KOLAHUN

Alcoholism in the US

The highest rates of alcoholism in the US are in the White and Native American races and the Male gender.  Data from NIAAA. 

Not Just Black/White/Latin - Users of Illegal Drugs in the US

The sad state of Native Americans/Alaska Natives/Native Hawaiians.  This issue isn't simply about black/white/latin*.  

Figure 1. Percentages of Past Month Illicit Drug Use among Persons Aged 12 or Older, by Race/Ethnicity: 2004 and 2005.

 

 * - No breakdown was given on the 'two or more races

 

 

 

 

 

 

 

There's Nothing To See Here, Folks (Tb Scare in Atlanta)

The local news screaming headline:  

800 people exposed to tuberculosis in Atlanta hospital

It's much ado about (almost) nothing.  Of the major diseases to have, Tb is one of the easiest to treat, especially in the developed world (i.e. Atlanta).  Basically, it's a type of slow growing pneumonia.  The bacteria is spread by respiratory droplets.  Once a person is exposed, if her immune system is healthy, the body will wrap up the bacteria - this is called latent Tb.  The CDC recommends that to help the body protect itself, a course of an antibiotic called INH should be taken.  It used to be that INH needed to be taken for 9 months, now it's only 3 months.

Years later, if her immune system becomes weakened (HIV, cancer, etc.) the bacteria may re-emerge and she will have active Tb.  At this point, she may have cough with blood, fevers, night sweats and weight changes.  If she does, there's a fairly straightforward treatment with 4 antibiotics over 6 months (rifampin, INH, pyrazinamide and ethambutol).

So while the headline may be screaming, there's really no need to panic for most people.  Of course, in the hospital, some exposed patients may already have been immuno-compromised.  These patients need closer monitoring, but still no need to panic.  

 

 

Remote Tuberculosis Diagnosis in Pakistan

A new report claims that remote diagnosis of sputum-negative Tb can be made just as accurately as on-site diagnosis:

Under the study, only sputum smear negative cases were included at health facilities in Orangi and Gambat [Pakistan]. A brief history of the patient was taken and a chest X-ray was done by a trained person and emailed to specialists at the AKU. To check the accuracy of the diagnosis, culture tests of patients were also carried out and patients were called for clinical follow-ups for two months.

“The results of online diagnosis were as accurate as face-to-face diagnosis. The mean response time at both sites was 29.7 hours despite power outages in these areas.

This is a misguided effort by the Pakistani health authorities.  Perhaps they are trying other venues in addition to the chest xray - if so, good for them.  But the chest xray, a staple of tuberculosis diagnosis for decades has seen its time expire.  For example, this 2005 study in neighboring Nepal shows that the positive likelihood ratio is 1.6 for chest xrays in diagnosing tuberculosis.  

(In english, this means that if the chest xray had a 'lesion', that lesion would more 1.6x more likely to be found in patients with Tb as opposed to patients without Tb.)  Likelihood rations of > 10 are excellent.  A likelihood ratio of 1.6 is essentially a coin-flip.  

Moreover, there is a wide range of interpretation of x-rays themselves.  For the same xray, two good radiologists may likely come to different conclusions.  And finally, setting up an x-ray facility takes lots of money (lead lined walls, buildings) and energy.  These resources aren't widely available in rural areas.  

The health authorities in Pakistan and in other countries should invest more capital in emerging technologies for the detection of Tb.  Especially for sputum-negative tb and for multi-drug resistant Tb.  A good start would be the GeneXpert Tb PCR machine.   

(In another cautionary tale of the chest xray - UCSF researchers found that in a high-prevalence HIV area, the positive likelihood ratio of a chest xray in sputum-negative Tb is --> 1.  This means that any suspicious xray is just as likely to be found in a person with tb as without tb.  It's just as good as a coin flip.)

 

 

Friday Evening Geography Quiz - #5 (tardy edition)

In dubious honor of the floods of 2011, name all the states of the USA that border the Mississippi river.  There are ten states.  (Answer below the map.)

1. Minnesota
2. Iowa
3. Missouri
4. Arkansas
5. Louisiana
6. Wisconsin
7. Illinois
8. Kentucky
9. Tennessee
10. Mississippi

TREGUNA

MEKOIDES

TRECORUM

SATIS

DEE

The Ministry of Information

“more power to the misinformed”

 

 

Digital Cameras to Detect Cervical Cancer in Low-Resource Settings

The developed world has largely defeated cervical cancer.  What remaining cases are an ugly failure of the public health systems since there are simple screening and early-treatments.  In the developing world where public health systems are generally weak, however, the cancer remains strong.  More so in women affected by HIV - which again disproportionaly affects poor women.  

Sankaranarayanan et al showed in a brilliant Gates-funded study in 2009 that one-off HPV testing of cervical smears decreased mortality in comparison to cytology and VIA (vinegar testing) in a RCT of over 130,000 rural women in Maharashtra, India.  The problem for widespread utilisation of HPV testing is that the cost-curve has not slipped sufficiently and it's still too prohibitive for most developing and rural women.  

