Pandemic flu: new version of an old threat

 There was a time, in the 1960s and 1970s, when public health experts had high hopes that perhaps humanity had conquered infectious diseases.

It was an era when new, effective vaccines and antibiotics were being introduced. The ancient global scourge of smallpox was well on its way to being eradicated. Life expectancy was rising, in part because far fewer children were dying from infectious childhood diseases such as diphtheria.

We need only look at the current outbreak of swine flu to realize the tenacity of germs and their perpetual ability to outsmart us.

The influenza virus is trickier than most. It’s constantly mutating. Even though vaccines are available to protect against it, the formula must be updated every year to ensure it remains effective against whatever flu virus strains happen to be most prevalent.

Most of the time, this antigenic drift, or mutation, is not significant. But it has long been a fear of world health authorities that, sooner or later, a larger shift in the virus will take place, rendering current vaccine formulas mostly ineffective and leaving millions of people unprotected from the flu.

That’s what has happened with swine flu. It is a novel virus, a combination of human, avian and swine influenza that hasn’t been seen before, said Ann Stehn, director of Kandiyohi County Public Health.

"It’s a new and different strain," she said. "It is different from seasonal influenza."

At media briefings on Monday, state and local health officials were diligent about sharing as much information as they could. But there’s still much about the new flu virus that isn’t known, explained Dr. Ruth Lynfield, state epidemiologist with the Minnesota Department of Health.

Why, for instance, does swine flu appear to be hitting hardest among adults in their 20s, 30s and 40s? Is this really the case or is it a premature conclusion based on incomplete data?

Lynfield’s response: "We don’t know the answer to those questions but we are all looking carefully."

One point the health authorities made during their briefing on Monday: It’s more accurate to call this "North American flu." For one thing, the virus contains elements of human and avian influenza, not just swine flu. For another, although forms of swine flu do exist, this particular version has not previously been reported among pigs, nor is it spread by eating pork. It is believed to spread through human-to-human contact.

In the absence of any current effective vaccine, the best weapon, say health officials, is old-fashioned, low-tech prevention: hand washing, covering coughs and sneezes, and staying home if you are ill. None of these are expensive, they don’t involve any fancy equipment or technology, and they can be done by everyone. It’s the same message health authorities push during the normal flu season and during outbreaks of other infectious diseases. In other words, something we should be doing anyway, whether there’s a threat of pandemic influenza or not.

"People need to take responsibility for lessening the transmission of germs," Lynfield said.

Image: three-dimensional structure of an influenza virus photographed via electron tomography. Courtesy of NIH/National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Getting the surgical site right

Doing the right surgery on the right patient at the right site sounds like it should be easy to accomplish. And, most of the time, it’s done correctly. But it remains a stubborn issue for hospitals to address.

Even when surgery teams are careful, there are dozens of ways in which the confirmation process – right patient, right procedure, right site – can be derailed. And making sure the process is adequately followed every single time is proving to be much harder than anyone thought.

Linkworthy 1.0

A sample of some of the more thought-provoking and/or interesting stories, essays and whatnot that I’ve encountered recently on the Web:

– The Minnesota Medical Association recently posted the latest issue online of its monthly magazine, Minnesota Medicine, and as always, it’s full of good stories. Start your reading with "Civic Duty," which profiles the community involvement of several small-town Minnesota doctors. One of the featured physicians is Dr. Richard Horecka, a family practice doctor at Affiliated Community Medical Center in Benson who also is active in local economic development.

Also check out the cover story, "Role Reversal." Four doctors describe their own experience with injury and illness, what it was like to be the patient instead of the doctor, and how it changed their perspective in caring for their own patients.

– On the New Old Age blog at the New York Times, there’s a fascinating discussion about the silence that often surrounds end-of-life issues. The title sums it up: "At the End of Life, Denial Comes at a Price."

– If you need money, how about becoming a clinical test subject? MinnPost explores this phenomenon in "In hard times, lure of guinea pigging grows." 

