the year in medical media

As we say farewell to 2009, LifeBridge Health is taking a look at some of the major events of the past year. Today, we look at a few of the medical stories that received media attention in 2009.

It is the waning hours of the year, and as such it is customary for many to make "Top xxxx Lists!" as a way of making 2009 into an artificial entity that we will shortly wave a fond farewell to, for better or worse, and leave behind in favor of the uncertain newness of 2010. Trying to craft any such a list for the year in medicine is a mad folly, given the sheer amount of news and discoveries that happened every week of these past 12 months. That noted, what follows is my completely subjective shortlist of medical stories that received media attention in 2009.

The dominant story of the year was clearly the new strain of H1N1 influenza virus. From it's discovery at the end of March, through its spread throughout the world and official classification as a pandemic by the World Health Organization, no other issue came close to the "swine flu's" saturation of the media. Unfortunately, much popular news coverage of the outbreak has ranged from barely adequate to frankly horrible (ABC2's H1N1 Day of Answers was an excellent event, and a notable exception to this). Often focused on fearful hype or dismissive ignorance, many media reports chose to sensationalize and misrepresent certain aspects of the pandemic (vaccines side effects, for one) while not actually doing their job - objectively reporting facts in an informed way. Coupled with some poor choices in government communication to the general public, and a failure of manufacturers to deliver vaccine on the promised timetable, the end result was unnecessary public fear, confusion, and public health inadequacy where there should have been a smooth, strong response. In this, we are fortunate that the 2009 H1N1 strain is less virulent than it might have been. I'll be taking a much closer look at the pandemic to date, and future prospects, next week.

If there is one thing that rivaled influenza in terms of media coverage this year, it was the process to craft legislation for United States health care reform. As I type this, both the US House of Representatives and the Senate have passed separate reform bills after months of deliberation, and now face the difficult prospect of merging them together. To call what has led up to this point a "debate" would be particularly generous - the amazing variety of agenda-driven nonsense that has spewed out from various political factions and interest groups is staggering, and has often threatened to drown out the basic facts involved. Add to this that said basic facts are rather complex, and that there is no "right answer", and you end up with a media message that just cannot report the issues involved adequately. The process, and the conversations it has generated, say alot about we as a people, and both the strengths and weaknesses of our political process. Our current health system (cue cutting glare at most insurance companies here) is quite deficient in some ways, and the proposed legislation is an imperfect tool to bring about needed change, but it is a start.

In the midst of this incendiary health care mess, the US Preventative Services Task Force released a long-prepared update to their mammography screening guidelines in November. Based on solid science and cost-benefit analyses, they changed their recommendations to be that women at low risk of breast cancer should start discussing mammograms with their physicians at age 40 and get them routinely starting at age 50 (as opposed to just starting at age 40), and once started, getting them every two years instead of annually. What was done in order to reduce the costs and harms (due to false positive results leading to unnecessary surgery, among other things) to a population of women in whom mammography as a screening tool doesn't work as well to detect breast cancer was then portrayed by some elements of the media as a womens' rights issue or an example of healthcare rationing (neither being true). The fundamental point that many seemed to miss is that guidelines such as these for certain populations of people are not mandates for individual patients or physicians. At the end of the day, it is unlikely that many physicians will change their breast cancer screening practices based on these recommendations alone, and hopefully more women will have informed discussions with their physicians about mammography. I'll also be going into more detail on these and other screening recommendations in future weeks.

