Dr. Buttery's Public Health BLOG

From today's MMWR comes the latest review of use of folic acid by women,. The health professions have known about the need for pre-pregnant and pregnant women to use folic acid to prevent Neural Tube Defect in tbeir children, yet we still have not even been able to ensure that the majority of women use folic acid, yet alone all.
The editors of this issue note:
"The 2005 findings indicated that only 33% of women of childbearing age reported consuming folic acid daily. Data from NHANES indicate no change during 1991–2000 in reported consumption of 400 μg of folic acid daily among nonpregnant women aged 15–44 years (CDC, unpublished data, 2005)."

Posted by at 1:45 PM | Permalink | Comments (0)

From today's JAMA an editorial by Dacey and Johnston states that "The costs of tobacco in both health and economic terms are enormous. Cigarette smoking causes approximately 5 million premature deaths each year around the world secondary to cardiovascular disease, chronic obstructive pulmonary disease, and lung cancer. In the United States, lung cancer is the leading cause of cancer-related deaths for both men and women. More than 170 000 new cases of lung cancer (13% of all cancer diagnoses) will be diagnosed this year, and more than 160 000 deaths from lung cancer will occur (28% of all cancer deaths). The 5-year survival for all patients who receive a diagnosis of lung cancer is an abysmal 14%, and even those who are diagnosed and definitively treated at the earliest stage (IA) have only a 67% 5-year survival.3 In the United States, direct medical costs for the treatment of lung cancer alone are approximately $5 billion annually.4 Years of research and innovative treatment for lung cancer have yielded improved amelioration of symptoms but little increase in overall survival. Clearly, the best treatment for lung cancer is prevention. Since smoking is responsible for 87% of deaths from lung cancer, tobacco avoidance or cessation is absolutely crucial for making any real progress in fighting this disease."

Posted by at 6:47 PM | Permalink | Comments (0)

From the Current MMWR is an editorial on infectious disease experience associated with hurricane Katrina. Worth reading by all. "The experience of the public health community with diarrheal disease after natural disasters suggests that evacuation centers should be prepared for considerable demands on clinic staff, janitorial services, and maintenance of personal hygiene. Access to functioning flush toilets and potable water are often impaired."
"Observations from previous natural disasters, such as the 2004 Asian tsunami, suggest that skin, diarrheal, and respiratory infections are the most common infectious diseases in survivors. Infectious disease outbreaks, however, are rare following natural disasters, especially in developed countries."

Posted by at 11:32 AM | Permalink | Comments (0)

The Food and Drug Administration (FDA) is issuing the 2005 edition of the Food Code, which contains the latest science-based information on food safety for retail and food service industries. The Food Code is used as a reference by nearly 3,000 regulatory agencies that oversee food safety in restaurants, grocery stores, nursing homes, and other institutional and retail settings.

"This year's Food Code not only includes the best practices for the retail and food service industries but it also provides valuable resources on food defense that will assist in protecting Americans against threats to the food supply," said FDA's Center for Food Safety and Applied Nutrition Director Robert Brackett.

Posted by at 11:24 AM | Permalink | Comments (0)

Despite the attempts to deny "Le Difference" here is an other fascinating study on the difference between men and women - Shopping! A study from Brunel University in London Shows that men go for the kill while women,as gatherers, eventually make a choice.

Posted by at 11:17 AM | Permalink | Comments (0)

You can fool some of the people all the time. I can never help but laugh when people turn out to buy the latest worthless fad. For several years copper rings and magnets have bene bought as cure alls. In a new study from the Mayo Clinic. Using carefully prepared placebos Dr Winemiller and associates were able to demonstrate that "Magentic Insoles do not provide pain relief"

Posted by at 12:25 PM | Permalink | Comments (3)

This week's editorial in the BMJ deals with the horrors of medically supervised dying. As the first paragraph of the editorial states: "Ask friends about the deaths of their loved ones, and the "bad death" stories crowd out the "good death" ones. Reflections along the lines of "They wouldn't let a dog die like my old Dad died," recur uncomfortably often. This is presumably one of the reasons why public support for legislation to permit assisted dying exceeds 80%. While doctors' attitudes are harder to summarise, there are signs that a majority of UK doctors now favour legalisation of physician assisted suicide with stringent safeguards" This may be a forum in which public health professionals could take a lead, it is much more a community than a medical issue.

