Medical News Blog

Haemorrhagic fever viruses...

haemorrhagic fever virus; HFV; Ebola virus;

A viral haemorrhagic fever (VHF) is an umbrella description for severe illnesses, usually discussed in relation to human and non-human primates, which can be associated with bleeding - although not always or even most of the time. VHF diseases often have fever and can affect multiple organs and systems within the body.

Outbreaks of VHFs are zoonotic (infection of humans after contact with an infected animal) and often irregular, reflecting sporadic transmission from an infected animal or insect host, spread between humans, or from an animal reservoir to other animal hosts.

As we learn more, it seems that the majority (?all) of viral infections result in outcomes that exist in a spectrum from severe to moderate to mild and even at times and perhaps controversially, asymptomatic infections (depending on what and how you measure and whether you look deeply enough and for long enough). Yet even though overt bleeding might not be obvious, there are frequently laboratory indications of clotting abnormalities in the blood of infected people-so the naming is still functional.[4] Bear in mind however, that "VHF" may not always be used to describe severe disease, but it will always be a term that pervades the historical literature.

VHF disease results mostly from infection by a number of viruses which have RNA genomes surrounded by a lipid envelope and which belong to a wide range of distinct viral families. Below I've listed some of these family names in italics (immediately adjacent to the filled bullet point) and under each family are some specific examples of viral species, also in italics (open bullet point):[3]

Arenaviridae including:

Lassa mammarenavirus (disease: Lassa fever)
Jun�n mammarenavirus (disease: Argentine haemorrhagic fever)
Machupo mammarenavirus (disease: Bolivian haemorrhagic fever)

Bunyaviridae including:

Crimean-Congo haemorrhagic fever virus
Rift Valley fever virus (disease: Rift Valley fever)
Hantaan virus (diseases: hantavirus pulmonary syndrome [HPS], hantavirus haemorrhagic fever with renal syndrome [HFRS])

Filoviridae including:

Zaire Ebolavirus (Ebola virus disease [EVD])
Marburg marburgvirus (Marburg virus disease)

Flaviviridae including:

Yellow fever virus
Dengue virus
Omsk hemorrhagic fever virus
Kyasanur Forest disease virus

This blog has recently acquired quite a bit of knowledge about one of these VHF viruses - a variant of Zaire ebolavirus called Makona.You may have heard about what a single "sporadic" transmission is capable of in the right setting and circumstances.

Just like those all over the world who got caught out in different ways by the scale and ferocity of the EVD epidemic in West Africa last year and early this year, VDU knew little about the virus or the disease before March 2014. It took a lot of reading to get blog posts together in the early days and weeks. Over time VDU aims to learn more about the other viruses listed above so it can more effectively communicate about them...should the need arise; and that list is not exhaustive. As VDU learns, it will share that knowledge here. VDU isn't a textbook of course or is it a peer-reviewed source - its what's may be called community grey literature,[5,6] and there already many excellent resources for this knowledge. But as ever, I do this because it teaches me some new things as well as one or two of you - that makes it well worth my spare time and basically for purely selfish reasons!

If you simply can't wait for more detail, you're now armed with a few names...so go forth and learn more!

References...

http://www.who.int/topics/haemorrhagic_fevers_viral/en/

http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/vhf.htm

http://ictvonline.org/virustaxonomy.asp

http://mmbr.asm.org.ezproxy.library.uq.edu.au/content/79/3/281.full.pdf+html

MERS simmers down in South Korea...did we learn anything this time?

hospital, ICP, infection prevention and control, MERS-CoV, Middle East respiratory syndrome, nosocomial spread, South Korea

No new cases reported in 8 days and the most recent known date of illness onset now 10 days ago, are good indications that the Middle East respiratory syndrome coronavirus (MERS-CoV) hospital-driven outbreak in South Korea is pretty much over. At the least, it's contained. Finally.

Roughly speaking - based on the data from the South Korean Ministry of Health and Welfare, the World Health Organization and KBS news - there were four rounds of infection. In all, 186 cases of MERS have been reported, with 36 (19.4%) resulting in death up until the 13th July AEST:

MERS case spread among hospitals in South Korea
between the 11th May and the 19th June.
Cowling et al. Eurosurveillance Vol 20,
Issue 24, 25-JUN-2-15.[4]
Click on image to enlarge.

the 1st round was the person who flew into South Korea after visiting all over the Arabian Peninsula - he became ill on the 11th of May.[1,2]
the 2nd round included approximately 45 cases.[3] This group started becoming ill on the 19th of May, continuing until the 4th of June.[5]
the 3rd round included approximately 108 cases.[3] These people started showing signs and symptoms of disease between the 27th of May and the 13th of June.[5]
the 4th round included approximately 22 cases.[3] This group became ill between the 5th of June and the 2nd of July.[5]

We've learned a few things (perhaps "relearned"?) and had a few things reinforced (even more) during this latest successful test of our healthcare systems ability to defend against a case becoming an outbreak...successful from the coronavirus' point of view that is.

