Type 2 diabetes: Work stress may raise risk in women

A new review featuring in the European Journal of Endocrinology suggests that a stressful work environment may increase the risk of developing type 2 diabetes in women.

A stressful work environment may increase the likelihood of type 2 diabetes in women, suggests new research.

More than 100 million people in the United States have diabetes or prediabetes, according to the latest statistics.

Over 9 percent of the U.S. population is living with diabetes, and more than 84 million people are living with prediabetes — a condition that is bound to develop into full-blown type 2 diabetes without treatment.

Risk factors for type 2 diabetes include a lack of physical activity, being overweight or having obesity, being aged 45 years or older, having high cholesterol and high blood pressure, or having a family history of diabetes, heart disease, or stroke.

Psychological factors may also play a role in the development of type 2 diabetes. Living with depression may make the risk higher, and a new study now suggests that work-related stress may also increase the likelihood of developing the condition, at least for women.

Guy Fagherazzi, a senior research scientist at the Centre for Research in Epidemiology and Population Health at the research institute Inserm in Paris, France, led the new study.

Mentally tiring work raises risk by 21 percent

Fagherazzi and his colleagues set out to examine whether there was a link between “mentally tiring work” and the incidence of type 2 diabetes in more than 70,000 women over a period of 22 years between 1992 and 2014.

About 75 percent of the women in the study were teachers, and 24 percent of them said at the start of the study that their work was “very mentally tiring.”

Throughout the study period, 4,187 women developed type 2 diabetes. The analysis revealed that the prevalence of diabetes was considerably higher among women who deemed their job to be more mentally draining.

Specifically, those who said that their job was “very” mentally taxing at the start of the study were 21 percent more likely to develop the condition than women with “little or not mentally tiring work.”

When the researchers adjusted for other factors, including unhealthful lifestyle habits and cardiometabolic risk factors, such as high blood pressure or a high body mass index, the association between work and diabetes risk stayed the same. Fagherazzi and colleagues conclude:

“These observational results suggest the importance of taking into consideration the potential long-term metabolic impact of work-related stress for women working in a demanding environment.”

The study’s senior author comments: “Although we cannot directly determine what increased diabetes risk in these women, our results indicate it is not due to typical type 2 diabetes risk factors. This finding underscores the importance of considering mental tiredness as a risk factor for diabetes among women.”

He goes on, “Both mentally tiring work and type 2 diabetes are increasingly prevalent phenomena. What we do know is that support in the workplace has a stronger impact on work-related stress in women than men.”

“Therefore, greater support for women in stressful work environments could help to prevent chronic conditions such as type 2 diabetes,” concludes the researcher.

In the near future, he and his team plan to examine the effect of mentally tiring work on people who are already living with type 2 diabetes. The researchers hope that their findings will aid the development of new ways to manage the condition.

Flu Season Far From Over, CDC Says

By Steven Reinberg

HealthDay Reporter

FRIDAY, Feb. 8, 2019 (HealthDay News) — Though much of the United States is in the grip of the flu, the season hasn’t peaked yet, health officials said Friday.

As of Feb. 2, flu is widespread in 47 states, and 24 states are experiencing high levels of the disease. In addition, hospitalizations are increasing, according to the U.S. Centers for Disease Control and Prevention.

“Flu activity has continued to increase this week,” said Lynnette Brammer, the lead of CDC’s domestic influenza surveillance team.

The most common type of flu around is still the influenza A strain H1N1. But it may be waning, Brammer said, as the level of influenza A H3N2 has increased.

Both of these flu strains are in this year’s vaccine, but while the H1N1 component is up to 65 percent effective, the effectiveness of the H3N2 is far less, according to the CDC.

Even though it is nearly mid-February, the flu season is expected to continue for several more weeks, probably well into March, Brammer said.

“There’s still a lot more flu season to come,” she said. “I expect activity to continue for several more weeks.”

That’s why she’s urging anyone who hasn’t yet been vaccinated to get a flu shot. “It’s not too late,” Brammer said.

An underrated benefit of the vaccine is that even if you get sick, your flu will be milder than if you haven’t been vaccinated. A milder flu can prevent complications like pneumonia that can be deadly, especially to the very young and very old.

Brammer also stressed that getting vaccinated not only protects you, but those around you, as well.

According to the CDC, flu activity is high in New York City, Alabama, Alaska, Arkansas, Colorado, Connecticut, Georgia, Indiana, Kansas, Kentucky, Massachusetts, Mississippi, Nebraska, New Jersey, New Mexico, North Carolina, Oklahoma, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, Virginia and West Virginia.

It’s still too early to tell how severe this season will be, Brammer said. So far, the season has been much less severe than last year when the H3N2 virus predominated. Last year, flu sent nearly 1 million Americans to the hospital and killed about 80,000.

This season is still classified as a less severe season, Brammer said. “But we’re not finished yet,” she said. “We’ll have to see how it plays out.”

The CDC doesn’t track adult deaths from flu, but they do keep tabs on pediatric deaths. This week, four more children died from flu, bringing the total to 28.

