Zika Virus Invades Puerto Rico
According to the Centers for Disease Control (CDC), Puerto Rico is about to experience an epidemic of Zika virus. A quarter of the population of the island will have Zika within the next year; eventually eighty percent of the 3.5 million residents will have been infected. Puerto Rico is a very dangerous spot for mosquito-borne infections because its sub-tropical climate is perfect for mosquitoes. There are also many people on the island who are exposed to mosquitoes due to lack of screening on windows and lack of air-conditioned spaces indoors. Most people living in Puerto Rico are poor and unable to afford any defenses against mosquitoes.
The New York Times, in the article cited above, states that thousands of workers needed to control mosquitoes have been laid off. In addition, the chemical used to fight adult mosquitoes no longer works, and the one used to attack larvae has been taken off the market. Nonetheless, the island’s health agencies have been doing their best to install screens in schools and clean up trash where standing pools of water can incubate mosquito larvae. Insecticide spraying has begun in many communities, although it is unlikely to be very effective.
Puerto Rico is in better shape than Brazil was because of the early warning that health officials have received. Only 249 confirmed cases of Zika virus have been reported so far, but officials believe many more cases have gone unreported. Workers are emphasizing protection of pregnant women, including wearing pants and using DEET insect repellent regularly. Putting screens on the windows in high schools can help because many girls in high school are already pregnant.
An agent in use since 1965 was discontinued by the manufacturer recently. The drug, temephos, is effective against mosquito larvae, but it didn’t have sufficient safety data on hand according to the Environmental Protection Agency. When the testing, which would cost $3 million, was demanded, the company that makes it decided to simply stop making it. Apparently the profit from making the drug wasn’t sufficient to justify the testing. There is still a nine month supply on hand in Puerto Rico, and the EPA could issue an emergency decree to make more.
The other problem besides mosquitoes is that Zika is transmitted sexually, and distribution of condoms is being tried to help block this method of spread. However, most islanders are Catholic, and the Church prohibits the use of “artificial” birth control methods. Instead, the Church has told its members to practice self-restraint. This is a particular problem because even pregnant women need to be protected from sexual transmission with condoms.
CDC Announces New Opioid Prescribing Guidelines; Naloxone Pen Distribution is Best Life Saver
There has been a big controversy over the release of the new guidelines by the Centers for Disease Control (CDC) but it seems to be an over-reaction. The guidelines advise that Vicodin or Norco are not first-line treatment for acute pain, nor for mild chronic pain. The guidelines do allow for some patients to use some quantities of opioids, but with caution. There is no prohibition on using opioids when a patient has severe, chronic, noncancer pain. The condition must be evaluated and properly diagnosed; efforts to correct orthopedic problems that cause wear and tear with chronic inflammation are very important.
If a patient has pain, it must be controlled well enough to continue with the activities necessary to daily living. Going to work is necessary for many people, and if it causes pain that can’t be controlled with non-steroidal anti-inflammatory drugs, then sometimes hydrocodone is necessary. The problem is that there are many people who say they have pain, who really don’t have significant pain. There are other people who have started taking opioids and are dependent on them, even though they don’t have significant pain.
The primary care provider, the receptionist, and the nurse take the brunt of patient demands for opioids. The patient is sure to be dissatisfied if their demands are not met. In some cases, the patient may become violent and there are stories about patients brandishing firearms in their efforts to get drugs. I know of more than one fatal shooting that occurred because the patient demanded, and was denied, a common narcotic pain killer.
What is just as bad, is the overdoses. The number of fatal opioid overdoses has increased by 200% since 2000 and is now at a record level, parallel with the increase in prescriptions and sales of narcotics. The exact mechanism for the increase in overdoses is not completely clear, but it appears that patients sometimes take an unexpectedly potent form of a known drug such as heroin, or take a larger than normal dose because of prior shortage. Perhaps the overdoses are in part intentional and reflective of a suicidal predisposition; that possibility has not been completely ruled out.
According to the CDC’s Morbidity and Mortality Weekly Report for January 1, 2016, there has been a dramatic rise in overdose deaths due to fentanyl because of the production of illicit fentanyl by underground chemists. In 2014, there were 47,055 deaths from all drug overdoses, exceeding deaths from motor vehicle crashes by one and a half times. There were significant increases in death rates in both sexes, all age groups, ethnic groups, and regions of the country. West Virginia had the highest rate of deaths from drug overdoses. 61% of drug overdose deaths were from all opioids, including heroin. Heroin overdose death rates increased 26% in one year and have more than tripled since 2010.