For example we saw that..

MERS-CoV detections, deaths, sex and age distribution in
the South Korean hospital outbreak.
From my MERS-CoV in South Korea page.
Click on image to enlarge

MERS-CoV doesn't spread efficiently between humans - over 16,100 contacts did not develop MERS.[6] 186 did.
While there were probably more infections among contacts (and future studies from South Korea will hopefully investigate and answer this), disease did not develop among many of those exposed to infected people.
Closing schools, wearing masks in public, putting thermal imaging cameras in office buildings and quarantining zoo camels when not a single case has been acquired without link to a hospital was an exercise in failed communication between government and public.
There was no indication that any of these costly, high profile measures prevented any transmission. There was also no point to them, precisely because transmission outside the hospital setting did not occur.[3]
We have to learn to talk more, more often, and more clearly to our populations about the realistic risks of a new and scary virus when it shows up on our shores. We need to build trust here. Trust and respect takes time to build. In these outbreaks, we're always forced to rush because we seem incapable of investing in this before an event. Gods forbid we'd teach these concepts at school. We need to make a bigger deal about educating and informing our public about virus transmission. That is best done if the materials and the processes to roll the messages out to the public are already in place
Holding back information that you have already collected doesn't build confidence in you.
Whether that is not releasing the name of a hospital or the detailed data about deidentified cases, or presenting a list without discussion, engagement or correction when necessary
Hospitals are great places to spread infections, if infection control is not constantly running.
Viruses aren't big on forgiving. Neither are zombies. The undead really suck that way. But the truth may well be that hospitals need to be on guard, cleaning surfaces and in PPE 24 hours day, 7 days a week if they are dealing with cases of infectious disease that can be expelled from a human in the form of coughing, sneezing, bleeding or vomiting. Judging whether to use "standard precautions", "droplet precautions" or "airborne precautions" at some point after a coughing and sneezing patient has been sitting in the waiting area for hours, is going to be too little too late to stop new healthcare worker infections
Allowing the public - that is, the otherwise healthy - to co-care for patients within hospitals and to sleep in rooms or wards with infected people expelling virus (as per #4) - is a bad idea if trying to contain an acute viral infection
People with other underlying diseases get more seriously sick after MERS-CoV infection.
Adult health in richer nations is not in a good way. When a wimpy spreader like MERS-CoV comes to town, it may do little damage to the young and otherwise healthy population, but we are not all healthy.

We all have a role to play in protecting those among us who will suffer more greatly from an otherwise simple acute viral infection by even a rare and obscure camel-cold virus. Whether that is getting a vaccine to prevent us from becoming a hijacked virus production facility, being mindful of others when we cough and sneeze, or seeking out information from trustworthy sources to learn about the realistic threats from a new (or old) virus when it comes to town, we can all make some difference here.

At some point, one of these viruses may well be better at hopping between us and may cause severe disease not just in those who have an existing ailment. If that day comes, we have proven yet again, that no facet of our response will be up to the task of halting its spread.

We're not ready.

But hey - that virus' arrival is probably many, many cycles of leadership change, war, and petty bickering away yet. We'll be ready by then. Right?

References..

Ebola virus disease, getting ahead of communication needs and WHO

disease communication, Ebola virus, EVD, WHO

California Has Finally Stopped Denying Organ Transplants to Medical Marijuana Users

Medical News

Nearly 19 years after her liver transplant, Yamileth Bolanos is no longer afraid of taking the medical marijuana that helps her get through the day.

Bolanos said her transplant doctors originally told her that if she used marijuana, she would be ineligible for an organ transplant if her liver failed again.

"I could be at the end of my warranty and what if they reject [me?]" she told VICE News.

This week, after California Governor Jerry Brown signed the Medical Cannabis Organ Transplant Act into state law, Bolanos was able to breathe a little easier.

The law bars medical officials from denying a patient a spot on a transplant list "solely upon a positive test for the use of medical marijuana," unless the drug use is clinically significant.

Bolanos' use of marijuana to cope with a major illness is becoming more common as 23 states have now legalized some form of medicinal marijuana. However, the drug can create problems at transplant centers since it is still illegal on the federal level, forcing medical staff and surgeons to consider if it should be considered an "illicit drug" that would make a patient ineligible for a transplant.

California is just the seventh state to pass a law protecting marijuana users from being removed from organ transplant lists, according to Americans for Safe Access, a pro-medical marijuana group.

As more states legalize medical marijuana, there are no guidelines or resolutions from the American Medical Association or the American Society of Transplant Surgeons regarding the issue as it relates to organ donation.

