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Archive for August, 2014

The Care Of An Ebola Patient

Friday, August 29th, 2014

Scientific American

This article is from the In-Depth Report Ebola: What You Need to Know
Ebola Doctor Reveals How Infected Americans Were Cured

Techniques used in the U.S. to treat symptoms and subdue the virus in patients could work overseas, Bruce Ribner says

Aug 27, 2014 |By Dina Fine Maron

Last week two American aid workers who had contracted Ebola while working in west Africa were released from a U.S. hospital and pronounced “recovered.” They had been flown to Emory University Hospital in Atlanta from Liberia earlier this month to receive care in the hospital’s specialized infectious disease unit. Kent Brantly, a physician with the humanitarian group Samaritan’s Purse, and missionary Nancy Writebol, of SIM USA, beat the strain of the disease they had contracted, which kills 52 percent of its victims. Bruce Ribner, medical director of the hospital’s Infectious Disease Unit, sat down with Scientific American to explain how the two Americans were cared for, the lessons that could be applied to help patients across Africa and why the hysteria over flying the two individuals back to the U.S. was unfounded.

[An edited transcript of the interview follows.]

Are Brantly and Writebol now immune to the Zaire strain of Ebola?
In general, patients who have recovered from Ebola virus infection do develop a very robust immunity to the virus. They develop antibodies against the virus and they also develop cell-mediated immunity—the lymphocytes important to form viral control of pathogens. In general, the finding is it’s basically like being immunized—it would be unusual to get infection with the same strain.

Will that immunity afford them protection against other strains of Ebola?
We are still evaluating that in our two patients. Cross-protection is not quite as robust. There are five strains of Ebola viruses. Even though that data is not great, the feeling is there is potential for being infected if you go to a different part of Africa and get exposed to a different strain.

You said “still evaluating.” Are you still caring for Brantly and Writebol?
We are going to be following those two patients as outpatients, and as part of our evaluation they have agreed to undergo additional testing so we can better understand immunity to Ebola virus. We are meeting with them periodically.

What sort of lessons has Emory learned from caring for these two people that would be transferrable to patients in west Africa?
We are not being critical of our colleagues in west Africa. They suffer from a terrible lack of infrastructure and the sort of testing that everyone in our society takes for granted, such as the ability to do a complete blood count—measuring your red blood cells, your white blood cells and your platelets—which is done as part of any standard checkup here. The facility in Liberia where our two patients were didn’t even have this simple thing, which everyone assumes is done as part of your annual physical.

What we found in general is that among our Ebola patients, because of the amount of fluid they lost through diarrhea and vomiting, they had a lot of electrolyte abnormalities. And so replacing that with standard fluids [used in hospital settings] without monitoring will not do a very good job of replacing things like sodium and potassium. In both of our patients we found those levels to be very low. One of the messages we will be sending back to our colleagues is even if you don’t have the equipment to measure these levels, do be aware this is occurring when patients are having a lot of body fluid loss.

Our two patients also gained an enormous amount of fluid in their tissues, what we call edema. In Ebola virus disease there is damage to the liver and the liver no longer makes sufficient amount of protein; the proteins in the blood are very low and there is an enormous amount of fluid leakage out into the tissues. So one of the takeaway messages is to pay closer attention to that and perhaps early on try to replace some of these proteins that patients’ livers lack.

Considering how limited resources are in some of these facilities, could health care workers really act on this information?
I think the world is becoming aware that issues like this are not going to go away. The developed countries of the world will have to do our part to assist our colleagues with less developed infrastructure to care for sick people. I think one of the messages that is going out from many sources is we really have to help countries such as the ones involved in this outbreak to develop their medical infrastructure. Hopefully in five years they will have this infrastructure.

You have said that you are helping to develop new Ebola care guidelines based on your experience. How will those be disseminated?
We have several articles that we have submitted to major medical journals, which are read overseas, where we will be pointing this out. We are working with several government agencies, including the U.S. State Department, to help them come up with lessons learned—guidelines which they will distribute in turn to other countries. It is our goal to help our colleagues overseas.

