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 outbreak...you 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 above...you 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 contrast...to 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 underestimate...as 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 CRISIS DEANS SYMPOSIUM

PART 1: FIGHTING EBOLA AS A COMMUNITY

PART 2: LESSONS FROM PAST & PRESENT OUTBREAKS

PART 3: FINANCING GLOBAL RESPONSE TO EBOLA

PART 4: EXPERIMENTAL TREATMENT FOR EBOLA

PART 5: IMMEDIATE & LONG TERM EBOLA MODELING

PART 6: CHALLENGES FOR UNPREPARED HEALTH SYSTEMS

PART 7: PANEL

PART 7: PANEL DISCUSSION

 

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.

 

 

Don't Let Fear And Panic Win

When fear and panic take over, intelligent, thoughtful logic is needed.

Ebola is a scary entity. Many of the individuals who become infected have, to date, died. It is true. And there is as yet no vaccine. Effective cure is not yet fully developed.

People are clamoring to close the U.S. borders to people travelling from West Africa.

But Charles Kenny, a senior fellow at the Center for Global Development and the author of "The Upside of Down: Why the Rise of the Rest is Great for the West," has exactly the intelligent, logical thoughts for us.

He states:

"In an average year, more than 23,000 deaths in America are associated with influenza. But this toll isn't enough for us to shut the borders in an attempt to keep influenza at bay. The idea that we could completely seal off the U.S. from the rest of the world is laughable - at best we might delay a disease from arriving by a few days or weeks. When it comes to the flu, we're not even willing to take considerably more targeted and effective measures, such as banning kids from school if they haven't received the vaccine or providing shots for free at pharmacies."

Measured, intelligent thought always makes more sense than panic-stricken flailing. Supporting the countries where the incidences of infection are greatest makes the most sense. We must offer our support and assistance as they try to fend off this disease. And the average American citizen would do well to keep cool under pressure, knowing that Ebola is a remote risk to most of us and that much more common infections, such as influenza and measles, are far more important for us to remain vigilant against.

Be safe. Stay healthy.

Essential Ebola Information - Courtesy of APIC


Essential knowledge about Ebola

Disease background
Ebola hemorrhagic fever, or just Ebola for short, is a severe disease often leading to death in humans and non-human primates (such as monkeys, gorillas, and chimpanzees). Five different Ebola virus species have been identified, and four of these cause disease in humans. The first Ebola species was discovered in 1976 near the Ebola River in what is now the Democratic Republic of Congo. Since then, sporadic outbreaks have occurred in Africa. Researchers believe the virus is carried in bats, but the exact source is unknown.

Ebola has been in the news over the last few months as the largest outbreak in history has developed in Western Africa. Several American healthcare workers who have worked with patients in Africa have become sick and been brought back to the United States for treatment. On September 30, 2014 the first case of Ebola was diagnosed in the United States in a patient who had recently traveled from Africa.

Signs and symptoms
A person infected with Ebola is not contagious until symptoms appear. Symptoms usually begin eight to 10 days after a person has been exposed to an ill Ebola patient. However, symptoms may begin anywhere from two to 21 days after the exposure.

Typical signs and symptoms of Ebola infection are:

  • Fever (greater than 101.5oF)
  • Severe headache
  • Muscle pain
  • Vomiting
  • Diarrhea
  • Stomach pain
  • Unexplained bleeding or bruising

How is the virus spread?
The virus can enter the body through broken skin or unprotected mucous membranes of the eyes, nose, or mouth. When a person is sick with Ebola there are several ways the virus can be spread to others.

  • Direct contact with the blood or body fluids (feces, saliva, urine, vomit, and semen) of the sick person.
  • Contact with objects (needles and syringes) that have been used and contain blood or body fluids of the infected person.

Ebola is not spread through the air or by water or food in the U.S.

Treatment
Currently, there are no specific vaccines or medicines (such as antiviral drugs) that have been proven to work against the Ebola virus. Sick patients are treated by providing relief to their symptoms as they appear. Typical treatment can involve providing intravenous (IV) fluids and monitoring body electrolytes, maintaining oxygen status and blood pressure, and treating other infections as they happen.

