Posts Tagged With: Medical Doctors

Thinking of Zebras #Rabies #Bats #Chiroptera #Medical

1024px-Equus_quagga

This is some of the research that contributed to the recently released Darwin’s Paradox: An international science mysteryhttp://amzn.to/2k8qJgi. When the pandemic strikes, the medical doctors are forced to look for more and more unlikely causes.

New medical students are regularly warned that when they hear hoof beats, they should think of horses, not zebras. Before they get their clinical experiences, new doctors treat all diseases as equally probable. After they become experienced, they naturally think of horses (the common causes) when they hear hoof beats (common symptoms).

This leads to an opposite problem. Experienced doctors have a blind spot when the hoof beats actually foretell zebras (a rare disease).

Consider this case from Canadian Journal of Infectious Disease, Volume 13, Number 2, March/April 2002.

A nine-year-old boy had upper arm pain and a slight fever. In a few days the pain extended down to his wrist and up to his shoulder and neck. The area was tender to touch and prevented him from sleeping. The next day he had tremors and was hospitalized.

This was followed by sore throat, difficulty swallowing, and intense itching. The doctors considered allergies and treated his with diphenhydramine (an antihistamine) which had little effect.

The tremors and spasms got worse, and the patient had difficulty speaking. Knee-jerk reflexes were normal, but the doctor considered epilepsy and ordered an electroencephalogram. This showed a slowing of brain activity, but not epilepsy.

The patient next developed aerophobia (fear of air blown on them) and hydrophobia (inability to drink water). This was accompanied by a rash, transient hallucinations, and intense itching.

The following day brought severe tremors of the face and all limbs, drooling, priapism, and the feeling of suffocation. At this point the doctors presumed that the patient had rabies.

Nine days later, “14 days after the onset of his initial symptoms, the patient presented a clinical picture compatible with brain death, was extubated and died.”

This is an example of how difficult it is to diagnose rabies, absent a reported bite.

Running_horse_(5210454901)

Here is another case from CDC Morbidity and Mortality Weekly Report, Volume 60, Number 14, April 15, 2011.

“The patient reportedly had awakened with a bat on his arm 9 months earlier, but had not sought medical evaluation. He went to a local emergency department (ED) on October 30 and soon after was hospitalized; he died 12 days later.”

Initially he was treated by a chiropractor for pain and numbness of his left hand and arm, lower neck and upper back. The chiropractic treatment relieved the back pain, but the arm numbness and tingling got worst.

At the hospital, the patient did not have a fever, blood pressure was normal, blood count and routine chemistries were normal. Strength and sensation were normal. The only symptoms were weakness of the left arm, elevated white blood cell counts, and elevated glucose. A CT scan also revealed some anomalies.

Most concerning, the patient had such difficulty breathing that he was put on ventilation.

AIDP and Guillain-Barre syndrome were the chief diagnoses considered at this point. MRI and entectromyography pointed to AIDP and treatment began.

A few days later, with the patient not improving, CSF (cerebrospinal fluid) analysis lead the staff to switch the diagnosis to meningoencephalitis. This treatment was also not effective.

At that point, “on November 4, the infectious disease physician asked the patient’s wife about any animal exposure history. … The wife had no knowledge of any recent animal bites. …
On November 8, another relative recounted an incident that had occurred approximately 9 months before onset of illness. The patient had told the relative about waking one night to a bat crawling on his arm. …
On November 11, the patient’s family elected to withdraw life support, and the patient died shortly afterward.”

Mustang_Utah_2005_2

Here is a third case from CDC Morbidity and Mortality Weekly Report, Volume 59, Number 13, April 9, 2010.

When an apparently healthy man visited a clinic with fever and a cough, the clinician diagnosed bronchitis and prescribed antibiotics.

By the follow-up, the patient now had fever, chills, chest pains and left arm numbness. An electrocardiogram did not indicate a heart attack. The diagnosis was musculoskeletal pain and the patient was prescribed pain killers and muscle relaxants at this time.

Next visit the patient was agitated and restless, which was presumed to be a side-effect of the muscle relaxants. Hospital observation was recommended, but the patient went home.

