Inflammatory Language: The Rain in Spain...

Sanidad publica
Illustration by Monica Lalanda 2012

...austerity, that is...falls on many of us (in the UK, Ireland, Greece and many other European Union countries including the Baltic States, and also the US). Austerity has finally pushed Spanish doctors into working together (a historically rare occurrence) to fight the break-up of their national health system. The UK is at risk as well.

In February, The Febrile Muse asked readers to submit to Inflammatory Language either a 300-500 word article and/or illustration that conveys inflammation. It could have been humorous, political, or encompassed pop culture or current events. The overall goal was to accurately inform readers. 

Dr. Monica Lalanda was the first to submit her work. She submitted three illustrations from her blog:  Medicoacuadros. Dr. Lalanda is a Spanish Emergency Medicine doctor who trained and worked in the UK before going back home. She fights for a better world with her stethoscope, her words, and her drawings, and strongly believes in a good public health service. She is married to a surgeon and has two kids. Please read her blog. It is passionate, and places her patients and vocation at the center of healthcare. I'm sure doctors, pharmacists and other health care professionals will be able to identify with her illustrations, such as this one: 

A punto de estellar (to burst)
llustration by Monica Lalanda 2012

Now, how does this relate to Inflammatory Language? Well, obviously financial tensions are inflammatory. Yet, my original intention was to focus on the science of inflammation and infection. After reading more submissions, and reading about the sequester (not to be confused with quarantine or isolation here), it hit me how healthcare systems and cuts to resources--to detect, research, control and treat infections was inflaming passions.

We all know that good accessible healthcare leads to the control and treatment of infectious disease. I will go a step further to say that we (physicians, pharmacists, nurses, scientists, and science writers) have an ethical obligation to worry and work against the unintended effects of austerity, sequester, and challenges to our health systems--on many levels, but for our sake here, on the prevention and treatment of infectious disease. 

What evidence do we have that austerity measures have already affected infectious disease? These four things are just the tip of the iceberg..... Feel free to add to the list in the comment section--a later post can expand upon the evidence.

• In Greece, drastic cuts to condom and needle exchange programs has lead to more HIV infections
• Also in Greece, overall infectious diseases morbidity/mortality in men has increased.
• No statistics done to find an association, but look at resistance pattern for Klebsiella pneumonia--appears to be higher in countries that have made drastic cuts to healthcare (austerity measures)
• Disease-carrying insect control has been drastically cut in Florida, where an uptick in home-grown Dengue fever seen in 2009 (before Mr. Scott took office) and 2010; Globally, dengue fever cases are up (in non-tropical areas too) and severely underestimated.

Angry Doctor
Illustration by Monica Lalanda 2012

Infectious diseases can spread globally, and a great deal of resources need to be in place (in all countries) to prevent widespread disease. An outbreak, if not contained, can spread to other countries, undetected until it is too late. And in the case of resistance, inadequate containment/treatment in one country may lead to inadequate treatment in others.


It will take global resources to prevent a backslide in protecting our people from infectious disease. It is imperative that we consider:

• The Healthcare labor-force
• Nursing shortages have been associated with increased mortality in patients due to urinary tract infections and pneumonia
• Number of clinical pharmacists in hospitals inversely related to medication errors
• Access to healthcare and nutrition
• When patients have limited access to healthcare, emergency rooms become overburdened. 
• Limited access either results in inappropriate use of ER departments and/or delayed treatment (if patient goes nowhere).
• Sequestration will lead to cuts in public health (the extent of cuts has been debated)
• Decreased funds to multiple programs to aid the poor
• Infant mortality is already high in poorer cities and states
• Decreased meals for seniors, due to sequestration
• Vaccinations
• Global vaccination programs require resources
• Lack of adequate vaccination coverage leads to more infection
• Sexually transmitted diseases and HIV/AIDS testing/treatment services
• Decreased HIV testing and for other STDs
• Decreased treatment programs
• Infection control and antimicrobial stewardship  
• Surveillance agencies need resources (sequestration has led to cuts at the Centers for Disease Control, CDC)
• Resistance
• Multidrug resistance among Gram negative infections, HIV, and TB are increasing (a recent example of carbapenem resistance)
• Treatment of resistant organisms is more expensive than prevention of or treatment of susceptible infections
• If resistance reaches the point where many infections are not treatable, routine surgeries such as cardiovascular procedures and joint replacement become more risky
• Research organizations need resources to develop new vaccines and antimicrobials and other methods to prevent and fight infection (sequestration has led to cuts to the National Institute of Health, the NIH) 
• Pharmaceutical companies have little financial incentive to develop new treatments
• Food and water inspection
• less inspection of food, water, and more antibiotic use in animals may lead to more food and waterborne illness.