Is there danger of Ebola spreading in the U.S.?
Please keep in mind the likelihood of contracting Ebola is considered extremely low unless there is direct exposure to the body fluids of an infected person. Ebola in not spread through casual contact; therefore, the risk of an outbreak in the U.S. is very low. The further spread of Ebola can be stopped through finding cases, isolating ill people, contacting people exposed to ill persons, and further isolating contacts if they develop symptoms. The U.S. public health and medical systems have had prior experience with sporadic cases of diseases such as Ebola. In the past decade, the United States had five imported cases of Viral Hemorrhagic Fever disease similar to Ebola. None resulted in transmission in the United States.

Advice for travelers
Centers for Disease Control and Prevention (CDC) has issued a travel notice for Ebola affected countries, which means travelers should avoid non-essential travel to Guinea, Liberia, and Sierra Leone. For current travel advisories please visit http://wwwnc.cdc.gov/travel/notices.

  • If you are returning from a country where the outbreak is occurring:
    • After you return, monitor your health for 21 days.
    • Seek medical care immediately if you develop the signs and symptoms of Ebola infection.
    • Tell your doctor about your recent travel and symptoms before you go to the office or emergency room. Advance notice will help your doctor care for you and protect other people who may be in the facility or office.
  • If you are traveling to an area where the outbreak in occurring:
    • Wash your hands frequently or use an alcohol-based sanitizer.
    • Avoid contact with blood and body fluids of any person, particularly someone who is sick.
    • Do not handle items that may have come in contact with an infected person’s blood or body fluids.
    • Do not touch the body of someone who has died from Ebola.
    • Do not touch bats and nonhuman primates or their blood and fluids and do not touch or eat raw meat prepared from these animals.
    • Avoid hospitals where Ebola patients are being treated. The U.S. Embassy or consulate is often able to provide advice on facilities.
    • Seek medical care immediately if you develop symptoms of Ebola virus.
      • Limit your contact with other people until and when you go to the doctor.
      • Do not travel anywhere else besides a healthcare facility.

 

Additional resources

CDC—Ebola

WHO—Ebola virus disease

APIC—Clean your hands often


Access a printer-friendly copy of this alert

 

 

 

Association for Professionals in Infection Control and Epidemiology, Inc.
1275 K Street, NW, Suite 1000 | Washington, DC 20005-4006
telephone: (202) 789-1890 | fax: (202) 789-1899 | Privacy Policy
email: info@apic.org

Ebola - Get Informed. Stay Cool

Evaluating Patients for Possible Ebola Virus Disease: Recommendations for Healthcare Personnel and Health Officials

This is an official

CDC HEALTH ADVISORY

Distributed via the CDC Health Alert Network
October 2, 2014, 20:00 ET (8:00 PM ET)
CDCHAN-00371

Summary

The first case of Ebola Virus Disease (Ebola) diagnosed in the United States was reported to CDC by Dallas County Health and Human Services on September 28, 2014, and laboratory-confirmed by CDC and the Texas Laboratory Response Network (LRN) laboratory on September 30. The patient departed Monrovia, Liberia, on September 19, and arrived in Dallas, Texas, on September 20. The patient was asymptomatic during travel and upon his arrival in the United States; he fell ill on September 24 and sought medical care at Texas Health Presbyterian Hospital of Dallas on September 26. He was treated and released. On September 28, he returned to the same hospital, and was admitted for treatment.

The purpose of this HAN Advisory is to remind healthcare personnel and health officials to:

(1) increase their vigilance in inquiring about a history of travel to West Africa in the 21 days before illness onset for any patient presenting with fever or other symptoms consistent with Ebola;

(2) isolate patients who report a travel history to an Ebola-affected country (currently Liberia, Sierra Leone, and Guinea) and who are exhibiting Ebola symptoms in a private room with a private bathroom and implement standard, contact, and droplet precautions (gowns, facemask, eye protection, and gloves); and

(3) immediately notify the local/state health department.