The best way to protect yourself and those around you is to get a flu shot, and there’s still time to get vaccinated, Brammer said.

The CDC recommends that everyone aged 6 months and older get vaccinated.

Getting a flu shot should be at the top of the list for those at high risk for flu, including the elderly, people with heart disease or lung disease, and pregnant women.

Brammer added that this year’s vaccine is well matched to the circulating strains of flu, and vaccine is still available. “I haven’t heard of any shortages,” she said.

As long as flu is circulating, it’s not too late to get vaccinated. “And right now, flu is circulating at a pretty high level,” Brammer said.

If you get the flu, antiviral drugs such as Tamiflu and Relenza can make your illness less severe. But if you’re sick, the CDC recommends that you stay home so you don’t infect others.

Brammer wouldn’t be surprised if the flu season doesn’t peak for several more weeks. It also wouldn’t surprise her if the H1N1 virus peaks before the H3N2 virus.

In any case, even when the season peaks, there’s still a long way to go before it’s over, she said.

Diabetes: Are you over-monitoring your blood sugar?

Many people living with type 2 diabetes monitor their blood sugar levels on a daily basis, but does that really make a difference to health? A new study suggests that they may be over-monitoring.

According to a recent Centers for Disease Control and Prevention (CDC) report, about 30.3 million people in the United States live with diabetes, which equates to almost one in 10 individuals.

The most commonly diagnosed form of diabetes is type 2 diabetes, which, more often than not, does not require insulin injections.

Instead, people with type 2 diabetes can manage their condition by taking the appropriate medication.

A drug that doctors often prescribe for this form of diabetes is metformin, which helps people keep their blood sugar levels under control.

As keeping blood sugar in check is so important in diabetes, endocrinologists advise people with this condition to perform regular, simple blood tests that they can do at home with the appropriate devices.

However, emerging evidence suggests that many people living with type 2 diabetes may be erring too much on the side of caution and taking these tests too often, without deriving any real benefits from doing so.

A new study by researchers from the University of Michigan in Ann Arbor suggests that a significant percentage of people with type 2 diabetes test their blood sugar levels at least twice a day.

These findings, which appear in the journal JAMA Internal Medicine, indicate that U.S. citizens or, in some cases, their insurance plans may pay excessive amounts of money for the supplies they require for unnecessary testing.
Too many prescriptions for test strips

Dr. Kevin Platt, who is in the Department of Internal Medicine at the University of Michigan, led a team who looked at the insurance data of 370,740 people with type 2 diabetes. The researchers specifically assessed how these individuals had been filling test-strip prescriptions for blood sugar tests following the updated guidelines that the Endocrine Society and Society of General Internal Medicine issued in 2013.

These guidelines recommended that people with type 2 diabetes reduced the frequency of at-home blood sugar level tests.

In their analysis, the researchers only looked at people with diabetes who did not require insulin or take medication that increases hypoglycemia (low sugar levels) risk. However, they did include people who took no medicine for the regulation of blood sugar, as well as those who took medicine that did not require them to check their blood sugar levels frequently.

The researchers found that “86, 747 (23.4 percent) of [the people in the study cohort] filled three or more claims for test strips during the course of the year.” They also noted that “more than half of these individuals,” equivalent to 51,820 people or 14 percent of the study population, were “potentially using the supplies inappropriately.”

Of these people, “32,773 individuals were taking agents not considered to be a risk for causing hypoglycemia (e.g., metformin hydrochloride) and 19,047 had no claims for any antidiabetic medications,” the authors write.
‘Reducing the use of unnecessary care’

Dr. Platt and team explain that once a person taking blood sugar medication has determined the dosage that works best for them, they no longer have to test their sugar levels on a daily basis.

However, the study findings indicate that even the people who did not need to take daily blood tests were still using an average of two test strips per day.

The researchers believe that people may keep on taking the tests to allow them to keep a log of their blood sugar levels and feel more in control of their condition.

However, they are spending a lot of money in doing so, whether it be on insurance plans or out of their own pocket in the absence of insurance.

“The median claims cost for test strips was $325.54 […] per person per year” in the case of people with an insurance plan, the researchers write, and the cost is likely to be even greater for those without insurance.

“Healthcare costs and access to care are an important issue for many Americans,” says Dr. A. Mark Fendrick, the study’s senior author.

Preventing sudden cardiac death with genome editing

Each year, at least 3 million people worldwide die of sudden cardiac death. In the U.S., this number reaches up to 450,000 people. Although sudden cardiac death is more common in older adults, younger people also are significantly affected. In the 1 to 40 age group, up to 9 per 100,000 people are affected each year. In this group, inherited cardiac diseases, including inherited cardiac arrhythmia disorders, cause a substantial proportion of sudden cardiac death.

In his lab at Baylor College of Medicine, Dr. Xander Wehrens and his colleagues study cardiac conditions, including inherited cardiac arrhythmia disorders. In addition to being often associated with a high incidence of sudden cardiac death, these disorders can be difficult to treat.