– Most Americans believe everyone should have some form of health coverage. But are there enough doctors to handle the increase in patients if there’s universal coverage? Dr. Marc Siegel sounds the alarm in an opinion piece for the Wall Street Journal, "When Doctors Opt Out." Although he is primarily addressing Medicare, his thoughts could equally apply to rural Minnesota, where the supply of doctors is steadily shrinking.

– Real doctors can’t stand "House" but they like "Scrubs" and the recently departed "ER." MedPage Today reports on a survey it conducted and the impact of TV shows on real-life relationships between doctors and patients. Surprisingly, some of the respondents thought the TV medical dramas were sometimes helpful in encouraging patients to seek needed care and in portraying the human side of the medical profession.

Young, sick and invisible

By the time he was 39, Craig Lustig had already gone through two bouts with brain cancer.

He describes what it was like to be a young patient facing a life-threatening illness:

Especially as a young adult, when we’re coming into our own as individuals, it is a very difficult experience to lose control of your body and to allow people to do some pretty awful things to it, as well as losing control over other parts of your life because you have to devote most of your time to getting well.

Craig’s story is one of dozens of personal reflections shared by the Lance Armstrong Foundation on its Web site. It especially illuminates a group of patients who all too often get overlooked: young adults with cancer.

It’s their turn to speak up this week during the seventh annual National Young Adult Cancer Awareness Week. Among their messages: Many of the advances in cancer treatment and outcomes have bypassed this age group, and more must be done to address their unique needs.

Cancer is generally considered a disease of older adults. Of the 1.6 million Americans diagnosed each year with cancer, fewer than 10 percent fall between the ages of 20 and 40, according to SEER, the database of the National Cancer Institute.

These younger patients are stranded by their minority status. In the oncology world, they’re caught between services for children and services for older adults. Nor do they fit easily among their peers, as Craig explains:

I worked through relationships with friends and family who didn’t have cancer – especially friends in  my own peer group who found it hard to watch me, a young adult like them, with a life-threatening disease. Our generation of young adults with a cancer history doesn’t necessarily fit the traditional treatment molds of either being among people who are often twice or three times our age, or in the environment of the real young ones.

Cancer in one’s 20s or 30s can severely disrupt a developmental stage in life that’s normally devoted to college, relationships, establishing independence, launching a career and starting a family. Survivors carry lifelong health risks as a result of their cancer history and treatment. They can face discrimination at work and in the health insurance market.

Perhaps most disturbing is how this age group has fallen behind while cancer survival rates have improved for almost everyone else. CA, the journal of the American Cancer Society, explored this issue in depth two years ago, concluding that this gap "is unacceptable."

Cancer kills more 20- to 30-year-olds than any other disease except depression-induced suicide, and in young women, cancer outranks all other disease killers by a wide margin. Yet cancer in young adults has been under-recognized and frequently not considered by internists, family physicians, pediatricians, gynecologists, other health professionals, and even, at times, oncologists.

Among some of the barriers: Many young adults have little contact with the health care system and hence are less likely to receive an early diagnosis of cancer. They might be uninsured, or they might shrug off symptoms because they perceive themselves as invincible. The relative rarity of cancer in this age group can also lead doctors to underestimate the likelihood that a young patient might have cancer, and fail to make a timely diagnosis.

There’s a push to do more. Among the resources that have sprung up are Vital Options, the first organization to specifically address the needs of young adults with cancer; the Ulman Cancer Fund for Young Adults; the edgy Planet Cancer; and the Lance Armstrong Foundation’s Young Adult Alliance.

Another promising development is the inclusion of research funding in the federal stimulus project to study the biology of young adult cancer.

So the news is beginning to look more encouraging for young adults. But there’s still a long way to go toward closing a gap that shouldn’t be there in the first place.