It seems that heroin use has also increased dramatically in the last few years and that the biggest factor in the increase has been the transition from prior use of prescription opiates. The relative cost of heroin and its high purity has contributed to the patients’ switches from prescription to illicit opioids. Illicit fentanyl has also been available and is sometimes mixed with heroin. Pure heroin and fentanyl are probably contributing to accidental overdoses due to product potency.
The fact that the quantity of opioids prescribed has increased four times since 2000 has a great deal to do with the epidemic of opioid overdose deaths. Patients receive significant amounts of drugs from doctors but are eventually cut off or find the drugs inadequate, so they switch to heroin. The high quality, nearly pure heroin cheaply available on the street is satisfying the desire to “get high” but puts the user at risk of accidental overdose.
Illicit fentanyl is being mixed with high purity heroin and sold as “China White”; since fentanyl is 50 times as potent as morphine, the chance of overdose increases further.
Based on this reasoning, the single action most likely to reduce overdose deaths is the widespread distribution of naloxone injectable pens to addicts, emergency workers, and anyone else who is likely to run into a patient who has overdosed. Naloxone can temporarily reverse the respiratory suppression caused by overdose and could save the life of a patient who has lapsed into a coma and stopped breathing after using too much heroin or fentanyl.
Zika Vaccine Not Soon
An article in the New York Times states that the World Health Organization (WHO) has announced that a vaccine against Zika virus will probably take years to develop and will not be in time to help with the current epidemic. Although many organizations are researching potential vaccines, the furthest along is six months from human trials and probably three years from widespread release.
Research has also shown that spraying insecticides against mosquitoes is ineffective at reducing the incidence of dengue fever, a closely related virus. Nonetheless, spraying will continue as there is no other effective approach. The use of genetically engineered mosquitoes to reduce the population is promising, but the numbers are still small and again there is likely to be several years delay before a large enough number of mosquitoes can be produced.
The most effective approach at present is to stay in air-conditioned residences and to wear mosquito repellent on exposed areas whenever outdoors.
At the current rate, Zika is expected to spread to the southern US within two years.
Anonymity and Anonymous
“Hacker, Hoaxer, Whistleblower, Spy: the many faces of Anonymous” written by Gabriella Coleman, is an account of her mostly online encounters with many personalities, most of them unidentified, collected over the period from 2010 to the present. It discusses what the writer describers as the “culture” of hackers. This “culture” includes a number of people who were arrested for Internet crimes such as the “theft” of information up to and including credit card numbers and passwords. The period of time referred to in the book runs from about 2010 to early 2015. A number of the people are identified by name only because they were arrested and imprisoned. During that time, the writer, acting as an anthropologist, communicated with many other, unidentified people who described themselves as hackers. She eventually did obtain a graduate degree in anthropology and now teaches.
The entire culture could be described as the Anonymous group or web, a large and very loosely associated group or groups of individuals who communicated over the Internet. Many of these groups claimed to be able to obtain information on a group that could be vulnerable, sometimes security firms. In more than one case, secret information was obtained from sensitive sites. A number of people were indicted and imprisoned for obtaining unauthorized information in the US. One young man, indicted for a wholesale downloading of an open-access journal, committed suicide after the prosecution demanded decades of imprisonment.
Many of these people were sincere in the belief that the vast majority of this information should be public and the government is in the wrong to punish people harshly for this kind of disobedience. Others felt that exposing oneself to danger in this fashion would be unwise in the long run. Fortunately for Anonymous as a movement, the most important members of the movement have managed to keep their identity, in fact their very existence, hidden from the government. Anonymous could only survive by being fully hidden from view.
The conclusion that the book makes is that any survivors have melted away and are saving their strength for a later occasion.
“The pipeline itself is just too small,” Marc Nivet, EdD, MBA, chief diversity officer of the Association of American Medical Colleges (AAMC), told MedPage Today. “The barriers exist up and down the continuum to our segregated education system … Too many of our minority students are in poor-performing or underperforming K-12 school systems.”
via Deep Roots for Lack of Minorities in American Medical Schools | Medpage Today.