Posted by at 12:43 PM | Permalink | Comments (0)

A fascinating article from the Lancet this week, by James Shelton et al. from AID discusses a report from Tanzania showing the the wealthier the household the more likely HIV! Volume 366, Issue 9491 , 24 September 2005, Pages 1057-1058

Posted by at 12:34 PM | Permalink | Comments (0)

This article authored by CDC staff used gene sequences to link infections of Hepatitis A at multiple sites from distribution of a single product - Green Onions - to outbreaks in GA, TN and PA from three farms in Northern Mexico.

Posted by at 10:30 AM | Permalink | Comments (1)

From Julie Geberding, Director, the CDC in this week's JAMA (use TMl E-Journal links):
Health is more than the absence of threats or disease and disability; it is a precious resource that helps to create productive satisfying lives for ourselves and our families and economic security for our nation. A very high value is placed on health, but all too often health is not protected. Indeed, the current investments in health protection are far overshadowed by expenditures to restore health once it is lost. Although the United States currently spends $1.9 trillion a year, or 15.5% of the gross domestic product, on health care, less than 1% of the $1.9 trillion [i.e. 1% of the 15.5%] is spent on protecting health and preventing the illnesses and injuries that require health care services in the first place. A similar disequilibrium characterizes the US health research portfolio
Now we know why we are one of the unhealthier countries in the world.

Posted by at 12:01 PM | Permalink | Comments (0)

In this note Don MacCorquodale reviews articles regarding health status in Cuba and China. He raises some interesting questions for those of us interested in public health outcome.

Posted by at 10:46 AM | Permalink | Comments (0)

From this week's BMJ (use the TML EJournal search and your EID) is a research paper from the U.K which states that:"The fourfold advantage of primary prevention becomes 12-fold greater when life years gained are considered, rather than simply deaths postponed. The authors have previously shown that a death prevented or postponed in a patient with recognised CHD gained an additional 7.5 years of life, on average. In contrast, each death prevented or postponed by primary prevention gained an additional 21 years of life, on average."
Further, The biggest single contribution reflected a large decrease in overall smoking prevalence."

Posted by at 2:41 PM | Permalink | Comments (0)

Editorial from the Sept 17 Lancet.
In the wake of hurricane Katrina, it comes as little surprise that yet another potential disaster the USA is not prepared for is emerging diseases. An Institute of Medicine (IOM) report issued on Sept 1 (Quarantine Stations at Ports of Entry Protecting the Public's Health) says that much more attention needs to be given to the management of quarantine for ill people coming into the USA.

Posted by at 2:10 PM | Permalink | Comments (0)

A fascinating editorial in this week's Lancet (get it on the EJournal search at the TML library, using your EID)
" John Snow, the London doctor who identified the source of the Soho cholera outbreak in 1854, has become a legend in epidemiology. This year marks the 150th anniversary of his seminal work On The Mode of Communication of Cholera, which describes in detail the events of the Soho outbreak. In truth, the outbreak was already on the wane and Snow's intervention did little to help the people of Soho, many of whom had already abandoned their homes. "

Posted by at 2:04 PM | Permalink | Comments (0)

From the Sept issue of Health Affairs (Use Ejournal search at TML) in an article by Richard Hillestad, James Bigelow and others:
"The U.S. health care industry is arguably the world’s largest, most inefficient information enterprise. However, although health absorbs more than $1.7 trillion per year—twice the Organization for Economic Cooperation and Development (OECD) average—premature mortality in the United States is much higher than OECD averages. Most medical records are still stored on paper, which means that they cannot be used to coordinate care, routinely measure quality, or reduce medical errors. Also, consumers generally lack the information they need about costs or quality to make informed decisions about their care. "

Posted by at 4:18 PM | Permalink | Comments (0)