The last two medical media-related stories on my hit list have to do with interesting research that was reported to be far more significant than it actually was. October saw headlines about a study from Thailand that finally demonstrated an "effective" and "promising" HIV vaccination strategy using a combination of vaccines. Upon examining the study however, the results were that 31% less of the patients that had the vaccine combination acquired HIV when compared with those who did not, and after correction for leaving out some who were already HIV infected, this dropped to a 26% difference. This is a potentially interesting result, but given the variables and statistics involved, hardly qualifies for language like "promising" or "effective." October also brought reporting on another paper that described a virus called XMRV that was reported to be associated with chronic fatigue syndrome. The study described finding this pathogen in 3.7% of healthy patients, but in 67% of people diagnosed with CFS. While the paper itself was appropriately conservative in suggesting the association, several news outlets and at least one of the paper's authors were outspoken on this being a clear infectious link to a rather unclear syndrome. The problem with such bold statements here is that this study, while interesting, is certainly not definitive; patients labeled as having chronic fatigue syndrome may comprise multiple groups of people with different underlying disorders; XMRV is a poorly understood virus; and as with life in general, in medicine it is vastly important not to confuse correlation (saying that the virus is there in many of the patients that have the syndrome) equals causation (saying that the virus is the cause of the syndrome). Both of these stories do have merit behind them, and I look forward to further progress here in the coming year.

2009 has been a whirlwind of new medical information, hampered by frequently poor media dissemination of that information. Just as it is incumbent on various news outlets to embark on informed, non-sensationalistic science reporting, it is equally critical for the medical community and the lay public to seek out rational facts about medical issues, and evaluate media reports with a skeptical eye. May 2010 see better medicine reporting, for the more knowledgeable health of us all.

"Swine Flu": Myths, Facts and Communication

I was recently interviewed by Philip and Lisa Mulford for this week's episode of their audio show, Communication 360. From the episode description:

Every day [swine flu] is in the news, often with conflicting information. Even the medical community is inconsistent. So what do you do? And more importantly what is the best decision for your child? Having already experienced the H1N1 with both their boys, Philip & Lisa are joined by infectious disease specialist Dr. John Cmar to identify the fact from the myth and put the H1N1 back in perspective.

Communication 360 in general focuses on the different roles that communication has in relationships, understanding how it can break down, and ways to mediate it after it has. Given how much of the recent "swine flu" hysteria has been due to often poor communication from news media and medical authorities to the general public, I was eager to explore influenza from this perspective.

Our hour chat was fun, and ended up covering a lot of ground. We had a good discussion of how many aspects of talking about influenza - such as basic questions like "is this a bad flu season?" or "is there more than one H1N1?" - are not straightforward, and require a nuanced discussion that is often difficult to communicate to laypersons in limited time. There were many questions raised that I didn't have a chance to discuss in detail, including some aspects of influenza vaccines and overhyped side effect possibilities. Now that some of the reactionary influenza coverage has died down a bit in the media at large, I'll be taking a closer look at some of these issues in future posts.

Go here to listen to the program, and remember: wash your hands.

(Please note that I was accidentally credited as being an "infectious diseases specialist at Johns Hopkins" early in the episode, but this was corrected later on in the program to reflect my infectious diseases and clinical work here at Sinai, and my teaching appointments through Johns Hopkins University.)

New Visitor Policy For Sinai and Northwest

Due to the widespread outbreak of H1N1, Sinai Hospital and Northwest Hospital will temporarily modify the visitation policy to ensure the well being of the patients as well as the health and safety of our staff. Effective November 1, the following visitor restrictions will be in place:

• No visitors under age 18.
• Those visitors experiencing flu-like symptoms are asked to remain at home. If you must visit, you may be required to wear a mask.
• Families are asked to limit visitors to two per patient in a 24 hour period.
• Visitation hours are between noon and 8 p.m.
• Exceptions may be made on an individual basis.

We also request your help in ensuring that our visitors follow basic precautionary measures to prevent the spread of the flu. Entrances have been equipped with hygiene stations.

• Wash your hands often with soap and water, or use an alcohol-based hand sanitizer.
• Cover your cough or sneeze with a mask, tissue or upper arm.

These restrictions may be downgraded or heightened based on recommendations of state and federal authorities. We realize this is a change from the usual policy and may present some challenges. We appreciate your continued efforts to provide the best care possible for our patients.

