War can paradoxically bring out the best in people. Despite the violence, tragedy, and pain, there are moments of kindness, compassion, and brave camaraderie. Soldiers band together as brothers and sisters under terrible circumstances to offer their lives in support of a nation they deem just and vulnerable. Often they are terribly wounded. Families on both sides of the conflict suffer and grieve sickening losses. The reasons for war seldom justify the human misery it causes, but perhaps one type of soldier has the luxury of always being on the right side. Consider the medic, nurse, or military doctor.

I’m reading an advanced readers copy of Coppola: A Pediatric Surgeon in Iraq. The book is written by Lt. Col. Dr. Chris Coppola, and gives an account of his two tours of duty in Iraq as a pediatric surgeon called upon to act as a trauma surgeon and physician for the war-wounded.

Dr. Coppola writes a compelling narrative about his experiences in Iraq away from his wife, children, and home in Texas. He takes the reader into Iraq as he first encountered the country through a head rattling, stomach nauseating descent via a C130 cargo plane combat landing. On the ground at Balad Air Base, we are given a tour of the bleak world and meager accommodations our military operate in. Sequestered behind walls, checkpoints, and sand bags, an entire makeshift hospital of sorts takes shape. The food is austere and makes going on a diet sound logical.
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He appears in the middle of the city park carrying only a guitar case. He’s in his late twenties, Asian, and wearing a t-shirt and jeans, which is somehow appropriate on this beautiful, sunny day snatched from the cold fingers of November. Children playfully scamper by and mothers give chase as he opens his guitar case. There’s a drunk stumbling from park bench to park bench, asking for just forty cents and he’ll go away. The guitar player slings his instrument around his neck and picks a few strings as young couples strut by and old men feed pigeons. And then he starts to play.

I look up from my book. He’s standing in the middle of the park. I recognize the chords. He’s going to sing U2’s One. It’s making me a little uncomfortable. No one is stopping to put money in his open guitar case. I’m sure his voice is going to crack.
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In my efforts to have a rational discussion about the H1N1 flu shot I have been increasingly confronted with the following fear, expressed most commonly by concerned mothers and teenagers:

Did you see that video on Youtube about the cheerleader who got the flu shot? Something called dystonia? She can’t walk unless she goes backwards. I don’t want to risk ending up like that.

Apparently Inside Edition broadcast a story featuring a woman who claims to have a movement disorder she attributes to an adverse effect of the seasonal flu shot. I had to take a look at this video along with the millions of other viewers. Here it is:

The video is confusing. The “seasonal flu shot” in question was given “August 23rd,” so we’re not even talking about an H1N1/swine flu vaccination. The movements and speech problems displayed are… perplexing. I’m not a neurologist, but fortunately there are experts who have had the courage to come forward and comment on this fearful video. From an article on Consumer Reports Health:

William Weiner, MD, Professor and Chairman of Neurology at the University of Maryland School of Medicine and Director of the Maryland Parkinson’s Disease and Movement Disorders Center, said this video has been making the rounds among colleagues who are dystonia experts. He reviewed the initial video as well as another showing Desiree in a recent 8k run.

“Without examining the patient, a neurologist cannot make a definitive diagnosis. But after viewing the multiple videotapes and discussing them with other dystonia experts there are many features that are not consistent with the diagnosis of true dystonia, but are much more in keeping with what is called a psychogenic movement disorder” he said. He further explains that several things about her case just don’t fit the diagnosis of dystonia:

* It was very sudden in onset—true dystonia has a slow onset and, if it progresses, does so very gradually
* The movements are not characteristic of dystonia or, for that matter, of any other known movement disorder
* Her speech has an unusual staccato pattern which is not seen in any neurological disorder and the degree of impairment is quite inconsistent
* The return of all normal motor behavior and speech when running forward is not consistent with true dystonia
* The report of additional neurological problems such as paralysis of the tongue, but normal speech while running is not consistent with true neurological problems

While physicians, including Dr. Weiner, are generally reluctant to discuss cases of patients that they haven’t personally examined, Dr. Weiner spoke out because of the ramifications to consumers. “This has nothing to do with the flu vaccine. There are no previously reported cases of dystonia following the flu vaccine. This is a public health policy issue because people are being scared away from getting vaccinated,” he said.

[ADDENDUM – the cheerleader has now been “cured” of her “illness”, with stunning rapidity and a slick public relations effort courtesy of an anti-vaccination group]

Steven Novella, in his neuroscience blog, highlights additional physician insights:

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More information keeps coming out about the benefits of eating in the Mediterranean style, broadly defined as rich in fresh fruits and vegetables, healthy fats, avoiding red meat and processed foods, drinking wine in moderation, and eating with friends and family.  Given the many variables that go into a cuisine, it is hard to tease out what exactly accounts for this risk reduction, and it might just be more general principles like small portions, daily exercise, and an emphasis on freshness, balance, and pleasure in food.

Studies demonstrating the health benefits, lower cancer risk, and lower heart disease risk of those following the Mediterranean diet are becoming more numerous, with a few of the major ones summarized on Wikipedia and in this meta-analysis in the BMJ.

