A Book Review: “Deadly Outbreaks” by A.M. Levitt, PhD

December 1, 2013

Phewww. It’s cold outside! This precious pic is my five-year-old grandson snuggled with a furry raccoon stuffed animal and wearing a soft and cuddly raccoon hat. For his nap. He knows how to stay warm!

I recently finished reading Levitt’s book, “Deadly Outbreaks: How Medical Detectives Save Lives Threatened by Killer Pandemics, Exotic Viruses, and Drug-Resistant Parasites.” [http://www.amazon.com/Deadly-Outbreaks-Detectives-Threatened-Drug-Resistant/product-reviews/1626360359/ref=dp_top_cm_cr_acr_txt?ie=UTF8&showViewpoints=1]

Published by Skyhorse Publishing in 2013, this book could provide the basis of a TV drama series and contribute to the audience’s understanding of how public health is organized and delivered in the US and why so many large nations want to model our approach.

The author hopes to introduce readers to field epidemiology, even getting them excited about it as a possible career choice. Because the book is carefully researched and provides a thorough narrative regarding the seven cases highlighted, she may achieve that aim. For these reasons, I will recommend it in future health communication seminars I teach and recommend it to you as well. Here’s more about why.

The CDC’s Epidemic Intelligence Service trains medical detectives, doctors who want to track down the source of population and health risks and guide the public health response. Dead birds, mosquitoes, New York City parks, and West Nile virus–collaboration with animal health officials brought a focus to disparate views about what was happening and what needed to be done in the book’s opening case.

Levitt then moves to a case giving us a historical context for modern policy related to refugees medical screening and movement into the US. This is a chapter that makes clear the need to be assertive in the public health sphere when faced with competing political agendas, to exercise skills that don’t traditionally come to mind when identifying the meaning of epidemiology. These skills include the ability to talk to [not ‘at’] members of local communities and to engage in participant observation, taking thorough notes to document both.

The third case takes us behind the scenes of a hospital in order to uncover the origin of unexplained deaths of children. A wide range of possible explanations were considered and found to be insufficient, including toxic fumes from repair work on the roof entering through air ducts. The point-by-point discourse guides us to both a conclusion and to new policy as accepted practice in most US hospitals today.

The fourth chapter guides the reader through the 1970s case of Legionnaires’ disease. Perhaps because I remember this one well, I was fascinated to read what was going on behind the scenes.

The last three cases introduce other contexts where the public’s health can either be supported or quickly go awry. I will never be on the interstate again passing a tanker-trailer truck labeled as carrying anything related to food without wondering about the conditions for keeping the food safe and bacteria free. Right now, most of the media images of the snowfall and road accidents involve those large semis. How many of them are carrying food-related products and what happens as they have to wait out the storm? What protocols kick-in? I feel comforted, but likely falsely so, that it is cold rather than blistering heat leading to breakdowns. I am thinking that keeping the chill on reduces bacteria’s chance to grow, thought it does not die, as discuss in the fifth case in the book. The case introduces us to FoodNet, a national surveillance system supported by the CDC to track foodborne pathogens.

The sixth chapter explicitly introduces the reader to the important principle of medical detectives sleuthing by asking ‘what if’. Asking that question and revealing the conversations that ensue really does remind me of one of the TV drama show that has been number one for years now and Abby’s character at work in the lab. Different context further broadened with the case in the last chapter. Not one we often have the privilege of looking behind the curtain at. But fascinating and filled with content to engage and inform. I highly recommend this book. Not one for light reading, but one that you will be glad you invested your time in.

Lyme’s disease is not just part of living in the woods

August 16, 2013

I was flipping through channels and saw Martha Stewart on David Letterman the other night. Dave was revealing that he had a ‘bull’s eye rash’–the stand-out characteristic of Lyme’s disease associated with exposure to ticks. Martha Stewart was completely dismissive, telling him she’d had it numerous times and it’s no big deal, just part of living in the woods. Basically, she told him she didn’t want to see his rash and to take some antibiotics and get over himself.

It is fortunate that Martha Stewart has not had any severe long-term and chronic conditions associated with having had Lyme’s disease. But many others are not as fortunate. For one, they do not display the ‘bull’s eye rash’ and the test for the condition is not very effective, so many people will not be correctly diagnosed. Many others may assume that it is no big deal after hearing Martha Stewart proclaim as much and fail to get care. She does say that antibiotics are needed, meaning that she does get care when she has the condition. So let’s not lose sight of that message. If you think you have been exposed, and if you have a bull’s eye rash most especially, see your doctor immediately and get on those antibiotics. Hopefully, you will have the same outcome as Martha and be fine after doing so.

