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Monthly Archives: April 2018

Global Warming May Pose Health Risks

Medical and public health groups are banding together to explain how global warming has taken a toll on human health and will continue to cause food-borne illnesses, respiratory problems, and deaths unless policy changes are enacted.

In a conference call with reporters, the heads of the American Medical Association (AMA) and the American Public Health Association (APHA) joined with a pediatrician and a scientist to lay out what they say is a major public health issue: climate change caused by global warming.

The “evidence has only grown stronger” that climate change is responsible for an increasing number of health ills, including asthma, diarrheal disease, and even deaths from extreme weather such as heat waves, said Dr. Georges Benjamin, executive director of the APHA.

For one, rising temperatures can mean more smog, which makes children with asthma sicker, explained pediatrician Dr. Perry Sheffield, assistant professor in the Department of Pediatrics and the Department of Preventive Medicine at the Mount Sinai School of Medicine, in New York.

There is also evidence that pollen season is also getting longer, she said, which could lead to an increase in the number of people with asthma.

Climate change also is thought to lead to increased concentrations of ozone, a pollutant formed on clear, cloudless days. Ozone is a lung irritant which can affect asthmatics, those with chronic obstructive pulmonary disease, and those with heart disease, said Dr. Kristie Ebi, who is a member of the Intergovernmental Panel on Climate Change.

More ozone can mean more health problems and more hospital visits, she said.

Aside from air-related ailments and illnesses, extreme weather can have a devastating effect on health, Sheffield said.

“As a result of global warming, extreme storms including hurricanes, heavy rainfall, and even snowstorms are expected to increase,” Sheffield said. “And these events pose risk of injury and disruption of special medical services, which are particularly important to children with special medical needs.”

Extreme heat waves and droughts are responsible for more deaths than any other weather-related event, Sheffield said.

The 2006 heat wave that spread through most of the U.S. and Canada saw temperatures that topped 100 degrees. In all, 450 people died, 16,000 visited the emergency room, and 1,000 were hospitalized, said Dr. Cecil Wilson, president of the AMA.

Climate change has already caused temperatures to rise and precipitation to increase, which, in turn, can cause diseases carried by tics, mosquitoes, and other animals to spread past their normal geographical range, explained Ebi.

For instance, Lyme disease is increasing in some areas, she said, including in Canada, where scientists are tracking the spread of Lyme disease north.

Ebi also recounted the 2004 outbreak of the leading seafood-related cause of gastroenteritis, Vibrio parahaemolyticus, from Alaskan seafood, which was attributed to increased ocean temperatures causing infected sea creatures to travel 600 miles north.

Salmonella outbreaks also increase when temperatures are very warm, Sheffield said.

A 2008 study also projected that global warming will lead to a possible increase in the prevalence of kidney stones due to increased dehydration, although the link hasn’t been proven.

Wilson said the AMA wants to make doctors aware of the projected rise in climate-related illnesses. To combat climate change, Wilson says physicians and public health groups can advocate for policies that improve public health, and should also serve as role models by adopting environmentally-friendly policies such as eliminating paper waste and using energy-efficient lighting in their practices.

“Climate instability threatens our health and life-supporting system, and the risk to our health and well-being will continue to mount unless we all do our part to stabilize the climate and protect the nation’s health,” said Wilson.

Benjamin added that doctors should pay attention to the Air Quality Index. For instance, if there’s a “Code Red” day, which indicates the air is unhealthy, physicians should advise patients (particularly those with cardiac or respiratory conditions) that it’s not the day to try and mow the grass.

“ER docs are quite aware of Code Red days because we know that when those occur, we’re going to see lots of patients in the emergency room,” Benjamin said.

The conference call came as Congress is considering what role the Environmental Protection Agency (EPA) should have in updating its safeguards against carbon dioxide and other pollutants.

While the EPA has the authority to regulate levels of CO2, a budget bill passed by the House of Representatives last the weekend prohibited the EPA from exercising that authority. Meanwhile, other bills are pending in Congress that would significantly delay the agency’s ability to regulate air pollutants.