“For this particular study, we were inspired by a young patient who has been affected by an inherited cardiac arrhythmia disorder called catecholaminergic polymorphic ventricular tachycardia (CPVT). Our patient has recurring arrhythmias — irregular and fast heartbeats — and fainting episodes,” said Wehrens, who is professor of molecular physiology and biophysics, the Juanita P. Quigley Endowed Chair in Cardiology and director of the Cardiovascular Research Institute at Baylor. “Several family members had near fatal arrhythmias or sudden cardiac death. Current treatment options including anti-arrhythmic drugs and an implantable defibrillator — a device to correct certain irregular heartbeats — are not optimal for this patient.”

Genetic studies have shown that the cause of the young patient’s arrhythmia is a mutation in gene RYR2. Mutations in this gene account for nearly 60 percent of all CPVT cases. This gene encodes proteins that form a channel that regulates calcium flow in heart muscle cells called cardiomyocytes. Cardiomyocytes require proper calcium flow to contract and relax in a coordinated manner.

Gene mutations that produce defective RYR2 proteins lead to defective calcium channels that promote uncontrolled calcium leak. During exercise or emotional stress, a heart with defective RYR2 proteins will not regulate calcium flow properly, and this can lead to potentially life-threatening arrhythmias.

Designing a permanent treatment for CPVT

Wehrens teamed up with Dr. William Lagor, associate professor of molecular physiology and biophysics, who is an expert in gene therapy using Adeno-Associated Viral (AAV) vectors. These viruses can be used to deliver the CRISPR/Cas9 genome editing machinery directly into the heart.

The long-term goal of this collaborative project is to develop a permanent treatment for CPVT in humans by editing the patient’s own DNA.

Wehrens and Lagor engineered AAV vectors to deliver CRISPR/Cas9 (AAV-CRISPR) into the hearts of live animals. They reasoned that eliminating the disease-causing copy of the RYR2 gene, called R176Q, could correct this lethal arrhythmia disorder in mice. To test this new approach, AAV-CRISPR was used to selectively disrupt the mutant RYR2 gene in the R176Q mouse model of CPVT.

Ten days after birth, mice carrying the R176Q mutation and normal mice received a single injection of AAV-CRISPR or placebo treatment. Five to six weeks later, the researchers evaluated the mice, and found very encouraging results.

None of the mice carrying the disease-causing R176Q mutation that were treated with AAV-CRISPR developed arrhythmias. In contrast, 71 percent of the mice that carried the mutation and received a placebo virus did develop arrhythmias. Editing of the defective copy of the gene using AAV-CRISPR greatly reduced the abundance of the dysfunctional RYR2 proteins. Furthermore, the single ‘healthy copy’ of the RYR2 gene that remained was enough to support proper heart function. No adverse events linked to treatments were observed in the groups of normal or affected mice.

“We are particularly excited that we were able to selectively disrupt the disease-causing R176Q mutated gene without adversely affecting the healthy gene variant in the genome,” Wehrens said.

“We are now testing the same approach in stem cells from patients with the same condition, to analyze efficacy and safety in human cells. This may enable us to develop this approach for future therapeutic studies in patients with this arrhythmia syndrome,” said Wehrens.

Lagor also is optimistic about this new therapeutic approach.

“There are many diseases that are unsuitable for additive gene therapy, either because the gene is too large to deliver or a defective copy of the gene acts in a dominant way. For many mutations in RYR2 that cause CPVT, both of these are the case,” Lagor said. “We believe that precision genome editing is the future for tissue-directed gene therapies, and severe cardiac diseases are an ideal place to start.”

It Takes an Army to Manage a Medical Tragedy

Broken-out windows (lower right in image) on the 32nd floor of Mandalay Bay Resort and Casino on Las Vegas Boulevard from which a shooter rained bullets down on innocent concert-goers, killing 58 and injuring nearly 500.

By Dr. Sudip Bose, MD, FACEP, FAAEM

“The worst act imaginable often brings out the best of people.”

You’ve likely heard that phrase, probably often repeated, during the news coverage of the horrific mass shooting at the Route 91 Harvest Festival outdoor concert on the Strip in Las Vegas on Sunday, Oct. 1, as well as during the aftermath of hurricanes Harvey, Irma and Maria.

As a physician and especially as an emergency department doctor, we train for mass casualty situations on a routine basis, always hoping we never have to experience such an incident in reality. It’s a concept I accepted as a medical officer on the front lines of Iraq in the Army: We prepare in peacetime for wartime. When a mass casualty situation happens, that’s exactly what it’s like – you get thrust into a war zone immediately.

And it takes an Army to carry out the mission needed to try to keep casualties as low as possible.