Alternatively, what lessons did you learn from those health care workers?
Mostly the clinical course of the patients—much like any physician sending a patient to a referral center. They admitted they knew they were kind of flying blind. They’d say, “this is what we observed but we had no way to test it.”

The World Health Organization maintains that patients can continue to be infectious via their sexual fluids for several months after recovery. What did you recommend to Brantly and Writebol?
There are data that go back several decades—over several outbreaks—that suggest when you have individuals that have recovered from Ebola virus infection they may still be shedding nuclear material [genetic material from the virus which could potentially help spread it] in semen in males and vaginal secretions in females and also, potentially in urine. People have done this by doing assays looking specifically at the nuclear material of the virus. There has been very little attempt to demonstrate if this is viable virus that these individuals are shedding. It’s important when looking at epidemiological investigations that no one has been able to show people shedding these nuclear materials as a source of infection after they are discharged.

Looking at Ebola survivors who were discharged and successfully resolved the infection, following up several months later and evaluating their family members, there has never been any evidence that family members became infected. A lot of the thinking now is this probably was not live and is not important in terms of control of infection. We did give both of our patients the standard recommendations, which are contained on the CDC [U.S. Centers for Disease Control] Web site—not having unprotected sex for three months.

How many doctors and nurses were on your team caring for these two Ebola patients?
Twenty-one nurses, five physicians and we had the support of hundreds. Just making sure all the disposables coming out of those rooms were sterilized before we put them on the federal highway system, for example—we had to certify to the contractor that takes our regulated medical waste that it didn’t have active Ebola virus inside it. We didn’t have the equipment to handle all of the waste but in two hours facilities brought in industrial autoclaves [which sterilize materials with extreme heat] to replace the system that we had. We would have been drowning in garbage without them.

It has been reported that Brantly received a blood transfusion from a recovered patient. What role might that have played and is it being tried in other contexts?
I wouldn’t be able to tell you what I read in his chart. The most accurate thing to say is we don’t have a clue [what role a blood transfusion could play]. It’s not part of our standard treatment in our country. We wouldn’t have any idea whether he benefited or it was detrimental.

Are current diagnostics to identify Ebola virus disease adequate for this outbreak?
Certainly in the United States they are adequate. The major way one would diagnose Ebola virus disease is through a process called PCR or polymerase chain reaction, where you take the patient’s blood, put it in a machine and it tells you in a few hours if the nuclear material from the Ebola virus is present. CDC is doing that for patients coming back from infected areas where virus is a potential. There are a number of labs, both local and courtesy of CDC, that are doing this testing in west Africa, and my sense is it’s not that difficult to get it done.

This past week WHO announced that one of its workers has been infected with Ebola virus disease and that person was given the option of being sent to a different country for treatment. A British nurse also contracted the virus and went home to the U.K. for care. What’s the value of getting treated elsewhere?
Given that there is no treatment for Ebola virus disease, the main intervention that will determine if someone lives or dies with this infection is supportive care: The ability to replace fluid and electrolytes if a patient is losing them. The ability to replace platelets if that count is low and a patient is starting to bleed. The ability to replace protein in the blood that may be deficient. A developed country has the capability because of our infrastructure to provide that level of support is at a much higher level than a hospital dealing with patients in west Africa.

Among the handful of patients that received the experimental drug ZMapp, some have died. Considering the mortality rate for the current Ebola strain is almost 50 percent what can we say about ZMapp?
Experimental drugs are experimental drugs because we don’t know if they will work. That is true both with the preparations patients received in Liberia and other preparations that are being considered for treating patients with this infectious disease. We are a long way from being able to say that someone that received one of these agents benefited, it had no impact or it may be that their outcome may be impeded. Until we have good studies looking at outcomes of patients who received these medications, compared to patients who didn’t receive them, we should be very cautious.