Taking an aging parent to the ER

Anyone who’s ever cared for aging parents knows how stressful it can be, especially when there’s a medical crisis that requires a trip to the emergency room.

Because emotions can be running high in these situations, it’s wise for caregivers to be prepared, advises the American College of Emergency Physicians.

Among the ACEP’s suggestions to help smooth an emergency room visit for an older parent:

– Compile a medical history form ahead of time so you can bring it to the emergency room and give it to the physician. There’s an online form available at Emergency Care for You. It can be filled out with a list of your parents’ current medications, their allergies and any past and current medical conditions. You should also keep track of your parents’ surgeries, especially if they involve an implanted device such as a hip replacement or a pacemaker.

– Do you know the names of all the doctors your parents see? Their specialties? Their contact information? This is information that should be collected and written down so it can be available if needed.

– Put together your parents’ insurance and identification information on a single sheet of paper.

– Anticipate that your parent might have to be admitted to the hospital. Bringing a change of clothing and some personal items – even if you just leave them in the car – will help you be prepared for this possibility.

– Give some thought to a living will. Do your parents already have a living will? Do you know what their wishes are? An honest family discussion ahead of time, before you’re faced with a critical situation, can help pave the way if and when difficult decisions are called for. To get the discussion started, here’s some information from Rice Memorial Hospital on Minnesota health care directives.

Adult children might need to help their parents communicate with the doctor and nurses. Do your best to try to make sure your parents understand what’s happening. If a parent seems confused, explain to the doctor what your parent’s normal behavior is like. If the doctor is talking to you, make sure you’re talking to your parent. Be aware that older patients might downplay their symptoms to doctors or nurses, and be ready to supply more information if it’s needed.

Finally, be patient, because things don’t always happen quickly in the emergency room. Bring a book or newspaper to read while you’re waiting. Based on recent family experience, I’d also recommend a cell phone in case you need to call siblings, other relatives, employers, a neighbor or whomever.

Even if your parents are relatively young and healthy, chances are they’ll eventually end up needing emergency care for something. Emergency room visits by the elderly are growing faster than for any other age group, and could exceed 11 million a year by 2013.

The 800-pound gorilla of health care reform

The Minnesota Department of Health is continuing to plow into the details of reforming the state’s health care.

It’s the public’s turn today to provide feedback at a meeting in St. Paul, hosted by the Health Department, on a plan to develop cost and quality comparison data. 

Here’s what it’s all about: As part of Minnesota’s 2008 health care reform bill, the Health Department has been asked to develop a "provider peer grouping" system. "Encounter data"  must be collected to give an overview of what kinds of health care services are being used and how much they cost. (You can read more about this initiative here.)

The idea is to help consumers compare cost and quality so they can make sure they’re getting good care that also gives them their money’s worth.

Few people can afford to be unconcerned nowadays about the cost of health care. The cost keeps going up; according to state figures, health care spending in Minnesota increased from $19 billion to almost $31 billion between 2000 and 2006.

How some of the current state initiatives will play out, however, is anyone’s guess. I confess to being disappointed that the Health Department has chosen to hold its one and only meeting on the encounter data proposal in St. Paul, during the day (2 to 4 p.m.) when most people are at work. Will so-called ordinary consumers be able to attend? (Clearly they’ll need to do some homework first if they want to contribute to the discussion; I had to do a fair amount of reading to gain even a basic grasp of this proposal.) What about people from rural Minnesota?

Rural Minnesotans have a considerable stake in this. Outside the Twin Cities area and possibly Duluth, Rochester and St. Cloud, the health care market doesn’t function in quite the same way. The market is smaller, hospitals are smaller, health care professionals are in shorter supply, and people often are traveling farther for certain kinds of care. It’s hard to picture how a rural patient, faced with the need for surgery or for chronic care, will genuinely be able to choose where to receive care on the basis of cost and quality.

Are these differences between rural and urban health care being recognized by the health care reformers? I hope so, but I don’t really know if this is truly the case.

