October 12, 2012 | 9:48 am

Fourteen Deaths Linked to Fungal Meningitis from Tainted Injections

Posted by Albert Fuchs, M.D.

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Exserohilum rostratum. Photo by Wikipedia

This week you’ll have to learn a little medical jargon, and I know that you love that. The meninges (men-IN-jees) are the membranes that line the brain and spinal cord. Meningitis is inflammation of those membranes, usually caused by an infection. Meningitis can lead to brain damage, deafness, and sometimes death. Meningitis is usually caused by viruses or bacteria. OK? That wasn’t so bad.

Recently an outbreak of meningitis has come under the attention of investigators. 170 patients in the last few months have been diagnosed with meningitis due to a fungus. This is strange because fungi are a very rare cause of meningitis. Investigators tracked the infection to contaminated vials of a steroid medication (methylprednisolone) prepared by New England Compounding Center (NECC), a Massachusetts compounding pharmacy.

The medication is used to administer epidural injections – injections into the spine intended to relieve back pain. This presumably introduced the contaminating fungus directly into the spinal fluid and resulted in meningitis.

Three lots of potentially contaminated medication have been recalled by NECC. Health officials have determined that about 14,000 people may have been injected with the medication since May 21. About 12,000 of the patients have already been contacted and informed. As of yesterday 14 have died of fungal meningitis. Two different fungus species have been isolated from sick patients, Exserohilum (pictured above) and Aspergillus.

Some of the medication was also used to inject painful joints, and one fungal ankle infection was found in a patient who earlier received an injection into that ankle.

There are four facilities in California which received medication from NECC that was later recalled: Cypress Surgery Center in Visalia, Encino Outpatient Surgicenter in Encino, Ukiah Valley Medical Center in Ukiah, and Universal Pain Management in Palmdale. (The complete list of facilities across the nation is here.)

Fungal meningitis and fungal joint infections are not transmissible from person to person. So if you have not received a steroid injection into your spine (epidural) or joint from a recalled medication lot since May 21 you have nothing to worry about.

If you have received such an injection, be aware that meningitis or joint infections can occur 1 to 4 weeks after the injection, or perhaps even later. These 14,000 exposed patients are being asked to be vigilant for symptoms, and to report symptoms immediately to their physician. Symptoms of fungal meningitis are fever, new or worsening headache, neck stiffness, sensitivity to light, new weakness or numbness, slurred speech, and increasing pain, redness or swelling at the injection site. Symptoms of an infected joint are fever, increased pain, redness, warmth, or swelling in the joint or at the injection site.

How the medication became contaminated is still being investigated.

Learn more:

Fungal meningitis outbreak: Death toll hits 14; Idaho reports case (Los Angeles Times)
CDC: Meningitis outbreak growing, 14 people dead (Associated Press)
Meningitis Deaths Increase (Wall Street Journal)
Frequently Asked Questions For Patients: Multistate Meningitis Outbreak Investigation (CDC)

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.

September 21, 2012 | 10:11 am

On Medicine and Absolution

Posted by Albert Fuchs, M.D.

… or Reflections on Yom Kippur

“My heart is blighted like grass, and withered, for I forget to eat my bread.”
– A patient’s prayer, Psalm 102

[None of the anecdotes in this post are descriptions of any specific patient. They are amalgams of many patients. Specific details have been distorted or invented to preserve anonymity.]

I diagnose and treat medical problems. I love doing it. Sometimes I make a big difference in someone’s life. More often, I just reassure them that they’re going to be OK. Or I give them advice about what they need to do to live healthier. But what I do has limits, and people frequently bring me problems that are well beyond my ken.

A business man comes to me for chest pain. He feels guilty because he has been misleading his business partner in a negotiation.

A wife has vague urinary symptoms after her affair of several years ends.

A middle aged man comes to me for insomnia. His endless work responsibilities have caused him to miss important events with his kids.

