Albert Provocateur: September 2009

Monday, September 07, 2009

Unkind Swine

The so-called plague is upon us. As some run for the hills, and others to their favorite apothecaries or foibles in white, we are besieged by incessant calls to action and a sense of urgency. We are told to vaccinate ourselves, our children, our loved ones, and our friends, lest we fall prey to a swine virus ever so unkind. As is usually the case when heart and emotions dictate to the mind, we jump on bandwagons, follow the Joneses, and are led by the blind, all the while ruminating in self-doubt and our abilities to make the right decisions. All we want to do is what is just and healthy. With little thought for our own well-being, all we aspire to, individually and collectively, is a safe environment for our children, first and foremost (if we want to be selfish, at the least), and for the rest of our nation and the world, when we are feeling especially magnanimous. No easy task when navigating through a morass of scientific information, pharmaceutical hustling over the airwaves, and a press more bent on sensationalism and selling copy than getting accurate information out to the public in a timely fashion. So, briefly, let’s debunk the hype, and with cooler heads take a look at this thing they call the swine flu, with a predominant eye turned more toward prevention with vaccination, than damage control after Pandora’s Box has been opened.

It is designated the 2009 H1N1 flu, and never before has the old adage that “an ounce of prevention is worth a pound of cure” been more apropos. After all, a fever of over 100 degrees, cough, body chills, congestion, diarrhea, and vomiting don’t make anyone’s day. In fact, they can be downright dangerous in pregnant women, people of any age with heart disease, asthma, diabetes, and other chronic maladies, children under 2 years of age, and people over 65. To make matters worse, fever is not always present, and that can lead to a dubious diagnosis between swine flu and the common cold. So, let the buyer beware! A short course of the new swine flu vaccine, whether that be one dose or two, depending on an as yet to be made pronouncement by the Centers for Disease Control (CDC) and experts in the field, along with the regular flu vaccine, may be just what the doctor ordered. While a maximum of three doses, with the two swine flu doses in one arm and the single regular flu dose in the other, may not be the pleasantest of experiences, it sure beats the hell out of the shortness of breath, chest pain and pressure, confusion or seizures, persistent vomiting or inability to hold down liquids, and bluish lips that mandate a high-speed cruise down to the emergency room. The problem is that while health authorities expect the swine flu to peak in October, affecting up to 50 percent of the U.S. population, most vaccine doses are not expected to arrive until November or December. So, what good is vigilance and proactivity, you ask? Not much, sometimes. All we can do is wait, hope, and keep our fingers crossed. Impotence in the face of possible imminent disaster is the stuff of horror movies and Halloween, and not what we’ve come to expect from a health care system that propones to be at the acme on the world scene.

Family physicians, internists, and pediatricians would much rather receive “preemptive” calls from their high-risk patients, than cries for help after the swine flu has already set in. Care should be taken by parents and teachers alike to watch the activity levels of children and, at the first sign of lethargy or listlessness in their charges, call in the cavalry. Anti-flu medications prescribed by the men and women in white, whether they be Tamiflu® or Relenza®, stand their best chance of working if they are administered within the first 48 hours of flu symptoms. A task made no easier by still another fork in the road, and, namely, the $100-price tag of the anti-flu drugs, which many uninsured Americans can ill-afford to pay. Those fathers, mothers, young children, and extended families are precisely the foci of prospective or actual infection that need to be targeted, too! Realizing this, the federal government has gotten off its duff, for once, and shipped millions of doses of the medications to the states, with Texas taking the lead to allocate a good portion of its ration to those most wanting economically. New York has also placed its best foot forward, offering free swine flu vaccinations to its over one million schoolchildren.

The stage is now set for the unkind swine flu to materialize, with its 1-3-day incubation period for symptoms to appear after exposure to the virus. Before high tech kicks in, Mom’s age-old remedies for the flu make good sense, and should stave off or at least ameliorate its onslaught. At first sign or symptom, stay at home and rest, limit your contact with people, drink plenty of fluids, practice good cough and sneeze hygiene, and wash your hands and the surfaces you come in contact with frequently. Only then can we envision a kinder, gentler swine flu.