Nice Shot!

LifeBridge Health leadership set the tone for this year's flu season yesterday: get your flu shot as soon as possible.

LifeBridge Health CEO Warren Green, Sinai Hospital President Neil Meltzer, Northwest Hospital President Erik Wexler and Levindale and Courtland Gardens President Aric Spitulnick all are pictured here getting their seasonal flu shot, courtesy of Peter Andrews, PA-C, Sinai and Levindale Director of Occupational Health.

This shot was for the "regular" seasonal influenza. LifeBridge Health is doing everything it can to make sure employees are as protected and prepared as possible. All employees are encouraged to get their seasonal flu shot, and receive a free meal ticket as an incentive. The seasonal flu peaks in February.

When the H1N1 vaccination becomes available, and, if there are enough, all LifeBridge Health employees will be offered that shot as well. If there is a shortage, those health care workers directly interacting with patients will be prioritized.

Meanwhile, there are cautionary steps everyone should take: wash your hands frequently; cough in the crook of your elbow; and stay home if you are sick. Stay tuned to learn more about what LifeBridge Health is doing to promote hand washing across Baltimore.

Ask the Expert Radio this Sunday - swine flu and infectious diseases

by: John Cmar, MD

What is the latest on the swine-origin influenza outbreak, and is it something that you should be concerned about?  What other infections are lurking as the summer kicks into full swing?

Myself and Jackie Daley, Director of Sinai Hospital's Infection Prevention and Control division, will be on hand to answer these and other infectious diseases-related questions on the Ask the Expert show this Sunday, May 31, from 08:00-09:00 EST on WHFS 105.7 FM radio.  Our regular hostess, the lovely and talented Rudy Miller, will be taking a much deserved vacation, and I will have the pleasure of filling in. 

If you have any questions for us, feel free to call 410-481-1057 between 08:00-09:00 Sunday morning, or post them as comments below.  You can tune in directly if you are in the Baltimore area, or check out the live feed from their website.

As "swine flu" excitement fades, hand washing should still remain

by: John Cmar, MD

Faculty, Division of Infectious Diseases

Sinai Hospital of Baltimore

Good news, everyone!  We have not seen the End of Days due to pandemic "swine flu" in the past week, and society still stands!

What we have seen is the expected progression of cases into Maryland, and a more detailed picture of an illness that in most respects, is not much different than seasonal influenza in terms of severity. There are currently 23 confirmed cases in Maryland, and 4 more reported as "suspected or probable." Of these, 3 of the confirmed cases and 1 unconfirmed case are in Baltimore county. There have been no fatalities in Maryland, and only 2 deaths out of the the 2254 cases confirmed nationwide.

As discussed last week, the swine-origin influenza virus isn't causing severe disease in most people. The vast majority who do get sick are having mild symptoms and an uncomplicated illness. That noted, there are still areas of concern. Those who do get seriously ill are more likely to be healthy young adults and children, than with seasonal influenza, which usually affects the very young and the very old more severely. Also, this virus does appear to have the potential for efficient, rapid spread among populations. This means that future mutations to the virus that increase it's infectivity and the severity of illness it causes could result in a pandemic situation.

As "swine flu" slowly fades from the headlines, our attention to the basic, simple things we can do to prevent getting and transmitting diseases like influenza must not similarly fade from our daily lives. Always be sure to wash your hands often, especially after being in a public place and before touching your eyes, nose, or mouth. When sick, wash your hands after coughing, sneezing, or wiping your nose. Cough or sneeze into the crook of your arm instead of your hands when possible, or an immediately disposable paper tissue. Also, stay away from crowded living areas, and avoid close contact with other people.

The medical community still has much work ahead in tracking and study this swine-origin influenza outbreak. Vaccine possibilities are being considered, although whether this will eventually be worked into the yearly seasonal influenza vaccine or be separate is still to be determined.

Continuously updated information can continue to be found on the websites of the Maryland DHMH, the CDC, and the WHO.