More to the point, it’s not at all clear whether consumers will be prepared to use cost and quality data in a meaningful way – or whether the system will be ready for them to do so. This was evident in a recent story reported by the Star Tribune of Minneapolis: An uninsured patient was seen at an urgent care clinic for a severe cough, was told she needed a CT scan and sent across the street to the hospital for the procedure. She wanted to find out first what it cost, but by the time an answer was provided it was too late – she’d already had the scan and was billed $780.

In hindsight, it’s easy to say she should just have refused the scan. But patients aren’t necessarily in a position to judge whether a CT scan is clinically appropriate. Maybe she could have shopped around, but this was the hospital to which she was sent. People who are sick can’t always be expected to check the prices at three or four different vendors before making their choice. In rural Minnesota, where the next closest CT scanner might easily be 30 or 40 miles away, this kind of comparison shopping doesn’t even make logistical or economic sense. And if this particular hospital couldn’t tell the patient the price of a basic CT scan or at least take the time to get her the information before going ahead with the procedure, then health care providers themselves are partly responsible for some of the barriers.

No one can argue that the current system is sustainable. It’s not. But the public will have to be far more informed and involved if Minnesota’s health care reform efforts are to be even halfway successful. The question of how patients are supposed to navigate this will have to be a much greater part of the discussion. And that’s the 800-pound gorilla that no one has really confronted yet.

Fast-food intake on the rise among teens

Compared to 10 years ago, teenagers are eating significantly more fast food, the University of Minnesota’s Project Eating Among Teens has found. Researcher Katherine Bauer also found that as teens move from middle school to high school, their intake of fast food goes up. A similar increase also was noted among teenaged boys between high school and young adulthood.

The study of fast-food intake trends among teens appears in the March issue of Preventive Medicine. A second study, exploring predictors of fast-food intake in this age group, is published in Public Health Nutrition.

Project EAT is a long-term study involving more than 2,500 teens in the Twin Cities. Using data from the study, Bauer found that the percentage of teenagers eating fast food three or more times a week nearly doubled between the middle school and high school years. Thirty percent of high school boys and 27 percent of high school girls reported eating fast food this often. From 1999 to 2004, the percentage of high school girls eating fast food three times a week also rose from 19 percent to 27 percent.

No surprises there. But what makes these studies really worthwhile is how they examine the reasons behind this trend. Bauer’s main observation is that the increasing consumption of fast food is most likely "due to changes in our communities and society."

She cites many factors. For one, the number of fast-food outlets has greatly increased, and many of them are located near schools or other places easily accessible to youths. As students enter high school, they often acquire cars, jobs, spending money and relatively more independence, allowing them to go to fast-food places with their friends after school and on weekends.

Busy schedules also mean more families are turning to fast food because it’s, well, fast.

A particularly interesting finding from this study: High school boys who were active in sports – and thus might be expected to show discipline about what they ate – actually had some of the largest increases in fast-food consumption. Bauer suggested this might be because of sports practice schedules that conflict with dinnertime, or the need for sports teams to be on the road for games. Kids might also turn to fast food after practice so they can eat with their friends, she said.

Boys might also eat more fast food as they move into young adulthood because they’re living away from home for the first time and don’t know how to cook, Bauer said.

Her analysis of the data uncovered demographic and socioeconomic differences as well. Girls who reported being white or Asian and who came from higher-income families were less likely to eat fast food. Among boys, fast-food habits appeared to be influenced by family and friends.

The take-home message here: There’s no one solution for changing the eating habits of this age group. Less hectic family schedules might help. Sports schedules that are family dinnertime-friendly would probably help. So would kitchen skills acquired earlier in life (do any kids take old-fashioned home economics classes anymore? If not, why not?). Nor should adults overlook the importance that teenagers place on hanging out and eating with friends. Understanding the factors behind the fast-food trends, however, is one step forward in coming up with some answers.