AMA has a number of policies on the books regarding climate change, including a resolution supporting the EPA’s authority to regulate the control of greenhouse gases, and a statement endorsing findings from the most recent Intergovernmental Panel on Climate Change report that concludes the Earth is undergoing adverse climate changes, and that humans are a significant contributor to the changing weather.

In that statement, the AMA said it supports educating the medical community about climate change and its health implications through medical education on topics such as “population displacement, heat waves and drought, flooding, infectious and vector-borne diseases, and potable water supplies.”

The statement also said the AMA supports physician involvement in policymaking to “search for novel, comprehensive, and economically sensitive approaches to mitigating climate change to protect the health of the public.”

Head Injuries Carry Long Term

The risk of death after head injury remained significantly increased for as long as 13 years, irrespective of the severity of the injury, results of a case-control study showed.

Overall, patients with a history of head injury had more than a twofold greater risk of death than did two control groups of individuals without head injury.

Among young adults, the risk disparity ballooned to more than a fivefold difference, Scottish investigators reported online in the Journal of Neurology, Neurosurgery and Psychiatry.

“More than 40% of young people and adults admitted to hospital in Glasgow after a head injury were dead 13 years later,” Dr. Thomas M. McMillan, of the University of Glasgow, and coauthors wrote in the discussion of their findings. “This stark finding is not explained by age, gender, or deprivation characteristics.”

“As might be expected following an injury, the highest rate of death occurred in the first year after head injury,” they continued. “However, risk of death remained high for at least a further 12 years when, for example, death was 2.8 times more likely after head injury than for community controls.”

Previous studies of mortality after head injury have focused primarily on early death, either during hospitalization or in the first year after the injury. Whether the excess mortality risk persists over time has remained unclear, the authors noted.

Few studies have compared mortality after head injury with expected mortality in the community. To provide that missing context, McMillan and coauthors conducted a case-control study involving 757 patients who incurred head injuries of varying severity from February 1995 to February 1996 and were admitted to a Glasgow-area hospital.

For comparison, the investigators assembled two control groups, both matched with the cases for age, sex, and socioeconomic status and one matched for duration of hospitalization after injury not involving the head.

One control group was comprised of persons hospitalized for other injured and other comparison group included healthy non-hospitalized adults.

The cases comprised 602 men and 155 women who had a mean age of 43, and almost 70 percent were in the lowest socioeconomic quintile.

At the end of follow-up, 305 of the head-injured patients had died, compared with 215 of the hospitalized control group, and 135 of healthy, non-hospitalized adults.

Mortality after one year remained significantly higher in the head-injury group—34 percent versus 24 percent among the hospitalized comparison group and 16 percent for the healthy non-hospitalized adults.

Overall, the head-injury group had a death rate of 30.99/1,000/ year versus 13.72/1,000/year in the community controls and 21.85/1,000/year in the hospitalized-other injury control group.

The disparity was greater among younger adults (15 to 54), who had a rate of 17.36/1,000/year versus 2.21/1,000/year in the community controls. Older adults in the head injury group had a death rate of 61.47/1,000/year compared with 39.45/1,000/year in the community controls.

“Demographic factors do not explain the risk of death late after head injury, and there is a need to further consider factors that might lead to health vulnerability after head injury and in this way explain the range of causes of death,” the authors wrote in conclusion. “The elevated risk of mortality after mild head injury and in younger adults makes further study in this area a priority.”

Time of Surgery Doesn’t Influence

The timing of an operation doesn’t affect a patient’s subsequent risk of complications or death, a new study finds.

For example, there’s no difference in death rates between elective surgery performed in the afternoon versus the morning or on Monday instead of Friday, the researchers said. Their findings should help to ease concerns that fatigue may lead to a higher rate of safety problems when operations are performed later in the day or week, they said.

