Largest Ebola Outbreak in History Continues to Spread

Doctors without Borders staff carry body of a patient killed by Ebola in Guinea. AFP/Getty Images

Doctors without Borders staff carry body of a patient killed by Ebola in Guinea.
AFP/Getty Images

Given the myriad horrors happening around the world this week you could be excused if West Africa has fallen off of your radar, but from a health perspective, it deserves some attention.

I wrote in April about an Ebola outbreak in southeastern Guinea that had spread to Liberia and Sierra Leone. (Browse that first post for a history of Ebola, its symptoms, and how it’s transmitted.) By April the outbreak had already become the most geographically widespread Ebola outbreak in history, and the first in West Africa. By that time it had reached the capital of Guinea and had infected over 130 people and killed 88.

As of now, the outbreak remains to be contained, and by any measure is now the worst outbreak ever. Over 1,000 have been infected, causing over 600 deaths. The outbreak has also reached the capital of Sierra Leone. Most worrisome is that new cases are still developing, with 67 new cases reported from July 15 to 17.

Emblematic of the struggles that local health officials have faced in containing this infection is the news that the lead physician treating Ebola patients in Sierra Leone has himself become infected. At least eight nurses in the same hospital have also contracted Ebola. This large number of infected healthcare workers hints at poor adherence to infection prevention guidelines or perhaps a simple lack of isolation supplies such as gloves and masks.

Officials are also battling public mistrust and false rumors about the cause and transmission of Ebola. Many locals also adhere to traditional funeral rites that involve contact with the deceased, increasing the likelihood of infection. A patient in the capital of Sierra Leone was forcibly removed from the hospital by her family and remains unaccounted for. Most recently, a possible Ebola case surfaced in Nigeria. If confirmed this would add a fourth country to this outbreak’s toll.

The World Health Organization’s recent update on the outbreak was quite frank about the shortcomings of the current efforts. It criticized

“low coverage of contact tracing; persisting denial and resistance in the community; weak data management; inadequate infection prevention and control practices, especially in peripheral health facilities; and weak leadership and coordination at sub-national levels.”

My last post worried about an Ebola patient getting off a plane in a large European or American city. I no longer have that concern. I think a country with an advanced healthcare system and an informed and cooperative public would quickly extinguish an Ebola outbreak. But the ensuing panic in which every fever is a potential Ebola case would cause much disruption.

I know you share my hope that the health workers toiling in West Africa gain the upper hand and contain this outbreak soon. Then we could go back to only worrying about all the other horrors in the world.

Learn more:

Worst Ebola outbreak ever gets worse: top Ebola doctor now infected (Vox)
A Doctor Leading The Fight Against Ebola Has Caught The Virus (NPR)
Ebola virus disease, West Africa – update (World Health Organization Global Alert and Response)
First Ebola victim in Sierra Leone capital on the run (Chicago Tribune)
Ebola Outbreak in West Africa Worries Health Officials (My post in April about the current outbreak)

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A Small Step Towards An Artificial Pancreas

Schematic of the bionic pancreas Image credit: Boston University Dept. of Biomedical Engineering / NEJM

Schematic of the bionic pancreas
Image credit: Boston University Dept. of Biomedical Engineering / NEJM

Patients with type 1 diabetes (T1D) are forced to spend much of their time obsessing about their blood sugar and insulin doses. The state of the art in treatment of T1D is an insulin pump that delivers insulin and a continuous glucose monitor that displays the glucose level and sounds alarms for values that are too low or too high. (See here for a refresher on the differences between type 1 and type 2 diabetes.)

Currently, patients have to evaluate the readings of the glucose monitor, calculate the appropriate doses of insulin for every meal, make mental adjustments for exercise, physical or emotional stress, or acute illness, and enter the appropriate dose into the insulin pump. This is a very inexact art. Too much insulin leads to low blood sugars which can be life threatening. Too little insulin keeps blood sugars too high which will result in complications decades later.

In people without diabetes, the pancreas regulates blood sugar levels automatically by regulating the release of two hormones, insulin which lowers blood sugar, and glucagon which increases it. I have the luxury of eating, exercising, and suffering from the flu without ever thinking about my blood glucose. My nephew Elliott, who has T1D, would be threatening his life if he did that.

