June 24, 2011 | 2:35 pm

When the Stool Hits the Sprouts

Posted by Albert Fuchs, M.D.

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... or Technology Phobia Can Be Fatal

[This post is perfectly safe for work, but may not be safe for lunch, as it mentions poop more frequently than you may find appetizing.]

This post is an update about the E. coli food poisoning outbreak in Germany that I posted about two weeks ago (link 1 below). If you didn’t read that post, please do, as it explains some important terms like hemolytic uremic syndrome (HUS) and shiga toxin-producing E. coli (STEC). Using these phrases at your next party will make you very popular. Trust me.

This week, the New England Journal of Medicine published a review of the data collected thus far on the STEC epidemic in Germany (2). A typical case consists of an incubation period of 8 days after eating contaminated food until symptoms occur. The typical symptoms have been bloody diarrhea and abdominal pain without fever. About 25% of patients have developed HUS several days later. More cases of bloody diarrhea and HUS are still being reported, so the outbreak is not yet over, though the incidence is declining. The incidence peaked on about May 22. As of June 18 a total of 3,222 cases have been identified, including 810 cases of HUS and 39 fatalities. About two thirds of the patients have been women.

This bacterial strain and this outbreak are unusual in that the fraction of cases that proceed to HUS is much higher than previous outbreaks. Also 89% of the cases have been in adults. Prior outbreaks have more predominantly affected children. This STEC strain is also resistant to antibiotics in the penicillin and cephalosporin families.

The New England Journal of Medicine article stated that “raw produce or salad condiments are suspected” and that the investigation was still ongoing, but a Wall Street Journal article (3) and the CDC investigation (4) state that the source of the outbreak has been traced to raw bean sprouts from one organic farm in Germany. How the E. coli contaminated the sprouts is still unclear, but E. coli contamination typically happens through contact with human or animal feces.

This is tragic, but doubly so because it was likely preventable. It’s also an important indictment of our society’s two most popular technology phobias.

The first phobia is our fear of radiation. I’ve written previously about the potential benefits of irradiating our food. It would eliminate much of bacterial food contamination. Even the LA Times is writing about this issue (5).

The second phobia is our fear of synthetic pesticides and fertilizers, manifested in our current infatuation with organic food. The fact that the contaminated bean sprouts were grown in an organic farm is relevant. Sprouts are among the most likely produce to be contaminated because they grow close to the ground in warm humid environments, perfect for contact with waste and for bacterial growth. And organic food that avoids synthetic fertilizer has to use natural fertilizer – animal waste.

Organic food has no health benefits over food grown with modern methods. Indeed it has health risks. It also uses more space and more resources (hence is more expensive) than food grown through modern farming. While I don’t begrudge those who wish to pay more because they believe that organic food tastes better, it is a solution that simply can never feed most of the world.

So carefully wash all your raw fruits and vegetables, support proposals for food irradiation, and reconsider your commitment to organic food. Because it turns out that the alternative to modern technology is stool in your salad.

Learn more:

(1) My post two weeks ago: Germany Struck by Major Food Poisoning Outbreak

(2) New England Journal of Medicine article: Epidemic Profile of Shiga-Toxin–Producing Escherichia coli O104:H4 Outbreak in Germany — Preliminary Report

(3) Wall Street Journal article: EU Confirms Bean Sprouts as E. Coli Source

(4) CDC Investigation Update: Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany

(5) LA Times article: Should food irradiation return to the table?

LA Times article: German E. coli strain combines deadly properties of two pathogens

For a very informative description of the benefits of modern farming, as well as other technical revolutions that make modern life possible, I highly recommend “The Rational Optimist: How Prosperity Evolves” by Matt Ridley.

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

June 17, 2011 | 10:01 am

FDA Warns of Risk of Highest Zocor Dose

Posted by Albert Fuchs, M.D.

What’s the difference between a medication’s intended effect and its side effects? Is there some physiologic difference between the beneficial effects of a medicine and the annoying or even toxic things that it does? Not really. All medications have lots of different effects on the body. The intended effect is simply the one that the patient (or doctor) hopes to achieve. The rest of the effects are by definition side effects. The difference lies purely in the intention of the patient and physician, not in any chemical or biological differences between the processes that result in the intended effect and the side effects. Similarly, software developers acknowledge an ambiguity between the intended and unintended effects of their applications when they joke “That’s not a bug. That’s a feature.”

About twenty years ago a new medication was being investigated as a possible treatment for heart attacks. It dilated blood vessels. So the hope was that during a heart attack dilated blood vessels would deliver more blood to oxygen-starved heart muscle and save lives. Unfortunately, the same fraction of heart attack patients died when taking this new medicine as when taking placebo. And many of the patients taking this new medicine had a side effect that was somewhat embarrassing in the cardiac care unit; they had erections. The new medication, sildenafil, marketed as Viagra, is a very effective medication, but not as a treatment for heart attacks, as a treatment for erectile dysfunction. The initial embarrassing side effect was simply switched to the intended effect. That’s not a bug. That’s a feature.