Of course, they each believe they may have a medical problem, so I examine them and order the appropriate tests. I rule out coronary disease, and infections, and hormonal problems. I call them with the good news. The tests are all normal. But they are not relieved. Their symptoms persist or even worsen.

I think I must be missing something. I send the business man to a cardiologist, the wife to a urologist, the father to a sleep specialist. More diagnostic tests are ordered. They are all normal. Good news, right? No. They are not reassured. Their symptoms continue and with every unrevealing test result they seem to give their symptoms more attention.

All primary care doctors see lots of these cases. These patients are seeking care in the wrong marketplace. They don’t have a medical problem. Their conscience is bothering them. They’re not sick; they’re guilty. They do not require medicine. They seek absolution.

But I have no prescription for that, no advice for attaining forgiveness, for undoing wrong deeds. Perhaps I should send them to a psychologist. I ask some questions looking for symptoms of depression or anxiety disorder. I come up empty. They’re mentally healthy, yet they are miserable.

What’s the medical specialty that helps people who’ve done wrong? What’s the service industry that undoes guilt? I’m no expert, but as far as I can tell, the only methodical approaches to this are in organized religions. My colleagues and friends who are psychologists and psychiatrists may object. But it seems to me that mental health professionals can only clarify the patient’s goals and feelings, clarify if the ethical damage can be undone, and work through the feelings. That’s a lot, but it doesn’t strike me as what these patients are craving. They want to atone. Organized religions have a formula for that.

I’m not here to tell you to go to church. And I’m certainly not going to delve into theology or suggest that any religion’s recipe for forgiveness is true in a fundamental or exclusive sense. I’m just suggesting that if you know you’ve done something wrong, and you feel terribly about it, maybe you don’t need a doctor. Maybe you need a minister, a priest, or a rabbi.

Like I said, I love what I do. I can fix some medical problems, and I can help prevent others. I can help you live more days and make those days healthier. But there is more to life than that. Sometimes there is also wrongdoing, and guilt, and redemption. For that, I have no training. Forgive me.

Learn more:

Forgiveness (Wikipedia)

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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September 14, 2012 | 11:59 am

Ninth hantavirus case linked to Yosemite

Posted by Albert Fuchs, M.D.

Yosemite National Park
Photo credit: CDC

In 1993 in the Four Corners region of the US Southwest a woman developed a cough and progressive shortness of breath and died shortly thereafter. A few days later, her fiancée, a young physically fit man developed similar symptoms was rushed to a hospital and also died. A series of laboratory tests failed to identify any known infectious agent. The Centers for Disease Control and Prevention (CDC) Special Pathogens Branch was notified. Further testing revealed a previously unknown strain of hantavirus. The new strain would eventually be named Sin Nombre hantavirus (perhaps the most paradoxical name I’ve ever encountered).

In Asia and Europe hantavirus infections in people cause a very different illness marked by hemorrhagic fever and kidney failure. This new illness in the US marked by progressive respiratory failure was named Hantavirus Pulmonary Syndrome (HPS). HPS has early symptoms that are very similar to the flu: fever, fatigue, and muscle aches in the thighs and back. About half the patients also experience headaches, chills, nausea, vomiting, and diarrhea. Four to 10 days after the initial symptoms a cough and progressive shortness of breath develop. The lungs fill with fluid. About one third of patients with HPS die.

Since 1993 there have been very few (587) cases of HPS nationwide. The hantavirus strains in the US, like elsewhere, are carried by rodents. Sin Nombre hantavirus is carried mostly by the deer mouse in the western and central US and Canada. People are infected with hantavirus through contact with infected rodents, or their urine and droppings. Hantavirus in the US cannot be transmitted from person to person.

This summer hantavirus claimed the spotlight because of a number of cases linked to Yosemite National Park. Nine visitors to Yosemite have become sick from hantavirus, the most recent this week. Most of them camped in tent cabins in Curry Village in early July. These cabins have since been closed. Three of the nine have died.