The United Network for Organ Sharing (UNOS), which administers the Organ Procurement and Transplantation Network, declined to speak directly on the issue but pointed out that transplant centers consider "all medical and social factors taken as a whole for any given patient."

While national medical associations have yet to comment, the California Medical Association passed a resolution in 2014 opposing "blanket restrictions of potential organ transplant donors and recipients based solely on reported or detected marijuana uses."

'Patients are often denied a life-saving organ transplant solely because they are prescribed medical cannabis.'

Bolanos started using medical marijuana four years after undergoing a liver transplant. The operation saved her life at age 41, but subsequent complications and medications left her with gastrointestinal problems that made her afraid to leave the house.

"There were days where I felt like it wasn't worth it," she said. Bolanos said it was life changing when she first tried taking a few puffs from a friend's joint.

"It was the first time I felt any relief after my transplant," the now outgoing 59-year-old medical marijuana advocate said. "Marijuana was what had given back to me my life and the quality of life."

While Bolanos said her doctors at UCLA initially said her marijuana use would disqualify her from getting a second organ, she felt she couldn't give up the drug. Years later, Bolanos said her physicians changed their minds, but she still feared that she could be barred from the transplant list due to her marijuana use.

California State Representative Marc Levine introduced the Medical Cannabis Organ Transplant Bill after hearing about patients similar to Bolanos being taken off transplant lists in the state.

"Arcane public health policies treat medical cannabis patients as drug abusers," Levine said in a statement. "As a result patients are often denied a life-saving organ transplant solely because they are prescribed medical cannabis. Many of these patients have died after being denied an organ transplant."

Bolanos herself was frightened into helping lobby for the bill after hearing about the death of Norman Smith, a 63-year-old cancer patient.

In a video made by Americans for Safe Access, Smith said he was taken off the organ transplant list at Cedars-Sinai Hospital after using medical marijuana that was prescribed to him by an oncologist at the same center.

Bolanos said after hearing Smith's story, she didn't really believe that he would remain off the organ transplant list as he got sicker.

"My thing has always been, 'What are they going to do, let him die?'" Bolanos recalled thinking at the time.

Smith did die in 2012 from complications of liver cancer, according to Americans for Safe Access.

A Cedars-Sinai spokeswoman declined to comment on Smith's case, citing federal patient privacy laws, but said at their "transplant program physicians take many complex factors into account in assessing every patient's viability for transplantation, ensuring the best chance for each patient's post-transplant health."

Dr. Christopher Wigfield, surgical director of the lung transplant program at the University of Chicago, said that transplant centers already consider multiple factors to determine a patient's transplant viability, including overall health, alcohol use, weight, and other chronic conditions.

"That's why transplant [surgery] is so complicated, we don't impose an abstinence policy just because," Wigfield said. "We need to be sure that we give the recipient [the] best chance of an outcome that matches their expectations."

Transplant patients who smoke marijuana have been found to have a higher risk of developing aspergillosis, a potentially fatal infection caused by a fungus that can grow on cannabis.

Wigfield said doctors also have to factor in how medical marijuana could interact with the delicately balanced regimen of drugs given post-surgery to keep patients alive.

Currently, 122,860 people are in need of an organ transplant in the US, according to UNOS.

Bolanos said she is now reveling in being able to use medical marijuana without the fear that she may be disqualified from getting a second transplant in the future. She uses the drug around three times a day just so she can bring herself to eat, but she isn't complaining about her daily regimen.

"I'm alive, honey, that's nothing — compared to being dead," she said.

[Original Article]

Recovering female stroke victims may benefit from uric acid

Medical News

A stroke is a life-changing event, impacting on an individual's psychological and physical well-being. Rehabilitation for recovering stroke victims is a crucial step for which many recovering patients struggle.

In the study - published in the journal, Stroke, for the American Heart Association (AHA) - Angel Chamorro, PhD, lead author and director of Barcelona's Comprehensive Stroke Center, Hospital Clinic Chamorro, Spain, sheds further light on what is the most effective treatment.

Dr. Chamorro and her colleagues re-analyzed 2014 data based on URIC-ICTUS, a randomized double-blind trial of patients admitted to stroke centers in Spain. The participants in the study were 206 women and 205 men who were all were given treatment to remove clots. Half of each gender group were randomly given either 1,000 mg of uric acid therapy or a placebo administered through intravenous infusion.

At the time, the results of the study interpreted the addition of uric acid therapy to neither increase the well-being of recovering stroke patients or lead to any safety concerns.

However, upon re-analyzing the data, researchers found 42% of women treated with uric acid reported less disability 3 months after a stroke compared with 29% of women treated with a placebo.

In addition, women had less dead tissue resulting from a lack of blood supply after receiving uric acid, but among men, there was essentially no difference between the uric acid treatment and the placebo.