My regular readers know that statins, a family of cholesterol-lowering medicines, have been proven to prevent strokes and heart attacks. They do this in a dose-dependent manner, meaning that higher doses prevent strokes and heart attacks more than lower doses. Then why don’t we all take a bucketful of a statin daily? Because of side effects. Statins have side effects that are also dose-dependent. They occur more commonly at high doses than at low doses. Muscle injury has long been known to be an occasional statin side effect. It can range from mild injury without symptoms that is noticed only on a blood test, to more severe injury in which muscle pain and weakness is noticed. Very rarely kidney failure and death can result from very severe muscle damage.

Last week the FDA reviewed the existing studies about statin-related muscle injury and concluded that

• muscle injury, though very rare, occurs more frequently on simvastatin (Zocor) than on the other statins,
• muscle injury occurs more frequently on the highest dose of simvastatin, 80 mg, than on lower doses, and
• muscle injury occurs more frequently in the first year of therapy than later.

It’s important to understand that serious muscle injury is very rare even at this highest dose, and this highest dose has greater benefits in terms of stroke and heart attack prevention than lower doses. So the FDA recommended that no new patients be started on 80 mg of simvastatin. Patients who have been taking that dose for over a year can continue it. If you’ve been taking simvastatin 80 mg for less than a year, a visit to your doctor for instructions is in order.

(By the way, with our electronic medical records we will identify all the relevant patients and reach out to them. With paper charts, doctors can only hope that the relevant patients hear the news and schedule appointments.)

Now if we can only figure out how to sell rare but serious muscle injury as a feature…

Learn more:

FDA Consumer Update: Limit Use of 80 mg Simvastatin

NY Times Prescriptions: F.D.A. Issues Safety Alert on Zocor

LA Times Booster Shots: FDA suggests new limits on cholesterol-lowering drug Zocor

Wall Street Journal article: FDA Urges Limits on Dosages of Zocor

New England Journal of Medicine perspective article: Weighing the Benefits of High-Dose Simvastatin against the Risk of Myopathy

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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June 10, 2011 | 2:03 pm

Germany Struck by Major Food Poisoning Outbreak

Posted by Albert Fuchs, M.D.

Since May Germany has been plagued with a particularly nasty outbreak of food poisoning. There have been almost 3,000 people who have become sick so far and 27 deaths, with a small number of cases in other countries.

The bacterium causing the outbreak has been identified, but the name of the bacterium is so convoluted that it needs explaining. The outbreak is caused by shiga toxin-producing Escherichia coli O104:H4 (or STEC O104:H4). Got that?

Please let me ‘splain. Escherichia coli (E. coli) is a very common bacterium. Most strains live harmlessly in human and animal colons (hence the name) and do not cause disease. Occasionally they cause bladder or kidney infections. The O104:H4 just identifies the specific strain of E. coli.

Shiga toxin is a particle produced by some strains of E. coli and other bacteria. It was named after Kiyoshi Shiga, the bacteriologist who first isolated the bacterium that causes dysentery – Shigella, which was also named after him. Shiga toxin is responsible for the particularly severe clinical features of STEC infection.

So now that we understand the name of the germ, what’s going on in Germany? Well, the source of the food contaminated with STEC is almost certainly some kind of fresh produce, but the specific food, farm or distributor has not yet been found. Cucumbers from Spain were initially blamed, and then sprouts from Northern Germany, but both of these turned out to be false alarms. Investigators are still working to track down the source.

What are the symptoms of STEC infection? That’s where our story’s antagonist, shiga toxin, comes in. Shiga toxin causes severe abdominal cramping, vomiting and acute (frequently bloody) diarrhea. That’s bad enough, but a week later, a minority of patients develop hemolytic uremic syndrome (HUS). HUS involves injury to the kidneys and destruction of the body’s blood cells. Symptoms include severe fatigue, decreased urine output, and pallor. In this outbreak over 600 people have required intensive care unit admission, likely because of HUS.

The only cases in the US have been just a handful of people who have recently travelled to Germany. No contaminated food has been imported from Europe to the US. If you’re planning a trip to Germany, review the Centers for Disease Control recommendations at the link below.

The loss of life and the thousands of people sickened is obviously tragic. The financial impact of the lost tourism and the losses to farmers and restaurants come at a particularly bad time given Europe’s financial crisis. What compounds the tragedy is that food-borne infections could be prevented if food was irradiated before it got to supermarkets or restaurants. I’ve written about food irradiation before (link below). To achieve improved safety, we wouldn’t even have to irradiate all food. If labeling was clear, consumers would have a choice. Those wishing to avoid STEC, Salmonella and Shigella would choose irradiated produce, and those with prejudices about gamma rays could still avoid irradiated produce and take their chances. Unfortunately, radiation is not an area in which we have devoted much effort in educating the public. In the wake of Japan’s Fukushima nuclear reactor disaster, Germany has recently decided to abandon nuclear power, even though Germany obtains a quarter of its electricity from nuclear power and has never had a serious reactor accident.