A fascinating study reported in today's JAMA (JAMA. 2005;294:1255-1259( you can access the journal through the TMW e-journal link using your VCU-EID)) on changes in the leading casues of death over the last 20 years.
This article provides a concise overview of trends in both age-standardized death rates and numbers of deaths for the 6 leading causes of mortality in the United States from 1970 to 2002, updating a similar analysis from 1950 to 1986.10 These findings illustrate the substantial and continuing progress in reducing the age-standardized death rate from heart disease, the lack of continuing progress for stroke and accidents, and the increase in the age-standardized rates for COPD and diabetes. The study also illustrates that the reduction in age-standardized death rates, the best measure of progress against diseases, is not synonomous with reducing the number of deaths from these conditions. In fact, the number of deaths continues to increase because of population growth and aging. It is the number of individuals affected by various conditions rather than the age-standardized rate that influence the planning and allocation of preventive and medical services.

Posted by at 12:33 PM | Permalink | Comments (0)

A good example of a foundation assistance for health improvement.
Global Polio Eradication Initiative receives critical Gates Foundation grant to protect 34 million children in the region,
The plan will see large-scale series of immunization campaigns coordinated across eight countries - Djibouti, Eritrea, Ethiopia, Somalia, Sudan, Yemen, and parts of Kenya and the Democratic Republic of the Congo - between September and November. The campaigns will reach more than 34 million children with multiple doses of polio vaccine and rapidly boost population immunity in the Horn of Africa. The rapid and large-scale response is largely possible due to a US$ 25 million grant provided by the Bill & Melinda Gates Foundation, and support by other donors including the Humanitarian Aid Department of the European Commission (ECHO).
The plan has been finalized over the past weeks, amid growing concern that outbreaks in neighbouring Ethiopia and Yemen could spread across porous borders with Somalia. Now, with confirmation of polio in Mogadishu, rapid implementation of the emergency measures are essential. Although five nationwide campaigns were conducted this year, most recently in June, July and August to prevent the risk of a large-scale epidemic, insecurity in the country and low routine immunization rates could still result in rapid spread of the virus across Somalia.
"The polio eradication initiative has shown the world that even in the poorest countries, widespread and debilitating disease can be defeated," said Patty Stonesifer, Co-chair and President of the Bill & Melinda Gates Foundation. "Today, as a resurgence of polio threatens to roll back the amazing progress of the past 20 years, it is more important than ever that governments and donors support the final push to eradicate polio."

Posted by at 12:18 PM | Permalink | Comments (0)

An Editorial in today's BMJ by Erica Franck. Professor of Public Health at Emory stated "Concerns about disproportionately funding the prevention of bioterrorism in the US rather than funding other public health functions have been building for some time. As early as 2002, many people working in public health thought that the Bush administration's plan for smallpox vaccination was a misguided redirection of public health funds for bioterrorism preparedness, and it was thwarted. Estimates of the initial costs of smallpox vaccination ranged from $600m to $1bn (£330m to 550m, 480m to 800m), and costs for vaccination and treatment of smallpox, anthrax, and botulism were projected to exceed $6bn over the following decade. The Centers for Disease Control and Prevention (CDC) publication Morbidity and Mortality Weekly Report documented state health departments' "difficulty allocating the necessary time and resources for the pre-event smallpox vaccination program."
My take in this (CMGB) is that once again, the need of Congress to pander to the public (anti-terrorism funding vs. clear public health needs) finds us less prepared to carry out needed community public health programs. The State and Federal Agency heads will not comment on this for political reasons.

Posted by at 1:54 PM | Permalink | Comments (0)

For those of us old enough to have made house calls a regular part of our practice this research, from Autrallia, comes as no surprise, for the 90% of physicians today who have never been inside their patient's home we need to reinvent history.
"This novel research, just published in the Medical Journal of Australia, demonstrates the value of home-based care, when supported by experienced medical and nursing staff. The research has been carried out by Dr Dee Richards from the Department of Public Health and General Practice at the School, in partnership with Pegasus Health and the Canterbury Respiratory Research Group and is one of a number of studies being undertaken into the effectiveness of community health care.
In this study a randomised controlled trial examined 55 Emergency Department patients from Christchurch Hospital and found that mild to moderately severe pneumonia can be managed at home by primary care teams, given adequate resources.