In the meantime, become better informed than Martha appeared to be. Skim some of the highlights at this site: http://www.lymemd.org/?gclid=CN2wm6uMiLkCFcRlOgodFigAfQ

Uncertainty, mammograms, and iodine–what do these things have in common?

August 10, 2013

As I looked at my grandson splashing about in the lake, I thought about the upcoming annual mammogram appointment. Last year, I had to go back for follow-up. That turned out to be an ultrasound and the ‘all clear’. More than ten years ago, I had a follow-up that required a needle biopsy but also worked its way to the ‘all clear’ signal. Because it had been so long ago, I wouldn’t say that I took my screening outcome for granted, but I didn’t feel uncertain about it the way that I did this year because of last year’s ‘call-back’.

I did a little research to settle my uncertainty while the days passed and I waited for my appointment. I searched for published science about what causes breast cysts. In one word, I came upon research linking iodine deficiency to breast cysts and a whole lot of other issues summarized by a physician in this Psychology Today article: http://www.psychologytoday.com/blog/complementary-medicine/201108/iodine-deficiency-old-epidemic-is-back

Here is an example of one of the published research studies related to iodine deficiency and breast cysts: http://link.springer.com/article/10.1023/A:1008925301459#page-1

I will be asking my primary care physician this week if I have iodine deficiency. In the meantime, while the technician took an additional x-ray picture at the screening, I did not get a call-back, and I did get a letter from the mammography site giving me the ‘all clear’ based on the screening.

It is interesting to ponder if this is a case of unintended consequences associated with communicating about the danger of consuming salt, which has been iodized to compensate for iodine deficiences noted in the 20th century.

Jennifer Ohs talks about how older adults make medical decisions

March 14, 2013

I am using a new text in my undergraduate health communication course. The text is edited by Maria Brann, a professor at West Virginia University. It is called, “Contemporary case studies in health communication” and is published by KendallHunt, 2011. The text has a unique approach that is working well to spark discussion in my diverse undergraduate classroom. Each case in the book leaves out the conclusion to the case, so that the class can speculate on the possible endings. Then, as the instructor, I have access to the conclusions written by the case study authors and can share these with the class. We have lively debates about how a case is resolved versus other ways it might have gone. For example, the case that I will discuss with the class tomorrow was written by Dr. Jennifer Ohs, a professor at Saint Louis University. The case discusses medical decision-making and uses the example of an older woman who is deciding whether to have sinus surgery. It is a case used to illustrate problematic integration theory, which is the theory we are discussing in class this week, a framework for understanding proposed by Professor Austin Babrow who is a faculty member at Ohio University. The theory explains why communication may cause us to form judgments that a good outcome is highly unlikely, while a bad outcome is very likely. Other situations that are problematic to integrate with our experiences include situations in which communication makes two options seem to be equal, both in terms of how likely or unlikely they may be and/or how good or bad we judge outcome linked to the option. The case discusses how an older woman considers what her husband, son, and daughter have to say about the surgery, the role of prayer, a friend’s view, and the conversations that her usual doctor and the specialist who would conduct the surgery have with her. In the end, she decides not to have the surgery. It is a good decision for her as it turns out, because she later learns that she needs dental surgery, and having that surgery resolves the issues she was having with her sinuses as well. Of course, she did not know that when she made the decision. Rather she made her decision because her daughter did not offer to come and be with her, because she really wanted a second opinion and her husband would not like to have to drive to the city to see another specialist, and because her son had a similar surgery that did not improve his health much. These were weighed with the doctor’s advice to have the surgery and led to her choice. It will be interesting to see how the class views this case and the ideas they come up with for possible conclusions.

The federal sequester and health communication

February 28, 2013

Little else dominates the news right now besides the sequester. I have to wonder if anyone has calculated the costs associated with calcuating the costs of cuts linked to the sequester. Here is just one example: http://astho.org/Advocacy/Sequestration-Fact-Page/ The Association of State and Territorial Health Officials has taken the time from their already overloaded and underfunded docket to explain the effects of the impending cuts as envisioned. The picture is not pretty.

Besides the lost dollars and lost work hours, the lost productivity across all kinds of spheres associated with this ‘event’ relates to emotional tolls and the anxiety within families created by such uncertainty. These events turn into physical and mental health problems, including diseases associated with stress and depression. Interpersonal violence increases in personal and social relationships.