Dr. Lalanda won this book!
Thank you for your submission.
Photograph by Monica Lalanda 2013

By working together, as healthcare professionals, as scientists, as writers and illustrators, we should fight for the resources to do what is right and just (because we have the information)...for humanity, not our individual pockets.

I realize that there is only so much money to go around, but we have made tremendous gains in the prevention and treatment of infectious diseases. When you only look at infectious diseases and what needs to be done to take care of our people in the best way possible, I see the Tea party as immoral...at least real tea has antimicrobial properties.

Winner of Inflammatory Language Contest!

from cofisher.blogspot.com

The Febrile Muse has chosen three illustrations by Dr. Monica Lalanda, an Emergency Room physician in Spain, as the winning entry of  the Inflammatory Language contest. Dr. Lalanda will receive The Best Science Writing Online 2012 as her prize. Congratulations!

In all honesty, I feel that by meeting Dr. Lalanda, I have won. She has great insight into the plight of healthcare on a global scale, namely that of Spain. In this day of austerity and sequesters and challenges to The Affordable Care Act, I worry about the unintended effects on management of infectious disease. Bolstered by what I have learned from Dr. Lalanda, a future post will discuss this, but most importantly--feature her wonderful illustrations.


Thank you to everyone that submitted material.   

Support Science Studio

Because of the generosity of readers and the science community, The Febrile Muse was able to help support this fabulous project, spearheaded by Rose Eveleth and her colleagues Ben Lillie (Story Collider) and Bora Zivkovic (Scientific American). They are developing a web-home for the best of science multimedia.

In support of science and science writing....and now....science multimedia! There are 8 more days to go on Kickstarter.


  

Contest for Inflammatory Language!

Inflammatory Language is a series of primers on inflammation science. Care to contribute? The first place winner will receive one copy of The Best Science Writing Online 2012 published by Scientific American/FSG! This contest is a great opportunity for students, but anyone can contribute.

Carefully select 300-500 words (or less) and/or an illustration that conveys inflammation. It can be humorous, political, or encompass pop culture or current events, but must be professional. It also needs to be appropriate for viewing/reading by most people.

The overall goal is to accurately inform readers.

Submissions can be sent to thefebrilemuse[at]gmail[dot]com. Please include your byline and link to your website, if you have one. Thank you in advance, and good luck! I look forward to reading your submissions.

Deadline:  February 28, 2013

The Birth of a Monocyte: Inflammatory Language No. 4

Monocyte by Asthydays 2012

Having only three days to live would be…daunting. I don’t suppose monocytes consider this, but once they enter the circulation, they have three days to either participate in inflammatory response reactions (be a reactionary) or die an oxidative death, only to be replaced by the next “frantic” monocyte. And so goes their life cycle.

Long before a monocyte is “born,” its ancestor or progenitor, a pluripotent stem cell, lives within bone marrow stromal cells and is capable of turning into any other kind of human cell: heart cell, liver cell, or a cell of the blood, to name a few. Some pluripotent stem cells develop into hematopoetic stem cells (HSC) that further develop into the blood cells of the human body—the lymphoid or myeloid cell lines. The myeloid cell line encompasses the platelets, red blood cells, mast cells, basophils, neutrophils, and eosinophils. It also encompasses monocytes, macrophages, and myeloid dendritic cells, leading to the birth of potential reactionaries.

From Wikipedia

In 1915, the movie The Birth of a Nation was released, triggering inflammatory responses all over the United States. Additionally, it became a recruitment tool for the KKK. The dangerous and faulty parallel between that movie and the monocyte is this: the monocyte can lead to inflammatory reactions, and the monocyte can recruit immune or reactionary cells. The parallel breaks down when there is no need to react, that it would be wrong and disease-causing to do so; so the tolerant monocyte just hangs out. There is no inflammation via its doing.

In the human, the majority of new monocytes are produced in the bone marrow of the vertebrae or sternum. In fetuses less than 4-5 months gestation, they are produced in the spleen and liver. Within a niche, a particular microenvironment of the bone marrow not yet determined, HSCs develop. This niche could be an osteoblastic (cell that builds bone) niche, an endothelial cell (lining of blood vessel) niche, a multipotent primitive mesenchymal cell (like CAR and nestin-expressing) niche in the stromal cells, or a combination of some or all of these.