I would go further to say that there is a fair amount of almost hysteria and people feeling they must have these preparations to survive. In the past people thought they needed agents for treatment, and the agents actually turned out to impair people’s ability to survive. The focus should remain on aggressive intensive care and the ability to correct abnormalities metabolically, rather than receiving any magic vaccine or product that may or may not improve survival.

For example, there used to be a belief that patients who had bacterial sepsis did much better if you gave them high doses of steroids. Now we know that these may be detrimental instead of beneficial. We know now since we’ve done the studies. Again, it was one of those things where people felt like “yeah this should be” but when they did the study in randomized patients they found it didn’t work at all.

As you know, two upcoming clinical trials will be looking at potential Ebola vaccines, and there are also a variety of experimental therapies that are being discussed in the U.S. and elsewhere beyond ZMapp. How should such information be coordinated? Does there need to be an entity overseeing that?
Given that we have multiple countries I don’t know that you can have any one entity. It’s tricky enough having the FDA [U.S. Food and Drug Administration] monitor what is going on in the United States. Clearly if you are talking about Canadian studies or European products, I don’t know that there is any entity that can provide that sort of coordination. My guess is that most of the manufacturers are aware of what the others are doing and are comparing notes because they feel it’s to their benefit to work together.

An ethics panel from WHO recently said that it is ethical to give out experimental treatments to Ebola patients, but it has not yet specified who should have priority in such circumstances or how such drugs should be doled out. They are taking up that issue at a meeting next week. What’s your thought?
I think it’s certainly ethical to study experimental biologicals and vaccines but we have to be extremely cautious. It’s not as though we have something that we know works. To say that anyone is withholding products implies we know that there’s a benefit, which gives me pause because we are a long long way from demonstrating that these offer any benefit in humans.

Is there anything you would like to add about insights you learned from your Ebola patient care?
The major thing I hope people have appreciated is there was a lot of anxiety, a lot of negative comment about our bringing these two patients back to our facility to care for them. Most of that we attribute to poor education, and I’m hoping that since we were successful in helping them resolve their infections it helps to dispel the idea that this is a disease that by nature has to be fatal. As we have been saying all along, we feel that the high fatality rates in developing parts of the world where this infection occurs are because of the lack of resources. We had always felt that the survival of patients with proper support would be a lot better than in developing countries.

The other thing I would hope we would get across to the public is this is a disease where we don’t have to have a lot of secondary infections—if we follow standard infection-control procedures. We had 26 people giving direct patient care to these patients and we did not have any secondary infections at all, and that’s as we expected.

We were using contact precautions and droplet precautions. Fortunately, we don’t have to go to that level of protection [wearing protective full-body suits like in west Africa]. You wear whatever you need so that the blood and body secretions don’t come into contact with you, depending on the quantity of fluids. We used gowns and gloves and foot coverings of the health care workers in order to prevent contact with the body materials of these individuals. Our approach was what CDC recommends: you wear a mask and goggles or a face shield to prevent that infection. Some of the nurses spending three to four hours in patients’ rooms were more comfortable wearing hoods than masks and face shields, though those would have been adequate. We can manage care with minimal chance for secondary spread. It’s not as though we brought the plague to American shores.

The Ebola Epidemic

Thursday, August 28th, 2014

The really most frightening news of the summer involves the terrible Ebola epidemic that has taken more than 1500 lives and is spreading quickly across Africa and potentially the entire planet. Modern medical procedures and programs are essential in combating this plague. But there is another, less “high tech” effort that might play an important role in stemming the tide.

The lack of shoes in  Sierra Leone and Liberia could be contributing to the spread of the Ebola virus”

In the bush there is no running water or flushing toilets.In the jungle, shoes are the exception and even if owned are rarely worn. That’s why most people in the bush have infected toes, a sure way to contract Ebola.