A study published this week in the New England Journal of Medicine (NEJM) brings patients with T1D a small step closer to living like the rest of us. The study tested a very preliminary attempt at an artificial pancreas in 52 adolescents and adults over a 5 day period. This bionic pancreas, as the researchers call it, consists of a continuous glucose monitor that is attached to a smart phone. The smart phone runs software that receives the glucose information from the glucose monitor and calculates the amounts of insulin and glucagon that should be delivered. The software connects via Bluetooth to two hormone pumps that deliver hormones through tubes inserted under the skin, one for insulin, and one for glucagon. The patient can interact with the software to announce that he’s about to have a meal or a snack. The software does the rest.

The study showed that the patients’ blood sugar was better controlled when they were using the bionic pancreas than during five days when they were managing their sugars themselves. Importantly, the bionic pancreas did not result in more episodes of seriously low blood sugars. And the difference in quality of life promises to be huge – no more careful counting of every carbohydrate ingested, no more calculating the appropriate insulin dose, no more obsessing about how much to compensate for 30 minutes of bike riding.

This study was small and preliminary. An artificial pancreas isn’t going to be mass marketed tomorrow. Lots of improvements still need to be made, and the entire unit needs to be consolidated into one box so that it doesn’t depend on a finicky Bluetooth connection. And then it needs to be tested on thousands of patients.

We now have machines and prostheses that do a reasonable job of replacing broken kidneys and cochleas and hip joints. This week brings promise that we are approaching a day when we’ll be able to do the same for broken pancreases.

Learn more:

Advances Made in Regulating Type 1 Diabetes (Wall Street Journal)
Father Devises A ‘Bionic Pancreas’ To Help Son With Diabetes (NPR Shots)
Bionic pancreas helps control diabetes, study says (USA Today)
A diabetic child spurs a race for a bionic pancreas (Bostonia)
ENG Prof’s Bionic Pancreas Takes a Big Step Forward (Boston University Biomedical Engineering News)
Outpatient Glycemic Control with a Bionic Pancreas in Type 1 Diabetes (NEJM)

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Eating Breakfast Neither Helps nor Hinders Weight Loss

Breakfast, entirely optional for weight loss Photo credit: Alisdair McDiarmid via Flickr, Creative Commons license

Breakfast, entirely optional for weight loss
Photo credit: Alisdair McDiarmid via Flickr, Creative Commons license

It’s nearly impossible for us not to believe that what we eat has a profound effect on our health. But what we know about the link between food and health is much less than what we believe. A study published this week provides a perfect example.

An overweight person trying to lose weight is likely to hear advice about the importance of eating breakfast. We have some reasons to guess that skipping breakfast might hamper weight loss efforts. Skipping breakfast should increase hunger which might cause overeating at lunch. Hunger can also trigger hormonal changes that make weight loss more difficult. There have even been some observational studies showing that people who eat breakfast are thinner than those who don’t. (See here for a quick primer on the difference between an observational study and a randomized study and why observational studies should be largely ignored.)

Of course in the past we had very good reasons to guess that heavier objects fall faster than lighter objects, that light travels faster going west than north, and that estrogen prevents heart attacks. These guesses were all proven false as soon as someone actually tested them.

In the study published this week, investigators enrolled about 300 overweight and obese adults and randomized them to three groups. One group in addition to receiving general weight loss advice was instructed to eat breakfast every day. The second group was instructed to skip breakfast every day. The third group received general nutrition advice that didn’t mention any advice about breakfast.

The groups were quite compliant with following their instructions. The group that was supposed to skip breakfast almost always did so, and the group that was supposed to eat breakfast almost always did so. The three groups lost equal amounts of weight. The senior investigator of the study, David Allison, summed it up well. “The field of obesity and weight loss is full of commonly held beliefs that have not been subjected to rigorous testing.”

There’s nothing wrong with educated guesses. They’re the seeds of discovery. But without testing we shouldn’t forget that they are not knowledge. We mistakenly keep guesses around for decades, grow comfortable with them, and forget that they’re untested. It seems that the field of nutrition is especially littered with these long-held assumptions. (The myth of the harms of saturated fats is another recent example.) I’m delighted that Dr. Allison is committed to either confirming or discarding them. I hope he gets some help.