From Wikipedia

Although the exact niche for HSC isn’t known, studies have revealed that CXCL12-CXCR4 (ligand-receptor) signaling is necessary for maintenance of HSC and their progenies. And, by influence of certain chemokines like interleukin-1 (IL-1), IL-3, IL-6, granulocyte-macrophage colony stimulating factor (GM-CSF), and stem cell factor (SCF), the myeloid cell line develops.

GM-CSF causes further differentiation (specialization) of the myeloid to a myeloblast, which is further differentiated into basophils, neutrophils, eosinophils, and monocytes. SCF, GM-CSF, IL-3 and IL-6, and specifically M-CSF aid in the development of promonoblasts, monoblasts, promonocytes, then finally—monocytes.

Macrophage: First Attempt by The Sensitive Scientist 2011 

The monocytes can reside within the marrow, be stored in the spleen, or nonchalantly patrol the blood for microbes—and await activation into macrophages or dendritic cells. If unchanged, the monocytes eventually die an apoptotic death. Their lack of DNA repair genes may have something to do with this for macrophages or dendritic cells are able to repair their DNA, and therefore live longer. I don’t suppose a monocyte considers this either, but it is their life.

Sources:

Apoptosis of monocyte: Bauer M, Goldstein M, Heylmann D, Kaina B (2012) Human Monocytes Undergo Excessive Apoptosis following Temozolomide Activating the ATM/ATR Pathway While Dendritic Cells and Macrophages Are Resistant. PLoS ONE 7(6): e39956. doi:10.1371/journal.pone.0039956

Bone marrow niches for HSC: Sugiyama T, NagasawaT ; Inf lamm Allergy Drug Targets. 2012 June; 11(3): 201–206. Published online 2012 June. doi:  10.2174/187152812800392689

Wikipedia: hematopoetic growth factors

There will be three Inflammatory Language posts devoted to monocytes. The first of which, Monocyte Fashion, addressed the style or types of monocytes. This post is the second devoted to monocytes. The third and forthcoming post will address cell trafficking, from the monocyte’s perspective. Future posts will eventually address the rest of Inflammatory Language, the song.

This is the fourth post of a series: Inflammatory Language. The series will briefly emphasize aspects of inflammation, mainly in response to microorganisms, but not always. You can contribute to this column by submitting a 300-500 word piece (or artwork) to me by email, along with byline. If deemed appropriate (it can be serious, political, scientific, or funny as long as it pertains to inflammation), we'll publish it here and the first place post (deadline February 28, 2013) will receive one copy of The Best Science Writing Online 2012 published by Scientific American/FSG!

Wherefore Science Writing? An Interview of Richard Wintle

Several wonderful interviews between authors in the anthology The Best of Science Writing Online 2012 (Scientific American/Farrar, Strauss and Giroux) have originally been posted here. As a newbie to the anthology, I felt humbled to have the opportunity to interview another newbie, although a more experienced writer than me.

Richard F. Wintle, the assistant director of The Centre for Applied Genomics at the Hospital for Sick Children in Toronto, Canada, joined me for an email chat over the last month. He writes about science, photography and motorsports at the Occam's Typewriter blog, Adventures in Wonderland. His contribution to the anthology is Genome Sequencing and Assembly, Shakespeare Style. It is a lively and witty explanation of genetic code and assembly that uses Romeo and Juliet and Julius Caesar to explain. Bravo. I loved the piece and requested to interview him. He graciously accepted. 

 

I had read his piece months ago, but for the interview I had to find him on the jacket cover (designed by Jason Heuer). The cover reminds me of the periodic table, but also stimulates faint memories of The Hollywood Squares. In order for me to ask Richard questions, I needed to lean out of my red square and look down and slightly to the right, to the next group over.

[waves to blue square] Hi Richard!

Hi right back at you! Hollywood Squares - now I know I've made it!

Richard, do you remember the moment when you decided to write this piece? What "forced" you to do it? I'm assuming a conscious decision took place, but maybe not.

I’d been thinking for a while about ways to try and get the genome analysis and assembly problems across to non-specialist audiences, and had been kicking around ideas using jigsaw puzzles, music, literature, and other things. Shakespeare seemed like a good choice, since most English-language readers would be at least a bit familiar with his writing. Likening genome sequence to text is fairly obvious, and I’m certainly not the first to do it – “the genome, if written out in full, would take so many pages,” that kind of thing.