When these people walk barefoot, the parasites, bacteria and viruses left behind from animal waste or human urine, enter thorough the micro-lacerations in their feet. They multiply with a vengeance, especially in the children. The worry used to be bilharzia or filaria or hook worm, but now the worry has turned deadly – Ebola.

Perhaps the shipment of thousands of pairs of shoes might be just as important as medicines, IV solutions, sterile gloves and surgical masks in combating this awful epidemic.

Soros and other wealthy liberals trying to rescue Senate Democrats

Thursday, August 28th, 2014

The Democrat “spin-meisters” and the Democrat media ( CBS, ABC, NBC, MSNBC, CNN, NYTimes, Wash. Post, etc.) have promulgated the idea that the Republican Party is heavily supported by all the “fat cat” business types, big corporations, multimillionaires and billionaires. IT’S JUST NOT TRUE. See the stories that follow.

The TEA Party Express
Taylor Budwich
August 24,2014

With the Democrats facing the very real possibility that they could lose control of the U.S. Senate in November, wealthy liberal donors are pouring millions into Super PACS to try and prevent it from happening.

Soros and Steyer  are spending big bucks in an effort to rescue the Democratic majority in the Senate. Tom Steyer, the big climate change activist gave $7.5 million in July to a Democrat superPAC.

In July, George Soros gave $500,000 to the House Democrat PAC and $500,000 to the League of Conservation Voters Victory Fund. By August 22, most Democrat Super PACs were getting ready for the Fall campaign by filing their disclosure reports that left a paper trail littered with big checks from big-time donors.

Democrats dominated the list of notable July donors since there have been many more Democrat dollars flowing to these outside PACs this year.

The hard reality in politics is that money wins elections, and they are spending big to protect their liberal interests. However while Tea Party supporters don’t have their deep pockets, our power and influence comes from our numbers and conviction for each individual to step up and help out as much as they can.

We have something they don’t, and that’s the fact that there are a lot more of us who care about our country and want to change the direction it’s headed in.

To match the war chest of the liberal Democratic elite, we need all Tea Party supporters to step up and make a contribution so that we can finally defeat Harry Reid and the Democrats.

Harry Reid has done everything in his power to push President Obama’s radical agenda through the U.S. Senate and if we don’t replace him as Majority Leader this year, we can be sure that he will continue to try and stuff the President’s liberal policies down our throats over the next two years.

But to make that happen we need to win at least 6 Democrat US Senate seats  this year.

Cronyism vs. the Constitution

Thursday, August 28th, 2014

The Obama Administration is well known for promulgating hundreds and thousands of new and often crippling regulations, in direct conflict with the responsibilities of the Congress and the Constitution. The following is an article from the Wall Street Journal that discusses this problem and how to deal with it.

Cronyism vs. the Constitution

Congress’s vague laws give too much discretion to regulators. It’s time to take its power back.

Allan H. Meltzer
Aug. 25, 2014 7:19 p.m. ET

Most of us learned in grade school that the Constitution parcels legislative, executive and judicial power into separate branches of the government. This separation of powers—the system of checks and balances—is to prevent tyranny and ensure that all citizens enjoy equal protection under the law. How true are these time-honored precepts today? Unfortunately, as some colleagues at the Hoover Institution’s program on regulation and the rule of law are finding, the answer is less and less.

With regard to presidential power, the Constitution is explicit: Congress is authorized to make laws, and the president must execute them. The Constitution does not authorize the executive branch to change the laws or decline to enforce them for its own convenience.

Yet President Obama has waived the requirements of laws such as the Affordable Care Act and some laws on immigration—effectively rewriting them. This practice is constitutionally dangerous: Unless it is checked, there is not much short of impeachment to prevent a future president from issuing his own laws by reinterpreting existing laws.

The Supreme Court has been loath to prevent the president from going beyond his authorized responsibility. But Speaker John Boehner has led the House to pass a resolution authorizing a lawsuit challenging the president’s actions on the grounds that his actions infringe on Congress’s legislative power.