The next day, the patient presented with twitches, high heart rate, low blood pressure, and fever. The doctor now considered sepsis and the patient was hospitalized.

The patient was intubated and tested extensively. The patient continued to deteriorate with low heart rate, low blood pressure, muscle wasting, and kidney failure requiring dialysis.

Two weeks after the initial clinic visit, rabies were considered. The patient died the next day.

Zebra_Botswana_edit02

Sometimes those hoof beats are zebras.

pub-shot-dp-13-cropped

Categories: Bats, Diseases | Tags: , , , , | Leave a comment

One pill makes you smaller… #SFRTG #IARTG #Kindle

GAA2

One pill makes you larger, and one pill makes you small
And the ones that mother gives you, don’t do anything at all

Grace Slick of the Jefferson Airplane

This is some of the research that contributed to the recently released Darwin’s Paradox: An international science mysteryhttp://amzn.to/2k8qJgi. “Doctor” Brian is in Mozambique and has been given pills to test for activity against a new disease. This raises all of the ethical issues associated with off-label drug use.

Grace Slick might have been singing about prescription drugs [I was there and I’m not talking]. If so, those pills would have been used off label. Off label is when a legal drug is used for something other than its FDA-approved indication. For example, drugs approved for bipolar disease or schizophrenia are often prescribed for depression, and blood thinners are prescribed for hypertensive and coronary heart disease.

This is legal. The FDA does not regulate the practice of the medicine, only the drug companies. For example, over three-quarters of children discharged from a hospital receive at least one off-label prescription.

What do you think about your doctor prescribing medications for you that have not been fully tested for safety or efficacy? What do you think about your doctor enrolling you, often without your knowledge, in an ad hoc science experiment?

Drugs are used off-label for many reasons. If a drug is generic, no one is motivated to spend the time and money to run the clinical trials required to get an indication approved, regardless of how safe and effective it is, or isn’t. Even if a drug is not generic, the approval process might not be deemed cost effective. Ironically, the larger the off-label market, the less a drug company would be motivated to fund a clinical trial. They (and the patients) are already benefiting from the sales, so why bother with the testing?

This is the conflict. If the doctors prescribe and the drug companies sell — all without clinical trials — who is protecting you? For example, estrogen medications were prescribed extensively to menopausal women to prevent coronary disease. It wasn’t until a government-sponsored trial found them to increase, not decrease, the risk of stroke and heart attack that this was curtailed.

You can think of each off-label prescription as a tiny clinical trial, without informed consent, without controls, without records, and without oversight. What do you think about being a test subject knowing that there is little chance that the result of your sacrifice and risk will add to scientific knowledge or benefit those who come after you?

Some might tell you the system is even more sinister. It turns out that drugs for rare diseases can be declared as orphan products. In this case the FDA streamlines (cuts corners) the approval process. This is good for those rare diseases, but once the drug is approved, it can be used off-label for whatever the doctors decide. This can be a cost-saving way for drug companies to get to market. For this reason, among others, drug companies are forbidden from promoting off-label uses. Regardless, drug companies have been penalized billions of dollars for violating the rules.

Who is protecting your well being? How can this system work at all?

This anxiety ignores one important fact of life. The fact of your unique DNA. People are different, and EVERY prescription (FDA approved or off label) is a science experiment. People respond individually to drugs. Side effects differ from patient to patient, ranging from benign headaches or muscle cramps to life-threatening reactions. Even popular over-the-counter (OTC) drugs like Tylenol(R) pose risks.

Doctors are the ones who read all that fine print and journals articles to be prepared and watchful for negative reactions from ALL prescriptions whether for FDA-approved or off-label.

In summary, around a billion off-label prescriptions are written each year with the overwhelming majority benefiting the patient. Like ALL medicine, there are benefits and risks, and doctors are the ones who balance them. Without doctors writing off-label prescriptions, millions would be suffering needlessly. It is the doctors who contribute the judgment that the bureaucracy can not.

So as Grace Slick recommended, “Go ask Alice,” especially if she is a doctor.

I am not an MD and am not giving medical advice.

For more information: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538391/

pub-shot-dp-13-cropped

Categories: Pharmaceutical Industry | Tags: , , , | Leave a comment

Blog at WordPress.com.