Learn more:

Skipping Breakfast May Not Be Bad For Weight Loss After All (Forbes)
Eating breakfast may not matter for weight loss (CNN Health blog)
Passing on Breakfast OK for Weight Loss (Medpage Today)
The effectiveness of breakfast recommendations on weight loss: a randomized controlled trial (The American Journal of Clinical Nutrition)

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The Anti-Medication Bias

pills

Photo credit: RayNata, Creative Commons license

[The patient interactions in this post are amalgams of hundreds of patient encounters over my career. They are not accurate depictions of any encounter with any single patient.]

“I don’t like taking medicines.”

All physicians hear some form of this opinion very frequently. Even more frequently, patients don’t state this view outright but rely on it to completely subvert their doctor’s plans.

When I was new to practice such an utterance would shock and confuse me.

“I don’t want to take any medicines,” a patient would declare.

“That’s fine,” I would reassure my interlocutor. “It’s a free country. No one is going to force you to take medicines. But you should know that I’m a primary care doctor. I don’t do surgeries or procedures. I diagnose and treat medical problems, usually with medications. I’m not saying you have to change your opinion. I’m just saying you might be in the wrong place. You’re like the vegan bursting into the butcher shop to declare that you don’t want to buy meat.”

I’ve heard some version of this aversion to medications hundreds of times. Over the years I’ve also realized that it is usually adopted by patients without any serious reflection.

“I’d like to be on the fewest medications as possible,” a patient with diabetes, heart disease, high cholesterol, and high blood pressure would announce.

“Well, the fewest medications you can take is zero. Should we just stop them all?”

Lots of patients adopt this anti-medication preference in the absence of any evidence or serious thought. A strong preference without analysis or evidence is simply a bias. (When I have a strong preference in the absence of evidence, it’s a philosophy; when other people have it, it’s a bias.)

Now, some biases are harmless. I like Folgers instant coffee (black), and you like vanilla Frappuccino. I bicycle; you jog. That’s all great. But if a bias threatens to worsen your health, it deserves a little attention. Some thinking might be useful to either confirm it as a belief you want to live by, or discard it to the cognitive ash heap.

The problem with the anti-medication bias is that most doctors are too busy to argue with you. Let’s say your cholesterol is extremely high. Your doctor might recommend attempts at exercise and weight loss for a few months. After that if your cholesterol is unimproved she may recommend a cholesterol-lowering medication. She may or may not have time to mention that this medication has been proven to prevent strokes and heart attacks in patients with high cholesterol. She might or might not mention the rare and usually tolerable side effects you might expect. But if all she hears from you is “I’m already taking too many medicines,” she may do the expedient thing, which is to document your refusal to take cholesterol medicine and leave it at that. If you’re lucky, she’ll readdress this again in more detail in a future visit. If you’re unlucky the future visit will be when she sees you in the emergency department during a heart attack.

Because I have more time to spend with each patient than most doctors, I have a lot of experience in trying to understand and overcome this anti-medication bias. I certainly don’t advocate compensating with the opposite bias – taking as many medications as possible. (A small number of patients do seem to believe that there is a pill for everything that ails them. That’s a subject for a different post.) My suggestion instead is that each medication be judged on the basis of its own benefits and harms. You don’t want to minimize the medicines that you take; you want to benefit from all the medicines whose benefits to you exceed the harms.

Now, don’t get me wrong. There are certainly good reasons not take a medication. You might develop a side-effect. Discuss that with your doctor. Some side-effects diminish with time. Some are annoying but not dangerous. But obviously some are intolerable and might be a good reason to stop taking a medication. So by all means balance the risks, the expense, and the side effects of medications against their benefits, but don’t make a decision before even doing the calculation.

Of course balancing these issues takes time and thought. It requires that the patient be willing to ask important questions (“What side effects should I expect?”) and express any apprehensions. It requires that the doctor answer the questions and make sure the patient understands why the medication is being recommended. That is more difficult and less efficient than writing a prescription and bolting to the next patient.

So please help me eradicate the anti-medication bias. Your health might improve, and you’ll save your doctor a headache or two. Which reminds me, I need some ibuprofen.

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Nearing a Cure for Hepatitis C

The Hepatitis C virus is what scientists call very small. Here is an electron micrograph of one. The scale bar is 50 nanometers. Photo credit: Wikimedia/Rockefeller University

The Hepatitis C virus is what scientists call very small. Here is an electron micrograph of one.
The scale bar is 50 nanometers. Photo credit: Wikimedia/Rockefeller University

In the contest to get a creative name, few pathogens have done worse than hepatitis C. In the 1970s there were two known viruses that caused hepatitis – liver inflammation. You might have already guessed that these two viruses were called hepatitis A and hepatitis B. It was known at that time that people sometimes developed hepatitis after blood transfusions and that the majority of those patients tested negative for hepatitis A and B. A new pathogen was hypothesized and called non-A-non-B hepatitis. It wasn’t until 1989 until the virus was isolated and named [drum-roll please] hepatitis C.