The first of the two new studies I’m going to highlight found that the Mediterranean diet can reduce the need for medications among people newly diagnosed with diabetes. From a summary of the study published in the Annals of Internal Medicine:

Researchers in Naples, Italy, compared a low-carbohydrate Mediterranean-style diet with a low-fat American Heart Association (AHA) diet in a 4-year randomized trial that involved 215 adults with newly diagnosed type 2 diabetes (not yet on medication), body-mass index >25 kg/m2, and glycosylated hemoglobin (HbA1c) levels <11%. Both diets were rich in whole grains and provided 1500 kcal daily for women and 1800 kcal daily for men. The Mediterranean diet was rich in vegetables and low in red meat (emphasis on poultry and fish), had no less than 30% of calories from fat (30–50 g olive oil daily), and allowed no more than 50% of calories from complex carbohydrates. The AHA diet was restricted in sweets and high-fat snacks and allowed no more than 30% of calories from fat and no more than 10% of calories from saturated fat.
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I received my H1N1 shot today. My arm hurts a little.

For the past week I’ve witnessed an explosion in the number of patients calling and visiting the office with flu symptoms. The pandemic is now apparent. Yesterday alone I saw at least 12 people with serious flu symptoms in the office, and personally triaged another 20 or so over the phone (in addition to seeing “regular” visits). I’ve been at work until 8 or 9 PM every night this week, and the office is humming with a concerted effort that starts at the front desk and extends back through the examining room.

I’ve sent only four people to the emergency room whom I felt looked really sick; the rest have managed quite well at home with appropriate medicine and rest. It is frightening to consider the capricious will of the virus to make some people extremely ill, and to take the life of an unfortunate set. I tie a surgical mask around my face before entering rooms of patients with flu-like symptoms. It probably breeds more fear than it helps, but my office cannot afford to have a doctor out with flu.

The strain on our health care system is evident, and can be seen in the microcosm that is our family practice. Sometimes I’m running late as I try to see as many people that need to be seen as I can. The front desk follows a telephone triage questionnaire to determine who needs to be seen, who can stay home, and who needs to go to the emergency room. We get hundreds of calls a day, ranging from routine refill requests to urgent concerns. It is sometimes difficult to make an outgoing call as most of the office lines are actively blinking.

Most people understand this strain, but others yell and literally berate the fatiguing staff. We all need to think of this issue as a community problem and contribute our patience and diligence; whether in the waiting rooms of primary care doctors or in the parking lot tents of makeshift expanded emergency rooms, no one is taking leisure time.

There have been a few deaths in my community, but the majority of people have been recovering. In addition to varying degrees of fever, muscle aches, headaches, sore throat, cough, nausea, diarrhea, and malaise, I wonder if a patient statement of Doc I’m sorry, but I just feel like shit should be added to the CDC diagnostic criteria.

Over 95% of influenza circulating right now is of the H1N1 strain. Keep educating yourself. Make your own decisions in consultation with your doctor. But I am appreciative of the Herculean effort that has brought an H1N1 vaccine into my muscle today, and I am hopeful it will offer protection to those who receive it, as it did in the clinical trials this summer.

You might also find the H1N1 shot by calling your doctor, county health department, Walgreens and other pharmacies, local hospital, school, or other organization. There is an order of priority of course. Don’t fail to take standard precautions to reduce transmission risk. Good luck. I’ll let you know how my personal vaccine experience goes.

While watching TV the other day I saw an amusing Corona beer commercial. A young couple is sitting on beach chairs next to an idyllic ocean as relaxing waves crest and fall. Into this Eden walks another scantily clad, curvaceous woman, who tempts the gaze of the man away from the sea and onto her hips. He is subtle as he obviously checks her out, but not subtle enough, as his girlfriend/wife punishes him with a massive squirt of lime juice from the lime wedge on his bottle.

Cute, but actually frightening if you consider that she has just set in motion a skin reaction that could potentially disfigure him for months, even years. The man rubs the lime juice into his face, and the two keep sitting there, presumably for several more hours tanning away.

The combination of lime juice (more from the peel) and ultraviolet radiation can cause a skin reaction called phytophotodermatitis, a red, blistering, burning inflammatory response that can leave behind dark pigmented spots on the skin for months.

Here is the commercial, for your entertainment and forewarning:

While some might argue that no retribution is too great for the transgression of looking at another woman, I would argue that the ensuing rash does not fit the crime. Limes are among the list of plants and fruits that contain photosensitizing chemicals such as psoralens and furocoumarins, which when combined with certain wavelengths of ultraviolet radiation induce a photochemical reaction that damages cell membranes and DNA. Erythema, blistering, epidermal necrosis, and eventual peeling soon follow.

Here’s an example:
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I came across a list of the 50 most prescribed medicines in the U.S. for 2008 and thought it was fascinating. Here is a sampling of the top 20, with discussion to follow:

#1. Hydrocodone (with acetaminophen)
Used to treat pain
121.3 million prescriptions / $5.88 billion retail cost

#2. Lisinopril
Hypertension
69.8 million prescriptions / $686 million retail cost

#3. Simvastatin
High cholesterol
49.0 / $1.45 billion

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