Finito, Alberto, La Musica

This was one of my mother’s favourite phrases, uttered when things had come to their inevitable conclusion. Had she been a fan of Douglas Adams she could equally have said, “So long, and thanks for all the fish.”

After three years of moaning, complaining and, hopefully, educating and entertaining I have decided to bring this blog to its inevitable conclusion. It has been an interesting foray into the world of social media, so different from the world I grew up in. The ability to connect with so many people from all over the world is truly amazing and should continue to shrink the world’s boundaries and bring us all closer together. Disaster and misfortune no longer occur in far off places to people we neither know nor care about. Even though we have never met them everyone is a potential friend, acquaintance or colleague with beliefs, hopes and ideas that are not so dissimilar to our own. Surely this can only help to break down our prejudices and barriers and make it more difficult to continue injustices and demonise people from other countries. With easy access to so much data each of us has a duty to be informed and act rationally. Irrational hatred based on race, nationality or religion can no longer be excused on the basis of ignorance.

Even this little blog has attracted almost 100 followers (modest, I know, compared with many others but intimidating enough for me when I think how many people are reading these words) and readers from 76 countries. I would like to thank everyone for reading, commenting and liking and I depart with one final request coming, of course, from another TED talk (http://www.ted.com/talks/myriam_sidibe_the_simple_power_of_hand_washing). Wash your hands! With soap! Do it frequently! Do it properly! Do it now!

Hand washing alone has a dramatic effect on infant mortality. It can reduce the incidence of diarrhoea by half, respiratory infections by a third and mitigate the spread of flu, trachoma, SARS, cholera and even Ebola. Regular hand washing with soap will allow 600,000 children to see their fifth birthday.

In conclusion, it is probably appropriate to finish with a line from Get Smart, one of my all time favourite TV shows.

Pausing to leave, Kubacheck utters the immortal words to Smart, 99 and the Chief, “As George Washington said in his farewell to his troops “Farewell, troops!””

Dr. F. Bunny

 

Run Till You’re Sick (Revisited)

After 18 weeks of running on my modified program (two weeks medium, two weeks hard, two weeks off for three cycles. See “Run Till You’re Sick”) I was retested and revisited the cardiologist. The news was less than sparkling. I appear to have sick sinus syndrome. The sinoatrial node, which is the structure in my heart charged with keeping the beat, is not doing its job. When I sleep the node does too. At times I went up to 11 seconds without a heart beat. Very exciting.

This is so exciting that the node has been sacked. Its job is being outsourced and it will be replaced with an artificial pacemaker, one that takes its job a little more seriously. I must confess to feeling let down, disappointed and more than a little annoyed that such a tiny part of my otherwise presumably healthy body can have such a profound and long lasting effect on my life. Woody Allen said, “My brain: it’s my second favorite organ”. My heart would have to come a close third, but I would be more than happy to promote it if I thought that would cheer it up enough that it would live up to its job description.

While the cardiologist thinks the running and the appearance of sick sinus syndrome are all just coincidence I find it a little too convenient that this should flare up shortly after completing my first marathon and settle down when I stop running. From what I have read of marathon runners an alarmingly large number of them have some level of scarring in their heart muscle. I suspect that something I may have been predisposed to was a little unhappy with the extreme level of effort I expended while running the marathon and decided to pack up shop and go home in a huff.

Apparently the good news, apart from not going through airport security scanners any more, is that once the pacemaker is installed I will be as good as new and able to run, jump and leap tall buildings in a single bound again, as long as I only use the mobile phone on my right side, avoid shop security scanners and give up contact sports. So much for Krav Maga. Maybe I could just give up running instead?

Dr. F. Bunny

Ebola

The Ebola virus was “discovered” in 1976 causing trouble for people living near the Ebola River in the Democratic Republic of Congo (DRC). Since then it has popped up several times in the DRC, Sudan and Uganda. The current outbreak is the first to involve Guinea, Liberia and Sierra Leone.