At 10:05 pm Sunday night, shots rang out from the upper floors of the Mandalay Bay Resort and Casino on Las Vegas Boulevard. Initially most people thought what they heard might be fireworks associated with the concert. But all too soon, concert-goers realized that they were being fired upon as hundreds of rounds of bullets rained down on them. It didn’t take long for that “Army” to swing into action on the ground to start treating the wounded. First responders, as well as concert-goers themselves, immediately started do what they could to stop the bleeding of those hit. They had to get the injured stabilized and transported to hospitals. Las Vegas area hospital emergency departments quickly became saturated with patients. Victims – 5, 6, 7, 8 at a time – were piled into ambulances at the scene of the shooting and rushed away for treatment. Eyewitnesses to the shooting event also reported that gunshot victims were loaded into pickup trucks and civilian cars in some cases and transported to hospitals.

Continue reading “It Takes an Army to Manage a Medical Tragedy”

Coping With Disaster: A Medical Overview

NASA Earth Observatory

By Dr. Sudip Bose, MD, FACEP, FAAEM

First there was Harvey, then Irma and, most recently, Maria. Hurricanes have hit Texas and the Gulf Coast, have torn through Florida, and have raked across the Caribbean, devastating Puerto Rico and the Virgin Islands. These disastrous power punches have left scores dead, millions uprooted and much physical and emotional devastation in their wake.

As of this writing, Hurricane Harvey has been reported to have caused 82 deaths; Hurricane Irma’s U.S. death toll stands at 75; and so far, Hurricane Maria has claimed 27 lives and likely will go higher. Some of those killed as a result of Irma involved nursing home patients.

How can that happen, you ask? Shouldn’t these kinds of victims have been our top priorities for keeping safe? Of course. But sometimes, all the planning and precaution in the world can’t overcome the unpredictability of Mother Nature, a disabled infrastructure and the failure of emergency backup power.

Every natural disaster, such as hurricanes Harvey, Irma and Maria, also becomes a looming public health disaster. As the storms approach, each hospital, nursing home and medical facility that houses patients must make difficult decisions between evacuating patients and staff and battening down to ride out the storm. Evacuations pose major logistical issues as patients, staff, equipment and medications all have to be transitioned from one location to another. An evacuation for a chronically or critically ill patient can be life-threatening. During the height of the storms, hospitals and other medical facilities face critical issues in trying to keep their patients not only alive, but also well cared for. Shortages of food, water, medicine and power can turn very bad very quickly.

After the Storm

After the brunt of hurricanes like Harvey, Irma and Maria push through, health resources re-focus on fighting infections, both from bacteria in floodwaters and from mosquitoes. Physicians scramble to contain potential epidemics that might arise after flooding. Based on the health problems that arose after Hurricane Katrina, medical professionals have to prepare to try to avert major public-health emergencies, environmental illnesses, and outbreaks, which could intensify in the aftermath of the devastating blows dealt by these hurricanes. Sewage that has overflowed its containment can pose a major health issue, as can spilled fuel and chemicals from tanks and pipelines torn apart during the hurricanes.

And not only that, but for hospitals and other facilities that made the decision to move patients, those same patients have to be transitioned back home to their original facilities at some point, assuming those facilities are able to open and operate again.

As you can see, there is much to consider when preparing for a natural disaster like hurricanes Harvey, Irma and Maria. In fact, the Centers for Medicare and Medicaid Services have established an Emergency Preparedness Rule that all hospitals and health care facilities must have a plan in place and be in compliance by Nov. 16, 2017. This emergency preparedness plan, by CMS guidelines, must address an all-hazards risk assessment and contain four core elements:

Four Core Elements of Emergency Preparedness
RISK ASSESSMENT AND EMERGENCY PLANNING (include but not limited to):

  • Hazards likely in geographic area
  • Care-related emergencies
  • Equipment and power failures
  • Interruption in communications, including cyber attacks
  • Loss of all/portion of facility
  • Loss of all/portion of supplies
  • Plan is to be reviewed and updated at least annually

COMMUNICATION PLAN

  • Complies with federal and state laws
  • System to contact staff, including patients’ physicians, other necessary persons
  • Well-coordinated within the facility, across health care providers, and with state and local public health departments and emergency management agencies.

POLICIES AND PROCEDURES

  • Complies with federal and state laws

TRAINING AND TESTING

  • Complies with federal and state laws
  • Maintain and at a minimum update annually

The plan must also consider those individuals locally who may be deemed “at risk.” To quote from the CMS guidelines:

“At-risk populations are individuals who may need additional response assistance, including … [those] from diverse cultures, [who] have limited English proficiency, or are non-English speaking.”

In addition to shelters, hospitals are often a focal point of their communities during a crisis. In addition to patients already admitted to a hospital, during a natural disaster like a hurricane, new patients are very likely to seek medical assistance by coming to the emergency department either on their own or after being rescued by a first responder. And first responders need to know the status of a hospital to ensure they’re transporting patients to an open, operating, safe medical facility. Hospitals need to work with other hospitals to know where to send or receive patients if any of the open facilities become overwhelmed. And as always, hospitals need to remain HIPAA-compliant regarding patient information; just because a hospital might be operating within a disaster doesn’t mean it can be casual or careless with personal patient information.