The park, along with state and national health agencies, have attempted to contact all campers who have visited Yosemite this summer to advise them to seek care promptly if they develop flu-like symptoms. There is no specific treatment for hantavirus, but prompt admission to intensive care can help support patients on ventilators until the illness resolves. The patients who have survived seem to have recovered completely.

For those of us who haven’t been to Yosemite recently, the CDC advises that the best way to avoid hantavirus is to keep your home and nearby structures (garages, sheds) free of rodents. The links below have some common-sense suggestions.

Our family’s rodent control strategy involves an attractive feline named Pancho. Perhaps we should make her available to the National Park Service.

Finally, with Rosh Hashannah a few days away, I wish my readers a year of prosperity and joy, and no exposures to dangerous untreatable viruses.

Learn more:

Hantavirus in Yosemite: Ninth case reported in another visitor (LA Times)
August 2012 – Yosemite National Park Outbreak Notice (CDC)
Hantavirus (CDC information page)
Tracking a Mystery Disease: The Detailed Story of Hantavirus Pulmonary Syndrome (CDC)

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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September 7, 2012 | 10:46 am

Still no evidence that organic food is healthier

Posted by Albert Fuchs, M.D.

Make mine with pesticides. Photo credit: Wikimedia Commons

“It’s not what you don’t know that hurts you, it’s what you know that isn't so.” -- attributed variously to Mark Twain and to Will Rogers

Many popular ideas are popular not because they're right but because of a widespread failure of skepticism. For example, in the 1970s the idea that wide lapels really make you look great was widely adopted without rigorous testing.

Organic food has grown to a $26 billion industry in the last couple of decades largely on public good will. This industry was perfectly poised at the intersection of several of our irrational biases – our fear of “chemicals”, our assumption that natural is better than artificial, and our suspicion of technology that alters living things. Surely our food must be healthier without all those industrial “chemicals”, we told ourselves as we spent sometimes twice as much for organic produce.

My regular readers know that I’ve written previously (links below) that there is no proof whatsoever that organic food is healthier than conventional food. In the current issue of the Annals of Internal Medicine, the question is finally given some rigorous examination.

Since the adjective “organic” is sometimes bandied about carelessly, we should have a general consensus about what it means. Organic plants are grown without synthetic pesticides or fertilizers and are not genetically modified. Organic livestock is raised without growth hormones or routine (i.e. preventive) antibiotics. Organic livestock is fed organically produced feed and is provided access to the outdoors and freedom of movement. Organic food is also generally manufactured without additives or irradiation.

The authors of the paper retrieved every peer-reviewed study that compared either organically and conventionally grown food or the people eating these foods. 240 of these studies were found and their findings were reviewed. The results were strikingly blah, prompting a flurry of media coverage (links below).

The studies found no difference in health outcomes between people eating organic and conventional food. Two studies found higher pesticide levels in the urine of children eating conventional food compared to organic food, but these levels were well below those that cause health problems. There were also no consistent meaningful differences in nutrient levels between the two groups.

I have long been suspicious that organic produce has higher risks for bacterial contamination since the alternative to synthetic fertilizer is fertilizer from animal waste. This also turns out to be unfounded. Bacterial contamination of food was similar in both groups.

There was one small but tantalizing difference. Bacterial contamination of meat was similar in frequency in both farming methods, but bacterial contamination with bacteria resistant to three or more antibiotics was significantly more common in traditionally grown chicken and pork than organically grown animals. That doesn’t prove that the humans who eat that meat are more likely to get sick or that their illnesses would be harder to treat, but it suggests that routine use of antibiotics in livestock has risks which require further study.

There may be lots of other good reasons to buy and eat organic food. Some people think organic food tastes better, and of course that is best left to each one’s palate. Others assert that organic farming practices are better for the environment. But organic farming consumes more resources and uses much more land per food produced, so if most of us ate organic food much more of the environment would be taken up for farming than is currently. There are also ethical reasons to refrain from supporting farming practices that treat animals cruelly. I’m not suggesting that we should not eat organic food, only that we should not do it with the expectation that it is healthier.