Protect tissue from free radicals

In an ischemic stroke, the most common form of stroke, a clot lodges in an artery supplying oxygen to the brain. Once doctors remove the clot, oxygen is free to re-enter the brain but it also releases harmful monocles, known as free radicals, which can damage surrounding tissue.

Although high levels of uric acid can lead to health problems such as kidney stones and gout, results show it can be used to counteract the dangers of free radicals. According to Dr. Chamorro, women fared better because they traditionally possess less uric acid in their bodies.

In the study, women were, on average, 7 years older than men and they were more likely to have an irregular heartbeat, high pressure and other conditions. Dr. Chamorro believes results of uric acid therapy would be even more impressive when tested on young and healthier stroke victims. The findings echo a study last year that discovered uric acid to be a major intracellular antioxidant.

Last year, the AHA reported 795,000 Americans suffer from a new or recurrent stroke every year. About 55,000 more women suffer strokes than men in the US, with 60% of stroke deaths occurring in women. In response, guidelines for the prevention of stroke in women were created for the first time.

[Original Article]

Mammography 'does not reduce breast cancer deaths'

Medical News

After skin cancer, breast cancer is the most common cancer among American women. Around 231,840 women in the US will be diagnosed with breast cancer this year, and around 40,290 will die from the disease.

As with other cancers, early detection of breast cancer is key for successful treatment, and this can be achieved through breast cancer screening. The main tool used for breast cancer screening is mammography, which involves taking an X-ray of each breast, allowing clinicians to see any tissue abnormalities.

The US Preventive Services Task Force (USPSTF) recommend that women aged 50-74 have a mammogram every 2 years.

According to the American Cancer Society, death rates from breast cancer have been falling since around 1989, and this is partly attributed to earlier detection as a result of breast cancer screening.

However, study co-author Richard Wilson, of Harvard University in Cambridge, MA, and colleagues note that there is increasing concern that mammography may lead to overdiagnosis by "identifying small, indolent or regressive tumors that would not otherwise become clinically apparent," which means many women may receive treatment they do not necessarily need.

What is more, although clinical trials have shown mammography is effective for early breast cancer diagnosis, Wilson and colleagues note that most of these trials are decades old. "There are concerns that the benefits and harms may have changed as treatments improved and screening was applied in general practice," they add.

Breast cancer screening increased diagnosis by 16%, but did not reduce death rates

For their study, the team set out to assess the link between rates of mammography for breast cancer detection and breast cancer incidence, tumor size and death rates from the disease.

They analyzed data from the Surveillance, Epidemiology and End Results (SEER) cancer registries, involving more than 16 million women aged 40 and older from 547 counties in the US.

Breast cancer was diagnosed in 53,207 of these women during the 12-month period, and these women were followed-up over the next 10 years.

The rate of breast cancer screening was assessed in each county, as determined by the percentage of women who underwent a mammogram in the previous 2 years.

Overall breast cancer incidence in the year 2000 was calculated for each county, as was the rate of breast cancer deaths during the 10-year follow-up. The team age-adjusted this data and applied it to the US population.

The results of the analysis revealed a 10% rise in breast cancer screening. This was associated with a 16% increase in breast cancer diagnosis. However, no reduction was found in the rate of breast cancer deaths.

In addition, the 10% increase in breast cancer screening was linked to a 25% rise in incidence of small breast cancers - defined as the presence of tumors 2 cm or less. However, the increase in breast cancer screening was not associated with a reduction in incidence of larger breast cancers - it was linked to a 7% increase.

Commenting on their findings, Wilson and colleagues say:

"Across US counties, the data show that the extent of screening mammography is indeed associated with an increased incidence of small cancers but not with decreased incidence of larger cancers or significant differences in mortality.

What explains the observed data? The simplest explanation is widespread overdiagnosis, which increases the incidence of small cancers without changing mortality, and therefore matches every feature of the observed data."

Clinicians 'right to be wary' of breast cancer screening studies

The researchers add, however, that clinicians are right to have concerns about ecological studies regarding breast cancer screening because of "ecological fallacy." Dr. Joann G. Elmore, of the University of Washington, agrees with this statement in a linked editorial.

"It is well known, for example, that ecological studies provide no information as to whether the people who were actually exposed to the intervention were the same people who developed the disease, whether the exposure or the onset of disease came first, or whether there are other explanations for the observed association," she explains.

As such, she says better tools and communication are required to help women make informed decisions about breast cancer screening.

"Perhaps most important, we need to learn how to communicate with our patients about uncertainty and the limits of our scientific knowledge," she adds. "In the end, we all need to become comfortable with informing women that we do not know the actual magnitude of overdiagnosis with precision. Part of informed decision making is providing all the information, even our uncertainty."

In contrary to these latest findings, a study reported by Medical News Today last month claims mammography is the best screening method for reducing breast cancer mortality among women aged 50 and older.

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