The rise of the drug-resistant infections

For many decades after the discovery of the first antibiotic, we have been able to root out and beat bacterial infections after bacterial infections. But when the medical professionals celebrated this invincibility with the widespread use of antibiotics, most of them forgot the fact that bacteria like any other life form know how to evolve. And thus after being victorious against even the most aggressive and deadly infections for almost a century, we are now facing a new breed of bacteria that have learned to survive even the strongest drugs in our antibiotic arsenal.

According to the CDC Antibiotic Resistant Threats 2013 Report;
Each year in the United States, at least 2 million people acquire serious infections with bacteria that are resistant to one or more of the antibiotics designed to treat those infections. At least 23,000 people die each year as a direct result of these antibiotic-resistant infections. Many more die from other conditions that were complicated by an antibiotic-resistant infection.
In addition, almost 250,000 people each year require hospital care for Clostridium difficile (C. difficile) infections.In most of these infections, the use of antibiotics was a major contributing factor leading to the illness. At least 14,000 people die each year in the United States from C. difficile infections. Many of these infections could have been prevented.
The most aggressive and lethal drug resistant infections are caused by gram-negative bacteria, which are mostly seen in healthcare settings, but other forms of bacteria are also showing presence of drug-resistant strains. As to who is more likely to be at high risk, according to the report, it is often individuals with suppressed, weak or damaged immunity. But many innovative treatments require effective treatment of any infection, as a result it is becoming very difficult to offer such options to individuals with other pre-existing conditions, such as diabetes, rheumatoid arthritis, and asthma.
Some of the common medical situations in which doctors are faced with this dilemma are;

1. Cancer Chemotherapy
2. Complex Surgeries (eg. Joint replacement, Cardiac Bypass)
3. Rheumatoid Arthritis
4. Dialysis for End-Stage Renal Disease
5. Organ and Bone Marrow Transplants

What makes these new infections worrisome it the fact these can happen anywhere. Data has shown that majority of these happen in the general population but the antibiotic resistance mostly develops in a healthcare setting such as a hospital or nursing home.


The CDC also classifies these drug-resistant superbugs by threat levels: 
Urgent:

These are high-consequence antibiotic-resistant threats because of significant risks identified across several criteria. These threats may not be currently widespread but have the potential to become so and require urgent public health attention to identify infections and to limit transmission.

Serious:

These are significant antibiotic-resistant threats. For varying reasons (eg.,low or declining domestic incidence or reasonable availability of therapeutic agents), they are not considered urgent, but these threats will worsen and may become urgent without ongoing public health monitoring and prevention activities.

Concerning: 

These are bacteria for which the threat of antibiotic resistance is low, and/ or there are multiple therapeutic options for resistant infections. These bacterial pathogens cause severe illness. Threats in this category require monitoring and in some cases rapid incident or outbreak response.

The report in the end points to the lack of certain measures that might help, as a result, these are some of the suggested steps, that might allow healthcare professionals everywhere, better understand and cope with this serious growing medical problem, include;

 An efficient capacity to detect and respond to urgent and emerging antibiotic resistance threats at national, state and federal levels.
-A collaborative systematic international surveillance of antibiotic resistance threats.
-Systematically collect data on antibiotic use in human healthcare and agriculture.
-More widely use programs to improve antibiotic prescribing practices in the United States.
-Promote the use of advanced technologies that can identify threats much faster then current practices.

P.S: 
CDC Antibiotic Resistant Threats 2013 Report
CDC sets threat levels for drug-resistant 'superbugs' (CNN News)

Obesity spreads to developing countries

A UK think tank The Overseas Development Institute  report concludes that number of obese and overweight adults in the developing world has  almost quadrupled to about one billion since 1980.
According to the report, there are almost as many overweight or obese adults in North Africa, Middle East and Latin America as there are in Europe. It also highlights the fact that one in three adults in the world (1.46 billion) were overweight or obese in 2008, up by 23% since 1980.
 If these figure are not enough to make us realize that obesity is no longer a rich countries' problem instead is more of a worldwide health issue, then I do not know what is going to!
A major change seen in worldwide diets is the increasing consumption of sugar and sweeteners, which has risen by over 20% per person between 1961 and 2009. One big culprit for that is the increased consumption and marketing of processed foods everywhere.
In countries with emerging economies, people are making bigger incomes and hence now can chose more varied foods and change diets. A huge majority of these individuals in developing countries live in highly congested urban settings and get very little exercise.

