Dallas Buyers Club: Bureaucracy vs. Life

Today I saw the movie Dallas Buyers Club and I thoroughly enjoyed it. The movie is focused on the early days of the AIDS pandemic in America and the struggle to find effective treatments.

Circa 1985, there was little a physician could do to forestall the inevitable death sentence imposed by the diagnosis of HIV infection. The movie portrays the real life efforts of Ron Woodruff to bring novel anti-HIV medications to the US, despite staunch opposition from the FDA.

Woodruff, expertly played by Matthew McConaughey (nominated for awards for this role), displays heroic intransigence in the face of a diagnosis of AIDS and the opposition of the FDA to his work. Throughout the film, it is the FDA that poses a greater threat to his life than the deadly virus because of their insistence that the drugs he employs, some of which were later FDA approved (e.g. ddC) were not safe and merited confiscation and destruction. Another drug Woodruff imported, Peptide T, may yet also find a place in the treatment of HIV.

Today, efficectiveHIV drugs are plentiful. This situation is due, in part, to the efforts of AIDS activists who would not allow bureaucracy to stifle their will to live. However, not all diseases share this status and many conditions could benefit from the efforts of a Woodruff-like character.

The tagline for the movie--"Dare to Live"--is a perfect encapsulation of Woodruff's heroism. We should all follow his example.

Snap, Crackle, Pop: You have Malaria

 Malaria, historically one of mankind's perpetual scourges, continues to devastate populations of humans worldwide. While effective treatments are available, the condition must be diagnosed first--a challenge in resource poor areas.

The diagnosis of malaria is based upon the  visual identification of parasites in a blood sample. Rapid antigen detection tests and PCR can also be used on blood samples.

A novel method, devoid of the need for blood samples, has just been described in a paper published in PNAS. The New York Times reported on the finding. 

The test is based upon detecting the acoustic signature of hemozoin molecules which are degradation products generated by the malaria parasites feasting on the red blood cell's hemoglobin. Using a laser device, hemozoin molecules can be vaporized and the acoustic signature of that process detected allowing malaria to be diagnosed.

Such a test, if technically feasible and scalable, has the potential to transform the way malaria is diagnosed enhancing accuracy and speed while diminishing the need for laboratory and phlebotomy equipment--potentially a giant leap forward.

Influenza: City flu vs. Country flu?

A recent news article reveled that my hometown, Butler County (PA), has the 3rd highest number of reported flu cases in the state with 121 reported cases.

I find that surprising given that our population is no where near the top of the list of the 67 counties that comprise Pennsylvania.

I don't think Butler County can have more influenza cases than Philadelphia County.

A couple of factors may be responsible for this disproportionate ranking:

• Many hospitals, given flu activity is widespread, may be making clinical diagnoses of influenza rather than running diagnostic tests
• The rapid influenza antigen test, which is used in many smaller hospitals (including in Butler), detects about a half of flu cases

In general, influenza diagnostics are very limited because of the unreliability of rapid antigen tests coupled with the fact that influenza PCR is done at few institutions and, when available, has a long turn-around-time.

However, I do recommend people avail themselves of whatever influenza diagnostics they have available in order to have some estimate available of influenza spread, alert infection control regarding hospitalized influenza patients, and to emphasize the need for antiviral treatment--which should not be withheld based on a negative rapid antigen test.

Rocky Mountain High: Could it be the result of a Fever?

One of my friends alerted me to the fact that Phoenix Coyote Shane Doan is recovering from Rocky Mountain Spotted Fever (RMSF), a dangerous tick-borne infection that often requires a competent clinician to diagnose and preemptively treat.

RMSF is caused by Rickettsia rickettsii and is spread to humans through the bite of one of three ticks: the American Dog Tick, the Rocky Mountain wood tick, or the brown dog tick. These ticks have a wide geographic spread. 

Despite its name, however, 4 states account for the majority of RMSF cases: North Carolina, Oklahoma, Arkansas, Tennessee, and Missouri. Interestingly, in Arizona--which may be relevant to Doan's case--there is a newly established foci of infection in the eastern part of the state which is tied to transmission via the brown dog tick and large populations of roaming dogs. 

The initial presentation of RMSF is what makes it so challenging as it can appear to be just an ordinary viral illness. If overlooked, individuals may develop more serious infections that can be debilitating or even fatal. The characteristic rash may not be present until later in the course of illness. In areas where RMSF is known to circulate, doxycycline is prescribed routinely for illnesses that fit wide criteria for possible RMSF in order to avoid any delays in treatment. 

So long as RMSF remains a clinical diagnosis, as the result of serological tests may take days to obtain, it serves as another example of the value of the astute clinician who is able to discriminate the hoofbeats of a zebra from a horse.

Chickenpox Party Pooper

Yet another reason to avail yourself of the shingles and chickenpox vaccines: shingles increases the risk of stroke and heart attack, especially in those under the age of 40.

This finding, published in Neurology, was a retrospective study that included over 100,000 individuals with shingles and found that those under 40 who experiencing shingles had a 50% increased risk for heart attacks as well as increased risk for mini-strokes (TIAs) and full strokes.

These findings reinforce the fact that this virus is not benign and should not have the privilege of having parties in its honor to help foster its spread.