So this is probably not a good time to remind them about the potential benefits of food irradiation. But I hope that after this outbreak is over some influential Germans will realize that more Germans have just died from shiga toxin than have ever died from radiation.

Learn more:

New York Times article (June 6): Deadly E. Coli Outbreak Linked to German Sprouts

Wall Street Journal article (June 7): E. coli’s Trigger Remains a Mystery

Wall Street Journal article (June 8): EU Seeks to Combat E. coli’s Hit to Farms

CDC Travel Notice: Shiga toxin-producing E. coli O104:H4 infections in Germany

CDC Investigation Update: Outbreak of Shiga toxin-producing E. coli O104 (STEC O104:H4) Infections Associated with Travel to Germany

My previous posts about food-borne illness:

Your Food Is Pretty Safe, But it’s Not Getting Safer

Would You Like Some Salmonella With That?

Gamma Rays are Good for Your Veggies

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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June 3, 2011 | 9:57 am

Cellphone Users Have a Higher Risk of Getting Annoyed at the World Health Organization

Posted by Albert Fuchs, M.D.

This week all the buzz is about cellphones and brain tumors. Who would possibly link cellphones and brain tumors? The World Health Organization, that’s WHO.

This week, an agency in WHO announced that it was declaring cellphone use to be “possibly carcinogenic”, adding it to a group of substances which include lead, engine exhaust, chloroform, coffee and pickled vegetables.

First, let’s make sure we understand what this does not mean. This does not mean that cellphone use is known to cause cancer. The WHO classifies tobacco and ultraviolet light as known carcinogens, which is not the group in which it classified cellphone use. It also doesn’t mean that cellphone use is a probable carcinogen, like some industrial chemicals and exhaust from wood combustion. Probable carcinogens have another group in the WHO classification.

This means that cellphone use might cause cancer, or not. The WHO clearly announced that adverse health effects of cellphone use have not yet been established.

So what’s the hubbub? Well, so many people use cellphones that even if a cancer link is possible, the WHO wants to keep an eye on it. Naturally, media outlets were all over this story with various levels of alarm and skepticism (links below). There are two specific concerns that some studies have suggested: gliomas and acoustic neuromas. Gliomas are malignant brain tumors. Acoustic neuromas are benign tumors of the nerve that connects the ear to the brain.

But the studies have not been consistent. Dr. David Savitz, professor of epidemiology at Brown, says that most studies looking at cellphone use and cancer failed to show a link. (The quotes are in the articles linked below.) He also cites data from Scandinavian countries which were early in cellphone adoption and yet have not seen any increased incidence in brain tumors.

So there may be no increased risk at all, and this is all very vague and preliminary. But my regular readers know I like to dive into the numbers. If we believe the scariest of the studies, how risky would cellphone use be? Well, one study suggested that the risk of glioma doubles with every decade of cell phone use. Good grief! That sounds terrible. But before resigning yourself to sending messages by carrier pigeon from now on, let’s figure out the magnitude of that risk. There are 10,000 to 12,000 new cases of glioma per year in the US. Taking the upper figure, in the US population of 300 million that yields a risk of 1 in 25,000 of developing a glioma every year. That means that the risk over a decade is 1 in 2,500. If cellphone use over that decade doubles the risk, that means that for every 2,500 people using a cellphone for ten years one additional glioma results and the other 2,499 people go on blabbering on their cellphone.

Numerically, that’s a pretty small risk. That’s much smaller, for example, than the risk that untreated high blood pressure will lead to stroke. And that’s if there’s any risk at all which has not yet been proven.

So does it make sense to use Bluetooth or wired headphones during a call to keep our cellphones a few inches from our heads? I don’t know. There’s certainly no harm in that precaution, but there may also be no benefit. Compared to cellphones distracting drivers and causing traffic collisions, and people’s phones ringing in lectures and at movies, the possible cancer connection strikes me as tentative and minor.

But perhaps the WHO actually helped by giving us another excuse to end an unwanted conversation. “I gotta go. You’re giving me a brain tumor.”

Learn more:

LA Times article (including KTLA news video clip): Study links cellphones to possible cancer risk

CNN article (including video clip): WHO: Cell phone use can increase possible cancer risk

Wall Street Journal article: Cellphone Cancer Warning

CNN Health article: Coffee, pickled veggies also ‘possibly’ cause cancer

Tangential Miscellany

Yet again the nice folks at US Airways Magazine reprinted one of my posts – This Isn’t Your Father’s Heart Disease. If you missed it when I first wrote it, give it a read. And if you fly US Airways in June, please grab a copy.

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.

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