The study included an analysis of the outcomes of more than 32,000 elective surgeries performed between 2005 and 2010. The overall complication rate before discharge was 13 percent, and the overall risk of death within 30 days of surgery was 0.43 percent.

After the researchers adjusted for other factors, the risk of complications or death was not significantly different for patients who had surgery at different times of the day — between 6 a.m. and 7 p.m. — or week.

The time of year also had no impact on the risk of complications or death. This included July and August, when most new residents start working in teaching hospitals.

The study appears in the December issue of the journal Anesthesia & Analgesia.

“Elective surgery thus appears to be comparably safe at any time of the workday, any day of the workweek, and in any month of the year in our teaching hospital,” Dr. Daniel Sessler, of the Cleveland Clinic, and colleagues concluded in a journal news release.

Some previous studies have suggested that patients are at greater risk if they undergo late-day surgery.

Health Reform Law Gaining

To be sure, Americans remain sharply divided over the legislation, with slightly more than one-third (36 percent) of adults saying they want the law repealed and 21 percent saying they want it to remain as is. Another 25 percent would like to see only certain elements of the law modified, the poll found.

“The public is still divided, mainly on partisan lines, as to whether to implement or repeal all, parts, or none of the health care reform bill,” said Harris Poll Chairman Humphrey Taylor.

The poll, conducted earlier this month, found that support for the legislation clearly breaks down along party lines. Almost two-thirds of Republicans (63 percent) said they wanted the Patient Protection and Affordable Care Act repealed, compared to 9 percent of Democrats.

But while poll respondents were split about the law as a whole, many strongly supported key elements of the bill, “with the notable exception of the individual mandate [the requirement that all adults purchase health insurance] which remains deeply unpopular,” Taylor said.

That support for certain components of the law seems to be increasing slowly with time. For instance, 71 percent of those polled now back the law’s provision that prevents insurance companies from denying coverage to those already sick. At the end of 2010, 64 percent supported this provision.

Other provisions that are showing a slow but steady rise in acceptance since November 2010 include:

  • Allowing children to stay on their parents’ insurance plans until they turn 26 — 57 percent in January 2012 versus 55 percent in November 2010.
  • Creating insurance exchanges where people can shop for insurance — 59 percent versus 51 percent.
  • Providing tax credits to small businesses to help pay for their employees’ insurance — 70 percent versus 60 percent.
  • Requiring all employers with 50 or more employees to offer insurance to their employees or pay a penalty — 53 percent versus 48 percent.
  • Requiring research to measure the effectiveness of different treatments — 53 percent versus 44 percent.
  • Creating a new Independent Payment Advisory Board to limit the growth ofMedicare spending — 38 percent versus 32 percent.

But the most controversial aspect of the law — the so-called individual mandate that requires all adults to have health insurance or face a fine — remains widely unpopular, with only 19 percent of those polled supporting it.

The U.S. Supreme Court is scheduled to hear arguments on the constitutionality of the law starting in late March.

“It’s clear that people really appreciate key reforms that are in the Affordable Care Act and it demonstrates how important it is for people to know that those reforms actually are embodied in the legislation,” said Ron Pollack, executive director of Families USA, a Washington, D.C.-based nonprofit, nonpartisan group that says it’s dedicated to quality, affordable health care for all Americans.

The problem is that many people don’t know what’s actually in the law, as previous polls, including some conducted by Harris Interactive/HealthDay, have shown.

“People do not understand the health reform bill,” said John Goodman, president of the National Center for Policy Analysis, a conservative public policy research organization in Dallas that says it backs private alternatives to government regulation and control. “This reflects a failure all the way around on the part of backers of the bill, critics and the health-care media. No one’s explained how this works.”

Pollack pointed out that some provisions of the Affordable Care Act aren’t scheduled to take effect until 2014.

The poll also found that, by a 55 percent to 45 percent margin, people think health care reform should be addressed by each state separately, rather than at the federal level.