Actually sitting down and writing it was, I’m not ashamed to admit, something I forced myself into because the deadline for OpenLab submissions was approaching, and that was as good a reason as any to finally get it done.

Deadlines can be incredibly helpful. Another deadline looms....any teasers you wish to give at this time?

Unfortunately, no. Somehow this year’s OpenLab/TBSWO deadline has slipped past me. I am still percolating a few ideas though. I’ve had an idea for using music to explain deletions and duplications in the genome, but I’m not sure it will work as a written piece. It will probably make its way into my teaching presentations, though. Otherwise, I’m still enjoying exploring my local part of southern Ontario – lots of history around here, and some interesting science connections that may spur some writing.

I like your musical idea. How about a podcast or some other way to incorporate music into the structure of your writing?

That's a good idea - but not one I think I'll take on. I'm not a huge fan of embedded audio or video in online writing, as I prefer to be able to simply read. Plus, nobody needs to hear me playing instruments or (shudder!) singing online. I'll leave that to someone more talentented, I think.

What were your challenges in writing this piece?

My biggest problem is that I’m very verbose – I constantly need to keep reminding myself to write more concisely. As a result, the posts went through many edits before I put them up on Occam’s Typewriter. The original posts also had a number of photographs with captions that I thought were rather witty. When it came time to include them in the book, I initially had trouble in letting them go – but fortunately it turned out that the writing didn’t depend on them to get the point across after all. I’m glad we had a good editor.

 I agree that editing is a key part of the writing process, very different from the initiation of writing. 

Where did you write your piece? I consider thinking about what you want to say, the pre-planning, a part of the writing process.

I probably thought of parts of this in many different places – while driving, sitting on the train, or when I was supposed to be thinking about something else. I’m pretty poor at formally planning my writing – I never sketch an outline, for example. I have a half-hour train commute every day, and I certainly typed some of it there. Other ideas I’d note down during the work day. But most of my writing I do at home in the evening, when there are fewer distractions, and when I have time and internet access so that I can check background material, access my photos on Flickr, and find links I want to include.

 I can identify with you needing research time without distraction.

I think it is great that you use commuting time for this creative venture. You have something in common with many writers...trains.   

Trains are good. Most of the time.

What are your dreams for your writing? Did inclusion in this anthology change your initial plans?

I don’t think I’m disciplined enough to have “big dreams” of authorship – like writing a book, for example. All the research would kill me.

Inclusion in TBSWO2012 hasn’t changed my plans much, although it’s certainly fun to be included and I would like to be again. My fellow Occam’s Typewriter blogger Stephen Curry has been in several successive editions, which is impressive. I do tend to blog in a much more narrative, diary-like way than I’d like. Writing with OpenLab/TBSWO in mind as a target forces me to be more didactic (and concise!), which I think is a good thing.

Along with your clinical and research genomics work, you mention teaching a non-specialist audience. Who is that audience, and how has your writing life co-existed with teaching? Do you use either your or other science bloggers' writings in a teaching capacity?

I should first clarify that what we do is 100% research, rather than clinical – although there are certainly diagnostic implications of some of the results we obtain.

Part of what I do is to introduce interested parties to the laboratory here – through seminars, tours, or both. These can range from high school students, through funders and other stakeholders, to people with no science background at all. Some may be philanthropists, some may be parents of patients, or representatives of organizations involved in Autism, which is a large focus of the research we do. One memorable tour was for high school science students from the National Ballet School, which was a slightly different and more athletic audience than usual.

I also do some teaching to community college and university students, typically studying bioinformatics or forensics. Most have some biology background, but generally not a lot of experience with high-throughput genomics, so the focus has to be a lot less specialized than, say, for a talk at a scientific conference. Some examples I use in these teaching activities are drawn from things I’ve written (and vice versa). I tend to stay away from using other science writers’ examples, though. And I’m increasingly using more visuals and less text in my presentations – being an avid photographer, I find I can work images in fairly readily. I’m not sure yet how much this helps to get the point across, but I’m experimenting.

It is great that you look at different ways to present and teach your field. What do your students and/or interested parties want to know about autism and the work you do in your laboratory?