I hardly know what to say. From an ethical perspective, the dilemma linked to distorting and manipulating information for so long leaves so many with feelings of distrust. I like a good debate probably even more so than the average citizen, but the time is long past for beating the drums of authority and power, and instead to lead by example.

Clean Your Hands Campaign

February 19, 2013

The World Health Organization — WHO — has long promoted hand-washing as an important way to reduce the risk of spreading infections. While we all can reduce the risk by washing our hands, we may also assume that healthcare workers would be among the people most likely to practice hand-washing. Apparently not. A study designed to increase hand-washing among healthcare works cites evidence that compliance with the practice is just 25-40%. The article appears online in PLOS ONE [ a publication of PLOS [ http://www.plos.org/] an organization designed to make peer-reviewed medical research accessible in less time and with less cost than more traditional approaches to publishing scientific results. The research led by Chrsitopher Fuller, “The Feedback Intervention Trial (FIT) — Improving Hand-Hygiene Compliance in UK Healthcare Workers A stepped Wedge Cluster Randomised Trial”, conducted the study in 60 locations that included 16 acute hospitals and 44 general medical wards or acute elderly care sites. All sites were already participating in the “Clean Your Hands” campaign. This campaign includes placing alcohol hand-rub at patient bedsides, using posters and other educational materials to encourage workers to clean their hands. an audit and feedback on compliance was cinluded at least once every six months, so workers knew that the behavior is expected and would be evaluated. The FIT focused on goal-setting for and rewarding of handwashing behavior as an additional compoment to the national campaign.

A significant increase in hand-washing occurred with the FIT, with more change in the 16 intensive therapy units than in the other sites — achieving 13-18% change versus 10-13% change, ranging about 60% to nearly 80% compliance. The improvement declined over time. There were difficulties associated with implementing the protocol, including that the trial place extra responsibilities on some ward staff, who did not receive additional training beyond the initial introduction to the intervention and were not monitored after the initial observation of their placement of materials bedside. To increase the likelihood that such a campaign would be successful over time, the authors recommend that the tasks be integrated into the role of some employees and audited regularly as part of job performance. As for me, I will be watching to be sure healthcare workers wash their hands. And I will do the same.

When is reading a mammogram like looking for a polar bear in a snowstorm?

August 9, 2012

When you have dense breast tissue… at least, that is what some physicians say [go here, for more: http://www.womentowomen.com/breasthealth/densebreasttissue-mammograms.aspx ].

It has been 15 years since my annual mammogram led to a callback from the doctor for more x-rays and then a needle biopsy and finally ‘the all clear’ — no sign of cancer pronouncement. But it happened again last week. I got my annual mammogram on my way out of town to go to Atlanta for a visit with my daughter and granddaughter and son-in-law. And the day after I had the screening, I got a message on my home machine to call for a return visit…

Things have changed in the last 15 years, of course. Now, digital mammography makes some things more likely to be seen on the x-ray compared to film. Go here for a comparison: http://www.umm.edu/breastcenter/digital_mammography.htm?gclid=CNbCiKu_27ECFUlnOgodsH4A_A

At any rate, I returned to the imagery center for more x-rays. Here is how the communication went. First, it was nearly impossible to understand the message on my answering machine. My husband and I listened to it a half dozen times. We looked up the phone numbers of the imagery center, and none of them matched what we thought we were hearing. Nonetheless, I wrote what we thought they were saying and tried the number. It rang out to a message saying that it was long distance. Not likely then to be what I needed to call. Next, I tried calling the number using the first 3 numbers that all the numbers online for the imagery center used. And the last 4 numbers we thought the caller was saying that appeared nowhere in the online listing. Success. I got a nurse who checked and said, “When can you come in?” And I made an appointment for the day after I would return from my visit, which was a week after the first mammogram.

I went to the imagery center, this time with my husband coming in. The volunteer greeted me with, “Oh. I am so sorry.” Yikes. Not what you want to hear. She remembered me from the week before because we had a long chat about my height. At any rate, I would venture to say–“so sorry” is not quite the right expression in this situation. Perhaps “sorry you have to come in for more tests” if ‘sorry’ is to be used at all. The expression and her empathy were, however, unsettling.

Once I was in the room with the x-ray technician, I encountered the other end of the spectrum. The communication was reactive rather than proactive regarding what she wanted me to do. “Put your arm up and grab the handle? I did. “No. Turn this way. Face the machine.” Her tone was irritated. Wow. It is 9:30 in the morning. Why is she so grumpy? I am the one getting my boob smashed again.