Once hurricanes like Harvey, Irma and Maria have passed and done their damage, the next challenge is keeping the most critically ill patients cared for. We’re seeing that now, and especially so, in Puerto Rico, which is an island. You just can’t drive trucks there loaded with food, fuel, water and medical supplies. All that has to be flown in or shipped in.

Finding Comfort

“The other challenge that we face, is unfortunately because of the severity of the hit [from Hurricane Maria] there is diminished capacity of local governments and state government to respond similar to what we saw with Texas and Florida,” said Brock Long, FEMA Administrator. “So therefore, it is requiring us to push forward a lot of resources, including the USS [sic] Comfort, which is on the way.”

The USNS Comfort is a Navy hospital ship that sails to points of distress when needed to assist medical personnel on the ground with there most dire patients and circumstances. It is heading to Puerto Rico. It has one of the largest trauma facilities in the United States. It has a supply of 5,000 units of blood, according to a U.S. Navy fact sheet about the vessel, and is equipped with a full spectrum of surgical and medical services including X-ray machines, CAT scan units, a dental office, an optometry facility, a physical therapy center and a pharmacy. The 1,000-bed ship was sent to Haiti in 2010 after a large earthquake killed upwards of 300,000 people. In 2005, the ship sailed to the Gulf Coast after Hurricane Katrina hit and more than 1,500 people were treated aboard the vessel. In 2003, the hospital ship spent two months in the Persian Gulf during the invasion of Iraq, and it also was deployed to New York in the aftermath of 9-11.

Getting medical support to areas ravaged by these hurricanes and other natural disasters can be formidable. The news media may leave these areas after the initial news is reported and the days march on; however, the support needed for medical personnel, supplies and treatment carries on for months until the area stabilizes.

Right now in Puerto Rico, according to a report by Reuters, “For hospitals across this region, the challenges are mounting. After the power went out, back-up generators at some hospitals failed quickly. Other hospitals are running critically low on diesel. Fuel is so precious that deliveries are made by armed guards to prevent looting, according to Dr. Ivan Gonzalez Cancel, a cardiovascular surgeon and director of the heart transplant program at Centro Cardiovascular,” the report said.

People line up for blocks trying to get enough fuel to power generators and vehicles, waiting for sometimes up to seven hours. Everything else there is in a shambles as well, adding to the urgency and stress. Food is scarce. The island’s electrical grid has gone down and may stay that way for months.

“Cellular service, internet, and email have virtually disappeared, hurling a modern society into a bygone era,” Reuters reported. “Radio has become a primary source of information.”

For hospitals that need to transfer critical patients because they can’t support them due to lack of electricity, the situation is dire. For them, the USNS Comfort can’t arrive fast enough. If necessary, the most critical patients can be evacuated via medevac and transferred to the USNS Comfort while it’s still underway and sailing towards Puerto Rico.

And in the meantime, if medical staff on the island can’t get gasoline for their cars, how can they even get to work to care for the sick and injured?

FEMA’s Twitter feed has been carrying photos of ongoing efforts in Puerto Rico: The American Red Cross is on the scene, as is the Salvation Army, U.S. state urban search and rescue teams, the National Guard, Customs and Border Protection is assisting, the U.S. Coast Guard, the U.S. Navy, Veterans Administration medical centers are supporting by taking in evacuated patients … it goes on and on. The effort is just massive and won’t end anytime soon. (Also see, The Guardian: Photos After Hurricane Maria)

Getting Help

All these areas – Texas with Hurricane Harvey, Florida with Hurricane Irma, and Puerto Rico with Hurricane Maria – need our continued help and support on a variety of fronts. And we also should not forget those suffering in Mexico, which was hit recently with major earthquakes resulting in a death toll of at least 333 people and counting. Here are some links and suggestions for ways you can donate, if you are moved to do so, culled from relief websites and media:

Those are just a handful of entry points for support and donations and sources for helping victims. Use your discretion for any donation should you decide to help out. Let’s hope these areas get the continued support they desperately need.


To learn more about Dr. Sudip Bose, MD, please go to SudipBose.com and visit his nonprofit TheBattleContinues.org where 100 percent of donations go directly to injured veterans.

The High Cost of Prescription Drugs in the United States

By Dr. Sudip Bose, MD, FACEP, FAAEM

Spending on prescription medications is higher in the US, per capita, than in any other country in the world, according to a recent Journal of the American Medical Association study. And, the report said, those costs are “largely driven by brand-name drug prices that have been increasing in recent years at rates far beyond the consumer price index.”

An NBC News report noted that, “Paying for medicine can be the most expensive out-of-pocket health cost for Americans.”

Why?

If you look at the landscape of prescription drugs in America, you’ll notice there is nothing in place to keep drug prices low. There are no specific regulations to keep a ceiling on costs. The pharmaceutical manufacturers have the very tempting opportunity to charge whatever they think a drug’s demand and the market will bear. It’s simply possible for a drug company to charge high prices if they want to, just because they can. There’s nothing regulating whatever cost they want to charge. So the opportunity to charge more exists.