Hepatitis C is transmissible through contact with blood. Before the advent of routine testing of the blood supply it was transmitted through transfusions. It is still transmitted through the sharing of drug and tattoo needles and, in less developed countries, through the reuse of unsterilized medical equipment. Hepatitis C can cause liver failure and liver cancer. There are over 3 million people in the US who are infected with hepatitis C. It is the leading cause of liver transplantation and liver cancer in the US.

There are vaccines against hepatitis A and B, but none yet for hepatitis C.

For decades the standard therapy for hepatitis C has been a regimen including interferon and ribavirin. Interferon has to be given by injection and can have debilitating side effects. A course of treatment lasts 6 to 12 months, and many who begin a course are unable to tolerate it. Fewer than 50% of patients who are treated with this regimen have a meaningful benefit. Because of the length and difficulty of the treatment many hepatitis C patients are thought to be poor candidates and never are offered treatment.

Most of my posts are about a new interesting study, but this post is about a whole crop of studies published in the last two months in the New England Journal of Medicine (NEJM) about the safety and efficacy of novel treatments for hepatitis C. (For links to the individual studies, see the right sidebar of this related NEJM editorial.) Eight recent studies have examined several new medication regimens with truly remarkable results.

The new regimens involve oral medications, so injections are unnecessary. Rather than lasting 6 to 12 months they last 8 to 12 weeks. They are very well tolerated with fairly mild side effects. Best of all, over 90% of the patients appear to have complete clearance of the virus. These results suggest that these medications are no longer in the realm of treating hepatitis C. Instead, for most patients, these medications are a cure for hepatitis C.

Of course, there’s a catch. The medications are astronomically expensive. One of the medications (sofosbuvir) costs $84,000 for a 12 week course. This has caused much consternation and bloviating about pharmaceutical corporate greed. (I’m fascinated by articles that rhapsodically praise the extraordinary medical and scientific breakthrough that these medications represent and a few sentences later vilify the companies that made those breakthroughs possible.)

If we keep our cool and do absolutely nothing, the prices will eventually drop. Competition from newer medications, expiration of patents, and negotiations with insurers will all drive prices down over the next several years. Remember, cell phones and cars were wildly unaffordable when they were new. If we all get angry and insist on making these medicines “affordable” by legislating that insurers cover them, we could make sure that their prices stay astronomic forever.

The exciting news is that within a decade or two we might be able to eradicate hepatitis C. Then maybe we can concentrate our resources on viruses with cooler names, like MERS and Ebola.

Learn more:

New Drug Combination Highly Effective For Hepatitis C (Forbes)
Eradication of hepatitis C on the horizon (The Washington Post)
A Costly Cure for Hepatitis C (The Medical Letter blog)
Therapy for Hepatitis C — The Costs of Success (NEJM editorial, by subscription only)
Therapy of Hepatitis C — Back to the Future (NEJM editorial, free without subscription. The right sidebar has links to all the recent studies of drug trials for hepatitis C.)

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Return of the Spirochete

Treponema pallidum spirochetes

Electron micrograph of Treponema pallidum bacteria
CDC / Dr. David Cox / Public Health Image Library #1977

“Example is the school of mankind, and they will learn at no other.”
– Edmund Burke

Syphilis has been around at least since Europeans arrived in the Western Hemisphere. It’s a sexually transmitted disease caused by Treponema pallidum, a member of a group of corkscrew-shaped bacteria called spirochetes. Sometimes it causes no symptoms at all, but typically it initially causes a painless sore on the mouth or genitals. Later it can cause a rash. Untreated it may lead to blindness, spinal cord and brain damage, and death.

After the discovery of penicillin in the 1940s syphilis was for the first time easily curable and the prevalence of syphilis in the US dropped precipitously.