The virus itself is a filovirus, a group of long filamentous RNA viruses that are surrounded by a lipid envelope. It causes a severe disease in people characterised by vomiting, abdominal pain, fever, headache and bleeding. Symptoms usually appear eight to 10 days after infection but this can range from two to 21 days. Mortality rates can be as high as 90%. Unlike influenza, people tend not to be infectious until they are symptomatic.

The virus is spread via direct contact with blood and body fluids, although there was a publication indicating airborne spread between pigs and monkeys (Weingartl et al 2012). Although not in direct contact the two groups of animals were caged only eight inches apart. According to a second report it appears that the Ebola virus causes a different disease in pigs compared with primates (http://www.vox.com/2014/8/10/5980553/ebola-outbreak-virus-aerosol-airborne-pigs-monkeys/in/5712456). The virus hits the lungs of pigs, whereas the liver is the main target organ in primates. Therefore, while pigs can cough and sneeze out viral particles, primates tend to shed large numbers of virus in the blood and faeces, making airborne transmission unlikely. This is borne out by the current situation. If the Ebola virus was as contagious as the influenza virus we would all be drowning in our own blood by now. Instead the outbreak has remained relatively localised.

The main reservoir of Ebola virus is unknown although, as with most emerging diseases nowadays, bats have been fingered as the main culprit. Ebola has been found in gorillas, chimpanzees and duikers but, as they also develop clinical disease and die, they are unlikely to be a reservoir. However, as they are part of the bush meat cycle they represent a great way for the virus to spread to people.

The virus itself is not particularly hardy. It can survive for several days at room temperature but is destroyed by boiling for five minutes, and common disinfectants such as bleach, phenolics, glutaraldehyde, formaldehyde and 3% acetic acid (vinegar is 4-8% acetic acid). Alcohol hand wipes and washing with soap and water are also effective at killing the virus.

Unfortunately there is no vaccine and no treatment. ZMapp, a drug made of monoclonal antibodies, has been used experimentally but, oddly, there appears to be some debate over the ethics of using this unlicensed drug on people. I know that if I was infected with Ebola and someone waved a drug at me that might or might not work, I would certainly risk it.

The biggest problem in controlling the current epidemic is a lack of infrastructure and knowledge. I can imagine that it is not easy to convince people with very little or no education that a thing that is far too small to see is killing off your family, friends and community. And no, it is not us, the aid workers, who are bringing it in. And yes, you really should stop eating bush meat, even though it is a centuries old tradition. And no, if someone dies don’t wash the body by hand. And yes, we really need you tell us if you, or someone you know, is feeling sick so we can stop them spreading the virus to other people. Please don’t hide them at home. With early medical care they do stand a chance of recovery. Previous Ebola outbreaks had mortality rates of 90%. This one is running at 60%. So it is possible to survive an Ebola infection.

As an interesting aside to the Ebola issue, in 1989 shipments of monkeys were imported into a holding facility in Reston in the US from the Philippines. Those monkeys died with symptoms similar to those caused by an Ebola virus infection. It turned out they were full of a related filovirus subsequently named Reston virus. Interestingly, 14% of the people who had contact with the monkeys had filovirus antibodies, indicating they had also been exposed to the virus. It was just lucky that this, closely related virus, does not appear to cause disease in people. It is amazing that such a small change in viral structure can turn a harmless virus into a lethal one.

Dr. F. Bunny

Reference

Weingartl H.M., C. Embury-Hyatt, C. Nfon, A. Leung, G. Smith, and G. Kobinger. 2012. Transmission of Ebola virus from pigs to non-human primates. Scientific Reports 2, 811; DOI:10.1038/srep00811.

Resistance Is Futile

1928 was a happy year for humanity as this was the year that a nondescript mould called Penicillium notatum was found to have antibacterial properties. This mould would prove to be the first in a long line of what we now know as antibiotics. Antibiotics are a group of drugs that kill bacteria for us either by interfering with their cell wall, mucking up their DNA or messing with their metabolic processes so they cease to function. Unfortunately they do not affect viruses.