So for now, I’ll take my apple with pesticides. Oh, and those lapels are still groovy, no matter what other people say.

Learn more:

Are Organic Foods Safer or Healthier Than Conventional Alternatives?: A Systematic Review (Annals of Internal Medicine)
Why Organic Food May Not Be Healthier For You (NPR Morning Edition)
Study Questions How Much Better Organic Food Is (Associated Press)
Organic food no more nutritious than non-organic, study finds (NBC News)
My previous posts about organic food:

When the Stool Hits the Sprouts
Would You Like Some Salmonella With That?

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.

Tangential Miscellany

Dr. Kevin Pho, the very well known physician blogger and outspoken advocate of social media in medicine, published my post about the coming flood of newly-insured patients. If you didn’t read it when I posted it three weeks ago, you might want to take a look. Check out the comments, too. Many of them are, shall we say, vigorously opposed to my point of view.

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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August 24, 2012 | 5:43 pm

Get Your Flu Shot

Posted by Albert Fuchs, M.D.

Photo credit:
Wikimedia Commons

Temperatures are dropping. Children are returning to school. (Parents are elated.) Families are planning a last summer outing on Labor Day. It must be time for flu shots.

This season’s influenza vaccine has shipped from manufacturers. Our office just received them. So it’s a good time to remind ourselves that the flu can be fairly nasty and that the most reliable way to protect yourself is the influenza vaccine.

The flu shot is recommended for everyone over six months of age. It’s especially important for the groups below.

• People who are at high risk of developing serious complications like pneumonia if they get sick with the flu. This includes:
• People who have certain medical conditions including asthma, diabetes, and chronic lung disease.
• Pregnant women.
• People 65 years and older
• People who live with or care for others who are high risk of developing serious complications. This includes:
• household contacts and caregivers of people with certain medical conditions including asthma, diabetes, and chronic lung disease.

The following groups should not receive the vaccine.

• People who have a severe allergy to chicken eggs.
• People who have had a severe reaction to an influenza vaccination.
• Children younger than 6 months of age (influenza vaccine is not approved for this age group), and
• People who have a moderate-to-severe illness with a fever (they should wait until they recover to get vaccinated.)
• People with a history of Guillain–Barré Syndrome

Follow the links below to learn more about the flu. And get the shot now, before the flu season starts.

Learn more:

Seasonal Influenza (Centers for Disease Control and Prevention page)
Key Facts About Seasonal Flu Vaccine (Centers for Disease Control and Prevention page)
Google Flu Trends

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.

0 Comments — Leave your comment

August 17, 2012 | 12:27 pm

The Anatomy of a Shortage

Posted by Albert Fuchs, M.D.

Image credit: Angry Doc
angrydr.blogspot.com

“If you think health care is expensive now, wait until you see what it costs when it’s free.”
– P.J. O’Rourke

I distinctly remember that in first grade I had an idea of breathtaking wisdom and profundity. Candy should be free. You may have had a similar thought at the same age. This idea was supported by an incontrovertible rationale, namely that I really liked candy. Tragically, it only took a moment for my parents to expose a flaw in my otherwise revolutionary scheme. They suggested that if candy were free, no one would bother making candy. All candy makers would do something else that allowed them to make a living. Thus exposed to the painful realities of life, I put the thought out of my head for about forty years.

But now I realize that modern bureaucracy makes my vision more possible than ever. Candy makers obviously won’t work for nothing, but they could be paid to give away candy by a national program (Candycare or maybe the Affordable Candy Act). Employees through their work could contract with third party payers (like Blue Candy) to pay for their candy needs. Thus candy would still be free to the consumer and no first grader would ever have to be denied his gummy bears.

