Category: Medicine

If you’re around my age, you remember the disappearance of the red M&M. One day, they were just…gone. Apparently, folks worried that a red food dye not even used in M&M’s caused cancer.

Well, the red ones came back, but food dyes are back in the news. The Center for Science in the Public Interest is concerned about a possible link between certain food dyes and (presumably bad) child behavior.

Now I don’t really care what color my food is (unless my lettuce is brown and my meat is green), but these dyes are used ubiquitously to make food appear appealing, appetizing, and profitable. Given that these dyes don’t contribute nutritionally, there really is no health reason to use them, but food producers like them because they work; they help sell food.

What’s the claim, and what’s the science?
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This topic has been running through my mind quite a bit lately. Infectious diarrhea is one of the world’s most vicious killers, but is susceptible to basic public health measures such as clean water and good sanitation, which is why cholera-ridden Americans aren’t dropping dead in pools of their own feces. (Citizens of other countries aren’t quite so lucky.)

There are many causes to this common problem—various bacteria, viruses, parasites, and a host of non-infectious causes. Even in here in the U.S., public health measures sometimes fail us, as seen in the ongoing Salmonella outbreak.

But diarrhea isn’t just a load of crap. Let me explain.
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West Nile season is starting up, with the first few case reports trickling in.

Back in the summer of 2002, I was introduced to West Nile fever. This mosquito-borne viral illness had a minimal presence in North America in the preceding three years, but made its real American debut that summer. It may have hitchhiked over on boats or in an infected traveler, but either way, it’s here to stay.

That summer, as I took over rounding on an inpatient medical service, I was suddenly faced with a relatively large number of very ill patients. They were usually elderly, and would be brought to the ER with fevers, headaches, low sodium levels, and confusion. More often than not, they developed weakness, often severe enough to land them in the ICU on a ventilator. Recovery was variable, with some people doing fine after rehabilitation, and others dying.

I went hiking in the woods that summer (with plenty of DEET solution) and saw a number of dead crows and blue jays, who also serve as unfortunate hosts to the virus.

There is no specific treatment for West Nile, but prevention involves mosquito control and avoidance.

There hasn’t been another summer like ’02. My state had over 600 cases in 2002, including 51 fatalities. Last year saw fewer than 20 cases. I’ve seen plenty of living blue jays so far.

Some of our success is due to vector control, but much is due to immunity. When the virus landed, very few Americans had been exposed. Now, many of us have, and our immune systems have been reasonably effective at mitigating the effects of this now wide-spread disease.

I still view mosquitoes differently. They never really bothered me, but after seeing so many horribly ill people, I think about those little pests before I go out in the evening.

West Nile is a beautiful model for emerging infectious diseases. I wonder what we’ll see next?

The fight against HIV occurs on several different levels: prevention of transmission and acquisition, treatment of the infection, and prevention and treatment of opportunistic illnesses.

Prevention has been addressed extensively (and perhaps will be again later), and opportunistic illnesses is a huge topic, so first I’ll delve a bit into the origins and biology of the treatment of HIV infection (and of course the usual caveat; this is grossly oversimplified, and Abbie has a whole lot of good, ungrammatical science over at her place).

For better or worse, this requires another short biology primer…
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A rather opinionated reader made me aware of a disturbing issue. In Connecticut–the state whose city of Lyme gave the name to the tick-borne disease–the Attorney General decided that the nation’s foremost infectious disease experts have their heads up their arses. Apparently responding to pressure from questionable advocacy groups, the AG launched an “investigation” into the Infectious Disease Society of America’s Lyme disease treatment guidelines. The excuse for the investigation was alleged anti-trust violations.

Let’s step back a little. As discussed yesterday, there is some controversy surrounding so-called “chronic Lyme disease”. The overwhelming majority of experts agree that there is no role for long-term antibiotics. There has been no evidence to support either the diagnosis of chronic Lyme disease (as it is used by advocacy groups and some physicians) or the use of expensive and dangerous therapies to treat it. The guidelines on treatment of infectious diseases issued by the ISDA are just that—guidelines. Physicians are not required to follow these guidelines, but insurance companies often use them to determine what therapies they will pay for. These guidelines are, however quite influential, as we physicians count on our specialist colleagues to help sort out these difficult issues.

The CT AG decided that these guidelines were tainted by anti-trust violations. I’m not sure how evidence-based guidelines put together by a diverse group of experts can violate anti-trust laws, which were designed to prevent corporate monopolies, but the AG tried to pull it off.

More below the fold—>
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New diseases are pretty rare these days. It used to be that a good observer could travel to the great unknown and acquire/discribe scads of new (to them) diseases. In the interconnected world of the present, “new” diseases spread rather quickly, and become old. When I was a young attending physician, I had heard of West Nile Fever from small chapters in medical school books. When I took over an inpatient medical service in the summer of 2002, I was taking care of several patients with the disease. It was new to me, but hardly new. Sometimes I wonder if people miss the great days of disease discovery, and try to make up for it by inventing their own diseases.

Here at denialism blog we’ve occassionally written about “fake diseases”, that is, diseases that are not recognized by science-based medice, have no clear definitions, and attract quackery. One of these diseases is Morgellons syndrome, an ill-defined malady recognized by no one other than patient advocacy groups and their stooges. Another plays on a real disease, but tries to stretch that disease’s definition to include just about any symptom you could imagine.
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The NIH announced today that it is launching its “Undiagnosed Diseases Program”. This program will evaluate patients who are referred by physicians. They will also ask for input from so-called advocacy groups.

This should be interesting. I’m sure they will be receiving requests from people with “chronic Lyme disase”, “Morgellons syndrome”, and “chronic fatigue syndrome”. From what I can tell from reading the press release, the program is aimed at the individual patient, and is does not focus on epidemiology. This has it’s pluses and minuses. The individual patient is the smallest “unit” of disease, and for very rare diseases, sometimes one patient is all you can find. On the other hand, it is more common to see an odd variant of a common disease, than a brand new strange disease.

The other interesting bit is that this counts on doctors to refer patients. Will regular docs like me do most of the referring? Or will it be docs that are aligned with “advocacy groups” who practice at the “outer limits” of medicine?

Either way, they will only be evaluating a handful of patients yearly. It will be interesting to follow their progress. Hopefully they will find a good way of reporting their findings.

MarkH recently gave us a case to play around with. Since this is usually great fun, I thought we could try another one. I’ll start you off with very little information, and I’ll answer any questions you bring up.

I’ll warn you that this one is complex, and shows off the type of intricate problems that internists deal with every day.

A woman in her 60’s came to the ER complaining of weakness and light headedness. This is one of my favorite places to stop. For the non-physicians in the crowd, I’ll give you a head start. Light headedness is often a sign of insufficient blood flow to the brain.

Perhaps this isn’t enough, but let’s start here.