A fair amount of the current Republican primary race to challenge President Obama in the November election has focused on pledges to repeal much or all of the health care act.

Slightly more than half of those polled — including 61 percent of Republicans — said they knew that when Mitt Romney was governor of Massachusetts he supported a law that provides health insurance to many people in the state. The law is similar to the federal law signed by Obama in March 2010.

Most poll respondents said they had little or no idea what the Massachusetts law has — and has not — accomplished. The legislation, which includes an individual mandate, has provided coverage to a majority of state residents, is popular with most people in the state, but has yet to contain costs.

The poll was conducted online Jan. 17-19 with 2,415 adults 18 years of age and older. Figures for age, sex, race/ethnicity, education, region and household income were weighted, where necessary, to bring them into line with their actual proportions of the U.S. population. So-called “propensity score weighting” was also used to adjust for respondents’ likelihood to be online.

How best to treat infections and tumors ?

In cases where drug resistance can lead to treatment failure, new research shows that therapies tailored to contain an infection or a tumor at tolerable levels can, in some cases, extend the effective life of the treatment and improve patient outcomes. In other cases, aggressive treatments aimed at eliminating as much of the infection or tumor as possible — the traditional approach — might be best. But how can we know which stands the better chance of working?

A new mathematical analysis by researchers at Penn State University and the University of Michigan, publishing February 9, 2017, in the Open-Access journal PLOS Biology, identifies the factors that determine which of the two approaches will perform best, providing physicians and patients with new information to help them make difficult treatment decisions.

“People die when their infections or tumors become drug resistant,” said Andrew Read, Evan Pugh Professor of Biology and Entomology and Eberly Professor of Biotechnology at Penn State and an author of the study. “We analyzed when it might be better to use drugs to contain rather than try to eliminate the infection or tumor. We find there are situations where containment would keep the patient alive longer, but also situations where it would make a dire situation even worse. That means using (and testing) the containment strategy needs to be done very carefully, but if done right, it could help patients with life-threatening infections and tumors live longer.”

The researchers compared the two treatment strategies with the goal of maximizing the amount of time until the treatment failed due to the development of drug resistance. For most infections and tumors, people can tolerate a certain amount of the pathogen without ill effects. For the analysis, a patient was considered healthy and the infection or tumor was considered to be managed if it was maintained at or below this level of “acceptable burden.” Treatment failed if the pathogen level rose above this level. The analysis showed that the treatment leading to the longest time until treatment failure will depend on the specific characteristics of the disease, or even of the patient being treated, but it provides a framework that doctors and patients can use to make more-informed decisions about treatments.

“There are situations where we can be relatively sure that treatment will completely eliminate the infection or tumor, so aggressive treatment is the obvious choice” said Elsa Hansen, a research associate at Penn State and an author of the paper. “On the opposite end of the spectrum, there are low-level situations like urinary-tract or ear infections where a doctor may decide not to treat at all. The majority of cases, however, are somewhere in between and require hard choices that balance the damage caused by the infection or tumor and the risk of mutation with the damage caused by the treatment itself and the risk of developing uncontrollable resistance. Our analysis provides guidance for making these decisions from a standpoint of maximizing patient well-being.”

The researchers focused on two main factors that influence whether or not an infection or tumor will develop drug resistance. The first is the rate at which cells that are initially sensitive to a particular treatment become resistant. The second factor is called “competitive suppression” and refers to the fact that the spread of resistance, once it appears, can be slowed through competition for resources with cells that are sensitive to treatment. More cells that still respond to treatment leads to more competition to prevent the spread of resistant cells, but it also means a greater risk of the sensitive cells developing resistance.

“The standard practice has been to treat infections and tumors as aggressively as possible to minimize the risk of cells becoming resistant,” said Read, “but our analysis shows that, in many situations, containing the infection or tumor to allow for competitive suppression of resistant cells can increase the time to treatment failure. Of course, the opposite can also be true, so determining which approach will be best has to be done carefully and on a case-by-case basis.”