South Korea's Health Wellness efforts at a national level have resulted in a 300% increase in fruit and 10% increase in vegetable consumption.  Major campaigns by the government and nutrition specialists to advertise and teach the public that the traditional diet which is low fat is a healthy diet. The most common ingredients in Korean traditional cuisine are vegetables along with use of ginger, garlic, herbs, and various condiments, the health benefits of which are well-known.  The educational and campaigning efforts also focused on providing new approaches to maintaining a traditional yet contemporary Korean diet. These efforts to improve the national diet has helped South Korea keep its obesity rate at 4%. This is the lowest in the OECD (The Organisation for Economic Co-operation and Developmen) but unfortunately it too is rising gradually and is expected to increase by about 5% in ten years.

I am sure that reasons and solutions as well, are far more complex and numerous then the ones I list, but it is clear that if we do not take major steps to change these dangerous dietary and lifestyle trends for the better, we are heading for a disastrous worldwide health catastrophe.


P.S:

• Obesity quadruples to nearly one billion in the developing world(BBC World)
• Overseas Development Institute(Website)
•  The unique aspects of the nutrition transition in South Korea: the retention of healthful elements in their traditional diet (Public Health Nutrition Publication)

Reduce risk of diabetes by making small lifestyle changes...

A recent trial by researchers at University of Edinburgh specifically focusing on individuals of South Asian descent, has shown that even small changes in lifestyle can lead to weight loss and significantly reduce the risk of type 2 Diabetes. It has been seen that men of Pakistani and Indian descent are three times more likely to develop diabetes as compared to men from the general population with similar body mass indexes.

This trial titled "Culturally adapting the prevention of diabetes and obesity in South Asians (PODOSA) trial", included 171 individuals of Pakistani and Indian descent living in Scotland with impaired glycemia thus at high risk of developing Type 2 diabetes.

As most South Asian cultural activities and traditions revolve around family and food. Participants were given detailed dietary advice by dieticians and provided culturally relevant lifestyle change plans and resources. The trials made use of professional translators and multilingual professionals for communicating instructions to participants. Also many of the manual and pamphlets were translated into participants' preferred languages, such as Urdu, Hindi, and Punjabi. In contrast, the control group was given basic instructions on weight control and management, it was not culturally specific.

According to Professor Raj Bhopal of Edinburgh University's Population Health Sciences Center 'These differing approaches show us that a more family-centred strategy, with culturally tailored lifestyle advice, can produce significant benefits to people's health through weight loss.'

 Although trials in Europe and North America have not so far reported on the impact on South Asian populations separately or provided the details of their cross-cultural adaptation processes. But there might be a more positive outcome of such efforts when instructions and advice are culture specific.



P.S: Small Lifestyle changes 'lower type 2 diabetes risk' (BBC World: Health)

Welcome to MINDbank a new resource for mental health information.

On December 10th 2013, the WHO released its gigantic online database by the name of MINDbank. This database contains information on mental health, substance abuse, disability, human rights and the different policies, strategies, laws and service standards being implemented in different countries. One can also find key international documents and treaties in the MINDbank.

Because mental health is still a topic shunned and avoided in many countries all over the world, it can often be difficult to find out information on resources pertaining to mental health. The MINDbank is the only single point globally to access all comprehensive information related to to mental health, substance abuse, disability, general health, human rights and development.

WHO announcement for the media says;

Launched on Human Rights Day, the platform is part of WHO’s QualityRights initiative, aiming to end human rights violations against people with mental health conditions.

“People with mental disabilities still face discrimination, violence and abuse in all countries,” says Dr Michelle Funk, from WHO’s Department of Mental Health and Substance Abuse. “The easy-to-use platform was established as a tool to facilitate debate, dialogue, advocacy and research on mental health, to improve care and to promote human rights across the globe.”

The care available in mental health facilities may often not only be of poor quality but can also hinder recovery. It can still be common in some countries for people to be locked away in small, prison-like cells with no human contact or to be chained to their beds, unable to move. The MiNDbank will help decision makers to address these issues, support reform efforts and ultimately improve the lives of people with mental health conditions in line with the Comprehensive Mental Health Action Plan 2013-2020, adopted by the World Health Assembly in May 2013.

“If a government, for example, wishes to develop a new mental health policy in line with international human rights standards it can - on the new platform - quickly get an overview about the policies of other countries and benefit from their experiences and an array of international guidance tools and resources,“ explains Nathalie Drew, WHO Technical Officer working on mental health and human rights. So far, already more than 160 countries are sharing key mental health information through the MiNDbank and updates will be provided on a regular basis.