Please disseminate this information to infectious disease specialists, intensive care physicians, primary care physicians, and infection control specialists, as well as to emergency departments, urgent care centers, and microbiology laboratories.

Background

The first known case of Ebola with illness onset and laboratory confirmation in the United States occurred in Dallas, Texas, on September 2014, in a traveler from Liberia. The West African countries of Liberia, Sierra Leone, and Guinea are experiencing the largest Ebola epidemic in history. From March 24, 2014, through September 23, 2014, there have been 6,574 total cases (3,626 were laboratory-confirmed) and 3,091 total deaths reported in Africa. Ebola is a rare and deadly disease caused by infection with one of four viruses (Ebolavirus genus) that cause disease in humans. Ebola infection is associated with fever of greater than 38.6°C or 101.5°F, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage. Ebola is spread through direct contact (through broken skin or mucous membranes) with blood or body fluids (including but not limited to urine, saliva, feces, vomit, sweat, breast milk, and semen) of a person who is sick with Ebola or contact with objects (such as needles and syringes) that have been contaminated with these fluids. Ebola is not spread through the air or water. The main source for spread is human-to-human transmission. Avoiding contact with infected persons (as well as potentially infected corpses) and their blood and body fluids is of paramount importance. Persons are not contagious before they are symptomatic. The incubation period (the time from exposure until onset of symptoms) is typically 8-10 days, but can range from 2-21 days. Additional information is available at http://www.cdc.gov/vhf/ebola/index.html.

Recommendations

Early recognition is critical to controlling the spread of Ebola virus. Consequently, healthcare personnel should elicit the patient’s travel history and consider the possibility of Ebola in patients who present with fever, myalgia, severe headache, abdominal pain, vomiting, diarrhea, or unexplained bleeding or bruising. Should the patient report a history of recent travel to one of the affected West African countries (Liberia, Sierra Leone, and Guinea) and exhibit such symptoms, immediate action should be taken. The Ebola algorithm for the evaluation of a returned traveler and the checklist for evaluation of a patient being evaluated for Ebola are available at http://www.cdc.gov/vhf/ebola/pdf/ebola-algorithm.pdfand http://www.cdc.gov/vhf/ebola/pdf/checklist-patients-evaluated-us-evd.pdf.

Patients in whom a diagnosis of Ebola is being considered should be isolated in a single room (with a private bathroom), and healthcare personnel should follow standard, contact, and droplet precautions, including the use of appropriate personal protective equipment (PPE). Infection control personnel and the local health department should be immediately contacted for consultation.

The following guidance documents provide additional information about clinical presentation and clinical course of Ebola virus disease, infection control, and patient management:

• Guidelines for clinicians in U.S. healthcare settings are available at http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html.

• Guidelines for infection prevention control for hospitalized patients with known or suspected Ebola in U.S. hospitals are available at http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html.

• Guidelines for safe management of patients with Ebola in U.S. hospitals are at http://www.cdc.gov/vhf/ebola/hcp/patient-management-us-hospitals.html.

The case definitions for persons under investigation (PUI) for Ebola, probable cases, and confirmed cases as well as classification of exposure risk levels are at http://www.cdc.gov/vhf/ebola/hcp/case-definition.html.

Persons at highest risk of developing infection are:

• those who have had direct contact with the blood and body fluids of an individual diagnosed with Ebola – this includes any person who provided care for an Ebola patient, such as a healthcare provider or family member not adhering to recommended infection control precautions (i.e., not wearing recommended PPE

• those who have had close physical contact with an individual diagnosed with Ebola

• those who lived with or visited the Ebola-diagnosed patient while he or she was ill.

Persons who have been exposed, but who are asymptomatic, should be instructed to monitor their health for the development of fever or symptoms for 21 days after the last exposure. Guidelines for monitoring and movement of persons who have been exposed to Ebola are available at http://www.cdc.gov/vhf/ebola/hcp/monitoring-and-movement-of-persons-with-exposure.html.