I trained in the bad-old-days of the mid-90s when HIV was killing tens of thousands of people in the US every year. On every inpatient ward rotation I met patients hospitalized with an opportunistic AIDS-related infection. On every ICU rotation I met patients dying of AIDS. Back then medications to treat HIV were few, new, and only modestly effective. HIV was usually a rapidly fatal disease. It was scary. Counseling patients about condom use and monogamy was not moralistic or theoretical. It had all the practical urgency of yelling at someone to get off the train tracks.

I have no evidence that HIV and the response to it was responsible for the subsequent fall in syphilis infections, but in fact syphilis did decline during the 90s and in 2000 reached its lowest rate ever in the US and was on the verge of being eliminated. You would think that a disease that can be easily diagnosed with blood tests, can be cured with antibiotics, and can be prevented with condoms would be on its way to the dustbin of history. You would be wrong.

This week the Centers of Disease Control and Prevention (CDC) published a review of syphilis trends in the US from 2005 to 2013. The statistics are dismaying. The number of syphilis cases almost doubled during that interval, from 8,724 cases in 2005 to 16,663 in 2013. 91% of the 2013 cases occurred in men. The number of cases in women was about the same in 2013 as in 2005. Of the male cases in 2013, 84% occurred in men who reported having sex with men.

The report breaks down the trends geographically and by ethnicity but it’s the age breakdown that I found fascinating. From 2005 to 2009 men aged 20 to 24 had the greatest percentage increase in syphilis rates, and from 2009 to 2013 men aged 25 to 29 had the greatest increase. But of course those two age categories are actually the same group – men born in the 1980s. I couldn’t help notice that these are the men who grew up after the bad-old-days, the men who think of HIV as the treatable chronic illness it has become, not the death sentence it was 20 years ago.

The CDC report offers wise advice to physicians. We should be testing gay and bisexual men for syphilis at least annually. Men who have multiple partners should be tested more frequently. We should be counseling consistent condom use except in prolonged monogamous relationships in which both partners have been tested.

But perhaps that won’t be enough. I have zero evidence that the attitudes about HIV contributed to the decline of syphilis in 2000 or its resurgence now, but the time course certainly seems to fit. It’s a testament to scientific research and drug development that in such a short time a disease that had the mortality of stage four lung cancer is now more like diabetes. But to young men this progress must make our advice about avoiding sexually transmitted diseases sound a lot less urgent – less like getting off the train tracks and more like putting on their seat belt. That complacency is a terrific opportunity for a patient and ambitious spirochete.

Learn more:

US Syphilis Rate Up; Mostly Gay And Bisexual Men (NPR)
Syphilis Made A Big Comeback In 2013, CDC Warns (Forbes)
CDC Reports Syphilis is Increasing in Homosexual and Bisexual Men (Science World Report)
Syphilis (CDC fact sheet)
Primary and Secondary Syphilis — United States, 2005–2013 (CDC Morbidity and Mortality Weekly Report)
Syphilis—Reported Cases by Stage of Infection, United States, 1941 – 2012 (CDC)

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There Has Never Been a Better Time to Have Diabetes

A patient’s blood glucose is measured. Credit: Biswarup Ganguly / Wikimedia Commons

A patient’s blood glucose is measured.
Credit: Biswarup Ganguly / Wikimedia Commons

The danger of diabetes is not only the immediate risk of very high blood sugar. Diabetes also has many dreaded long-term complications. (In this post I am referring to both type 1 and type 2 diabetes mellitus. For an explanation of the differences between these two very different diseases see the first half of this post.) Diabetes greatly increases the risk of stroke, heart attack, and amputation. In the US it is the leading cause of kidney failure and of blindness in adults.

A study performed by researchers at the Centers for Disease Control and Prevention and published in the current issue of the New England Journal of Medicine tracked the frequency in the US of five serious complications of diabetes over the two decades from 1990 to 2010. This was not an experiment in which a medication or diagnostic test is evaluated. This was simply counting how many people had diabetes in the US, and how many of them suffered heart attacks, strokes, kidney failure, amputations, or death due to very high blood sugar.

The results were very encouraging. The rate of heart attacks among diabetics fell by two thirds, as did the rate of death due to very high blood sugar. This parallels a similar but smaller drop in the frequency of heart attacks in the general population. Stroke and amputation rates both declined by about half. The risk of permanent kidney failure declined by about a quarter.

What accounts for these favorable trends? Part of the credit lies with earlier detection and better treatment of diabetes. Screening for early complications of diabetes by checking for early signs of kidney injury and for the first signs of skin sores helps prevent amputations and kidney failure.