Drug companies will tell you immediately that their costs to research, develop and bring a drug to market are astronomical, and they have to cover those costs and make a profit to continue to stay in business and develop even more innovative prescription medications that will help save more lives. That’s a primary reason pharmaceutical companies will point to as a reason for escalating prices on all the medications they manufacture. And that’s true – to a degree.

Continue reading “The High Cost of Prescription Drugs in the United States”

The Opioid Crisis in the United States

By Dr. Sudip Bose, MD, FACEP, FAAEM

“The opioid crisis is an emergency, and I’m saying officially right now it is an emergency. It’s a national emergency. We’re going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis,” President Donald Trump said yesterday.

It’s likely that President Trump was influenced by an interim report that was presented to him last week by the Commission on Combating Drug Addition and the Opioid Crisis, which compared the nation’s overdose death toll to the toll that resulted from the terrorist attacks on 9-11: “With approximately 142 Americans dying every day, America is enduring a death toll equal to September 11th every three weeks,” the commission’s interim report noted. And the commission urged the president to declare a national emergency under either the Public Health Service Act or the Stafford Act.

President Trump and the commission are right in placing such an emphasis on this national crisis – and it is a national crisis. It’s the biggest epidemic to have hit our country since the HIV epidemic of years ago, so much so that in the emergency room as an emergency physician, I’m seeing patients come in dead from opioid overdoses. People are getting addicted and are coming into our emergency rooms and they’re dying from this. A couple of those instances I remember very vividly – one where a young girl went downstairs at her house to find her older brother and his girlfriend blue and not breathing; in another case a man looked out of the window of his house and saw a teenager lying still on his lawn. I know the stories, because the brother, the girlfriend and the teen on the lawn all came through my emergency room and all were dead from overdosing on opioids. You don’t forget those kinds of things.

Continue reading “The Opioid Crisis in the United States”

Transgenders in the Military: A Cause for Concern?

By Dr. Sudip Bose, MD, FACEP, FAAEM

President Trump announced via Twitter last week in a series of three Tweets that United States government would no longer accept or allow transgender individuals to serve “in any capacity” as the military “cannot be burdened with the tremendous medical costs and disruption that transgender in the military would entail.” His three Tweets compiled:


“After consultation with my Generals and military experts, please be advised that the United States Government will not accept or allow transgender individuals to serve in any capacity in the U.S. Military. Our military must be focused on decisive and overwhelming victory and cannot be burdened with the tremendous medical costs and disruption that transgender in the military would entail. Thank you”

@realDonaldTrump


That’s quite a stance President Trump has taken, and a change to the military’s current policy of allowing gay, lesbian and bisexual people to serve openly after President Bill Clinton opened the door with his implementation of a “don’t ask, don’t tell” policy beginning in 1993 when it came to sexual preference/orientation in the military. The debate on this issue has gone back and forth over the past seven decades. Even as far back as World War II, those policies were the subject of substantial debate as the military eventually brought in some 18 million men over the course of that war. One of the “deviations,” as it was termed then, that physicians giving physicals to incoming soldiers joining to fight in WWII were asked to look for was listed as “homosexual proclivities,” which would disqualify someone trying to enter the military. Various administrations wrestled with the subject over the next five decades with the result being that of exclusion throughout the armed forces, until 1993, when Congress passed and President Clinton signed a law instituting the policy commonly referred to as “don’t ask, don’t tell” (DADT), which allowed gay, lesbian, and bisexual people to serve as long as they did not reveal their sexual orientation.

Then in 2010, the ban on openly gay, lesbian, and bisexual service personnel was ruled by two federal courts as being unconstitutional, and a federal appeals court suspended the DADT policy. In December 2010, Congress passed and President Barack Obama signed the Don’t Ask, Don’t Tell Repeal Act of 2010 and, under its provisions, restrictions on service by gay, lesbian, and bisexual personnel ended as of Sept. 20, 2011. Transgender people were allowed to openly serve starting June 30, 2016.

Now, let’s remember, this recent discussion was started by a Tweet from President Trump. And a Tweet is not an official directive. A day after the president Tweeted about transgenders in the military, Joint Chiefs of Staff Chairman, Gen. Joseph Dunford, announced that the current policy – meaning that policy set in place over a year ago regarding transgender people being allowed to openly serve in the military – will remain intact until the president issues an official directive.

Since that set of Tweets, there has been quite a bit of back-and-forth on both sides of the issue. Much of the discussion has been around a couple of things:

  1. The medical costs of being transgender and maintaining a transgender status in the military and,
  2. That the armed services should not be a place of implementing progressive social engineering and that the military should not have its readiness impacted by transgenders.

I have experience on the medical side of things as well as military (Dr. Sudip Bose’s profile). As far as the medical side of things go, most transgender patients do not undergo sexual reassignment surgery, which is expensive, has risks, and has a long timeline. Patients do have cosmetic surgeries to help assume a more masculine or feminine appearance, depending on the transformation aesthetics they’re looking for. Hormone therapy is common.