One thing I've been told is to always try and bring the abstract, technical aspects of the genomic science we do back to a disease or disorder, something that people can more easily relate to. In our case, that means patients and families - and for us, the patients are kids. Having said that, I'm not sure that my Shakespeare piece does that at all. But students, particularly younger ones, can easily relate to autism because it's much more recognized now than, say, when I was in grade school. Younger students all seem to know someone in their classroom, or the one next door, who is autistic.

One other thing people ask about is the genetics. Autism is highly heritable - meaning it has a strong component determined by changes in genes, either de novo in the child, or possibly inherited. Many people don't realize that the genetic basis is so strong, so that's often something I'm asked about.

I assume you read many different writings, and you are a photographer. What author and/or photography have particularly inspired you?

I do read a lot, and diverse things. On the scientific side, I like a few that I’ve mentioned from time to time – The Nobel Duel by Nicholas Wade, which is a great example of high-level competition in scientific research, and is clearly thoroughly researched and told in a very engaging way. I like a lot of popular science writing, particularly the books of Jay Ingram. On the photography side, Last Chance to See is wonderful – both versions, the first by Douglas Adams and the more recent one by Stephen Fry, with gorgeous pictures by Mark Carwardine. The photos really help to tell the story – in this case, of highly-endangered species. I also enjoy non-science photography, in particular the wartime reporting of Robert Capa and Gerda Taro. Capa’s autobiography, Slightly Out of Focus, is a hoot, as is his excursion through post-war Russia with John Steinbeck, A Russian Journal. Both are good reads, and great examples of how words and images can enhance each other.

I haven’t gotten to the stage of being able to take a photograph that immediately tells a story without need for any accompanying text, but that’s something to aspire to.

I think readers would miss your text, but I’m sure your wit would become evident through pictures.

Thank you for your time and for answering my questions; I greatly enjoyed our correspondence. Best of luck to you in your writing at Occam’s typewriter, your photography, and in your career. I wish you and your family all the best. I’m going to the library now to look up those books you mentioned.

Perhaps we’ll see you back when The Best of Science Writing Online 2014 is published?

Thanks, Cindy. It should be a New Year's Resolution for me, every year - write more! Maybe 2013 will be the year. All the best!

Richard also interviewed me, which can be read at his blog, Adventures in Wonderland.

Monocyte Fashion

Hyperbolic Blood Cells,
by Cyberxaos; Feb. 2008 

Monocytes play a role in infection-fighting and in inflammation. However, they are only one type of cell that run the body's immune system. But they do it with style.

Each monocyte has different abilities to react to and release chemokines (chemicals that cause action), and each has a different surface, a surface decorated with different types of CD molecules. There are three basic types of monocyte: classic, non-classic or patrolling, and intermediate. They are categorized by their CD molecules, their fashion.

The classic monocyte sports relatively a lot of CD14 and no CD16 molecules. Tim Gunn refers to them as CD14++CD16-; at least he would if he wrote about the fashion of monocytes. These are the monocytes we mainly think of, the divas or warriors that go to sites of infection and differentiate further into macrophages and dendritic cells. If the body does not need all of them, they are sent back to the bone marrow fitting room where their fashion is altered...they get down-regulated to CD14+CD16++ and become patrolling monocytes.

Different cells within blood
from Wikipedia

The CD14+CD16++  non-classic patrolling monocytes hang out on the lining of blood vessels and in the spleen, but also participate in general, not-too-inflammatory, wound healing. These monocytes are the least inflammatory of the bunch.

Of course, there are monocytes in the middle: the intermediate, pro-inflammatory ones. They secrete tumor necrosis factor and other chemokines to keep inflammation going. They have been linked to atherosclerotic activity. The fashion for this function is CD14++CD16+, in between the classic and non-classic patrolling design.

Most fashion is superficial, but the surface of monocytes determines their actions and how they react to their environment. And we have only touched the surface of monocytes. Other posts will convey how they develop, how they are trafficked within the body, and how they function in trauma and infections.

Source: Pamer EG, Shi C. Monocyte recruitment during infection and inflammation. Nature Reviews/Immunology. November 2011; 11:762-74.

This is the third post of a series: Inflammatory Language. The series will briefly emphasize aspects of inflammation, mainly in response to microorganisms, but not always. You can contribute to this column by submitting a 300-400 word piece to me by email, along with byline.  If deemed appropriate (it can be serious, political, scientific, or funny as long as it pertains to inflammation), we'll publish it here and not use it for anything else--thank you. At some point, I may be able to offer compensation, but can only now offer the warm fuzzy feeling you get when you post something for people to read.