Posted by at 1:43 PM | Permalink | Comments (0)

Well, now that we have had one more unnecessary law suit, which will work its way through the courts for a couple more years we find out from Duke University Medical Center that low dose aspirin ( which many if us over 65 years of age are already taking) may prevent the problams over which the law suit developed. too many ambulance chasers, too much advertising. We never seem to learn from our mistakes.
"Our data suggests that therapies that block unrestrained thromboxane actions – for example, low doses of aspirin -- might protect against end-organ damage without affecting blood pressure in patients taking cox-2 inhibitors," Coffman said. "However, the practical utility of such an approach would depend on whether such a therapy would retain the gastrointestinal protection afforded by cox-2 inhibitors alone."

Posted by at 12:58 PM | Permalink | Comments (0)

An editorial in this week's Lancet states that despite warnings from the IOM in 2002 (Future of PH in the 21st Century), the Federal Government has failed to provide necessary infrastructure support for the Public Health System in the U.S. The editorial discusses the weakness of links within the public health system, and lack of response coordination among the local. state and federal public health agencies. There is no formal cordination and response, just plans on paper without force of law. The editorial suiggests that rather than placing public health response within Homeland Security it should be within HHS. Further, the editorial states that "assessment criteria to test states' compliance with national obligations have been criticised as meaningless and impossible to measure"

Posted by at 11:28 AM | Permalink | Comments (0)

From today's Telegraph we find The following account of poor care in the U.K.
Thousands of patients are being denied the best treatment by the NHS because a third of hospital trusts say they have too little money to follow best practice, the Government's spending watchdog said yesterday.
Only 25 per cent of the trusts surveyed could verify that they were implementing Nice appraisals of drugs and treatments within three months. A third said they had been unable to fund guidance issued by Nice in 2002-03.

Is this really much different from the Medicare programs and many insurance companies which pay for 'hands on' care but not for advice and consultation, which is often more effective than pills, for chronc diseases?

Posted by at 11:33 AM | Permalink | Comments (0)

The death from rabies of a British woman, bitten by a dog in Goa, reported in the news and in an article in this week's BMJ, highlights the issue of rabies prophylaxis for people who travel to and live in endemic areas.
Around 90% of deaths from rabies occur in the developing world, with more than half in the Indian subcontinent, where dogs that roam freely are largely responsible.
The probability of contact with an infected animal depends in part on anticipated activities, locality, and length of time spent in the country. For example, hiking in a rural area of the Indian subcontinent where dogs commonly roam free carries a sufficient risk of exposure—combined with potential difficulties in obtaining early, safe, and effective post-exposure prophylaxis—to warrant vaccination before travelling.

Posted by at 2:11 PM | Permalink | Comments (9)

Maybe by Psyche also? From the BMJ
31% of Londoners reported substantial stress and 32% reported an intention to travel less. Among other things, having difficulty contacting friends or family by mobile phone (odds ratio 1.7, 95% confidence interval 1.1 to 2.7), having thought you could have been injured or killed (3.8, 2.4 to 6.2), and being Muslim (4.0, 2.5 to 6.6) were associated with a greater presence of substantial stress, whereas being white (0.3, 0.2 to 0.4) and having previous experience of terrorism (0.6, 0.5 to 0.9) were associated with reduced stress. Only 12 participants (1%) felt that they needed professional help to deal with their emotional response to the attacks.
Although the psychological needs of those intimately caught up in the attacks will require further assessment, we found no evidence of a widespread desire for professional counselling. The attacks have inflicted disproportionately high levels of distress among non-white and Muslim Londoners.

Posted by at 4:53 PM | Permalink | Comments (0)

From the University of Leeds in the U.K. One more liberal myth discounted.
Scientists from the institute of cancer research have today published results from the largest investigation to date into the relationship between mobile phone use and the risk of acoustic neuroma, a nervous system tumour that occurs close to where mobile phones are held to the head.
The study found no relation between the risk of acoustic neuroma and the number of years for which mobile phones had been used, the time since first use, the total hours of use or the total number of calls, nor were there any relations separately for analogue or digital phone use. There was relatively little information, and the results did not give a clear interpretation, for the risk of tumours after use of a phone for 10 years or longer.