The MINDbank is meant to be the go-to site for everyone, from clinicians, health policy makers, legislators, academics research professionals to educationists and anyone anywhere in the world interested in finding reliable information on mental health and related topics. 

PS:  MINDbank Website
WHO launches MINDbank News

Heart Attacks, Strokes and Apples

We all heard our parents encouraging us to eat fresh fruit and vegetable, specially apples, and all of them used the old Victorian saying " An Apple a Day Keeps the Doctor Away" to further motivate us. Well, more then a century later it still holds true, especially for the above 50 population.
According to an article published in the christmas edition of the British Medical Journal, a research study led by Dr Adam Briggs of the BHF Health Promotion Research Group at Oxford University came to the conclusion that about 8500 deaths from heart attacks and strokes could be averted if all adults of 50 years and above were prescribed an a apple a day. The significance of this outcome is more apparent when compared to another recent study that showed that if adults 50 and above not already on it, were prescribed statins, it could prevent about 9400 deaths from heart diseases. 
Dr. Adam Briggs says 'It just shows how effective small changes in diet can be, and that both drugs and healthier living can make a real difference in preventing heart disease and stroke.' But the researchers stress that this does not encourage individuals already on statins to stop taking them, just try adding apples to your daily diet.
Although apples appear to be exceptionally good for maintaining a healthy heart, it is clearly essential to eat a variety of fresh fruits and vegetable on a daily basis to stay healthy.





P.S:
An Apple A Day Keeps The Heart Doctor Away (University of Oxford)
Apple Nutrition and Composition Facts(USDA Database)

What are the real benefits of antibacterial soaps, if any?

Probably because of my medical background I have always worried about the indiscriminate use of antibiotics, which can consequently create antibiotic-resistant bacteria called 'Super Bacteria'. Treating the infections caused by these super bacteria can be a nightmare, often leading to disastrous outcomes, even death.

It is in the same vein, I have always been a bit skeptical of the antibacterial soaps sold to consumers. Since antibacterial soaps are supposed to be killing everyday bacteria we end up collecting on our hands, they are also indirectly creating super bacteria. And besides that these antibacterial soaps are also killing off the normal bacterial flora on our hands. 

What is normal bacterial flora on our hands?

According to the 'WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care.' and Medical Microbiology. 4th edition :
The bacteria found on our hands can be divided into two types; namely resident and transient. The resident bacteria being the ones normally residing on our hands, these predominantly include Gram-positive organisms (e.g., staphylococci, micrococci, diphtheroids). The resident flora primarily plays a protective role by providing microbial antagonism and the competition for nutrients in the ecosystem. Hence the resident flora rarely causes infections.
The transient bacteria are the one we acquire through contact with infected individuals or surfaces. These can lead to infections and spread from person to person. This transfer of bacteria through direct contact is highest in health care workers. In fact their hands may constantly become colonized by some pathogenic flora such as Staphylococcus Aureus and Gram-negative bacilli.

The main bacteria killing ingredient in majority antibacterial soaps is Triclosan. Although Triclosan is meant to rid our hands of the transient kind of bacteria, over time it indiscriminately also kills the resident kind. 

What is Triclosan?

According to the FDA Consumer Update on Triclosan:

'Triclosan is an ingredient added to many consumer products to reduce or prevent bacterial contamination. It may be found in products such as clothing, kitchenware, furniture, and toys. It also may be added to antibacterial soaps and body washes, toothpastes, and some cosmetics—products regulated by the U.S. Food and Drug Administration (FDA).'

'Triclosan is not currently known to be hazardous to humans. But several scientific studies have come out since the last time FDA reviewed this ingredient that merit further review.

Concerns about Triclosan:

According to the FDA Consumer Update on Triclosan:

'Animal studies have shown that triclosan alters hormone regulation. However, data showing effects in animals don’t always predict effects in humans. Other studies in bacteria have raised the possibility that triclosan contributes to making bacteria resistant to antibiotics.

In light of these studies, FDA is engaged in an ongoing scientific and regulatory review of this ingredient. FDA does not have sufficient safety evidence to recommend changing consumer use of products that contain triclosan at this time.

For some consumer products, there is clear evidence that triclosan provides a benefit. In 1997, FDA reviewed extensive effectiveness data on triclosan in Colgate Total toothpaste. The evidence showed that triclosan in this product was effective in preventing gingivitis. 