Before the discovery of antibiotics people died from all sorts of minor complaints such as small infected skin wounds (before penicillin1 in 9 skin infections killed people), mild burn infections, tooth abscesses and infected insect stings. Unfortunately, according to a recently published World Health Organisation report (http://www.who.int/drugresistance/documents/surveillancereport/en/), that time could be returning as more and more bacteria are laughing in the face of the antibiotics we use.

The natural world uses a marvellous tool to adapt to changing circumstances. It is called natural selection and it is based on genetic diversity. This means that when a disease comes along it rarely kills everyone. Some people will be naturally resistant to it. They will survive and breed and, before you know it, most people will be resistant and the disease will no longer kill people. Unfortunately the same is true for bacteria and antibiotics. In any given bacterial population some bacteria will be resistant to a given antibiotic. Using that antibiotic will kill off the sensitive bacteria, leaving the resistant ones behind to proliferate. This activity can be accelerated by increasing the use of antibiotics, especially when they are prescribed for conditions that cannot be resolved by antibiotic use, such as the common cold or flu, both of which are viruses and completely unaffected by antibiotics.

If you are prescribed antibiotics, to delay the onset of resistance appearing, it is vital to take your full dose and complete the prescription, even if you feel better ahead of time. Otherwise you have not killed the bacteria but only wounded them, allowing them the opportunity to strike back bigger and better than before.

It is also important to practice effective preventative medicine to minimise the number of times that antibiotics are needed. An example of this is gonorrhoea. More than one million people are infected with gonorrhoea around the world every day. Resistance of this bacterium to all antibiotics is becoming more and more common. Prevention is simple and obvious. All it requires is a condom. Preventative measures for other diseases can include vaccination, washing your hands with soap and water, wearing your protective gear at work, not allowing your pets to stick their tongues down your throat, washing your hands with soap and water, observing good hygiene when preparing food, washing your hands with soap and water, and sticking with bottled water if you are uncertain of the quality of the water supply. Oh, and did I mention washing your hands with soap and water?

Dr. F. Bunny

MERS

MERS (Middle East Respiratory Syndrome) is the latest disease in nature’s little bag of tricks, which could turn into the next pandemic and solve our population issues for us. It is closely related to SARS (Severe Acute Respiratory Syndrome), both belonging to the same virus family. But, while SARS appeared in Asia, MERS first popped up in Saudi Arabia in 2012. Since then all cases have been seen either in the Middle East or in people who have travelled to the Middle East. As of June 2014 we have had 697 cases of which 210 people have died. As usual symptoms have been flu-like.

This is quite a high case fatality rate but, like bird flu, the virus has not raced around the world killing a third of the world’s population because it is not easily transferred from person to person, yet.

Any time one of these new diseases pops up it requires quite a bit of detective work to try and determine where it came from and how it works. It will probably come as no surprise that bats are once again implicated, the virus having been found in Egyptian tomb bats, a name guaranteed to generate sympathy with a nervous public.

Intriguingly the virus has also been found in camels, a situation which has some similarities with Hendra virus in Australia. Hendra virus lives happily in bats, infects horses (and kills them) and then spreads from horses to humans. However, as yet, there are no recorded cases of MERS causing disease in camels (although a number of camels have died in the UAE recently of undetermined cause, so this situation may change) and we have only recently seen the first confirmed case of a human catching the disease from a camel. Most of the other cases have been in people who have had very close contact with other sufferers. Where they caught it originally is still open to speculation.

It makes me think that the practice of veterinary medicine may be more dangerous than first thought. While we are all aware of the wonderful things we can catch from our primate neighbours no one really believed there was anything worth catching from our more distant cousins, like horses. Twenty years ago you would not have thought twice about examining a snuffly horse. Two years ago you would not have thought twice about examining a camel.

Australia has the largest feral camel population in the world, but no human cases of MERS. Preliminary testing of 25 camels has failed to find any evidence of MERS, implying that the Middle East camels may have been infected from the tomb bats or that the virus appeared in Middle East camels after the Australian population was established.

