Thursday, November 21, 2013

Explore the Source: Epidemiologists at Work

this book and provided me a reviewer's 
copy. They gave no renumeration or 
editorial guidance for this review.
African Water Pump H53
Acrylic byMariah Hamman
posted: Eckhart Public Library 2012

How to save millions of people? Hire epidemiologists—medical detectives who investigate: foodborne and food industry illness, increased and unexplained mortality rates, higher than expected rates of pneumonias and fevers, and global migration of highly resistant organisms, among many other events. Often they work behind the scenes—behind newspaper headlines with sensational ledes.

Epidemiologists are day-to-day, often meticulous personnel at local, state, federal, and global health organizations who observe patterns of disease, discuss their concerns with colleagues, involve experts from several disciplines and organizations, talk to patients and families affected by illness, enter data into databases and analyze it, study maps, use statistics and graphs to see patterns, and discuss and publish their findings so that others can learn. They are detailed people who love medicine, who love to solve puzzles, and who help to control outbreaks and prevent reoccurrences.

Alexandra M. Levitt in Deadly Outbreaks: How Medical Detectives Save Lives Threatened by Killer Pandemics, Exotic viruses, and Drug-Resistant Parasites (Skyhorse Publishing, September 2013) asks:
"What type of person is ready and able to pit his or her wits against the endless inventiveness of infectious microbes?"
She answers this question by highlighting epidemiologists—their lives, the people they work with, and their science.

John Snow (the father of epidemiology) was an inquisitive person too, who in 1854 instructed the Broad Street Directors to remove the pump handle from the Broad Street pump as it was, according to his astute observations, allowing people to drink Cholera-contaminated well water. He observed and documented and analyzed what was happening to people of Victorian Soho London. In the words of Steven Johnson, author of Ghost Map: The Story of London’s Most Terrifying Epidemic—and How it Changed Science, Cities, and the Modern World,“…[It was the] first time a public institution had made an informed intervention into a Cholera outbreak based on a scientifically sound theory of the disease.”  His scientific methods and communication of his conclusions saved hundreds of lives at that time, and it could be argued that his methods, that live on now, have saved millions more. His search for source (the pump!) and his action (remove the pump handle!) led to epidemiology.

Much like Maryn McKenna’s 2004 book Beating Back the Devil: On the Front Lines with the Disease Detectives of the Epidemic Intelligence Service, the people and the circumstances in which they live are central to the story. However, McKenna’s book focuses, with a more finessed narrative, on the training and experiences of the Center for Disease Control’s Epidemic Intelligence Service. Dr. Levitt’s well-written book provides a more state and local epidemiologist’s perspective on what an epidemiologist does.