Complications may still arise in this ingenious scheme. Prices, after all, play a critical role in marketplaces. They reflect the resources consumed and risks taken in producing a product. They force consumers to make important decisions about what they need and what they can do without. And they encourage conservation. The only reason we don’t all buy the most expensive product in any class of products (cars, houses, shoes, whatever) is because we’d rather do something else with the money we save. Prices also give producers a powerful incentive to improve quantity and keep prices low, that is they cause competition between producers.

In the absence of prices, all these details become corrupted in our otherwise idyllic candy utopia. Customers would demand more candy than they ever ate before. They may simply eat more candy, but much would just go to waste. If it’s free, no one will stop to think about whether they really want another Snickers bar. Attention to quality would also decline for two reasons. Consumers would not be able to pay more for better candy, so they would have to be satisfied with whatever they got. And candy makers would no longer have to compete since they would suddenly have all the business they could handle.

There would be a dramatic imbalance between supply and the very high demand. Economists call this imbalance a shortage. Long lines would form at candy stores and supplies would not last until the end of the day. Lots of people who previously were content paying for their candy would now not be able to get any. And though the costs to the consumer would be zero, the cost to society would keep escalating as candy makers would consume ever more resources trying to meet a bottomless demand. In a few years candy would become both mediocre and, for society, disastrously expensive.

Sounds familiar?

Healthcare in general, and especially primary care, is operating in exactly such a system. I’ve been writing for years (see links below) about the shortage of primary care doctors that will happen as the baby boom ages. But with the implementation of the Affordable Care Act (ACA) looming in 2014 the shortage promises to worsen dramatically and is receiving some media attention.

An opinion piece in the Wall Street Journal warns that 30 million people will acquire health plans starting in 2014. The article predicts “the result will be gridlock.” Waits for care will lengthen, and many practices will close to new patients. The author predicts that concierge medicine will grow rapidly as patients flock to doctors who promise them attention and access. I urge you to read the very sobering article.

A recent Medical Economics article asks how an influx of 30 million patients will impact primary care. New physicians certainly will not be trained in time. The article suggests various bureaucratic solutions and states “nurse practitioners know they are about to be elevated in the national healthcare dialogue.” This is jargon for “patients should not expect to see a doctor.” The article warns that in Massachusetts, a leader in experimenting with universal health insurance, only half of primary care practices are accepting new patients.

Finally, The Doctor’s Company, a medical malpractice insurance company recently released a survey of 5,000 physicians to measure doctors’ opinions and thoughts about the coming ACA implementation. 60% of respondents thought that the increased patient volume will hurt the level of care they can provide. 43% said they are thinking about retiring in the next five years. And nine out of ten said they would discourage friends and family members from pursuing a career in medicine.

Sooner or later we will be forced to rediscover the credo that there’s no such thing as a free lunch. Shifting costs from one person to another doesn’t lower costs. A central plan to make something affordable always makes it unaffordable.

Until then, patients should find a primary care doctor who they really like. They should do so right now. And they should ask frankly how he or she plans to handle the coming wave of newly-insured patients. And now that I’m thinking of it, they should buy him some candy.

Learn more:

John C. Goodman: Why the Doctor Can’t See You (Wall Street Journal Opinion)
Affordable Care Act brings influx of patients (Medical Economics)
Nine Out of 10 Physicians Unwilling to Recommend Health Care As a Profession, Exacerbating Anticipated Physician Shortage (The Doctors Company press release)

My previous posts on the primary care shortage and the economics of healthcare:
Rescuing Primary Care
More Match Day Misery
Rational Rationing
Torpedoing Primary Care
The Healthcare Meltdown
On Being Doc and Being Happy
Will Primary Care Survive?

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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August 10, 2012 | 12:51 pm

Preventing Falls in Older Patients

Posted by Albert Fuchs, M.D.

Image credit:
MaineHealth.org

Falls are the most common cause of injury in adults 65 years or older. About one third of adults in that age group fall at least once per year, and 5% to 10% of those falls result in a broken bone, a laceration, or a head injury. Injuries sustained due to falls can cause a permanent decrease in mobility and independence.