Appendiceal Appeal

They say it’s no good to anybody. They say it serves no useful purpose. But it’s hard to believe it would exist in the first place were it not for the divine plan of a deity, evolution, or some heretofore unknown life force. Is it a mere vestige of something far greater in our ancestry, or is it the key to wonders cloaked in mystery behind still another locked genomic door? It might just be a simple fellow, and yet it is part of us all and, as such, merits a closer look. What are we talking about here? Why, that enigmatic body part known as the appendix. Darwin himself was fully aware of its existence, and, yet, the conventional wisdom of his time led him to believe that it was a mere vestigial organ, a useless sac embedded in the lower right quadrant of the body, between the small and large intestines. And he knew that it was not limited to Homo sapiens, but ran the gamut of numerous animal species, including flying squirrels, to boot. Now we know, through the advances of modern technology and medical science that the appendix dates back 80 million years, and we are learning that it may be a “magic bullet” of some sort, aiding the human body in its defense against disease by releasing a flotilla of good bacteria into our guts and white blood cells into our bloodstreams when our immune systems are most in need. Yes, the appendix may be appealing, after all.

We often hear that someone we know has had an appendix removed, due to the sudden fever and excruciating lower right abdominal pain of an appendicitis attack. In fact, 1 in 20 people has an appendix taken out, with no dire consequences. That alone has given the medical community license to declare that the slimy dead-end sac known as the appendix is of little or no need to us all. Wrong! Recently, it has been suggested that the appendix is a storehouse, a Big Wal-Mart, if you will, of good bacteria. When a subject’s colon is devastated by the ravages and diarrhea subsequent to a severe case of food poisoning or any number of acute and chronic gastrointestinal maladies, the “good-for-nothing little engine that could,” otherwise known as the vermiform appendix, comes to the rescue, releasing good bacteria or normal flora into our guts to repopulate the healthy bacterial lining that forms an integral part of our gastrointestinal systems and that is often the first to go after a nasty diarrheal attack. But the job of our newfound friend, the appendix, doesn’t end there. Recent studies indicate that it may, indeed, even make, direct, and train white blood cells, which, as you may or may not know, are key to our bodies’ defenses. So, perhaps we should reevaluate the little fella we were so anxious to write off, without giving the benefit of the doubt, a proper chance, or a respite for all the medical data to come in.

Now we must determine what actually causes appendicitis, or that potentially deadly inflammation of the appendix. In reality, the prevailing opinion of experts no longer inculpates a faulty appendix as its cause. You may, in fact, be surprised at whom the finger has been pointed. It now appears that cultural changes due to an industrialized society and improved sanitation are the culprits. The appendix, as a storehouse of what had been good and healthy for our guts and immune systems, was rendered useless and obsolete by the very advances that contributed to our clinical and public health betterment as a society, those being widespread use of sewer systems and clean drinking water. With infection of the gut on the decline due to the latter, there was really no further need of an arsenal of good bacteria and white blood cells to defend us. Why maintain a large standing army when there are no wars to fight? So, the appendix was wrongly relegated to the ranks of a mere vestige. Now, all that has changed. With what has recently come to light on the normal function of our “long-lost friend,” we must look at the question of what can be done to prevent appendicitis, to the chagrin and reduced bank ledgers of general surgeons. If we can find the means to instigate the appendix in much the same way as in the past, and consequently incite our immune systems, through release by the former of good bacteria and white blood scavenger cells, then allergies, autoimmune diseases, and even appendicitis may go the route of imminent extinction. Wishful thinking? Perhaps. But then, again, it certainly is appealing. Darwin would be pleased.

Don't Bug Me!

Make no bones about it, superbugs will inherit the earth, or at least our hospitals, for the time being. There is no escaping them. Go into the hospital for one thing, and come out with something entirely different, if not in a pine box. So, those hallowed halls of healing are slowly but surely becoming more known for what ails them, than for what ails us. Methicillin-resistant Staphylococcus aureus (MRSA), an antibiotic-resistant bacterium, has passed from the exception to the rule in the 1970s to a predominant “mover and shaker” on the Ten Most Wanted list of our nation’s hospitals. The organism lives harmlessly on the skin, but just grant it access to and safe passage through a portal into our bodies, and all hell breaks loose. Its close companion and fellow hit man, Clostridium difficile, an intestinal bacterium, is no less troublesome, and is a force to be reckoned with that even that age-old “bug slayer,” alcohol, cannot neutralize.