This article was linked to by Ivan Oransky’s Twitter feed. I don’t normally read Twitter feeds, but it caught my attention because it is reposted along with his regular web site / blog posts.
This calls attention to a serious problem which has gotten worse, not better, since I was in medical school. Only five percent of the first year class in my school was African-American. What’s worse, half of them dropped out after the first year. They just couldn’t cut it academically. I talked to some of them, and they studied hard, they seemed intelligent, they didn’t goof off, but they couldn’t cut the material. Either they hadn’t taken enough courses in college that prepared them, like biochemistry, or they just hadn’t been exposed to large amounts of rote memorization, like anatomy and the rest of the first year courses.
The problem is that most black kids start first grade at schools that are just no good. They are relatively or absolutely underfunded, they have lousy teachers, low standards, and an environment not conducive to learning. So even black kids who want to become doctors, in the worst way, either wind up following the Ben Carson path, or just don’t make it.
It’s not their fault. It’s the fault of the system of funding for primary education, which is based primarily or entirely on local funds. Since black kids live in low-rent districts, their tax base is grossly inadequate to fund their primary schools. This is a political crime, and it has been perpetrated against low-income, primarily black or Mexican kids ever since universal primary schooling was instituted (after the Civil War?)
The only solution is federal funding for primary school to make sure everyone gets an equal amount of money (if not extra money to make up for other deficits) to attend school.
It’s not fair to send black kids to crummy grade schools. It just perpetuates the disadvantages they were born with and aggravates the other problems, the chronic lead poisoning, the broken families (one or both parents in prison for no good reason), etc. I could go on, but I only have so much space, and what I’m saying is well known to everyone with a brain who has been exposed to the facts. The system is unfair from the beginning.
A dozen cases of Zika virus in China have been reported in the last month, all imported, according to the National Health and Family Planning Commission in Beijing. An article in the New York Times (NYT) indicates that the islands of Taiwan and Hainan are at risk for locally transmitted Zika because the Aedes aegypti mosquito, which carries the virus, is resident in those areas. Zika virus has not yet been reported north of Thailand and Polynesia, but it has been spreading rapidly in South America.
Taiwan had a severe outbreak of dengue fever last year, which is caused by a similar virus that is carried by the same mosquito. Because of the dengue outbreak, Taiwanese authorities are taking special precautions to prevent entry of Zika, dengue, and chikungunya, all of which are carried by the same mosquito.
A laboratory study also reported in the NYT showed that fetal cells which form the precursors to the cortex in the brain are especially susceptible to infection and death from the Zika virus. This study forms a basis for the finding of microcephaly that has so alarmed scientists in Brazil recently. Babies born with microcephaly are missing a large part of the cortex of their brains, dooming them to mental retardation. This study doesn’t prove that Zika is the cause of microcephaly, but it makes scientists very suspicious.
Ryan Hoffman was a college football player, a star offensive linesman, at the University of North Carolina. After college, he began a downward spiral that included alcoholism, drug abuse, and homelessness. He said repeatedly, “Something is wrong with my brain.”
It was not until he died in November 2015, and his brain was pathologically examined, that he was diagnosed as having chronic traumatic encephalopathy (CTE), now known to be caused by multiple concussions while playing football. He was said to have Stage 2 (out of 4) of CTE by the pathologist at Boston University (Dr. Ann McKee) who examined his brain. This is the same stage as the football player Junior Seau, who shot himself in the chest in 2012 after suffering the agonies of depression, loss of memory, loss of impulse control, and fits of rage.
The New York Times (NYT) reporter who knew him stated:
“Dr. McKee said that Stage 2 C.T.E. can be especially symptomatic, causing problems like depression, short-term memory loss, lack of impulse control, irritability and mood swings, and that some of those symptoms could be confused with mental illness. Last year, Hoffman told me that he had received diagnoses of various mental illnesses, including manic depression, but that medications never seemed to help.”
Mr. Hoffman was jobless and homeless, penniless, and dependent on drugs and alcohol when he died. His sister said, ““I wanted to know exactly what happened to my brother, and I just knew football did it…” He rode his bicycle head on into traffic on a dimly lit road in Haines, Florida, and died in an ambulance on the way to the hospital.
Peach Orchard 2016
Peaches and Plums
Peach Blossom 2016