She sighed. Letting out a clear expression of annoyance, she said. “Stick your bum out.” Who talks like that? “No. Look at me– Like this–” she said as though talking to someone she regarded to be extremely stupid. Finally, she was satisfied.

Time for another image. She turns me a bit and I try to enact what I have learned. I stick my bum out. “No.” she says harshly. “Stand up straight.” My arm began to quiver. Unavoidably uncertain about what I was doing wrong. Several more images and abrupt commands later, we were done.

“Will the radiologist come in here to discuss these with me?”

“No. Wait in the waiting room. I will get you when he is ready for you.”

I asked the volunteer if she would get my husband when I got called to the radiologist meeting. She told me to ask the technician to do it. So, when the technician came to get me, I asked her. And she did. No attitude. Wow!

And then there was the radiologist. I don’t think he could have been nicer or clearer. He put two pictures up on a screen and pointed to a small round dark spot about the size of a pellet for a BB gun. “This is what we’re looking at that’s different,” he said. “All this is your muscle and dense breast tissue.” It all looked like a lot of snow to me but I could see the BB…

“We’re going to do an ultrasound to see what we can learn about that spot.”

“What will the ultrasound tell you?”

He launched into a helpful answer that I will summarize as, ‘if the sound waves go through the mass, it’s a cyst. If they don’t it may be something we need to take a look at.’

The sound waves showed no mass. He spent plenty of time making sure that it did not appear in any direction. And then he announced, “I believe it’s a cyst. I will call this ‘normal’ and you won’t need to return for a year. Unless, of course, you see or notice changes that should be checked. Any questions.”

Hip Hip Hooray…. But I wish someone would give me a satisfaction survey to fill out about the volunteer and x-ray technician. I have a few thoughts about how their communication could be improved.

Health communication about medical test sensitivity: The TSH and CA 125 blood tests example

July 23, 2012

Doctors often recommend blood tests to help them diagnose our condition or to check our health status. For example, I have an underactive thyroid condition. As discussed in my book ‘Talking about health’ — my ‘normal’ numbers fall outside the range of a healthy ‘normal’ [see for a discussion http://www.denvernaturopathic.com/news/TSH.html]. I was diagnosed with this condition in my 20s and have taken daily medication to address it since that time. My mother was diagnosed with the condition in her 20s as well. I go to see my internist annually, and he puts in an order for a TSH [thyroid stimulating hormone] test [http://www.endocrinology-online.com/Content/For%20Patients/TSH.htm] that I go to the lab for several weeks before my scheduled appointment. This test is considered to be very sensitive–but what does that mean? It is the probability that a person having a disease will be correctly identified by a clinical test. However, a careful reading of the article at the link shows that the results may depend on the time off day you were tested–a reason why the test is given in the morning after fasting.

But aren’t all medical tests highly sensitive? Otherwise, why do them?

The answer to the latter is ‘because that is the best that can be done’. The answer to former is ‘no’.

Take the CA 125 test, for example. The test was hoped to be a valid indicator of ovarian cancer. However, the test indicates the presence of other disease as well. So a positive CA 125 test validly indicates the presence of ovarian cancer sometimes but often does not:

“The result of a Ca-125 test is interpretable only by considering the context in which it was ordered. When you order a Ca-125 test you will have to estimate your patient’s risk for having ovarian cancer. If your patient can be put in a group in which the likelihood of cancer is high then a positive test is probably correct and a negative test wrong. If your patient can be placed in a low risk group then the positive test is probably wrong and the negative test meaningless. Furthermore, there is no way to evaluate a positive test. You can repeat the test and pick the best 2 out of 3; 3 out of 5; 4 out of 7, etc. Otherwise, she will be heading for surgery” [http://www.gynoncology.com/ca-125/].

So if your doctor orders a CA 125 test, remember that the results should be discussed. This is true of all medical tests.But when a test that has been ordered is not highly sensitive, it is really important to discuss the meaing of the test result. If the test comes back positive and is not highly sensitive, have a conversation and ask: ‘What’s next to rule in or rule out the condition you were testing for?’ AND ‘What other conditions could the positive test result suggest I may have? How will we rule out whether I do or do not have them?’