But much of the credit for these positive trends has nothing to do with diabetes, but with general improvements in preventing cardiovascular disease. Fewer people are smoking. Statins have revolutionized treatment for high cholesterol and have drastically reduced the incidence of strokes and heart attacks in the general populations. Improved use of blood pressure medications have also contributed to stroke and heart attack prevention and have prevented kidney failure. And all of these measures have helped reduce the frequency of amputations.

So as cardiovascular risks have declined in the general population, people with diabetes who are at very high risk have benefited most. That’s great news.

The one bit of data in the study that is terrible news is that from 1990 to 2010 the number of people with diabetes in the US grew from 6.5 million to 20.7 million. So the frequency of terrible complications from diabetes is declining, but the number of people subject to these complications has more than tripled. This is terrific news for the individual with diabetes. Diabetes has never been less scary or more manageable. But for the society as a whole, the news is mixed.

To make further progress in decreasing complications from diabetes we must figure out how to stem the tide of the diabetes epidemic. For type 2 diabetes this may mean earlier detection of risk factors and expanded use of weight loss surgery for appropriate patients. It may also mean working to reverse the epidemic of obesity – a quixotic task. For type 1 diabetes this may mean further work on an artificial pancreas and on immunotherapy that might arrest the disease in its very early stages when some pancreatic function remains.

We’ve come a long way. We’ve got a long way to go.

This post is dedicated to my nephew Elliott who has type 1 diabetes. His parents, Matt and Violet, have become very active with the Juvenile Diabetes Research Foundation (JDRF), an organization that funds research seeking a cure for type 1 diabetes. They are being honored for their indefatigable support of JDRF at a gala next month. Please consider supporting JDRF’s important work with your involvement or a donation. Thank you.

Learn more:

For Diabetics, Health Risks Fall Sharply (New York Times)
Study: Diabetic heart attacks and strokes falling (Washington Post)
Diabetes complications show significant decline in past two decades (Reuters)
Changes in Diabetes-Related Complications in the United States, 1990–2010 (New England Journal of Medicine article, abstract available without subscription)

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Ebola Outbreak in West Africa Worries Health Officials

Electron micrograph of Ebola virus particle Credit: CDC Public Health Image Library #1832 / Cynthia Goldsmith

Electron micrograph of Ebola virus particle
Credit: CDC Public Health Image Library #1832 / Cynthia Goldsmith

In 1976 a new virus entered the pantheon of lethal human pathogens – Ebola virus. That year outbreaks in Zaire and Sudan sickened 284 people and killed about half of them. Ebola virus causes an illness that initially resembles a typical intestinal virus, with fever, headache, joint and muscle aches, vomiting and diarrhea. Most patients quickly worsen and develop a rash, easy bleeding, and liver and kidney failure. About two thirds of the people who are infected die. Ebola is transmitted from person to person through infected bodily fluids, but since patients are frequently vomiting and suffering from diarrhea, and since outbreaks happen frequently in places with poor sanitation, infection can spread quickly. Without medical protective equipment, like gloves and masks, healthcare workers are often infected. The incubation period is two to four weeks. Ebola is also carried by wild animals, and bats are thought to be a reservoir of the disease.

Because Ebola is so rapidly fatal, previous outbreaks have been geographically very limited. It may infect everyone in a small remote village, but at least until now, infected people have been too ill to get on a plane or take a long car ride. The worst outbreaks have killed almost 300 people. New outbreaks have recurred in Central Africa every few years, presumably from contact with infected animals.

So far there is no vaccine or specific treatment for Ebola. It cannot be spread by respiratory particles (i.e. by coughing or sneezing). If it could, it would make the perfect bioterrorism weapon. The Centers of Disease Control and Prevention lists it as a Category A bioterrorism agent.

About ten days ago an Ebola outbreak was discovered in southeastern Guinea. This in itself is worrisome as it is the first Ebola outbreak in Guinea and in West Africa. But more worrisome is that this outbreak has spread geographically more than any other. Cases have been reported in Conakry, the capital of Guinea, a city of a million and a half people. Conakry is over 400 miles away from the region of the initial cases. And cases are also suspected in Liberia and Sierra Leone. In all (as of April 1) there have been over 130 confirmed and suspected cases and 88 deaths. 14 of the infected people are healthcare workers.