The upshot of all this is that we have absolutely no idea where the next fun plague might be coming from. As I get older and more paranoid I am becoming increasingly more nervous about travelling on crowded trains, planes and buses, full of sneezing and coughing people. And I am starting to think that sport is much more enjoyable when viewed from the comfort of my living room than from one of those packed sporting stadiums. I can see the day coming when I refuse to venture outside without my biohazard suit on.

Paranoia aside, most viruses are transferred between us via the things we touch, such as door handles, coffee cups, pens, etc. The best way to prevent this is by washing your hands frequently, with soap and water. To do it properly, sing the Happy Birthday song through twice while you are soaping up your hands. Oh, and don’t kiss bats, camels or any other non-human life forms. And maybe not even the human life forms.

Dr. F. Bunny

What’s In A Name

Veterinarians are simple practical people. This is reflected in the names of many veterinary diseases. Maladies like lumpy jaw, woody tongue, footrot, chronic wasting disease, white spot and white nose syndrome are sensible practical names that describe the most recognisable symptoms and tell you exactly what to expect.

Medicos, on the other hand, seem to think it more important to immortalise themselves by naming afflictions after themselves. Diseases such as Creutzfeldt-Jakob disease, Wernicke’s disease, Perthe’s syndrome and Häusler’s disease, as well as being impossible to pronounce, tell you nothing about the condition except who first described it.

Perhaps it is time to follow the veterinary example? Instead of Creutzfeldt-Jakob disease we could have “mad human” disease. Wernicke’s disease becomes “booze rots your brain” disease. Perthe’s syndrome turns into “motorcycle riding crushed chest” syndrome and Häusler’s disease morphs into “skier’s insanity”.

Dr. F. Bunny

Hospital Hysterics

The other day I felt something odd inside my left cheek. At first I thought I had just bitten myself without realising but then I noticed the cheek was actually swollen. Over the next hour or so this swelling engulfed the side of my face and crept towards my lower lip. It then proceeded to spread along my entire lower lip until it looked like someone had gone seriously overboard with the silicone injection. As my lip now felt like it was going to burst and I was concerned about the swelling spreading into my throat and asphyxiating me, I took myself off to the local hospital’s emergency department.

As always emergency departments are a hive of frenetic activity, particularly in the evenings, and I marvelled at all the doctors, nurses and ancillary staff racing about much like bees in a hive. Each one had their job and I was very impressed with the skill and efficiency with which they carried them out. I was examined and treated promptly and courteously and cannot speak highly enough of the staff, even the nurse who blew my vein trying to get the catheter in. I have certainly blown more veins in my time than most people have had hot dinners.

Watching it all swirl by I reflected on my choice of profession and was glad to have picked veterinary medicine over human medicine. The hospital environment felt very confining and I don’t think I have the temperament to cope with that constant stream of people and their various ailments.

This decision is strongly supported by an experience I had many years ago. A friend of mine was one of the doctors in the emergency department at a large American hospital. He had dropped by with a friend of his to visit, and I had shown them around. Now my wife and I were visiting him and I thought it might be interesting to see the emergency department from the inside.

After some cajoling he agreed to let us tag along, as long as we threw on a pair of white coats and pretended to act like medical residents on rotation.

Much of the day passed reasonably uneventfully but then a fellow came in who had been in a car accident. He was not seriously injured but he had tried to ram his head through the windscreen, resulting in a nasty gash to the top of his head. My friend took him into one of the consulting rooms, and we dutifully followed. He then proceeded to clean and disinfect the patient’s head, inject local anaesthetic and start stitching the wound. I leaned in a little closer for a better look and marvelled at how similar human medicine is to veterinary medicine.

It was then that I started feeling a little odd. My wife told me afterwards that she was wondering why I had started leaning against her so heavily. As all loving wives do she stepped aside and I crashed to the ground. Through my rapidly receding consciousness I could dimly perceive the room exploding into chaos. My doctor friend leapt to his feet and began elevating mine. The patient wanted to know what was going on, obviously thinking I had made a rather bad career choice. And I lay on the ground feeling perplexed and confused.