Health communication and Dr. Oz’s message about paraben

May 1, 2012

I am in the midst of final exam week and grading. In the background, Dr. Oz started talking about ‘paraben’ and how it acts as an estrogen. I am always on the alert for these kind of messages. Hormones, research, cancer, blood clotting… these all came to mind. I got up from the computer and went to listen carefully. And then I went to my bathroom. My shampoo have five kinds of paraben in it. My two different types of body lotions had multiple forms of paraben as well. I got rid of them. Trash. Not a moment’s hesitation.

Why? Well, one of the facts Dr. Oz shared is that in one research study, 19 of 20 women diagnosed with breast cancer had significant levels of paraben in their breast tissue. I will hunt down the research and share it soon. For now, here is a summary of content from Dr. Oz with the link to the story at the end:

”

Flushed Away

We all know about industrial pollution and climate change, but there’s a new threat to the environment much closer to home – pharmaceutical and personal care product pollution (PPCP). Experts are increasingly worried that marine life across America is showing us the harm it’s doing to our planet and ourselves.

What’s Happening to the Environment?

In river basins around the country, the United States Geological Survey has found fish with both female and male sex organs. Intersex frogs are also popping up all over. And experts have found evidence of chemicals called endocrine disruptors, such as atrazine (an herbicide) and Bisphenol-A (BPA) in the country’s water supplies.

What are Endocrine Disruptors?

These chemicals alter the actions of hormones in our body, which can hurt us in 2 ways. First, they can block our hormones from acting as they normally would, and, secondly, they can act like hormones triggering effects that may include early onset puberty in adolescents.

What’s Happening to Us?

Breast cancer rates are increasing, girls are entering puberty earlier, sperm counts and testosterone levels are falling drastically, and certain genital abnormalities are on the rise.

What Should We Watch Out For?

Though the evidence is not definitive, experts fear that products we are introducing into our environment could be to blame, and they are urging us to decrease the use of certain chemicals. Here’s what to look for:

Bisphenol-A (BPA)You may have heard about BPA, the chemical used to make hard plastics, line cans, and create carbonless receipts. It’s proven to raise the risk of breast cancer in rats and the FDA has raised an alarm about the potential harm BPA can cause; Connecticut even banned its use in children’s products.

Ninety-three percent of us have BPA in our bodies. We live with it, and we excrete it when we go to the bathroom, sending the chemical into the environment.

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Phthalates

These difficult-to-pronounce ingredients help fragrance linger on the body after you have applied a lotion or body cream to your skin. They’re also found in toys, floor coverings, detergent, soaps, nail polish, and shampoos. Unfortunately, they mimic the hormone estrogen and have been linked to reproductive problems in rodents, such as lower testosterone and fetal malformation. Often they are not listed on beauty products, so the best rule of thumb is to avoid any products with fragrance.

Parabens

Found in moisturizing shampoos and body lotions, parabens are the most widely used preservatives in the beauty product industry, and they also act similar to estrogen in our bodies. One study found parabens in the breast cancer tissue of 19 out of 20 women studied; experts worry there could be a connection.

Use these chemicals as a litmus test for a healthy product. If you see them listed on the label (often as methylparaben, butylparaben, or propylparaben), it shows that the manufacturer is not concerned about limiting exposure to potentially harmful chemicals.

Leftover Prescription Medicine

The medication we take ends up in our water supply in 1 of 2 ways. We secrete it in our urine (which we can’t control), but many of us also flush unused medication down the toilet, contributing to the rising amount of pharmaceutical pollution found in our water supply. In 2008, the Associated Press found that dozens of pharmaceuticals end up in our water supplies, and eventually, in our tap water. That’s because water treatment plants are designed to neutralize biological hazards, such as bacteria, but not pollutants such as antibiotics. Scientists are now discovering bacteria in the wild that are not only resistant to antibiotics, they can actually live off them.

What Can You Do?

Drink water from stainless steel bottles
Avoid plastics with the numbers 3, 6, and 7 on the bottom
Never heat plastic in the microwave (even if it says it is microwave safe)
Choose frozen and fresh produce over canned
Use BPA-free baby bottles
Avoid any products that contain fragrances; opt for those that get their scent from essential oils
Stay away from parabens
Choose products that are paraben- and phthalate-free
Dispose of leftover medication by throwing it in the trash with coffee grinds or cat litter (to keep harmful medications from being picked from the trash), return the unused portion to your pharmacy, or go online to find your local hazardous waste disposal facility.”

http://www.doctoroz.com/videos/flushed-away?page=2

Telling it like it is…communicating about end-of-life

March 13, 2012