International health officials are scrambling to deliver isolation equipment to hospitals and are trying to educate the public to avoid touching people who become sick. They are also identifying and trying to isolate people who were in contact with patients. The media reports (links below) suggest the mood in Conakry is understandably tense.

Time will tell how much farther this outbreak will reach and how many lives it will claim. We hope that as resources are rushed to where they are needed human-to-human transmission will be interrupted soon.

But we are reminded that in less than 40 years after making the jump from other animals to humans Ebola virus has found its way to an African capital city. How many more years will it be until someone, unaware that he is infected and still in the incubation period, boards a plane and becomes violently ill while browsing paintings at the Louvre, or riding a double-decker bus in London, or seeing a Broadway play? Will our health systems be prepared to manage the ensuing chaos?

Learn more:

Q&A: Challenges of Containing Ebola’s Spread in West Africa (National Geographic)
Ebola outbreak spreads panic in West Africa (USA Today)
Why West Africa’s Ebola Outbreak Is So Scary (Slate)
6 Things to Know About the Latest Ebola Outbreak (Time)
Outbreak of Ebola in Guinea and Liberia (Centers for Disease Control and Prevention)

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What We Don’t Know About Eating Fat

A hamburger patty is loaded with saturated fats and is delicious. Image credit: Jeff’s Gourmet Sausage Factory, from their Facebook page

A hamburger patty is loaded with saturated fats and is delicious.
Image credit: Jeff’s Gourmet Sausage Factory, from their Facebook page

Most humans have spent most of human history nearly starving to death. So it’s no surprise that we spend a lot of time thinking about food. And it’s no surprise that food has acquired cultural, social, and religious significance in almost every society. Because food is so important, and because it’s nearly impossible for us not to ascribe powerful effects to anything important to us, every society imbues special health properties to various foods.

From believing that some foods are aphrodisiacs to believing that some foods improve sleep or fertility or athleticism, superstitions about the effects of food on health are ubiquitous. But we are modern, rational creatures that would never subscribe to such claptrap. Right? Wrong. We also cling to our own mythology about the health effects of food but we dress up our ignorance in scientific words. We (correctly) sneer at anyone who asserts that ingesting powdered rhinoceros horn improves erectile function. After all, there’s no scientific reason to even believe such a thing, and the connection between a rhinoceros horn and erectile dysfunction is purely visual. That’s like eating a giraffe because you want to be taller.

But take the assertion that eating saturated fat increases the risk of heart disease. We all believe that. After all, saturated fat is a molecule. Molecules are very scientific, which means there are men in white lab coats somewhere with blinky machines proving that saturated fats are very very bad to eat. In fact, current cardiovascular guidelines from respected groups like the American Heart Association suggest low consumption of saturated fats and high consumption of polyunsaturated fats. And the American Heart Association would never recommend rhinoceros horn.

This week’s study is an important reminder that we know much less than we believe, but before we dive into it, allow me a paragraph to make sure we know what we’re talking about.

There are three families of energy containing molecules in food – fats, carbohydrates, and proteins. Fats are further subdivided into saturated fats and unsaturated fats. Saturated fats are typically found in dairy products and fatty meats and are typically solid at room temperature (like butter, lard, and beef fat). Unsaturated fats are found in vegetable oils and fish oils and are typically liquid at room temperature (like olive oil).

For decades we have been hearing and repeating to our patients that saturated fats are unhealthy for hearts and unsaturated fats are healthy. A meta-analysis (study of studies) published in the current issue of Annals of Internal Medicine attempted to review all the studies that have ever examined the link between saturated and unsaturated fats and cardiovascular health. What they found was underwhelming. There were 45 observational studies, the kind that I routinely criticize in my posts and urge readers to ignore. There were 27 randomized studies that looked at the effects of fatty acid supplementation on heart disease. All of them tested whether supplements of unsaturated fatty acids (like fish oil) helped prevent stroke and heart attacks. None of them tested whether supplements of saturated fatty acids (lard capsules!) increased cardiovascular risks.

The results were meh. The data as a whole showed no significant increase in risk from saturated fats, nor decrease in risk from unsaturated fats. The authors conclude

“[T]his analysis did not yield clearly supportive evidence for current cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of saturated fats.”

Not surprisingly none of the experts quoted in the media coverage said the simple truth, which is that we have no idea if dietary fats affect health apart from the calories they contain. It would be nice to hear an expert declare “We have no clue about whether some fats are healthy or unhealthy” since that statement would be solidly supported by the evidence.