The harm that results from falls is much harder to treat than to prevent. One way to prevent the harms due to falls is to test for and to treat osteoporosis. Another way is to try to prevent older people from falling in the first place.

In the current issue of Annals of Internal Medicine, the US Preventive Services Task Force reviewed the existing evidence about various methods of fall prevention and recommended that all adults aged 65 or older who are at increased risk for falls receive vitamin D supplementation and exercise or physical therapy.

Who is at increased risk of falling? Very simple assessments that are easily done by primary care doctors can identify these patients. Patients with a history of falls, a history of mobility problems, or poor performance on a simple walking test are likely to fall in the future.

The fact that vitamin D supplementation prevents falls in older patients is not new. (I wrote about it two years ago.) The mechanism by which it does this is unclear. Perhaps it helps muscle strength or balance. But it’s a simple and harmless intervention. Exercise and physical therapy are also well-established methods to improve balance and mobility and help patients stay on their feet. And of course exercise has lots of other benefits.

A home assessment for fall risks by a geriatric case manager can also be helpful, though the USPSTF did not find enough evidence to recommend this for all older adults. Making sure that loose rugs are either secured or taken away, that stairs are well lit and have rails, and that grab bars are available in bathrooms can help someone with imperfect vision or imperfect gait stay stable.

So if you have a loved one who is stumbling occasionally, make sure her doctor knows. Some vitamin D and some physical therapy may make a big difference.

Learn more:

Scientists Weigh In on Fall Prevention (NY Times)
Prevention of Falls in Community-Dwelling Older Adults: U.S. Preventive Services Task Force Recommendation Statement (Annals of Internal Medicine)
The Most Recent Celebrity Vitamin: D (My post in 2010 summarizing the current evidence about vitamin D supplements)
Tai Chi Improves Balance in Patients with Parkinson’s (My post in February about Tai Chi for fall prevention)
The timed Get-Up-and-Go test (The Society of Hospital Medicine)

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.

0 Comments — Leave your comment

August 3, 2012 | 10:38 am

West Nile Virus Cases at Eight Year High

Posted by Albert Fuchs, M.D.

Photo credit:
Wikimedia commons

It’s summertime! Summer is the perfect time for swimsuits, outdoor grilling, throwing Frisbees, and contracting dangerous untreatable viral infections.

West Nile is a virus that is transmitted by mosquito bites. Four out of five people infected with West Nile Virus have no symptoms and never feel sick. About one in five infected people develop fever, headache, body aches, vomiting, or a rash. Less than one in a hundred will develop serious neurologic complications such as inflammation of the brain or inflammation of the tissues that surround the brain. Some of those people will have permanent neurological deficits, and some will die.

The Centers for Disease Control and Prevention (CDC) issued a press release this week warning that more West Nile Virus cases were reported in the US this year than at any time since 2004. 241 cases have been reported this year, including four deaths. Most of the cases have been in Texas, Mississippi, and Oklahoma, but a handful have been in California.

There is no specific treatment for West Nile Virus infection, and no vaccine. So the only way to battle this illness is prevention.

The CDC information page on West Nile Virus has some useful common sense advice about avoiding mosquito bites and eliminating mosquito breeding sites. They suggest the following.

• Use insect repellents when you go outdoors.
• Wear long sleeves and pants during dawn and dusk.
• Install or repair screens on windows and doors. Use air conditioning rather than leave unscreened doors or windows open.
• Empty standing water from items outside your home such as flowerpots, buckets, and kiddie pools.

So stay away from mosquitoes this summer. Because this advice is about all we can do for West Nile Virus.

Learn more:
West Nile virus disease cases up this year (CDC press release)
Severe West Nile Cases Rise (NY Times)
CDC: Most cases of West Nile virus reported since 2004 (CBS News)
West Nile Virus (CDC information page)

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.

0 Comments — Leave your comment