Diagnostic tests are available for detection of Ebola at LRN laboratories as well as CDC. Consultation with CDC is required before shipping specimens to CDC. Information about diagnostic testing for Ebola can be found at http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collection-submission-patients-suspected-infection-ebola.html.

Healthcare personnel in the United States should immediately contact their state or local health department regarding any person being evaluated for Ebola if the medical evaluation suggests that diagnostic testing may be indicated. If there is a high index of suspicion, U.S. health departments should immediately report any probable cases or persons under investigation (PUI) (http://www.cdc.gov/vhf/ebola/hcp/case-definition.html) to CDC’s Emergency Operations Center at 770-488-7100.

Killing Cancer...By Genetic Targeting

Gene therapies to combat cancers are becoming a reality. It may take a few more years before such therapies are widespread but it is happening. To me, this is one of the most exciting developments to occur in healthcare in recent years. Stay tuned.

From the AMA Daily email: 

Study: Lung cancer medicine reduced tumor size in patients with gene defect.

"Bloomberg News (9/28, Ostrow) reports Pfizer Inc.’s Xalkori (crizotinib) for advanced lung cancer reduced tumors in patients suffering from a rare genetic mutation, citing a study “that may provide the first targeted treatment for these patients.” The medicine shrunk the size of tumors in 36 of 50 patients in the study “while halting tumor growth in another nine, according to company-funded research released today at the European Society for Medical Oncology meeting in Madrid and online in the New England Journal of Medicine.” The company notes that around 15,000 people, “or 1 percent of the estimated 1.5 million annual new cases of non-small-cell lung cancer, have an abnormality to the ROS1 gene.”

        MedPage Today (9/28) reports that “ROS1 rearrangement defines a second molecular subgroup of NSCLC for which crizotinib is highly active,” Shaw and colleagues noted in the article published in the New England Journal of Medicine.

        Reuters (9/28, Berkrot) also covers the news."

Cancer Sucks. But Don't Let Fear Rule.

When faced with an illness, a natural reaction can be an overwhelming fear of imminent death. For this reason, it is imperative that you clearly understand the ramifications of what you are up against. 

The tendency to over-treat is widespread. Doctors and patients alike, as a broad generalization, tend to feel that the best answer to a problem is to ferret it out with the most powerful weapons available.  

But that sort of aggressiveness comes with a price. Aggressive medical therapy carries the potential for side effects, a potential with any drug regimen. Aggressive surgery carries the obvious potential for physical deformity as well as immediate and subsequent complications. Even the smallest abdominal surgery can still predispose a person to subsequent bowel obstructions.

To be clear, I am absolutely not advocating that you forego appropriate, necessary treatments for an illness. I am merely pointing out the need for clear understanding of the risks and benefits of any regimen. 

Dont let fear overwhelm you. Get informed so you can maximize your chances of getting back to health. 

What prompts my post today? The following excerpt from the AMA Daily Email: 

Bilateral mastectomy may not increase survival chances for most women with breast cancer.

The AP (9/3, Tanner) reports that research published in the Journal of the American Medical Association suggests that “removing both breasts to treat cancer affecting only one side doesn’t boost survival chances for most women, compared with surgery that removes just the tumor.”

        Bloomberg News (9/3, Cortez) reports that “the surgery...carried a survival rate of 81 percent over 10 years in about 200,000 women studied.” According to Bloomberg News, “That compares with 83 percent for patients who underwent a lumpectomy...followed by radiation.”

        TIME (9/3, Sifferlin) reports that the investigators “found that double mastectomies for early-stage breast cancer increased significantly from 1998 to 2011.” The data also indicated that “double mastectomies increased the most among women who were under age 40 when they were diagnosed.”

        The San Francisco Chronicle (9/3, Colliver) reports that while “physicians and researchers aren’t exactly sure why more women are having double mastectomies...they say that anxiety about getting a second cancer, improvements in reconstruction surgeries and concern about breast symmetry may play a role.”