Regardless of the outcome of this lawsuit, Congress has other ways to protect the rule of law. Article III of the Constitution authorizes Congress to make rules for the judiciary. It can—and should—directly change the scope of standing to permit courts to restrain the president from rewriting laws.

That would be a good start, but more is needed. The power of federal regulatory agencies to issue rules, enforce them and penalize violators is also subject to abuse. Congress itself created this problem long ago by writing broad, vague general laws and letting regulatory agencies fill in the details. It continues to do so.

This arrangement is tailor-made for influence-peddling and cronyism. Lobbyists and other special interest groups negotiate the rules with unelected bureaucracies. Inevitably, those with pull get favorable treatment. Larger firms can impose disadvantages on competitors; smaller firms that cannot afford to participate in the process lose. Regulators, in short, are too easily captured by the industries and companies they are supposed to regulate. And they have much weaker incentives to act in the best interest of firms than do these firms’ principal stockholders.

Here is one example. After the financial crisis of 2008, bank regulators should have increased bank capital requirements enough to provide managers with stronger incentives to avoid high-risk loans and investments. Instead regulators are more directly attempting to monitor and manage financial risk-taking. This arrangement raises the possibility of gaming the system.

Another example: The Dodd-Frank Act of 2010 was passed in part to eliminate bank bailouts brought about by banks that have grown “too big to fail.” But the law has not eliminated the too-big-to-fail problem, and massive taxpayer bailouts are still possible. The largest banks have retained their competitive advantage and can borrow at a lower interest rate because their creditors are protected against failure. As a result, merely big banks cannot compete with the largest banks, and many have sold out to them. For example, J.PMorgan acquired Chase National, and J.P. MorganChase acquired Bank One. The biggest banks became even bigger, and concentration of lending greatly increased.

There are better alternatives. One of them, the bipartisan Brown-Vitter bill, (introduced by Sen. Sherrod Brown (D., Ohio) and Sen. David Vitter (R., La.) would substantially raise capital requirements of all the largest banks. Large stockholders would have incentives to enforce prudential behavior by bank managers more effectively than regulators because their investment is at risk.

Regulations that favor some interests over others is not a problem confined to finance. It is a feature of environmental protection, labor markets and much else. The U.S. regulatory system does a poor job of fulfilling the main economic reason for regulation—closing any demonstrated gaps between private and social cost. It is much more likely to find ways to help specific, favored groups of constituents, shifting the costs to others. The Consumer Financial Protection Bureau, a creature of Dodd-Frank, takes funding from the Federal Reserve’s massive earnings on its huge portfolio to direct credit toward individuals and groups it claims are disadvantaged. This is an invitation to cronyism and corruption.

To help strengthen the rule of law, Congress could require that all regulations above some specified cost be approved by both houses. That would provide oversight by elected officials who could reject special privileges and cronyism. It could also insist that all spending by any agency for any purpose requires direct congressional authorization, a fundamental principle of the Constitution.

Mr. Meltzer is the University Professor of Political Economy at the Tepper School, Carnegie Mellon University, and the director of the Hoover Institution’s program on regulation and the rule of law.

ISIS makes liberals rediscover the necessity of hard power.

Wednesday, August 27th, 2014

The Neo-Neocons

By Bret Stephens
Aug. 25, 2014 7:22 p.m. ET

So now liberals want the U.S. to bomb Iraq, and maybe Syria as well, to stop and defeat ISIS, the vilest terror group of all time. Where, one might ask, were these neo-neocons a couple of years ago, when stopping ISIS in its infancy might have spared us the current catastrophe?
Oh, right, they were dining at the table of establishment respectability, drinking from the fountain of opportunistic punditry, hissing at the sound of the names Wolfowitz, Cheney, Libby and Perle.

And, always, rhapsodizing to the music of Barack Obama.
Not because he is the most egregious offender, but only because he’s so utterly the type, it’s worth turning to the work of George Packer, a writer for the New Yorker. Over the years Mr. Packer has been of this or that mind about Iraq. Yet he has always managed to remain at the dead center of conventional wisdom. Think of him as the bubble, intellectually speaking, in the spirit level of American opinion journalism.

