a cervical rib can cause a form of thoracic outlet syndrome due to compression of the lower trunk of the subclavian artery. These structures become encroached upon by the cervical rib and scalene muscles. Aneurysm formation can occur, followed by distal embolization if not earlier identified and treated.

Compression of the brachial plexus may be identified by weakness of the muscles around the muscles in the hand, near the base of the thumb. Compression of the subclavian artery is often diagnosed by finding a positive Adson's sign on examination, where the radial pulse in the arm is lost during abduction and external rotation of the shoulder. A positive Adson's sign is non-specific for the presence of a cervical rib, however, as many individuals without a cervical rib will have a positive test.”

The importance of the above vignette and discussion is that some abnormalities are difficult to identify. Often, the appropriate specialists, in this case a vascular/interventional radiologist, are needed to identify the underlying abnormalities, and a vascular surgeon and a cardiothoracic surgeon are needed to treat them. With a coordinated team approach to health care, the highest quality of care can be delivered and patients will have the best chance at prompt diagnoses and treatments.