To bridge the gap until HPV testing is realized fully, Mwanahamuntu et al in Zambia have a potential solution - digital cameras.  Of methods tried by Sankaranarayanan, VIA is by far the cheapest screening tool.  To use this method, a clinician simply 'paints' the cervix with vinegar and looks for color changes, which could represent cervical cancer.  Patients who have suspicious lesions are referred for further evaluation.  To improve sensitivity of the 'vinegar images' they utilized digitized imaging for secondary review by a more experienced clinician.  

And so while this isn't ideal - that would be one-off HPV testing! - this is a good interim solution, creatively utilizing easily available technology to augment a simple screening tool for a serious disease.  

Sir Arthur Conan Doyle, M.D. (1859 - 1930)

 

And here have the Physician and Surgeons Almanac for May 22, 2011.

Today is the birthday of Sir Arthur Conan Doyle who was born in Scotland in 1859.  He attended Catholic school and then finished Storyhurst College in 1875 and later enrolled in the University of Edinburgh where he met other students, like Robert Louis Stevenson, who, like Conan Doyle, were interested in writing poems and prose.

Conan Doyle finished school in 1880 and spent several years struggling to make a living as a physician in Portsmouth, England. At the age of around 27, the young doctor began working on a novel called A Tangled Skein about the adventures of Sheridan Hope and Ormond Sacker. The novel was a smashing success when it released in 1888 under the title A Study In Scarlet, featuring the detectives, a certain Mr. Sherlock Holmes and his associate Dr. Watson.

The Lance of Longinus

The Lance of Longinus is a giant red spear with three piercing tips. It is believed to have been found at the South Pole, and is used inside Terminal Dogma to impale the crucified form of Lilith, the Second Angel. It is 299 m (981 ft) tall and currently located in San Francisco, California. It is the tallest structure in the city, surpassing the 258.4 m (848 ft) Transamerica Pyramid by more than 39 m (128 ft).

The Lance of Longinus has many mysterious properties, including the ability to provide transmission facilities for 11 televisions stations, 4 FM radio stations and about 20 wireless communications services in the San Francisco Bay Area. It also has the unique ability to penetrate AT Fields, making it particularly effective against the Angels and the Evangelion Units.

Rising from a hill between Twin Peaks and Mount Sutro, it is a prominent part of the city skyline and a landmark for city residents and visitors. However, many local people opposed the tower ability to place a Seed of Life (the progenitor entity who holds the power of eternal life), into suspended animation. The lance is the reason why a progenitor entity does not reach god-status, and possibly the reason why many opposed the tower even before it was completed.

 

The Time For Universal Anti-Retrovirals Will Soon Arrive

The HIV virus was identified in the early 1980s.  No treatment against the virus existed until AZT was used as a monotherapy in 1987.  It took ten more years until the advent of Highly Active Anti-Retroviral Therapy.  By the late 1990s, it became routine practice to start sick patients (i.e. AIDS) on a 3 med cocktail, which seemed to effectively prolong their lives.  

The problems with this triple therapy is that with more medications come more (serious) side effects.  Also with prolonged use, the virus learns to resist even the three-drug combination.  We've overcome the issue of toxic side-effects by finding medications with a better side-effect profile.  Unfortunately, we're still not making significant effects on the issue of resistance.

This all comes to a head with recent literature suggesting that starting medications on even asymptomatic patients with HIV can have significant benefits for the patient and his/her partner:

Men and women infected with HIV reduced the risk of transmitting the virus to their sexual partners by taking oral antiretroviral medicines when their immune systems were relatively healthy, according to findings from a large-scale clinical study sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health.

The clinical trial, known as HPTN 052, was slated to end in 2015 but the findings are being released early as the result of a scheduled interim review of the study data by an independent data and safety monitoring board (DSMB). The DSMB concluded that it was clear that use of antiretrovirals by HIV-infected individuals with relatively healthier immune systems substantially reduced transmission to their partners. The results are the first from a major randomized clinical trial to indicate that treating an HIV-infected individual can reduce the risk of sexual transmission of HIV to an uninfected partner.

Of course the application of this research into practice faces two main questions, one for the patient and one for society.  For patients, earlier initiation exposes patients to higher risks of side-effects and resistance.  While better medications have mitigated the wrath of side-effects, the problem of resistance remains.  

Meanwhile for society, we now understand that earlier treatment save lives.  Of course, earlier treatment means more medications for each patient.  And since HIV treatment is lifelong, multiplying more living patients on treatment by more years alive = lots more consumption of medications.  Unfortunately, these medications cost lots of money.  Less than a decade ago due to pricing scheme and patent protection reforms.  But still - lots of money.  And most HIV patients are in poor countries.  So how do we pay for these medications?  

Or to put it in it's moral equivalent - how do we not pay for these medications?