        The Pittsburgh Post-Gazette (9/3, Carpenter) points out that the majority of patients “choosing double mastectomies are white, have private insurance and receive treatment at a National Cancer Institute-designated cancer center, the researchers found.” The NPR (9/3, Shute) “Shots” blog and HealthDay (9/3, Doheny) also cover the story.

Remove IVC Filters When Not Needed

For years I have been pointing out to friends and colleagues that certain IVC filters can and should be removed because they migrate ever so slightly and could cause damage to surrounding structures. 

A news article states: "“Heidi is a poster child for this” problem, said Scott O. Trerotola, chief of interventional radiology at Penn, who treated her. “There is relatively little recognition [of it] among anyone except interventional radiologists.”" 

Some filters migrate ever so slightly with the normal pulsations that occur due to the pumping of the heart, breathing, movement, etc. These filters have thin legs that can begin protrude, as a result of the slow migration, and potentially cause problems. While these migrations are not rare, clinically apparent problems are, fortunately, still quite uncommon. Nevertheless, it is prudent to remove such a "foreign body," as we call a device that is otherwise not native to a human being.

If you or a loved one has an IVC filter, please make sure you discuss with your doctor whether it can or should be removed. And if your doctor is unfamiliar with a good interventional radiologist in town...find one and ask him! Or ask me.

Keep Scope of Practice Limited - Patients Depend On Us

There has been much discussion and some movement on the issue of expansion of the "scope of practice" of nurse practitioners. While nurse practitioners are important to the health care team, simply giving full independence on the level of trained physicians may not result in improved patient care.

Non-physician caretakers, such as nurse practitioners, are a crucial component of our healthcare system. They are hard-working, dedicated, patient-centered individuals who are more than likely the first person a patient encounters. Together, the nurse practitioner and physician care for patients. The nurse practitioner typically obtains the information and creates a coherent list of a patient's presenting complaint, history and physical exam findings. Nurse practitioners work collaboratively with physicians for their patients, communicating information and findings, arming the physicians with the necessary information to allow him/her to put together accurate diagnoses. Such collaboration saves time for everyone involved. The physician considers the gathered information and generates a clinical picture from the various pieces, thereby making a diagnosis. That is not to say that a few nurse practitioners may exceed the clinical expertise of a few physicians. But physicians have a long head start due to their years of training and education. The clinical acumen that physicians acquire cannot be underestimated, nor discounted. 

To better understand the levels of training of various caretakers, including physicians and nurse practitioners, click here for a graphic depiction, originally published by the Florida Medical Association. Importantly, the very different types of training and lengths of education make physicians and nurse practitioners well-suited to work collaboratively. The vast importance of the medical school years, coupled with years of residency and standardized, extremely rigorous and challenging medical board exams has to be acknowledged and understood in this context. 

But what is also important to note is that the physician is the person who is primarily responsible, from a legal standpoint, for the patient's care. Expansion of the scope of practice of nurse practitioners, allowing them to practice independently, must also carry the same liability as physicians currently carry.

The Florida House (@MyFLHouse) recently agreed to expand the scope of practice of nurse pratitioners but, fortunately, the Florida Senate (@FLSenateGOP) did not. This mixed result has many people thinking that it is only a matter of time before the scope of practice expansion bill passes, allowing nurse practitioners to practice independently, without physician oversight and guidance.

Fortunately, there is an alternative plan that deserves much consideration. The Florida Medical Association has published the Five Pillars of Expanded Access, which addresses the shortage of physicians and access to care issues. It calls for increased collaboration between physician assistants, nurse practitioners and physicians. And it aims to regulate and codify telemedicine, an important developing component of health care in the 21st century. It is worth understanding this plan as the preferred alternative to unnecessarily expanding the scope of practice of nurse practitioners.

If you understand this issue as I do, and you live in Florida, please call your Representative and let them know that the solution to the physician shortage is not independently practicing non-physician caretakers. The solution to access to care issues is the Five Pillars plan promoted by the FMA. Please call your state Senator and thank them for not passing the bill and also impress upon them the importance of maintaining a firm stance against the expansion of the scope of practice of nurse practitioners. Ask them to keep the valuable and long-standing cooperative structure in place, allowing nurse practitioners and physicians to continue to work together for the safety and health of all patients.