Also, making a transition from one gender identity to another is not just about a physical, outward appearance. That’s important to understand. Transitioning to become a man or a woman is an important part of a patient’s identity. A vast number of transgender people see themselves as, and identify themselves with being a male or female – opposite of the way they were born – at a very young age, often as children. For example, that “tomboy” girl who always wanted to play with the boys and associated with more traditionally masculine activities and possessions; then there’s the young boy who always wanted to play with the girls and befriend them, who felt more comfortable in his own identity playing with dolls or wearing a dress – typically more traditionally feminine behavior.

Becoming a transgender person is a long and complicated process for an individual. Some people may modify the way they look and dress and become more feminine or masculine in appearance and may even change their name before doing it legally. Some transgenders will make the transition in only part of their lives, for example assuming a male or female persona personally, while at home, but may remain the opposite gender at work. There are those who have come into the emergency department and present themselves as their original birth gender, despite having made the transition to the opposite sex in every other aspect of their lives.

However a transgender person presents him or herself – male or female –however they identify themselves, regardless of what you might initially perceive them to be, is the way they need to be treated. It’s actually pretty simple to do and not a deterrent to their care if you just focus on the issue they’ve come to the ED to get treatment for.

On the military side of things, and having been in combat on the front lines, you don’t much care who is what – male or female – as long as they’re doing their jobs. When you’re fighting the enemy, you’re not taking an attendance check to see who’s showed up next to you to join in the fight – male, female, straight, gay, lesbian, bisexual, transgender – none of that matters. You engage your enemy with an application of force to make sure the enemy goes away and you remain living, breathing and standing. The readiness argument, in my opinion, is a bit of a red herring. You fight together. And you really don’t care whether it’s Bruce or Caitlyn Jenner fighting next to you as long as they’re engaged in the fight keeping your butt and their butt safe. When bullets are flying at you, you become instantly ready to apply lethal force, transgender or not.

At his confirmation hearing on Capitol Hill prior to his becoming President Trump’s Secretary of Defense, Gen. James “Mad Dog” Mattis was asked a question by Sen. Kirsten Gillibrand (D-N.Y.) pertinent to this debate. She asked of the general, “Do you believe that allowing LGBT Americans to serve in the military, or women in combat, is undermining our lethality?”

“Frankly senator,” Gen. Mattis replied, “I’ve never cared much about two consenting adults and who they go to bed with.”

“So… the answer is ‘no’?” asked Sen. Gillibrand.

“Senator, my concern is on the readiness of the force to fight, and to make certain that it’s at the top of its game,” he said. “So, when we go up against an enemy, the criteria for everything we do in the military up until that point when we put our young men and women across the line of departure, is that they will be at their most lethal stance.”

An important perspective to remember as this debate moves forward.


To learn more about Dr. Sudip Bose, MD, please go to SudipBose.com and visit his nonprofit TheBattleContinues.org where 100% of donations go directly to injured veterans.

The Threat to America That No One is Talking About

By Dr. Sudip Bose, MD, FACEP, FAAEM

Our country has to maintain a strategy to use against a potential microbial attack that would strike terror in the hearts of every American if we’re not prepared for it when it hits. And make no mistake, it will come. It’s only a question of when.

Are we ready for the next pandemic? I would say no. We’ve made a start in preparing, but we’re not ready for a full-on microbial assault by any stretch.

According to a 2013 assessment by the World Bank:


“Pathogens with pandemic potential continue to emerge, and most of them are of animal origin (zoonotic). They include, for example, Ebola, H5N1 avian flu, H7N9 avian flu, HIV/AIDS, and two kinds of coronavirus: severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS).”


The World Bank also points out that that:


“The 1918 pandemic flu, the most severe of the four flu pandemics in the last 100 years, infected up to 40 percent of some national populations and killed 50–100 million people.”


Let’s start at the beginning: a pandemic is an epidemic of infectious disease that spreads through human populations across a large region – a country or countries, a continent, or even worldwide ― usually resulting in health issues serious enough to cause massive death among those infected.

“If anything kills over 10 million people in the next few decades, it’s most likely to be a highly infectious virus rather than a war. Not missiles, but microbes.”

That’s a quote from a TED Talk given by Microsoft co-founder Bill Gates in early 2015, only about a year after the start of an Ebola outbreak in West Africa, which ultimately claimed almost 29,000 lives. It’s now two years later, and the warning Gates gave still rings true as a very valid concern. In his talk, he said that there was no need to panic about this, but that, as a country, “we need to get going.”

He may have been right about not needing to panic. But it’s time to get going now.

The big question, though, is how? What do we do? How do we prepare for something that is ultimately unknowable until it hits?

We have a fairly recent example of a viral outbreak that can help us get ready for that fight – the Ebola virus outbreak in West Africa of just a few years ago that I just mentioned. It was an unprecedented epidemic with an unprecedented response that took years to get under control. The independent medical humanitarian organization, Medecins Sans Frontieres (MSF) – more widely known in the U.S. as Doctors Without Borders – organized a global response to the outbreak. The group is primarily made up of doctors who volunteer their time and expertise to any given global medical threat.