How did saturated fat’s bad reputation ever get started? I’m not sure. It’s conceivable some observational study that should have been ignored suggested that saturated fat was unhealthy. It’s also possible that saturated fat’s ignominy began because lard and butter look so much like the fat in a cholesterol plaque that blocks an artery. Olive oil is liquid. How could that block an artery? Maybe the whole idea was as simple-minded and as visual as the rhinoceros horn remedy.

Learn more:

Saturated Fat Is Back! (NPR)
Saturated fat ‘ISN’T bad for your heart’: Major study questions decades of dietary advice (Daily Mail Online)
Review questions effects of saturated fats on heart disease (Fox News)
Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk: A Systematic Review and Meta-analysis (Annals of Internal Medicine)
Even More Studies You Should Ignore (my last post about fish oil)

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Posted in Diet, Heart Disease, New Study, Prevention | Comments Off

When Less is More

A patient undergoing a treadmill EKG stress test, hopefully for good reason. Credit: Blue0ctane / Wikipedia / public domain

A patient undergoing a treadmill EKG stress test, hopefully for good reason.
Credit: Blue0ctane / Wikipedia / public domain

When I meet a new patient, I’m frequently astounded by the healthcare he has received. I’ve met patients with absolutely no cardiac symptoms who have been receiving EKGs every six months for years. I’ve had patients brag to me about their annual executive physicals in which myriad tests including treadmill stress tests and chest X rays were routinely performed. Patients get head-to-toe CT scans under the mistaken hope that they might save their lives by finding something. I’ve seen patients with no family history of colon cancers have colonoscopies every two years, because they really want to make sure that they don’t get colon cancer. Some patients do the best they can to be tested for everything.

In the absence of appropriate indications, all these tests are not only without value, they can be harmful. Even in perfectly healthy patients they can yield abnormal results simply through error. (These results are called false positives.) These results then have to be pursued with more invasive tests that can have complications and risks. This isn’t just a theoretical risk. I’ve seen patients harmed by tests that should never have been done.

Doctors are quick (and correct) to roll their eyes when patients take various unproven alternative medicines. When they take Echinacea for their colds, pop their multivitamins, and take black cohosh for menopausal symptoms. Patients should know that what they’re doing is unproven. But it occurs to me that doctors are much less critical when unproven or ineffective interventions are pushed by our colleagues. An unindicated stress test is every bit as unlikely to help a patient as a multivitamin, but potentially riskier. After all, a false positive result from a stress test may lead to an unnecessary angiogram, a risk that the multivitamin doesn’t carry.

The incentives that perpetuate the first type of ineffective medicine – the herbs, supplements, and vitamins – are obvious. Suppliers want to sell their product. They label and advertise their product with messages that fall just below the threshold for fraud, and patients interpret these messages to mean far more than they do. Eager to find something effective for what is frequently an untreatable problem (like a cold) patients understandably flock to these ineffective remedies.

But ironically, ineffective tests and remedies prescribed by physicians have even more perverse incentives. At least the patient has to pay for her own Echinacea and her own vitamins. The pointless EKG and stress test are covered by insurance! In a system in which tests are covered and the prices are fixed by the insurance company, the incentive is to deliver as many tests as possible. The doctor doesn’t lose anything if some of those tests lead to needless anxiety and further invasive testing. The patient doesn’t think to ask questions about the proven risks and benefits because he’s not getting the bill. The incentives do not reward achieving health, or preventing disease, or maximizing patient satisfaction. They reward delivering services. And we’re surprised that the result is the delivery of lots of services with no value.

Escaping the insurance system makes it easier to see the problem more objectively. I get paid by patients to listen to them and give them advice. I don’t get paid more if I order a test, and I also don’t get paid less. And I’m not paid by anyone but the patient. So I can actually take the time to educate the patient about the risks and benefits and figure out if she really wants the test. The net result is that patients pay me more so I can make sure they get more education and less healthcare.

I’ve written before about how our current healthcare market broke and how I believe it could be fixed. I think insurance coverage of routine care is a major flaw in the current system. We are currently expending enormous resources trying to insure everyone. If, as I believe, insurance is the problem and not the solution, the results will be even worse than the broken system we started with.

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Posted in Alternative Medicine, Concierge Medicine, Government and Law, Prevention | Comments Off