Patients depend on their caretakers to give them the best care possible. The highest level of expertise must remain clearly spelled out in the laws so that people everywhere can continue to have confidence in the medical profession. 

 

Chew Longer. Lose Weight!

One of the simplest things to remember is chew your food thoroughly. So many people wolf down their meals like there's no tomorrow. The simplest thing to remember is the longer you chew, the sooner your brain will indicate the "full feeling." 

From the AMA daily email:

Devices, apps help people eat more slowly by chewing longer.

On the front of its Personal Journal section, the Wall Street Journal (8/12, D1, Reddy, Subscription Publication) reports on new medical devices and applications designed to help people eat more slowly by chewing longer. Chewing food thoroughly appears to make people feel fuller sooner, and some studies indicate that people who chew their food the most may consume fewer calories. One group of researchers is using funding from the National Institutes of Health to design a study which will test the efficacy of a diet in which participants will be restricted to just 100 bites of food on a daily basis.

FDA Approves First Colon cancer Screening Lab Test

My hope is that a simple screening test soon replaces colonoscopy or CT colonography, eliminating the discomfort, preparation and small risk of perforation.

As reported by the AMA daily email: 

Bloomberg News (8/12, Edney) reports the FDA gave approval to Exact Sciences Corp. to sell “the first noninvasive DNA screening test for colorectal cancer that patients can use at home.” The article notes that the FDA “cleared Cologuard, which screens stool samples for the presence of red blood cells and DNA mutations that may indicate the presence of cancer.” The article notes that in a study, Cologuard “detected 92 percent of cancers and 42 percent of advanced precancerous growths, significantly more than an older test that looks only for blood in the stool.”

        The AP (8/12, Perrone) notes that the new test, however, “was not superior on all counts.” The AP notes that Cologuard “was less accurate than older blood tests at correctly ruling out cancer, reporting more growths when none were actually present.”

        The news was also covered by the Wall Street Journal (8/12, Walker, Subscription Publication), the St. Paul (MN) Pioneer Press (8/12), the Wisconsin State Journal (8/12), Medscape (8/12, Nelson) and HealthDay (8/12).

Caretakers are Products of Years of Training AND Experience

DON'T just take a drug because your doctor prescribes it.

Ask WHY?

We doctors are products of the knowledge we gain through training AND years of experience. Nurse practitioners and physician assistants have vastly different training pathways and typically much different experiences compared to licensed, board-certified physicians. This point cannot be under-emphasized (although it is certainly being under-appreciated of late).

Personally, I also subscribe to the tenet "If it ain't broken don't fix it." So many people nowadays are swayed by unfortunate social standards that prompt them to cut and change and alter otherwise intact parts of their bodies simply to achieve a more desirable aesthetic. As an interventional radiologist, I often see the complications of some of those adventures. 

Just something to consider.

As to the excerpt below, get informed so you know what the risks and benefits are.

As reported by the AMA: 

Pfizer faces mounting number of lawsuits over Lipitor side effects.

The Wall Street Journal (8/8) reports on the growing number of lawsuits filed against Pfizer by women who claim the company failed to warn the public about the side effects of type 2 diabetes or memory loss from the use of its cholesterol medication Lipitor (atorvastatin calcium). Over the past five months lawsuits by women in the US who allege Lipitor caused them to develop type-2 diabetes soared to almost 1,000 from 56.

Powdered Caffeine is Dangerous! Do Not Use!

Please educate everyone, especially teenagers who might not realize the dangers associated with this powerful drug! Powdered caffeine is causing deaths. Only 1 teaspoon is equivalent to 25 cups of coffee! 

As reported in my daily AMA email: 

Use of powdered caffeine may result in death.