At its peak, MSF employed nearly 4,000 national staff and over 325 expatriate staff to combat the epidemic across the three countries.

In Liberia – just one of the three primary countries where the Ebola outbreak extended to – 189 health care workers died after contracting the virus. That’s one of every 10 workers who dedicated themselves to stopping the spread of the outbreak. Unfortunately, that pales in comparison to the general mortality numbers of the outbreak, which show that of the total 28,636 documented cases of people infected by the Ebola virus between 2014 and January 2016, there was a resulting 11,315 deaths, according to the World Health Organization (WHO). That’s a mortality rate of nearly 40 percent. Very scary stuff.

According to the non-fiction book, The Hot Zone, written by Richard Preston and published in the mid-’90s after the Ebola virus first emerged from the jungles of Africa and claimed its first human victim, Preston writes:


“A hot virus from the rain forest lives within a twenty-four-hour plane flight from every city on earth. All of the earth’s cities are connected by a web of airline routes. The web is a network. Once a virus hits the net, it can shoot anywhere in a day – Paris, Tokyo, New York, Los Angeles ― wherever planes fly. Charles Monet and the life form inside him had entered the net.”


Charles Monet was the man initially infected with that life form – the Ebola virus ― who Preston was writing about in The Hot Zone. Monet was trying to get to a hospital in Nairobi, Kenya, flying aboard a Kenya Airways flight. It was nothing more than luck that Monet didn’t infect anyone on the plane and luck that the virus really didn’t “enter the net” and spread worldwide. And this was some 35 years before the Ebola outbreak in 2014.

The next big viral outbreak doesn’t necessarily have to be something as exotic as an Ebola virus or some other as yet unknown zoonotic pathogen. It could simply be the next strain of influenza – the flu – that we’ve never seen before that could turn deadly. The source could be a natural epidemic, or it could be bio-terrorism.

Here are some of the steps we need to take to avoid at least a major worldwide health scare or at worst a pandemic:

Speed is the first factor. We’ve got to be able to quickly identify the threat and move to treat it as fast as possible. Speed is the ultimate weapon. Identification usually the easy part. Then what, though? How do we minimize the spread of the infection and contain it?

Reserves – in a word – just as in we have now as part of our current military. We need medical reservists who can be called up to handle an infectious outbreak – a U.S. medical dream team ready to be deployed to the hot spots and begin front-line treatment and containment.

We need a group of key epidemiologists also ready to evaluate the disease and formulate a plan for the most effective treatment of the “microbial missile.” We need dedicated researchers who can identify and formulate treatment protocols, develop vaccines and research the most effective ways to eliminate the threat. Modern advances in biology should lessen the turnaround in the time it takes to look at a pathogen and then find a quick path to manufacturing drugs and vaccines at scale that could work against that pathogen or develop a universal treatment protocol to be implemented.

Exercises – practice. Now is the time to identify the personnel who would make up these teams and train them. We need to perform military-like exercises – “germ games” as Bill Gates called them in his TED Talk – to be ready for an outbreak. We’ve invested a lot as a nation to build up our military defenses – people, weapons and weapons platforms, hardware, software, logistics, networks, command structure – all of it. But if the next big threat to US human lives is microbial, what do we have invested right now to stop a major epidemic? Very little.

So we’ve got to get a response team ready. We’ve got to get a preparedness team ready to roll.

WHO is funded to monitor epidemics, but not to take action to stop them. We can’t let that gap go unfilled here in America.

The World Bank estimates that if we have a worldwide flu epidemic, we’d have millions of deaths. And they also say that as a result of the epidemic, global wealth would depreciate by more than $3 trillion. Not million, not billion – trillion.

Invest now. If we invested even a small fraction of that astronomical amount of money in readying to stop such an outbreak, wouldn’t it be worth it? And this kind of investment would evolve significant benefits beyond just being ready for the next pandemic. This should absolutely be a priority. We can build a terrific response system.

Leverage technology. Technology is advancing at such a rapid pace that we’re barely able to keep up with and implement the improvements made on a monthly and yearly basis. So who knows the kind of technology we’d be able to leverage in the future. But even so, currently we can use modern technology that is now as simple and basic as cell phones. Cell phones can get information fed in from the public and can also be used to get information back out instantaneously. Satellite tracking can monitor people movement.

Response. Why not pair the medical people with the military to take advantage of the military’s ability to move quickly in response to a threat? It’s an idea Bill Gates surfaced in his talk, and I would agree with the strategy. There’s not one area of America we couldn’t get to quickly if we paired up the medical personnel with military movement and transportation.

There is a lot of room for progress and a lot we can do to be ready for the next pandemic. And we need to start now.


To learn more about Dr. Sudip Bose, MD, please go to SudipBose.com and visit his nonprofit TheBattleContinues.org where 100% of donations go directly to injured veterans.