There you have it. It’s bad enough that the out-of-the-ordinary causes your hospitalization, without being further insulted by a totally unexpected bug brigade. Unexpected is a poor choice of words, however, as each year 90,000 Americans pick up hospital-acquired infections that kill them, and many more suffer the ravages of diarrhea and other unpleasantries so severe that even Montezuma’s heirs would most likely disown them. It has been estimated that in 2008, on an average day, 7,200 hospitalized patients or 13 of every 1,000 were colonized or infected with Clostridium difficile, and 300 did not survive it. Add those numbers to the toll of MRSA infections in patients with weakened immune systems, or those requiring catheters, intravenous lines, or ventilators, and we become witness to a mathematician’s worst nightmare, that being the formula for a lethal one-two punch.

And to think, in many cases we brought this on ourselves! While the young and very old are often the first and foremost to be “bugged” in the hospital setting, whoever dreamed that the very antibiotics conceived of and developed to thwart any number of serious infectious maladies might boomerang, strip our guts of friendly, protective organisms, and, as a consequence, fertilize the terrain for florid Clostridium difficile growth and proliferation thereafter. MRSA, on the other hand, being a normal inhabitant of the skin, has a tendency to congregate around cuts and scrapes, where it is held in check by a healthy immune system. Impairment of the latter is an open invitation to bloodstream incursion, with resulting sepsis a formidable foe to even the most heavily reinforced arsenal of antibiotics and antimicrobials. The death toll and morbidity rates generated by MRSA and Clostridium difficile come at a stiff price in greenbacks also, to the tune of an estimated $250 billion a year.

The story doesn’t end there, however. The profuse diarrhea incited by Clostridium difficile is the vehicle of a riot or a wildfire, if you’ll allow for literary license, facilitating spread of the bacterium onto hands, bed rails, sheets, IV poles, and uniforms. Person-to-person transmission, from patients or medical equipment to the hands of health care workers and then onwards to other unsuspecting souls, is the name of the game. In short, the bug is spread everywhere. MRSA, for its part, while far removed in its mechanism of action from a potential enrollment in a “defecatory duo” spearheaded by Clostridium difficile, is nonetheless anything but innocuous. In fact, about 250,000 Americans a year receive a nasty surprise when catheters inserted into their large veins to provide fluids or medications become the sources of bloodstream infection with MRSA. One in four of these unlucky souls meets his or her Maker, and just for having been in the wrong place at the wrong time.

So, what’s the solution? How do we stop superbugs in their tracks? What measures can be taken against an MRSA adversary resistant to penicillin and other antibiotics? Is diarrhea lasting longer than 24 hours and accompanied by weakness, a racing heart, or blood in the stool a sign of something as sinister as Clostridium difficile infection or just symbolic of a bad night on the town and a cheap Chinese restaurant? Frequent hand washing, limited use of antibiotics to only cases absolutely necessary, the wearing of sterile gloves and gowns by medical personnel, the use of antiseptics and sterile drapes and dressings to protect patients, and even a probiotic, helpful yeast called Saccharomyces boulardii (or commonly Florastor®) taken orally can go far to checking the advance, if not exterminating entirely, the superbugs. Government and state oversight, public scrutiny, and state laws requiring hospitals to report infection rates to the public can also be strong deterrents to harmful laissez-faire attitudes on the part of health facilities. Case in point, preventives measures, both voluntary and imposed, were instrumental in reducing the rate of MRSA bloodstream infections by about 50 percent from 1997 to 2007.

Superbugs may one day inherit the earth, but not on our watch, as long as actions speak louder than our collective “Don’t bug me!”

Albert Provocateur

Monday, September 07, 2009

Unkind Swine

Appendiceal Appeal

Don't Bug Me!

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