"NBC Nightly News (8/3, story 7, 2:40, Holt) reported on the “troubling trend involving caffeine, including the growing use a pure powdered form” which is marketed as a dietary supplement to increase “alertness and athletic performance.” NBC News correspondent John Yang explained that just one teaspoon of the unregulated substance “is the equivalent of 25 cups of coffee.” Taking it can result in “irregular heartbeat, muscle spasms and kidney failure.”

        The NPR (8/1, Hobson) “Shots” blog reported that in the aftermath of an overdose last May, the “Food and Drug Administration issued a warning about powdered caffeine, saying it’s impossible to accurately measure it with your standard kitchen equipment.” An excess of caffeine powder “can speed the heart and cause seizures and death, the FDA says.”"

"The Pill Linked to Breast Cancer Risk"...OR NOT! Whatever Happened to Responsible Journalism?!

The recently published article, entitled "The Pill linked to breast cancer risk for younger women," is an example of the typical irresponsible journalism rampant in today's media publications. The title is inflammatory and unnecessarily raises fears where there is already enough fear. To make matters worse, the conclusion of the article is that birth control pills remain safe for thousands of women and no change in behavior is recommended on the basis of the study. So why write the article? The title is obviously a pathetic ploy to get more people to read it. Beyond that, I see no redeeming qualities.

Excerpts as follows:

"But birth control pills have evolved over the decades since their introduction and the hormone doses they contain have dropped steadily, so many studies are based on data for formulations that are no longer used, Beaber and her colleagues point out in the journal Cancer Research."

""Use of formulations with high dose estrogen, ethynodiol diacetate (synthetic progestin), and specific triphasic oral contraceptives in the past year was associated with an increased breast cancer risk in our study, while other formulations, including low dose estrogen oral contraceptives, did not appear to be associated with an elevated risk," Beaber told Reuters Health."

"“Weak associations, consistent with noise and not signal, were the overall finding,” Dr. David A. Grimes told Reuters Health by phone.

Grimes is a clinical professor in the department of Obstetrics and Gynecology at UNC School of Medicine in Wilmington, North Carolina."

The new results are not important for women or doctors, Grimes said. Other, better studies have found no increase in breast cancer risk with birth control, which is essential for women’s health, he said."

Physician-Patient Relationship Is Obsolete

Well, of course I'm not serious about the title! I'm merely pointing out the obvious lunacy associated with a recent court decision that Florida physicians are not permitted to imquire (merely ASK?!!!) about firearms or discuss firearm safety with their patients. 

How unbelievably intrusive must your physician be (sarcasm alert) to want to inquire into whether you have guns, like guns, want to shoot guns, and whether you might possibly keep them safely locked up when not in use!  

We physicians understand the importance of privacy. With HIPAA rules, and associated large fines, ever hanging over our heads, no physician wishes to knowingly violate the sanctity of the physician-patient relationship.

In that same vein, don't you think it is reasonable for a physician to want to discuss aspects of a person's life that may affect their health?  seems acceptable to me, but I'm sure I may hear equal and opposite reactions to such a query.

Here are some excerpts of the reports of the AMA reaction (from the daily AMA email): 

AMA critical of ruling upholding Florida law restricting physicians from discussing gun risks with patients.

Politico (7/30, Villacorta) reported in a brief piece in “Politico Pulse” that the AMA is not “pleased” with a recent “court ruling upholding a...Florida law that restricts” physicians from discussing the risks of firearms with patients. AMA President Robert Wah said, “This law poses real harm to patients as it interferes with physicians’ ability to deliver safe care, and hinders patients’ access to the most relevant information available.”

        MedPage Today (7/30, Wallan) reported, “The American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the” AMA “all issued statements condemning the legislation and the...ruling.”

        In the New York Times (7/30, Subscription Publication) “The Upshot” blog, Aaron E. Carroll, a professor of pediatrics at Indiana University School of Medicine, wrote that physicians “who ask about guns aren’t doing so because they’re nosy.” Carroll writes, “If the courts decide that people have the right never to be asked sensitive questions, they’re interfering with the relationship between” physician “and patient,” and “they’re deciding that some health risks are worth minimizing and others are not.”