As a zoo veterinarian I was certainly no stranger to blood and entrails, having necropsied elephants, giraffes and even a whale. So what was this all about? I could only conclude that I had some kind of an issue with damaged human skin. To this day it continues to astonish me, the way my body’s unconscious desire to pass out completely overrode my body’s conscious desire to watch the task at hand.

Dr. F. Bunny

Run Till You’re Sick

“Running the miles, pretty damn quick. Run through the wilds. Run till you’re sick”

(Going To Mexico, Motörhead, from the album “Aftershock”)

I have finished my six weeks in running purgatory (See “Too Fit To Run” 5/4/14) and visited a new cardiologist, one who looks fit, has Tour de France athletes on his books and seems to understand the concept of exercise. I passed my follow up heart test which means that, as my fitness level drops, my heart rate comes back into the “normal” range. Apparently there is “normal” and there is “normal”. Unfortunately my “normal” is closer to the “needs a pacemaker” kind of normal. But for now I can run again.

In order to try and keep my heart under control I have been put on a modified program of two weeks hard running, two weeks moderate running, two weeks no running, for 18 weeks (three cycles). Then I have a heart stress test and repeat heart monitor assessment. If all is good I assume that will be my foreseeable future. If all is not good then it’s back to the drawing board.

And I am allowed to run a marathon because I don’t have any myocardial scarring. The cardiologist was quite disparaging about my previous marathon result. Apparently, if it takes me four hours to complete a marathon, then I am not running nearly hard enough to damage my heart.

I guess that’s good news but I don’t think I will take up that particular challenge, at least not this year. After six weeks off I feel understandably sluggish and slow. I dare say that will all improve reasonably rapidly but, for now, I think I will confine myself to half marathons and see what happens.

Dr. F. Bunny

Too Fit To Run

I ran my first (and probably last) marathon in October last year. About a month later I started getting heart palpitations. I have always thrown the odd palpitation and been assessed several times by cardiologists, as I have a family history of heart disease. No matter how many times they make me run up the vertical treadmill they have always failed to kill me.

However, the sporadic nature of these palpitations changed rather dramatically just before Christmas. Now I was getting them every day for most of the day. If you have never had a palpitation the feeling is quite hard to describe. It is a bit like a cross between having butterflies in your chest and going down a roller coaster or hitting a massive air pocket, only it is happening all the time. If I take my pulse I can feel the missed beats and irregularities that correlate with the butterflies. It is amazing that my heart can be bouncing around like that without producing any symptoms.

These particular palpitations went away with exercise, which seemed like a good excuse to run, run, run. Thanks to the shorter waiting times, because of my private health insurance, I only had to wait three months to see a cardiologist.

When I finally did darken his door he just waved the palpitations away as being inconsequential, because there were no accompanying symptoms. No exercise intolerance. No shortness of breath. No chest pain. Not completely inconsequential, however, because he warned me off any future marathons. 15 km was okay, 42.2 km was not. Apparently that amount of cardiac stress for that long tends to cause myocardial fibrosis, or scarring, which can then lead to potentially fatal arrhythmias (http://running.competitor.com/2012/06/news/how-much-running-is-bad-for-your-heart_54331, http://www.mayoclinicproceedings.org/article/S0025-6196(12)00473-9/abstract). Happy news.

And he stuck a 24 hour monitor on me just to see what my heart was getting up to when no one was watching. Not much, it seems. While I am asleep, so is my heart. My sleeping heart rate dropped to as low as 27 beats per minute (60-80 is average) with up to six seconds between beats. Apparently this means I am either fit or have severe conduction issues that will need a pacemaker to sort out. Ironically the only way to decide is to make me unfit and see if anything changes.

So for the next six weeks I have been banned from running. He wanted to ban me from doing anything at all but I convinced him to let me keep going to the gym as long as I didn’t “do anything silly” as he put it. That’s two races I now have to miss, including chasing a historic steam train into the hills.

I must admit to having mixed feelings about the marathon ban. I wasn’t too sure if I wanted to put myself through all that training again anyway. However, the complete running ban is something different altogether. I can already feel my fast (and slow) twitch fibres getting twitchy.