And of course, wash your hands.

Vaccines Important for Public Health

With all the talk about the H1N1 virus (swine flu), it’s a good time to talk to your physician about what vaccines you may need. A recent Centers for Disease Control (CDC) and Prevention study, conducted in the summer of 2007, indicates that not enough American adults are getting vaccinated and as a result are leaving themselves vulnerable to a range of avoidable disease
“Vaccinations are second only to washing your hands in terms of prevention of disease,” says John Cmar, M.D., a faculty member in the Division of Infectious Diseases at Sinai Hospital. “Vaccines and using them are among the most successful things we do today as a measure of public health.”
Relatively new vaccines tackle diseases such as meningitis and shingles. Click here to read more.

"Swine flu" is no cause for panic, but a good cause to wash your hands

by: John Cmar, MD
Faculty, Division of Infectious Diseases
Sinai Hospital of Baltimore

Anyone exposed to the media reporting on "swine flu" this past week could come away with the impression that the whole of civilization is soon to collapse under the weight of a pig-fueled pandemic. Needless to say, this isn't going to happen. There was was much uncertainty at the start of the outbreak and several questions do remain. That noted, the hard work of the CDC and the WHO has given enough answers for all of us to proceed with our normal daily activities with informed awareness.

Swine influenza is respiratory disease of pigs that is caused by one of several types of influenza virus. It rarely causes disease in humans, and when it does, it has only briefly been transmitted from person to person. The virus involved in the current outbreak is a new strain of type A H1N1 influenza that resulted from the mixing of the genes of swine, avian, and human viruses during animal infections. This is similar to how previous influenza pandemics have started, such as the 1918-1919 "Spanish flu." In these instances, the result was a virus that could be easily passed from person to person, and could cause human infections much more severe than seasonal influenza. At this point, however, the latter seems not to be the case.

As of the time of this post, the WHO has identified 367 confirmed cases of this swine-origin influenza and 10 deaths in 13 countries. There have been 141 cases confirmed in the US, and only one death reported. At this time, there have been no confirmed cases in Maryland, but 8 probable cases have been identified, 4 of which are in Baltimore county. A probable case is defined as someone with an acute febrile respiratory illness who tests positive for influenza A virus, but negative for the seasonal H1 and H3 strains.

While no cases have been confirmed in our area yet, it is very likely that there will be shortly. This is a cause for caution, not panic, as this strain of swine-origin influenza virus seems to be causing illnesses that are not much more severe or fatal than seasonal influenza at this time. If you develop fever >100 F with cough or sore throat, and have either traveled to an affected area within 7 days, or been exposed to someone is ill who has traveled to those areas, stay at home and call your doctor. LifeBridge Health is working closely with the Maryland DHMH, and is well prepared for any cases that may occur.

As with seasonal influenza, the most important thing that you can do to prevent getting infected with the new strain of swine-origin influenza virus is to wash your hands often, especially after being in a public place and before touching your eyes, nose, or mouth. There is no reason to wear a mask in general situations, or to avoid public air or ground travel, to prevent getting the virus. If you do have a respiratory illness, there are several practical steps you can do to avoid transmitting it to others. Wash your hands, especially after coughing, sneezing, or wiping your nose. Cough or sneeze into the crook of your arm instead of your hands when possible, or an immediately disposable paper tissue. Finally, stay away from crowded living areas, and avoid close contact with other people.

Myself and Jackie Daley, Director of Infection Prevention and Control at Sinai Hospital, will be on the Ask the Expert show this Sunday, May 3, from 08:00-09:00 EST on WHFS 105.7 FM radio to discuss the current state of the swine-origin influenza outbreak, and to take any call-in questions. Please tune in to hear the latest news, and feel free to give us a call. Further updated information can be found on the websites of the Maryland DHMH, the CDC, and the WHO.

Oh, yeah, for good measure - wash your hands.