Thus Mr. Packer was for the war when it began in 2003, although “just
barely,” as he later explained himself. In April 2005 he wrote that the “Iraq war was always winnable” and “still is”—a judgment that would have seemed prescient in the wake of the surge. But by then he had already disavowed his own foresight, saying, when he was in full mea culpa mode, that the line was “the single most doubtful” thing he had written in his acclaimed book “The Assassins’ Gate.”

An F/A-18 Hornet takes off for northern Iraq, Aug. 18. AFP/Getty Images
Then the surge began to work, a reality the newly empowered Democrats in Congress were keen to dismiss. (Remember Hillary Clinton lecturing David Petraeus that his progress report required “a willing suspension of disbelief”?) “The inadequacy of the surge is already clear, if one honestly assesses the daily lives of Iraqis,” wrote Mr. Packer in September 2007. The title of his essay was “Planning for Defeat.”

Next, Mr. Packer pronounced himself bored with it all. “By the fall of 2007, my last remaining Iraqi friend in Baghdad had left,” he wrote a few years later. “Once he was gone, my connection to the country and the war began to thin, even as the terror diminished. I missed the improvement that came with the surge, and so, in my nervous system, I never quite registered it.” This was Mr. Packer in Robert Graves mode, bidding Good-Bye to All That.

And then came Mr. Obama. Was ever a political love more pure than what Mr. Packer expressed for the commander in chief? Mr. Obama, he wrote in 2012, was “more like J.F.K. than any other president.” Or was T.R. the better comparison? “On foreign policy, Obama has talked softly and carried a big stick.” He had “devastated the top ranks of Al Qaeda.” On Iran, he had done a “masterful job.” On Syria, “the Administration was too slow in isolating Assad, but no one has made a case for intervention that has a plausibly good outcome.”

As for Iraq, Mr. Obama withdrew “after eight years of war in a way that left the U.S. with almost no influence—but he could have tried to force matters with the Iraqis and left behind far more bitterness.”
Elsewhere, Mr. Packer has written that “American wars in Muslim countries created some extremists and inflamed many more, while producing a security vacuum that allowed them to wreak mayhem.” This is the idea, central to the Obama administration’s vision of the world, that wisdom often lies in inaction, that U.S. intervention only makes whatever we’re intervening in worse.

It’s a deep—a very deep—thought. And then along came ISIS.
In the current issue of the New Yorker, Mr. Packer has an essay titled “The Common Enemy,” which paints ISIS in especially terrifying colors: The Islamic State’s project is “totalitarian.” Its ideology is “expansionist as well as eliminationist.” It has “many hundreds of fighters holding European or American passports [who] will eventually return home with training, skills, and the arrogance of battlefield victory.” It threatened a religious minority with “imminent genocide.” Its ambitions will not “remain confined to the boundaries of the Tigris and the Euphrates.” The administration’s usual counterterrorism tool, the drone strike, is “barely relevant against the Islamic State’s thousands of ground troops.”

“Pay attention to other people’s nightmares,” he concludes, “because they might be contagious.”

Correcto-mundo. Which brings us back to the questions confronting the Bush administration on Sept. 12, 2001. Are we going to fight terrorists over there—or are we going to wait for them to come here? Do we choose to confront terrorism by means of war—or as a criminal justice issue? Can we assume the cancer in the Middle East won’t spread so we can “pivot” to Asia and do some more “nation-building at home”? Can we win with a light-footprint approach against a heavy-footprint enemy?

Say what you will about George W. Bush: He got every one of these questions right while Mr. Obama got every one of them wrong. It’s a truth that may at last be dawning on the likes of Mr. Packer and the other neo-neocons, not that I expect them ever to admit it.

William S. Frankl, MD, All Rights Reserved