For other consumer products, FDA has not received evidence that the triclosan provides an extra benefit to health. At this time, the agency does not have evidence that triclosan in antibacterial soaps and body washes provides any benefit over washing with regular soap and water.

We are engaged in a comprehensive scientific and regulatory review of all the available safety and effectiveness data. This includes data relevant to the emerging safety issues of bacterial resistance and endocrine disruption due to triclosan in FDA-regulated products.'

On December 16  2013, FDA finally came out with the verdict FDA Taking Closer Look at 'Antibacterial' Soap.  Colleen Rogers, Ph.D., a lead microbiologist at FDA stated that "there currently is no evidence that over-the-counter (OTC) antibacterial soap products are any more effective at preventing illness than washing with plain soap and water." She goes on to say "New data suggest that the risks associated with long-term, daily use of antibacterial soaps may outweigh the benefits."

The update states "In light of these data, the agency issued a proposed rule on Dec. 16, 2013 that would require manufacturers to provide more substantial data to demonstrate the safety and effectiveness of antibacterial soaps. The proposed rule covers only those consumer antibacterial soaps and body washes that are used with water. It does not apply to hand sanitizers, hand wipes or antibacterial soaps that are used in health care settings such as hospitals.

According to Rogers, the laboratory tests that have historically been used to evaluate the effectiveness of antibacterial soaps do not directly test the effect of a product on infection rates. That would change with FDA's current proposal, which would require studies that directly test the ability of an antibacterial soap to provide a clinical benefit over washing with non-antibacterial soap, Rogers says."

In the end, it seems to be wise to continue washing our hands with just plain ol' soap and water, and postpone the use of these fancy antibacterial soaps till further notice. 



References:
Dangers of Antibiotic Resistance
WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care.
Medical Microbiology. 4th edition 
FDA Consumer Update on Triclosan
FDA Taking Closer Look at 'Antibacterial' Soap. 

Frankenstein may not be just fiction anymore....

Some recent headlines in the world of medicine have been unusual and a little unsettling, they sound like sci-fi more then actual reality.

One of them was in September ' Doctors grow nose on man's forehead' on ABC News Medicine Unit. Yes it is exactly what it says. A young man Xiaolian 22, in China, injured his nose in a traffic accident in 2012, subsequent infections lead to the corrosion of the damaged cartilage in the nose. Doctors could no longer fix it, hence they decided to grow him a new one at the Fuzhou hospital in China. Now that the nose is grown, doctors can transplant it to his face successfully.

Then yesterday read this headline ' Severed hand kept alive on man's ankle ' on BBC World News. Xiao Wei in China severed his right hand in an accident at work, his arm extremity was in such a bad shape that surgeons could not re-attach the hand immediately. To keep the hand healthy and alive, the surgeons then grafted the hand to his  left ankle and supplied it with a steady blood supply. After about a month the surgeons successfully reattached the hand to his right arm. According to latest reports from his doctors Xiao Wei will need several surgeries before he can regain full function of his hand, which is highly likely.

But the most disturbing one was in July 2013 'Human Head Transplants Could Become Reality' on ABC News Medicine Unit. Here is part of the report;
' In the journal Surgical Neurology International, Canavero outlined a procedure for taking the head of one person and transplanting it onto the body of another. It involves inducing hypothermia and cutting the spinal cord with an “ultra-sharp blade” so it can be fused with the donor’s spinal cord.
“This is, of course, totally different from what happens in clinical spinal cord injury, where gross damage and scarring hinder regeneration,” Canavero wrote.
He outlined a hypothetical scenario in which the body donor is a brain dead patient. He said the recipient could be anyone dying of cancer or anything else  that leaves the brain intact.
For the head transplant to work, two surgeries would have to take place in the same operating room in which both spinal cords would be severed simultaneously but only after all other cuts had been made. Then, the donor body’s spinal cord would be “chemofused” to the recipient head’s spinal cord using a substance called polyethylene glycol, or PEG. Canavero called his surgery the Heaven surgery, for “head anastomosis venture.” '
Heaven! Really? I would think more like Hell! This is not an issue of it being scientifically possible or not, to me it is a matter of whether it is ethical or not. Who gets a transplant? Whose body and whose head? Do we honestly want Frankensteins to be a reality? 
Mankind loves to challenge nature and overcome it's limitations, but trying to make this happen would not be wise, there is just so much meddling nature can take. Let's keep this one limited to our scifi books and movies...