Each epidemiological case has clues, a beginning. In this book, there are seven chapters and an epilogue, with eight beginnings that draw the reader in:
“Medical detective Annie Fine was reluctant to venture out to Queens for a routine check on a few encephalitis patients at a neighborhood hospital in Flushing.”
“Patrick J. McConnon, the U.S. CDC Regional Southeast Asia Coordinator for Refugees, was sick to his stomach, dreading the decision he had to make.”
“In March 1981, the coroner’s office of the Province of Ontario alerted the Toronto police to four suspicious deaths in cardiology Ward 4A of the hospital for Sick Children, a hospital that specializes in caring for babies with complex heart disease.”
“On Monday, August 2, in the bicentennial year of 1976, an official of the Pennsylvania chapter of the American Legion reported something strange: same-day obituary notices for four middle-aged legionnaires, briefly sick with an influenza-like illness, who had attended a convention in Philadelphia during the third week in July.”
“Medical detective Craig W. Hedberg first learned about the rise in food poisoning cases from a microbiologist at the Minnesota state lab lab [sic] who visited his office in late September, 1994.”
“In September 2007, an attending physician at the Austin Medical Center (AMC) in Austin, Minnesota, examined a patient with numbness, tingling, fatigue, and weakness in the legs and feet—symptoms that suggested damage to the peripheral nervous system, the network of nerve cells that transmit information between the brain and spinal cord (the central nervous system) and other parts of the body.”
“Dr. Thomas Hennessy remembers the spring of 1993 as green, lush, and beautiful, in the special way of desert lands after rain.”
“Because new microbes continue to emerge, we must always be prepared for the unexpected. As this book goes into production, international investigations are underway—one in the Middle East and one in China—involving new respiratory diseases with high fatality rates and the potential for global spread.”
The epidemiologist investigates as seen here in Chapter 3: Sorrow and Statistics:
“What could medical detectives do that the Sick Kids doctors and the police had not already done? The doctors had focused on the details of each baby’s illness, finding a natural reason for each death. The police, on the other hand, had focused on a particular suspect, seeking legal evidence to build a case against her. The epidemiologists viewed the evidence from a different angle. Unlike the police or the doctors, they looked at all of the deaths at once, as part of a single mission, trying to figure out what all of the cases had in common—somewhat like an FBI analyst examining deaths linked to a single serial killer.”
Epidemiologists come up with a potential source (an aha! Or a “pump handle” moment) and take action, like in Chapter 6: Red Mist:
“Staring spellbound at the head table and its workers—who looked both strong and vulnerable—Lynfield said to Wadding, ‘Kelly, what do you think is going on?’ Wadding responded by deciding, then and there, to stop using air-blasting machinery to harvest brains. On the spot, he ordered the device dismantled and brought to his office. He also agreed to provide the head table workers with additional protective equipment.”
Sometimes epidemiologists stumble upon a new organism, as Chapter 4: Obsession or Inspiration details:
“Armed with the new culture technique and silver stain, the CDC scientists demonstrated unequivocably [sic] that the new microbe was a gram-negative bacterium rather than a ricketssial bacterium, although it turned out to be closely related genetically to Coxicella burnetii—the rickettsia that causes Q fever. (Gram negative bacteria are characterized by an inability to take up certain dyes because of the structures of their cell walls) It was named Legionella pneumophila (“lung-loving”), in honor of the American Legionnaires. Although many affected groups do not want the stigma of having an organism or disease named after them, the leaders of the American Legion decided that the name would honor their fallen colleagues.”
The science in Deadly Outbreaks is rich and understandable. It may be a bit tough for the uninitiated, however, but the people-centeredness of the stories will bring in most curious readers. There are two infectious disease errors I assume (given Dr. Levitt’s expertise in infectious disease) were due to unnoticed autocorrect functions within the word processing program used to write the book: Typhoid Mary was said to have typhus. She was a Salmonella typhi carrier, not a typhus carrier. And mycoplasma was once misspelled as micoplasma.

What will appeal to many readers is that Dr. Levitt is well read and steers the reader to interesting and lesser known resources:
“…Hedberg remembers working long but productive hours to make sure more people did not become sick. He also recalls that once the tainted meat was off the market and things began to wind down, MDH [Minnesota Department of Health] shut down the investigation for a week to give him time off to get married. A few years later, this unusual foodborne outbreak became the topic of the last New Yorker article by Berton Roueché, the author of Eleven Blue Men, a classic collection of outbreak stories from the 1940’s and 1950’s5
Deadly Outbreaks also has a note section in the back, with further references. There are several photographs of the people involved in the investigations as well as short biographies of each.

Deadly Outbreaks is an important addition to the science literature, as it highlights epidemiologists via a new perspective, and it details who they are and how they do their work: from clues, to source, to action.

Tuesday, May 7, 2013

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 meals for seniors, due to sequestration
  • Vaccinations
  • 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
  • Food and water inspection
    • less inspection of foodwater, and more antibiotic use in animals may lead to more food and waterborne illness.
Embedded image permalink
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 least real tea has antimicrobial properties.

Friday, March 22, 2013

Winner of Inflammatory Language Contest!


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.   

Thursday, February 7, 2013

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 multimedia! There are 8 more days to go on Kickstarter.


Tuesday, January 22, 2013

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

Wednesday, January 16, 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.


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

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!
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