Posted by at 2:49 PM | Permalink | Comments (0)

This comprehensive survey from USA Today, the Kaiser Family Foundation, and the Harvard School of Public Health examines how Americans are being affected by health care costs. The survey includes information on the barriers health care costs pose to obtaining medical care and the alternative measures people take to lower their medical and prescription drug bills.

Posted by at 2:37 PM | Permalink | Comments (0)

From the BMJ - Sept 2.
Crying wolf
At 11 pm, an ambulance screeched to a halt at my gate. Two paramedics, holding a glass jar at arm's length, climbed out and came up to the house. A local nursing home had an emergency and needed help: a patient had felt a sting while reaching into his bedside cabinet for his medicine and, on peering into the recess of the cabinet, had screamed "Snake."
The 40 cm serpent was battered into pulp, put in a jar, and rushed to me for identification. Poisonous or not, was the query.
Unwilling to seem nonplussed, I referred to the atlas of common Indian snakes and, handling a magnifying lens for effect, peered at the limp strip of flesh. Rat snake? Trinket? Cat snake? Keelback? Wolf? I flipped the pages of the book—aha, here it was, the Indian wolf snake, Lycodon aulicus. Those tell-tale eyes, like ophidian exophthalmoses. Non-venomous.
Off went the ambulance, siren screaming—my neighbours much impressed with the show. An hour later, however, the ambulance was back, with a white-coated medic.
"Reaction," he said gravely. "To what?" I asked, somewhat apprehensive that my snake identification was amiss.
"Anaphylaxis, to the shot."
"Allergic reaction to tetanus toxoid?" This was news for me.
"No, not to tetvac, sir, to the anti-rabies."
"Anti-rabies vaccine? A dog had bitten him?"
"No, not a dog, a wolf."
"Incredible, a wolf bit him too?"
"What do you mean `incredible'? It was you who said that a wolf had got him."
"Me? I never..." Then it struck me, those idiots who had come earlier must have reported back that I, the "snake doc," had said it was a "wolf."
"Never mind," the medic said as he left, "It's no big deal really; a bite from a snake bitten by a wolf, or a bite from a wolf bitten by a snake."
"What's in a name?" asks the Bard. A lot, sir, especially if you are a semi-schooled, snake-fancying doctor trying to school hospital staff on lycodons, not lobos.

Arunachalam Kumar, head of anatomy

Kasturba Medical College, Mangalore, India (ixedoc@hotmail.com)

Posted by at 11:27 AM | Permalink | Comments (0)

From this weeks JAMA.
Childhood Vaccination and Nontargeted Infectious Disease Hospitalization
The results do not support the hypotheses that multiple-antigen vaccines or aggregated vaccine exposure increase the risk of nontargeted infectious disease hospitalization.
One more answer to those who repudiate vaccines beause of their supposed dangers.

Posted by at 11:13 AM | Permalink | Comments (0)

This piece from the BMJ today also applies just to the U.S.
Patients may be putting themselves at unnecessary risk—with very little benefit to their health—by opting to undergo scans and genetic tests that are offered to them as part of a screening programme by private sector healthcare organisations.

That is the warning of a briefing paper by the BMA's Board of Science, which fears that many people are not told of the potential risks before undergoing the tests, such as whole body magnetic resonance imaging or the prostate specific antigen test for prostate cancer. It is calling on the government to address the growing problem of unregulated screening that is offered outside the formal NHS screening programmes. An estimated £65m ($117m; 95m) was spent in Britain last year on private screening.

Speaking at the launch of the paper, Steven Laitner, a consultant in public health medicine, said unregulated screening was often provided for profit. "It is often marketed to certain sections of the population but not necessarily those suffering from disease. It is not quality assured."

Dr Laitner warned that the tests did not necessarily offer any benefit and could run the risk of harm, which patients were not always made fully aware of. A whole body scan carried the equivalent dose of 100 chest radiographs, he said, and increased the risk of a fatal cancer developing by one in every 2000 patients screened.

He also explained that because the tests could be inconclusive and give false positive results patients often needed further, more invasive tests to estabilish the results' accuracy.

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CDC has an "Emergency Preparedness & Response" Web page and has ipdated is fcat sheets on Safe Food and Water, Mental Health, amd Eletrical Hazards this week

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