And how confident can you be in the prognostications of a fat cardiologist? Isn’t obesity one of the key risk factors for heart disease? I half expected him to light up a Marlboro and start chewing on a lard sandwich.

Still, for the moment at least, the running ban is irrelevant as I smashed my back escaping from Eddie’s headlock at last Monday’s Krav Maga session. I have so much pain in my right thigh (referred presumably from my spine) and have taken so many different analgesics that even typing is a challenge at the moment.

The unbelievable irony of all this has not escaped me. Everything I read, see, and hear tells me to go out and exercise. Be active and I will live to 156. Having taken that advice I am now being told that I am too active, and possibly too fit and that I need to spend the next month sitting on the couch watching television. This could get very ugly before it is over.

Dr. F. Bunny

 

Turn Your Head And Cough

Socialized medicine seems like a pretty good idea to me and I cannot really understand why so many people are opposed to it. I recently finished a Lionel Shriver book entitled, “So Much For That”. One of the main characters is diagnosed with mesothelioma and, if the book is at all accurate about US health care, then it truly boggles the mind that one chemotherapy treatment could cost as much as $40,000! Who can afford that? And the idea that your place of employment should fund your health care also seems bizarre.

While the Australian system of Medicare is not perfect it certainly seems to work a lot better, based on the World Health Organisation’s Disability Adjusted Life Expectancy (a measure of the number of years of life expected to be lived in full health, or healthy life expectancy): http://search.who.int/search?q=disability+adjusted+life+expectancy+&ie=utf8&site=who&client=_en_r&proxystylesheet=_en_r&output=xml_no_dtd&oe=utf8&getfields=doctype&as_q=filetype:pdf . Using this index Australia comes in at number two (behind the Japanese), whereas the US pops up at number 24.

While I have no major complaints about Medicare the Australian government decided some years ago that it was tired of funding Australia’s health care and wanted the public to carry more of the burden i.e. take out more private health cover. Instead of using the carrot method by lauding the advantages of private health care they chose to use the stick method by fining tax payers an additional 1-1.5% of their incomes if they did not have private health insurance at the end of each tax year. And the longer you wait to take it out the more expensive the cover becomes.

I admit that private cover can be useful for things like dental and optical, as they are not covered by Medicare (why is beyond me. Don’t most of us have eyes and teeth?). Unfortunately being insured for those extras does not remove the surcharge. For that you need to take out full private cover, and what do you get for it? Virtually nothing.

Private health insurance is supposed to cut waiting lists. I still had to wait six weeks to see a cardiologist (lucky I wasn’t having a heart attack) and my son had to wait three months to see a wrist specialist. The private insurance covered none of these costs, leaving me $500 out of pocket after my son’s MRI and X-rays. Obviously the amount Medicare reimburses patients for a specialist consultation is based on what they were charging in the 1950s.

Apparently private health cover lets me choose my own doctor and hospital, but who has the background knowledge to decide between Sleep Apnoea Specialist A and Sleep Apnoea Specialist B? Don’t we just let our GP choose for us? And once I had my Sleep Apnoea Specialist he told me which hospital I would be visiting for my sleep test, a hospital that left me $800 out of pocket for one night’s stay.

Ironically, when I had my nose surgery that specialist did give me a choice of hospitals. I could wait three months and have the surgery in his nice inner city private hospital, which would still have left me hundreds of dollars out of pocket, or I could wait three months and go to the nice rural public hospital where the entire procedure would cost absolutely nothing, because it then fell under the Medicare umbrella. Needless to say I chose the room with the kangaroos grazing outside and the birds chirping merrily in the trees.  

I imagine they chirped so merrily because they weren’t being ripped off by private health insurance companies, backed by the government. Maybe it is really a three way conspiracy with the health funds in bed with the government and the accountants. Much as I would like to make it a four way conspiracy veterinarians, naively, appear to put their clients’ interests first. Instead of pushing for twice yearly check-ups veterinarians have discovered that their vaccinations work too well, only requiring boosters every three years, meaning that you don’t need to bring Rover or Puss in Boots back for a booster every year. How stupid is that?

Dr. F. Bunny